06/11/2024 - PacketUtilities Committee Meeting Agenda
June 11, 2024, 5:00 p.m.
Remote access:
https://us02web.zoom.us/j/87414029386
Meeting ID: 874 1402 9386
• Utility Facility Tour
• Project Updates
o Foster Pilot Project
o Well 11 Upgrade
o Well 7 Upgrade
o Melcher Pump Station
o Water System Plan
o General Sewer Plan
o Marina Lift Station
• Fluoridation
Next Meeting: TBD
Future Agenda Items:
• Well 13 and PRV's
• McCormick Sewer PS #1 Repairs
• Option to Levy Excise Taxes on W/S
• Bay Street Utility Plan
• Sanitary Side Sewer Policy
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is( KITSAP PUBLIC
HEALTH DISTRICT
To: Port Orchard Mayor Robert Putaansuu
From: Gib Morrow, MD, MPH, Health Officer
Re: Municipal Water Fluoridation
Date: April 24, 2024
345 6th Street, Suite 300
Bremerton,WA 98337
360-728-223S
Kitsap Public Health District supports community water fluoridation as a sound, population -
based public health measure and encourages communities to begin and maintain optimal
fluoride levels for health benefits in drinking water systems.
With seventy years of scientific evidence and over seventy percent of U.S. residents drinking
fluoridated water, we know that fluoridation reduces tooth decay in children and adults, helps
address disparities for families with low incomes, and saves money by reducing the need for
dental treatment. Fluoridation is cost-effective, practical, and safe. Research shows that water
fluoridation is the most cost-effective and equitable way of preventing cavities and tooth decay
in people of all ages. People who live in communities with fluoridated water are more likely to
have healthier teeth than those living in communities without fluoridated water.
Tooth decay is the result of a preventable bacterial disease process that occurs throughout life.
Exposure to optimally fluoridated water improves dental health. Fluoride is a naturally
occurring mineral, present in nearly all water supplies, that strengthens the enamel of teeth.
Community water fluoridation adjusts the concentration of fluoride to a level that is safe and
optimal for preventing tooth decay and is a proven public health prevention measure that
benefits both children and adults, regardless of age, race, gender, or income. When in contact
with teeth, it helps to repair early signs of tooth decay, hardens the tooth's surface, and slows
decay -causing bacteria.
The Surgeon General of the United States and over one hundred national and international
organizations endorse water fluoridation. The U.S. Centers for Disease Control and Prevention
recognized fluoridation of drinking water as one of ten great public health achievements of the
twentieth century.
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Washington State does not require public water systems to add fluoride to drinking water.
Local communities make their own decisions. Starting July 23, 2023, after passage of House Bill
1251, public water systems considering starting or discontinuing fluoridation of their water on a
continuing basis must notify their customers at least 90 days prior to a vote or decision on the
matter. Water systems can notify customers by radio, television, newspaper, regular mail,
electronically, or by any combination of methods that most effectively notify customers. If a
water system fails to meet the new notification requirements it must continue with its current
fluoridation practice until it meets the notification requirements.
You may recall that Port Orchard considered defluoridating its water in 2011 and went through
this process, learning that a significant majority of Port Orchard residents desire fluoridated
water. We encourange you, in the interest of public health, health equity, and cost-effective,
evidence -based preventive health strategies, to continue to adjust fluoride to optimal levels in
Kitsap water systems.
Sincerely,
Gib Morrow, MD, MPH
Is Fluoridation Effective?
Is fluoride safe?
Fluoride Myths & Facts
What do health experts say?
FLOURIDE IN DRINKING WATER in Kitsap
kitsappublicheaIth.org
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Elementary Schools in Port Orchard Free or Reduced Meal Support
1. East Port Orchard Elementary: Student count 425, students receiving free and
reduced support 76.5%
2. Sidney Glen Elementary: Student count 508, students receiving free and reduced
support 42%
3. Sunnyslope Elementary: Student count 488, students receiving free and reduced
support 34%
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Community Water Fluoridation
Community Water Fluoridation Home
Water Fluoridation Basics
The mineral fluoride occurs naturally on earth and is released from rocks into the soil, water, and air. All water contains some
fluoride. Usually, the fluoride level in water is not enough to prevent tooth decay; however, some groundwater and natural
springs can have naturally high levels of fluoride.
Fluoride has been proven to protect teeth from decay. Bacteria in the mouth produce acid when a person eats sugary foods.
This acid eats away minerals from the tooth's surface, making the tooth weaker and increasing the chance of developing
cavities. Fluoride helps to rebuild and strengthen the tooth's surface, or enamel. Water fluoridation prevents tooth decay by
providing frequent and consistent contact with low levels of fluoride. By keeping the tooth strong and solid, fluoride stops
cavities from forming and can even rebuild the tooth's surface.
Community water fluoridation is the process of adjusting the amount of fluoride in drinking water to a level recommended for
preventing tooth decay.
Although other fluoride -containing products, such as toothpaste, mouth rinses, and dietary supplements are available and
contribute to the prevention and control of tooth decay, community water fluoridation has been identified as the most cost-
effective method of delivering fluoride to all, reducing tooth decay by 25% in children and adults.'
Benefits: Strong Teeth
Fluoride benefits children and adults throughout their lives. For children younger than age 8, fluoride helps strengthen the
adult (permanent) teeth that are developing under the gums. For adults, drinking water with fluoride supports tooth enamel,
keeping teeth strong and healthy. The health benefits of fluoride include having:
• Fewer cavities.
• Less severe cavities.
• Less need for fillings and removing teeth.
• Less pain and suffering because of tooth decay.
History of Fluoride in Water
In the 1930s, scientists examined the relationship between tooth decay in children and naturally occurring fluoride in drinking
water. The study found that children who drank water with naturally high levels of fluoride had less tooth decay.2 This
discovery was important because during that time most children and adults in the United States were affected by tooth decay.
Many suffered from toothaches and painful extractions —often losing permanent teeth, including molars, even as teenagers.
After much scientific research, in 1945, the city of Grand Rapids, Michigan, was the first to add fluoride to its city water system
in order to provide residents with the benefits of fluoride. This process of testing the water supply for fluoride and adjusting it
to the right amount to prevent cavities is called community water fluoridation.
Since 1945, hundreds of cities have started community water fluoridation and in 2020, nearly 73% of the United States served
by community water systems had access to fluoridated water. Because of its contribution to the dramatic decline in tooth
decay over the past 75 years, CDC named community water fluoridation as 1 of 10 great public health achievements of the
20th century.
See where your state ranks in percent of the population that receives water with fluoride. back to agenda
Cost: Saves Money, Saves Teeth
Community water fluoridation has been shown to save money, both for families and the health care system. The return on
investment for community water fluoridation varies with size of the community, increasing as the community size increases.
Community water fluoridation is cost -saving, even for small communities. The estimated return on investment for community
water fluoridation (including productivity losses) ranged from $4 in small communities of 5,000 people or less, to $27 in large
communities of 200,000 people or more.4
Fluoride in the Water Today
In 2020, community water systems that contain enough fluoride to protect teeth served more than 200 million people or
nearly 73% of the US population. Because it is so beneficial, the United States has a national goal for 77% of Americans to
have water with enough fluoride to prevent tooth decay by 2030.
Learn more about this goal C, .
Learn about CDC's methodology for calculating fluoridation statistics.
Learn about the history and science behind water fluoridation, and how water fluoridation systems are implemented and
operated in Fluoridation Learning Online, CDC's free online training.
Find out if your water system has fluoride at My Water's Fluoride.
Learn more about fluoride and its role in oral health at the CDC podcast: Go With the Flow.
References:
1 Griffin SO, Regnier E, Griffin PM, Huntley VN. Effectiveness of fluoride in preventing caries in adults. J Dent Res.
2007;86(5):410-414.
2 Dean HT. On the epidemiology of fluorine and dental caries. In: Gies WJ, ed. Fluorine in Dental Public Health. New York, NY:
New York Institute of Clinical Oral Pathology., 1945:19-30.
3 Arnold FJ, Dean HT. Effect of fluoridated public water supply on dental caries prevalence. Public Health Rep. 1956;71:652-
658.
4Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Public Health Dent. 2001;61(2):78-
86.
Last Reviewed: June 13, 2023
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1 1Control
ont of aond Prevention
Community Water Fluoridation
Cost Savings of Community Water Fluoridation
Community water fluoridation is recognized as one of the most cost-effective, equitable, and safe measures communities can
take to prevent cavities and improve oral health. That's why it was named 1 of 10 great public health achievements of the 20th
century.'
Various methods may be utilized for determining costs and benefits of community water fluoridation. Newer studies have
been able to make use of actual costs from water systems rather than relying primarily on expert estimates. The fact that
multiple studies using different methods reach the same conclusion increases confidence in the general finding that
community water fluoridation can be cost saving for communities.
Economic Impact
Economic evaluations reaffirm the cost benefits of community water fluoridation. Studies continue to show that widespread
community water fluoridation prevents cavities and saves money, both for families and the health care system.
An economic review of multiple studies found that savings for communities ranged from $1.10 to $135 for every $1 invested.z
Per capita annual costs for community water fluoridation ranged from $0.11 to $24.38, while per capita annual benefits
ranged from $5.49 to $93.19.2
A recent 2016 economic analysis found that for communities of 1,000 or more people, the savings associated with water
fluoridation exceeded estimated program costs, with an average annual savings of $20 per dollar invested.3 Additionally,
individuals in communities that fluoridate water save an average of $32 per person by avoiding treatment for dental
caries.' Nationwide, this same study found, community water fluoridation programs have been estimated to provide nearly
$6.5 billion dollars a year in net cost savings by averting direct dental treatment costs (tooth restorations and extractions) and
indirect costs (losses of productivity and follow-up treatment).'
The 2016 study, "Costs and Savings Associated with Community Water Fluoridation in the United States," used documented
program costs to determine:
• The costs of installing and maintaining necessary equipment and operating water plants;
• the expected effectiveness of fluoridation; estimates of expected cavities in non -fluoridated communities;
• direct and indirect costs of treating cavities; and
• time lost visiting the dentist for initial and follow-up treatment over a lifetime to maintain a treated tooth.
Consistent with prior analyses, this study supports the finding that community water fluoridation remains one of the most
cost-effective methods of delivering fluoride to all community members regardless of age, educational attainment, or income
level.
Halo Effect
In addition to providing an oral health benefit for people with access to fluoridated water, a related analysis found that
children living in communities that do not adjust fluoride may still receive partial benefits of fluoridation from eating foods
and drinking beverages processed in fluoridated communities. The study, "Quantifying the Diffused Benefit from Water
Fluoridation," examined the differences in tooth decay rates in 12-year-old children who live in states where at least 50% of
the communities have fluoridated water and those in states where less than 25% of communities practice fluoridation.'
The study found that the children residing in the higher fluoridated states experienced less decay each year than children who
live in states where water fluoridation is less common.'
"Widespread community water fluoridation prevents cavities even in neighboring communities that are not fluoridated;"
according to Dr. Susan Griffin, the study's main author. "For instance, a 12-year-old child who has lived in a back to agenda
community in a state with a higher proportion of fluoridated water systems would typically have one fewer cavity than a child
in a low -fluoridated state."
Summary
Tooth decay contributes to reduced quality of life and increased need for costly restorative dental care.' People who consume
fluoridated water experience fewer and less severe cavities, resulting in a reduced need for fillings and removing or replacing
teeth, and less time taken off from school or work because of dental problems or pain.','-' Water fluoridation benefits all
members of a community by preventing tooth decay, improving oral health and saving money for everyone.
References
1. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: fluoridation of drinking water to
prevent dental caries. MMWR. 1999;48(41):933-940. View report
2. Ran, T., S.K. Chattopadhyay, and Community Preventive Services Task Force, Economic Evaluation of Community Water
Fluoridation: A Community Guide Systematic Review. Am J Prev Med, 2016. 50(6): p. 790-6. View abstract on PubMed Cj'
3. O'Connell JM, Rockwell J, Ouellet J, Tomar SL, Maas W. Costs and Savings Associated with Community Water Fluoridation in
the United States. Health Affairs. 2016. 1;35(12):2224-2232. View abstract on PubMed C",
4. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Publ Health Dent 2001;61(2):78-
86. View abstract on PubMed C',
5. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US
Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of
Health; 2000. View Report Cli
6. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res. 2007;86:410-
415. View abstract on PubMed C',
7. Guarnizo-Herreno CC, Wehby GL. Children's dental health, school performance, and psychosocial well-being. J Pediatr.
2012;161:1153-9. View abstract on PubMed C',
Page last reviewed: July 22, 2019
Fluoridation Facts
ADA American Dental Association°
America's leading advocate for oral health
Dedication
................................................................................................................................................................
This 2018 edition of Fluoridation Facts is dedicated to Dr. Ernest Newbrun, respected researcher, esteemed
educator, inspiring mentor and tireless advocate for community water fluoridation.
About Fluoridation Facts
Fluoridation Facts contains answers to frequently asked questions regarding community water fluoridation.
A number of these questions are responses to myths and misconceptions advanced by a small faction opposed
to water fluoridation. The answers to the questions that appear in Fluoridation Facts are based on generally
accepted, peer -reviewed, scientific evidence. They are offered to assist policy makers and the general public in
making informed decisions. The answers are supported by over 400 credible scientific articles, as referenced
within the document. It is hoped that decision makers will make sound choices based on this body of generally
accepted, peer -reviewed science.
Acknowledgments
This publication was developed by the National Fluoridation Advisory Committee (NFAC) of the American Dental
Association (ADA) Council on Advocacy for Access and Prevention (CAAP). NFAC members participating in the
development of the publication included Valerie Peckosh, DMD, chair; Robert Crawford, DDS; Jay Kumar, DDS,
MPH; Steven Levy, DDS, MPH; E. Angeles Martinez Mier, DDS, MSD, PhD; Howard Pollick, BIDS, MPH; Brittany
Seymour, DDS, MPH and Leon Stanislav, DDS.
Principal CAAP staff contributions to this edition of Fluoridation Facts were made by: Jane S. McGinley, RDH,
MBA, Manager, Fluoridation and Preventive Health Activities; Sharon (Sharee) R. Clough, RDH, MS Ed Manager,
Preventive Health Activities and Carlos Jones, Coordinator, Action for Dental Health. Other significant staff
contributors included Paul O'Connor, Senior Legislative Liaison, Department of State Government Affairs.
In addition to her legal review, Wendy J. Wils, Esq., Deputy General Counsel, Division of Legal Affairs provided
greatly to the vision of this publication.
Disclaimer
This publication is designed to answer frequently asked questions about community water fluoridation, based on a summary of
relevant published articles. It is not intended to be a comprehensive review of the extensive literature on fluoridation and fluorides
or to promote professional advice. Readers must also rely on their own review of the literature, including the sources cited herein
and any subsequently published, for a complete understanding of these issues.
@2018 American Dental Association
This publication may not be reproduced in whole or in part without the express written permission of the American Dental
Association except as provided herein.
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American Dental Association
Fluoridation Facts 2018
Executive Summary
• Fluoridation of community water supplies is the
single most effective public health measure to
prevent tooth decay.
• Throughout more than 70 years of research and
practical experience, the overwhelming weight
of credible scientific evidence has consistently
indicated that fluoridation of community water
supplies is safe.
• Studies prove water fluoridation continues to be
effective in reducing tooth decay by more than
25% in children and adults, even in an era with
widespread availability of fluoride from other
sources, such as fluoride toothpaste.
• Because of the important role it has played in the
reduction of tooth decay, the Centers for Disease
Control and Prevention has proclaimed community
water fluoridation (along with vaccinations and
infectious disease control) one of ten great public
health achievements of the 20th century.
• Community water fluoridation is the controlled
adjustment of fluoride that occurs naturally in all
water to optimal levels to prevent tooth decay.
• Community water fluoridation benefits everyone,
especially those without access to regular dental
care. Fluoridation is a powerful tool in the fight for
social justice and health equity.
• Simply by drinking water, people can benefit from
fluoridation's cavity protection whether they are at
home, work or school.
• Water that has been fortified with fluoride is similar
to fortifying salt with iodine, milk with vitamin D
and orange juice with vitamin C — none of which
are medications.
When compared to the cost of other prevention
programs, water fluoridation is the most cost-
effective means of preventing tooth decay for
both children and adults in the United States.
The cost of a lifetime of water fluoridation for
one person is less than the cost of one filling.
For community water systems that serve more
than 1,000 people, the economic benefit of
fluoridation exceeds the cost. And the benefit -cost
ratio increases as the size of the population served
increases (largely due to economies of scale).
Fluoridation is a cost -saving method to prevent
tooth decay.
• According to data from 2014, nearly 75% of
the population (3 out of 4 people) in the United
States are served by public water systems that
are optimally fluoridated.
• Fluoridation has been thoroughly tested in the
United States' court system, and found to be
a proper means of furthering public health
and welfare. No court of last resort has ever
determined fluoridation to be unlawful.
• The ADA supports community water fluoridation
as a safe, effective, cost -saving and socially
equitable way to prevent tooth decay.
• One of the most widely respected sources for
information regarding fluoridation and fluorides
is the American Dental Association. The ADA
maintains Fluoride and Fluoridation web pages
at http://www.ADA.org/fluoride.
Permission is hereby granted to reproduce and distribute this Fluoridation Facts Executive Summary in its entirety, without
modification. To request any other copyright permission, please contact the American Dental Association at 1.312.440.2879.
...............................................................................................................................................................
Executive Summary I Fluoridation Facts 1
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American Dental Association
Fluoridation Facts 2018
Table of Contents
Executive Summary......................1
Introduction ............................... 5
Benef its...................................13
1.
What is fluoride? .........................13
2.
Fluoride prevents tooth decay?.............13
3.
Water fluoridation? .......................14
4.
Fluoride is in your water? ..................15
5.
Fluoride additives? ........................16
6.
Natural vs. adjusted? ......................16
7.
Effectiveness?............................17
8.
Still effective?............................20
9.
Discontinued?............................21
10.
Tooth decay problem?.....................22
11.
Adult benefits? ...........................24
12.
Fluoride supplements? ....................25
13.
Fluoride for children?......................27
14.
Alternatives? .............................28
15.
Bottled water? ...........................31
16.
Home treatment systems?.................32
Safety.....................................37
17.
Harmful to humans?.......................37
18.
More studies needed?.....................38
19.
Recommended level? .....................39
20.
EPA maximum? ...........................40
21.
EPA secondary level?......................41
22.
Total intake? .............................43
23.
Daily intake? .............................44
24.
Prenatal dietary fluoride supplements? ......46
25.
Body uptake? ............................47
26.
Bone health? .............................47
27.
Dental fluorosis?..........................49
28.
Fluoridated water for infant formula? .......52
29.
Prevent fluorosis?.........................52
30.
Warning Label? ...........................54
31.
Acute and chronic toxicity? ................55
32.
Cancer?.................................56
33.
Osteosarcoma?...........................57
34.
Enzyme effects?..........................58
35.
Thyroid?.................................59
36.
Pineal gland? .............................60
37.
Allergies?................................60
38.
Genetic risk? .............................61
39.
Fertility?.................................61
40.
Down Syndrome?.........................62
41.
Neurological impairment/IQ?...............62
42.
Lead poisoning? ..........................64
43.
Alzheimer's disease? ......................65
44.
Heart disease? ...........................66
45.
Kidney disease?...........................67
46.
Erroneous health claims? ..................68
..............................................................................................................................................................
Table of Contents I Fluoridation Facts 3
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Fluoridation Practice....................75
47.
Who regulates?...........................75
48.
Standards for additives? ...................76
49.
Lead, arsenic and other contamination? .....77
50.
Additives safety? .........................78
51.
Source of additives?.......................78
52.
System safety concerns? ..................79
53.
Engineering? .............................80
54.
Corrosion of water pipes?..................81
55.
Damage to water facilities? ................81
56.
Environment? ............................82
Public Policy..............................85
57.
What is public health? .....................85
58.
Valuable measure? ........................86
59.
Reduce disparities? .......................88
60.
Support for fluoridation? ..................89
61.
Courts of law?............................91
62.
Opposition?..............................92
63.
Opposition tactics? .......................93
64.
Internet?................................96
65.
Public votes? .............................97
66.
International fluoridation? ...............
101
67.
Banned in Europe? ......................
102
Cost ..................................... 106
68. Cost-effective and cost -saving?.......... 106
69. Practical? .............................. 109
Figures
1. Reviewing Research ........................6
2. Tooth Decay and Dental Fluorosis Graph .....
17
3. EPA and USPHS Numbers ..................42
4. Examples of Toothpaste for Children ........46
5. Opposition Tactics ........................95
6. ADA.org Fluoride and Fluoridation ..........97
7. Largest Fluoridated Cities..................98
8. States Meeting National Goals .............99
9. State Fluoridation Status .................
100
Tables
1. Dietary Fluoride Supplements ..............26
2. Dietary Reference Uptakes ................45
3. Categories of Dental Fluorosis..............51
.....................................................................................................................................................................
4 American Dental Association
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Fluoridation Facts has been published by the
American Dental Association (ADA) since 1956
Revised periodically, Fluoridation Facts answers
frequently asked questions about community
water fluoridation. In this 2018 edition, the
ADA Council on Advocacy for Access and
Prevention provides updated information for
individuals and groups interested in the facts
about fluoridation. The United States now has
more than 70 years of extensive experience
with community water fluoridation. Its
remarkable longevity and success is testimony
to fluoridation's significance as a public health
measure. In recognition of the impact that
water fluoridation has had on the oral and
general health of the public, in 1999, the
Centers for Disease Control and Prevention
(CDC) named fluoridation of drinking water
as one of ten great public health achievements
of the 20th century.' z
Many organizations in the United States and
around the world recognize the benefits of
community water fluoridation.
Support for Water Fluoridation
Since 1950, the American Dental Association (ADA)
has continuously and unreservedly endorsed the
optimal fluoridation of community water supplies
as a safe and effective public health measure for
the prevention of tooth decay. The ADA's policy is
based on the best available scientific evidence on the
safety and effectiveness of fluoridation. Since the
ADA first adopted policy recommending community
water fluoridation in 1950, the ADA has continued to
reaffirm its position of support for water fluoridation
and has strongly urged that its benefits be extended
to communities served by public water systems.'
Over the years, additional support has come from
numerous U.S. Surgeons General who are the leading
spokespersons on matters of public health in the
federal government. In 2016, Surgeon General
Dr. Vivek H. Murthy in his "Statement on Community
Water Fluoridation,"' noted:
Water fluoridation is the best method for delivering
fluoride to all members of the community, regardless
of age, education, income level or access to routine
dental care. Fluoride's effectiveness in preventing
tooth decay extends throughout one's life, resulting
in fewer — and less severe — cavities. In fact, each
generation born over the past 70 years has enjoyed
better dental health than the one before it. That's the
very essence of the American promise.'
In addition to the American Dental Association, the
American Medical Association,' the American Academy
of Pediatrics6 and the World Health Organization' also
support community water fluoridation.
Many organizations in the United States and around
the world recognize the benefits of community water
fluoridation. The ADA has developed a list of "National
and International Organizations that Recognize
the Public Health Benefits of Community Water
Fluoridation for Preventing Dental Decay." Please
see the ADA website at www.ADA.org/fluoride for
the most current listing as well as information on
reproduction and distribution of the list.
...............................................................................................................................................................
Introduction I Fluoridation Facts 5
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Scientific Information on Fluoridation
The ADA's policies regarding community water
fluoridation are based on the best available
scientific knowledge. This body of knowledge
results from the efforts of nationally recognized
scientists who have conducted research using
the scientific method, have drawn appropriate
balanced conclusions based on their research
findings and published their results in refereed
(peer -reviewed) professional journals that are
widely held or circulated. Studies showing the
safety and effectiveness of water fluoridation
have been confirmed by independent scientific
studies conducted by a number of nationally and
internationally recognized scientific investigators.
While opponents of fluoridation have questioned its
safety and effectiveness, none of their charges has
ever been substantiated by scientific evidence.
Question The Author
Actively search for study authors' intellectual
and financial conflicts of interest that
may have affected the conduct of the
study or results interpretation.
Mice vs. Humans
Wait for studies with human subjects
to confirm animal studies' results before
considering applying the research
findings in practice.
High Impact Journals
Impact factor and reputation of a journal do
not necessarily relate to the quality of the
published study in question, so
always remain skeptical.
■
With the advent of the Information Age, a new type
of "pseudo -scientific literature" has developed. The
public often sees scientific and technical information
quoted in the press, printed in a letter to the editor or
distributed via an internet web page. Often the public
accepts such information as true simply because it is
in print. Yet the information is not always based on
research conducted according to the scientific method
and the conclusions drawn from research are not always
scientifically justifiable. In the case of water fluoridation,
an abundance of misinformation has been circulated.
Therefore, scientific information from all print and
electronic sources must be critically reviewed before
conclusions can be drawn. (See Figure 1.) Everyone
is entitled to his or her own opinion but not his or her
own facts. Pseudo -scientific literature can pique a
reader's interest but when read as science, it can be
misleading. The scientific validity and relevance of
claims made by opponents of fluoridation might be
Correlation Does Not Imply
Causation
The fact that two things happen
together does not mean that one
necessarily causes the other.
Consider The Big Picture
Identify systematic reviews that
comprehensively summarize the evidence
instead of using single studies that present
only a small part of the big picture.
The Right Study Design
Some clinical questions cannot be studied
using the classic randomized control (RCT)
study design and non-RCT designs may
be a suitable alternative
6 American Dental Association
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best viewed when measured against criteria set forth
by the U.S. Supreme Court.8
6 Additionol information about this topic can be
found in the Public Policy Section, Question 61.
History of Water Fluoridation
Research into the effects of fluoride began in the early
1900s. Dr. Frederick McKay, a young dentist, opened a
dental practice in Colorado Springs, Colorado, and was
surprised to discover that many local residents exhibited
brown stains on their permanent teeth. Dr. McKay
could find no documentation of the condition in the
dental literature and eventually convinced Dr. G.V. Black,
dean of the Northwestern University Dental School in
Chicago, to join him in studying the condition. Through
their research, Drs. Black and McKay determined that
mottled enamel, as Dr. Black termed the condition,
resulted from developmental imperfections in teeth. Drs.
Black and McKay wrote detailed descriptions of mottled
enamel.9•10 (Mottled enamel is a historical term. Today,
this condition is called dental or enamel fluorosis.)
In the 1920s, Dr. McKay, along with others, suspected
that something either in or missing from the drinking
water was causing the mottled enamel. Dr. McKay wrote
to the Surgeon General in 1926 indicating that he had
identified a number of regions in Colorado, New Mexico,
Arizona, California, Idaho, South Dakota, Texas and
Virginia where mottled enamel existed. Also in the late
1920s, Dr. McKay made another significant discovery —
these stained teeth were surprisingly resistant to decay10
Following additional studies completed in the early
1930s in St. David, Arizona11 and Bauxite, Arkansas; 2
it was determined that high levels of naturally occurring
fluoride in the drinking water were causing the mottled
enamel. In Arizona, researchers studied in great
detail 250 residents in 39 local families and were
able to rule out hereditary factors and environmental
factors, except for one — fluoride in the water which
occurred naturally at levels of 3.8 mg/L to 7.15
mg/L11 In Bauxite, H. V. Churchill, chief chemist with
the Aluminum Company of America (later changed to
ALCOA), was using a new method of spectrographic
analysis in his laboratory to look at the possibility
that the water from an abandoned deep well in the
area might have high levels of aluminum -containing
bauxite that was causing mottled teeth. What he
found was that the water contained a high level of
naturally occurring fluoride (13.7 mg/L). When McKay
learned of this new form of analysis and Churchill's
findings, he forwarded samples of water from areas
where mottled enamel was commonplace to Churchill.
All of the samples were found to have high levels of
fluoride when compared to waters tested from areas
with no mottled enamel10
During the 1930s, Dr. H. Trendley Dean, a dental
officer of the U.S. Public Health Service, and his
associates conducted classic epidemiological studies
on the geographic distribution and severity of fluorosis
in the United States 13 These early studies quantified
the severity of tooth decay and dental fluorosis, called
mottled enamel at that time, according to fluoride
levels in the water. In so doing, it was observed that
"at Aurora, IL where the domestic water contained
1.2 ppm of fluoride (F) and where a relatively low tooth
decay prevalence was recorded, mottled enamel as an
esthetic problem was not encountered"14 Dean and
his staff had made a critical discovery. Namely, fluoride
levels of up to 1.0 ppm in drinking water did not cause
enamel fluorosis in most people and only mild dental
fluorosis in a small percentage of people.' 4-16
In 1939, Dr. Gerald J. Cox and his associates at
the Mellon Institute evaluated the epidemiological
evidence and conducted independent laboratory
studies. While the issue was being discussed in the
dental research community at the time, they were
the first to publish a paper that proposed adding
fluoride to drinking water to prevent tooth decay.17
In the 1940s, four classic, community -wide studies
were carried out to evaluate the controlled addition of
sodium fluoride to fluoride -deficient water supplies.
The first community water fluoridation program, under
the direction of Dr. Dean, began in Grand Rapids,
Michigan, in January 1945 with Muskegon, Michigan as
the nonfluoridated control community. The other three
studies were conducted in the following three pairs of
cities with the fluoridated city listed first: Newburgh
and Kingston, New York (May 1945); Brantford and
Sarnia, Ontario, Canada (June 1945) and Evanston
and Oak Park, Illinois (February 1947.)18-20
In the 1940s, four classic, community -wide
studies were carried out to evaluate the
controlled addition of sodium fluoride to
fluoride -deficient water supplies.
Introduction I Fluoridation Facts 7
back to agenda
The astounding success of these comparison studies
firmly established the practice of water fluoridation
as a practical, safe and effective public health
measure to prevent tooth decay that would quickly
be embraced by other communities.
The history of water fluoridation is a classic example
of a curious professional making exacting clinical
observations which led to epidemiologic investigation
and eventually to a safe and effective community -
based public health intervention which even today
remains the cornerstone of communities' efforts to
prevent tooth decay.
In addition to the studies noted above, a number of
reviews on fluoride in drinking water have been issued
over the years. For example, in 1951 the National
Research Council (NRC), of the National Academies,
issued its first report stating fluoridation was safe
and effective. The NRC has continued to issue reports
on fluoride in drinking water (197721 and 199322)
with the most recent review published in 2006.21
Additional reviews completed over the ten year
period from 2007-2017 include:
2017 Australian Government. National Health and
Medical Research Council (NHMRC).
Information Paper — Water Fluoridation:
Dental and Other Human Health Outcomes.24
2016 O'Mullane DM, Baez RJ, Jones S, Lennon
MA, Petersen PE, Rugg -Gunn AJ, Whelton H,
Whitford GM. Fluoride and Oral Health.25
2016 American Water Works Association.
Water Fluoridation Principles and Practices.
AWWA Manual M4. Sixth edition.26
2015 Water Research Foundation. State of the
Science: Community Water Fluoridation.27
2015 The Network for Public Health Law. Issue Brief:
Community Water Fluoridation.28
2015 Ireland Health Research Board. Health Effects
of Water Fluoridation: An Evidence Review.29
2015 U.S. Department of Health and Human Services
Federal Panel on Community Water Fluoridation
U.S. Public Health Service Recommendation
for Fluoride Concentration in Drinking Water
for the Prevention of Dental Cories.30
2014 Public Health England. Water Fluoridation:
Health Monitoring Report for England.31
2014 Royal Society of New Zealand and the Office
of the Prime Minister's Chief Science Advisor.
Health Effects of Water Fluoridation: a Review
of the Scientific Evidence.12
2013 U.S. Community Preventive Services Task
Force. The Guide to Community Preventive
Services. Preventing Dental Caries:
Community Water Fluoridation.13
2011 European Commission of the European
Union Scientific Committee on Health and
Environmental Risks (SCHER). Fluoridation.14
2008 Health Canada. Findings and Recommendations
of the Fluoride Expert Ponel.31
2007 Australian Government. National Health and
Medical Research Council A Systematic Review
of the Efficacy and Safety of Fluoridation;
Part A: Review Methodology and Results.16
Water Fluoridation as a Public Health
Measure
Throughout decades of research and more than 70
years of practical experience, fluoridation of public
water supplies has been responsible for dramatically
improving the public's oral health. In 1994, the
U.S. Department of Health and Human Services
(HHS) issued a report which reviewed public health
achievements.37 Along with other successful public
health measures such as the virtual eradication
of polio and reductions in childhood blood lead
levels, fluoridation was lauded as one of the most
economical preventive interventions in the nation.37
Because of the important role fluoridation has played in
the reduction of tooth decay, the Centers for Disease
Control and Prevention proclaimed community water
fluoridation one of ten great public health achievements
of the 20th century.',' Other public health achievements
included in the 1999 announcement were vaccinations
(which have been responsible for the elimination of polio
in the Americas), recognition of tobacco use as a health
hazard and the decline in deaths from coronary heart
disease and stroke. In 2000, U.S. Surgeon General Dr.
David Satcher issued the first ever Surgeon General
8 American Dental Association
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report on oral health, Oral Health in America. a Report
of the Surgeon General.38 In the report, Dr. Satcher
stated that community water fluoridation continues to
be the most cost-effective, practical and safe means for
reducing and controlling the occurrence of tooth decay
in a community. Additionally, Dr. Satcher noted that
water fluoridation is a powerful strategy in efforts to
eliminate health disparities among populations. Studies
have shown that fluoridation is the most significant
strategy employed to reduce disparities in tooth
decay.38-42
e Additional information about this topic can be
found in the Public Policy Section, Question 59.
Because of the important role fluoridation has
played in the reduction of tooth decay, the
Centers for Disease Control and Prevention
proclaimed community water fluoridation one
of ten great public health achievements of the
20th century.' z
...............................................................................
In the 2003 National Coll to Action to Promote Oral
Health'43 U.S. Surgeon General Dr. Richard Carmona
called on policymakers, community leaders, private
industry, health professionals, the media and the public
to affirm that oral health is essential to general health
and well-being. Additionally, Dr. Carmona urged these
groups to apply strategies to enhance the adoption and
maintenance of proven community -based interventions
such as community water fluoridation.
Writing in Public Health Reports in 2010, Surgeon
General Dr. Rebecca Benjamin noted that, "Community
water fluoridation continues to be a vital, cost-effective
method of preventing dental caries„44
In a 2015 Surgeon's General Perspective41 issued
to coincide with the release of the updated USPHS
recommendation on fluoride levels in drinking water
to prevent tooth decay, Surgeon General Dr. Vivek
H. Murthy stated, "As Surgeon General, I encourage
all Americans to make choices that enable them to
prevent illness and promote well-being. Community
water fluoridation is one of the most practical, cost-
effective, equitable, and safe measures communities
can take to prevent tooth decay and improve oral
health"45
Established by the U.S. Department of Health and
Human Services (DHHS), Healthy People 202046
provides a science -based, comprehensive set of
ambitious, yet achievable, ten-year national objectives
for improving the health of the public. Included under
oral health is an objective to expand the fluoridation
of public water supplies. Objective 13 states that
at least 79.6% of the U.S. population served by
community water systems should be receiving the
benefits of optimally fluoridated water by the year
2020.41 In 2014, the CDC indicated that 74.4% of the
U.S. population on public water systems, or a total
of 211.4 million people, had access to fluoridated
water.48
After more than four years of additional research and
review following the initial notice of intent, in 2015
the DHHS announced that the U.S. Public Health
Service had made a final recommendation on the
fluoride level in drinking water30 that updated and
replaced the 1962 Drinking Water Standards related
to community water fluoridation. In this guidance,
the optimal concentration of fluoride in drinking
water of 0.7 mg/L (milligrams per liter) was defined
as "the concentration that provides the best balance
of protection from dental caries while limiting the
risk of dental fluorosis "30
6 Additional information about this topic con be
found in the Safety Section, Question 19.
Water Fluoridation's Role in Reducing
Tooth Decay
Water fluoridation has played a significant role in
improving oral health. Numerous studies and reviews
have been published making fluoridation one of
the most widely studied public health measures in
history. Fluoridation of community water supplies is
the single most effective public health measure to
prevent tooth decay. Studies show that community
water fluoridation prevents at least 25 percent of
tooth decay in children 49 and adults,50 even in an era
with widespread availability of fluoride from other
sources, such as fluoride toothpaste. Fluoridation
helps to prevent, and in some cases, reverse tooth
decay across the life span. Increasing numbers of
adults are retaining their teeth throughout their
lifetimes due in part to the benefits they receive
from water fluoridation. Dental costs for these
individuals are likely to have been reduced and many
Introduction I Fluoridation Facts 9
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hours of needless pain and suffering due to untreated
tooth decay have been avoided. By preventing tooth
decay, community water fluoridation has been shown
to save money, both for families and the health care
system. The return on investment for community
water fluoridation varies with size of the community,
and in general, increases as the community size
increases. Community water fluoridation is cost -
saving, even for small communities.
6 Additional information about this topic con be
found in the Cost Section, Question 68.
Fluoridation of community water supplies is
the single most effective public health measure
to prevent tooth decay. Studies show that
community water fluoridation prevents at
least 25 percent of tooth decay in children
and adults, even in an era with widespread
availability of fluoride from other sources,
such as fluoride toothpaste.
Community water fluoridation is a most valuable
public health measure because:
• Optimally fluoridated water is accessible to the
entire community regardless of socioeconomic
status, educational attainment or other social
variables."
• Individuals do not need to change their behavior
to obtain the benefits of fluoridation.
• Frequent exposure to small amounts of fluoride
over time makes fluoridation effective through the
life span in helping to prevent tooth decay."
• Community water fluoridation is more cost-
effective and cost -saving than other forms of
fluoride treatments or applications.53,54
Tooth decay is caused by sugars in snacks, food and
beverages being converted into acid by the bacteria
in dental plaque, a thin, sticky, colorless deposit
on teeth. The acid attacks the tooth enamel (the
hard surface of the tooth) or root surface. After
repeated attacks, the enamel or root surface loses
minerals (demineralization) and the acids and bacteria
penetrate the dentin and finally the pulp. The soft
tissue of the pulp contains nerves and blood vessels.
Once the decay enters the pulp, it becomes infected
and without treatment, the infection progresses and
travels into the surrounding tissues. It can enter the
bloodstream and potentially spread the infection to
other parts of the body which can be life -threatening.
6 Additional information about this topic can be
found in the Benefits Section, Question 2.
There are a number of factors that increase an
individual's risk for tooth decay:14-19
• Recent history of tooth decay
• Elevated oral bacteria count
• Inadequate exposures to fluorides
• Exposed roots
• Frequent intake of sugar/sugary foods and
sugar -sweetened beverages
• Poor or inadequate oral hygiene
• Decreased flow of saliva
• Deep pits and fissures on the chewing surfaces
of teeth
Exposure to fluoride is a key component in any
recommended decay prevention strategy; however,
the use of fluoride alone will not prevent all tooth
decay. In formulating a decay prevention program,
in additional to consuming fluoridated tap water, a
number of intervention strategies may be considered
such as improved daily home care, reducing sugar in
the diet, placement of dental sealants and prescription
strength fluoride toothpaste for home use and
professionally applied topical treatments.
Ongoing Need for Water Fluoridation
Because of the risk factors for tooth decay noted
previously, many individuals and communities still
experience high levels of tooth decay. Although water
fluoridation demonstrates an impressive record of
effectiveness and safety, only 74.4% of the United
States population on public water supplies in 2014
received fluoridated water containing protective
levels of fluoride.411 Unfortunately, some people
continue to be confused about this effective public
health measure. If the number of individuals drinking
fluoridated water is to increase, the public must be
accurately informed about its benefits and safety.
10 American Dental Association
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Introduction References
1. Centers for Disease Control and Prevention. Ten great public health
achievements --United States, 1990-1999. MMWR 1999;48(12):241-3.
Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.
htm. Accessed October 2, 2017.
2. Centers for Disease Control and Prevention. Achievements in Public Health,
1900-1999: Fluoridation of drinking water to prevent dental caries.
MMWR 1999;48(41):933-40. Available at: https://www.cdc.govlmmwrl
preview/mmwrhtm1/mm4841a1.htm. Accessed October 28, 2017.
3. American Dental Association. Policy on fluoridation of water supplies.
(Trans.2015:274) 2015. Available at: http://www.ADA.org/en/Public-
programs/ad vocating-for-the-public/fluoride-and-fluoridation/ada-
fluoridation-policy. Accessed October 28, 2017.
4. U.S. Department of Health and Human Services. Public Health Service.
Surgeon General Vivek H. Murthy. Statement on community water
fluoridation. Office of the Surgeon General. Rockville, MD. 2016. Available
at: https://www.cdc.gov/fluoridation/guidelines/surgeons-general-
statements.htmL Accessed October 3, 2017.
5. American Medical Association Water fluoridation H-440.972. 2011. In:
American Medical Association Policy Finder. Available at: https://www.
ama-assn.org/about-uslpolicyfinder. Accessed October 3, 2017.
6. American Academy of Pediatrics Section on Oral Health. Maintaining and
improving the oral health of young children. Pediatrics 2014;134(6):1224-
9. Abstract at: https://www.ncbi.nlm.nih.govlpubmedl25422016.
Accessed October 28, 2017.
7. Petersen PE, Ogawa H. Prevention of dental caries through the use of
fluoride --the WHO approach. Community Dent Health 2016;33(2):66-8.
8. Doubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113, S.Ct.
2786 (1993).
9. McKay FS. Mottled enamel: the prevention of its further production
through a change of the water supply at Oakley, Ida. J Am Dent Assoc
1933;20(7):1137-49.
10. McClure FJ. Water fluoridation: the search and the victory. Bethesda, MD:
National Institute of Dental Research; 1970. Available at: https://www.
dentalwatch.org/fl/mcc/ure.pdf. Accessed October 28, 2017.
11. Smith MC, Lantz EM, Smith HV. The cause of mottled enamel, a defect of
human teeth. University of Arizona, College of Agriculture, Agriculture Exp.
Station. Technical Bulletin 32. 1931:253-82.
12. Churchill HV. The occurrence of fluorides in some waters of the United
States. Ind Eng Chem 1931;23(9):996-998. Available at: http://pubs.acs.
org1doi1abs110.10211ie50261a007 Accessed October 28, 2017.
13. Dean HT. Chronic endemic dental fluorosis. JAMA 1936;107(16):1269-
73. Article at: https://jamanetwork.com/journals/jama/article-
abstract/273186. Accessed October 28, 2017.
14. National Institute of Dental and Craniofacial Research. The story of
fluoridation. Available at: http://www.nidcr.nih.gov/oralhealth/topics/
fluoride/thestoryoffluoridation.htm. Accessed September 4, 2017.
15. Dean HT. Endemic fluorosis and its relation to dental caries. Public
Health Rep 1938;53(33):1443-52. Article at: https.,Ilwww.jstor.org/
stable/4582632. Accessed October 28, 2017.
16. Dean HT, Arnold FA, Elvove E. Domestic water and dental caries: V.
Additional studies of the relation of fluoride domestic waters to dental
caries experience in 4,425 white children, aged 12 to 14 years, of 13 cities
in 4 states. Public Health Rep 1942;57(32):1155-79. Article at: https://
www.jstor.org/Stab/el4584182. Accessed October 28, 2017.
17. Cox GJ, Matuschak MC, Dixon SF, Dodds ML, Walker WE. Experimental
dental caries IV. Fluorine and its relation to dental caries. J Dent Res
1939;18(6):481-90.
18. Dean HT, Arnold Jr FA, Knutson JW. Studies on mass control of dental
caries through fluoridation of the public water supply. Public Health
Rep 1950;65(43):1403-8. Article at: https://www.ncbi.nlm.nih.govl
pubmed114781280. Accessed October 23, 2017.
19. Ast DB, Smith DJ, Wachs B, Cantwell KT. Newburgh -Kingston caries -
fluorine study: final report. J Am Dent Assoc 1956;52(3):290-325.
20. Brown HK, Poplove M. The Bra ntford-Samia-Stratford fluoridation caries
study: final survey, 1963. Med Sery J Can 1965;21(7):450-6.
21. National Research Council. Drinking water and health, Volume 1.
Washington, DC: The National Academies Press;1977. Available at: https://
www. nap. edu/catalog/1780/drinking-water-and-health -volume-1.
Accessed October 23, 2017.
22. National Research Council. Health effects of ingested fluoride.
Report of the Subcommittee on Health Effects of Ingested Fluoride.
Washington, DC: National Academy Press;1993. Available at: https://
www.nap.edu/catalog/2204/hea/th-effects-of-ingested-f/uoride.
Accessed October 23, 2017.
23. National Research Council of the National Academies. Division of
Earth and Life Studies. Board on Environmental Studies and Toxicology.
Committee on Fluoride in Drinking Water. Fluoride in drinking water:
a scientific review of EPA's standards. Washington, D.C: The National
Academies Press;2006. Available at: https://www.nap.edu/catalog/11571.
Accessed October 23, 2017.
24. Australian Government. National Health and Medical Research Council
(NHMRC). Information paper - water fluoridation: dental and other human
health outcomes. Canberra. 2017. Available at: https://www.nhmrc.gov.
au/guidelines-publications/eh43-0. Accessed October 23, 2017.
25. O'Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg -Gunn
AJ, Whelton H, Whitford GM. Fluoride and oral health. Community Dent
Health 2016;33(2):69-99. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/27352462. Accessed October 3, 2017.
26. American Water Works Association. Water fluoridation principles and
practices. AW WA Manual M4. Sixth edition. Denver. 2016.
27. Water Research Foundation. State of the science: community
water fluoridation. 2015. Available at: http://www.waterrf.org/
PublicReportLibrary/4641.pdf. Accessed October 1, 2017.
28. The Network for Public Health Law. Issue brief: community water
fluoridation. 2015. Available at: https://www.networkforphl.org/
resources_collection/2015/07/17/664/issue_brief community -water
fluoridation. Accessed October 2, 2017.
29. Sutton M, Kiersey R, Farragher L, Long J. Health effects of water
fluoridation: an evidence review. 2015. Ireland Health Research Board.
Available at: http://www.hrb.ie/publications/hrb-publication/
publications//674. Accessed October 28, 2017.
30. U.S. Department of Health and Human Services. Federal Panel on
Community Water Fluoridation. U.S. Public Health Service recommendation
for fluoride concentration in drinking water for the prevention of dental
caries. Public Health Rep 2015;130(4):318-331. Article at: https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC4547570. Accessed October 24, 2017.
31. Public Health England. Water fluoridation: health monitoring report
for England 2014. Available at: https://www.gov.uk/government/
publications/water-fluoridation -health -monitoring -report-for-
england-2014. Accessed October 28, 2017.
32. Royal Society of New Zealand and the Office of the Prime Minister's
Chief Science Advisor. Health effects of water fluoridation: a review of
the scientific evidence. 2014. Available at: https.Ilroyalsociety.org.nzl
what-we-dolour-expert-advice/all-expert-advice-papers/health-
effects-of-water-fluoridation. Accessed October 28, 2017.
33. U.S. Community Preventive Services Task Force. Oral Health: Preventing
Dental Caries (Cavities): Community Water Fluoridation. Task Force
finding and rationale statement. 2013. Available at: https://www.
thecommunityguide. org/findings/dental-caries-cavities-community-
water-fluoridation. Accessed October 24, 2017.
34. Scientific Committee on Health and Environmental Risks (SCHER) of the
European Commission. Critical review of any new evidence on the hazard
profile, health effects, and human exposure to fluoride and the fluoridating
agents of drinking water. 2011. Available at: http://ec.europa.eu/health/
scientific_committees/opinions_layman/fluoridation/en/1-3/index. htm.
Accessed October 24, 2017.
Introduction I Fluoridation Facts 11
back to agenda
35. Health Canada. Findings and recommendations of the fluoride expert panel 50. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in
(January 2007). 2008. Available at: http://www.hc-sc.gc.calewh-semt/
preventing caries in adults. J Dent Res 2007;86(5):410-415. Abstract at:
pubs/water-eau/2008- fluoride -fluorure/index-eng.php. Accessed
https://www.ncbi.nlm.nih.gov/pubmed/17452559. Accessed October
October 24, 2017.
24, 2017.
36. Australian Government. National Health and Medical Research Council.
51. Horowitz HS. The effectiveness of community water fluoridation in the
A systematic review of the efficacy and safety of fluoridation. Part A:
United States. J Public Health Dent 1996;56(5 Spec No):253-8. Abstract
review of methodology and results. 2007. Available at: https://www.
at: https://www.ncbi.nlm.nih.govlpubmedl9034970. Accessed October
nhmrc.gov.au/guidelines-publications/eh41. Accessed October 24, 2017.
24, 2017.
37. U.S. Department of Health and Human Services. For a healthy nation:
returns on investment in public health. Washington, DC: U.S. Government
Printing Office, August 1994. Available at: https://archive.org/details/
forhealthynation00unse. Accessed October 28, 2017.
38. U.S. Department of Health and Human Services. Oral health in America: a
report of the Surgeon General. Rockville, MD: U.S. Department of Health
and Human Services, National Institute of Dental and Craniofacial Research,
National Institutes of Health; 2000. Available at: https://profiles.nlm.
nih.gov/ps/retrieve/ResourceMetadata/NNBBJT Accessed October 28,
2017.
39. Burt BA. Fluoridation and social equity. J Public Health Dent 2002;62(4):195-
200. Abstract at: https://www.ncbi.nlm.nih.govlpubmed/12474623.
Accessed October 24, 2017.
40. Slade GD, Spencer AJ, Davies MJ, Stewart JF. Influence of exposure to
fluoridated water on socioeconomic inequalities in children's caries experience.
Community Dent Oral Epidemiol 1996;24(2):89-100. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/8654039. Accessed October 24, 2017.
41. Riley JC. Lennon MA. Ellwood RP. The effect of water fluoridation
and social inequalities on dental caries in 5-year-old children. Int J
Epidemiol 1999;28:300-5. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/10342695. Accessed October 24, 2017.
42. Jones CM, Worthington H. The relationship between water fluoridation and
socioeconomic deprivation on tooth decay in 5-year-old children. Br Dent
J 1999;186(8):397-400. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/10365462. Accessed October 24, 2017.
43. U.S. Department of Health and Human Services. A national call to action to
promote oral health. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease Control and Prevention,
National Institutes of Health, National Institute of Dental and Craniofacial
Research. NIH Publication No. 03-5303, May 2003. Available at: https://
www. nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/
nationalcalltoaction.htm. Accessed October 28, 2017.
44. Benjamin RM. Surgeon General's Perspectives. Oral health: the silent epidemic.
Public Health Reports 2010;126(2):158-9. Available at: https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC2821841. Accessed October 28, 2017.
45. Murthy VH. Surgeon General's Perspectives. Community water fluoridation:
one of CDC's "l0 Great Public Health Achievements Of The 20th Century."
Public Health Rep 2015;130(4):296-8. Article at: https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC4547574. Accessed October 28, 2017.
46. U.S. Department of Health and Human Services. Office of Disease
Prevention and Health Promotion. HealthyPeople.gov. Healthy People
2020. About healthy people. Available at: https://www.healthypeople.
gov/2020/About-Healthy-People. Accessed October 28, 2017.
47. U.S. Department of Health and Human Services. Office of Disease
Prevention and Health Promotion. HealthyPeople.gov. Healthy People
2020. Topics and Objectives. Oral health objectives. Available at: https://
www. healthypeople.govl2020/topics-objectivesltopicloral-health/
objectives. Accessed October 24, 2017.
48. Centers for Disease Control and Prevention. Community Water
Fluoridation. Fluoridation statistics. 2014. Available at: https://www.cdc.
gov/fluoridation/statistics/2014stats.htm. Accessed October 24, 2017.
49. Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans, Jr CA,
Griffin SO, Carande-Kulis VG. Task Force on Community Preventive
Services. Reviews of evidence on interventions to prevent dental caries,
oral and pharyngeal cancers, and sports -related craniofacial injuries. Am
J Prev Med 2002;230S):21-54. Abstract at: https://www.ncbi.nim.nih.
gov1pubmed112091093. Accessed October 24, 2017.
52. Buzalaf MAR, Pessan JP, Honorio HM, ten Cate MJ. Mechanisms of actions
of fluoride for caries control. In Buzalaf MAR (ed): Fluoride and the Oral
Environment. Monogr Oral Sci. Basel, Karger. 2011;22:97-114. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl2l70ll94. Accessed October
24, 2017.
53. Garcia Al. Caries incidence and costs of prevention programs. J Public
Health Dent 1989;49(5 Spec No):259-71. Abstract at: https://www.ncbi.
nlm.nih.gov1pubmed/2810223. Article at: https://deepblue.lib.umich.
edulhandlel202Z42166226. Accessed October 24, 2017.
54. Milgrom P, Reisine S. Oral health in the United States: the post -fluoride
generation. Annu Rev Public Health 2000;21:403-36. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/10884959. Accessed October 24, 2017.
55. American Dental Association Council on Access Prevention and
Interprofessional Relations. Caries diagnosis and risk assessment: a
review of preventive strategies and management. J Am Dent Assoc
1995;126(Suppl):1S-24S. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/7790681. Accessed October 28, 2017.
56. Mariri BP, Levy SM, Warren JJ, Bergus GR, Marshall TA, Broffitt B.
Medically administered antibiotics, dietary habits, fluoride intake and
dental caries experience in the primary dentition. Community Dent Oral
Epidemiol 2003;31(1):40-51. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/12542431. Accessed October 24, 2017.
57. Dye BA, Shenkin JD, Odgen CL, Marshall TA, Levy SM, Kanellis MJ.
The relationship between healthful eating practices and dental caries
in children aged 2-5 years in the United States, 1988-1994. J Am Dent
Assoc 2004;135(1):55-66. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed114959875. Accessed October 24, 2017.
58. Tinanoff N, Palmer CA. Dietary determinants of dental caries and
dietary recommendations for preschool children. J Public Health Dent
2000:60(3):197-206. Available at: https://www.ncbi.nim.nih.govl
pubmed/11109219. Accessed October 24, 2017.
59. Marshall TA. Chairside diet assessment of caries risk. J Am Dent Assoc
2009;140(6):670-4. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed119491162. Accessed October 24, 2017.
12 American Dental Association
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1. What is fluoride?
Answer.
Fluoride is a naturally occurring mineral that can
help prevent tooth decay.
Fact.
The element fluorine is abundant in the earth's crust
as a naturally occurring fluoride compound found in
rocks and soil? As ground water moves through the
earth, it passes over rock formations and dissolves
the fluoride minerals that are present, releasing
fluoride ions that are naturally occurring fluoride in
the rocks. This increases the fluoride content of the
water. The concentration of fluoride in ground water
(e.g., wells, springs) varies according to such factors
as the depth at which the water is found and the
quantity of fluoride -bearing minerals in the area.
Fluoride is present at varied concentrations in all
water sources including rainwater and the oceans.
For example, the oceans' fluoride levels range from
1.2 to 1.4 mg/L.z In the United States, the natural
level of fluoride in ground water varies from very low
levels to over 4 mg/L.3 In comparison, the fluoride
concentrations in surface water sources such as
lakes and rivers is very low. For example, the water
analysis completed by the city of Chicago for the
year 2016 lists the range for Lake Michigan's natural
fluoride level as 0.11 to 0.13 mg/L.4
2. How does fluoride help prevent tooth
decay?
Answer.
Tooth decay begins when the outer layer of a tooth
loses some of its minerals due to acid produced
by bacteria in dental plaque breaking down the
sugars that we eat. Fluoride protects teeth by
helping to prevent the loss of these minerals and
by restoring them with a fluoride -containing
mineral that is more resistant to acid attacks. In
other words, fluoride protects teeth by reducing
demineralization and enhancing remineralization.
Fluoride also works to hinder bacterial activity
necessary for the formation of tooth decay.
Fact.
One of fluoride's main mechanism of action is its
ability to prevent or delay the loss of minerals from
teeth.s•6 Cavities start to form when minerals are lost
due to acid attacks from bacteria in dental plaque (a
soft, sticky film that is constantly forming on teeth).
Bacteria grow rapidly by feeding on the sugars and
refined carbohydrates that we consume. This process
of losing minerals is called demineralization.
Fluoride's second mechanism of action is called
remineralization, which is the reversal of this
demineralization process.6,7 Teeth gain back
the minerals lost during acid attacks through
remineralization but with an important difference.
Some of the hydroxyapatatite crystal lost is replaced
with fluorapatite. This fluoride -rich replacement
mineral is even more resistant to acid attacks than
the original tooth surface.6
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Benefits I Fluoridation Facts 13
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Studies indicate fluoride has a third mechanism
of action that hinders the ability of bacteria to
metabolize carbohydrates and produce acids.'
It can also hinder the ability of the bacteria to
stick to the tooth surface."
Fluoride and minerals, including calcium and
phosphate, are present in saliva6•8 and are stored in
dental plaque. To halt the formation of tooth decay
or rebuild tooth surfaces, fluoride must be constantly
present in low concentrations in saliva and plaque.6
Frequent exposure to small amounts of fluoride, such
as that which occurs when drinking fluoridated water,
helps to maintain the reservoir of available fluoride
in saliva and plaque to resist demineralization and
enhance remineralization.6.9 In other words, drinking
fluoridated water provides the right amount of
fluoride at the right place at the right time. Fluoride in
water and water -based beverages is consumed many
times during the day, providing frequent contact
with tooth structures and making fluoride available
to fluoride reservoirs in the mouth. This helps explain
why fluoride at the low levels found in fluoridated
water helps to prevent tooth decay.6
Additionally, studies have concluded that fluoride
ingested during tooth formation becomes
incorporated into the tooth structure making
the teeth more resistant to acid attacks and
demineralization 10-14 In particular, this pre -eruptive
exposure to fluoride, before the teeth come into the
mouth during childhood, can play a significant role
in preventing tooth decay in the pits and fissures of
the chewing surfaces, particularly of molars.6,11,16
Sources of fluorides in the United States that provide
this pre -eruptive effect include fluoridated water
and dietary fluoride supplements as well as fluoride
present in foods and beverages. Additionally, young
children often swallow substantial percentages
of the fluoride toothpaste and other fluoride -
containing dental products which adds to their intake
of fluoride. Originally, it was believed that fluoride's
action was exclusively pre -eruptive, meaning the
benefit occurred only during tooth formation, but
by the mid-1950s there was growing evidence
of the importance of fluoride's important roles in
demineralization and remineralization 11
Pre -eruptive effects are sometimes called systemic,
while post -eruptive effects are called topical. These
terms refer to different things. Pre- and post -eruptive
refer to the timing of fluoride benefits while systemic
and topical refer to the mode of administration or
source of fluoride. Defining the effects of fluoride
from a specific source as solely systemic or topical is
not entirely accurate. For example, water fluoridation
provides both a systemic (during tooth development)
and topical effect (at the time of ingestion
strengthening the outside of the tooth).
Today it is understood that the maximum reduction in
tooth decay occurs when both effects are combined,
that is when fluoride has been incorporated into
the tooth during formation and when it is available
at the tooth surface during demineralization and
remineralization. Water fluoridation works in both
ways to prevent tooth decay.8.11.11,11,16
Today it is understood that the maximum
reduction in tooth decoy occurs when both
effects ore combined, that is when fluoride
has been incorporated into the tooth during
formation and when it is available of the
tooth surface during demineralization and
reminerolizotion. Water fluoridation works in
both ways to prevent tooth decoy.
3. What is water fluoridation?
Answer.
Water fluoridation is the controlled adjustment of
the natural fluoride concentration in community
water supplies to the concentration recommended
for optimal dental health. Fluoridation helps prevent
tooth decay in children and adults.
Fact.
In 2015, the U.S. Department of Health and Human
Services (HHS), using the best available science,
established the recommended concentration for
fluoride in the water in the United States at 0.7
mg/L 17 This level effectively reduces tooth decay
while minimizing dental fluorosis.
The level of fluoride in water is measured in milligrams
per liter (mg/L) or parts per million (ppm). When
referring to water, a concentration in milligrams per
liter is identical to parts per million and the notations
can be used interchangeably. Thus, 0.7 mg/L of
fluoride in water is identical to 0.7 ppm. The preferred
notation is milligrams per liter.
14 American Dental Association
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At 0.7 mg/L, there are seven -tenths of one part
of fluoride mixed with 999,999.3 parts of water.
While not exact, the following comparisons can be of
assistance in comprehending 0.7 mg/L:
• 1 inch in approximately 23 miles
• 1 minute in approximately 1000 days
• 1 cent in approximately $14,000.00
• 1 seat in more than 34 Wrigley Field baseball
parks (seating capacity 41,268)
The following terms and definitions are used in this
publication:
Community water fluoridation is the controlled
adjustment of the natural fluoride concentration
in water up to 0.7 mg/L, the level recommended
for optimal dental health. Other terms used
interchangeably are water fluoridation, fluoridation
and optimally fluoridated water. Optimal levels of
fluoride can be present in the water naturally or by
adjusted means.
• Sub -optimally fluoridated water is water
that naturally contains less than the optimal level
(below 0.7 mg/L) of fluoride. Other terms used are
nonfluoridated water and fluoride -deficient water.
6 Additional informotion on this topic con be found
in this Section, Question 6.
The level of fluoride in water is measured in
milligrams per liter (mg/L) or parts per million
(ppm). When referring to water, a concentration
in milligrams per liter is identical to parts
per million and the notations can be used
interchangeably. Thus, 0.7 mg/L of fluoride in
water is identical to 0.7 ppm. The preferred
notation is milligrams per liter.
4. How much fluoride is in your water?
Answer.
If your water comes from a public/community water
supply, the options to learn the fluoride level of the
water include contacting the local water supplier or
the local/county/state health department, reviewing
the Consumer Confidence Report (CCR) issued by
your local water supplier, and using the Centers for
Disease Control and Prevention's internet based
"My Water's Fluoride." If your water source is a
private well, it will need to be tested and the results
obtained from a certified laboratory.
Fact.
The fluoride content of the local public or community
water system can be obtained by contacting the
local water supplier or the local/county/state health
department. The name of your water system might
not be the same as the name of your community.
In 1999, the U.S. Environmental Protection Agency
(EPA) began requiring water suppliers to make annual
drinking water quality reports accessible to their
customers. Available prior to July 1 each year for the
preceding calendar year, these Consumer Confidence
Reports (CCRs), or Water Quality Reports; a can be
mailed to customers, placed in the local newspaper or
made available through the internet. To obtain a copy
of the report, contact the local water supplier. If the
name of the community water system is unknown,
contact the local health department.
There are two sites on the internet that supply
information on water quality of community water
systems. The online source for Water Quality
Reports or CCRs is the EPA website19 at: https.11
ofmpub.epa.gov/apex/safewater/f?p=136:102.
Additionally, the Centers for Disease Control and
Prevention's (CDC) fluoridation website, "My Water's
Fluoride,"20 is available at: https.11nccd.cdc.govl
DOH_MWF/Default/Default.aspx. The website
allows consumers in currently participating states
to learn the fluoridation status of their water system.
It also provides information on the number of people
served by the water system, the water source, and
if the water system is naturally fluoridated or
adjusts the fluoride level in the water supply.20
The EPA does not have the authority to regulate private
drinking water wells. However, the EPA recommends
that private well water be tested once a year.21 For
Benefits Fluoridation Facts 15
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the most accurate results, a state certified laboratory
that conducts drinking water tests should be used
for fluoride testing. For a list of state certified
laboratories, contact the local, county or state
water/health department.
The EPA does not specifically recommend testing
private wells for the level of fluoride. However, if
a household with a private well has children under
16 years of age, their health professionals will need
to know the fluoride level of the well water prior
to consideration of prescription of dietary fluoride
supplements$ or to counsel patients about alternative
water sources to reduce the risk of fluorosis if the
natural fluoride levels are above 2 mg/L.
Dietary fluoride supplements (tablets, drops or
lozenges) are available only by prescription and are
intended for use by children ages six months to 16
years living in nonfluoridated areas and at high risk
of developing tooth decay. Your dentist or physician
can prescribe the correct dosage."
6 Additional information on this topic can be found
in this Section, Question 12 and in the Safety Section,
Questions 21, 27, 28 and 29.
5. What additives are used to fluoridate
water supplies in the United States?
Answer.
Sodium fluoride, sodium fluorosilicate and
fluorosilicic acid are the three additives approved
for use in community water fluoridation in
the United States. Sodium fluorosilicate and
fluorosilicic acid are sometimes referred to as
silicofluoride additives.
Fact.
The three basic additives used to fluoridate water
in the United States are: 1) sodium fluoride which is
a white, odorless material available either as a
powder or crystals; 2) sodium fluorosilicate which is
a white or yellow -white, odorless crystalline material
and 3) fluorosilicic acid which is a white to straw-
colored liquid.22
Water fluoridation began in the U.S. in 1945 with
the use of sodium fluoride; the use of silicofluorides
began in 1946 and by 1951, they were the most
commonly used additives.23 First used in the late
1940s, fluorosilicic acid is currently the most
commonly used additive to fluoridate communities
in the United States.24 To ensure the public's safety,
regardless of where the additives are manufactured,
they should meet safety standards for water
treatment in the U.S." Specifically, additives used
in water fluoridation should meet standards of the
American Water Works Association (AWWA). With
respect to NSF/ANSI certification, fluoride additives
are considered no different than other water
additives. Fluoride additives, like any other water
additive should also meet NSF/ANSI Standards.22 In
the United States, the authority to regulate products
for use in drinking water, including additives used
to fluoridate community water systems, rests with
individual states. In 2013, AWWA reported that 47
states had adopted the NSF/ANSI Standard 60 which
specifies the product quality with validation supplied
by independent certification entities.22
To ensure the public's safety, regardless of
where the additives ore manufactured, they
should meet safety standards for water
treatment in the U.S.
Additional information on the topic of fluoride additives
can be found in the Fluoridation Practice section of
this publication and at the CDC's fluoridation website,
"Water Operators and Engineers" at https://www.cdc.
gov/fluoridation/engineering/index. htm.
6. Is there a difference in the effectiveness
between naturally occurring fluoridated
water (at optimal fluoride levels) and water
that has fluoride added to reach the
optimal level?
Answer.
No. The dental benefits of optimally fluoridated
water occur regardless of the fluoride's source.
Fact.
Fluoride is present in water as "ions" or electrically -
charged atoms.25 These ions are the same whether
acquired by water as it seeps through rocks and
sand or added to the water supply under carefully
controlled conditions.
16 American Dental Association
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It has been observed that the major features of
human fluoride metabolism are not affected by the
three fluoride additives used in community water
fluoridation nor are they affected by whether the
fluoride is present naturally or added to drinking
water.26 In more simple terms, there is no difference
chemically between natural and adjusted fluoridation
When fluoride is added under controlled conditions
to fluoride -deficient water, the dental benefits are
the same as those obtained from naturally fluoridated
water. Fluoridation is merely an increase of the level of
the naturally occurring fluoride present in all drinking
water sources to the level recommended for optimal
dental health.
Fluoridation is merely on increase of the level
of the naturally occurring fluoride present
in oll drinking water sources to the level
recommended for optimal dental health.
For example, a fluoridation study conducted in the
Ontario, Canada, communities of Brantford (optimally
fluoridated by adjustment), Stratford (optimally
fluoridated naturally) and Sarnia (fluoride -deficient),
revealed much lower decay rates in both Brantford
and Stratford as compared to nonfluoridated Sarnia.
There was no observable difference in the decay -
reducing effect between the naturally occurring
fluoride and adjusted fluoride concentration water
supplies, proving that dental benefits were similar
regardless of the source of fluoride.27
Some individuals use the term "artificial fluoridation"
to imply that the process of water fluoridation is
unnatural and that it delivers a foreign substance into
a water supply when, in fact, all water sources contain
some fluoride. The fluoride ion released in water is the
same regardless of the source25 and is metabolized
(processed) by the body in the same way no matter
what the source.26 Community water fluoridation is
a natural way to improve oral health.
7. Is water fluoridation effective in helping
to prevent tooth decay?
Answer.
Yes. According to the best available scientific evidence,
community water fluoridation is an effective public
health measure for preventing, and in some cases,
reversing tooth decay, in children, adolescents and
adults. With hundreds of studies published in peer -
reviewed, scientific journals, fluoridation is one of
the most studied public health measures in history
and it continues to be studied today.
Fact.
The effectiveness of fluoride in drinking water to
prevent tooth decay has been documented in the
scientific literature for over 70 years. Before the
first community fluoridation program began in 1945,
epidemiologic data from the 1930s and 1940s were
collected and analyzed.28-30 What began as research
to learn what caused "Colorado Brown Stain" (dental
fluorosis) led to the discovery of strikingly low tooth
decay rates associated with fluoride in drinking water
at approximately 1 ppm (mg/Q. Figure 2 shows the
results of early research by Dr. H. Trendley Dean noting
the relationship between children's experience with
tooth decay (solid line), dental fluorosis (dotted line)
and the fluoride concentration in drinking water.28,29
6 Additional information on this topic con be found
in the Introduction Section.
s
7
6
5
4
3
2
0
0 1 2 3
Fluoride Concentration in Water (ppm)
3
7
x
a
v
c
0
1 0
2
LL
6J
Benefits
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Fluoridation Facts 17
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Since that time, hundreds of studies have been done,
including a number of systematic reviews which
continue to show fluoride's effectiveness in helping
to prevent tooth decay. A systematic review is an
analysis of studies that identifies and evaluates all of
the evidence with which to answer a specific, narrowly
focused question. It entails a systematic and unbiased
review process that locates, assesses and combines
high quality evidence from a collection of scientific
studies to obtain a comprehensive, valid and reliable
review on a specific topic. Systematic reviews provide
the highest level of scientific evidence about a specific
research question. Below is a discussion of major
reviews of community water fluoridation, beginning
with two systematic reviews published in 2017
and 2013, respectively, demonstrating that water
fluoridation is effective in reducing tooth decay.
On November 9, 2017, the Australian Government's
National Health and Medical Research Council
(NHMRC) released the NHMRC Public Statement
2017 — Water Fluoridation and Human Health
in Australia" recommending community water
fluoridation as a safe, effective and ethical way to help
reduce tooth decay. Based on a comprehensive review
of the evidence, published in 2016, and the translation
of that evidence into the NHMRC Information Paper —
Water Fluoridation. Dental and Other Human Health
Outcomes,32 published in 2017, the Public Statement
notes that the NHMRC found that water fluoridation
reduces tooth decay by 26% to 44% in children and
adolescents, and by 27% in adults. Additionally, it notes
that recent Australian research found that access to
fluoridated water from an early age is associated with
less tooth decay in adults. The Statement notes that
NHMRC supports Australian states and territories
fluoridating their drinking water supplies within the
range of 0.6 to 1.1 mg/L.31
Established by the U.S. Department of Health and
Human Services in 1996, the Community Preventive
Services Task Force develops and disseminates
guidance on which community -based health
promotion and disease prevention intervention
approaches work, and which do not work, based
on available scientific evidence. The Task Force
issues findings based on systematic reviews of
effectiveness and economic evidence. The Guide to
Community Preventive Services ("The Community
Guide") is a collection of evidence -based findings
of the Community Preventive Services Task Force
and is designed to assist decision makers in selecting
interventions to improve health and prevent
disease."
The Community Guide reviews are designed to
answer three questions:
1. What has worked for others and how well?
2. What might this intervention approach cost, and
what am I likely to achieve through my investment?
3. What are the evidence gaps?33
In a 2013 update of the evidence, the Community
Preventive Services Task Force continued to
recommend community water fluoridation to
reduce tooth decay, noting that cavities decreased
when fluoridation was implemented and that
cavities increased when fluoridation was stopped,
as compared to communities that continued
fluoridation."
A summary of systematic reviews by the Oral
Health Services Research Centre at the University
Dental School in Cork, Ireland, published in 2009,
reviewed results from three systematic reviews, all
of which were published between 2000 and 2007.
The summary of results concluded that the best
available scientific evidence demonstrated that water
fluoridation was an effective community -based
method to prevent tooth decay, especially for the
disadvantaged who bear the greatest burden of
disease."
A meta -analysis (a type of systematic review that
seeks to determine a statistical estimate of an
overall benefit based on the results of the collection
of studies included in the review), which was
published in 2007 in the Journal of Dental Research,
demonstrated the effectiveness of water fluoridation
for preventing tooth decay in adults. Twenty studies
representing over 13,500 participants were included
in the analysis. Of the 20 studies, nine examined
the effectiveness of water fluoridation. The review
of these studies found that fluoridation prevents
approximately 27% of tooth decay in adults.36
Besides systematic reviews, significant additional
studies conducted since the initiation of water
fluoridation in 1945, also have demonstrated the
effectiveness of water fluoridation in reducing the
occurrence of tooth decay.
18 American Dental Association
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• In Grand Rapids, Michigan, the first city in the
world to fluoridate its water supply, a 15-year
landmark study showed that children who consumed
fluoridated water from birth had 50-63% less
tooth decay than children who had been examined
during the original baseline survey completed in
nonfluoridated Muskegon, Michigan.31
In 1985, the National Preventive Dentistry
Demonstration Program38 analyzed various types
and combinations of school -based preventive dental
services to determine the cost and effectiveness
of these types of prevention programs. Ten sites
from across the nation were selected. Five of the
sites had fluoridated water and five did not. Over
20,000 second and fifth graders participated in
the study over a period of four years. Students
were examined and assigned by site to one or a
combination of the following groups:
• biweekly in class brushing and flossing plus a
home supply of fluoride toothpaste and dental
health lessons (ten per year);
• in -class daily fluoride tablets (in nonfluoridated
areas);
• in -school weekly fluoride mouthrinsing;
• in -school professionally applied topical fluoride;
• in -school professionally applied dental sealants,
and
0 a control.18
After four years, approximately 50% of the original
students were examined again. The study affirmed
the value and effectiveness of community water
fluoridation. At the sites where the community
water was fluoridated, students had substantially
fewer cavities, as compared to those sites without
fluoridated water where the same preventive measures
were implemented. In addition, while sealants were
determined to be an effective prevention method,
the cost of a sealant program was substantially more
than the cost of fluoridating the community water,
confirming fluoridation as the most cost-effective
preventive option.31
In another review of studies conducted from
1976 through 1987 and published in 1989,39
data for different age groups were separated
into categories by the types of teeth present in
the mouth. The results demonstrated a 30-60%
reduction in tooth decay in primary teeth, a 20-
40% reduction in the mixed dentition (having both
baby and adult teeth) and a 15%-35% reduction
in the permanent dentition (adults and seniors) for
those living in fluoridated communities.39
In the United States, an epidemiological survey of
nearly 40,000 schoolchildren was completed in
1987.41 Nearly 50% of the children aged 5 to 17
years who participated in the study were decay
free in their permanent teeth, which was a major
change from a similar survey conducted in 1980
in which approximately 37% were decay free.
This dramatic decline in decay rates was attributed
primarily to the widespread use of fluoride in
community water supplies, toothpastes, dietary
fluoride supplements and mouthrinses. Although
decay rates had declined overall, data also
revealed that the decay rate was 25% lower in
children with continuous residence in fluoridated
communities when the data were adjusted
to control for exposure to dietary fluoride
supplements and topical fluoride treatments.40
In 1993, the results of 113 studies in 23 countries
(over half of the studies were from the U.S.) were
compiled and analyzed.41 This review provided
effectiveness data for 66 studies of primary teeth
and 86 studies of permanent teeth. The analysis
of the studies demonstrated a 40-49% decay
reduction for primary (baby) teeth and a 50-59%
decay reduction for permanent (adult) teeth for
those living in fluoridated communities.41
A comprehensive analysis of the first 50 years of
community water fluoridation in the United States
concluded that "Community water fluoridation
is one of the most successful public health
disease prevention programs ever initiated"42
While noting that the difference in tooth decay
between optimally fluoridated communities and
fluoride -deficient communities was smaller than
in the early days of fluoridation, largely due to
additional sources of fluoride, the difference was
still significant and the benefits for adults should be
emphasized. The report ended by noting that water
fluoridation is a near -ideal public health measure
whose benefits can transcend racial, ethnic,
socioeconomic and regional differences.42
The systematic reviews and studies noted above
provide science -based evidence that, for more than
70 years, fluoridation has been effective in helping
to prevent tooth decay.
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Benefits I Fluoridation Facts 19
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8. With other sources of fluoride now
available, is water fluoridation still an effective
method for preventing tooth decay?
Answer.
Yes. Even in an era with widespread availability
of fluoride from other sources, studies show
that community water fluoridation prevents at
least 25% of tooth decay in children and adults
throughout the life span.
Fact.
During the 1940s, studies demonstrated that
children in communities with optimally fluoridated
drinking water had reductions in tooth decay rates
of approximately 40% to 60% as compared to those
living in nonfluoridated communities.17,44 At that time,
drinking water was the only source of fluoride other
than fluoride that occurred naturally in foods.
Increase in the Number of Sources of Fluoride
Fluoride is available today from a number of sources
including water, beverages, food, dental products
(toothpaste, rinses, professionally applied fluoride
foams, gels and varnish and dietary supplements.)"
As a result of the widespread availability of these
various sources of fluoride, the difference between
decay rates in fluoridated areas and nonfluoridated
areas is somewhat less than several decades ago, yet
it is still significant?7 Studies show that community
water fluoridation prevents at least 25% of tooth
decay in children and adults throughout the life
span.16,41 The benefits of fluoridation are extended
to everyone in a community where they live, work,
attend school or play — and it does not require a
change of behavior or access to dental care.
The benefits of fluoridation are extended to
everyone in a community where they live, work,
attend school or play — and it does not require
a change of behavior or access to dental care.
...............................................................................
The Diffusion or Halo Effect
The diffusion or "halo' effect occurs because foods
and beverages processed in optimally fluoridated
cities generally contain higher levels of fluoride than
those processed in nonfluoridated communities. This
exposure to fluoride in nonfluoridated areas through
the diffusion effect lessens the differences in the
amount of tooth decay between communities.39,42,43
The best available national data demonstrate that
the failure to account for the diffusion effect results
in an underestimation of the total benefit of water
fluoridation especially in areas where large quantities
of fluoridated beverage and food products are
brought into nonfluoridated communities.46
Exposure to Fluoridation over the Life Span
Another factor in the difference between decay
rates in fluoridated areas and nonfluoridated areas
is the high geographic mobility of our society. On a
day-to-day basis, many individuals may reside in a
nonfluoridated community but spend a significant
part of their day in a fluoridated community at work,
school or daycare. Additionally, over their lifetime,
people tend to move and reside in a number of
communities, some with optimally fluoridated water
and some without. This mobility makes it increasingly
difficult to study large numbers of people who
have spent their entire lives in one (fluoridated or
nonfluoridated) community.39 It also means that many
individuals receive the benefit of fluoridation for at
least some part of their lives. For children who have
resided in fluoridated communities their entire lives,
studies demonstrated they had less tooth decay than
children who never lived in fluoridated communities.40
Despite fluoride from a number of other sources,
the "halo effect" and the mobility of today's society,
studies show that community water fluoridation
prevents at least 25% of tooth decay in children
and adults throughout the life span.16,41
20 American Dental Association
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9. What happens if water fluoridation is
discontinued?
Answer.
Tooth decay can be expected to increase if water
fluoridation in a community is discontinued even
if topical products such as fluoride toothpaste and
fluoride mouthrinses are widely used.
Fact.
In 2013, using an updated systematic review, the
Community Preventive Services Task Force, established
by the U.S. Department of Health and Human Services,
continued to recommend community water fluoridation
to reduce tooth decay, noting that cavities decreased
when fluoridation was implemented and that cavities
increased when fluoridation was stopped, as compared
to communities that continued fluoridation.34 This
confirmed the Task Force's earlier systematic review
published in 200241 which also noted an increase in
tooth decay when fluoridation was halted (a median
17.9% increase in tooth decay during 6 to 10 years of
follow-up).
Historical Studies Noting an Increase in Tooth
Decay after Discontinuation of Fluoridation
Antigo, Wisconsin, began water fluoridation in
June 1949 and ceased adding fluoride to its water
in November 1960. After five and one-half years
without optimal levels of fluoride, second grade
children had a 200% increase in tooth decay
experience, fourth graders a 70% increase and sixth
graders a 91 % increase in decay experience compared
with the levels of those of the same ages in 1960.
Residents of Antigo re -instituted water fluoridation in
October 1965 on the basis of the severe deterioration
of their children's oral health.47
A study that reported the relationship between
fluoridated water and tooth decay prevalence focused
on the city of Galesburg, Illinois, a community whose
public water supply contained naturally occurring
fluoride at 2.2 mg/L. In 1959, Galesburg switched
its community water source to the Mississippi
River. This alternative water source provided the
citizens of Galesburg a sub -optimal level of fluoride
at approximately 0.1 mg/L. In the period of time
between a baseline survey conducted in 1958 and a
new survey conducted in 1961, data revealed a 10%
decrease in the percentage of decay free 14-year-
olds (oldest group observed), and a 38% increase
in mean tooth decay experience. Two years later, in
1961, the water was fluoridated at the recommended
level of 1.0 mg/L.48
Because of a government decision in 1979,
fluoridation in the northern Scotland town of Wick
was discontinued after eight years. The water was
returned to its sub -optimal, naturally occurring
fluoride level of 0.02 mg/L. Data collected to
monitor the oral health of Wick children clearly
demonstrated a negative health effect from the
discontinuation of water fluoridation. Five years after
the cessation of water fluoridation, decay in primary
(baby teeth) had increased 27%. This increase in
decay occurred during a period when there had been
a reported overall reduction in decay nationally and
when fluoride toothpaste had been widely adopted.
These data suggest that decay levels in children
can be expected to rise where water fluoridation
is interrupted or terminated, even when topical
fluoride products are widely used.41
In a similar evaluation, the prevalence of tooth
decay in 5- and 10-year-old children in Stranraer,
Scotland, increased after the discontinuation of
water fluoridation. This increase in tooth decay was
estimated to result in a 115% increase in the mean
cost of restorative dental treatment for decay. These
data support the important role water fluoridation
plays in the reduction of tooth decay.so
Historical Studies and Factors Noting No
Increase In Tooth Decay after Discontinuation
of Fluoridation
There have been several studies from outside the
United States that have not reported an increase
in tooth decay following the discontinuation of
fluoridation. In all of these, the discontinuation of
fluoridation coincided with the implementation of
other measures to prevent tooth decay.
In La Salud, Cuba, a study on tooth decay in children
indicated that the rate of tooth decay did not increase
after fluoridation was stopped in 1990. However,
at the time fluoridation was discontinued a new
preventive fluoride program was initiated where all
children received fluoride mouthrinses on a regular
basis and children two to five years of age received
fluoride varnish once or twice a year."
In Finland, a longitudinal study in Kuopio (fluoridated
from 1959 to 1992) and Jyvaskyla (with low levels
of natural fluoride) showed little difference in
...............................................................................................................................................................
Benefits I Fluoridation Facts 21
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decay rates between the two communities that are
extremely similar in terms of ethnic background and
social structure.52 This was attributed to a number
of factors. The dental programs exposed the Finnish
children to intense topical fluoride regimes and dental
sealant programs. Virtually all children and adolescents
used the government -sponsored, comprehensive, free
dental care. As a result, the effect of water fluoridation
appeared minimal. Because of this unique set of
factors, it was concluded that these results could not
be replicated in countries with less intensive preventive
dental care programs."
No significant decrease in tooth decay was seen after
fluoridation was discontinued in 1990 in Chemniz and
Plauen, located in what was formerly East Germany."
The intervening factors in these communities
include improvements in attitudes toward oral health
behaviors, and broader availability and increased use
of other preventive measures including fluoridated
salt, fluoride toothpaste and dental sealants."
A similar situation was reported from the Netherlands.
A study was conducted of 15-year-old children
in Tiel (fluoridated 1953 to 1973) and Culemborg
(nonfluoridated) comparing tooth decay rates from
a baseline in 1968 through 1988. The lower tooth
decay rate in Tiel after the cessation of fluoridation
was attributed in part to the initiation of a dental
health education program, free dietary fluoride
supplements and a greater use of professionally
applied topical fluorides.14
In the preceding examples, communities that
discontinued fluoridation either found higher tooth
decay rates in their children or a lack of an increase
that could be attributed to the availability and
use of free dental services for all children or the
implementation of wide -spread decay prevention
programs that require significant professional and
administrative support and are less cost-effective
than fluoridation.
10. Is tooth decay still a serious problem
in the United States?
Answer.
Yes. Tooth decay is an infectious disease that
continues to be a significant oral health problem.
Fact.
Good oral health is often taken for granted by many
people in the U.S. Yet, while largely preventable, tooth
decay, cavities or dental caries (a term used by health
professionals) remains a common, debilitating, chronic
condition for many children and adults.
Tooth decay begins with a weakening and/or
breakdown (loss of minerals) of the enamel (the
hard outer layer of teeth) caused by acids produced
by bacteria that live in plaque. Dental plaque is a
soft, sticky film that is constantly forming on teeth.
Eating foods or drinking beverages that contain
sugars or other refined carbohydrates allow the
bacteria in the plaque to produce acids that attack
the enamel. The plaque helps to keep these acids in
contact with the tooth surface and demineralization
(loss of mineral) occurs. After repeated acid attacks,
the enamel can breakdown creating a cavity. Left
unchecked, bacteria and acid can penetrate the
dentin (the next, inner layer of teeth) and then finally
the pulp, which contains nerves and blood vessels.
Once the bacteria enter the pulp, the tooth becomes
infected (abscessed) and, without treatment, the
infection can progress and travel into the surrounding
tissues. The infection can enter the bloodstream and
potentially spread the infection to other parts of the
body which, in rare cases, becomes life -threatening.
6 Additional information on this topic con be found
in this Section, Question 2.
Tooth decay can negatively affect an individual's
quality of life and ability to succeed. Tooth decay
can cause pain — pain that can affect how we eat,
speak, smile, learn at school or succeed at work.
Children with cavities often miss more school and
receive lower grades than children who are cavity-
free.ss More than $6 billion of productivity is lost
each year in the U.S, because people miss work to
get dental care.16
22 American Dental Association
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While cavities are often thought of as a problem for
children, adults in the U.S. are keeping their teeth
longer (partially due exposure to fluoridation) and
this increased retention of teeth means more adults
are at risk for cavities — especially decay of exposed
root surfaces.17,18 Tooth root surfaces are covered
with cementum (a softer surface than the enamel)
and so are susceptible to decay. As Baby Boomers
age, root decay experience is expected to increase in
future years possibly to the point where older adults
experience similar or higher levels of new cavities
than do school children.17
6 Additional information on this topic can be found
in this Section, Question 11.
Additionally, once an individual has a cavity repaired
with a filling (restoration), that filling can break down
over time especially around the edges. These rough
edges (or margins) can harbor bacteria that start the
cavity process over again or leak which allows the
bacteria to enter the tooth below the existing filling.
These fillings often need to be replaced — sometimes
multiple times over decades — each time growing
larger to the point where the best restoration for the
tooth is a crown that covers the entire tooth surface.
Preventing cavities and remineralizing teeth at the
earliest stages of decay is very important not only in
saving tooth structure but also in reducing the cost
for dental care. Community water fluoridation is an
effective public health measure that is a cost -saving
and cost-effective approach to preventing tooth decay
6 Additional information on this topic can be found
in the Cost Section, Question 68.
Oral health disparities exist in the United States and
have been documented through extensive studies
and reviews.59-61 Despite the fact that millions of
people in the U.S. enjoy good dental health, disparities
exist for many racial and ethnic groups, as well as
by socioeconomic status, sex, age and geographic
location.61 Water fluoridation helps to reduce the
disparities in oral health at the community level as
it benefits all residents served by community water
supplies. In his 2001 Statement on Community Water
Fluoridation'61 former Surgeon General Dr. David
Satcher noted:
...community water fluoridation continues to be
the most cost-effective, practical and safe means
for reducing and controlling the occurrence of
dental decay in a community... water fluoridation is
a powerful strategy in efforts to eliminate health
disparities among populations.61
6 Additional information on this topic con be found
in the Public Policy Section, Question 59.
Today, the major focus for achieving and maintaining
oral health is on prevention. Established by the
U.S. Department of Health and Human Services,
Healthy People 202064 provides a science -based,
comprehensive set of ambitious, yet achievable,
ten-year national objectives for improving the
health of the public. Included under oral health is
an objective to expand the fluoridation of public
water supplies. Objective 13 states that at least
79.6% of the U.S. population served by community
water systems should be receiving the benefits of
optimally fluoridated water by the year 2020.61 Data
from the CDC indicate that, in 2014, 74.4% of the
U.S. population on public water systems, or a total
of 211.4 million people, had access to fluoridated
water.66 Conversely, approximately 25% or more than
72.7 million people on public water systems do not
receive the decay preventing benefits of fluoridation.
...............................................................................
While cavities are often thought of as a
problem for children, adults in the U.S. are
keeping their teeth longer (partially due
exposure to fluoridation) and this increased
retention of teeth means more adults are at
risk for cavities — especially decay of exposed
root surfaces.
...............................................................................
...............................................................................................................................................................
Benefits I Fluoridation Facts 23
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11. Do adults benefit from fluoridation?
Answer.
Yes. Fluoridation plays a protective role against
tooth decay throughout life, benefiting both
children and adults.
Fact.
While the early fluoridation trials were not designed
to study the possible benefits fluoridation might have
for adults, by the mid-1950s, it became evident from
the results of the first fluoridation trial in Grand Rapids,
Michigan, that the beneficial effects of fluoridation
were not confined to children drinking the fluoridated
water from birth. The fact that a reduction in tooth
decay was observed for teeth which had already been
calcified or were erupted when fluoridation was started
indicated that a beneficial effect could be gained by
older age groups.67, 68 Today it is understood that
the maximum reduction in tooth decay occurs when
fluoride has been incorporated into the tooth during
formation and when it also is available at the tooth
surface during demineralization and remineralization.
Fluoridation works in both ways to prevent tooth
decay.',' 2,14,16,17
Fluoride and minerals, including calcium and phosphate,
are present in saliva 7,9 and are stored in dental plaque
(a soft, sticky film that is constantly forming on
teeth). To halt the formation of tooth decay or rebuild
tooth surfaces, fluoride must be constantly present
in low concentrations in saliva and plaque' Frequent
exposure to small amounts of fluoride, such as occurs
when drinking fluoridated water, helps to maintain the
reservoir of available fluoride in saliva and plaque to
resist demineralization and enhance remineralization 7,10
In other words, drinking fluoridated water provides the
right amount of fluoride at the right place at the right
time. Fluoride in water and water -based beverages
is consumed many times during the day, providing
frequent contact with tooth structures and making
fluoride available to fluoride reservoirs in the mouth.
This helps explain why fluoride at the low levels found
in fluoridated water helps to prevent tooth decay in
teeth after they have erupted 7
6 Additional information on this topic can be found in
this Section, Question 2.
While teeth already present in the mouth when
exposure to water fluoridation begins receive the
benefit of decay protection, studies have indicated
that adults who have consumed fluoridated water
continuously from birth receive the maximum
protection against tooth decay.lo-14
An Australian study published in 2008 investigating
decay experience among Australian Defense Force
personnel showed that a longer period of exposure
to water fluoridation was associated with lower
decay rates in adults between the ages of 17 and
44. Adults who lived at least 90% of their lifetime
in communities with fluoridated water had 24% less
decay than adults who lived in fluoridated areas for
less than 10% of their lifetimes.69
A meta -analysis published in 2007 examining the
effectiveness of fluoridation for adults found that
fluoridation prevents approximately 27% of tooth decay
in adults. It included only studies that were published
after 1979. The studies were limited to participants who
were lifelong residents of communities with fluoridated
water and a control group of lifelong residents of
communities without fluoridated waters?
A study published in 2002 examined the differences in
tooth decay patterns between two cohorts of young
adults: the first grew up before fluoridation was widely
available and the second after fluoridation became
more widespread. Comparing data from two different
U.S. National Health and Nutrition Examination Surveys
(NHANES), NHANES 1 (1971-1974) and NHANES III
(1988-84), results indicated that total tooth decay
declined among people aged 45 years and younger.
No decline was observed in people aged 46 to 65,
a cohort that grew up during the late 40s and early
50s before fluoridation was widely available. This was
identified as the major reason this older cohort did not
show a decline in tooth decay.70
In 1989, a study conducted in the state of Washington
found that adults (20-34 years of age) who had a
continuous lifetime exposure to fluoridation water
had 31 % less tooth decay experience compared to
similar aged adults with no exposure to fluoridated
water. It also concluded that exposure to fluoridation
only during childhood has lifetime benefits since adults
exposed to fluoridated water only during childhood had
decay experience similar to those adults exposed to
fluoridated water only after age 14.11
An important issue for adults is the prevention of root
decay.17,11 People in the United States are living longer
and retaining more of their natural teeth than ever
24 American Dental Association
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before — in part due to water fluoridation. Adults
with gum recession are at risk for root decay because
the root surface, a much softer tooth surface than
enamel, becomes exposed to decay -causing bacteria
in the mouth as gums recede. Data from the ongoing
NHANES survey indicate that root decay experience
has declined in recent years among older adults with
teeth (ages 65-years and older), decreasing from 46%
(NHANES 1988-1994) to 36% (NHANES 1999-2004).
However, the prevalence of root decay increases
markedly as adults age and escalates more rapidly
after age 65. Specifically, the 75-years and older group
had 23% greater prevalence of root surface decay
than did the 65- to 74-years-old age group72 While
most studies related to the prevention of root decay
focus on professional fluoride treatments such as
fluoride varnish, there is evidence that demonstrates
fluoridation may have an impact on root decay.73-75
For example, in Ontario, Canada, lifelong residents
of the nonfluoridated community of Woodstock
had a 21 % higher root surface decay experience than
those living in the naturally fluoridated (1.6 ppm)
matched community of Stratford?' Similarly, Iowa
residents more than 40 years of age living long-term
in fluoridated communities had significantly less
root decay than lifelong residents of nonfluoridated
communities (0.56 versus 1.11 surfaces).75
Adults in the U.S. are keeping their natural teeth
longer — partially due to exposure to water
fluoridation. But as adults age with their teeth, it
means more teeth will be at risk for tooth decay.
It has been suggested in the literature that decay
experience for adults could increase to the point where
older adults experience similar or higher levels of new
cavities than do school children.11,76,77 It continues to
be important to document and acknowledge the
effectiveness of fluoridation in preventing tooth decay
in adults because virtually all primary preventive dental
programs target children and adolescents — with one
exception — community water fluoridation. Fluoridation
is unique in that it remains the one dental public health
measure that reaches all members of a community
including young, middle-aged and older adults.s6
12. Are dietary fluoride supplements
effective in helping to prevent tooth decay?
Answer.
Yes. Dietary fluoride supplements can be effective
in preventing tooth decay.
Fact.
Dietary fluoride supplements are available only by
prescription in the United States and are intended for
use by children who are at high risk for developing
tooth decay and living in areas where the primary
source of water is deficient in fluoride.8
Recommendations for health professionals seeking
to prescribe dietary fluoride supplements are found
in The Evidence -Based Clinical Recommendations on
the Prescription of Dietary Fluoride: A Report of the
American Dental Association Council on Scientific
Affairs published in 2010.8 The report and a Choirside
Guide: Dietary Fluoride Supplements: Evidence -based
Clinical Recommendations can be accessed at http://
ebd.ADA.org/en/evidence/guidelineslfluoride-
supplements. The current dietary fluoride supplement
schedule appears in this section as Table 1.
6 Additional information on this topic can be found
in this Section, Question 13.
As noted in Table 3 of the report, "Clinical
recommendations for the use of dietary fluoride
supplements:"
The expert panel convened by the American Dental
Association Council on Scientific Affairs developed
the following recommendations. They are intended
as a resource for dentists and other health care
providers. The recommendations must be balanced
with the practitioner's professional judgment and
the individual patient's needs and preferences.
Children are exposed to multiple sources of
fluoride. The expert panel encourages health care
providers to evaluate all potential fluoride sources
and to conduct a caries risk assessment before
prescribing fluoride supplements.
Fluoridation is unique in that it remains the As noted in the recommendations, prior to prescribing
one dental public health measure that reaches dietary fluoride supplements, accurate assessment
all members of a community including young, of the fluoride content of the patient's primary
middle-aged and older adults. drinking water source(s) should be conducted.8 The
.............................................................................. identification of the "primary" sources is sometimes
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Benefits I Fluoridation Facts 25
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difficult due to the fact that some patients have
multiple sources of drinking water during a typical
day. For example, while a patient may have access
to drinking water in the home, they often also spend
a large part of their day accessing drinking water at
day care or school, which could be a different water
system. It might be necessary to contact the local,
county or state health departments for information
on the fluoride content of public water sources or to
be referred to a certified laboratory that can provide
a fluoride test for private wells.
e Additional information on this topic con be found
in this Section, Question 4.
The ADA offers information on caries risk
assessment'$ on the web at http://www.ADA.org/
en/member-center/oral-health-topics/caries-risk-
assessment-and-management. It should be noted
that dietary fluoride supplements are recommended
only for children at high risk for tooth decay.$ Caries
risk assessments should be completed for patients on
a regular basis to determine their risk for tooth decay
which can change over time.
Dietary fluoride supplements can be effective in
helping to prevent tooth decay. To receive the
optimal benefit from fluoride supplements, the use of
supplements should begin at six months of age and
continue daily until the child is 16 years old.8 However,
individual patterns of compliance can vary greatly.
For that reason, the report suggests that providers
carefully monitor the adherence to the schedule to
maximize the therapeutic benefit of supplements
in caries prevention. If the health care provider
has concerns regarding a lack of compliance to the
schedule, it might be best to consider other sources
of fluoride exposure for the patient, such as bottled
water with fluoride.$
While dietary fluoride supplements can be effective
in reducing tooth decay, there are a number of
factors that can impede their use and resulting
therapeutic value:
• Patients/parents/caregivers must have access
to a professional health care provider who can
provide the necessary assessments and provide
prescriptions for the supplements — often
repeatedly over time.
• The supplements must be obtained through a
pharmacy/pharmaceutical service and refilled
as necessary.
• The cost of supplements can be a financial
hardship for some individuals.
• The compliance required (a child should take the
supplement every day until 16 years of age) to
obtain the optimal therapeutic affect often is
difficult to achieve.
SupplementTable 1. Dietary Fluoride
Age Fluoride ion level in drinking water (ppm)*
<0.3 ppm
0.3-0.6 ppm
>0.6 ppm
Birth - 6 months
None
None
None
6 months - 3 years
0.25 mg/day**
None
None
3-6 years
0.50 mg/day
0.25 mg/day
None
6-16 years
1.0 mg/day
0.50 mg/day
None
* 1.0 part per million (ppm) = 1 milligram/liter (mgL) **2.2 mg sodium fluoride contains 1 mg fluoride ion.
26 American Dental Association
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Noting the potential obstacles listed above, where
feasible, community water fluoridation offers proven
decay prevention benefits without the need for
access to a health care professional or a change
in behavior on the part of the individual. Simply
by drinking water at home, school, work or play
everyone in the community benefits regardless
of socioeconomic status, educational attainment
or other social variables.79 While dietary fluoride
supplements can reduce a child's risk of tooth decay,
fluoridation extends that benefit to adults in the
community. Additionally, the cost of dietary fluoride
supplements over an extended period of time can be
an economic concern to a family. In looking at overall
costs, consideration should be given to the cost per
person and the number of people who can benefit
from a dietary fluoride supplement or community
fluoridation program?'
13. The ADA Dietary Fluoride Supplements
Schedule 2010 contains the word "none"
in specific boxes. Does this mean the ADA
does not recommend fluoride for children?
Answer.
No, that would be a misinterpretation of the
purpose of the schedule. The schedule reflects the
recommended dosage of fluoride supplements
based on age and the fluoride level of the child's
primary source of drinking water, in addition to
what would be consumed from other sources.
Fact.
The dietary fluoride supplement schedule (Table 1.) is
just that — a supplement schedule. Children residing
in areas where the drinking water is not fluoridated
will receive some fluoride from other sources such as
foods and beverages. Dietary fluoride supplements
are designed for children over six months of age
who do not receive a sufficient amount of fluoride
from those sources. The dosage amounts in the table
reflect the additional amount of supplemental fluoride
intake necessary to achieve an optimal anti -cavity
effect. To reduce the risk of dental fluorosis, children
under six months of age should not take dietary
The dietary fluoride supplement schedule should
not be viewed as a recommendation of the absolute
upper limits of the amount of fluoride that should be
ingested each day. In 2011, the Food and Nutrition
Board of the Institute of Medicine developed Dietary
Reference Intakes, a comprehensive set of reference
values for dietary nutrient values. The values present
nutrient requirements to optimize health and, for the
first time, set maximum -level guidelines to reduce the
risk of adverse effects from excessive consumption
of a nutrient. In the case of fluoride, levels were
established to reduce tooth decay without causing
moderate dental fluorosis.S0
For example, the dietary fluoride supplement schedule
recommends that a two -year -old child at high risk
for tooth decay living in a nonfluoridated area (where
the primary water source contains less than 0.3 ppm
fluoride) should receive 0.25 mg of supplemental
fluoride per day. This does not mean that this child
should ingest exactly 0.25 mg of fluoride per day
total. Instead, a two -year -old child could receive
important anti -cavity benefits by taking 0.25 mg
of supplemental fluoride a day without causing any
adverse effects on health. This child would most
probably be receiving fluoride from other sources
(foods and beverages) even in a nonfluoridated area
and the recommendation of 0.25 mg of fluoride per
day takes this into account. In the unlikely event the
child did not receive any additional fluoride from
food and beverages, the 0.25 mg per day could be
inadequate fluoride supplementation to achieve an
optimal anti -cavity effect.
6 Additional information on this topic con be found
in the Safety Section, Question 23.
The following statement is correct. "Fluoride
supplement dosage levels have been lowered in the
past as exposure to fluoride from other sources has
increased" Rather than being a problem, as those
opposed to the use of fluoride might imply, this is
evidence that ADA policy is based on the best available
science. The ADA periodically reviews the dosage
schedule and issues updated recommendations
based on the best available science.
fluoride supplements. In 1994, a Dietary Fluoride Supplement Workshop,
co -sponsored by the ADA, the American Academy
6 Additional information on this topic can be found of Pediatric Dentistry and the American Academy of
in the Safety Section, Question 29. Pediatrics, was held in Chicago. Based on a review
of scientific evidence, a consensus was reached on a
.....................................................................................................................................................................
Benefits I Fluoridation Facts 27
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new dosage schedule developed acknowledging that
numerous sources of topical and systemic fluoride
are available today that were not available many
years ago.81
The supplement schedule was reviewed and reissued
in December 2010. At that time, the American
Dental Association Council on Scientific Affairs (CSA)
published evidence -based clinical recommendations
for the schedule of dietary fluoride supplements.8
The evidence -based review recommended that the
age stratification established in the ADA's 1994
supplement schedule remain unchanged. The review
also recommended that prior to prescribing fluoride
supplements, the prescribing provider should assess
the patient's risk for cavities and only those at high
risk should receive supplements.8 If at high risk, then
the fluoride level of the patient's primary drinking
water source should be assessed.8 It should be noted
that an accurate assessment of the patient's primary
drinking water source can be difficult due to the
various sources of fluoridated water. For example, the
patient might not have access to fluoridated water
in the home, but may drink fluoridated water while
at day care or school. The current dietary fluoride
supplement schedule appears as Table 1.8
6 Additional information on this topic con be found
in this Section, Question 12.
14. What are salt and milk fluoridation and
where are they used?
Answer.
Salt and milk fluoridation are fluoridation methods
used to provide community -based fluoridation in
countries outside of the United States where various
political, geographical, financial or technical reasons
prevent the use of water fluoridation.
Fact.
The practice of salt fluoridation began in the 1950s,
approximately 10 years after water fluoridation was
initiated in the United States.81 Based on the success
several decades earlier of the use of iodized salt for
the prevention of goiter, fluoridated salt was first
introduced in Switzerland in 1956.83
According to a review published in 2013, salt
fluoridation is available in a number of countries in
Europe but its coverage varies greatly.8' Germany
and Switzerland have attained a coverage exceeding
two-thirds of their populations (67% and 85%
respectively). In other European countries including
Austria, the Czech Republic, France, Slovakia and Spain,
salt fluoridation is reportedly used on a very limited
scale.81 Additional countries, such as Hungary, Romania,
Slovenia, Croatia and Poland, have considered salt
fluoridation but have failed to take action.84
European regulations (current as of 2017) permit
the addition of fluoride to salt and water.82 However,
it appears that the majority of European countries
favor the twice daily use of fluoride toothpaste as the
most important measure for improving the public's
dental health.84 In Europe, toothpaste sold over the
counter typically contains 1,500 ppm fluoride'81 while
toothpaste in the United States typically contains
1,000 to 1,100 ppm fluoride.86
On a historical note, prior to the political changes that
occurred in the late 1980s and early 1990s in Europe,
water fluoridation was widely available in the German
Democratic Republic and the Czechoslovak Republic
and to a lesser extend in Poland. With the end of the
Communist regimes, efforts related to public health
dentistry were largely discontinued. While fluoridation
continued in several small towns until 1993, in
general, it was abandoned.84
In North and South America, salt fluoridation is
available in Belize, Bolivia, Colombia, Costa Rica,
Dominican Republic, Ecuador, Mexico, Peru, Uruguay
and Venezuela. Like in Europe, the extent of salt
fluoridation varies between countries. Columbia,
Costa Rica, Jamaica, Mexico and Uruguay provide
fluoridated salt to nearly their entire populations while
there is less coverage in other countries.81
In 2013, it was estimated that approximately 60
million people in Europe and 160 million in the
Americas had access to fluoridated salt.82
The Pan American Health Organization (PAHO), a
regional division of the World Health Association
(WHO) with responsibilities for health matters in
North, South and Central America and the Caribbean,
has been active in developing strategies to implement
decay prevention programs in the regions of the
Americas using water and salt fluoridation.87 In order
to achieve the greatest reduction in tooth decay while
minimizing the risk of dental fluorosis, it is advisable
that a country implement only one of these two
28 American Dental Association
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public health measures — either community water
fluoridation or salt fluoridation. The United States has
implemented water fluoridation. The U.S. Food and
Drug Administration has not approved fluoridated salt
for use in the U.S.
Early studies evaluating the effectiveness of salt
fluoridation conducted in Columbia, Hungary and
Switzerland indicated that fluoride delivered via salt
might produce a reduction in tooth decay similar
to that seen with optimally fluoridated water.88,89
When all salt destined for human consumption (both
domestic salt and bulk salt that is used by commercial
bakeries, restaurants, institutions, and industrial food
production) is fluoridated, the decay -reducing effect
could be comparable to that of water fluoridation over
an extended period of time.88,89 When only domestic
salt is fluoridated, the decay -reducing effect is
diminished.88 Studies conducted in Costa Rica, Jamaica
and Mexico in the 1980s and 1990s also showed
significant reductions in tooth decay. However, it was
noted that these studies did not include other variables
that could have contributed to the reductions.S8
The fact that salt fluoridation does not require a
centralized piped water system is of particular value
in countries that do not have such water systems.
Fluoridated salt is also a very cost-effective public
health measure. For example, in Jamaica, where all
salt destined for human consumption is fluoridated,
the use of fluoridated salt was reported to reduce
tooth decay by as much as 84% at a cost of 6 cents
per person per year.81 In some cases, the cost to
produce fluoridated salt is so low that for consumers,
the cost of fluoridated salt is the same as for
nonfluoridated salt.90
The implementation of salt fluoridation has unique
challenges not incurred with water fluoridation.
Sources of salt, the willingness of local manufacturers
to produce fluoridated salt or the need to import
fluoridated salt would need to be studied. Because
fluoridated salt should only be consumed by the
public in areas with a naturally low level of fluoride,
it would be necessary to completely map the
naturally occurring levels of fluoride and devise a
plan to keep fluoridated salt out of the areas with
moderate to high naturally occurring fluoride (to aid
in reducing the risk of dental fluorosis). Additionally,
a plan would need to be developed to monitor the
fluoride level in urine of those consuming fluoridated
salt starting with a baseline before implementation
and including follow-up testing on a regular basis.
While salt fluoridation typically is not implemented
through a public vote, it would be necessary to
gain the cooperation of salt manufacturers and
institutions of all kinds that would use salt in their
food preparation .89 Additionally, educational efforts
would need to be directed at health professionals and
health authorities to avoid referendum approaches
and identify enabling regulations.81
In a number of European countries, consumers
have a choice of purchasing either fluoridated or
nonfluoridated salt for use in the home. While it
has been argued that, unlike water fluoridation, this
option to purchase fluoridated or nonfluoridated
salt allows for personal choice, studies indicate that
fluoridated salt is not as effective a public health
measure when only a small portion of the population
opts to purchase and use the product.88 For example,
in France, fluoridated salt for home use became
available to the consumer by decree in 1986, while
nonfluoridated salt remained available for purchase.
By 1991, with an aggressive public health campaign,
the market share of fluoridated salt was 50% and it
reached a high of 60% in 1993. Then the public health
campaign ended. By 2003, the market share had
decreased to 27%.82.91 It has been suggested that, in
order to be a successful public health measure that
effectively reaches those who are disadvantaged,
approximately 70% of the population needs to use
fluoridated salt. Conversely, usage rates less than
50% should be considered as having minimal effect
on public health.82 While the situation described in
Europe allows for personal choice, salt programs
in the Americas where all salt destined for human
consumption is fluoridated would seem at odds
with the issue of personal choice, yet the program
is apparently working well with fluoridated salt well
accepted by the public.92
A number of studies have shown an increase in the
occurrence of dental fluorosis in areas where salt
fluoridation programs have been implemented.
For example, a 2006 cohort study examined
the prevalence and severity of dental fluorosis in
children before and after the implementation of salt
fluoridation in Campeche, Mexico, in 1991.91 The
study showed, that while 85% of the dental fluorosis
identified was categorized as very mild, children
born in 1990-1992 were more likely to have dental
fluorosis than those born in the period 1986-198991
A study published in 2009 of children in Jamaica
...............................................................................................................................................................
Benefits I Fluoridation Facts 29
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showed similar results.94 Jamaica began a fluoridated
salt program in 1987. In 1999, an area around St.
Elizabeth was found to have a high prevalence of
dental fluorosis. Examiners returned in 2006 to
re-evaluate students in the area. While their results
indicated a slightly reduced tooth decay experience
for 6-year-olds in 2006 compared to 6-year-olds
in 1999, they also found that 6-year-olds also had
a higher prevalence of dental fluorosis in 2006 than
the 6-year-olds examined in 1999. In addition to the
implementation of salt fluoridation, other factors
including the use of increased use of fluoridated
toothpaste and mouthrinses could have played a
role.94 However, both of these studies point out the
need to carefully monitor fluorides from multiple
sources especially when implementing fluoridated
salt programs.
Fluoridated milk has been suggested as another
alternative to community water fluoridation in
countries outside the United States. Studies on the
effectiveness of milk fluoridation have been carried
out in numerous countries, including but not limited
to, Brazil, Bulgaria, China, Israel, Japan, Russia and the
United Kingdom.95 Many of these studies have found
milk fluoridation programs to be an efficient and cost-
effective method to prevent cavities.95 For example, a
2001 study of Chilean preschoolers using fluoridated
powdered milk and milk derivatives resulted in a
41 % reduction in the number of primary decayed
missing and filled tooth surfaces as compared to the
control group that did not receive fluoridated milk.96
Additionally, in the same study, the proportion of
decay free children increased from 22% to 48% in
the study group after four years of implementing
the program.96
In 2004, the dental health of school children from the
northwest of England, who were enrolled in the school
milk fluoridation program, was compared to children
with similar characteristics who were not consuming
fluoridated milk.97 The average age of the children
in the study was 11 years old. In order to participate
in the study, participants chosen for the test group
were required to have been receiving fluoridated milk
for a minimum of 6 years. First permanent molars
were examined for tooth decay experience. Results
from the study indicated that children consuming
fluoridated milk had less tooth decay experience
(1.01 DMFT) than the children who did not receive
fluoridated milk (1.46 DMFT).97
A study of community milk programs in Bulgaria
examined children at age 3 and again at age 8.98
The study indicated that tooth decay experience
was substantially lower in the cohort of children
who had received fluoridated milk in school for five
years compared with the cohorts of children who
had received milk in school without fluoride added.
At the end of the five-year trial in 2009, tooth
decay experience was lower in children who received
fluoridated milk (5.61 dmfs and 0.48 DMFS) than in
the control community children who received milk
with no fluoride (9.41 dmfs and 1.24 DMFS).98
In these two examples "dmfs" is the mean number of
decayed, missing or filled tooth surfaces on primary
(or baby) teeth while "DMFS" is the mean number
of decayed missing or filled tooth surfaces on
permanent teeth.
Studies completed on milk fluoridation to date largely
target children. There has been only a very small
number that have looked at the role fluoridated milk
might play for adults. These studies have largely
examined fluoridated milk and its possible effect on
root decay. For example, a study published in 2011
and conducted in Sweden indicated that fluoridated
milk could be of value in remineralizing early tooth
decay in root surfaces.99
It was estimated that as of 2013, more than one
million children worldwide were receiving fluoridated
milk.94 The majority of studies conducted have
indicated that fluoridated milk is effective in
preventing tooth decay under certain conditions.
It is most effective if the consumption of fluoridated
milk starts before 4 years of age and continues until
the permanent teeth are present in the mouth. Most
successful programs are conducted through schools
where the natural fluoride levels in water are low and
children are able to consume fluoridated milk for a
minimum of 200 days a year.95 While these conditions
prevent fluoridated milk from being recommended
as a public health measure for an entire community,
fluoridated milk might be the most appropriate and
effective means of fluoride exposure for children in
some circumstances.
30 American Dental Association
back to agenda
15. Can the consistent use of bottled water
result in individuals missing the benefits of
optimally fluoridated water?
Answer.
Yes. The majority of bottled waters on the market
do not contain optimal levels (0.7 mg/L) of fluoride
Fact.
There is not a large body of research regarding the
risk for tooth decay associated with the consumption
of bottled water. However, a lack of exposure to
fluoride could increase an individual's risk for tooth
decay. The vast majority of bottled waters do not
contain significant amounts of fluoride100 Individuals
who drink bottled water as their primary source of
water could be missing the decay preventive effects
of optimally fluoridated water available from their
community water supplies. These consumers should
seek advice from their dentists about their risk for
tooth decay and specific fluoride needs.
While drinking water from the tap is regulated by
the U.S. Environmental Protection Agency (EPA),
bottled water is regulated by the U.S. Food and Drug
Administration (FDA)101 The FDA has established
maximum allowable levels for physical, chemical,
microbiological, and radiological contaminants in
bottled wateC01
Individuals who drink bottled water os their
primary source of water could be missing
the decoy preventive effects of optimally
fluoridated water available from their
community water supplies.
Noting that fluoride can occur naturally in source
waters used for bottled water or can be added by a
bottled water manufacturer, the FDA has approved
standards for the fluoride content of bottled water.'02
However, the FDA regulations require the fluoride
content of bottled water to be listed on the label only
if fluoride is added during processing 103 If the fluoride
level is not shown on the label of the bottled water,
the company can be contacted, or the water can be
tested to obtain this information. Most consumers
are unaware that the vast majority of bottled waters,
especially those treated by distillation or reverse
osmosis, are largely fluoride -free. Unknowingly,
individuals who drink bottled water as their primary
source of water could be missing the decay preventive
effects of optimally fluoridated water available from
their community water supplies. The American Dental
Association supports the labeling of bottled water
with the fluoride content to aid consumers in making
informed decisions about choices of drinking waterloo
Recognizing the benefit of fluoride in drinking water,
in 2006 the FDA issued the "FDA Health Claim
Notification for Fluoridated Water and Reduced
Risk of Dental Caries"105 which states that bottled
water meeting the specific standards of identity
and quality set forth by FDA, and containing greater
than 0.6 mg/L up to 1.0 mg/L total fluoride,
can be labeled with the following health claim:
"Drinking fluoridated water may reduce the risk of
[dental caries or tooth decay]" This health claim
is not intended for use on bottled water products
specifically marketed for use by infants 1os
6 Additional informotion on this topic con be found
in the Safety Section, Question 28.
According to a 2017 press release from the Beverage
Marketing Corporation,'06 bottled water surpassed
carbonated soft drinks in 2016 to become the
largest beverage category by volume in the United
States. Per capita consumption of bottled water
was approximately 39.3 gallons in 2016, while the
average consumption of carbonated soft drinks was
approximately 38.5 gallons per person per year.
The majority (67.3%) of U.S. bottled water is sold in
single -serving PET (polyethylene terephthalate or
plastic resin' 07) bottles. Bottled water is also sold via
bulk deliveries to homes and offices (approximately
11%) and by retail sales in different sizes of gallon
containers (approximately 9%)106
Individuals choose to drink bottled water for various
reasons. Some find it a calorie -free substitute for
carbonated soft drinks or other sugary beverages.
Others dislike the taste of their tap water or have
concerns about the possible contaminants in their
local water supply.
In a small study published in 2012, a convenience
sample of caretakers and adolescents at an urban
clinic found that 17% drank tap water exclusively,
38% drank bottled water exclusively and 42% drank
both. Bottled water was ranked significantly higher
Benefits Fluoridation Facts 31
back to agenda
in taste, clarity, purity and safety than tap water.
Only 24% of caretakers of children and adolescents
knew whether or not fluoride was in their drinking
water. The authors concluded that perception of
the qualities of water were responsible for choices
of drinking water.108 Similar findings have been
echoed in earlier studies 109-111 Additionally, cultural
influences can affect drinking water preferences. In
some Latino communities, parents were less likely
to give tap water to their children because they
believed tap water would make them sick based in
part on the fact that many have come to the U.S.
from places with poor water quality where water-
borne illness was common 111 Besides missing the
decay preventive effects of fluoridated tap water,
it has been determined that families spend hundreds
of dollars more each year on purchasing water than
if they were to consume tap water.109.111
16. Can home water treatment systems
such as water filters, reverse osmosis and
water softeners remove fluoride from
drinking water?
Answer.
Some types of home water treatment systems
can reduce the fluoride levels in water supplies.
Individuals who drink water processed by home
water treatment systems as their primary source
of water could be losing the decay preventive
effects of optimally fluoridated water available
from their community water supply.
Fact.
There are many kinds of home water treatment
systems including reverse osmosis systems,
distillation units, water softeners and water filters
such as carafe filters, faucet filters, under the sink
filters and whole house filters. There has not been a
large body of research regarding the extent to which
these treatment systems affect the fluoride content
of optimally fluoridated water.
However, it has been consistently documented that
reverse osmosis systems and distillation units remove
significant amounts of fluoride from the water
supply.1"I" Studies regarding water softeners show
clearly that the water softening process does not
significantly change fluoride levels.' 14,115
With water filters, the fluoride concentration
remaining in the water depends on the type and
quality of the filter being used, the status of the
filter and the filter's age. Most carbon filters do not
remove fluoride. However, some filters containing
activated alumina can remove significant amounts
of the fluoride. Additionally, some filters containing
bone char also can remove significant amounts of
fluoride."','16 Accordingly, each type of filter should
be assessed individually.
Individuals who drink water processed by home
water treatment systems as their primary source of
water could be losing the decay preventive effects
of optimally fluoridated water available from their
community water supply. Therefore, it might be
necessary to contact the installer, distributor or
manufacturer of the water treatment system or
water filter in question to determine whether the item
removes fluoride. Information regarding the existing
level of fluoride in a community's public water system
can be obtained by asking a local dentist or contacting
the local or state health department or the local water
supplier. If the consumer is using a private well, it is
suggested that it be tested yearly for fluoride levels.
6 Additional information on this topic con be found
in this Section, Question 4.
32 American Dental Association
back to agenda
Benefit References
1. Abundance of elements in Earth's crust. Wikipedia, the free encyclopedia.
Available at: https://en.wikipedia.org/wiki/Abundance_of elements_in_
Earth%27s_crust. Accessed on October 21, 2017.
2. Edmunds WM, Smedley PL. Fluoride in natural waters. In Selinus O. (ed):
Essentials of Medical Geology, Revised Edition. Netherlands, Springer.
2013:311-336.
3. National Research Council of the National Academies. Division on Earth and
Life Studies. Board on Environmental Studies and Toxicology. Committee
on Fluoride in Drinking Water. Fluoride in drinking water: a scientific review
of EPA's standards. Report in brief. 2006. Available at: http://dels.nas.edu/
Materials/Report-In-Brief/4775-Fluoride. Accessed October 21, 2017.
4. Comprehensive Chemical Analysis Reports for 2016. City of Chicago.
Department of Water Management. Bureau of Water Supply. Water
Quality Division -Water Purification Laboratories. Available at: https://
www.cityofchicago.org/city/en/depts/waterlsupp_info/water quality_
resultsandreports/comprehensive_chemicalanalysis.htmL Accessed
October 21, 2017.
5. O'Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg -Gunn AJ,
Whelton H, Whitford GM. Fluoride and oral health. Community Dent
Health 2016;33(2):69-99. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/27352462. Accessed October 23, 2017.
6. Buzalaf MAR, Pessan JP, Honorio HM, ten Cate JM. Mechanisms of actions
of fluoride for caries control. In Buzalaf MAR (ed): Fluoride and the Oral
Environment. Monogr Oral Sci. Basel, Karger. 2011,22:97-114. Abstract
at: https://www.ncbi.nlm.nih.govlpubmedl2l70ll94. Accessed
October 26, 2017.
7. Lambrou D, Larsen MJ, Fejerskov O, Tachos B. The effect of fluoride in saliva
on remineralization of dental enamel in humans. Caries Res 1981;15(5):341-5.
8. Rozier RG, Adair S, Graham F, lafolla T, Kingman A, Kohn W, Krol D, Levy
S, Pollick H, Whitford G, Strock S, Frantsve-Hawley J, Aravamudhan K,
Meyer DM. Evidence -based clinical recommendations on the prescription
of dietary fluoride supplements for caries prevention: a report of the
American Dental Association Council on Scientific Affairs. J Am Dent
Assoc 2010;141(12):1480-9. Abstract at: https://www.ncbi.nim.nih.
gov/pubmed/21158195. Article at: http://ebd.ADA.org/en/evidence/
guidelines/fluoride-supplements. Accessed October 26, 2017.
9. Zero DT, Fontana M, Martinez -Mier A, Ferreira-Zandona A, Masatoshi
A, Gonzalez-Cabezas C, Bayne S. The biology, prevention diagnosis and
treatment of dental caries: scientific advances in the United States. J Am
Dent Assoc 2009;140 Suppl 1:25S-34S. Abstract at: https://www.ncbi.
nlm.nih.gov/pubmed/19723928. Accessed October 26, 2017.
10. Cho HJ, An BH, Park DY, Jung SH, Lee HS, Paik DI, Bae KH. Systemic effect
of water fluoridation on dental caries prevalence. Community Dent Oral
Epidemiol 2014;42(4):341-8. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/24428350. Accessed October 28, 2017.
11. Newbrun E. Systemic benefits of fluoride and fluoridation. J Public
Health Dent 2004;64;(Spec Iss 1):35-9. Article at: http://onlinelibrary.
wiley.com/doi/lO.1111/j.1752-7325.2004.tbO2775.x/abstract.
Accessed September 20, 2017.
12. Singh KA, Spencer AJ, Armfield BA. Relative effects of pre- and
posteruption water fluoride on caries experience of permanent first
molars. J Public Health Dent 2003;63(1):11-19. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/12597581. Accessed October 28, 2017.
13. Hargreaves JA. The level and timing of systemic exposure to fluoride with
respect to caries resistance. J Dent Res 1992;71(5):1244-8. Abstract at:
https://www.ncbi.nim.nih.govlpubmed/1607441. Accessed October 28,
2017.
14. Groeneveld A, Van Eck AA, Backer Dinks O. Fluoride in caries prevention:
is the effect pre -or post -eruptive. J Dent Res 1990;69 Spec No:751-
5; discussion 820-3. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/2179337 Accessed October 28, 2017.
16. Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure at
crown completion and maturation on caries of permanent first molars.
Caries Res 2007;41(1):34-42. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/17167257 Accessed October 28, 2017.
17. U.S. Department of Health and Human Services. Federal Panel on
Community Water Fluoridation. U.S. Public Health Service recommendation
for fluoride concentration in drinking water for the prevention of dental
caries. Public Health Rep 2015;130(4):318-331. Article at: https://www.
ncbLnlm.nih.gov/pmc/articles/PMC4547570. Accessed October 24, 2017.
18. U.S. Environment Protection Agency. Consumer Confidence Reports (CCR).
CCR information for consumers. Available at: https://www.epa.govlccrl
ccr-information-consumers. Accessed on September 18, 2017.
19. U.S. Environment Protection Agency. Consumer Confidence Reports
(CCR). Find your local CCR. Available at: https://ofmpub.epa.gov/apex/
safewater/f?p=136:102. Accessed on September 18, 2017.
20. Centers for Disease Control and Prevention. My water's fluoride. Available
at: https.11nccd.cdc.govIDOH_MWF/DefaultIDefault.aspx. Accessed
September 18, 2017.
21. U.S. Environmental Protection Agency. Private drinking water wells. Available
at: https://www.epa.govlprivatewells. Accessed September 18, 2017.
22. American Water Works Association. Water fluoridation principles and
practices. AW WA Manual M4. Sixth edition. Denver. 2016.
23. Maier FT Manual of water fluoridation practice. New York: McGraw-Hill
Book Company, Inc.;1963.
24. Duchon K National Fluoridation Engineer. Centers for Disease Control and
Prevention. Personal communication. CDC WFRS database query. August
24, 2017.
25. U.S. Department of Health and Human Services, Centers for Disease Control,
Dental Disease Prevention Activity, Center for Prevention Activity. Water
fluoridation: a manual for engineers and technicians. Atlanta. 1986. Available
at: https://stacks.cdc.gov/view/cdc/13103. Accessed October 2, 2017.
26. Whitford GM, Sampaio FC, Pinto CS, Maria AG, Cardoso VE, Buzalaf MA.
Pharmacokinetics of ingested fluoride: lack of effect of chemical compound.
Arch Oral Biol 2008;53(11):1037-41. Abstract at: https://www.ncbi.nim.
nih.gov/pubmed/18514162. Accessed on October 2, 2017.
27. Brown HK, Poplove M. The Brantford -Sam ia-Stratford fluoridation caries
study: final survey, 1963. Med Sery J Can 1965;21(7):450-6.
28. Dean HT, Arnold FA, Elvove E. Domestic water and dental caries. Public
Health Reports 1942;57(32):1155-79.
29. Dean HT. The investigation of physiological effects by the epidemiological
method. In: Moulton FR, ed. Fluorine and dental health. American
Association for the Advancement of Science, Publication No. 19.
Washington, DC;1942:23-31.
30. Dean HT. Endemic fluorosis and its relation to dental caries. V. Additional
studies of the relation of fluoride domestic waters to dental caries
experience in 4,425 white children, aged 12 to 14 years, of 13 cities in 4
states. Public Health Rep 1942;57(32):1155-79. Article at: https://www.
jstor.org/Stab/e/4584182. Accessed October 28, 2017.
31. Australian Government. National Health and Medical Research Council.
NHMRC Public Statement 2017: Water fluoridation and human health
in Australia. Available at: https://www.nhmrc.gov.aulguidelines-
publications/e44-0. Accessed November 12, 2017.
32. Australian Government. National Health and Medical Research Council
(NHMRC). Information paper - water fluoridation: dental and other human
health outcomes. Canberra. 2017. Available at: https://www.nhmrc.gov.
au/guidelines-publications/eh43-0. Accessed October 23, 2017.
33. The Community Guide. About the community guide. Available at: https://
www.thecommunityguide.org/about/about-community-guide. Accessed
October 26, 2017.
15. Singh KA, Spencer AJ. Relative effects of pre- and post -eruption water 34. The Community Guide. Dental Caries (Cavities): Community Water
fluoride on caries experience by surface type of permanent first molars. Fluoridation. What the CPSTF found. Available at: https://www.
Community Dent Oral Epidemiol. 2004;32(6):435-46. Abstract at: thecommunityguide.org/findings/dental-caries-cavities-community-
https://www.ncbi.nlm.nih.gov/pubmed/15541159. Accessed October water -fluoridation. Accessed October 26, 2017.
28, 2017.
...............................................................................................................................................................
Benefits I Fluoridation Facts 33
back to agenda
Benefit References
35. Parnell C, Whelton H, O'Mullane D. Water fluoridation. Eur Arch Paediatr
Dent 2009;10(3):141-8. Abstract at: https://www.ncbi.nim.nih.govl
pubmed119772843. Accessed October 23, 2017.
36. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in
preventing caries in adults. J Dent Res 2007;86(5):410-415. Abstract at:
https://www.ncbi.nim.nih.govlpubmed/17452559. Accessed October
26, 2017.
37. Arnold FA Jr., Likins RC, Russell AL, Scott DB. Fifteenth year of the Grand
Rapids fluoridation study. J Am Dent Assoc 1962;65(6):780-5.
38. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost
and effectiveness of school -based preventive dental care. Am J Public
Health 1985;75(4):382-91. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/3976964. Article at: https://www.ncbi.nlm.nih.govlpmcl
articles/PMC1646230. Accessed October 25 2017.
39. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent
1989;49(5):279-89. Abstract at: https://www.ncbLnim.nih.govl
pubmed/2681730. Accessed October 25, 2017.
40. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the
effect of water fluoridation. J Dent Res 1990;69(Spec No):723-7. Abstract
at: https://www.ncbi.nlm.nih.govlpubmedl2312893. Accessed October
26, 2017.
41. Murray JJ. Efficacy of preventive agents for dental caries. Systemic
fluorides: water fluoridation. Caries Res 1993;27(Suppl 1):2-8. Abstract at:
https://www.ncbi.nlm.nih.gov/pubmed/8500120. Accessed October 25,
2017.
42. Ripa LW. A half -century of community water fluoridation in the United
States: review and commentary. J Public Health Dent 1993;53(1):17-44.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl8474047 Accessed
on October 4, 2017.
43. Kumar JV. Is water fluoridation still necessary? Adv Dent Res
2008;20(1):8-12.
44. Blayney JR, Hill IN. Fluorine and dental caries: findings by age group. J Am
Dent Assoc 1967(Spec Iss);74(2):246-52.
45. Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans, Jr CA,
Griffin SO, Carande-Kulis VG. Task Force on Community Preventive
Services. Reviews of evidence on interventions to prevent dental caries,
oral and pharyngeal cancers, and sports -related craniofacial injuries. Am
J Prev Med 2002;23(lS):21-54. Abstract at: https://www.ncbi.nlm.nih.
gov1pubmed112091093. Accessed October 2, 2107.
46. Griffin SO, Gooch BF, Lockwood SA, Tomar SL. Quantifying the diffused
benefit from water fluoridation in the United States. Community Dent Oral
Epidemiol 2001;29(2):120-9. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/11300171. Accessed October 4, 2017.
53. Kunzel W, Fischer T, Lorenz R, Bruhmann S. Decline of caries prevalence
after the cessation of water fluoridation in the former East Germany.
Comm Dent Oral Epidemiol 2000;28(5):382-9. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/11014515. Accessed October 4, 2017.
54. Kalsbeek H, Kwant GW, Groeneveld A, Dirks OB, van Eck AA, Theuns
HM. Caries experience of 15-year-old children in The Netherlands after
discontinuation of water fluoridation. Caries Res 1993;27(3):201-5.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl8519058.
Accessed October 4, 2017.
55. Jackson SL, Vann WF Jr, Kotcy JB, Pahel BT, Lee JY. Impact on poor oral
health on children's school attendance and performance. Am J Public
Health 2011;101(10):1900-6. Abstract at: https://www.ncbi.nlm.nih.
gov1pubmed121330579. Article at: https://www.ncbi.nim.nih.govlpmcl
articles/PMC3222359. Accessed October 4, 2017.
56. Centers for Disease Control and Prevention, Oral Health Home. Oral health
basics. Available at: https://www.cdc.gov/oralhealth/basicslindex.htmt
Accessed October 4, 2017.
57. Griffin SO, Griffin PM, Swann JL, Zlobin N. Estimating rates of new root
caries in older adults. J Dent Res 2004;83(8):634-8. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/15271973. Accessed October 26, 2017.
58. McNally ME, Matthews DC, Clovis JB, Brillant M, Filiaggi MJ. The oral
health of ageing baby boomers: a comparison of adults aged 45-64 and
those 65 years and older. Gerodontology 2014;31(2):123-35. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl23216625. Accessed October
26, 2017.
59. Watt RG. From victim blaming to upstream action: tackling the social
determinants of oral health inequalities. Community Dental Oral
Epidemiology 2007;35(1):1-11. Abstract at: https://www.ncbi.nlm.nih.
gov/pubmed/17244132. Accessed October 26, 2017.
60. Locker D. Deprivation and oral health: a review. Community Dent Oral
Epidemiol 2000;28(3):161-9. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/10830642. Accessed October 26, 2017.
61. Burt BA. Fluoridation and social equity. J Public Health Dent 2002;
62(4):195-200. Abstract at: https://www.ncbLnlm.nih.gov/
pubmed112474623. Accessed October 24, 2017.
62. Centers for Disease Control and Prevention, Oral Health Home, Oral Health
Basics. Disparities in oral health. Available at: https://www.cdc.govl
oralhealth/oralhealth_disparities/index.htm. Accessed October 4, 2017.
63. U.S. Department of Health and Human Services, Public Health Service.
Surgeon General David Satcher. Statement on community water
fluoridation. Office of the Surgeon General. Rockville, MD; 2001.
Available at: https://www.cdc.govlfluoridation/guidelineslsurgeons-
general-statements.html. Accessed October 28, 2017.
47. Lemke CW, Doherty JM, Arra MC. Controlled fluoridation: the dental
64. U.S. Department of Health and Human Services. Office of Disease
effects of discontinuation in Antigo, Wisconsin. J Am Dent Assoc
Prevention and Health Promotion. HealthyPeople.gov. Healthy People
1970;80(4):782-6.
2020. About healthy people. Available at: https://www.healthypeople.
gov/2020/About-Healthy-People. Accessed October 26, 2017.
48. Way RM. The effect on dental caries of a change from a naturally fluoridated
65. U.S. Department of Health and Human Services. Office of Disease
to a fluoride -free communal water. J Dent Child 1964;31:151-7.
Prevention and Health Promotion. HealthyPeople.gov. Healthy People
49. Stephen KW, McCall DR, Tullis A. Caries prevalence in northern
2020. Topics and Objectives. Oral health objectives. Available at: https://
Scotland before, and 5 years after, water defluoridation. Br Dent J
www.healthypeople.govl202Oltopics-objectivesltopicloral-health/
1987;163(10):324-6.
objectives. Accessed October 26, 2017.
50. Attwood D, Blinkhorn AS. Dental health in schoolchildren 5 years
66. Centers for Disease Control and Prevention. Community Water
after water fluoridation ceased in south-west Scotland. Int Dent
Fluoridation. Fluoridation statistics. 2014. Available at: https://www.cdc.
J 1991;41(1):43-8. Abstract at: https://www.ncbi.nlm.nih.gov/
gov/fluoridation/statistics/2014stats.htm. Accessed October 26, 2017.
pubmed/2004838. Accessed October 4, 2017.
67. Hayes RL, Littleton NW, White CL. Posteruptive effects of fluoridation on
51. Kunzel W, Fischer T. Caries prevalence after cessation of water fluoridation
first permanent molars of children in Grand Rapids, Michigan. Am J Public
in La Salud, Cuba. Caries Res 2000;34(1):20-5. Abstract at: https://www.
Health Nations Health 1957;47(2):192-9. Article at: https://www.ncbi.
ncbi.nlm.nih.gov/pubmed/10601780. Accessed October 4, 2017.
nlm.nih.gov/pmc/articles/PMC1551168. Accessed October 4, 2017.
52. Seppa L, Hausen H, Karkkainen S, Larmas M. Caries occurrence in
68. Arnold FA Jr, Dean HT, Philip J, Knutson JW. Effect of fluoridated public
a fluoridated and a nonfluoridated town in Finland: a retrospective
water supplies on dental caries experience. 1956. (Tenth year of the Grand
study using longitudinal data from public dental records. Caries Res
Rapids -Muskegon study) Bull World Health Organ 2006;84(9):761-4.
2002;36(5):308-14. Abstract at: https://www.ncbi.nlm.nih.gov/
Article at: https://www.ncbi.nim.nih.gov/pmc/articles/PMC2627464.
pubmed112399690. Accessed October 4, 2017.
Accessed October 3, 2017.
34 American Dental Association
back to agenda
Benefit References
69. Mahoney G, Slade GD, Kitchener S, Barnett A. Lifetime fluoridation
exposure and dental caries experience in a military population. Community
Dent Oral Epidemiol 2008;36(6):485-92. Abstract at: https://www.ncbi.
n1m.nih.gov/pubmed/18422709. Accessed on October 3, 2017.
70. Brown LJ, Wall TP, Lazar V. Trends in caries among adults 18 to 45 years
old. J Am Dent Assoc 2002;133(7):827-34. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/12148675. Accessed on October 3, 2017.
71. Grembowski D, Fiset L, Spadafora A. How fluoridation affects adult
dental caries: systemic and topical effects are explored. J Am Dent
Assoc 1992;123(2):49-54. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/1541781. Accessed October 3, 2017.
72. Dye B, Tan S, Smith V, Lewis B, Barker L, Thornton -Evans G, Eke P, Beltran -
Aguilar E, Horowitz A, Li CH. Trends in oral health status: United States,
1988-1994 and 1999-2004. National Center for Health Statistics. Vital
Health Stat 2007;11(248). Abstract at: https://www.ncbi.nlm.nih._qovl
pubmed/17633507 Article at: https://www.cdc.govinchs/data/series/
sr 111sr11_248.pdf. Accessed October 3, 2017.
73. Brustman BA. Impact of exposure to fluoride -adequate water on root
surface caries in elderly. Gerodontics 198612(6):203-7.
74. Burt BA, Ismail Al, Eklund SA. Root caries in an optimally fluoridated and a high -
fluoride community. J Dent Res 1986;65(9):1154-8. Abstract at: https:l/
www.ncbi.nlm.nih.gov/pubmed/3461032. Accessed October 3, 2017.
75. Hunt RJ, Eldredge JB, Beck JD. Effect of residence in a fluoridated
community on the incidence of coronal and root caries in an older adult
population. J Public Health Dent 1989;49(3):138-41. Abstract at: https.11
www.ncbi.nlm.nih.gov/pubmed/2788735. Accessed October 18, 2017.
76. Griffin SO, Griffin PM, Swann JL, Zlobin N. New coronal caries in older
adults: implications for prevention. J Dent Res 2005;84(8):715-720.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedll604O728.
Accessed September 16, 2017.
77. Garcia Al. Caries incidence and costs of prevention programs. J Public
Health Dent 1989;49(5 Spec No):259-71. Abstract at: https://www.ncbL
n1m.nih.gov/pubmed/2810223. Article at: https.Ildeepblue.lib.umich.
edulhandlel202742166226. Accessed October 26, 2017.
78. American Dental Association. Member Center. Oral Health Topics. Caries
risk assessment and management. Available at: http://www.ADA.org/
en/m ember-cen ter/oral -heal th-topics/caries-risk-assessment-and -
management. Accessed September 26, 2017.
79. Horowitz HS. The effectiveness of community water fluoridation in the United
States. J Public Health Dent 1996 Spec Iss;56(5):253-8. Abstract at: https://
wwwncbi.nlm.nih.gov/pubmed/9034970. Accessed October 24, 2017.
80. Institute of Medicine. Food and Nutrition Board. Dietary reference intakes
for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington,
DC: National Academy Press;1997. Available at: https://www.nap.edu/
catalog/5776/dietary-reference-intakes-for-calcium-phosphorus-
magnesium-vitamin-d-and-fluoride. Accessed October 29, 2017.
81. Preface: Dosage Schedule for Dietary Fluoride Supplements. J Public Health
Dent 1999;59(4):203-4. Available at: http://0nlinelibrary.wiley.com/
doi/10.1111/j.1752-7325.1999.tbO3270.x/epdf. Accessed October 4, 2017,
82. Marthaler TM. Salt fluoridation and oral health. Acta Med Acad.
2013;42(2):140-55. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/24308394. Accessed October 24, 2017.
83. Gillespie GM, Baez R. Development of salt fluoridation in the Americas.
Schweiz Monatsschr Zahnmed 2005;115(8):663-9. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/16156168. Accessed October 24, 2017.
84. Marthaler TM, Pollak GE. Salt fluoridation in Central and Eastern Europe.
Schweiz Monatsschr Zahnmed 2005;115(8):670-674. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/16156169. Accessed October 24, 2017.
85. Rugg -Gunn A, Banoczy J. Fluoride toothpastes and fluoride mouthrinses
for home use. Acta Med Acad 2013;42(2):168-78. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/24308396. Accessed October 24, 2017.
86. The ADA/PDR Guide to Dental Therapeutics. Fifth Edition. 2009.
87. Estupinan-Day S. Promoting Oral Health: The use of salt fluoridation to
prevent dental caries. Pan American Health Organization (PAHO) 2005.
Scientific and technical Publication No. 615.
88. Marthaler T. Increasing the public health effectiveness of fluoridated salt.
Schweiz Monatsschr Zahnmed 2005;115(9):785-92. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmedl16231748. Accessed October 24, 2017.
89. Marthaler TM, Petersen PE. Salt fluoridation -an alternative in automatic
prevention of dental caries. Int Dent J 2005;55(6):351-8. Abstract at:
https://www.ncbi.nlm.nih.govlpubmedll6379137 Accessed October
24, 2017.
90. Gillespie GM and Marthaler TM. Cost aspects of salt fluoridation. Schweiz
Monatsschr Zahnmed 2005;115(9):778-84. Abstract at: https://www.
ncbi.n1m.nih.gov/pubmed/16231747 Accessed October 24, 2017.
91. Tramini P. Salt fluoridation in France since 1986. Schweiz Monatsschr
Zahnmed 2005;115(8):656-8. Abstract at: https://www.ncbi.nim.nih.
gov/pubmed/16156166. Accessed October 24, 2017.
92. Jones S, Burt BA, Petersen PE, Lennon M. The effective use of fluorides
in public health. Bulletin of the World Health Organization September
2005;83(9):670-76. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/16211158. Article at: https://www.ncbi.nim.nih.govlpmcl
articles/PMC2626340/ Accessed October 24, 2017.
93. Vallejos-Sanchez AA, Medina -Solis CE, Casnova-Rosado JF, Maupome
G, Minaya-Sanchez M, and Perez-Olivares S. Dental fluorosis in cohorts
born before, during and after the national salt fluoridation program in a
community in Mexico. Acta Odontologica Scandinavica 2006;64(4):209-
13. Abstract at: https://www.ncbi.nlm.nih.govlpubmedll6829495.
Accessed September 16, 2017.
94. Meyer-Lueckel H, Bitter K, Hopfenmuller W, & Paris S. Reexamination of
caries and fluorosis of children in an area of Jamaica with relatively high
fluorosis prevalence. Caries Res 2009;43(4):250-53. Abstract at: https.11
www.ncbi.nlm.nih.gov/pubmed/19439945. Accessed October 24, 2017.
95. Banoczy J, Rugg -Gunn A, Woodward M. Milk fluoridation for the
prevention of dental caries Acta Med Acad 2013;42(2):156-67.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl24308395.
Article at: http://www.ama.balindex.phplama/article/viewll861pdf 19.
Accessed October 24. 2017.
96. Marino R, Villa A, Guerrero S. A community trial of fluoridated powdered
milk in Chile. Community Dent Oral Epidemiol 2001;29(6):435-42.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedlll784286.
Accessed October 21, 2017.
97. Riley JC, Manning JC, Davies GM, Graham J and Worthington HV. Milk
fluoridation: a comparison of dental health in two communities in England.
Community Dental Health 2005;22(3):141-45. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmedl16161876. Accessed October 24, 2017.
98. Petersen PE, Kwan S. Ogawa H. Long-term evaluation of the clinical
effectiveness of community milk fluoridation in Bulgaria. Community Dent
Health 2015;32(4):199-203. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/26738215. Accessed October 21, 2017.
99. Petersson LG, Magnusson K, Hakestam U, Baigi A, Tweman S. Reversal
of primary root caries lesions after daily intake of milk supplemented
with fluoride and probiotic lactobacilli in older adults. Acta Odontol
Scand 2011;69(6):321-7. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/21563871. Accessed October 21, 2017.
100. Quock RL, Chan J. Fluoride content of bottled water and its implications
for the general dentist. Gen Dent 2009;57(1):29-33. Abstract at:
https://www.ncbi.nim.nih.govlpubmedll9l46140. Accessed
October 3, 2017.
101. Federal Register 1979 Jul 20;44(141):42775-8. National Archives and
Records Administration. Library of Congress. Available at: https://www.
loc.gov/itemlfr044141. Accessed October 3, 2017.
102. 21 CFR 165.110. Bottled Water. Available at: https://www.ecfrgovl
cgi-bin/text-idx?SID=5c34abfa5cd 6e4f55395aa 78348c26ae&mc=t
rue&node=pt21.2.165&rgn=div5. Accessed October 3, 2017.
103. Federal Register 1995 Nov 13;60(218):57079-57080. Available at:
https://www.federairegister.govldocumentsll995111113195-277981
beverages -bottled -water. Accessed October 3, 2017.
...............................................................................................................................................................
Benefits I Fluoridation Facts 35
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Benefit References
104. American Dental Association. Policy on bottled water, home water
treatment systems and fluoride exposure. Adopted by the American Dental
Association 2013 House of Delegates. Available at: http://www.ADA.org/
en/about-the-ada/ada-positions-policies-and-statements/policy-on-
bottled-water-home-water-treatment-syste. Accessed October 1, 2017.
105. U.S. Department of Health and Human Services. U.S. Food and Drug
Administration. Health claim notification for fluoridated water and
reduced risk of dental caries. Available at: https://www.fda.gov/food/
labelingnutrition/ucm073602.htm. Accessed September 19, 2017.
106. Beverage Marketing Corporation. Bottled water becomes number -one
beverage in the U.S., data from beverage marketing corporation show. Press
Release March 9, 2017. Available at: https://www.beveragemarketing.
com/news-detaiLasp?0=438. Accessed October 4, 2017.
107. International Bottled Water Association. PET facts. Available at: http://
www.bottledwater.org/education/recycling/pet-facts. Accessed
October 4, 2017.
108. Huerta-Saenz L, Irigoyen M, Benavides J, Mendoza M. Tap or bottled
water: drinking preferences among urban minority children and
adolescents. J Community Health 2012,37(1):54-8. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl2l643824. Accessed
October 3, 2017.
109. Scherzer T, Barker JC, Pollick H, Weintraub JA. Water consumption
beliefs and practices in a rural Latino community: implications for
fluoridation. J Public Health Dent 2010;70(4):337-43. Abstract
at: https://www.ncbi.nim.nih.govlpubmedl20735717 Article at:
https://www.ncbi.nim.nih.govlpmclarticiesIPMC3536824.
Accessed October 3, 2017.
110. Sriraman INK, Patrick PA, Hutton K, Edwards KS. Children's
drinking water: parental preferences and implications for fluoride
exposure. Pediatr Dent 2009;31(4):310-5. Abstract at:
https://www. ncbi.nlm. nih.gov/pubmed/19722439.
Accessed October 3, 2017.
111. Hobson WL, Knochel MI, Byington CL, Young PC, Hoff CJ, Buchi KF.
Bottled, filtered, and tap water use in Latino and non -Latino children.
Arch Pediartr Adolesc Med 2007;161(5):457-61. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/17485621. Article at: https://
jamanetwork.com/journa/sljamapediatricslfu//artic/el570296.
Accessed October 3, 2017.
112. Brown MD, Aaron G. The effect of point -of -use water conditioning
systems on community fluoridated water. Pediatr Dent 1991;13(1):35-
8. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/1945982.
Accessed September 18, 2017.
113. Jobson MD, Grimm SE 3rd, Banks K, Henley G. The effects of water
filtration systems on fluoride: Washington, D.C. metropolitan area. ASDC
J Dent Child 2000;67(5):350-4. Abstract at: https://www.ncbi.nlm.nih.
gov1pubmed111068668. Accessed September 18, 2017.
114. Robinson SN, Davies EH, Williams B. Domestic water treatment
appliances and the fluoride ion. Br Dent J 1991;171(3-4):91-3. Abstract
at: https://www.ncbi.nlm.nih.gov/pubmed/1888589. Accessed
September 18, 2017.
115. Full CA, Wefel JS. Water softener influence on anions and cations. Iowa
Dent J 1983;69(4):37-9.
116. Konno H, Yaegaki K, Tanaka T, Sato T, Itai K, Imai T, Murata T, Herai M.
Neither hollow -fibre filters nor activated -charcoal filters remove fluoride
from fluoridated tap water. J Can Dent Assoc 2008;74(5):443. Abstract
at: https://www.ncbi.nlm.nih.govlpubmed/18538069.
Article at: http://www.cda-adc.ca/jcda/vol-74/issue-5/443.html.
Accessed September 18, 2017.
36 American Dental Association
back to agenda
17. Does fluoride in the water supply, at the
levels recommended for the prevention of
tooth decay, adversely affect human health?
Answer.
The overwhelming weight of scientific evidence
supports the safety of community water
fluoridation.
Fact.
For generations, millions of people have lived in areas
where fluoride is found naturally in drinking water
in concentrations as high or higher than the optimal
level recommended to prevent tooth decay. Research
conducted among these persons confirms the safety
of fluoride in the water supply.'-'
As with other nutrients, fluoride is safe and effective
when used and consumed as recommended.
No charge against the benefits and safety of
fluoridation has ever been substantiated by generally
accepted scientific knowledge. A number of reviews
on fluoride in drinking water have been issued
over the years. For example, in 19516 the National
Research Council (NRC), of the National Academies,
issued its first report stating fluoridation was
safe and effective. Additional reviews by the NRC
followed in 1977' and 19938 with the most recent
NRC review completed in 2006.1 Additional reviews
completed over the ten year period from 2007-
2017 include:
2017 Australian Government. National Health
and Medical Research Council (NHMRC).
Information Paper — Water Fluoridation:
Dental and Other Human Health Outcomes.1 °
2016 O'Mullane DM, Baez RJ, Jones S, Lennon
MA, Petersen PE, Rugg -Gunn AJ, Whelton H,
Whitford GM. Fluoride and Oral Health."
2016 American Water Works Association.
Water Fluoridation Principles and Practices.
AWWA Manual M4. Sixth edition 12
2015 Water Research Foundation. State of the
Science: Community Water Fluoridation.13
2015 The Network for Public Health Law. Issue Brief:
Community Water Fluoridation.14
...............................................................................................................................................................
Safety I Fluoridation Facts 37
back to agenda
2015 Ireland Health Research Board. Health Effects
of Water Fluoridation: An Evidence Review"
2015 U.S. Department of Health and Human Services
Federal Panel on Community Water Fluoridation.
U.S. Public Health Service Recommendation for
Fluoride Concentration in Drinking Water for
the Prevention of Dental Cories16
2014 Public Health England. Water Fluoridation:
Health Monitoring Report for England.17
2014 Royal Society of New Zealand and the Office
of the Prime Minister's Chief Science Advisor.
Health Effects of Water Fluoridation: a Review
of the Scientific Evidence.18
2013 U.S. Community Preventive Services Task
Force. The Guide to Community Preventive
Services. Preventing Dental Caries:
Community Water Fluoridation 19
2011 European Commission of the European
Union Scientific Committee on Health and
Environmental Risks (SCHER). Fluoridation.20
2008 Health Canada. Findings and Recommendations
of the Fluoride Expert Ponel.21
2007 Australian Government National Health and
Medical Research Council A Systematic Review
of the Efficacy and Safety of Fluoridation;
Part A: Review Methodology and Results.12
.............................................................................
The overwhelming weight of scientific evidence
supports the safety of community water
fluoridation.
18. Are additional studies being conducted
to determine the effects of fluorides in
humans?
Answer.
Yes. Since its inception, fluoridation has undergone
a nearly continuous process of re-evaluation. As
with other areas of science, additional studies on the
effects of fluorides in humans can provide insight as to
how to make effective choices for the use of fluoride.
The American Dental Association and the U.S. Public
Health Service support this on -going research.
Fact.
For more than 70 years, detailed reports have
been published on multiple aspects of fluoridation.
The accumulated dental, medical and public health
evidence concerning fluoridation has been reviewed
and evaluated numerous times by academicians,
committees of experts, special councils of
governments and most of the world's major national
and international health organizations. The consensus
of the scientific community is that water fluoridation,
at the level recommended to prevent tooth decay,
safely provides oral health benefits which in turn
supports improved general health. The question of
possible secondary health effects caused by fluorides
consumed in optimal concentrations throughout life
has been the object of thorough medical investigations
which have failed to show any impairment of general
health throughout life10-22
...............................................................................
The consensus of the scientific community
is that water fluoridation, at the level
recommended to prevent tooth decay, safely
provides oral health benefits which in turn
supports improved general health.
...............................................................................
In scientific research, there is no such thing as
"final knowledge." New information is continuously
emerging and being disseminated. Government
agencies, such as the U.S. National Institutes of
Health, National Institute of Dental and Craniofacial
Research, and others continue to fund fluoride
research. One example is the National Toxicology
Program's systematic review using animal studies
to evaluate potential neurobehavioral effects from
exposure to fluoride during development which began
in 2015 and continues in 2017.21
.....................................
38 American Dental Association
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In 2011, the U.S. Department of Health and Human
Services and the U.S. Environmental Protection
Agency (EPA) issued ajoint press release21 outlining
important steps the respective agencies were
taking to ensure that standards and guidelines on
fluoride in drinking water continue to ensure the
safety of the public while supporting good dental
health, especially in children. Those actions resulted
in the 2015 report issued by the U.S. Public Health
Service16 regarding the recommended level of
fluoride in drinking water and the EPA activity was
informational to the 2016 EPA Six -Year Review 321
in which the Agency completed a detailed review of
drinking water regulations including the regulation
for naturally occurring fluoride in water.
19. Why did the U.S. Public Health Service
issue a report in 2015 recommending 0.7
milligrams per liter (mg/L) as the optimal
level for fluoride in drinking water for all
temperature zones in the U.S.?
Answer.
The U.S. Public Health Service (USPHS) updated and
replaced its 1962 Drinking Water Standards related
to community water fluoridation to establish a single
value of 0.7 mg/L as the optimal concentration
of fluoride in drinking water. This concentration
provides the best balance of protection from tooth
decay while limiting the risk of dental fluorosis 16
Fact.
The previous U.S. Public Health Service recommendations
for optimal fluoride concentrations were based on
average ambient air temperatures of geographic
areas and ranged from 0.7-1.2 mg/L. In 2011, the U.S.
Department of Health and Human Services (HHS) issued
a notice of intent in the Federol Register26 proposing that
community water systems adjust the amount of fluoride
to 0.7 mg/L to achieve an optimal fluoride level.
The new guidance was based on several considerations
that included:
• Scientific evidence related to effectiveness of
water fluoridation on caries prevention and
control across all age groups.
Fluoride in drinking water as one of several
available fluoride sources.
Trends in the prevalence and severity of dental
fluorosis.
• Current evidence on fluid intake in children across
various ambient air temperatures.
As part of the process leading to the notice of intent, the
U.S. Department of Health and Human Services (HHS)
convened a federal interdepartmental, interagency panel
of scientists to review the scientific evidence relevant
to the 1962 USPHS Drinking Water Standards for
fluoride concentrations in drinking water in the United
States and to update these recommendations based
on current science. Panelists included representatives
from the Centers for Disease Control and Prevention,
the National Institutes of Health, the U.S. Food and
Drug Administration, the Agency for Healthcare
Research and Quality, the Office of the Assistant
Secretary for Health, U.S. Environmental Protection
Agency, and the U.S. Department of Agriculture16
A public comment period followed the publication
of the notice of intent during which time more than
19,000 comments were received. The vast majority
(more than 18,000) were variations on a letter
submitted by an organization opposing community
water fluoridation. Comments received were
summarized and reported to the full federal panel.
The panel then spent several years reviewing each
comment in light of the best available science. After
completing their extensive review, the panel did not
alter the recommendation based on the following:
• Community water fluoridation remains an effective
public health strategy for delivering fluoride to
prevent tooth decay and is the most feasible
and cost-effective strategy for reaching entire
communities.
• In addition to drinking water, other sources
of fluoride exposure have contributed to the
prevention of dental caries and an increase in
dental fluorosis prevalence.
• Caries preventive benefits can be achieved and the
risk of dental fluorosis reduced at 0.7 mg/L.
• Recent data do not show a convincing relationship
between water intake and outdoor air temperature.
Thus, recommendations for water fluoride
concentrations that differ based on outdoor
temperature are unnecessary.16
Safety Fluoridation Facts 39
back to agenda
In 2015 the USPHS published a final report
establishing guidance for water systems that are
actively fluoridating or those that may initiate
fluoridation in the future 16 For community water
systems that add fluoride to their water, the USPHS
recommends a uniform fluoride concentration of 0.7
mg/L (parts per million [ppm]) for the entire United
States to maintain caries (tooth decay) prevention
benefits and reduce the risk of dental fluorosis.
The USPHS further noted that surveillance of dental
caries (tooth decay), dental fluorosis, and fluoride intake
through the National Health and Nutritional Examination
Survey will be done to monitor changes that might occur
following implementation of the recommendation 16
20. What is the recommendation for the
maximum level of naturally occurring
fluoride in drinking water contained in the
2016 EPA Six -Year Review 3?
Answer.
As established by the U.S. EPA, the maximum
allowable level of naturally occurring fluoride in
drinking water is 4 milligrams/liter (mg/L or ppm).
Under the Maximum Contaminant Level (MCL)
standard, if the naturally occurring level of fluoride
in a public water supply exceeds the MCL, the water
supplier is required to lower the level of fluoride
below the MCL — a process called defluoridation.
The MCL is a federally enforceable standard.27
(Additional details regarding the EPA maximum
contaminant standards can be found in the Figure 3.)
Fact.
Under the Safe Drinking Water Act (SDWA)'27 the EPA
is required to periodically review the existing National
Primary Drinking Water Regulations (NPDWRs) "not
less often than every 6 years." This review is a routine
part of the EPA's operations as dictated by the SDWA.
In April 2002, the EPA announced the results of
its preliminary revise/not revise decisions for 68
chemical NPDWRs as part of its first Six -Year Review
of drinking water standards.28 Fluoride was one of
the 68 items reviewed. While the EPA determined
that it fell under the "Not Appropriate for Revision at
this Time" category, the agency asked the National
Academies (NA) to update the risk assessment for
fluoride. Prior to this time, the National Academies'
National Research Council (NRC) completed a review
of fluoride for the EPA which was published as "Health
Effects of Ingested Fluoride" in 1993.8
The National Research Council's Committee on Toxicology
created the Subcommittee on Fluoride in Drinking
Water9 which reviewed toxicologic, epidemiologic, and
clinical data published since 1993, and exposure data
on orally ingested fluoride from drinking water and
other sources (e.g., food, toothpaste, dental rinses).
Based on these reviews, the Subcommittee evaluated
independently the scientific and technical basis of
the U.S. Environmental Protection Agency's (EPA)
maximum contaminant level goal (MCLG) of 4 milligram
per liter (mg/L or ppm) and secondary maximum
contaminant level (SMCL) of 2 mg/L in drinking water.
On March 22, 2006, almost three years after work
began, the NRC issued a 500-page report titled Fluoride
in Drinking Water — A Scientific Review of the EPA's
Stondords9 to advise the EPA on the adequacy of its
fluoride MCLG (maximum contaminant level goal) and
SMCL (secondary maximum contaminant level) to
protect children and others from adverse effects. (For
additional information on the EPA maximum contaminant
standards, please refer to Figure 3.) The report contained
two major recommendations related to the MCLG:
In light of the collective evidence on various health
end points and total exposure to fluoride, the
committee concludes that EPA's MCLG of 4 mg/L
should be lowered. Lowering the MCLG will prevent
children from developing severe enamel fluorosis
and will reduce the lifetime accumulation of fluoride
into bone that the majority of the committee
concludes is likely to put individuals at increased
risk of bone fracture and possibly skeletal fluorosis,
which are particular concerns for subpopulations that
are prone to accumulating fluoride in their bones.9
To develop an MCLG that is protective against
severe enamel fluorosis, clinical stage II skeletal
fluorosis, and bone fractures, EPA should update the
risk assessment of fluoride to include new data on
health risks and better estimates of total exposure
(relative source contribution) for individuals. EPA
should use current approaches for quantifying
risk, considering susceptible subpopulations, and
characterizing uncertainties and variability.9
The 2006 NRC report9 contained one major
recommendation related to the Secondary Maximum
Contaminant Level (SMCL):
40 American Dental Association
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The prevalence of severe enamel fluorosis is very
low (near zero) at fluoride concentrations below
2 mg/L. From a cosmetic standpoint, the SMCL
does not completely prevent the occurrence of
moderate enamel fluorosis. EPA has indicated that
the SMCL was intended to reduce the severity and
occurrence of the condition to 15% or less of the
exposed population. The available data indicate that
fewer than 15% of children will experience moderate
enamel fluorosis of aesthetic concern (discoloration
of the front teeth) at that concentration. However,
the degree to which moderate enamel fluorosis
might go beyond a cosmetic effect to create an
adverse psychological effect or an adverse effect
on social functioning is not known.'
Additionally, the Subcommittee identified data gaps and
made recommendations for future research relevant to
future revisions of the MCLG and SMCL for fluoride.9
It should be emphasized that the 2006 NRC report was
not a review of fluoride as used in community water
fluoridation. In fact, the 2006 NRC Report in Brief29
states: "The committee did not evaluate the risks or
benefits of the lower fluoride concentrations (0.7 to
1.2 mg/L) used in water fluoridation. Therefore, the
committee's conclusions regarding the potential for
adverse effects from fluoride at 2 to 4 mg/L in drinking
water do not apply at the lower water fluoride levels
commonly experienced by most U.S. citizens"29
In response to the recommendations noted above from
the NRC report, in 2011, the EPA completed and peer -
reviewed a quantitative dose -response assessment
based on the available data for severe dental fluorosis
as recommended by the NRC.30 Additionally, the EPA
completed and peer -reviewed a document on the
environmental exposure of children and adults to
fluoride and the relative source contribution for water
which is needed in order to derive the MCLG from the
dose -response assessment.30 These efforts were being
undertaken during Six -Year Review 2 and so no action
on fluoride was taken during Six -Year Review 2.
In December 2016, the EPA announced the review
results for the Agency's third Six -Year Review (called
Six -Year Review 3),21 in which the Agency completed
a detailed review of 76 national primary drinking
water regulations. The regulation for naturally
occurring fluoride in water was examined as part of
this review and is included among the list of regulated
contaminants considered to be "Low priority and/or
no meaningful opportunity" under "Not Appropriate
for Revision at this Time.1121
The announcement of the results of the EPA's Six -Year
Review 3 in the Federol Register31 indicates that, with
the reviews of fluoride conducted since the first Six -
Year Review (including but not limited to the 2006
NRC report and the EPA Fluoride Risk Assessment and
Relative Source Contribution) and noting that other
contaminants are of much greater concern, the EPA is
recommending that no further action be taken at this
time to change the current MCL/MCLG of 4 mg/L
(the maximum level of naturally occurring fluoride
allowed in drinking water).31
21. What is the Secondary Maximum
Contaminant Level (SMCL) for naturally
occurring fluoride in drinking water
established by the EPA?
Answer.
The Secondary Maximum Contaminant Level (SMCL)
for naturally occurring fluoride in water is 2 mg/L
(or ppm). This is a non -enforceable federal standard.
Fact.
In addition to the MCL, the EPA has established a
Secondary Maximum Contaminant Level (SMCL) of 2.0
mg/L and requires consumer notification by the water
supplier if the naturally occurring fluoride level exceeds
2.0 mg/L. The SMCL, while not federally enforceable,
is intended to alert families that regular consumption
of water with natural levels of fluoride greater than
2.0 mg/L by young children could cause moderate to
severe dental fluorosis in the developing permanent
teeth.32 The notice to be used by water systems that
exceed the SMCL must contain the following points:
1. The notice is intended to alert families that children
under nine years of age who are exposed to levels
of fluoride greater than 2.0 mg/liter may develop
dental fluorosis.
2. Adults are not affected because dental fluorosis
occurs only when developing teeth are exposed
to elevated fluoride levels.
3. The water supplier can be contacted for information
on alternative sources or treatments that will insure
the drinking water would meet all standards
(including the SMCL).32
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Safety I Fluoridation Facts 41
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U.S. Environmental Protection Agency (EPA) Standards for Fluoride in Drinking Water
The EPA standards for fluoride in drinking water apply to the naturally occurring fluoride in water.
They are the:
• Maximum Contaminant Level Goal (MCLG) — 4 mg/L
• Maximum Contaminant Level (MCL) — 4 mg/L
• Secondary Maximum Contaminant Level (SMCL) — 2 mg/L
MCLG — The MCLG is the level of contaminants in drinking water at which no adverse health effects are
likely to occur. This health goal is based solely on possible health risks and exposure over a lifetime with
an adequate margin of safety. The current MCLG for fluoride is 4 mg/L and is set at this level to provide
protection against the increased risk of crippling skeletal fluorosis.
MCL — The MCL is an enforceable standard which is set as close to the health goal as possible, considering
the benefit to the public, the ability of public water systems to detect and remove contaminants using
suitable treatment technologies and cost. In the case of fluoride, the MCL is set at the MCLG.
Under the MCL standard, if the naturally occurring level of fluoride in a public water supply exceeds 4 mg/L,
the water supplier is required to lower the level of fluoride or defluoridate. Community water systems that
exceed the fluoride MCL of 4 mg/L must notify persons served by that system as soon as practical, but no
later than 30 days after the system learns of the violation.
SMCL — Secondary standards are non -enforceable guidelines regulating contaminants that may cause
cosmetic effects (such tooth discoloration). The EPA recommends secondary standards to water systems
but does not require systems to comply. However, states may choose to adopt them as enforceable standards.
Tooth discoloration and/or pitting is caused by excess fluoride exposures during the formative period prior to
eruption of the teeth in children. The level of the SMCL was set based upon a balancing of the beneficial effects
of protection from tooth decay and the undesirable effects of excessive exposures leading to discoloration.
Under the SMCL, if water exceeds 2 mg/L, the water system is to notify consumers that regular consumption
of water with fluoride above 2 mg/L, may increase the risk for fluorosis in young (under 9 years of age)
children. Community water systems that exceed the fluoride secondary standard of 2 mg/L must notify
persons served by that system as soon as practical but no later than 12 months from the day the water
system learns of the exceedance.
U.S. Public Health Service (USPHS) Recommendation for Fluoride in Drinking Water
In 2015, the USPHS published a final report establishing guidance for water systems that are actively
fluoridating or those that may initiate fluoridation in the future. For community water systems that add
fluoride to their water, the USPHS recommends a uniform fluoride concentration of 0.7 mg/L for the entire
United States to maintain caries (tooth decay) prevention benefits and reduce the risk of dental fluorosis.
Why is the EPA MCL of 4 mg/L different from the USPHS recommendation of 0.7 mg/L?
The two benchmarks have different purposes and are set under different authorities. The EPA MCL of
4 mg/L is set to protect against risks from exposure to too much fluoride. The USPHS recommended level
of fluoride on 0.7 mg/L is set to promote the benefit of fluoride in preventing tooth decay while minimizing
the chance for dental fluorosis.
Information Source: EPA Fact Sheet: Questions and Answers on Fluoride. 2011. Available at
https://www.epa.govldwsixyearreviewlfact-sheet-questions-and-answers-fluoride
6 Additional information on these topics con be found in this Section, Questions 19, 20 and 21.
42 American Dental Association
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22. Does the total intake of fluoride from
air, water and foods in a community in the
United States with drinking water fluoridated
at the recommended level pose significant
health risks?
Answer.
The total intake of fluoride from air, water and
foods in a community in the United States with
drinking water fluoridated at the recommended
level does not pose significant health risks.
Fact.
Fluoride from the Air
The atmosphere normally contains negligible
concentrations of airborne fluorides. Studies
reporting the levels of fluoride in air in the United
States suggest that ambient fluoride contributes
very little to a person's overall fluoride intake.9,30
Fluoride from Water
For generations, millions of people have lived in areas
where fluoride is found naturally in drinking water
in concentrations as high as or higher than those
recommended to prevent tooth decay. Research
conducted among these people confirms the safety
of fluoride in the water supply'-'
A ten-year comparison study of long-time residents
of Bartlett and Cameron, Texas, where the water
supplies contained 8.0 and 0.4mg/L of fluoride,
respectively, included examinations of organs, bones
and tissues. Other than a higher prevalence of dental
fluorosis in the Bartlett residents (8.0 mg/L fluoride),
the study indicated that long-term consumption
of fluoride from water and food sources (resident
average length of fluoride exposure was 36.7 years),
even at these levels more than 10 times higher than
recommended for tooth decay prevention, resulted
in no clinically significant physiological or functional
effects.'
In the United States, the natural level of fluoride in
ground water varies from very low levels to over 4
mg/L. Public water systems in the U.S. are monitored
by the Environmental Protection Agency (EPA), which
requires that public water systems not exceed a
naturally occurring fluoride level of 4 mg/L.31 The
recommended level for fluoride in drinking water in
the United States has been established at 0.7 mg/L
by the U.S. Public Health Service 16 This level has been
established to reduce tooth decay while minimizing
the occurrence of dental fluorosis.
Individuals living in a community with water
fluoridation get a portion of their daily fluoride
intake from fluoridated water and a portion from
dietary sources which would include foods and other
beverages. Water and water -based beverages are the
chief source of dietary fluoride intake. Conventional
estimates are that approximately 75% of dietary
fluoride comes from water and water -based
beverages.13,34 When considering water fluoridation,
an individual consuming one liter of water fluoridated
at 0.7 mg/L receives 0.7 milligram of fluoride.
Fluoride in Foods
In looking at the fluoride content of foods and beverages
over time, it appears that fluoride intake from dietary
sources has remained relatively constant .31 Except for
products prepared (commercially or by the individual)
or cooked with fluoridated water, the fluoride content
of most foods and beverages is not significantly
different between fluoridated and nonfluoridated
communities. When fluoridated water is used to
prepare or cook the samples, the fluoride content
of foods and beverages is higher. This difference has
remained relatively constant over time.33,35
Launched in 2004 and updated in 2005, the National
Fluoride Database is a comprehensive, nationally
representative database of the fluoride concentration
in 427 foods across 27 food groups and beverages
consumed in the United States.34 This database for
fluoride was designed for use by epidemiologists and
health researchers to estimate fluoride intake and to
assist in the investigation of the relationships between
fluoride intake and human health. The database
contains fluoride values for beverages, water, and
some lower priority foods.34
The fluoride content of fresh solid foods in the
United States generally ranges from 0.01 to 1.0
part per million.31 The foods highest in fluoride are
fish and shellfish, reflective of the fluoride found in
ocean water, and the presence or absence of bone
fragments such as those in sardines.31 (Fluoride has an
affinity for calcified tissues such as bones.) Cereals,
baked goods, breads, and other grain products were
estimated to have fluoride concentrations between
0.06 and 0.72 ppm. The majority of vegetables (leafy,
root, legumes, green or yellow) have a relatively low
fluoride concentration (ranging from 0.01 to 0.5 ppm)
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Safety I Fluoridation Facts 43
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with fruits generally having lower concentrations
(ranging from 0.01 to 0.2 ppm) than in vegetables.
Raisins are one exception in the fruit category with a
higher fluoride concentration due to the use of certain
pesticides and concentration through drying."
Brewed teas can contain fluoride concentrations of
1 ppm to 6 ppm depending on the amount of dry
tea used, the water fluoride concentration and the
brewing time.36 The fluoride value for unsweetened
instant tea powder appears very high when reported
as a dry powder because this product is extremely
concentrated. However, when one teaspoon of the
unsweetened tea powder is added to an eight ounce
cup of tap water, the value for prepared instant tea is
similar to the values reported for regular brewed tea."
Foods and beverages commercially processed
(cooked or reconstituted) in cities fluoridated to the
recommended level generally contain higher levels
of fluoride than those processed in nonfluoridated
communities. These foods and beverages are
consumed not only in the city where processed,
but also are often distributed to and consumed in
nonfluoridated areas.37 This "halo" or "diffusion"
effect results in increased fluoride intake by people
in nonfluoridated communities, providing them
increased protection against tooth decay.18,1e As a
result of the widespread availability of these various
sources of fluoride, the difference between tooth
decay rates in fluoridated areas and nonfluoridated
areas is somewhat less than several decades ago but
this difference is still significant. Failure to account
for the diffusion effect results in an underestimation
of the total benefit of water fluoridation especially in
areas where large amounts of fluoridated products
are brought into nonfluoridated communities.38
The average daily dietary intake of fluoride
(expressed on a body weight basis) by children
residing in communities with water fluoridated at
1.0 mg/L is 0.05 mg/kg/day (milligram per kilogram
of body weight per day).40 In communities without
optimally fluoridated water, average intakes for
children are about 50% lower.40 Dietary fluoride
intake by adults in communities where water is
fluoridated at 1.0 mg/L averages 1.4 to 3.4 mg/day,
and in nonfluoridated areas averages 0.3 to 1.0 mg/
day.40 With the 2015 recommendation that drinking
water be fluoridated at 0.7 mg/L, average intakes
would be 30% lower in fluoridated communities than
when they were fluoridated at 1.0 mg/L.
23. How much fluoride is recommended
to maximize the tooth decay prevention
benefits of fluoride?
Answer.
As with all nutrients, the appropriate amount
of daily fluoride intake varies with age and body
weight. Fluoride is safe and effective when used
and consumed properly.
Fact.
In 1997, the Food and Nutrition Board of the Institute
of Medicine developed a comprehensive set of
reference values for dietary nutrient intakes.40 These
new reference values, the Dietary Reference Intakes
(DRI), replace the Recommended Dietary Allowances
(RDA) which had been set by the National Academy of
Sciences since 1941. The new values present nutrient
requirements to optimize health and, for the first
time, set maximum -level guidelines to reduce the
risk of adverse effects from excessive consumption
of a nutrient. Along with calcium, phosphorous,
magnesium and vitamin D, DRIs for fluoride were
established because of its proven preventive effect
on tooth decay. (See Table 2 in this Question.)
The Adequate Intake (AI) establishes a goal for
intake to sustain a desired indicator of health without
causing side effects. In the case of fluoride, the Al is
the daily intake level required to reduce tooth decay
without causing moderate dental fluorosis. The
Al for fluoride intake from all sources (fluoridated
water, foods, beverages, fluoride dental products
and dietary fluoride supplements) is set at 0.05
mg/kg/day. Using the established Al of 0.05 mg/
kg, the amount of fluoride for optimal health to be
consumed each day has been calculated by sex and
age group (expressed as average weight).40
The Tolerable Upper Intake Level (UL) establishes
a maximum guideline. The UL is higher than the Al
and is not the recommended level of intake. The UL
is the estimated maximum intake level that should
not produce unwanted effects on health. The UL for
fluoride intake from all sources (fluoridated water,
foods, beverages, fluoride dental products and dietary
fluoride supplements) is set at 0.10 mg/kg/day
(milligram per kilogram of body weight per day) for
infants, toddlers, and children through eight years of
age. For older children and adults, who are no longer
at risk for dental fluorosis, the UL for fluoride is set at
44 American Dental Association
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Table
Food and Nutrition Board of the Institute of Medicine 199740
Age Group
Reference Weights
kg (lbs)*
Adequate Intake
(mg/day)
Tolerable Upper
Intake (mg/day)
Infants 0-6 months
7 (16)
0.01
0.7
Infants 7-12 months
9 (20)
0.5
0.9
Children 1-3 years
13 (29)
0.7
1.3
Children 4-8 years
22 (48)
1.0
2.2
Children 9-13 years
40 (88)
2.0
10.0
Boys 14-18 years
64 (142)
3.0
10.0
Girls 14-18 years
57 (125)
3.0
10.0
Males 19 years and over
76 (166)
4.0
10.0
Females 19 years and over
61 (133)
3.0
10.0
* Value based on data collected during 1988-94 as part of the Third National Health and Nutrition Examination Survey
(NHANES III) in the United States.40
10 mg/day regardless of weight. Using the established
ULs for fluoride, the amount of fluoride that can be
consumed each day to reduce the risk of moderate
enamel fluorosis for children through age eight, has
been calculated by sex and age group (expressed as
average weight).40 (See Table 2.)
As a practical example, daily intake of 2 mg of
fluoride is adequate for a 9- to 13-year-old child
weighing 88 pounds (40 kg). This was calculated
by multiplying 0.05 mg/kg/day (AI) times 40 kg
(weight) to equal 2 mg. At the same time, that 88
pound (40kg) child could consume 10 mg of fluoride
a day as a tolerable upper intake level.
Children living in a community with water fluoridation
get a portion of their daily fluoride intake from
fluoridated water and a portion from dietary sources
which would include foods and other beverages. When
considering water fluoridation, an individual must
consume one liter of water fluoridated at 0.7 mg/L to
receive 0.7 milligrams (0.7 mg) of fluoride. Children
under six years of age, on average, consume less than
one-half liter of drinking water a day.35 Therefore,
children under six years of age would consume, on
average, less than 0.35 mg of fluoride a day from
drinking optimally fluoridated water (at 0.7 mg/L).
If a child lives in a nonfluoridated area and is
determined to be at high risk for tooth decay,
the dentist or physician may prescribe dietary
fluoride supplements.41 As shown in Table 1
"Dietary Fluoride Supplement Schedule" (See
Benefits Section, Question 12.), the current dosage
schedule recommends supplemental fluoride
amounts that are below the Al for each age group.41
The dosage schedule was designed to offer the
benefit of decay reduction with a margin of safety
to prevent mild to moderate enamel fluorosis. For
example, the Al for a child 3 years of age is 0.7 mg/
day. The recommended dietary fluoride supplement
dosage for a child 3 years of age in a nonfluoridated
community is 0.5 mg/day. This provides leeway
for some fluoride intake from processed foods and
beverages, and other sources.
Tooth decay rates are declining in many population
groups because children today are being exposed
to fluoride from a wider variety of sources than
decades ago 16 Many of these sources are intended
for topical use only; however, some fluoride is
ingested inadvertently by children.42,43 By reducing the
inappropriate ingestion of fluoride from toothpaste,
the risk of dental fluorosis can be reduced without
jeopardizing the benefits to oral health.
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Safety I Fluoridation Facts 45
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For example, it has been reported in a number of
studies that young children inadvertently swallow
an average of 0.30 mg of fluoride from fluoride
toothpaste at each brushing.44-48 If a child brushes
twice a day, 0.60 mg of fluoride could be ingested
inappropriately. This could slightly exceed the
Adequate Intake (AI) values from Table 2. The 0.60
mg consumption is 0.10 mg higher than the Al value
for children 6 to 12 months and is 0.10 mg lower than
the Al for children from 1-3 years of age.40 Although
toothpaste is not meant to be swallowed, children
could consume the daily recommended Adequate
Intake amount of fluoride from toothpaste alone.
In order to decrease the risk of dental fluorosis, the
American Dental Association (ADA) recommends:49
For children younger than 3 years, caregivers
should begin brushing children's teeth as soon
as they begin to come into the mouth by using
fluoride toothpaste in an amount no more than a
smear or the size of a grain of rice (Figure 4). Brush
teeth thoroughly twice per day (morning and night)
or as directed by a dentist or physician. Supervise
children's brushing to ensure that they use the
appropriate amount of toothpaste.
For children 3 to 6 years of age, caregivers should
dispense no more than a pea -sized amount (Figure
4) of fluoride toothpaste. Brush teeth thoroughly
twice per day (morning and night) or as directed by
a dentist or physician. Supervise children's brushing
to minimize swallowing of toothpaste.49
6 Additional information on this topic can be found
in this Section, Question 29.
For children under three
years old, use no more than
a smear or grain -of -rice -
sized amount of fluoride
toothpaste.
For children three to six
years old, use only a pea -
sized amount of fluoride
toothpaste.
It should be noted that the amounts of fluoride
discussed here are intake, or ingested, amounts.
When fluoride is ingested, a portion is retained in
the body and a portion is excreted.
6 Addition information on this topic can be found
in this Section, Question 25.
24. Is there a need for prenatal dietary
fluoride supplementation?
Answer.
There is no scientific basis to suggest any need
to increase a woman's daily fluoride intake during
pregnancy or breastfeeding to protect her health.
At this time, scientific evidence is insufficient to
support the recommendation for prenatal fluoride
supplementation for decay prevention for infants.
Fact.
The Institute of Medicine determined that, "No data
from human studies document the metabolism of
fluoride during lactation. Because fluoride concentrations
in human milk are very low (0.007 to 0.011 ppm)
and relatively insensitive to differences in the fluoride
concentrations of the mother's drinking water, fluoride
supplementation during lactation would not be expected
to significantly affect fluoride intake by the nursing
infant or the fluoride requirement of the mother.'40
A 2005 a randomized, double blind study50
compared the amount of fluoride incorporated
into primary teeth exposed to prenatal and post
natal fluoride supplements to primary teeth that
were exposed to only postnatal fluoride. The study
concluded that teeth exposed to prenatal and
postnatal fluoride supplements had no additional
measurable fluoride other than that attributable to
postnatal fluoride alone.5' This study confirmed the
findings of a 1997 randomized, double blind study
that evaluated the effectiveness of prenatal dietary
supplementation which concluded that the data did
not support the hypothesis that prenatal fluoride had
a strong decay preventive effect on primary teeth."
46 American Dental Association
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25. When fluoride is ingested, where does
it go?
Answer.
Much of the ingested fluoride is excreted. Of the
fluoride retained, almost all is found in calcified
(hard) tissues, such as bones and teeth.
Fact.
After ingestion of fluoride, such as drinking a glass
of fluoridated water, the majority of the fluoride is
absorbed from the stomach and small intestine into
the blood stream. This causes a short-term increase
in fluoride levels in the blood. Fluoride is distributed
through the body by plasma (a component of blood)
to hard and soft tissues. Following ingestion, the
fluoride plasma levels increase quickly and reach
a peak concentration within 20-60 minutes. The
concentration declines rapidly, usually approximating
the baseline levels within three to six hours, due
to the uptake of fluoride by calcified tissues and
excretion in urine. In adults, approximately 50% of the
fluoride absorbed each day becomes associated with
calcified tissues within 24 hours while the remainder
is excreted in the urine. Approximately 99% of the
fluoride present in the body is in calcified tissues
(mainly bone).12
Ingested or systemic fluoride becomes incorporated
into forming tooth structures. Fluoride ingested
regularly during the time when teeth are developing
is deposited throughout the tooth structure and
contributes to long lasting protection against tooth
decay.53-57
6 Additional information on this topic can be found
in the Benefits Section, Question 2.
An individual's age and stage of skeletal development
will affect the rate of fluoride retention. The amount
of fluoride taken up by bone and retained in the body
is inversely related to age. A greater percentage
of fluoride is absorbed in young bones than in the
bones of older adults.52 However, once fluoride is
absorbed into bones, it is released back into plasma (a
component of blood) when fluoride levels in plasma
fall. This absorption and release cycle continues
throughout the life span.52
26. Will drinking water that is fluoridated
at the recommended level adversely affect
bone health?
Answer.
According to the best available science, drinking
water that has been fluoridated at the recommended
level does not have an adverse effect on bone health.
Fact.
Several systematic reviews have concluded that
fluoride at the level used in community water
fluoridation has no adverse effect on bone health.
A systematic review published in 2000 concluded
that there was no clear association between water
fluoridation and hip fracture.59 Twenty-nine studies
that looked at the association between bone fracture/
bone development and water fluoridation were
included in the review. The evidence regarding other
types of bone fractures was similar.59 A systematic
review published in 201710 concurred with the
earlier review concluding that there is evidence that
fluoridated water at recommended levels is not
associated with bone fracture 10
In addition to the systematic reviews, a number of
individual studies have investigated the bone health
of individuals residing in communities with fluoride in
drinking water at the recommended levels and higher
than recommended levels. Most of these studies
have focused on whether there exists a possible link
between fluoride and bone fractures. Additionally,
the possible association between fluoride and bone
cancer has been studied. None of the studies provide
a legitimate reason for altering public health policy
regarding fluoridation and bone health concerns.
The following studies, listed in chronological order,
add to the body of evidence indicating that there is
no association between consumption of optimally
fluoridated water and bone fracture.
The Iowa Fluoride Study/Iowa Bone Development
Study60 looked at the association of fluoride intake
with bone measures (bone mineral content and
bone mineral density) in a cohort of Iowa children.
Assessment of the participants' dietary fluoride intake
had been ongoing since birth with parents completing
detailed fluoride questionnaires at numerous time
periods through 15 years of age. These children had
combined fluoride intake estimated from a number
of sources including water, other beverages, selected
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Safety I Fluoridation Facts 47
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foods, dietary fluoride supplements and fluoride
toothpaste. Estimated fluoride intake was noted during
different time periods and cumulatively from birth to
15 years of age. The findings indicate that fluoride
exposures at typical levels for most U.S. adolescents
in fluoridated areas do not have significant effects on
bone mineral measures. These findings are generally
comparable with those from the analyses of this cohort
at age 11 years.61 During the intervening 4 years,
cohort members generally experienced a substantial
increase in bone mass accrual. For example, mean
whole -body bone mineral content showed mean
increases of approximately 61 % in females and 96% in
males. Despite the acceleration of bone growth near
puberty, the associations between fluoride intake and
bone outcome measures remained weak and none was
significant after adjustment for other variables.60
In one of the largest studies of its kind with nearly
half a million subjects, Swedish researchers looked at
residents' chronic consumption of various levels of
fluoride and the risk of hip fracture. All individuals born
in Sweden between January 1, 1900 and December
31, 1919, alive and living in their municipality of birth
at the time of the start of follow-up, were eligible
for the study. Information on the study population
was linked to the Swedish health registers. Estimated
individual drinking water fluoride exposure was
stratified into 4 categories: very low, < 0.3 mg/L;
low, 0.3 to 0.69 mg/L; medium, 0.7 to 1.49 mg/L; and
high, >_ 1.5 mg/L. Published in 2013, the researchers
found Swedish residents chronically exposed to various
levels of fluoride in drinking water did not show any
differences in rates of either hip fracture or low -trauma
osteoporotic hip fracture due to fluoride exposure.62
A study published in 2005 evaluated the bone
mineral density levels and rate of bone fracture of
1,300 women living in three separate communities.
To be included in the study, the women had to be
ambulatory. The ages of the women ranged from
20 years to 92 years. The size and demographics
of the three communities were similar. One part of
the study looked at whether fluoride was associated
with adverse bone -related outcomes. The study
measured fluoride serum levels, fluoride exposure,
and bone metabolism as related to fluoride exposure
and fluoride's interaction with other important
bone factors including age, menopause status and
medications. The study concluded that long-term
exposure to fluoride was not associated with
adverse effects on bone health.61
A study published in 200164 examined the risk of
bone fractures, including hip fractures associated with
long-term exposure to fluoridated water in six Chinese
populations. The water fluoride concentrations ranged
from 0.25 to 7.97 mg/L. A total of 8,266 male and
female subjects, all of whom were 50 years old or
older participated in the study. The results showed
an interesting and potentially important finding
regarding overall bone fractures. Whereas there
appeared to be a trend for higher fracture rates from
1.00 to 4.00 mg/L, the fracture rate in the 1.00 to
1.06 mg/L category was lower than the rate in the
category with the lowest fluoride intake (0.25 to
0.34 mg/Q. The study concluded that long-term
fluoride exposure from drinking water containing
4.32 mg/L or more increases the risk of overall
bone fracture, as well as hip fracture, while water
fluoride levels of 1.0 to 1.06 mg/L decreased the
risk of overall fractures relative to negligible fluoride
in water.64 (Note that 4.32 mg/L is more than six
times the fluoride level currently recommended for
community water fluoridation in the United States).
While a number of studies reported findings at a
population level, both the Hillier and Phipps studies
published in 2000, examined risk on an individual,
rather than a community basis, taking into account
other risk factors such as medications, age of
menopause, alcohol consumption, smoking, dietary
calcium intake and physical activity. Using these more
rigorous study designs, these two studies reported
no effect of the risk of hip fracture61 and no increase
in the risk of hip fracture in those drinking fluoridated
water,66 respectively.
According to the best available science,
drinking water that has been fluoridated at the
recommended level does not have on adverse
effect on bone health.
48 American Dental Association
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27. What is dental fluorosis or enamel
fluorosis?
Answer.
Dental fluorosis is a change in the appearance of the
tooth enamel that only occurs when younger children
consume too much fluoride, from all sources, over
long periods when teeth are developing under the
gums.36 In the United States, most commonly these
changes are not readily apparent to the affected
individual or casual observer and require a trained
specialist to detect. This type of dental fluorosis
found in the United States has no effect on tooth
function and can make the teeth more resistant to
decay.67 Photographs of mild dental fluorosis can
be viewed at https://www.ADA.org/en/member-
center/oral-health-topics/fluoride-topical-and-
systemic-supplements. (Note that mild dental fluorosis
is generally less evident than on these photographs. This
is because the teeth were dried very well to improve the
photography and this makes the mild dental fluorosis
stand out, but if the tooth had saliva on it as it usually
does, then it would be less noticeable.)
Fact.
The crown of the tooth (the part covered in enamel)
is formed under the gums before the teeth erupt.
Enamel formation of permanent teeth, other than
third molars (wisdom teeth), occurs from about the
time of birth until approximately eight years of age.6S
Because dental fluorosis occurs only while teeth are
forming under the gums, teeth that have erupted
are not at risk for dental fluorosis; therefore, older
children and adults are not at risk for the development
of dental fluorosis.69 It should be noted that there are
many other developmental changes that affect the
appearance of tooth enamel which are not related
to fluoride intake. In other words, not all opaque or
white blemishes on teeth are caused by fluoride.
Furthermore, dental fluorosis occurs among some
people in all communities, even in communities that
do not have community water fluoridation, or that
have a low natural concentration of fluoride in their
drinking water.70-71
Classification of Dental Fluorosis
Dental fluorosis has been classified in a number of
ways. One of the most widely used classifications was
developed by Dean in 1942.71 (See Table 3.)
In using Dean's Fluorosis Index, each tooth in an
individual's mouth is rated according to the fluorosis
index in Table 3. The individual's dental fluorosis score
is based upon the most severe form of fluorosis
recorded for two or more teeth. Dean's Fluorosis
Index, which has been used since 1942, remains
popular for prevalence studies in large part due to its
simplicity and the ability to make comparisons with
findings from a number of earlier studies.74
In 2010, a report by the U.S. National Center for Health
Statistics described the prevalence and changes in
prevalence and severity of dental fluorosis in the United
States and among adolescents between 1986-1987
and 1999-2004.71 According to the report, in 1999
to 2004, 40.7% of adolescents had dental fluorosis.
It should be noted that dental fluorosis can occur not
only from fluoride intake from water but also from
fluoride products, such as toothpaste, mouthrinses and
excessive use of fluoride supplements during the ages
when teeth are forming. A 1994 analysis of five studies
showed that the amount of dental fluorosis attributable
to water fluoridation at 1.0 mg/L was approximately
13%.76 In other words, at that time the amount of dental
fluorosis would have been reduced by only 13% if water
was not fluoridated. Now it would be less of a reduction,
since fluoridation uses the lower level of 0.7 mg/L.
The majority of dental fluorosis in the U.S. is caused
by the inappropriate ingestion of fluoride products 76
The vast majority of dental fluorosis in the United
States is the very mild or mild type. This type of
dental fluorosis is not readily apparent to the affected
individual or casual observer and often requires a
trained specialist to detect. In contrast, the moderate
and severe forms of dental fluorosis, characterized by
esthetically (cosmetically) objectionable changes in
tooth color and surface irregularities, respectively, are
not common in the United States. Most investigators
regard even the more advanced forms of dental
fluorosis as a cosmetic effect rather than a functional
adverse effect.41 In 1993, the U.S. Environmental
Protection Agency, in a decision supported by the
U.S. Surgeon General, determined that objectionable
dental fluorosis is a cosmetic effect with no known
health effects.77 However, in 2003, the EPA requested
that the National Research Council (NRC) evaluate
the adequacy of its MCLG for fluoride to protect
public health. A committee was convened to review
recent evidence and eventually developed the
2006 report titled, Fluoride in Drinking Water — A
Scientific Review of the EPA's Stondords.9 As part of
that report, a majority of the committee members
found severe dental fluorosis to be an adverse health
...............................................................................................................................................................
Safety I Fluoridation Facts 49
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effect based on suggestive but inconclusive evidence
that severe dental fluorosis (characterized by pitting
of the enamel) increased the risk of tooth decay. All
members of the committee agreed that the condition
damages the tooth and that the EPA standard should
prevent the occurrence of this unwanted condition.
The prevalence of severe enamel fluorosis is very low
below 2 mg/L of fluoride in drinking water in the U.S.'
6 Additional information on this topic con be found
in this Section, Questions 20 and 21.
The vast majority of dentol fluorosis in the
United States is the very mild or mild type. This
type of dental fluorosis is not readily apparent
to the affected individual or casual observer and
often requires o trained specialist to detect.
Limited research on the psychological effects of
dental fluorosis on children and adults has been
conducted. However, a 2009 literature review that
assessed the relationships between perceptions of
dental appearance/oral health related quality of life
(OHRQoL) and dental fluorosis concluded that very
mild to mild dental fluorosis has little impact and in
some cases evidence suggested enhanced quality of
life with mild dental fluorosis?8 When evaluating the
oral health related quality of life of children by tooth
decay (cavities) and dental fluorosis experience, a
2007 study concluded that cavities were associated
with a negative impact while mild dental fluorosis
had a positive impact on children's and parents'
quality of life.79
Very mild to mild dental fluorosis has no effect
on tooth function and can make the tooth enamel
more resistant to decay. A study published in
200967 investigated the relationship between dental
fluorosis and tooth decay in U.S. schoolchildren. The
study concluded that teeth with dental fluorosis
were more resistant to tooth decay than were teeth
without dental fluorosis. Not only should the cavity
preventive benefits of fluoridation be considered
when evaluating policy to introduce or retain water
fluoridation, but the cavity preventive benefits of
mild dental fluorosis should also be considered.67
Very mild to mild dental fluorosis has no effect
on tooth function and con make the tooth
enamel more resistant to decoy.
A report published in 201071 described the prevalence
(total percentage of cases in a population) of dental
fluorosis in the United States and discussed the changes
in the prevalence and severity of dental fluorosis among
adolescents between 1986-1987 and 1999-2004.
The report used data from the National Health and
Nutrition Examination Survey (NHANES) 1999-2004
and the 1986-1987 National Survey of Oral Health in
U.S. School Children. The data represented persons from
6 to 49-years of age and varied races and ethnicities
including non -Hispanic black and Mexican -American
persons. The oral exams for both surveys were
conducted by trained dental examiners and included
a dental fluorosis assessment of permanent teeth.
The Dean's Fluorosis Index was used to determine
the prevalence and severity of dental fluorosis.
The data published in 201071 showed that less than
one -quarter of persons aged 6-49 in the United States
had some form of dental fluorosis. For the remaining
three-quarters of persons in this age group, 60.6%
were unaffected by dental fluorosis and 16.5% were
classified as having questionable dental fluorosis.
The percent distribution of the types of dental fluorosis
in persons aged 6-49 years observed was:
Very mild fluorosis 16.0%
Mild fluorosis 4.8%
Moderate fluorosis 2.0%
Severe fluorosis less than 1
While moderate and severe dental fluorosis comprise
less than 3% of dental fluorosis in all persons aged 6-49,
the prevalence of moderate or severe dental fluorosis in
this age group comprised a very small portion (less than
10%) of the total number of all cases of dental fluorosis.
In other words, approximately 90% of all dental fluorosis
observed was very mild to mild form 75
In regards to dental fluorosis in adolescents, children
aged 12-15 years in 1999-2004 had higher
prevalence of dental fluorosis compared with the
same aged children in 1986-1987.71
.....................................................................................................................................................................
50 American Dental Association
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In reviewing this report'71 it should be noted that
dental fluorosis was not assessed in NHANES 1988-
1994 and so it was not possible to compare the
NHANES 1999-2002 to the earlier NHANES report.
The only other previously collected national data
on dental fluorosis were the 1986-1987 National
Institute of Dental Research (NIDR) National Survey
of Oral Health in U.S. School Children. Differences
in study design between NIDR 1986-1987 and
NHANES 1999-2002 should be considered when
drawing inferences about changes in prevalence
and severity of enamel fluorosis.75 Examples of
differences in these two surveys include but are
not limited to:
• NIDR survey is a school -based survey while the
NHANES is a household survey.
• NHANES did not collect residential histories;
NIDR did gather residential histories but it is
unknown if NIDR reported dental fluorosis data
only for those with a single residence history.
NIDR collected water samples from schools for
fluoride analysis; NHANES did not collect water
samples for analysis until the 2013-14 survey cycle.
As defined in Table 3, very mild dental fluorosis is
characterized by small opaque, paper -white areas
covering less than 25% of the tooth surface. The risk
of teeth forming with the very mildest form of dental
fluorosis must be weighed against the benefit that the
individual will have fewer cavities thus saving dental
treatment costs, avoiding patient discomfort and
reducing tooth loss.81,82 In addition, the risk of dental
fluorosis can be viewed as an alternative to having
tooth decay,81 which is a disease that causes cosmetic
problems, pain, missed school and work, and can lead
to infection and, in advanced cases, life -threatening
health effects. This is in contrast to dental fluorosis
which is not a disease and is not life -threatening.
...............................................................................
The risk of teeth forming with the very mildest
form of dental fluorosis must be weighed
against the benefit that the individual will hove
fewer cavities thus saving dental treatment
costs, avoiding patient discomfort and
reducing tooth loss.
...............................................................................
Table•
Classification
,
Criteria -Description of Enamel
Normal
Smooth, glossy, pale creamy -white translucent surface
Questionable
A few white flecks or white spots
Very Mild
Small opaque, paper -white areas covering less than 25% of the tooth surface
Mild
Opaque white areas covering less than 50% of the tooth surface
Moderate
All tooth surfaces affected; marked wear on biting surfaces; brown stain may be present
Severe
All tooth surfaces affected; discrete or confluent pitting; brown stain prsent
...............................................................................................................................................................
Safety I Fluoridation Facts 51
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28. Is it safe to use fluoridated water to
reconstitute infant formula?
Answer.
It is safe to use fluoridated water to reconstitute
infant formula.
Fact.
Fluoridated water can be used to prepare infant
formula. However, if the child is exclusively consuming
infant formula reconstituted with fluoridated water,
there could be an increased chance of mild dental
fluorosis.86 To lessen this chance, parents can use low -
fluoride bottled water some of the time to mix infant
formula. These bottled waters are labeled as de -
ionized, purified, demineralized, or distilled. However,
parents should be aware that using these types of
waters exclusively means an infant does not receive
the amount of fluoride the Institute of Medicine
indicated is required to prevent tooth decay.40 On the
other hand, the exclusive use of nonfluoridated water
to reconstitute infant formula will not guarantee
that an infant will not develop dental fluorosis. The
chance of development of dental fluorosis exists
through approximate eight years of age when the
permanent teeth are still forming under the gums.
Fluoride intake from other sources during this time
such as toothpaste, mouthrinse and dietary fluoride
supplements also contributes to the chance of dental
fluorosis for children living in nonfluoridated and
fluoridated communities.84
In response to the report of the National Research
Council (NRC) Fluoride in Drinking Water. A
Scientific Review of EPA's Standards' in November
2006, and with an abundance of caution, the ADA
issued the Interim Guidance on Fluoride Intake for
Infants and Young Children (Interim Guidance). The
Interim Guidance is no longer current and has
been replaced. Unfortunately, those opposed to
fluoridation continue to publicize and use the Interim
Guidance in efforts to halt fluoridation.
The Interim Guidance was replaced in January 2011
by the ADA Evidence -Based Clinical Recommendations
Regarding Fluoride Intake From Reconstituted Infant
Formula and Enamel Fluorosis A Report of the American
Dental Association Council on Scientific Affairs.84 The
report encourages clinicians to follow the American
Academy of Pediatrics guidelines for infant nutrition
which advocates exclusive breastfeeding until the child
is aged 6 months and continued breastfeeding until the
child is at least 12 months of age, unless specifically
contraindicated. Additionally, the ADA report, designed
for use by clinical practitioners, offers the following
suggestions to practitioners to use in advising parents
and caregivers of infants who consume powdered or
liquid concentrate infant formula as the main source
of nutrition:84
• Suggest the continued use of powdered or liquid
concentrate infant formulas reconstituted with
optimally fluoridated drinking water while being
cognizant of the potential risk of enamel fluorosis
development.89
When the potential risk of enamel fluorosis
development is a concern, suggest ready -to -feed
formula or powdered or liquid concentrate formula
reconstituted with water that either is fluoride free
or has low concentrations of fluoride.84
It should be noted that the Centers for Disease
Control and Prevention,81 as well as other agencies,
such as the U.S. Department of Health and Human
Services,86 American Public Health Association'81
and health departments such as the New York State
Health Department88 provide similar information
regarding the use of fluoridated water to
reconstitute infant formula.
29. What can be done to reduce the
occurrence of dental fluorosis in the U.S.?
Answer.
The vast majority of enamel fluorosis in the United
States can be prevented by limiting the ingestion
of topical fluoride products (such as toothpaste)
and recommending the appropriate use of
dietary fluoride supplements — without denying
young children the decay prevention benefits of
community water fluoridation.
Fact.
Tooth decay has decreased substantially in the United
States because more children today are benefitting from
access to fluoride which is available from a wider variety
of sources than decades ago. Many of these sources
are intended for topical use only; however, when they
are used, some fluoride is inadvertently swallowed by
children.41,41,81 Inappropriate ingestion of topical fluoride
can be minimized, thus reducing the risk for dental
fluorosis without reducing decay prevention benefits.
52 American Dental Association
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Fluoride Toothpaste
Fluoride toothpastes are effective in helping to prevent
tooth decay but have been identified as a major risk factor
for enamel fluorosis when used inappropriately.42,43,89
In order to decrease the risk of dental fluorosis, the
American Dental Association (ADA) recommends:49
For children younger than 3 years, caregivers should
begin brushing children's teeth as soon as they begin
to come into the mouth by using fluoride toothpaste
in an amount no more than a smear or the size of a
grain of rice. (See Figure 4 in Question 23.) Brush
teeth thoroughly twice per day (morning and night)
or as directed by a dentist or physician. Supervise
children's brushing to ensure that they use the
appropriate amount of toothpaste.
For children 3 to 6 years of age, caregivers should
dispense no more than a pea -sized amount (Figure
4) of fluoride toothpaste. Brush teeth thoroughly
twice per day (morning and night) or as directed by
a dentist or physician. Supervise children's brushing
to minimize swallowing of toothpaste.
The reason for including age information on directions
for use for fluoride toothpaste is because it takes
into account the ages during which teeth are most
susceptible to dental fluorosis (during the time when
the teeth are forming under the gums). Additionally,
until approximately six years of age, children have
not developed the full ability to spit and not swallow
toothpaste. Inadvertently swallowing toothpaste during
brushing can increase the risk of dental fluorosis. After
age eight, the enamel formation of permanent teeth
(with the exception of the third molars) is basically
complete;68 therefore, the risk of developing dental
fluorosis is over. Because dental fluorosis occurs while
teeth are forming under the gums, individuals whose
teeth have erupted are not at risk for enamel fluorosis.
6 Additional information on this topic can be found
in this Section, Question 27.
Numerous studies have established a direct relationship
between young children brushing with more than a
pea -sized amount of fluoride toothpaste and the risk
of very mild or mild dental fluorosis in both fluoridated
and nonfluoridated communities.42.43,48,71,89 It was
noted that 34% of the dental fluorosis cases in a
nonfluoridated community were explained by children
having brushed with fluoride toothpaste more than
once per day during the first two years of life.90 In the
optimally fluoridated community, 68% of the fluorosis
cases were explained by the children using more than
a pea -sized amount of toothpaste during the first year
of life.90 However, recognizing that the risk tooth decay
can start before a child's first birthday, it is considered
important to begin using a fluoride toothpaste when
the child's first tooth appears in the mouth.49
Dietary Fluoride Supplements
A systematic review published in 2006 concluded that
the use of supplements during the first six years of life,
and especially during the first three years, is associated
with a significant increase in dental fluorosis.91
Dietary fluoride supplements should only be
prescribed for children at high risk for tooth
decay who live in nonfluoridated areas.41
Dietary fluoride supplements should be prescribed
according to the dosage schedule found in the Evidence -
based Clinical Recommendations on the Prescription of
Dietary Fluoride Supplements for Caries Prevention:
A Report of the American Dental Association Council
on Scientific Affairs published in 2010.41 The current
dietary fluoride supplement schedule41 is shown in
the Benefits Section, Question 12, Table 1.
Determination of the level of risk for tooth decay
is accomplished through the use of a professional
caries risk assessment that assists the health provider
identify and assess factors that could contribute to
the development of cavities.41 A child's caries (cavity)
risk should be assessed on a routine basis because
risk status can be affected by changes in the child's
development, home conditions, dietary regimen and
oral hygiene practices. Additional information on caries
risk assessments can be found on the ADA website.92
Because of the many sources of fluoride in the diet,
proper prescribing of fluoride supplements can be
complex. It is suggested that all sources of fluoride
be evaluated with a thorough fluoride history before
supplements are prescribed for a child.41 This evaluation
should include testing of the home water supply if
the fluoride concentration is unknown. Families on
community water systems should contact their water
supplier to ask about the fluoride level. Consumers
with private wells should have the water tested yearly
to accurately determine the fluoride content.
6 Additional information on this topic can be found
in the Benefits Section, Question 4.
...............................................................................................................................................................
Safety I Fluoridation Facts 53
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Dietary fluoride supplements can be considered
for infants and children aged 6 months to 16 years.
Compliance with the daily administration of the
supplement will enhance the cavity prevention
benefits. Providers should consider and monitor the
ability of the caregiver and child to adhere to the
schedule. If compliance is an issue, another mode
of fluoride delivery should be considered.41
Use of Over the Counter Fluoride -Containing
Dental Products in the Home
Parents, caretakers and health care professionals
should judiciously monitor use of all fluoride -
containing dental products by children under
age six. As is the case with any therapeutic product,
more is not always better. The same is true for most
products found in the medicine cabinet; care should
be taken to adhere to label directions on fluoride
prescriptions and over-the-counter products (e.g.,
fluoride toothpastes and rinses).
The ADA recommends the use of fluoride
mouthrinses, but not for children less than six
years of age because they may swallow the
rinse.93 These products should be stored out of the
reach of children. Additional information regarding
the use of mouthrinses can be found on the ADA
website.93
Drinking Water That Has Been Fluoridated at
the Recommended Levels
In 2015, the U.S. Public Health Service made a
recommendation on the level of fluoride to be used
in water fluoridation (0.7mg/L) to provide the best
balance of protection from tooth decay while limiting
the risk of dental fluorosis 16
6 Additional information on this topic can be found
in this Section, Question 19.
Drinking Water With High Levels of Naturally
Occurring Fluoride
In areas where naturally occurring fluoride
levels in ground water are higher than 2 mg/L,
the U.S. EPA has recommended that consumers
should consider action to lower the risk of
dental fluorosis for young children such as
providing drinking water from an alternative
source.32
Families with young children on community water
systems should contact their water suppliers to
ask about the fluoride level in their drinking water.
Consumers with private wells should have the water
tested yearly to accurately determine the fluoride
content. Consumers should consult with their
dentist regarding water -testing results and discuss
appropriate dental health care measures.
In homes where young children (with developing
permanent teeth) are faced with consuming water
with a fluoride level greater than 2 mg/L, families
should use an alternative primary water source that
contains the recommended level of fluoride for
drinking and cooking.12
6 Additional information on this topic con be found
in this Section, Question 21.
30. Why is there a warning label on a tube
of fluoride toothpaste?
Answer.
The U.S. Food and Drug Administration (FDA) has
established regulations for warning labels for a
number of over-the-counter items it considers
safe and effective including fluoride toothpaste.
Fact.
The FDA has published regulations regarding
warning labels for over-the-counter (OTC) drugs
in the Code of Federal Regulations (CFR).94 All the
non-prescription drugs covered by these regulations
must display the general warning "Keep out of the
reach of children" in bold type. The regulations
outline three additional warning statements (based
on the most likely route of exposure) to be listed on
the label in the event the drug is misused. While they
vary slightly, they all include the following language:
"...get medical help or contact a Poison Control
Center right away.""
In the CFR, the FDA has outlined the drug categories
to be covered by these warning labels.95 Some of
the 26 categories include antacids, allergy treatment
products, antiperspirants, cold remedies, ophthalmic
products and dentifrices and dental products such as
analgesics, antiseptics, etc.95
54 American Dental Association
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A specific FDA regulation96 applies to "Anticaries
Drug Products for Over -The -Counter Human Use"
which provides the exact language for the warning
label to be used on "fluoride dentifrice (gel, paste,
and powder) products" The regulation requires the
following language appear on these products under
the heading "Warning":
"Keep out of reach of children under 6 years of
age. [highlighted in bold type] If more than used for
brushing is accidentally swallowed, get medical help
or contact a Poison Control Center right away."96
The over-the-counter (OTC) drugs listed in these
regulations are generally recognized as safe and effective
by the FDA.94 Fluoride toothpaste is just one of a long
list of OTC products that carries a warning label.
The over-the-counter (OTC) drugs listed in
these regulations are generally recognized
os safe and effective by the FDA. Fluoride
toothpaste is just one of o long list of OTC
products that carries o warning label.
While the FDA has required such label language since
1997, the ADA has required manufacturers seeking
the ADA Seal of Acceptance to place a label on
fluoride toothpaste since 1991 to help ensure proper
use and thereby reduce the risk of dental fluorosis.
At that time, the ADA required the label to include:
"Do not swallow. Use only a pea -sized amount for
children under six. To prevent swallowing, children
under six years of age should be supervised in the
use of toothpaste."
Additionally, to ensure children's safety, the ADA
limits the total amount of fluoride allowed in any one
tube of ADA-Accepted toothpaste. If a child were to
ingest an entire tube of fluoride toothpaste at one
time, the total fluoride content of a single tube is not
enough to cause a fatal event. In fact, because of
some of the (non -fluoride) additives in toothpaste,
a child attempting to ingest a tube of toothpaste
would most likely vomit before they could eat
enough to become seriously ill.
31. Is fluoride, as provided by community
water fluoridation, a toxic substance?
Answer.
No. Fluoride in water at the recommended level is
not toxic according to the best available scientific
evidence.
Fact.
Toxicity is related to dose. While large doses of
fluoride could be toxic, it is important to recognize
the difference between the effect of a massive dose
of an extremely high level of fluoride versus the
fluoride level currently recommended for public water
systems. Like many common substances essential to
life and good health — salt, iron, vitamins A and D,
chlorine, oxygen and even water itself — fluoride
can be toxic in massive quantities. Fluoride at the
much lower recommended concentrations (0.7 mg/L)
used in community water fluoridation is not harmful
or toxic 16
Fluoride of the much lower recommended
concentrations (0.7 mg1Q used in community
water fluoridation is not harmful or toxic.
The single dose (consumed all at one time) of
fluoride that could cause acute fluoride toxicity is
5 mg/kg of body weight (11mg/kg of body weight
of sodium fluoride).97 This dose is considered the
probably toxic dose (PTD) which "is defined as the
minimum dose that could cause serious or life -
threatening systemic signs and symptoms and that
should trigger immediate therapeutic intervention
and hospitalization"97 Acute fluoride toxicity
occurring from the ingestion of optimally fluoridated
water is impossible.97 With water fluoridated at 1
mg/L, an individual would need to drink five (5)
liters of water for every kilogram of body weight.
For example, for an adult male (155 pound/70.3
kilogram man), it would require that he consume
more than 350 liters (nearly 93 gallons) of water
at one time to reach an acute fluoride dose. With
optimally fluoridated water now set at 0.7 mg/L, it
would take almost 30% more, or nearly 120 gallons
(more than 1,900 eight ounce glasses) of water at
one time to reach the acute dose.
Safety Fluoridation Facts 55
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Chronic fluoride toxicity can develop after 10 or more
years of exposure to very high levels of fluoride, levels
much higher than what is associated with drinking
water fluoridated at recommended levels. The primary
functional adverse effect associated with long-term
excess fluoride intake is skeletal fluorosis.40,18 The
development of skeletal fluorosis and its severity is
directly related to the level and duration of fluoride
intake. For example, the ingestion of water naturally
fluoridated at approximately 5 mg/L or greater for
10 years or more is needed to produce clinical signs
of osteosclerosis (a mild form of skeletal fluorosis that
can be seen as a change in bone density on x-rays) in
the general population. In areas naturally fluoridated
at 5 mg/L, daily fluoride intake of 10 mg/day would
not be uncommon.40 A survey of X-rays from 170,000
people in Texas and Oklahoma whose drinking water
had naturally occurring fluoride levels of 4 to 8 ppm
revealed only 23 cases of osteosclerosis and no cases
of crippling skeletal fluorosis.98 Evidence of advanced
skeletal fluorosis, or crippling skeletal fluorosis, was not
seen in communities in the United States where water
supplies contained up to 20 mg/L of naturally occurring
fluoride.40,99 In these communities, "daily fluoride
intake of 20 mg/day would not be uncommon."40
Crippling skeletal fluorosis is extremely rare in the
United States and is not associated with water
fluoridated at the recommended level.40,58
6 Additional information on this topic con be found
in this Section, Question 26.
The Environmental Protection Agency (EPA) identifies
the most serious hazardous waste sites in the nation.
These sites make up the Superfund: National Priorities
List (NPL) and are the sites targeted for long-term
federal cleanup activities 100 The Agency for Toxic
Substances and Disease Registry (ATSDR) prepares
toxicological profiles for hazardous substances that
describe the effects of exposure from chemicals found
at these sites and acute releases of these hazardous
substances 101 The ATSDR provides answers to the
most frequently asked questions about exposure to
hazardous substances found around hazardous waste
sites and the effects of exposure on human health. The
Toxicological Profile for Fluorides, Hydrogen Fluoride
and Fluorine indicates that subsets of the population
could be unusually susceptible to the toxic effects of
fluoride and its compounds at high doses, such as what
might be encountered in the cleanup of a chemical spill.
However, there are no data to suggest that exposure
to the low levels of fluoride associated with community
water fluoridation would result in adverse effects
in these potentially susceptible populations 101 The
ATSDR's Public Health Statement on Fluorides states
that "when used appropriately, fluoride is effective in
preventing and controlling dental caries"101
While large doses of fluoride could be toxic, it is
important to recognize the difference in the effect of
a massive dose of an extremely high level of fluoride
versus the recommended amount of fluoride found
in optimally fluoridated water. The implication that
fluoride in large doses and fluoride in trace amounts
have the same effect is completely unfounded. Many
substances in widespread use are very beneficial in
small amounts while toxic in large quantities.
The possibility of adverse health effects from
continuous low level consumption of fluoride over
long periods has been studied extensively. As with
other nutrients, fluoride is safe and effective when
used and consumed properly. No charge against the
safety of fluoridation has ever been substantiated by
generally accepted scientific knowledge. After more
than 70 years of research and practical experience,
the best available scientific evidence indicates that
fluoridation of community water supplies is safe.
After more than 70 years of research and
practical experience, the best available
scientific evidence indicates that fluoridation
of community water supplies is safe.
32. Does drinking water fluoridated at the
recommended levels cause or accelerate the
growth of cancer?
Answer.
According to the best available scientific evidence,
there is no association between cancer rates in
humans and drinking water that is fluoridated at the
recommended levels.
Fact.
Since community water fluoridation was introduced in
1945, more than 50 epidemiologic studies in different
populations and at different times have failed to
demonstrate an association between fluoridation
and the risk of cancer.' Studies have been conducted
56 American Dental Association
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in the United States; 03-108 Japan; 09 the United
Kingdom,"` Canada"' and Australia"4 In addition,
over the years, a number of independent bodies from
around the world have conducted extensive reviews of
the scientific literature and concluded that there is no
relationship between fluoridation and cancer1,2,4,19,111
At the beginning of the Safety Section in Question 17,
a number of recent reviews are listed that have also
concluded there is no relationship between fluoridation
and cancer.' 0,11,13,15-18,20,21 Clearly, the best available
science indicates there is no association between
fluoridation and cancer.
Clearly, the best available science indicates
there is no association between fluoridation
and cancer.
Many of the questions about a possible association
between fluoride and cancer center around a form
of bone cancer called osteosarcoma. This topic is
covered in the next question.
In October 2011, the California Office of
Environmental Health Hazard Assessment (OEHHA)
through its Carcinogen Identification Committee
(CIC) determined that fluoride does not cause cancer.
The review was part of California's Proposition 65
listing process."' Proposition 65 was enacted in 1986
with the intent to protect California citizens and the
State's drinking water sources from chemicals known
to cause cancer, birth defects or other reproductive
harm and to inform citizens about exposure to such
chemicals. It requires the Governor to publish, at
least annually, a list of chemicals known to the state
to cause cancer or reproductive toxicity. The OEHHA
administers meetings of the CIC and the list of items
to be reviewed through the Proposition 65 process.
On May 29, 2009, fluoride was selected by OEHHA
for review by the CIC. Due to widespread exposure
to fluoride, it was identified as one of five high
priority chemicals to be evaluated. A public comment
period followed. On July 8, 2011, as the next step
in the Proposition 65 process, the CIC released a
hazard identification document, "Evidence on the
Carcinogenicity of Fluoride and its Salts". It was used
by the CIC in its deliberations on whether fluoride
should be listed as a carcinogen under Proposition
65. A second public comment period followed. At
a public meeting on October 12, 2011, the CIC
heard additional testimony and then voted on the
question, "Do you believe that it has been clearly
shown, through scientifically valid testing according
to generally accepted principles, that fluoride causes
cancer?" The CIC's vote was unanimous (6-0) that
fluoride had not been clearly shown to cause cancer'17
On its website, the American Cancer Society (ACS)
provides a page titled, "Water Fluoridation and Cancer
Risk."18 In question and answer format, the ACS
provides basic information regarding fluoridation
as well as information on a number of studies that
examined the possible association between fluoridation
and cancer — many of which are referenced in the
opening paragraph of this Safety Section. Near the
bottom of the ACS web page, under the header
"Assessments by Expert Groups" is this paragraph:
The general consensus among the reviews done
to date is that there is no strong evidence of a link
between water fluoridation and cancer. However,
several of the reviews noted that further studies
are needed to clarify the possible link'18
33. Does fluoridated water cause
osteosarcoma?
Answer.
No. The best available scientific evidence shows that
fluoridated water does not cause osteosarcoma.
Fact.
In 2016, the American Society of Clinical Oncology
estimated that a total of 1,000 people, including
450 children and teens younger than 20, would be
diagnosed with osteosarcoma (a form of bone cancer)
in the United States during the year. About 2% of
all childhood cancers are osteosarcoma which most
often affects those between the ages of 10 and 30.
Osteosarcoma is about 50% more common in boys
than girls. The 5-year survival rate for children and
teens with osteosarcoma that is only in one place at
the time of diagnosis is 70% 119
In 2014, researchers from England published the
largest study ever conducted examining the possible
association between fluoride in drinking water and risk
of osteosarcoma or Ewing sarcoma. Analyzing 2,566
osteosarcoma cases and 1,650 Ewing's sarcoma cases
from 1980 to 2005, the study found that higher
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Safety I Fluoridation Facts 57
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levels of natural or adjusted fluoride in drinking water
in Great Britain (England, Scotland and Wales) had
no impact on the incidence of either osteosarcoma
or Ewing's sarcoma in people aged 0-49. Water
fluoride levels ranged from near zero to a maximum
of approximately 1.26 ppm 120
A case -control study121 published in 2011 found no
significant association between the fluoride levels
in bone and osteosarcoma risk. Led by a Harvard
researcher, the study analyzed fluoride levels in
bone samples from 137 patients with primary
osteosarcoma and bone samples from 51 patients
with other newly -diagnosed malignant bone tumors
who served as a control group. Conducted in nine U.S
hospitals over an eight -year period (1993 and 2000),
the study was considered the most extensive to date
on the issue. The vast majority of fluoride in the body
is located in calcified tissue such as bone. The study
hypothesized that if chronic exposure to fluoride
was a risk factor for osteosarcoma, then those cases
would have a significantly higher level of fluoride in
bone than the controls. This was not the case. The
major advantage of this study was the ability to use
actual bone fluoride levels as a measure of fluoride
intake rather than estimating fluoride exposure.
Focusing on fluoride intake from water as a primary
source of fluoride, in earlier studies122,121 members of
the research team noted the difficulty in obtaining
accurate information on fluoride levels of drinking
water at the subjects' homes. Even when accurate
information could be obtained, that information did
not reflect actual consumption of water by the study
subjects. Funding for the study came from three
agencies of the National Institutes of Health — the
National Cancer Institute, the National Institute of
Environmental Health Sciences and the National
Institute of Dental and Craniofacial Research121
The best available scientific evidence shows
that fluoridated water does not cause
osteosarcoma (a form of bone cancer).
34. Does fluoride, as provided by community
water fluoridation, inhibit the activity of
enzymes in humans?
Answer.
The best available scientific evidence demonstrates
that the recommended levels of fluoride in drinking
water, has no effect on human enzyme activity.
Fact.
Enzymes are organic compounds that promote
chemical change in the body. The best available
scientific evidence has not indicated that water
fluoridated at the recommended levels has any
influence on human enzyme activity. There are no
available data to indicate that, in humans drinking
water fluoridated at the recommended levels,
the fluoride affects enzyme activities with toxic
consequences.' 14 The World Health Organization
report, Fluorides and Human Heolth states, "No
evidence has yet been provided that fluoride
ingested at 1 ppm in the drinking water affects
intermediary metabolism of food stuffs, vitamin
utilization or either hormonal or enzymatic activity."1 '
In 2006, the National Research Council Report
stated that the available data were not sufficient to
draw any conclusions about potential effects or risks
to liver enzymes from low-level long-term fluoride
exposures such as those seen with community
water fluoridation.'
The concentrations of fluoride used in laboratory
studies to produce significant inhibition of enzymes
are hundreds of times greater than the concentration
present in body fluids or tissues.' 16 While fluoride
could affect enzymes in an artificial environment
outside of a living organism in the laboratory, it is
unlikely that adequate cellular levels of fluoride to
adversely alter enzyme activities would be attainable
in a living organism. The two primary physiological
mechanisms that maintain a low concentration of
fluoride ion in body fluids are the rapid excretion of
fluoride by the kidneys and the uptake of fluoride
by calcified tissues."
58 American Dental Association
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35. Does the ingestion of optimally
fluoridated water adversely affect the
thyroid gland or its function?
Answer.
The best available scientific evidence indicates
optimally fluoridated water does not have an
adverse effect on the thyroid gland or its function
Fact.
A number of systematic reviews completed in the
last ten years have looked at a possible association
between exposure to fluoride and thyroid function
In 2017, the Australian National Health and Medical
Research Council's systematic review Information
Paper — Water Fluoridation: Dental and Other Human
Health Outcomes10 concluded, "There is no reliable
evidence of an association between water fluoridation
and current Australian levels and thyroid function"
(Current recommendations for fluoride levels in
drinking water in Australia are a range of 0.6 to
1.1 mg/L depending on climate.)10
A scientific evaluation of fluoridating agents of drinking
water was done by the Scientific Committee on Health
and Environmental Risks (SCHER) as requested by the
European Commission (EC). The EC is the European
Union's (EU) executive body with responsibility to
manage EU policy. The final report, Critical review of
any new evidence on the hazard profile, health effects,
and human exposure to fluoride and the fluoridating
agents of drinking water, was released in 2011. It stated
that "A systematic evaluation of the human studies
does not suggest a potential thyroid effect at realistic
exposures to fluoride"20
In 2015, the U.S. Public Health Service Recommendation
for Fluoride Concentration in Drinking Water for the
Prevention of Dental Cories16 was released. It referred
to the 2006 National Research Council's report, Fluoride
in Drinking Water — A Scientific Review of the EPA's
Stondords,9 stating:
The 2006 NRC review considered a potential
association between fluoride exposure (2-4 mg/L)
and changes in the thyroid, parathyroid, and pineal
glands in experimental animals and humans. The
report noted that available studies of the effects
of fluoride exposure on endocrine function have
limitations. For example, many studies did not
measure actual hormone concentrations, and several
studies did not report nutritional status or other
factors likely to confound findings. The NRC called
for better measurement of exposure to fluoride in
epidemiological studies and for further research
"to characterize the direct and indirect mechanisms
of fluoride's action on the endocrine system and
factors that determine the response, if any, in a
given individual."9
On March 22, 2006, during the press webcast127
for the release of the 2006 National Research Council
(NRC) Report,9 John Doull, M.D., Ph.D., Professor
Emeritus of Pharmacology and Toxicology, University
of Kansas Medical Center, Kansas City and Chair of
the NRC Committee was asked about the conclusions
reached on fluoride and the endocrine system
(which includes the thyroid). Dr. Doull replied:
The Endocrine Chapter (of the NRC Report) is a
relatively new chapter. It has not been extensively
reviewed previously and our feeling was that we
needed to provide a baseline of all the adverse
effects and a lot of the systems that hadn't really
been looked at very closely. We have a chapter for
example on the central nervous system which has
not been reviewed in detail previously. We went
through all those effects in the endocrine chapter,
the thyroid effect, the parathyroid effect, calcitonin
to see whether there were sufficient evidence
for us to include any of those effects as specific
adverse effects at 4 mg/L and the conclusion of
our Committee was that those were all things we
needed to worry about. Those were all things that
we made recommendations for additional research.
But, none of them reached the level where
we considered them to be signs of adverse
effects at the 4 mg/L level. (Emphasis added.)"'
A population -based Canadian study128 was released in
2017 that examined the association between fluoride
exposure and thyroid conditions. Data for the analysis
came from Cycles 2 (2009-2011) and 3 (2012-2013)
of Statistics Canada's Canadian Health Measures Survey
(CHMS). The CHMS'target population is all Canadian
residents between the ages of 3 and 79 living in all ten
Canadian provinces. It collects health information by
an individual in -home interview followed by a clinical
exam conducted in a mobile clinic. The researchers'
reported findings suggest that, at the population level
in Canada, fluoride exposure does not contribute to
impaired thyroid functioning during a time when multiple
sources of fluoride exposure, including community water
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Safety I Fluoridation Facts 59
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fluoridation, exist. It was additionally noted that the
findings could be broadly relevant to other countries
with similar populations and water fluoridation 128
In 2015, a study was published in which the authors
claimed to have found a positive association between
fluoride levels in drinking water and hypothyroidism.
Drawing immediate criticism, the published critiques
noted that a major weakness of this study was the
failure to consider a number of potential confounding
factors. The only confounders taken into consideration
were age, sex and socioeconomic status. While
acknowledging that iodine intake is associated with
thyroid health, the authors failed to consider iodine
as a factor along with the impacts of smoking and
medications. The strong conclusion of the paper was
not supported by the work of the authors or other
published literature.' 30-133
In addition, two studies have explored the association
between fluoridated water and cancer of the thyroid
gland. Both studies found no association between
optimal levels of fluoride in drinking water and
thyroid cancer'06,110
36. Does water fluoridation affect the pineal
gland causing the early onset of puberty?
Answer.
The best available scientific evidence indicates that
water fluoridation does not cause the early onset of
puberty.
Fact.
The pineal gland is an endocrine gland located in the
brain which produces melatonin 133 Endocrine glands
secrete their products into the bloodstream and
body tissues and help regulate many kinds of body
functions. The hormone, melatonin, plays a role in
sleep, aging and reproduction 134
A single researcher has published one study in a
peer -reviewed scientific journal regarding fluoride
accumulation in the pineal gland. The purpose of the
study was to discover whether fluoride accumulates
in the pineal gland of older adults. This limited study,
conducted on only 11 cadavers whose average age at
death was 82 years, indicated that fluoride deposited in
the pineal gland was significantly linked to the amount of
calcium in the pineal gland.131 It would not be unexpected
to see higher levels of calcium in the pineal gland of
older individuals as this would be considered part of
a normal aging process. As discussed in Question 25,
approximately 99% of the fluoride present in the body
is associated with hard or calcified tissues.52 The study
concluded fluoride levels in the pineal gland were not
indicators of long-term fluoride exposure131
The same researcher had theorized in her 1997
dissertation, portions of which are posted on numerous
internet sites opposed to fluoridation, that the
accumulation of fluoride in children's pineal glands leads
to an earlier onset of puberty. However, the researcher
notes in the dissertation that there is no verification
that fluoride accumulates in children's pineal glands.
Moreover, a study conducted in Newburgh (fluoridated)
and Kingston (nonfluoridated), New York found no
statistically significant difference between the onset
of menstruation for girls living in a fluoridated versus
nonfluoridated area136 The National Research Council's
2006 report, Fluoride in Drinking Water: A Scientific
Review of EPA's Standards, stated that a connection
between fluoride pineal function in humans remains
to be demonstrated "9
37. Can fluoride, at the levels found in drinking
water that is fluoridated to the recommended
levels, alter immune function or produce an
allergic reaction (hypersensitivity)?
Answer.
There is no scientific evidence of any adverse effect
from fluoridation on any specific immunity, nor have
there been any medically confirmed reports of
allergic reaction from drinking or being in contact
with optimally fluoridated water.
Fact.
There is no scientific evidence linking health
conditions related to immune function such as HIV or
AIDS (acquired immune deficiency syndrome) with
community water fluoridation 137
There are no confirmed cases of allergy to fluoride,
or of any positive skin testing in human or animal
models138 A committee of the National Academy of
Sciences evaluated clinical reports of possible allergic
responses to fluoride in 1977 and stated, "The
reservation in accepting (claims of allergic reaction)
at face value is the lack of similar reports in much
larger numbers of people who have been exposed to
considerably more fluoride than was involved in the
60 American Dental Association
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original observations"' The World Health Organization
also judged these cases to represent "a variety of
unrelated conditions" and found no evidence of
allergic reactions to fluoride' 19,140
38. Is fluoride, as provided by community
water fluoridation, a genetic hazard?
Answer.
The best available scientific evidence indicates that
drinking water fluoridated at the recommended
levels is not a genetic hazard.
Fact.
Chromosomes are the DNA -containing bodies of
cells that are responsible for the determination and
transmission of hereditary characteristics. A single
chromosome contains many genes which are the
functional hereditary units that occupy a fixed location
on a chromosome. Many studies have examined the
possible effects of fluoride on chromosome damage.
In 1993, the National Research Council (NRC) of the
National Academies issued a report$ that supported the
conclusion that drinking optimally fluoridated water is
not a genetic hazard. In a statement summarizing its
research", the NRC stated, "in vitro data indicate that:
1. the genotoxicity of fluoride is limited primarily to
doses much higher than those to which humans
are exposed,
2. even at high doses, genotoxic effects are not
always observed, and
3. the preponderance of the genotoxic effects that
have been reported are of the types that probably
are of no or negligible genetic significance"8
The lowest dose of fluoride reported to cause
chromosomal changes in mammalian cells was
approximately 170 times that normally found in
human cells in areas where drinking water was
fluoridated at 1.0 mg/L, which indicates a large
margin of safety.a (Note that this would be 242 times
greater with fluoridation now set at 0.7 mg/L.)
In its subsequent 2006 report,9 the NRC stated after
reviewing the evidence available since its 1993 report,
that the weight of evidence from studies on rodents
indicated a very low probability that fluoride presents
a risk of genetic mutation for humans.9
In addition, the 2006 NRC report9 indicated that the
results of human studies related to fluoride and its effect
on genotoxicity since its 1993 report are inconsistent
and do not strongly indicate the presence or absence
of genotoxic potential for fluoride. Continued research
and evaluation are recommended.9
39. Does fluoride at the levels found
in water fluoridation affect human
reproduction, fertility or birth rates?
Answer.
According to the best available scientific evidence,
water fluoridation does not have an adverse effect
on human reproduction, fertility or birth rates.
Fact.
In 2011, the European Commission requested
the European Scientific Committee on Health and
Environmental Risks (SCHER) perform a critical review
of fluoridating agents of drinking water. A portion of
that report looked at reproductive issues. The report
concluded that there is no new evidence from human
studies indicating that fluoride in drinking water
influences male and female reproductive capacity.20
In its 2006 report,9 the National Research Council
(NRC) indicated that since 1990, the quality and
number of reproductive and developmental studies
using laboratory animals have improved significantly.
These high -quality studies indicate adverse
reproductive and developmental effects occur only
at levels of fluoride much higher than 4 mg/L.9 The
NRC also indicated that a few studies conducted
with human populations have suggested that fluoride
might be associated with alterations in reproductive
hormones and fertility. However, the report continued
on to explain that limitations in study design, such as
the lack of control of reproductive variables, make
these studies of little value for risk evaluation.9
A study examining the relative risk of stillbirths
and congenital abnormalities (facial clefts, Down
syndrome and neural tube defects) found no
evidence that fluoridation had any influence on the
rates of congenital abnormalities or stillbirths 141
The study, conducted in 2003, analyzed data from
two population based registries to identify all
stillbirths and congenital abnormalities occurring
in northeastern England between 1989 and
1998 and compared the rates of stillbirths and
Safety Fluoridation Facts 61
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specific congenital abnormalities in fluoridated and
nonfluoridated communities. The study found no
significant association between the occurrence of
stillbirths or specific congenital abnormalities and
fluoride levels in drinking water.141
40. For women, does drinking water
fluoridated at the recommended levels
create a risk for their children to be born
with Down syndrome?
Answer.
There is no known association between the
consumption of drinking water fluoridated at the
recommended levels and Down syndrome.
Fact.
All people with Down syndrome have an extra,
critical portion of chromosome 21 present in all or
some of their cells. This additional genetic material
alters the course of development and causes the
characteristics associated with Down syndrome. The
cause of the extra full or partial chromosome is still
unknown. Maternal age is the major factor that has
been linked to an increased chance of having a baby
with Down syndrome. There is no definitive scientific
research that indicates that Down syndrome is caused
by environmental factors or the parents' activities
before or during pregnancy.141
However, those opposed to fluoridation sometimes
still assert that consuming fluoridated tap water can
cause Down syndrome.
In 2014, the systematic review published by Public
Health England reviewed the literature and concluded
that there was no evidence of a difference in the rate
of Down syndrome in fluoridated and nonfluoridated
areas"
A number of studies have looked at this issue in the
past. Several are summarized below.
A detailed study of approximately 2,500 children
born with Down syndrome was conducted in
Massachusetts. A rate of 1.5 cases per 1,000 births
was found in both fluoridated and nonfluoridated
communities, providing strong evidence that
fluoridation does not increase the risk of Down
syndrome 141
Another large population -based study with U.S.
national data relating to nearly 1.4 million births
showed no association between water fluoridation
and the incidence of congenital malformations
including Down syndrome 144
A comprehensive study of Down syndrome births was
conducted in 44 U.S. cities over a two-year period.
Rates of Down syndrome were comparable in both
fluoridated and nonfluoridated cities 14s
41. Does ingestion of water fluoridated at
recommended levels have any effect on
intelligence (IQ) in children or neurological
impact?
Answer.
The best available science -based evidence does
not establish a causal relationship between
consumption of water fluoridated at recommended
levels and lowered intelligence (IQ) or behavioral
disorders in children.
Fact.
A number of systematic reviews and individual studies
provide evidence that consumption of optimally
fluoridated water at levels recommended in the U.S.
(0.7 mg/L) does not lower IQ or cause behavior
problems in children. The following conclusions from
a number of systematic reviews and individual studies
support the safety of community water fluoridation.
A number of systematic reviews and individual
studies provide evidence that consumption
of optimally fluoridated water of levels
recommended in the U.S. (0.7 mg/L) does not
lower IQ or cause behavior problems in children.
In 2017, the Australian National Health and Medical
Research Council's systematic review Information
paper — Water Fluoridation: Dentol and Other Human
Health Outcomes1 ° concluded, "The evidence from a
single study of acceptable quality shows that there is
no association between water fluoridation at current
Australian levels and the cognitive function of children
or adults." (Current recommendations for fluoride
levels in drinking water in Australia are a range of
0.6 to 1.1 mg/L depending on climate.)10
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62 American Dental Association
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The report, Health Effects of Water Fluoridation:
An Evidence Review, issued in 2015 by the Ireland
Health Research Board noted," "There was only one
study carried out in a non -endemic or CWF area
(like Ireland) that examined fluoride and IQ. This
was a prospective cohort study (whose design is
appropriate to infer causality) in New Zealand. The
study concluded that there was no evidence of a
detrimental effect on IQ as a result of exposure to
CWF (community water fluoridation)"15
In 2014, a scientific review, Health effects of water
fluoridation: A review of the scientific evidence,'$
commissioned by the New Zealand Prime Minister's
Chief Science Advisor and the President of the Royal
Society of New Zealand concluded: "There is no
convincing evidence of neurological effects at fluoride
concentrations achieved by CWF."18
At the request of the European Commission, the
Scientific Committee on Health and Environmental
Risks (SCHER) conducted a critical review20 of any new
evidence on the hazard profile, health effects, and
human exposure to fluoride and the fluoridating agents
of drinking water. Their report of May 2011 reviewed
animal and human studies concluding that "there is not
enough evidence to conclude that fluoride in drinking
water at concentrations permitted in the EU may impair
the IQ of children. SCHER also agreed that a biological
plausibility for the link between fluoridated water and
IQ has not been established:'20
As noted in the preceding paragraphs, at least three
systematic reviews'0,11,18 indicated that there was
only one high -quality prospective cohort study
that addressed the issue of IQ. Published in 2014,
a study146 conducted in New Zealand followed a
group of more than 1,000 people born in the early
1970s and measured childhood IQ at the ages of
7, 9, 11 and 13 years and adult IQ at the age of 38
years. Early life exposure to fluoride from a variety of
sources was recorded and adjustments were made for
factors potentially influencing IQ. Childhood factors
associated with IQ variation included socio-economic
status of parents, birth weight and breastfeeding,
as well as secondary and tertiary educational
achievement, which is associated with adult IQ. This
detailed study revealed no evidence that exposure to
water fluoridation in New Zealand affects neurological
development or IQ. (Recommended levels of fluoride
used in New Zealand's fluoridation program range
from 0.7 mg/L to 1.0 mg/L.)146
Those opposed to water fluoridation have promoted
studies that reportedly show fluoridation causes
lower intelligence (IQ) in children. The studies cited
are often from China, Mexico, India or Iran where social,
nutritional and environmental conditions are significantly
different from those in the United States. The vast
majority of these studies have not been published in
peer -reviewed English language journals. The consensus
of those who have reviewed these studies is that the
quality of these studies does not stand up to scientific
scrutiny. The studies are of low quality, have a high risk of
bias and use a study design unsuited to prove or disprove
theories. They take no or little account of other factors
that are known to cause a lowering of IQ (also called
confounders) such as nutritional status, socioeconomic
status, iodine deficiency and consumption of other
harmful elements in ground water (arsenic or lead).
At the request of the U.S. EPA, a report on fluoride in
drinking water issued in 2006 by the National Research
Counci19 noted that the significance of the Chinese
studies reviewed was "uncertain" "Most of the papers
were brief reports and omitted important procedural
details ... Most of the studies did not indicate whether
the IQ tests were administered in a blinded manner.
Some of the effects noted in the studies could have
been due to stress induced by the testing conditions.
Without detailed information about the testing
conditions and the tests themselves, the committee
was unable to assess the strength of the studies"9
In England in 2009, the South Central Strategic
Health Authority requested an independent critical
appraisal of 19 papers and one abstract that reported
an association between fluoride in drinking water
and IQ in countries outside England. The appraisa1141
noted that the study design and methods used by
many of the researchers in these studies had serious
limitations. The researchers also exhibited a lack of
a thorough consideration of confounding factors as
a source of bias in the results. From these studies
alone, it was "uncertain how fluoride was responsible
for any impairment in intellectual development"
Significant differences were noted in conditions
between the communities studied and conditions in
England. For example, some studies noted high levels
of naturally occurring fluoride in drinking water and
exposure to fluoride from other sources including the
practice of burning high fluoride coal to heat poorly
ventilated homes in China. Additionally, in many cases,
there were stark differences in other environmental
conditions and socioeconomic characteristics 141
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In November 2016, those opposed to fluoridation
filed a legal petition148 with the U.S. Environmental
Protection Agency (EPA) in Washington, D.C. calling
for the EPA to ban the addition of fluoridating
chemicals to public drinking water on the grounds
that a large body of animal, cellular, and human
research showed that fluoride is neurotoxic at doses
within the range now seen in fluoridated communities
in the U.S. (0.7 mg/L). The EPA responded to the
petition in February 2017 noting, "After careful
consideration, EPA denied the TSCA section 21 petition,
primarily because EPA concluded that the petition
has not set forth a scientifically defensible basis to
conclude that any persons have suffered neurotoxic
harm as a result of exposure to fluoride in the U.S.
through the purposeful addition of fluoridation
chemicals to drinking water or otherwise from fluoride
exposure in the U.S"148 As allowed under the TSCA
process, the petitioners filed a lawsuit challenging the
EPA ruling in April 2017 in the U.S. District Court for
the Northern District of California at San Francisco.
In late 2017, a federal judge denied an EPA motion
to dismiss the lawsuit.
In 2017 a study from Mexico City149 received
some coverage in the popular press. The authors
concluded higher urinary fluoride levels of pregnant
women were associated with lower scores on
tests of cognitive function in their children. This
was an observational study that by definition could
only show a possible association between fluoride
exposure and IQ — not cause and effect. This small
study did not adequately address a number of
potential confounders that might explain the possible
association such as breast feeding, maternal age,
gestational age, birth weight and education as well
as exposures to lead, mercury, arsenic and iodine
that affect IQ and other measures of cognitive ability.
Unlike conditions in the U.S., the pregnant women
participating in the study were exposed to varied
fluoride levels from naturally occurring fluoride in the
water supply (in some cases at levels almost twice as
high as the level recommended for community water
fluoridation in the U.S.) and fluoridated sa1t149
Additional research on this topic is underway through the
National Toxicology Program's systematic review using
animal studies to evaluate potential neurobehavioral
effects from exposure to fluoride during development.
Initiated in 2015, work continued in 2017.21
42. Does drinking fluoridated water increase
the level of lead in the blood or cause lead
poisoning in children?
Answer.
The best available scientific evidence has not shown
any association between water fluoridation and
blood lead levels.
Fact.
A number of reviews and data analyses indicate no
association between water fluoridation and blood
lead levels.
In 2011, the European Commission requested
that the European Scientific Committee on Health
and Environmental Risks (SCHER) perform a
critical review of fluoridating agents of drinking
water. The committee concluded that "it is
highly unlikely that there would be an increased
release of lead from pipes due to hexafluorosilicic
acid.211 Hexafluorosilicic acid is another name for
fluorosilicic acid which is one of the additives used
to fluoridate water in the U.S.
6 Additional information on this topic can be found
in the Fluoridation Practice Section, Question 49.
A 2006 study analyzed data from the Third National
Health and Nutrition Examination Survey (1988-
1994) and the 1992 Fluoridation Census to evaluate
the relationship between water fluoridation and lead
concentrations in children. The study concluded that
the results did not support that the silicofluorides
used in community water systems caused higher
lead concentrations in children 150
According to the Centers for Disease Control and
Prevention,"' the average blood lead levels of
young children in the U.S. have continued to decline
since the 1970s primarily due to lead poisoning
prevention laws such as the phase -out of leaded
paint and leaded gasoline. The primary remaining
sources of childhood lead exposure are deteriorated
leaded paint, house dust contaminated by leaded
paint and soil contaminated by leaded paint and/or
decades of industrial and motor vehicle emissions.
Besides exposure to lead paint in older homes, lead
water pipes and fixtures also can be found in homes
built before 1978. In some areas of the county, folk
remedies and pottery also add to lead exposure"'
Findings from the National Health and Nutrition
64 American Dental Association
back to agenda
Examination Surveys (NHANES) from 1976-1980 to
2003-2008 show that the percentage of children
aged 1- to 5-years-old having high lead blood levels
(>_10 ug/dL) declined dramatically from 88.2%
to 0.9% 152 During that same time period (1976
to 2008), the percentage of the U.S. population
receiving fluoridated water rose from approximately
48.8% to 64.3% 153 Moreover, in the 1991-1994
NHANES, the overall (all age groups) prevalence of
high lead blood levels (>_10 ug/dQ was 2.2% but
decreased to 0.7% by the 1999-2002 survey"'
While antifluoridationists claim that fluoridated water
increases lead blood levels in children, the fact is
that since 1976 while the use of water fluoridation
has increased, the percentage of children in the U.S.
with high lead blood levels actually has continued
to decreased substantially. This demonstrates
that the claim made by those opposed to water
fluoridation that fluoride in water increases lead
concentrations in children is unfounded. It should
be noted that approximately 95% of the primary
sources of adult lead exposure are occupational 1s4
In general, adult blood lead levels have continued to
decline over recent decades due largely to improved
prevention measures in the workplace and changes
in employment patterns.' 14
Those opposed to water fluoridation sometimes
claim that there is an increase in acidity when fluoride
is added to water and that the acidic water in the
system leaches lead from pipes and fixtures. The
process of adding fluoride to water has minimal
impact on the acidity or pH of drinking water. Under
some water quality conditions, a small increase in
the acidity of drinking water that is already slightly
acidic can be observed after treatment with alum,
chlorine, fluorosilicic acid or sodium fluorosilicate. In
such cases, additional water treatment to adjust the
pH to neutralize the acid in water distribution systems
is standard practice in water plants 1ss Water facilities
typically maintain a pH of between 7.0 and 8.0 as
standard practice indicating that the water leaving
the plant is slightly alkaline and non-acidic.'56
Despite this information, antifluoridationists
continue to exploit their unfounded claims that
fluoridation can lead to an increased uptake of lead
by children. A 1999 study157 charged that fluorosilicic
acid and sodium silicofluoride did not disassociate
completely when added to water systems and could
be responsible for lower pH (more acidic) levels of
drinking water, leaching lead from plumbing systems
and increasing lead uptake by children. In response
to the study, scientists from the EPA reviewed the
basic science that was the foundation for the claim
that silicofluorides leach lead from water pipes and
found that many of the chemical assumptions made
in the original ecological study were scientifically
unjustified158 Fluoride additives do disassociate very
quickly and completely release fluoride ions into
the water. The research from the 1999 study was
inconsistent with accepted scientific knowledge
and the authors of that study failed to identify or
account for those inconsistencies. The EPA scientists
discounted the 1999 study and said there were no
credible data to suggest any link between fluoridation
and lead. Overall, the EPA scientists concluded
that "...no credible evidence exists to show that
water fluoridation has any quantifiable effects on
the solubility, bioavailability, bioaccumulation, or
reactivity of lead compounds."1s8
43. Does drinking water fluoridated at
recommended levels cause Alzheimer's
disease?
Answer.
The best available scientific evidence has not
indicated an association between drinking optimally
fluoridated water and Alzheimer's disease.
Fact.
Scientists believe the causes of late -onset
Alzheimer's, the most common form of the disease,
include a combination of age -related brain changes,
genetic, lifestyle, and environmental factors. The
importance of any one of these factors in increasing
or decreasing the risk of developing Alzheimer's could
differ from person to person. Early -onset Alzheimer's
is less common (fewer than 10% of Alzheimer's
cases) with the first signs of the disease typically
appearing between an individual's 30s and mid-60s.
It is believed to be caused primarily by gene changes
passed down from parent to child 1s9
A study published in 1998161 raised concerns about
the potential relationship between fluoride, aluminum
and Alzheimer's disease. However, several flaws in the
study's experimental design precluded any definitive
conclusions from being drawn161 Concerns were
noted about a number of aspects of the protocol
including, but not limited to, the high percentage
of the test rodents dying during the study and that
...............................................................................................................................................................
Safety I Fluoridation Facts 65
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the researchers failing to account for the high levels
of aluminum and fluoride in the chow fed to all test
rodents 161 For decades, a small number of researchers
have implicated aluminum in the development
of late -onset Alzheimer's disease. However, the
"Aluminum Hypothesis" has been abandoned by the
majority of mainstream scientists."'
In 2000, a study16' investigated the relationships
between trace elements in drinking water and the
thought processes of 1,016 subjects over the age
of 65 living in two rural areas of China. In today's
U.S. society, people are very mobile and tend to live
in multiple places during their lifetimes. In contrast,
the rural residents of China rarely move and so in
this study the researchers were able to assume
that this elderly population had used the same
water and food sources throughout their lifetimes.
The researchers evaluated the effects on thought
processes of seven elements (cadmium, calcium,
fluoride, iron, lead, selenium and zinc) found in the
water sources at the two study sites. The study
assessed thought processes in three areas (memory,
language and attention) using a Chinese translation of
the Community Screening Interview for Dementia.
Taking into account the effects of the seven trace
elements, the authors concluded that fluoride is
not significantly related to impairment of thought
processes such as is seen in Alzheimer's disease 161
44. Does drinking water fluoridated at
recommended levels cause or contribute
to heart disease?
Answer.
Drinking water fluoridated at recommended levels is
not a risk factor for heart disease.
Fact.
The American Heart Association identifies aging, male
gender, heredity, cigarette and tobacco smoke, high
blood cholesterol levels, high blood pressure, physical
inactivity, obesity and diabetes mellitus as major risk
factors for cardiovascular disease.164
The American Heart Association's website notes:
"No evidence exists that adjusting the fluoride
content of public water supplies to a level of about
one part per million has any harmful effect on the
cardiovascular system."16s
A number of historical studies have evaluated
urban mortality in relation to fluoridation status.
Researchers from the National Heart, Lung and
Blood Institute of the National Institutes of Health
examined a wide range of data from communities
that had naturally high levels, optimal levels and
low levels of fluoride in water. The results of their
analysis published in 1972166 concluded, "Thus,
the evidence from comparison of the health of
fluoridating and nonfluoridating cities, from medical
and pathological examination of persons exposed
to a lifetime of naturally occurring fluorides
or persons with high industrial exposures, and
from broad national experience with fluoridation
all consistently indicate no adverse effect on
cardiovascular health."166 Two additional studies
were published in 1978. In the first study,104 the
mortality trends from 1950-70 were studied for
473 cities in the United States with populations of
25,000 or more. Findings showed no relationship
between fluoridation and heart disease death rates
over the 20-year period 104 In the second study,los
the mortality rates for approximately 30 million
people in 24 fluoridated cities were compared with
those of 22 nonfluoridated cities for two years.
No evidence was found of any harmful health
effects, including heart disease, attributable to
fluoridation 105
The misinterpretation of the results of a study by
those opposed to fluoridation167 led the opposition
to claim that "research highlights the fact that
mass fluoride exposure may be to blame for the
cardiovascular disease epidemic that takes more
lives each year than cancer."167 In fact, the study
published in Nuclear Medicine Communications in
January 201216e examines the possible benefits of
using a sodium fluoride isotope marker in testing to
determine the presence of atherosclerosis and risk
for coronary disease. In this case, fluoride's affinity
for calcified tissue aided in the location of calcium
deposited in arterial walls which could be associated
with an increased risk of coronary artery disease.
The study made no reference to any relationship
between the consumption of fluoridated water and
heart disease168
66 American Dental Association
back to agenda
45. Is the consumption of water fluoridated
at recommended levels harmful to kidneys?
Answer.
Consuming water fluoridated at recommended
levels has not been shown to cause or worsen
kidney disease.
Fact.
Approximately 60% of the fluoride absorbed daily
by adults (45% for children) is removed from the
body by the kidneys.52 Because the kidneys are
constantly exposed to various fluoride concentrations,
any health effects caused by fluoride would likely
manifest themselves in kidney cells. However, several
large community -based studies of people with
long-term exposure to drinking water with fluoride
concentrations up to 8 ppm have failed to show an
increase in kidney disease.','16•169
In a report issued in 1993 by the National Research
Council (NRC), the Subcommittee on Health Effects
of Ingested Fluoride stated that the threshold dose of
fluoride in drinking water which causes kidney effects
in animals is approximately 50 ppm — more than 12
times the maximum level allowed in drinking water
by the Environmental Protection Agency. Therefore,
they concluded that "ingestion of fluoride at currently
recommended concentrations is not likely to produce
kidney toxicity in humans"8 Furthermore, the NRC
report on fluoride in drinking water issued in 2006
concluded that there were no published studies
that demonstrate that drinking water fluoridated at
recommended levels can damage kidneys. The report
further concluded that fluoride concentrations need
to be higher than 4 ppm to affect kidney tissues and
function.9
A review of scientific studies completed in 2007 for
Kidney Health Australia (KHA)'170 summarized findings
from the recent literature related to the health
effects of fluoridated water for people with chronic
kidney disease (CKD). The purpose of the review
was to provide an up to date summary of studies
on the topic so that KHA, the leading organization
in Australia that promotes kidney and urinary tract
health, could develop a fluoride position paper. The
review concluded that while studies on the topic are
limited, "there is no evidence that consumption of
optimally fluoridated drinking water increases the
risk of developing CKD" For those people who have
CKD, the report stated that "there is no evidence that
consumption of optimally fluoridated drinking water
poses any health risks for people with CKD, although
only limited studies addressing this issue are available"
There is limited evidence that people with advanced
CKD (stages 4 or 5) "who ingest substances with a high
concentration of fluoride may be at risk of fluorosis"
Accordingly, the report recommended that it would be
"prudent" for patients with advanced CKD to monitor
fluoride intake and avoid fluoride -rich substances. These
conclusions are the basis for KHA's position statement
on fluoride which was released in 2007.10 The position
statement was updated in 2011 and concluded that
"there has been no new published evidence to contradict
the 2007 KHA Position Statement .•171
According to information on their website, the National
Kidney Foundation is the leading organization in the
U.S. dedicated to the awareness, prevention and
treatment of kidney disease. A paper titled Fluoride
Intake in Chronic Kidney Disease dated April 15, 2008; 72
developed by the National Kidney Foundation (NKF) and
posted on the NKF website includes the following points
under the header "Analysis and Recommendations":
• Dietary advice for patients with CKD should
primarily focus on established recommendations
for sodium, potassium, calcium, phosphorus,
energy/calorie, protein, fat, and carbohydrate
intake. Fluoride intake is a secondary concern.
Individuals with CKD should be notified of the
potential risk of fluoride exposure by providing
information on the NKF website including a link to
the Report in Brief of the National Research Council
and the Kidney Health Australia position paper.
The risk is likely greatest in areas with naturally
high water fluoride levels.
• The NKF has no position on the optimal fluoridation
of water. The oral health of people with CKD is
certainly of interest to the NKF, but balancing the
overall benefits and risks of fluoride exposure is
the primary concern 172
Many people with kidney failure depend on
hemodialysis (treatment with an artificial kidney
machine) for their survival. During hemodialysis, the
patient's blood is exposed to large amounts of water
each week (280-560 quarts). Therefore, procedures
have been designed to ensure that the water utilized
in the process contain a minimum of dissolved
substances that could diffuse indiscriminately into
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Safety I Fluoridation Facts 67
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the patient's bloodstream171 Both KHA and the NKF
recommend careful monitoring of hemodialysis
systems to ensure proper mechanical function 170,171
Since the composition of water varies in different
geographic locations in the United States, the U.S.
Public Health Service recommends dialysis units use
techniques such as reverse osmosis and de -ionization
to remove excess iron, magnesium, aluminum,
calcium, and other minerals, as well as fluoride, from
tap water before the water is used for dialysis 173
46. What are some of the erroneous health
claims made against water fluoridation?
Answer.
From sources such as the internet, newsletters,
social media and personal anecdotes in emails,
it is frequently claimed that community water
fluoridation causes the following adverse health
effects:
• AIDS
• Allergic Reactions (e.g.,loss of hair, skin that burns
and peels after contact with fluoridated water)
• Accelerated Aging
• Alzheimer's disease
• Arthritis
• Asthma
• Austism
• Behavioral Problems (e.g., attention deficit
disorders)
• Bone Disease (e.g.,osteoporosis —increased bone/
hip fractures)
• Cancer (all types including osteosarcoma or bone
cancer)
• Chronic Bronchitis
• Colic (acute abdominal pain)
• Cystic Fibrosis
• Down Syndrome
• Emphysema
• Enzyme Effects (gene -alterations)
• Flatulence (gas)
• Gastrointestinal Problems (irritable bowel
syndrome)
• Harmful Interactions with Medications
• Heart Disease
• Increased Infant Mortality
• Low Birth Weight for Infants
• Kidney Disease
• Lead Poisonings
• Lethargy (lack of energy)
• Lower IQ scores
• Malpositioned Teeth
• Parkinson's Disease
• Calcification of the Pineal Gland (causing early
puberty) (chronic insomnia);
• Reproductive issues (damaged sperm) (reduced
fertility)
• Skin Conditions (redness, rash/welts, itching)
• Sudden Infant Death Syndrome (SIDS)
• Thyroid Problems (goiter and obesity due to
hypothyroidism)
AND
• Tooth Decay
Fact.
As discussed throughout this document, the
best available scientific evidence consistently has
indicated that fluoridation of community water
supplies is safe and effective. The possibility of any
adverse health effects from continuous low-level
consumption of fluoride has been and continues to
be studied extensively. Of the thousands of credible
scientific studies on fluoridation, none has shown
health problems associated with the consumption of
optimally fluoridated water.
Of the thousands of credible scientific studies
on fluoridation, none has shown health
problems associated with the consumption of
optimally fluoridated water.
.....................................................................................................................................................................
68 American Dental Association
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Safety References
1. U.S. Department of Health and Human Services, Public Health Service.
Review of fluoride: benefits and risks. Report of the Ad Hoc Subcommittee
on Fluoride. Washington, DC; February 1991. Available at: https://health.
gov/environment/ReviewofFluoride. Accessed October 28, 2017.
2. Royal College of Physicians. Fluoride, teeth and health. London; Pitman
Medical:1976. Abstract at: https://www.bfsweb.org/fluoride-teeth-
and-health. Accessed October 28, 2017.
3. Johansen E, Taves D, Olsen T (ed). Continuing evaluation of the use of
fluorides. AAAS Selected Symposium 11. Boulder, Colorado; Westview
Press:1979.
4. Knox EG. Fluoridation of water and cancer: a review of the epidemiological
evidence. Report of the Working Party. London: Her Majesty's Stationary
Office;1985. Available at: https://archive.org/detailslopl276356-1001.
Accessed October 28, 2017.
5. Leone NC, Shimkin MB, Arnold FA, Stevenson CA, Zimmermann ER, Geiser
PB, Lieberman JE. Medical aspects of excessive fluoride in a water supply.
Public Health Rep 1954;69(10):925-36. Article at: https://www.ncbi.nim.
nih.gov/pmc/articles/PMC2024409. Accessed October 28, 2017.
6. Maxcy KF, Amleton JILT, Bibby BG, Dean HT, Harvey AM, Heyroth FF. National
Research Council fluoridation report. J Public Health Dent 1952;12(1):24-33.
Abstract at: http://0nlinelibrary.wiley.com/doi/lO.1111/j.1752-7325.1952.
tb03609.x/abstract. Accessed October 28, 2017.
7. National Research Council. Drinking water and health, Volume 1.
Washington, DC: The National Academies Press;1977. Available at: https://
www. nap. edu/catalog/1780/drinking-water-and-health-volume-1.
Accessed October 28, 2017.
8. National Research Council. Health effects of ingested fluoride. Report of
the Subcommittee on Health Effects of Ingested Fluoride. Washington,
DC: National Academy Press;1993. Available at: https://www. nap. edu/
catalog/2204. Accessed October 28, 2017.
9. National Research Council of the National Academies. Division on Earth and
Life Studies. Board on Environmental Studies and Toxicology. Committee on
Fluoride in Drinking Water. Fluoride in drinking water: a scientific review of
EPA's standards. Washington, DC: National Academy Press;2006. Available
at: https://www. nap. edu/catalog/11571. Accessed October 28, 2017.
10. Australian Government. National Health and Medical Research Council
(NHMRC). Information paper - water fluoridation: dental and other human
health outcomes. Canberra. 2017. Available at: https://www.nhmrc.gov.
au/guidelines-publications/eh43-0. Accessed October 23, 2017.
11. O'Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg -Gunn AJ,
Whelton H, Whitford GM. Fluoride and oral health. Community Dent
Health 2016;33(2):69-99. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/27352462. Accessed October 23, 2017.
12. American Water Works Association. Water fluoridation principles and
practices. AW WA Manual M4. Sixth edition. Denver. 2016.
13. Water Research Foundation. State of the science: community
water fluoridation. 2015. Available at: http://www.waterrf.orgl
PublicReportLibrary/4641.pdf. Accessed October 1, 2017.
14. The Network for Public Health Law. Issue brief: community water
fluoridation. 2015. Available at: https://www.networkforphLorgl
resources_collection/2015/07/17/664/issue_brief community water
fluoridation. Accessed October 2, 2017.
15. Sutton M, Kiersey R, Farragher L, Long J. Health effects of water
fluoridation: an evidence review. 2015. Ireland Health Research Board.
Available at: http://www.hrb.ie/publications/hrb-publication/
publications/674. Accessed October 28, 2017.
16. U.S. Department of Health and Human Services. Federal Panel on
Community Water Fluoridation. U.S. Public Health Service recommendation
for fluoride concentration in drinking water for the prevention of dental
caries. Public Health Rep 2015;130(4):318-331. Article at: https://www.
ncbLnlm.nih.gov/pmc/articles/PMC4547570. Accessed October 24, 2017.
17. Public Health England. Water fluoridation: health monitoring report
for England 2014. Available at: https://www.gov.uk/government/
publications/wa ter-fl uorid a tion-health -monitoring-report-for-
england-2014. Accessed October 28, 2017.
18. Royal Society of New Zealand and the Office of the Prime Minister's Chief
Science Advisor. Health effects of water fluoridation: a review of the
scientific evidence. 2014. Available at: https://royalsociety.org.nzlwhat-
we-dolour-expert-advice/all-expert-advice-papers/heal th-effects-
of-water-fluoridation. Accessed October 28, 2017.
19. U.S. Community Preventive Services Task Force. Oral Health: Preventing
Dental Caries (Cavities): Community Water Fluoridation. Task Force
finding and rationale statement. 2013. Available at: https://www.
thecommunityguide. org/findings/dental-caries-cavities-community-
water-fluoridation. Accessed October 28, 2017.
20. Scientific Committee on Health and Environmental Risks (SCHER) of the
European Commission. Critical review of any new evidence on the hazard
profile, health effects, and human exposure to fluoride and the fluoridating
agents of drinking water. 2011. Available at: http://ec.europa.eu/health/
scien tific_ commi tte es/o pinions_ I ayman/fluoridation/en/1-3/index. h tm.
Accessed October 24, 2017.
21. Health Canada. Findings and recommendations of the fluoride expert panel
(January 2007). 2008. Available at: http://www.hc-sc.gc.ca/ewh-semt/
pubs/water-eau/2008-fluoride-fluorure/index-eng.php. Accessed
October 24, 2017.
22. Australian Government. National Health and Medical Research Council. A
systematic review of the efficacy and safety of fluoridation. Part A: review
of methodology and results. 2007. Available at: https://www.nhmrc.gov.
au/guidelines-publications/eh41. Accessed October 24, 2017.
23. U.S. Department of Health and Human Services, National Toxicology
Program. Fluoride: potential developmental neurotoxicity. Available at:
https://ntp.niehs.nih.govlgol785076. Accessed October 28, 2017.
24. ADA News. Federal agencies announce scientific assessments and an update
to the recommended community water fluoridation level. January 31, 2011.
25. U.S. Environmental Protection Agency. Six -Year review 3 of drinking water
standards. 2016. Available at: https://www.epa.govldwsixyearreview/six-
year-review-3-drinking-water-standards. Accessed October 24, 2017.
26. Federal Register. 2011 Jan 13;76(9):2383-8. Available at: https://www.
federairegister.govldocumentsl20111011l3l2011-6371proposed-hhs-
recommendation -for-fluoride- concentration -in- drinking- water -for -
prevention - of- dental. Accessed October 28, 2017.
27. U.S. Environmental Protection Agency. Overview of the safe drinking water
act. 2015. Available at: https://www.epa.govlsdwa/overview-safe-
drinking-water-act. Accessed October 28, 2017.
28. U.S. Environmental Protection Agency. Six -Year review 1 of drinking water
standards. 2003. Available at: https://www.epa.govldwsixyearreview/six-
year-review-1-drinking-water-standards. Accessed October 28, 2017.
29. National Research Council of the National Academies. Division on Earth and
Life Studies. Board on Environmental Studies and Toxicology. Committee
on Fluoride in Drinking Water. Fluoride in drinking water: a scientific review
of EPA's standards. Report in brief. 2006. Available at: http://dels.nas.edu/
Materials/Report-In-Brief/4775-Fluoride. Accessed October 28, 2017.
30. U.S. Environmental Protection Agency. Fluoride risk assessment and
relative source contribution. 2011. Available at: https://www.epa.govl
d wstandardsregula tions/fl uorid e-risk-assessment-and -relative -source-
contribution. Accessed October 28, 2017.
31. Federal Register 2017 Janl1;82(7):3518-3552. Available at: https://www.
fed eralregister. go v/do cum ents/2017/01 / 11 /2016-31262/na tional -
primary-drinking-water-regulations-announcement-of-the-results-of-
epas-review-of-existing. Accessed October 28, 2017.
32. Federal Register 1986 Apr 2;51(63):11410-11412. Available at: https://
cdn.loc.govlservice/ll/fedreglfr051/fr05lO631fr05lO63.pdf. Accessed
October 28, 2017.
33. Jackson RD, Brizendine EJ, Kelly SA, Hinesley R, Stookey GK, Dunipace AJ.
The fluoride content of foods and beverages from negligibly and optimally
fluoridated communities. Comm Dent Oral Epidemiol 2002;30(5):382-
91. Abstract at: https://www.ncbi.nim.nih.govlpubmed/12236830.
Accessed October 28, 2017.
...............................................................................................................................................................
Safety I Fluoridation Facts 69
back to agenda
34. U.S. Department of Agriculture, Agricultural Research Service, Beltsville
Human Nutrition Research Center, Nutrient Data Laboratory. USDA national
fluoride database of selected beverages and foods, Release 2. 2005.
Available at: https://www.ars.usda.gov/northeast-area/beltsville-md/
beltsville -human-nutrition -research-center/nutrient-data-lab oratory/
docs/usda-national-fluoride-database-of-selected-beverages-and-
foods-release-2-2005. Accessed August 18, 2017.
35. U.S. Environmental Protection Agency, Health and Ecological Criteria
Division, Office of Water. Fluoride: exposure and relative source
contribution analysis. 820-R-10-015. Washington, DC; 2010. Available
at: https://nepis.epa.gov/ExelZyPURL.cgi?Dockey=PlOON49K.TXT.
Accessed October 28, 2017.
36. Whitford GM. The metabolism and toxicity of fluoride. 2nd rev. ed.
Monographs in oral science, Vol. 16. Basel, Switzerland: Karger; 1996.
37. Horowitz HS. The effectiveness of community water fluoridation in the
United States. J Public Health Dent 1996;56(5 Spec no):253-8. Abstract
at: https://www.ncbi.nlm.nih.gov/pubmedl9O34970. Accessed October
29, 2017.
38. Griffin SO, Gooch BF, Lockwood SA, Tomar SL. Quantifying the diffused
benefit from water fluoridation in the United States. Community Dent Oral
Epidemiol 2001;29(2):120-9. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/11300171. Accessed October 29, 2017.
39. Slade GD, Davies MU, Spencer AJ, Stewart JF. Associations between
exposure to fluoridated drinking water and dental caries experience among
children in two Australian states. J Public Health Dent 1995;55(4):218-28.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl8551461. Accessed
October 2, 2017.
40. Institute of Medicine. Food and Nutrition Board. Dietary reference intakes
for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington,
DC: National Academy Press;1997. Available at: https://www. nap.edu/
catalog/5776/dietary-reference -intakes-for-calcium -phosphorus-
magnesium - vitamin-d-and- fluoride. Accessed October 29, 2017.
41. Rozier RG, Adair S, Graham F, lafolla T, Kingman A, Kohn W, Krol D, Levy
S, Pollick H, Whitford G, Strock S, Frantsve-Hawley J, Aravamudhan K,
Meyer DM. Evidence -based clinical recommendations on the prescription
of dietary fluoride supplements for caries prevention: a report of the
American Dental Association Council on Scientific Affairs. J Am Dent
Assoc 2010 Dec;141(12):1480-9. Abstract at: https://www.ncbi.nlm.nih.
gov/pubmed/21158195. Article at: http://ebd.ADA.org/en/evidence/
guidelines/fluoride-supplements. Accessed October 2, 2017.
42. Franzman MR, Levy SM, Warren JJ, Broffitt B. Fluoride dentifrice
ingestion and fluorosis of the permanent incisors. J Am Dent Assoc
2006137(5):645-52. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/16739545. Accessed October 2, 2017.
43. Buzalaf MAR, Levy SM. Fluoride intake of children: considerations for
dental caries and dental fluorosis. In Buzalaf MAR (ed): Fluoride and the
Oral Environment. Monogr Oral Sci. Basel, Karger. 2011;22:1-19. Abstract
at: https://www.ncbi.nlm.nih.govlpubmedl2l70ll88. Accessed October
2, 2017.
44. Levy SM. Review of fluoride exposures and ingestion. Community Dent
Oral Epidemiol 1994;22(3):173-80. Abstract at: https://www.ncbi.nlm.
nih.gov/pubmed/8070245. Accessed October 2, 2017.
45. Barnhart WE, Hiller LK, Leonard GJ, Michaels SE. Dentifrice usage and
ingestion among four age groups. J Dent Res 1974;53(6):1317-22.
Abstract at: http://journals.sagepub.com/doi/abs/10.1177/002203457
40530060301. Accessed October 22, 2017.
46. Ericsson Y, Forsman B. Fluoride retained from mouthrinses and dentifrices
in preschool children. Caries Res 1969;3:290-9.
47. Ekstrand J, Ehmebo M. Absorption of fluoride from fluoride dentifrices.
Caries Res 1980;14:96-102. Abstract at: https://www.karger.com/
Article/PDF1260442. Accessed October 2, 2017.
48. Levy SM. A review of fluoride intake from fluoride dentifrice. J Dent
Child 1993;60(2):115-24. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/8486854. Accessed October 2, 2017.
49. American Dental Association Council on Scientific Affairs. Fluoride
toothpaste use for young children. J Am Dent Assoc 2014;145(2):190-
1. Article at: http://jada.ADA.org/artic/e/SO002-8177(14)60226-9/
fulltext. Accessed October 2, 2017.
50. Sa Roriz Fonteles C, Zero DT, Moss ME, Fu J. Fluoride concentrations in
enamel and dentin of primary teeth after pre- and postnatal fluoride
exposure. Caries Res 2005;39(6):505-8. Abstract at: https://www.ncbi.
nlm.nih.gov/pubmed/16251796. Accessed September 20, 2017.
51. Leverett DH, Adair SM, Vaughan BW, Proskin HM, Moss ME. Randomized
clinical trial of effect of prenatal fluoride supplements in preventing dental
caries. Caries Res 1997;31(3):174-79. Abstract at: https://www.ncbi.nlm.
nih.gov/pubmed/9165186. Accessed September 20, 2017.
52. Buzalaf MAR, Whitford GM. Fluoride metabolism. In Buzalaf MAR
(ed): Fluoride and the Oral Environment. Monogr Oral Sci. Basel,
Karger. 2011;22:20-36. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/21701189. Accessed September 20, 2017.
53. Newbrun E. Fluorides and dental caries: contemporary concepts for
practitioners and students (3rd ed). 1986. Springfield, Illinois: Charles C.
Thomas, publisher.
54. Newbrun E. Systemic benefits of fluoride and fluoridation. J Public Health
Dent 2004;64;(Spec Iss 1):35-9. Article at: http://0nlinelibrary.wiley.
com/doi/10.1111/j.1752-7325.2004.tb02775.x/abstract. Accessed
September 20, 2017.
55. Singh KA, Spencer AJ, Armfield BA. Relative effects of pre- and
posteruption water fluoride on caries experience of permanent first
molars. J Public Health Dent 2003;63(1):11-19. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/12597581. Accessed September 20, 2017.
56. Singh KA, Spencer AJ. Relative effects of pre- and post -eruption water
fluoride on caries experience by surface type of permanent first molars.
Community Dent Oral Epidemiol 2004;32(6):435-46. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/15541159. Accessed September 20, 2017.
57. Singh KA, Spencer AJ, Brennan IDS. Effects of water fluoride exposure at
crown completion and maturation on caries of permanent first molars.
Caries Res 2007:41(1):34-42. Abstract at: https://www.ncbi.nim.nih.govl
pubmed117167257. Accessed September 20, 2017.
58. U.S. Environmental Protection Agency, Health and Ecological Criteria
Division, Office of Water. Fluoride: dose -response analysis for non -cancer
effects. 820-R-10-019. Washington, DC; 2010. Available at: https://
nepis.epa.gov/Exe/ZyPURL.cgi?Dockey=P100N458.TXT. Accessed
September 20, 2017.
59. McDonagh MS, Whiting PF, Wilson PM, Sutton AJ, Chestnutt I, Cooper
J, Misso K, Bradley M, Treasure E, Kleijnen J. Systematic review of water
fluoridation. BMJ 2000;321(7265):855-9. Abstract at: https://www.ncbi.
nlm.nih.gov/pubmed/11021861. Article at: https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC27492. Accessed October 28, 2017.
60. Levy SM, Warren JJ, Phipps K, Letuchy E, Broffitt B, Eichenberger-Gilmore
J, Burns TL, Kavand G, Janz KF, Torner JC, Pauley CA. Effects of life-long
intake on bone measures of adolescents; a prospective cohort study. J
Dent Res 2014;93(4):353-9. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/24470542. Article at: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3957342. Accessed August 18, 2017.
61. Levy SM, Eichenberger-Gilmore J, Warren JJ, Letuchy E, Broffitt B, Marshall
TA, Burns T, Willing M, Janz K, Torner JC. Associations of fluoride intake
with children's bone measures at age 11. Community Dent Oral Epidemiol
2009;37(5):416-26. Available at: https://www.ncbi.nim.nih.gov/pmc/
articles/PMC2765810. Accessed August 18, 2017.
62. Nasman P, Ekstrand J, Granath F, Ekbom A, Fored CM. Estimated drinking
water fluoride exposure and risk of hip fracture: a cohort study. J Dent
Res 2013;92(11):1029-34. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/24084670. Accessed August 18, 2017.
63. Sowers M, Whitford G, Clark M, Jannausch M. Elevated serum fluoride
concentrations in women are not related to fractures and bone mineral
density. J Nutr 2005;135(9):2247-52. Abstract at: https://www.ncbi.nim.
nih.gov/pubmed/16140906. Accessed August 18, 2017.
64. Li Y, Liang C, Slemenda C, Ji R, Sun S, Cao J, Emsley C, Ma F, Wu Y, Ying
P, Zhang Y, Gao S, Zhang W, Katz B, Niu S, Cao S, Johnston Jr. C. Effect
of long-term exposure to fluoride in drinking water. J Bone Miner
Res 2001;16(5):932-9. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/11341339. Accessed August 18, 2017.
65. Hillier S, Cooper C, Kellingray S, Russell G, Hughes H, Coggon D. Fluoride
in drinking water and risk of hip fracture in the UK: a case -control study.
Lancet 2000;22;355(9200):265-9. Abstract at: https://www.ncbi.nlm.
nih.gov/pubmed/10675073. Accessed August 18, 2017.
70 American Dental Association
back to agenda
66. Phipps KR, Orwoll ES, Mason JD, Cauley JA. Community water fluoridation,
bone mineral density, and fractures: prospective study of effects in older
women. BMJ 2000;7;321(7265):860-4. Abstract at: https://www.ncbi.
nlm.nih.gov1pubmed111021862. Article at: https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC27493. Accessed August 18, 2017.
67. lida H, Kumar JV. The association between enamel fluorosis and dental
caries in U.S. schoolchildren. J Am Dent Assoc 2009;140(7):855-62.
Abstract at: https://www.ncbi.nim.nih.govlpubmed/19571049.
Accessed August 28, 2017.
68. Massler M, Schour I. Chronology of crown and root development.
In Massler M, Schour I (ed): Atlas of the Mouth in Health and Disease
(2nd ed). Chicago: American Dental Association; 1982.
83. Horowitz HS. Fluoride and enamel defects. Adv Dent Res 1989;3(2):143-6.
Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/2701157 Accessed
August 28, 2017.
84. Berg J, Gerweck C, Hujoel PP, King R, Krol DM, Kumar J, Levy S, Pollick H,
Whitford GM, Strock S, Aravamudhan K, Frantsve-Hawley J, Meyer DM.
American Dental Association Council on Scientific Affairs Expert Panel on
Fluoride Intake From Infant Formula and Fluorosis. Evidence -based clinical
recommendations regarding fluoride intake from reconstituted infant
formula and enamel fluorosis: a report of the American Dental Association
Council on Scientific Affairs. J Am Dent Assoc 2011;142(1):79-87.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl2l243832.
Accessed August 23, 2017.
69. Horowitz H5. Indexes for measuring dental fluorosis. J Public Health 85. Centers for Disease Control and Prevention. Overview: infant formula.
Dent 1986;46(4):179-83. Abstract at: https://www.ncbi.nim.nih.govl Available at: https://www.cdc.govlfluoridation/fags/infant-formula.
pubmed/3465956. Accessed August 28, 2017. html. Accessed August 23, 2017.
70. Levertt D. Prevalence of dental fluorosis in fluoridated and nonfluoridated
communities - a preliminary investigation. J Public Health Dent
1986;46(4):184-7. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/3465957 Accessed August 28, 2017.
71. Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a
nonfluoridated population. Am J Epidemiol 1996;143(8):808-15. Abstract
at: https://www.ncbi.nim.nih.govlpubmedl8610691. Accessed August
28, 2017.
72. Pendrys DG, Stamm JW. Relationship of total fluoride intake to beneficial
effects and enamel fluorosis. J Dent Res 1990169(Spec No):529-38.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl2l79311.
Accessed August 28, 2017.
73. Dean HT. The investigation of physiological effects by the epidemiological
method. In: Moulton FIR, ed. Fluorine and dental health. American Association
for the Advancement of Science, Publication No. 19. Washington,
DC;1942:23-31.
74. Kumar JV, Swango PA, Opima PN, Green EL. Dean's fluorosis index: an
assessment of examiner reliability. J Public Health Dent 2000;60(1):57-
9. Abstract at: https://www.ncbi.nlm.nih.govlpubmed/10734619.
Accessed August 28, 2017.
75. Beltran -Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental
fluorosis in the United States, 1999-2004. NCHS data brief, no 53. Hyattsville,
MD: National Center for Health Statistics. 2010. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/21211168. Available at: https://www.cdc.govl
nchs/data/databriefs/db53.pdf. Accessed August 28, 2017.
76. Lewis DW, Banting DW. Water fluoridation: current effectiveness and
dental fluorosis. Community Dent Oral Epidemiol 1994;22(3):153-
8. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/8070242.
Accessed August 28, 2017.
77. Federal Register 1993 Dec 29;58(248):68826-68827. Available at:
https.11cdn.loc.govlservice/11/fedreglfr0581fr0582481fr058248. pd f.
Accessed August 28, 2017.
78. Chankanka 0, Levy SM, Warren JJ, Chalmers JM. A literature review
of aesthetic perceptions of dental fluorosis and relationships with
psychosocial aspects/oral health -related quality of life. Community Dent
Oral Epidemiol 2010;38(2):97-109. Abstract at: https://www.ncbi.nlm.
nih.gov1pubmed120002631. Accessed August 28, 2017.
79. Do LG, Spencer A. Oral health -related quality of life of children by dental
caries and fluorosis experience. J Public Health Dent 2007;67(3):132-
9. Abstract at: https://www.ncbi.nlm.nih.govlpubmed/17899897
Accessed August 28, 2017.
80. Centers for Disease Control and Prevention. Surveillance for dental caries,
dental sealants, tooth retention, edentulism, and enamel fluorosis -
United States, 1988-1994 and 1999-2002. MMWR 2005:54(No. SS-3).
Available at: https://www.cdc.govlmmwrlindss_2005.htmL Accessed
August 28, 2017.
86. U.S. Department of Health and Human Services. HHS: Proposed guidelines
on fluoride in drinking water. 2011 Mar 8. Available at: https://www.
medscape.com/viewartic/e/738322. Accessed August 23, 2017.
87. American Public Health Association. Policy Statement Data Base. Policy
20087. Community water fluoridation in the United States. 2008 Oct 28.
Available at: https://www.apha.org/policies-and-advocacylpublic-
health-policy-statements. Accessed August 23, 2017.
88. New York State Department of Health. Guidance for use of fluoridated
water for feeding during infancy. Available at: http://www.health.ny.gov/
prevention/dental/fluoride_guidance_during_infancy.htm. Accessed:
August 23, 2017.
89. Celeste RK, Luz PB. Independent and additive effects of different sources
of fluoride and dental fluorosis. Pediatr Dent 2016;38(3):233-8. Abstract
at: https://www.ncbi.nlm.nih.gov/pubmed/27306248. Accessed August
23, 2017.
90. Pendrys DG. Risk of enamel fluorosis in nonfluoridated and optimally
fluoridated populations: considerations for the dental professional. J Am
Dent Assoc 2000;131(6):746-55. Abstract at: https://www.ncbi.nlm.nih.
gov1pubmed110860326. Accessed August 23, 2017.
91. Ismail Al, Hasson H. Fluoride supplements, dental caries and fluorosis: a
systematic review. J Am Dent Assoc 2008;139(11):1457-68. Abstract at:
https://www.ncbi.nlm.nih.gov/pubmed/18978383. Accessed October 2,
2017.
92. American Dental Association. Oral health topics. Caries risk assessment
and management. Available at: http://www.ADA.org/en/member-center/
oral-health-topics/caries-risk-assessment-and-management. Accessed
October 2, 2017.
93. American Dental Association. Oral Health Topics. Mouthwash (mouthrinse).
Available at: http://www.ADA.org/en/member-center/oral-health-
topics/mouthrinse. Accessed October 2, 2017.
94. 21 CFR 330.1 General conditions for general recognition as safe, effective
and not misbranded. Available at: https://www.ecfr.govlcgi-bin/text-idx?
SID=9b3e9844e3dadeee276f8c08d75bca82&mc=true&node=se21.5.
330_11&rgn=div8. Accessed October 27, 2017.
95. 21 CFR 330.5 Drug categories. Available at: https://www.ecfr.govlc_qi-
bin/retrieveECFR?gp=&SID=9b3e9844e3dadeee276f8c08d 75bca82
&mc=true&n=pt21.5.330&r=PART&ty=HTML#se21.5.330_5. Accessed
October 27, 2017.
96. 21 CFR 355.50 Labeling of anticaries drug products. Available at: https://
www. ecfr.gov/cgi-bin/text-idx?SI D=ec4da50b801 ce 671286ff761 c73
0113f&mc=true&node=se21.5.355_150&rgn=div8. Accessed October
27, 2017.
97. Whitford GM. Acute toxicity of ingested fluoride. In Buzalaf MAR
(ed): Fluoride and the Oral Environment. Monogr Oral Sci. Basel,
Karger. 2011;22:66-80. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/21701192. Accessed October 2, 2017.
81. Dean HT. Endemic fluorosis and its relation to dental caries. Public
98. Stevenson CA, Watson AR. Fluoride osteosclerosis. American Journal of
Health Rep 1938;53(33):1443-52. Article at: https://wwwjstor.org/
Roetgenology, Radium Therapy and Nuclear Medicine 1957;78(1):13-18.
stable/4582632. Accessed August 28, 2017.
99. Hodge HC. The safety of fluoride tablets or drops. In: Continuing evaluation
82. Dean HT, Arnold FA, Elvove E. Domestic water and dental caries: V.
of the use of fluorides. Johansen E, Tavaes DR, Olsen TO, eds. Boulder,
Additional studies of the relation of fluoride domestic waters to dental
Colorado; Westview Press:1979:253-75.
caries experience in 4,425 white children, aged 12 to 14 years, of 13 cities
100. U.S. Environmental Protection Agency. Superfund: national priorities
in 4 states. Public Health Rep 1942;57(32):1155-79. Article at: https://
list (NPL). Available at: https://www.epa.govlsuperfund/superfund-
www.jstor.org/Stab/el4584182. Accessed August 28, 2017.
.....................................................................................................................................................................
national-priorities-list-npL Accessed August 16, 2017.
Safety I Fluoridation Facts 71
back to agenda
101. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological
Profile for fluorine, hydrogen fluoride, and fluorides. Atlanta, GA: U.S.
Department of Health and Human Services, Public Health Service. 2003.
Available at: https://www.atsdr.cdc.gov/substancesltoxsubstance.
asp?toxid=38. Accessed August 16, 2017.
102. Agency for Toxic Substances and Disease Registry (ATSDR). Public health
statement for fluorides. Atlanta, GA: U.S. Department of Health and
Human Services, Public Health Service. 2003. Available at: http://www.
atsdr.cdc.gov/PHS/PHS.asp?id=210&tid=38. Accessed August 16, 2017.
103. Hoover RN, McKay FW, Fraumeni JF. Fluoridated drinking water and the
occurrence of cancer. J Natl Cancer Inst 1976;57(4):757-68. Abstract
at: https://www.ncbi.nim.nih.govlpubmed/1003528. Accessed August
16, 2017.
104. Erickson JD. Mortality in selected cities with fluoridated and
nonfluoridated water supplies. New Eng J Med 1978;298(20):1112-6.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl543029. Accessed
August 16, 2017.
105. Rogot E, Sharrett AR, Feinleib M, Fabsitz RR. Trends in urban mortality
in relation to fluoridation status. Am J Epidemiol 1978;107(2):104-12.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl623093. Accessed
August 16, 2017.
106. Chilvers C. Cancer mortality and fluoridation of water supplies in 35 U.S.
cities. Int J Epidemiol 1983;12(4):397-404. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/6654558. Accessed August 16, 2017.
107. Mahoney MC, Nasca PC, Burnett WS, Melius JM. Bone cancer incidence
rates in New York State: time trends and fluoridated drinking water. Am J
Public Health 1991;81(4):475-9. Abstract at: https://www.ncbi.nlm.nih.
gov/pubmed/2003628. Accessed August 16, 2017.
108. Cohn PD, New Jersey Department of Health, New Jersey Department
of Environmental Protection and Energy. An epidemiologic report on
drinking water and fluoridation. Trenton, NJ;1992.
118. American Cancer Society. Water fluoridation and cancer risk. Available at:
https://www. cancer. org/cancer/cancer-causes/water-fluoridation-
and-cancer-risk.html. Accessed August 16, 2017.
119. American Society of Clinical Oncology. Osteosarcoma - childhood and
adolescence: statistics. Available at: https://www.cancer.net/cancer-
types/osteosarcoma-childhood/statistics. Accessed August 16, 2017.
120. Blakey K, Feltbower RG, Parslow RC, James PW, Gomez Pozo B, Stiller
C, Vincent TJ, Norman P, McKinney PA, Murphy MF, Craft AW, McNally
RJ. Is fluoride a risk factor for bone cancer? Small area analysis of
osteosarcoma and Ewing sarcoma diagnosed among 0-49-year-olds in
Great Britain, 1980-2005. Int J Epidemiol 2014;43(1):224-34. Abstract
at: https://www.ncbi.nim.nih.govlpubmedl24425828. Article at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937980. Accessed
August 16, 2017.
121. Kim FM, Hayes C. Williams PL, Whitford GM, Joshipura KJ, Hoover RN,
Douglass CW. National Osteosarcoma Etiology Group. An assessment
of bone fluoride and osteosarcoma. J Dent Res 2011;90(10):1171-6.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl2l799046.
Article at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC3173011.
Accessed August 16, 2017.
122. Bassin EB, WypiJ D, Davis RB, Mittleman MA. Age specific fluoride
exposure in drinking water and osteosarcoma (United States). Cancer
Causes Control 2006;17(4):421-8. Abstract at: https://www.ncbi.nim.
nih.gov/pubmed/16596294. Accessed August 16, 2017.
123. Bassin B, Mittleman Murray, Wypij D, Joshipura K, Douglass C. Problems
in exposure assessment of fluoride in drinking water. J Public Health
Dent 2004;64(1):45-9. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed115078061. Accessed August 16, 2017.
124. Kaminsky LS, Mahoney MC, Leach J, Melius J, Miller MJ. Fluoride: benefits
and risks of exposure. Crit Rev Oral Biol Med 1990;1(4):261-81.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl2l29630.
Accessed August 18, 2017.
109.
Tohyama E. Relationship between fluoride concentration in drinking water
125.
Jenkins G, Venkateswarlu P, Zipkin I. Physiological effects of small doses
and mortality rate from uterine cancer in Okinawa Prefecture, Japan. J
of fluoride. In: Fluorides and human health. World Health Organization
Epidemiol 1996;6(4):184-190. Abstract at: https://www.ncbi.nlm.nih.
Monograph Series No. 59. Geneva;1970:163-223.
ov/ ubmed/9002384. Article at: htt //www. sta st. o. /article/
9 s
P P� a 1 91 9 1P
jea1991/6/4/6_4_184/ article. Accessed August 16, 2017.
126.
Hodge HC, Smith FA. Biological properties of inorganic fluorides.
110.
Kinlen L. Cancer incidence in relation to fluoride level in water supplies. Br
n: Fluorine chemistry. Simons HH, ed. New York: Academic
Dent 1975;138(6):221-4.
Press;1965:1-42.
111.
Chilvers C, Conway D. Cancer mortality in England in relation to levels
127.
The National Academies of Sciences, Engineering, and Medicine. Office
of naturally occurring fluoride in water supplies. J Epidemiol Comm
on News and Public Information. Fluoride in drinking water: a scientific
Health 1985;39(1):44-7. Abstract at: https://www.ncbi.nim.nih.gov/
review of EPA's standards. March 22, 2006. Audio available at: https://
pubmed/3989433. Article at: https://www.ncbi.nlm.nih.gov/pmc/
www•nap.edu/webcast/webcast_detai/.php?webcast_id=325.
articles/PMC1052399. Accessed August 16, 2017.
Accessed August 18, 2017.
112.
Cook-Mozaffari PC, Bulusu L, Doll R. Fluoridation of water supplies and
128.
Barberio AM, Hosein F5, Quinonez C, McLaren L. Fluoride exposure
cancer mortality: a search for an effect in the UK on risk of death from
and indicators of thyroid functioning in the Canadian population:
cancer. J Epidemiol Comm Health 1981;35:227-32. Article at: https://
implications for community water fluoridation. J Epidemiol Community
www.ncbi.nlm.nih.gov/pmc/articles/PMC1052168. Accessed August
Health 2017;71(10):1019-25. Abstract at: https://www.ncbi.nlm.
2017.
nih.gov1pubmed/28839078. Article at: http://jech.bmj.com/
content/7111011019. long. Accessed September 22, 2017.
113.
Raman S, Becking G, Grimard M, Hickman JR, McCullough IRS, Tate
129.
Peckham S, Lowery D, Spencer S. Are fluoride levels in drinking
RA. Fluoridation and cancer: an analysis of Canadian drinking water
water associated with hypothyroidism prevalence in England? A large
fluoridation and cancer mortality data. Environmental Health Directorate,
observational study of GP practice data and fluoride levels in drinking
Health Protection Branch. Ottawa, Canada: Authority of the Minister of
water. J Epidemiol Community Health 2015;69(7):619-24. Abstract
National Health and Welfare;1977.
at: https://www.ncbi.nlm.nih.govlpubmedl25714098. Accessed
114.
Richards GA, Ford JM. Cancer mortality in selected New South Wales
September 22, 2017.
localities with fluoridated and nonfluoridated water supplies. Med J
130.
Foley M. Fluoridation and hypothyroidism -a commentary on Peckham et
Aust 1979;2(10):521-3. Abstract at: https://www.ncbi.nlm.nih.gov/
al. Br Dent J 2015;219(9):429-31. Abstract at: https://www.ncbi.nlm.
pubmed/530145. Accessed August 16. 2017.
nih.gov/pubmed/26564353. Accessed September 22, 2017.
115. World Health Organization. International Agency for Research on Cancer.
IARC monographs on the evaluation of the carcinogenic risk of chemicals
to humans, Vol. 27. Switzerland;1982. Available at: http://monographs.
iarc.fr/ENG/Monographs/vo11-42/index.php. Accessed August 16, 2017.
116. California Office of Environmental Health Hazard Assessment
(OEHHA). About Proposition 65. Available at: https.Iloehha.ca.govl
proposition- 65/about-proposition-65. Accessed August 16, 2017.
117. California Office of Environmental Health Hazard Assessment (OEHHA).
Meeting synopsis and slide presentations carcinogen identification
committee meeting held on October 12, 2011. Available at: https://oehha.
ca.gov/proposition- 65/transcript-comment-presentation/meeting-
synopsis-and-slide-presentations-carcinogen. Accessed August 16, 2017.
131. Grimes DR. Commentary on "Are fluoride levels in drinking water
associated with hypothyroidism prevalence in England? A large
observation study of GP practice data and fluoride levels in drinking
water". J Epidemiol Community Health 2015;69(7):616. Abstract
at: https://www.ncbi.nim.nih.govlpubmedl25788719. Accessed
September 22, 2017.
132. Newton JN, Young N, Verne J, Morris J. Water fluoridation and hypothyroidism:
results of this study need much more cautious interpretation. J Epidemiol
Community Health 2015;69(7):617-8. Article at: https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC44842601. Accessed September 22, 2017.
72 American Dental Association
back to agenda
133. Warren JJ, Saraiva MC. No evidence supports the claim that water
fluoridation causes hypothyroidism. J Evid Based Dent Pract
2015;15(3):137-9. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/26337589. Accessed September 22, 2017.
134. Pineal gland. Encyclopaedia Britannica. Available at: https://www.
britannica.com/science/pineal-gland. Accessed September 20, 2017.
135. Luke J. Fluoride deposition in the aged human pineal gland. Caries Res
2001;35(2):125-28. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed/11275672. Accessed September 20, 2017.
136. Schlesinger ER, Overton DE, Chase HC, Cantwell KT. Newburgh -Kingston
caries -fluorine study XIII: pediatric findings after ten years. J Am Dent
Assoc 1956;52(3):296-306. Abstract at: https://www.ncbi.nim.nih.
gov/pubmed/13294993. Accessed September 20, 2017.
137. U.S. Department of Health and Human Services. Centers for Disease
Control. Dental Disease Prevention Activity. Update of fluoride/acquired
immunodeficiency syndrome (AIDS) allegation. Pub. No. FL-133. Atlanta;
June 1987.
138. Challacombe SJ. Does fluoridation harm immune function? Comm Dent
Health 1996;13(Suppl 2):69-71. Abstract at: https://www.ncbi.nlm.nih.
gov/pubmed/8897755. Accessed September 26, 2017.
139. World Health Organization. Fluorine and fluorides: environmental health
criteria 36. Geneva, Switzerland;1984.
140. Schlesinger E. Health studies in areas of the USA with controlled water
fluoridation. In: Fluorides and Human Health. World Health Organization
Monograph Series No. 59. Geneva;1970:305-10.
141. Lowry R, Steen N, Rankin J. Water fluoridation, stillbirths, and congenital
abnormalities. J Epidemiol Comm Health 2003;57(7):499-500. Article
at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC1732512.
Accessed September 26, 2017.
142. National Down Syndrome Society. What is Down syndrome? Available
at: https://www.ndss.org/about-down-syndrome/down-syndrome.
Accessed September 26, 2017.
143. Needleman BL, Pueschel SM, Rothman KJ. Fluoridation and the
occurrence of Down's Syndrome. New Eng J Med 1974;291(16):821-3.
144. Knox EG, Armstrong E, Lancashire R. Fluoridation and the prevalence of
congenital malformations. Comm Med 1980;2(3):190-4.
145. Erickson JD. Down syndrome, water fluoridation and maternal age.
Teratol 1980;21(2):177-80. Abstract at: https://www.ncbi.nim.nih.
gov1pubmed16446780. Accessed September 26, 2017.
146. Broadbent JM, Thomson WM, Ramrakha S, Moffitt TE, Zeng J. Foster
Page ILL. Poulton R. Community water fluoridation and intelligence:
prospective study in New Zealand. Am J Public Health 2015;105(1):72-
76. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/24832151.
Article at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC4265943.
Accessed October 29, 2017.
147. Bazian Ltd. Independent critical appraisal of selected studies reporting an
association between fluoride in drinking water and IQ. London;2009.
148. U.S. Environmental Protection Agency. Assessing and Managing
Chemicals under TSCA. Support documents for fluoride chemicals in
drinking water Section 21 petition. Available at: https://www.epa.govl
assessing -and-managing- chemicals-under-tscalsupport- documents -
fluoride -chemicals -drinking- water Accessed October 29, 2017.
149. Bashash M, Thomas D, Hu H, Angeles Martinez -Mier E, Sanchez BIN, Basu
N, Peterson KE, Ettinger AS, Wright R, Zhang Z, Liu Y, Schnaas L, Mercado -
Garcia A, Maria Tellez-Rojo M, Hernandez -Avila M. Prenatal fluoride
exposure and cognitive outcomes in children at 4 and 6-12 years of age in
Mexico. Environ Health Perspect 2017;125(9):097017-1-12. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl28937959. Article at: https://
ehp.niehs.nih.gov/ehp655. Accessed October 29, 2017.
150. Macek MD, Matte TD, Sinks T, Malvitz D. Blood lead concentrations in
children and method of water fluoridation in the United States, 1988-1994.
Environ Health Perspect 2006;114(1):130-4. Abstract at: https://www.
ncbi.nlm.nih.gov/pubmed/16393670. Article at: https://wwwncbi.nlm.
nih.gov/pmc/articles/PMC1332668. Accessed October 2, 2017.
152. Centers for Disease Control and Prevention. Ten great public health
achievements --United States, 1990-1999. MMWR 1999;48(12):241-3.
Available at: https://wwwcdc.gov/mmwr/preview/mmwrhtml/00056796.
htm. Accessed October 2, 2017.
153. Centers for Disease Control and Prevention. Fluoridation growth data
Table (1940-2014). Available at: https://www.cdc.gov/fluoridation/
statistics/fsgrowth.htm. Accessed October 29, 2017.
154. Centers for Disease Control and Prevention. Adult Blood Lead
Epidemiology and Surveillance - United States, 1998-2001. MMWR
2002;51(No. SS-11):1-12. Available at: https://www.cdc.govlmmwrl
indss_2002.htmL Accessed October 29, 2017.
155. American Water Works Association. Internal corrosion control in water
distribution systems. AW WA Manual M58. Second edition. Denver. 2017.
156. U.S. Environmental Protection Agency. Drinking Water Requirements for
States and Public Water Systems. Optimal corrosion control treatment
evaluation technical recommendations. 2016. Available at: https://www.
epa.gov/dwreginfo%ptimal-corrosion-control-treatment-evaluation-
technical-recommendations. Accessed September 20, 2017.
157. Master RD, Coplan MJ. Water treatment with silicofluoride and lead
toxicity. Int J Environ Studiesl999;56:435-49.
158. Urbansky ET, Schock MR. Can fluoridation affect lead(II) in potable
water? Hexafluorosilicate and fluoride equilibria in aqueous solution. Int J
Environ Studies 2000;57:597-637.
159. U.S. Department of Health and Human Services. National Institute on
Aging. What causes Alzheimer's disease? Available at: https://www.nia.
nih.gov/health/what-causes-alzheimers-disease. Accessed August 23,
2017.
160. Varner JA, Jensen KF, Horvath W, Isaacson RL. Chronic administration
of aluminum -fluoride or sodium -fluoride to rats in drinking water:
alterations in neuronal and cerebrovascular integrity. Brain Res
1998;784(1-2):284-98. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/9518651. Accessed August 23, 2017.
161. American Dental Association. Health Media Watch: Study linking fluoride
and Alzheimer's under scrutiny. J Am Dent Assoc 1998;129(9):1216-8.
162. Lidsky T. Is the aluminum hypothesis dead? J Occup Environ Med 2014;
56(5 Suppl):573-9. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/24806729. Article at: https://www.ncbi.nim.nih.gov/pmc/
articles/PMC4131942. Accessed August 23, 2017.
163. Emsley CL, Gao S, LI Y, Liang C, Ji R, Hall KS, Cao J, Ma F, Wu Y, Ying
P, Zhang Y, Sun S, Unverzagt, FW, Slemenda CW, Hendrie HC. Trace
element levels in drinking water and cognitive function among elderly
Chinese. Am J Epidemiol 2000;151(9):913-20. Abstract at: https://
www.ncbi.nlm.nih.govlpubmedll0791564. Accessed August 23, 2017.
164. American Heart Association. Coronary artery disease - coronary heart
disease. Available at: http://www.heart.org/HEARTORG/Conditions/
M ore/MyHeartan dStro ke Ne ws/Coronary-Artery-Disease- - -The-
ABCs-of- CAD_UCM_436416_Article jspkWgEWVmeotow. Accessed
August 28, 2017.
165. American Heart Association. Minerals, inorganic substances: fluoridation.
Available at: http://www.heart.org/HEARTORG/Hea/thyLiving/
Heal thyEating/Minerals-Inorganic-Substances_ UCM_ 306012_
Article jspkWgEWAmeotow. Accessed August 28, 2017.
166. U.S. Department of Health, Education and Welfare, National Institutes
of Health, Division of Dental Health. Misrepresentation of statistics on
heart deaths in Antigo, Wisconsin Pub. No. PPB-47. Bethesda, MD;
November 1972.
167. Gucciardi A. Breaking: fluoride linked to #1 cause of death in new
research. The Natural Society Newsletter. January 17, 2012. Available at:
http://naturalsociety.com/breaking-fluoride-linked-to-1 -cause-of-
death-in-new-research. Accessed August 16, 2017.
168. Li Y, Berenji GR. Shaba, Tafti B, Yevdayev E, Dadparvar S. Association of
vascular fluoride uptake with vascular calcification and coronary artery
disease. Nucl Med Commun 2012;33(1):14-20. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/21946616. Accessed August 16, 2017.
151. Centers for Disease Control and Prevention. Lead in drinking water and 169. Geever EF, Leone NC, Geiser P, Lieberman J. Pathologic studies in man
human blood lead levels in the United States. MMWR 2012;61(Suppl; after prolonged ingestion of fluoride in drinking water. I. Necropsy
August 10, 2012):1-9. Available at: https://www.cdc.govlmmwrl findings in a community with a water level of 2.5 ppm. J Am Dent Assoc
preview/mmwrhtml/su6104al.htm?s_cid=su6104al_w. Accessed 1958;56(4):499-507.
October 2, 2017.
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Safety I Fluoridation Facts 73
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170. Ludlow M, Luxton G, Mathew T. Effects of fluoridation of community
water supplies for people with chronic kidney disease. Nephrol Dial
Transplant 2007;22(10):2763-7. Article at: https://academic.oup.com/
ndt/article/22/10/2763/1833116. Accessed October 29, 2017.
171. Kidney Health Australia. 2011 Review of Kidney Health Australia
fluoride position statement. 2011. Available at: http://kidney.org.aul
curs_uploads/docs/2011-review-of-fluoride-position-statement. pdf.
Accessed October 29, 2017.
172. National Kidney Foundation. Fluoride intake in chronic kidney disease.
April 15, 2008. Available at: https://www.kidney.org/atoz/content/
fluoride. Accessed August 28, 2017.
173. U.S. Department of Health and Human Services, Public Health Service.
Surgeon General's advisory: treatment of water for use in dialysis:
artificial kidney treatments. Washington, DC: Government Printing
Office 872-021;June 1980.
.....................................................................................................................................................................
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s
47. Who regulates drinking water additives
in United States?
Answer.
The United States Environmental Protection Agency
(EPA) regulates drinking water additives.
Fact.
In 1974, Congress passed the Safe Drinking Water
Act (SDWA) which protects the public's health by
regulating the nation's public drinking water supply.'
The SDWA, as amended in 1986 and 1996,' requires
the Environmental Protection Agency (EPA) to ensure
the public is provided with safe drinking water.' On
June 22, 1979, the Food and Drug Administration
(FDA) and the EPA entered into a Memorandum
of Understanding (MOU) to clarify their roles and
responsibilities in water quality assurance.2 The stated
purpose of the MOU is to "avoid the possibility of
overlapping jurisdiction between the USEPA and FDA
with respect to control of drinking water additives"
The two agencies agreed that the Safe Drinking
Water Act's passage in 1974 implicitly repealed FDA's
jurisdiction over drinking water as a 'food' under the
Federal Food, Drug and Cosmetic Act (FFDCA). Under
the MOU, EPA enjoys exclusive regulatory authority
over drinking water provided by public water systems,
including any additives in such water. FDA retains
jurisdiction over bottled drinking water under Section
410 of the FFDCA and "over water (and substances in
water) used in food or food processing once it enters
the food processing establishment"2
While drinking water from the tap is regulated by the
EPA, bottled water is regulated by the FDA which
has established standards for its quality.2 The FDA
has noted that fluoride can occur naturally in source
waters used for bottled water or may be added by a
bottled water manufacturer. Recognizing the benefit
of fluoride in water, the FDA has stated that bottled
water that meets specific standards of identity and
quality set forth by FDA, and the provisions of the
authorized health claim related to fluoride, may be
labeled with the following health claim: "Drinking
fluoridated water may reduce the risk of [dental
caries or tooth decay]."'
While drinking water from the top is regulated
by the EPA, bottled water is regulated by the
FDA which has established standards for its
quality. The FDA has noted that fluoride con
occur naturally in source waters used for bottled
water or may be added by o bottled water
manufacturer. Recognizing the benefit of fluoride
in water, the FDA has stated that bottled water
that meets specific standards of identity and
quality set forth by FDA, and the provisions of
the authorized health claim related to fluoride,
may be labeled with the following health claim:
"Drinking fluoridated water may reduce the risk
of [dentol caries or tooth decoy]."
From time to time, states and communities have had
to deal with legislation or ballot initiatives aimed at
requiring the approval of the FDA before any agent
can be added to community water systems. Often
referred to as the Fluoride Product Quality Control
Act, Water Product Quality Ordinance or Pure Water
Ordinance, the legislation is specifically used by those
opposed to water fluoridation as a tool to prevent
water systems from providing community water
fluoridation. Often this legislation does not specifically
Fluoridation Practice I Fluoridation Facts 75
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mention fluoride or fluoridation. Those supporting this
type of legislation may claim that they are not against
water fluoridation but are proponents of pure water
and do not want anything added to water that has not
been approved by the FDA. On the surface, this may
appear to be a "common sense' approach. However,
its only real purpose is to defeat efforts to provide
water fluoridation. That is because this proposed
legislation would require the FDA — which does NOT
regulate public water systems — to approve any
water additive. By mistakenly (and perhaps craftily)
naming the wrong federal agency, the probable
outcome is to stop or prevent water fluoridation.
48. What standards have been established
to ensure the safety of fluoride additives
used in community water fluoridation in the
United States?
Answer.
The three fluoride additives used in the U.S. to
fluoridate community water systems (sodium
fluoride, sodium fluorosilicate, and fluorosilicic
acid) meet safety standards established by the
American Water Works Association (AWWA) and
NSF International (NSF).4
The three fluoride additives used in the U.S. to
fluoridate community water systems (sodium
fluoride, sodium fluorosilicote, and fluorosilicic
acid) meet safety standards established by the
American Water Works Association (AWWA)
and NSF International (NSF).
Fact.
Additives used in water treatment meet safety
standards prepared in response to a request by
the Environmental Protection Agency to establish
minimum requirements to ensure the safety
of products added to water for its treatment,
thereby ensuring the public's health.' Specifically,
fluoride additives used in water fluoridation meet
standards established by the American Water Works
Association (AWWA) and NSF International (NSF).4
Additionally, the American National Standards
Institute (ANSI) endorses both AWWA and NSF
standards for fluoridation additives and includes
its name on these standards.'
The American Water Works Associations is an
international nonprofit scientific and educational
society dedicated to providing total water solutions to
assure the effective management of water. Founded
in 1881, the AWWA is the largest organization
of water supply professionals in the world. The
membership represents the full spectrum of the
water community: public water and wastewater
systems, environmental advocates, scientists,
academicians, and others who hold a genuine interest
in water. AWWA unites the diverse water community
to advance public health, safety, the economy, and
the environment.'
NSF International,6 an independent, accredited
organization, is dedicated to being the leading global
provider of public health and safety -based risk
management solutions. Manufacturers, regulators
and consumers look to NSF to develop public health
standards and certifications that help protect food,
water, consumer products and the environment.
Its professional staff includes microbiologists,
toxicologists, chemists, engineers, and environmental
and public health professionals. Founded in 1944 as
the National Sanitation Foundation, NSF's mission is
to protect and improve global human health.6
The American National Standards Institute (ANSI)' is a
private, non-profit organization that administers and
coordinates the U.S. voluntary standardization and
conformity assessment system. The Institute's mission
is to enhance both the global competitiveness of U.S.
business and the U.S. quality of life by promoting
and facilitating voluntary consensus standards and
conformity assessment systems, and safeguarding
their integrity.'
The AWWA documents provide manufacturers,
suppliers and purchasers with standards for the
manufacturing, quality and verification for each of
the three fluoride additives listed below. The AWWA
standards set the physical, chemical and impurities
standards including information on verification of the
standard requirements and requirements for delivery.4
• ANSI/AWWA B701 Sodium Fluoride
• ANSI/AWWA B702 Sodium Fluorosilicate
• ANSI/AWWA B703 Fluorosilicic Acid
76 American Dental Association
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NSF/ANSI Standard 604,E provides for purity of
drinking water additives as it limits an additive's
contribution of harmful contaminants to drinking
water. The Standard also provides for safety
assurances from production through distribution to
ensure product quality is maintained. Additionally,
the Standard requires documentation of the purity of
the additives including specific criteria for products
imported from other countries. NSF/ANSI Standard
614.E is a related standard that provides guidance for
equipment/products used in water treatment plants
that come in contact with drinking water. Both NSF/
ANSI standards were developed by a consortium of
associations including NSF, AWWA, the Association
of State Drinking Water Administrators and the
Conference of State Health and Environmental
Managers with support from the U.S. Environmental
Protection Agency.4
Fluoride additives, like all of the more than 40
additives typically used in water treatment, are "water
grade" additives. All additives used at the water plant
are classified as water grade additives meeting NSF
Standard 60 requirements. Examples of other "water
grade" additives which are commonly used in water
plant operations are chlorine (gas), ferrous sulfate,
hydrochloric acid, sulfur dioxide and sulfuric acid.8
Sometimes antifluoridationists express the view
that they are not really opposed to fluoridation,
but are opposed to the use of "industrial grade"
fluoride additives. They may even go so far as to
state that they would support fluoridation if the
process was implemented with pharmaceutical
grade fluoride additives that were approved by the
U.S. Food and Drug Administration (FDA). On the
surface, this may appear to be a "common sense"
approach. In fact, this is usually a ploy whose only
real purpose is to stop fluoridation. First, the EPA,
not the FDA, has regulatory authority for additives
used in public water systems. Second, and perhaps
most importantly, the U.S. Pharmacopeia (USP)
monograph on sodium fluoride does not provide
for certification of quality by an independent
credentialing body.4.9 Third, the USP and The National
Formulary (USP-NF) standards used to formulate
prescription drugs are not appropriate for water
fluoridation additives as they could actually allow
higher levels of contaminants to be introduced into
drinking water than is allowed by the current EPA
standard s.4.9 According to the CDC:'
The USP does not provide specific protection
levels for individual contaminants, but establishes
a relative maximum exposure level for a group of
related contaminants. Some potential impurities
have no restrictions by the USP, including arsenic,
some heavy metals regulated by the U.S. EPA, and
radionuclides. Given the volumes of chemicals
used in water fluoridation, a pharmaceutical
grade of sodium fluoride for fluoridation could
potentially contain much higher levels of arsenic,
radionuclides, and regulated heavy metals than an
NSF/ANSI Standard 60-certified product.
6 Additional information about this topic con be
found in this Section, Question 49.
Lastly, USP-grade sodium fluoride product is more
likely to result in water plant personnel being exposed
to fluoride dust as it is more powder -like than the
preferred AWWA-grade sodium fluoride which is
crystalline and so minimizes dusting when handled.'
6 Additional informotion about this topic con be
found in this Section, Question 52.
49. Does fluoridating the community water
supply raise concerns about lead, arsenic
and other toxic contaminants to the water
supply?
Answer.
No. The concentrations of contaminants in drinking
water as a result of fluoridation do not exceed, but
are in fact, well below regulatory standards set to
ensure the public's safety.
Fact.
Fluorosilicic acid is used to fluoridate the majority
of community water systems in the United States10
Because the additive is derived from ore mined
from the earth, fluorosilicic acid may contain minute
amounts of contaminants such as lead and arsenic.
However, existing regulations and standards require
that these contaminants, and others, be at levels
considered acceptable by the U.S. Environmental
Protection Agency when the fluorosilicic acid or
other fluoridation additives are diluted to produce
optimally fluoridated water.' NSF International and
the American National Standards Institute (NSF/
ANSI) Standard 60 as well as AWWA standards are
applicable to all fluoride additives.4,6
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Testing of fluoride additives provides evidence that
the levels of these contaminants do not exceed, but
are in fact, well below regulatory standards set to
ensure the public's safety. NSF has prepared a detailed
fact sheet, NSF Fact Sheet on Fluoridation Products
(2013)11 that provides the documented quality of
fluoride additives based on product samples analyzed.
The NSF reports that the majority of fluoridation
products as a class, based on NSF test results, do not
add measurable amounts of arsenic, lead, or other
heavy metals, or radionuclides to drinking water.9.11
50. Have fluoride additives been tested
for safety?
Answer.
The claim is sometimes made that no studies
on safety exist on the additives used in water
fluoridation. This statement is a ruse because the
scientific community does not study the health
effects of the concentrated additives; studies are
done on the health effects of the treated water.
Fact.
A 1999 study12 charged that fluorosilicic acid and
sodium silicofluoride did not disassociate (break
down) completely when added to water systems
and may be responsible for lower pH (acid) levels of
drinking water, leaching lead from plumbing systems
and increasing lead uptake by children. Scientists
from the U.S. Environmental Protection Agency (EPA)
evaluated the disassociation of fluoride additives13
and concluded that at the typical pH level of drinking
water (which is normally slightly alkaline) and the
fluoride levels used in drinking water, the fluoride
additives quickly and completely broke down to
fluoride ions and silica.
Published in 2006'14 researchers at the University
of Michigan verified for the EPA that theoretical
predictions that hexafluorosilicate completely
hydrolyzed (broke down) when added to water
separating into free fluoride ions and silica ions were
confirmed. The research demonstrated that there
was no hexafluorosilicate that could be measured
in the finished water.14
While sodium fluoride was the first additive used in
water fluoridation, the use of silicofluoride additives
(sodium fluorosilicate and fluorosilicic acid) began in
the late 1940s. By 1951, silicofluorides had become
the most commonly used fluoride additives in water
fluoridation 15 Many of the early studies on the health
effects of fluoridation were completed in communities
that were using the silicofluoride additives, most
generally fluorosilicic acid 16-21 However, at that
time, the additives used to fluoridate were not
always identified in research reports. As the body
of research on fluoridation grew, it became evident
that there were no adverse health effects associated
with water fluoridation regardless of which fluoride
additive was used. Additionally, over time, a number
of comprehensive reviews of the health effects of
fluoridation were published. These reviews which
support the safety of water fluoridation include many
studies conducted in large fluoridated communities
which used the silicofluoride additives.12-29
There is now more than 70 years of practical experience
that lends additional credence to the best available
science that concludes that fluoridation is safe.
51. What is the source of the additives
used to fluoridate water supplies in the
United States?
Answer.
The majority of fluoridation additives used in the
United States are derived from the mineral apatite
(a component of calcium phosphate).
Fact.
About 95% of the fluoridation additives used in water
fluoridation are by-products which come from the
processing of calcium phosphate into phosphate
fertilizer. About 4% are derived from the processing
of calcium fluoride and the remaining 1 % derived
from the production of high -purity silica.*
In the production of phosphate fertilizer, calcium
phosphate ore (which contains apatite) is mixed with
sulfuric acid resulting in a calcium sulfate (gypsum)
slurry. The gaseous phosphoric acid released from this
process is collected by vacuum extraction, condensed
and then desiccated (dried) and formed into phosphate
fertilizer pellets. Fluoride is a trace constituent (3-7%)
of the mineral apatite found in calcium phosphate
ore. Silica tetrafluoride is also released as a gas in the
creation of the calcium sulfate slurry and is collected by
vacuum extraction along with the gaseous phosphoric
acid. In about half the phosphate fertilizer plants in
the U.S., the silica tetrafluoride gas is condensed and
78 American Dental Association
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processed along with the phosphoric acid and becomes
a trace component of the phosphate fertilizer. In the
other plants, the silica tetrafluoride gas is separated
from the phosphoric acid. Roughly 60% of the fluoride
recovered from processing calcium phosphate ore is
sold for use as fluoridation additives. The fluoridation
additive produced by this process is fluorosilicic acid.
While most of the product is sold as fluorosilicic acid,
some of the product is partially neutralized to sodium
fluorosilicate salt and some is fully neutralized to
sodium fluoride salt. In the U.S., 77% of the fluoridation
additives used are fluorosilicic acid, 15% are sodium
fluorosilicate and 8% are sodium fluoride.*
About 4% of the fluoridation additives used are derived
from the processing of calcium fluoride into hydrogen
fluoride using a gas separation technique to recover
the fluorosilicic acid from the hydrogen fluoride.*
About 1 % of the fluoridation additives used
are derived from the production of high -purity
silica. Fluorosilicic acid is produced as part of the
purification of the silica.*
*The preceding paragraphs were developed
using references 4, 30 through 35 and personal
communication from Mr. Kip Duchon, P.E.,
national fluoridation engineer, CDC.
From time to time, opponents of fluoridation
allege that fluoridation additives are by-products
of the phosphate fertilizer industry in an effort to
suggest the additives are not safe. By definition,
by-products are materials produced as a result of
producing something else. In the chemical industry,
a byproduct (secondary product) is anything other
than the principal product produced. The fact that a
product is a secondary product of a manufacturing
process should not suggest the item is bad, harmful
or a waste product. On the contrary, by-products
may have certain characteristics which make them
valuable resources. In the production of phosphate
fertilizer, the fluoridation additive, fluorosilicic acid,
is a by-product along with gypsum.36 Gypsum is
commonly use in manufacturing wall board used
in construction. The production of orange juice
provides another example of valuable by-products.
In addition to orangejuice, various by-products are
obtained from oranges during juice production that
are used in cleaners, fragrances and flavorings.37
Fluoridation additives are valuable by-products produced
as a result of producing phosphate fertilizer. To ensure
the public's safety, additives used in water fluoridation
meet standards of the American Water Works
Association (AWWA) and NSF International (NSF).4
52. Does the process of water fluoridation
present unusual safety concerns for water
systems and water facility operators?
Answer.
No. With proper monitoring, maintenance, water
facility operator training and systems planning,
water fluoridation is a safe and reliable process.
Fact.
Water facilities and water facility operators perform a
valuable public service by carefully adjusting the level
of fluoride in water to improve the oral health of the
community. Facilities and personnel are subject to a
number of regulations designed to ensure safety.
Employers must conform to Occupational Safety and
Health Administration (OSHA) requirements.38 OSHA's
mission is to assure safe and healthful workplaces
by setting and enforcing standards, and by providing
training, outreach, education and assistance. Under
the OSH Act, employers are responsible for providing
a safe and healthful workplace. Employers must
comply with all applicable OSHA standards.38
Additionally, in order to assist in protecting the
professionals who produce sustainable supplies of
high -quality drinking water, the American Water
Works Association publishes detailed guidance on
safety and safe working conditions for water plant
personnel.39
Furthermore, OSHA requires that Safety Data
Sheets (SIDS), previously known as Material Safety
Data Sheets (MSDS), be readily available to all
employees for potentially harmful substances handled
in the workplace under the Hazard Communication
regulation.40 A SIDS may include instructions for the
safe use and potential hazards associated with a
particular material and are typically made available
in the area where the material is stored or used.
Information contained in a SIDS focuses on the
potential hazards of working with the material in an
occupational setting. Adherence to the SIDS guidelines
for handling fluoride additives helps to ensure the
Fluoridation Practice I Fluoridation Facts 79
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recommended level of fluoride in drinking water
flows through the water system while maintaining
water operator safety. In the case of fluoride, the
potential hazards faced by a water facility employee
in dealing with concentrated fluoride additives before
they enter the water system are not related to the
level of fluoride in water as used by consumers. The
information found in the SIDS for fluoride additives
is not applicable to water with fluoride at the
recommended level. Therefore, SIDS sheets should not
be used by consumers to gauge potential hazards of
community water fluoridation.
As part of safety procedures, water facility personnel
receive training on the management of the additives
in water plants. While the recommended fluoride
level found in drinking water has been proven safe,
water facility operators and engineers may be
exposed to much higher fluoride levels when handling
fluoride additives at the water treatment facility.4
Fluoride additives present risks comparable to other
water additives in common use at water facilities,
such as hypochlorite, quicklime, aluminum sulfate,
sodium hydroxide and ferrous sulfate. In some cases,
the fluoride additives are much less dangerous
than many other additives, including chlorine gas
commonly used in many water plants.39
Today's equipment allows water facility personnel
to easily monitor and maintain the desired fluoride
concentration. Automatic monitoring technology is
also available that can help to ensure that the fluoride
concentration of the water remains within the
recommended range.4
It is important that the water facility personnel
responsible for monitoring the addition of fluoride to
the water supply are appropriately trained and that
the equipment used for this process is adequately
maintained.4 With over 70 years of experience and
thousands of water systems adding fluoride every
day, water facility personnel have an excellent safety
record related not only to their personal safety but in
providing safe drinking water to their customers.
53. Does fluoridation present difficult
engineering problems?
Answer.
No. Adding fluoride products to water is no
different than adding other commonly used water
treatment additive products using the same
equipment and techniques.
Fact.
Fluoride additives used to adjust the fluoride level
in drinking water are compatible with other water
treatment processes often using the same type of
equipment and other standard materials designed for
the safe handling of other water treatment additive
products in drinking water treatment facilities.
Fluoride additives are introduced to the water supply
as liquids. There are many control devices, some in use
for decades and some newer equipment, that allow
water facility personnel to easily monitor and maintain
the desired fluoride level as well as levels of other
water treatment additives and naturally occurring
substances that may be in the water. Automatic
monitoring technology is available that can help to
ensure that the fluoride concentration of the water
remains within the recommended range.4
When added to community water supplies, the
concentrated fluoride additives become greatly
diluted. For example, typically fluorosilicic acid
is diluted approximately 315,000 times to reach
the recommended target concentration of 0.7
mg/L. The exact dilution factor depends on the
concentration of the fluoride additive and the
amount of additive being used to reach the
concentration of 0.7mg/L. At 0.7mg/L (or 0.7 parts
per million), seven -tenths of one part of fluoride is
diluted in is diluted in 999,999.3 parts of water.
To place this concentration in perspective, the
following comparisons can be of assistance.
inch in approximately 23 miles
minute in approximately 1,000 days
cent in approximately $14,000
seat in more than 34 Wrigley Field baseball parks
(seating capacity 41,268)
With more than 70 years of experience with water
fluoridation, there is considerable guidance on sound
engineering practices to design, construct, operate
and maintain water fluoridation systems. By design,
and with proper maintenance and testing, water
80 American Dental Association
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systems can provide the recommended level of
fluoride within a narrow control range of the target
of 0.7mg/L.41,11 Additional design features such
as the use of a day tank (that holds only one day's
supply of fluoride) can limit the amount of fluoride
that can be added to a water system in a 24-hour
period and is the most reliable method to ensure
overfeed protection.4 The State Office of Drinking
Water, or similar state agency, will normally establish
engineering requirements for safety. Additional
standards and references on best engineering
practice are available from the American Water Works
Association and the Centers for Disease Control and
Prevention.4,41
54. Does fluoride at levels used in
fluoridation corrode water pipes?
Answer.
No. Allegations that fluoridation causes corrosion of
water pipes are not supported by the best available
scientific evidence.
Fact.
The process of adding fluoride to water has minimal
impact on the acidity or pH of drinking water and
therefore will not corrode water pipes. Corrosion of
drinking water pipes is related primarily to induced
electrical current between dissimilar metals. Other
contributing factors include the dissolved oxygen
concentration, water temperature, acidity/alkalinity
(pH), hardness, salt concentration, hydrogen sulfide
content and the presence of certain bacteria. Under
some water quality conditions, a small increase in the
acidity of drinking water that is already slightly acidic
may be observed after treatment with alum, chlorine,
fluorosilicic acid or sodium fluorosilicate. In such cases,
further water treatment to adjust the pH to neutralize
the acid for corrosion control in water distribution
systems is standard procedure in water plants.44
The process of adding fluoride to water
has minimal impact on the acidity or pH of
drinking water and therefore will not corrode
water pipes.
Note that the Water Quality Report or Consumer
Confidence Report that all water systems must make
available to customers on a yearly basis, may list the
pH of the system's finished water.41 Control of neutral
pH (7.0) is essential as part of corrosion control
requirements. Water facilities typically maintain a pH
of between 7.0 and 8.0 as good practice indicating
that the water leaving the plant is slightly alkaline
and non-acidic.46
55. Does fluoride at levels used in water
fluoridation corrode glass, concrete or
other surfaces in water plants?
Answer.
No. A correctly engineered and maintained system
will not result in damage to the water plant.
Fact.
Fluorosilicic acid in a concentrated form can be
corrosive if not correctly handled. The concentrated
fluorosilicic acid is 75% water, and 25% fluorosilicic
acid. Up to 1 % of the fluorosilicic acid can be other
acids including hydrogen fluoride. Hydrogen fluoride
is volatile near room temperature so it will evaporate
from the solution if the system is not properly
engineered and maintained. The evaporation process
occurs at an extremely slow rate. Less than 1
of fluorosilicic acid will be lost over a month from
the evaporation of hydrogen fluoride. However,
only a small release of hydrogen fluoride may be
very corrosive to concrete, glass, and electrical
components.10
If a water system is reporting problems with corrosion
from evaporating hydrogen fluoride in the storage
room or fluoride handling room (i.e. the glass in the
facility has become "frosted"), the system is being
inadequately maintained. The storage tank and other
locations in the fluorosilicic acid feed system may not
be sealed or correctly vented and hydrogen fluoride
gas can be released (leaked) at those points. All fluoride
products storage, handling, and feed systems should
be vented to the outside of the building and the system
and piping should be pressure tested (low pressure
is sufficient) to identify possible locations of leaks.
Leaks should be promptly corrected.10
With no system leaks and proper venting to outside
the building, there will be no corrosion problems.30
Fluoridation Practice Fluoridation Facts 81
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56. Does fluoridated water harm the
environment?
Answer.
No. Scientific evidence supports the fluoridation of
public water supplies as safe for the environment
and beneficial for people.
Fact.
Fluoride is naturally occurring in the environment
and is the 13th most abundant element in the earth's
crust. It is found in naturally in all water sources as
noted below.47
Rain — between 0.1 to 0.2 mg/L
Streams and lakes — between 0.1 to 0.3 mg/L
Groundwaters — between 0.1 to 10 mg/L
Oceans and seawater — between 1.2 to 1.4 mg/L
A comprehensive literature review published in
2004 revealed no negative environmental impacts
as a result of water fluoridation.41 A 1990 study
concluded that fluoridation has little or no impact on
surrounding aquatic environment or soil.49 Historically,
issues surrounding problems with fluoride and the
environment have involved incidents related to
serious industrial pollution or accidents.49
Under the Washington's State Environmental Protection
Act (SEPA), a study was conducted in Tacoma -Pierce
County to investigate the environmental consequences
of adding optimal levels of fluoride to drinking water.
Noting that the amount of fluoride in the water does
not reach levels that are harmful to plants or animals,
the SEPA study concluded that there are "no probable
significant adverse environmental impacts"50
There is no evidence that the recommended level of
fluoride in drinking water has any adverse effect on
gardens, lawns or plants.50
Additional information regarding water fluoridation
additives and engineering issues can be found on the
Mcs fluoridotion website, "Water Operators and
Engineers" at https://www.cdc.gov/fluoridation/
engineering/index. htm.
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Fluoridation Practice References
1. U.S. Environmental Protection Agency. Overview of the safe drinking water
act. 2015. Available at: https://www.epa.govlsdwa/overview-safe-
drinking-water-act. Accessed September 19, 2017.
2. Federal Register 1979 Jul 20;44(141):42775-8. National Archives and
Records Administration. Library of Congress. Available at: https://www.
loc.gov/itemlfr044141. Accessed October 3, 2017.
3. U.S. Department of Health and Human Services. U.S. Food and Drug
Administration. Health claim notification for fluoridated water and
reduced risk of dental caries. Available at: https://www.fda.gov/food/
labelingnutritionlucm073602.htm. Accessed September 19, 2017.
4. American Water Works Association. Water fluoridation principles and
practices. AWWA Manual M4. Sixth edition. Denver. 2016.
5. American Water Works Association. About us. Available at: https://www.
awwa.org/about-us.aspx. Accessed September 20, 2017.
6. NSF International. The public health and safety organization. Available at:
http://www.nsf.org. Accessed September 20, 2017.
7. ANSI. American National Standards Institute. About us. Available at:
https://www.ansi.org/about�_ansi/0verviewloverview?menuid=l.
Accessed September 20, 2017.
8. U.S. Department of Health and Human Services, Centers for Disease Control,
Dental Disease Prevention Activity, Center for Prevention Activity. Water
fluoridation: a manual for engineers and technicians. Atlanta. 1986. Available
at: https://stacks.cdc.gov/view/cdc/13103. Accessed October 2, 2017.
23. U.S. Department of Health and Human Services, Public Health Service.
Review of fluoride: benefits and risks. Report of the Ad Hoc Subcommittee
on Fluoride. Washington, DC; February 1991. Available at: https://health.
gov/environment/ReviewofFluoride. Accessed September 22, 2017.
24. Royal College of Physicians. Fluoride, teeth and health. London; Pitman
Medical:1976. Abstract at: https://www.bfsweb.org/fluoride-teeth-
and-health. Accessed October 28, 2017.
25. Knox EG. Fluoridation of water and cancer: a review of the epidemiological
evidence. Report of the Working Party. London: Her Majesty's Stationary
Office;1985. Available at: https://archive.org/detailslopl276356-1001.
Accessed September 23, 2017.
26. National Research Council. Health effects of ingested fluoride. Report of
the Subcommittee on Health Effects of Ingested Fluoride. Washington,
DC: National Academy Press;1993. Available at: https://www.nap.
edu/catalog/2204/health-effects-of-ingested-fluoride. Accessed
September 23, 2017.
27. Crisp MP. Report of the Royal Commissioner into the fluoridation of public
water supplies. Hobart, Tasmania, Australia: Government Printers;1968.
28. Myers DM, Plueckhahn VD, Rees ALG. Report of the committee of inquiry
into fluoridation of Victorian water supplies. 1979-80 Melbourne, Victoria,
Australia: FD Atkinson, Government Printer;1980:115-25.
29. Ad Hoc Committee for the U.S. Surgeon General Koop, Shapiro JR,
Chairman. Report to the Environmental Protection Agency on the medical
(non -dental) effects of fluoride in drinking water. 1983:1-9.
9. Centers for Disease Control and Promotion. Water fluoridation additives.
30. D K. National. Fluoridation Engineer. Centers for Disease Control and
Available at: https://www.cdc.govlfluoridation/engineering/wfadditives.
Prevention.
ion. Personal communication. October 24, 2017.
htm. Accessed September 20, 2107.
10. Duchon K. National. Fluoridation Engineer. Centers for Disease Control and
31. U.S. Patent 3,091,513. Fluorine recovery. May 28, 1963. Available at:
Prevention. Personal communication. CDC WFRS database query. August
https://patents.google.com/patent/US3091513A/en. Accessed August
24, 2017.
28, 2017.
11. NSF International. NSF fact sheet on fluoridation products. Available at:
32. U.S. Patent 3,386,892. Purification of fluosilicic acid solution by distillation
http://www.nsf.orglnewsroom_pdf/NSF Fact_ Sheet_ on_ Fluoridation.
with phosphoric acid solution. June 4, 1968. Available at: https://patents.
pdf. Accessed September 20, 2017.
google.com/patent/US3386892A/en. Accessed August 28, 2017.
12. Master RD, Caplan MJ. Water treatment with silicofluoride and lead
33. U.S. Patent 3,615,195. Fluosilicic acid recovery. October 26, 1971.
toxicity. Int J Environ Studies1999;56:435-49.
Available at: https.Ilpatents.google.com/patent/US3615195A/en.
Accessed August 28, 2017.
13. Urbansky ET, Schack MR. Can fluoridation affect lead(II) in potable water?
34. U.S. Patent 3,764,658. Production of fluosilicic acid. October 9, 1973.
Hexafluorosilicate and fluoride equilibria in aqueous solution. Int J Environ
Available at: https://patents.google.com/patent/US3764658A/en.
Studies 2000;57:597-637.
Accessed August 28, 2017.
14. Finney WF, Wilson E, Callender A, Morris MD, Beck LW. Reexamination
35. U.S. Patent 4,762,698. Method for increasing fluosilicic acid recovered
of hexafluorosilicate hydrolysis by fluoride NMR and pH measurement.
from wet process phosphoric acid production. August 9, 1988. Available
Environ Sci Technol 2006;40(8):2572-7. Abstract at: https://www.ncbi.
at: https://patents.google.com/patent/US4762698A/en. Accessed
nlm.nih.gov/pubmed/16683594. Accessed September 21, 2017.
August 28, 2017.
15. Maier FJ. Manual of water fluoridation practice. New York: McGraw-Hill
Book Company, Inc.;1963.
16. DeEds F, Thomas JO. Comparative chronic toxicities of fluorine compounds.
Proc Soc Exper Biol and Med 1933-34;31:824-5.
17. McClure FJ. A review of fluorine and its physiological effects. Phys Reviews
1933;13:277-300.
18. McClure FJ. Availability of fluorine in sodium fluoride vs. sodium fluosilicate.
Public Health Rep 1950;65(37):1175-86. Article at: https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC1997098. Accessed September 22, 2017.
19. Zipkin I, Likins RC, McClure FJ, Steere AC. Urinary fluoride levels associated
with the use of fluoridated water. Public Health Rep 1956;71(8):767-72.
Article at: https://www.ncbi.nim.nih.gov/pmc/articlesIPMC2031051.
Accessed September 22, 2017.
20. Zipkin I, Likins RC. Absorption of various fluoride compounds from the
gastrointestinal tract of the rat. Amer J Physical 1957;191(3):549-50.
36. U.S. Patent 4,026,990. Production of low -fluoride gypsum as a by-product
in a phosphoric acid process. May 31, 1977. Available at: https://patents.
google.com/patentIUS4026990A/en. Accessed August 28, 2017.
37. O'Phelan, AM. Fruit's pulp, seeds, oil all involved in making a number of
products. Times Publishing Company. March 18, 2013. Available at: http://
www. tbo. com/orange-peels-and-everything-else-put-to-good-
use-504764. Accessed October 2, 2017.
38. U.S. Department of Labor. Occupational Safety and Health Administration.
OSHA Law & Regulation. Available at: https://www.osha.gov/law-regs.
html. Accessed October 2, 2017.
39. American Water Works Association. Safety Management for Utilities.
AW WA Manual M3. Seventh Edition. 2014.
40. Federal Register 2012 Mar 26;77(58):11573-896. Available at: https://
www. federalregistergov/documents/2012/03/26/2012-4826/hazard-
communication. Accessed October 2, 2017.
21. McClure FJ, Zipkin I. Physiologic effects of fluoride as related to water
41. Brown R, McTigue N, Graf K. Monitoring fluoride: how closely do utilities
fluoridation. Dent Clin N Am 1958:441-58.
match target versus actual levels? AW WA Opflow 2014;40(7):10-14.
22. McClure FJ. Water fluoridation: the search and the victory. Bethesda, MD:
42. Barker LK, Duchon KK, Lesaja S, Robison VA, Presson SM. Adjusted fluoride
National Institute of Dental Research; 1970. Available at: https://www.
concentrations and control ranges in 34 states: 2006-2010 and 2015.
dentalwatch.org/fl/mcclure.pdf. Accessed October 28, 2017.
AW WA Journal 2017;109(8):13-25. Abstract at: https://www.awwa.org/
publications/journal-awwa/abstract/articleid/65512820.aspx. Accessed
October 2, 2017.
Fluoridation Practice I Fluoridation Facts 83
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Fluoridation Practice References
43. Centers for Disease Control and Prevention. Engineering and
administrative recommendations for water fluoridation, 1995. MMWR
1995;44(No.RR-13). Available at: https://www.cdc.govlmmwr/preview/
mmwrhtm1/00039178.htm. Accessed October 2, 2017.
44. American Water Works Association. Internal corrosion control in water
distribution systems. AW WA Manual M58. Second edition. Denver. 2017.
45. Federal Register 1998 Aug 19;53(160):44512-36. Available at:
https://www.federairegister.govldocumentsll998108119198-220561
national-primary-drinking-water-reguations-consumer-confidence-
reports. Accessed September 20, 2017.
46. U.S. Environmental Protection Agency. Drinking Water Requirements for
States and Public Water Systems. Optimal corrosion control treatment
evaluation technical recommendations. 2016. Available at: https://www.
epa.gov/d wreginfo%ptimal-corrosion-control-treatment-evaluation-
technical-recommendations. Accessed September 20, 2017.
47. Edmunds WM, Smedley PL. Fluoride in natural waters. In Selinus 0. (ed):
Essentials of Medical Geology, Revised Edition. Netherlands, Springer.
2013:311-336.
48. Pollick PF. Water fluoridation and the environment: current perspective
in the United States. Int J Occup Environ Health 2004;10(3):343-
50. Abstract at: https://www.ncbi.nlm.nih.govlpubmed/15473093.
Accessed on September 20, 2017.
49. Osterman JW. Evaluating the impact of municipal water fluoridation
on the aquatic environment. Am J Public Health 1990;80(10):1230-5.
Article at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC1404812.
Accessed on September 20, 2017.
50. Tacoma -Pierce County Health Department. Tacoma -Pierce County Health
Department fluoridation resolution. WAC197-11-960 environmental
checklist. August 2002.
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57. What is public health?
Answer.
Public health promotes and protects the health of
people and the communities where they live, learn,
work and play. Public health measures improve the
quality of life for members of the community.
Fact.
Public health has numerous definitions and
dimensions. It can encompass issues of research,
education, regulation, policy and more. It focuses
on the health of entire populations that can vary
in size from as small as a local neighborhood to a
small -sized community and a large -sized city. It also
can focus on populations with a state, national or
even global perspective. But how does public health
affect our everyday lives? Individuals are touched
by public health measures every day without giving
them a second thought. For example, garbage pick-
up and disposal prevent the spread of disease. The
stoplight at a busy intersection protects motorists
and pedestrians from injury. Building sidewalks in
communities provides the option for people to walk
to help control their weight and improve their heart
health. Smoke -free laws help prevent lung cancer.
All of these are public health in action.
Community water fluoridation is another example
of a public health measure.
• Optimally fluoridated water is accessible to the entire
community regardless of socioeconomic status,
educational attainment or other social variables'
Frequent exposure to small amounts of fluoride
over time makes fluoridation effective through the
life span in helping to prevent tooth decay.'
• Community water fluoridation is more cost-
effective and cost -saving than other forms of
fluoride treatments or applications.', a
During the 20th century, the health and life
expectancy of persons residing in the United States
improved dramatically. Since 1900, the average life
span of persons in the United States lengthened
by greater than 30 years; 25 years of this gain are
attributable to advances in public health. Many
notable public health achievements occurred during
the 1900s. In a series of reports during 1999, the
Morbidity and Mortality Weekly Report (MMWR)
profiled 10 public health achievements chosen to
highlight the contributions of public health and to
describe the impact of these contributions on the
health and well being of persons in the United States.5
Ten Great Public Health Achievements —
United States, 1900-1999'
• Vaccination
• Motor -vehicle safety
• Safer workplaces
• Control of infectious diseases
Decline in deaths from coronary heart
disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
Individuals do not need to take special action or Recognition of tobacco use as a health
otherwise change their behavior to obtain the hazard
benefits of fluoridation.
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Public Policy I Fluoridation Facts 85
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In discussing the contribution of fluoridation, the
October 22,1999 MMWR6 noted fluoridation of
community drinking water was a major factor
responsible for the decline in tooth decay during
the second half of the 20th century. Although
other fluoride -containing products are available,
water fluoridation remains the most equitable and
cost-effective method of delivering fluoride to
all members of communities, regardless of age,
educational attainment, or income level.'
58. Is water fluoridation a valuable public
health measure?
Answer.
Yes. Community water fluoridation is a public
health measure that benefits people of all ages
and is a public health program that saves money
for families and the health care system. Because
fluoridation reaches large numbers of people
where they live, learn, work and play, it is more
effective than other forms of fluoride delivery.
Water fluoridation reaches everyone in the
community regardless of age, race, education,
income level or access to routine dental care.
Because of the important role it has played in the
reduction of tooth decay, the Centers for Disease
Control and Prevention (CDC) has proclaimed
community water fluoridation one of 10 great
public health achievements of the 20th century.s,6
Community water fluoridation is a public
health measure that benefits people of all
ages and is a public health program that
saves money for families and the health
care system.
Fact.
Throughout decades of research and more than 70
years of practical experience, fluoridation of public
water supplies has been responsible for dramatically
improving the public's oral health status.
It has been said that those who cannot remember
the past are condemned to repeat it. As generations
pass, details from life in the 1930s and 1940s fade.
The oral health of Americans suffered greatly during
the time of the Great Depression and into the era of
World War II. There were no public health programs
in place that addressed tooth decay and the loss
of teeth was viewed as an eventuality. In fact, as
World War II approached, those joining the U.S. Army
were required to have six back teeth (three on the
top and three on the bottom) that opposed each
other to serve the function of chewing food and
six front teeth (three on the top and three on the
bottom) that opposed each other for the purpose
of biting into food. The number of men disqualified
for dental reasons far exceeded all expectations
as "dental disease" became the most common
reason for military deferment. One out of eleven
registrants examined was disqualified for military
service due to dental issues.' After Pearl Harbor it
was apparent that the manpower needed to fight a
global war could be obtained only if dental standards
for induction were drastically relaxed. By March
1942, the standards had been revised so that a
man who was "well nourished, of good musculature,
and free from gross dental infections" but who was
completely edentulous (without any teeth) could be
inducted if his condition was corrected or could be
corrected with dentures 7
Because fluoridation reaches large numbers
of people where they live, learn, work and
play, it is more effective than other forms
of fluoride delivery.
In January 1945, a community water fluoridation
trial began in Grand Rapids, Michigan followed within
months by trials in Newburgh, NY (May 1945),
Brantford, Ontario (June 1945) and Evanston, IL
(February 1947). Reductions in tooth decay were
dramatic leading to the rapid adoption of fluoridation in
cities across the U.S. As a result, tooth decay declined
sharply during the second half of the 20th century.
Tooth loss was no longer considered inevitable.
Former U.S. Surgeon General, Dr. Luther Terry,
called fluoridation as vital a public health measure as
immunization against disease, pasteurization of milk
and purification of water.8
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86 American Dental Association
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Another former U.S. Surgeon General, Dr. C. Everett
Koop, wrote:
...this preventive measure (fluoridation) is the single
most important commitment that a community
can make to the oral health of its children and to
future generations. I urge all health officials and
concerned citizens to join me in supporting this
commitment and in the task of achieving water
fluoridation for all community drinking water
supplies which lack the fluoride content needed for
the prevention of dental caries.9
In 1999, because of the dramatic role it played in the
reduction of tooth decay, the Centers for Disease
Control and Prevention (CDC) proclaimed community
water fluoridation one of 10 great public health
achievements of the 20th century.1,6
In May 2000, U.S. Surgeon General Dr. David Satcher
issued the first ever Surgeon General's report on
oral health titled, Oral Health in America: A Report of
the Surgeon General.10 In 2001, Dr. Satcher issued a
statement on fluoridation in which he noted:
...community water fluoridation continues to be
the most cost-effective, practical and safe means
for reducing and controlling the occurrence of
dental decay in a community... water fluoridation is
a powerful strategy in efforts to eliminate health
disparities among populations 11
In the 2003 National Call to Action to Promote Oral
Health,12 U.S. Surgeon General Dr. Richard Carmona
called on individuals and groups who are most
concerned and in a position to act to apply strategies
to enhance the adoption and maintenance of proven
community -based interventions such as community
water fluoridation.12 In his 2004 Statement on
Community Water Fluoridation,13 Dr. Carmona wrote:
While we can be pleased with what has already
been accomplished, it is clear that there is much
yet to be done. Policymakers, community leaders,
private industry, health professionals, the media,
and the public should affirm that oral health is
essential to general health and well-being and take
action to make ourselves, our families, and our
communities healthier. I join previous Surgeons
General in acknowledging the continuing public
health role for community water fluoridation in
enhancing the oral health of all Americans"
In 2013, U.S. Surgeon General Dr. Regina M. Benjamin
wrote:14
...As Surgeon General I have been working hard to
encourage individuals and communities to make
healthy choices because I believe it is better to
prevent illness and disease rather than treat it after
it occurs. Community water fluoridation is one of
the most effective choices communities can make
to prevent health problems while actually improving
the oral health of their citizens... Fluoridation's
effectiveness in preventing tooth decay is not limited
to children, but extends throughout life, resulting
in fewer and less severe cavities. In fact, each
generation born since the implementation of water
fluoridation has enjoyed better dental health than
the generation that preceded it..14
U.S. Surgeon General Dr. Vivek H. Murthy issued
a video statement supporting community water
fluoridation in December 201511 In his video and
written statement on fluoridation issued in 2016; 5, 16
Surgeon General Murthy emphasized:
Our progress on this issue over the past 70 years
has been undeniable. But we still have work to do.
Because we know that so much of our health is
determined by zip code rather than genetic code.
That's why creating a culture of disease prevention
through community efforts — and ensuring health
equity for all — is one of my highest priorities.
Community water fluoridation helps us meet these
goals; as it is one of the most cost-effective,
equitable, and safe measures communities can take
to prevent tooth decay and improve oral health 1s,16
Today, the focus in achieving and maintaining health
is on prevention. Established by the U.S. Department
of Health and Human Services, Healthy People
202017 provides a science -based, comprehensive
set of ambitious, yet achievable, ten-year national
objectives for improving the health of the public.
Included under oral health is an objective to expand
the fluoridation of public water supplies. Objective
13 states that at least 79.6% of the U.S. population
served by community water systems should be
receiving the benefits of optimally fluoridated water
by the year 202011 Data from the CDC indicate that
in 2014, 74.4% of the U.S. population on public water
systems, or a total of 211.4 million people, had access
to fluoridated water.19
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Established by the U.S. Department of Health and
Human Services in 1996, the Community Preventive
Services Task Force develops and disseminates
guidance on which community -based health
promotion and disease prevention intervention
approaches work, and which do not work, based
on available scientific evidence. The Task Force
issues findings based on systematic reviews of
effectiveness and economic evidence. The Guide to
Community Preventive Services ("The Community
Guide") is a collection of evidence -based findings
of the Community Preventive Services Task Force
and is designed to assist decision makers in selecting
interventions to improve health and prevent disease.20
The Community Guide reviews are designed to
answer three questions:
1. What has worked for others and how well?
2. What might this intervention approach cost, and
what am I likely to achieve through my investment?
3. What are the evidence gaps?20
The Community Preventive Services Task Force
recommends community water fluoridation to
reduce tooth decay.21
Reports have been released by the U.S. Department
of Health and Human Services that encourage the
use of preventive interventions to improve the overall
and oral health of the nation.22,21 Specific to oral
health, two reports issued in 2011 by the Institute
of Medicine acknowledge water fluoridation is an
effective intervention for the prevention of tooth
decay. Advancing Oral Health in Americ024 referred
to water fluoridation as an effective prevention
intervention, while Improving Access to Oral Health
Care for Vulnerable and Underserved Populations"
acknowledged that evidence regarding community
water fluoridation programs continues to validate its
effectiveness, safety and cost -saving benefits.
59. Does water fluoridation reduce
disparities in dental health?
Answer.
Yes, evidence indicates water fluoridation helps
to reduce the disparities in dental health at
the community level. Populations with lower
socioeconomic status (SES) who live in fluoridated
communities have less tooth decay than their
peers in nonfluoridated communities.
Fact.
In the first ever Surgeon's General Report on Oral
Health issued in May 2000, U.S. Surgeon General David
Satcher noted that community water fluoridation is
safe and effective in preventing dental caries in both
children and adults. Fluoridation benefits all residents
served by community water supplies regardless of their
social or economic status10 In 2001, Dr. Satcher issued
a statement on fluoridation in which he noted:
...community water fluoridation continues to be
the most cost-effective, practical and safe means
for reducing and controlling the occurrence of
dental decay in a community... water fluoridation is
a powerful strategy in efforts to eliminate health
disparities among populations"
"...water fluoridation is a powerful strategy in
efforts to eliminate health disparities among
populations."
...............................................................................
Established by the U.S. Department of Health and
Human Services, Healthy People 2020 provides a
science -based, comprehensive set of ambitious,
yet achievable, ten-year national objectives for
improving the health of the public and reducing health
disparities" Starting with Healthy People 2000, one
of the overarching goals of Healthy People has focused
on disparities. With Healthy People 2020, that goal was
expanded to achieve health equity, eliminate disparities,
and improve the health of all groups.25 Healthy People
2020 provides the following definitions.
Health disparity — a particular type of health
difference that is closely linked with social,
economic, and/or environmental disadvantage.
Health disparities adversely affect groups of people
who have systematically experienced greater
obstacles to health based on their racial or ethnic
88 American Dental Association
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group; religion; socioeconomic status; gender;
age; mental health; cognitive, sensory, or physical
disability; sexual orientation or gender identity;
geographic location; or other characteristics
historically linked to discrimination or exclusion."
Heolth equity — the attainment of the highest level of
health for all people. Achieving health equity requires
valuing everyone equally with focused and ongoing
societal efforts to address avoidable inequalities,
historical and contemporary injustices, and the
elimination of health and health care disparities."
The association between social class and disparities in
dental health has been established through extensive
studies and reviews.26-18 Studies in communities
both with and without fluoridated water consistently
have shown higher levels of tooth decay in lower
socioeconomic groups. Additional studies have
evaluated the differences in children's tooth decay
experience among socioeconomic groups and the effect
that community water fluoridation has had on that
experience.29-11 In areas with water fluoridation, children
with low socioeconomic status (SES) had greater cavity
experience than those with high SES. However, the tooth
decay rates were higher for children with low SES who
had no exposure to fluoridation compared to children
with low SES who had exposure to fluoridated water29-11
These studies demonstrate the positive effects that
fluoridation has in reducing oral health disparities.
In 2011, a report by the Institute of Medicine,
Improving Access to Orol Heolth Core for Vulnerable
and Underserved Populotions,36 acknowledged that
evidence regarding community water fluoridation
programs continues to validate its effectiveness,
safety and cost -saving benefits.
Under the topic "Oral Health," Healthy People 2020
includes an objective to expand the fluoridation of
public water supplies. Objective 13 states that at least
79.6% of the U.S. population served by community
water systems should be receiving the benefits of
optimally fluoridated water by the year 202011 Data
from the CDC indicate that in 2014, 74.4% of the
U.S. population on public water systems, or a total
of 211.4 million people, had access to fluoridated
water.19 Conversely, approximately 25% or more than
72.7 million people on public water systems do not
receive the decay preventing benefits of fluoridation —
a powerful strategy communities can implement in
efforts to eliminate health disparities.
60. Along with the American Dental
Association, who supports community
water fluoridation?
Answer.
Many organizations, such as the National Dental
Association, Hispanic Dental Association, American
Academy of Pediatrics, American Medical
Association, American Public Health Association and
the World Health Organization also have policies
that support community water fluoridation.
Many organizations, such os the National
Dentol Association, Hispanic Dentol Association,
American Academy of Pediatrics, American
Medical Association, American Public Heolth
Association and the World Heolth Organization
also hove policies that support community
water fluoridation.
Fact.
The American Dental Association (ADA) adopted its
original resolution in support of fluoridation in 195031
and has repeatedly reaffirmed its position publicly and in
its House of Delegates based on its continuing evaluation
of the safety and effectiveness of fluoridation.27
The National Dental Association (NDA) is the largest and
oldest organization of minority oral health professionals
in the world.39 Representing more than 7,000 minority
dentists, nationally and abroad,39 the NDA seeks to
provide continued advancement of the highest quality
of oral health care and safety for the public.40 In 2012,
the NDA adopted the following position 40
It is therefore, the position of the National Dental
Association that Community Water Fluoridation is
safe, beneficial and cost-effective and should be
encouraged and supported under the following
conditions:
Community water supplies should contain the
optimal fluoride levels as recommended by the
U.S. Public Health Service (a range from 0.7 -
1.2 parts per million)
• Local communities and dental societies should be
in agreement with and support the fluoridation
project in their communities.
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Appropriate resources monitoring capabilities "the fluoridation of all community water systems as
should be available to ensure that the appropriate a safe and effective public health measure for the
water fluoride monitoring infrastructures are in prevention of tooth decay.1149
place at all times in the impacted communities.41
In a policy position released in 2012,41 the Hispanic
Dental Association (HDA) noted that the HDA mission
works toward the elimination of oral health disparities
in the Hispanic community and that the benefits of
fluoridation are critical to HDA's endorsement. The
HDA position statement4l includes the following item:
Therefore, it is the position of the Hispanic Dental
Association to:
Endorse community water fluoridation in all
communities — especially the Hispanic and
underserved communities — as a safe, beneficial
and cost-effective public health measure based
on science for preventing dental caries and to
aid in the reduction of oral health disparities."
As part of its core values42 the American Academy of
Pediatrics (AAP) is dedicated to promoting optimal
health and wellbeing for every child. With a strong
emphasis on policy, advocacy and education,42 the AAP
is a strong advocate for community water fluoridation.
In support of water fluoridation41 the AAP states:
Water fluoridation is a community -based
intervention that optimizes the level of fluoride
in drinking water, resulting in preeruptive and
posteruptive protection of the teeth. Water
fluoridation is a cost-effective means of
preventing dental caries, with the lifetime cost
per person equaling less than the cost of 1 dental
restoration.41
The American Medical Association's (AMA) mission is
to promote the art and science of medicine and the
betterment of public health.44 Its House of Delegates
first endorsed fluoridation in 195141 and the AMA
reaffirmed its support for water fluoridation in 2011.41
The American Public Health Association (APHA)
champions the health of all people and all communities
and speaks out for public health issues and policies
backed by science.41 It has supported community
water fluoridation as a safe and effective public health
measure for the prevention of tooth decay since
1950.41 The APHA reaffirmed its support in 2008 by
stating that it strongly endorses and recommends
The goal50 at the World Health Organization (WHO)
is to build a better, healthier future for people all over
the world. The WHO, which initially adopted policy
recommending the practice of water fluoridation
in 1969,51 reaffirmed its support for fluoridation in
199452 stating:
Providing that a community has a piped water
supply, water fluoridation is the most effective
method of reaching the whole population, so that
all social classes benefit without the need for
active participation on the part of individuals.s2
In 2004, the WHO once again affirmed its support
stating that "Water fluoridation, where technically
feasible and culturally acceptable, has substantial
public health benefits"53 In 2007, the Sixtieth World
Health Assembly adopted WHA60.17-Oral health
action plan for promotion and integrated disease
prevention54 which urges member states to:
(4) for those countries without access to optimal
levels of fluoride, and which have not yet established
systematic fluoridation programmes, to consider
the development and implementation of fluoridation
programmes, giving priority to equitable strategies
such as the automatic administration of fluoride, for
example, in drinking -water, salt or milk, and to the
provision of affordable fluoride toothpaste;54
In 2016, WHO officials wrote:
The use of fluoride is a major breakthrough in public
health. Controlled addition of fluoride to drinking
water supplies in communities where fluoride
concentration is below optimal levels to have a
cariostatic effect began in the 1940s and since then
extensive research has confirmed the successful
reduction in dental caries in many countries."
Additionally a list of more than 35 organizations
with positions/policies supporting community water
fluoridation can be viewed on ADA's website at www.
ADA.org/fluoride in the section marked "Fluoridation
Links" Each organization is listed with a link to their
specific fluoridation position/policy. Below arejust a
few of the organizations listed on the website.
90 American Dental Association
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• American Association of Dental Research
• American Association of Public Health Dentistry
• American Water Works Association
• Association of State and Territorial Dental Directors
• Centers for Disease Control and Prevention
• International Association of Dental Research
• National Institute of Dental and Craniofacial Research
Many organizations in the United States and around
the world recognize the benefits of community
water fluoridation. The ADA has developed a list
of "National and International Organizations that
Recognize the Public Health Benefits of Community
Water Fluoridation for Preventing Dental Decay."
Please see the ADA website at www.ADA.org/fluoride
for the most current listing as well as information on
reproduction and distribution of the list.
However, support for fluoridation doesn't end with a
list of organizations. In many cases, local newspaper
editorial boards support fluoridation. Perhaps the
most notable of these efforts occurred when the
2013 Pulitzer Prize for Journalism — Editorial
Writing56 was awarded to Tim Nickens and Daniel
Ruth of the Tampa Boy Times, St. Petersburg, Florida,
for their diligent campaign that helped reverse a
decision to end fluoridation of the water supply for
the 700,000 residents of the newspaper's home
(Pinellas) county. Copies of their 10 editorials from
2012 can be viewed at http://www.pulitzer.org/
winners/tim-nickens-and-daniel-ruth.
61. Has the legality of water fluoridation
been upheld by the courts?
Answer.
Yes. Fluoridation has been thoroughly tested in
the United States' court system, and found to be
a proper means of furthering public health and
welfare. No court of last resort has ever determined
fluoridation to be unlawful. Moreover, fluoridation
clearly has been held not to be an unconstitutional
invasion of religious freedom or other individual
rights guaranteed by the First, Fifth or Fourteenth
Amendments to the U.S. Constitution. And while
cases decided primarily on procedural grounds
have been won and lost by both pro- and anti -
fluoridation interests, to ADA's knowledge, no final
ruling in any of those cases has found fluoridation
to be anything but safe and effective.
Fact.
The legality of fluoridation in the United States
has been thoroughly tested in our court systems.
Fluoridation is viewed by the courts as a proper
means of furthering public health and welfare.17 No
court of last resort has ever determined fluoridation
to be unlawful. The highest courts of more than a
dozen states have confirmed the constitutionality
of fluoridation.58 In 1984, the Illinois Supreme Court
upheld the constitutionality of the state's mandatory
fluoridation law, resolving 16 years of court action
at a variety of judicial levels.59 Moreover, the U.S.
Supreme Court has denied review of fluoridation
cases thirteen times, citing that no substantial federal
or constitutional questions were involved.18
Fluoridation is viewed by the courts as a proper
means of furthering public health and welfare.
No court of last resort has ever determined
fluoridation to be unlawful.
It has been the position of the American courts
that a significant government interest in the
health and welfare of the public generally overrides
individual objections to public health regulations8
Consequently, the courts have rejected the
contention that fluoridation ordinances are a
deprivation of religious or individual freedoms
guaranteed under the Constitutions$,60 In reviewing
the legal aspects of fluoridation, the courts have
dealt with this concern by ruling that: (1) fluoride is
a nutrient, not a medication, and is present naturally
in the environment; (2) no one is forced to drink
fluoridated water as alternative sources are available;
and (3) in cases where a person believes that
fluoridation interferes with religious beliefs, there is a
difference between the freedom to believe, which is
absolute, and the freedom to practice beliefs, which
may be restricted in the public's interest.61,62
Fluoridation is the adjustment of the level of a
naturally occurring mineral found in water in order
to prevent tooth decay. Courts have consistently
ruled that water fluoridation is not a form of compulsory
mass medication or socialized medicine.58,61,63
In fact, water that has been fortified with fluoride is
similar to fortifying salt with iodine, milk with vitamin
D and orange juice with calcium — none of which
are medications.
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In recent years, challenges to fluoridation have been
dismissed for a variety of reasons, including that
plaintiffs admitted they could not establish injury by
virtue of fluoridation and that state law supporting
fluoridation prevailed over local attempts to oppose
fluoridation.
Interestingly, pro- and anti- fluoridation interests
have each won and lost legal challenges regarding
which state or local agency has regulatory authority
over fluoridation, which of course varies by state and
locality.
State law variances have also led to different rulings
on other issues, such as whether downstream end -
users of fluoridation must be given an opportunity to
vote on whether to fluoridate. While cases decided
primarily on procedural grounds have been won and
lost by both pro- and anti- fluoridation interests, to
the ADA's knowledge no final ruling in any of those
cases has found fluoridation to be anything but safe
and effective.
For additional information regarding the legal status
of community water fluoridation in the United States,
refer to The Fluoride Legislative User Information
Database (FLUID) which is a comprehensive database
containing historical information on legal cases
decided by U.S. courts. The database also contains
current information on federal and state policies
regarding community water fluoridation. The website
can be accessed at: http://fluidlaw.org.
62. Why does opposition to community
water fluoridation continue?
Answer.
Public health controversies sometimes exist
regarding public health interventions. In public
health there can be tension between "public good"
and "individual freedoms." Because public health
deals with populations it is all but impossible
to resolve issues to achieve approval from 100
percent of the individuals within the population.
When looking at fluoridation, some individuals
opposed to fluoridation are sincere in their beliefs.
Others ignore what constitutes reputable scientific
evidence as defined by the vast majority of the
scientific community and choose instead to base
their beliefs on personal opinions and studies with
flawed methodologies.
Fact.
Fluoridation is considered beneficial by the
overwhelming majority of the health and scientific
communities as well as the general public. A vast body
of scientific literature endorses water fluoridation
as a safe means of reducing the incidence of tooth
decay. Support for fluoridation among scientists and
health professionals, including physicians and dentists,
is nearly universal. Recognition of the benefits of
fluoridation by the American Dental Association, the
American Medical Association, the American Academy
of Pediatrics, governmental agencies and other
national health and civic organizations continues as a
result of published, peer -reviewed research.
Fluoridation has a long history of being a political issue,
as well as a scientific one, with opposition including
activists from both the right and the left of the political
spectrum. In the late 40s, opposition to fluoridation
began to appear nationwide. Reportedly, one of the
first public votes on fluoridation occurred in 1950
in Stevens Point, Wisconsin'64 when a local activist
initiated a campaign to stop the introduction of what
he called "poison" into the water system. The campaign
quickly moved from being a discussion of the science
to a political campaign that included the involvement
of a large number of civic groups, unofficial public
petitions, calls for a debate, campaign rallies and
numerous letters to the editor that "kept typesetters
busy preparing for print the thousands of words
that poured into the editor's desk" After 1950 when
the U.S. Public Health Service and ADA endorsed
fluoridation, proponents became more organized
in their efforts to promote fluoridation while the
opposition capitalized on the political nature of the
struggle and used lessons learned in Stevens Point.
Of the small faction that opposes water fluoridation
for philosophical reasons, freedom of choice probably
is one of the most frequently cited issues. People
take the stance that society should not "force"
individuals to act in ways that are beneficial to their
own health or the health of others. They are opposed
to "government interference" in their lives.61 Some
individuals are opposed to community action on any
health issue, others are opposed due to environmental
or economic concerns and some are opposed because
they are simply misinformed.
Opposition to fluoridation has existed since the
initiation of the first programs in 1945 and continues
today despite over 70 years of practical experience
92 American Dental Association
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showing fluoridation to be safe and effective.
An articles that appeared in the local newspaper
shortly after the first fluoridation program was
implemented in Grand Rapids, Michigan, noted that
the fluoridation program was slated to commence
January 1, but did not actually begin until January
25. Interestingly, health officials in Grand Rapids
began receiving complaints of physical ailments,
including "teeth falling out and enamel peeling off
their teeth," attributed to fluoridation from citizens
weeks before fluoride was actually added to the
water.66 In 1992 a community in Finland opted to
stop their fluoridation program at the end of the
year in December. However, it was discontinued at
the end of November without the public being told.
Public surveys conducted in November and December
and again in March the following year revealed the
occurrence and mean number of symptoms (the
most common being itching and dryness of skin)
were fairly similar during the periods of actual and
supposed fluoridation indicating the symptoms were
not caused by fluoride in the water. Interestingly,
those who claimed to be able to taste the fluoride in
the water made this claim equally often during actual
and supposed fluoridation. A significant reduction in
the symptoms occurred after those responding to the
surveys became aware that fluoridation had stopped.
The authors concluded that the prevalence rates of
the symptoms were connected to the psychological
rather than the physical effects of exposure to
fluoride in water.67
Over time, antifluoridation leaders and organizations
have come and gone, but their basic beliefs have
remained the same. These include: fluoride is toxic
and causes numerous harmful health effects;
fluoride does not prevent tooth decay; fluoridation
is costly; and fluoridation interferes with freedom of
choice and infringes on individual rights.
Opinions are seldom unanimous on any scientific
subject. In fact, there really is no such thing as "final
knowledge," since new information is continuously
emerging and being disseminated. As such, the
benefit evidence must be continually weighed against
risk evidence. Health professionals, decision makers
and the public should be cooperating partners in the
quest for accountability where decisions are based
on proven benefits measured against verified risks.68
Dentists are a valuable source of accurate information
regarding water fluoridation for both their patients
and their communities.
63. What are the tactics fluoridation
opponents use to provoke opposition
to water fluoridation?
Answer.
Fluoridation opponents use numerous tactics to
disseminate misinformation and raise the fears of
the public about the safety of water fluoridation.
Routinely, they use scare techniques'69 present half-
truths, downplay the significance of science -based
evidence and use selective reporting of results and
studies to support their false allegations.59
Fact.
While many of the arguments against fluoridation
have remained relatively constant over the years,
antifluoridationists have used different approaches
that play upon the popular concerns of the public at
the time.61 For example, in the 1950s fluoridation was
said to be a Communist plot. With America's growing
concern for environmental issues in the 1960s,
fluoridation was called pollution. After the Vietnam
War in the 1970s, the antifluoridationists capitalized
on the popularity of conspiracy theories by portraying
fluoridation as a conspiracy between the U.S.
government, the dental -medical establishment and
industry. As the population became more concerned
about their health in the 1980s, antifluoridationists
claimed fluoridation caused AIDS and Alzheimer's
disease. In the 1990s, claims of hip fractures and
cancer were designed to resonate with aging baby
boomers. With the new millennium, overexposure and
toxicity, in association with lead poisoning, surfaced as
common themes. Since the economic crisis of 2008,
discussions about the cost of fluoridation are more
commonplace. In the 2010s, neurotoxicity became a
constant theme with charges of lower IQ and autism.
Over the years, none of these approaches have ever
really disappeared, but instead are often recycled as
antifluoridationists choose which approach will have
the greatest effect on the intended audience.65
The internet has breathed new life into the
antifluoridation effort bringing the antifluoridation
message into voters' homes 71•72 With just a click of
the mouse, search engines can locate a large number
of websites denouncing fluoridation, which can give
the impression that this is a one-sided argument.
Individuals who look to the internet as a source of
valid and reliable information often fail to recognize
that these sites frequently contain personal opinion
rather than scientific fact. Newspaper stories,
Public Policy I Fluoridation Facts 93
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press releases and letters to the editor are often
posted as documentation of the "science" behind
antifluoridationists' claims. All too often, the public
accepts this type of information as true simply
because it is in print. Opposition videos are available
from national antifluoridation organizations and
are shared at no cost via vehicles such as YouTube
making it possible for every campaign to bring an
antifluoridationist to the community. Social media
such as Facebook and Twitter are used to spread
antifluoridation messaging to the public and to assist
in organizing local efforts. These venues have allowed
the small faction of antifluoridationists to be linked
across the country and around the world and promote
their message quickly, repeatedly and economically.
Spreading misinformation impacts public policy and
costs society in immeasurable ways. The opponents'
claims and opinions can escalate to emotional
arguments that, in the end, can delay, or prevent
the introduction of a water fluoridation program or
stop an existing program 70 More people, especially
those involved in policy decisions, need to be better
informed about these tactics. In making decisions that
affect the health of the community, it is important
to distinguish between someone's personal opinion
disguised as science and information based on the best
available scientific evidence. It is perfectly acceptable
to have your own opinion but it is unacceptable to have
your own "facts' derived from something less than
reputable science.
In making decisions that affect the health of
the community, it is important to distinguish
between someone's personal opinion disguised
os science and information based on the best
ovoiloble scientific evidence.
In 1993 the U.S. Supreme Court issued a landmark
decision that many view as likely to restrict the use of
information inferred as science in the federal courts
and in those state courts which adopt this reasoning.
The Court determined that while "general acceptance'
is not needed for scientific evidence to be admissible,
federal trial judges have the task of ensuring that an
expert's testimony rests on a reasonable foundation
and is relevant to the issue in question" According
to the Supreme Court, many considerations will bear
on whether the expert's underlying reasoning or
methodology is scientifically valid and applicable in a
given case. The Court set out four criteria that judges
could use when evaluating scientific testimony:
1. whether the expert's theory or technique can be
(and has been) tested, using the scientific method,
whether it has been subject to peer review and
publication (although failing this criteria alone
is not necessarily grounds for disallowing the
testimony),
its known or potential error rate and the existence
and maintenance of standards in controlling its
operation and
4. whether it has attracted widespread acceptance
within a relevant scientific community, since a
known technique that has been able to attract
only minimal support may properly be viewed
with skepticism?3
The scientific validity and relevance of claims
made by opponents of fluoridation might be best
viewed when measured against these criteria.71 The
techniques used by antifluoridationists are well known
and have been discussed at length in a number of
published articles that review the tactics used by
antifluoridationists.58,65,6s-70,74-77 Examples of a few
of the techniques can be viewed in Figure 5.
94 American Dental Association
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Targeting Politicians and Community Leaders: Antifluoridation websites contain draft letters to
be sent to newspaper publishers, water departments, and community public officials warning them of
their "liability" should they support or endorse water fluoridation. Leaders are urged to remain "neutral"
and allow fluoridation decisions to be put to a public vote, therefore, relieving the leaders of any and all
responsibility in the matter. Antifluoridationists use the time gained to conduct a public referendum to
bombard the public with misinformation designed to turn public opinion against fluoridation.
Unproven Claims: Antifluoridationists have repeatedly claimed fluoridation causes an entire laundry list
of human illnesses, including AIDS, Alzheimer's disease, cancer, Down Syndrome, genetic damage, heart
disease, lower intelligence, kidney disease, osteoporosis and hip fractures. None of these claims has a
basis in fact. These allegations are often repeated so frequently during campaigns that the public assumes
they must be true. Their appearance in print, even if only in letters to the editor of the local newspaper,
reinforces the allegation's credibility. With just a small amount of doubt established, the opposition
slogan, "If in doubt, vote it out," often rings true with voters.
Innuendo: The statement, "Fifty years ago physicians and dentists posed for cigarette ads," is an
example of innuendo or, more specifically, guilt by association. Even though fluoridation is not mentioned,
individuals are expected to make the connection that the medical community changed its position on
smoking so it is possible health professionals are wrong about fluoridation, too.
Outdated Studies and Statements from "Experts": Antifluoridation websites often offer a list of
"respected medical professionals and scientists" who have spoken out against fluoridation. One of those
often quoted is Dr. Charles Gordon Heyd who is noted to be a Past President of the American Medical
Association (AMA). What is not disclosed is the source of the quote or that Dr. Heyd was President of the
AMA in 1936 — almost ten years before water fluoridation trials began. His decades -old quote certainly
does not represent the current AMA position of support for water fluoridation and is characteristic of
antifluoridationists' use of items that are out of date. Additionally, antifluoridationists have claimed that
fourteen Nobel Prize winners have "opposed or expressed reservations about fluoridation" It should be
noted that the vast majority of these individuals were awarded their prizes from 1929 through 1958.
Statements Out of Context: One of the most repeated antifluoridation statements is, "Fluoride is a
toxic chemical. Don't let them put it in our water." This statement ignores the scientific principle that
toxicity is related to dosage and not just to exposure to a substance. Examples of other substances that
can be harmful in the wrong amounts, but beneficial in the correct amounts, are salt, vitamins A and D,
iron, iodine, aspirin and even water itself.
Conspiracy Theories: Hardly a fluoridation campaign goes by without those opposed to fluoridation
bringing up any number of conspiracy theories about fluoridation. Whether it is the claim that scientists
from the original atomic bomb program secretly shaped and guided the early Newburgh, NY, fluoridation
trial or that chemtrails are a government plot to spread fluoride, these claims have no basis in fact. Even
the belief that fluoridation was a communist plot to destroy America was famously parodied in the 1964
movie Dr. Strangelove. Over the decades, those opposed to fluoridation have used propaganda schemes
and conspiracy theories that reflected the social and political environment of the times. Today, "follow the
money" is a common theme as the opposition claims that the beverage industry, the companies supplying
fluoride additives and others are financially backing researchers, as well as dental and medical groups,
who are promoting fluoridation. None of these claims has a basis in fact.
J
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Public Policy I Fluoridation Facts 95
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Treating Correlation as Causation: Many people have heard the phrase that "correlation does not imply
causation" In other words, just because two events seem to fluctuate in tandem does not prove that they
are meaningfully related to one another. For example, statistics show that sales of ice cream increase in
warm summer months. Statistics also show that crime goes up in large cities in the summer. However, it
would be ludicrous to draw the conclusion that ice cream causes an increase in crime. Yet this is exactly
the type of logic exercised in some arguments and studies promoted by those opposed to fluoridation.
For example, the opposition often points to Kentucky as having a large portion of the population on public
water supplies receiving fluoridated water. And that's correct. In 2014, Kentucky was ranked the number
one state in the U.S. as 99.9% of its public water systems were fluoridated. But the opposition also points
to the fact that Kentucky suffers from a large number of people who have lost their teeth. They draw the
conclusion that this proves fluoridation does not work — without looking at other factors that influence this
outcome. For example, while there is a large number of public water systems that are fluoridated, Kentucky
has a large rural population that does not have access to public water supplies. Additionally, and perhaps
most importantly, Kentucky's population has a high rate of tobacco use which is known to be a risk factor
for periodontal (gum) disease which can lead to the loss of teeth.
64. Where can valid, evidence -based
information about water fluoridation be
found on the internet?
Answer.
There are many reputable sites on the internet that
provide information on fluorides and fluoridation
including the American Dental Association as well
as other reputable health and science organizations
and government agencies. These sites provide
information that is consistent with the best
available scientific evidence.
Fact.
One of the most widely respected sources for
information regarding fluoridation and fluorides is
the American Dental Association's (ADA) Fluoride
and Fluoridation website at www.ADA.org/fluoride.
(See Figure 6.) From the ADA website individuals can
link to other fluoridation websites such as:
• Centers for Disease Control and Prevention at
www.cdc.gov/fluoridation
• The Community Guide at
https://www.thecommunityguide.org
• Fluoride Science at http://fluoridescience.org
The internet contains numerous sources of
information on fluoridation. However, not all
"science" posted on the internet is based on
scientific fact. Searching the internet for "fluoride' or
"water fluoridation" directs individuals to numerous
websites. Some of the content found in the sites
is scientifically sound. Other less scientific sites
look highly technical, but contain information
based on science that is unconfirmed or has not
gained widespread acceptance. In many cases,
the information is largely opinion. While everyone
is entitled to their opinion, they are not entitled
to make that opinion appear as scientific fact.
Commercial interests, such as the sale of water
filters, are often promoted.
Today's technology can put the world at your
fingertips but search engine technology can
influence what is returned in searches. The first
time the search for "fluoridation" is made, it is
likely that the returns will include both pro- and
anti- fluoridation websites. When you click to
view a website, the search engine takes note and
on subsequent searches for the same term, the
search engine will return items similar to what you
chose initially. For example, if you choose a pro -
fluoridation website initially, the next time you
search for "fluoridation," the search engine will
likely return a selection of other pro -fluoridation
websites for your review. Of course the converse
is also true. Clicking on anti -fluoridation websites
will allow you to see a search ladened with similar
anti -fluoridation sites.
96 American Dental Association
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FLUORIDATION AT YOUR
FINGERTIPS!
httP://www.ADA.org/f luoride
• ADA Fluoridation Resources
• ADA Fluoridation Videos
• ADA Fluoridation News Stories
• ADA Policy and Statements
• Links to Additional Fluoridation Websites
ADA American Dental Association®
America's leading advocate for oral health
www.ADA.org
Many ADA resources are at your fingertips
24/7/365. Order a library book or products
online, read JADA articles, discuss important
topics with colleagues, find helpful information
on professional topics from accreditation to
X-rays and recommend our dental education
animations, stories and games to your patients.
Be resourceful.
Visit ADA.org today!
65. Why does community water fluoridation
sometimes lose when it is put to a public
vote?
Answer.
Voter apathy or low voter turnout due to the vote
being held as a special election or in an "off" year,
confusing ballot language (a "no" vote translates
to support for fluoridation), blurring of scientific
issues, the use of scare tactics by those opposed to
fluoridation, long campaigns that lead to "fluoridation
fatigue," lack of leadership by elected officials and
a lack of political campaign skills among health
professionals are some of the reasons fluoridation
votes are sometimes unsuccessful.
Fact.
The fact is that fluoridation votes in the U.S. are
more often successful than not. In 2016, it was
common to see those opposed to fluoridation make
statements such as "450 communities had rejected
fluoridation since 2000" or similar statements using
different numbers. What is not made clear is that
the number of communities in these statements
is a global number. Many of these communities
are outside the United States.78 In fact from 2000
through 2016, more than 515 U.S. communities
in 42 states voted to adopt or retain successful
fluoridation programs.79 In the five years from
2012 to 2016, U.S. communities voted in favor of
fluoridation programs by a two to one margin?1,79
The fact is that fluoridation votes in the U.S.
are more often successful than not ... In the five
years from 2012 to 2016, U.S. communities
voted in favor of fluoridation programs by a
two to one margin.
Since 2000, nearly 50 million people have been
added to the population on public water systems
in the United States that enjoys the benefit of
optimally fluoridated water.80 In 2000, 65% of
the public on public water systems received
fluoridated water." In 2014, the percentage had
increased nearly 10% to 74.4% of the population?9
But despite the continuing growth of fluoridation
in this country over the past several decades,
millions of people in the U.S. do not yet receive
the protective benefit of fluoride in their drinking
...............................................................................................................................................................
Public Policy Fluoridation Facts 97
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Two cities (Jacksonville, Florida and El Paso, Texas) are naturally fluoridated.*
in
Sac rame to Omaha Columbus Philadelphia
•
Oakland • • Baltimore Washington
r Denver Kansas CityIndianapolis 9
San Francisco
Yn Jose Las Vegas St. Louis
Nas
hville -Davidson Virginia Beach
Los Angeles Tulsa • Charlotte
• • Memphis
Long Beach Albuquerque Oklahoma City •
••Mesa •
Phoenix Atlanta
Fort Worth
• • Dallas
El Paso (natural)
• Jacksonville (natural)
Austin Houston New Orleans
San Antonio •
Miami
v v
* Data compiled by the American Dental Association and Centers for Disease Control and Prevention/Division of Oral Health.
Information current as of October 2017.
water. Centers for Disease Control and Prevention
(CDC) data from 2014 indicated more than 25%
of the population served by public water systems
did not have access to fluoridated water.19 In 2017,
44 of the 50 largest cities were fluoridated.S2 Of
the 44 cities, 42 were fluoridated by adjustment
and two had naturally occurring fluoride at the
recommended levels (Figure 7). The remaining six
largest nonfluoridated cities (in order of population
largest to smallest) were: Portland, Oregon;
Albuquerque, New Mexico; Tucson, Arizona; Fresno,
California; Colorado Springs, Colorado; and Wichita,
Kansas. In October 2017, the Albuquerque Bernalillo
County Water Utility Authority authorized budget
monies to restore fluoridation to their customers.
It is estimated that fluoridated water will be
available in six to eight months.
In 2010, recognizing the ongoing need to improve
health and well-being, the U.S. Department of Health
and Human Services revised national health objectives
to be achieved by the year 2020. Included under oral
health was an objective to significantly expand the
fluoridation of public water supplies. Specifically,
Objective 13 of Healthy People 2020 states that at
least 79.6% of the U.S. population served by community
water systems should be receiving the benefits of
optimally fluoridated water by the year 202011 This
replaced the Healthy People 2010 objective of 75%.83
As of 2014, twenty states met or exceeded the 2020
objective 19 (See Figure 8.) Although water fluoridation
reaches some residents in every state the coverage
is uneven. Data from 2014 indicated that 26 states
provided fluoridation benefits to 75% or more of their
residents on community water systems while eight
states were at or below 50%19 (See Figure 9.)
.....................................
98 American Dental Association
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States Meeting the Healthy People 2020 Goal Of 79.6% of the Population Served by Community Water Supplies
Receivino Fluoridated Water*
Fluoridation campaigns can vary greatly from
community to community. To paraphrase an old
saying, "If you've seen one fluoridation campaign,
you've seen one fluoridation campaign" A number of
factors commonly come into play when fluoridation
is put to a public vote and does not succeed. Among
those factors are a lack of funding, public and
professional apathy, the failure of many legislators
and community leaders to take a stand because
of perceived controversy, low voter turnout and
the difficulty faced by an electorate in evaluating
scientific information in the midst of emotional
charges by opponents. Voters are often unaware of
the fluoride content of their water. Unfortunately,
citizens sometimes mistakenly believe their water
contains the recommended level of fluoride when, in
fact, it does not. On the other hand, people sometimes
say they have great teeth and don't need fluoridation
when in fact, the major reason they have such good
teeth is because they've had the benefit of fluoride
in the water their entire lives. And, in some cases,
because fluoridation campaigns often become political
campaigns, there are political factors that can sway a
vote that have nothing at all to do with fluoridation.
Clever use of emotionally charged "scare" propaganda
by fluoride opponents creates fear, confusion and
doubt within a community when voters consider the
use of fluoridation.84,85
Defeats of referenda or the discontinuance of
fluoridation have occurred most often when a small,
vocal and well organized group has used a barrage
of fear -inspiring allegations designed to confuse the
electorate. In addition to attempts to influence voters,
opponents have threatened community leaders with
Public Policy I Fluoridation Facts 99
back to agenda
k- Figure 9. State Fluoridation Status P11- Ad
Percentage of population on community water systems receiving fluoridated water.*
personal litigation.86 While no court of last resort has
ever ruled against fluoridation, community leaders
can be swayed by the threat of litigation due to the
cost and time involved in defending even a groundless
suit, not to mention threats of political fallout. The
American Dental Association (ADA) knows of no
cases in which community leaders have been found
liable for their pro -fluoridation efforts. In no instance
has fluoridation been discontinued because it was
proven harmful in any way.85-87
..............................................................................
Defeats of referenda or the discontinuance of
fluoridation have occurred most often when a
small, vocal and well organized group has used
a barrage of fear -inspiring allegations designed
to confuse the electorate.
Adoption of fluoridation is ultimately a decision of
state or local decision makers, whether determined by
elected officials, health officers or the voting public.
Fluoridation can be enacted through state legislation,
administrative regulation, ordiance or a public
referendum. While fluoridation is not legislated at
the federal level, it is legislated at the state and local
level. As with any public health measure, a community
has the right and obligation to protect the health and
welfare of its citizens, even if it means overriding
individual objections to implement fluoridation.
Those opposed to fluoridation sometimes comment
that "the government is forcing fluoridation" on the
community. But who is "the government?" The fact
is that since fluoridation is implemented by state or
local votes (by city councils or public vote), the people
are "the government" Voters elect officials at the
.....................................................................................................................................................................
100 American Dental Association
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state and local level to act on their behalf. Voters
participate directly in public votes on fluoridation.
Each spring as part of the yearly ADA/ASTDD/CDC
Community Water Fluoridation Awards program, the ADA,
Association of State and Territorial Dental Directors
and the CDC Division of Oral Health compile a list of
water systems/communities in the United States that
have adopted or retained community water fluoridation in
the previous year." This list is posted on the ADA website
at http://www.ADA.org/fluoride. The ADA has also
compiled a master list of U.S. communities voting to adopt
or retain fluoridation programs dating from 1998 which
is also available on the ADA website.79 From 2000 through
2016, more than 515 U.S. communities in 42 states have
voted to adopt or retain fluoridation. The size of these
water systems/communities varies greatly — from
those with a few thousand residents to the Metropolitan
Water District of Southern California which provides
fluoridated water to more than 18 million people 79
The primary source for technical assistance with
fluoridation efforts is the ADA's Council on Advocacy for
Access and Prevention (CAAP) at the ADA. Additional
support for fluoridation is available from the ADA's
Division of Legal Affairs, Division of Communications
and Department of State Government Affairs. Dental
and health professionals seeking technical assistance
can reach CAAP at 312.440.2500.
66. Is community water fluoridation
accepted by other countries?
Answer.
According to the British Fluoridation Society,89 as of
November 2012, approximately 377.7 million people
in 25 countries worldwide were supplied with water
fluoridated by adjustment. Additionally, the number
of people receiving naturally fluoridated water at
the optimum level is approximately 57.4 million.
Worldwide, the estimated number of people with
access to optimally fluoridated water is 435.1 million
and it continues to grow each year.89 A second
study estimates the number at 437.2 million.90
According to the British Fluoridation Society, os
of November 201Z approximately 377.7 million
people in 25 countries worldwide were supplied
with water fluoridated by adjustment.
Fact.
The value of water fluoridation is recognized
internationally. Countries and geographic regions with
water fluoridated by adjustment include the U.S.,
Argentina, Australia, Brazil, Brunei, Canada, Chile, China
(Special Administrative Region of Hong Kong), Fiji,
Guatemala, Guyana, the Irish Republic, Israel, Malaysia,
New Zealand, Panama, Papua New Guinea, Peru,
Republic of Korea (South Korea), Serbia, Singapore,
Spain, the United Kingdom and Vietnam.89 Major
cities (outside the U.S.) with fluoridated water include
Adelaide, Auckland, Bilbao, Birmingham, Brisbane,
Buenos Aires, Cork, Dublin, Edmonton, Ho Chi Minh
City (Saigon), Kuala Lumpur, Melbourne, Newcastle
upon Tyne, Perth, Rio de Janeiro, San Paolo, Santiago,
Seville, Sydney, Toronto, Wellington and Winnipeg.89
Thorough investigations of fluoridation, conducted
in a number of countries in addition to the U.S.
including Australia, England, Ireland, New Zealand
as well as by the European Commission and the
World Health Organization, support the safety and
effectiveness of water fluoridation.90-95
Considering the extent to which fluoridation has
already been implemented throughout the world,
the lack of documentation of adverse health effects
is remarkable testimony to its safety.91 -94,96 The
World Health Organization (WHO) has endorsed the
practice of water fluoridation since 1969.51 In 1994,
an expert committee of the WHO published a report
which reaffirmed its support of fluoridation as being
safe and effective in the prevention of tooth decay,
and stated that "provided a community has a piped
water supply, water fluoridation is the most effective
method of reaching the whole population, so that
all social classes benefit without the need for active
participation on the part of individuals"52 In 2004, the
WHO once again affirmed its support.53 In 2007, the
Sixtieth World Health Assembly recommended that
countries without access to optimal levels of fluoride
or systemic fluoridation programs should consider
initiating fluoridation programs.54
A scientific evaluation of fluoride was conducted by
the Scientific Committee on Health and Environmental
Risks (SCHER) upon request by the European
Commission (EC).81 The EC is the European Union's
(EU) executive body with responsibility to manage EU
policy. The Committee was asked to critically evaluate
any new evidence on the hazard profile, health effects
and human exposure to fluoride. The final report,
Public Policy Fluoridation Facts 101
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Critical review of any new evidence on the hazard profile,
health effects, and human exposure to fluoride and the
fluoridating agents of drinking water was released in
2011.91 It stated that exposure to levels of fluoride used
for fluoridation of drinking water is not expected to lead
to unacceptable risks to the environment. Additionally,
the report concluded there was insufficient evidence
or no evidence that fluoridation was linked to endemic
skeletal fluorosis, osteosarcoma, lower IQs in children,
thyroid or reproductive problems.91
There are parts of the world where water fluoridation
is not common. In some of these instances water
fluoridation is not feasible due to the lack of a
central water supply, the existence of other more
life -threatening health needs, the lack of trained
technical personnel or sufficient funds for start-up
and maintenance costs. In some cases where water
fluoridation has not been implemented, countries
have chosen to institute salt fluoridation programs.
67. Is community water fluoridation banned
in Europe?
Answer.
No country in Europe bans community water
fluoridation.
Fact.
Under European Union (EU) law and regulations, the
individual Member States can decide whether to or not
to fluoridate water. Members of the European Union
(EU) construct their own water quality regulations
within the framework of the Drinking Water Directive97
adopted in 1998 which outlines the quality of water
intended for human consumption. They can also
decide whether to or not to add fluoride to milk or
salt products. There is no EU-wide obligation to add
fluoride to any product consumed by humans including
water nor is there an EU-wide obligation not to add
fluoride to any product including water.87
The Directive provides maximum admissible
concentrations for many substances, one of which is
fluoride. The Directive does not require or prohibit
fluoridation; it merely requires that the fluoride
concentration in water does not exceed the
maximum permissible concentration of 1.5 mg/L.97
Many fluoridation systems that used to operate
in Eastern and Central Europe did not function
properly and when the Iron Curtain fell in 1989-90,
fluoridation stopped because of obsolete technical
equipment and lack of knowledge as to the benefits
of fluoridated water.$$
Water fluoridation is not practical in some European
countries because of complex water systems with
numerous water sources. As an alternative to water
fluoridation, many European countries have opted
for the use of dietary fluoride supplements or salt
fluoridation.
Basel, Switzerland is one such example.98 Those opposed
to water fluoridation claimed a large victory when Basel
voted to cease water fluoridation in 2003. The facts
are that Basel was the lone city with fluoridated water
surrounded by communities that used fluoridated salt.
In the mid-1990s, trade barriers that had prevented
fluoridated salt from being sold to those living in
Basel fell and soon it was evident that residents
were receiving fluoride from salt as well as through
drinking water. The government voted to cease water
fluoridation in 2003 in light of availability and use of
fluoridated salt in the community. Basel, Switzerland
did not stop providing fluoride. Officials simply chose
another type of fluoridation — salt fluoridation.98
Again, no European country bans fluoridation. It
has simply not been implemented for a variety of
technical, legal, financial or political reasons.
Those opposed to fluoridation sometimes comment
that "97% of western Europe has rejected water
fluoridation," although frequently the line becomes
"most of Europe has rejected water fluoridation" But
what is not mentioned is that there are a number of
countries in Europe that have opted to use fluoridated
salt or milk fluoridation. (Additional information on
this topic can be found in Benefits Section, Question
14.) Letters have appeared on the internet reportedly
from officials in foreign countries who comment
negatively regarding their country's position on
fluoridation. However, from the letters it is apparent
the writers are responding to a question that is not
publically available and that was designed to illicit a
negative response. Additionally the credentials of the
respondents do not provide any insight as to what
relationship, if any, they have with the governmental
bodies who have jurisdiction over fluoridation
practices in their respective countries. These letters
should not be construed as any country's official
position on fluoridation.
102 American Dental Association
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Public Policy References
1. Horowitz HS. The effectiveness of community water fluoridation in the United
States. J Public Health Dent 1996;56(5 Spec No):253-8. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/9034970. Accessed October 26, 2017.
2. Buzalaf MAR, Pessan JP, Honorio HM, ten Cate JM. Mechanisms of actions
of fluoride for caries control. In Buzalaf MAR (ed): Fluoride and the Oral
Environment. Monogr Oral Sci. Basel, Karger. 2011;22:97-114. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl2l701194. Accessed October
26, 2017.
3. Garcia Al. Caries incidence and costs of prevention programs. J Public
Health Dent 1989;49(5 Spec No):259-71. Abstract at: https://www.ncbi.
nlm.nih.gov/pubmed/2810223. Article at: https://deepblue.lib.umich.
edulhandlel202Z42166226. Accessed October 26, 2017.
4. Milgrom P, Reisine S. Oral health in the United States: the post -fluoride
generation. Annu Rev Public Health 2000;21:403-36. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/10884959. Accessed October 26, 2017.
5. Centers for Disease Control and Prevention. Ten great public health
achievements --United States, 1900-1999. MMWR 1999;48(12):241-3.
Available at: https://www.cdc.govlmmwr/previewlmmwrhtmIl00056796.
htm. Accessed October 26, 2017.
6. Centers for Disease Control and Prevention. Fluoridation of drinking
water to prevent dental caries. MMWR 1999;48(41):933-40. Available
at: https://www.cdc.gov/mmwr/previewlmmwrhtmllmm484lal.htm.
Accessed October 26, 2017.
7. Jeffcott GF. United States Army. Dental service in World War II. Chapter
VI. Operation of the dental service -general considerations. Medical
Department. United States. Army. Office of the Surgeon General.
Department of the Army. Washington, D.C. 1955. Available at: http://
history. amedd.army. mil/booksdocs/wwii/dental/DEFAULT. htm.
Accessed October 26, 2017.
8. McClure FT Water fluoridation: the search and the victory. Bethesda, MD:
National Institute of Dental Research; 1970. Available at: https://www.
dentalwatch.org/fl/mcc/ure.pdf. Accessed October 28, 2017.
9. U.S. Department of Health and Human Services, Public Health Service.
Surgeon General C. Everett Koop. Surgeon General urges adoption of
fluoridation. Water fluoridation. J Public Health Dent 1983;43(2):185.
10. U.S. Department of Health and Human Services. Oral health in America: a
report of the Surgeon General. Rockville, MD: U.S. Department of Health
and Human Services, National Institute of Dental and Craniofacial Research,
National Institutes of Health; 2000. Available at: https://profiles.nlm.nih.
gov/ps/retrieve/ResourceMetadata/NNBBJT Accessed October 28, 2017.
11. U.S. Department of Health and Human Services, Public Health Service.
Surgeon General David Satcher. Statement on community water
fluoridation. Office of the Surgeon General. Rockville, MD; 2001. Available
at: https://www.cdc.govlfluoridation/guidelines/surgeons-general-
statements.htmL Accessed October 28, 2017.
12. U.S. Department of Health and Human Services. A national call to action
to promote oral health. Rockville MD: U.S. Department of Health and
Human Services, Public Health Service, Centers for Disease Control and
Prevention, National Institutes of Health, National Institute of Dental and
Craniofacial Research. NIH Publication 03-5303, May 2003. Available
at: https://www.nidcr.nih.govIDataStatisticsISurgeonGenerall
NationalCalltoAction. Accessed October 28, 2017.
13. U.S. Department of Health and Human Services, Public Health Service. Surgeon
General Richard H. Carmona. Statement on community water fluoridation.
Office of the Surgeon General. Rockville, MD. 2004. Available at: https://
www. cdc.gov/fluoridation/guidelines/surgeons-general-statements. html.
Accessed October 28, 2017.
14. U.S. Department of Health and Human Services, Public Health Service. Surgeon
General Regina M. Benjamin. Statement on community water fluoridation.
Office of the Surgeon General. Rockville, MD. 2013. Available at: https://
www. cdc.gov/fluoridation/guidelines/surgeons-general-statements. html.
Accessed October 28, 2017.
15. U.S. Department of Health and Human Services, Public Health Service.
Surgeon General Vivek H. Murthy. Statement on community water
fluoridation. (Video). Washington, D.C. 2016. Available at: https://www.
youtube.com/watch?/ist=PL050E3432C9D6BE2B&v=VPEuOO-gW2/.
Accessed October 28, 2017.
16. U.S. Department of Health and Human Services. Public Health Service.
Surgeon General Vivek H. Murthy. Statement on community water
fluoridation. Office of the Surgeon General. Rockville, MD. 2016. Available
at: https://www.cdc.govlfluoridation/guidelines/surgeons-general-
statements.htmL Accessed October 28, 2017.
17. U.S. Department of Health and Human Services. Office of Disease
Prevention and Health Promotion. HealthyPeople.gov. Healthy People
2020. About healthy people. Available at: https://www.healthypeople.
gov/2020/About-Healthy-People. Accessed October 26, 2017.
18. U.S. Department of Health and Human Services. Office of Disease
Prevention and Health Promotion. HealthyPeople.gov Healthy People
2020. Topics and Objectives. Oral health objectives. Available at: https://
www. healthypeople.govl202Oltopics-objectivesltopicloral-health/
objectives. Accessed October 26, 2017.
19. Centers for Disease Control and Prevention. Community Water
Fluoridation. Fluoridation statistics. 2014. Available at: https://www.cdc.
gov/fluoridation/statistics/2014stats.htm. Accessed October 26, 2017.
20. The Community Guide. About the community guide. Available at: https://
www.thecommunityguide.org/about/about-community-guide. Accessed
October 26, 2017.
21. The Community Guide. Dental Caries (Cavities): Community Water
Fluoridation. Snapshot. Available at: https://www.thecommunityguide.
org/findings/dental -caries-ca vi ties- community- water -fluoridation.
Accessed October 26, 2017.
22. U.S. Department of Health and Human Services. Promoting and enhancing
the oral health of the public: HHS oral health initiative. 2010. Available at:
www.hrsa.gov/sites/default/files/oralhealth/hhsinitiative.pdf. Accessed
October 26, 2017.
23. U.S. Department of Health and Human Services. Office of the Surgeon
General. National Prevention Council. National prevention strategy.
Washington, D.C. The National Academies Press. 2011. Available at:
https://www.surgeongeneral.govlpriorities/prevention/strategy/index.
htmL Accessed October 28, 2017.
24. Institute of Medicine of the National Academies. Advancing oral health in
America. Washington, D.C. The National Academies Press. 2011. Available
at: http://www.nationalacademies.org/hmd/reports/2011/advancing-
oral-health-in-america.aspx. Accessed October 26, 2017.
25. U.S. Department of Health and Human Services, Office of Disease Prevention
and Health Promotion. Healthy people.gov. Healthy People 2020. Disparities.
Available at: https://www.healthypeople.govl2O2Olaboutlfoundation-
health-measures/Disparities. Accessed October 26, 2017.
26. Watt RG. From victim blaming to upstream action: tackling the social
determinants of oral health inequalities. Community Dental Oral
Epidemiology 2007;35(1):1-11. Abstract at: https://www.ncbi.nlm.nih.
gov/pubmed/17244132. Accessed October 26, 2017.
27. Locker D. Deprivation and oral health: a review. Community Dent Oral
Epidemiol 2000;28(3):161-9. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/10830642. Accessed October 26, 2017.
28. Burt BA. Fluoridation and social equity. J Public Health Dent 2002;
62(4):195-200. Abstract at: https://www.ncbLnlm.nih.gov/
pubmed112474623. Accessed October 24, 2017.
29. Cho HJ, Lee HS, Pak DI, Bae KH. Association of dental caries with
socioeconomic status in relation to different water fluoridation levels.
Community Dent Oral Epidemiol 2014;42(6):536-42. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/24890821. Accessed October 26, 2017.
30. McGrady, M.G., Ellwood RP, Maguire A, Goodwin M, Boothman N, Pretty
IA. The association between social deprivation and the prevalence and
severity of dental caries and fluorosis in populations with and without water
fluoridation. BMC Public Health 2012;12:1122-39. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/23272895. Article at: https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC3543717 Accessed October 26, 2017.
31. Jones CM, Worthington H. Water fluoridation, poverty and tooth decay in
12-year-old children. J Dent 2000;28(6):389-93. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/10856802. Accessed October 26, 2017.
...............................................
Public Policy I Fluoridation Facts 103
back to agenda
Public Policy References
32. Jones CM, Worthington H. The relationship between water fluoridation and 51. World Health Organization. Fluoridation and dental health. (WHA22.30)
socioeconomic deprivation on tooth decay in 5-year-old children. Br Dent
1969 Jul 23. Available at: http://apps.who.int/iris/handle/10665191255.
J 1999;186(8):397-400. Abstract at: https://www.ncbi.nim.nih.govl
Accessed October 28, 2017.
pubmed19329305. Accessed October 26, 2017.
52. WHO Expert Committee on Oral Health Status and Fluoride Use. Fluorides
33. Slade GD, Spencer AJ, Davies MJ, Stewart JF. Influence of exposure to
and oral health: report of a WHO expert committee on oral health status
fluoridated water on socioeconomic inequalities in children's caries experience.
and fluoride use. WHO Tech Rep Ser 1994;846:1-37. Available at: http://
Community Dent Oral Epidemiol 1996;24(2):89-100. Abstract at: https://
apps.who.intliris/bitstream/10665139746111WHO_TRS_846.pdf.
www.ncbi.nlm.nih.gov/pubmed/8654039. Accessed October 26, 2017.
Accessed October 28, 2017.
34. Provart S, Carmichael C. The relationship between caries, fluoridation
53. Petersen PE, Lennon MA. Effective Use of fluorides for the prevention of
and material deprivation in five-year old children in County Durham.
dental caries in the 21st century: the WHO approach. Community Dent
Community Dent Health 1995,12(4):200-3. Abstract at: https://www.
Oral Epidemiol 2004,32(5):319-21. Abstract at: https://www.ncbi.nim.
ncbi.nlm.nih.gov/pubmed/8536081. Accessed October 26, 2017.
nih.gov/pubmed/15341615. Accessed October 26, 2017.
35. Ellwood RP, O'Mullane DM. The association between area deprivation and
54. Petersen PE. World Health Organization global policy for improvement of
dental caries in groups with and without fluoride in their drinking water.
oral health --World Health Assembly 2007. Int Dent J 2008;58(3):115-
Community Dent Health 1995;12(1):18-22. Abstract at: https://www.
21. Abstract at: https://www.ncbi.nim.nih.govlpubmed/18630105.
ncbi.nlm.nih.gov/pubmed/7697558. Accessed October 26, 2017.
Accessed October 26, 2017.
36. Institute of Medicine of the National Academies. Improving access to oral
55. Petersen PE, Ogawa H. Prevention of dental caries through the use of
health care for vulnerable and underserved populations. Washington,
fluoride --the WHO approach. Community Dent Health 2016;33(2):66-8.
D.C. The National Academies Press. 2011. Available at: http://
56. 2013 Pulitzer Prizes. Journalism. Editorial Writing. Available at: http://
nationalacademies.org/HMD/Reports/2011/Improving-Access-to-
i ww.pulitzer.org/prize-winners-by-year/2013. Accessed October 26,
Oral -Health -Care -for -Vulnerable -and- Underserved-Populations. aspx.
2017.
Accessed October 28, 2017.
37. American Dental Association. Fluoridation of water supplies.
(Trans.1950:224) 1950.
38. American Dental Association. Policy on fluoridation of water supplies.
(Trans.2015:274) 2015. Available at: http://www.ADA.org/en/public-
programs/ad vocating-for-the-public/fluoride-and-fluoridation/ada-
fluoridation-policy Accessed October 26, 2017.
39. National Dental Association. Membership. Available at: http://www.
ndaonline.org/membership. Accessed October 26, 2017.
40. National Dental Association. Position on water fluoridation. 2012. Available
at: http://www.ndaonfine.org/position-on-water-fluoridation. Accessed
October 26, 2017.
41. Hispanic Dental Association. Advocacy: HDA Working for You. Community
Water Fluoridation. Hispanic Dental Association endorses community
fluoridation. Available at: http.11hdassoc.org/about-us/advocacy.
Accessed October 26, 2017.
42. American Academy of Pediatrics. AAP core values. Available at: https://
www.aap.org/en-us/about-the-aap/aap-facts/Pages/Strategic-Plan.
aspx. Accessed October 26, 2017.
43. American Academy of Pediatrics Section on Oral Health. Maintaining and
improving the oral health of young children. Pediatrics 2014;134(6):1224-
9. Abstract at: https://www.ncbi.nim.nih.govlpubmedl25422016.
Accessed October 28, 2017.
44. American Medical Association. About us. 2017. Available at: https://www.
ama-assn.org/about. Accessed October 26, 2017.
45. McKay FS. The fluoridation of public water supplies. Ann Dent
1951;10(3):87-9.
46. American Medical Association. Water fluoridation H-440.972. In: American
Medical Association Policy Finder. Available at: https://www.ama-assn.
org/about-us/policyfinder. Accessed October 28, 2017.
47. American Public Health Association. About APHA. 2017. Available at:
https.11www.apha.org/about-apha. Accessed October 26, 2017.
48. American Public Health Association. Policy 5005. Fluoridation of public water
supplies. 1950 Jan 01. Available at: https://www.apha.org/policies-and-
advocacy/public-health-policy-statements. Accessed August 23, 2017.
49. American Public Health Association. Policy 20087. Community water
fluoridation in the United States. 2008 Oct 28. Available at: https://www.
apha.org/Po/icies-and-advocacylpub/ic-health-po/icy-statements.
Accessed August 23, 2017.
50. World Health Organization. About WHO. The guardian of global health.
Available at: http://www. who.int/about/what-we-do/global-guardian-
public-health/en. Accessed October 25, 2017.
57. Safe Water Association, Inc. v. City of Fond du Lac, 184 Wis.2d 365,
516, N.W. 2d 13. (Wis. Ct. App. 1994). Available at: http://fluidlaw.org/
caselaw/safe-water-association-inc-v-city-fond-du-lac. Accessed
October 28, 2017.
58. Block LE. Antifluoridationists persist: the constitutional basis for fluoridation.
J Public Health Dent 1986;46(4):188-98. Abstract at: https://www.ncbL
nlm.nih.gov/pubmed/3465958. Accessed October 26, 2017.
59. Christoffel T. Fluorides, facts and fanatics: public health advocacy shouldn't
stop at the courthouse door. Am J Public Health 1985;75(8):888-91.
Abstract at: https://www.ncbi.nlm.nih.govlpubmedl4025650. Article
at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC1646352. Accessed
October 26, 2017.
60. McMenamin JP. Fluoridation of water in Virginia: the tempest in the teapot.
J Law Ethics Dent 1988;1(1):42-6.
61. Roemer R. Water fluoridation: public health responsibility and the democratic
process. Am J Public Health Nations Health 1965;55(9):1337-48. Article
at: https://wwwncbi.nlm.nih.gov/pmc/articles/PMC1256473. Accessed
October 26, 2017.
62. Strong GA. Liberty, religion, and fluoridation. J Am Dent Assoc
1968;76(6):1398-409.
63. Easlick KA. An appraisal of objections to fluoridation. J Am Dent Assoc
1962;65(5):868-93.
64. McNeil DR. The fight for fluoridation. New York: Oxford University Press;
1957.
65. Newbrun E. The fluoridation war: a scientific dispute or a religious
argument? J Public Health Dent 1996;56(5 Spec No):246-52. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl9034969. Accessed October 26,
2017.
66. Scott DB. The dawn of a new era. J Public Health Dent 1996;56(5
Spec No):235-8. Abstract at: https://www.ncbi.nlm.nih.govl
pubmed19034966. Accessed October 26, 2017.
67. Lamberg M, Hausen H, Vartiainen T. Symptoms experienced during
periods of actual and supposed water fluoridation. Community Dent Oral
Epidemiol 1997;25(4):291-5. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/9332806. Accessed October 26, 2017.
68. Hazard vs outrage: public perception of fluoridation risks. J Public Health
Dent 1990;50(4):285-7.
69. Reekies D. Fear of fluoride. Br Dent J 2017;222(1):16-18. Abstract at:
https://www.ncbi.nim.nih.govlpubmedl28084346. Accessed October
26, 2017.
104 American Dental Association
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Public Policy References
70. Armfield JM. When public action undermines public health: a critical
examination of antifluoridationist literature. Aust New Zealand Health
Policy 2007;4:25. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/18067684. Article at: https://www.ncbi.nim.nih.govlpmcl
articles/PMC2222595. Accessed October 26, 2017.
71. Mertz A, Allukian M Jr. Community water fluoridation on the internet and
social media. J Mass Dent Soc. 2014;63(2):32-6. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/25230407 Accessed October 26, 2017.
72. Seymour B, Getman R, Saraf A, Zhang LH, Kalenderian E. When advocacy
obscures accuracy online: digital pandemics of public health misinformation
through an antifluoride case study. Am J Public Health 2015;105(3):517-
23. Abstract at: https://www.ncbi.nlm.nih.govlpubmedl25602893.
Article at: https://www.ncbi.nim.nih.govlpmc/articlesIPMC4330844.
Accessed October 26, 2017.
73. Doubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113, S.Ct.
2786 (1993).
74. Neenan ME. Obstacles to extending fluoridation in the United States.
Community Dent Health 1996;13 Suppl 2:10-20. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/8897746. Accessed October 26, 2017.
75. Lowry RJ. Antifluoridation propaganda material --the tricks of the trade.
Br Dent J 2000;189(10):528-30.
76. Mandel I. A symposium on the new fight for fluorides. J Public Health Dent
1985;45(3):133-79.
77. Lang P, Clark C. Analyzing selected criticisms of water fluoridation.
J Can Dent Assoc 1981;47(3):i-xii.
78. Fluoride Action Network. Communities which have rejected fluoridation
since 1990. Available at: http://fluoridealert.org/content/communities.
Accessed October 26, 2017.
79. American Dental Association. U.S. communities voting to adopt
fluoridation. 2017. Available at: http://www.ADA.org/en/public-
programs/ad vocating-for-the-public/fluoride-and-fluoridation/ada-
fluoridation-resources. Accessed October 28, 2017.
80. Centers for Disease Control and Prevention. Fluoridation. Fluoridation
growth. Available at: https://www.cdc.gov/fluoridation/statistics/
fsgrowth.htm. Accessed October 26, 2017.
81. Centers for Disease Control and Prevention. Fluoridation Statistics. 2000.
Available at: https://www.cdc.govlfluoridation/statisticsl2000stats.
htm. Accessed October 26, 2017.
82. American Dental Association. Water fuoridation status of the 50largest
cities in the United States. 2017. Available at: http://www.ADA.org/en/
public- programs/ad vocating-for-the-public/fluoride -and -fluoridation/
ada-fluoridation-resources. Accessed October 28, 2017.
83. U.S. Department of Health and Human Services. Archive Healthy People
2010. 21 Oral health. Available at: http://www.healthypeople.govl2010/
Document/HTML/Volume2/21OraLhtm. Accessed October 28, 2017.
84. Frazier PJ. Fluoridation: a review of social research. J Public Health Dent
1980;40(3):214-33.
85. Margolis FJ, Cohen SIN. Successful and unsuccessful experiences in
combating the antifluoridationists. Pediatrics 1985;76(1):113-8. Abstract
at: https://www.ncbi.nlm.nih.govlpubmedl40ll342. Accessed October
26, 2017.
86. Easley MW. The new antifluoridationists: who are they and how do they
operate? J Public Health Dent 1985;45(3):133-41. Abstract at: https://
www.ncbi.nlm.nih.gov/pubmed/3861861. Accessed October 26, 2017.
87. Wulf CA, Hughes KF, Smith KG, Easley MW. Abuse of the scientific
literature in an antifluoridation pamphlet. Columbus OH: American Oral
Health Institute Press; 1988. Available at: http://www.cyber-nook.com/
wa ter/AbuseO fTheScien tificL iterature I nAnAn ti fluorida tionPam phlet.
htm. Accessed October 28, 2017.
88. ADA/ASTDD/CDC. Fluoridation awards. Available at: http://www.
ADA.org/en/Public-programsladvocating- for- the -public/fluoride -
and-fluoridation/ada-fluoridation -resources/fl uoridation-awards.
Accessed October 26, 2017.
89. British Fluoridation Society. One in a million: the facts about fluoridation.
Third edition. 2012. Available at: https://www.bfsweb.org/one-in-a-
million. Accessed October 26, 2017.
90. O'Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg -Gunn
AJ, Whelton H, Whitford GM. Fluoride and oral health. Community Dent
Health 2016;33(2):69-99. Abstract at: https://www.ncbi.nim.nih.govl
pubmed/27352462. Accessed October 26, 2017.
91. Australian Government. National health and medical research council
public statement: efficacy and safety of fluoridation. 2007. Available at:
https://www.nhmrc.gov.au/guidelines-publications/eh41. Accessed
October 26, 2017.
92. Public Health England. Water fluoridation: health monitoring report
for England 2014. Available at: https://www.gov.uk/government/
publicationslwater- fluoridation -health -monitoring -report-for-
england-2014. Accessed October 26, 2017.
93. Sutton M, Kiersey R, Farragher L, Long J. Health effects of water
fluoridation: an evidence review. 2015. Ireland Health Research Board.
Available at: http://www.hrb.ie/publications/hrb-publication/
publications//674. Accessed October 26, 2017.
94. Royal Society of New Zealand and the Office of the Prime Minister's Chief
Science Advisor. Health effects of water fluoridation: a review of the
scientific evidence. 2014. Available at: http://royalsociety.org.nzlwhat-
we-dolour-expert-ad vice/all-expert-ad vice-papers/health-effects-
of-water-fluoridation. Accessed October 26, 2017.
95. Scientific Committee on Health and Environment Risks (SCHER) of the
European Commission. Critical review of any new evidence on the hazard
profile, health effects, and human exposure to fluoride and the fluoridating
agents of drinking water. 2011. Available at: http://ec.europa.eu/health/
scientific_committees/opinions_layman/fluoridation/en/1-3/index. htm.
Accessed October 26, 2017.
96. U.S. Department of Health and Human Services. Federal Panel on Community
Water Fluoridation. U.S. Public Health Service recommendation for fluoride
concentration in drinking water for the prevention of dental caries. Public
Health Rep 2015;130(4):318-331. Article at: https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC4547570. Accessed October 26, 2017.
97. European Commission. Drinking water directive. (Council Directive 98/83/
EC of 3 November 1998). Available at: http://ec.europa.eu/environment/
water/water-drink/legislation_en.html. Accessed October 26, 2017.
98. Marthaler TM. Water fluoridation results in Basel since 1962: health and
political implications. J Public Health Dent 1996;56(5 Spec No):265-70.
Abstract at: https://www.ncbi.nim.nih.govlpubmedl9034972.
Accessed October 26, 2017.
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Public Policy I Fluoridation Facts 105
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68. Is water fluoridation a cost-effective
and cost -saving method of preventing
tooth decay?
Answer.
Yes. When compared to the cost of other prevention
programs, water fluoridation is the most cost-
effective means of preventing tooth decay for both
children and adults in the United States. A number
of studies over the past 15 years have attempted
to place a specific dollar value on the benefit of
fluoridation. These studies, conducted in different
years (and therefore using different dollar values),
encompassing different communities/populations
and different methodologies have two conclusions
in common: 1) for systems that serve more than
1,000 people, the economic benefit of fluoridation
exceeds the cost and 2) the benefit -cost ratios
increased as the size of the populations increase
largely due to economies of scale.
Fact.
The cost of community water fluoridation varies for
each community depending on the following factors'
Size of the community (population and water
usage);
2. Number of fluoride injection points where fluoride
additives will be added to the water system;
3. Amount and type of equipment used to add and
monitor fluoride additives;
4. Amount and type of fluoride additive needed to
reach the target fluoride level of 0.7 mg/L; its
price, cost of transportation and storage; and
5. Expertise and preferences of personnel at the
water plant.
In 2016, a study' led by researchers from the
Colorado School of Public Health created a model of
fluoridation program costs, savings, net savings and
return on investment for the 2013 U.S. population
with access to optimally fluoridated water systems
that served 1,000 or more people. The researchers
found that savings associated with individuals avoiding
tooth decay in 2013 as a result of fluoridation were
estimated at $6.8 billion, or $32.19 per person, for
the more than 211 million people who had access
to fluoridated water through community water
systems serving more than 1,000 people that
year. Based on the estimated cost of the systems
to fluoridate ($324 million), the net savings from
fluoridation was estimated at $6.5 billion and the
estimated return on investment (ROI) averaged 20
to 1 across water systems of all sizes (from 1,000
to over 100,000 people with a ROI range of 15.5
to 26.2). However, it was noted that the cost per
person to fluoridate can vary significantly among
different sizes of communities based on a number
of the factors outlined in the previous paragraph.
Because of those variables, the researchers urged
communities to inform their policy decisions by
identifying their specific water system's annual cost
and comparing that cost to the annual estimated per
person savings ($32.19) in averted treatment costs.
The researchers noted that in 2013, while 211 million
people had access to fluoridated water, more than
78 million people had access to a public water system
that served 1,000 or more people that was not
fluoridated. The study findings suggest that if those
water systems had been fluoridated, an additional
$2.5 billion could have been saved as a result of
reductions in tooth decay.'
The economic benefits of fluoridation were also
reconfirmed in a systematic review' conducted in
2013 by the Community Preventive Services Task
Force which sought to update their prior review
conducted in 20024 which also found that fluoridation
saved money. The 2013 review concluded that recent
106 American Dental Association
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evidence continues to indicate the economic benefit of
fluoridation programs exceeds their cost. The review
also noted that benefit -cost ratio increases with the
population of the community.
Because of the decay reducing effects of fluoride,
the need for restorative dental care is typically lower
in fluoridated communities. Therefore, an individual
residing in a fluoridated community will typically pay for
fewer dental restorative services (such as fillings) during
a lifetime. A study' published in 2005, estimated the
cost and treatment savings resulting from community
water fluoridation programs in Colorado. The study also
estimated the added savings if communities without
water fluoridation initiated a fluoridation program. The
study estimated a community fluoridation program
generated treatment savings through prevented tooth
decay of $61 for every $1 spent to fluoridate the
community's water. On a state level, results indicated
an annual savings of nearly $150 million associated
with the water fluoridation programs and projected
a nearly $50 million annual savings if the remaining
52 nonfluoridated water systems in Colorado were
to implement water fluoridation programs.'
There are various types of dental restorations
(fillings) commonly used for the initial treatment of
tooth decay (cavities) including amalgam (silver) and
composite resins (tooth -colored). In the 2016 study
noted earlierz, the most commonly used treatment
was a two -surface composite resin restoration in
posterior (back) permanent teeth. Considering the
fact that in the United States the fee for a two -
surface composite resin restoration in a permanent
tooth placed by a general dentist typically ranges
from $165-$305*, fluoridation clearly demonstrates
significant cost savings. An individual can enjoy a
lifetime of fluoridated water for less than the cost
of one dental filling.
An individual can enjoy a lifetime of fluoridated
water for less than the cost of one dental filling
*The Survey data should not be interpreted as
constituting a fee schedule in any way, and should not
be used for that purpose. Dentists must establish their
own fees based on their individual practice and market
considerations. The American Dental Association
discourages dentists from engaging in any unlawful
concerted activity regarding fees or otherwise.
When it comes to the cost of treating dental disease,
everyone pays. Not just those who need treatment,
but the entire community — through higher health
insurance premiums and higher taxes. Cutting dental
care costs by reducing tooth decay is something a
community can do to improve oral health and save
money for everyone. With the escalating cost of
health care, fluoridation remains a community public
health measure that saves money and so benefits
all members of the community.
When it comes to the cost of treating dental
disease, everyone pays. Not just those who need
treatment, but the entire community — through
higher health insurance premiums and higher
taxes. Cutting dental care costs by reducing
tooth decay is something a community can do to
improve oral health and save money for everyone.
The economic importance of fluoridation is
underscored by the fact that the cost of treating
dental disease frequently is paid not only by the
affected individual, but also by the general public
through services provided by health departments,
community health clinics, health insurance premiums,
the military and other publicly supported medical
programs.' For example, results from a New York
State study published in 20101 that compared the
number of Medicaid claims in 2006 for cavity -related
procedures in fluoridated and nonfluoridated counties
showed a 33.4% higher level of claims for fillings, root
canals and extractions in nonfluoridated counties as
compared to such claims in fluoridated counties.8
Fluoridation contributes much more to overall health
than simply reducing tooth decay. It prevents needless
infection, pain, suffering and loss of teeth and saves
vast sums of money in dental treatment cost —
particularly in cases where dental care is received
through surgical intervention in a hospital or through
hospital emergency services.
In a study9 conducted in Louisiana, Medicaid -eligible
children (ages 1-5) residing in communities without
fluoridated water were three times more likely than
Medicaid -eligible children residing in communities
with fluoridated water to receive dental treatment in
a hospital and the cost of dental treatment per eligible
child was approximately twice as high. In addition
Public Policy Fluoridation Facts 107
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to community water fluoridation status, the study
took into account per capita income, population and
number of dentists per county.9
By preventing tooth decay, fluoridation also plays a
role in reducing visits to hospital emergency rooms
(ERs) for toothaches and other related dental problems
where treatment costs are high. Most hospitals do not
have the facilities or staff to provide comprehensive
or even emergency dental care. Many patients receive
only antibiotics or pain mediation but the underlying
dental problem is not addressed. In too many cases,
the patient returns to the ER in a few days with the
same problem or worse.
School -based dental disease prevention activities
such as fluoride mouthrinse or tablet programs,
professionally applied topical fluorides, dental health
education and placement of dental sealants are
beneficial but have not been found to be as cost-
effective in preventing tooth decay as community
water fluoridation 10 In 1985, the National Preventive
Dentistry Demonstration Program10 analyzed
various types and combinations of school -based
preventive dental services to determine the cost and
effectiveness of these types of prevention programs
Ten sites from across the nation were selected. Five
of the sites had fluoridated water and five did not.
Over 20,000 second and fifth graders participated
in the study over a period of four years. Students
were examined and assigned by site to one or a
combination of the following groups:
• biweekly in class brushing and flossing plus a
home supply of fluoride toothpaste and dental
health lessons (ten per year);
• in -class daily fluoride tablets (in nonfluoridated
areas);
• in -school weekly fluoride mouth rinsing;
• in -school professionally applied topical fluoride;
• in -school professionally applied dental sealants, and
• a control10
After four years, approximately 50% of the original
students were examined again. The study affirmed
the value and effectiveness of community water
fluoridation. At the sites where the community
water was fluoridated, students had fewer cavities,
as compared to those sites without fluoridated
water where the same preventive measures were
implemented. In addition, while sealants were
determined to be an effective prevention method,
the cost of a sealant program was substantially
more than the cost of fluoridating the community
water demonstrating fluoridation as the most cost-
effective preventive option 10
In an effort to balance budgets, decision makers
sometimes make economic choices that amount to
being "penny wise and pound foolish" In other words,
they cut an expense today that appears to be a sure
money saver. But they fail to take a long-term view
(or see the big picture) on the consequences of that
action. They fail to see how money spent now can
provide greater savings in the future. A decision to
eliminate funding for a successful community water
fluoridation program would be an example of that
kind of action. Often decision makers are swayed by
the promise of an alternative fluoride delivery system
without considering who it will cover (and who it will
not cover), how it will be administered and what it will
cost. Examples of these alternative fluoride delivery
programs include school -based fluoride mouthrinse
programs, fluoride supplements, fluoride varnish and
other professionally applied topical fluorides. Often
dental health education programs including dispensing
"free" toothbrushes and fluoridated toothpaste are
mentioned as an alternative to fluoridation. All of
these programs can be beneficial but are not as
cost-effective as fluoridation programs because they
typically require additional personnel to facilitate the
programs, action on the part of the recipient and
have much higher administrative and supply costs.
Additionally, these programs typically target only
children and so do not provide decay preventing
benefits to adults. Fluoridation benefits all members
of the community — children and adults — and is
more cost-effective.
The CDC's "Health Impact in 5 Years" (HI-5)
initiative11 launched in 2016 highlights community -
wide approaches that have evidence reporting 1)
positive health impacts, 2) results in five years and 3)
cost-effectiveness or cost savings over the lifetime
of the population or earlier. Fluoridation is one of the
community approaches included in the HI-5 Initiative
as it has great potential to help keep people healthy
as it reaches all members of a community where they
live, learn, work, and play. Documenting the impact
108 American Dental Association
back to agenda
of fluoridation can be challenging partially because
the beneficial effect is not immediately apparent12
Cost savings from fluoridation would be expected to
increase over several years' time. The most notable
decrease in tooth decay would be anticipated in young
children who received the benefits of fluoridation over
their lifetime in both their primary teeth and as their
adult teeth begin to appear when the children are
approximately six years old. More immediate savings
could be realized in recently fluoridated communities as
children who had once received fluoride supplements
would no longer require these prescriptions which are
typically recommended for children from six months to
16 years of age, whose primary drinking water source
is not fluoridated and have been determined to be at
high risk for tooth decay.
Benefits from the prevention of tooth decay can
include:
• freedom from dental pain
• a more positive self-image
• fewer missing teeth
• fewer cases of poorly aligned tooth aggravated
by tooth loss
• fewer teeth requiring root canal treatment
reduced need for crown, bridges, dentures and
implants
• less time lost from school or work because of
dental pain or visits to the dentist
While some of these types of benefits are difficult
to measure economically, they are extremely
important.","
Fluoridation remains the most cost-effective and
practical form of preventing tooth decay in the United
States and other countries with established municipal
water systems. It is one of the very few public health
measures that actually saves more money than it
costs.,,,, 5-17
69. Why fluoridate an entire water system
when the vast majority of the water is not
used for drinking?
Answer.
It is more practical and less costly to fluoridate an
entire water supply than to attempt to treat only
the water that will be consumed.
Fact.
Water systems treat all the water supplied to
communities to the same high standards, for
disinfection, clarity or fluoridation, whether the
water is to be used for washing dishes, washing a car,
watering lawns, preparing food or drinking. Although
not all that water needs to be disinfected, clarified or
fluoridated, it is more practical and cost efficient to
treat all the water delivered to the customer to the
same standard.
Fluoride is only one of more than 40 different
chemicals/additives that can be used to treat water
in the United States. Many are added for aesthetic
or convenience purposes such as to improve the
odor or taste, prevent natural cloudiness or prevent
staining of clothes or porcelain?8 The cost of
additives for fluoridating a community's water
supply is very low on a per capita basis; therefore,
it is practical to fluoridate the entire water supply.
It would be prohibitively expensive and impractical
for a community to have two water systems — one
that provided drinking water and another for all other
water use (watering lawns, laundry, flushing toilets).
Many organizations that are concerned about water use,
conservation and quality support the practice of water
fluoridation. For example, the American Water Works
Association, an international nonprofit scientific and
educational association dedicated to the improvement
of drinking water quality and supply, supports the
practice of fluoridation of public water supplies 19
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Public Policy I Fluoridation Facts 109
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Cost References
1. Centers for Disease Control and Prevention. Recommendations for using
16. Garcia Al. Caries incidence and costs of prevention programs. J Public
fluoride to prevent and control dental caries in the United States. MMWR
Health Dent 1989;49(5 Spec No):259-71. Abstract at: https://www.ncbi.
2001;50(No.RR-14):22. Available at: https://www.cdc.govlmmwrl
nlm.nih.gov/pubmed12810223. Article at: https://deepblue.lib.umich.
preview1mmwrhtm11rr5014a1.htm. Accessed October 25, 2017.
edu/handle12027.42166226. Accessed October 26, 2017.
2. O'Connell J, Rockell J, Ouellet J, Tomar SL, Maas W. Cost and savings
17. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water
associated with community water fluoridation in the United States. Health
fluoridation. J Public Health Dent 2001;61(2):78-86. Abstract at: https://
Aff (Millwood) 2016;35(12):2224-32. Abstract at: https://www.ncbi.nim.
www.ncbi.nlm.nih.gov/pubmed/11474918. Accessed October 26, 2017.
nih.gov/pubmed/27920310. Accessed October 25, 2017.
18. American Water Works Association. Water fluoridation principles and
3. Ran T, Chattopadhyay SK. Community Preventive Services Task Force.
practices. AW WA Manual M4. Sixth edition. Denver. 2016.
Economic evaluation of community water fluoridation: a Community
19. American Water Works Association. Policy Statement. Fluoridation of
Guide systematic review. Am J Prev Med 2016;50(6):790-6. Abstract at:
public water supplies. 2016. Available at: https://www.awwa.org/about-
https://www.ncbi.nim.nih.govlpubmedl26776927 Accessed October
us/policy-statements/policy-statementlarticleidl202/fluoridation-of-
25, 2017.
public- water -supplies. aspx. Accessed October 26, 2017.
4. Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans, Jr CA,
Griffin SO, Carande-Kulis VG. Task Force on Community Preventive
Services. Reviews of evidence on interventions to prevent dental caries,
oral and pharyngeal cancers, and sports -related craniofacial injuries. Am
J Prev Med 2002;23(lS):21-54. Abstract at: https://www.ncbi.nim.nih.
gov/pubmed112091093. Accessed October 24, 2017.
5. O'Connell JIM, Brunson D, Anselmo T, Sullivan PW. Cost and savings
associated with community water fluoridation programs in Colorado.
Prev Chronic Dis 2005;2(Spec no A06). Abstract at: https://www.ncbi.
nlm.nih.gov1pubmed/16263039. Article at: http://www.cdc.gov/pcd/
issues120051nov105_0082.htm. Accessed October 24, 2017.
6. American Dental Association. 2016 Survey of dental fees. Center for
Professional Success. 2016. Available at: http://Success.ADA.org/en/
practice-management/finances/survey-of-dental-fees. Accessed
October 24, 2017.
7. White BA, Antczak-Bouckoms AA, Weinstein MC. Issues in the
economic evaluation of community water fluoridation. J Dent Educ
1989;53(11):1989. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/2509526. Accessed October 26, 2017.
8. Kumar JV, Adekugbe O, Melnik T. Geographic variation in Medicaid
claims for dental procedures in New York State: role of fluoridation under
contemporary conditions. Public Health Reports 2010;125(5):647-54.
Abstract at: https://www.ncbi.nlm.nih.gov/pubmedl2O873280. Article
at: https://www.ncbi.nlm.nih.gov/pmc/articlesIPMC2925000. Accessed
October 26, 2017.
9. Centers for Disease Control and Prevention. Water fluoridation and costs
of Medicaid treatment for dental decay - Louisiana, 1995-1996. MMWR
1999;48(34):753-7. Available at: https://www.cdc.gov/mmwr/preview/
mmwrhtml/mm4834a2.htm. Accessed October 26, 2017.
10. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost
and effectiveness of school -based preventive dental care. Am J Public
Health 1985;75(4):382-91. Abstract at: https://www.ncbi.nlm.nih.gov/
pubmed/3976964. Article at: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1646230. Accessed October 25, 2017.
11. Centers for Disease Control and Prevention. Office of the Associate
Director for Policy. Health impact in 5 years. Available at: https://www.
cdc.gov/policy/hst/hi5/index.htmL Accessed October 26, 2017.
12. Kumar JV. Is water fluoridation still necessary? Adv Dent Res
2008;20(1):8-12.
13. U.S. Department of Health and Human Services, Public Health Service.
Toward improving the oral health of Americans: an overview of oral status,
resources on health care delivery. Report of the United States Public Health
Service Oral Health Coordinating Committee. Washington, DC; March
1993. Article at: https://www.jstor.org/Stab/el4597481. Accessed
October 28, 2017.
14. Schlesinger E. Health studies in areas of the USA with controlled water
fluoridation. In: Fluorides and Human Health. World Health Organization
Monograph Series No. 59. Geneva;1970:305-10.
15. U.S. Department of Health and Human Services. For a healthy nation:
returns on investment in public health. Washington, DC: U.S. Government
Printing Office; August 1994. Available at: https://archive.org/details/
forhealthynation00unse. Accessed October 28, 2017.
110 American Dental Association
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Fluoridation Facts
Fluoridation Facts contains answers to frequently asked questions regarding
community water fluoridation. As ADA's premier resource on fluoridation,
the booklet contains information regarding the latest scientific research in
an easy to use question and answer format to assist policy makers and
the general public in making informed decisions about fluoridation. Over
400 references are used to answer questions related to fluoridation's
effectiveness, safety, practice and cost-effectiveness.
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