TORONTO, Sept. 19-Tooth decay is making a comeback, fueled by junk food, spurred by social changes, and abetted by an unusual culprit – bottled water.

“I had a three-year-old kid come in the other day,” says Toronto dentist Sheldon Rose, D.D.S., “and he had at least two cavities that I could see. I haven’t seen that for years.”

Like most dentists, Dr. Rose blames the usual suspects – snack foods, soft drinks, lack of parental supervision of food. But bottled water also plays a role, he and others suspect.

“It’s not the water that’s causing the decay,” said Jack Cottrell, D.D.S., president of the Canadian Dental Association (CDA). “It’s the lack of fluoride.”

The bottled water issue was raised at the World Dental Congress in Montreal, Dr. Cottrell said, as part of a general discussion about what to do about the sudden rise in tooth decay in children.

The American Dental Association says that more and more “health-conscious consumers are sipping bottled water.”

Indeed, says the International Bottled Water Association, in 2004 Americans drank nearly 6.8 billion gallons, for a per capita consumption level of 23.8 gallons. That’s an 8.6% increase over the previous year, the association says.

The problem is that people are turning away from tap water – which for over two-thirds of Americans contains all of the fluoride that they need to prevent tooth decay – and most bottled waters don’t have enough fluoride.

“If bottled water is your main source of drinking water, you could be missing the decay-preventive benefits of fluoride,” the ADA says.

(The bottled water association notes that more than 20 U.S. companies do produce fluoridated products; the association has more than 80 bottlers among its members.)

Part of the rise in bottled water is lack of trust in municipal water. In Canada, for instance, a mismanaged town water system in Walkerton, Ontario, was blamed for killing seven people and making 2,000 others ill in 2000.

One result of such occurrences is that people think tap water is “not safe,” Dr. Cottrell said, and begin drinking and cooking with bottled water, with detrimental outcomes for their kids’ teeth.

Ground zero for fluoridation was the city of Grand Rapids, Mich., which 60 years ago began adding small amounts of fluoride to city water – enough to bring the level to the U.S. Public Health Service recommended level of between 0.7 and 1.2 parts per million.

Since then, fluoridation has become recognized as a key intervention. The CDC in December 1999 put fluoridation among the top 10 public health achievements of the 20th Century, along with such things as vaccination and control of infectious diseases.

The Task Force on Community Preventive Services, an independent group appointed by the CDC director, found that – in studies that measured decay rates before and after water fluoridation – the median decrease in tooth decay among children ages four to 17 years was 29.1%.

“We know the effectiveness of fluoride,” says the CDA’s Dr. Cottrell.

But the chemical is only part of the equation, he adds. “We’re seeing changes in the diets of children,” says Dr. Cottrell, a combination of more readily available sugary snacks and – because more families are working couples – less parental supervision of the kids’ diets.

At the same time, he said, the protective element of fluoride is being removed as more parents switch their kids to bottled water and fruit juices. “We’re not getting the advantages of it,” he said.

“When I graduated in 1965,” said Dr. Rose, “it was a rarity to see a kid with no decay.”

Then Toronto’s municipal water supply was fluoridated and the rate of cavities plummeted. “It became very unusual to see a kid with any decay,” Dr. Rose says.

“But in the past 10 years,” he says, “it seems we’re going back to the way it used to be.”

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