Excerpt from: The Fluoride Debate: The Pros and Cons of Fluoridation
by Aoun A, Darwiche F, Al Hayek S, and Doumi J.
Preventive Nutrition and Food Science, Sept 30, 2018.
Case Study: Salt Fluoridation in Lebanon
In 1994, a national Oral Health Survey was conducted in Lebanon and showed a high prevalence of dental caries in all age groups (62), which consequently encouraged the Ministry of Health (MOH) to work on the introduction of a massive oral health preventive program, particularly through systemic fluoride supplementation (63). Salt fluoridation was chosen as an alternative to water fluoridation deemed a non-feasible approach in Lebanon. On the third of September 2011, the Lebanese parliament approved the salt fluoridation law number 178 mandating that all table and kitchen salts in Lebanon be fluoridated by potassium fluoride at a concentration of 250 mg/kg salt. The law was supposed to come into effect on December 2014, but it stirred up controversy among the Lebanese population (64). On the one hand, supporters of the law argued that salt fluoridation can help reduce tooth decay especially since its rate in Lebanese children was among the highest in the world. On the other hand, their opponents claimed that fluoride is toxic and that various adverse effects may be caused by its addition to salt, thus questioning whether the assumed dental benefits outweigh the risks.
In order to reflect on the levels of fluoride exposure and intake in Lebanon, a number of local Lebanese studies, supported by the MOH, have been conducted among Lebanese school children. The results showed that the Lebanese population was not exposed to sufficient fluoride (62). However, the studies had several limitations, including a narrow age range, and 15 of the tested water sources (2 of which fall within an industrial zone) had fluoride concentrations within or above the minimum recommended level of 0.5 mg/L fluoride in water (20,65). Moreover, a significant amount of fluoride surpassing the estimated safe and adequate intake is being consumed by the Lebanese population through non-milk products (especially tea), as shown by Jurdi et al. (66). No data were found regarding local and imported foods which contain high levels of fluoride (67). Furthermore, it was found that a subgroup of the Lebanese population suffers from mild iodine deficiency (68,69) which can be aggravated in the presence of fluoride (64).
Therefore, for all these reasons, the Lebanese law number 178 of salt fluoridation was not clearly applied.
National Research Council. Fluoride in drinking water: a scientific review of EPA’s standards. The National Academies Press; Washington, DC, USA: 2006. pp. 85–106.
Doumit M, Doughan B. Oral health in school children in Lebanon. Sante. 2002;12:223–228.
Ministry of Health. [accessed Jun 2017]; http://www.moph.gov.lb/ar/Pages/13/2024/press-conference-for-he-minister-abou-faour-on-6-7-2015-
Fadlallah R, El-Jardali F, Ghaddar F, Hamad L. K2 Prapid response: informing the salt fluoridation law in Lebanon. Knowledge to Policy (K2P) Center; Beirut, Lebanon: 2015. pp. 5–6.
WHO Expert Committee on Oral Health Status and Fluoride Use & World Health Organization. Fluorides and oral health: report of a WHO Expert Committee on Oral Health Status and Fluoride Use. World Health Organization; Geneva, Switzerland: 1994. (WHO technical report series; 846). [PubMed]
Jurdi M, Abi Said D, Al Kouatly Kambris M. Decision to fluoridate. 1. Fluoride levels in herbal teas used in Lebanese communities. Food Nutr Bull. 2001;22:62–66. doi: 10.1177/156482650102200110.
AbuZeid K, El Hatow L. Impact of fluoride content in drinking water. Presented at Arab Water Healthy Conference; Cairo, Egypt. 2007. [accessed Jun 2017].
Haddad L, Achadi E, Bendech MA, Ahuja A, Bhatia K, Bhutta Z, Blössner M, Borghi E, Colecraft E, de Onis M, Eriksen K, Fanzo J, Flores-Ayala R, Fracassi P, Kimani-Murage E, Nago Koukoubou E, Krasevec J, Newby H, Nugent R, Oenema S, Martin-Prével Y, Randel J, Requejo J, Shyam T, Udomkesmalee E, Reddy KS. The Global Nutrition Report 2014: actions and accountability to accelerate the world’s progress on nutrition. J Nutr. 2015;145:663–671. doi: 10.3945/jn.114.206078.
Brough L, Thomson BM, Skeaff SA. Revisiting the Iodine Global Network’s definition of iodine status by country. Br J Nutr. 2016;115:374–376. doi: 10.1017/S0007114515004389.