Community water fluoridation has been around for more than 65 years, and although proponents cite many benefits, the practice has come under fire recently as critics are questioning the amount our children are consuming – and if it’s even necessary.
Touted as one of 10 great public health achievements of the 20th century by the Centers for Disease Control and Prevention, community water fluoridation has been shown to significantly decrease tooth decay. Systematic reviews conducted by the Community Preventive Services Task Force found that tooth decay in children ages 4 to 17 years old declined by 29 percent as a result of fluoride in the water.
“Children who are in communities with fluoridated water have fewer and less severe cavities,” said Dr. Bill Bailey, acting director of the division of oral health at the Centers for Disease Control and Prevention. “Good oral health not only affects your physical health, but also your psychological, emotional, and social health – and your economic health as a family.”
Community fluoridation also saves money on costly dental treatments, according to a report in the Journal of Public Health Dentistry.
“It’s still the single most effective public health measurement to prevent dental decay,” said Dr. Adriana Segura, chair of the American Academy of Pediatrics section on oral health.
In 2010, approximately 73 percent of the population had access to fluoridated water, according to the CDC. The decision to add fluoride to the water supply is decided at the community or state level. Thirteen states plus the District of Columbia currently have legislation that mandates it.
Despite the benefits, tooth decay remains a problem for children of all ages. In fact, 25 percent of children 6 to 11 years old and 59 percent of adolescents 12 to 19 years old have tooth decay, according to the CDC. But experts say the problem goes beyond fluoride.
“Tooth decay, like all other diseases, is multi-factorial” said Bailey, who added that brushing, diet, and access to care – in addition to fluoride – provides the best protection.
Another issue is the benefit of drinking fluoridated water versus applying it topically. A 2008 study published in the Journal of Public Health Dentistry found that the benefits of fluoride are topical, and intake has more of an effect on dental fluorosis—a visible change in the tooth’s enamel that usually shows up as white markings but could be more severe—than on preventing cavities.
“Fluoride in water in very small levels throughout the day helps to replenish the amount you have in your mouth,” said Bailey, who says that although the predominant benefit is topical, drinking fluoridated water helps to re-mineralize the teeth and is better than just brushing.
“Fluoride is not a nutrient and not essential to healthy teeth,” said Carol S. Kopf, Media Director for the Fluoride Action Network, who says tooth decay is a diet-based disease. “Rotten diet makes rotten teeth.”
Evidence against fluoridated water
In 2006, The National Research Council published an extensive review of the Environmental Protection Agency’s standards. In it, they state fluoride is an endocrine disruptor that can interfere with the functions of the brain and body, although it does not mimic normal hormones. The committee reviewed various studies that link fluoride to adverse health effects and recommended more research be done to ascertain the actual risk.
The EPA includes fluoride on their list of chemicals that have “substantial evidence of developmental neurotoxicity.” According to a 2011 review published in the journal Neurologia, ingesting fluoride over a long period of time may cause damage to the nervous system.
A 2012 review published in the journal Environmental Health Perspectives found that children had lower IQ scores when they lived in areas with high levels of fluoridation.
Fluoride exposure during pregnancy is also a concern. In 2009, researchers at the State University of New York reported that more premature births occurred in fluoridated communities than in non-fluoridated communities in upstate New York.
Osteosarcoma, a serious form of bone cancer usually affecting teens, is another subject of debate. In 2006, a Harvard study found a strong link between fluoride and osteosarcoma in boys, yet in 2012, a study published in the journal Cancer Epidemiology found no link between the two.
Despite the studies that suggest adverse health effects, the CDC says community water fluoridation is safe and cites its use of systemic reviews and expert panels for their evaluations. “Consistently these systematic reviews say there is no compelling evidence for any other health effects than dental fluorosis,” Bailey said.
“We here at the CDC take these studies very seriously,” said Dr. Barbara Gooch, associate director for science at the CDC’s Division of Oral Health, who says the CDC, along with the National Institutes of Health and the EPA, consistently review the latest data. “They [the EPA] have the duty here within the federal government to assure the safety of fluoride in water.”
In 2007, the Fluoride Action Network issued a statement to end community water fluoridation, and many communities have rejected it. Today, more than 4,000 medical and environmental professionals have signed with the goal of ending community fluoridation for good.
“The wheels of government work very slowly,” Kopf said. “They’re waiting for absolute, 100 percent proof that fluoridation is harmful and we’re saying we have enough proof already that it’s harmful.”
Where does fluoride come from?
Produced from phosphorite rock and used to manufacture phosphate fertilizer, three fluoride additives are used in the United States: sodium fluorosilicate, sodium fluoride, and the most common, fluorosilicic acid or hydrofluosilicic acid. “Hydrofluosilicic acid is a waste product of the phosphate fertilizer industry,” Kopf said. In addition, trace amounts of arsenic, copper, lead, cadmium, and mercury exist in the additives, but at levels that are considered safe by the EPA.
“It’s never purified so I don’t know how they think that lead disappears,” said Kopf, who noted that while it’s watered down, it doesn’t make sense that these chemicals are making their way into the water supply in the first place.
In response, the CDC cites a study published in the journal Environmental Science and Technology that found that the fluorosilicate ion doesn’t exist by the time it makes its way to the faucet.
“There is very careful oversight of these additives that go into water,” said Bailey, who says there’s a stringent system of standards, testing and certificates in place by the EPA, the American Water Works Association and National Sanitation Foundation/American National Standards Institute.
Fluoride occurs naturally in water and is also found in formula, fruit juice and baby food, as well as toothpaste, mouth rinses, floss and dental treatments. And with all of the fluoride children are being exposed to before their teeth develop, dental fluorosis is becoming a bigger problem. The CDC estimates approximately 33 percent of children ages 6 to 11 and approximately 40 percent of teens ages 12 to 15 have dental fluorosis.
In 2011, the U.S. Department of Health and Human Services and the EPA issued a new recommendation to reduce the amount of fluoride in drinking water to 0.7 milligrams per liter from the previous recommendation which was a range of 0.7 to 1.2.
“It’s recognized that children and adults can likely receive enough fluoride if the level of fluoride in the water is slightly reduced,” Gooch said.
What you should know
If you are concerned about fluoride in your drinking water, contact your local water supplier for a copy of the Consumer Confidence Report. Also, choose bottled water that is lower in fluoride content, which includes de-ionized, purified, demineralized, or distilled. You should also consider installing a reverse osmosis filter in your home. Segura suggests speaking with your child’s dentist to evaluate how much fluoride your child is exposed to and to make decisions about care.