On Nov. 6 Wichita voters will decide whether to fluoridate tap water. Proponents say fluoridation has been widely used since the 1960s, will reduce cavities in young and old alike and save Wichitans $25?million a year in dental bills.

Opponents say it’s a form of forced medication and can cause health problems. Here are answers to some questions about fluoride submitted by readers.

Q. How does Wichita’s dental health compare to cities that fluoridate their water?

A. According to the 2012 Smiles Across Kansas report by the Kansas Bureau of Oral Health, 58 percent of children in south-central Kansas have had cavities, making it the worst region in the state for cavities. “As South Central Kansas has many of the same advantages of the North East region (a large dental professional community, multiple safety net dental clinics, local foundations and academic institutions with interests in oral health),” the report says, “the lack of community water fluoridation is a probable causal factor for the significantly higher level of disease in Wichita’s children.” The report says that fluoridating the water can reduce dental decay as much as 25 percent.

Q. How much is this going to increase my water bill?

A. The answer depends on several decisions that the Wichita City Council will have to make after any vote to approve fluoride, such as who picks up the $2.3 million in capital startup costs and how the costs are apportioned to residential and commercial users. None of those decisions have been finalized.

However, based on very preliminary estimates from the city’s public works department, residential customers could see increases of 15 to 91 cents a month, depending on the amount of water they use and whether the startup costs are paid from a grant or by the city. Business and industrial customers could see bigger increases, ranging from $2.16 a month for small business users to almost $270 a month for large industrial users.?

Q. Is there a more cost effective way of delivering fluoride to children, since most of the water is not used for drinking?

A. The short answer is no. In the United States, fluoridation of the public water supply is generally considered to be the most cost-effective way to supply fluoride to an entire population, even though much does go to waste on watering and washing. In communities with non-fluoridated water, such as Wichita, parents who want the benefit of fluoride for their children’s teeth must obtain a prescription and purchase fluoride supplement drops or tablets. In some countries, especially in Europe, fluoride is added to table salt instead of to the water. But that’s not an option here since the United States has committed to large-scale water fluoridation instead.

Q. Where will Wichita get the fluoride that it may add to our drinking water?

A. The Wichita Water Department has said that if the ballot measure passes, it will seek bids for fluoride.

Most municipal water systems use fluorosilicic acid, also known as FSA, a liquid byproduct of phosphate production. According to the Centers for Disease Control, FSA is favored because of its “favorable cost and high purity.”

Some systems use sodium fluorosilicate or sodium fluoride, dry additives that come largely from FSA.

Fluoride additives are subject to standards, testing, and certification by the American Water Works Association and the National Sanitation Foundation/American National Standards Institute.?

Q. Are there any negative effects to consuming fluoridated water?

A. Dental fluorosis is the most common effect. It is mainly characterized by white spots or a pitting of the enamel on teeth. A Centers for Disease Control study from 1999 to 2004 showed that 33 percent of children ages 6 to 11 had it, 41 percent of ages 12 to 15 had it, and 36 percent of ages 16 to 19 had it.

Supporters of fluoridated water say that mild cases are barely noticeable and that the side effect is small compared with tooth decay.

Most other health effects caused by fluoride occur from industrial exposure or in areas where high levels of fluoride occur naturally in the soil and water.

“Small amounts of fluoride are added to toothpaste or drinking water to help prevent dental decay,” according to the Agency for Toxic Substances & Disease Registry of the U.S. Department of Health and Human Services. “However, exposure to higher levels of fluoride may harm your health. Skeletal fluorosis can be caused by eating, drinking, or breathing very large amounts of fluorides. This disease only occurs after long-term exposures and can cause denser bones, joint pain, and a limited range of joint movement…Skeletal fluorosis is extremely rare in the United States; it has occurred in some people consuming greater than 30 times the amount of fluoride typically found in fluoridated water. It is more common in places where people do not get proper nutrition. At fluoride levels 5 times greater than levels typically found in fluoridated water, fluoride can result in denser bones. However, these bones are often more brittle or fragile than normal bone and there is an increased risk of older men and women breaking a bone. Some studies have also found a higher risk of bone fractures in older men and women at fluoride levels typically found in fluoridated water. However, other studies have not found an effect at this fluoride dose.”

Robert Hinshaw, a physician at the Riordan Clinic in Wichita and an opponent of fluoridation, says that skeletal fluorosis is probably an unrecognized cause of arthritis. He says that fluorosis in the teeth is an indicator of fluorosis in the skeleton.

Q. How can they control the dose since water will be consumed by both 2 year olds and 250-pound men?

A. The Centers for Disease Control recommends .7 parts per million of fluoride in municipal water. That amount is believed to be the sweet spot for getting the benefits of stronger teeth while minimizing the risk of fluorosis. Quoting CDC: “If you and your child are among the 196 million Americans who receive their water from an optimally fluoridated community water system (0.7 to 1.2 milligrams per liter) and you follow guidelines in your child’s toothbrushing, then it is highly unlikely that your child is receiving too much fluoride.” The CDC recommends parents monitor their children’s brushing habits up to age 8 to ensure that they use an appropriate amount of fluoride toothpaste — a pea-sized drop — and that they avoid swallowing toothpaste.

Wichita’s water already has some fluoride naturally — .32 parts per million.

Q. What are sources of fluoride in a typical diet?

Black tea, wine, raisins and mechanically deboned chicken are among the foods and drinks with higher levels of fluoride. The levels in produce, for example, vary depending on whether fruits and vegetables have been treated with pesticides and water that contain fluoride, said Albert Burgstahler, professor emeritus of chemistry at the University of Kansas and an opponent of fluoride.

Bill Maas, the former director of the Division of Dental Health for the CDC, said that for 1- to 5-year-old children, food contributes about 30 percent of the fluoride they ingest, with water being the main and toothpaste being the other sources. A food from which a child might get fluoride is processed chicken, Maas says.

According to a story by Georgia Health Sciences University News and Information in 2010, “the average person ingests a very safe amount, 2 to 3 milligrams, daily through fluoridated drinking water, toothpaste and food. It would take ingesting about 20 milligrams a day over 10 or more years before posing a significant risk to bone health.”

Q. How do I know if I am getting too much fluoride?

A. Dental fluorosis is the main sign, Hinshaw says.

Q. Is fluoride safe for babies?

A. The CDC says that if a baby consumes only infant formula reconstituted with fluoridated water, there may be an increased chance of mild dental fluorosis.

“When used appropriately, fluoride is both safe and effective in preventing and controlling cavities,” the Agency for Toxic Substances & Disease Registry says. “Drinking or eating excessive fluoride during the time teeth are being formed (before 8 years of age) can cause visible changes in teeth. This condition is called dental fluorosis. At very high concentrations of fluoride, the teeth can become more fragile and sometimes can break. ?

Q. How can I remove fluoride from my drinking water if I don’t want it?

A. That’s difficult. Standard charcoal-type filters and Brita or similar purifying pitchers do not remove fluoride. Boiling the water on the stove doesn’t either. In fact, that concentrates the fluoride instead of reducing it.

About the only two methods that work, according to the Centers for Disease Control, are reverse-osmosis filtration or distillation. Such systems are quite a bit more expensive and require more maintenance than standard charcoal filters. It could be more convenient for homeowners wanting non-fluoridated water to contract with a water-purification service or bottled-water delivery company.

Q. Does most bottled water contain fluoride?

A. Some contain fluoride; some do not, according to the Centers for Disease Control and Prevention’s division of oral health. Further, the Food and Drug Administration does not require bottled water manufacturers to list the fluoride content on the label, so the only way to be sure is to contact the manufacturer.

Q. Do the military bases around the USA fluoridate their water when it reaches their bases?

A:.Most bases already have fluoridated water and have for decades. This year, the Department of Defense issued orders that all its water systems serving 3,300 or more people provide optimally fluoridated water, to help prevent tooth decay and maintain military readiness.

Q. In what year and for what reason were iodine added to salt and vitamin A and D added to milk? What nutrient was put in bread to assist in stopping a public health issue?

This could be a term paper, but here’s the short version:

• Iodine: According to the American Thyroid Association, this mineral is necessary for proper function of the thyroid gland in the neck. Iodine deficiency can lead to a swelling of the thyroid called goiter and extreme deficiency can cause severe birth defects. People generally get iodine from the soil through food crops, but several areas of the United States, including the Great Lakes region, Appalachia and the Pacific Northwest, have little iodine in the soil. After scientists recognized the connection between iodine deficiency and goiter early in the 1900s, suppliers in the 1920s began adding iodine to salt to ensure that people got an adequate amount. This has virtually eliminated goiter as a public health concern.

• Vitamins A and D in milk: According to the National Institutes of Health, dairies have voluntarily added Vitamin D to milk since the 1930s. This has virtually eliminated the potentially crippling bone disease rickets, a major public health problem before the fortification of milk began. Vitamin A is generally added to skim or reduced-fat milk to restore the amount of the vitamin lost in processing, according to the California Milk Advisory Board. Vitamin A is primarily associated with maintaining good eyesight and skin health.

• Folic acid in bread: In 1996, the Food and Drug Administration introduced regulations requiring enrichment of bread, cereals, grain and pasta products with folic acid, or folate. According to the NIH, folate deficiency is linked to severe neural tube birth defects such as spina bifida, anencephaly and encephalocele. In children and adults, folates aid in cell formation and prevention of anemia.