Community Water Fluoridation
Community water fluoridation is the
practice of adding a small amount of
fluoride to the water supply. It has been
heralded as 1 of the top 10 public health
achievements of the 20th century by the
CDC.34 Community water fluoridation is
a safe, efficient, and cost-effective way
to prevent tooth decay and has been
shown to reduce tooth decay by 29%.35
It prevents tooth decay through the
provision of low levels of fluoride exposure
to the teeth over time and
provides both topical and systemic
exposure. It is estimated that every
dollar invested in water fluoridation
saves $38 in dental treatment costs
(http://www.cdc.gov/fluoridation/benefits/).
Currently, although more than
210 million Americans live in communities
with optimally fluoridated water,
there are more than 70 million others
with public water systems who do not
have access to fluoridated water.33 The
fluoridation status of a community
water supply can be determined by
contacting the local water department
or accessing the Web site My Water’s
Fluoride (http://apps.nccd.cdc.gov/MWF/
Index.asp).
Recommended Concentration
Water fluoridation was initiated in the
United States in the 1940s. In January
2011, the US Department of Health and
Human Services proposed a change to
lower the optimal fluoride level in
drinking water. The proposed new recommendation
is 0.7 mg of fluoride per
liter of water to replace the previous
recommendation, which was based on
climate and ranged from 0.7 mg/L in the
warmest climates to 1.2 mg/L in the
coldest climates.36 The change was
recommended because recent studies
showed no variation in water consumption
by young children based on
climate and to adjust for an overall increase
in sources of fluoride (foods and
beverages processed with fluoridated
water and fluoridated mouth rinses
and toothpastes) in the American diet.
Evidence Supporting Community
Water Fluoridation
Despite overwhelming evidence supporting
the safety and preventive benefits
of fluoridated water, community
water fluoridation continues to be a
controversial and highly emotional issue.
Opponents express a number of concerns,
all of which have been addressed
or disproven by validated research. The
only scientifically documented adverse
effect of excess (nontoxic) exposure to
fluoride is fluorosis. An increase in the
incidence of mild enamel fluorosis
among teenagers has been cited as
a reason to discontinue fluoridation,
even though this condition is cosmetic
with no detrimental health outcomes.
Recent opposition has sometimes centered
on the question of who decides
whether to fluoridate (elected/public
officials or the voters), possibly reflecting
a recent trend of distrust of the US
government. Many opponents believe
fluoridation to be mass medication and
call the ethics of community water
fluoridation into question, but courts
have consistently held that it is legal and
appropriate for a community to adopt
a fluoridation program.37 Opponents
also express concern about the quality
and source of fluoride, claiming that
the additives (fluorosilicic acid, sodium
fluoride, or sodium fluorosilicate), in
their concentrated form, are highly toxic
and are byproducts of the production of
phosphate fertilizer and may include
other contaminants, such as arsenic. The
quality and safety of fluoride additives
are ensured by Standard 60 of the National
Sanitation Foundation/American
National Standards Institute, a program
commissioned by the Environmental
Protection Agency (EPA), and testing has
been conducted to confirm that arsenic
or other substances are below the levels
allowed by the EPA.38 Finally, there have
been many unsubstantiated or disproven
claims that fluoride leads to kidney disease,
bone cancer, and compromised IQ.
More than 3000 studies or research
papers have been published on the
subject of fluoride or fluoridation.39 Few
topics have been as thoroughly researched,
and the overwhelming weight
of the evidence—in addition to 68 years
of experience—supports the safety
and effectiveness of this public health
practice.