Defenders of Community Water Fluoridation

The United States Centers for Disease Control and Prevention (CDC) has designated community water fluoridation as one of the 10 greatest public health accomplishments of the 20th century.¹ In an effort to improve the oral health of all Americans and decrease the prevalence of oral disease, the US Department of Health and Human Services’ (HHS) Healthy People initiative has targeted a 10% increase in the number of communities receiving fluoridation by 2020 as one of its goals.² Even with evidence of significant caries reduction among water fluoridated communities, the practice remains controversial in many areas.³ As the anti-fluoride movement continues to gain momentum,¹ oral health professionals must be prepared to effectively support and defend the benefits of community water fluoridation.⁴

SCIENTIFIC EVIDENCE

Numerous studies have been conducted on the safety and efficacy of community water fluoridation. A systematic review by Yeung⁵ evaluated studies that assessed community water fluoridation by both the decayed, missing, filled tooth caries index and the proportion of children who were caries-free compared to nonfluoridated areas during the same time. Yeung concluded that the evidence supports water fluoridation as helpful in decreasing caries rates.⁵

An analysis by Truman6 evaluated community water fluoridation as an intervention for dental caries prevention. The review evaluated 21 qualifying studies that included communities with fluoride concentration levels ranging from 0.6 parts per million (ppm) to 1.8 ppm; children between the ages of 4 and 17; and caries evaluation in both primary and permanent dentitions. The study evaluated caries development before and after fluoridation, and the effects of community water fluoridation on caries experience. Truman et al⁶ concluded that the evidence strongly supports community water fluoridation as an effective approach to reducing dental caries by up to 50%. The economic feasibility of community water fluoridation was also analyzed, with results demonstrating that it provided cost savings in all studies.⁶

McDonagh et al⁷ conducted a systematic review to determine the effects of community water fluoridation in comparison to communities without water fluoridation. One of the objectives was to evaluate the negative effects of fluoride, such as fluorosis and bone fractures. Researchers assessed 88 dental fluorosis studies and found that 87 of the studies were of low quality.⁷ The systematic review concluded mild fluorosis of water fluoridation of 1 ppm may occur, but that there was no clear association between bone fractures and consumption of fluoridated water.⁷

The National Cancer Institute has reviewed numerous studies on water fluoridation and a potential association with cancer.⁸ Not only has the organization found no relationship between fluoride intake and cancer risk, it endorses community water fluoridation for caries prevention.⁸

COMMUNITY PREPARATION

Oral health professionals need to know the fluoridation status and caries prevalence rates in the communities they serve. The local/state boards of health should be able to provide this information. Also, the CDC provides the fluoridation status of public water systems on the My Water’s Fluoride website (apps.nccd.cdc.gov/MWF/Index.asp). Dental practitioners must be prepared to advocate for community water fluoridation.

Using credible resources when researching community water fluoridation is imperative. Professional organizations—such as the American Dental Association, American Association of Public Health Dentistry, Association of State and Territorial Dental Directors, and the recently launched Campaign for Dental Health’s ilikemyteeth.org—can provide scientific evidence on water fluoridation.

The next step is to conduct an inquiry, and identify potential allies of water fluoridation within the community and state. Advocacy partners may be both public and private and include: state dental associations; highly respected local oral health professionals; state medical associations; local pediatricians and physicians; community and state health departments; children’s advocacy groups; school/teacher associations; state water quality programs, such as the town drinking water operator or water engineer; state and local legislators; and valued community leaders, such as clergy or town elders.⁹ Partnerships should be aligned to organize a plan within communities, and strategies developed to counter efforts of fluoride opposition.⁹

FLUORIDE OPPOSITION

Water fluoridation opponents believe that the inclusion of fluoride in commonly used products, such as toothpastes and mouthrinses, make community water fluoridation unnecessary.¹⁰ They dispute that these readily available products make the benefits and cost of water fluoridation redundant. Though there has been an improvement in the fight against dental caries among certain populations—largely due to community water fluoridation and the availability of consumer products containing fluoride—60% of children continue to experience dental caries.⁹

Some of the major social determinants of oral health are socioeconomic status, race, and ethnicity.¹¹ Populations at low-income levels and racial/ethnic minorities are at the greatest risk of dental caries.¹² There are financial, cultural, and educational barriers preventing at-risk populations from properly obtaining and utilizing “common” fluoride products. In these circumstances, community water fluoridation remains an inexpensive means to prevent caries. It is estimated that every $1 invested in community water fluoridation saves $38 in the costs of dental treatment.¹³ Health equality for all Americans justifies the need to continue community water fluoridation.

Another argument is that fluoride is neurotoxic, with many anti-fluoride activities citing a paper by Choi et al¹⁴ as proof that fluoridating public water systems is dangerous. The study is a meta-analysis on fluoride neurotoxicity culled from research conducted in China. The study’s attempt to compare fluoride intake in the US with a reduction in the intelligence of American children to the drinking water in China and decreased intelligent quotient (IQ) scores among Chinese children has many shortcomings. For example, the fluoridation levels examined in China’s water supply were excessive—11.5 mg/L. Additionally, the status of China’s water system cannot be compared to the US’s strict water quality standards, which are regulated by the US Environmental Protection Agency (EPA) and certified by two nonprofit/nongovernmental organizations: the American Water Works Association and the National Sanitation Foundation/American National Standards Institute.¹⁵ The official lead concentration reports from the Chinese villages tested were also not included in the study.¹⁴ Further weaknesses were that fewer than 20% of the studies reported parental education levels, and only 7% of the studies reported income levels.¹⁴ Socioeconomic status and parental education levels are potential determinants for IQ scoring among the children assessed in these studies.

Opponents to water fluoridation have also cited the federal government’s recent inability to come to a decision on fluoridation levels in the public water supply. Anti-fluoridationists argue that a change to previous fluoridation guidelines suggests the government’s uncertainty about fluoride use. Their suspicion with the government’s water fluoridation evaluation is, in reality, only a review of a 60-year-old community water fluoridation policy. Fluoride opponents are mistaking the government’s decision to evaluate and adjust fluoride levels and provide the best standards for oral health as a departure from community water fluoridation altogether. Most American communities have optimal fluoridated water concentrations, ranging from 0.7 mg/L to 1.2 mg/L.16. In 2011, the HHS and EPA proposed a review of fluoride-level recommendations in community drinking water.¹⁶ The suggestion is to adjust fluoride to the lowest level of the current optimal range (0.7 mg/L) and to review an acceptable upper limit.¹⁶ Currently, the EPA states 4.0 mg/L as the maximum amount of fluoride allowed in public water systems where fluoride is naturally present at higher levels.¹⁵

CONCLUSION

Oral health professionals must lead the charge on community water fluoridation to make a difference in improving oral health and disease prevention. Community water fluoridation is the most effective and economically feasible method to combat dental caries. With updated knowledge of fluoridation, oral health professionals should be confident in their ability to effectively advocate and defend water fluoridation in their communities.

REFERENCES

1. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999:48:241–243.
2. United States Department of Health and Human Services. Healthy People 2020. Available at: healthypeople.gov/2020/default.aspx. Accessed January 12, 2014.
3. George C. Battle renewed over value of fluoridation. CMAJ. 2011;183:E531–E532.
4. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50:1–42.
5. Yeung CA. A systematic review of the efficacy and safety of fluoridation. Evid Based Den. 2008;9:39–43.
6. Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med. 2002;23(1 Suppl):21–54.
7. McDonagh M, Whiting PF, Wilson PM, et al. Systematic review of water fluoridation. BMJ. 2000;321:855–859.
8. National Cancer Institute, National Institutes of Health. Fluoridated Water FactSheet. Available at: cancer.gov/cancertopics/factsheet/Risk/fluoridated-water. Accessed January 12, 2014.
9. Association of State and Territorial Dental Directors. Best Practice Approach Reports. Use of Fluoride: Community Water Fluoridation. Available at: astdd.org/use-of-fluoride-community-water-fluoridation-introduction. Accessed January 12, 2014.
10. Fluoride Action Network. 50 reasons to oppose fluoridation. Available at: fluoridealert.org /articles/50-reasons. Accessed January 12, 2014.
11. United States Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Available at: nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ExecutiveSummary.htm. Accessed January 12, 2014.
12. United States Senate Committee on Health, Education, Labor & Pensions. Dental Crisis in America, A Report from Chairman Bernard Sanders, Subcommittee on Primary Health and Agin. Dental Crisis in America, the Need to Expand Access. Available at: sanders.senate.gov /imo/media/doc/DENTALCRISIS.REPORT.pdf. Accessed January 12, 2014.
13. Centers for Disease Control and Prevention. Community Water Fluoridation: Fluoridation Basics. Available at: cdc.gov/fluoridation /basics/index.htm. Accessed January 12, 2014.
14. Choi AL, Sun G, Zhang Y, Grandjean P. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect. 2012;120:1362–1368.
15. Committee on Fluoride in Drinking Water, National Research Council. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. Washington, DC: The National Academies Press; 2006.
16. US Department of Health and Human Services. News Release: HHS and EPA announce new scientific assessments and actions on fluoride. Available at: hhs.gov/news/press/2011pres/01/20110107a.html. Accessed January 12, 2014.

From Dimensions of Dental Hygiene. February 2014;12(2):41–43.