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Is water fluoridation a beneficial practice? An analysis of the risks and benefits of the artificial fluoridation of municipal water supplies.
Marianne Biggs University of Warwick

Marianne Biggs

Is water fluoridation a beneficial practice? An analysis of the risks and benefits of the artificial fluoridation of municipal water supplies.
What Is Artificial Water Fluoridation? Artificial water fluoridation is the practice of adding fluoride to water supplies in controlled amounts; it is used as a measure to prevent tooth decay. Fluoridation can prevent tooth decay in two ways; as a topical treatment whereby fluorides strengthen fully formed teeth by making the tooths surface more resistant to decay, and as a systemic treatment whereby fluoride is deposited in still-growing teeth. The systemic treatment is only relevant to children as their teeth are still growing, but of the two treatments it is seen to be the most effective as the whole tooth becomes better protected from decay, rather than simply the surface area. The practice of adding fluoride to water supplies has now been in action for over fifty years, many years after the dentist Dr Fredrick McKay first noted a pattern of mottled teeth in children from the town of Colorado Springs (Colorado Department of Public Health and Environment, 2012), and that these teeth were less prone to decay. The first practice of artificial fluoridation was recorded in Grand Rapids, Michigan in 1945 (National Institute of Dental and Craniofacial Research, 2012) as a project spanning fifteen years. The rate of tooth decay amongst a pool of 30,000 children was observed over time and compared with close by Muskegon, and results of the project after eleven years concluded that the addition of fluoride to the towns water supply had reduced the rate of dental cavities. The concluding evidence of the project explained that the cases of dental cavities amongst the children of Grand Rapids had fallen by nearly fifty 50% (Beck, 2012), further studies were undertaken across the United States and those results confirmed what Dr Fredrick McKay had first observed: there was a direct correlation between the presence of fluoride in the water supplies of the towns and the reduction of cavities. As a result of these studies, in 1969 the World Health Organisation endorsed the measured addition of fluoride up to 1ppm into public drinking water and described the process as practical and effective (Muthu and Sivakumar, 2009). In the UK, water fluoridation is still not a widely distributed process, only 10% of the country has a fluoridated water supply (British Dental Association, 2011)

Marianne Biggs from a local health authority. In southern Birmingham, where artificial fluoridation occurs, only 25% of five year olds have evidence of tooth decay whereas 42% of five year olds in Southampton, where the water is not fluoridated, have experienced the problem (Bennet, 2012). These statistics should be placing pressure on the political system to pass legislation on the need for fluoridation across the country to all municipal water supplies, however controversy surrounds this initiative as organisations such as the National Pure Water Association oppose fluoridation claiming numerous health risks associated with consuming fluoridated water on a regular basis, has prevented such action. Risks Associated with Artificial Water Fluoridation: The most well evidenced negative effect as a result of fluoride being present in drinking water is dental fluorosis, which is the discolouring of the tooths enamel to create a mottled effect which in its severest form is a dark brown stain in the tooth. Children are susceptible to dental fluorosis while their teeth are still forming, and are reportedly as a result of consuming too much fluoride. This fluoride can be obtained either in toothpaste, fluoridated drinking water, mouth washes or food processed with fluoridated water. In May 2011 the Scientific Committee on Health and Scientific Risks found there to be a narrow margin between achieving the beneficial effects of fluoride in cavity prevention and the adverse effects of dental fluorosis (McDonagh et al. 2000; cited by SCHER 2010). This is in response to studies which have shown children ingesting a small amount of fluoride have little to no signs of dental fluorosis, compared with children ingesting a larger amount. The ranges between which fluorosis is a risk or not is minute and many researching bodies have yet to conclude a point at which the risks outweigh the benefits. There have been other claims made against fluoridation such as it being one cause of osteosarcoma, a cancer of the bones; however this claim has been rebuffed repeatedly. The International Agency for Research on Cancer found there to be no substantial link between fluoride in drinking water and an increased risk of osteosarcoma (International Agency for Research of Cancer 1998; cited by Australian Dental Association). Furthermore, fluoride has been found naturally occurring in some water sources, and has been consumed by people for centuries without any obvious negative health effects besides superficial tooth mottling. The image below shows the

Marianne Biggs distribution of natural fluoride, and artificial fluoride, in England and Wales. As shown, areas such as Essex and Hartlepool have a high natural fluoride concentration of >1.1-1.5mgl-1 around the same concentration that is accomplished by artificial fluoridation 0.9-1.1mgl -1. The effects of this naturally fluoridated water have been documented in history.

Figure 1: Mapping of natural and artificial concentrations of fluoride in water across England and Wales, http://labspace.open.ac.uk/mod/resource/view.php? id=446160 During World War 2 evacuee children from the area of South Shields were moved to the Lake District, where natural levels of fluoride in drinking water are comparatively lower than in South Shields, and it was noted by a local Dentist that these evacuees teeth had fewer cavities and points of wear than the children born in the area. This observation was made before the first artificial schemes were implemented and suggested the negative effects of fluoridation to be minor, or insignificant, as the people of South Shields had been drinking this water for generations with no obvious adverse effects. The most worrying risk associated with artificial water fluoridation is fluoride poisoning particularly amongst young children as their daily recommended intake of fluoride (1.2mg) can easily be reached or surpassed; fluoride intake will

Marianne Biggs come from fluoride toothpaste, fluoridated water, and food grown in areas containing fluorides. Effects of fluoride poisoning include irritation of the stomach lining as fluoride forms hydrofluoric acid and stomach cramps. More severe reactions to fluoride such as organ failure would unlikely occur as a much larger concentration of fluoride would need to be ingested. As a preventative measure, most fluoridated toothpastes for children have a very small recommended usage to help prevent children from being exposed to large amounts of fluoride.

Benefits of Artificial Water Fluoridation: Around 416,000,000 million people are expected to be regularly using fluoridated water around the world either as a naturally occurring substance, or as an artificial addition (British Fluoridation Society, 2012). Artificial water fluoridation works so well as a preventative measure against the development of cavities because it is a blanket treatment the whole population of an area attached to a fluoridated water supply will benefit from the effects of the water treatment with minimal changes to their lifestyle. Consequentially, the dental health of the area will rise without needing to construct expensive dental services, and will benefit people of all social classes. This is significant as dental cavities are generally more prevalent in youths from deprived backgrounds whom do not have access to private dental services. As previously evidenced artificial fluoridation has had a significant impact on the reduction of cavities amongst children, such as the original documented case in Grand Rapids, the significant different in cavities amongst the populations of Birmingham and Southampton, and the children of South Shields. The U.S. Center for Disease Control has described artificial water fluoridation as one of the "ten greatest public health achievements of the 20th century" (Center for Disease Control, 1999) This strong reference of the scheme has been supported by numerous scientific studies which show amongst adults the prevalence of dental cavities has fallen between 15-35% and amongst children aged 8 to 12 the prevalence has fallen between 20-40% (Newbrun, 1989). Alternative Methods of Artificial Fluoridation:

Marianne Biggs In Europe, a popular alternative to water fluoridation is salt fluoridation. This is where fluoride is added in controlled amounts to standard table salt. An attraction of salt fluoridation is that consumers are able to regulate their own fluoride intake and decide whether it would be beneficial to them, unlike water fluoridation which becomes a blanket treatment for an entire population and cannot easily be stopped or started. However it has been argued that the potential dental benefits of fluoridated salt are inconsistent with the negative health effects of a high salt intake (Scottish Consultants in Dental Public Health, 2008). Another viable alternative is milk fluoridation, whereby both powdered and liquid milk can be fluoridated by adding controlled amounts of fluorides. This method of treatment is particularly targeted at young children for whom milk is an extremely important dietary need and is particularly effective in areas where the general population have good dental health and would only used as a preemptive treatment for youths Conclusion: Artificial water fluoridation should be considered in areas of poor dental health as a preventative measure against cavities in young children, but should not be relied upon for maintaining the teeth of adults as toothpastes and mouthwashes should be an equally effective topical treatment. Areas with a significant natural concentration of fluoride should also not be considered for artificial water fluoridation to reduce the risk of the local population regularly exceeding their recommended daily intake of fluorides. From the evidence collected, fluoridation can been seen to provide an important service for dental care and should not be opposed for its risk of fluorosis as this is most commonly a minor superficial stain and does not affect the tooth in any other detrimental way. In areas where cases of dental cavities is rising slowly it would possibly be better to consider alternative methods of artificial fluoridation such as salt and milk fluoridation where the population is given the ability to control their exposure to fluorides. It would be especially beneficial where the adult population has good dental health, and only children could be singled out for treatment. As concluded by the World Health Organisation it can be assessed that artificial water fluoridation is a beneficial preventative dental care measure for the reduction of cavities for people living in areas of low concentrations of natural fluoridation. Fluoridation of water supplies significantly improves dental health

Marianne Biggs fluoridation of water supplies, where possible, is the most effective public health measure for the prevention of dental decay (World Health Organisation, 2001).

References
Books: Beck, JA (2012) The Fluoride Myth pg.79 Muthu, MS and Sivakumar, N (2009) Pediatric Dentistry: Principles and Practice Reed Elsevier India Pvt. Ltd, India pg.178 Internet: Colorado Department of Public Health and Environment [online] (cited 26 th September 2012, 16:35) Available from <URL: http://www.chd.dphe.state.co.us/Resources/cms/pp/oralhealth/fluoridation/backr groundfluoride.html> National Institute of Dental and Craniofacial Research [online] (cited 24 th September 2012, 12:40) Available from <URL:http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.ht m> International Agency for Research on Cancer, International Incidence of Childhood Cancer 1998; cited by Australian Dental Association [online] (cited 26 th September 2012, 17:00) Available from <URL: http://www.ada.org.au/app_cmslib/media/lib/0703/m50781_v1_osteosarcomaand fluoride.pdf>

Marianne Biggs British Fluoridation Society, One In A Million: The Facts About Fluoridated Water, 2012 (3rd edn) [online] United States of America Center for Disease Control [online] (cited 13 th October 2012, 18:00) Available from <URL:http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm> World Health Organisation, Water Sanitation and Health, 2001 [online] (cited 13th October 2012, 18:50) Available from <URL:http://www.who.int/water_sanitation_health/oralhealth/en/index2.html> Journals: Newbrun, E, (1989) Effectiveness of Water Fluoridation, Journal of Public Health Dentistry, Vol.49 Issue 5, p.279-289 Government Publications: Bennet, O (2012) Fluoridation House of Commons Library, London Miscellaneous Publications: Scientific Committee on Health and Environmental Risks (SCHER), Critical Review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridation agents of drinking water , 2010 British Dental Association February, 2001 Scottish Consultants in Dental Public Health, 2008 Fluoridated Salt Interim Position Statement [online] Available From: <URL:www.scottishdental.org/index.aspx?o=2744> Images: Natural and Artificial Fluoride Concentrations in Water Supplies in England and Wales, Map, [online] (Cited 15th October 2012, 14:00) Available from <URLhttp://labspace.open.ac.uk/mod/resource/view.php?id=446160>