Water fluoridation

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Water fluoridation is the practice of adding fluoride chemicals to water with the intended purpose of reducing tooth decay in the general population. Fluoride compounds are found naturally in the ground water in some regions but not in others. Fluoridation chemicals are typically added to potable water in the form of sodium hexafluorosilicate or hexafluorosilicic acid (also known as hydrofluorosilic acid). [1][2]

Contents

[edit] History

While the use of fluorides for prevention of dental caries (cavities) was discussed in the 19th century in Europe,[3] community water fluoridation in the United States owes its origin in part to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into what was then known as "Colorado brown stain."[4] The condition, now known as dental fluorosis, when in its severe form is characterized by cracking and pitting of the teeth. [5][6][7] In 1909, of the 2,945 children seen by Dr. McKay, 87.5% had some degree of stain or mottling. All the affected children were from the Pikes Peak region. Despite having a negative impact on the physical appearance of their teeth, the children with stained, mottled and pitted teeth also had fewer cavities than other children. McKay brought the problem to the attention of Dr. G.V. Black, and Black's interest into the Colorado stain led to greater interest throughout the dental profession.

Photograph of Dr. G.V. Black (left) and Drs. Isaac Burton and F. Y. Wilson, 1909, studying the "Colorado Brown Stain" (picture taken by McKay, printed in Douglas W.A.:"History of dentistry in Colorado, 1859-1959").
Photograph of Dr. G.V. Black (left) and Drs. Isaac Burton and F. Y. Wilson, 1909, studying the "Colorado Brown Stain" (picture taken by McKay, printed in Douglas W.A.:"History of dentistry in Colorado, 1859-1959").

Initial hypotheses for the staining included poor nutrition, overconsumption of pork or milk, radium exposure, childhood diseases, or a calcium deficiency in the local drinking water.[4] In 1931, researchers from the Aluminum Company of America (ALCOA) finally concluded that the cause of the Colorado stain was a high concentration of fluoride ions in the region's drinking water (ranging from 2 to 13.7 ppm) and areas with lower concentrations had no staining (1 ppm or less).[8] Pikes Peak's rock formations contained the mineral cryolite, one of whose constituents is fluorine. As the rain and snow fell, the resulting runoff water dissolved fluoride which made its way into the water supply.

Dental and aluminum researchers then moved toward determining a relatively safe level of fluoride chemicals to be added to water supplies. The research had two goals: (1) to warn communities with a high concentration of fluoride of the danger, initiating a reduction of the fluoride levels in order to reduce incidences of fluorosis, and (2) to encourage communities with a low concentration of fluoride in drinking water to add fluoride chemicals in order to help prevent tooth decay.

A study of varying amounts of fluoride in water was led by Dr. H. Trendley Dean, a dental officer of the U.S. Public Health Service.[9][10] In 1936 and 1937, Dr. Dean and other dentists compared statistics from Amarillo, which had 2.8 - 3.9 ppm fluoride content, and low fluoride Wichita Falls. The data is alleged to show less cavities in Amarillo children, but the studies were never published.[11] Dr. Dean's research on the fluoride - dental caries relationship, published in 1942, included 7,000 children from 21 cities in Colorado, Illinois, Indiana, and Ohio. The study concluded that the optimal amount of fluoride which minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 mg. per day, per adult. Although fluoride is more abundant in the environment today, this was estimated to correlate with the concentration of 1 part per million (ppm).

In 1939, Dr. Gerald J. Cox [12] conducted laboratory tests using rats that were fed aluminum and fluoride. The anti-carries data from his studies were described as, "inconclusive" and, "anything but convincing," by fluoride historian Peter Meiers.[13] But Dr. Cox suggested adding fluoride to drinking water (or other media such as milk or bottled water) in order to improve oral health.[14] In 1937, dentists Henry Klein and Carroll E. Palmer had considered the possibility of fluoridation to prevent cavities after their evaluation of data gathered by a Public Health Service team at dental examinations of Native American children.[15] In a series of papers published afterwards (1937-1941), yet disregarded by his colleagues within the U.S.P.H.S., Klein summarized his findings on tooth development in children and related problems in epidemiological investigations on caries prevalence.

In the mid 1940s, four widely-cited studies were conducted. The researchers investigated cities that had both fluoridated and unfluoridated water. The first pair was Muskegon, Michigan and Grand Rapids, Michigan, making Grand Rapids the first community in the world to add fluoride chemicals to its drinking water to benefit dental health on January 25, 1945.[16] Kingston, New York was paired with Newburgh, New York.[17] Oak Park, Illinois was paired with Evanston, Illinois. Sarnia, Ontario was paired with Brantford, Ontario, Canada.[18]

In 1951, a member of the Newburgh - Kingston Fluoridation Committee, Katherine Bain, stated: "the technical committee set up to work with that study set itself a goal which it wasn´t able to achieve. It had hoped to keep the study under wraps for ten years, and at the end of ten years come out with a definitive answer about what fluoride did, what its harmful effects might be. As you know, that study and other studies began having such results that people became interested, and the pressure was such that people felt we must go ahead with these programs."[19]

In 1952 Nebraska Representative A.L. Miller complained that there had been no studies carried out to assess the potential adverse health risk to senior citizens, pregnant women or people with chronic diseases from exposure to the fluoridation chemicals.[20] A decrease in the incidence of tooth decay was found in some of the cities which had added fluoride chemicals to water supplies. However, tooth decay was declining in similar rates in non-fluoridated cities.[21] The early comparison studies would later be criticized as, "primitive," with a, "virtual absence of quantitative, statistical methods...nonrandom method of selecting data and...high sensitivity of the results to the way in which the study populations were grouped..." in the journal Nature.[22] The Bartlett-Cameron and the Newburgh-Kingston studies have been sharply criticized by the Fluoride History website for their, "ludicrous inadequacy," and for engaging in, "obvious manipulations."[23]

[edit] Effects

Fluoride, while toxic at moderate to high doses, may be beneficial for dental health at very low doses. Fluoridation is intended to reduce tooth decay, with its associated health problems, at a low cost.[24] However, in 2001, the United States Centers for Disease Control and Prevention stated, “Although solid data on the cost-effectiveness of fluoride modalities alone and in combination are needed, this information is scarce.” [25] Many communities need to reduce fluoride exposure. Consumption of water exceeding 10 ppm fluoride has been shown to lead to pathalogical changes in bone structure, and skeletal fluorosis.[26] [27] Debilitating environmental fluorosis of a substantial portion of the population is a problem in several developing countries, where it is complicated by malnutrition. The effects of skeletal fluorosis can be slowly reversed through a reduction of fluoride intake and improved diet.[28]

Data on fluoride's ability to cause cancer is mixed. Human and animal studies have shown an increase in osteosarcoma, a rare bone cancer, coinciding with exposure to fluoride, including fluoridated water. [29][30][31][32]

[edit] Opposition

Main article: Water fluoridation opposition

Water fluoridation by public authorities has provoked controversy. Opposition to water fluoridation arises from concern over the quality of the available research data,[33] evidence suggesting that it may cause serious health problems, and a general resistance to the idea of compulsory 'mass medication' which takes away an individual's right to choose. Some concerns raised include:

  • A 2006 National Academy of Sciences panel's conclusion that 4 ppm fluoride that 4 ppm fluoride in drinking water is not sufficiently protective against dental fluorosis. A majority of the researchers also agreed that 4 ppm fluoride in drinking water is also not protective against bone fractures.[34]
  • A high prevalence of dental fluorosis (especially with concern to children) from an overdose of fluoride due to additional sources of fluoride (such as processed foods[35] and dental products).[35][36]
  • A link between high levels of fluoride and bone weakening[35] and more recently with bone cancer in boys.[35][37][38]
  • A 2001 report by Dr. Roger Masters that linked elevated blood-lead levels with consumption of fluorosilicates (chemicals used in the fluoridation of drinking water).[39][40]
  • A lowering of IQ where drinking water fluoride levels were greater than 3 mg/L[41] which is within the limits of the standard set by the United States Environmental Protection Agency (EPA).[42]
  • The EPA published a study that reported that fluoridated water helped carry aluminum into rat's brains, producing Alzheimer's-like lesions.[43]
  • A disruption in endocrine function, especially in the thyroid.[44]

[edit] Fluoridated Milk

The Borrow Foundation, previously known as the Borrow Dental Milk Foundation[45], was founded in 1971 by Dr. Edgar Wilfried Borrow. The foundation holds a British Patent detailing a process for the fluoridation of milk, and Dr. Borrow holds British Patents as well as a European Patent and a US Patent which relate to mixing and dispensing apparatus for the fluoridation and the flavoring of milk.[46]

The foundation is involved the development of the international milk fluoridation program in close collaboration with the World Health Organization, as well as research to strengthen the scientific argument for the fluoridation of milk through clinical, laboratory and applied research.

[edit] Fluoridated Salt

Salt was first fluoridated in Switzerland in 1955 followed by France in 1986 and shortly after by Jamaica and Costa Rica. Costa Rica, Jamaica and Columbia today practice universal salt fluoridation, whereby all salt bound for human consumption is fluoridated, this includes salt that is added to ready prepared food, and where no fluoride free salt is available.[47]

[edit] Bottled water and fluoridation

Some dental professionals are concerned that the growing use of bottled water may decrease the amount of fluoride exposure people will receive.[48] Some bottlers such as Danone have begun adding fluoride to their water.[49] On April 17, 2007, Medical News Today stated, "There is no correlation between the increased consumption of bottled water and an increase in cavities."[50]

In October 2006, the United States Food and Drug Administration issued a health claim notification permitting water bottlers to claim that fluoridated bottled water can promote oral health. The claims are not allowed to be made on bottled water marketed to infants.[51] Fluoridated bottled water uses a cleaner fluoridation chemical than is commonly used in fluoridated tap water. This is because the FDA regulates bottled water, mandating that food grade fluoride is used, but FDA does not regulate tap water, which has less stringent safety and purity guidelines.[52]

[edit] Malfunctions in water fluoridation equipment

At least 17 incidences of fluoridation equipment malfunction, and their associated deaths and poisonings, have been documented in U.S. newspapers and medical journals. [53][54] [55] [56] [57][58] [59]

Perhaps the worst incident in the United States occurred in Hooper Bay, Alaska in 1992. When fluoridation equipment failed, a large amount of fluoride was released into the drinking water supply and 296 people were poisoned; 1 person died,[60] marking the first reported death due to fluoride toxicity caused by drinking water from a community water system.[61]

3 dialysis patients died and 6 were sickened at the University of Chicago Hospitals when the water filtration system failed on July 16, 1993. A hospital spokesperson said that the deaths and reactions “were consistent with fluoride exposure.”[62]

Schoolchildren in Portage, Michigan experienced vomiting and stomach pains when an electrical surge caused excessive amounts of fluoridation chemical to be injected into the school’s well in July 1991. [63]

In June, 2002, 23 employees of Humphry Systems Inc. in Dublin, California became ill after a fluoride pump malfunctioned near the business. All of the affected workers had drank from the water fountains, and experienced vomiting and nausea. [64]

34 restaurant diners became sick after a fluoridation equipment malfunction caused an acute outbreak of fluoride poisoning in August 1993, in Poplarville, Mississippi. Severe gastrointestinal illness was reported by 34 out of 62 customers in a 24 hour period. [65]

A dialysis patient died from fluoride overdose in Annapolis, Maryland when 1,000 gallons of excess fluoride chemical spilled into the drinking water on November 11, 1979. 7 others became critically ill. Brain damage, a heart attack and many other illnesses resulted.[66]

[edit] International status

 This section needs additional citations for verification.
Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (August 2007)

[edit] Africa

South Africa's Health Department recommends adding fluoridation chemicals to drinking water in some areas. It also advises removal of fluoride from drinking water (defluoridation) where the fluoride content is too high.[67]

[edit] Asia

[edit] China

In China, water fluoridation began in 1964 in Guangzhou, and ceased in 1983.[68] The Chinese government considers any water supply containing over 1 ppm fluoride a risk for skeletal fluorosis.[69]

A pilot fluoridated milk project was conducted in the Haidian district of Beijing between 1994 and 1999. This involved children aged 3 - 6 years. The Borrow Foundation are currently trying to obtain the support of the Chinese dental community in re-introducing a similar scheme in China.[70]

[edit] Japan

Less than 1% of Japan practices water fluoridation. [71][72]

[edit] India

Water fluoridation is not practiced in India.[73][74] Fluorosis is endemic in at least 20 states, including Uttaranchal, Jharkhand and Chhattisgarh.[75] The maximum permissible limit of fluoride in drinking water in India is 1.2mg/L.[76]

[edit] Thailand

Fluoridated milk was introduced in 2000 and currently involves 400,000 children. The scheme is coordinated by Department Of Health.[77]

[edit] Europe

[edit] Austria

Water has never been fluoridated in Austria.[citation needed]

[edit] Belgium

Drinking water has never been fluoridated in Belgium.[citation needed]

[edit] Bulgaria

In 1998 a Borrow Foundation fluoridated milk project began in the city of Plovdiv and in the nearby town of Asenovgrad. It has since grown to include the cities of Shoumen, Veliko Turnovo, Stara Zagora, and Bourgas. A national steering group has also been created to extend the program to other regions of the country. The program involves over 31,000 children between the ages of 3-7 years of age on approximately 180-200 days a year. A comprehensive World Health Organization evaluation study, involving six test sites and two control sites, is being conducted, coordinated by the World Health Organization Collaborating Centre in Sofia.[78]

[edit] Denmark

Drinking water has never been fluoridated in Denmark.[citation needed]

[edit] Finland

There was fluoridation of the drinking water of Kuopio eastern Finland and with a population of about 80,000 people (1.6% of the Finnish population) from 1959 to 1992.[citation needed]

[edit] France

Fluoridation is not practised in France.[citation needed]

[edit] Germany

In the former German Democratic Republic in several districts the drinking water was fluoridated but after the unification of Germany in 1990 fluoridation was stopped. In the Federal Republic of Germany there was in about 1952 a drinking water fluoridation experiment for one or two years.[citation needed]

[edit] Greece

Water fluoridation is not practiced in Greece.[79]

[edit] Hungary

In Hungary, one city, Szolnok, was fluoridated for a short time in the 1960s. Fluoridation is not presently practised in Hungary.[citation needed]

[edit] Irish Republic

In the Republic of Ireland the majority of drinking water is fluoridated. The fluoridation agent currently used in Ireland for addition to drinking water supplies is hydrofluorosilicic acid (HFSA; H2SiF6).[80] The original legal basis for fluoridation of water in the Irish Republic until 2007 was the Fluoridation of Water Supplies Regulations, 1965. Those regulations set the level of fluoride in drinking water to between 0.8 to 1.0 ppm. Since 1st July 2007, the legal basis for the fluoridation of drinking water in Ireland is the Fluoridation of Water Supplies Regulations, 2007.[81] These regulations set the level of fluoride in drinking water to between between 0.6 and 0.8 ppm, with a target value of 0.7 ppm.

[edit] Luxemburg

Drinking water has never been fluoridated in Luxemburg.[citation needed]

[edit] Netherlands

In the Netherlands the Supreme Court ruled there was no legal basis for fluoridation.[citation needed]

[edit] Norway

There is no fluoridation of drinking water in Norway.[citation needed]

[edit] Russian Federation

Milk fluoridation was introduced through the kindergarten system in the cities of Voronezh, Maikop and Smolensk. Fluoridated milk was given to children aged between 3-7 years. The Republic of Tatarstan has implemented a program including 14,500 kindergarten children in the city of Niznekamsk and the neighbouring community of Zelenodolsk.[82]

[edit] Spain

Around 10% of the population receives fluoridated water.[83][84]

[edit] Sweden

In 1952, Norrköping in Sweden became one of the first cities in Europe to fluoridate its water supply.[85] It was declared illegal by the Swedish Supreme Administrative Court in 1961, re-legalized in 1962[86] and finally prohibited by the parliament in 1971,[87] after considerable debate. The parliament majority said that there were other and better ways of reducing tooth decay than water fluoridation. Four cities received permission to fluoridate tap water when it was legal.[88] An official commission was formed, which published its final report in 1981. They recommended other ways of reducing tooth decay (improving food and oral hygiene habits) instead of fluoridating tap water. They also found that many people found fluoridation to impinge upon personal liberty/freedom of choice, and that the long-term effects of fluoridation were not sufficiently known. They also lacked a good study on the effects of fluoridation on formula-fed infants.[89]

[edit] Switzerland

In Switzerland since 1962 two fluoridation programmes had operated in tandem: water fluoridation in the City of Basel, and salt fluoridation in the rest of Switzerland (around 83% of domestic salt sold had fluoride added). However it became increasingly difficult to keep the two programmes separate. As a result some of the population of Basel were assumed to use both fluoridated salt and fluoridated water. In order to correct that situation, in April 2003 the State Parliament agreed to cease water fluoridation and officially expand salt fluoridation to Basel.[90]

[edit] United Kingdom

Around 10% of the population of the United Kingdom receives fluoridated water.[91][92] The All Party Parliamentary Group on Primary Care and Public Health recommended in April 2003 that fluoridation be introduced "as a legitimate and effective means of tackling dental health inequalities", laws were created allowing but not requiring fluoridation of water. The following UK utilities companies Fluoridate their water Anglian Water Services Ltd., Northumbrian Water Ltd., South Staffordshire Water plc, Severn Trent plc and United Utilities Water plc. Earlier schemes were undertaken in the Health Authority areas of Bedfordshire and Hertfordshire, Birmingham and the Black Country, Cheshire and Merseyside, County Durham and Tees Valley, Cumbria and Lancashire, North and East Yorkshire and Northern Lincolnshire. Northumberland, Tyne and Wear, Shropshire and Staffordshire, Trent, and West Midlands South whereby fluoridation was introduced progressively in the years between 1964 and 1988[93].The water supply in Northern Ireland has never been artificially fluoridated except in two small localities where fluoride was added to the water for about 30 years. By 1999, fluoridation ceased in those two areas, as well. [94] Scotland's parliament rejected proposals to fluoridate public drinking water following a public consultation. Instead relying on other methods to improve dental health of children[95].

[edit] North America

[edit] Canada

Approximately 40% of the Canadian population receives fluoridated water[96]

Implementation of fluoridation usually lies with provincial or city governments. Brantford, Ontario became the first city in Canada to fluoridate its water supplies in 1945. In 1955, Toronto approved water fluoridation, but delayed implementation of the program until 1963 due to a campaign against fluoridation by broadcaster Gordon Sinclair.[97] The city continues to fluoridate its water today.[98] There have been some recent decreases in the amount of fluoridation used, however, from 1 mg per litre to between 0.6 and 0.8 mg per litre. Historically, British Columbia has been the province with least percentage of its population receiving fluoridated water;[99] Greater Vancouver Water District member municipalities within the Metro Vancouver region receive water supplies that do not have added fluoride.[100]

On April 21, 2008, the town of Dryden, Ontario overwhelmingly rejected a water fluoridation proposal at the ballot box. [101]

[edit] United States

As of May 2000, 42 of the 50 largest U.S. cities have water fluoridation.[102] According to a 2002 study,[103] 67% of Americans are living in communities with fluoridated water. As of 2001, 19 states have at least 75% of their population receiving fluoridated water.[104]

The United States Centers for Disease Control proclaims, "Community water fluoridation is safe and effective in preventing tooth decay, and has been identified by CDC as one of 10 great public health achievements of the 20th century." [105]The CDC states that water fluoridation is safe at a level of (0.7 mg/L-1.2 mg/L). The CDC also advises avoiding water with fluoride concentrations of 2mg/L or higher for children up to age 8.[106] There is a CDC database for researching the water fluoridation status of neighborhood water.[107]

In 1998, 70% of people polled in a survey conducted by the American Dental Association (ADA) believed community water should be fluoridated, with 18% disagreeing and the rest undecided.[108] In November of 2006, the ADA began recommending to parents that infants from 0 through 12 months of age should have their formula prepared with water that is fluoride-free or contains low levels of fluoride to reduce the risk of fluorosis.[109]

The issue of whether or not to fluoridate water supplies frequently arises in local governments. For example, on November 8, 2005, citizens of Mt. Pleasant, Michigan voted 63% to 37% in favor of reinstating fluoridation in public drinking water after a 2004 ballot initiative ceased water fluoridation in the city.[110] At the same time, voters in Xenia, Ohio; Springfield, Ohio; Bellingham, Washington; and Tooele City, Utah all rejected water fluoridation.[111]

The cost of adding fluoridation chemicals to the water of 44 Florida communities has been researched by the State Health Office in Tallahassee.[112] In communities with a population of over 50,000 people, fluoridation costs were estimated at 31 cents per person per year. The estimated cost rises to $2.12 per person in areas with a population below 10,000. Unintended consequences, such as equipment malfunction, can substantially raise the financial burden, as well as the health risks, to the consumer.[113][114] [115] [116] [117] [118][119] [120]

[edit] Oceania

[edit] Australia

Australia has fluoridation in all but one state, Queensland, in which water fluoridation is under local government control. However, on 5 December 2007 Queensland Premier Anna Bligh announced fluoridation of most of Queensland's water supply will begin in 2008.[121] The city of Geelong, west of Melbourne, does not fluoridate its water supplies. This is despite the fact that all of Melbourne's water is fluoridated. The first town to fluoridate the water supply in Australia was Beaconsfield, Tasmania in 1953.[122] Fluoridation commenced January 7th, 2008 in the City of Gosford, New South Wales.[123]

[edit] New Zealand

New Zealand has fluoridated nearly all water-supplies except those in remote areas. The use of water fluoridation first began in New Zealand in Hastings in 1954. A Commission of Inquiry was held in 1957 and then its use rapidly expanded in the mid 1960s.[124]

[edit] South America

[edit] Brazil

In Brazil, about 45% of cities have a fluoridated water supply.[citation needed]

[edit] Chile

In Chile 70.5% of the population receive fluoridated water (10.1 million added by chemical means, 604,000 naturally occurring).[125] In addition to the this introduced a fluoridated milk program in 1994 to the rural community of Codegua. Powdered milk fluoridated with disodium monofluorophosphate are given to children aged 0-6 years old and also in 2000 a School Food Assistance Program gave children from 6-14 years of age a free breakfast including fluoridated milk. It has since grown to include approximately 22,000 children.[126]

[edit] Peru

Between 1999 and 2005 a fluoridated milk project was introduced in Trujillo but was later discontinued due to the raised levels of fluorides due to the introduction of fluoridated salt. The project was established under a national nutrition programme, the Programa del Vaso de Leche. It was aimed at poorer families and administered to children from weaning to 14 years of age through local community centers.[127]

[edit] See also

[edit] References

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  10. ^ Dean, H.T. "Chronic endemic dental fluorosis." Journal of the American Dental Association, 16, 1269 - 1273, 1936.
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