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Human or Artificial Fluoridation of water, salt, and milk varies from country to country. Water fluoridation has been introduced to varying degrees in many countries, including Australia, Brazil, Canada, Chile, Ireland, Malaysia, the U.S., and Vietnam,[1] and is used by 5.7% of people worldwide.[2] Continental Europe largely does not fluoridate water, although some of its countries fluoridate salt; locations have discontinued water fluoridation in Germany, the Netherlands, and other countries.[2] Although health and dental organizations support water fluoridation in the countries that practice water fluoridation,[3] there has been considerable opposition to water fluoridation whenever it is proposed.
Egypt does not fluoridate water, although a pilot study commenced in Alexandria.[4]
Only a small fraction of Nigerians receive water from waterworks, so water fluoridation would benefit only a few people. About 20% of water sources are naturally fluoridated to recommended levels, about 60% have fluoride below recommended levels, and the remainder are above recommended levels.[5]
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.[6][7]
Legislation around mandatory fluoridation was introduced in 2002, but has been on hold since then pending further research after opposition from water companies, municipalities and the public.[8]
In China, water fluoridation began in 1965 in the urban area of Guangzhou. It was interrupted during 1976–1978 due to the shortage of sodium silico-fluoride. It was resumed only in the Fangcun district of the city, due to objections, and was halted in 1983. The fluoridation reduced the number of cavities, but increased dental fluorosis; the fluoride levels could have been set too high, and low-quality equipment led to inconsistent, and often excessive, fluoride concentrations.[9]
In Hong Kong, water is totally fluoridated,[10] at an average level of 0.49 mg/L[11]
Less than 1% of Japan practices water fluoridation.[12]
Water fluoridation is not practiced in India.[13][14] Fluorosis is endemic in at least 20 states, including Uttaranchal, Jharkhand and Chhattisgarh.[15] The maximum permissible limit of fluoride in drinking water in India is 1.2 mg/L,[16] and the government has been obligated to install reverse osmosis water treatment plants to reduce fluoride levels from industrial waste and mineral deposits.[17]
In 1956, Singapore was the first asian country to institute a water fluoridation program that covered 100% of the population.[18][19] Water is fluoridated to a typical value of 0.4-0.6 mg per litre.[20]
Many european countries have chosen fluoride-free water . This includes: Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, Netherlands, Northern Ireland, Norway, Scotland, Sweden, and Switzerland
Austria has never implemented fluoridation.[12]
Belgium does not fluoridate its water supply, although legislation permits it.[12]
Czech Republic (Czechoslovakia respectively) started water fluoridation in 1958 in Tábor. After six years, 80% reduction of decay was asserted . This led to widespread introduction of fluoridation. In Prague, fluoridation started in 1975. It was stopped in 1988 there and subsequently in the whole country too. Currently (2008) no water is fluoridated.[21] Fluoridated salt is available.[22]
Croatia does not fluoridate its water.[23]
Denmark does not fluoridate its water, although the National Health Board is in favour.[12]
The Finnish government supports fluoridation, although only one community of 70 000 people was fluoridated, Kuopio.[12] Kuopio stopped fluoridation in 1992.[24]
France fluoridates salt; but none of its water.[12]
Drinking water is not fluoridated in any part of Germany. The GDR used to fluoridate drinking water, but it was discontinued after the German reunification.[1]
In the Republic of Ireland the majority of drinking water is fluoridated; 71% of the population in 2002 resided in fluoridated communities.[25] The fluoridation agent used is hydrofluosilicic acid (HFSA; H2SiF6).[26] In a 2002 public survey, 45% of respondents expressed some concern about fluoridation.[27]
In 1957, the Department of Health established a Fluorine Consultative Council which recommended fluoridation at 1.0 ppm of public water supplies, then accessed by c.50% of the population.[28] This was felt to be a much cheaper way of improving the quality of children's teeth than employing more dentists.[29] The ethical approval for this was given by the "Guild of Saints Luke, Cosmas and Damian", established by Catholic Archbishop of Dublin, John Charles McQuaid.[28] This led to the Health (Fluoridation of Water Supplies) Act 1960, which mandated compulsory fluoridation by local authorities.[29][30] The statutory instruments made in 1962–65 under the 1960 Act were separate for each local authority, setting the level of fluoride in drinking water to 0.8–1.0 ppm.[31][32] The current regulations date from 2007, and set the level to 0.6–0.8 ppm, with a target value of 0.7 ppm.[33]
Implementation of fluoridation was held up by preliminary dental surveying and water testing,[34] and a court case, Ryan v. Attorney General.[35] In 1965, the Supreme Court rejected Gladys Ryan's claim that the Act violated the Constitution of Ireland's guarantee of the right to bodily integrity.[35][36] By 1965, Greater Dublin's water was fluoridated; by 1973, other urban centres were.[37] Dental surveys of children from the 1950s to the 1990s showed marked reductions in cavities parallel to the spread of fluoridation.[38]
Water was fluoridated in large parts of the Netherlands from 1960 to 1973, when the High Council of The Netherlands declared fluoridation of drinking water unauthorized.[39] Dutch authorities had no legal basis adding chemicals to drinking water if they will not improve the safety as such.[4] Drinking water has not been fluoridated in any part of the Netherlands since 1973.
Around 10% of the population receives fluoridated water.[40]
In 1952, Norrköping in Sweden became one of the first cities in Europe to fluoridate its water supply.[41] It was declared illegal by the Swedish Supreme Administrative Court in 1961, re-legalized in 1962[42] and finally prohibited by the parliament in 1971,[43] 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.[41]:56-57 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 by forcing them to be medicated, and that the long-term effects of fluoridation were insufficiently acknowledged. They also lacked a proper study on the effects of fluoridation on formula-fed infants.[41]:29
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.[44]
Around 10% of the population of the United Kingdom receives fluoridated water[40] about half a million people receive water that is naturally fluoridated with calcium fluoride which is different to sodium fluoride, and about 6 million total receive fluoridated water.[45] 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". The Water Act 2003 required water suppliers to comply with requests from local health authorities to fluoridate their water.[45]
The following UK water utility companies fluoridate their supply:
Earlier schemes were undertaken in the Health Authority areas of Bedfordshire, Hertfordshire, Birmingham, Black Country, Cheshire, Merseyside, County Durham, Tees Valley, Cumbria, Lancashire, North, East Yorkshire, Northern Lincolnshire, Northumberland, Tyne and Wear, Shropshire, Staffordshire, Trent and West Midlands South whereby fluoridation was introduced progressively in the years between 1964 and 1988.[46]
The South Central Strategic Health Authority carried out the first public consultation under the Water Act 2003, and in 2009 its board voted to fluoridate water supplies in the Southampton area to address the high incidence of tooth decay in children there.[45] Surveys had found that the majority of surveyed Southampton residents opposed the plan, but the Southampton City Primary Care Trust decided that "public vote could not be the deciding factor". A judicial review has been initiated.[47] Fluoridation plans have been particularly controversial in the North West of England and have been delayed after a large increase on projected costs was revealled.[48]
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. Scotland's parliament rejected proposals to fluoridate public drinking water following a public consultation.
Water supply in Israel is artificially fluoridated since the 1970s. Settlements with more than 5000 citizens and settlements sharing water infrastructure with large settlements receive fluoridated water. About 67% of Israel's population receives fluoridated water.[49]
The decision whether to fluoridate lies with local governments, with guidelines set by provincial, territorial, and federal governments. Brantford, Ontario became the first city in Canada to fluoridate its water supplies in 1945.[50] In 1955, Toronto approved water fluoridation, but delayed implementation of the program until 1963 due to a campaign against fluoridation by broadcaster Gordon Sinclair.[51] The city continues to fluoridate its water today.[52] In 2008 the recommended fluoride levels in Canada were reduced from 0.8–1.0 mg/L to 0.7 mg/L to minimize the risk of dental fluorosis. Ontario, Alberta, and Manitoba have the highest rates of fluoridation, about 70–75%. The lowest rates are in Quebec (about 6%), British Columbia (about 4%), and Newfoundland and Labrador (1.5%), with Nunavut and the Yukon having no fluoridation at all.[50] Overall, about 45% of the Canadian population had access to fluoridated water supplies in 2007.[50] A 2008 survey found that about half of Canadian adults knew about fluoridation, and of these, 62% supported the idea.[53]
As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation.[55] According to a 2002 study,[56] 67% of U.S. residents were living in communities with fluoridated water at that time. In 2010, a U.S. Centers for Disease Control and Prevention study determined that "40.7% of adolescents aged 12–15 had dental fluorosis [in 1999–2004]" [57]. In response, the U.S. Department of Health and Human Services together with the U.S. Environmental Protection Agency are proposing[58] to reduce the recommended level of fluoride in drinking water to the lowest end of the current range, 0.7 milligrams per liter of water (mg/L), from the previous recommended maximum of 1.2 mg/L. [59] This could effectively terminate municipal water fluoridation in areas where fluoride levels from mineral deposits and industrial pollution exceed the new recommendation.[60]
Australia now has fluoridation in all states and territories.
Queensland - On 5 December 2007 Queensland Premier Anna Bligh announced fluoridation of most of Queensland's water supply will begin in 2008, making Queensland the last state to legally require the addition of fluoride to drinking water.[61] The Water Fluoridation Act 2008 was passed as promised, and requires the addition of fluoride to any "water supply supplying potable water to at least 1000 members of the public," unless an exemption is granted based on safety or naturally occurring levels that meet the required levels (ss 6 and 8). However, the towns of Biloela, Dalby, Gatton, Mareeba, Moranbah, and Townsville/Thuringowa have been adding fluoride to their drinking water since 1972, though some of these towns stopped adding fluoride prior to the Water Fluoridation Act. [62] Additionally, several areas of Queensland, such as Julia Creek, Quilpie, Thargomindah and Adavale are known to have naturally occurring fluoride present in their drinking water, a characteristic that has been studied since the late 1920s. [63]
On May 2, 2009 an accident occurred at the North Pine Dam treatment plant where it was believed that 300,000 litres of contaminated water was pumped into up to 4000 homes in the northern suburbs of Brendale and Warner for three hours. Subsequent investigation showed that most of this water did not leave the drinking water treatment plant. The investigation also showed that while it was first believed the water contained 30 to 31 mg/L of fluoride instead of the maximum allowable 1.5 mg/L, the true value was between 17 and 19.6 mg/L [64][65] Anna Bligh expressed her concerns stating "This is unacceptable and I, like other Queenslanders, have questions about it, and I'm not happy,".[66][67]
Side effects in Queensland: There is a vocal minority[68] in Queensland that claims negative effects from the addition of fluoride to drinking water. To date there has been no evidence linking the addition of fluoride to the negative effects claimed by those opposed to fluoride within Queensland.
Claims about the negative effects of the addition of fluoride within Queensland are unsupported, as the addition of fluoride to drinking water supplies has only occurred in major metropolitan areas since late 2008, and no studies have been conducted to discern what effects have resulted specifically in Queensland as a consequence. For example, the claim that in 2008-2009 the Queensland Police recorded +40% increase in juvenile violence related crimes and all worst types of crimes increased more than the national average might be linked to the addition of fluoride does not have merit, since such consequences could not have been possible given that fluoride was not in the water in Queensland long enough or in the amount necessary to cause this effect. Such a claim links an event that shares the same time period and falsely associates a cause and effect between the two, also known as a Post hoc ergo propter hoc fallacy. Additionally, some anti-fluoridation scientists have claimed a negative effect cause by augmented accumulation of lead in the brain. According to Prof. Roger Masters' studies, lead accumulation is induced by the Silicofluorides used to fluoridate water which do not electrolise in F- and Si+ ions as simplistically described by fluoridation's supporters and government agencies. Again, such claims do not relate to Queensland as this research was conducted in 2001 based on surveys of populations in the United States [69] There have been no similar studies within Queensland. Between 2007 and 2010, Queensland Health recorded + 40% increase in diabetes and in 2007 Queensland's dental health was at least better than Tasmania's in 2008 ; after fluoridation, Queensland's dental health considerably worsened despite the national consumes of sugar diminished 20% . The substantial increase in diabetes cases has been associated by some independent researchers to the semi-unknown bio-dynamics of fluorinated ammino-acids that are stongly bipolar and super-hydrophobic. The worsened dental health was eventually a simple effect of the increased number of people who did not regularly brush their teeth because wrongly thinking that fluoride ingestion could successfully replace oral hygiene after meals.
An exception exists in Western Australia where approximately 20,000 residents within the Busselton, Vasse and Wonnerup townsites, do not receive artificially fluoridated water.[70]
The first town to fluoridate the water supply in Australia was Beaconsfield, Tasmania in 1953.[71]
New Zealand has fluoridated water supplied to about half of the total population.[72] Christchurch is the only main centre not to have a fluoridated water supply.[73] 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.[74] In a 2007 referendum about half of voters in the Central Otago, South Otago and the Southland Region did not want fluoridation[75] and voters in the Waitaki District were against water fluoridation for all Wards.[76] Ashburton and Greymouth also voted against fluoridation.[77]
Water fluoridation was first adopted in Brazil in the city of Baixo Guandu, ES, in 1953.[78] A 1974 federal law required new or enlarged water treatment plants to have fluoridation, and its availability was greatly expanded in the 1980s, with optimum fluoridation levels set at 0.8 mg/L. Today, the expansion of fluoridation in Brazil is a governmental priority; state-sponsored research points to a sharp correlation between the availability of fluoridation and benefits to human health.[79] Between 2005 and 2008, fluoridation became available to 7.6 million people in 503 municipalities.[79] As of 2008, 3,351 municipalities, 60.3% of total, adopted fluoridation, up from 2,466 in 2000.[80] The proportion of the national population affected is greater, because cities with fluoridation tend to be larger.
In Chile 70.5% of the population receive fluoridated water (10.1 million added by chemical means, 604,000 naturally occurring).[81]
