Drawbacks of public water fluoridation and current stances

This table examines the drawbacks of public water fluoridation and the current stances of the ADA and U.S. Centers for Disease Control and Prevention (CDC).

Possible drawbacks of community water fluoridation ADA stance
Based on "Fluoridation Facts" and www.mouthhealthy.org
CDC stance

The level of fluoride added in water fluoridation programs is far higher than in almost all unpolluted fresh surface water, according to FluorideAlert.org's "10 Facts About Fluoride" and the 2007 National Research Council's (NRC) "Report on Earth Materials and Health: Research Priorities for Earth Sciences and Public Health."

In addition, about 90% of fluoride added to community water supplies is hydrofluosilicic acid, a byproduct of the manufacturing of phosphate fertilizers. These industrial-grade chemicals are contaminated with heavy metals such as lead, arsenic, and radium.

A recent citizens' petition asking the Environmental Protection Agency (EPA) to stop the adding of hydrofluosilicic acid to community water supplies, headed by a former EPA senior scientist, points out that hydrofluosilicic acid meets U.S.-government criteria for classification as a hazardous waste.

In the U.S., the natural level of fluoride in ground water varies from very low levels to more than 4 parts per million (ppm). Fluoridation of community water supplies is simply the precise adjustment of existing naturally occurring fluoride levels in drinking water to an optimal fluoride level recommended by the U.S. Public Health Service (0.7-1.2 ppm) for the prevention of dental decay.

Byproducts are simply materials produced as a result of producing something else -- they are by no means necessarily bad, harmful, or waste products. For example, in addition to orange juice, various byproducts are obtained from oranges during juice production that are used in cleaners, disinfectants, flavorings, and fragrances. Additives used in water fluoridation meet standards of the American Water Works Association and NSF International.

Nearly all naturally occurring water sources contain fluoride, a mineral that has been proved to prevent, and even reverse, tooth decay.

Contrary to the CDC's claim, the 2007 NRC report on earth materials and health did not conclude "that fluoride is an element essential for human life based on its role in cellular functions involving metabolic or biochemical processes." The report only has one sentence bearing any resemblance to this statement; it is a list on page 37 of "mineral elements currently considered essential for human health and metabolism." The list does include fluorine (the most common form of which is fluoride), but the citation for the list is from 1979. Today, it is the consensus among scientists that fluoride is not an essential element, and as extensively documented in the 2006 NRC "Fluoride in Drinking Water: A Scientific Review of EPA's Standards" report -- which focused on the effects of fluoride on human health, unlike the 2007 report, which had only two pages on fluoride -- fluoride has significant deleterious effects.

Water that has been fortified with fluoride is similar to fortifying salt with iodine, milk with vitamin D, and orange juice with vitamin C. Like many common substances essential to life and good health -- salt, iron, vitamins A and D, chlorine, oxygen, and even water itself -- fluoride can be toxic in excessive quantities. Fluoride in the much lower concentrations (0.7 to 1.2 ppm) used in water fluoridation is not harmful or toxic.

The 2007 NRC report on earth materials and health identified fluoride as a mineral that can positively influence human health, and although earlier NRC reports were inconclusive in their opinions, this report concluded that fluoride was considered to be an element essential for human life based on its role in cellular functions involving metabolic or biochemical processes (CDC's website on fluoridation safety).

There has been a significant increase in dental fluorosis rates in step with expansion of U.S. community water fluoridation; the rate among 12- to 15-year-olds increased from 22.6% in 1986-1987 to 40.7% in 1994-2004, including a sharp rise in the rate of moderate and severe fluorosis from 1.3% to 3.6% in that period (National Center for Health Statistics, November 2010, Data Brief, No. 53).

Approximately 10% of dental fluorosis is attributable to water fluoridation. Most investigators regard even the more advanced forms of dental fluorosis as a cosmetic effect rather than a functional adverse effect.

The inappropriate use of fluoride-containing dental products is the largest risk factor for increased fluorosis, as fluoride intake from food and beverages has remained constant over time. The vast majority of dental fluorosis in the U.S. can be prevented by limiting the ingestion of topical fluoride products (such as toothpaste) and the appropriate use of dietary fluoride supplements without denying young children the decay prevention benefits of community water fluoridation.

Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpaste -- especially if swallowed by young children -- and dietary prescription supplements in tablets or drops (particularly if prescribed to children already drinking fluoridated water).

The NRC's 2006 report found the following:

More research is needed to clarify the relationship between fluoride ingestion, fluoride concentrations in bone, and stage of skeletal fluorosis; there is scientific evidence that under certain conditions fluoride can weaken bone and increase the risk of fractures; more research is needed to clarify the effect of fluoride on brain chemistry and function; further research is needed to explore the possibility that high levels of fluoride intake associated with community-water fluoridation, especially in infants and children with high water intake, are linked to changes in thyroid function, increased calcitonin activity, increased parathyroid hormone activity, secondary hyperparathyroidism, impaired glucose tolerance, and possible effects on timing of sexual maturity; and may initiate or promote bone cancers.

Some subsequent research has added to these concerns, such as a 2012 study on developmental fluoride neurotoxicity that concluded that their "results support the possibility of an adverse effect of high fluoride exposure [from water with fluoride of 'substantially above' 1 mg/L] on children's neurodevelopment. Future research should include detailed individual-level information on prenatal exposure [and] neurobehavioral performance" (Environmental Health Perspectives, October 2012, Vol. 120:10, pp. 1362-1368).

In August 1993, the NRC released a report prepared for the EPA that confirmed that the currently allowed fluoride levels in drinking water do not pose a risk for health problems such as cancer, kidney failure, or bone disease. After 60 years of research and practical experience, the preponderance of scientific evidence indicates that fluoridation of community water supplies is both safe and effective. The ingestion of optimally fluoridated water does not have an adverse effect on bone health.

A small faction continues to speak out against fluoridation of municipal water supplies. Some individuals may view fluoridation of public water as limiting their freedom of choice; other opposition can stem from misinterpretations or inappropriate extrapolations of the science behind the fluoridation issue. While the arguments against fluoridation have remained relatively constant over the years, those opposed to fluoridation have used different approaches that play upon popular public concerns at the time. For example, in the 1950s fluoridation was a Communist plot.

Opponents have repeatedly claimed fluoridation causes various human illnesses, including AIDS, Alzheimer's disease, cancer, Down syndrome, genetic damage, heart disease, lower intelligence, kidney disease, and osteoporosis (hip fractures). These allegations are often repeated so frequently during campaigns that the public assumes they must be true.

CDC media relations told DrBicuspid.com: "The current levels set by EPA, which are set to protect against severe dental fluorosis, likely are also protective against other fluoride-related adverse effects in adults, including risk of bone fractures. Concerning its review of studies of low IQ and endocrine disruption, the NRC report noted that current studies have limitations -- including problems related to their methods and consideration of potential confounding factors -- and thus the significance of some of the studies was uncertain. As a result, they recommend that future studies have better measurement of factors/variables such as actual fluoride exposure."

The Institute of Medicine recommends that babies up to 6 months of age consume only 0.01 mg/day of fluoride. Infants and children living in areas of the U.S. where the community water supply is fluoridated are exposed to up to 0.20 mg/kg/day and 0.23 mg/kg/day, respectively (Environmental Health Perspectives, January 2005, Vol. 113:1, pp. 111-117). Bottled "infant"or "nursery" water contains 0.5-0.8 mg/L ("Fluoride in Drinking Water: A Scientific Review of EPA's Standards," National Academy of Sciences, 2006, table 2-1, p. 28), while in addition, toothpaste use adds 0.1 mg/day to infants' fluoride intake and 0.15-0.3 mg/day to children's fluoride intake (ibid, table 2-7, p. 42). While "individuals could have substantially higher intakes" (ibid, p. 42), these values significantly exceed the EPA's safe reference dose (the Integrated Risk Information System [IRIS] value) for children and adults of 0.06 mg/kg/day.

Recent evidence suggests that mixing powdered or liquid infant formula concentrate with fluoridated water on a regular basis may increase the chance of mild or very mild fluorosis. Parents and caretakers should consult with their dentist or physician about the type of water to use to reconstitute infant formula.

Decay rates are declining in many population groups because children today are being exposed to fluoride from a wider variety of sources than decades ago. Many of these sources are intended for topical use only; however, some fluoride is ingested inadvertently by children. Inappropriate ingestion of fluoride can be prevented, thus reducing the risk for dental fluorosis without jeopardizing the benefits to oral health.

You can use fluoridated water for preparing infant formula. However, if your child is exclusively consuming infant formula reconstituted with fluoridated water, there may be an increased chance for mild dental fluorosis. To lessen this chance, parents can use low-fluoride bottled water some of the time to mix infant formula; these bottled waters are labeled as deionized, purified, demineralized, or distilled.

World Health Organization data indicate that rates of dental caries have been declining significantly since the mid-1970s in both regions and countries that have nonfluoridated and fluoridated water. Furthermore, in many countries that do not have community water fluoridation, the rates of decayed, missing, and filled teeth in 12-year-olds are far lower than in the U.S.

Water fluoridation continues to be effective in reducing dental decay by 20% to 40%, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste.

Over time, dental decay can be expected to increase if water fluoridation in a community is discontinued, even if topical products such as fluoride toothpaste and fluoride rinses are widely used. Studies from outside of the U.S. that have reported no increase in dental decay following the discontinuation of fluoridation all coincided with the implementation of other measures to prevent dental decay, such as topical fluoride programs, free dietary fluoride supplements, and fluoridated salt.

Even today, with other available sources of fluoride, studies show that water fluoridation reduces tooth decay by about 25% over a person's lifetime.

The widespread availability of fluoride through water fluoridation, toothpaste, and other sources, however, has resulted in the steady decline of dental caries throughout the U.S.

There are very high rates of dental caries in U.S. cities such as Boston, Chicago, and Cincinnati despite decades of water fluoridation, and the people in the lowest socioeconomic strata have the highest caries rates, with children having the highest rates of all.

Dental decay continues to be a significant oral health problem. Despite progress in reducing dental decay, individuals in families living below the poverty level experience more dental decay than those who are economically better off. Some of the risk factors that increase an individual's risk for decay are inadequate exposure to fluoride, irregular dental visits, deep pits and fissures in the chewing surfaces of teeth, inadequate flow of saliva, frequent sugar intake, and very high oral bacteria counts. Dental decay is one of the most common childhood diseases -- five times as common as hay fever in 5- to 17-year-olds.

Adding fluoride to community water supplies benefits all people -- regardless of age, income, education, or socioeconomic status. A person's income and ability to get routine dental care are not barriers since all residents of a community can enjoy fluoride's protective benefits just by drinking tap water and consuming foods and beverages prepared with it.

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