The Ins and Outs of Water Fluoridation: A Public Health Issue
The topic of water fluoridation is a major public health issue, particularly in the Northern Rivers of NSW, where recent votes in various local councils have just approved fluoridation in the local water supply. The community is divided about the presence of fluoride in the water supply. This paper looks at what fluoride is, where it comes from, the arguments for and against the fluoridation of water supplies, the credibility of claims for its benefits, alternative methods to prevent dental caries, and the role of natural medicine practitioners in educating their patients about fluoride.
Fluoride, which is the ionic form of the 9th element Fluorine, is a natural chemical and the 13th most abundant element in the Earth’s crust (1). It is found naturally in varying quantities in most water supplies on the planet. In minute quantities it is an essential component for the normal mineralisation of bones and formation of dental enamel (2) but in higher quantities it can have serious health consequences, which will be discussed later. When it is artificially added to water supplies by local water treatment plants, it is usually in the forms of hydrofluosilicic acid, sodium silicofluoride or sodium fluoride, which are commonly sourced from phosphate fertiliser manufacturers or aluminium smelters (3).
Fluoride is added to the water supply with the aim of reducing the incidence of dental caries, which is a “bacterial disease that causes the demineralisation and decay of teeth and can involve inflammation of the central dental pulp” (4) and which is commonly referred to as tooth decay (5). This process is recommended by Australian health groups such as the Australian Dental Association (ADA), the Australian Medical Association (AMA) and the National Health and Medical Research Centre (NHMRC), as well as the World Health Organisation (WHO), the Environmental Protection Agency (EPA) and the Centre for Disease Control (CDC), which hailed water fluoridation as “one of the top ten achievements of the twentieth century” (6). There have been many studies on the efficacy of fluoridated water, including a systematic review by the NHMRC (7) which showed that populations with access to fluoridated water have a significant decrease in the number of dental caries as opposed to those in non-fluoridated areas.
These health groups argue that although there is a financial cost of fluoridating water supplies, it is outweighed 7:1 by the public health costs associated with dental caries and subsequent chronic health issues (3). Problems associated with dental caries include tooth, jaw and facial pain, avoidance of certain foods due to pain and feeling self-conscious about mouth and facial appearance after the removal of decayed teeth (8). Longer term problems that can arise from inadequate oral health include chronic conditions such as heart disease, stroke and diabetes, which can cause financial strain to both the individual and the health system (8). As of 2009 approximately 85% of Australians had access to fluoridated water (9).
However, not everyone is happy about the use of fluoride in the water supply. There has been much opposition to the practice, with many groups and websites speaking out about the dangers to health of fluoride. Numerous health claims have been made about fluoride, including that it can cause dental fluorosis (discolouration and pitting of teeth), skeletal fluorosis (a painful bone disease), bone cancer, thyroid disease, and arthritis (10). Anti-fluoride groups have also made more radical claims, such as that the Nazi regime used fluoride in concentration camps for mind control and sterilisation, that it doesn’t actually reduce caries but hardens the outer enamel and rots the teeth, and that it lowers IQ in children (11).
It is difficult to find reputable studies to support some of these claims. For example, the studies about fluoride decreasing IQ in children were all done in areas of China and India where the local water supply had natural levels of fluoride well above the EPA’s recommended .07-1.5 mg/L (12). However, one study showed that higher levels of fluoride did reduce IQ and could damage neurodevelopment in the foetus and in children. The claim that the Nazis used fluoridation in concentration camps has been widely rejected by sceptic websites (13, 14) as there is no evidence for these claims, which appear to be anecdotal.
On the other hand, many studies that describe the benefits of fluoridation fail to take long-term health effects into consideration. The NHMRC’s systematic review established that there is insufficient evidence about the long term health risks of populations who consume fluoride (7). There is a need for further studies on the effect of fluoridation on systemic diseases such as arthritis, cancer and cardiovascular diseases.
Anti-fluoride groups are concerned about the possibility that recommended maximum daily limits of fluoride for infants and children up to 8 years (0.7mg per day and 2.2mg per day respectively) (15) may be exceeded. Health authorities believe that even though most individuals in both these groups are likely to be exceeding these limits, even when fluoride levels are at the lowest recommended value of 0.7mg/L, it is still acceptable for infant and children to consume fluoridated products. However, consuming fluoride beyond the recommended daily limits could put them at risk of developing adverse side-effects (3, 16).
Another concern of those opposed to fluoridation is whether it is ethical, as it constitutes mass medication without consent of the whole population (16). The counter-argument is that fluoride is not a medication but a food which is being added to water to boost the levels needed for healthy teeth (3, 16).
Some alternative forms of fluoride for those without access to fluoridated water are topical fluoride, fluoridated toothpastes, fluoridated mouthwashes and fluoride tablets. Several Cochrane reviews show the efficacy of these alternatives, but they all state the research is not very rigorous and caution may need to be taken when using such alternatives (17-20). The Australian Research Centre for Population Oral Health recommends that fluoride tablets, lozenges or drops that are chewed or swallowed should be avoided altogether, but without giving reasons (21).
Some studies that have shown a decrease in dental caries in fluoridated areas have also reported a worldwide decrease in dental caries in areas that have never had fluoridated water supplies or that have removed fluoride from them, such as Europe (22). Price(23), a dentist practising in the early 1900s, travelled among indigenous cultures and tribes and examined their teeth and facial features. Comparisons with people in developed countries showed almost no evidence of dental caries or other oral diseases in the indigenous populations. He concluded that diet was the main contributor to oral health. The indigenous populations experienced very low rates of diseases, like diabetes and cancer, found in developed countries. He theorised that diets high in sugar and carbohydrates, along with decreased nutrient density in soil, contributed to increases in dental caries and other diseases, factors still considered to be relevant today (5). Other risk factors for poor dental health include education in dental care, socio-economic status and access to dental professionals (4).
The Northern Rivers has a higher incidence of dental caries than the rest of NSW which some health authorities attribute to the absence of fluoridation of local water supplies (7). A health survey conducted in 2008 found that 76% of residents in the Northern Rivers supported fluoridation compared to 82-93% in the rest of the state (24). However, a survey conducted by a local newspaper The Northern Star in 2010 reported that only 25% of people supported fluoridation (25). Nevertheless, in 2013 the local councils of Ballina, Lismore and Richmond Valley voted to approve the fluoridation of local water supplies (26). The Byron Shire Council voted against fluoridation. The mayor said that “Byron should be a test case in achieving improved dental through education rather than medication” (27).
What implications for natural medicine practitioners are suggested by this debate? Patients may ask their practitioner’s advice or views on fluoridation. A practitioner’s role is to help inform our patients so that they can make an informed choice. We can direct them to various sources of information so that they can do their own research on fluoride and judge for themselves what is best for their and their family’s health. Practitioners also need the skills to identify possible side-effects of over-consumption of fluoride. Acute fluoride poisoning symptoms can include abdominal pain, diarrhea, headaches, nausea, tachycardia and vomiting (28). Long term side-effects of fluoride use can include osteoarthritis, mottled nails, skeletal fluorosis, dental fluorosis and neurotoxic effects (29). Dental fluorosis is more likely to develop when children between the ages of 3-6 are exposed to fluoride containing products and will affect their teeth well into adult hood (29). If any of these symptoms are noted and fluoride poisoning is suspected, health practitioners need to refer their patients for appropriate care.
In conclusion, the fluoride debate is a complex one. Although there is substantial evidence showing the efficacy of fluoride in preventing dental caries in the general population, many continue to claim that fluoridation carries serious risks. There is evidence that improved dental outcomes can be achieved without the use of fluoride and its associated health risks. More studies need to be done, particularly to investigate the long-term effects and possible risks of fluoride use and its possible correlation with the prevalence of other systemic diseases.
By Dr John-Paul Lo Giudice (Registered Osteopath)
1. Kohn WG, Maas WR, Malvitz DM, Presson SM, Shaddix KK. Recommendations for using fluoride to prevent and control dental caries in the United States. Morbid Mortal Wkly Rep. 2001;50.
2. Maheshwari R. Fluoride in drinking water and its removal. Journal of Hazardous materials. 2006;137(1):456-63.
3. NSWHealth. Water Fluoridation: Questions and Answers: NSW Health; 2013 [cited 2014 29 March]. Available from: http://www.health.nsw.gov.au/environment/water/Documents/fluoridation-questions-and-answers-nsw.pdf.
4. Chrisopoulos S, Beckwith K, Harford J. Oral health and dental care in Australia. 2011.
5. Harford J, Luzzi L. Child and Teenager Oral Health and Dental Visiting: Results from the National Dental Telephone Interview Survey 2010: Australian Institute of Health and Welfare; 2013.
6. CenterforDiseaseControl. Ten great public health achievements–United States, 1900-1999. MMWR Morbidity and mortality weekly report. 1999;48(12):241.
7. Yeung C. A systematic review of the efficacy and safety of fluoridation. Evidence-based dentistry. 2008;9(2):39-43.
8. Harford J, Amarasena N. Chronic conditions and oral health. Research report series no. 56. Canberra: 2012.
9. QLDHealth. Fluoride: QLD Health; 2009 [cited 2014 5 April]. Available from: http://www.health.qld.gov.au/fluoride/water_fluoridation.asp.
10. FluorideActionNetwork. Health Effects: Fluoride Alert; 2012 [cited 2014 5 April]. Available from: http://fluoridealert.org/new-visitors/health_effects/.
11. InformationLiberation. The Fluoride Conspiracy Information Liberation 2006 [cited 2014 3 April]. Available from: http://www.informationliberation.com/?id=14949.
12. Choi AL, Sun G, Zhang Y, Grandjean P. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environmental Health Perspectives. 2012;120(10):1362.
13. SkepticsStackExchange. Did the Nazis maliciously fluoridate drinking water? : Skeptics Stack Exchange; 2013 [cited 2014 6 April]. Available from: http://skeptics.stackexchange.com/questions/14042/did-the-nazis-maliciously-fluoridate-drinking-water.
14. Bowers B. Truth about fluoride doesn’t include Nazi myth: Politifact; 2011 [cited 2014 6 April]. Available from: http://www.politifact.com/florida/statements/2011/oct/06/critics-water-fluoridation/truth-about-fluoride-doesnt-include-nazi-myth/.
15. Capra S. Nutrient reference values for Australia and New Zealand: Including recommended dietary intakes. 2006.
16. Shattuck A. The Fluoride Debate: A Response to the American Dental Association’s Booklet Fluoridation Facts. San Marcos: Health Way House [cited 2006 Dec] Available from: http://www fluoridedebate com. 2000.
17. Yeung C, Hitchings J, Macfarlane T, Threlfall A, Tickle M, Glenny A. Fluoridated milk for preventing dental caries. Cochrane Database of Systematic Reviews. 2005;20.
18. Marinho V, Higgins J, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;1(1).
19. Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Gerbaud L, Ruffieux C, et al. Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane Database Syst Rev. 2011;12.
20. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013;11(7).
21. Armfield J, Spencer A. Dental health behaviours among children 2002–2004. 2012.
22. Marthaler T. Changes in dental caries 1953–2003. Caries research. 2004;38(3):173-81.
23. Price WA. Nutrition and physical degeneration: Price-Pottenger Nutrition Foundation; 2003.
24. CentreforEpidemiologyandResearch. 2008 Report on Adult Health from the New South Wales Population Health Survey. Sydney: 2009.
25. Weekes P. Fluoride ultimatum for Rous Water. The Northern Star. 2010 22 April.
26. Lollback R. All Rous Water councils to pay for Byron anti-fluoride vote. The Northern Star. 2013 28 November.
27. Lovejoy H. Byron to stay fluoride free. The Byron Echo. 2013.
28. Jacob L. Heller M. Fluoride Overdose: MedlinePlus [Internet]; 2014 [cited 2014 19 November]. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/002650.htm.
29. Erdal S, Buchanan SN. A Quantitative Look at Fluorosis, Fluoride Exposure, and Intake in Children Using a Health Risk Assessment Approach. Environmental Health Perspectives. 2005;113(1):111-7.