Water Fluoridation – Safety and Efficacy

Water Fluoridation: Safety and Efficacy
Bernadette Callender, MPH student Walden University
PH 6165-5
Instructor: Dr. Donald Goodwin
Autumn, 2009

Audience: Elementary school parents in the local community


The target audience is the local community with special emphasis on elementary school parents. There are millions of people who still don’t have access to water that’s fluoridated. (Healthy People, 2000, p. 5). One of the Health People Objectives 2000 is to have at least 75% of the people in the U.S to be recipients of fluoridated water. (Healthy People, 2000, p. 24). During the fluoridation process additional fluoride is added to fluoride already existing in natural water to a level established as preventative against dental caries. As a primary means of prevention, it has been effective, safe, convenient (not requiring any action on the part of the individual community member or professional services), and accessible regardless of one’s socioeconomic status. (Healthy People, 2000, p. 24). In addition, the use of fluoridation eliminates any disparities that may arise in reference to different demographic groups. (Bailey, Barker, Duchon, & Maas, 2008, p.1).
Upon initiation in 1945, The U.S Public Health Services began tracking the number of people receiving fluoride water. (Bailey et al., 2008, p. 1). Thirty years later in 1975, the Centers for Disease Control (CDC) and the Association of State and Territorial Dental Directors partnered and created a voluntary Water Fluoridation Reporting System (WFRS) to oversee the states’ efforts at fluoridation. (Bailey et al., 2008, p. 1). EPA doesn’t regulate water fluoridation but Safe Drinking Water Information System (SDWIS) monitors for levels in excess of the regulation maximum of 4.0 parts per million (ppm) in naturally fluoridated water supply. Ultimately, fluoridation is managed by the individual states who report community water system data such as the fluoridation source, concentration and population being served. (Bailey et al., 2008, p. 1).
In evaluating the progress towards the objectives of Healthy People 2000, the CDC found that between 1992 and 2006, there were noticeable increases from 62.1% to 69.2% in the amount of communities receiving fluoridated water. (Bailey et al., 2008, p. 1). In addition, in 2006 there were successful outcomes from half the states and the District of Columbia (DC) in meeting the 75% target. For example over 100 million persons received processed fluoridated water and 8 million received water which contained fluoride naturally. (Bailey et al., 2008, p. 2). Yet seven major cities in the U.S still did not embrace such benefits. (Healthy People, 2000, p. 24). For example, here in Nassau County N.Y, fluoride isn’t added to the water supply and the amount naturally found by the local Water Quality Monitoring Program is recorded at 0.2 ppm. (Nassau County, 2007, p.10). Upon completion of questionnaires and examinations from 309 third graders in nine different Nassau County schools, results showed that poorer oral health and less access to dental care were found among children with lower socio-economic status (SES). More than twice as many children had untreated tooth decay in low SES schools, 36.2% vs. 17.8%. (Nassau County, 2007, p. 10).
Consuming water treated with fluoride provides protection twofold – systemically to teeth about to erupt and topically to those that have already erupted. Cavities in childhood remain one of the most seen chronic diseases and can be found among children as young as 1 to 6 years old. (Healthy People, 2000, p. 2). It occurs in about a 1:5 ratio in relation to childhood asthma, which is the second most seen chronic disease. During their elementary school years over 50% of the children have cavities affecting their primary teeth and upon graduation from high school, about 80 percent have caries. (Healthy People, 2000, p. 3). A number of factors play significant roles in regard to the precise cause of early childhood caries including large family size, mother/infant nutritional status and feeding practices in which children fall asleep with a bottle of milk or juice.
When fluoride is at a level of 0.7 to 1.2 ppm in drinking water, it has proven to be ideal in efforts to avoid decayed teeth. (New York State, 2008a, p. 1). A review of studies of community water fluoridation done by a CDC appointed Task Force on Community Preventive Services discovered that in communities that initiated fluoridation there was a 30% decrease in childhood tooth decay. These findings were apparent in a follow-up that was made 3–12 years later.
On the other hand, not initiating fluoridation showed that tooth decay was more prevalent. (New York State, 2008a, p. 1). Fluoridated water isn’t the only way to ensure young children receive sufficient fluoride in order to prevent cavities. The ADA agrees that there are other sources of fluoride including fluoride toothpaste/mouthwash, dietary fluoride supplements as well as the naturally occurring fluoride in water. (ADA, 2006, p.2). Despite these available alternatives recommended precautions still need to be taken in regard to the amount of toothpaste used, mouthwash allowed only for children 6+ years , supplements only for children over 6 months, etc.
Several studies have shown that too much fluoride can cause moderate to severe fluorosis which causes the enamel to become discolored or the teeth to have indentations. (New York State, 2008b, p. 1). More severe conditions would include Stage III skeletal fluorosis which affects the joints and causes the bones to deteriorate. One study which took place in two different villages of China where fluorosis was high, found an association between the level of fluoride in water consumed and urinary output. (Zhu, Fang, Ba, Cheng, Cui, 2006, p. 58). Fluorosis was prevalent at approximately 45%, and the high end urine concentration was 1 ½ mg/L. (Zhu et al., 2006, p. 57). The researchers found that even with fluoridated water at 1.22 ppm this concentration was still above the WHO recommendation and should therefore still be of concern. (Zhu et al., 2006, p. 59)
My position is that fluoride should be added as a supplement to water if the concentrations don’t meet the standards set by the state. At 0.2 ppm, Nassau County’s level of naturally occurring fluoride in water is below recommendations and in violation of the standard set by the New York State Department of Health. (NYSDOH). For tooth decay prevention in NYS the recommended target fluoride concentration in water is set at 1 mg/L. (New York State, 2008b, p. 1). The maximum concentration allowed including what’s already in the water is a level of 2.2 mg/L, which is still lower than the amount of 4 mg/L that the federal authorities require State public water systems to meet. To ensure that fluoride levels remain between 0.8 and 1.2 mg/L, the NYSDOH monitors all water systems for compliance. (New York State, 2008b, p.1).
The evidence isn’t clear regarding whether or not fluoride is associated with cancer because there are those studies concluding that the likelihood is there while others show none. One study conducted at 11 different U.S hospitals found that children under the age of twenty differed as far as their risk of osteosarcoma. (Bassin, Wypij, Davis & Mittleman, 2006, p. 424). Due to intake of fluoridated water, there was an association observed in males but none found in females. In determining causality and explaining association, biological factors such as bone growth in males and the role fluoride played during childhood were observed. It was concluded that bones absorb a large percentage of fluoride and this is usually means by which osteosarcoma first invades the body. (Bassin, et al., 2006, p. 426).
The American Dental Association (ADA) stance is for communities to fluoridate water because they consider it to be an effective measure taken in fighting dental caries and considers it to be effective in safeguarding teeth. (ADA, 2006, p.2). It costs less in comparison to other treatment methods using fluoride and is instrumental in resolving any controversy related to disparities between the different groups of a community. The estimated expense of initiating a fluoridation system is done at the state level and costs are dependent on community size. One study conducted in Colorado concluded that Community Water Fluoridation Programs (CWFPs) had saved $148.9 million in 2003, resulting in approximately $60.78 per person. . (O’Connell, Brunson, Anselmo, & Sullivan, 2005, p. 1). The ratio of savings or benefits in relation to costs for installation of a small fluoridated system versus a large one ranged from $21.82 to $135.00. It was further estimated that an additional $46.6 million could be saved annually if the other 52 water systems implemented fluoridation programs as well. (O’Connell et al., 2005, p. 8). In another study, recognizing the significance of breast milk, researchers sought to examine the role/effect of fluoride in the diets of infants. (Sener, Tosun, Kahveciolu, Gokalp, & Koc, 2007, p.21). It was discovered that the amount of fluoride found in the breast milk and blood collected from a sample of mothers was within the guidelines. At a fluoride level of 0.008 ppm, the results were still within the parameters set by the WHO of 0.005 – 0.010 ppm. (Sener et al., 2007, p. 23). Despite the fact that the level in the blood was at a higher concentration, a lesser amount was transferred to the babies while breastfeeding. (Sener et al., 2007, p. 23).
Recommendations for action would have to include the local community, who need to be pro-active in making the necessary changes. It is important for residents to educate themselves by conducting their own research regarding levels in their individual towns. With such knowledge, they can then take a stance for or against fluoridation. For example, the CDC provides information where anyone can learn the particular fluoride levels in their particular water system. (CDC, 2008, p.1). Finally, it is equally important for health policy makers and the local officials to allow their constituents to know the status of changes being made in reference to fluoridation and water quality.
ADA. (2006). Interim Guidance on Fluoride Intake for Infants and Young. Retrieved on October 23, 2009 from http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp
Bailey, W., Barker, L., Duchon, K., Maas, W. (2008). Populations Receiving Optimally Fluoridated Public Drinking Water — United States, 1992—2006. MMWR, 57(27), 737-741. Retrieved on September 21, 2009 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5727a1.htm
Bassin, E. B., Wypij, D., Davis, R. B., Mittleman, M. A. (2006). Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes and Control, 17, 421-8. Retrieved on November 15, 2009 from

CDC. (2008). My Water’s Fluoride. Retrieved on October 23, 2009 from http://apps.nccd.cdc.gov/MWF/Index.asp
Healthy People. (2000). Oral Health. Retrieved on September 21, 2009 from http://www.healthypeople.gov/document/html/volume2/21oral.htm#_Toc489700409

Nassau County. (2007). Nassau County Community Health Assessment 2005-2010. (NCDOH Publication). Uniondale, NY: U.S. Government Printing Office. Retrieved on October 11, 2009 from http://www.nassaucountyny.gov/agencies/Health/documents/NassauCounty2005-2010_CHA_revised6_14_07.pdf
New York State. (2008a). Fluoridation in New York State: Benefits. Retrieved on October 17, 2009 from http://www.health.state.ny.us/prevention/dental/fluoridation/benefits.htm
New York State. (2008b). Fluoridation in New York State: Addressing Safety Concerns. Retrieved on October 17, 2009 from http://www.health.state.ny.us/prevention/dental/fluoridation/safety.htm
O’Connell, J. M., Brunson, D., Anselmo, T., Sullivan P. W. (2005). Costs and Savings Associated With Community Water Fluoridation Programs in Colorado. Retrieved on October 23, 2009 from http://www.cdc.gov/pcd/issues/2005/nov/05_0082.htm
Sener, Y., Tosun, G., Kahveciolu, F., Gokalp, A., Koc, H. (2007). Fluoride levels of human plasma and breast milk. European Journal of Dentistry, 1(1), 21–24. Retrieved on November 16, 2009 from http://ukpmc.ac.uk/articlerender.cgi?accid=PMC2612944&tool=pmcentrez

Zhu, J., Fang, L., Ba, Y., Cheng, X., Cui, L. (2006). Prevalence of dental fluorosis in children from fluorosis-endemic areas. Life Science Journal, 3(4), 57-60. Retrieved on November 17, 2009 from

Further reading:
ADA. (2005). Fluoride & Fluoridation. Retrieved on October 23, 2009 from http://www.ada.org/public/topics/fluoride/infantsformula_faq.asp
ADA. (2006). ADA Guidance: Other Sources of Fluoride for Young Children. Retrieved on October 23, 2009 from http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp
CDC. (2009). Background: Infant Formula and the Risk for Enamel Fluorosis. Retrieved on October 23, 2009 from http://www.cdc.gov/fluoridation/safety/infant_formula.htm
Community Water Fluoridation. (2009). Retrieved on October, 23, 2009 from http://www.cdc.gov/fluoridation/index.htm
Healthy People. (2000). Healthy People 2010 Objectives. Retrieved on September 21, 2009 from http://www.healthypeople.gov/document/html/volume2/21oral.htm#_Toc489700409


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