Fluoridate or not to fluoridate water? What’s your opinion?

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Fluoridate or not to fluoridate water? What’s your opinion?


Do you get patients who are against fluoride whether it is in the form of toothpaste or in the water supplies? I know I do! It can be difficult to convince them that fluoride in the small amounts used is not harmful but is actually beneficial.  The British Dental Association in February 2001 stated that only 10% of the UK population benefited from fluoridated water. These areas are Coventry City and Tamworth, Staffordshire. In addition, plans for Southampton to receive this method of fluoridation were approved in 2009. 10% covers such a small area of the UK which is a really shame as it is a simple and low patient compliance form of maintaining good oral health. Whereas, for the USA 43 out of the 50 largest cities in the country are fluoridated. Various research conducted over the years have all concluded that fluoride is effective at reducing dental caries in all age groups (in addition to the use of fluoridated toothpaste), but has no bearing on a patient’s general/ medical health. So why is there a problem in the UK??

Fluoride Alert is one such campaign group which is ‘anti-fluoride’. It is a fascinating website and despite me being ‘pro-fluoride’ it is interesting to consider the opposite view point. They call fluoride “the most damaging environmental pollutant of the cold war”, but do make some valid points with regards to consumption. They say ‘a half tube of candy flavoured toothpaste has enough fluoride to kill a small child’ and that ‘excessive fluoride can cause osteoarthritis’. These statements are correct but like anything we eat or drink, excess will cause damage. Fluoride is not alone in this equation. Take a common addition to foods such as sugar (glucose, sucrose etc)- too much sugar from a dentist’s point of view can lead to caries but from a medical perspective it can lead to weight gain and thus increasing the risk of diabetes type II etc. Other viewpoints which I have read on forums and articles are that fluoride is an infringement of personal freedom with the idea of mass medication without consent. Besides the harmful connotations which have been mentioned already, belief is that fluoride can also interfere with alternative remedies such as herbal medicines.

So I have mentioned an example of the ‘not to fluoridate’ part of my article. So let’s consider evidence for the ‘to fluoridate’ idea. As far back as when the first use of fluoridated water was implemented, evidence concluded that fluoride in the water has major plus points to our oral health in the form of reducing the caries risk of patients. Dr Frederick McKay in 1901 was the pioneer into research carried out into fluoridation in the water supplies. He noted that individuals living in Colorado Springs had brown stains on their teeth and made the connection of this ‘Colorado brown stain’ to the fluoride in their water supply. These brown stains are now known to be dental fluorosis. Dr McKay also detected that the tooth decay levels in this area were significantly lower than the rest of the surrounding areas which were not exposed to this fluoride. Following on from this, further research was carried out into two links:

  1. That fluoride in the water supply was linked to dental mottling/ fluorosis.

  2. That fluoride in the water correlated with reduced caries levels in the population.

In 1942, Dean et al published an epidemiological study known as the ’21-City Study’ in the USA which related fluoride content in the water and caries experience. He established from his results that 1ppm fluoride in the water supply was the optimal level for having a caries preventative effect while also preventing mottling of the teeth and other nasty side effects. Since then, 1ppm is the gold standard in water fluoridation levels with strong evidence of fluoride’s benefits. In 1953, Arnold et al reported that the caries experience of 6 year olds in Grand Rapids halved compared to the control town of Muskegon. Grand Rapids was the first town in the United States to have its water artificially fluoridated with 1ppm fluoride whereas Muskegon acted as the control. More recent evidence published also demonstrates that fluoride has a similar effect. McDonagh et al (2000) demonstrated that in high fluoridated areas tooth decay, as measured by DMFT (decayed, missing, filled teeth), in 5 year old children was notably reduced compared to low fluoridated areas in all social classes. In higher social classes, the mean DMFT was 1.8 in low fluoridated areas, but in higher fluoridated areas the score was approximately 1.1. A more significant difference was spotted in lower social classes where the scores for higher and lower fluoridated areas were 1.8 and 3.8, respectively.

However, the main question to ask is do we really need water fluoridation now that other forms of fluoride are readily available? These days compared to the 1940s, fluoride mouthwashes as well as fluoride toothpastes can be found in any supermarket or pharmacy, and fluoride varnishes, gels and higher concentration fluoride toothpastes can be obtained from the dentist. They are highly effective at reducing tooth decay but are only required for high caries risk patients. In addition, these forms of fluoridation require patient cooperation and compliance which is not the case however with water. Another growing issue with regards to water fluoridation is dental fluorosis, especially if it is of aesthetic concern. Beltran et al in 2010 reported results that 10% of 12-15 year olds in fluoridated communities in the USA had fluorosis in 1950, whereas between 1999 and 2004, this percentage rose to 41%.

So what is your opinion? Are you for or against water fluoridation in the UK?

Maya Rao Karnad

BDS 4 dental student at Kings College London

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