Fluoride FAQ's
The most frequently asked questions about water fluoridation are answered below.
What is fluoride?
The facts: Fluorides are naturally occurring compounds containing fluorine, one of the most common elements in the earth's crust. Fluoride compounds and ions are found naturally in soil, minerals, plants, rivers and all water sources. It is found naturally in seawater at much higher levels than those used in the fluoridation of drinking water. In your body, fluoride helps stabilise the mineral content of bones and teeth and helps prevent tooth decay.
How did water fluoridation begin?
The facts: In the early 1900s, a dentist in the small town of Colorado Springs, Colorado noted that most local people had brown staining on their teeth, but very little tooth decay. Research eventually linked both the staining and the reduction in tooth decay to the level of fluoride in the water supply. Further research showed that a fluoride level of one part per million in the water supply strengthened teeth without causing staining, leading to the town of Grand Rapids, Michigan being artificially fluoridated in 1945. A dramatic reduction in tooth decay was noticed within a few years, and other towns and cities across the world soon followed their example. In 1953, Beaconsfield near Launceston became the first Australian town to be fluoridated, and all Australian capital cities except Brisbane followed in the 1960s and 70s. In 1964, Townsville became the largest Queensland city to fluoridate its water supply, and studies since have shown children in Townsville to have significantly fewer cavities than children in Brisbane. Large numbers of studies over the last fifty years have shown conclusively that fluoride strengthens teeth against decay without causing harmful effects. Major health authorities across the world have consistently supported water fluoridation and continue to do so.
How does fluoride work?
The facts: Fluoride acts in a number of ways to strengthen teeth and make them more resistant to tooth decay. Originally it was thought that the benefits of fluoride were only systemic, ie fluoride being built into a child's developing tooth enamel, making the enamel more resistant to the acid that causes tooth decay. This would have meant that only people exposed to fluoridated water as a child could benefit from water fluoridation. We now know that while some of fluoride's effect is systemic, most is a topical effect, ie fluoride applied directly to the tooth surface and strengthening tooth enamel. Remember the famous early 1970s fluoride toothpaste ads with Mrs Marsh? "Just like the liquid gets into the chalk". "Tough teeth, Mrs Marsh!" Topical fluoride can not only stop the development of tooth decay, but also make the enamel more resistant to future acid attacks. It also helps by reducing the amount of acid produced by the bacteria in your mouth. Drinking fluoridated water several times a day is the ideal way to give your teeth a quick fluoride treatment.
Why do I have to swallow fluoridated water if most of the effect is a topical one?
The facts: For a few reasons. 1. While most of the fluoride effect is topical, a systemic effect still occurs, and enamel with built-in fluoride is still more decay resistant. 2. Fluoride from fluoridated water is found in saliva and provides a wonderful, low concentration fluoride treatment for your teeth. 3. Because it's the safest, most cost effective way to gain the benefits of fluoride.
What is fluorosis?
The facts: Dozens of factors (eg trauma, infection, or medication) can cause mottling or staining of teeth, and excess fluoride is just one possible cause. Fluorosis generally presents as a mild or very mild mottling of teeth when high levels of fluoride have been taken in while tooth enamel is forming. Very high levels can even cause brown staining or pitted enamel. This is very uncommon, and usually results from children swallowing too much fluoride from toothpaste or fluoride tablets rather than from drinking fluoridated water. To reduce the chance of fluorosis, health authorities recommend that children use only a small amount of toothpaste on their toothbrush, and rinse after brushing. Water fluoridation is the ideal way of providing the benefits of fluoride, as it delivers very low levels on a regular basis, similar to naturally fluoridated water. It's important to keep fluorosis in perspective. Most fluorosis is mild or very mild, and causes no aesthetic concerns. Decayed and missing teeth on the other hand are much more disfiguring, are a threat to general health and well-being, and affect far more people.
Is water fluoridation the best way of providing fluoride?
The facts: The benefits of fluoride can be provided in many forms, including fluoridated water, salt, milk, tablets and drops. Many countries, particularly in Europe, that have elected for practical, legal or political reasons not to introduce water fluoridation have encouraged the use of fluoride in other forms. While these are still beneficial, the safest and most cost effective method, with the greatest reduction in tooth decay is seen when teeth are exposed to frequent, low concentrations of fluoride as in water fluoridation. The Centers for Disease Control and Prevention state: "Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level." Another landmark study by the University of York (September 2000) reviewed 3200 research articles and concluded that: "water fluoridation has an effect over and above that of fluoridated toothpaste and other sources of fluoride."
Is water fluoridation a form of medication?
The facts: Fluoride is a naturally occurring nutrient already found in the water, and is used by your body to strengthen teeth and bones. In 2003, the British Medical Association endorsed the addition of vitamins, minerals and nutrients to various foods, noting that many more children and adults would otherwise suffer deficiencies in basic nutrients. In Australia , for example, we add vitamin B1 to flour, vitamins A & D to margarine, as well as folic acid and other nutrients to most breakfast cereals. Water fluoridation simply supplements the level of fluoride found naturally in the water supply and should be considered no differently.
Doesn't water fluoridation just benefit children?
The facts: No. Because of the mainly topical effect of fluoride, people of all ages and backgrounds will benefit. With better dental care, older Queenslanders are now keeping their teeth longer. As we age, many factors can result in less saliva, a condition known as "dry mouth". The risk of tooth decay increases with dry mouth, particularly on the softer root surfaces. When fluoride is in the mouth, the teeth become much more resistant to decay. Fluoridated water is the safest, most effective, and least expensive way to reduce tooth decay in children and adults. For example, a 2002 New Zealand report on Preventive Dental Strategies for Older Populations noted that "fluoride was the most important preventive measure available against decay for this group."
Is fluoride poisonous?
The facts: Toxicity is related to the dose of a substance rather than merely exposure to the substance itself. Many substances (eg chlorine, iodine, fluoride, iron, salt, vitamins A & D, antibiotics, painkillers, oxygen, and even water) can be dangerous at very high levels, but beneficial and even essential at low levels. Fluoride is a naturally occurring substance, and even after increasing the amounts of fluoride to optimal levels, the level in drinking water is less than one part per million. In 1993, the US Agency for Toxic Substances and Disease Registry stated: "When used appropriately, fluoride is both safe and effective in preventing and controlling cavities."
What about the chemicals used in fluoridating water supplies? Are they safe?
The compounds most commonly used for fluoridating water are sodium fluoride and fluorosolicic acid, chosen because they dissolve completely in water and break down into harmless compounds, leaving none of the original chemical. Queensland's fluoridated towns (Townsville, Mareeba, Moranbah and Dalby) all use sodium fluoride, the same substance used in the fluoride tablets many of us took as children. When dissolved in water, it breaks down into harmless sodium and fluoride ions. Large cities often use fluorosolicic acid, which dissolves in water to produce harmless hydrogen ions, fluoride ions, silica and water. The fluoride ions in artificially fluoridated water are identical to those already found naturally in the water. The facts: In 2002, the UK's Medical Research Council noted concerns "related to the chemicals that are added during the fluoridation process, and to indirect effects such as increased leaching of lead from pipes and aluminium from cooking utensils and altered uptake or toxicity of these substances…" and found "no evidence for any significant health effects of this type…"
Is the fluoride used in artificial fluoridation any different to that already found naturally in the water?
Anti-fluoridationists have often suggested that fluoride occurring naturally is different to that from artificial fluoride compounds, that absorption of fluoride could be lower in hard water (because calcium in high concentrations can bind to fluoride and reduce its absorption) and that fluoride from artificial chemical is absorbed at nigher amounts that naturally occurring fluoride. The UK Department of Health commissioned the University of Nottingham to investigate these claims, and their report "Bioavailability of fluoride in drinking water - a human experimental study" was released in 2004. It found "no evidence for any differences between the absorption of fluoride ingested in artificially fluoridated drinking water and in drinking water in which the fluoride is present naturally at fluoride concentrations close to 1 part per millions". Nor did they find any evidence for difference between the absorption of fluoride from hard and soft waters at these fluoride concentrations.
Is water fluoridation cost effective?
The facts: Yes. The savings in dental treatment costs to a community by providing water fluoridation are substantial. It has been calculated in the United States that the lifetime cost per person of providing fluoridated water is less than that of a single filling. In 2002, Queensland Health commissioned an independent report into the cost effectiveness of water fluoridation. This 2002 Impact Analysis of Water Fluoridation stated that if all Queensland towns over 5000 people were to be fluoridated, the expected cost benefit to the state over a thirty year equipment lifespan would be more than $1 billion (at 2002 figures). In 2002, the Victorian Health Minister stated that "…every dollar invested in fluoride saves over $30 of dental treatment. The cost of dental treatment in Victoria is over $600 million each year. In the past 25 years fluoridation has saved the Victorian community nearly $1 billion in avoided dental costs, lost productivity and saved leisure time." In speaking about Sydney's water fluoridation, the New South Wales Chief Health Officer in 2002 reported "a significant dental health benefit, by reducing dental caries, along with the associated savings in the cost of treatment."
Will water fluoridation harm the land or marine environments?
The facts: The possible environmental impact of fluorides has been studied for decades. The World Health Organization and the UK's Royal College of Physicians have both concluded that water fluoridation does not cause fluoride pollution or harm the environment and a very recent investigation in America agreed. This latest assessment quotes studies showing that damage to aquatic life is possible only at much higher levels than that found in optimally fluoridated water. It reinforces the message that fluoride is a naturally occurring substance already found in land and water. Damage to the marine environment is highly unlikely since the level of fluoride in river water is low, and the fluoride level in seawater is already much higher than that found in fluoridated water supplies. All Australian capital cities except Brisbane have been fluoridated for up to forty years, with minimal harmful effects to the environment noted.
Does water fluoridation increase the risk of bone disease or fractures?
The facts: A 1999 Australian review of the scientific literature stated: "Water fluoridation both at levels aimed at preventing dental caries and, possibly, at higher naturally occurring levels appears to have little effect on fracture risk, either protective or deleterious, at a population level." "There is no evidence for either an osteoporosis risk or benefit from water fluoridation." (NH&MRC, 1999) In 2000, a similar review in the British Medical Journal also concluded that: "…long term exposure to fluoridated water does not increase the risk of osteoporotic fractures among elderly people." They noted that previous studies claiming a link between water fluoridation and hip fractures had not taken into account the potential confounding effect of other factors known to be associated with fractures, such as oestrogen use, smoking, and bodyweight. Studies that did take these confounding factors into account predictably found no link between fluoridation and hip fractures. All Australian capital cities (except Brisbane) have been fluoridated for decades and have not seen an increase in bone fractures or other ill effects.
Does fluoridated water cause kidney disease or affect dialysis patients?
The facts: The National Kidney Foundation in the United States says there's no risk. Along with major health organisations worldwide, they support water fluoridation. A 1998 Canadian expert panel agreed. They stated that "there is no evidence that low levels (up to 8 mg/l in drinking water) of fluoride are associated with kidney dysfunction or increased mortality from a kidney disorder" and quoted the U.S. Public Health Service, National Research Council, and Centres for Disease Control and Prevention in support of their conclusion. Patients with kidney failure often depend on kidney dialysis. Because they are exposed to extremely high amounts of water during dialysis, the water must have very low levels of minerals and ions. The level of all minerals and ions, including fluoride, is reduced before water is used for kidney dialysis.
Does water fluoridation cause cancer?
The facts: The National Cancer Institute in the United States says very clearly that there is no evidence linking water fluoridation to any form of cancer. National Cancer Institute fact sheet The Centers for Disease Control and Prevention stated that studies to date have produced "no credible evidence" of an association between fluoridated drinking water and an increased risk for cancer. The American Cancer Society agrees; they also support water fluoridation.
Does water fluoridation cause asthma?
The facts: No. Along with other leading health authorities, the American Academy of Allergy, Asthma and Immunology has supported water fluoridation. Not surprisingly, since asthma patients often experience more tooth decay and erosion, health authorities in Australia and overseas recommend the use of fluoride to strengthen their teeth. Supporting websites: Child Youth Health , South Australia University of Maryland Medicine
Does fluoridated water cause any other disease or medical condition?
The facts: One of the world's leading health authorities, the Centers for Disease Control and Prevention has strongly endorsed water fluoridation. In 1999, they stated: "Early investigations into the physiologic effects of fluoride in drinking water predated the first community field trials. Since 1950, opponents of water fluoridation have claimed it increased the risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, acquired immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions. The safety and effectiveness of water fluoridation have been re-evaluated frequently, and no credible evidence supports an association between fluoridation and any of these conditions." The British Medical Association says: "…there is no convincing evidence of any adverse risk to human health by the introduction of water fluoridation. Evidence through scientific studies shows that fluoride in water, at or around one part per million, does not have any effect on the health of the body other than reducing decay in teeth. This view is supported by the World Health Organisation, the Royal College of Physicians, and the British Dental Association, among others." The world's major health authorities and specialist medical organisations have repeated this view for many decades. Australians have now been drinking fluoridated water for over fifty years, with the only noticeable effect being significantly healthier teeth.
Could I be allergic to fluoride?
The facts: After a thorough review of the scientific literature, the American Academy of Allergy, Asthma and Immunology stated: "There is no evidence of allergy or intolerance to fluorides as used in the fluoridation of community water supplies."
Can fluoridated water affect people's behaviour?
The facts: A seven-year New Zealand study comparing the behaviour of children in fluoridated and non-fluoridated communities predictably found "no association between exposure to fluoridated water and a large range of measures of child health and behaviour…" Source: Shannon FT, Fergusson DM, Horwood LJ. Exposure to fluoridated public water supplies and child health and behaviour. NZ Medical Journal 1986;99(803):416-8.)
Does a government have a right to introduce water fluoridation into a water supply?
The facts: A government not only has a right to introduce water fluoridation, it has a responsibility to do so! John Harris from the Centre for Social Ethics & Policy, University of Manchester, UK wrote: "In considering the ethics of fluoridation one might legitimately reverse the question and ask if fellow citizens are entitled to impose, not only a disadvantage on the community at large, but impose actual deaths and the risk of death on children for the sake of a minor diminution in the range of choices available? We should ask not are we entitled to impose fluoridation on unwilling people but are the unwilling people entitled to impose the risks, damage and costs of failure to fluoridate on the community at large. When we compare the freedoms at stake, the most crucial is surely the one which involves liberation from pain and disease."
Will fluoridated water taste or smell different?
The facts: No
Shouldn't we be concentrating on improving people's diets and reducing sugar intake rather than just looking at water fluoridation?
The facts: The Australian Dental Association and Australian Medical Association have been advising people for decades to live healthier lives, eat a balanced diet and reduce their sugar intake. This will continue. The introduction of water fluoridation is just one part of improving people's dental health and general health.
What do the world's major health authorities say about water fluoridation?
The facts: Water fluoridation has been one of the most widely studied and endorsed public health measures of all time. World Health Organisation : "Fluoridation of water supplies significantly improves dental health…" and "…fluoridation of water supplies, where possible, is the most effective public health measure for the prevention of dental decay." Centers for Disease Control and Prevention : "Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century…" They also describe the fluoridation of drinking water as one of the "10 Greatest Public Health Achievements in the 20th Century." International Association for Dental Research : "…taking into account that over 50 years of research have clearly demonstrated its efficacy and safety; and noting that numerous national and international health-related organizations endorse fluoridation of water supplies; fully endorses and strongly recommends the practice of water fluoridation for improving the oral health of nations." United States Food and Drug Administration : "Public health measures, such as fluoridation of drinking water and consumer education on proper dental hygiene, have helped bring about a decline in cavities in the past 50 years." United States Surgeon General : "Community water fluoridation remains one of the great achievements of public health in the twentieth century - an inexpensive means of improving oral health that benefits all residents of a community, young and old, rich and poor alike." The British Medical Association : "Fluoridation of water is an effective public health strategy for reducing tooth decay in the population. The evidence accumulated over many years shows fluoride is highly protective to the teeth of children, and is very safe. Water fluoridation is one of the most effective ways of reducing tooth decay in the community. Not only does water fluoridation reduce tooth decay and consequently the number of extractions needed, but it also brings the added and welcome benefit of a reduction in the number of general anaesthetics administered to children. Evidence through scientific studies shows that fluoride in water, at or around one part per million, does not have any effect on the health of the body other than reducing decay in teeth. This view is supported by the World Health Organisation, the Royal College of Physicians, and the British Dental Association, among others." United States Public Health Service : " The PHS report concluded that fluoride has substantial benefits in the prevention of dental caries. Numerous studies have established a clear causal relation between use of fluoridated water and the prevention of dental caries…" and "... fluoridation of water is the most cost-effective method (of providing fluoride) and provides the greatest benefit to those who can least afford preventive and restorative dentistry..." Public Health Association of Australia : "Water fluoridation has been demonstrated to be effective in preventing tooth decay"…and…"should continue to be regarded as a safe and effective public health measure."