POLICY STATEMENT

Fluoridation of Public Drinking Water | Updated 21 August 2020

www.publichealthmdc.com

INTRODUCTION

Communities throughout the United States have used the fluoridation of drinking water

supplies for over 70 years as a strategy to reduce tooth decay (dental caries)

1-7

. The observed

decline in national averages for the prevalence and severity of dental caries since the initiation

of the program in 1945 has been deemed one of the greatest modern public health successes

of the 20

century

3, 5 - 9

. Despite these gains, a debate exists concerning the potential health

risks of water fluoridation versus the observed benefit of the intervention

1, 10, 11

. As a result,

Public Health Madison & Dane County occasionally receives phone calls, emails, and letters

from residents expressing concern about the fluoridation of local water supplies. Therefore, this

document was produced and regularly reviewed to provide a brief overview of the current

status of public concerns and an overview of the scientific literature.

OVERVIEW

Naturally occurring fluoride is found in all water supplies across the United States; the

concentration is dependent upon the geology of the water body and the occurrence of fluoride-

bearing minerals and materials

1, 6, 8

. The discovery of the potential health applications of

fluoride in the early 1930s led to the development of the first clinical trial of artificial

fluoridation of community water supplies in Grand Rapids, MI in 1945. The trial was designed

to last for 15 years prior to any potential recommendation for the expansion of water

fluoridation to other communities; however, the popularity of the program led to its initiation

in other cites the following year

. The City of Madison, Wisconsin began the fluoridation of

drinking water supplies in 1948.

EFFECTIVENESS OF WATER FLUORIDATION TO PREVENT DENTAL CARIES

Opponents of water fluoridation of community water supplies cite two major issues to question

the effectiveness of the program; a comparable reduction in dental caries in non-fluoridated

communities and the improved availability of fluoride-containing products make the treatment

of community drinking water unnecessary.

Research has demonstrated that differences in the rate of dental caries in fluoridated and non-

fluoridated communities have gradually decreased since the inception of water fluoridation

programs. Opponents have used this and similar research to question the continued

effectiveness of water fluoridation but this argument ignores the diffusion effect of fluoride

containing products including food, beverages, dietary supplements, and dental products that

were manufactured in fluoridated communities and sold in non-fluoridated areas

1, 6, 8

Therefore, the non-fluoridated communities also experience an indirect benefit derived from

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water fluoridation programs resulting in the comparable reduction of dental caries observed in

these areas. This argument also ignores the larger benefit repeatedly reported among lower

income and minority populations and the noted increase in dental caries among communities

that have discontinued water fluoridation

3, 5, 6, 7, 12 - 17

Oral hygiene has gradually improved in the United States over the past several decades,

including the increased use of fluoride-containing dental products such as rinses, toothpaste,

and topical gels

12-16

. However, disparities in use of and access to products and services

promoting oral health remain, especially among low income and minority populations. The use

of water fluoridation has provided an effective and cost efficient method to deliver

preventative services to promote oral health to all residents within a community served by

municipal water supplies, regardless of income, race or ethnicity, ability level, insurance status,

or access to care

3, 8, 12, 13, 17

. Currently, over 200 million Americans are served by drinking water

supplies that contain the accepted levels of fluoride to reduce dental caries (approximately

75%); the Healthy People 2020 initiative calls for an expansion of this coverage to 80% of the

population receiving drinking water from public water systems

3, 6, 15, 16, 18

POTENTIAL HEALTH CONCERNS

The beneficial health effects of exposure to low concentrations of fluoride result from its ability

to reduce tooth enamel solubility, decrease acid production of plaque-producing organisms,

and promote the remineralization of the enamel

1, 6, 16

. Efforts to prevent or remove water

fluoridation in Dane County communities are most commonly motivated by concerns of

fluorosis of teeth and bone, toxicity of fluoride, increased risk of hip fracture among the elderly,

decreased IQ among children, hypothyroidism and cancer.

1. Acute fluoride toxicity

This condition has been reported when fluoridated drinking water supplies reach a level of

30ppm

. Due to the utilization of well-designed fail-safe equipment, proper maintenance

and calibration, and appropriate operating procedures these overdosing incidents are rare

in the United States. Symptoms normally occur within hours of exposure and include skin

irritation, nausea, vomiting, diarrhea, and muscle weakness. Depending upon severity,

observable symptoms resolve quickly following cessation of exposure. In severe cases,

fluoride poisoning may result in cardiac arrest.

19-21

2. Dental and skeletal fluorosis

These conditions are well-documented results of prolonged exposure to excess fluoride

1, 9,

15, 16

. The development of dental fluorosis and skeletal fluorosis are attributed to the

toxicokinetic properties of fluoride following exposure. Following ingestion, 75-90% of the

compound is absorbed and readily distributed throughout the body

. Approximately 35-

48% of the absorbed fluoride is retained by the body; an estimated 99% of the compound

body burden is stored in the calcium rich areas of the bones and teeth (dentine and

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enamel)

9, 22

. This pattern of distribution and storage may lead to adverse impacts on the

teeth and skeletal systems of individuals chronically exposed to excess natural and/or

introduced levels of fluoride in public drinking water supplies

1, 9, 15, 16, 22

Dental fluorosis is characterized by the staining and disruption of normal enamel

formation of the teeth; the markings can range from unnoticeable in very mild cases (most

common) to brown stains and pitting of the enamel in severe cases (rare)

1, 9, 16, 23

Although severe cases can lead to brittle teeth and more teeth wear, all forms of dental

fluorosis are considered by the United States Centers for Disease Control and Prevention

(CDC) and the Department of Health and Human Services (DHHS) to be a cosmetic concern

rather than an adverse health effect

. Reported cases of dental fluorosis have increased in

the United States since the widespread initiation of water fluoridation. Prior to the

adoption of the program, the prevalence of dental fluorosis was 12-15%; modern rates of

this condition have shown reported increases

24-26

. A study conducted by the CDC reported

that an estimated 23% of persons aged 6 to 39 years had a very mild or greater dental

fluorosis while approximately 32% of children and adolescents aged 6 to 19 years were

reported with the condition. The risk of dental fluorosis development is limited to children

8 years of age or younger; tooth development occurs during this age range and the enamel

is susceptible to the effects of fluoride when chronically exposed to levels of fluoride larger

than 2 ppm. The current optimal level of fluoride recommended for drinking water sources

is 0.7 ppm. Children older than 8 years, adolescents, and adults are not susceptible to

dental fluorosis

Skeletal fluorosis is a disease characterized by increased density and brittleness of the

skeletal system; the disease occurs in a range of severity dependent upon the level and

duration of fluoride exposure. The mildest form of the disease can lead to arthritis-like

symptoms including painful joints, limitations in movement, and reduced flexibility.

Continual exposure to fluoride concentrations of 5ppm or greater may lead to

osteosclerosis

1, 9

. In the most severe cases, skeletal fluorosis can be a crippling disease,

confining a patient to a wheelchair. The condition is extremely rare in the United States

with only 5 confirmed cases reported in the last 35 years; each of these cases occurred in

areas where natural fluoride levels were greater than 20ppm

3. Hip fracture

Both excessive and inadequate intake of fluoride has been associated with an increased

risk of hip fracture among the elderly

1, 9-10

. However, research does not support an

association between water fluoridation and increased rates of hip fracture

16, 27, 28

. In fact,

two systematic reviews of the literature published in 2000 and 2017 evaluating hip

fracture and other types of bone fracture, respectively, also concluded that risk was not

associated with water fluoridation

4. Reduction of IQ in children

Concerns have also been raised that water fluoridation is associated with lowered IQ and

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other neurological effects from exposure. However, this concern is not supported by the

science-based evidence. A number of systematic reviews of the literature and individual

investigations does not support this association; including the recent response by the US

Environmental Protection Agency (US EPA) to a TSCA Section 21 petition and a study

released in 2018 conducted by the National Toxicology Program (NTP)

15, 16, 29 - 31

. Despite

this fact, some published investigations continue to suggest or imply neurological impacts

among communities with fluoridated water at recommended levels

15, 16, 29, 31 - 36

The human epidemiology studies that are often cited to support this concern are typically

conducted in areas of the world with high naturally occurring levels of fluoride in the

drinking water (e.g. China and Iran) and imply or are used by opponents of fluoridation to

imply an association with community water fluoridation programs at recommended

fluoride levels. In addition, limitations in the methodology of many of these studies lead to

unsupported conclusions due to the impact of potential confounding factors that were not

controlled or considered during the investigation

29, 34. 35, 37, 38

One important limitation is that many of these studies use a cross-sectional design; a type

of study design that does not establish causality because it cannot be determined if the

health conditions occurred before or after the exposure in question. Cross-sectional study

designs are best suited to help generate potential causal hypotheses further evaluated by

more robust epidemiological investigations

. Another important limitation of these

studies is that potential founding factors are not adequately recognized and/or controlled

which results in the inability to attribute the reported conclusions to fluoride exposure or

other factors or exposures potentially present and not accounted for by the investigation.

Examples include, but are not limited to, estimated water intake and not actual

consumption, a lack of standardized testing of mental IQ, the failure to address other

potential exposures that are associated with neurological impacts (e.g. lead and arsenic),

exposure to other sources of fluoride (e.g. burning coal for heating), social inequities of the

study population (e.g. poverty, nutritional deficiencies, and parental educational

attainment), and/or measuring fluoride delivery in salt and imply association with water

fluoridation

15, 16, 28, 29, 31-36, 38-40

5. Hypothyroidism

An association has also been suggested between exposure to community water

fluoridation and the incidence of hypothyroidism; a condition in which the thyroid gland

doesn’t produce a sufficient amount of hormones to function at a normal level

41-43

. This

suggested association is inconsistent with the literature and not supported by subsequent

investigation of this potential association

42, 44 - 46

Hypothyroidism is largely classified as an autoimmune disease (e.g. Hashimoto’s

thyroiditis) that is strongly associated with age (over 50 years) and sex (female). However,

the condition can also be attributed to other underlying variables including the use of

certain medications (e.g. lithium), both an increased or decreased intake of dietary iodine,

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socioeconomic status, pregnancy, family history of thyroid disease, surgery, and radiation

therapy

16, 44, 46 - 48

. Many of the studies that report an association between water

fluoridation at the recommended optimal level and hypothyroidism fail to account for

many of these potential confounding factors that could result in spurious associations that

are not reliable, representative, or generalizable to communities with fluoridated water

resources.

6. Cancer

According to the World Health Organization (WHO), a large number of studies exploring

the issue demonstrate no consistent evidence of any association between the

consumption of controlled fluoridated drinking water with an increased risk of cancer

9, 16

The majority of the concern about a potential cancer risk associated with the exposure to

fluoridated drinking water is the development of osteosarcoma; a rare type of bone cancer

typically diagnosed in children and teens in the United States. Similar to other types of

cancers, the body of evidence does not display a consistent association between the

consumption of drinking water fluoridated at recommended levels and the risk of

osteosarcoma

11, 49 - 52

. For example, research performed by the Harvard School of Public

Health in 2006 reported that water fluoridation was associated with a higher risk of

osteosarcoma in males but not females. However, early results from the second half of this

investigation did not match the initial findings and the researchers advised caution in

interpreting the results. The second part of the Harvard study was published in 2011 and

found no association between water fluoridation and osteosarcoma risk

50 52

More recent studies have compared rates of osteosarcoma in areas of higher versus lower

levels of water fluoridation in the United States, Great Britain, and Ireland; these studies

have also not reported an increased risk in areas of water fluoridation

FLUORIDATION COMPOUND SOURCES AND POTENTIAL

CONTAMINATES

There are three basic compounds that are utilized for water fluoridation; sodium fluoride,

sodium fluorosilicate, and fluorosilicic acid. Each of these compounds is derived from

phosphorite rock, a source that is primarily used in the production of phosphate fertilizer.

Phosphorite contains a mixture of calcium phosphate, calcium carbonate (limestone), and

apatite; the mineral apatite contains approximately 3 to 7% fluoride overall and is considered

the primary source of the fluoride used in water treatment

1, 16

. The association of water

fluoridation additives and the production of phosphate fertilizer have led to safety concerns by

opponents of the intervention

. The majority of these concerns center on potential impurities

entering the drinking water supply as a result of the water fluoridation; specifically lead,

arsenic, and radionucleotides

1, 16, 53

Regulatory processes are in place to protect community water supplies that either restricts

and/or prevents the introduction of impurities from the fluoridation of drinking water. The U.S.

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Environmental Protection Agency (US EPA) is responsible for the regulation of drinking water

and to assure its safety in accordance with the Safe Drinking Water Act (SDWA). The SDWA

requires that all additives used in water treatment plants, including fluoride additives, must

meet strict regulatory standards in regards to their production, maintenance, and application.

Each additive is subject to a system of standards, testing, and certification by the American

Water Works Association (AWWA) and the National Sanitation Foundation/ American

Standards Institute (NSF/ ANSI). Testing by the NSF for water quality has demonstrated that

the vast majority of fluoride additive samples do not have detectable levels of arsenic derived

from the addition of these compounds; water samples that do test positive are much lower

than the EPA allowable levels. Other impurities, including lead and radionucleotides, are

typically reported at levels lower than the detected arsenic levels

22, 53, 54

. Aside from the testing

of impurities, the recommended optimum fluoride concentration is 0.7 ppm; these levels are

monitored to ensure appropriate concentrations are maintained in communities that fluoridate

drinking water supplies

3, 15, 16

The water fluoridation program for the City of Madison currently utilizes hydrofluorosilicic acid

as its primary source for the fluoridation of community drinking water supplies. The compound

is obtained from Hawkins Chemical, Inc. via an annual renewable contract. In addition to the

federal requirements to ensure water quality, the City of Madison Water Utility has also

designed and initiated additional safe guards to maintain safe water supplies. Standard

operating procedures (SOPs) were designed in cooperation with Public Health Madison and

Dane County to govern the operation of water fluoridation, routine maintenance of all

equipment associated with the fluoridation process, and the daily monitoring of the water

fluoride levels to ensure optimal recommended levels of fluoridation. Impurities, including

potential impurities introduced by water fluoridation are also monitored in order to ensure that

water quality standards are in accordance with regulatory policies; samples are derived from

water entering the distribution center, which occurs after fluoridation to ensure the accurate

reporting of water quality

SUMMARY AND RECOMMENDATIONS

The occurrence of dental caries has been substantially reduced in the United States in recent

decades, predominately through the widespread use of fluoride. Unfortunately, disparities

among low income and minority populations are still quite prevalent

2, 3, 9, 15, 16, 17

. This trend has

also been reported in Wisconsin including Dane County; especially among populations of color.

For example, between September 2014 and June of 2015, the Madison Metropolitan School

District (MMSD) reported that 47% of students reporting urgent dental needs were African

American children. In 2013, the rates for patients visiting hospital emergency departments in

Dane County for dental pain were also higher for African Americans than for Whites, Hispanics,

or other racial groups; similar findings were reported in 2015 providing further evidence of the

persistence of oral health disparities

56, 57

. These inequities underline the need for continued

intervention efforts to address this inequity; water fluoridation is one of these tools.

To reach children and other at-risk populations for dental caries, water fluoridation is still the

most efficient method of delivering safe and effective levels of fluoride. Therefore, Public

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Health Madison and Dane County supports and recommends water fluoridation using the

optimum fluoride concentration of 0.7 ppm as recommended by the United States Department

of Health and Human Services

3, 15, 16

. However, it should be recognized that drinking water

fluoridation is a complex process that must be well monitored and controlled.

Careful review of the scientific literature and consultation with local and national experts has

identified no evidence for adverse health impacts associated with water fluoridation at

recommended levels. This fact and the continued high prevalence of dental caries and

associated pain, expense and potentially serious medical consequences make the continuation

and expansion of well controlled drinking water fluoridation a public health necessity in Dane

County.

Prepared by: Jeffery S. Lafferty, Environmental Epidemiologist

Doug Voegeli, Director of Environmental Health

Janel Heinrich, Director of Public Health

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55. Personal conversation with Joseph Grande, Water Quality Manager, City of Madison Water

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