Water

Fluoridation helps to protect against tooth decay in two main ways.

First, during tooth formation, while the teeth are still in the gum, fluoride is built into the teeth before they emerge from the gum. Fluoride in the outer enamel helps to make the enamel stronger and more resistant to the acids produced by the breakdown of dietary sugars, that attack it during eating and drinking.

Secondly, once a tooth has come through into the mouth, the acids attack the tooth and dissolve some of its surface. However, if fluoride is present in the plaque and tooth surface, it reduces the damaging effect of the acid and helps the saliva to repair any damage. Fluoride in the plaque speeds up this process and completes the repair before the next acid attack.

Research has shown that the best protection against tooth decay is to have a continual supply of small amounts of fluoride in the mouth.

It is estimated that over 300 million people worldwide drink artificially fluoridated water; 13 million of whom live in Europe.

A further 40 million people drink water that naturally contains about the recommended level of fluoride, including a proportion in the UK.

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Countries where artificial fluoridation exists include the United States, Canada, Argentina, Ireland, Spain, Australia, New Zealand, Hong Kong, Singapore, Israel and the UKMore

Approximately six million people in the UK drink artificially fluoridated water at the recommended level. The West Midlands is the largest region, with about 3.5 million people. This makes it one of the largest schemes in the world. Other smaller schemes exist in Yorkshire, Trent, Mersey, Oxford and North West Thames.

In a temperate climate, such as the UK, the recommended level to help reduce tooth decay is one milligram of fluoride to every litre of water (1mg/l). This is usually called one part per million (1ppm).

There is no difference in look, taste or smell between naturally and artificially fluoridated water and a systematic review of fluoridation carried out by the University of York in 2000, found there was no evidence to suggest that artificially or naturally fluoridated water had any effect on general health.

However, it was acknowledged that evidence on this issue was weak and that more studies were needed before a complete answer could be given.

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Fluoride that is naturally present in most water supplies comes from the rocks that the water flows through on its way to the sea. These rocks consist of complex calcium fluoride compounds which dissolve to form fluoride ions, which are the simplest form in which fluoride can exist.


Only two substances are used to artificially fluoridate water. One is hexafluorosilicic acid and the other is disodium hexafluorosilicate. When they are added to water at the level of one part per million fluoride they completely break down into their component parts releasing fluoride ions which are identical to those found in naturally fluoridated water. Therefore, they have exactly the same effect upon the teeth and the rest of the body.More

The costs of fluoridation are usually given as the price per person receiving it, or the price per tooth saved. The cost varies due to several reasons.

The first is how many people get their water from a source to which fluoride has been added. The larger the population, the smaller the cost per person. Secondly, if an area has a water supply from more than one source, the cost increases.

A third factor is the level of tooth decay in the population. The higher the level of decay, the lower the cost of saving a tooth from needing treatment. Another factor which affects cost is the mixing of water supplies. Modern water supplies can be diverted from one system to another as the need arises. This means some people might receive less than the recommended level of fluoride. Others might only receive fluoride for short periods of time. All these factors affect the cost per person and will differ according to local circumstances.

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The cost of fluoridation can be divided into the capital costs of setting up the scheme and the subsequent revenue costs including the cost of the fluoride products added to the water. The capital costs are considerable during the first year, but can be discounted over the next 20 years that the capital equipment lasts. The main cost overall therefore rests on the revenue costs. In England the capital costs of any approved scheme will be funded up to 60% by the Department of Health, subject to the availability of funding. The remaining capital costs and the revenue must be paid for by the Primary Care Trusts (PCTs) involved. It is therefore up to those PCTs to decide whether its value for money. This will be based on local circumstances. Strategic Health Authorities (SHAs) have the statutory responsibility to conduct consultations on behalf of the PCTs receiving the water, so the SHA may well undertake the cost calculations.More

Worldwide hundreds of water works add fluoride to the water. There are several in this country, so the system is now routine and well tested.
One of only two chemicals is used for fluoridation. These are added as a liquid to the water supplies at the water treatment works.

The chemicals are delivered to the water works and held in large storage tanks. Fluoride is then fed into smaller tanks designed to hold only enough for a day's supply. From these smaller tanks, fluoride is pumped into the mains water at the correct level. Pumps run at full capacity so if a breakdown occurs smaller, not greater, amounts of fluoride will be passed into the water supply.

At all stages, strict regulations means the chance of any accident is extremely low, especially as the tanks only hold enough fluoride for one day's supply.

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The chemicals used to fluoridate water are hexafluorosilicic acid or disodium hexafluorosilicate. Both are manufactured to high standards of purity laid down by the Department of the Environment.

The water suppliers in the UK work to a strict Code of Practice for adding fluoride to the water. This has been laid down by the Department of the Environment It means that the fluoride level stays between 0.8 and 1.2 parts per million (the recommended level is 1.0 parts per million) and never exceeds 1.5 parts per million as laid down by the European Union.More

The protective properties of naturally fluoridated water were discovered in America and England in the early 20th century.

In the 1950s, a group of British scientists examined these studies and as a result, recommended to the Ministry of Health that similar research be carried out in Britain. These studies found similar results to those in North America.

In 1962 the Ministry of Health published an evaluation of initiatives which showed that fluoride was safe and effective. This decision led the way for individual local authorities to decide whether to fluoridate their water supplies.

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In 1964, the City of Birmingham implemented a fluoridation scheme and is today, one of the most extensive schemes worldwide. Newcastle followed in 1969, with a scheme that again, is still in operation today. Outside of the UK, many other countries have implemented fluoridation schemes, but some have stopped operating for a number of reasons.

The town of Kilmarnock in Scotland stopped fluoridation in 1985 because it was found to be against Scottish law, whilst Anglesey in Wales stopped the water fluoridation scheme they had implemented because of a failure to replace obsolete equipment. Similarly, a scheme in Holland was also stopped for legal reasons. Some communities in the United States have stopped fluoridation for political reasons, whilst others have restarted.More

Water fluoridation is the adjustment, or addition, of fluoride levels in a water supply. This can help to protect the health of the teeth of the people drinking the water.

Fluoridation chemicals are specifically manufactured to strict quality standards. They must meet the Department of Environment and European Union purity specifications. The end product is not a waste product.

The Water Industry Act 1991 says only two compounds may be added to water supplies: Hexafluorosilicic acid and Sodium hexafluorosilicate. Both of these meet the concentration of fluoride of one part per million.

Both are of accepted European standards (BS EN) and purity requirements.
When a water company agrees to add one of these compounds, they, and the health authority, must arrange to keep the fluoride concentration at one part per million (one milligram per litre), as far as reasonably practical and always within the limit set in the European Union Water Supply Regulations of 1.5 milligrams of fluoride per litre.

Water fluoridation is really the only way in which fluoride can be used to help prevent tooth decay in communities and populations, others include salt and milk fluoridation.

Fluoride toothpaste and fluoride mouth rinses, can be used by individuals to help fight tooth decay. Dental professionals can also put fluoride varnishes or gels on patient's teeth.

Water companies who add fluoride to the water must follow technical guidelines. These are contained in a Code of Practice on Technical Aspects of Fluoridation issued by the former Department of the Environment.

This Code includes a wide range of measures to ensure that water fluoridation is undertaken effectively and safely.

Ask your dentist. They can advise which strength of fluoride toothpaste to use for your child. This advice is based on whether your child is receiving fluoride from other sources. These include fluoride drops/tablets; fluoridated water or milk.

It is also important that you supervise brushing. Put only a smear of toothpaste on the the brush of children 0-3 years and a pea-sized amount of toothpaste on the brush of a child aged 3-6 years.

Remember to keep toothpaste out of the reach of small children.

In the 1950s and 1960s before fluoride toothpaste was widely available, the amount of tooth decay in children and adults was so high that water fluoridation was implemented in many countries. Beginning at this time in the United States and Canada, water fluoridation quickly spread to other countries including New Zealand, Australia, Great Britain, Hong Kong, Singapore and Ireland.

Dental experts believe that the general use of fluoride toothpaste has reduced overall levels of tooth decay by 50%.

However, although the dental health of fluoridated and non-fluoridated communities has improved, there are communities in the UK where levels of decay are still unacceptably high. Water fluoridation would help to improve the dental health of such communities.

The NHS Centre for Reviews and Dissemination at the University of York found, in a systematic review that, on average, more than two teeth per child would be saved from decay by fluoridation, and that about 15 per cent more children would have healthy mouths.

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Since fluoride toothpaste became universally available, levels of decay have reduced even where fluoridation has not been established. This has raised the question of whether it is now needed?

There are considerable differences in the amounts of decay in different parts of the UK with the more affluent South of England having lower levels than in the North, Scotland, Wales and Northern Ireland. For example, there is more than four times as much decay in 5-year-old children in Manchester, Belfast and Glasgow than in Surrey, Kent and Hampshire. Therefore fluoridation may be necessary in some parts of the country but not in others. The idea of targeting fluoridation to those areas in need is now official policy at the Department of Health who are leaving the final decision to individual or groups of health authorities around the country. A recent report from the British Medical Research Council recommends more research should be carried out in this country on this matter.More

Although water fluoridation schemes are safe, over the last 60 years it has been suggested that water fluoridation could be blamed for many health problems. Medical organisations, including the World Health Organisation and the BMA and American Medical Associations give their support to the safety of these schemes, at the recommended level of fluoridation.

A judicial enquiry in Scotland in 1985 concluded there was no evidence to suggest any health problems, apart from the risk of mild tooth fluorosis.

In 2000, the University of York looked at the data for and against the safety and benefit of water fluoridation. While they found no evidence of harm to health, they did make recommendations for further research into several areas.

In 2002, a review by the British Medical Research Council also made several recommendations. Like York, they concluded that areas of concern in the past no longer required any further investigation.

These studies concluded that, apart from dental fluorosis, which shows higher levels in places with fluoridated water, there was no clear evidence of harm to health of fluoridated water at the recommended level of one milligram of fluoride to every litre of water (1ppm).

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Fluoridated water has been carefully monitored in a large number of studies over generations. Several commissions of enquiry including the Royal College of Physicians have been established in countries with fluoridated water but none have discovered any conclusive evidence of detrimental health effects. Yet suggestions of a link between fluoridation and health problems still persist.

A Judicial Review into all aspects of fluoridation was conducted by Mr Justice Kenny in Dublin in 1964. After hearing evidence, both for and against, he concluded that there was no evidence against the safety of fluoridation.

In 1985 a similar Judicial enquiry, led by Lord Jauncey, once again invited evidence from all sides and again, the judge concluded that there was no evidence to suggest any health problems apart from the risk of mild dental fluorosis.

In 2000, a systematic review, carried out by the NHS Centre for Reviews and Dissemination at the University of York found no evidence of harm to health but did make recommendations for further research into several aspects.

These included dental fluorosis, bone fractures, cancer, infant mortality, congenital defects and IQ.

Apart from dental fluorosis, which does show higher levels in fluoridated communities, there was no clear evidence of harmful effects caused by fluoridated water at the recommended level of one part of fluoride to every million parts of water (1ppm). The review found that the expected level of any dental fluorosis in a fluoridated community was 48%, whereas in a community with little fluoride in the water supply, the expected level would be 15%.

The reasons why some fluorosis can be found in communities with little fluoride in the water is that there are other causes, including young children being given too much fluoride in tablets or drops or swallowing too much fluoride toothpaste. The term dental fluorosis includes a range of types, even the mildest form, which most people find acceptable or even attractive. For this reason the review also included an analysis of fluorosed teeth of "aesthetic concern". If only dental fluorosis of "aesthetic concern" is taken into account then at 1ppm fluoride in the water (the recommended level) the expected proportion of people affected would be 3 % compared to 1 % with little fluoride in the water.

In 2003 a review of the safety of water fluoridation was carried out by a Working Group established by the British Medical Research Council and it made several recommendations.
Firstly, more research should be carried out on the total intake of fluoride, particularly in children, as more recently other sources of fluoride, i.e. fluoride toothpaste, has now entered the food chain.

Secondly, although there was no evidence to suggest that water fluoridation at the recommended level of 1ppm has any effect, one way or another, on the rate of hip fractures among the elderly, further research was still needed in this area.

Again, although there was no evidence of a relationship between water fluoridation and the occurrence of any cancers, further research was needed on this subject.

However, areas of past concern that now required no further investigation included effects on the immune system, reproduction and birth defects as well as effects on the kidneys, stomach and bowel.

There was also no need for further specific investigation of the effect of fluoridation on lead piping or aluminium cooking utensils.

Overall the evidence to date points to the conclusion that water fluoridation at the recommend level of 1pmm is safe and further schemes in the UK in greatest need can proceed.More

Water fluoridation in the UK was made legal by the Water (Fluoridation) Act of 1985. This came into effect in 1991 by the Water Industry Act. This said that decisions to fluoridate were the responsibility of the Strategic Health Authorities in England and of the health boards in Scotland and Wales.

In Northern Ireland, the relevant authorities are the health and social services board.

Each health authority is responsible for the costs of fluoridation but it will receive a grant from the Depertment of Health if it decides to start or continue a scheme. Legally there is nothing to stop sensible local fluoridation schemes.

Dental fluorosis can range in appearance from very mild to very severe. In the UK, cases are usually mild or very mild. Most people find the earliest stage, fine white lines, does not affect the look of the teeth but later stages, white opaque patches, are often considered to be unattractive.

There are many causes of white marks or defects on teeth. These range from white circular patches, often caused by injury to the tooth surface during formation, to a pitting of the surface which is associated with genetic problems. This can often make it very difficult to say what caused a defect.

Stages of Dental Fluorosis:

Very Mild:







Mild:







Moderate:







Severe:

The European Union Water Supply Regulations says that all drinking water supplies should have a maximum concentration of 1.5 milligrams of fluoride per litre.
In areas where fluoridation schemes operate, the target fluoride concentration is 1.0 milligram per litre.

The mildest form of dental fluorosis may result in the ingestion of as little as 0.02 milligrams of fluoride per kilogram body weight. Mild to moderate fluorosis may be caused by taking in as much as 0.1 milligrams per kilogram body weight.

Tooth mottling, or 'mottled enamel', is a white or brown stain on the surface of the tooth sometimes associated with pitting of the surface. This should not be confused with stains on the surface of the tooth.

Mottled enamel is present when the tooth erupts and is caused by a problem when the tooth is forming. Stains on the tooth surface occur after the tooth has come through and are usually caused by food or drink.

Fluoride can also cause tooth mottling. This is called 'dental fluorosis''

During early fluoridation trials, it was found that one milligram of fluoride per litre of water in temperate climates such as the UK gave a balance between minimising the risk of dental fluorosis whilst also giving major reductions in tooth decay.

The Medicines and Healthcare Products Regulatory Agency decides if a product is medicinal.

The MHRA has decided neither fluoride added to drinking water nor the fluoridated water this creates are medicinal products. Therefore they do not need marketing authorisations as medicines.

Fluoridated water can reduce tooth decay in children by up to 50% and in adults up to 30%.
There are more studies of the effects of water fluoridation on the dental health of children than there are for adults. This is because the people in the study have to receive the same level of fluoride in their drinking water all their lives. The first report of the effect on adults came from the USA in 1943. It suggested that adults in naturally fluoridated areas had nearly half the decay of those in fluoride-low areas. Further reports came from the USA, UK and Sweden, all agreeing with these results.

More recently, there have been several studies, from the USA, Australia, the UK and Ireland, In all these countries, the dental health of adults living in the fluoridated areas was significantly better than those living in non-fluoridated areas.

Five studies: three in the USA, one in Canada, one in Ireland, looked at the effect of water fluoridation on the rate of root decay in older adults; all reported that adults living in the fluoridated areas had less root caries than adults living in non-fluoridated areas. To date, 17 studies into the effect of water fluoridation on dental decay in adults have been published. In all of these the rate of decay was lower in adults who lived in fluoridated areas compared with those who had lived in fluoride-low areas. The size of the difference was approximately 20 to 30% less in the fluoridated areas. Four of these studies showed less occurrence of root decay in older adults.

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There have been over 100 studies reporting the effects of water fluoridation on the health of children's teeth, but far fewer have studied adults. It is more difficult to access adults than children and to measure the benefits. It is necessary to follow groups of adults who have drunk fluoridated water all their lives.

The studies that do exist looked at the tooth decay levels of people living a lifetime in communities drinking naturally fluoridated water at about the recommended level of one part of fluoride to every million parts of water (1ppm), and compared these with adults living all their lives in similar communities with little or no fluoride in the water.

In addition, because artificial water fluoridation has been established for over 50 years, it is also possible to compare levels of tooth decay in adults drinking artificially fluoridated water with similar adults who do not.

The earliest study, reported in the USA in 1943, showed that dental decay in young adults was 43% less in the naturally fluoridated areas than in the fluoride-low areas. This was followed by other studies which all showed lower dental decay in the naturally fluoridated areas.

In the UK study, women attending a maternity hospital in north Wales who had lived all their lives in the fluoridated area of Anglessey had 30% less dental decay (four fewer teeth affected) than those on the mainland who had lived in the low fluoride area. Further studies in Australia and Ireland showed similar results.

Fluoride toothpaste would have been available to these adults, so the benefit of water fluoridation was in addition to the benefit of fluoride toothpaste.

While in young adults, most dental decay affects the crowns of teeth, in older adults, gums recede exposing the roots of teeth which may then decay. There have been five studies of the effect of water fluoridation on the occurrence of root caries. In all of these, adults living in the fluoridated areas had fewer root caries lesions than those living in fluoride low areas.
The 17 studies on adults have all shown that decay was less in adults who lived in fluoridated areas compared with those who had lived in non-fluoridated areas, but that the difference is not as marked as it is in children.More

There are a number of ways you can find out.

A map showing the average concentration of fluoride in drinking water supplies is available.

Ask your dentist or contact your local Primary Care Trust www.nhs.uk or water supply company.

Find your water company

There is no evidence that food and drink companies extract the fluoride.
If food is prepared in a fluoridated area, then it will have used fluoridated water.

Many medical and dental associations in the UK and worldwide, support the fluoridation of public water supplies. This includes the World Health Organisation which recommends that member states introduce water fluoridation, when and where appropriate, to improve dental health. There are no formal medical groups opposed to fluoridation. However, organisations against this public health measure include the National Pure Water Association and the Green Party.

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In the UK, the leading medical and dental organisations who support fluoridation include
Royal College of Physicians (www.rcplondon.ac.uk)
Royal College of Surgeons (www.rcseng.ac.uk/)
Royal College of General Practitioners (www.rcgp.org.uk/)
British Medical Association (www.bma.org)
British Dental Association (www.bda.org/)
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Lots of foods and products contain fluoride, including tea, fish meal (fish bones) and saltwater fish but not factory-farmed fish.