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Family Health Magazine - DENTAL HEALTH

Water Fluoridation
Fact and Fiction

Communities in western Canada have been adding fluoride to public water supplies for almost 60 years to support good oral health and reduce dental caries (cavities). Even after years of scientific study and enquiry about water fluoridation, there is still controversy.

What should I do if my community's water is not fluoridated?

  • Start by discussing fluoridation with your dentist, dental hygienist or family doctor. If you are at low risk for dental caries, regular use of fluoridated toothpaste may be sufficient. If you are at higher risk for dental caries, other sources of fluoride may be recommended.
  • Ask your dentist or dental hygienist about in-office fluoride treatments.
  • Follow your dentist's instructions when using fluoride at home. Ask for printed directions if you need them.
  • Check with local public health programs for information about dental preventive programs available in your community.
  • Supervise the daily care of your child's teeth and mouth. Teeth should be brushed with a pea-sized amount of toothpaste to prevent excess fluoride being swallowed.
  • Keep all fluoride products out of the reach of small children.
  • Control the amount of sugar consumed, particularly between meals.
  • See your dentist and hygienist regularly.

Most Manitobans, two in five Saskatchewanians, almost one in two Albertans, but fewer than one in ten British Columbians, live in communities with fluoridated water. Some people are concerned about this practice. Many communities have been considering whether to continue with it. They look to experts, community members, and scientific literature to help make the decision. In some places, residents have been asked to vote or give their views. To make an informed decision about this practice, water fluoridation and the issues around it must be fully explored.

What is fluoride and where can it be found?

Fluoride is a natural element found in varying amounts in air, earth, and all water. It is also found in food and drink made from water containing fluoride. Fluoride and products containing fluoride are used in industry and health care. Many personal dental care products such as toothpastes and mouth rinses contain high levels of fluoride.

What is water fluoridation?

Water fluoridation is the controlled addition of fluoride to public water systems that have naturally low levels of fluoride. The goal is to bring the fluoride to a level where it can help reduce dental caries. In Canada, the current standard for fluoride in water systems is 0.8 parts per million (ppm) or 0.8 milligrams per litre of water.

At these levels, fluoride and accompanying compounds found in products added to our water do not exceed currently accepted guidelines for public water systems. Local municipalities or water commissions control the addition. As with any substance added to the water supply, it undergoes quality assurance to control levels in the water.

How much does it cost?

The annual cost per person can average between fifty cents in large communities to three dollars in smaller ones. In most cities, every dollar spent on fluoridation can save on average as much as $38 in dental treatment for those drinking the water. Fluoridation has the potential to greatly reduce dental disease for much less than it takes to treat it.

Why is there concern and conflicting evidence?

Water fluoridation has been used in North America for over sixty years. During this time, significant research has considered its effectiveness and safety.

Thousands of scientific articles that address fluoride in some way have been written in the past decade alone. Varying types and qualities of research exist on both the pro- and anti- fluoridation sides. In particular, the Internet is an easy way for people to read and share information on this topic. Although an article may have been published, the scientific methodology it refers to is not always strong.

The challenge in making the best choice involves sifting through a huge amount of material. When most people research a topic like water fluoridation, they actually see only a very small portion of the vast amount of information available. Some of it can be biased and of questionable quality. Making a good decision about such a complex issue involves reviewing all of the available information and choosing the best evidence.

How can I decide what is best?

Decisions about health should be based on the strongest evidence you can find. Otherwise, you could make a choice that harms your health or puts you at risk of disease.

Pay attention to both the amount and quality of the evidence presented. Reading one or even dozens of articles cannot answer the complex questions involved in such an issue. This is especially true for self-published opinion pieces. Articles that have been evaluated (peer-reviewed) by experts in the field are usually of higher quality. Even then, the information needs careful review before it is accepted.

Systematic review

This type of research is one of the strongest tools available for complex questions like water fluoridation. Systematic review is especially useful for reviewing scientific literature that is extensive and at times divided on a given issue. Investigators that complete a systematic review do not just look at a few of the articles on a topic. Rather, they scan the entire scope of the literature. They remove articles that do not exactly address the question being asked, as these potentially bias the findings. Articles with weak evidence are also removed. The remaining body of research is of high quality, with the least bias and error.

Most people do not have the time or specialized knowledge that systematic review requires. Our best bet is to look for information that has been given this careful, critical, and systematic scrutiny by peer-review investigators.

What do systematic reviews say about water fluoridation?

Acids made by bacteria decay tooth enamel. Fluoride reduces dental caries by helping teeth regain minerals after there has been some erosion of the enamel. The best way to deliver fluoride is through constant or regular low doses in the mouth. Water fluoridation and other fluorides like toothpaste and mouth rinses do this. This benefits not only children, but anyone who has teeth and so is at risk of dental disease.
Over the past decade, a number of systemic reviews have examined all of the scientific literature on water fluoridation, both published and unpublished. After selecting the best evidence, water fluoridation was found to be effective in reducing dental caries. An expert panel called together by Health Canada in 2007 stated, "Community drinking water fluoridation is still an effective public health method to reduce the prevalence of dental caries in the Canadian population."

This effective tool is available to all Canadians with access to publicly fluoridated water, not just people who purchase or use other fluorides like toothpaste.

Is water fluoridation safe?

Some fluoride found in water, foods, and dental products is swallowed and taken into the body. (This is called systemic application.) Other fluorides are applied to the teeth, but are spit out. Most of it is not swallowed. (This is called topical application.) Like many other substances we ingest, fluoride can do harm if too much is taken in.

The levels of fluoride in fluoridated water are well below those that might be harmful. One key possible side effect involves slightly higher levels of fluoride being swallowed over time while the teeth are developing. Called enamel or dental fluorosis, this generally shows as fine, white lines or spots on the teeth. It is usually hardly noticeable. In those few children swallowing very high levels of fluoride (well above 1.5 to 2.0 ppm), fluorosis can cover much of the teeth. At those levels it may also be brown in color and cause small pits in the enamel.

Recently, the Canadian Health Measures Survey (2007) looked at dental health across Canada. Only one in six children in Canada were found to have mild or very mild fluorosis. There were very few with moderate to severe fluorosis.

When weighing possible harm from fluoride, the risk of cancer, bone fracture, mental illness, goiter and other health concerns were considered. Systematic reviews found the amount taken in through water fluoridation poses no significant risk to health. As with other health measures, research continues. Water fluoridation is still being monitored to ensure safety.

Is it ethical to add fluoride to the water system?

Traditionally, decisions regarding health are approached using a biomedical ethics model. Following this model, health professionals must provide all of the information people need to make independent choices about their health. However, this is very difficult to do with large public health strategies designed to improve both the environment and the health of those living in it. Instead, communities must be consulted as part of the decision-making process.

Who decides whether a community water supply will be fluoridated or not?

"The most appropriate way of deciding whether fluoride should be added to water supplies is to rely on democratic decision-making procedures. These should be implemented at the local and regional, rather than national level, because the need for, and perception of, water fluoridation varies in different areas. Account should be taken of relevant evidence, and of alternative ways of achieving the intended benefit in the area concerned. Whatever policy is adopted, dental health and any adverse effects of fluoridation should be monitored."

- Nuffield Council on Bioethics, 2007

In Western Canada, local municipal councils usually make decisions about water fluoridation. Often, the public voices opinion in a plebiscite or public forum.
Still, many attempts at public input on fluoridation have not allowed all residents to voice their opinion equally. It is critical for those making decisions to understand the will of the people through properly developed polls or plebiscites. They should also consult experts who fully understand how to evaluate scientific literature. This is an important part of ensuring that decisions affecting public health are not made based on biased opinion or political whim.

The issue of water fluoridation is complex. It cannot be easily addressed in public forums or debates in the media, which are often dominated by emotion and bias on both sides and are not of sufficient scope to truly evaluate the scientific evidence. These exchanges may stimulate a desire to know more about the issue. However, knowing the will of the community and careful evaluation of all available evidence by decision-makers is required to make a truly informed decision on behalf of the public. This attention to detail makes certain that valuable services that maintain health will not be removed, while ensuring that these same services are effective and safe. To date, careful reviews of the scientific literature continue to support the effectiveness and safety of water fluoridation. Close examination and research is required to ensure that, in our ever-changing environment, we can maintain this standard.

For more information about
water fluoridation in your province, visit:

Alberta: www.albertahealthservices.ca/3474.asp
British Columbia: www.healthlink-bc.ca/healthfiles/hfile28.stm
Manitoba: www.gov.mb.ca/health/publichealth
(on the left hand sidebar, select 'Environmental Health' and then 'Dental/Oral Health'
Saskatchewan: www.health.gov.sk.ca/community-water-fluoridation

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FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
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