What is Community Water Fluoridation?

Tooth Decay and Fluoride

What is community water fluoridation?

Community water fluoridation is the adjustment of the fluoride concentration in the community water supply to a level beneficial to reduce tooth decay and promote good oral health. The mineral fluoride is essential for strong healthy teeth that resist decay. Almost all waters contain some quantity of naturally occurring fluoride, but usually at levels insufficient to prevent decay. The optimum concentration of fluoride in water has been determined to be between 0.7 to 1.2 milligrams per liter (mg/L) depending on the air temperature in a given region. Given the dramatic decline in tooth decay during the past 60 years, the Centers for Disease Control and Prevention (CDC) named water fluoridation one of Ten Great Public Health Interventions of the 20th Century. Community water fluoridation has been recommended by the past five United States Surgeon General’s. More information can be found on our Benefits page.

How does fluoride work?

Tooth decay is caused by bacteria in the mouth. When a person eats sugar, or other refined carbohydrates, these bacteria produce acid that removes minerals from the surface of the tooth, a process known as demineralization. If demineralization goes on long enough, a cavity is formed. Fluoride can promote the remineralization of enamel, thereby preventing the cavity from continuing to form. In addition, fluoride reduces the ability of the oral bacteria to produce acid. More information can be found in a fact sheet on Background Information.

Is tooth decay still a serious problem?

Yes. More than two-thirds of U.S. children and adolescents aged 19 years or younger, 91% of U.S. adults, and 93% of Americans aged 60 years and older have experienced tooth decay.

Will community water fluoridation benefit my family?

Fluoride’s action in preventing tooth decay benefits both children and adults throughout their lives. The health benefits of fluoridation are:

  • Fewer cavities and less severe cavities.
  • Less need for fillings and tooth extractions.
  • Less pain and suffering associated with tooth decay.
  • Better self-esteem from teeth that work well and look good.
  • See the The Benefits of Fluoride statement from the Office of the Surgeon General

Have Americans had less tooth decay since water fluoridation began?

Yes. Independent studies initiated in 1945 and 1946 followed four communities and assessed the value of water fluoridation. By 1960, tooth decay rates in these communities declined, on average, 56% more than in demographically similar communities whose water supplies were not fluoridated. Now that there are additional ways of obtaining fluoride benefits such as in toothpaste, rinses, and professional treatments, as well as in many foods and beverages produced in fluoridated areas; more recent studies show that water fluoridation reduces tooth decay in permanent teeth by approximately 18%—40%. Although this reduction in decay is not as dramatic as it was in the 1950s and 1960s, it continues to be significant when compared with tooth decay in many nonfluoridated communities.

Is community water fluoridation a cost-effective method for disease prevention?

Yes. In 2004, an estimated $78 billion was spent on dental services, representing about 5% of all expenditures for personal health care in the United States. A CDC study estimated that every $1 invested in community water fluoridation saved $38 in avoided costs for dental treatment. The national average cost to fill one cavity with dental amalgam is approximately $65—the approximate cost of providing fluoridation to an individual for a lifetime.

Safety and Fluoridation

Is community water fluoridation safe?

Yes. Extensive research conducted over the past 60 years has shown that fluoridation of public water supplies is a safe and effective for all community residents. More recent reviews of the safety of water fluoridation include a comprehensive review of the scientific literature by the U.S. Public Health Service in 1991 and by the University of York in 2000. Additional information on safety can be viewed.

The overall value and safety of community water fluoridation has been endorsed by:

  • CDC.
  • U.S. Surgeons General (Oral Health in America and other reports).
  • U.S. Task Force on Community Preventive Services.
  • American Dental Association.
  • American Medical Association.
  • American Association of Public Health.
  • U.S. Public Health Service.
  • World Health Organization.

Can I use fluoridated water for preparing infant formula?

Yes. You can use fluoridated water for preparing infant formula. However, if your child is exclusively consuming infant formula reconstituted with fluoridated water, there is the increased potential for mild dental fluorosis, which is a white spotting on teeth. Additional information can be found in a fact sheet on Infant Formula.

Fluoride in Drinking Water

How can I find out the fluoride concentration of my drinking water?

All public water systems are required by the U.S. Environmental Protection Agency (EPA) to publish an annual Consumer Confidence Report with information about their drinking water, including the fluoride level.

If you are on a public water system, you can call the water utility company and request a copy of the utility’s most recent Consumer Confidence Report.

If you live in a state that participates in CDC’s My Water’s Fluoride you can go online and find information on your water system’s fluoridation status.

My home gets it water from a private well. What do I need to know about fluoride and groundwater from a well?

Although most U.S. households are connected to a public water system, the U.S. Geological Survey estimates that approximately 14% of U.S. residents rely on private wells that are not regulated by the EPA Safe Drinking Water Act. Fluoride is present in virtually all waters at some level, and it is important to know the fluoride content of your water since too little may not protect against tooth decay and too much may be a health concern. It is recommended that you have a sample of your well water analyzed by a laboratory. If you have water fluoride levels under 0.6 ppm, your child’s dentist or pediatrician should evaluate whether your child can benefit from daily fluoride supplements. Their recommendation will depend on your child’s risk of developing tooth decay and as well as exposure to other sources of fluoride (e.g., drinking water at school or daycare, toothpaste). If the natural fluoride level of your well or community drinking water is greater than 2 ppm, you should consider an alternate source of drinking water for any child 8 years and younger. Their teeth are still developing and will be at risk for enamel fluorosis. If you have an infant which is predominately consuming infant formula reconstituted with water with fluoride greater than 0.7 mg/L, you may wish to review the fact sheet on Infant Formula and the Risk for Enamel Fluorosis. If you have additional questions on your well and fluoride levels, please see the Fact Sheet on Private Well Water and Fluoride FAQs.

How much does it cost the community to fluoridate the water?

The per person cost of fluoridation varies by the size of the community population. The average cost of providing fluoridated water to communities with more than 20,000 residents is about 50 cents per year. For communities of 10,000–20,000 residents, the cost is about $1, and for those living in communities of less than 5,000, the cost is about $3 per year.

Will using a home water filtration system take the fluoride out of my home’s water?

Removal of fluoride from water is difficult. Most home treatment systems are installed at single faucets and use activated carbon filtration, which does not remove fluoride.

If your fluoride level is above 2 ppm and you are trying to reduce the amount of fluoride in your water a home device must meet National Sanitation Foundation (NSF) Standard 58 criteria for fluoride removal. The Standard 58 requirements are for a device to achieve a 1.5 milligrams per liter (mg/L) concentration in the product water if the original concentration was 8.0 mg/L, or approximately an 80 percent removal. This percentage removal may not be consistent at lower concentrations of fluoride. Check with the manufacturer of the individual product for specific product information. If you are concerned about the fluoride level in your home water (above the level of 2 mg/L), you may consider using water from a commercial bottler whose water has the level of fluoride you desire as an alternative to removing the fluoride.

Fluoride is not released from water when it is boiled or frozen. One exception would be a water distillation system. These systems heat water to the boiling point and then collect water vapor as it evaporates. Water distillation systems are typically used in laboratories. For home use, these systems can be expensive and may present safety and maintenance concerns.

Does bottled water have fluoride?

Some bottled waters contain fluoride but most do not. The U.S. Food and Drug Administration (FDA) does not require bottlers to list the fluoride content of water, and only requires that if fluoride is added, the additive used be listed. Most bottlers will use National Sanitation Foundation certified additives for quality control. If you are interested in the fluoride content of a specific water brand, you should ask the bottler. In 2006, the FDA announced that bottled water with greater than 0.6 and up to 1.0 mg/L could be labeled with the statement “Drinking fluoridated water may reduce the risk of tooth decay.” Additional information is available in our Fact Sheet on Bottled Water and Fluoride.

Does water fluoridation result in pipe corrosion or increased lead in drinking water?

Water fluoridation does not increase corrosion of pipes or cause lead to leach (dissolve) from pipes and household plumbing fixtures. Although lead in public drinking water is typically found to be very low or is below laboratory detection, there are locations where old lead pipes, solder, or plumbing fixtures in old homes may leach lead into water. This is principally a problem in some older homes because newer homes have been constructed in accordance with new plumbing standards that prohibit the use of lead in plumbing pipes and fixtures.

Ask your local water utility system if there have been problems with higher lead levels in water from older homes in your community. Claims that fluoride might result in increased lead leaching from pipes and fixtures have not been substantiated in the peer-reviewed literature.

Regulations, Standards

What standards does the U.S. Environmental Protection Agency (EPA) set for levels of fluoride in water?

The EPA establishes criteria for safe drinking water under the Safe Drinking Water Act and its amendments (1974, 1986, and 1996). These standards include the maximum contaminant level goal (MCLG), the maximum contaminant level (MCL), and the secondary maximum contaminant level (SMCL).

The MCLG is a health goal set at a concentration to minimize adverse health effects. This goal is not enforceable and serves as an advisory to the states. The MCL is an enforceable regulatory standard that is set as close to the MCLG as practical, taking into consideration factors such as treatment technology and costs. The SMCL is a nonenforceable secondary standard that, in the case of fluoride, provides guidance on cosmetic or aesthetic considerations related to tooth enamel fluorosis.

In 1986, the EPA established an MCLG and MCL for fluoride at a concentration of 4 milligrams per liter (mg/L) and an SMCL of 2 mg/L. The Safe Drinking Water Act requires periodic reassessment of regulations for drinking water contaminants.

Does the U.S. Food and Drug Administration (FDA) or U.S. Environmental Protection Agency (EPA) regulate fluoride added to drinking water?

The EPA and FDA established in a 1979 Memorandum of Agreement that the EPA would regulate drinking water for public water systems and the FDA would regulate consumer beverages, including commercial bottled water. The EPA has issued maximum drinking water contaminant standard for fluoride of 4 mg/L, based on health considerations, and has entered into an agreement with National Sanitation Foundation (NSF) International to formulate program standards for drinking water additives. Those standards are known as NSF/ANSI (American National Standards Institute) Standard 60. The FDA requires bottlers to list the chemical used to adjust the fluoride concentration, and permits manufacturers to claim the benefits for improved oral health when fluoride is adjusted to a range of 0.6 to 1.0 mg/L.

How does the release of the 2006 National Research Council (NRC) report affect the standards set by the EPA?

On March 22, 2006, the NRC issued the committee’s report, Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. The report addresses the safety of high levels of fluoride in water that occur naturally at levels of 2 mg/L and higher, and does not question the use of lower levels of fluoride to prevent tooth decay. The findings are consistent with CDC’s assessment that water fluoridation at optimal levels (0.7 mg/L–1.2 mg/L) is beneficial for good oral health. For more information on this report and other publications by the National Academy of Sciences referencing fluoride in drinking water, see the findings on National Academy of Sciences on Fluoride in Drinking Water.

The recommendations from CDC remain the same—that community water fluoridation is safe and effective for preventing tooth decay. CDC continues to recommend steps to prevent moderate and severe enamel fluorosis; these recommendations were made in the August 17, 2001, MMWR report, “Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States” . These steps include using an alternate water source for children aged 8 years and younger if the primary drinking water source has naturally occurring fluoride above 2 mg/L, and supervising the use of toothpaste by children younger than 6 years to prevent swallowing excess toothpaste. Fluorosis can only occur when the teeth are developing (ages 0 to approximately 8) Other steps to prevent fluorosis include: Parents should place only a pea-sized amount of toothpaste on the child’s brush. Children under age 6 should not use fluoride rinses as they are prone to swallow them. Check with your child’s medical doctor or dentist about the use of dietary fluoride supplements if you live in an area with low levels of fluoride in your water.

Fluoride Additives for Water

What additives are used to fluoridate water?

Fluorosilicic acid is the most commonly used additive for water fluoridation, followed by two dry additives—sodium fluorosilicate and sodium fluoride. Fluorosilicic acid is derived from production of phosphate fertilizers. Phosphate rock which is comprised of calcium phosphate, calcium fluoride, apatite ore, and limestone, is mixed and heated with sulfuric acid to form a phosphoric acid-gypsum slurry, the starting point to make pelletized phosphate fertilizers. The hydrogen fluoride and silicon tetrafluoride that would otherwise be left in the gypsum slurry is deliberately recovered from the slurry by evaporators and condensed to a high purity fluorosilicic acid that can be used for water fluoridation. Both sodium fluorosilicate and sodium fluoride are created by neutralizing fluorosilicic acid with either sodium chloride (table salt) or caustic soda. See Water Fluoridation Additives for a more detailed explanation.

Do these additives have to meet standards for quality and purity?

The American Water Works Association (AWWA) prepares standards for the manufacturing, quality, and verification of the fluoride additives. NSF/ANSI (National Sanitation Foundation/American National Standards Institute) prepares standards that cover impurities of drinking water treatment additives from their production and distribution to user, and documents the purity of additives. Verification testing by independent certification entities including NSF and Underwriters Laboratories documents that the actual purity exceeds the NSF Standard 60 requirements.* A key concept is that an additive should not add more than 10% of the EPA-established MCL (Maximum Contaminant Level) of any regulated drinking water substance in order to ensure the protection of the public. The NSF/ANSI standard 60 was developed by a consortium of associations, including NSF International, AWWA, ANSI, the Association of State Drinking Water Administrators, and the Conference of State Health and Environmental Managers.

Is fluorosilicic acid the residue of the production of pesticides, rodenticides, or the nuclear industry?

No. It is a valuable coproduct derived from the production of fertilizer. It is not derived from pesticide, rodenticide, or nuclear power production.

Date last modified: February 2, 2010

Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion

From 4-16-2010

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