Fluoride in water – what’s the fuss?

tap water with fluorideClaire Dewshi explores the arguments behind water fluoridation and why she believes it is such an important step to tackle child decay.

On the 23 of September 2021, the chief medical officers across the UK agreed that fluoride is safe to add to drinking water. They confirmed it would help bridge the health gap inequality seen between the richest and poorest parts of society, and reduce the incidence of dental disease.

You may think that this sounds pretty obvious. You would even be forgiven if you assumed that there was already fluoride added to your water.

However, the history between the public and water fluoridation is turbulent. The evidence review, which was just published, is a welcome sign.

Living in a time when vaccines are questioned, 5G phone masts are blamed for causing cancer, and more and more people are becoming ‘experts’ after a 10-minute Google search, it is refreshing to know that the powers higher up are making decisions that benefit the health of the nation.

This is a small step, and the intention is for the intervention to be in place by April 2022. The Health Bill, which will be presented to MPs, gives the Health Secretary power to authorise national water fluoridation.

So why is this such a contested topic? Where did it start, and why is it so important?

Fluoride impact

Just over one in 10 three-year-olds have tooth decay nationwide. In certain parts of England that figure rises to over one in four. Considering these teeth have only been in the mouth for 12-24 months by this time, this is a solemn statistic.

The exact number varies between different areas related to socio-economic factors; children in northern parts of England are twice as likely to have dental decay compared to their counterparts in the east.

Last year, 35,190 children under 19 were admitted to hospital for the extraction of carious teeth in England. This cost the NHS £33 million.

Tooth decay is an entirely preventable disease related directly to the volume and frequency of sugar consumption, the bacteria on your teeth, and the strength of the tooth surface.

Exposure to fluoride in toothpaste, or indeed in water, means this mineral incorporates itself into the tooth’s enamel creating a surface that is less prone to acid attack and demineralisation.

Artificially fluoridated water is an easy way to deliver this key mineral to every household. This is especially important to those families who struggle to obtain fluoride from dental interventions, or from regular brushing.

Fluoridation history

Fluoride naturally occurs in water. However, its concentration can vary depending on geographic location.

Around 10% of the UK population have the optimum level of 1ppm in their drinking water. Durham and Essex naturally have over 0.5ppm fluoride in the water, whereas Birmingham, and Yorkshire and The Humber have fluoride added to reach 1ppm.

In these fluoridated areas, the incidence of dental caries reduces by up to 28% (Kazmi, Ismail and Kazmi, 2021).

So, if some regions are already doing it, why did it take so long to agree to national water fluoridation? This comes down to two main arguments:

  • Overdose of fluoride is toxic – leading to public hesitation
  • Supplying the country with fluoridated water means citizens don’t get to choose if they receive artificial fluoridation or not.

Evidence – fluoride, fluorosis, fatality

Overdose of fluoride can cause nausea, vomiting, pain and gastro-intestinal upset. In severe cases, it is lethal.

However, to reach these probably toxic doses (PTD) you would need to ingest 5mg/kg of fluoride (Whitford, 1987). For an average five-year-old child who weighs 18kg, that’s 90mg of fluoride in one go.

There is 1mg of fluoride per litre of water. So to reach anywhere near the toxic dose, your child would need to drink 90 litres of water. Remember, fully grown adults should drink two litres a day. And even that sometimes is a struggle.

So we can safely say children aren’t going to overdose on fluoride when trying to quench their thirst.

Fluorosis is a more realistic compilation of excess fluoride. It occurs if we ingest too much fluoride during tooth formation (which starts in utero) as it alters the protein and mineral interactions.

It can manifest in the mouth as white-opaque patches, or white horizontal lines. In very severe cases, the tooth can become chalky and even lead to enamel breakdown.

This however only occurs if the level of fluoride in the water is above 1.5ppm (DenBesten and Li, 2011). The new fluoridation schemes would aim to maintain a level at 1ppm, specifically for this reason.

Of course, we should take fluoride in toothpaste and mouthwashes into consideration. Although an adult won’t swallow these products, a child may ingest more than they spit out.

It is therefore essential that parents or guardians supervise brushing up to the age of seven. Not only to ensure that they are using the toothbrush effectively and for a full two minutes, but also to prevent swallowing of dental products.

Mass fluoridation, mass medication

Some people oppose fluoride on ethical grounds. They claim that it is a form of ‘mass medication’ and, as we rightly advocate, everyone should have a choice about their healthcare.

However, fluoride is a mineral, not a medicine.

Just recently on the 21 of September 2021, two days before the fluoride review, the government announced the proposal to add folic acid to flour in the UK. The aim is to decrease neural tube defects.

Folic acid in the first four weeks of pregnancy is vital to the development of the fetus. Educating young women on the importance of this micronutrient has had limited effect (just like educating the population of the importance of fluoride in daily oral hygiene).

When the government announced this proposal, there wasn’t an outcry or backlash. Indeed many bodies and women applauded the result.

It is therefore difficult to believe that something so similar, like national water fluoridation, can cause such unrest.

Conclusion

The benefits of fluoride is something that we have known about for over 60 years. And the addition of fluoride to oral hygiene products is so commonplace that you would struggle to find a product without it. We know from looking worldwide, and at regions within the UK, that fluoride at 1ppm is a safe and effective way to prevent dental caries.

I, for one, am pleased to know that future generations are less likely to experience pain and complications from tooth decay following this national rollout.

Who knows, maybe one day, the incidence of decay will be so low that dentists across the country will be made redundant. Until that day, all I can say is spit don’t rinse, and stay hydrated.


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References

DenBesten P and Li W (2011) Chronic Fluoride Toxicity: Dental Fluorosis. Fluoride and the Oral Environment 81-96

Kazmi A, Ismail M and Kazmi N (2021) Why do children still have preventable caries? BDJ Team 8(2): 10-1

Whitford G (1987) Fluoride in Dental Products: Safety Considerations. J Dent Res 66(5): 1056-60

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