Abagaile Gehrke

The Efficacy and Ethicality of Fluoridating Water

Fluoride is a compound of fluorine, a naturally occurring chemical element. It is used

mainly in the oral health field as a treatment and prevention method for ailments such as caries

(commonly known as cavities) and white spot lesions. Some of the main forms of fluoride are in

toothpastes, mouthwashes, varnishes, tablets, and in drinking water. Fluoride varnishes are a

very common treatment used for preventing and treating caries at any dental office, and

fluoridated toothpastes and mouthwashes are commonplace for many people. Some, however, do

not agree that fluoride is beneficial. It is argued that fluoride is a health risk not worth the

questionable good results. The one form of fluoride that is most greatly disagreed upon is

fluoridated water. The CDC (2016, para. 5) says that “community water fluoridation is

recommended by nearly all public health, medical, and dental organizations”, yet there are still

many people, both professionals and patients, who do not trust the safety of fluoridated water. It

is important to look at the facts and research behind this issue and make an informed opinion.

For patients (the general public) knowing both the benefits and dangers can help them to make

the choice of whether or not to receive fluoride treatments. For professionals, having more

information on fluoride can help them know when it may or may not be appropriate to use these

types of treatments on patients, if at all. It will also prepare them to answer possible questions

patients may have about it, or to advise for or against it. Being educated on fluoridated water is

beneficial when a community decides to fluoridate its water or not, or to stop the fluoridation.

This topic interests me because it is so debated in the dental health field, and no one, it seems,

has come to a clear and fact-based conclusion.

 Fluoride is a naturally occurring mineral and is released “from rocks into the soil, water,

and air” (CDC, 2016, para. 1). It can be found in all water at varying levels; the common level of

fluoride in the ocean is around 1.2 to 1.4 ppm (parts per million) (ASTDD, 2016, para. 1) while

most other sources of water usually do not naturally contain more than 0.3 ppm (Main, 2015,

para. 4). In some areas, though, natural fluoride levels can exceed 10 ppm. Fluoride also

naturally occurs in small levels in most foods and drinks, with two of the food and drinks with

the highest levels of fluoride being black tea prepared with tap water and seedless raisins (Top 10

Foods and drinks highest in fluoride, 2017, para. 5,6).

Starting in the 1930’s, scientists began to observe the effect of fluoride on tooth decay,

and “after much scientific research, in 1945, the city of Grand Rapids, Michigan, was the first to

add fluoride to its city water system in order to provide residents with the benefits of fluoride”

(CDC 2016, para. 6,7). This was the beginning of the use of water fluoridation and other forms

of fluoride in dental care. Fluoridated water is now used in about 74.7% of the United States

(CDC, 2016, Table 1) and is used in a few other countries (Nordqvist, 2016, para. 10).

Along with fluoridated water, other substances containing the mineral such as toothpaste,

mouthwash, tablets, and varnishes are now commonly used to treat and prevent dental caries,

another name for tooth decay, and white spot lesions, white spots on a tooth most commonly

caused by demineralization of enamel (Abdullah, 2016, para. 1). Fluoride prevents and treats

these problems by interacting with the compound that makes up tooth enamel, hydroxyapatite

(which is what is affected by caries and white spot lesions), and forming a stronger compound

(Helmenstine, 2017, para. 2,4). This strengthens the tooth enamel, preventing further decay, and

even remineralizing damaged enamel. There was a trial done in Brazil published in 2012 in the
Community Dentistry and Oral Epidemiology journal that researched the efficacy of using a 5%

Fluoride varnish to slow down the progression of decay in dental caries (Arruda, Senthamarai

Kannan, Inglehart, Rezende, & Sohn, 2012). The trials used two groups of children ages 7-14

with caries, with one group receiving the fluoride varnish treatment and the other group getting

the placebo treatment. The rate of decay was then assessed 3 times during the 12 month trial. The

trial found that the rate of decay was significantly slower for the children in the group receiving

the varnish than for the children getting the placebo treatment. They concluded that “the results

of this study suggest that applications of 5% [fluoride] varnish can be recommended as a public

health measure for reducing caries incidence in this high-caries-risk population” (Arruda et al.,

2012, p. 267). This trial shows that the topical application of fluoride on teeth, in the form of

varnishes, toothpaste, and mouthwashes, does have an impact on dental caries. Some argue,

however, that fluoridated drinking water does not have the same effect on dental caries because it

does not remain on the teeth as the varnish form does. Research done in New South Wales,

Australia found otherwise. Analyzing the prevalence of dental caries in three different areas

(fluoridated, pre-fluoridated, and non-fluoridated) in over 1,000 5-7 year old children, they found

that “the children living in the well-established fluoridated area had less dental caries and a

higher proportion free from disease when compared with the other two areas which were not

fluoridated. Fluoridation demonstrated a clear benefit in terms of better oral health for young

children”(Blinkhorn et al., 2015, p. 1). In some studies, though, it is observed that when

fluoridation in drinking water is stopped, there is no significant increase in dental caries.

So why continue fluoridating water when the benefits are questionable? Because it is the

only way to get dental help to those who cannot otherwise afford it. In the U.S., around 130
million people do not have dental insurance and cannot afford to pay for dental care when they

need it (Weissmann, 2015, para. 1). So fluoridated drinking water is one of the only ways to give

them dental care. Also, “community water fluoridation has been shown to save money, both for

families and the health care system. The return on investment for community water fluoridation

varies with size of the community, increasing as the community size increases. Community

water fluoridation is cost-saving, even for small communities” (CDC, 2016, para. 9).

Fluoride does treat and prevent dental caries and WSLs, but it can also be toxic in certain

doses. An intake of high fluoride levels can cause mild to severe dental fluorosis, a “condition

[that] is characterized by failure of tooth enamel to crystallize properly leading to defects such as

brittleness, staining that is barely noticeable to severe brown stains and surface pitting”

(Srivastava, 2017, para. 2), Kidney toxicity, and Gastrointestinal problems, such as “erosion of

the mucosal lining of the stomach, duodenal ulcers and long-term inflammation of the stomach

lining” (Srivastava, 2017, para. 4). Fluoride can also have a great impact on children in their

early years and even in their mother’s womb. A study done in Mexico looked at mothers while

pregnant and the level of fluoride in their urine and later in their children’s urine when they were

6-12 years old. They then measured the children’s intelligence quotient (IQ) and compared it to

the amount of fluoride exposure while in the womb. They “found that an increase in maternal

urine fluoride of 0:5 mg=L … predicted 3.15 … and 2.50 … lower offspring GCI and IQ scores,

respectively” (Bashash et al., 2017, p. ?). One of the possible problems with this study is that

researchers cannot tell for sure whether the children’s lowered IQ was caused by exposure to

fluoride in the womb, or if it was exposure after birth. Either way, exposure to high levels of

fluoride has been shown to lower children’s IQ. Another study that got similar results was
looking at 219 children aged 12-14 years old and the effect different fluoride levels had on their

intelligence quotient. They had participants from three different areas with three different levels

of fluoride, 0.60 ppm, 1.70 ppm, and 4.99 ppm. The results were very significant: “The

comparison of IQ score showed that 35 (46.7%) participants from the high fluoride and 10

(13.3%) participants from the medium-fluoride areas had below average IQ. Further, it was noted

that the lowest mean marks were obtained by the children in the high-fluoride region (13.9467)

followed by those in medium (18.9467) and uppermost in least noted fluoride area (38.6087)”

(Razdan et al., 2017, p. 252). These studies show that the development of children can be

compromised by certain levels of fluoride exposure. At high enough levels, fluoride can also

cause death for people of any age.

Fluoride at high levels can be a toxin, but in the United States the levels of fluoride in

drinking water are well monitored, the upper limit level being 0.7 ppm in drinking water. “The

minimum dose of fluoride that can kill a human being is currently estimated to be 5 mg/kg (5

milligrams of fluoride for each kilogram of body weight)” (Connett, 2012, para. 1), or 5 ppm,

over 5 times the legal upper limit of fluoride in drinking water. To ingest this much at the highest

legal fluoride level, an adult male would have to drink at least 1,520 glasses of water in a day,

and a baby between 0-6 months would have to drink at least 140 glasses of fluoridated water

(NFIS, 2013, Table 2). This is highly unlikely, as many people do not even drink the

recommended 8 glasses a day. It is also unlikely, however possible, that one would drink enough

fluoridated water to cause any serious side effects. The level of fluoride that can affect children

before or after birth is unknown, but one study showed that a level of 0.6 ppm did not have any

distinguishable effect (Razdan et al., 2017, p. 252), so it is unlikely that 0.7 ppm of fluoridated
drinking water being drank at normal levels by children or by pregnant women has any serious

side effects. More research should be done to determine the risk at levels that are common in the

U.S. Overall, by drinking fluoridated water and consuming the naturally occurring fluoride in

food and other drinks, the most likely negative side effects would be very mild. The other serious

side effects are more likely to be caused by ingestion of other fluoride forms, such as swallowing

a significant amount of fluoridated toothpaste or mouthwash, fluoride tablets, or swallowing the

water used to rinse off a fluoride varnish.

So are the benefits worth the risks? Despite the very serious risks that can come from

fluoride, the levels that cause them are very rare in monitored drinking sources in the U.S.

Therefore, water fluoridation is very unlikely to cause any harmful side effects and the slight risk

is worth the benefits. Research still needs to be done to determine the safest level of fluoride and

to know the possible dangers for more at-risk people (children for example). Until further

research is done and a safe level is determined, the legal upper level of fluoride in drinking water

should be lowered, just to be safe.

Fluoride has many benefits and many risks. Some people do not support fluoridating

drinking water because of the potential risks, but to ingest enough fluoride through drinking

water to cause these side effects is nearly impossible. Because of this, fluoridated water is an

effective and ethical way to prevent and treat dental caries and white spot lesions, and should be

continued in the U.S. As a future dental hygienist, I can now advise my patients on whether or

not they should receive fluoride treatments and will be able to educate them on the benefits and

risks.
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