The ongoing debate regarding the addition of fluoride to tap water is not a new one.
For the past 60 years, this practice has aimed at reducing tooth decay.
However, with the widespread availability of fluoride toothpaste in the 1970s, questions have arisen about the necessity of still adding it to the drinking water supply.
Recent remarks by Robert F Kennedy Jr, the health secretary pick for Donald Trump, advocating for a ban on fluoride have reignited public discourse on the issue.
Despite RFK being known for his controversial views on public health, the topic of fluoridation cannot be completely dismissed.
Studies in the US have linked fluoride to lower children’s IQ levels, while in the UK, concerns have been raised about its overall effectiveness when added to water.
So, what is fluoride, what do experts say, and what is the situation in the UK?
What is fluoride and what does it do?
Fluoride is a natural mineral found in rocks that seeps into soil, rivers, and lakes.
It promotes dental health by strengthening tooth enamel, making it more resistant to decay, and reducing the acid produced by bacteria on teeth, as stated by the Oral Health Foundation.
Fluoride is particularly beneficial for children’s dental health, as previous studies suggest that ingesting it during tooth development strengthens enamel, making it more resistant to decay in the future.
According to Dr. Kunal Patel, a dentist with 15 years of experience, the benefits of fluoride are widely recognized in the dental community, with scientifically proven advantages of incorporating fluoride into oral hygiene routines.
Fluoride serves as a passive way to protect teeth, Dr. Patel explains.
“If you opt out of fluoride, then you need to ensure your techniques for brushing, flossing, and other cleaning methods are even more effective,” he adds.
How do we get fluoride?
While most water contains trace amounts of naturally occurring fluoride, it is usually insufficient to prevent tooth decay.
Some regions have water supplies naturally high in fluoride, a point that will be addressed later.
Fluoride is present in small amounts in many food and drinks, with brewed tea being a significant source due to tea plants absorbing fluoride from the soil.
Most toothpaste brands today incorporate fluoride for added decay protection.
When did water fluoridation start?
Many dental health experts believe that adding fluoride to water, a process known as fluoridation, is the most effective way to reduce dental issues, especially in disadvantaged areas.
The practice began in 1945 in Grand Rapids, Michigan, after researchers observed lower rates of tooth decay in areas with naturally higher fluoride levels in tap water.
In England, water fluoridation began in 1964 with a pilot program in Birmingham.
Over the years, fluoridation has been implemented for about 75% of the US population and around 10% in England.
According to the World Health Organization (WHO), around 400 million people in 25 countries receive artificially fluoridated water, while about 50 million have naturally high fluoride levels.
What is the recommended fluoride level in water?
The WHO suggests a maximum level of 1.5mg per liter.
This level aims to strike a balance where tooth decay is minimized without causing dental fluorosis or skeletal fluorosis.
Dental fluorosis is a common cosmetic condition resulting from excessive fluoride ingestion during tooth development, leading to white flecks, spots, or lines on teeth.
Skeletal fluorosis, a rare condition, is a chronic bone and joint disease caused by high fluoride consumption.
The UK government aims for fluoride levels of 1mg per liter in drinking water, while levels are kept around 0.7mg per liter in the US.
Potential risks to children’s IQ
Fluoridation has been a divisive issue in the US, with over 100 lawsuits attempting to halt it, according to the American Fluoridation Society.
The anti-fluoride group Fluoride Action Network reports that over 150 US towns and counties have voted against fluoride in public water systems.
Concerns spiked earlier this year when a US government report linked fluoride levels in drinking water above the recommended limit to lower IQ in children.
The report, based on a study published in JAMA Pediatrics, found slightly lower IQ levels in children whose mothers had higher fluoride levels in urine during pregnancy.
In September, a California judge ordered the EPA to review fluoridation regulations, citing a potential risk to children.
The judge emphasized that he was not conclusively stating that fluoridated water poses a public health threat, but rather a risk.
Debates on fluoride’s effectiveness
In the UK, while the government is considering increasing fluoride levels and expanding their distribution, a comprehensive review suggests that fluoridation might only have a minimal benefit.
A study by academics at Manchester, Dundee, and Aberdeen universities compared 157 studies on the impact of fluoridation on dental health.
In the early stages of water fluoridation, the number of decayed, missing, or filled teeth decreased by two among children with baby teeth on average, researchers revealed.
However, as fluoride toothpaste became prevalent, this number decreased, now equating to an average reduction of a quarter of a tooth that is decayed, missing, or filled.
“Water fluoridation has only a slight impact on dental caries, and these benefits may take time to materialize,” noted Professor Anne-Marie Glenny of the University of Manchester, a co-author of the study.
Could fluoride be discontinued in the US?
Mr. Kennedy Jr. has stated that Mr. Trump plans to eliminate fluoride from drinking water as soon as he takes office, referring to it as “industrial waste” in a statement.
He also linked fluoride to various health issues, but no conclusive studies support these claims.
While Mr. Trump expressed openness to the idea, the decision to add fluoride to water is ultimately left to state and local authorities, with the federal government only providing guidance.
‘Balancing risk and benefit’
Professor Stephen Peckham, a health policy expert at the University of Kent, led a study on fluoride’s potential impact on hypothyroidism and is currently part of a team investigating its effects on IQ in the UK.
He acknowledges the benefits of fluoride but questions its necessity, especially in water.
“We know that ingesting fluoride is not an effective method of preventing tooth decay,” he states. “If you want fluoride, use it on your toothbrush. It should be applied directly to the tooth and not swallowed.”
While he notes limited benefits, the US study on children’s IQ raises concerns about the neurotoxic effects of fluoride ingestion.
“We know that fluoride ingestion has a neurotoxic effect. The level at which this effect occurs is less certain,” he explains.
“The judge’s argument is, shouldn’t we be more cautious? Shouldn’t we limit pregnant women’s exposure to fluoridated water? The maximum fluoride intake depends on water consumption. The more you drink, the more fluoride you get.”
He emphasizes the importance of balancing risk and benefit, stating that if there is minimal benefit, there should not be any risk.
‘Focus on disadvantaged regions’
Dr. Kunal Patel, owner of six dental clinics in Surrey, believes fluoridation was beneficial when dental education and fluoride toothpaste were less accessible.
However, he now suggests a more targeted approach, limiting fluoridation to rural or deprived areas where it can have a greater impact.
He highlights the need for education in areas where dental health is poor, advocating for providing toothpaste to schools and enhancing dental health education rather than fluoridating water.
A spokesperson for the Department of Health and Social Care emphasized the role of water fluoridation in reducing tooth decay and keeping children out of hospitals.
Is your water fluoridated?
About 330,000 people in England have natural fluoride in their drinking water, while approximately 5.8 million receive artificially fluoridated water.
Artificial fluoridation is present in about 10% of areas in England, primarily in the West Midlands and North East.
Fluoridation is not practiced in Wales, Scotland, or Northern Ireland.
The following areas in England receive artificial fluoridation according to the British Fluoridation Society:
- Cumbria – 120,000
- Cheshire – 137,000
- Tyneside – 643,000
- Northumbria – 101,000
- County Durham – 85,000
- Humberside – 136,000
- Lincolnshire – 250,000
- Nottinghamshire – 287,000
- Derbyshire – 43,000
- Birmingham – 1,000,000
- Solihull – 200,000
- Coventry – 300,000
- Sandwell – 300,000
- Dudley – 305,000
- Walsall – 253,000
- Wolverhampton – 236,000
- Staffordshire – 497,000
- Shropshire – 22,000
- Warwickshire – 431,000
- Worcestershire – 253,000
- Bedfordshire – 198,000
The following areas receive the “optimal” amount of natural fluoride:
- Hartlepool, County Durham – 89,000
- Easington, County Durham – 47,000
- Uttoxeter, Staffordshire – 13,000
- Redbridge, London Borough – 180,000
Where could fluoride be added next?
The government had proposed expanding fluoridation schemes in England’s North East region due to dental health inequalities.
A public consultation was conducted on the expansion plans, though it remains uncertain if they are still being pursued under the current government.
The proposed areas for fluoride extension include:
- Darlington
- Durham
- Gateshead
- Hartlepool
- Middlesbrough
- Newcastle
- Northumberland
- North Tyneside
- Redcar and Cleveland
- South Tyneside
- Stockton
- Sunderland