Community water fluoridation (herein called simply “fluoridation”) is the precise adjustment of the concentration of the essential trace element fluoride in the public water supply to protect teeth and bones. In 1945 Grand Rapids, Michigan, became the first city in the world to fluoridate its public water supply. Since then, communities throughout the United States have adopted the practice. Fluoridation is similar to food fortification and enrichment, which encompass the addition of iodine to table salt; vitamins to fruit drinks, milk, and various kinds of pasta; and vitamins and minerals to breakfast cereals and bread. Fluoridation is the perfect public health intervention. Whole towns are protected in a nondiscriminatory manner. The protection is continuous and effortless to obtain. The fluoride in the water is incorporated into the enamel of developing teeth in children below the age of 16, making their teeth more resistant to decay for a lifetime. It also promotes remineralization of early decay in adults and interferes with the life cycle of decay-causing bacteria present in the mouths of both children and adults.

Fluoridation is remarkably simple to implement and mimics nature: Virtually all sources of drinking water in North America naturally contain some fluoride. Fluoride levels in the United States are adjusted to about one part fluoride per million parts of water — a minute concentration.

The Antifluoridationists

While only a minuscule percentage of Americans opposes fluoridation, an extremist minority urges avoidance of fluoridation. These antifluoridationists or flurophobics falsely allege that it is unsafe, ineffective, or costly. They assert that exposure to fluoridated water increases the risk of contracting AIDS, cancer, Down’s syndrome, heart disease, kidney disease, osteoporosis, and many other health problems. But the overwhelming weight of scientific evidence confirms fluoridation’s safety and effectiveness, and hundreds of peer-reviewed studies on fluoride have discredited antifluoridation propaganda. Almost at the moment Grand Rapids became the first community to adjust the fluoride content of its water supply, small groups of ill-informed people began objecting to water fluoridation. Early opponents included chiropractors, health food advocates, and members of fringe political and religious groups. The convergence of such individuals and groups led to the formation of small but highly active regional societies whose primary mission was to fight fluoridation. Most of these organizations lacked the funds, political expertise, or scientific credibility to have an impact outside their respective communities. Eventually, however, a few better-funded national organizations appeared whose agendas included opposition to fluoridation. By exploiting scientific illiteracy, common phobias, paranoia concerning communist plots and Big Brotherism, and occasional acceptance of folk medicine, these organizations persuaded a minority of Americans. Their tactics included attracting the media; holding demonstrations at the local-government level; promoting referenda; lobbying public health agencies, state legislatures, and the United States Congress; and litigating at state and federal levels. The effects of such activities did not have lasting importance, and antifluoridation efforts have diminished significantly in recent years. Today, most fluoridation initiatives are successful; court challenges by antifluoridationists are rare; and effective antifluoridation lobbying at both state and federal levels is virtually nonexistent. A latter-day antifluoridationist highspot was the movement’s extensive campaign in 1995 to prevent enactment of mandatory statewide fluoridation in California. The campaign failed.

. . . And Justice for All

Despite the decrease in antifluoridation activities, they remain a factor — albeit a minor one — in the success or failure of profluoridation efforts in most American cities. The tactics of contemporary antifluoridationists tend more to delay fluoridation than to stop it, but in some areas of the United States fluoridation remains in limbo. This lack of implementation translates into tooth decay, pain, infection, and dental-care expense (see sidebar on page XX). Moreover, antifluoridation efforts cost taxpayers money by compelling defense of fluoridation to legislators, judges, and the media. But litigation, which antifluoridationists once considered the ultimate solution to the “fluoridation menace,” has failed as an antifluoridation tactic. No American court of last resort has ever ruled against community water fluoridation. And court decisions that uphold fluoridation as an acceptable public health measure within the police powers of state and local government have bolstered profluoridation efforts. Furthermore, with only two exceptions, American courts have never ruled on the scientific merits of fluoridation but have allowed the scientific method — which includes clinical research and peer review — to determine whether community water fluoridation is acceptable. In both of the exceptions, higher courts overruled lower-court judges and decreed continuance of fluoridation in the communities in question.

“Quackery” versus Science

Fluoride is harmless at the levels necessary for maximum benefits. Thousands of studies on fluorides and fluoridation have been completed in the last 50 years — more than 3,700 since 970 alone. Over 50 peer-reviewed epidemiological studies have dealt with the claim that fluoridation increases cancer risk. None has substantiated the claim. A number of nationally and internationally recognized scientific organizations, including the National Cancer Institute, have reviewed all the available scientific studies on the health of populations with fluoridated water supplies and the health of fluoride-deficient populations. These reviewers have declared fluoridation safe. Indeed, no legitimate epidemiological, laboratory, or clinical study has demonstrated that lifelong ingestion of fluoride at optimal levels in water causes disease in any form. We now have over fifty years’ experience with water fluoridation. Moreover, many generations of Americans have spent their lives in areas whose water supplies had naturally occurring fluoride levels 800 to 1,300 percent higher than the levels in fluoridated water. There is no evidence that members of communities with fluoridated water supplies, or with naturally high concentrations of fluoride in their water supplies, have had a higher incidence of any disease than have their contemporaries in areas with water supplies low in fluoride. In 1978 Consumer Reports magazine summed up the situation well: “The simple truth is that there’s no ‘scientific controversy’ over the safety of fluoridation. The practice is safe, economical, and beneficial. The survival of this fake controversy represents, in our opinion, one of the major triumphs of quackery over science in our generation.” Nearly 145 million Americans can avail themselves of water whose fluoride concentration is optimal. Of the 50 largest municipalities in the United States, 43 have fluoridated water supplies, including four of the five largest cities. Eight states, the District of Columbia, and Puerto Rico have mandated fluoridation throughout their respective territories. Three states and the District of Columbia have fluoridated all of their treatable community water supplies. Viable options to community water fluoridation as a public health measure do not exist. There are other community-based methods of fluoride delivery — school-based programs that involve rinsing the mouth with a fluoride preparation, ingesting fluoride tablets, or submitting to professional dental application of fluoride, for example. But these methods cost considerably more than community water fluoridation, are much more difficult to implement, and are available only to limited numbers of people and only under special circumstances. Such methods are useful to populations without public water systems but decidedly are second-rate.

The Bottom Line

In recent years public resistance to water fluoridation has waned across the United States, partly because of a higher level of education among voters and partly because of consumers’ positive experiences with fluoride (as an ingredient in fluoride toothpastes, for example). Healthcare reform movements have made all Americans aware of the importance of disease prevention. Federal, state, and local officials have acted on this awareness, and the pace of efforts to fluoridate America’s remaining deficient water supplies has increased markedly. Fluoridation is the high-water mark of efficient public health intervention.

Michael W. Easley, DDS, MPH, is an associate professor in the Department of Oral Health Services and Informatics, School of Dental Medicine, State University of New York at Buffalo.

Dollars and Sense

The dental benefits — and concomitant cost savings — from fluoridation have been documented for more than half a century. Here are a few facts:

* People who drink fluoridated water for a lifetime will develop up to 70 percent fewer cavities (occurrences of tooth decay) than they would have without fluoridation.
* Because the technology is so simple and the fluoride supplement so inexpensive, fluoridation is extremely cost-effective. Studies indicate that a $100,000 investment in water fluoridation prevents 500,000 cavities.
* Each dollar invested in fluoridation prevents over $80 of dental treatment. Few disease-prevention efforts, and even fewer government-sponsored programs, achieve that level of return on investment.
* The average per capita cost of fluoridating America’s public water supplies is 54 cents per year (or $40.50 over a lifetime). The cost of an average single-surface dental restoration is $55. Thus, provision of fluoride in water for a lifetime costs less than one small dental filling.

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