Please find a clickable list of Frequently Asked Questions regarding the British Fluoridation Society. Please contact us if we haven’t covered something you would like answered.
All water contains fluoride to some extent. Water fluoridation is the controlled adjustment of fluoride to a public water supply to reduce tooth decay.
Children living in fluoridated areas have less tooth decay compared with children in non-fluoridated areas. A greater percentage of children in fluoridated areas have never experienced tooth decay.
In other words, fluoridation reduces the number of children who get tooth decay in the first place. Also, among those children who do get tooth decay, fluoridation reduces the number of teeth affected by it. All this means that children who drink fluoridated water suffer less toothache and need less treatment for tooth decay. And because they have less tooth decay, they are less likely to need a general anaesthetic in order to have a decayed tooth extracted.
No, it doesn’t. Children in fluoridated areas do not have to wait longer for their primary teeth to erupt than children in non-fluoridated areas. Furthermore, studies of children aged over five years old and adults show that the benefits of fluoridation can last throughout life. It is therefore wrong to claim that the onset of caries is simply delayed.
Yes, there is evidence to show that fluoridation offers additional benefits. For example, a study published in 1985 in the American Journal of Public Health (Klein, Bohannan, Bell et al) compared the experience of children in fluoridated and non-fluoridated areas who had also benefited from a range of other interventions, including fluoride tablets, rinses, sealants, gels, toothpaste and oral hygiene lessons. In all instances, the children who had been drinking fluoridated water, in addition to receiving the other fluoride products, had lower levels of tooth decay than those who had simply used the other products.
Fluoridation is effective. But the prevalence of tooth decay depends on a wide range of factors including social class, dietary habits and regular and thorough brushing of teeth with a fluoride toothpaste. Studies suggest that, all other things being equal, tooth decay rates are higher among children from lower socio-economic groups than higher socio-economic groups. This may be due to poorer diet, a lower level of parental understanding about effective methods of oral hygiene, higher sugar consumption, and an inability to afford dental hygiene products out of a much more limited family budget than more affluent households enjoy. Ordinarily, it is to be expected that children in areas with high levels of deprivation would have a high rate of tooth decay and that those who live in very affluent areas would have a low rate of tooth decay.
Fluoridation reduces the dental health gap that normally separates children from affluent backgrounds and those from socially disadvantaged backgrounds. This has been confirmed by a team of independent researchers from the University of York. A few years ago they looked very closely at studies comparing the dental health of children from different social groups in fluoridated and non-fluoridated areas. They found that, on average, 5-year old children from the poorest social groups in non-fluoridated areas have over twice as many teeth affected by decay as those from the most affluent social groups. They also found that, in fluoridated areas, this enormous difference in dental health between the social groups is generally halved.
In other words, all children benefit from fluoridation, but the ones who benefit most are those from the least well-off families who would otherwise tend to have most decayed teeth.
Yes, fluoridation benefits adults as well as children. Most of the publicity is about children, because they are the group in the population for whom tooth decay is the most distressing and they are the ones who could be said to need fluoridation most. But studies in North Wales, Ireland and the United States have shown that adults who live all or most of their lives in a fluoridated area have between 30% and 50% fewer decayed teeth than those who live mainly in a non-fluoridated area. The benefits also extend to people aged 65 and over. We know from studies in Ireland, for example, that older people who have lived mainly in fluoridated areas have 50% less decay in the roots of teeth, which are exposed as the gums recede with age and is a difficult and costly condition to treat. So the conclusion from all this is that people who drink fluoridated water throughout their lives are more likely to keep all or most of their natural teeth.
That is because there is no direct link between whether or not an area receives one part per million of fluoride in its water supply (in some instance naturally) and whether or not dentists are allowed to set up in practice. Indeed, dentists have always been free to establish practices in whatever part of the country they wish to work in. The distribution of dental practices was well established long before the first major fluoridation schemes were introduced in Britain in the 1960s and 1970s.
The main effect of fluoride on teeth is topical (a technical term for fluoride in the saliva acting locally on the tooth surface). At this point, the fluoride does two important things. First, it helps to prevent bacteria in the mouth from producing acid that attacks the enamel on tooth surfaces. In this way, it is acting as a defender of teeth. Secondly, the fluoride helps to restore and strengthen the surface enamel on teeth that may be in the early stages of decay Thus, fluoride may help both to correct damage that may already have been done and to stave off future attacks. It is because fluoride acts topically that adults are protected from tooth decay as well as children. In fact, anyone who still has natural teeth in the mouths stands to benefit from fluoridated water.
To a large extent there is no difference at all. First, fluoride occurs naturally in all water supplies. This is how the benefits were originally discovered. Where the natural fluoride occurs at the right concentration – which is around one part of fluoride per million parts of water – it reduces tooth decay. Places in this country where this happens include Hartlepool in the North East of England and Uttoxeter in Staffordshire. However, where the natural fluoride concentration is too low (as it is in most places), it does not reduce tooth decay. Artificial fluoridation is therefore the process of topping up the natural fluoride and ensuring that it stays at or around the optimum level for dental health.
The fluoride that occurs naturally as a result of being dissolved from rocks by the water it comes into contact with, is identical to fluoride that is added in tiny quantities at the waterworks. Chemically, natural and artificial fluoride exist in water as the simple fluoride ion. So, in an area where the water has had its fluoride artificially topped up, it is not possible to distinguish between those fluoride ions and the fluoride ions that were there anyway.
All children should be encouraged to brush their teeth at least twice a day, and all children should be encouraged not to eat too many sweets and sugary foods and not to drink too many sugary drinks. But all the evidence suggests that fluoridating water is the single most effective step we can take to reduce tooth decay generally, both among children and among adults, and irrespective of personal behaviour. Drinking fluoridated water and observing good personal oral hygiene is the ideal combination.
Like toothbrushing and avoiding sweets, milk fluoridation depends on individual compliance. Unlike water fluoridation, it is not a population-level intervention with all the benefits that such interventions bring in terms of reaching the most vulnerable groups. Whilst some studies have suggested that milk fluoridation programmes may be effective in reducing caries, a number of practical issues have been identified which may reduce their overall effectiveness across an overall population. These include problems with distribution of fluoridated milk to schools and difficulties in obtaining parental consent or sustained compliance with the programme.
Several European countries, including France and Germany, have opted to fluoridate salt. So have a number of South American countries. However, this is often because the complexity of the water supply system means that fluoridating water is not technically feasible or would be disproportionately expensive. Where water fluoridation is feasible, it is a more reliable and effective method of protecting an entire population. Nevertheless, the fact that some countries use salt fluoridation underlines their confidence in fluoride for the purpose of reducing tooth decay.
First, there is the experience of communities where people have been drinking naturally fluoridated water for a very long time. Secondly, there is the experience of communities where people have, for over 60 years, been drinking water whose natural fluoride content has been adjusted to the optimum level. Today, over 300 million people in some 30 countries around the world are served by water fluoridation schemes.
There has been no evidence of any harmful effects from fluoridation. Many leading medical and scientific bodies from the UK, the United States and other countries have carried out detailed studies to verify the safety of fluoridation. Consistently, they have found no evidence of harm, but plenty of evidence that fluoridation successfully reduces tooth decay.
Fluoride is no different from any other substance – salt, iron, vitamins, oxygen or even water itself – in that it can potentially be harmful at a particular concentration or if a particular quantity is consumed. However, fluoride in water at a concentration of one part per million (or 1 mg per litre) is not associated with any harmful effects.
No. Many of the world’s leading cancer experts have closely compared cancer trends and found no evidence of any link with fluoridated water. For example, in 1985 a scientific working party led by Professor George Knox from the University of Birmingham Medical School concluded that fluoridation does not have any effect on people’s risk of getting or dying from cancer. In 1993, the US National Cancer Institute conducted a study which found no relationship between fluoridation and cancer. In 1999/2000, an independent team of researchers at the University of York reviewed 26 different studies that had previously been carried out to see whether cancer rates went up after people started drinking fluoridated water. Having looked in detail at all the evidence, the York scientists concluded that there is no link between fluoride and any type of cancer.
A few years ago, researchers from the University of York looked at a total of 29 studies that had previously been carried out around the world to see whether bone fractures increased after people started drinking fluoridated water. They found that some studies show people in fluoridated areas are at a slightly lower risk of bone fractures than people in non-fluoridated areas. In about a similar number of studies, they found that people in fluoridated areas might have a slightly higher risk. Other studies suggested that there was no difference either way. All in all, the scientific evidence would appear to show that there is no link between fluoridation and bone fractures.
Toothpaste is not generally swallowed by adults, who spit it out after brushing their teeth. To ensure that children do not swallow fluoride toothpaste, their parents are advised to supervise them during toothbrushing up to the age of six and to place only a pea-sized amount or thin smear of toothpaste on the brush.
As far as fluoride in food is concerned, the Food Standard Agency’s total diet survey of the UK population in 1997 estimated that the average consumption per person amounted to 1.2 mg per day, compared with a slightly higher figure of 1.8 mg per day nearly ten years earlier. It does not appear, therefore, that there has been an increase in the amount of fluoride consumed from food during that period.
There is no credible evidence linking fluoridated water with thyroid problems. At least three major reviews of the scientific literature have confirmed this over the past thirty years. For example, in the 1970s the Royal College of Physicians concluded that there was no evidence that fluoride is responsible for any disorder of the thyroid, including goitre, which is caused by iodine deficiency.
For reasons that are not directly related to fluoridation, it is standard practice for the renal dialysis equipment to include reverse osmosis, which effectively removes most of the fluoride from the water being used in the dialysis process. The National Kidney Foundation in the United States recommends adherence to the standards for dialysis equipment set by the Association for the Advancement of Medical Instrumentation in 1981, which includes a haemodialysis water quality standard for fluoride at less than 0.2 mg/L (0.2 part per million).
There is no convincing evidence that water fluoridation has any effect on childhood IQ either way. This is not surprising as research into IQ is notoriously unreliable. There has been discussion for some years around an association between ingested fluoride and IQ. The alleged association has been questioned in a detailed review from the prestigious National Academy of Sciences, Engineering and Medicine (NASEM), the US equivalent of the UK’s Royal Society.
No, there is no evidence to support these claims. A study of a register of birth defects in the North East England (Lowry, R, Steen N, Rankin J.) concluded that no evidence was found that fluoridation increased the incidence of congenital abnormalities and stillbirths. It also suggested that the incidence of cleft palate may be reduced in fluoridated areas.
The National Research Council (NRC) of the Nation¬al Academy of Sciences (USA) supports the conclusion that drinking optimally fluoridated water is not a genetic hazard. In a statement summarizing its research, the NRC states, “in vitro data indicate that:
1) the genotoxicity of fluoride is limited primarily to doses much higher than those to which humans are exposed,
2) even at high doses, genotoxic effects are not al¬ways observed, and
the preponderance of the genotoxic effects that have been reported are of the types that probably are of no or negligible genetic significance.
Alzheimer’s disease has never been convincingly linked to water fluoridation. The exact cause of Alzheimer’s disease has yet to be identified. Scientists have identified the major risk factors for Alzheimer’s as age and family history. Scientists believe that genetics may play a role in many Alzheimer’s cases. Other possible risk factors that are being studied are level of education, diet, environment and viruses to learn what role they might play in the development of this disease (Source: fluoridatiqion facts).
The minute concentration of fluoride used in fluoridation schemes – one part of fluoride per million parts of water – is not poisonous. But in the wrong concentrations, almost any substance is potentially poisonous. This includes, for example, oxygen, iron and vitamins, which we all need in the right concentrations for a healthy existence.
There has been a substantial amount of research into the safety of fluoridation. In fact, a systematic review into the evidence on fluoridation that was conducted just a few years ago by a team of independent scientists at the University of York looked at as many as 251 different studies that had been carried out in 30 countries over 70 years. Like all public health programmes, however, fluoridation is subject to constant monitoring and review. This is perfectly normal practice in order to ensure that it is safe, effective and good value for money.
Dental fluorosis (usually pearlescent white flecks on the teeth) affects children in non-fluoridated and fluoridated areas. In most cases, neither the children themselves nor their parents are likely to notice it. There are many different causes of this form of mottling on the surface enamel of the teeth. Fluoride is one of them.
No, it isn’t. Fluorosis is a sign of the teeth taking up too much fluoride during the period (up to about 7 years of age) when children’s teeth are being formed. Whilst fluoride makes teeth more resistant to decay, an excess of fluoride can result in changes to the enamel surfaces – but not once the teeth have erupted in the mouth. Hence, the start of a fluoridation scheme cannot affect children, young people or adults whose teeth have already formed, other than by enhancing their protection against decay. It is estimated that for chronic or acute poisoning from fluoride in water at a concentration of one part per million to occur, an individual would need to consume a vast amount of water – such that the volume of water itself would cause health problems first. One estimate is that, even for a baby weighing only 9 pounds, the lowest potentially toxic dose would be after drinking around 26 gallons of water containing one part per million of fluoride. The equivalent amount for an adult is something in excess of 450 gallons consumed at one time.
Is it true that mothers are now being advised in the United States not to give their babies infant formula feeds that have been made up with fluoridated water, and to use non-fluoridated bottled water instead for this purpose? If that is the case, what are the health implications for babies whose mothers ignore that advice?
This question probably arises from the fact that the American Dental Association has issued advice to US parents who are concerned about the risk of fluorosis if they feed their babies infant formula made up with fluoridated water.
The American Dental Association strongly supports water fluoridation and there is no suggestion in its advice about infant formula that there are any risks to the health of babies and children. On the contrary, the ADA believes that fluoridation will benefit their general health by giving them stronger, healthier teeth that are protected from decay.
The US Centers for Disease Control have published their latest fluoridation statistics for 2018. They have introduced a new method for calculating population coverage in the US. So, in 2018 207.4 million residents were receiving fluoridated water or 73% of those on community water systems. This represents a 1.4% drop from the earlier 2014 calculation.
In Brazil coverage continues to expand. The most recent data for 2008 suggests around 144.7 million residents receive fluoridated water (Frazio and Narvai, 2017).
BFS has not undertaken a detailed review of our 2012/3 estimate but believe worldwide coverage is now in excess of 400million people.
The World Health Organisation states that “Community water fluoridation is safe and cost-effective and should be introduced and maintained where ever is it socially acceptable and feasible”. Studies suggest that, in terms of cost, effect and the certainty of that effect, the most cost-effective policy for reducing tooth decay is fluoridation of water supplies. The higher the incidence of tooth decay before fluoridation starts and the larger the population to be served, the greater the economic benefits are likely to be. In the parts of the UK where tooth decay remains a significant public health problem, patients and the NHS economy would benefit hugely from water fluoridation.
Fluorides are very common in the environment: they exist naturally in lakes, rivers, groundwater and the oceans. Reviews of the literature and environmental impact assessments have found no evidence of any adverse environmental effects resulting from water fluoridation. Water fluoridation could be described as environmentally friendly since it ensures maximum utilisation of natural resources, and reduces waste.
Decisions about fluoridation in the UK have always been taken at a local level. They depend on levels of dental health need, public support and other factors. In the cases of Anglesey and Huddersfield, fluoridation schemes were stopped by the water companies concerned in the late 1980s/early 1990s without prior consultation with the relevant health authorities, who very much wanted the schemes to continue.
No. First, let us remember that some 30 countries across six continents are currently operating schemes that supply fluoridated water to around 350 million people with fluoridated water. They include the United States, Canada, Australia, New Zealand, Spain, Ireland, Brazil, Israel, Hong Kong, Singapore, Malaysia and, of course, the UK. In Europe, around 10 million people drink fluoridated water in four different countries. Some other European countries, including Italy and Greece, for example, have legislation in place that would enable fluoridation schemes to be introduced. Some European countries have opted to fluoridate salt rather than their water supplies. This applies, for example, to France, Germany and Switzerland. Often, these decisions have reflected the complexity of water supply systems that would have made fluoridation difficult and possibly not cost-effective.
Fluoridation schemes have been operating in the UK for over 40 years and in the United States for over 60 years. Health authorities in these and many other countries around the world have therefore accumulated an enormous amount of practical experience in monitoring the outcomes of their local schemes.
During the very long period in which fluoridated water has been supplied to many millions of people, no credible scientific evidence has emerged from specific studies, routine health monitoring or systematic reviews, to suggest that it has harmful effects on health.
On the other hand, considerable evidence has accumulated to indicate that it benefits dental health, resulting in significant reductions in tooth decay among both children and adults.
The Cochrane reviews (authoritative and well respected) on water fluoridation for the prevention of dental caries (2015) and Fluoride toothpastes for preventing dental caries in children and adolescents (2003), both concluded that water fluoridation and using fluoride toothpaste are complementary. These systematic reviews show that there is a further preventive benefit when both are used. Therefore, to maximise reductions in tooth decay children (and elsewhere) using both fluoride toothpaste and water fluoridation will produce the greatest dental health gain. Every country which has adopted water fluoridation also uses fluoride toothpaste. Water fluoridation in Bradford would also benefit pre-school children before they carry out daily school based toothbrushing. Water fluoridation will also reduce levels of tooth decay in school leavers; so adults and the elderly will also benefit, including schoolteachers.
(Assuming that the community fluoride application programme is the 6-monthly application of fluoride varnish (22,600ppm)) In every country which has adopted water fluoridation (they all also use fluoride toothpaste), the dental professions in those countries also use topical fluoride varnish. So to maximise dental health benefits for your population the bi-annual fluoride varnish applications should continue. Water fluoridation will also help to reduce levels of tooth decay for children who do not attend nursery schools.
The process of topping up the natural level of fluoride in water is controlled by stringent safety regulations and a detailed technical code of practice issued by the Department of the Environment. There are several key features of the code designed to ensure that only the right concentration of fluoride is achieved and maintained: The feeder tank of fluoride compound at the water treatment plant holds only one day’s supply at a time; The pump used to feed fluoride into the mains is only capable of adding it at the rate required in relation to the flow of the water; There is constant electronic monitoring of the fluoride level in the water as it leaves the plant and goes into the mains supply; If the fluoride in the water exceeds the required level, the process automatically stops and alarms sound.
Around the world the optimum concentration of fluoride in water for promoting good dental health and minimising the risk of dental fluorosis depends mainly on climatic conditions. Hotter climates where people tend to drink more water require a slightly lower level of fluoride in water in order to achieve the desired dental benefits.
Fluoride occurs naturally in minerals such as appatite, cryolite and fluospar. It is from these minerals that fluoride is found naturally in water, and the same minerals are used to produce the fluoride for water fluoridation schemes. Only two compounds are permitted for use in the fluoridation process. These are manufactured to exacting quality standards and must conform to the necessary British Standard.
There is no difference.
That depends on the size of the scheme. The more people served by a single fluoridation scheme, the more cost-effective it becomes. The scheme which fluoridates Birmingham’s water supply, for example, works out at around 15 pence per person per annum. This contrasts with the £10 a time it costs the NHS for a single filling in a someone’s decayed tooth. Some smaller schemes are likely to cost more per head than the Birmingham one. Nevertheless, experts at the University of York have calculated that where populations of 200,000 or more people with high levels of tooth decay are served by a fluoridation scheme, there are likely to be cost benefits as well as dental benefits.
Dental decay rates usually rise in spite of other preventive measures. A review (McClaren and Singhal 2016) concluded that, “overall, the published research points more to an increase in dental caries post community water fluoridation cessation than otherwise”.
Most UK water companies have information on their websites; they provide a simple online service where customers can check the fluoride level of their supply by entering their postcode. The information is usually provided by the water company under the heading of `water quality’. The results are shown in either parts per million (ppm), milligrams per litre (mg/l), or micrograms per litre (µg/l). 1ppm is the same as 1.0 mg/l which is the same as 1000 µg/l. For dental health the `optimum’ level of fluoride in drinking water is around one part of fluoride to 1 million parts water (1ppm). Anything less than 0.3ppm (0.3mg/l, or 300 µg/l) is too low to give any dental benefit.
Quite the opposite, in fact. Over the past 25 years, several national opinion surveys have been conducted by independent research companies, including NOP, Gallup and MORI.
Using sampling techniques designed to reflect accurately the views of the population as a whole, these surveys have consistently found that between about two thirds and three quarters of people think fluoride should be added to water if it can reduce tooth decay.
Supporters of fluoridation have generally outnumbered opponents in these polls by a majority of three or four to one.
Some commentators have argued that it might be unethical not to fluoridate water. After all, it is known that fluoridation reduces tooth decay and reduces the risk of a child having to be given a general anaesthetic for tooth extractions.
In other words, we have the knowledge and the ability to top up a naturally occurring substance in water in order to prevent a disease that causes pain and suffering among children and is a threat to their general well-being
It is also important to remember that fluoride is present in all water supplies, whether individuals like that idea or not. It is a natural substance. In some places, such as Hartlepool or Uttoxeter, the natural fluoride content in local peoples water is high enough (at one part of fluoride per million parts of water) to protect their teeth from decay.
So there is no such thing as the right to drink fluoride-free water. Unfortunately, in most places, the fluoride level is too low to do any good. Fluoridation is merely the process of topping it up to the level at which it is capable of reducing tooth decay.
First, it is important to stress that everyone drinks water with fluoride in it thanks purely to nature alone. In some parts of the UK, such as Hartlepool and Uttoxeter, the natural level is already at one part per million. In parts of Essex, for example, the natural fluoride in water approaches one part per million and, even if slightly below this level, is high enough to make a difference to oral health.
Fluoridation is a tried and tested method of replicating the dental benefits that naturally fluoridated water at the 1 ppm concentration provides. The answer is dental caries, which is one of the commonest diseases in terms of the numbers of people affected. Children are particularly vulnerable. Despite reductions in prevalence over the past 40 years, dental caries remains a major public health problem.
Given that there is evidence to show that fluoridation does reduce tooth decay, and given that the benefits tend to be greatest among socially deprived children suffering the highest levels of decay, is there not an ethical imperative on those of us concerned about the public health to take action?
And should not those who perhaps have a personal preference to drink non-fluoridated water set aside that preference so that others less fortunate than themselves, especially children, can benefit?
A medication is typically used to relieve symptoms. Fluoride is a mineral, not a medication. It is proven by decades of research to prevent tooth decay. Fluoride is not used to relieve the symptoms of a decayed tooth. Prevention is what we seek by giving people access to fluoridated drinking water so they can live healthier lives.