Community Water Fluoridation

Explaining the most cost-effective public health measure known Produced by the National Fluoridation Committee of the Department of Health

THE FACTS

COMMUNITY WATER FLUORIDATION - THE FACTS
Tooth decay is a preventable disease. It is caused by the action of oral bacteria and enzymes on sugars and carbohydrates beneath the plaque. The acids dissolve the tooth enamel, and allow the bacteria to penetrate the tooth. Tooth decay is the most common chronic disease known to humankind. More than 90 out of every 100 South Africans experience some tooth decay by the time they reach adulthood.

Fluoride increases the resistance of the enamel of the teeth to attack by acid. Surveys have shown that most people in South Africa do not know what fluoride or water fluoridation is. They also do not realize that fluoride is a natural constituent of water supplies, and that water fluoridation is simply the process of topping up something which is there already, but at insufficient levels.

This booklet has been produced by the National Fluoridation Committee of the Department of Health, to give health workers more information about fluoridation, so that they may in turn help people understand the benefits that water fluoridation can bring.

What is community water fluoridation?
All natural sources of water contain the mineral fluoride, which reaches the rivers through rocks and soil. It has been found that when the natural level of fluoride in the water is correct, the teeth are protected against decay. For over 50 years it has been known that this can happen at about the level of one part of fluoride in one million parts of water. This is a very small amount - the equivalent proportion of about one minute in two years, or 1 cent in 10,000.00 rands.

As correct fluoride levels in the water strengthen the teeth and reduce tooth decay by up to 60%, it is necessary to adjust the amount of fluoride to bring it to the right level. In some areas of the country there is no need to add fluoride because there is enough in the water already, but in other regions the level is too low and needs to be topped up. In still others, there is too much, and it should be reduced.

Tooth decay is at unacceptably high levels in certain communities in South Africa, and it is likely that these levels will increase especially amongst the poor. It is vital, therefore, that we take action to improve public dental health.

Cost
Water fluoridation is cheap. The cost of adjusting the existing fluoride concentration in the water supply is much less than R1.00 per person per year. Water fluoridation is the most cost-effective way of preventing tooth decay. It is 18 times cheaper than toothpaste's, and 61 times cheaper than filling one tooth. The preventive benefits of fluorides will save the many days lost at work and at school.

World-wide experience
Today there are about 300 million people all over the world benefiting from community water fluoridation. A further 300 million people drink water which naturally has the correct amount of fluoride. Fluoride toothpaste is used by about 450 million people, and about 60 million use fluoridated salt. So over a billion people around the world, now benefit from fluorides. Countries with programmes for topping up the natural fluoride in the water where it is too low include the United States, Canada, Brazil, Australia, New Zealand, Spain, Greece, Switzerland, Finland, Ireland, the former USSR and the United Kingdom to name a few.

The most recent studies amongst people who drink fluoridated water show that fluoridation reduces

- tooth decay in baby teeth by 40 to 60 percent and
- tooth decay in permanent teeth by 25 to 40 percent.

The benefits
If you live in a part of the country where the natural fluoride level in water is below the optimum, everyone will gain from the adjustment of that level to the best amount. Children will benefit the most, but adults will also benefit.

In practice, fluoridated water means:

- Less toothache;
- Fewer and smaller dental bills;
- More people keeping their teeth throughout life;
- Better-looking teeth because they are not affected by decay;
- Less fear and anxiety about visits to the dentist as treatment would be less complicated, with less anaesthesia and drilling;
- More opportunities for dentists to concentrate on other preventive work and health education;
- Better general health for all as a result of improved dental health.

Alternative forms of fluoridation
Fluoride toothpaste is used all over the world, but for the poor, the relatively high cost means it is difficult to afford, and so it is not used. It should therefore only be used as a public health measure where water fluoridation is not practicable. A programme of subsidization will be required to improve the availability of fluoride toothpaste's to those communities most in need. Cost-saving measures such as the removal of VAT, and providing supplies of un-packaged toothpaste to schools and community clinics, will need to be used.

The effectiveness of fluoridated salt is about the same as that of water, but only when appropriate concentrations and patterns of use occur. It could be considered at a later stage in specific areas, after appropriate studies are carried out on the patterns of salt intake, manufacture and distribution.

Fluoride can also be applied topically to the teeth by oral health professionals, and fluoride rinses, drops and tablets are also available. But these other forms of supplementing fluoride do not guarantee a consistent intake, and are much more expensive than water fluoridation. The greatest reductions in tooth decay have been shown where water fluoridation is available in addition to topical fluorides, toothpaste, and fluoride rinses.

The medical effects of fluoride
There are absolutely no proven problems with fluoride at the correct, small levels needed to prevent tooth decay. Fluoride in large doses, over long periods of time, can have an effect on teeth and bone. In the teeth, dental fluorosis only occurs during the time the teeth are forming. When they erupt, small white patches and lines may appear, but most dental fluorosis is difficult to detect, even by oral health professionals. In extremely high fluoride concentrations, brown mottling of the tooth enamel occurs, and bone may become more dense, although this does not always happen.

For these reasons, those areas that have existing levels of fluoride higher than recommended, will require some form of defluoridation, so the beneficial effects of fluoride can be retained, without experiencing fluorosis.

Fluoridation: safety first
We know that fluoride at the right level succeeds in reducing tooth decay by as much as 60%. Since tooth decay is one of our most common diseases, that's good news. But naturally we need to know whether it is safe to drink water with this level of fluoride, and so it is necessary to examine the evidence. Fortunately, there is a very large body of scientific literature that has been devoted to this over the last 50 years, and many individuals and communities have been carefully and scientifically studied.

One of the reasons that several thousand references on the biological properties of fluorides and the effect of fluoride on bones and teeth now exist, is that some people have made some strange claims about fluoridation, none of which have been shown to be true. This has even been tested in courts of law: a few years ago, after the longest civil court case in British history, the judge concluded that fluoridation was both beneficial and safe. The US courts, as well as the British, have also ruled that fluoridation does not impinge on a fundamental right, does not violate a recognized constitutional right to privacy, and does not constitute compulsory medication.

Sorting out the facts from the propaganda
But it does appear to be the case that a tiny minority of individuals are still against fluoridation. It is difficult to imagine why they oppose something which obviously promotes so much benefit to health. Unfortunately, many opponents still make the wildest statements, which have not been proven by controlled, scientific investigation. To the lay person caught up in the debate, it is a question of trying to sort out the facts from the propaganda.

No harm to the kidneys and no allergic reactions
It is interesting to note that the allegations of anti-fluoridation groups about medical side effects are invariably refuted by the specialized research organisations and medical experts such as the Royal College of Physicians. Kidney problems and allergic reactions are often cited by opponents. By contrast, the National Kidney Foundation of America says that fluoridation does not harm the kidneys. And both the American Association for the Study of allergy and the British Society of allergy and Clinical Immunology insist that there is no evidence of intolerance to fluoride as used in community water fluoridation.

No association with cancer
Nothing could be more calculated to frighten people than to suggest that something causes cancer. Some people have made such a claim about fluoridation. There is no scientific evidence for this. The claim, however, is clearly capable of upsetting individuals who live in an area that is already fluoridated or is about to become fluoridated. Throughout the world, the US National Cancer Institute, the Royal Statistical Society, Oxford University, the US Centers for Disease Control and Prevention, the National Heart, Lung and Blood Institute and the Royal College of Physicians have all refuted unanimously the claim that fluoride causes cancer. In South Africa the Cancer Association of South Africa and the South African Society for Medical Oncology support water fluoridation.

To show that fluoridation is a cause of cancer, it must be demonstrated, with accepted epidemiological methods, that it significantly increases the incidence of cancer in a community. So far, this has not been shown. The studies that have been published that have made such claims have all been discredited for unscientific manipulation of the facts. Each time, the same data have been re-analysed correctly, and shown to have been incorrectly and unscientifically manipulated to show a relationship that just does not exist.

No Difference between natural and adjusted fluoridation
It has been claimed that the fluoride occurring naturally is not the same as that used when adjusting the levels of fluoride in the water supplies. The fact is, that the body uses the fluoride "ion" (electrically charged atom), which is the same whether the fluoride in the water has come from the rocks and soil, or from a chemical added under controlled conditions.

Evidence from the most extensively fluoridated country in the world
The United States is the most extensively fluoridated country in the world. Over half of all Americans drink fluoridated water. Currently, 42 of the largest 50 cities in the US fluoridate their drinking water supplies. The safety aspects have been of prime concern to the US Centers for Disease Control and Prevention, which fully endorses fluoridation and actively promotes it. Fluoridation is also supported by the American Dental and Medical Associations and by the American Oral Health Institute, which has published a 180-page long analysis showing how anti-fluoridation groups abuse basic scientific principles in putting across their particular viewpoint. The Food and Drug Administration (FDA) also supports water fluoridation.

Support from our public representatives...
All the major political parties in South Africa support water fluoridation. The Minister and Department of Health is leading the campaign to fluoridate the piped water supplies in South Africa, and is supported by the Minister and Department of Agriculture, and the Minister and Department of Environmental Affairs and Tourism.

... and from the public ...
In the 1995 survey conducted by the Human Sciences Research Council as many as six out of ten South Africans supported the addition of fluoride to water if it can reduce tooth decay.

Professional and scientific support
More than 60 major international health organisations throughout the world support community water fluoridation, including the

- World Health Organization
- International Dental Federation
- Pan American Health Organisation, and
- Every national dental association in the world.

There is no doubt about the depth of professional and scientific support for fluoridation in South Africa. It is endorsed by the most authoritative dental and medical organisations including the:

- National Dental Forum
- Dental Association of South Africa
- Medical Association of South Africa
- Oral Hygienists' Association of South Africa
- Dental Therapy Association of South Africa
- Dental Assistants' Association of South Africa
- Dental Traders Association of South Africa
- International Association for Dental Research
- World Health Organisation Collaborating Centre for Oral Health, University of the Western Cape
- Medical Research Council
- Community Health Association of Southern Africa
- Nutrition Society of Southern Africa
- Group for Environmental Monitoring
- South African Society of Medical Oncology
- Cancer Association of South Africa
- National Council against Smoking
- Centre for Health Policy, University of the Witwatersrand
- South African Health and Social Services Organisation

The ethics of water fluoridation
Some opponents of fluoridation argue against it on the grounds that it is unethical. Do they have a point? Or are they a tiny minority out of step with the mainstream of society and its values and moral attitudes?

John Harris is Professor of Applied Philosophy at the Centre for Social Ethics and Policy of the University of Manchester. His role is to examine major issues affecting society from an ethical point of view. He sees no dilemma about fluoridation. It is, he argues, perfectly ethical because:

- It is a safe process which confers benefits on human beings (protection from tooth decay, one of the commonest diseases).

- It does not in any way conflict with basic human rights (there is no such thing as the right to drink fluoride-free water, only a personal preference to do so; and there is, in fact, no such thing as fluoride-free water).

- It is replicating a situation which occurs naturally (where fluoride already exists at the correct levels).

- It does not have any harmful consequences (its safety has been demonstrated over fifty years of experience and by the wealth of endorsements from leading dental, medical and scientific organisations),

Indeed, John Harris argues that as dental decay may itself be responsible for a small number of deaths each year from anaesthesia used in treatment, fluoridation could be described as "life saving" if it prevents the need for treatment. Viewed in this light, it could be said to be unethical not to fluoridate water where it is practicable to do so.

Helping those least able to help themselves

It is important to remember that while fluoridation benefits everyone with natural teeth, the greatest benefit of all goes to those least able to help themselves, namely children. But more especially, it is the children from impoverished and increasingly urbanized communities who will benefit the most. For most people in South Africa, the cost of toothbrushes and toothpaste takes up a large proportion of their incomes. Fluoridation is an intervention that transcends the barriers of class and race and so will level out the differences in dental health which normally separate children from better-off and poorer backgrounds. Fluoridation will therefore contribute greatly to equity in health and the building of a healthy nation.

In summary:

Community water fluoridation is the most efficient way to prevent tooth decay. The following key facts about fluoridation summarize why this is so:

- Fluoridation is the least expensive and most effective way to reduce tooth decay.
- Fluoridation is safe.
- Fluoridation benefits children and adults.
- Fluoridation provides benefits that continue for a lifetime when consumption of fluoridated water continues.
- Fluoridation reduces the need for and cost of dental treatment.
- Fluoridation is the surest way for everyone in the community to benefit.

For additional information
contact :

The Directorate : Oral Health
Department of Health
Private Bag X828
Pretoria
0001