I was actually surprised this week to learn that water fluoridation in England was not already standard practice throughout this part of the UK. Only certain areas in the midlands and the north-east of England have water fluoridation schemes. Public Health England (PHE) recently released a report detailing the monitored effects of these schemes and showed that in these areas there were significantly fewer incidences of tooth decay in comparison to non-fluoridated counterparts. However, the addition of fluoride to our water is by no means a clear cut issue.
Fluoride is a mineral already found in drinking water, fluoridation schemes merely adjust the amount to 1 part per million (ppm), or 1mg per litre. It has been observed, since the early 20th century, that a higher level of fluoride in drinking water is associated with lower levels of tooth decay. Originally described independently in both Colorado and Naples, lower levels of tooth decay were linked to the water supply amid the appearance of dental fluorosis (initially known as “Rocky Mountain Mottled Teeth”), the staining of the teeth with little white marks due to fluoride activity. However, it took almost 30 years for researchers to link higher levels of fluoride in the water to lower levels of tooth decay and an increase in this essentially cosmetic condition, which rarely occurs with concentrations of fluoride at 1ppm or below. On top of this, according to PHE, mild fluorosis is usually not even noticeable.
The National Health Service (NHS) states that tooth decay is a major problem for the country, which remains a leading cause of the admission of young children to hospital. This latest report is part of the “Giving all children a healthy start in life” policy initiative led by the Department of Health and the Department for Education, with the aim of helping children receive the best possible care from an early age.
Fluoride helps to protect the teeth against decay by making the outer layer of our teeth, enamel, more structurally resistant to acid while also reducing the ability of the bacteria, which make up plaque, to produce the acid that initiates tooth decay, which, in extreme cases, can lead to horrendous damage, if the infection spreads.
It is estimated that half a million people in the UK receive naturally fluoridated water (these areas include Essex and North East London, Bath, Slough, and Norfolk), and a further 6 million people receive fluoridated water thanks to national schemes, some of which have been active for more than 40 years. This amounts to around 10% of the population, in some of the most deprived areas of the country. In other countries, such as the USA, there are more widespread national schemes of fluoridation. While in mainland Europe and the rest of the UK there are very few such initiatives.
The latest figures from PHE reported that as many as 45% fewer children (aged 1-4) were admitted to hospital for tooth decay in fluoridated areas. When taking deprivation and ethnicity into account the report found that 28% fewer children (aged 5) reported tooth decay, in 12-year old this figure stood at 21%. Fluoridation seemed to have the greatest impact in the most deprived areas monitored.
The report also found that there was no significant evidence of harm caused by the fluoridated water, which backs up a 2012 study in Newcastle that showed only 1% of 12 year olds developed moderate dental fluorosis as a result of the water treatment. But it is not here that the bulk of the arguments against fluoridation lie. Does the government have the right to administer, what some describe as a medication, to non-consenting members of the population?
While I would argue that fluoride should not be considered a medicine, it is already a natural constituent of drinking water and represents a nutrient needed by many, others may disagree. It seems that the evidence out there clearly shows there is a higher benefit associated with fluoridation than there is risk. Another common argument against widespread fluoridation is that dosage is difficult to control considering it is impossible to regulate just how much water a person consumes. On top of this there are alternative sources of fluoride such as wide variety of toothpastes that already contain the mineral. But of course this study showed no evidence of a harm to health while those in fluoridated areas had free access to as much water and toothpaste as they wanted. The National Pure Water Association has said that the concentration of health chiefs should be on alternatives. These could include increasing education and awareness around dental hygiene and also improving dental care in general.
It is of course essential to look at the incidence of tooth decay from another perspective, one that was drilled into me from an early age (although I may not always have listened), the foods we eat contain sugar, and in general, this is not good for your teeth. Sugars can combine with proteins to form glycoproteins that can stick to teeth. Bacteria can then use some sugars as sources of energy, producing the lactic acid involved in decay as a by-product. Increased education about the risks of sugary foods is necessary and the companies producing these foods should ensure their products do not cause any increase in tooth decay when consumed in moderation.
So, while this report from PHE does go some way to showing that water fluoridation is effective and safe, especially in areas that need it the most, it may not put to bed the ethical concerns of many and it is not the only option shown to be effective and available. If the alternatives of increased dental education, awareness, and better dental care can be implemented then they should be. The question remains though as to whether these should be implemented alongside fluoridation. At the end of the day one thing is sure, reducing the incidence of dental decay and caries is an important subject and one that, if properly addressed, could help many to avoid unnecessary health issues, and take some pressure off of our over-burdened health service.