Fluoride is a natural element found in rocks and soil, in fresh water, and in ocean water. Waters in and around the United States have natural fluoride levels that range from 0.1 to more than 12 parts per million (ppm). The optimal fluoride level to prevent tooth decay for a community water system is 0.7ppm.
Community water fluoridation is adding enough fluoride to the natural level of fluoride in the water to reach the recommended level for preventing tooth decay.
Health experts endorse water fluoridation as the single, most effective public health measure to improve oral health.
Prevents tooth decay.
Strengthens tooth enamel.
Kills germs that cause tooth decay.
Is a cost effective means of improving community health.
Virtually all major national and international health, service and professional organizations endorse or support water fluoridation, including the following:
- American Dental Association
- American Medical Association
- American Academy of Pediatrics
- American Academy of Pediatric Dentistry
- US Public Health Service
- Centers for Disease Control and Prevention
- World Health Organization
- National Academy of Sciences
- American Water Works Association
- Maryland Department of Health
- Maryland Department of the Environment
Updated Water Fluoridation Recommendations:
Public Health Officials Reconfirm the Benefits of Community Water Fluoridation
While Assuring Optimal Benefits for Children
Federal public health officials on January 7, 2011 reaffirmed the safety and effectiveness of community water fluoridation while updating their recommendation on the optimal level for preventing tooth decay based on the latest science. The United States Department of Health and Human Services (HHS) and the Environmental Protection Agency (EPA) acknowledged the trend of increased dental fluorosis in children in the United States, an esthetic condition that can result in discoloration of teeth. To address this issue, the updated recommendation from HHS is to set the optimal level for fluoride in drinking water at 0.7 parts per million (ppm). This is well within the previous optimal range of 0.7ppm - 1.2ppm that had been recommended for more than 50 years. Recognizing that a range based solely on mean temperature is no longer applicable because water consumption no longer varies by temperature zone, a single optimal level is now recommended.
The Maryland Department of Health, Office of Oral Health (OOH) supports this recommendation and applauds the continued evaluation of this cornerstone public health measure. OOH is committed to educating the public about proper use of fluorides for preventing tooth decay, including fluoride toothpaste and the benefits of community water fluoridation. The new recommendation assures there is the right balance given the multitude of fluoride sources available today to prevent tooth decay while protecting against dental fluorosis.
Dental fluorosis is a change in the appearance of the tooth's enamel. It can result when children regularly consume higher-than-recommended amounts of fluoride during the teeth forming years, age 8 and younger. According to the Centers for Disease Control and Prevention (CDC), most dental fluorosis in the U.S. - about 92 percent - is very mild to mild, appearing as white spots on the tooth surface that in many cases only a dental professional would notice (see Figure 1).
Figure 1 - Mild Fluorosis
(Courtesy of the National Maternal and Child
Oral Health Resource Center)
Figure 2 - Tooth Decay
(Courtesy of Dr. Norman Tinanoff,
University of Maryland Dental School)
Moderate and severe forms of dental fluorosis, which are less common and found in naturally fluoridated areas higher than the optimal level set by HHS, cause more extensive enamel changes. Brown stain of the tooth enamel often is present in moderate fluorosis which may also demonstrate marked wear on the biting surfaces of the teeth. In the rare, severe form, pits may form in the teeth. EPA will address naturally fluoridated areas by determining whether to scale back the maximum level of fluoride - currently set at 4.0ppm - that community public water systems are legally allowed to maintain.
Fluoride is a naturally occurring element and is present, usually at a very low level, in all water. The fluoridation of community water supplies is essentially taking the natural level of fluoride already in the water and supplementing it to reach an optimal level known to prevent tooth decay. Tooth decay is the outcome of dental caries, a transmissible infectious disease and the most common chronic disease affecting children. Tooth decay, also known as dental cavities, destroys the outer layer (enamel) of the tooth (see Figure 2). Fluoride works by strengthening tooth enamel to effectively reduce the risk of tooth decay.
Community water fluoridation remains the cornerstone of dental caries prevention in the United States and has been demonstrated to be safe, cost-effective and beneficial through every stage of life and for all people, regardless of age, race, ethnicity or socio-economic status. It has been recognized by CDC as one of the ten great public health achievements of the 20th Century. Numerous worldwide academic and governmental studies have reaffirmed the association between optimal levels of natural and supplemental fluoride in water supplies with improved oral health and the absence of any negative health impacts. Water fluoridation has received the approval of the Surgeon General of the United States, American Medical Association, American Dental Association, American Public Health Association, National Academy of Sciences, and the United States Public Health Service. From 2000-2006 more than 235 U.S. communities in 36 states, including Maryland, voted to adopt community water fluoridation. Consumers served by public water systems who wish to learn about fluoridation of their drinking water can visit the CDC's 'My Water's Fluoride' Web site.
In tandem with the Maryland Department of the Environment (MDE), OOH continues to strongly endorse fluoridation of community water supplies at the optimal level recommended by CDC. Approximately 93% of Maryland residents on public water supplies receive optimally fluoridated water, either naturally or by supplementation. OOH continues to encourage communities to adjust the level of fluoride in drinking water to a level that prevents tooth decay while protecting the cosmetic appearance of teeth.
OOH promotes oral health as an essential component of overall health, well-being, and self- esteem and supports public health efforts to continually update research on the appropriate use of fluorides to benefit people of all ages. As it is OOH policy to follow without reservation all established national oral health guidelines including community water fluoridation, OOH is pleased that HHS and EPA are exercising their responsibilities to review standards and offer guidance on public health issues. The Office welcomes calls for additional controlled studies on the safety, health benefits and cost-effectiveness of community water fluoridation as a means of assuring the public about its safety. These joint reports from HHS and EPA strengthen the public's health and affirm the safety of fluoride in water supplies at the level considered optimal to prevent tooth decay.
The Office of Oral Health will share additional information as it becomes available.
Fluoride and Infant Formula
Exposure to fluoride during infancy helps prevent tooth decay. Breastfeeding is ideal for infants. If breastfeeding is not possible, several types of formula are available for infant feeding. The Centers for Disease Control and Prevention, the American Dental Association and others considered it safe to use fluoridated tap water to prepare infant formula.
Infants consume little other than breast milk or formula during the first 4 to 6 months of life, and continue to have a high intake of liquids during the entire first year. Therefore, proportional to body weight, fluoride intake may be higher for younger or smaller children than for older children, adolescents, or adults.
There are three types of formula available in the United States for infant feeding. These are powdered formula, which comes in bulk or single-serve packets, concentrated liquid, and ready-to-feed formula. Ready-to-feed formula contains little fluoride and does not contribute to development of dental fluorosis. Those types of formula that require mixing with water -- powdered or liquid concentrates -- can be a child's main source of fluoride intake (depending upon the fluoride content of the water source used) and may increase the chance of dental fluorosis.
Regularly mixing powdered or liquid infant formula concentrate with fluoridated water may increase your child's risk of developing faint white markings or streaks on the teeth -- a sign of mild enamel fluorosis. Fluorosis is a cosmetic issue that affects both baby teeth and permanent teeth while they're forming under the gums. In children younger than age 8, combined fluoride exposure from all sources -- water, food, toothpaste and other products -- contributes to fluorosis. However, unlike tooth decay which is an infectious disease, fluorosis does not affect the health of your child or the health of your child's teeth.
Infant formula manufacturers take steps to assure that infant formula contains low fluoride levels -- the products themselves are not the issue. Although formula itself has low amounts of fluoride, if your child is exclusively consuming infant formula reconstituted with fluoridated water, there may be an increased chance for mild dental fluorosis.
If you're concerned about fluorosis, you can minimize your baby's exposure to fluoride by using ready-to-feed formula. You can also alternate using tap water and nonfluoridated water for formula preparation, or mix powdered or liquid infant formula concentrate with low-fluoride water most or all of the time. CDC also recommends that parents can use low-fluoride bottled water some of the time to mix infant formula; these bottled waters are labeled as de-ionized, purified, demineralized, or distilled.
Nearly all tap water contains some natural fluoride, but, depending on the water system, the concentration can range from very low (0.2 mg/L fluoride or less) to very high (2.0 mg/L fluoride or higher). Approximately 72% of all public water systems serving about 195 million people adjust the fluoride in their water to the level recommended to prevent tooth decay which recently has been set at 0.7 mg/L fluoride. The best source of information on fluoride levels in a water system is the local water utility. Other knowledgeable sources can be the local or state public health authority, dentist, dental hygienist, or physician.
Using only water with low fluoride levels to mix formula will reduce, but will not eliminate, the risk for dental fluorosis. Children can take in fluoride from other sources during the time that teeth are developing (birth through age 8). These sources include drinking water, foods and beverages processed with fluoridated water, and dental products, such as fluoride toothpaste, that can be swallowed by young children whose swallowing reflex is not fully developed.
Of course, parents and caregivers are encouraged to speak with their pediatrician and/or dentist about what type of infant formula is best suited for their child.
The Office of Oral Health will share additional information as it becomes available.