The epidemic of poor oral health in young children, and the problems it can cause has been in the news. I recently wrote about how hard it is to keep young children’s teeth clean. (Thanks to some amazing reader suggestions, I’m happy to say that we’ve now got a great routine going that might actually approach two minutes of brushing.) But, today I want to highlight an important public health measure that is helping many of us keep our kids teeth (and our own) healthier, and we might not even know it.
Fluoridation of drinking water has been recommended by public health agencies for the last 65 years as a safe means of preventing tooth decay. The most current CDC statistics (2008) show that 72% of the public drinking water in the US is now optimally fluoridated. And, there is good reason to support this measure. Fluoride, when present in the mouth, can help prevent the breakdown of tooth enamel, thus helping to prevent tooth decay and cavities. Of course, fluoride is now available via sources other than drinking water- fluoride toothpaste, fluoride varnish, and fluoride supplements. But fluoridated water is the most cost-effective, universally available way to get fluoride.
From the CDC,
“This method of fluoride delivery benefits all people―regardless of age, income, education, or socioeconomic status. A person’s income and ability to get routine dental care are not barriers since all residents of a community can enjoy fluoride’s protective benefits just by drinking tap water and consuming foods and beverages prepared with it. Fluoride from other sources prevents tooth decay as well, whether from toothpaste, mouth rinses, professionally applied fluoride treatments, or prescription fluoride supplements. These methods of delivering fluoride, however, are more costly than water fluoridation and require a conscious decision to use them.”
So, if fluoridated drinking water is effective, and most people are getting it, why do I bring it up now? Well, because there are still 100 million Americans without fluoridated drinking water, and that number may soon increase. Water fluoridation has again come under attack. I say again because water fluoridation has had a long and storied history, including a strange episode during the 1950s when it was thought to be part of a communist plot. Currently, many communities have discontinued their fluoridation programs, or are considering doing so. As the New York Times recently noted, today’s critics “express concerns about the costs involved, improper government control over a personal decision, and potential health dangers. Let’s look at each of these concerns.
Cost: As previously stated, fluoridation of drinking water is actually a quite cost-effective measure. It is estimated that for every $1 spent on fluoridation, approximately $38 is saved in dental treatment costs (this number is slightly less in smaller communities, but the program still provides net savings). This takes into account cost of installation, maintenance of necessary equipment, and operation of water plants.
Government control: This is a personal decision I’m willing to give up. Who doesn’t want to protect their kids from hours spent in the dentist’s chair? I practice pediatrics in the largest city in the US that does not have universally fluoridated water. I consider the early oral health of my patients an important responsibility. I’d much rather be able to tell families that their tap water will help to protect their teeth, than check zip codes to determine whether they need fluoride supplementation (and then help them to convince their children to take a rather foul-tasting medicine every day).
Potential health dangers: Over the years, there have been many potential health problems attributed to ingestion of fluoridated water. You may still see sources on-line putting forth these claims. But, when consumed in doses provided by appropriately fluoridated drinking water, none of these risks has ever been validated in scientific studies, except one. Fluorosis. Fluorosis is a change in the appearance of tooth enamel from exposure to too much fluoride over a period of time. The tooth enamel may appear to have whitish spots (mild cases) or brown discoloration (more severe cases). This is a valid concern. The Department of Health and Human Services and the EPA are currently considering recommendation to slightly lower the optimal level of fluoridation in order to avoid this problem.
I hope that these agencies will make a recommendation and help to clear up confusion and misinformation soon. Tooth decay is the most prevalent chronic infectious disease among young children in the US. We need every tool available to fight this disease. Water fluoridation is one safe and effective tool.
In the meantime, find out if your water is fluoridated by calling your water company or checking here. If you use a filter or bottled water, read the labels. Ask your pediatrician or dentist whether your kids need supplementation. Oh, and keep on brushing.
I practice in an area where not everyone’s water is fluoridated, and it is a total pain to check who has fluoride. It would be nice if the water companies put this information on every monthly statement so families would have easier access to this information. Also, the concern re: fluorosis is sometimes enough for me to not push a family too hard to have their kids take fluoride.
Also, what should we do if our patients have started seeing the dentist and getting fluoride treatments there? I agree that some guidelines for treatment in areas where the fluoride is not sufficient to prevent decay would be helpful, and that having fluoride in the water is an extremely beneficial public health practice.
I completely agree with your points, Kara. I approach it like this- in the roughly 6 month to 3 year old age group, in whom I can reasonably assure there is very little other fluoride exposure (i.e. not yet using fluoride toothpaste, no fluoride in water, etc), I prescribe oral fluoride supplement. We are very lucky in that we have a dedicated nurse who reviews overall oral health with families, and also reviews all possible sources of fluoride and the risk of fluorosis. If there is any sign of fluorosis I have the families stop the supplement.
I think the question about what to do once kids are getting fluoride varnish and seeing the dentist is a good one. In our patients who do not drink fluoridated water, our practice policy is to provide both varnish and fluoride drops. In the kids who have fluoridated water, they only receive the varnish.
I think it would simplify things for everyone if drinking water had a standardized, safe level of fluoride sufficient to help prevent decay. We could do away with the poorly tolerated oral drops, and the guessing game about how much fluoride patients are actually receiving via drops and varnish. And, most importantly, it would help protect the teeth of our young patients, many of whom have inadequate access to dental care.
Thanks so much for reading!
Thanks for the CDC resource. I find it totally confusing to figure out whether patients have adequate fluoride or not. Santa Clara county appears to mix multiple water sources, making it differ even within zip codes. Also, I wish pediatricians and dentists could have a more consistent message for families. Many dentists don’t seem to even address fluoride supplementation and water sources!
I completely agree about how confusing Santa Clara county can be. Our EMR now has a tool that helps us figure things out based on the address listed in the system. This has been a great addition, although I still worry about accuracy sometimes. And, yes, I feel like communication between docs and dentists is pretty non-existent in our area, which is too bad.
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