Americans are getting fluoride from a variety of sources that did not exist in the 1940s, when community water fluoridation first got under way. Water consumption patterns have changed too.

So, while continuing to stress the benefits of fluoride, officials from the U.S. Department of Health and Human Services (HHS) have proposed that the recommended level of fluoride in drinking water be set at the lowest end of the current optimal range to prevent tooth decay. At the same time, officials from the U.S. Environmental Protection Agency (EPA) announced they are initiating a review of the maximum amount of fluoride allowable in drinking water.
In a joint statement released January 7, officials from both agencies framed the actions as a way of maximizing the health benefits of water fluoridation to Americans by continuing to prevent tooth decay while reducing the possibility of ill effects.
“One of water fluoridation’s biggest advantages is that it benefits all residents of a community — at home, work, school, or play,” said HHS Assistant Secretary for Health Howard Koh, MD, MPH, in the statement. “And fluoridation’s effectiveness in preventing tooth decay is not limited to children but extends throughout life, resulting in improved oral health.”
EPA Assistant Administrator for the Office of Water Peter Silva stressed that the agencies are reviewing fluoride levels in response to “the most up-to-date scientific data.”
“EPA’s new analysis will help us make sure that people benefit from tooth decay prevention, while at the same time avoiding the unwanted health effects from too much fluoride,” he said.
Fluoride occurs naturally in drinking water, but levels vary from low to high in different regions of the U.S.
Lifestyle changes
At what are considered optimum levels, public health officials and the ADA have long promoted fluoride as a way of reducing dental caries. But research has also found that consumption at excess levels may cause fluorosis and skeletal deformities (Journal of the American Dental Association, November 2008, Vol. 139:11, pp. 1457-1468; October 2009, Vol. 140:10, pp. 1228-1236; January 2011, Vol. 142:1, pp. 79-87).
For the past 65 years, communities across the country have been supplementing naturally occurring fluoride in their water supplies to reach a level considered sufficient to promote oral health, especially among children. The fluoride level long recommended by health officials to prevent caries has been set at a range of 0.7 to 1.2 milligrams per liter (mg/L) of water. The HHS is now proposing the level be set at 0.7 mg/L of water.
The reassessment was initiated in part due to new research into changes in diet and lifestyle, as well as regional water consumption patterns seen over time, officials said. The old range was in part based upon differences in regional climate and water consumption that have become somewhat outdated with the advent of air conditioning. In addition, Americans have access to more sources of fluoride than in the past. Besides water, other sources of fluoride include dental products such as toothpaste and mouth rinses, prescription fluoride supplements, and fluoride applied by dental professionals.
The findings are also being used to guide the EPA in making a determination of whether to lower the maximum amount of fluoride allowed in drinking water.
Under the Clean Water Act passed by Congress in 1974, the EPA must determine the level of contaminants in drinking water at which no adverse health effects are likely to occur. The EPA has set the maximum contaminant level goal for fluoride at 4.0 mg/L, based on the best available science to prevent potential health problems.
But in 2006, an analysis by the National Research Council concluded the EPA’s drinking water standard was too high to protect against adverse health effects.
And the National Academy of Sciences reviewed new data on fluoride and issued a report recommending that EPA update its health and exposure assessments to take into account bone and dental effects and to consider all sources of fluoride.
Any formal change to the drinking water regulation would be made only after a formal proposal, public comment period, and finalization process.
As of 2008, 195.5 million Americans, or 72.4 % of the population on public water systems, had access to optimally fluoridated water, according to the most recent statistics available from the Centers for Disease Control and Prevention, which has hailed the fluoridation of drinking water as one of the 10 great public health achievements of the 20th century.
Opposition and support
In some communities, however, efforts have met continued resistance from opponents who contend that fluoridation amounts to forced medication or an unwanted intrusion of government into private life.
Fluoridation opponent Paul Connett, PhD, who heads the Fluoride Action Network, dismissed the January 7 announcement as “spin and collusion” between federal health officials and the dental establishment to continue fluoridation, which he argues is dangerous, especially to children.
“It’s a stupid bloody practice,” Connett said. “Once you put a medicine in the water, you can’t control the dose.”
The ADA commended the move by health officials to revisit fluoride guidelines and standards.
“As a science-based organization, the ADA supports the Department of Health and Human Services’ recommendation,” the ADA said in a statement. “This adjustment will provide an effective level of fluoride to reduce the incidence of tooth decay while minimizing the rate of fluorosis in the general population.”
ADA President Raymond Gist, DDS, called the HHS recommendation “a superb example of a government agency fulfilling its mission to protect and enhance the health of the American people.”
Shelly Gehshan, director of the Pew Children’s Dental Campaign, praised the actions of the HHS and EPA. “These announcements show that federal health officials are carrying out their proper role and relying on the best science to do so,” she told DrBicuspid.com. “The public can feel reassured that optimally fluoridated water is a safe, effective way for people of all ages to prevent tooth decay.”
The notice of the proposed recommendation will be published in the Federal Register soon, and HHS will accept comments from the public and stakeholders on the proposed recommendation for 30 days at CWFcomments@cdc.gov. HHS is expecting to publish final guidance for community water fluoridation by spring 2011.
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