Should Fluoride be added to drinking water in the UK?

1.1 Introduction

Fluoride has been added to drinking

water in parts of the UK since the
1960’s, and today approximately 5
million people in the west Midlands,
Yorkshire and Tyneside receive water
with added fluoride. The UK’s first
fluoridation scheme took place in
Birmingham and Solihull in a bid to
increase dental health in areas of
deprivation. Recent scientific studies
have sought to establish a fluoride /
cancer connection. So, whilst the
current Health Secretary puts pressure
on health chiefs in areas of very high
levels of tooth decay to proceed with
fluoridation, there is a growing
opposition who claim, “the entire
population will be medicated because a
small minority fail to brush their
teeth.”1 Some doctors argue that while
Figure 1. Chris Neurath,
fluoridation would cut the levels of
tooth decay in children, the long-term medical consequences are unknown. FAN, WHO

Figure 1 demonstrates relative rates of tooth decay in fluoridated and

unfluoridated nations. Although all four nations with fluoridated drinking water are in the lower part of the
graph with the least tooth decay, there is not a great disparity between the fluoridated and unfluoridated
nations. Whilst the lowest incidence of DFMT (decayed, missing or filled teeth index) is in Australia, which is
just under 70% fluoridated, the next five countries with the lowest level of DFMT are unfluoridated.

1.2 Biological Methods and Processes

Data collected for Figure 1 comes from oral health surveys undertaken by WHO (World Health
Organisation).2

To achieve standardised and valid results the Oral Health Survey devised a basic method as follows:
Examination with a plane mirror and explorer was used to keep a consistent methodology. The recording of
the data was standardised in the following way: the assessment of each individual’s teeth was recorded
consistently with the use of universal codes and with the use of condition charts (see figure 2). The WHO
advise examiners to take a systematic approach proceeding from one tooth to the adjacent. When any part
of the tooth is visible or can be touched with the explorer it should be considered present. If a permanent
and a primary tooth occupy the same tooth space, the status of the permanent tooth only should be
recorded.

Dentition Status

A numerical coding system is used for recording the status of permanent teeth and an alphabetical coding
system for primary teeth. An entry must be made in every box on the chart. Codes for the dental caries
status of primary and permanent teeth are as follows:

Code Condition/status
Primary Permanent teeth

The Times, 3 February, 2008

2
World Health Organisation 2004 – Chris Neurath, FAN http://www.whocollabo.mah.se/

1
 teeth
Crown Crown Root
A O O Sound
B 1 1 Decayed
C 2 2 Filled, with decay
D 3 3 Filled, no decay
E 4 - Missing as result of caries
- 5 - Missing , any other reason
F 6 - Fissure sealant
G 7 7 Bridge abutment, special crown or veneer implant.
- 8 8 Unerupted tooth (crown) / unexposed root.
T T - Trauma (fracture)
- 9 9 Not recorded
Figure 2. Extracts of the Third edition of "Oral Health Surveys - Basic methods", Geneva 1987.

How Fluoride Helps

Fluoride concentrates in the growing bones

and developing teeth of children, helping to
harden the enamel on baby and adult teeth
before they emerge. Fluoride helps to
harden the enamel on adult teeth that have
already emerged.

Fluoride works during the demineralisation

and remineralisation processes that
naturally occur in your mouth. After you eat,
your saliva contains acids that cause
demineralisation a dissolving of the calcium
and phosphorous under the tooth's surface.
At other times when your saliva is less
acidic it does just the opposite, replenishing
the calcium and phosphorous that keep
your teeth hard. This process is caused
remineralisation. When fluoride is present
during remineralisation, the minerals
deposited are harder than they would
otherwise be, helping to strengthen your
teeth and prevent dissolution during the
next demineralization phase.

An Excess of Fluoride Can Cause Dental

Figure 3 Diagram of effects of
Fluorosis
fluoride on enamel
Dental fluorosis is a health condition caused by a child receiving too much fluoride http://www.pwista.com
during tooth development. The critical period of exposure is between 1 and 4 years
old; children over age 8 are not at risk. In its mild form, which is the most common, fluorosis appears as tiny
white streaks or specks that are often unnoticeable. In its severe form it is characterized by black and brown
stains, as well as cracking and pitting of the teeth.
The severity of dental fluorosis depends on the amount of fluoride exposure, the
age of the child, individual response, and nutritional and other factors. Although
water fluoridation can cause fluorosis, most of this is mild and not usually of
aesthetic concern. Severe cases can be caused by exposure to water that is
naturally fluoridated to levels well above the recommended levels, or by exposure
to other fluoride sources such as brick tea or
pollution from high fluoride coal. Figure 4 Dental Fluorosis
http://homepage.eircom.net
1.3 Validity of Methods

Figure 1 gives an extensive overview of the DMFT status of

fluoridated countries against the unfluoridated countries. Although this gives the broadest possible data on
the matter, the validity of the methods can be questioned on two counts.

2
Firstly, the “low tech” collection of data probably results in underestimation of caries. The WHO admits this;
“Radiography is not recommended because of the impracticability of using the equipment in all situations. It
should be realized, however, that without radiographic information the need for restorative care will be
underestimated. The extent of this underestimation varies with disease prevalence and the number of
restorations in the population.” 3 Radiology produces a 3D image of the tooth structure so that any damage
to the tooth below the gum-line can be identified. The problem with this method for such a huge study is the
expense of machinery and training along with the risk of exposing participants and dentists to small levels
of radiation.

Secondly, the graph generalizes countries by using the mean average, where it might be the case that
different parts of the country may have chosen differently about the fluoridation of drinking water. The
WHO noted the limitations of this study, when detailed analysis of the caries situation in many countries
was carried out; it showed that there is a skewed distribution of caries prevalence. This means that a
proportion of twelve year olds still have a high or even very high DMFT value even though a proportion is
totally caries free. Clearly, the mean DMFT value does not always accurately reflect this skewed distribution
leading to the incorrect conclusion that the caries situation is controlled while in reality; several individuals
have a high number of caries. This is clearly demonstrated in the case of the Aboriginal population in
Australia, as noted in Figure 1, Australia has one of the lowest levels of DMFT at 0.8 in 2002, but when a new
index, the Significant Caries Index,4 was introduced in order to bring attention to the individuals with the
highest caries values in each population under investigation, it showed there was huge variation in DMFT
values for individuals. Aboriginal and Torres Strait Islander children from the Northern Peninsula area of
Queensland had more than four times the caries experience of Australian children for both 6-year-olds and
12-year-olds. The 12-year-old DMFT SiC was 7.08, and only 28.9 per cent of 12-year-old children had DMFT
that equaled 0. Dental caries was a significant problem for these remote communities. 5

A national study was conducted in 2002 in all Australian states and territories except New South Wales. 6
The researchers discovered that among 12 year olds, over 40% had some history of decay in their
permanent teeth and in those 10% with the most pronounced level of tooth decay, it was discovered that
they had around five and a half times the national average of DMFT. This study also compared the level of
tooth caries in Australia’s 12 year olds with those countries who have comparable national data available.
They placed Australia 7th and concluded that children from areas with drinking water with negligible
fluoride had poorer dental health than children from areas with either naturally or artificially fluoridated
water. This factor was also shown to be more influential than the socio-economic status of the children.

2.1 Implications of the Biology

There are economic and ethical dimensions to this argument. Firstly, the economic benefits of fluoridating
water are that for a very little financial resource, the National Health Service (NHS) can instigate
preventative measures against tooth decay. In 1998 the University of York Health Economics Consortium
undertook a further detailed examination of the costs and benefits of water fluoridation and concluded: ‘In
areas where the average number of decayed, missing or filled teeth per child (DMFT) is 2.0 or more (and
especially if there are districts where it is greater than 2.6), and where the local water treatment works
serve populations of at least 200,000 people the benefits of water fluoridation are likely to be significantly
greater than the costs.’7 In Southampton and West Hampshire, 2008-9 it was estimated that the actual
fluoridation of the water supply would cost £471,000, (this does not include the £140,000 for public
consultation). The Primary Care Trust, PCT, also estimated that over the next 20 years it will cost

3
http://www.whocollab.od.mah.se/expl/orhsurvey.html
4
The Significant Caries Index is calculated as follows:

 Individuals are sorted according to their DMFT values

 One third of the population with the highest caries scores is selected
 The mean DMFT for this subgroup is calculated.

World Health Organisation Expert Committee on Oral Health Status and Fluoride Use, (1994): Fluorides and Dental
Health. WHO Technical Report Series No 846. Geneva: World Health Organisation.

5
Armfield, J. M., GD Slade, G. D., Spencer, A. J. (2002) Water Fluoridation and Children’s Dental Health, The Child Dental
Health Survey, University of Adelaide, Australia.

6
Ibid.
7
Sanderson D, (1998): Water Fluoridation - An Economics Perspective. York: York Health Economics Consortium.
University of York.

3
£1.2million for the upkeep of the scheme.8 Alan Johnson, the Health Secretary argues that the government
has a duty to prevent tooth decay in areas of high deprivation 9. Thereby cutting down on the dental work
children will need in the future at a huge cost to the public purse. For him, it is an ethical and economic
debate. He sees “fluoridation [as] an effective and relatively easy way to address health inequalities – giving
children from poorer backgrounds a dental health boost that can last a lifetime.” 10 The WHO endorses this
view, “community water fluoridation is safe and cost-effective and should be introduced and maintained
wherever it is socially acceptable and feasible.” 11

Fluoridation is cost-effective as it reaches the entire target population and the population does not have to
change their behaviour to receive the benefits. It is estimated that each tooth saved would cost just £0.32 12.
In certain areas, tooth decay cost the NHS a significant amount, especially as the most common treatment
for tooth decay in children is extraction, which must be carried out under general anesthetic. This makes it
particularly expensive. Fluoridation of Manchester’s water supply could reduce demand for tooth
extraction under a general anesthetic by between 35% and 67%, bringing the number of cases to between
500 and 1000 a year rather than the present 1500.13

The ethics of fluoridation are fiercely contested. Those in favour point to the increased health and wellbeing
of huge numbers of children. Professor John Harris from the Centre for Social ethics and Policy argues that, ‘
The right to fluoride free water is not a basic civil right … we should ask not are we entitled to impose
fluoridation on unwilling people, but are the unwilling people entitled to impose the risks, damage, and the
costs of failure to fluoridate on the community at large.’ 14 On the other hand the National Pure Water
Association argues that ‘The entire population will be forced to take medication because a minority fail to
brush their teeth’ and “these children are already being identified and treated in more effective ways’. 15

Those that believe fluoridation is at best ineffective and at worst dangerous to health question the moral
justification of Fluoridation. Those who question the wisdom of adding fluoride to the water suggest that’ ‘
It is not enough that you were unable to show it did cause
cancer. The onus would be on you to show that is does not
cause cancer’.16 David R Hill argues that while the risk seems
statistically negligible because the entire population is at risk, a
small risk can affect a large number of people.17 He adds that
this means the addition of fluoride ‘becomes completely
unethical’. Many believe that the adverse effects have been
suppressed. The late Dr Colqhuoun asked ‘ How many teeth
would you have to save to justify one child dying from
osteosarcoma?’18

The Fluoride-Cancer connection has been investigated since

the 1950s. In 1977 Yiamouyiannis and Burk carried out an
ecological cancer mortality study of major cities and
discovered overall cancer death rates continued climbing in
fluoridated cities after fluoridation but started leveling off in
never-fluoridated cities. (o = nonfluoridated before 1969, o =
fluoridated 1952 and thereafter). Some scientists also consider
there is a link between fluoride and kidney disease. As the
kidney accumulates more fluoride than other soft

tissues, there is a concern that an excess of fluoride causes Figure 5

damage to the kidney and in turn the bone and other organs. The http://www.newmediaexplore
Fluoride Action Network states that even the kidney foundation admits r.org/chris/Yiamouyiannis.jpg
8
Jon Reeve, ‘Southampton: The Real Cost of Fluoride’, Daily Echo, 28 Feb 2009.
9
The Times, 3 Feb 2008
10
ibid
11
World Health Organisation Expert Committee on Oral Health Status and Fluoride Use, (1994): Fluorides and Dental
Health. WHO Technical Report Series No 846. Geneva: World Health Organisation.
12
Abacus International, (2008), NHS Report, Costs and Benefits, NHS South Central
13
Professor John Harris, (1998) The Ethics of Fluoridation, University of Manchester.
14
The Times, 3 February, 2008
15
David R. Hill, (1997), Fluoride: Risks and Benefits, University of Calgary, Canada
16
ibid
17
ibid
18
Dr. Colqhuoun (2006) cited in Chris Neurath, The Fluoride Cancer-Connection, Fluoride Action Network

4
that kidney patients should be notified of the potential risk from fluorides and fluoridated drinking water.
They also believe there is a link between fluoride and liver damage, brain damage, bone degradation and
gastrointestinal problems.19

2.2 Benefits and Risks to Organisms and the Environment

Scientists have proven that fluoridation of the water has widespread environmental implications. Fluorine
occurs naturally and fluoridation will only increase concentration fluorine around urban environments.
When fluorine from the air enters the water cycle it will settle in the sediment. When it settles in soils,
fluorine will become strongly attached to soil particles. In the environment fluorine cannot be destroyed; it
can only change form. Fluorine that is located in soils may accumulate in plants. The amount of uptake by
plants depends upon the type of plant of the type of soil and the amount and type of fluorine found in the
soil. With plants that are sensitive to fluorine exposure even low concentrations can cause leaf damage and
a declining growth. Too much fluoride whether taken from the soil by roots, or absorbed through the leaves
retards growth and reduces crop yields. Those most affected are corn and apricots.

Animals that eat fluorine-containing plants, may accumulate large amounts of fluorine in their bodies,
bioaccumulation. Fluorine primarily accumulates in bones. Consequently, animals that are exposed to high
concentrations of fluorine suffer from dental decay and bone degradation.

2.3 Alternative Methods

Method 1: The addition of fluoride to milk.

The advantages of fluoridated milk are that the child can have a measured dose of fluoride and the milk can
be targeted at an age of high caries risk, which is from 3-12 years of age. This method allows health
professionals to target vulnerable children and avoids medication of the entire population. Future
generations could be exposed to fluoride when they are most vulnerable to dental caries for the years
needed. When the leave primary education they would stop ingesting fluoridated milk and therefore the
suggested long-term risk of fluoride such as liver disease, kidney disease and cancers would all be vastly
reduced if the risk were real. The parent would give consent to whether the child receives fluoridated milk
or non-fluoridated milk, allowing parental choice over the exposure of fluoride to their child.

Since the 1950s fluoridated milk has been investigated and favorable results obtained from early studies
lead to the establishing of the Borrow Dental Milk Foundation 20. This institution, which has collaborated
with the WHO on clinical trials and clinical studies with community preventative programmes, showed that
milk fluoridation programmes can be recommended as a preventative measure for caries.

The efficacy of fluoridated milk was tested by Steven et al in 1984 21. Children in a test group consumed
200ml of milk containing 1.5mg of fluoride on school days, whereas those in the control group received
200ml of non-fluoridated milk. The results were that in those children that had received fluoridated milk
showed a reduction in the incidence of tooth decay by 31.2%.

A community trial of fluoridated powdered milk was tested in Chile in 1994-1999. 22

The objective was to investigate the efficacy fluoridated powdered milk and milk derivatives on the dental
caries prevention programme.

Method: Fluoridated milk was given to 1000 pre-school children in Codegua, Chile, using the standard
National Complementary Feeding Program (PNAC). The daily fluoride dose from fluoridated powdered milk
was 0.25 mg for infants aged 0-2 years, 0.5 mg for children aged 2-3 years and 0.75 for children aged 3-6
years. Cross-sectional samples of children aged 3-6 years were taken from Codegua (study community)
from 1994 to 1999 and from La Punta (control community) from 1997 and 1999.

19
Fluoride Action Network, Health Effects, http:/fluoridealert.org.uk
20
The Borrow Foundation seeks to promote the study and research into the fluoridation of milk and to publish and
disseminate the results of such work. http://www.borrowfoundation.org/
21
Stephen K. W., Boyle I. T., Campbell D., McNee S., Boyle P., (1984), Five-Year Double Blind Fluoridated Milk Study in
Scotland. Community Dentistry and Oral Epidemiology, vol., 12: pp.223-229.
22
Marino R, Villa A, Guerrero S., ‘A Community Trial of Fluoridated Powdered Milk in Chile’. Community Dentistry and
Oral Epidemiology (2001); 29 (6): 435-442

5
Results: Reductions of 72% were observed in the DMFT indices in the 3-6-year-old groups when comparing
with children in the control group who did not receive fluoridated milk. In 1999, children in the study group
showed 41% lower DMFTs than children in the control group. The proportion of caries-free children in the
study group increased after 4 years of program implementation from 22.0% to 48.4%.

Those conducting the trial concluded that under Chilean rural conditions, fluoridation of powdered milk
distributed through the PNAC is an effective caries prevention alternative for areas where water
fluoridation might not be feasible.

Fluoride has been added to the milk in 42 Primary Schools in Sheffield in response to the high levels of tooth
decay (1.72 which is higher than the national average of 1.47) and to tackle the huge problem in the city’s
deprived areas (4.21 DMFT).23

However, there are certain disadvantages with the use of milk to administer fluoride. On a practical level
some children may not like milk, be lactose intolerant or may not drink milk for ethical beliefs i.e. vegan
children. A larger issue than these administrative factors and the health factors are the political factors and
the outcry of groups like FAN who oppose water fluoridation and would see the fluoridation of milk as mass
medication.

Method 2: Increased dental health education in young children.

The promotion of dental health does not always reach the target audience. The British Dental Health
Foundation24 and other charitable groups promote good dental health. The National Smile Month in 2007
was supported by politicians, Tesco and several national newspapers. It included the distribution of 38,000
guides to dentists, schools and pharmacies. The aim was to encourage everyone to brush his or her teeth
thoroughly twice a day. The programme also offers dentists educational resources. In Scotland health
visitors were encouraged to talk about good oral health in babies and young children, nurseries and
playgroups disseminate oral health messages, especially among the most disadvantaged children and tooth
brushing schemes are being targeted in deprived communities. 25

Research undertaken in both Toronto, Canada and Manchester, England 26, asked the question, “Is dental
health education effective?” Their conclusion from systematically reviewing current evidence in both
countries suggested that any improvement in dental health is at best temporary. “This combination of
qualitative and quantitative review techniques showed that dental health interventions have: a small
positive, but temporary effect on plaque accumulation, no discernable effect on caries increment and a
consistent positive effect on knowledge levels.” In other words people know more about dental health, but it
does not change their behaviour significantly.

Conclusion

To conclude, the addition of fluoride to the drinking water in the UK, would prevent a significant number of
dental caries. The financial case is hard to establish with any certainty, not least because of the public
consultation needed to impose an unpopular fluoridation scheme. That fluoride causes negative health risks
to certain individuals is fiercely contested by scientists on both sides of the debate and the question
remains, is an improvement in the dental health of the nation enough to justify the risk to a small
percentage of that population? Using the data from the Chris Neurath WHO graph (figure 1), the evidence
points towards the invalidity of the addition of fluoride as the disparity between the DMFT values between
fluoridated and unfluoridated nations has become negligible at present. This suggests there are too many
other positive factors that deem fluoridation unnecessary regarding health and therefore would be a waste
of economic resources. In short the positive effects of our dentistry practice and dietary habits outweigh the
effects of fluoridation on the DMFT values.

23
Jeni Harvey ‘Sheffield: Fluoride is added to children's milk in 42 primary schools’ Yorkshire Post October 14, 2008.

24
British Dental Health Foundation, (2007), Annual Review.
25
Towards Better Oral Health in Children, Scottish Executive www.scotland.gov.uk (accessed 22.2.2010)
26
E. J. Kay and D. Locker, (1996) ‘Is Dental Health Education Effective? A Systematic Review of Current Evidence,
Community’ Dentistry and Oral Epidemiology, Manchester and Ontario, Vol. 24, pp. 231-235.

6
Bibliography

Abacus International, (2008), NHS Report, Costs and Benefits, NHS South Central.

Armfield, J. M., GD Slade, G. D., Spencer, A. J. (2002) Water Fluoridation and Children’s Dental Health, The
Child Dental Health Survey, University of Adelaide, Australia.

British Dental Health Foundation, (2007), Annual Review.

Harris, J. (1998), ‘The Ethics of Fluoridation’ Journal of Medical Ethics, University of Manchester.

Harvey, J. ‘Sheffield: Fluoride is added to children's milk in 42 primary schools’ Yorkshire Post October 14,
2008.

Hill, D. R., (1997), Fluoride: Risks and Benefits, University of Calgary, Canada

Kay, E. J., and Locker, D. (1996) ‘Is Dental Health Education Effective? A Systematic Review of Current
Evidence, Community’ Dentistry and Oral Epidemiology, Vol. 24, pp. 231-235.

Evaluation: This research was conducted by members of two Universities in Manchester, UK and Ontario,
Canada. The research took the form of an in depth study into the various educational programmes in both
countries and was peer reviewed. By looking at so many studies, local anomalies would become
insignificant and therefore give a more reliable outcome. It was both qualitative and quantitive data that
was collected making the study more valid as it was both accurate and in depth. For example they measured
the plaque on children’s teeth and number of caries after health education, but unlike the WHO study, they
also used qualitative data such as collecting data on knowledge and attitudes towards dental health.

Marino R, Villa A, Guerrero S., ‘A Community Trial of Fluoridated Powdered Milk in Chile’.Community
Dentistry and Oral Epidemiology (2001); 29 (6): 435-442.

Reeve, J., ‘Southampton: The Real Cost of Fluoride’, Daily Echo, 28 Feb 2009.

Sanderson, D., (1998): Water Fluoridation - An Economics Perspective. York: York Health Economics
Consortium. University of York.

Stephen K. W., Boyle I. T., Campbell D., McNee S., Boyle P., (1984), Five-Year Double Blind Fluoridated Milk
Study in Scotland. Community Dentistry and Oral Epidemiology, vol., 12: pp.223-229.

Minister orders fluoride to be added to water, The Sunday Times, 3 February, 2008,
http://www.timesonline.co.uk/tol/news/uk/health/article3295310.ece

World Health Organisation (2004) – Chris Neurath, FAN http://www.whocollabo.mah.se/

World Health Organisation Expert Committee on Oral Health Status and Fluoride Use, (1994): Fluorides
and Dental Health. WHO Technical Report Series No 846. Geneva: World Health Organisation.

Evaluation: The WHO, World health Organisation, is a specialized agency of the United Nations, it is the
coordinating authority on international public health. The work in this report is based on empirical
evidence and the research has been extensively peer reviewed and the methodology in the public domain. In
addition there have been many contributions from many centres therefore findings are corroborated. The
report makes clear that it has limitations so while the data is very broad and even flawed in places because
of this, it presents a relatively reliable source of data.

Websites:

The Borrow Foundation http://www.borrowfoundation.org.

Neurath, C. The Fluoride Cancer-Connection, Fluoride Action Network, http:/fluoridealert.org.uk

7
Evaluation: The Fluoride-Cancer Connection, Fluoride Action Network are an international coalition who
say they are’ “seeking to broaden public awareness of the toxicity of fluoride.” So the article gives a detailed
history of the research into fluoridated water, but only sights research that substantiates its views on
fluoride being toxic. Articles are peer-reviewed, but only articles in agreement with this stance are
published by FAN and therefore it must be concluded that this evidence is biased.

Towards Better Oral Health in Children, Scottish Executive www.scotland.gov.uk (accessed 22.2.2010)

List of Figures:

Figure 1. World Health Organisation, 2004 – Chris Neurath, FAN http://www.whocollabo.mah.se/

Figure 2. Extracts of the Third edition of "Oral Health Surveys - Basic methods",

Figure 3. Geneva 1987. Figure 3 Diagram of effects of fluoride on enamel http://www.pwista.com

Figure 4. Dental Fluorosis http://homepage.eircom.net2

Figure 5 http://www.newmediaexplorer.org/chris/Yiamouyiannis.jpg