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FluorideinDrinkingWater
WesternWashingtonUniversity
AmyEllsworth

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EnterfluoridatingpublicwaterintoasearchengineandsomewhereintheUnitedStates
thistopicisupforreviewindifferentcitiesandfordebate.Governmentandpublicsafetyisa
hotbuttontopicandinthiscasethedebateisonfluoridatingpublicwater.Thisconcernarises
whenthegovernmenthascontrolinsomethingthatisunavoidable.Waterisusedeverydaywith
manydifferentways.Thefluoridatingpublicwaterdebateisanongoingsagaofgovernment
influence,cost,conspiracytheories,andpublichealth.Inthispaperareviewonsomeofthe
debatesandtheprosandconswithaddingfluoridetopublicdrinkingwater.Afterreviewof
thesedebatesitisevidentthatexposuretofluoridedecreasesdentalcariesandneedstobe
includedindailylife.
Fluorideisanaturallyoccurringmineralandinwateritisnaturallypresentintrace
amounts.Fluorideisnotconsideredanessentialmineralforsustaininglifeasourbodiescan
livewithoutfluoride.Accordingtogeosciencenewsandinformation,fluoridehasmanydifferent
usesanddifferentgrades.Theseusesoffluorideandgradesoffluorideincludetheproduction
ofacid,ceramics,metals,optics,andgems(n.d.).FluorideisanelementandInsteadofthe
hydroxylgrouportheOH,onthehydroxyapatite,fluoridecombineswiththecalciumfor
mineralizationandpreventstoothdecay.Fluorideexposureisalsousedinaidingtheand
protectingthemineralizedcomponentsoftoothenamel.Overtimeenamelbreaksdownandis
lost.Fluorideisawaytoremineralizetheenamelonteeth.Thewaythatthisoccursisthrough
creationoffluorapatitefromhydroxylapatite(Kensche,2016),hydroxylapatiteisthenaturally
occurringmineralfortoothenamel.Exposuretofluorideaidsincreatingamineralizedstructure
calledafluorapatitethatislesssolublethanthebiologicalversionofthecrystallizedstructure
calledanapatite.Aclinicalstudy(2016)comparingtheerosionofatreatmentofCalcium

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Phosphateorhydroxylapatiteandatreatmentoffluorideunderelectronmicroscopy.The
findingswerethatthefluoridetreatmentcreatesafluorapatitewhichislesssolubleandhas
betterprotectivecomponentsthanhydroxylapatitewhenexposedtoacids(Kensche,et.al).This
studyshowsthatexposuretofluorideaidsincreatinganenamelhasbetterprotectiontowards
acidsincomparisontoanenamelthathasdoesnothaveexposuretofluoride.
Increasedresistancetoacidsisneededforbettertoothhealthandinpreventingtooth
decay.DrJayasudhaofDayanandSagaranexpertinBangaloreIndiastatesthatEnamelis
composedofcrystallinecalciumphosphateof96%mineralandtheremaining4%consistingof
organiccompoundsandwater.Fluoridatingtoothenamelisimportantduetotheinabilityof
enameltoregenerateitself.Matureenamelisacellularanddoesnotregenerateitselfduetothe
degradationofenamelproteinamelogeninaftertootheruption(Jayasudha,2014).Current
studiesareshowingthataftertheseproteinsarelost,withoutfluoridesupplementationthereis
anincreaseofdentalcariesanddentaldecay.Therearecurrenttrendsinstudyingthe
regenerationabilitiesofdifferentcellsandgenerationoftoothenamel.Theconclusionto
Jayasudha'slaststudywasthatregenerationoftoothenameliscomplicatedandrequires
furtherresearch.
Creationofanenamelthathasbetterwithstandingabilityisimportant.Fluoride
consumptionisendorsedbytheCenterforDiseaseControl,theWorldHealthOrganization,and
otherpublicorganizationsforthepreventionofdentalcariesandmaintenanceoftoothenamel.
Fluoridatingpublicwaterisconsideredtobeoneofthebestwaysincreasefluorideconsumption
onalargescale(CDC,2014).AddingfluoridetopublicwaterinAmericabeganinthe1940sas
asafetymeasureforbetterdentalhealth.ThisperiodinAmericashistorymarkedatimewhen
developmentofconspiracytheoriesandadistrustofpublicentitieswasoccurring.Oneaspect

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ofthiswastheconcernthattherewerelimitedstudiesonfluorideanditseffectsonpeopleand
theenvironment.
Acriticalconcernthatarisesintheaddingfluorideinwateristheclaimthattherewerent
studiesoffluorideexposuretohumanspriortoaddingittothewater.Thisisnotthecase,
humanexposuretofluorideanditseffectswerestudiedpriortoaddingittothewater(Pollock
2014).Inadditiontothehumanexposurestudiespriortoaddingfluoridetothewater,there
havebeenmanyindependentandpeerreviewedstudiesafterfluoridatingthewater.
Throughoutdecadesinadjunctionwiththeoriginalstudiestheevidenceshowsthatexposureto
fluoridereducesdentalcaries.
Includedwiththesestudiesaresafeexposurelevelsreviewedasrecentlyas2013bya
Marthalerarticlewhichshowedthatexposuretofluorideconcentrationsof0.9.1.3ppmin
drinkingwaterreducedthenumberofdecayed,missing,orfilledteeth(DMF).Thetestingwas
on1214yearoldadolescents,andcomparisonDMFwashalved.Thecomparablewasfluoride
concentrationsof0.10.6ppmindrinkingwater(Marthaler,2013).Thisstudyhasaddedtothe
debateoffluorideconsumptionanddrinkingwater.Otherobservations(2015)occurredin
Australiaafternoticingthatindigenouschildrenexperiencesignificantlymoredentalcariesthan
nonindigenouschildren.Amaindifferencethatpresenteditselfamongthesechildrenwas
exposuretofluoridation.
FurtherevidencethataddingfluoridepreventsdentalcariesAcochranereviewofpublic
waterfluoridationandtoothdecayamongchildrenfoundthatafterintroductionoffluoridatingthe
waterin1945therewasanationaldecreaseintoothdecay.Otherenvironmentalchanges
duringthisperiodwasthewidespreadexposureoffluoridatedtoothpastesstudiesdonot
accountforthisenvironmentalchangeandsothecausaleffectofaddingfluoridetopublicwater
andreductionoftoothdecayamongchildrenbythecochranereviewremainsinconclusive.

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Thecochranstudystatesthatthereisntenoughevidencetosaythatinductionof
fluoridationofwaterconclusivelyreducesdentalcaries,althoughthereisahighprobabilityof
this.Thetrendsofdentalcarieshasreducedsincetheinductionperiodin1945,whetherthis
wasduetoaddingfluoridetowaterisnotconclusiveduetotherebeingotherfactorsinthe
environmentthatcouldreducedentalcaries.Reportsandstatisticssincethefluorideinduction
periodconcludethatthereisalsoareductionofdentaldecay(JournaloftheAmericanMedical
Association,1985).Thisreductionofdentaldecaycouldbefromavarietyofdifferentmethods
suchas:waterfluoridation,fluoridetablets,anddrops,clinicallyappliedfluorides,fluoride
rinses,anddentifrices.Itisundeterminedwhichmodalityoffluorideexposurepreventsdental
decaythebest.
TheAmericanDentalAssociation(2016)recommendshavingexposuretofluoridefor
toothmaintenance,andforadequateoralhygiene.Havingfluorideexposurereducesdental
caries,andaddingfluorideinthedrinkingwatercontinuestobeanoptionofchoiceforpublic
healthofficials.Themainobjectiveofaddingfluoridetodrinkingwateristoincreasefluoride
consumptiononalargescale.ArecentstudyinLatinAmerica(2016)hasfoundthatthereisa
highprevalenceofdentalcariesamongchildren.Intheconclusionofthisstudy,the
recommendationfordecreasingdentalcariesfrompublichealthofficialsisincreasingfluoride
exposureinthispopulation.
Addingtothedebate,istheconcernforfluorosis.Fluorosisisaestheticallyunpleasing,
andpresentsitselfthroughwhitespotsontheteeth.Thisoccursiftheteethareexposedtotoo
muchfluorideandasaresult,theCDChasguidelinesonprevention.Fluorosisoccursmainly
inchildrenundertheageof8years,intoothdevelopment.ContinuedresearchfromtheJournal
oftheAmericanMedicalAssociationhasbeenevaluatingtheincidenceoffluorosisintheUnited
States.Fluorosisoccurswhenthereisexposuretofluoridethatisovertherecommended

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amounts(2011).Forpreventionoffluorosisbeingcognizantofhowmuchfluorideisbeing
consumedisrecommended.RecommendationsfromtheCenterforDiseaseControl(2014)for
thisincludeensuringthatchildrendonotswallowfluoridatedtoothpaste,andnotbeingexposed
tofluoridatedtabletsifthedrinkingwaterisfluoridated.
Whetherfluoridereducesdentalcariesisnottheentiredebatewhenaddingfluorideto
publicdrinkingwater.Otherconcernsarise,andoneofthemisthedebateonenvironmental
exposureandwhetherincreasingfluorideinthewaterharmstheenvironment.InanOsterman
(1990)literaturereview,itisfoundthatareaswithlowvegetationsuchasareasofwastealso
containhighconcentrationoffluorideinwater.Thereareinconclusiveresultsofwastelands,
lowvegetationandfluoridelevelsduetoareasofhighlevelsoffluoride,areincreasedlevelsof
otherindustrialwastes.
Duetodrinkingwatersmanyusages,itcouldbeclaimedthataddingfluoridetodrinking
wateriswastefulsinceonly1%ofwaterusageisforconsumption.TheCDCanalyzesthecosts,
andstatesthatdependingonthesizeofthecommunity,savingswouldrangefrom$1619per
personinthecommunity.Thecostsassociatedwithfluorinatingthewaterincludeinstallingand
maintainingnecessaryequipment,andoperatingwaterplants,comparedtotheestimatedcosts
ofexpectedcavitiesinnonfluoridatedcommunities,treatment,andtimelostvisitingthedentist
fortreatment(CDC,2013).Addingfluoridetothewaterorincreasingfluorideexposureasa
publicsafetymeasuredependsontheoralhealthofyourcommunityandtheaccessibilityfor
dentalcare.
Oralhealthanddentalcareisaluxuryinthehealthcaresystem.AccordingtotheU.S.
DepartmentofHealthandHumanServices(HRSA)about108millionpeopleintheU.S.have
nodentalinsurance(2015).TheHRSAhasincreasedprograms,fundingandinitiativesfor
increasingaccessibledentalcareintrainingmoredentalprofessionalsandinincreasingdental

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servicesforcommunitybasedpartnershipsindentalhealth.TheHRSAsprogrammissionis
statedastoimprovethehealthoftheNationsunderservedcommunitiesandvulnerable
populationsbyassuringaccesstocomprehensive,culturallycompetent,qualityprimaryhealth
careservices(2015).Thisprogramhasincreasedthenumberofpatientsandvisitsandaidsto
theinconclusivedatathatfluoridereducesdentalcaries.
Otherdebatesthatariseistheideaofconspiracyandgovernmentcontrol.Inthis,the
governmenthasaccesstowasteorafluoridatedbyproductoffertilizerandneedstodisposeof
it.Asaresultofneedingtodisposeofthiswaste,itisaddedtopublicdrinkingwater.Other
claimsagainstfluoridatingdrinkingwaterrangefromfluoridationcausingbraintumorsand
kidneydamage,andtheseclaimsshowlackofconclusiveevidence.Aninterestingdevelopment
inaddingfluoridetopublicwaterandresearchofbonefractures(2001)istheevidencethatin
peoplewhosustainmultiplefractures,thereisanincreasedamountoffluorideinthebone
matrixmakeup(AlarconHerreraMT,etal.).Thissuggeststhatmineralizationwithfluorideis
occurringatfracturesites.
Asstatedabove,fluorideisanelementandisusedforenamelprotectionthrough
bindingtocalcium.Inadebateagainstfluoridatingdrinkingwaterthereisaclaimthatadding
fluoridetodrinkingwaterbindswiththecalciuminbonesandcausesosteosarcoma.Apeer
reviewedstudy(Archer,2015)performedinTexasanalyzedfluoridelevelsindrinkingwaterand
apossiblerelationshipofexposureoffluorinationandchildrendiagnosedwithosteosarcoma
between19962006.Thestudystatesthatthereisnorelationshipbetweenfluoridelevelsand
osteosarcomainTexas.
Thedebateofaddingfluoridetodrinkingwatercontinuestobehadoverthecountry,
andovertheworld.Withcontinueddistrustofthegovernment,thisdebateislikelytocontinue.
Exposuretofluoridehasbeenproventodecreasedentaldecayandpromoteenamel

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remineralization.FluorideexposureisendorsedbytheAmericanDentalAssociation,theCenter
forDiseaseControl,theWorldHealthOrganization,andavarietyofotherpublichealth
agencies.Waysoffluoridationinclude,havingfluorideinthewater,addingfluoridesalttablets
topersonalwater,useoffluoridetoothpaste,doingdentalfluoridetreatments.Fluoride
exposurecontributestoreduceddentaldecay,andaddingittowateristhepreferredoptionfor
widedistribution.Oneofthemostimportanttakeawaysistoknowthedebateinyourcity,and
whetherfluorideisbeingaddedtothewater.Knowledgeofthiswillprovideinformationon
fluorideexposureandifitshouldbeobtainedthroughmeansotherthanwaterconsumption.

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