Water fluoridation in the United States

As with some other countries water fluoridation

Water fluoridation

Water fluoridation is the controlled addition of fluoride to a public water supply to reduce tooth decay. Fluoridated water has fluoride at a level that is effective for preventing cavities; this can occur naturally or by adding fluoride...

in the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

is a contentious issue. As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation.

Fluoridation became an official policy of the U.S. Public Health Service by 1951, and by 1960 water fluoridation had become widely used in the U.S., reaching about 50 million people. By 2006, 69.2% of the U.S. population on public water systems were receiving fluoridated water, amounting to 61.5% of the total U.S. population; 3.0% of the population on public water systems were receiving naturally occurring fluoride.

While doctors, dentists, and public health scientists largely supported water fluoridation in the U.S., waterworks engineers were initially divided in their position despite having faced controversy earlier with chlorination.

U.S. regulations for bottled water

Bottled water

Bottled water is drinking water packaged in plastic or glass water bottles. Bottled water may be carbonated or not...

do not require disclosing fluoride content, so the effect of always drinking it is not known. Surveys of bottled water in Cleveland and in Iowa found that most contained well below optimal fluoride levels.

History

Opposition to community water fluoridation in the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

is partly due to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into what was then known as "Colorado Brown Stain." The condition, now known as dental fluorosis, when in its severe form is characterized by cracking and pitting of the teeth. Of 2,945 children examined in 1909 by Dr. McKay, 87.5% had some degree of stain or mottling. All the affected children were from the Pikes Peak

Pikes Peak

Pikes Peak is a mountain in the Front Range of the Rocky Mountains, west of Colorado Springs, Colorado, in El Paso County in the United States of America....

region. Despite the negative impact on the physical appearance of their teeth, the children with stained, mottled and pitted teeth also had fewer cavities than other children. McKay brought this to the attention of Dr. G.V. Black

Greene Vardiman Black

Greene Vardiman Black , commonly known as G.V. Black, is known as one of the founders of modern dentistry in the United States. He was born near Winchester, Illinois on August 3, 1836 to William and Mary Black. He spent his early life on a farm and quickly developed an interest in the natural world...

, and Black's interest was followed by greater interest within the dental profession.

Initial hypotheses for the staining included poor nutrition

Nutrition

Nutrition is the provision, to cells and organisms, of the materials necessary to support life. Many common health problems can be prevented or alleviated with a healthy diet....

, overconsumption of pork

Pork

Pork is the culinary name for meat from the domestic pig , which is eaten in many countries. It is one of the most commonly consumed meats worldwide, with evidence of pig husbandry dating back to 5000 BC....

or milk

Milk

Milk is a white liquid produced by the mammary glands of mammals. It is the primary source of nutrition for young mammals before they are able to digest other types of food. Early-lactation milk contains colostrum, which carries the mother's antibodies to the baby and can reduce the risk of many...

, radium

Radium

Radium is a chemical element with atomic number 88, represented by the symbol Ra. Radium is an almost pure-white alkaline earth metal, but it readily oxidizes on exposure to air, becoming black in color. All isotopes of radium are highly radioactive, with the most stable isotope being radium-226,...

exposure, childhood diseases, or a calcium

Calcium

Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...

deficiency in the local drinking water. In 1931, researchers from the Aluminum Company of America (ALCOA) concluded that the cause of the Colorado

Colorado

Colorado is a U.S. state that encompasses much of the Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains...

stain was a high concentration of fluoride ions in the region's drinking water (ranging from 2 to 13.7 mg/L) and areas with lower concentrations had no staining (1 mg/L or less). Pikes Peak's rock formations contained the mineral

Mineral

A mineral is a naturally occurring solid chemical substance formed through biogeochemical processes, having characteristic chemical composition, highly ordered atomic structure, and specific physical properties. By comparison, a rock is an aggregate of minerals and/or mineraloids and does not...

cryolite

Cryolite

Cryolite is an uncommon mineral identified with the once large deposit at Ivigtût on the west coast of Greenland, depleted by 1987....

, one of whose constituents is fluorine. As the rain and snow fell, the resulting runoff water dissolved fluoride which made its way into the water supply.

Dental

Dentistry

Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...

and aluminum researchers then moved toward determining a relatively safe level of fluoride

Fluoride

Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

chemicals to be added to water supplies. The research had two goals: (1) to warn communities with a high concentration of fluoride of the danger, initiating a reduction of the fluoride levels in order to reduce incidences of fluorosis, and (2) to encourage communities with a low concentration of fluoride in drinking water to add fluoride

Fluoride

chemicals in order to help prevent tooth decay. By 2006, 69.2% of the U.S. population on public water systems were receiving fluoridated water, amounting to 61.5% of the total U.S. population; 3.0% of the population on public water systems were receiving naturally occurring fluoride.

Early studies

A study of varying amounts of fluoride in water was led by Dr. H. Trendley Dean, a dental officer of the U.S. Public Health Service. In 1936 and 1937, Dr. Dean and other dentists compared statistics from Amarillo, which had 2.8 - 3.9 mg/L fluoride content, and low fluoride Wichita Falls. The data is alleged to show fewer cavities in Amarillo children, but the studies were never published. Dr. Dean's research on the fluoride-dental caries relationship, published in 1942, included 7,000 children from 21 cities in Colorado

Colorado

Colorado is a U.S. state that encompasses much of the Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains...

, Illinois

Illinois

Illinois is the fifth-most populous state of the United States of America, and is often noted for being a microcosm of the entire country. With Chicago in the northeast, small industrial cities and great agricultural productivity in central and northern Illinois, and natural resources like coal,...

, Indiana

Indiana

Indiana is a US state, admitted to the United States as the 19th on December 11, 1816. It is located in the Midwestern United States and Great Lakes Region. With 6,483,802 residents, the state is ranked 15th in population and 16th in population density. Indiana is ranked 38th in land area and is...

, and Ohio

Ohio

Ohio is a Midwestern state in the United States. The 34th largest state by area in the U.S.,it is the 7th‑most populous with over 11.5 million residents, containing several major American cities and seven metropolitan areas with populations of 500,000 or more.The state's capital is Columbus...

. The study concluded that the optimal amount of fluoride which minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 mg per day, per adult. Although fluoride is more abundant in the environment today, this was estimated to correlate with the concentration of 1 mg/L.

In 1937, dentists Henry Klein and Carroll E. Palmer had considered the possibility of fluoridation to prevent cavities after their evaluation of data gathered by a Public Health Service team at dental examinations of Native American children. In a series of papers published afterwards (1937–1941), yet disregarded by his colleagues within the U.S.P.H.S., Klein summarized his findings on tooth development in children and related problems in epidemiological investigations on caries prevalence.

In 1939, Dr. Gerald J. Cox conducted laboratory tests using rats

RATS

RATS may refer to:* RATS , Regression Analysis of Time Series, a statistical package* Rough Auditing Tool for Security, a computer program...

that were fed aluminum and fluoride. Dr. Cox suggested adding fluoride to drinking water (or other media such as milk

Milk

or bottled water) in order to improve oral health.

In the mid 1940s, four widely cited studies were conducted. The researchers investigated cities that had both fluoridated and unfluoridated water. The first pair was Muskegon, Michigan

Muskegon, Michigan

Muskegon is a city in the U.S. state of Michigan. As of the 2010 census, the city population was 38,401. The city is the county seat of Muskegon County...

and Grand Rapids, Michigan

Grand Rapids, Michigan

Grand Rapids is a city in the U.S. state of Michigan. The city is located on the Grand River about 40 miles east of Lake Michigan. As of the 2010 census, the city population was 188,040. In 2010, the Grand Rapids metropolitan area had a population of 774,160 and a combined statistical area, Grand...

, making Grand Rapids the first community in the world to add fluoride chemicals to its drinking water to try to benefit dental health on January 25, 1945. Kingston, New York

Kingston, New York

Kingston is a city in and the county seat of Ulster County, New York, USA. It is north of New York City and south of Albany. It became New York's first capital in 1777, and was burned by the British Oct. 16, 1777, after the Battles of Saratoga...

was paired with Newburgh, New York

Newburgh (city), New York

Newburgh is a city located in Orange County, New York, United States, north of New York City, and south of Albany, on the Hudson River. Newburgh is a principal city of the Poughkeepsie-Newburgh-Middletown metropolitan area, which includes all of Dutchess and Orange counties. The Newburgh area was...

. Oak Park, Illinois

Oak Park, Illinois

Oak Park, Illinois is a suburb bordering the west side of the city of Chicago in Cook County, Illinois, United States. It is the twenty-fifth largest municipality in Illinois. Oak Park has easy access to downtown Chicago due to public transportation such as the Chicago 'L' Blue and Green lines,...

was paired with Evanston, Illinois

Evanston, Illinois

Evanston is a suburban municipality in Cook County, Illinois 12 miles north of downtown Chicago, bordering Chicago to the south, Skokie to the west, and Wilmette to the north, with an estimated population of 74,360 as of 2003. It is one of the North Shore communities that adjoin Lake Michigan...

. Sarnia, Ontario

Sarnia, Ontario

Sarnia is a city in Southern Ontario, Canada . It is the largest city on Lake Huron and is located where the upper Great Lakes empty into the St. Clair River....

was paired with Brantford, Ontario

Brantford, Ontario

Brantford is a city located on the Grand River in Southern Ontario, Canada. While geographically surrounded by the County of Brant, the city is politically independent...

, Canada

Canada

Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

.

In 1952 Nebraska Representative A.L. Miller complained that there had been no studies carried out to assess the potential adverse health risk to senior citizens, pregnant women or people with chronic diseases from exposure to the fluoridation chemicals. A decrease in the incidence of tooth decay was found in some of the cities which had added fluoride chemicals to water supplies. The early comparison studies would later be criticized as, "primitive," with a, "virtual absence of quantitative, statistical methods...nonrandom method of selecting data and...high sensitivity of the results to the way in which the study populations were grouped..." in the journal Nature

Nature (journal)

Nature, first published on 4 November 1869, is ranked the world's most cited interdisciplinary scientific journal by the Science Edition of the 2010 Journal Citation Reports...

Water fluoridation

As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation. According to a 2002 study, 67% of U.S. residents were living in communities with fluoridated water at that time.

The U.S. Centers for Disease Control has identified community water fluoridation as one of ten great public health achievements of the 20th century. The CDC recommends water fluoridation at a level of 0.7–1.2 mg/L, depending on climate. The CDC also advises parents to monitor use of fluoride toothpaste, and use of water with fluoride concentrations above 2 mg/L, in children up to age 8. There is a CDC database for researching the water fluoridation status of neighborhood water.

In 1998, 70% of people polled in a survey conducted by the American Dental Association

American Dental Association

The American Dental Association is an American professional association established in 1859 which has more than 155,000 members. Based in Chicago, the ADA is the world's largest and oldest national dental association and promotes good oral health to the public while representing the dental...

(ADA) believed community water should be fluoridated, with 18% disagreeing and the rest undecided. In November 2006, the ADA

American Dental Association

began recommending to parents that infants from 0 through 12 months of age should have their formula

Formula

In mathematics, a formula is an entity constructed using the symbols and formation rules of a given logical language....

prepared with water that is fluoride-free or contains low levels of fluoride to reduce the risk of fluorosis.

The issue of whether or not to fluoridate water supplies frequently arises in local governments. For example, on November 8, 2005, citizens of Mt. Pleasant, Michigan voted 63% to 37% in favor of reinstating fluoridation in public drinking water after a 2004 ballot initiative ceased water fluoridation in the city. At the same time, voters in Xenia, Ohio; Springfield, Ohio; Bellingham, Washington; and Tooele City, Utah all rejected water fluoridation.

In Skagit County in the state of Washington, the county commissioners in 2007 voted 2 to 1 to order the local public utility district to begin fluoridating the public water supply by Jan. 2009. $1.2 million was to be provided by the privately funded Washington Dental Service Foundation to begin building the equipment needed to add fluoride chemicals to the Judy Reservoir

Reservoir

A reservoir , artificial lake or dam is used to store water.Reservoirs may be created in river valleys by the construction of a dam or may be built by excavation in the ground or by conventional construction techniques such as brickwork or cast concrete.The term reservoir may also be used to...

, which supplies the majority of Skagit Valley's water customers. The source and type of fluoride to be added to the drinking water of more than 70,000 citizens had not been disclosed. However, in February 2009, Skagit County commissioners rescinded the 2007 order, citing costs and possible lawsuits.

The cost of adding fluoridation chemicals to the water of 44 Florida communities has been researched by the State Health Office in Tallahassee. In communities with a population of over 50,000 people, fluoridation costs were estimated at 31 cents per person per year. The estimated cost rises to $2.12 per person in areas with a population below 10,000. Unintended consequences, such as equipment malfunction, can substantially raise the financial burden, as well as the health risks, to the consumer.
In the U.S., Hispanic and Latino Americans

Hispanic and Latino Americans

Hispanic or Latino Americans are Americans with origins in the Hispanic countries of Latin America or in Spain, and in general all persons in the United States who self-identify as Hispanic or Latino.1990 Census of Population and Housing: A self-designated classification for people whose origins...

are significantly more likely to consume bottled instead of tap water, and the use of bottled and filtered water grew dramatically in the late 1990s and early 2000s.

Court cases

Fluoridation has been the subject of many court cases

Legal case

A legal case is a dispute between opposing parties resolved by a court, or by some equivalent legal process. A legal case may be either civil or criminal...

wherein activists have sued municipalities, asserting that their rights to consent to medical treatment and due process

Due process

Due process is the legal code that the state must venerate all of the legal rights that are owed to a person under the principle. Due process balances the power of the state law of the land and thus protects individual persons from it...

are infringed by mandatory water fluoridation. Individuals have sued municipalities for a number of illnesses that they believe were caused by fluoridation of the city's water supply. In most of these cases, the courts have held in favor of cities, finding no or only a tenuous connection between health problems and widespread water fluoridation. To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.

Early cases

A flurry of cases were heard in numerous state courts across the U.S. in the 1950s during the early years of water fluoridation. State courts consistently held in favor of allowing fluoridation to continue, analogizing fluoridation to mandatory vaccination and the use of other chemicals to clean the public water supply, both of which had a long-standing history of acceptance by courts.

In 1952, a Federal Regulation

Code of Federal Regulations

The Code of Federal Regulations is the codification of the general and permanent rules and regulations published in the Federal Register by the executive departments and agencies of the Federal Government of the United States.The CFR is published by the Office of the Federal Register, an agency...

was adopted that stated in part, "The Federal Security Agency

Federal Security Agency

The Federal Security Agency was an independent agency of the United States government established in 1939 pursuant to the "Reorganization Act of 1939"...

will regard water supplies containing fluorine, within the limitations recommended
by the Public Health Service, as not actionable under the Federal Food, Drug, and Cosmetic Act

Federal Food, Drug, and Cosmetic Act

The United States Federal Food, Drug, and Cosmetic Act , is a set of laws passed by Congress in 1938 giving authority to the U.S. Food and Drug Administration to oversee the safety of food, drugs, and cosmetics. A principal author of this law was Royal S. Copeland, a three-term U.S. Senator from...

."

The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case. The court noted, "we think the weight of well-reasoned modern precedent sustains the right of municipalities to adopt such reasonable and undiscriminating measures to improve their water supplies as are necessary to protect and improve the public health, even though no epidemic is imminent and no contagious disease or virus is directly involved .... To us it seems ridiculous and of no consequence in considering the public health phase of the case that the substance to be added to the water may be classed as a mineral rather than a drug, antiseptic or germ killer; just as it is of little, if any, consequence whether fluoridation accomplishes its beneficial result to the public health by killing germs in the water, or by hardening the teeth or building up immunity in them to the bacteria that causes caries or tooth decay. If the latter, there can be no distinction on principle between it and compulsory vaccination or inoculation, which, for many years, has been well-established as a valid exercise of police power."

In the 1955 case Froncek v. City of Milwaukee, the Wisconsin Supreme Court

Wisconsin Supreme Court

The Wisconsin Supreme Court is the highest appellate court in the state of Wisconsin. The Supreme Court has jurisdiction over original actions, appeals from lower courts, and regulation or administration of the practice of law in Wisconsin.-Location:...

affirmed the ruling of a circuit court which held that "the fluoridation is not the practice of medicine, dentistry, or pharmacy, by the City" and that "the legislation is a public health measure, bearing a real, substantial, and reasonable relation to the health of the city."

The Supreme Court of Ohio

Supreme Court of Ohio

The Supreme Court of Ohio is the highest court in the U.S. state of Ohio, with final authority over interpretations of Ohio law and the Ohio Constitution. The court has seven members, a chief justice and six associate justices, each serving six-year terms...

, in 1955's Kraus v. City of Cleveland, said, "Plaintiff's argument that fluoridation constitutes mass medication, the unlawful practice of medicine and adulteration may be answered as a whole. Clearly, the addition of fluorides to the water supply does not violate such principles any more than the chlorination of water, which has been held valid many times."

Fluoridation consensus

In 1973, as cases continued to be brought in state courts, a consensus developed that fluoridation, at least from a legal standpoint, was acceptable. In 1973's Beck v. City Council of Beverly Hills, the California Court of Appeal

California Court of Appeal

The California Courts of Appeal are the state intermediate appellate courts in the U.S. state of California. The state is geographically divided into six appellate districts...

, Second District, said, "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power

Police power

In United States constitutional law, police power is the capacity of the states to regulate behavior and enforce order within their territory for the betterment of the general welfare, morals, health, and safety of their inhabitants...

in the interest of public health. The matter is no longer an open question."

Contemporary challenges

Advocates continue to make contemporary challenges to the spread of fluoridation. For instance, in 2002, the city of Watsonville

Watsonville, California

Watsonville is a city in Santa Cruz County, California, United States. The population was 51,199 according to the 2010 census.Located on the central coast of California, the economy centers predominantly around the farming industry. It is known for growing strawberries, apples, lettuce and a host...

, California

California

California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...

chose to disregard a California law mandating fluoridation of water systems with 10,000 or more hookups, and the dispute between the city and the state ended up in court. The trial court and the intermediate appellate court ruled in favor of the state and its fluoridation mandate, and the Supreme Court of California declined to hear the case in February 2006. Since 2000, courts in Washington, Maryland, and Texas have reached similar conclusions.

History

Early studies

Water fluoridation

Court cases

Early cases

Fluoridation consensus

Contemporary challenges

See also