More than a third of Canadians and nearly three-quarters of Americans who use public water systems receive fluoridated water. Fluoride helps prevent caries by promoting remineralization and decreasing demineralization. Community water fluoridation is a primary source of fluoride exposure for Canadians today. For more than 50 years, community water fluoridation initiatives have been used (McGrady et al., 2011). Despite opposition from some human rights and environmental groups, there has been a lot of interest in lowering fluoride levels or eliminating fluoride from drinking water over the years. There is still resistance, doubt, and antagonism to community water fluoridation, particularly in terms of human and environmental health. There are numerous viewpoints on community water fluoridation, some of which are based on scientific proof of clinical value. Other arguments include the existence of alternate oral public health programs or therapies that avoid CWF-related problems. In locations across Canada, alternative publicly supported oral public health programs, such as school-based topical fluoride varnishes, are available. Although fluoride helps to prevent tooth decay, some research suggests that increased prenatal fluoride exposures may have an impact on neurodevelopment (Choi et al., 2012). The scientific evidence for community water fluoridation, a long-established public health intervention, has been studied from both the pro and con sides.
The scientific evidence can be used to explain fluoridated community water risk assessments for vulnerable people who are more vulnerable to harmful environmental exposures, and it should be considered in legislation. Till says, “with new knowledge, we revaluated safe thresholds for lead, arsenic, organophosphate pesticides, and PCBs, so why not fluoride? (Till et al., 2018)”. Recognizing pregnancy's vulnerability as a deep, complex transformation can be unsettling. Even though emotional and physical vulnerability are common during pregnancy, women with histories of trauma, abuse, or loss, those who have experienced prior psychiatric difficulties, teenage mothers, and/or women who are stressed by poverty or a lack of social support are more likely to experience anxiety, stress, and/or depression. When these changes are not anticipated, or when the stress or depression that results is not treated with care, the effects can also affect the infant. Researchers evaluated urine fluoride concentrations in 1,566 pregnant women from ten Canadian cities as part of the Maternal–Infant Research on Environmental Chemicals (MIREC) Study. Seven of the localities add fluoride to the public water supply, whereas the other three do not. After adjusting for urine dilution and potential confounders such as maternal age, pre-pregnancy BMI, smoking status, water and tea consumption, education, and income, mean fluoride concentrations in the urine of women living in localities with fluoridated water were found to be about twice as high as those in the urine of women living in cities with non fluoridated water (Nicole, 2019). Official fluoride recommendations, many of which are not followed, were clearly based on insufficient research, and were only updated after permanent harm had occurred. The influence of all these sources' exposure levels is sometimes neglected. Nonetheless, this cumulative fluoride exposure has the potential to cause fluoride-related ailments for the rest of one's life.
All uses of fluoride, including water fluoridation and dental-based products, require informed consumer agreement, whether administered at home or in the dental office. To improve the future of public health, medical and dental practitioners, consumers, and policymakers must be educated about fluoride hazards and toxicity. There are fluoride-free methods for preventing dental cavities that can be used as they are safer and more effective. The necessity for community water fluoridation to be justified in ethical considerations has been discovered, and public health ethics is an appropriate framework for the discussion. Song et al. offered three caveats before establishing the ethical rationale for public health intervention: "procedural justice," "social circumstances," and "trust preservation." Community water fluoridation can be fit for the community and openly communicative for healthcare professionals by considering social circumstances and maintaining trust, which will be a major challenge and shift for the field in the future. CWF can be good for the community and openly communicative for healthcare professionals. Now that the underlying cognitive dissonance has been established, as well as the cautions for ethical considerations, more research is needed to determine how to create an agreement among important stakeholders on the actual implementation of community water fluoridation.
In the United States and Canada, the recommended fluoride concentration in drinking water for preventing dental cavities is 0.7 mg/L, and the maximum acceptable fluoride concentration in drinking water is 1.5 mg/L (Health Canada, 2010). Higher fluoride levels in the water have been related to a variety of negative impacts, including a reduction in the number of hours spent sleeping in older teenagers and adults. According to data supplied by members of the Federal-Provincial-Territorial Committee on Drinking Water in 2005, fluoride levels in fluoridated drinking water systems in Canada range from 0.46 to 1.1 mg/L on average (Health Canada, 2010). According to a study, fluoride exposure may cause clinically significant sleep length reductions in those who reside in areas with high fluoride levels in their drinking water (Cunningham et al., 2021). Fluoride levels in tap water have been associated with an increase in ADHD symptoms and diagnoses among Canadian children and adolescents, particularly teens (Riddell, 2019). Fluoride exposure has also been linked to thyroid dysfunction; however, adequate iodine consumption can assist to mitigate this effect (Malin et al., 2018). Adults in Canada who have high urine fluoride levels and moderate-to-severe iodine deficiency may be at risk for thyroid gland underactivity (Malin et al., 2018). Skeletal fluorosis is the most serious adverse health outcome connected to long-term exposure to high levels of fluoride in drinking water. Skeletal fluorosis is a rare occurrence in Canada that happens when people are exposed to extremely high doses of fluoride (Health Canada, 2010). Choi's systematic evaluation of the studies on the relationship between fluoride and children's IQ levels found that children who lived in high-fluoride areas had significantly lower IQ scores than children who lived in low-fluoride areas (Choi et al., 2012). According to the research, excessive fluoride exposure may harm children's neurodevelopment. Future studies need to be done to determine the association between the incidence of caries prevention and neurotoxic effects of community water fluoridation to determine whether community water fluoridation is beneficial at this time or not.
Further reading:
References:
Choi, A.L., Sun, G., Zhang, Y., Grandjean, P. (2012). Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect 120(10):1362– 1368, PMID: 22820538. https://doi.org/10.1289/ehp.1104912.
Cunningham, J., McCague, H., Malin, A. J., Flora, D., & Till, C. (2021). Fluoride exposure and duration and quality of sleep in a Canadian population-based sample. Environmental health : a global access science source, 20(1), 16. https://doi.org/10.1186/s12940-021-00700-7
Health Canada (2010) Guidelines for Canadian Drinking Water Quality: Guideline Technical Document —Fluoride. Water, Air and Climate Change Bureau, Healthy Environments and Consumer Safety Branch, Health Canada, Ottawa, Ontario. (Catalogue No. H128-1/11-647E-PDF)
Malin, A. J., Riddell, J., McCague, H., & Till, C. (2018). Fluoride exposure and thyroid function among adults living in Canada: Effect modification by iodine status. Environment international, 121(Pt 1), 667–674. https://doi.org/10.1016/j.envint.2018.09.026
McGrady, M. G., Ellwood, R. P., & Pretty, I. A. (2011). The water fluoridation debate. Dental update, 38(1), 12–22. https://doi.org/10.12968/denu.2011.38.1.12
Nicole,W., (2019). Comparing Fluoride Exposures in Pregnant Canadian Women: Fluoridated versus Nonfluoridated Drinking Water Environmental Health Perspectives.127:7 CID: 074002. https://doi.org/10.1289/EHP4903
NRC (National Research Council). (2006). Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. Washington, DC: National Academies Press.
Riddell, J. K., Malin, A. J., Flora, D., McCague, H., & Till, C. (2019). Association of water fluoride and urinary fluoride concentrations with attention deficit hyperactivity disorder in Canadian youth. Environment international, 133(Pt B), 105190. https://doi.org/10.1016/j.envint.2019.105190
Song, Y., Kim, J., Int, J. (2021). Community Water Fluoridation: Caveats to Implement Justice in Public Oral Health. Environ. Res. Public Health.18(5), 2372. https://doi.org/10.3390/ijerph18052372
Till, C., Green. R., Grundy, J.G., Hornung, R., Neufeld, R., Martinez-Mier, E.A. (2018). Community water fluoridation and urinary fluoride concentrations in a national sample of pregnant women in Canada. Environ Health Perspect 126(10):107001, PMID: 30392399. https://doi.org/10.1289/EHP3546.
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