In a landmark decision, a United States federal court has ordered the Environmental Protection Agency (EPA) to reevaluate the safety of fluoride in drinking water. The ruling highlights growing concerns about the potential health risks associated with fluoride exposure, particularly for infants and children.
This decision could lead to significant changes in the way fluoride is regulated and used in the United States. Currently, over 200 million Americans consume fluoridated water. However, the recent court ruling suggests that the current regulations may not be sufficient to protect public health.
- What the Ruling is About:
The ruling addresses whether the current optimal levels of fluoride in U.S. drinking water, particularly at 0.7 mg/L, pose an unreasonable risk to public health under the amended Toxic Substances Control Act (TSCA). The plaintiffs argued that fluoridated water leads to cognitive impairments in children, particularly reduced IQ, and that the Environmental Protection Agency (EPA) has failed to address this risk appropriately.
- What the Court Said:
The court found that fluoridation of drinking water at 0.7 mg/L does pose an unreasonable risk to public health, particularly for pregnant women and young children. The court was persuaded by scientific evidence, including multiple studies indicating a link between fluoride exposure and reduced IQ in children. Importantly, the court ruled that the EPA must now engage in regulatory action, though it left the specifics of that action up to the EPA. The court did not dictate a complete ban on fluoridation but acknowledged the need for the EPA to address the risks in some regulatory capacity.
- What are the Implications:
The implications of this ruling are significant. The EPA must now reconsider its stance on water fluoridation and determine what regulatory steps to take to mitigate the risks. This could involve lowering the recommended fluoride levels in drinking water, issuing warnings to vulnerable populations (e.g., pregnant women), or potentially banning fluoridation altogether. This case sets a precedent for how other chemical substances might be reviewed under the amended TSCA, particularly when there is robust evidence of harm to public health.
A brief history of community water fluoridation
The discovery that fluoride was beneficial for reducing cavities began in 1901 in Colorado, when Dr. Frederick McKay observed that some of his patients had mottling of the teeth (dental fluorosis), and that these individuals also had lower incidences of caries. Dr Green Vardiman Black later helped him underpin the cause, the presence of fluoride in the drinking water [1,2]. Before fluoride toothpastes were invented and accessible, water fluoridation was utilized as the first approach, from the 1940’s to the 1970’s, for improving public oral health [3].
Fluoridated water in South Africa
Given the media attention surrounding community water fluoridation in the United States, you may be wondering if South Africa also implements community water fluoridation. Preparatory work has been done to implement community water fluoridation. This included the drafting of regulations and identifying potential regions for implementation. However, due to the high costs involved, South Africa currently does not have any operational artificially fluoridated water schemes. Let’s look at South Africa’s preparatory effects on a timeline:
- In 2000, the South African government, through the Oral Health Committee, established the National Fluoridation Committee (NFC). The NFC was tasked with overseeing the implementation of water fluoridation across the country and drafting regulations to guide this process. On 8 September 2000, the Minister of Health approved these regulations as part of the Health Act No. 63 of 1977. This Act made it mandatory for every water supplier in the country to fluoridate water unless they were granted an exemption.
- To further support the NFC, an advisory body called the Joint Fluoridation Implementation Committee (JFIC) was created. The JFIC was responsible for developing criteria to identify specific regions, referred to as “front runner sites,” where water fluoridation could be safely implemented. Four coastal cities—Cape Town, Port Elizabeth, East London, and Durban—were identified as potential pilot sites for water fluoridation.
- In 2003, a new Health Act (Act No. 61 of 2003) was introduced in South Africa. This Act necessitated amendments to the existing fluoridation regulations. As part of this process, consultations began to update the regulations on fluoridating water supplies. However, as of today, the amended regulations are still under review and have not been finalized or approved [4].
Current Status of Water Fluoridation in South Africa
Although fluoride is not added to the drinking water, there is fluoride present in surface, ground and oceanic water. Ground water tends to be high in fluoride due to the leaching of fluoride from rock formations [5].
It remains crucial to monitor fluoride concentrations in drinking water. The SANS 241:2015 standards recommend maintaining fluoride levels below 1.5 mg/L. While the Department of Water and Sanitation in South Africa provides general water quality data online, specific fluoride concentrations for individual areas are not included.
The most recent available data on fluoride levels in South African water was published by Mulder in 2018. This report covers fluoride concentrations across various provinces for the years 2016-2017. The data, obtained through direct communication with the Department of Water and Sanitation, presents the average fluoride concentration per province (see table below) [5].
Fluoride content | < 0.3 mg/L | 0.3-0.6 mg/L | 0.6-0.99 mg/L | > 1mg/L |
Province | • Western Cape | • Limpopo | • Gauteng | • Eastern Cape |
Unfortunately, we could not find more up-to-date data on the fluoride concentrations in South Africa tap water. What should you do if you are concerned about the fluoride concentration in your tap water? You could:
- Check the level: Determine the fluoride level in your drinking water by contacting a laboratory to test the water.
- Use a different water source: Consider using bottled water or purified water from a reputable refill water station.
- Use a filter: You can use a filter to reduce the amount of fluoride in your water. Some filters that can remove fluoride include reverse osmosis, deionizers, and activated alumina.
Should you brush with a fluoride toothpaste?
Due to the rising concerns and media attention surrounding fluoridated water, questions have also been raised regarding the safety of fluoridated oral care products.
It is advisable to utilise a toothpaste that contains, an agent that can facilitate remineralisation, the reincorporation of minerals into the tooth enamel. Fluoride toothpaste is still recommended by many dentists and oral hygienists because it is proven to prevent demineralisation and promote remineralisation, making it effective at reducing the risk of caries and cavities.
Although fluoride has been a staple in the oral care industry over the last few decades there are niche populations that may benefit from a fluoride free toothpaste, such as children, individuals that live in regions with high fluoride levels in the drinking water, individuals with dental or skeletal fluorosis, or titanium based dental implants [6–8]. There are alternatives to fluoride that are equally effective, such as toothpaste containing 10% nano-hydroxyapatite. Nano-hydroxyapatite has been successfully confirmed by several in vitro [9–11] and human clinical trials [12–14] to be as effective as fluoride in promoting remineralisation and preventing cavities. EvaGlo has chosen to use nano-hydroxyapatite as an effective alternative to fluoride in toothpaste.
Conclusion
While fluoridated water has played a role in preventing cavities and improving oral health for decades, emerging scientific evidence suggests that its ingestion at high concentrations, and possibly at concentrations previously considered to be optimal, may pose health risks, particularly in children and pregnant women. This ruling does not call for a ban on water fluoridation but compels the EPA to reevaluate its safety and consider regulatory changes.
In South Africa, although no fluoridation schemes are currently in place, naturally occurring fluoride in water still makes it important to monitor levels. Individuals can test their tap water or use alternatives if they are concerned that fluoride levels are high.
Fluoride toothpaste remains widely recommended for cavity prevention, but fluoride-free options like nano-hydroxyapatite offer effective alternatives for those concerned about overall fluoride exposure.
References
1. ten Cate, J.M.; Buzalaf, M.A.R. Fluoride Mode of Action: Once There Was an Observant Dentist . . . J Dent Res 2019, 98, 725–730, doi:10.1177/0022034519831604.
2. Duffin, S.; Duffin, M.; Grootveld, M. Revisiting Fluoride in the Twenty-First Century: Safety and Efficacy Considerations. Frontiers in Oral Health 2022, 3, doi:10.3389/froh.2022.873157.
3. Buzalaf, M.A.R.; Pessan, J.P.; Honório, H.M.; ten Cate, J.M. Mechanisms of Action of Fluoride for Caries Control. In Impact of Fluoride in the Prevention of Caries and Erosion; Karger, 2011; Vol. 22, pp. 97–114.
4. Kroon, J.; Van Wyk, P.J. A Retrospective View on the Viability of Water Fluoridation in South Africa to Prevent Dental Caries. Community Dent Oral Epidemiol 2012, 40, 441–450, doi:10.1111/j.1600-0528.2012.00681.x.
5. Mulder, R. Systemic Fluoride Supplementation in South Africa – Updated Guidelines for Practitioners. INTERNATIONAL DENTISTRY – AFRICAN EDITION 2018, 8, 20–28.
6. Peñarrieta‐Juanito, G.; Sordi, M.B.; Henriques, B.; Dotto, M.E.R.; Teughels, W.; Silva, F.S.; Magini, R.S.; Souza, J.C.M. Surface Damage of Dental Implant Systems and Ions Release after Exposure to Fluoride and Hydrogen Peroxide. J Periodontal Res 2019, 54, 46–52, doi:10.1111/jre.12603.
7. Joshi, S.; Hlaing, T.; Whitford, G.M.; Compston, J.E. Skeletal Fluorosis Due to Excessive Tea and Toothpaste Consumption. Osteoporosis International 2011, 22, 2557–2560, doi:10.1007/s00198-010-1428-6.
8. Kurland, E.S.; Schulman, R.C.; Zerwekh, J.E.; Reinus, W.R.; Dempster, D.W.; Whyte, M.P. Recovery From Skeletal Fluorosis (an Enigmatic, American Case). Journal of Bone and Mineral Research 2007, 22, 163–170, doi:10.1359/jbmr.060912.
9. Kasemkhun, P.; Rirattanapong, P. The Efficacy of Non-Fluoridated Toothpastes on Artificial Enamel Caries in Primary Teeth: An In Vitro Study. J Int Soc Prev Community Dent 2021, 11, 397–401, doi:10.4103/jispcd.JISPCD_64_21.
10. Huang, S.; Gao, S.; Cheng, L.; Yu, H. Remineralization Potential of Nano-Hydroxyapatite on Initial Enamel Lesions: An in Vitro Study. Caries Res 2011, 45, 460–468, doi:10.1159/000331207.
11. Paszynska, E.; Pawinska, M.; Enax, J.; Meyer, F.; Schulze zur Wiesche, E.; May, T.W.; Amaechi, B.T.; Limeback, H.; Hernik, A.; Otulakowska-Skrzynska, J.; et al. Caries-Preventing Effect of a Hydroxyapatite-Toothpaste in Adults: A 18-Month Double-Blinded Randomized Clinical Trial. Front Public Health 2023, 11, doi:10.3389/fpubh.2023.1199728.
12. Schlagenhauf, U.; Kunzelmann, K.H.; Hannig, C.; May, T.W.; Hösl, H.; Gratza, M.; Viergutz, G.; Nazet, M.; Schamberger, S.; Proff, P. Impact of a Non-Fluoridated Microcrystalline Hydroxyapatite Dentifrice on Enamel Caries Progression in Highly Caries-Susceptible Orthodontic Patients: A Randomized, Controlled 6-Month Trial. J Investig Clin Dent 2019, 10, e12399, doi:10.1111/jicd.12399.
13. Paszynska, E.; Pawinska, M.; Gawriolek, M.; Kaminska, I.; Otulakowska-Skrzynska, J.; Marczuk-Kolada, G.; Rzatowski, S.; Sokolowska, K.; Olszewska, A.; Schlagenhauf, U.; et al. Impact of a Toothpaste with Microcrystalline Hydroxyapatite on the Occurrence of Early Childhood Caries: A 1-Year Randomized Clinical Trial. Sci Rep 2021, 11, 1–15, doi:10.1038/s41598-021-81112-y.
14. Grocholewicz, K.; Matkowska-Cichocka, G.; Makowiecki, P.; Droździk, A.; Ey-Chmielewska, H.; Dziewulska, A.; Tomasik, M.; Trybek, G.; Janiszewska-Olszowska, J. Effect of Nano-Hydroxyapatite and Ozone on Approximal Initial Caries: A Randomized Clinical Trial. Sci Rep 2020, 10, 11192, doi:10.1038/s41598-020-67885-8.
