The science and controversy of water fluoridation

In the pursuit of national strategies to improve oral health, few interventions have sparked as much debate and divided opinions as water fluoridation. Whilst some have voiced concerns about water fluoridation in recent years, viewing it as mass medicalisation and an intrusion into personal choice, researchers and dental professionals continue to champion its benefits as a cost-effective, population-wide approach that can significantly reduce tooth decay and enhance the oral health of communities across the country.

The statistics from 2021-2022 paint a concerning picture, with a staggering 26,741 extractions performed on 0-19-year-olds under the NHS due to preventable tooth decay, amounting to an estimated cost of £50 million.

With the NHS bearing the responsibility of providing dental care to millions of people nationwide, the introduction of water fluoridation stands out as a promising ally in the quest for more efficient healthcare and the alleviation of the burden on our already-strained healthcare system, all while improving dental health in a cost-effective manner.

Fluoride is a naturally occurring chemical element found in soil, plants and groundwater, which can reduce dental decay through a dual mechanism; fluoridating water reduces dental decay by both impeding demineralisation of enamel and enhancing remineralisation of teeth following acid attacks in the mouth. When sugars from food or drinks enter the mouth, the bacteria present in plaque act to convert these sugars to acid, demineralising the outer surface of teeth and leading to the formation of cavities. The incorporation of fluoride into the structure of tooth enamel during remineralisation strengthens and hardens the outer layer of teeth, rendering teeth less susceptible to damage and more resistant to acid-induced demineralisation. Moreover, fluoride has also been proven to reverse early tooth decay by repairing and remineralising weakened enamel, thus averting the need for restorative dental procedures such as fillings. The inhibition of demineralisation and encouragement of remineralisation overall prevents cavities forming and preserves the vitality of our smiles.

The main adverse effect of fluoridating water is the risk of dental fluorosis, which affects the appearance of teeth. Dental fluorosis is a cosmetic dental condition caused by excessive fluoride exposure, resulting in changes in tooth colour and texture. It presents as small opaque white spots or streaks on the tooth surface. It is important to note that these conditions generally occur at fluoride levels significantly higher than those recommended for water fluoridation. Opponents of water fluoridation also argue on ethical grounds, citing concerns about mass medication infringing on personal choice and the right to decide whether to use fluoride or dental products containing fluoride. In some cases, opposition is rooted in conspiracy theories and scepticism about government motives.

Findings from the Office for Health Improvement and Disparities and the UK Health Security Agency highlight the benefits of water fluoridation. The data collected illustrates young populations in areas of England with higher fluoride concentrations are up to 63% less likely to be admitted to hospital for tooth extractions due to decay compared to their counterparts in areas of lower fluoridation levels. This disparity is most pronounced in the most deprived areas, where children and young adults benefit the most from the addition of fluoride to the water supply. These findings strongly support the evidence for the advantages of water fluoridation and highlight how this simple method can substantially improve health outcomes for our population.  

While fluoridation has proven beneficial for communities, especially those from deprived backgrounds, it has demonstrated successful outcomes for individuals across all demographics, irrespective of age, education, employment, or oral hygiene habits. It's essential to emphasize that water fluoridation should not replace other essential oral health practices such as regular tooth brushing, prudent sugar intake, and dental appointments. Instead, it should complement these practices, working in synergy to optimize oral health.

As of now, approximately 10% of the population in England receives water from a fluoridation scheme. While the protective and beneficial effects of fluoridation are well-established, the decision to move towards a nationwide water fluoridation scheme ultimately rests with the Secretary of State for Health in the coming years.

Written by Isha Parmar