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Making the case for fluoridated drinking water

Water fluoridation is lauded by the US Centers for Disease Control as one of the top 10 public health achievements of the 20th century, but far too many Australians still miss out on the dental health benefits of fluoridated drinking water, writes Dr Michael Foley.

Australians spend more than $10 billion each year on dental care; more than for all cancers combined, and more than for all mental illness and dementia combined. 

The substantial costs of fillings, root canal treatments, extractions, dentures, crowns, bridges and implants all begin with tooth decay. A filling placed in a teenager’s tooth will likely be replaced many times over a lifetime, with each subsequent restoration being larger, more complex and more expensive. 

Directly or indirectly, we all pay for the level of disease in our communities, whether diabetes, dementia or tooth decay, and we all benefit from a healthier society. Spending ever more dollars on dental treatment, painkillers and antibiotics, school dental services and public dental clinics is not the answer. Prevention is better than a cure. Education, health promotion and preventive measures such as water fluoridation must play a role in reducing this massive dental cost burden to society.

Community water fluoridation – topping up fluorides found naturally in water supplies to a level optimal for dental health – began in America in 1945 after scientists and public health experts realised that people living in communities with about 1.0 part per million of fluoride in the water had much less tooth decay. Fluoride ions incorporated into tooth enamel help make teeth much stronger and more decay-resistant.

Drinking fluoridated water reduces tooth decay in Australian children by about 26% to 44% (1), but what does this mean in the real world? 

The Queensland Child Oral Health Survey 2010-12 (QCOHS) found 57% percent of young children in most of northern and central Queensland, and almost half of young children in south-east Queensland, had experienced tooth decay, compared with only 39% in Townsville (2). Tens of thousands of Queensland children had suffered tooth decay unnecessarily. 

Young children in the rest of northern and central Queensland and south-east Queensland had an average of about 2.4 teeth decayed, filled or extracted, compared with only 1.4 for Townsville children. Some children will have no decay, but others will suffer many more cavities, fillings and extractions. The only difference between the groups is that Townsville children have enjoyed the dental health benefits of fluoridated drinking water for decades; the other children have not. 

The QCOHS confirmed that Queensland children have poorer dental health than children in any other Australian state, with only Townsville children comparing favourably. Is this acceptable?

Tooth decay adversely affects a child’s development, appearance, behaviour and performance at school, and impacts on their family, our health system, and society. It causes pain, discomfort and significant expense, and is associated with difficulty in eating, poorer general health, greater difficulty in finding later employment, days lost from school and work, lower self esteem and dignity, and a reduced quality of life.

Fluoridated drinking water strengthens adults’ teeth too. Those at greatest risk for tooth decay benefit the most: frail and elderly people unable to brush their teeth perfectly or prepare healthy meals as they once did; people taking multiple medications; those with disabilities, mental illness, dementia, or drug dependencies; disadvantaged groups in society; and people living regionally and remotely or with limited access to dental care. 

Do we ignore high levels of dental disease where they occur, or do we accept that social, demographic, geographic and health determinants play a major role and lend a hand with a simple, safe and effective public health initiative?

Blame, shame and finger-pointing do not help improve people’s oral health, but water fluoridation does. To some extent we are all our brother or sister's keeper, and water fluoridation particularly helps those who may not have had the advantages in life that many of us take for granted. Water fluoridation is simply the cheapest, safest and easiest way of providing the health benefits of fluoride to the greatest number of people, and the benefits are in addition to those already obtained from fluoride toothpaste.

Every reputable medical, dental and scientific agency in Australia, every federal, state and territory health department, and leading social support agencies strongly endorse water fluoridation. 

Australia’s National Oral Health Plan 2015-2024 urges all communities to fluoridate their drinking water where practical. Most have done so, but Queensland is the only state or territory where the spread of water fluoridation in recent years has been decreasing. 

State legislation in 2008 mandated water fluoridation, but legislative amendments in 2012 once again placed fluoridation decision-making in the hands of local councils. South-east Queensland councils elected to continue with water fluoridation, but many regional councils did not. 

The 2012 legislative amendments directed councils to make fluoridation decisions “in the best interests of their community”, but more fillings and extractions are surely not in the best interests of regional Queenslanders and their children. Only 72% of Queenslanders (mostly in south-east Queensland and Townsville) currently have access to fluoridated drinking water, compared with more than 90% in the rest of Australia. 

Introducing and reintroducing fluoridated drinking water in regional and remote Queensland communities with the highest levels of tooth decay is essential. Some communities that ceased fluoridation have non-operational fluoridation plants that could be recommissioned quickly. For most towns and cities, operational costs are very cheap; a lifetime of water fluoridation per person costs less than a single filling. Money spent on water fluoridation is repaid many times over in saved dental treatment costs; and healthier teeth and a better smile are just a great bonus.

Unfortunately, councils considering implementation of water fluoridation know they will face a relentless barrage of scaremongering claims that they are often ill-equipped to answer. These attacks invariably come from a few misguided locals backed by well-resourced and well-connected anti-fluoridation and conspiracy theory groups in Australia and overseas. But while passionately delivered, their claims have little scientific credibility and have been repeatedly rejected and condemned by health and scientific authorities. 

State and local governments must work together to ensure that decisions on water fluoridation are made in the best health interests of residents after community consultation and education, and based on valid scientific evidence.

Decades of water fluoridation and fluoride toothpastes have helped us enjoy better dental health than our parents and grandparents. No longer are false teeth an inevitable end to a lifetime of dental treatment. But don’t all Australians deserve healthier teeth and a great smile with the help of fluoridated drinking water? Dental health should not be a residential lottery.

Dr Michael Foley BDSc MPH MEpi is Director of Research and Advocacy, Metro North Oral Health Services, Queensland Health.

References

  1. National Health and Medical Research Council. Information paper—Water fluoridation: dental and other human health outcomes. Canberra, Australia: National Health and Medical Research Council 2017.
  2. Do L, Spencer AJ. The Beginning of Change: Queensland Child Oral Health Survey 2010-2012: Australian Research Centre for Population Oral Health, The University of Adelaide; 2014.