Dr. Royal P. DeLegge
Environmental Health Director
Salt Lake County Health Department
The story of fluoridation begins with a
mystery staining of the teeth first described
by dentist Dr. Frederick McKay in Colorado
in 1901 and, independently in Naples, Italy in
1902 by Dr. J.M. Eager, an American dentist
stationed there.
Dr. McKay became aware of several cases that
suggested that the water supply might be responsible
for the staining. He also noted that decay rates were
much lower in areas with endemic dental staining
than they were in other adjacent areas.
In Essex, United Kingdom, a dentist named Norman
Ainsworth had found local dental staining similar to
McKay's description of “Rocky Mountain Mottled Teeth”.
In a 1925 study Dr. Ainsworth examined more than 4,000
children and produced a statistical comparison of decay
rates between populations with the staining and those
without.
This study showed that individuals living in areas where
mottled teeth were most common tended to have a much
lower incidence of dental decay.
The US Public Health Service investigated this
relationship and appointed a dentist, Dr. H.T.
Dean, to carry out the research.
In a series of epidemiological investigations, Dr.
Dean established that mottling of the teeth was
extremely rare at fluoride levels of 1ppm or below,
while there was a significant preventive effect for
dental caries found at 1ppm.
Public health authorities in the United States decided
to try and reproduce this effect in low-fluoride areas
by adding fluoride to community water systems.
No obvious negative health effects had been noted in
those populations served by naturally fluoridated
water.
Pilot Programs
A number of pilot programs were set up to see whether the idea could
work in practice.
On 25th January 1945, Grand Rapids, Michigan, became the first town
in the world to be artificially fluoridated. The previous year, a baseline
study comparing Grand Rapids with the neighboring town of
Muskegon had found similar decay levels in deciduous and permanent
teeth in both areas.
Six years later, surveys indicated that decay levels in 6 year-old children
(i.e. those born since fluoridation commenced) in Grand Rapids was
almost half of that in Muskegon.
In July 1951, city officials in Muskegon decided to fluoridate that town's
water supply.
Other Pilot Programs
Newburgh, New York, started fluoridating in May 1945.
Evanston, Illinois, began fluoridating in January 1946.
As with the Grand Rapids scheme, these towns were paired
with nearby “control” towns (Kingston, New York and Oak
Park, Illinois) in order to measure the effectiveness of the
fluoridation scheme.
In both cases, significant reduction in dental decay rates
were described in the fluoridating towns, with little or no
change found in the control towns.
Early studies reported reductions in decay on the order
of 50% or more.
This was at a time when fluoridated water offered the
only significant source of fluoride available to people.
Utah Fluoridation History
In 1970, only 2.5% of Utah’s population had access to
community fluoridated water systems and served
fewer than 30,00 customers.
Naturally fluoridated water systems supplied fewer
than 3,000 persons.
Only five artificially fluoridated water systems were in
place:
Brigham City
Helper
Hill Air Force Base
Two Native American Reservations
Opposition to Fluoridation
There has been opposition to artificial water fluoridation
since its inception. Opponents were concerned about
placing a chemical, mandated by the government, into
water supplies and posed numerous arguments over the
need and expense of implementation.
Also, since fluoride did not treat the water for safety,
although it had a population-wide positive health effect, it
was viewed as an unwarranted government intrusion on
personal rights.
Utah Freedom from Compulsory
Medication Act of 1976
“Public water supplies…shall not have fluoride or any
of its derivatives or compounds, or any other
medication added thereto without the approval of a
majority of voters in a duly constituted election in the
area affected thereby.”
1976 Act
The Act moved the debate away from cost to
effectiveness and safety.
Concern was expressed that the issue was one of
free choice, mass medication and government
interference in the lives of citizens.
The Act was passed in a statewide election with a
51.6% majority.
Pro-fluoridation groups continued to work to
implement fluoridation at the local level, mostly in
Northern Utah.
The most active efforts were in Salt Lake and Davis
counties.
Current Fluoridation Programs
In November 2000 the voters passed a ballot initiative
in Salt Lake County approving the fluoridation of
public drinking water supplies.
At the same time, an advisory referendum for
fluoridation was passed in Davis County.
Fluoridation Status
In the wake of the 2000 votes Utah moved from 50th in
the nation, with 2.0% of the population fluoridated, to
39th with 54.3% of the population receiving fluoridated
water.
Safety of Water Fluoridation
The question of the safety of water fluoridation has been investigated
time and time again by numerous national and international
commissions.
One of the most recent, and arguably the best, is the United Kingdom’s
National Health Service Centre for Reviews and Dissemination in 2000,
also known as the York Review.
This meta-study provides a systematic review of more than 3,000
studies relevant to dental and general effects of water fluoridation on
humans.
The main conclusion was that there was no clear evidence of any
adverse effect from water fluoridation other than staining of enamel
(dental fluorosis).
Adverse Effect Claims
Claims have been made that water fluoridation is linked to almost
every conceivable condition known to medicine - and some conditions
beyond.
The range of allegations covers such diverse items as cancer,
Alzheimer's disease, effects on salmon spawning, and even increasing
crime rates in American cities.
The fact that none of these have so far been found to have any
substance should not be surprising; there are populations that have
been drinking naturally fluoridated water at around 1ppm for centuries
for whom no obvious adverse effects have been demonstrated.
Other forms of community fluoridation
used worldwide
Salt
Toothpaste
Milk
Food & Beverages
Fluoridated Salt
Several other methods have been evaluated for providing
community water fluoridation.
Fluoridated salt is used quite successfully and widely in
Europe and South America. In situations where all salt in
the economy is fluoridated, including that used in food
production, its effectiveness comes close to that of water
fluoridation.
However, where fluoridated salt is simply provided on sale
along with unfluoridated salt, its effectiveness on a
population basis has been shown to be limited.
Milk Fluoridation
Milk fluoridation programs have been implemented most
notably in the United Kingdom and in Chile.
In the Manchester, UK area, the Borrow Scheme was set up
to provide fluoridated milk to primary school children.
In Chile, fluoridated milk is provided through the health
service rather than through schools. This method of
fluoridation is quite promising but, while beneficial, the
effect does not appear to provide as strong an effect as does
water fluoridation.
Fluoridated Toothpaste
A major method of fluoridation is, of course, the use
of fluoridated toothpastes. It is estimated that in
excess of 95% of toothpaste sales are of fluoridated
products.
Current Fluoridation Regulations
After the November 2000 ballot initiative in Salt Lake
County and advisory referendum in Davis County,
both local health departments worked to implement
their mandates.
 The Salt Lake Valley Board of Health adopted
implementation target dates of by November 1, 2001 for
surface water sources and January 1, 2002 for groundwater
sources.
 The Board also invited Salt Lake County water districts to a
meeting to discuss the issues relating to implementation
and agreed to form a Task Force comprised of
representatives from each affected water district, SLVHD,
UDOH, and UDEQ to work out implementation issues.
 In July 2001 the Task Force recommended a new
implementation date of October 1, 2003, which was
accepted by the Board of Health.
 The SLVHD Water Quality Bureau staff and Davis County
staff worked together to develop local regulations, which
were discussed with, and modified by, the Task Force over a
period of more than a year.
In Salt Lake County, SLVHD Health Department staff
members met with personnel of several water systems to
devise methods of reducing costs by fluoridating only
certain water sources, rather than all of the system’s
sources, in ways that would still provide uniform
concentrations throughout their systems.
In the case of one system, Holliday Water, this reduced
their estimated costs by more than 80%.
 There are 14 systems that are actively fluoridating in Salt Lake County. Four
other systems: Bluffdale, Draper, South Jordan, and the University of Utah, all
import their water from fluoridated systems.
 One system, Holliday Water Company, is not adjusting its fluoride levels above
natural levels (of 0.4 ppm) as a result of legislative action that allows a privately
held water company to decide its own fluoridation status.
 Another system with a population over 3,300, White City Water, is not
fluoridating due to its recognized status as a functionally separate system. The
health regulation was amended to add such an exemption status.
 The combined population served by fluoridated systems is approximately 96%
of the county’s population that is served by water systems.
Fluoridation Chemical Impurities
Much has been made of the source of, and impurities
in, fluoridation chemicals (primarily hydrofluosilicic
acid).
Opponents have claimed that arsenic and lead are
contaminants of concern.
Since implementation, opponents to water
fluoridation have brought up a number of strategies to
prevent or delay the implementation of community
water fluoridation. One of the strategies is to question
the quality and safety of chemicals used in the
fluoridation process.
Hazardous Waste
One claim regarding hydrofluosilicic acid used in water fluoridation is
that it is a hazardous waste. The claim that hydrofluosilicic acid used in
water fluoridation in the United States is a hazardous waste that has
been redirected to water systems to avoid disposal issues is simply not
true. The designation of hydrofluosilicic acid as hazardous material is
due to its low pH (1.2). When considering the application rate of the
chemical in drinking water supplies the pH hazard does not exist.
There are numerous chemicals used in water purification, food
production and preparation and the pharmaceutical industry that if
discarded as waste would be classified as hazardous waste. None of
these chemicals are designated as hazardous waste in their intended
use.
Contaminants
Two heavy metals, lead and arsenic, have been
targeted as contaminants of fluoridation
chemicals that would place the public at risk when
the water is fluoridated.
The question of arsenic contamination has been
spurred with the lowering of the U.S. Safe
Drinking Water Act maximum contaminate level
(MCL) from 50 ppb (parts per billion or
micrograms per liter [ug/L]) to 10 ppb.
Laboratory Analysis of Water at
Weber Basin Treatment Plant
Chemical
Fluoride
Arsenic
Chromium
Iron
Mercury
Silver
Barium
Copper
Lead
Selenium
Pre-fluoridation
0.1 mg/L
<1.0 ug/L
<5.0
ug/L
Jason,
Karen, APC
<0.02 mg/L
<0.2 ug/L
<2.0 ug/L
0.0975 mg/L
<12.0 ug/L
<3.0 ug/L
<1.0 ug/L
Post-flouridation
0.9 mg/L
<1.0 ug/L
<5.0 ug/L
<0.02 mg/L
<0.2 ug/L
<2.0 ug/L
0.0969 mg/L
<12.0 ug/L
<3.0 ug/L
<1.0 ug/L
Recent Legislative Action
In 2013, the Utah legislature passed a law requiring
original certification documents for fluoride
chemicals added to community water systems.
All of these chemicals are currently certified by NSF
or UL.
Certification Documentation
Original certification documentation for
hydrofluorosilicic acid are readily available and have
been obtained by water systems.
Original certification documentation for sodium
fluoride has been more difficult to secure.
Local History
In 2010 the SLVHD and Board and Davis County
Boards of Health, as a result of the biennial review and
under recommendations by the CDC, decreased the
targeted average annualized concentration of fluoride
from 0.8 mg/L (ppm) to 0.7 mg/L (ppm).
The change to a lower annualized target concentration
is to balance overall exposure to fluoride given the
extraneous exposure now provided in the United
States by processed foods and especially by soft drinks.
The change was also a response to an advisory that
parents of infants under 6 months of age should
consider reconstituting formula with unfluoridated
water to reduce the already low possibility of dental
fluorosis developing in deciduous teeth.
Dental fluorosis
It is known that fluoridation of water supplies would be
associated with low levels of enamel discoloration.
Early studies predicted that very mild enamel fluorosis
would affect a small proportion of a population receiving
fluoridated water.
The medical and dental communities have accepted that a
low level of fluorosis is well worth the large reduction in
dental decay brought about by fluoridation.
Dental fluorosis is a health condition caused by a child receiving too
much fluoride during tooth development.
The critical period of exposure is between 1 and 4 years of age; children
over age 8 are not at risk.
In its mild form, the most common, fluorosis appears as tiny white
streaks or specks that are often unnoticeable to the untrained eye.
In its severest form, also known as mottling of the tooth enamel, it is
characterized by black and brown stains, and may include cracking and
pitting of the teeth.
Mild case of dental fluorosis, visible as white
streaks on the subject's upper right central incisor
Severe case of dental fluorosis
Dental fluorosis is not a health problem but is
considered only cosmetic.
When it occurs it is treatable by a dentist.
The incidence of fluorosis associated with community
water fluoridation concentrations is negligible.