Water fluoridation by country

Water fluoridation is the controlled addition of fluoride to a public water supply to reduce tooth decay, and is handled differently by countries across the world. Water fluoridation is considered very common in the United States, Canada, Ireland, Chile and Australia where over 50% of the population drinks fluoridated water. Most European countries including Italy, France, Finland, Germany, Sweden, Netherlands, Scotland, Austria, Poland, Hungary and Switzerland do not fluoridate water, but use fluoridated salt, milk, and toothpastes to reduce cavities. Fluoridated water contains fluoride at a level that is proven effective for preventing cavities; this can occur naturally or by adding fluoride. Fluoridated water creates low levels of fluoride in saliva, which reduces the rate at which tooth enamel demineralizes, and increases the rate at which it remineralizes in the early stages of cavities. Typically, a fluoridated compound is added to drinking water, a process that in the U.S. costs an average of about $1.39 per person-year. Defluoridation is needed when the naturally occurring fluoride level exceeds recommended limits. In 2011, the World Health Organization suggested a level of fluoride from 0.5 to 1.5 mg/L (milligrams per liter), depending on climate, local environment, and other sources of fluoride. Bottled water typically has unknown fluoride levels.

Health effects Dental cavities remain a major public health concern in most industrialized countries, affecting 60–90% of schoolchildren and the vast majority of adults. Water fluoridation may slightly reduce cavities in children, while efficacy in adults is less clear. Recent studies suggest that water fluoridation, particularly in industrialized countries, may be unnecessary because topical fluorides (such as in toothpaste) are widely used and cavity rates have become low. For this reason, some scientists consider fluoridation to be unethical due to the lack of informed consent. However, a recent study funded by NHS found no significant difference between individuals who receive fluoridated water and those who don't in terms of missing teeth and reducing social inequities. Although fluoridation can cause dental fluorosis, which can alter the appearance of developing teeth or enamel fluorosis, the differences are mild and usually not considered to be of aesthetic or public-health concern. There is no clear evidence of other adverse effects from water fluoridation, as revealed by the York review from 2000. A 2007 Australian systematic review used the same inclusion criteria as York's, plus one additional study. This did not affect the York conclusions. Fluoride's effects depend on the total daily intake of fluoride from all sources. Drinking water is typically the largest source; other methods of fluoride therapy include fluoridation of toothpaste, salt, and milk. The views on the most effective method for community prevention of tooth decay are mixed. The Australian government states that water fluoridation is the most effective means of achieving fluoride exposure that is community-wide. The World Health Organization states water fluoridation, when feasible and culturally acceptable, has substantial advantages, especially for subgroups at high risk, while the European Commission finds no advantage to water fluoridation compared with topical use. Currently about 372 million people (around 5.7% of the world population) receive artificially fluoridated water in about 24 countries, including Australia, Brazil, Canada, Chile, Republic of Ireland, Malaysia, the U.S., and Vietnam. 57.4 million people receive naturally occurring fluoridated water at or above optimal levels in countries such as Sweden, China, Sri Lanka, Finland, Zimbabwe and Gabon. Community water fluoridation is rare in Continental Europe, with 97–98% choosing not to fluoridate drinking water. Fluoridated salt and milk is promoted in some European countries instead. Water fluoridation has been replaced by other modes in many countries where water supplies are too decentralized for it to be a practical choice, or existing natural fluoride levels were already ample, including Germany, Finland, Japan, Netherlands, Sweden, Switzerland (Switzerland has 1 mg fluoride per 1 liter, USA only between 0.3 mg and 0.7 mg) water Denmark and at a time Israel. Cessation of water fluoridation has been demonstrated in scientific studies such as a recent one in Calgary, Alberta, to result in increased rates of dental decay. While fluoridation can result in mild dental fluorosis, this effect is barely detectable and causes no concerns with the appearance or health of teeth. Countries practicing artificial water fluoridation vary in their recommended fluoride levels according to what health authorities in each have determined to be most effective for its citizens. The US recently reset the recommended optimal level of fluoride in drinking water, lowering it slightly, because of observed increased fluorosis levels, likely due to additional fluoride sources like toothpaste and mouthwash which were not present when this level was originally set.

Africa

Libya Before 2003, 400,000 Libyans were receiving artificially fluoridated water.

Nigeria Only a fraction of Nigerians receive water from waterworks, so water fluoridation affects very few people. A 2009 study found that about 21% of water sources naturally contain fluoride to the recommended range of 0.3–0.6 ppm. About 62% have fluoride below this range.

South Africa South Africa's Health Department recommends adding fluoridation chemicals to drinking water in some areas. It also advises removal of fluoride from drinking water (defluoridation) where the fluoride content is too high. Legislation around mandatory fluoridation was introduced in 2002, but has been delayed since then pending further research after opposition from water companies, municipalities and the public.

Zambia Approximately 947,000 (7% of the population) receives water with naturally occurring fluoride in it.

Zimbabwe Roughly 2,600,000 (21% of the population) receives water with naturally occurring fluoride in it.

Asia

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