797274
research-article2018
JDRXXX10.1177/0022034518797274Journal of Dental ResearchAADR Policy Statement
Policy Statement
American Association for Dental
Research Policy Statement on
Community Water Fluoridation
A.S. Ajiboye1, D.R. Dawson III2, C.H. Fox1,
and AADR Science Information Committee†
Keywords: prevention, dental caries, dental fluorosis, fluoride, dentistry, public health
Introduction
One of the missions of the American Association for Dental
Research (AADR; 2018b) is “to facilitate the communication
and application of research findings by enhancing science
transfer to scientific and professional societies, educators, cli-
nicians and the public.” One of the ways that the AADR
accomplishes this mission is through policy statements. The
goal of these statements is to provide the aforementioned
stakeholders with a unified and authoritative voice on issues
related to dental, oral, and craniofacial health and research.
AADR has a number of policy statements freely accessible
online (AADR 2018c).
The policy development process allows the AADR to care-
fully deliberate an issue—weighing supporting evidence,
opposing viewpoints, and knowledge gaps—to rigorously con-
sider and defend what the AADR, as an organization of
researchers, can support given the best available scientific evi-
dence at the time. The AADR Science Information Committee
is responsible for overseeing the multistep policy development
and approval process. The committee consults peer-reviewed
scientific studies—often utilizing systematic reviews—and
multiple subject matter experts to accurately understand, inter-
pret, and apply research findings.
Recommendations for topics for which to develop new
statements can originate from AADR leadership, individual
members, or staff. Topics may also emerge from conversations
with federal officials who indicate interest in specific dental,
oral, and craniofacial issues for which it would be useful to
have official positions. Ultimately, the decision to move for-
ward with developing a policy statement rests with the AADR
Board of Directors, and the potential adoption or revision of a
policy statement rests solely with the AADR Council.
During the 47th Annual Meeting and Exhibition of the
AADR, the AADR Council approved a new policy statement
supporting the safety and efficacy of community water fluori-
dation for the prevention of dental caries. This statement was
requested at the previous AADR Council meeting and is espe-
cially timely given recent research developments and frequent
and persistent challenges to water fluoridation. Since the
Journal of Dental Research
2018, Vol. 97(12) 1293­–1296
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passage of the statement, a study published in the Journal of
Dental Research further confirmed the efficacy of community
water fluoridation in preventing caries in the primary and per-
manent teeth of US children and adolescents, a significant
update to the evidence showing that community water fluori-
dation still plays an important role in oral health and caries
prevention (Slade et al. 2018).
Additionally, at the request of “private individuals” (NTP
Board of Scientific Counselors 2015), scientists at the National
Toxicology Program (NTP) at the National Institute of
Environmental Health Sciences have been studying neurotox-
icity associated with systemic fluoride exposure from drinking
water. The AADR provided comments on the proposed
research project for consideration at the NTP Board of
Scientific Counselors meeting in December 2015, advising the
counselors that 1) there was a lack of high-quality studies on
the neurotoxicity of fluoride to do a meaningful evaluation; 2)
several recent safety reviews from scientists in the United
States and Europe affirmed the overall safety of fluoride; and
3) if NTP was going to go forward with the study, it should
evaluate the safety of the therapeutic range of fluoride up to the
maximum containment goal levels (primary and secondary, 4
and 2 mg/L, respectively) established by the Environmental
Protection Agency (NTP 2015a). The NTP’s most recent con-
tribution to fluoride research found no evidence of neurotoxic-
ity in rats exposed to fluoride through drinking water
(McPherson et al. 2018). The AADR (2018a) released a com-
ment on the study and referenced the new policy statement on
community water fluoridation.
The practice of community water fluoridation has been in
effect since the mid-1940s, and the overwhelming balance of
1
American Association for Dental Research, Alexandria, VA, USA
2
College of Dentistry, University of Kentucky, Lexington, KY, USA
†
See Acknowledgments for the full list of committee members.
Corresponding Author:
A.S. Ajiboye, American Association for Dental Research, 1619 Duke
Street, Alexandria, VA 22314-3406, USA.
Email: sajiboye@iadr.org
1294 Journal of Dental Research 97(12)
evidence is in favor of its safety; yet, it remains an active and
controversial issue. For example, the majority of the comments
submitted to the NTP (2015b) regarding the neurotoxicity
study during the proposal stage were from private citizens and
activist groups against fluoridation. At the time of this publica-
tion, activists are suing the Environmental Protection Agency
to ban water fluoridation (Showalter and Ajax 2018) and are
involved in a statewide ballot initiative in California unto the
same end (Office of the Attorney General 2018; Padilla 2018).
These instances underscore the obligation of the research com-
munity to help the public understand and properly apply
research to policy decisions.
Because the policy statements represent the collective assess-
ment of the best available evidence, AADR members, staff, and
volunteer leadership are empowered to speak confidently on
behalf of the organization in comments on policy and research
developments, in response to requests for information from fed-
eral agencies, and in advocacy efforts or legislative initiatives.
These efforts also require membership engagement to pre-
serve the gains in public oral health attributable to fluoridation.
The AADR strongly encourages its members to actively
engage with their state and local governments. Civic engage-
ment is particularly relevant to water fluoridation since the
decision to fluoridate occurs at the local level. Members can
reference AADR policy statements (and the research cited in
such statements) in op-eds and letters to the editor in local
newspapers, in public comments at hearings on fluoridation, in
visits to district offices to meet with their representatives, and
in community science outreach events.
As an association of >3,400 dental, oral, and craniofacial
researchers, the AADR has the expertise to credibly contribute
to and influence policies that affect dental, oral, and craniofa-
cial health and research. The AADR strongly encourages its
members to frequently consult and reference these policy state-
ments. It is the AADR’s intent that these statements will be a
useful and influential resource to advance research and improve
dental, oral, and craniofacial health in the United States.
Policy Statement on Community
Water Fluoridation
The AADR supports community water fluoridation as a safe
and effective evidence-based intervention for the prevention of
dental caries. While fluoride occurs naturally in water, fluori-
dation is the controlled addition of fluoride to community
water systems to the level recommended for caries prevention.
The practice of adding fluoride to community water supplies
began after Dr. H. Trendley Dean—the first director of what
became the National Institute of Dental and Craniofacial
Research—observed that residents of communities who drank
from naturally fluoridated water supplies experienced less
tooth decay than those living in communities without naturally
fluoridated water. What began as a small trial of the controlled
addition of fluoride to water in Grand Rapids, Michigan, has
now reached 75% of the US population who drink from a com-
munity water system and has resulted in a significant decrease
in dental caries (Gutmann 2009; Centers for Disease Control
and Prevention [CDC] 2016).
Dental caries—the destruction of dental hard tissues—can
result in pain, infection, and tooth loss. Caries is caused by
acidic by-products produced from bacterial fermentation of
sugar. Dental caries is a very common disease that affects
adults and children. Over one-third of children aged 2 to 8 y
experience caries in their primary teeth. Furthermore, 1 in 5
children aged 6 to 11 y and over half of adolescents aged 12 to
19 y experience caries in their permanent teeth. On average,
older adults can expect at least 1 new decayed tooth surface per
year. Children with poor oral health are more likely to miss
school and suffer academically. Parents may also accrue
absences from school or work to seek treatment for their chil-
dren. Children and adults with caries may experience embar-
rassment, exhibit withdrawal, have difficulty eating and
sleeping, and may limit facial expressions and behaviors that
facilitate social interaction (Low et al. 1999; Griffin et al. 2004,
2005; Jackson et al. 2011; Griffin et al. 2012; Seirawan et al.
2012; Dye et al. 2015).
Many studies point to the effectiveness of community
water fluoridation in decreasing dental caries. A systematic
review of 20 studies by Cochrane, an independent group that
reviews medical research to inform evidence-based policies
and health guidelines, showed that water fluoridation
decreased tooth decay in the primary and permanent teeth of
children and increased the number of children who were free
of decay in primary and permanent teeth (Iheozor-Ejiofor et
al. 2015; Rugg-Gunn et al. 2016). Note that the authors of the
Cochrane systematic review determined that the evidence for
community water fluoridation for the prevention of dental car-
ies was low quality and that many studies were conducted
before 1975. The Cochrane review method considers random-
ized clinical trials as the gold standard of evidence and auto-
matically rates common methods for evaluating public health
interventions as low. However, randomized trials are usually
not feasible for interventions at the population level. The
authors noted this gap in their evidence grading system and
that the evidence pointed in the same direction of fluoridation
reducing tooth decay.
In another review, the Community Preventive Services Task
Force (CPSTF), an independent panel of public health experts
appointed by the director of the CDC, found that starting water
fluoridation decreased caries in children aged 4 to 17 y by 30%
to 50% and that stopping water fluoridation increased caries by
18% (Truman et al. 2002). Furthermore, reducing childhood
caries experience and severity may have benefits into adult-
hood by halting disease progression that can result in adult
tooth loss. Lifelong exposure to fluoridated water has been
associated with reduced tooth decay in adults (Griffin et al.
2007; Neidell et al. 2010).
Community water fluoridation is a cost-effective method of
delivering caries prevention to a large population. A systematic
review by the CPSTF compared the cost of fluoridation with
the money saved on dental restorations in communities that
drink from fluoridated water sources. CPSTF found that water
AADR Policy Statement 1295
fluoridation is cost-saving. In other words, the savings from
fewer dental restorations are greater than the cost of fluorida-
tion for communities >1,000 people and that the larger the
community, the greater the cost saving (Ran et al. 2016). A
2016 analysis confirmed this finding (O’Connell et al. 2016).
Community water fluoridation may also reduce oral health
disparities. Children and adults from socioeconomically disad-
vantaged backgrounds are more likely to suffer from dental
caries and are less likely to be treated for the disease (Beltrán-
Aguilar et al. 2005; Griffin et al. 2012). When added to drink-
ing water, fluoride can be delivered to community residents
regardless of socioeconomic status or ability to access dental
services. Some studies showed decreased inequalities in caries
in communities that drink from a fluoridated community water
source, revealing that children of a lower socioeconomic status
who have access to a fluoridated water source have less severe
tooth decay and require less expensive care than do children of
lower socioeconomic status who do not drink fluoridated
water. More research is needed to determine the circumstances
in which water fluoridation reduces disparities, as not all fluo-
ridated communities show such a reduction (Burt 2002;
Iheozor-Ejiofor et al. 2015).
Community water fluoridation is a safe method of deliver-
ing fluoride on a population level. There have been numerous
systematic reviews on claims of the potential adverse health
effects of water fluoridation. None concluded that there is a
significant or consistent association between water fluorida-
tion and the outcomes examined, including neurologic condi-
tions, cancer, or osteoporosis (Jones et al. 1999; McDonagh
et al. 2000; Agency for Toxic Substances and Disease Registry
2001; Demos et al. 2001; Whiting et al. 2001). Dental fluorosis
resulting in tooth discoloration is the only known adverse
health effect of water fluoridation. Teeth are at risk of fluorosis
only until 8 y of age, during enamel formation. The US Public
Health Service recommends a concentration of 0.7 mg of fluo-
ride per liter of water to achieve caries prevention while mini-
mizing the risk of dental fluorosis (HHS Federal Panel 2015).
While people who drink from fluoridated water sources are at
greater risk of dental fluorosis, most people who drink fluori-
dated water do not develop it. The cases that do develop are
mild such that discoloration is not usually visible to the naked
eye and does not affect the function of the teeth. Severe cases
of dental fluorosis are rare. Some studies showed that Black/
African American and Mexican American children are at
greater risk of developing dental fluorosis. However, this has
not been clearly linked to fluoridated water and may be due to
cumulative fluoride intake from various sources, such as tooth-
paste, supplements, and food and beverages prepared with
fluoridated water (Beltrán-Aguilar et al. 2005; Martinez-Mier
and Soto-Rojas 2010; Iheozor-Ejiofor et al. 2015).
Community water fluoridation is supported by various
groups, including the American Association of Public Health
Dentistry, the American Public Health Association, the
American Dental Association, and the American Academy of
Pediatrics, among others. Additionally, in 1999 the CDC iden-
tified community water fluoridation as 1 of 10 great public
health achievements of the 20th century because of its
effectiveness and ability to distribute fluoride equitably and
cost-effectively (National Center for Chronic Disease
Prevention and Health Promotion 1999). Information about the
fluoride concentration of communities participating in water
fluoridation can be found on the CDC’s (2017) website.
While the AADR always welcomes research on water fluo-
ridation safety and effectiveness in the current context of fluo-
ride availability, the balance of evidence currently shows that
community water fluoridation is safe, effective, and cost sav-
ing and, in some communities, reduces oral health disparities.
Therefore, the AADR supports community water fluoridation
and recommends the fluoridation of community water sources
to a level of 0.7 mg of fluoride per liter of water.
Author Contributions
A.S. Ajiboye, contributed to conception, design, data acquisition,
analysis, and interpretation, drafted and critically revised the man-
uscript; C.H. Fox, contributed to conception, critically revised the
manuscript; D.R. Dawson III, all members of the AADR Science
Information Committee, contributed to conception and design,
critically revised the manuscript. All authors gave final approval
and agree to be accountable for all aspects of the work.
Acknowledgments
The members of the 2017 to 2018 AADR Science Information
Committee were D.R. Dawson, S. Duarte, E.T. Everett, O.D.
Klein, G. Kugel, K.S. Kurtz, L. London, J. Merritt, and S.M.
Wallet. The committee thanks Drs. E. Angeles Martinez-Mier,
Eugenio D. Beltrán-Aguilar, Scott Tomar, Tim Wright, and Linda
Kaste for providing subject matter expertise during the drafting of
the policy statement. The authors received no financial support
and declare no potential conflicts of interest with respect to the
authorship and/or publication of this article.
References
Agency for Toxic Substances and Disease Registry. 2001. Toxicological pro-
file for fluorides, hydrogen fluoride, and fluorine. Washington (DC): US
Department of Health and Human Services.
American Association for Dental Research. 2018a. AADR comment on fluo-
ride exposure animal study from NIEHS. Alexandria (VA): American
Association for Dental Research [accessed 6 May 2018]. http://
ga.dentalresearchblog.org/?p=3077.
American Association for Dental Research. 2018b. AADR mission. Alexandria
(VA): American Association for Dental Research [accessed 25 June 2018].
http://www.iadr.org/AADR/About-Us/Who-We-Are.
American Association for Dental Research. 2018c. Science policy. Alexandria
(VA): American Association for Dental Research [accessed 25 June 2018].
http://www.iadr.org/AADR/About-Us/Policy-Statements.
Beltrán-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin
SO, Hyman J, Jaramillo F, Kingman A, Nowjack-Raymer R, et al. 2005.
Surveillance for dental caries, dental sealants, tooth retention, edentulism,
and enamel fluorosis United States, 1988–1994 and 1999–2002. Surveill
Summ. 54(3):1–44.
Burt BA. 2002. Fluoridation and social equity. J Public Health Dent. 62(4):195–200.
Centers for Disease Control and Prevention. 2016. Water fluoridation basics.
Washington (DC): US Department of Health and Human Services [accessed
8 September 2017]. https://www.cdc.gov/fluoridation/basics/index.htm.
Centers for Disease Control and Prevention. 2017. My water’s fluoride.
Washington (DC): US Department of Health and Human Services [accessed
3 February 2017]. https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx.
Demos LL, Kazda H, Cicuttini FM, Sinclair MI, Fairley CK. 2001. Water
fluoridation, osteoporosis, fractures—recent developments. Aust Dent J.
46(2):80–87.
1296 Journal of Dental Research 97(12)
Dye B, Thornton-Evans G, Li X, Iafolla T. 2015. Dental caries and sealant prev-
alence in children and adolescents in the United States, 2011–2012. NCHS
data brief 191. Hyattsville (MD): National Center for Health Statistics.
Griffin SO, Griffin PM, Swann JL, Zlobin N. 2004. Estimating rates of new root
caries in older adults. J Dent Res. 83(8):634–638.
Griffin SO, Griffin PM, Swann JL, Zlobin N. 2005. New coronal caries in older
adults: implications for prevention. J Dent Res. 84(8):715–720.
Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. 2012. Burden of oral
disease among older adults and implications for public health priorities. Am
J Pub Health. 102(3):411–418.
Griffin SO, Regnier E, Griffin PM, Huntley V. 2007. Effectiveness of fluoride
in preventing caries in adults. J Dent Res. 86(5):410–415.
Gutmann JL. 2009. The evolution of America’s scientific advancements in den-
tistry in the past 150 years. J Am Dent Assoc. 140 Suppl 1:8S–15S.
HHS Federal Panel on Community Water Fluoridation. 2015. US public health
service recommendation for fluoride concentration in drinking water for the
prevention of dental caries. Pub Health Rep. 130(4):318–331.
Iheozor-Ejiofor Z, Worthington HV, Walsh T, O’Malley L, Clarkson JE,
Macey R, Alam R, Tugwell P, Welch V, Glenny A-M. 2015. Water fluo-
ridation for the prevention of dental caries. Cochrane Database Syst Rev.
(6):CD010856.
Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. 2011. Impact of poor oral
health on children’s school attendance and performance. Am J Pub Health.
101(10):1900–1906.
Jones G, Riley M, Couper D, Dwyer T. 1999. Water fluoridation, bone mass
and fracture: a quantitative overview of the literature. Aust N Z J Public
Health. 23(1):34–40.
Low W, Tan S, Schwartz S. 1999. The effect of severe caries on the quality of
life in young children. Pediatr Dent. 21(6):325–326.
Martinez-Mier EA, Soto-Rojas AE. 2010. Differences in exposure and bio-
logical markers of fluoride among White and African American children.
J Public Health Dent. 70(3):234–240.
McDonagh MS, Whiting PF, Wilson PM, Sutton AJ, Chestnutt I, Cooper J,
Misso K, Bradley M, Treasure E, Kleijnen J. 2000. Systematic review of
water fluoridation. BMJ. 321(7265):855–859.
McPherson CA, Zhang G, Gilliam R, Brar SS, Wilson R, Brix A, Picut C, Harry
GJ. 2018. An evaluation of neurotoxicity following fluoride exposure from
gestational through adult ages in long-evans hooded rats. Neurotox Res
[epub ahead of print 5 Feb 2018]. doi:10.1007/s12640-018-9870-x
National Center for Chronic Disease Prevention and Health Promotion. 1999.
Achievements in public health, 1900–1999: fluoridation of drinking water
to prevent dental caries. MMWR Weekly. 48(41):933–940.
National Toxicology Program. 2015a. Letter from AADR to EPA. Washington
(DC): Environmental Protection Agency [accessed 12 August 2018].
https://ntp.niehs.nih.gov/ntp/ohat/publiccomms/2015/aadr20151130.pdf.
National Toxicology Program. 2015b. Public comments for ongoing evalua-
tions and topics under consideration for the Office of Health Translation.
Research Triangle Park (NC): National Institute of Environmental Health
Sciences [accessed 6 June 2018]. https://ntp.niehs.nih.gov/pubhealth/hat/
publiccomms/index.html.
Neidell M, Herzog K, Glied S. 2010. The association between community water
fluoridation and adult tooth loss. Am J Pub Health. 100(10):1980–1985.
NTP Board of Scientific Counselors. 2015. Summary minutes. Research
Triangle Park (NC): National Institute of Environmental Health Sciences
[accessed 6 June 2018]. https://ntp.niehs.nih.gov/ntp/about_ntp/bsc/2015/
december/bsc_dec2015_minutes_508.pdf.
O’Connell J, Rockell J, Ouellet J, Tomar SL, Maas W. 2016. Costs and savings
associated with community water fluoridation in the United States. Health
Affairs. 35(12):2224–2232.
Office of the Attorney General. 2018. Regulates various substances and prac-
tices related to agriculture, consumer products, and health: initiative stat-
ute. AG file 17-0052. Sacramento (CA): California Department of Justice
[accessed 8 August 2018]. https://oag.ca.gov/system/files/initiatives/
pdfs/17-0052%20%28Clean%20Environment%29.pdf.
Padilla A. 2018. Proposed initiative enters circulation: regulates various sub-
stances and practices related to agriculture, consumer products, and health.
Initiative statute. Sacramento (CA): California Secretary of State Press
Office [accessed 8 Aug 2018]. http://www.sos.ca.gov/administration/news-
releases-and-advisories/2018-news-releases-and-advisories/proposed-initi
ative-enters-circulation6/.
Ran T, Chattopadhyay SK, Community Preventive Services Task Force. 2016.
Economic evaluation of community water fluoridation. Am J Prev Med.
50(6):790–796.
Rugg-Gunn AJ, Spencer AJ, Whelton HP, Jones C, Beal JF, Castle P, Cooney
PV, Johnson J, Kelly MP, Lennon MA, et al. 2016. Critique of the review
of “Water fluoridation for the prevention of dental caries” published by the
Cochrane Collaboration in 2015. Br Dent J. 220(7):335–340.
Seirawan H, Faust S, Mulligan R. 2012. The impact of oral health on the
academic performance of disadvantaged children. Am J Pub Health.
102(9):1729–1734.
Showalter JM, Ajax CM. Federal court issues key decision on NGO challenge
to use of fluoride in water. 2018 February 27. The Western Springs (IL):
National Law Review. https://www.natlawreview.com/article/federal-
court-issues-key-decision-ngo-challenge-to-use-fluoride-water.
Slade GD, Grider WB, Maas WR, Sanders AE. 2018. Water fluoridation and
dental caries in U.S. children and adolescents. J Dent Res. 97(10):1122–
1128.
Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans CA Jr,
Griffin SO, Carande-Kulis VG. 2002. Reviews of evidence on interventions
to prevent dental caries, oral and pharyngeal cancers, and sports-related cra-
niofacial injuries. Am J Prev Med. 23(1):21–54.
Whiting P, McDonagh M, Kleijnen J. 2001. Association of Down’s syndrome
and water fluoride level: a systematic review of the evidence. BMC Pub
Health. 1:6.
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