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expert reaction to statement from the UK Chief Medical Officers on Water Fluoridation

The UK Chief Medical Officers (CMOs) have issued a statement suggesting that water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay and improving oral health inequalities across the UK.


Dr John Morris, Senior Lecturer in Dental Public Health, University of Birmingham, said:

“We have 75 years of experience of water fluoridation internationally and nearly 60 years in England.  Furthermore there are areas where the water supply naturally contains fluoride at levels similar to fluoridation schemes and has done so for several decades.  The evidence base is strong for benefit in terms of improved oral health.  Despite repeated assertions of harm by those opposed to water fluoridation and studies into the question, there is no convincing scientific evidence that fluoride in drinking water is a risk to people or the environment at the levels achieved by fluoridation schemes or allowed for by WHO water quality standards.  What we do know is that tooth decay is a significant source of harm to individuals, to society and to the environment.

“Water fluoridation is a highly effective public heath intervention for combating tooth decay.  It is also a very cost effective intervention and, unlike most other public health approaches to tackling tooth decay, reaches both adults and children from all parts of society.

“Tooth decay remains a significant burden for individuals and for society as a whole.  Extending water fluoridation would have substantial benefits; a review in 2015 estimated that decay in baby teeth would be reduced by over a third and in permanent teeth by over a quarter.  An analysis of more recent data for England estimated that young children living in more deprived areas would see a halving of their disease if their water was fluoridated.  Tooth decay is the commonest cause of young children to be admitted to hospital and fluoridation would also halve that.  All in all fluoridation brings significant benefits for people, the environment and for the hard-pressed NHS.

“As we have been reminded with the COVID-19 pandemic, public health measures tend to attract commentary that is not based on sound science.  Some of this is well intentioned from people trying to contribute, some perhaps less so.  The introduction of basic sanitation to avoid cholera outbreaks was saw fierce opposition in the 19th Century and a lively discourse is part of public health.  Fluoridation is really just like other public health programmes in that regard and it is important that the overall body of evidence is looked at critically and dispassionately.  Again, the COVID-19 pandemic has reminded us of the potential harm that misinformation can cause and that the motives behind such stories are variable.  Ensuring that people have easy access to authoritative sources of information is important to allay concerns and put scaremongering stories into perspective.” 


Prof David Conway, Professor of Dental Public Health and Director of Dental Research, University of Glasgow, said:

“I am very supportive of this statement. It’s great to see such high-level support from the UK Chief Medical Officers for a water fluoridation – a key dental public health issue.

“Oral health has long been a challenge across the UK – with wide health inequalities: the greatest burden of disease falling among the poorest and most vulnerable groups. This challenge is further exacerbated by the COVID-19 pandemic.

“This statement is welcome. It is positive to see that water fluoridation is back on the table. Implementation is the challenge, and requires political leadership at national and local levels and engagement with local communities.

“There is an anti water fluoride lobby, which is not dissimilar to the anti-vax / anti-mask groups – their voices can be loud and drown out the public health evidence and advice, so a clear public health campaign is essential.”


Prof John Fawell, Visiting Professor at the Cranfield University Water Institute, Cranfield University, said:

“The statement from the CMOs is reasonable although I feel that they have missed some practical points as water supply areas and health areas do not always coincide so it would be difficult for water suppliers to guarantee unfluoridated water to some adjacent areas that have not voted to accept fluoridation. It is clear that fluoridation is of significant benefit, particularly to children from deprived communities where the uptake of dental hygiene measures is much lower. The level normally recommended for fluoridation of drinking water to reduce the risk of dental decay is between 0.5 and 1 mg/L fluoride. As the fluoride concentration rises above 1 mg/litre the risk of dental fluorosis gradually increases with increasing concentration and the WHO guideline value of 1.5 mg/L is a compromise to minimise dental fluorosis while allowing drinking water fluoridation. It is also a value to which a number of regions with elevated natural fluoride can more readily achieve by blending and local treatment techniques.”



Declared interests

Dr John Morris: “I am an academic employed by the University of Birmingham and I have honorary clinical contracts with the NHS and Public Health England. I am also a self-employed dental practitioner working in the Midlands.”

Prof David Conway: “No conflicts.”

Prof John Fawell: “I am the lead author of the book on fluoride in water published by WHO and a member of the WHO Expert Committee on the Guidelines for Drinking Water Quality.”

None others received.

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