HHS: Proposed Guidelines on Fluoride in Drinking Water

A Commentary By Howard K. Koh, MD, MPH

Howard K. Koh, MD, MPH


March 08, 2011

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Hello, I'm Dr. Howard Koh, the Assistant Secretary for Health at the US Department of Health and Human Services.

Disease prevention is at the foundation of almost all of my work at the Department. We encourage individuals and communities to make prevention a priority and to make healthy choices. As a physician who has treated patients for many years, I know the benefits of preventing illness and disease before they occur.

One of the most effective prevention choices for a community is to advance oral health through community water fluoridation. For more than 65 years, community water fluoridation has been a safe and healthy way to prevent tooth decay and improve the oral health of people across the nation. One of water fluoridation's biggest advantages is that it benefits all residents of a community—at home, work, school, or play. And the Centers for Disease Control and Prevention has recognized water fluoridation as one of the ten greatest public health achievements of the 20th century. [1]

In January 2011, we announced important steps to ensure that guidelines on fluoride in drinking water continue to provide proper protection to support good dental health -- especially in children.[2] HHS is proposing that the recommended level of fluoride in drinking water be adjusted to the lowest end of the current optimal range to prevent tooth decay. The new HHS fluoridation guidelines have been released for public comment. HHS will review the comments and issue final guidance later this year.

HHS's proposed recommendation of 0.7 milligrams of fluoride per liter of water replaces the current recommended range of 0.7 to 1.2 milligrams. This updated recommendation is based on recent HHS and Environmental Protection Agency scientific assessments to optimize the benefits of preventing tooth decay while limiting any unwanted health effects.

There are several reasons for the changes seen over time, including that Americans have access to more sources of fluoride than they did when water fluoridation was first introduced in the United States in the 1940s.

Water is now one of several sources of fluoride. Other common sources include dental products such as toothpaste and mouth rinses, prescription fluoride supplements, and fluoride applied by dental professionals. Water fluoridation and fluoride toothpaste are largely responsible for the significant decline in tooth decay in the US over the past several decades.

While the impact of fluoride on reducing decay is life long, tooth enamel formation occurs from birth until about 8 years old. This is also the time when dental fluorosis may occur with excess fluoride consumption. Dental fluorosis is a change in the appearance of the tooth's enamel, and in the United States it appears mostly in the very mild or mild form – as barely visible lacy white markings or spots. The severe form of dental fluorosis, with staining and pitting of the tooth surface, is rare in the United States.

The current recommendations for fluoride use state that all persons should drink optimally fluoridated water and brush their teeth twice daily with fluoride toothpaste.

Dentists, physicians and other healthcare providers can promote the benefits of fluoride for preventing tooth decay while reducing the risk of dental fluorosis by counseling parents on the appropriate use of fluoride toothpaste by young children.

As soon as the first tooth appears, health professionals should counsel parents to begin cleaning by brushing without toothpaste with a small, soft toothbrush and water. Children younger than 6 years old do not have a well-developed swallowing reflex and may like the taste of the toothpaste; therefore, they often swallow a large portion of it. It's recommended that children begin using toothpaste with fluoride at 2 years old, and use only a pea-sized amount on the child's toothbrush. Encourage parents to supervise their child's tooth brushing, and to teach the child to spit out the toothpaste rather than swallow it.

Fluoride supplements can be prescribed for children at high risk of tooth decay and whose primary drinking water has a low fluoride concentration. For children 8 years and younger, the dentist, physician, or other health care provider should weigh the risk for decay without fluoride supplements, the decay prevention offered by supplements, and the potential for dental fluorosis.

Parents and caregivers may also have questions and concerns about infant formula. All formula, either concentrates or ready-to-feed, have some fluoride, but most infant formula manufacturers develop their products to ensure low levels of fluoride. Parents and caregivers can use fluoridated water for preparing infant formula. However, if the child is exclusively consuming infant formula reconstituted with fluoridated water, there is an increased potential for mild dental fluorosis. The majority of fluoride comes from the water used to mix the formula. Some parents may choose to use low-fluoride bottled water some of the time to mix infant formula.

Oral health is an essential component of general health and well-being. Community water fluoridation remains an effective public health strategy and its advancement and expansion will continue to enhance the oral health of all Americans.

Editor's Note: HHS has extended the comment period for the proposed recommendation that community water systems adjust the amount of fluoride in drinking water to 0.7 mg/L to April 15, 2011, 11:59 EST. The Federal Register notice of extension of comment period is available at "Proposed HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries; Extension of Comment Period." The proposed recommendation was published in the Federal Register on January 13, 2011, and is available at "Proposed HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries."

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Howard K. Koh MD, MPH, serves as the 14th Assistant Secretary for Health for the US Department of Health and Human Services (HHS), after being nominated by President Barack Obama and confirmed by the U.S. Senate in 2009. Dr. Koh oversees 14 core public health offices, including the Office of the Surgeon General and the U.S. Public Health Service Commissioned Corps, 10 Regional Health Offices across the nation, and 10 Presidential and Secretarial advisory committees. He also serves as senior public health advisor to the Secretary. The Office of Assistant Secretary for Health implements an array of interdisciplinary programs relating to disease prevention, health promotion, the reduction of health disparities, women's and minority health, adolescent health, HIV/AIDS and chronic infectious diseases, vaccine programs, fitness, sports and nutrition, bioethics, population affairs, blood supply, research integrity and human research protections. As the Assistant Secretary for Health, Dr. Koh is dedicated to the mission of creating better public health systems for prevention and care so that all people can reach their highest attainable standard of health.

Dr. Koh previously served as the Harvey V. Fineberg Professor of the Practice of Public Health and Associate Dean for Public Health Practice at the Harvard School of Public Health. He was also Director of the Harvard School of Public Health Center for Public Health Preparedness. He has published more than 200 articles in the medical and public health literature in areas such as disparities, cancer control, melanoma and skin oncology, tobacco control, public health preparedness, disease prevention and health promotion, and public health leadership.

Dr. Koh graduated from Yale College, and completed postgraduate training at Boston City Hospital and Massachusetts General Hospital, serving as chief resident in both hospitals. He has earned board certification in four medical fields: internal medicine, hematology, medical oncology, and dermatology, as well as a Master of Public Health degree from Boston University.


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