Monday, April 8, 2013

CRS Report Released: Fluoride in Drinking Water: A Review of Fluoridation and Regulation Issues

The Congressional Research Service (CRS), the public policy research arm of Congress, recently issued the report Fluoride in Drinking Water: A Review of Fluoridation and Regulation Issues (Apr. 5, 2013). The 24-page report authored by Mary Tiemann discusses the following:


According to the Centers for Disease Control and Prevention (CDC), in 2010, 73.9% of the people in the United States who receive their water from a public water system received fluoridated water (roughly 204.3 million people). One of CDC’s national health goals is to increase the proportion of the U.S. population served by community water systems with “optimally” fluoridated drinking water to 79.6% by 2020. The decision to add fluoride to a water supply is made by local or state governments. The Department of Health and Human Services (HHS) had long recommended an optimal fluoridation level in the range of 0.7 to 1.2 milligrams per liter (mg/L) to prevent tooth decay.
The fluoridation of drinking water often generates both strong support and opposition within communities. This practice is controversial because fluoride has been found to have beneficial effects at low levels and is intentionally added to many public water supplies; however, at higher concentrations, it is known to have toxic effects. The Environmental Protection Agency (EPA) regulates the amount of fluoride that may be present in public water supplies to protect against fluoride’s adverse health effects. Fluoridation opponents have expressed concern regarding potential adverse health effects of fluoride ingestion, and some view the practice as an unjustified infringement on individual freedom. The medical and public health communities generally have recommended water fluoridation, citing it as a safe, effective, and equitable way to provide dental health protection community-wide.
Because the use of fluoridated dental products and the consumption of food and beverages made with fluoridated water have increased since HHS recommended optimal levels for fluoridation, many people now may be exposed to more fluoride than had been anticipated. Consequently, questions have emerged as to whether current water fluoridation practices and levels offer the most appropriate ways to provide the expected beneficial effects of fluoride while avoiding adverse effects (most commonly, tooth mottling or pitting—dental fluorosis) that may result from ingestion of too much fluoride when teeth are developing. Also, scientific uncertainty regarding the health effects of exposure to higher levels of fluoride adds controversy to decisions regarding water fluoridation. In 2011, HHS proposed to reduce the recommended level to 0.7 mg/L.
Although fluoride is added to water to strengthen teeth, some communities must treat their water to remove excess amounts of fluoride that is present either naturally or from pollution. In 1986, EPA issued a drinking water regulation for fluoride that includes an enforceable standard—a maximum contaminant level (MCL)—and an MCL goal (MCLG) of 4 mg/L to protect against adverse effects on bone structure. EPA acknowledged that the standard did not protect infants and young children against dental fluorosis, which EPA considered a cosmetic effect rather than a health effect. To address this concern, EPA included in the regulation a secondary (advisory) standard of 2 mg/L to protect children against dental fluorosis and adverse health effects. As part of its current review of the fluoride regulation, EPA asked the National Research Council (NRC) to review the health risk data for fluoride and to assess the adequacy of EPA’s standards. In March 2006, NRC released its study and concluded that EPA’s 4 mg/L MCLG should be lowered.
In 2011, EPA released new risk and exposure assessments for fluoride. The agency announced its intent to use this science and additional research to review the primary and secondary drinking water standards for fluoride and to determine whether to revise them. To make a regulatory determination, EPA also must consider analytical methods for testing for fluoride at lower concentrations, treatment feasibility (including cost), occurrence, and exposure.

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