page_title: Water fluoridation
section_title: Alternatives
hierarchical_section_title: Water fluoridation / Alternatives
caption_attribution_description: English: Fluoridated iodized salt sold in Germany Deutsch: Bad Reichenhaller fluoridiertes Jodsalz 中文（简体）‎: 德国销售的加氟碘盐
context_page_description: Water fluoridation is the controlled adjustment of fluoride to a public water supply to reduce tooth decay. Fluoridated water contains fluoride at a level that is effective for preventing cavities; this can occur naturally or by adding fluoride. Fluoridated water operates on tooth surfaces: in the mouth, it 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 $1.11 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, depending on climate, local environment, and other sources of fluoride. Bottled water typically has unknown fluoride levels.
  Tooth decay remains a major public health concern in most industrialized countries, affecting 60–90% of schoolchildren and the vast majority of adults. Water fluoridation reduces cavities in children, while efficacy in adults is less clear.
context_section_description: The views on the most effective method for community prevention of tooth decay are mixed. The Australian government review states that water fluoridation is the most effective means of achieving fluoride exposure that is community-wide. The European Commission review states "No obvious advantage appears in favour of water fluoridation compared with topical prevention". Other fluoride therapies are also effective in preventing tooth decay; they include fluoride toothpaste, mouthwash, gel, and varnish, and fluoridation of salt and milk. Dental sealants are effective as well, with estimates of prevented cavities ranging from 33% to 86%, depending on age of sealant and type of study.
  Fluoride toothpaste is the most widely used and rigorously evaluated fluoride treatment. Its introduction is considered the main reason for the decline in tooth decay in industrialized countries, and toothpaste appears to be the single common factor in countries where tooth decay has declined. Toothpaste is the only realistic fluoride strategy in many low-income countries, where lack of infrastructure renders water or salt fluoridation infeasible. It relies on individual and family behavior, and its use is less likely among lower economic classes; in low-income countries it is unaffordable for the poor. Fluoride toothpaste prevents about 25% of cavities in young permanent teeth, and its effectiveness is improved if higher concentrations of fluoride are used, or if the toothbrushing is supervised. Fluoride mouthwash and gel are about as effective as fluoride toothpaste; fluoride varnish prevents about 45% of cavities. By comparison, brushing with a nonfluoride toothpaste has little effect on cavities.
  The effectiveness of salt fluoridation is about the same as that of water fluoridation, if most salt for human consumption is fluoridated. Fluoridated salt reaches the consumer in salt at home, in meals at school and at large kitchens, and in bread. For example, Jamaica has just one salt producer, but a complex public water supply; it started fluoridating all salt in 1987, achieving a decline in cavities. Universal salt fluoridation is also practiced in Colombia and the Swiss Canton of Vaud; in Germany fluoridated salt is widely used in households but unfluoridated salt is also available, giving consumers a choice. Concentrations of fluoride in salt range from 90 to 350 mg/kg, with studies suggesting an optimal concentration of around 250 mg/kg.
  Milk fluoridation is practiced by the Borrow Foundation in some parts of Bulgaria, Chile, Peru, Russia, Macedonia, Thailand and the UK. Depending on location, the fluoride is added to milk, to powdered milk, or to yogurt. For example, milk powder fluoridation is used in rural Chilean areas where water fluoridation is not technically feasible. These programs are aimed at children, and have neither targeted nor been evaluated for adults. A systematic review found low-quality evidence to support the practice, but also concluded that further studies were needed.
  Other public-health strategies to control tooth decay, such as education to change behavior and diet, have lacked impressive results. Although fluoride is the only well-documented agent which controls the rate at which cavities develop, it has been suggested that adding calcium to the water would reduce cavities further. Other agents to prevent tooth decay include antibacterials such as chlorhexidine and sugar substitutes such as xylitol. Xylitol-sweetened chewing gum has been recommended as a supplement to fluoride and other conventional treatments if the gum is not too costly. Two proposed approaches, bacteria replacement therapy (probiotics) and caries vaccine, would share water fluoridation's advantage of requiring only minimal patient compliance, but have not been proven safe and effective. Other experimental approaches include fluoridated sugar, polyphenols, and casein phosphopeptide–amorphous calcium phosphate nanocomplexes.
  A 2007 Australian review concluded that water fluoridation is the most effective and socially the most equitable way to expo
caption: Fluoridated iodized salt sold in Germany
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