the major anticaries benefit of fluoride is topical and not systemic (Zero et al. 1992; Rölla and Ekstrand 1996; Featherstone 1999; Limeback 1999a; Clarkson and McLoughlin 2000; CDC 2001; Fejerskov 2004). Thus, it has been argued that water fluoridation might not be the most effective way to protect the public from dental caries.

Public health agencies have long disputed these claims. Dental caries is a common childhood disease. It is caused by bacteria that colonize on tooth surfaces, where they ferment sugars and other carbohydrates, generating lactic acid and other acids that decay tooth enamel and form a cavity. If the cavity penetrates to the dentin (the tooth component under the enamel), the dental pulp can become infected, causing toothaches. If left untreated, pulp infection can lead to abscess, destruction of bone, and systemic infection (Cawson et al. 1982; USDHHS 2000). Various sources have concluded that water fluoridation has been an effective method for preventing dental decay (Newbrun 1989; Ripa 1993; Horowitz 1996; CDC 2001; Truman et al. 2002). Water fluoridation is supported by the Centers for Disease Control and Prevention (CDC) as one of the 10 great public health achievements in the United States, because of its role in reducing tooth decay in children and tooth loss in adults (CDC 1999). Each U.S. Surgeon General has endorsed water fluoridation over the decades it has been practiced, emphasizing that “[a] significant advantage of water fluoridation is that all residents of a community can enjoy its protective benefit…. A person’s income level or ability to receive dental care is not a barrier to receiving fluoridation’s health benefits” (Carmona 2004).

As noted earlier, this report does not evaluate nor make judgments about the benefits, safety, or efficacy of artificial water fluoridation. That practice is reviewed only in terms of being a source of exposure to fluoride.

HISTORY OF EPA’S REGULATION OF FLUORIDE

In 1975, EPA proposed an interim primary drinking-water regulation for fluoride of 1.4-2.4 mg/L. That range was twice the “optimal” range of 0.7-1.2 mg/L recommended by the U.S. Public Health Service for water fluoridation. EPA’s interim guideline was selected to prevent the occurrence of objectionable enamel fluorosis, mottling of teeth that can be classified as mild, moderate, or severe. In general, mild cases involve the development of white opaque areas in the enamel of the teeth, moderate cases involve visible brown staining, and severe cases include yellow to brown staining and pitting and cracking of the enamel (NRC 1993). EPA considered objectionable enamel fluorosis to involve moderate to severe cases with dark stains and pitting of the teeth.

The history of EPA’s regulation of fluoride is documented in 50 Fed. Reg. 20164 (1985). In 1981, the state of South Carolina petitioned EPA



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