Better oral health for all Australians: Marking 70 years of fluoridation

Since its Australian beginnings in 1953, water fluoridation has played a crucial role in improving the nation’s oral health, growing to provide access to fluoridated drinking water to almost 90% of the population. Its positive impact on dental health is undeniable, with significant reductions in tooth decay observed among children, adolescents, and adults.

According to the National Health and Medical Research Council (NHMRC), water fluoridation reduces tooth decay by 26% to 44% in children and adolescents, and by 27% in adults. Furthermore, Australians born after 1970 are found to have about half the level of tooth decay compared to their parents’ generation.

The practice of water fluoridation was first introduced in the United States in the mid-20th century, following epidemiological studies by the US National Institutes of Health (NIH) that suggested a fluoride concentration of about 1mg/L was associated with significantly fewer cavities in temperate climates. This led to a controlled experiment in Grand Rapids, Michigan, starting in January 1945, which confirmed the hypothesis that adding fluoride to water could prevent cavities.

In Australia, the benefits of water fluoridation were recognised in late 1953, about two years after its acceptance in the United States. The first Australian town to introduce fluoride to its drinking water was Beaconsfield, Tasmania, with the initiative later extended to parts of New South Wales in 1956, and many other Australian towns and cities in the 1960s and 1970s. By 1984, almost two-thirds of the Australian population had access to fluoridated drinking water, with an additional big improvement in 2008, when a few million people in South East Queensland gained access to fluoridated water.

Internationally, as of 2012, artificial water fluoridation was practiced in 25 countries, with more than half of their population drinking fluoridated water in 11 of those countries. Additionally, there are at least 28 countries where some of the water is naturally fluoridated at around optimal levels. Approximately 435 million people worldwide received water fluoridated at the recommended level as of 2012, with about half residing in the United States. Other countries have implemented fluoridation of salt or even milk, while many lower-income countries, where infrastructure constraints make water or salt fluoridation unfeasible, must rely on oral health messaging and products such as toothpaste.
 

Paving the way to equitable oral health

Dr Michael Foley, whose extensive service to community health and to dental education was recognised last year by an appointment to the Order of Australia, says that fluoridation is inextricably linked with equitable access to good health.

“We often think that the objective of public health is to reduce disease in the population, and thereby make the population healthier,” he says. “That’s true, but there’s another related objective of public health, and that’s to reduce health inequalities in the population.

“Most people would accept that having a section of society with ongoing, inter-generational poor health is not a good thing, either for those people or for society in general. Whether it’s diabetes or dementia or tooth decay, all of society eventually pays for the level of disease in our community. Those sectors of the community with poor health that often transcends generations tend to be those from disadvantaged
communities – people living in poverty, people living regionally and remotely, people with mental illness and disabilities, people with drug dependencies, and people from Aboriginal and Torres Strait Islander communities.

“Education programs certainly have a role, but by themselves, education programs (and any programs that rely solely on behaviour change) can easily increase health inequalities, not decrease them,” states Dr Foley. “That’s because people in big cities who are already well educated and well off have greater choices and freedoms, much easier access to healthcare, and a greater ability to purchase aids to better health.”
 

When prevention becomes policy

“In 2000, the Centers for Disease Control in the US published its 10 Great Public Health Achievements 1900-1999,” Dr Foley explains. “Most (vaccination programs, motor vehicle safety, safer workplaces, safer and healthier foods, healthier mothers and babies, family planning, recognition of tobacco use as a health hazard, and water fluoridation) are largely driven by government interventions, not individual pieces of research. Some of the conservatives and libertarians complain about ‘nanny state’ interventions and ‘socialised medicine’, but governments should play a major role in the health of society.

“Ready access to healthcare and health treatments should be available to everyone in our communities, but it’s far better to prevent the disease in the first place if we can. Water fluoridation is one of those government interventions that doesn’t rely on behaviour change, and it will result in significantly better health, particularly for those from disadvantaged sectors of the population who already experience the poorest health. Better oral health improves quality of life, and at a practical level it gives you a better chance of finding a job.

“In the last few generations we’ve gone from just about everyone in society having very high levels of dental caries, fillings and extractions to a situation where most people have pretty good dental health and an expectation that they’ll have most of their teeth for life,” says Dr Foley. “Very few other disease conditions have seen the same dramatic improvement that we’ve seen for dental caries. The early fluoride researchers, public health experts and dentists (yes, and also the politicians who implemented these fluoridation programs) deserve huge credit.”
 

This article was first published in the ADA's News Bulletin, October 2023