Benefits l Fluoridation Facts 21 9. What happens if water fluoridation is discontinued? Answer. Tooth decay can be expected to increase if water fluoridation in a community is discontinued even if topical products such as fluoride toothpaste and fluoride mouthrinses are widely used. Fact. In 2013, using an updated systematic review, the Community Preventive Services Task Force, established by the U.S. Department of Health and Human Services, continued to recommend community water fluoridation to reduce tooth decay, noting that cavities decreased when fluoridation was implemented and that cavities increased when fluoridation was stopped, as compared to communities that continued fluoridation.34 This confirmed the Task Force’s earlier systematic review published in 200245 which also noted an increase in tooth decay when fluoridation was halted (a median 17.9% increase in tooth decay during 6 to 10 years of follow-up). Historical Studies Noting an Increase in Tooth Decay after Discontinuation of Fluoridation Antigo, Wisconsin, began water fluoridation in June 1949 and ceased adding fluoride to its water in November 1960. After five and one-half years without optimal levels of fluoride, second grade children had a 200% increase in tooth decay experience, fourth graders a 70% increase and sixth graders a 91% increase in decay experience compared with the levels of those of the same ages in 1960. Residents of Antigo re-instituted water fluoridation in October 1965 on the basis of the severe deterioration of their children’s oral health.47 A study that reported the relationship between fluoridated water and tooth decay prevalence focused on the city of Galesburg, Illinois, a community whose public water supply contained naturally occurring fluoride at 2.2 mg/L. In 1959, Galesburg switched its community water source to the Mississippi River. This alternative water source provided the citizens of Galesburg a sub-optimal level of fluoride at approximately 0.1 mg/L. In the period of time between a baseline survey conducted in 1958 and a new survey conducted in 1961, data revealed a 10% decrease in the percentage of decay free 14-year- olds (oldest group observed), and a 38% increase in mean tooth decay experience. Two years later, in 1961, the water was fluoridated at the recommended level of 1.0 mg/L.48 Because of a government decision in 1979, fluoridation in the northern Scotland town of Wick was discontinued after eight years. The water was returned to its sub-optimal, naturally occurring fluoride level of 0.02 mg/L. Data collected to monitor the oral health of Wick children clearly demonstrated a negative health effect from the discontinuation of water fluoridation. Five years after the cessation of water fluoridation, decay in primary (baby teeth) had increased 27%. This increase in decay occurred during a period when there had been a reported overall reduction in decay nationally and when fluoride toothpaste had been widely adopted. These data suggest that decay levels in children can be expected to rise where water fluoridation is interrupted or terminated, even when topical fluoride products are widely used.49 In a similar evaluation, the prevalence of tooth decay in 5- and 10-year-old children in Stranraer, Scotland, increased after the discontinuation of water fluoridation. This increase in tooth decay was estimated to result in a 115% increase in the mean cost of restorative dental treatment for decay. These data support the important role water fluoridation plays in the reduction of tooth decay.50 Historical Studies and Factors Noting No Increase In Tooth Decay after Discontinuation of Fluoridation There have been several studies from outside the United States that have not reported an increase in tooth decay following the discontinuation of fluoridation. In all of these, the discontinuation of fluoridation coincided with the implementation of other measures to prevent tooth decay. In La Salud, Cuba, a study on tooth decay in children indicated that the rate of tooth decay did not increase after fluoridation was stopped in 1990. However, at the time fluoridation was discontinued a new preventive fluoride program was initiated where all children received fluoride mouthrinses on a regular basis and children two to five years of age received fluoride varnish once or twice a year.51 In Finland, a longitudinal study in Kuopio (fluoridated from 1959 to 1992) and Jyväskylä (with low levels of natural fluoride) showed little difference in