Benefits l Fluoridation Facts 31 15. Can the consistent use of bottled water result in individuals missing the benefits of optimally fluoridated water? Answer. Yes. The majority of bottled waters on the market do not contain optimal levels (0.7 mg/L) of fluoride. Fact. There is not a large body of research regarding the risk for tooth decay associated with the consumption of bottled water. However, a lack of exposure to fluoride could increase an individual’s risk for tooth decay. The vast majority of bottled waters do not contain significant amounts of fluoride.100 Individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supplies. These consumers should seek advice from their dentists about their risk for tooth decay and specific fluoride needs. While drinking water from the tap is regulated by the U.S. Environmental Protection Agency (EPA), bottled water is regulated by the U.S. Food and Drug Administration (FDA).101 The FDA has established maximum allowable levels for physical, chemical, microbiological, and radiological contaminants in bottled water.102 Individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supplies. Noting that fluoride can occur naturally in source waters used for bottled water or can be added by a bottled water manufacturer, the FDA has approved standards for the fluoride content of bottled water.102 However, the FDA regulations require the fluoride content of bottled water to be listed on the label only if fluoride is added during processing.103 If the fluoride level is not shown on the label of the bottled water, the company can be contacted, or the water can be tested to obtain this information. Most consumers are unaware that the vast majority of bottled waters, especially those treated by distillation or reverse osmosis, are largely fluoride-free. Unknowingly, individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supplies. The American Dental Association supports the labeling of bottled water with the fluoride content to aid consumers in making informed decisions about choices of drinking water.104 Recognizing the benefit of fluoride in drinking water, in 2006 the FDA issued the “FDA Health Claim Notification for Fluoridated Water and Reduced Risk of Dental Caries”105 which states that bottled water meeting the specific standards of identity and quality set forth by FDA, and containing greater than 0.6 mg/L up to 1.0 mg/L total fluoride, can be labeled with the following health claim: “Drinking fluoridated water may reduce the risk of [dental caries or tooth decay].” This health claim is not intended for use on bottled water products specifically marketed for use by infants.105 Additional information on this topic can be found in the Safety Section, Question 28. According to a 2017 press release from the Beverage Marketing Corporation,106 bottled water surpassed carbonated soft drinks in 2016 to become the largest beverage category by volume in the United States. Per capita consumption of bottled water was approximately 39.3 gallons in 2016, while the average consumption of carbonated soft drinks was approximately 38.5 gallons per person per year. The majority (67.3%) of U.S. bottled water is sold in single-serving PET (polyethylene terephthalate or plastic resin107) bottles. Bottled water is also sold via bulk deliveries to homes and offices (approximately 11%) and by retail sales in different sizes of gallon containers (approximately 9%).106 Individuals choose to drink bottled water for various reasons. Some find it a calorie-free substitute for carbonated soft drinks or other sugary beverages. Others dislike the taste of their tap water or have concerns about the possible contaminants in their local water supply. In a small study published in 2012, a convenience sample of caretakers and adolescents at an urban clinic found that 17% drank tap water exclusively, 38% drank bottled water exclusively and 42% drank both. Bottled water was ranked significantly higher