As bottled sales soar, so may cavities

By Neil D. Rosenberg
of the Journal Sentinel staff
January 25, 2002

As consumption of bottled water continues to sky rocket, dental officials are warning that consumers may be robbing themselves and their children of enough fluoride to protect their teeth.

Unless water bottlers actually add fluoride to their products, the Food and Drug Administration requires no labeling on fluoride content. Tests in Wisconsin show that most bottled water contains very little fluoride -- far below recommended levels.

Random sampling of water bottled in Wisconsin shows most of the products contain no fluoride, according to tests conducted in 1997 by the Department of Agriculture, Trade and Consumer Protection. Nine out of 12 products tested were negative for fluoride.

"The concern, therefore, is that higher caries (cavity) rates may result from bottled water," said Warren LeMay, chief dental officer for the Bureau of Public Health for the state Division of Health.

The rising concern matches the increasing sales of bottled water nationwide.

Over the past 20 years, consumption of bottled water has grown a staggering 1,053%. In 1977, Americans drank 280 million gallons of bottled water, according to the Beverage Marketing Association. In 1997, they drank 3.2 billion gallons.

Per capital consumption increased from 5.7 gallons in 1987 to 12.1 gallons in 1997, according to the BMA.

"Some parents mistakenly believe that they can give their children bottled water because they are healthier, not realizing they are not getting the fluoride that children need to create strong enamel and fight dental decay," said Mary Starsiak, a Chicago general dentist speaking on behalf of the Chicago Dental Society.

Concurring was Michael Easley, associate professor at the School of Dental Medicine at the State University of New York at Buffalo and a spokesman for the American Dental Association.

"The ADA has expressed its concern that if children are using bottled water mostly or exclusively for drinking, they may not be getting enough fluoride to prevent decay," Easley said.

At the very least, the FDA should require labeling of fluoride content so consumers can find out what they are drinking, he said.

Fluoride also is critical for adult teeth because it promotes enamel remineralization. Recent research also shows it helps prevent root caries, cavities at the gum line, in adults, LeMay said. And there is research showing that adequate fluoride consumption is important for maintaining overall bone health.

A spokeswoman for the International Bottled Water Association said the FDA "highly regulates" fluoride in drinking water.

The FDA does regulate the amount of fluoride in bottled water, but only at upper limits. Bottlers may add no more than 1.3 milligrams per liter of fluoride to water, or as much as 2 milligrams per liter if that is what naturally occurs in the water source they use.

Those upper limits were set because fluoride levels above them could produce fluoride toxicity, known as fluorosis, which can leave teeth mottled and discolored.

According to the IBWA's most recent information, 14 U.S. bottlers add fluoride. But there may be as many as 400 bottlers selling their products in the United States, according to the IBWA. That means only a fraction of the bottled water sold nationwide is labeled.

Cindy Yablonski, vice president of research science and technical affairs for the IBWA, said consumers can find out the fluoride content by calling the individual bottler of the brand they buy. Most bottlers put a toll-free telephone number on the label, so consumers can call for more information.

LeMay said consumers also can have their water tested to determine fluoride levels. "But how many do that? Not many, unless they are highly motivated."

The FDA does not require minimum levels of fluoride in bottled water. And in the IBWA's own fact sheet on fluoride, it states "Most brands and types of bottled water do not contain the level of fluoride recommended to fight tooth decay."

That raises a dilemma for dentists, said Easley.

Dentists screen children to determine adequate fluoride intake by getting information about what they drink. Because bottled water is not labeled, their assessment is hampered. If a child appears to be consuming inadequate fluoride, a dentist will recommended fluoride supplements.

In Wisconsin, the recommended level of fluoride in drinking water -- and the level municipalities use when adding fluoride to water -- is 1.1 parts per million, according to LeMay. At that level, literally hundreds of research studies have shown, it reduces cavities by at least 30% compared to water with low levels or no fluoride at all.

"There needs to be a uniform system of listing the amount of fluoride on the bottle so that consumers know exactly how much fluoride they are getting," said Starsiak, of the Chicago society. "I believe the consumer has the right to know." Easley said soft drinks tend to have adequate amounts of fluoride. "If they (children) were to drink exclusively soft drinks, they would be OK," he said, although that is not what he and other dentists recommend.

If your drinking water is from an non-fluoridated system, such as from a well, you can have your water tested with a kit from the State Laboratory of Hygiene, at a cost of $17. For information or to obtain a kit, write to the lab at 465 Henry Mall, Madison, WI 53706 or call at (800) 442-4618.

For more information on fluoride and bottled water or related topics, call Warren LeMay at (608) 266-5152, the International Bottle Water Association at (800) 928-3711; or see the Web site at