Health effects of water fluoridation

Community water fluoridation, also known as artificial water fluoridation, is the addition of fluoride to drinking water with the aim of reducing tooth decay. This practice adjusts the natural fluoride concentration of water to that recommended for improving oral health. Good oral health is an integral part of good general health1, and allows people to eat, speak and socialise without discomfort or embarrassment. In Australia, dental health has improved since water fluoridation began in the 1950s and Australians born after 1970 have, on average, half the level of tooth decay of their parents’ generation2.


In 2006, NHMRC undertook a systematic review of the evidence for the efficacy and safety of fluoride interventions. This review focused on sources that could be used to deliver fluoride to the Australian community including drinking water, milk, salt and topical fluoride treatments. The review, titled “A Systematic Review of the Efficacy and Safety of Fluoridation” (the 2007 Systematic Review) considered possible benefits and harms of these different sources of fluoride.

As a result of the 2007 Systematic Review, NHMRC released the

(the 2007 Public Statement). This recommends that water be fluoridated in the target range of 0.6 to 1.1 mg/L, depending on climate, to balance reduction of dental caries (tooth decay) and occurrence of dental fluorosis (mottling of teeth). It also states that fluoridation of drinking water is an effective way to ensure people across the community are exposed to fluoride and can benefit from its preventative role in tooth decay, regardless of age, gender or socioeconomic status.

At its meeting in November 2012, the Council of NHMRC (Council) advised that NHMRC consider options for investigating new evidence on the health effects of fluoridation. In response, on 20 June 2013, NHMRC hosted a meeting of experts in the field and state and territory government health representatives to consider NHMRC’s advice on water fluoridation. The main outcome of this meeting was that an update of the 2007 Systematic Review should be undertaken, subject to the availability of funding.

Following this meeting, Council reaffirmed its position on the 2007 Public Statement, and recommended that the Office of NHMRC update the body of evidence to include more recent studies and assess their relevance in the Australian context. An update of the evidence is now in its final stages.

Current evaluation of the evidence on the health effects of water fluoridation

The objectives of the current evaluation of the evidence are:

  1. To critically appraise the Cochrane review by Iheozor-Ejiofor et al3  published on 18 June 2015 whose objectives are:
    1. To evaluate the effects of water fluoridation (artificial or natural) for the prevention of dental caries.
    2. To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis.
  2. To undertake a systematic review to identify and evaluate evidence on the possible health effects of water fluoridation not covered by the above Cochrane review.

The NHMRC appointed a team from the University of Sydney to undertake this evaluation. In seeking a Contractor to undertake this work, NHMRC sought quotes from panellists on its Health Evidence Panel (HEP). The responses were evaluated and the preferred panellist, the University of Sydney, was selected as providing the best value for money. The HEP was established in June 2013 through an open market activity. The HEP is a continuing offer over three years for suppliers to provide services relating to the development and presentation of evidence based health advice, at agreed prices, terms and conditions. Panel arrangements are established to increase efficiency, reduce administration costs and reduce risk. The names of suppliers on the HEP are available on the AusTender website.

Fluoride Reference Group

In May 2014, NHMRC established the Fluoride Reference Group to guide the evaluation of the evidence on the health effects of water fluoridation. The Fluoride Reference Group considered the outcomes of the evidence evaluation and advise on how relevant these findings are for Australia, given that concerns regarding water fluoridation vary across international and geographic regions. The group also used the findings to provide advice on a draft Information Paper, which provides a summary of the evidence evaluation and its key findings.

Public call for evidence

The Australian community was invited to submit published studies to be evaluated as part of the systematic review on the health effects of water fluoridation from 23 July until 22 August 2014. Literature that met the scope of the systematic review was provided to the evidence review team at the University of Sydney. They evaluated studies identified by the community in exactly the same way that they evaluated studies found using their own systematic searches.

Public consultation

The next opportunity for the Australian community to be involved in NHMRC’s work on water fluoridation will occur around September/October 2016. At this time the draft Information Paper will be available for comment via NHMRC’s public consultation portal. This site provides all the necessary information for making a submission. From this site you can also subscribe to NHMRC’s public consultations, which means you will be notified by email when a new public consultation opens.

Key milestones

Public call for evidence 23 July – 22 August 2014
Evidence evaluation completed Early 2016
Public consultation on draft Information Paper September/October 2016
Expert review of the Information Paper Early 2017
Final Information Paper issued Early to mid 2017

Relevant resources

NHMRC 2007 Review

Further information

For further information please contact NHMRC at


1 Australian Institute of Health and Welfare 2012. Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW

2 Australian Institute of Health and Welfare 2012. Australia’s Health 2012: in brief. Cat. no. AUS 157. Canberra: AIHW

3 Iheozor-Ejiofor Z,Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, AlamR, Tugwell P, Welch V, Glenny AM. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010856. DOI: 10.1002/14651858.CD010856.pub2