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Previous recommendations were based on evaluations from 1962, when the U.S. specified the optimal level of fluoride to range from 0.7 to 1.2 mg/L (milligrams per liter, equivalent to parts per million), depending on the average maximum daily air temperature; the optimal level is lower in warmer climates, where people drink more water, and is higher in cooler climates.<ref name=CDC-1992-2006>{{cite journal | vauthors = Bailey W, Barker L, Duchon K, Maas W | title = Populations receiving optimally fluoridated public drinking water--United States, 1992-2006 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 57 | issue = 27 | pages = 737–41 | date = July 2008 | pmid = 18614991 | url = http://cdc.gov/mmwr/preview/mmwrhtml/mm5727a1.htm }}</ref>
These standards are not appropriate for all parts of the world, where fluoride levels might be excessive and fluoride should be removed from water, and is based on assumptions that have become obsolete with the rise of [[air conditioning]] and increased use of [[soft drinks]], [[processed food]], [[Toothpaste#Fluorides|fluoridated toothpaste]], and other sources of fluorides.<ref name=WHO2011/> In 2011, the World Health Organization stated that 1.5 mg/L should be an absolute upper bound and that 0.5 mg/L may be an appropriate lower limit.<ref name=WHO2011>[http://apps.who.int/iris/bitstream/10665/44584/1/9789241548151_eng.pdf Guidelines for Drinking-water Quality, 4th Edition] WHO, 2011. {{ISBN|9789241548151}}. Page 168, 175, 372 and see also pp 370–73. See also J. Fawell, et al [http://apps.who.int/iris/bitstream/10665/43514/1/9241563192_eng.pdf?ua=1 Fluoride in Drinking-water]. WHO, 2006. Page 32. Quote: "Concentrations in drinking-water of about 1 mg l–1 are associated with a lower incidence of dental caries, particularly in children, whereas excess intake of fluoride can result in dental fluorosis. In severe cases this can result in erosion of enamel. The margin between the beneficial effects of fluoride and the occurrence of dental fluorosis is small and public health programmes seek to retain a suitable balance between the two"</ref> A 2007 Australian systematic review recommended a range from 0.6 to 1.1 mg/L.<ref name=NHMRC>{{cite book |url=http://nhmrc.gov.au/_files_nhmrc/file/publications/synopses/Eh41_Flouridation_PART_A.pdf |access-date=13 October 2009 |year=2007 |title=A systematic review of the efficacy and safety of fluoridation |author=National Health and Medical Research Council (Australia) |isbn=978-1-86496-415-8 |archive-date=14 October 2009 |archive-url=https://web.archive.org/web/20091014191758/http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/Eh41_Flouridation_PART_A.pdf |url-status=dead }} Summary: {{cite journal | vauthors = Yeung CA | title = A systematic review of the efficacy and safety of fluoridation | journal = Evidence-Based Dentistry | volume = 9 | issue = 2 | pages = 39–43 | year = 2008 | pmid = 18584000 | doi = 10.1038/sj.ebd.6400578 |
[[File:Groundwater-fluoride-world.svg|thumb|300px|alt=World map with several land areas highlighted, especially in China, India, east Africa, southwest U.S., and Argentina.|Geographical areas associated with [[groundwater]] having over 1.5 mg/L of naturally occurring fluoride, which is above recommended levels.<ref name=NHMRC/>]]
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Fluoridation costs an estimated ${{inflation|US|0.72|1999|r=2}} per person-year on the average (range: ${{inflation|US|0.17|1999|r=2}}–${{inflation|US|7.62|1999|r=2}}; all costs in this paragraph are for the U.S.<ref name=FRWG/> and are in {{Inflation-year|US}} dollars, inflation-adjusted from earlier estimates{{Inflation/fn|US}}). Larger water systems have lower per capita cost, and the cost is also affected by the number of fluoride injection points in the water system, the type of feeder and monitoring equipment, the fluoride chemical and its transportation and storage, and water plant personnel expertise.<ref name=FRWG/> In affluent countries the cost of salt fluoridation is also negligible; developing countries may find it prohibitively expensive to import the fluoride additive.<ref name=Marthaler>{{cite journal | vauthors = Marthaler TM, Petersen PE | title = Salt fluoridation--an alternative in automatic prevention of dental caries | journal = International Dental Journal | volume = 55 | issue = 6 | pages = 351–8 | date = December 2005 | pmid = 16379137 | doi = 10.1111/j.1875-595x.2005.tb00045.x | url =https://www.who.int/oral_health/publications/orh_IDJ_salt_fluoration.pdf }}</ref> By comparison, fluoride toothpaste costs an estimated ${{inflation|US|6|1999}}–${{inflation|US|12|1999}} per person-year, with the incremental cost being zero for people who already brush their teeth for other reasons; and dental cleaning and application of [[fluoride varnish]] or gel costs an estimated ${{inflation|US|66|1999}} per person-year. Assuming the worst case, with the lowest estimated effectiveness and highest estimated operating costs for small cities, fluoridation costs an estimated ${{inflation|US|11|1999}}–${{inflation|US|17|1999}} per saved tooth-decay surface, which is lower than the estimated ${{inflation|US|65|1999}} to restore the surface<ref name=FRWG/> and the estimated ${{inflation|US|100.62|1995}} average [[Present value|discounted]] lifetime cost of the decayed surface, which includes the cost to maintain the restored tooth surface.<ref name=Griffin-econ>{{cite journal | vauthors = Griffin SO, Jones K, Tomar SL | title = An economic evaluation of community water fluoridation | journal = Journal of Public Health Dentistry | volume = 61 | issue = 2 | pages = 78–86 | year = 2001 | pmid = 11474918 | doi = 10.1111/j.1752-7325.2001.tb03370.x | url = http://cdc.gov/fluoridation/pdf/griffin.pdf }}</ref> It is not known how much is spent in industrial countries to treat dental fluorosis, which is mostly due to fluoride from swallowed toothpaste.<ref name=Sheiham/>
Although a 1989 workshop on [[cost-effectiveness]] of cavity prevention concluded that water fluoridation is one of the few public health measures that save more money than they cost, little high-quality research has been done on the cost-effectiveness and solid data are scarce.<ref name=FRWG>{{cite journal | title = Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention | journal = MMWR. Recommendations and Reports | volume = 50 | issue = RR-14 | pages = 1–42 | date = August 2001 | pmid = 11521913 | url = http://cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm}}
U.S. data from 1974 to 1992 indicate that when water fluoridation is introduced into a community, there are significant decreases in the number of employees per dental firm and the number of dental firms. The data suggest that some dentists respond to the [[demand shock]] by moving to non-fluoridated areas and by retraining as [[Dentistry#Specialties|specialists]].<ref>{{cite journal |author=Ho K, Neidell M |year=2009 |title=Equilibrium effects of public goods: the impact of community water fluoridation on dentists |publisher=National Bureau of Economic Research |url=http://www.columbia.edu/~mn2191/w15056.pdf |journal=NBER Working Paper No. 15056 |access-date=13 October 2009 |url-status=dead|archive-url=https://web.archive.org/web/20121023074617/http://www.columbia.edu/~mn2191/w15056.pdf |archive-date=23 October 2012 }}</ref>
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