Americans are abandoning tap water as their primary source of drinking water, and safety isn’t the issue. Thanks to tough Environmental Protection Agency, or EPA, regulations, water from the tap rarely poses a disease threat. The same cannot be said for its taste, color and odor, all of which can make the drinking experience less than enjoyable. It’s no wonder that so many now seek filtered or non-public sources of water for their daily requirements.

Consider that in 1992, just over 2 billion gallons of bottled-water products were sold—about nine gallons per capita. Beverage industry statistics for 1999 show that U.S. per capita consumption skyrocketed to almost 16 gallons.

With sales doubling over the previous year, the bottled-water industry now claims 8.1 percent of all beverages sold. These percentages don’t include individuals and families who have chosen to filter their home tap water. According to a marketing report, the top seller of home water filters sold more than 4 million in the first six months of 1999.

For regular purchasers of bottled water, a recently published report indicates that they may not be getting the extra benefits they desire.¹ In laboratory tests, 57 samples of five categories of bottled water were analyzed for coliform organisms. Bacterial counts in the bottled water samples ranged from less than 0.01 to 4,900 colony-forming units per milliliter. In contrast, tap water demonstrated counts ranging from just 0.2 to 2.7 CFU/mL.

However, it’s not coliform levels that make bottled water an issue for dentistry. Rather, it’s determining the fluoride content of these alternative water supplies. Suboptimal levels might be detrimental—especially for high-risk children and adults whose oral health depends on receiving adequate amounts of fluoride.

Seems that determination would be a no-brainer—just read the fluoride level on the label of the bottled water container. Wrong! Only a few manufacturers’ labels contain this information. Indeed, one study noted that of 78 different bottled waters examined, not one had fluoride concentrations on the label.²

Where is the EPA? Nowhere. Since water is classified as a food, it’s the U.S. Food and Drug Administration, or FDA, that has oversight responsibility for bottled water. If fluoride is added during processing, the FDA requires the fluoride content of bottled water to be listed on the label. But that regulation doesn’t apply to bottled water that already contains fluoride. In this circumstance, both consumer and dentist must rely on optional labeling or must contact the bottling company for fluoride information.

The ADA doesn’t like that situation and has been lobbying the FDA to require fluoride-concentration information on all bottled-water labels. Its argument is cogent. If the EPA requires community water suppliers to provide their customers with yearly drinking-water quality reports, why shouldn’t the FDA require similar information for bottled water?

Producers of bottled water cite cost and monitoring difficulties as the two major reasons for not labeling their products. They claim that fluoride levels of the same product can vary according to the source of the water, seasonal variations, different fluoride testing methods and inconsistencies in fluoride concentration tests even within the same batch.

The industrial concerns appear to have been heeded by the FDA, which, under the direction of Congress, recently completed its final study on the "appropriate" and "feasible" methods of informing consumers about the contents of bottled water.

Two suggestions were made. The first called on bottled-water manufacturers to offer a phone number or address on the label directing consumers to where they can receive information from the company. The second offered a combination approach in which some information is placed on the label "provided that [it] does not result in excessive information," with the remainder of the information available through contact with the company by phone or mail.

Will these "suggestions" ensure that consumers will get ready access to information regarding whether their bottled drinking water contains fluoride and, if so, how much?

I think not. Searching for a phone number (which, according to the FDA, need not be toll-free) is hardly user-friendly. Most consumers wouldn’t bother.

While Congress could ask for more explicit labeling or the FDA could consider making further rules, it appears that a more definitive labeling of the fluoride content in bottled water will not be coming in the near future.

The ADA can be expected to continue its lobbying efforts but will face an uphill battle unless it can show that the use of bottled water with reduced fluoride content is associated with increased caries in children or adults.

With only anecdotal reports linking increased caries to the ingestion of bottled water, this type of research would require costly investigations of large population groups. However, dentists know that fluoride, especially in a topical role, is critical to the remineralization process that can retard or stop caries. Good sense says that removing a well-documented preventive agent like fluoride cannot be beneficial.

Dentists interested in ensuring that their patients are not harmed by drinking bottled water or filtered home drinking water should include questions in their patients’ health history questionnaire pertaining to their water-drinking habits. Daily amount ingested, origin of water for cooking and other sources of liquid consumed during the day also require documentation.

For people at high risk of developing caries who are unable or do not wish to discontinue use of waters containing a suboptimal amount of fluoride, supplementary fluoride office procedures or use of home fluoride products should be considered.

In addition to continuing its lobbying activities with the FDA, the ADA also should consider alerting bottled-water manufacturers that labeling the fluoride content of their products actually may give them a sales advantage. Many parents purchasing bottled water still want their children to have caries protection.

Eventually, I envision packagers of bottled water asking to be included in the ADA Seal of Acceptance program. Why not an ADA Seal for bottled waters that contain the optimal amount of fluoride? Safe and effective? History says yes!