by Connie L. Sidder, RDH, BS
One doesn't have to travel far to find a community mired in a water fluoridation debate. Numerous cities voted to discontinue water fluoridation in 2001, including Flagstaff, Ariz., Worcester, Mass., Eureka Springs, Ark., Centerville, Utah, and Modesto, Calif., to name a few. Fluoridating water was once called "one of the greatest public health achievements of the century." Today's opposition claims fluoridation is our own government poisoning us. Some citizens believe dentists are to blame and are part of a conspiracy to defraud Medicare. One Web page calls fluoridation a "50-year-old blunder and cover-up," and cautions against "mercury fillings."
Dentists and hygienists have always supported water fluoridation. Many have worked in non-fluoridated communities or public health settings and seen the benefits of topical fluoride applications. If there is a water fluoride debate playing out in your community, the opposition will present the results of many studies as fact, yet many of these studies are flawed. Many factions of the population, including the health-conscious as well as the uninformed, are challenging members of the dental community. Fear of the unknown is a powerful tool.
There are four main arguments against continuing water fluoridation in the U.S.:
• There are no current studies on side effects, and the benefit studies are outdated.
• There is no FDA approval of the fluoride.
• It is forced mass medication.
• There are impure forms of fluoride being used.
Anyone interested in researching the topic will find numerous results on the Internet by typing "water fluoridation" in the search engine. Many of the sites haven't been updated in years. Yet in 2001 alone, many towns eliminated fluoride based on these studies.
What motivates people to oppose such an obviously harmless government act? My city councilman believes, "It is mass medication of an entire population without regard to individual dosage, the source of fluoride is controversial, and it poses a danger to water department workers."
Many argue that most of the European Union does not fluoridate water. This is true. Bottled water has long been the choice of Europeans. Complex water systems have made it difficult for fluoridation. Other modes of fluoridation are salt and milk. Salt fluoridation is used in many countries from Mexico to Bolivia. However, one's salt intake will vary greatly from person to person and not many babies are introduced to salt.
Another method is to add it to milk. This mode would seem to target children at least. Countries that partake of this form of fluoridation include the United Kingdom, China, Russia, Chile, Peru and Thailand. Dental decay is obviously a worldwide disease. There is no answer without some opposition.
The Irish way
Ireland is one European country that does add fluoride to water. The country went through a review process in 2002 and concluded to continue water fluoridation as a public health measure. They did rule, however, to lower the optimal level from 1.0 parts per million (ppm) to a target of 0.7 ppm. They decided that due to the availability of fluoride from other sources, this new level would be sufficient to fight decay while reducing the occurrence of dental fluorosis. (The Irish "Forum on Fluoridation 2002" is available online.)
One study cited as a reason to stop fluoridation in Ireland compared osteosarcoma rates in Northern Ireland, where there is no fluoride, to the rest of the country. The study was conducted for 1999 only, and there was one more case noted in the fluoridated area, which some claim is significant. No other factors were noted. Yet those opposing fluoridation claimed the study was proof that fluoride causes cancer.
Some studies attempt to link fluoride to ADHD and other attention deficit-related problems, yet they lump too much data together. California had a threefold increase in child mental health problems reported between 1987 and 1996, yet fluoride wasn't mandated for municipalities over 100,000 people until 1996. Data is still being collected on this issue.
Close to home in Colorado
Bringing the fight closer to home, my hometown of Fort Collins, Colo., has been debating the issue for two years. Ft. Collins is home to Colorado State University and has a population of about 125,000. Other large employers include Hewlett-Packard, LSI Logic, and Agilent.
Water fluoridation was initiated in the town in 1967 after voters approved adding sodium fluoride to the water. Fluoridation was the result of 13 years of hard work by a group of local dentists. The original ordinance was defeated in 1954, and the battle continued until 1966 when the city council passed an ordinance prohibiting fluoridation. It took citizen initiative to put it on the ballot the following year. In 1992, the fluoride was changed from sodium fluoride (NaFl) to hydrofluorosilicic acid (HFS). In April 2001, the Water Board voted to stop fluoridation rather than spend the $500,000 to upgrade equipment. (This amounts to $4 per person for one year only.)
Since this is a "hot" issue, the city council decided to convene a panel of experts to advise them. They also wanted public input. The experts, called the Technical Study Group (TSG), were comprised of representatives from the Water Board, Water Department, Health District, a dentist, chiropractor, toxicologist, epidemiologist, and environmentalist. The first meeting was in January 2002, and the public was allowed to address their concerns to the TSG. Approximately 50 people attended; some carried "no fluoride" signs; and others carried babies, hoping the fluoridation would continue.
The debate raised an interesting question: What is the role of public health organizations? The local medical director of the Health District said, "The goal of public health is to move from intervention to prevention." But doesn't that put children at risk for dental fluorosis?
Studies have been conducted linking fluoride to lead uptake, skeletal fluorosis, low IQ's and cancer. In order to understand these studies and advise, the TSG reviewed reams of literature. Their conclusions were stated in a 500-page document, and their recommendation was to continue water fluoridation.
The political emotions
However, I believe it comes down to politics. At present, the Health Board recommends continuing and the Water Board recommends discontinuing fluoridation. The city council is split four to three in favor of retaining fluoridation. The mayor is also in support. So after all the work, meetings, and public forums, it remains an emotional issue.
As for my city councilman, who believes fluoride is mass medication, I suggest that to arrive at 1 ppm, a lot of research goes into the dosage. The toxic level for an eight-year-old who weighs 45 pounds is 655mg. By comparison, an eight-ounce glass of fluoridated water contains 0.25mg of fluoride. A dab of toothpaste contains 0.24mg. One can conclude that it's very hard to achieve toxic levels. The Ft. Collins water quality is tested daily and has been shown to exceed safety standards. In 2001, the Water Department conducted nearly 51,000 tests for the presence of microorganisms, minerals, etc. Arsenic and lead have always been in trace amounts and never exceeded any EPA regulation.
As for the danger to employees, there is risk in most professions. Even dental hygienists are exposed to various diseases, but with proper precautions, the risk is minimal.
Chlorine, which is added to water to disinfect, has also come under scrutiny. It has been linked to colon, kidney, and bladder cancers. These risks purportedly increase over time. No doubt, the water issues are far from over. It is very hard to isolate the chemicals for study, and more research is needed.
Hopefully, common sense will prevail. Our city council voted to continue fluoridation and update the equipment. The opposition, though they claim to have only 600 followers, plans to continue the fight. They want to target future city council candidates to make it an issue. Those in favor of fluoride need to remain vocal. Many of my neighbors and friends have approached me to discuss the issue. They are familiar with my "Letters to the Editor" and feel I have helped diffuse the alarmist rhetoric they have read. Though fluoridation will still come down to politics, but citizens can have input.
Water fluoridation ranks as one the greatest achievements in public health policy. If your community is unsure of its position, it is time to motivate the dental community to speak up. The opposition is very vocal, and studies will be continued. So it is important for members of the dental community to stay up-to-date on the research.
Connie L. Sidder, RDH, BS, is based in Fort Collins, Colo. She can be reached by e-mail at [email protected].