Fluorides and the changing prevalence of dental caries

[Drsumitra]

The issue of water fluoridation has flared up again in communities across the U.S. In October, an article in the New York Times contended that budget constraints and skepticism over fluoride’s effectiveness were responsible for some 200 communities abandoning the practice. And MSNBC reported that tea party activists had hijacked a fluoridation debate in Pinellas County, FL, resulting in the end of fluoridated water for 700,000 people there.
More news from the fluoride front poured in on November 15, when the Santa Clara Valley Water District in California voted unanimously to fluoridate water to segments of San Jose, which will give access to more than 280,000 residents. The move was applauded by the Pew Children’s Dental Campaign, which had teamed with two other organizations, Voices for America’s Children and the American Academy of Pediatrics, to sound the alarm about "misinformation" being spread by antifluoridation activists through its new Campaign for Dental Health, also launched on November 15.

South of San Jose, the city of Watsonville’s efforts to fluoridate its water have been conflicted for nearly a decade. In 2002, residents voted by a small margin to eliminate fluoridation. But a subsequent court battle, which Watsonville lost, led to a city council vote last year to accept $1.6 million in funding from the California Dental Association (CDA) to build a fluoridation system. Per state law, a California city with a population greater than 10,000 must fluoridate its water if outside funding is provided.

“The voters didn’t feel fluoridation was necessary.”
— Steve Palmisano, city water division
manager, Watsonville, CA
"The decision on whether or not to fluoridate was purely political, based on the efforts of the city council," Steve Palmisano, the city’s water division manager told DrBicuspid.com. "Although it was 10 years ago, I think the primary objection was to putting additional substances in the water with potentially harmful side effects. The voters didn’t feel it was necessary."

They may ultimately get their wish. Watsonville’s fluoridation project stalled last month when all five construction bids arrived between $1.2 and $1.9 million above the CDA’s grant. The CDA is unlikely to get help from the city as it ponders its next move. Palmisano asserted that Watsonville won’t build the fluoridation devices unless they are paid for with outside funding, and that the city is unable to chip in anyway.

"The decision really is in the hands of the CDA," he said. "I had a conversation with them, asked for an indication if it will go through, and they didn’t give me any at all."

3 treatment plants, $10 million

Despite the November 15 vote endorsing fluoridation for the Santa Clara Valley Water District, Donald Gage, director of District 1 and 2011 chair, shared a similar view.

"We have three things in our charter: One, provide clean, safe drinking water. Two, flood control. And three, environmental issues," Gage told DrBicuspid.com. "[Fluoridation] is not something we’re supposed to do, and we don’t have the money anyway."

Because it is a wholesaler, the Santa Clara Valley Water District is not beholden to the state’s fluoridation law. But the district intends to move forward with water fluoridation anyway — if the cost issues can be adequately addressed.

The equipment the Santa Clara Valley Water District needs to provide fluoridation at its three treatment plants will cost $10 million, Gage said. The district’s looming priorities, per its charter, start with what Gage estimates to be $500 million needed to seismically retrofit aging area dams. Replacing antiquated levies around the region’s delta may cost even more.

"What we’re doing is setting up a general policy that will enable the people who want water fluoridation to move forward with it," Gage said. "There’s some wording in there that needs to be changed because it doesn’t allow public/private partnership." The details, he explained, will be addressed later.

Now the Health Trust, a Silicon Valley nonprofit promoting wellness, and the California Department of Public Health are working to identify potential funding sources for the equipment installation. Gage believes that the communities that will receive fluoridated water, such as San Jose and Sunnyvale, should foot the bill for operations and maintenance once the infrastructure is in place, at a cost of about $1 per person annually. That is where his opinion about fluoridation ends.

"If the majority wants it, because we’re a democratic society, I’m willing to do it," he said. "But other than that, because I’m not scientist, I have to look to the federal and state government to tell me whether it’s safe or not."

Science and budget concerns

For one Florida county commissioner, contradictions between federal agencies regarding fluoridation led to his determination that it should be ended. Norm Roche, who has an extensive background in Pinellas County Water Department policy research, became a national lightening rod for his stance on fluoridation when he led a successful effort to cease fluoridating the water supply for roughly 700,000 Floridians this year. But he believes his position has been mischaracterized.

Roche told DrBicuspid.com that he has expressed concerns about fluoridation since 2003, when the council first voted in favor of it.

"My issue back then, as it is today, is with the actual chemical we use to fluoridate the water, fluorosilicic acid," he explained. "On the one hand, the U.S. Centers for Disease Control and Prevention talks of fluoridation as a great concept. But the U.S. Food and Drug Administration will not approve fluorosilicic acid for human consumption. So there are competing federal agencies there on the issue."

He is also concerned by a lack of consensus among physicians, dentists, and chemists about which particular type of chemical should be used and whether ingesting fluoridated water was better than a topical delivery via dentifrice.

"Expecting seven politicians to watch experts, doctors, accuse each other of faulty information and then look at us saying, ‘You make the call …’ — I don’t find that to be our role," he explained.

There were other complications with fluoridation as well. Pinellas switched to a regional water source about 10 years ago, and now receives a blended mix of desalinized water, ground water, and surface water from a local river.

"All of them have various degrees of naturally occurring fluoride, which made our plant operators almost daily have to tweak the fluorosilicic acid drip," he explained. "It became a complex issue — and guesswork."

While the cost of fluoridation was not a major consideration, Roche acknowledged that it played a role in the issue. "It was born, if you will, of the budget discussion," he said. "But the fiscal impact was the least of my concerns."

A philosophic disagreement

Scott Tomar, DDS, DrPH, a professor at the department of community dentistry and behavioral science at the University of Florida College of Dentistry, is worried that other communities will take a similar tack while governments look to trim budgets.

“It came down more to a philosophic disagreement than a financial one.”
— Scott Tomar, DDS, DrPH, University
of Florida College of Dentistry
"I think it certainly has emboldened opponents to fluoridation to seize on it," he told DrBicuspid.com. "What I’m seeing more of lately, and I think what happened in Pinellas County, it came down more to a philosophic disagreement than a financial one."

That is the sort of impression that has dogged the Pinellas County city commission’s decision. After the narrow 4-3 vote, national attention ensued — due primarily to the Associated Press describing the decision as a tea party victory for smaller government, according to Roche.

"I interviewed with the NY Times, "NBC Nightly News," Rachel Maddow, "The Daily Show" even, all based on the misinterpretation of the decision," he recalled. "And they all went, ‘This isn’t really the story we got on the AP wire.’ "

The perception of tea party politicians blocking fluoridation has been aided by the way other districts have handled fluoridation. Dr. Tomar referenced a recent example in High Springs, FL, where fluoridation landed on the city council’s agenda.

"In my testimony before the city council, I raised the point that of $8,000 that they might save, all they’re really going to do is transfer it onto the backs of their citizens," he recalled. "But they said, it was never about the money, it was more a discussion of whether city or county government should be providing preventive services."

Dr. Tomar cited other examples in which opposition to fluoridation centered on whether it is an essential service. While most are swayed by the notion that the savings end up coming out of the pockets of the community needing greater dental work, he said the role of government is an argument that’s been coming up a lot.

"The science is on our side, fully supported by every legitimate health and medical organization," he said. "But if there’s a political opposition to it that has nothing to do with the science, there isn’t much you can do to change that."

While Roche has asserted that he’s unconcerned with the political aspect of the issue, he sees inefficiency in the fluoridation process.

"If you want to reach 10,000 underprivileged people who aren’t getting adequate access to dental care, do you publicly fluoridate the water for 1 million just to get to them?" he asked. "Or do you focus your resources in order to get them the help that they need?"

Trust also appears to be a factor.

"One of the other issues arising here is, even though cities and counties have been fluoridating for quite a long time, Florida still gets an F for dental care for the indigent and underprivileged," Roche said, also noting that only 25% of dentists in the state will see Medicaid patients. "Is their position to keep fluoride in the water so that they won’t have to see them? I think that’s a valid part of the discussion."