Policy Alternatives to Water Fluoridation

This essay appears in the book Tobacco and Fluoride, available in paperback and Kindle.

Policy Alternatives to Water Fluoridation

I. Introduction
II. Who Decides to Fluoridate a City’s Water?
III. The Chemicals Used in Fluoridation
IV. What does it Cost to Fluoridate?
V. What are the Dental Health Benefits of Fluoride?
VI. What are the Health Risks of Ingesting Fluoride?
VII. Policy Options for Citizens
VIII. Conclusion
References

Introduction

In recent interviews, former Minnesota governor Jesse Ventura has advocated an end to adding fluoride to municipal water supplies. He has claimed the Nazis used fluoride in drinking water to pacify people (Isquith, 2014). Ventura has claimed that fluoride is an ingredient in Prozac, and the USA has been effectively dosing its citizens with mood-altering chemicals. Is there any truth to Ventura’s confrontational statements about fluoridation? Jay Lehr, author of The Fluoride Wars, told interviewers from a Florida newspaper, “The World War II death camp statement is an absurd lie” (Bowers, 2011).  But, one can easily look up the chemical composition of Prozac and verify it contains fluorine atoms.

For every refuted claim about fluoridation, a new one seems to appear. Paul Connett, PhD, executive director of the Fluoride Action Network, published fifty reasons to oppose in fluoridation in 2004. He continues to present his arguments to municipalities like Dallas, TX, where the January, 2015 renewal of a fluoridation contract recently reopened the fluoride debate (Activists, 2014). Connett’s reasons range from the cumulative effects of fluoride as a poison, to questioning some studies which link fluoride to decreased rates of tooth decay (Connett, 2004, p. 70-74).

In this atmosphere of conflicting claims and seemingly contradictory information, fluoridation remains a contentious public health policy in the twenty-first century. Both peer-reviewed research and celebrity claims ride a rising tide of public inquiry into the long-accepted practice of fluoridation. The first controlled municipal water fluoridation trial began in 1945 in the USA (Lennon, 2006, p. 759). But 70 years later, citizens continue to argue its merits in city councils and on public ballots across the country. This paper will look at some of those cities.

This paper will also establish, in plain language, facts agreed upon by both sides of the debate, and propose alternative policy measures which simultaneously meet the needs of fluoride supporters and objectors alike. It will give examples of current fluoridation policies in well-known cities, review the claims about health risks and benefits, and provide a clear explanation of what fluoridation really means in chemical terms.

The political realities of changing a fluoride policy require not just cooperation between city councils and their constituents, but between two groups with apparently conflicting public health concerns: one concerned about tooth decay, and one concerned about drinking a toxic chemical. That both of these groups seek to advance the cause of public health provides an opportunity for them to collaborate and bring mutually agreeable, politically feasible policies to a public referendum.

Who Decides to Fluoridate a City’s Water?

If citizens feel concerned the government is fluoridating their water, they first need clarity about which government is involved. The federal government does have a role in setting limits of fluoride in water systems, but the decision to fluoridate comes from municipal governments in most states, and from the state government in a minority of states.

The Federal Government’s Role.

The federal government does not set fluoridation policy, though federal agencies offer recommendations, and the Environmental Protection Agency (EPA) mandates an upper limit to fluoride content. In April, 2015, the US Department of Health & Human Services (HHS) issued a new recommendation for the optimum level of fluoridation, now set at 0.7 milligrams per liter of water. This represents the lower limit of their previous range of 0.7–1.2 mg/L, a range unchanged since HHS issued it in 1962 (HHS, 2015).

This new recommendation is not a mandate to states and municipalities. However, in cities like Boulder, CO, a resulting review of current policy is already underway, including obtaining non-binding recommendations from state governmental agencies like the Colorado Department of Public Health and Environment (Linenfelser, 2015). Boulder’s Water Quality Manager explained the review will include an evaluation of whether or not adjusting the fluoridation process to the new target level would still meet the intent of the existing policy.

For some cities, the new federal recommendation has given administrators an opportunity to review policy, but their fluoridation levels are already close to the target. For example, a 1993 census of fluoride levels in Arizona showed Phoenix targeting an optimum level of 0.7 mg/L (HHS, 1993, p. 47). The city’s annual water analysis for 2014 shows a minimum fluoride level of 0.5 mg/L and a maximum level of 0.8 mg/L, with average levels at 0.6 mg/L (City of Phoenix, 2014, p.2). This annual analysis by the Water Services Department tests levels at approximately twenty-two different sites (Espericueta, 2015). Phoenix is already very close to its historical target and the new HHS recommendation.

Federal mandate on fluoride comes from the Environmental Protection Agency. The EPA sets a legal cap on the amount of fluoride in public water systems, a cap called the Maximum Contaminant Level (MCL). This cap is public knowledge and appears on the EPA’s website about fluoride in drinking water as 4 mg/L. The EPA also sets a secondary level at 2 mg/L, a level intended to prevent a well-documented discoloration in children’s teeth which results from excessive fluoride. This secondary level is not mandated, but the EPA does require public water systems to notify them when average levels exceed this threshold (EPA, 2011). Note: The measurements of milligrams per liter convert directly to a “parts per million” figure. 4 mg/L equals 4 ppm (EPA, 2015).

Decisions at the Municipal Level.

Aside from the federally mandated Maximum Contaminant Level, the decision to fluoridate remains a city or county decision in most states. A minority of states mandate fluoridation for the entire state, and the laws vary somewhat in establishing the minimum size of communities covered by the mandate, and also in their requirements for a public referendum to approve fluoridation (Juneau, 2006, p. 98-101). Therefore, in most US cities, control of fluoridation rests in the hands of voters at the municipal level, and in fewer cases at the state level.

However, it is not always as simple as taking a vote. In Boulder, CO, for example, voters in 2006 had an opportunity to reconsider the fluoridation policy begun in 1969. A ballot initiative gained enough signatures to put fluoride to a public vote. A majority of voters decided to continue fluoridating Boulder’s water, though the city’s Water Quality Manager reports the measure was only “barely defeated” (Linenfelser, 2015).

A public referendum does not always happen. In 2012, a sub-committee of the city council in Phoenix, AZ addressed concerns about fluoridation. The question of fluoridation was not a ballot initiative in this case, but a matter brought before the city council due to one citizen’s concerns about her hypothyroidism (Forsythe, 2012). A council sub-committee heard testimony from chemistry professors, dentists, and public health administrators, but no vote was held. The council sub-committee members agreed to continue the fluoridation policy without taking a vote and without bringing the matter before the full city council for review (Gardiner, 2012). The matter of fluoridation was settled by only a sub-committee of a city council.

Local politics clearly play a role in these decisions. Furthermore, a city council does not always agree with the public when fluoridation is put on the ballot. For example, the city council of Portland, OR voted in 2012 to begin fluoridation, only to have voters refuse fluoridation on the May, 2012 ballot (Innes, 2014).

In some cases, local implementation faces not political challenges but practical ones. In Tucson, AZ, local dentists persuaded their mayor and city council to begin fluoridation in 1992, without resorting to a ballot initiative. But more than two decades later, the fluoridation has not begun. The “first attempt to deliver the water was disastrous, and Tucson Water scrapped a single-point facility, which was part of the original fluoridation plan” (Innes, 2014). A plan to begin fluoridation includes constructing the facility and obtaining equipment to do the job, and this requires planning and budget considerations as well as architectural ones.

Therefore, the decision to fluoridate municipal water systems falls partly to municipal governments, including their administrators, and partly to voters, with voters having recourse to ballot initiatives if they disagree with city council. Regardless of mandate, the logistical and infrastructure realities of a community can determine whether or not the city can truly take action. One would also expect this to hold true even in the minority of states mandating fluoridation from the state level.

The Chemicals Used in Fluoridation

Questions over the toxicity of fluoride must address the specific chemicals used to add it to water systems. The EPA’s Maximum Contaminant Level concerns fluoride specifically. But fluoride, a negatively charged ion of the element fluorine, is never added directly to public water systems in the fluoridation process. To fluoridate water, cities choose to use one of three chemicals: sodium fluoride, hydrofluorosilicic acid, and sodium fluorosilicate. (Sodium fluorosilicate, Na2SiF6, is also known as sodium silicofluoride or disodium hexafluorosilicate. Hydrofluorosilicic acid, H2SiF6, is also called fluorosilicic acid, or HFS, or FSA in the literature.) Each of these three chemicals has a Material Data Safety Sheet, a document well-known to American workers as required for all hazardous substances in workplaces, per the Occupational Safety & Health Administration (OSHA).

Sodium Fluoride.

Sodium fluoride is the active ingredient in over-the-counter fluoride mouthwash. The ingredients label on a bottle of ACT Anticavity Fluoride Rinse, for example, shows an active ingredient of 0.05% sodium fluoride (ACT, 2015). Per the instructions on the bottle, anticavity mouth rinses are meant to be held in the mouth for a minute and spit out, never swallowed.

Is sodium fluoride toxic? The Material Data Safety Sheet says yes. The MSDS for sodium fluoride warns of irritant and corrosive effects to eyes and skin, that it “may be toxic to kidneys, lungs, the nervous system, heart, gastrointestinal tract, cardiovascular system, bones, teeth”, that “repeated or prolonged exposure” can cause organ damage, and that “severe over-exposure can result in death” (ScienceLab, 2015). The MSDS continues with warnings to not ingest it or breathe its dust in solid form, and specifically says to “prevent entry into sewers.” The chemical is slightly explosive in the presence of heat.

Sodium Fluorosilicate.

The MSDS for sodium fluorosilicate (sodium silicofluoride) reads similarly to that of sodium fluoride. It notes the irritant and corrosive effects to eyes and skin, warns against breathing the dust, and mentions repeated exposure may cause the chemical to accumulate in the organs, leading to a “general deterioration” in health. The MSDS includes a warning to “prevent entry into sewers,” as well as a warning to “never add water to this product” (ScienceLab, 2015).  These warnings seem almost intentionally ironic, considering the chemicals are purchased to be added to the water supply system.

Hydrofluorosilicic Acid.

Hydrofluorosilicic acid is a byproduct of phosphate production, specifically phosphate-based fertilizer production. The anti-fluoride website FluorideAlert.org claims the acid is a hazardous waste mostly retrieved from fertilizer production in Florida (Fluoride Action Network, 2015). Finding facts to prove this statement turns out to be surprisingly easy.

For example, the city of Boulder, CO, uses hydrofluorosilicic acid in its fluoridation program (Boulder, 2015). In a phone interview, Boulder’s Water Quality Manager pulled a recent invoice from the supplier for this chemical. The acid comes from a chemical company in Florida called Mosaic (Linenfelser, 2015). Mosaic’s web page about hydrofluorosilicic acid confirms it is:

produced during the concentration of phosphoric acid in an evaporation process unique to the phosphate industry. The vapor stream from the phosphoric acid reaction is scrubbed with water to form [hydrofluorosilicic acid] from the naturally occurring silica and fluorine in the phosphoric acid.” (Mosaic, 2015).

The Mosaic chemical company includes Mosaic CropNutrition, a fertilizer company. The link between hazardous waste from fertilizer manufacturers and the chemicals used in fluoridation is not a hoax, a scare tactic, or a conspiracy theory. It is an easily verifiable fact. When this fact was brought up in a phone interview with the Chief Water Quality Inspector of the City of Phoenix, he simply agreed (Espericueta, 2015). While the general public may find this connection between fertilizer, hazardous waste, and fluoridation startling or even sinister, public administrators involved in fluoridation are well aware of it and make no attempt to deny it. Safe or not, fluoridation is not a cover-up.

The Material Data Safety Sheet provided on Mosaic’s page confirms hydrofluorosilicic acid’s toxicity. Like the other two chemicals, it is “corrosive to the skin, eyes, and mucous membranes through direct contact, inhalation, or ingestion.” The MSDS warns “overexposure may lead to coma or death.” It says “prolonged or repeated exposure to fluoride compounds may cause fluorosis,” a condition characterized not only by discolored tooth enamel but by hardening or softening of bones, joint pain, and limited range of motion (Mosaic, 2015). And like the other two chemicals, users are explicitly warned to “prevent discharge into waterways and sewers.”

Therefore, claims that water fluoridation puts hazardous waste into public water are partially correct. Sodium fluoride would not be considered a waste product, but its toxicity and hazardous nature are plainly stated on the Material Data Safety Sheet. Hydrofluorosilicic acid is indeed a reclaimed waste from the fertilizer industry, with a clearly documented toxicity and hazardous nature. Sodium fluorosilicate is produced by taking that hydrofluorosilicic acid and neutralizing it with sodium carbonate to produce a solid matter, making it merely one more step removed from its origin as hazardous waste (BFS, 2015).

To summarize so far, the EPA has determined any fluoride concentration above 4 mg/L to be unsafe for consumption and illegal. To reach the historical target range of 0.7–1.2 mg/L recommended for dental health by the HHS, cities must add fluoride-containing chemicals, not pure fluoride. These chemicals are known to be toxic and hazardous, and described as such on their OSHA-mandated Material Safety Data Sheets. The decision to add these chemicals is made on the local and municipal level in most states, and occasionally at the state level. Voters have recourse to public ballot initiatives whether they want to begin or end the addition of these chemicals to their water systems.

What Does It Cost to Fluoridate?

Setting aside the one-time costs of installing a new fluoridation system, the ongoing costs depend on several things. A city’s population and water usage determine the volume of its water system, which determines the amount of chemicals needed to reach the target level of fluoridation. The natural level of fluoride in local water also affects how much chemical needs to go in the water to reach the HHS target level. The city pays both the cost of the chemicals and the cost of infrastructure (maintenance, labor, testing) to administer them. Public policy debates over fluoridation compare these costs to the reduction in individual costs to treat tooth decay and the related health problems it causes. Federal sources claim the cost of fluoridation on a per-citizen or per-household basis is offset by preventing far greater costs for care.

Example Fluoridation Costs for Three Cities.

The city of Boulder, CO shows on its public fluoridation web page an annual cost of $60,000 to buy hydrofluorosilicic acid (Boulder, 2015). Boulder calculates this cost at approximately 85 cents per household annually. A decision to use a different chemical would affect the cost:

There are other options and methods that vary in cost due to pureness of grade, availability, and form (powder or liquid). The preliminary cost estimates to purchase the additive for these options vary from about $25,800 annually to over $1.3 million annually. Some options would require additional capital costs to enable city equipment to use the new product and for employees to safely handle the additive (Boulder, 2015).

Costs for Dallas, TX are somewhat greater. The Dallas City Council recently reviewed a three-year, $1,060,800 contract for fluoridation expiring in January, 2015 (Mercola, 2014). The Dallas Morning News reported in January the city council voted to continue the contract, with two council members opposed. The beneficiary of this contract is Mosaic CropNutrition (Wilonsky, 2015). Mosaic CropNutrition is a company of Mosaic, Boulder’s supplier of hydrofluorosilicic acid, and it is a fertilizer company (Mosaic CropNutrition, 2015).

As of 2012, Phoenix, AZ, spends $420,000 per year for its fluoridation chemicals, part of the total annual cost of $582,000 to fluoridate the water system (City of Phoenix, 2012). Phoenix uses hydrofluorosilicic acid, like Boulder and Dallas, but has a contract with Thatcher Company for the product (Espericueta, 2015). Thatcher Group is a chemical manufacturer and distributor in Utah with a public website at Tchem.com. Thatcher is a supplier of fertilizer products, listed on their site, including the phosphoric acid from which hydrofluorosilicic acid comes (Thatcher, 2015.)

Indirect Cost Reduction to Citizens.

The justification of these costs is the simultaneous reduction in health care costs for a city’s citizens. A pamphlet made publicly available through a joint effort between the American Dental Association and the Centers for Disease Control claims “for most cities, every $1 invested in community water fluoridation saves $38 in dental treatment costs” and suggests that fluoridation means lower taxes and lower health insurance premiums for the general public (CDC, 2006). The CDC bases these figures, adjusted for current dollar value, on a 2001 economic analysis of fluoridation published in the Journal of Public Health Dentistry (CDC, 2015). This analysis determined “the annual per-person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities” (Griffin, 2001). The CDC explains:

The analysis takes into account the costs of installing and maintaining necessary equipment and operating water plants, the expected effectiveness of fluoridation, estimates of expected cavities in non-fluoridated communities, treatment of cavities, and time lost visiting the dentist for treatment. (CDC, 2015).

What Are the Dental Health Benefits of Fluoride?

The consistent ingestion of fluoride has no benefits to the human body in any of the literature either for or against fluoridation, excepting cases where doctors administered high doses as a temporary treatment for specific ailments. Some sources warn of the health risks of ingesting fluoride and others claim ingestion at current municipal levels is safe. But no one touts any benefits of repeatedly ingesting fluoride.

The benefits of fluoride come from its lingering presence on teeth. Its contact with the tooth enamel provides the benefits. No dentist will argue this point. It is why mouthwash says to swish it and hold it on your teeth, spit it out, and avoid eating or drinking anything for a time. The benefits of fluoride derive from its presence on your teeth, not from digesting it in your body. Medical literature is clear on this point, and any family dentist can confirm it.

Fluoride Versus the Real Cause of Tooth Decay.

Tooth decay does not occur simply due to a lack of fluoride in drinking water. Tooth decay happens when sugar interacts with bacteria in the mouth. As the World Health Organization states in the WHO Guidelines for Drinking-Water Quality:

The etiology of dental caries [tooth decay] involves the interplay on the tooth surface between certain oral bacteria and simple sugars (e.g. sucrose) derived from the diet. In the absence of those sugars in foods and drinks, dental caries will not be a public health problem. However where sugar consumption is high or is increasing, dental caries will be or will become a major public health problem unless there is appropriate intervention.  (Lennon, 2004, p.1)

Fluoridation, therefore, is a measure designed to compensate for two things: one, a diet high in added sugar and, two, a level of personal dental hygiene inadequate to compensate for the lingering presence of sugar on one’s teeth. As the WHO report makes clear, a low-sugar diet would contribute to a reduction in tooth decay. A dental hygiene regimen focused on removing those sugars before bonding with oral bacteria would also reduce tooth decay.

Many dentists speak out in favor of fluoridation because, especially in demographics with low incomes, dental hygiene is not maintained by parents and therefore not by their children. As Tucson dentist and advocate of fluoridation Dr. Philip Mooberry told the Arizona Daily Star, “The kids in my practice are decay-free, most of them. Who this affects is kids who don’t get in to see the dentist” (Innes, 2014). This would be predominantly children from low-income families. Dentists hope the lack of adequate dental hygiene and regular care will be compensated for by keeping a low level of fluoride in the mouth due to drinking a city’s tap water.

Dental Health Benefits of Topical Fluoride Use.

The American Academy of Pedodontics published research by a team of dentists in 1982. The study examined reductions in tooth decay using different concentrations of sodium fluoride-based mouthrinse. “The study was conducted in eight Polk County, FL, high schools… where water fluoride level was less than 0.3 ppm,”  and it compared reduction rates between daily and weekly rinsing, too (Ringleberg, 1982, p. 305). Over a period of two years, students received a rinse in their classrooms, monitored by a teacher.

This simple classroom activity showed significantly reduced rates of tooth decay from both daily and weekly rinses, and from both 0.2% mouthrinse and 0.05% mouthrinse. (0.05% is the sodium fluoride concentration listed on over-the-counter product ACT Anticavity Fluoride Rinse.) The group with the greatest reduction used 0.05% mouthrinse daily. This easy, daily routine resulted in a difference of 46.2% fewer signs of tooth decay after two years. However, Dr. Ringleberg, the study’s leading author and an assistant public health director at the time, noted similar studies in the literature showed “no significant differences between the effect of daily and weekly rinses.” He concluded the differences between frequencies of use were “not sufficient to recommend daily rather than weekly doses.” Dr. Ringleberg points out this fact for schools and administrators considering a school-based fluoride rinse program, noting “the cost-effectiveness of a weekly rinse is better.”  In other words, even a single weekly fluoride rinse creates a marked reduction in tooth decay.

What Are the Health Risks of Ingesting Fluoride?

Fluoride and Prozac.

Fluoride is a negatively charged ion of the element fluorine. Fluorine is found on our planet in mineral forms where it combines in molecules with other elements, such as the bond between one calcium and two fluorine atoms in fluorite (CaF2). Fluorine is “never found in a free state in nature, but always in combination with other elements as fluoride compounds” (BFS, 2015). Bonded sets of fluorine atoms do appear in chemicals, such as the group of three fluorine atoms making up part of the fluoxetine molecule (C17H18F3NO). Fluoxetine hydrochloride is better known by its brand name, Prozac, and other branded and generic forms of the chemical sold as a drug. This explains the chemical truth behind claims about fluoride’s role as an ingredient in Prozac.

Claims that the chemicals in fluoridation systems have the same mood-altering and serotonin reuptake-inhibiting effects as the chemicals in Prozac, however, have no supporting research. It would be a mistake to assume a single element determines the properties of all the different molecules where it can be found. For example, pure sodium reacts with water by exploding quite powerfully. A potentially fatal force could result from just a handful of pure sodium thrown into water. But when bonded to chlorine, sodium makes a table salt which dissolves peacefully in water. This example should make it clear that fluorine’s well-documented presence in Prozac does mean one can assume every substance with fluorine will act like Prozac.

Fluoride and the Thyroid.

Although the World Health Organization believes fluoridation is a beneficial public health policy, they do not deny its dangers. Their report on fluoride in drinking water says the “adverse effects… range from mild dental fluorosis [a discoloration of the tooth enamel] to crippling skeletal fluorosis… a significant cause of morbidity in a number of regions around the world” (WHO, 2006). Skeletal fluorosis manifests as increased bone fractures, joint pain, and impaired mobility. Even those who claim fluoridation is safe cannot deny certain levels of exposure to fluoride through ingestion are not safe for humans.

When a citizen concerned about the effect of fluoride on her thyroid brought the matter to city council in Phoenix, she was not alone in this concern. Fluorine’s ability to damage the parathyroid glands and lead to hyperparathyroidism is known from examining patients with skeletal fluorosis. As far back as 1973, a British Medical Journal article found five patients of twenty with skeletal fluorosis also had “clear evidence of secondary hyperparathyroidism” (Teotia, 1973, p. 637).

On the other hand, symptoms of hyperthyroidism “were completely relieved by administration of fluorine in 6 of 15 patients; tachycardia was stopped and tremor disappeared with four to eight weeks and loss of weight was stopped” in a 1958 Swiss study which administered, orally and by injection, very large doses of fluoride, as high as 20mg in a single dose (Galetti, 1958).  The researchers believed the results stemmed from fluoride’s ability to inhibit the “thyroid iodide-concentrating mechanism” and this inhibitory effect on the thyroid took place when iodide levels in the blood were low, but not when iodide was plentiful in blood.

Either way, both sides of the fluoride debate can agree that fluoride can affect the thyroid and parathyroid glands. A high dose administered by a medical professional in a clinical setting may effectively treat specific symptoms, but uncontrolled doses can be clearly dangerous. The World Health Organization does not include thyroid concerns in its 2006 publication Fluoride in Drinking Water, though it does believe the studies it reviewed show no cause for concern about fluoride in relation to cancer (p. 34), and no cause for concern about damage to reproductive organs (p. 31) or DNA mutation (p. 31).

Dosage.

The World Health organization, like the US Department of Health & Human Services, believes their recommended fluoridation levels make ingestion of fluoride safe and, in fact, beneficial due to a reduction in tooth decay. The exposures to levels of fluoride which cause significant harm are greater than the levels recommended for municipalities. The message is clear. Fluoride in large amounts or over long periods of time can be harmful to human health, though citizens may drink it at low concentrations.

Most reports of fluoride damage to the body take place at levels far above the EPA’s Maximum Contaminant Level. But to put the EPA’s figure of 4 mg/L into perspective, the same MCL applies to bleach. The EPA sets an enforceable level for chlorine, the disinfectant ingredient in bleach, at the same level as fluoride: 4mg/L (EPA, 2015). In other words, the recommended levels of fluoride in city water are just as safe to drink as bleach diluted to the same level. This does not necessarily mean that either chemical is “safe.”

Policy Options for Citizens

Citizens concerned about fluoridation should seek change through public referendum. In areas of state-mandated fluoridation, this may be a greater task than in areas where individual municipalities choose their own fluoridation policy. Fluoridation has far too much popular support currently, not to mention federal support from the CDC and international support from the WHO, to expect a federal initiative to have any political feasibility.

However, the question of whether or not to fluoridate always arrives at city council or on the ballot as an either/or proposition. Either we add the chemicals, or we do not. The concerns of dentists and parent groups are never met with an alternative solution. As Boulder’s recent example demonstrates, many voters want to maintain the dental health benefits of fluoridation. A simple repeal of their fluoridation policy offers no new policy in its place. Without an alternative that pleases dentists and parents, the effort to repeal fluoridation with a public referendum can prove wasted effort.

Therefore, the anti-fluoridation movement faces a considerable hurdle which often goes unnoticed amidst the arguments over whether or not fluoride is “safe,” or if its benefits are “real.” These questions politicize and polarize the discussion. An alternative policy which removed the risks of ingesting fluoride while making its topical benefits widely available, especially to low-income families and citizens, would instead unify the discussion. With this in mind, what policy options could citizens offer as alternatives?

Elements of a Comprehensive Alternative.

Dr. Ringelberg’s study of daily and weekly fluoride rinses in classrooms provides a model for a policy which could replace fluoridation. A school-based program would reach children without adequate dental care at home, the group which most concerns dentists who advocate fluoridation. A policy targeting only schools in low-income areas would still reach the children of greatest concern and reduce the overall cost of the policy. City funds currently spent on purchasing hazardous chemicals from out-of-state suppliers could be redirected towards a school-based fluoride rinse program. Cities making decisions to begin fluoridation would have even more funding for a program, as they would not bear the costs of constructing and staffing new facilities or purchasing equipment. For a city like Tucson, where infrastructure challenges prevent a fluoridation citizens requested, an alternative program could meet their needs.

Such a program would provide benefits no fluoridation policy offers. The daily or weekly routine of rinsing makes dental hygiene part of children’s lives. It builds long-term habits. It raises their awareness that their teeth may be something worth taking extra care of. The programs offer an opportunity to educate about dental hygiene and its importance, through presentations or literature. Informational literature distributed to children and parents as part of the program would raise community awareness. Fluoridating water provides dental benefits but zero education. Fluoridation does not change behavior or move our culture any closer towards healthy dental hygiene habits. Education will.

Purchasing and distributing fluoride mouthwash to schools may appear less cost-effective than buying hydrofluorosilicic acid by the gallon. But, a comprehensive public health program involves communities. A school-based rinse program provides an opportunity for retailers to subsidize its costs. A branded mouthwash company might welcome the opportunity to provide its product to schools at a reduced cost or even no cost as an advertising and marketing opportunity. Manufacturers of fluoride toothpastes, tooth brushes, and dental floss would welcome an opportunity to sponsor a daily or weekly dental hygiene program in schools, especially if they could distribute branded promotional items as part of the program. Providing the tools for dental care from program sponsors would especially benefit low-income families and families in crisis.

One city’s perfect solution may not be the ideal policy for another city. In a city with few or no low-income residents, an awareness and education campaign may be all that is needed to make fluoridation unnecessary. Where people have the means and the education to adopt a topical fluoride program personally, distribution of fluoride rinses at schools could be an unnecessary expense. Therefore, citizen groups seeking to craft alternative policy should consider the basic elements of a comprehensive strategy, but tailor them to fit the needs of each unique community.

Such a comprehensive policy would involve the most threatened citizens with their communities and schools, open a public dialogue, and provide opportunities for everyone to contribute to positive change. Fluoridation is far from comprehensive, as it is a benefit received passively and without any awareness or behavior change. If anything, fluoridation encourages poor dental hygiene habits by treating citizens as too simple-minded to take care of themselves. School-based rinse programs would bring the same benefits as fluoridation while working to bring about a culture of dental hygiene where further fluoridation would be unnecessary.

No single tactic can comprehensively solve a public health problem like tooth decay, not when the causes are many and the solution which works in one case may not work in another. As other public health programs demonstrate, such as the recent tobacco control and packaging laws in Australia, citizens need information and support at multiple places and multiple times to effect large-scale changes in behavior. As researchers from the International Tobacco Control Project concluded in regards to the effectiveness of campaigns to reduce tobacco smoking in Australia, the policies are effective because they are part of a comprehensive set of policies aimed at multiple media channels and including warnings both at the point of sale and on packaging (Li, 2012, p. 430). Comprehensiveness matters.

Options for Those Who Cannot Stop Fluoridation.

In communities where the majority favors fluoridation, policy should make some allowance for those who object. It seems contrary to fundamental American ideals such as liberty and self-determination to force people to accept a known hazardous chemical in their water, regardless of what benefits it may have. An option to buy bottled, purified water is open to anyone who can afford the cost, but it does nothing to address the use of fluoridated water for bathing, hygiene, or cooking, nor the needs of those low-income families who may find the cost a burden.

Fortunately, one state has already come up with a politically feasible and fair policy. According to a 2000 review of fluoridation laws in all 50 states, Georgia “specifies that any person deemed allergic to fluoridated water who finds it necessary, upon advice of a physician or approval of the Department of Human Resources, to buy a defluoridation device may count it as a tax deductible item” (qtd. in Juneau, 2006, p. 98). This policy still places the initial cost of opting out of fluoridation on the individual objector, but it offers a corresponding reduction in tax liability. A tax deduction could easily be extended to any resident who objects to fluoride and wants to install a filtration system to remove it. While Georgia’s measure is laudable, it should go farther in offering the deduction to anyone and remove the administrative hurdles of proving an allergy or seeking approval. An objection to drinking toxic chemicals should be sufficient.

A truly egalitarian policy of this nature would include an additional allowance for those who only claim the standard deduction on their income taxes. After all, a tax credit is only good to someone who itemizes their deductions, and the people who do not itemize tend to be lower income people. To avoid placing an undue burden on low-income citizens for opting out of community-mandated fluoride, the tax credit could be made available to all taxpayers regardless of itemizing their deductions or not, much like the Earned Income Credit and other tax credits any tax filer may calculate individually on their return.

Conclusion

Anti-fluoridation efforts have failed for two main reasons. First, the number of unsupported claims and wild accusations harm the efforts by exchanging controversy for hard facts. Citizens with legitimate concerns about consuming a hazardous waste product find themselves associated with “tin foil hats” and “conspiracy theories.” Second, when the seriousness of their claims becomes a matter of discourse in city councils and public ballots, no alternative policy is provided for concerned dentists and parents.

To succeed in removing the toxic chemicals of the fluoridation process from water supplies, anti-fluoride activists need to find a way to provide the topical benefits of fluoride to communities. A school-based program of supervised daily or even weekly fluoride rinses would bring the benefits of fluoride to communities, and it would provide a touch point for other comprehensive measures for education and awareness. If sugar and dental hygiene are the real culprits behind tooth decay, a comprehensive policy would address them directly, rather than indirectly through addition of hazardous chemicals to the water supply.

References

ACT. (2015). ACT Anticavity drug facts. Retrieved from http://www.actoralcare.com/products/act-anticavity/

Activists for Truth and Liberty. (June 16, 2014). Dr. Paul Connett, PhD speaks to Dallas City Council on June 11, 2014. Video retrieved from https://youtu.be/xguPD85-BH4

Bowers, Becky. (October 6, 2011). Truth about fluoride doesn’t include Nazi myth. Politifact Florida (Tampa Bay Times, Miami Herald). Retrieved from http://www.politifact.com/florida/statements/2011/oct/06/critics-water-fluoridation/truth-about-fluoride-doesnt-include-nazi-myth/

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One thought on “Policy Alternatives to Water Fluoridation

  1. 1. “Connett’s reasons range from the cumulative effects of fluoride as a poison, to questioning some studies which link fluoride to decreased rates of tooth decay (Connett, 2004, p. 70-74).” In Paul Connett’s list of 50 reasons, the first one is that fluoride is the only chemical added to water for the purpose of medical treatment, the second is that fluoridation is unethical because it violates the principle of informed consent, and the third is that the dose cannot be controlled.
    2. “The EPA sets a legal cap on the amount of fluoride in public water systems, a cap called the Maximum Contaminant Level (MCL). This cap is public knowledge and appears on the EPA’s website about fluoride in drinking water as 4 mg/L. The EPA also sets a secondary level at 2 mg/L, a level intended to prevent a well-documented discoloration in children’s teeth which results from excessive fluoride.” The 12-member committee which produced the 2006 US National Research Council report Fluoride in Drinking Water: A Scientific Review of EPA’s Standards unanimously recommended that the maximum contaminant level goal (MCLG) for fluoride in drinking water be reduced from its level of 4 mg/L because it does not protect against adverse health effects. The EPA has still not acted on that recommendation. Clearly, if 4 mg/L does not protect against adverse health effects, the MCL should also be reduced. The SMCL does not prevent discolouration in children’s teeth, i.e. dental fluorosis, which is a toxic effect. According to the latest official figures, 41% of American 12 to 15-year-olds had dental fluorosis. Dentists make money from cosmetically treating dental fluorosis.
    3. “The city council of Portland, OR voted in 2012 to begin fluoridation, only to have voters refuse fluoridation on the May, 2012 ballot (Innes, 2014)”. The public vote in Portland was in May 2013, and the result was 61% to 39% against forced-fluoridation.
    4. “Therefore, the decision to fluoridate municipal water systems falls partly to municipal governments, including their administrators, and partly to voters, with voters having recourse to ballot initiatives if they disagree with city council.” Voters have recourse to ballot initiatives only in some countries which force-fluoridate, and in the US only in some States, not all States.
    5. “Safe or not, fluoridation is not a cover-up.” Fluoridation is a cover-up. There is not a single credible study which indicates that taking fluoridated water is anything but harmful and useless. Poor quality studies are used to fool people who are scientifically illiterate and/or not willing to take the time to actually read the studies. Fluoride was a major industrial air pollutant prior to the start of forced-fluoridation in 1945, and industry faced the prospect of being held legally liable for its fluoride pollution. The rebranding of fluoride as essentially harmless tooth medicine was a major public relations coup. The Fluoride Deception by Christopher Bryson is essential reading for anyone who wants to understand the history.
    6. “To reach the historical target range of 0.7–1.2 mg/L recommended for dental health by the HHS, cities must add fluoride-containing chemicals, not pure fluoride. These chemicals are known to be toxic and hazardous, and described as such on their OSHA-mandated Material Safety Data Sheets.” This could easily be misinterpreted as meaning that pure fluoride (if there were such a thing) would be relatively harmless, but in reality fluoride itself is highly toxic, and the toxicity of hydrofluorosilicic acid, sodium fluorosilicate, and sodium fluoride come predominantly from the fluoride itself.
    7. “The CDC bases these figures, adjusted for current dollar value, on a 2001 economic analysis of fluoridation published in the Journal of Public Health Dentistry (CDC, 2015).” The claim for cost-effectiveness has been thoroughly debunked. See: Ko L, Thiessen KM. 2015. A critique of recent economic evaluations of community water fluoridation. International Journal of Occupational and Environmental Health, Volume 21, Issue 2.
    8. “The group with the greatest reduction used 0.05% mouthrinse daily. This easy, daily routine resulted in a difference of 46.2% fewer signs of tooth decay after two years.” The figure of 46.2% is selective, and doesn’t take into account missing teeth. Fluoride is linked to tooth loss.
    9. “The World Health organization, like the US Department of Health & Human Services, believes their recommended fluoridation levels make ingestion of fluoride safe and, in fact, beneficial due to a reduction in tooth decay.” The World Health Organization does what it is told to do by the member states of the United Nations, of which the most influential is the United States of America.
    10. “Dr. Ringelberg’s study of daily and weekly fluoride rinses in classrooms provides a model for a policy which could replace fluoridation. A school-based program would reach children without adequate dental care at home, the group which most concerns dentists who advocate fluoridation. A policy targeting only schools in low-income areas would still reach the children of greatest concern and reduce the overall cost of the policy.” This single study only lasted two years, did nothing to assess potential adverse health effects, did not take into account ethnicity, and did not produce dramatic results. A stronger evidence base is required before promoting a medical treatment for large numbers of schoolchildren. Banning the advertising of sugary food to children, having supervised toothbrushing in schools (without fluoridated toothpaste), and funding good quality studies would be a much more sensible starting point.

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