Fluoride Fighters Versus the Anti-Cavity Crusaders

Remember the toothpaste commercial in which the child proclaims, “Look, Ma, no cavities!”? For many of us, that decades-old line sums up the way we thought about the benefits of fluoride.

Yet more than 50 years after communities across the United States began getting fluoride from the tap, at a time when most Americans take for granted that having it in their drinking glass--and their toothpaste--gives them better dental checkups, anti-fluoride sentiment persists.

California remains one of the few states where fluoride is still a contentious subject, thanks to a vocal minority who like to remind the public that fluoride is a waste byproduct of fertilizer production. They question why anyone would put it in their own body.

Of course, many of them have similar concerns about chlorine and opt for bottled water rather than the tap. In a nation where 40% of American adults drink bottled water, Californians are the largest bottled water consumers. They drank an average of 27.9 gallons per person in 1997, contrasted with 12.7 gallons per person nationwide, according to the Beverage Marketing Corp. in New York.

Although the state Legislature mandated fluoridation of water supplies in 1995 to combat cavities, lawmakers never supplied the funding to carry it out. As a result, 83% of Californians still don’t get fluoride through their drinking water.

That’s about to change.

Los Angeles ponied up money to fluoridate the water for 3.3 million city residents beginning next month in the San Fernando Valley, West Los Angeles, West Hollywood and parts of Hollywood. Two Los Angeles County communities, Long Beach and Beverly Hills, have been fluoridating for 20 years.

“All water supplied to Los Angeles has some fluoride in it, so it’s not like we’re adding something foreign to the water,” says Dr. Timothy Collins, dental director for the county Department of Health Services and co-chairman of the California Fluoridation Task Force. “We’re adjusting upward the naturally occurring level to a level that would prevent tooth decay.”

Currently, water coming to the city has levels ranging from 0.3 to 0.6 parts per million. The fluoridation will increase that to 0.8 ppm. At that level, it should be safe and within the optimal daily dose, he said.

*

Children Won’t Need to Take Supplements

Officials expect that fluoridation could produce 40% fewer cavities, particularly among children of poorer families, who traditionally have higher-than-average rates of dental decay. They plan to get the word to dentists, doctors, pediatricians and parents that once the water supply is fluoridated, they must stop giving fluoride supplements to their children or risk too high a dose.

Sacramento voted March 30 to accept $1.4 million in fluoridation funding from the California Endowment, a not-for-profit health care charity that has promised $10 million so far toward community fluoridation. City councils in Mountain View and Yuba City have voted to proceed with fluoridation. The city of San Diego, which voted about 20 years ago to ban it, is reconsidering.

But voters in the Northern California college town of Santa Cruz and others around San Diego, including the city of Escondido and the Helix Water District in east San Diego County, recently approved bans.

“The biggest issue for us is the opponents have managed to create a level of fear among people,” says Ken August, spokesman for the state Department of Health Services.

Fluoridation advocates acknowledge that vocal foes have grabbed footholds in some communities.

“In politics, it’s always easier to block something than it is to do something,” says Dr. Donald O. Lyman, a Department of Health Services official and co-chairman of the California Fluoridation Task Force. “It’s embarrassing that of all the states, we are No. 47 in terms of proportion of population covered by fluoride.”

Back in Cold War times, opponents branded fluoridation part of a conspiracy, an allegation that made its way in satiric form into director Stanley Kubrick’s film “Dr. Strangelove.”

Today, when 56% of Americans drink fluoridated tap water, opponents have more sophisticated arguments. It’s wrong, they say, to force everyone to ingest fluoride when there are drops and tablets for those who want it, and when soft drinks and juices are formulated with fluoridated water. They’re armed with human and animal studies linking fluoride to bone fractures, genetic and neurological damage and cancer.

“The first thing we’re concerned with is no one has a choice,” says Jeff Green, director of San Diego-based Citizens for Safe Drinking Water. “We’re all overexposed already . . . even in non-fluoridated communities.”

*

Fluoride Effective When Used Topically

Opponents also argue that fluoride only does good when applied topically: “Credible science shows that fluoride topically can kill bacteria and help reduce tooth decay. Ingested fluoride does not reduce tooth decay,” Green says.

Supporters agree topical action is most important, but say exposure during cooking and drinking gets fluoride into the saliva. Bathing the teeth this way protects young children’s enamel as well as the tooth roots exposed when gums recede in later years.

By reducing dental decay, fluoridated water confers more benefits at lower cost (just 50 cents per person) than almost any other public health initiative to date, supporters boast.

Neither side in the dispute contests the fact that more fluoridation has led to an increase in dental fluorosis, an abnormality in children’s tooth enamel. From the beginning, dentists and health officials expected that about 10% of children drinking fluoridated water would develop white spotting in their teeth from higher fluoride exposure. But that was thought to be an acceptable trade-off for reduced cavities. However, today, 22% of children who drink fluoridated water have permanent white spots on their teeth, studies show.

Opponents say fluorosis has been whitewashed by dentists who say it’s purely a cosmetic issue and contend teeth with mild fluorosis are more resilient to decay.

Dr. Stanley Heifetz, of the USC department of dental medicine and public health, maintains that mild fluorosis “has no effect on tooth function. If it was my child, I’d rather have this fluorosis” than cavities or other dental problems that can lead to root canals or dental surgery later on.

He says opponents are “focusing on the wrong sources.”

Swallowing toothpaste during brushing--something children under age 6 often do--is the principal problem. Recent product labeling advises putting only a pea-sized amount of toothpaste on the youngster’s brush. Secondary to that, some children are getting too much fluoride because their doctors are prescribing supplements without adjusting quantities to account for naturally occurring fluoride in the water.

Opponents of fluoridation try to bolster their case by pointing out that 98% of European countries don’t fluoridate.

*

Preventive Care More Costly Than Fluoridation

European countries have well-financed child dental care systems that pay for more preventive care “than anything in this country. It’s a very expensive route to go compared to fluoridation,” says Dr. Scott Presson, an oral health expert at the Centers for Disease Control and Prevention in Atlanta.

“I’m very excited for L.A.,” said Presson. “The vast majority of scientists and health organizations that have looked at this issue have concluded that it is safe, it is beneficial and that more communities should consider it.”

But the opponents aren’t giving up. Citizens for Safe Drinking Water challenges claims that fluoridated water is responsible for lower rates of cavities. It has been filing lawsuits, circulating petitions and organizing voter initiatives in communities nationwide to oppose fluoridation of water supplies. The coalition has been joined by the union representing 1,500 scientists, lawyers and engineers at the Environmental Protection Agency in Washington in opposing fluoridation for California.

USC’s Heifetz says the studies cited by such opponents are flawed. For example, he says those who link fluoridated water with increased risk of hip fracture in the elderly don’t factor in such variables as medical records, estrogen therapy, smoking, diet, alcohol and heredity.

Lyman of the Centers for Disease Control and Prevention scoffs at studies linking fluoride with an increased risk of cancer. Lyman said a statewide cancer registry shows no difference in cancer patterns between the East Bay area near San Francisco, which has been fluoridated the longest, and the rest of the state.

And as for opponents’ argument that the industrial grade fluoride used in water is merely a poison being pawned off for easy disposal, Heifetz says: “All substances are poisons. The right dose distinguishes a poison and a therapeutic effect.”