It’s either one of the greatest public health achievements of the last century or a prime example of government intrusion into a private decision.
It depends on whom you ask.
Adding fluoride to public water began in some places more than 50 years ago, but the debate over whether it should be done continues today.
Studies conducted in the last 50 years have shown that children who live in areas with fluoridated water have significantly fewer dental cavities than those who don’t. And experts at the U.S. Centers for Disease Control and Prevention say that fluoride in the amount that is added to most water systems is safe. No verifiable link between fluoridated water and any illness has ever been established, according to the CDC.
But some people don’t want their local governments to make health-care decisions for them. People who need fluoride would be better off getting prescriptions from their dentists, they say, so that others won’t have to ingest the chemical at a dose that hasn’t been prescribed for them. In addition, some fluoridation opponents say that excessive fluoride from public water can be harmful, leading to tooth discoloration, hip fractures and bone cancer. Others cite costs.
Who gets it?
In Pennsylvania, 53 percent of residents who receive public water get fluoride when they turn on the tap, said Dr. Neil Gardner, a dentist with the Pennsylvania Department of Public Health.
In northern Allegheny County, most residents receive fluoridated water. West View Water Authority, which pumps or sells water to 27 municipalities in the northern suburbs, began fluoridating nearly 25 years ago. Several communities, however, have never added fluoride to their water, usually because residents opposed it.
Revisiting the issue can stir endless debate.
That’s happening in Shaler, where the public water has never been fluoridated. About 15 years ago, Shaler officials voted not to add fluoride to the water, but this year Commissioner William Cross asked the township to reconsider the issue to find out whether public sentiment had changed. Cross also asked that a position paper be drafted after a decision is made.
Township Manager Tim Rogers has been receiving comments from residents and will continue to collect input through the summer. In the fall, the commissioners plan to vote on whether to fluoridate, taking residents’ feedback into consideration.
Rogers said he’s received dozens of e-mails from residents about the issue, with most saying they’d prefer not to have fluoride in their water. He said most of the support for fluoridation has come from dentists, and most of the opposition from an organized group that opposes the practice.
Residents of Harmar also receive unfluoridated water, and they recently voted by a narrow margin to keep it that way. Tom Lukasik, manager of the Harmar water authority, said residents were surveyed about fluoridation in August 2000 and the results were almost evenly split, with slightly more people opposed. The water authority board subsequently voted not to fluoridate.
Several northern suburbs pump water to customers but buy the water from authorities in other places.
Hampton buys water from Shaler and West View, which means that some Hampton residents get fluoride in their water and some don’t.
“People don’t necessarily know,” said Carol Richards, who works for the Hampton water authority. She said customers sometimes call to find out whether their water is fluoridated so they will know if they need fluoride supplements from their dentist.
Communities that have fluoridated their water for a long time periodically get calls from people opposed to fluoridation, but most of the opposition usually surfaces when a water authority initially decides to add the chemical to the water supply.
That was the case with West View Water Authority, which has been fluoridating since 1978 but had to go to court to do so.
“When we initially started to fluoridate, there was a considerable amount of opposition,” said Joseph Dinkel, plant manager for the authority. “It was basically one group, an anti-fluoride conglomeration. There’s been none since then.”
Those opposed to fluoridation sued the water authority, and Allegheny County Common Pleas Judge John Flaherty ordered the authority not to fluoridate. The case went to the Pennsylvania Supreme Court, which eventually ruled in favor of the authority.
Pittsburgh began fluoridating its water in the early 1950s, said Stanley States, water quality manager for the Pittsburgh Water and Sewer Authority. Like most communities with long histories of fluoridating, not many people oppose the practice.
“There are always a few people that call,” States said. “I’ve been here 25 years and there’s never been a major move not to fluoridate.” He said opposition to fluoridation is usually based on a philosophical objection to being subjected to an enforced medication.
That’s one reason Kevin Cridge, water plant foreman for Shaler, believes adding fluoride to water is a bad idea.
“Our job is putting out safe water. We’re not in the business of medicating people,” he said. “We shouldn’t be doing anything that actually doesn’t treat or purify the water.”
Like most water treatment plants, Shaler’s plant adds chemicals to help remove iron and manganese from the water, and it cleanses the water with chlorine, as required by the federal Environmental Protection Agency.
Cridge said parents who want their children to receive daily fluoride doses can get prescriptions from their dentists.
“I just can’t see putting something in the water for a condition that is noncontagious and nonlife-threatening,” he said. “Would people be in favor of putting a weight-loss drug in the water?”
Fluoridated water prevents 40 percent to 60 percent of dental decay, according to Gardner.
Dr. Michael Melnick, a Pittsburgh dentist, put it this way:
“If you compare the average population of dental patients who had fluoride in drinking water with those who didn’t, it’s like one grew up in the U.S. and one in the Third World.”
Fluoride is helpful to children from the fifth month of pregnancy to age 14, when, if ingested, it can bond with the enamel in teeth to make them more resistant to decay, said Dr. John Schrenker, a dentist who has offices in Shaler and Monroeville.
Fluoride that is applied to the outside of teeth, as with toothpaste, is also helpful in preventing cavities by repairing teeth that have started to decay and preventing further decay, said Dr. Robert Selwitz, a dentist and researcher at the National Institute of Dental and Craniofacial Research.
Dentists agree that taking fluoride daily in the form of tablets or drops provides the same benefit as drinking fluoridated water, but an advantage of having fluoride in the water is that it can help youngsters who don’t have access to good dental care.
Dentists are quick to note that fluoridated water alone won’t prevent all cavities.
“Fluoride is just one piece of the dentistry puzzle,” Melnick said.
Dental hygiene, regular visits to the dentist and in-office fluoride treatments also are important. Diet, hygiene and heredity also play a role, but even siblings who have the same water source and similar eating habits may have different rates of decay.
“A lot of factors go into who is susceptible to decay. It is a disease process, mediated by bacteria,” Schrenker said.
While Schrenker agrees that fluoride is beneficial and safe, he also said he understands why people may not want it in their water.
“I can argue the case both ways,” he said. “I can understand people who say they don’t benefit and don’t want it in the municipal water supply.
“As a dentist, I think it’s a great public health measure.”
“A parent should certainly have the right to give their child a drug or not give them a drug,” he said. But, he added, the benefits of fluoride are evident.
How much is enough?
Opponents of fluoridation have claimed for years that fluoride can cause bone cancer, hip fractures and other serious ailments and they cite studies that support these claims.
Schrenker, however, said none of the bone cancer studies have stood up to peer review or have been duplicated by other researchers.
Organizations ranging from the CDC to the World Health Organization to the American Dental Association say that optimally fluoridated water poses no serious health risks.
Dr. Robert Weyant, chairman of the department of dental public health at the University of Pittsburgh, said very large doses of fluoride can make people more susceptible to hip fractures, but that occurs only at levels eight to 10 times greater that those present in most drinking water. Such doses used to be prescribed to people with osteoporosis.
“It’s rare to see people with those types of exposure,” he said. “You just never see that in normally fluoridated water.”
One condition that is related to fluoride ingestion is fluorosis, in which teeth become discolored.
Selwitz said the incidence of dental fluorosis is greater in areas where the public water is fluoridated.
“Most are still in the mildest forms,” he said. Severe fluorosis is characterized by brown spots and pits on the teeth. In milder cases, opaque white spots appear on the teeth.
“The issue is total fluoride intake,” Selwitz said.
In addition to getting fluoride from water, children may get fluoride from beverages or packaged foods that are made with fluoridated water. Swallowing fluoridated toothpaste also can contribute to fluorosis, which usually appears in children by age 6.
Cridge pointed out that a typical daily dose of prescription fluoride is about 1 milligram — the amount ingested by drinking four glasses of fluoridated water.
“If water is fluoridated, how do you regulate your dose?” he asked.
Ellie Rudolph of Oakmont, who describes herself as a safe-water advocate and who was one of the fluoridation opponents in the West View Water Authority case, concurred.
“Everyone from a child to a man with kidney problems all get the same dose,” she said. “It’s like taking a sledge hammer to short swat a fly.”
Weyant said the level of fluoride in public water is calculated according to the amount of water the average person drinks.
“Even if they drank a whole lot more, they would still be safe,” Weyant said.
A CDC report in August called the low prevalence of fluorosis “a reasonable and minor consequence” balanced against the benefits of fluoridated water.
“The good far outweighs the bad,” Weyant said. Dental cavities can cause chronic pain and infection in young children and may interfere with a child’s ability to maintain healthy body weight.
“Certainly it’s bad for a kid to be in chronic pain,” he said. “No one can demonstrate that [fluoride is] any less than a health benefit. The alarmist approach is not founded and it’s not productive.”
Fluoridation opponents also argue that fluoride is a dangerous chemical that comes from industrial waste.
Thomas Reeves, national fluoridation engineer for the CDC, acknowledged that almost all the fluoride used in municipal water supplies is a byproduct of phosphate fertilizers.
“We don’t have any problem with it,” he said. “A lot of useful things are byproducts of other things.”
Cridge said the fluoride produced this way contains traces of lead and arsenic.
Reeves acknowledged that the fluoride can contain traces of arsenic, zinc or chromium, but not lead. He said the concentrations of arsenic, for example, are not dangerous and are well below EPA requirements.
“There are trace amounts of arsenic, but we don’t believe it’s a problem,” he said.
Right now the EPA requires that water contain an arsenic content of no more than 50 parts per billion. Arsenic that is distributed with fluoride would constitute about 0.4 parts per billion, Reeves said. He compared that to about one drop per bathtub of water.
By reducing tooth decay, fluoridation not only provides a health benefit but also a financial one in terms of reducing the cost of dental treatments, health organizations say.
According to the CDC, it costs on average 50 cents per person per year to fluoridate a water supply. In smaller communities, however, where fluoridation is most expensive, it costs up to $5.40 per person per year.
Cost is what concerns Lukasik in Harmar. “I personally don’t like it from the standpoint of cost,” he said, adding that the additional expense would put a strain on Harmar water authority. In addition to annual cost of about $2,500 to buy fluoride, he said, adding fluoride requires special equipment to mix in the chemical and safety equipment for the people who handle it.
Gardner said that on average, the cost of fluoridated water for a person’s lifetime is roughly $65, about the cost of one filling.
Every dollar spent to fluoridate water saves about $38 worth of dental treatments for decay, he said.
“This is one of the few public health measures that actually saves money,” he said.