Water fluoridation prevents tooth decay by providing consistent contact with low levels of fluoride, reducing the risk of tooth decay by about 25% in children and adults, according to the Centers for Disease Control and Prevention. Although nearly all water contains some fluoride, the amount is not enough to help prevent tooth decay or cavities. Community water fluoridation adds a small amount of fluoride to public water supplies to a level shown to make teeth stronger and prevent cavities. Community water fluoridation began in the United States in 1945, when Grand Rapids, Michigan, first fluoridated its water. Today, almost 75% of Americans nationwide are served by fluoridated public water systems, according to the American Dental Association. The CDC named community water fluoridation as one of 10 great public health achievements of the 20th century, alongside vaccination and control of infectious diseases. Yet only 13 states—including Louisiana—have statutes or regulations requiring community water systems to fluoridate drinking water to a specific concentration or range. In other areas, community fluoridation typically is initiated by local authorities, such as city councils. Despite its statewide requirement, Louisiana lags far behind most of the United States. About 220,000 Louisiana residents are served by community water systems that have naturally occurring, optimally fluoridated water; another 1.8 million are served by community water systems that fluoridate their water. With a population of 4.65 million, though, the majority of Louisiana residents do not have fluoridated water, ranking the state 45th in the percentage of people served by a community water system who received fluoridated water, according to the CDC. Richard, who serves on the state’s Fluoridation Advisory Board, says community water fluoridation provides benefits, regardless of socioeconomic status, and contributes to a cost-savings for the state. “We spend all this money to treat dental disease, but we do little on prevention,” he says. “Yet dental disease in children is more prevalent than childhood asthma.” Schoolchildren living in fluoridated communities on average have 2.25 fewer decayed teeth compared with children who do not live in a fluoridated community, according to the CDC. A 1996 a study conducted in Louisiana found that Medicaid-eligible children living in communities without fluoridation were three times more likely to end up in the hospital for dental treatment than Medicaid-eligible children who lived in fluoridated communities. “It’s not a hard sell from a public health standpoint. It increases the cost of health care if you don’t do it,” adds Guidry, who is a practicing pediatrician. Part of the challenge, Richard adds, is that the benefits of water fluoridation are not instantly apparent. “It takes three to five years to see results of community fluoridation, as kids drink fluoridated water and then get their adult teeth,” he says. “It’s a long-term process.” “Clinically, we can see the difference—it’s anecdotal, but we see a higher incidence of cavities when there is no community fluoridation,” says Richard, whose 30-year career has been in communities with and without water fluoridation. “The biggest obstacle, though, is getting the funding.”
Yet even if funding was not an obstacle, statewide community fluoridation is not a sure thing. In recent years, communities throughout the U.S. have voted against community fluoridation. The 2008 act allows communities to opt out of fluoridation if at least 15% of registered voters sign a petition forcing a local election, which then results in a “no” vote. Those opposed to fluoridating are active in Louisiana and other states, with efforts focused largely on education. Carol Kopf, media director for the Fluoride Action Network, says that while “other nations follow the science, which shows ingesting fluoride is ineffective, harmful and unnecessary, in the U.S., fluoridation has become a political issue.” With the Internet, people have better access to information about fluoridation, which has led to more people questioning the need for and safety of it, she says. Controversy over safety, ethics and cost has surrounded community water fluoridation from the beginning. Opponents view fluoridation initiatives as a form of community-wide medication. They point out that most developed countries do not fluoridate, with additional countries having ended the practice. Conflicting research also exists about the extent to which fluoridation prevents tooth decay. “Studies show that when fluoridation ends, tooth decay rates either stay the same or go down,” Kopf says. “Fluoride is neither a nutrient nor essential for healthy teeth. Consuming a fluoride-free diet does not lead to tooth decay. Sugar is the only cause of tooth decay.” Possible alternatives, Kopf notes, include taxing soda, restricting advertisements to children, and educating parents that bad diet can lead to rotten teeth and chronic health conditions, such as obesity and diabetes. Better access to dental care is also needed, she says. “The real crisis is the growth of untreated tooth decay because most dentists refuse to treat Medicaid patients,” Kopf says. “The American Dental Association lobbied to have dental care not included in Medicare, so 130 million Americans don’t have dental insurance. As a result, they are flocking to hospital emergency rooms when the pain is too intense to bear, costing taxpayers 10 times the cost of a simple filling.” Those supporting fluoridation agree that other factors are essential for good oral health. “Fluoridation is not going to make people bulletproof,” Richard says. “Diet plays a role, as does good hygiene.” With greater availability of fluoride products, such as toothpaste, mouth rinses and supplements, some have raised concern that people—particularly children—are exposed to toxic amounts of fluoride. Earlier this year, the U.S. Department of Health and Human Services reduced the recommended amount of fluoride for the first time since 1962, to 0.7 milligrams of fluoride per liter of water instead of the range of 0.7 to 1.2 milligrams, in part because of an increase in fluorosis. The condition consists of white or yellow spotting on teeth caused by overexposure to fluoride during enamel formation, typically in the first eight years of life.