The Centers of Disease Control and Prevention (CDC) has named water fluoridation one of the 10 great public health achievements of the 20th century. As of 2012, 74.6% of the US population on public water systems was receiving fluoride. Also, studies have shown that fluoridated water can reduce tooth decay by 25% beyond brushing and other oral care.

Yet grassroots organizations are pushing against this system. Online and in person, they lobby for fluoride’s removal from public water. They also claim to have research proving that fluoridation is dangerous to public health. With the support of the Delta Dental Foundation of California, the American Fluoridation Society (AFS) is fighting back.

“There is a national group of us that works to counter misinformation spread by antifluoridationists,” said Johnny Johnson Jr, DMD, MS, president of the AFS. “Our group got together and said enough is enough.”

Battle Lines Are Drawn

Like many battles today, this one began in cyberspace. During the past few years, whenever an article about fluoridation appeared on the Internet, antifluoridationists would dominate its comments section with statements about fluoride’s dangers and expenses, Johnson said. The AFS then responded with research from prominent and respected journals.

“About 4 years ago, those comments sections were owned by the antifluoridationists,” Johnson said. “So we began to post science-based facts debunking what they were saying, and within 2 to 3 years, we owned 70% of the comments sections. We began to beat back the movement.”

The struggle spilled over into politics when the commissioners of Pinella County in Florida voted 4 to 3 to eliminate fluoride from their public water supply. When Johnson asked the commissioners why they voted that way, one told him that he had heard the Environmental Protection Agency had classified fluoride as a neurotoxin.

“I said anything could be a neurotoxin. Drinking too much water could throw your electrolytes off,” Johnson said. “Your nervous system shuts down and your heart shuts down. And he said he didn’t know that. And I said, now that you do, would you reverse your vote? And he said no. He didn’t want to flip-flop.”

Throughout the following year, Johnson met with the commissioners who voted against fluoridation to change their minds, but to no avail. The political atmosphere, he said, favored small government. With the help of a series of Pulitzer Prize-winning editorials in the Tampa Bay Times, though, those commissioners were voted out of office. It’s a struggle repeated in municipal and county governments nationwide, too.

The Economics

“It’s a common political issue that decides water fluoridation. It’s decided at the local level,” said Johnson. “And very few communities stop it because of money, because it’s such a huge savings.”

These savings vary based on the size of the community. But for most cities, reports the CDC, one dollar invested in fluoridation saves $38 in dental treatment costs per person per year. Another study in Texas reported savings of $24 per child per year in Medicaid expenditures, showing how these benefits especially help low-income patients.

“Water fluoridation cuts out a huge burden of decay, and the indigent population faces a disproportionate load of that burden,” said Johnson. “Eighty percent of all cavities happen to about 20% of the population, so we’re talking about a major impact on those who don’t see the dentist.”

Patients who don’t have access to a dentist often go to hospital emergency rooms to treat their pain, adding more costs to the medical infrastructure. A 2010 survey of hospitals in the state of Washington reported that dental disorders were the leading reason why uninsured patients visited emergency rooms.

“In my county in 2013, ER visits strictly for dental pain cost almost $14 million dollars. And all they got was antibiotics and pain pills. That’s it. No treatment,” said Johnson. “That’s over $2,000 per person to walk into the emergency room. That’s a huge issue nationally where people are trying to figure out ways to divert that pain into dental treatment.”

The Science & Legality

When the AFS enters a local debate on fluoridation, though, it doesn’t just rely on the economic argument. Its members have examined common antifluoridation talking points and are prepared to refute them. For example, many antifluoridationists focus on how fluoride can lead to fluorosis, or the brown staining and pitting of teeth.

“We have pockets in this country where 200,000 people live at levels of fluoride above 4 parts per million because it’s in the groundwater naturally,” said Johnson. “Pitted teeth can happen at 4 parts per million, but it disappears at 2 parts per million, and we’re fluoridating at a third of that, 0.7 parts per million.”

Poor aesthetics aren’t the only claim for alarm that antifluoridationists state, Johnson said. Many of them also claim that fluoridation can lead to lower IQs, based on their interpretations of a meta-analysis by Harvard University researchers examining a series of other studies conducted in China about 20 years ago.

“Those studies were very poorly done. They would never be looked at as scientifically sound because they used low numbers of people. They did not account for confounding factors such as mercury or arsenic in the water,” Johnson said. “And when all factors are considered, when you actually look at it versus the control group, there is no change in IQ.”

Antifluoridationists also have said that fluoride leads to higher rates of ADHD; it makes teeth more prone to crumbling under high friction loads; it causes fluorine intoxication; it can lead to bone fracture; and it can interfere with the thyroid. The AFS rejects all of these assertions, with cited evidence, based on the consensus of the medical community.

“The CDC, the American Academy of Pediatrics, the American Medical Association, the ADA, the Mayo Clinic, the Institute of Medicine, the World Health Organization, and dozens and dozens of other credible scientific groups back and endorse water fluoridation,” said Johnson. “Not a single one of them opposes it. At all.”

Additionally, many antifluoridationists attempt to make their case on philosophical grounds. They say that governments lack the right to mass-medicate their populations, leaving residents without any choice in what they drink. Instead, they say, citizens should rely on their own oral hygiene habits to combat tooth decay.

“They have challenged it in the courts, and they have never been successful in getting fluoride to be considered illegal, unconstitutional, or an infringement of our rights,” Johnson said. “The courts have ruled that it is not a medication. It is a mineral that is naturally existing, and it is being adjusted to what Mother Nature has shown us that works.”

Boots on the Ground

Dentists and other citizens who find themselves facing any of these antifluoride arguments can turn to the AFS for assistance. Its website provides answers to frequently asked questions, news, and research including links to studies that support fluoridation. It also features responses to commonly circulated antifluoride statements.

When that isn’t enough, members of the AFS will volunteer to travel to local municipalities to advocate for fluoridation. Delta Dental supports their efforts by covering the volunteers’ transportation and boarding costs. Often, AFS members are called in when antifluoridationists have brought experts of their own into town.

“This Delta Dental grant allows us to now travel to a community and be an expert on the ground because that’s what the antifluoridationists will do. They will have their so-called expert come into the area and spread their misinformation to the community as well as in front of testimony to the commission,” Johnson said. “And we have been able to beat them back.”

AFS volunteers can provide expert testimony during municipal meetings. They also can train local advocates to promote and defend fluoridation in their communities and in surrounding communities. And while the AFS notes the consensus among dental organizations supporting fluoridation, it formed as an independent group.

“We have autonomy to be able to say what we want to say,” Johnson said. “And if there’s a politician against it, and that politician needs to be educated, we help the locals do that. We also help them establish whether a candidate for office is going to be in favor of fluoride and if that flows through their entire decision-making process.”

Looking ahead, the group aims to organize scientific meetings to promote oral health through fluoridation while working to safeguard or extend fluoridation plans at the local, state, and national levels. It also will continue to produce scientifically sound and reader-friendly publications on fluoridation.

“Our group supplies literature that is absolutely based in science so advocates can use it, but we have compiled it in such a way that it’s short and sweet,” Johnson said. “The more you get into the technical details, the more you lose people. You lose their concentration. You lose their ability to listen.”

And, the AFS responds to requests for information from around the world and maintains links with its international colleagues such as those in the British Fluoridation Society. While the Internet has given antifluoridationists a larger platform to broadcast their views, it also has enabled collaboration among fluoridation’s supporters.

“We are now interconnected with the entire world and working with other groups in other countries. This is an international effort,” said Johnson. “There are groups around the world that have been fighting this battle for years, but now we are collaborating and helping each other.

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