Oral hygiene is not something taken lightly in Brenna Ordway’s household.
The 28-year-old Cornish resident has two young children, ages 6 and 4, in whom she has instilled a devotion to dental care that she calls “religious.”
“If I forget, they remind me they need to brush their teeth,” she said.
It was the way Ordway says she was raised. She never had a cavity until she was well into her 20s, she said. Both children go to the dentist.
And for added insurance, Ordway gives her children fluoride tablets every day. Fluoride is a mineral that occurs naturally in many water supplies, but not always to the level where it can help prevent tooth decay.
Supplements like the ones Ordway gives her kids would be an unnecessary precaution if she lived in a place where fluoride were added to the water.
But, like a majority of Upper Valley residents, Ordway does not live in such a place. She’s not on a public water system, drawing her tap water instead from an artesian well.
But even if she lived in nearby Claremont, which has a public water system, Ordway still wouldn’t be getting fluoridated water. Claremont is among the many Upper Valley communities that do not add it.
Water fluoridation has been taken for granted in many places throughout the nation since Grand Rapids, Mich., became the first city to add it to public drinking water in 1945. Nearly three-quarters of all Americans who are on public water systems receive fluoride, according to the Centers for Disease Control and Prevention. It is considered among the greatest public health achievements of the 20th century by the CDC, with such programs being touted as a safe and cost effective way to address tooth decay, the most chronic disease affecting children and adolescents over the age of 6.
But the story is different here in the Twin States. Only 57 percent of Vermont residents and 43 percent of New Hampshire residents on public water systems had access to fluoridated water in 2010, ranking the states 39th and 42nd, respectively, according to the latest CDC figures.
In the Upper Valley, just six municipalities — Hanover, Lebanon, Norwich, Randolph, Newbury, Vt., and Springfield, Vt. — add fluoride to the drinking water. The list included Bradford, Vt., until October, when the town’s Water and Sewer Commission voted to stop adding it to the water.
Bradford’s decision caused an outcry from residents, dentists and other public health officials who said it was a step backward in the fight to prevent tooth decay. As Vermont and New Hampshire struggle to improve access to dental care, fluoridated water is one way in which residents, particularly those with lower incomes or without dental coverage, could get some level of preventive care, health officials said.
“I thought it was a tough blow,” said Charlie Barton, a dentist in Bradford at Barton Street Dental. “There’s so many kids that need it and I don’t see all those kids because we’re so busy.”
As popular as water fluoridation has become among health professionals, however, it remains controversial.
Anti-fluoride groups have said water fluoridation is not only unnecessary, but can be extremely harmful to infants and elderly residents with compromised health. Overexposure, they say, leads to chronic problems — from weakening of the bones to brain damage to an increased risk of cancer.
A majority of mainstream health professionals dispute those concerns and the studies that support them. But fluoride as an issue has refused to disappear. In 2006, Burlington and Montpelier both considered ending their fluoridation programs, although residents ultimately voted overwhelmingly to keep them. The issue is currently being fought over in Portland, Ore.
Public water fluoridation has been hotly debated for decades. The fears around it were immortalized in the 1964 movie Dr. Strangelove, when the character Gen. Jack D. Ripper calls fluoridation a communist plot: “A foreign substance is introduced into our precious bodily fluids without the knowledge of the individual. Certainly without any choice. That’s the way your hard-core Commie works.”
Even now, water fluoridation sparks arguments every bit as charged as those over gun control or climate change. It is an emotional topic that its defenders wish would be settled already, but that those who oppose it fight furiously to keep in the public consciousness.
“All the evidence that fluoride damages the brain is completely ignored,” said Paul Connett, executive director of the anti-fluoride advocacy group, Fluoride Action Network. “As if the only (expletive) tissues in the body that’s of concern is teeth. Teeth, teeth, teeth (expletive) teeth!”
Oral Health Concerns
The long-simmering debate over fluoride’s health effects was the backdrop against which Bradford’s water commission decided to stop adding powdered fluoride to the town’s water system.
Chairman Robert Nutting said he couldn’t remember how the question arose. But the commissioners had heard some of the allegations about the toxic effects of fluoride and figured, with all of the fluoridated toothpastes out there and fluoride programs in schools, they’d rather end the program and save a little money than take a chance on causing people harm.
“It’s up and down. The doctors say one thing. Everybody’s got an opinion,” Nutting said. “But I don’t think we as a board should be putting anything in the water that would hurt anybody.”
In ending the program, Bradford saved about $1,300 annually. But health professionals say the real costs — to the local economy and public health — will be many times greater. Ending fluoridation will result in more people going to the emergency room for dental problems, lost productivity in the workplace and long-term consequences for overall health.
A 2000 study that appeared in the Journal of Public Health Dentistry found that water fluoridation led to annual savings of between $15.95 per person in small communities to $18.62 in larger ones. The study accounted for the economic costs due to disease and productivity losses.
In the Upper Valley, however, access to fluoride isn’t as widespread as in other regions. Some larger communities, such as Claremont and Hartford, don’t fluoridate their water supplies, and residents in more rural areas rely on well water.
Meanwhile, access to quality dental care continues to be a serious issue, particularly for children from low-income families. Grafton and Sullivan counties have by far the lowest percentages — 34 and 39 percent, respectively — of Medicaid-enrolled children accessing dental services in the state, according to a 2010 report from the New Hampshire Center for Public Policy Studies.
The same year, Claremont had the highest proportion of children under the age of 18 who ended up in the emergency room for a dental problem.
In Vermont, despite the fact that the state provides dental insurance to all children enrolled in Medicaid, an estimated 24,000 kids weren’t able to get the dental care they needed in 2009, according to the Vermont Department of Banking, Insurance, Securities and Health Care Administration. Access to dentists has been cited as a major problem in Vermont and New Hampshire, particularly in more rural areas, and oral health advocacy groups have argued for the need to boost the number of practitioners.
Fluoridated water is one way to ensure that everybody gets a little bit of protection from tooth decay, even if they can’t get to a dentist, health professionals say.
When a person eats sugar and other refined carbohydrates, bacteria in the person’s mouth produce acid that removes minerals from the surface of the tooth, according to the CDC. Fluoride helps to remineralize tooth surfaces and prevents cavities from continuing to form.
Fluoride occurs naturally in some groundwater. But where it doesn’t, health professionals recommend fluoride supplements, particularly for children whose teeth are forming, as a way to strengthen enamel.
Steve Chapman, medical director of Dartmouth-Hitchcock’s Boyle Community Pediatrics Program, has advocated for water fluoridation programs as a cost-effective way to help a broad swath of the population, particularly people living in poverty and with special health care needs.
Oral health has been a growing concern for pediatricians. Chapman begins talking about oral health with parents during wellness visits starting when the child is 4 months old. He urges those with well water to test for fluoride, and if they don’t have it, then he recommends supplements.
He said he’s noticed differences in the mouths of children who come from fluoridated communities and those who don’t.
“We see the cavities when they first are getting started,” he said. “It just seems to happen less frequently in kids that live in places that either have community water fluoridation or naturally occurring fluoride in the water.”
Chapman said he has never seen a patient who was harmed by over-exposure to fluoride.
“Anything you can list as something potentially going wrong, but you just don’t see it,” Chapman said.
In October, a study that came out of the Harvard School of Public Health and published in Environmental Health Perspectives linked fluoride consumption to lower IQ rates in children in China.
The study’s critics said it was based on data from a foreign country where fluoride levels were many times higher than allowed in the United States. But Connett, of the Fluoride Action Network, said U.S. public health officials were simply using that as an excuse to ignore talking about fluoride, which he said has become a “holy” topic and “taboo subject.”
“The pediatricians are completely oblivious,” he said.
Connett, who has a doctorate in chemistry from Dartmouth College, said pediatricians and dentists don’t understand the science behind fluoride. His arguments against it, however, go beyond toxicology and range from violating the principal of informed consent to “medication,” to simply being an inefficient way of combating tooth decay.
When you put fluoride in the water, he said, you may be able to control the amount in the supply, but you can’t control how much water people will drink.
Dental fluorosis — a change in the appearance in the tooth enamel, often looking like white spots or pitting in the more severe cases — is among the most common concerns that anti-fluoride groups express. It is caused when younger children consume too much fluoride over long periods when teeth are developing under the gums, according to the CDC.
Concerns over fluorosis actually led the U.S. Department of Health and Human Services to lower the recommended level for adding fluoride to drinking water in 2011.
Health professionals concede that fluoridated water supplies alone are not a perfect solution to combating cavities.
“I think it can substantially address (oral health problems) but not completely,” Chapman said.
One wrinkle is that fluoridation programs are not going to reach every person in town, or even most people, particularly in the rural communities. Many kids live in households with wells, which means that other interventions, such as giving them chewable fluoride tablets or going into schools to do “swish and spit” treatments or varnishes, in which a fluoride gel is painted on the teeth with a brush, could be more effective. (See related story, page A7.)
In the long term, states will need to do more to boost the number of dentists in an area to improve access, health officials say. And education about good oral health habits is essential.
“We’re talking about behavior modification,” said Bob Keene, a dentist who supervises Upper Valley Smiles, an Alice Peck Day Memorial Hospital program that goes into schools to treat children. “There are so many ways to help people inform themselves.”
Tim Clancy is proof that a fluoridated water supply alone cannot solve the oral health challenges in the Twin States.
The 55-year-old Lebanon resident lived in Bradford from 1986 to 2005 and spent time in Boston as well. He has had plenty of access to fluoridated water, yet recently had seven teeth pulled. “Water didn’t seem to help me,” he said. “They were just rotting out of my head.”
He said he brushes every day, but also smokes, which may have contributed to his dental problems.
Helping people improve their diet is another big challenge facing oral health. Sugary beverages and snacks have not only resulted in climbing rates of obesity, but have also kept dentists busy.
Barton, the Bradford dentist, said he has stopped taking on new patients for the time being.
Anyone who wants to get on the list for new patients would have to wait at least three months before being considered, he said.
“We’re trying to get our schedule where it’s not so frantic,” he said. “Getting here early, staying late, it’s wearing after a while.”
Norwich dentist Toby Kravitz is also looking at a packed schedule. He’s seen rates of tooth decay climb over the past decade and has plenty of thoughts about how to address it. Certainly patients need to improve their habits, but there are some external factors that could change, too. One might be schools getting rid of sugary snacks, he said. And then there’s expanding dental coverage to more people.
There are few fast and affordable ways to address the oral health problems here and throughout the nation. But one came to mind.
“That’s the nice thing about fluoridated water,” he said. “There are folks that can’t afford to go to the dentist or get fluoride supplements who would still be getting some protection.”