In the late 1990s, New Bedford’s anti-poverty agency, PACE, found that the single most important form of health care that many poor people in our community wanted and needed was dental care.
At that time, PACE found that of the 88 dentists practicing in the New Bedford area only two were accepting patients who had Medicaid coverage. Dentists rejected these people for three reasons: The reimbursement rate was low, there was a history of patients not showing up for appointments and dentists had to wait so long for Medicaid to pay them for their work.
That left thousands of poor New Bedford residents with no way to get their teeth cleaned and filled and little opportunity to prevent much worse health problems, including severe decay, abscesses, facial infections and even heart problems caused by sepsis infections that begin in the mouth.
Over the next few years, PACE and the New Bedford Community Health Center began efforts to address this massive problem, which has only become worse since the state eliminated dental coverage for Medicaid recipients. In 2002, the state cut coverage for routine dental care for adults on Mass Health, the Medicaid program. Poor residents are only covered for extractions and oral surgery, when dental problems have already reached a crisis.
Working with the Greater New Bedford Vocational-Technical School, PACE started a dental sealant clinic that was open to any second-grader in the public schools whose parent gave permission. Several dentists volunteered to work with the vocational school to provide dental checks of children’s teeth and to apply sealant to prevent decay on molars. PACE found that 145 of the 594 students in the first year needed immediate dental care for tooth decay. Six children had abscesses.
Many of these children had daily pain in their mouths from rotting teeth at an early age. PACE was also seeing children with multiple cavities at the age of 4 in its Head Start program.
It was for this reason that PACE went to the Board of Health several years ago to request the city consider injecting fluoride into the water, a measure that is endorsed by the federal Centers for Disease Control, the U.S. Department of Health and Human Services and the American Dental Association. Some 170 million Americans live in cities and towns with fluoridated water.
Dr. William Bailey of the CDC says that fluoride that comes in contact with teeth through brushing with fluoridated toothpaste or drinking fluoridated water reduces the ability of bacteria in the mouth to produce acid that eats at tooth enamel, causing cavities. He also believes that ingested fluoride in the early years of a child’s life contributes to the building of stronger teeth.
Years ago, there was a stronger belief that ingesting fluoride helped build stronger teeth, but this has been refined by federal officials, who now say that the most important way fluoride works is in the mouth, mixing with saliva and coming in contact with teeth, not through swallowing
PACE knew that there had been controversy about fluoride for the more than 50 years and it knew it was in for a fight.
The Board of Health, headed by Dr. Patricia Andrade, a thoughtful surgeon who has seen the devastating effects of dental decay in her own practice and throughout the community, studied the fluoride issue and decided that it would not be a silver bullet, but that fluoride in water at the recommended 1 part per million would help poor New Bedford residents who do not have access to regular dental care. It would help them reduce the level of dental decay. The CDC estimates it can help reduce decay from 18 to 40 percent.
Dr. Andrade told the Editorial Board of The Standard-Times last week that regular dental care and regular brushing would do far more to help the thousands of poor residents without insurance or the ability to get dental care. But at least fluoridated water would be a start at attacking a problem that affects people’s health, their self esteem and their ability to get a job.
The Board of Health voted more than a year ago to fluoridate water under Massachusetts law and allowed for the legally required 90-day period for the public to gather signatures to hold a referendum on fluoridation.
When there was no petition, the board then worked with the city’s water department to be sure that fluoride could be added safely and at the right concentration to the water. Fluoride is purchased from companies that extract the substance from the air emissions of the phosphate fertilizer industry. Hydrofluorosilicic acid is then diluted in the water system.
The state Department of Environmental Protection finally approved the city’s fluoride application system in December 2005 in the final days of Mayor Frederick M. Kalisz Jr.”s administration.
When the new mayor came into office, the Board of Health decided to work with Scott Lang to institute this major policy change. The mayor has held up the fluoridation order to allow the public to comment and the comments at several hearings have been mostly against the policy. The Board of Health has the authority under state law to turn on fluoride, but the issue is at a standstill.
There is a vast international network of fluoride opponents that include environmentalists, federal scientists at the Environmental Protection Agency, a Nobel Prize scientist from Sweden who likens fluoridation to mass medication and even members of a National Academy of Science panel that recently issued a report on the toxicology of fluoride at concentrations between 2 and 4 parts per million.
Thoughtful opponents of water fluoridation say there is a growing body of science that shows the ingestion of fluoride in small doses over a lifetime may contribute to several health problems, including fluorosis or staining of the teeth, bone fractures, impaired thyroid function, learning deficits in children and a rare form of bone cancer.
The studies that point to these problems are fairly recent and have looked mostly at doses of fluoride in excess of 2 parts per million.
It was this new body of science published in the 1990s that was reviewed by 12 leading scientists brought together by the National Research Council and National Academies of Science to examine the 4 part per million maximum contaminant level for fluoride established by the EPA in 1986. The NRC decided that drinking water with 4 parts per million of fluoride over a lifetime could harm a person’s health and EPA should lower its standard. The NRC said that this concentration could lead to fluorosis, the discoloring and weakening of the teeth. It could contribute to a greater number of bone fractures, primarily in older people. The NRC reviewed, but did not find conclusive, some studies that connect fluoride to damage to the thyroid or a body of studies by the Chinese that show intelligence deficits in children living in communities with fluoride levels above 2 parts per million.
Animal studies on fluoride and bone cancer also led to a study of whether fluoride may be contributing to osteosarcoma in young boys. A small, highly preliminary study at Harvard saw some evidence that this very rare form of cancer may increase among boys who live in communities with fluoridated water. A larger study by Harvard on osteosarcoma is expected to be completed this summer.
The National Research Council said it did not analyze the CDC recommended fluoride level of 1 part per million.
Dr. Andrade calls the fluoride question a classic risk-benefit analysis.
In a community such as New Bedford, with very high dental decay among many poor people and very little opportunity for thousands of people to get proper dental care, the benefits of splashing fluoridated water regularly on teeth when drinking water outweigh the risks the substance will build up in the body over a lifetime and possibly contribute to fluorosis, bone fracture or a case of a highly rare form of bone cancer.
In many of the state’s suburban communities, a different decision is possible. The benefits of fluoride are not worth the risks of adding this substance to water. In these more privileged communities, most children and adults have access to regular dental care. They brush their teeth, get regular checkups and can get to a dentist if they have a rare abscess.
These people get 1,000 parts per million of fluoride onto their teeth in the best way possible, every time they brush with most toothpastes.
And just as important, they spit out the fluoride so it has no chance of circulating in the body and affecting other areas where newer studies are pointing to potential problems.
The new and important frontier for science is to do a better job accounting for how much fluoride individual people take in through the increasing number of sources in our environment from food to air to water and whether people are harmed by this element if enough is absorbed into their system.
The ideal would be for New Bedford’s poor children and adults to have the kind of regular dental care and regular brushing that is routine in some homes.
This is a much better way to develop strong teeth than by drinking fluoridated water. But this nation, the richest in the world, has failed miserably at providing basic preventative dental care to millions of people who live at or below the poverty level.
The state should work to change that situation and at least restore dental care to those on Medicaid. But until that is done, fluoridating the water at 1 part per million is taking a small step to help a large number of New Bedford residents. The benefits of fluoride, at this point and at this concentration, outweigh the risks.