By one measure, Alabama is doing pretty well on the dental front: More than 80 percent of Alabamians drink water with plenty of fluoride in it. That’s well above the national average, and better than most Southern states.
But that percentage is misleading.
It’s high because the most heavily populated areas have water with added fluoride, a natural element that has been proven time and again to safely prevent tooth decay. The parts of the state that need help the most, those with the fewest dentists and some of the worst oral health problems, also have the least amount of fluoridated water, state health statistics show.
And despite the relatively low cost of fluoridation and the availability of federal grants to help water systems provide it, some county water officials say they’re unaware of the need.
“I never really thought about it,” said Horace Weaver, water operator for the McIntosh Water and Fire Protection Authority in rural Washington County, which lies immediately north of Mobile County. “I’ll have to get with our board and see what they know about it.”
Washington is one of three Alabama counties in which no water systems are fluoridated. The county has a little fluoride in some water supplies, but not enough to do any good, say state health department officials.
Washington County also has three dentists, none of whom accept Medicaid patients, the poorest citizens who often have the most – and the most severe – dental decay, according to dental experts.
Even in Mobile County, outside the city of Mobile, 13 of the 17 water systems are not fluoridated, the health department reports. In Baldwin County, Mobile’s eastern neighbor, about six water systems don’t have enough fluoride to prevent tooth decay.
Across the state, at least half the households in 16 counties do not receive the recommended level of fluoride, according to standards set by the U.S. Centers for Disease Control and Prevention in Atlanta. Most of those counties are in the rural, southern part of the state where unemployment is high, income is low, and dentists are scarce.
Seventeen water systems in Alabama have enough naturally occurring fluoride, and don’t need to add any to bring it up to the recommended level of 0.7 to 1.2 parts per million.
The lack of fluoride is one of the great ironies of the modern age. The CDC lists water fluoridation as one of the greatest public health achievements of the 20th century, along with control of infectious disease and the development of vaccines. Yet, whole segments of the population in Alabama and other parts of the country don’t get to partake.
“Water fluoridation is a major, cost-effective public health achievement, and the most effective measure in preventing caries (tooth decay),” a panel of scientists wrote in the Nov. 22-29 issue of the Journal of the American Medical Association.
“However, lack of fluoridation may disproportionately affect poor and minority children, who are less likely to receive other preventive interventions.” That, in turn, increases the severity and cost of the problem.
All water naturally contains some fluoride, which does two things that make it a perfect cavity-fighter, scientists have determined: It blocks the ability of mouth bacteria to make enamel-destroying acids; and it attracts calcium in the tooth, which helps build a harder surface.
Nine states have decided that the health implications are so important that they have required all water systems to move toward full fluoridation. In Georgia, a 1972 state law requires that water systems fluoridate, with the help of state funding, unless voters pass a referendum against it.
While some people have claimed that fluoridation is everything from a communist plot for mind control to the source of cancer, Georgia has seen very few local referendums against it, said Dr. Joe Alderman, director of the oral health section for the Georgia Department of Public Health. Today, about 92 percent of Georgians on community water systems receive fluoridated water, he said.
Alabama doesn’t require fluoridation, but the state health department does recognize the need for more water systems to get on board. Unfortunately, the state has only one worker who’s responsible for letting more than 550 water systems know what’s available.
“We have a real lack of staff up here. It’s just me who’s doing it,” said Mac Spurlin, fluoride coordinator for the health department. “I kind of have to wait for them (water systems) to approach me.”
A fluoridation system can run as much as $25,000 for the chemicals, tanks and equipment, Spurlin said. But the Centers for Disease Control provides $6,000 grants per system for the initial investment. The fluoride itself can cost about $800 a year for a typical system that provides 300,000 gallons of water per day.
Overall, providing fluoride averages out to about 50 cents to $2 per customer, per year, depending on the size of the system, according to the Centers for Disease Control.
While Alabama provides some state funding for fluoride, the pot of money is tiny, and grants are usually very small, Spurlin said. Other states, like Georgia, go much further, and provide regular grants that cover most of the cost. Alabama’s health department in recent years has asked the Legislature for an extra $1 million to fluoridate more systems, said Don Williamson, the state health officer. Lawmakers have refused to fund the request, he said.
“We could have complete fluoridation of the state for another $1 million,” he said.
The investment easily pays for itself, Alderman and others say. In Louisiana, for example, a 1996 study by the CDC showed that in parishes without fluoride, dental costs for children were twice as high as those in parishes with fluoridated water. Most of the children who need dental care are on Medicaid. Fluoridated water then saves taxpayer-funded Medicaid money in the long run, the study found.
Nationwide, studies show that the amount of tooth decay is about 27 percent lower in areas with fluoride in the water.
“You can tell where there’s fluoride and where there isn’t,” said Dr. Gary Silbernagel, a dentist in Flomaton who once practiced in Mobile. Flomaton’s water, like much of Escambia County outside of Brewton and Atmore, is not fluoridated.
“We’ve seen more toothaches in a week than I used to see in Mobile in a month.”
Sam Hodges contributed to this report.