Fluoride Action Network

Forum paper: Putting the Mouth Back in the Body

Source: The Massachusetts Health Policy Forum. Issue Brief No. 36. | June 16th, 2009 | Paper prepared by Signe Peterson Flieger, M.S.W. and Michael T. Doonan, Ph.D.


This forum was made possible by special grants from the DentaQuest Foundation and the Massachusetts Dental Society.

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The Office of Oral Health at the Department of Public Health aims to improve oral health through education about preventing dental disease, community water fluoridation, and school-based fluoride and sealant programs… Community water fluoridation is the most cost effective way to prevent dental disease. In Massachusetts, 140 out of 351 cities and towns (59.1% of residents) have access to fluoridated water. The process of community water fluoridation is primarily local, and politically difficult. Opposition endures despite extensive scientific evidence of the safety and effectiveness of community water fluoridation. Typically fluoridation efforts are successful only half of the time. Recent successes include North Attleboro, New Bedford, Acushnet, Dartmouth, and Woburn.

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the Oral Health Advocacy Task Force was established in 2002 after a series of budget cuts resulted in the elimination of adult dental benefits in Medicaid.16 The task force is a broad-based coalition of advocates, health care professionals, consumers, policymakers, insurers and researchers. Working statewide, the task force partners with the leaders of the Legislative Oral Health Caucus to improve oral health through advocacy.16 The task force took on many of the objectives outlined by the 2000 Commission report. The priorities of the task force are to: increase access to dental insurance, bolster the safety net of oral health providers in Massachusetts, increase the prevalence of community water fluoridation, and expand awareness of oral health issues.

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Public Health and Prevention

Office of Oral Health

The Office of Oral Health within the Massachusetts DPH aims to prevent and control dental disease and improve overall oral health throughout the Commonwealth.110 The office promotes the use of evidence-based prevention strategies such as fluorides and sealants and seeks to improve access to dental services, particularly among historically underserved populations.110 The primary goal of the office is to eliminate dental disease in the state.110 Three main strategies are used to reach these goals: education about preventing dental disease, community water fluoridation, and school-based sealant and fluoride mouth rinse programs.110 Due to state budget constraints, the latest senate budget proposal for FY 2010 will put funding for DPH below FY 2009 levels.49

Education and Awareness

The campaign works closely with the Oral Health Advocacy Task Force to promote increased access to preventive services including dental sealants, community water fluoridation, and dental exams for all children, and encourages citizens to advocate for good oral health for children.

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Community Water Fluoridation

Community water fluoridation has reduced the number of caries found in permanent teeth of children since 1945. Fluoridation works in two ways: systemically, and topically.113 Ingesting fluoride through public water systems allows fluoride to be incorporated into the developing tooth structure, which strengthens the tooth. Additionally, the presence of fluoride in saliva coats and protects the teeth.113 Topical fluorides—such as toothpastes, varnishes, foams, and gels— strengthen teeth by coating the smooth surfaces and in between the teeth to protect against dental decay.113 The optimal fluoridation level recommended by the U.S. Public Health Service for public water systems is between 0.7 and 1.2 parts per million (ppm).113 In Massachusetts, the recommended fluoridation level is 1ppm.104, 114 Community water fluoridation is effective for several reasons: its benefits can reach the entire community, regardless of socioeconomic status; it does not require individuals to change behavior to receive the benefits; repeated exposures to small amounts of fluoride are beneficial over the lifespan; and it is the most cost effective way to improve oral health.113

Community water fluoridation offers both oral health benefits and cost savings. Research suggests that community water fluoridation reduces the incidence of dental decay by between 20 and 40%.113 The average cost of community water fluoridation is $0.72 per person per year.98 In most cities, for every dollar spent on community water fluoridation, $38 can be saved in treatment of dental decay.30, 38, 113 Put another way, the estimated total life costs of community water fluoridation is less than the cost of one filling per person.115 Maps showing the number of MassHealth participants under age 21 (Figure 2) and the status of community water fluoridation by cities and towns (Figure 3) can be found in Appendix IV. This comparison offers insight into where the state could save the most money from community water fluoridation efforts.

According to the Centers for Disease Control and Prevention (CDC), in 2008, 59.1% of Massachusetts residents benefit from fluoridated public water systems.38, 90 This is an increase from 56.7% in 2004,116 but this is well below the national average of 69%.90 Furthermore, both Massachusetts and the U.S overall have not yet met the Healthy People 2010 target of fluoridated public water systems in 75% of communities.38 As of December 2008, 140 out of 351 Massachusetts communities and towns are fluoridated.114, 115 Thus, 3.9 out 6.5 million Massachusetts residents have access to fluoridated water.90, 114 Additionally, there are 62 communities in Massachusetts that are unable to fluoridate because they lack access to a public water supply (L. Bethel, RDH, MPH, oral communication, March 26, 2009).117 Currently, Massachusetts ranks 36th in the nation with regard to community water fluoridation.118 While work remains to improve the prevalence of community water fluoridation, Massachusetts continues to receive recognition for its quality and monitoring efforts. Each year, since 2006, Massachusetts has received a State Fluoridation Quality Award granted jointly by the CDC, the ADA, and ASTDD.119, 120

The process and politics surrounding community water fluoridation are complicated. In Massachusetts, the fluoridation process takes place at the local level. Additionally, the Oral Health Advocacy Task Force and the Office of Oral Health provide support and assistance to communities establishing fluoridation programs.16, 110 The Office of Oral Health also monitors and evaluates existing systems.110 To initiate the community water fluoridation process, the State Commissioner of Public Health must recommend fluoridation of the community and then the local Board of Health can order fluoridation.115, 121 Following public notice of the order, citizens have 90 days to gather signatures from 10% of registered voters to bring the issue to a referendum.115 Between 1968 and 1997, there were 135 orders for fluoridation in Massachusetts, 67 (49.6%) of which went to referendum.121 Of those, 30 (45%) won.121 If the majority of votes are in opposition to fluoridation, the town will not be fluoridated.122 In total during that time period, 78 (58%) fluoridation orders were implemented.121

Despite the ADA’s continued endorsement of the safety and effectiveness of community water fluoridation, a vocal minority opposition remains. Historically, opponents’ arguments against fluoridation have ranged from a Communist conspiracy to toxicity. One of the most common arguments against fluoridation is that it limits freedom of choice, by forcing people to ingest a chemical through the public water system.113 Additionally, some opponents claim that fluoride is toxic, and can result in harmful health effects such as fluorosis. Fluorosis is defined as the disruption or change in enamel when higher than optimal amounts of fluoride are ingested during early childhood.113 When fluorosis occurs it appears as white flecks on the teeth.104 The ADA acknowledges the low risk of fluorosis but advises that if recommended levels are used, community water fluoridation can both prevent dental decay and avoid fluorosis.113 Furthermore, the ADA argues that these supposed science-based claims are unfounded and cautions readers to be wary of “junk science.”113

Despite complicated politics, communities can be successful with fluoridation efforts. Between 1998 and 2007, seven Massachusetts communities have fluoridated their water supply, including Wayland (2000), Northborough (2001), North Attleboro (2002), New Bedford (2007), Acushnet (2007), Dartmouth (2007), and Woburn (2008),114, 115, 123 providing fluoridated public water to an additional 226,109 Massachusetts residents.114 A recent analysis by Robyn Olson, Ph.D. compares the failed outcome of a fluoridation campaign in Worcester in 2001 with the success of community water fluoridation in New Bedford in 2006 (implemented in 2007).115 Olson’s assessment suggests that in both cases, the proponents and opponents framed their positions in similar ways; however, public perceptions about what the controversy was about helped frame the debates.115 In Worcester, the Central Massachusetts Health Foundation was portrayed as “big business” trying to force their views on the citizens of Worcester.115 According to Olson, this sentiment may have resonated with Worcester citizens and reinforced a negative view of big business in the community. Thus, the opposition weaved this theme through its campaign and was able to convince Worcester residents that fluoridation was not in the community’s best interest.115 Alternatively, in New Bedford, unusual circumstances over the firing of the Commissioner of the Board of Health who supported fluoridation, by a new mayor who opposed fluoridation, changed the discourse.115 The conflict became more about the unfair firing of the Commissioner, with less attention focused on the controversial issue of fluoridation.115

In part because there is no one explanation for why fluoridation efforts succeed or fail, it is very difficult to predict whether a referendum on fluoridation will pass in any given community. Thus, there is an ongoing debate about how much to focus on community water fluoridation. On the one hand, studies have shown that fluoridation is very effective at preventing dental decay and can provide significant cost savings on later dental care. However, because of the fluoridation authorization process and the power of the opposition, initiatives are often unsuccessful. Experts debate whether local community water fluoridation efforts should continue as is or whether there should be a push for statewide mandatory fluoridation. Currently, eleven states including California, Connecticut, Delaware, Georgia, Kentucky, Illinois, Michigan, Minnesota, Nebraska, Ohio, and South Dakota, plus the District of Columbia mandate community water fluoridation.115 Even with state mandates, variation in process, enforcement, and funding results in fluoridation rates between 27.7% and 100%.115 However, nine out of the 12 entities that mandate fluoridation have surpassed the Healthy People 2010 goal of 75% fluoridation.115 Although mandatory fluoridation may be the most cost-effective way to improve oral health, many politicians are hesitant to support a mandate. Alternatively, some experts suggest a strategy of targeting community fluoridation efforts at those communities identified as having the highest chances for success.