It took three decades of lobbying and two hard-fought elections before residents of Tacoma agreed in 1989 to add fluoride to their drinking water.
Similar battles are still being waged at the polls in cities, counties and states across the country.
Now, the Tacoma/Pierce County Health Department is proposing what its director says is a more expedient approach. Instead of putting the question to a fractious public vote, fluoridation should be mandated for much of Pierce County, says Federico Cruz-Uribe. And, he contends, the board of health has the power to do it.
“We have a big problem here with kids’ teeth, and this is a very straightforward way of addressing it,” Cruz-Uribe said. “We certainly feel it is within the purview of public health, and we have a solid legal standing to do it.”
On Wednesday, Cruz-Uribe will brief the board on his proposal and present a draft resolution to require fluoridation of all county water systems serving more than 5,000 people. That would cover 238,000 people in 14 water districts, including Lakewood, Spanaway, Parkland, Puyallup, Bonney Lake, Edgewood, Sumner and Milton.
The public can comment on fluoridation at Wednesday’s board meeting and the April 3 meeting, said board Chairman Kevin Phelps, a Tacoma city councilman. The April meeting is the earliest the board could vote on the proposal.
It’s rare for a health board to tackle fluoridation. Local and state governments generally have the authority to order it, but elected officials tend to shy away from the topic by putting it to a public vote.
“Honestly, I don’t know of any other health department that has done this, and it’s always puzzled me why they haven’t,” Cruz-Uribe said.
Dentists are delighted, but the department’s unorthodox tack is taking fluoride opponents and local water districts by surprise.
“I think it’s unprecedented,” said Emily Kalweit, president of Washington State Citizens for Safe Drinking Water. Organized to fight a statewide fluoridation bill two years ago, the group has helped with anti-fluoride campaigns across the state. Kalweit predicts an outcry in Pierce County, too.
Water districts are wondering how to pay for fluoridation.
“It was kind of a bombshell,” said Randy Black, manager of Lakewood Water District. As the largest water system covered by the proposal, Lakewood faces costs of up to $800,000, he estimates.
Jim Sherrill, manager of Parkland Light and Water Co., predicted lawsuits. “I don’t think the utilities will accept a mandate and a financial burden without questioning whether there’s the authority to do that,” he said.
But Phelps said fluoridation is no different from anti-smoking programs, AIDS testing or any other health-related subject the board has dealt with.
“I don’t believe it’s something (the public) should vote on,” he said. “These health issues are not things you want to leave up to a popularity contest.”
Cavities: Forgotten but not gone
About 43 percent of Pierce County’s 700,000 residents receive fluoride in their water. That includes Tacoma and communities along the city’s Green River pipeline; Fort Lewis and McChord; Fircrest; and University Place.
The rest of the county’s residents drink unfluoridated water. For those who don’t have their own wells, water comes from public and private water districts, ranging from tiny, neighborhood systems to major utilities such as Lakewood, which serves 71,000 people.
Nationally, nearly 66 percent of people served by public water systems receive fluoridated water. In Washington, it’s 57 percent.
“That probably helps explain the high decay rates in Washington,” said Dr. William Maas, director of the Division of Oral Health at the U.S. Centers for Disease Control and Prevention.
One-year-old children in Washington have a cavity rate five times higher than the national average, according to the Washington Department of Health. For 2-year-olds, Washington’s rate is twice as high as the rest of the country.
By third grade, six out of 10 children in Washington suffer from tooth decay. Nationally, half of children between the ages of 5 and 9 have cavities.
“A lot of people – particularly policy-makers – don’t realize tooth decay is a major problem,” Maas said. “It’s still the most common chronic disease of childhood.”
In Washington, as in the rest of the country, children from low-income families are hardest hit.
“They’re the children that fall through the cracks,” said Linda Gillis, oral health specialist for the Tacoma/Pierce County Health Department. “Their parents may be uneducated, they don’t have the money to take the kids to the dentist and they may not know much about dental hygiene.”
Those are the kids the health department hopes to help by expanding fluoridation in Pierce County.
Whether they drink fluoridated water or not, children from more affluent families are likely to get regular dental care, including fluoride treatments. For poorer kids, fluoride in the drinking water could well be their main defense against decay, Gillis said.
There are nearly 75,000 low-income children in Pierce County. All qualify for free dental care under the state’s Medicaid program, but fewer than a third ever visit a dentist. Gillis said few dentists work on low-income children because they’re paid so little for doing it.
Of Pierce County’s approximately 400 dentists, only 148 treated Medicaid children last year, according to the Washington Department of Social and Health Services. Of those, only 53 treated more than 25 Medicaid children.
The health department and a handful of clinics try to take up the slack by offering fluoride coatings called varnishes, and dental sealants that help block decay. But the programs reach only a small fraction of kids who need care, Gillis said.
Fluoride: effective and safe?
Public health officials are unanimous in declaring fluoridated water the most cost-effective way to reduce tooth decay.
Nationally, the per capita cost of fluoridation averages 72 cents a year. Every dollar spent on fluoridation saves $38 in dental bills, Maas said.
In the early years of fluoridation in the United States, cavity rates dropped 50 percent to 60 percent in communities after fluoride was added to the water. More recently, studies document 15 percent to 40 percent fewer cavities in fluoridated areas.
The decline in benefit, experts say, is because fluoride use is so ubiquitous that people who don’t get it in their drinking water get some exposure via bottled drinks, prepared foods and toothpaste.
Brushing twice a day with fluoride toothpaste does cut the risk of cavities, experts say, but isn’t as effective as toothpaste combined with fluoridated water.
In Pierce County, the health department found that 50 percent of low-income toddlers living in unfluoridated areas have cavities, compared with 35 percent of low-income toddlers who live where the water is fluoridated.
And it’s not just youngsters that are protected, Maas pointed out. Cavities are nearly as common in adults as children. The elderly are particularly vulnerable to root decay as a result of receding gums and common medications that leave their mouths dry.
University Place dentist Rhonda Savage sees the benefits of fluoride every time she drills a patient’s tooth.
“People who have grown up in fluoridated areas, their teeth are like rocks,” said Savage, past president of the Pierce County Dental Society. “People who grew up in unfluoridated areas, sometimes the enamel is almost like butter.”
However, opponents of fluoridation contend the chemical’s benefits have been exaggerated. One 1987 study concluded that children living in fluoridated areas averaged one fewer cavity than children living without fluoride. Another Pierce County survey found only a 7 percent difference in the number of schoolchildren with no history of cavities in fluoridated versus unfluoridated areas.
Other critics are philosophically opposed to having any chemical added to drinking water. But most of the anti-fluoride arguments revolve around possible health effects.
Kalweit cites everything from brain damage and brittle bones to cancer, thyroid disease, arthritis and kidney lesions as side effects of fluoride. The dental and medical establishments refuse to acknowledge the harm fluoride can do, she argues, because the government doesn’t want to admit a program promoted for 50 years could be threatening public health.
“There are studies out there being ignored because of inertia,” she said.
A small group of researchers, including some from the Environmental Protection Agency, say they were fired for suggesting fluoride might be harmful. Some say research results were manipulated to minimize damaging evidence.
Mainstream experts reject all of those claims.
Scientific and public health organizations including the National Research Council, the Institute of Medicine, the U.S. surgeon general and the World Health Organization have concluded there is no health risk from fluoridated drinking water.
“It’s not that we’re weighing the adverse health effects versus the benefits,” Maas said. “At present, we have no evidence of adverse health effects.”
Children under the age of 6 who are exposed to higher-than-recommended levels of fluoride can develop white or brown spots on their teeth – a condition called fluorosis. That’s why tubes of fluoride toothpaste carry a warning about how much young children should use.
A scientific review published this year found that more than a quarter of kids in areas with fluoridated water developed some form of fluorosis, though fewer than 6 percent of cases were severe enough to be visible.
Fluorosis can be largely eliminated by ensuring that young children who drink fluoridated water don’t get too much of the chemical from other sources,including toothpaste and dietary supplements, the researchers said.
There’s a new wrinkle in the fluoride debate in areas with endangered salmon. There are some hints that the chemical could harm the fish, which has led the Sierra Club to oppose fluoridation in favor of individually targeted treatments like fluoride gels.
Kalweit says public money would be better spent on programs to teach kids and parents better dental hygiene.
“It’s not really that difficult.” Her own 4-year-old daughter gets no fluoride, she said, yet has perfect teeth.
Politics and money
About half of the recent fluoridation efforts in Washington have been defeated, said Sean Pickard, governmental relations director for Washington Dental Services, a major insurer. Kennewick’s City Council rejected fluoridation earlier this year, while Pasco’s approved it a few years ago. Residents of Yakima voted in favor of fluoridation in 1999. In Olympia, voters have rejected fluoridation three times. Bremerton’s City Council said yes, but the measure was overturned by a public vote in 1999.
A few states, including California, now require the phase-in of fluoridation for all large water systems.
“It really should be a no-brainer, and there should be no controversy about it,” Pickard said. “But there’s a small, very focused group of people who oppose it … and a lot of information on the Internet that isn’t scientifically grounded.”
Most Pierce County water districts would rather see the issue put to a vote than imposed on their customers.
Lakewood water manager Randy Black says he gets frequent calls from people checking to make sure their water isn’t fluoridated. It’s much rarer, he said, to hear from somebody who wants fluoride.
“I personally think it should be a local decision, made by the citizens,” Black said – especially since water rates will probably have to be raised to pay for fluoridation.
But Cruz-Uribe insists the board of health has the responsibility – and authority – to protect dental health. As a joint city-county agency, the department has both police powers and a clear mandate to adopt regulations that safeguard public health, he said.
The seven-person health board comprises one member of the Tacoma City Council; one representative of the Tacoma mayor’s office; two members of the Pierce County Council; one representative from the Pierce County executive; one member from other Pierce County cities and towns; and one member at large.
Pierce County Executive John Ladenburg endorsed fluoridation last fall at an oral health summit sponsored by the health department. Cruz-Uribe says he has the political support he needs to approve the proposal but acknowledges that the debate is likely to become heated.
“Who knows what will come out of it?” he said. “All I can say is that we’ve got what we consider a critical problem, and we think this is the best option for addressing it.”