Earlier this week, Dr. Lena Natapov, the head of the Department of Dental Health of the Israel Ministry of Health, gave a 1 hour Zoom presentation under the auspices of the Colgate company and the Israel Dental Association.

Most of the lecture was an overview of the actions of the department regarding the COVID-19 pandemic. I do have a lot to say regarding the department’s policies, or lack of policies regarding corona, but that is not the purpose of this article.

During her presentation, Dr. Natapov described a program started by her department to educate pre-schoolers on tooth brushing, where a hygienist also applies a fluoride varnish to the children’s teeth. She showed pictures of the pre-corona program and of the program using corona protocols. She went on to stress the importance of trying to continue such programs because rampant caries in pre-schoolers is a serious problem in Israel, mostly affecting the lower economic classes, but also affecting the more affluent.

As a dentist who has treated children in two of the kupot cholim over the past 5 years I can confirm that this is a major problem.

At the end of her presentation, Dr. Natapov took questions from viewers that were submitted via chat. One of the questions was: Is fluoride going to be restored to the drinking water in Israel? A second question was why (in the absence of fluoride in the drinking water) are fluoride supplements no longer available in Israel? (They have not been available for at least 5 years).

A brief history of fluoride  policy in Israel. Prior to 2013, it was mandated by Israeli law that every community of more than 30,000 people would have the water fluoridated. Most of the larger towns and cities complied with the law. Some authorities , Modi’in for example, were lax in following the law. In 2013 Yael German of Yesh Atid was appointed Health Minister. When she was mayor of Herzliah, Mrs. German opposed fluoridation, and as Health Minister, one of her first decisions was to cancel the fluoridation program in the entire country, against the advice of all relevant health care professionals. Under the previous Health Minister, Yaacov Litzman, the Department of Dental Health was very pro-fluoride. Rabbi Litzman, now in the opposition, was very upset by the decision.

Just before the cancellation of the fluoride program came into effect, a number of Knesset members called for an emergency meeting of the Knesset’s Health and Welfare committee to discuss and try to stop the cancellation. A video recording of this session was and still is available for public viewing. Health Minister German did not attend. Most of the speakers opposed the cancellation, with one or two anti fluoridaters supporting. MK Litzman was very critical of Mrs. German’s decision. Present at the meeting  was Dr. Shlomo Zussman, head of the Department of Dental Health at the time. I do not remember if Dr. Natapov attended. During the entire meeting,  Dr.  Zussman did not say a word. Near the end, the chairman of the committee asked Dr. Zussman for his opinion. Dr. Zussman refused to speak. When repeatedly pressed by the chairman, the only thing Dr. Zussman said was “No sugar, no cavities.”

I watched the recording of this meeting from start to finish two or three times, and every time it is astonishing to me how the representatives of the Department of Dental health showed a complete lack of professional integrity. They failed in their job of protecting the dental interests of Israel’s children, with the repercussions persisting until today.

I asked Dr. Zussman a few years later about the cancellation of the fluoride program, and he admitted that he went against his professional judgment in implementing that decision. A man of stronger ethical fiber would have resigned from his position rather than implement the decision. The other dental professionals in the department, like  Dr. Natapov, could also have taken a stand, but they showed the same lack of integrity as Dr. Zussman.

When the next government was formed, Rabbi Litzman returned to the Health Ministry and immediately announced he would reverse the policy and restore fluoride to the drinking water. The website of the Department of Dental Health added information about the importance of fluoride to its website. Today, on the main page of the website this is mentioned twice, as official department policy, the importance of fluoridating the drinking water.

I was under the impression, as were most dentists in the country, that the water was being fluoridated, from 2015 onward. This past year I attended a meeting where a high ranking official of one of the kupot cholim dental departments claimed that the water was not being fluoridated. I tried to confirm this via the Health Ministry hotline the next day, but they did not have the information.

This week, Dr. Natapov admitted that the water is not being fluoridated, and hasn’t been for the past 5 years, because of disagreements between the water authorities. To compound the seriousness of this scandal, the dental community has been misled, possibly intentionally, into thinking that the water was being fluoridated. Anybody reading the department’s current website would automatically assume that it was. Over the past 5 years I have given incorrect information to concerned parents who asked me about water fluoridation, and about the possible need for fluoride supplements.

This brings us to the second question and Dr. Natapov’s answer. Why, in the absence of water fluoridation, are supplements not available.  Dr. Natapov answered that for fluoride supplements to have the optimum effect, they must be given on a continual basis. Parents cannot be relied upon to administer the fluoride to their children in the proper manner. They forget some days to give the supplements. Also with supplements the level of fluoride in the system spikes when taken and drops. It is not an even supply. Children that drink water during the day at normal intervals are more likely to have an even distribution of fluoride to the developing teeth. Therefore the department does not recommend fluoride supplements.

But there is no fluoride in the water and there has not been for 7 years. Parents who want to give supplements cannot, because the Ministry of Health does not allow for their importation.

Am I the only one who sees the correlation between the rampant caries in children and the lack of fluoridation? Does Dr. Natapov think that the application of fluoride varnish on the teeth once a year provides an even distribution of fluoride ions to the teeth on a continuing basis.

If there are unsolvable bureaucratic  problems that prevent water fluoridation, shouldn’t the public be informed of the facts, and shouldn’t parents have the right to decide to give their children supplements? If those bureaucrats have failed for 5 years to implement their decisions, shouldn’t they be replaced ?

Since I have already written about one scandal with regards to dentistry and children in Israel, I will conclude this piece with another one.

10 years ago, the Health Ministry took the responsibility for treating the children up to age 6 from the private sector and handed it over to the kupot cholim. (Incrementally over the years it was increased to age 18). Most children under the age of 4-5, and some older ones as well, cannot be treated in dental clinics under regular conditions, because of problems of non cooperation. These children need to be treated under general anesthesia, or sedation. In the kupot cholim this is done in a hospital setting.

In Israel today, children aged 2-6 with rampant caries are waiting 3-6 months for  appointments. Small children are being brought in pain to the kupot clinics for emergency treatment that cannot be performed because of cooperation problems. There are no facilities for emergency treatment for children under general anesthesia or sedation, and the facilities and manpower available for scheduled appointments are inadequate  to meet the need in a reasonable amount of time. A 2-4 year old child diagnosed with caries in their tiny primary teeth should be treated within 2-3 weeks, and not 3-6 months. Multiple times children that have appointments for treatment in a few months are being brought in to the regular clinics in pain, and they cannot be treated.

I consider this to be a failed system. Obviously that fluoride situation has added significantly to the problem, by greatly increasing the need for treatment in children under the age of 6, as well as in older children.

About the Author – Dr. Dan Cheifetz is a graduate of Georgetown University Dental School. He has been practicing dentistry in Israel for 36 years. He served in the IDF as a dentist from 1989-1991.