Louisiana’s fluoride flop

On July 6, 2008, Gov. Bobby Jindal signed Act No. 761 into law. Known as the Louisiana Community Water Fluoridation Act, the legislation mandated that water systems with over 5,000 connections throughout the state add fluoride to their water supply with the purpose of protecting Louisianans’ dental health. “This was a fairly significant statement by the state that community water fluoridation is an important public health issue,” says Ward Blackwell, executive director of the Louisiana Dental Association. Yet Act No. 761 was an unfunded mandate, specifying that public water systems—of which there are about 1,400 in the state—only must comply if sufficient funds, provided by the Legislature, grants or other state-identified funds, exist to cover the cost of engineering, acquiring and installing fluoridation treatment equipment, and maintenance of designated fluoride levels for at least six months. At the same time the water fluoridation requirements became law, however, the financial crisis was taking hold. Coupled with more recent falling energy prices, the state began facing significant budget shortfalls. Opportunities for funding the Community Water Fluoridation Act dried up. So although more than seven years have passed since community water fluoridation became a requirement in Louisiana, the state has made little progress in providing fluoridated drinking water. Today, just 43% of Louisianans live in a community that fluoridates its water—about the same percentage as when the bill passed. “We went through a lot to get the bill passed, but we’ve never been able to get the Legislature to appropriate any funding to help local communities,” says C.J. Richard, Jr., a general dentist in Walker. Given the state’s current budget woes, identifying funding anytime soon remains unlikely, Richard adds. “From a budgetary standpoint, Louisiana is really hurting. It’s hard to go to the Legislature when everyone else is also asking for money and we’re seeing deep cuts in things such as higher education.” Dr. Jimmy Guidry, state health officer of Louisiana and the Department of Health and Hospitals’ medical director, agrees that Louisiana’s lack of progress on community water fluoridation boils down to lack of funding. “We live in a state that has difficulty meeting financial needs,” he says. “Some communities have an issue adding chlorine [to eliminate bacterial contamination], while many water systems have aging infrastructure that is expensive to replace. They often are just trying to make sure the water isn’t contaminated, so spending on fluoridation in addition is difficult.” Although some areas in Baton Rouge have sufficient levels of natural fluoridation, most of the city’s water supply is not fluoridated. Fluoridating a single well can cost from $38,000 to $50,000. If a water system has a coordinated infrastructure, such as a single water-treatment facility, the cost is minimal. However, the Baton Rouge metro area’s water comes from more than 60 wells, so the cost to fluoridate would run in the millions. East Baton Rouge Parish’s two major water companies estimated the cost would be $8.5 million. “That makes it a very expensive proposition in Baton Rouge,” Blackwell says. DHH oversees community water fluoridation in the state. This includes helping communities secure funding—typically federal funding—to implement water fluoridation. For example, recent federal grants include $100,000 to the cities of Gonzales and Sulphur. The department also addresses scientific, health, safety and technical matters regarding fluoridation, including training operators and monitoring individual water systems, and provides education and outreach to communities and public water systems.

THE BENEFITS

Water fluoridation prevents tooth decay by providing consistent contact with low levels of fluoride, reducing the risk of tooth decay by about 25% in children and adults, according to the Centers for Disease Control and Prevention. Although nearly all water contains some fluoride, the amount is not enough to help prevent tooth decay or cavities. Community water fluoridation adds a small amount of fluoride to public water supplies to a level shown to make teeth stronger and prevent cavities. Community water fluoridation began in the United States in 1945, when Grand Rapids, Michigan, first fluoridated its water. Today, almost 75% of Americans nationwide are served by fluoridated public water systems, according to the American Dental Association. The CDC named community water fluoridation as one of 10 great public health achievements of the 20th century, alongside vaccination and control of infectious diseases. Yet only 13 states—including Louisiana—have statutes or regulations requiring community water systems to fluoridate drinking water to a specific concentration or range. In other areas, community fluoridation typically is initiated by local authorities, such as city councils. Despite its statewide requirement, Louisiana lags far behind most of the United States. About 220,000 Louisiana residents are served by community water systems that have naturally occurring, optimally fluoridated water; another 1.8 million are served by community water systems that fluoridate their water. With a population of 4.65 million, though, the majority of Louisiana residents do not have fluoridated water, ranking the state 45th in the percentage of people served by a community water system who received fluoridated water, according to the CDC. Richard, who serves on the state’s Fluoridation Advisory Board, says community water fluoridation provides benefits, regardless of socioeconomic status, and contributes to a cost-savings for the state. “We spend all this money to treat dental disease, but we do little on prevention,” he says. “Yet dental disease in children is more prevalent than childhood asthma.” Schoolchildren living in fluoridated communities on average have 2.25 fewer decayed teeth compared with children who do not live in a fluoridated community, according to the CDC. A 1996 a study conducted in Louisiana found that Medicaid-eligible children living in communities without fluoridation were three times more likely to end up in the hospital for dental treatment than Medicaid-eligible children who lived in fluoridated communities. “It’s not a hard sell from a public health standpoint. It increases the cost of health care if you don’t do it,” adds Guidry, who is a practicing pediatrician. Part of the challenge, Richard adds, is that the benefits of water fluoridation are not instantly apparent. “It takes three to five years to see results of community fluoridation, as kids drink fluoridated water and then get their adult teeth,” he says. “It’s a long-term process.” “Clinically, we can see the difference—it’s anecdotal, but we see a higher incidence of cavities when there is no community fluoridation,” says Richard, whose 30-year career has been in communities with and without water fluoridation. “The biggest obstacle, though, is getting the funding.”

FIGHTING FLUORIDE

Yet even if funding was not an obstacle, statewide community fluoridation is not a sure thing. In recent years, communities throughout the U.S. have voted against community fluoridation. The 2008 act allows communities to opt out of fluoridation if at least 15% of registered voters sign a petition forcing a local election, which then results in a “no” vote. Those opposed to fluoridating are active in Louisiana and other states, with efforts focused largely on education. Carol Kopf, media director for the Fluoride Action Network, says that while “other nations follow the science, which shows ingesting fluoride is ineffective, harmful and unnecessary, in the U.S., fluoridation has become a political issue.” With the Internet, people have better access to information about fluoridation, which has led to more people questioning the need for and safety of it, she says. Controversy over safety, ethics and cost has surrounded community water fluoridation from the beginning. Opponents view fluoridation initiatives as a form of community-wide medication. They point out that most developed countries do not fluoridate, with additional countries having ended the practice. Conflicting research also exists about the extent to which fluoridation prevents tooth decay. “Studies show that when fluoridation ends, tooth decay rates either stay the same or go down,” Kopf says. “Fluoride is neither a nutrient nor essential for healthy teeth. Consuming a fluoride-free diet does not lead to tooth decay. Sugar is the only cause of tooth decay.” Possible alternatives, Kopf notes, include taxing soda, restricting advertisements to children, and educating parents that bad diet can lead to rotten teeth and chronic health conditions, such as obesity and diabetes. Better access to dental care is also needed, she says. “The real crisis is the growth of untreated tooth decay because most dentists refuse to treat Medicaid patients,” Kopf says. “The American Dental Association lobbied to have dental care not included in Medicare, so 130 million Americans don’t have dental insurance. As a result, they are flocking to hospital emergency rooms when the pain is too intense to bear, costing taxpayers 10 times the cost of a simple filling.” Those supporting fluoridation agree that other factors are essential for good oral health. “Fluoridation is not going to make people bulletproof,” Richard says. “Diet plays a role, as does good hygiene.” With greater availability of fluoride products, such as toothpaste, mouth rinses and supplements, some have raised concern that people—particularly children—are exposed to toxic amounts of fluoride. Earlier this year, the U.S. Department of Health and Human Services reduced the recommended amount of fluoride for the first time since 1962, to 0.7 milligrams of fluoride per liter of water instead of the range of 0.7 to 1.2 milligrams, in part because of an increase in fluorosis. The condition consists of white or yellow spotting on teeth caused by overexposure to fluoride during enamel formation, typically in the first eight years of life.