Fluoridation is supposed to improve our dental health, yet an increasing number of Canadian municipalities are taking it out of the water. Citizens’ groups form to fight it, academic studies come up with different conclusions and even dentists duel over its desirability.
Fluoridation has a long and heated history for an element found naturally everywhere in trace amounts — in the soil, in the air we breathe and the water we drink. Fluoride, at the proper concentration, has been found to promote remineralization of teeth that are being eaten away from acids in the food we eat. Putting fluoride in drinking water keeps it in saliva and it keeps working on strengthening the teeth, reducing the likelihood of cavities.
Dental associations, including the Alberta Dental Association, support fluoridation wholeheartedly. A Health Canada panel of experts in 2007 reviewed the literature — some of which suggests a risk of cancer, kidney problems, skeletal weakness and other potential problems — and concluded it’s a safe method of improving dental health.
In the United States, the Center for Disease Control has called fluoridation one of the top 10 public health measures ever taken, improving the oral health of the population, regardless of income.
Who’s Wrong? Who’s Right?
Despite the official endorsements, many health care and dental professionals are concerned that we still haven’t ruled out possible links to serious health problems. A key article in Scientific American last year called for second thought about fluoride, citing opinions from experts that there are still many unanswered questions, such as possible effects on thyroid and brain activity.
Anti-fluoride groups have formed in Canada and the U.S. Home systems to filter fluoride out of tap water have become popular, and sell on the Internet for more than $600.
Fluoridation has always had its detractors. In the 1950s some accused it of being a Communist conspiracy, a suggestion made in the classic Cold War film Dr. Strangelove. Opponents showed how corrosive fluoride is by dissolving cattle bones in concentrated sodium fluoride.
The level of rhetoric has cooled since then, and the opponents are different. Rather than right-wing conspiracy theorists, opponents are more likely to eat natural foods, come from all parts of the political spectrum, and include many professionals in their ranks, including dentists.
In Canada, individual municipalities are responsible for deciding whether to fluoridate drinking water. About 60 per cent of Canadians don’t have fluoridated water, including the vast majority of residents of Quebec and British Columbia, according to a survey done by Epcor Water Services in 2006.
In Alberta, 75 per cent of residents drink fluoridated water, including one million people in the Edmonton region, where fluoride has been added to the water since 1966.
But fluoridation is under attack in some parts of Alberta. The city of Calgary, which has had fluoride in its water for 20 years, recently turned down a motion to take fluoride out of the drinking water by a 7-6 margin, and there is a campaign to get a plebiscite on the 2010 election ballot. In recent years, the towns of Drayton Valley and Hanna voted to take fluoride out of the water, while a new anti-fluoridation group has been formed in Red Deer.
Getting Alberta cities to accept fluoridation has been almost as difficult as getting a recalcitrant five-year-old to open wide for the dentist. Edmonton started putting the issue to a plebiscite in 1957, but it didn’t get approved until the third try in 1966. Calgarians didn’t opt for fluoridation until 1989.
The issue has never completely died, and some communities are opting out of fluoridation.
Southern Opposition, Northern Apathy
Moe Hamdon, the mayor of Drayton Valley, says the idea of removing fluoride from the local water supply was raised by town staff when the equipment they were using needed replacing. They didn’t like handling the concentrated hydrofluorosilicic acid, which is the source of fluoride for most municipalities.
At the same time, some local citizens wanted it out of their water supply. Although Hamdon personally felt safe drinking fluoridated water, he agrees that the conflicting scientific views raise enough questions that people should have the right not to have fluoridated tap water.
“If you do not treat the water, those who want it (fluoride) have access to it through other means. If you do treat the water, you’re taking away the choice from those who do not want it.”
One of the questions in Hamdon’s mind is how officials know it’s safe at a certain concentration in drinking water, because people drink varying amounts of water.
Calgary Alderman Druh Farrell, who initiated the unsuccessful vote this spring to stop fluoridating the water, questions the validity of adding fluoride to drinking water.
Chlorine and alum are put into the water during treatment, but fluoride is different because its purpose is to medicate, not to ensure that the water is safe, Farrell says. To put it in context, she says many doctors believe vitamin D is valuable for the body, but there is no thought of adding it to the drinking water.
Farrell says there’s no doubt that treating teeth on a topical basis with fluoride is effective, but she would prefer to see the $600,000 the city of Calgary spends annually on fluoridation used instead to provide topical treatment for children.
Like five of her council colleagues, she is not convinced that fluoridating water is either safe or effective. She cites risk to people on dialysis and a possible risk of thyroid disease, for instance, although neither has been proven, at least to the satisfaction of health authorities in Canada or the United States.
“If there’s a risk of harming people, then I would say the precautionary principle should come into play.”
Farrell doesn’t expect the different sides of the issue to agree any time soon. That was clear during the debates leading to the Calgary vote, when health and dental experts presented conflicting opinions.
“The interesting thing about the fluoride debate is that each side accuses the other of using junk science,” Farrell says.
In Red Deer, businesswoman Diane Hermary started an anti-fluoridation Facebook group this spring after the city began fluoridating the water again. It had been suspended for several weeks due to a continent-wide fluoride shortage partly attributed to Hurricane Katrina.
Hermary thinks the issue “boils down to money.” If Health Canada admitted that fluoride could cause health problems after having said for so many years that it was safe, the government could be exposed to hefty lawsuits.
She also has ethical objections: “They are medicating me against my will, whether I want it or not.”
In Edmonton, fluoridation has not been a major issue since the 1960s, although officials and politicians expect it could have some profile after the Calgary vote.
The city of Edmonton still regulates what goes into our water, while Epcor, the city-owned, arm’s length corporation, supplies the water to about a million people in the city and surrounding regions that operate the purification independently.
Les Gammie, director of quality assurance for Epcor Water Services, says Epcor follows Health Canada guidelines and the water is closely moni-tored, with sample results submitted daily to Alberta Environment.
“There’s lots of stuff on the World Wide Web and there are conflicting opinions,” Gammie says. “We rely on Health Canada to come up with the answer as to what level is safe and what the problems are.”
Epcor sells Edmonton water to a large area outside the city, including such cities and towns as St. Albert, Spruce Grove and Leduc. There have been no concerns voiced by these communities, although Gammie says the odd citizen outside of Edmonton does complain.
Social Issue?
Steve Hrudey, a professor in the school of public health at the University of Alberta, has spent much of his professional life studying the safety of drinking water. His independent inquiry into Edmonton’s water in the late 1980s led to upgrades of the city’s water treatment. He also sat on the research committee formed in the wake of the E. coli disaster involving drinking water in Walkerton, Ont., in 2000.
He feels that the controversy is “at least as much of a social issue as a science issue.”
Some people feel that the idea of putting something in the drinking water because it is good for their health is an attack on their autonomy, says Hrudey.
“It’s the idea that the state is putting something in the water that drives the outrage about it,” Hrudey says. “It’s not based on the evidence, but that somebody is imposing something on people.” Given this attitude, he is surprised that fluoridation is as widespread as it is.
He compares fluoridation to other public health measures, such as vaccination. Just as a small minority receiving vaccinations run the risk of an allergic reaction, he says, there is a slight risk of fluorosis — weakened enamel and discoloration in the teeth of young children — from too much fluoride. And like the opponents of fluoridation, there are opponents of vaccination who refuse to immunize their kids.
Hrudey says the only populations he has heard of who suffered from the effects of too much fluoride are those living in areas where the natural concentration in drinking water is extremely high.
But even supporters of fluoridation suggest we may be getting too much of a good thing when we consider the fluoride is in our food, drink and toothpaste. The panel of experts formed by Health Canada for reviewing fluoridation recommended in 2007 that the level be lowered to .7 parts per million from the current maximum of one part per million, citing a moderate risk of fluorosis. Fluoride has been removed from baby formula for that reason.
Epcor is in the midst of the approval process to lower the level of fluoride in the water to .7 parts per million from .8 following the Health Canada recommendation.
So far there are no definitive comparisons of dental health between fluoridated and non-fluoridated cities, although the Canadian Health Measures Survey in 2010 is expected to contain comparisons of oral health. Pinpointing the effect of fluoridation can be difficult because of other factors that impact dental health, such as income, and because of the “halo” effect of fluoride being in much of the food and beverages we consume.
Polarizing Debate
While fluoridation has support from the medical and dental establishment, opponents listed in Professionals Against Fluoride Canada include family physicians, professors, water plant operators, naturopaths and a number of dentists.
“I tell my patients that fluoride is poison,” says Dr. Nestor Shapka, a Bonnyville dentist. “I no longer believe I can use it in my practice.”
He believes fluoride can reduce cavities when applied topically to the teeth. But with the amount that’s being ingested through drinking water, toothpaste and other sources, he believes people are already exposed to an unsafe level, and he’s loathe to add to it.
Shapka acknowledges he is going against the establishment in his profession, but says it only shows how entrenched the beliefs are that dentists encounter during their training.
One of the leaders of Canada’s anti-fluoridation movement is Dr. Hardy Limeback, a dentist and academic who heads the preventive dentistry department at the University of Toronto.
In 1999, Limeback released a widely quoted statement entitled, Why I am Now Officially Opposed to Adding Fluoride to Drinking Water.
In an interview by e-mail, Limeback says even after 50 years, evidence of fluoridation’s benefits is weak, while evidence that it is harmful is still incomplete. In the meantime, Limeback says, every city should err on the side of caution and stop fluoridating water immediately, as many European cities have done, at least until definitive studies have been completed.
Yet the medical and dental establishments continue to support fluoridation, as they did during the recent public hearings in Calgary. Limeback accuses them of being “evasive” and not properly reviewing the literature.
“In my opinion, careers are at stake and no public health official wants to admit that the policy they have been pushing on the public may no longer be safe and effective. It is human nature to want to save face, so no one in Canada wants to admit that it is time to stop fluoridation.”
Dr. Steven Patterson, associate professor of dentistry at the University of Alberta, says there are scientific papers on both sides of the issue, but whenever experts have done a systematic review of the literature, the evidence has come out strongly in favour of fluoridation. For example, a review in Australia examined about 5,500 scientific articles written between 1996 and 2006, evaluating each on rigid criteria based on the strength of evidence.
“In scientific reviews that look at both sides of the question, I have yet to see one that comes out and says it is harmful and it doesn’t work,” Patterson says.
He says while it’s unfortunate that fluoridation is such a polarizing and emotional issue, at least science continues to look at it, and the research has led to modifications such as Health Canada’s recent recommendation.
For much of his career, Limeback supported fluoridation. The turning point came when he discovered that most municipal water systems don’t use sodium fluoride, but hydrofluosilicic acid.
Limeback says this acid exposes children to lead contamination and contains arsenic. It has never been properly tested, and most people aren’t aware that it is being used. In essence, residents are being experimented on without their consent, he says. “This is not only immoral but may actually be illegal,” says Limeback.
Gammie says the charge that this form of fluoride is unpurified industrial waste is false.
He says although the fluoride added into Edmonton’s water system is a byproduct of the fertilizer industry, coming from the same rock from which phosphate is derived, hydrofluosilicic acid is purified before it is sent out from the U.S. plant at the National Sanitation Foundation, and every tanker truckload is analyzed before it is put in the water.
The acid, which is 29 per cent concentration when it arrives, contains silicon, hydrogen, fluorine and water. It’s possible there could be impurities such as lead or arsenic, Gammie says, but they are so low as to be insignificant, especially after the liquid is diluted to .7 parts per million.
While the concentrated acid needs to be handled like a hazardous material, so do the other chemicals that are put into the water to kill pathogens. As Gammie puts it: “One hundred Aspirins will kill you, but one will cure your headache.”
Dr. Leonard Smith, a Calgary pediatric dentist speaking for the Alberta Dental Association, says he has never seen anything in the scientific literature to convince him that fluoride taken in the proper dose can be harmful. He stands behind the conclusions of all major health authorities that it’s beneficial and without risk, and attributes ongoing opposition to a freedom-of-choice issue.
“There’s not really any science behind it — it’s based on emotion and scare tactics,” Smith says.
Yes, he says, it’s not advisable to swallow fluoride toothpaste, but that is many times more concentrated than fluoride in the water.
Smith says even with fluoridation, there is an “epidemic” of tooth decay in children under the age of five, related to neglect and overconsumption of sugar and lack of proper oral hygiene. He says 28 per cent of children under five have cavities, and one quarter of children aren’t getting dental treatment, resulting in chronic pain, oral infections, sleep deprivation, malnutrition and possible effects on brain development.
“The disease is growing, and fluoridation is one way of slowing it down. If you take it out of the water, I don’t want to think how high it will go.”
No Easy Solution
Edmonton City Councillor Don Iveson says in nearly two years in office, he has had three calls on the issue of fluoridation.
He expects there could be more chatter about the issue in the wake of the Calgary vote. Iveson says it would take a referendum or a change in health regulations to take fluoride out of Edmonton’s water because it was decided directly by the voters back in 1966.
“It’s a question of the tyranny of the majority, and this is a philosophical issue that bugs a lot of people,” Iveson says. “Some people may resent that a community has decided democratically to add this substance to our drinking water.”
Iveson calls fluoridation a “wicked problem.”
“Some problems have clear solutions you can find through investigation — if you heat water enough, it turns to steam,” says Iveson. “But fluoridation is one of those problems that has no clear answer as to what is right and what is wrong, with conflicting opinions, conflicting studies and no clear solution.
It’s like the issues surrounding poverty — people can’t agree on what defines poverty, let alone on what needs to be done to solve it. But if Health Canada deems that the science shows that it should be taken out of the water, then it will be removed no matter what city council says.”
Until then, he expects the controversy to continue to rage.
“May the best argument win.”
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How it All Began
Fluoride came to our drinking water almost by chance.
Its effects were first noticed a century ago in Colorado Springs, Col., when a dentist saw an unusually high percentage of people with brown-stained teeth because of the high concentration of natural fluoride in the local water. This was later dubbed the “Colorado effect,” but along with the brown teeth came a much lower rate of tooth decay than expected.
By 1942, a study by the U.S. National Institute of Health involving 7,000 children concluded that adding about one part per million of fluoride would significantly reduce cavities without causing the mottling and discolouration found with the much higher concentration in Colorado Springs.
By the 1950s, communities in the United States and Canada started fluoridating their drinking water. In 1955 Procter and Gamble hit the market with Crest toothpaste, the first with fluoride.
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What’s in Your Water
Avenue enlisted the help of Bodycote Testing Group to independently check the quality of our tap water in Edmonton, which receives treated water from Epcor. We then tested the water in St. Albert, which also receives fluoridated water from Epcor (as do most other communities in the Capital region), and also got water samples from Ponoka, which does not receive Epcor water and does not add fluoride. The results were fairly similar across the board, with a few minor exceptions. The amount of lead in the water was slightly higher in Edmonton and St. Albert, while aluminum, copper and zinc levels in both cities were deemed “acceptable” but not a “pass” by Bodycote. Boron levels in St. Albert were significantly higher than in Edmonton or Ponoka. Not surprisingly, fluoride levels were higher in Edmonton and St. Albert (0.78 ppm and 0.73 ppm, respectively).
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