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The state of fluoridation

After 67 years, challenges continue across nation

For 67 years, community water fluoridation has been part of the landscape in the United States public health arena. Hundreds of studies have confirmed its safety and effectiveness in reducing caries rates since 1945, when Grand Rapids, Mich., became the first community to adjust the fluoride levels in its water supply to lower tooth decay rates in children.

Image: States with Fluoridation activity

According to the latest statistics from the Centers for Disease Control and Prevention, fluoridated water now reaches more than 204 million U.S. residents—just under 74 percent of the population on public water systems. In 1999, the CDC proclaimed community water fluoridation as one of 10 great public health achievements of the 20th century.

Dental professionals might think policymakers and the public understand that community water fluoridation is a safe, effective and cost-effective measure to prevent dental decay, but the latest information compiled by the ADA indicates that 43 states have experienced activity to initiate, retain or defeat fluoridation programs—or a combination of these—from January 2011 through May 2012. While in some cases the activity didn’t end in an official vote, some communities were involved with challenges that required action on the part of dentist members and dental societies.

Although a handful of states have mandatory fluoridation laws, the vast majority of the debate happens at the local level, where many city councils, boards of health or water district officials have authority to make fluoridation decisions.

“A fluoridation debate might be happening in your community right now,” said Dr. John Hanck, chair of the National Fluoridation Advisory Committee and member of the ADA Council on Access, Prevention and Interprofessional Relations. “And you are not alone. Communities that have been fluoridated—even for decades—are facing challenges. However the question is raised, it can lead to high emotions.”

The ADA’s policy on fluoridation, added Dr. Hanck, calls for “individual dentists and dental societies to exercise leadership in all phases of activity which lead to the initiation and continuation of community water fluoridation, including making scientific knowledge and resources available to the community and collaborating with state and local agencies” and “encourages individual dentists and dental societies to utilize Association materials on the community organization and public education aspects of fluoridation.”

“We have a vast amount of resources available to our members for use in educating the decision-makers and the residents of their communities about the safety, benefits and cost-effectiveness of fluoridation as well as strategies that can help them initiate or face a challenge to fluoridation,” Dr. Hanck said.

Form a coalition

In the city of Bozeman, Mont., where residents have had fluoridated water for 60 years, health professionals, public health groups and others joined together earlier this year to educate and advocate for fluoridation with city commissioners and the public, said Dr. Jane Gillette, a Bozeman dentist and member of the ADA Council on Access, Prevention and Interprofessional Relations.

Image: Dr. Gillette
Dr. Gillette
“A few months ago a local college student came to a regular Monday night city commission meeting to speak in an open mike forum which started a chain of events,” she said. “The student said he wouldn’t drink or bathe in Bozeman’s tap water because it was fluoridated.”  

The result, she said, was that a vocal minority of people against fluoridation appeared every Monday for weeks to speak at commission meetings.

Bozeman dentists, hygienists, physicians, nurses, health department officials, public health advocates and groups like the local Head Start program responded by working in collaboration to show the city commissioners not only that they support fluoridation, but why.

“We had about 120 health professionals and other advocates sign on to a letter of support,” said Dr. Gillette. “Our supporters included not only most of Bozeman’s dentists, but pediatricians, water scientists and the dean of Montana State University College of Nursing.”

The coalition, she added, held many early morning conference calls to solidify its messages and plan for the city commission’s final hearing on fluoridation on April 23.

“Our message is that fluoridation is safe, effective and cost-effective and we developed talking points,” said Dr. Gillette. “We also planned to have as many coalition supporters as possible attend the meeting. We virtually flooded the meeting room and the coalition members who spoke at the meeting were articulate and persuasive.”

Dr. Gillette said the coalition wanted to give city commissioners a visual cue that the coalition was large and broad-based, so they developed 4-inch diameter buttons to wear to the meeting that said “Yes! Fluoride for a Healthy Bozeman.”

At the meeting, the commissioners unanimously decided to continue fluoridation, but antifluoridationists have started a petition drive, gathering signatures from Bozeman voters to bring the question to a ballot in November. The group has until mid-July to collect 4,041 signatures—one quarter of the voters in Bozeman—to get fluoridation on the ballot.

“Our main objective now is to encourage local health professionals and advocates to inform and educate their patients and clients about the benefits of fluoridation,” she said. “The community support I’ve personally gotten from this is amazing. Lots of people I hardly know have offered me their thanks for supporting fluoridation. The truth is our community is pretty well informed about its benefits and they appreciate our work. I’m proud of our community, and especially of all of our health professionals who worked together to advocate for fluoridation.” 

Get involved before challenges happen

Florida has been the site of a number of fluoridation changes in the past 18 months. Six communities have voted to retain their fluoridation programs following a challenge; two communities have voted to initiate fluoridation; two have discussed fluoridation in public forums without any action to date; and Pinellas County, which provides water to some 700,000 residents, voted to discontinue its fluoridation program by a county board vote of 4-3.

While the Pinellas County Board of County Commissioners opted to stop fluoridating the water supplied to some county residents at the end of 2011, several communities within the county have their own water systems and may not be affected by the decision. A few of the affected communities in the county are actively working to bring fluoridation back to their residents.

Image: Dr. Johnson
Dr. Johnson

Tarpon Springs recently held a city commission meeting to discuss fluoridating its water supply when the city’s desalination plant is completed in two years. A previous commission had voted not to fluoridate it. Dr. Johnny Johnson, a pediatric dentist in Palm Harbor, said that local dentists and other profluoridation activists have been working hard to educate the Tarpon Springs City Commission about the benefits of fluoridation and provided references and answers to questions from an antifluoridation group. Currently, the city depends on Pinellas County for most of its water.

“We worked hard to reach out to each commission member and make sure they had all the scientific information they needed to make a sound decision,” said Dr. Johnson. “We provided each member with an ADA Fluoridation Facts booklet; plus Internet links to websites like the ADA, CDC, the American Water Works Association and others; and the table of contents to a 500-page binder filled with information on the science and history of fluoridation.

“We also asked local dentists, pediatricians and other health professionals as well as local residents to send emails to commissioners supporting fluoridation and to attend the hearing on fluoridation,” Dr. Johnson said.

“The email contacts were huge,” he said. “Politicians depend on emails from experts and citizens to gauge public opinion, and even though it may not be scientific, it definitely influences their decisions.”
On April 17, the Tarpon Springs city commission cast a unanimous vote to fluoridate when the water system goes on line.

“I am so proud of everyone who got involved in this effort. The key is to stay involved,” he said. “Be involved even when things are going well. It’s good to have a personal relationship with your policymakers before you need to ask for their support. Your elected officials may or may not know the science behind fluoridation, and it’s easier to touch base with them when you are already involved with them.”

The issues are changing

In Milwaukee, Ald. Jim Bohl in May proposed that the city immediately stop fluoridating its water because he said fluoridated water is not safe. His proposal set off a firestorm in Wisconsin’s largest city, which has been fluoridated for 59 years and prompted a contentious seven-hour Common Council Steering and Rules Committee hearing May 31. The committee voted 5-2 to hold his proposal in committee and schedule an additional hearing on the issue. As of late June, no follow-up hearing date had been scheduled.

Image: Dr. Donohoo
Dr. Donohoo
Photo by Emily Bultman, WDA Communications Coordinator/Managing Editor.

“It has become apparent that the fight is no longer over fluoride’s effectiveness (even the opposition acknowledges that the topical application is beneficial in fighting decay), but whether or not it is ever safe to add fluoride to the water supply for ingestion,” said Mark Paget, Wisconsin Dental Association executive director. “Organized dentistry and advocates of water fluoridation must have the research and evidence to show that fluoride is not only effective in preventing cavities but is also safe for consumption/ingestion.”

The WDA has long worked to address community fluoridation issues as part of a coalition, he added, teaming up with the Wisconsin Department of Health Services Division of Public Health, Marquette University School of Dentistry, grassroots member dentists and local public health departments.

Wisconsin’s coalition reacted swiftly to reach out to all Milwaukee City Council members in advance of the hearing with factual information. WDA member Dr. Mike Donohoo of Milwaukee was one of several dentists who testified.

Sound strategies to help protect fluoridation

Image: Dr. Hanck
Dr. Hanck

There are a few simple steps individual dentists, dental societies and oral health coalitions can take to help protect fluoridation for residents in their communities, said Dr. John Hanck, chair of the National Fluoridation Advisory Committee and member of the ADA Council on Access, Prevention and Interprofessional Relations:

• Read your annual Water Quality Report—Water systems are required to provide their customers with this report, sometimes called the Consumer Confidence Report, by July 1 of each year. The reports, which detail quality and content of water, may be mailed to consumers’ homes (often with the water bill), published in local newspapers or posted online. Dental professionals should review the report to check the level of fluoride in the water.

• Know your policymakers—It’s easier to meet a fluoridation challenge head on when you are familiar with those who make decisions in your community and have already established a relationship of trust and mutual respect.

• Work with the local or state oral health coalition—Dentists who work with dental hygienists and dental assistants, physicians, nurses, public health officials and other individuals and groups in the community can show policymakers and the public that fluoridation has broad-based support and endorsement.

• Tour your local water plant—Seeing how the water plant operates and getting to know its personnel builds bridges and opens lines of communication and education with the water system, policymakers and the public.

• Use ADA and other fluoridation resources—From the ADA’s comprehensive Fluoridation Facts booklet (available at ada.org/4378.aspx), to links for information from dozens of other respected organizations on fluoridation, visit ADA.org/fluoride. The ADA also offers personalized help for communities facing hearings, ballot initiatives or other measures where fluoridation is an issue. The ADA Councils on Communications and Access, Prevention and Interprofessional Relations have created a new resource kit for dental societies. Fluoridation: Tap In To Your Health, will be available in late July. Watch upcoming issues of the ADA News for more information. For more information, contact Jane McGinley, manager, Fluoridation and Preventive Health Activities for the ADA Council on Access, Prevention and Interprofessional Relations, at mcginleyj@ada.org or call toll free, Ext. 2862.

“I attended the city fluoride hearing, and it was disheartening to see out-of-state antifluoride activists attack local dentists who serve local children, adults, seniors and families,” said Dr. Donohoo in a letter to the Milwaukee Journal Sentinel. “Wisconsin’s dentists donate tens of millions of dollars in charitable care through various programs annually. We work with federal, state and local officials to expand access to oral health care, and we support numerous preventive education programs.”

Dr. Donohoo, who has practiced dentistry in Milwaukee for 32 years, said he had many conversations about fluoridation with his late father, Dr. Stanley Donohoo, who practiced in Milwaukee for 57 years. The elder Dr. Donohoo’s career began before fluoridation was implemented in Milwaukee.

“He and I often discussed the dramatic, positive health changes he witnessed as Milwaukee transitioned from nonfluoridated to fluoridated water,” said Dr. Donohoo. “As someone dedicated to serving low-income and Medicaid patients, I love that water fluoridation makes cavity prevention so much easier for everyone. It’s accessible for even the poorest of families. When I see a patient—and sadly, I see this kind of patient weekly—who’s never learned how to brush and can’t always afford fluoride toothpaste, mouthwashes and rinses, I say a silent prayer of thanks that safe, fluoridated water provides them with at least some barrier to extreme dental decay.

“Wisconsin’s dentists want what’s best for our patients. And science shows that what’s best for our patients today is optimally fluoridated water.”

You’re not alone

Help is as close as the ADA’s Fluoridation Facts booklet and resources available to ADA members, said Dr. Mark Peppard, president of the Capital Area Dental Society, which serves the Austin, Texas, metropolitan area.

“The best advice I can give anyone or any group of dentists in a community is to be prepared,” said Dr. Peppard. “Read Fluoridation Facts cover to cover several times. Read The Journal of the American Dental Association scientific articles on fluoridation, on baby formulas, on the valid epidemiological studies on the benefits of water fluoridation and the reason why the recommendations have evolved. Immerse yourself in the concepts of the scientific method and the principals of peer review and why a study has authenticity and validity. Understand how a controlled study is validated epidemiologically. Know the history of fluoridation in the United States. Know the variables of European fluoridation policies.”

For more than a year now, Texas Dental Association members and others in Austin (Texas) have been working to stop fluoridation challenges. The end result is that the Austin City Council last December decided to continue fluoridation of its water system that serves more than 736,000 residents and nearby Water District 17, which serves another 16,000 local residents also reaffirmed fluoridation in April.

“Without question, our members were well prepared thanks to the support of ADA and TDA staff and the resources they provided for us,” Dr. Peppard added. “Our team consisted of general dentists, specialists and dental hygienists and we enlisted the support of the state’s fluoridation engineer for expertise in the chemical engineering of water fluoridation science. We received the support of the medical director for the city of Austin, who presented medical testimony.”

Dr. Peppard said the Texas coalition’s sharing of scientific knowledge and background gave policymakers the confidence to make the decision to continue fluoridating.

“We are the professionals they look to,” he said. “We are the educated and experienced individuals in the trenches they can trust. We have the scientific background and clinical experience necessary to help them make the decision.”

“This is not a walk in the park confrontation. The Fluoridation Facts booklet is organized to help users to address specific claims commonly used by antifluoridationists. Prepare your group and trust your knowledge that in the world of public health, what we strive for is the best method of providing the greatest benefit to those most in need.”

Image: Dr. Peppard
Dr. Peppard