Commentary: Is Fluoride Right for Davis?

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fluoride-waterby Tia Will

Over the past few months, much has been discussed in public, before the WAC, in letters to the editor of the Enterprise and in this blog about the pros and cons of water fluoridation. Some of the comments pertain to the effectiveness of fluoride in the prevention of tooth decay, some to the safety, some to the costs, some to whether or not this is an appropriate public health measure at all.

All of these are valid concerns which should and have been addressed at length. We are approaching time for the City Council to make a decision. This is not a “no brainer” as some from each side of the issue have suggested. What I think is true of both proponents and opponents is that everyone who cares enough to educate themselves and comment on this issue has the best interest of the community in mind. What we have are differences of opinion about what is the “best interest” of our community.

I see much of the debate as centering around false dichotomies. A number of folks have suggested alternatives  involving provision of care by such programs as Step by Step or by Communicare using funds that would otherwise be spent for water fluoridation. Others have suggested simply teaching people to eat better or to take better care of their teeth.

These comments are all well intentioned and overlook a vital point. The people that are the most in favor of water fluoridation are those who are already the most active in the public health sphere and are seeing the problems with and short falls of these programs. These are the same private health care and public health care providers who are saying that, yes, we need to pursue these kinds of programs as many of us have been in our own practices, and we need water fluoridation. This does not have to be an either/or situation. We can chose to fluoridate our water, and still make efforts to address the other contributory factors.

A second mistaken argument surrounds what other communities have chosen to do.

Much has been made of the fact that some other communities, cities, and countries have chosen not to fluoridate their water. What is often missing from this discussion is that water fluoridation is simply one of a number of strategies for providing supplemental fluoride to a population whose water sources do not provide the demonstrated optimal amount for prevention of decay.  Because other communities have adopted other strategies does not in any way mean that water fluoridation is not the best current option for the City of Davis given that we are unlikely to have readily available, single payer, universal health and dental care provision in the foreseeable future as many of these countries do.

Adoption of water fluoridation does not preclude anyone from providing what they consider to be the best option for their own family. However, not fluoridating the water will mean that many in our community will not be receiving optimal and safe levels of fluoride for primary prevention of the common problem of tooth decay.

My advocacy for water fluoridation stems from my interest in primary prevention as an effective way of strengthening individuals and communities. The less time and money that is diverted from the productive activities of school, work, recreational and community activities to sit in a dentist chair for the repair of cavities, the more productive will be the individual and the stronger the community. A guiding principle in health care both individual and public is to assess the risk benefit ratio of any policy before implementation.

As an initially neutral party in this debate, after many hours spent assessing the claims of each side, I arrived at the conclusion that in the case of water fluoridation for Davis, the benefits far outweigh the potential demonstrated risks.  It is this, and only this consideration that leads me to conclude that the decision by the City Council to fluoridate the water would be the best option for Davis at this point in time.

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33 thoughts on “Commentary: Is Fluoride Right for Davis?”

  1. EastDavid

    From what I have read, the most effective application is directly to the teeth and does not really help adults whose teeth have already developed. Therefore, why not use (considerably less) funds to allow children to receive fluoride treatments in school? This has been done successfully in other places in the USA.

  2. B. Nice

    @ Tia Will. Thanks for researching this issue and sharing the knowledge you gained. I’ve learned a lot of quality, substantive, information regarding the fluoridation issue from your thoughtful articles and blog comments.

  3. davisite2

    ” City of Davis given that we are unlikely to have readily available, single payer, universal health and dental care provision in the foreseeable future as many of these countries do.”

    Children who need dental care but do not get it because of the cost are now covered by Federal and State legislation. The absence of universal single payer health coverage is just NOT a valid public health argument for fluoridation.

  4. medwoman

    EastDavid

    [quote]From what I have read, the most effective application is directly to the teeth and does not really help adults whose teeth have already developed. [/quote]

    I had this same question myself until it was explained to me by a local dentist, and subsequently confirmed by others, that the mechanism of action of ingested fluoride is direct application to the teeth, continuously applied by our saliva. This ensures that the presence is constant and consistent, not sporadic.

    This is actually very consistent with how most medications are delivered. For the patient with pneumonia,
    we provide antibiotics either orally, with intramuscular injection, or through intravenous lines depending on the severity of the illness. The actual molecules are supplied to the bacteria via the blood. We know that some of the antibiotic will reach other body organs, but the potential risk to those organs that did not need the antibiotic is minimal in comparison to the benefit to the lungs.
    In case of fluoride the application medium is saliva rather than blood but the principle is the same.

    The question of benefit to adult teeth is one of degree. While it is true that the most benefit will be seen by children, some benefit will also accrue to adult teeth through antimicrobial action and to a lesser degree than with children to maintenance of enamel strength.

  5. medwoman

    davisite2

    [quote]The absence of universal single payer health coverage is just NOT a valid public health argument for fluoridation.[/quote]

    I am sure that there are those among the proponents of fluoridation who would agree with you on this point.
    I happen to disagree. That is why when I post, I post as a doctor and private citizen, not as representing any other entity.

  6. Growth Izzue

    Medwoman, funny how you left out the davisite2’s other part of the post:

    [quote]Children who need dental care but do not get it because of the cost are now covered by Federal and State legislation. The absence of universal single payer health coverage is just NOT a valid public health argument for fluoridation. [/quote]

    Underprivileged kids will have access to care through Federal and State legislation (Obabacare)

  7. medwoman

    GI

    [quote]Underprivileged kids will have access to care through Federal and State legislation (Obabacare)[/quote]

    David has covered this point repeatedly. I do not feel the need to reiterate points that have been made on numerous occasions by other posters.

    My intent is to share the information that I have gained through my own reading and conversations with professionals more knowledgeable than I in a number of areas regarding prevention of tooth decay and both private and public health care strategies. I also am happy to share my perspective on the strengths and weaknesses of the various strategies based on over 30 years as a health care professional ( Ob/Gyn).

  8. Growth Izzue

    David, that’s a weak argument and the people that want to fluoridate know it and try to use the “bad parents” that won’t apply fluoride to their children as a lame excuse.

  9. medwoman

    GI

    [quote]try to use the “bad parents” that won’t apply fluoride to their children as a lame excuse.[/quote]

    This is not, as you have implied repeatedly, an issue of “bad parents”. Life presents different challenges to different individuals and families.

    I do not consider my own parents to have been “bad”. There were however, limiting circumstances that posed many challenges to obtaining appropriate health care. Neither of my parents was highly educated. We lived rurally. Only my father drove, and we only had one car in any event. My father worked long hours distant from home and frequently hunted, fished, or picked fruit on the weekends distant from our home to supplement our food. This did not make trips to the dentist a common event for our family. In retrospect, my sister and I would probably have benefitted from fluoride in our water supply. While Davis is not a rural community, and these particular challenges do not pertain, there are many other challenges that prevent people from obtaining optimal health care. Here is where we have an opportunity to make a substantial difference.

    This is not an either/or situation. I hope that many, many people will have improved health care outcomes with the changes in our health insurance delivery system. I can still foresee that for many, addition of fluoride to the already present amount to achieve an amount known to prevent cavity formation, will provide added benefit.

  10. Growth Izzue

    Medwoman, we’re talking about fluoridation here. Is it so hard for parents to buy fluoride toothpaste for their kids to brush with even if they have to walk uphill in the falling snow to the store with no shoes on? ……………Sheesh…………

  11. Growth Izzue

    This is supposed to be about fluoridating our water or not. It’s not about revamping the underprivileged dental programs of our community. How did that get thrown into the equation anyway?

  12. David M. Greenwald

    GI: Because that’s the problem that fluoridiation is seeking to fix. Or at least some proponents of it. So if you don’t want to do fluoridation, but still believe there is a problem, then you start looking for alternatives.

  13. medwoman

    GI

    [quote]It’s not about revamping the underprivileged dental programs of our community. How did that get thrown into the equation anyway?[/quote]

    The factual answer to your question is that opponents of water fluoridation raised the issue of alternatives involving dental care for the underprivileged. I am sure that many of the proponents would have preferred a straight up or down vote on the issue of fluoridation alone.

  14. ebowler

    [quote] the mechanism of action of ingested fluoride is direct application to the teeth, continuously applied by our saliva.[/quote]

    Since you agree with fluoride opponents that fluoride is primarily effective as a topical agent, and since highly effective topical agents are widely available in the form of fluoridated toothpastes and mouthwashes, why should the citizens of Davis, especially children, be subjected to the potentially harmful effects of systemic fluoride? I am particularly concerned about neurotoxicity and neurobehavioral effects and, while more studies need to be done in these areas, the initial reports are quite disturbing.

  15. medwoman

    ebowler

    Because I do not share your view that “widely available” equals effectively used.

    And because I do not believe that the literature supports your concern about neurotoxicity and neurobehavioral effects. I do not find any of the reports that have been directed to me as “quite disturbing”. When faced with a known and demonstrable problem such as cavity formation as the preventive benefit, and speculation about a possible, undemonstrated harm, I will weight the risk benefit ration in terms of the known, not the speculative.

  16. medwoman

    To all. I am leaving for an event in Berkley. I believe in being available to answer questions about articles I have written and so will check back in upon my return this evening.

  17. ebowler

    [url]http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/[/url]

    The 2012 Harvard meta-analysis is the most recent study to sound the alarm about adverse effects of fluoride on neurodevelopment. When fluoridation proponents began using this study in the Wichita and Portland fluoride debates as alleged evidence of the safety of water fluoridation, the senior scientist on this study, Philippe Grandjean MD, responded with the following:

    [quote]Chemical brain drain should not be disregarded. The average IQ deficit in children exposed to increased levels of fluoride in drinking water was found to correspond to about 7 points – a sizable difference. To which extent this risk applies to fluoridation in Wichita or Portland or elsewhere is uncertain, but definitely deserves concern.[/quote]

    When the senior scientist in this field of study warns that we should be concerned about the possible neurotoxic effects of fluoride, it would be reckless and irresponsible to ignore such a warning and proceed.

  18. gordonite

    Fluoridated water seems to me a scatter-shot solution for an identifiable and specific target.
    My concerns are with the accumulation of fluorides in the environment.

    The conclusions on pages 15-16 (36-37 in a pdf viewer) of this WHO report on fluorides include, “There is a need to improve knowledge on the accumulation of fluoride in organisms and on how to monitor and control this”, and “Excess exposure to bioavailable fluoride constitutes a risk to aquatic and terrestrial biota”. That’s enough to prevent me from supporting fluoridated water.
    http://whqlibdoc.who.int/ehc/WHO_EHC_227.pdf

  19. davisite2

    “…Because that’s the problem that fluoridation is seeking to fix.”

    The data indicates that there is NO significant difference in cavity incidence between children who drink fluoridated water and those who don’t.
    Granted that this data may have been collected by dental exams and missed those who were not examined by a dentist. If this was not considered in previous studies, it can be readily studied now that children in poor circumstances can receive dental care at no cost. The data that we do have now tells us that fluoridation in the water supply has no appreciable effect on the incidence of dental decay and its public health dental benefits are speculation, without hard data. We should not proceed with fluoridating Davis’ water supply, with its documented negative side effects and cost to the city, until new studies,if necessary, include these children,now a significant number under the Affordable Care Act, who did not previously see a dentist. As is the case in the history of medical/dental practice, resistance to change and inertia are part of the pro-fluoridation equation here.

  20. Frankly

    There appears to be three opinion drivers for the pro fluoridation people:

    1. Medical – The belief of medical professionals that fluoride is effective and safe enough to prescribed to the entire population so as to help a few.

    2. Social Justice – The belief that some people cannot or will not take care of their own, or their children’s’, dental hygiene; and the corresponding believe that society must step in a do it for them even when the cost is high and the help causes harm to others.

    3. Stubborn Bias – The belief that it is more important to win the position taken rather than concede “defeat” to those taking the opposite position. Or those that stubbornly trust tradition – The belief that since we have been doing it, it must be good… and hence we should keep doing it.

    Rebuttals to these positions.

    [b]1. Medical[/b]

    This is not medical grade fluoride. It is a toxic and hazardous industrial-grade waste by-product of fertilizer manufacturing. The very doctor-prescribed pharmaceutical-grade sodium fluoride used in toothpastes, mouthwashes is too expensive to dump in the water as a shotgun approach to hit a few targets

    Doctor over-prescription of drugs is a well-documented problem in society. It is understandable that people so invested in a career helping to improve the health situations of patients would push the boundaries prescribing the drugs that are designed to help. However, most progressive doctors suggest patient involvement and patient advocacy and collaborative decision processes for treatment options. Fluoride in the drinking water risks over-prescribing the drug to some people, and also eliminates the modern practice of doctor-patient collaborative decisions on treatment options.

    Doctors take an oath to do no harm. It is clear that this industrial-grade fluoride supplement in the water would be harmful to some people. There are numerous scientific studies on the health risks of ingesting excess fluoride. The concentrations in fluoridated water, combined with the growth in abundance of fluoride in other products, increase the risk that some people will ingest enough fluoride to cause them health problems.

    The bottom line here is that doctors are human and fallible… and they are out of the boundaries of their professional credibility on this topic. Those pushing fluoridation of the drinking water from a medical perspective should be rigorously challenged for the reasons above.

    [b]2. Social Justice[/b]

    The damage caused by the soft bigotry of low expectations is real and pervasive. It is a primary reason that we have multiple, ongoing generations of the same families on welfare and food stamps. Fluoride in the water only treats the symptom of other problems: primarily poor dental hygiene and poor diet.

    Put fluoride in the water, and many people stop caring about dental hygiene and diet because they believe the water does the job. Also people that would otherwise contribute time and resources to improving dental hygiene and diet would decline that effort believing that we are doing enough putting fluoride in the water. We can include our city in this… since we would need to spend about $2 million in capital costs, and then about $250,000 per year in ongoing costs… it is likely that we would lack the public support for spending even MORE money on other health-related programs.

    Lastly, every compound we add to the water makes it back to nature. Fluoride would accumulate in wetlands from our waste water. It would damage wildlife in ways we both understand and don’t understand.

    The bottom line here is that those pushing fluoridation of the water for reasons of social justice need to be rigorously challenged to seek more creative and long-term solutions for the people that need help.

    [b]Stubborn Bias[/b]

    Not much to comment on this one. These people are not worth any time to debate… and generally don’t want to debate.

    And in the end, we can respect everyone’s right to have an opinion, even if that opinion is wrong. But should not have to pull any punches telling them they are wrong and why.

  21. B. Nice

    “Put fluoride in the water, and many people stop caring about dental hygiene and diet because they believe the water does the job.”

    Most people, poor, middle class, rich, educated, or uneducated, have no idea wether or not there is fluoride in their water.

  22. medwoman

    ebowler

    [quote]When the senior scientist in this field of study warns that we should be concerned about the possible neurotoxic effects of fluoride, it would be reckless and irresponsible to ignore such a warning and proceed.[/quote]

    I would agree if I were not very familiar with the meta analysis in question. Your comment does not take into account the following points.
    1) The authors themselves in the body of their study caution about extrapolation of their results to industrialized countries in which the levels of fluoride to not reach toxic levels ( < 1ppm)
    2) The measured IQ differentials of 7 points are within 1 standard deviation and thus do not reach levels of clinical significance according to my statistical consultant.
    3) The studies in question did not control for other possible major contributory factors such as the IQs of the parents.
    So I agree with the author that we should be cautious about the effects of fluoride in much the same way that we should be cautious when driving an automobile or using any medication. Each potentially hazardous object or substance we use should be used within its safe range of operation or consumption. The proposed level is well within the safe range for fluoride.

    While we are drawing our articles for consideration from the FAN site, one might also want to consider the study by Bhatnager who considered fluoride content of water at < 1ppm as so safe that he considered this the safe level in the water to administer to patients being treated for acute fluoride toxicity. I do not often see this study mentioned by the opponents of fluoridation, but it is there.

  23. medwoman

    Frankly

    [quote]There appears to be three opinion drivers for the pro fluoridation people

    1. Medical – The belief of medical professionals that fluoride is effective and safe enough to prescribed to the entire population so as to help a few.

    2. Social Justice – The belief that some people cannot or will not take care of their own, or their children’s’, dental hygiene; and the corresponding believe that society must step in a do it for them even when the cost is high and the help causes harm to others.

    3. Stubborn Bias – The belief that it is more important to win the position taken rather than concede “defeat” to those taking the opposite position. Or those that stubbornly trust tradition – The belief that since we have been doing it, it must be good… and hence we should keep doing it.
    [/quote]

    1. Medical – The belief of medical professionals that fluoride is effective and safe enough to prescribed to the entire population so as to help a few.

    2. Social Justice – The belief that some people cannot or will not take care of their own, or their children’s’, dental hygiene; and the corresponding believe that society must step in a do it for them even when the cost is high and the help causes harm to others.

    3. Stubborn Bias – The belief that it is more important to win the position taken rather than concede “defeat” to those taking the opposite position. Or those that stubbornly trust tradition – The belief that since we have been doing it, it must be good… and hence we should keep doing it.
    [/quote]

    And now for the actual rebuttal of these mythical positions you have ascribed to the proponents:

    1. I do not want to prescribe for the entire population “to help a few”. I believe that optimal amounts of fluoride would actually be beneficial for most of the population. I am not asking you to agree with me. I am asking you to not misrepresent my position.

    2.Social Justice – I certainly do believe that a society that has the resources has an obligation to help those who are vulnerable and in need regardless of the reason. And I do not believe that there is a significant risk or that the cost is too high. Obviously, if I believed either of these to be true, I would not be a supporter.

    3.Stubborn bias – since I am a new convert to fluoridation after having been a neutral party prior to my own
    investigation of the pros and cons, I do not see how this would apply.

  24. davisite4

    Don’t adults and children actually have to drink the water to get the benefit? Do we know what %s of the target populations (those not getting sufficent dental care) drink much tap water?

  25. davisite2

    ” The belief of medical professionals that fluoride is effective and safe enough to prescribed to the entire population so as to help a few. “

    “Medical professionals” have held “beliefs” that were wrong and harmed their patients. You don’t have to look much further than the past medical practice of unconscionable excessive hysterectomy procedures.

  26. medwoman

    davisite4

    Yes, they would have to drink the water. And no we don’t know this exact percentage. And we also don’t know the percentage that actually brush their teeth or floss or take part in any other preventive measure with precision. We do not even have exact statistics on how many children and adults do and don’t obtain dental care. ( At least I do not have the precise information). It may well be that someone has a good estimate.

    I agree that it would be nice to have precise numbers. However, that is not the world in which we live and so we, as individual health care providers and as individuals involved in the public health sphere make our best estimates just as everyone else does with incomplete information within their own areas of expertise.

  27. davisite4

    [quote]I agree that it would be nice to have precise numbers. However, that is not the world in which we live and so we, as individual health care providers and as individuals involved in the public health sphere make our best estimates just as everyone else does with incomplete information within their own areas of expertise.[/quote]

    I am not looking for precise numbers. Here’s the thing, though. We pay lots of money to put fluoride in the water — water that is used for washing dishes, watering lawns, taking showers, flushing toilets, washing cars and sidewalks… etc., etc. And maybe, in some households, drinking water. (Mine, for instance). But I think in a lot of households, the kids don’t drink much water, much less tap water. They drink soda or juice or milk. So then, we’ve spent a lot of money and aren’t even sure that it’s doing what it’s supposed to be doing, while meanwhile, we’re dumping fluoride into all kinds of places where it isn’t needed. That seems wasteful and unnecessary to me.

    At the very least, the city ought to have done the simplest survey, querying people on their drinking of tap water, correlated with socioeconomic status. Has it? Some people don’t like Davis water. Perhaps our %s of tap water drinking are lower than other communities, so that their results would not be comparable to ours. This ought to be determined before we spend $$$ to put fluoride in our water.

    This money weighs particularly heavily when we consider that we’d be acting against the wishes of citizens who want to choose for themselves whether they want their children exposed to fluoride in this way. Water is an [i]essential[/i] need, which we owe to all citizens; fluoride is not.

  28. medwoman

    davisite4

    [quote]But I think in a lot of households, the kids don’t drink much water, much less tap water. They drink soda or juice or milk[/quote]

    This is a good point, and is one of the reasons that fluoridation is not seem by the proponents as an isolated step in public health policy. The proponents are the same people who are advocating for drinking more water, cutting out sweetened beverages and juices ( many of which are reconstituted at home using water) and eating more healthy foods as aspects of healthier living. I do not know anyone who is saying “let’s just put fluoride in the water and forget about it”.

    As for the cost, fluoride is probably the lease expensive preventive measure that we could be choosing on an individual household basis. The cost for fluoridating has been estimated as an additional two dollars per month per household. A single cavity filling costs from $300 to $350, plus time away from school or work. People whose job it is to figure out the numbers have estimated something like a 38 dollar savings in medical cost for every dollar spent on fluoride. I don’t pretend to know how they derived this number however, from 30 years in medicine, I do know that prevention is always less costly than fixing a problem medically or surgically once it has occurred.

  29. ebowler

    [quote]I would agree if I were not very familiar with the meta analysis in question. Your comment does not take into account the following points.
    1) The authors themselves in the body of their study caution about extrapolation of their results to industrialized countries in which the levels of fluoride to not reach toxic levels ( < 1ppm)
    2) The measured IQ differentials of 7 points are within 1 standard deviation and thus do not reach levels of clinical significance according to my statistical consultant.
    3) The studies in question did not control for other possible major contributory factors such as the IQs of the parents.
    So I agree with the author that we should be cautious about the effects of fluoride in much the same way that we should be cautious when driving an automobile or using any medication. Each potentially hazardous object or substance we use should be used within its safe range of operation or consumption. The proposed level is well within the safe range for fluoride.[/quote]

    Then you should know that the Harvard meta-analysis did NOT suggest that their results were not applicable to US water fluoridation programs. That false allegation was made by a pro-fluoridation Wichita newspaper at the height of the Wichita debate and was quickly disavowed by the paper’s authors, who were appalled that their study was being misrepresented in this way (you can read the response from the senior author here [url]http://braindrain.dk/2013/02/fluoridated-water-and-brains[/url]). These and other shenanigans were perpetrated by the pro-fluoridationists in Kansas and subsequently in Portland. It is unfortunate to see the same misrepresentations being inserted into the discussion here. You can read the entire meta-analysis posted in my previous comment, which links to the original article not the FAN site.

    An IQ drop of 7 points is very worrisome as the authors suggest. One IQ point decrease is associated with an up to 10% drop in productivity and as a result has significant societal implications. This is, in fact, the most significant and worrisome aspect of this study.

    Since this was a meta-analysis, the authors did not control for anything but they excluded some reports that they did not feel met their rigorous criteria. You can read their inclusion criteria in the report. They note, however, that none of the studies controlled for parental education which would possibly be one indication of native intelligence, although not necessarily. These studies have yet to be been done but, but the lack of evidence does not imply safety. The authors call for further studies to more thoroughly explore these issues.

    I am happy to discuss the 2006 Bhatnager study which concludes “Excessive intake of F from NaF significantly reduces AchE and BchE activity in the hippocampus.” In addition to neurotransmitter system disruption, impairment in the antioxidant system was also found. The authors did not study the effect of lower levels of fluoride on brain structure or function. Again, these studies have yet to be done, but lack of evidence is not evidence of lack of harm. Besides, we are not talking about adding sodium fluoride to the Davis municipal water, but rather a fluorosilicic acid.

    The 2012 Harvard meta-analysis, conducted by the Harvard School of Public Health, is currently the state of the art science in the area of neurofunction and neurotoxicity. Certainly more studies need to be done, but to claim that fluoride is safe because the studies do not yet exist is to potentially jeopardize the brain health of our children. We ignore the warnings of these scientists at our peril.

  30. davisite4

    [quote]The proponents are the same people who are advocating for drinking more water, cutting out sweetened beverages and juices ( many of which are reconstituted at home using water) and eating more healthy foods as aspects of healthier living. [/quote]

    If you could get people to do that, you could get people to buy fluoride toothpaste for their kids and instruct them in proper brushing. If anything, that seems like an easier change in habit than changing what one eats.

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