Thursday, December 06, 2012

Fluoridation of water: an idea whose time is passed

To the Editor, Valley News (Lebanon, N.H. & White River Junction, Vt.):

The editorial of Dec. 2 suggests that Bradford commissioners took a step backward in deciding not to continue fluoridation of the town water supply. The Centers for Disease Control is cited, recognizing "water fluoridation as one of ten great public health achievements of the 20th century."

Bradford, however, has taken a step forward, into the 21st century. Fluoride has long been established as an essential ingredient in toothpaste and other mouth care products. Vermont, where a large proportion of the population use water from their own wells, provides regular fluoride treatment to schoolchildren. And health risks from systemic ingestion of fluoride are increasingly acknowledged, for example, by the American Academy of Family Physicians (AAFP). That's why we are warned against swallowing toothpaste and fluoride rinses. Last year the U.S. Department of Health and Human Services and Environmental Protection Agency drastically lowered their recommended levels for water fluoridation. Most European countries do not fluoridate their water.

The AAFP also notes that dental health in communities that don't fluoridate their water improved over the past decades along with those that do. Adding fluoride to the water is a crude approach to dental health compared to improved dental care.

Finally, the editorial attitude that the concerned minority "can opt out by buying bottled water" is arrogant and backwards. The burden should be to "opt in" to systemic fluoride dosing. In fact, fluoridated salt is fairly popular in Europe, just as iodized salt is common here.

Eric Rosenbloom

Update:  In a letter in support of the Valley News editorial, a Hanover pediatrician, Steven Chapman, claims to "see children every week from Bradford who will be hurt by the removal of fluoride from the water". But that is precisely the question: will they, particularly as dental care continues to expand and improve? Or if so, is it enough to warrant the crude dosing of systemic fluoride via the water system instead of more targeted topical delivery (such as fluoride washes in the schools)? Does water fluoridation only serve to take attention away from the real problem, which the writer recognizes, that at least one-third of Americans do not have medical insurance that includes dental care?

The writer also notes that fluoride is a naturally occurring mineral. So is arsenic. And he gives examples of everyday products that are fortified with minerals and vitamins to enhance public health. They are, of course, products that you can choose or choose not to buy, like fluoridated toothpaste. And they are additives that are not potentially harmful if too much is ingested, unlike fluoride.

Finally, he cites the "evidence" that every $1 invested in fluoridation saves $38 in dental treatment costs. That oft-repeated figure comes from one paper from Spring 2001 ("An economic evaluation of community water fluoridation"; Susan Griffin, Karl Jones, and Scott Tomar; Journal of Public Health Dentistry 61(2):78-86), which is not an analysis of historical costs but an estimate of future costs based on caries and fluoridation data from the 1970s and 1980s. But it is precisely the decline of caries since then, because of widespread toothpaste fluoridation and improved dental care, that calls into question the continued effectiveness of systemic fluoridation via the water supply. Even so, the authors recognize that estimating caries incidence in nonfluoridated versus fluoridated communities is difficult, as is identifying costs of both fluoridation and caries, further underscoring Chapman's irresponsible use of the word "evidence".

But this source for the claim of $38 dental cost savings for $1 of fluoridation doesn't even state that. It presents three scenarios in four community sizes, with resulting annual per-person savings ranging from 85 cents to $33.71. The $38 claim seems to be derived from the estimates for a community of >20,000 people of base-case net savings of $18.62 per person plus the cost of fluoridation of 50 cents per person: i.e., 50 cents invested in fluoridation might result in $19.12 in savings, or $1 saves $38. This ignores the full range of estimates, however, particularly for smaller communities. By the authors' estimates, a community of <5,000 people (like Bradford) would likely save only $6, but possibly as little as $1.25, for every $1 of fluoridation.

But again, those are broad estimates only, and they are based on decades-old data.

human rights, Vermont