Filtering through the confusion of fluoride
July 23, 2013
After taking her 8-year-old daughter for a routine dental checkup, Tara Walker noticed small brown spots on the child's teeth. A friend mentioned it looked like dental fluorosis – cosmetic discoloration caused by a surplus of fluoride in drinking water.
Walker had never heard of the term before and delved into Internet research. But the more she searched, the less she understood.
"When I did the search I found there was a big controversy over the benefits of fluoride, and I was concerned," Walker said. "It was hard to tell what was rumor and what was fact."
Finally, Walker, a resident of Granby Ranch, called her local public water provider. After learning they didn't add fluoride to her drinking water and nothing could really be done about fluorosis anyway, she dropped her search.
Still, her confusion lingered.
Walker isn't alone in her befuddlement and her case isn't limited to Grand County. With a glut of misinformation and pseudo-science exploding on the Internet, public confusion abounds. As doubt circulates, many public water providers are dropping their fluoridation programs, from Portland, Ore. to Colorado Springs. In the spring of 2012, the Dillon Valley Water District stopped adding fluoride to its public water system, leading to a Summit County campaign to debunk public fluoridation myths.
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A plethora of scientific and public health organizations emphatically support public water fluoridation, including the American Dental Association, The U.S. Department of Health and Human Services, the World Health Organization, the Colorado Department of Public Health and Environment and The Center for Disease Control recognize water fluoridation as one of the 10 greatest public health achievements of the 20th century. Dental cavities have considerably declined over the last 50 years since the United States began adding fluoride to water, according to the National Academy of Sciences.
"I think it's fabulous, and I wish more places in the county had it," said Dr. Andrew Burns, dentist at Granby Dental. "It helps eliminate decay, and especially childhood decay."
Furthermore, agencies like the Environmental Protection Agency, the National Research Council and the National Cancer institute have debunked myths about adverse health effects from fluoride, as long as it's kept at safe levels.
'Sunscreen for your teeth?
"It's almost like sunscreen for your teeth," said Jen Fanning, director of the Grand County Rural Health Network. "It creates a barrier and makes them strong, reinforcing what's already there for adults, and helping to build it in kids."
Fluoride only becomes problematic when people are exposed to it at high levels over long periods of time. After reviewing community scientific studies and surveys from multiple sources, the U.S. Department of Health and Human Services recommends 0.7 to 1.2 parts per million (ppm) fluoride in drinking water.
One part per million is the equivalent of one penny in $10,000.
"Like most things, anything in excess is bad for you," Dr. Burns said. "People say it's poison, and if there's too much it can be. But in the right dosage it's very beneficial."
Among the most common anti-fluoridation claims made by interest groups like Fluoride Action Network and Mercola.com are that it has negative health consequences and it represents an unethical form of mass medication.
These groups assert that public water fluoridation negatively affects bones, joints, brain tissue and glands, among other things.
However, fluorosis is the only health effect scientifically linked to consuming fluoride in drinking water. With low levels of fluoride, fluorosis is purely cosmetic with no adverse health impacts. It occurs in childhood, resulting in tooth discoloration that ranges from light, lacey patterns to brown spots and pitting.
For infants, a 2011 American Dental Association panel found that formula reconstituted with fluoridated drinking water only increased the risk for mild enamel fluorosis, but it didn't significantly alter the child's health or teeth. The risk can be avoided by breastfeeding for the baby's first year or using non-fluoridated water. Above all, the association recommends parents consult their dentist.
At extremely high levels, ingested fluoride can penetrate bone and cause joint pain and decreased mobility. However, according to studies reviewed by the National Research Council and the World Health Organization, these conditions only occurred when humans were exposed to fluoride concentrations exceeding 8 ppm in drinking water over many years. And according to the American Dental Association, only five cases of crippling skeletal fluorosis have been confirmed in the U.S. in the last 35 years.
As far as the claim of mass-medicating — considered unethical in most other developed nations, particularly in Western Europe — countries like Switzerland, Germany, Spain and France distribute fluoride through table salt, much like the U.S. does with iodine. According to the Pew Research Center, at least 70 million Europeans consume fluoridated salt, and milk fluoridation programs reach many other European citizens.
"I think it's all this anti-government stuff, people don't want the government getting into any part of their lives, that's my personal opinion," said Gail Van Bockern, Public Nurse at Grand County Public Health.
Numerous community studies since the 1940s have proven fluoride's benefits in preventing dental cavities. As infants and young children ingest fluoride it incorporates into their developing teeth, strengthening them and protecting them from future decay. Fluoride in drinking water holds the maximum benefit for children in this developing stage, but it also helps adults, just like topical treatments including toothpaste and mouthwash.
Recommended levels in water
The levels recommended by the U.S. Department of Health and Human Services are a range (0.7-1.2 ppm) that fluctuates to lower levels in the summer, when water consumers are expected to drink more, and higher levels in the winter, when water consumption is expected to drop. The Colorado Department of Public Health and Environment has adopted the same recommended levels for water providers in the state. About 70 percent of Colorado residents receive fluoridated water
But in Grand County, the Town of Granby's North Service Area is the only water district that adds fluoride to drinking water. Water Superintendent Rich Schroer acknowledged that adding fluoride can sometimes open a political can of worms.
"We have a lot of people making arguments that they don't want people adding stuff to their water. But if you talk to dentists and doctors, they think it's a great deal," he said.
Schroer's district serves the portion of Granby north of the Fraser River. During their last round of testing in 2012, they had fluoride levels at 0.95. Equipment constantly measures levels to ensure water remains safe.
Fluoride occurs naturally in almost all water sources at varying levels. It forms as water passes through fissures and pores in rocks with fluoride-bearing minerals. According to the Environmental Protection Agency, fluoride can also enter drinking water through runoff from fertilizer or aluminum manufacturers.
To ensure fluoride remains at safe levels, the Environmental Protection Agency has set maximum levels at 4 ppm. To prevent tooth discoloration in children, it has a set a non-enforceable secondary standard at 2 ppm. The agency has federal authority to regulate and monitor public drinking water, granted by the Clean Water Act.
Levels around Grand County
According to most recent results reported by Grand County's water districts, no major public water system has fluoride levels exceeding 1.1 ppm, presumably making water safe from fluorosis.
But most water districts fall considerably short of optimum fluoride levels recommended by public health agencies.
In their reluctance to add fluoride to the county's public water, district operators largely point to controversy, inconclusive data on fluoride's benefits and a lack of public interest in fluoride. Many also point to cost.
"There's never really been a request for it," said Allen Nordin, public works director for the Town of Fraser. "Probably the bigger picture is that it's fairly costly to add that to a water system." Nordin noted that Fraser has two water plants, so the expense would double for the town.
Paul Strauss, who operates the water system for Lake Forest Mutual near Grand Lake, removes high levels of naturally occurring fluoride. He said the system's groundwater has levels of fluoride at 11 ppm – well above EPA's action levels. Through reverse osmosis, he filters fluoride to concentrations down around 0.2 ppm – well below levels recommended by health professionals.
"In my experience, you cannot please everyone in your district with the addition of fluoride," he said. "A good solution is to let the end user add their own at the tap and forgo the expense of adding it on a large scale."
But Superintendent Shroer, operating the water district in north Granby and the only district that adds fluoride in the county, says his costs are minimal. He adds one 50-pound bag of fluoride-bearing mineral to the water supply a month, which costs about $27. He estimated another $70 in expenses operating the water plant's analyzing equipment. In total, fluoride costs his district about $100 a month, or less than 70 cents per district resident each year.
Lauralee Kourse, who operates Tabernash Meadows Water and Sanitation District, has decided to take a "practical approach" to managing her area's water, following the science recommended by the American Dental Association.
While Kourse doesn't add fluoride to her water system, the Tabernash area's aquifer has higher levels of fluoride at deeper levels. She blends it with water containing lower levels to get a ratio between 0.7 ppm and 1 ppm, and then distributes the water to district residents.
But she admits fluoride is a complicated issue.
"There are a lot of people that are afraid of anything added to their water, like chlorine," she said, referring to a 2008 salmonella outbreak in Alamosa that resulted in 442 illnesses and one death. Prior to the outbreak, the city did not use chlorine for disinfection – it had obtained a waiver from complying with state regulations in the 1970s.
"You have to trust scientists and doctors on some things," Kourse said.
Residents with well water
Kourse's district is small, serving about 150 residents. Many Tabernash homes are on private wells, which aren't required to test for fluoride. Some of those wells tap deeper water that may have higher fluoride concentrations.
"A lot of people have well water, and they wouldn't even think of testing it for fluoride," Kourse said
Well-water users can have their water tested, and those with well water exceeding recommended levels, or who wish to remove fluoride from their water, can do so with household reverse osmosis filtering systems. Traditional charcoal filters and boiling will not remove fluoride.
County families who feel their children are not receiving adequate levels of fluoride through drinking water can ask dentists for drops and edible tablets, available through prescription.
"It's been significantly proven over and over again that fluoride's an amazing form of preventive care for cavities, especially while teeth are forming," said Jen Fanning of the Rural Health Network. "Personally, I have a one year old, and she's on fluoride drops, so I put money where my mouth is."