After Juneau stopped adding fluoride to drinking water in 2007, Dr. David Logan says he quickly saw an increase in patients with cavities.
Now executive director for the Alaska Dental Society, Logan practiced dentistry in Juneau for 28 years and his retirement came in 2013 — about six years after the City and Borough of Juneau stopped fluoridation.
“I saw almost immediate effects in the adult population,” he said in a recent interview.
In many communities in Alaska and the U.S., the mineral fluoride is added to drinking water in an effort to promote better dental health. About two-thirds of the country’s population and half of Alaskans receive fluoridated water, according to the Centers for Disease Control and Prevention.
Fluoridation stopped in Juneau back in January 2007.
But even today, 12 years later, the issue flares up. Right now fluoridation is receiving renewed scrutiny after a recent study that examined dental health in Juneau published in December in the journal BMC Oral Health “reaffirm(ed) that optimal CWF (community water fluoridation) exposure prevents dental decay.”
Subsequent reporting on the study by KTOO found children under 6 are experiencing one additional cavity per year, which translates to an expense of about $300 per child.
Dr. Jessica Blanco, pediatric dentist, told the Empire she’s only been practicing in Juneau for the past three years but did work as a dental assistant when the water was fluoridated.
“It certainly felt like it was a change,” Blanco said. “Studies show there is a correlation, and fluoride is an easy, kind of economic way to help strengthen teeth. I think understanding how it works is the most important thing.”
Blanco, who is board-certified through the American Board of Pediatric Dentists, said anytime someone eats or drinks something that isn’t water, even fruit, the mouth becomes acidic. That’s when cavities form.
“When fluoride gets incorporated in the teeth, the Ph has to go down all the way to 3.5 before you have a breakdown of the teeth,” Blanco said. “Normally, a tooth that doesn’t have fluoride, at 5.5, you’re already getting demineralization of your teeth.”
Gnashing of teeth
Fluoridation advocates insist it is important for dental health, and detractors insist it is at best unnecessary and at worst harmful.
“Fluoride strengthens the teeth in ways that there’s no substitute for,” Logan said.
He compared applying topical fluoride to painting the surface of a rusted building and said it is not as useful as systemic exposure to fluoride from community water sources.
Blanco said fluoridated water has been shown help dental health, but those totally opposed to fluoride could look to brush their teeth with toothpaste containing baking soda, which would help neutralize an acidic mouth.
“I do still advocate for it, but you have to help people who feel strongly against it,” Blanco said.
In addition to the non-fluoridation’s reported effects on children, Logan said he saw an uptick in the number of older patients with root cavities, which are cavities near the root surface of the tooth.
“I didn’t expect it, but I sure noticed it,” Logan said.
Blanco said fluoride would help plug microscopic openings that lead to the tooth’s nerves.
“I can see how you might see that correlation,” Blanco said.
Fluoridation’s detractors maintain it is potentially dangerous.
“I think if people want to consume fluoride, there’s fluoridated toothpaste,” said David Ottoson, owner and manager for organic downtown food store Rainbow Foods, who was on the record as being against fluoridation more than a decade ago. He said in a recent interview he has not changed his opinion. “Medicating people through the municipal water supply is a very crude way to deliver something that you’re describing as basically a medicine.”
“The idea that fluoride just affects the teeth and doesn’t affect any other organs is an unsupportable position,” he added.
Both the Centers for Disease Control and Prevention and World Health Organization say low levels of fluoride typical of fluoridated water are safe and likely beneficial. Those organizations also acknowledge high concentrations of fluoride can be harmful.
Ottoson said the report could be taken as support for the idea that fluoridation does have a positive effect on dental health, but he said there are other factors that could impact dental health. The study’s focus on Juneau doesn’t consider whether communities who have continued fluoridation have seen a similar increase in cavities, Ottonson said.
“It’s just one data point,” Ottoson said.
Mayor Beth Weldon said the city is unlikely to begin fluoridation again since the matter was put to a vote in 2007’s October citywide election and non-fluoridation won 5,975-3,803.
Despite the recent study, Weldon said she has not recently received many fluoridation-related communications.
Logan similarly said he has not heard of a renewed effort for fluoridation in Juneau among dentists and such a push would need to come at the local level.
“The last fight there was pretty bruising,” Logan said. “It was unfortunately a pretty convincing defeat.”
Blanco said while local dentists do discuss water fluoridation, opposition to fluoridation can make public advocacy unappealing.
“With things have gone in the past, somebody can get a bad name right away,” Blanco said. “Maybe some of their patients that feel strongly against it say, ‘Oh, gosh, I don’t want to go there, they’re the face of fluoride. I think there might be some hesitation when it comes to that. “
Brushing up on recent history
The decision to remove fluoride from the drinking water was reached in December 2006 and fluoridation stopped on Jan. 15, 2007.
The action came after the issue was examined by a six-person commission over a period of more than two years.
At the time, three commission members recommended continuing fluoridation based on overwhelming support from the medical community, two opposed fluoridation because it could be harmful and one concluded evidence slightly supported fluoridation but not overwhelmingly so.
The Assembly ultimately decided to cease fluoridation.
Reflecting upon that decision, then-Mayor Bruce Botelho said in an interview this week he initially anticipated continued fluoridation to be overwhelmingly the right move. But he said he came away less certain and in favor of a “do no harm” approach.
“One of the things that was fascinating to me is that most western European countries do not fluoridate, but their (cavities’) rate were not different, or in some cases lower than the U.S.” Botelho said. “What put me over the top was trying to reconcile the Western Europe carrier differences.”
The Assembly directed the city manager to cease fluoridation at a Dec. 11, 2006 meeting, but the matter stayed in the public consciousness and was on ballots in October 2007, where non-fluoridation was resoundingly favored.
Botelho said he has read reporting on the December study that indicated there has been an increase in cavities but not the study itself.
“It’s clear from at least the study as reported that we have a higher tooth decay rate than we did before, and that should be a matter of concern,” Botelho said. “I’m not in a position to judge how serious that is or to weigh it against the amelioration of harm for those who are fluoride sensitive. I’m not willing to jump too far in making conclusions other than to acknowledge and accept there has been an increase in the number of carries.”
“I’m someone who would be open to be persuaded that this topic should be revisited, but I’m not going to lead it,” he added.
Both the CDC and World Health Organization note people with kidney troubles could be adversely affected by fluoride, but the population is small and difficult to study. The National Kidney Foundation has not issued specific guidelines for fluoride intake for similar reasons.
On the levels
Whether fluoride in water has an adverse impact on those who drink it depends on the concentration of fluoride in the water, according to both the CDC and WHO.
Their standards say up to 1.5 milligrams of fluoride per liter of water can be safe. When Juneau’s water was fluoridated, Botelho said it was at .7-.9 mg/l.
A fluoride concentration of about .5 mg/l is needed to have positive effects on tooth decay, according to the WHO. That’s five times the level in Juneau’s water without fluoridation, according to annual CBJ drinking water reports.
Reaching the upper limits of what the CDC and WHO deem safe can have some unwanted effects in some cases.
Water with fluoride levels approaching the 1.5 mg/l figure can cause dental fluorisis, according to the CDC. Fluorosis usually manifests as white spots on the tooth that do not affect dental function.
Children 8 and younger are generally the only ones at risk because that is when their permanent teeth are developing, according to the CDC.
Higher concentrations can have more severe effects.
Negative skeletal affects from fluoride can be observed at 3-6 mg/l. Those levels are two to four times as high as what the CDC and WHO call safe and more than three and six times as high as Juneau’s water during fluoridation.
Studies did not find a link between fluoride and cancer or Down syndrome, according to the WHO.
Despite the possibility for some negative effects if high concentrations of fluoride are consumed, the CDC and WHO both largely endorse water fluoridation.
The CDC’s Morbidity and Mortality Weekly Report even listed Community water fluoridation is one of the 10 Great Public Health Inventions of the 20th Century.
In light of that, Logan said he is ultimately perplexed there is a staunch opposition to fluoridation.
“That’s one of the mysteries of life,” Logan said. “It kind of leaves you shaking your head. It’s taken on a resistance movement that’s so disproportional to the benefit.
• Contact reporter Ben Hohenstatt at (907)523-2243 or firstname.lastname@example.org.