In New Jersey Dental School’s pediatric clinic in Newark, Dr. Nanci S. Tofsky and her students peer into the mouths of very young children whose teeth are already filled with decay.
“We’re seeing significant dental caries in kids as young as a year and a half old,” says Tofsky. “It’s to the point sometimes that we aren’t even able to save their teeth. When I see that, I get very sad.”
Poor oral hygiene and a carbohydrate-rich diet contribute to the problem, but such children, says Tofsky, are also “not getting the right amount of fluoride.” As a remedy, she prescribes a dietary fluoride supplement—a therapy that works well enough, as long as parents remember to refill the prescriptions, which many do not. Tofsky and many of her colleagues would prefer that Newark’s inner-city children receive fluoride in the public water supply. “Having it in the water would make their teeth stronger and more resistant to decay from other sources,” she says.
Newark, however, is one of a number of large cities in New Jersey—Camden, Elizabeth, Jersey City, and Paterson are others—that do not add fluoride to their drinking water.
In fact, only 22.6 percent of New Jerseyans served by a public water system drink fluoridated water, according to data from the Centers for Disease Control and Prevention (CDC) in Atlanta. Only Hawaii has a lower percentage of residents receiving fluoridated water.
A bill introduced in the New Jersey Assembly in February would change that. Sponsored by, among others, Assemblyman Herb Conaway (D-Burlington), chair of the Assembly Health and Senior Services Committee and a medical doctor, the bill, the first of its kind in New Jersey, would mandate fluoridation in all public community water supply systems. Currently, the state leaves the fluoride decision up to individual municipalities. The bill has already been reported out of Conaway’s committee and awaits action by the Assembly Appropriations Committee.
But the bill is not without its opponents—notably environmental groups and water companies. They object to mandated fluoridation on a number of grounds: its impact on the environment, what they see as potentially deleterious effects on humans, and the cost of implementation. And though some of these critics find it odd to be at loggerheads with the health community, they are united in their opposition to the fluoride legislation.
Conaway claims his bill would have multiple benefits. Not only would it address a public health problem—one that he says hits “the less affluent in society” especially hard—it would also save money in the long run. “For every dollar we invest, we can expect to save about $40 in treatment and other costs,” says Conaway, citing CDC figures.
The New Jersey Dental Association supports the Conaway bill. Arthur Meisel, NJDA executive director and general counsel, agrees that it would not only benefit the entire state but would have an especially big impact on “persons who don’t have the same access to [dental] care as everyone else.” The CDC, citing studies indicating that fluoridation reduces decay in permanent teeth by up to 40 percent, is another proponent of fluoridation.
Individual dentists feel much the same way. Dr. Elisa J. Velazquez, a pediatric specialist who practices in the non-fluoridated town of Toms River and is a 2009 Top Dentist according to the New Jersey Monthly survey, says she’s “a fluoride advocate.” So is Dr. Irvin B. Sherman, also a 2009 Top Dentist.
Sherman has practiced pediatric dentistry for 33 years in East Brunswick, which has been fluoridating its water supply for at least that length of time. “I can tell you that the population of children in East Brunswick has a lower cavity rate than the children I see in the immediately surrounding towns, like Old Bridge, South River, and Englishtown,” says Sherman. Dr. Joseph Banker, a 2009 Top Dentist who practices general dentistry in Westfield, where the water is fluoridated, and Elizabeth, where it is not, says, “I think it would be pretty hard to find a dentist who wouldn’t be an advocate of water fluoridation.”
Jeff Tittel, chapter director of the New Jersey Sierra Club, is one of those who regrets the split the Conaway bill has caused between the “normally allied” health and environmental communities. Still, he thinks the fluoride debate is one in which “good intentions” come with “a whole range of other problems.”
Among other things, Tittel fears that cost-conscious water companies would use a cheap and less pure form of fluoride, which he refers to as industrial grade, rather than a medical grade. The cheaper fluoride, he says, is a by-product of phosphate fertilizer production. “It’s actually coming out of the plant’s air filters, and it contains heavy metals, including arsenic and lead,” says Tittel. “Our concern is that, as we are fluoridating the water with these materials, we are also adding a lot of other toxic chemicals.”
Tittel’s other big concern is the danger of overfluoridation in certain areas of the state, including the Passaic River Basin. “There are 70 sewage plants that discharge treated water already containing some fluoride above the Little Falls intake on the Passaic River,” he says. “If the river water taken up at Little Falls is then fluoridated to standard, you pick up not only the added fluoride but also the fluoride from all the sewage plants above.” Unless the standard were reset, Tittel says, the fluoride buildup in the water could end up overfluoridatng people and causing harm to macroinvertabrates and other parts of the ecosystem.
Other New Jersey environmentalists are even more critical of fluoridated water. “We don’t think fluoride should be added to the water at all,” says Sharon Finlayson, board chair of the New Jersey Environmental Federation, a state chapter of Clean Water Action, a national organization based in Washington, D.C. “There are other ways to obtain it if a doctor thinks you need it.”
The most common of these are the over-the-counter fluoride dental products, such as toothpastes and mouth rinses. Fluoride can be applied directly to the teeth in a dentist’s office or, as in the case of the dentists in Nanci Tofsky’s pediatric clinic, it can be prescribed as a dietary supplement, which is available in tablets or drops. In some New Jersey communities—including Burlington, Chester, Glassboro, Vernon, and New Milford—residents already get naturally occurring fluoridated water that is at or near desired concentration levels.
Finlayson and her group express concern about the “negative health impacts” of fluoridated water, especially at a time when people are receiving fluoride from multiple other sources. In testimony before Conaway’s committee in February, she reeled off a list of these impacts, including a condition in children known as dental fluorosis, in which young teeth overexposed to fluoride become pitted, mottled, and discolored.
Finlayson also alluded to research that showed suspected links between fluoride in the water and skeletal fluorosis, which in extreme forms (possibly following long-term ingestion of large amounts of fluoride) can lead to crippling; hypothyroidism; osteosarcoma (a rare type of malignant bone cancer seen only in boys); lowered IQ; and male reproductive damage, among other problems. “The list of potential side effects should be enough to stop mandatory fluoridation,” she told committee members.
Confronted with the environmentalists’ criticisms, proponents of fluoridation cite CDC assurances that fluoride is safe and effective.
On the charge that fluoridated water has potentially dangerous health effects, Dr. Bill Bailey, a dental officer in the CDC’s Division of Oral Health, cites the “weight of the evidence” to the contrary. “Opponents might point to a single study from China that says water fluoridation is lowering IQ,” Bailey says, “but our approach is to consult expert panels that look at all the evidence, not just one study.” (The “weight of the scientific evidence,” says the CDC, also does not support the alleged association between fluoridation and osteosarcoma.) Bailey quickly adds, though, that the CDC always has an eye out for new research.
CDC is equally confident in addressing other environmental concerns, including the fears articulated by Tittel and others that an industrial grade of fluoride will add to the contaminants in New Jersey waters, and that regulating the amount of fluoride in certain areas will prove problematic.
On the first point, CDC National Fluoride Engineer Kip Duchon pulls no punches: “We really don’t have illegal immigrants scraping fluoride off the inside of smokestacks in phosphate fertilizer plants.” Instead, says Duchon, fluoride additives are produced from phosphorite rock—which is mined from the earth—in the process of manufacturing phosphate fertilizer. “This isn’t like some waste product,” says Duchon. “It’s a very high-quality product.”
Does it contain impurities, as Tittel and other environmentalists contend? “Of course it does, because we live on an imperfect planet, and everything has an impurity,” Duchon says. The real question for the EPA, the agency in charge of water safety, is whether the fluoride water additive contains dangerous levels of contaminants—and there, Duchon says, the evidence is clear.
As he explains, the EPA is responsible for developing maximum contaminant levels (MCLs) for drinking water—that is, levels below which contaminants pose no health risk. In the case of fluoridated water, it went a step further, partnering with outside groups, including the National Sanitation Foundation, to develop a safe standard for fluoride additives.
When the NSF tested fluoride products for arsenic, for example, 57 percent of the samples showed no evidence of the contaminant, though all were tested at much higher-than-permitted use levels. The remaining 43 percent showed detectable arsenic, but no sample exceeded 6 percent of the regulatory limit. Lead testing showed even lower contaminant levels.
The second big concern raised by environmentalists—that some areas like the Passaic River Basin will end up with too much fluoride—is also overstated, Duchon maintains. For one thing, he says, any water discharged from sewage plants will already contain significantly reduced fluoride levels, since “a portion of the wastewater reaching a sewage plant is ground water that leaked into the sewer pipes.”
The groundwater acts to dilute the fluoride in the wastewater. Significantly more dilution of any discharged water occurs as it flows into the river. If this river water is then taken up and fluoridated, the treatment plant is supposed to only add the amount of fluoride that it needs to.
Also critical of the Conaway measure are many of the state’s investor-owned and public water companies. “We’re against the bill’s overly simplistic approach,” says Ellen Gulbinsky, executive director of the Association of Environmental Authorities of New Jersey, which represents publicly owned facilities. “We think the decision-making should remain at the local level.”
The New Jersey Utilities Association, a trade group representing investor-owned utility companies, including water companies whose rates are set by the state Board of Public Utilities, is similarly opposed to taking the decision-making out of local hands and giving it to Trenton.
“It’s inappropriate in light of the costs involved, costs that would have to be passed along to customers, especially given that the vast majority of New Jersey people can obtain fluoride for dental hygiene through less expensive means,” says Karen Alexander, NJUA’s president and CEO. (One NJUA member, New Jersey American Water, which is the state’s largest investor-owned water company and already serves a number of fluoridated communities, is “neutral” on the bill.)
In a letter to Assembly Appropriations Committee chair Nelida Pou, a Democrat representing District 35, which includes Paterson, Alexander said that “upfront costs” would range from $400,000 for smaller utilities to more than $64 million for the largest ones. Annual operating costs, she noted, would range from $20,000 to $533,000. “These costs would be incurred by any system…not already adding fluoride to its water supply,” Alexander explained in her letter.
On December 1, 2002, for example, the city of South Brunswick began a fluoridation program. According to spokesperson Ron Schmalz, installation of the fluoridation system for the city of 44,000 people was about $800,000. Annual operating costs range from $30,000 to $40,000, depending on the price of the fluoride additives and other factors.
The more cost-effective way to go if the goal is to reach underserved populations, Alexander says, is to “devise a very targeted outreach to these populations.”
Conaway is skeptical of this approach. Once the required setup, staffing, and management resources are added up, he says, this outreach program would end up being “a much costlier proposition” and one that would ultimately reach far fewer people. He argues that spreading the cost among large populations reduces it “to a trivial amount.” (In South Brunswick, it breaks down to between 70 cents and 90 cents per capita annually—not including the installation cost.)
Asked about the likely fate of his proposal, Conaway ticks off the public health, cost savings, and scientific arguments in its favor. “When you have that kind of force behind a proposal, I think it’s irresistible,” says Conaway, who predicts action on his measure before the end of the year.
At least some of his critics are betting otherwise. “In its current form, it won’t go anywhere,” says Tittel.
CLICK HERE FOR A LIST OF FLUORIDATED COMMUNITIES IN NJ. (this file is in PDF format, if you have trouble viewing it you may need to download Adobe Acrobat Reader located here or download an alternative copy here)
Correspondent Wayne J. Guglielmo reports on health issues for New Jersey Monthly.