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The Big Lie: Fluoridation Helps the Poor July 29, 2002 Time and time again, promoters of fluoridation - from the US Surgeon General down to the local dentist - have told an unsuspecting public that the reason we have to fluoridate public water supplies is because it is an "equitable" thing to do. We are told that it helps all people, regardless of income, and provides much needed "dental care" to the poor. This argument is, of course, very powerful emotionally, as most people want to do what they can to help the poor, particularly children. It is, however, another example of the "Big Lie". Lack of Dental Care Whether intended or not, for over 50 years fluoridation has served to distract attention from the fact that the US, despite its enormous wealth, provides very poor dental care to families of low income. Today, roughly 80% of US dentists refuse to treat children on Medicaid because Medicaid's compensation is too low. One mother of a Medcaid insured child recently told a group of researchers from the University of North Carolina : "I could not get a dentist to take Medicaid. I got the book out, the telephone book, and I went through about 10-15 dentists, and no one wanted to take Medicaid. I just gave up." She is not alone. The University
of North Carolina researchers found that Medicaid-eligible residents
in 40 North Carolina counties have no private dentist available
to them. To remedy this situation, US health departments, instead of calling for more investment in Medicaid, all too frequently seek the cheap and easy, albeit illusionary, "fix" of water fluoridation. In such campaigns, the challenge of finding the much-needed government funds for strengthening Medicaid is usually bypassed and ignored. This is, of course, probably one of the attractions of water fluoridation - no difficult budget decisions - simply add an inexpensive chemical (inexpensive because it's a hazardous industrial waste product) to the water, and presto - the poor can enjoy the dental care they wouldn’t otherwise receive. In a sense, water fluoridation has become a de facto substitute for dental insurance. Perhaps this is one of the reasons why western Europe hasn't felt as compelled as the US to fluoridate their water - because most of these nations have universal health insurance. As a result, poor children do not have the same kind of difficulty finding dentists who will treat them. Of course, just because fluoridation is cheaper and easier for government, doesn't necessarily mean that it is an effective substitute for dental insurance. Indeed, there would be a good discussion to be had, were fluoridation a safe and effective means of reducing dental decay among the poor. Unfortunately, however, that is not the case... As a mounting body of evidence now indicates, fluoridation does not reduce inequalities in dental health. Such was the conclusion of the recent systematic review of fluoridation, published in the British Medical Journal (the "York Review") and commissioned by the British Government. According to Dr. Trevor Sheldon, the Chair of the York Review's advisory board, in a letter sent to the House of Lords: "There was little evidence to show that water fluoridation has reduced social inequalities in dental health." The US Experience Perhaps nothing illustrates Dr. Sheldon’s point more clearly than the experience of poor urban areas in the US. Despite the fact that the vast majority of urban areas in the US have been fluoridated for decades, dental decay is rampant. The US Surgeon General recently described the level of decay typically found in such areas as a "silent epidemic" and an "oral health crisis." Now, if fluoridation was an effective cure for poverty-related dental decay, why is it that the nation's highest level of dental decay is commonly found in the nations' inner cities, the vast majority of which are fluoridated? Take, for instance, the situation in Boston. In 1999, the Boston Globe ran a front page story detailing the oral health crisis among Boston's poor. According to the Globe: "With a study estimating that the number of untreated cavities among Boston students greatly exceeds the national average, public health officials are about to launch an offensive against what they say is a growing dental crisis in the city." As the article points out, Boston has been fluoridated since 1978. And Boston's situation is by no means unique. In his book Savage Inequalities, Jonathan Kozel notes the oral health problems he has observed in the Bronx (a borough of New York City). "Bleeding gums, impacted teeth and rotting teeth are routine matters for the children I have interviewed in the South Bronx. Children get used to feeling constant pain. They go to sleep with it. They go to school with it. Sometimes their teachers are alarmed and try to get them to a clinic. But it's all so slow and heavily encumbered with red tape and waiting lists and missing, lost or canceled welfare cards, that dental care is often long delayed. Children live for months with pain that grown-ups would find unendurable...Many teachers in the urban schools have seen this. It is almost commonplace." The Bronx has been fluoridated
since the 1960s. A recent study published in the journal Pediatric
Dentistry compliments Kozel's observations. According to the
study, children from poor areas in New York City have much higher
rates of dental decay than the national average. The study also
notes that just 10% of the cavities among these children had
ever been filled by a dentist. It would be bad enough, of course, if fluoridation were simply an ineffective policy that diverted time and attention away from the efforts and policies that would actually work. But it doesn't just stop there. Adding insult to injury, it is precisely the poor who are often most susceptible to the toxic effects of fluoride. As noted in a report by the National Research Council of Canada, fluoride increases the body's metabolic requirement of certain nutrients. In other words, the more fluoride one consumes, the more essential nutrients (e.g., calcium, magnesium, vitamin C) the body will need in order to stay healthy. As a consequence, those with deficient nutritional status (which is often the case with poor children) have less inborn-defense against fluoride's toxic effects. The most tangible example of this disparity can be witnessed in India, China, and other poorer nations, where just slightly elevated levels of fluoride in the water (e.g., 2 to 3 parts per million) cause a whole array of health problems, the most prominent being a severe arthritic bone disorder known as skeletal fluorosis (for more information see http://www.fluoridealert.org/s-fluorosis.htm ). The importance of nutrition in influencing fluoride's toxicity may actually be one of the factors explaining why a couple of recent studies have noted that African-Americans have higher levels of dental fluorosis than Caucasians. Dental fluorosis , a defect of the tooth enamel that causes white and/or brown spots on the teeth, is one of the first symptoms of excessive exposure to fluoride. Incidentally, dental fluorosis
is now at near epidemic proportions in the US. The largest US
government survey looking into the matter recently noted that
roughly one-third of children living in fluoridated areas have
dental fluorosis on at least 2 teeth. The British government
review, noted above, reckoned that approximately 48% of children
living in fluoridated areas develop some form of dental fluorosis,
with roughly 12% developing fluorosis of great enough severity
to cause significant esthetic concern. Lastly, let’s be clear about what is, and what is not, the cause of tooth decay among the poor. What is NOT the cause of tooth decay among the poor is lack of fluoride. Despite some claims to the contrary, fluoride is not an essential nutrient, and is not needed for the development of healthy teeth. As stated recently by the Centers for Disease Control: "The prevalence of dental caries in a population is not inversely related to the concentration of fluoride in enamel, and a higher concentration of enamel fluoride is not necessarily more efficacious in preventing dental caries." What is the cause of tooth decay among the poor is a bit more complex, but basically boils down to two basic issues:
In sum, "dental equity" will not come with the lazy "magic bullet" of fluoridation, but rather will require the much more demanding measures of improving education, improving diet, providing free dental clinics to serve those on Medicaid, and providing free toothbrushes and possibly toothpaste to children in school. In short, if you truly care about poor children, don't give them poison - give them genuine care.
For further reading: Dentists Show Fluoridation a Failure Fluoridation Fails Poor Children, New Studies Show Dental caries among disadvantaged 3- to 4-year-old children in northern Manhattan (Pediatr Dent 2002 May-Jun;24:229-33) Oral health status of preschool children attending head start in Maryland, 2000 (Pediatr Dent 2002 May-Jun;24:257-63) Untreated cavities more common in poor children (Reuters Health June 14, 2002) City to launch battle against dental crisis (Boston Globe November 11, 1999) |