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Feds Urge Fluoride Levels Be Watered Down

Mild forms of dental fluorosis (shown in teeth pictured above) are increasingly common, according to the American Dental Association, and cause teeth to become discolored, most often with white streaks.
Courtesy of UCSF
Mild forms of dental fluorosis (shown in teeth pictured above) are increasingly common, according to the American Dental Association, and cause teeth to become discolored, most often with white streaks.
Feds Urge Fluoride Levels Be Watered Down
As San Diego waits for water fluoridation, the U.S. Departments of Health and Human Services and the Environmental Protection Agency re-evaluate how much fluoride is too much fluoride.

It started as a simple idea to help kids avoid getting cavities. But back in the Cold War days, the effort to put fluoride in local water supplies mushroomed into a wide-spread political battle. And perhaps nowhere in the nation were people more actively engaged in the fight against fluoridation than right here in San Diego.

Move forward 50 years and San Diego is on the cusp of finally joining the rest of the nation in getting fluoride added to the water supply when the city announced a delay. And the Environmental Protection Agency released information that it is reviewing the amount of recommended fluoride in water supplies because people may be getting too much.

So will San Diego ever get fluoride added to the water supply and if so, how much?



Ellie Nadler is executive director of the San Diego Fluoridation Commission and a dental hygienist.

Dr. Howard Pollick is a professor of preventive and restorative dentistry at the UCSF School of Dentistry and a spokesperson on fluoridation for the American Dental Association

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This is a rush transcript created by a contractor for KPBS to improve accessibility for the deaf and hard-of-hearing. Please refer to the media file as the formal record of this interview. Opinions expressed by guests during interviews reflect the guest’s individual views and do not necessarily represent those of KPBS staff, members or its sponsors.

MAUREEN CAVANAUGH: I'm Maureen Cavanaugh, and You're listening to These Days on KPBS. It started as a simple idea to help kids avoid getting cavities, but back in the cold war days, the effort to put fluoride in local cart supplies mushroomed interest a widespread political battle, and perhaps nowhere in the nation were people more actively engaged in the fights against fluoridation than right here in San Diego. Move forward 50 years and San Diego is on the cusp of finally joining the rest of the nation in getting fluoride added to the water supply when the city announces a delay, then the federal government releases information that agencies are reviewing the amount of recommended fluoride in water because people may be getting too much. So will San Diego ever get fluoride added to the water ply 1234 and if so, how much? I'd like to welcome my gets, Ellie Nadler is [CHECK] and a practicing dental hygienist. Ellie, good morning.

NADLER: Good morning. Thank you for having me.


MAUREEN CAVANAUGH: And doctor Howard pollack [CHECK] UCFF school, [CHECK] doctor Pollack, good morning.

POLLACK: Morning, Maureen.

MAUREEN CAVANAUGH: Now, we'd like to invite our listeners to join the conversation. [CHECK] do you think adding fluoride is necessary anymore? Give us a call with your questions and your comments, the number is 1-888-895-5727. Well, Ellie, San Diego was preparing to add fluoride to the drinking water in San Diego, as I said, and then postponed that. Why?

NADLER: Well, first of all, there's never been I targeted date for a large water system to not have delays, to start on the targeted date.


NADLER: And not have delays. You might remember upon back to 2007 when the metropolitan water direct was fluoridating [CHECK].


NADLER: Because it's a big system. San Diego has three water treatment plants, and there's a lot to do and a lot to make sure that everything, technically, is working properly. And that everybody's comfortable with what they're doing.

MAUREEN CAVANAUGH: So this delay is particular that particularly surprises you?

NADLER: Oh, no. I would have been surprised beyond belief if they had started on December 22nd on that target date. I never expected it to start then.

MAUREEN CAVANAUGH: Ellie, give us a little bit of a background on why we don't have fluoride in our drenching water here in San Diego. I think we are the last major city in the United States whose water is not fluoridated.

NADLER: Right. When the San Diego system does start very soon now, it will take us out of having the unfortunate title of being the largest city in the United States without water fluoridation. I do want to remind you and listeners, though, that we have had, as I mentioned with the metropolitan water district, the wholesaler, [CHECK] because we have a number of water treatment plants throughout the county, not just the city's [CHECK] but we have more. That water has been coming to us since 2007. And I might point out that the city of Escondido began over six years to fluoridate its water.

MAUREEN CAVANAUGH: It has been quite a battle, though, to get fluoridation here in San Diego.

NADLER: Well, it's a costly installation process, but once that's done, then the ongoing cost, and especially if you break it down per person per year is infinitesimal.

MAUREEN CAVANAUGH: Doctor pollack, why, if you could bring us back to the origin of this, why do cities add fluoride to drinking water? Is there no fluoride in the water to begin with?

POLLACK: Every water system has some fluoride, and most water systems have eye [CHECK] prevention of tooth decay on a community wide basis. So the water fluoridation trial started in 1945 based upon the evidence that it had been accumulated to that date, that showed that where there was about one part per million of fluoride in the U.S., that there was about 60 percent less tooth decay than in other communities that had negligible amounts of fluoride. So it seemed natural to try to simulate that natural environment and provide that benefit to all communities.


Q. So, doctor polling, are why is the government now considering changing at this time recommendations for fluoride in drinking water?

POLLACK: That being, I think we're catching up with the science now, in terms ever this policy. The evidence has been pointing this direction for some time. One of the criteria for the amount of fluoride that would be in fluoridated water was based upon evidence that was accumulated from 50 years ago that children in hot climates would consume more water because they're playing outside and it's hot out there. Similarly, children in colder climates wouldn't be playing outside as much of or if they were, they wouldn't be as thirsty. So there was a range that was recommended since 1962, by the public health service, to have .7 parts per million of fluoride in the very warmest part of the United States, in southern Texas and Florida, and up to 1.2 parts per million in the coldest parts in Alaska and Minnesota and Maine. And the recent evidence has pointed to the fact that children are leading a more sedentary lifestyle by and large, and with air conditioning and heating, we don't see this variation in water consumption that we used to see 50 years ago of so that's one of the reasons why the department of health and human services recommended to have a standard .7 parts per million across the country, whether you're in Alaska or Hawaii or the lower 48.

MAUREEN CAVANAUGH: I see. And Ellie, is there also a possible additive to this in that there are more products that now contain fluoride than there used to be?

NADLER: Absolutely. And I think it's important to backtrack just a little bit and explain to your listeners what -- when we use the term risk, scientists use the term risk and risk management a lot, and it means different things to everybody. And it means different things to us as those of us who are not science trained. The only risk, whatsoever, is what we call enamel fluorosis, and it shows up, at this range, at these quantities that we're talking about, about one part per million or less than one part per million, which is what we're talking about now, and it's important to realize that the city was aiming for .8, so their recommendation, .7, makes no difference, really. Getting that understanding that enamel fluorosis --

MAUREEN CAVANAUGH: Well, tell us --

NADLER: White spots.

MAUREEN CAVANAUGH: White spots on your teeth is the risk.

NADLER: And as a dental hygienist [CHECK].

MAUREEN CAVANAUGH: Gotcha, and just to be clear.


MAUREEN CAVANAUGH: What the risk that we're keeling with here is the possibility that getting too much fluoride will put white spots on the enamel of children's teeth.

NADLER: That's right. And they also won't have cavities.

MAUREEN CAVANAUGH: All right. Let's start that take some calls. We're talking your calls at 1-888-895-5727. Mark is calling from San Diego. Good morning, mark, and welcome to These Days.

NEW SPEAKER: Good morning, thank you. Yeah, my question -- well, it's not a question, it's more of an experience. My daughter's actually allergic to fluoride, she had a fluoride treatment and broke out in hives, both in her mouth and on her hands. And now we don't use any kind of fluoride products at all, and she goes to the dentist and has her teeth cleaned, they use a nonfluoride tooth cleaning compound. So I'm a little concerned about adding something that she's allergic to the water that she's unable to, you know, remove from the water in order to have a drink of water, you know?

MAUREEN CAVANAUGH: Well, let me get a reaction to that, mark. Thank you. And doctor pollack, being allergic fluoride? Does that happen frequently?

POLLACK: No, it does not. And it's very unusual and has not been reported in the scientific literature. And there could be -- I don't doubt the caller's statement about it, however, there may be potentially other reasons why his daughter broke out in hives in her mouth and on her hands. And I was just wording whether or not she was seen by an aller gist, because there may be something else that's caused this. And that would be important for mark to know about it.

MAUREEN CAVANAUGH: Mark, has she been seen by an aller gist?

NEW SPEAKER: No, she has not.


NEW SPEAKER: The dentist however, did mention that he had seen it happen before.

POLLACK: Well, like I say, you want to be sure that your daughter's health is safeguarded in this way. And obviously, if the statement was made, then you have to take that into the conversation. But at the same time, there may be something else. There's a lot of other things that could have caused this, so I would recommend that she be seen by an aler gist.

MAUREEN CAVANAUGH: Ellie, how frequently have you ever heard of an allergy to fluoride?

NADLER: Well, very, very rarely that something comes up like that. But what I am familiar with is the fact that the products that we use in the dental office as a fluoride treatment -- as a topical fluoride treatment will have multiple, thousands parts per million. I wanted to mention earlier that toothpaste itself, in order to be sold in the United States and approved by the American dental association as effective in reducing tooth decay, has to have at least 1000 parts per million of. Of when we're talking about the all of fluoride in drinking water controlled by a public water system, we're looking at less than one part per million. Of a thousand times Hess. So wife seen children that just may gag on the fluoride treatment that we put on the trays and have them rinse with, and that is very, very rare. But a child could be sensitive in that way. Breaking out in hives, I have not seen.

MAUREEN CAVANAUGH: And your point being that the amount of fluoride in the water would be drastically less than what is in a typical dental treatment.

NADLER: Well, if you use one part per million, 1 whole part per million, and we're talking about less than that, we've always talking about less than that with new recommendations, as I said, it's a thousand times les, and it's equivalent to one drop in a million drops ever water, or $0.01, 1 penny in 10 thousand dollars, if that helps listeners understand the amount. But you've got at least a thousand parts per million this toothpaste. That's why we don't want young children to swallow it, we don't want them to use very much of it, just a little smear of it, until parents are sure or care givers are sure that they can spit it out.

MAUREEN CAVANAUGH: I'm speaking with Ellie Nadler, she's [CHECK] and doctor Howard pollack is professor of preventive and restorative dentistry at UCFF school of dentistry, [CHECK] we're taking your calls at 1-888-895-5727. That's 1-888-895-KPBS. Ellie, let me ask you, since San Diego has been holding out to fluorination for such a long time, do we have any evidence that kids in San Diego are getting more cavities?

NADLER: Oh, absolutely. Yes. We have at least 50 percent. And sometimes that number appears to be even higher. Sometimes even 60, 65 percent of young children who have experienced tooth decay or have decay in their mouth when we see them, when we do screenings in the schools, that's when we're aware of it the most. We have vast community efforts to bridge this down by every other means butch water fluoridation is the basic foundation that's needed to reduce.

MAUREEN CAVANAUGH: So there are 50 to 65 percent of the kids who are screened, young children who are screened that have cavities. What would it be in a city that has fluorination?

NADLER: We know that fluoridation brings that down to 20 to 40 percent. [CHECK].


NADLER: [] But so are our senior citizens. Very vulnerable.

MAUREEN CAVANAUGH: Let's take a call. Justin is calling from San Diego. Good morning, Justin, welcome to These Days.

NEW SPEAKER: Good morning, I hope you can hear me okay.


NEW SPEAKER: I'm actually [CHECK] and I just wanted the speakers to -- in my opinion, with all due respect, it's been kind of glazed over, the risks involved with fluoride in water, and there are [CHECK] but I'm familiar that there is quite a bit other research out there, into the concerns of fluoride in the water, and the real necessity of it. And so I was wondering if they might be able to speak with the concerns about bone dense is, and bone maturation, things like that.

MAUREEN CAVANAUGH: Thank you very much, Justin. And doctor pollack, let me bring this to you. There have been some concerns about bones being affected by fluoride, the strength of bones, and also some people claim there's a connection between fluoride and cancer. I'd like you to address those concerns.

POLLACK: Yes, I'd be happy to do that. In 2006, the nation academy of sciences committee looked at all of the evidence, fluoride in drinking water, and published a report. And concluded that there were the potential for bone problems when the fluoride in the water, naturally occurring, exceeded four parts per million. Which is four times the one part per million that used to be the standard, and is even more than that when we look at the new .07, or .7 standard. Of and the concern with bone at those very high levels applies to individuals living in communities where there's high natural fluoride in that cart supply. In California, won't believe we have any water systems that approach four parit is per million. We see these in some of the other southern states in the United States, and in fact, the CDC has estimated there are currently 200000 people or so living in such communities where there's very, very high levels of natural occurring fluoride. And in fact, where the water supply contains more than two parts marine million, there is a requirement by water districts to send out a notice to consumers and users that children under the age of nine should not use that water for consumption on the basis that it will lead to an increased risk for more of the severe forms of dental fluorosis, and the potential for some bone problems.


POLLACK: So, it's all a matter of dose and concentration. We know that everything can be good or bad depending upon the dose.

MAUREEN CAVANAUGH: Certainly. And what about these concerns about fluoride and cancer?

POLLACK: Well, that's been looked into extensively. And like I say, the studies were looked at by this nation academy of sciences report. And they -- recommendations were for further research. But there were no -- there was no compelling evidence that the studies that have been done showed that there was link between fluoride at the levels that we're talking about, and cancer.

MAUREEN CAVANAUGH: I see. Let me ask you this, there's a couple people on the line who want to ask some questions. But does filtration affect fluoride waters in water? Ellie, if you have a little Brita machine at home or a Pur machine, one of those home systems?

MAUREEN CAVANAUGH: [CHECK] who may not have a refrigerator filter. All of these are considered carbon based filters, and they do not take out the fluoride, certainly not very much of it. If you go for a whole house reverse osmosis system, then you'll take out maybe 65, [CHECK] including the natural fluoride.

MAUREEN CAVANAUGH: I want to ask you both, starting with you, doctor pollack, is it possible since the government is reviewing the idea of lowering the amount of recommended fluoride in drinking water supplies that perhaps we are at this point with so much fluoridation in other materials and toothpastes and mouth washes and so forth that we don't need fluoride in the water anymore?

POLLACK: Well, you know, there is a risk there of not having fluoride in water as Ellie Nadler pointed out. So we do see the benefit it is of a reduced amount of tooth decay. So we would expect an increase in tooth decay across the country if that practice were to be stopped. The other announcement that was made in conjunction with the reducing the target fluoridation level to .7 was this announcement by the EPA, the environmental protection. Agency, to hook at lowering the [] current standard by the EPA, but the secondary standard is two parts per million. And they are now taking the report that was done by the national academy of sciences and saying they're going to look the rate lowering that maximum allowable level on the basis that it will increase the amount of severe dental fluorosis. Of and severely dental fluorosis is not very much seen in this country. You do see it in areas where there's high natural fluoride in the water.


POLLACK: Parts of Mexico and other places in the world. But we are concerned about trying to protect all citizens and residents of the United States. So they're looking at that aspect which is somewhat different than the targeted fluorination level.

MAUREEN CAVANAUGH: Ellie, let me ask you, could we be beyond the need of having fluoride added to the water?

NADLER: No. I don't believe that at all. Of and I don't think that our scientists who study this and have studied this for -- we have had fluoridation in this country for 65 years, began in 1945. I think it's extremely important to provide that basis, that foundation for helping to reduce a really serious disease. Of it isn't always given the attention that it needs.


NADLER: Right. But those of us who are out there in the public health clinics in the [CHECK] by the way, there's one coming up at southwestern college, [CHECK] but to come there. We're out there in the community all the time trying to make a defense. But you cannot really affect -- you cannot provide enough treatment or provide enough access to care for children especially, and for senior citizens. And you know, we have a social -- your previous guest, father Joe, not only is a big supporter of fluorination, but he's also dealing with what is the social contract that we have with the least among us to make the world better.

MAUREEN CAVANAUGH: We have to end it there. [CHECK].

NADLER: Thank you for having me.

MAUREEN CAVANAUGH: [CHECK] please go on-lining Days. Stay with us for hour two, coming up in just a few minutes right here on KPBS.