Fluoridation remains a complicated matter for Worcester
Dr. G. Robert Evans said he was always determined his kids wouldn't have any cavities.
As a dentist, he had his children use fluoride drops, fluoride tablets and fluoride gels, especially his son, a budding actor.
"Then his permanent teeth came in," said Dr. Evans, who runs a holistic medical and dental practice in Groton. "And I thought, 'Oh my God, what have I done?' "
The enamel was severely mottled, blemished by unsightly brown and white spots.
"This was a kid who grew up on stage acting. He can't have ugly teeth."
The dentist says he no longer uses fluoride in his practice, nor does he carry any fluoride products in his office. He said his son uses veneers to hide the mottling.
Dr. Evans was convinced the mottling occurred because of the fluoride treatments his son had, something considered by many to be a dental staple. He began to do some research and his findings floored him, launching his anti-fluoride crusade. He is an especially staunch opponent of community water fluoridation, which the federal Centers for Disease Control and Prevention calls one of the 10 great public health achievements of the 20th century. He has traveled to different communities in Massachusetts since, including Worcester, to speak out against it.
A report released Feb. 8 by the Massachusetts Health Council and the University of Massachusetts Medical School's Center for Health Law and Economics strongly supports community water fluoridation, an opinion not everyone shares. It is a biennial report the health council puts out called the Common Health for the Commonwealth on social determinants of health and preventable health conditions.
Worcester has a long history when it comes to community water fluoridation. Despite the strong endorsements by the American Dental Association, the American Academy of Pediatrics, the U.S. Public Health Service and the World Health Organization, Worcester remains one of the few Massachusetts communities that remains non-fluoridated, along with Barnstable, Brockton, Chicopee and Springfield. Worcester's voters have rejected ballot questions to fluoridate the local public water supply four times since 1963, with the last referendum in 2001.
Janice B. Yost, president and CEO of the Health Foundation of Central Massachusetts, which led the 2001 pro-fluoride campaign, does not think Worcesterites will change their minds any time soon.
"Every time there's a movement to do it again, and the resistance rises up again with a little more fervor," she said. "I think Worcester has probably voted it down as much as anybody in the state has. They're sort of leaders in that."
Yost's organization spent $400,000 on pro-fluoridation ads and education efforts during the 2001 referendum, but voters still rejected fluoridation 56 percent to 44 percent.
According to the CDC's Division of Oral Health, community water fluoridation is a cost-saving, effective way to prevent and reduce tooth decay in both children and adults.
"The nice thing about fluoridation is everyone benefits," said Dr. Myron Allukian Jr., president of the Massachusetts Coalition for Oral Health and former president of the American Public Health Association. "While the teeth are growing, the fluoride becomes part of the tooth and gets stronger, but there's also a topical benefit ... as it flows over the teeth and the ions get into the saliva and the plaque."
"One of the most beneficial effects is in low-income communities because they tend to have poor diets, heavily laden with sugar," said Dr. Raymond K. Martin, president of the Massachusetts Dental Society.
He acknowledged that fluoride can cause enamel mottling at high levels. "But down at the right concentrations, it's very effective and very cost effective," he said.
Most of the arguments against fluoridation cluster around consent, autonomy and the idea that fluoride is toxic.
For Deirdre Healy, a Worcester attorney who does not support community water fluoridation and campaigned against it during the 2001 referendum, much of her opposition centers around the right to refuse medical treatment.
"It really is an issue of ethics," she said. "It's an infringement on our personal liberties, our constitutional liberty interests."
She sees fluoridation as the government medicating the public water supply. "We have no informed consent over whether we consume that medication or not," she said.
Dr. Deborah E. Moore, who led the anti-fluoride push in 2001, speaks for many who believe that fluoride can cause more than just enamel mottling.
"There is great reason to be concerned about the health effects," she said in an email interview, citing studies that examine the adverse effects of fluoride.
"It is a toxin that affects all systems of the body," she said. "It is a potent synergistic agent for other chemicals both inside and outside of the body."
While there are studies showing a correlation between adverse health effects and high levels of fluoride in water, or fluorosis, the majority of medical professionals and peer-reviewed literature agree that controlled low levels of fluoride confer a public health benefit.
At the same time, the National Toxicology Program, which is headquartered at the National Institute of Environmental Health Sciences and evaluates agents of public health concern, examines the work that indicates there may be adverse effects to higher levels of fluoride.
"There is a body of evidence that is suggestive of learning and memory issues (in animals), but the studies are generally not of very high quality," said Dr. John R. Bucher, the associate director of the National Toxicology Program. "We identified some data gaps and are carrying out some studies of our own in the institute to try to do a better job."
He acknowledged people's concerns about fluoride's possible adverse effects. "Until we finish our evaluations, I can't say one way or the other. The literature on fluoride is diverse," he said.
He agreed with the president of the Massachusetts Dental Society that there is a public health benefit to fluoridation.
"There's reasonable evidence that fluoridation improves dental health, particularly in areas of low socioeconomic status where individuals aren't getting the dental care they would get if they had access to dentistry and a higher level of care," he said.
"We want to make sure that if there is a benefit, it far exceeds the potential downsides," he said. "That's why we are doing what we are doing."
Under Massachusetts law, the local board of health has the jurisdiction to order fluoridation, Dr. Allukian noted. However, if 10 percent of a community's registered voters sign a petition within 90 days of the publication of the order, it must be placed on the ballot for a vote at the next city, town or district election.
Worcester's Board of Health, which was primarily an advisory board for many years and only had its regulatory powers restored in 2014, does not have any plans to do that, said Karyn E. Clark, the director of Worcester's Division of Public Health and the Central Massachusetts Regional Health Alliance.
"The fluoridation issue is not something they have even discussed at this time," said Ms. Clark, whose agency works with the board in a research and advisory role.
"Most of the data that we've seen and that is typically discussed in the public health community and medical community shows that it is beneficial," she said. "But it's not something that we are having a conversation about."