What do you really know about fluoride except that it's in toothpaste? Hopefully, you know something, because when you vote on Tuesday, you'll have to decide whether it should be added to the city wells in Spokane. Since this summer, two groups in Spokane have fought passionately to win your vote.
On one side, the People For Healthy Teeth (PFHT) is campaigning for adding fluoride because it cuts down on dental decay and is an inexpensive preventive measure.
On the other side is the Fluoride Awareness Coalition (FAC) and several other groups that argue fluoride is poisonous and can cause fluorosis of the teeth and bones if ingested throughout life.
The two groups have fought long and hard, throwing research studies, books and lectures at each other at a frantic pace.
Fluoridation of drinking water has been on the ballot in Spokane twice before, and lost both times. This time around, proponents collected about twice as many signatures as needed to get the initiative on the ballot again. Their central argument is that adding fluoride to drinking water may reduce cavities by as much as 65 percent, as found in people who grow up with fluoride in the water. Even adults who don't get exposed to fluoride until later in life may cut down on their cavities. And it's already being used by more than half of the water municipalities in the United States.
It may be cheap, but it's certainly not free, and if the initiative passes, the city of Spokane is looking at quite a bill, says Brad Blegen, director of the city's water department.
"We need to be neutral in this, but we would prefer not to do it," he says. "I do want to emphasize that we are here to serve our customers, so whatever they vote for, we will do. But I hope the proponents of fluoridation understand it's not free."
Considering that the city could barely balance its latest budget, Blegen is very concerned about where the money for fluoridation is going to come from.
"To install the equipment would cost about $1 million, and then it would be about $300,000 a year to maintain it," says Blegen. "Our water revenue is about $20 million a year, so I figure we'd have to raise the rates about 2 percent per household to cover it."
And there is another problem. The solution that is often used to fluoridate drinking water, hydrofluorosilisic acid (HFS), may contain very low concentrations of contaminants such as lead and arsenic, both elements that are already present in the environment around here.
"Those contaminants are a concern, even if they don't make a significant contribution in the percentages reported; we must be very cautious," says Lloyd Brewer, environmental programs manager with the city of Spokane. "The majority of Spokane's water goes to lawn watering and things like that. Much of that does not go through the wastewater treatment plant, but drains directly into the river or somehow into the aquifer."
The agrochemical company IMC Agrico sells HFS that's approved for use in drinking water. It provides the following chemical analysis: Between 23 and 26 percent of its water additive is HFS (the complete formula is H2SIF6). Between 18 and 21 percent of the solution is fluorine. Beyond that, the product also contains traces of iron, phosphorous, arsenic, iodine and lead. The company did not respond to a request for more information regarding the purity of the HFS it sells.
This makeup matches the HFS the city is looking at, though the city's provider is a different company.
"As it is right now, the Environmental Protection Agency allows for 50 parts per billion (ppb) of arsenic, but they are talking about lowering that threshold to 5 ppb," says Brewer. "We have readings that are around 3-4 ppb in city water, and I am aware of readings outside of the city that have exceeded 5 ppb." The reason why the EPA is considering lowering the acceptable threshold is that the regulatory agency believes there are significant health concerns related to arsenic.
"Regardless of the EPA lowering the threshold, I still believe the arsenic and lead contributions from the HFS would be relatively insignificant," says Brewer. "And if the threshold does go down, I would expect the manufacturers of HFS to be asked to lower the contents in the HFS as well."
Brewer says there is naturally occurring fluoride in the water already, some readings show around 100 ppb, but he adds that the level usually sought when fluoridating is between 800 to 1100 ppb.
And there's another problem, this time with logistics. Spokane does not have a central treatment plant for drinking water, so it's not like someone could climb a ladder and drop a gallon of fluoride into the big tank every morning.
"Most cities get their water from rivers and lakes, and they must treat it with chlorine, for instance, before it goes out to the public," says Blegen. "Our dilemma is that we start with clean water we don't have to treat, but it comes from wells all over the place. To retrofit our system is a lot more difficult than if we had a central supply."
The city operates seven wells, but depends on water from as many as 90 different sources. The wells are scattered, and some are on very small properties. Blegen says it will be difficult to fit the needed holding tanks and equipment for the HFS on-site.
"The HFS would have to come in by railroad tank cart, and we may need to purchase one of those," he says. "Once it's here, it would have to be transferred into a tank truck, which we don't have either. And we'd need specially trained staff who would have to wear rubber suits and face masks." Actually, Blegen is not sure $1 million is enough to cover the initial cost.
"I look at these numbers and think they may be too low. But, like I said, we are going to do exactly what our customers want us to do, and I do think the proponents of fluoridation have demonstrated that it is beneficial," he says. "I'm just not sure they know how much it costs. In my mind, this is a social program, and it's up to our customers to decide if that's what they want to do."
A social program? There are state-run dental programs available for low-income families, and dental care often ends up low on the to-do list if you worry about where dinner is going to come from. The low-income segment of the population will benefit the most from added fluoride, but instead of giving it to everyone through the water, some have suggested making fluoride drops and tablets available at community centers for free.
This is, however, not very likely to happen. Since fluoride is a drug, you need a prescription for it -- it can't be handed out at random. Also, handing out tablets and drops may increase the risk of accidental poisoning.
Regardless of all that's being said in opposition to fluoridation, there is plenty of evidence that fluoride does make tooth enamel stronger. Proponents say there is no need to fear toxicity since once in the drinking water, it's present in such low concentrations that it cannot hurt anybody.
The American Dental Association has stated officially that there has never been a single valid, peer-reviewed laboratory, clinical or epidemiological study showing fluoride in drinking water (at 1 ppm) causes cancer, heart disease or any multiple of diseases claimed by anti-fluoridationists.
A World Health Organization study says that, "Dental caries [cavities] and gum disease are two of the most widespread diseases. They affect between 50 percent and 99 percent of people in every community. Prevention based on good oral hygiene habits, use of fluorides and prudent diet has dramatically reduced the level of these diseases..."
And the U.S. Centers for Disease Control estimates that for every dollar spent on fluoridation, $80 are saved in dental treatment.
But how, exactly, does it work?
"The fluoride used in this matter is found in phosphate rocks," says Jeff Corkill, a chemistry professor at Eastern Washington University. "In those rocks, there is also calcium phosphate, called apatite, and in that apatite is fluoride apatite, or calcium fluoride, and fluoride phosphate. They use fluoride phosphate to produce phosphorous and fertilizer. In both cases, the calcium fluoride and phosphate is heated up in the presence of silica [sand] and carbon. Part of the byproduct is hydrogen fluoride and hydrofluorosilicic acid (HFS)." During the heating process, the fluoride distills out in what's called scrubbers, it's dissolved in water -- that's how they make the HFS proposed for the city's water supply.
Corkill says that where the opponents get tangled up is that HFS as a concentrate is highly corrosive and a pretty dangerous compound. But the amounts in the final drinking water are very miniscule and therefore no longer corrosive or poisonous. Chlorine, which is already in much of the nation's drinking water, but not Spokane's, is also poisonous in high concentrations, but only serves to kill bacteria (and is harmless to people) in the concentrations used for drinking water.
So how does fluoride work on your teeth? "Teeth contain the same kind of 'rock,' apatite. The reason it works is that there is a chemical group in that apatite which the fluoride replaces and forms a compound that is a lot less dissolvable than it was prior. That's how it makes tooth enamel stronger," says Corkill.
So, knowing all this, does he support fluoridation? "I'm not certain, but I lean toward it. I think it has been demonstrated in the research that it cuts down on cavities, and to me the benefits far outweigh the risks."
Maybe the third time is the charm, and fluoridation will pass this time. If that happens, many fluoride opponents say they may have to move away from the area. Some say they are allergic to fluoride, others blame various illnesses from cancer to rashes on fluoride.
But finding a community to move to may be hard, since more than 60 percent of the public water facilities in the nation already fluoridate their water.
Before you call U-Haul, there is one other option: get a filter. But a regular countertop Britta won't do.
"You'd need a reverse-osmosis filter," says Chris Henderson, general manager at County Wide Water. "This takes out all of the particulate matter, and it's going to remove fluoride, bacteria and most viruses, down to the size of 9/10,000 of a micron. It goes under the kitchen sink. You can brush teeth in fluoridated water if you like, but you don't have to ingest it."
Henderson says his company's philosophy is that there shouldn't be anything in water but water, but adds that the purest you can get is 99.7 percent -- there'll always be a little something else left. When asked how much such a filter costs, Henderson refuses to get more specific than "less than $1,000." Then, in a sense, he sums up the entire fluoridation debate: "This is really not a question of price, it's a question of how much it's worth to you as a person -- what value you put on the water you drink. That's how you should think about it."