Calgary’s reasons for ending community water fluoridation doesn’t add up, experts say
Experts agree that community water fluoridation is safe and effective in preventing dental cavities. So why doesn’t Calgary implement the public health measure?
At a dental office in northwest Calgary, Dr. Sandra Pannell shares her point of view with me.
Not only is she frustrated that city council ended water fluoridation in 2011 with little consultation from the public or experts, but she sees it affecting her patients on a day-to-day basis.
With fingers in my mouth, fitting a crown onto a tooth that recently went through a root canal, she says fluoridation is one of a few ways to help prevent dental caries, also known as cavities.
We discuss, or rather she explains, because I cannot talk as she pushes on my tooth to cement the crown in place, about water fluoridation.
Later, the receptionist hands me a small book of printed pages.
“Sandy printed this off for you,” she says to me.
It reads, “CDA Position on Use of Fluorides in Caries Prevention.” In the top left corner, the Edgepointe Dental Centre logo is placed on the paper. It details why fluoride, including water fluoridation, is beneficial in preventing cavities.
I found myself wondering, “Who else is asking for this information?”
As it turns out, Calgary is still passionate about fluoride, even though we don’t fluoridate our water.
It might not sound like an exciting topic, but from either side, Calgarians are fighting for, or against, community water fluoridation for the city.
Juliet Guichon, president of Calgarians’ for Kids Health, a water fluoridation advocacy group, is on one side of the fight.
“To the extent that they can prevent harm, they ought to prevent harm,” says Guichon, referring to the city fluoridating the water in Calgary. “They do that routinely with respect to traffic lights, crosswalks, schools zone and safe off-ramps on roadways.”
While there is a vocal minority of individuals who don’t want fluoride in the water, and even believe it to be harmful, their claims are typically baseless as the scientific research is at a consensus.
“The city councillors have been victimized by people who have given them incorrect information about fluoridation safety and ethicacy,” Guichon explains.
She’s referring to a letter that was read to city council during the period in which they were deciding if water fluoridation should be ended.
The letter, from Dr. Robert C Dickson, is dated Jan. 26, 2011, and advocates for the end of water fluoridation in Calgary.
“Harm is most certainly being done, slowly and insidiously, to the average citizen, but take a moment to think about those who cannot vote and often don’t have a voice of their own- infants and small children, the elderly, thyroid and kidney patients, the poor,” the letter reads.
“This brings up another adage incessantly repeated - fluoridation is good for the poor. That is far from the truth. Very good studies show that it is poverty, not fluoridation, that makes it or breaks it for poor kids,” it continues.
Despite this letter being one of the few pieces of evidence brought to council’s attention at the time, much of the evidence available in the academic and public health fields shows otherwise.
Community water fluoridation, according to Alberta, Canada and international voices on dental health, is one of the key pieces in preventing dental cavities. There has been no reputable research that links fluoride to any negative health effects except dental fluorosis, which only occurs when ingested at high levels.
Dental fluorosis affects the way teeth look. At its mildest and most common, it affects the look of teeth with small white specks that are often not noticeable. At its most serious but rarest, it can cause a mottling of the teeth, affecting the bone structure. However, optimal levels of fluoridation in Canada take this into consideration.
So how did Calgary get to this point?
The timeline of community water fluoridation has been one based on a rocky foundation. The timeline on the City of Calgary’s website shows that between 1957 and 1971, Calgarians voted against water fluoridation three times. Then, between 1988 and 1999, the City and Alberta Health Services consulted with a panel of experts that eventually led to a vote for fluoridation in a plebiscite.
Then, in 2011, with no review or expert consultation, the City of Calgary put forward a motion.
“Now therefore be it resolved that Council repeal the existing Fluoridation bylaw and direct Administration to apply to Alberta Environment for an amendment to the City’s License for its water treatment plants to discontinue the addition of fluoride to Calgary’s water supply.”
In May 2011, that motion was voted on and Calgary ended water fluoridation.
So what did the motion say, and how valid is it today, according to experts on the topic?
1. Fluoride is readily available from sources such as toothpastes, mouth rinses, supplements and topical applications
Lindsay McLaren, a public health researcher at O’Brien Institute for Public Health, confirms that this part of the motion is true.
“You have to go out of your way nowadays to buy toothpaste that doesn’t have fluoride in it,” she says.
She explains that a lot of the research on the benefits of water fluoridation come from the 60s and 70s, when community water fluoridation was likely the only way people had access to fluoride. Now? It’s hard to find dental hygiene items without fluoride.
However, it’s not that easy for everyone. “Some of those other sources of fluoride are not equally accessible to all. Dentistry is a health care profession that's situated in the private sector,” McLaren says. “So you basically have to pay for dental care which creates a barrier to access that is actually very, very strong, whereas fluoride in the water — it's simply there, you don't have to do anything to get the benefits of it.”
She does say this is something that inspired her to get into research about fluoride. “I don't think we have a good handle from a research point of view on whether fluoridation — community water fluoridation — is indeed necessary nowadays.”
But Dr. Tony Odenbach, president of the Alberta Dental Association and College, says water fluoridation is a vital part of dental health. He says there are four main things that contribute to having the lowest chances of developing decay. This includes brushing and flossing, limiting intake of sugar, regular dental care and community water fluoridation.
“Community water fluoridation, particularly in children, is really beneficial because of the systemic effect of the community water fluoridation. Community water fluoridation is particularly beneficial to older or adult patients who sometimes are at a higher risk for developing decay as well,” he explains.
“How do you prevent a car accident? You need to know how to drive, you need to respect the traffic laws, you need to drive slowly, you should not drink [alcohol], you need to use seat belt. It's the same with preventing tooth decay. So the fluoride in the water is really important.”
Drinking fluoridated water also has greater benefits because the fluoride in your saliva from drinking water gets reintroduced in your mouth and acts topically, according to Dr. Odenbach.
Rafael Figueiredo, provincial dental public health officer with Alberta Health Services, agrees with the statement as well, but says that only one preventative measure is not enough.
“How do you prevent a car accident? You need to know how to drive, you need to respect the traffic laws, you need to drive slowly, you should not drink [alcohol], you need to use seat belt. It's the same with preventing tooth decay. So the fluoride in the water is really important,” he says.
Guichon says it’s all about accessibility and that often times, brushing and flossing, limiting sugar intake and regular dental visits aren’t as easily achieved.
“The first three [measures] are dependent upon parental and individual knowledge and financial ability,” she says.
“Fluoridation is not 100 per cent effective in eliminating tooth decay, but it is the most cost effective and equitable way to help reduce tooth decay because it helps everyone.”
2. The Ontario Ministry of Health, the Centre for Disease Control and Prevention, and the American Dental Association have concluded that fluoridated water should not be given to infants, either by itself or in infant formula
This piece of the motion points out that dental fluorosis is a concern for parents who give their infants fluoridated water.
“I think it would be really important to ensure or understand that we're talking about maximum concentration of fluoride,” Dr. Odenbach explains.
In Canada, the maximum acceptable concentration is 1.5 ppm, and the recommended concentration is 0.7 ppm.
“I believe that’s how you'll get the most benefits for the community population that you're trying to address. So I'm not familiar with this statement that the American Dental Association made, but I certainly do know that there is a maximum allowed concentration and that's 1.5, and what we're talking about here for Alberta communities is at a level of 0.7 which is well below what that maximum is.”
Most experts, like Dr. Odenbach, are confused about where city council got this information, as each of these organizations support community water fluoridation.
In a statement via email, the American Dental Association says, “It is safe to use fluoridated water to mix infant formula. If your baby is primarily fed infant formula, using fluoridated water might increase the chance for mild enamel fluorosis, but enamel fluorosis does not affect the health of your child or the health of your child's teeth. Parents and caregivers are encouraged to talk to their dentists about what's best for their child.”
Additionally, the Ontario Ministry of Health also said in a statement via email that, “The [Ontario] Ministry of Health and Long-Term Care supports community water fluoridation as a safe and cost-effective measure to promote oral health and prevent oral disease.”
In an email, the Centers for Disease Control and prevention stated, “As noted by the American Academy of Pediatrics and supported by the CDC, infants less than 6 months should be limited to breastmilk or formula; drinking water should be introduced around 6 months of age.
“Additionally, as noted in CDC’s FAQs about water fluoridation and infant formula, people can use fluoridated water for mixing infant formula; however, exclusive use of infant formula made with fluoridated water could increase the chance for mild dental fluorosis. To lessen this chance, parents can use low-fluoride bottled water some of the time.”
On their website, the organization also calls community water fluoridation, “One of 10 great public health achievements of the 20th century.”
They also say on their website that “because most infant formulas contain low levels of fluoride, regularly mixing powdered or liquid infant formula concentrate with fluoridated water may increase the chance of a child developing the faint white markings of mild fluorosis.”
However, when looking more closely at this statement, it’s not because fluoridated water is unsafe for infants. It’s simply that children might be more susceptible to dental fluorosis, which only affects how your teeth look, not the health of your teeth. Once your adult teeth grow in, you cannot get dental fluorosis.
“The Canadian Health Measures Survey found that 16 per cent of children may have very mild or mild dental fluorosis. So few children had moderate or severe dental fluorosis that the number of children affected was too low to report,” the Government of Canada website states.
3. The amount of fluoride ingested is not controlled because it is dependent on how much water is consumed, and the effects on the individuals are not monitored
This is where it gets more scientific for public health researcher McLaren. Most countries have a maximum acceptable concentration and a recommended concentration of fluoride, similarly to Canada.
Therefore, the levels of fluoride in the water are controlled.
As Dr. Odenbach previously mentioned, the maximum acceptable level in Canada is 1.5 ppm. In Alberta, the recommended concentration is 0.7 ppm.
“At what point will those most vulnerable citizens be at risk for getting the least of the consequences?” McLaren says.
She explains the process to identify the maximum concentration factors this in. “It's a very conservative process for identifying at what point would we not want to go any higher.”
Essentially, McLaren explains, you would have to drink an inhumane amount of water before you would overdose on fluoride, but you would probably first suffer from water poisoning, which occurs when you drink so much water that it creates an overbalance of electrolytes and affects your brain.
4. Adding fluoride is an “unnecessary expense” since it is not required to produce potable water, and only a fraction of potable water is consumed as drinking water
Potable water is another term for safe drinking water. It’s the water that comes out of your taps and is deemed safe to drink and cook with. It’s not something the population generally thinks about in North America, but there are plenty of places where water would not be deemed potable, such as in developing countries, or even here in Canada on some reserves.
Yet the price of water fluoridation is not as high as one might think.
McLaren says if the annual operating cost is $750,000, then that’s less than 60 cents per citizen.
“With today's population it has been well demonstrated in the research literature that if fluoridation has any benefit at all, no matter how small, it's cost effective in terms of the money that is saved in terms of dental treatment down the road. That's very well established,” she says.
Alberta’s dental public health officer agrees with McLaren.
“I think they are just playing with the words and the numbers,” Figueiredo says of this part of the motion.
“We had a couple of [studies] done on return on investment … There is a cost to implement fluoride in the public water supplies but that cost is minimal compared with other costs. Some of these studies say that every dollar invested in community water fluoridation save minimum $38 in dental treatments costs.”
A big issue for Figueiredo is the amount wasted in emergency care because citizens can’t afford to go see a dentist.
“People go to hospital emergency departments for dental problems because they can’t afford to go to a dentist. I did some calculation since 2011 — we have on average 7,000 emergency department visits for dental problems,” he explains.
Lack of water fluoridation, according to Figueiredo, is costing the province. While the City of Calgary pays for water treatment, public health costs like emergency department visits fall to the province.
While he says community water fluoridation won’t stop that from happening, it can at least contribute to minimizing the problem.
5. The operating cost of fluoride is $750,000 annually and the estimated capital costs of required upgrades to the Bearspaw and Glenmore fluoride systems is up to $6 million
Fast-forward to 2018, and the updates are now complete. In fact, updates are constantly being made to improve Calgary’s water supply plants and other resources, including updates to the Glenmore reservoir happening now.
However, Guichon says the $6-million upgrades were also an oversight on the part of council.
“Had they done it in 2011 it would have been less expensive than it's going to be when we finally have fluoridation back,” she says. “The fluoridation equipment would have been incorporated in the renovations. Now they have to be added on.”
Guichon says that city council has admitted to the fact that $750,000 isn’t that much money for something that can improve dental health.
“By their own admission, this is 60 cents per resident per year. Can they find a better public health measure? A less expensive public health measure than that?”
What does this mean for Calgarians?
While experts are in consensus about community water fluoridation, city council shows no signs of revisiting the topic any time soon.
On Oct. 27, 2018, Calgarians’ for Kids Health along with Guichon invited all the members of city council and mayor Naheed Nenshi to attend an event that would provide them with access to experts on the topic of water fluoridation.
“We invited all of them,” Guichon says, with an exasperated tone to her voice. “We invited every single one … One member city council arrived, and that event was meant to help them, to give them access to experts who would give them the correct information.”
Councillor Druh Farrell, who was on the guest list for the event, and was a champion of the motion to remove fluoride from Calgary’s water in 2011, did not attend
The Calgary Journal contacted Farrell’s office, which declined to comment on her behalf.
It seems the city is trying to shift the focus to the province of Alberta. In an interview with Farrell on CBC’s Calgary Eyeopener, she explains why city council turned down the motion for the O’Brien Institute for Public Health to conduct research on the topic for free.
“It’s not a bad idea. The studies need to occur,” she says. “We ask Alberta Health Services to do that work. I would hope they have that information. They should be relaying that information to the city.”
Experts and researchers do have the information. They’re just waiting for city council to listen.