“What? There’s No Fluoride in Worcester’s Water?”

Lynda Young, MD

Let's take a look at the history of Community Water Fluoridation (CWF). If you Google the top public health achievements since 1900, CWF is right up there. It all started in the early 1900s. A dentist in Colorado, Dr. Frederick McKay, noticed a lot of “grotesque brown stains” on the teeth of Colorado Springs natives. Several years later, he and a colleague, Dr. G.V. Black, noted that children with “Colorado Brown Stain” were remarkedly resistant to tooth decay. It wasn’t until 1931 when Dr. McKay and other colleagues discovered that the culprit causing this staining and decay resistance was the high level of fluoride in well water in certain areas of our country. Drawing on Dr. McKay’s studies and those of others, in 1945, Grand Rapids, Michigan became the first city in the world to add fluoride to its water supply. Over the next 11 years, researchers monitored the level of dental decay in almost 30,000 school children. The caries rate in those children who were born after fluoride was added to water had dropped over 60%. This finding was a huge breakthrough in dental care and made tooth decay a preventable disease for most people. That formative event, over subsequent years, led to 73% of communities in the U.S. fluoridating their water supplies as of 2018.

So, what’s with Worcester?

When I began my pediatric practice in Worcester, I was taken aback by the level of significant dental decay in the children I saw. How can this happen? I asked the then Commissioner of Public Health in Worcester, Dr. Arnold Gurwitz, who said, “Well, for starters, there’s no fluoride in our water.” To which I replied, “WHAT? There’s no fluoride in Worcester’s water? How come?” “Long story,” he said.

CWF in Massachusetts, as in many other states, is done on a town by-town initiative. In Worcester, the Board of Health can mandate the addition of fluoride to the city water, but the Worcester voters can initiate a ballot referendum on the mandate. This process has actually occurred four times, beginning in the 1950s. Then, it was soundly defeated as “a Communist plot” with little discussion of improving the public health of our citizens. CWF in Worcester was a ballot referendum three more times, the last being in 2001. At that time, the Health Foundation of Central Massachusetts provided a $400,000 grant to an oral health collaborative coalition to provide public education on oral health and the value of adding fluoride to the city’s water supply. This time, the opposition’s issue was “forced medication” and no one should have to take something that they have not consented to. Once again, fluoridation was defeated. Currently, there seems to be no appetite to bring CWF up again and certainly not with this method of approval. It seems, after four failures, there is little chance of this issue passing. What’s interesting, though, is if you look up our city’s status on CWF, it states we are “partially” fluoridated since 1995. This is true, to a degree. There is a small section in our city that receives water from Holden which does fluoridate its water. Only about 250 Worcesterites benefit from this CWF.

Is CWF or lack thereof a serious public health issue?

The lack of fluoridation in Worcester leads to consideration of the troubling inequities or disparities in oral health. Even with significant improvements that have occurred over the years, disparities exist in certain ethnic and racial groups. In the United States, in general, the poorest oral health of any racial or ethnic groups occurs in non-Hispanic Blacks, Hispanics, American Indians and Alaska Natives. The majority of reasons are social determinants of health including poverty, lack of access to health and dental care, and lack of health insurance. CWF in Worcester is a single intervention that would go a long way to close the inequities of oral health in our community.

Why do people oppose CWF?

Some of the reasons have been mentioned above. There are some issues that are founded in real or questionable studies. The browning of teeth, as seen in Colorado Springs, is called fluorosis, and has been consistently brought up by opponents to CWF. The level of fluoride in CWF is safely below fluorosis-inducing levels.

As you can imagine, too much of a good thing can lead to problems. And fluoride is no exception. Besides staining of teeth, this mineral has purportedly been linked to all sorts of health problems: skeletal fluorosis, osteosclerosis, osteosarcoma, and other bone deformities. These findings have never been duplicated in more recent and peer-reviewed publications, or in studies examining people consuming normal levels of fluoride, but you will hear about these concerns and others any time you raise adding fluoride to the water supply.

How could we expand fluoridation to Worcester, given the opposition and the previous history of failures?

One option is to replicate the state-wide initiative of making the legal age to purchase tobacco 21 years old. As with CWF, tobacco legislation is done on a town-by-town basis. But coalitions in favor of 21 instead of 18 years of age in most towns were able to get legislators in the State House to draft a bill that eventually passed. Would this work for fluoride? It worked in Connecticut. Look, no one likes to be told what to do, many do not understand the concept of public health and given the current pandemic, this issue is way down on the to-do list. But do not despair – we will test these un-fluoridated waters in the future!

Lynda Young, MD, FAAP, Professor of Pediatrics UMass Medical School.