Tucson is one of just six major U.S. cities without optimally fluoridated tap water, putting residents at an increased risk for cavities and other health problems, dentists and public health leaders say.
The U.S. Centers for Disease Control and Prevention says fluoride in water helps prevent and even reverse tooth decay. It deemed fluoridation of the public water supply one of the 10 greatest health achievements of the 20th century.
Three quarters of Americans who use community water systems get fluoridated tap water, the latest CDC data show. In Arizona, it’s lower than the national average, with 57 percent of the population getting fluoridated water. Arizona cities and towns that add fluoride to their water supplies include Bisbee, Mesa, Chandler, Phoenix, El Mirage, Tempe, Gilbert, Yuma and Glendale.
“Virtually every health organization recommends that communities have fluoridated water. It reduces decay a minimum of 50 percent,” said Dr. Richard Chaet, a Scottsdale pediatric dentist who is former president of the Arizona Academy of Pediatric Dentistry and consultant to the Arizona Board of Dental Examiners.
“It is the easiest, least expensive public health measure that can be used basically in the world to reduce cavities in children.”
Tucson dentist Dr. Philip Mooberry knows that only too well. Mooberry was among a contingent of local dentists who in 1992 persuaded the Tucson City Council to fluoridate the local water supply in conjunction with the introduction of Central Arizona Project water to the local supply. But the fluoridation never happened.
The federal definition of fluoridated is 0.7 milligrams per liter or more of fluoride in the water supply. Most Tucson Water users — 709,000 people — receive water that averages 0.4 milligrams per liter of naturally occurring fluoride.
Three major U.S. cities don’t add fluoride to their water, but they have naturally occurring levels at or above the 0.7 milligram-per-liter optimal level recommended by the CDC to prevent tooth decay. Those cities are Colorado Springs, Colorado; Jacksonville, Florida; and El Paso.
According to the American Dental Association, fluoride supplementation should be considered for children who drink water with less than 0.6 milligrams per liter.
“The overwhelming public health evidence supports getting the level to 0.7,” said Dr. Daniel Derksen, a professor at the Mel and Enid Zuckerman College of Public Health at the University of Arizona, and director of its Center for Rural Health.
fluoride in America
U.S. cities began adding fluoride to the water supply in the 1940s and by the end of the century had reduced childhood cavities by an estimated 40 percent to 70 percent, the CDC says.
An increasingly vocal opposition to fluoridated water has emerged in recent years, fueled by a distrust in government. But supporters say scientific evidence is on their side — at the recommended levels, fluoridation is helpful, not harmful.
San Francisco started fluoridating its water in the 1950s. New York City started in 1965, and Dallas started in 1966, says the American Dental Association, which calls water fluoridation, “one of the very few public health measures that actually saves more money than it costs.”
The World Health Organization says fluoridation of water supplies, where possible, “is the most effective public health measure for the prevention of dental decay.”
Among the 50 largest cities in the country, six do not add fluoride to their water and don’t have enough naturally occurring fluoride to optimally prevent tooth decay, according to research by the American Dental Association and the CDC’s Division of Oral Health. Those cities are Tucson; Wichita, Kansas; Fresno, California; Albuquerque; Portland, Oregon; and San Jose, California.
San Jose’s water district has voted in favor of fluoridating, but the process of retrofitting its complex system of water plants to bring fluoride to consumers is expected to take several years.
Tucson’s effort to fluoridate the water here, motivated by the fact that Central Arizona Project water has very low levels of fluoride, called for fluoride to be added to the water one year after the introduction of the new water source.
But that first attempt to deliver the water was disastrous, and Tucson Water scrapped a single-point-treatment facility, which was part of the original fluoridation plan. At that time, the cost was estimated at an extra cent per month per water customer.
If fluoride were to be added to local water now, it would be at various different points in the system, making it more costly and logistically challenging than the Tucson City Council originally envisioned.
“We lobbied, and the mayor and council voted and mandated it,” Mooberry said. “I am so frustrated. I almost think it’s a situation for a class-action suit by poor people. They are suffering and have no means to fix it.”
Adding fluoride to Tucson’s water now would require a directive from the mayor and council, and it would also mean higher water rates, city officials say.
Tucson Mayor Jonathan Rothschild says he understands the health benefits of water fluoridation, but it’s expensive to consumers. He said the issue of adding fluoride to the water has not been raised during his time in office.
It typically takes public action for governments to consider fluoridating water. In Portland, a citizens group trying to combat a rising problem of tooth decay in low-income kids approached a member of the City Council to sponsor a fluoridation measure.
City officials in Portland commissioned a study on the issue, and in 2012 the council voted to fluoridate its water supply. The issue then went to a public referendum in May and failed. Portland still does not fluoridate its water.
Phoenix went through a similar process two years ago when a resident questioned the safety of fluoridation. The city decided to continue fluoridating — something Phoenix has done since 1990. But as in Portland, the debate was emotional for those who believe adding fluoride to the water is unsafe.
The most recent data from the CDC listed the Phoenix Municipal Water System’s fluoride rate at 0.8 milligrams per liter — about double Tucson’s average.
The kids in my practice are decay-free, most of them,” Mooberry said. “Who this affects is kids who don’t get in to see the dentist.”
Also affected are senior citizens who may be living on Social Security. Medicare does not cover dental services, so older people may avoid dental visits. And Mooberry says medications often cause dry mouth, which makes teeth more prone to decay.
From a public health standpoint, Pima County Health Department Director Dr. Francisco Garcia supports fluoridation. He grew up in Tucson without fluoridated water and says that could be why he has more cavities than his wife, who grew up with a fluoridated water supply.
how much is too much?
Tucson Water’s system is recharge and recovery, which means the water goes into the ground before it’s delivered to consumers. The local geology has naturally occurring fluoride from the bedrock and soil, which raises the fluoride level to about 0.4 milligrams per liter at the point of distribution, said Remy Sawyer, an environmental scientist with Tucson Water.
But that’s an average — some areas have fluoride levels that are higher; some are close to zero.
Active and impassioned opposition to fluoridated water has been growing nationally, and some smaller communities around the country have removed fluoride from their water, arguing that it's a toxic chemical and harmful to health.
Fluoride indeed can be unhealthy at higher levels.
The maximum allowed level of fluoride in U.S. water systems by the Environmental Protection Agency is 4 milligrams per liter. Levels of 2 milligrams per liter or higher put water users at higher risk for dental fluorosis, a painful condition caused by overexposure to fluoride that mottles teeth. Too much fluoride could also cause a bone disease called skeletal fluorosis.
At high levels of fluoride, children age 8 and younger shouldn’t drink tap water, medical experts say.
“We’re coming from the angle where we’re not going to exceed the regulated (fluoride) levels. We’re trying to protect people from dental fluorosis,” Sawyer said. But the CDC and HHS (U.S. Department of Health and Human Services) are trying to protect people from cavities.”
There is no evidence that community water fluoridation results in severe dental fluorosis, says the national Community Preventive Services Task Force, an independent, unpaid panel of public health and prevention experts. The group provides evidence-based findings and recommendations about community preventive services, and says evidence shows the prevalence of cavities is substantially lower in communities with optimally fluoridated water.
The U.S. Department of Health and Human Services has proposed a slight change to the recommended level of fluoridation — from a range of 0.7 to 1.2 milligrams per liter, to just 0.7 milligrams per liter.
The main reason for the change was that there are now more sources of fluoride than when community water fluoridation was introduced almost 70 years ago, CDC spokeswoman Brittany Behm said. She stressed that while other sources of fluoride — such as toothpaste — exist, water fluoridation provides an additional benefit.
However, fluoridating Tucson’s water would require initial capital expenditures for equipment, daily operation and monitoring, and fluoride additives.
When Portland considered adding fluoride to its water, it estimated the cost at an extra 25 cents per month on an average water bill, said Chad Lapora, regulatory compliance supervisor with Tucson Water. The cost of designing and constructing a fluoride-delivery facility was $5 million, and the cost to operate was put at about a half million dollars per year.
Even if the city were to fluoridate its tap water, some residents would not benefit from its cavity-preventing properties, noted Paloma Beamer, an associate professor of environmental health sciences at the UA. That’s because some people drink only bottled water, believing it to be healthier.
Tap water is regulated by the U.S. Environmental Protection Agency under the Safe Drinking Water Act. Bottled water is regulated by the U.S. Food and Drug Administration as a food.
The FDA does not require bottled-water manufacturers to list the fluoride content on the label, but it does require that fluoride additives be listed.
A vast majority of bottled water does not have optimal levels of fluoride, the American Dental Association says. Some brands have no fluoride at all. Many popular brands of bottled water undergo reverse osmosis or distillation, which removes all of the fluoride from the water.
Beamer’s family, including her young son, drink only tap water. They use fluoridated toothpaste and periodically, a fluoridated mouthwash. Her advice is that families consult medical and dental providers about the right amount of fluoride supplements for their children.
“According to Tucson Water’s reports, there is a range in fluoride values depending upon the part of the city that you are in,” she said. “There is also a large range among the smaller systems that they monitor. It would be important for families to know which water system they belong to.”