Keep fluoride in Bay Area water? What RFK Jr. means for our dental health

California is one of the few states in the nation that requires fluoridation in tap water in an effort to reduce tooth decay.

But many communities in the Bay Area and elsewhere are exempt – and if Donald Trump’s pick for Health and Human Services secretary Robert F. Kennedy Jr. takes aim at fluoride in the water as promised, others could feel pressure to opt out. That, dental experts warn, could make for more cavities.

“The federal government does not have control over state or local decisions on community water fluoridation,” said Howard Pollick, UC San Francisco dentistry professor and fluoridation consultant for the California Department of Public Health. “However, the general public and decision makers at the state or local level may be influenced by the administration’s stance.”

If confirmed, Kennedy could have far-reaching authority to undercut promotion of water fluoridation.

“I am going to advise the water districts about their legal liability, their legal obligations, their service to their constituents, and I’m going to give them good information on the science and fluoride will disappear,” Kennedy told NBC on Nov. 2.  He linked fluoride to various illnesses, despite consensus among major dental and medical associations that fluoride is safe and benefits public health.

A recent decision by an Obama-appointed federal judge in San Francisco could also shift the pro-fluoride tide. Ruling against the U.S. Environmental Protection Agency, U.S. District Judge Edward Chen ruled on Sept. 24 that the current maximum concentration of fluoride concentration poses an “unreasonable risk” to children and must be reduced.

More than 70 years ago, Antioch became the first community in California, joined by cities served by San Francisco’s Public Utilities Commission, to add fluoride to its public water supply, according to a history of the state’s fluoridation by UCSF emeritus professor of oral biology Ernest Newbrun.

That simple step transformed the dental health of Antioch’s children, research found. Between 1952 and 1962, the number of decayed, extracted and filled teeth fell 55% in 5-year-olds, 84% in 6-year-olds and 60% in 8-year-olds.

Within several years, the communities of Hayward, Healdsburg, Morgan Hill, Palo Alto, Pleasanton and Vallejo followed in Antioch’s footsteps. The Contra Costa Water District added fluoride in 1965. In 1976, the East Bay Municipal Water District put it in the water that serves 30 cities in Alameda and Contra Costa counties.

When a city’s leadership makes the decision, divisive and expensive referenda can be avoided, Newbrun wrote.

Yet by 1992, only 15.7% of California’s population on public water systems was receiving fluoridated water.

The turning point came in 1995 when former Assemblymember Jackie Speier (D-Burlingame) pressed for a statewide fluoridation bill, which led to the California Fluoridation Act of 1995.

Now all three of the Bay Area’s largest water providers — Santa Clara Valley Water District, East Bay MUD and SFPUC — add one drop of fluoride to every 18 gallons of water.

It occurs naturally in all water. But supplemental fluoride helps protect teeth by remineralizing tooth enamel and making it more resistant to cavities.

“The safety and effectiveness of optimal community water fluoridation has been supported by countless scientific studies over the past 75 years,” according to the California Dental Association.

But not every community is covered by California’s mandate.

Only water systems with 10,000 or more service connections, serving about 25,000 people, are covered by the rule. And it specified that funding must come from a source other than taxpayers or rate payers – and if no “outside” funds are available, it cannot be enforced. Finally, the large number of homes and water districts in rural regions rely on well water, which doesn’t have added fluoride.

“It is up to each community to decide,” said UCSF’s Pollick.

As a result, fluoride is missing from 43% of Californian faucets, far more than the national average of 25.6%. The state ranks 37th in the nation, behind states like Kentucky and North Dakota. When water lacks fluoride, residents can seek a fluoride treatment at the dentist’s office. Fluoride is also present in much toothpaste.

There are myriad reasons communities opt out, said Stuart Cooper, executive director of Fluoride Action Network, which opposes its use.

“California is one of the few states in the country that has a statewide mandate, but communities have pushed back and independently ended fluoridation without penalty,” he said.

Parts of Sunnyvale, Los Gatos, San Jose and Santa Clara blend their fluoridated Valley Water supplies with non-fluoridated groundwater supplies, so fall below recommended standards.

Los Altos is served by Cal Water, which doesn’t add fluoride to the water supply. Its water district has estimated it would cost $4.5 to $9.6 million to fluoridate its water and $837,000 per year to maintain the system.

Large swaths of Livermore, served by Livermore Municipal Water and Cal Water, don’t have fluoride.

While most of Marin County’s public water is fluoridated, Novato’s water is not — because it gets water from the Sonoma County Water Agency, where efforts have languished. Sonoma is the last holdout of major communities in California.

The city of Santa Clara says it’s unaffordable. “The capital and operational costs associated with fluoridating are cost prohibitive,” according to the city. “To date, funding has not been available from the state. ”

Some places are ideologically opposed. Santa Cruz prohibited fluoride in 1999, saying  “each individual possesses the inalienable right to choose or reject what he or she consumes…The public water supply shall not be used…for the purpose of affecting the physical or mental functions of the body of any person.”

Political pushback has stalled negotiations in Watsonville, despite a California appellate court ruling two years ago that ordered the city to fluoridate. Opponents want the California Dental Association to take on liability for any unforeseen harm due to fluoride exposure.

In rural parts of the Santa Cruz Mountains and Diablo Range, community wells are without added fluoride.

The Santa Clara Valley Water District didn’t start delivering fluoridated water in some areas until 2016, after many years of debate and four years after district officials first voted to go ahead. Its $6.6 million retrofit project demanded a complex public-private partnership with support from three nonprofits, including The Health Trust, First 5 Santa Clara County and the California Dental Association Foundation.

What RFK Jr. is suggesting, said UCSF’s Pollick, is stopping the adjustment of fluoride levels in community drinking water to the level of 0.7 mg/L that reduces tooth decay. There is no proposal to eliminate natural fluoride.

If he prevails, the U.S. Department of Health and Human Services could reduce its promotion of fluoridation. The Trump Administration could also influence the EPA’s response to the recent court case, he said.

Steps could include adding a warning label or changing drinking water standards, said Cooper.

But communities still have the right to take their own public health measures, said Blair Robertson of the State Water Resources Control Board, which monitors California’s fluoride use. They could follow the example set by Mountain View, for instance, which opted to fluoridate its own water.

“Every city has the option to add fluoride if they so choose,” Robertson said, “even if the federal government no longer recommends it.”