Seth A. Richardson

srichardson@rgj.com

Washoe County remains in the minority of the country by not having a fluoridated water supply, but one Reno assemblywoman is looking to change that.

Currently, Clark County is the only county in Nevada required to fluoridate its water after a 1999 bill passed requiring counties of more than 700,000 people to treat water. Now, Assemblywoman Amber Joiner, D-Reno, wants to change that law so it includes counties with more than 100,000 people — which would add Washoe County to the mix.

“I think it’s time we revisit that,” Joiner said. “We’re a larger community now and I don’t know why it hasn’t happened.”

Despite the overwhelming amount of scientific and medical support for fluoridating water, that doesn’t mean everyone is on board. The scientific community is at a consensus that small amounts of fluoride delivered over an extended period of time are beneficial and the water system is the best method of delivery.

Yet people remain opposed to adding fluoride to water, some based on philosophical grounds, some based on cost and some based on questionable scientific findings.

How does fluoridated water work?

Fluoride is a naturally occurring mineral that is already found in many water supplies. Its most common usage is preventing tooth decay, according to Dr. John Novak, a pediatric dentist and vice-chairman of the Washoe County District Board of Health.

“In simple terms, it makes the tooth structure less susceptible to acid,” he said. “Acid is what makes the decay in your tooth process. That’s why when you eat a lot of candy and junk and stuff, that’s turned into acid more than something that may not break down into an acid as well. The sugar breaks down into an acid that the tooth is very susceptible to without the fluoride.”

While most people associate fluoride with dental health, Novak said other studies show it helps with either prevent or treat other ailments such as gum disease, osteoporosis and bone lesions.

Grand Rapids, Mich., became the first city in the nation to adjust its water’s fluoride levels in 1945. Since then, it’s become very common across America.

Statistics from the CDC show around 75 percent of people receiving community water services – about 211 million people – received fluoridated water in 2014.

Water authority pushes back

Joiner is already facing resistance from the Truckee Meadows Water Authority, which voted to oppose the bill at a Feb. 14 meeting. Board members cited cost and circumventing the voters as the main reasons.

A fiscal note from TMWA estimated the cost of fluoridating the water system at around $70 million in capital projects with a further $3 million annually for maintenance. That translates to a $3.90 per month increase per customer, according to TMWA General Manager Mark Foree.

The TMWA board is comprised of local lawmakers and public officials including the Reno City Council, Sparks City Council and Washoe County Commission.

“I don’t have anything against fluoridation in particular,” said Sparks Councilman Ron Smith. “It’s the amounts, the costs that would cost us not only to set up everything, but then to maintain it.”

Voters struck down water fluoridation in a 2002 county ballot initiative. Reno Councilwoman Neoma Jardon said she had political concerns about not putting fluoridation to a vote – especially since TMWA is seeking to impose a 3 percent rate increase of about $1.42 a month per customer after residents cut water usage by 20 percent during the drought.

“We tack on anywhere near an 8 percent increase and the voters are going to take us to the shed,” she said.

Reno Councilwoman Jenny Brekhus said she had problems using water as a distribution system in general.

“I’ve always personally – and it’s philosophical – had an objection to thinking of the water system as a medical delivery system,” she said.

The science

Novak said there is a lot of “junk science” floating around about fluoride. While it can cause fluorosis – an over-saturation of the mineral that discolors teeth – that only happens in water systems where there is too much fluoride.

“I heard it expressed at a meeting recently that the concern about it is it’s going to kill the ancient fish in Pyramid Lake,” Novak said. “I’ve heard it’s going to kill the grass in your yard or trees. None of that is true.”

Fluoride is one of the most studied minerals and many scientific reports and medical organizations recommend using community water as a means of delivery.

The Centers for Disease Control and Prevention, the American Dental Association, the American Medical Association and the World Health Organization all recommend community water fluoridation. The CDC has called it one of the 10 greatest public health achievements of the 20th Century, alongside vaccinations and regulating tobacco use.

Dr. Robert Talley, executive director of the Nevada Dental Association, said his organization is in strong support of Joiner’s bill. The Washoe County District Board of Health is also supporting the measure.

Brekhus said she believed in the benefits of fluoride, but has concerns about how it's distributed.

"I feel that if medicine is going to be delivered to someone, it should be with their fully-informed consent," she said in an interview with the RGJ.

“I know people have told me of approaches they have in their personal lives and I have my own history of that in the school being able to take shots of fluorided (sic) water,” Brekhus added. “I know my mother gave me pills growing up outside of a fluorided (sic) system. That’s where everyone can be informed and consenting of this.”

Kevin Dick, Washoe County district health officer, said that idea is mistaken.

“Just to start with on a basic level, fluoride isn’t medicine. It’s a mineral,” he said. “We’re just adjusting the concentration to that optimal level that in the water.”

The website for the CDC states “community water fluoridation is the most cost-effective way to deliver fluoride to people of all ages, education levels, and income levels who live in a community.”

Fluoride pills and supplements can also be more expensive than the proposal to add it to the water. Dick said there are a range of prices and he’s heard anywhere from $5 per month to $11 per month – assuming the person has insurance.

That puts low-income earners and minorities – who are more likely to not have proper fluoride levels or insurance – at a disadvantage, he said.

“Ms. Brekhus may not understand the challenges that many in our community face with coping with having a place to sleep, with having to feed themselves and their children,” he said. “It doesn’t leave them with a lot of time to figure out what their fluoridation options are and how they can get those types of things.”

The cost

The nearly $70 million price tag and $3.90 increase in rates per month was the main argument against the bill from TMWA board members during the Feb. 14 meeting.

Multiple organizations, including the CDC and ADA, estimate the return on investment at fluoridated water at a high yield. For every $1 spent on water fluoridation, the public receives anywhere between $4 and $38 in public health benefits.

“One estimate shows that TMWA customers would enjoy a savings in general cost alone of over $12 million per year,” Joiner said. “When you look at something like that, it is worth the investment. That would be my key point. We can go back and forth about how much we think this will cost up front, but it is absolutely worth the investment in the long term.”

Scientific reports routinely find significant differences in overall dental health as well as risk factors between communities with fluoridated water and communities without.

Dr. Marcia Ditmyer, an assistant dean at the University of Nevada, Las Vegas school of dental medicine, said in one of her studies, fluoridated water was one of the top factors in determining how much tooth decay might affect children.

“Those that lived in an area that was not fluoridated were at two times the risk of getting decayed teeth than those that lived in the areas that were fluoridated,” she said.

A separate adolescent oral health study conducted from 2001 through 2009 headed by Ditmyer found children in Clark County with access to fluoridated water were less susceptible to tooth decay. It also found women, Hispanics, blacks and uninsured children were at greater risk for developing tooth decay because of a lack of access to fluoridated water.

“At the community level, action should focus on retaining and expanding the community fluoridation program as an effective preventive measure,” the report concludes. “At the individual level the study identifies the need for more targeted efforts to reach children early with a focus on females, Hispanics and blacks, and uninsured children."

Dick, the Washoe County health officer, said beyond the health benefits, there’s also an economic cost. People aren’t productive when they’re visiting the emergency room for dental problems and it also puts a strain on Medicaid, he said.

“We also have $12 million a year that is spent with people visiting the emergency room because of dental health problems,” he said. “That $12 million isn’t even used to treat their dental problems. It’s spent on pain pills and on antibiotics to fight the infections that they have because of their dental disease. That’s another expense and obviously those people are not being productive if they have that level of disease if it’s sending them to the emergency room.”

State lawmakers last considered fluoridating Washoe County's water in 2009 and TMWA estimated the cost to be around $5.5 million, far from the estimated $70 million presented at the February board meeting.

Foree said the 2009 fiscal note only accounted for the surface water whereas the 2015 bill would require groundwater wells to also comply, leading to higher costs.

Joiner said she’d always planned to work with TMWA and was surprised the numbers were made public before she had a chance to see them or discuss the plan with the board. She also questioned if those numbers were correct and said it sounded high compared with other municipalities.

'A modern community'

Joiner and the public health officials said they were simply surprised that Reno’s water isn’t treated, especially given the scientific consensus and because Reno is often billed as an increasingly cosmopolitan community.

“Most people think that we have it because we’re a modern community,” Joiner said. “When you tell them that we don’t – I think this is also just an educational issue. People don’t know that they need the supplements and they’re not getting them.”

Reno Mayor Hillary Schieve declined to comment.

Joiner’s bill is currently awaiting a hearing in the Assembly Committee on Natural Resources, Agriculture and Mining.

Seth A. Richardson covers politics for the Reno Gazette-Journal. Like him on Facebook here or follow him on Twitter at @SethARichardson.