Is Water Fluoridation the Answer to Hawai‘i’s Rampant Tooth Decay Problem?

Why does Hawai‘i fight fluoridation despite a dismal record of dental decay? Community leaders blame fear, misinformation … and deposed Honolulu City Councilmember Rod Tam.

By James Charisma

When the Hawai‘i State Department of Health provided dental screenings for 3,184 third-grade children in 67 public schools, the results were staggering: Hawai‘i’s children have the highest prevalence of tooth decay in the United States. We’re literally the worst in the nation when it comes to taking care of our kids’ teeth.

That was the 2014-2015 school year, and the screenings focused on third graders, because that’s the target elementary school population for the National Oral Health Surveillance System; they targeted schools across six islands to create the most complete statewide picture possible.

The department compiled the findings in a comprehensive 20-page report called “Hawai‘i Smiles,” which yielded such depressing conclusions as “many children are not aware that teeth are not supposed to hurt,” and if these dental care assessments “applied to all children in kindergarten to sixth grade, more than 6,600 children in Hawai‘i’s public elementary schools experience pain or infection due to dental disease on any given day.” Yikes.

Hawai‘i isn’t the only state struggling with high levels of tooth decay in children. In fact, the national average is 52 percent. We top the charts with a 71-percent ranking. The second worst is Texas, with 67 percent. If our kids’ teeth got a report card, the difference would be an entire letter grade.

Click on the image to enlarge the map.

State health officials have one primary solution: fluoridation. Yet Hawai‘i has resisted a practice that’s commonplace across the country. Not a single Hawai‘i county fluoridates its drinking water, and Honolulu county actually went so far as to specifically ban it. In 2004, the Honolulu City Council passed an ordinance that prohibits fluoridation of O‘ahu’s public water system. Just four years before, in his 2000 State of the State address, then-Governor Ben Cayetano had declared an objective to fluoridate water across the Islands: “Hawai‘i’s children have one of the worst rates of tooth decay in the nation. We can, and we must, do better. We need to fluoridate our water. For every $1 we spend fluoridating, we’ll save $80 in dental expenses down the road.”

In a recent interview with HONOLULU Magazine, Cayetano said, “What we found at the time was that the military families at Schofield, where the water is fluoridated, their teeth were in so much better shape than places like Wai‘anae. It’s sad because, in the poorer areas, you see a lot of the kids there 11 or 12 years old and they already lost some of their permanent teeth.” He had hoped to adopt fluoridation, but, at the time, “The Legislature didn’t have the will to do it, and we failed.”

Which seems a shame, because the effectiveness of fluoride in tap water isn’t some fringe scientific theory. It’s a public health program that Hawai‘i is choosing not to adopt.

Think of it this way: On one side of the field, the American Dental Association, the American Medical Association and the World Health Organization all say yes to water fluoridation. On the other side of the field, sitting alone with some of the worst dental decay in this country, is Hawai‘i.

Dr. Derek B. Tom, children’s dentist at ‘Aiea Pediatric Dental Center, says, “I think fluoride should be thought of in the same way we look at vaccines in medicine. You need to consider whether or not the benefits outweigh the negatives.” He says fluoride is very beneficial for children, strengthening permanent teeth while they are being formed under the gums, and remineralizing tooth enamel.

“Fluoride should be thought of in the same way we look at vaccines in medicine. You need to consider whether the benefits outweigh the negatives.”—Dr. Derek B. Tom

This isn’t to say that fluoridating Hawai‘i’s water will suddenly cure dental decay statewide. Tom believes in the benefits of water fluoridation, “but it must be mentioned that children living in fluoridated water communities still get decay, so fluoride is not the only solution. There are many children in Hawai‘i who, without fluoride, are cavity-free, while there are children living in states with fluoridated water that have rampant decay.”

What community water fluoridation can do, however, is provide a baseline level fluoride to homes. There are other ways to receive fluoride, including toothpaste, mouthwash or pills prescribed by a dentist, but these options may not be available to lower-income Hawai‘i residents. This makes fluoridation not only a public-health issue but a social-justice topic as well.

Honolulu City councilmember Ann Kobayashi voted to ban fluoridated water in 2004, but says she understands both sides of the fluoride debate.

“My father was a dentist, three of my uncles were dentists and I’m married to a dentist,” Kobayashi says. “I’ve been hearing dental hygiene all my life. I feel really badly that we have such bad records of dental hygiene for our children because it really affects the whole body. If you’re very low income and every penny is going for food, are you going to spend more money for fluoride drops? Even though it affects your child’s whole health, some people don’t have a choice because they make so little money. That’s why there’s the push to have fluoridated water, fluoride in the whole system so people don’t have to use their food money to purchase fluoride drops because they want their children to have good dental hygiene.”

So how did Kobayashi end up backing a ban? She points to the advocacy of a controversial former council member. “Rod Tam introduced [the antifluoridation ordinance]. He felt very strongly about that and asked me to sign on and I did. There are many people in my district who like clean water and clean air,” she says.

It’s clear Kobayashi has spent time mulling this issue. Yet the argument persists. “Drinking water should not be used as a means for delivery of chemicals for medical or dental purposes when other alternatives are available,” states the opening words of the 2004 Honolulu ordinance against fluoridation. Critics of public-water fluoridation argue it’s about keeping Hawai‘i’s community tap water pure and untreated. But Hawai‘i tap water is already treated: with chlorine, to kill bacteria and viruses.

In 1999, the Centers for Disease Control and Prevention, America’s leading national public-health institute, created a list of the “Ten Greatest Public Health Achievements” of the 20th century. Along with the control of infectious diseases through sanitation and vaccination, and vehicle safety features such as airbags and seatbelts, fluoridation of community drinking water is on this list. Many of these advancements seem like common sense today. But, at the time, these measures were revolutionary and often controversial.

Hundreds of millions of Americans have benefited in cities across this country for more than seven decades, with countless studies demonstrating that fluoride is effective in preventing cavities and dental decay.

Now that the state Department of Health’s recent study has branded Hawai‘i’s children with the worst tooth decay in the nation, the debate is back. It remains to be seen whether the dismal report will spur any legislative initiative to support fluoridation of community tap water.

Get your fluoride here

While Hawai‘i thinks about fluoridation (and thinks about it and thinks about it), pediatric dentist Derek Tom has recommendations on how to seek fluoride elsewhere, in addition to using fluoride toothpaste:

“For children over 6 months of age, their doctor or dentist can prescribe them supplemental fluoride via pills or drops and it can be incorporated in the form of a multivitamin. For children older than 6, over-the-counter fluoride mouthwashes can be used (and must be spit out).”