This legislative session, two fluoride-related bills cycled through the Hawaii Senate, each with the opposite intention.
The first was a proposal to fluoridate Hawaii’s public drinking water, something that has failed over and over in previous legislative sessions. The other was the first of its kind: a bill that would place an outright ban on water fluoridation in Hawaii.
Both bills died. But their fates shed light on why Hawaii, whose population has some of the worst oral health in the nation, isn’t likely to get fluoridation anytime soon.
A 2015 Hawaii Department of Health study found the state has the highest rate of tooth decay in the nation among third graders, and nearly half of Hawaii adults have lost at least one tooth because of tooth decay or gum disease.
Yet lawmakers remain split on the use of fluoridation to address poor oral health in Hawaii, even as community water fluoridation has become a relatively common practice, with about 71% of Americans receiving it through their public water systems.
Hawaii’s fluoridation debate is mostly split between two camps: dentists and public health advocates on the pro-fluoride side, and anti-fluoridation activists and some longtime Hawaii lawmakers on the other.
Water fluoridation is endorsed by the Hawaii Dental Association, which cites the global backing of the scientific and medical community, including the World Health Organization, American Academy of Pediatrics, and the U.S. Centers for Disease Control and Prevention. In 2015, the CDC touted community water fluoridation as one of the greatest public health achievements in the country’s history, citing it as a cost-effective initiative that has been shown to reduce tooth decay by about 25% in children and adults.
Hawaii Sens. Mike Gabbard and Donna Mercado Kim reject those recommendations and remain rooted in the belief that community water fluoridation equates to unnecessary “mass-medication,” a term both of them used.
Gabbard, who proposed the ban on water fluoridation, said he has many constituents in opposition.
“Many folks are saying, ‘Look, I’m a taxpayer and this is big government shoving this down my throat, and it’s not fair, especially when you have other solutions that can help kids overcome tooth decay,’” Gabbard said. “The bottom line is that we greatly value our pristine water.”
Gabbard said Senate Bill 2732 was requested by a retired chemist and he received advice on drafting the legislation from Stuart Cooper, campaign director for Fluoride Action Network, a donations-based anti-fluoride group.
Gabbard’s bill wasn’t scheduled for a hearing and ultimately failed to move forward this legislative session.
The legislation in support of fluoridation, Senate Bill 2997, also stalled when Sen. Karl Rhoads wasn’t able to garner enough votes in the Senate Judiciary Committee, whose members include Gabbard and Kim.
“When you hold a hearing on fluoride, it’s a zoo,” Rhoads said in an interview with Civil Beat before the hearing. “There’s definitely a vocal minority who will come out and make all kinds of wild claims about the effects of fluoride.”
His bill had a new twist, requiring water to be fluoridated until the Department of Health verifies that 100% of the population has dental insurance or has rejected dental insurance. DOH, which testified in favor of the bill, estimated the cost of modifying 169 Hawaii public water supply systems would cost between $9.3 million and $18.6 million, as well as other expenses.
A National Fight Gone Local
This fight is not unique to the Aloha State. Anti-fluoride efforts have a history that spans the past seven decades.
Public water fluoridation first began in the 1940s to prevent tooth decay. It came after decades of research.
Fluoride is a mineral that can be found naturally in water, which is how its benefits were discovered. In the early 1900s, scientists found naturally occurring fluoride had an effect on teeth — in fact, naturally occurring high dosages of fluoride caused a brown stain to the enamel of Colorado residents.
Eventually, scientists decided its merits in small controlled dosages were a public benefit, and the practice was quickly picked up across the country, but not without vocal opposition. In the 1960s, the right-wing political advocacy group John Birch Society painted water fluoridation as a communist plot.
Each time opposition raises the question of fluoride’s safety, the scientific consensus rejects the claims, which in turn sows more doubt.
In Hawaii, opposition to community water fluoridation also has a long history.
In 2003, the City and County of Honolulu, which spans Oahu, essentially banned it when it finalized an ordinance that prohibits any additives to public drinking water. The county ordinance would be trumped by any future state legislation.
City Council member Ann Kobayashi told Honolulu Magazine in 2017 that she opposed fluoridation, partly because former council member Rod Tam backed it, and also because of broad constituent opposition. Many of her family members including her spouse are dentists, she said.
Online Research Wars
In mid-February, testimony at the State Capitol about the bill that would have introduced fluoridation was heated, Sen. Mike Gabbard recalled.
Those who testified in favor “were kind of like, ‘Our science is better than your science,’” Gabbard said. “That’s why I don’t see this ending.”
Both senators Gabbard and Kim say fluoridation is not necessary and cite online research that links fluoride to bad health outcomes, such as lower IQ, or compromised autoimmune systems. Such studies have been listed on the anti-fluoridation group Fluoride Action Network’s website, and are largely dismissed by health authorities such as the CDC because they study the effects of extremely high levels of naturally occurring fluoride. In some areas, the mineral actually needs to be filtered out.
Both Gabbard and Kim said they’d prefer initiatives that would improve oral health education in schools and programs that would make topical fluoride treatments available to “financially distressed” populations.
“My argument is that dentists can address that issue by teaching oral hygiene in our schools, and also using topical fluoride treatments when necessary,” Gabbard said. “It’s not necessary to force everybody to have fluoridated water.”
But those in favor of water fluoridation say it would help the large number of people who do not have dental insurance or may not have the means to see a dentist.
The scientific and medical community also responds by noting that much of the anti-fluoride rhetoric online draws on the extremes of fluoride toxicity, unfairly relating it to community water fluoridation which uses diluted and vetted therapeutic small doses.
“We’re not talking about making you drink a 50% solution,” Rhoads said.
The majority of public water systems that have fluoridation include the mineral at 0.7 milligrams of fluoride per liter, which is considered to be the most effective level to prevent tooth decay and minimize risk for dental fluorosis, according to the national recommendation by the U.S. Public Health Service.
A Senator Switches Sides
During the three decades Donna Mercado Kim has been in office, her stance on fluoride has evolved. She used to support fluoride in drinking water and now she opposes it.
Kim explained her stance by sharing her story of not having the best dental hygiene as a child.
“We were poor and went to the dental clinic in Palama Settlement where they’d drill all my teeth, and I still have a lot of silver cavities,” she said. “I used to think that when I reached adulthood, if we had fluoride in the water, maybe I wouldn’t have bad teeth. But more recently within the past five or 10 years I’ve become more health-conscious and more aware of putting chemicals in my body.”
Hawaii Dental Association’s Executive Director Kim Nguyen pointed to kupuna as another population in critical need of oral health support who would benefit from fluoridated water.
“Seniors are getting to the point where they don’t have the tactile mobility to do the basic flossing and brushings, so we’re relying on their caregivers to help them even with basic health care needs,” Nguyen said. “Rightly so, there’s emphasis on the kids, but we also have to think about the adults who don’t have access to health insurance or benefits. We the general public can help by ensuring that they get fluoridated water.”
Battling ‘Dr. Google’
In a world of readily available information from the internet for whatever side you choose, dentists like Dr. Anthony Kim feel as if they are in a battle with “Dr. Google.”
“Long gone are the days when you can say, ‘Trust me I’m a doctor,’” he said. “That’s the biggest challenge because when it goes to the Legislature you’re already starting at very two polarized sides.”
Dr. Kim is the dental director at the Waimanalo Health Clinic and on the board of trustees of the Hawaii Dental Association. He has encountered many parents who fear using topical fluoride for their children is toxic or poisonous.
“It definitely keeps us on our toes,” he said. “We have to really understand our science behind what we do. We have to acknowledge their concerns and fears — we can’t be dismissive of what they’ve heard or what their friends might have told them.”
“We talk to them about how effective it is in reducing decay and about appropriate dosages,” he added. “Once you acknowledge their concern and have that discussion over what is the meaning of a therapeutic dose and how impactful it can be for strengthening their child’s teeth, they have to take that information and make a decision at that point, but it’s very difficult to do at chair side.”
Sen. Donna Kim emphasized she gained her knowledge about the subject through personal education from books, seminars and discussion with people as reasons for her opposition to community water fluoridation. When asked for sources, she said she didn’t have any to share.
“I don’t have anything that formalized as far as my own personalized research; it’s not like I was going to write a paper,” she said.
The Military Difference
Fluoridated water is only found at U.S. military bases in Hawaii, where about 12% of Hawaii’s population drinks it. The Department of Defense issued a memo in 2013 mandating that its bases fluoridate their water supply.
Dr. Kim says he and other dentists can quickly guess which patients grew up in places with fluoridated water compared to those who did not.
When working at the Army’s Schofield Barracks in the past, he saw some of the best tooth enamel among soldiers who weren’t raised in Hawaii. And today, he can immediately guess who among his patients didn’t grow up in the islands.
“It’s obvious; you can see it in the quality of their enamel,” he said. “It also becomes apparent when they’re cavity free. The quality of enamel and the amount of decay that might have been present in their mouth is not comparable to what we have here, and sadly, especially among the kids.”
A few years ago, Kim participated in a third grade dental screening program at the Marine Corps Base Hawaii in Kaneohe for the Hawaii Smiles Report. The differences in cavities among elementary schoolers was also eye-opening, he said.
“It was remarkable to see the kids from different parts of the country and much lower incidences of decay,” he said.
Kim believes fluoride is bad for people, but acknowledged its topical merits, and said other topical fluoride applications such as tooth paste, fluoride filters or topical treatments at the dentist are preferable to her compared to putting it in drinking water.
Time and again, dentists have testified that fluoridation is an effective way to improve dental health, especially among children.
Kim said she has heard that testimony but doesn’t see the merit in public water fluoridation, especially if it is intended to help children, because they would only account for a quarter of Hawaii’s population.
“We’re medicating 100% of the population for your entire life so that we can help 20% of the population’s children, 40% of them which are at risk, for up to only one-fourth of their life,” she said. “So everybody else, seniors, will have to drink this fluoride in their water when you can get it in other ways.”