What happens when fluoridated water goes away? (with Dr. Helen Lee)

In this episode, pediatric anesthesiologist Helen Lee discusses the vital role fluoridated water plays in preventing tooth decay and protecting children's health. Drawing on her experience caring for children, especially those enrolled in Medicaid who often face barriers to dental care, she explains the consequences communities can face when fluoridation is removed, the potential costs for Illinois if it were discontinued, and the scientific debate surrounding the recent National Toxicology Program report on fluoride and neurological health.

Read the full report: https://bit.ly/4eBQBew
Learn more about Dr. Lee's PROTECT Lab: https://sites.google.com/uic.edu/protect/home

Transcript

Kristen Chandler

Hello everyone, and welcome to Illinois Policy Unpacked podcast, where we inform the policy conversation in Illinois and beyond. Today, we’re joined by Helen Lee, a pediatric anesthesiologist and associate professor at the University of Illinois Chicago College of Medicine. Her research examines inequities in pediatric oral health and the policies that impact children’s long-term well-being. In this episode, we’ll discuss Dr. Lee’s latest publication with the Institute of Government and Public Affairs on the downstream effects of removing fluoride from drinking water. Dr. Lee, thank you for joining us.

Dr. Helen Lee

Thank you for inviting me.

Kristen Chandler  

Great, happy you're here. To start, can you explain how fluoridated water has historically benefited public health in the United States?

Dr. Helen Lee

Great question. So, there have been a lot of observational studies where scientists have noticed that when people have access to fluoridated water, either through naturally occurring water sources, or if fluoride is added to the community water, that the populations that have access to that water have significantly less cavities. And so, as a result of that, the CDC voted fluoridated water systems as one of the top 10 public health interventions that has improved population health.

Kristen Chandler  

That's great. This is something, the fluoridated water, that's something that's implemented at a local municipality, right? Okay. Recently, a National Toxicology Program report sparked renewed debate about fluoridated water, despite you mentioning the CDC saying that this was a public health success for many, many decades. Could you briefly explain the report and why it has drawn public attention?

Dr. Helen Lee

Sure, so there has historically been a lot of back and forth from community advocates as well as scientists on either side, on the pros and cons of fluoridated water. And because of that activity there the growing concern amongst policy makers and other stakeholders in this space was that despite being, you know, an effective and cost-effective public health intervention for oral health across the lifespan, that there might be more risk than appreciated for systemic health, there had been some high-profile studies that implicated access to fluoridated water in neurodevelopment, looking at pregnant women and their offspring. So, the National Toxicology Program was tasked and said, you know, a nationally representative group of scientific experts who look at, you know, environmental exposures, and they did a review of literature globally, and in their report, they had made some conclusions. 

The reason why it became policy relevant was there was an advocacy group that was advocating for the removal or deregulation of fluoridated water. There was a judge in California who wanted to await the findings of this National Toxicology Program report to determine how they would rule, and it hinged on the level of risk, not for people's teeth, their oral health, which is, you know, had been shown to be effective, in preventing or mitigating the risk of cavities, but what are the other risks? And so the report provided some evidence or association with mild to moderate risks, and they couldn't conclusively rule it out, and so the judge then interpreted that as, you know, this is added risk at whatever level, and so the ruling was in favor of, you know, opening up the doorway for deregulation of fluoridated water. 

The National Toxicology Report is exhaustive, and it's technical, and when people are reviewing it from a scientific perspective, you start to see some gaps and holes in a lot of the assumptions in how you can interpret that, right? So, a lot of these studies were based on findings in other countries that might not have the same regulatory standards, environmental protections, or exposures, and none of the studies specifically looked at the effect of exposure of fluoridated water in drinking systems. It was just sort of global exposure. So, fluoride can be found in, you know, pesticides in chemicals found in other products, things that are ingested, but there was no way to sort of accommodate for all the different types of exposures. And in countries like Iran, China, they perhaps have exposure levels that might differ from someone in Illinois, Rockford, Peoria, or Chicago. So, it is a little bit unclear what the science is showing, it's unclear if there's comparability across populations, and it also wasn't clear how much of the impacts or outcomes were related to drinking water versus other types of exposures. This kind of highlights the value of communications in science, and also the role that that the judicial branch has in influencing policy that has health impacts.

Kristen Chandler  

Absolutely, thanks for highlighting the controversy surrounding the National Toxicology Program report. I know in your report you said you know for every $1 spent on fluoride, you save, what was it around $28 or maybe $30 in public health dollars, you know, supporting you know, this dental care. You work at a pediatric clinic in Chicago. What are the effects on these children in Illinois who do not receive dental care?

Dr. Helen Lee

Great question, and it's a very specific population. So, I work at UIC, and I'm a provider in the University of Illinois Health System. Right, so it's the hospitals, but it's also the College of Dentistry. And as part of my role, I put young children, three to eight years-of-age, to sleep under general anesthesia to treat their cavities. But it's not all children, it's a self-selecting population. We're a safety net hospital, and so we are the place of last resort for a lot of Illinois residents that cannot access dental care and general anesthesia services, if they are primarily enrolled in the Medicaid program. And it's not necessarily that they're enrolled in Medicaid. It might also relate to not having access to a dentist who's comfortable providing that extensive treatment in conjunction to that provider's access to a location and an anesthesiologist. So, it's many different things that are linked together. It's not just having severe cavities, it's layered with the type of insurance you have, it's layered with your geographic location. We know that there are desert counties in southern Illinois where there are no dental providers that are that are participating in the Medicaid program, so there are vast geographic regions, right? So, it's a series of events and circumstances and characteristics about populations and areas and the dental delivery system and the safety net that result and culminate in who comes to UIC for their care with me.

Kristen Chandler  

Absolutely, and for the listeners who are joining us right now, Dr. Lee has a map in her [IGPA] report that highlights Medicaid providers, dental Medicaid providers in the state, and in the map you can really see where there are areas that that do not have that care. And it's like you say, Dr. Lee, people who are on Medicaid may not have the ability to travel or take time off, and then that's exacerbating probably to the pediatric dental care. 

Dr. Helen Lee

Absolutely, we have families that drive three hours. You know, they come from the very edges of the state, and they'll drive three hours to get to our location, and it requires several visits to Chicago. If you're not familiar with the hospital district, it's a very urban setting, right? So, it's expensive, and they have to take the day off from work. We require two adults to be present with the child when they're coming out of general anesthesia for safety reasons, so it's loss of school time, work productivity, which means income, and because some people come from so far away, they may choose or have to find accommodations overnight if they have to be at the College of Dentistry at 7:30 in the morning. So it's costs that are hidden when you look at just reimbursement dollars - there's societal costs. 

Being a provider in the system for the last 15 years, you've heard all of the stories of what people have to go through. We've had people that have gotten into car accidents, you know, trying to get to the hospital. That happens, but the consequences of that are their children don't get the care, and these families have a hard time finding their place that will provide the care, so they're usually 6-12 months in looking around for a provider and a location, so they've invested a lot of time, and so the children are typically sitting with really severe cavities, living in pain, not able to chew properly, eat properly, sleep properly, that has impacts on educational outcomes, quality of life, their self-esteem. All of that is on the line when the parents are simply trying to get their child to receive treatment and care.

Kristen Chandler  

Absolutely. And as you mentioned, you've been working in this area for 15 years, and you sound very passionate on in helping these kids. So, thank you so much for the work that you do for them. In your report, you reference Israel's experience with fluoridated water. After implementing and later removing fluoridation policies, the country saw a significant increase in dental treatments among children. Illinois has required fluoride in community water systems since 1967. What could the potential impacts look like if the state were to remove fluoride from its water systems?

Dr. Helen Lee

That's a great question. We don't know, and but there are some predictable patterns that we can glean from what happened in Israel when they kind of abruptly removed water from their community systems similar natural experiments. I'll use the social science term, where you have an “arbitrary change” in the environment, and then we get to observe what happens in terms of health outcomes as a result of that. There was a similar natural experiment that occurred in Alaska, where they removed fluoridated water, and in both of those populations, you did see significantly associated increase in treatments. And that's what we tracked - the reimbursements and treatments for cavities, so we can infer that the level of disease arbitrarily, or perhaps linked to that floor removal of fluoridated water disease got worse, and because disease got worse. More people were seeking treatment, and so the providers were tasked with growing demand for their services. 

Now, the reason why that's interesting is because of all the things I had just described, we're already safety net hospital, and the people who are at greater risk for cavities are generally people who have health-related social risk factors, right? Financial security issues, food security issues, housing security issues, job security, those all of those characteristics or environments that they're the children are living in the household, put them at greater risk for cavities. When you remove the layer, a protective layer that is perhaps not measured, which is access to fluoridated water, it seems reasonable that in a large population there's going to be an uptick of disease for certain groups of people. Now, predicting who those people are is the tricky part, but based on experiences in Israel and Alaska, I think it's safe to assume that there are going to be more adults and children that are going to have cavities, and the trickle-down effect is because they're young kids, many of those people may end up coming to UIC, if they're Medicaid enrolled, or they have other security issues, and they just can't find a provider near them where they can afford to pay out of pocket. 

So, what this highlights is, what are the other protective factors for these families? What's happening in their homes? How, how are they able to mitigate the risks of not having fluoridated water? Are they effectively brushing their child's teeth twice a day? Are they able to monitor what their children are eating and drinking to make sure that the sort of the substrate of the bacteria is kept bay? So it pulls at households functioning, how parents and children relate to each other, and how sort of those health-promoting behaviors is going to compensate for a lack of that large layer of protection from fluoridated water systems. I think that the parents and households that have that in place in terms of their health promoting behaviors will not be affected, and parents that do not, who are struggling, will end up coming to us.

Kristen Chandler  

Absolutely. And as you just mentioned, these health promoting behaviors, they have that's another added layer of time that you're spending, and if families don't have that time, if they're working two jobs, and don't have time to necessarily do a bedtime routine or morning routine every night, you know that just puts even more burden on people or families that may be in Medicaid. So, thank you for highlighting that. Based on the findings that you mentioned in your report, what policy recommendations would you offer to Illinois lawmakers moving forward regarding fluoridated water, and in response to the conversation around the National Toxicology Program report?

Dr. Helen Lee

You know, I think if there is a decision to remove fluoride from the water systems, and I hope that there isn't. But if there is, I mean, it's a risk analysis, and if the people of Illinois do not find the risk marginal, and maybe marginal to moderate, not supported by solid science, but there is science out there. If that decision is made, then we should be forward thinking, right? People don't exist in silos, and when you change the environment in which people live and grow for children, you have to anticipate that there are going to be downstream consequences, and for a lot of these environmental issues, there are health consequences. 

So, not being a reactive policy maker, I think, would be my plea. If there is a removal of fluoride from the drinking water, understand that there are going to be health consequences, and be proactive in supporting the capacity for dental care and treatment across Illinois. Recognize who the people are that are most likely going to need it. What, where they are going, and shore up the public health infrastructure. It's the federally qualified health centers (FQHCs) that have medicine and dentistry co-located in in a building, maybe supporting more access and providers, and incentivizing these providers in the most vulnerable geographic locations, so on the map, just all those counties with no provider, or providing more funding for those FQHCs, or dental providers that are participating, to make sure that they have the stability and the infrastructure to handle populations right. And then you know, obviously I'm going to advocate for UIH, because I am such a believer in the mission of the institution. It's also paying attention to what we're doing here in Chicago to serve all of Illinois state residents, because we don't serve just Chicago, we see people from all over.

Kristen Chandler  

Absolutely, and as you mentioned, you know, Illinois is a big state, in many people travel 3-4 hours to come get your care. So, thank you for highlighting those policy recommendations. And then, what we could look to moving forward, if Illinois lawmakers did pursue removing fluoridated water. At the time of this recording, I don't believe there's any legislation proposed to remove fluoride, but something to talk about, as it's been a national conversation. All right. And finally, where can listeners go to learn more about your research and work?

Dr. Helen Lee

So, currently I'm co-investigator on a project and I have a partner at DePaul, Dr. Joanna Bushemi, who's a clinical psychologist. She and I are partner principal investigators of a clinical trial that's funded by NIH, and the acronym is PROTECT. What we do is we provide parents support when their child presents to UIC for dental surgery under general anesthesia and we help them coach it through coaching change the way that their children eat and drink and establish routines so they can really brush their child's teeth. We do it through positive parenting, because children who are three to seven are generally very receptive to praise, and so they will, like, like plants to sunlight, they will move towards sunshine from their parents. So we, we would like to see them adopting these healthy behaviors, through positive praise, right? So, parents can be that sunshine for their children, and the children can maintain good oral health after they've had dental treatment under surgery, because the evidence shows that up to 50% of these kids, after they see me, will have another cavity within six to 12 months after surgery. 

So, we're trying to, we're trying to break the cycle, we're trying to help these families, all of these families care about their children, all of these families prioritize their children's health, otherwise they wouldn't have gotten to us. There are many families we know whose children have severe teeth, and they don't come to see us because they can't get through the barriers, the ones that do are extremely motivated. It's not parental neglect. It's other issues that make it difficult. And so we're testing PROTECT, which is the program to help those families overcome those barriers and make sort of sustained change in their lives, so they don't ever come back to see me. You can find the website to PROTECT by looking under Google and typing out the acronym PROTECT UIC, and you can put my name in, Dr. Helen Lee, and you'll find information about that study.

Kristen Chandler  

Thank you for joining us for this important conversation with Dr. Helen Lee. Her research highlights the potential impacts that removing fluoride from drinking water could have on oral health and the well-being of Illinois children. Stay tuned for more conversations that help inform the policy discussion in Illinois and beyond. Until next time, thanks for listening.