TOO MUCH FLUORIDE

Sep 23, 2023

For decades, Virginia brushed off the ill health effects associated with high levels of fluoride in rural drinking water. But the problem has not gone away.

Pictures clutter Lemander Haley's bookshelves, her end tables and her kitchen counter.

But none of the photos — not the high school graduation portrait, not the prom snapshot, not the faded Christmas prints — show Haley smiling.

More often than not, the 27-year-old Franklin native wears a tightly drawn expression, with lips pursed to hide a mouth filled with pitted and brown-speckled teeth.

Years of ridicule are partly to blame for this look and led her to skip college in favor of a more solitary life, she said. For the past seven years she has driven trucks solo and done odd jobs for a contractor with the Surry Nuclear Power Station.

"During job interviews, nobody wants to hire somebody like this," she said, managing to speak while barely opening her mouth.

For 17 years, the U.S. Environmental Protection Agency has tried to prevent the very thing that ruined Haley's teeth — drinking groundwater with unusually high amounts of fluoride. Research has shown that low levels of fluoride are good for fighting tooth decay, but high amounts can stain children's teeth and cause skeletal fluorosis, a bone problem, in older people, according to the EPA.

The federal agency set a standard in 1987 for acceptable levels of fluoride in drinkable groundwater, but the EPA left it up to individual states to enforce these regulations. At least two nearby states with similar fluoride problems acted immediately.

Until recently, Virginia did very little.

Now that the state Health Department is requiring communities to fix the fluoride levels, it is costing rural areas millions of dollars, raising residents’ water bills and in some cases slowing development in areas bursting with growth.

After the acceptable level was set, officials with the Virginia Department of Health did not force rural communities that drink groundwater to lower high fluoride levels and exempted them from doing anything about the problem. The places in the state with high fluoride levels — Suffolk, Smithfield and Franklin; Isle of Wight and Southampton counties; and parts of Chesapeake — were given a pass because department officials said the effects of too much fluoride are simply cosmetic.

It didn't warrant, state Health Department officials said, the millions of dollars it might cost to pay for filtering systems or the drilling of new wells. A town like Smithfield with a $1.9 million budget in 1990 couldn't afford a filtering system that might cost millions of dollars.

Because of the state Health Department's lack of enforcement, these communities were not required to tell the public about the health effects. For two decades, a notice or a stamp on the water bill that said fluoride would cause "no unreasonable health effects" was good enough, allowing a generation of children to grow up with stained and pitted teeth.

That wasn't the case in at least two other states, where pockets of fluoride-rich groundwater also are a problem. North Carolina and South Carolina officials said they addressed the problems once the EPA set a standard in 1987. For the most part communities in those two states didn't buy expensive filtering systems, instead opting to hook into surface water, dilute fluoride-rich water or drill new wells.

EPA officials today say they had no idea Virginia didn't make communities lower unsafe levels of fluoride.

"We did not know that there were MCL (maximum containment level) violations in Virginia until a couple of years ago," said Karen Johnson, the EPA's chief of the Safe Drinking Water program for the region that includes Virginia. "And we are pushing Virginia to address that."

EPA officials have told Virginia the state must force communities to come into compliance with acceptable fluoride levels as soon as possible.

Virginia health officials say that they told the EPA in the early 1980s about the exemptions and that several communities had levels of fluoride above the EPA standard.

"It certainly wasn't a secret," said Dan Horne with the state Health Department. But Horne said the state never notified the EPA of any violations after the standard was set in 1987. But notification also wasn't a requirement.

Then technology and growth began to force the state's hand. With cheaper filtering systems available and rural communities eager to expand water lines into new subdivisions, the state Health Department gradually began to enforce EPA standards starting in 2000. But in many cases, that process will take years.

And even when towns, cities and counties fix fluoride problems, thousands of private wells will remain unregulated. The water in private wells from which fewer than 15 households draw drinking water doesn't have to be tested under the EPA's rules.

In the meantime, the state Health Department is forcing localities with high levels of fluoride to come up with plans to lower the levels in order to expand water lines into not-yet-built neighborhoods. This has halted new subdivisions and growth — if only temporarily — in some places.

At least two subdivisions in Smithfield were on hold until this week. Wednesday night, Smithfield officials agreed to sign a plan to fix the water, and Church Square and the Villas of Smithfield can now continue with their developments, adding 196 homes to the town.

In addition to stopping more water lines from going in, the state Health Department could also take noncomplying well owners or localities to court, or fine them, but that hasn't happened.

The more populous parts of Virginia with fluoride-rich groundwater don't have to worry about this problem. Many of these places in the fluoride-rich belt — an area that starts at the lower Potomac and sweeps southward to encompass Richmond and much of Middlesex, New Kent, James City, Charles City, Surry, Isle of Wight and Southampton counties, as well as the northwestern tip of Gloucester County and most of Suffolk — draw water from reservoirs, not groundwater.

But rural communities still pull most of their drinking water from the ground, and fluoride — with its associated health effects — remains a serious matter.

WATER COSTS CLIMBING

In rural Franklin, where Lemander Haley's family once lived, most drinking water comes from wells. Franklin lies in the broad swath of eastern Virginia where shifts in ocean and river shores many years ago left crusts of chemicals that infuse a high concentration of fluoride into the groundwater that fills wells. The same conditions extend areas of fluoride-rich waters into parts of North Carolina and westward to Texas and Oklahoma and some of the Pacific Northwest states.

Fluoride is formed when fluorine, a highly active gas, combines with another chemical element.

Almost 20 years ago, when the health effects of consuming too much fluoride became apparent, the EPA set a standard for acceptable levels in drinking water at 4 parts per million. The regulation means that for every million gallons of water, four gallons of fluoride is the maximum allowable level.

But in several Hampton Roads communities, the fluoride levels remain higher than the EPA standards. In some sections of Smithfield, the fluoride level in the water is between 4.5 and 5 parts per million, while in the Holland area of Suffolk it's as high as 6.6 parts per million. In contrast, Newport News, which is outside fluoride-rich pockets, adds about 1 part fluoride to every million parts of its drinking water to prevent tooth decay.

That level is considered optimal in fighting cavities, said Rebecca King, chief of the oral health section at the North Carolina Division of Public Health and Human Services.

"I don't want to see a young child drinking 4 parts per million or even 2 parts per million," she said. It could stain their teeth, King said.

As a result of the federal regulations, South Carolina put fluoride rules into place in 1987, when about 70 water systems in the state exceeded federal levels. Today, only two water systems barely test above the EPA's standard of 4 parts per million, according to South Carolina health officials. North Carolina sets its fluoride level at 1.2 parts per million and has only a few wells that exceed this more stringent level.

But the Virginia Department of Health has consistently argued that the fluoride problem is cosmetic and does not affect health.

Fluoride "does not make you immediately sick and it does not poison you like lead and arsenic," Horne said.

He also said residents would not suffer from skeletal fluorosis, or bone problems, from the fluoride levels in southeast Virginia.

But the EPA's guidelines say people who drink water in excess of the federal standard for many years can get bone disease and children who drink water with half of the standard — 2 parts per million — may get stained and pitted teeth, also called dental fluorosis.

"Our philosophy has always been that people deserve the same water quality and the same protection regardless of the size system they are on," said Joe Rucker, assistant chief of the bureau of Water for the South Carolina Department of Health and Environmental Control.

In Virginia, no one has tried to hide the fluoride issues and its health effects from residents, officials said.

"People who have grown up here knew that it was there," said Isle of Wight Public Utilities Director Wayne Rountree. "There wasn't a big conspiracy to cover up that fluoride would stain teeth. People knew that most small children here would have mottled teeth."

And local officials said they trusted the state Health Department and its guidelines.

"We did everything the Health Department asked us to do," said Peter Stephenson, Smithfield's town manager.

Newcomers, however, are often startled to learn about the fluoride when they receive the now-required quarterly notices.

"Luckily we found out about it," said Pat Bourassa, who moved four years ago with her two children to Gatling Pointe, an upscale subdivision on the outskirts of Smithfield.

About six months after moving in, a pediatric dentist warned the family not to drink the water, she said. High fluoride levels stain children's teeth as the enamel of their permanent teeth begins to develop.

Karla Myers, who moved six years ago to Carrsville, in southern Isle of Wight, first learned from neighbors about the water. In 2003, Carrsville's wells tested at 5.3 parts per million.

"It's just hard," said the mother of two young children. "They’ll grab a glass, fill it up and you go screaming, ‘No, don't drink the water.’ I just wish they’d fix it."

Isle of Wight is pushing to have a new well in place in Carrsville by next year.

The fluoride compliance came for many small and rural communities such as Suffolk, Isle of Wight and now Smithfield at a hefty financial toll.

Suffolk paid $8 million in 1993 for a special filtering system and approved about $1.89 million this year to buy several contaminated community wells. Isle of Wight County set aside about $1.4 million two years ago to drill for better groundwater, and the EPA is requiring Smithfield to spend more than $2 million for a filtering system.

To pay for this, the price of water is going up.

Smithfield may have to double its water rates next year, which could raise an average two-month water and sewer bill to $94 from about $52. The new filtering system will bring Smithfield's levels down to the optimal level — around 1 part per million. Suffolk jacked up its rates in the early 1990s to help pay for the $8 million filtering system. Suffolk is now asking some residents to pay more than $1,000 to connect to the city's water.

Suffolk buys some water from Portsmouth and draws additional drinking water from its own reservoir. But for years, the city also maintained a web of community wells that served rural areas of the second-fastest-growing city in the state.

It takes communities about five years to lower fluoride levels once they are cited for violating the rules, according to the state Health Department.

That may not be soon enough for some people. The publicity about the health effects of high fluoride levels has prompted residents to take matters into their own hands. More people with wells are investing in home filtering systems, which can cost up to $1,000. Others buy their own distillers or lug bottled water into their homes.

"I knew the water was bad and fluoride could hurt my bones," said Katharine Goodridge, 57, who suffers from a mild form of osteoporosis, an illness that causes bones to become fragile and more likely to break in people 50 and older.

Goodridge and her husband moved across the James River into the tranquil Jericho Estates subdivision in Smithfield nine years ago. For them, the osmosis filtering system that extracts fluoride from tap water was a must.

LEVELS ARE RED FLAG

After decades of study, scientists are still debating the health effects of fluoride in drinking water.

EPA scientists emphasize that the agency built in a safety factor when establishing the 4 parts per million threshold in 1987. Health effects such as brittle bones usually occur only when the fluoride content exceeds the standard by several parts per million.

Edward Ohanian, director of the EPA's Health and Ecological Criteria Division, calls the staining of teeth a cosmetic or aesthetic problem, not a health risk. So do some in the dental community, including the American Dental Association and Lisa Syrop, a dentist and Virginia's dental health fluoridation coordinator.

Paul Connett, a professor of environmental chemistry and toxicology at St. Lawrence University in Canton, N.Y., and founder of the Vermont-based Fluoride Action Network, calls it a red flag.

"It's a warning sign that the child is overexposed to fluoride," said Connett, who studied the health effects for years. "There may be other toxic effects that are not visible. It would be a miracle if the child that has dental fluorosis does not have other effects."

Federal officials started worrying about fluoride in the mid-1970s. The EPA first tinkered with a level of 1.7 parts per million and later began suggesting a threshold of 4 parts per million. The EPA has also set a secondary, nonenforceable fluoride standard of 2 parts per million to protect against the brown staining and pitting of permanent teeth in children.

Some states, such as South Carolina — which had large rural pockets of localities with high fluoride levels — challenged the 1.7-part standard in 1984 because it was going to force cities and counties to install filtering systems paid for by higher water rates.

Later, the Natural Resources Defense Council, a national nonprofit organization of scientists, lawyers and environmental specialists, filed a countersuit asserting that the 4-parts-per-million threshold was too lenient. At the time, it argued some scientific evidence showed that fluoride at levels as low as 3 parts per million could cause brittle bones.

In 1987, the EPA settled for the 4-parts-per-million standard despite some evidence that "it would expose at least 1 percent of the U.S. population to fluoride levels that may cause skeletal fluorosis" according to EPA documents.

"It's an unhealthy level," said Robert J. Carton, an environmental scientist who worked for the EPA in Washington, D.C., from 1972 to 1992 writing regulations, managing risk assessments on toxic chemicals and overseeing medical research conducted by the government.

"I was one of the true believers that fluoride is one of the best things since sliced bread," Carton said, "until it became pretty clear to me that this number doesn't anywhere near represent the correct information."

But Ohanian, with the EPA, said he doubts people will suffer from brittle bones by consuming moderate levels of between 4 and 6 parts of fluoride per million. He says high fluoride levels could affect bones only in levels of 8 to 10 parts per million.

"One person would need to drink two liters of such drinking water every day for the past 20 years," he said. "Then you would see some change in the bone structure."

There is a chance that this year, the acceptable level of fluoride could be lowered below 4 parts per million, although that is unlikely, officials said.

The EPA has asked the National Research Council, which is part of the National Academy of Sciences in Washington, D.C, to review whether the fluoride standard should be stricter — a process done every five or six years. That decision could come by December.

‘I CAN’T SMILE’

Residents in fluoride-rich areas know all too well what too much can do to them.

Ray Rickerson's opinion of his tap water is simple.

"I don't even give it to my dogs," he said.

To this day, Rickerson blames the high level of natural fluoride in his family's drinking water for his wife, Jean's, disease, a bone illness that deteriorates her joints, which some of her doctors said could be caused by high levels of fluoride.

But there has never been a confirmed case of skeletal fluorosis in Virginia and only five cases in the United States, according to the state Health Department.

The Rickersons, who moved to Driver in the outskirts of Suffolk more than 30 years ago, raised two children in the neighborhood. The family draws its drinking water — with 70 other people in the area — from a privately owned community well just down the street, where the fluoride level is hovering around 4.8 milligrams per liter.

Thirty years ago, the Rickersons loved the well's natural spring water, its softness and taste. It was great to shampoo hair or wash clothes with.

"And then it became this horror story," Ray Rickerson said.

Both of his children grew up with mottled and pitted teeth "that looked like the Grand Canyon."

Sadness cracks Lemander Haley's voice when she talks about her teeth.

"Having white teeth would be like a million dollars for me," Haley said. "It would be like winning the lottery. My extreme makeover. You know, like on TV."

Before she advanced into second grade, Haley noticed her teeth getting stained. Health class, where she and her classmates learned how to brush, became torture.

"I didn't want to be in there," Haley said. "I was so embarrassed. I didn't want to bring any attention to myself."

When her family moved to Newport News from Franklin, she knew she was different.

"I knew their teeth weren't brown," Haley said. " ‘Why don't you smile?’ people asked me."

Some people can afford to have their teeth fixed, said Haley, leaning back on her sofa. "I can't. My family paid taxes, and I can't smile." *

AT ISSUE

* The fluoride levels in some water systems in Suffolk, Isle of Wight and Smithfield exceed the federal standard. Too much fluoride can cause staining of children's teeth.

* Until 2000, the state health department gave these areas exemptions from the 1987 standard set by the Environmental Protection Agency.

A PLAN OF ACTION

Isle of Wight County, Smithfield and Suffolk have taken different approaches to complying with federal regulations.

* Smithfield officials are planning to purchase a $2 million state- of-the-art filtering system to lower fluoride to the optimal level of around 1 part per million.

* Isle of Wight County abandoned most of its fluoride-contaminated wells last year. The county has drilled new wells to find acceptable fluoride levels.

* Suffolk is buying community wells, abandoning them and connecting residents to the city's surface water.

Source: Localities *

THE PRICE TAG

The effects of high levels of naturally occurring fluoride cost communities and their residents.

For residents

* The most effective treatment for dental fluorosis, to cap teeth, costs about $800 to $1,000 a tooth.

* Home filtering systems to remove fluoride can cost about $1,000.

* Smithfield is studying how much it will have to increase its water rates to pay for lowering fluoride levels. Some Suffolk residents will have to pay $1,060 to connect to the city's water system.

For localities

* Smithfield will have to spend about $2 million for a system that will remove fluoride from the groundwater.

* Isle of Wight has allocated $1.4 million to pay for drilling new wells with lower fluoride levels.

* Suffolk just purchased $1.89 million worth of small community wells that have been out of compliance for decades.

Source: Localities and local dentists *

FLUORIDE TESTS

Out-of-compliance localities are required to test drinking water for fluoride quarterly. In 2003, several local areas tested above the 4- parts-per-million EPA standard.

* Suffolk's wells (city- and community-owned wells that serve more than 15 homes) tested on average between 4.3 parts per million at Nansemond Shores and 6.6 parts per million in Holland.

* Isle of Wight's wells tested on average between 4.1 parts per million in Riverview and 6.3 in Battery Park (this well is now closed).

* In 2003, Smithfield's wells tested around 4.3 parts per million, but in 2004, they tested at 5 parts per million.

Source: Virginia Department of Health *

TIMELINE OF COMPLIANCE

Fluoride began to emerge as a health concern in the mid-1970s, but the state health department did not enforce federal regulations in rural communities until the summer of 2000.

1977: The EPA discusses the need for interim standard for fluoride first set at 1.7 parts per million.

1987: The EPA sets drinking water standard for fluoride at 4 parts per million.

Early 1990s: The state health department begins requiring localities, such as Suffolk, to comply with regulations if they plan to expand large water systems.

1996: The Safe Drinking Water Act is amended, requiring annual consumer water-quality reports.

Fall 1999: Virginia localities mail out their first annual consumer water-quality reports that detail the health effects of high fluoride levels.

August 2000: The Virginia Department of Health revokes exemptions for small community wells in rural areas to comply with the EPA's drinking water standards.

Summer 2003: Isle of Wight signs a consent order with the health department to take steps to comply with new standards.

Fall 2004: Smithfield signs a consent order with the health department.

December 2004: National Research Council will release findings that could affect the EPA's drinking water standard of 4 parts per million. *

Sources: National Academy of Sciences and the Virginia Department of Health *

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