Putting a taste-less, odorless, colorless chemical in our water is among the most effective public health interventions known to humans. So why are there so many conspiracy theories about fluoride? Abdul reflects on the low-key importance of oral health. Then he sits down with Tooka Zokaie, Senior Health Policy Analyst for the California Dental Association to talk about fluoridation and its detractors.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: Fentanyl crime bills sweep conservative state legislatures. Scientists successfully transplanted frozen rat organs. And it’s been a year since the Supreme Court ended the constitutional right to an abortion in this country. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] You know what the dirtiest part of your body is? Relax, folks. It’s not that kind of podcast, but it is that kind of podcast. The dirtiest part of your body is one you probably spend a lot of time washing at least twice a day if you follow recommendations and think of yourself as at all a clean person. It’s your mouth. Think about it. It’s dark, wet and warm. Exactly the kind of place that bacteria love to hang out in, which is why so many of them do. Our mouths are, well, let’s face it, cesspools of bacteria. Which is why it should come as no surprise that oral health is so hard to get right. How many of you have ever had a cavity? Okay, good news is that nobody can hear you. Bad news is that 90% of us have had at least one. I have. And here’s the astounding part. One in four of us has a cavity right now. In order to prevent them, we spend time brushing at least two times a day, flossing, which we really should do after every meal and using mouthwash. And yet our mouths are awash in bacteria. Back in the day, losing all your teeth was simply a matter of time. It was expected that you would lose your natural teeth into early adulthood and that if you had the means, you’d replace them with dentures. Today, we expect to keep our adult teeth well into adulthood, if not all the way through our lives. But here’s the interesting part. If you brushed your teeth this morning, even flossed, it might not have been the most important thing you did for your teeth. The most important thing you did for your teeth might have been taking that first drink of basic tap water. That’s right, most tap water in America is fluoridated, meaning that every time you drink your water, you’re bathing your teeth in a compound that binds with the stuff your teeth is made of to make a stronger, more decay resistant compound. Scientists discovered the decay fighting properties of fluoride by accident, observing that local residents in Colorado Springs had unusually hardy teeth owing to the naturally occurring high concentration of fluoride in their local water. And by the end of World War Two, the city of Grand Rapids became the first community to begin adding fluoride to its water. Over the next decade and a half, the rates of cavities called dental caries was down 60%. I want to remind you, your mouth is literally the biggest opening to the inside of your body. And when you have bacteria making snug homes for themselves in the insides of your teeth, that’s not a good thing. Poor oral health has been linked to all sorts of other diseases, including strokes, heart attacks, and dementia. While excessive fluoride, far higher than the amount added to drinking water, has been linked to a number of outcomes, there hasn’t been any strong consistent evidence linking any side effects to fluoride in water at the recommended level of one part per million. But that hasn’t stopped conspiracy theorists and fearmongers from taking aim at water fluoridation. In fact, owing to this wayward activism, some communities have elected to take fluoride out of their drinking water. And sure enough, play stupid games win stupid prizes. The scientific evidence has shown consistent increases in the risk of cavities after fluoridation stops. As you all probably know, water fluoridation isn’t the only public health intervention that’s fallen prey to mis and disinformation. It’s part of a long growing list. But it hasn’t gotten the attention it deserves. So today, I wanted to invite someone on the front line of the Fight for Fluoride to share a bit more about this critical oral public health tool, why it’s been under such attack and what we all can do about it. Our guest today is Tooka Zokaie. She’s the senior health policy analyst for the California Dental Association. Here’s my conversation with Tooka Zokaie. 

Dr. Abdul El-Sayed: All right, let’s get going. Can you introduce yourself for the tape? 

Tooka Zokaie: My name is Tooka Zokaie. And I’m the senior health policy analyst for the California Dental Association. 

Dr. Abdul El-Sayed: We really appreciate you uh coming to talk to us today about something that most of us benefit from and very few of us think much about. And if you’ve ever brushed your teeth, uh I want you to understand that that is maybe the second most important thing that you do for your dental health every single day. Well, it might be the most important thing you do, but it’s maybe the second most important thing done for your dental health every single day. And the most important thing may actually be uh fluoride in the water. Now um, most of the time we talk about fluoride in the water we’re talking about conspiracy theories, about people telling you about why it’s so bad. But today, I want to talk about why it’s so good and why a lot of folks want you to think it’s so bad. So just jumping in um tell us, what is fluoride and why do we put it in the water? 

Tooka Zokaie: So fluoride is a naturally occurring mineral and when we talk about putting it in the water, it’s typically an adjustment of the naturally occurring fluoride in our drinking water. In fact, this whole public health program started because they noticed a community in Colorado had naturally better, longer lasting teeth than other Americans. And as researchers started to study why that may be happening, they saw that there was about one parts per million fluoride in the drinking water. Now, too much fluoride in water can lead to fluorosis, dental fluorosis. But community water fluoridation as a public health program is now about 0.7 parts per million in our water. And this mineral is part of our bodies health. It remineralizes our tooths enamel to make them stronger and longer lasting. And we now have 73% of the U.S. population on water systems with optimal water fluoridation. So it is a very powerful public health program. It’s a privilege to have I’m lucky to be in a community that has fluoridated water um and I haven’t had cavities the whole time I’ve been here, so who knows? [laugh]

Dr. Abdul El-Sayed: I. You know, it’s interesting. I live in a home with a well and um my spouse and I think a lot about um whether or not we should be fluoridating our well water. And we had it tested and found that actually there’s uh enough fluoride in that water. But we have two young children who have growing developing teeth and it’s a thing that we think a lot about. Now, you mentioned two things I want to dig into there. The first is um that community in Colorado. Can you walk us through that history? What did what was found about them? Why were they such an important uh sentinel event in in alerting us to the value of fluoride in water? 

Tooka Zokaie: Yes. So when we were uh in the early 1930s, there was really rampant tooth decay in the United States. And in fact, it was one of the reasons a lot of individuals could not serve and enlist in the Army. Um. Actually, one of the top graduation gifts were new teeth or fake teeth for uh graduating high schoolers. Um. And in 1931, Dr. H. Trendley Dean, he was a founder of the NIH Dental Hygiene Unit in the U.S. Public Health Services. And he began a long running epidemiologic study and explored the relationship between fluoride intake, dental fluorosis and tooth decay. And by 1942, the NIH published this study that accounted for about 7200 children aged 12 to 14, and it was from 21 cities in Colorado, Illinois, Indiana and Ohio. And children tended to have fewer cavities and less severe decay in cities with more fluoride in the community water supply. And this effect plateaued at around one part per million. And so additional studies you know, we have now over 75 years of studies, led to pilot fluoridation programs. The first one was Grand Rapids, Michigan, and it began to fluoridate their drinking water supply. And they saw that developing children you know, you mentioned, you know, two young ones with developing teeth in your family, um the new teeth that would erupt in water fluoridated communities, um had fewer cavities, had longer lasting teeth and less caries. Um caries means decay. Uh. Tooth decay. So cavities and, you know, there were over um 11 years of observational children’s studies. Ages six to nine uh in New York, for example, they compared Newburgh and Kingston. And as they continued these different kinds of epidemiological studies and observational studies and classic studies, um they saw that repeatedly at 0.7 to one part per million, that tooth decay was decreasing. And um the mechanism makes sense because, you know, our teeth, our enamel are made of fluoride, and when we drink fluoride in our water, it becomes part of our saliva, it bathes our teeth in this kind of enamel saving mineral, and we have longer lasting teeth as a result. 

Dr. Abdul El-Sayed: Walk us through what’s happening in communities where there’s not fluoride. You talked a little bit about a new set of teeth being [laugh] the the the standard go to gift for graduation from high school. And you’re talking about these aren’t your baby teeth. These are your adult teeth that come in decay and then fall out and you need new teeth by the time you graduate high school. Walk us through just how bad circumstances were prior to fluoridation. 

Tooka Zokaie: Yeah, so prior to fluoridation and even now, tooth decay is the number one chronic disease in children. Um. So it is a chronic condition, but there are ways to reduce that rate of decay in our populations um and there are many reasons for oral health kind of worsening in our history. Some of it has to do with higher sugar consumption in our foods. Um. It has to do with how we chew our foods, processed foods. So nutrition is definitely a part of oral health, but with fluoride, we we are able to make our teeth stronger during development. Now, while fluoride in water has lifelong benefits, it really has the biggest impact as teeth are developing because your body is making teeth out of what you consume. So when you have fluoride um again, this natural mineral that is in a lot of different products, um but specifically when you’re in a fluoridated area, tooth decay is decreasing. And to this day, 25% reduction in cavities are due to water fluoridation. Now we have fluoride in other products, but even to this day, uh studies show that about 25% of the reduction in cavities is due um to the fluoride in our drinking water that serves about three fourths of the U.S. population. 

Dr. Abdul El-Sayed: And [sigh] you talked a bit about fluorosis earlier. What is that? 

Tooka Zokaie: So dental fluorosis is when we have too much fluoride, um we usually consider the minimum threshold effect for chronic consumption of fluoride at 1.5 parts per million. So that is more than double of what we have in our drinking water. And it’s purely an esthetic side effect of when you have too much fluoride, it’s pretty small white lines that show up on your teeth. There isn’t anything um physically like physiologically harmful from fluorosis, um at least when you have about 1.5 to 2.5 parts per million. But it does lead to an esthetic effect. Now, unfortunately, with misinformation campaigns and confusion and hesitancy regarding water fluoridation, there are other concerns about fluoride and their possible side effects. And even though these have been researched for over 75 years, and even as research studies get stronger and scientists continue to investigate to see you know if we can find something new, the only real side effect we find from water fluoridation is reduced dental cavities. 

Dr. Abdul El-Sayed: So there’s there’s no real uh demonstrated evidence driven side effect that we know of that can be reproduced in in studies? 

Tooka Zokaie: Exactly. Especially at optimal fluoride levels. Now, there’s been some recent research that’s very important, looking at different fluoride intake, total fluoride intake and how high consumption, high uh fluoride exposure could lead to potential side effects. And even that has not been um replicated at this point in time. There’s continued call for research to see if there are side effects from high consumption of fluoride, but at water fluoridation levels, just like any mineral, calcium, sodium, vitamin D, um so you know, other vitamins and minerals, there’s a threshold effect, there’s an optimal amount. It’s the same with fluoride. There’s an optimal amount for health and development. 

Tooka Zokaie: So when you talk about uh potential consequences. I mean, how much fluoride are we talking about where there really could be any real detrimental issue aside from fluorosis? 

Tooka Zokaie: An expert once told me, for water fluoridation, you would overdose on the water before you would overdose on the fluoride. So it would be a lot. And this is most researched in fetal development in young kids because everything again, if you’re doing a standard dose in the water, eh just like we fortify milk and with calcium and vitamin D, um you know, to see really is this safe at all ages and all stages of development and continually 0.7 parts per million is a very safe amount. Um. To give a comparison on natural fluoride in other products. You know I’m Iranian, so I love my black tea, and black tea has 3 to 4 parts per million of fluoride. Um. Our ocean water. You know it has fluoride. Um. So there’s a lot of different substances and products that naturally have fluoride. Spinach, you know one of the great greens that we consume that has fluoride. Uh. So it’s it’s tasteless, it’s odorless, you can’t really tell it is there, but it’s a it’s a powerful mineral. Um. And one of the you know, one of the bigger concerns about fluoride that some communities have when considering fluoridation is, is this going to change the taste of my uh food or the agriculture? And to that I say, you know, I’ll ask you, where in the U.S. do you think they have the best bagels and pizza? 

Dr. Abdul El-Sayed: New York City. 

Tooka Zokaie: And they have fluoridated water. And when I was in Portland, Oregon, working on a campaign uh for fluoride, they were concerned that it would change the taste of their kombucha and their beer. Um. But, you know, New York hasn’t had issues. Seattle hasn’t had issues. And when you compare Seattle and Portland and you look at child development, kids are pretty much scoring the same on everything except Portland has a 40% higher uh tooth decay rate in kids than Seattle. And the biggest difference is Portland does not fluoridate and Seattle does. 

Dr. Abdul El-Sayed: Hmm. That’s the most Portland thing I’ve ever heard, [laughter] which is concern over the quality of kombucha. Portland, get your act together. Come on now. [laughter] Um. So I want to I want to um just ask because I think I think sometimes when we talk about tooth decay, people don’t quite appreciate the broader consequences. And part of that is because we’ve done this disservice to oral health, implicitly marginalizing it from the rest of health. Can you talk to us about some of the broader consequences of chronic tooth decay? 

Tooka Zokaie: Absolutely. That’s my that’s my life. [laugh] So, you know, oral health, unfortunately, has been separated from total health. And we say we’ve pretty much taken the mouth out of the body when it comes to insurance coverage, to care, to education. And as I said a little earlier, dental cavities, dental caries are the number one chronic disease in children. You know, you think it’s asthma or um something else that we hear a lot more in our in our public health education. But it really is a public health issue to think about oral health. And in my work, we usually make this the dentist or dental hygienist or dental assistants role. You know it’s the dental professionals to address dental health and oral health. But how come every other medical profession and specialty has public health allies, has health systems allies, um and, you know, researchers and supporters that aren’t dentists? I myself am not a dentist, but I’m so lucky for the ones that I work with because they’ve become the public health champions for community water fluoridation, for oral health access and beyond. So it really is um a call to action that I have for my colleagues in public health and population health to think about oral health because it is impacting their communities. And the number one reason for missed school days is dental pain. One of the top reasons for emergency department visits is a non traumatic dental condition, one that could have been addressed by a dentist or, you know, a dental team. So um we have a systems issue and we have um a fairly fragmented oral health system, specifically within public health. As someone who’s an advocate for oral health and public health and I go to, um for example, EPHA and these wonderful uh health meetings and summits, the folks in the room, when the topic is oral health tends to be the folks in the room that are always there when it’s about oral health. And when I go to other topics that are very important, we see more diversity of interests when it comes to public health. So, you know, my my ask for anyone listening is uh if you’re a public health champion, what are you doing to address oral health? Who’s someone you can call when it comes to oral health? And are you, you know aware of your local oral health program? 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Tooka Zokaie after this break. 

[AD BREAK]

Dr. Abdul El-Sayed: Fluoride in the water has become such a meme of a conspiracy theory. [laugh] When did this become? When did this conspiracy theory take hold? 

Tooka Zokaie: Well, that’s before my time. I mean, it’s been around for a while, and we kind of call it the the flavor of the month, like in the ice cream shops, that there’s always something new when it comes to fluoride and why there is some fear around it. And a lot of this has to do with the same campaigns that cause vaccination hesitancy and other public health program hesitancy. A lot of this has started because there was a concern of how fluoride is um is used in our water treatment process and the products used to adjust fluoride in drinking water and that it is a byproduct of other um, you know, manufacturing, even though the fluoride used for drinking water is fluoride binded with silica um it’s called uh fluorosilicic acid and say that three times. Um. But it when it goes in the water, it’s like many other um kinds of fortification where it’s the fluoride and then the silica is then filtered out um so it’s totally safe to drink. But there was this original conspiracy that it was a way of doing mind control or a, you know, like, you know, I’ve heard the communist plot theory and that kind of goes around a lot, but um that has now evolved to be a full spectrum of hesitancy, from neurodevelopment to osteosarcoma to any other um scary sounding phrase of, you know, this is because of the fluoride. And with the water treatment process, I mean, it’s a it’s a five part process. We got calcium carbonate, we got chlorine like it is a it props to the water engineers because they do a fabulous job when it comes to keeping our drinking water safe and clean and then adding the fluoride as an extra public health benefit. But because the fluoride is a part that we talk about in public health, it’s also easy to latch onto as something to be afraid of. 

Dr. Abdul El-Sayed: And the Internet has given a platform for all sorts of conspiracy theories. You know, there’s a there’s a quote that I often like will quote from a from a book I read about the way that the Internet has been weaponized, which is that in the past, every village had an idiot. Now, all the village idiots share a chat room. And there’s this sort of concentration effect where like can find like and when like is um is someone who wants to demagogue basic science and drive conspiracy theories. The Internet has quite a lot of places for that. How has the conspiracy theory around fluoride and water changed? Um. And how has it uh potentially taken on legs with the advent of Internet based misinformation? 

Tooka Zokaie: So I think a big part of the fluoride issue with misinformation is that we have a translational science opportunity that we’re missing. Um. So when there’s a lot of research being done, for example, on the impact of fluoride and IQ and there is multiple studies done. When one study, you know, one of the standalone studies finds a small effect in boys and not in girls. That’s what was found in a 2019 study that there was a small IQ decrease in boys that was significant, actually had an increase in girls, not statistically significant. Um. And I remember [laughing] waking up to almost every major news channel sharing fluoride in water can decrease IQ. And I just get, got all these calls about what is going on? Why is why is fluoride decreasing IQ? What is the issue? And it was just, you know, that phrase continuing to be shared. You know, fluoride impacts neurodevelopment, fluoride decreases IQ. And just last month, another publication looked at a meta analysis of all the studies that have been published looking at fluoride and neurodevelopment, especially looking at optimal fluoride exposure. So not those endemically high fluoride areas. And they found no association. Not better, not worse, none. And that’s kind of what’s expected. But we’re still seeing those news articles that touted fluoride as this neurodevelopmental um impact element, that it’s still something that we’re trying to share at local city council meetings and even with some larger science groups. And what was interesting is when that study came out, you know, again, so New York Times, NPR, um they were all sharing how fluoride decreases IQ and the major medical public health, dental associations, major universities, um even organizations that specifically look at science, misinformation and communication. It was about 25 organizations, you know, top scientists all saying that this study does not mean fluoride decreases IQ. But my family and you know my community is not going to be looking at that. They’re going to be seeing what, you know, their iPhone brings up or what pops up on their screen where um it’s the it’s the scary skull and bones next to fluoride. And it’s not going to be these ivory tower publications saying, no, no, it’s safe. Um. No, we need more research. But there’s multiple studies that have contradictory findings and overall fluoride’s safe in drinking water. You’re good to go. That’s not what people are seeing. So I don’t blame the individuals in the public to be afraid because they’re being fed fear and the public health professionals are continuing to share amongst themselves, you know, what is safe and what isn’t and what the research states. And, you know, as I said, a lot of dental providers are educating their patients and their community members on the safety because they get, you know, the journals and the blasts and, you know, the work that my organization does to share the latest research. But that’s not going to the general public. And the public health professionals haven’t engaged with this enough. So the translational science of the safety and efficacy of water fluoridation, even with continued research, uh has a long way to go. 

Dr. Abdul El-Sayed: Let me guess the meta analysis that failed to confirm that one study didn’t get the same kind of coverage as the more alarmist study did, right? 

Tooka Zokaie: Absolutely. It came out a month ago and I’ve only seen it in our public health circles. And um I’m currently working, you know, to write a commentary and try to do some more translational science to share what this means. Um. I use the metaphor you know if a tree were to fall in the woods and no one was there to hear it, would it make a sound? And we do the same thing with public health. We are publishing and we’re talking amongst ourselves, but we’re not making enough noise. And it’s time that we learn how to engage with translational science, not just to help water fluoridation, um which of course is extremely important and part of my work, but also to address the other areas of work where the professionals and the scientists and the researchers are not really engaging with their community and the public. Um. But the fear about these possible interpretations are. 

Dr. Abdul El-Sayed: Yeah, there’s a bunch of pieces of that that I want to comment on. You know, the first is just to explain what a meta analysis is to folks. The thing about science is that it’s noisy, especially um associational science. When you’re looking at observational studies. What do I mean by an observational study? I mean it’s a study where you didn’t necessarily randomize people to the thing that you’re trying to study. In this case, you’re looking at the relationship between fluoridation and IQ. And when you do a meta analysis, what you’re trying to do is you’re trying to separate the signal from the noise. Now you have one study that clearly was some of the noise, and then you have a confirmatory study that did not show the same relationship. That’s more about the signal. It’s just higher powered. So it’s a study of studies that is intended to identify that signal that showed no effect. Now, of course, the second piece here is that what the public sees as a function of a media apparatus that is built around driving clicks and even very well-meaning media outlets, New York Times, NPR, who are not in the business of misinforming people when they bias their coverage around those pieces of science that will drive the most number of clicks and do not do the work of cleaning up after themselves. What happens, in effect, the emergent phenomenon is, in effect, misinformation because you’re only covering the noise and not the signal. And then the third piece of that is even if this study was confirmed over and over and over again, it fails to put in context the broader uh benefits of fluoridation. Because I want you to think about what a cavity is and and Tooka’s used the word um carie quite a number of times, a carie is just a medical term for a cavity. It is literally a bacterial infection of the tooth. And so what you’re talking about is a consistent infection, bacteria seeding the central opening of your body. And one of the things that we’ve identified uh time and again about the impact of tooth decay is that it does not uh it does not stop at the mouth. Right? It when you have a chronic infection in your body, there is a level of stress that that imposes because of your body’s persistent effort to fight this infection that has all kinds of other consequences on your body. And so even if you were to find that there was a minimal but significant impact on uh IQ in boys, what you’re not measuring in that study is all the benefits of fluoridation. So you might actually even see that there’s a circumstance where the benefits outweigh the costs. But all you’re showing in this one noisy study uh is the cost. And so the coverage itself is is skewed. And so one of the hard parts about interpreting science is that no study can can usually be interpreted on its own and has to be interpreted within the broader context of all of the research that’s done. And the way that the media often covers these studies tends to leave you with a decontextualized, noisy uh sense of what of what the research shows. And I think this is just like a perfect example of that. Now, I want to ask you, right, when enough people come together in their chat room on the Internet, they can have some real power. And you see that spilling over into places like uh county commission meetings or city council meetings. Have there been communities that have stopped their water fluoridation programs because of this misinformation? 

Tooka Zokaie: Yes, there are. And a lot of them were um actually between 2020 and 2021. We saw a lot of not not just campaigns to remove fluoride. And, you know, we had individuals come and speak to the local city council members or their um advisory councils on health to share the latest evidence, um but it was more about trying to stop a removal um rather than initiating new fluoridation systems. So community members would hear about the, um you know, the information about fluoride and IQ or fluoride in drinking water and some level of hesitancy and go to their local city council to try to remove or stop water fluoridation. And there was a draft uh what they call National Toxicology Program report. So there was a draft released in 2019 that looked at fluoride and neurodevelopment as a result of a number of studies that, as I said, there were different studies done on fluoride and IQ and some showed no association, some did. So they were trying to see what’s really going on. And the the report did not look at uh different thresholds of fluoride. So there were studies used in that draft report that looked at high levels of fluoride. There’s some areas in the world that have endemically high fluoride, so it just means they naturally the fluoride is higher than what you’d recommend. Um. Even in fact in the United States some fluoridation programs filter fluoride out, so not all of them are adding fluoride. It’s an adjustment. And that draft analysis that didn’t it have any kind of threshold affect it or it wasn’t meant to be used for water fluoridation. It did have an original draft um presumed neurotoxic effect of fluoride. And again, this this study was not meant to be used for water fluoridation because it wasn’t looking at the levels used for water fluoridation. Um. And this draft report was taken to city council meetings saying, look at this report, it’s from the National Toxicology Program under the National Academies of Science, Engineering and Medicine. We need to stop fluoride. And some places were successful at stopping fluoride. In some places we were able to do enough education and explanation to continue water fluoridation as a program. But um this draft report that again, was not meant to be used for water fluoridation that wasn’t even meant to be used for decision making yet because it was a draft form. Um. It stopped fluoride in about six cities in the United States, um and there were about six more that we were able to maintain. And it’s difficult because one of the healthy people 2030 goals. Um. So, you know, it’s a it’s a set of goals that we’re trying to reach for public health is to increase um water fluoridation in the United States to 77.1%. That important 0.1 [laugh] in water systems that have recommended amount of fluoride. And the public health community are those that are, you know, involved in this. We’re trying to just stay above water at this point because we don’t have enough public health professionals that are comfortable talking about fluoride and are comfortable with this kind of science um because there is so much to know when you’re in public health. And um it’s a it’s a very important area that I think there can be some more education. So it’s not about stopping removal attempts and more about doing more initiation and community education. So they feel comfortable about really this privilege. 

Dr. Abdul El-Sayed: You know, I, I hear uh from you a theme I’ve been hearing for the last several years, which is we’re playing defense when we really need to be going on offense. Because I got to ask you, you’re a public health professional first and foremost who happens to work on the really important issue of oral health. How much of the effort to repeal water fluoridation programs do you see as a broader attack on the very concept of public health in general? The idea that we as a collective would do things to improve our collective health and that uh there is the lack of an ability to opt out. And you’re seeing that you know across the board, whether it’s vaccinations or water fluoridation programs, as we’re talking about right now. Um. So how much do you feel like this is more about public health than it is about fluoride? And how do you think we push back? 

Tooka Zokaie: It’s a very important question. And like you said, you know, I happen to work on tooth decay, but my broader area is truth decay and that’s kind of how–

Dr. Abdul El-Sayed: I love that. 

Tooka Zokaie: Thank you.

Dr. Abdul El-Sayed: Thank you. Thank you with the dad jokes. I love it. In honor of in honor of fathers day. 

Tooka Zokaie: Yes. [laughing] So we we do and there’s a lot of research on this right now on truth decay and that there’s a lot of evidence out there that is accessible and interesting and catchy, but it’s not rooted in the science, um but it’s accessible and it’s it is usually about not doing something right. So don’t get the vaccine, don’t wear the mask, don’t have the fluoride. It’s easier to not do something than to do something. So already, you know, part of that the game of public health is to encourage someone to do something because there’s enough evidence and support for it to be um beneficial to their overall health. And um a big part of, you know, looking at water fluoridation and this larger concept of sharing the science um has to do with the kind of separation of community and connection from the work that we do. Um. I don’t know how many people know their local public health officer um or or know um their local public health advocate at the county or state. Um. And there’s a lot of different types of community health workers and educators trying to share the best evidence. But it’s still not coming through the channels that people are interacting with and that kind of word of mouth. Um. And another part of it is we don’t present scientific information in a health literate way. And there’s a lot of work right now to try to improve health literacy. Um. In fact, California has the country’s only oral health literacy toolkit. So I recommend you check that out. Um. But there’s a lot of different ways to try to make our information more accessible, more legible. And one of the tough things with fluoride is it’s a nuanced science. There’s a lot of engineering that goes into it. It’s part of the five part process of of the water treatment um that again our amazing local water engineers are trained to understand well, it is a it’s a nuance. And that’s what makes it a little bit difficult in public health in this and this, you know, this issue with trust, because we haven’t done the work to build trust um and why, you know, trust is earned. And a lot of practitioners, especially public health practitioners, um have work to do to earn that trust again, especially with COVID 19 and the pandemic and um other outbreaks and the impacts of a life changing uh pandemic that we have a lot of work to do to try to rebuild trust and emphasize that public health is more than you know responding to infectious disease outbreaks and giving mandates. It really is about being a community member and wanting to foster health and wellness for the people, for all the people in your community. You know, water fluoridation impacts the lowest income and most vulnerable groups that um that are in a community because they’re more more likely to drink the water that comes out of the tap. And I don’t know how many public health programs can say that, that they’re an equitable public health program by design because it is offered to the entire community and it is meant to be something that is accessible, because one of the arguments against water fluoridation is, well, just get it from your toothpaste or get it from your mouthwash. That’s a privilege. Whereas water fluoridation is accessible to the whole community when you offer it. But are people even drinking their tap water? You know, there’s that extra step of building trust and making sure folks are comfortable drinking their their water that comes out of the tap. So we have a lot of work to do in public health, not just in oral health, to rebuild trust, to connect with our communities, and to see how how we share the best science. So it is something that individuals are comfortable engaging with. And I think the first step to that is asking, am I even a trusted person to be sharing this information? 

Dr. Abdul El-Sayed: Yeah. Part of the problem is that public health is invisible unless it’s a moment of crisis, in which case we are by definition, playing catch up. And that’s not when we’re best. And so being active and engaged in the moments of people’s lives when they’re not in a crisis and being consistent about how we communicate and speaking in language that is intended to speak to everybody rather than to others with similar educational or socioeconomic background, to many of the folks who do the public health work every day, I think is absolutely critical. And this is one of those um fights that I think is a really important testing ground for us because, you know, at the end of the day, maintaining good public health is not a series of wins and losses. It is a ongoing game of tug of war. And uh at any given time, the ground can slip out from underneath you. And this is what’s happened in six different communities across our country where those kids will now suffer the consequences of worse teeth as they grow up and they’re going to live on with that. They could go and move into a a perfectly well fluoridated community afterwards, and they’re still going to suffer the consequences of having had their teeth erupt in a circumstance where they’re not fluoridated. And that’s a real loss. That is an opportunity to have intervened that we’ve missed. 

Tooka Zokaie: One thing that you mentioned and we see when we do take fluoride out of the water now with these campaigns is the result of doing so. And we have the evidence now that shows that when you remove fluoride from drinking water, that tooth decay and the cost of dental care in those communities actually increases. For example, in Anchorage, when they removed decades of water fluoridation from the community, they saw that in the next generation there was about a um inflation adjusted $300 increase in children for dental care and a statistically significant increase in dental caries. And we have this in cavities. We have this opportunity now, unfortunately, with the removal of fluoride from communities that we still can see that doing so increases pain, increases disease, increases costs, and that water fluoridation does still work. 

Dr. Abdul El-Sayed: Well, I really appreciate that point. And those kinds of studies, those natural experiments, they are a gold standard in this space because they’re telling us the population level impact of our now lack of intervention. I appreciate you sharing that. Our guest today is somebody who is fighting both tooth decay and truth decay. She is Tooka Zokaie and she is a public health professional and senior health policy analyst for the California Dental Association. Tooka, thank you so much for taking the time to join us. 

Tooka Zokaie: Thank you for your time today. Yeah. [laugh]

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. Fentanyl is a synthetic opioid that is up to 50 times more potent than heroin. It’s extremely addictive and way less expensive to manufacture. It’s flooding the U.S. drug supply. It’s also leading to a surge in opioid overdoses. While claiming to be fighting fentanyl, the conservative response is amounted to doing one of two things. Blaming the influx of fentanyl on the southern border or passing draconian anti-fentanyl laws designed to punish dealers and deter use. These bills were proposed in 46 of 50 states. Virginia codified fentanyl as a, quote, “weapon of terrorism.” 30 states have a drug induced homicide statute on the books. Look, fentanyl is a scourge. There’s no doubt about it. And we absolutely need to protect unsuspecting people from it. But the question is, does the law and order throw the book at them approach actually work? There’s a long history in this country of criminalizing drugs and the costs of that fall hardest on people who suffer substance use. And too often, the enforcement has targeted Black and Brown people. And when it comes to this most recent crackdown, a study published in the American Journal of Public Health found that drug overdoses soared in a county in Indiana after drug dealers were swept up in a drug bust. Their buyers, frantic for a source ended up buying from new dealers whose potencies they didn’t have any knowledge of, leading them to O.D.. And we thought we’d turned the page on this, focusing instead on harm reduction approaches intended on treating the underlying disorder and minimizing the risks associated with use. But old habits die hard, and so are too many folks in this country. In other news, it’s been a year since this happened. 

[clip of unknown news reporter] The Supreme Court has just issued and this is the decision many were waiting for, a ruling in Dobbs versus Jackson Women’s Health Organization. 

Dr. Abdul El-Sayed, narrating: And over this past year, we’ve watched as half of the states in this country have moved to limit the right of bodily autonomy in their states, eliminating or restricting access to abortions. The consequences have been profound as thousands have had to sit in limbo without the care they need. 22 million people are without access to reproductive health care. The number of abortions with providers has dropped nearly 3000 per month on average. In a poll of OB-GYNs in states with abortion bans, 40% said that the bans impacted their care in cases of miscarriages or emergencies in pregnancy. In short, it has been chaos simply because six people in robes decided that they knew what was best for the bodies of millions of other people. Let’s end on a positive note, shall we? Scientists may have unlocked a breakthrough that could fundamentally transform transplant medicine. They successfully froze and then thawed rat organs and transplanted them into a live rat who survived. Look, this is a BFD. Here’s why. 100,000 people are currently waiting for transplants in the United States. Last year, only about 41,000 of those people got them. And that’s because transplantation is a logistical tight wire act. It involves harvesting, transporting and transplanting an organ within an hours long window without the ability to plan any of it. Successfully freezing and thawing organs could address these logistical quandaries once and for all. Science here is equally incredible. The challenge with freezing living organs is that ice crystals basically act like gigantic saws inside of a cell. They shred everything from the inside. And so the process involves infusing those organs with nanoparticles that protect this from happening and then cooling them using liquid nitrogen at about 24 degrees per minute, which is extremely fast. Then the trick is rewarming them all at once, so the organ itself doesn’t split. The breakthrough could open the door for cryopreservation. Previously the holdout of science fiction. And that’s pretty cool. That’s it for today on your way out, don’t forget to rate and review the show. It really does go a long way. Look, friends, I ask you this all the time, rate and review. It really takes you like a minute. Please do. Also, if you love the show and want to rep us drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production Support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services. 

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