Kelly Keyes operates a busy dental practice in Saint John, having treated patients of all ages for three decades, but a decline in the oral health of her younger patients is a growing concern. 

Those patients sometimes require treatment in hospital, which comes after a lengthy waiting period, adding to the overall strain on the health-care system, she said. 

Keyes said the great equalizer in oral health care was the addition of fluoride in the city’s drinking water in the 1980s, protecting developing teeth from decay by strengthening enamel and suppressing plaque bacteria.

But as the Port City’s financial health came under increasing pressure, councillors looking for easy savings decided to cut the fluoridation program. The move saved taxpayers $177,000 annually but may have cost its residents much more in dental health.

Dentists and physicians in the city fought against the removal of fluoride from the water supply but failed to stop it. And in the 12 years since it’s removal, Keyes said, the city’s most vulnerable have paid the price.

“We see a lot of kids under the age of four who have rampant decay,” she said. “We’re fooling ourselves thinking that the status quo is good for kids or that it’s good for the community in general.”

Keyes said the effects on children can be devastating, with interruptions in their schooling due to toothaches, with decay and extractions robbing children of their self-esteem at a young age. 

Those problems can continue into adulthood, she said, with poor dental health leading to heart disease and further pain and suffering. 

Brantford, Ont., was the first city in Canada to embrace water fluoridation, in 1945. Other communities across the country soon followed, encouraged by public health, medical and dental groups, as well as the World Health Organization.

But the debate over adding the mineral to municipal drinking water has raged on for almost as long, with critics citing cost, and pointing to an increased risk of an enamel discoloration known as fluorosis, which can occur if children consume more than the recommended amount.

Moncton had its own heated fluoride debate in 2011, which led to a five-year moratorium on the issue and a decision to make that removal permanent in 2017. 

Oromocto quietly became the last New Brunswick municipality to fluoridate its water in 2023. 

Fluoridation a ‘no-brainer,’ mayor says

Saint John Mayor Donna Reardon was one of five councillors at the time who voted to keep fluoride in the city’s drinking water. It was a 50-50 split that was ultimately decided by then-mayor Mel Norton, who voted with the nays in “light of certain financial realities,” he said at the time.

Reardon said she thought if fellow councillors read the information she and others presented, that “it was a no brainer.”

But staff looked at the question through an affordability lens, she said. That’s why, she argues, dental health should not be a municipal responsibility but rather defined and supported by the government of New Brunswick, with a policy from the Health Department.

Instead, she said, communities that can afford fluoride and have the infrastructure to provide it have the option to decide. That creates inconsistencies in health-care opportunities, she said, further delineating Saint John’s poverty. 

“It makes me feel sad that it happened,” she said. “Because it’s so overwhelming to think about trying to get it back in the system.”

WATCH | ‘We see a lot of kids under the age of four who have rampant decay,’ dentist says:

Tooth decay on the rise following fluoride removal

It’s been 12 years since Saint John voted to stop fluoridating its water, despite objections from the dental community. Now, dentists say young patients are paying the price of that decision with their smiles.

She said it would likely entail a plebiscite to get the community involved, and building a case with supporting data so people can make an evidence-based decision. 

But building that case would likely mean relying on metrics from other jurisdictions. 

Paul Blanchard, the executive director of the New Brunswick Dental Society, said New Brunswick is a bit of an outlier with no data collected on fluoride removal or dental health in general.

However, one national study from 2015 highlighted Saint John as having the second-highest rate of surgical intervention for cavities in children aged one to four.

“That indicator right there should tell you that there’s an issue here in New Brunswick,” he said. “But there are very few metrics other than that report, which is already 10 years old. So that’s the concern.”

As bad as things were when that study was conducted, Blanchard believes they are worse now with the removal of fluoride.

“We’d like to see either the province or the federal government measure the status of oral health, and children especially, like they are doing in other provinces. And so far, we haven’t seen any interest or traction in that.”

Blanchard would also like to see the reintroduction of the school screening and varnish programs, which are in place in provinces such as Quebec and Nova Scotia. New Brunswick cancelled funding for this under the Higgs government. 

Blanchard said it’s disappointing there is nobody inside the Health Department who is providing expert advice about oral health care, looking at “everything that we can do from a prevention perspective.”

CBC News requested an interview with Health Minister John Dornan, but the request went unanswered.

Some municipalities reintroducing fluoride

In other provinces, that work is being done, and in some cases, it’s prompting municipalities to rethink earlier decisions to remove fluoride. 

The Ontario communities of Windsor, Tecumseh and LaSalle brought fluoride back to their drinking water system in 2022, nearly a decade after the mineral was removed.

A   health report  showed the percentage of children in the area with “decay and/or requiring urgent care” increased 51 per cent in 2016-2017 over 2011-2012.

Calgary followed suit last year,  reintroducing fluoride  after a 14-year hiatus. 

A report from the University of Calgary’s Cumming School of Medicine in 2021 found children’s dental health was getting worse after fluoride was removed from drinking water. 

Among Grade 2 students in Calgary and Edmonton, children in Calgary were more likely to have cavities than those living in Edmonton, where water has been fluoridated since 1967.

The Office of the Chief Dental Officer of Canada updates the national data on the state of community water fluoridation across the country every five years.

The latest information published in 2022 shows 38.8 per cent of the country adds fluoride to municipal water, with little to no fluoride in New Brunswick, Quebec, Newfoundland and Labrador, Yukon, and British Columbia.

The next study is scheduled to be completed in 2027.

Fluoridation a cost-effective preventive step

With the introduction of the Canadian Dental Care program in 2023, Keyes said dentists are also seeing a lot of older adults who have gone years without treatment, who are now coming back into the system with root decay and tooth loss. 

While she’s happy to see affordable coverage for low-income Canadians, preventive measures such as fluoridation programs would benefit everyone for a fraction of the cost.

By removing fluoride from water supplies, she said, it also adds to the speculation about its safety and effectiveness. She now spends much of her patient window on educating people about the importance of fluoride treatments and toothpaste.

“The decay rate I see in kids is the same for people using un-fluoridated toothpaste and kids that don’t brush their teeth,” she said. “So it’s that profound.”

Keyes said it’s devastating to see children in pain and embarrassment with a preventable disease. Part of that frustration is with the parent for not seeking out that information, she said. 

The other part of that frustration is with the municipal government for removing a safe and effective means of decreasing tooth decay. The fact that it disproportionately impacts the city’s most vulnerable people, is a nagging pain no penicillin can relieve.