At 4 p.m. on Jan. 25, 1945, Grand Rapids, Mich. became the first city in the world to introduce fluoride into its water supply. It was a gutsy move, as the fluoride addition was part of a study to see if it would impact the residents’ oral health. The risk paid off: A long-range evaluation showed a dramatic 60 to 65 percent reduction in tooth decay among the area’s school children. “We’re proud of it, I’m proud of it,” said Joellen Thompson, manager of the Grand Rapids Water System, an AWWA member that serves 275,000 customers. “It took a lot of courage to make that decision to add something to the drinking water for a study like that. It took fortitude to say, ‘Yeah, we should try it’ and ‘We’re not afraid to try it.’” The utility is the winner of the 2016 Dr. John L. Leal Award, which honors courageous leadership in advancing public health. Leal was a physician and water treatment expert who introduced chlorine into a U.S. drinking water supply in 1908. Today, more than 210 million people in the United have access to fluoridated water through public water systems. The U.S. Centers for Disease Control named fluoridation of drinking water as one of the Ten Greatest Public Health Achievements of the 20th Century. Although the Grand Rapids milestone occurred more than 70 years ago, the AWWA awards committee honored the utility partly because of the similarities between its achievement and Leal’s. “It was a pretty obvious choice,” said John Donahue, committee member and former AWWA president. Though the two achievements occurred nearly four decades apart, Donahue noted they both involved water treatment milestones that dramatically improved public health. Children studied Dr. Chase Klinesteker, now a retired dentist in Grand Rapids, was among the thousands of school children who took part in the historic study. He was 5 years old when it began at the end of World War II. “I remember we’d chew this wax and spit into a bottle,” Klinesteker told Connections . “Every few years, they would test us. I saved one of those canisters we spit into and eventually gave it to the American Dental Association in Chicago so they could make it available for others to see.” At that time, 80 percent of first graders in the United States had an average of 14 cavities, Klinesteker said. By age 55, half of all Americans needed dentures. Klinesteker, whose father also was a dentist in Grand Rapids, has researched the history of fluoride’s addition to public water supplies. Clues about fluoride’s significance emerged at the turn of the 19th century when a young dentist in Colorado Springs, Colorado tried to figure out why so many of his patients had grotesque brown stains on their teeth. That dentist, Dr. Frederick McKay, heard about brown-stained teeth in other towns and advised residents in one to avoid drinking from the communal water pipeline. Within a couple of years, they sported pearly whites. Eventually McKay, and a dental researcher who visited Colorado Springs to study McKay’s findings, came to a startling realization: the mottled teeth were remarkably resistant to decay. McKay and a dentist from the United States Public Health Service published a paper on the brown-stain phenomenon, which caught the attention of ALCOA’s chief chemist, who had recently refuted claims that aluminum cookware was poisonous, according to an article published by the National Institute of Dental and Craniofacial Research. The chemist worried the paper might provide fodder for the company’s detractors and ordered his assistant to study water samples from affected towns. The assistant discovered the high concentrations of fluoride, which can occur naturally in soil and rock. By this time, it was the 1930s. The National Institutes of Health discovered a more accurate way to measure fluoride in drinking water, and reported that levels of up to 1.0 ppm did not cause brown stains in the teeth of most people. Grand Rapids Meanwhile, Klinesteker was growing up in Grand Rapids with his parents and two older sisters, Sally and Judy. Klinesteker’s father, Dr. Russell Edward Klinesteker, was president of the West Michigan District Dental Society, which encompasses Grand Rapids. Young Klinesteker, whose parents preached good dental hygiene, was acquainted with his father’s colleagues. Dr. Bill VerMeulen was booked solid on Saturday mornings, Klinesteker said, “to remove ‘rotting stumps’ for teeth. It was not uncommon for young ladies to get full dentures to look nice for their boyfriends.” In 1938, the military had a rule that “you had to have six teeth touch before you could get into the service,” Klinesteker said. “When the war came, they dropped that rule because they needed more people. Forty percent of new inductees into the service had to have immediate treatment for dental pain.” By 1943, federal officials decided to conduct fluoride tests on a large population, under the direction of Dr. David B. Scott of the U.S. Public Health Service. Several cities were considered, but Grand Rapids was chosen because of the state’s strong Bureau of Public Health Dentistry and the University of Michigan’s trailblazing cavity-reduction research. And perhaps the most important reason: Grand Rapids got its water fluoride-free from Lake Michigan. The nearby city of Muskegon, which also drew its water from the lake, was the control. Klinesteker’s father made the case with the Grand Rapids Board of Education and City Council to participate in the study. “Public cooperation was outstanding due to the severity” of the tooth decay, Klinesteker said. In 1945, on the last Thursday in January, fluoride was added to the supply by a worker at the Monroe Water Treatment Plant. The fluoride was purchased in paperboard drums, likely similar to the 55-gallon standard metal drums common today, said Thompson, who has been the utility manager for the past eight years. “It was added by hand to the fluoride dosing equipment, which mixed the compound with water and fed the fluoride into the water at a controlled rate of 1 ppm,” said Thompson, pictured at right. The city’s annual report that year noted: “Two chemical feed machines and a yearly supply of 11,000 dollars worth of sodium fluoride is provided.” Nearly 30,000 school children in Grand Rapids underwent periodic dental exams and x-rays, and gave saliva and urine specimens. Dr. Scott routinely traveled to Grand Rapids to oversee the 15-year study. During his visits, he stayed with the Klinestekers. All three of the Klinesteker children fared well. Chase, now 76, has had only three cavities in his life. Sally and Judy, both a few years older, already had several cavities when the study began, but “had far less than some” throughout their lives, Chase Klinesteker said. Five years after the study began, it became clear that the prevalence of tooth decay had dramatically declined among Grand Rapids’ children. Muskegon dropped out of the study and fluoridated its own water. The utility today In 2010, a Michigan Historical Marker was dedicated in front of the filtration plant on Monroe Avenue, which was retired in 1992 after providing safe drinking water for more than 80 years. The building now contains condos and businesses. In downtown Grand Rapids, a 33-foot tall steel sculpture was dedicated in 2007 to commemorate the city’s achievement. As the birthplace of fluoridation, the Grand Rapids utility still finds itself in a continuing debate. It frequently receives letters from groups that maintain children are being overexposed to the mineral, and noting that it is available in other products, such as toothpaste and mouthwash. 'We receive these emails several times a year and especially when we have newly elected leaders in our community,' Thompson said. “We monitor current research and studies, and I prefer to place my trust in the Surgeon General and the large body of medical and dental research done by professional organizations.” In 2011, the U.S. Department of Health and Human Services recommended the optimal amount of fluoride in drinking water be reduced from a range of 1.2 to 0.7 ppm to a single value of 0.7 ppm because of its use in other products. That recommendation became final in April 2015. “Grand Rapids did not hesitate to lower its fluoride level to the recommendation,” Thompson said. Klinesteker still lives in Grand Rapids and occasionally gives talks about the study that led to improved oral health for millions. He still takes pride in his participation. “It’s hard to imagine how much it’s benefited people,” Klinesteker said. “In those days, few people had no cavities, and now 50 percent of kids have no cavities coming out of high school.” Like others, Klinesteker worries that the consumption of bottled water – which isn’t always fluoridated – will increase the prevalence of cavities over time. Donahue expressed similar concerns, while focusing on the utility’s contribution. “They were willing to be a leader, and they still are to this day, even in the face of considerable opposition,” Donahue said. “That’s the thing that’s really impressive here: You have a community that was willing to be the first.” Do you have a question or story idea for Connections? Please contact Ann Espinola at email@example.com.