Fluoride In Drinking Water
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Public Health Service Report on
Fluoride Benefits and Risks
Ad Hoc Subcommittee on Fluoride
Committee to Coordinate Environmental Health and Related Programs
Frank E. Young, M.D., Ph.D., Chair
Ronald F. Coene, P.E., Executive Secretary
Richard H. Adamson, Ph.D.
Robert W. Miller, M.D., Dr.P.H.
Carolyn Fulco, Ph.D.
Arthur R. Norris
Lawrence J. Furman, D.D.S., M.P.H.
Edward V. Ohanian, Ph.D.
David Hoel, Ph.D. (EPA Observer)
Daniel A. Hoffinan, Ph.D.
Bill F. Pearson, P.E.
Vemon N. Houk, M.D.
Richard J. Riseberg, lD.
Raju G. Kamula, D.V.M., Ph.D.
Paul Simmons
Edward J. Kelty, Ph.D.
Daniel F. Whiteside, D.D.S.
Henry M. Kissman, Ph.D.
Deborah M. Winn, Ph.D.
Harald Loe, D.D.S.
Fluoride Final Report Workgroup
Frank E. Young, M.D., Ph.D., Chair
Ronald F. Coene, P.E., Executive Secretary
Richard H. Adamson, Ph.D.
Robert W. Miller, M.D., Dr.P.H.
Stephen B. Corbin, D.D.S., M.P.H.
Edward V. Ohanian, Ph.D.
Miriam Davis, Ph.D (EPA Observer)
Lawrence J. Furman, D.D.S., M.P.H.
Judith L. Weissinger, Ph.D.
David W. Gaylor, Ph.D.
Elizabeth K. Weisburger, Ph.D.,
Daniel A. Hoffinan, Ph.D. (Consultant)
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Fluoride Benefit Workgroup
Robert W. Miller, M.D., Dr.P.H.,
Chair Stephen B. Corbin, D.D.S., M.P.H.
Lawrence J. Furman, D.D.S., M.P.H.
Peter J. Gergen, M.D.
Stephen L. Gordon, M.D
Richard B. Hayes, M.D.
Henry M. Kissman, Ph.D
James L. Mills, M.D.
Edward V. Ohanian, Ph.D. (EP A Observer)
Walter J. Rogan, M.D.
John P. Rosetti, D.D.S.
Errol Zeiger, Ph.D.
Elizabeth K. Weisburger, Ph.D. (Consultant)
Fluoride Risk Workgroup
Daniel A. Hoffinan, Ph.D., Chair
Kenneth P. Cantor, Ph.D.
Stan Freni, M.D., Ph.D.
Lawrence J. Furman, D.D.S., M.P.H.
Dennis E. Jones, D.V.M.
Henry M. Kissman, Ph.D.
Stuart A. Lockwood, D.M.D., M.P.H.
Mark A. McClanahan, Ph.D.
Timothy P. O'Neill, D.V.M.
Edward V. Ohanian, Ph.D. (EPA Observer)
Judith L. Weissinger, Ph.D.
Preface
This report, "Public Health Service Report on Fluoride Benefits and Risks" is a summary of the
findings, conclusions, and recommendations of Review of Fluoride Benefits and Risks: Report of the
Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and
Related Programs, published in February 1991. The full report was prepared by an ad hoc
subcommittee of the United States Public Health Service's Committee to Coordinate Environmental
Health and Related Programs (CCEHRP) at the request of the Assistant Secretary for Health. The full
report can be obtained from the Public Health Service, Department of Health and Human Services.
Public Health Service Report on Fluoride Benefits and Risks
BACKGROUND
In the early part of this century, researchers observed that persons with "mottled teeth," or dental
fluorosis, experienced fewer dental caries than persons without that pattern of tooth discoloration.
Naturally occurring fluoride in the drinking water was identified later as being responsible for this
effect on tooth enamel. Community studies conducted in the 1940s established that as the level of
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natural fluoride in the drinking water increased, the prevalence of dental caries declined. These
studies led to the public health practice of adjusting fluoride concentration levels in fluoride-deficient
drinking water supplies to bring the total level of fluoride to approximately 1 part per million (PPM).
The optimal range of community water fluoridation (optimal with respect to reducing dental caries
and minimizing the risk of dental fluorosis) has been determined previously by the United States
Public Health Service to be 0.7- 1.2 ppm.
Controversy over the purported adverse health effects of fluoride has been associated with
community water fluoridation programs since widespread implementation began in the 1950s. This
controversy is related in part to evidence that exposure to fluoride in sufficiently high doses can
produce toxicity in animals and humans. In the 1970s, a limited number of studies reported increased
cancer mortality in cities with adjusted water fluoridation relative to cities without adjusted water
fluoridation programs. Although this claim subsequently was refuted by numerous investigators, the
concern over a possible association between cancer and water fluoridation prompted the National
Toxicology Program (NTP) of the United States Public Health Service (PHS) to conduct a long-term
study of the toxicity and carcinogenicity of sodium fluoride exposure in rodents. This study
employed a standard rat and mouse bioassay that has been useful in evaluating the potential
carcinogenicity or toxicity of numerous chemicals.
In the spring of 1990, NTP released the findings of its fluoride study. Although the study found no
evidence of carcinogenicity in female rats or in mice of either sex, it did find "equivocal evidence" of
carcinogenicity based on a small number of osteosarcomas in male rats in the medium and high-
dosed exposure groups. The term "equivocal evidence" is one of five standardized categories used by
NTP to describe the strength of evidence of carcinogenicity of individual experiments. The category
"equivocal evidence" is used to describe the results of studies in which an association between
administration of a chemical and a particular tumor response is uncertain.
ASSESSMENT OF THE HEALTH BENEFITS OF FLUORIDE
The PHS report concluded that fluoride has substantial benefits in the prevention of dental caries.
Numerous studies have established a clear causal relation between use of fluoridated water and the
prevention of dental caries. Although the occurrence of caries can be reduced through the use of
fluoridated toothpaste and mouth rinses, professional fluoride treatment, and fluoride dietary
supplements, fluoridation of water is the most cost-effective method and provides the greatest benefit
to those who can least afford preventive and restorative dentistry. In the 1940s, children in
communities with fluoridated drinking water experienced reductions in caries experience (as
measured by decayed, missing, and filled tooth scores) of about 60% relative to those for persons
living in nonfluoridated* communities. Although studies conducted in the 1980s continued to
demonstrate that caries scores are lower in fluoridated areas, studies show that the differences in
caries scores between fluoridated and nonfluoridated areas have declined to 20%-40%. This apparent
change may reflect the presence and use--in nonfluoridated areas--offluoride in beverages, food,
dental products, and dietary supplements.
ASSESSMENT OF THE HEALTH RISKS OF FLUORIDE
The PHS Subcommittee undertook a comprehensive review ofthe possible association between
fluoride exposure and carious adverse health outcomes. The report concluded that there is a lack of
evidence of associations between levels of fluoride in water and birth defects or problems of the
gastrointestinal, genito-urinary, and respiratory systems. Three possible health effects-cancer, effects
on bone, and dental fluorosis-were addressed in greater detail.
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Cancer
The two approaches used to determine whether there is an association between exposure to
fluoridated water and cancer are: a) carcinogenicity studies of rodents and b) epidemiologic analyses
to compare cancer incidence and mortality rates in communities with fluoridated water and in those
with negligible levels of fluoride in drinking water.
Animal Studies
The NTP study found that rates of osteosarcomas rose as the dose of sodium fluoride exposure for
male rates increased, but not for female rats or for mice of either gender. These findings were
interpreted as "equivocal evidence" of carcinogenicity for male rats but no evidence of
carcinogenicity for the other gender/species tested. In another recent carcinogenicity study conducted
by Maurer, Cheng, Boysen, and Anderson and sponsored by Procter and Gamble (P&G), no evidence
was found for an association between the development of malignant tumors and exposure to sodium
fluoride in rodents of either gender. Taken together, the NTP and P&G studies fail to establish an
association between fluoride and cancer.
Epidemiologic Studies
The ad hoc subcommittee ofthe Committee to Coordinate Environmental Health and Related
Programs reviewed the results from numerous epidemiologic studies ofthe relation between exposure
to fluoridated water and cancer that have been conducted during the last 40 years. In addition to the
review of these studies, the Subcommittee reviewed the findings ofa recent study from the National
Cancer Institute (NCI), which updated and expanded an earlier county-specific analysis for cancer
mortality in the United States in relation to water fluoridation. This study evaluated cancer mortality
data and examined patterns of cancer incidence from 1973 through 1987 in the Surveillance,
Epidemiology and End Results (SEER) program cancer registries. The Seer registries were used to
obtain data on incidence for all types of cancer, with special emphasis placed on trends in
osteosarcomas.
The NCI study identified no trends in cancer risk that could be attributed to the introduction of
fluoride into drinking water. There were no substantial differences in cancer mortality rates among
persons whom lived in counties that had initiated water fluoridation and those in persons who lived in
counties without water fluoridation. Similarly, there was no apparent relation between introduction
and duration of fluoridation and the incidence of cancer, including bone and joint cancer and the
subset of osteosarcomas.
The NCI also conducted a more detailed evaluation of osteosarcomas using nationwide age-adjusted
incidence from the entire SEER database for the years 1973-1987. During this time, the annual
incidence of osteosarcoma among males <20 years of age increased from 3.6 casesll 06 population to
5.5 cases/l06 population. The incidence among females decreased slightly during the same period
(from 3.8 casesll06 population to 3.7 cases/l 06 population). Although the increase in rates of
osteosarcoma for males during this period was greater in fluoridated than nonfluoridated areas,
extensive analyses revealed that these patterns were unrelated to either the introduction or duration of
fluoridation. Consequently, the NCI report concluded that, while the explanation for the increase in
rates of osteosarcoma among young males is unknown, it is not due to exposure to water fluoridation.
Both this report and the reports from previous international expert panels which have reviewed earlier
data concluded that there is no credible evidence of any association between the risk of cancer and
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exposure to either natural or adjusted fluoride in drinking water.
Effects on Bone
Although some epidemiologic studies have suggested that the incidence of certain types of bone
fractures may be higher in some communities with either naturally high or adjusted fluoride levels,
other studies have not detected increased incidence of bone fractures. However, a variety of
potentially confounding factors must be examined to assess whether there is association between
exposure to fluoride and bone fractures.
Fluoride has a complex dose-related action on bone. Although crippling skeletal fluorosis is more
common in parts of the world with high natural fluoride (>10 ppm) levels in drinking water, its
occurrence is affected by a variety of factors, including nutritional deficiencies, impaired renal
function, and age at exposure. Human crippling skeletal fluorosis is endemic in several countries of
the world, but is extremely rare in the United States.
Dental Fluorosis
Although the precise mechanism that causes dental fluorosis is unknown, the likelihood of dental
fluorosis is related directly to the level of fluoride exposure during tooth development. The clinical
spectrum of dental fluorosis varies from symmetrical whitish areas on teeth (very mid) to secondary,
extrinsic, brownish discoloration and varying degrees of pitting of the enamel (severe dental
fluorosis). Among children, the prevalence of moderate and severe forms of dental fluorosis is
estimated to be 1.3% nationally. Although fluorosis has historically been considered to be a cosmetic
problem, these forms of dental fluorosis do not produce adverse dental health effects, such as tooth
loss or impaired tooth function.
In the 1940s and 1950s, the major sources of fluoride were from drinking water and food. Since then,
additional sources of fluoride have become available, including processed beverages and food, dental
products containing fluoride (e.g., toothpastes and mouth rinses), and fluoride dietary supplements. In
appropriate use of these products can substantially increase total fluoride intake.
In the 1940s, approximately 10% of the population had fluorosis when the concentration of fluoride
found naturally in the drinking water was about 1 ppm. Since the 1950s, in nonfluoridated areas, the
total prevalence of dental fluorosis has clearly increased. During the same period, in areas where
water fluoride concentrations have remained in the optimal range (about 1 ppm fluoride), the total
prevalence of dental fluorosis may have increased. Increases in the prevalence of dental fluorosis
suggest that total fluoride exposure is increasing. Because dental fluorosis does not compromise oral
health or tooth function, an increase in dental fluorosis does not represent a public health concern;
however, it indicates that total fluoride exposure may be higher than that necessary to prevent tooth
decay. In general, prudent public health practice dictates using no more than the amount necessary to
achieve a desired effect.
RESEARCH AND POLICY RECOMMENDATIONS
The report of the PHS Subcommittee includes a variety of recommendations regarding health policy
and research about the risks and benefits of fluoride. The policy implications pertain to federal, state,
and local health agencies concerned with fluoridation of community water supplies. The research
recommendations on both the benefits and risks of fluorides provide direction and scope to
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investigators and agencies concerned with these aspects of exposure of populations to water
fluoridation and fluoride- containing products.
Policy Recommendations
. The PHS should continue to recommend the use of fluoride to prevent dental caries. · The PHS
should continue to support optimal fluoridation (i.e., 0.7-1.2 ppm) of drinking water.. The
PHS should sponsor scientific conferences to assess both the optimal level oftotal fluoride
exposure form all sources combined and the appropriate usage of fluoride-containing dental
products in order to achieve the benefits of reduced dental caries and to minimize the risk of
dental fluorosis.
. In accordance with prudent health practice of limiting exposure to no more than that necessary
to achieve a desired effect, health professionals and the public should avoid excessive and
inappropriate exposure to fluoride (e.g., health professionals should prescribe fluoride dietary
supplements only when the fluoride level of the home water supply is known to be deficient.
Parents should educate young children to minimize swallowing of fluoridated toothpaste and to
use only small amount of toothpaste on the brush).
. State health departments and drinking-water programs should continue to inform physicians,
dentists, and communities about the fluoridation status of drinking water to enable the
determination for the need for water fluoridation or for supplemental forms of fluoride.
. The U.S. Environmental Protection Agency (EP A) should review its regulations concerning
naturally occurring fluoride in drinking water on the basis of the outcome of the recommended
scientific conference( s) and the information in this report.
. The FDA should review the labeling requiring for toothpaste and other fluoride-containing
products to ensure that information is sufficient to enable the public to make informed
decisions about their use, especially for young children (i.e., those >6 years of age).
. Manufacturers of toothpaste should be encouraged to clearly communicate the fluoride levels
in their products. Manufacturers should determine whether toothpaste can be dispensed in a
dose-limited container for use by children. Manufacturers of dental products should determine
whether the levels of fluoride can be reduced while preserving clinical effectiveness.
. Communities with high natural fluoride levels in the public drinking water supply should
comply with EPA regulations as mandated by the Safe Drinking Water Act. The current
primary and secondary maximum contaminant levels for fluoride are 4ppm and 2ppm,
respectively.
. The PHS is to develop an action plan to implement research and policy recommendations.
Research Recommendations
The following research recommendations are purposely broader than the policy recommendations to
invite participation by a variety of public and private agencies and organizations.
Research on the Benefits of Fluorides
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. Conduct surveys to evaluate the prevalence of dental caries over time and accurately assess
exposure to fluoride.
. Undertake studies to elucidate further the role of fluoride in preventing coronal and root decay
of adult teeth. Undertake studies to identify effective means of providing fluoride to individuals
at high risk of dental caries.
. Continue long-term studies of caries scores in cities after defluoridation or the discontinuation
of fluoridation as a supplement to past information that covers only 2-5 years of follow-up
period.
. Document the marginal risks, costs, and benefits of providing multiple fluoride regiments in
the prevention of dental caries.
. Determine the relationship among socioeconomic status, water-fluoridation status, and the use
of fluoride products.
· In scoring dental caries, count individual surfaces rather than just the number of teeth because
such scoring provides more information and greater sensitivity. Express reductions in caries
scores as the number of tooth surfaces saved from caries, in addition to the percentage of
reduction.
Research on the Risks of Fluoride
· Continue studies to elucidate the mechanisms of fluoride action on bone and teeth at the
molecular and physical chemical level.
. Develop a method of quantitatively identifying dental fluorosis that is sensitive, specific,
reliable, and acceptable to the public.
· Continue to study dental fluorosis to determine the etiology and trends in the prevalence of
dental fluorosis.
. Conduct analytical epidemiologic studies of osteosarcoma to determine the risk factors
associated with its development. Fluoride exposure and bone levels of fluoride should be
included in the study design.
· Evaluate the scientific merit of conducting further animal carcinogenicity studies that us a wide
range of chronic doses of fluoride. Industries sponsoring studies of fluoride should be
encouraged to make their data publicly available to aid in this evaluation.
· Conduct analytic epidemiologic studies to determine the relationship, if any, among fluoride
intake, fluoride bone levels, diet, body levels of nutrients such as calcium, and bone fractures.
· Conduct studies on the reproductive toxicity of fluoride using various dose levels, including
the minimally toxic maternal dose.
. Conduct further studies to investigate whether fluoride is genotoxic.
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Yiamouyiannis J. Burk D. Fluoridation and cancer: age-dependence of cancer mortality related to
artificial fluoridation. Fluoride 1977;10:102-23.
Yiamouyiannis J. Prepared statement to subcommittee ofthe Committee on Government Operations
by the National Cancer Program: fluoridation of public drinking water. Part 2. 1977:61-72.
Yiamouyiannis J. Water fluoridation and tooth decay: results of the 1986-1987 national survey of
U.S. school children. Fluoride 1990;23:55-67.
Zeiger E. Haseman 1K, Shelby MD, Margolin BH. Tennant RW. Evaluation of four in vitro genetic
toxicity tests for predicting rodent carcinogenicity: confirmation of earlier results with 41 additional
chemicals. Environ Mol Mutagen 1990;16:1-41.
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Fluoridated Water
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Cancer Facts · Risk Factors
Fluoridated Water
-- .- ,-- .-. --
Table of Contents
Fluoridated Water
Fluoridated Water
Virtually all water contains fluoride. In the 1940s, scientists discovered that the higher the level of
natural fluoride in the community water supply, the fewer the dental caries (cavities) among the
residents. Currently, more than half of all Americans live in areas where fluoride is added to the
water supply to bring it up to the level considered best for dental health.
The possible relationship between fluoridated water and cancer has been debated at length. Although
earlier animal studies revealed no evidence that fluoride is carcinogenic, a National Toxicology
Program study completed in April 1990 generated considerable interest in this subject. In this study, a
small number of male rats (4 of 130) developed bone cancer after drinking water containing fluoride
in amounts that were 25 to 100 times greater than the levels found in municipal fluoridated water. No
cancers were seen in the female rats or in the male or female mice that were also tested. According to
the scientists who conducted the study, the fact that a few male rats developed tumors could not be
used as firm evidence to link fluoride ingestion with cancer.
In February 1991, the Public Health Service reported the results ofa year-long survey that showed
no evidence of an association between fluoride and cancer in humans. The survey, which involved a
review of more than 50 human epidemiology studies produced over the past 40 years, led the
investigators to conclude that optimal fluoridation of drinking water "does not pose a detectable risk
of cancer to humans."
In one recent study, scientists at the National Cancer Institute evaluated the relationship between
fluoridation of drinking water and the cancer mortality (deaths) in the United States during a 36-year
period and the relationship between fluoridation and the cancer incidence (rate) during a IS-year
period. After examining more than 2.2 million cancer death records and 125,000 cancer case records
in counties using fluoridated water, the researchers saw no indication of a cancer risk associated with
fluoridated drinking water.
National Cancer Institute Information Resources
You may want more information for yourself, your family, and your doctor. The following National
Cancer Institute (NCI) services are available to help you.
http://cancemet.nci.nih.gov /clinpdq/risk/Fluoridated _ Water.html
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Fluoridated Water
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Telephone...
Cancer Information Service (CIS)
Provides accurate, up-to-date information on cancer to patients and their families, health
professionals, and the general public. Information specialists translate the latest scientific information
into understandable language and respond in English, Spanish, or on TTY equipment.
Toll-free: 1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615
Internet...
These web sites may be useful:
http://www.nci.nih.gov - NCl's primary web site; contains information about the Institute and its
programs. Also includes news, upcoming events, educational materials, and publications for patients,
the public, and the mass media on http://rex.nci.nih.gov.
http://cancernet.nci.nih.gov - CancerNet; contains material for health professionals, patients, and the
public, including information from PDQ about cancer treatment, screening, prevention, supportive
care, and clinical trials, and CANCERLIT, a bibliographic database.
http://cancertrials.nci.nih.gov - cancerTrials; NCl's comprehensive clinical trials information center
for patients, health professionals, and the public. Includes information on understanding trials,
deciding whether to participate in trials, finding specific trials, plus research news and other
resources.
E-mail...
CancerMail
Includes NCI information about cancer treatment, screening, prevention, and supportive care. To
obtain a contents list, send e-mail tocancermail@icicc.nci.nih.gov with the word "help" in the body
of the message.
Fax...
CancerFax
Includes NCI information about cancer treatment, screening, prevention, and supportive care. To
obtain a contents list, dial 301-402-5874 from a fax machine hand set and follow the recorded
instructions.
Date Last Modified: 12/1992
............-- .. ..............~ .............. .........................._.. .. .._........... .mm....._....._._ ........._....................__.._
I Home
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American Water Works Association - Fact Sheets
Page 1 of 1
Press Room. II!
FACT SHEETS ~
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Return to Press Room Home
Fluoridation
· Fluorine is a naturally occurring element. Fluoride is a negatively charged fluorine
atom. Trace amounts of fluoride occur naturally in water.
· Fluoride, when administered at low levels of concentration, is proven to help
prevent tooth decay.
· Since 1945, American water systems have added fluoride to their water supplies.
This process is known as "fluoridation".
· American water supplies have low concentration levels of fluoride.
· The three primary agents used in fluoridation are sodium fluoride (sodium and
fluoride atoms bonded together), sodium fluorosilicate (sodium, silicon and
fluoride) and fluorosiJic acid (hydrogen, silicon and fluoride).
· The American Dental Association (ADA) endorsed fluoridation in 1950, reaffirming
its endorsement in 1997. The American Medical Association endorsed fluoridation
in 1951, and reaffirmed its endorsement in 1996. The U.S. Public Health Service
has also endorsed fluoridation.
· AWWA endorsed fluoridating public water systems in 1976. The endorsement was
reaffirmed in 1982.
· As part of its "Healthy People 2000" project, the Center for Disease Control and
Prevention (CDe) set a goal of increasing the level of the American population
serviced by fluoridated water systems to 75 percent by the year 2010.
· In 1995, the U.S. Surgeon General estimated that 62 percent of Americans --
approximately 167 million people-- had access to fluoridated water.
· Drinking water's fluoride content is limited under federal law. The level of fluoride
deemed acceptable by the U.S. Environmental Protection Agency (USEPA) is 4
milligrams per liter (mg/L). The CDC has established the "optimal level" for
fluoride content in drinking water to be the in the range of 0.7 mg/L to 1.2 mg/L.
· Despite fluoridation's benefits to dental health, exposure to high levels of fluoride
can cause dental fluorosis, a condition which leads to mottled tooth enamel, tooth
discoloration, and in some cases erosion of effected teeth to the gumline.
· The US Department of Health and Human Services has not recognized a causal
link between low-level fluoride exposure and occurrences of cancer, brain damage
or osteoporosis.
· The USEPA has found a link between prolonged exposure to high-level fluoride
concentration and skeletal fluorosis, a condition similar to osteoporosis, as well as
digestive and nervous system disorders.
· Although the amount of fluoride and duration of exposure necessary to cause
such ailments differs from person to person, there is no data linking these
ailments to the level of fluoride in drinking water.
Return to the Press Room
Home
~ 2000 American Water Works Association.
Char1es W. Berberich. Webmaster
Torev Liahtcao. Deouty Webmaster
Revised: 02118/2000 12:10:08
http://www.awwa.org/pressroom/fluoride.htm
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American Dental Association Statement on Water Fluoridation Efficacy and Safety
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Search Contact Us About the ADA What's New
ADA Statement
Related resources:
Fluoride and
Fluroidation
American Dental Association Statement on
Water Fluoridation Efficacy and Safety
The American Dental Association has endorsed
fluoridation of community water supplies as safe
and effective for preventing tooth decay for more
than 40 years. Fluoride is nature's cavity fighter,
occurring naturally in the earth's crust, in
combination with other minerals in rocks and soil.
Small amounts of fluoride occur naturally in all
water sources, and varying amounts of the mineral
are found in all foods and beverages. Water
fluoridation is the process of adjusting the natural
level of fluoride to a concentration sufficient to
protect against tooth decay, a range of from 0.7
parts per million to 1.2 ppm.
"Water fluoridation has been recognized by the
Centers for Disease Control and Prevention as one
of the 10 great public health achievements of the
20th Century," said ADA President Richard F.
Mascola, D.D.S. "Fluoride's benefits are particularly
important for those Americans, especially children,
who lack adequate access to dental care. It is safe,
effective and by far the best bang for the nation's
public health buck."
. Thanks in large part to community water
fluoridation, half of all children ages 5 to 17 have
never had a cavity in their permanent teeth.
According to the April 2000 Journal of Dental
Research, the use of fluoride in the past 40 years
has been the primary factor in saving some $40
billion in oral health care costs in the United States.
In addition to the ADA, nearly 100 national and
international organizations recognize the public
health benefits of community water fluoridation for
preventing dental decay. They include the World
Health Organization, the U.S. Public Health
Service, the American Medical Association, the
American Academy of Pediatrics, the American
Academy of Family Physicians, the International
A _ _ _ ~. _ I. _ _ ,. _ _ roo.. _ _ I _. r-\ _ _ _ _ . _ . _ . 1_ _ . I _ .. _ _ I ,...,.,.,... A
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American Dental Association Statement on Water Fluoridation Efficacy and Safety
ASSOCiatiOn TOr uemal Kesearcn, me l'IaIlOnal t-" I A
and the American Cancer Society. And just last
month, Surgeon General David Satcher wrote in his
report, Oral Health in America, "Community water
fluoridation is safe and effective in preventing dental
caries in both children and adults. Water fluoridation
benefits all residents served by community water
supplies regardless of their social or economic
status. "
Unfortunately, despite overwhelming evidence of
fluoridation's safety and efficacy, more than 100
million Americans still do not benefit from
fluoridated water. The ADA, along with state and
local dental societies, continues to work with
federal, state and local agencies to increase the
number of communities that benefit from community
water fluoridation.
The ADA's policies regarding community water
fluoridation are based on generally accepted
scientific knowledge. This body of knowledge is
based on the efforts of nationally recognized
scientists who have conducted research using the
scientific method, have drawn appropriate balanced
conclusions based on their research findings and
have published their results in refereed (peer-
reviewed) professional journals that are widely held
or circulated. Confirmation of scientific findings also
reinforces the validity of existing studies.
For more information about fluoride and fluoridation,
please visit the relevant area of ADA.org, at
http://www.ada.org/consumer/f1uoride/f1-menu.html.
Copyright @ 2000 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
June 29, 2000
Document address: http://www.ada.org/praclposition/fluoride2.html
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Fluoridation Facts: Introduction
AD4GI&INE Search Contact Us About the ADA What's New
Fluoridation Facts
Introduction
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
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Consumers
publicinfo@ada.org
Dental Professionals
online@ada.org
Background
Since 1956, the American Dental Association (ADA) has
published Fluoridation Facts. Revised periodically, Fluoridation
Facts answers frequently asked questions about community
water fluoridation. In this 1999 edition, the ADA Council on
Access, Prevention and Interprofessional Relations provides
updated information for individuals and groups interested in the
facts about fluoridation. The United States now has over 50
years of practical experience with community water
fluoridation. Its remarkable longevity is testimony to
fluoridation's significance as a public health measure.
Important points to remember about fluoride and community
water fluoridation are:
. Fluoridation is considered beneficial by the
overwhelming majority of the health and scientific
communities as well as the general public.
. Fluoride helps prevent tooth decay. All ground and
surface water in the U.S. contains some naturally
occurring fluoride. If a community's water supply is
fluoride-deficient (less than 0.7 parts fluoride per million
parts water) fluoridation simply adjusts the fluoride's
natural level, bringing it to the level recommended for
decay prevention (0.7-1.2 parts per million).
. Fluoridation is a community health measure that
benefits children and adults. Simply by drinking
optimally fluoridated water, members of a community
benefit, regardless of income, education or ethnicity -
not just those with access to dental care.
. Fluoridation protects over 360 million people in
approximately 60 countries worldwide, with over 10,000
communities and 145 million people in the United States
alone.1
. As with other nutrients, fluoride is safe and effective
when used and consumed properly. From time to time,
opponents of fluoridation have questioned its safety and
effectiveness. None of these charges has ever been
substantiated by generally accepted science. After 50
years of research and practical experience, the
overWhelming weight of scientific evidence indicates
that fluoridation of community water supplies is both
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Fluoridation Facts: Introduction
I
saTe ana errecllve.
I
. Just fifty cents per person per year covers the cost of
fluoridation in an average community. Over a lifetime,
that is the approximate price of one dental filling,
making fluoridation very cost effective.
I
. Time and time again, public opinion polls show an
overwhelming majority of Americans support water
f1uoridation.l
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Support for Water Fluoridation
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Since 1950, the American Dental Association (ADA), along
with the United States Public Health Service (USPHS), has
continuously and unreservedly endorsed the optimal
fluoridation of community water supplies as a safe and
effective public health measure for the prevention of dental
decay. The ADA's policy on fluoridation is based on its
continuing evaluation of the scientific research on the safety
and effectiveness of fluoride. Over the years, and as recently
as 1997. the ADA has continued to reaffirm its position of
support for water fluoridation and has strongly urged that its
benefits be extended to communities served by public water
systems~ Today, fluoridation is the single most effective public
health measure to prevent tooth decay and to improve oral
health over a lifetime.
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The American Dental Association, the U.S. Public Health
Service, the American Medical Association and the World
Health Organization all support community water fluoridation.
Other national and international health, service and
professional organizations that recognize the public health
benefits of community water fluoridation for preventing dental
decay may be viewed in the Compendium.
I
Scientific Information on Fluoridation
I
The ADA's policies regarding community water fluoridation are
based on generally accepted scientific knowledge. This body
of knowledge is based on the efforts of nationally recognized
scientists who have conducted research using the scientific
method, have drawn appropriate balanced conclusions based
on their research findings and have published their results in
refereed (peer-reviewed) professional journals that are widely
held or circulated. Confirmation of scientific findings also
reinforces the validity of existing studies.
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From time to time, opponents of fluoridation have questioned
its safety and effectiveness. None of these charges has ever
been substantiated by generally accepted science. It is
important to review information about fluoridation with a critical
eye. Listed below are several key elements to consider when
reviewing information about fluoride research.
1. The author's background and credentials should reflect
expertise in the area of research undertaken.
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I Fluoridation Facts: Introduction Page 3 of7
I 2. The year of the publication should be apparent. The
information should be relatively current, although well-
designed studies can stand the test of time and
I scientific scrutiny (e.g., overwhelming evidence already
exists to prove the effectiveness of water fluoridation). A
review of existing literature can provide insight into
whether the results of older studies have been
I superceded by subsequent studies.
3. If the information is a review of other studies, it should
I be representative of the original research. Information
quoted directly from other sources should be quoted in
its entirety.
I 4. The research should be applicable to community water
fluoridation and use an appropriate type and amount of
fluoride. Many research projects investigate the use of
fluoride at much higher levels than recommended for
I community water fluoridation. For example, the results
of a study using a concentration of 125 parts per million
(ppm) doses of fluoride are not comparable to water
I fluoridated at 0.7 to 1.2 ppm.
5. How the research is conducted is relevant. Research
conducted in vitro (outside the living body and in a
I laboratory environment) may not lead to the same
results as research conducted in vivo (in a living human
or other animal).
I 6. Animal studies should be carefully reviewed. In animal
studies (e.g., rodent), excessively high doses of fluoride
are sometimes used. In addition, the fluoride used in
I these experiments is often administered by means other
than in drinking water (e.g., by injection). Information
obtained in animal studies may be highly questionable
I as a predictor of the effects of human exposure to low
concentrations of fluoride, such as those used to
fluoridate water.
I 7. Publications presenting scientific information should
have an editorial review board to help ensure that
scientifically sound articles are published.
I 8. The publication should be easily obtainable through a
medical/dentallibrary.
I With the advent of the Information Age, a new type of "pseudo-
scientific literature" has developed. The public often sees
scientific and technical information quoted in the press, printed
I in a letter to the editor or distributed via an Internet Web page.
Often the public accepts such information as true simply
because it is in print. Yet the information is not always based
on research conducted according to the scientific method, and
I the conclusions drawn from research are not always
scientifically justifiable. In the case of water fluoridation, an
abundance of misinformation has been circulated. Therefore,
I scientific information from all print and electronic sources must
be critically reviewed before conclusions can be drawn.
Pseudo-scientific literature may peak a reader's interest but
whAn rA::Irl ::I!': !':r.iAn('.A it ('.::In hA mi!':IA::Irlinn ThA !':r.iAntifir.
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Fluoridation Facts: Introduction
........... .--- -- -_'_'.__,... __I' __ "'''_I___'''~, 1.1_ __._...........
validity and relevance of claims made by opponents of
fluoridation might be best viewed when measured against
criteria set forth by the u.s. Supreme Court. (Additional
discussion on this topic may be found in Question 36.)
Fluoridation Facts is designed to answer frequently asked
questions about fluoridation by summarizing relevant published
articles as indicated by numbered references within the
document. A corresponding list of references appears in the
back of the booklet. Fluoridation Facts is not intended to
include and review the extensive literature on community water
fluoridation and fluorides.
History of Water Fluoridation
Research into the beneficial effects of fluoride began in the
early 1900s. Frederick McKay, a young dentist, opened a
dental practice in Colorado Springs, Colorado, and was
surprised to discover that many local residents exhibited
strange brown stains on their permanent teeth. McKay could
find no documentation of the condition in the dental literature
and eventually convinced Dr. G.v. Black, an expert on dental
enamel, to study the condition. Through their research, Black
and McKay determined that mottled enamel, as Black termed
the condition, resulted from developmental imperfections in
teeth. (Mottled enamel is a historical term. Today, this
condition is called severe dental fluorosis.) Black and McKay
also noted that these stained teeth were surprisingly resistant
to decay.
Following years of observation and study, McKay determined
that it was high levels of naturally occurring fluoride in the
drinking water that was causing the mottled enamel. McKay's
deductions were researched by Dr. H. Trendley Dean, a dental
officer of the U.S. Public Health Service. Dean designed the
first fluoride studies in the United States. These early studies
were aimed at evaluating how high the fluoride levels in water
could be before visible, severe dental fluorosis occurred. By
1936, Dean and his staff had made the critical discovery that
fluoride levels of up to 1.0 part per million (ppm) in the drinking
water did not cause mottling, or severe dental fluorosis. Dean
additionally noted a correlation between fluoride levels in the
water and reduced incidence of dental decay.!. ~ Following
Dean's initial findings, communitywide studies were carried out
to evaluate the addition of sodium fluoride to fluoride-deficient
water supplies. The first community water fluoridation program
began in Grand Rapids, Michigan, in 1945.2. I
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Water Fluoridation as a Public Health Measure
Throughout decades of research and more than fifty years of
practical experience, fluoridation of public water supplies has
been responsible for dramatically improving the public's oral
health status. In 1998, recognizing the ongoing need to
improve health and well being, the U.S. Public Health Service
revised national health objectives to be achieved by the year
2010. Included under oral health was an objective to
sianificantlv exoand the fluoridation of Dublic water sUDDlies!! In
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Fluoridation Facts: Introduction
-'~-'-'+------'J ---,------- ..-- ..-.-..-.-...-.. -. r-"-"- ..-.--- ---rl-----
1994, the U.S. Department of Health and Human Services
issued a report which reviewed public health achievements.
Along with other successful public health measures such as
the virtual eradication of polio and reductions in childhood
blood lead levels, fluoridation was lauded as one of the most
economical preventive values in the nationJt Finally, a policy
statement on water fluoridation reaffirmed in 1995 by the
USPHS stated that water fluoridation is the most cost-effective,
practical and safe means for reducing the occurrence of tooth
decay in a community.1o
Simply by drinking optimally fluoridated water, the entire
community benefits regardless of age, socioeconomic status,
educational attainment or other social variables.ll Community
water fluoridation does not discriminate against anyone based
on income, education or ethnicity. Fluoridation's benefits are
realized without behavior change on the part of an individual.
The benefits of water fluoridation are not limited to those with
access to dental care.
Water Fluoridation's Role in Reducing Dental Decay
Water fluoridation and the use of topical fluoride have played a
significant role in improving oral health. Studies show that
water fluoridation can reduce the amount of cavities children
get in their baby teeth by as much as 60%; and can reduce
tooth decay in permanent adult teeth by nearly 35%.
Increasing numbers of adults are retaining their teeth
throughout their lifetimes due in part to the benefits they
receive from water fluoridation. Dental expenditures for these
individuals are likely to have been reduced and innumerable
hours of needless pain and suffering due to untreated dental
decay have been avoided.
It is important to note that dental decay is caused by dental
plaque, a thin, sticky, colorless deposit of bacteria that
constantly forms on teeth. When sugar and carbohydrates are
eaten, the bacteria in plaque produce acids that attack the
tooth enamel. After repeated attacks, the enamel breaks down,
and a cavity (hole) is formed (See Figure 1). There are several
factors that increase an individual's risk for decay:12
. Recent history of dental decay
. Elevated oral bacteria count
. Inadequate exposure to fluorides
. Exposed roots
. Frequent sugar and carbohydrate intake
. Fair to poor oral hygiene
. Inadequate saliva flow
. Deep pits and fissures in the chewing surfaces of teeth
Exposure to fluoride is not the only measure available to
decrease the risk of decay. In formulating a decay prevention
program, a number of intervention strategies may be
recommended.
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Fluoridation Facts: Introduction
Figure 1
DENTAL DECAY
Mild decay
Moderate decay
Severe decay
Ongoing Need for Water Fluoridation
Because of the decay risk factors noted previously, many
individuals and communities still experience high levels of
dental decay. Although water fluoridation demonstrates an
impressive record of effectiveness and safety, only 62.2% of
the United States population on public water supplies receives
fluoridated water containing protective levels of f1uoride.13
Unfortunately, some people continue to be confused about this
effective public health measure. If the number of individuals
drinking fluoridated water is to increase, the public must be
accurately informed about its benefits.
Disclaimer
This publication is designed to answer frequently asked
questions about community water fluoridation, based on a
summary of relevant published articles. This booklet is not
intended to be a comprehensive review of the extensive
literature on fluoridation and fluorides. Readers must also rely
on their own review of the literature, including the sources cited
herein and any subsequently published, for a complete
understanding of these issues.
~ Table of Contents
Benefits ~
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Fluoridation Facts: Introduction
Copyright @ 1999 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
March 12, 1999
Document address: http://www .ada.org/consumer/fluoride/facts/intro.htrnl
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Fluoridation Facts: Benefits
Al:14GI&INI Search Contact Us About the ADA What's New
Fluoridation Facts
Benefits
Fluoridation Facts
Introduction
Benefits
Safilli
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
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Consumers
publicinfo@ada.org
Dental Professionals
online@ada.org
1. What is fluoride?
2. What is water fluoridation?
3. Natural vs adiusted?
4. More proof needed?
5. Discontinuance?
6. Still effective?
7. Is decay still a problem?
8. Adult benefits?
9. Dietary supplements?
10. Alternatives?
11. Bottled water?
12. Home treatment (filter) systems?
Question 1
What is fluoride and how does it reduce tooth decay?
Answer
Fluoride is a naturally occurring element that prevents
tooth decay systemically when ingested during tooth
development and topically when applied to erupted teeth.
Fact
The fluoride ion comes from the element fluorine. Fluorine, the
17th most abundant element in the earth's crust, is a gas and
never occurs in its free state in nature. Fluorine exists only in
combination with other elements as a fluoride compound.
Fluoride compounds are constituents of minerals in rocks and
soil. Water passes over rock formations and dissolves the
fluoride compounds that are present, creating fluoride ions.
The result is that small amounts of soluble fluoride ions are
present in all water sources, including the oceans. Fluoride is
present to some extent in all foods and beverages, but the
concentrations vary widely.14-16
Simply put, fluoride is obtained in two forms: topical and
systemic. Topical fluorides strengthen teeth already present in
the mouth. In this method of delivery, fluoride is incorporated
into the surface of teeth making them more decay-resistant.
Topically applied fluoride provides local protection on the tooth
surface. Topical fluorides include toothpastes, mouthrinses
and professionally applied fluoride gels and rinses.
Systemic fluorides are those that are ingested into the body
and become incorporated into forming tooth structures. In
contrast to topical fluorides, systemic fluorides ingested
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regUlarlY aUrlng me time wnen teem are aeveloplng are
deposited throughout the entire surface and provide longer-
lasting protection than those applied topically.17 Systemic
fluorides can also give topical protection because ingested
fluoride is present in saliva, which continually bathes the teeth
providing a reservoir of fluoride that can be incorporated into
the tooth surface to prevent decay. Fluoride also becomes
incorporated into dental plaque and facilitates further
remineralization.18 Sources of systemic fluorides include
water, dietary fluoride supplements in the forms of tablets,
drops or lozenges, and fluoride present in food and beverages.
Researchers have observed fluoride's decay preventive effects
through three specific mechanisms:.1Jl.. 20
1. it reduces the solubility of enamel in acid by converting
hydroxyapatite into less soluble fluorapatite;
2. it exerts an influence directly on dental plaque by
reducing the ability of plaque organisms to produce
acid; and
3. it promotes the remineralization or repair of tooth
enamel in areas that have been demineralized by acids.
The remineralization effect of fluoride is of prime importance.
Fluoride ions in and at the enamel surface result in fortified
enamel that is not only more resistant to decay, but enamel
that can repair or remineralize early dental decay caused by
acids from decay-causing bacteria..1I... 21-25 Fluoride ions
necessary for remineralization are provided by fluoridated
water as well as various fluoride products such as toothpaste.
Maximum decay reduction is produced when fluoride is
available for incorporation during all stages of tooth formation
(systemically) and by topical effect after eruption.26
Question 2
What is water fluoridation?
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Answer
Water fluoridation is the adjustment of the natural fluoride
concentration of fluoride-deficient water to the level
recommended for optimal dental health.
Fact
Based on extensive research, the United States Public Health
Service (USPHS) established the optimum concentration for
fluoride in the water in the United States in the range of 0.7 to
1.2 parts per million.* This range effectively reduces tooth
decay while minimizing the occurrence of dental fluorosis. The
optimum level is dependent on the annual average of the
maximum daily air temperature in the geographic area.27
* One milligram per liter (mg/L) is identical to one part per
million (ppm). At 1 ppm, one part of fluoride is diluted in a
--..:11:_.... .....".U'...,.. _~ u,,,,,,f._r I _r__ ""'1........h_..1I' ,.... .,..h ~U" "'" .......ali_..... ,..""'" h_
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IIIIIIIUII I-'CII L;:' UI WOLCI. LOIl:lC IIUIIIUCI;:' ;:'U\III 0;:' 0 IIIIIIIUII \lOll uc
difficult to visualize. While not exact, the following comparisons
can be of assistance in comprehending one part per million:
1 inch in 16 miles
1 minute in 2 years
1 cent in $10,000
For clarity, the following terms and definitions are used in this
booklet:
Community water fluoridation is the adjustment of the natural
fluoride concentration in water up to the level recommended
for optimal dental health (a range of 0.7 to 1.2 ppm). Other
terms used interchangeably in this booklet are water
fluoridation, fluoridation and optimally fluoridated water.
Optimal levels of fluoride (a range of 0.7 to 1.2 ppm) may be
present in the water naturally or by adjusted means.
(Additional discussion on this topic may be found in Question
~.)
Sub-optimally fluoridated water is water that contains less than
the optimal level (below 0.7 ppm) of fluoride. Other terms used
interchangeably in this booklet are nonfluoridated water and
fluoride-deficient water supplies.
(Additional discussion on this topic may be found in Question
32.)
Question 3
Is there a difference in the effectiveness between naturally
occurring fluoridated water (at optimal fluoride levels) and
water that has fluoride added to reach the optimal level?
Answer
No. The dental benefits of optimally fluoridated water
occur regardless of the fluoride's source.
Fact
Fluoride is present in water as "ions" or electrically charged
atoms.27 These ions are the same whether acquired by water
as it seeps through rocks and sand or added to the water
supply under carefully controlled conditions. When fluoride is
added under controlled conditions to fluoride-deficient water,
the dental benefits are the same as those obtained from
naturally fluoridated water. Fluoridation is merely a
supplementation of the naturally occurring fluoride present in
all drinking water sources.
Some individuals mistakenly use the term "artificial fluoridation"
to imply that the process of water fluoridation is unnatural and
that it delivers a foreign substance into a water supply when, in
fact, all water sources contain some fluoride. Community water
fluoridation is a natural way to improve oral health.~
(Additional discussion on this topic may be found in Question
32.)
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Prior to the initiation of "adjusted" water fluoridation, several
classic epidemiological studies were conducted that compared
naturally occurring fluoridated water to fluoride-deficient water.
Strikingly low decay rates were found to be associated with the
continuous use of water with fluoride content of 1 part per
million.~
A fluoridation study conducted in the Ontario, Canada,
communities of Brantford (optimally fluoridated by adjustment),
Stratford (optimally fluoridated naturally) and Sarnia (f1uoride-
deficient) revealed much lower decay rates in both Brantford
and Stratford as compared to nonfluoridated Sarnia. There
was no observable difference in decay-reducing effect
between the naturally occurring fluoride and adjusted fluoride
concentration water supplies, proving that dental benefits were
similar regardless of the source of f1uoride.29
Question 4
Is further proof of the effectiveness of water fluoridation
needed?
Answer
Overwhelming evidence already exists to prove the
effectiveness of water fluoridation.
Fact
The effectiveness of water fluoridation has been documented
in scientific literature for well over 50 years. Even before the
first community fluoridation program began in 1945,
epidemiologic data from the 1930s and 1940s revealed lower
decay rates in children consuming naturally occurring
fluoridated water compared to children consuming f1uoride-
deficient water.!.. ~ Since that time, numerous studies have
been done which continue to prove fluoride's effectiveness in
decay reduction. Three selected reviews of this work follow.
In 1993, the results of 113 studies in 23 countries were
compiled and analyzed..32 (Fifty-nine out of the 113 studies
analyzed were conducted in the United States.) This review
provided effectiveness data for 66 studies in primary teeth and
for 86 studies in permanent teeth. Taken together, the most
frequently reported decay reductions observed were:
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40-49% for primary teeth or baby teeth; and
50-59% for permanent teeth or adult teeth.
In a second review of studies conducted from 1976 through
1987,31 when data for different age groups were isolated, the
decay reduction rates in fluoridated communities were:
30-60% in the primary dentition or baby teeth;
20-40% in the mixed dentition* (aged 8 to 12);
15-35% in the permanent dentition or adult teeth
(aged 14 to 17); and
15-35% in the permanent dentition (adults and seniors).
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Fluoridation Facts: Benefits
(* A mixed dentition is composed of both baby teeth and adult
teeth.)
Lastly, a comprehensive analysis of the fifty-year history of
community water fluoridation in the United States further
demonstrated that the inverse relationship between higher
fluoride concentration in drinking water and lower levels of
dental decay discovered a half-century ago continues to be
true today. 32
(Additional discussion on this topic may be found in Question
2.)
Many well-documented studies have compared the decay
rates of children before and after fluoridation in the same
community, as well as with children in naturally fluoridated
and/or nonfluoridated communities. The earlier studies were
conducted at a time when sources of topical fluoride, such as
toothpastes, mouth rinses and professionally applied fluoride
gels were not available. The results from these early studies
were dramatic. Over the years, as sources of topical fluoride
became more readily available, the decay reductions observed
in these comparative evaluations, although still significant,
tapered off. Because of the high geographic mobility of our
populations and the widespread use of fluoride toothpastes,
supplements and other topical agents, such comparisons are
becoming more difficult to conduct.31
Nevertheless, recent data continue to demonstrate that decay
rates are higher for individuals who reside in nonfluoridated
communities than that of individuals living in fluoridated
communities.~ 33-36 The following paragraphs provide a
sample of studies conducted in the subsequent decades on
the effectiveness of water fluoridation.
In Grand Rapids, Michigan, the first city in the world to
fluoridate its water supply, a 15-year landmark study showed
that children who consumed fluoridated water from birth had
50-63% less tooth decay than children who had been
examined during the original baseline survey.~
Ten years after fluoridation in Newburgh, New York, 6- to 9-
year-olds had 58% less tooth decay than their counterparts in
Kingston, New York, which was f1uoride-deficient. After 15
years, 13- to 14-year-olds in Newburgh had 70% less decay
than the children in Kingston.38
After 14 years of fluoridation in Evanston, Illinois, 14-year-olds
had 57% fewer decayed, missing or filled teeth than control
groups drinking water low in f1uoride.~ In 1983, a study was
undertaken in North Wales (Great Britain) to determine if the
decay rate of fluoridated Anglesey continued to be lower than
that of nonfluoridated Arfon, as had been indicated in a
previous survey conducted in 1974. Decay rates of life-long
residents in Anglesey aged 5, 12 and 15 were compared with
decay rates of similar aged residents in nonfluoridated Arfon.
Study results demonstrated that a decline in decay had
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Fluoridation Facts: Benefits
occurred in both communities since the previous survey in
1974. However, the mean decay rate of the children in
fluoridated Anglesey was still 45% lower than that of those
living in nonfluoridated Arfon.4o These findings indicated a
continuing need for fluoridation although decay levels had
declined.41
A controlled study conducted in 1990 demonstrated that
average tooth decay experience among school-children who
were lifelong residents of communities having low fluoride
levels in drinking water was 61-100% higher as compared with
tooth decay experience among schoolchildren who were
lifelong residents of a community with an optimal level of
fluoride in the drinking water.36 In addition, the findings of this
study suggest that community water fluoridation still provides
significant public health benefits and that dental sealants can
playa significant role in preventing tooth decay.
Using data from the dental surveys in 1991-2 and 1993-4, a
British study predicted that on average, water fluoridation
produces a 44% reduction in tooth decay in 5-year-old
children. The study further demonstrated that children in lower
socioeconomic groups derive an even greater benefit from
water fluoridation with an average 54% reduction in tooth
decay. Therefore, children with the greatest dental need
benefit the most from water f1uoridation.42
In 1993-4, an oral health needs assessment of children in
California found that children living in nonfluoridated areas had
more tooth decay than those in fluoridated areas.~ Of most
concern was the high decay rate affecting young children from
low income families. Specifically, children in grades K-3,
whose families were lifetime residents of nonfluoridated
communities and whose income was below 200% of the
Federal Poverty Level, had 39% more decay in their baby
teeth when compared to counterparts who were lifetime
residents of optimally fluoridated areas.35
Question 5
What happens if water fluoridation is discontinued?
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Answer
Dental decay can be expected to increase if water
fluoridation in a community is discontinued for one year
or more, even if topical products such as fluoride
toothpaste and fluoride rinses are widely used.
Fact
The following paragraphs provide a summary of some of the
historical studies that have been conducted on the
discontinuation of water fluoridation.
Antigo, Wisconsin began water fluoridation in June 1949, and
ceased adding fluoride to its water in November 1960. After
five and one-half years without optimal levels of fluoride,
second grade children had over 200% more decay, fourth
nr~c1Ar!': 70% morA ~nc1 !':hcth nr~c1Ar!': A1 % morA th~n thO!':A of
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Fluoridation Facts: Benefits
~._-_.- . - IV ..._._, _.._ _.1...... t:"---'- _"V ..._._ ..._.. ....____.
the same ages in 1960. Residents of Antigo reinstituted water
fluoridation in October 1965 on the basis of the severe
deterioration of their children's oral health.44
Because of a government decision in 1979, fluoridation in the
northern Scotland town of Wick was discontinued after eight
years. The water was returned to its sub-optimal, naturally
occurring fluoride level of 0.02 ppm. Data collected to monitor
the oral health of Wick children clearly demonstrated a
negative health effect from the discontinuation of water
fluoridation. Five years after the cessation of water fluoridation,
decay in permanent (adult) teeth had increased 27% and
decay in primary (baby) teeth increased 40%. This increase in
decay occurred during a period when there had been a
reported overall reduction in decay nationally and when
fluoride toothpaste had been widely adopted.~ These data
suggest that decay levels in children can be expected to rise
where water fluoridation is interrupted or terminated, even
when topical fluoride products are widely used.
In a similar evaluation, the prevalence of decay in 10-year-old
children in Stranraer, Scotland, increased after the
discontinuation of water fluoridation, resulting in a 115%
increase in the mean cost of restorative dental treatment for
decay and a 21 % increase in the mean cost of all dental
treatment. These data support the important role water
fluoridation plays in the reduction of dental decay.46
A U.S. study of 6- and 7-year-old children who had resided in
optimally fluoridated areas and then moved to the
nonfluoridated community of Coldwater, Michigan, revealed an
11 % increase in decayed, missing or filled tooth surfaces
(DMFS) over a 3-year period from the time the children moved.
These data reaffirm that relying only on topical forms of
fluoride is not an effective or prudent public health practice..3.1..
47 Decay reductions are greatest where water fluoridation is
available in addition to topical fluorides, fluoride toothpaste and
fluoride rinses.
Finally, a study that reported the relationship between
fluoridated water and decay prevalence focused on the city of
Galesburg, Illinois, a community whose public water supply
contained naturally occurring fluoride at 2.2 ppm. In 1959,
Galesburg switched its community water source to the
Mississippi River. This alternative water source provided the
citizens of Galesburg a sub-optimal level of fluoride at
approximately 0.1 ppm. During the time when the fluoride
content was below optimal levels, data revealed a 10%
decrease in the number of decay-free 14-year-olds (oldest
group observed), and a 38% increase in dental decay. Two
years later, in 1961, the water was fluoridated at the
recommended level of 1.0 ppm.48
Question 6
Is water fluoridation still an effective method for
preventing dental decay?
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Answer
Water fluoridation continues to be a very effective method
for preventing tooth decay for children, adolescents and
adults. Continued assessment, however, is important as
the patterns and extent of dental decay change in
populations. Although other forms of fluoride are
available, persons in nonfluoridated communities
continue to demonstrate higher dental decay rates than
their counterparts in communities with water fluoridation.
Fact
Numerous recent studies indicate a trend toward decreased
decay prevalence in children living in the United States. This
trend also has been reported for children in other developed
countries. One of several factors that explains these findings is
the increased use of fluorides, including water fluoridation and
fluoride toothpaste. In studies conducted from 1976 through
1987,n the level of decay reduction achieved through water
fluoridation in industrialized countries was:
30-60% in the primary dentition or baby teeth;
20-40% in the mixed dentition* (aged 8 to 12);
15-35% in the permanent dentition or adult teeth
(aged 14 to 17); and
15-35% in the permanent dentition (adults and seniors).
(*A mixed dentition is composed of both baby teeth and adult
teeth )
(Additional discussion on this topic may be found in Question
~.)
Community water fluoridation remains the safest, most cost-
effective and most equitable method of reducing tooth decay in
a community in the United States and in other countries..1L ~
M. 49-52 A controlled study conducted in 1990 demonstrated
that average tooth decay experience among schoolchildren
who were lifelong residents of communities having low fluoride
levels in drinking water was 61-100% higher as compared with
tooth decay experience among schoolchildren who were
lifelong residents of a community with an optimal level of
fluoride in the drinking water.~ In addition, the findings of this
study suggest that community water fluoridation still provides
significant public health benefits and that dental sealants can
playa significant role in preventing tooth decay.
Baby bottle tooth decay is a severe type of early childhood
decay that seriously affects babies and toddlers in some
populations. Water fluoridation is highly effective in preventing
decay in baby teeth, especially in children from low
socioeconomic groups.~ For very young children, water
fluoridation is the only means of prevention that does not
require a dental visit or motivation of parents and caregivers. 53
In the 1940s, children in communities with optimally fluoridated
drinking water had reductions in decay rates of approximately
60% as compared to those IivinQ in non-fluoridated
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Fluoridation Facts: Benefits
. -
communities. At that time, drinking water was the only source
of fluoride other than fluoride that occurs naturally in foods.
Recent studies reveal that decay rates are lower in naturally or
adjusted fluoridated areas and nonfluoridated areas as well
because of the universal availability of fluoride from other
sources including food, beverages, dental products and dietary
supplements.54 Foods and beverages processed in optimally
fluoridated cities can contain optimal levels of fluoride. These
foods and beverages are consumed not only in the city where
processed, but may be distributed to and consumed in non-
fluoridated areas..11 This "halo" or "diffusion" effect results in
increased fluoride intake by people in non-fluoridated
communities, providing them increased protection against
dental decay.~ ~ As a result of the widespread availability of
these various sources of fluoride, the difference between
decay rates in fluoridated areas and nonfluoridated areas is
somewhat less than several decades ago but still significant. 55
A British study conducted in 1987 compared the decay scores
for 14-year-old children living in South Birmingham, fluoridated
since 1964, with those of children the same age living in
nonfluoridated Bolton. The two cities had similar social class
profiles and similar proportions of unemployed residents and
minority groups. The average decayed, missing, and filled
tooth score for the children of South Birmingham was 2.26,
compared to an average score of 3.79 for children in
nonfluoridated Bolton. These scores indicate a statistically
significant difference of 40% between the decay rates in the
two cities. Because of the similarity in social and demographic
factors, the investigators attributed difference in decay
experience found in this study to differences in water fluoride
level. 56
In the United States, an epidemiological survey of nearly
40,000 schoolchildren was completed in 1987.~ Nearly 50%
of the children in the study aged 5 to 17 years were decay-free
in their permanent teeth, which was a major change from a
similar survey in 1980 in which approximately 37% were
decay-free. This dramatic decline in decay rates was attributed
primarily to the widespread use of fluoride in community water
supplies, toothpastes, supplements and mouthrinses. Although
decay rates had declined overall, data also revealed that the
decay rate was 25% lower in children with continuous
residence in fluoridated communities when the data was
adjusted to control for fluoride exposure from supplements and
topical treatments.
More recently, data from the Third National Health and
Nutrition Examination Survey (NHANES III), conducted from
1988 to 1991, yielded weighted estimates for over 58 million
U.S. children. Nearly 55% of the children aged 5 to 17 years
had no decay in their permanent teeth.~
(Additional discussion on this topic may be found in Question
fl.)
Question 7
. -. .. - - ....- -. -- - _. .."" - - ..!'
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IS toom aecay Stili a senous prODlem(
Answer
Yes. Tooth decay or dental decay is an infectious disease
that continues to be a significant oral health problem.
Fact
Tooth decay is, by far, the most common and costly oral health
problem in all age groups.58 It is one of the principal causes of
tooth loss from early childhood through middle age. A dramatic
increase in tooth loss occurs among people 35 through 44
years of age. The two leading causes of tooth loss in this age
group are dental decay and periodontal diseases!!. Decay
continues to be problematic for middle-aged and older adults,
particularly root decay because of receding gums. In addition
to its effects in the mouth, dental decay can affect general well-
being by interfering with an individual's ability to eat certain
foods and by impacting an individual's emotional and social
well-being by causing pain and discomfort. Tooth decay,
particularly in the front teeth, can detract from appearance,
thus affecting self-esteem.
Despite a decrease in the overall decay experience of U.S.
schoolchildren over the past two decades, tooth decay is still a
significant oral health problem, especially in certain segments
of the population. The 1986-1987 National Institute of Dental
Research (NIDR) survey of approximately 40,000 U.S. school
children found that 25% of students ages 5 to 17 accounted for
75% of the decay experienced in permanent teeth..Q!!. Some of
the risk factors that increase an individual's risk for decay are
irregular dental visits, deep pits and fissures in the chewing
surfaces of teeth, inadequate saliva flow, frequent sugar intake
and very high oral bacteria counts.
(Additional discussion on this topic may be found in the
Introduction - Water Fluoridation's Role in Reducing Dental
Decay. )
Because dental decay is so common, it mistakenly tends to be
regarded as an inevitable part of life. Data from NHANES III
collected on adults aged 18 and older revealed that 94%
showed evidence of past or present decay in the crowns of
teeth, and 22.5% had evidence of root surface decay.59
In addition to impacting emotional and social well-being, the
consequences of dental disease are reflected in the cost of its
treatment. The nation's dental health bill in 1997 was $50.6
billion.20. Again, the goal must be prevention rather than repair.
Fluoridation is presently the most cost-effective method for the
prevention of tooth decay for residents of a community in the
United States.~ 62
Question 8
Do adults benefit from fluoridation?
Answer
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Fluoridation Facts: Benefits
I-Iuorlaatlon plays a protective rOle against aental aecay
throughout life, benefiting both children and adults. In
fact, inadequate exposure to fluoride places children and
adults in the high risk category for dental decay.
Fact
Fluoride has both a systemic and topical effect and is
beneficial to adults in two ways. The first is through the
remineralization process in enamel, in which early decay does
not enlarge, and can even reverse, because of frequent
exposure to small amounts of fluoride. Studies have clearly
shown that the availability of topical fluoride in an adult's mouth
during the initial formation of decay can not only stop the
decay process, but also make the enamel surface more
resistant to future acid attacks. Additionally, the presence of
systemic fluoride in saliva provides a reservoir of fluoride ions
that can be incorporated into the tooth surface to prevent
decay.63 (Additional discussion on this topic may be found in
Question 1.)
Another protective benefit for adults is the prevention of root
decay. Adults with gumline recession are at risk for root decay
because the root surface becomes exposed to decay-causing
bacteria in the mouth. Studies have demonstrated that fluoride
is incorporated into the structure of the root surface, making it
more resistant to decay.~ 63-66 In Ontario, Canada, lifelong
residents of the naturally fluoridated (1.6 ppm) community of
Stratford had significantly lower root decay experience than
those living in the matched, but nonfluoridated, community of
Woodstock.~
People in the United States are living longer and retaining
more of their natural teeth than ever before. Because older
adults experience more problems with gumline recession, the
prevalence of root decay increases with age. A large number
of exposed roots or a history of past root decay places an
individual in the high risk category for decay.12 Data from the
1988-1991 National Health and Nutrition Examination Survey
(NHANES III) showed that 22.5% of all adults with natural
teeth experienced root decay. This percentage increased
markedly with age:
1. in the 18- to 24-year-old age group, only 6.9%
experienced root decay;
2. in the 35- to 44-year-old age group, 20.8% experienced
root decay;
3. in the 55- to 64-year-old age group, 38.2% showed
evidence of root decay; and
4. in the over-75 age group, nearly 56% had root decay. 59
In addition to gumline recession, older adults tend to
experience decreased salivary flow, or xerostomia, due to the
use of medications or medical conditions.2L. ~ Inadequate
saliva flow places an individual in the high risk category for
de{".av..12 This decrease in salivarv flow {".an increase the
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----.I" ....- ---.----... __"'_0" ..-... --.. ...-.---- ...-
likelihood of dental decay because saliva contains many
elements necessary for early decay repair - including
fluoride.
There are data to indicate that individuals who have consumed
fluoridated water continuously from birth receive the maximum
protection against dental decay. However, teeth present in the
mouth when exposure to water fluoridation begins also benefit
from the topical effects of exposure to fluoride. In 1989, a small
study in the state of Washington suggested adults exposed to
fluoridated water only during childhood had similar decay rates
as adults exposed to fluoridated water only after age 14. This
study lends credence to the topical and systemic benefits of
water fluoridation. The topical effects are reflected in the decay
rates of adults exposed to water fluoridation only after age 14.
The study also demonstrates that the pre-eruptive, systemic
effects of fluoridation have lifetime benefits as reflected in the
decay rates of adults exposed to fluoridation only during
childhood. The same study also noted a 31 % reduction of
dental disease (based on the average number of decayed or
filled tooth surfaces) in adults with a continuous lifetime
exposure to fluoridated water as compared to adults with no
exposure to water f1uoridation.54
A Swedish study investigating decay activity among adults in
optimal and low fluoride areas revealed that not only was
decay experience significantly lower in the optimal fluoride
area, but the difference could not be explained by differences
in oral bacteria, buffer capacity of saliva or salivary flow. The
fluoride concentration in the drinking water was solely
responsible for decreased decay rates.~
Water fluoridation contributes much more to overall health than
simply reducing tooth decay: it prevents needless infection,
pain, suffering and loss of teeth; improves the quality of life;
and saves vast sums of money in dental treatment costs.ll
Additionally, fluoridation conserves natural tooth structure by
preventing the need for initial fillings and subsequent
replacement fillings.7o
Question 9
Are dietary fluoride supplements effective?
Answer
For children who do not live in fluoridated communities,
dietary fluoride supplements are an effective alternative to
water fluoridation for the prevention of tooth decay.a. 71-
73
Fact
Dietary fluoride supplements are available only by prescription
and are intended for use by children living in nonfluoridated
areas to increase their fluoride exposure so that it is similar to
that by children who live in optimally fluoridated areas.I!
Dietary fluoride supplements are available in two forms: drops
for infants aged six months and up, and chewable tablets for
. 1?
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Fluoridation Facts: Benefits
cnllaren ana aaolescems........ In oraer to aecrease me riSK OT
dental fluorosis in permanent teeth, fluoride supplements
should only be prescribed for children living in
nonfluoridated areas. The correct amount of a fluoride
supplement is based on the child's age and the existing
fluoride level in the drinking water.12. ~ 75 Consideration
should also be given to the child's risk for decay and to all
sources of fluoride exposure for children. (An excellent source
of information regarding decay risk assessment and prevention
is the American Dental Association's "Caries Diagnosis and
Risk Assessment: A Review of Preventive Strategies and
Management. "12)
Because fluoride is so widely available, it is recommended that
dietary fluoride supplements be used only according to the
recommended dosage schedule and after consideration of all
sources of fluoride exposure. For optimum benefits, use of
supplements should begin at six months of age and be
continued daily until the child is at least 16 years 01d.12 The
current dietary fluoride supplement schedule is shown in Table
1.
The need for compliance over an extended period of time is a
major procedural and economic disadvantage of community-
based fluoride supplement programs, one that makes them
impractical as an alternative to water fluoridation as a public
health measure. In a controlled situation, as shown in a study
involving children of health professionals, fluoride supplements
achieve effectiveness comparable to that of water fluoridation.
However, even with this highly educated and motivated group
of parents, only half continued to give their children fluoride
tablets for the necessary number of years.I2 Independent
reports from several countries. including the United States,
have demonstrated that communitywide trials of fluoride
supplements in which tablets were distributed for use at home
were largely unsuccessful because of poor compliance. 77
While total costs for the purchase of supplements and
administration of a program are small (compared with the initial
cost of the installation of water fluoridation equipment), the
overall cost of supplements per child is much greater than the
per capita cost of community fluoridation.22. In addition,
community water fluoridation provides decay prevention
benefits for the entire population regardless of age,
socioeconomic status, educational attainment or other social
variables.ll This is particularly important for families who do
not have access to regular dental services.
Question 10
In areas where water fluoridation is not feasible because
of engineering constraints, are alternatives to water
fluoridation available?
Answer
Yes. Some countries outside the United States that do not
have piped water supplies that can accommodate
community water fluoridation have chosen to use salt
.cl..__ll-l_&:__
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Fluoridation Facts: Benefits
Jluonoatlon.
Fact
Studies evaluating the effectiveness of salt fluoridation outside
the U.S. have concluded that fluoride delivered via salt
produces decay reductions similar to that of optimally
fluoridated water. 78 Salt fluoridation is used in over 30
countries, including Switzerland, Columbia, Jamaica, Costa
Rica, Mexico, France, Spain and Germany.N. ~ Published
results of studies in many of these countries show that, for 12-
year-old children, the initial level of decay reduction due to salt
fluoridation is between 35% and 80%.M An advantage of salt
fluoridation is that it does not require a centralized piped water
system. This is of particular use in many developing countries
that do not have such water systems. When both domestic salt
and bulk salt (used by commercial bakeries, restaurants,
institutions, and industrial food production) is fluoridated, the
decay-reducing effect may be comparable to that of water
fluoridation over an extended period of time.M On the other
hand, when only domestic salt is fluoridated, the decay-
reducing effect may be diminished.78
Salt fluoridation has several disadvantages that do not exist
with water fluoridation. Challenges occur with implementation
of salt fluoridation when there are multiple sources of drinking
water in an area. The natural fluoride level of each source
must be determined and, if the level is optimal or excessive,
fluoridated salt should not be distributed in that area. Also, salt
fluoridation requires refined salt produced with modern
technology and technical expertise.!l2 Finally, there is general
agreement that a high consumption of sodium is a risk factor
for hypertension (high blood pressure}.~!l:1 People who have
hypertension or must restrict their salt intake may find salt
fluoridation an unacceptable method of receiving fluoride.
Fluoridated milk has been suggested as another alternative to
community water fluoridation in countries outside the United
States. Studies among small groups of children have
demonstrated a decrease in dental decay rates due to
consumption of fluoridated milk; however, these studies were
not based on large-scale surveys. More research is needed
before milk fluoridation can be recommended as an alternative
to water or salt f1uoridation.~ The rationale for adding fluoride
to milk is that this method "targets" fluoride directly to children.
Concerns have been raised about decreased widespread
benefits due to the slower absorption of fluoride from milk than
from water and the considerable number of persons, especially
adults, who do not drink milk for various reasons.86 The
monitoring of fluoride content in milk is technically more difficult
than for drinking water because there are many more dairies
than communal water supplies. In addition, because
fluoridated milk should not be sold in areas having natural or
adjusted fluoridation, regulation would be difficult, and
established marketing patterns would be disrupted.17
(Additional discussion on this topic may be found in Question
40.)
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Fluoridation Facts: Benefits
Question 11
Can the consistent use of bottled water result in
individuals missing the benefits of optimally fluoridated
water?
Answer
Yes. The majority of bottled waters on the market do not
contain optimal levels (0.7-1.2 ppm) offluoride.
Fact
Individuals who drink bottled water as their primary source of
water could be missing the decay preventive effects of
optimally fluoridated water available from their community
water supply. Therefore, consumers should seek advice from
their dentist about specific fluoride needs.
The fluoride content of bottled water can vary greatly. A 1989
study of pediatric dental patients and their use of bottled water
found the fluoride content of bottled water from nine different
sources varied from 0.04 ppm to 1.4 ppm..!rr In a 1991 study of
39 bottled water samples, 34 had fluoride levels below 0.3
ppm. Over the two years the study was conducted, six
products showed a two- to four-fold drop in fluoride content. 88
In evaluating how bottled water consumption affects fluoride
exposure, there are several factors to consider. First is the
amount of bottled water consumed during the day. Second is
whether bottled water is used for drinking, in meal preparation
and for reconstituting soups, juices and other drinks. Third is
whether another source of drinking water is accessed during
the day such as an optimally fluoridated community water
supply at daycare, school or work. A final important issue is
determining the fluoride content of the bottled water. If the
fluoride level is not shown on the label of the bottled water, the
company can be contacted, or the water can be tested to
obtain this information. The fluoride level should be tested
periodically if the source of the bottled water changes and, at a
minimum, on a yearly basis.8?
Information regarding the existing level of fluoride in a
community's public water supply can be obtained by asking a
local dentist, contacting the local or state health department, or
contacting the local water supplier.
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Question 12
Can home water treatment systems (e.g., water filters)
affect optimally fluoridated water supplies?
Answer
Yes. Some types of home water treatment systems can
reduce the fluoride levels in water supplies potentially
decreasing the decay-preventive effects of optimally
fluoridated water.
Fact
There are many kinds of home water treatment systems
:__1. ....:__ ____z_ .t:.&__ z_. .__& ,c.,,___ __. .____ _____:_ _. ._...___
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Fluoridation Facts: Benefits
I
1III,,;IUUIII\:lI,,;C::IIC::lIt: 11Ilt:1:S, IC::IUI,,;t:L IIILt:I:S, It:Vt:I:st: U:SIIIU:SI:S :SY:SLt:IIl:S,
distillation units and water softeners. There has not been a
large body of research regarding the extent to which these
treatment systems affect fluoridated water. Available research
is often conflicting and unclear. However, it has been
consistently documented that reverse osmosis systems and
distillation units remove significant amounts of fluoride from the
water supply..1Q.. 89 On the other hand, a recent study regarding
water softeners confirmed earlier research indicating the water
softening process caused no significant change in fluoride
levels.~ 91 With water filters, the fluoride concentration
remaining in the water depends on the type and quality of the
filter being used, the status of the filter and the filter's age.
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Individuals who drink water processed by home water
treatment systems as their primary source water could be
losing the decay preventive effects of optimally fluoridated
water available from their community water supply. Therefore,
consumers should seek advice from their dentist about specific
fluoride needs.
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Consumers using home water treatment systems should have
their water tested at least annually to establish the fluoride
level of the treated water. More frequent testing may be
needed. Testing is available through local and state public
health departments. Private laboratories may also offer testing
for fluoride levels in water.
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Information regarding the existing level of fluoride in a
community's public water system can be obtained by asking a
local dentist, contacting your local or state health department,
or contacting the local water supplier.
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Consumers should seek advice from their dentist about
specific fluoride needs.
~ Introduction
Safety: ...
Questions 13-22 r
I
Copyright @ 1999 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
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March 12, 1999
Document address: http://www.ada.org/consumer/fluoride/facts/benefits.html
I
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Fluoridation Facts: Safety: Questions 13-22
~ Search Contact Us About the ADA What's New
Fluoridation Facts
Safety
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
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Consumers
publicinfo@ada.org
Dental Professionals
online@ada.org
13. Harmful to humans?
14. More studies needed?
15. Total intake?
16. Daily intake?
17. Body uptake?
18. Bone health?
19. Dental fluorosis?
20. Prevent fluorosis?
21. Toxicity?
22. Cancer?
23. Enzyme effects?
24. Allergies?
25. AIDS?
26. Genetic risk?
27. Down Syndrome?
28. Neurological impact?
29. Alzheimer's?
30. Heart disease?
31. Kidney disease?
32. Water quality?
33. Engineering?
Question 13
Does fluoride in the water supply, at the levels
recommended for the prevention of tooth decay, adversely
affect human health?
Answer
The overwhelming weight of scientific evidence indicates
that fluoridation of community water supplies is both safe
and effective.
Fact
For generations, millions of people have lived in areas where
fluoride is found naturally in drinking water in concentrations as
high or higher than those recommended to prevent tooth decay.
Research conducted among these persons confirms the safety
of fluoride in the water supply.M. 92-95 In fact, in August 1993, the
National Research Council, a branch of the National Academy of
Sciences, released a report prepared for the Environmental
Protection Agency (EPA) that confirmed that the currently
allowed fluoride levels in drinking water do not pose a risk for
health problems such as cancer, kidney failure or bone
disease.96 Based on a review of available data on fluoride
toxicity, the expert subcommittee that wrote the report concluded
that the EPA's ceiling of 4 ppm for naturally occurring fluoride in
drinking water was "appropriate as an interim standard."96
Subsequently, the EPA announced that the ceiling of 4 ppm
would protect against adverse health effects with an adequate
margin of safety and published a notice of intent not to revise the
fluoride drinking water standard in the Federal Register.9?
As with other nutrients, fluoride is safe and effective when used
~nrl ""nC,'ll.......orl nr^r"u~..h, 1\1", ,..h~r"'o ~,,~inC"'. tho honofi+C'" ~nrl
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Fluoridation Facts: Safety: Questions 13-22
GlIIU '"'VI I.,UI I I.::;;:U fJl VtJvll y. . 'tV \"llal ~o a~alll"" U Ie:; Uc;llCI 11.., ell IU
safety of fluoridation has ever been substantiated by generally
accepted scientific knowledge. After 50 years of research and
practical experience, the preponderance of scientific evidence
indicates that fluoridation of community water supplies is both
safe and effective. 98 (Additional discussion on this topic may be
found in Question 19 and Question 32.)
Many organizations in the U.S. and around the world involved
with health issues have recognized the benefits of community
water fluoridation. The American Dental Association adopted its
original resolution in support of fluoridation in 1950, and has
repeatedly reaffirmed its position publicly and in its House of
Delegates based on its continuing evaluation of the safety and
effectiveness of f1uoridation~ The American Medical
Association's (AMA) House of Delegates first endorsed
fluoridation in 1951. In 1986, and again in 1996, the AMA
reaffirmed its support for fluoridation as an effective means of
reducing dental decay.99 The World Health Organization, which
initially recommended the practice of water fluoridation in
1969,100 reaffirmed its support for fluoridation in 1994 stating
that: "Providing that a community has a piped water supply,
water fluoridation is the most effective method of reaching the
whole population, so that all social classes benefit without the
need for active participation on the part of individuals.".62.
Following a comprehensive 1991 review and evaluation of the
public health benefits and risks of fluoride, the U.S. Public Health
Service reaffirmed its support for fluoridation and continues to
recommend the use of fluoride to prevent dental decay.54
National and international health, service and professional
organizations that recognize the public health benefits of
community water fluoridation for preventing dental decay may be
viewed in the Compendium.
Question 14
Are additional studies being conducted to determine the
effects of fluorides in humans?
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Answer
Yes. Since its inception, fluoridation has undergone a nearly
continuous process of reevaluation. As with other areas of
science, additional studies on the effects of fluorides in
humans can provide insight as to how to make more
effective choices for the use of fluoride. The American
Dental Association and the U.S. Public Health Service
support this ongoing research.
Fact
For the past 50 years, detailed reports have been published on
all aspects of f1uoridation..a ~ The accumulated dental, medical
and public health evidence concerning fluoridation has been
reviewed and evaluated numerous times by academicians,
committees of experts, special councils of government and most
of the world's major national and international health
organizations. The verdict of the scientific community is that
water fluoridation, at the recommended levels, provides major
- -- -. 1- _ _ ....._ 1_ _._ _~... _ "'r'_ _ __ _ . _ _...! _ __ _I: _ _ _ _ !L I _ _ _ _ _ __ -' _._ . 1_ _ _ ILI_
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Fluoridation Facts: Safety: Questions 13-22
oral nealtn oenems. I ne question or posslOle seconaary nealtn
effects caused by fluorides consumed in optimal concentrations
throughout life has been the object of thorough medical
investigations which have failed to show any impairment of
general health.~ 92-95
In scientific research, there is no such thing as "final knowledge."
New information is continuously emerging and being
disseminated. While research continues, the weight of scientific
evidence indicates water fluoridation is safe and effective in
preventing dental decay in humans. 54
(Additional discussion on this topic may be found in Question
36.)
Question 15
Does the total intake of fluoride from air, water and food
pose significant health risks?
Answer
The total intake of fluoride from air, water and food in an
optimally fluoridated community in the United States does
not pose significant health risks.
Fact
Fluoride from the Air
The atmosphere normally contains negligible concentrations of
airborne fluorides. Studies reporting the levels of fluoride in air in
the United States suggest that ambient fluoride contributes little
to an individual's overall fluoride intake..1Q1. 102
Fluoride from Water
Fresh or ground water in the United States has naturally
occurring fluoride levels that can vary widely from less than 0.1
to over 13 parts per million. Few private well water sources
exceed 7 ppm.102 Public water systems in the U.S. are
monitored by the Environmental Protection Agency (EPA), which
requires that public water system~ not exceed fluoride levels of 4
ppm.N The optimal concentration for fluoride in water in the
United States has been established in the range of 0.7 to 1.2
ppm. This range will effectively reduce tooth decay while
minimizing the occurence of mild dental fluorosis. The optimal
fluoride level is dependent on the annual average of the
maximum daily air temperature in the geographic area.27
(Additional discussion on this topic may be found in Question
32.)
Children living in a community with water fluoridation get a
portion of their daily fluoride intake from fluoridated water and a
portion from dietary sources which would include food and other
beverages. When considering water fluoridation, an individual
must consume one liter of water fluoridated at 1 part per million
(1 ppm) to receive 1 milligram (1 mg) of f1uoride.1L ~ Children
under six years of age, on average, consume less than one-half
liter of drinking water a day.1M Therefore, children under six
years of age would consume, on average, less than 0.5 mg of
fl. Inrino ~ rI'O\I frnrn ...trinl,inn nntirnollu fI, In"irlo+.an UI'!:3lt.o.I" {'O+ 1
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Fluoridation Facts: Safety: Questions 13-22
IIUVllUg Cl UQ1"UIII UIIlIn..III~ VP"IIIIQII1I1UV11\....;u.vU .WQL'VI \elL I
ppm).
A ten-year comparison study of long-time residents of Bartlett
and Cameron, Texas, where the water supplies contained 8.0
and 0.4 parts per million of fluoride respectively, included
examinations of organs, bones and tissues. Other than a higher
prevalence of dental fluorosis in the Bartlett residents, the study
indicated that long term consumption of dietary fluoride (resident
average length of fluoride exposure was 36.7 years), even at
levels considerably higher than recommended for decay
prevention, resulted in no clinically significant physiological or
functional effects.95
Fluoride in Food
The fluoride content of fresh solid foods in the United States
generally ranges from 0.01 to 1.0 part per million.104 Fish, such
as sardines, may contribute to higher dietary fluoride intake if the
bones are ingested. Brewed teas may also contain fluoride
concentrations of 1 ppm to 6 ppm depending on the amount of
dry tea used, the water fluoride concentration and the brewing
time.104
The average daily dietary intake of fluoride (expressed on a body
weight basis) by children residing in optimally fluoridated (1 ppm)
communities is 0.05 mg/kg/day; in communities without optimally
fluoridated water, average intakes for children are about 50%
lower.l! Dietary fluoride intake by adults in optimally fluoridated
(1 ppm) areas averages 1.4 to 3.4 mg/day, and in nonfluoridated
areas averages 0.3 to 1.0 mg/day,14
A 1990 review of literature identified no significant increases in
concentrations of fluoride in food associated with water
f1uoridation.105
Questions concerning the possible concentration of fluoride
through the biologic food chain have been addressed by the
National Academy of Sciences, which concluded:106
Indeed, domestic animals can serve as a protective
barrier for humans. Approximately 99% of the
fluoride retained in the body is stored in bone, and
only slight increases in the concentration of soft
tissue fluoride occur even at high levels of dietary
fluoride intake. There is, therefore, little danger to
humans from the consumption of meat or milk from
domestic animals even if the animals have
ingested excessive fluoride. A few meat and fish
products prepared for human consumption contain
portions of comminuted (crushed) bone that may
contribute to a higher fluoride content. The
proportion of the total diet represented by these
products, however, would generally be very small
indeed.
The U.S. Food and Drug Administration has established "market
baskets" which reflect the actual 14-day consumption of various
food items by an average individual in different age groups from
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Fluoridation Facts: Safety: Questions 13-22
. - .
six-month-old children to adults. In a nationwide study of market
baskets from areas with varying levels of fluoride in water
supplies, it was determined that little or no change in food
fluoride content has occurred as a result of the fluoridation of
U.S. water supplies.1QI. 108
Question 16
How much fluoride should an individual consume each day
to reduce the occurrence of dental decay?
Answer
The appropriate amount of daily fluoride intake varies with
age and body weight. As with other nutrients, fluoride is
safe and effective when used and consumed properly.
Fact
In 1997, the Food and Nutrition Board of the Institute of Medicine
developed a comprehensive set of reference values for dietary
nutrient intakes.74 These new reference values, the Dietary
Reference Intakes (DRI), replace the Recommended Dietary
Allowances (RDA) which had been set by the National Academy
of Sciences since 1941. The new values present nutrient
requirements to optimize health and, for the first time, set
maximum-level guidelines to reduce the risk of adverse effects
from excessive consumption of a nutrient. Along with calcium,
phosphorous, magnesium and vitamin 0, ORis for fluoride were
established because of its proven effect on tooth decay.
As demonstrated in Table 2, fluoride intake in the United States
has a large range of safety.
The first DRI reference value is the Adequate Intake (AI) which
establishes a goal for intake to sustain a desired indicator of
health without causing side effects. In the case of fluoride, the AI
is the daily intake level required to reduce tooth decay without
causing moderate dental fluorosis. The AI for fluoride from all
sources (fluoridated water, food, beverages, fluoride dental
products and dietary fluoride supplements) is set at 0.05
mg/kg/day (milligram per kilogram of body weight per day).
Using the established AI of 0.05 mg/kg, the amount of fluoride for
optimal health to be consumed each day has been calculated by
gender and age group (expressed as average weight). See
Table 2.
The ORis also established a second reference value for
maximum-level guidelines called tolerable upper intake levels
(UL). The UL is higher than the AI and is not the recommended
level of intake. The UL is the estimated maximum intake level
that should not produce unwanted effects on health. The UL for
fluoride from all sources (fluoridated water, food, beverages,
fluoride dental products and dietary fluoride supplements) is set
at 0.10 mg/kg/day (milligram per kilogram of body weight per
day) for infants, toddlers, and children through eight years of
age. For older children and adults, who are no longer at risk for
dental fluorosis, the UL for fluoride is set at 10 mg/day
reQardless of weiQht.
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Fluoridation Facts: Safety: Questions 13-22
Using the established ULs for fluoride, the amount of fluoride that
may be consumed each day to reduce the risk of moderate
dental fluorosis for children under eight, has been calculated by
gender and age group (expressed as average weight). See
Table 2.
As a practical example, daily intake of 2 mg of fluoride is
adequate for a nine to 13-year-old child weighing 88 pounds (40
kg). This was calculated by multiplying 0.05 mg/kg/day (AI) times
40 kg (weight) to equal 2 mg. At the same time, that 88 pound
(40kg) child could consume 10 mg of fluoride a day as a
tolerable upper intake level.
Children living in a community with water fluoridation get a
portion of their daily fluoride intake from fluoridated water and a
portion from dietary sources which would include food and other
beverages. When considering water fluoridation, an individual
must consume one liter of water fluoridated at 1 part per million
(1 ppm) to receive 1 milligram (1 mg) of f1uoride.1L 103 Children
under six years of age, on average, consume less than one-half
liter of drinking water a day.103 Therefore, children under six
years of age would consume, on average, less than 0.5 mg of
fluoride a day from drinking optimally fluoridated water (at 1
ppm).
If a child lives in a nonfluoridated area, the dentist or physician
may prescribe dietary fluoride supplements. As shown in Table 1
"Dietary Fluoride Supplement Schedule 1994" (See Question 9),
the current dosage schedule recommends supplemental fluoride
amounts that are below the AI for each age group. The dosage
schedule was designed to offer the benefit of decay reduction
with margin of safety to prevent mild to moderate dental
fluorosis. For example, the AI for a child 3 years of age is 0.7
mg/day. The recommended dietary fluoride supplement dosage
for a child 3 years of age in a nonfluoridated community is 0.5
mg/day. This provides leeway for some fluoride intake from
processed food and beverages, and other sources.
Decay rates are declining in many population groups because
children today are being exposed to fluoride from a wider variety
of sources than decades ago. Many of these sources are
intended for topical use only; however, some fluoride is
inadvertently ingested by children.m Inappropriate ingestion of
fluoride can be prevented, thus reducing the risk for dental
fluorosis without jeopardizing the benefits to oral health.
For example, it has been reported in a number of studies that
young children inappropriately swallow an average of 0.30 mg of
fluoride from fluoride toothpaste at each brushing.110-113 If a child
brushes twice a day, 0.60 mg may be inappropriately ingested.
This may slightly exceed the Adequate Intake (AI) values from
Table 2. The 0.60 mg consumption is 0.10 mg over the AI value
for children 6 to 12 months and is 0.10 mg under the AI for
children from 1-3 years of age.I! Although toothpaste is not
meant to be swallowed, children may consume the daily
recommended Adequate Intake amount of fluoride from
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Fluoridation Facts: Safety: Questions 13-22
---.... ",...--..- -.-. .-. ... -. --. ..- ---. ---- ....- . .-... -. --. ...-. ..--. --.-,
the American Dental Association has since 1992 recommended
that parents and caregivers put only one pea-sized amount of
fluoride toothpaste on a young child's toothbrush at each
brushing. Also, young children should be supervised while
brushing and taught to spit out, rather than swallow, the
toothpaste.
It should be noted that the amounts of fluoride discussed here
are intake, or ingested, amounts. When fluoride is ingested, a
portion is retained in the body and a portion is excreted. This
issue will be discussed further in Question 17
Question 17
When fluoride is ingested, where does it go?
Answer
Much is excreted; almost all of the fluoride retained in the
body is found in calcified (hard) tissues, such as bones and
teeth. Fluoride helps to prevent dental decay when
incorporated into the teeth.
Fact
After ingestion of fluoride, such as drinking a glass of optimally
fluoridated water, the majority of the fluoride is absorbed from
the stomach and small intestine into the blood stream.114 This
causes a short term increase in the fluoride levels in the blood.
The fluoride levels increase quickly and reach a peak
concentration within 20-60 minutes.ill The concentration
declines rapidly, usually within three to six hours following the
peak levels, due to the uptake of fluoride by hard tissue and
efficient removal of fluoride by the kidneys.104 Approximately
50% of the fluoride absorbed each day by young or middle-aged
adults becomes associated with hard tissues within 24 hours
while virtually all of the remainder is excreted in the urine.
Approximately 99% of the fluoride present in the body is
associated with hard tissues.ill
Ingested or systemic fluoride becomes incorporated into forming
tooth structures. Fluoride ingested regularly during the time when
teeth are developing is deposited throughout the entire surface
of the tooth and contributes to long lasting protection against
dental decay.lI (Additional discussion on this topic may be found
in Question 1.)
An individual's age and stage of skeletal development will affect
the rate of fluoride retention. The amount of fluoride taken up by
bone and retained in the body is inversely related to age. More
fluoride is retained in young bones than in the bones of older
adults..1M.. .1H.ill
According to generally accepted scientific knowledge, the
ingestion of optimally fluoridated water does not have an adverse
effect on bone health.~ Evidence of advanced skeletal
fluorosis, or crippling skeletal fluorosis, "was not seen in
communities in the United States where water supplies
contained up to 20 ppm {natural levels offluoride)."74, 121 In
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Fluoridation Facts: Safety: Questions 13-22
these communities, daily fluoride intake of 20 mg/day would not
be uncommon.74 Crippling skeletal fluorosis is extremely rare in
the United States and is not associated with optimally fluoridated
water; only 5 cases have been confirmed during the last 35
years.74 (Additional discussion on this topic may be found in
Question 18.)
The kidneys play the major role in the removal of fluoride from
the body. Normally kidneys are very efficient and excrete fluoride
very rapidly. However, decreased fluoride removal may occur
among persons with severely impaired kidney function who may
not be on kidney dialysis.96 No cases of dental fluorosis or
symptomatic skeletal fluorosis have been reported among
persons with impaired kidney function; however, the overall
health significance of reduced fluoride removal is uncertain and
continued follow-up is recommended especially for children with
impaired kidney function.54 (Additional discussion on this topic
may be found in Question 31.)
Question 18
Will the ingestion of optimally fluoridated water over a
lifetime adversely affect bone health?
Answer
According to generally accepted scientific knowledge, the
ingestion of optimally fluoridated water does not have an
adverse effect on bone health.116-120, 122
Fact
The weight of scientific evidence does not supply an adequate
basis for altering public health policy regarding fluoridation
because of bone health concerns. A number of investigations
have studied the effects on bone structure of individuals residing
in communities with optimal and higher than optimal
concentrations of fluoride in the drinking water. These studies
have focused on whether there exists a possible link between
fluoride and bone fractures. In addition, the role of fluoride in
strengthening bone and preventing fractures has been
investigated. Lastly, the possible association between fluoride
and bone cancer has been studied.
Water Fluoridation Has No Significant Impact on Bone Mineral
Density
In 1991, a workshop, co-sponsored by the National Institute of
Arthritis and Musculoskeletal and Skin Diseases and the
National Institute of Dental Research, addressed the potential
relationship of hip fracture and bone health in humans to fluoride
exposure from drinking water. Meeting at the National Institutes
of Health, researchers examined historic and contemporary
research on fluoride exposure and bone health. At that time,
participants concluded there was no basis for altering current
public health policy regarding current guidelines for levels of
fluoride in drinking water. Recommendations were made
regarding additional research in several areas.ill
In 1993, two studies were published demonstrating that
exposure to fluoridated water does not contribute to an increased
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Fluoridation Facts: Safety: Questions 13-22
risk for hip fractures. One study looked at the risk of hip fractures
in residents of two similar communities in Alberta, Canada.ill In
this study, researchers compared a city with fluoridated drinking
water optimally adjusted to 1 ppm to a city whose residents
drank water containing naturally occurring fluoride at a
concentration of only 0.3 ppm. No significant difference was
observed in the overall hip fracture hospitalization rates for
residents of both cities. "These findings suggest that fluoridation
of drinking water has no impact, neither beneficial nor
deleterious, on the risk of hip fracture."ill
The second study examined the incidence of hip fracture rates
before and after water fluoridation in Rochester, Minnesota.lli
Researchers compared the hip fracture rates of men and women
aged 50 and older from 1950 to 1959 (before the city's water
supply was fluoridated in 1960) with the ten-year period after
fluoridation. Their findings showed that hip fracture rates had
decreased, and that the decrease began before fluoridation was
introduced, and then continued. These data demonstrate no
increase in the risk of hip fracture associated with fluoridation of
the public water supply in Rochester, Minnesota.
Prior to 1993, the lead author of the 1993 Minnesota study had
authored two earlier fluoridation-hip fracture studies showing a
very slight increase in fracture risk in fluoridated communities.m..
124 The 1990 study examined the regional variation within the
United States in the incidence of hip fracture in women aged 65
and over. The analysis of hip fracture incidence data at the
county level demonstrated a strong pattem of regional variation
among women, with a band of increased risk in the southem
United States. The results of the analysis suggested that soft
and fluoridated water, poverty, reduced sunlight exposure and
rural location all increased the risk of hip fracture. In the
summary, the author stated that no presently recognized factor
or factors adequately explained the geographic variation.123 The
second study, published in 1992, was a national ecologic study
of the association between water fluoridation and hip fractures in
women and men aged 65 and over. (In ecological studies,
groups of people are studied instead of individuals.) The study
reported a small positive ecologic association between
fluoridation of public water supplies and the incidence of hip
fracture among the aged. The authors stated that this
observation did not yet provide a firm platform for health policy,
but stated further research was warranted.124
In 1997, the lead author of the 1993 Minnesota study and the
two studies noted in the preceding paragraph, issued a
statement which concluded: "To my knowledge, no study has
demonstrated that the introduction of fluoride to the public water
supplies has increased the risk of (hip) fracture, let alone a
doubling of the risk."ill
An ecological study conducted in eastem Germany compared
the incidence of hip fractures for adults living in Chemnitz
(optimally fluoridated) and Halle (fluoride-deficient). The results
suggested the consumption of optimally fluoridated water
reduced the incidence of hip fractures in elderly individuals,
especially women over 84 years of age.122
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Fluoridation Facts: Safety: Questions 13-22 Page 10 of 18
According to generally accepted scientific knowledge, the
ingestion of optimally fluoridated water does not have an adverse
effect on bone health.116-120, 122 Exposure to fluoride at levels
considered optimal for the prevention of dental decay appears to
have no significant impact on bone mineral density.126
Fluoride's Role in Strengthening Bone
The second major area of study regarding fluoride and bone
health is the role of fluoride in strengthening bone and preventing
fractures. For nearly 30 years, fluoride, primarily in the form of
slow-release sodium fluoride, has been used as an experimental
therapy to treat osteoporosis, a condition characterized by a
reduction in the amount of bone mass. Individuals with
osteoporosis may suffer bone fractures as a result of what would
be considered minimal trauma. Sodium fluoride therapy has
been used in individuals in an effort to reduce further bone loss,
or add to existing bone mass and prevent further fractures.ill
The results of the clinical trials have been mixed as noted in the
two following studies. The need for further research is indicated.
In 1995, the final report of a four year study was published
demonstrating the ability of fluoride to aid in an increase in bone
mass.127 The study examined females with post-menopausal
osteoporosis who took slow-release sodium fluoride (25 mg
twice a day) and calcium citrate (400 mg twice a day) for four
years in repeated 14 month cycles (12 months receiving
treatment and 2 months not receiving treatment). The study
concluded this treatment was safe and effective in reducing the
number of new spinal fractures and adding new bone mass to
the spine.127
In a six-year clinical trial in 50 postmenopausal women,
treatment with sodium fluoride and supplemental calcium was
not effective in the treatment of osteoporosis. 128
No Association Between Fluoride and Bone Cancer
Lastly, the possible association between fluoride and bone
cancer has been studied. In the early 1990s, two studies were
conducted to evaluate the carcinogenicity of sodium fluoride in
laboratory animals. The first study was conducted by the
National Toxicology Program (NTP) of the National Institute of
Environmental Health Sciences.m The second study was
sponsored by the Proctor and Gamble Company.~ In both
studies, higher than optimal concentrations of sodium fluoride
were consumed by rats and mice. When the NTP and the
Proctor and Gamble studies were combined, a total of eight
individual sex/species groups became available for analysis.
Seven of these groups showed no significant evidence of
malignant tumor formation. One group, male rats from the NTP
study, showed "equivocal" evidence of carcinogenicity, which is
defined by NTP as a marginal increase in neoplasms - Le.,
osteosarcomas (malignant tumors of the bone) - that may be
chemically related. The Ad Hoc Subcommittee on Fluoride of the
U.S. Public Health Service combined the results of the two
studies and stated: "Taken- together, the two animal studies
available at this time fail to establish an association between
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Fluoridation Facts: Safety: Questions 13-22 Page 11 of18
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be found in Question 22.)
Question 19
What is dental fluorosis?
Answer
Dental fluorosis is a change in the appearance of teeth and
is caused when higher than optimal amounts of fluoride are
ingested in early childhood while tooth enamel is forming.
The risk of dental fluorosis can be greatly reduced by
closely monitoring the proper use of fluoride products by
young children.
Fact
Dental fluorosis is caused by a disruption in enamel formation
which occurs during tooth development in early childhood.104
Enamel formation of permanent teeth, other than third molars
(wisdom teeth), occurs from about the time of birth until
approximately five years of age. After tooth enamel is completely
formed, dental fluorosis cannot develop even if excessive
fluoride is ingested.ill Older children and adults are not at risk
for dental fluorosis. Dental fluorosis only becomes apparent
when the teeth erupt. Because dental fluorosis occurs while
teeth are forming under the gums, teeth that have erupted are
not at risk for dental fluorosis.
Dental fluorosis has been classified in a number of ways. One
the most universally accepted classifications was developed by
H. T. Dean in 1942; its descriptions can be easily visualized by
the public (See Table 3).m
In using Dean's Fluorosis Index, each tooth present in an
individual's mouth is rated according to the fluorosis index in
Table 3. The individual's fluorosis score is based upon the
severest form of fluorosis recorded for two or more teeth.
Very mild to mild fluorosis has no effect on tooth function and
may make the tooth enamel more
resistant to decay. This type of fluorosis is not readily apparent to
the affected individual or casual observer and often requires a
trained specialist to detect. In contrast, the moderate and severe
forms of dental fluorosis are generally characterized by
esthetically (cosmetically) objectionable changes in tooth color
and surface irregularities. Most investigators regard even the
more advanced forms of dental fluorosis as a cosmetic effect
rather than a functional adverse effect,14 The EPA, in a decision
supported by the U.S. Surgeon General, has determined that
objectionable dental fluorosis is a cosmetic effect with no known
health effects.~ Little research on the psychological effects of
dental fluorosis on children and adults has been conducted,
perhaps because the majority of those who have the milder
forms of dental fluorosis are unaware of this condition.M In a
1986-7 national survey of U.S. school children conducted by the
National Institute of Dental Research, dental fluorosis was
present in 22.3% of the children examined using Dean's Index.54
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Fluoridation Facts: Safety: Questions 13-22
These children were exposed to all sources of fluoride
(fluoridated water, food, beverages, fluoride dental products and
dietary supplements). The prevalence of the types of fluorosis
were:
Very mild fluorosis
Mild fluorosis
Moderate fluorosis
Severe fluorosis
17.0%
4.0%
1.0%
0.3%
Total cases of fluorosis
22.3%
The incidence of moderate or severe fluorosis comprised a very
small portion (6%) of the total amount of fluorosis. In other
words, 94% of all dental fluorosis is the very mild to mild form of
dental fluorosis (See Figure 2).
As with other nutrients, fluoride is safe and effective when used
and consumed properly. The recommended optimum water
fluoride concentration of 0.7 to 1.2 ppm was established to
maximize the decay preventive benefits of fluoride, and the same
time minimize the likelihood of mild dental f1uorosis.54
As with all public health measures, the benefits and risks of
community water fluoridation have been examined. The benefits
of water fluoridation are discussed extensively in the Benefits
Section of this document and the safety of water fluoridation is
discussed in great detail in the remainder of this (Safety)
Section. In assessing the risks in regards to dental fluorosis,
scientific evidence shows it is probable that approximately 10%
of children consuming optimally fluoridated water, in the absence
of fluoride from all other sources, will develop very mild dental
f1uorosis.133 As defined in Table 3, very mild fluorosis is
characterized by small opaque, paper-white areas covering less
than 25% of the tooth surface. The risk of teeth forming with the
very mildest form of fluorosis must be weighed against the
benefit that the individual's teeth will also have a lower rate of
dental decay thus saving dental treatment costs.i. ~ In addition,
the risk of fluorosis may be viewed as an alternative to having
dental decay, which is a disease that may cause cosmetic
problems much greater than fluorosis (See Figure 2).134
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Figure 2
DENTAL FLUOROSIS VERSUS
TOOTH DECAY
Mild dental fluorosis
Severe dental decay
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Fluoridation Facts: Safety: Questions 13-22
I
III I~~"". i::I r~vl~w UI IIV~ r~(;~1Il ~lUUI~~ "IUI(;i::Il~U llli::lllll~ i::IfllUUIIl
of dental fluorosis attributable to water fluoridation was
approximately 13%. This represents the amount of fluorosis that
might be eliminated if community water fluoridation was
discontinued.52 In other words. the majority of dental fluorosis
can be associated with other risk factors such as the
inappropriate ingestion of fluoride products. (Additional
discussion on this topic may be found in Question 20.)
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The type of fluorosis seen today remains largely limited to the
very mild and mild categories. although the prevalence of
enamel fluorosis in both fluoridated and nonfluoridated
communities in the United States is higher than it was when
original epidemiological studies were done approximately 60
years ago. Because fluoride intake from water and the diet
appears not to have increased since that time. the additional
intake by children at risk for dental fluorosis is believed to be
caused by consumer's inappropriate use of fluoride-containing
dental products. As the ADA has recommended. the risk of
fluorosis can be greatly reduced by following label directions for
the use of these fluoride products.H....'OO'
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Question 20
Can fluorosis in children's teeth be prevented?
I
Answer
Because risk factors have been identified and verified by
generally accepted scientific knowledge, the occurrence of
dental fluorosis in the United States can be reduced without
denying young children the decay prevention benefits of
community water fluoridation.
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Fact
During the period of enamel formation in young children (before
teeth appear in the mouth), inappropriate ingestion of high levels
of fluoride is the risk factor for dental f1uorosis.~ 135 Studies of
fluoride intake from the diet including foods, beverages and
water indicate that fluoride ingestion from these sources has
remained relatively constant for over half a century and,
therefore, is not likely to be associated with an observed
increase in dental f1uorosis.1M. 107
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Dental decay has decreased because children today are being
exposed to fluoride from a wider variety of sources than decades
ago. Many of these sources are intended for topical use only;
however. some fluoride is inadvertently ingested by children.109
Inappropriate ingestion of topical fluoride can be prevented, thus
reducing the risk for dental fluorosis without reducing decay
prevention benefits.
I
Since 1992, the American Dental Association has required
manufacturers of toothpaste to include the phrase "Use only a
pea-sized amount (of toothpaste) for children under six" on
fluoride toothpaste labels with the ADA Seal of Acceptance. The
rationale for choosing six years of age for the toothpaste label is
based on the fact that the swallowing reflex is not fully developed
in children of preschool age and they may inadvertently swallow
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Fluoridation Facts: Safety: Questions 13-22 Page 14 of 18
"""''''''.1,.,.....'''''''''' UUIIII~ ..,.....'"'....,~. II' .....""'''-1.".'''.., ",...... v............. .V. II I.......",. 1 v.
permanent teeth is basically complete at six and so there is a
decreased risk of fluorosis. Because dental fluorosis occurs
while teeth are forming under the gums, individuals whose teeth
have erupted are not at risk for dental fluorosis.
(Additional discussion on this topic may be found in Question 16
and Question 19.)
Numerous studies have established a direct relationship
between young children brushing with more than the
recommended pea-sized amount of fluoride toothpaste and the
risk of very mild or mild dental f1uorosis.136-138 One study of 916
children residing in a fluoridated community revealed that an
estimated 71 % of identified fluorosis cases could be explained
by a history of having brushed more than once a day with more
than the recommended amount (only one pea-sized dab at each
brushing) of fluoride toothpaste throughout the first eight years of
Iife.m Parents and caregivers should put only one pea-sized
amount of fluoride toothpaste on a young child's
toothbrush at each brushing. Young children should be
supervised while brushing and taught to spit out, rather
than swallow, the toothpaste.
Additionally, it has been shown that 25% of the fluorosis cases
could be explained by a history of taking dietary fluoride
supplements inappropriately (Le., while also consuming
fluoridated water) during the first eight years of life. 139 Dietary
fluoride supplements should be prescribed as recommended in
the Dietary Fluoride Supplement Schedule approved by the
American Dental Association, the American Academy of
Pediatrics and the American Academy of Pediatric Dentistry in
1994 (See Table 1.)12. Fluoride supplements should only be
prescribed for children living in nonfluoridated areas.
Because of many sources of fluoride in the diet, proper
prescribing of fluoride supplements can be complex. It is
suggested that all sources of fluoride be evaluated with a
thorough fluoride history before supplements are prescribed for a
child.73 Included in that evaluation is the testing of the home
water supply if the fluoride concentration is unknown.
Parents, caregivers and health care professionals should
judiciously monitor use of all f1uorlde-contalning dental
products by children under age six. As is the case with any
therapeutic product, more is not always better. Care should be
taken to adhere to label directions on fluoride prescriptions and
over-the-counter products (e.g., fluoride toothpastes and rinses).
The American Dental Association recommends the use of
fluoride mouthrinses, but not for children under six years of
age because they may swallow the rinse. In addition, these
products should be stored out of the reach of children.
Finally, in areas where naturally occurring fluoride levels in
ground water are higher than 2 ppm, consumers should consider
action to lower the risk of dental fluorosis for young children.
(Adults are not affected because dental fluorosis occurs only
when developing teeth are exposed to elevated fluoride levels.)
Families on community water systems should contact their water
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Fluoridation Facts: Safety: Questions 13-22 Page 15 of 18
--,...,.....-. ..- --... ____. ...._ ..__..__ 0_"_.. __..__..._._ ........ '-"._"_
home wells should have the source tested to accurately
determine the fluoride content. Consumers should consult with
their dentist regarding water testing and discuss appropriate
dental health care measures. In homes where young children are
consuming water with a fluoride level greater than 2 ppm,
families should use an alternative primary water source, such as
bottled water, for drinking and cooking. Private wells should be
tested at least yearly due to possible fluctuations in water tables.
It is important to remember that the American Dental Association
recommends dietary fluoride supplements only for children living
in areas with less than optimally fluoridated water.
(Additional discussion on this topic may be found in Question 9
and Question 32.)
Question 21
Is fluoride, as provided by community water fluoridation, a
toxic substance?
Answer
Fluoride, at the concentrations found optimally fluoridated
water, is not toxic according to generally accepted scientific
knowledge.
Fact
Like many common substances essential to life and good health
- salt, iron, vitamins A and 0, chlorine, oxygen and even water
itself - fluoride can be toxic in excessive quantities. Fluoride in
the much lower concentrations (0.7 to 1.2 ppm) used in water
fluoridation is not harmful or toxic.
Acute fluoride toxicity occurring from the ingestion of optimally
fluoridated water is impossible.104 The amount of fluoride
necessary to cause death for a human adult (155 pound man)
has been estimated to be 5-10 grams of sodium fluoride,
ingested at one time.140 This is more than 10,000-20,000 times
as much fluoride as is consumed at one time in a single 8 ounce
glass of optimally fluoridated water.
Chronic fluoride toxicity may develop after 10 or more years of
exposure to very high levels of fluoride, levels not associated
with fluoride intake in drinking optimally fluoridated water. The
primary functional adverse effect associated with long term
excess fluoride intake is skeletal fluorosis. The development of
skeletal fluorosis and its severity is directly related to the level
and duration of fluoride exposure. For example, the ingestion of
water naturally fluoridated at approximately 5 ppm for 10 years
or more is needed to produce clinical signs of osteosclerosis, a
mild form of skeletal fluorosis, in the general population. In areas
naturally fluoridated at 5 ppm, daily fluoride intake of 10 mg/day
would not be uncommon. 74 A survey of X-rays from 170,000
people in Texas and Oklahoma whose drinking water had
naturally occurring fluoride levels of 4 to 8 ppm revealed only 23
cases of osteosclerosis and no cases of skeletal f1uorosis.ill
Evidence of advanced skeletal fluorosis, or crippling skeletal
fluorosis, "was not seen in communities in the United States
where water supplies contained up to 20 ppm (natural levels of
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Fluoridation Facts: Safety: Questions 13-22 Page 16 of 18
fluoride). "Rill In these communities, daily fluoride intake of
20mg/day would not be uncommon.74 Crippling skeletal fluorosis
is extremely rare in the United States and is not associated with
optimally fluoridated water; only 5 cases have been confirmed
during the last 35 years,?4
(Additional discussion on this topic may be found in Question 16
and Question 32.)
The possibility of adverse health effects from continuous low
level consumption of fluoride over long periods has been
extensively studied. As with other nutrients, fluoride is safe and
effective when used and consumed properly. No charge against
the benefits and safety of fluoridation has ever been
substantiated by generally accepted scientific knowledge. After
50 years of research and practical experience, the
preponderance of scientific evidence indicates that fluoridation of
community water supplies is both safe and effective.98
At one time, high concentrations of fluoride compounds were
used in insecticides and rodenticides.27 Today fluoride
compounds are rarely used in pesticides because more effective
compounds have been developed.1M While large doses of
fluoride may be toxic, it is important to recognize the difference in
the effect of a massive dose of an extremely high level of fluoride
versus the recommended amount of fluoride found in optimally
fluoridated water. The implication that fluorides in large doses
and in trace amounts have the same effect is completely
unfounded. Many substances in widespread use are very
beneficial in small amounts, but may be harmful in large doses
- such as salt, chlorine and even water itself.
Question 22
Does drinking optimally fluoridated water cause or
accelerate the growth of cancer?
Answer
According to generally accepted scientific knowledge, there
is no connection between cancer rates in humans and
adding fluoride to drinking water.142
Fact
Since community water fluoridation was introduced in 1945,
more than 50 epidemiologic studies in different populations and
at different times have failed to demonstrate an association
between fluoridation and the risk of cancer.M Studies have been
conducted in the United States,143-148 Japan,ill the United
Kingdom,150-152 Canada153 and Australia.1M In addition, several
independent bodies have conducted extensive reviews of the
scientific literature and concluded that there is no relationship
between fluoridation and cancer..M..!M.. 22. ~
The United States Environmental Protection Agency (EPA)
further commented on the safety of appropriate fluoride exposure
in the December 5,1997, Federal Register.156 In a notice of a
final rule relating to fluoride compounds the EPA stated, ".the
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Fluoridation Facts: Safety: Questions 13-22 Page 17 of 18
weight of evidence from more than 50 epidemiological studies
does not support the hypothesis of an association between
fluoride exposure and increased cancer risk in humans. The EPA
is in agreement with the conclusions reached by the National
Academy of Sciences (NAS)."
Despite the abundance of scientific evidence, claims of a link
between fluoridation and increased cancer rates continue. This
assertion is based on one study comparing cancer death rates in
ten large fluoridated cities versus ten large nonfluoridated cities
in the United States. The results of this study have been refuted
by a number of organizations and researchers.157 The National
Cancer Institute analyzed the same data and found that the
original investigators failed to adjust their findings for variables,
such as age and gender differences, that affect cancer rates. A
review by other researchers pointed to further shortcomings in
the study. The level of industrialization in the fluoridated cities
was much higher than the nonfluoridated cities. Researchers
noted that a higher level of industrialization is usually
accompanied by a higher incidence of cancer. While the
researchers noted that the fluoridated cities did have higher
cancer rates over the twenty year study, the rate of increase in
the nonfluoridated cities was exactly the same (15%) as the
fluoridated cities. Following further reviews of the study, the
consensus of the scientific community continues to support the
conclusion that the incidence of cancer is unrelated to the
introduction and duration of water f1uoridation.~
In the early 1990s, two studies using higher than optimal levels
of fluoride were conducted to evaluate the carcinogenicity of
sodium fluoride in laboratory animals. The first study was
conducted by the National Toxicology Program (NTP) of the
National Institute of Environmental Health Sciences.m The
second study was sponsored by the Proctor and Gamble
Company..uQ In both studies, higher than optimal concentrations
of sodium fluoride were consumed by rats and mice. When the
NTP and the Proctor and Gamble studies were combined, a total
of eight individual sex/species groups became available for
analysis. Seven of these groups showed no significant evidence
of malignant tumor formation. One group, male rats from the
NTP study, showed "equivocal" evidence of carcinogenicity,
which is defined by NTP as a marginal increase in neoplasms -
Le., osteosarcomas (malignant tumors of the bone) - that may
be chemically related. The Ad Hoc Subcommittee on Fluoride of
the U.S. Public Health Service combined the results of the two
studies and stated: "Taken together, the two animal studies
available at this time fail to establish an association between
fluoride and cancer."54
In a 1990 study, scientists at the National Cancer Institute
evaluated the relationship between fluoridation of drinking water
and cancer deaths in the United States during a 36 year period,
and the relationship between fluoridation and the cancer rate
during a 15 year period. After examining more than 2.3 million
cancer death records and 125,000 cancer case records in
counties using fluoridated water, the researchers saw no
. indication of a cancer risk associated with fluoridated drinking
water.~
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Fluoridation Facts: Safety: Questions 13-22
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In a document entitled "Fluoride and Drinking Water
Fluoridation," the American Cancer Society states, "Scientific
studies show no connection between cancer rates in humans
and adding fluoride to drinking water."142
~ Benefits
Safety: ....
Questions 23-33 ~
Copyright <9 1999 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
March 12, 1999
Document address: http://www . ada. org/consumer/fluoride/facts/saf13- 22 .html
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Fluoridation Facts: Safety: Questions 23-33
ADADI&INE Search Contact Us About the ADA What's New
Fluoridation Facts
Safety: Questions 23-33
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
Consumers
publicinfo@ada.org
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23. Enzyme effects?
24. Allergies?
25. AIDS?
26. Genetic risk?
27. Down Syndrome?
28. Neurological impact?
29. Alzheimer's?
30. Heart disease?
31. Kidney disease?
32. Water quality?
33. Engineering?
Question 23
Does fluoride, as provided by community water
fluoridation, inhibit the activity of enzymes in humans?
Answer
Fluoride, in the amount provided through optimally
fluoridated water, has no effect on human enzyme activity
according to generally accepted scientific knowledge.
Fact
Enzymes are organic compounds that promote chemical
change in the body. Generally accepted scientific knowledge
has not indicated that optimally fluoridated water has any
influence on human enzyme activity. There are no available
- data to indicate that, in humans drinking optimally fluoridated
water, the fluoride affects enzyme activities with toxic
consequences.1M The World Health Organization report,
Fluorides and Human Health states, "No evidence has yet
been provided that fluoride ingested at 1 ppm in the drinking
water affects intermediary metabolism of food stuffs, vitamin
utilization or either hormonal or enzymatic activity.n158
The concentrations of fluoride used in laboratory studies to
produce significant inhibition of enzymes are hundreds of times
greater than the concentration present in body fluids or
tissues.14o While fluoride may affect enzymes in an artificial
environment outside of a living organism in the laboratory, it is
unlikely that adequate cellular levels of fluoride to alter enzyme
activities would be attainable in a living organism.1M The two
primary physiological mechanisms that maintain a low
concentration of fluoride ion in body fluids are the rapid
excretion of fluoride by the kidneys and the uptake of fluoride
by calcified tissues.
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Fluoridation Facts: Safety: Questions 23-33
Question 24
Can fluoride, as found in optimally fluoridated drinking
water, alter immune function or produce allergic reaction
(hypersensitivity)?
Answer
According to generally accepted scientific knowledge,
there is no evidence of any adverse effect on specific
immunity from fluoridation, nor have there been any
confirmed reports of allergic reaction.1.~
Fact
There are no confirmed cases of allergy to fluoride, or of any
positive skin testing in human or animal models.159 The
American Academy of Allergy reviewed clinical reports of
possible allergic responses to fluoride and concluded, "There
is no evidence of allergy or intolerance to fluorides as used in
the fluoridation of community water supplies.,,12Q A committee
of the National Academy of Sciences evaluated the same
clinical data and reported, "The reservation in accepting
(claims of allergic reaction) at face value is the lack of similar
reports in much larger numbers of people who have been
exposed to considerably more fluoride than was involved in the
original observations."14 The World Health Organization also
judged these cases to represent "a variety of unrelated
conditions" and found no evidence of allergic reactions to
f1uoride.121.. 162
A 1996 review of the literature on fluoride and white cell
function examined numerous studies and concluded that there
is no evidence of any harmful effect on specific immunity
following fluoridation nor any confirmed reports of allergic
reactions. 159
Question 25
Does drinking optimally fluoridated water cause AIDS?
Answer
There is no generally accepted scientific evidence linking
the consumption of optimally fluoridated water and AIDS
(acquired immune deficiency syndrome).
Fact
AIDS is caused by a retrovirus known as the human
immunodeficiency virus (HIV). The routes of transmission of
HIV include unprotected sexual activity, exposure to
contaminated blood or blood products and as a result of an
infected woman passing the virus to the fetus during
pregnancy or to the newborn at birth.~
There is no scientific evidence linking HIV or AIDS with
community water f1uoridation.12!
Question 26
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Fluoridation Facts: Safety: Questions 23-33
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Is fluoride, as provided by community water fluoridation, a
genetic hazard?
Answer
Following a review of generally accepted scientific
knowledge, the National Research Council of the National
Academy of Sciences supports the conclusion that
drinking optimally fluoridated water is not a genetic
hazard.96
Fact
Chromosomes are the DNA-containing bodies of cells that are
responsible for the determination and transmission of
hereditary characteristics. Genes are the functional hereditary
unit that occupy a fixed location on a chromosome. Many
studies have examined the possible effects of fluoride on
chromosome damage. While there are no published studies on
the genotoxic (damage to DNA) effect of fluoride in humans,
numerous studies have been done on mice.96 These studies
have shown no evidence that fluoride damages chromosomes
in bone marrow or sperm cells even at fluoride levels 100
times higher than that in fluoridated water.165-171 Another
independent group of researchers reported a similar lack of
fluoride-induced chromosomal damage to human white blood
cells, which are especially sensitive to agents which cause
genetic mutations. Not only did fluoride fail to damage
chromosomes, it protected them against the effect of a known
mutagen (an agent that causes changes in DNA).1I& ill The
genotoxic effects of fluoride were also studied in hamster bone
marrow cells and cultured hamster ovarian cells. Again, the
results supported the conclusion that fluoride does not cause
chromosomal damage, and therefore, was not a genetic
hazard.174 In further tests, fluoride has not caused genetic
mutations in the most widely used bacterial mutagenesis
assay (the Ames test) over a wide range of fluoride levels.174-
177
Occasional questions arise regarding fluoride's effects on
human reproduction, fertility and birth rates. Very high levels of
fluoride intake have been associated with adverse effects on
reproductive outcomes in many animal species. Based on
these findings, it appears that fluoride concentrations
associated with adverse reproductive effects in animals are far
higher (100-200 ppm) than those to which human populations
are exposed. Consequently, there is insufficient scientific basis
on which to conclude that ingestion of fluoride at levels found
in community water fluoridation (0.7-1.2 ppm) would have
adverse effects on human reproduction.96
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One human study compared county birth data with county
fluoride levels greater than 3 ppm and attempted to show an
association between high fluoride levels in drinking water and
lower birth rates.ill However, because of serious limitations in
design analysis, the investigation failed to demonstrate a
positive correlation).~
Tho II.lotinnol I;)o""oor,.h ("noln"il 111.11;)("\ nf tho lI.Iotinnol
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Fluoridation Facts: Safety: Questions 23-33
r Ilg ''IOIl'VIIQ. I ,g~v~" \.III VVUllvll \'''' '\."" J VI 1.1 Iv ''IQLIVllc.ll
Academy of Sciences (NAS) supports the conclusion that
drinking optimally fluoridated water is not a genetic hazard. In
a statement summarizing its research, the NRC states, "in vitro
data indicate that:
1. the genotoxicity of fluoride is limited primarily to doses
much higher than those to which humans are exposed,
2. even at high doses, genotoxic effects are not always
observed, and
3. the preponderance of the genotoxic effects that have
been reported are of the types that probably are of no or
negligible genetic significance."oo
The lowest dose of fluoride reported to cause chromosomal
changes in mammalian cells was approximately 170 times that
found normally found in human cells in areas where drinking
water is fluoridated, which indicates a very large margin of
safety. 96
Question 27
Does drinking optimally fluoridated water cause an
increase in the rate of children born with Down
Syndrome?
Answer
There is no generally accepted scientific knowledge
establishing a relationship between Down Syndrome and
the consumption of optimally fluoridated drinking water.
Fact
This question originally arose because of two studies
published in 1956 and 1963. Data collected in several Midwest
states in 1956 formed the basis for two articles published in
French journals, purporting to prove a relationship between
fluoride in the water and Down Syndrome.~ ill
Experienced epidemiologists and dental researchers from the
National Institute of Dental Research and staff members of the
National Institute of Mental Health have found serious
shortcomings in the statistical procedures and designs of these
two studies. Among the most serious inadequacies is the fact
that conclusions were based on the fluoridation status of the
communities where the mothers gave birth, rather than the
status of the rural areas where many of the women lived
during their pregnancies..M2 In addition, the number of Down
Syndrome cases found in both fluoridated and nonfluoridated
communities were much lower than the rates found in many
other parts of the United States and the world, thus casting
doubt on the validity of findings.
The following paragraphs provide a summary of numerous
studies that have been conducted which refute the conclusions
of the 1956 studies.
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Fluoridation Facts: Safety: Questions 23-33
A British physician reviewed vital statistics and records from
institutions and school health officers, and talked with public
health nurses and others caring for children with Down
Syndrome. The findings noted no indication of any relationship
between Down Syndrome and the level of fluoride in water
consumed by the mothers.182
These findings were confirmed by a detailed study of
approximately 2,500 Down Syndrome births in Massachusetts.
A rate of 1.5 cases per 1,000 births was found in both
fluoridated and nonfluoridated communities, providing strong
evidence that fluoridation does not increase the risk of Down
Syndrome.183
Another large population-based study with data relating to
nearly 1 .4 million births showed no association between water
fluoridation and the incidence of congenital malformations
including Down Syndrome.184
In 1980, a 25-year review of the prevalence of congenital
malformations was conducted in Birmingham, England.
Although Birmingham initiated fluoridation in 1964, no changes
in the prevalence of children born with Down Syndrome
occurred since that time.jM
A comprehensive study of Down Syndrome births was
conducted in 44 U.S. cities over a two-year period. Rates of
Down Syndrome were comparable in both fluoridated and
nonfluoridated cities.186
Question 28
Does ingestion of optimally fluoridated water have any
neurological impact?
Answer
There is no generally accepted scientific knowledge
establishing a causal relationship between consumption
of optimally fluoridated water and central nervous system
disorders, including effects on intelligence.
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Fact
There have been claims that exposure to fluoride presents a
neurotoxic (harmful or damaging to nerve tissue) risk or
lowered intelligence. Such claims are based on a 1995 study in
which rats were fed fluoride at levels up to 125 times greater
than that found in optimally fluoridated water..1lU. The study
attempted to demonstrate that rats fed extremely high levels of
fluoride (75 ppm to 125 ppm in drinking water) showed
behavior-specific changes related to cognitive deficits.
In addition, the experiment also studied the offspring of rats
who were injected two to three times a day with fluoride during
their pregnancies in an effort to show that prenatal exposure
resulted in hyperactivity in male offspring.
However. two scientists who reviewed the 1995 studv~ have
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Fluoridation Facts: Safety: Questions 23-33
. .
suggested that the observations made can be readily
explained by mechanisms that do not involve neurotoxicity.
The scientists found inadequacies in experimental design that
may have led to invalid conclusions. For example, the results
of the experiment were not confirmed by the use of control
groups which are an essential feature of test validation and
experimental design. In summary the scientists stated, "We do
not believe the study by Mullenix et al. can be interpreted in
any way as indicating the potential for NaF (sodium fluoride) to
be a neurotoxicant." Another reviewer1M noted, "...it seems
more likely that the unusually high brain fluoride concentrations
reported in Mullenix et al. were the result of some analytical
error. "
A seven-year study compared the health and behavior of
children from birth through six years of age in communities
with optimally fluoridated water with those of children the same
age without exposure to optimally fluoridated water. Medical
records were reviewed yearly during the study. At age six and
seven, child behavior was measured using both maternal and
teacher ratings. The results suggested that there was no
evidence to indicate that exposure to optimally fluoridated
water had any detectable adverse effect on children's health or
behavior. These results did not differ even when data was
controlled for family social background.189
Question 29
Does drinking optimally fluoridated water cause
Alzheimer's disease?
Answer
Generally accepted science has not demonstrated an
association between drinking optimally fluoridated water
and Alzheimer's disease.
Fact
The exact cause of Alzheimer's disease (AD) has yet to be
identified. Scientists have identified the major risk factors for
AD as age and family history. Other possible risk factors
include a serious head injury and lower levels of education.
Scientists are also studying additional factors to see if they
may be associated with the disease. These include genetic
(inherited) factors, viruses and environmental factors such as
aluminum, zinc and other metals. Researchers have found
these metals in the brain tissue of people with AD, but it is not
known if these metals cause AD or build up in the brain as a
result of the disease.190
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Because aluminum has been found in the brain tissue of
people with AD, claims have been made that fluoridated water
"leaches" out the aluminum in cookware when used for boiling
water, thereby implicating fluoride as a co-factor in the
development of AD. One experiment attempted to test this
claim by measuring the release of aluminum from aluminum
cookware under the most adverse conditions, with and without
the presence of fluoride. Throughout these trials, scientists .
were unable to leach out significant amounts of aluminum from
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Fluoridation Facts: Safety: Questions 23-33
any of the cookware, including those that were exposed to
extreme acidic or alkaline conditions)M
A study published in 199am raised concerns about the
potential relationship between fluoride and Alzheimer's
disease. However, several flaws in the experimental design
preclude any definitive conclusions from being drawn.193
Interestingly, there is evidence that aluminum and fluoride are
mutually antagonistic in competing for absorption in the human
body.1L 194 While a conclusion cannot be made that
consumption of fluoridated water has a preventive effect on
AD, there is no generally accepted scientific knowledge to
show consumption of optimally fluoridated water is a risk factor
for AD.
Question 30
Does drinking optimally fluoridated water cause or
contribute to heart disease?
Answer
Broad national experience and generally accepted
scientific knowledge demonstrate that drinking optimally
fluoridated water is not a risk factor for cardiovascular
disease.
Fact
This conclusion is supported by results of a study conducted
by the National Heart and Lung Institute of the National
Institutes of Health. Researchers examined a wide range of
data from communities that have optimally fluoridated water
and from areas with insufficient fluoride. The final report
concluded that:
Thus, the evidence from comparison of the
health of fluoridating and non-fluoridating cities,
from medical and pathological examination of
persons exposed to a lifetime of naturally
occurring fluorides or persons with high industrial
exposures, and from broad national experience
with fluoridation all consistently indicate no
adverse effect on cardiovascular health.195
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The American Heart Association has reaffirmed its historical
position that heart disease is not related to the amount of
fluoride present in drinking water.ll!2 The American Heart
Association identifies cigarette and tobacco smoke, high blood
cholesterol fevels, high blood pressure, physical inactivity and
obesity as major risk factors for cardiovascular disease.197
A number of studies have considered trends in urban mortality
in relation to fluoridation status. In one study, the mortality
trends from 1950-70 were studied for 473 cities in the United
States with populations of 25,000 or more. Findings showed no
"relationship between fluoridation and heart disease death rates
over the 20-year period.1~ In another study, the mortality rates
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Fluoridation Facts: Safety: Questions 23-33
for approximately 30 million people in 24 fluoridated cities were
compared with those of 22 nonfluoridated cities for two years.
No evidence was found of any harmful health effects, including
heart disease, attributable to fluoridation. As in other studies,
crude differences in the mortality experience of the cities with
fluoridated and nonfluoridated water supplies were explainable
by differences in age, gender and race composition.144
Question 31
Is the consumption of optimally fluoridated water harmful
to kidneys?
Answer
Generally accepted scientific knowledge suggests that the
consumption of optimally fluoridated water does not
cause or worsen human kidney disease.
Fact
Approximately 50% of the fluoride ingested daily is removed
from the body by the kidneys.1M..1H. 115 Because the kidneys
are constantly exposed to various fluoride concentrations, any
health effects caused by fluoride would likely manifest
themselves in kidney cells. However, several large community-
based studies of people with long-term exposure to drinking
water with fluoride concentrations up to 8 ppm have failed to
show an increase in kidney disease.~ ~ m
In a report issued in 1993 by the National Research Council,
the Subcommittee on Health Effects of Ingested Fluoride
stated that the threshold dose of fluoride in drinking water
which causes kidney effects in animals is approximately 50
ppm - more than 12 times the maximum level allowed in
drinking water by the Environmental Protection Agency.
Therefore, they concluded that "ingestion of fluoride at
currently recommended concentrations is not likely to produce
kidney toxicity in humans."Jl2
Many people with kidney failure depend on hemodialysis
(treatment with an artificial kidney machine) for their existence.
During hemodialysis, the patient's blood is exposed to large
amounts of water each week (280-560 quarts). Therefore,
procedures have been designed to ensure that the water
utilized in the process contain a minimum of dissolved
substances that could diffuse indiscriminately into the patient's
bloodstream.200 Since the composition of water varies in
different geographic locations in the United States, the U.S.
Public Health Service recommends dialysis units use
techniques such as reverse osmosis and deionization to
remove excess iron, magnesium, aluminum, calcium, and
other minerals, as well as fluoride, from tap water before the
water is used for dialysis.2QQ... 201
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(Additional discussion on this topic is available in Question 17.)
Question 32
Will the addition of fluoride affect the quality of drinking
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Fluoridation Facts: Safety: Questions 23-33
water?
Answer
There is no scientific evidence that optimal levels of
fluoride affect the quality of water. All ground and surface
water in the United States contains some naturally
occurring fluoride.
Fact
Nearly all water supplies must undergo various water
treatment processes to be safe and suitable for human
consumption. The substances used for this purpose include
aluminum sulfate, ferric chloride, ferric sulfate, activated
carbon, lime, soda ash and, of course, chlorine. Fluoride is
added only to water that has naturally occurring lower than
optimal levels of this mineral.27
Fluoridation is the adjustment of the fluoride concentration of
fluoride-deficient water supplies to the recommended range of
0.7 to 1.2 parts per million of fluoride for optimal dental health.
The EPA has stated that fluoride in children's drinking water at
levels of approximately 1.0 ppm reduces the number of dental
cavities.202 The optimal level is dependent on the annual
average of the maximum daily air temperature in the
geographic area.27
(Additional discussion on this topic may be found in Question
1.... Question 3 and Question 33.)
Under the Safe Drinking Water Act, the EPA has established
drinking water standards for a number of substances, including
fluoride, in order to protect the public's health. There are
several areas in the United States where the ground water
contains higher than optimal levels of naturally occurring
fluoride. Therefore, federal regulations were established to
require that naturally occurring fluoride levels in a community
water supply not exceed a concentration of 4.0 mg/L.~ Under
the Safe Drinking Water Act, this upper limit is the Maximum
Contaminant Level (MCL) for fluoride. Under the MCL
standard, if the naturally occurring level of fluoride in a public
water supply exceeds the MCL (4.0 mg/L for fluoride), the
water supplier is required to lower the level of fluoride below
the MCL. This process is called defluoridation.
The EPA has also set a Secondary Maximum Contaminant
Level (SMCL) of 2.0 mg/L, and requires consumer notification
by the water supplier if the fluoride level exceeds 2.0 mg/L.
The SMCL is intended to alert families that regular
consumption of water with natural levels of fluoride greater
than 2.0 mg/L by young children may cause dental fluorosis in
the developing permanent teeth, a cosmetic condition with no
known health effect. 202 The notice to be used by water
systems that exceed the SMCL must contain the following
points:
1 . The notice is intended to alert families that children
under nine years of age who are exposed to levels of
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Fluoridation Facts: Safety: Questions 23-33
fluoride greater than 2.0 mg/liter may develop dental
fluorosis.
2. Adults are not affected because dental fluorosis occurs
only when developing teeth are exposed to elevated
fluoride levels.
3. The water supplier can be contacted for information on
alternative water source or treatments that will insure
the drinking water would meet all standards (including
the SMCL).
The 1993 National Research Council report, "Health Effects of
Ingested Fluoride," reviewed fluoride toxicity and exposure
data for the EPA and concluded that the current standard for
fluoride at 4.0 mg/L (set in 1986) was appropriate as an interim
standard to protect the public health.~ In the EPA's judgment,
the combined weight of human and animal data support the
current fluoride drinking water standard and, in December
1993, the EPA published a notice in the Federal Register
stating the ceiling of 4 mg/L would protect against adverse
health effects with an adequate margin of safety and published
a notice of intent not to revise the fluoride drinking water
standards in the Federal Register.97
The EPA further commented on the safety of fluoride in the
December 5, 1997, Federal Register.156 In a notice of a final
rule relating to fluoride compounds the EPA stated, "There
exists no directly applicable scientific documentation of
adverse medical effects at levels of fluoride below 8 mg/L
(0.23mg/kg/day)." The EPA's Maximum Concentration Limit
(MCL) of 4.0 mg/L (O.ill mg/kg/day) is one half that amount,
providing an adequate margin of safety.
The EPA indirectly regulates the intentional fluoridation of
drinking water by having an enforceable Federal standard for
fluoride at 4.0 mg/L. As long as the 4.0 mg/L standard is not
exceeded, State or local authorities determine whether or not
to f1uoridate.237
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(Additional discussion on this topic may be found in Question
.2.)
Question 33
Does fluoridation present difficult engineering problems?
Answer
No. Properly maintained and monitored water fluoridation
systems do not present difficult engineering problems.
Fact
With proper planning and maintenance of the system, fluoride
adjustment is compatible with other water treatment
processes. Today's equipment allows water treatment
personnel to easily monitor and maintain the desired fluoride
concentration. Automatic monitoring technology is available
thRt ('oRn helo to Rssure thRt the fluoride concentrRtion of the
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Fluoridation Facts: Safety: Questions 23-33
."-- -_.. "-'r- -- ----.- ...-- ...- ..--..-- --..__......_...._.. _. ..._
water remains within the recommended range. Depending on
the climate, the range for optimally fluoridated water is 0.7-1.2
ppm for an individual water plant,27
There are only three basic compounds used to fluoridate
community drinking water: 1) sodium fluoride, a white, odorless
crystalline material; 2) sodium f1uorosilicate, a white or yellow-
white, odorless crystalline powder; and 3) f1uorosilicic acid, a
white to straw-colored liquid. The three fluoride compounds are
derived from the mineral apatite which is a mixture of calcium
compounds. Apatite contains 3% to 7% fluoride and is the
main source of fluorides used in water fluoridation at the
present time. Apatite is also the raw material used for
production of phosphate fertilizers;2Z. m however, standards
and minimum requirements have been established for all three
compounds used in water f1uoridation.204
From time to time, opponents of water fluoridation allege that
the three compounds used in water fluoridation are impure or
contain impurities at a level that may be potentially harmful. To
help ensure the public's safety, compounds used for water
fluoridation conform to standards established by the American
Water Works Association.204 The American Water Works
Association (AWWA) is an international nonprofit scientific and
educational society dedicated to the improvement of drinking
water quality and supply. Regarding impurities, the AWWA
Standards state, "The [fluoride
compound] supplied under this standard shall contain no
soluble materials or organic substances in quantities capable
of producing deleterious or injurious effects on the health of
those consuming water that has been properly treated with the
[fluoride compound]." Certified analyses of the compounds
must be furnished by the manufacturer or supplier.204
When added to community water supplies fluoride compounds
become diluted to the recommended range of 0.7 to 1.2 parts
per million. At 1 ppm, one part of fluoride is diluted in a million
parts of water. Large numbers such as a million can be difficult
to visualize. While not exact, the following comparisons can be
of assistance in comprehending one part per million:
1 inch in 16 miles
1 minute in 2 years
1 cent in $10,000
(Additional discussion on this topic may be found in Question
21.)
Fluoride compounds are added to the water supply as liquids,
but are measured by two basic types of devices, dry feeders or
solution feeders (metering pumps). By design, and with proper
maintenance and testing, water systems limit the amount of
fluoride that can be added to the system (Le., the use of a day
tank that only holds one day's supply of fluoride) so prolonged
over-fluoridation becomes a mechanical impossibility.27 It is
very important that the water treatment operators responsible
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Fluoridation Facts: Safety: Questions 23-33
for monitoring the addition of fluoride to the water supply be
appropriately trained, and that the equipment used for this
process is adequately maintained..223. As with any mechanical
equipment, water fluoridation equipment should be tested,
maintained and replaced as needed. State health departments
can procure federal grant monies for these purposes.
While the optimal fluoride concentration found in drinking water
has been proven safe, water plant operators and engineers
may be exposed to much higher fluoride levels when handling
fluoride compounds at the water treatment facility.27 In order to
prevent overexposure to fluoride compounds by water plant
operators, and ensure that fluoridated water systems provide
optimal fluoride levels, the Centers for Disease Control and
Prevention and the Occupational Safety and Health
Administration provide guidelines! recommendations for
managers of fluoridated public water systems.~ 204
Adherence to these guidelines should assure continuous
levels of optimally fluoridated drinking water while maintaining
safe operation of all fluoridated water systems.
Allegations that fluoridation causes corrosion of water delivery
systems are not supportable.27 Corrosion by drinking water is
related primarily to dissolved oxygen concentration, pH, water
temperature, alkalinity, hardness, salt concentration, hydrogen
sulfide content and the presence of certain bacteria. Under
some water quality conditions, a small increase in the
corrosivity of drinking water that is already corrosive may be
observed after treatment with alum, chlorine, fluorosilicic acid
or sodium florosilicate. In such cases, further water treatment
is indicated to adjust the pH upward. This is part of routine
water plant operations.
~ Safety:
~ Questions 13-22
Public Policy ~
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Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
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See also:
American Dental
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Topical Index:
Fluorides & Fluoridation
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34. Valuable measure?
35. Courts of law?
36. Opposition?
37. Internet?
38. Public votes?
39. International fluoridation?
40. Banned in Europe?
Question 34
Is water fluoridation a valuable public health measure?
Answer
Yes. Fluoridation is a public health program that benefits
people of all ages, is safe and is cost effective because it
saves money.
Fact
A former Surgeon General of the United States, Dr. Luther
Terry, called fluoridation as vital a public health measure as
immunization again disease, pasteurization of milk and
purification of water.205 Another former U.S. Surgeon General,
Dr. C. Everett Koop, has stated, "Fluoridation is the single
most important commitment that a community can make to the
oral health of its citizens." In 1998, the U.S. Public Health
Service revised national health objectives to be achieved by
the year 2010. Included under oral health was an objective to
significantly expand the fluoridation of public water suppliesa.
Water fluoridation has been lauded as one the most
economical preventive values in the nation,~ and today still has
the greatest dental public health impact. 36
Question 35
Has the legality of water fluoridation been upheld by the
courts?
Answer
Yes. Fluoridation has been thoroughly tested in the United
States' court system, and found to be a proper means of
furthering public health and welfare. No court of last
resort has ever determined fluoridation to be unlawful.
Moreover, fluoridation has been clearly held not to be an
unconstitutional invasion of religious freedom or other
individual rights guaranteed by the First, Fifth or
Fourteenth Amendments to the U.S. Constitution.
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Fluoridation Facts: Public Policy
issue.
Fact
A vast body of scientific literature endorses water fluoridation
as a safe means of reducing the incidence of tooth decay.
Support for fluoridation among scientists and health
professionals, including physicians and dentists, is nearly
universal. Recognition of the benefits of fluoridation by the
American Dental Association, the American Medical
Association, governmental agencies and other national health
and civic organizations (see Compendium) continues as a
result of published, peer-reviewed research.
The majority of Americans also approves of water fluoridation.
In June 1998, the Gallup Organization conducted a national
survey of just over 1,000 adults on their attitudes toward
community water fluoridation. When asked, "Do you believe
community water should be fluoridated?", 70% answered yes,
18% answered no and 12% responded don't know (See Figure
~). Results characterized by U.S. Census Region showed the
level of support for community water fluoridation to be
relatively constant throughout the United States, with 73% in
the Northeast, 72% in the Midwest, 68% in the South and 70%
in the West favoring community water f1uoridation2. These
results are consistent with a December 1991 Gallup survey
that asked 1,200 parents, "Whether or not you presently have
fluoridated water, do you approve or disapprove of fluoridating
drinking water?" More than three-quarters (78%) of the
responding parents approved, 10% disapproved and 12%
answered don't know or refused to answer the question (See
Figure 4). Disapproval ranged from 4% in communities where
water was fluoridated to 16% in communities where it was
not.~ 214
Figure 3
1998 Consumers' Opinions Regarding Community Water
Fluoridation Survey of 1,000 adults, American Dental
Association, Survey Center, June 199a2
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100%
W%
10%
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Fluoridation Facts: Public Policy
% of Adults
Yes
No
Don't Know
Do you believe community water should be
fluoridated?
Figure 4
Approval of Fluoridating Drinking Water Survey of 1,200
parents, Gallup Organization, December 1991214
100%
80'K,
% of Parents
Approve
Disapprovt:.' Doo't Know
Whether or not you presently have fluoridated
water, do you approve or disapprove of
fluoridating drinking water?
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Opposition to fluoridation has existed since the initiation of the
first community programs in 1945. An article that appeared in
the local newspaper shortly after the first fluoridation program
was implemented in Grand Rapids, Michigan, noted that the
fluoridation program was slated to commence January 1 but
did not actually begin until January 15. Interestingly, health
officials in Grand Rapids began receiving complaints of
physical ailments attributed to fluoridation from citizens weeks
before fluoride was actually added to the water.I
Of the small faction that opposes water fluoridation for
philosophical reasons, freedom of choice probably stands out
as the most important single issue.ill Some individuals are
opposed to community action on any health issue, others
because of environmental or economic arguments and some
because they are misinformed. Some opponents may
knowingly or unknowingly use half-truths and innuendoes to
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Fluoridation Facts: Public Policy
support tnelr OpiniOnS, eltner misquoting or applYing
statements out of context. The sometimes alarming statements
used by some antifluoridationists, however, are not
substantiated by general accepted scientific knowledge.~
215.216
"Junk science," a term coined by the press and used over the
past decade to characterize data derived from atypical or
questionable scientific techniques, also can playa role in
provoking opposition to water fluoridation. In fact, decision
makers have been persuaded to postpone action on several
cost-effective public health measures after hypothetical risks
have made their way into the public media.217 Junk science
impacts public policy and costs society in immeasurable ways.
More people, especially those involved in policy decisions,
need to be able to distinguish junk science from legitimate
scientific research. Reputable science is based on the
scientific method of testing hypotheses in ways that can be
reproduced and verified by others; junk science, which often
provides too-simple answers to complex questions, often
cannot be substantiated.
In 1993 the U.S. Supreme Court issued a landmark decision
that many view as likely to restrict the use of junk science in
the courts. The Court determined that while "general
acceptance" is not needed for scientific evidence to be
admissible, federal trial judges have the task of ensuring that
an expert's testimony rests on a reasonable foundation and is
relevant to the issue in question. According to the Supreme
Court, many considerations will bear on whether the expert's
underlying reasoning or methodology is scientifically valid and
applicable in a given case. The Court set out four criteria
judges could use when evaluating scientific testimony: (1)
whether the expert's theory or technique can be (and has
been) tested, using the scientific method, (2) whether it has
been subject to peer review and publication (although failing
this criteria alone is not necessarily grounds for disallowing the
testimony), (3) its known or potential error rate and the
existence and maintenance of standards in controlling its
operation, and (4) whether it has attracted widespread
acceptance within a relevant scientific community, since a
known technique that has been able to attract only minimal
support may properly be viewed with skepticism. The scientific
validity and relevance of claims made by opponents of
fluoridation might be best viewed when measured against
these criteria.218
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Opinions are seldom unanimous on any scientific subject. In
fact, there may be no such thing as "final knowledge," since
new information is continuously emerging and being
disseminated. As such, the benefit evidence must be
continually weighed against risk evidence. Health
professionals, decision makers and the public should be
cooperating partners in the quest for that accountability.219
(Additional discussion on this topic may be found in the
Introduction - Scientific Information on Fluoridation.)
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Fluoridation Facts: Public Policy
yuestlon ~ {
Where can reliable information about water fluoridation be
found on the Internet and World Wide Web?
Answer
The American Dental Association, as well as other
reputable health and science organizations, and
government agencies have sites on the InternetlWeb that
provide information on fluorides and fluoridation. These
sites provide information that is consistent with generally
accepted scientific knowledge.
Fact
The Internet and World Wide Web are evolving as accessible
sources of information. However, not all "science" posted on
the Internet and Web is based on scientific fact. Searching the
Internet for "fluoride" or "water fluoridation" directs individuals
to a number of Web sites. Some of the content found in the
sites is scientifically sound. Other less scientific sites may look
highly technical, but contain information based on science that
is unconfirmed or has not gained widespread acceptance.
Commercial interests, such as the sale of water filters, may
also be promoted.
One of the most widely respected sources for information
regarding fluoridation and fluorides is the American Dental
Association's (ADA) home page at http://www.ada.org. From
the ADA Web site individuals can make contact with other Web
sites for more information about fluoride.
Question 38
Why does community water fluoridation sometimes lose
when it is put to a public vote?
Answer
Voter apathy, blurring of scientific issues, lack of
leadership by elected officials and a lack of political
campaign skills among health professionals are some of
the reasons fluoridation votes are sometimes
unsuccessful.
Fact
Despite the continuing growth of fluoridation in this country
during the past decades, millions of Americans do not yet
receive the protective benefits of fluoride in their drinking
water. At the present time, only 62.2% of the population served
by public water systems have access to fluoridated water.llln
1992, approximately 70% of all U.S. cities with populations of
more than 100,000 fluoridated their water, including 42 of the
50 largest cities (See Figure 6}.222 In 1998, the U.S. Public
Health Service revised national health objectives to be
achieved by the year 2010. Oral Health Objective 10 deals
specifically with community water fluoridation and states that at
least 85% of the population served by community water
systems should be receiving the benefits of optimally
fluoridated water by the year 201 ~ At the time the objectives
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Wt:1 t: I t:VI:st:U, It::s:s L1lal) lIall UI Lilt: :Slalt::S IIIt:l Lilt: 0070 YUal
(See Figure 7).
The adoption of fluoridation by communities has slowed during
the past several decades. Social scientists have conducted
numerous studies to determine why this phenomenon has
occurred. Among the factors noted are lack of funding, public
and professional apathy, the failure of many legislators and
community leaders to take a stand because of perceived
controversy, low voter turnout and the difficulty faced by an
electorate in evaluating scientific information in the midst of
emotional charges by opponents. Unfortunately, citizens may
mistakenly believe their water contains optimal levels of
fluoride when, in fact, it does not.
Clever use of emotionally charged "scare" propaganda by
fluoride opponents creates fear, confusion and doubt within a
community when voters consider the use of f1uoridation..221.. 222
Defeats of referenda or the discontinuance of fluoridation have
occurred most often when a small, vocal and well organized
group has used a barrage of fear-inspiring allegations
designed to confuse the electorate. In addition to attempts to
influence voters, opponents have also threatened community
leaders with personallitigation.215 While no court of last resort
has ever ruled against fluoridation, community leaders may be
swayed by the threat of litigation due to the cost and time
involved in defending even a groundless suit. In no instance
has fluoridation been discontinued because it was proven
harmful in any way.lli.. ~ 223
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Adoption of fluoridation is ultimately a decision of state or local
decision makers, whether determined by elected officials,
health officers or the voting public. Fluoridation can be enacted
through state legislation, administrative regulation or a public
referendum. Fluoridation is not legislated at the federal level
and is perceived in most states as a local issue. From 1989-
94, 318 communities authorized fluoridation by administrative
governmental action. In the same time period, 32 referenda
were held with fluoridation authorization approved in 19 and
defeated in 13.224 As noted above, referenda can be
unsuccessful for a variety of reasons. Nonetheless, a
community's decision to protect the oral health and welfare of
its citizens must, in some cases, override individual Objections
to implement appropriate public health measures.
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Question 39
Is community water fluoridation accepted by other
countries?
Answer
Yes. Water fluoridation is practiced in approximately 60
countries benefiting over 360,000,000 (three hundred sixty
million) people.1
Fact
The value of water fluoridation is recognized internationally.
Countries and geographic regions with extensive fluoridation
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IrlGluue Ule U.\:)., I-\USlrClIICl, crClZII, \",C1I1C1UCI, nOllg "Ollg,
Malaysia, United Kingdom, Singapore, Chile, New Zealand,
Israel, Columbia, Costa Rica and Ireland.79 The most recent
countywide decision for fluoridated drinking water occurred in
South Africa.225 Following the recommendations of the World
Health Organization (WHO), the initial phase of the project is
expected to reach 40% of the country's population. By the year
2000, the goal is to reach 60% of the population which is
widely spread in rural areas. Some of the most thorough
investigations of fluoridation have been conducted in Britain
and Australia. These investigations have resulted in a
significant amount of published documentation which supports
the safety and effectiveness of water f1uoridation..92.. ~ 226
Considering the extent to which fluoridation has already been
implemented throughout the world, the lack of documentation
of adverse health effects is remarkable testimony to its
safety.M. 92-96
The World Health Organization (WHO) and the Pan American
Health Organization have endorsed the practice of water
fluoridation since 1964. In 1994, an expert committee of WHO
published a report which reaffirmed its support of fluoridation
as being safe and effective in the prevention of tooth decay,
and stated that "provided a community has a piped water
supply, water fluoridation is the most effective method of
reaching the whole population, so that all social classes benefit
without the need for active participation on the part of
individuals."82 In many parts of the world, fluoridation is not
feasible or a high priority, usually due to the lack of a central
water supply, the existence of more life threatening health
needs and the lack of sufficient funds for start-up and
maintenance costs.
Political actions contrary to the recommendations of health
authorities should not be interpreted as a negative response to
water fluoridation. For example, although fluoridation is not
carried out in Sweden and the Netherlands, both countries
support WHO's recommendations regarding fluoridation as a
preventive health measure, in addition to the use of fluoride
toothpastes, mouthrinses and dietary fluoride supplements.~
227
Question 40
Is community water fluoridation banned in Europe?
Answer
No country in Europe has banned community water
fluoridation.
Fact
The claim that fluoridation is banned in Europe is frequently
used by fluoridation opponents. In truth, European countries
construct their own water quality regulations within the
framework of the 1980 European Water Quality Directive. The
Directive provides maximum admissible concentrations for
many substances, one of which is fluoride. The Directive does
not require or prohibit fluoridation, it merely requires that the
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fluoride concentration in water does not exceed the maximum
permissible concentration. 228
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Many fluoridation systems that used to operate in Eastern and
Central Europe did not function properly and, when the Iron
Curtain fell in 1989-90, shut down because of obsolete
technical equipment and lack of knowledge as to the benefits
of fluoridated water.m Water fluoridation is not practical in
many European countries because of complex water systems
with numerous water sources. As an alternative to water
fluoridation, many European countries have opted for salt
fluoridation, in addition to the use of fluoride toothpaste for
topical benefits, as a means of bringing the protective benefits
of fluoride to the public.
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(Additional discussion on this topic may be found in Question
1Q.)
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Again, no European country has specifically imposed a "ban"
on fluoridation, it has simply not been implemented for a
variety of technical or political reasons.
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~ Safety:
~ Questions 23-33
Cost Effectiveness ~
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Fluoridation Facts: Cost Effectiveness
ADADI&INI Search Contact Us About the ADA What1s New
Fluoridation Facts
Cost Effectiveness
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
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Fluoridation Facts, see
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41. Cost effective?
42. Practical?
Question 41
Is water fluoridation a cost-effective means of preventing
tooth decay?
Answer
Yes. Data from generally accepted scientific studies
continue to confirm that fluoridation has substantial
lifelong decay preventive effects and is a highly cost-
effective means of preventing tooth decay in the United
States, regardless of socioeconomic status.a. 6h ~ 230-232
Fact
It has been calculated that the annual cost of community water
fluoridation in the U.S. is approximately $0.50 per person.m
The annual cost ranges between $0.12 and $5.41 per person,
depending mostly on the size of a community, labor costs, and
type of fluoride compounds and equipment utilized.2I. 22.. ~
~ 234 It can be calculated from these data that the lifetime
cost per person to fluoridate a water system is less than the
cost of one dental filling. With the escalating cost of health
care, fluoridation remains a preventive measure that benefits
members of the community at minimal cost.
Historically, the cost to purchase fluoride compounds has
remained fairly constant over the years in contrast to the
continued rising cost of dental care.2I School-based dental
disease prevention activities (such as fluoride mouthrinse or
tablet programs), professionally applied topical fluorides and
dental health education are beneficial but have not been found
to be as cost-effective in preventing tooth decay as community
water f1uoridation.230 Fluoridation remains the most cost-
effective and practical form of preventing decay in the United
States and other countries with established municipal water
systems.~ ~ 22.. ~ 234
Due to the decay-reducing effects of fluoride, the need for
restorative dental care is typically lower in fluoridated
communities. Therefore, an individual residing in a fluoridated
community will generally have fewer restorative dental
expenditures during a lifetime. Health economists at a 1989
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.__. '.......11_" __.._.___.... .., ._... '"""_, .--...-.. ---..- -t"',...' -,.......-..-.J
$3.35 per tooth surface when decay is prevented, making
fluoridation "one of the very few public health procedures that
actually saves more money than it costs."234 Considering the
fact that the national average fee for a two surface amalgam
(silver) restoration in a permanent tooth placed by a general
dentist is $75.84*, fluoridation clearly demonstrates significant
cost savings,235
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The economic importance of fluoridation is underscored by the
fact that frequently the cost of treating dental disease is paid
not only by the affected individual, but also by the general
public through services provided by health departments,
welfare clinics, health insurance premiums, the military and
other publicly supported medical programs.61
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Indirect benefits from the prevention of dental decay may
include:
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. freedom from dental pain
. a more positive self image
. fewer missing teeth
. fewer cases of malocclusion aggravated by tooth loss
. fewer teeth requiring root canal treatment
. reduced need for dentures and bridges
. less time lost from school or work due to dental pain or
visits to the dentist
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These intangible benefits are difficult to measure economically,
but are extremely important.~ m
*The survey data should not be interpreted as constituting a
fee schedule in any way, and should not be used for that
purpose. Dentists must establish their own fees based on their
individual practice and market considerations.
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Question 42
Is it practical to fluoridate an entire water system?
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Answer
It is more practical to fluoridate an entire water supply than to
attempt to treat individual water sources.
Fact
It is technically difficult, perhaps impossible, and certainly more
costly to fluoridate only the water used for drinking. Community
water that is chlorinated, softened, or in other ways treated is
also used for watering lawns, washing cars and for most
industrial purposes. The cost of compounds for fluoridating a
community's water supply is inexpensive on a per capita basis;
therefore, it is practical to fluoridate the entire water supply.
Fluoride is but one of more than 40 different chemicals that
may be used to treat water in the United States.27 The
American Water Works Association, an international nonprofit
scientific and educational society dedicated to the
imnrnVAmFmt nf rlrinkinn w~tAr n11~litv ~nrl ~llnnlv ~llnnnrt~ thA
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0I.'t"".............. I_I" _. -... ........~ ".-"""" .....-_.....1 -...... --,.......'} 1 .........,...t"'........- ....-
practice of fluoridation of public water supplies.~
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~ Public Policy
References: ...
1-99 ,.
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See Terms & Conditions of Use for further legal information.
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ACMDI&INI Search Contact Us About the ADA What's New
Fluoridation Facts
Cost Effectiveness
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
I
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I
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
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Consumers
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Dental Professionals
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41. Cost effective?
42. Practical?
Question 41
Is water fluoridation a cost-effective means of preventing
tooth decay?
Answer
Yes. Data from generally accepted scientific studies
continue to confirm that fluoridation has substantial
lifelong decay preventive effects and is a highly cost-
effective means of preventing tooth decay in the United
States, regardless of socioeconomic status.~ M.. ~ 230-232
Fact
It has been calculated that the annual cost of community water
fluoridation in the U.S. is approximately $0.50 per person.233
The annual cost ranges between $0.12 and $5.41 per person,
depending mostly on the size of a community, labor costs, and
type of fluoride compounds and equipment utilized.ll.. Qb. m..
~ 234 It can be calculated from these data that the lifetime
cost per person to fluoridate a water system is less than the
cost of one dental filling. With the escalating cost of health
care, fluoridation remains a preventive measure that benefits
members of the community at minimal cost.
Historically, the cost to purchase fluoride compounds has
remained fairly constant over the years in contrast to the
continued rising cost of dental care.2I School-based dental
disease prevention activities (such as fluoride mouthrinse or
tablet programs), professionally applied topical fluorides and
dental health education are beneficial but have not been found
to be as cost-effective in preventing tooth decay as community
water f1uoridation.230 Fluoridation remains the most cost-
effective and practical form of preventing decay in the United
States and other countries with established municipal water
systems.~ ~ Qb. ~ 234
Due to the decay-reducing effects of fluoride, the need for
restorative dental care is typically lower in fluoridated
communities. Therefore, an individual residing in a fluoridated
community will generally have fewer restorative dental
expenditures during a lifetime. Health economists at a 1989
wnrk~hnn ~nn~h IrlArl th::lt fh Inrirl::ltinn ~n~t~ ::Innrmdm::ltAlv
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Fluoridation Facts: Cost Effectiveness
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.. _, .,..... ._..... __I .......____ ... ._.. ............. .__.......... ___...... -,...,..... ............. '-"_OJ
$3.35 per tooth surface when decay is prevented, making
fluoridation "one of the very few public health procedures that
actually saves more money than it costS."234 Considering the
fact that the national average fee for a two surface amalgam
(silver) restoration in a permanent tooth placed by a general
dentist is $75.84*, fluoridation clearly demonstrates significant
cost savings.235
The economic importance of fluoridation is underscored by the
fact that frequently the cost of treating dental disease is paid
not only by the affected individual, but also by the general
public through services provided by health departments,
welfare clinics, health insurance premiums, the military and
other publicly supported medical programs.51
Indirect benefits from the prevention of dental decay may
include:
. freedom from dental pain
. a more positive self image
. fewer missing teeth
. fewer cases of malocclusion aggravated by tooth loss
. fewer teeth requiring root canal treatment
. reduced need for dentures and bridges
. less time lost from school or work due to dental pain or
visits to the dentist
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These intangible benefits are difficult to measure economically,
but are extremely important.~ 231
*The survey data should not be interpreted as constituting a
fee schedule in any way, and should not be used for that
purpose. Dentists must establish their own fees based on their
individual practice and market considerations.
Question 42
Is it practical to fluoridate an entire water system?
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Answer
It is more practical to fluoridate an entire water supply than to
attempt to treat individual water sources.
Fact
It is technically difficult, perhaps impossible, and certainly more
costly to fluoridate only the water used for drinking. Community
water that is chlorinated, softened, or in other ways treated is
also used for watering lawns, washing cars and for most
industrial purposes. The cost of compounds for fluoridating a
community's water supply is inexpensive on a per capita basis;
therefore, it is practical to fluoridate the entire water supply.
Fluoride is but one of more than 40 different chemicals that
may be used to treat water in the United States.27 The
American Water Works Association, an international nonprofit
scientific and educational society dedicated to the
imnrnVAml'mt nf nrinkinn w~tAr n11~litv ~nn ~Ilnnlv ~llnnnrt~ thA
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Fluoridation Facts: Cost Effectiveness
....,............................. _.....,...~ ..-....... ...,--.....1 -"- --....,.....1' ............................ ....-
practice of fluoridation of public water supplies.236
~ Public Policy
References: ..
1-99 r
Copyright (Q 1999 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
March 12, 1999
Document address: http://www .ada.org/ consumer/fluoride/facts/cost.html
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Fluoridation Facts: References: 1-99
C AClv1Dl..... Search Contact Us About the ADA Whatls New)
Fluoridation Facts
References: 1-99
Fluoridation Facts
Introduction
Benefits
Safety
Public Policy
Cost Effectiveness
References
Compendium
Disclaimer
See also:
American Dental
Association Statement on
Water Fluoridation
Efficacy and Safety
Topical Index:
Fluorides & Fluoridation
For information on
ordering a print copy of
Fluoridation Facts, see
the ADA Best Sellers
Catalog.
For more information:
Consumers
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Dental Professionals
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1. British Fluoridation Society. Optimal water fluoridation:
status worldwide. Liverpool; May 1998.
2. American Dental Association, Survey Center. 1998
Consumers' opinions regarding community water fluoridation.
Chicago; June 1998.
3. American Dental Association. Resolution 5H-1997. In: ADA
Transactions 1997. Chicago: American Dental
Association; 1998:673.
4. Dean HT. Endemic fluorosis and its relation to dental caries.
Public Health Reports 1938;53(33):1443-52.
5. Dean HT, Arnold FA, Elvove E. Domestic water and dental
caries. Public Health Reports 1942;57(32):1155-79.
6. American Dental Association. Fluoride and oral health: a
story of achievements and challenges. J Am Dent Assoc
1989;118:529-40.
7. Scott DB. The dawn of a new era. J Public Health Dent
1996;56(5 Spec No):235-8.
8. US Department of Health and Human Services. Healthy
People 2010 Objectives: Draft for public comment. (Oral
Health Section) Washington, DC: US Government Printing
Office; September 15, 1998.
9. US Department of Health and Human Services. For a
healthy nation: returns on investment in public health.
Washington, DC: US Government Printing Office; August
1994.
10. US Department of Health and Human Services, Public
Health Service. Surgeon General statement on community
water fluoridation. Washington, DC; December 14,1995.
11. Horowitz HS. The effectiveness of community water
fluoridation in the United States. J Public Health Dent 1996;56
(5 Spec No):253-8.
12. American Dental Association, Council on Access
Prevention and Interprofessional Relations. Caries diagnosis
and risk assessment: a review of preventive strategies and
management. J Am Dent Assoc 1995;126(Suppl).
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Fluoridation Facts: References: 1-99
13. US Department of Health and Human Services, Centers
for Disease Control and Prevention, Division of Oral Health.
Fluoridation fact sheet. No. FL-141. Atlanta; December 1993.
14. Safe Drinking Water Committee, National Research
Council. Drinking water and health. National Academy of
Sciences. Washington, DC; 1977.
15. Largent E. The supply of fluorine to man: 1. Introduction.
In: Fluorides and human health. World Health Organization
Monograph Series No. 59. Geneva;1970:17-8.
16. Levy SM, Kiritsy MC, Warren JJ. Sources of fluoride intake
in children. J Public Health Dent 1995;55(1 ):39-52.
17. Newbrun E. Fluorides and dental caries, 3rd ed.
Springfield, Illinois: Charles C. Thomas, publisher; 1986.
18. Lambrou D, Larsen MJ, Fejerskov 0, Tachos B. The effect
of fluoride in saliva on remineralization of dental enamel in
humans. Caries Res 1981;15:341-5.
19. Mellberg JR, Ripa LW. Fluoride in preventive dentistry:
theory and clinical applications. Chicago:
Quintessence; 1983:41-80.
20. DePaola PF, Kashket S. Prevention of dental caries. In:
Fluorides, effects on vegetation, animals and humans. Schupe
JL, Peterson HB, Leone NC, eds. Salt Lake City: Paragon
Press;1983:199-211.
21. Backer-Dirks 0, Kunzel W, Carlos JP. Caries-preventive
water fluoridation. In: Progress in caries prevention. Ericsson
Y, ed. Caries Res 1978;12(SuppI1):7-14.
22. Silverstone LM. Remineralization and enamel caries: new
concepts. Dental Update 1993; May:261-73.
23. Featherstone JD. The mechanism of dental decay.
Nutrition Today 1987;May-Jun:10-6.
24. Fejerskov 0, Thylstrup A, Larsen MJ. Rational use of
fluorides in caries prevention. Acta Odontol Scan 1981 ;39:241-
9.
25. Silverstone LM, Wefel JS, Zimmerman BF, Clarkson BH,
Featherstone MJ. Remineralization of natural and artificial
lesions in human dental enamel in vitro. Caries Res
1981 ;15:138-57.
!I
26. Hargreaves JA. The level and timing of systemic exposure
to fluoride with respect to caries resistance. J Dent Res
1992;71 (5):1244-8.
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27. US Department of Health and Human Services, Centers
fnr ni"'O<ll"'O ("'nntrnl nont<lll ni"'O<ll"'O Pro_\Iontinn 6"ti\lit\l
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Fluoridation Facts: References: 1-99
IVI ""'''''''U",",'''' '"'VI 11.. V" ""''''''10.'''''1 ....,."'''"'''"'''"''' I IV ",",II"'VI, ~v"'Y'Ll'
Water fluoridation: a manual for engineers and technicians.
Atlanta; September 1986.
28. Horowitz HS. American Journal of Public Health 1997;87
(7):1235-6. Letter to the editor.
29. Brown HK, Poplove M. The Brantford-Samia-Stratford
fluoridation caries study: final survey, 1963. Med Serv J Can
1965;21 (7):450-6.
30. Murray JJ. Efficacy of preventive agents for dental caries.
Caries Res 1993;27(SuppI1 ):2-8.
31. Newbrun E. Effectiveness of water fluoridation. J Public
Health Dent 1989;49(5):279-89.
32. Ripa LW. A half-century of community water fluoridation in
the United States: review and commentary. J Public Health
Dent 1993;53(1):17-44.
33. Evans OJ, Rugg-Gunn AJ, Tabari ED, Butler T. The effect
of fluoridation and social class on caries experience in 5-year-
old Newcastle children in 1994 compared with results over the
previous 18 years. Comm Dent Health 1996;13:5-10.
34. Spencer AJ, Slade GO, Davies M. Water fluoridation in
Australia. Comm Dent Health 1996;13(SuppI2):27-37.
35. Pollick H, Kipnis P. The effect of fluoride con-centration of
water supplies on caries experience in California children
attending preschools and grades K-3 (Abstract no. 2197).
Abstract presented at the 1997 Annual Meeting of the
American Public Health Association.
36. Selwitz RH, Nowjack-Raymer RE, Kingman A, Driscoll WS.
Dental caries and dental fluorosis among schoolchildren who
were lifelong residents of communities having either low or
optimal levels of fluoride in drinking water. .,J Public Health Dent
1998;58(1 ):28-35.
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37. Arnold FA Jr., Likins RC, Russell AL, Scott DB. Fifteenth
year of the Grand Rapids fluoridation study. J Am Dent Assoc
1962;65:780-5.
38. Ast DB, Fitzgerald B. Effectiveness of water fluoridation. J
Am Dent Assoc 1962;65:581-7.
39. Blayney JR, HilliN. Fluorine and dental caries: findings by
age group. J Am Dent Assoc 1967 (Spec 155);74(2):246-52.
40. Jackson 0, James PM, Thomas FD. Fluoridation in
Anglesey 1983: a clinical study of dental caries. Br Dent J
1985;158(2):45-9.
41. Jackson D. Has the decline of dental caries in English
children made water fluoridation both unnecessary and
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Fluoridation Facts: References: 1-99
uneconomic? Br Dent J 1987;162(5):170-3.
42. Jones CM, Taylor GO, Whittle JG, Evans D, Trotter DP.
Water fluoridation, tooth decay in 5 year olds, and social
deprivation measured by the Jarman score: analysis of data
from British dental surveys. BMJ 1997;315:514-7.
43. Selected findings and recommendations from the California
oral health needs assessment of children, 1993-94. The oral
health of California's children: a neglected epidemic. San
Rafael, CA: The Dental Health Foundation 1997.
44. Lemke CW, Doherty JM, Arra MC. Controlled fluoridation:
the dental effects of discontinuation in Antigo, Wisconsin. J Am
Dent Assoc 1970;80:782-6.
45. Stephen KW, McCall DR, Tullis JI. Caries prevalence in
northern Scotland before, and 5 years after, water
defluoridation. Br Dent J 1987;163:324-6.
46. Attwood 0, Blinkhorn AS. Dental health in schoolchildren 5
years after water fluoridation ceased in south-west Scotland.
Int Dent J 1991;41 (1 ):43-8.
47. Burt BA, Eklund SA, Loesche WJ. Dental benefits of limited
exposure to fluoridated water in childhood. J Dent Res 1986;61
(11):1322-5.
48. Way RM.The effect on dental caries of a change from a
naturally fluoridated to a fluoride-free communal water. J Dent
Child 1964;31 :151-7.
49. Driscoll WS, Horowitz HS, Meyers RJ, Heifetz SB,
Kingman A, Zimmerman ER. Prevalence of dental caries and
dental fluorosis in areas with negligible, optimal and above.
optimal fluoride concentrations in drinking water. J Am Dent
Assoc 1986; 113:29-33.
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50. Brunelle JA, Carlos JP. Recent trends in dental caries in
U.S. children and the effect of water fluoridation. J Dent Res
1990;69(Spec Iss):723-7.
51. Horowitz HS. The future of water fluoridation and other
systemic fluorides. J Dent Res 1990;69(Spec Iss):760-4.
52. Lewis OW, Banting OW. Water fluoridation: current
effectiveness and dental fluorosis. Community Dent Oral
EpidemioI1994;22:153-8.
53. Ismail AI. Prevention of early childhood caries. Community
Dent Oral Epidemiol 1998;26 (Suppl 1 ):49-61 .
54. US Department of Health and Human Services, Public
Health Service. Review of fluoride: benefits and risks. Report
of the Ad Hoc Subcommittee on Fluoride. Washington, DC;
February 1991.
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Fluoridation Facts: References: 1-99
55. National Institute of Dental Research. Statement on
effectiveness of water fluoridation. Bethesda; December 1989.
56. Mitropoulos CM, Langford JW, Robinson DJ. Differences in
dental caries experience in 14-year-old children in fluoridated
South Birmingham and in Bolton in 1987. Br Dent J
1988;164:349-50.
57. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn
DM, Brown LJ. Coronal caries in the primary and permanent
dentition of children and adoles-cents 1-17 years of age:
United States, 1988-1991. J Dent Res 1996;75(Spec 155):631-
41.
58. US Department of Health and Human Services, Public
Health Service. Toward improving the oral health of
Americans: an overview of oral status, resources on health
care delivery. Report of the United States Public Health
Service Oral Health Coordinating Committee. Washington, DC;
March 1993.
59. Brown LJ, Winn DM, White BA. Dental caries, restoration
and tooth conditions in U.S. adults, 1988-1991. J Am Dent
Assoc 1996;127:1315-25.
60. Palmer C. Dental spending exceeds $50 billion. ADA News
1998;29(22): 1,30.
61. White BA, Antczak-Bouckoms AA, Weinstein MC. Issues in
the economic evaluation of community water fluoridation. J
Dent Educ 1989;53(11):1989.
62. Garcia AI. Caries incidence and costs of prevention
programs. J Public Health Dent 1989;49(5):259-71.
63. McGuire S. A review of the impact of fluoride on adult
caries. J Clin Dent 1993;4(1 ):11-13.
64. Grembowski D, Fiset L, Spadafora A. How fluoridation
affects adult dental caries: systemic and topical effects are
explored. J Am Dent Assoc 1992;123:49-54.
65. Stamm JW, Banting DW, Imrey PB. Adult root caries
survey of two similar communities with contrasting natural
water fluoride levels. J Am Dent Assoc 1990;120:143-9.
66. Newbrun E. Prevention of root caries. Gerodont 1986;5
(1 ):33-41.
67. Papas AS, Joshi A, MacDonald SL, Maravelis-Splagounias
L, Pretara-Spanedda P, Curro FA. Caries prevalence in
xerostomic individuals. J Can Dent Assoc 1993;59(2):171-9.
68. Jones JA. Root caries: prevention and chemotherapy. Am
J Dent 1995;8(6):352-7.
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Fluoridation Facts: References: 1-99
69. Wiktorsson A, Martinsson T, Zimmerman M. Salivary levels
of lactobacilli, buffer capacity and salivary flow rate related to
caries activity among adults in communities with optimal and
low water fluoride concentrations. Swed Dent J 1992; 16:231-7.
70. Anusavice KJ. Treatment regimens in preventive and
restorative dentistry. J Am Dent Assoc 1995;126:727-43.
71. Driscoll WS. The use of fluoride tablets for the prevention
of dental caries. In: International workshop on fluorides and
dental caries prevention. Baltimore, University of
Maryland;1974:25-111.
72. Aasenden R, Peebles TC. Effects of fluoride supple-
mentation from birth on human deciduous and permanent
teeth. Arch Oral Bioi 1974;19:321-6.
73. Margolis FJ, Reames HR, Freshman E, Macauley CD,
Mehaffey H. Fluoride: ten year prospective study of deciduous
and permanent dentition. Am J Dis Child 1975;129:794-800.
74. Institute of Medicine, Food and Nutrition Board. Dietary
reference intakes for calcium, phosphorus, magnesium,
vitamin D and fluoride. Report of the Standing Committee on
the Scientific Evaluation of Dietary Reference Intakes.
Washington, DC: National Academy Press;{ln press).
75. Levy SM. Review of fluoride exposures and ingestion.
Community Dent Oral EpidemioI1994;22:173-80.
76. Arnold FA, McClure FJ, White CL. Sodium fluoride tablets
for children. Dental Progress 1960;1 {1 ):8-12.
77. Newbrun E. Systemic fluorides: an overview. J Can Dent
Assoc 1980;1 :31-7.
78. Marthaler TM, Mejia R, Vines JJ. Caries-preventive salt
fluoridation. Caries Res 1978;12{SuppI1):15-21.
79. Federation Dentaire Internationale. World fluoridation
status. Basic Facts 1990.
80. Thomas Reeves, personal communication, July 25,1997.
81. Kunzel W. Systemic use of fluoride-other methods: salt,
sugar, milk, etc. Caries Res 1993;27{SuppI1):16-22.
82. World Health Organization. Fluorides and oral health.
Report of a WHO Expert Committee on Oral Health Status and
Fluoride Use. WHO Technical Report Series 846.
Geneva;1994.
83. Bergmann KE, Bergmann RL. Salt fluoridation and general
health. Adv Dent Res 1995;9(2):138-43.
84. The sixth report of the joint national committee on
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prevention, detection, evaluation and treatment of high blood
pressure. Arch Intern Med 1997; 157:2422.
85. Pakhomov GN. Objectives and review of the international
milk fluoridation program. Adv Dent Res 1995;9(2):110-1.
86. Burt BA, Marthaler TM. Fluoride tablets, salt fluoridation
and milk fluoridation. In: Fluoride in Dentistry, 2nd ed.
Fejerskov 0, Ekstand J and Burt B, eds. Munksgaard,
Copenhagen; 1996:291-310.
87. Flaitz CM, Hill EM, Hicks MJ. A survey of bottled water
usage by pediatric dental patients: implicaions for dental
health. Quintessence Int1989;20(11 ):847-52.
88. Tate WH, Chan JT. Fluoride concentrations in bottled and
filtered waters. Gen Dent 1994;42(4):362-6.
89. Brown MD, Aaron G. The effect of point-of-use conditioning
systems on community fluoridated water. Pediatr Dent 1991; 13
(1 ):35-8.
90. Full CA, Wefel JS. Water softener influence on anions and
cations. Iowa Dent J 1983;69:37-9.
91. Robinson SN, Davies EH, Williams B. Domestic water
treatment appliances and the fluoride ion. Br Dent J
1991 ;171 :91-3.
92. Fluoride, teeth and health. Royal College of Physicians.
Pitman Medical, London;1976.
93. Johansen E, Taves D, Olsen T, eds. Continuing evaluation
of the use of fluorides. MAS Selected Symposium 11 .
Boulder, Colorado:Westview Press;1979.
94. Knox EG. Fluoridation of water and cancer: a review of the
epidemiological evidence. Report of the Working Party.
London: Her Majesty's Stationary Office;1985.
95. Leone NC, Shimkin MB, Arnold FA, et al. Medical aspects
of excessive fluoride in a water supply. Public Health Rep
1954;69(10):925-36.
96. National Research Council. Health effects of ingested
fluoride. Report of the Subcommittee on Health Effects of
Ingested Fluoride. Washington, DC: National Academy
Press;1993.
97.58 Fed. Reg. 68826,68827 (Dec. 29, 1993).
98. US Department of Health and Human Services, Public
Health Service. Facts on the ATSDR toxicological profile for
fluorides, hydrogen fluoride, and fluorine. CDC Atlanta, GA;
May 15, 1998.
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~~. Amencan Mealcal ASSOCiatiOn. M-44U.~40 ana M-44U.~( L.
In: American Medical Association Policy Compendium.
Chicago: American Medical Association;1998:633,637.
~ Cost Effectiveness
References: ....
100-199 "
Copyright ~ 1999 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Terms & Conditions of Use for further legal information.
March 12, 1999
Document address: http://www .ada.org/ consumer/fluoride/facts/refl-99 .html
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Fluoride: risks and benefits?
Page 1 of 25
Please contact the author directly for reprint permission. The draft version was
presented to Calgary's Operation and Environment Committee meeting on
September the 10th, along with my own submission: calgaryb.htm
This paper was updated in August 1997 from an earlier version presented by invitation at the public
forum on fluoride and fluoridation, sponsored by the Chemical Institute of Canada, and CADACT,
held at the Petroleum Recovery Institute, 3512-33rd. Street NW, CALGARY, Tuesday September
29th 1992. Note that footnotes and first references provide hypertext links to the relevant material,
with provision for returning to the current point ("return to main text").
Fluoride: risks and benefits?@
Disinformation in the service of big industry.
by David R. Hill, P.Eng. hill@cpsc.ucalgary.ca
Professor Emeritus, The University of Calgary, CALGARY, Alberta, Canada T2N IN4
A majority vote which violates ethical or moral principles, or deprives individuals of rights they
should be free to enjoy, is not democracy but tyrrany. It is a subversion of democracy that will bring
democracy to an end in the degree that it is allowed to operate. (the late F.B. Exner, MD FACR,
Seattle)
SUMMARY
Promoters of water fluoridation offer the lure of strong, healthy teeth and reduced dental bills as
inducements for communities to fluoridate their water. Fluoride is also promoted for other tooth-
related uses. However, even the promoters have scaled down the benefits claimed for water
fluoridation and admitted the danger of fluorosis from toothpaste. For every study by promoters over
recent years repeating old messages that claim undisputed water fluoridation benefits-particularly
reduction of cavities, there are equally reputable studies showing little or no effect on cavity rates.
Studies in mainstream peer-reviewed medical journals and government reports now document the
fact that serious harms are associated with exposure to small amounts of fluoride-including hip
fracture, cancer, and intellectual impairment. There is evidence that both individual and institutional
fluoride promoters have stacked the deck, manipulated experimental results, suppressed evidence that
spoke against their view, and victimised or smeared those who spoke out against them.
When old ways and knowledge are increasingly found to be based on false premises, incompetence,
bias and worse, it is important to re-examine the old claims , and to take account of the growing body
of research that show they are at best equivocal and at worst completely opposite to the truth, and
based on vested interest.
Fluoride promotion often proceeds with no understanding of the scientific method and sometimes
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without even the ability to perform simple arithmetic. The most important US Congress-mandated
study in recent times on the suspected connection between fluoride and cancer was subjected to a
series of Public Health Service review stages that successively downgraded the results from the
original independent laboratory study to the point where they were declared "equivocal" and largely
ignored. The proven association of fluoride and water fluoridation with increased hip fractures and
reduced bone quality has been denied or downplayed. Many other lines of investigation have been
ignored or not followed up in an open-minded manner.
Medical ethics, morality, economics, legal and political issues have not deterred fluoride promoters in
their efforts. Indeed, the problem has been declared a legislative matter, rather than under the
jurisdiction of courts oflaw which might introduce such notions as ethics and reasonableness. The
main beneficiaries from fluoride use are the big industries that find a profitable outlet for their
otherwise embarrassing toxic byproducts. It is time for change.
1. Introduction
We should all like to have strong, healthy teeth, the "benefit" promoters of water fluoridation offer.
Water fluoridation, they say, has been proven in literally tens of thousands of studies to be
completely safe, to provide a reduction in tooth decay of anything up to 70%, and has never caused
an adverse reaction at the "optimal concentration" of one part per million (1 ppm)- no allergies, no
cancer risks, nothing. It is not just good for children's teeth, but for everyone's teeth-especially old
people's, and it may even strengthen bones. Why would any sane person oppose water fluoridation?
The answer is complex, but can be characterised by five statements of fact documented, where
appropriate, in the peer reviewed medical literature:
. If it works at all, the benefits are very much less than claimed
. It is strongly linked to three-fold increases in hip and other non-vertebral fracture rates; there is
growing evidence of other even more serious medical consequences
. A recent study showed evidence of intellectual impairment caused by fluoride
. There is clear evidence that promoters have stacked the deck, suppressed evidence, and
victimised or smeared those who speak out against the practice
. Given a recommendation for medication, individuals in a free society have a right to choose
whether or not to accept treatment, a right to expect properly controlled dosage and medical
supervision, and a right to be told the truth. Water fluoridation abrogates these rights
Much more information is available than is reasonable to present in this paper. However, the reader
should gain some insight into the problems occurring in the debate on water fluoridation, and be able
to decide for themselves whether the controversy is false or not. My own conclusion is that there are,
at best, real unresolved and serious questions about the safety and benefit of water fluoridation and
related uses of fluoride. The most recent evidence suggests it is not particularly beneficial, and
certainly not safe. The most charitable interpretation that one can put on the situation is that old
habits die hard, and the medicaVdental establishment is slow to adapt to the realities of modem
research, and fearful of losing both face and law suits if they admit they made a mistake.
2. The scientific method
The controversy surrounding the risks and benefits of water fluoridation switched from science to
politics almost as soon as it started in the 40s and 50s, though the story goes back further than that. In
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order to bring a little science back into the debate, a quick review of the scientific method is in order.
Very few things in this life are certain, except for death and taxes. Scientific theories are no
exception-they stand, and become accepted as laws only as long as no-one manages to refute
them.You do not prove a theory is correct; but if you try very hard and ingeniously to prove it wrong,
without success, then the theory may be generally accepted for the time being ~opper 1972).
Ptolemy's epicyclic theory of heavenly body motions gave quite accurate predictions of the state of
the sky seen at night, but the theory was wrong and eventually was replaced by a better theory. The
theory has been updated more than once since.
Statistical methods play an important part in testing scientific theories, especially theories that
suggest one way of doing things is better than another, or that some treatment is effective or
dangerous-experiments that involve physical measurements of differences in some way. Statistics
provide a way of distinguishing between differences due to chance factors (measurement error,
uncontrolled factors, ...) and differences that cannot be due to chance. Science is ultimately based on
probability, but with suitably large sets of data samples, the probability of being wrong can be made
very small.
Suppose, for example, it was suggested that ingesting fluorides (Note 1) causes or facilitates cancer
growths. One might set up an experiment in which groups of animals in identical situations (genetic
heritage, environment, diet, etc) were given differing amounts of fluoride in their food and water in
such a way that the amounts ingested could be accurately controlled. The group receiving no fluoride
would be known as the control group and the other groups-experimental groups-would receive
varying amounts of the suspected substance-the controlled variable. A null hypothesis would be set
up stating that the number of cancers occurring in the various groups did not depend on the amount of
fluoride ingested.
The experiment would then run its allotted course, and eventually there would be information about
the numbers and types of cancers occurring for the various groups. The numbers would vary from
group to group, perhaps due to chance factors, perhaps due to the different conditions (treatments),
and perhaps due to lack of control of the conditions. However, statistics would allow you to compare
the numbers for the different groups and decide whether the variation was simply due to chance, or
was too great and systematic to be due to chance and must therefore be due to the treatment.
This is what statistical significance is all about, and is how it is applied in scientific experiments. A
difference may be observed, but it is only considered statistically significant if it is so large and
systematic in relation to the treatment that the possibility of it being due to chance is very small-how
small depends on the cost of being wrong, and is decided by the experimenter, using accepted norms,
before the experiment is run. Statistical judgements are thus bets in a very real sense.
It is important 0 note that, in experiments like this, lack of statistical significance does not prove the
treatment has no effect; it merely fails to show that it does have an effect with a small enough chance
of being wrong. This can occur for all kinds of reasons including bad experimental design, excess
natural variability for the sample sizes used, failure to control the conditions of the experiment
properly, and so on. Moreover, a result may not reach the rigorous standard set for statistical
significance, but still be highly suggestive of a trend that merits further investigation. A series of
experiments that all showed the same trend could be very convincing, even if no given experiment
achieved the standard of significance set by the experimenter (generally a very high standard). It
should also be noted that an effect can be found statistically significant, but may not be of practical
significance because the magnitude ofthe effect is small. It depends what situation you are dealing
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with. However, when small effects are applied to large populations, even very small effects can be
important because a large number of individuals will still be involved-O.l % of twenty million is
20,000.
One important reason for failing to achieve statistical significance is lumping things together that
should be separate. Thus treating all cancers as the same in a population of animals prone to cancer
might hide an effect of the treatment that would be obvious if common cancers were separated from
ones that normally did not occur, and were therefore much more likely to show a pattern with the
treatment if they occurred. Lumping things together can hide differences.
If fluoride merely fails to reach statistical significance as a carcinogen in a controlled, well-designed
and run experiment, you may not be scientifically convinced that it is a carcinogen, but you certainly
have not proved that it isn't. You might, in fact, still have good reason to believe that it is. If you have
been careless in interpreting your data (e.g. classifying cancers of various types), you may even have
hidden a statistically significant effect.
3. The US NTP study of sodium fluoride & cancer
The situation just described characterises the essence ofthe National Toxicology Program study of
the effect of sodium fluoride on rats and mice (NTP Technical Report 1990), except that one set of
cancer data showed a statistically significant effect of sodium fluoride in causing cancer-that is, the
null hypothesis that fluoride does not cause cancer was rejected. With a very small chance of being
wrong, the study showed that sodium fluoride does cause cancer at cumulative doses comparable to
those ingested by humans over a number of years. The NTP study was contracted out to the Battelle
Institute, of Columbus, Ohio, but was subsequently subjected to several levels of review and
adjustment in which, against the advice of qualified experts, some rare cancer types were lumped
with common cancers. Other problems such as fluorosed bones were found.
In the light of this finding of a statistically significant link between fluoride consumption and cancer,
it is especially interesting that the concurrent control group animals in the study actually received
non-zero amounts of fluoride in their food (8 ppm) (US DHHS Subcommittee Review 1991. p73).
Historical controls (animals used in tests on other suspected carcinogens, and much quoted to argue
that the animals were inherently cancer prone thereby effectively hiding statistical significance)
received even more fluoride in their food (28-47 ppm) (US Dept of Health & Human Services
Subcommittee 1991 pp 89-90). The control animals were not controls at all, but low-dose
experimental animals-at least some of their cancers quite possibly due to the fluoride they ingested.
This would raise the level of cancers observed in all animals and hide the effect supposedly being
studied.
Drs. Carton and Marcus (Note 2) noted this and a number of other problems, including the fact that
many ofthe cancers found by Battelle's histopathologists were downgraded to commoner types, or
eliminated altogether, over the objections of outside experts (Carton & Marcus 1990). Despite the
manipulations, the occurrence of osteosarcomas (unusual for rodents (Note 3]) in male rats showed a
statistically significant positive relationship to fluoride dose (more fluoride, more cancers). The
original unexpurgated Battelle results showed statistically significant dose-related occurrence of
cancers of various sorts, including an extremely rare form of mixed bile-duct/liver cancer-
hepatocholangiocarcinoma (Carton & Marcus 1990).
The osteosarcomas in male rats become even more significant in the light of an epidemiological
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study of a large human population by the State Board of Health in New Jersey (Cohn 1992). That
well conducted and thoroughly peer-reviewed study found that males aged 10-19 were nearly 7 times
more likely to get bone cancer if they lived in a fluoridated municipality than if they lived in a non-
fluoridated municipality (a statistically significant rate ratio of6.9). The general population in those
areas was 5 times as likely to get it (also statistically significant). Given the large number of people in
the study, and the results ofthe NTP study, alarm bells should have rung loudly for the US Public
Health System, especially given they had previously noted a rise in such cancers for young males in
fluoridated areas during the first five years of fluoridation (US Dept of Health & Human Services
Subcommittee 1991 p 82). Instead, the executive summary (the only part likely to be read by
important people) starts by praising the dental benefits of fluoridation, and then fails to present the
results clearly.
It has been suggested that the experimental animals received abnormally high doses-so high that
many common substances like sodium chloride (common salt) would show ill effects at the same
dose and that in any case a person would have to drink 79litres of water a day for life to equal the
fluoride dose. Actually, as Table 1 shows, the fluoride doses were low compared to many other
substances tested for carcinogenicity, where doses ranged from 6 to 500 times the fluoride dose. Only
vinyl chloride was tested at a lower dose. People regularly ingest over 100 times the amounts of
common salt without ill effects. The cumulative dose of fluoride ingested by average people in
fluoridated communities reaches the low dose rats after only 38 years; many people will equal the
mid-dose rats in a lifetime, and some even approach the high dose rats (see below, pp 9-10). Citing a
Scandinavian study, Danielson et al. (1992) say:
· "Fluoridation of water supplies was initiated prior to long-term studies of its effects on bone
density. Recent studies suggest that fluoride accumulates with age and may reach toxic bone
levels in a person's lifetime (at a water content of 0.97 ppm)."
Many people exceed the average, some by 6 times or more. With increasingly widespread fluoride
contamination these amounts will rise, and the time to accumulate similar doses to the rats will thus
fall. Marcus (Carton & Marcus 1990) quoting an earlier study notes that people accumulate up to
7 ,000 ppm of fluoride in their bones, when ingesting water containing 4 ppm (the EP As Maximum
Contaminant Level or MCL), while the high dose rats had only 5,470 ppm. He comments that it is the
first time he can remember test animals having lower concentrations of a suspected substance than
humans at the site of adverse effect.
The NTP study did not give fluoride a clean bill of health, despite all the reviews and corrections that
acted to hide statistical significance. Fluoride's particular affinity for bone adds to the significance of
the link with bone cancers. Females were more susceptible to soft tissue cancers. The New Jersey
study (Cohn 1992) also showed that fluoride affects males differently from females (which means it
is important to consider them separately in trials to avoid hiding significant effects-see Section 2). It
is interesting to plot the dose-related composite incidence of neoplasms (Note 4), including those that
were rejected or downgraded by the public review committee, despite the contrary evidence of
appropriately qualified experts (including, for the hepatocholangiocarcinomas, the person who
discovered them -- Dr. Mel Reuber). Figures 1 (a) & 1(b) show the plots. The trend is suggestive.
4. Ethics and practical significance
There is also the question of ethics and practical significance. If you are adding something to the
public water supply that everybody will have to consume (Note 5), it is not enough that you were
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unable to show it did cause cancer. The onus would be on you to show that it does not cause cancer.
Proving a negative scientifically is quite difficult, because ofthe demands of the scientific method.
However, it is not ethical to leave the impression you have proved fluoride doesn't cause cancer when
the trend is highly suggestive that it does cause cancer and at least one statistically significant result
from your experiment provides scientifically compelling odds that fluoride does cause cancer. It is
even more reprehensible to continue asserting that there is no evidence fluoride causes cancer when a
reputable epidemiological study on humans (Cohn 1992) finds exactly the same sex-related cause-
effect relationship for humans that appeared in the experiment on rats.
If you are adding something to the public water supply that will affect the entire population, even a
very small risk can affect a large number of people. With high rates of water fluoridation (60% of
North America is fluoridated), the argument that the risk may be statistically significant, but is too
small to be of practical clinical significance, becomes completely unethical. And that is ignoring the
amount of fluoride taken into the body through dental treatments-including fluoridated toothpaste
(Minister of Supply & Services Canada 1993. p27). This is a particular concern for children under six
who swallow up to 50% or more of the toothpaste they use, which contains 1000 to 2000 times the
concentration of fluoride found in fluoridated water.
5. Hip Fractures
The scientific case for saying the administration of fluoride is positively correlated with excess hip
fractures is very solid. Ironically, "fluoride therapy" has been used experimentally as a possible cure
for osteoporosis(Note 6) for about 25 years, though it is not yet approved for general use. It turns out
that not only does fluoride therapy have serious side effects, but it actually causes a three-fold
increase in non-vertebral fractures (Riggs et al. 1991). This is because, although the therapy increases
bone density, the bone structure is seriously compromised, forming a coarse crystalline matrix with
reduced tensile strength; but tensile strength is necessary resist to bending fractures, including those
affecting the hip joint. Sogaard et al. (Sogaard et al. 1994) also found fluoride compromised bone
quality specifically related to the hip.
Three other papers, all published in the Journal ofthe American Medical Association, showed
statistically significant relationships between water fluoridation and increased hip fractures (Jacobsen
et al. 1990; Cooper et al. 1991; and Danielson et al. 1992). These were major studies on large
populations. The first two covered all counties in the US and a large area of Britain. The third, which
was carried out in Utah, is of particular interest because the effect of confounding factors(Note 7)
such as smoking and coffee drinking were likely very much reduced due to the Mormon culture of
the communities studied. The unanimous conclusion from the studies was that there is a significant
increase in the occurrence of hip fractures amongst elderly people who have lived in regions with
fluoridated water.
More recently a French study found an 86% increase in hip fracture rates amongst elderly French
people living in regions with fluoride in the water (i.e. nearly double the normal rate) (Jacqumin-
Gadda 1995). The above studies are in stark contrast to a US study ~ak 1994) which found fluoride
therapy "inhibits new vertebral fractures, increases the mean spinal bone mass without decreasing the
radial shaft bone density (Note 8), and is safe to use." I would describe this conclusion as "weasel
worded" since it avoids most of the contentious issues whilst saying that fluoride therapy is "safe".
Given the well-documented increase in hip fractures, the conclusion lends a whole new meaning to
the word "safe". The medical/dental establishment is heavily into denial, and I have heard much
nonsense of the same kind, first hand, from medically qualified people who should have known
better. The Pak et al. (1994) study has been criticised for avoiding the issue of bone quality, and for
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being too short for proper evaluation of the therapy due to the slow turnover of bone in post-
menopausal women. What the experiment really documents is the induction of osteofluorosis as an
iatrogenic (Note 9) pathological condition!
It might be suggested that other factors such as variation in calcium intake were at work in these
studies (confounding factors again). The French study (Jacqumin-Gadda 1995) specifically
considered calcium, as well as fractures at sites other than the hip. The effect they found related to
fluoride in the water causing hip fractures, with no effect either way by calcium. Sowers et al.
(Sowers et al. 1991) also found increased hip fractures to be significantly associated with higher
fluoride content ofthe water, and unrelated to varying calcium content. Although the fluoride content
of the water in the last named study was equal to or greater than normal water fluoridation levels, the
findings are significant in the light of increasing total fluoride intakes, and the elimination of low
calcium as a factor causing fragility. Interestingly, Teotia and Teotia (1994) found that tooth decay
was also associated with high fluoride and low calcium interactions in the diet.
Taken altogether, these studies show that fluoride causes bone damage whether at therapeutic or
water fluoridation levels.
6. Incomplete disclosure of evidence, suppression and other dirty tricks
Fluoride promoters usually accuse people who oppose them of quoting material out of context, or
incorrectly, or without understanding, when embarrassing facts are lined up against them. No doubt
this happens sometimes. However, promoters invariably fail to acknowledge the evidence against
them and there is excellent evidence that they ignore and suppress reputable studies and expert
opinions that are unfavourable to their case, and discredit or dismiss the reputations of experts they
cannot bring into line (e.g. Hileman 1988). The most blatant recent example of this occurred when
Dr. William Marcus, then a Senior Science Advisor and toxicologist in the Office of Drinking Water
(ODW) of the US Environmental Protection Agency, who had strongly criticised the emasculation of
the NTP study results, was fired for alleged misconduct unrelated to fluoride. In the subsequent court
case against the EP A by Dr. Marcus it was proven that the EP A had used false evidence in order to
try to incriminate Dr. Marcus. Judge David A. Clarke Jr. declared in his decision on this case on
December 3rd 1992 that "the reasons given for Dr. Marcus' firing were a pretext ... his employment
was terminated because he publicly questioned and opposed EP A's fluoride policy." Marcus was
ordered to be reinstated, with back pay, fringe benefits and interest, attorney's fees and was awarded
$50,000 US in compensatory damages (Carton 1993). Robert Reich, the Secretary of Labour,
criticised a number ofEPA managers, including the Director of the ODW which regulates fluoride
levels, for acting improperly in discharging Marcus (Lowey 1994). Most people who speak out
against fluoride--especially if they are experts--are trashed by promoters, in one way or another (Note
10).
Documentary evidence that promoters were "economical with the truth" and used dirty tricks from
the beginning is available. One of the best known amongst those who have studied the topic dates
from as long ago as 1951, just as the big push for universal water fluoridation really got going. It is a
transcript of a meeting of State Dental Directors in the US at which Dr. Frank Bull, Director of
Dental Education for the State Board of Health in Madison, Wisconsin, provided insights from his
experience on how to get fluoridation accepted, or at least approved (Eederal Security Administration
1951)). Here are some quotes from Dr. Bull's presentation:
· "Now we tell them this, that at one part per million dental fluorosis brings about the most
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beautiful looking teeth that anyone ever had" [p 11]
· "... Dr. Bain used the term 'adding sodium fluoride'. We never do that. That is rat poison. You
add fluorides. ... But this toxicity question is a difficult one." p 12]
· "One thing that is hard to handle is the charge that fluoridation is not needed. They talk of other
methods, and when they get through adding up all the percentages of decay that we can reduce
by such methods, we end up with a minus. When they take us at our own word they make
awful liars out of us. And that will be brought up." [p 15]
· "Now, why should we do a pre-fluoridation survey? Is it to find out if fluoridation works? No.
We have told the public it works, so we can't go back on that. Then why do we want a pre-
fluoridation survey?" [p 17]
· "The question of toxicity is on the same order. Lay off it altogether. Just pass over, 'We know
there is absolutely no effect other than reducing tooth decay,' you say" ...[p 20]
. "And certainly don't stress the cost." [p 20]
· "Let me tell you, the PTA is a honey when it comes to fluoridation. ... They said 'What can we
do?' We said, 'How many of these PTA people can you get down to your council meeting on
Monday night?" They didn't think they'd have any trouble getting a couple of hundred. 'Well,' I
said to this dentist, 'how much does that room hold?' He said, 'Fifty.' I said, 'That will be good.
Get them down.' They were down. The council pulled it out from underneath the table, and put
it above board, voted, and they got fluoridation.''[p 21]
Edward Bernays, Freud's nephew, and the original spin doctor would have been proud of the
appropriately named Dr. Frank Bull.
A more recent example is taken from a newsletter from Partners for Better Oral Health, a coalition of
fluoride promoters located in Harrisburg, Pennsylvania. It is undated, but was provided by Dr. Brent
Friesen, Medical Officer of Health in Calgary, to the mayor Al Duerr on May 28th 1990, to refute
citizen concerns about the NTP study. Dr. William Gross, DDS said, in relation to the dosage ofNTP
study test animals:
· "For a human to receive the equivalent of79 ppm ofthe fluoride ion at the recommended level
of 1 ppm, one would have to drink 79 litres of water per day for a lifetime"
The effect of drugs and chemicals on organisms usually depends on total body weight. Doses are
typically expressed as mglkglday. The rats did not drink a litre of water a day, but between 13 and 21
grams of water (NTP Technical Report 1990). Thus the controlled doses for the four groups of rats,
based on average weights of rats, were 0, 1.3,5.5 and 9 mglkglday-a total dose of 0, 949, 4,015 and
6,570 mglkg respectively over the two year period. Rose & Marier (1977) estimated an average
fluoride intake of between 3.5 and 5.5 mg daily for persons living in fluoridated regions. Take a an
intermediate value of 4.75 mg. Thus an average adult male human weighing 70 kg would be exposed
to roughly 0.07 mglkglday (24.8 mglkglyear)-a figure confirmed on p 85 ofthe NTP report. This is
certainly conservative because fluoride intakes have been rising since 1977, as evidenced by the
increasing problem of dental fluorosis, and is an average for males-females' mglkglday would likely
be higher as their body weight is lower. Many people will ingest far more than the average.
Thus 79 times the dose ingested by the average person in fluoridated regions would be required to
equal the daily dose administered not to the high dose rats, but to the medium dose rats (Note 11 ).
This is Gross mistake number 1. Apparently it leads to stronger support for his case. However, the
effect of fluoride being studied was its chronic (cumulative) poisoning effect, not its acute poisoning
effect (Note 12) because fluoride is a cumulative poison. The total cumulative dose depends on the
time for which a daily dose is taken. The rats took it for two years (dosage figures above). Thus the
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average person living in a fluoridated region would consume the same total dose as the low dose rats
in just 38 years. At this stage, the animals had serious dental and skeletal fluorosis, as well as
assorted cancers. By the time they were elderly, the person would be well on the way towards the
dose administered the medium dose rats. This is a far cry from the 791itres of water a day that Dr.
Gross claimed would be needed to equal the dose given to rats, and is Gross mistake number 2.
Actually, Dr. Gross really only made one mistake. He confused the concentration of fluoride ions in
the water drunk with the dose administered by drinking the water. This is one of the fundamental
mistakes made by nearly all fluoride promoters. It doesn't matter what the concentration in the water
is if! don't drink any. Equally, if! drink a lot of water, and eat mainly foods and beverages prepared
in fluoridated regions, I could easily ingest the fluoride equivalent to 10 litres of fluoridated water a
day. That would be double Rose & Marier's estimate. At 70 kg I would reach the dose administered
to the medium dose rats in less than an average lifetime, and the high dose rats in 126 years. The
world's oldest women recently died at age 120, and has been replaced by a 116 year old Canadian in
the Guiness Book of Records. Many people these days, unfluoridated in their early life, are living
beyond their 80s. These days they would accumulate unacceptably high lifetime doses, if they
survived that long. It is very unusual (as previously noted) to test a suspected carcinogen at such low
doses compared to normal human exposure. However, the researchers could not administer higher
doses because of the adverse effects on the animals' health (NTP Technical Report, p 41).
The misrepresentation of the main NTP study results has already been touched on. It is particularly
bad to misrepresent evidence against fluoride in a report that specifically addresses the question of its
risks and benefits. In the subsequent review, which further downgraded (Note 13) the findings ofthe
NTP study (US DHHS Subcommittee 1991) the Riggs et al. (1990) study on fluoride treatment for
post-menopausal women is referenced on page 41. The discussion fails to mention the statistically
highly significant threefold increase in non-vertebral fractures in the experimental (fluoride-taking)
group, compared to the placebo (non-fluoride) control group, and concentrates instead on the lack of
difference in vertebral fractures and changes in bone mineral density-an effect of iatrogenic
osteofluorosis that we have already discussed. Moreover, the subcommittee report specifically and
incorrectly states, without qualification, that "hip fractures did not occur at different rates between
groups" when there were seven complete hip fractures in the fluoride group but only three in the
control group. Two from each group died, partly as a result of the fractures. The difference in number
of fractured hips may not have reached the level of statistical significance set for the particular
experiment, but to deny they occurred is to hide an obvious trend which should certainly not be
ignored-given the results of related experiments, and the statistically highly significant difference in
total non-vertebral fractures. Other misleading statements occur elsewhere. For example, on page 64
the subcommittee quotes a study of two teenage patients who drank water containing between 1.7 and
2.6 ppm of fluoride who developed fluorosed teeth and bones, and suffered renal (kidney) failure.
(Juncos & Donadio 1972). One the following page, in the summary of this material, it ignores the
previous statement and says "the overall health significance of reduced fluoride clearance is
uncertain, with no cases of symptomatic skeletal fluorosis being reported among persons with
impaired renal function." Renal failure is the ultimate in impaired renal function! Clearly there are
question marks concerning the health of people with renal problems who drink fluoridated water.
Then, in discussing mutagenicity (the ability of fluoride to damage genes), the report says "Sodium
fluoride inhibits both protein and DNA synthesis in cultured mammalian cells. ... Fluoride can react
with [elements] in the cell so as to affect enzyme activities that are necessary for DNA or RNA
synthesis, or chromosome metabolism or maintenance; ... or it can disrupt other cellular processes
such as cellular differentiation or energy metabolism ..." But in the summary on the next page, it goes
on: "Genotoxicity studies of sodium fluoride ... often show contradictory findings. ... The most
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consistent finding is that fluoride has not been shown to be mutagenic in standard tests in bacteria
(Ames test)" even though admitting that fluoride "has been reported to induce mutations and
chromosome aberrations in cultured rodent and human cells" (pages 70-71 and 89 ofthe same
subcommitttee report).
What they do not say is that, in the NTP study they are supposed to be reviewing (NTP Technical
Report 1990), four kinds of tests for mutagenicity were carried out-including the Ames test, and three
out ofthe four came up positive, showing fluoride is mutagenic. Only the Ames test came out
negative. The weight of evidence says fluoride is mutagenic. What makes this kind of misdirection
particularly unacceptable is that Bruce Ames, the inventor of the Ames test, is on record as stating
that the test is not appropriate for fluoride for technical reasons (Carton & Marcus 1990--Ames' letter
was introduced into the congressional record by Arthur Upton). Mutagens are usually also
carcinogens. Although the results of the mutagenicity testing appeared in the body of the original
NTP study report, they were excluded from the executive summary, despite their obvious relevance
and importance.
Frank Young, the chairman, admitted that the review committee had zero members opposed to
fluoride on it, while many were enthusiastically pro-fluoride (Young & Yiamouyiannis 1991). When
pro- fluoride experts overlook or misrepresent parts of the very material they quote, when it is against
them, one wonders how much other material was passed over without proper assessment.
7. Effects on reproduction
The same PHS report (US DHHS Subcommittee 1991) admits that the effects of fluoride on
reproduction needs further study (p 88). In the W.S. Meader fish hatchery suit against fluoride-
polluting industries in 1961, over $60,000 US in damages were awarded-equivalent to around half a
million dollars in today's money. The court records report that "the eggs were worthless" and did not
hatch properly, while the fish exhibited malformations. Fluoride levels in the water were between 0.5
and 4 ppm (Waldbott et at. 1978. p 296). The DHHS Subcommittee report states clearly, on page 87:
· "Several species are sensitive to fluoride levels higher than those normally encountered, such
that their fertility and reproductive performance is impaired. The potential for adverse
reproductive effects of fluoride exposure to humans has not been adequately evaluated."
There have been a number of news reports declining sperm counts and seminal volumes for humans
over the last 50 years, perhaps reflecting a drop in male fertility, whilst there has been a sharp
increase in male genital cancers over the same period (e.g. MihillI992). It is suggested that
environmental pollution may be responsible. A possible role for fluoride has not been considered, and
other chemicals were introduced widely over the same period as the declining sperm counts and the
introduction of fluoridation. Nevertheless, it would certainly seem prudent to check out these
suggestive correlations in view of the importance of the matters involved, and the lack of previous
research, especially given the known effects of fluoride in interfering with DNA, RNA and cell
metabolism. In this connection, another report is of interest. Apparently organic farmers have about
double the current average sperm density (Reuters 1994). One of the known effects of pesticides is to
contaminate the treated produce with fluoride (Stannard et al. 1991). Organic farmers have a
particular commitment to avoid any involvement with pesticides, and very likely consume, as well as
produce, only organic produce.
Freni (1994) found increasing fluoride decreased birth rates. It is an understatement to say that the
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effects of fluoride on reproduction need further study!
8. Reduction of tooth decay and related matters
The supposed reduction of tooth decay due to the use of fluoride and especially water fluoridation is
the core ofthe fluoride promoters' case for making fluoride the priviliged pollutant that it has
become, and for pushing it on communities whether or not they want it. For example, California has
recently made water fluoridation mandatory without an appropriate vote. What you believe depends
on who you listen to.
During 1986-87, in a survey of 39,207 children between the ages of 5 and 17, the US National
Institute for Dental Research (a long-time advocate of water fluoridation) found children living in
fluoridated areas had 18% less tooth decay than children living in non-fluoridated areas, based on
Decayed, Missing and Filled tooth Surfaces (DMFS). Additional corrections raised this to 25%. The
first point to note here is that this is a far cry from various earlier claims that originally put the figure
at up to 75% reduction, or even claimed that fluoridation eliminates tooth decay (Note 14).
The NIDR seemed reluctant to release the data for the above study, which were subsequently
obtained under the US Freedom of Information Act (Yiamouyiannis 1990). Careful re-analysis of the
data brought Dr. Yiamouyiannis to a strikingly different conclusion from that reached by the NIDR.
He found no statistically significant difference between the age adjusted Decayed, Missing and Filled
Teeth (DMFT) rates (Note 15) for permanent teeth between the fluoridated, partially fluoridated and
non-fluoridated groups in the study at any age in the 84 areas throughout the US. An analysis of the
ordering of these areas by DMFT rate in permanent teeth showed no statistically significant rank
order effect-that is, there was no clustering of decay or lack of decay according to the level of
fluoride, and no trend for fluoridated, partially fluoridated or non-fluoridated regions to occupy any
particular areas of the rank-ordered table. In plain terms and with high confidence, being fluoridated
or not fluoridated did not affect DMFT rates. The one finding that was in favour of fluoridation
concerned lower DMFT rates for 5 year old children living in fluoridated regions. This is consistent
with the documented effect of fluoride in delaying the eruption of deciduous teeth (Waldbott 1978
p186)-the teeth had not erupted as early, so could not suffer the DMFT effects to the same extent. Dr.
John Colquhoun, one-time Principal Dental Officer for Auckland, Chairman of the Fluoridation
Promotion Committee for the New Zealand Dental Health Foundation, and President ofthe New
Zealand Society of Dentistry for Children set out to prove once and for all the benefits of water
fluoridation based on analysing the dental records of New Zealand children (which were very
comprehensive). The results shocked him and caused him to change his stance, since he found no
statistically significant effect either way. The caries rate was just as likely to be higher in fluoridated
regions as in non-fluoridated regions. He was eased out of his appointments as a reward! Dr. Richard
Foulkes who recommended water fluoridation in BC in 1973 underwent a similar conversion when
he discovered the facts. He said he had been "snowed".
Colquhoun went on to write up and publish his results (Colquhoun 1985; 1987). The earlier study
even found evidence that caries rates might be higher in fluoridated regions. The later study covered
98% of the New Zealand children aged 5-13 and 68% ofthe pre-schoolers with the result already
mentioned. Colquhoun's study has been criticised because it used tooth filling rates, reflecting NZ
dental practice, rather than the usually accepted DMFT. The 1986-87 NIDR study used DMFS as
already noted. Other similar studies in recent times have supported the view that there is little if any
difference in tooth decay rates between fluoridated and non-fluoridated regions (Diesendorf 1986;
Gray 1987; Hildebolt 1989). Gray, who was Director of Dental Health Services for British Columbia,
found that the DMFT rates in British Columbia, which was only 11 % fluoridated, were lower than
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the other Canadian provinces which are 40-70% fluoridated. He commented that:
· "A 60% reduction in DMFT rate of children when the average DMFT rate is 8-10 teeth is very
significant. A 60% reduction in the DMFT rate when the average DMFT rate is less than 4
teeth is of less significance. If the reduction that is occurring through fluoridation is not 60%
but closer to 25%, then it is something else again. There are significant costs to purchasing,
operating, maintaining and replacing equipment and supplies. Perhaps the greatest cost to the
community is the emotional upheaval that a fluoridation referendum causes in the minds of
some of its residents. These are points that need to be considered when community fluoridation
is proposed, and balanced against the benefits to be derived."
Gray goes on to suggest that, now that we know more about the likely mechanisms involved in tooth
decay, fluoride toothpaste should be considered more appropriate than fluoridation in these changing
times. Colquhoun (1990)) says categorically that brushing it on is better. Gray subsequently felt
obliged to write a letter stating that he still supported water fluoridation (Gray 1988).
Fluoride promoters frequently confuse the issue of topical application of fluoride (applying it to the
teeth directly-in principle, external application; in practice, varying amounts are swallowed), with
systemic treatment (taking it internally-eating and drinking it). The successful fluoridation plebiscite
in Calgary in 1989, after five previous rejections, was mainly founded on just this confusion. A
dental hygiene unit was prepared for schools in Calgary by the Calgary Health Services in
conjunction with teachers from the Calgary School Board (Calgary Health Services. undated).
Students were invited to paint an egg with sodium fluoride (topical application) and then invited them
to draw positive conclusions about water fluoridation (systemic application) for their community.
It was these students who supposedly petitioned City Hall to hold another plebiscite on fluoridating
Calgary. I have seen the letter in the city archives and it was actually signed by the teacher who ran
the class. The possibility that eggs and teeth do not react in quite the same way was not discussed,
nor was the difference in application techniques, nor the political and ethical implications. No
possibilities of harms (such as fluorosed teeth) were discussed, and opponents were caricatured in an
unfavourable manner. Few people would quarrel with a person's right to brush their teeth iliote 16)
with whatever substance they feel is best for them, including fluoridated toothpaste. However, the
lesson promoted water fluoridation based on an abuse of the scientific method, and a totally one-
sided and ill-founded view of the risks and benefits. It effectively did not deal with the medical,
moral and political issues at all, and it discredited, by association, those with opposing views.
At current DMFS/DMFT rates, even the most optimistic estimate of the effect of water fluoridation
made by the NIDR-an organisation that has consistently promoted water fluoridation for more than
45 years, is a reduction from around four or five cavities to around three or four cavities-a 25%
reduction in affected tooth surfaces. The same data says that the difference in the number ofteeth
affected by decay is zero, a finding confirmed by the other studies cited.
9. In conclusion: medical, moral, economic, legal and political issues
From a medical point of view, water fluoridation makes little sense. People's water intake varies a
great deal. More importantly, since water is so widely used in the food and beverage processing
industry, the fluoride intake from fluoridated water is not confined to the water people drink. In the
overview of their classic work on fluoride, Rose and Marier (1977, pp 108-110) said:
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. "There is no doubt that inadequate nutrition increases the severity of fluoride toxicosis" (Note
17)
. "Fluoride has displayed mutagenic activity in studies of vegetation, insects, and mammalian
oocytes"
. "Long-term ingestion, with accumulation of fluoride in animals and man, induces metabolic
and biochemical changes, the significance of which has not yet been fully assessed. ... There is
evidence that neurologic complaints are related to the early histologic changes that precede
overt skeletal fluorosis."
· "Fluoride is a persistent bioaccumulator, and is entering into human food-and-beverage chains
in increasing amounts. Careful consideration of all available data indicates that the amount of
fluoride ingested daily in foods and beverages by adult humans living in fluoridated
communities currently ranges between 3.5 and 5.5 mg. For a 70 kg human adult, this range is
close to the 0.03 to 0.07 mglkg/day estimated for 'an acceptable daily intake'. In addition to the
food chain, dentrifices and pharmaceuticals can contribute significantly to the fluoride intake of
some individuals."
. "In addition to industrial workers, there are several sub-groups of the population who may be
more affected by environmental fluoride than the population at large."
Some people, by accident or design, make life choices that avoid many sources of fluoride (purchase
of organic foods, minimal use of prepared foods, bottled or other water supplies free of fluoride ...).
Dose equals concentration times volume when you calculate medication. To fluoridate a community
water supply as a means of providing a dose of fluoride is like a doctor handing out dangerous drugs
at random: "Here, take a few of these tablets, they'll do you good." Such medication is uncontrolled,
unsupervised and not subject to informed consent--especially when the risks are hidden. Do you
know which cities in your country are fluoridated?
Then there is the moral aspect. Some children will be harmed, requiring corrective dentistry for
fluorosed teeth. There is good evidence of other harms, such as increased hip fractures in the
population, and increased cancer rates, as discussed. The most chilling recent result was a study
(Mullenix et al. 1995) which showed various neurologic effects in rats (Note 18). The effects
depended on the timing of exposure and ranged from behaviour typical of drug-induced
hyperactivity, to behaviour-specific changes related to cognitive defects. The effects were age and
sex-related, and were associated with elevated fluoride levels in brain areas corresponding to the
behaviours. Should you be forced to take medication because I have a medical problem-especially if
my medication may cause medical problems, or worse (Note 19), for you? Especially ifmy
medication has unkown effects on your reproductive performance!
From an economic point of view there are problems. Gray noted the costs of installing, maintaining
and running the fluoridation facilities themselves. When Calgary decided to fluoridate its water, the
annual running costs for water fluoridation for that one city were estimated at $230,000 CDN per
year just for the chemicals (Note 20), of which 99.9% was destined not to be drunk, but to be flushed
straight down the sewers. Overall, 150 tonnes of fluoride will be dumped into the Bow River and the
environment each year (the city uses over 600 tonnes of25% hydrofluosilicic acid every year
[Jamieson 1990]). For comparison, at the same time the Reynolds Aluminium Company in Baie
Comeau, Quebec, was only allowed to discharge 36.5 tonnes (100 kg/day) of fluoride into the St.
Lawrence river each year under pollution control regulations ~icard 1989). The Bow river is a major
trout river and fluoride is harmful to fish spawning, hatching or growth (Waldbott et al. 1978). It is a
pollutant (Hammer 1983). Why does the city pay to help polluting industries get rid of their toxic
industrial waste and risk damaging such an important resource?
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Hip fractures are a serious and very costly community health problem. Kleerekoper (1992) quotes a
US DHHS directive to reduce hip fractures by 15%. Danielson et al. (1992) quote the annual cost of
hip fractures in the US as $7 billion US, so a 15% reduction would save over $1 billion. Factors
which increase hip fracture rates by even small amounts will cost many millions (even for Canada) at
a time when health care costs have been cut to the bone (pun appropriate, though not intended).
Chrischilles et al. (1994) quote $45.2 billion US as the cost of osteoporetic fractures of the forearm,
spine and hip, describing the estimate as "conservative". Hip fractures are especially expensive as
they are most frequent amongst the over 65s and involve extensive nursing home utilisation, but
given the findings of Riggs et al. (1990) the whole $45.2 billion cost is the relevant total one ought to
worry about in terms of the effect of fluoride on increasing the fracture rates.
Then there are the costs of other medical and dental problems. And not just problems caused by
fluoride from water fluoridation. In a recent trend-setting case in Britain, Colgate-Palmolive paid an
out-of-court "goodwill" payment of?lOOO sterling ($2300 CDN) to the parents of a 10 year old boy
in Essex who was diagnosed by an independent specialist as suffering from dental fluorosis caused by
fluoridated toothpaste. Lawyers observing the payout said the settlement was a significant
breakthrough, even though the manufacturer has denied any liability and is refusing to discuss the
case (Individual Inc. 1996). In the same news service article, David Kennedy DDS, past president of
the International Academy of Oral Medicine and Toxicology is quoted on the absurdity of saving less
than one filling (Note 21) by paying thousands of dollars for crowns and veneers. Multiplying those
kinds of costs by the numbers involved soon produces millions of dollars, not to mention the effect
on the victims and their loss of time.
However, the real economic aspect of fluoridation is not concerned with the costs, benefits, harms or
any other aspect of people's teeth. It has to do with solving an industrial problem. The solution
involves political aspects as well and the whole story is too long to include here, but a very brief
summary provided as Appendix A. In essence, there is strong circumstantial evidence that propitious
circumstances, and a little encouragement ofthe "right" research lines, coupled with considerable
political clout, allowed polluting industries to deal with their serious problems in disposing of highly
toxic fluoride byproducts by selling them as tooth decay preventatives. This strategy was based on
"research" and "trials" which would not be accepted as scientifically sound by today's standards.
The legality of water fluoridation is interesting. In Allegheny County, Pennsylvania, it was tested in
front of Judge Flaherty, now a Justice of the Supreme Court of Pennsylvania (Elaherty 1979; 1988,
1996). He found that:
· "the evidence is quite convincing that the addition of sodium fluoride to the public water
supply is extremely deleterious to the human body"
and wrote that:
· "what I have read [since] convinces me all the more that in-depth, serious scientific effort
should be undertaken before further expansion of this questionable practice. Those who belittle
critics of fluoridation do the public a misservice, yet it seems in the face of strong,
uncontradicted prima facie evidence, that is the tactic most often employed".
The injunction obtained in his court against water fluoridation was, in fact, set aside by a higher
court. However, it was set aside on the legal technicality that water fluoridation is a legislative matter,
and beyond the jurisdiction of the courts. The same jurisdictional argument prevailed when a legal
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challenge to fluoridation was mounted in Calgary, based on a properly constituted petition signed by
more than 45,000 citizens. The scientific case against fluoridation, proven in Flaherty's court, remains
unchallenged, and there is now much more evidence on that side.
In conclusion, there is a political aspect. People in a free society have a right to choose whether or not
they will accept medication, and they have a right to individual treatment and monitoring. Those who
believe fluoride works are entitled to their opinion. They may choose their own experts and distrust
the proven evidence of legal proceedings in court. They may ignore their own peer-reviewed medical
journal reports showing significant and serious risks. That is their right. But they have no right to
force others to drink or use fluoride against their will, especially in the face of so much credible
evidence of harms, with little or no benefit, and when more effective, democratic and medically
responsible forms of medication exist. Nor should they promote the use of fluoride without reference
to its dangers. The only people who truly benefit from the widespread use of fluoride for "dental"
purposes are the big industries that generate fluoride as a waste product. They not only solve their
pollution problems, but make a handsome profit by selling their toxic residues to be eaten, drunk, and
~pread on teeth ~y an ~nsuspec~in~ population governed by gullible officials.
10. References
CALGARY HEALTH SERVICES (undated-some time in the 80s) Dental Hygiene Unit. Science
Teaching Unit (originally for Science 25 and later used in similar classes) (hack to main text)
CALGARY HEALTH SERVICES (1989) Focus on fluoridation Calgary Herald Oct 8th (hack to
main text)
CARTON RJ (1993) Affidavit of Dr. Robert J. Carton in support of motion for summary judgement.
Case No. 92 CV 579 Safe Water Foundation vs. City of Fond du Lac, State of Wisconsin Circuit
Court, Fond du Lac County, Feb 10th (hack to main text)
CARTON RJ & MARCUS WL (1990) A collection of internal memoranda from the US
Environmental Protection Agency where Dr. Carton was an Environmental Scientist and Dr. Marcus
was a Senior Science Advisor and toxicologist in the Office of Drinking Water. The memoranda are
dated 90-05-01,90-06-01,90-09-24 and 90-10-18 (back to main text)
CHRISCHILLES E SHIREMAN T & WALLACE R (1994) Costs and health effects of osteoporetic
fractures Bone 15 (4), 377-386, Jul/Aug (hack to main text)
COHN PD (1992) An epidemiologic report on drinking water andjluoridation Trenton, NJ: State of
New Jersey, Dept. of Health (hack to main text)
COLQUHOUN J (1985) Influence of social class and fluoridation on child dental health. Community
Dent Oral Epidemiol13, 37-41 (hack to main text) [abstract]
COLQUHOUN J (1987) Child dental health differences in New Zealand. Community Health Studies
(Journal of the Public Health Association of Australia & New Zealand) XI (2),85-90 (hack to main
text) [abstract]
COLQUHOUN J (1990) The balance sheet on fluoridation: some harm, little or no benefit. NZ
Environment 66,5-10 (hack to main text)
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COOPER C WICKHAM CAC BARKER DIR & JACOBSEN SJ (1991) Water fluoridation and hip
fracture J American Medical Assoc 266 (4),513 July 24/31 (back to main text) [abstract]
COX G (1939) Experimental dental caries-IV. Fluorine and its relation to dental caries J Dental
Research 18,481-490 (hack to main text)
DANIELSON C LYON JL EGGER M & GOODENOUGH GK (1992) Hip fractures and fluoridation
in Utah's elderly population. J Amer Medical Assoc 268 (6), 746-748, Aug 12th (back to main text)
[ abstract]
DIESENDORF M (1986) The mystery of declining tooth decay. Nature 322, 125-129, July 10th
(hack to main text)
EDITORIAL (1943) Chronic fluorine intoxication J American Medical Assocation 123, Sep 18th,
150 (hack to main text) [Actual quote]
EDITORIAL (1944) Effect of fluorine on dental caries J American Dental Association 31, 1360-1363
(back to main text) [Actual quote]
FEDERAL SECURITY ADMINISTRATION (1951) Proc Fourth Annual Conference of State
Dental Directors with the Public Health Service and the Childrens Bureau, US Dept of Health,
Education & Welfare Library RK 21.C55 1951 (also available in Volume 5 of Hearings, 89th
Congress, Dept. of Health, Education and Welfare Appropriations for 1967; and are recorded as Case
# 8425, Exhibit 108, of Public Utilities Commission of California, 1966; copies also from Health
Action Network Society, #202-5262 Rumble St, Burnaby BC V5J 2B6 Canada (hack to main text)
FLAHERTY JP (1979) Letter to Sir Dove-Myer Robinson, Mayor of Auckland, NZ, July 31st (hack
to main text)
FLAHERTY JP (1988) Letter to Ms. Evelyn Hannan, New York State Coalition Opposed to
Fluoridation, PO Box 263, Old Beth Page, New York, Jan 26th (hack to main text)
FLAHERTY JP (1996) Letter to the N Y State Coalition Opposed to Fluoridation, PO Box 263, Old
Beth Page, New York, Jan 5th (hack to main text)
FRENI SC (1994) Exposure to high fluoride concentrations in drinking water associated with
decreased birth rates J Toxicology & Environmental Health 42 109-121 (hack to main text) [abstract]
GRAY AS (1987) Fluoridation: time for a new baseline. J Canadian Dental Association 10, 763-765
(hack to main text) [abstract & excerpts]
GRAY AS (1988) Letter from Dr. A.S. Gray, Director of Dental Health, Province ofBC to Dr. John
Osterman, Lakeshore General Hospital, Quebec, Mar 7th (hack to main text)
HAMMER R (1983) Letter from Rebecca Hammer, Deputy Assistant Administrator for Water for the
US Environmental Protection Agency to Dr. L. A. Russell, DMD, Newtonvil/e MA, Mar 30th (hack to
main text)
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HILDEBOLT CF ELVIN-LEWIS M MOLNAR S McKEE JK PERKINS MD & YOUNG KL
(1989) Caries prevalence amongst geochemical regions of Missouri. American J Physical
Anthropology 78, 79-92 (The paper starts offwith the official catechism about the undoubted benefits
of fluoride, before showing that it doesn't work. Maybe a necessary opener to get into print-see
section 6.) (back to main text) [abstract]
HILEMAN B (1988) Fluoridation of water Chemical & Engineering News (American Chemical
Society) 66 (31) 26-42 Aug 1 st (back to main text) [ excerpt]
HODGE HC (1979) The safety of fluoride tablets or drops. In Continuing evaluation of the use of
fluorides (Johansen et al. editors), Boulder, Colorado: Westview Press (back to main text)
HULEN D (1992) Officials check fluoride in Hooper Bay death case Anchorage Daily News XLVII
(149), Al (back to main text) [journal abstract]
INDIVIDUAL INC (1996) Claims offluoride safety shattered by Colgate payoutfor ruined teeth
http://www.newspage.com [requires password] (Contact Citizens for Safe Drinking Water, Jeff Green
1-800-728-3833 or 1-619-551-8893 direct) (back to main text)
JACOBSEN SJ GOLDBERG J MILES TP BRODY JA STIERS W & RIMM AA (1990) Regional
variation in the incidence of hip fracture: US white women 65 years and older. J American Medical
Assoc 264, (4) 500-502, Jul25th (back to main text) [abstract]
JAMIESON, D (1990) Personal communicationfrom Calgary City Engineering Dept. in response to
a request for information. (back to main text)
JACQUMIN-GADDA H COMMENGES D DARTIGUES J-F (1995) Fluorine concentration in
drinking water and fractures in the elderly J American Medical Assoc 273 (10), 775-776 (back to
main text) [study]
JUNCOS LI & DONADIO N Jr (1972) Renal failure and fluorosis. J American Medical Assoc 222
(7), 738-852 (back to main text)
KLEEREKOPER M (1992) Please pass the roach poison again. J American Medical Assoc 268 (6),
781-782 Aug 12th (back to main text)
LEVY T (1994) Fluoridation: paving the road to the final solution Extraordinary Science (Journal of
the International Tesla Society) VI (1), Jan-Mar, 29-40 (back to main text)
LOWEY M (1994) Fluoride 'whistleblower' gets job back Calgary Herald February 19th (back to
main text)
MlHILL C (1992) Pollution may cause lower sperm count. Manchester Guardian Weekly 147 (12),
Sep 20th (back to main text)
McMAHON CR (1993) Alaska Court System Memorandum to LJ Hancock, Health Action Network
Society, confirming Dominic Smith's death due to fluoride overdose through the village water supply.
April3rd (back to main text)
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MINISTER OF SUPPLY & SERVICES CANADA (1993) Inorganic Fluorides Ottawa: Canada
Communications Group, 72 pp (back to main text)
MULLENIX PJ DENBESTEN PK SCHUNIOR A & KERNAN WJ (1995) Neurotoxicity of sodium
fluoride in rats Neurotoxicology & Teratology 17 (2) (hack to main text) [abstract]
NTP TECHNICAL REPORT (1990) Toxicology and Carcinogens is Studies of Sodium Fluoride in
F344/N Rats and B6C3F1 Mice, NTP TR 393 (Draft), National Toxicology Program, US Dept of
Health & Human Services: Washington, DC, 106pp + 370pp of appendices (hack to main text)
P AK CYC SAKHAEE K PIZIAK V PETERSON R BRESLAU NA BOYD P POINTDEXTER JR
HERZOG J HEARD-SAKHAEE A HAYNES S ADAMS-HUETT B & REISCH JS (1994) Slow-
release sodium fluoride in the management of post-menopausal osteoporosis Annals of Internal
Medicine 120 (8), 625-690, April (back to main text)
PICARD A (1989) Montreal decision to delay fluoridation pleases environmentalists, irks dentists.
Toronto Globe & Mail, November 11 th, All (hack to main text)
POPPER KR (1972) Conjectures and refutations London: Routledge & Kegan Paul, 431 pp (hack to
main text)
PORTERFIELD E (1994) Hazards lurk in toothpaste tube: Enumc1aw sisters' illness traced at last to
chemicals. The News Tribune (Tacoma, W A) Apr 5th (hack to main text)
REUTER (1994) Sperm density study surprising Toronto Globe & Mail Jun 10 All (hack to main
text)
RIGGS BL STEPHEN MD HODGSON SF O'F ALLON WM CHAO EYS W AHNERHW MUHS
1M CEDEL SL & MELTON LJ (1990) Effect of fluoride treatment on the fracture rate in
postmenopausal women with osteoporosis New England Journal of Medicine 322 (12), 802-809, Mar
22nd (hack to main text) [abstract]
ROSE D & MARIER JR (1977) Environmental Fluoride. NRCC Number 16081, Ottawa: National
Research Council of Canada (100 Sussex Drive, Ottawa, KIA OR6) (hack to main text)
S0GAARD CH et al. (1994) Marked decrease in trabecular bone quality after five years of sodium
fluoride therapy-assessed by biomechanical testing of iliac crest bone biopsies in osteoporetic
patients Bone 15 (4), 393-399 Jul/Aug (hack to main text) [abstract]
SOWERS M-FR CLARK MK JANNAUSCH ML & WALLACE MB (1991) A prospective study of
bone mineral content and fracture in communities with different fluoride exposure American J
Epidemiology 133 (7), 649-660, Apr 1st (hack to main text) [abstract]
STANFORD U NEWS SERVICE (1993) The 'scientist-advocate' should be prepared for a rough
time. News Release embargoedfor the AAAS Meeting, 9am Friday Feb 12th 1993, Stanford: Stanford
University News Service, 2pp (hack to main text)
STANNARD JG SHIM YS KRITSINELI M LABROPOULOU P & TSMATSOURIS A (1991)
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Fluoride levels and fluoride contamination of fruit juices J Clinical Pediatric Dentistry 16 (1) (hack
to main text) [abstract]
STOCK P (1993) Tests show high fluoride levels in Hooper Bay Anchorage Times Bl, May 29th
(hack to main text)
SUTTON PRN (1959) Fluoridation: errors and omissions in experimental trials Melbourne,
Australia: Melbourne U Press (second edition 1960) (hack to main text)
TEOTIA SPS & TEOTIA M (1994) Dental caries: a disorder of high fluoride and low dietary
calcium interactions Fluoride 27 (2) 59-66 (hack to main text) [study]
TRENDLEY-DEAN H & ELVOLVE E (1937) Further studies on minimum threshold of chronic
endemic dental fluorosis. Public Health Reports 52, 1249-1264 (back to main text)
US DEPT OF AGRICULTURE(1972) Handbook Number 380 (back to main text)
US DEPT OF HEALTH & HUMAN SERVICES SUBCOMMITTEE (1991) Review offluoride:
benefits and risks. Washington, DC: US Public Health Service, Dept of Health & Human Services,
Feb (hack to main text)
W ALDBOTT GL BURGST AHLER A W & McKINNEY HL (1978) Fluoridation: the great
dilemma. Lawrence, Kansas: Coronado Press, 423 pp (hack to main text)
YIAMOUYIANNIS J (1986) Fluoride: the ageingfactor Delaware: Health Action Press (hack to
main text)
YIAMOUYIANNIS J (1990) Water fluoridation and tooth decay: results from the 1986-87 National
Survey of US Schoolchildren. Fluoride 23 (2), 55-67, Apr (hack to main text)
YOUNG F & YIAMOUYIANNIS J (1991) Taped transcript ofmeeting between Dr. Frank Young
(Chairperson of the Fluoride Review Sub-committee, US Dept of Health & Human Services 1991-see
above), Dr. John Yiamouyiannis (biochemist and noted anti-jluoridationist), and Kay Turner; held
March 14th 1991 at Dr. Young's invitation. (hack to main text)
Some other sources consulted
CALABRESE EJ (1991) Evaluation of the National Toxicology Program (NTP) cancer bioassay on
sodium fluoride. Environmental Science Health Program (EHSP) School of Public Health, U
Massachusetts, Amherst, MA 01003 Technical Report (Dr. Calabrese is Professor of Toxicology in
the EHSP) [study]
EBERT ill (1959) The first heartbeats Scientific American, 3-9, March (low concentrations primarily
affect heart of embryos, higher destroy starting at heart)
GRIFFITHS J (1992) Fluoride: commie plot or capitalist ploy. Covert Action 42, Fall, 26-30 and 63-
66 (Joel Griffiths is a medical writer living in New York who has written for the Medical Tribune.
This paper is a comprehensive overview of the political and scientific aspects of the fluoride
controversy from a North American perspective) [full article]
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LEGISLATIVE ASSEMBLY FOR THE AUSTRALIAN CAPITAL TERRITORY (1991) Inquiry
into the Water Fluoridation Act. (Standing Committee on Social Policy, Chairperson W [Bill]
Woods) (This report is really two reports, providiong a baalance between the opposing forces because
of the dissenting [ minority] report by Dennis Stevenson, MLA, included as Appendix 6 on pages
133-309. There is a wealth of information for both sides. The final recommendation ofthe committee
was to halve the concentration of fluoride added to the water [sic])
NATIONAL ACADEMY OF SCIENCES (1971) Biologic Effects of Atmospheric Pollutants
(Committee on the Biologic Effects of Atmospheric Pollutants, chairperson JJ Vostal), Washington,
DC: National Academy of Sciences, 295pp
NATIONAL HEALTH & MEDICAL RESEARCH COUNCIL OF AUTRALIA (1991) The
Effectiveness of Water Fluoridation (Working Group, Chairperson Prof AJ McMichael), Canberra:
Australian Government Publishing Services, 193pp (Statement of the official view: "fluoridation...
has ... conferred substantial protective benefit", "Fluoridation ... remains the most effective and
socially equitable means of achieving community-wide exposure", "There is no evidence of adverse
health effects").
VARNEY W(1986) Fluoride in Australia: a case to answer. Sydney: Hale & Iremonger PTY Ltd,
GPO Box 2552, Sydney, Australia, 195pp (The book is a succinct, revealing summary ofthe politics
and history of fluoridation in Australia from when it started until the date of publication)
Appendix A: A brief look at the industrial connection
(Levy's paper (994) and the book by Waldbott et al. (1978) have provided valuable detail for this
appendix)
Companies that generate fluoride compounds as a byproduct of their operations were forced to clean
up their effluent (gaseous in the case of Aluminum smelting) following successful and expensive
lawsuits in the latter half ofthe nineteenth and on into the 20th century seeking compensation for
environmental damage of various sorts, including the ruination of farm livestock that ate fodder
contaminated by fluoride (Note AI). The Aluminum Company of America (ALCOA) was owned by
the Mellon family, especially Andrew Mellon, who served as Secretary of the Treasury between 1921
and 1932, ajob which placed him in charge of the US public Health Service. Around this time, a
number of researchers were looking at the relationship between minerals in water supplies and effects
on teeth, especially caries (decay) and mottled teeth and disfigured teeth-known in some regions as
"Colorado brown stain" or "Texas teeth". In 1931 three groups, including Churchill's group at the
Mellon Institute (Note A2) showed that fluoride was responsible for the disfigured teeth (Walbott et
al. 1978). Trendley Dean, first Director ofthe National Institute for Dental Research (NIDR), took up
this finding and ran with it (Note A3). In the process, he and others came to the conclusion fluoride
was also linked to lower caries rate, but without taking proper account of other minerals in the water,
or dietary effects (Note A4).
In the mid 30s, Dr. Gerald Cox, a researcher at the Mellon Institute began lauding the benefits of
fluoride in the water and conducting experiments. In 1939 he published in the J Dental Research
(Cox et al. 1939) to the effect that "fluorine is responsible for the increased resistance to caries ... the
case should be regarded as proved" and was the first to recommend the artificial addition of fluorides
to drinking water. His experiments were based on unscientific data and analysis. For example he did
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an 8-week [sic] study of pregnant female rats fed varying amounts of fluoride which was
methodologically and statistically unsound. (Yiamouyiannis 1986). Many experts made gloomy
predictions about the consequences of adding fluoride to water supplies. Philip Sutton's book (1959)
documents problems with such early "experiments" and the later "trials" on selected North American
cities in which there was an unreasonable rush to judgement on the benefit of water fluoridation and a
lack of scientific method, not to mention a lack of ethics in experimenting on human populations
without informed consent.
Waldbott et al. (1978) provide an excellent summary ofthe history, trials, and pros and cons of
fluoride as they appeared at the time.
At first the proposal to add fluoride to water supplies was greeted with incredulity and opposition by
doctors and dentists, who regarded fluoride as a dangerous "protoplasmic poison" (Editorial 1943;
Editorial 1944), because of its effect on cell metabolism and its role in fluorosis. But a few years
later, they suddenly switched and began promoting it as already noted (see, for example, the quotes
from Dr. Frank Bull in Section 6).
Interestingly, Oscar Ewing, a lawyer and powerful political figure previously fingered by
Congressman Dr. A.L. Miller as a likely key player in driving the entire fluoridation campaign was
(Miller alleged) paid a $750,000 fee (Note A5) by industrial interests, including ALCOA, to leave his
lucrative Wall St. law practice to become head ofthe Federal Security Adminstration (Note A6), in
charge ofthe US Public Health Service, the Social Security Administration and the Office of
Education. Despite opposition from the American Medical Association and its head Dr. Morris
Fishbein, Ewing was politically powerful enough to push the fluoridation campaign to its successful
conclusion of full acceptance, commitment and promotion by the medical-dental establishment. The
current target is 100% fluoridation of North America by the year 2000. Miller pointed out that neither
the US Public Health Service nor the dental profession had done research of their own on which to
base their reversal of position, and expressed his opinion that the USPHS had misled all concerned
without providing facts. He went on (Yiamouyiannis 1986. p 140):
· "I sometimes wonder if the Aluminum Company of America, and its many subsidiary
companies, might not have a deep interest in getting rid of the waste products from the
manufacture of aluminum, because these products contain a large amount of fluoride. In this
connection it is intersting to know that Oscar Ewing, who now heads up the Federal Security
Administration (parent organization of the USPHS), and the firm of attorneys he was with--
Hubbard, Hill, and Ewing--represents the Aluminum Company of America." [Italics added]
ALCOA is not the only company with a fluoride byproduct disposal problem, so others would
undoubtedly be supportive of any economical solution. In a letter in response to an enquiry, the
Deputy Assistant Administrator of the US Environmental Protection Agency stated that:
· "In regard to the use of fluosilicic acid as a source of fluoride for fluoridation, this agency
regards such use as an ideal environmental solution to a long standing problem. By recovering
byproduct ... air and water pollution are minimized, and water utilities have a low-cost source
of fluoride available to them." (Hammer 1983)
Footnotes
1. Fluorides: a generic term referring to inorganic comp.ounds containing the element fluorine.
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Sodium fluoride contains 19 parts of fluoride to 23 parts of sodium. (hack to main text)
2. Dr. Carton was an EP A Environmental Scientist and Dr. Marcus was Senior Science Advisor and a
trained toxicologist at the time. back to main text)
3. The report comments on the rarity of these bone cancers in rodents on page 76. (hack to main text)
4. Abnormal new growths where multiplication is uncontrolled and progressive. May be benign or
malignant (cancerous-having the property of anaplasia, invasiveness, and metastasis; leading to
death). The data were obtained from the unpublished Battelle report. (hack to main text)
5. Unavoidably in the prepared foods and beverages from fluoridated regions that they buy-they can
obtain fluoride-free bottled water to avoid drinking the public water itself. (back to main text)
6. Osteoporosis is a name for loss of bone strength due to calcium depletion that particularly affects
post-menopausal women. (hack to main text)
7. Sources of uncontrolled but possibly systematic variation that could produce spurious results.
(hack to main text)
8. The radial shaft is the shaft ofthe radius, the larger bone in the lower arm. (hack to main text)
9. Iatrogenic-caused by doctors. (back to main text)
10.. Climatologist Stephen Schneider puts it bluntly, advising science advocates "not to be naive
about how extensive a career risk they may face." especially if they get involved with public policy
controversy. The result can be character assasination by Ph.D-wielding critics parading as defenders
of the sanctity of science (Stanford U News Service 1993). (hack to main text)
11. Dose for medium dose ratsl average human dose = 5.510.07 = 79). (hack to main text)
12. Its acute effects are well known. Fifty parts per million in the water is considered by doctors
dealing with real situations to be a lethal concentration (Stock 1992) whilst 50 mglkg-body-weight of
fluoride, administered in one dose (3.5 grams for a 70 kg person), is considered a certainly lethal dose
by toxicologists (Hodge 1979). For a 10 kg child, the certainly lethal single dose would be 500 mg,
an amount about the size of a pea. (back to main text)
13. The draft report (NTP Technical report 1990) was already watered down from the original
Battelle study report by one review committee, as noted (Carton & Marcus 1990). (hack to main text)
14. As recently as 1989 when Calgary Health Services were promoting fluoridation, they placed an
advertisement in the Calgary Herald claiming both a possible reduction of 50% in the tooth decay
rate and that tooth decay could be "extinct" (like the dinosaur) ifthe Calgary water was fluoridated
(Calgary Health Services 1989). (hack to main text)
15.. DMFT has been the more usual measure for tooth decay. (hack to main text)
16. It is worth mentioning that young children are estimated to swallow at least one third of the
toothpaste they use. Since toothpaste contains at least 1000 and as much as 2000 times the
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concentration of fluoride that fluoridated tap water contains, the 1 gram typically used to brush the
teeth contains as much fluoride as one or two litres ofthe water, and is in addition to all other
sources. When fluoride was first added to toothpaste, warnings were printed on the tubes and boxes.
Such warnings are now being issued by concerned fluoridation proponents in the face of rising rates
of dental fluorosis (up from 10% in the 50s to 30-80% in modem times). Dental fluorosis is regarded
by some experts as the first sign of systemic fluoride poisoning. The ridiculous aspect of this is that
much of the fluoride intake these days is the uncontrolled intake due to processed foods and
beverages from fluoridated regions for which the only cure is not to fluoridate the water-the opposite
of what promoters wish to achieve. Promoters deny that the fluoride in toothpaste is harmful but,
apart from fluorosis, toothpaste can cause illness (Poterfield 1994). (back to main text)
17. So, far from being of most "benefit" to poor people, fluoride is likely most harmful. Teotia &
Teotia (1994) found that tooth decay is specifically associated with high fluoride and low calcium
intake, as already noted in section 5. (back to main text)
18. Rats are considered a good model of the human for such purposes by medical researchers, just as
they are for cancer studies. (back to main text)
19. On Friday May 22nd 1992, Dominic Smith of Hooper Bay, Alaska, died of an overdose of
fluoride from the village's public water supply after an equipment failure that raised the fluoridation
level to between 57 and 150 ppm. The medical director for the region stated that levels in excess of
50 ppm could be lethal. (Stock 1992; McMahon 1993).
· "Doctors said they were skeptical that so much fluoride was in the water that it caused a death
and widespread illness so quickly." (Hulen 1992)
20. Then there was the cost of amortising the $1.2 million capital equipment expense, plus staff and
maintenance costs. These likely should have included the new plastic-lined water pipes laid by the
city. The city has denied there is any connection, but the old cast iron pipes were susceptible to
corrosion caused by the water fluoridation, as had been found in US cities ( e.g. Seattle), and the
timing of the replacement was most fortuitous. (back to main text)
21. If the claimed benefits truly occurred. As noted, studies show they don't-so there are likely no
reduction in total fillings at all. (back to main text)
AI.. "Airborne fluorides have caused more damage to domestic animals than any other air
pollutant" (lIS Dept of Agriculture 1972). (back to main text)
A2. The Mellon Institute was typical of research institutions run by industrial consortiums for their
own purposes (e.g. Kettering Laboratory at the U Cincinnati) and was privately funded by the Mellon
family. In 1967 the Mellon Institute merged with the Carnegie Institute of Technology (which
included the Margaret Morrison Carnegie Institute) to become Carnegie-Mellon University. (back to
main text)
A3.. Dr. H. Trendley-Dean published the results of an experiment showing the "dose-related"
incidence of dental fluorosis which reached 100% at a fluoridation level of 4 ppm (Trendley-Dean et
al. 1937). As Dr. Thomas Levy comments, it is ironic that the only "dose-related" effect of fluoride
on dentition that has been clearly documented is disfigurement of children's teeth (Levy 1994). Of
course, the dose really depended on the water actually drunk. (back to main text)
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A4. For example, in 1942, Hereford, Texas was dubbed "the town without toothache" because oflow
tooth decay rates. The water contained 2.3-3.2 ppm fluoride but also generous amounts of calcium,
magnesium and other minerals, while the wheat grown in the area was particularly rich in these
minerals as well as phosphorous, all of which are good for teeth. Hereford's dentist opined that the
role of fluoride was greatly overplayed (Waldbott et al. 1978 pp 191-192). (back to main text)
5. This fee would be at least 10 times that figure in today's dollars. (back to main text)
A6. The Federal Security Adminstration sponsored the Fourth Annual Conference of State Dental
Directors at which Dr. Frank Bull made his presentation on how to promote fluoride. (back to main
text)
I Substance
I Fluoride
I Daily Dose Maximum Contaminant Level (MCL)
(mglkg/day) (mglIitre)
II 7.9 4
IVinyl chloride II 1.7 0.002
I Carbon tetrachloride 47 0.005
I Benzene 50 0.005
I Chloroform 160 0.100
I Tetrachlorethylene 386 0.005
IRed dye #3 4000 none
Table 1: Comparison of fluoride dose causing bone cancer with doses used
to test other suspected carcinogens and their Maximum Contaminant Levels
(back to main text)
Figure 1 (a) & (b): Histograms showing composites ofrat neoplasms, many cancerous
160/0 - Percent of animals affected 8% Percent of animals affected
140/0 - 7%
120/0 H 6% H
(a): male (b): female
100/0. 5%
80/0 lFCA 4%
H
60/0 3% IF(
40/0 lFCA
0 2%
r:l R
20/0 0 S
j;l 1% ~
s s
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I
o 11 49
PPM Fluoride
- I
79
I .-
o
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11 49 7~
PPM Fluoride
H: Hepatocholangiocarcinoma S: Squamous TFCA: Thyroid follicular cell adenoma 0:
Osteosarcoma
Go back to text
.11
Fluoride: Protected Pollutant or Panacea?
Are the claimed benefits of ingesting fluoride over-rated
and the risks to our health and ece-system under-reported?
- ---~ -~ ~-~~~
l~
Bones I ~I Cavities I Fertility I Cancer I Health risks I Neuroloaicall Dental Fluorosis and Pictures
ISFR I Ethics I Tributes I Fraud I Authors I Deaths I Quotes I Environment I Skeletal Fluorosis I Definitions
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QUIXOTE'S HORSE - Fluoride & the Manhattan Project
Page 1 of 14
QUIXOTE'S HORSE
TOXIC SECRETS
Fluoride & the A-Bomb
Program
Extracted from Nexus Magazine, Volume 5, #3 (April-May 1998).
(Q Joel Griffiths and Chris Bryson 1997
4 West 104th Street
New York, NY 10025, USA
During the ultra-secret Manhattan Project, a report was commissioned to
assess the effect of fluoride on humans. That report was classified "secret" for
reasons of "national security"... here is why.
Some 50 years after United States authorities began adding fluoride to public water
supplies to reduce cavities in children's teeth, recently discovered declassified
government documents are shedding new light on the roots of that still-controversial
public health measure, revealing a surprising connection between the use of fluoride and
the dawning of the nuclear age.
Today, two-thirds of US public drinking water is fluoridated. Many municipalities still
resist the practice, disbelieving the government's assurances of safety.
Since the days of World War II when the US prevailed by building the world's first
atomic bomb, the nation's public health leaders have maintained that low doses of
fluoride are safe for people and good for children's teeth.
That safety verdict should now be re-examined in the light of hundreds of once-secret
WWII-era documents obtained by these reporters [authors Griffiths and Bryson),
including declassified papers of the Manhattan Project-the ultra-secret US military
program that produced the atomic bomb.
Fluoride was the key chemical in atomic bomb production, according to the documents.
Massive quantities-millions of tons-were essential for the manufacture of bomb-grade
uranium and plutonium for nuclear weapons throughout the Cold War. One ofthe most
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toxic chemicals known, fluoride emerged as the leading chemical health hazard of the US
atomic bomb program, both for workers and for nearby communities, the documents
reveal.
Other revelations include:
. Much of the original proof that fluoride is safe for humans in low doses was
generated by A-bomb program scientists who had been secretly ordered to provide
"evidence useful in litigation" against defence contractors for fluoride injury to
citizens. The first lawsuits against the American A-bomb program were not over
radiation, but over fluoride damage, the documents show.
· Human studies were required. Bomb program researchers played a leading role in
the design and implementation of the most extensive US study of the health effects
of fluoridating public drinking water, conducted in Newburgh, New York, from
1945 to 1955. Then, in a classified operation code-named "Program F", they
secretly gathered and analysed blood and tissue samples from Newburgh citizens
with the cooperation of New York State Health Department personnel.
· The original, secret version (obtained by these reporters) of a study published by
Program F scientists in the August 1948 Journal of the American Dental
Association1 shows that evidence of adverse health effects from fluoride was
censored by the US Atomic Energy Commission (AEC)-considered the most
powerful of Cold War agencies-for reasons of "national security".
· The bomb program's fluoride safety studies were conducted at the University of
Rochester-site of one of the most notorious human radiation experiments of the
Cold War, in which unsuspecting hospital patients were injected with toxic doses of
radioactive plutonium. The fluoride studies were conducted with the same ethical
mindset, in which "national security" was paramount.
EVIDENCE OF FLUORIDE'S ADVERSE
HEAL TH EFFECTS
The US Government's conflict of interest and its motive to prove fluoride safe in the
furious debate over water fluoridation since the 1950s has only now been made clear to
the general public, let alone to civilian researchers, health professionals and journalists.
The declassified documents resonate with a growing body of scientific evidence and a
chorus of questions about the health effects of fluoride in the environment.
Human exposure to fluoride has mushroomed since World War II, due not only to
fluoridated water and toothpaste but to environmental pollution by major industries,
from aluminium to pesticides, where fluoride is a critical industrial chemical as well as a
waste by-product.
The impact can be seen literally in the smiles of our children. Large numbers (up to 80
per cent in some cities) of young Americans now have dental fluorosis, the first visible
sign of excessive fluoride exposure according to the US National Research Council. (The
signs are whitish flecks or spots, particularly on the front teeth, or dark spots or stripes in
more severe cases.)
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Less known to the public is that fluoride also accumulates in bones. "The teeth are
windows to what's happening in the bones," explained Paul Connett, Professor of
Chemistry at St Lawrence University, New York, to these reporters. In recent years,
paediatric bone specialists have expressed alarm about an increase in stress fractures
among young people in the US. Connett and other scientists are concerned that fluoride-
linked to bone damage in studies since the 1930s-may be a contributing factor.
The declassified documents add urgency: much of the original 'proof' that low-dose
fluoride is safe for children's bones came from US bomb program scientists, according to
this investigation.
Now, researchers who have reviewed these declassified documents fear that Cold War
national security considerations may have prevented objective scientific evaluation of
vital public health questions concerning fluoride.
"Information was buried," concludes Dr Phyllis Mullenix, former head of toxicology at
Forsyth Dental Center in Boston and now a critic of fluoridation. Animal studies which
Mullenix and co-workers conducted at Forsyth in the early 1990s indicated that fluoride
was a powerful central nervous system (CNS) toxin and might adversely affect human
brain functioning even at low doses. (New epidemiological evidence from China adds
support, showing a correlation between low-dose fluoride exposure and diminished IQ in
children.) Mullenix's results were published in 1995 in a reputable peer-reviewed
scientific journaI.2
During her investigation, Mullenix was astonished to discover there had been virtually no
previous US studies of fluoride's effects on the human brain. Then, her application for a
grant to continue her CNS research was turned down by the US National Institutes of
Health (NIH), when an NIH panel flatly told her that "fluoride does not have central
nervous system effects".
Declassified documents of the US atomic bomb program indicate otherwise. A Manhattan
Project memorandum of29 April 1944 states: "Clinical evidence suggests that uranium
hexafluoride may have a rather marked central nervous system effect... It seems most
likely that the F [code for fluoride] component rather than the T [code for uranium] is
the causative factor." The memo, from a captain in the medical corps, is stamped
SECRET and is addressed to Colonel Stafford Warren, head of the Manhattan Project's
Medical Section. Colonel Warren is asked to approve a program of animal research on
CNS effects. "Since work with these compounds is essential, it will be necessary to know
in advance what mental effects may occur after exposure... This is important not only to
protect a given individual, but also to prevent a confused workman from injuring others
by improperly performing his duties."
On the same day, Colonel Warren approved the CNS research program. This was in
1944, at the height of World War II and the US nation's race to build the world's first
atomic bomb.
For research on fluoride's CNS effects to be approved at such a momentous time, the
supporting evidence set forth in the proposal forwarded along with the memo must have
been persuasive. The proposal, however, is missing from the files at the US National
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Archives. "If you find the memos but the document they refer to is missing, it's probably
still classified," said Charles Reeves, chief librarian at the Atlanta branch of the US
National Archives and Records Administration where the memos were found. Similarly,
no results of the Manhattan Project's fluoride CNS research could be found in the files.
After reviewing the memos, Mullenix declared herself "flabbergasted". "How could I be
told by NIH that fluoride has no central nervous system effects, when these documents
were sitting there all the time?" She reasons that the Manhattan Project did do fluoride
CNS studies: "That kind of warning, that fluoride workers might be a danger to the
bomb program by improperly performing their duties-I can't imagine that would be
ignored." But she suggests that the results were buried because of the difficult legal and
public relations problems they might create for the government.
The author of the 1944 CNS research proposal attached to the 29 April memo was Dr
Harold C. Hodge-at the time, chief of fluoride toxicology studies for the University of
Rochester division of the Manhattan Project.
Nearly 50 years later at the Forsyth Dental Center in Boston, Dr Mullenix was introduced
to a gently ambling elderly man, brought in to serve as a consultant on her CNS research.
This man was Harold C. Hodge. By then, Hodge had achieved status emeritus as a world
authority on fluoride safety. "But even though he was supposed to be helping me," said
Mullenix, "he never once mentioned the CNS work he had done for the Manhattan
Project. "
The "black hole" in fluoride CNS research since the days of the Manhattan Project is
unacceptable to Mullenix who refuses to abandon the issue. "There is so much fluoride
exposure now, and we simply do not know what it is doing. You can't just walk away
from this."
Dr Antonio Noronha, an NIH scientific review advisor familiar with Dr Mullenix's grant
request, told us that her proposal was rejected by a scientific peer-review group. He
termed her claim of institutional bias against fluoride CNS research "far-fetched". He
then added: "We strive very hard at NIH to make sure politics does not enter the
picture. "
THE NEW JERSEY FLUORIDE
POLLUTION INCIDENT
The documentary trail begins at the height of World War II, in 1944, when a severe
pollution incident occurred downwind of the E.I. DuPont de Nemours Company chemical
factory in Deepwater, New Jersey. The factory was then producing millions of pounds of
fluoride for the Manhattan Project whose scientists were racing to produce the world's
first atomic bomb.
The farms downwind in Gloucester and Salem counties were famous for their high-
quality produce. Their peaches went directly to the Waldorf Astoria Hotel in New York
City; their tomatoes were bought up by Campbell's Soup.
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But in the summer of 1944 the farmers began reporting that their crops were blighted:
"Something is burning up the peach crops around here." They said that poultry died
after an all-night thunderstorm, and that farm workers who ate produce they'd picked
would sometimes vomit all night and into the next day.
"I remember our horses looked sick and were too stiff to work," Mildred Giordano, a
teenager at the time, told these reporters. Some cows were so crippled that they could not
stand up; they could only graze by crawling on their bellies.
The account was confirmed in taped interviews with Philip Sadtler (shortly before he
died), of Sadtler Laboratories of Philadelphia, one of the nation's oldest chemical
consulting firms. Sadtler had personally conducted the initial investigation of the
damage.
Although the farmers did not know it, the attention of the Manhattan Project and the
federal government was rivetted on the New Jersey incident, according to once-secret
documents obtained by these reporters.
A memo, dated 27 August 1945, from Manhattan Project chief Major-General Leslie R.
Groves to the Commanding General of Army Service Forces at the Pentagon, concerns
the investigation of crop damage at Lower Penns Neck, New Jersey. It states: "At the
request of the Secretary of War, the Department of Agriculture has agreed to cooperate
in investigating complaints of crop damage attributed...to fumes from a plant operated in
connection with the Manhattan Project"
After the war's end, Dr Harold C. Hodge, the Manhattan Project's chief of fluoride
toxicology studies, worriedly wrote in a secret memo (1 March 1946) to his boss, Colonel
Stafford L. Warren, chief ofthe Medical Section, about "problems associated with the
question of fluoride contamination of the atmosphere in a certain section of New Jersey".
"There seem to be four distinct (though related) problems:
1. A question ofinjury of the peach crop in 1944.
2. A report of extraordinary fluoride content of vegetables grown in this area.
3. A report of abnormally high fluoride content in the blood of human individuals
residing in this area.
4. A report raising the question of serious poisoning of horses and cattle in this area."
FLUORIDE DAMAGE: THE FIRST
LA WSUITS
The New Jersey farmers waited until the war was over before suing DuPont and the
Manhattan Project for fluoride damage-reportedly the first lawsuits against the US
atomic bomb program. Although seemingly trivial, the lawsuits shook the government,
the secret documents reveal.
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Under the personal direction of Major-General Groves, secret meetings were convened in
Washington, with compulsory attendance by scores of scientists and officials from the US
War Department, the Manhattan Project, the Food and Drug Administration, the
Agriculture and Justice departments, the US Army's Chemical Warfare Service and
Edgewood Arsenal, the Bureau of Standards, as well as lawyers from DuPont.
Declassified memos of the meetings reveal a secret mobilisation of the full forces of the
government to defeat the New Jersey farmers.
In a memo (2 May 1946) copied to General Groves, Manhattan Project Lt Colonel
Cooper B. Rhodes notes that these agencies" are making scientific investigations to
obtain evidence which may be used to protect the interest of the Government at the trial
of the suits brought by owners of peach orchards in...New Jersey".
Regarding these lawsuits, General Groves wrote to the Chairman of the Senate Special
Committee on Atomic Energy in a memo of 28 February 1946, advising that "the
Department of Justice is cooperating in the defense of these suits".
Why the national security emergency over a few lawsuits by New Jersey farmers? In 1946
the United States began full-scale production of atomic bombs. No other nation had yet
tested a nuclear weapon, and the A-bomb was seen as crucial for US leadership of the
postwar world. The New Jersey fluoride lawsuits were a serious roadblock to that
strategy. "The specter of endless lawsuits haunted the military," wrote Lansing Lamont
in Day of Trinity, his acclaimed book about the first atomic bomb test.3
"If the farmers won, it would open the door to further suits which might impede the
bomb program's ability to use fluoride," commented Jacqueline Kittrell, a Tennessee
public interest lawyer who examined the declassified fluoride documents. (Kittrell
specialises in nuclear-related litigation and has represented plaintiffs in several human
radiation experiment cases.) "The reports of human injury were especially threatening
because of the potential for enormous settlements-not to mention the PR problem," she
added.
Indeed, DuPont was particularly concerned about the "possible psychologic reaction" to
the New Jersey pollution incident, according to a secret Manhattan Project memo of 1
March 1946. Facing a threat from the Food and Drug Administration (FDA) to embargo
the region's produce because of "high fluoride content", DuPont dispatched its lawyers to
the FDA offices in Washington, DC, where an agitated meeting ensued. According to a
memo sent next day to General Groves, DuPont's lawyer argued that "in view of the
pending suits...any action by the Food and Drug Administration...would have a serious
effect on the DuPont Company and would create a bad public relations situation". After
the meeting adjourned, Manhattan Project Captain John Davies approached the FDA's
Food Division chief and "impressed upon Dr White the substantial interest which the
Government had in claims which might arise as a result of action which might be taken
by the Food and Drug Administration" .
There was no embargo. Instead, according to General Groves' memo of27 August 1946,
new tests for fluoride in the New Jersey area were to be conducted not by the Department
of Agriculture but by the US Army's Chemical Warfare Service (CWS)-because "work
done by the Chemical Warfare Service would carry the greatest weight as evidence
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if...lawsuits are started by the complainants".
Meanwhile, the public relations problem remained unresolved: local citizens were in a
panic about fluoride. The farmers' spokesman, Willard B. Kille, was personally invited to
dine with General Groves (then known as "the man who built the atomic bomb") at his
office at the War Department on 26 March 1946. Although diagnosed by his doctor as
having fluoride poisoning, Kille departed the luncheon convinced of the government's
good faith. Next day he wrote to the general, expressing his wish that the other farmers
could have been present so that "they too could come away with the feeling that their
interests in this particular matter were being safeguarded by men of the very highest type
whose integrity they could not question" .
A broader solution to the public relations problem was suggested by Manhattan Project
chief fluoride toxicologist Harold C. Hodge in a second secret memo (1 May 1946) to
Medical Section chief Colonel Warren: "Would there be any use in making attempts to
counteract the local fear of fluoride on the part of residents of Salem and Gloucester
counties through lectures on F toxicology and perhaps the usefulness of F in tooth
health?" Such lectures were indeed given, not only to New Jersey citizens but to the rest
of the nation throughout the Cold War.
The New Jersey farmers' lawsuits were ultimately stymied by the government's refusal to
reveal the key piece of information that would have settled the case: how much fluoride
DuPont had vented into the atmosphere during the war. "Disclosure would be injurious
to the military security ofthe United States," Manhattan Project Major C. A. Taney, Jr,
had written in a memo soon after the war's end (24 September 1945).
The farmers were pacified with token financial settlements, according to interviews with
descendants still living in the area.
"All we knew is that DuPont released some chemical that burned up all the peach trees
around here," recalled Angelo Giordano whose father James was one of the original
plaintiffs. "The trees were no good after that, so we had to give up on the peaches." Their
horses and cows acted and walked stiffly, recalled his sister Mildred. "Could any of that
have been the fluoride?" she asked. (The symptoms she detailed are cardinal signs of
fluoride toxicity, according to veterinary toxicologists.) The Giordano family has also
been plagued by bone and joint problems, Mildred added. Recalling the settlement
received by the family, Angelo Giordano told these reporters that his father said he "got
about $200".
The farmers were stonewalled in their search for information about fluoride's effects on
their health, and their complaints have long since been forgotten. But they unknowingly
left their imprint on history: their complaints of injury to their health reverberated
through the corridors of power in Washington and triggered intensive, secret, bomb
program research on the health effects of fluoride.
"PROGRAM F": SECRET FLUORIDE
RESEARCH
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A secret memo (2 May 1946) to General Groves from Manhattan Project Lt Colonel
Rhodes states: "Because of complaints that animals and humans have been injured by
hydrogen fluoride fumes in [the New Jersey] area, although there are no pending suits
involving such claims, the University of Rochester is conducting experiments to
determine the toxic effect of fluoride. "
Much of the proof of fluoride's alleged safety in low doses rests on the postwar work done
at the University of Rochester in anticipation of lawsuits against the bomb program for
human injury.
For the top-secret Manhattan Project to delegate fluoride safety studies to the University
of Rochester was not surprising. During WWII the US Federal Government became
involved for the first time in large-scale funding of scientific research at government-
owned labs and private colleges. Those early spending priorities were shaped by the
nation's often-secret military needs.
The prestigious upstate New York college in particular had housed a key wartime
division of the Manhattan Project to study the health effects of the new" special
materials" such as uranium, plutonium, beryllium and fluoride which were being used in
making the atomic bomb. That work continued after the war, with millions of dollars
flowing from the Manhattan Project and its successor organisation, the Atomic Energy
Commission (AEC). (Indeed, the bomb left an indelible imprint on all of US science in the
late 1940s and 1950s. Up to 90 per cent of all federal funds for university research came
from either the Department of Defense or the AEC in this period, according to Noam
Chomsky in his 1997 book, The Cold War and the University.4)
The University of Rochester Medical School became a revolving door for senior bomb-
program scientists. The postwar faculty included Stafford Warren, the top medical
officer of the Manhattan Project, and Harold C. Hodge, chief of fluoride research for the
bomb program.
But this marriage of military secrecy and medical science bore deformed offspring. The
University of Rochester's classified fluoride studies, code-named "Program F", were
started during the war and continued up until the early 1950s. They were conducted at its
Atomic Energy Project (AEP), a top-secret facility funded by the AEC and housed at
Strong Memorial Hospital. It was there that one of the most notorious human radiation
experiments of the Cold War took place, in which unsuspecting hospital patients were
injected with toxic doses of radioactive plutonium. Revelation of this experiment-in a
Pulitzer Prize&endash;winning account by Eileen Welsome-led to a 1995 US presidential
investigation and a multimillion-dollar cash settlement for victims.
Program F was not about children's teeth. It grew directly out of litigation against the
bomb program, and its main purpose was to furnish scientific ammunition which the
government and its nuclear contractors could use to defeat lawsuits for human injury.
Program F's director was none other than Dr Harold C. Hodge- who led the Manhattan
Project investigation of alleged human injury in the New Jersey fluoride pollution
incident.
Program F's purpose is spelled out in a classified 1948 report. It reads: "To supply
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evidence useful in the litigation arising from an alleged loss of a fruit crop several years
ago, a number of problems have been opened. Since excessive blood-fluoride levels were
reported in human residents of the same area, our principal effort has been devoted to
describing the relationship of blood fluorides to toxic effects."
The litigation referred to and the claims of human injury were of course against the
bomb program and its contractors. Thus the purpose of Program F was to obtain
evidence useful in litigation against the bomb program. The research was being
conducted by the defendants.
The potential conflict of interest is clear. If lower dose ranges were found hazardous by
Program F, this might have opened the bomb program and its contractors to public
outcry and lawsuits for injury to human health.
Lawyer Jacqueline Kittrell commented further: "This and other documents indicate that
the University of Rochester's fluoride research grew out of the New Jersey lawsuits and
was performed in anticipation of lawsuits against the bomb program for human injury.
Studies undertaken for litigation purposes by the defendants would not be considered
scientifically acceptable today because of their inherent bias to prove the chemical safe. "
Unfortunately, much of the proof of fluoride's safety rests on the work performed by
Program F scientists at the University of Rochester. During the postwar period, that
university emerged as the leading academic centre for establishing the safety of fluoride
as well as its effectiveness in reducing tooth decay, according to Rochester Dental School
spokesperson William H. Bowen, MD. The key figure in this research, Bowen said, was
Dr Harold C. Hodge-who also became a leading national proponent of fluoridating public
drinking water.
THE A-BOMB AND WATER
FLUORIDATION
Program F's interest in water fluoridation was not just "to counteract the local fear of
fluoride on the part of residents", as Hodge had earlier written to Colonel Warren. The
bomb program required human studies of fluoride's effects, just as it needed human
studies of plutonium's effects. Adding fluoride to public water supplies provided one
opportunity.
Bomb-program scientists played a prominent, ifunpublicised, role in the nation's first-
planned water fluoridation experiment in Newburgh, New York. The Newburgh
Demonstration Project is considered the most extensive study of the health effects of
fluoridation, supplying much of the evidence that low doses are allegedly safe for
children's bones and good for their teeth.
Planning began in 1943 with the appointment ofa special New York State Health
Department committee to study the advisability of adding fluoride to Newburgh's
drinking water. The chairman of the committee was, again, Dr Harold C. Hodge, then
chief of fluoride toxicity studies for the Manhattan Project. Subsequent members of the
committee included Henry L. Barnett, a captain in the Project's Medical Section, and
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John W. Fertig, in 1944 with the Office of Scientific Research and Development-the
super-secret Pentagon group which sired the Manhattan Project. Their military
affiliations were kept secret. Hodge was described as a pharmacologist, Barnett as a
paediatrician. Placed in charge of the Newburgh project was David B. Ast, chief dental
officer of the New York State Health Department. Ast had participated in a key secret
wartime conference on fluoride, held by the Manhattan Project in January 1944, and
later worked with Dr Hodge on the Project's investigation of human injury in the New
Jersey incident, according to once-secret memos.
The committee recommended that Newburgh be fluoridated. It selected the types of
medical studies to be done, and it also "provided expert guidance" for the duration of the
experiment.
The key question to be answered was: "Are there any cumulative effects, beneficial or
otherwise, on tissues and organs other than the teeth, of long-continued ingestion of such
small concentrations?" According to the declassified documents, this was also key
information sought by the bomb program. In fact, the program would require "long-
continued" exposure of workers and communities to fluoride throughout the Cold War.
In May 1945, Newburgh's water was fluoridated, and over the next 10 years its residents
were studied by the New York State Health Department.
In tandem, Program F conducted its own secret studies, focusing on the amounts of
fluoride Newburgh citizens retained in their blood and tissues-information called for by
the bomb program in connection with litigation. "Possible toxic effects of fluoride were in
the forefront of consideration," the advisory committee stated. Health department
personnel cooperated, shipping blood and placenta samples to the Program F team at the
University of Rochester. The samples were collected by Dr David B. Overton, the
department's chief of paediatric studies at Newburgh.
The final report of the Newburgh Demonstration Project, published in 1956 in the
Journal ofthe American Dental Association,S concluded that "small concentrations" of
fluoride were safe for US citizens. The biological proof, "based on work performed...at
the University of Rochester Atomic Energy Project", was delivered by Dr Hodge.
Today, news that scientists from the A-bomb program secretly shaped and guided the
Newburgh fluoridation experiment and studied the citizens' blood and tissue samples is
greeted with incredulity.
"I'm shocked...beyond words," said present-day Newburgh Mayor Audrey Carey,
commenting on these reporters' f"mdings. "It reminds me of the Tuskegee experiment that
was done on syphilis patients down in Alabama. "
As a child in the early 1950s, Mayor Carey was taken to the old Newburgh firehouse on
Broadway which housed the public health clinic. There, doctors from the Newburgh
fluoridation project studied her teeth, and a peculiar fusion of two fingerbones on her left
hand which she's had since birth. (Carey said that her granddaughter has white dental-
fluorosis marks on her front teeth.)
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Mayor Carey wants answers from the government about the secret history of fluoride
and the Newburgh fluoridation experiment. "I absolutely want to pursue it," she said. "It
is appalling to do any kind of experimentation and study without people's knowledge and
permission. "
When contacted by these reporters, the now 95-year-old David B. Ast, former director of
the Newburgh experiment, said he was unaware that Manhattan Project scientists were
involved. "If I had known, I would have been certainly investigating why, and what the
connection was," he said. Did he know that blood and placenta samples from Newburgh
were being sent to bomb-program researchers at the University of Rochester? "I was not
aware of it," Ast replied. Did he recall participating in the Manhattan Project's secret
wartime conference on fluoride in January 1944, or going to New Jersey with Dr Hodge
to investigate human injury in the DuPont case, as secret memos state? He told these
reporters he had no recollection of any such events.
Bob Loeb, a spokesperson for the University of Rochester Medical Center, confirmed
that blood and tissue samples from Newburgh had been tested by the University's Dr
Hodge. On the ethics of secretly studying US citizens to obtain information useful in
litigation against the A-bomb program, he said: "That's a question we cannot answer."
He referred inquiries to the US Department of Energy (DOE), successor to the Atomic
Energy Commission.
Jayne Brady, a spokesperson for the Department of Energy in Washington confirmed
that a review of DOE files indicated that a "significant reason" for fluoride experiments
conducted at the University of Rochester after the war was "impending litigation between
the DuPont company and residents of New Jersey areas". However, she added: "DOE
has found no documents to indicate that fluoride research was done to protect the
Manhattan Project or its contractors from lawsuits."
On Manhattan Project involvement in Newburgh, Brady stated: "Nothing that we have
suggests that the DOE or predecessor agencies-especially the Manhattan Project-
authorised fluoride experiments to be performed on children in the 1940s."
When told that these reporters have several documents that directly tie the AEP-the
Manhattan Project's successor agency at the University of Rochester-to the Newburgh
experiment, DOE spokesperson Brady later conceded her study was confined to "the
available universe" of documents.
Two days later, Brady faxed a statement for clarification. "My search only involved the
documents that we collected as part of our human radiation experiments project; fluoride
was not part of our research effort."
"Most significantly," the statement continued, "relevant documents may be in a classified
collection at the DOE Oak Ridge National Laboratory, known as the Records Holding
Task Group. This collection consists entirely of classified documents removed from other
files for the purpose of classified document accountability many years ago [and was] a
rich source of documents for the human radiation experiments projects."
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SUPPRESSION OF ADVERSE HEALTH
FINDINGS
The crucial question arising from the investigation is whether adverse health findings
from Newburgh and other bomb-program fluoride studies were suppressed. All AEC-
funded studies had to be declassified before publication in civilian medical and dental
journals. Where are the original classified versions?
The transcript of one of the major secret scientific conferences of World War II-on
"fluoride metabolism"-is missing from the files of the US National Archives and is
"probably still classified", according to the librarian. Participants in the January 1944
conference included key figures who promoted the safety of fluoride and water
fluoridation to the public after the war: Harold Hodge of the Manhattan Project, David
B. Ast of the Newburgh Demonstration Project, and US Public Health Service dentist H.
Trendley Dean, popularly known as "the father of fluoridation".
A WWII Manhattan Project classified report (25 July 1944) on water fluoridation is
missing from the files of the University of Rochester Atomic Energy Project, the US
National Archives, and the Nuclear Repository at the University of Tennessee, Knoxville.
The next four numerically consecutive documents are also missing, while the remainder
of the "M-1500 series" is present.
"Either those documents are still classified, or they've been 'disappeared' by the
government," said Clifford Honicker, Executive Director of the American Environmental
Health Studies Project in Knoxville, Tennessee, which provided key evidence in the
public exposure and prosecution of US human radiation experiments.
Seven pages have been cut out of a 1947 Rochester bomb project notebook entitled
"DuPont Litigation". "Most unusual," commented the medical school's chief archivist,
Chris Hoolihan.
Similarly, Freedom of Information Act (FOIA) requests lodged by these reporters over a
year ago with the DOE for hundreds of classified fluoride reports have failed to dislodge
any. "We're behind," explained Amy Rothrock, chief FOIA officer at Oak Ridge
National Laboratories.
So, has information been suppressed? These reporters made what appears to be the first
discovery of the original classified version of a fluoride safety study by bomb program
scientists. A censored version of this study was later published in the August 1948
Journal of the American Dental Association.6 Comparison of the secret version with the
published version indicates that the US AEC did censor damaging information on
fluoride-to the point of tragicomedy. This was a study of the dental and physical health of
workers in a factory producing fluoride for the A-bomb program; it was conducted by a
team of dentists from the Manhattan Project.
The secret version reports that most of the men had no teeth left. The published version
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reports only that the men had fewer cavities.
The secret version says the men had to wear rubber boots because the fluoride fumes
disintegrated the nails in their shoes. The published version does not mention this.
The secret version says the fluoride may have acted similarly on the men's teeth,
contributing to their toothlessness. The published version omits this statement and
concludes that "the men were unusually healthy, judged from both a medical and dental
point of view" .
After comparing the secret and published versions of the censored study, toxicologist
Phyllis Mullenix commented: "This makes me ashamed to be a scientist." Of other Cold
War&endash;era fluoride safety studies, she asked: "Were they all done like this?"
Asked for comment on the early links of the Manhattan Project to water fluoridation, Dr
Harold Slavkin, Director of the National Institute for Dental Research-the US agency
which today funds fluoride research-said: "I wasn't aware of any input from the Atomic
Energy Commission." Nevertheless, he insisted that fluoride's efficacy and safety in the
prevention of dental cavities over the last 50 years is well proved. "The motivation of a
scientist is often different from the outcome," he reflected. "I do not hold a prejudice
about where the knowledge comes from."
Endnotes:
1. Dale, Peter P., and McCauley, H. B, "Dental Conditions in Workers Chronically
Exposed to Dilute and Anhydrous Hydrofluoric Acid", Journal of the American Dental
Association, vol. 37, no. 2, August 1948, pp. 131-140. Note that Dale and McCauley were
both Manhattan Project and, later, Program F personnel; they also authored the secret
Manhattan Project paper.
2. Mullenix, Phyllis et aI., "Neurotoxicity of Sodium Fluoride in Rats", Neurotoxicology
and Teratology, vol. 17, no. 2, 1995, pp. 169-177.
3. Lamont, Lansing, Day of Trinity, Atheneum, New York City, 1965.
4. Chomsky, Noam, The Cold War and the University, New Press, New York City, 1997
(distributed by W.W. Norton & Co. Inc., NYC).
5. Hodge, H. C., "Fluoride metabolism: its significance in water fluoridation", in
"Newburgh-Kingston caries-fluorine study: final report", Journal of the American
Dental Association, vol. 52, March 1956.
6. Dale and McCauley, ibid.
About the Authors:
Joel Griffiths is a medical writer based in New York City. He is the author of a book on
radiation hazards that included one of the first revelations of human radiation
experiments, and has contributed numerous articles to medical journals and popular
publications.
Chris Bryson, who holds a Master's degree in journalism, is an independent reporter for
BBC Radio, ABC-TV and public television in New York City, and writes for a variety of
publications.
The authors wish to thank Clifford Honicker, Executive Director of the American
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Environmental Health Studies Project, Knoxville, TN, for his indispensable archival
research.
Resources:
Copies of 155 pages of supporting documents, including all the declassified papers
referred to in this article, can be obtained from the following contacts for a small fee to
cover copying and postage:
M Australia: Australian Fluoridation News, GPO Box 935G, Melbourne, Victoria 3001,
phone (03) 9592 5088, fax (03) 9592 4544.
M New Zealand: New Zealand Pure Water Association, 278 Dickson Road, Papamoa, Bay
of Plenty, phone (07) 542 0499.
M UK: National Pure Water Association of the UK, 12 Dennington Lane, Crigglestone,
Wakefield, WF4 3ET, phone 01924 254433, fax 01924 242380.
M USA: Waste Not newsletter, 82 Judson Street, Canton, NY 13617, phone (315) 379 9200,
fax (315) 379 0448, e-mail wastenot@northnet.org.
ack to The Truth?
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