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Agenda 05/10/2016 Item #11B5/10/2016 11. B. EXECUTIVE SUMMARY Recommendation to provide direction to staff regarding the use of fluoride in the public potable water supply distributed by the Public Utilities Department's Water Division. OBJECTIVE: To provide information to the Board and the public regarding the practice of fluoridating drinking water in Collier County and elsewhere. CONSIDERATIONS: On January 12, 2016, the Board of County Commissioners heard a public petition from Ms. Camden Smith advocating for the Collier County Water/Sewer District to discontinue the use of fluoride in the public potable water supply. In response to Ms. Smith's presentation, the Board directed staff to schedule the issue for further discussion and evaluation. The following information is included for the Board's consideration: • A Power Point presentation from the Collier County Health Department Administrator • The Power Point presentation presented by Ms. Smith in January • A copy of the minutes from the September 13, 2011 Board of County Commissioners meeting (item I OC), which is the most recent full discussion of this issue by the Board. • The Collier County Water Division is one of several potable water providers operating in Collier County. The following is a list of the utilities providing drinking water locally: utility Number of Customers Fluoridation Ave Maria 2,792 No Marco Island 27,500 No of Naples 52,906 Yes -City Collier County 156,080 Yes FGUA (Water Utility Company) 15,381 Yes Immokalee Water/Sewer 26,837 Yes • Using data from The South Florida Water Management District's 2012 update to its Lower West Coast Water Supply Plan, staff estimates that in 2016, there are approximately 40,000 households in Collier County presently using domestic water wells for their drinking water. FISCAL IMPACT: The Public Utilities Department reports that it costs approximately $30,000 annually to fluoridate the drinking water supply. This equates to about $0.0033 per 1,000 gallons of water produced, which equates to $0.02 per month or 24 cents per year per customer. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney. This is a pure policy decision, as there is no legal requirement that Collier County add fluoride to its drinking water. This item requires majority vote for Board action. -JAK GROWTH MANAGEMENT IMPACT: None Packet Page -57- 5/10/2016 11.B. RECOMMENDATION: That the Board of County Commissioners provides direction to staff regarding the use of fluoride in the public potable water supply distributed by the Public Utilities Department's Water Division. Prepared By: Steve Messner, Public Utilities Water Division Director Attachments: 1. PowerPoint presentation from the Collier County Public Health Department 2. Letter to Board May 3 2016 Camden Smith 3. Camden Smith Backup to BOCC May 10, 2016, due to the size of this PDF, which is 5.25 MB and 93 pages long, it is accessible at: httR:H=s3.colliergov.net/agenda/ftp/2016BCCMeetingsagendaMn 10 1 6/PubServices/CAMD ENSMITHBACKUPTOBOCCMAY 102016.pdf 4. Ms. Camden Smith Back-up due to the size of this PDF, which is 33.07 MB and 58 pages long, it is accessible at: httv://Ms3.colliergov.net/a eg nda/ftp/2016BCCMeetings/AgendaMav1016/PubServices/Back- W pdf 5. Agenda item IOC September 13, 2011 Executive Summary 6. Agenda item l OC September 13, 2011 Health Department Power Point 7. Agenda item l OC September 13, 2011 Exhibit A 8. Agenda item IOC September 13, 2011 Exhibit B 9. Agenda item 1 O September 13, 2011 Exhibit C 10. Minutes from the September 13, 2011 (pages 47 pertaining to item 10.C) T� Packet Page -58- COLLIER COUNTY Board of County Commissioners Item Number: 11.11.8. 5/10/2016 11.B. Item Summary: This item to be heard at 10:00 a.m. Recommendation to provide direction to staff regarding the use of fluoride in the public potable water supply distributed by the Public Utilities Department's Water Division. (Steve Carnell, Public Services Department Head) Meeting Date: 5/10/2016 Prepared By Name: AlonsoHailey Title: Operations Analyst, Public Services Department 4/29/2016 9:06:56 AM Approved By Name: AlonsoHailey Title: Operations Analyst, Public Services Department Date: 4/29/2016 9:58:07 AM Name: Steve Messner Title: Division Director - Water, Water Date: 4/29/2016 1:08:35 PM Name: YilmazGeorge Title: Department Head - Public Utilities, Public Utilities Department Date: 5/2/2016 3:12:29 PM Name: CarnellSteve Title: Department Head - Public Services, Public Services Department Date: 5/2/2016 5:15:08 PM Name: KlatzkowJeff Title: County Attorney, Date: 5/3/2016 10:52:22 AM Name: FinnEd �.� Title: Management/Budget Analyst, Senior, Office of Management & Budget Packet Page -59- Date: 5/3/2016 6:19:14 PM Name: KlatzkowJeff Title: County Attorney, Date: 5/4/2016 3:19:45 PM 5/10/2016 11.B. Name: CasalanguidaNick Title: Deputy County Manager, County Managers Office Date: 5/4/2016 3:50:08 PM Packet Page -60- m flori da Department of Health is strongly committed r p gY - e-fluoridation of community water systems. It is an. =a1publ i c health measure where everyone benefits, tda ether rich or poor, no matter the age, without g in an conscious effort of the individual. 4 _ Y John H. Armstrong, MD, FACS Former Surgeon General & Secretary Florida Department of Health 2 v v m CU as rn w 01 O N O 07 W 4 4 "perience, broad recognition and tecommenciation ,.,r,ommunitv Wates Fluoridation' duces Disparities One of e thTopTen Achievements in Public Health o the 201hCenturyf May 3, 2016 Board of County Commissioners 3299 E. Tamiami Tr. Suite 303 Naples, Florida 34112 Dear Honorable Commissioners, 5/10/2016 11. B. Camden Smith 6145 Montelena Circle #5102 Naples, Florida 34119 It is with great respect I bring before the Board of County Commissioners today my request for the County to end the water fluoridation program. Included in my End Water Fluoridation Packet is my previous presentation to the Board with backup for the studies mentioned in the presentation including those addressing decreased IQ effects caused by over exposure to Fluoride. While I am not a toxicologist or a medical expert, I am an expert on public policy with a Masters in Public Administration and strategic planning. As we already know, water fluoridation was brought about in the 1950s predominately, but few studies have been conducted in the United States since that time to truly determine the cause and effect of water fluoridation. Fluoride is currently the only medical preventative method allowed to be placed in the public drinking water to actually prevent a medical problem such as tooth decay. There are no other drugs allowed in drinking water or public utilities for any medical disease or issue not even for ADD, Alzheimer's or heart disease. There is a reason for this and it is because patients are required, by law, to consent to being given drugs. No one has consented to water fluoridation and yet the FED and local municipalities continue to administer this drug for preventative measures in the water. This absolutely boggles my mind. Arguments on both sides may be made for keeping fluoride in the water and for taking it out, but the basic premise of a patient's right to offer consent should be the final deciding factor. While I may not want fluoride in my water or system, some of you may wish to internally take fluoride. It is each of our rights to decide what we place in our body. Chlorine is placed in the water to make it safe not to treat a disease. I ask you to seriously consider this as you review all sides on the water fluoridation matter before you on Tuesday, May 10, 2016. Rather than keeping with the old, we must recognize that medicine changes, hygienic care has certainly improved since the 1950s and people who wish to have access to Fluoride are certainly able to without the water fluoridation program. While water fluoridation costs the County if my accounting is correct less than $30,000 per year, over exposure to Fluoride in sensitive systems such as mine can cause medical problems that cost someone quality of life which is invaluable to us all. Sincerely, Camden Smith Packet Page-68- 5/10/2016 11. B. EXECUTIVE SUMMARY Provide a staff response to the question of using fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department, as directed by the Board of County Commissioners during its June 14, 2011 meeting. OBJECTIVE: To provide a staff response to the question of using fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department, in response to a Public Petition presented by Mr. Frank Oakes during Agenda Item 6.1). at the Board of County Commissioner's June 14, 2011, meeting. CONSIDERATIONS: A recommendation to stop the use of fluoride in the county -supplied potable water was proposed during a Public Petition by Mr. Frank Oakes, a private citizen and customer of the Public Utilities Division's Water Department. The Board of County Commissioners voted to bring the issue back at a later meeting so that they could hear from staff on this issue. The Board asked that staff review the use and safety of adding fluoride to the public potable water supply, and provide a presentation. Three exhibits are provided for information and review: • Exhibit A, Fluoridation and Neurotoxicity, was provided by an interested citizen, and is included by request; it includes a one-page release by the United States Environmental Protection Agency and a web -article from Mercola.com by Drs. Paul and Ellen Connett • Exhibit B, Fluoridation Facts, was provided by the American Dental Association. • Exhibit C, Fluoridation Information, provided by the Collier County Department of Health, is a compilation of fluoridation -related information from various agencies and organizations, including the United States Centers for Disease Control, the United States Public Health Service, Department of Health and Human Services, the Florida Dental Hygiene Association, the Florida Medical Association, the Florida Journal of Environmental Health, the Florida Dental Association, the Association for Dental Research, and the Florida Department of Health. The fluoridation of the public water supply is not mandated by any regulatory agency. Rather, the question of whether or not to fluoridate the public water supply is one of public health. The Collier County Water Department has provided drinking water with the optimal amount of fluoride since August 28, 1984. There has been no finding or evidence of negative public health impact provided by the Florida Department of Health or the Collier County Department of Health. FISCAL IMPACT: The estimated annual cost of fluoridation is $32,600.00; the source of funding is Water User Fees. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney and raises no legal issues. —JAK. GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this item. Packet Page -69- 5/10/2016 11.B. RECOMMENDATION: That the Board of County Commissioners provide direction to staff regarding .-. the use of fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department. Prepared By: Paul E Mattausch, Director, Collier County Water Department Attachments Packet Page-70- C)l C) N O W Considerations • • s is $32,600 t7 rD rD V -P _� .,}•-- � _-,..�_�. ��'e 'QVC \ �f'.�1.. C6 'n<izna�Dd5,I rtc. rtntet ra nin ` irpinia e4i-t._ 1 c:n�,��re5etty � ��—� Tuisa ti��f5.•,Ite-D�+, c cn—� � � .,,-.�,- 4 • •.. i -=rylemphis —.. LC;3 1I6 qu arrug �klznc-ma �iC�,1 1 Hat i;m r, r ti i R A�,ampiled b the rm66,an l7era#aC FksQ ci,it;oF, endCeprErs forDisease Control l arid Oraf He,�ith- I46r,Motion curram ei0f MtaY,2(105. O N O I CY) National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay Officials ria . Academy of Dentistry International American College of Dentists Academy of _General Dentistry American College of Physicians -American Academy for Sports Dentistry Society Alzheimer's Association of Internal Medicine America's Health Insurance Plans American College of Preventive Medicine American Academy of family Physicians American College of Prosthodontists American Academy of Nurse American Council on Science and Health F,. Practitioners American Dental Assistants Association American Academy of Oral and American Dental Association Maxillofacial Pathology American Dental Education Association American Academy of Orthopaedic American Dental Hygienists' Association Surgeons _ American Dietetic Association American Academy of Pediatrics American Federation of Labor and American Academy of Pediatric Congress Dentistry of Industrial Organizations American Academy of Periodontology American Hospital Association American Academy of Physician American Legislative Exchange Council Assistants American Medical Association C, American Association for Community American Nurses Association Dental Programs American Osteopathic Association American Association for Dental American Pharmacists Association Research American Public Health Association American Association for Health American School Health Association Education American Society for Clinical Nutrition Am erican Association for the American Society for Nutritional Sciences Advancement of Science American Student Dental Association American Association of endodontists American Water Works Association American Association of oral and Association for Academic Health Centers- Maxillofacial Surgeons Association of American Medical Colleges American Association of Orthodontists Association of Clinicians for the American Association of Public' Health Underserved Dentistry Association of Maternal and Child Health American Association of Women Programs ;. Dentists Association of State and Territorial Dental American Cancer Society Directors Association of State and Territorial Health Officials ria . National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay Association of State and Territorial National Confectioners Association Public Health National Council Against Health Fraud Nutrition Directors British Fluoridation Society National Dental Assistants Association National Dental Association Canadian Dental Association Canadian Dental Hygienists Association C National Dental Hygienists Association National Down Syndrome Congress Canadian Medical Association National Down Syndrome Society .Canadian Nurses Association National Eating Disorders Association Canadian Paediatric Society National Foundation of Dentistry for the Canadian Public Health Association Child Welfare League of America Handicapped ' Children's Dental Health Project National Head Start Association National Health Law Program Chocolate Manufacturers Association National Healthy Mothers, Healthy Consumer Federation of America Babies Coalition Council of State and Territorial Oral Health America Epidemiologists Robert Wood Johnson Foundation Delta Dental Plans Association Society for Public Health Education FDI World Dental Federation Federation Society of American Indian Dentists of American Hospitals Special Care Dentistry ` Hispanic Dental Association Academy of Dentistry for Persons with Indian Dental Association (U.S.A.) Disabilities Institute of Medicine American Association of Hospital International Association for Dental ResearchDentists International Association for American Society for Geriatric Dentistry The Children's Health Fund Orthodontics The Dental Health Foundation (of <x International College of Dentists California) March of Dimes Birth Defects U.S. Department of Defense Foundation National Association of Community - U.S. Department of Veterans Affairs P-4 Health Centers U.S. Public Health Service National Association of County and City... Health Resources and Services Health Officials Administration (HRSA) ational Association of Dental Centers for Disease Control and Assistants National Association of Local Boards of Prevention (CDC) National Institute of Dental and Health Craniofacial Research (NIDCR) """ik�sNntinnAl Accnrantinn of SocialWorkers World Federation of Orthodontists Cal C) N O d7 C go to n ID rrt v UU (D V 00 1, Centerefor LDiseat.e IZ:oratrol,and Prevention. Ten grt vt prrfa€c health avlsiaveneea»,—La rdtesd.States$ 1990-19199- M141WR 1999,43r121:2x31-3- 2. Ce nturs for Dissase Contraland Prvventitnna Fluo- ridation of drinking water to prevent dental sari+ ti. M-Mk?4+'R 1;y33 18i4ik,933-40. 3 Operational periiries and recommendations regarding community waterfluorrdetlpn (7'r zr?r�. 1697-6573), 4. AIDA statement cQmmemoratrn,g the 6011, annive-rsory of r-omrnunity, water luoriciAtian;2005- 5. US EDepaeronerit ref Health and Hurn an Servicus, Public Health Service-_ SurgconGgeneral statement can+-urnmunity ti++.rater- fluoreidatlon- Washington, DC.- December C.Dece ber a. 2oo1 �. ivlcK yfS, Mott€gad enamel_ the prevention of its further productian through a chance of the water Supply at Oakleyr, lds. J Am Oent "Assoc -11933;20( `?. 1137-49- - McClure FJ. Water- flu ori dation; the aearch'and the `uiirrtory, Sethesda, Maryland: Naria nal institute of dental Research;'1970, $_ Srnith MCI Lantz EM, Smith H%/- THe rr Avta of mottled enamel, ,fix dcfesct of humanteeth-Utlivursity cri",�`krizaria. College of Agriculture, Agriculture Exp. =i3t, r Technical Bulletin :32 1931,25.3-82.` 9. Churchill 1-I'tf- The oct„urrsnce of fluorides io,sotria wate3rs of the 1Jnited States- J Arn Wata r Works Asace 1831;23(9)_139 1407 _ t 10- D eaaq, T: Chronic endemic dental fiuOrca;;is, ,J^N?IA 193667 4 a �)� l 2.€9-73. '11- Dears HT, Endermic fl€raroals::and Its relation to dental caries. Public'Health Rup -144-3-52< 12'. Lean F T;,Arnold FAA9... ! .F f orgiastic water and dental canes_ Pub ielt"Orfth £i sp-7942;67132#a'i 155-79, 13. Cox GJ, (3t1, iuschak MC,. drxon SFr Dodds MLr Walker WE_ Experimental dental caries Irl. Fluorine ci ad its: relation to denri3i Carics. J. Cent Rss 1935; 1571=431 -SCF; "14, mean H -T. Arrtg1c(, if FA, Kntttsrxn JW Studias.orl. naa3s r€xntF'ta€isagS thruat�h f1,Er��cfct of the publrcti��[ t. fxpojy, Public Health 0,640dsc; n5{431.;.1493 -8n:. i5.A. L7B',, et al_ Ne+vtauralG-Kiragstvn caries -fluorine st lel(:' final red cert, J Am Dent Assoc 1 6;52i31:29G-325- 145- Rrov;n'HK,,. Poplovr- Mi, Thu Brantford-Samir.-�Str"atlord fl€ E)iridation varies study: final t.41rvgV, 1963_ luted Serv- 13 US CDeoartmant-OtFie�#tl� raracJ Haarri3n Sorvices. 1 few€#Jay ire i + j i#? Bead ad. With r-sn0crstanding 3ratt treater ov9ri 1 hea1"6 snd r7 je3rtrV+3& for irrt s +�irrg hsaltI1. 2"vols- Wnahiraton. DC_US Govern. mint ing Offrce�Novum ber2000- 20, 0_20, US Department of Health and 1-IrrrnOn SSerylbes. Oral health in America., s report of the Surgeon "Oerac Rockville, MD., U,$ Oupartment, of HeaJrh'and Hca Servvive-s, National Institute of Dental and _Crani Research, Nationtil Institutes of �7". 21; Burt 13A. Fluoridation and social equity.J Public, HealLl�s CD�rac 2EDCi2:fr2�d-i 'L9rs^=L1t3a 22. S1 Abu ncerA " Sta%vartJF rrrFiu ?tc �" - h� watery on s660- econamiO4 sariea experien,ce- r:rars munj*LM #yi 23- Riley .Jl„ L.enn©n NW"- # ;T'pf. water - fluoridation an al inequalRiew'.0 a,don-ta;l caries in s-: aor told childran. int ltoderraical 9 P 3c3t31]= 24, Jones, ir' }+i,orthington H_The reli"� .hi{Yta r3en water lotion einel st7cinseonortl ile fC xr on tool yrin 5: yrear-old cholarc3n Bryjoent J ' 25. U,$. Ovpartrnent of Healiht and Humanr Anations l Call to action try pronate arm Department of Health and Human Ser+tF 26. Hart #Riot 1195e 27: M#!$1 thel 2000 28, Navy J Pu 29 SnM 1n J ❑ 30: Arriii Prcatl diag tine 1@�5 3l_ J Can 19s35;21t7}; Upiderniol'n 12- U;� 06partment of Health arae! Herman Services- For 32_ Dye, g! S1 a hasy, wuxtion. returns onnves!% tent in. public- Sdtfl .i €►ef# heW,pwax CSC; US Cavernment Printing Of d fir +� ire :1 rr� ,� 1r Oat_ z 75- LJ'-'; [3epa neat cl l i Orad. iuman Serv#ees, Pub#iu klealttF xl ei��d [3 ! sLaBetr�6rtx: , ars cortlrntjiington, Jam, •' sl3?J irE th&�s� '�fi60"Anrr Rev PAllot i � ftracrriCtzl#ion. criO N O 07 Q U1 O N O 0) All sv n CD N C14 N 80 O e 72, :A!S)-,21-54.F's Ewena DJ, Ru9tff i urrrt A J. 'i-abarl ED, Bufler E_ The m Narioriar Institute of Dental Fte g;ea eh- Statement on Ggr;ch, 13F, Truman 61, Grlffirt Std, Kohn y."1G, Sul+e-.. offucri of fluoridation acid acci-2il clann on nar49;3 ` eflcctivrncaSS of water fluoridation, Betbesda:Decersnber � Dent Oral Epidemipf t.xp4rIancc`:in 5 -year --ofd Newcastie chitC.le-ea in: 1994. comp3rtson Cal electe: vi€fr na r� on Inter en Buns t. Ka[Sbeec H, Kwan! Gw, Garoeneveld , Oirkn QB, van rirsm,pareq+; 1v'-;n6tu[t.ovar ae,pre'vious'lsyesria;'. � rra Dent i#_ BAK Lem" CVV.D3 ho -MV Ji'1,Aria MC- Cc.nrrnlW�dfluorida- end 3 arts -r ix Berl c rai4f� nal Injuries. Am l F'rcv -e.er-c-xls9 f Chili i*n In °l'hti Ni th"Hpnds after c&iac 3tttaryu Y3on cf. tion: the dental.e ftects Pf di*continuaiion rti-AntirTo, 73 tsr,aail Al_ Prrvrantfnn of early childhood sarin--;- 5-ponccrAJ, Slaae GD, Cevie��- Ni_ Wnt.r..r fluoridation In i oar min_ J A n Dent AaseaGr1970,{fch132-�, Commun1ty Dent Ornf Epi0prnical 1998;2btsuppi,71: 8±3: a"tEf3he, i KW, McCall DFL'rulli'a JI_ C:aria s prevalence: Gra!y, frl Mr E3�vies- yEcwach J� Changes in the percent_ 49-1611 in northern Scotialld bccfcare, and S yea r,v— aftor, v.•, tear 74. NIH consansuns statement 2001. Ditgn4;+5is and decay in Dudley towns since the irnplementa= deiluorirfatiVn Br Dent J e'rtanagernerit of comal caries thrt>tagh,out life- March ',.3' 0 An wood D, glinkhorrt.AS, E]v�x�tl�l ho;,Ith in school- . 9$. Niessen LC 'klft, yin€ RJB- Causes of routh los in a 87, c-hildren 9 vesture aftervvarrrftraorfdaiada5 ce4!,t4.r-d in -'S_ CA'�rttiors for Qisv3ise C Oruxod en -d Fr'eventisn_ Prornot- cnriq�; in 9 --and T2 -Veer -old chilcIrgn from C'. nterbur'y. souen-vvest Sr-ptfen€i..Int l?es€tJ ing,orat health.- interventions for preventing dental ::1c Burt BA. Eklund SA. Loss -c �e "�'s J- Drnt�� h� r�eflta of caries, acral and 1pharyn5g�icancor�, and spo t -stated 32:_ _ linmited exposure Grs f'h2prirl;jed watar In dhildhQud. .for ail HMO dental p-.�putation- J Public Health IIertnr rz�nis #:�cia( ink€ €ies-, a report eta r4-C42i nrnon a€ions of" .Brumley atatus and i�arie"r� enf�7#Yri�f1�+� ire Chfldnin_ J Public: ,J Dent Res. 1986;161 tlI I.,T322-5_ the "yank Forc- an Carii=unit'y' Preventive °*,3`ervfeee- UZ Way 13.ty,'1_Thc_ offa3�ct on dental, caries of rE Janos toM, b7 xhln1#6n 1-l- Water fkjori,�atf on' h.1r,a1V^Ft 2 1;6r7jNp. RH-211.1-12, a n4turatly fluoridated is ,1 -fhaoride-Free cornrrtcnat 76 Teak Force:on!Dom unity Flreventtve Serl+iCe!�t- J Deni 2x00 2 -q$ 3 'µvetar J Dent Child 19F54.31 ASIT. Racomrnendatlot,v!s on sofuiatqri inter-ventions' to !93n Kunzeel W, Vrxcmer T Carl pr--evalenap after ce33sa€I ual-I proyent dental caries, oral artd phatyngoal cancers. : of water ftuo r[d,ati on in 1,.a Salud. Cuba- Caries Ror and imports-rotatod craniofaciai injuries - Am J Fro -v 2000;3411l)-20-5, lS�is,#'2i3cp2:� 11:5J: tri -30, 9af_ S-2ppo L, Hzusen H, l arkkairaan S, Lrermas NI, Carlen 7-- in4man St, mooch BF, Suluaiana 1. Gift HC, f-rorowitz 'occurrence in a fluoride ted and a nonfluorid.atod ANI, Eva n4, Jr CA, €,�:riffin SO, Cassie-KuH VG, ')"ask town in Finland: a retro-- ctivc 5tvdy Usin-1 longir Forte an Community PTUV4fnfiv8 :S�j9%1 -ea_ ftevrevv-e of tudt tail data rrt1M Public dental set:-€rrds. Carlos €tee ovidonco orr interveh donaD to prevent dcnt�;! caries. oral i .'002-;3F3{5}; 8-14# and pharyngeal eanncers, and sPok'ts-ralstcd craniaf.,1- 25 - Kun;el MY Fi f7 -r L C: fi a4- UJ5 C-spr at-crnervt or Health and 1-1umars ServU e3. Public Health Sc rvic#a.. Review of ffuorkde- ber:cf _ and risks.: 1 Repor€ of the Ad Npc Subccmmattea on Piuuride. wraAS;in9t4ru, �CsFab�ruary- 991 102, - k3 , l_eerwr3 [ VVa Ranting Q'01, Watef flamuriz3atEon . cElrran:€ nFfV tfv8ne and tje-faut flunrc^,i,., Community airy Dent Ora l,Ep5ns dmiol t9!)4,222153 -e_ 816 Griffin SOf Guoch EJ -F, Lcc.kw-co-d 5A, Touiar,Si-. Quan- Iifyrang the diffused tmoofit from Water flucarid ttion to t1143 United statam- Cammun:.hy Dent Oral Epidormo,t i :�tc§gv.:.. t.lnev47.r5it-Y of North OtrrMainn 1997,. xF Medicare & Modicairt S arui+xe , Crf3c Uary,, NO -fir oaf Health Stili-t[cs. Ta We sl taiees iof hteittlt services and supe lea; �.pragrams, by type of expdr t stilre.snid ggjsf ar year 2GU3, ,RFtcza -86uckums AA. Wei, 61a nat *q rr'i�aJaI!! nr« CJS:_ r'hisn._�i' Cr O N O tial iniurlea.m,JFrevly ool2000 t;23 _ ss er rr,era2 , ru man d, Decllnt!. n of carke ma Preual nce aftor the, cessati art or wrote r +8_ Ggr;ch, 13F, Truman 61, Grlffirt Std, Kohn y."1G, Sul+e-.. �fluorici ntivn in the font -1 r E:�st G17Tmanyr. C-arnrnUlbfty, mana3 1, Girt HC, Hgfow� l NIS Evao!�, Jr CA— A � Dent Oral Epidemipf comp3rtson Cal electe: vi€fr na r� on Inter en Buns t. Ka[Sbeec H, Kwan! Gw, Garoeneveld , Oirkn QB, van prevenii dcn.zal r9t�t'i•ars, ❑rat 3cts9 ¢t'inrrt•ngaaat-car+3rs, t-.. :Ee#t`AA Tk,rxucts l-!i`J1. c.`:�r as e.cperirzedi3 of l9- end 3 arts -r ix Berl c rai4f� nal Injuries. Am l F'rcv -e.er-c-xls9 f Chili i*n In °l'hti Ni th"Hpnds after c&iac 3tttaryu Y3on cf. trL .€t'' �f82, 4 7 raF_S5 d swster ckrsf`I€fafian. Caries Rem 1993,2743)-201-5. 79- 5-ponccrAJ, Slaae GD, Cevie��- Ni_ Wnt.r..r fluoridation In 97. ;LT5 04p4lrtrnem 3f Health and Human Senerces, Public Austtal'axiz Ccamrst Qent Health }896,93(supp`1 2);27-37. HaaftK orvice- Toward t9Tipro,.'fj,,V rho rarnl fry alth u0. Gra!y, frl Mr E3�vies- yEcwach J� Changes in the percent_ c fAriaar• gane:._en overview oforaf status, reeavccrcas ago df 5—year—.raid childrera'niaaeih no oxpnrir3ncq of ` on health Carel:. dGfivrr,+ Report t5t the Uni#rd S'"tgs. decay in Dudley towns since the irnplementa= I ' F ublic Health Se.rvite,f iral Health Coon- inatiog tion of fIuoridet#on xchomc- in 1V;37. Pr Dent,JCvmrtnttree- .. Wa—,hingtaan, [?C-Marefi 1983. -. - . 2041:-�1900f;30-2, 9$. Niessen LC 'klft, yin€ RJB- Causes of routh los in a 87, Les rta>, Dennfaun PJ- Water BrsrJ e3'm "forark population. J Public Hoalth Dent 198..9;4:941t,` cnriq�; in 9 --and T2 -Veer -old chilcIrgn from C'. nterbur'y. and I/Vollincrtort, New ZeatanO Dent J 2t304�10 (1l z 99. )?hips KIS, Steven--,; VJ Relative ccintributinn Of daries and PeH ac ental di7aeata in adult tooth lass 32:_ Giltcri rk -FA, DE- CurrnmunftV fluofidatlOrl: ... .for ail HMO dental p-.�putation- J Public Health IIertnr .Brumley atatus and i�arie"r� enf�7#Yri�f1�+� ire Chfldnin_ J Public: :7�H5sFs5f�1;2�Q-2a Hnalfh Uent2001,61f3)-1t3R-71- 1100 'Griffin SO, Griffin Ptl. Y„ralAn JL, N. Es-tirnat- 83- Janos toM, b7 xhln1#6n 1-l- Water fkjori,�atf on' }} )ng rk-If.$' .r7}^il'L Vii lr}Qi C-F�r,P [rf.: i 1 3i�Lllr`s.-..f Don -4 poverty and`tooth decay in 12-year-cicl children. Ftezt J Deni 2x00 2 -q$ 3 fol,: aiftmc' ofal heaf€h uutcomc; r areb7 Challerneaoat end a4- UJ5 C-spr at-crnervt or Health and 1-1umars ServU e3. Public Health Sc rvic#a.. Review of ffuorkde- ber:cf _ and risks.: 1 Repor€ of the Ad Npc Subccmmattea on Piuuride. wraAS;in9t4ru, �CsFab�ruary- 991 102, - k3 , l_eerwr3 [ VVa Ranting Q'01, Watef flamuriz3atEon . cElrran:€ nFfV tfv8ne and tje-faut flunrc^,i,., Community airy Dent Ora l,Ep5ns dmiol t9!)4,222153 -e_ 816 Griffin SOf Guoch EJ -F, Lcc.kw-co-d 5A, Touiar,Si-. Quan- Iifyrang the diffused tmoofit from Water flucarid ttion to t1143 United statam- Cammun:.hy Dent Oral Epidormo,t i :�tc§gv.:.. t.lnev47.r5it-Y of North OtrrMainn 1997,. xF Medicare & Modicairt S arui+xe , Crf3c Uary,, NO -fir oaf Health Stili-t[cs. Ta We sl taiees iof hteittlt services and supe lea; �.pragrams, by type of expdr t stilre.snid ggjsf ar year 2GU3, ,RFtcza -86uckums AA. Wei, 61a nat *q rr'i�aJaI!! nr« CJS:_ r'hisn._�i' Cr O N O I -ta4, itpra"ta`AI. rias incidenum, anal costs of prevention 123.Institute of Modicin9r Food anci Nutrition Board- prPccgrnrrts_.J Publicf��T+i9t�) Dietary refark-nae intakes for caiciurn Phosphorus. x 4Ur*, to, fluoride- 1015. ErustY'rian H�1, Im ,pct of e�0 msgne:aturni vitamin D and flttdricle. Report of the 'ITrf plammittee on Ulu Sricnt'ifi;- Evaluation 4'f ade uate wateron root surface carl$B In elderly. F .standi Diaiary Reference Intakes. VVashin+Tt ri, 0(7-, National ,ecvntica l fa3 4.fsJ:�03-?w Ac,3do ty Pre•sa;1807- Icia. BurtSA, Ismail A], Eklund SA..Root caries In an opti- mally fluoridated and a hfgh-ffuoride community. J 124. Horr,wilz HS. The role, of dietary fluoride s rr'pl.�• p est:.Rse, 19> 8(9;t':1 .t=5; mcints in caries preventiori_J Public Health Tient 1958 Sgt i#:tJ 11, 107, Brown 1-J, WWI TP, Lazaris, Trends in caries 128: P�xfacs; Dosage Schedule for f�Ietary Fluoride among adults 18 to 48 yr,ers old, J Am Dent Assoc � --50RPIem4nts= J Public Health Dent 1999;59(41`_203.4. 200.2;12247)-827-3.E_- [utEI- MtaliLY�rg,JR,: Ripri Lel- Fluurid& in r3mvmntiv�u 125:- L.,cvy .SM, Cuba-Chodk7urys N_ Total flucaridet in[akm dietary ietauoride:$1.1pplernenlallior;_ _ and lit pliGcatlonz for dI.l 'vial Strfill�5tir]n3_��kYrL`aj¢3: dertcistr+f_ ti-reor�r .a d clrxc` J Public. Health Dent_1`,Y�`3,�{3i�ic213-23_ CluIntesseric:.e=I0a3_41-E0_ 109- McGuire S. A review or the inippact>or fliaurldo on 1277, Arnold FA, McClure FJ, Ir4'hffe CL. Sodium rlur3ridr sdultcarleaiJ,Clin Denti�3,df.1,fe1`3-i3� tnblofsforcbildren-Dental Progress 1560:9�'a#`H-'f�2� 7 0, Grembo*nrski D, =iset LF Rpadafora A. How lituarlda- 128 k -€.nm i ha AAS Levy '=*M, Broifitt Bi Warren JJ, F itczr nr of dietmry florrride supplement use In children,frorn, tion affests,adurz clsar?taf c viers; s stemiGaCtd,tol3a 1 cfPrc#b Rr t� purr ia.J Am 2antA*soc'Eg ;42i birth to gei month. mf age. J Public Health Dent '111- Stamm JW, Elarlting:.. QW, tralroy° P5, Advit ry tcaries 129_ Levy Sru-1, %o arren JJ, arof»itt:8, Patterns of flu oride:� sur y,af two sirr'cilar craettrt{iunitia!s wvith rontm*C- intake from 36 tv- 72 months r)f 3qe. J Public 3 le$itn Ir)g,naluraP vvaEer fluoride J'Arn Dent Ai�,-Wc € ent 2=3,6314#:211-211, 130. Levy SM, Warra+n -1J„ Davis CS, Kirchner HL, Kaneiils i 12. ulcer Brun E. Prevention of root cartes_ GefodOrxt MJ, 'Were) JS_ F':_ttfirns of fluori& intake from birth to a 88,,51 7#s3 -47. 36 inlanths_ J Public: Hc71th Dont 2001;61(2t:70-7. v k ' f13, Brown LJ, WinnDM, VA/hite Esq._ Dental an: overview. J Can 13 T. NewDent bru canis-ts�ara- n tion and tooth conditions in'1J,.S. ad c �€_-un"7 �°loridoa „ 7 _ r'am Dent Aasuc SS96;127.1 315-28. 152. The Sriti%tc Fluorid.,%livn Socioty. The UK Public rr 1114. Papas AS, Josh) A, iviacDonald SL, Marauelle-Spia- Heafth+Assotiarion, Ther Oritish Dental Association- -D R Curry Fri. Caries - The FStuJtyol PuJ.ibt- Iles ajxh Sbv Rsaya) CiW1,0ge of pi 00 prevfE.lent iagerza-; [xrrsic u�:U➢-Jidi�.L._�.nonQ ' Physlc ane One in a million -the fa t- abobt wwaer_r - . tion. Mancttestsr. L�r4 1r3n tZ4Q c+v3itaEil at 19_+3:6Dt2J:177 9_ Assocfleori -chttp.-[,,"-i,, v,bfsweb org/+�nemillion_htrnif - Accessed � 11&- .J`.�r€aaJA. Roe�t carlea- pr e�.rertEiun .3rac.i �tl�t'rxotl'tcr,�F�-: 00 CUT�Y 23,'2006'J, Am ,J' Dent 1996 £1(B#;352-7- 133. Estupinan-Day S. IntaFnatic rlal p rspe�i, a n i xsr:ae- �' r7 , ie �`i etoFssora . ILlertinason "4; Jrrlri�, rmsn M. Salivary Y applications �� )2004 fevols:of lactobacilli, buffer capacity and s,allva 'g � rV 64(ckes pe Iss- 'Ii:40-3- J PaaErli� H+ea[th Lient2t1t3+fC�A:%Spec: is 1i:d1O'3. J P fIovv Tato'relzted'to-carl4s activity among adults in . y-�sr-n Til ni[ic�y:•.dq+'iEt�'1 optimal and 1rYMM ?,•uatBr fluoride 134. Horowitz HS, Decision-rnakin ix:;; nation -pop c'o rar'rt -��' 9 `" - ". . ..'. ,.. 'gig �`.i Rani e_ntrs.€ir3n5. Swod Dont=J 1992;,1 g; 231-7, of community fluoride use. Community Dene Arai 117. Anunavicc, KJ Trow -mon, r�/mond in preventive and Ef"[femr+nF 20i�i? 2tS 32, . a_ r£ turetive' dc_n.5ntry--. J elm 0i!nf.A ::nom 1988:126; V35- tMorthaler TNT, McPia R, ViYies J.J. Carle s -prem rativr- 5-T7i- salt flu nri ci ztira n- t`a r igs Rea' 1918:1 2,( S li p ri l 7 tt 75-21- A 118. Hopceaft N1S,; Moy9an rye's'- Exposure >o fluoridated135; Kunarl W Sy,Qcnic use offluorlde-ether metbod drinking Viater and dente. c-aries ,=xpeVlent--a in A.umra- Bait. .uga., milk, +etc, Caries Res 1993 27(SUPPl 1h,1 -;22: iia n army recruits, 1999. t�,jmrn Denvorai Epidemiol 137. Estupinan-DF1y SR. Rees R, I-ornwitF_ H. Warbeha R: 20103;31(1#408-74.: suoit:rl .rld B,.:T6ornrr M. Sr<FHt flvrr ri.d370,7n and clr;ntai :T`ti_ ioroI itz HS_ The future ofwvawr fltataridat%vin-anal caries in Jarnaie;a_ Cornmunny Dr;rit'CIr J Epide-ricin; 'atter-&"Iernlc rtuorldec=: J' DoLnt Fix -t 59907,89(spor-, 138`'Weirlti Vfr_alxh rgani7.ati,..n, FEuorid,35 A-nd oral health,. 12h_ Dri�*cc11 ' V5. The u o of nuoricirr eaglets, for the RHport or n 'u+rHO Zxris rt C ur mitteo on Or_at He,11t Frevenii n rat`)tea`bai c: rh5 !4_ ir1;:iCtt an tinnYzl +.vnrk-.= Sratu!, arid Flunridn klnm WI -10 Tuch,nittal Report at -top on fluvrldes and dental prev=_^miner_ seri; 8A8_ Gran.=,ra:T99 * EialtDmalr6, U€1�lvarsity ofr511 ,'y{larlr2,'3g3 1 "'`a-1 i T_ l3'3_ �ei'irr9anr ICS, CSrergrr.73Rn RI,� aft ;011)9" #+6##�3.tion anri 12�' Aasanden,R,�Pasbles TIC. FFtetns of>flu_�ride suppler � Qerjec�l kec=alth. r"-tdv Ortnt Rr.M 199 9 139-4=3- � 3 rno ntka tion from birth on hLl rnan deet i du t7e_ts and r' 140-C}'lKStSx`starsn A1+; H Ikn C'L IJiaa-k HF3, Ce3hman '+1'�.-. f errTwin mxrsf tb- Arch Oral-Esiol 1:9` 4_ tS:321-£_ Green LA, I"b JL, Jr, Joni ; Di#V MntXraors Ei.l, Dparif 122, Margolis PJ, Reamr-s HR, Freshman E. Macauley CD, I S, wrr �Ai �� rJ, Jct€nt Nnsl Cornrrifttee 0 Mehafrey H, Fluoride_, tae) year prPsfi r_t„� 3+rriy cif n?c Riau tf �" E+r�Ce3a lex is ita�}r rdr t _ ' deciduous arid, permar ant oen&11> jn# f� ors J Dis diad � ref High BI � = rid � 1975;129;7`3+Fi4i}. 4locrirq_ CY) to los tit�ce I'rugrarrn Coordinating Comm Moo- Sevearnth` report of %he! i -int national committr3a-sin provenctcln,: detection. uvztlwati-on, and treatmei nt of bigh, b(ogd' praaaurg, Hyo rtensirarn 24 49; 2{i7.B2JEt . 41. World Organiz;'Volt. DevelOPment Of a milk fluoridation deme €or proverit[on of dental caries - preliminary "sssasan er�t orf "fn-�siiaits't}t_ Ciartc ra;2t}ti+1 42: Pakhomov GN_Objectives and rd,,"aw ur the Inter n.ationM rtalik fluoridation pro resn, Adv Dent Flea j99h�i2;:t T�-t_ 43 vi,-, BA, m.,,rthaler 'rm- Fluoride tableM *alt ffucuida- tion ;.1nd milk €lui�irfdation. In- Fluoride iri Dent --Ory. 2nd ud_ Fr�!icmkov CJ, r-kstand J and Burt S, uds- A.rTt�r€€v�a3aard.�u(aenl�;sga�ro.l�k'i�'z91-�1Q� Iwo. 1-4idemever Rte, Fitz, ilia, :fired Pikarski J0_ Fluoride: surprising factors in bdtitt7rl wrster_ Penr, Dent.J iPhila l 7996;u3+➢Feld-i_ 145. Var. Winklr a, L` -'.+y SM, KFritsy MTC,1-lnilmnn .JR, Wcrel isand- Marshall T. Water and formula fluoride rc�rr rtEr rti<at z• significance, for infant* Fer #c encuE�_: PiaP R�rnt i9'g5,..lut-t�ug.7if#t;�rx-�U- 146. Wisconsin Deportment. of Agriculture, Trade and Consumer Frotccticn. Mate of Wisconsin bottled: drinkinra veatcir and analysis test results. June. 1M. E47_ Chan, JT, Liu CF and Tate WHI Ftuaride concentration in rmik tea and bottled wgUir"in Hoo4 ,ton- ,J Gt B- oust:. 1 _Johrizon 5A. C;,e6iaae,C_ Concentration lowits of ne,Qridc in,b3bitied drinking water, J Dont H rg - 200,' - - 14:o. Severage Marketing Qqr ortatiurs- Bottled , aUelr stre ngthetne position or, no -2 beverage, repUrr-ts SaVer- age M?l.arkevnd: Press Rofga o; dated April 25, 2005_ +available atiitt2�;#w+.-,r�e,crk.ating_eorm_ Accessed Affil 29, 2005, " 160. Full'CA. 6P44a#0 JS. Watersaftenar influence ren tanfons and cations. Iowa Dent 1683;6x';#:37-9. 151. RobinsonZN, Davies EH, Williams S. Domestic water treatment appliances and the fluoride ion, F,lr Dent J 1901;171:91-3. 152_ Jotisa3n MD. Grimm SE 3fd„ Banks K Henley 4.3, 7be effeet:3 of water filtration systems on fluoride, 'Nash irngtons D.C.metroptoli,zan area. ASDL J DRm Child: 2000;fs7(a)=3#12, 3G4, :3�541-4. 1&3. Fluoride,' teeth and health -`Royal College of Physt= cians. Pitmart Medical, London,l,97th. 164- Johansen E, Taves 13, Olsen F ads. Continuing evaluatican of the use offluorides. {HAAS S iracmd Symposium 11, Boulder. Cc lorado WP.*tv:cw Press;t"3T6 165_ Knijx Ery. Flunfidatinn ut ` e-ar and canner_ a review of tht, epidarrni0iogical ?vide - nee_ Report oftbe VV, rkiiifq Party_ London, Hee Majesty's Stationary o r1'ice;1, 285_' 155_ Leone NC, Shinilkirn M6, A:rnoid FA.: at al, 'jVIsdir_zJ a!-ipects of excessive fluoride in a irxatersupply, Public Healoi Repj11464i (101;926-:;6. x37. tvatiur,al Pleaearch Council.. Health effects of inge-st d fluoride_ Report of ttte Subcommi€ ee on, Hcalth Effae:ts of togested Fluoride. Washing;ton, ESE., Nation, al JAcaderny f rens 99azl, 1 Esti. 58 Fec'fi. Rely- 58&25,68i327,Jr3ec_ 2S,. 1"3t., 1i9, 4,i5:t vp;7irtmerltofHeallri rind Human Ser4ces, Pu!bPcJ Hcbltit e=rvi - F*tjrt art tl e! ATSOR toxicaloaical prdfilc for fluprid�-t, hydrogen fluoride_ and fluo6re, - CDC Altonta, C;A,Mriy 15, 19923. 170. American Mtedical A*zocFati?an_ 11-440-245 :arid H.- 440,912. inn Amcrirarr NI—H-1 t? i-ciatiori-. ifc-100's+:. Compendium. Chicng4: AnIeritin medical 171. Fluoridation. and dant?) ;rkT.glth. t+trc.rl hlealttt Organi- ,t"yv;gl"Jakitb"aR 4http!),%V1, w.vee eraemarlcwtfrag com,=--. ) completion of EPNs rcvi+,w of f-xisting drinking Sveter Ai;r,orf April"a9, 2005- ( standards (EP,A,815-F-4 Q0 t 1 .lune 20x73_ 153. Weissman fi4M- Bottled vstvr, tree ire art irnmiaram,' 175. National Academy ref sr cm ; Fruit," Tick .-_, 'r xlcotogic eomn-enFrxis'ty. a pubtic hen' nth issue? Am Public Health Risktaf Fludride in Chinking AvatlzlblI - a[-_F7tra: �' 1B37;37i$}:i379 1- wuvvtnt»F xt3s Ft5lt Gp,rpt#Fn77t` t. n2G_,hy%24_P1Na8EST-K- .5a-Flai=Ctv1,'Hill EIi 'HicksNTJ,,A"survey'ct€L etl dxs ter 02"-0&A70ponDocurrivenvl= ;i+T-_s_-stldMay+.6,200E. uiaage by pediatric dental patients', irnplicatinn, rur" 174_ US..Environment Protection Agcncnf, 'dentsl lteelth- Quinteaiseetca Int 798gq;2Qi33JrS47- . and Eicinkarxg Yilat r=Litt cf,drinkIrl3 �xworcetminn'-0s- 153_ Tit tiyfH= C1asn Yfi f=luoride cure-.erntmtion in J QUInd 'pants and tti" CLC. Availablear �httT °w.vw too. : etd.ff€{gereci •n eers. en C7ent 1954,f2(49fs+wat r r al:hEmk�_ 4tces�ad Api11 28. 2a0 1Fa_4,, 0at�e(s D, Horn-y'K. Khaientia,SS: FIIuoride concen- 178. US Ehvironment FTratvIctica"n Ag"pn r, Crryurid *Facer tratibns in battled wuatrr_ Oklzlfesrna DentAss€,o.J and,i:Jrirxkiri Watae; RrinMng vv-,orir glo sry. Avt?il- 2 0`1$=22, able at �fltxp }dt++nv elaa_garrParaFcvk ,€rr. r]iu :ser. $ htm; clinic . A:cGcss4n+�. April 2 QfbS_ 155. et£ �.?'i- 42775-76 20, 1979t- 175. Hodge HC, Smith, FA�� fir 3t"as sx�i 1 taarid'� a pzastrr�_ 156.21 CFR 155.SeC_ 165.-110, � J Cc,cup ,Med 1973�1�,1?-�P, I"�c, n r3- Si 0 9 +1 JaderalGcr lJ_ t B57. 117 -Committee or, Biologic Effects of Atmospheric Falliit- 1 . Maier F -J, 117 a-nua€ cif wm(r5r rluorida'60et Pr,aeic__ New pollutants" i6601c;McQraWf ll.Elo k COrnpatty. InG41863. EluoridimW hln4yi 1 iNatianal Acaderilvct 1 ? 464"I}ivasl�Y? tY� Slclence ort behalf of ADA Counc0 Sciences nn SFi4n�>y#�CytT Tap, r+eaEer filters -,1 Am Dent 178- Rug,09unii i'twttion anti dental health, New 01 C) \ N O I� = _Ci=i tEi ck{i f grivuiture, Agelculturaf Reaaarch ` F97�_ Caui JA, furp by %tie Riley rJ; 8uhar 't�iVi. Effects Sargatae, BeltsvII1e Hurnan Nutrition Research Cent#Gi q flaacaritiatad cfritydCdrt0 zrvaee€ on bony muss arld free- llutifio tt Data national r uorlde ntras; the study ref osteoporotic fractaxrc:s. ,1 R, ons M I n databeae of selected beveragvs ansa fr oda - 24074.' ries Awillahie at ttttp ata +ram_rr2p,us tv, �rr1"i is F�eac�izrp.� £fat 7; Fluoride Fluaride_htrnla_ ACc Oct, May �. zoos- 1�JJ, Hodge Wil. The safety of fEurtrid taEiet a3 or rc ws. in: }�raContinuing evaluation tir titre uas3 ❑f fluorides..Johan- 784. N-Mzfrym OG, Stamm JS+y/_ ae-lstians;hip Oftotal fluofi-J& sen E, "Mivaon DR. OlaenO, ed _ Uoulder, ColueadKa; r .. lnt:.�krr to b-nrrici.al-effects and enarnot flunrosis,. -'. Westview Prrz r1878;L1--3-75-.. _. i J sua R&-- r9��1, 9jspac tss .52 151. 1as!k r n Rt7, Prezrrradlne EJ, Kelly`SA, Hinrssle,t P, 24ri• Leh", ann ft. WJopnitrrz M. Hofman B, P iprr Et, Haubitz l,Altolki B. Drin n vwart�r fiud.r,rJ tion bone' LSl' sikcy QlK,,Darrtipy qe Ad, The'riuorre? . rnntent of mineral density and hip# Gture ilii-idt nce. Beier; foods- and betworago.s from negligibly mrid ptimally fluoridated-clommunitiv*. Community OL-eye Oral �J�Idet3tio{ 2t3,i]2 3t4t6}; 92- 1. 201_ Phipps KR, Orwroill ES, Bevan L, 1 h5 assoctaiWm' r JB2. Whitford GM. The metabol m and toxi6jy or fluor between water-barr a fluor ida and bone. miner-al denaity' In older iidults....{ Dent fta.e. y . ' ride, 2n.d rest, ,ed. Nlonragraphs in izurtl srrienae, Vols -1-. I Basel, Sxritzz rinst4l-;K.rp8r�1�'BEr. 2r}2_ T] mcsy. LL. r azdi H, Cicu.r ctir'�I Fi'. r, Sincia�€r' i411, F: irtez•.+_ . 188- Levy 5I1, Mourirc-TJ, Jakobaen JR. f-ncding patterns, CK- Waterflu€sridation,o toopotosis,frotuaan-=r�cnnt water sour er z and -fluoride expposure5 of infztnta and tgevel�.pment�. Aust rent u 2S.uJ1.-rr34.2i.80 ,�. 1-year=olds ,J Am Dent Assoc 1IP3,1�Z4_65--q. 2173: Hillier'. , Coupr,r:C, Kelifngray S. Russell G, Hugnes 184. Levy SM. Review,Vf'r'duoride exposurres anti ing--�stion- Fd, CoIgrgdn d. Fluoride in drinking •n-,iter an-J risk of Community dent Oral Epidemiol '1!)94.22rt73 ,,), hip fracture in the UK; a card oritrni-stvdy, Larc.et -�' - ry 115- Barnhart nr E, Hiltur'LK. Lsonard" , Nucha: !1s 5E. Dentifrice usage' L^nO ingestion al'nong four age 204- Phipps KR, Dave rr 1 a'. Mason JD, C'auley JA. 4dm rnxr- groups. •1 0bnr fie ' 1 +721-52jg3;1317-22- pity water fluoridation, bona minerat den!�itp: ?srd rracturas; prospective tudy of affects in uldt--r, '1r, Fer'sroart El_ Fluoride retained warn mouth--0 Fir I�,AedJ 2flaC5.- 1265):86-4- nnscti and dentifrlces in pri;*chuol children- Carie ,fig<Jon�s �s�E3i1vhF.� Dn❑ er ti,.C3 � Y p wy+rrTWaterfluoeide- n.. tion, bone mass and Fracture. a quantitative 4V8C\rle4*a 7 - 157_ f3ruun �, ThyJstrup: Al Dent Fri--e uzage arnong Dartirh of the llteraturt•_AustN ZJ �utlpiC I-r estt2ax:1�S ;x;391?3 (1) chilBrun.3laontRes 18fi3,��tfi7-t1YH=7, 341-40, -0 18,�. EkstrianciJ, Ehmebo Fal. Absorption or fiti.ofi le from doe_ nix�rs.'ty 3rYork Centre doe Flavrews anO Dissernrn.s- !v nuorf-de dentifr es,; Caries Res T980;14.98� q2, tion.-C19D ReportTB-Syatern3rir review of the e+fl acs 'Q ¢ CD 1K'+. Levy M_ A n:w.r ,+.•'of.fiuoride 4nrak& from fluoride ' and sarfuty of the'fluaridstion of drinking water 2000, I �_ dentifrice. J Ovnt Ch id 1 0a8 60J2k=115-24. E:tecutiv Summary Av €ilab16 at <http.rr'wwvi_ydrk. us ,'e . " Vi`t rev, Leverei2 ®]d Adair SI%A, Vaughan 8W. Proskin H[vi, a vnvvcrd}reptsrtTB_JtteFi _ A.cassazf fu�cli 28:2ii�8. Mass. ME: Rarieiomized riinical triad: of efrect df prrsna- 207,. ijS Deparrrhent s6f Health and Huriian Scr`ices.:Bone rtrl fluc+ride sarp}3lerracnt , in preventing dentalrira$. -! health acrd teoporvsis; 6 repot 37Rtlra 3urgeo€t Carl es Rsa tt3B'aC31 _97;1-7r3_ .. iaenerat.-ftrriAvilte. Pa1S)< US Depae trnrrnt tai Health and 151_ Ar-noriran Dental Asaciciition,ADA,guicle tel dental ; Human Services, Office of the surgeon Genlerai 2004-' thvi:rapoutiGs, Third Edition. Chjcagael2003.. Chapter 7. Table 7-5-1i , ,152.. WhFtford"f Nl, The ph ySrulcjgir.al and toxiedto'gicat 208, Etucher JR, Heptme nclk NIf3, Trsft JP IL Parsing HL, Eustis SLc,Hp5cmaq cliaragtgirstics of flucra_e_ J,Dent Ras lB (Spee' JK_ Results and roctsita i+�tt$ of Jss).5M- 49.� the National Ta xico l o any' P irog rarEt'# rndcmt ,, a rc i n o-.. '�S3_ WIhitford �3tb-,lnt;skr_ and m;3tzboli!3nt of fluoride, genicity studies cwith scxdium ftu€?ride_ frit 4 Cancer Adv ;l7eni Fias 1 R44;;50):5'1 Sri Gordon aL-Corbin,.,_ Sdmmar� of wnrks€ pR on 2419. Maurer JK, Cheng MC, F3o"cm F-G Anderson RL. €irro-yrtsar carcinogenicitystudy. cif spdiuRl fiuors3e in tfrinJt6ng ave rftucr'Fts3aticxn influence on hip fracture rets. J l*d tl rracicer, ins 19gi3;82at118- ,' 43rr.bione health_ 47sf t4pssnsis Int i98c:2.109-17- 1 . 3 JmazorDrl�: iFtavuerdsw Ca,= Saunders 1 O 210. Banting Dw ,t#0 ,future sof fluoride- An update, one year after, the ktii Tonal Toxiacirogiy Rrggra—Stu dy so*korna, CL- Russelt AS- i rev fluor datlnn of shrink= 3rtg water and hip fracture h0spt-;6, 11 sa'ticn rates in J Am Clarri Assoc_ f9'g1i#2 df '8r9i_ nAW, Canadfon communities- .4rn J Public Health 211. Horowitz: HS. indexes for ms.asurfng denial fluoruxis. J Public Heaittr C7c nt t9 t €� izl i-hEi iw3Ei..Pat bh!E3 en SJ, Q'Fall+an W-M.'.,Nleitpn I,a. Hip fracture- 212. Dear. i-kT_. The investigation mai phy !7ialQgical effects L-y° `:: 01 ipcidencc- beforo ani E.ftes the C{uirrida[ion rsf the thea epIdettfiolQgicaf method Im Ntoulton FR' etll Flu's-- � puttruo r.•ater a apply, i��hrstar, Nliane!sam Am d y rims and dente Py, CiLFFt.Amerl air n fnr the e� O Public C�vairl 19 3, t5>_3 Karagis MI 1, 9arnn JA, darrett.J.:y. Jacob~*- rn SJI :4d"ncerne"t c�rs6i,ani;s, Pu 61 �i�x. 16. Wash- [ tv C7 1 ; 3 1 O Patterns of rracarc among the 4Jnit d States el+girls: lipuricis tom. Fy7i["t Ep iS[nrYl 213, Kumar JV 1q {4. ymicr€►a�#xL�, fa e I L A!ks l gcographic,and ks�f fluorosisi " 0) 1 1�9 $t3J:209 6, .a �Lr& iC _. T� rr lence arid -trends in ertumat fluorosis In the United tine States from the 1930* to tlae 1980s -, J Am Dent A;s*c cancer iri` 2CKY2,,,133.757-455. r i 215_ 1�riffln SQ, Beltran €D. Lockwood SA, Barites M 233- Klnlen E$iheticsily obiecuon a1>1v fluoros{e attributable t4 irr wY9leir $Ll wvtee fluoridation. Cor mupity Dent Oral Ep�idemipl 2,3;4 �h� 2002;30{;3}.195-209.' yn�� +�� in trt IiliDr7i AS, r1iH�tlCBrry.'�L 216_ [ 3ofow� HS.. F6u4rid� and. enarrel-eI$�Feczs. Adv Dent �scrp{�ti�.,.r Epide�+iv["�arem -FTc�alttr "t9B6 38: Rea ,1969,,3(2);143:13- 44;,Z - 217. 4;,Z217. Peridrys E)G- Don -tai finarosis in perspective, J Am 235, Uouk-Mazaffar6 Pq t Doll R. Plug ric#atn4r} of t3enE Assoc 1991022:62-6- water suprpli** 4 rntartelity h a search for on effect in- 2,'S8_ Stookey GK. Reviow of fitiatoala risk of self-aPPMcr . rt'riahcr t11Qfrom Gactcdr. J �f?irlet "� ol topk�st fluorides: dentifrices, rrrouthrinses and 901s- Com'" f man J13, c rnrrtunity Dent i3f Epizirtfaiol 1994^•22(3)a18T=8_ n 235- RsmaS, sn D 219- Find s D0 Katz,FW, Morse: i=_ Frisk facwrs feu M ullri ' a i"K�tti and cancer' an aiaaiysis r nuoric9artfrzrand ertamal fluorosis in 4 nonfluorlusted population, cancer ma � �t Heatth 01rec =- Arn J Epidemiol199p=943(8)-808-75. torsrta. Heattlt �anaati8_ 720_ Pegvdrya CSG. £tiers srF'onarnei fiuornsis in nonfluv AUtbotlty of th18 Wit is 9t Gra t4iti�P ltldlYtc ss�a3 ridated and optimakly Fiooridated {populations: Wal�nre:1s77 considerations for tho dent_a[ professional. J Arra 1]e}1111 F37, Richards i!A„ Pard JM- Cancer mortality in sFaleCted Ass c 2000;131(6);748-55_ Kew SQutftNr� localities. with fluorid�tY�41l�d'"On- 221- rrz- 227_ American n i?ent,[ p oeiation_ A©A statement on' FDA iiaond{r#�i srfipP?wL Mad J Aust 19TS toothpaste warning warning tab ets_ �Avaltable at -chnp;flwv tiw. 238.1 " a Hr arcri on Cancvr. ada�orn pre€fres©urccsfposS#ions/steiementsNlcsrarirle+_ 1,qR n��4`ttt&evaiu tion of"the card- asg-, Accessed May Ei. 2t7f15 rage ' , lie miwls to humarts. Val. 27, 222_ Hodge HC, Smith FA-, Uiologlsal prbperties of inor, Swltzeielert4f•[�tf�. garlic ftuorides. In: Fluorina.eilerrilstry. Simons HH. 239. 62 Feed Oeg-642417 JDec. 5,.. 1997), 'ed. New York- Acadisrra7a re 240. S;Iem J- i h aI ed aasvciatinn krr #v ee n 223. St er-s rr CA, Watson AR -Fluoride oeteos+clerosis, artMe1al'if dttEton of water suppites anri rare€er= Axrcer n r3rarrta n and Nuclear Metfrdne 1957,78{1]:13-18. 224_ Agency forTpxte substances and Disea9s Registry 241 IfterS�'1C%i " ,' r kiwantg SA, Pubrow (ATS r. `ioxi4oloo?cat Profile for ftuorino, Hydrogen R. Fluoride e' " idY6 U14 "i omta+3sar. fluafride, and fluorzc€ss_Atlanta, GA; US Department � comae a case�taR sk€rrfy_ Am J f'utrlle. Health of Health and F7umAn,Services, Public Health Seryticff_ TS95s8S(i2] i $133. 2003, Ava}ilshlr-- At s lattp °�NtWW.atStlr�d�_govftrbx� �3 242- McGulte SM, , Sftnabie EP, 1-r_Gy irn MH auckwa ter I *tel l.ititrr� _ Apcessed April,213'i 2005- JAL i7oUgIass.CY1t_ is their a link belwi, !en f9uori 225_ Atru'tricsn Cancer Society. A- ternent on fluoride slated water and osteosarcorn,7 J ArTi Dent Assoc incl drttrking waterfluoradaii0rr by Clark 1N_ Heath. Jr. i991;1?,2t4)_3�45_ mo. Vice President of Epidurniology,and Surveillance Rt, rch of A, erican Cancer Szxi*tyg February 17, 19918 243 .ws Hoover RN, Mr -Kay Fw, Pfaumeni JF. Flu Eaririated , 9o_ drinking water ,-, nd the occurrence of cancer_ J Nall ate" ra neer. lrnst 1978 5744X=578. 244- 1k.227, 227 Erickson JD1 MOrtatity in *eicpetrexl citie f, with fluor€- darud and non-fluoridatrd vventar supplies- .New Eng J Mad T978;2!Y8t213,i;11 245-' Rogot E, Sharre-te AR. Palnlelb M, Fabsita RR- Trends i,n 13rban,mof—tality its reiatlan to f uoridat€on trta'Ttu- Am J E1.idemici 5978.107{2} Soo -72. i*S3.Chii G Care rrnoetalrtyantifluoridvtionr.fsrster lr.Er7rasle� _ suppliaa in 36 1JS citfc�3. int;3 Epidipm of l!3B3,' 12{41,1. 246 397=4D4, _I 230, Mr lione3y MC, Plasms FIC. Surnntt WS. MelfusJN1. ®cert! censer inYden i""3t' in .lwr YourtatP�. tlrl"I? 247_ treride and nuoredatetd den#ing waxer, Am J Public Health 1991;81,M;47�i-9- 237_ Cohn M 4+aw Jor!wxy Devao— nt-of Health„ Newz I: Jersey Departrocrrts ts1 Prot k2jo and 278,.- Energy. Anepidert4 ' ,�• 3� drinitlt�. .,, , yy7j, 'l RS uetEdation. i.5 y�..t rbey MC, 1-013tiee 08, Nascs PC. VV0119 .reg PE. rMVtIS.Fopulation- density and cannerm ar3ali€Y 9F1'Zt ;i ork-S7iate. 'IS78-1482, Inn J E-Pi6L- i 99 rye 9o_ 3+y :.C,L. €iarltet..F Fincham S_ Drink- rink-ate ate" Carr J a Hem F5-6- 0=11 2L r Flesearcfr nn oqn, e r_.J Eprda- .,, a r 'oe'-�R S> MeEBU'SY lr.Er7rasle� _ ta `� a+ofsxpspsarr` ,_.Y.A6Y 3iof meted 1 s and xa r 3} ffl�lonograiph C) \ N C) VJ At 1 249, Kirile L_ Cancer I cidence'ln raiation to tlusirlde level 28'F_'l'�1,ilrtirt GR. Brown �ta5ter , qpi aug ft l acobecern= in,i1�ft=r supplies,U47carr Da6eif_-J_ I_Sig;j38{61.221-4• Krarvi D. Cyiagenic andtatuta�etiic aSSay � flaorida_ 250. G;vlletti FNI, ,foyet G- _Effeet,of fluorine on thyroidal In:'Fluoridas, cfftrs� rsn vOgetatiori, animal OPO humans.. SchlSpR JL, petermon HB.,Leone NC, ed ,< Salt - iocjin rn>=tet3t'.11s>in = hypar'tte'yrraidism, G.l"+h >=.n Isa-. Lake Circ; Paragon Fr+^55 18133.2'7'!-Sg. criniaing'y- 1958.18-11,02-10_ 25r3_ Martin CR, Brown K5, t�athe von EiV , Let:��.•�ritz Hr 257. €itannina vise Er yclotar lia_Piiheel isi3dc�ivailab3sa I Singer L, € pl)aua R. Lack of cytogonrrtic effects In et i ftp..;` wv ^.bri r fit; a <orr?a'al r'att cic?tc 6d X52 5 +Sec OeL'eri%fir 2s, mice or mutations in salmonella receiving 1-udiulr Lo u t y'-p6cteal aglzf3d'vrt . rd fluoride, Mutat Rer. 19?G 66'153-67' Vex. Lu ".11 F(uo<da deP s' tion in the aged hum8n pineal � . 69> Lf Y Dnnip_i :e AJ, Stookey GK Abuence cit Mutagenic activitlas of fWO idg in Aait s placid_ Caries Fi+ 2p4i1.3Bti 125-2& and amimut29eriic salmonella asays, ltlutrtt limos 19 7 12f?: 9� 6. ER, CNert , Dt,,Chasa HICa Canorrevll r KTI N�.•ruurrgh-King bxn cer5c�s-fitiorine study XHh -. 21U. Tong CC, MrChwfe n''A. Brat S3f )Niitaam�,GNi.'fs tlubrlde in a IaR rter*y ut pediatric fisni ingis sear Zerr year_ ,j as m Cera Asspi; la&. of geirvo.oxicity of !.ndlurii >vellulattests. cei,:Bial sox:ca91.938,3(21,17 13.-. 2!53_ C'srail:acon-sGa SJ, fluorl•dation barrn irYgnrune .171. Sfianl SC;_ Exposure to high fluoride concentra- Purnctlatt r Bit 0e,Flt Health-egg6z,'j3i5uppl-2)'.t39-7.1. #iau� In [1rE74CS1ri� 4�'atsriss"ai5rrciAFe r*t#t1i {f9cieic birth rater- t ?taxicelo�ey and Er u rr�nm«arrtal Health 2 . US i7caartrt�•'nG of Health ar ea Human Service*. Certka ; ror bisease _GontmL Dental Dlsease - _ Prevention Attjyity_:Update ofdfl.i id-_ i 272. Thoma* Sinks. F'it_ii., personal communication, 3a q Girred rr;�acatais deft fan Y `'Y Pu h, November 6, 1892 No, ri-133. At'lantax-1unc '1367_ 1 273. Lowry HrStu on N, Rankin J YU'ater fluciridbtfOn, stili - 2 Ci, vVr?r`1d Health Organization' Fluorin sand fluoride-; births, and congrni-fol abo arrnaiitiea„i Ephdelf r;01 a nesirarvr.tertal health criteria 36_ Geneva Sw!tzdr- Carom Health 2403i�i3{31,,4-99-5o8. land,lga'4� 271_ h Rapaport Contributleft 2 1'etu de do MVJr1goiLsrare_ 257_ Sc-hiFsingor E_ Hezaill, s.udies ifi arr!aN wtl7e USA rule pathaganique dim Refer. Bull Ac -ad M lRrtri 0 -T953;'. with -can troi led wntr r fluoridation. tr , Fluorides and 1 •© 529-31_ ED f'i human health_'Wizirld �fealth Organization Mon<igraphi ^ r",TS,irYI. tii,7trhranir_ nic�ngullenne at �.a�r: 77 Sr_rit Nr3..65 t3eai€t, ar137f1.3o5-1 C1_ iiF7nt�c�_ Fi+�r StCr=rrry-y[;al Chir l}rlaxiiiuta=- 1�7;t„ �i�-2?Pc� _- . r -r - 25 Kraus D, 5chrrrefdey EL, SEr:ger L. Martin GR.Tbe effects of *ori ih and €avi fluoride d3�t5 7n the frequen- of the incidonce r t eonrgcrl sm, in 276, Scrry IXT. Stud n J Mem of 3iStaY chrcralccf ext5anreg. Mutat cs ; relation tra thr flur5iide c4giterat of Vatnr. tint ' �S 5751_6 e"aat 1�5f3,62 4-�l (Diti 25;x. Li'l..:1753dnipac"_ AJ., S,t=ooka'F GI- LaLk. of gienotiaxic 277_ INe+adleman EIL, F'tSe3trl1£ SNI, Pcit'`rrnuar J i-luat'wr_'�a- 6Mown Syridrnrnt�. NeW effa_ts of fluintride in the r ou—io bc'7m-rnarro m1cr+o- tion and the 9ccurran s 6 stuctaus tact. J C7ant- Fives 1 8111 ;1{ 7 9 Cn i Mart 781b,2 d,�21 3_ 2t'ao. Li Y, Dunipac$.Aj, Ste-->kr?!y LK. Effects of fluoride '. 27'a. Erieksocln JD, Oakley ,;.F1 Jr-, FI*�,nt.,!W Jr., Hoy S- the louse sperm rnnrgholugvl.test_ J Dent 5lotac i i-tariclation andrnalformatiomi. do Gen 7 66{9t.'154;I-11- c;iatioo_ J rim De*s'nt 5r,)T-' 1976;93 981-4y: 2€z1,-Zo iter E. dolati DK Kaur ai;,tei o tay-ned AH, Ravazo a E. 219_ ,"a"iox EG, Armstn7ing E. Lanoashl a H, Flkl rid--ATAu,i ,. J, Deaton TC3. Cylogeneti studit*,Pf sOctium fluoriidazncE the y=sralEetca rsE r czar nic l eYlalfocnai TOrj ss:T."994;:9i1�51. i-}1- 0-A. Comm i�:=iUri 1980"2,190-A., in mice_ agan 262. Lx 'f,. ,'^1�t-�r2mi a 4VA.-GT4n1p,3ce A.d, Stookey Gif, Qerta- 2Fsdl. JD_ L7csicun synrlromc, ,,eater tl uu rirj�tis�n ani .. ,« - s to lc clfGs;S� df fluorgde'ev"a.(u:4ed by, sisterrrchirrarnatiic3 oge_ Teratol 19e.0;21_177-80. exc:han]r- Njulat Res 1907` *92;'191-241_ 281,'j%,lrrllonix f'J, Oenbesten PK, Srh'unIult, A. Kernart 'a'u.!_ .; -253. Ltunipace AJ,Zang� W. NobktlVW.. ilii Y, Strilakeyy GK_ Neurratcr riceig Pf sodiums flunr fio in ra�t�.Neurvtoslc�?y j�lerlctcxiG e,, - ivation of chronic fivoridc OxPoBur-_ 1'arat i 19G5'17(2) -"k69 -i r - miL'rCt[luclett afar; ap rnY M r'ili"ph 11+?$3y Sitli r!•.,4:_._ ,.! aefltr 1 2;x.2_ Rose JF, { irst67n S T4s -tie 'K irynt'-iqy artd TeI ratr_+lQ+oy 995,17l8l,' - Lc eer to The PdktOr 254, Li Y Zheng Lie+, Noolltt € %M DunrP.tr:eh�l, 5t�iolts 263. �ftenntn %� Fcr�u _. rt E3�v1. H�r,vQgt f i! -J- Expo."r�a rl' . Genot axic cvalUatioa of chronir, flu arida expmo-: r:hil to rluoi`l hied pubi,r, :�au�r atipolie6 andd health score's: Slate -r ?rt't�FEid cx_lls3n is Study. [�€u2, t s..'. and behaviour-, N Z 111rrt 1 4913�.,9J(73f};'#„sypi fl_ 5 U6q.227"1 - - - r 1 tsy t ;�8 �i_ �'lfiSt�S�x �.. E8t1 rl"5 �t rJ -Gist C3a `;??feriae ,ui[i p rc�un ptiprx '. x n r Cil 265= OLn2 G, Sldcik-Erben R. u igSr ,i z'a acuway ,lufJ- s11 Cas4 tSte:Indu t7S Ii of arhttCss rr s lY3a abi=rr tion_; In Balm E1 h C+jun y. Pr sentatdty Falm Bei hcf� uFi 12r�inar4 •:C]115 aa3d &lEti'yfaALr;C„f a r+nt :lira vitro- f+tluTat ka-T1 >ur5dtlmfSu4Clrs. F4.u'g i]3t 26, C) C) 266. acik,-Erberr Fi, Qbe �G, The uit of soaiurn fluoride 285.-1�rFnm& Eu. Schock kip. Cart fluoridation 3ffecr � � f Eaoe i€�[B ivzSOf� HL' isalunrrssilF��Le and N O on':G P!# Sy ratla�s33.'t3 t8tisS1C BREiit # Rrri chromosomal Trx?t3a-to- �{�.fRr � tf4r7 E,?rrzf in ea, ueox� solution [rlt..l eft@lft';bti=.' � aberrations iR 4kF1'1,dlrt lrCiiKflG' RQ dj'ea'Cracb WitFt €nears in vitro_ i ,5u $ t� er*it6rs, Fsir C7 a+a;�xe central tt d Pr v ntioa�, ! '3€73', NSV lbterrratioreal Standard ea-ciip2_ Drinking water treatment ahemicaFs - healer affe4tts> NSF lnterna- Survi7iji3nee for elevatsd blood to ad Duals 1917-2001- tioral, Ann h r,, 2ti<. ami5ong chlil3rmAbited $totes, 3(J4, 1`4SI: €riterriatiOnal Standard 6j-,ZQ0>j- rlriclking ovate�r 20 ;52fSS�tll:1-27. for Disease Co, and Prevention- Adult. � ' system car�s�r[rriant�� hemi& effVCt,%..,NSF Irrtcrnatic n;t1, 2 etit a tlrid atrrua€€! naeNitr€rted 'blood lead eFr'denllology" a Ann Arbon, Mk,2002_ S;ar 16 9R2t14X1. CN1MVVk 2f 02;514SS1 ):1---l0. 306_ Deeds F 7;harnar.J0_ ComMirntive. -hroniics tQXl`-Qr'os of fluorin cornpound.- Pcoc S+a47 Exper Biot jorid Mori 28$- Alztta9ntars Dliseaso E it�atityn 13gfarrs[ e car. .. 1' 3 3 * 37 =Fi Causes-, what causes ACID "sr�rla�iie 1>r �tttip t��wu+r,+vq' cueao6d € lay 6. 2000... . 3QEt C4rc lure r-J. A review off uarine and its ph-is€ological alit'r k �r -etK f� take .r rx-rt "i, faaa�won F#L. €af ects. Phys �4-views'J93.a.13,-V; ]Q_ 2', xiarnar 3A, 3erv.ii F. iSr tttr R=t"ir 3t .o act rrti Yl lstraitix n �* tet, raialurnuflux�rldax rkr s ,o7, ['its Clure OJ, Av�iIabffity of nuodfle in s�ciiJ"'s� #Izua- fIL3Q-%i€€r:ale- Pvhlic Heelth Rap sci i5.arn-;luarlaaat ta.Fs in dr4r'tEclrl yw iert altsrati,)f: [7ronest andccrci3i ^r �.ct.d5,&FYnt tri lRfnin Res O ridge vs. sodium 1u ft�Et5#37)-1375 in fT5 ii 3t_78_ ZFpkin 1, Likins RC . b.�leClur Fj. Steer'a ACL-. Urinary 'l3y�?ciat{Sd 4tiitFi the iEST' offluor,dilted 2SV_ h�rneric— Dental A-. arrclatlr�n HaoirbrMedie'41,'aturj: � Ai<rteirnr`s underserutlnY, f�taorle�i�f 4�'4£Is water_ Put's€er, Health Rep 11-450;71 x767-12,. Study linkJn'g f?4aekdg1 and hoc 4€'9"56;129,,1' 16-9_ 3G3_ Zipkin 1. Likins RC,-�Gst7rPti¢n oFvarlola ;fkucarlde ,J'Arri"DestitA 'trtra A.ra, WF. A]u Mi nu rn,. fluor Ido and Inc- gat1e5.inl9stirtat ly8ct of tht! ia.t - compounds fro ',x..`3'7. Uv Forbett Alzljeirnar'r. Qkeea$e- Can J, Public Amer Ptr y" 19�', provamtlon, of t1 1 2;$312;:57-ir14 394, McClure Pd, zipkin t. Physio€tagic gfieets of fluoride nttlr of Hcallo, Edtscatioal and Welfare, as r latet9 to water r€uoridhtion_ [pent Curt 4N ryrru 2 t_ tP5 LSepaiti�t:*rrt 1.1; tional ln.titutaa of M&a1th 13ivision of Dental heart 1958 lAl-5fi_ Crrxp 11e1P Report f-ttle_FlsryralmmissiOn9r intG the Hr�9ttn. (k; iardprea8rlt}ticTn u: staUstC� on dSaitlts.irl Anti gasconsin Pub- PJTi_ PPS-47. 377, f€uQ1lt#Uar+ rst�t�iNkz'fi!+fter supe€i2e-x NQl7s�rt, iasiri�r BethMa. is;Noventrer'1972_ nia A'.9 (�` pffiR7@rltPrinter6„1968- v 4� Hart Ass_c laSFraFl, Mincr&la and "'or gni 312. fJlyars . P€ueckha3art y16, Rs es'r�LG, Rqp it Of the 23'x_ fi`rric ria_:an aua�iancos-- fluoridativri-Availableat rhrt'PViwwM- ,, 'tbieuiririp fluoridation of t:lciorian Melbourne, Vlictoria, ust -oIGa> rD rh4l l+3srt3iftar, �#f33€t - w tersuippties>E979-80 FCAtlki1son, brver5mOntPei nt€r980:115-5. rr m _ "cceea4f May 6,3_ .' �ICarR r7 Risk Y&Gt rs a.r3cY - 313. t' d 14oc C4�' mitt�c� tOr th£a !x 5_ SUPSEE�S�n >ry.a rl�@r.'t F. �r ly s -.-Ci'=.fin x h�.asnCi,.9LiO c,2 rfonaryr heart disciIA--kL available at--hLtp:ix'�v+� w- i+cynp. StSal+ireS F€i, Chairrrtan. F[et�nittz5 t to Frt dont on t€9e'rnedica9 {Ft17n-drZn[t11S (D ° : l 3rcr,.zsite'3ct 4 rq}i !e350ntc r_j7§t krit3sntiFi6"r=4,726cs_ nleint,xl FYr tection'Agency eife�s 6f' fikuoridei In drinking w6ther X983 €-9- Qi 0�4[' C EF, L'3 onr&` f ],�-t�Ti�rr F. Lleborman �J. i3; th(-%- ! �1 a,. H1i4�� reef P`€III1 �3�'S4kos E, Mulkeyo, •r` oreen Tr ct trus Indu--- -y'.+£ Iu iG studies In'marr afCer p,rcalc n� 3 t int#estlon of I ne4r�p rY finding-� in A cJlu �� E?rcj� ttsi7� aloes 9ge IJnvlers r{ dtF9�rida � t '/r AvaiFablcs 'luoride irT drinking water crJrr+mtznittir"Wit; yvith a ' atsr I eI cls 2.5 r3pi'rt_ J ,A,m Dent � Institute of Food=arrd .AurIcultur-Fa soienceN_ tiY€�=�ttillH,ifas_uFl.e a?E: ��E:C3?=.A"es*t=d .tl9soc195i,t 9-stiff, fsril 78, 24_ .. ` .536_ iJl t1sparBt'f'ient of He3a€ttl ind' Hurt am i�efvires- Public 315,. ntorx for piZom5o Contrni arl-d prev,xntiun. Engine++r- ' Health Sar�{iee.Surgg00n, Goneral"e advisrory�,�Ireat- For use, in dialyt4! : vrtrriCiai kidney iet and ,adrnirl intra live retOrrim L�dai>�'�'r,5 for r;3ier 9915 h'IFVI`+' R 995;.44(r,1o.J9R-13), _ mrrrt of water tre ttnertta; Washlwlgri E)C: Government Printing fluoridation, 3i§i, 15+9ater fa,oi�lmn I#J. 4uatcr trr?aKrreant with r, t7Fice 87 C�2i; lurt&-11BQ_ $rid lead tuxir:ity. lrtt J Environ 217, Cr nteia for Disess.a Conuol Flucridle in a diatysis .+.i€ie:ofltta3rids= Stu dir:*1995:56;435-s3- r; rsrrifi-alldSykanx�_ i41(t,1'u't+' 15857-29(12itT34-6- '. 317_ l.J En-.,Fr6nrYs>a_r". I Prcta:ctrran AVency, Gansu mer 21 3. 5'1 'Fee"d. Rog-11x410,11312 tAp rii 2. 1aL5). , fact sheet'on lead_ Availrrkrl� at Envir'eonfrtontal p mtrcdo t i' goncy- Sa.�t DrinF in4] saFetiraatirr,`le`.6"1't1r�Yaa�d`-tri�nl , Accessed On Nlay 8, %Nater Act-Basic LnfoTeriaelon, Avsi;lable of <btEP:)j,, 318, U.S_ rz±lvirrannaental Protection Agnnay T amid in _ • .+�tiYu.917x: r v, of '+ratter{a.G1.WaitssslCillf[AraYa't3t3rs.. s'1r4Rkincf water- :A-+ ailsbla at •cittfi}��+'1't^R�'!+44` ep _ (s3wl afe- _ htfrii . Accessed i'+:+ti V 8.'21006. mater t rnrrlraa[9_i3ttrt6� #ttx�69�t3 ran itE54+ r�', rSi�. 300- Assterican MjSLr`Works ,? socinbon_ WS,Io'we are'. n 39 41TEPSi otiC9anC@- L9rt 1 1827rt. i-i t58r8i ' ixvalabla at �3mf5iaa'a`r�� aras�_cr ,'A7�c3afti ..t ?sed �aitager. DrikikaYt V.V,,o".r ldWvj,"'Certifkcatican February 18. 24246,': P,-ogr:mn N SrlsFt��r�N A'1�6 to bavt d sspatf Catkfami. C # 1 ' rwatr3?.€A i�R of Drinkaing'WatNG � \ �aelitatiiorr Foundation Ir'tC�rrxtsteF3rc�sl, .askshttt �hJ;tP: pjWw_oaf_argibu-3inz_.st&Qtit_ pertsrrenr. rri$ 1ar��7 r tYG�.� 3) f768 � `rr�u 3cnl l via J - NSF_ AvoIlabla°at 10, 2005. r +3itrvr.pciT r+�? esstl a frniseid�[sn_.yr�j��+�ctssctrrSt�� on O � ^iSFfa. Aacaas8€-F*;'ISrx.iary- Arilericarr l�ationsik €aeldardi Irt.titute, Aboutr'+ANSI May 2006 ��€7_ ��5. Envir�rla`[t.artkal Fr�ievttr�rc fS.��rr�sr`= Of Q ovetview,-Available at drip;/' w1 _an*e,oT-jq abQ,ut_'.. 5zire,ru gyyi?rn e,uidsl Accessed Water, Offica 6f,,Sciehee anij Fluuridc: � M1 arts3s vsl ersw>9 F#tFa KY 9i3 itis a,mvutattary fact she t aJ n X - (D r* v Oro FD W v i 321_Ts o£ria-Faeroe COU"'tyr 140421th Dep�rsrrer,t_Ta4ccrrta- :. 343: Margolis F -J, Cohen SN, Successful sna unsuccess- Pierce County Health Dripartmorrt filsJrcridatiorl f rl experiences in eomk:,atin5l ihA antifkiortdationi�Ft!5- ru� nrIvironmentol r-hac ;Lrt- ia4rirt 1986, 0,11t_yi3-8_ Au use =602_ 3444 Easley #4'1W. The, new are 327.. Po€ric.•k PF. Watvr Fluoridation and the an'Vlfonnient' . ' tl'FSA'rr mnt nrpw rin they opi-rtratr17 J: >"kttlli- Hc.7,lth Dent ourrqnr primpective in the sJtnited ' t ate lrt.,l Occup 198£s,45i3b:t33-41. Snvirpn Health 200-1-; 0.'343-5G. : 345, VSrUItC.A, HLI(shes, KP, arl5ith JAG, Eel -ley t.4i�+°4'..Abuse +31.. -__. OsEetmn dW. Fv,;0uating the impact of rnunicip&l �' al the scientific literature in an antifluox'dation pernPhlet. fn. 19E 11, ,,.tater fluoridation or the a stir #tn Ficotrmc*nt_ Amt Baltimorat AmerlGan Oral i-ieakth t ,.uta Public Healet'i 199TJ, 3.1,C3L1-saw 346. Nationel.Health and Medical Fes*aroh Council. The 3Z4 Sgf 'r6=.ir.�r ,�s�ci lic5ra. ?no. v G';a"y,orFood .:dU Lu G:: +3ffc��tiVi[a�n��S of .:*tatitr f1waridntion. Cnnburrn. Aw5ara- Jia: Australian t;dvernrncnt Pub izhinq rviGt;1,�39 c1'2fi�5, 5tS r3_W-2-21' 13 (Noma. Ct_ APP. 1994): _ 2,25- Icscl;. LE. 7Y, rotitl�tr€trid&Li,3ni3t +ersi .t= the ec rrg:itu.:... A oil l orifi tionists 247- Jcrnaxs S. Wsatnr fluorida.tirm in Europe Paper to the Britinh S:wC cim66rk Fvr the Staidy Pirs!35 1-isyr.(ctr €it nal lx3 [u ut!ai':ttur fl.3.. presente-d of cornmurrily Dentian-Y.. 1996 Springy S, ierrtirle i9,8 s.' - ! 141eetin!p.'..L1r,itrdae-,: Scottand. -.r, _st=_ r;h.ri--tcaF£a3t g. FiztrtSrl+13=9-_i`.eciiand fanatics: :pgxkttir_-. I :?'d.;a_ 1++1�r?haier'FFfI,•M'�Sstat t"lu�esri+�st€z�r: re�ult�'i,? Baselhaaith md- roc,acy shouldn't stop at.the courthouse since T9€2-, health and Political ire p0cations. J Pubtno door Am J-FubtiG Health 1935„7546 €88#i--wtt kealth Dent -4SO$ S pec t,'S {64 l��tYS-1Y9 127 - f4lcM1ietratnIn JF Pluortdstvon'ofwatgr in Virgin in, thrt 345, Mayer J, Nlarthakef TNI. Burgf i -i. -The change from tur=npeat in thetespor-,) Laws Ethics Dent 1`� .401, 42,o-3 - -.crater tosalt at; the main vaMrcle:.fo r. community-v4rde 3'28. FiLiYSr' ti, titV3C3r i'i t3rnr rlddtiQnr #'aLYzalQc health responsi- fic.tarida:-expalsur icY Basle, s+,VitYe rteittl fEel lEo dell. L,ility and -she democratic Pracsaa, Ann J Public Hemith Cerommunity.0ent Aral Epldenlldl 2043;31(6),401-2. 1985;555{9}_ 1337-45- 350_ Roemer R_ Legislation on Fluoridation ttf wfster 229 -Strong GA- Lioet-vy,reli3ion and fluoridation, J Am ` supplies in: Experlenae on, wafer fluoridation in -. Dint Ftaaa5ic;1966,7cszf358-7R(] . Europe.:.. Copenhagen-. World Health Orgainiza- 33Z- €aedic k KA -Ail appfai',al of objections tv fl 29riE ROon. J .Aims Dant ate uc i- 62:65s ss -63 351, Kleln SR Sohannsn HM, Bell FIN{, Disney JA, mach 3r?i_ American Dental A--S��ratlon, Sur4,Iy Cenizer, 191-48 � CB. J"ara'✓F3s �14r, The �rG�#:nra�¢ �£+,'tirzrsn�[`--;� afscl-toal- liasnd prrivantivct dental care. Arta J Public Heath r�'zansurrraa•s':opinirn�s reps 6:11 �rre€rrunitlf a+rat�r_ (( 1s�s6:ifs;�i3s8:z-S3_ fluoridation, .2. G a]Iup Ory onacaLiun, irrc_ A GatIup study of parents" 352_ Fa-dcration, niaire Internatiunaie_ Gest -art* �l t'nc� OT rur irn [nity+ r1tiatrde Pfograff a tot c..arlePf-even- F-ahn-.,icor, kriu vtad L• and sttitatdes town, rd,fivaarida„ tso i° technical rs�port'13. Chicago; Quinti nn4r 1921 a -inceWars, td t' Gallup Orllarli etlon, Inc T 1,' 3`,3- MJICIP-Jbia%€Q ML, Allen SJ, Brown U. Cost of Fits wicin- tt33. �Je r f}rta,Y c: hh.� tt :+ar'fd2'Ei7rt'r'vnr:' 'ociersiif dispute tr3n:.ta,Flor6cla remmtrnti:xis_ J lxat-.4.s_ l-9nalth C1cnT ure relisai.0 ,ar atti+ief2t? J-:i�ubiro Health rani. 1996: 556511,up$iChniOt255-52 and Ppu vcarnin G�,rirorr� '. 36+i, Centers for Kfor S.. t DB -The id;aWet W Ee new era. J -Public Health L.jsa ig flurari n mentle'rC fen, for r.. 53nr.� u riU vnnti and Ccret 19'98;'S645i4 p ts;t_b35-B_ ted S control Lft! ntni. carie 5 In the United vC3 tL a. arl lti'VW 235- P.Irk 5, Smith,K; lLlslvitz 0, Furman L. Hazard Y* 2001:5i?(No.RF-14)'22, outragi� ' pukriio Perception of fSuaridatlon risks, 35'5. C,riffira So, Jc neIs K, TDrY\er SL- An er;onoriate:: evsl,-fa- J Public Heaithi Dent T997.5g(4).�8a �a tion of ecrnrnunliV wvatarfluorldatio,n. J Poblic Hc,rc:t;7 -3`u- Ndae can ME_' obstacles to extendinr,f tlu�widation in the -- gent 2001 t61 t21,7 3-535. rJnitcclsteEi rnn-1- Cyerrttteatth 99 6:13ESa pPl21:iC1 aCR, 356, r' marioan U9ntel',A!' wc'iation, SurW'ny Cont -r. 20 ;3 71,371. Lowry R_ AssEEfluoridett+on propaganda matatriel-vthe t<urvgy of dental ,- Ch cago:Aprit 2004 - tricks of the trade.: Sr Dent J s tlUrl;t$;�11�1, �'2$-3'ra. 357_ American'atar,UVor�a Fassaca?tiora_ F[rtoridntion 336. Mandel, 1. :A, syfnp aszium ofttre rl*vv fight for flora; 4Pf pP1br1c water 5upEsl"nxm—Adopted by he BoaTd at rides. -J Public Hea th Diant:lt 5;46f31.133-41. Oiractov--,Jen. 25; 19776, reartirrnedJsr, Sax 19087 and revaaed Jan. Z4, 2002. Availa61S at nttp ff �'v:. 339_ Lang T3 Glary C. Analvzznc;,seleater critici mnv of s a,.vw a. a r g3A b a 1 U0andClio ffict aIdprniX-PAV.4STA T_ water fluoridsa6in_ J Can nt Assoc 1g#t3a f�d3)a- til - cfmtt ,. fio6a&sed April 219, 200f, 3SCF, Lei erro2so AJ, The.Atnerican Council an Sotence and 358. Centers. fear disease Control and PTcvgntk?n.'Nmtor . Health. Fad s. v 2ratl;s tears_ a rev ie or ttte 29 €Jreatest �f100ridatiOn xan i c:ns,`t a of M ioniraid trratirnant unf, urlded health scares of reoent �ln'r -a. 7€ o ed: Ne v for,dental dec;iy-Lou3siarim, 19951-1925. 16rTPd1tir R `fork,,! 99 e_ 1999,.4& + 53-7 341, }0svbert v. f Co 6Y, ,�,� aFinac.autj C Sts, 1n c._ 50 3665 Bur-, SA, ad. Prco,+-eed`ttags for the workshop-, roe rrfF-m,-_ 4.1_S; 579. 1 13, s -Cr- 2 BES {1,,393 _ bl - fivRn*'+t&,-;:. 4i'�k-?ri a��c ��r�vaPnti['�n 3n dental �stlbli� tlealtts- 342-'El'ezier i'J- Fluoridavvtt_ a r viaw ul _6ai t*ssr_aret _ rvv�ult-�5 oftho wc;rk hllop_ J Pplmlic Health Dent 1989, ,8 ]blic Freolth'Dant 1a i7a4Et31_ 'I • - _ 56 45 Spec No) s31-40- Cn C) N C) Recommendation *That • Board of County ulornmissioners provide direction t staff on the use of fluoride in thed ,WIN supply _ublic drinking water Building a Database of Developmental Neurotoxicants: Evidence from Human and Animal Studies W. Mundy', S. Padilla', T. Shafer', M, Gilbert', J. Breier' 2, J. Cowden', K Crofton', D. Herr'', K. Jensen', K Raffaele', N. Radio4, and K. Schumacher. 'Neurotoxicology Div. U.S. EPA, RTP, NC 27711; ZCurriculum in Toxicology, Univ. of N.C. at Chapel Hill, Chapel Hili, NC, 27514; 3 NCEA/ORD, U.S. EPA, Washington, DC, 20460; 4Cellumen, Inc., Pittsburgh, PA. 15238; 5U.S. EPA, Region 7, Kansas City, KS, 66101. Introduction EPA's program for the screening and prioritization of chemicals for developmental neurotoxicity makes it essential to assemble a list of chemicals that are toxic to the developing mammalian nervous system. Listed chemicals will be used to evaluate the sensitivity, reliability, and predictive power of alternative developmental neurotoxicity assays. To establish this list, a literature review was conducted for over 400 compounds that have been suggested to be developmental neurotoxicents, neurotoxicants, or developmental toxicants. Compounds were assigned one of three groups based on the strength of the evidence for developmental neurotoxicity: (i) no evidence; either there were no reports that met our criteria for evidence, or there were reports which showed no developmental neurotoxicity; (2) minimal evidence: one report only or multiple reports from only one laboratory; or substantial evidence; reports from more than one laboratory. The chemicals in the tatter group will be especially useful for vetting protocols that have been proposed as screens for developmental neurotoxicity. P4 yxcr,berr Msbar, mviawadbYMNrMM Naamrtl ErMrxne VW arc. Raaasnw L"Wr Yrdappr d. Arp aoa mr dYSY .anti. arxrw nide dr rr.ex tyre aa.s'x Approach Collect lists of putative DNT chemicals (n-400) Each chemical was assigned to one of three categories: 1. No available evidence existed: exclude from manuscript. 2. Minimal evidence existed: put in table in manuscript. 3. Substantial evidence existed: write a descriptive paragraph for manuscript. 'Registration Eligibility Decision Documents (available onkne or via Freedom of Information Act) Evidence: Criteria for Assessment and Endpoints a) We Included only mommaigan spades. -no in vitro studies were included. b) We included only studies with the pure chemical (or reasonably so). -no mixture studies were included. -no human studies ware Included wherein there was exposure to more than one compound. -no fomrulabons ware included. c) We included only studies whom the exposure took piece during pregnancy or during the period before wesning. I d) We included only studies in which the administered does was below 5 gramalkg. e) Where knowledge was available, we considered only studies where the administered dose would not be lethal to the offspring. 0 We dud not include any use reports. i g) In studies Where the chemical was administered during gestation, to the extent possible, we looked for a lieerbased statistical design. h) If only acute pharmacological effects ware Imported (either during dosing or shortly ` thereafter), we did not include that study. Endpoints assessed included, but wan not limited to: ® Head Circumference 2 Grip Strength W Brain Weight R Negative Geotaxis ® Exencephsly 9 Starde Response ` 50 Brain Morphology ®Righting Reflex i ® Motor Activity ® Neurochemical Levels W Learning and Memory ® Receptor Al(iniy/Number �. ..... ... .. _.__ .............. ... ..........___..._.._.... ...... Chemicals with Minimal Evidence of Developmental Neurotoxicity (n=100) 1,1,f-Tdchlorasthsns oirrdnotolrata 12.6i 1.1do.61no Abamecan eloldmomomrr (msthysera chbrwe) Mel.tlrbn AwPNIo D.N—IDovP) M..*.b Aeea.rlptld Diemfopla. MaytansNa A.5—yeteD DlmamnamylemitlrlM MalhamdepAcs Amk.b—(MKH 261111/) Dim.arwb MMhyt Ethyl Ksaa AbYmlmb Massa MNDA At—tsan INph.0yrtim Ins Moa.eb Aeaa uv MOW. Hded AtMO. maerY1 Emsmecl. nabxme BAK 619 f9maxd) Endead0han races erbanYl D"D670H Endrin Pe J lum" eame,dn EPIC (S-EOYI dlpropythmoeamamry Phots. farts 225 0 &.north Rib --hands E+g w b. Pbroludn b arem.red yeg oil Etlaxyaearal (24 Pmrddons Guam. Milan* dUstnmWPran Carbaftimn Ethylens oxide PMnommleconvals Gabon eleutmb Ero/snamc aebMum compwands Cabrdrrs Fa,snepra. slmvesban CNorAmamm Fadtroeacn 6plrodM2oMn Chblyenapyr F—lamw a—mr CHortse, sodium FK 22424 t6ynaaaa mruphaknl Tsraufs, C1443 (Anapsycheac) Flurk-sstf0d fluam(ds) brt4luty1hydrogaIms e, 2- ClodlnenopTmPagYl Formaldehyde Tatrachlwdi)4enre ClodtrlkHn alufeskrsb amrcnam Tetracycline Coumaplus o"house blesehim, Thirnxsm asOr Cyauardn lis2aah..Pl.anals IN-) Trihues(DEF) LyhMotlrdn Iniad prid Trkarynrrs OrYoa dims" ager cyme." Ivermectin Tdnaarsdcas Dnmtol Laaclndtms Trlphenyl Phosphate DDT Law.slph.—Y earadol vwaa (Taw +pMe) mM Dextmerade VP46413 (Ellopoalds) Chemicals with Substantial Evidence of Developmental Neurotoxicity (n=100) 2-Elherp" AwYb Ismis— MYrrasom AdIs aebr4raskryl Cybsnre AmbirMlde NWOm Aerylu.tla DEET Meewaysewrot, 2- Alacal► OsltsarsNrtn Marey rimrsoun of AilesuNr Dlshran � Alomloum(aorlasbtal Dialed. owns pMUbeWci artlo P ... suet A.mePt� DtPksnybydrdoln Panrhbn O"YO Amphef.Mas(d-) EpMamrl anmrM FactorPem Anank elft«.( Peas (a—".) Asprtrra f,044ms thburse P_ R..# - Fie. 1116i Par..M I. tivatha n Phenylseetate lumasne fluadde PImirldnlm(dn eloaaenrb OdseotulMn Pn I m42 �rAtl aa(HAhWirl"mc!" rlde11s"Ie .i m O alepho al A Halonhms Ra6nnold.ML/Nsedstlrrain ananedsexWralra(FI H.ptrsrbr aslleybte sutybW llydmry Anisol H. balucans Tem.xm.m. auty(slad hydmxy"k— 1HU. T.O.W. (salt) C.".. Hydmxywas Tarin elms C.1lWa rmmmodrproPdonmNlamM ThaliderMds Cararne»pme KOMMna THC Carbayl Laad TaaaM Carbon mo 40 Word— IJndra LAD TdamelnWons THMMM ableouss ehbMaeapoxWa Manes Trkidorbn Chlodnedlexlde Medraxyto esse.— Tdcblom.". Ctdrprom.d.s M.Pivacams TdaMryErd Td thylan coon. M.armol Tdm MAIn Cok<mld Mathimamis Tww Was C.ICMoaw MOMAPaMhlon umesme CypermadinIn Momaoeam OlutamNa valPrads MPTP wnsdsma rM hydrochloride DlrmpM N.W— Sample Paragraph DEXAMETHASONE CAS Number. 50-02.2 Formula: Dexamethasone is synthetic member of the gacocartkoid clan of steroid ..It I. used W heat inflammation and autoimmune conditions (mg.. rheumatoid arthritis), and to counteract Gals. eflecte an chenothempy in cancer patients. Synthetic gamcoNcads, Including dexamethasone, aro also administered to women at risk for paam labor to advance fetal mahxation and reduce neonatal morDd ity and mortally. Numerous stldba len anima have shown neumdevebpm Mal effects of pednwud dexamethasone heatmmt in rodent. Doses of 0.2- 3 mgikg (vMch encompass s the therapeutic range to humars) given to the pregnant dam during gestation or to the offspring postnatally .Ker neurogenesis and differerdlstion (Bohn, 1954; Carlos at al., 1992), decrease Wain sae and brain weight (O.Koekey at al., 1952; Calls at al., 1997 Faryraon and Holson, 1999), and other locomotor activity and learning and memory behavior (DeKoakey at of, 1992; VicedoMM at M., 1986; Ferguson et d., 2001; Kreber at al., 2005.). Relatively, bwdoees (0.05 - 0.2 mykg) have apo been shv to result in long-batkg charges M newohana iter systems and IMracelular signaling (Kreider at al., 2005b; Kreider at al., 2006; Motion at M., 2006). Exacts o1 dexamethasone, Inducing decreased Wain weight ab hippocampal damage, ' also been oteamed in nonhuman primates (reviewed in Coe and Wbach, 2005). Human developmental reurotoxicthy Is associated wdh path" exposure to dexamethasone. Preva st cloamethes" is routinely administered to mothers at risk lot petam c uce to redmortality and the Incbence of respkdory, detreas syndrome and irbavenh)wbr hemore( Premature Intanb. Postnatal dexamethasone treatment In Preterm infants Is also used to reduce th Q and severity of chronic king disease. A preponderance of epidmr9dogic and clinical evidence, hov Indicates that both pe. and pct -nidal exposure to dexamethasone can result In an increased risk N cerebral patsy, decreased brain aim, and long-term effects an cognition and behaviof (reviewed In O 2004; Purdy, 2004; Purdy and Wiley. 2004; Slobeda at at, 2005). C) W Fluoride Linked to Lower IQ and Neurological Impairment Mercolaxom Call Toll Free: 877.985-2695 Study Proves: This Everyday Dank Lowers Your ICS Posted By Dr. Mercola I August 12 2011 1 136,968 We" By Drs. Paul and Ellen Connett Paul Connett co-author of the book, The Case Against Fluoride, is joined by his wife, Ellen, webmaster of the Fluoride Action Network (FAN), and Tara Blank, PhD, Science Liason Officer for FAN, in authoring this article on fluoride and the brain. Together they have recently provided an extensive commentary to the EPA's Office of Drinking water in response to its proposed safe reference dose for fluoridel Fluoride Action Network 409 :..i've 12,536 In an ongoing effort to determine which chemicals may damage the developing brain, scientists from the U.S. Environmental Protection Agency (EPA) recently conducted an extensive literature review of over 400 chemicals, including fluoride. Fluoride is Classified as a Neurotoxin While the Centers for Disease Control (CDC) would have us all believe that fluoride is perfectly innocuous and safe, scientists from the EPA's National Health and Environmental Effects Research Laboratory have classed fluoride as a "chemical having substantial evidence of developmental neurotoxicity".2 Consistent with the EPA's conclusion, a continually growing body of human and animal research strongly suggests that fluoride can damage the developing brain. Consider for example: • 24 studies have now reported an association between fluoride exposure and reduced IQ in children • Three studies have reported an association between fluoride exposure and impaired neurobehavioral development • Three studies have reported damage to the brain of aborted fetuses in high fluoride areas, and • Over 100 laboratory studies have reported damage to the brain and/or cognitive function among fluoride -exposed animals3. Most of the 30 studies linking fluoride to reduced IQ, impaired neurobehavioral development, and fetal brain damage have come from China where fluoride occurs at moderate to high levels in the drinking water in what is known as "endemic areas for fluorosis:' While there have been shortcomings in the methodologies of some of these studies, they have been remarkably consistent in their findings. Children exposed to excessive fluoride have been consistently observed to suffer from some form of neurological impairment. Your Brain Under Attack Statistics tell us that our brains are under attack. For example: • Autism Spectrum Disorders: The rates in the U.S. are now 1 in 110 children and are "4 to 5 times more likely to occur in boys than in girls," or as many as 1 in 60 bons. • Attention Deficit Hyperactivity Disorder: According to a November 2010 CDC report, nearly 1 in 10 U.S. children have ADHD - an increase of about 22 percent from 2003. • Alzheimer's Disease: According to the Alzheimer's Association, 5.4 million Americans are living with it and every 69 seconds an American is diagnosed with it. By 2050, it is estimated that as many as 16 million Americans will have the disease. Pagel of 9 5/10/2016 11.B. �N,fp`Y, MOR FriFry;+: C.:. d Yn77ea PAM AOL (aTMroae.aro: ' ;onn•a7aot Article Tools Print this Page Save as Favorites Current Newsletter Share Your Comment Poticasts ,Submit My Stony Newsietter Feed Hearth Sion Feed BROWSE BY CATEGORY A gin Alzheimer's Arthritis Artificial sweeteners Aspartame Rack Pain TRANSLATE THIS PAGE: wF For online Shopping CLICK IN HERE .�,. Top Products N®11 Whole Food Multivitamin PLUS tablets (240 per bottle): 3 bottles Sale Price: $129.97 Discover More , We do not know the causes for the alarming increases in these diseases but we do know that wherever possible, everything must be done by regulatory agencies and caregivers to protect the brain from known neurotoxins. http://articles.mercola.com/sites/articles/archive/20l l /08/ 12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -90- Fluoride Linked to Lower IQ and Neurological Impairment Palle 2 of 9 5/10/2016 11. B. Fluoride is a known neurotoxin and it is time to stop adding it to public drinking water systems. However, convincing U.S. regulatory authorities of this urgent necessity is proving very difficult. Developmental Neurotoxicity In 2007 Choi and Grandj'ean° stated: !n humans, only five substances have so far been documented as developmental neurotoxicants., lead, methylmercury, polychlorinated biphanyls, arsenic, and toluene. From this evidence, including our own studies on some of these substances, parallels may be drawn that suggest that fluoride could well belong to the same class of toxins, but uncertainties remain..." Health Agencies are Ignoring Fluoride -Brain Studies Even though health agencies in the U.S. and other fluoridating countries have recognized that children are being grossly over- exposed to fluoride (41 percent of American children aged 12-15 now have some form of dental fluorosis), they are unwilling to concede that fluoride may be impacting the brain. Their approach has been either to ignore these studies completely or to challenge the relevance and the methodology of the fluoride -brain studies. They have thus far failed to conduct any IQ studies of their own. Bottle -Fed Babies at Risk The level of fluoride in mothers' milk is remarkably low; only about0.004 ppm . In the view of many critics of fluoridation, including Arvid Carlsson, Nobel laureate in medicine/physiology, it is reckless to expose infants to levels of fluoride orders of magnitude higher than that found in breast milk. In the U.S., infants who are fed formula reconstituted with fluoridated tap water receive the highest levels of fluoride (per kilogram bodyweight) in the human population. Specifically, infants who are fed formula made with fluoridated water at the current level of 1 part -per -million (1 ppm = 1 mgniter) fluoride will receive a dose up to 250 times more than the breastfed infant. Even with the proposal by the U.S. Department of Health and Human Services to lower fluoride to 0.7 ppm in fluoridation schemes, bottle-fed infants will still receive up to 175 times more fluoride than the breastfed infant. In addition to bottle-fed infants, others at heightened risk include those with poor nutrition and both African American and Mexican - American children. Recent studies indicate that African American and Mexican -American children have higher rates of the more severe forms of dental fluorosis than white chikirenl. As dental fluorosis provides a visual indication that fluoride has exerted a toxic effect on your body, it is reasonable to assume that these same children will also be more vulnerable to other toxic effects of fluoride including damage to the brain. EPA Protecting Fluoridation Program, Not Public Health On January 7, 2011, the EPA's Office of Water (OW), while pursuing its mandate to set a new safe drinking water standard for fluoride, made it clear that it would do so without jeopardizing the water fluoridation program. According to Peter Silva, EPA Assistant Administrator for the OW: "EPA's new analysis will help us make sure that people benefit from tooth decay prevention while at the same time avoiding the unwanted health effects from too much fluoride'. Silva was referring to severe dental fluorosis, broken bones, and skeletal fluorosis as the unwanted health effects. These were the three health effects that the National Research Council of the National Academies in its 2006 report Fluoride in Drinking Water A Scientific Review of EPA's Standards singled out. The report recommended that the EPA perform a new health risk assessment to determine a safe drinking water standard for fluoride because they found the current level of 4 ppm was not protective of health. In its first draft risk assessment, EPA claimed that the most sensitive health effect of fluoride was severe dental fluorosis2. Brain effects were ignored by EPA even though many more studies have been published since the NRC made its recommendation. Science does not stand still. The NRC examined five IQ studies; there have now been nearly five times more at 241 Making matters worse, the EPA's Office of Water risk assessment excluded the fetus and infants under 6 months of age, as the EPA does not expect them to get dental fluorosis! Whether fluoride impacts the growing tooth enamel during this period or not, this is a very important period for brain development. As noted above, an infant fed formula made with fluoridated water at the proposed lower level of 0.7 ppm will receive 175 times more fluoride than the breast-fed infant. EPA Research Laboratory Takes Different View Fortunately, the EPA does not speak with a single voice on fluoride's neurotoxicity. While the EPA's Office of Water ignored any brain effect in its 2011 risk assessment, the Neurotoxicology Division at the EPA's National Health and Environmental Effects http://articles.mercola.com/sites/articles/archive/2011 /08/12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -91- Fluoride Linked to Lower IQ and Neurological Impairment Page 3 of 9 5/10/2016 11. B. Research Laboratory included fluoride in its list of "Chemicals with Substantial Evidence of Developmental Neurotoxicity", for a new project expected to be launched this yearlD. Ultimately, therefore, the EPA administrator will have to resolve the following question: Is it more important to protect our children's brains or the fluoridation experiment? Fluoridation Proponents' False Claim Proponents of fluoridation have dismissed the fluoride -IQ studies on the basis of the claim that the children in these studies were drinking water containing fluoride at much higher levels than used for water fluoridation (approximately 1 ppm). However, such claims do not bear close scrutiny, Xiang1 estimated that the threshold for IQ lowering was 1.9 ppm and more recently Ding et al. (2011) found a lowering of IQ in the range of 0.3 to 3 ppm. These findings reveal that there is no adequate margin of safety to protect ALL American children drinking uncontrolled amounts of fluoridated water and ingesting fluoride from other sources (e.g. toothpaste). While we will discuss this crucial margin of safety argument in more detail below, suffice it to say here that when harm is found in a small human study a safety factor of 10 to 100 is typically applied in order to extrapolate to a level designed to protect a whole population from harm. The NRC (2006} Review of Fluoride The NRC panel devoted a whole chapter on the brain in its 507 -page 2006 review and concluded: "it is apparent that fluorides have the ability to interfere with the functions of the brain and the body by direct and indirect means." Of the five IQ studies reviewed by the NRC the panel drew special attention to the study by Xiang at al.2, which they indicated had the strongest design. The panel described this study: "This study compared the intelligence of 512 children (ages 8-13) living in two villages with different fluoride concentrations in the water. The iQ test was administered in a double-blind manner. The high -fluoride area had a mean water concentration of 2.47 t 0.79 mg/L (range 0.57-4.50 milligrams per liter [mg&]), and the low -fluoride area had a mean water concentration of 0.36 t 0.15 mgt (range 0.18-0.76 mg&). The populations studied had comparable iodine and creatinine concentrations, family incomes, family educational levels, and other factors. The populations were not exposed to other significant sources of fluoride, such as smoke from coal fires, industrial pollution, or consumption of brick tea. Thus, the difference in fluoride exposure was attributed to the amount in the drinking water... the average intelligence quotient (IQ) of the children in Wamiao was found to be significantly lower (92.2 f 13. 00, range, 54-126) than that in Xinhuai (100.41 t 13.21; range, 60-128). The IQ scores in both males and females declined with increasing fluoride exposure." The shift in the IQ curves for both males and females are shown in Figures 1 and 2. , 0 :oae so L? �-0 AS 110-119 120 121 120 Figure 1. Distribution of IQ scores from males in Wiamiao and Xinuai. Source: data from Xiang at al. 2003a (as shown in NRC, 2006, Figure 7-2, p. 207). http://articles.mercola. com/sites/articles/archive/2011 /08/ 12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -92- Fluoride Linked to Lower IQ and Neurological Impairment tQ (d�PCJb.•135 ItJJI Page 4 of 9 5/10/2016 11.B. Figure 2. Distribution of /Q scores from females in Wiamiao and Xinuai. Source: data from Xiang at al. 2003a (as shown in NRC, 2006, Figure 7-1, p. 207). According to the NRC (p. 206): 'A follow-up study to determine whether the lower IQ scores of the children in Wamiao might be related to differences in lead exposure disclosed no significant difference in blood lead concentrations in the two groups of children." Xiang extrapolating from the whole set of data estimated that the threshold for IQ lowering would be 1.9 ppm. Below we use this estimate in a margin of safety analysis to calculate a level that would be sufficient to protect all children drinking fluoridated water. The NRC panel's overall conclusion based on its review of these five IQ studies was: A few epidemiologic studies of Chinese populations have reported IQ deficits in children exposed to fluoride at 2.5 to 4 mg1L in drinking water. Although the studies lacked sufficient detail for the committee to fully assess their quality and relevance to U.S. populations, the consistency of the results appears significant enough to warrant additional research on the effects of fluoride on intelligence. " Incredibly, no fluoridating country has followed up on this. We continue to fly blind on this critical issue. One of the animal studies reviewed by the NRC was the study by Julie A. Varner and co-workersfrom the State University of New York at Binghamton. These authors fed rats for one year with 1 ppm fluoride in their water. One group received sodium fluoride, the other aluminum fluoride. In the rats treated with either fluoride compound, Vamer at al. discovered the following: • Morphological changes in the kidney and the brain • An increased uptake of aluminum into the brain • The formation of beta-amyloid deposits, which are a hallmark for Alzheimer's disease More Brain Studies Published Since NRC 2006 Review Since the NRC panel wrote its report in 2006 many more animal studies have been published and another 14 IQ studies have either been published or translated. Five more IQ studies wait translation from the original Chinese. This brings the total to 24 IQ studies that have found exposure to fluoride associated with lowered IQL. At least 16 studies on animals have shown that fluoride has an effect upon the hippocampus and nine of these have been published since the NRC's 2006 review. Damage in this area of your brain usually results in difficulties in forming new memories and recalling events that occurred prior to the damage. Xiang Updates His Work�7 An updated version of Xiang et al's (2003a) workil, which included new information about the relationship between the level of fluoride in the children's plasma and IQ was accepted for publication in Environmental Health Perspectives (the journal of the National Institute of Environmental Health Sciences) and made available online on December 17, 2010. This article was later withdrawn when it was found that some of the material had been previously published. However, for those who have used criticisms of the methodologies of some of the 24 IQ studies to justify ignoring the issue completely, it is important to note that the Xiang et al, paper successfully passed the peer -review process of this important journal. http://articles.mercola. comisites/articles/archive/2011 /08/ 12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -93- Fluoride Linked to Lower IQ and Neurological Impairment Page 5 of 9 5/10/2016 11. B. Another Important Fluoride 10 Study An IQ study published in 2011 by Ding et al. 19 investigated the effects of low levels of fluoride on IQ. Children were exposed to 0.3 to 3 mg F/L fluoride via drinking water. The authors found a very significant linear correlation (p <0.0001) between fluoride levels in the children's urine and lowered IQ (Figure 3). They calculated that there will be a lowering of IQ by 0.59 points for each increase of 1 mg/L urinary fluoride. Figure 3. The relationship between IQ differences and urine fluoride concentrations. Multiple linear regression model was carried out to confirm the association with urine fluoride exposure and /Q scores (F=9.85, p < 0.0001) (Figure 2, Ding at al., 2011) Margin of Safety: The Safety Factors Used in Toxicological Assessments Promoters of fluoridation, either through ignorance or design, betray little understanding of the concept of margin of safety. This is revealed when they dismiss studies carried out at levels higher than 1 ppm as being irrelevant for assessing the risks posed by water fluoridation. This indicates that they have no appreciation of the difference between concentration and dose. Someone drinking three liters of water with 1 ppm fluoride would get a higher dose (3 mg) than someone drinking one liter of water with 2 ppm fluoride (2 mg). In other words, it is the dose that hurts people, and thus finding harm at levels as high as 4 ppm are still relevant to a high water consumer drinking water at 1 ppm. Toxicologists usually have to work from high dose animal experiments to extrapolate to a safe level for humans. This typically requires the application of a safety factor of 10, when extrapolating from the dose that causes harm in animals to predict a safe dose for humans (in order to account for the potential variation between species). Then a second safety factor of 10 is commonly applied to take into account the full range of sensitivity to any toxic substance that is to be expected in any large population. In other words some individuals are likely to be 10 times more sensitive to fluoride than others. In the case of fluoride we are in the unusual situation of having quite a large amount of human data to work with, especially in the case of its neurotoxic effects, so it is only necessary to address the variation in sensitivity expected in a large population. In its January 7, 2011, draft risk assessment the EPA Office of Water took the most unusual tack of not using any safety factor at all when extrapolating from the dose that causes severe dental fluorosisLo. In other words they believed that they had enough data to state - with no uncertainty—that no one consuming less than 0.08 mg of fluoride per kilogram bodyweight per day would develop severe dental fluorosis. For them to legitimately forego any safety factor they need to demonstrate that this purported "threshold" dose is based on sufficiently large numbers of subjects to represent the full range of different vulnerabilities and sensitivities in the U.S. population. Such variations include: age, income levels, nutritional status, genetic and ethnic variability. It is notable therefore, that the study on which the EPA's calculations were basedL' did not include African American or Mexican - American children, or children from a full range of family income levels. Dr. Paul Conned, director of the Fluoride Action Network believes that the EPA Office of Water was forced to choose this "uncertainty factor" of 1 in order to produce a "safe reference dose" that was higher than the dose deemed necessary to protect teeth against decay. In other words, this was a political decision made to protect the water fluoridation program. Even more political was the EPA's willingness to ignore the studies that indicate that fluoride lowers IQ. No Margin of Safety for Fluoride The level at which Ding et al. (2011) researchers found a lowering of IQ (0.3-3 ppm) overlaps the range at which fluoride is added to water in the US (0.7 -1.2 ppm). Even without applying a safety margin to this finding, it would suggest that there is no safe level that would protect ALL of America's children from potential interference with mental development from fluoride exposure via the water supply. http://articles.mercola.com/sites/articles/archive/2011 /08/12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -94- Fluoride Linked to Lower IQ and Neurological Impairment Page b of 9 5/10/2016 11. B. However, Ding et al. state that this is a preliminary finding, and more work should be done to control for possible confounding factors. Meanwhile, it is possible to use the findings of Xiang et al .2� to estimate a safe reference dose to protect all American children from this effect. This is the task that the EPA Office of Water should have undertaken. However, as indicated above, their preliminary calculations for the safe reference dose published on January 7, 2011, failed to consider fluoride's potential to lower IQ. The EPA defended its decision to only consider severe dental fluorosis, by claiming that this is the most sensitive endpoint of fluoride's toxicity. The EPA made this claim despite the fact that, in both the Ding and Xiang studies, reductions in IQ were observed among children without severe dental fluorosis. This clearly challenges the EPA's claim that severe dental fluorosis is the most sensitive adverse effect of fluoride. Other Human Brain Studies Three other studies from Chinas indicate that aborted fetuses in endemic areas for fluorosis show signs of brain changes compared to aborted fetuses in non -endemic areas. Moreover, in a study from Mexico, Rocha-Amador at al found that children exposed to moderate levels of fluoride had impaired visual -spatial recognition abilities. Such impairments could affect a child's development. In 2009 the Rocha-Amador team performed tests on children exposed to various neurotoxicants (Fluoride, Arsenic, Lead, DDT, DDE or PCBs). Fluoride exposed children were selected if they had dental fluorosis (a bio -marker for fluoride over-exposure). All the children exposed to the various neurotoxicants "had very poor performance in Copy and Immediate Recall tests and in general they recalled less information on the Construction/Memory score." As the authors of these studies note, fluoride's impact on the brain may be evident in the absence of crude reductions in IQ. Indeed, the authors note that IQ tests may well fail to detect fluoride's more subtle effects on cognitive function. Consistent with Rocha-Amadoes research on non -IQ effects, Li et al., reported that infants born in areas with high fluoride levels had "significant differences in the non -biological visual orientation reaction and biological visual and auditory orientation reaction" compared to infants born in areas with low fluoride levels. Establishing a Safe Drinking Water Level for Fluoride MCLG The most important step in setting a federally enforceable safe drinking water standard (maximum contaminant level or MCL) is the determination of the Maximum Contaminant Level Goal (MCLG). This determination is made by the EPA's Office of Water. The MCLG is the level of a contaminant in water below which there is no known or reasonably anticipated risk to health. The MCLG is the basis for setting the enforceable standard (MCL). This enforceable standard takes into account the cost of removing the contaminant and is therefore not as protective as the MCLG level. For example the MCLG for arsenic is zero, but the MCL is set at 15 ppb (parts per billion) due to the costs of removing natural arsenic from some water supplies. For fluoride, Xiang et al. (2003a, b) estimated that the lowest water concentration associated with a lowering of IQ was 1.9 mg F/L. Ironically, this is the same threshold that the EPA's Office of Water offers for severe dental fluorosis. We convert this to a dose by assuming that the children in the Xiang study were consuming on average one liter of water a day. One liter of water at 1.9 mg F/L translates into a dose of 1.9 mg/day. This is called the lowest observable adverse effect level (LOAEL). Because these studies only dealt with 500 children, with fairly similar genetics, lifestyles and nutritional status, we would need at least the standard uncertainty factor of 10 to account for the full range of sensitivity expected in the whole population in the U.S. to arrive at a safe daily dose. 1.9 mg F/day divided by 10 equals 0.19 mg F/day and thus a safe daily dose should be set no higher than this. Such a dose would be exceeded by a child drinking less than one glass of water (250 ml) at 1 ppm (1 ppm = 1 mg/liter). In other words water fluoridation is not safe; some children could have their mental development impaired by drinking as little as one glass of fluoridated water on a daily basis. As far as setting a maximum contaminant level goal (MCLG) for safe drinking water is concerned, we should note that this safe daily dose of 0.19 mg/day is already being exceeded from other sources. For example the EPA OW estimates that mean fluoride ingestion from toothpaste among children between the ages of 1 and 4 is 0.34 mg/dayu. Fluoride intake from toothpaste alone, therefore, contributes twice the safe daily dose of 0.19 mg/day. Thus, since some children will exceed the safe dose of fluoride from non -water sources alone, it is difficult to understand how the MCLG for fluoride could be set any higher than ZERO if the EPA were to acknowledge the existence of these IQ studies and follow routine procedures. Of all the dangers posed by fluoridation (and there are many others) the potential to impact a child's mental development must be considered one of the most serious. Just how long can promoters continue to ignore the voluminous evidence of these dangers? And how long will the public let them? http://articles.mercola.comisites/articles/archive/2011 /08/12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -95- Fluoride Linked to Lower IQ and Neurological Impairment Page 7 of 9 5/10/2016 11. B. Importantl The producers of this powerful film are allowing a full and FREE preview through August 13th in celebration of Fluoride Awareness Week (Aug 7 -13)I You can support Fluoride Action Network by purchasing the Professional Persoectives DVD at a special price of $10 during Fluoride Awareness Week. What You Can Do TODAY' The Fluoride Action Network has a game plan to END water fluoridation in both Canada and the United States, and this Fluoride Awareness Week will hopefully bring us a lot closer to that goal by spreading mass awareness. Our fluoride initiative will primarily focus on Canada since 60 percent of Canada is already non -fluoridated. If we can get the rest of Canada to stop fluoridating their water, we believe the U.S. will be forced to follow. Please, join the anti -fluoride movement in Canada, New Zealand and the United States by contacting the representative for your area below. If you are a mom and want to see an end to water fluoridation, you can also contact a new group called "Moms Against Fluoridation" by sending an email to: infoOMomsAgainstFluoridation.org. Contact Information for Canadian Communities: 1. If you live in Ontario, Canada, please join the ongoing effort by contacting Diane Sprules at diane.sorules0 cogeco.ca. 2. The point -of -contact for Toronto, Canada is Aliss Terpstra. You may email her at alissgbnutrimom.ca. Contact Information for American Communities: We're also going to address three US communities: New York City, Austin, and San Diego: 1. New York City, NY: With the recent victory in Calgary, New York City is the next big emphasis. The anti -fluoridation movement has a great champion in New York City councilor Peter Vallone, Jr. who introduced legislation on January 18 "prohibiting the addition of fluoride to the water supply." A victory there could signal the beginning of the end of fluoridation in the U.S. If you live in the New York area I beg you to participate in this effort as your contribution could have a MAJOR difference. Remember that one person can make a difference. The point person for this area is Carol Kopf, at the New York Coalition Opposed to Fluoridation (NYSCOF). Email her at NYSCOFaaol.com . Please contact her if you're interested in helping with this effort. 2. Austin, Texas: Join the effort by contacting Rae Nadler-Olenick at either: info0fluoridefreeaustin.com or fluoride.info4_)vahoo.com, or by regular mail or telephone: POB 7486 Austin, Texas 78713 Phone: (512) 371-3786 3. San Diego, California: Contact Patty Ducey -Brooks, publisher of the Presidio Sentinel at pbrooks936(&aol.com. Contact Information for New Zealand Communities: 1. New Zealand: Contact Mary Byrne if you would like to be involved in stopping fluoridation in New Zealand. Mary would like to hear from you! Email her at: mbvrne64Ca)vahoo.co.nz In addition, you can: • Tell the EPA you expect them to uphold their duty to protect you and your children from this toxic food fumigant. http://articles.mercola.com/sites/articles/archive/2011 /08/ 12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -96- Fluoride Linked to Lower IQ and Neurological Impairment Page 8 of 9 5/10/2016 11. B. • Make a generous tax-deductible donation to the Fluoride Action Network, to help them fight for your rights to fluoride -free food and water. • Check out FAN's Action Page, as they are working on multiple fronts to rid our food and water supplies of fluoride. • For timely updates, join the Fluoride Action Network Facebook page. References: 'FAN (Fluoride Action Network). 2011a. Comments on the U.S. EPA's ReportFluoride: Dose -response analysis for non -cancer effects. Submission to the U.S. Environmental Protection Agency, April 21, 2011 (revised). Online at hltyJ/0uorideslen orasan-dose•ro=nse wmments as 2011.odf hnp•/Muorideebrtoralfan exposure revised 4.22-11 coli z Mundy W, Padilla S, Shofar T, Gilbert M, Breier J, Cowden J, Crofton K. Herr D, Jensen K, Raffaele K Radio N, Schumacher K. Undated. Building a database of developmental neurotoxicants: Evidence from human and animal studies. U.S. Environmental Protection Agency. Online at htto /A cow eoa wv/ncGHoxcasi files/summit(46P%ZOMVn"20TDAS coli a Canned P, Beet J, Micklem HS. 2010, Appendix 1, Fluoride and the Brain in Tires se Against Fluoride How Hazardous Writs Ended Up in OurD11110 p Water and the Bad Science ant Puhwnhrf POW'm That Keep It Thera. Chelsea Green Publishing, VT. 2010. Detg Y, YanhuiGao, Sun H, Han H, Wang W, Ji X. Liu X, Sun D. 2011. The relationships between low levels of urine fluoride on children's intelligence, dental fluorosis in endemic fluorosis areas in Husunbuir, Inner Mongolia, China- Journal of Hazardous Materials Feb 28;186(2-3):1942-6. Choi AL and Grandjeen P. 2007. Potentials for developmental fluoride neurotoxicity. XXVIITH Conference of the International Society for Fluoride Research, October 9.12, 2007, Boiling china. I BehrAn-Aguilar ED, Barker L, Dye B. 2010. Prevalence and severity of dental fluorosis in the United States, 1998-2004..NCHS Data Brief No, 53. U.S. DHHS, CDC, National Center for Health Statistics. Online at hW,thww.cdr.ao-yb2ghs/daWdstobriefs/db53.htm e NRC (National Research Council of the National Academies). 2006. Fluoride in Drinking Water, A Scientific Review of EPA's Standards. Washington D.C.: The Naional Academies Press. Orilhe at http,lh ww rue anw at&W php7recdd jowl 1571 i see Table 23 from Behrim-Aguilar at at., 2005 a HHS (U.S. Department of Health and Human Services). 2011. HHS and EPA announce new scientific assessments and actions on fluoride. News Release. January 7. Online at htlOJ/wvrw hhs aoyinswslpress/20l i pmsgl20110107a htmI I EPA OW (Office of Water). 2010s, Fluoride: Dose -response analysis for non -cancer effects. Office of Science and Technology, Health and Ecological Criteria Division. 820-R-10-019, U.S. Environmental Protection Agency. Online at http•//Aumideaiwtotn/fan-dose-response comments aor 2011 otff EPA OW (Office of Water). 2010b. Fluoride: Exposure and relative source contribution analysis. Office of Science and Technology, Health and Ecological Criteria Division. 820-R-10.015, U.S. Environmental Protection Agency. Online at http,/A w✓r fluoridealert ora/epa exposuresource Ian 2011 pdf "Kaplan S. 2010. EPA develops naurotoxicants list, nen testing. Investigative Reporting Workshop. December 22. Online at heplfinvestwbvereporonoworkshoo ora(lrvastioetionsrtoxic- influsodatpp/ega-develops-neuroto)icantplisV 11 Xiang a Uang Y, Chen L, Wang C, Chen B, Chen X, Zhou M. 2003a. Effect of fluoride in drinking water on children's intelligence. Fluoride 38(2):84.94. Online at tap, /Mudideabrtorolsdhandeno-2003e coli Xiang 0, Liang Y, Zhou M, Zhang H. 2003b. Blood lead of children in Wamiso-Xinhuai intelligence study. Fluoride 35(3):196199. Online at h= //OuOdealertoruLacherhdano-2003b UdF 12 Xiang 0, Liarg Y. Chen L Warp C, Chen B, Chen X, Zhou M. 2003x. Effact of fluoride In drinking wets on children's intelligence. Fluoride 38(2):84-94. Online at nee•//fluoridm*rt ordarha/xiano-2003a coli 12 Xiang 0, Liang Y, Zhou M, Zhang H. 2003b. Blood lead of children in Wamiao•Xinhuai intelligence study, Fluoride 36(3):196199.Online at http /Mooride dertom/scherhdono-2003b colt 14 Varner JA, Jensen KF, Horvath W, Isaacson RL. 1998. Chronic administration of aluminum -fluoride and sodwm-fluoride to rats in drinking water. alterations in neuronal and cerebrovascular Integnily. Bran Research. 784(1-2):284298. February 16. 1i FAN (Fluoride Action Network). 2011 e. Fluoride & 10: The Studies. January. Online at httyNfluoridealert order studies htmt 1a Bhotnaga M, Rao P, Sushme J, Sh"ar R. 2002. Neurotoxicity, of fluoride: neurodegeneration in hippocampus of female mica. Indian Journal of Experimental Biology 40: 546.54. Chlrumari K, Reddy PK. 2007. Dose-dependent effects of fluoride on neurochemical milieu in the hippocampus and neocortax of rat brain. Fluoride 40(2):101-10. Online at htt ,int ww fluorideresearch ora'402/files/FJ2007 v40 n2 0101-110 golf Inkielenicz I, Krechniak J. 200. Fluoride content in soh tissues and urine of rats exposed to sodium fluoride in drinking water. Fluoride 36(4):263-88.0Mine at trUpIlwyew. fluoride- )gy«;aI coM03J64/384-263 colt Key AR, Miles R, Wong RK. 1986. Intracolluler fluoride alters the kinetic properties of calcium currents facilitating the investigation of synaptic events in hippocampal neurons. J Neurosci. 6 (10):2915.20. Online at httOJMuoddealert.ordrelkav-19W-pdf Niu R, at ad. 2009. Decreased leaning ability and low hippocampus glutamate in offspring rats exposed to fluoride and lead. Environmental Toxicology and Pharmacology 28:25458. Pereira M, Dombrowski PA, Losso EM, at al. 2009. Memory impairment induced by sodium fluoride Is associated with changes in brain monoamine levels. Neurotoxicity Research, December 2009 (in press). van der Voet GB, Schi)ns O, de Wolff FA. 1999. Fluoride enhances the effed of aluminium chloride on interconnections between aggregates of hippocampal neurons. Archives of Physiology and Biochemistry 107(1):15.21. February. Verner JA, Jensen KF, Horvath W, Isaacson RL 1998. Chronic administration of aluminum -fluoride and sodium -fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity. Brain Research. 784(1-2):284298. February 16. Xia T, Zhang M, He VIM, at al. 2007. Effects of fluoride on neural telt adhesion molewles mRNA and protein expression levels in primary rat hippocampal neurons. (Antide in Chinese). Zhonghua Yu Fang Yi Xue Za Zhi 41(6):475-78, Zhal JX, Guo ZY, Hu CL, at al. 2003. Studies on fluoride concentration and cholinesterase activity in rat hippocampus. (Article in Chinese). Zhonghue Lao Dong Wei Shang Zhi Ye Bing Za Zhi21(Z):102-4. Zhang J, at el. 2010. Effect of fluoride on calcium ion concentration and expression of nUplear transcription factor Kappa -B Rho85 in rat hippocampus. Experimental and Toxicologic Pathology [n press; available online March 19, 2010). Zhang M. Wang A, He W, et al. 2007. Effects of fluoride on the expression of NCAM, oxidative stress, and apoposis in primary cultured hippocampal neurons. Toxicology236(3):208-16. Zhang M, Wang A. Xia T, He P. 2008. Effects of fluoride on DNA damage, S -phase call -cycle arrest and the expression of NF-Kapp89 in primary cultured rat hippocampal neurons. Toxicology Letters 179(1):1-5. http://articles.mercola.com/sites/articles/archive/20l l /08/12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -97- Fluoride Linked to Lower IQ and Neurological Impairment Page 9 of 9 5/10/2016 11. B. Zhang Z, Shen X, XU X 2001. Effects of selenium on the damage of learning -memory ability of mice induced by fluoride. (Article in Chinese). Wei Shang Yen Jiu. 30(3):144-6. Zhang Z, Xu X, Shen X, Xu X. 2006. Effect of fluoride exposure on synaptic structure of brain areas related to leaming•memory in mice. Fluoride 41(2)139-143, April -June. Online at h8p lhvww flt-derecearch oro1412 les/F 12008 v41 n2 0131143 ndf Zhu W. Zhang J, Zhang Z. 2011. Effects of fluoride on synaptic membrane fluidity and PSD -85 expression level in rat hippocampus. Biological Trace Element Research 139(2):197-203. Feb. II Xiang at at. 2010 14 Xiang 0, Liang Y, Chen L, Wang C, Chen B, Chen X, Zhou M. 2003x. Effect of fluoride in drinking water on children's intelligence. Fluoride 36(2):84.94. Online at httpl/fiuondestertordscher/xiano-2003a orf 2 Ding Y, YenhuiGao, Sun H, Han H, Wang W, Ji X, Liu X. Sun D. 2011. The relationships between low levels of urine fluoride on children's intelligence, dental fluorosis in endemic fluorosis areas in Hukmbuir, Inner Mongolia, China. Journal of Hazardous Materials Feb 28;188(2-3):1942-8. ora EPA OW (Office of Water). 2010a. Fluoride: Dose -response analysis for non -cancer effects. Office of Science and Technology, Health and Ecological Criteria Division. 820• R-10.019, U.S. Environmental Protection Agency. Online at htto dAuoridealertore/fan-dowrore oonsa comments aor 2011 rxN 21 Dean HT, Arnold FA Jr., Elvove, E. 1942. Domestic water and dental caries, V. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4425 white children, age 12-14 years, of 13 cities in 4 states. Public Health Reports 57:1155-79. Online at htto //www nebi nlm nit coy/omdsrtldes/PMC19880831odNpubhealttceoario01481-0001 orf 4 Xiang Q, Liang Y, Chen I- Wang C, Chen B, Chen X, Zhou M. 20030. Effect of fluoride in drinking water on children's intelligence. Fluoride 38(2):84.94. Online at hmrna,orin>.uw or lsrherhdano-2003avdf Xiang Q. Liang Y. Zhou M, Zhang H. 2003b. Blood lead of children in Wamiao-Xinhusi intelligence study. Fluoride 36(3):198-199. Online at httrx//I1uoridealertoroischiloardr2003b orf Xiang at al. 2010 M Translated into English and published in 2008; Du at al., He at al., Yu at al. 24 Rocha-Amador D, Navarro ME, Canizdes L, Morales R, Caldsr in J. 2007. Decreased intelligence in children and exposure to fluoride and arsenic in drinking water. Caderros de Sa6de Pi/blics 23(suppi.4) Rio de Janeiro. Online at htoJ/www sciMoso ore/pciMo oho?saint-sd amext8.oid=S0102 311X2007001600018 Rocha-Amador D, Navarro M, Trejo-Acevado A, at al. 2009. Use of the Rey-Osterrieth Complex Figure Test for neurotoxicity evaluation of mixtures in children. Neurotoxicology Nov;30 (6):1149.54. 22 LI J, Yao L, Shao QL, Vila CY. 2008. Effects of high fluoride on neonatal neurobehavioral development Fluoride 41(2):16x70.Online at htb)�//www fluoridere"erch ord412/files/FJ2006 v41 nal ole5170 pdf u (EPA, 2010b, Table 64, p. 94) EPA OW (Office of Water). 2010b. Fluoride: Exposure and relative source contribution analysis. Office of Science and Technology, Health and Ecological Criteria Division. 820-R-10-015, U.S. Environmental Protection Agency. Online at htoJtwww fluohOslertomleoa exposure source ian 2011 odF Addtional Sources: Bel"n-Aguilar ED, Barker LK, Canto MT, st al. 2005. Surveillance for dental caries, dental sealants, tooth retention, endentulism, and enamel fluorosis-Unftetl States, 1988- 1994 and 1999- 2002. 9992002. CDC, MMWR, Surveillance Summaries, August 28, 2005, vol. 54, No SS -3, pp. 1-44. See Table 23 at h32:/muohdealertorMable23 htmf - Full article online at blip //www cdc pow/mmwr/pf*Aow/mmwahtmVss5403a1 him Brunelle JA, Carlos JP. 1990, Recent trends in dental caries In U.S. children and the effect of water fluoridation. Journal of Dental Research 69, (Special edition), 723727. Du L, Wan C, Cao X, Liu J. 2008. The effect of fluorine on the developing human Wain. Fluoride 41(4):327-30. Online at htto //www fluoddemsearch orot414/files/FJ2008 v41 n4 P327- 330, FAN (Fluoride Action Network). 2011 d. PubMed refuses to include the most referenced journal in a U.S. landmark report on fluoride. Controversy and Censorship in Science: Fluoride and Fluoridation. Online at httn'//www fluordealert.om/nm2006.mostcbd.html Gao 0, Liu YJ, Guan ZZ. 2009. Decreased learning and memory ability in rats with fluorosis: Increased oxidative stress and reduced cholinesterese activity. Fluoride 42(4):277-85. Online at htti)/Mww fluoridemsewcllorot424/424Tiws/FJ2009 v42 rA p277 285 pdf Gunn ZZ, Wang YN, Xiao Ka at al. 1998. Influence of chronic fluorosis on membrane fipids In rat brain. Neurotoxicology and Teralology20(5):537-42. He H, Chang Z, Liu W0.2008. Effects of fluorine on the human fetus. Fluoride 41(4):321-26. Ondine at htto;//www fluoddereseumh orcV414MIes/FJ2008 v41 M -p321.328 oto Kom4rek A, Lesaffre E, 1-18rkanen T, Decierck D, Virtanen JI. 2005. A Bayesian analysis of multivariate doubly-interval-cansored dental data. Biostatistics 8(1):4555. January. Lt XS, Zhi JL, Gao RL 1995. Effect of fluoride exposure on intelligence in children. Fluoride. 28(4):189-192. Online at hWillfuoridealertoro/scher/1i-1995 act Liu YJ, Gao 0, Wu CX, Guan ZZ. 2010. Alterations of nACARs and ERK1/2 in to brains of rats with chronic fluorosis and their connections with to decreased capacity of learning and memory. Toxicology Letters192(3):324-29. Mulienix P, Denbesten PK, Schunior A, Keenan WJ. 1995. Neurotoxicity of sodium fluoride in rets. Neurotoxicology and Teratology 17(2):169.177. Mar -Apr. Yu Y, Yang W, Dong Z, Wan C, Zhang J, Liu J, Xlan K Huang Y, W B. 2008. Neurotransmitter and receptor changes in the trains of fetuses from areas of endemic fluorosis. Fluoride 41 (2):134-08. Online at htto'l/www fluorideresearch ord/412/fl VFJ2M v41 n2 0134138 orf Zhso LB, Using GH, Zhang ON, Wu XR. 1998. Effect of high -fluoride water supply on children's intelligence. Fluoride 29(4):19(1-192. Online at http pAuoridestertordscharhhao-1998orf :..Wl One like. Flgr t;; to see what your friends like. Related Links: Fluoride Awareness Week http://articles.mercola.com/sites/articles/archive/201 l /08/12/fluoride-and-the-brain-no-mar... 8/19/2011 Packet Page -98- American Dental Association www.ada.org Packet Page -99- Celebrating 6o YearA of Water Fluoridation ntribUl .3er and Ms.'' public in making informed supported by thous to his legal review, Mr, Mark Rubin, Esq., As including the more �ratCoansol, Division of Legal Affairs, made document. Itis hoped that dcr�=�, a r "� ignlfaoanf contributions to the vision ofthi,, booklet. sou rid choices based on this body ofg ner r ccopted, peer-reviewed science. Other significant staff contributors included, 'Mr. Paul O'Connor, Legislative Liaison, Department of State Gov- ernment Affairs; Ms. Helen Ristic, Ph.D., Director of Sci- ence, Information, Council on Scientific Affairs and Mr. � Chakwan Siew, Ph.D., Senior Director, Research and Laboratories, Council on Scientific Affairs. A special thanks to the National Fluoridation Advisory 41 Committee members who contributed to this edition: Ms. Diane Brunson, Dc. Robert N. Crawford, Jr., Dr. Lisa P. Howard, Dr. JayanthV. Kumar, Dr. Ernest Newbrun, Mr. Thomas G. Reeves and Dr. Michael S. Swartz. DISCLAIMER This publication is designed to answer frequently asked questions about community water fluoridation, based on a summary of relevant published articles. It is not intended to be comprehensive; review of the extensive literature an fluoridation and fluorides. Readers must also rely on their own review of the literature, including the sources cited herein and any subsequent published, for a complete understanding of these issues. © 2005 American Dental Association This publication may not be reproduced in whole or in part without the express written permission of the American Dental Associa- tion except as provided herein. American Dental Association www.ada.org ADA Statement Commemorating the 601 Anniversary of Community Water Fluoridation Sixty years ago, Grand Rapids, Michigan became the world's first city to adjust the level of fluoride in its water supply. Since that time, fluoridation has dramatically improved the oral health of tens of millions of Americans. Community water fluoridation is the single most effective public health measure to prevent tooth decay. Additionally, the Centers for Disease Control and Prevention proclaimed community water fluoridation as one of 10 great public health achievements of the 20th century. Fluoridation of community water supplies is simply the precise adjustment of the existing naturally occurring fluoride levels in drinking water to an optimal fluoride level recommended by the U.S. Public Health Service (0.7 — 1.2 parts per million) for the prevention of dental decay. Based on data from 2002, approximately 170 million people (or over two-thirds of the population) in the United States are served by public water systems that are fluoridated. Studies conducted throughout the past 60 years have consistently indicated that fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. It is the most efficient way to prevent one of the most common childhood diseases — tooth decay (5 times as common as asthma and 7 times as common as hay fever in 5- toll -year-olds). Early studies, such as those conducted in Grand Rapids, showed that water fluoridation reduced the amount of cavities children get in their baby teeth by as much as 60% and reduced tooth decay in permanent adult teeth nearly 35%. Today, studies prove water fluoridation continues to be effective in reducing tooth decay by 20-40%, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. The average cost for a community to fluoridate its water is estimated to range from approximately $0.50 a year per person in large communities to approximately $3.00 a year per person in small communities. For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs. The American Dental Association continues to endorse fluoridation of community water supplies as safe and effective for preventing tooth decay. This support has been the Association's position since policy was first adopted in 1950. The ADA's policies regarding community water fluoridation are based on the overwhelming weight of peer-reviewed, credible scientific evidence. The ADA, along with state and local dental societies, continues to work with federal, state, local agencies and community coalitions to increase the number of communities benefiting from water fluoridation. 2005 211 East Chicago Avenue Chicago, Illinois 60611-2678 i 5/10/2016 11.B. - Permission is hereby granted to reproduce and distribute this ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1-312-440-2879. TABLE OF ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation Executive Summary Introduction CO 1 4 6 BENEFITS Question Topic 10 Page 1. What is fluoride? 10 2. How does fluoride help prevent dental decay? 10 3. What is water fluoridation? 11 4. How much fluoride is in your water? 11 5. Fluoride additives? 12 6. Natural vs adjusted? 12 7. Effectiveness? 13 8. Still effective? 14 9. Discontinuance? 15 10. Is decay still a problem? 16 11. Adult benefits? 16 12. Dietary supplements? 17 13. Fluoride for children? 18 14. Alternatives? 19 15. Bottled water? 19 16. Home treatment (filter) systems? 21 LATENTS SAFETY Question Topic 22 Page 17. Harmful to humans? 22 18. More studies needed? 23 19. Total intake? 24 20. Daily intake? 25 21. Prenatal dietary fluoride supplements? 26 22. Body uptake? 26 23. Bone health? 27 24. Dental fluorosis? 28 25. Prevent fluorosis? 30 26. Warning label? 31 27. Toxicity? 31 28. Cancer? 32 29. Enzyme effects? 33 30. Thyroid gland? 34 31. Pineal gland? 34 32. Allergies? 34 33. Genetic risk? 35 34. Fertility? 35 35. Down Syndrome? 35 36. Neurological impact? 36 37. Lead poisoning? 37 38. Alzheimer's disease? 37 39. Heart disease? 38 40. Kidney disease? 38 41. Erroneous health claims? 39 --- .-...-- ----- -- --- ------ ---- - ---- - --. ................ ....... ........ - - - .....-._._ 2 American Dental Association Packet Page -102- _ FLUORIDATION PRACTICE 40 Question Topic Page 42. Water quality? 40 43. Regulation? 41 44. Standards? 42 45. Source of additives? 43 46. System safety concerns? 43 47. Engineering? 44 48. Corrosion? 44 49. Environment? 45 PUBLIC POLICY 46 Question Topic Page 50. Valuable measure? 46 51. Courts of law? 47 52. Opposition? 47 53. Internet? 51 54. Public votes? 51 55. International fluoridation? 54 56. Banned in Europe? 54 COST EFFECTIVENESS 56 Question Topic Page 57. Cost effective? 56 58. Practical? 57 �1 Call to Action 57 References 58 Statements from Five Leading Health 68 Organizations Regarding Community Water Fluoridation Compendium 69 Figures 1. Reviewing Research 7 2. Effectiveness List 13 3. ADA.org - Bottled Water 20 4. Safety List 23 5. 1998 Consumers' Opinions 48 6. Approval of Fluoridating 48 Drinking Water 7. Opposition Tactics 50 8. ADA.org - Fluoride and 51 Fluoridation 9. Largest Fluoridated Cities 52 10. States Meeting National Goals 53 Tables 1. Dietary Fluoride Supplements 18 2. Bottled Water 20 3. Dietary Reference Intakes 25 4. Categories of Dental Fluorosis 28 Fluoridation Facts 3 Packet Page -103- _ 5/10/2016 11.B. vice and professional organizations recognize the pub- • More than two-thirds of the population in the United lic health benefits of community water fluoridation for States are served by public water systems that are preventing dental decay. optimally fluoridated. • Studies prove water fluoridation continues to be ef- • In the past five years (2000 through 2004), more fective in reducing dental decay by 20-40%, even in than 125 U.S. communities in 36 states have voted an era with widespread availability of fluoride from to adopt fluoridation. SUMMARY • Fluoridation of community water supplies is the sin- For most cities, every $1 invested in water fluorida- gle most effective public health measure to prevent tion saves $38 in dental treatment costs. dental decay. • Water that has been fortified with fluoride is simi • Throughout more than 60 years of research and prac- lar to fortifying salt with iodine, milk with vitamin tical experience, the overwhelming weight of credi- D and orange juice with vitamin C. ble scientific evidence has consistently indicated that fluoridation of community water supplies is safe. • The Centers for Disease Control and Prevention has proclaimed community water fluoridation (along with vaccinations and infectious disease control) as one of ten great public health achievements of the 20th century. • Simply by drinking water, people can benefit from fluoridation's cavity protection whether they are at home, work or school. • The average cost for a community to fluoridate its wa- ter is estimated to range from approximately $0.50 a yearperperson in large communities to approximately_ $3 00 a year per person in small communities. • More than 100 national and international health, ser- vice and professional organizations recognize the pub- • More than two-thirds of the population in the United lic health benefits of community water fluoridation for States are served by public water systems that are preventing dental decay. optimally fluoridated. • Studies prove water fluoridation continues to be ef- • In the past five years (2000 through 2004), more fective in reducing dental decay by 20-40%, even in than 125 U.S. communities in 36 states have voted an era with widespread availability of fluoride from to adopt fluoridation. other sources, such as fluoride toothpaste. 0 Fluoridation has been thoroughly tested in the Unit- • Community water fluoridation benefits everyone, es- ed States' court system, and found to be a proper pecially those without access to regular dental care. means of furthering public health and welfare. No It is the most efficient way to prevent one of the most court of last resort has ever determined fluoridation common childhood diseases- dental decay (5 times to be unlawful. as common as asthma and 7 times as common as hay fever in 5 -to -17-year-olds). Without fluoridation, • Be aware of misinformation on the Internet and other there would be many more than the estimated 51 junk science related to water fluoridation. million school hours lost per year in this country be- cause of dental -related illness. • One of the most widely respected sources for in- formation regarding fluoridation and fluorides is • Community water fluoridation is the adjustment of the American Dental Association. The: ADA main - fluoride that occurs naturally in water to optimal lev- tains Fluoride and Fluoridation Web pages at els to protect oral health. http://www.ada.org[aoto/fluoride. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Executive Summary in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1-312-440-2879. 4 American Dental Association Packet Page -104 i 5/10/2016 11.B. Packet Page -105 INTRODUCTION ince 1956, the American Dental Association (ADA) has published Fluoridation Facts. Revised periodically, Fluoridation Facts answers frequently asked questions about community water fluoridation. In this 2005 edition issued as part of the 6011 Anniversary celebration of com- munity water fluoridation, the ADA Council on Access, Prevention and Interprofessional Relations provides up- dated information for individuals and groups interested in the facts about fluoridation. The United States now has over 60 years of practical experience with community wa- ter fluoridation. Its remarkable longevity is testimony to fluoridation's significance as a public health measure. In recognition of the impact that water fluoridation has had on the oral and general health of the public, in 1999, the Centers for Disease Control and Prevention named fluori- dation of drinking water as one of ten great public health achievements of the 2011 century. 1,2 Support for Water Fluoridation 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 is based on its continuing evaluation of the scientific research on the safety and effectiveness of fluoridation. Since 1950, when the ADA first adopted policy recommending com- munity water fluoridation, 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.3 The 2005 "ADA Statement Commemorating the 6011 Anni- versary of Community Water Fluoridation" reinforced that position." Fluoridation is the most effective public health measure to prevent dental decay for children and adults, reduce oral health disparities and improve oral health over a lifetime.5 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 rec- ognize the public health benefits of community water fluoridation for preventing dental decay are listed on the inside back cover of this publication. Scientific Information on Fluoridation The ADAs policies regarding community water fluorida- tion are based on generally accepted scientific knowledge. This body of knowledge is based on the efforts of nation- ally recognized scientists who have conducted research using the scientific method, have drawn appropriate bal- anced conclusions based on their research findings and have published their results in refereed (peer-reviewed) professional journals that are widely held or circulated. Studies showing the safety and effectiveness of water fluoridation have been confirmed by independent sci- entific studies conducted by a number of nationally and internationally recognized scientific investigators. While opponents of fluoridation have questioned its safety and effectiveness, none of their charges has ever been sub- stantiated by generally accepted science. 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 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 the conclusions drawn from research are not always scientifically justifi- able. In the case of water fluoridation, an abundance of misinformation has been circulated. Therefore, sci- entific information from all print and electronic sources must be critically reviewed before conclusions can be drawn. (See Figure 1.) Pseudo -scientific literature may peak a reader's interest but when read as science, it can be misleading. The scientific 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 information on this topic may be found in Question 52. 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, Colo- rado, and was surprised to discover that many local residents exhibited brown stains on their permanent teeth. Dr. McKay could find no documentation of the condition in the dental literature and eventually con- vinced Dr. G.V. Black, dean of the Northwestern Univer- sity Dental School in Chicago, to join him in studying the condition. Through their research, Drs. Black and McKay determined that mottled enamel, as Dr. Black termed the condition, resulted from developmental imperfections in teeth. (Mottled enamel is a historical term. Today, this condition is called dental or enamel fluorosis.) Drs. Black and McKay wrote detailed de- scriptions of mottled enamel.6-1 In the 1920s, Dr. McKay, along with others, suspected that something either in or missing from the drinking American Dental Association Packet Page -106- Itis important to review information about fluorida- tion with a critical eye. Listed below are key elements to consider when reviewing information about fluori- dation research. 1. Credentials: The author's background and cre- dentials should reflect expertise in the area of research undertaken. 2. Date: The year of the publication should be ap- parent. The information should be relatively cur- rent, although well-designed studies can stand the test of time and scientific scrutiny. A review of existing literature can provide insight into whether the results of older studies have been superseded by subsequent studies. 3. Accuracy: If the information is a review of other studies, it should be accurate and representative of the original research. Information quoted di- rectly from other sources should be quoted in its entirety. 4. Statistical Methods: The methods used to ana- lyze the data should be generally accepted and appropriate. 5. Comparability: The research should be applica- ble 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 community water fluoridation. For example, the results of a study using a concentration of 125 parts per million (ppm) fluoride are not compa- rable to research findings regarding water fluori- dated at 0.7 to 1.2 ppm. 6. Type of Research: Howthe research is conducted is relevant. Research conducted in vitro (outside the living body and in a laboratory environment) may not have the same results as research conducted in vivo (in a living human or other animal). 7. Research Model: A good study will try to repli- cate real life situations as close as possible. For example, results from animal studies using high doses of fluoride that are injected rather than provided in drinking water should be cautiously interpreted. Such studies are highly question- able as a predictor of the effects of human ex- posure to low concentrations of fluoride, such as those used to fluoridate water. 8. Peer Review: Publications presenting scientific information should be peer reviewed to help ensure that scientifically sound articles are pub- lished. Peer review involves evaluation and rat- ing of the scientific and technical merit of an ar- ticle by other qualified scientists. 9. Weight of Evidence: Conclusions from one partic- ular study or one particular researcher should be weighed against the bulk of established, gener- ally accepted, peer-reviewed science. No single study by itself is conclusive. If other researchers have not been able to replicate the results of a particular study or the work of one researcher, the results of that study or body of research should be viewed with some skepticism. 10. Easily Accessible: Reputable studies on fluori- dation are typically published in peer-reviewed journals and other vehicles that are easily `obtain- able through a medical/dental library or through PubMed, a service of the National Library: of Medicine which can be accessed via the Internet at htto://www.nlm.nih.ciov/. Fluoridation Facts 7 Packet Page -107- water was causing the mottled enamel. Dr. McKay wrote to the Surgeon General in 1926 indicating that he had identified a number of regions in Colorado, New Mexico, Arizona, California, Idaho, South Dakota, Texas and Vir- ginia where mottled enamel existed. Also in the late 20s, Dr. McKay made another significant discovery — these stained teeth were surprisingly resistant to decay.' Following additional studies completed in the early 1930s in St. David, Arizonas and Bauxite, Arkansas,9 it was determined that high levels of naturally occurring fluoride in the drinking water were causing the mottled enamel. In Arizona, researchers scrutinized 250 resi- dents in 39 local families and were able to rule out he- reditary factors and environmental factors, except for one - fluoride in the water which occurred naturally at levels of 3.8 to 7.15 ppm. In Bauxite, H. V. Churchill, chief chemist with the Aluminum Company of America (later changed to ALCOA), was using a new method of spectrographic analysis in his laboratory to look at the possibility that the water from an abandoned deep well in the area might have high levels of aluminum - containing bauxite that was causing mottled teeth. What he found was that the water contained a high level of naturally occurring fluoride (13.7 ppm). When Dr. McKay learned of this new form of analysis and Dr. Churchill's findings, he forwarded samples of water from areas where mottled enamel was commonplace to Dr. Churchill. All of the samples were found to have high levels of fluoride when compared to waters tested from areas with no mottled enamel 7 During the 1930s, Dr. H. Trendley Dean, a dental of- ficer of the U.S. Public Health Service, and his associ- ates conducted classic epidemiological studies on the geographic distribution and severity of fluorosis in the United States.10 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 the more severe forms of dental fluorosis. Dean additionally noted a correla- tion between fluoride levels in the water and reduced incidence of dental decay."," In 1939, Dr. Gerald J. Cox and his associates at the Mel- lon Institute evaluated the epidemiological evidence and conducted independent laboratory studies. While the is- sue was being discussed in the dental research commu- nity at the time, they were the first to publish a paper that proposed adding fluoride to drinking water to prevent dental decay. 13 In the 1940s, four classic, community- wide studies were carried out to evaluate the addition of sodium fluoride to fluoride -deficient water supplies. The first community water fluoridation program, under the direction of Dr. Dean, began in Grand Rapids, Michigan, in January 1945. The other three studies were conducted in Newburgh, New York (May 1945); Brantford, Ontario (June 1945) and Evanston, Illinois (February 1947.)13-16 The astounding success of these studies firmly estab- lished fluoridation as a practical and safe public health measure to prevent dental decay that would quickly be embraced by other communities. The history of water fluoridation is a classic example of a curious professional making exacting clinical observa- tions which led to epidemiologic investigation and even- tually to a safe and effective community-based public health intervention which even today remains the corner- stone of communities' efforts to prevent dental decay. "The Centers for water "one of ten great public health,` achievements of the 20th century noting that it is a major factor responsible for the decline in dental decay." Water Fluoridation as a Public Health Measure Throughout decades of research and more than sixty years of practical experience, fluoridation of public water supplies has been responsible for dramatically improving the public's oral health. In 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 laud- ed as one of the most economical preventive inter- ventions in the nation .17 A policy statement on water fluoridation reaffirmed in 1995 by the USPHS stated that water fluoridation is the most cost-effective, prac- tical and safe means for reducing the occurrence of dental decay in a community.18 In 1998, recognizing the ongoing need to improve health and well being, the USPHS revised national health objectives to be achieved by the year 2010. Included under oral health was an objective to significantly expand the fluorida- tion of public water supplies. Specifically, Objective 21-9 states that at least 75% of the U.S. population served by community water systems should be receiv- ing the benefits of optimally fluoridated water by the year 2010.19 In 1999, the Centers for Disease Control and Preven- tion named fluoridation of drinking water one of ten American Dental Association Packet Page -108- great public health achievements of the 2011 century not- ing that it is a major factor responsible for the decline in dental decay.1,2 Former U.S. Surgeon General David Satcher issued the first ever Surgeon General report on oral health in May 2000. In Oral Health in America: A Report of the Sur- geon General, Dr. Satcher stated that community water fluoridation continues to be the most cost-effective, prac- tical and safe means for reducing and controlling the oc- currence of dental decay in a community.6,20 Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations. Studies have shown that fluoridation may be the most significant step we can take toward reducing the disparities in dental decay.6,20-24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called on policymakers, community leaders, private industry, health professionals, the media and the public to affirm that oral health is essential to general health and well be- ing. Additionally, Surgeon General Carmona urged these groups to apply strategies to enhance the adoption and maintenance of proven community-based interventions such as community water fluoridation 25 Community water fluoridation is a most valuable public health measure because: • Optimally fluoridated water is accessible to the en- tire community regardless of socioeconomic status, educational attainment or other social variables.26 • Individuals do not need to change their behavior to obtain the benefits of fluoridation. • Frequent exposure to small amounts of fluoride over time makes fluoridation effective through the life span in helping to prevent dental decay. • Community water fluoridation is more cost effec- tive than other forms of fluoride treatments or ap- plications.21 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. Early studies showed that water fluoridation can re- duce the amount of cavities children get in their baby teeth by as much as 60% and can reduce dental decay in permanent adult teeth by nearly 35%. Since that time, numerous studies have been published mak- ing fluoridation one of the most widely studied public health measures in history. Later studies prove water fluoridation continues to be effective in reducing den- tal decay by 20-40%, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste .28,21 Increasing numbers of adults are retaining their teeth throughout their lifetimes due in part to the benefits they receive from water fluoridation. Dental costs for these individuals are likely to have been reduced and many hours of need- less 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 bacte- ria that constantly forms on teeth. When sugar and oth- er carbohydrates are eaten, the bacteria in plaque pro- duce acids that attack the tooth enamel. After repeated attacks, the enamel breaks down, and a cavity (hole) is formed. There are a number of factors that increase an individual's risk for dental decay:21,30-33 • Recent history of dental decay • Elevated oral bacteria count • Inadequate exposure to fluorides • Exposed roots • Frequent intake of sugar and sugary foods • Poor or inadequate oral hygiene • Decreased flow of saliva • Deep pits and fissures in the chewing surfaces of teeth Exposure to fluoride is not the only measure avail- able to decrease the risk of decay. In formulating a de- cay prevention program, a number of intervention strat- egies may be recommended such as changes in diet and placement of dental sealants. However, fluoride is a key component in any recommended strategy. Ongoing Need for Water Fluoridation Because of the risk factors for dental decay noted previously, many individuals and communities still experience high levels of dental decay. Although wa- ter fluoridation demonstrates an impressive record of effectiveness and safety, only 67.3 % of the United States population on public water supplies receives fluoridated water containing protective levels of flu- oride.34 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. Fluoridation Facts Packet Page -109- BENEFITS Q 1. What is fluoride? P. 10 Q 2. How does fluoride help prevent dental decay? p. 10 Q 3. What is water fluoridation? P. 11 Q 4. How much fluoride is in your water? P. 11 05. Fluoride additives? p. 12 QUESTION 1. What is fluoride? Q 6. Natural vs adjusted? p. 12 Q 7. Effectiveness? p. 13 Q 8. Still effective? p. 14 Q 9. Discontinuance? p. 15 Q 10. Is decay still a problem? p. 16 Q 11. Adult benefits? p. 16 Q 12. Dietary supplements? p. 17 Answer. Fluoride is a naturally occurring compound that can help prevent dental decay. Fact. The fluoride ion comes from the element fluorine. Fluorine is an abundant element in the earth's crust in the form of the fluoride ion. As a gas, it never oc- 2. curs in its free state in nature, but exists only in com- a bination with other elements as a fluoride compound. Fluoride compounds are components of minerals in 4. rocks and soil. Water passes over rock formations and dissolves the fluoride compounds that are present, re- leasing fluoride ions. The result is that small amounts of fluoride are present in all water sources. Gener- ally, surface water sources such as lakes, rivers and streams have very low levels of fluoride. For example, Lake Michigan's fluoride level is 0.17 ppm.35 As water moves through the earth, it contacts fluoride -contain- ing minerals and carries away fluoride ions. The con- centration of fluoride in groundwater varies according to such factors as the depth at which the water is found and the quantity of fluoride bearing minerals in the area .36 In the United States, the natural level of fluoride in ground water varies from very low levels to over 4 ppm. The fluoride level of the oceans ranges from 1.2 to 1.4 ppm 37,3a Fluoride is naturally present to some extent in all foods and beverages, but the concentrations vary widely.39-41 QUESTION 2. How does fluoride help prevent dental decay? Answer. Fluoride protects teeth in two ways - systemically and topically. 10 Q 13. Fluoride for children? P. 18 014. Alternatives? P. 19 015. Bottled water? P. 19 Q 16. Home treatment (filter) systems? p. 21 Fact. Systemic fluorides are those ingested into the body. During tooth formation, ingested fluorides become in- corporated into tooth structures. Fluorides ingested regularly during the time when teeth are developing (preeruptively) are deposited throughout the entire tooth surface and provide longer -lasting protection than those applied topically.62 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 incorporat- ed into the tooth surface to prevent decay. Fluoride also becomes incorporated into dental plaque and facilitates further remineralization .43 Sources of systemic fluoride in the United States include fluoridated water, dietary fluoride supplements in the forms of tablets, drops or lozenges and fluoride present in food and beverages. "Fluoride protects teeth in two ways y." - systemically and topically. While it was originally believed that fluoride's action was exclusively systemic or preeruptive, by the mid- 1950s, there was growing evidence of both systemic and topical benefits of fluoride exposure .14 (+Additional information on this topic may be found in Question 11. Topical fluorides strengthen teeth already present in the mouth (posteruptively). 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 profes- sionally applied fluoride foams, gels and varnishes. As mentioned previously, systemic fluorides also pro- vide topical protection. Low levels of fluoride in saliva and plaque from sources such as optimally fluoridated water can prevent and reverse the process of dental decay.45 In clarifying the effectiveness of water fluorida- tion, John D.B. Featherstone, PhD, Professor and Chair, Packet Page -110- American Dental Association Department of Preventive and Restorative Dental Ser- vices, University of California San Francisco, noted: "... There is irrefutable evidence in numerous studies that fluoride in the drinking water works to reduce dental caries in populations. This is still the case. 1146 The remineralization effect of fluoride is important. Flu- oride ions in and at the enamel surface result in fortified enamel that is not only more resistant to decay (loss of minerals or demineralization), but enamel that can repair or remineralize early dental decay caused by acids from decay -causing bacteria 4247-51 Fluoride ions necessary for remineralization are provided by fluoridated water as well as various fluoride products such as toothpaste. The maximum reduction in dental decay is achieved when fluoride is available preeruptively (systemically) for incorporation during all stages of tooth formation and posteruptively (topically) at the tooth surface. Wa- ter fluoridation provides both types of exposure 44,12-e4 QUESTION 3. What is water fluoridation? Answer. Water fluoridation is the adjustment of the natural fluo- ride 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 con- centration 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 dental decay while minimizing the occurrence of dental fluorosis. The optimum level is de- pendent on the annual average of the maximum daily air temperature in the geographic area." One milligram per liter (mg/L) of fluoride in water is identical to one part per million (ppm). At 1 ppm, one part of fluoride is diluted in a million parts of water. Large numbers such as a million can be very difficult to visual- ize. 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 Fluoridation Facts 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 op- timally fluoridated water. Optimal levels of fluoride may be present in the water naturally or by adjusted means. (Additional information on this topic may be found in Question 6. Sub -optimally luoridated water is water that natural- ly 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. QUESTION 4. How much fluoride is in your water? Answer. If your water comes from a public/community water supply, the options to learn the fluoride level of the wa- ter include contacting the local water supplier or the local/county/state health department, reviewing your Consumer Confidence Report (CCR) and using the Inter- net based "My Water's Fluoride." If your water source is a private well, it will need to be tested and the results obtained from a certified laboratory. Fact. The fluoride content of the local public or community wa- ter supply can be obtained by contacting the local water supplier or the local/county/state health department. In 1999, the U.S. Environmental Protection Agency (EPA) began requiring water suppliers to put annual drinking water quality reports into the hands of its cus- tomers. Typically available around July ls1 each year, these Water Quality Reports, or Consumer Confidence Reports (CCRs), may be mailed to your home, placed in the local newspaper or made available through the Internet.56 To obtain a copy of the report, contact the local water supplier. The name of the water system (of- ten not the name of the city) can be found on the water bill. If the name of the public water system is unknown, contact the local health department. There are two sites on the Internet that supply in- formation on water quality. The online source for water quality reports or CCRs is the EPA web site at http://www.epa.ciov/safewater/`dwinfo/index.html.51 Additionally, the Centers for Disease Control and Prevention's (CDC) fluoridation Web site, "My Water's Fluoride," is available at http://apps.nced.cdc.ciov/MWF/ Index.aSp.58 For those states that have provided infor- mation to the CDC, the site lists fluoridation status by water system. Packet Page -111- 11 The EPA does not have the authority to regulate private drinking water wells. However, the EPA recom- mends that private well water be tested every year. While the EPA does not specifically recommend testing for the level of fluoride, health professionals will need this information prior to consideration of prescription of dietary fluoride supplements or to counsel patients about alternative water sources to reduce the risk of fluorosis if the fluoride levels are above 2 ppm.59 (Additional information on this topic may be found in Questions 12, 24, 25 and 42. Always use a state certified laboratory that conducts drinking water tests.59 For a list of state certified labs, con- tact the local, county or state water/health department. QUESTION 5. What additives are used to fluoridate water supplies in the United States? Answer. Sodium fluoride, sodium fluorosilicate and fluorosilicic acid are the three additives approved for community water fluoridation in the United States. Sodium fluoro - silicate and fluorosilicic acid are sometimes referred to as silicofluoride additives. Fact. The three basic additives used to fluoridate water in the United States are: 1) sodium fluoride which is a white, odorless material available either as a powder or crys- tals; 2) sodium fluorosilicate which is a white or yellow - white, odorless crystalline material and 3) fluorosilicic acid which is a white to straw-colored liquid .11,60 While fluoridation began in 1945 with the use of so- dium fluoride, the use of silicofluorides began in 1946 and, by 1951, they were the most commonly used ad- ditives." First used in the late 1940s, fluorosilicic acid is currently the most commonly used additive to fluori- date communities in the U.S.36,61 "To ensure the public's safety, standards have been established to ensure the safety of fluoride additives used in water treatment in the U.S." To ensure the public's safety, standards have been established to ensure the safety of fluoride additives used in water treatment in the U.S. Specifically, addi- tives used in water fluoridation meet standards of the American Water Works Association (AWWA) and NSF International (NSF). (Additional information on the topic of fluoride addi- tives may be found in Fluoridation Practice Section. 12 QUESTION 6. Is there a difference in the effectiveness between natu- rally 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.36 These ions are the same whether ac- quired 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 ben- efits are the same as those obtained from naturally fluo- ridated water. Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all drinking water sources. "Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all drinkingwater sources. Some individuals use the term "artificial fluorida- tion" 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 natu- ral way to improve oral health." Additional information on this topic may be found in Question 45. Priorto 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.12 A fluoridation study conducted in the Ontario, Cana- da, communities of Brantford (optimally fluoridated by adjustment), Stratford (optimally fluoridated naturally) and Sarnia (fluoride -deficient) revealed much lower de- cay rates in both Brantford and Stratford as compared to nonfluoridated Sarnia. There was no observable dif- ference in decay -reducing effect between the naturally occurring fluoride and adjusted fluoride concentration water supplies, proving that dental benefits were simi- lar regardless of the source of fluoride.16 Packet Page -112- American Dental Association QUESTION i. Is water fluoridation effective in helping to prevent den- tal decay? Answer. Overwhelming evidence exists to prove the effective- ness of water fluoridation. Water fluoridation is a very effective method for preventing dental decay for chil- dren, adolescents and adults. Continued assessment, however, is important as the patterns and extent of dental decay change in populations. Fact. The effectiveness of water fluoridation has been docu- mented in scientific literature for over 60 years. (See Figure 2.) Even before the first community fluoridation program began in 1945, epidemiologic data from the 1930s and 1940s revealed lower number of cavities in children consuming naturally occurring fluoridated wa- ter compared to children consuming fluoride -deficient water. 11.12 Since that time, thousands of studies have been done which continue to prove fluoride's effective- ness in decay reduction. 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 dental decay than children who had been examined during the original baseline survey completed in nonfluoridated Muskegon, Michigan." Ten years after fluoridation in Newburgh, New York, 6- to 9 -year-olds had 58% less dental decay than their counterparts in nonfluoridated Kingston, New York, which was fluoride -deficient. After 15 years, 13- to 14 - year -olds in Newburgh had 70% less decay than the children in Kingston .14 • Centers for Disease Control and Prevention. Recom- mendationsfor Using Fluorideto Prevent and Control Dental Caries in the United States. MMWR 2001;50 (No. RR -14). (Guidelines on the use of fluoride.) • Horowitz HS. The effectiveness of community wa- ter fluoridation in the United States. J Public Health Dent 1996;56(5 Spec No):253-8. (A review of fifty years of water fluoridation.) Murray JJ. Efficacy of preventive agents for dental caries. Caries Res-1993;27(Suppl 1):2-8.(A review of studies conducted from 1976 through 1987.) • Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49(5):279-89. (The analysis of the results of 113 studies in 23 countries.) Ripa I.W. A half -century of community water fluorida- tion in the United States: review and commentary. J Public Health Dent 1993;53(1):17-44. (The analysis of fifty years of water fluoridation.) Fluoridation Facts After 14 years of fluoridation in Evanston, Illinois, 14 -year-olds had 57% fewer decayed, missing or filled teeth than the control group in Oak Park, Illinois, who drank water low in fluoride.66 In 1983, a study was undertaken in North Wales (Great Britain) to determine if the decay rate of fluori- dated Anglesey continued to be lower than that of non - fluoridated Arfon, as had been indicated in a previous survey conducted in 1974. Decay rates of life-long resi- dents in Anglesey, aged 5, 12 and 15, were compared with decay rates of identically aged residents in nonflu- oridated Arfon. Study results demonstrated that a de- cline in decay had 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.11 These findings indicated a continuing need for fluorida- tion although decay levels had declined.67 In the United States, an epidemiological survey of nearly 40,000 schoolchildren was completed in 1987.29 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 dra- matic 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 ex- posure from supplements and topical treatments. A controlled study conducted in 1990 demonstrated that average dental decay experience among schoolchil- dren who were lifelong residents of communities with low fluoride levels in drinking water was 61-100% high- er as compared with dental decay experience among schoolchildren who were lifelong residents of a com- munity with an optimal level of fluoride in the drinking water.68 In addition, the findings of this study suggest that community water fluoridation still provides signifi- cant public health benefits and that dental sealants can play a significant role in preventing dental 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 dental 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 dental decay. Therefore, children with the greatest dental need benefit the most from water fluoridation.69 In 1993, the results of 113 studies in 23 countries were compiled and analyzed .70 (Fifty-nine out of the 113 stud- ies analyzed were conducted in the United States.) This review provided effectiveness data for 66 studies in pri- mary teeth and for 86 studies in permanent teeth. Taken Packet Page -113- 13 8. 9, together, the most frequently reported decay reductions observed were: 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 1987,25 when data for different age groups were separated, reductions in dental decay in fluoridated communities were: 30-60% in the primary dentition or baby teeth; 20-40% in the mixed dentition* (aged 8 to 12); (*A mixed dentition is composed of both baby teeth and adult teeth.) 15-35% in the permanent dentition or adult teeth (aged 14 to 17); and 15-35% in the permanent dentition (adults and seniors). A comprehensive analysis of the 50 -year history of community water fluoridation in the United States further demonstrated that the inverse relationship be- tween higher fluoride concentration in drinking water and lower levels of dental decay discovered a half -cen- tury ago continued to be true." Baby bottle tooth decay is a severe type of early child- hood 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.72 In a 1998 review of the effectiveness of methods currently used to prevent this type of decay, water fluoridation received the high- est rating. 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.73 In 2001, the National Institutes of Health (NIH) held a consensus development conference, "Diagnosis and Management of Dental Caries Throughout Life." As part of the Consensus Statement issued at the conclusion of the conference, the panel noted that water fluoridation is widely accepted as both effective and of great impor- tance in the primary prevention of tooth decay." "Children with the greatest dental need benefit the most from water fluoridation ... The U.S. Task' Force strongly recommended that community water fluoridation be included as part of a comprehensive population -based strategy to prevent or control tooth decay in communities." A systematic review of published studies conducted in 2001 by a team of experts on behalf of the U.S. Task Force on Community Preventive Services found that flu- oridation was effective in reducing tooth decay among populations. Based on strong evidence of effectiveness, the Task Force strongly recommended that community water fluoridation be included as part of a comprehen- sive population -based strategy to prevent or control tooth decay in communitie S.75-76 14 QUESTION 8. With other forms of fluoride now available, is water flu- oridation still an effective method for preventing dental decay? Answer. Although other forms of fluoride are available, persons in nonfluoridated communities continue to demon- strate higher dental decay rates than their counterparts in communities with water fluoridation 68'70,72,79-83 Fact. In the 1940s, children in communities with optimally fluoridated drinking water had reductions in decay rates of approximately 60% as compared to those living in nonfluoridated communities. At that time, drinking wa- ter was the only source of fluoride other than fluoride that occurs naturally in foods. Recent studies reveal that decay rates have declined in naturally or adjusted fluoridated areas and nonfluo- ridated areas as well. One factor is the high geographic mobility of our populations. In other words, it is becom- ing increasing difficult to study large numbers of people in one location who have a history of consuming only fluoridated or nonfluoridated water. "Even in an era with widespread availability of fluoride from other sources, studies prove - water fluoridation continues to be effective in reducing dental decay by 20-40%. A second factor is the universal availability of fluo- ride from other sources including food, beverages, den- tal products (toothpaste, rinses, professionally applied foams, gels and varnish) and dietary supplements 84 Foods and beverages processed in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and beverages are consumed not only in the city where processed, but may be distributed to and consumed in nonfluoridated areas.266 This "halo" or "diffusion" effect results in increased fluoride intake by people in nonfluori- dated communities, providing them increased protection against dental decay.52.71,86 As a result of the widespread availability of these various sources of fluoride, the dif- ference between decay rates in fluoridated areas and nonfluoridated areas is somewhat less than several de- cades ago but it is still significant.87 Failure to account for the diffusion effect may result in an underestimation of the total benefit of water fluoridation especially in ar- eas where large quantities of fluoridated products are brought into nonfluoridated communities.16 Even in an era with widespread availability of fluo- ride from other sources, studies prove water fluorida- tion continues to be effective in reducing dental decay by 20-40%.28,29 Packet Page -114- American Dental Association QUESTION 9. What happens if water fluoridation is discontinued? Answer. Over time, dental decay can be expected to increase if water fluoridation in a community is discontinued, even if topical products such as fluoride toothpaste and fluo- ride rinses are widely used. Fact. The following paragraphs provide a summary of key his- torical studies that have been conducted on the discon- tinuation of water fluoridation. Antigo, Wisconsin began water fluoridation in June 1949, and ceased adding fluoride to its water in Novem- ber 1960. After five and one-half years without opti- mal levels of fluoride, second grade children had over 200% more decay, fourth graders 70% more, and sixth graders 91% more than those of the same ages in 1960. Residents of Antigo re -instituted water fluoridation in October 1965 on the basis of the severe deterioration of their children's oral health.88 Because of a government decision in 1979, fluorida- tion in the northern Scotland town of Wick was discon- tinued 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 89 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, result- ing 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 re- duction of dental decay.90 A U.S. study of 6- and 7 -year-old children who had re- sided 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 28,97 Decay reductions are greatest where water fluoridation is available in addition to topical fluorides, such as fluoride toothpaste and fluoride rinses. Finally, a study that reported the relationship be- tween fluoridated water and decay prevalence focused Fluoridation Facts 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 Gales- burg 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% de- crease 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.92 There have been several studies from outside the United States that have reported no increase in den- tal decay following the discontinuation of fluoridation. However, in all of the cases reported, the discontinua- tion of fluoridation coincided with the implementation of other measures to prevent dental decay. For example, in La Salud, Cuba a study on dental decay in children indicated that the rate of dental de- cay did not increase after fluoridation was stopped in 1990. However, at the time fluoridation was discontin- ued a new topical fluoride program was initiated where all children received fluoride mouthrinses on a regular basis and children two to five received fluoride varnish once or twice a year.91 In Finland, a longitudinal study of Kuopio (fluoridat- ed from 1959 to 1992) and Jyvaskyla (low levels of natu- ral fluoridation) showed little differences in decay rates between the two communities. This was attributed to a number of factors. The populations are extremely simi- lar in terms of ethnic background and social structure. Virtually all children and adolescents used the govern- ment-sponsored, comprehensive, free dental care. The dental programs exposed the Finnish children to intense topical fluoride regimes and dental sealant programs. The result was that the effect of water fluoridation ap- peared minimal. Because of these unique set of factors, it was concluded these results could not be replicated in countries with less intensive preventive dental care programs9° No significant decrease in dental decay was seen after fluoridation was discontinued in 1990 in Chemniz and Plauen which are located in what was formerly East Germany. The intervening factors in this case include improvements in attitudes toward oral health behav- iors, broader availability and increased use of other preventive measures including fluoridated salt, fluoride toothpaste and dental sealants.95 A similar scenario is reported from the Netherlands. A study of 15 -year-old children in Tiel (fluoridated 1953 to 1973) and Culemborg (nonfluoridated) was conduct- ed comparing dental decay rates from a baseline in 1968 through 1988. The lower dental decay rate in Tiel after the cessation of fluoridation was attributed in part to the initiation of a dental health education program, free dietary fluoride supplements and a greater use of professionally applied topical fluorides .96 Packet Page -115- 15 10. W 12, QUESTION 10. Is dental decay still a serious problem? Answer. Yes. Dental decay or tooth decay is an infectious disease that continues to be a significant oral health problem. Fact. Dental decay is, by far, the most common and costly oral health problem in all age groups.97 It is one of the principal causes of tooth loss from early childhood through middle age.98•99 Decay continues to be problem- atic for middle-aged and older adults, particularly root decay because of receding gums. Older adults may ex- perience similar or higher levels of dental decay than do children.100 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 impact- ing an individual's emotional and social well-being by causing pain and discomfort. Dental decay, particularly in the front teeth, can detract from appearance, thus af- fecting self-esteem and employability. "Decay continues to be problematic for middle-aged and older adults, particularly root decay because of receding gums." Despite a decrease in the overall decay experience of U.S. schoolchildren over the past two decades, dental decay is still a significant oral health problem, especial- ly 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 97 Despite prog- ress in reducing dental decay, individuals in families living below the poverty level experience more dental decay than those who are economically better off.20 Some of the risk factors that increase an individual's risk for decay are inadequate exposure to fluoride, irregular dental visits, deep pits and fissures in the chewing sur- faces of teeth, inadequate flow of saliva, frequent sugar intake and very high oral bacteria counts. Dental decay is one of the most common childhood diseases — five times as common as asthma and seven times as common as hay fever in 5- to 17-year-olds. Without fluoridation, there would be many more than the estimated 51 million school hours lost per year in this country because of dental -related illness.101 In addition to impacting emotional and social well- being, the consequences of dental disease are reflected in the cost of its treatment. According to the Centers for Medicare and Medicaid Services, the nation's total bill (including private and public spending) for dental services in 2003 was estimated to be $74.3 billion. This figure does not include indirect expenses of oral health 16 problems or the cost of services by other health care providers. 102 Again, the goal must be prevention rather than repair. Fluoridation is presently the most cost-ef- fective method for the prevention of dental decay for residents of a community in the United States. 103,104 QUESTION 11. Do adults benefit from fluoridation? Answer. Fluoridation plays a protective role against dental de- cay 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. While the early fluoridation trials were not designed to study the possible benefits fluoridation might have for adults, by the mid-1950s, there was growing evidence of both systemic and topical benefits of fluoride exposure. It soon became evident that fluoridation helped prevent decay in adults, too." 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 re- verse, because of frequent exposure to small amounts of fluoride. Studies have clearly shown that the avail- ability 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 resis- tant to future acid attacks. Additionally, the presence of systemic fluoride in saliva provides a reservoir of fluo- ride ions that can be incorporated into the tooth surface to prevent decay.63 (Additional information on this topic may be found in Question 2. "People in the United States are living" longer and retaining more of their natural teeth than ever before. " Another protective benefit for adults is the prevention of root decay. 101,101-101 Adults with gum recession are at risk for root decay because the root surface becomes ex- posed 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.' 18-112 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 retain- ing more of their natural teeth than ever before. Because older adults experience more problems with gum reces- Packet Page -116- American Dental Association sion, 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 de- cay.30 Data from the 1988-1991 National Health and Nutri- tion Examination Survey MANES III) showed that 22.51/6 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.13 In addition to gum recession, older adults tend to ex- perience decreased salivary flow, or xerostomia, due to the use of medications or medical conditions. 14.15 In- adequate flow of saliva places an individual in the high risk category for decay.30 This decrease in salivary flow can increase the likelihood of dental decay because sa- liva contains calcium, phosphates and fluorides — all necessary for early repair of dental decay. 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 preeruptive, systemic effects of fluoridation have lifetime benefits as reflected in the de- cay 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 de- cayed or filled tooth surfaces) in adults with a continu- ous lifetime exposure to fluoridated water as compared to adults with no exposure to water fluoridation.10 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 Fluoridation Facts 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. 116 Water fluoridation contributes much more to overall health than simply reducing dental 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.26 Additionally, fluori- dation conserves natural tooth structure by preventing the need for initial fillings and subsequent replacement fillings.' 11,118 Additional information on this topic may be found in Question 2. QUESTION 12. Are dietary fluoride supplements effective? Answer. For children who do not live in fluoridated communi- ties, dietary fluoride supplements are an effective alter- native to water fluoridation for the prevention of dental decay.' 16-122 Fact. Dietary fluoride supplements are available only by pre- scription in the United States and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that received by children who live in optimally fluoridated area S.123,121 Di- etary fluoride supplements are available in two forms: drops for infants aged six months or older, and chewable tablets for children and adolescents. 124 Fluoride supple- ments 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. 121 Because fluoride is so widely available, it is recommended that dietary fluoride supplements be used only according to the rec- ommended dosage schedule and after consideration of all sources of fluoride exposure 30,126 For optimum ben- efits, use of supplements should begin at six months of age and be continued daily until the child is at least 16 years old .126 The current dietary fluoride supplement schedule is shown in Table 1 on the next page. The relatively higher cost and need for compliance over an extended period of time is a major procedural and economic disadvantage of community-based fluo- ride supplement programs, one that makes them imprac- tical 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 edu- cated and motivated group of parents, only half continued to give their children fluoride tablets for the necessary number of years. 127 Additional studies have verified that Packet Page -117- 17 13 14 is 11 aMl' s� Approved by the American Dental Association, AmericanAcademy of Pediatrics, American Academy of Pediatric Dentistry Age Fluoride ion level in drinking water (ppm)* * 1.0 part per million (ppm) = 1 milligram/liter (mg/L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary great Iy.121,121,130 In- dependent reports from several countries, including the United States, have demonstrated that community -wide trials of fluoride supplements in which tablets were dis- tributed for use at home were largely unsuccessful be- cause of poor compliance.137 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 fluori- dation equipment), the overall cost of supplements per child is much greater than the per capita cost of com- munity fluoridation. 104 In addition, community water fluoridation provides decay prevention benefits for the entire population regardless of age, socioeconomic sta- tus, educational attainment or other social variables .26 This is particularly important for families who do not have access to regular dental services. (Additional information on this topic may be found in Questions 4, 13, 24 and 25. QUESTION 13. Does the ADA recommend fluoride for children under six years of age? Answer. Yes. The ADA recognizes that lack of exposure to fluo- ride places individuals of any age at risk for dental decay. Fluoride exposure may take many forms including wa- ter fluoridation and dietary fluoride supplements. Fact. For children who live in nonfluoridated communities, dietary fluoride supplements are an effective alterna- tive to water fluoridation to help prevent dental decay. Dietary fluoride supplements are available only by pre- scription and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that experienced by children who live in optimally fluoridated area 6.124 The dietary fluoride supplement schedule is just that — a supplement schedule (Table 1). Recognizing 18 that children will receive fluoride from other sources (food and beverages) even in nonfluoridated areas, the amounts in the table reflect the additional amount of fluoride intake necessary to achieve an optimal anti - cavity effect. "The dietary fluoride supplement schedule is just that— a supplement schedule." The dietary fluoride supplement schedule should not be viewed as recommending the absolute upper limits of the amount of fluoride that should be ingested each day. In 1997, the Food and Nutrition Board of the Institute of Medicine developed the Dietary Reference Intakes, a comprehensive set of reference values for dietary nutri- ent values. 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. In the case of fluo- ride, levels were established to reduce dental decay with- out causing moderate dental fluorosis.113 For example, the dietary fluoride supplement sched- ule recommends that a two-year-old child living in a non -fluoridated area (where the primary water source contains less than 0.3 ppm fluoride) should receive 0.25 mg of supplemental fIuoride per day. This does not mean that this child should ingest exactly 0.25 mg of fluoride per day. On the contrary, a two-year-old child could re- ceive important anti -cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- verse effects on health. This child would most probably be receiving fluoride from other sources (foods and bev- erages) even in a non -fluoridated area and the recom- mendation of 0.25 mg of fluoride per day takes this into account. In the unlikely event the child did not receive any extra fluoride from food and beverages, the 0.25 mg per day could be inadequate fluoride supplementation to achieve an optimal anti -cavity effect. The following statement is correct. "The dosage has been lowered two different times as evidenced of too much fluoride has appeared." Rather than being a prob- Packet Page -118- American Dental Association <0.3 ppm 0.3-0.6 ppm >0.6 ppm Birth — 6 months None None None 6 months -3 years 0.25 mg/day** None None 3 — 6 years 0.50 mg/day 0.25 mg/day None 6 — 16 years 1.0 mg/day 0.50 mg/day None * 1.0 part per million (ppm) = 1 milligram/liter (mg/L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary great Iy.121,121,130 In- dependent reports from several countries, including the United States, have demonstrated that community -wide trials of fluoride supplements in which tablets were dis- tributed for use at home were largely unsuccessful be- cause of poor compliance.137 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 fluori- dation equipment), the overall cost of supplements per child is much greater than the per capita cost of com- munity fluoridation. 104 In addition, community water fluoridation provides decay prevention benefits for the entire population regardless of age, socioeconomic sta- tus, educational attainment or other social variables .26 This is particularly important for families who do not have access to regular dental services. (Additional information on this topic may be found in Questions 4, 13, 24 and 25. QUESTION 13. Does the ADA recommend fluoride for children under six years of age? Answer. Yes. The ADA recognizes that lack of exposure to fluo- ride places individuals of any age at risk for dental decay. Fluoride exposure may take many forms including wa- ter fluoridation and dietary fluoride supplements. Fact. For children who live in nonfluoridated communities, dietary fluoride supplements are an effective alterna- tive to water fluoridation to help prevent dental decay. Dietary fluoride supplements are available only by pre- scription and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that experienced by children who live in optimally fluoridated area 6.124 The dietary fluoride supplement schedule is just that — a supplement schedule (Table 1). Recognizing 18 that children will receive fluoride from other sources (food and beverages) even in nonfluoridated areas, the amounts in the table reflect the additional amount of fluoride intake necessary to achieve an optimal anti - cavity effect. "The dietary fluoride supplement schedule is just that— a supplement schedule." The dietary fluoride supplement schedule should not be viewed as recommending the absolute upper limits of the amount of fluoride that should be ingested each day. In 1997, the Food and Nutrition Board of the Institute of Medicine developed the Dietary Reference Intakes, a comprehensive set of reference values for dietary nutri- ent values. 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. In the case of fluo- ride, levels were established to reduce dental decay with- out causing moderate dental fluorosis.113 For example, the dietary fluoride supplement sched- ule recommends that a two-year-old child living in a non -fluoridated area (where the primary water source contains less than 0.3 ppm fluoride) should receive 0.25 mg of supplemental fIuoride per day. This does not mean that this child should ingest exactly 0.25 mg of fluoride per day. On the contrary, a two-year-old child could re- ceive important anti -cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- verse effects on health. This child would most probably be receiving fluoride from other sources (foods and bev- erages) even in a non -fluoridated area and the recom- mendation of 0.25 mg of fluoride per day takes this into account. In the unlikely event the child did not receive any extra fluoride from food and beverages, the 0.25 mg per day could be inadequate fluoride supplementation to achieve an optimal anti -cavity effect. The following statement is correct. "The dosage has been lowered two different times as evidenced of too much fluoride has appeared." Rather than being a prob- Packet Page -118- American Dental Association lem, as those opposed to the use of fluoride might imply, this is evidence that the ADA is doing the right thing. The ADA continually reviews available scientific evidence, and revises its statements based on the most current scien- tific information. In 1994, a Dietary Fluoride Supplement Workshop cosponsored by the ADA, the American Acad- emy of Pediatric Dentistry and the American Academy of Pediatrics was held in Chicago. Based on a review of scien- tific evidence, a consensus was reached on a new dosage schedule developed in recognition that numerous sources of topical and systemic fluoride are available today that were not available many years ago.125 The revised dietary fluoride supplement schedule appears as Table 1. QUESTION 14. In areas where water fluoridation is not feasible be- cause of engineering constraints, are alternatives to water fluoridation available? Answer. Yes. Some countries outside the United States that do not have piped water supplies capable of accommodat- ing community water fluoridation have chosen to use salt fluoridation. Fact. Salt fluoridation is used extensively in a number of countries in Europe (examples: France, Hungary, Ger- many, Spain and Switzerland) and Central and South America (examples: Boliva, Colombia, Cuba, Domini- can Republic, Ecuador, EI Salvador, Honduras, Nica- ragua, Venezuela, Costa Rica, Jamaica, Mexico, Peru and Uruguay. )131,133 The Pan American Health Organi- zation (PAHO), a regional division of the World Health Association (WHO), with responsibilities for health matters in North, South and Central America as well as the Caribbean has been active in developing strate- gies to implement decay prevention programs in the regions of the Americas using both water and salt fluoridation .133,134 Studies evaluating the effectiveness of salt fluoridation outside the U.S. have concluded that fluoride delivered via salt may produce decay reductions similar to that of optimally fluoridated water. 131 An analysis of published results of studies from some countries shows that, for 12 -year-old children, the initial level of decay reduction due to salt fluoridation is between 35% and 80% 135,131 An advantage of salt fluoridation is that it does not require a centralized piped water system. This is of par- ticular use in many developing countries that do not have such water systems. When both domestic salt and bulk salt (used by commercial bakeries, restaurants, in- stitutions, and industrial food production) is fluoridated, the decay -reducing effect may be comparable to that of water fluoridation over an extended period of time. 116 On the other hand, when only domestic salt is fluori- dated, the decay -reducing effect may be diminished .135 Fluoridation Facts Salt fluoridation has several disadvantages that do not exist with water fluoridation. Challenges occur with implementation of salt fluoridation when there are mul- tiple 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.13' Finally, there is general agreement that a high consumption of sodium is a risk factor for hypertension (high blood pressure) .139,110 Peo- ple who have hypertension or must restrict their salt in- take may find salt fluoridation an unacceptable method of receiving fluoride. (Additional information on this topic may be found in Question 56. Fluoridated milk has been suggested as another alterna- tive to community water fluoridation in countries outside the U.S. WHO has supported milk fluoridation feasibil- ity projects in the United Kingdom, People's Republic of China, Peru and Thailand.14' Studies among small groups of children have demonstrated a decrease in dental de- cay levels resulting from consumption of fluoridated milk; however, these studies were not based on large-scale sur- veys. More research is needed before milk fluoridation can be recommended as an alternative to water or salt fluoridation."' The rationale for adding fluoride to milk is that this method "targets" fluoride directly to children, but the amount of milk consumed by children is quite variable, more so than water. 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.743 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 fluo- ridated milk should not be sold in areas having natural or adjusted fluoridation, regulation would be difficult, and established marketing patterns would be disrupted 42 QUESTION 15. Can the consistent use of bottled water result in indi- viduals 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) of fluoride. 144-148 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. The consumption of bottled water in the United States has been growing by at least one gallon per person each year - more than doubling in the last ten years. Consump- tion rates for the past five years are shown in Table 2.14 Packet Page -119- 19 it Per Capita Consumption 2000-2004 Gallons Annual Year Per Capita % Change 2000 17.2 --- 2001 18.7 8.7% 2002 20.7 10.8% 2003 22.1 7.0% 2004 23.8 7.6% In 2004, total U.S. sales of bottled water surpassed 6.8 billion gallons, an 8.6% advance over 2003 with whole- sale dollar sales reaching a record of approximately $9.2 billion. This category includes sparkling and non -spar- kling water, domestic and imported water, water in single - serve bottles and larger packages as well as vended and direct delivered waters. U.S. residents now drink more bottled water annually (23.8 gallons per person in 2004) than any other beverage with the exception of carbonated soft drinks. 149,110 In 2004, consumption of carbonated soft drinks fell for the sixth straight year after several decades of uninhibited growth (53.7 gallons per person in 2004 compared to 54.8 gallons per person in 1999).750 "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." \ J In 1994, a small study at two community health centers in Rhode Island showed that 55% of the total households responding used only bottled water for drinking while 59% of the households with children reported using only bottled water for drinking. The vast majority of these bottled wa- ters had less than optimal levels of fluoride. While most of the patient population of the health centers was either on public assistance (60%) or uninsured (20%), families spent their limited resources to purchase bottled water. It was reported that 52% of children on public assistance and 35% of the uninsured children used bottled water. 151 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.152 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.15' A similar study of five national brands of bottled water conducted in 2000, showed that significant differences in fluoride concentra- tion existed between the five brands and that three of the 20 five brands tested demonstrated significant differences between the various batches tested of the same brand .154 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 drink- ing, 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 day- care, school or work. A final important issue is determining the fluoride content of the bottled water. While drinking water is reg- ulated by the U.S. EPA,"' bottled water is regulated by the U.S. Food and Drug Administration (FDA) which has established standards for its quality.1' 3+ Additional information on this topic may be found in Question 43. Bottled water is defined as water that is intended for human consumption sealed in bottles or other containers with no added ingredients except that it may optionally contain safe and suitable antimicrobial agents. The FDA has established maximum allowable levels for physical, chemical, microbiological, and radiological contaminants in the bottled water quality standard regulations. The FDA has also approved standards for the optional addition of fluoride. 156 Effective in 1996, FDA regulations require fluo- ride content of bottled water to be listed on the label only if fluoride is added during processing.151 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. For additional information on bottled water and fluo- ride exposure, view the ADA's Web page "Bottled Water, Home Water Treatment Systems and Fluoride Exposure" at http://www.ada.org[goto/`bottledwater. (Figure 3) • Does your bottled water contain fluoride? • Does your water filter remove fluoride? /A1Vl/ k American Dental. Association www.ada.org Many ADA resources are at your fingertips 24/7/365. Order a library book or products online, read JADA articles, discuss important topics with colleagues, find helpful information on professional topics from accredi- tation to X-rays and recommend our dental education animations, stories and games to your patients. Packet Page-120- (. Visit ADA.org today! American Dental Association \.LV LV I IVIY ■ V. 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 including water filters (for example: carafe filters, faucet filters, under the sink filters and whole house filters), reverse osmosis systems, 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 con- flicting and unclear. However, it has been consistently documented that reverse osmosis systems and distilla- tion units remove significant amounts of fluoride from the water supply.61.1e8,199 On the other hand, repeated studies regarding water softeners confirm earlier re- search indicating the water softening process caused no significant change in fluoride levels.180,181 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. Some acti- vated carbon filters containing activated alumina may remove significant amounts of the fluoride .112 Each type of filter should be assessed individually.159 Individuals who drink water processed by home wa- ter treatment systems as their primary source of water could be losing the decay preventive effects of opti- mally fluoridated water available from their community water supply. Consumers using home water treatment systems should have their water tested at least annu- ally to establish the fluoride level of the treated water. More frequent testing may be needed. Testing is avail- able through local and state public health departments. Private laboratories may also offer testing for fluoride levels in water. 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. (Additional information on this topic may be found in Question 4. For additional information on home water treatment systems and fluoride exposure, view the ADA's Web page "Bottled Water, Home Water Treatment Systems and Flu- oride Exposure" at http://www.ada.org/goto/bottledwater. (Figure 3) Fluoridation Facts 21 Packet Page -121- I.. to SAFETY Q 17. Harmful to humans? p. 22 Q 18. More studies needed? p. 23 Q 19. Total intake? p. 24 Q 20. Daily intake? p. 25 Q 21. Prenatal dietary fluoride supplements? p. 26 Q 22. Body uptake? p. 26 Q 23. Bone health? p. 27 Q 25. Prevent fluorosis? p. 30 Q 34. Fertility? p. 35 Q 26. Warning label? p. 31 Q 35. Down Syndrome? p. 35 027. Toxicity? p. 31 Q 36. Neurological impact? p.36 Q 28. Cancer? p. 32 Q 37. Lead poisoning? p. 37 Q 29. Enzyme effects? p. 33 Q 38. Alzheimer's disease? p. 37 Q 30. Thyroid gland? p. 34 Q 39. Heart disease? p. 38 031. Pineal Gland? p. 34 040. Kidney disease? p. 38 Q 32. Allergies? p. 34 Q 41. Erroneous health p. 39 claims? Q24. Dental fluorosis? p. 28 Q 33. Genetic risk? p. 35 QUESTION 17. Does fluoride in the water supply, at the levels recom- mended for the prevention of dental decay, adversely affect human health? Answer. The overwhelming weight of scientific evidence indi- cates that fluoridation of community water supplies is safe. (See Figure 4.) Fact. For generations, millions of people have lived in ar- eas where fluoride is found naturally in drinking water in concentrations as high or higher than those recom- mended to prevent dental decay. Research conducted among these persons confirms the safety of fluoride in the water supply.84,163-166 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 prob- lems such as cancer, kidney failure or bone disease.167 Based on a review of available data on fluoride tox- icity, the expert subcommittee that wrote the report concluded that the EPA's ceiling of 4 ppm for naturally occurring fluoride in drinking water was "appropri- ate as an interim standard."167 Subsequently, the EPA announced that the ceiling of 4 ppm would protect against adverse health effects with an adequate mar- gin of safety and published a notice of intent not to revise the fluoride drinking water standard in the Fed- eral Register.188 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 sub - 22 stantiated by generally accepted scientific knowledge. After 60 years of research and practical experience, the preponderance of scientific evidence indicates that fluo- ridation of community water supplies is both safe and effective.169 Many organizations in the U.S. and around the world involved with health issues have recognized the value of community water fluoridation. The American Dental Association (ADA) adopted its original resolu- tion in support of fluoridation in 1950 and has repeat- edly reaffirmed its position publicly and in its House of Delegates based on its continuing evaluation of the safety and effectiveness of fluoridation .3 The 2005 "ADA Statement Commemorating the 6011 Anniver- sary of Community Water Fluoridation" reinforced that position .4 The American Medical Association's (AMA) House of Delegates first endorsed fluoridation in 1951. In 1986, and again in 1996, the AMA reaffirmed its sup- port for fluoridation as an effective means of reducing dental decay.170 The World Health Organization, which initially recommended the practice of water fluorida- tion in 1969,111 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. "1311 Fol- lowing a comprehensive 1991 review and evaluation of Packet Page -122- American Dental Association Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for calcium, phospho- rus, magnesium, vitamin D and fluoride. Report of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Wash- ington, DC: National Academy Press;1997. • National Research Council. Health effects of in- gested fluoride. Report of the Subcommittee on Health' Effects of Ingested Fluoride. Washing- ton, DC: National Academy Press;1993. • US Department of Health and Human Services, Public Health Service. Review of fluoride: ben- efits and risks. Report of the Ad Hoc Subcommit- tee on Fluoride. Washington, DC; February 1991. • World Health Organization. Fluorides and hu- man health. Monograph series no 59. Geneva, Switzerland;1970. the public health benefits and risks of fluoride, the U.S. Public Health Service reaffirmed its support for fluori- dation and continues to recommend the use of fluoride to prevent dental decay.64 Recent statements by five leading health authorities on community water fluoridation can be found in the back of this publication. National and international health, service and pro- fessional organizations that recognize the public health benefits of community water fluoridation for prevent- ing dental decay are listed on the inside back cover of this publication. QUESTION 18. Are additional studies being conducted to determine the effects of fluorides in humans? 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 on-going research. Fact. For more than 60 years, thousands of reports have been published on all aspects of fluoridation.6 ,"' The accumulated dental, medical and public health evi- dence concerning fluoridation has been reviewed and evaluated numerous times by academicians, commit - Fluoridation Facts most of the world's major national and internation- al health organizations. The verdict of the scientific community is that water fluoridation, at recommend- ed levels, safely provides major oral health benefits. The question of possible secondary health effects caused by fluorides consumed in optimal concentra- tions throughout life has been the object of thorough medical investigations which have failed to show any impairment of general health throughout life. 138,113-161 "The verdict of the scientific community is that water fluoridation, at recommended levels, safely provides major oral health benefits." In scientific research, there is no such thing as "final knowledge." New information is continuously emerg- ing and being disseminated. Under the Safe Drinking Water Act (SDWA), the U. S. Environmental Protection Agency (EPA) must periodically review the existing Na- tional Primary Drinking Water Regulations (NPDWRs) .not less often than every 6 years." This review is a routine part of the EPA's operations as dictated by the SDWA.172 In April 2002, the EPA announced the results of its preliminary revise/not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re- viewed. The EPA determined that it fell under the "Not Appropriate for Revision at this Time" category, but not- ed that it planned to ask the National Academy of Sci- ence (NAS) to update the risk assessment for fluoride. The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the Sub- committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data pub- lished since 1993 and exposure data on orally ingest- ed fluoride from drinking water and other sources (e.g., food, toothpaste, mouthrinses). Based on this review the Subcommittee will evaluate the scien- tific and technical basis of the EPA's maximum con- taminant level (MCL) of 4 milligram per liter (mg/L or ppm) and secondary maximum contaminant level (SMCL) of 2 mg/L for fluoride in drinking water. The Subcommittee will advise the EPA on the adequacy of its fluoride MCL and SMCL to protect children and others from adverse health effects and identify data gaps and make recommendations for future research relevant to setting the MCL and SMCL for fluoride. The Subcommittee began its work in November 2002 and is currently projected to complete the project in early 2006.173 The definition of a contaminant is a function of the National Primary Drinking Water Regulations. The EPA Packet Page -123- 23 19. 20. considers a contaminant to be ANYTHING found in wa- ter that may be harmful to human health. The EPA has designated 90 microorganisms, minerals and chemicals as contaminants. 1415 While research continues, the weight of scientific evi- dence indicates water fluoridation is safe and effective in preventing dental decay in humans." j+Additional information on this topic may be found in Questions 7, 8, and 42. QUESTION 19. 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 concen- trations of airborne fluorides. Studies reporting the lev- els of fluoride in air in the United States suggest that ambient fluoride contributes little to a person's overall fluoride intake .179,180 Fluoride from Water In the United States, the natural level of fluoride in ground water varies from very low levels to over 4 ppm. Public water systems in the U.S. are monitored by the Environmental Protection Agency (EPA), which requires that public water systems not exceed fluoride levels of 4 ppm.163 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 den- tal decay while minimizing the occurrence of mild den- tal fluorosis. The optimal fluoride level is dependent on the annual average of the maximum daily air tempera- ture in the geographic area.36 Children living in a community with water fluori- dation 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 con- sume one liter of water fluoridated at 1 part per million (1 ppm) to receive 1 milligram (1 mg) of fluoride .11,118 Children under six years of age, on average, consume less than one-half liter of drinking water a day.ne There- fore, children under six years of age would consume, on average, less than 0.5 mg of fluoride a day from drink- ing optimally fluoridated water (at 1 ppm). A ten-year comparison study of long-time residents of Bartlett and Cameron, Texas, where the water sup- plies contained 8.0 and 0.4 parts per million of fluo- ride, respectively, included examinations of organs, bones and tissues. Other than a higher prevalence of 24 dental fluorosis in the Bartlett residents, the study in- dicated that long term consumption of dietary fluoride (resident average length of fluoride exposure was 36.7 years), even at levels considerably higher than recom- mended for decay prevention, resulted in no clinically significant physiological or functional effects.166 Fluoride in Food Foods and beverages commercially processed (cooked or reconstituted) in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and bev- erages are consumed not only in the city where pro- cessed, but may be distributed to and consumed in nonfluoridated areas.26 This "halo" or "diffusion" ef- fect results in increased fluoride intake by people in nonfluoridated communities, providing them increased protection against dental decay." -85-86 As a result of the widespread availability of these various sources of fluoride, the difference between decay rates in fluo- ridated areas and nonfluoridated areas is somewhat less than several decades ago but still significant8' Failure to account for the diffusion effect may result in an underestimation of the total benefit of water fluo- ridation especially in areas where a large amount of fluoridated products are brought into nonfluoridated communities.16 Water and water-based beverages are the chief source of dietary fluoride intake. Conventional estimates are that approximately 75% of dietary fluoride comes from water and water-based beverages."' The average daily dietary intake of fluoride (ex- pressed 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% low- er.123 Dietary fluoride intake by adults in optimally fluo- ridated (1 ppm) areas averages 1.4 to 3.4 mg/day, and in nonfluoridated areas averages 0.3 to 1.0 mg/day. 113 In looking at the fluoride content of food and bever- ages over time, it appears that fluoride intake from di- etary sources has remained relatively constant. Except for samples prepared or cooked with fluoridated wa- ter, the fluoride content of most foods and beverages is not significantly different between fluoridated and nonfluoridated communities. When fluoridated water is used to prepare or cook the samples, the fluoride content of foods and beverages is higher as reflected in the intake amounts noted in the previous paragraph. This difference has remained relatively constant over t i rn e.180,181 The fluoride content of fresh solid foods in the Unit- ed States generally ranges from 0.01 to 1.0 part per million.10',"' It has long been known that fish, such as sardines, may contribute to higher dietary fluoride in- take if the bones are ingested as fluoride has an affin- ity for calcified tissues. Additionally, brewed teas may also contain fluoride concentrations of 1 ppm to 6 ppm depending on the amount of dry tea used, the water flu - Packet Page -124- American Dental Association oride concentration and the brewing time.782 The fluo- ride value for unsweetened instant tea powder appears very high when reported as a dry powder because this product is extremely concentrated. However, when one teaspoon of the unsweetened tea powder is added to an eight ounce cup of tap water, the value for prepared instant tea is similar to the values reported for regular brewed tea.7' Unveiled in 2004, the National Fluoride Database is a comprehensive, nationally representative database of the fluoride concentration in foods and beverages con- sumed in the United States. The database for fluoride was designed for use by epidemiologists and health re- searchers to estimate fluoride intake and to assist in the investigation of the relationships between fluoride in- take and human health. The database contains fluoride values for beverages, water, and some lower priority foods. 19 QUESTION 20. How much fluoride should an individual consume each day to reduce the occurrence of dental decay? Answer. The appropriate amount of daily fluoride intake var- ies 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.12' These new refer- ence 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 D, DRIs for fluoride were established because of its proven ef- fect on dental decay. As demonstrated in Table 3, fluoride intake in the United States has a large range of safety. The first DRI reference value is the Adequate In- take (AI) which establishes a goal for intake to sustain a desired indicator of health without causing side ef- fects. In the case of fluoride, the Al is the daily intake level required to reduce dental decay without causing moderate dental fluorosis. The Al 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 Al 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 3 in this Question. The DRIB also established a second reference value for maximum -level guidelines called tolerable upper intake levels (UL). The UL is higher than the Al and is notthe recommended level of intake. The UL is the es- timated 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 bodyweight 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 regardless of weight. Table 3. Dietary Reference Intakes for Fluoride Food and Nutrition Board of the Institute of Medicine 1997723 Age Group Reference Weights kg (lbs)* (' Adequate Intake (mg/day) Tolerable Upper Intake' (mg/day) Infants 0-6 months 7 (16) 0.01 0.7 Infants 7-12 months 9 (20) 0.5 0.9 Children 1-3 years 13 (29) 0.7 1.3 Children 4-8 years 22 (48) 1.0 2.2 Children 9-13 years 40 (88) 2.0 10.0 Boys 14-18 years 64 (142) 3.0 10.0 Girls 14-18 years 57 (125) 3.0 10.0 Males 19 years and over 76 (166) 4.0 10.0 Females 19 years and over 61 (133) 3.0 10.0 * Value based on data collected during 1988-94 as part of the Third National Health and Nutrition Examination Survey (NHANES III) in the United States. 123 Fluoridation Facts Packet Page -125- 25 21 22 23. 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 (ex- pressed as average weight). (See Table 3.) 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 fluori- dation 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 con- sume one liter of water fluoridated at 1 part per million (1 ppm) to receive 1 milligram (1 mg) of fluoride .42,118 Children under six years of age, on average, consume less than one-half liter of drinking water a day. 178 There- fore, children under six years of age would consume, on average, less than 0.5 mg of fluoride a day from drink- ing 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 12), the current dosage schedule rec- ommends supplemental fluoride amounts that are below the AI for each age group. The dosage schedule was de- signed to offer the benefit of decay reduction with margin of safety to prevent mild to moderate dental fluorosis. For example, the Al for a child 3 years of age is 0.7 mg/day. The recommended dietary fluoride supplement dosage fora 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 ingested inadvertently by children .181 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 inadvertantly swallow an average of 0.30 mg of fluoride from fluoride toothpaste at each brush ing.184.18r-189 If a child brushes twice a day, 0.60 mg may be ingested inappropriately. This may slightly exceed the Adequate Intake (AI) values from Ta- ble 3. The 0.60 mg consumption is 0.10 mg higher than the Al value for children 6 to 12 months and is 0.10 mg lower than the Al for children from 1-3 years of age .113 Although toothpaste is not meant to be swallowed, chil- dren may consume the daily recommended Adequate Intake amount of fluoride from toothpaste alone. In or- der to decrease the risk of dental fluorosis, the American Dental Association since 1992 has recommended that parents and caregivers put only one pea-sized amount 26 of fluoride toothpaste on a young child's toothbrush at each brushing. Also, young children should be super- vised while brushing and taught to spit out, rather than swallow, the toothpaste. Consult with your child's den- tist or physician if you are considering using fluoride toothpaste before age two. (Additional information on this topic may be found in Question 25. It should be noted that the amounts of fluoride dis- cussed here are intake, or ingested, amounts. When flu- oride is ingested, a portion is retained in the body and a portion is excreted. This issue will be discussed further in Question 22. QUESTION 21. Is there a need for prenatal dietary fluoride supplemen- tation? Answer. There is no scientific basis to suggest any need to in- crease a woman's daily fluoride intake during preg- nancy or breastfeeding to protect her health. At this time, scientific evidence is insufficient to support the recommendation for prenatal fluoride supplementation for decay prevention for infants. 123,180 Fact. The Institute of Medicine has determined that, "No data from human studies document the metabolism of fluoride during lactation. Because fluoride concen- trations in human milk are very low (0.007 to 0.011 ppm) and relatively insensitive to differences in the fluoride concentrations of the mother's drinking water, fluoride supplementation during lactation would not be expected to significantly affect fluoride intake by the nursing infant or the fluoride requirement of the mother." 123 The authors of the only prospective, randomized, double blind study to evaluate the effectiveness of prenatal dietary supplementation have concluded that the data do not support the hypothesis that prenatal fluoride has a strong decay preventive effect.190 More- over, prenatal dietary fluoride supplementation will not have an affect on the baby's permanent teeth be- cause permanent teeth do not begin to develop during pregnancy.191 QUESTION 22. When fluoride is ingested, where does it go? Answer. Much of the fluoride is excreted. Of the fluoride retained, almost all is found in calcified (hard) tissues, such as bones and teeth. Fluoride helps to prevent dental decay when incorporated into the teeth. Packet Page-126- American Dental Association 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.192 This causes a short term increase in fluoride levels in the blood. The fluoride levels in- crease quickly and reach a peak concentration within 20-60 minutes.193 The concentration declines rapidly, usually within three to six hours following peak lev- els, due to the uptake of fluoride by calcified tissues and efficient removal of fluoride by the kidneys. 112 Ap- proximately 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.192 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 contrib- utes to long lasting protection against dental decay.42 Additional information on this topic may be found in Question 2. An individual's age and stage of skeletal devel- opment 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 ad u I tS. 183,192,193 According to generally accepted scientific knowl- edge, the ingestion of optimally fluoridated water does not have an adverse effect on bone health.194-199 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 fluoride)."123.199 In these communities, daily fluoride intake of 20 mg/day would not be uncom- mon.123 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.123 (Additional information on this topic may be found in Question 23. The kidneys play the major role in the removal of fluoride from the body. Normally kidneys are very ef- ficient and excrete fluoride very rapidly. However, de- creased fluoride removal may occur among persons with severely impaired kidney function who may not be on kidney dialysis.76' No cases of dental fluorosis or symptomatic skeletal fluorosis have been reported among persons with impaired kidney function; how- ever, the overall health significance of reduced fluoride removal is uncertain and continued follow-up is recom- mended especially for children with impaired kidney function 84 (Additional information on this topic may be found in Question 40. Fluoridation Facts QUESTION 23. Will the ingestion of optimally fluoridated water over a lifetime adversely affect bone health? Answer. No, the ingestion of optimally fluoridated water does not have an adverse effect on bone health .194-198,203-205 Fact. The weight of scientific evidence does not provide an adequate basis for altering public health policy regard- ing fluoridation because of bone health concerns. A number of investigations have studied the effects on bone structure of individuals residing in communi- ties with optimal and higher than optimal concentra- tions of fluoride in the drinking water. These studies have focused on whether there exists a possible link between fluoride and bone fractures. Additionally, the possible association between fluoride and bone cancer has been studied. In 1991, a workshop, co-sponsored by the Nation- al Institute of Arthritis and Musculoskeletal and Skin Diseases and the then National Institute of Dental Re- search, addressed the potential relationship of hip frac- ture and bone health in humans to fluoride exposure from drinking water. Meeting at the National Institutes of Health, researchers examined historic and contem- porary research on fluoride exposure and bone health. At that time, participants concluded there was no basis for altering current public health policy regarding cur- rent guidelines for levels of fluoride in drinking water. Recommendations were made regarding additional re- search in several areas. 194 In 1993, two studies were published demonstrating that exposure to fluoridated water does not contribute to an increased risk for hip fractures. One study looked at the risk of hip fractures in residents of two similar communities in Alberta, Canada.195 In this study, re- searchers 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 signifi- cant difference was observed in the overall hip frac- ture hospitalization rates for residents of both cities. "These findings suggest that fluoridation of drinking water has no impact, neither beneficial nor deleteri- ous, on the risk of hip fracture."195 The second study examined the incidence of hip frac- ture rates before and after water fluoridation in Roches- ter, Minnesota.199 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 in- troduced, and then continued. These data demonstrate no increase in the risk of hip fracture associated with water fluoridation. Packet Page -127- 27 24. An ecological study conducted in eastern 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 .210 The ingestion of optimally fluoridated water does not have an adverse effect on bone health .194-198,200 Exposure to fluoride at levels considered optimal for the prevention of dental decay appears to have no significant impact on bone mineral density or risk of bone fracture 201-205 Some studies have reported hip fracture risk increased slightly, decreased slightly or was unchanged in fluoridated areas compared to nonfluoridated areas. A recent systematic review of these studies concluded there was no clear as- sociation with water fluoridation and hip fracture .206 "Exposure to fluoride at levels considered optimal for the prevention of dental decay appears to have no significant impact on bone mineral density or risk of bone fracture. " While a number of studies reported findings at a population level, both the Hillier and Phipps studies examined risk on an individual rather than a commu- nity basis taking into account other risk factors such as medications, age of menopause, alcohol consumption, smoking, dietary calcium intake and physical activity. Using these more rigorous study designs, Hillier and Phipps reported no change or lower hip fracture risk in those drinking fluoridated water."',"' In Bone Health and Osteoporosis: A Report of the Sur- geon General issued in 2004, fluoride is listed as a nutri- ent that has potentially beneficial effects on bone .211 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 206 The second study was sponsored by the Proctor and Gam- ble Company.209 In both studies, higher than optimal con- centrations of sodium fluoride (25, 100 and 175 ppm) were consumed by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual 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 carcinoge- nicity, which is defined by NTP as a marginal increase in neoplasms - i.e., osteosarcomas (malignant tumors of the bone) - that may be chemically related. The Ad Hoc Sub- committee 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. "84,210 (Additional information on this topic may be found in Question 28. QUESTION 24. 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 for- mation which occurs during tooth development in early childhood related to a higher than optimal intake of flu- oride .182 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 can- not develop even if excessive fluoride is ingested .211 Older children and adults are not at risk for the development of dental fluorosis. Dental fluorosis becomes apparent only afterthe teeth erupt. Because dental fluorosis occurs while teeth are forming under the gums, teeth that have erupted are not at risk for dental fluorosis. It should be noted that many other developmental changes that affectthe appear- ance of tooth enamel are not related to fluoride intake. Table Classification 4. Dental Fluorosis Classification by H.T. Dean -1942212 Criteria -Description of Enamel Normal Smooth, glossy, pale creamy -white translucent surface Questionable A few white flecks or white spots Very Mild Small opaque, paper -white areas covering less than 25% of the tooth surface Mild Opaque white areas covering less than 50% of the tooth surface Moderate All tooth surfaces affected; marked wear on biting surfaces; brown stain may be present Severe All tooth surfaces affected; discrete or confluent pitting; brown stain present 28 Packet Page -128- American Dental Association Dental fluorosis has been classified in a number of ways. One of the most universally accepted classifications was developed by H. T. Dean in 1942; its descriptions can be easily visualized by the public (see Table 4) 272 In using Dean's Fluorosis Index, each tooth present in an individual's mouth is rated according to the fluo- rosis index in Table 4. The individual's fluorosis score is based upon the severest form of fluorosis recorded for two or more teeth. Dean's Index, which has been used for more than 60 years, remains popular for prevalence studies in large part due to its simplicity and the ability to make comparisons with findings from a number of earlier studies 213 Very mild to mild fluorosis has no effect on tooth function and may make the tooth enamel more resis- tant to decay. These types of fluorosis are not readily apparent to the affected individual or casual observ- er and often require a trained specialist to detect. In contrast, the moderate and severe forms of dental fluorosis, characterized by esthetically (cosmetically) objectionable changes in tooth color and surface ir- regularities, are typically easy to detect. Most investi- gators regard even the more advanced forms of dental fluorosis as a cosmetic effect rather than a functional adverse effect. 123 The U.S. Environmental Protection Agency, in a decision supported by the U.S. Surgeon General, has determined that objectionable dental fluorosis is a cosmetic effect with no known health ef- fects.168 Little research on the psychological effects of dental fluorosis on children and adults has been con- ducted, perhaps because the majority of those who have the milder forms of dental fluorosis are unaware of this condition .84 In a 1986-7 national survey of U.S. school children conducted by the National Institute of Dental Research (NIDR), dental fluorosis was present in 22.3% of the children examined using Dean's Index.84 These children were exposed to a variety of sources of fluoride (fluori- dated water, food, beverages, fluoride dental products and dietary supplements). The prevalence of the types of dental fluorosis observed was: Very mild fluorosis 17.0% Mild fluorosis 4.0% Moderate fluorosis 1.0% Severe fluorosis 0.3% Total 22.3% The incidence of moderate or severe fluorosis com- prised a very small portion (6%) of the total amount of fluorosis. In other words, 94% of all dental fluorosis was the very mild to mild form of dental fluorosis. This survey conducted by NIDR remains the only source of national data regarding the prevalence of den- tal fluorosis. In a study that compared this data with data recorded by H. Trendley Dean in the 1930s, it was de- termined that the greatest increase in fluorosis from the 1930s to the 1980s appeared in the group with subopti- mally fluoridated water. During the last ten years of this period, children were exposed to fluoride from multiple Fluoridation Facts sources including water, infant formula, foods, foods and drinks prepared with fluoridated water as well as dietary supplements and the ingestion of fluoride tooth- paste making it difficult to pinpoint the effect any one item had on the development of fluorosis. As part of the most recent National Health and Nutrition Examination Survey (NHANES) 1999-2002, new fluorosis data has been collected as a representative sample of the U.S. population. By comparing NIDR and the latest NHANES data, researchers will be able to determine trends in the prevalence and severity of dental fluorosis in the past 15 years and examine if changes in exposure to systemic fluorides such as infant formulas, toothpaste and dietary fluoride supplements have had some effect.214 Using the same NIDR study, researchers looked at chil- dren aged 12-14 years who had never received dietary fluoride supplements and had only lived in one home. Through their analysis, they found that approximately 2% of U.S. school children may experience perceived es- thetic problems which could be attributed to the currently recommended levels of fluoride in drinking water. They reported that dental fluorosis in the esthetically important front teeth occurs less often and is less severe than when looking at all teeth in an individual. While the researchers were not able to provide a cost estimate associated with the treatment of this fluorosis, they did note that such estimates are frequently an overestimation of the actual costs. Additionally, any change recommended to the cur- rent fluoridation policy would need to be weighed against fluoridation's lifetime benefits and the feasibility and as- sociated costs of alternative solutions 275 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 ben- efits of fluoride, and the same time minimize the likeli- hood of mild dental fluorosis 84 The benefits and risks of community water fluoridation have been examined and are discussed extensively in the Benefits Section and the safety of water fluoridation is discussed in great detail in the remainder of this (Safety) Section of this document. In assessing the risks of den- tal fluorosis, scientific evidence indicates 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 fluorosis.t0 As de- fined in Table 4, very mild fluorosis is characterized by small opaque, paper -white area covering less than 25% of the tooth surface. The risk of teeth forming with the very Packet Page -129- 29 25. 26. 27 mildest form of fluorosis must be weighed against the benefit that the individual's teeth will also have a lower level of dental decay thus saving dental treatment costs, patient discomfort and tooth loss.11•12 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 dental fluorosis?76 In 1994, a review of five recent studies indicated that the amount of dental fluorosis attributable to water flu- oridation was approximately 13%. This represents the amount of fluorosis that might be eliminated if com- munity water fluoridation was discontinued 86 In other words, the majority of dental fluorosis can be associ- ated with other risk factors such as the inappropriate ingestion of fluoride products. +3 Additional information on this topic may be found in Question 25. The type of fluorosis seen today remains largely limited to the very mild and mild categories; however, the preva- lence of dental fluorosis in both fluoridated and nonfluo- ridated communities in the United States is higher than it was when the original epidemiological studies were con- ducted approximately 60 years ago84 The inappropriate use of fluoride -containing dental products is the largest risk factor for increased fluorosis as fluoride intake from food and beverages has remained constant overtime.18o,161 The risk of fluorosis can be greatly reduced byfollowing la- bel directions for the use of these fluoride products."',,' 0+ Additional information on this topic may be found in Question 25. QUESTION 25. What can be done to reduce the occurrence of dental fluorosis in the U.S.? Answer. The vast majority of dental fluorosis in the United States can be prevented by limiting the ingestion of topical fluoride products (such as toothpaste) and the appropriate use of dietary fluoride supplements with- out denying young children the decay prevention ben- efits of community water fluoridation. 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 fluoro- sis85,21' Studies of fluoride intake from the diet including foods, beverages and water indicate thatfluoride ingestion from these sources has remained relatively constant for over half a century and, therefore, is not likelyto be associ- ated with an observed increase in dental fluorosis.110-182 (Additional information on this topic may be found in Question 19. 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 30 topical use only; however, some fluoride is ingested inad- vertently by children.'$' Inappropriate ingestion of topical fluoride can be minimized, thus reducing the risk for den- tal fluorosis without reducing decay prevention benefits. Since 1992, the American Dental Association (ADA) 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 chil- dren of preschool age and they may inadvertently swal- low toothpaste during brushing. In addition, the enamel formation of 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 information on this topic may be found in Question 24. Numerous studies have established a direct relation- ship between young children brushing with more than a pea-sized amount of fluoride toothpaste and the risk of very mild or mild dental fluorosis in both fluoridated and nonfluoridated communities. 189.216.219 It was noted that 34% of the dental fluorosis cases in a nonfluoridated community were explained by children having brushed more than once per day during the first two years of life. In the optimally fluoridated community, 68% of the fluo- rosis cases were explained by the children using more than a pea-sized amount of toothpaste during the first year of life .221 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. Consult with your child's dentist or physician if you are considering using fluoride toothpaste before age two. Additionally, it has been shown that 65% of the fluo- rosis cases in a nonfluoridated area were attributed to fluoride supplementation under the pre -1994 protocol. Thirteen percent of fluorosis cases in a fluoridated com- munity could be explained by a history of taking dietary fluoride supplements inappropriately."' Dietary fluoride supplements should be prescribed as recommended in the dietary fluoride supplement schedule approved by the American Dental Association, the American Acade- my of Pediatrics and the American Academy of Pediatric Dentistry in 1994 (see Table 1) 30.126 Fluoride supplements should only be prescribed for children living in nonfluori- dated 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 sup- plements are prescribed for a child .112 That evaluation should include testing of the home water supply if the fluoride concentration is unknown. (Additional information on this topic may be found in Question 42. Packet Page -130- American Dental Association Parents, caretakers and health care professionals should judiciously monitor use of all fluoride -contain- ing dental products by children under age six. As is the case with any therapeutic product, more is not always better. Care should betaken to adhere to label directions on fluoride prescriptions and over-the-counter products (e.g. fluoride toothpastes and rinses). The ADA recom- mends the use of fluoride mouthrinses, but not for chil- dren under six years of age because they may swallow the rinse. 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, consum- ers should consider action to lower the risk of dental fluorosis for young children. (Adults are not affected because dental fluorosis occurs only when develop- ing teeth are exposed to elevated fluoride levels.) Families on community water systems should contact their water supplier to ask about the fluoride level. Consumers with private wells should have the source tested yearly to accurately determine the fluoride con- tent. Consumers should consult with their dentist re- garding 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. It is also important to remember that the ADA recommends dietary fluoride supplements only for children living in areas with less than optimally fluori- dated water. Additional information on this topic may be found in Questions 4, 12 and 42. QUESTION 26. Why is there a warning label on a tube of fluoride tooth- paste? Answer. The American Dental Association originally required manufacturers to place a label on fluoride toothpaste in 1991 to ensure proper use and therefore reduce the risk of dental fluorosis. Fact. In 1991, the American Dental Association (ADA) began requiring toothpaste manufacturers to include the follow- ing language on all ADA -Accepted toothpastes: "Do not swallow. Use only a pea-sized amount for children under six. To prevent swallowing, children under six years of age should be supervised in the use of toothpaste." "To ensure children's safety, the ADA limits the total amount of fluoride allowed in ADA -Accepted toothpaste." Fluoridation Facts The ADA warning labels were adopted to help reduce the risk of mild dental fluorosis. This type of fluorosis is not readily apparent to the affected individual or ca- sual observer and often requires a trained specialist to detect. Dental fluorosis only occurs when more than the optimal daily amount of fluoride is ingested. Additionally, to ensure children's safety, the ADA lim- its the total amount of fluoride allowed in any one tube of ADA -Accepted toothpaste. Since 1997, the U.S. Food and Drug Administration (FDA) has required the label language, "If you acci- dentally swallow more than used for brushing, seek professional help or contact a poison control center im- mediately" on all fluoride toothpastes sold in the U.S. The new FDA labels are consistent with the ADA statements, with the exception of the poison control warning. The ADA Council on Scientific Affairs believes that the last sentence on the label could unnecessarily fright- en parents and children and that this portion of the label overstates any demonstrated or potential danger posed by fluoride toothpastes. The ADA notes that a child could not absorb enough fluoride from one tube of toothpaste to cause a seri- ous problem and that the excellent safety record on fluoride toothpaste argues against any unnecessary regulation."' QUESTION 27. Is fluoride, as provided by community water fluorida- tion, a toxic substance? Answer. No. Fluoride, at the concentrations found in optimally fluoridated water, is not toxic according to generally ac- cepted scientific knowledge. Fact. Like many common substances essential to life and good health — salt, iron, vitamins A and D, chlorine, oxygen and even water itself — fluoride can be toxic in excessive quantities. Fluoride in the much lower con- centrations (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.1B2 The amount of fluoride necessary to cause death for a hu- man adult (155 pound man) has been estimated to be 5-10 grams of sodium fluoride, ingested at one time .222 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 optimal fluoride intake in drinking water. The primary functional adverse effect associated with long term excess fluoride intake is Packet Page -131- 31 28. 29 skeletal fluorosis. The development of skeletal fluoro- sis and its severity is directly related to the level and duration of fluoride exposure. For example, the inges- tion 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 that can be seen as a change in bone density on x-rays) in the general population. In areas naturally fluoridat- ed at 5 ppm, daily fluoride intake of 10 mg/day would not be uncommon.12' 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 crippling skeletal fluorosis.223 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 fluoride)."723.198 In these communities, daily fluoride intake of 20mg/day would not be uncommon .121 Crip- pling 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. 123 (Additional information on this topic may be found in Question 20. The Agency for Toxic Substances and Disease Regis- try (ATSDR) prepares toxicological profiles for various hazardous substances most commonly found at facili- ties on the CERCLA National Priorities List (Superfund Sites). The Toxicological Profile for Fluorides, Hydrogen Fluoride and Fluorine was revised in 2003. The ATSDR states that existing data indicates that subsets of the population may be unusually susceptible to the toxic ef- fects of fluoride and its compounds at high doses. How- ever, there are no data to suggest that exposure to the low levels associated with community water fluorida- tion would result in adverse effects in these potentially susceptible population S.214 "The possibility of adverse health effects from continuous low level consumption of fluoride over long periods has been studied extensively. As with other nutrients, fluoride is safe and effective when used and consumed properly." The possibility of adverse health effects from con- tinuous low level consumption of fluoride over long periods has been studied extensively. 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 60 years of research and practical experience, the preponder- ance of scientific evidence indicates that fluoridation of community water supplies is both safe and effective. 32 At one time, high concentrations of fluoride additives were used in insecticides and rodenticides.36 Today fluo- ride additives are rarely used in pesticides because more effective additives have been developed .183 While large doses of fluoride may be toxic, it is im- portant 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 sub- stances 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 28. Does drinking optimally fluoridated water cause or ac- celerate the growth of cancer? Answer. According to generally accepted scientific knowledge, there is no association between cancer rates in humans and optimal levels of fluoride in drinking water .225 Fact. Since community water fluoridation was introduced in 1945, more than 50 epidemiologic studies in different populations and at different times have failed to dem- onstrate an association between fluoridation and the risk of cancer."' Studies have been conducted in the United States '216-231 Japan '212 the United Kingdom?33-235 Canada 216 and Australia .231 In addition, several indepen- dent bodies have conducted extensive reviews of the scientific literature and concluded that there is no rela- tionship between fluoridation and cance r.84,163,165,175,205,238 The U.S. Environmental Protection Agency (EPA) fur- ther commented on the safety of appropriate fluoride exposure in the December 5, 1997, Federal Register .231 In a notice of a final rule relating to fluoride additives; the EPA stated, "...the weight of evidence from more than 50 epidemiological studies does not support the hypothesis of an association between fluoride expo- sure and increased cancer risk in humans. The EPA is in agreement with the conclusions reached by the Na- tional Academy of Sciences (NAS)." Despite the abundance of scientific evidence to the contrary, claims of a link between fluoridation and in- creased cancer rates continue. This assertion is largely 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 research- ers.240 Scientists at 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 Packet Page -132- American Dental Association 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 fur- ther 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 fluoridation84 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.20' The second study was sponsored by the Proctor and Gamble Company.206 In both studies, higher than optimal concentrations of sodium fluoride (25, 100 and 175 ppm) were consumed by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual sex/species groups became available for anal- ysis. Seven of these groups showed no significant evidence of malignant tumor formation. One group, male rats from the NTP study, showed "equivocal" evi- dence of carcinogenicity, which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas (malignant tumors of the bone) — that may be chemi- cally 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."64,210 Since that time, a number of studies have examined the hypothesis that fluoride is a risk factor for bone can- cer. None of these studies reported an association be- tween optimal levels of fluoride in drinking water and cancer of the bone 241-244 (+ Additional information on this topic may be found in Question 23. In a 1990 study, scientists at the National Cancer In- stitute 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 re- cords 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.84 In 2001, researchers from Japan analyzed data on cancers taken from the International Agency for Re- search on Cancer World Health Organization in 1987, 1992 and 1997 and concluded that fluoridation may increase the risk for numerous types of cancers.246 However, the methodology used in this analysis was inherently flawed as there are major and obvious dif- ferences in a number of factors relevant to the risk Fluoridation Facts for cancer in the fluoridated and nonfluoridated com- munities. For example, this analysis did not control for differences in urbanization, socioeconomic status, geographic region, occupations, industries, diet, medi- cal practices or tobacco use between the fluoridated and nonfluoridated communities. Thus any attempt to interpret cancer risk between these communities with this number of uncontrolled variables is scientifically inappropriate. "The American Cancer Society states, 'Scientific studies show no connection between cancer rates in humans and adding fluoride to drinking water. In a document entitled "Fluoride and Drinking Water Fluoridation," the American Cancer Society states, "Sci- entific studies show no connection between cancer rates in humans and adding fluoride to drinking water.""' QUESTION 29. Does fluoride, as provided by community water fluori- dation, inhibit the activity of enzymes in humans? Answer. Fluoride, in the amount provided through optimally flu- oridated water, has no effect on human enzyme activity according to generally accepted scientific knowledge. Fact. Enzymes are organic compounds that promote chem- ical change in the body. Generally accepted scientific knowledge has not indicated that optimally fluoridat- ed water has any influence on human enzyme activity. There are no available data to indicate that, in humans drinking optimally fluoridated water, the fluoride af- fects enzyme activities with toxic consequence S.146 The World Health Organization report, Fluorides and Human Health states, "No evidence has yet been pro- vided that fluoride ingested at 1 ppm in the drinking water affects intermediary metabolism of food stuffs, vitamin utilization or either hormonal or enzymatic activity."247 The concentrations of fluoride used in laboratory studies to produce significant inhibition of enzymes are hundreds of times greater than the concentration pres- ent in body fluids or tissues .112 While fluoride may af- fect enzymes in an artificial environment outside of a living organism in the laboratory, it is unlikely that ad- equate cellular levels of fluoride to alter enzyme activi- ties would be attainable in a living organism251 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. Packet Page -133- 33 QUESTION 30. Does the ingestion of optimally fluoridated water ad- versely affect the thyroid gland or its function? Answer. There is no scientific basis that shows fluoridated wa- ter has an adverse effect on the thyroid gland or its function. Fact. In an effort to determine if fluoride in drinking water af- fects the function, shape and size of the thyroid gland, researchers conducted a study comparing one group of people who consumed water that contained natural fluoride levels of 3.48 ppm and one group who con- sumed water with extremely low fluoride levels of 0.09 ppm. The researchers noted that all study participants had been residents of their respective communities for more than 10 years. The researchers concluded that prolonged ingestion of fluoride at levels above optimal to prevent dental decay had no effect on thyroid gland size or function. This conclusion was consistent with earlier animal studies.248 In addition, two studies have explored the associa- tion between fluoridated water and cancer of the thy - 30. roid gland. Both studies found no association between — optimal levels of fluoride in drinking water and thyroid 31, cancer. 226,249 — In an effort to link fluoride and decreased thyroid func- 32, tion, those opposed to fluoridation cite one small study — from the 1950's in which 15 patients who had hyperthy- 33. roidism (an overactive thyroid) were given relative large — amounts of sodium fluoride orally or by injection in an ef- 34. fort to inhibit the thyroid's function. The researchers con - 35. eluded that efforts to treat hyperthyroidism with fluoride was successful only occasionally among persons sub- jected to massive doses of fluoride. This study does not support claims that low fluoride levels in drinking water would cause hypothyroidism (an underactive thyroid ).210 QUESTION 31. Does water fluoridation affect the pineal gland causing the early onset of puberty? Answer. Generally accepted science does not suggest that wa- ter fluoridation causes the early onset of puberty. Fact. The pineal gland is an endocrine gland located in the brain which produces melatonin .21' Endocrine glands secrete their products into the bloodstream and body tissues and help regulate many kinds of body functions. The hormone, melatonin, plays a role in sleep, aging and reproduction. A single researcher has published one study in a peer- reviewed scientific journal regarding fluoride accumula- 34 tion in the pineal gland. The purpose of the study was to discover whether fluoride accumulates in the pineal gland of older adults. This limited study, conducted on only 11 cadavers whose average age at death was 82 years, indicated that fluoride deposited in the pineal gland was significantly linked to the amount of calcium in the pineal gland. It would not be unexpected to see higher levels of calcium in the pineal gland of older indi- viduals as this would be considered part of a normal ag- ing process. As discussed in Question 22, approximately 99% of the fluoride present in the body is associated with hard or calcified tissues. 112 The study concluded fluoride levels in the pineal gland were not indicators of long- term fluoride exposure .252 The same researcher has theorized in unpublished reports posted on the Internet that the accumulation of fluoride in children's pineal gland leads to an earlier on- set of puberty. However, the researcher notes that there is no verification that fluoride accumulates in children's pineal glands. Moreover, a study conducted in New- burgh (fluoridated) and Kingston (non -fluoridated), New York found no statistical significance between the onset of menstruation for girls living in a fluoridated verses non -fluoridated area 253 QUESTION 3'i2. Can fluoride, at the levels found in optimally fluoridated drinking water, alter immune function or produce aller- gic reaction (hypersensitivity)? Answer. There is no scientific evidence of any adverse effect on specific immunity from fluoridation, nor have there been any confirmed reports of allergic reaction .214 Fact. There is no scientific evidence linking problems with immune function such as HIV or AIDS (acquired im- mune deficiency syndrome) with community water fluoridation .211 There are no confirmed cases of allergy to fluoride, or of any positive skin testing in human or animal mod- e1s.254 A committee of the National Academy of Sciences evaluated clinical reports of possible allergic responses to fluoride 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."39 The World Health Organization also judged these cases to repre- sent "a variety of unrelated conditions" and found no evidence of allergic reactions to fluoride .256,257 A 1996 review of the literature on fluoride and white cell function examined numerous studies and conclud- ed that there is no evidence of any harmful effect on specific immunity following fluoridation nor any con- firmed reports of allergic reaction 6.254 Packet Page -134- American Dental Association QUESTION 33. Is fluoride, as provided by community water fluorida- tion, a genetic hazard? Answer. Following a review of generally accepted scientific knowledge, the National Research Council of the Na- tional Academy of Sciences supports the conclusion that drinking optimally fluoridated water is not a ge- netic hazard.167 Fact. Chromosomes are the DNA -containing bodies of cells that are responsible for the determination and transmis- sion of hereditary characteristics. Genes are the func- tional hereditary unit that occupies a fixed location on a chromosome. Many studies have examined the pos- sible effects of fluoride on chromosome damage. While there are no published studies on the genotoxic (dam- age to DNA) effect of fluoride in humans, numerous studies have been done on mice .161 These studies have shown no evidence that fluoride damages chromo- somes in bone marrow or sperm cells even at fluoride levels 100 times higher than that in fluoridated water.216- 264 Another independent group of researchers reported a similar lack of fluoride -induced chromosomal damage to human white blood cells, which are especially sensi- tive 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).261,266 The genotoxic effects of fluoride were also studied in hamster bone marrow cells and cultured hamster ovarian cells. Again, the re- sults supported the conclusion that fluoride does not cause chromosomal damage, and therefore, was not a genetic hazard 267 In further tests, fluoride has not caused genetic mutations in the most widely used bac- terial mutagenesis assay (the Ames test) over a wide range of fluoride levels.267-270 The National Research Council (NRC) of the Nation- al Academy of Sciences 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 al- ways 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."167 The lowest dose of fluoride reported to cause chro- mosomal changes in mammalian cells was approxi- mately 170 times that found normally found in human cells in areas where drinking water is fluoridated, which indicates a large margin of safety.167 Fluoridation Facts QUESTION 34. Does fluoride at the levels found in water fluoridation affect human reproduction, fertility or birth rates? Answer. There is no credible, scientific evidence that fluorida- tion has an adverse effect on human reproduction, fer- tility or birth rates. Fact. 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 repro- ductive 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 .161 One human study compared county birth data with county fluoride levels greater than 3 ppm and attempt- ed to show an association between high fluoride lev- els in drinking water and lower birth rate s.271 However, because of serious limitations in design and analysis, the investigation failed to demonstrate a positive cor- relation.272 A study examining the relative risk of stillbirths and congenital abnormalities (facial clefts and neural tube defects) found no evidence that fluoridation had any ef- fect of these outcomes. 273 The National Research Council (NRC) of the National Academy of Sciences (NAS) supports the conclusion that drinking optimally fluoridated water is not a genetic hazard.t67 (+ Additional information on this topic may be found in Question 33. QUESTION 35. Does drinking optimally fluoridated water cause an increase in the rate of children born with Down Syndrome? Answer. There is no known association between the consump- tion of optimally fluoridated drinking water and Down Syndrome. Fact. This question originally arose because of two studies published in 1956 and 1963 by a psychiatrist. Data col- lected in several Midwest states in 1956 formed the basis for his two articles published in French journals, purporting to prove a relationship between fluoride in the water and Down Syndrome.27aa76 Experienced epidemiologists and dental research- ers from the National Institute of Dental Research and Packet Page -135- 35 36. 37 38. staff members of the National Institute of Mental Health have found serious shortcomings in the statistical pro- cedures and designs of these two studies. Among the most serious inadequacies is the fact that conclusions were based on the fluoridation status of the commu- nities where the mothers gave birth, rather than the status of the rural areas where many of the women lived during their pregnancies."' In addition, the num- ber of Down Syndrome cases found in both fluoridat- ed and nonfluoridated communities were much lower than the rates found in many other parts of the United States and the world, that casting doubt on the validity of findings. The following paragraphs provide a summary of nu- merous studies that have been conducted which refute the conclusions of the 1956 studies. 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?'s These findings were confirmed by a detailed study of approximately 2,500 Down Syndrome births in Massa- chusetts. 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 in- crease the risk of Down Syndrome .211 Another large population -based study with data re- lating to nearly 1.4 million births showed no association between water fluoridation and the incidence of con- genital malformations including Down Syndrome .211 In 1980, a 25 -year review of the prevalence of con- genital 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 .211 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 flu- oridated and nonfluoridated cities .280 QUESTION 36. Does ingestion of optimally fluoridated water have any neurological impact? Answer. There is no generally accepted scientific evidence es- tablishing a causal relationship between consumption of optimally fluoridated water and central nervous sys- tem disorders, attention deficit disorders or effects on intelligence. Fact. There have been claims that exposure to fluoride pres- ents a neurotoxic (harmful or damaging to nerve tis- sue) risk or lowered intelligence. Such claims are based 36 partly on one 1995 study in which rats were fed fluoride at levels up to 125 times greater than that found in opti- mally fluoridated water.28' The study attempted to dem- onstrate that rats fed extremely high levels of fluoride (75 ppm to 125 ppm in drinking water) showed behav- ior -specific changes related to cognitive deficits. In addition, the experiment also studied the off- spring 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 hyperactiv- ity in male offspring. However, two scientists who reviewed the 1995 study282 have suggested that the observations made can be readily explained by mechanisms that do not involve neurotoxicity. The scientists found inadequa- cies in experimental design that may have led to in- valid conclusions. For example, the results of the experiment were not confirmed by the use of control groups which are an essential feature of test valida- tion and experimental design. In summary the scien- tists 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 neurotoxi- cant." Another reviewer 112 noted, "...it seems more likely that the unusually high brain fluoride concen- trations reported in Mullenix et al. were the result of some analytical error." i "A seven-year study compared the health and behavior of children from birth through six years of age in communities with optimally fluoridated water .'.The results suggested that there was no evidence to indicate that exposure to optimally fluoridated water had any detectable effect on children's health or behavior." A seven-year study compared the health and be- havior 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 re- viewed 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 opti- mally fluoridated water had any detectable effect on children's health or behavior. These results did not differ even when data was controlled for family social background .112 The research conducted by Mullenix et al discussed in this question has not been replicated by other researchers. (Additional information on how to critically review re- search can be found in the Introduction and Figure 1. Packet Page -136- American Dental Association QUESTION 37. Does drinking fluoridated water increase the level of lead in the blood or cause lead poisoning in children? Answer. Generally accepted scientific evidence has not shown any association between water fluoridation and blood lead levels. Fact. One set of researchers has claimed that the silicofluo- ride additives used in community water fluoridation may be responsible for acidic drinking water which leaches lead from plumbing systems thereby increas- ing lead uptake by children. They go on to theorize that communities that use the silicofluorides have greater numbers of children with high levels of lead in their blood than nonfluoridated communities and that the results of the use of silicofluorides are reflected in these communities' residents exhibiting higher rates of learning disabilities, attention deficit disorders, vio- lent crimes and criminals who were using cocaine at the time of arrest .284 From his research, Masters has claimed to be able to predict the estimated cost of increased prison popula- tions due to water fluoridation. For example, in a 2003 appearance before the Palm Beach County (Florida) Commission, Masters stated that if the county fluoridat- ed with silicofluorides, they could expect an additional 819 violent crimes per year directly related to water fluoridation with a minimum additional annual cost of imprisonment of $14,391,255.2114 Scientists from the Environmental Protection Agency (EPA) have reviewed the basic science that was the foundation for the claim that silicofluorides leach lead from plumbing systems and found that many of the chemical assumptions made and statisti- cal methods utilized in the original ecological study were scientifically unjustified. They went on to state that the research was inconsistent with accepted scientific knowledge and the authors of the original studies (Masters et all failed to identify or account for these inconsistencies. Overall, the EPA scientists concluded that "no credible evidence exists to show that water fluoridation has any quantitatable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead (0) or lead (II) compounds."' According to the Centers for Disease Control and Prevention, the average blood lead levels of young children in the U.S. have continued to decline since the 1970s primarily due to the phase-out of leaded gaso- line and the resulting decrease in lead emissions. The primary remaining sources of childhood lead exposure are deteriorated leaded paint, house dust contaminated by leaded paint and soil contaminated by both leaded paint and decades of industrial and motor vehicle emis- sions.286 Approximately 95% of the primary sources of Fluoridation Facts adult lead exposure are occupational. Adult blood lead levels have continued to decline over the last ten years due largely to improved prevention measures in the workplace and changes in employment patters 2B1 It should be noted that since the 1970s, while blood lead levels have continued to decline, the percentage of the population receiving optimally fluoridated water has continued to increase.34 The research conducted by Masters et al discussed in this question has not been replicated by other researchers. 3+ Additional information on how to critically review re- search can be found in the Introduction and Figure 1. QUESTION 33. Does drinking optimally fluoridated water cause Alzheim- er's disease? Answer. Generally accepted science has not demonstrated an association between drinking optimally fluoridated wa- ter and Alzheimer's disease. Fact. The exact cause of Alzheimer's disease has yet to be identified. Scientists have identified the major risk fac- tors for Alzheimer's as age and family history. Sci- entists believe that genetics may play a role in many Alzheimer's cases. Other possible risk factors that are being studied are level of education, diet, environment and viruses to learn what role they might play in the development of this disease."' A study published in 1998289 raised concerns about the potential relationship between fluoride and Al- zheimer's disease. However, several flaws in the experi- mental design preclude any definitive conclusions from being drawn."' Interestingly, there is evidence that aluminum and fluoride are mutually antagonistic in competing for absorption in the human body.42,211 While a conclusion cannot be made that consumption of fluoridated wa- ter has a preventive effect on Alzheimer's, there is no generally accepted scientific knowledge to show con- sumption of optimally fluoridated water is a risk factor for Alzheimer's disease. Packet Page -137- 37 39. 40, 41 QUESTION 39. Does drinking optimally fluoridated water cause or con- tribute to heart disease? Answer. Drinking optimally fluoridated water is not a risk factor for heart disease. Fact. This conclusion is supported by results of a study conducted by the National Heart and Lung and Blood Institute of the National Institutes of Health. Research- ers 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 nonfluoridating cities, from medical and pathological examination of persons exposed to a lifetime of naturally occurring fluo- rides or persons with high industrial exposures, and from broad national experience with fluorida- tion all consistently indicate no adverse effect on cardiovascular health.""' "The American Heart Association states: 'No evidence exists that adjusting the fluoride content of public water supplies to a level of about one part per million has any harmful effect on the cardiovascular system."' The American Heart Association states: "No evidence exists that adjusting the fluoride content of public water supplies to a level of about one part per million has any harmful effect on the cardiovascular system .11113 The American Heart Association identifies aging, male sex, heredity, cigarette and tobacco smoke, high blood cho- lesterol levels, high blood pressure, physical inactivity, obesity and diabetes mellitus as major risk factors for cardiovascular disease."' A number of studies have considered trends in ur- ban 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 be- tween fluoridation and heart disease death rates over the 20 -year period .228 In another study, the mortality rates for approximately 30 million people in 24 fluori- dated cities were compared with those of 22 nonfluo- ridated cities for two years. No evidence was found of any harmful health effects, including heart disease, at- tributable to fluoridation. As in other studies, crude dif- ferences in the mortality experience of the cities with fluoridated and nonfluoridated water supplies were explainable by differences in age, gender and race composition.227 38 QUESTION 40. Is the consumption of optimally fluoridated water harm- ful to kidneys? Answer. The consumption of optimally fluoridated water has not been shown to cause or worsen human kidney disease. Fact. Approximately 50% of the fluoride ingested daily is re- moved from the body by the kidneys .111,112,"1 Because the kidneys are constantly exposed to various fluoride concentrations, any health effects caused by fluoride would likely manifest themselves in kidney cells. How- ever, 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 in- crease in kidney disease .166,253,295 In a report issued in 1993 by the National Research Council, the Subcommittee on Health Effects of Ingest- ed 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 max- imum level allowed in drinking water by the Environ- mental Protection Agency. Therefore, they concluded that "ingestion of fluoride at currently recommended concentrations is not likely to produce kidney toxicity in humans."167 Many people with kidney failure depend on hemo- dialysis (treatment with an artificial kidney machine) for their survival. 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.296 Since the composition of water var- ies in different geographic locations in the United States, the U.S. Public Health Service recommends dialysis units use techniques such as reverse osmosis and de -ionization to remove excess iron, magnesium, aluminum, calcium, and other minerals, as well as fluoride, from tap water before the water is used for dialysis.296,291 (+ Additional information on this topic is available in Ques- tion 22. Packet Page -138- American Dental Association QUESTION 41. What are some of the erroneous health claims made against water fluoridation? Answer: From sources such as the Internet, newsletters, and personal anecdotes in e-mails, community water fluo- ridation is frequently charged with causing all of the following adverse health effects: • AIDS • Allergic Reactions (loss of hair, skin that burns and peels after contact with fluoridated water) • Alzheimer's disease • Arthritis • Asthma • Behavior Problems (attention deficit disorders) • Bone Disease (osteoporosis —increased bone/hip fractures) • Cancer (all types including osteosarcoma or bone cancer) • Chronic Bronchitis • Colic (acute abdominal pain) • Down Syndrome • Emphysema • Enzyme Effects (gene -alterations) • Flatulence (gas) • Gastrointestinal Problems (irritable bowel syndrome) • Harmful Interactions with Medications • Heart Disease • Increased Infant Mortality • Kidney Disease • Lead Poisonings • Lethargy (lack of energy) • Lower 10 (mental retardation) • Malpositioned Teeth • Pineal Gland (early puberty) (chronic insomnia) • Reproductive Organs (damaged sperm) (reduced fertility) • Skin Conditions (redness, rash/welts, itching) • Sudden Infant Death Syndrome (SIDS) • Thyroid Problems (goiter and obesity due to hy- pothroidism) AND • Tooth Decay Fact. As discussed throughout this booklet, the overwhelming weight of credible scientific evidence has consistently in- dicated that fluoridation of community water supplies is safe and effective. The possibility of any adverse health effects from continuous low-level consumption of fluo- ride has been and continues to be extensively studied. It has been determined that approximately 10% of dental fluorosis is attributable to water fluoridation. This type of very mild to mild fluorosis has been determined to be a cosmetic effect rather than an adverse health effect. Of the thousands of credible scientific studies on fluorida- tion, none has shown health problems associated with the consumption of optimally fluoridated water. Fluoridation Facts Packet Page-139- 39 42 43. FLUORIDATION PRACTICE Q42. Water quality? p. 40 Q45. Source of additives? p. 43 Q 43. Regulation? p. 41 Q 46. System safety concerns? p. 43 Q 44. Standards? p. 42 Q 47. Engineering? QUESTION 42. Will the addition of fluoride affect the quality of drink- ing water? Answer. Optimal levels of fluoride do not affect the quality of water. All ground and surface water in the United States contain some naturally occurring fluoride. Fact. Nearly all water supplies must undergo various water treatment processes to be safe and suitable for hu- man consumption. During this process, more than 40 chemicals/additives are typically used including alumi- num sulfate, ferric chloride, ferric sulfate, activated car- bon, lime, soda ash and, of course, chlorine. Fluoride is added only to water that has naturally occurring levels lower than optimal.-" Fluoridation is the adjustment of the fluoride concen- tration of fluoride -deficient water supplies to the recom- mended range of 0.7 to 1.2 parts per million of fluoride for optimal dental health. The U.S. Environmental Protec- tion Agency (EPA) recognizes that fluoride in children's drinking water at levels of approximately 1.0 ppm reduc- es the number of dental cavities 298 The optimal level is dependent on the annual average of the maximum daily air temperature in a given geographic area."," (Additional information on this topic may be found in Questions 3 and 6. Under the Safe Drinking Water Act, the EPA has es- tablished drinking water standards for a number of sub- stances, 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 regula- tions were established to require that naturally occurring fluoride levels in a community water supply not exceed a concentration of 4.0 mg/L.298 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 sup- ply 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 Con- taminant Level (SMCL) of 2.0 mg/L, and requires con- sumer notification by the water supplier if the fluoride 40 p. 44 Q 48. Corrosion? p. 44 Q 49. Environment? p. 45 level exceeds 2.0 mg/L. The SMCL, while not federally enforceable, 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 moderate to severe dental fluorosis in the developing permanent teeth, a cosmetic condition with no known adverse health effect .211 The notice to be used by water systems that exceed the SMCL must contain the follow- ing points: 1. The notice is intended to alert families that children under nine years of age who are exposed to levels of fluoride greater than 2.0 mg/liter may develop dental fluorosis. 2. Adults are not affected because dental fluorosis oc- curs only when developing teeth are exposed to el- evated fluoride levels. 3. The water supplier can be contacted for information on alternative sources or treatments that will insure the drinking water would meet all standards (includ- ing 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 EPA's judgment, the combined weight of hu- man and animal data supportthe current fluoride drinking water standard. 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 ad- equate margin of safety and published a notice of intent not to revise the fluoride drinking water standards."e The EPA further commented on the safety of fluo- ride in the December 5, 1997, Federal Register .239 In a notice of a final rule relating to fluoride additives the EPA stated, "There exists no directly applicable scien- tific 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 (0.114 mg/kg/day) is one half that amount, providing an ade- quate margin of safety. Under the Safe Drinking Water Act (SDWA), the EPA must periodically review the existing National Primary Drinking Water Regulations (NPDWRs) "not less often than every 6 years." This review is a routine part of the EPA's operations as dictated by the SDWA. NPDWRs, or primary standards, are legally enforceable standards that Packet Page -140- American Dental Association apply to public water systems. Primary standards protect public health by limiting the levels of contaminants in drinking water. In April 2002, the EPA announced the results of its preliminary revise/not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re- viewed. The EPA determined that it fell under the "Not Appropriate for Revision at this Time" category, but not- ed that it planned to ask the National Academy of Sci- ence (NAS) to update the risk assessment for fluoride. The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the Sub- committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data published since 1993 and exposure data on orally ingested fluo- ride from drinking water and other sources (e.g., food, toothpaste, dental rinses). Based on this review the Subcommittee will evaluate the scientific and technical basis of the EPA's maximum contaminant level (MCL) of 4 milligram per liter (mg/L or ppm) and secondary maxi- mum contaminant level (SMCL) of 2 mg/L for fluoride in drinking water and advise EPA on the adequacy of its fluoride MCL and SMCL to protect children and others from adverse health effects. Additionally, the Subcom- mittee will identify data gaps and make recommenda- tions for future research relevant to setting the MCL and SMCL for fluoride. The Subcommittee began its work in November 2002 and is currently projected to complete the project in early 2006.13 QUESTION 43. Who regulates drinking water additives in United States? Answer. The United States Environmental Protection Agency regulates drinking water additives. Fact In 1974, Congress passed the original Safe Drinking Water Act (SDWA) which protects the public's health by regulating the nation's public drinking water supply.29' The SDWA, as amended in 1986 and 1996,299 requires the U.S. Environmental Protection Agency (EPA) ensure the public is provided with safe drinking water.1' On June 22, 1979, the U.S. Food and Drug Administra- tion (FDA) and the EPA entered into a Memorandum of Understanding (MOU) to clarify their roles and respon- sibilities in water quality assurance. The stated purpose of the MOU is to "avoid the possibility of overlapping jurisdiction between the EPA and FDA with respect to control of drinking water additives. The two agencies agreed that the SDWAs passage in 1974 implicitly re - Fluoridation Facts pealed FDA's jurisdiction over drinking water as a 'food' underthe Federal Food, Drug and Cosmetic Act (FFDCA). Under the agreement, EPA enjoys exclusive regulatory authority over drinking water served by public water supplies, including any additives in such water. FDA re- tains jurisdiction over bottled drinking water under Sec- tion 410 of the FFDCA and over water (and substances in water) used in food or food processing once it enters the food processing establishment."155 "From time to time, states and communities have had to deal with legislation or ballot initiatives aimed at requiring the approval of the FDA before any agent can be added to community, water systems ... On the surface, this may appear to be a 'common sense' approach. However, its only real purpose is to defeat efforts to provide water fluoridation. That is because it would require the FDA —which does NOT regulate water systems — to approve any water additive. By mistakenly (and perhaps craftily) naming the wrong federal agency, the probable outcome is to stop or prevent water fluoridation. " From time to time, states and communities have had to deal with legislation or ballot initiatives aimed at re- quiring the approval of the FDA before any agent can be added to community water systems. Often referred to as the Fluoride Product Quality Control Act, Water Product Quality Ordinance or Pure Water Ordinance, the legislation is specifically used by those opposed to wa- ter fluoridation as a tool to prevent water systems from providing community water fluoridation. Often this leg- islation does not mention fluoride or fluoridation. Those supporting this type of legislation may claim that they are not against water fluoridation but are proponents of pure water and do not want anything added to water that has not been approved by the FDA. On the surface, this may appear to be a "common sense" approach. However, its only real purpose is to defeat efforts to provide water fluoridation. That is be- cause it would require the FDA — which does NOT reg- ulate water systems — to approve any water additive. By mistakenly (and perhaps craftily) naming the wrong federal agency, the probable outcome is to stop or pre- vent water fluoridation. Packet Page -141- 41 121cN 45. 46. QUESTION 44. What standards have been established to ensure the safety of fluoride additives used in community water fluoridation in the United States? Answer. The three fluoride additives used in the U.S. to fluori- date community water systems (sodium fluoride, so- dium fluorosilicate, and fluorosilicic acid) meet safety standards established by the American Water Works Association (AWWA) and NSF International (NSF). Fact. Additives used in water treatment meet safety stan- dards prepared in response to a request by the Environ- mental Protection Agency (EPA) to establish minimum requirements to ensure the safety of products added to water for its treatment, thereby ensuring the public's health. Specifically, fluoride additives used in water fluoridation meet standards established by the Ameri- can Water Works Association (AWWA) and NSF Inter- national (NSF). Additionally, the American National Standards Institute (ANSI) endorses both AWWA and NSF standards for fluoridation additives and includes its name on these standards. The American Water Works Association is an interna- tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply. AWWA is the authoritative resource for knowl- edge, information, and advocacy to improve the quality and supply of drinking water in North America and be- yond. Founded in 1881, AWWA is the largest organiza- tion of water supply professionals in the world300 NSF International, a not-for-profit, non-governmental organization, is the world leader in standards develop- ment, product certification, education, and risk -man- agement for public health and safety. For 60 years, NSF has been committed to public health, safety, and protec- tion of the environment. NSF is widely recognized for its scientific and technical expertise in the health and environmental sciences. Its professional staff includes engineers, chemists, toxicologists, and environmental health professionals with broad experience both in pub- lic and private organizations .311 The American National Standards Institute (ANSI) is a private, non-profit organization that administers and coordinates the U.S. voluntary standardization and con- formity assessment system. The Institute's mission is to enhance both the global competitiveness of U.S. business and the U.S. quality of life by promoting and facilitating voluntary consensus standards and conformity assess- ment systems, and safeguarding their integrity. 101 The purpose of AWWA standards for fluoride ad- ditives is to provide purchasers, manufacturers and suppliers with the minimum requirements for fluoride additives, including physical, chemical, packaging, shipping and testing requirements. In part, the AWWA standards for fluoride additives state, "The [fluoride compound] supplied under this standard shall contain EK no soluble materials or organic substances in quanti- ties capable of producing deleterious or injurious ef- fects on the health of those consuming water that has been properly treated with the [fluoride compound]." Certified analyses of the additives must be furnished by the manufacturer or supplier .61 NSF Standard 60 ensures the purity of drinking wa- ter additives. NSF Standard 61 provides guidance for equipment used in water treatment plants. The NSF/ ANSI Standards were developed by a consortium of associations including NSF, AWWA, the Association of State Drinking Water Administrators and the Con- ference of State Health and Environmental Manag- ers with support from the EPA. In part, they establish minimum requirements for the control of potential adverse human health effects from products added to water for its treatment .303,304 Fluoride additives, like all of the more than 40 addi- tives typically used in water treatment, are "industrial grade" additives. The water supply is an industry and all additives used at the water plant are classified as in- dustrial grade additives. Examples of other "industrial grade" additives which are commonly used in water plant operations are chlorine (gas), ferrous sulfate, hy- drochloric acid, sulfur dioxide and sulfuric acid.36 Sometimes antifluoridationists express the view that they are not really opposed to fluoridation, but are op- posed to the use of "industrial grade" fluoride additives. They may even go so far as to state that they would sup- port fluoridation if the process was implemented with pharmaceutical grade fluoride additives that were ap- proved by the Food and Drug Administration (FDA). On the surface, this may appear to be a "common sense" approach. In fact, this is usually a ploy whose only real purpose is to stop fluoridation. The EPA, not the FDA, regulates additives in drinking water. Additional information on this topic may be found in Question 43. The claim is sometimes made that no studies on safety exist on the additives used in water fluoridation. The scientific community does not study health effects of concentrated additives as put into water; studies are done on the health effects of the treated water. While sodium fluoride was the first additive used in water fluoridation, the use of silicofluoride additives (sodium fluorosilicate and fluorosilicic acid) began in the late 1940s. By 1951, silicofluorides had become the most commonly used fluoride additives in water fluorida- tion 61 Many of the early studies on the health effects of fluoridation were completed in communities that were using the silicofluoride additives, most generally fluo- rosilicic acid 306-310 However, at that time, the additives used to fluoridate were not always identified in research reports. As the body of research on fluoridation grew, it became evident that there was no adverse health ef- fects associated with water fluoridation regardless of which fluoride additive was used. (Additional information on this topic may be found in Question 5. Packet Page -142- American Dental Association Beyond the foundation that has been established through the overwhelming weight of credible, peer- reviewed scientific evidence, there is over 60 years of practical experience that lends additional credence to the science that concludes that fluoridation is safe. QUESTION 45. What is the source of the additives used to fluoridate water supplies in the United States? Answer. Fluoride additives used in the United States are derived from the mineral apatite. Fact. The three fluoride additives used in the United States for water fluoridation (sodium fluoride, sodium fluoro - silicate, and fluorosilicic acid) are derived from apatite which is a type of limestone deposit used in the produc- tion of phosphate fertilizers. Apatite contains 3-7% fluo- ride and is the main source of fluorides used in water fluoridation .31 During processing, apatite is ground up and treated with sulfuric acid, producing phosphoric acid (the main ingredient in the production of phosphate fertilizer) plus a solid and two gases. The solid, calcium sulfate (also known as gypsum) is the material used to form drywall or sheetrock. The two gases, hydrogen fluoride and silicon tetrafluoride, are captured in water to form fluo- rosilicic acid which today is the most commonly used fluoride additive in the United States.60 Thetwo remaining fluoride additives (sodium fluoride and sodium fluorosilicate) are derived from fluorosilicic acid. Sodium fluoride is produced when fluorosilicic acid is neutralized with caustic soda. Fluorosilicic acid is neutralized with sodium chloride or sodium carbonate to produce sodium fluorosilicate 36 From time to time opponents of fluoridation al- lege that fluoridation additives are byproducts of the phosphate fertilizer industry in an effort to infer the additives are not safe. Byproducts are simply materi- als produced as a result of producing something else — they are by no means necessarily bad, harmful or waste products. In the chemical industry, a byproduct is anything otherthan the economically most important product produced. Byproducts may have certain char- acteristics which make them valuable resources. For example, in addition to orange juice, various byprod- ucts are obtained from oranges during juice produc- tion that are used in cleaners, disinfectants, flavorings and fragrance S.114 Fluoridation Facts Fluoride additives are valuable byproducts produced as a result of producing phosphate fertilizer. To ensure the public's safety, additives used in water fluoridation meet standards of the American Water Works Associa- tion (AWWA) and NSF International (NSF). (Additional information on this topic may be found in Question 44. QUESTION 46. Does the process of water fluoridation present unusual safety concerns for water systems and water operators? Answer. No. With proper planning, maintenance and monitor- ing, water fluoridation is a safe process. Fact. Water plant facilities and water plant personnel per- form a valuable public service by carefully adjusting the level of fluoride in water to improve the oral health of the community. Facilities and personnel are subject to a number of regulations designed to ensure safety. The Occupational Safety and Health Administration (OSHA) provides guidelines for the safety of employ- ees in the workplace.61,311 Additionally, the American Water Works Association publishes detailed guidance on safety and safe working conditions for water plant personnel. Furthermore, the Centers for Disease Con- trol and Prevention has established safety procedures designed specifically for water plant operators in charge of implementing fluoridation.31' Adherence to these guidelines helps to ensure continuous levels of optimally fluoridated drinking water while maintain- ing water operator safety. As part of the safety procedures, water plant per- sonnel receive training on the management of the chemicals/additives in water plants. While the optimal fluoride concentration found in drinking water has been proven safe, water plant operators and engi- neers may be exposed to much higher fluoride levels when handling fluoride additives at the water treat- ment facility.36 Fluoride additives present comparable risks as other chemicals/additives in common use at water treatment facilities, such as hypochloride, quick -lime, aluminum sulfate, sodium hydroxide and ferrous sulfate. In fact, the fluoride additives are much less dangerous than chlorine gas commonly used in water plant operations. Today's equipment allows water treatment personnel to easily monitor and maintain the desired fluoride con - Packet Page -143- 43 47 48. 49. centration. Automatic monitoring technology is available that can help to ensure that the fluoride concentration of the water remains within the recommended range. It is important that the water treatment operators re- sponsible for monitoring the addition of fluoride to the water supply be appropriately trained and thatthe equip- ment used for this process is adequately maintained."' As with any mechanical equipment, water fluoridation equipment should be tested, maintained and replaced as needed. With over 60 years of experience and thou- sands of water systems in operation, there have been remarkably few untoward incidents. QUESTION 47. Does fluoridation present difficult engineering problems? Answer. No. Properly maintained and monitored water fluo- ridation 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 that can help to ensure that the fluoride concentration of the water remains within the recommended range. When added to community water supplies the con- centrated fluoride additives become greatly diluted. For example, fluorosilicic acid is diluted approximately 180,000 times to reach 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 'Because there is more than 60 years of experience with water fluoridation,there is considerable guidance on sound engineering practices to design, construct, operate and maintain water fluoridation systems." Because there is more than 60 years of experience with water fluoridation, there is considerable guidance on sound engineering practices to design, construct, operate and maintain water fluoridation systems. Fluoride addi- tives are introduced to the water supply as liquids, but are measured by two basic types of devices, dry feeders or 44 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 (i.e., the use of a day tank that only holds one day's supply of fluoride) so prolonged over -fluoridation becomes a me- chanical impossibility.36 QUESTION U. Will fluoridation corrode water pipes or add lead, arse- nic and other toxic contaminants to the water supply? Answer. Allegations that fluoridation causes corrosion of water delivery systems are not supported by current scientific evidence.36 Furthermore, the concentrations of con- taminants in water as a result of fluoridation do not ex- ceed, but, in fact, are well below regulatory standards set to ensure the public's safety. Fact. Water fluoridation has no impact on the acidity or pH of drinking water and will not cause lead and copper to be leached from water pipes. Corrosion of pipes by drink- ing water is related primarily to dissolved oxygen con- centration, 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 acidity of drinking water that is already slightly acidic may be observed af- ter treatment with alum, chlorine, fluorosilicic acid or sodium florosilicate. In such cases, further water treat- ment is indicated by water plant personnel to adjust the pH upward to neutralize the acid. This is part of routine water plant operations. Note that the Water Quality Re- port or Consumer Confidence Report that all water sys- tems send to customers on a yearly basis, lists the pH of the system's finished water and compares that level against the standard set at a pH of 7.0 (neutral) or higher indicating that the water leaving the plant is non -acidic. (Additional information on this topic may be found in Question 4. A 1999 study316 charged that fluorosilicic acid and so- dium silicofluoride did not disassociate completely when added to water systems and may be responsible for low- er pH levels of drinking water, leaching lead from plumb- ing systems and increasing lead uptake by children. In response to the study, scientists from the U.S. En- vironmental Protection Agency (EPA) have reviewed the basic science that was the foundation for the claim that silicofluorides leach lead from water pipes and found that many of the chemical assumptions made in the original research were scientifically unjustified. Fluoride additives do disassociate very quickly and completely releasing fluoride ions into the water. The research was inconsistent with accepted scientific knowledge and the authors of the original studies failed to identify or account for these inconsistencies. The EPA scientists discounted Packet Page -144- American Dental Association any link between fluoridation and lead."' Fluorosilicic acid is the additive used to fluoridate the vast majority of community water systems in the U.S. Be- cause it is a natural substance derived from apatite which is mined from the earth, fluorosilicic acid may contain minute amounts of contaminants such as lead and arse- nic. However, existing regulations and standards require that these contaminants, including arsenic and lead, be at levels considered safe by the EPA when the fluorosilicic acid is diluted to produce optimally fluoridated water.117,"' Evidence of testing by the fluoride additive manufacturer documents that the concentrations of these contaminants do not exceed, but, in fact, are well below regulatory stan- dards set to ensure the public's safety. Most batches of the additive do not contain any detectable amount of either lead or arsenic. On average, the concentration of arsenic and lead in optimally fluoridated drinking water created using fluorosilicic acid is less than 0.1 part per billion 319 QUESTION 49. Does fluoridated water harm the environment? Answer. Scientific evidence supports the fluoridation of public _ water supplies as safe for the environment and benefi- cial for people. Fact. The U.S. Environmental Protection Agency (EPA) has set an enforceable Federal drinking water standard for fluoride at 4.0 mg/L. As long as the 4.0 mg/L standard is not exceeded, State and local authorities determine whether or not to fluoridate."' "Under the Washington's State Environmental Protection Act (SEPA), a study concluded that there are 'no probable significant adverse environmental impacts. Under the Washington's State Environmental Protec- tion Act (SEPA), a studywas conducted in Tacoma -Pierce County to investigate the environmental consequences of adding optimal levels of fluoride to drinking water. Noting that the amount of fluoride in the water does not reach levels that are harmful to plants or animals, the SEPA study concluded that there are "no probable significant adverse environmental impacts. 11321 There is no evidence that optimally fluoridated wa- ter has any effect on gardens, lawns or plants."" A comprehensive literature review conducted in 1990 revealed absolutely no negative environmental impacts as a result of water fluoridation. Historically, issues surrounding problems with fluoride and the en- vironment have involved incidents related to industrial pollution or accidents .123 Fluoridation Facts Packet Page -145- 45 50. 51 52. PUBLIC POLICY Q50. Valuable measure? Q 51. Courts of law? Q 52. Opposition? p. 46 Q 53. Internet? p.51 p. 47 Q 54. Public votes? p. 51 p. 47 Q55. International fluoridation? p. 54 QUESTION 50. Is water fluoridation a valuable public health measure? Answer. Yes. Water fluoridation is a public health measure that benefits people of all ages, is safe and is a community public health program that saves money. Fact. Throughout decades of research and more than 60 years of practical experience, fluoridation of public water sup- plies has been responsible for dramatically improving the public's oral health status. Former Surgeon General of the United States, Dr. Luther Terry, called fluoridation as vital a public health measure as immunization again disease, pas- teurization of milk and purification of water.' Another for- mer U.S. Surgeon General Dr. C. Everett Koop stated that fluoridation is the single most important commitment that a community can make to the oral health of its citizens. In 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 re- ductions in childhood blood lead levels, fluoridation was lauded as one of the most economical preventive values in the nation.17 A policy statement on water fluoridation reaf- firmed in 1995 by the U.S. Public Health Service (USPHS) stated that water fluoridation is the most cost-effective, practical and safe means for reducing the occurrence of dental decay in a community.18 In 1998, recognizing the ongoing need to improve health and well being, the USPHS revised national health objectives to be achieved by the year 2010. Included under oral health was an ob- jective to significantly expand the fluoridation of public water supplies. Specifically, Objective 21-9 states that at least 75% of the U.S. population served by community water systems should be receiving the benefits of opti- mally fluoridated water by the year 2010.19 46 Q56. Banned in Europe? p. 54 "Former U.S. Surgeon General David Satcher, noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations." In 1999, the Centers for Disease Control and Preven- tion named fluoridation of drinking water one of ten great public health achievements of the 20th century noting that it is a major factor responsible for the de- cline in dental decay. 1,2 Former U.S. Surgeon General David Satcher, issued the first ever Surgeon General report on oral health in May 2000. In Oral Health in America: A Report of the Surgeon General, Dr. Satcher stated that community water fluoridation continues to be the most cost-effective, practical and safe means for reducing and controlling the occurrence of dental decay in a community. Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations. Studies have shown that fluoridation may be the most significant step we can take toward reducing the dis- parities in dental decay.21-24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called on policymakers, community leaders, private industry, health professionals, the me- dia and the public to affirm that oral health is essential to general health and well being. Additionally, Surgeon General Carmona urged these groups to apply strat- egies to enhance the adoption and maintenance of proven community-based interventions such as com- munity water fluoridation.25 Community water fluoridation is a most valuable public health measure because: • Optimally fluoridated water is accessible to the entire community regardless of socioeconomic status, edu- cational attainment or other social variables;26 • Individuals do not need to change their behavior to obtain the benefits of fluoridation. • Frequent exposure to small amounts of fluoride over time makes fluoridation effective through the life span in helping to prevent dental decay. • Community water fluoridation is more cost ef- fective than other forms of fluoride treatments or applications.21 Packet Page -146- American Dental Association QUESTION 51. 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 free- dom or other individual rights guaranteed by the First, Fifth or Fourteenth Amendments to the U.S. Constitu- tion. And while cases decided primarily on procedural grounds have been won and lost by both pro and anti fluoridation interests, to ADA's knowledge no final rul- ing in any of those cases has found fluoridation to be anything but safe and effective. Fact. During the last sixty years, the legality of fluoridation in the United States has been thoroughly tested in our court systems. Fluoridation is viewed by the courts as a proper means of furthering public health and welfare 324 No court of last resort has ever determined fluoridation to be un- lawful. The highest courts of more than a dozen states have confirmed the constitutionality of fluoridation 325 In 1984, the Illinois Supreme Court upheld the constitution- ality of the state's mandatory fluoridation law, culminat- ing 16 years of court action at a variety of judicial levels 325 Moreover, the U.S. Supreme Court has denied review of fluoridation cases thirteen times, citing that no substantial federal or constitutional questions were involved 325 It has been the position of the American courts that a significant government interest in the health and wel- fare of the public generally overrides individual objec- tions to public health regulation 333 Consequently, the courts have rejected the contention that fluoridation ordinances are a deprivation of religious or individual freedoms guaranteed under the Constitution 325,32' In reviewing the legal aspects of fluoridation, the courts have dealt with this concern by ruling that: (1) fluoride is a nutrient, not a medication, and is present naturally in the environment; (2) no one is forced to drink fluo- ridated water as alternative sources are available; and (3) in cases where a person believes that fluoridation interferes with religious beliefs, there is a difference be- tween the freedom to believe, which is absolute, and the freedom to practice beliefs, which may be restricted in the public's interest328,329 Fluoridation is the adjustment of a naturally occur- ring element found in water in order to prevent dental decay. Courts have consistently ruled that water fluo- ridation is not a form of compulsory mass medication or socialized medicine. 325,328,330 Fluoridation is simply the adjustment of a naturally occurring element found in water in order to prevent dental decay. In fact, water that has been fortified with fluoride is similar to forti- fying salt with iodine, milk with vitamin D and orange juice with vitamin C — none of which are medications. "To ADA's knowledge no final ruling in any of those cases has found fluoridation to be anything but safe and effective. " In recent years, challenges to fluoridation have been dismissed for a variety of reasons, including that plaintiffs admitted they could not establish injury by virtue of fluoridation, and that state law supporting fluoridation prevailed over local attempts to oppose fluoridation. Interestingly, pro and anti fluoridation interests have each won and lost legal challenges re- garding which state or local agency has regulatory authority over fluoridation, which of course varies by state and locality. State law variances have also led to different rulings on other issues, such as whether downstream end users of fluoridation must be given an opportunity to vote on whether to fluoridate. While cases decided primarily on procedural grounds have been won and lost by both pro and anti fluoridation interests, to ADA's knowledge no final ruling in any of those cases has found fluoridation to be anything but safe and effective. QUESTION 52. Why does opposition to community water fluoridation continue? Answer. Fluoridation is considered beneficial by the overwhelm- ing majority of the health and scientific communities as well as the general public. However, a small faction continues to speak out against fluoridation of municipal water supplies. Some individuals may view fluorida- tion of public water as limiting their freedom of choice; other opposition can stem from misinterpretations or inappropriate extrapolations of the science behind the fluoridation issue. Fact. A vast body of scientific literature endorses water fluo- ridation as a safe means of reducing the incidence of dental decay. Support for fluoridation among scientists and health professionals, including physicians and den- tists, is nearly universal. Recognition of the benefits of Fluoridation Facts 47 Packet Page -147- 52 fluoridation by the American Dental Association, the American Medical Association, governmental agencies and other national health and civic organizations con- tinues as a result of published, peer-reviewed research. (See Compendium at back of booklet.) The majority of Americans also approves of water fluoridation. In June 1998, the Gallup Organization con- ducted 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 fluo- ridated?", 70% answered yes, 18% answered no and 12% responded don't know (Figure 5). 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 Westfavoring community water fluoridation.331 These re- sults 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% disap- proved and 12% answered don't know or refused to an- swer the question (Figure 6). Disapproval ranged from 4% in communities where water was fluoridated to 16% in communities where it was not.332 Of the small faction that opposes water fluoridation for philosophical reasons, freedom of choice probably stands out as the most important single complaint .113 Some individuals are opposed to community action on any health issue, others because of environmental or economic arguments and some because they are mis- informed. Opposition to fluoridation has existed since the initi- ation of the first community programs in 1945 and con - 48 Figure"' • Opinions Regarding Community Water Fluoridation"' Do You Believe Community MterBe Fluoridated Yes A 70% No 18% Don't Know 12% 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Adults tinues today with over 60 years of practical experience showing fluoridation to be safe and effective. 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 25. 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. 312 Since that time, antifluoridation leaders and orga- nizations have come and gone, but their basic beliefs have remained the same. These include: fluoride is tox- ic and causes numerous harmful health effects; fluoride does not prevent dental decay; fluoridation is costly; and fluoridation interferes with freedom of choice and infringes on individual rights. While the arguments against fluoridation have re- mained relatively constant over the years, the antifluo- ridationists have used different approaches that play upon the popular concerns of the public at the time. For example, in the 1950s fluoridation was a Communist plot. With America's growing concern for environmen- tal issues in the 1960s, fluoridation was pollution. After the Vietnam War in the 1970s, the antifluoridationists capitalized on the popularity of conspiracy theories by portraying fluoridation as a conspiracy between the U.S. government, the dental -medical establishment and industry. As Americans became more concerned about their health in the 1980s, antifluoridationists claimed fluoridation caused AIDS and Alzheimer's disease. In the 1990s, claims of hip fractures and cancer were de- signed to resonate with aging baby boomers. With the new millennium, overexposure and toxicity, in associa- tion with lead and arsenic poisoning, have surfaced as Whether or Not You Presently Have FI Water, Do You Approve Disapr of Fluoridating Drinking Water Approve 78% Disapprove 10% Don't Know/ Refused12% d� 0 10% 20% 30% 40% 50% 60% 70% 60% Percent of Parents Packet Page -148- American Dental Association common themes. None of these approaches has ever really disappeared, but are often recycled as antifluo- ridationists choose which approach will have the most effect on the intended audience .333 Antifluoridationists have eagerly embraced technol- ogy such as videos and the Internet to spread their mes- sage to the public. These two venues have allowed the small faction of antifluoridationists to be linked across the country and around the world and promote their message economically. A number of opposition videos are available from na- tional antifluoridation organizations. These economical- ly -priced videos make it affordable for every campaign to bring an antifluoridationist to the community via local cable access television. However, it has been the Internet that has breathed new life into the antifluoridation effort. The Internet has brought the antifluoridation message into voters' homes. With just a click of the mouse, search engines can locate hundreds of Web sites denouncing fluoridation, which may give the impression that this is a one-sided argument. Individualswho looktothe Internet as a source of reliable information may fail to recognize that these sites often contain personal opinion rather than scientific fact. Newspaper stories, press releases and letters to the editor are often posted as documenta- tion of the "science" behind antifluoridationists' claims. All too often, the public accepts this type of information as true simply because it is in print. The techniques used by antifluoridationists are well known and have been discussed at length in a number of published articles that review the tactics used by an- tifluoridationlStS.325,333,335-339 Examples of a few of the techniques can be viewed in Figure 7 on the next page. "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." "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 play a role in provoking opposition to water fluorida- tion. 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 .141 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 legiti- mate 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. Fluoridation Facts In 1993 the U.S. Supreme Court issued a landmark de- cision that many view as likely to restrict the use of junk science in the federal courts and in those state courts which adopt this reasoning. 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 con- siderations will bear on whether the expert's underlying reasoning or methodology is scientifically valid and ap- plicable 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 pub- lication (although failing this criteria alone is not nec- essarily 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 tech- nique that has been able to attract only minimal sup- port 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 34' "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 accountability where decisions are based on proven benefits measured against verified risks.'f Opinions are seldom unanimous on any scientific sub- ject. In fact, there may be no such thing as "final knowl- edge," 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 accountability where decisions are based on proven benefits measured against verified risks 335 Additional information on this topic may be found in the Introduction and Figure 1. Packet Page -149- 49 53. 54, Targeting Politicians and Community Leaders Antifluoridation Web sites contain draft letters to be sent to newspaper publishers, water departments, and community public officials warning them of their "liability" should they support or endorse water fluo- ridation. Leaders are urged to remain "neutral" and allow fluoridation decisions to be put to a public vote therefore relieving the leaders of any and all respon- sibility in the matter.' Antifluoridationists use the time gained to conduct'a public referendum to bombard the public with misinformation designed to turn pub- lic opinion against fluoridation. Unproven Claims Antifluoridationists have repeatedly claimed fluo- ridation causes an entire laundry list of human ill- nesses including AIDS, Alzheimer's disease, cancer, Down Syndrome, genetic damage, heart disease, lower intelligence, kidney disease and osteoporosis (hip factures). These allegations are often repeated so frequently during campaigns that the public as- sumes they must be true. Their appearance in print, even if only in letters to the editor of the local news- paper, reinforces the allegation's credibility. With just a small amount of doubt established, the op- position slogan, "If in doubt, vote it out," may ring true with voters. Innuendo The statement, "Fifty years ago physicians and den- tists posed for cigarette ads," is an example of innu- endo or, more specifically, guilt by association. Even though fluoridation is not mentioned, individuals are expected to make the connection that the medical community changed its position on smoking so it is possible health professionals are wrong about fluori- dation, too. Outdated Studies and Statements from "Experts" Antifluoridation Web sites often offer a list of "re- spected medical professionals and scientists" who have spoken out against fluoridation. One of those often quoted is Dr. Charles Gordon Heyd who is not- ed to be a Past President of the American Medical Association (AMA). What is not disclosed is the source of the quote or that Dr. Heyd was President of the AMA in 1936 -almost ten years before wa- ter fluoridation trials began. His decades -old quote certainly does not represent the current AMA posi- tion of support for water fluoridation and is charac- teristic of antifluoridationists' use of items that are out of date. Additionally, antifluoridationists have claimed that fourteen Nobel Prize winners have "opposed or expressed reservations about' fluori- dation." It should be noted that the vast majority of these individuals were awarded their prizes from 1929 through 1958. Statements Out of Context One of the most repeated antifluoridation state- ments is, "Fluoride is a toxic chemical. Don't let them put it in our water. This statement ignores' the scientific principle that toxicity, is related to dosage and not just to exposure to a substance. Examples of other substances that can be harmful in the wrong amounts but beneficial in the correct amounts are salt, vitamins A and D, iron, iodine, as- pirin and even water itself. In another example, a press release from the New York State Coalition Opposed to Fluoridation (NYSCOF) posted on the Internet in August 2001 and again in March 2005, stated, "Fluoridation is based more on unproven theories than scientific evidence, according to a revised dental textbook by leaders in the field. The press release also includes a number of items "quoted" from the textbook. The American Dental Association contacted the textbook authors who immediately wrote a letter responding to the press release. Drs. Brian A. Burt and Dr. Stephen A. Eklund responded, "The NYSCOF article takes a se- ries of disconnected quotes from our textbook (Burt BA, Eklund SE. The Dentist, Dental Practice, and the Community 5th edition. Philadelphia: Saunders, 1999) and puts its own interpretation on them. The result is to portray Drs. Burt and Eklund as being op- posed to fluoridation, which is most definitely not the case." Moving Targets In venues ranging from the media to the courts, opponents have been known to shift their theories of opposition frequently and mid -stream. This of- ten appears to occur when one of their originally advanced points of opposition has been unveiled as being without merit. Some examples: A parent who told the media that he would need to move his family out of town because of past allergies to fluoride had to change his position after it was disclosed that the family had previously lived in a fluoridated community; and 'opponents filing re- peated amendments to their; legal complaints, in one case moving from an all out attack to the posi- tion that that they are not opposed to fluoridation, but just to one particular chemical without telling the court that the chemical has been safely and ex- tensively used for decades. ; 50 American Dental Association Packet Page -150- /0-N, Where can reliable information about water fluorida- tion be found on the Internet and World Wide Web? Answer. The American Dental Association, as well as other rep- utable health and science organizations, and govern- ment agencies have sites on the Internet/Web that pro- vide information on fluorides and fluoridation. These sites provide information that is consistent with gener- ally accepted scientific knowledge. Fact. The Internet and World Wide Web are evolving as ac- cessible sources of information. However, not all "sci- ence" posted on the Internet and World Wide 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 infor- mation regarding fluoridation and fluorides is the Ameri- can Dental Association's (ADA) Fluoride and Fluoridation Web site at http:www.ada.org/goto/fluoride (Figure 8). From the ADA Web site individuals can link to other Web sites, such as the Centers for Disease Control and Pre- vention, National Institute of Dental and Craniofacial Re- search, Institute of Medicine, National Cancer Institute, and state/local health departments for more information about fluoride and water fluoridation. • ADA Fluoridation Resources • Fluoridation Facts Online • ADA Fluoridation News Stories • ADA Policy and Statements • Links to Additional Fluoridation Web Sites American Dental Association www.ada.org Many ADA resources are at your fingertips 24/7/365. Order a library book or products online, read JADA articles, discuss important topics with colleagues, find helpful information on professional topics from accredi- tation to X-rays and recommend our dental education animations, stories and games to your patients. Fluoridation Facts ADA.org today! Why does community water fluoridation lose when it is put to a public vote? sometimes Answer. Voter apathy or low voter turnout due the vote being held as a special election or in an "off" year, confusing ballot language (a "no" vote translates to support for fluoridation), blurring of scientific issues, lack of leader- ship by elected officials and a lack of political campaign skills among health professionals are some of the rea- sons fluoridation votes are sometimes unsuccessful. Fact. Despite the continuing growth of fluoridation in this country over the past decades, millions of Americans do not yet receive the protective benefits of fluoride in their drinking water. Centers for Disease Control and Prevention (CDC) data from 2002 indicate, only two- thirds (67.3%) of the population served by public water systems have access to fluoridated water.34 Forty-two of the 50 largest cities are fluoridated by adjustment. Another two have natural optimal levels of fluorida- tion (Figure 9). The remaining six nonfluoridated cities are: Fresno, California; San Jose, California; Colorado Springs, Colorado; Honolulu, Hawaii; Wichita, Kansas and Portland, Oregon. In 1998, recognizing the ongo- ing need to improve health and well being, the U.S. Public Health Service revised national health objec- tives to be achieved by the year 2010. Included under oral health was an objective to significantly expand the fluoridation of public water supplies. Specifically, Ob- jective 21-9 states that at least 75% of the U.S. popu- lation served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2010.19 Although water fluoridation reaches some residents in every state, 2002 data indicates that only 24 states are providing these benefits to 75% or more of their residents.34 (Figure 10). Social scientists have conducted studies to exam- ine why fluoridation fails when put to a public vote. 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 per- ceived controversy, low voter turnout and the difficulty faced by an electorate in evaluating scientific informa- tion 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 fluoridation." Packet Page -151- 51 54. Seattle G SacramentoOakland Chicago F��Toje Columahmbusittsburgh Oa • (010 San Francisco Denver Kansas City Indianapolis Cincinnati \ St. Louis `1 Nashville -Davidson Los Angeles Tu Ise • Charlotte �• • • Memphis Long Beach Albuquerque Oklahoma City • Phoenix Fort Worth Atlanta • • Dallas EI Paso (natural) 00 Q Austin • Clever use of emotionally charged "scare" propa- ganda by fluoride opponents creates fear, confusion and doubt within a community when voters consider the use of fluoridation .111,343 Defeats of referenda or the discontinuance of fluoridation have occurred most of- ten 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 in- fluence voters, opponents have also threatened com- munity leaders with personal litigation .314 While no court of last resort has ever ruled against fluoridation, community leaders may be swayed bythe threat of liti- gation due to the cost and time involved in defending even a groundless suit, not to mention threats of po- litical fallout. The American Dental Association (ADA) 52 16. York Virginia Beach (natural) Miami knows of no cases in which community leaders have been found liable for their pro -fluoridation efforts. In no instance has fluoridation been discontinued be- cause it was proven harmful in anyway. 343-345 Adoption of fluoridation is ultimately a decision of state or local decision makers, whether determined by elected officials, health officers or the voting pub- lic. Fluoridation can be enacted through state legisla- tion, administrative regulation or a public referendum. While fluoridation is not legislated at the federal level, it is legislated at the state and local level. As with any pubic health measure, a community has the right and obligation to protect the health and welfare of its citi- zens, even if it means overriding individual objections to implement fluoridation. Packet Page -152- American Dental Association "In the past five years (2000 through 2004), more than 125 communities in 36 states have decided to provide the benefits of fluoridation for their residents. " Each spring as part of the yearly Community Water Fluoridation Awards program, the ADA, Association of State and Territorial Dental Directors and the CDC Division of Oral Health compile a list of water sys- tems/communities in the United States that have ad- opted community water fluoridation in the past year. This list is posted on the ADA Web site at http://www. ada.org/goto/fluoride. In the past five years (2000 Fluoridation Facts through 2004), more than 125 communities in 36 states have decided to provide the benefits of fluori- dation for their residents. The size of these water sys- tems/communities varies greatly — from those with a few thousand residents to the Metropolitan Water District of Southern California which will provide flu- oridated water to more than 18 million people. Technical assistance with fluoridation efforts is avail- able from the Council on Access, Prevention and Inter- professional Relations at the ADA. Additional support for fluoridation is available from ADAs Division of Legal Affairs, Division of Communications and Department of State Government Affairs. Packet Page-153- 53 55. 56. QUESTION 55. Is community water fluoridation accepted by other countries? Answer. Over 405 million people in more than 60 countries worldwide enjoy the benefits of fluoridated water. 132 Fact. The value of water fluoridation is recognized interna- tionally. Countries and geographic regions with exten- sive water fluoridation include the U.S., Australia, Brazil, Canada, Chile, Columbia, Ireland, Israel, Malaysia, New Zealand, People's Republic of China (Hong Kong only), Singapore and the United Kingdom.132 Thorough inves- tigations of fluoridation have been conducted in Britain and Australia supporting the safety and effectiveness of water fluoridation.163,1e6,s46 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. 84,163-167,210 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 dental 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. "t38 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 exis- tence of more life threatening health needs or the lack of trained technical personnel or sufficient funds for start- up and maintenance costs. QUESTION 56. 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 coun- 54 tries construct their own water quality regulations within the framework of the 1980 European Water Quality Direc- tive. The Directive provides maximum admissible con- centrations for many substances, one of which is fluoride. The Directive does not require or prohibit fluoridation, it merely requires that the fluoride concentration in water does not exceed the maximum permissible con- centration.141 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 .348 Wa- ter fluoridation is not practical in some European coun- tries because of complex water systems with numerous water sources. As an alternative to water fluoridation, many European countries have opted for the use of fluo- ride supplements or salt fluoridation. Basel, Switzerland is one such example. Those op- posed to water fluoridation claimed a large victory when Basel voted to cease water fluoridation in 2003. The facts are that Basel was the Ione city with fluoridated water surrounded by communities that used fluoridated salt. In the mid 90s, trade barriers that had prevented fluoridated salt from being sold to those living in Basel fell and soon it was evident that residents were receiv- ing fluoride from salt as well as through drinking water. The government voted to cease water fluoridation in 2003 in light of availability and use of fluoridated salt in the community. Basel, Switzerland did not stop fluori- dating. Officials simply chose another type of fluorida- tion — salt fluoridation .319 (Additional information on this topic may be found in Question 14. No European country has imposed a 'ban' on water fluoridation." Again, no European country has imposed a "ban" on water fluoridation, it has simply not been imple- mented for a variety of technical, legal, financial or political reasons. 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 World Health Organization's recommendations regarding fluoridation as a preventive health measure, in addition to the use of fluoride toothpastes, mouthrinses and dietary fluoride supplements .111,310 Packet Page -154- American Dental Association ,/� Fluoridation Facts Packet Page -155- 55 57 58, COST EFFECTIVENESS Q 57. Cost effective? p. 56 Q 58. Practical? p. 57 QUESTION 57. Is water fluoridation a cost-effective means of prevent- ing tooth decay? Answer. Yes. Fluoridation has substantial lifelong decay preven- tive effects and is a highly cost-effective means of pre- venting tooth decay in the United States, regardless of Socioeconomic status 97,103,104,351-353 Fact. The cost of community water fluoridation can vary in each community depending on the following factors .154 1. Size of the community (population and water usage); 2. Number of fluoride injection points where fluoride additives will be added to the water system; 3. Amount and type of equipment used to add and monitor fluoride additives; 4. Amount and type of fluoride compound used, its price, and its costs of transportation and storage; and 5. Expertise of personnel at the water plant. The annual cost for a U.S. community to fluoridate its water is estimated to range from approximately $0.50 per person in large communities to approximately $3.00 per person in small communities .355 "For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs. " It can be calculated from these data that the average lifetime cost per person to fluoridate a water system is less than the cost of one dental filling. When it comes to the cost of treating dental disease, everyone pays. Not just those who need treatment, but the entire com- munity -through higher health insurance premiums and higher taxes. For most cities, every $1 invested in wa- ter fluoridation saves $38 in dental treatment costs. 355 Cutting dental care costs by decreasing dental decay is something a community can do to improve oral health and save money for everyone. With the escalating cost of health care, fluoridation remains a preventive mea- sure that benefits members of the community at mini- mal cost.25 Fluoridation is a community public health measures that saves money. 56 School-based dental disease prevention activities (such as fluoride mouthrinse or tablet programs), pro- fessionally applied topical fluorides and dental health education are beneficial but have not been found to be as cost-effective in preventing dental decay as com- munity water fluoridation.35' Fluoridation remains the most cost-effective and practical form of preventing decay in the United States and other countries with es- tablished municipal water systems. 17,97.104.355 Because of 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 typically have fewer restorative dental expenditures during a lifetime. Health economists at a 1989 workshop con- cluded that fluoridation costs approximately $3.35 per tooth surface when decay is prevented, mak- ing fluoridation "one of the very few public health procedures that actually saves more money than it costs.11355 Considering the fact that the national aver- age fee for a two surface amalgam (silver) restoration in a permanent tooth placed by a general dentist is $101.94*, fluoridation clearly demonstrates signifi- cant cost savingS.355 In a study conducted in Louisiana, Medicaid -eligible children (ages 1-5) residing in communities without fluoridated water were three times more likely than Medicaid -eligible children residing in communities with fluoridated water to receive dental treatment in a hospital and the cost of dental treatment per eligible child was approximately twice as high. In addition to community water fluoridation status, the study took into account per capita income, population and num- ber of dentists per county.359 "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, community health clinics, health insurance premiums, the military and other publicly supported medical programs. Packet Page -156- American Dental Association scored by the fact that frequently the cost of treating dental disease is paid not only bythe affected individual, but also by the general public through services pro- vided by health departments, community health clinics, health insurance premiums, the military and other pub- licly supported medical programs.'o3 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, bridges and implants • less time lost from school or work because of dental pain or visits to the dentist These intangible benefits are difficult to measure economically, but are extremely important.97,257 *The survey data should not be interpreted as con- stituting 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. Why fluoridate an entire water system when the vast majority of the water is not used for drinking? 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 cer- tainly 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 additives for fluoridating a community's water supply is inexpensive on a per capita basis; therefore, it is prac- tical to fluoridate the entire water supply. Fluoride is but one of more than 40 different chemi- cals/additives that may be used to treat water in the United States. Most are added for aesthetic or conve- nience purposes such as to improve the odor or taste, prevent natural cloudiness or prevent staining of clothes or porcelain .31 The American Water Works Association, an interna- tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply, supports the practice of fluoridation of public water supplies .311 (Additional information on this topic may be found in Question 44. CALL TO ACTION n April' 2003, 'Surgeon General Richard H. Car- nity water systems should be mona issued a National Call to Action to Promote optimally fluoridated water b) )ral Health. The report was a wake-up call, raising Fluoridation efforts at the.l powerful voice against the silence. It called upon be greatly enhanced and the l olicymakers, community leaders, private industry, Objective reached with the, E ealth professionals, the media, and the public to of agencies and individuals who irm that oral health is essential to general health and to the benefits of community vell-being and to take action. Technical assistance with While the effectiveness of preventive interventions available from the Council on uch as community water fluoridation have been Interprofessional Relations�a ersuasively demonstrated, less than half of the fifty port for fluoridation is availak tates have implemented fluoridation at the level to of Legal Affairs, Division of C neet the national health objectives to be achieved by partment of State Governme he year 2010. Specifically, Objective 21-9 states that i a °o of the U.S. population served by commu- i Fluoridation Facts Packet Page -157- 57 REFERENCES 1. Centers for Disease Control and Prevention. Ten great 1 19. 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Neurotoxicity of sodium fluoride inrats. Neurotoxicoi Genotoxic evaluation of chronic fluoride exposure: Teratoi 1995;17(2):169-77. micronucleus and sperm morphology studies. J Dent Res 1989;68(11):1525-8.- 282. Ross JF, Daston GP. Neurotoxicology and Teratology 1995;17(6):685-6. Letter to the editor. 264. Li Y, Zhang W, Noblitt TW, Dunipace AJ, Stookey GK. Genotoxic evaluation of chronic fluoride expo- 283. Shannon FT, Fergusson DM, Horwood LJ. Exposure sure: sister-chromatid exchange study. Mut Res' to fluoridated public water supplies and child health 1989;227:159-65. and behaviour. N Z Med J 1986;99(803):416-8. 265. Obe G, Slacik-Erben R. Suppressive activity by fluo- 284. Masters R. Estimated cost of increased prison popula ride'onthe induction of chromosome aberrations in tion predicted to result from use of silicofluorides in human cells and alkylating agents invitro. Mutat Res Palm Beach County.' Presented to Palm Beach County " 1973;19:369-71 Commission, August 26; 2003. 266. Slacik-Erben R, Obe G. The effect of sodium fluoride 285. Urbansky ET, Schock MR. Can fluoridation affect on DNA synthesis, mitotic indices and chromosomal lead(II) in potable water? Hexafluorosilicate and aberrations inhuman leukocytes treated with Tremni- fluoride equilibria in aqueous solution. Int J Environ mon in vitro. Mutat Res 1976;37:253-66. Studies 2000;57:597-637. Fluoridation Facts 65 Packet Page -165- 286. Centers for Disease Control and Prevention. 303. NSF International Standard 60-2002. Drinking water Surveillance for elevated blood lead levels treatment chemicals- health effects. NSF Interna- among children-United States, 1997-2001. MMWR tional, Ann Arbor, M1;2002. 2003;52(SS10):1-21, 305. DeEds F, Thomas JO. Comparative chronic toxicities 287. Centers for Disease Control and Prevention. Adult of fluorine compounds. Proc Soc Exper Biol and Med blood lead epidemiology and surveillance -United 1933-34;31:824-5. States, 1998-2001. MMWR 2002;51(SS11):1-10. 306. McClure FJ. A review of fluorine and its physiological 288. Alzheimer's Disease Education &Referral Center. effects. Phys Reviews 1933;13:277-300. Causes: what causes AD? Available at <http://www. alzheimers.org/ca uses.htm>. Accessed May 6, 2005. 307. McClure FJ. Availability of fluorine in sodium fluo- 289. Varner JA, Jensen KF, Horvath W, Isaacson RL ride vs. sodium fluosilicate. Public Health Rep Chronic' administration of aluminum-fluoride or 1950;65(37):1175-86. sodium-fluoride to rats in drinking water: alterations 308. Zipkin I, Likins RC, McClure FJ, Steere AC. Urinary in neuronal and cerebrovascular integrity. Brain Res fluoride levels associated with the use of fluoridated 1998;784:284-98. ` water. Public Health Rep 1956;71:767-72 290. American Dental Association. Health Media Watch: 309. Zipkin I, Likins RC. Absorption of various fluoride Study linking fluoride and Alzheimer's under scrutiny. compounds from the gastrointestinal tract of the rat. J Am Dent Assoc 1998;129:.1216-8. Amer J Physicol 1957;191:549-50. 291. Kraus AS, Forbes WE Aluminum, fluoride and the 310. McClure FJ, Zipkin I. Physiologic effects of fluoride prevention of Alzheimer's Disease. Can J Public as related to water fluoridation. Dent Clin N Am Health 1992;83(2):97-100. ' 1958:441-58. 292. US Department of Health, Education and Welfare, 311. Crisp MP. Report of the Royal Commissioner into the - National Institutes of Health, Division of Dental fluoridation of public water supplies. Hobart, Tasma- Health. Misrepresentation of statistics on heart nia, Australia: Government Printers;1968 deaths' in Antigo, Wisconsin Pub. No. PPB-47. Beth esda;N ovem ber 1972. 312. Myers DM, Plueckhahn VD, Rees ALG. Report of the 293. American Heart Association. Minerals and inorganic committee of inquiry into fluoridation of victorian water supplies. 1979-80 Melbourne, Victoria, Australia, substances: fluoridation. Available at <http://www. FD Atkinson, Government Printer,1980:115 25 americanheart.org/presenter.jhtml?identifier=4698>. Accessed' May 6, 2005. 313. Ad Hoc Committee for the U.S. Surgeon General 294. American Heart Association. Risk factors and Koop, Shapiro JR, Chairman. Report to the Environ- coronary heart disease. Available at <http://www. mental Protection Agency on medical (non-dental) americanheart.org/presenter.jhtml?identifier=4726>. effects of fluoride in drinking water. 1983:1-9. Accessed May 6, 2005. 314. Hodges A, Philippakos E, Mulkey D, Spreen T, 295. Geever EF, Leone NC, Geiser P, Lieberman J. Patho-' Murraro R. Economic impact of Florida's citrus indus- logic studies in man after prolonged ingestion of try, 1999 - 2000. Gainesville, University of Florida, fluoride in drinking water I: necropsy findings in a Institute of Food and Agricultural Sciences. Available community with a water level of 2.5 ppm. J Am Dent at <http://edis.ifas.ufl.edu/BODY_FE307>. Accessed Assoc 1958;56;499-507. April 18, 2005. 296. US Department of Health and Human Services, Public 315. Centers for Disease Control and Prevention. Engineer- Health Service. Surgeon General's advisory:. treat- ing and administrative recommendations for water ment of water for use in dialysis: artificial kidney fluoridation, 1995. MMWR 1995;44(No.RR-13).' treatments. Washington, DC: Government Printing 316. Master R, Coplan MJ. Water treatment with Office 872-021;June 1980, silicofluoride and lead toxicity. Int J Environ 297. Centers for Disease Control. Fluoride in a dialysis Studies1999;56:435-49. unit-Maryland. MMWR 1980;29(12):134-6. 317. U.S. Environmental Protection Agency. Consumer 298. 51 Fed. Reg. 11410,11412 (April 2, 1986). fact sheet on lead. Available at <http://www.epa.gov/ 299. Environmental Protection Agency. Safe Drinking safewater/Icrmr/lead.html>. Accessed on May 8, 2005. Water Act. Basic Information. Available at <http:H 318. U.S. Environmental Protection Agency. Arsenic in www.epa.gov/safewater/sdwa/basicinformation. drinking water. Available at <http://www.epa.gov/safe- html>. Accessed May 8, 2005. water/Icrmr/lead.html>. Accessed on May 8, 2005. 300. American Water Works Association. Who we are. 319. Personal correspondence. Stan Hazan. General Available at <http://www.awwa.org/About/>. Accessed manager, Drinking Water Additives Certification February 18, 2005. Program, NSF International to David Spath, California 301. National Sanitation Foundation International. About Department of Health Services, Office of Drinking Water. NSF. Available at <http://www.nsf.org/business/about_ March 30, 2000. Available at <http://www.dentalhealth- NSF/>. Accessed February 18, 2005. foundation.org/documents/NSFLetter.pdf>. Accessed on 302. American National Standards Institute. About ANSI May 8, 2005. overview. Available at <http://www.ansi.org/about_ 320. U.S. Environmental Protection Agency, Office of ansi/overview/overview.aspx?menuid=1>. Accessed Water, Office of Science and Technology. Fluoride: �� February 18, 2005. a"regulatory fact sheet. 66 American Dental Association Packet Page -166- 321. Tacoma -Pierce County Health Department. Tacoma- 343. Margolis FJ, Cohen SN. Successful and unsuccess- Pierce County Health Department fluoridation ful experiences in combating the antifluoridationists. resolution. WAC197-11-960 environmental checklist. Pediatrics 1985;76(1):113-8. August 2002. 344. Easley MW. The new antifluoridationists: who are 322.-Pollick PRWater fluoridation and the environment: they and how do they operate? J Public Health Dent current perspective in the United States. Int J Occup 1985;45(3):133-41. Environ Health 2004;10:343-50. 345. Wulf CA, Hughes KF, Smith KG, Easley MW. Abuse 323. Osterman JW. Evaluating the impact of municipal of the scientific literature in an antifluoridation water fluoridation on the aquatic environment. Am J pamphlet. Baltimore: American Oral Health Insti- Public Health 1990;80:1230-5. tute;1985. 324. Safe Water Association, Inc. v. City of Fond du Lac, 346. National Health and Medical Research Council The 184 Wis.2d 365, 516 N.W.2d 13 (Wis. Ct. App. 1994). effectiveness of water fluoridation. Canberra, Austra- lia`. Australian Government Publishing Service;1991. 325. Block LE. Antifluoridationists persist: the constitu tional basis for fluoridation. J Public Health Dent 347. Jones Water fluoridation in Europe. Paper 1986;46(4):188-98. present ed to the British Association for the. Study of Community Dentistry,, 1996 Spring Scientific 326. Christoffel T.Fluorides; facts and fanatics: public Meeting., Dundee, Scotland. health ad J Public shouldn't stop a( the 88c8ouu1 house 348. Marthaler TM. Water fluoridation results in Basel door.Y P since 1962: health and political implications. J Public 327. McMenamin JR Fluoridation of water in Virginia: the Health Dent 1996 Spec Iss;56(5):265-70. tempest in the teapot. J Law Ethics Dent 1988;1(1): 349. Meyer J, Marthaler TM, Burgi H. The change from 42-6, water to salt as the main vehicle for community -wide 328. Roemer R. Water fluoridation: public health responsi- fluoride exposure in Basle, Switzerland (Editorial). bility and the democratic process. Am J Public Health Community Dent Oral Epidemiol 2003;31(6):401-2: 1965;55(9):1337-48. 350. Roemer R. Legislation on fluoridation of water 329. Strong GA. Liberty, religion and fluoridation. J Am supplies. In: Experience on water fluoridation in Dent Assoc 1968;76:1398-1409. Europe. Copenhagen: World Health Organiza- 330. Easlick KA. An appraisal of objections to fluoridation. tion;1987:23-36. J Am Dent Assoc 1962;65:868-93. 351. Klein SP, Bohannan HM, Bell RM, Disney JA Foch 331. American Dental Association, Survey Center. 1998 CB, Graves RC. The cost and effectiveness of school - Consumers' opinions regarding community water based preventive dental care. Am J Public Health fluoridation. Chicago;June 1998. 1985;75(4):382-91. 332. Gallup Organization, Inc. A Gallup study of parents' 352. Federation Dentaire Internationale. Cost-effectiveness behavior, knowledge and attitudes toward fluoride. of community fluoride programs for caries preven Princeton, NJ:Gallup Organization, Inc.;1991. tion: technical report 13. Chicago: Quintessence;1981. 333. Newbrun E. The fluoridation war: a scientific dispute 353. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluorida- or a religious argument? J Public Health Dent tion: 44 Florida communities. J Public Health Dent 1996;56(5)(Spec Iss):246-52. 1992;52(2):75-80. 334. Scott DB. The dawn of a' new era. J Public Health 354. Centers for Disease Control and Prevention. Recom- Dent 1996;56(5)(Spec Iss):235-8. mendations for using fluoride to prevent and control dental caries in the United States. MMWR 335. Park B, Smith K Malvitz D, Furman L. Hazard vs 2001;50(No.RR-14):22. outrage: public perception of fluoridation risks. 355. Griffin SO, Jones K, Tomar SL. An economic evalua- J Public Health Dent 1990;50(4):285-7. tion of community water fluoridation. J Public Health 336. Neenan ME. Obstacles to extending fluoridation in the Dent 2001;61(2):78-86. United States. Comm Dent Health 1996;13(Suppl 2): 356. American Dental Association, Survey Center. 2003 10-20. survey of dental fees. Chicago;April 2004.E,t' 337. Lowry R. Antifluoridation propaganda material -the tricks of the trade. Br Dent J 2000;189(10):528-30. 357. American Water Works Association. Fluoridation of public water supplies. Adopted by the Board of 338. Mandel I. A symposium of the new fight for fluo- Directors Jan. 25, 1976, reaffirmed Jan. 31, 1982 rides. J Public Health Dent 1985;45(3)`.133-41. and revised Jan. 20, 2002. Available at <http.//www. 1 339. Lang P, Clark C. Analyzing selected criticisms of awwa.org/About/OandC/officialdocs/AWWASTAT. water fluoridation. J Can Dent Assoc 1981;47(3);1-xii. cfm>. Accessed April 29, 2005. 340. Lieberman AJ, The American Council on Science and 358. Centers for Disease Control and Prevention. Water Health. Facts versus fears: a review of the 20 greatest fluoridation and costs of Medicaid treatment for dental decay -Louisiana, unfounded health scares of recent times. 2nd ed. New 1995 1996 MM York;1997. 1999;48(34):753-7.410 341. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 ti U.S. 579, 113, S.Ct. 2786 (1993). �� . �* �.� *r�� 342. Frazier PJ. Fluoridation: a review of social research. J Public Health Dent 1980;40(3):214-33. Fluoridation Facts 67 e Packet Page -167- -1 � Statements from Five Leading Health Organizations Regarding Community Water Fluoridation AMERICAN DENTAL ASSOCIATION (ADA) "TheAssociation endorses corn munitywaterfluoridation as a safe, beneficial and cost-effective public health measure for preventing dental caries. This support has been the Association's policy since 1950." — ADA Operational Policies and Recommendations Regarding Community Water Fluoridation (Trans. 1997:673)• CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) "During the 20th century, the health and life expectancy of persons residing in the United States improved dramatically. To highlight these advances, MMWR will profile 10 public health achievements in a series of reports published through December 1999 (Fluoridation of drinking water was chosen as one of these achievements and profiled in the October 22, 1999 MMWR). Fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions in tooth decay (40%-70% in children) and of tooth loss in adults (40%-60%)." — CDC, Morbidity and Mortality Weekly Report. "Ten Great Public Health Achievements -United States 1900-1999" April 1999. AMERICAN MEDICAL ASSOCIATION (AMA) "The AMA recognizes the important public health benefits of drinking properly fluoridated water and encourages its member physicians and medical societies to work with local and state health departments, dental societies, and concerned citizens to assure the optimal fluoridation of community drinking water supplies." — AMA Letter to the American Dental Association, March 10, 1995. 68 U.S. SURGEON GENERAL "A significant advantage of water fluoridation is that all residents of a community can enjoy its protective benefit – at home, work, school or play – simply by drinking fluoridated water or beverages and foods prepared with it ... Water fluoridation is a powerful strategy in our efforts to eliminate differences in health among people and is consistent with my emphasis on the importance of prevention... Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for both children and adults. While we can be pleased with what has already been accomplished, it is clearthatthere is much yetto be done. Policymakers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and well being and take action to make ourselves, our families, and our communities healthier. I join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans. " — Surgeon General Richard H. Carmona, Statement on Community Water Fluoridation, July 28, 2004. NATIONAL INSTITUTE OF DENTAL & CRANIOFACIAL RESEARCH (NIDCR) "The National Institute of Dental and Craniofacial Research continues to support water fluoridation as a safe and effective method of preventing tooth decay in people of all ages. Community water fluoridation is a public health effort that benefits millions of Americans. For more than half a century, water fluoridation has helped improve the quality of life in the U.S. through reduced pain and suffering related to tooth decay, reduced tooth loss, reduced time lost from school and work, and less money spent on dental care." — NIDCR: Statement on Water Fluoridation, June 2000. Packet Page -168- American Dental Association >1__N COMPENDIUM National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay Academy of Dentistry International Academy of General Dentistry Academy for Sports Dentistry Alzheimer's Association America's Health Insurance Plans American Academy of Family Physicians American Academy of Nurse Practitioners American Academy of Oral and Maxillofacial Pathology American Academy of Orthopaedic Surgeons American Academy of Pediatrics American Academy of Pediatric Dentistry American Academy of Periodontology American Academy of Physician Assistants American Association for Community Dental Programs American Association for Dental Research American Association for Health Education American Association for the Advancement of Science American Association of Endodontists American Association of Oral and Maxillofacial Surgeons American Association of Orthodontists American Association of Public Health Dentistry American Association of Women Dentists American Cancer Society American College of Dentists American College of Physicians—American Society of Internal Medicine American College of Preventive Medicine American College of Prosthodontists American Council on Science and Health American Dental Assistants Association American Dental Association American Dental Education Association American Dental Hygienists' Association American Dietetic Association American Federation of Labor and Congress of Industrial Organizations American Hospital Association American Legislative Exchange Council American Medical Association American Nurses Association American Osteopathic Association American Pharmacists Association American Public Health Association American School Health Association American Society for Clinical Nutrition American Society for Nutritional Sciences American Student Dental Association American Veterinary Medical Association American Water Works Association Association for Academic Health Centers Association of American Medical Colleges Association of Clinicians for the Underserved Association of Maternal and Child Health Programs Association of State and Territorial Dental Directors Association of State and Territorial Health Officials Association of State and Territorial Public Health Nutrition Directors British Fluoridation Society Canadian Dental Association Canadian Dental Hygienists Association Canadian Medical Association Canadian Nurses Association Canadian Paediatric Society Canadian Public Health Association Child Welfare League of America Children's Dental Health Project Chocolate Manufacturers Association Consumer Federation of America Council of State and Territorial Epidemiologists Delta Dental Plans Association FDI World Dental Federation Federation of American Hospitals Hispanic Dental Association Indian Dental Association (U.S.A.) Institute of Medicine International Association for Dental Research International Association for Orthodontics International College of Dentists March of Dimes Birth Defects Foundation National Association of Community Health Centers National Association of County and City Health Officials National Association of Dental Assistants National Association of Local Boards of Health National Association of Social Workers National Confectioners Association National Council Against Health Fraud National Dental Assistants Association National Dental Association National Dental Hygienists' Association National Down Syndrome Congress National Down Syndrome Society National Eating Disorders Association National Foundation of Dentistry for the Handicapped National Head Start Association National Health Law Program National Healthy Mothers, Healthy Babies Coalition Oral Health America Robert Wood Johnson Foundation Society for Public Health Education Society of American Indian Dentists Special Care Dentistry Academy of Dentistry for Persons with Disabilities American Association of Hospital Dentists American Society for Geriatric Dentistry The Children's Health Fund The Dental Health Foundation (of California) U.S. Department of Defense U.S. Department of Veterans Affairs U.S. Public Health Service Centers for Disease Control and Prevention (CDC) National Institute of Dental and Craniofacial Research (NIDCR) World Federation of Orthodontists The list above was current at the time Fluoridation Facts went to press. As organizations and entities continue to be added to the Compen- dium, the most current Compendium can be viewed on ADA.org at htto•//www ada org/cioto/ffcompendium. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Compendium in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1-312-440-2879. Fluoridation Facts Packet Page -169- 69 American Dental Association www.ada.org 211 East Chicago Avenue Chicago, Illinois 60611-2678 Packet Page -170- Ten Great Public Health Achievements -- United States, 1900-1999 Page 1 of 1 5/10/2016 11.B. Weekly December 24,1999148(50);1141 Ten Great Public Health' Achievements -- United States, 1900-1999 e Vaccination e Motor -vehicle safety e Safer workplaces e Control of infectious diseases e Decline in deaths fiom coronary heart disease and stroke e Safer and healthier foods e Healthier mothers and babies e Family planning e Fluoridation of drinking water e Recognition of tobacco use as a health hazard Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Prbiting Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. ' **Questions or messages regarding errors in formatting should be addressed to mmwrcl@cdc.gov. Page converted: 12/21/1999 HOME l ABOUT MM Wf2 l MMWR SEARCHl DOVtMLOADS R S 1 QONTAC7 POLICY { DISCLAIMER j ACCESSIBILITY 6AFCR • HIIALRHICR - PROPLIV Morbidity and Mortality Weekly Report i, Department of Health Centers for Disease Control and Prevention, Ag t^- and Human Services 1600 Clifton Rd, MallStop E•90, Atlanta, GA 0awmmeM i •apeefir 30333, U.S.A This page last reviewed 5/2/01 http://www.cdc,gov/mmwr/preview/mmwr Packet Page -171-m 3/19/2009 Populations Receiving Optimally Fluoridated Public Drinking Water --- United States, 19. p -n- 1 of 1 n 5/10/2016 11.B. Weekly July 11, 2008 1 67(27);737-741 Populations Receiving Optimally Fluoridated Public Drinking Water --- United States, 1992-- 2006 Water fluoridation has been identified by CDC as one of 10 great public health achievements of the 20th century. The decline in the prevalence and severity of dental caries (tooth decay) in the United States during the past 60 years has been attributed largely to the increased use of fluoride (1). Community water fluoridation is an equitable and cost-effective method for delivering fluoride to the community (2--!0. A Healthy People 2010 objective is to increase to 75% the proportion of the U.S. population served by community water systems who receive optimally fluoridated water* (5). To update and revise previous reports on fluoridation in the United States (4} and describe progress toward the Healthy People 2010 objective, CDC analyzed fluoridation data for the period 1992--2006 from the 50 states and District of Columbia (DC). The results indicated that the percentage of the U.S. population served by community water systems who received optimally fluoridated water increased from 62.1% in 1992, to 65.0% in 2000, and 69.2% in 2006, and those percentages varied substantially by state. Public health officials and policymakers in states with lower percentages of residents receiving optimal water fluoridation should consider increasing their efforts to promote fluoridation of community water systems to prevent dental caries. Since 1945, the U.S. Public Health Service and CDC -(beginning in 1975) have tracked the number of persons in the United States receiving fluoridated water.1 The U.S. Environmental Protection Agency (EPA) does not regulate water fluoridation, and EPA`s Safe Drinking Water Information System (SDWIS) only tracks fluoride concentrations in water systems with naturally occurring fluoride levels above the established regulatory maximum contaminant level (4.0 ppm). Water fluoridation is managed at the state level, and CDC relies on states to provide data on individual community water systems (e.g., population served, fluoride concentration, and fluoride source). During 1998--2000, CDC, in partnership with the Association of State and Territorial Dental Directors, developed the Water Fluoridation Reporting System (WFRS) to support management and tracking of state fluoridation programs. WFRS is a voluntary system designed, in part, to make additional use of community water system data that states were already required to report to EPA as part of SDWIS. In March 2007, CDC asked state dental directors and drinking water administrators to validate their state data reported via WFRS for 2006. Estimates of the population served by community water systems were based on the number of households served (i.e., service connections) and the number of persons in each household. Some states supplemented population data in WFRS with population data from SDWIS, which can differ slightly from WFRS. The percentage of the population served by community water systems who received optimally fluoridated water was calculated by dividing the population served by community water systems with optimal fluoride levels by the total population Packet Page -172- http://www.cdc.gov/mmwr/preview/mmwi http://www.cdc.gov/mmwr/preview/mmwiAA.A1uJ 11usRJ .......... 5/10/2016 11.B. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Recommendations and Reports November 30, 2001 / 50(RR-21);1-13 Promoting Oral Health: Interventions for Preventing Dental Caries. Oral and Pharyngeal Cancers, and Sports -Related Craniofacial Injuries A Report on Recommendations of the Task Force on Community Preventive Services Report reinforces the efficacy of fluoridation Excerpt The Task Force on Community Preventive Services (the Task Force) conducted systematic reviews of the evidence of effectiveness of selected population -based interventions to prevent and control dental caries (tooth decay), oral (mouth) and pharyngeal (throat) cancers, and sports -related craniofacial injuries. The Task Force strongly recommends community water fluoridation. More widespread use of effective population -based interventions could help reduce the morbidity, mortality and economic burden associated with dental caries... Packet Page-173- Oral Health in America: A Report of the Surgeon General May, 2000 Excerpt: 5/10/2016 11. B. Community water fluoridation remains one of the great achievements of public health twentieth century — an inexpensive means of improving oral health that benefits all residents of a community, young and old, rich and poor alike. Fluoridation remains an ideal public health measure based on the scientific evidence of its safety and effectiveness in preventing dental decay and its impressive cost effectiveness. Further, one of my highest priorities as Surgeon General is reducing disparities in health that persist among our various populations. Fluoridation holds great potential to contribute toward elimination of these disparities. I am pleased to join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing oral health protection for Americans. Report available on Internet: http://www.nidcr.nih.gov/sgr/oralhealth.htm U.S. PUBLIC HEALTH SERVICE DEPARTMENT OF HEALTH AND HUMAN SERVICES Packet Page -174- FLORIDA DENTAL HYGIENE ASSOCIATION Leaders In Pro ventive oral Health March 6, 2009 Hang W. Davis, DDS, MPH Public Health Dental Program Florida Department of Health HSFDF, Bin #A14 4052 Bald Cypress Way Tallahassee, Florida 32399-1724 5/10/2016 11. B. Dear Dr. Davis, The Florida Dental Hygiene Association advocates offective, preventive measures for comprehensive oral health and fully supports water fluoridation for the citizens of Florida. With a distressed economy many cities and counties are looking at cost savings measures to function within a decreasing budget. The Florida Dental Hygiene Association is concerned that the decision to eliminate water fluoridation will detrimentally affect the citizens of Florida. The progressive, destructive nature of dental decay can significantly diminish the general health and quality of life for the affected person. Tooth decay is the most common chronic disease in children. By utilizing the benefits of water fluoridation in the early years of tooth development, costly and disruptive intervention can be avoided. According to reports from the Centers for. Disease Control and Prevention, for every $1 invested in fluoridation, $38 in dental treatment costs is saved, In addition, Medicaid programs costs are as much as 50% less in fluoridated communities compared to non -fluoridated communities. The United States Department of Health and Human Services (HHS) is leading The Healthy People 2010 initiative which addresses a vision of "a healthy, strong United States where diseases are prevented when possible, controlled when necessary, and treated when appropriate." Water fluoridation is an essential -component of this plan. Sincerely, Tami J. Miller, RDH, BS Executive Director PD 860 5896 420 -0603 phone; (8 0) 896 0604 fax ( www.fdha.org Packet Page -175- Steven R. West, M.D. President James B. Dolan, M.D. Presldent-Elect Madelyn E. Butler, M.D. Vice President Vincent A. DeGennero, M.D. Secretary W. Alan Harmon, M.D. Treasurer Alan B. Plllersdorf, M.D. Speaker David J. Becker, M.D. Vice Speaker Karl M. Altenburger, M.D. immediate Past President John N. Katopodis, M.D. District A Eli N. Lerner, M.D. District B David M. McKalip, M.D. District C Harold L. Greenberg, M.D. District D Ralph J. Nobo, Jr., M.D. District E Nabil EI Sanadl, M.D. District F Stephan Baker, M.D. District G Silvio A. Garcia, M.D. At Large Neal P. Dunn, M.D. At Large Lisa A. Cosgrove, M.D. Primary Care Specialties Linda S, Cox, M.D. Medical Specialties Alan S. Routman, M.Q. Surgical Specialties Miguel A. Machado, M.D. council on Legislation E. Coy Irvin, M.D. Florida AMA Delegation James H. Rubenstein, M.D. FMA PAC M. Kernel Elzawahry, M.D. Specialty Society Section Ashley E. Booth, M.D. Young Physician Section Joel R. Judah, M.D. Resident & Fellow Sectlon Jeremy L. Tharp Medical Student Section Donald F. Foy, Sr. Public Member Diane R. Andrews, Ph.D., R.N. FMA Alliance Karen Wendiand, M.S. Council of Ftorkla Medical Society Executives FloridaMedical A S S O C l A T! O N Helping Physicians Practice Medicine. June 26, 2009 5/10/2016 11. B P.O. Box 10269 1 Tallahassee, FL j 32302 123 South Adams Street I Tallahassee, FL ( 32301 850.224.6496 ( 850.224.6627 Fax f www.fmaonline.org State Surgeon General Florida Department of Health 4052 Bald Cypress Way, BIN# A-14 Tallahassee, FL 32399-1724 Re: Community Water Fluoridation The Florida Medical Association (FMA) works with the Department of Health to improve the health of the people of Florida and supports community water fluoridation, The FMA's Council on Public Health finds the Florida Dental Association's resolution which states it "unequivocally supports the optimal fluoridation of drinking water as a safe, effective, and economical way to prevent dental caries" to be consistent with FMA and AMA policies, and accordingly strongly endorses it for the stated purpose of preventing dental caries through appropriate fluoridation of public water supplies for the benefit of the public's health. The FMA agrees that fluoridation serves as one of the most cost effective public health measures a community can take to help prevent dental decay and supports this measure as not just cost-effective but a producer of cost -savings as well. We applaud and support your efforts to provide for community water fluoridation. Sincerely, `�,.�, � . X� 11 M.&. John J. Lanza, M.D., PhD, MPH, FAAP Chairman, FMA Council on Public Health JJL: sf Weir Packet Page -176-lice Medicine pill gm �' Public Health Focus: Fluoridation of Community Water Systems 5/10/2016 11. B. Weekly May 29,1992! 41(21);372-375, 381 Public Health Focus: Fluoridation of Community Water Systems Although fluoridation of community water is highly effective in reducing the occurrence of dental caries, the prevalence of dental caries remains high in the United States. For example, a survey of school -aged children during 1986-1987 indicated that 50% of those aged 5-17 years had caries in their permanent teeth, and among 17-year-olds, the prevalence of caries was 84% (1). In addition, among certain populations (e.g., rural and innef-city residents, children whose parents have less than a high school education, and some racial/ethnic minorities), the prevalence of dental caries among children ranges from 52% to 92%. This report summarizes information regarding the efficacy, effectiveness, and cost-effectiveness of fluoridation of public water supplies in the United States. Efficacy/Effectiveness The association between fluoride in drinking water and reduction of dental caries was first documented in the 1930s in communities with naturally occurring fluoride (2). However, it became necessary to validate and quantify efficacy when alternate systemic and topical methods to deliver fluoride were proposed. 'In 1945 and 1946, independently conducted community trials to assess the effectiveness of water fluoridation were initiated in four communities in Canada and the United States (Brantford, Ontario; Evanston, Illinois; Grand Rapids, Michigan; and Newburgh, New York) (Table 1). Four nearby and demographically similar communities were selected for comparison. Following fluoridation for 13-15 years, the prevalence of caries decreased 48%-70% among 12- 14 -year-olds in the four communities (2). Studies in other communities indicated that, following fluoridation for 10 years, the prevalence of caries decreased 45%-94% (median: 58%) among children (3). By the early 1980s, epidemiologic evidence indicated that the prevalence of dental caries was declining throughout the United States (5), From 1971 through 1987, three national surveys of U.S. children demonstrated a continued decrease in caries prevalence (1,6,7) (Figure 1). The most recent national survey, conducted during 1986-1987 (1), indicated that the prevalence of caries among children with a history of lifelong exposure to optimally fluoridated water decreased 18% when compared with the prevalence among children with no exposure to optimally fluoridated water. Prevalence decreased 25% when the analysis excluded children with any history of fluoride therapy (e.g., dietary supplements or professionally applied topical treatments) (4). In addition, recent studies have found consistently lower caries prevalence, both ^ on coronal and root surfaces, among adults who live in communities with optimal or greater fluoride than among those from communities with lower fluoride levels in the water supply (4) (Table I). Packet Page -177- http://www.cdc.goy/mmwr/preview/mmwrhtml/00016840,htm 3/19/2009 Public Health Focus: Fluoridation of Community Water Systems 5/10/2016 11. B. In clinical trials, epidemiologic studies, and national surveys conducted during 1973-1988 (8), children aged 6-13 years living in fluoridated communities averaged 0.8 new dental .caries . (decayed, missing, or filled surfaces (DMFS)) per year. In comparison, an average of 1.3 DMFS occurred each year among children living in fluoride -deficient communities. Cost -Effectiveness The direct cost of fluoridating public water supplies is related to a variety of factors, including size of the community, number of wells and treatment plants, amount and type of equipment, amount and type of fluoride chemical, and personnel costs (9). Annual costs of water fluoridation per capita varied inversely with community size, ranging from 12 cents to 21 cents forwater systems serving populations greater than 200,000 persons, 18 cents to 75 cents for Sys tems serving 10,000-200,000 persons, and 60 cents W45.41 for'systems serving fewer than 10,000 persons; the mean national weighted estimate is 51 cents (10). Of all persons receiving optimally fluoridated community drinking water, approximately 85% are served by water systems for which the annual per capita cost of fluoridation is 12 6ents-75 cents (11). For 1990, the Health Care Financing Administration estimated that $34 billion (5% of all U,S. expenditures for health care) was spent for dental services (12); of which $4.5 billion (13.2%) may have been spent on dental amalgam restorations (American Dental Association, personal communication, 1992). Based on a national average cost per restoration of $40 (13) and a mean national weighted cost of 51 cents per person per year to fluoridate drinking water (10), each $1 expenditure for water fluoridation could result in a savings of $80 in dental treatment costs. Estimated nondiscounted per capita expenditures for water fluoridation during a lifetime ($38.25 at 51 cents per year for 75 years) are approximately equal to the average nondiscounted cost of one dental restoration. n Reported by: Div of Oral Health, National Center for Prevention Svcs, CDC. Editorial Note Editorial Note: Since 1945, 9411 community water systems serving 8081 communities in the United States have instituted water fluoridation. By the end of 1989, approximately 70% of all U.S. cities with populations of more than 100,000 --including 42 of the 50 largest cities -- were fluoridating water: Thirty-five states, Puerto Rico, and the District of Coluinbia provide fluoridated water to more than half of their populations (11) (Figure 2), and nine states and Puerto Rico have enacted legislation for mandatory water fluoridation. Approximately 135 million U.S. residents are served by water supplies in which the fluoride concentration either has been adjusted to an optimal level (126 million persons) or the natural fluoride content is sufficient for improved dental health (9 million persons) (11). Because efforts to fluoridate drinking water were effective in reducing the risk for dental caries, dental researchers developed other methods to deliver fluoride to the public (e.g., fluoride - containing dentifrices, fluoride gels, fluoride mouth rinses, and dietary fluoride supplements). In addition, foods and beverages processed in fluoridated cities may be sold in nonfluoridated areas. The widespread use of these products assures that virtually all persons are exposed to fluoride. This exposure may have contributed substantially to the degrease in caries reduction observed during 1986-1987 (1) when comparing fluoridated and nonfluoridated communities. The possibility of adverse effects of water fluoridation has been investigated since this preventive measure was first introduced. Although recent reviews have confirmed the benefit of exposure to appropriate levels of fluoride for dental health (14,15), a Public Health Service Packet Page -178- httn,/Iwww.f,dc_c,nv/mmwr/preview/mmwrhtml/00016840.htm 3/19/2009 Public Health Focus: Fluoridation of Community Water Systems 5/10/2016 11.B. report (14) recommended further assessment of potential problems associated with or other -� aspects of fluoride use, such as the relation between fluoride intake and bone (i.e., osteosarcoma and bone fractures); the mechanisms of fluoride action on bone and teeth at the molecular level; the marginal risks, costs, and benefits of multiple fluoride regimens; the caries effect after a community discontinues water fluoridation; temporal changes in the prevalence of dental caries; and the prevalence and extent of dental fluorosis. One national health objective for the year 2000 is to increase to at least 75% the proportion of persons served by community water systems providing optimal levels of fluoride (objective 13.9) (16) -- a goal already achieved by 20 states and the District of Columbia (Figure 2) (11). To achieve this objective nationally, an additional 30 million persons must receive optimally fluoridated water from public water systems. References 1. National Institute of Dental Research. Oral health of United States children: the National Survey of Dental Caries in U.S. School Children: 1986-87; national and regional frndings.Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1989; NIH publication no. 89-2247. 2. Striffler DF, Young WO, Burt BA. Dentistry, dental practice, and the community. 3rd ed. Philadelphia: WB Saunders, 1983. 3. Dunning JM. Principles of dental public health. 4th edition. Cambridge, Massachusetts: 10-1-1 Harvard University Press, 1986, 4. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279-89. 5. Burt BA. The future of the caries decline. J Public Health Dent 1985;45:261-9. 6. NCHS. Basic data on dental examination findings of persons 1-74 years: United States, .1971-74. Hyattsville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, 1979; DHEW publication no. (PHS)79-1662. (Vital and health statistics; series 11, no. 214). 7. National Institute of Dental Research. The prevalence of dental caries in United States children, 1979-80: National Dental Caries Prevalence Survey. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1981; NIH publication no. 82-2245. 8. Garcia Al. Caries incidence and costs of prevention programs. J Public Health Dent 1989;49:259-71. 9. CDC. Water fluoridation: a manual for engineers and technicians. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, September 1986. �-. 10. Burt BA. (Concluding statement). In: Proceedings for the workshop: cost effectiveness of caries prevention in dental public health. J Public Health Dent 1989;49:338-40. Packet Page-179- http://www.cdc.gov/mmwr/preview/mmwrhtmYO0016840.htm 3/19/2009 Public Health Focus: Fluoridation of Community Water Systems 5/10/2016 11. B. • y 11. CDC. Fluoridation census 1989: summary. Atlanta: US Department of Health and Human ;..� Services, Public Health Service, 1991. 12. Palmer C. Dental spending hits.$34 billion. American Dental Association News 1992;23:25. 13. American. Dental Association. The 1990 survey of dental fees,. Chicago: American Dental Association, 1992. 14., Public Health Service, Review of fluoride benefits and risks: report of the ad hoc subcommittee on fluoride of the committee to coordinate environmental health and related programs. Washington, DC: US Department of Health;and Human Services, Public Health Service, 1991. 15. Kaminsky LS, Mahoney MC, Leach J, Melius J, Miller MJ. Fluoride: benefits and risks of exposure, Clinical Reviews in Oral Biology and Medicine 1990;1:261-81. 16. Public Health Service. Healthy people 2000: national health promotion and disease . prevention objectives -- full report, with commentary. Washington, DC: US Department Of Health and Human Services, Public Health Service, 1991; DHHS publication no. _ (PHS)91-50212. o Ranges from 0,7 mg/L to 1.2 mg/L based on an annual average of the maximum daily air temperature, n Disclaimer All MMWR HTML documents published before January 1993 are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users'should not rely on this HTML document, but are referred to the original M,LIYYR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. '*Questions or messages regarding errors in formatting should be addressed to mmwr cdc,gov, Page converted: 08/05/98 • HOME I ABOUT MMWR I MMWR SEARCH I DOWNLOADS I RSS i CONTACT POLICY l DISCLAIMER l ACCESSIBILITY fJtl'itR•HltAL'YHlRR•P:OPLL` Morbidity and Mortality Weekly RveDepartment of Health Centers for Disease Control an rentfon , },!� and Human Services 1800 Clifton Rd, MallStop E-90, Atlanta, GA 9e�aenuwdanr 30333, U.S.A This page last reviewed 5/2/01 Packet Page -180- L44---1/- .,,, -A,n,,,./wimiznIrr�v;aw/mmwrhtml/0(lQl6R40.httn - 3/19/2009 5/10/2016 11.13. Florida ,Journal of Environmental Health, Vol. 191, Dec. 2005, pp.14-20. Perspectives on the Science Supporting Florida's Public Health Policy for Community Water Fluoridation Michael W. Easley, DDS, MPH INTRODUCTION: Community water fluoridation has been utilized for more than 60 years as the principal public health measure to prevent the ravages of dental caries, a chronic infectious disease commonly referred to as dental cavities or dental decay. Dental caries can ultimately lead to acute or chronic dental infections (abscesses), pain, loss of teeth, speech impediments, compromised nutrition, systemic infections, complications for other chronic diseases, and occasionally death. Children are frequently absent from school because of the pain from acute dental infections or for dental treatment. The treatment of dental decay also results in substantial direct and indirect costs to individuals, their employers, insurance companies, consumers, and taxpayers. Community water fluoridation is one of the safest, most effective, and most economical programs that public officials can provide for their constituents in order to prevent the pain, suffering, and costs of dental caries. Community water fluoridation is generally easy and inexpensive to implement - costing public water systems, on average, about 50 cents per person per ear in large communities to $3.00 per person a year for small communities to operate "z, 65. The return on investment is tremendous — with various studies reporting.$38-$80 indetal treatment cost savings for each doilar invested in community water fluoridation' -2-6.5'. Few taxpayer -financed programs, result in such a large amount of savings for such a small investment. Moreover, since fluoridation has proven to be a safe, effective, efficient, economical, and environmentally sound means to prevent dental caries in children and adults, its implementation by public and private water systems serves as an excellent example of good public policy at work. What Is Fluoride And Why Is It Necessary? Fluoride is a naturally occurring substance that is present in virtually all sources of drinking water In the United States. It serves as an essential trace element necessary for the proper development of teeth and bones, and for the protection of teeth once they have erupted into the mouth","-"'. Therefore, fluoride not only benefits children before their teeth have erupted, but it also protects the teeth of children and adults after all of their teeth are present in the mouth",".". Those fortunate enough to have had access 3 9 32-A8 to community water fluoridation experience 40-60% fewer dental cavities " Community water fluoridation is the precise adjustment of the existing naturally occurring fluoride levels in drinking water to a safe level that has been determined to be ideal for the prevention of dental caries in children and adults. There are even some locations in the United States where naturally occurring fluoride levels are adequate for the prevention of dental caries - these communities do not have to fluoridate their drinking water. However, most communities in the U. S. have insufficient levels of fluoride for effective prevention of dental caries and therefore require the addition of very small amounts of fluoride to achieve the optimal level for good health. Community water fluoridation mimics a naturally occurring process and can be considered to be a form of enrichment or supplementation of the drinking water. The process of fluoridation as a measure to prevent dental caries is very similar in concept to the supplementation of: milk and breads with Vitamin D to prevent rickets;.fruit drinks with Vitamin C to prevent scurvy; table salt with iodine to prevent goiter; breads and Packet Page -181- 5/10/2016 11.B. pastas with fotic acid to prevent certain birth defects; various foods with calcium to prevent osteoporosis; and cereals with many different vitamins and minerals in order to provide for proper human development and to promote good health. Why Use The Public Water System To Provide Fluoride? First of all, public water systems have been used for the purpose of preventing diseases in the United States since the 1840's. The original reason for the establishment and widespread use of community water systems by cities and villages was to prevent the outbreak of serious diseases like cholera, hepatitis A, glardiasis, and typhoid fever. These and many other diseases, including dental cartes, are prevented through the treatment of drinking water. Water treatment for disease prevention is considered to be a primary public health activity and is essential for the control of many diseases that would otherwise plague modern society. Don't We Have Other Ways Of Getting Fluoride? There are other ways to provide fluoride, but none are as effective as community water fluoridation for the prevention of dental -decay in children and adults4'9. Fluoride benefits teeth in two general ways - there are (1) benefits from systemic sources and (2) benefits from topical sources. (1) Systemic Sources of Fluoride:' Benefits from systemic sources are gained when one drinks water and eats•food that contain fluoride. Systemic benefits can also be obtained by taking fluoride tablets or vitamins with fluoride that have been prescribed by a family's physician or dentist. More permanent in nature, the fluoride obtained from systemic sources actually becomes part of the tooth structure as baby teeth and permanent teeth develop under the gums of infants and children 4. These teeth are then considerably stronger and resist dental decay much better once they have erupted into the mouth. This protection, gained from getting fluoride from systemic sources, generally stays with the teeth throughout life. Systemic sources of fluoride also benefit older children and adultsa-5,5x•57 Fluoride from food and drink eventually ends up in a person's saliva. The fluoride in the saliva constantly bathes the teeth, so that the teeth are protected continuously through exposure to small amounts of fluoride. For those older children and adults fortunate enough to live in fluoridated communities, this constant protection of the teeth by saliva containing small amounts of fluoride is substantial. The fluoride from saliva not only. prevents some cavities from ever starting, but it also repairs early dental decay through a process called rem ineralization5,5s•5r With remineralization,' some very small cavities are not only prevented from getting larger, they actually can "heal" or repair themselves because of the action of these low levels of fluoride present in the salivas,5s 57 Fluoride in saliva also inhibits attachment, metabolism, and reproduction of the bacteria implicated in the decay process, such that it Inhibits the ability of these bacteria to produce enamel -destroying acids56•57 It should be noted that community water fluoridation is much more effective, much safer, and much more economical than the use of prescribed fluoride supplements (fluoride. tablets or fluoride vitamins)4.9,57. Community water fluoridation is always the best choice to prevent dental decay in children and adults, not only because it is safer, more effective, and more economical, but because it benefits all people using the public water system, regardless of age, race, ethnic background, or socioeconomic status4-9,". Fluoride tablets or vitamins with fluoride can and should be used in the absence of community water fluoridation, but are meant only as a temporary substitute until a community's water system can be fluoridated. Because they must be prescribed by a Packet Page -182- 5/10/2016 11. B. physician or a dentist, fluoride tablets or vitamins with fluoride often are only available to people fortunate enough to be able to afford regular visits to a family dentist or physician. (2) Topical Sources of Fluoride: Benefits from topical sources tend to be temporary and are accrued when fluoride from external sources comes into direct contact with the surfaces of the teeth' 07. Topical benefits can be obtained through use of such things as fluoride toothpaste, fluoride mouthrinses, fluoride varnishes, and fluoride treatments that are provided in dentists' offices. Fluoride toothpaste does a great job in helping to prevent dental decay, but only provides a temporary topical benefit to the tooth surfaces. Fluoride toothpaste, by itself, also does not prevent decay as well as fluoride from the previously mentioned systemic sources 3-4,64,56-67 Readily available from grocery stores, drug stores, -and other commercial establishments, fluoride toothpaste is safe and should be used according to directions on the label. Fluoride toothpaste can be used by children and adults in areas served by fluoridated community water systems and does provide additional protection to teeth. Fluoride mouthrinses are effective in preventing dental decay, but also only provide a temporary benefit and are not as effective as fluoride from systemic sources 3- 4.s-s,5T They are available over the counter (grocery stores, drug stores, etc.) or by prescription from dentists and physicians. Fluoride mouthrinses may be used at the same time that people are getting fluoride from systemic sources (community water fluoridation or fluoride tablets/vitamins with fluoride), however fluoride mouthrinses should only be used in these situations after consulting with the family's dentist or physician. Fluoride varnishes and topical fluoride treatments from a family's dentist also provide a temporary topical benefit to the tooth surface 4. 6"857: These topical fluoride treatments may be used at the same time that an individual is receiving fluoride from systemic sources, but only if the dentist has determined that there is a need for a fluoride varnish or topical fluoride treatment because of the level of decay present in that individual. It is important to remember that fluoride from topical sources, while effective in preventing dental decay, is not nearly as effective as fluoride from systemic sources 4-6 Moreover, fluoride from topical sources should never be considered to serve as an adequate substitute for fluoride from systemic sources. The gold standard for dental disease prevention is community water fluoridation 4,6,55-5T Community water fluoridation should be implemented whenever it Is technically feasible. Fluoride tablets are meant to be used as a temporary substitute for community water fluoridation only until a community water system can be fluoridated. Topical sources of fluoride (fluoride toothpaste, fluoride mouthrinses, and fluoride treatments provided in dental offices) are only meant to be used as adjuncts to systemic sources of fluoride. How Much Fluoride Is Added To The Drinking Water? Only a very small amount of fluoride is added to the drinking water to achieve the desired maximum benefits. The existing natural fluoride levels in drinking water supplies are adjusted slightly in order to raise them to between 0.7 and 1.2 parts per million o,ST This very small amount of fluoride being added is considered to be a trace amount. The precise level of fluoride calculated to be appropriate for each individual community is determined based on that community's annual average daily temperature . Depending on the precise calculation, each community's water fluoride levels will be adjusted to between 0.7 and 1.2 parts per million depending on where the community is 3 Packet Page -183- 5/10/2016 11.B. located and what type of climate it has' 1.57. Florida typically adjusts fluoride levels in its community water systems to 0.8 parts. per million. Whichever level of fluoride is determined to be the correct level for an individual community, it bears repeating that only a very small amount of.fluoride is ultimately added to the drinking water: it also is important to remember that the optimal amount of fluoride in fluoridated drinking water has been calculated to take into account the fluoride the people get from other sources, like food and drink. Fluoridated drinking water provides only about one-third to one-half the amount of fluoride that an individual should be getting on a daily bas€s12. Is The Amount Of Fluoride In Fluoridated Water Systems Safe? The amount of fluoride present in fluoridated community water systems Is miniscule and has been determined to be safe for all individuals, regardless of age, race, gender, or health status13, 39.48.57 In other words, community water fluoridation is safe for infants, children, teenagers, young adults, mature adults, and senior citizens' 3, 39.48,67 it is safe for everyone, even those with chronic diseaseS13, 39•x8,67 Community water fluoridation harms no one and it is also effective in preventing dental decay in people of all ages, races, ethnic groups, or socioeconomic backgrounds"' 39-48,67 Fluoride, like many other substances that are required to sustain life and promote health, is beneficial in small amounts and harmful in large amounts. Such common substances as vitamins, minerals, table salt, food, even water, are helpful in the correct amounts and harmful in excessive amounts. For example, fluoride levels in fluoridated water are so low that an adult would have to consume 660 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride that would cause death 14. It is physically impossible for an adult to ever consume that amount of water - the adult would die of other causes long before they were able to accumulate enough fluoride to cause a probleml4. Likewise, a 12-18 month old child would have to drink 85 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride. that would cause death, again a physical impossibility I.4. - In order to suffer chronic skeletal effects of too much fluoride, an adult would have to consume roughly 6 to 14 gallons of fluoridated water every day for 10 to 20 years - again physically impossible for virtually all adultst4. Most adults drink far less than 1 gallon of water or other liquids a day,'more likely drinking about a quart per day. Children consume even much lower amounts of liquids than do adults on a daily basis. A lifetime of exposure to water fluoridated at the optimum level (0.7 to 1.2 parts per million) results in no adverse effects io any individual or group of individuals 13, 39-48,56- 57 Thousands of scientific studies have been completed which looked at individuals and groups who used water with optimum levels of fluoride their entire lives 13 39-48,56-57 Lifetime exposure to fluoridated water caused no diseases, no disabilities, nor any other adverse conditions for any group or individuals13,39-48,5657 Lifetime exposure to fluoridated water only resulted in benefits - lower rates of dental decay and lower health care bills", 1111,56-57 How Widespread Is The Practice of Community, Water Fluoridation In the United States and in Florida? Currently over 152 million Americans are benefiting from community water fluoridation's". Another 10 million Americans are fortunate enough to live in communities with adequate levels of naturally occurring fluoride'6 e. That means that over 162 million Americans and more than 67 percent of those with access to community water systems currently benefit from fluoridation's continuous protection against dental decay's,sa In addition, over 12 million people in Florida are benefiting from water fluoridation'S,'a. This represents 76.8% of Florida's population having access to public Packet Page -184- 5/10/2016 11. B. water supplies1$58. While in 2002 Florida ranked 31st among the 51 recognized jurisdictions (50 states + the District of Columbia) in the percentage of those on community water systems benefiting from fluoridation, recent implementation of fluoridation by a number of communities appears to place Florida about 241h out of 51 jurisdictions reporting to CDCs Water Fluoridation Reporting System (WFRS) Florida's fluoridation efforts began more than half a century ago, with Gainesville commencing fluoridation in 1949, the same year that the Florida Department of Health strongly endorsed its use'S58. Miami and Dade County's population (currently numbering over 2.4 million people) has had access to the health benefits of community 5 8 water fluoridation since 19521. Other large counties in Florida provide fluoridated water to the majority of their citizens (Broward, 1.6 million; Duval, 902,000; and Hillsborough, 780,000; just to name a few)15,58. The 162 million Americans benefiting from fluoridation live in more than 10,500 communities that are served by over 14,300 water systems'"a. In addition, 46o f the 50 largest cities in the United States are currently fluoridating their water systems . It is also important to remember that some communities in the United States have been fluoridating their public water systems since 1945, many since the 1950's and 1960's. We have over 60 years experience adjusting fluoride levels in community water systems. Are There States That Require Fluoridation of Some Community Water Systems? Many states have passed legislation requiring community water systems to provide the benefits of water fluoridation for their customers. California, Connecticut, Delaware, Georgia, Illinois, Minnesota, Nebraska, Nevada, Ohio, and South Dakota ; require certain communities to fluoridate their public water systems . Both the Commonwealth of Puerto Rico and the District of Columbia have also legislatively mandated fluoridation'e. Additionally, Kentucky requires statewide fluoridation by administrative regulation 18. Moreover, many local governments, including local governments in Florida, have required fluoridation through laws, regulations, and ordinances. Who Benefits From The Cost Savings That Result From Fluoridation? The total cost to the nation for dental treatment services reported in 1997 was $50.6 billion, while $60.7 billion was spent in 2000; and the total has climbed to $78.2 billion in 2004 - a substantial amount usually paid for by individuals, employers, government agencies, and insurance companies19,69 . Nationally, the tax -funded Medicaid program �a►d $2.1 billion for dental services in 1998, $3.0 billion in 2001, and $4.4 billion in 2004 9. Florida's Medicaid Dental Program expended $94.7 million of taxpayers' money in FY 2001-2002 at a utilization rate of 18.3% for children and only 8.3% for adults (which means that if all eligible patients sought services, the total annual cost for the program could be four to ten times the current rate). In FY 2002-2003, the Medicaid Dental Program expended $84.7 million — $10 million lower than the previous year's total because all adult dental services (except emergency services) were eliminated as an attempt to lower program costs. Interestingly, while approximately $20 million was saved by eliminating adult services (which totaled $4.9 million for the year), the cost of children's dental services increased by over $10 million to $79.8 million for the year. Utilization rates for children had risen to 21.4%, while adult utilization rates plummeted to 3.0%. Better utilization rates would yield much higher costs, but more widespread use of community-based prevention measures, such as community water fluoridation, goes a long way toward moderating the need for such expenditures. There are a number of ways in which individuals and groups benefit from the costs savings brought on by community water fluoridation, costs which are avoided 5 Packet Page -185- 5/10/2016 11. B. because of the need for less dental treatment. For example, taxpayers benefit because public programs paying for dental care for disadvantaged populations require fewer local, state, and federal tax dollars for each.person covered by the program2b. It is expected that in the Florida communities that implement water fluoridation, Medicaid dental costs would be reduced by at least one half. Other states have demonstrated significant cost savings in their Medicaid programs as a result of community water fluoridations2" The Federation of American Societies for Experimental Biology, in testimony before the Congressional Biomedical Research Caucus (U.S. Congress) in February 1995, documented that the national cost savings resulting from fluoridation totaled $3.84 billion each yearns. In addition, employers benefit because their costs for prepaid dental care fringe benefits for their employees are lower20. Employers also avoid the extra costs required when their employees are absent from work due to personal or family visits for dental care20. Consumers benefit because they pay lower costs for consumer goods since employers' costs for insurance and employee absences is lower20. In other words, the cost of doing business in a fluoridated community is lower for employers. Additionally, all patients benefit in several ways. First, their overall health care bills and insurance premiums are lower in fluoridated communities because there are fewer expensive hospital emergency room visits for dental emergencies, costs of which are usually passed on to everyone able to pay through their health care bills and insurance premiums20. Secondly, patients in fluoridated communities avoid having to pay higher health care bills, dental bills, and insurance premiums that often result from the need for physicians, dentists, and hospitals to pass on their extra costs for uncompensated care to those who can pay20 . it is most apparent that everyone wins with fluoridation. Not only do individuals benefit because of their improved oral health, but they benefit greatly because cost savings resulting directly and indirectly from a community's decision to fluoridate. Fluoridation ultimately promotes lower health care costs, lower insurance costs, lower tax -supported costs for public programs, lower business costs for employers, and lower costs for consumer goods and services20. What Other Impact Is Water Fluoridation Having On Consumer Or Taxpayer Costs? The extensive use of community water fluoridation in the United States has contributed substantially to decreasing consumer and taxpayer costs for supporting dental education. Because of lower levels of dental decay in the U. S. population, fewer dentists are needed to care for those currently in the health care system. As a result, seven dental schools have ceased operations since 198521. In addition since. 1980, enrollment reductions in the remaining dental schools have been equivalent to the closure of another 20 average size dental schools2S. Community water fluoridation has also had an impact on the costs of dentists' malpractice insurance. Dentists practicing in fluoridated communities pay significantly lower malpractice insurance premiums than dentists practicing in non -fluoridated communities". These lower malpractice insurance rates occur for several reasons. First, since the population suffers from much less decay in fluoridated communities, dentists do not spend as much time providing extensive reparative procedures and therefore are less likely to run into treatment complications. Secondly, dentists also require less use of general anesthesia and other forms of premedication in fluoridated communities because there are fewer cases of rampant decay in young children. Packet Page -186- 5/10/2016 11.B. Who Supports Community Water Fluoridation? Most legitimate organizations representing health professionals, public health agencies, and scientists strongly support community water fluoridation. The American Medical Association, American Public Health Association, American Nurses Association, American Osteopathic Association, American Academy of Pediatrics, American Academy of Family Physicians, American Dental Association, American Dental Hygienists Association, Association of State & Territorial Health Officials, National Association of County & City Health Officials, American Dietetic Association, U. S. Public Health Service, National Institutes of Health, Centers for Disease Control, World Health Organization, American Water Works Association, and National Rural Water Association represent just a few of the hundreds of organizations that support fluoridation . It is important to note that these broadly based organizations represent millions of health practitioners, scientists and other professionals. These credible and respected organizations have also been working to improve the lives of Americans for many years. They are organizations and agencies with established administrative offices, some with state and local chapters, and many publishing peer-reviewed scientific journals. Community water fluoridation has also been repeatedly shown to have wide support of the American publlc24"26. Most recently, a national scientific poll taken by the prestigious Gallup Organization documented that 70% of Americans thought community water systems should be fluoridated, 12% did not know, and only 18% thought that community water systems should not be fluoridated24 . Who Opposes Community Water Fluoridation? While there is a small, very vocal, minority of the population that opposes the implementation of community water fluoridation, n credible national scientific or professional organization opposes the practice . Individuals who oppose fluoridation are often called'antifluoridationists;' Most groups that claim to oppose fluoridation have few members, have no history because they have been organized for relatively short periods of time, have no established offices because they often operate out of individuals' homes, and have unfamiliar names and spokespersons",". These groups have been granted no professional credibility or scientific standing by the scientific or healthcare communities, publish no accepted scientific journals, and frequently use multiple names in order to appear to have more support for their position than actually exists" -'1141, Most of the groups lack any stability, disbanding and reforming periodically as interest in.their movement periodically increases or subsides'6'26 34. The antifluoride groups often publish pseudoscientific propaganda pieces which, when vigorously 18, zs-3i reviewed and investigated, lack any basis in science . Many of these organizations operate exclusively though the Internet where there is little in place to9p protect consumers from their scientifically invalid claims and their extensive propaganda . Summary and Conclusions Community water fluoridation has served the American public extremely well as the cornerstone of dental caries prevention activities for more than 60 years. The dental health and general health benefits associated with the consumption of water -borne fluorides have been documented for over 100 years. Ongoing research, often conducted in response to the repeated allegations by those opposed to fluoridation, continues to confirm the safety, effectiveness, efficiency, cost-effectiveness, and environmental compatibility of community water fluoridation. Fluoridation also continues to be acclaimed as an important contributor to the health of the nation, most recently being named as one of the twentieth century's ten greatest public health achievements49. Dr. David Satcher, previously the Assistant 7 Packet Page -187- 5/10/2016 11. B. Secretary for Health and the Surgeon General of the United States, reconfirmed the support of his office for community water fluoridation as part of his focus on America's oral heal0a5'. In addition, Vice Admiral Richard H. Carmona, the current Surgeon General of the United States, stated: "Policy makers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and well being and take action to make ourselves, our families, and our communities healthier. I join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans;"" The adoption of community water fluoridation by local communities and state legislatures represents an excellent example of good public policy. Communities throughout the United States continue to exhibit sound decision-making and evidence their continued trust and faith in science and the health professions by adopting fluoridation. The acceptance of community water fluoridation by public officials ensures that'all citizens of a community, regardless of age, race, ethnic background, religion, gender, educational status, or socioeconomic level, receive the same substantial dental disease prevention benefits currently available to the 162 million. Americans on fluoridated water systems. REFERENCES' 1, Garcia Al; Caries incidence and costs of prevention programs. J Public Health Dent 1989; 49(5):259-71. 2. U. S. Centers for Disease Control & Prevention, Public health focus: fluoridation of community water. systems. MMWR: Update 1992; 41(21):372-5. 3, Murray JJ. Efficacy of preventive agents for dental caries. Caries Res 1993; .27(Suppl 1):2-8. 4. Newbrun E. Fluorides and dental caries, 3�d ed. Springfield, IL; Charles C. Thomas, publisher, 1986. 5. Lambrou D, Larsen MJ, Fejerskov 0, & Tachos G. The effect of fluoride in saliva on remineraiization of dental enamel in humans. Caries Res 1981; 15:341.5. 6. Burt BA (ed.). The relative efficiency of methods of caries prevention in dental public health: proceedings of a workshop at the University of Michigan, Jun 5-8,1978, Ann Arbor, Ml; University of Michigan Press, 1978. 7. Burt BA (ed.). Proceedings for the workshop: cost effectiveness of caries prevention in dental public health, held at Ann Arbor, MI, May 17-19, 1989. J Public Health Dent 1989; 56(5, Spec Issue):249-344. 8. Murray JJ, Rugg -Gunn AJ, & Jenkins GN. Fluoride in caries prevention, 3`a ed. Oxford, England, Uk; Wright, publisher, 1991. 9. Levy $M, Kiritsy MC, & Warren JJ. Sources of fluoride intake In children. J Public Health Dent 1995; 55(1):39-52. 10. U. S, Centers for Disease Control & Prevention. Water fluoridation: a manual for water plant operators. Atlanta, GA; The Agency, Apr 1994. 11. Galagan DJ & Vermillion JR, Determining optimum fluoride concentrations. Public Health Rep 1957; 72:491-93. 12. National Academy of Sciences, Institute of Medicine (Food & Nutrition Board). Dietary reference intakes for calcium, phosphorous, magnesium, vitamin D, & fluoride; report of the standing,committee on scientific evaluation of dietary reference intakes. Washington, DC; National Academy Press; 2000. 13'. U. S. Department of Health & Human Services, Public Health Service. Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs.. Washington, DC; The Agency; Feb 1991. 14, Hurt BA & Eklund SA. Dentistry, dental practice, & the community, 4°i ed. Philadelphia, PA; W. B. Saunders Company, publisher, 1992. pp.146-147. Packet Page-188- 5/10/2016 11.B. 15. U. S. Centers for Disease Control. Fluoridation Census, 2000. Atlanta, GA; The Agency; 2001.. 16. Easley, MW. The status of community water fluoridation in the United States, Public Health Rep 1990; 105(4):348-353. 17. Delaware State Senate, 139t' General Assembly, Senate Bili No. 173 - An act to amend title 16 of the Delaware Code relating to fluoridation of water supplies. Delaware Online Legislative Information Service at http://www.state.de.us/govern/agencies/legis/lis/139/bills/107796.htm. 18. Kentucky Administrative Regulations. Title 401, Chap. 8 - Public Water Supply; 401 KAR 8:650 - Supplemental Fluoridation. 19. Palmer C. Dental spending exceeds $50 billion. Am Dent Assoc News, 1998; 29(22):1,30. 20. White BA, Antczak-Bouckoms AA, Milton C, & Weinstein MC. Issues in the economic evaluation of community water fluoridation. J Dent Educ 1989; 53(11):646-657. 21. Nash, DA. And the band played on. J. Dent Educ, 1998; 62(12):964-974, 22. Conrad DA, Whitney C, Milgrom P, O'Hara D, Ammons R, Fiset L, & Vesneski W. Malpractice premiums in 1992: results of a national survey of dentists. J Am Dent Assoc, 1995; 126:1045-1056. 23, American Dental Association (Council on Access, Prevention, & Interprofessional Relations), Fluoridation Facts. Chicago, IL; The Organization, 2005.70p. 24. Am. Dent A. (Survey Center). 1998 consumers' opinions regarding community water fluoridation. Chicago, IL; The Organization, Aug 1998. ' 25. Gallup Organization, Inc. A Gallup study of parents' behavior, knowledge, and attitudes toward fluoride. Princeton, NJ; The Organization, 1991. 26. Easley MW. The new antifluoridationists: who are they and how do they operate? J Public Health Dent 1985; 45(3):133-141. 27. Barrett S & Rovin S (eds.). The tooth robbers: a pro -fluoridation handbook: Philadelphia, PA; George F. Stickley Company, 1980. 28. Wulf CA, Hughes KF, Smith KG, & Easley MW. Abuse of the scientific literature in an antifluoridation pamphlet (2na ed.). Baltimore, MD; American Oral Health Institute Press', 1988. 29. Easley MW. Celebrating 50 years of fluoridation: a public health success story. British Dent J 1995;178(2):72-5. 30. Easley MW. Fluoridation: a triumph of science over propaganda. Priorities (J American Council on Science & Health)1996; 8(4):35-39. 31. Easley MW. Community water fluoridation. p.48-49, In American Council on Science & Health. Facts versus fears, special report: a review of the greatest unfounded health scares of recent times. New York, NY; The Organization, 1998. 32. McGuire S. A review of the impact of fluoride on adult caries. J Clin Dent 1993; 4(1):11-13. 33. Meibert JR & Ripa LW. Fluoride In preventive dentistry: theory and clinical applications. Chicago, It.; Quintessence; 1983:41-80. 34. 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. 35. Stamm JW, Banting DW & lmrey PB. Adult root caries survey of two similar communities with contrasting natural water fluoride levels. J Am Dent Assoc 1990; 120143-149. 36. Newbrun E. Prevention of root caries. Gerodont 1986; 5(1):33-41. 37. Am. Dent A. (Council on Access, Prevention, & interprofessional Relations). Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc 1995;126(Suppi). 38. Brown LJ, Winn DM, & White 13A. Dental caries restoration and tooth conditions In U. S. adults, 1988-1991. J Am Dent Assoc 1996; 127:1315-1325. Packet Page-189- 5/10/2016 11.B. 39. Rugg -Gunn AJ. Nutrition and dental health. New York, NY; Oxford University Press; 1993. 40. Kaminsky LS, Mahoney MC, Leach J, Melius J, & Miller MJ. Fluoride: benefits and risks of -exposure. Crit Rev Oral Blot Med 1990;1:261-281. 41. National Academy of Sciences (Committee on Animal Nutrition and the Subcommittee on Fluorosis). Effects of fluorides in animals. Washington, DC; The Organization; 1974. 42. Pendrys DG & Stamm JW. Relationship of total fluoride intake to beneficial effects and enamel fluorosis. J Dent Res 1990; 69(Spec issue):529-538. 43. Olson RE (ed.). Fluoride in food and water. Nutr Rev 1986; 44(7):233-235. 44. Leone NC, Shimkin MB & Arnold 1=A, et at. Medical aspects of excessive fluoride in a water supply. Public Health Rep 1954; 69(10):925-936. 45. Whitford GM. The metabolism and toxicity of fluoride (2"4 rev. ed.) in Monographs in oral science. Basel, Switzerland; Karger;1996. (Vol. 16). 46. Dean HT. The investigation of physiological effects by the epidemiological method in Moulton FR (ed.). Fluorine and dental health. Washington, DC; Am Assoc Advancement Sci Publ. No. 19; 1942:23-31. 47, Lewis DW & Bantling DW. Water fluoridaEion'. current effectiveness and dental fluorosis. Community Dent Oral Epidemiol 1994; 22:153-158. 48. National Research Council. Health effects of ingested fluoride: report of the Subcommittee on Health Effects of Ingested Fluoride. Washington, DC; National Academy Press; 1993. even#ion. Ten Great Public Heath Achievements: 49. U. S. Centers for Disease Control & Pr United States, 1900-1999. Morbidity & Mortality Weekly Report; 48(12);241-243, April 2, 1999. 50. Satcher D. (U.S. Surgeon General). Letter to Collins, TR (Chairman, California Fluoridation Task Force). October 19, 1998, 51. Satcher D. (U.S. Surgeon General). Oral Health in America: A Report of the Surgeon General. Rockville, MD; U.S. Department of Health & Human Services; June 2000. 311p. 52. Barsiey, R. Sutherland J. & McFarland L. Water Fluoridation and the Costs of Medicaid Treatment for Dental Decay, Louisiana, 1995-1996. Morbidity & Mortality Weekly Report, 48(34):753-757, September 3, 1999. 53. Texas Department of Health. Weter Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid). Austin, TX; The Agency; May 2000. 14p. 54, Carmona, RHI. (U.S. Surgeon General): Official Signed Statement on Comm uniEy Water Fluoridation. Press Release from the U.S. Department. of Health &:Human Services, Centers for Disease Control & Prevention. Atlanta, GA; July 28, 2004. 55. Silverstein, SC. Testimony Before Congressional BHiil, edit l Res n, ch Caucus, U:S. Congress. Rayburn House Office Building, p February 10, 1995. 65. Griffin, SO. Jones, K., Tomar, SL.. An Economic Evaluation of Community Water Fluoridation. J. Public Health Dent 2001;61(12):78-86. 56. Jones, S. Burt, BA. Petersen, PE. & Lennon, M.A. The Effective Use of Fluorides in Public Health. Bull World Health Organization. Sept 2005. pp.670-676. 57. Am Dent A. Fluoridation Facts. Chicago, IL, The Association. 2005, 70p. 58. Centers for Disease Control. Water Fluoridation Reporting System (WFRS), 2005. 59. USDHHS/CMS. Health Accounts: National Health Accounts/national Health Expenditures (Table 3) and National Health Expenditure Projections 2003-13 (Table 8). http://dms.hhs.gov/statistics/nhe/ ACKNOWLEDGEMENT: The editor wishes'to thank Dr. Harry W. Davis, Dental Executive Director; Dr. Millard Howard, Dental Coordinator; and Mr. Sean P. Isaac, _ Fluoridation Coordinator; all of the Bureau of Dental Public Health; Florida Department of Health for their assistance in updating Florida health & demographic data and in revidwing the manuscript. Packet Page-190- About the Author:. M 5/10/2016 11.B. Dr. Michael W. Easley currently serves as Dental Coordinator for the Bureau of Dental Public Health, Division of Family Health, Florida Department of Health. He also serves as the volunteer Director of the National Fluoridation Center at Oral Health America. He has a doctorate in dentistry from Ohio State University & a masters in dental public health administration from the University of Michigan. He completed a one- year public health leadership fellowship with the National Public Health Leadership Institute at the University of California -Berkeley and completed a two-year residency in Dental Public Health through the University of Texas Health Science Center at Houston. Prior to coming to Florida, Dr. Easley served as the President & Chief Executive Officer of International Health Management & Research Associates, a public health consulting firm. He recently served as a full-time Associate Professor in the College of Health Sciences, Eastern Kentucky University, was a full-time Associate Professor in the Schools of Medicine and Dental Medicine, University at Buffalo, served a term as Governor Brereton Jones' appointee in the position of Director of Environmental Health & Community Safety for the Commonwealth of Kentucky, and served as the Commissioner of Health & Environment for the Middletown [Ohio] City Department of Health & Environment. Dr. Easley was Associate Director of Professional Relations for Procter & Gamble's Health Care Products Division and Coordinator of Worldwide Pharmaceutical Research for Procter & Gamble's Oral Care Research Section. He previously was Director of the Division of Dental Health for the Ohio Department of Health and also was Director of the Division of Dental Health for the Maryland Department of Health & Mental Hygiene. He served as a clinical general dentist in private practice and a clinical dental surgeon and hospital clinic manager in the U.S. Navy and U.S. Public Health Service. He also served as the Associate Director of Clinics (and Associate Professor) at the University of Detroit's School of Dentistry and was the manager of a large hospital dental clinic affiliated with the University of Detroit, Wayne State University, and Detroit Receiving Hospital. Doctor Easley has held a number of offices in national health and public health organizations, including President of the American Association of Public Health Dentistry, Chair of the Oral Health Section of the American Public Health Association, two terms as a member of the Board of Directors of the Association of State & Territorial Dental Directors, and two terms as President of the American Oral Health Institute. He has authored or co-authored several textbooks and monographs and has published more than one hundred articles in professional journals. I 1 Packet Page -191- Cost Savings - Fact Sheets - Community Water Fluoridation - Oral Health 5/10/2016 11.13. Home About CDC Press Room A-2 Index Contact Us CC Search: 0 E-mail this pac Community Water Fluoridation B Printer -friendly Oral Health Home > Community Water Fluoridation Home > Fact Sheets View by Topic Cost Savings of Community Water Fluoridation > Benefits > aet Two published studies conducted by CDC reaffirm the benefits of community water fluoridatli the studies continue to show that widespread community water fluoridation prevents cavities > Statistics money, both for families and the health care system. in fact, the economic analysis found the > Engineering and communities of more than 20,000 people where it costs about 50 cents per person to fluoridt Operations every $1 Invested In this preventive measure yields approximately $38 savings In dental trea > Other Fluoride Products > Fact Sheets "An Economic Evaluation of Community Water Fluoridation"I presents the results of an ecot > FAQs analysis of water fluoridation under modem conditions of widespread availability of fluorides. from CDC and Terry College of Business, University of Georgia, found that under typical con > Guidelines and per -person cost savings In fluoridated communities ranged from $16 in very small cot Recommendations (<5,000) to nearly $19 for larger communities (>20,000). The analysis takes Into account the (<6,000) > Journal Articles installing and maintaining necessary equipment and operating water plants, the expected eff• > Related Links fluoridation, estimates of expected cavities in non -fluoridated communities, treatment of cavil lost visiting the dentist for treatment. Contact into A related analysis found that children living In non-fluorldated communities in states that are Centers for Disease Control fluoridated receive partial benefits of fluoridation from eating foods and drinking beverages p and Prevention Division of Oral Health fluoridated communities. This second study, Quantifying the Diffused Benefit from Wafer Fit reports that 12 -year-old children living in states where more than half of the communities hay Mail Stop F-10 water have 26% fewer decayed tooth surfaces per year than 12 -year-old children living in stE 4770 Buford Highway NE Atlanta, GA 30341 less than one-quarter of the communities are fluoridated. 'Widespread community water fluoridation prevents cavities even in neighboring communitie Contact Us fluoridated,' according to Dr. Susan Griffin, the study's main author. For instance, a 12 -year ."•"•""'""""""""""""""""""""" who has lived In a non -fluoridated community in a highly fluoridated state would typically hav cavity than a child in a low -fluoridated state." References 1. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluor Publ Health Dent 2001;61(2):78--86. View abstract on PubMed. 2. Griffin SO, Gooch BF, Lockwood $A, Tomar SL. Quantifying the diffused benefit fluoridation in the United States. Community Dent Oral Epldemlol2001;29:120-1 abstract on PubMed. Related Links •' Recommendations for Using_ Fluoride to Prevent and Control Dental Caries in the States. WW -R, Vol. 50, No. RR14;1-42. (August 17, 2001) • Water Fluoridation Fact Sheef_1992 Date last reviewed: September 26, 2007 Date last updated: August 9, 2007 Content source: Division of Oral Health, Natrona) Cenfer.for Chronic Disease _P_rM-0 ia1 and Promotion .Home J Policies and Regulations i Disclaimer I e -Govern en I FOIA i Contac Us Packet Page-192- http://Wmv.cdr,.gov/fluoridation/fact sheets/cost.htm 3/19/2009 Fluoridation - Fact Sheets - Bo diits '. W'atex Fluoridation . Oral Health Home Water Fluoridation _ Key Resources on Topic } Home Fact Sheets } Benefl s Safet y •Sial€stirs Engineering and Operations Other Fluoride Products -Publications - Related Links Contact Info Centers for Disease Control and Prevention Division of Oral Health Mail Stop F-10 4770 Buford Highway NE Atlanta, GA 30341 Contact Us Guidelines & Recommendations 5/10/2016 11.B. ®.....Email this oaae.... g Printer -friendly version ......................................................... Questions & Answers The Benefits of Fluoride`��y u � From the Office of the Surgeon General, a U.S. Department of Health and Human Services May 2000 ' 1796 . Community water fluoridation is an effective, safe, and inexpensive way to prevent tooth decay. This method of fluoride delivery benefits Americans of all ages and socioeconomic status. . Brushing twice a day with a fluoride toothpaste Is an easy way to prevent tooth decay. e Fluoridation, which was started In Grand Rapids, Michigan in 1845, has been used successfully In the United states for more than 50 years. It benefits both children and adults. . Fluoride works by stopping or even reversing the decay process. it keeps tooth enamel strong and solid. . Community water fluoridation is considered one of 10 great public health achievements of the 20th century. . Of the 50 largest cities In the United States, 42 have community water fluoridation (and 2 cities are have natural fludride levels that are optimal). Fluoridation reaches 67 percent of the population on public water supplies— more than 170 million people, • The annual cost of fluoridation Is approximately $0.50 in communities of Z 20,1)00 to approximately $3.00 per person In communities 5 5,000 (in 1995 dollars) for all but the smallest water systems. Even so, 100 million Americans do not have access to fluoridated water. . Communities with fluoridated drinking water in the United States, Australia, Britain, Canada, Ireland, and New Zealand show striking reductions In tooth decay—those with fluoridated drinking systems have 15-40 percent less tooth decay, . Nearly all tooth decay can be prevented when fluoridation Is combined with dental sealants and other fluoride products, such as toothpaste. • Fluoride dietary supplements can provide fluoride to those who do not have adequate levels In their drinking water. They are available as tablets, drops, or lozenges. . Over-the-counter fluoride dental products such as toothpastes and mouth rinses are effective In preventing . decay. o Products with high concentrations of fluoride that are applied in the dental office or prescribed for home use offer additional protection for those at Increased risk of tooth decay. . Because older Americans are now keeping their teeth longer, fluoride will continue to be Important for preventing tooth decay in this age group. Older Americans are especially susceptible to tooth decay because of exposed root surfaces and mouth dryness that may result from many medications. For more Information, contact: fitel//CyDocuments%20and%20Set(ings/rsaacSP/Desktop/Fluoridation%20•'/20Fact%20Sheet0Q0%208encfirs.h,m0 of2)9127/2006 10:42:58 AM Packet Page -193 - Osteosarcoma - Safety - Community Water Fluoridation - Oral Health 5/10/2016 11.B. Home About CDC Press Room A-2 index Contact Us Search: Community Water Fluoridation 0 E -mall ti„S pa` y� g Printer -friendly Oral Health Nome > Community Water Fluoridation Home > Safes View by Topic CDC Statement on Water Fluoridation and Osteosarcoma > Benefits > Safety Osteosarcoma is a type of rare bone cancer. About 400 children and adolescents in the Unit, > Statistics diagnosed each year, approximately 250 of whom are males. An observed association betty( to fluoride in drinking water and the incidence (new cases) of osteosarcoma in young males I ) Engineering and reported in a paper entitled Age-specific Fluoride Exposure in Drinking Water and Osteosarc Operations States) (Bassin at al., 2006). No apparent association was observed in females. This resear( > Other Fluoride Products author describes as an exploratory analysis, adds to the scientific knowledge base on this tol > Fact Sheets author acknowledges that this study has limitations and further research is required to confirr this observation. > FAQs > Guidelines and This paper is based on the analysis of an initial set of cases from a 15 -year effort to study flu Recommendations osteosarcoma by the Harvard School of Dental Medicine and collaborating organizations. Th > Journal Articles investigator for the overall study cautions against over interpreting or generalizing the results > Related Links Bassin analysis, stressing that preliminary analysis of a second set of cases does not appeal the findings (Douglass et al., 2006). Publications from the forthcoming analyses are expecte( further information as to whether and to what extent an association may exist between osteo Contact; info exposure to fluoride. Centers for Disease Control and Prevention A number of studies regarding water fluoridation and osteosarcoma have been published in i Division of Oral Health this time, the weight of the scientific evidence, as assessed by independent committees of e) Mail Stop F-10 comprehensive systematic reviews, and review of the findings of individual studies does not 4770 Buford Highway NE association between water fluoridated at levels optimal for oral health and the risk for cancer Atlanta, GA 30341 osteosarcoma. in a report issued in March 2006, Fluoride in Drinking Water.' A Scientific Rev Standard, the National Research Council (NRC, 2006) considered all available evidence on I Contact Us osteosarcoma, including pre -publication data from the analysis by Dr. Bassin. The NRC Corr the overall evidence on osteosarcoma to be tentative and mixed, and no recommendations v ...................................................... related to this health concern for revising current allowable fluoride levels in drinking water. T stated that the results of the larger Harvard study, once published, may provide an important addition to the weight of scientific evidence regarding this condition. CDC's mission includes monitoring health, detecting and investigating health problems, deve advocating for sound public health policies, implementing prevention strategies, promoting hi behaviors, and fostering safe and healthful environments. The overriding goal and concern I: the health and well being of the public. CDC continually monitors and evaluates scient€fic inf( fluoridation as part of its responsibility for public health assurance and protection. CDC, alon! experts in'the scientific community, will review published studies when they become availabit continue to monitor other scientific developments related to water fluoridation, and will proved and recommendations about fluoride to the public. CDC continues to strongly support community water fluoridation as a safe and effective pubil measure to prevent and control tooth decay and to improve overall health. Water fluoridation people of all ages and socioeconomic groups, including those difficult to reach through other programs and private dental care. CDC has recognized community water fluoridation as one public health achievements of the 20th century. Those wishing to learn more about fluoridate( CDC's Recomm_e_ndations for Us€ng_Fluor€de to.. Prgve�t and_Cotatroi.Dental Caries, in. the_UN info and other rmation of www.cdc.govloralhealth. References Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in drinking watt osteosarcoma (United States). Cancer Causes and Control 2006;17:421-428. Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Ca, Control 2006;17:481-482. Packet Page-194- http://www.cdc.gov/fluoridation/safety/osteosarcoma.htm 3/19/2009 Trends in Children"s Oral Health The Surgeon General's Report on Oral Health identifies a "silent epidemic" of dental and oral diseases, and calls for a national effort to improve oral health among Americans.) Left untreated, the pain and infection caused by dental caries (tooth decay) can lead to problems in eating, speaking, and the ability to learn.2 Access to Children from families with low incomes had five times Oral Health Care more untreated dental caries than children from higher income families. For each child without medical insurance, there are almost three children without dental insurance. Only about 50 percent of white children, 39 percent of African-American children, and 32 percent of Mexican - American children have dental insurance. 5/10/2016 11. B. Serious facial swelling from a tooth abscess resulting from decay. Children with Results of the 1994-95 National Health Interview Survey on access to care and use of ser - Special Health vices by children with special health care needs indicate that the most prevalent unmet health need is dental care. Among the respondents, 8.1 percent reported unmet dental care needs, Care Needs .4.1 percent reported unmet prescription and eyeglass needs, 3.2 percent reported unmet med- ical care needs, and 1.2 percent reported unmet mental health care needs.s More than half of the dental schools in the United States provide students with less than 5 hours of classroom instruction on patients with special health care needs and devote less than 5 percent of clinical time to this population.6 Early Childhood It is recommended that professional intervention begin at approximately 12 months of age or Caries shortly after the primary teeth begin to erupt. The goal of the first dental visit is to assess the risk for dental disease, initiate a preventive program, provide anticipatory guidance, and decide on the periodicity of subsequent visits? Children with early childhood caries weigh significantly less than their peers. With compre- hensive dental rehabilitation, these children can experience significant "catch-up" growth s The average Medicaid cost for providing restorative dental care for early childhood caries under general anesthesia in the hospital is $2,000 per case.9 Fluoridation Water fluoridation reduces dental caries in perma- nent teeth by 17 to 40 percent.10 However, more than 100 million Americans (38 percent of those on public water systems) do not have access to water that contains enough fluoride to protect their teeth." us.a��ott�a�s.�es n Oe t{:aithResoes¢¢scedSerrit¢sAuxi']strufba Rs�, Irtafernalsxidt60dHeahitBweov 9i� Although other fluoride -containing products are available, water remains the most equitable and cost- effective method of delivering fluoride to members of a community, regardless of an individual's age, educational attainment, or income level. 12 Nationally, the average per capita cost of water fluoridation is $0.51 per year.lo Over a life- time, this can be ler- `'-- `_ ,.,,... "F" 1""ing one dental filling.lt Packet Page -195- Dental Sealants 5/10/2016 11.B. Over 80 percent of tooth decay in school children is on the chewing surfaces of the teeth; use of dental sealants can prevent this type of decay.13 Only 23 percent 'of all children have dental sealants. Further, as few as Xpercettt•of children from low-income families have dental sealants.14 In 1999 the average cost for placing a dental sealant was $29.09, compared to the average cost of $65,09 for a one -surface dental filling.ls Most dental sealants are placed in private -practice dental offices, but the children ai the greatest risk for problems resulting from tooth decay are those least likely to receive dental care in a private practice.13 Injury and By age 16 years, 35 percent of children will have sustained dental trauma at least,once,16 ViolenCe Craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse.17 Dentists and dental hygienists are in a unique position to recognize child abuse and neglect. Used during sports, mouth guards offer a substantial degree of protection to the teeth and oral soft tissues, as well as protecting children and adolescents from.concussion.Ig Tobacco Tobacco use, especially cigarette smoking, is a significant risk factor for periodontal disease.19 Cancer -related signs and symptoms may include sores that do not heal, gingival recession, or difficulty in chewing; swallowing, or moving the tongue or jaw.2e Smokeless tobacco can result in advanced gum disease that is irreversible. As teeth lose their gum and bone support, they may loosen and eventually have to be removed21 Among students in grades 9 through 12, 9 percent currently use spit tobacco, and 43 percent use some form of tobacco (cigarettes, spit tobacco, or cigars). In this age group, 29 percent of black or-, frican Americans, 37 percent of Hispanic or Latinos, and 47 percent of whites smoke tobacco.15 References 1. National Institute of Dental and Craniofacial Research. 2000. The Surgeon General's Report on Oral Health. In National Institute of Dental and Cranio- facial Research [Web site]. Cited December 4,20M available at httpJ/wvnvnidr.nih.gov/sgrlsgr.htrn. 2. U.S. General Accounting Office, 2000.OralHealtb: Dental Disease Ira Chronic Pra6ltmAmongLow- Income Populations and Vulnerable Populations. Washington, DC: U.S. General Accounting Office. 3, Vargas CM, Isman RE, Crab JJ In press. Comparison of childreds medical and dental insur- ance coverage by socioeconomic characteristics, U.S. 1995. [journal name to come] 4. US. Department of Health and Human Services, Public Health Service, 1992. Current Ertimaterfrom the National Health Interview Suivey.1991. Hyattsville, MD: U.S. Department of Health and Human Services. 5. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. 2000. Access to health care for children with special health care needs. Pediatrics 105(4 Pt. 1):760-766. 6. Romer M, Dougherty N, Amores-L-Aeur E.1999. Predoctoral education in special care dentistry: Paving the way to better access? Joumal ofDrntutry for Children 66(2):132-135. 7. Nowak AJ. 1997. Rationale for the timing of the fust oral evaluation: Pediatric Dentistry 19(1):8-11. S. Acs G, Shulman R, Ng MW, Chussid S. 1999. The effect of dental rehabilitation on the bodyweight of. children with early childhood caries. journal of Pediatric Dentistry 21(2):109-113. NICIE M C. H Nattanaf Centvfor Eduction ' . Hxb+��tivsnul&GW In Maternal and Child Health Oral Health G tOtrttOxn Unher,:ty ttiouk" CiNrrt 9. Kanellis MJ, Damiano PC, Momany ET. 2000. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. journal of Public Health Dentistry 60(1):28-32. 10. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2000. Water fluoridation frequently asked questions. In CDC National Center for Chronic Disease Prevention and Health Promotion [Web site]. Cited December 15, 2000; available at http.J/wmv.cdr-govinccdphp/olVfl-faqs.htm. 11. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2000. CDC's oral health pro- gram, at -a -glance. In CDC National Center for Chronic Disease Prevention and Health Promotion [Web site]. Cited December 15,2000; available at http-J/www.cdc.govinccdphp/0h/2taglanc.htm. 12, Centers for Disease Control and Prevention. 2000. Achievements in public health, 1900-1999: Fluori- dation of drinking water to prevent dental caries. CDC MMWR Weekly [Web site]..Cited October 25, 2000; available at http-l/x"vw.cdc.gov/`mwr/ prevIeNy/mfnwrhftWmnl484lal.htm. 13. Siegal MD, Farquhar CL, Bouchard JM. 1997. Dental sealants: Who needs them? Public Health Reports 112(2):98-106. 14. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 2000. Healthy People. In U.S. Department of Health and Human Services, Office ofUsease Prevention and Health Promotion [Web site]. Cited December 4, 2000; available at httpJ/www.health.goy/bealthyp-ple. 15. Crall J. Faculty member, Department of Pediatric Dentistry. 2000, June 21. Personal communication. Farmington, CT: University of Connecticut Health Center. 16. Slavkin HC, 2000. Compassion, communication and craniofacial orodental trauma: Opportunities abound. Journal oftheAmeriran DentaldSSariatlori 131(4): 507-510. 17, American Academy of Pediatrics, Committee on Child Abuse and Neglect, and American Academy of Pediatric Dentistry, Ad Hoc Work Group on Child Abuse and Neglect. 1999. Oral and dental aspects of child abuse and neglect Pidiatria 104(2 Pt 1):348-350- 18. Sullivan, JA, Anderson SJ, eds. 2000. Can oftbe YoungArblete. Rosemont, IL: American Academy of Pediatrics and American Academy of Orthopaedic Surgeons. 19. Genco RJ, 1996. Current view of risk factors for periodontal diseases.JournalofPer{odontalogy 67 (Suppl.l0):1041-1049. 20. American Dental Association. 1998. ADA Guide to DmtalTherapeuties (1st ed.). Chicago, IL: American Dental Association. 21, Brown L, Lewis G, Martin M, Fowler R, Spohn E, Hardison D, eds. 1996. Kentucky Smile Curriculum: An oral Health Education Maifual. Louisville, KY: College of Dentistry, Urtive.rsity of Kentucky, and Kentucky Cancer Program; Frankfurt, KY: Kentucky Cabinet for Human Resource; and n.p.: Kentucky Oral Health Consortium. This publication has been produced by the National Matemal and Child Oral Health Resource Center sup- ported at the National Center for Education in Maternal and Child Heath, Georgetown University, cinder its cooperative agreement (MCU -119301) with the Maternal and Child Health Bureau, Health Resources and Services ea-,:..:.t..,t:.... rt a n..,-.,,.,Pnt of Health and Human Services, with assistance from the National Oral He Packet Page -196- and manycolleaguesworkinginoral health.February2001. GOVERNMENTAL AFFAIRS OFFICE 116 E. Jefferson SL Tallahassee, FL 32301 Phone., 904-224-1089 9 Fax: 904-224-7058 5/10/2016 11. B. IFn) a M a 0, / P4�\� DENTISTRY: HEALTHCARE THAT WORKS FLORIDA DENTAL- ASSOCIATION October 13, 1997 Dr. Harry Davis Department of Health Public Health Dental Program 1323 Winewood Tallahassee, FL 32399-0700 Re: FDA Endorsement of Community Water Fluoridation Projects Dear Dr. Davis: The Florida Dental Association's Board of Trustees and House of Delegates unanimously adopted the following resolution, on August 3, 1991: WHEREAS,. forty-five years of exhaustive study and more than fifty years of community experience have demonstrated community water fluoridation to be the safest and most effective method to prevent dental caries (decay); and, WHEREAS, the health and economic benefits of water fluoridation accrue to individuals of all ages and socioeconomic groups, especially poor children; and WHEREAS, The February, 1991 study released by the U.S. Public Health Service reaffirms.the effectiveness of community water fluoridation and strongly recommends that municipalities "Continue the addition of fluorides to water supplies wherever it Is deficient," Therefore be it RESOLVED, that the FDA unequivocally supports the optimal fluoridation of drinking water as a safe; effective and economical way to prevent dental caries. You may assure the Department of Health and others that The Florida Dental Association continues to strongly support the optimal fluoridation of drinking water as a safe, effective, and economical way to prevent dental caries. Sincerely, Carol A. Berkowitz, Esq. Governmental Affairs CB/rr cc: Dr. Thomas P. Floyd, President Dr. Hai Haering, Chairman of Governmental Affairs Dan Buker, Executive Director Packet Page -197- Debbie Huey, Director of Governmental Affairs 5/10/2016 11. B. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Office of the Surgeon General Rockville MD 20857 July 28, 2004 SURGEON GENERAL STATEMENT ON COMMUNITY WATER FLUORIDATION As noted in Oral Health inAmerica: A Report of the Surgeon General, community water fluoridation continues to be the most cost-effective, equitable and safe means to provide protection from tooth decay in a community. Scientific studies have found that people living in communities with fluoridated water have fewer cavities than those living where the water is not fluoridated. For more than 50 years, small amounts of fluoride have been added to drinking water supplies in the United States where naturally -occurring fluoride levels are too low to protect teeth from decay. Over 8,000 communities are currently adjusting the fluoride in their community's water to a level that can protect the oral health of their citizens. Over 170 million people, or 67 percent of the United States population served by public water supplies, drink water with optimal fluoride levels for preventing decay. Of the 50 largest cities in the country, 43 are fluoridated. Although water fluoridation reaches some residents in every state, unfortunately, only 24 states are providing these benefits to 75% or more of their residents. A significant advantage of water fluoridation is that all residents of a community can enjoy its protective benefit—at home, work, school or play—simply by drinking fluoridated water or beverages and foods prepared with it. A person's income level or ability to receive routine dental care is not a barrier to receiving fluoridation's health benefits. Water fluoridation is a powerful strategy in our efforts to eliminate differences in health among people and is consistent with my emphasis on the importance of prevention. The U.S, Centers for Disease Control and Prevention has recognized the fluoridation of drinking water as one of ten great public health achievements of the twentieth century. Water fluoridation has helped improve the quality of life in the United States by reducing pain and suffering related to tooth decay, time lost from school and work, and money spent to restore, remove, or replace decayed teeth, An economic analysis has determined that in most communities, every $1 invested in fluoridation saves $38 or more in treatment costs, Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral- health over a lifetime, for both children and adults. While we can be pleased with what has already been accomplished, it is clear that there is much yet to be done. Policymakers, community leaders, private industry, health professionals, the media, and the public should affirm thatoral health is essential to general health and weil'being and take action to make ourselves, our families, and our communities healthier. I join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans. c a •s�i.t/ ichard I -I. Carmona, d., M.P.H., F.A.C.S. VADM, USPHS United States Surgeon General Packet Page-198- Fluoridation - Benefits - Background Water Fluoridation-. Oral Health Home Water Fluoridation } Horne > Benefit Safety } Statistics Engineering and Operations Other Fluoride Products Publications Related Links r Contact Info Centers for Disease Control and Prevention Division of Oral Health Mail Stop F-10 4770 Buford Highway NE Atlanta, GA 30341 Contact Us Key Resources on Topic Fact Sheets Guidelines & Recommendations ' Background Information 5/10/2016 11.B. ......................................................... 0 Email this page g Printer -friendly version ......................................................... questions & Answers August 2005—Tooth decay, also known as dental caries, is a health problem that has plagued humankind for centuries. Until as recently as 60 years ago, the damage caused by cartes was an inevitable fact of life foc most people. The disease often meant many visits to the dentist to have damage and painful teeth repaired or removed. Today, primarily as a result of fluoride, damage caused by decay can be reduced and. In many instances, prevented. Fluoride's benefits for teeth were discovered in the 1930s; Dental scientists observed remarkably low decay rates among people whose water supplies contained significant amounts of natural fluoride. Several studies conducted during the 1940s and 1950s confirmed that when a small amount of fluoride is added to the community water supply, decay rates among residents of that community decrease. Although these studies focused primarily on the benefits of water fluoridation for children, more recent studies demonstrate that decay rates In adults are also reduced as a result of fluoride in the drinking water. Water fluoridation (fluoride In water) prevents tooth decay two ways: primarily through direct contact with teeth throughout life, and when consumed by children during the tooth forming years. The most Inexpensive way to deliver the benefits of fluoride to all residents of a community is through water fluoridation. Ali water naturally contains some fluoride. When a community fluoridates Its water, It adjusts the level of fluoride in the water to the optimal level for preventing tooth decay. Currently, more than 170 million people in the United Slates using public water supplies drink water containing enough fluoride to protect teeth. One of the health objectives contained In Healthy People 2010, the plan that sets health goals for the nation for the year 2010, calls for at least 75 percent of the population served by community water systems to receive optimal levels of fluoride. The current level Is 67 percent. To reach this goal, approximately 14.3 million more people must gain access to fluoridated water through public water systems. Other sources of fluoride are also available. Fluorlde can be applied directly to teeth through toothpaste, mouth rinses, and professionally applied fluoride treatments available in the dental office. Children who have been evaluated by their dentists as being at high risk for tooth decay and whose home water supplies contain low amounts of fluoride can take dietary fluoride supplements. This dally supplement, which can be prescribed by a dentist or a physician, should be taken only by children If the home water supply has been verified to contain a low concentration of fluoride. These methods of delivering fluoride are more expensive than water fluoridation and require a conscious decision to use them. However, the widespread availability of fluorides, via water fluoridation, toothpaste, and other sources, has resulted in the steady decline of dental caries throughout the United States. Date last reviewed: 08/03/2006 Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion Home I Policies and Regulations I Disclaimer ( e -Government I FOIA Contact Us .�AtRa•HKXt,THfirt•r;�kCSPL1t"' ,,.,, Centers tar Disease Control and Prevantion,1600 G11fton Rd; AEtanta,.GA 30333; U.S. r De �arfinent of Health A FI J4 afzei-Fiurnan Services rir7kzFra`t►.IF� Wwrid�iE '4 Tel: (404) 839-33# 11 Public 3nquifles'r (40it) 63935347'{80Q).311 $435. - 5to)11CPocuments%20and%20Senings/isaacSP/Desktop/Fluoridation°G20-%2oBcnarits%20-%20Background, htm927/2006 10;27:36 AM Packet Page-199- Chariic Crist Govenior 5/10/2016 11. B. PLORIDA DEPART E T H E LT Ana M. Vlamontc Ros, M.D., M.P.H. State Surgeon General January 2008 POLICY STATEMENT ON COMMUNITY WATER FLUORIDATION The Florida Department of Health Is strongly committed.to the fluoridation of community water systems. Fluoridation began nationally over sixty years ago and the Florida State Board of Health officially endorsed fluoridation In 1949. Strong support and active promotion of the measure as a safe, economical and effective means of reducing tooth decay has continued. Today, fluoridation is still the most cost-effective way to prevent dental cavities. it Is an ideal public health measure where everyone benefits, whether rich or poor, no matter the age, without requiring any conscious effort of the Individual. Beginning in. Gainesville in 1949, Florida cities have embraced the concept of fluoridation for their citizens. At present, approximately 12.9 million people are benefiting from fluoridation in Florida. Nationally, over 170 million people benefit from water containing fluoride at the recommended level for controlling dental.decay. National surveys of oral health dating back several decades document the continued benefit of fluoride In decreasing tooth decay in children and adults. it Is doubtful that any other public health procedure has undergone more research, epidemiological study and Intense public scrutiny than water fluoridation. The federal Centers for Disease Control and Prevention (CDC) in 1999 recognized fluoridation as one of the ten great public health achievements of the twentieth century. In the last few years, systematic reviews of community water fluoridation studies through the Surgeon's General's Report on Oral Health, CDC's Recommendations for Using Fluoride to Prevent and Control Dental Carlos In the United States, and the Oral Health Report Issued by the Task Force on Community Preventive Services have ail reinforced the safety and efficacy of fluoridation in preventing dental decay in both children and adults. Along with the overwhelming majority of the world's health care organizations and leaders within the scientific community, the Florida Department of Health firmly supports and continues to recommend water fluoridation as the most economical and effective means to control the major public health problem of dental caries. Ana M. Vlamonte Ros, M.D., M.P.H. State Surgeon General office of the state surgeon General 405213ald Cypressee, FL 32399-1701 Packet Page -200- . . 5/10/2016 11.B. Partial list of national and international organizations that endorse or support fluoridation of drinking water for preventive dental health: American Hospital Association American Medical Association American Psychiatric Association Florida Medical Association American Academy of Pediatrics American Association of Dental Research American Association of Dental Schools American Association of Public Health Dentistry American College of Dentists American Dental Association American Dental Hygienists Association Florida Dental Association Florida Dental Hygiene Association Federation of Dentaire International National Institute of Dental Research State and Territorial Dental Directors Association American Water Works Association Conference of State Sanitary Engineers American Association for the Advancement of Science American Pharmaceutical Association American Public Health Association American Public Welfare Association American School Health Association National Cancer Institute National Research Council State Territorial Health Officer Association Department of Defense U.S. Public Health Service World Health Organization Florida Public Health Association Florida Department of Health State of Florida Department of Health Department of Health Public Health Dental Program 4052 Bald Cypress Way Bin # A-14 Tallahassee, Florida 32399-1724 Packet Page -201- 5/10/2016 11.B. Achievements in Public Health, 1900-1999; Fluoridation of Drinking Water to Prevent D... Page 1 of 8 Weekly October 22,1999 /48(41);933-940 Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century. The history of water fluoridation is a classic example of clinical observation leading to epidemiologic investigation and community-based public health intervention. Although other fluoride -containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level. Dental Caries Dental caries is an infectious, communicable, multifactorial disease in which bacteria dissolve the enamel surface of a tooth (1). Unchecked, the bacteria then may penetrate the underlying dentin and progress into the soft pulp tissue. Dental caries can result in loss of tooth structure and discomfort. Untreated caries can lead to incapacitating pain, a bacterial infection that leads to pulpal necrosis, tooth extraction and loss of dental function, and may progress to an acute systemic infection.. The major etiologic factors for this disease are specific bacteria in dental plaque (particularly Streptococcus mutans and lactobacilli) on susceptible tooth surfaces andthe availability of fermentable carbohydrates. At the beginning of the 20th century, extensive dental caries was common in the United States and in most developed countries (2). No effective measures existed for preventing this disease, and the most frequent treatment was tooth extraction. Failure to meet the minimum standard of having six opposing teeth was a leading cause of rejection from military service in both world wars (3,4). Pioneering oral epidemiologists developed an index to measure the prevalence of dental caries using the number of decayed, missing, or filled teeth (DMFT) or decayed, missing, or filled tooth surfaces (DMFS) (5) rather than merely presence of dental caries, in part because nearly all persons in most age groups in the United States had evidence of the disease. Application of the DMFT index in epidemiologic surveys throughout the United States in the 1930s and 1940s allowed quantitative distinctions in dental caries experience among communities --an innovation that proved critical in identifying a preventive agent and evaluating its effects. History of Water Fluoridation Packet Page -202- 5/10/2016 11 R Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent D... Page 2 of 8 Soon after establishing his dental practice in Colorado Springs, Colorado; in 1901, Dr. Frederick S. McKay noted an unusual permanent stain or "mottled enamel" (termed "Colorado. brown stain" by area residents) on the teeth of many of his patients (6). After years of personal field investigations, McKay concluded that an agent in the public water supply probably was responsible for mottled enamel. McKay also observed that teeth affected by this condition seemed less susceptible to dental caries (7). Dr. F. L. Robertson, a dentist in Bauxite, Arkansas, noted the presence of mottled enamel among children after a deep well was dug in 1909 to provide a local water supply. A hypothesis -that something in the water was responsible for mottled enamel led local officials to abandon the well in 1927. In 1930, H. V. Churchill, a chemist with Aluminum Company of America, an aluminum manufacturing,company that had bauxite mines in the town; used a newly available method of spectrographic analysis that identified high concentrations of fluoride (13.7 parts per million [ppm]) in the water of the abandoned well (8). Fluoride, the ion of the element fluorine, almost universally is found in soil and water but generally in very low concentrations (less than 1.0 ppm). On hearing of the new analytic method, McKay sent water samples to Churchill from' areas where mottled enamel was endemic; these samples contained. high levels of fluoride (2.0- 12.0 ppm). The identification of a possible etiologic agent for mottled enamel led to the establishment in 1931 of the Dental Hygiene Unit at the National Institute of Health headed by Dr. H. Trendley Dean. Dean's primary responsibility was to investigate the association between fluoride and ^ mottled enamel (see box). Adopting the term "fluorosis" to replace "mottled enamel," Dean conducted extensive observational epidemiologic surveys and by 1942 had documented the prevalence of dental fluorosis for much of the United States (9). Dean developed the ordinally scaled Fluorosis Index to classify this condition. Very mild fluorosis was characterized by small, opaque "paper white" areas affecting less than or equal to 25% of the tooth surface; in mild fluorosis, 26%-50% of the tooth surface was affected. In moderate dental fluorosis, all enamel surfaces were involved and susceptible to frequent brown staining. Severe fluorosis was characterized by pitting of the enamel, widespread brown stains, and a "corroded". appearance (9)• Dean compared the prevalence of fluorosis with data collected by others on dental caries prevalence among children in 26 states (as measured by DMFT) and noted a strong inverse relation (10). This cross-sectional relation was confirmed in a study of 21 cities in Colorado; Illinois, Indiana, and Ohio (11). Caries among children was lower in cities'with more fluoride in their community water supplies; at concentrations greater than 1.0 ppm, this association began, to level off. At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild. The hypothesis that dental caries could be prevented by adjusting the fluoride level of community water supplies from negligible levels to 1.0-1.2 ppm was tested in a prospective field study conducted in four pairs of cities (intervention and control) starting in 1945: Grand Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; Evanston and Oak Park, Illinois; and Brantford and Sarnia, Ontario, Canada. After conducting sequential cross-sectional surveys in these communities over 13-15 years, caries was reduced 50%-70% among children in ^ the communities with fluoridated water (12). The prevalence of dental fluorosis in the intervention communities was comparable with what had been observed in cities where drinking water contained natural fluoride at 1.0 ppm. Epidemiologic investigations of patterns of water consumption and caries experience across different climates and geographic regions in the United States led in 1962 to the development of a recommended optimum range of fluoride concentration of 0.7-1.2 ppm, with the lower c, Packet Page -203- mended for warmer climates 5/10/2016 11.B. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent D... Page 3 of 8 (where water consumption was higher) and the higher concentration for colder climates (13). The effectiveness of community water fluoridation in preventing dental caries prompted rapid adoption of this public health measure in cities throughout the United States. As a result, dental caries declined precipitously during the second half of the 20th century. For example, the mean DMFT among persons aged 12 years in the United States declined 68%, from 4.0 in 1966-1970 (14) to 1.3 in 1988-1994 (CDC, unpublished data, 1999) (Figure 1). The American Dental Association, the American Medical Association, the World Health Organization, and other professional and scientific organizations quickly endorsed water fluoridation. Knowledge about the benefits of water fluoridation led to the development of other modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, and drops. Several countries in Europe and Latin America have added fluoride to table salt. Effectiveness of Water Fluoridation Early studies reported that caries reduction attributable to fluoridation ranged from 50% to 70%, but by the mid-1980s the mean DMFS scores in the permanent dentition of children who lived in communities with fluoridated water were only 18% lower than among those living in communities without fluoridated water (15). A review of studies on the effectiveness of water fluoridation conducted in the United States during 1979-1989 found that caries reduction was 8%-37% among adolescents (mean: 26.5%) (16). Since the early days of community water fluoridation, the prevalence of dental caries has declined in both communities with and communities without fluoridated water in the United States. This trend has been attributed largely to the diffusion of fluoridated water to areas without fluoridated water through bottling and processing of foods and beverages in areas with fluoridated water and widespread use of fluoride toothpaste (17). Fluoride toothpaste is efficacious in preventing dental caries, but its effectiveness depends on frequency of use by persons or their caregivers. In contrast, water fluoridation reaches all residents of communities and generally is not dependent on individual behavior. Although early studies focused mostly on children, water fluoridation also is effective in preventing dental caries among adults. Fluoridation reduces enamel caries in adults by 20%- 40% (16) and prevents caries on the exposed root surfaces of teeth, a condition that particularly affects older adults. Water fluoridation is especially beneficial for communities of low socioeconomic status (18). These communities have a disproportionate burden of dental caries and have less access than higher income communities .to dental -care services and other sources of fluoride. Water fluoridation may help reduce such dental health disparities. Biologic Mechanism Fluoride's caries -preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid -resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children (1). These mechanisms include 1) inhibition of demineralization, 2) enhancement of remineralization, and 3) inhibition of bacterial Packet Page -204- 5/10/2016 11.B. Achievements in Public Health, 1900-1999; Fluoridation of Drinking Water to Prevent D... Page 4 of 8 activity in dental plaque (1). Enamel and dentin are composed of mineral crystals (primarily calcium and phosphate) embedded.in an organic proteMipid matrix. Dental mineral is dissolved readily by acid produced by cariogenic bacteria when they metabolize fermentable carbohydrates. Fluoride present in solution at low levels, which becomes concentrated in dental plaque, can substantially inhibit dissolution of tooth mineral by acid. Fluoride enhances remineralization by adsorbing to the tooth surface and attracting calcium ions present in saliva. Fluoride also acts to bring the calcium and phosphate ions together and is included in the chemical reaction that takes place, producing a crystal surface that is much less soluble in acid than the original tooth mineral (1). Fluoride from topical sources such as fluoridated drinking water is taken up by cariogenic bacteria when they produce acid. Once inside the cells, fluoride interferes with enzyme activity of the bacteria and the control of intracellular pH. This reduces bacterial acid production, which directly reduces the dissolution rate of tooth mineral (19). Population Served by Water Fluoridation . By the end of 1992, 10,567 public water systems serving 135 million persons in 8573 U.S. communities had instituted water fluoridation (20). Approximately 70% of all U.S. cities with populations of greater than. 100,000 used fluoridated water: In addition, 3784 public water systems serving 10 million persons in 1924 communities had natural fluoride levels greater than or equal to.0.7 ppm. In total, 144 million persons in the United States (56% of the population) were receiving -fluoridated water in 1992, including 62% of those served by public water systems. However, approximately 42,000 public water systems and 153 U.S, cities with populations greater than or equal to 50,000 have not instituted fluoridation. Cost Effectiveness and Cost Savings of Fluoridation Water fluoridation costs range.from a mean of 31 cents per person per year in U.S. communities of greater than 50,000 persons to a mean of $2.12 per person in communities of less than 10,000 (1988 dollars) (21). -Compared with other methods of community-based dental caries - prevention, water fluoridation is the most cost effective for most areas of the United States in terms of cost per saved tooth surface (22).- Water 22). Water fluoridation reduces direct health-care expenditures through primary prevention of dental caries and avoidance of restorative care. Per capita cost savings from 1 year of fluoridation may range from negligible amounts among very small communities with very low incidence of caries to $53 among large communities with a high incidence of disease (CDC, unpublished data, 1999). One economic analysis estimated that prevention of dental caries, largely attributed to fluoridation and fluoride -containing products, saved $39 billion (1990 dollars) in dental -care expenditures in the United States during 1979-1989 (23). " Safety of Water Fluoridation Early. investigations into the physiologic effects of fluoride in drinking water predated the first community field trials. Since 1950, opponents of water fluoridation have claimed it increased the risk for cancer, Down syndrome, heart disep,P nrtPr%nnrr%Qk nrid bone fracture, acquired Packet Page -205- - 5/10/2016 11.B. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent D... Page 5 of 8 immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions (24). The safety and effectiveness of water fluoridation have been re-evaluated frequently, and no credible evidence supports an association between fluoridation and any of these conditions (25). 21st Century Challenges Despite the substantial decline in the prevalence and severity of dental caries in the United States during the 20th century, this largely preventable disease is still common. National data indicate that 67% of persons aged 12-17 years (26) and 94% of persons aged greater than or equal to 18 years (27) have experienced caries in their permanent teeth. Among the most striking results of water fluoridation is the change in public attitudes and expectations regarding dental health. Tooth loss is no longer considered inevitable, and increasingly adults in the United States are retaining most of their teeth for a lifetime (12). For example, the percentage of persons aged 45-54 years who had lost all their permanent teeth decreased from 20.0% in 1960-1962 (28) to 9.1% in 1988-1994 (CDC, unpublished data, 1999), The oldest post -World War II "baby boomers" will reach age 60 years in the first decade of the 21 st century, and more of that birth cohort will have a relatively intact dentition at that age than any generation in history. Thus, more teeth than ever will be at risk for caries among persons aged greater than or equal to 60 years. In the next century, water fluoridation will continue to help prevent caries among these older persons in the United States. Most persons in the United States support community water fluoridation (29). Although the proportion of the U.S. population drinking fluoridated water increased fairly quickly from 1945 into the 1970s, the rate of increase has been much lower in recent years. This slowing in the expansion of fluoridation is attributable to several factors: 1) the public, some scientists,.and policymakers may perceive that dental caries is no longer a public health problem or that fluoridation is no longer necessary or effective; 2) adoption of water fluoridation can require political processes that make institution of this public health measure difficult; 3) opponents of water fluoridation often make unsubstantiated claims about adverse* health effects. of fluoridation in attempts to influence public opinion (24); and 4) many of the U.S. public water - systems that are not fluoridated tend to serve small populations, which increases the per capita cost of fluoridation. These barriers present serious challenges to expanding fluoridation in the United States in the 21st century. To overcome the challenges facing this preventive measure, public health professionals at the national, state, and local level will need to enhance their promotion of fluoridation and commit the necessary resources for equipment, personnel, and training. Reported by Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. References 1. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31-40. 2. Burt BA, Influences for change in the dental health status of populations: an historical perspective. J Public Health Dent 1978;38:272-88. 3. Britten RH, Perrott GSJ. Summary of physical findings on men drafted in world war. Pub Health Rep 1941;56:41-62. Packet Page -206- 5/10/2016 11. B. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent D... Page 6 of 8 4. Klein H. Dental status and dental needs of young adult males, rejectable, or acceptable for military service, according to Selective Service dental requirements. Pub Health Rep 1941; 56:1369-87. 5. Klein H, Palmer CE, Knutson JW. Studies on dental caries. I. Dental and dental needs of elementary school children. Pub Health Rep 1938;53:751-65. 6.' McKay FS, Black GV. An investigation of mottled teeth: an endemic developmental imperfection of the enamel of the teeth, heretofore unknown in. the literature of dentistry. Dental Cosmos 1916;58:477-84. 7. McKay FS. Relation of mottled enamel to caries. J Am Dent A 1928;15:1429-37. 8. Churchill HV. Occurrence of fluorides in some waters of the United States. J Ind Eng Chem 1931;23:996-8. 9. Dean HT. The investigation of physiological effects by the epidemiological method. In: Moulton FR, ed. Fluorine and dental health. Washington; DC: American Association for the Advancement of Science 1942:23-31. ' 10. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep 1938;53:1443-52. 11. Dean HT. On the epidemiology of fluorine and dental caries. In: Gies WJ, ed. Fluorine in dental*public health. New. York, New York: New York Institute of.Clinical Oral Pathology, 1945;19-30. 12. Burt BA, Eklund SA. Dentistry; dental practice, and the community. 5th ed. Philadelphia, Pennsylvania: WB Saunders, 1999. 13, Public Health Service..Public Health Service drinking water standards --revised 1962.. Washington, DC: US Department of Health, Education, and Welfare, 1962. PHS publication no. 956. 14. National Centex for Health Statistics. Decayed, missing, and filled teeth among youth -12- 17 years --United States. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service; Health Resources Administration; 1974. Vital and health statistics, vol 11, no. 144. DREW publication no. (HRA)75-1626. 15. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water fluoridation. J Dent Res 1990;69:723-7. 16. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279-89. 17. Horowitz HS. The effectiveness of community water fluoridation in the United States. J. Public Health�Dent 1996;56:253-8. 18. Riley JC, Lennon MA, Ellwood RP. The effect of water fluoridation and social inequalities on dental caries in 5 -year-old children. Int J Epidemiol 1999;28:300-5. 19. Shellis RP, Duckworth RM. Studies on the cariostatic mechanisms of fluoride. Int Dent J 1994;44(3 suppl 1):263-73. . 20. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human Seivices, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993. 21. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluoridation: 44 Florida communities. J Public Health Dent 1992;52:75-80. 22. Burt BA, ed. Proceedings for the workshop: cost effectiveness of caries prevention in . dental public health. J Public Health Dent 1989;49(5, special issue):251-344, 23. Brown LJ, Beazoglou T, Heffley D. Estimated savings in U.S. dental expenditures, 1979- 89. Public Health Rep 1994;109:195-203. 24. Hodge HC. Evaluation of some objections to water fluoridation. In: Newbxun E, ed. Fluorides and dental caries. 3rd ed. Springfield, Illinois: Charles C. Thomas, 1986:221- 55. 25. National Research Council. Health effects of ingested fluoride. Washington, DC: National Academy Press, 1993. Packet Page -207- 5/10/2016 11. B. Achievements in Public Health, 1900-1999: FIuoridation of Drinking Water to Prevent D... Page 7 of 8 26. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DVI, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res 1996;75:631-41. 27. Winn DM, Brunelle JA, Selwitz RH, et al. Coronal and root caries in the dentition of adults in the United States, 1988-1991. J Dent Res 1996;75:642-51. 28. National Center for Health Statistics. Decayed, missing, and filled teeth in adults --United States, 1960-1962. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1973. Vital and health statistics vol 11, no. 23. DHEW publication no. (HRA)74-1278. 29. American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois: American Dental Association, 1998. Figure Y FIGURE 1. Percentage of population residing in areas with fluoridated community water systems and mean number of decayed, missing (because of caries), or filled permanent teeth (DIbMFT) among children aged 12 years --• United States, 1967-1992 L. 100 5 90 80 -Mean Mean [MFT ;L. 70- 0 EE: eQ Percentage Drinking 50 .Fluoridated Water.......r.....-...... ....._....�........._.. ... -� D 40 ... C �L 2 �1 30 . t m MM 20 1 10 -- Lr 0' CL 0 1967 1977 1987 Year Sources. 1. CDC. Fluoridation census 1992, Atlanta, Georgia,US Department of hleaith and Human Serv- ices, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993. 2. National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12- 17 years --United States. Rockville, Maryland; US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1974. Vital and health statistics, vol 11, no, 144. DHEW publication no. (HRA175-1626. 3. National Center for Health Statistics. Decayed, missing, and filled teeth among persons 1- 74 years ---United States. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, Office of Health Research, Statistics, and Technology, 1981. Vital and health statistics, vol 11, no. 223. DHHS publication no. (PHS)81-1673. 4. National Institute of Dental Research. Oral health of United Statos children: the National Survey of Dental Caries in U.S. School Children, 1986-1987, Bethesda, Maryland. US Department of Health and Human Services, Public Heafth Service, National Institutes of Health, 1989. NIH Publication no. 89-2247. 5. CDC, unpublished data, third National Health and Nutrition Examination Survey, 1988-.1994. Return to top. Packet Page -208- 5/10/2016 11.B. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent D... Page 8 of 8 Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmwrg@cdg.gov. .page converted: 10/21/1.999 HQME I ABOUT MM WR I S I DOWNLOAD I I C9NTACT POLICY I DISCLAIMER I ACCESSIBILITY SIS'F3R • N 6ALY}it II q i� C6 P4iE" w•L4 Morbidity and Mortality Weekly Report1� Qenartment of Health Centers for Disease Control and PreventioT-Nn �} Y ..and Homan Services 1600 Clifton Rd, MailStop E-90, Atlanta, GA �exrnmrutFiidk$ea/. . 30333, U.SA This page last reviewed 5/2/01 Packet Page -209- 5/10/2016 11.B. An. ounce- of Prevention. r r r What Are the Returns?* Second Edition 7999 (EXCERPTS) y,�M ssavctr 6r� rpt r U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention nt�on Atlanta, Georgia 30333 Packet Page -210- I 5/10/2016 11.6. the United States, 1988-1991. J Dent Res 1996;75:642-51. 28. National Center for Health Statistics. Decayed, missing, and filled teeth in.adults--United States, 19604962. Rockville, Maryland: US Department of Health; Education, and Welfare; Public Health Service, Health Resources Administration, 1973. Vital and health statistics vol no.'23. DREW publication no. (HR.A)74-1278. 29. 'American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois: American Dental Association, 199'8.. Figure 1 FIGURE 1, Percentage of population residing in areas with fluoridated community Water systems and mean number of decayed, missing (because of caries), or rilled permanent teeth (DMFT) among. children aged 12 years -- United States, 1967,1992 CD f0 v so so M c 70 0 60 C 50 c 40 a 30. as 207 ami 10- L! 0 -U CL 1967 1977 1987 5 a K. 3CD m Year Sources: I. CDC. Fluoridation census 1992; Atlanta, Georgia: US Department of Health and Human 5erv- ices, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993. ' 2. National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12- 17 years --United States. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources -Administration, 1974. Vital and health statistics, vol 11, no. 144. (THEW publication no. (HRA)75.1628. 3. National Center for Health Statistics. Decayed, missing, and filled.teeth among persons I- 74 years—United States. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, Office of Health Research, Statistics, and Technology, 1981. Vital and health statistics, vol 11, no. 223. DHHS publication no. (PHS)81-1673. A. National Institute of Dental Research. Oral health of United States children: the Nnilonal Survey of Dental Caries in U.S. School Children, 1986-1987. Bethesda, Maryland; US Depsrtmenl of Health and Hurnan Services, Public Health Service. National Institutes of Health, 1989, NIH publication no. 89.2247. 5. CDC, unpublished data, third•Naiional Health and Nurrition Examination -Survey. 1988-1984; Return to toe. Packet Page -211- 5/10/2016 11.B. September 03,1999148(34);753.757 Water Fluoridation and Costs of Medicaid Treatment for Dental Decay -- Louisiana, 1995-1996 Treatment costs for dental decay in young children can be substantial, especially if extensive dental procedures and general anesthesia in a hospital operating room (OR) are needed. Because caries in the primary dentition disproportionately affect children from low-income households (1,2 ), the costfor care frequently is reimbursed by state Medicaid programs. To determine whether the average treatment cost for Medicaid - eligible children in Louisiana differed by community fluoridation status, the Louisiana Department of Health and Hospitals (LDHH) and CDC analyzed Medicaid dental reim- bursements and Medicaid eligibility records from July 1995 through June 1996 for children aged 1-5 years. Findings suggest that Medicaid -eligible children in eommunl- ties without fluoridated water were three times more likely than Medicaid -eligible chil- dren in communities with fluoridated water to receive dental treatment In a hospital OR, and the cost of dental treatment per eligible child was approximately twice as high. •' .ental reim- . The Louisiana Bureau of Health Financing provided data on Medicaid d bursements and Medicaid eligibility from July 1995 through June 1996 for children aged 1-5 years and the number, of dentists practicing In each parish (county) in 1995. Demographic data for each parish were obtained from the Bureau of the Census (3). The proportion of the population that received optimally fluoridated water in each parish was estimated based on CDC's 1992 fluoridation census (4) and a study by LDHH (LDHH, unpublished data, 1996). A parish was designated as optimally fluori- dated (F) if 100% of its population received fluoridated water (optimal level: z0.7 ppm) In both 1992 and 1996, and nonfluoridated (NF) if 0% received fluoridated water in both -years. Of 64 parishes, five F parishes with 38,162 Medicaid -eligible preschoolers and 14 NF parishes with 16,444 Medicaid -eligible preschoolers were included in this analysis..All analyses were conducted at the parish level. . For each F and NF parish, the percentage of Medicaid -eligible children aged 1--5 years who, during the study period, received one or more of the following types of services was calculated: 1) caries -related services (e.g., fillings, crowns, and pulpo- tomies); 2) *examinations or preventive care (topical fluoride or prophylaxis) but no caries -related services; 3) topical fluoride application (with or without caries -related care); and 4) dental care In a hospital OR. The mean value for each of these measures was calculated for F and NF parishes for each of the five ages. Medicaid reimbursements for dental procedures likely to be associated with treat- ment for dental caries were totaled for each parish for each age group. If dental care was provided in a hospital, a payment of $650 (based on estimates from the.Louislana Bureau of Health Financing) was added fnr niz cien and ^Pneral anesthesia. The aver- age'cories-related cost per Medicaid-el.?acket Page -212-garish was obtained by di - 5/10/2016 11. B. 754 MMWR September 3,1999 Dental Decay -=-Continued viding parish Medicaid reimbursements by the number of Medicaid -eligible children in the parish in each age group. For each age group, linear regression was used to examine the association be- tween parish average caries -related cost per Medicaid -eligible child and fluoridation status of the parish. In addition to*fluoridation status, per capita income, population, and dentists per 1000 residents were included in the model as dichotomous variables. Independent variables that added no explanatory power were eliminated through backward elimination to obtain the reduced model (5). Children residing in F parishes were slightly more likely to have received only ex- aminations or preventive services (Table 1). The proportions of children who received topical fluoride were similar, with younger children in F and older children in NF slightly more likely to have received the procedure. For all age groups, the percentage of Medicaid -eligible children who received one or more caries -related procedures was higher in NF parishes. The difference in treatment costs .per Medicaid -eligible child residing in F parishes compared with those residing''in NF parishes ranged from $14,68 for 1 -year-olds to $58.91 for 3 -year-olds (Table 2); at all ages, costs were higher in NF than in F parishes. Louisiana Medicaid -eligible children were distributed uniformly by age; the mean dif- ference in treatment costs per eligible preschooler was $36.28 (95% confidence inter- val -$9.69-$62,87). Reported by: R Barsley, DDS, Louisiana State Univ, New Orleans; J Sutherland, DDS; L McFarland, DrPH, State Epidemiologist, Office of Public Health, Louisiana Dept Public Health and Hospitals. Surveillance, -Investigations, and Research Br, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In, this analysis of Medicaid claims, more Medicaid -eligible children in NF parishes receivedcaries-related dental treatment and OR -based care at greater cost than did Medicaid -eligible children in F parishes. In 1998,1.3 million Louisianans received nonfluorldated water from public water systems that served approximately 10,000 customers (S. Hoffman, Office of Public Health Engineering Services, personal communication, 1999), and 3% of the state population were Medicaid -eligible children aged 1-5 years (S). These data suggest that at least 39,000 preschoolers in Louisiana could potentially benefit from water fluoridation, the expected annual reduction in their dental treatment costs is $1.4 million. The findings in this report are subject to at least four limitations. First; although the analysis showed an association between lower caries -related costs and residence.in one of the five F parishes, the analysis did not measure the length or magnitude of the children's exposure to fluoride, Some children classified as residing in NF parishes once may have resided in F parishes and vice versa. It also did not verify that the water systems serving the five F parishes maintained fluoride concentration 'at the optimal level. However, misclassification of exposure status would be more likely to reduce the observed effect of fluoridation. Second, if access to dental care were better in NF than in F parishes, children with decay who resided in F parishes would be less likely to seek restorative care, resulting in an underestimate of treatment costs in f parishes and an overstatement of water fluoridation's benefits, The observed rates for preven- tive care in F and NF parishes suggest similar rather tharr differential access. Further more, this analysis controlled for differences in access to dental care. Third, the -:-'-•ion would be overstated if difference in treatment costs attributab'Packet Page -213- ` Vol. 48 / No. 34 MMWR Dental Decay =— Continued �•`0 0 _ .. rO1rCV (fl C M O)N Ui 0 L. CL S 6) Ln Q1 M O (0nr,a04ir y � z= a000l:o C1 �+ N 0 C1 Cl In CO N O s-rNr Q to M OR r C Mm CII t� Iti aS M of �� 69 Vi b964 Ni O y vl � 3M+ r mncgmr; - i (A OCYN(V r •` N cv N4C) �i o 000at� r 3 •� E P Z — ,* Ln M r" N N > ID y .0 NP O t� OO �Q p lI} v `T� tL U a` NN��N 14 LL ttv- O � *•' 0 0 fl• G � VU. 1A �C n, p 13 ;a�l MtnNM� Ui a; "i 'CG Olb It N —Z:== Cm �4) 2 R' R 3° lb Ui C; tb f'! d LO `aroi i' "'r,vvq r d O bIV 'o MNr LA d ^ Q U-) "Y > m t�• o. y � � ) v r Ui Ld a; 'd`� O, © V ^^M L V t. 4+Z7 U.o c a u. 'nNNeca�to�o n M vm r ro� ., ry j)II v) ca o` -- L v d rL Cq NO . Q? U O. Z a fD iD O N Ln !� U 00 0! Cl N °m d CL �N r;c�wln E N000 NO eUp G x Mme- MNL 0.0 d Q SOD OI tt N yE C1 tQ C4 to o ai o mo c j -y �f aj cp In r dlflrd FQ C1 d rMMM pui V V m '!r J y C. ro C '�. ,IC • M O fD f� (O p,w M��N00 N T3� �LC)a a oar C'4 C') -7u> *,.w Packet Page -214- 5/10/2016 11. B 755 5/10/2016 11. B. 766 MMWR September 3,1999 Dental Decay—Continued TABLE 2. Results of multivariate regression* analysis: adjusted Rz and estimated treatment cost savings associated with water fluoridation for Medicaid -eligible children aged 1-8 years residing in fluoridated and nonfluoridated parishes, by age — Louisiana, July 1995 -June 1996 Age (yrs) Estimated treatment cost savings associated with water Adjusted R2 fluoridation (95% Ci§), 1 0.59 $14.68 $ 5.58-$23.77 2 0.27 $40.17 $ 9.81-$70.53 3 0.42 $58.91. $19.45-$98.37 4 0.47 $36.08 $11.81-$60.35 5 0.18 $31.55 $ 1.79-$61.31 All age groupst $36.28 $ 9.69-$62.87 *Controlling for the parish variables of per capita income, population, and number of dentists per -1000 population., tAssumes children are distributed uniformly by age. 4Confidence Interval. children in F parishes had.more exposure to other sources of fluoride (e.g., toothpaste or topical application in a dental office). Although fluoride toothpaste use could not be determined, toothpastes containing fluoride accounted for>94% of the market in 1984 (6). Different uses of topical applications was probably not a substantial factor be- cause children in F and NF parishes received topical fluoride in the dental office at similar rates. Finally, lower treatment costs associated with water fluoridation should not be generalized to preschoolers from high- and middle -Income families because of their lower prevalence of dental caries in primary teeth (9,2 ). The lower treatment costs associated with residence in F parishes is a conservative estimate of benefits because the analysis did not consider benefits that accrue to populations other than Medicaid -eligible preschoolers. For this group, however, treat- ment cost savings associated with fluoridating the 39 NF water systems that serve populations of X10,000 could be substantial. In 1996, approximately 50% of Louisiana's population using public water suppiies received fluoridated water, a percentage well below the 2000 objective of 75% (objec- tive 13.9) (7). The 1996 assessment of community water fluoridation in Louisiana also found that of 73 water systems adjusting fluoride content in 1986, only 45 were still doing so in 1996 (S ). This decline prompted passage of state legislation in 1997 that 1) established a water fluoridation program within LDHH; 2) encouraged fluoridation of public water systems serving at least 5000 households (because the average number of persons per U.S, household in 1996 was 2.66, this equals approximately 13,000 persons (3 )); and 3) created a Fluoride Advisory Board to assist in locating public and private funding to cover the costs of initiating water fluoridation in these locations. In addition, LDHH is planning an early intervention program to ensure that infants and toddlers at high risk far early childhood caries are screened and referred for clinical preventive services (e.g., topical fluoride application), prompt treatment of incipient disease, and education of the parent or caregiver. Packet Page -215 5/10/2016 11.B. Vol. 48 i No. 34 MMWR 757 Dental Decay—Continued References 1. Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of NHANES III estimates of early childhood caries. J Public Health Dent 1999 (in press). 2. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc 1998;129:1229-38. 3. Bureau of the Census. USA counties 1996. Atlanta, Georgia: Bureau of the Census, US De- partment of Commerce, Economics and Statistics Administration, Bureau of the Census, 1996. 4. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human Ser- vices, Public Health Service, CDC, 1993. 5. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research principles and quantitative methods. Belmont, California: Life -Time Learning Publications, 1982. 6. Bohannan HM, Graves RC, Disney JA, at al. Effect of secular decline in caries on the evaluation of preventive dentistry demonstrations. J Public Health Dent 1985;45:83-9. 7. US Department of Health and Human Services. Devetoping objectives for healthy people 2010. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, September 1997. 8. Sutherland J, Ray TJ. Community water fluoridation in Louisiana: an update. LDA J 1996; 55:16-7. Congenital Syphilis -- United'States,1998 Congenital syphilis (CS) occurs when the spirochete Treponema pallidum is trans- mitted from a pregnant woman with syphilis to her fetus. A multiorgan infection, CS may result in a neurologic or musculoskeletal handicap or death in the fetus when not properly treated. Trends in CS rates in women of childbearing age follow by approxi- mately 1 year the rates of primary and secondary syphilis (1). The last national syphi- lis epidemic, which was followed by a CS epidemic, occurred during the late 1980s and early 1990s. The syphilis rate began to decline in 1991 (2); the CS rate began to decline in 1992 (1). To evaluate CS epidemiology since this decline, CDC analyzed 1998 CS notifiable disease data and assessed rate changes during 1992-1998. This report summarizes the results, which indicate that the CS rate declined 78.2% from 1992 to 1998, and that rates remained disproportionately high in the southeastern United States and among minority racial/ethnic populations. CS surveillance data were reported to CDC from the 50 states and District of Colum- bia. For the purpose of public health surveillance, CS is defined as 1) infants manifest- ing typical signs of CS or in whom 7. pallidum is identified from lesions, placenta, umbilical cord, or autopsy specimens; 2) infants whose mothers have a syphilitic le- sion at delivery, 3) infants born to women with untreated or inadequately treated syphilis before or during pregnancy, and to women whose serologic response to peni- cillin therapy was not documented, and either a) no examination of the infant was performed radiographically and by cerebrospinal fluid (CSF), or b) one or more rad(- ologic or CSF tests were consistent with CS.* CS rates per 100,000 live births were determined from state natality data.t *Congenital Syphilis Case Investigation and Report Form 73.126. tFrom the National Center for Health Statistics, Vital Statistics: Natality Tapes 1989-1996. Packet Page -216- American .Association of Public Health Dentistry 1224 Centre West, Suite 400B Springfield, IL 62704 sv TET,: (217) 391-0218 n FAX: (217) 793-0041 Internet: www.auphd.org � >a -p kmericaa Dental Association W :ouncil on Access, Prevention and Interprofessional Relations 2111. Chicago Avenue N Chi IL 60611 N TEL: (312) 440-2500 Ext: 2860 �I FAX: (312) 440-7494 Interne www.ida.org N Centers for Disease Control & Prevention Division of Oral Health 4770 Buford Highway, NE Mailstop F-10 Atlanta, GA 30341 TEL• (770) 488-6056 FAX: (770) 488-6080 Internet: www.edr-gov/nccdphp/olt Department of Health Public Health Dental Program 4052 Bald Cypress Way, Bin #A-14 TalLlhassee, FL 32399-1724 � Commuiu Water Fluoi�oatto ''��:� All drinking water supplies contain some fluoride naturally. Getting the right amount of fluoride is important to prevent tooth decay. Water plant operators continuously monitor the fluoride content of drinking water in communities that fluoridate. The most favorable concentration for fluoride in drinking water in the United States varies from 0.7 parts -per millioa (ppm) in hot climates to 12 ppm in cold climates. For moderate climates, l ppm is recommended. (One ppm is the same as 1 mg&.) Iits `a arida Hundreds of studies conducted in the United States and other countries during the past 50 years show that community water fluoridation prevents tooth decay. Because fluoride is so successful in preventing decay, it is incorporated into many dental etre products, such as toothpastes and mouthrinses. Most people in non fluoridated communities now receive some protection against cavities from fluoride in these dental etre products and is food and beverages processed in fluoridated communities. Although people Paving in non -fluoridated communities have benefited from these other sources of fluoride, those living in fluoridated communities generally experience 2040% less tooth decay. The measurable benefits of wafter fluoridation are: 0 20 to 40 percent less dental decay in persons of all ages, 0 More children free of dental decay, 0 Many fewer children having permanent teeth extracted because of decay. 0 More adults keeping their teeth for a Lifetime. 0 Prevention and reversal of early stages of tooth decay in adults. 0 Older adults less likely to develop decay on the roots of their teeth. ® Lower dental bills for repairing decayed teeth. * Less need forprocedures that require anesthesia and drilling. C) N O Me It is a popular misconception that fluoridation zelps only children. Adults as well as children )encfit from drinking fluoridated water hroughout their lives. Because of water luorie .D r, people are enjoying a lifetime of iealth nr :eth. n Absolutely! The safety of community water fluoridation has been studied more thoroughly than any other public health measure during the past 50 years_ Hundreds of clinical, animal, and laboratory.studies support its safety. i M r* MD � l �. • i Con N ity water fluoridation is cffective, We, nexp< N :, and practical. The average cost of luork 00 ; is about 50 cents per person a year. Chu is one of the best bargains in health today! The entire commu >enefits from comms vater fluoridation, egardless of a persa Ige, income, level of :ducation, or ability o get dental care. 'veryone benefits vhcn they drink luoridated water ant :onsume foods and >cveragcs prepared vith it. Community water fluoridation has the unqualified approval of every major health organization in the United States and many other countries. The American Dental Association, the U.S, Department of Health and Human Services, the American Medical Association, and the World Health Organization strongly endorse water fluoridation. Many organizations support fluoridation, including the AmericanAssociation of Public Health Dentistry, American Academy of Pediatrics, American Cancer Society, ai 1 American Dental Hygienists'Association, s'c� Amcrican Heart Association, American Public Health Association, and f•; h,K57.Z 1 . International Association for Dentalii t f Research. More than half of the U.S. population (about 150 million people) live in communities served by fluoridated water supplies. This includes about 10 million people who live in communities I with sufficient naturally occurring fluoride in their drinking water. About 30 million Americans cannot benefit from fluoridation because they live in areas, Largely rural, that Iack community water supplies. Currently, most large cities in the U.S. fluoridate their drinking water supplies. Several of them, including San Francisco, Baltimore, Pittsburgh, and Washington, D.C., have had fluoridated water for about 45 years. However, a number of the nation's 50 largest 3 cities, including San Diego, San Antonio and Honolulu, still have not fluoridated their water supplies and, consequently, are not }f. providing the known dental benefits of fluoridation to their residents. 4 There are several ways to learn if your community maintains optimum �nM'"��'`,-q levels of fluoride in its drinking ri st a water. A telephone call or letter to the utility that provides water for oG%� , „ J• your community is probably the N 1MN easiest way. You also Can ask rf sxt = physicians, dentists, and pharmacists in your community, or check with your local, county or state health dcpartment. "V! aP4 The American Association of Public Health Dcntistry urges you to 1 fsl��.si,7r. support the adoption continuation of community water fluoridation for your community. Find out if your iw;N+y�C community is fluoridated. If it isn't, ask our political leaders and local health 4,'" officials why not. You have a right to the improved dental health that comes from living in a fluoridated community! E'lprevent y,community water tion is the most efficient way tooth. decay. The following key facts about fluoridation summarize why this is so. 19 Fluoridation is the least expensive and most effective way to reduce tooth decay, ® Fluoridation benefits children and adults when they drink fluoridated water and consume foods and beverages prepared with it: • Fluor/dation is safe. ® Fluoridation provides benefits that continue for a lifetime. ® Fluoridation reduces the need for dental treatment and its costs. Cal O N O a Your dentilstA dental hygienist are your partners for good oral health See them for regular cleanings and checkups starting at age one. Ask the county health department about programs if you cannot afford care. Putting off treatment costs more in the long run and can result in pain and inf=don. Public Health Dental Program Florida Department of Health Contact` yourcounty'.:.. health department for:'...,_ ^ dental resource options: iJ;rte, .4.1 WO Y..'1$w h•.. SrH �I Faf u.L Bureau of `< u CUnicat & Preventive Practice Mana ement* r i:✓"n11.;:r''rRj �° �� PubLie HeaLth Dental Program i^s„ ti A -N 4052 Bald Cypress Way Bin OA14 Tallahassee, FL 32399-1724 0 N O W -v v rD ,-r v aq rD N N O i �7, 1ir. J. TI -11, r� k. Tooth decoy and gum disease are mainly caused by plague, a coating of harmful, infectious germs that is constantly forming on the teeth. When foods or beverages containing sugars or starches are in the mouth, the germs in the plaque make an acid that destroys the surface of the teeth and causes decay. Both can be painful and costly. Fluoride #1 FOR PREVENTING TOOTH DECAY. Putting fluoride on tooth surfaces is the best protection from decay. Drinking fluoridated water throughout the day protects teeth and even reverses beginning tooth decay in children and adults. It is the least expensive way to prevent tooth decay. The health department or water utility company can tell you if the fluoride level of its water is at the best level to prevent tooth decay. Bottled water usually does not provide the same decay prevention since -most bottled water does not contain fluoride. Brushing with fluoride toothpaste twice a day helps prevent tooth decay. Be sure that young children use only a pea -size amount of toothpaste and do not swallow it Parents should provide supervision until child can spit. Using an over-the-counter fluoride mouthrinse is another way to put fluoride on teeth regularly. Weekly fluoride mouthrinse for children is available at some schools where fluoride levels of drinking water are not high enough to prevent decay. Check with your child's school to sec if a fluoride mouthrinse program is available. Dentists also provide fluoride treatments during regular visits. Sealants shield teeth from decay Sealants are plastic coatings that are applied to the back chewing teeth. They keep decay out of the deep grooves in your teeth where fluoride can't reach. Most decay happens in the deep grooves of the permanent 6 and 12-yearmolars. Sealants can prevent most decay if placed an the permanent molars as soon as possible after they come in. Your dentist may recommend sealing more teeth for added benefit. Children depend on adults to prevent decay Young children who drink baby ,. bottles or "sippy cups" of juice, milk or sweetened beverages throughout the day develop decay of the front teeth called a1,gin early childhood caries or baby bottle F: ; tooth decay. To keep this from happening, Iimit children over the age of one to only water at bedtime and between -meal bottles and in "sippy cups." Clean your child's teeth and gums every day with a soft toothbrush or clean washcloth and a pea -size amount of fluoride toothpaste. Make tooth caro fun—with games and play—so that children learn to look forward to caring -for their teeth. :7Col—(Lunt at I. feve"Ttarlr--- irs up to you • Use toothpaste and/or mouthrinse containing fluoride. e Brush teeth after breakfast and before bedtime to remove decay causing plaque. Tooth surfaces should feel smooth—not "fuzzy" • Brush your tongue, roof of mouth, and inside of cheeks gently. • Floss teeth daily under the gum line to clean areas your toothbrush can't reach. Daily flossing may help prevent gum disease. • Replace•your toothbrush when frayed of after a respiratory illness. • Remove tongue and lip jewelry that can chip and wear teeth. • Chewing Xylitol sweetened gum after meals and snacks may help prevent decay. • Eat a well-balanced, nutritious diet that is rich in calcium and low in sugar. If you are pregnant, , remember that your child's teeth are forming and need good nutrition to develop properly. • Be aware of medications that may cause "dry mouth" and increase risk of tooth decay. • PLEASE DONT SMOKE! People who smoke have more gum disease than those that don't! • Avoid smokeless tobacco. It causes dental disease and oral cancer by irritating gums and cheek p linings with cancer causing chemicals. Spit: N tobacco is more.addicting than tigarettes.•Check with your doctor or health department about getting help to "quit spit" e e e i e e �C,�! de ` t ��4m. u � die.rer� e^ •n..a r --'.w � O��pe• avec. t hN •o }oyo pro ni e. o;, 4`. vuShOt rf ::F 5/10/2016 11.B. Community Water Fluoridation is the most efficient way to prevent dental decay, thereby preventing dental problems and leading to optimum oral health. Varying Degrees of Dental Problems Interproximal Caries 19 -year-old Rampant posterior decay 7 -year-old Cellulitis -full-blown systemic infection from Abscessed tooth 6 -year -ofd child Caries -Free Mouth Demonstrating Optimum Oral Health Packet Page -221 - OPTIMALLY FLUORIDATED WATER IN FLORIDA - 2005 un ALACHUA BAKER SAY BRADFORD BREVARD BROWARD CALHOUN CITRUS CLAY COLLIER L70'0 ; DESOTO DUVAL ESCAMBIA FRANKLIN GADSDEN GLADES GULF HARDEE HENDRY Seine Re« ' 61% Walfon ox Com unities Alachua NoM• py, l.ceson O% Communities High Springs ox MacClonny 0% Brooksville Callaway HIGHLANDS �: x;:.rr?:.ki'kzit�t<,•yl?��:;, Lake Alfred u•.ne�. 0% MM iryler ''�6 _ pax Gainesville County Communities High Springs ox MacClonny HERNANDO Brooksville Callaway HIGHLANDS Avon Park Cedar Grove Lake Alfred Sabring7,:,- PanamaCity HILLSBOROUGH Hershel Heights Panama City Beach PUTNAM Oak Estates Parker Palatka Tampa Springfield Temple Terrace Southport Ponta Vedra County unincorporated areas Mexico Beach♦ INDIAN RIVER Vero Beach Starke County unincorporated areas County unincorporated areas Lawtey ♦ JEFFERSON Monticello Cocoa LAKE Eustis Cocoa Beach Tavares Indialantic Navarre Beach Umatilla Indian Harbour Beach LEE Ft Myers Melbourne County unincorporated areas County unincorporated areas Melboume Beach LEON Tallahassee Merritt Island MADSION Madison Mims MANATEE Anna Maria Palm Bay County unincorporated areas Bradenton Port Malabar TAYLOR Holmes Beach Port St John Daytona Beach Long Beat Key Rockledge 1e1a1.nd. Palmetto Satellite Beach Deland Sunny Shores Suntroe More County unincorporated areas Titusville Ormond Beach West Melbourne MARION Ocala County unincorporated areas MONROE All communities All communities NASSAU Fernandina Beach Blountstown ♦ Amelia Island Inverness OKALOOSA Crestview Crystal River Niceville Golden Terrace Destin Green Cove Springs FortWalton Beach ♦ Immokalee Mary Ester Golden Gate Seashore Naples Shalimar ♦ County unincorporated areas County unincorporated areas AN communities, except Florida City ORANGE Apopka County unincorporated areas Crescent Heights Arcadia ♦ Eatonvllle Entire County natural optimal Maitland Ocoee fluoride except Baldwin Orlando County unincorporated areas Winter Park Pensacola OSCEOLA Kissimmee County unincorporated areas St. Cloud Apalachicola ♦ PALM BEACH Belle Glade County unincorporated areas Boynton Beach Quincy Delray Beach Lake Port ♦ Pahokee Port SL Joe ♦ Wellington Port St Joe Beach ♦ West Palm Beach Wewahitchka New Port Richey y County unincorporated areas County unincorporated areas PINELLAS Belleair Wauchula ♦ Clearwater Zolfo Springs ♦ Dunedin Clewiston St. Petersburg LaBelle County unincorporated areas Sr 'gores FmNiln 1a% rgsiatta OX County o i ies ora. ox POLK Auburndale Bartow Fluoridated Water Haines City Lake Alfred Lakeland eMr iri.m: Winter Haven PUTNAM Crescent City Palatka ST. JOHNS Hastings Palm Valley Ponta Vedra Inlet Beach North At Augustine Beach County unincorporated areas ST. LUCIE Ft. Pierce Port St Lucio 20% County Unincorporated areas SANTA ROSA Milton Navarre ♦ - - -. Navarre Beach SARASOTA Sarasota "' ❑1-20% '25L Siesta Key = County unincorporated areas SEMINOLE Altamonte Springs e% oz Lake Mary Longwood Oviedo Sanford County unincorporated areas SUWANNEE Live Oak TAYLOR Perry VOLUSIA Daytona Beach Daytona Beach Shores 1e1a1.nd. South Daytona Deland Holly Hilt Now Smyrna Beach Ormond Beach Ponce Inlet G.d« gr.wa4. Port Orange as R N•s«u .. 64% 70.9% of Florida's Population Receives Optimally Fluoridated Water 20% aoz - °ox" • eMr iri.m: 78.7% of Florida's Population aid "` 7N6 Served by Community Water ?YuJNIrbb'..It;YFluoridated Systems Receives Optimally y Water M.rbnA4 Percent by County 20% ".. 0% -. aw• wz •r r..r. lax ,,} ,. f XAOIMOW � "' ❑1-20% '25L Na % 1 ex = 21-40% e% oz a 41-60% 81-100% • 1e1a1.nd. Natural Fluoride Ch.r" G.d« gr.wa4. Q (� Percent of Population on Community Water Systems Receiving Fluoridated Water by 5 Year Intervals 809'° :iyj,,°��.i�`?r'.�.�4i��'�.•ft;l?<`3±'{.;g'ty_,;i. z'�I.,ieb,Y''..j„rY.. id ,a sp, i^':n n�t.r Ott'1( aotb`' 0% 19s0 1955 1990 1995 2000 2005 I PLOMADEPARTMAIW OF 1 N O ®I� PubU6 eatth� C7 Dental Program a � ingrovlrrgQ•LM«trh � 0! OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated ALACHUA 173,950 92.3% 70.0% Alachua, City of 6,135 Jun -80 Alachua Gainesville Regional. Utilities 963,976 Oct -49 Gainesville High Springs, City of 3,838 Jan -79 High Springs BAY 151,248 90.4% 89.8% Bay County Water System 2,555 Apr -90 Unincorporated Area Bayside Utility Services 745 (cons to say County W.S.) Unincorporated Area Callaway, City of Water System 15,760 (cons to Bay county W. S.) Callaway Cedar Grove Water System 2,450 (cons to say County W.S.) Panama City Beach Lake Powell Community Development 952 (cons to Panama City Beach) Panama City Water System 40,466 (cons to Bay County W.S.) Panama City Shaded areas are natural optimal fluoridation H 04/08 Cil C:) fV C) 0) .1 Z Starke, City of 5,364 Nov -96 Starke v v BREVARD 516,815 97.0% 96.6% rD Cocoa, City of 219,294 r+ m Nov -55 Cape Canaveral Cocoa m Cocoa Beach N Merritt Island Kingswood Manor (cons to North Brevard Cry) Malabar, Town of (cons to City of Palm Bay) Shaded areas are natural optimal fluoridation Port St. John Rockledge Suntree .Viera Unincorporated Area Unincorporated Area Malabar 2 162 04108 Cn O N O O OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated BAY Parker, City of Wafer System 4,792 (cont.) (cons to Bay County W.S.) Parker Southport Water System 3,271 (cons to Bay County W.S.) Southport Springfield, City of Water System 10,223 (cons to Bay County W.S.) Springfield BRADFORD 7,115 42.2% 24.4% Starke, City of 5,364 Nov -96 Starke v v BREVARD 516,815 97.0% 96.6% rD Cocoa, City of 219,294 r+ m Nov -55 Cape Canaveral Cocoa m Cocoa Beach N Merritt Island Kingswood Manor (cons to North Brevard Cry) Malabar, Town of (cons to City of Palm Bay) Shaded areas are natural optimal fluoridation Port St. John Rockledge Suntree .Viera Unincorporated Area Unincorporated Area Malabar 2 162 04108 Cn O N O O v rP v v oa rD N N T OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated BREVARD Melbourne, City of 404 (cont.) Nov -66 lndialantic Indian Harbour Beach Melboume Melbourne Beach. Satellite Beach Mims Water Treatment/North Brevard 7,637 Aug -02 Mims Unincorporated Area Oakwood Manor 644 (cons to North Brevard Cty) Unincorporated Area Palm Bay Estates MHP 781 (cons to City of Palm Say) Unincorporated Area Palm Bay, City of 76,443 Sep -2003 Palm Bay Pon` Malabar Titusville, City of 42,241 Aug -83 Titusville West Melbourne Water System 17,362 (cons to Crit' of Melbourne) West Melbourne BROWARD 1,769,993 100.0% 99.9% Broward County Utilities District 1A 61,024 Aug -76 Lauderdale Lakes Broward County Utilities District 2A Aug -76 Broward County Utilities District 3A (cons to Hollywood) Shaded areas are natural optimal fluoridation Pompano Park Unincorporated Area 70,537 Lighthouse Point Unincorporated Area 19,470 Unincorporated Area 3 04/08 W COUNTY BROWARD (cont.) OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not fisted) SYSTEM AND DATE FLUORIDATED Broward County Utilities District 3C (cons to Hollywood) Broadview Park Water Co. (cons to Ft Lauderdale) Coconut.Creek, City of (cons to BCOES 2A) Colonies of Margate (cons to Margate) Cooper City May -91 . Coral Springs,. City of May -88 Coral Springs lmprovement District March -92 Dania Beach, City of Jan -78 Davie (Hacienda Village) (cons to Ft. Lauderdale) Davie, Town of Jan -78 Deerfield Beach, City of may -95 Ferncrest Utilities Feb -77 Shaded areas are natural optimal fluoridation Area OR COMMUNITY SERVED Unincorporated Area Broadview Park Coconut Creek Unincorporated Area Cooper City Coral Springs Unincorporated Area Dania Beach Unincorporated Area Unincorporated Area Davie Deerfield Beach Silver Oaks Everglades Lakes Unincorporated Area 4 POPULATION % Water. Sys Pop % Cty Pop SERVED Fluoridated Fluoridated 3Z389 '6,416 45,402 1,497. 31,788, 55,599 35,476 17,000 128 i 30,420 50,250 .5,881 04/08 tai O N O H d7 W 1 1 OPTIMALLY FLUORIDATED WATER SYSTEMS 1N FLORIDA 2007 (Counties without fluoridated water systems are not fisted) Shaded areas an: natural optimal fluoridation 5 % Water Sys Pop % Cty Pop Fluoridated Fluoridated 04108 Cn —11O N O W SYSTEM AND DATE Area OR POPULATION COUNTY FLUORIDATED COMMUNITY SERVED SERVED BROWARD Ft. Lauderdale, City of 184,632 (cant.) Aug -83 Ft. Lauderdale Lauderdale -by -the -Sea Sea Rach Lakes Lazy Lake Unincorporated Area Hallandale Beach, City of 33,142 Sep -76 Hallandale Beach Hillsboro Beach, Town of 1,890 Oct -82 Hillsboro Beach Hollywood, City of 152,582 Jun -77 Hollywood Unincorporated Area v n Indian Trace Comm_ Dev. Dist 52,058 77 m (cons to Sunrise 91) Unincorporated Area r* Lauderhill, City of 53,995 v Mar -75 Lauderhill (D Margate, City of 60,213 Nov -77 Margate V Miramar (East & West) Plants 94,479 Jan -75 Miramar North Lauderdale, City of 27,086 Oct -76 North Lauderdale North Springs Improvement District 29,556 Mar -92 Unincorporated Area Oakland Park, City of 37,204 (cons to Ft. Lauderdale) Oakland Park Parkland Utilities, Inc. 2,459 Jan -90 Parkland Pembroke Pines, City of 156,546 Feb -89 Pembroke Pines Shaded areas an: natural optimal fluoridation 5 % Water Sys Pop % Cty Pop Fluoridated Fluoridated 04108 Cn —11O N O W OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are' not listed) CITRUS SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated Nov -87 Inverness BROWARD Plantation, East & Central 99,360 (cont.) Dec -74 Plantation Pompano Beach, City of 80,191 Aug -99 Pompano Beach Royal Utilities Co., Inc. 1,882 Jan -75 Unincorporated Area South Broward Utility/Sunrise 11,900 Feb -91 Unincorporated Area City of Sunrise #1 122,319 Nov -83 Sunrise Sunrise 03 (Sawgrass) 21,384 (cons to Sunrise #1) Sunrise Tamarac (East), City of 1,604 (cons to Ft. Lauderdale) Tamarac Tamarac (West), City of 66,619 Sep -88 Tamarac Unincorporated Area Wilton Manors, City of 15,612 (cons to Ft. Lauderdale) Wilton Manors CALHOUN 4,333 83.3% 29.8% PA::rY. !4Yda�a�� . ,.. _ r.41rir31NlC+i'9d4lD.'1�}� .. 39Mi�'•4�}F4[6.'�R'F��.IS'"'�5°.t�"13 CITRUS 14,000 17.6% 9.9% Crystal River, City of 5,107 Jan -97 Crystal River Golden Terrace 434 (cons to Inverness) Golden Terrace Inverness, City of 8,459 Nov -87 Inverness Shaded areas are natural optimal fluoridation 6 04/08 Cr O fV O O) Q OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) Shaded areas are natural optimal fluoridation 7 V7 O N O O') 04108 Q SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated CLAY 10,204 8.0% 5.5% Green Cove Springs Water Systems 10,204 Mar -83 Green Cove Springs Unincorporated Area COLLIER 248,918 80.2% 74.40/6 Collier County Regional WTP 147,684 1985 Unincorporated Area Florida Governmental UtilityAuth. 12,093 Oct -88 Golden Gate Immokalee Water 25,224 Nov -96 Immokalee Naples Water Dept 63,996 n Oct -51 Naples Unincorporated Area DADE 2,453,142 99.7% 99.4% rD Bal Harbour Village 3,038 N N (cons to MDWASA) Bal Harbour Village 1P Bay Harbor Islands, Town of 5,007 (cons to North Miami Bch) Bay Harbor Islands Hialeah Gardens 7,838 (cons to MDWASA) Hialeah Gardens Hialeah, City of 146,318 (cons to MDWASA) Hialeah Homestead, City of 33,349 Dec -86 Homestead Indian Creek Village 907 (cons to MDWASA) Indian Creek Village Shaded areas are natural optimal fluoridation 7 V7 O N O O') 04108 Q OPTIMALLY FLOORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) Shaded areas are natural optimal fluoridation 8 04/08 01 O N) O TT VJ 06-vj SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated DADE Miami -Dade Water & Sewer Authority 1,782,105 (cont.) Apr -52 Miami Unincorporated Area MDWASA/Rex Utilities 43,372 (cons to MDWASA) Unincorporated Area Medley Water Department 13,378 (cons to MDWASA) Medley Miami Beach, City of 130,436 (cons to MDWASA) Miami Beach Miami Springs, City of 14,631 (cons to MDWASA) Miami Springs North Bay Village, City of 6,062 (cons to MDWASA) North Bay Village North Miami, City of 71,382 r° Feb -69 North Miami North Miami Beach 167,220 v Dec -96 ' North Miami Beach N Opa Locka, City of 15,939 w (cons to MDWASA) Opa Locka Rex UtilitiesJRedavo 208 (cons to MDWASA) Redavo Surfside, Town of 4,484 (cons to MDWASA) Surfside Virginia Gardens, Village of 2,311 (cons to MDWASA) Virginia Gardens West Miami, City of 5,957 (cons to MDWASA) West Miami DESOTO 8,141 55.9% 24.0%' Shaded areas are natural optimal fluoridation 8 04/08 01 O N) O TT VJ 06-vj COUNTY SYSTEM AND DATE FLUORIDATED OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) Area OR POPULATION % Water Sys Pop % Cty Pop COMMUNITY SERVED SERVED Fluoridated Fluoridated ESCAMBIA 240,025 80.7% 76.8% Emerald Coast Utility Authority 239,760 Nov -01 Pensacola Innerarity Island W/S 265 (cons to ECUA) Unincorporated Area FRANKLIN 2,210 19.4% 18.0% GADSDEN 9,340 19.0% 23.6% Atlanta Street 373 (cons to Quincy) Shaded areas are natural optimal fluoridation Unincorporated Area 9 W08 01 O IV O 0) W OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated HENDRY 22,308 78.4019 55.9% Clewiston, City of 12,334 2007 Clewiston LaBelle, City of 5,375 Sep -98 LaBelle South Shores Water Assoc 4,599 (cons to City of Clewiston) Unincorporated Area HERNANDO 12,200 7.7% 7.5% Brooksville, City of 92,200 Sep -86 Brooksville HIGHLANDS 55,597 61.0% 57.1% Avon Park, City of 18,570 Feb -83 Avon Park Sebring Water & Sewer System Nov -79 Sebring 37,027 HILLSBOROUGH 1,013,194 88.8% 84.6% City of Tampa 563,917 Mar -88 Tampa Fairview MHP 110 (cons to City of Tampa) Unincorporated Area HCWRS/Northwest Utilities 149,029 Sept -94 Corp. & Unincorp. Area Gunn Townhomes 184 (cons to HCIMRSNorthwest UVV On the Park Townhomes 77 (cons to HCINRSVorthwest UtN) Shaded areas are natural optimal fluoridation 11 04/08 CJl O N O Q OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE COUNTY FLUORIDATED HILLSBOROUGH HCWD/Oakview Estates (Cont.) (cons to Lakeland) . HCWRS/South Central Sept -94 Hacienda Heights MHP (cons to HCWRS/South Central) South Shore Falls South Master (cons to HCWR=outh Central) Hershel Heights Area OR POPULATION COMMUNITY SERVED SERVED 669 Oakview Estates Unincorporated Area 255,851 Corp. & Unincorp. Area 33,149 1984 1,507 409 1,323 % Water Sys Pop. % Cty Pop Fluoridated Fluoridated (cons to City of Tampa) Pebble Creek Promenade Subdivision 113 (cons to City of Tampa) Unincorporated Area Temple Terrace Utility 33,149 1984 Temple Terrace INDIAN RIVER 114,526 95.80/0 81.4% Indian River County Ufilities 67,006 Sept -91 Unincorporated Area Vero Beach, City of 47,520 Jan -86 Vero Beach LAKE 50,972 18.2% 17.7% Eustis, City of 28,186 Aug -85 Eustis Tavares Water Department 18,421 Feb -84 Tavares Shaded areas are natural optimal fluoridation 12 04108 is O N O CF) 1 1 ► OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated LAKE Umatilla Water Works 4,365 (cont.) Feb -85 Umatilla LEE 338,565 43.4% 43.3% Ft. Myers Water Department 58,295 Jan -75 Gateway Services District (cons to Lee Cty Uil) Lee County Utilities Feb -00 Town of Fort Myers Beach (cons to Lee Cry Util) Mobile Manor Mobile Home Paris (cons to Lee Cty Util) Old Bridge Village Mobile Home (cons to Lee Cty Utd) Pine Lakes Mobile Home Park (cons to Lee Cty USI) Tamiami Village Mobile Home Park (cons to Lee Cly U61) Ft. Myers Unincorporated Area Corp. & Unincorp. Area Ft Myers Beach Unincorporated Area Unincorporated Area Unincorporated Area Area 7,364 151,200 14,727 711 1,311 1,639 1,967 LEON 180,898 83.8% 66.1% Tallahassee, City of 180,698 Aug -88 Tallahassee MADISON 6,674 72.9% 33.4% Madison Water Department 6,674 Aug -85 Madison Shaded areas are natural optimal fluoridation 13 04/08 V1 O N O ME -v a, ro v o•o rD N W T OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) Cn O N O 04/08 (3] Shaded areas are natural optimal fluoridation 14 Q SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated MANATEE 289,547 99.8% 91.2% Bradenton, City of 55,345 Nov -99 Bradenton Manatee County Utilities 294,462 Jun -95 Anna Maria Holmes Beach Palmetto Water Dept 10,686 (cons to Manatee Co. URI. Palmetto Sunny Shores Water Co. 577 (cons to Manatee Co. UNI. Sunny Shores Longboat Key, Town of 7,760 (cons to Manatee Co. Util. Long Boat Key MARION 65,532 32.0%. 20.0% Ocala Palms 194 (cons to City of Ocala) Unincotporated Area Ocala, City of 65,418 Nov -56 Ocala MONROE 79,203 100.0% 100.0% Florida Keys Aqueduct 79,203 Jan -63 Monroe County - NASSAU 37,751 74.0% 54.0% Cn O N O 04/08 (3] Shaded areas are natural optimal fluoridation 14 Q OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated OKALOOSA 137,471 71.0% 70.0% ORANGE 839,891 85.8% 76.0% Audubon Village MHP 680 (cons to OCUD/Westem) Unincorporated Area Crescent Heights SID 1,013 (cons to Orlando Utilities) Crescent Heights Davis Shores 149 (cons to OCUD/Westem) Davis Shores Eatonville Water Department 2,707 Dec -01 Eatonville Fairways Country Club 2,986 (cons to OCUD/Eastern) Unincorporated Area Maitland, City of 13,386 Mar -78 Maitland Ocoee South 37,587 Aug -88 Ocoee Cn 0 N O C -L 04/08 Shaded areas are natural optimal fluoridation 15 � W OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are -not listed) Cn • O N O 04/08 d7 Shaded areas'are natural optimal fluoridation 16 SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated ORANGE OCUD1Bradford Cove 127 (cont.) (cons to Winter Park) Bradford Cove OCPU/Corrine Terrace 1,706 (cons to Orlando Utilities) Conine Terrace OCUD/Daetwyler Shores 464 - (cons to Orlando utilities) Daetwyler Shores OCUD/Eastem Water System 181,903 Sep -2004 Orlando OCUD/Hunter's Ridge_ 1,043 (cons to Winter Park) Hunter's Ridge OCUD/Lake Conway Park . 311 (cons to Orlando Utilities) Lake Conway Park OCUD/South Regional W S 49,602 Sep -2004 Orlando 0CUD/University Forest 91 (cons to W,nterPark) University Forest OCUD/Westem Regional W S 88,356 CD Sep -2004 Orlando w Apopka 00 Orlando. Utilities Commission 374,114 Nov -56 Orlando Unincorporated Area Winter Park, City of 83, 666 Jul -86 Winter Park OSCEOLA 196,462 73.3% 73.1% Eastern Regional, Tohopekallga 190,496 Jun -81 Kissimmee Northwest System - Kissimmee 41,464 Jun -81 Kissimmee Cn • O N O 04/08 d7 Shaded areas'are natural optimal fluoridation 16 v (D v a, as rD N W 1P M 1 OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) South Shore WaterAssn (cons to South Bay WTP) Wellington WTP Jan -02 Shaded areas are natural optimal fluoridation Boca Raton (west) Boynton Beach (west) Lantana (west) Lake Harbor Wellington 17 174 44,692 04/08 Cr O fV O a SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated OSCEOLA St Cloud, Cityof 38,420 (cont.) Apr -86 St. Cloud Unincorporated Area Enterprise CDD 6,162 (consecutive) Unincorporated Area PALM BEACH 770,594 62.0% 59.3% Atlantis Utilities Company Atlantis 1,859 (cons to Palm Beach Cty #8) Belle Glade Waterworks Belle Glade 18,881 Nov -56 Boynton Beach WTP Boynton Beach 80,793 Jan -02 Delray Beach Water Department Delray Beach 66,862 Apr -91 Gulfstream Water Dept. Gulfstream 755 (cons to Delray Beach) Pahokee, City of Pahokee 11,245 Dec -96 Palm Beach County #8 WTP 443,483 Jan -05 West Palm Beach South Shore WaterAssn (cons to South Bay WTP) Wellington WTP Jan -02 Shaded areas are natural optimal fluoridation Boca Raton (west) Boynton Beach (west) Lantana (west) Lake Harbor Wellington 17 174 44,692 04/08 Cr O fV O a OPTIMALLY FLilORIDATED vVATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) 04/08 Shaded areas are natural optimal fluoridation 18 C57 O N O O) JI—1 COUNTY PALM BEACH (cont.) SYSTEM AND DATE FLUORIDATED West Palm Beach, City of July -91 Area OR COMMUNITY SERVED West Palm Beach Palm Beach South Palm Beach POPULATION SERVED 97,774 % Water Sys Pop Fluoridated % Cty Pop Fluoridated PASCO 40,970 12.0% 9.4% Barbara Ann Acres 59 (cons to New Port Richey) Unincorporated Area Gulf Harbors 9,499 (cons to New Port Richey) Gulf Harbors Shamrock Hts Lakewood Villas 657 (cons to New Port Richey) Unincorporated Area New Port Richey Water Dept. 30,631 rD Sep -90 New Port Richey Port Richey Unincorporated Area rD Silver Oaks 124 Np (cons to New PortRichey) Silver Oaks O PINELLAS 919,967 99.8% 97.3% Belleair Water Plant 5,093 Feb -89 Belleair Clearwater Wafer System 84,073 (cons to Pinellas County) Clearwater Dunedin Water System 35,777 Nov -92 Dunedin Gulfport Water System 12,109 (cons to St. Petersburg) . Gulfport Oldsmar Wafer System 12,153 (cons to Pinellas County) Oldsmar 04/08 Shaded areas are natural optimal fluoridation 18 C57 O N O O) JI—1 v v 77 rD v v o4 rD N N OPTIMALLY FLUORIDATED WATER SYSTEMS 1N FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated PINELLAS Pinellas County Utilities 390,340 (cont.) Jun -2004 St. Petersburg Largo Seminole Palm Harbor Unincorporated Area Pinellas Park Water Dept. 49,734 (cons to Pinellas County) Pinellas Park Safety Harbor Water Dept. 15,870 (cons to Pinellas County) Safety Harbor St Petersburg, City of 309,879 Dec -92 SL Petersburg Tarpon Springs Water System 11,594 (cons to Pinellas County) Tarpon Springs Westin Innisbrook Resort 1,345 (cons to Pinellas County) Unincorporated Area POLK 299,286 58.0% 61.2% Auburndale, City of 26,435 Sep -87 Auburndale Bartow, City of 17,712 Jan -2004 Bartow Citrus Woods 542 (cons to Lakeland) Unincorporated Area Foxwood Lake Estates 1,727 (cons to Lakeland) Unincorporated Area Haines City, City of 25,198 Aug -86 Haines City Lake Alfred, City of 6,073 Jun -83 Lake Alfred Shaded areas are natural optima! fluoridation 19 04108 U1 O IV O O Lv!v OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) Shaded areas are natural optimal fluoridation 20 c31 O IV O 04108 CY) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop COUNTY. FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated POLK Lakeland, City of 165,698 (cont.) Apr -83 Lakeland Padgett Estates 266 (cons to Lakeland) Unincorporated Area Pines, The 723 (cons to Lakeland) Unincorporated Area Skyview South 370 (cons to Lakeland) Unincorporated Area Skyview Waters 381 (cons to Lakeland) Unincorporated Area Sunshine Village Mobile Home 606 (cons to Lakeland) Unincorporated Area v Timber Creek Subdivision 811 (cons to Lakeland) Unincorporated Area 77 Village Wafer/Aqua Source 537 (cons to Lakeland) Unincorporated Area Winter Haven Water Dept. 52,207 rD Jan -90 Winter Haven N PUTNAM 18,901 63.4% 25.2% Crescent City WTP 3,150 Jan -98 Crescent City R C Willis WTP City of Palatka 15,751 Sep -98 Palatka Shaded areas are natural optimal fluoridation 20 c31 O IV O 04108 CY) COUNTY SAINT JOHNS (cont.) OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) SYSTEM AND DATE Area OR POPULATION % Water Sys Pop % Cty Pop FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated SAINT LUCIE 204,790 92.5% 75.0% City of Port St. Lucie 120,191 May -95 Port St. Lucie Fort Pierce Utility Authority 59,714 Jun -63 Ft. Pierce Nettles Island 3,796 (cons to Ft. Pierce) Nettles Island North Hutchinson island 3,630 (cons to Ft Pierce) North Hutchinson Island St Lucie County Utilities NOR 1,081 (cons to Ft. Pierce) Unincorporated Area Shaded areas are natural optimal fluoridation 21 04/08 O N O 07 a OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) . SYSTEM AND DATE Area OR POPULATION . % Water Sys Pop % Cty Pop COUNTY FLUORIDATED COMMUNITY SERVED SERVED Fluoridated Fluoridated SAINT LUCIE St. Lucie West Utilities 96,378 (cont.) May -99 Unincorporated Area SANTA ROSA 57,917 41.5% 41.0% Gulf Breeze Water Dept. 5,398 Cme....W nwwnI I — A �,rrf ial..nh.e. Ir?Da'Iaa7�7VJla' - f� '� a - n �Ya�t,f1S a 7C' rD SARASOTA 238,640 70.0% 61.3% Aqua Utilities Florida, Inc., (KPU) 8,638 (cons to Sarasota Co. UN.) Unincorporated Area N Aqua Utilities Florida, Inc., (TRI -PAR) 4,260 (cons to Sarasota Co: LIN.) Kensington Park Sarasota County Special Utilities Dist 150,629 (cons to Manatee Co_ PV.) Unincomorated Area ,,outngate Utilities 98,968 (cons to Sarasota Co. Special Util.) Unincorporated Area SEMINOLE 285,728 69.4% 67.0% Altamonte Springs Water Dept 59,641 Feb -91 Altamonte Springs Shaded areas are natural optimal fluoridation 22 04/08 O fV O 07 1 OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) COUNTY SYSTEM AND DATE FLUORIDATED Area OR POPULATION % Water Sys Pop % Cty Pop COMMUNITY SERVED SERVED Fluoridated Fluoridated SEMINOLE Black Hammock MSBU (cont.) (cons to Oviedo) Unincorporated Area 589 Chase Groves (cons to Sanford) Chase Groves 3,673 Fern Park Subdivision (cons to Altamonte Springs) Fern Park 622 Lake Mary, City of 15,352 Sep -87 Lake Mary Longwood, City of Jun -83 Longwood 97,909 Oviedo & A.M.Jones WTPS 31,342 Nov. 97 Oviedo Sanford, City of 49,090 Jan -66 Sanford Seminole County Northeast 20,250 Dec -88 Greenwood Lakes Country Club Heights Seminole County Northwest 16,853 Dec -88 Heathrow Hanover Woods Seminole County Southwest 9,912 Dec -88 Belaire Lynwood Seminole County Southeast 68,495 Dec -88 Indian Hills Lake Hayes SUWANNEE Live Oak WTP 7,287 72.1% 18.3% Sep -82 Live Oak 7 287 TAYLOR10,075 Perry Water System 77.0% 45.0% Mar -96 Pony 10,075 VOLUSIA City of Daytona Beach 332,622 66.1% 65.3% 98,591 Shaded areas are natural optimal fluoridation 23 04/08 V1 O Ni O OPTIMALLY FLUORIDATED WATER SYSTEMS IN FLORIDA 2007 (Counties without fluoridated water systems are not listed) COUNTY SYSTEM AND DATE FLUORIDATED Area OR COMMUNITY SERVED POPULATION % Water Sys Pop % Cty Pop SERVED Fluoridated Fluoridated Jan -66 Daytona Beach Daytona Beach Shores City of Deland 39,823 Oct -98 Deland City of Holly Hill 13,434 Jun -93 Holly Hill City of New Smyrna Beach 44,341 Mar -85 New Smyrna Beach Unincorporated Area City of Ormond Beach 48,1 p2 Aug -61 Ormond Beach City of South Daytona (cons to Daytona Beach) South Daytona 17,293 v Ponce Inlet Water Dept. (cons to Port orange) Unincorporated Area 3,399 Port Orange, City of 66,511 Feb -83 Port Orange m Tymber Creek Utilities 1,128 (cons to Ormond Beach) Tymber Creek rn STATE TOTAL; 13,150,284 77.8% 70.1% Shaded areas are natural optimal fluoridation 24 04/08 cri O N O O Q International Association for Dental Research 5/10/2016 11. B. Ct, AADR American Association for Dental Research EMBARGOED UNTIL 12 P.M, EDT, THURSDAY, JULY 28, 2011 IADR contact: Ingrid L. Thomas +1.703.299.8084 or ithomas iadr.or3 July 28, 2011 Study Shows Bone Fluoride Levels Not Associated with Osteosarcoma Alexandria, VA, USA — The International and American Associations for Dental Research have released in its Journal of Dental Research a study that investigated bone fluoride levels in individuals with osteosarcoma, which is a rare, primary malignant bone tumor that is more prevalent in males. Since there has been controversy as to whether there is an association between fluoride and risk for osteosarcoma, the purpose of this study, titled "An Assessment of Bone Fluoride and Osteosarcoma," was to determine if bone fluoride levels were higher in individuals with osteosarcoma. No significant association between bone fluoride levels and osteosarcoma risk was detected in this case -control study, based on controls with other tumor diagnoses. In the case -control study, by lead researcher Chester Douglass of Harvard University, patients were identified by physicians in the orthopedic departments from nine hospitals across the U.S. between 1993 and 2000. In this report, the study sample included incident cases of primary osteosarcoma and a control group of patients with newly -diagnosed malignant bone tumors. Specimens of tumor -adjacent bone and iliac crest bone were analyzed for fluoride content. The study was approved by the Institutional Review Boards of the respective hospitals, Harvard Medical School and the Medical College of Georgia. Logistic regression of the Incident cases of osteosarcoma (N=137) and tumor controls (N=51), adjusting for age and sex and potential confounders of osteosarcoma, was used to estimate odds ratios (OR) and 95% confidence intervals (CI). There was no significant difference in bone fluoride levels between cases and controls. The OR adjusted for age, gender, a history of broken bones was 1.33 (95% Cl: 0.56-3.15). "The controversy over whether there is an association between fluoride and risk for osteosarcoma has existed since an inconclusive animal study 20 years ago," said IADR Vice-president Helen Whelton. "Numerous human descriptive and case -control studies have attempted to address the controversy, but this study of using actual bone fluoride concentrations as a direct indicator of fluoride exposure represents our best science to date and shows no association between fluoride in bone and osteosarcoma risk." The study design was approved by the National Institutes of Health's National Cancer institute (NCI), with funding provided by the National Institute of Environmental Health Sciences, National Institute of Dental and Craniofacial Research and NCI. Visit httpT////jdr sagepub com/content/earl) lrecent for a link to the complete article or contact Ingrid L. Thomas at ithomas@ladr.org to request the PDF. About the Journal of Dental Research The IADR/AADR journal of Dental Research is a multidisciplinary journal dedicated to the dissemination of new knowledge in all sciences relevant to dentistry and the oral cavity and associated structures in health and disease. At .02261, the JDR holds the highest Eigenfactor Score of all dental journals publishing original research and continues to be ranked number one in Article Influence Score, reflecting the Influential nature of the Journars content. About the International Association for Dental Research The International Association for Dental Research (IADR) is a nonprofit organization with nearly 11,000 individual members worldwide, dedicated to: (1) advancing research and increasing knowledge to improve oral health, (2) supporting the oral health research community, and (3) facilitating the communication and application of research findings for the Improvement of oral health worldwide. To learn more, visit wL wJadr.ore. The American Association for Dental Research (AADR) is the largest Division of IADR, with nearly 4,000 members in the United States. To learn more, visit www aadronline.or�. 1619 Duke Street, Alexandi iaYA 22.314-3406, USA Packet Page -247- T +1.703.548.0066 • F +1.703.S48.1883 www.iadc0rg 5/10/2016 11.6. September 13-14, 2011 UNIDENTIFIED SPEAKER: It's commercial. MR. YOVANOVICH: It's office and -- COMMISSIONER HENNING: Who's the Chairman here -- COMMISSIONER FIALA: That's all I need to know. Thank. you. CHAIRMAN COYLE: Ladies and gentlemen, we're going to take a 10 -minute break, as required for our court reporter. And when we come back, we have a time certain for 4:00. We will take that time certain item, because it appears we will never get this one done tonight. So we'll continue it probably tomorrow morning. Okay. (A recess was taken.) CHAIRMAN COYLE: Ladies and gentlemen, Board of County Commission meeting is back in session. For those of you who are here with respect to the shopping -- Estates Shopping Center, if you haven't already heard, we're going to begin public input tomorrow morning at 9:00. It seems that we can't get started on this hearing, but we will get started on the hearing tomorrow morning at 9:00, and that's when we'll have you have a chance to speak. And we'll have it all done in one big leap tomorrow. And I apologize that you've been delayed in getting this resolved. But nevertheless, we've got two time certains that we've got to get in before the end of the day. One at 4:00, we're already 20 minutes late, and one at 5:00. We are closing this meeting at 6:00 p.m. tonight. So we're going to get those things done and pick up on the Estates Shopping Center tomorrow morning at 9:00. Okay, now, County Manager. Item #I OC STAFF RESPONSE TO THE QUESTION OF USING FLUORIDE IN THE PUBLIC POTABLE WATER SUPPLY DISTRIBUTED BY THE PUBLIC UTILITIES DIVISION'S WATER Page 189 Packet Page -248- 5/10/2016 11. B. September 13-14, 2011 DEPARTMENT, AS DIRECTED BY THE BOARD OF COUNTY COMMISSIONERS DURING ITS JUNE 14, 2011 MEETING - MOTION TO CONTINUE USING FLUORIDE IN THE PUBLIC WATER — APPROVED MR. OCHS: Yes, sir. Mr. Chairman, we're on Item 10.0 on your agenda, 4:00 time certain. Items to,provide a staff response to the question of using fluoride in the public potable water supply, distributed by the Public Utilities Division's water department, as directed by the Board of County Commissioners during its June 14, 2011 meeting. Dr. Yilmaz will make the initial opening remarks, followed by Dr. Joan Colfer, the director of your Collier County Health Department. Dr. Yilmaz? DR. YILMAZ: Good afternoon, Commissioners. For the record, George Yilmaz, Public Utilities. On June 15th, 2011, at the Board meeting a public petition was presented requesting our Collier County water sewer district to stop the addition of allowable levels of fluoride to our finished drinking water supply. During the same meeting, request was made to hear from dental profession and from medical profession in addition to dental profession, MD's to testify for an informed decision-making process, giving all the information provided by all parties. Given that general direction, now I'd like to invite our water director to make a brief introductory presentation, including our cost of current fluoridation, followed by Dr. Colfer, MD, Director of Collier County Public Health Director, so that when we start our presentation, our Board members know about the cost, total cost of fluoridation, as well as our Board members is aware of cost of per thousand gallon fluoridation as we currently practice. Page 190 Packet Page -249- 5/10/2016 11.6. September 13-14, 2011 With that, sir? MR. MATTAUSCH: Thank you, Dr. Yilmaz. For the record, Paul Mattausch, Water Department Director. During that meeting you requested to be provided with the cost of fluoridation. And I want to give you the annualized all -in cost of fluoridation. This includes time, materials and replacement costs. And that is $32,600 per year. And putting that cost into perspective, the cost of fluoridation is in dollars, $0.0038, or 3.8 cents -- actually, 0.3 -- I'm sorry, 0.38 cents per thousand gallons of water. That's a penny in the cost of 2,577 gallons. Or for a typical family of four using around 7,000 gallons a month, that's a little less than three cents per month. That is an all -in cost. There is no regulatory requirement to feed fluoride to optimally fluoridate public drinking water supply. But consistent with recommendations of the Florida Department of Public Health, the Collier County water sewer district has adjusted the level of fluoride in drinking water since the first water treatment plant was brought on line in August of 1984. Fluorine is the 13th most common element the earth's crust, and because it's so prevalent, fluoride occurs naturally in all natural water supplies, all raw water supplies. And ours is no different. Our freshwater, that from the Tamiami aquifer, has somewhere between 0.25 milligrams per liter or parts per million of fluoride to 0.3 parts per million. So it's relatively low in the amount of fluoride that's present naturally. The brackish raw water ranges, depending on the well and the source, between 1.0 and 2.8 milligrams per liter of naturally occurring fluoride. The finished water averages somewhere around 0.3 or 0.35 milligrams per liter of naturally occurring fluoride before we do any adjustment. So I just want you to understand that the amount of natural fluoride in the water after treatment is about one-half of the Page 191 Packet Page -250- 5/10/2016 11.B. September 13-14, 2011 recommended 0.7 amount of fluoride for optimally fluoridated water supply. And that recommendation is new. That recommendation was made by -- jointly by the United States EPA, the Environmental Protection Agency, and the United States Department of Health and Human Services. And this was an easy date for us to remember. We made the change from the old range of 0.7 to 1.2 parts per million, they used to give us a range to stay within. Now that it's no longer a range, it's just the recommended optimal amount of fluoride in finished water is 0.7, and that happened on 1/11/11. So all ones. That was the date that we implemented as a county the new level of fluoride in water. But the decision to fluoridate is not really one of the economics or how much water, how much is in the water naturally, but it's really one of public health. And I've asked Dr. Colfer to make a presentation based on the public health implications of fluoridation. Dr. Colfer. DR. GOLFER: Mr. Chairman, members of the Board, for the record Dr. Joan Colfer, Director of the Collier County Health Department. Here with me today are researchers from the University of Florida, as well as members of your medical and dental community in response to your request for a presentation on fluoridation. This is an important. issue for Collier County. In addition to the county supply, the City of Naples drinks fluoridated water, people out in Immokalee drink fluoridated water. Over 200,000 people are drinking fluoridated water today in Collier County. In Florida that number is about 13 million people or 77 percent of the population that has any access to a public water supply. In the United States that number is 170 million people or 72 percent of the population on a public water supply. As recently as last year, the Department of Health and Human Services set a goal for the country to be at about 79 percent by the Page 192 Packet Page -251- 5/10/2016 11. B. September 13-14, 2011 r-. year 2020. And indeed, as the population has increased and the availability of public water supplies have increased, more and more people are drinking fluoridated water. The red line on the slide is the growth of the population. The blue line under it is people that are on a. public supply. And then the lines under it indicate the numbers of people that are drinking a fluoridated supply. The next slide is a map that I think you're going to see better on the visualizer. Help me, Leo, please. MR.00HS: Sure. DR. COLFER: This is an interesting map. You have to blow it up a little bit for me so they can see better. Great, that's terrific. This is a map of 42 of the 50 largest cities in the United States that fluoridate their water supply. I mean, you can just look at them, Baltimore, Washington, Philadelphia, New York, Boston, work your way on down the coast to Florida, Jacksonville, Miami. Tampa and Orlando fluoridate their water supply. They're not on the map because they're not one of the top 50 cities by population. Am I back on the Power Point now? This isn't working up here, Leo. Okay, thank you. Now, from a public health perspective, fluoridation is considered one of the top 10 great public health achievements of the last century. We fluoridate so people don't have tooth decay. This group of presenters believe that fluoridation in the levels used in water supplies is safe, it's effective against tooth decay and it's accessible to anybody that drinks from a public water supply that's fluoridated. The following organizations recognize the benefits of fluoridation. It takes two slides to show them all to you, there's about a hundred. Notably among them is the American Dental Association, the American Academy of Pediatrics, the American Cancer Society, American College of Physicians, the Centers for Disease Control and the World Health Organization. The next slides, there's 10 of them, represent just some of the Page 193 Packet Page -252- 5/10/2016 11.6. September 13-14, 2011 research that supports the safety and efficacy of fluoridation. And I just am going to leaf through them just to give you a sense of the volume of research that's supportive of fluoridation. Clearly, after 60 years of research and experience, the preponderance of credible scientific evidence indicates that fluoridation of community water supplies is safe and effective. Commissioners, this is no different than what we do when we add Vitamin D to milk or iodine to salt. It's the same thing. Vitamin D prevents rickets. Iodine in salt prevents people having goiters. We add fluoride to our drinking water to prevent decay. This is not a picture of somebody off the internet, this is a child in our dental clinic that does not live in a place that has fluoridated water. As you all know, you all support that dental clinic to some extent. You do that under contract with us. We fill cavities over there every day. But that's secondary prevention. Putting fluoride in your water supply is primary prevention and helps us avoid decay. The research shows that if you remove fluoride from the water you will increase the cavities rate. And the best example I have is Antigo, Wisconsin. That's a community that stopped fluoridating their water supply for five years. They went back and looked at the children's caries rate and they went up to as high as 200 percent. They put fluoride back in the water supply. Commissioners, I've expanded the little dental clinic that I have at the Health Department twice now. I have seven chairs, and we provide 8,000 visits to poor children, mostly to poor children, and we're able to see some adults. I have no more space, and nobody I know has any more money. If you take the fluoride out of the water, i hate to tell you this, but I don't think I would be able to respond in any fashion. I'm taking all I can take and I have nowhere else to go. Next, Commissioners, before we go to our next presenter, we'd all like to show you just a short video about fluoride. It's only six minutes long, if you would, please. Page 194 Packet Page -253- 5/10/2016 11.B. September 13-14, 2011 (A video was shown.) DR. GOLFER: Thanks, Claire. Commissioners, our next presenter is Dr. Lauren Governale. She is a dentist with a master's in public health. She is board certified in pediatric dentistry, has a certificate in dental public health, and is a fellow of the American Academy of Pediatric Dentistry. But what should be important to you is she's also a clinical associate professor at the University of Florida and serves as your clinic director of the Naples Children and Education Foundation Pediatric Dental Center here in Collier at Edison College. She has worked extensively on dental public health issues, and just this morning helped launch Collier County's first school based dental sealant program. She's a member of numerous professional organizations, including the American Dental Association, Florida Dental Association, and the Collier County Dental Association. Dr. Lauren Governale. DR. GOVERNALE: Good afternoon, ladies and gentlemen. First of all, I'd just like to review the decay process. We have those sugars that are found in diet reacting with the bacteria found in plaque which forms the acid, and that acid in turn turns a healthy tooth into a decayed tooth. There's a few ways that fluoride works. The first one is that it acts to inhibit the demineralization of teeth. The fluoride is beneficial to protect the tooth from the acids that we just talked about that cause the decay. It enhances remineralization of the tooth by creating a fluoride reservoir to strengthen the enamel. The lower diagram shows a regular enamel crystal that's transformed with fluoride into a flora appetite -like crystal, which is considered to be much stronger. Fluoride also inhibits bacterial metabolism, therefore the bacteria has difficulty producing the acids that's necessary to cause tooth decay. Page 195 Packet Page -254- 5/10/2016 11.6. September 13-14,2011 How fluoride works, it works in a couple of ways, one is considered the systemic effect. For decades it was believed that community water fluoridation worked only by incorporating itself into the enamel during tooth formation, only benefitting those who grew up in a fluoridated community. They call it a pre -eruptive effect. And although this is absolutely still the case, there's also for the past 20 years it's been believed that the mechanism of action of fluoride works mostly by providing the ideal amount of fluoride to benefit the tooth by providing primarily a topical effect as well. It's known that community water fluoridation is very well suited for delivering low levels of fluoride in plaque, so you have appropriate levels of fluoride between the plaque and the enamel to prevent the tooth decay. In terms of accessibility, one of the major benefits of community water fluoridation is that no one has to change their habits to receive it. According to the American Academy of Pediatric Dentistry, their .� guidelines state that they recommend children that are receiving non -fluoridated water receive fluoride supplements. That means the families must then access a medical or dental professional to obtain a prescription for the fluoride supplement. And unfortunately for low income families, compliance with this method is not possible due to many barriers such as transportation, et cetera. More recent findings have suggested that there's evidence that fluoride also aids in the prevention of crown and root surface decay in adults due to the topical effect. So it's considered to be effective for all members of the community. I'd like to talk to you a little bit about what we're doing at the NCEF Pediatric Dental Center here located on the campus of Edison College. The trustees of the Naples Children and Education Foundation recognize the need for dental services for low income children as their highest priority compared to all other health needs in their 2005 sponsored needs assessment survey called Study of a Child Page 196 Packet Page-255- 5/10/2016 11.B. September 13-14, 2011 Well-being in Collier County, and decided to do something about it. With state matching dollars, they funded the NCEF Pediatric Dental Center, along with additional supporting funds. In that study it was estimated that 1.7,000 children, 31 percent that is in Collier County lacked access to dental care and low income children were suffering from tooth decay and there were not enough dentists to treat them. The results of dental examinations performed on all students in one high poverty elementary school by the Ronald McDonald caremobile was a staggering 68 percent of children had one or more cavities. The average number was 4.5, and 18 percent had such extreme decay that they needed to be referred for immediate dental care. We have the caremobile dentist here today, Dr. Kelly Johnson, and she just advised me that this week she evaluated a four-year-old in the City of Naples, and that four-year old had 20 teeth, and out of 20, 16 were already decayed. Additional data from HERSA suggests that dental resources in Collier County were not able to meet the demands, and at that time there were many Medicaid eligible children who had not received any dental care, and the utilization rates were very low for ethnic and racial minority Medicaid eligible children. The goals of the Pediatric Dental Center was to build a world class pediatric dentistry program to expand clinical services to at risk children due to what was considered a catastrophic crisis in rural health found in Collier County. Another goal was to deliver advanced care and specialty services such as sedation and hospital based pediatric dentistry services to meet the severe needs of the population. So 20,000 square foot facility was constructed with 17 operatories, including two sedation suites. The University of Florida currently trains nine pediatric dental residents, while Collier Health Services administrates the program at this facility. Page 197 Packet Page -256- 5/10/2016 11.B. September 13-14, 2011 And I have a couple pictures here of actual patients of ours. These patients aren't found in a third world country, they're right here in Naples. Since December of 2009, the facility has performed over 450 dental rehabilitations to low income children in the OR. The decay is so extensive that this environment is required for the young children to be able to comfortably receive their dental care. The waiting list is currently six months long and there's no other facility providing this care to low income children in Southwest Florida. Additionally, we've treated 219 patients with our IV sedation service. We have a pediatric anesthesiologist that comes to the clinic. These children also lack the ability to cooperate for these highly specialized services due to their young age and severe needs. The waiting list for this service is nine months long, and there's also no other facility providing this service. You may ask why is there so much decay if the water is fluoridated. You have to remember, here's a little equation, where fluoride is only considered one factor in the equation, it helps tip the balance toward less disease, but it does not completely prevent it. I think you can see on the right side it mentions pathological factors. There's some dietary components that we're working to help solve as well. In terms of some of the benefits of fluoride, it causes less pain and suffering for the children, fewer school days lost and as many as 51 million school hours lost nationally. Another benefit is fewer cavities and less severe cavities. One more benefit, less need for fillings and teeth extractions. It increased self-esteem. And it produces 18 to 40 percent in dental caries of both children and adults. Even with other fluoridated toothpaste and topical fluorides. Concerns about the discontinuation of community water fluoridation. The citizens should not have to endure potential 200 percent increase in the decay rate. The county does not have the Page 198 Packet Page -257- 5/10/2016 11.B. September 13-14, 2011 capacity, even with our Pediatric Dental Center, two other Collier Health Services dental clinics, the Ronald McDonald caremobile and the Collier County Health Department. These are the agencies that provide services to low income children. But we cannot handle a significant increase in tooth decay if the community water fluoridation is stopped. The surgical approach is not the best solution to the epidemic. Prevention is the best solution. And community water fluoridation is the foundation. Thank you for your time. CHAIRMAN COYLE: Commissioner Hiller, did you have a question? COMIVIISSIONER HILLER: Yeah, I do. Do you want to leave the -- can the professor stay at the podium. I appreciate your presentation. I -- coincidentally someone had given me an article that was recently published in the Bradenton Times that quoted a Dartmouth College research scientist, Dr. Roger Masters. Have you heard about the studies that Dartmouth is doing on fluoridation? Are you familiar with the concerns about the hazards of the fluoride, which are, as I understand, waste from, I guess -- what industry is it that they're a waste from? DR. GOLFER: I think our next speaker is more familiar with that research, if you would indulge us just three more minutes, we could get to him. COMMISSIONER HILLER: Yeah, because, I mean, I'm very concerned. I'd like to know where we're buying our fluoride from and if it's the same toxic substance that I'm reading about here. Because I don't know if you're aware of this, but there's just been a very large lawsuit filed. I'll be happy to share the details with you about it. DR. COLFER: Paul can answer the question about where we buy it from. But if we could go ahead with Dr. Scott Tomar, who's our next presenter and really is a national expert on fluoridation, I think he can answer your question about the Dartmouth research. We Page 199 Packet Page -258- 5/10/2016 11.B. September 13-14, 2011 were just talking about it this morning. Dr. Scott Tomar is a dentist with both a masters and a doctorate in public health, and who is -- COMMISSIONER HENNING: Can I interrupt for a minute? DR. COLFER: Certainly. COMMISSIONER HENNING: How many more presenters do we have? DR. COLFER: We have Dr. Tomar, we have Dr. Richard Garcia, who is the president of your dental association -- COMMISSIONER HENNING: Is this all necessary? DR. COLFER: We have Dr. Todd Vedder, who's the Chair of the Department of Pediatrics. And we have Dr. Allen Weiss, who is the President of Naples Community Hospital. COMMISSIONER HENNING: County Manager, is this all necessary? DR. COLFER: I thought we were providing what you asked for, sir. MR. OCHS: Commissioners -- COMMISSIONER HENNING: Some of it's repetitive. And I'm just saying, we have the public speakers. We have another item. Is there any way to cut this down a little bit? DR. COLFER: I think each of our speakers can try and make their time a little bit shorter, if you would like. COMMISSIONER HENNING: Thank you. DR. COLFER: Absolutely. Dr. Tomar is a nationally recognized expert. Let me just pick out a few important things. He is a professor at the Department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry in Gainesville. He has worked at the Centers for Disease Control as an epidemiologist. He's well published. He's been an editor of the Journal of Public Health Dentistry. Is very familiar with the literature and research on fluoridation. And he also serves as a consultant to the Page 200 Packet Page -259- 5/10/2016 11. B. September 13-14, 2011 World Health Organization, the Mayo Clinic and the National Cancer Institute. And he has been kind enough to assist us with our review of fluoridation. Dr. Tomar. DR. TOMAR: Thank you very much. Yeah, thank you for the opportunity to speak to the safety of community water fluoridation. And I'll try to answer the question that was asked starting with that one study at Dartmouth. First just as a disclosure, I have no financial or other relationship with anybody that manufactures dental products, pharmaceuticals, fluoride products. Receive no pay for being here. In fact I'm here on my own dime down from Gainesville. Just a reminder that fluoridation is a process of adjusting the natural occurring fluoride concentration in drinking water. As was mentioned, and I reiterate it just because I think that there's misinformation about what fluoride is and how it winds up in our water. Fluoride is a naturally occurring substance. It's ubiquitous, which means it's in all water supplies. It's in all soil and rock. Fluoridation is simply the adjustment of that level to optimal levels to prevent tooth decay. One of the courses that I teach at the University of Florida College of Dentistry is evidence based dentistry. We teach our students how to synthesize information, how to use that information to make clinical decisions, and in this case public health decisions. We don't make clinical or public health policy decisions based on a single study. Because you can almost find one study that shows one thing or the other. What we use is what we call systematic review, which as you see here is really considered of a pinnacle of the pyramid. It's really a synthesis of the entire body of literature on a specific scientific subject. And that's what we use as the scientific basis for making clinical and public health decisions. Page 201 Packet Page -260- 5/10/2016 11.6. September 13-14, 2011 And in fact there have been quite a number of systematic reviews done on fluoridation over the years, and I list just a few of them here. Almost all of these are internationally recognized experts on not only fluoridation but on the conduct of systematic reviews. These are not based on individual studies but really the entire body of literature at the time that they were done, as well as several communities that have also reviewed this. So I just chose to present just a couple of quotes, but I'm happy to present the full text of these systematic reviews if you would like to peruse those. But just a few quotes. Water fluoridation both at levels aimed at preventing dental caries and possibly at higher levels appears to have little effect on fracture risk -- talking about bone fracture -- either protective or deleterious at a population level. There's a substantial body of evidence that fluoride up to one part per million -- which is actually higher than the level that we now have in Collier County -- does not have an adverse effect on bone strength, bone mineral density or the incidence of fractures. No clear association between fluoridation and bone fractures, cancer or any other adverse effects. And then one of the accusations that's out there related to water fluoridation and Downs Syndrome, and in fact there's no evidence of association there. There's actually a study that just came out just a month or so ago on fluoridation osteosarcoma, and in fact, consistent with all other studies that have been done on this, in fact found no significant difference in bone mineral fluoride concentration between persons with osteosarcoma and those who did not have that condition. And so, you know, just in summary, the highest level of available scientific evidence, the systematic review, consistently and repeatedly over years has demonstrated no association between community fluoridation and cancer, bone fracture or essentially any other adverse health effect. The safety of community water fluoridation, again Page 202 Packet Page -261- 5/10/2016 11. B. September 13-14, 2011 repeatedly upheld by virtually all leading medical and public health authorities. And I'd be happy to answer your questions. MS. HILLER: Can I go ahead now? CHAIRMAN COYLE: How about the Dartmouth study? DR. TOMAR: I'd be happy to speak with that if you'd like. That study, in fact, I had reviewed that study a while ago. The claim was in that study that the fluoride in the drinking water leached the lead out of the plumbing and caused lower levels of IQ, higher levels of behavior problems, higher levels of incarceration, poor school performance. The study unfortunately committed some of the most egregious violations of some of the principles of epidemiology, which is if you're going to compare communities, for one thing, the communities you're comparing should be relatively comparable. They actually compared a low income inner city low SES population with one of much higher SES. And in doing so, they also compared a community living in very old housing stock, almost all the houses built before 1940 in the community that where supposedly fluoride was responsible for increasing the lead levels. In fact it had nothing to do with the fluoride, it's that they had plumbing that was put in in the 1930's and 40's. The community they compared it to was all relatively new housing. The communities were just completely different in many ways. You know, rates of incarceration, poor school performance, these are complex sociological phenomenon, not at all due to water fluoridation. COMMISSIONER HILLER: Can I comment on that? DR. TOMAR: Absolutely. COMMISSIONER HILLER: What I'm reading here doesn't address what you're talking about at all. As a matter of fact, what this talks about is that fluoride that's used in our drinking waters is actually a waste by-product of the phosphate rock fertilizer industry, Page 203 Packet Page -262- 5/10/2016 11.B. September 13-14, 2011 fluorosilicic -- silicic -- I can't say it, acid. And essentially the quote that I'm going to read you from this professor at Dartmouth, which, I mean, most everybody here knows is ranked as probably one of the top research universities in America, Ivy league school. The quote is as follows, you know, regarding the dumping of billions of -- industry billions of dollars to dump it's hazardous neurotoxin described by Dartmouth College research scientist Dr. Rogers Masters is potentially the worst environmental poison since leaded gasoline into our public water supplies and bottled waters. In other words, how this is happening is the question obviously raised. You know, this article goes on to discuss what's going on in California. A suit was filed against the Metropolitan Water District of Southern California, the largest water wholesaler in the area on behalf .-. of millions of citizens and water consumers in San Diego, Los Angeles and Ventura Counties, California. Suit alleges willful misrepresentation and deceptive business practices by water supplier for delivering a hydrofluosilic (sic) acid drug through their water system that has never been approved for safety and effectiveness nor in the expected dosages delivered by NWD, which is the water district, through retail water districts, either topically, systemically through ingestion or transdermal exposures through baths and showers. And again, it's addressing this fluoride product, which is bought from the phosphate rock fertilizer companies and basically added to our waters. And with very significant maladies as a result of this forced pollution being the consequence. And just as an example, Manatee County confirmed that, you know, they only pay 86,000, but, you know what, the cost is probably a lot higher than that when you consider the other consequences. So it's a serious concern. And you know what you're describing Page 204 Packet Page -263- 5/10/2016 11.6. September 13-14, 2011 when you describe -- when the other professor was describing the real problems that we're having in Collier County with tooth decay among children, I understand that the argument you're trying to make is that if we eliminate fluoride in water that these children are going to have even worse problems than what we're experiencing now. But it seems when I'm reading other articles, like for example, in Canada, less than half of the communities in Canada use fluoridated water. And what they -- you know, what the Canadian health authorities say that's it's, you know, the toothpaste, the fluoridated toothpaste that's critical, and the mouthwashes and the frequency of the brushing, and like you pointed out, the type of diet. You know, obviously if you drink soda and go to sleep and don't brush your teeth, you will have problems. I mean, we've all seen what Coca-Cola does to a penny. So I appreciate, you know, your comments, but there seems to be evidence that goes to the contrary of what you're saying. Now, if young kids need more fluoride or, you know, I don't know if certain adults need more fluoride, everybody can voluntarily supplement to do what's necessary for themselves and we can have programs for those who can't afford to supplement. But to put it in drinking water and subject everybody, people who don't need it, to the hazards of this toxin just doesn't make any sense. And it's not about money, this is about public health. And I'm reading right here that, you know, one of top universities in the country sees this as a health hazard. So unless George can tell me we're not using that type of fluoride and we're using some other natural occurring fluoride that isn't a by-product of the phosphate rock fertilizer industry, then I have serious concerns. DR. TOMAR: Well, I can respond just to one of the points. I'm not exactly sure what the question was. But to just one of your points, you know, first I would ask you to weigh the expertise of this Page 205 Packet Page -264- 5/10/201611.B. September 13-14, 2011 professor at Dartmouth, who in fact has no grounding in either toxicology, medicine, epidemiology or chemistry. He's a professor of government. He really lacks the expertise. And I want you to weigh that against the list of World Health Organization, American Public Health Association groups that actually use science to make public health policy. I'm a public health dentist. I went into public health to help communities. If in fact I had any doubt about the safety of this, I wouldn't drink it, I wouldn't have given it to both my boys who grew up caries free. It just -- it defies logic why world authorities on medicine, public health and dentistry would be on one side and yet we put a tremendous amount of weight on this one professor who in fact lacks expertise in the claims he's making. COMMISSIONER HILLER: I'm not citing that as the only source. But no one is saying that the right type of fluoride applied in the right situation for the right reason doesn't make sense. This fluoridation of all our water supplies, subjecting every citizen to fluoride is the issue. And the type of fluoride. So -- COMMISSIONER FIALA: Mr. Chairman, could we get the rest of the presentation. CHAIRMAN COYLE: Yeah, we're not here to argue with the presenters, Commissioner Hiller. Let's hear the presentations and then we can form our own opinions. DR. COLFER: Thank you, Commissioner Coyle. Our next speaker is Dr. Richard Garcia. He's been practicing dentistry in your community since 1979. He's a graduate of Temple University in Philadelphia. His practice is an adult practice, which delivers all phases of general and cosmetic dentistry. He's probably a member of more associations than the rest of us, except Dr. Tomar. And is -- he's here really in his role as the President of the Collier County Dental Association. DR. GARCIA: Thank you, it's an honor to be here today. I'm Page 206 Packet Page -265- 5/10/2016 11. B. September 13-14, 2011 just a regular dentist. I don't have a Ph.D., I'm a general dentist in town here, so -- I've been a dentist here for 12 years. My practice concentration is adult patients. I'm also the current President of the American -- of the Collier County Dental Association. I represent over 110 active member dentists in Collier County. Our members include periodontists, pediodontists prosthodontists, endodontists, orthodontists, oral surgeons. As a voice for our professional association, we support keeping fluoride in the drinking water supply. As this date came closer, Dr. Primera, another CCDA member that's sitting in our audience here, thought what can we do to -- what can we do because schedules are kind of tight and we wanted to get a lot of advocates here. So my wife, my wife sent out 100 faxes before 2:00 p.m. on Thursday, September 1 st. By the end of the day we were flooded with faxes containing the majority of our 120 signatures of the dental professionals in support of keeping fluoride in our water supply. I was proud of our quick response of our members. As you can see, this issue is important to dentists. Our professional code puts the welfare of our patients first. This is at the heart of preventative dentistry. I wish we lived in a perfect dental world where all children had access to dental care, where all patients did what we asked them, to brush, to floss, to watch your sugar intake. But unfortunately this is not the case. Fluoride needs to be in our drinking water, even though it benefits adults and children alike, the lower socioeconomic segments of our population will benefit the most. And I was doing some research on websites on the topic and I came across some interesting websites. Some were negative websites against the fluoride issue. And you know, they're discussing fluoride as a tool by the government of -- they discussed social engineering. You know, governmental agencies in cahoots with large corporations, Page 207 Packet Page -266- 5/10/2016 11.B. September 13-14, 2011 greed and money as a central issue. I think this is really, you know, an issue, or it's a matter of trust. Do we trust that our governmental agencies, scientists, medical and dental professionals want to do the right thing for our citizens. I'm not saying to follow professionals blindly, but look at the overwhelming evidence that supports keeping fluoride in water without this conspiratorial backdrop. Let's be practical. Let's use common sense when approaching this issue. Fluoride at recommended levels have been used for more than 50 years. I'll close by a quote by the Surgeon General, Dr. C. Everett Koop: Fluoridation is the single most important commitment a community can make to the oral health of its citizens. So please, on behalf of the dental professionals that take care of the residents of Collier County, vote to keep fluoride in our water. Thank you for your time. CHAIRMAN COYLE: Thank you. DR. COLFER: Commissioners, our next to the last speaker is Dr. Todd Vedder. You've met Dr. Vedder before a couple times here. He is a board certified pediatrician, Chairman of the Department of Pediatrics for the Naples Community Hospital health care system, and graciously has agreed to be Chair of Collier County's Safe and Healthy Children's Coalition. Dr. Vedder's been in practice here in Collier County for over eight years. Dr. Vedder. DR. VEDDER: Thank you, Commissioners for your time. And we are limited on time, so I will try to abbreviate my comments. How do I forward, I just click? I'm here to just talk about the safety of optimally fluoridated water from the medical perspective. You've heard over and over that in some form or variation there's countless world organizations, both international and national that advocate this statement to some extent or another, and it's been done repeatedly over the decades, that Page 208 Packet Page -267- 5/10/2016 11.B. September 13-14,2011 optimally fluoridated water provides a safe, effective and accessible means for preventing dental caries. But if we don't want to believe the international agencies, and we don't want to believe the Florida Council of Aging or the national organizations that sponsor the vast majority of physicians who provide medical care in our communities and around -- across the nation and around the globe, then perhaps we might listen to our local physicians, the local doctors who are providing care for you, for your children, and for your grandchildren. And I just wanted to show you a list of the pediatricians, family physicians, and med-pedes physicians in our community that support overwhelmingly and very strongly that optimally fluoridated water is safe. The first group from CHS, Collier Health Services, and when I bring up the slide, if you just stand just briefly. Collier Health Services represents 33,000 children in Collier County, most of whom are disadvantaged, underinsured or uninsured. We have Dr. Jerry Williamson, we have Dr. Scott Needle from North Naples. Dr. Jerry Williamson is the CMO of CHS. We also have Dr. Camina -- or Jorge Camina from Golden Gate Pediatrics. From NCH Health Care Group, we have Dr. Deborah Shepherd and Dr. Andrew Podos. And from among the other 45 -- nearly 40 physicians, I don't believe any of the other ones are here in this room, but they represent a broad swath of our community. In fact, if you look at all of these physicians and all of the children and adults that they care for, we're probably talking about 60,000 of the roughly 75,000 children who reside in Collier County. That's 80 percent. And then some of these physicians also see a number of adults. So a few thousand adults as well. I think that this is the strongest statement one can make from the medical community about how safe and secure we feel about optimally fluoridated water. Page 209 Packet Page -268- 5/10/2016 11.B. September 13-14, 2011 One other local physician I forgot to mention, I should mention is Dr. Pia Myers. Unfortunately not every child in Collier County has the ability to go to the number of physicians that we've listed. They don't have a medical home there. Their only medical home is the emergency room. And Dr. Myers is the director of the pediatric emergency room at NCH. She comes from Jacksonville where water is naturally fluoridated. And she is -- expressed a great deal of angst if the fluoride was removed from our county supply. She would be seeing more children like this, a seven-year-old with a dental abscess. And we've already talked about the pain, the suffering, the loss of self esteem, the loss of school days, the loss of the parent's ability to work on account of these issues. You know, essentially the preponderance of scientific evidence shows that fluoride, when it is ingested, it crosses the bloodstream through the small intestine and the stomach. There is a brief period of time where it enters the bloodstream, it interacts with the soft tissues, peaks in 20 to 60 minutes, then declines rapidly within three to six hours. Depending on how old you are determines how much of that fluoride you've ingested stays in your body. If you're younger, like Dr. Camina, he could probably absorb 50 percent of what -- of the fluoride he's ingested. My age, we're looking at closer to 10 percent. Actively growing bones you can harbor more fluoride. The fluoride that is not harbored in the hard tissues is excreted in the kidneys. And if you look at the whole body, where all that fluoride is, 99 percent of it is deposited in the hard tissues. Again, the rest is excreted by the kidneys. So the logical areas of concern from a medical perspective would be from the teeth, the bones or the kidneys. Ten percent of dental fluorosis is attributable to water fluoridation alone. This is the mottling of the teeth that actually led to the whole discovery of fluoride back in the'20's and'30's with Dr. Dean and McKay. They saw this mottling of teeth in these children from the west and midwest. And they realized that these kids with the Page 210 Packet Page -269- 5/10/2016 11.B. September 13-14, 2011 mottled teeth also had much lower incidence of dental decay. So 10 percent of dental fluorosis, which is this mottling is a attributed to water fluoridation alone, and of these cases, only six percent -- actually not of these cases, I should say of all cases of dental fluorosis, only six percent are considered moderate to severe. The remaining 94 percent is very mild to mild. And we heard from the county water manager about the fluoride content in the water. It has been shown that the fluoride content in the water must exceed two parts per million to start seeing dental fluorosis. The water is continuously analyzed in one plant at the 0.7 parts per million, and it's checked three times a day at the other county plant. And never, as long as our county water manager has been here, he at least told me that he's never seen a level exceed the two parts per million. Then there's the bone disease issue, bone mineral density and fractures we've heard about. In fact, there was a report from the Surgeon General I believe in 2004 that said fluoride might actually be beneficial to bone and reduce the number of fractures, because there were some comparative studies between a couple of cities that had optimally fluoridated water and some that did not have any. And there was actually no change or even a decrease in the number of hip fractures. Osteosclerosis is actually fluoride binding to the bone. There have been cases in the literature of crippling bone disease from fluoride. However, these can be counted probably on two hands. The case reports in the medical literature, there was a survey of x-rays from 170,000 people in Texas and Oklahoma drinking water at four to eight parts per million, and that revealed only 23 cases of osteosclerosis and no cases of debilitating skeletal fluorosis. And then the last area, the kidneys. There has been no cases of dental fluorosis or symptomatic skeletal fluorosis reported among persons with impaired kidney function. And the National Research Page 211 Packet Page -270- 5/10/2016 11.B. September 13-14, 2011 Council in 1993 concluded that the dose of fluoride which causes adverse kidney effects in animals is 50 parts per million, which is greater than 50 times what we see in our water supply -- county water supply. Now, I did mention that there is the 99 percent -- 99 percent of the fluoride in your tissues is held in the hard tissues. But there's also that one percent factor. And I know opponents of fluoridation like to cling to this one percent. Where is that other one percent, what is it doing, what is it doing to harm us. And we've already heard from Dr. Tomar about some of the other allegations as far as cancer, Downs Syndrome, heart disease, AIDS, low intelligence, behavioral problems, precocious puberty, but time again and time again we've seen that the science is flawed, no control groups, observer bias, and they're not reproducible studies. So in summary, optimally fluoridated water provides a safe, effective and accessible means for preventing dental caries. The doctors here in this audience today sacrificed seeing patients or being with their families to be here today because they felt so strongly about this issue. There's 40 other doctors on that list as well. If we take fluoride out of the water, I'm afraid when I see -- I'm going to be seeing more patients in my office where I'm going to see Johnny coming in, and I'm going to say where does it hurt, Johnny. Or Dr. Camina's going to say, donde to duele, Johnny. Or Dr. Valcourt is going to say, ki kote li fe mal, Johnny. And the child is going to point to their teeth. And then I'm going to turn to Johnny's mother, his father, his grandparents, essentially our taxpayers, and I'm going to ask the same question. Where does it hurt? Right here (holding up his wallet) and this is the same in any language, the same meaning in any language. Thank you very much. DR. GOLFER: Commissioners, our last speaker probably needs no introduction, but for the TV cameras, let me tell you that that's Dr. Allen Weiss, the President and CEO of Naples Community Hospital Page 212 Packet Page -271- 5/10/2016 11. B. September 13-14, 2011 health care system. He is board certified in three specialties, internal medicine, rheumatology and geriatrics. Dr. Weiss has been a practicing physician in your community since 1977. He had his own practice for 23 years before becoming president and later president and CEO of NCH. Dr. Allen Weiss. DR. WEISS: Thank you, Dr. Colfer, and thank you, Commissioners. I'm here actually as a father of two children who grew up in the area. And I know some of you are also parents. I've got two preschool children. And I think what we've just heard scientifically really makes the point. We want to take care of our children, we want to take care of our children's teeth, and we want to be able to take care of the 69,000 kids who are under age 18 right now in the country. We'll have about 3,800 children born this year. They'll go through the schools, and so on. We can see all the good that we can do. We're fortunate and we can be very proud of being in a county that has been ranked twice now two years in a row as the healthiest county in the State of Florida by the Robert Wood Johnson Foundation, which is a very credible source. It's based on morbidity, mortality, socioeconomic factors. As we add disease, we will drop that ranking. We are fortunate now that the University of Wisconsin in a recent study has shown that women in Collier County have the longest of life expectancy of anywhere in our country of 87 years. Happy to produce that article for you. Men are the second longest at 81 years, Fairfax, Virginia being the number one for men. So we've got the longest longevity, we've got the healthiest county of 67 counties, we have, we have things going in the right direction. We still have huge problems with smoking. When I walked on the campus here today, somebody was walking off smoking. We're taking care of that in our local institution in a big way. We've seen Page 213 Packet Page -272- 5/10/2016 11.B. September 13-14, 2011 our numbers of smokers go from 20 percent, which is the national average, down to 12 percent. 61 percent of Floridians right now are either overweight, obese or morbidly obese. We've got all these real, legitimate public health problems to work on. And as we're spending time with this august audience and taking your time to talk about something that's been solved for over 60 years, I urge you to make the right decision and to continue with our county's health. Thank you very much. DR. COLFER: Commissioners, that concludes our presentation. But there are a number of dentists, hygienists, physicians, school nurses and others that are here in support of fluoridation and are signed up as public speakers if you would like to hear from them as well CHAIRMAN COYLE: How many public speakers do we have? MR. MITCHELL: Sir, we have 21. CHAIRMAN COYLE: Twenty-one. Okay. Would all those who are in favor of keeping fluoridated in Collier County please stand up. There's more than 41 here. DR. GOLFER: They're not all signed up as speakers but they are here in support. CHAIRMAN COYLE: Take your seats, please. Now, all those people who want to stop fluoridation in Collier County, will you please stand up. Is it safe to assume that all the people who are in favor of fluoridation agree with the comments that have already been made publicly? (Affirmative response.) If it's acceptable to you, so that we can get this issue decided before it gets dark, I'd like to let the eight people who are standing have a chance to speak. And then if you feel compelled to speak, we'll give you that opportunity too. But you can also just waive and say you agree with the information that has already been provided in Page 214 Packet Page -273- 5/10/2016 11.B. September 13-14, 2011 support of fluoridation, if that's acceptable to you. So call -- you don't know speaking for or against, do you. Why don't we just start in order. Young lady, could we start with you, come UP and give us your name. MS. WOODWARD: My name's Amanda Woodward. I'm a recent college graduate. And I rent a home here in Naples, Florida. I am a lower income. I have a lot of student loans, and I have no health or dental insurance. The only way to remove fluoride from the water is a reverse osmosis system, which costs 4,000 to $5,000. This isn't feasible for me or anyone else in this economy, especially when I don't own my own place. Anyone who wants fluoride simply has to pay two to $5.00 for toothpaste, something that is much more affordable. Because I don't have health insurance I worry about showering in a toxic chemical that affects my immune system. When you -- your skin is the biggest organ of your body, so when you shower, your pores open up and it goes straight into your bloodstream. Because I don't have dental insurance, I worry that what has already happened to 36,000 Americans who have dental fluorosis will affect me as well, because I have white and brown stains on my teeth. Sorry, I get so nervous to talk publicly, but I'm very passionate, so excuse the shaking voice. What about my friends with newborns? The ADA recommends infants should not receive fluoridated water, which is impossible to avoid unless they buy bottled water or a reverse osmosis system, which again is too expensive. How can they avoid the toxic chemical on low income? My grandfather had kidney failure. I believe one of the doctors mentioned that it -- the only way to get rid of toxins in your body is through the kidney. And since he was drinking fluoridated water, bathing in it due to the county putting it in the water, it was so hard for him to be able to heal in time. Page 215 Packet Page -274- 5/10/2016 11.B. September 13-14, 2011 So that's -- my concern is for people in the community who can't afford another option to get it out. We can't remove it. And so we'll be forced to shower in it, put it in our teeth. And even though I buy toothpaste without fluoride in it, I will still have to, you know -- thank you for saying what you did today, that was very good. My last thing is I feel like one of the dentist said that it defies logic. But it's unethical and unlogical to be giving people medicine without their consent. And you don't have my consent, and it's poison. And it's disgusting, you know. So I just want you to think about it. It's in rat poisoning. It can't be that good. And a lot of those statistics, especially that map up there. I just went to Austin Texas, and that map was for 2005 and now those cities, a lot of them have removed it. And we have a whole list of cities, especially in Florida that have also removed it. So thank you for considering and taking the time. CHAIRMAN COYLE: Thank you. Next speaker. MS. RAINEY: Hi, my name is -- go ahead. CHAIRMAN COYLE: Just state your name for the record so we'll know what name to take off the list. MS. RAINEY: My name is Jessica Rainey, and I'm here to share about my condition, hypothyroidism. Fluoride affects hypothyroidism negatively. It's a dentist -- I think you mentioned that a chemist should say it's toxic. I just learned that fluoride is one of the most -- one of the more toxic elements in the halogen group. It's in the same group as iodine. And iodine is what the thyroid absorbs. And when fluoride enters into the system, it blocks the iodine from being absorbed into the thyroid, causing hypothyroidism or an underactive thyroid. And symptoms like sleep -- lethargy and even personality changes have been -- there's other diseases that happen after that that get worse, like fibromyalgia and bipolar disorder. I just want to raise the question, is it safe to have this in our Page 216 Packet Page -275- 5/10/2016 11.6. September 13-14, 2011 public's water? Is it even ethical to have it in our people's water? For me it's not good because it affects the -- my person -- in my personal experience, it -- I mean, I had to leave school because I was sleeping all day. And -- MR. MITCHELL: You're okay. CHAIRMAN COYLE: That's merely a caution signal. You've got about 30 more seconds. MS. RAINEY: I also wanted to bring up that there are numerous studies out there that show it affects the IQ in a negative way, in the physical development of people in a bad way. Several counties have already taken it out. In fact, one that was listed on there, Calgary of Canada, I have an article by them, have taken it out, and a doctor from that area, Dr. Beck, has written about it. I want to end on this, this is the medical credo -- of medical professions: Above all, do no harm. Thank you. CHAIRMAN COYLE: Thank you. Who's the next speaker? There was another lady here on the front. Were you a registered speaker? Okay, all right. So we'll start in back. MR. MITCHELL: Sir, if I could explain to the speakers, you're given three minutes. When you've got one minute left, it gives you a beep just to tell you you've one minute left. MR. OAKES: Thank you. I'm honored to be here, thanks for having this forum. We as politicians, you all know the how to get to the root of a problem is to follow the money. The phosphorous fertilizer industry and the aluminum industry has sold over $900,000,000 worth of fluoride collected in taxpayers' money over the last eight years. If they didn't get that money from municipalities, the only other thing they could do with their fluoride is to sell it as rat poison, and there's just not that big a market for rat poison. One of the speakers mentioned that we put iodine in salt and Vitamin D in milk, We sell a lot of milk at our store, most of it Page 217 Packet Page -276- 5/10/2016 11.B. September 13-14, 2011 without Vitamin D. We sell a lot of salt in our store, and it has no iodine. And people can choose whether they want it or not. What we're doing, we're being forced into putting something in our body that we don't want. With every medicine, with every chemical there's a benefit to risk ratio. There's approximately 30,000 people in Collier County who don't have any teeth. Now, if they're being forced -- I mean, what's the upside, where's the benefit. There's no benefit for somebody that has no teeth. The only benefit you're talking about is enamel on teeth. You have no teeth but you have to shower in it, you have to bathe in it. There's no benefit to risk. I also know that the CDC and the American Dental Association has said that we must take fluoride water out of babies' formulas. How do you get it out? How do you get it out if you're poor. How do you get the fluoride out of--- and all we're asking here is for a choice. You need a choice. You can have all the fluoride you want. It is ubiquitous, and it's more ubiquitous than it was 10 years ago, because it's in every frying pan. When you fry an egg, every teflon pan, every soda you drink, every can of vegetables you eat, every prescription has this crap in it. That was not true 20 or 30 years ago. But the biggest thing of all, and you're talking about the World Health organization, and I'd like to hand this to all you guys, we have a good study. There's 14 western countries that has no fluoride in the last 40 years and four that do. This is the World Health Organization. The incidence of caries is either the same or better in those 14 countries. The same or better and they have no fluoride. And that is because all western nations did go to fluoride toothpaste. God bless fluoride. You can have it all you want. Don't force it down a baby that's being bathed in it at one month of old or that has to drink it in their -- CHAIRMAN COYLE: Sir, you didn't state your name for the Page 218 Packet Page -277- 5/10/2016 11.B. September 13-14, 2011 record. MR. OAKES: My name is Frank Oakes. CHAIRMAN COYLE: That's right. Okay, thank you. COMMISSIONER HILLER: Commissioner Coyle, may I address Mr. Oakes? CHAIRMAN COYLE: Go ahead. COMMISSIONER HILLER: Mr. Oakes, I want to thank you. You're the one who brought this forward through a public petition. So I want to thank you for bringing this issue to our attention. I want to address the point you just paid. Today what we have is the medical lobby that has brought a number of people. And I know there are many, many citizens in this community who oppose fluoridation of water because I have received so many e-mails in opposition to fluoridating the public waters that, I mean, my mailbox was on overload. I mean, it was unbelievable. It's 5:30 in the afternoon, these people are all working, because it's not season yet so we don't have the community of retirees who have the luxury of being here during the work day. So the group of people who stood up definitely outnumbers the number of people you have here. However, based on the e-mails I received, the e-mails far outnumber then the people who are present today. So I have a real concern about making a decision as a Board member based on who is in the audience, rather than, you know, people who I know who are concerned. I want to address the discussion that you had with us here regarding the World Health Organization. Germany does not fluoridate its water. The Netherlands does not fluoridate its water. France does not fluoridate its water. I can go on and on and on. Quebec, where I was born, doesn't fluoridate its water. British Columbia, where my parents live, does not fluoridate its water. And the other lady just said Calgary just decided not to fluoridate its water. The trend is not to fluoridate public drinking water. And I will Page 219 Packet Page -278- 5/10/2016 11. B. .—, September 13-14, 2011 also on a matter of principle say that with respect to choice, it is a choice, and there are benefits to fluoride in certain situations. To add fluoride in public drinking water has not been established as necessary for everybody's health. And government shouldn't be interfering where this is really a matter of choice. If we want to have a program for indigent children to help them, that's one thing. I can understand that and I appreciate it. But to force it down our throats when it hasn't been proven necessary is a big issue CHAIRMAN COYLE: Can we hear from the rest of the speakers, please -- COMMISSIONER HILLER: So I want to commend you very much for the points you made. And I wanted to clarify what's going on in terms of how many people are standing up. MR. OAKES: We have a petition here signed by 1,500 Collier County residents to get it out that we want to present to you along with the other packet. And I want to thank you very much. This is a very important issue to all of us. Thank you. CHAIRMAN COYLE: Thank you. MR. MARBLE: My name is Charles Marble. And I'm a nurse, I've been a nurse for over 20 years, and I just wanted to make some statements in response to the statements promoting fluoridation. I'm appalled that any health care practitioner would dare to claim the audacity to medicate myself or my family without my prior consent. To me this is the greatest issue at hand. Everything that I saw discussed today was to promote the fluoridation of water on the basis that it would prevent tooth decay. That's a form of treatment. Every individual in this country has the right to informed consent. They have the right to know the information or the medication or the treatment they are to receive. And they also have the right to choose another option. Page 220 Packet Page -279- 5/10/2016 11.B. September 13-14, 2011 What we're proposing here is the blanket fluoridation of water to every single citizen, whether they choose to have it or not. We are actually claiming to be able to treat every person, that's what I've heard today, that the medical professionals claim that they have the right to promote the treatment of every individual, even without their individual consent. And I have a few issues here to bring up. And this was a quote from Dr. Charles Gordon Heyd, the past President of the American Medical Association stated, and I quote, I am appalled at the prospect of using water as a vehicle for drugs. Fluoride is a corrosive poison that will produce serious effects on a long-range basis. Any attempt to use water this way is deplorable. That was the past President of the American Medical Association. And when I saw the claim that there was a one percent retention of fluoride in the body as though this was not an issue, what wasn't discussed and what has not been studied is the cumulative one percent. What happens year after year, 10 years, 20 years, 30 years of exposure of that one percent cumulatively. There is evidence of harm. The CDC itself in 2005 stated that 32 percent of American children have dental fluorosis. Now, I saw a quote listed on the screen that 10 percent of fluorosis was attributed to fluoride in the water. Ten percent of those individuals out of that 32 percent were affected by the fluoridation of their water. And I will also assure you that it was without their consent. CHAIRMAN COYLE: Can you turn down the volume, please. Thank you. MR. MARBLE: I'm sorry. I'll calm down. I apologize. As a parent, I also have a defined concern. The American Dental Association itself in November 2006 reversed its recommendation and recommended that all infants below 12 months of age with all their formulas when they're produced, that it be produced without fluoridated water, purified water because the body mass index of an Page 221 Packet Page -280- 5/10/2016 11. B. September 13-14, 2011 infant is far less than that of adult. On the screen it said you can drink 25 gallons and that's where the toxic range was -- CHAIRMAN COYLE: Your time has expired. MR. MARBLE: -- well, an infant doesn't have that ability. It's 250 times more concentrated in an infant. So are you going to put a disclaimer to every parent. CHAIRMAN COYLE: We got it. Your time has expired. MR. MARBLE: Oh, has it? CHAIRMAN COYLE: Yes, it has, about a minute ago. MR. MARBLE: Okay. Thank you. I do have the packets if you would like the facts from the CDC. CHAIRMAN COYLE: If you'd like to leave one for the record, that would be fine. COMMISSIONER HENNING: I would like one. Ian, give me that copy. I want a copy. I want a copy. He had -- several copies. I want a copy of it. MR. HUGHES: Hi. For the record, my name is Martin Hughes, and I'm here to speak in opposition to the fluoridation of the water supply here in Collier County. From what I understand, fluoridation started approximately 60 years ago. And it was at a time when it was a by-product of the -- both the aluminum production from smelting of the bauxite and also from the phosphorous for fertilizer, phosphates. And basically the same individual who -- the industry, they were getting sued because what was coming out of the smokestacks at the time was going downwind and taking out crops and also livestock, and they hired a gentleman by the name of Ed Bernays, who actually led campaigns to have women smoking cigarettes. He was also one who had a campaign of 12,000 doctors recommend smoking Chesterfield filtered cigarettes, and he wrote a famous book called Propaganda. And that's initially how the fluoridation of our water supply started. Another thing I think should be brought up is that in the Page 222 Packet Page -281- 5/10/2016 11.B September 13-14, 2011 groundwater here in Collier County, we're at something like 3.32 parts per million as far as the fluoride level. After the filtration has been done, we're still at .27 or .3, which is, you know, almost halfway to the safety -- the safe maximum limit that was set by the ADA. And it just -- it makes you wonder, how much fluoride do we actually need. If we had -- there's fluoride in what we drink, there's fluoride in the food. We're not living in a third world country, so there's adequate access to dental care. There's a topical -- they can go anywhere in Collier County, no matter at what economic level they're at and they're provided with dental care. Also, if someone -- there's also the topical application from toothpaste. if someone wants, they can go to your local CVS and get two trays and put your toothpaste in it and let your teeth soak in it 24 hours a day. And it just -- it just, you know, how much fluoride do we actually need? And, you know, it's in mouthwashes. Also, you know, there's -- the ADA has actually put out recent statements that it admits that it causes caries and fluorosis and the mottling of teeth. And also, another thing that I think should be brought up. There's also other countries, there's Pinellas County, Pasco County, Clearwater, Bradenton, Palm Beach County and Boca Raton have all rejected fluoridation. And I recommend we do the same here. Thank you. MR. BOLDUC: Good afternoon. My name is David Bulduke, and I'm a citizen of Collier County. And I am here today because the fluoride that Collier County adds to the water supply is not the pharmaceutical grade fluoride that you would find in your toothpaste. In fact, it fluoridates it's water supply with sodium silica fluoride, which has never been proven to be safe or effective through scientific testing. In fact, Commissioner Hiller referred to the studies by -- well, Page 223 Packet Page -282- 5/10/2016 11.B. September 13-14,2011 co-authored by Mr. Masters from Dartmouth College. In response to his first study in the year 2000, he wrote a letter to the EPA, and the EPA responded to, quote, to answer your question of whether we have in our possession empirical scientific data on the effects of fluorosilisilic acid or sodium silica fluoride on behavior or health, our answer is no. That is probably why the EPA recently looked at a whole host of, I guess, scientific studies, both human and animal, and has classified fluoride as a chemical with substantial evidence for developmental neurotoxicity. So let's look at the science a little bit further. The EPA, when it, I guess, defines sodium silica fluoride, it defines it as a highly toxic to all plant and animal life. Looking at some of the index material from Dr. Colfer's presentation, specifically the paper by Dr. Easley, where he states fluoride serves as an essential trace element and that the concept of fluoridation is very quite similar to adding Vitamin D to milk or adding Vitamin C to fruit juice. But really, it's not that case at all. If you look at studies from the National Research Council along with the National Academy Of Sciences, the Institute of Medicine, they state that fluoride is no longer considered an essential factor for human growth and development. That means no disease, including dental decay, has ever been attributed to a lack of fluoride. When you look at how does the FDA classify fluoride. Quote, it is a drug. So we are adding a drug without any way of, I guess, accommodating or tracking or following how much everyone is taking of that drug on a daily basis. In fact, in a published paper from the Journal of American Dental Association in'95, it says the optimal level of fluoride intake has never been determined scientifically and has been used only in general terms. Looking at the CDC statement, the one from 1999 where they say fluoridation is one of the top 10 public health achievements in the Page 224 Packet Page -283- 5/10/2016 11.6. September 13-14, 2011 last hundred years for the 20th century, they state within this paper, research suggests that fluoride prevents dental caries predominantly after eruption and of the tooth into the mouth, and its actions primarily are topical and for adults and children. Again, in 2001, the CDC follows this up with another paper that states fluoride's predominant effect is post -eruptive and topical. Again, this is another supplementation from Dr. Colfer's presentation, it's a full paper called Fluoride Facts. It's outside. In it it says fluoride protects teeth in two ways, systemically and topically. And that they have a quote from professor John D.B. Featherstone, who states that there is irrefutable evidence in numerous studies that fluoride in drinking water works to reduce dental caries in populations. Well, I wonder where he's getting that statement. He has two published papers. The first one where he states the effect of systemically ingested fluoride on caries is minimal. And that one from the ADA, or the Journal of the ADA, fluoride, the key agent in battling caries, works primarily via topical mechanisms. CHAIRMAN COYLE: Sir, your time has expired. Thank you very much. MR. BOLDUC: Okay, thank you. CHAIRMAN COYLE: Is that the last speaker? Now, is there anyone who wants to speak from the others group? Yes, sir. MR. POINTER: I would like to. CHAIRMAN COYLE: Okay. Oh, you want to speak, Jack? MR. POINTER: Yes, sir. CHAIRMAN COYLE: Okay. MR. POINTER: My name is Jack Pointer. I live in North Naples. The World Book Encyclopedia under the title of fluoridation says fluoride is used to treat certain bone diseases such as osteoporosis. Fluoride also may help keep bones from getting hard and Page 225 Packet Page -284- 5/10/2016 11.6. September 13-14, 2011 brittle in old age. Among those here present, I believe that those with the title of old age, I am chief. CHAIRMAN COYLE: Okay, I'll give you the prize, Jack. MR. POINTER: I've lived here for 25 years and have used Collier County tap water to drink. During those 25 years, I have not suffered a broken bone. DR. PRIMERO: Good afternoon. thank vou. I am Dr. Patricia Primero. Like Mr. Henning said, yes, it's repetitive, so I will speak to you as a mother, as a citizen of this area, but also because I have 25 years of dental practice. And because I was not born in this country, I have a different perspective. I was able to work in a foreign country and I have been able to work in several cities here in the United States. And I have been able to experience firsthand what it can do to you when the water in your area is non -fluoridated. Unfortunately I see it today, not only in children but also in adults. And remember, our population, it's increasing here, is not only made up of young families like mine, but also made up of all the retirees that decide to take our city as their final destination. I see a lot of these adults which are probably part of the baby boomer generation, and they come with extensive bridge work. Sometimes they have rampant decay under their crowns. And many have compromised immune systems, and many take several medications. Now that I'm mentioning the several medications, so many of them can cause dry mouth syndrome, Xerostomia. And because of this, you have all of these exposed roots. And because those roots are exposed and you have high acidity in the mouth, then you tend to develop not only recurring decay, but severe sensitivity in all those areas. So then what is going to happen to all those patients. These patients that have those roots exposed can also be requiring surgical restorations and expensive reconstruction or even Page 226 Packet Page -285- 5/10/2016 11. B. September 13-14,2011 tooth loss. Why? Why would we want to have something like this. These are actual patients in my practice and they have moved into our area and they have come from areas where there was no fluoridation in their water. Very good, if you look at this one. Very good oral hygiene. There's no plaque, there's no tartar. This person has an excellent oral hygiene. But the only explanation that I can find is the lack of fluoride. So if most of the situations may be preventive by continuing to provide our community with optimal levels of fluoride in our drinking water. Why not. Thank you. CHAIRMAN COYLE: Thank you. Is that it? Another person wants to speak? Okay. I'd like to get this over. I've got to go home and brush my teeth with fluoride water and lots of fluoride toothpaste. DR. DOLAN: That's a great thing to do. Good afternoon, thank you for the time. My name is Dr. Terry Dolan. I'm a dentist. I'm the Dean at the University of Florida College of Dentistry. My dental specialty is dental public health. I'm board certified in that dental speciality. I live in Gainesville, I'm not a member of your community. So you might be asking why am I here speaking with you. I want you to know that the University of Florida has become very invested in the oral health of the children in this community, largely at the invitation of the Naples Children and Education Foundation, who through their study of children's well-being in this community identified dental disease as one of the top four problems facing children in this community. They invited us to come down and work with them. They have invested -- your colleagues have invested more than $10 million to attempt to address this problem facing the children. in your community. That's a significant investment. And we have partnered together with Collier Health Services and many of the leaders in this Page 227 Packet Page-286- 5/10/2016 11.B. September 13-14, 2011 community to address this problem. I implore you to think long and hard about this decision to remove fluoride from your community water source, because it clearly is a safe and effective preventive agent, particularly benefitting low income children and adults. Why work against these initiatives that have been well funded and well supported by leaders in your community because they have identified this as an important issue. So I thank you for the time. And I'd also compliment your professional community for coming out in such large numbers. These are very busy people, and they have come out in large numbers and in very forceful and influential presentations, because they really believe this to be an important issue. And I encourage you to listen to your professional leaders. They're not here out of self interest, they're here because they care about the people in your community. Thank you. CHAIRMAN COYLE: Okay. Okay, unless somebody jumps up and runs to a podium real fast, that's going to be the last -- COMMISSIONER HENNING: It's going to go on forever. CHAIRMAN COYLE: Is this the last one? Everything else will be repetitive. MS. COVINO: Yes. My last effort to speak. I'm Antoinette Covino, and I represent the registered dental hygienists of Collier County. I've been working for the past 42 plus years helping people to prevent oral disease, and I just wanted to relate to you that this month, not in Collier County, but in Cincinnati, Ohio a 24 -year-old single father without health insurance who could not afford medicine passed away because of dental disease. It's not an uncommon story. Yes, I understand from the opposition that they would like to have pro choice, and I think many of us are fortunate enough to have a choice to purchase bottled water without fluoride. If that's the case, go for it. But the people that can't afford a choice, the people that have income issues and low education and low socioeconomic status need you to protect them. And the fluoride in the water benefits far exceed Page 228 Packet Page -287- 5/10/2016 11.B. September 13-I43 2011 h the risks. And you can stand all day and talk about statistics, but look at the scientific evidence and you see which way is stronger. Thank you for your efforts to protect Collier County, keeping it strong and not allowing it to get weak. CHAIRMAN COYLE: Thank you very much. I'm going to start with Commissioner Henning. COMMISSIONER FIALA- I was first. CHAIRMAN COYLE: I'm sorry. You want to be first? COMMISSIONER FIALA: It's all right, you can start with Commissioner Henning. But I was first. We have a little button thing here. You can go with him first. CHAIRMAN COYLE: He's a lot younger than you are. COMMISSIONER FIALA: I know he is, yes. CHAIRMAN COYLE: Should let the younger people go ahead. COMMISSIONER FIALA: You would have to mention that, right. COMMISSIONER HENNING: Okay. I could have been done by now. It was stated by Dr. Colfer's presenters there was a four-year-old that had something like 20 cavities within the City of Naples. Sixteen? The City of Naples, Florida ain't their water, okay. You know, what I was looking for is factual information. This is highly, highly an emotional issue. And I'm very disappointed that we couldn't get some factual information. Dr. Colfer, is this factual -- I mean, this is an emotional picture that you're putting up here. That's what you're trying to portray here, okay. What I was looking for is evidence from a medical journal that it does not affect things like Jessica brought up, about low thyroid. The things that Commissioner Fiala is bringing up -- or Commissioner Hiller is bringing up about the Dartmouth study. The thing the gentleman brought is fluoridealert.org and we know that's Page 229 Packet Page -288- 5/10/2016 11.B. September 13-14, 2011 what's kind of causing this. What I'm looking for is to make a rational, factual decision on whether to pull the fluoride out or leave it in. And I'm going to keep on searching that, because we didn't -- I know where the dental association is, there's no question about it. I know where fluoride alert is, there's no question about it. And the doctor and I and the director for the water department and I were talking about if the citizens want it out of the system, please bring a peer review study that shows it has medical effects on whatever the disease is, Fluorosis or low thyroid or whatever. Let's get that information and make a decision. CHAIRMAN COYLE: Okay. Commissioner Coletta? COMMISSIONER COLETTA: Well, I haven't had an opportunity to speak in an awful long time. No, it's most welcome. It just seemed like the last issue that came up, I was sitting over here in the corner while the whole world was resolving around me. And believe me, I do have opinions, and I think I'm right. But just if I may, I'd like to draw some comparisons. These kinds -- well, first, fluoride issue, this thing has been around. This is a Fifties, Sixties, Seventies thing. I can remember the national protest that took place and the yelling and the screaming way back. I thought it all went away, but it didn't, it's still here. Is there some dangers for fluoride, I suppose in probably excessive amount there probably is dangers. But the good far outweighs the bad by all means. We've been through the same thing with mosquito control. This is not the Mosquito Control Board. I personally got involved with Dr. Colfer, thank you very much. We petitioned the Mosquito Control Board to expand their range. Golden Gate Estates, later Immokalee, we did it two or three times and we were very successful in doing it. And every time we had people come forward about the great dangers of the spray that they're going to be using in minute doses, the danger to their pets, the danger to this, the danger to that. Thank God there Page 230 Packet Page -289- 5/10/2016 11.B. September 13-14, 2011 was enough people that were willing to stand up and say, you know, there might be a small danger with these particular chemicals, but by God, being without mosquitos and the dangers of the disease and the uncomfort (sic) that takes place with them being here in such great numbers, it's worth it. CHAIRMAN COYLE: Commissioner -- COMMISSIONER COLETTA: I'm going to continue. CHAIRMAN COYLE: Could I interrupt just to trim down -- COMMISSIONER COLETTA: You can, but I don't appreciate it. CHAIRMAN COYLE: Well no, but why don't you give us a motion. Let's get a decision on this thing -- COMMISSIONER COLETTA: I'm going to but I'm going to go through my thing -- CHAIRMAN COYLE: This trip down memory lane is getting us nowhere. COMMISSIONER COLETTA: Everybody else -- COMMISSIONER HENNING: If you could stay on point, on the topic -- COMMISSIONER COLETTA: I am staying on point, sir, and you're interrupting me, and I'd appreciate it if you wouldn't -- COMMISSIONER HENNING: It has nothing to do with mosquito spray. COMMISSIONER COLETTA: It has everything to do with mosquito spray, it's the public's perception of what's taking place. The public is supportive of fluoridation or it would not be where it is today. I thank the medical community for coming out in such force to stand up to what's taking place today. I never thought we'd see the day in the Collier County Commission that we would have to prove something that's been a proven fact for a long time. I make a motion that, one, to thank everybody for coming, for all Page 231 Packet Page -290- 5/10/2016 11. B. September 13-14, 2011 the presentations we received and to maintain the fluoridation of our water now and in the future. CHAIRMAN COYLE: Okay. Now we're getting somewhere. A motion by Commissioner Coletta to approve the use of fluoride in the public potable water supply. It was seconded by Commissioner Fiala. Now, is there any discussion about that motion? Commissioner Fiala, go ahead. COMMISSIONER FIALA: Well, it's not about the motion, I was just -- CHAIRMAN COYLE: Not down memory lane again, please. COMMISSIONER FIALA: No, no, no. I was just going to say you would have gotten a motion a lot sooner if you would have called on me first. Actually, when this first was brought to us, I called my dentist, David Clary. And I said, Dr. Clary, is this really true? And he assured me that we must have fluoridation in our water to protect the health and the teeth of all of our residents, not only children but all of us. So then I called Dr. Colfer, and I said, have we had signs of any of these problems? I want to do whatever I can to research. And she said, no, this is a very important health care issue for all of us and we must keep it. So then I called my personal physician, Dr. Julie Harris, and I asked her. And she said sometimes it's the only health care provision the children get, those especially in the lower income strata have no other way of getting health because they can't afford anything else, but they get the water. Well, you know, I felt that that was really important to hear. And I've lived here 37 years and I've raised five kids in this community and none of us have ever had any problems, nor anybody that I know. So I wholeheartedly second your motion. CHAIRMAN COYLE: Commissioner Hiller. Page 232 Packet Page -291- 5/10/2016 11.B. September 13-14, 2011 �. COMMISSIONER HILLER: George, can you come to the stand, I have a question for you, and then I have a couple of comments. What type of fluoride do we use in our drinking water? Who do you purchase it from? DR. YILMAZ: For the record, George Yilmaz, Public Utilities. We use sodium silica fluoride, and we do not use hydrofluoric acid as a by-product. And sodium silica fluoride is Standard 60 certified by National Sanitation Foundation. And it's an NFS certified additive to drinking water. And it goes through numerous testing prior to utilization. COMMISSIONER HILLER: Thank you. You know, with respect to Commissioner Henning's question about the proof, there is no proof to support the benefits that are being touted, that was why those European governments in the World Health Organization basically said no, we're not going to do it. Because there is no evidence to support that it's beneficial. And that's why Germany doesn't have it. That's why Holland doesn't have it. You know, that's why all these -- that's why so much of Canada doesn't have it. And that's probably why a lot of the communities in the States don't have it. Because there is no proof of the positive. But there does seem to be quite a bit of evidence about the negative. And I agree with you, that was not brought forward. That was not brought forward. In fact, the evidence that was brought forward was that the fluoride that is beneficial is topical, it's not the ingested fluoride. So we have a real issue here. And I'm very concerned, I'm concerned about the litigation that's coming forward, I'm concerned about that the liability that the government is assuming by in effect medicating individuals. And as far as the opinion of the community, I would like a copy -- I don't want the original, but I would like a copy of the petition that Mr. Oakes got with over a thousand signatures of Page 233 Packet Page -292- 5/10/2016 11.B. September 13-14, 2011 people that in the community opposed it. The community does for the most part, from what I have heard and from what I have seen, oppose the fluoridation of our drinking water. It should be an individual choice. And it shouldn't be forced on individuals by government through the water they have to drink, and citizens should not have to be forced to go out and buy unfluoridated water. Water is essential. CHAIRMAN COYLE: Commissioner Henning. COMMISSIONER HENNING: Yeah -- COMMISSIONER HILLER: Fluoride is not. COMMISSIONER HENNING: -- to answer your question, it's on the motion. My discussion is on the motion. I'm going to support the motion because I could count the votes. But if I support the motion and find evidence that doesn't support the water department and the fluoridation, I get to bring it back. And nobody has in my opinion, and I'll repeat it again, has provided medical evidence on either side the effects of fluoride in the water system. Except for the dental association and the Florida alert -- fluoridealert.org. I want something on a peer review, scientific based opinion. CHAIRMAN COYLE: Okay. All in favor of the motion, please signify by saying aye. COMMISSIONER COLETTA: Aye. COMMISSIONER FIALA: Aye. COMMISSIONER HENNING: Aye. CHAIRMAN COYLE: Aye. Any opposed by like sign? COMMISSIONER HILLER: Aye. CHAIRMAN COYLE: Okay, the motion passes 4-1, with Commissioner Hiller dissenting, to support the continued fluoridation of water in the public water supply. Thank you all for being here, both sides. Sorry this took so long, Page 234 Packet Page -293- 5/10/2016 11.B. September 13-14, 2011 but thank you very much. Okay, Leo, we said we were going to quit at 6:00. MR. OCHS: Yes, sir, and that's fine, Commissioners. Item #I OA REVIEW AND APPROVAL THE PARKS AND RECREATION MASTER PLAN PREPARED BY TINDALE-OLIVER AND ASSOCIATES, INC. WITH THE ADDITION OF CITIZEN INPUT MEETINGS HELD APRIL 6 AND 75 2011— CONTINUED TO THE SEPMBER 27 i0 TE�iBCC MEETING — CONSENSUS CHAIRMAN COYLE: Do the staff s presentation on the park master plan tomorrow. COMMISSIONER HENNING: Well, we have a professional that we're paying that has to stay overnight. MR. OCHS: Commissioner, I was going to suggest our consultant on the Parks and Rec Master Plan cannot be here tomorrow, but he will be here on the meeting of September 27th on another item, so if the Board would allow us to continue this item, we can -- for one meeting, we can make the presentation then and he will be present, or we can go over, whatever the pleasure of the Board. CHAIRMAN COYLE: It's okay with me, okay with the majority of the Board? MR. OCHS: It's up to the Board. COMMISSIONER COLETTA: All right. COMMISSIONER HENNING: That's fine. CHAIRMAN COYLE: Okay. MR. OCHS: We will continue that item till the next meeting. CHAIRMAN COYLE: Okay, that's fine. Now, we'll do communications tomorrow? MR. OCHS: Yes, sir. Page 235 Packet Page -294- Presentation to Request Ending COLLIER COUNTY WATER FLUORIDATION FLUORIDE What is Fluoride? Fluoride is an element also classified as a Drug by the FDA if "intended for use in the diagnosis, cure, mitigation, BENEFITS OF FLUORIDE Dentists Discuss Water Fluoridation THE FREVSMILES ORAL HEALTH NETWORK Dr. Scott Frey of Frey Smiles (Allentown, PA) "...you don't need to actually consume fluoride (via water, supplements, etc.) to receive the benefits." 44 ... we have found that the protective qualities of fluoride are derived from its direct contact with tooth enamel, strengthening it and buffering it against acids. In fact, the topical application of fluoride from toothpastes and mouth rinses for example is more effective than systemic delivery." Source: FreySmiles.com BENEFITS OF FLUORIDE Fluoride benefits • Children ages 10 and under ✓ fluoride hardens the enamel in developing teeth. • Pregnant women ✓ Fluoride benefits fetal development Fluoride DOES NOT stop Strep Mutans which are the cause of tooth decay. Products and Foods Containing Fluoride • Toothpaste - all traditional shelf brands have fluoride ✓ Fluoride -free toothpaste available at organic/health stores • Fluoride Drops available at pharmacy's • Fluoride supplements/pills available through prescription • Highest Food Sources for Pregnant Women ✓ Pickles, Spinach, Apple Juice, most canned vegetables and fruit Sources: America nDentalAssociation.com, Nutritiondata.self.com & Interview with Dentist Dr. Garry L. Smith (Anderson, Indiana) practicing 38 years. COLLIER COUNTY CENSUS POPULATION The character of our beautiful community. ■ Under 5. Collier County Demographics 5.20% LJ 5 - 9 years. 11 60 and over. r _ 5.40% 33.70% 10- 14Y ears. ML�5.40% ■ 40 - 59 years. 24.70% Ll 15 - 39 years. 25.70% ■ Under 5 ■ 5 - 9 years 10- 14 years X15-39 years 40 - 59 years 60 and over STUDIES ON FLUORIDE EXPOSURE CDC reports higher Dental Fluorosis rate in Children Ages 12 - 15 Figure 2. Prevalence of dental fluorosis among persons aged 6-49, by age group. United States, 1999-2004 confidence intervals. SOURCE: COC/NCHS, National Health and Nutrition Examination Survey, 1999--2004. Source. htt). www.hhs. oyabout newsj2015L 4122�hhs-issues-final-recommenciation-for-community-water- fluoridation.htmW and htt_p:/Jwww.cdc.gov1 nchs data) databriefs db53.htm STUDIES ON FLUORIDE EXPOSURE Dental Fluorosis REPEATED FLUORIDE EXPOSURE EFFECT Harvard School of Public Health 2012 Study Conclusion: "Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain." - Philippe Grandjean, adjunct professor of environmental health at HSPH National Research Council scientists agree Fluoride affects intelligence and may contribute to dementia in the elderly. A study of more than 300 animal, human and cell studies is being review to determine Fluoride 7s full effects. (video) �.. Source: http:Z/www.hsph.harvard.edu news features/fluoride-childrens-health-grandjean-choiZ Other Sources: httD://www.medicalnewstoday.com/articies 154164.php httwww.washingtonsblo�g.com/2014/O2Z/harvard-studv-published-national-institute-health journal-finds-fluoride-lowers-childrens-intelligence-7-iq-points.html EMBRACING PERSONAL HEALTH Additional Studies and Body Processes r�nc�nd prl hn �nnd nn rnr�n(lp n n� fnVi n ) � ��, (lnn�ncn n rn 4 ren n g 4 q n n n n OPPORTUNITY TO REDUCE EXPOSURE Empower the public to decide how it accesses Fluoride CDC I Data and Statistics I Community Water Fluoridation I Division of Oral Health Page 1 of 2 Centers for Disease Control and Prevention CDC 24/7: Saving Lives. Protecting People'" Water Fluoridation Data & Statistics Monitoring Fluoridation in the United States The number of communities and people who benefit from water fluoridation is continuing to grow. This effective public health intervention was initiated in the United States in 1945. In 2012,74.6% of the U.S. population on public water systems, or a total of 210,655,401 people, had access to fluoridated water. CDC monitors the progress of the nation and individual states toward meeting the HealthyPeople 2020objective on community water fluoridation—that 79.6% of people on public water systems will receive water that has the optimum level of fluoride recommended for preventing tooth decay. Data Summaries 2012 Statistics for Water Fluoridation Status These statistics were prepared using water system data reported by states to the CDC Water Fluoridation Reporting System as of December 31, 2012, and the U.S. Census Bureau estimates from 2012. 2010 Statistics for Water Fluoridation Status (http://www.cdc.gov/fluoridation/statistics/2010stats.htm) These statistics were prepared using water system data reported by states to the CDC Water Fluoridation Reporting System as of December 31, 2010, and the U.S. Census Bureau estimates from 2010 Reference Statistics for Water Fluoridation Status The U.S. Public Health Service has reported water fluoridation statistics periodically since 1956. The Water Fluoridation Census (Census) was published periodically from 1963 through 1992 and reported data compiled from the EPA, U.S. Census Bureau, and surveys of state drinking water and oral health programs. Data are also available on this page for the years 2000, 2002, 2004, 2006, 2008, and 2010. Graph of U.S. Percentage Fluoridation Status 1940 - 2012 (http://www.cdc.gov/fluoridation/statistics/fsgrowth.htm) Calculating Fluoridation Statistics httr):/Iwww.cdc.gov/fluoridation/factsheetsl ngineering/wf statistics.htm) This fact sheet describes the methodology used by state drinking water programs, the U.S. Environmental http://www.cdc.gov/fluoridation/statistics/index.htm 1/11/2016 CDC I Data and Statistics I Community Water Fluoridation I Division of Oral Health Page 2 of 2 Protection Agency, and CDC to estimate the number of people served by water systems, the number of people receiving fluoridated water, and the Healthy People objective for water fluoridation. Resources Water Fluoridation Reporting System (WFRS) (http://wwwdev.cdc.gov/fluoridation/factsheets/engineerinp-/wfrs factsheet.htm) WFRS is a water fluoridation monitoring data system for state and tribal water fluoridation program managers and oral health program directors or managers. Data from WFRS are summarized in the biennial report of national and state fluoridation statistics. My Water's Fluoride (MWF)(httr)s://nccd.cdc.gov/DOH MWF/Default/Default aspx) MWF allows consumers in states participating in the CDC water fluoridation data systems (http://wwwdev.cdc.gov/oralhealth/data systems/data relates.htm) to learn basic information about their water system. Other data sources are available in Data Systems http://wwwdev.cdc.gov/oralhealth/data systems/index.htm). Top of Page Page last reviewed: November 22, 2013 Page last updated: July 29, 2015 Content source: Division of Oral Health (/oralhealth), National Center for Chronic Disease Prevention and Health Promotion (/chronicdisease) http://www.cdc.gov/fluoridation/statistics/index.htm 1/11/2016 Source Slide 4 Benefits of Fluoride Brought to you by Crest r Caries Process and Prevention Strategies: Intervention Marjolijn Hovius, RDH Continuing Education Units: 1 hour Online Course: www dentalcare.com/en-US/dental-education/continying-educationlee376/ce376.asp Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures info their practice. Only sound evidence -based dentistry should be used in patient therapy. This is part 9 of a 10 -part series entitled Caries Process and Prevention Strategies. This course introduces the dental professional to the important role of fluoride in the prevention and control of dental caries. Systemic and topical forms of fluoride delivery are discussed as options for the majority of patients, and professional forms of fluoride delivery are discussed as sometimes -necessary measures for high-risk patients with severe caries. Conflict of Interest Disclosure Statement • The author reports no conflicts of interest associated with this work. ADEA This course was developed in collaboration with the American Dental EducationnfrlrA i n,cVoceOcr-rtCW a'rv: ��J�'1 Association. ADEA members are encouraged to go to the AREA Curriculum Resource Center for additional comprehensive curriculum modules. To learn more about the ADEA Curriculum Resource Center, visit: http:/fwww.adea.org/crc ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the ^ D Continuing tdmato provider or to ADA CERP at: http://www.ada.org/cerp ADA C•E•R•P I RetogrwWn Program Cresta + Oral -W at dentalcare.com Continuing Education Course, Revised August 18, 2014 Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this Academy program provider are accepted by AGD for Fellowship, Mastership, and Membership of G--11 V -1, -Maintenance Credit. Approval does not imply acceptance by a state or provincial board PACE of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to I_- Aa 7/31/2017. Provider ID# 211886 Con Unuing Educ�Elon Overview This course introduces the dental professional to the important role of fluoride in the prevention and control of dental caries. Systemic and topical forms of fluoride delivery are discussed as options for the majority of patients, and professional forms of fluoride delivery are discussed as sometimes necessary measures for high-risk patients with severe caries. Clinical Significance Snapshots How can I find out if my patients are getting fluoridated water? Contact the local water supplier or State Health Department. Almost 70% of the US population receives water in which the concentration of fluoride has been adjusted to optimal levels. This percentage cannot increase much more, as it is challenging to adjust the fluoride content of wells and other individual water sources. With the increased consumption of bottled water, not all people living in an area of water fluoridation may be receiving the optimal amount of fluoride. Are all fluoride toothpastes the same? Not necessarily. Every manufacturer uses its own proprietary formulations. Fluoride compounds are very reactive, and without good chemistry at the formulation stage, some or all of the fluoride can become bound to other ingredients in the paste and not be available for binding to the surfaces of teeth. Commonly used fluoride sources include Stannous fluoride, Sodium fluoride, and Sodium monofluorophosphate. A toothpaste brand carrying the Seal of Acceptance of the American Dental Association will have demonstrated in various studies that the fluoride is both safe and effective. Learning Objectives Upon completion of this course, the dental professional should be able to: • Be familiar with the history of fluoride in caries control. Discuss how fluoride is processed by the body. Describe how fluoride concentration varies in different parts of the tooth. Identify the multiple ways in which fluoride provides protection from caries. Explain the dental health consequences of too much fluoride exposure. • Discuss the primary methods of systemic and topical fluoride delivery. • Understand when professional forms of fluoride delivery may be necessary. 2 Crest` + Oral-B` at dentalcare.com Continuing Education Course, Revised August 18, 2014 Course Contents • Glossary • Introduction • Brief History of Fluoride in Caries Control • Fluoride in the Body and its Role in Enamel Development o Fluoride Concentration in Teeth • Fluoride in Caries Protection and Fluorosis e Reduced Demineralization and Enhanced Remineralization • Antimicrobial Qualities o Fluorosis • Systemic Fluoride Delivery • Topical Fluoride Delivery o Fluoridated Dentifrice e Hecommendations for Fluoride Toothpaste Use Other Ingredients in Dentifrice o Fluoride Mouth Rinses • Professional Delivery of Fluoride e Professional Fluoride Gels, Foams, and Solutions o Professional Fluoride Varnishes o Professional Slow -Release Fluoride • Conclusion • Course Test Preview • References • About the Author Glossary biofilm —An aggregation of microorganisms in which cells adhere to each other forming small communities that are held together by an extracellular polymeric matrix. Different communities are co-dependent on each other, and the whole biofilm forms a defensive mechanism requiring much higher concentrations of antimicrobials to control its growth. Dental plaque is a classic biofilm. demineralization — The chemical process by which minerals (mainly Calcium) are removed from the dental hard tissues — enamel, dentin, and cementum. The chemical process occurs through dissolution by acids or by chelation, and the rate of demineralization will vary due to the degree of supersaturation of the immediate environment of the tooth and the presence of fluoride. In optimal circumstances, the minerals may be replaced through the process of remineralization. 3 dental fluorosis —An abnormal condition caused by the excessive intake of fluorine, such as from fluoridated drinking water, during the period in which tooth buds are developing (amelogenesis), and is characterized in the developed tooth chiefly by mottling of the enamel. This condition can range from white flecks in the enamel (mild fluorosis) up to brown, stained and pitted enamel (severe). enzyme — Protein that catalyzes, or facilitates, biochemical reactions. fluoride —The anion of the halogen fluorine (F-). Compounds containing the fluoride anion are collectively called fluorides. Fluoride compounds very commonly occur, from simple fluoride toothpastes to PTFE (Teflon). fluoride dentifrice — A toothpaste that has been formulated to deliver clinically proven amounts of fluoride into the oral cavity, and to bind to tooth surfaces creating fluorapatite and Calcium fluoride, both of which protect the tooth from the acids produced by cariogenic bacteria. fluoride supplements — The diet of children can be supplemented with sodium fluoride, similar to vitamin supplementation, in areas where water fluoridation, or availability of fluoride by other means, such as milk or salt, may not be available. fluorapatite —A crystal structure in tooth mineral (Cats (PO,), F2) resulting from the replacement of hydroxyl ions (OH-) in the hydroxyapatite structure with fluoride ions (F-). Fluorapatite (also commonly referred to as fluoroapatite, fluorhydroxyapatite or fluorohydroxyapatite) is stronger and more acid resistant than hydroxyapatite. hydroxyapatite — Crystals of calcium phosphate - Ca,o(POa)6 OH2 that form the mineral structure of teeth and bone. Enamel comprises approximately 98% hydroxyapatite. Much of the hydroxyapatite in enamel, however, is a calcium - deficient carbonated hydroxyapatite, the crystals of which are readily dissolved by acids. The addition of fluoride creates fluorapatite, which is less soluble and more acid -resistant. Crest' + Oral -W at dentWcare.com Continuing Education Course, Revised August 18, 2014 hypomineralization — Relating to or characterized by a deficiency of minerals. milk fluoridation — Milk provides an ideal vehicle to deliver the correct amount of fluoride to children. However, well-controlled studies have not yet been conducted to confirm the anticaries benefits of this approach, and this is necessary before this method can be recommended for implementation in the United States. mottled enamel — A chronic endemic form of hypoplasia (incomplete development) of the dental enamel caused by excessive intake of fluoride by a child during key stages of tooth formation. It is characterized by defective calcification that results in a chalky appearance to the enamel, which gradually undergoes brown discoloration. remineralization — The chemical process by which minerals (mainly Calcium) are replaced into the substance of the dental hard tissues - enamel, dentin and cementum. The process requires an ideal environment that includes supersaturation with calcium and phosphate ions, the presence of fluoride, and adequate buffering. water fluoridation — The addition or removal of fluoride from domestic water supplies to achieve the optimal concentration of fluoride. The optimal concentration varies due to ambient temperature of the climate and thus water intake. Hexafluorosilicic acid (H,SiF,) and its salt sodium hexafluorosilicate (Na2SiF6) are the more commonly used additives, especially in the United States. Introduction It can be argued that the role of fluoride in caries prevention is one of the biggest success stories in the field of public health. In fact, in 1999, the U.S. Center for Disease Control (CDC) declared water fluoridation to be "one of the 10 most important public health measures of the 20th century." However, just as it is well-documented that fluoride has beneficial effects on dentition because of its ability to reduce caries, it is also well known that an excessive amount of fluoride can also have detrimental effects on teeth, namely in the form of dental fluorosis. Because of that, there are many in the dental profession 4 who advocate the use of fluoride, but some who are adamantly against it.' What follows is a summary of what is known about the effects of fluoride on developing and erupted teeth, as well as information on the current forms of fluoride delivery. The goal is to get dental health professionals on the road to making informed decisions about fluoride use that maximize the anticaries benefits, while minimizing the risk of dental fluorosis. Brief History of Fluoride in Caries Control The credit for the identification of fluoride as an effective means of caries prevention can be largely accredited to two American dentists, Frederick McKay and H. Trendley Dean. Interestingly, this knowledge came about by first noting the detrimental effect of excessive fluoride on tooth enamel. This is a condition called dental fluorosis, in which teeth become speckled with white flecks. In more severe cases of excessive fluoride ingestion, teeth can become mottled with brown stains and chunks of surface enamel might easily break off, though these types of effects are limited to the most severe cases and are not generally seen in the United States. As a practicing dentist in Colorado Springs, Colorado, in 1901, McKay noticed many of his patients had what was locally called "Colorado brown stain." He moved out of the area, but returned in 1908 to study the phenomenon Video 1. Mechanisms of Action - What is the mechanism of action of fluoride? Click here to view this video on dentalcare.com. Crest"' + Oral -W at dentalcare.com Continuing Education Course, Revised August 18, 2014 in more detail, and found that as many as 90% of children were affected.' In addition, after conferring with other dentists worldwide, he found similar occurrences of mottled or brown enamel in other towns in the United States, England, and Italy.'' Because the phenomenon was isolated to specific geographical areas, McKay thought that the water supply might be an important factor. He put this theory to the test in Oakley, Idaho, where mottled enamel was common, by having a pipeline with an alternative water source pumped into the town. After 10 years of the new water supply, new cases of "brown stain" had disappeared.' To add another piece to the puzzle, analysis of water in another American town plagued by mottled enamel, Bauxite, Arkansas, uncovered an unexpectedly high level of fluoride—and these high levels were confirmed in the water supply of other towns with rampant dental fluorosis.5' The discovery of high concentrations of fluoride was a concern because it was known that high doses of the mineral could be poisonous. This is when H. Trendley Dean, who worked with the US Public Health service, came on the scene. He took up the investigation, mapping areas where mottled enamel was present and relating the severity of mottled enamel to fluoride concentrations, noting that a certain range of fluoride concentrations in drinking water that was not very high or very low was linked with a reduced caries risk. In a publication in 1942, Dean published his findings of his landmark "21 city study" (actually a series of studies) where he examined the association between the fluoride levels in drinking water and caries levels in children, and developed the first classification system for recording the severity of mottled enamel, using the terms questionable, very mild, mild, moderate, and severe.' S These findings from the first half of the 1900s led to a greater understanding of fluoride's effects on enamel development, how dental fluorosis develops, and advances in the delivery of beneficial amounts of fluoride to reduce caries. Fluoride in the Body and its Role in Enamel Development Following the ingestion of fluoride from a water, food, or supplement source, 86% to 97°0 of the element is absorbed in the stomach and small 5 Video 2. Enamel Maturation - How is fluoride incorporated into the inorganic phase of enamel, pre- and post -eruptive? Click her to view this video on denialcare corn. intestine. Fasting states (ingestion on an "empty stomach") increases fluoride absorption, while the intake of other dietary nutrients such as calcium, aluminum, and magnesium tends to decrease fluoride absorption. Most of the fluoride absorbed systemically that is not excreted via normal pathways (i.e through the kidneys, the colon or by sweating) is deposited in mineralizing tissues such as bone and developing teeth. Fluoride is present in saliva at very low levels (0.01 ppm to 0.04 ppm) and in human milk at low levels (0.1 ppm). While the concentration of fluoride in these body fluids is minimal, studies show it is enough to impact dental caries.` Fluoride Concentration in Teeth After fluoride is ingested, it is distributed from the plasma to all tissues and organs of the body, and gradually becomes incorporated into the crystal lattice structure of teeth in the form of fluorapatite. In teeth, the fluoride concentration is very high on surface enamel, but falls steeply within the first 100 um. Then fluoride concentration remains constant up to the enamel—dentin junction. Fluoride concentration once again increases inside the dentin, increasing deeper into the tooth, with fluoride steadily accumulating over a lifetime at the dentin—pulp surface. It should be noted that there is no homeostatic mechanism that maintains fluoride concentration in the body. Therefore, regular exposure is required to maintain fluoride concentration in enamel, saliva, and in biofilm on dental surfaces.' Crest' + Oral-B' at dentalcare.com Continuing Education Course, Revised August 18, 2014 Fluoride in Caries Protection and Fluorosis Reduced Demineralization and Enhanced Remineralization This is the main mechanism by which fluoride exerts its anticaries benefits. It has been established that hydroxyapatite starts to dissolve when pH drops below 5.5, and fluorapatite starts to dissolve when the pH drops below 4.5. If biofilm pH is lower than 5.5 but higher than about 4.5 and fluoride is available in low concentrations, fluorapatite forms on the surface layers of enamel even if hydroxyapatite dissolves in the subsurface enamel. The overall effect is reduced dental demineralization thanks to the protective outer layer of fluorapatite. When oral pH normalizes after an acid attack and rises again above 5.5, fluoride enhances enamel— dentin remineralization. If fluoride is no longer available, the oral environment begins to favor demineralization if the pH falls below 5.5.' Antimicrobial Dualities Fluoride ions inhibit the bacterial enzyme enolase, which interferes with the production of phosphoenolpyruvate (PEP). PEP is a bacterial source of energy and a molecule that is necessary for the uptake of sugar, which provides bacterial nutrition. A dental biofilm that contains just 1 ppm to 5 ppm of fluoride (an amount that is reached by using fluoridated toothpaste) is found to inhibit the adhesion, growth, metabolism, and multiplication of caries -linked oral streptococci. The presence of higher concentrations of fluoride -10 ppm to 100 ppm, which can be obtained in prescription fluoride preparations— has also been found to inhibit acid production by most plaque bacteria." Fluorosis An abnormally high concentration of fluoride leads to hypomineralization of the tooth's enamel and increased porosity that is reflected in the opacity of enamel as chalky white lines or stains. In general, teeth with more severe dental fluorosis have significantly higher levels of fluoride in enamel than those with less severe forms of dental fluorosis. Also, the extent and degree of hypomineralization increases with increased fluoride exposure during development. In cases of severe hypomineralization, porous 6 enamel appears brown and it can be very fragile, with surface damage occurring quite easily during chewing, attrition, and abrasion.' Systemic Fluoride Delivery A primary method of fluoride delivery is systemic, being artificially provided in water, milk, salt, or supplements, which must be ingested to be able to have any effect on teeth. In all of these applications, the primary action of fluoride in promoting remineralization and reducing demineralization is due to the presence of fluoride in a beneficial amount and at the right time. What follows is a brief discussion of the main forms of systemic fluoride delivery employed by dental professionals worldwide today: Water Fluoridation — Water fluoridation is the primary systemic method of fluoride delivery to the American population. Fluoride occurs naturally in water supplies, usually at very low concentrations of 0.1 ppm. Community water studies have uncovered a few key findings: Overall, there is a 50% reduction in dental caries rates among children with 1 ppm fluoride in the community drinking water." However, this caries protection occurs only with consistent fluoride exposure. This is evident in studies that found that children who move to a nonfluoridated water community experience an increase in caries rates. In addition, adults also benefit from fluoride, with reduced coronal and root caries rates among those residing in fluoridated water communities.' In the United States, it is estimated that more than 204 million people (approximately 75% of the population) are served by fluoridated water supply systems. This is a relatively inexpensive endeavor: The annual cost of fluoridating the drinking water for a community larger than 20,000 people in this country averages 50 cents per person. Just $1 invested in this preventive measure yields approximately $38 savings in dental treatment costs. The CDC monitors the progress of the country, as well as each individual state, toward meeting the Healthy People 2020 objective on community water fluoridation — that by the year 2020, 79.6% of people on community water systems will receive water that has to optimal level of fluoride recommended for preventing tooth decay. Crest' + Oral-B`' at dentalcare.com Continuing Education Course, Revised August 18, 2014 Salt Fluoridation — This is a method of fluoride delivery used primarily in Europe, as well as Costa Rica, Columbia, and Jamaica. A landmark Swiss study found that fluoridating table salt reduced children's caries levels by 50% over a 10 -year period.12 There are concerns about excessive fluoride intake and the emergence of dental fluorosis, as well as concerns about increased salt intake.' Milk Fluoridation —Adding fluoride to liquid, powdered, and long -life milk has been implemented in Eastern Europe, Chtna, the UK, and South America. It has the advantage over water fluoridation in that it can be targeted directly at certain segments of the population, and intake can be controlled." However, well- controlled studies have not yet been conducted, and this is necessary before this method can be recommended for implementation in the United States.' Fluoride Supplements — The Centers for Disease Control (CDC) currently recommend that oral fluoride supplements be used only in high- risk children residing in nonfluoridated areas. The recommended Supplemental Fluoride Dosage Schedule is as follows (Table 1):" Topical Fluoride Delivery Another main method of fluoride delivery is topical, in the form of toothpastes, gels, varnishes, paint -on formulations, and mouth rinses that come into contact with the surface of the tooth. Fluoridated Dentifrice Toothpaste has come a long way from its beginnings as pastes made from things like mashed eggshells and bones mixed with myrrh. The first clinically proven fluoride toothpaste was introduced in 1955 by Crest; it contained 0.4% stannous fluoride (SnF,). Each decade after that brought further advancements: In the 1960s, gel products hit the markets; in the 1970s antiplaque claims were introduced; tartar control products were first marketed in the 1980s; and the 1990s were marked by specialty products on the market, such as antigingivitis, whitening agents, and changes in the type of container used to deliver the dentifrice, such as pumps and dual chambers.' Today, over-the-counter dentifrice products in the United States contain between 850 ppm to 1150 ppm fluoride. Clinical trials indicate a dose-dependent relationship between fluoride concentration and caries prevention, with a 6% increase in efficacy and 8.6% reduction in caries for every 500 ppm fluoride increase.'" To recap the caries -reducing benefits of fluoridated dentifrice: Research has documented that a regular low-dose source of fluoride is the most efficient means to prevent demineralization of teeth and to enhance remineralization. Fluoride becomes incorporated with the enamel apatite crystal, rendering the enamel more resistant to acid dissolution. Fluoride in saliva and plaque also promotes remineralization. And finally, fluoride also has a modest antimicrobial effect on plaque bacteria, with stannous fluoride being particularly effective against Streptococcus mutans.' The most common forms of fluoride used in U.S. dentifrices are sodium monofluorophosphate (SMFP), sodium fluoride (NaF), and stannous fluoride (SnF,). Mixtures of NaF and SMFP, and amine fluoride (AmF) are also recognized as safe and effective forms of fluoride in over-the-counter therapeutic dentifrices in markets outside of the United States. There are also prescription fluoridated gels that contain 5000 ppm fluoride that are intended for limited use in high caries risk patients. One Table 1. Recommended Supplemental Fluoride Dosage Schedule 7 Crest' + Oral-B` at dentalcare.com Continuing Education Course, Revised August 18, 2014 Less than 0.3 ppm water 0.3 ppm to 0.6 ppm Greater than 0.6 ppm Age of child fluoride concentration water fluoride water fluoride concentration concentration Birth to 6 months 0 0 0 6 months to 3 years 0.25 mg I quid drops 0 0 3 to 6 years 0.5 mg drops or tabs 0.25 rrg 0 6 to 16 years 1 mg 0.5 rng 0 7 Crest' + Oral-B` at dentalcare.com Continuing Education Course, Revised August 18, 2014 6 -month study conducted in adults found that 57% of root caries lesions became hard in subjects using a 5000 -ppm gel, compared to 29% for subjects who used a 1100 -ppm toothpaste. Recommendations for Fluoride Toothpaste Use Clinical studies have found little association between the amount of toothpaste used and anticaries efficacy; instead, as explained above, fluoride concentration is the important determinant of anticaries efficacy. Therefore, using more toothpaste than is recommended (such as a pea- sized amount for children) does not provide more caries protection.' Brushing behavior is also important: Brushing twice a day is linked to a 20% to 30% lower likelihood of caries compared to brushing once or less daily." It should be noted that brushing frequency is linked to socioeconomic status, with children in poorer families brushing less, and this being one reason they experience more caries.te While there has been much debate about whether it is better to brush before or after meals, there is little scientific evidence to indicate the better option. However, data do show that brushing immediately before bed plays an important role in reducing plaque load in the oral environment during sleep, when salivary flow and buffering capacity are naturally reduced. Therefore, the recommendation to brush just before going to bed and at least one other time during the day before or after a mealtime is appropriate for most patients.' Fluoridated toothpaste can also be used therapeutically by asking the patient to apply a dab of paste with a finger or brush directly to a cleaned active lesion immediately before going to bed. This also allows an increased concentration of fluoride in the vicinity of the lesion at a time of day when salivary output is naturally low. Rinsing behavior is another determinant of anticaries efficacy. Studies show that people who use a cup to rinse with water after brushing (and so put more water in their mouths) have approximately 20% more caries than those who use the toothbrush or hand to collect water. This is because more fluoride is washed away when rinsing with a cup of water after brushing.' In summary, dental professionals should recommend to their patients: 1. An accredited fluoride toothpaste. 2. A toothpaste with an appropriate fluoride concentration after assessing potential caries risk and overall fluoride exposure. 3. To brush twice daily; once at night and once more at another time during the day, preferably around a mealtime. 4. That children be given a minimum amount of toothpaste and be supervised when brushing. Other Ingredients in Dentifrice Toothpastes and gels also contain abrasives (such as hydrated silica) to clean teeth; binders (such as xanthan gum, carrageenan or carbopol) to prevent the separation of ingredients; coloring for visual appeal; humectants (such as glycerin or sorbitol) to retain moisture; buffers (such as phosphates) to maintain product stability; flavorings (such as peppermint and cinnamon); and surfactants (such as sodium lauryl sulfate) to produce a foaming action and reduce surface tension. While the focus of this education course is caries, it is also useful to know of the other types of dentifrices to help address other individualized needs of the patient. These types provide plaque and gingivitis protection, tartar control, whitening, sensitivity protection, and protection from oral malodor. Many fluoride dentifrices today cover some combinations or all of these benefit areas in one dentifrice. Fluoride Mouth Rinses These are most commonly available as 0.02% NaF (100 ppm F) for twice a day rinsing, 0.05% NaF (227 ppm F) for daily rinsing and 0.2% NaF (909 ppm F) for weekly rinsing. These latter two higher concentration rinses may need a prescription even if they are intended for home use. Mouthwashes have also been formulated with acidulated phosphate fluoride, stannous fluoride, ammonium fluoride, and amine fluoride, although some of these come with precautions. For example, stannous fluoride rinses have been associated with discoloration of teeth and tooth restorations, and acidulate phosphate fluoride is contraindicated in people with porcelain or composite restorations because it can cause pitting or etching.' Many of the fluoride mouth washes on the market internationally also contain antimicrobial ingredients. These include chlorhexidine, cetylpyridinium chloride, triclosan, delmopinol, hexetidine, and Sanguinaria extract. Many of Crest" + Oral-B' at dentalcare.com Continuing Education Course, Revised August 18, 2014 these have little to no caries -reducing effects or have not been studied for their anti -caries effects.' Typically, it is recommended that 10 ml of the mouth rinse solution be swirled around in the mouth for 1 minute. Clinical trials of both the daily and weekly regimen show an average caries reduction of 30%." The benefit of daily rinsing is marginally greater than weekly rinsing but not statistically significant. Overall, fluoride mouth rinses are considered beneficial from a public health perspective only if groups of people at high risk of caries are being targeted, since they are not cost-effective in a population with a low incidence of disease. While weekly rinsing public health programs have been used in the United States to target groups of people that are at high risk of caries, other countries stopped regular rinsing (either daily or weekly) with fluoridated mouthwashes in the 1980s.' Professional Delivery of Fluoride When a patient is at extremely high risk of caries, and appropriate dental care measures (such as good oral hygiene or the use of a fluoride toothpaste) are not working or are not being followed, professional forms of fluoride delivery may be considered. Professional Fluoride Gels, Foams, and Solutions These contain higher concentrations of fluoride than products sold over the counter for home use They typically contain 5000 ppm to 12300 ppm and are applied only in the dental office. They are generally recommended for use twice yearly, although in severe cases, they may be applied more frequently. Significant reductions in dental caries—as much as 41%—have been seen when applied in this way.19 However, no benefit has been seen with the use of single applications or infrequent applications. Professional Fluoride Varnishes These contain a high level of fluoride (22600 ppm) and are applied only in a dentist's office. Varnishes are used to deliver fluoride to specific sites or surfaces within the mouth and are typically applied every 3 months or 6 months. The correct application of a fluoride varnish has been linked with a 38% reduction in dental caries.", Varnishes are designed to harden on the tooth, forming 9 a deposit of calcium fluoride that can act as a reservoir for the slow release of fluoride over time. Professional Slow -Release Fluoride Methods to deliver small amounts of fluoride throughout the day are still being developed. Currently, materials such as silicate and glass- ionomer cements that contain between 15% to 20% fluoride are being used, and this amount of fluoride is also being added to composite and amalgam fillings. The concept is that these materials could provide a reservoir of fluoride to prevent secondary caries and to help remineralize caries in adjacent surfaces. Fluoride release begins high, but reduces as the available reservoir depletes.' Glass-ionomer cements are unique in that they are also able to absorb fluoride from other sources, such as toothpaste, and also slowly release this into the oral cavity, long after the fluoride that was originally placed in the glass- ionomer has dissipated. It should be noted, however, that clinical data on these methods of slow-release delivery have not yet confirmed the extent to which they are able to provide any therapeutic benefits.' Conclusion Fluoride is an effective therapeutic and preventive agent for dental caries. The mineral alters the caries process by interfering with the dynamic of lesion development by enhancing Video 3. How do you determine which preventive agent to use? dick here to view this video on dentalcare.com. Crest` + Oral-B` at dentalcare.com Continuing Education Course, Revised August 18, 2014 remineralization, reducing demineralization, and inhibiting bacteria. While there are many forms of fluoride delivery, the incorporation of fluoride in a dentifrice has proven to be one of the most effective prevention and intervention strategies for dental caries. It should be noted that although fluoride therapy is important for caries control, it does not always stop caries development and progression. The tried-and-true public health recommendations of proper oral hygiene, such as brushing tooth at least twice a day, flossing to clean in between teeth, and cutting back on dietary sugar intake, continue to be very important in fighting caries. 10 Crest' + Oral -Bat dentalcare.com Continuing Education Course, Revised August 18, 2014 Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to: ~' www.dentalcare.com/en-US/dental-education/continuing-education/ce376/Ce376-test asp 1. Which of the following is a key finding that led to the understanding of the benefit of fluoride in public dental health? a. Children who lived in towns with abnormally high levels of fluoride in the water supply had perfectly healthy teeth. b. A new pipeline with an alternative water source pumped into the town of Oakley, Idaho, led to the disappearance of "brown stain' on teeth. c. Analysis of the water supply of Bauxite, Arkansas, uncovered an unusually high level of fluoride and this was confirmed in other towns with fluorosis. d. B and C 2. The majority of fluoride ingested in water or food is absorbed in which body organ(s)? a. Lymphatic system b. Kidneys c. Stomach and small intestine d. Liver 3. The incorporation of fluoride into enamel structure is called a. hydroxyapatite b. apalite crystal c. fluorhydroxyapatite d. enameloxyapatite 4. Which of the following is true about the concentration of fluoride in teeth? a. Fluoride concentration is highest on surface enamel. b. Fluoride concentration is high in dentin. c. Fluoride accumulates over a lifetime at the dentin -pulp surface. d. All of the above. 5. What is the main mechanism by which fluoride protects the tooth from caries? a. Reduced demineralization and enhanced remineralization. b. Increased saliva production. c. Keeping enamel white. d. None of the above. 6. Which of the following defines the mode of action for the antimicrobial effects of fluoride? a. Inhibits growth and metabolism of streptococci. b. At higher concentrations, it can inhibit acid production by plaque bacteria. c. Interferes with the production of PEP, a bacterial energy source. d. All of the above. 7. Chalky white lines or stains are believed to be caused by which of the following? a. An abnormally high level of Streptococcus mutans in plaque. b. An abnormally high concentration of fluoride that leads to hypomineralization of tooth enamel. c. Excessive consumption of vitamin C. d. Excessive consumption of calcium. 11 Crest4 + Orai-B� at dentalcare.com Continuing Education Course, Revised August 18, 2014 What is the average percentage in caries reduction among children where community drinking water contains 1 ppm fluoride? _ a. 10% b. 30% c. 50% d. 90% Which of the following research findings validates that consistent fluoride protection is needed to maintain a reduction in caries rate? a. Children who move from non -fluoridated areas to other non -fluoridated areas experienced a caries decrease. b. Children who move from fluoridated areas to non -fluoridated areas experienced a caries increase. c. Children who move from non -fluoridated areas to fluoridated areas experienced a caries increase. d. Children who move from fluoridated areas to non -fluoridated areas experienced a caries decrease. 10. Fluoride supplements are recommended for which population of people? a. Everyone b. Adults only regardless of caries risk. c. Children at high risk of caries residing in non -fluoridated areas. d. Children only regardless of caries risk. 11. How much fluoride does most over-the-counter dentifrice contain in the United States? a. 100 ppm to 200 ppm b. 850 ppm to 1150 ppm C. 3000 ppm d. 1 ppm 12. Which forms of fluoride are the most commonly used in dentifrice? a. Stannous fluoride b. Sodium fluoride c. Sodium monofluorophosphate d. All of the above. 13. Which of the following mechanisms explains why using a cup to rinse the mouth with water after brushing with fluoridated dentifrice is linked to more caries? a. Water makes fluoride more acidic. b. Water diminishes fluoride's ability to work as an antimicrobial. c. Water reduces saliva production. d. The large amount of water from using a cup as a rinsing aide flushes away the beneficial fluoride. 14. Which of the following types of fluoride should be recommended with caution due to the potential for it to cause pitting and etching of porcelain or composite restorations? a. Stannous fluoride b. Sodium monofluorophosphate c. Acidulate phosphate fluoride d. Sodium fluoride 15. Which of the following is true about professionally applied fluoride varnish? a. Used correctly, it is linked to a 38% reduction in caries. b. It forms a hardened deposit of calcium fluoride on the tooth acting as a reservoir for the release of fluoride over time. c. It usually contains about 22600 ppm of fluoride. d. All of the above. 12 Crest + Oral -W at dentalcare.com Continuing Education Course, Revised August 18, 2014 References 1. Fejerskov O, Kidd E, eds. Dental Caries: The Disease and its Clinical Management. 2nd ed. Oxford, United Kingdom: Blackwell Munksgaard; 2008. 2. Black GV, McKay FS. Mottled enamel. An endemic developmental imperfection of the teeth, heretofore unknown in the literature of dentistry. Dental Cosmos. 1916;58:129-156. 3. Ainsworth NJ. Mottled Teeth. Br Dent J. 1933;55:233-250. 4. McKay FS. Mottled teeth: the prevention of its further production through a change in the water supply at Oakley, Idaho, J Am Dent Assoc. 1933;20:1137-1149. 5. Kempf GA, McKay FS. Mottled enamel in a segregated population. Public Health Rep. 1930;45:2923-2940- 6. 930;45;2923-2940_6. Churchill HV. Occurrence of fluorides in some waters of the United States. Ind Eng Chem. 1931;23:996-998. 7. Dean HT, Jay P, Arnold FA, Elvove L. Domestic water and denial caries, including certain epidemiological aspects of oral L. acidophilus. Public Health Rep. 1939;54:862-888. 8. Dean HT, Jay P, Arnold FA, Elvove E. Domestic water and dental caries. ll. A study of 2832 white children aged 12-14 years of eight suburban Chicago communities, including Lactobacillicus acidophilus studes of 1761 children. Public Health Rep. 19411-56:761-792. 9. Dean HT, Jay P, Arnold FA, Elvove E. Domestic water and dental caries. V. Additional studies of the relation of fluoride domestic waters to dental caries expeirence in 4425 white children aged 12-14 years of 13 cities in 4 states. Public Health Rep. 1942;57:1151-1179. 10. Baron S. ed. Medical Microbiology. 4th. Galveston, Texas: University of Texas Medical Branch -,1996. 11. Murray JJ, Rugg AJ, Jenkins GN. Fluorides in Caries Prevention. 3rd ed. Oxford, United Kingdom: Wright -,1991. 12. Marthaler TM, Steiner M, Menghini JE, Bandi A. Caries prevalence in schoolchildren in the canton of Zurich, The results in the period of 1963 to 1987. Schweiz Monatsschr Zahnmed. 11988;98:11309-1315. 13. Stephen KW, Banockzy J, Pahkamov GN, Milk Fluoridation for the Prevention of Dental Caries. Geneva: World Health Organization/Borrow Milk Foundation, 1996. 14. Dietary Fluoride Supplement Schedule. Last reviewed: April 2010. Centers for Disease Control. Accessed: August 24, 2010. 15. Stephen KW, et al. A 3 -year oral health dose -response study of sodium monofluorophosphate dentifrices with and without zinc citrate: anti -caries results. Community Dent Oral Epidemiol. 1988;16:321-325. 16. Baysan A, et al. Reversal of primary root caries using dentifrices containing 5000 and 11000 ppm fluoride. Caries Res. 2001;35:41-46. 17. Ashley PF, Attrill DC, Ellwood RP, et al. Toothbrushing habits and caries experience. Caries Res. 1999;33:401-402. 18. Walker A, Gregory J, Bradnock G, et al. National Diet and Nutrition Survey: young people aged 4-18 years, Vol. 2; Report of the Oral Health Survey 2000. London: The Stationery Office; 2000. 19. Ripa LW. A critique of topical fluoride methods (dentifrices, mouthrinses, operator-, and self -applied gels) in an era of decreased caries and increased fluorosis prevalence. J Public Health Dent. 1991;51:23-41. 20. Helfenstein U, Steiner M. Fluoride varnishes (Duraphat): a meta-analysis. Community Dent Oral Epidemiol. 1994;22:1-5. 13 Crest`' + Oral-B' at dentalcare.com Continuing Education Course, Revised August 18, 2014 About the Author Marjolijn Hovius, RDH For more than 38 years, Ms Hovius has been the director of a baccalaureate dental hygiene program with more than 350 students in Amsterdam, the Netherlands. Ms. Hovius work has been published extensively, and she has conducted many continuing education programs. She has lectured extensively at home and abroad. She has been the editor -in chief of the International Journal of Dental Hygiene, associate editor of ACTA Quality Practice for Dental Hygienists and is a past president of the International Federation of Dental Hygienists. Right now she represents the Dutch Dental Hygienists' Association (NVM) in developing the new guidelines for infection prevention in the dental and dental hygiene offices and is a member of the international dental hygiene advisory board from P&G. She is an honorary member of the NVM. 14 Crest + Oral -W at dentalcare.com Continuing Education Course, Revised August 18, 2014 rce: Slide 7 Studies on Fluoride Exposure Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004 Eugenio D. Beltran -Aguilar, D.M.D., M.S., Dr.P.H.; Laurie Barker, M.S.P.H.; and Bruce A. Dye, D.D.S., M.P.H. Key findings Data from the National Health and Nutrition Examination Survey, 1999-2004 and the 1986- 1987 National Survey of Oral Health in U.S. School Children • Less than one-quarter of persons aged 6-49 in the United States had some form of dental fluorosis. • The prevalence of dental fluorosis was higher in adolescents than in adults and highest among those aged 12-15. • Adolescents aged 12-15 in 1999-2004 had a higher prevalence of dental fluorosis than adolescents aged 12-15 in 1986-1987. x tunc4, 1 10 Dental fluorosis refers to changes in the appearance of tooth enamel that are caused by long-term ingestion of fluoride during the time teeth are forming (1). Studies conducted in the 1930s showed that the severity of tooth decay was lower and dental fluorosis was higher in areas with more fluoride in the drinking water (2). In response to these findings, community water fluoridation programs were developed to add fluoride to drinking water to reach an optimal level for preventing tooth decay, while limiting the chance of developing dental fluorosis (3). By the 1980s, studies in selected U.S. communities reported an increase in dental fluorosis (4,5), paralleling the expansion of water fluoridation and the increased availability of other sources of ingested fluoride, such as fluoride toothpaste (if swallowed) and fluoride supplements (6). This report describes the prevalence of dental fluorosis in the United States and changes in the prevalence and severity of dental fluorosis among adolescents between 1986-1987 and 1999-2004. Keywords: children • dental public health • National Health and Nutrition Examination Survey • National Survey of Oral Health in U.S. School Children Less than one-quarter of persons aged 6-49 had dental fluorosis. Figure 1. Percent distribution of dental fluorosis among persons aged 6-49: United States, 1999-2004 2.0 Less than 1 4.8 Unaffected Questionable Very mild 60.6 ® Mild 16.5 Moderate Severe NOTES: Dental fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index. Percentages do not sum to 100 due to rounding. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 1999-2004. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESr►■• � Centers for Disease Control and Prevention Lm IF National Center for Health Statistics SAFER • HEALTHIER• PEOPLE'"' Among persons aged 6-49, 16.0% had very mild fluorosis, 4.8% had mild fluorosis, 2.0% had moderate fluorosis, and less than 1% had severe fluorosis (Figure 1). For the remaining three-quarters of persons in this age group, 60.6% were unaffected by dental fluorosis and 16.5% were classified as having questionable dental fluorosis. Prevalence of dental fluorosis was higher among younger persons and ranged from 41% among adolescents aged 12-15 to 9% among adults aged 40-49. Adolescents aged 12-15 had the highest prevalence of dental fluorosis (40.6%) (Figure 2). The prevalence is lower among older age groups. The lowest prevalence was among those aged 40-49 (8.7%). The prevalence of dental fluorosis among children aged 6-11 (33.4%) was lower than the prevalence among those aged 12-15 (40.6%). Fiaure 2. Prevalence of dental fluorosis among persons aced 6-49, by ace group: United States, 1999-2004 NOTES: Dental fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index. Error bars represent 9b confidence intervals. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 1999-2004. ■2■ NCHS Data Brief ■ No. 53 ■ November 2010 Children aged 12-15 in 1999-2004 had higher prevalence of dental fluorosis �- compared with the same aged children in 1986-1987. In 1986-1987, 22.6% of adolescents aged 12-15 had dental fluorosis, whereas in 1999-2004, 40.7% of adolescents aged 12-15 had dental fluorosis (Figure 3). The estimates for severe alone were statistically unreliable. The prevalence of very mild fluorosis increased from 17.2% to 28.5% and mild fluorosis increased from 4.1% to 8.6%. The prevalence of moderate and severe fluorosis increased from 1.3% to 3.6%. Figure 3, Change in dental fluorosis prevalence among children aged 12-15 participating in two national surveys: United States, 1986-1987 and 1999-2004 NOTES: Dental Fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index, Percentages do not sum to 100 due to rounding. Error bars represent 95% confidence intervals. SOURCES, CDCINGHS, National Health and Nutnton Examination Survey, 1999-2004 and National Institute of Dental Research, National Survey of Oral Health in U.S. School Children, 1986--1987. ■ 3 ■ NCHS Data Brief ■ No. 53 ■ November 2010 Summary Twenty-three percent of persons aged 6-49 had dental fluorosis in 1999-2004. Approximately 2% had moderate dental fluorosis and less than 1% had severe dental fluorosis. Dental fluorosis was most prevalent among children aged 12-15, and less prevalent among older age groups. The prevalence of dental fluorosis among children aged 6-11 was lower than the prevalence among adolescents aged 12-15. This may be explained by an incomplete set of permanent teeth among children aged 6-11; some posterior permanent teeth, including premolars and second molars, erupt between ages 10 and 12. The levels of very mild, mild, and moderate or severe dental fluorosis were higher among adolescents aged 12-15 in 1999-2004 than in 1986-1987. In the analyses of changes in prevalence between both national surveys, moderate and severe dental fluorosis were aggregated into one category because all estimates of severe fluorosis were statistically unreliable after stratification (standard error of the percentage was greater than 30% the value of the percentage). ■4■ Definitions Dental fluorosis: Defined as a change in the mineralization of the dental hard tissues (enamel, dentin, and cementum) caused by long-term ingestion (eating and drinking) of fluoride during the period of tooth development prior to eruption into the mouth (first 8 years of life for most permanent teeth excluding third molars). Once the tooth erupts, dental fluorosis refers to a range of visually detectable changes in enamel. Changes range from barely visible lacy white markings in milder cases to converged opaque areas and pitting of the teeth in severe forms. After eruption the pitted areas can become stained yellow to dark brown. Dean's Fluorosis Index: Developed in the 1930s by H.T. Dean to assess the prevalence and severity of dental fluorosis in various communities in the United States (2). Major criteria for each category are listed below: • Unaffected: The enamel is translucent. The surface of the tooth is smooth, glossy, and usually has a pale creamy white color. • Questionable: The enamel shows slight changes ranging from a few white flecks to occasional white spots. This classification is utilized in those instances in which a definitive determination of the mildest form of fluorosis is not warranted and a classification of unaffected is not justified. • Very mild. Small opaque paper -white areas are scattered over the tooth surface, but do not involve as much as 25% of the surface. • Mild: White opaque areas on the surface are more extensive, but do not involve as much as 50% of the surface. • Moderate: White opaque areas affect more than 50% of the enamel surface. • Severe: All enamel surfaces are affected. The major aspect of this classification is the presence of discrete or confluent pitting. Prevalence of dental fluorosis: Defined as the proportion of the population with very mild or higher levels of dental fluorosis, by convention established by H.T. Dean (2). The questionable category is excluded. ■5■ Data source and methods Data from the National Health and Nutrition Examination Survey (NHANES) were used for most of these analyses. NHANES is a cross-sectional survey designed to monitor the health and nutritional status of the civilian noninstitutionalized U.S. population. The oral health exam was conducted in mobile examination centers by trained dentists. In 1999, NHANES became a continuous survey with each year of data collection based on a representative sample covering all ages. The NHANES sample is selected through a complex, multistage design that includes selection of primary sampling units (PSUs) (counties or county equivalents), household segments within the PSUs, and finally, sample persons from selected households. The sample design includes oversampling in order to obtain reliable estimates of health and nutritional measures for population subgroups. In 1999-2004, oversampling included non -Hispanic black and Mexican - American persons as well as adolescents. Additional information on NHANES can be located at http://www.cdc.gov/nclis/nhanes/nhanes_questionnaires.htni. Data from the 1986-1987 National Survey of Oral Health in U.S. School Children were also used, which was conducted by the National Institute of Dental Research (NIDR, currently the National Institute of Dental and Craniofacial Research). The oral health exam was conducted using portable dental equipment on the school premises by trained dentists. The 1986-1987 NIDR sample was selected through a multistage design that included selection of school districts, schools, and classrooms. Because the 1986-1987 NIDR survey was school-based, children not attending school were not part of the sampling frame. Additional information for the 1986-1987 NIDR survey is available in the public -use data file documentation and survey methodology report (7). Both surveys included intraoral assessment of all permanent teeth conducted by trained and standardized dental examiners who used the Dean's Fluorosis Index (2). Accordingly, each tooth was assigned one of six diagnostic codes: unaffected, questionable, very mild, mild, moderate, and severe. Examiners in both surveys reached acceptable levels of interexaminer reliability against a standard examiner (8-10). Data from the 1986-1987 NIDR survey represent the first national data on dental fluorosis, while data from the 1999-2004 NHANES represent the most recent national data. The age group 12-15 was used to compare changes between surveys because, on average, all permanent teeth are fully erupted at that age. Publicly available datasets from both surveys were used to calculate a person -based score for dental fluorosis following Dean's criteria, that is, using the score corresponding to the two most affected teeth. For example, in order to have a category of "moderate" fluorosis, the person should have at least two permanent teeth with the score of moderate. For analyses using age, data from the 1999-2004 MANES were grouped into six age groups (6-11, 12-15, 16-19, 20-29, 30-39, and 40-49) and comparisons to the 1986-1987 NIDR survey used data from respondents aged 12-15. Population estimates and standard errors were calculated in SAS -callable SUDAAN software (release 9.0; Research Triangle Institute, Research Triangle Park, N.C.). Sample weights provided by the National Center for Health Statistics and NIDR to account for differing probabilities of selection, nonresponse, and noncoverage, were used for analysis. The standard errors of the percentages were estimated using Taylor Series Linearization to take into account the complex sampling design. Graphs include 95% confidence intervals. u ■6■ About the authors Eugenio D. Beltran -Aguilar and Laurie Barker are with the Centers for Disease Control and Prevention's (CDC) National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health. Bruce A. Dye is with CDC's National Center for Health Statistics, Division of Health and Nutrition Examination Surveys. References 1. Aoba T, Fejerskov O. Dental fluorosis: Chemistry and biology. Crit Rev Oral Biol Med 13(2):155-70. 2002. 2. Dean HT. The investigation of physiological effects by the epidemiological method. Report no 19. Washington, DC: American Association for the Advancement of Science. 1942. 3. CDC. Fluoridation of drinking water to prevent dental caries. MMWR 48:933-40. 1998. 4. Leverett D. Prevalence of dental fluorosis in fluoridated and nonfluoridated communities -A preliminary investigation. J Public Health Dent 46(4):184-7. 1986. 5. Szpunar SM, Burt BA. Dental caries, fluorosis, and fluoride exposure in Michigan schoolchildren. J Dent Res 67(5):802-6. 1988. 6. Mascarenhas AK. Risk factors for dental fluorosis: A review of the recent literature. Pediatr Dent 22(4):269-77. 2000. 7. National Institute of Dental Research. Oral health of United States children. The National Survey of Oral Health in U.S. School Children, 1986-1987. Public -use data file documentation and survey methodology. Bethesda, MD: National Institutes of Health. 1992. 8. National Institute of Dental Research. Oral health of United States children. The National Survey of Dental Caries in U.S. School Children, 1986-1987. National and regional findings. NIH Publ no 89-2247. Bethesda, MD: National Institutes of Health. 1989. 9. Dye BA, Barker LK, Selwitz RH, Lewis BG, Wu T, Fryar CD, et al. Overview and quality assurance for the National Health and Nutrition Examination Survey (NHANES) oral health component, 1999-2002. Community Dent Oral Epidemiol 35(2):140-51.2007. 10. Dye BA, Nowjack-Raymer R, Barker LK, Nunn JH, Steele JG, Tan S, et al. Overview and quality assurance for the oral health component of the National Health and Nutrition Examination Survey (NHANES), 2003-04. J Public Health Dent 68(4):218-26. 2008. ■7■ NCHS Data Brief ■ No. 53 ■ November 2010 U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics 3311 Toledo Road Hyattsville, MD 20782 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 To receive this publication regularly, contact the National Center for Health Statistics by calling 1-800-232-4636 E-mail: cdcinfo@cdc.gov Internet: http://www.cdc.gov/nchs ISSN 1941-4927 (Print ed.) ISSN 1941-4935 (Online ed.) CS218649 T38041 11/2010 DHHS Publication No. (PHS) 2011-1209 Suggested citation Beltran -Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. NCHS data brief, no 53. Hyattsville, MD: National Center for Health Statistics. 2010. Copyright information All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. National Center for Health Statistics Edward J. Sondik, Ph.D., Director Jennifer H. Madans, Ph.D., Associate Director for Science Division of Health and Nutrition Examination Surveys Clifford L. Johnson, M.S.P.H., Director FIRST CLASS MAIL POSTAGE & FEES PAID CDC/NCHS PERMIT NO. G-284 NWA OWA Source: Slide 8 / Embracing Personal Health OTHER DOCUMENTED ADVERSE HEALTH EFFECTS FROM FLUORIDE Fluoridation's adverse health effects are not recognised by most physicians but they are documented in blind and double-blind studies. Allergy, Hypersensitivity, gastrointestinal and skin irritation are known side effects of fluoride ingestion. The toxicity of fluoride is increased in people with inadequate nutrition (sub -standard vitamin -mineral intake) or who are immune -compromised (eg., diabetics, renal disease, etc) Source link: http:Ilfluoridation.com/adverse.htm#Contraindications Contraindications and Side Effects of Sodium Fluoride (NaF) supplements Animal & Human studies • Ba u. Priya CAY, et al., Toxicity of Fluoride to Diabetic Rats, Fluoride, 1997, 30:1 • Baykov AA, et al., A two-step mechanism of fluoride inhibition of rat liver inorganic pyrophosphatase, Arch Biochem Biophys, 1992, 294:1 • Eckerlin RH et al., Milk production of cows fed fluoride contaminated commercial feed. Comell Vet 1986 Oct;76(4):403-14 • Gibson S, Effects of fluoride on immune system function, Complimentary Med. Res, 1992, 6:3 • Boros I, et al , Fluoride intake, distribution, and bone content in diabetic rats consuming fluoridated drinking water, Fluoride, 1998, 31:1 • Chen GL, Experimental study of antagonizing effect of calcium and magnesium against fluoride toxicity in collagen, Chung Hua Yu Fang I Hsueh Tsa Chih, 1992, 26:2 • Gupta IP, et al., Fluoride as a Possible Etiological Factor in Non -Ulcer Dyspepsia, J. of Gastroenterology and Hepatology, 1992, 7, 355-356 • Kumari DS, Rao PR, Red cell membrane alterations in human chronic fluoride toxicity, Biochem Int, 23:4, 1991 —� • Lantz 0, et al., Fluoride -induced chronic renal failure, Am J Kidney Dis, 1987, 10:2 • Muller P, et al., Sodium fluoride -induced gastric mucosal lesions: comparison with sodium monofluorophosphate, Gastroenterol, 1992 April, 30:4 • Pillai KS, et al., Effect of subacute dosage of fluoride on male mice, Toxicol Lett, 1988, 44:1-2 • Li R, et al., Fluoride in Drinking Water and Intracardiac Blood Flow Defects in Iowa, Am. J. ofEpidem, 1992 Oct, 136, 1030 • Shea JJ, et al., Allergy to Fluoride. Annals of Allergy, 1967, 25 • Shen N, et al., Relationship between height, collagen metabolism, hair zinc and excessive fluoride intake, Hua Hsi I Ko Ta Hsueh Hsueh Pao, 1992, 23:1 • Smostrom S, Kalfas S Tissue necrosis after subgingival irrigation with fluoride solution, J of Clinical Periodontology • Spittle B, Allergy and Hypersensitivity To Fluoride, Fluoride, 1993, 26:4 • Strunecka A Patocka J, Pharmacological implications of aluminofluoride complexes, A review of the evidence for pathophysiological effects of aluminium and fluoride on living organism. • Susheela AK, et al., Fluoride ingestion and its correlation with gastrointestinal discomfort, Fluoride, 1992, 25:1 • Waldbott GL, The Preskeletal Phase of Chronic Fluoride Intoxication, Fluoride, 1998, 31:1 • Whitford GM, Pashley DH, Garman RH, Effects of fluoride on structure and function of canine gastric mucosa, Dig Dis Sci, 1997, 42(10) Banu Priya CAY, Anitha K, Murali Mohan E, Pillai KS, Murthy PB, Toxicity of Fluoride to Diabetic Rats, Fluoride, 1997 Feb, 30:1, 43-50 Wistar rats were given 20 ppm fluoride in drinking water, or single administration of 115 mg/kg alloxan i.m. to induce diabetes, or single administration of 115 mg/kg alloxan i.m. followed by 20 ppm fluoride for 31 days. Blood sugar level increased in rats given alloxan and alloxan + fluoride. Body weight gain in rats given alloxan + fluoride decreased significantly compared to other groups. Decrease in haemoglobin and glutamic oxaloacetate transaminase (GOT) was seen only in rats given alloxan + fluoride. In this group alkaline phosphatase, the target enzyme in fluoride toxicosis, increased considerably. The toxicity of fluoride in diabetic rats was further reflected in organ weight data. This investigation shows that fluoride toxicity is greater in diabetic rats. Baykov AA, Alexandrov AP, Smirnova IN, A two-step mechanism of fluoride inhibition of rat liver inorganic pyrophosphatase, Arch Biochem Biophys, 1992 Apr, 294:1, 238-43 Product formation curves for inorganic pyrophosphatase -catalyzed hydrolysis of pyrophosphate in the presence of fluoride were analyzed in order to get insight into the mechanism of its inhibitory action on this enzyme. The enzymatic reaction was monitored with a phosphate analyzer operating on the time scale of seconds. Inhibition patterns were virtually identical for cytosolic and mitochondrial pyrophosphatases. The effect of fluoride was biphasic: it caused a rapid (t112 less than 1 s) decrease in the initial velocity of the reaction followed by slow (t 112 greater than or equal to 4 s) inactivation of the enzyme during catalysis. The slow phase resulted in trapping intact substrate at the active site, and the resulting complex could be isolated by gel filtration. Pyrophosphatase remained active when incubated with fluoride in the absence of pyrophosphate or in the presence of its bisphosphonate analogs, which are bound to but not hydrolyzed by this enzyme. These features of the inhibition are consistent with the mechanism in which rapid binding of the inhibitor to the enzyme. substrate complex is followed by its slow isomerization. Kinetic parameters obtained in this work indicate that appreciable inactivation of pyrophosphatase can occur at fluoride concentrations found in human plasma. This effect may therefore be one of the major factors contributing to fluoride toxicity. Boros I, Keszler P, Csikos G and Kalisz H, Fluoride intake, distribution, and bone content in diabetic rats consuming fluoridated drinking water, Fluoride, 1998, 31:1, 33-41 SUMMARY: The aim of this study was to determine how metabolic and functional changes in diabetes affect the fluoride intake, distribution, and concentration in bone tissue, and whether alterations in fluoride metabolism in diabetes may influence the severity of the disorder. Two groups of rats received 0 (D) or 10 ppm (DF10) fluoride via drinking water for three weeks, ad libitum. Two other groups were treated with a single dose of streptozotocin to induce diabetes, and also received 0 (D) or 10 ppm fluoride (DF10). The quantity of fluoride consumed via water by the DF10 animals was calculated daily and an equal amount was added to the drinking water of another group of non-diabetic animals (FF). In the diabetic group (DF10) the intake of fluoride gradually increased, hyperglycemia was more severe, and renal hypertrophy was expressed less than in the diabetic group (D) which consumed deionized water. The femoral fluoride concentration increased in proportion to fluoride intake. The high fluoride intake of FF animals resulted, when compared to DF10 ones, in a further increase in the bone tissue and in relatively less elevation in plasma fluoride concentrations. It is concluded that (i) fluoride supply via drinking water may enhance the severity of diabetes in rats, and (ii) due to diabetic metabolic and functional imbalance, the fluoride metabolism may also change. Chen GL, Experimental study of antagonizing effect of calcium and magnesium against fluoride toxicity in collagen, Chung Hua Yu Fang 1 Hsueh Tsa Chih, 1992 Mar, 26(2), 80-82 (Article in Chinese) SD rats were given fluoride 20 mg/kg for 14 days through a gastrointestinal tube, body weight growth depressed obviously, the ratio of the Liver and Kidney weight to body weight increased significantly, hemoglobin concentration dropped and morphology and metabolism of collagen all became abnormal. Al} these effects can be antagonised by giving calcium (100 mg/kg), magnesium (100 mg/kg) or calcium and magnesium combined (50 mg/kg each). When Ca and Mg is given combined, the antagonizing effect is even better. Eckerlin RH, Maylin GA, Krook L, Milk production of cows fed fluoride contaminated commercial feed. Cornell Vet 1986 Oct;76(4):403-14 A commercial feed concentrate and a mineral mix with excessive amounts of fluoride were introduced into a Holstein dairy herd with an average milk production well above national standards. Milk production decreased drastically, and during the following 6 years the deficit in milk production in the herd ranging from 52 to 120 milking cows was 1.5 million Kg (3 114 million lbs.). The tolerance levels set by the National Academy of Sciences for fluoride ingestion by lactating cow were found to be inadequate. Kumari DS, Rao PR, Red cell membrane alterations in human chronic fluoride toxicity, Biochem Int, 23:4, 1991 Mar, 639-48 Red cells from humans exposed chronically to toxic levels of fluoride through drinking water showed significant increase in lipid peroxidation and membranous cholesterol and phospholipids. Additionally, electrophoretic patterns of ghost membrane proteins revealed the presence of a new band in the range of congruent to 66 Kd and increase in the high molecular weight protein and predominance of bands with a molecular weight of congruent to 93 Kd and congruent to 20 Kd The activities of total, Na(+) -K(+)-, Mg(2+)- and Ca(2+)-ATPases were significantly decreased in the red cell ghosts of fluorotic patients. Lantz Q, Jouvin MH, De Vernejoul MC, Druet P, Fluoride -induced chronic renal failure, Am J Kidney Dis, 1987 Aug, 10:2, 136-9 Renal fluoride toxicity in human beings is difficult to assess in the literature Although experimental studies and research on methoxyflurane toxicity have shown frank renal damage, observations of renal insufficiency related to chronic fluoride exposure are scarce. We report a case of fluoride intoxication related to potomania of Vichy water, a highly mineralized water containing 8.5 mglL of fluoride. Features of fluoride osteosclerosis were prominent and end-stage renal failure was present. The young age of the patient, the long duration of high fluoride intake, and the absence of other cause of renal insufficiency suggest a causal relationship between fluoride intoxication and renal failure. Muller P, Schmid K, Warnecke G. Setniker I, Simon B. Sodium fluoride -induced gastric mucosal lesions: comparison with sodium monofluorophosphate, Gastroenterol, 1992 April, 30:4 252-4 In a randomized double-blind study with two parallel groups of 10 male healthy volunteers each the response of gastric mucosa after a 7 days ingestion of sodium fluoride tablets (NaF) or sodium monofluorophosphate tablets (MFP) was compared. Gastroscopic evaluations were preformed before treatment, day 1 and day 7. Simultaneously blood samples were collected for determination of laboratory data and serum fluoride values. In the MFP-group no severe gastric lesions were observed, whereas in the NaF-group in 7 of the 10 subjects significant gastric mucosal lesions including acute hemorrhages and free blood in the gastric lumen were found. The differences of the lesions scores in both groups were statistically significant (p = 0.0015). The serum fluoride content was comparable in both treatment groups. Possible adverse drug reactions were reported in 4 subjects with NaF and in 1 subject with MFP. In summary, under the experimental conditions used MFP is well tolerated by the stomach while NaF produces significant gastric mucosal lesions. Pillai KS, Mathai AT, Deshmukh PB, Effect of subacute dosage of fluoride on male mice, Toxicol Lett, 1988 Nov, 44:1-2, 21-9 A sublethal concentration (one-tenth of the LD50) of fluoride (F) (5.2 mg Flkg body weight) was administered to Swiss albino mice (male) daily for 35 days. These mice showed a decrease in body weight gain, and food and water consumption. A significant decrease in red blood cell counts and an increase in white blood cell counts were seen in fluoride -administered mice. These animals also showed a decline in albumin, total protein, cholesterol, glucose and alkaline phosphatase activity in the serum. The fluoride content significantly increased in different organs of these animals. Sperm did not show any abnormalities due to fluoride toxicity in this specific instance [editor's note: recently, the 5.2 mg Flkg body weight has been classified as the "Probably Toxic Dose" (PTD) for Humans] Shea JJ, Gillespie SM, Waldbott GL, Allergy to Fluoride, Annals of Allergy, 1967 July, 25, 388- 391 [Abstract -- Six children and one adult exhibited various allergic reactions after the use of toothpaste and vitamin preparations containing fluoride. The following conditions were encountered: Urticaria, exfoliative dermatitis, atopic dermatitis, stomatitis, gastro-intestinal and respiratory allergy.] The literature contains little information concerning allergic reactions to the fluorine ion. Indeed some have questioned the possibility that fluoride in such a small amount as is present in vitamin tablets, toothpastes or water could act as a sensitizer. Two other halogens, iodine and bromine are recognized as sources of allergic manifestations. Feltman and Koseli noted atopic dermatitis, urticaria, epigastric distress, emesis and headache in one per cent of 672 pregnant women and children to whom they had administered fluoride tablets as a prevention of dental caries. Waldbott reported urticarial and dermatitis3 due to fluoride in drinking water. The causal relationship of these diseases to fluoride was established by blind and double blind tests. Epstein4 encountered a case of general dermatitis in one out of 20 patients with acne to whom he administered, on an experimental basis, 1 mg of fluoride per day for one to eleven weeks. Douglas presented an account of stomatitis in 133 cases due to fluoride -containing dentifrices. The patients' ages ranged from 2A'/2 to 92 years. His series included a family of six and another of tour, every member of which was adversely affected by fluoride toothpaste. Several of these patients had gastro-intestinal disturbances. The ulcers in the mouth were refractory to antibiotic therapy and to local medication, but cleared up promptly when nonfluoride toothpaste was substituted for the fluoride toothpaste. In 32 patients Douglas reproduced the stomatitis by reapplying the dentifrice, in some cases as often as six times. [case reports omitted] Comment [... ] Of special interest are the gastro-intestinal manifestations in five of the seven children, particularly the presence of blood in stool in three of the cases. Gastric hemorrhages are a major feature in acute fluoride intoxication8 and gastro-intestinal disturbances such as gastritis and spastic bowels, have been reported by FradA and Mentesana9 in about one half of their 62 cases of hydrofluorosis. Gastric symptoms must be anticipated especially in subjects who have hyperacidity of the stomach. When inorganic fluoride compounds combine with gastric HCI, hydrofluoric acid (HF) is formed which exerts an irritating action upon the mucosa of the stomach and the upper gastro-intestinal tract.10 [...references not scanned] Shen N, Li X, Wei S, Relationship between height, collagen metabolism, hair zinc and excessive fluoride intake, Hua Hsi I Ko Ta Hsueh Hsueh Pao, 1992 Mar, 23(1), 83-86 (Article in Chinese) After eliminating confounding factors, the study was made on the relationship between height, collagen metabolism, hair zinc and excessive fluoride intake. 140 schoolchildren aged 12-13 years born and reared in endemic fluorosis areas were surveyed. The results were as follows: 1. The average height of children with dental fluorosis III degree (DF III degree) was appreciably smaller than that of children without dental fluorosis. Among children with excessive fluoride intake, a negative correlation between the height and fluoride level in staple foods was seen. 2. The more the fluoride ingested, the higher the urinary THP excreted, showing that fluoride intoxication interfered with the collagen metabolism. 3. Among children with excessive fluoride intake, the height showed negative correlation with urinary THP/Cr, suggesting that the effect of fluoride on collagen metabolism indicated the mechanism of height retardation. 4. As compared to control group with the excessive fluoride intake but without dental fluorosis group, there was a significant reduction in hair zinc in group with DF III degree, suggesting that the zinc in the body decreased because of zinc metabolism disturbance by excessive fluoride intake. But among cases with excessive fluoride intake, no appreciable correlation between hair zinc and height was found. Therefore, it could not be confirmed that the effect of fluoride on zinc metabolism affected the height development. (editor's note: collagen is a major structural component of skin, ligaments, tendons, muscles, cartilage, bones and teeth] Sjostrom S, Kalfas S, Tissue necrosis after subgingival irrigation with fluoride solution, J of Clinical Periodontology 26(4):257-260, 1999 Irrigation of periodontal pockets with fluoride solution after scaling and root planing is occasionally recommended to inhibit the growth of pathogenic bacteria in the periodontal pocket. At the same time, irrigation enables mechanical removal of loosely adhering plaque and debris. Due to its toxicity, fluoride solution deposited in the periodontium may lead to tissue damage. We report in this paper, a case of extensive periodontal tissue necrosis and permanent loss of alveolar bone after irriga-tion of periodontal pockets with stannous fluoride solution. The literature on the toxic effects of fluo-ride on the local tissues is briefly reviewed and arguments for a re-evaluation of the use of stannous fluoride for pocket irrigation are provided. [References: 27] Reprint Sjostrom S, Umea Univ, Sch Dent, dept Oral Biol S-90185 Umea Sweden Spittle B, Allergy and Hypersensitivity to Fluoride, Fluoride, 1993, 26:4, 267-273 A review of the literature was undertaken in response to four recent reviews which found that the evidence that fluoride was an allergen was unconvincing Reports were found of urticaria, contact dermatitis and stomatitis occurring in response to fluoride, settling on the withdrawal of fluoride and recurring with appropriate challenges. It is concluded that the four reviews were seriously incomplete in their coverage of the literature, and that when a more complete examination is made there are reasonable grounds for concluding that there are individuals in whom allergy or hypersensitivity to fluoride has been demonstrated. The sources of fluoride included those used in the fluoridation of community water supplies A review of the literature was undertaken in response to four recent reviews which found that the evidence that fluoride was an allergen was unconvincing. Reports were found of urticaria, contact dermatitis and stomatitis occurring in response to fluoride, settling on the withdrawal of fluoride and recurring with appropriate challenges. It is concluded that the four reviews were seriously incomplete in their coverage of the literature, and that when a more complete examination is made there are reasonable grounds for concluding that there are individuals in whom allergy or hypersensitivity to fluoride has been demonstrated. The sources of fluoride included those used in the fluoridation of community water supplies. Introduction Four recent reviews, from the United States of America (1,2), Australia (3) and New Zealand (4), have concluded that claims that fluoride is an allergen could not be supported from studies undertaken to date, and that the weight of evidence shows that fluoride is unlikely to produce hypersensitivity and other immunological effects. Although the two US subcommittees involved were different, the sections dealing with the effects of fluoride on hypersensitivity and the immune system are almost the same. Thus although all four reports reached a similar conclusion that fluoride was unlikely to produce allergic or hypersensitivity effects, the 1993 reports (2,4) refer to those published in 1991 (1,3) and are not completely independent. The present review was undertaken to see if the same conclusion was reached. Literature Review In dismissing the occurrence of allergic reactions to fluoride, the New Zealand report (4) refers to the earlier United States (1) and Australian (3) reviews both of which in turn cite a statement by Austen et al (5) on behalf of the American Academy of Allergy. The Academy reviewed reports of fluoride allergy and found no evidence of allergy or intolerance to fluorides as used in the fluoridation of community water supplies (5). Waldbott made a rebuttal of the findings of Austen et at in 1971 (6) and noted that in 1978 this was still unrefuted (7). He observed that the statement by Austen et at cited only seven references, of which only five referred to fluoride (6). He commented that the committee had referred to a book of his, A Struggle with Titans (8), which was written for lay persons, but had apparently not given attention to 19 articles of his in scientific journals (6). Austen et at conclude that in the review of the cases reported there was insufficient evidence to state that true syndromes of fluoride allergy or intolerance existed (5). This included the cases reported by Feltman and Kosel (9). They had reported that l% of their cases reacted adversely to fluoride tablets (9). Atopic dermatitis and urticaria occurred with the use of fluoride tablets, disappeared with the use of placebo tablets, and recurred when the fluoride tablets were, unknowingly to the patient, given again (9). Kaplan (10) notes that when an urticarial drug reaction is suspected, this diagnosis may be tested by eliminating the agent. If it is correct, gradual resolution of the urticaria is anticipated. He notes that all medications should be considered a potential cause of urticaria. Except for penicillin, it is stated that no routine tests are available that can reliably confirm or refute the diagnosis of drug-induced urticaria or angioedema, and an empirical approach is therefore indicated (10). The empirical approach adopted by Feltman and Kosel of withdrawal of the fluoride tablets, substitution with placebo tablets and later a blind challenge with fluoride tablets (9) appears to be in keeping with the guidelines of Kaplan (10) Contrary to the view of Austen ct al, the results suggest that there is clinical evidence that a syndrome of fluoride allergy exists. Another paper reviewed by Austen et at, by Shea, Gillespie and Waldbott (11), reported allergy to fluoride in �. toothpaste and drops. In one case, involving a 48 -year-old man with giant urticaria, double-blind testing was used to confirm the etiologic relationship with fluoride (11). The lesions had involved mainly the hands and feet but sometimes the entire body surface. They usually occurred about one hour after breakfast. He had been using a fluoridated toothpaste at the time. Six days after discontinuing this he was completely free of symptoms. Three years later he experienced another episode of generalized urticaria. This occurred within an hour of his inadvertently brushing his teeth with a fluoridated toothpaste. The double-blind testing involved taking a tablespoonful of water each morning from three bottles labelled 1, 2 and 3 with each bottle being used in turn for a week at a time. Bottle 2 contained 1 mg of fluoride per tablespoonful, this code being known only by the pharmacist who prepared the bottles. On the fourth day on bottle 2 he developed generalized pruritis and oedema in the distal joints of his extremities. Nevertheless he continued taking the water from bottle 2 for another three days during which time he developed hives on the right elbow and pains in the lumbo -sacral area followed by an outbreak of generalized urticaria. These symptoms disappeared 2 days after the patient discontinued the use of bottle 2 (11). In a second case the aetiological role of fluoride was confirmed using a patch test (11). The patient, a 9 - year -old female, had frequent urticaria, allergic conjunctivitis and minor asthmatic attacks. There had been constant episodes of ulcers distributed throughout the oral cavity. Slight abdominal tenderness was present. A fluoridated toothpaste had been used since the onset of the oral lesions. A patch test gave a two plus reaction to the fluoride toothpaste but not to chewing gum, Lifesavers, or a non -fluoride toothpaste. During the development of the positive patch test reaction the patient experienced a flare-up of the oral lesions associated with severe abdominal pain. After changing to a non -fluoride toothpaste the oral lesions as well as the abdominal pains subsided completely. One year later a recurrence of the stomatitis occurred within 15 minutes of inadvertently brushing her teeth with a fluoridated toothpaste. Severe abdominal pain also occurred (11). Again in this case the guidelines of Kaplan (10) appear to have been followed and indicate that there is clinical evidence to show that a syndrome of fluoride allergy exists. Although the above cases refer to the use of fluoride tablets and toothpaste in contrast to the mention in the statement by Austen et a/ of fluorides as used in the fluoridation of community water supplies, this qualification is not mentioned earlier in the article by Austen et a! (5). There it is stated that there is not sufficient clinical evidence to state that a true syndrome of fluoride allergy exists (5). Urticaria is characterized by the appearance of pruritic, erythematous, cutaneous elevations that blanch with pressure, indicating the presence of dilated blood vessels and oedema (10). Urticaria, both local and generalized, was described with acute sodium fluoride poisoning by Lidbeck, Hill and Beeman (13). In 1959 Waldbott described six cases of urticaria due to fluoridated water (13). In one case, Mrs PO aged 40 years, the relation of the urticaria to fluoride in water was substantiated by a double-blind test (14). The patient was required to take a tablespoonful of water daily from three bottles labelled 1, 2 and 3, using each for a week at a time. One bottle contained 1 mg of fluoride per tablespoonful but neither the patient nor her attending physician knew which one it was. The urticaria reappeared on the third day of using the fluoride solution. Another patient, Mrs HP aged 48 years, had generalized urticaria which began three weeks after moving to a fluoridated area. On using water with a low amount of fluoride in hospital (0.1 ppm) the urticaria subsided. Within 24 hours of resuming using fluoridated water the urticaria recurred. An intradermal skin test with a 1:100 dilution of a 1 % aqueous solution of sodium fluoride gave a 3 -plus wheal reaction. This was followed by a generalized outbreak of urticaria within ten minutes. Control tests with a 1 % solution of sodium bromide and sodium iodide were negative. With double-blind testing involving three bottles of water only one of which contained fluoride, urticaria recurred within two days of taking the water from the fluoride -containing Mottle (14). Contact dermatitis is a term used to describe any rash resulting from a substance touching the skin and as a synonym for allergic contact dermatitis (15). Allergic contact dermatitis is the result of a substance contacting skin that has undergone an acquired specific alteration in its reactivity (15). This altered reactivity is the result of prior exposure of the skin to the material eliciting the dermatitis or a chemically closely related substance (15). The patch test, whereby the suspected substance is applied to the skin under an occlusive dressing for one to two days and the test site observed after removal, remains the only practical test for demonstrating contact dermatitis (15). In 1948 Abelson reported a typical contact dermatitis with vesiculo- papular pruritic lesions on the hand of a dentist occurring immediately upon application of a 2% solution of sodium fluoride to a patient's teeth (16). Waldbott reports observing repeatedly the same pattern of dermatitis in dentists with confirmation by patch testing (17). Waldbott (14) also described a scaly erythematous pruritic lesion on the thighs of a woman aged 20 years which subsided after moving for observation to a nonfluoridated area. After she had been symptom-free the dermatitis recurred at the same site with papulous, vesicular lesions and intense pruritis within an hour of receiving a test dose of 6.8 mg of fluoride in 300 mi of water. A placebo test with 300 ml of distilled water produced no ill effect (14). Aphthous stomatitis and ulcers of the mouth have been described as being not uncommon in persons using fluoride toothpaste and in children who have had topical fluoride applications applied to their teeth (14). Douglas (18) has described 133 cases of stomatitis from fluoride containing toothpaste. All the lesions were refractory to antibiotic therapy and local medication. The lesions cleared up with changing to a nonfluoride toothpaste. In 32 patients the stomatitis was reproduced by applying the fluoride toothpaste, in some as often as six times (18). Waldbott (14) records the case of Mrs LCH aged 62 years who developed a mouth ulcer within three days of starting the use of a fluoride toothpaste. Elimination of the fluoride toothpaste caused the condition to gradually disappear. Application of a saline solution with a cotton swab beneath her tongue produced no ill effect. When a 1 % aqueous solution of sodium fluoride was applied, there developed, within five minutes, a hyperaemic oedematous intensely pruritic lesion in the test area which extended into a large portion of the oral mucosa. A smear of the mucus from the area showed marked eosinophilia (14). Waldbott (19) also reported the case of Mrs WEA aged fit years who developed the allergic symptoms of rhinitis, allergic sinus disease and urticaria within hours of using fluoridated water with an intake of 1 to 2 mg a day. A typical allergic appearance of the nasal mucosa eosinophilia and an allergic wheal followed the intradermal injection of 0.1 mg of sodium fluoride. Control injections with horse serum, saline solution and weaker aqueous dilutions of sodium fluoride had no adverse effect (19). Zanfagna (20) has reported on Mrs MET aged 48 years who developed acute generalized urticaria after drinking fluoridated water. A further attack was also traced to fluoridated water. It was stated that sensitivity to fluoride was confirmed by positive challenge tests (20). Discussion Currently allergy is considered to be synonymous with hypersensitivity in meaning (21). They usually refer to type 1 immediate hypersensitivity, mediated by specific IgE antibodies in genetically predisposed individuals and resulting in symptoms characteristic of eczema, urticaria, rhinitis, asthma and anaphylaxis, although it is noted that several types of allergic states encompass all the mechanisms described by Gell and Coombs (21). Waldbott (14) saw a difference between reactions to fluoride due to the toxic action of the fluoride ion and allergic sensitivity. He pointed out that the degree of tissue damage from the toxic action of the fluoride ion has been seen to depend on numerous factors including the dose of the fluoride ion, the duration of the contact with the involved tissue, the pH of the intracellular and extracellular fluids, and the presence of calcium, magnesium and other metals. When in contact with fluids in an acid medium such as gastric juice, fluoride compounds tend to induce undissociated hydrofluoric acid which has a corrosive action. True allergic reactions, on the other hand, can result from relatively insignificant doses and from short exposures. The presence of such allergic symptoms as urticaria, vasomotor rhinitis, dermatitis and eosinophilia, a prompt response to adrenaline, and occasionally positive skin and patch test reactions, point to allergy (14). As an example of the difference between allergy or hypersensitivity to a drug and intolerance to it, reactions to aspirin can be considered (7). Intolerance to aspirin is characterized by hemorrhages in the stomach whereas allergy to aspirin results in such symptoms as hives, asthma, allergic nasal and sinus disease or even anaphylactic shock (7). To establish the existence of allergy to fluoride, community studies which are prone to the ecological fallacy (22) are insufficient and stronger evidence based on the studies of individuals is required. Although in the above discussion reference is made to cases of allergy related to fluoride tablets and toothpaste, there are included cases (Mrs PO, Mrs HP, Mrs WEA, Mrs MET) in which the reaction of allergy has been to fluorides as used in the fluoridation of community water supplies. Although Waldbott found that allergic reactions to fluoride could occur, it was not considered that this was the only mechanism whereby adverse reactions to fluoride were experienced (7). Intolerance to fluoride was seen to occur for example through the formation of corrosive undissociated hydrofluoric acid when fluoride ions were in contact with acidic gastric secretions. This potential mechanism for fluoride damaging the gastroduodenal mucosa has been supported by Susheela et al (23) along with other potential mechanisms such as enzyme system inhibition. By studying patients intensively, including by endoscopy and biopsy for histopathological and scanning electron microscope examination, they found that the gastroduodenal mucosa could be severely damaged by the toxic effects of fluoride resulting in dyspeptic symptoms. The changes found included surface abrasions with loss of microvilli in the gastric antrum and duodenum, and a 'cracked -clay' appearance of the duodenal mucosa. Gastrointestinal discomfort, in the form of dyspeptic symptoms was thus seen to be an important diagnostic feature in identifying persons affected by fluoride and it was considered that such symptoms should not be dismissed as non-specific (23). Moolenburgh (24) described abdominal discomfort occurring on a double-blind basis with exposure to fluoride. He found in his Dutch general practice patients with illnesses similar to those described by Waldbott. He considered that far from having exaggerated the side-effects, Waldbott had, on the contrary, been inclined to under -statement. Although Moolenburgh expected to find an allergic basis for the adverse effects associated with fluoride, he considered that the symptoms represented poisoning with inhibition of the immune system by a toxic substance in sensitive persons Where an exacerbation of illnesses with an allergic component such as eczema and asthma occurred, his view was that immune system inhibition by fluoride had resulted in a loss of the ability to cope with the allergy (24). The work by Moolenburgh and his colleagues has been described by Grimbergen (25). By double-blind testing with 60 patients he showed that certain individuals were intolerant to fluoride and that exposure to this could reproduce gastrointestinal symptoms, stomatitis, joint pains, polydipsia, headaches and visual disturbances. Grimbergen noted that Young had found that intracutaneous injections of sodium fluoride gave positive reactions in four persons with urticaria associated with the use of fluoridated water but no such reactions in four persons without urticaria (25). Petraborg (26, 27) similarly described a wide spectrum of symptoms in 27 persons exposed to fluoridated water. He considered that since none of the persons were aware that their drinking water was fluoridated or were familiar with the manifestations of fluoride toxicity, that the accounts of their illnesses were equivalent in validity to those associated with double-blind procedures. He noted that several patients were not convinced that something in their drinking water was causing their illness and resumed drinking fluoridated water. Relapses of their illnesses followed. The symptoms included extreme chronic fatigue, polydipsia, general pruritis, headaches and gastrointestinal symptoms (26,27). Another adverse effect of fluoride, described by Lee (28), involved an elevation of the serum bilirubin level in six patients with Gilbert's disease. Long-term testing and studying the effect of fluoride tablets in one patient gave evidence that the hyperbilirubinaemia was due solely to fluoride and not to some other ingredient of the water supply. An enzyme -inhibiting action by fluoride was considered to be the most likely mechanism involved (28). It is concluded, on the basis of the above examination, that the recent North American, Australian and New Zealand reviews (1-4) were seriously incomplete in their coverage of the literature. There are some individuals in whom allergy or hypersensitivity to fluoride has been demonstrated by appropriate challenge tests. This is seen to be just one of a number of mechanisms whereby adverse reactions to fluoride occur. I is considered that intolerance to fluoride may also follow the formation of corrosive hydrofluoric acid or through enzyme inhibition. Dr. Spittle is with the Dept of Psychological Medicine, School of Medicine, University of Otago, Dunedin, NZ. References 0 1 Subcommittee on fluoride of the committee to coordinate environmental health and related programs Review of Fluoride Benefits and Risks. Department of Health and Human Services, Public Health o Service Washington 1991 c 2 Wagner BM, Burt BA, Canter KP et at (Subcommittee on health effects of ingested fluoride, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council). Health Effects of Ingested Fluoride. National Academy Press, Washington DC 1993 pp 8-9 0 3 National Health and Medical Research Council. The Effectiveness of Water Fluoridation. Australian Government Publishing Service, Canberra 1991 o 4 Public Health Commission. Fluoridation of water supplies- draft policy statement. Public Health Commission, Wellington 1993 o 5 Austen KF, Dworetzky M, Farr RS et al. A statement on the question of allergy to fluoride as used in the fluoridation of community water supplies [editorial]. Journal of Allergy 47 347-348 1971 o 6 Waldbott GL Fluoridation of community water supplies [letter]. Journal of Allergy and Clinical Immunology 48 253-254 1971 0 7 Waldbott GL, Burgstahler AW, McKinney HL. Fluoridation the great dilemma. Coronado Press, Lawrence, Kansas 1978 a 8 Waldbott GL. A Struggle With Titans. Carlton Press, New York 1965 0 9 Feltman R, Kosel G. Prenatal and postnatal ingestion of fluoride: fourteen years of ivestigation; final report. Journal of Dental Medicine 16 190-198 1961 0 10 Kaplan AP. Urticaria and angioedema. In: Middleton E, Reed CF, Ellis EF (Eds). Allergy: Principles and Practice. vol 2 2nd ed CV Moseby, St. Louis 1983 pp 1341-1360 0 11 Shea JJ, Gillespie SM, Waldbott GL. Allergy to fluoride. Annals of Allergy 25 388-391 1967 a 12 Lidbeck WL, Hill IB, Beeman JA. Acute sodium fluoride poisoning. Journal of the American Medical Association 121 826-827 1943 0 13 Waldbott GL. Urticaria due to fluoride. Acta Allergologica 13 456-468 1959 a 14 Waldbott GL. Allergic reactions to fluoride. Journal of Asthma Research 2 51-64 1964 0 15 Maibach HI, Epstein E. Contact dermatitis. In: Middleton E, Reed CF, Ellis EF (Eds). Allergy: Principles and Practice. vol 2 2nd ed CV Moseby, St. Louis 1983 pp 1313-1339 0 16 Abelson JH. Case of hypersensitivity to sodium fluoride in a dentist. Chicago Dental Society Fortnightly Review 16 6 1948 0 17 Waldbott GL. Contact dermatitis CC Thomas, Springfield 1953 0 18 Douglas TE. Fluoride dentifrice and stomatitis. Northwestern Medicine 56 107-139 1957 0 19 Waldbott GL. Fluoride in clinical medicine. lntemational Archives of Allergy and Applied Immunology 20 (Suppl 1) 1-60 1962 0 20 Zanfagna PE. Allergy to fluoride. Fluoride 9 36-41 1976 a 21 Facial RG, Nalebuff DJ, Ali M. The importance of total and allergen -specific IgE measurements. In: Johnson F, Spencer JT (Eds). Allergy: Immunology and Medical Treatment, Symposia Specialists, Miami 1980 pp 15--28 0 22 Morgenstern H. Uses of ecologic analysis in epidemiologic research. American Journal of Public Health 72 1336-1344 1982 0 23 Susheela AK, Das TK, Gupta IP et al. Fluoride ingestion and its correlation with gastrointestinal discomfort. Fluoride 25 5-22 1992 0 24 Moolenburgh H. Fluoride: The Freedom Fight. Mainstream Publishing, Edinburgh 1987 pp 65- 66, 146-147 0 25 Grimbergen GW. A double blind test for determination of intolerance to fluoridated water (preliminary report). Fluoride 7 146-152 1974 �.. o 26 Petraborg HT. Chronic fluoride intoxication from drinking water (preliminary report). Fluoride 7 47-521974 a 27 Petraborg HT. Hydrofluorosis in the fluoridated Milwaukee area. Fluoride 10 165-169 1977 0 28 Lee JR. Gilbert's disease and fluoride intake. Fluoride 16 139-145 1983 Strunecka A, Patocka J, Pharmacological implications of aluminofluoride complexes, A review of the evidence for pathophysio logical effects of aluminium and fluoride on living organism. Charles University, Faculty of Sciences, Department of Physiology, Prague. Department of Toxicology, Purkyni Military Medical Academy, Hradec Kralove, Czech Republic Susheela AK, Das TK, 2 Gupta IP,2 Tandon RK,2 Kacker SK,2 Ghosh P,3 and Deka,3 Fluoride ingestion and its correlation with gastrointestinal discomfort, Fluoride, 1992, 25:1, pp 5-22 SUMMARY: This study was carried out to assess the effect on the human gastroduodenal mucosa of drinking naturally fluoridated water and treating patients with 30 mg sodium fluoride for otosclerosis. Ten cases each of skeletal fluorosis and otosclerosis and twenty cases of non -ulcer dyspepsia (NUD) were investigated through routine clinical investigations, chemical investigations of body fluids and drinking water for fluoride, radiographs, stool examination for ova, cysts and worms, abdominal sonography, upper gastrointestinal endoscopy, jejunal aspirates for Giardia lamblia, histopathology of biopsies of intestinal and gastric mucosa and scanning electron microscopy of the mucosa. Patients of all three groups, compared with a control group of normal healthy volunteers, presented gastrointestinal problems and discomfort. Four patients with non -ulcer dyspepsia also presented radiological evidence of skeletal fluorosis. Analysis of ingested drinking water revealed fluoride concentrations of 0.49 - 11.36 ppm. Histopathological studies revealed non-specific lesions. Stool examination revealed ova of Ascaris lumbricoides in two NUD patients, while the rest had normal stool on examination. Jejunal aspirates were negative for Giardia lamblia in all the subjects. Scanning electron microscopic studies revealed widespread damage to the mucosa, viz. (a) mucus .� droplets were not visible, (b) loss of microvilli, (c) cracked -clay appearance of the duodenal mucosa and (d) desquamated epithelium of gastric mucosa. It is concluded- 1) Ingested fluoride damages gastroduodenal mucosa. 2) Gastrointestinal discomfort car be an early warning sign of fluorosis. 3) Fluoride toxicity should be considered a possible reason for non -ulcer dyspepsia, especially in fluorosis endemic areas. 4) v Gastrointestinal discomfort during sodium fluoride therapy calls for extreme caution and close monitoring. 5) Gastrointestinal discomfort in the form of dyspeptic symptoms should be an important diagnostic feature when identifying fluorosis patients and should not be dismissed as non-specific. Department of Anatomy, 2Department of Gastroenterology. 3Department of Otolaryngology, All India Insitute of Medical Sciences, New Delhi, India Waldbott GI_, The Preskeletai Phase of Chronic Fluoride Intoxication, Fluoride, 1998, 31:1, 13-20 Whitford GM, Pashley DH, Garman RH, Effects of fluoride on structure and function of canine gastric mucosa, Dig Dis Sci 1997, 42(10), 2146-2155 These studies were done to determine the effects of fluoride (F) on the structure and function of the canine gastric mucosa and the possible protective effects of 16,16 -dimethyl -prostaglandin E2 (dmPGE2). A portion of the stomach with its vascular supply intact was mounted in a two-compartment chamber, one side of which contained a control solution. Minor effects were caused by exposure to 1 mmollliter F. Both 5 and 10 [190 ppm] mmol/liter F caused marked increases in the fluxes of water and Na, K, and H ions; mucus secretion; and tissue swelling and redness. The extent of these changes did not increase appreciably upon exposure to 50 or 100 mmol/liter F. Histological findings included marked thinning of the surface cell layer, reduced uptake of PAS stain, localized exfoliation and necrosis of surface cells, acute gastritis, and edema. It was concluded that: (1) the threshold F concentration for effects on the structure and function of the gastric mucosa was approximately 1 mmol/liter; (2) the maximum or near -maximum effects were caused by 10 mmol/liter F; (3) the effects persisted for at least 6 hr after the exposure; and (4) dmPGE2 (0.5 microglml) did not attenuate the effects induced by F. CONTRAINDICATIONS AND SIDE EFFECTS OF NaF Health Canada's Drugs Directorate warning -- "should not be given to infants under 6 months of age and not consumed in areas with fluoridated water supplies" -- is woefully inadequate. The following information (not exhaustive) has appeared in various pharmaceutical books and is consistent with the medical research on NaF (including blind and double-blind studies and/or clinical evidence): Those indicating need for medical attention [United States Pharmacopoeia, 1986] U Skin rash (allergic reaction) CI Sores in the mouth and on the lips (mucous membrane ulceration) Signs of chronic fluoride overdose [United States Pharmacopoeia, 1986] o Constipation or a Loss of appetite or o Nausea or vomiting or o Pain and aching of bones or o Stiffness or o Weight loss or o White, brown, or black discoloration of teeth (fluorosis, osteosclerosis) Adverse Reactions [Physicians Desk Reference 1994] In hypersensitive individuals, fluorides occasionally cause skin eruptions such as atopic dermatitis, eczema or urticaria, Gastric distress, headache and weakness have also been reported. These hypersensitivity reactions usually disappear promptly after discontinuation of the fluoride. In rare cases, a delay in the eruption of teeth has been reported. Precautions/Contraindications/Adverse Effects [Canadian Compendium of Pharmaceuticals and Specialties, 1989 --TRI-VI-FLUOR and/or SODIUM FLUORIDE] o Should not be administered to infants and children using other fluoride -containing drugs, or to patients with frank dental fluorosis [emphasis mine] o Sodium -free diets o Ingestion of fluorides may cause eczema, atopic dermatitis and urticaria o Reports include skin rash, gastrointestinal upsets and headache. These usually disappear when administration is discontinued o Chronic toxicity of fluoride is manifest in mottling of the dental enamel (dental fluorosis) and may result in increased density of bone Warnings [By the Editors of Consumer Guide Prescription Drugs, Beekman House, New York, 1988; o Poly-Vi-Flor {similar to Tri -Vi -Fluor} vitamin and fluoride supplement]: This drug should be used cautiously by those with heart disease, kidney disease, bone disease, or thyroid disease Source Slide 9 Harvard Study Impact of fluoride on neurological development in children Explore research by topic Source link: b ILwww.hsph.harvard.edu/news/features/fluoride-childrens-health-grandjean-choiL FEATURES Healthy eating Assessing the new U.S. dietary guidelines Maternal health Oral contraceptives not linked with birth defects Related Links • environmental health • child health July 25, 2012 — For years health experts have been unable to agree on whether fluoride in the drinking water may be toxic to the developing human brain. Extremely high levels of fluoride are known to cause neurotoxicity in adults, and negative impacts on memory and learning have been reported in rodent studies, but little is known about the substance's impact on children's neurodevelopment. In a meta-analysis, researchers from Harvard School of Public Health (HSPH) and China Medical University in Shenyang for the first time combined 27 studies and found strong indications that fluoride may adversely affect cognitive development in children. Based on the findings, the authors say that this risk should not be ignored, and that more research on fluoride's impact on the developing brain is warranted. The study was published online in Environmental Health Perspectives on July 20, 2012. The researchers conducted a systematic review of studies, almost all of which are from China where risks from fluoride are well-established. Fluoride is a naturally occurring substance in groundwater, and exposures to the chemical are increased in some parts of China. Virtually no human studies in this field have been conducted in the U.S., said lead author Anna Choi, research scientist in the Department of Environmental Health at HSPH. Even though many of the studies on children in China differed in many ways or were incomplete, the authors consider the data compilation and joint analysis an important first step in evaluating the potential risk. "For the first time we have been able to do a comprehensive meta-analysis that has the potential for helping us plan better studies. We want to make sure that cognitive development is considered as a possible target for fluoride toxicity," Choi said. Choi and senior author Philippe Grandjean, adjunct professor of environmental health at HSPH, and their colleagues collated the epidemiological studies of children exposed to fluoride from u drinking water. The China National Knowledge Infrastructure database also was included to locate studies published in Chinese journals. They then analyzed possible associations with IQ measures in more than 8,000 children of school age; all but one study suggested that high fluoride content in water may negatively affect cognitive development. The average loss in IQ was reported as a standardized weighted mean difference of 0.45, which would be approximately equivalent to seven IQ points for commonly used IQ scores with a standard deviation of 15.* Some studies suggested that even slightly increased fluoride exposure could be toxic to the brain. Thus, children in high -fluoride areas had significantly lower IQ scores than those who lived in low -fluoride areas. The children studied were up to 14 years of age, but the investigators speculate that any toxic effect on brain development may have happened earlier, and that the brain may not be fully capable of compensating for the toxicity. "Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain," Grandjean says. "The effect of each toxicant may seem small, but the combined damage on a population scale can be serious, especially because the brain power of the next generation is crucial to all of us." * This sentence was updated on September g, 2012. Read a September 2012 statement by the authors. Statement on Fluoride Paper September 11, 2012 When considering the risks and benefits of fluoride exposure, the level of intake needs to be considered. Possible risks to brain development in children have been studied in China, but this possible hazard has not received much, if any, consideration in the U.S. Our study summarized the findings of 27 studies on intelligence tests in fluoride -exposed children; 25 of the studies were carried out in China. On average, children with higher fluoride exposure showed poorer performance on IQ tests. Fluoride released into the ground water in China in some cases greatly exceeded levels that are typical in the U.S. In general, complete information was not available on these 27 studies, and some limitations were identified. All but one of the 27 studies documented an IQ deficit associated with increased fluoride exposure. These results do not allow us to make any judgment regarding possible levels of risk at levels of exposure typical for water fluoridation in the U.S. On the other hand, neither can it be concluded that no risk is present. We therefore recommend further research to clarify what role fluoride exposure levels may play in possible adverse effects on brain development, so that future risk assessments can properly take into regard this possible hazard. --Anna Choi, research scientist in the Department of Environmental Health at HSPH, lead author, and Philippe Grandjean, adjunct professor of environmental health at HSPH, senior author Need more information? Please refer to the feature story on the Harvard School of Public Health website. You are welcome to quote from it for your story. Link to HSPH feature story: Impact of Fluoride on Neurological Development in N".01 Childrenhttp://www.hsph.harvard.edu/news/features/fluoride-childrens-health-grandjean-choi/ Link to study: "Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis," Anna L. Choi, Guifan Sun, Ying Zhang, Philippe Grandjean, Environmental Health Perspectives, 2012,120(10):1362-1368. http://ehp.niehs.nih.gov/wp-content/uploads/2012/09/ehp.1104912.pdf ** Learn more about the IQ measurements by HSPH's Anna L. Choi and Philippe Grandjean in response to a letter to the journal published in the March 2013 (Vol. 121, No. 3) Environmental Health Perspectives. Follow-up Fluoride Study Published December 19, 2014 — As a follow-up, Philippe Grandjean, adjunct professor of environmental health at Harvard School of Public Health (HSPH), Anna Choi, research scientist in the Department of Environmental Health, and colleagues have published a pilot study of cognitive functions in Chinese children exposed to different levels of fluoride from drinking water. The new paper, entitled "Association of lifetime exposure to fluoride and cognitive functions in Chinese children: A pilot study," has been published online and in the January -February 2015 issue of Neurotoxicology and Teratology. — Marge Dwyer u u u' Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 1 of 10 Environ Health Perspect. 2012 Oct; 120(10): 1362 -1368 - Published online 2012 Jul 20. doi- 10,12991ehp.1104912 Review PMCID_ PMC3491930 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Anna L. Choi 01 Guifan Sun,2 Ying Zhang,3 and Philippe Grandjeanl,4 'Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA 2School of Public Health, China Medical University, Shenyang, China 3School of Stomatology, China Medical University, Shenyang, China 41nstilute of Public Health, University of Southem Denmark, Odense, Denmark `Corresponding author_ Address correspondence to A.L. Choi, Department of Environmental Health, Harvard School of Public Health, Landmark Center 3E, 401 Park Dr., Boston, MA 02215 USA. Telephone- (617) 3846646. Fax: (617) 364-8994. E-mail- as �hsph.harvard.edu Received 2011 Dec 30; Accepted 2012 Jul 20. Copyright notice Publication of EHP lies in the public domain and is therefore without copyright. All text from EHP may be reprinted freely. Use of materials published in EHP should be acknowledged (for example, ?Reproduced with permission from Environmental Health Perspectives?). pertinent reference information should be provided for the article from which the material was reproduced. Articles from EHP, especially the News section, may contain photographs or illustrations copyrighted by other commercial organizations or individuals that may not be used without obtaining prior approval from the holder of the copyright. This article has been cited by other articles in PMC. Abstract Go to: Background: Although fluoride may cause neurotoxicity in animal models and acute fluoride poisoning causes neurotoxicity in adults, very little is known of its effects on children's neurodevelopment. Objective: We performed a systematic review and meta-analysis of published studies to investigate the effects of increased fluoride exposure and delayed neurobehavioral development. Methods: We searched the MEDLINE, EMBASE, Water Resources Abstracts, and TOXNET databases through 2011 for eligible studies. We also searched the China National Knowledge Infrastructure (CNKI) database, because many studies on fluoride neurotoxicity have been published in Chinese journals only. In total, we identified 27 eligible epidemiological studies with high and reference exposures, end points of IQ scores, or related cognitive function measures with means and variances for the two exposure groups. Using random -effects models, we estimated the standardized mean difference between exposed and reference groups across all studies. We conducted sensitivity analyses restricted to studies using the same outcome assessment and having drinking - water fluoride as the only exposure. We performed the Cochran test for heterogeneity between studies, Begg's funnel plot, and Egger test to assess publication bias, and conducted meta -regressions to explore sources of variation in mean differences among the studies. Results: The standardized weighted mean difference in IQ score between exposed and reference populations was —0.45 (95% confidence interval: —0.56, —0.35) using a random -effects model. Thus, children in high -fluoride areas had significantly lower 1Q scores than those who lived in low -fluoride areas. Subgroup and sensitivity analyses also indicated inverse associations, although the substantial heterogeneity did not appear to decrease. bttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 2 of 10 Conclusions: The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment. Future research should include detailed individual -level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment. U Keywords: fluoride, intelligence, neurotoxicity A recent report from the National Research Council (NRC 2006) concluded that adverse effects of high fluoride concentrations in drinking water may be of concern and that additional research is warranted. Fluoride may cause neurotoxicity in laboratory animals, including effects on learning and memory (Chioca et al. 2008, Mullenix et al. 1995). A recent experimental study where the rat hippocampal neurons were incubated with various concentrations (20 mg/L, 40 mg/L, and 80 mg/L) of sodium fluoride in vitro showed that fluoride neurotoxicity may target hippocampal neurons (Zhang M et al. 2008). Although acute fluoride poisoning may be neurotoxic to adults, most of the epidemiological information available on associations with children's neurodevelopment is from China, where fluoride generally occurs in drinking water as a natural contaminant, and the concentration depends on local geological conditions. In many rural communities in China, populations with high exposure to fluoride in local drinking -water sources may reside in close proximity to populations without high exposure (NRC 2006). Opportunities for epidemiological studies depend on the existence of comparable population groups exposed to different levels of fluoride from drinking water. Such circumstances are difficult to find in many industrialized countries, because fluoride concentrations in community water are usually no higher than 1 mg/L, even when fluoride is added to water supplies as a public health measure to reduce tooth decay. Multiple epidemiological studies of developmental fluoride neurotoxicity were conducted in China because of the high fluoride concentrations that are substantially above 1 mg/L in well water in many rural communities, although microbiologically safe water has been accessible to many rural households as a result of the recent 5 -year plan (2001-2005) by the Chinese government. It is projected that all rural residents will have access to safe public drinking water by 2020 (World Bank 2006). However, results of the published studies have not been widely disseminated. Four studies published in English (Li XS et al. 1995; Lu et al. 2000; Xiang et al. 2003; Zhao et al. 1996) were cited in a recent report from the NRC (2006), whereas the World Health Organization (2002) has considered only two (Li XS et al. 1995; Zhao et al. 1996), in its most recent monograph on fluoride. Fluoride readily crosses the placenta (Agency for Toxic Substances and Disease Registry 2003). Fluoride exposure to the developing brain, which is much more susceptible to injury caused by toxicants than is the mature brain, may possibly lead to permanent damage (Grandiean and Landrigan 2006). In response to the recommendation of the NRC (2006), the U.S. Department of Health and Human Services (DHHS) and the U.S. EPA recently announced that DHHS is proposing to change the recommended level of fluoride in drinking water to 0.7 mg/L from the currently recommended range of 0.7-1.2 mg/L, and the U.S. EPA is reviewing the maximum amount of fluoride allowed in drinking water, which currently is set at 4.0 mg/L (U.S. EPA 2011). To summarize the available literature, we performed a systematic review and meta-analysis of published studies on increased fluoride exposure in drinking water associated with neurodevelopmental delays. We specifically targeted studies carried out in rural China that have not been widely disseminated, thus complementing the studies that have been included in previous reviews and risk assessment reports. Methods Go to: Search strategy. We searched MEDLINE (National Library of Medicine, Bethesda, MD, USA; http://www.ncbi.nlm.nih.gov/pubmed), Embase (Elsevier B.V., Amsterdam, the Netherlands; http://www.embase.com), Water Resources Abstracts (Proquest, Ann Arbor, MI, USA; http://www.csa.com/factsheets/water-resources-set-c.php), and TOXNET (Toxicology Data Network; National Library of Medicine, Bethesda, MD, USA; http://toxnet.nlm.nih.gov) databases to identify studies of drinking- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 3 of 10 water fluoride and neurodevelopmental outcomes in children. In addition, we searched the China National Knowledge Infrastructure (CNKI; Beijing, China; http://www.cnki.net) database to identify studies published in Chinese journals only. Key words included combinations of "fluoride" or "drinking water fluoride," "children," Nft./ "neurodevelopment" or "neurologic" or "intelligence" or "IQ." We also used references cited in the articles identified. We searched records for 1980`201 1. Our literature search identified 39 studies, among which 36 (92.3%) were studies with high and reference exposure groups, and 3 (7.7%) studies were based on individual - level measure of exposures. The latter showed that dose-related deficits were found, but the studies were excluded because our meta-analysis focused on studies with the high- and low -exposure groups only. In addition, two studies were published twice, and the duplicates were excluded. Inclusion criteria and data extraction. The criteria for inclusion of studies included studies with high and reference fluoride exposures, end points of IQ scores or other related cognitive function measures, presentation of a mean outcome measure, and associated measure of variance [95% confidence intervals (Cls) or SEs and numbers of participants]. Interpretations of statistical significance are based on an alpha level of 0.05. Information included for each study also included the first author, location of the study, year of publication, and numbers of participants in high -fluoride and low -fluoride areas. We noted and recorded the information on age and sex of children, and parental education and income if available. Statistical analysis. We used STATA (version 11.0; StataCorp, College Station, TX, USA) and available commands (Stern 2009) for the meta-analyses. A standardized weighted mean difference (SMD) was computed using both fixed -effects and random -effects models. The fixed -effects model uses the Mantel—Haenszel method assuming homogeneity among the studies, whereas the random -effects model uses the DerSimonian and Laird method, incorporating both a within -study and an additive between -studies component of variance when there is between -study heterogeneity (Egger et al. 2001). The estimate of the between -study variation is incorporated into both the SE of the estimate of the common effect and the weight of individual studies, which was calculated as the inverse sum of the within and between study variance. We evaluated heterogeneity among studies using the 1' statistic, which represents the percentage of total variation across all studies due to between -study heterogeneity (Higgins and Thompson 2002). We evaluated the potential for publication bias using Begg and Egger tests and visual inspection of a Begg funnel plot (Been and Mazumdar 1994; Egger et al. 1997). We also conducted independent meta -regressions to estimate the contribution of study characteristics (mean age in years from the age range and year of publication in each study) to heterogeneity among the studies. The scoring standard for the Combined Raven's Test—The Rural edition in China (CRT -RC) test classifies scores of < 69 and 70-79 as low and marginal intelligence, respectively (Wang D et al. 1989). We also used the random -effects models to estimate risk ratios for the association between fluoride exposure and a low/marginal versus normal Raven's test score among children in studies that used the CRT -RC test (Wang D et al. 1989). Scores indicating low and marginal intelligence (< 69 and 70-79, respectively) were combined as a single outcome due to small numbers of children in each outcome subgroup. Results Go to: Six of the 34 studies identified were excluded because of missing information on the number of subjects or the mean and variance of the outcome [see Figure_ 1 for a study selection flow chart and Supplemental Material, Table S1 (http:1/dx.doi.or i0, 1289/ehn.1104912) for additional information on studies that were excluded from the analysis]. Another study (Trivedi et al. 2007) was excluded because SDs reported for the outcome parameter were questionably small (1.13 for the high -fluoride group, and 1.23 for the low -fluoride group) and the SMD (-10.8; 95% Cl: —11.9, —9.6) was > l0 times lower than the second smallest SMD (-0.95; 95% Cl: —1.16, —0.75) and 150 times lower than the largest SMD (0.07; 95% Cl: —0.083, 0.22) reported for the other studies, which had relatively consistent SMD estimates. Inclusion of this study in the meta-analysis resulted with a much smaller pooled random -effects SMD estimate and a much larger P (-0.63; 95% Cl: —0.83, —0.44, P 94.1%) compared with the estimates that excluded this study (-0.45; 95% Cl: —0.56,-0.34, P 80%) (see Supplemental Material, Figure SI). Characteristics of the 27 studies included are shown in Table I An et al. 1992; Chen et al. 1991; Fan http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 4 of 10 et al. 2007; Guo et al. 1991; Hong et al. 2001; Li FH et al. 2009; Li XH et al. 2010; Li XS 1995; Li Y et al. 1994; Li Y et al. 2003; Lin et al. 1991; Lu et al. 2000; Poureslami et al. 2011; Ren et al. 1989, Serai et al. 2006; Sun et al. 1991; Wang G et al. 1996; Wang SH et al. 2001; Wang SX et al. 2007; Wang ZH et al. 2006; Xiang et al. 2003; Xu et al. 1994; Yang et al. 1994; Yao et al. 1996, 1997; Zhang JW et al. 1998; Zhao et al. 1996). Two of the studies included in the analysis were conducted in Iran (Poureslami et al. 2011; Seraiet al. 2006); the other study cohorts were populations from China. Two cohorts were exposed to fluoride from coal burning Guo et al. 1991; Li XH et al. 2010); otherwise populations were exposed to fluoride through drinking water. The CRT -RC was used to measure the children's intelligence in 16 studies. Other intelligence measures included the Wechsler Intelligence tests (3 studies; An et al. 1992; Ren et al. 1989; Wang ZH et al. 1996), Binet IQ test (2 studies; Guo et al. 1991; Xu et al. 1994), Raven's test (2 studies; Poureslami et al. 2011; Seraj et al. 2006), Japan IQ test (2 studies; Sun et al. 1991; Zhang JW et al. 1998), Chinese comparative intelligence test (1 study; Yana et al. 1994), and the mental work capacity index (I study; Li Y et al. 1994). Because each of the intelligence tests used is designed to measure general intelligence, we used data from all eligible studies to estimate the possible effects of fluoride exposure on general intelligence. Figure l Flow diagram of the meta-analysis. �.b q..pyYr� W V.O+enw �.M v v Table 1 Characteristics of epidemiological studies of fluoride exposure and children's cognitive outcomes. In addition, we conducted a sensitivity analysis restricted to studies that used similar tests to measure the outcome (specifically, the CRT -RC, Wechsler Intelligence test, Binet IQ test, or Raven's test), and an analysis restricted to studies that used the CRT -RC. We also performed an analysis that excluded studies with co -exposures including iodine and arsenic, or with non -drinking -water fluoride exposure from coal burning. Pooled SMD estimates. Among the 27 studies, all but one study showed random -effect SMD estimates that indicated an inverse association, ranging from —0.95 (95% Cl: —1.16, —0.75) to —0.10 (95% Cl: —0.25, 0.04) Fi ure 2). The study with a positive association reported an SMD estimate of 0.07 (95% Cl: —0.8, 0.22). Similar results were found with the fixed -effects SMD estimates. The fixed -effects pooled SMD estimate was —0.40 (95% Cl: —0.44, —0.35), with ap-value < 0.001 for the test for homogeneity. The random -effects SMD estimate was —0.45 (95% Cl: —0.56,-0.34) with an 12 of 80% and homogeneity test p -value < 0.001Fi ure 2). Because of heterogeneity (excess variability) between study results, we used primarily the random -effects model for subsequent sensitivity analyses, which is generally considered to be the more conservative method (Egger et al. 2001). Among the restricted sets of intelligence tests, the SMD for the model with only CRT -RC tests and drinking -water exposure (and to a lesser extent the model with only CRT -RC tests) was lower than that for all studies combined, although the difference did not appear to be significant. Heterogeneity, however, remained at a similar magnitude when the analyses were restricted Table 2). I1 . Figure 2 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 u Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Random -effect standardized weighted mean difference (SMD) estimates and 95% CIs of child's intelligence score associated with high exposure to fluoride. SMs for individual studies are shown as solid diamonds (*), and the pooled SMD is ... Table 2 Sensitivity analyses of pooled random -effects standardized weighted mean difference (SMD) estimates of child's intelligence score with high exposure of fluoride. Page 5 of 10 Sources of heterogeneity. We performed meta -regression models to assess study characteristics as potential predictors of effect. Information on the child's sex and parental education were not reported in > 80% of the studies, and only 7% of the studies reported household income. These variables were therefore not included in the models. Among the two covariates, year of publication (0.02; 95% Cl: 0.006, 0.03), but not mean age of the study children (-0.02; 95% CI: —0.094, 0.04), was a significant predictor in the model with all 27 studies included. 12 residual 68.7% represented the proportion of residual between -study variation due to heterogeneity. From the adjusted R2, 39.8% of between -study variance was explained by the two covariates. The overall test of the covariates was significant (p = 0.004). When the model was restricted to the 16 studies that used the CRT -RC, the child's age (but not year of publication) was a significant predictor of the SMD. The R2 of 65.6% of between -study variance was explained by the two covariates, and only 47.3% of the residual variation was attributable to heterogeneity. The overall test of both covariates in the model remained significant (p = 0.0053). On further restriction of the model to exclude the 7 studies with arsenic and iodine as co -exposures and fluoride originating from coal burning (thus including only the 9 with fluoride exposure from drinking water), neither age nor year of publication was a significant predictor, and the overall test of covariates was less important (p = 0.062), in accordance with the similarity of intelligence test outcomes and the source of exposure in the studies included. Although official reports of lead concentrations in the study villages in China were not available, some studies reported high percentage (95 —100%) of low lead exposure (less than the standard of 0.01 mg/L) in drinking -water samples in villages from several study provinces (Bi et al. 2010; Peng et al. 2008; Sun 2010). Publication bias. A Begg's funnel plot with the SE of SMD from each study plotted against its corresponding SMD did not show clear evidence of asymmetry, although two studies with a large SE also reported relatively large effect estimates, which may be consistent with publication bias or heterogeneityFi ure 3 . The plot appears symmetrical for studies with larger SE, but with substantial variation in SMD among the more precise studies, consistent with the heterogeneity observed among the studies included in the analysis. Begg (p = 0.22) and Egger (p = 0.11) tests did not indicate significant (p < 0.05) departures from symmetry. Figure 3 Begg's funnel plot showing individual studies included in the analysis according to random -effect standardized weighted mean difference (SMD) estimates (x-axis) and the SE (se) of each study -specific SMD (y-axis). The solid vertical line indicates ... Pooled risk ratios. The relative risk (RR) of a low/marginal score on the CRT -RC test (< 80) among children with high fluoride exposure compared with those with low exposure (16 studies total) was 1.93 (95% CI: 1.46, 2.55;12 58.5%). When the model was restricted to 9 studies that used the CRT -RC and included only drinking -water fluoride exposure (Chen et al. 1991; Fan et al. 2007; Li XH et al. 2010; Li XS et al. 1995; Li Y et al. 2003; Lu et al. 2000; Wang ZH et al. 2006; Yao et al. 1996, 1997), the estimate was similar (RR = 1.75; 95% Cl: 1. 16, 2.65; 12 70.6%). Although fluoride exposure showed inverse associations with test scores, the available exposure http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 6 of 10 information did not allow a formal dose–response analysis. However, dose-related differences in test scores occurred at a wide range of water -fluoride concentrations. Discussion Go to: 1./ Findings from our meta-analyses of 27 studies published over 22 years suggest an inverse association between high fluoride exposure and children's intelligence. Children who lived in areas with high fluoride exposure had lower IQ scores than those who lived in low -exposure or control areas. Our findings are consistent with an earlier review (Tang et al. 2008), although ours more systematically addressed study selection and exclusion information, and was more comprehensive in a) including 9 additional studies, b) performing meta -regression to estimate the contribution of study characteristics as sources of heterogeneity, and c) estimating pooled risk ratios for the association between fluoride exposure and a low/marginal Raven's test score. As noted by the NRC committee (NRC 2006), assessments of fluoride safety have relied on incomplete information on potential risks. In regard to developmental neurotoxicity, much information has in fact been published, although mainly as short reports in Chinese that have not been available to most expert committees. We carried out an extensive review that includes epidemiological studies carried out in China. Although most reports were fairly brief and complete information on covariates was not available, the results tended to support the potential for fluoride -mediated developmental neurotoxicity at relatively high levels of exposure in some studies. We did not find conclusive evidence of publication bias, although there was substantial heterogeneity among studies. Drinking water may contain other neurotoxicants, such as arsenic, but exclusion of studies including arsenic and iodine as co -exposures in a sensitivity analysis resulted in a lower estimate, although the difference was not significant. The exposed groups had access to drinking water with fluoride concentrations up to 11.5 mg/L (Wang SX et al. 2007); thus, in many cases concentrations were above the levels recommended (0.7 –1.2 mg/L; DHHS) or allowed in public drinking water (4.0 mg/L; U.S. EPA) in the United States (LJ S. EPA 2011). A recent cross-sectional study based on individual -level measure of exposures suggested that low levels of water fluoride (range, 0.24-2.84 mg/L) had significant negative associations with children's intelligenceDin et al. 2011). This study was not included in our meta-analysis, which focused only on studies with exposed and reference groups, thereby precluding estimation of dose-related effects. The results suggest that fluoride may be a developmental neurotoxicant that affects brain development at exposures much below those that can cause toxicity in adults (Grandjean 1982). For neurotoxicants such as lead and methylmercury, adverse effects are associated with blood concentrations as low as 10 nmol/L. Serum fluoride concentrations associated with high intakes from drinking water may exceed 1 mg/L, or 50 pmoVL—more than 1,000 times the levels of some other neurotoxicants that cause neurodevelopmental damage. Supporting the plausibility of our findings, rats exposed to 1 ppm (50 pmoVL) of water fluoride for 1 year showed morphological alterations in the brain and increased levels of aluminum in brain tissue compared with controls (Varner et al. 1998). The estimated decrease in average IQ associated with fluoride exposure based on our analysis may seem small and may be within the measurement error of IQ testing. However, as research on other neurotoxicants has shown, a shift to the left of IQ distributions in a population will have substantial impacts, especially among those in the high and low ranges of the IQ distribution (Bellinger 2007). Our review cannot be used to derive an exposure limit, because the actual exposures of the individual children are not known. Misclassification of children in both high- and low -exposure groups may have occurred if the children were drinking water from other sources (e.g., at school or in the field). The published reports clearly represent independent studies and are not the result of duplicate publication of the same studies (we removed two duplicates). Several studies (Hong et al. 2001; Lin et al. 1991; Wang SH et al. 2001; Wang SX et al. 2007; Xiang et al. 2003; Zhao et al. 1996) report other exposures, such as iodine and arsenic, a neurotoxicant, but our sensitivity analyses showed similar associations between high fluoride exposure http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 7 of 10 and the outcomes even after these studies were excluded. Large tracts of China have superficial fluoride -rich minerals with little, if any, likelihood of contamination by other neurotoxicants that would be associated with fluoride concentrations in drinking water. From the geographic distribution of the studies, it seems unlikely that fluoride -attributed neurotoxicity could be attributable to other water contaminants. Still, each of the articles reviewed had deficiencies, in some cases rather serious ones, that limit the conclusions that can be drawn. However, most deficiencies relate to the reporting of where key information was missing. The fact that some aspects of the study were not reported limits the extent to which the available reports allow a firm conclusion. Some methodological limitations were also noted. Most studies were cross-sectional, but this study design would seem appropriate in a stable population where water supplies and fluoride concentrations have remained unchanged for many years. The current water fluoride level likely also reflects past developmental exposures. In regard to the outcomes, the inverse association persisted between studies using different intelligence tests, although most studies did not report age adjustment of the cognitive test scores. Fluoride has received much attention in China, where widespread dental fluorosis indicates the prevalence of high exposures. In 2008, the Ministry of Health reported that fluorosis was found in 28 provinces with 92 million residents (China News 2008). Although microbiologically safe, water supplies from small springs or mountain sources created pockets of increased exposures near or within areas of low exposures, thus representing exposure settings close to the ideal, because only the fluoride exposure would differ between nearby neighborhoods. Chinese researchers took advantage of this fact and published their findings, though mainly in Chinese journals and according to the standards of science at the time. This research dates back to the 1980s, but has not been widely cited at least in part because of limited access to Chinese journals. In its review of fluoride, the NRC (2006) noted that the safety and the risks of fluoride at concentrations of 2-4 mg/L were incompletely documented. Our comprehensive review substantially extends the scope of research available for evaluation and analysis. Although the studies were generally of insufficient quality, the consistency of their findings adds support to existing evidence of fluoride -associated cognitive deficits, and suggests that potential developmental neurotoxicity of fluoride should be a high research priority. Although reports from the World Health Organization and national agencies have generally focused on beneficial effects of fluoride Centers for Disease Control and Prevention 1999; Petersen and Lennon 2004), the NRC report examined the potential adverse effects of fluoride at 2-4 mg/L in drinking water and not the benefits or potential risks that may occur when fluoride is added to public water supplies at lower concentrations (0.7-1.2 mg/L) (NRC 2006). In conclusion, our results support the possibility of adverse effects of fluoride exposures on children's neurodevelopment. Future research should formally evaluate dose—response relations based on individual -level measures of exposure overtime, including more precise prenatal exposure assessment and more extensive standardized measures of neurobehavioral performance, in addition to improving assessment and control of potential confounders. Supplemental Material Go to: (94 KE) PDF Click here for additional data file! 106K, vao Acknowledgments Go to: We thank V. Malik, Harvard School of Public Health, for the helpful advice on the meta-analysis methods. S�.w Footnotes Go to: This study was supported by internal institutional funds. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 8 of 10 The authors declare they have no actual or potential competing financial interests. References Go to: Agency for Toxic Substances and Disease Registry. Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (Update). 2003 Available: hqp://www.atsdr.cdc.sov/toxprofiles/tyI l.pdf [accessed 5 April 20101 An JA, Mei SZ, Liu AP, Fu Y, Wang CF. Effect of high level of fluoride on children's intelligence. Chin J Control Endem Dis. 1992;7(2):93-94. [in Chinese] Begg CB, Mazumdar M. 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PubMed Zhao LB, Liang GH, Zhang DN, Wu XR. Effect of a high fluoride water supply on children's intelligence. Fluoride. 1996;29(4):190-192. Articles from Environmental Health Perspectives are provided here courtesy of National Institute of Environmental Health Science http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 1 of 10 Environ Health Perspect. 2012 Oct, 120(10): 1362-1368. Published online 2012 Jul 20. doi: 10.12891ehp.1104912 Review PMCID PMC3491930 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Anna L. Choi 0t Guifan Sung Ying Zhang,1 and Philippe Grandieanl,4 'Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA 2School of Public Health, China Medical University, Shenyang, China 3School of Stomatology, China Medical University. Shenyang, China 41nstitute of Public Health, University of Southern Denmark, Odense, Denmark Corresponding author. Address correspondence to A.L. Choi, Department of Environmental Health, Harvard School of Public Health, Landmark Center 3E, 401 Park Dr., Boston, MA 02215 USA. Telephone: (617) 3848646. Fax, (617) 384-8994_ E-mailL achoi h5 h.harvard.edu Received 2011 Dec 30; Accepted 2012 Jul 20. Copyright notice Publication of EHP lies in the public domain and is therefore without copyright. Alt text from EHP may be reprinted freely_ Use of materials published in EHP should be acknowledged (for example, ?Reproduced with permission from Environmental Health Perspectives?); pertinent reference information should be provided for the article from which the material was reproduced. Articles from EHP, especially the News section, may contain photographs or illustrations copyrighted by other commercial organizations or individuals that may not be used without obtaining prior approval from the holder of the copyright. This article has been cit_ ed by other articles in PMC, Abstract Go to: Background: Although fluoride may cause neurotoxicity in animal models and acute fluoride poisoning causes neurotoxicity in adults, very little is known of its effects on children's neurodevelopment. Objective: We performed a systematic review and meta-analysis of published studies to investigate the effects of increased fluoride exposure and delayed neurobehavioral development. Methods: We searched the MEDLINE, EMBASE, Water Resources Abstracts, and TOXNET databases through 2011 for eligible studies. We also searched the China National Knowledge Infrastructure (CNKI) database, because many studies on fluoride neurotoxicity have been published in Chinese journals only. In total, we identified 27 eligible epidemiological studies with high and reference exposures, end points of IQ scores, or related cognitive function measures with means and variances for the two exposure groups. Using random -effects models, we estimated the standardized mean difference between exposed and reference groups across all studies. We conducted sensitivity analyses restricted to studies using the same outcome assessment and having drinking - water fluoride as the only exposure. We performed the Cochran test for heterogeneity between studies, Begg's funnel plot, and Egger test to assess publication bias, and conducted meta -regressions to explore sources of variation in mean differences among the studies. Results: The standardized weighted mean difference in IQ score between exposed and reference populations was —0.45 (95% confidence interval: —0.56, —0.35) using a random -effects model. Thus, children in high -fluoride areas had significantly lower IQ scores than those who lived in low -fluoride areas. Subgroup and sensitivity analyses also indicated inverse associations, although the substantial heterogeneity did not appear to decrease. http://www.ncbi.nlm.nih.gov/pmc/articlesfPMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 2 of 10 Conclusions: The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment. Future research should include detailed individual -level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment. Keywords: fluoride, intelligence, neurotoxicity A recent report from the National Research Council (NRC 2006) concluded that adverse effects of high fluoride concentrations in drinking water may be of concern and that additional research is warranted. Fluoride may cause neurotoxicity in laboratory animals, including effects on learning and memory (Chioca et al. 2008; Mullenix et al. 1995. A recent experimental study where the rat hippocampal neurons were incubated with various concentrations (20 mg/L, 40 mg/L, and 80 mg/L) of sodium fluoride in vitro showed that fluoride neurotoxicity may target hippocampal neurons (Zhang M et al. 2008). Although acute fluoride poisoning may be neurotoxic to adults, most of the epidemiological information available on associations with children's neurodevelopment is from China, where fluoride generally occurs in drinking water as a natural contaminant, and the concentration depends on local geological conditions. In many rural communities in China, populations with high exposure to fluoride in local drinking -water sources may reside in close proximity to populations without high exposure (NRC 2006). Opportunities for epidemiological studies depend on the existence of comparable population groups exposed to different levels of fluoride from drinking water. Such circumstances are difficult to find in many industrialized countries, because fluoride concentrations in community water are usually no higher than 1 mg/L, even when fluoride is added to water supplies as a public health measure to reduce tooth decay. Multiple epidemiological studies of developmental fluoride neurotoxicity were conducted in China because of the high fluoride concentrations that are substantially above 1 mg/L in well water in many rural communities, although microbiologically safe water has been accessible to many rural households as a result of the recent 5 -year plan (2001-2005) by the Chinese government. It is projected that all rural residents will have access to safe public drinking water by 2020 (World Bank 2006). However, results of the published studies have not been widely disseminated. Four studies published in English (Li XS et al. 1995; Lu et al. 2000; Xiang et al. 2003; Zhao et al. 1996) were cited in a recent report from the NRC (2006), whereas the World Health Organization (2002) has considered only two (Li XS et al. 1995; Zhao et al. 1996) in its most recent monograph on fluoride. Fluoride readily crosses the placenta (Agency for Toxic Substances and Disease Registry 2003). Fluoride exposure to the developing brain, which is much more susceptible to injury caused by toxicants than is the mature brain, may possibly lead to permanent damage (Grandiean and Landrigan 2006). In response to the recommendation of the NRC (2006), the U.S. Department of Health and Human Services (DHHS) and the U.S. EPA recently announced that DHHS is proposing to change the recommended level of fluoride in drinking water to 0.7 mg/L from the currently recommended range of 0.7-1.2 mg/L, and the U.S. EPA is reviewing the maximum amount of fluoride allowed in drinking water, which currently is set at 4.0 mg/L (U.S. EPA 2011). To summarize the available literature, we performed a systematic review and meta-analysis of published studies on increased fluoride exposure in drinking water associated with neurodevelopmental delays. We specifically targeted studies carried out in rural China that have not been widely disseminated, thus complementing the studies that have been included in previous reviews and risk assessment reports. Methods Go to: Search strategy. We searched MEDLINE (National Library of Medicine, Bethesda, MD, USA; http://www.ncbi.ntm.nih.gov/pubmed), Embase (Elsevier B.V., Amsterdam, the Netherlands; http://www.embase.com), Water Resources Abstracts (Proquest, Ann Arbor, MI, USA; hi!p://www.csa.com/factsheets/water-resources-set-c.l)hp), and TOXNET (Toxicology Data Network; National Library of Medicine, Bethesda, MD, USA; http://toxnet.nim.nih.gov) databases to identify studies of drinking- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 3 of 10 water fluoride and neurodevelopmental outcomes in children. In addition, we searched the China National Knowledge Infrastructure (CNKI; Beijing, China; hn://www.cnki.net) database to identify studies published in Chinese journals only. Key words included combinations of "fluoride" or "drinking water fluoride," "children," "neurodevelopment" or "neurologic" or "intelligence" or "IQ." We also used references cited in the articles identified. We searched records for 1980-2011. Our literature search identified 39 studies, among which 36 (92.3%) were studies with high and reference exposure groups, and 3 (7.7%) studies were based on individual - level measure of exposures. The latter showed that dose-related deficits were found, but the studies were excluded because our meta-analysis focused on studies with the high- and low -exposure groups only. In addition, two studies were published twice, and the duplicates were excluded. Inclusion criteria and data extraction. The criteria for inclusion of studies included studies with high and reference fluoride exposures, end points of IQ scores or other related cognitive function measures, presentation of a mean outcome measure, and associated measure of variance [95% confidence intervals (Cls) or SEs and numbers of participants]. Interpretations of statistical significance are based on an alpha level of 0.05. Information included for each study also included the first author, location of the study, year of publication, and numbers of participants in high -fluoride and low -fluoride areas. We noted and recorded the information on age and sex of children, and parental education and income if available. Statistical analysis. We used STATA (version 11.0; StataCorp, College Station, TX, USA) and available commands (Stern 2009) for the meta-analyses. A standardized weighted mean difference (SMD) was computed using both fixed -effects and random -effects models. The fixed -effects model uses the Mantel—Haenszel method assuming homogeneity among the studies, whereas the random -effects model uses the DerSimonian and Laird method, incorporating both a within -study and an additive between -studies component of variance when there is between -study heterogeneity (Egger et at. 2001). The estimate of the between -study variation is incorporated into both the SE of the estimate of the common effect and the weight of individual studies, which was calculated as the inverse sum of the within and between study variance. We evaluated heterogeneity among studies using the F statistic, which represents the percentage of total variation across all studies due to between -study heterogeneity (Higgins and Thompson 2002). We evaluated the potential for publication bias using Begg and Egger tests and visual inspection of a Begg funnel plot (Begg and Mazumdar 1994; Egger et al. 1997). We also conducted independent meta -regressions to estimate the contribution of study characteristics (mean age in years from the age range and year of publication in each study) to heterogeneity among the studies. The scoring standard for the Combined Raven's Test—The Rural edition in China (CRT -RC) test classifies scores of S 69 and 70-79 as low and marginal intelligence, respectively (Wang D et al. 1989). We also used the random -effects models to estimate risk ratios for the association between fluoride exposure and a low/marginal versus normal Raven's test score among children in studies that used the CRT -RC test (Wang D et al. 1989). Scores indicating low and marginal intelligence (< 69 and 70-79, respectively) were combined as a single outcome due to small numbers of children in each outcome subgroup. Results Go to: Six of the 34 studies identified were excluded because of missing information on the number of subjects or the mean and variance of the outcome [see Figure 1 for a study selection flow chart and Supplemental Material, Table Sl(http_//dx.doi.org/10.1289/ehp.1104912) for additional information on studies that were excluded from the analysis]. Another study (Trivedi et al. 2007) was excluded because SDs reported for the outcome parameter were questionably small (1.13 for the high -fluoride group, and 1.23 for the low -fluoride group) and the SMD (-10.8; 95% Cl: —11.9, —9.6) was > 10 times lower than the second smallest SMD (-0.95; 95% Cl: —1.16, —0.75) and 150 times lower than the largest SMD (0.07; 95% Cl: —0.083, 0.22) reported for the other studies, which had relatively consistent SMD estimates. Inclusion of this study in the meta-analysis resulted with a much smaller pooled random -effects SMD estimate and a much larger 12 (-0.63; 95% CI: —0.83, —0.44,12 94.1%) compared with the estimates that excluded this study (-0.45; 95% CI: —0.56, —0.34,1'- 80%) (see Supplemental Material, Fi ure S 1 . Characteristics of the 27 studies included are shown in Table I (An et al. 1992; Chen et al. 1991; Fan http:l/www.nebi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 4 of 10 et al. 2007; Guo et al. 1991; Hong et al. 2001; Li FH et al. 2009; Li XH et al. 2010; Li XS 1995; Li Y et al. 1994; Li Y et al. 2003; Lin et al. 1991; Lu et al. 2000; Poureslami et al. 2011; Ren et al. 1989; Seraj et al. 2006; Sun et al. 1991; Wang G et al. 1996; Wang SH et al. 2001; Wang SX et al. 2007; Wang ZH et al. 2006; Xiang et al. 2003; Xu et al. 1994; Yang et al. 1994; Yao et al. 1996,1997; Zhang JW et al. 1998; Zhao et al. 1996). Two of the studies included in the analysis were conducted in Iran (Poureslami et al. 2011: Seraj et al. 2006); the other study cohorts were populations from China. Two cohorts were exposed to fluoride from coal burning Guo et al. 1991; Li XH et al. 2010); otherwise populations were exposed to fluoride through drinking water. The CRT -RC was used to measure the children's intelligence in 16 studies. Other intelligence measures included the Wechsler Intelligence tests (3 studies; An et al. 1992; Ren et al. 1989; Wang ZH et al. 1996), Binet IQ test (2 studies; Guo et al. 1991; Xu et al. 1994), Raven's test (2 studies; Poureslami et al. 2011; Seraj et al. 2006), Japan IQ test (2 studies; Sun et al. 1991; Zhang JW et al. 1998), Chinese comparative intelligence test (1 study; Yang et al. 1994), and the mental work capacity index (1 study; Li Y et al. 1994). Because each of the intelligence tests used is designed to measure general intelligence, we used data from all eligible studies to estimate the possible effects of fluoride exposure on general intelligence. Figure I Flow diagram of the meta-analysis. o;. L Table 1 - - _ Characteristics of epidemiological studies of fluoride exposure and - children's cognitive outcomes. In addition, we conducted a sensitivity analysis restricted to studies that used similar tests to measure the outcome (specifically, the CRT -RC, Wechsler Intelligence test, Binet IQ test, or Raven's test), and an analysis restricted to studies that used the CRT -RC. We also performed an analysis that excluded studies with co -exposures including iodine and arsenic, or with non -drinking -water fluoride exposure from coal burning. Pooled SMD estimates. Among the 27 studies, all but one study showed random -effect SMD estimates that indicated an inverse association, ranging from —0.95 (95% Cl: —1.16, —0.75) to —0.10 (95% Cl: —0.25, 0.04) Fi ure 2). The study with a positive association reported an SMD estimate of 0.07 (95% Cl: —0.8, 0.22). Similar results were found with the fixed -effects SMD estimates. The fixed -effects pooled SMD estimate was —0.40 (95% Cl: —0.44,-0.35), with ap-value < 0.001 for the test for homogeneity. The random -effects SMD estimate was —0.45 (95% Cl: —0.56, —0.34) with an Iz of 80% and homogeneity test p -value < 0.001Fi ure 2 . Because of heterogeneity (excess variability) between study results, we used primarily the random -effects model for subsequent sensitivity analyses, which is generally considered to be the more conservative method (Egger et al. 2001). Among the restricted sets of intelligence tests, the SMD for the model with only CRT -RC tests and drinking -water exposure (and to a lesser extent the model with only CRT -RC tests) was lower than that for all studies combined, although the difference did not appear to be significant. Heterogeneity, however, remained at a similar magnitude when the analyses were restrictedTable 2). Figure 2 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 5 of 10 Random -effect standardized weighted mean difference (SMD) estimates and 95% CIs of child's intelligence score associated with high exposure to fluoride. SMs for individual studies are shown as solid diamonds (1), and \./ the pooled SMD is ... .._..._. Table 2 Sensitivity analyses of pooled random -effects standardized weighted mean difference (SMD) estimates of child's intelligence score with high exposure of fluoride. Sources of heterogeneity. We performed meta -regression models to assess study characteristics as potential predictors of effect. Information on the child's sex and parental education were not reported in > 80% of the studies, and only 7% of the studies reported household income. These variables were therefore not included in the models. Among the two covariates, year of publication (0.02; 95% Cl: 0.006, 0.03), but not mean age of the study children (-0.02; 95% Cl: —0.094, 0.04), was a significant predictor in the model with all 27 studies included. 12 residual 68.7% represented the proportion of residual between -study variation due to heterogeneity. From the adjusted R2, 39.8% of between -study variance was explained by the two covariates. The overall test of the covariates was significant (p = 0.004). When the model was restricted to the 16 studies that used the CRT -RC, the child's age (but not year of publication) was a significant predictor of the SMD. The R'- of 65.6% of between -study variance was explained by the two covariates, and only 47.3% of the residual variation was attributable to heterogeneity. The overall test of both covariates in the model remained significant (p = 0.0053). On further restriction of the model to exclude the 7 studies with arsenic and iodine as co -exposures and fluoride originating from coal burning (thus including only the 9 with fluoride exposure from drinking water), neither age nor year of publication was a significant predictor, and the overall test of covariates was less important (p = 0.062), in accordance with the similarity of u intelligence test outcomes and the source of exposure in the studies included. Although official reports of lead concentrations in the study villages in China were not available, some studies reported high percentage (95 —100%) of low lead exposure (less than the standard of 0.01 mg/L) in drinking -water samples in villages from several study provinces (Bi et al. 2010; Peng et al. 2008; Sun 2010). Publication bias. A Begg's funnel plot with the SE of SMD from each study plotted against its corresponding SMD did not show clear evidence of asymmetry, although two studies with a large SE also reported relatively large effect estimates, which may be consistent with publication bias or heterogeneity (Figure 3 . The plot appears symmetrical for studies with larger SE, but with substantial variation in SMD among the more precise studies, consistent with the heterogeneity observed among the studies included in the analysis. Begg (p = 0.22) and Egger (p = 0.11) tests did not indicate significant (p < 0.05) departures from symmetry. Figure 3 Begg's funnel plot showing individual studies included in the analysis according to random -effect standardized weighted mean difference (SMD) estimates (x-axis) and the SE (se) of each study -specific SMD (y-axis). The solid vertical line indicates ... Pooled risk ratios. The relative risk (RR) of a low/marginal score on the CRT -RC test (< 80) among children with high fluoride exposure compared with those with low exposure (16 studies total) was 1.93 (95% Cl: 1.46, 2.55;12 58.5%). When the model was restricted to 9 studies that used the CRT -RC and included only drinking -water fluoride exposure (Chen et al. 1991; Fan et al. 2007; Li XH et al. 2010; Li XS et al. 1995; Li Y et al. 2003; Lu et al. 2000; Wang ZH et al. 2006; Yao et al. 1996, 1997), the estimate was similar (RR = 1.75; 95% Cl: 1. 16, 2.65; 12 70.6%). Although fluoride exposure showed inverse associations with test scores, the available exposure http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 6 of 10 information did not allow a formal dose—response analysis. However, dose-related differences in test scores occurred at a wide range of water -fluoride concentrations. Discussion Go to: u' Findings from our meta-analyses of 27 studies published over 22 years suggest an inverse association between high fluoride exposure and children's intelligence. Children who lived in areas with high fluoride exposure had lower IQ scores than those who lived in low -exposure or control areas. Our findings are consistent with an earlier review (Tang et al. 2008), although ours more systematically addressed study selection and exclusion information, and was more comprehensive in a) including 9 additional studies, b) performing meta -regression to estimate the contribution of study characteristics as sources of heterogeneity, and c) estimating pooled risk ratios for the association between fluoride exposure and a low/marginal Raven's test score. As noted by the NRC committee (NRC 2006), assessments of fluoride safety have relied on incomplete information on potential risks. In regard to developmental neurotoxicity, much information has in fact been published, although mainly as short reports in Chinese that have not been available to most expert committees. We carried out an extensive review that includes epidemiological studies carried out in China. Although most reports were fairly brief and complete information on covariates was not available, the results tended to support the potential for fluoride -mediated developmental neurotoxicity at relatively high levels of exposure in some studies. We did not find conclusive evidence of publication bias, although there was substantial heterogeneity among studies. Drinking water may contain other neurotoxicants, such as arsenic, but exclusion of studies including arsenic and iodine as co -exposures in a sensitivity analysis resulted in a lower estimate, although the difference was not significant. The exposed groups had access to drinking water with fluoride concentrations up to 11.5 mg/L (Wang SX et al. 2007); thus, in many cases concentrations were above the levels recommended (0.7 —1.2 mg/L; DHHS) or allowed in public drinking water (4.0 mg/L; U.S. EPA) in the United StatesU( S. EPA 2011). A recent cross-sectional study based on individual -level measure of exposures suggested that low levels of water fluoride (range, 0.24-2.84 mg/L) had significant negative associations with children's intelligence Pi Lng et al. 2011). This study was not included in our meta-analysis, which focused only on studies with exposed and reference groups, thereby precluding estimation of dose-related effects. The results suggest that fluoride may be a developmental neurotoxicant that affects brain development at exposures much below those that can cause toxicity in adults (Grandjean 1982). For neurotoxicants such as lead and methylmercury, adverse effects are associated with blood concentrations as low as 10 nmol/L. Serum fluoride concentrations associated with high intakes from drinking water may exceed 1 mg/L, or 50 pmol/Lmore than 1,000 times the levels of some other neurotoxicants that cause neurodevelopmental damage. Supporting the plausibility of our findings, rats exposed to 1 ppm (50 gmol/L) of water fluoride for 1 year showed morphological alterations in the brain and increased levels of aluminum in brain tissue compared with controls (Varner et al. 1998). The estimated decrease in average IQ associated with fluoride exposure based on our analysis may seem small and may be within the measurement error of IQ testing. However, as research on other neurotoxicants has shown, a shift to the left of IQ distributions in a population will have substantial impacts, especially among those in the high and low ranges of the IQ distribution (Bellinger 2007). Our review cannot be used to derive an exposure limit, because the actual exposures of the individual children are not known. Misclassification of children in both high- and low -exposure groups may have occurred if the children were drinking water from other sources (e.g., at school or in the field). The published reports clearly represent independent studies and are not the result of duplicate publication of the same studies (we removed two duplicates). Several studies (Hong et al. 2001; Lin et al. 1991; Wang SH et al. 2001; Wang SX et al. 2007; Xiang et al. 2003; Zhao et al. 1996) report other exposures, such as iodine and �../ arsenic, a neurotoxicant, but our sensitivity analyses showed similar associations between high fluoride exposure http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta -Analysis Page 7 of 10 and the outcomes even after these studies were excluded. Large tracts of China have superficial fluoride -rich minerals with little, if any, likelihood of contamination by other neurotoxicants that would be associated with fluoride concentrations in drinking water. From the geographic distribution of the studies, it seems unlikely that �—/ fluoride -attributed neurotoxicity could be attributable to other water contaminants. Still, each of the articles reviewed had deficiencies, in some cases rather serious ones, that limit the conclusions that can be drawn. However, most deficiencies relate to the reporting of where key information was missing. The fact that some aspects of the study were not reported limits the extent to which the available reports allow a firm conclusion. Some methodological limitations were also noted. Most studies were cross-sectional, but this study design would seem appropriate in a stable population where water supplies and fluoride concentrations have remained unchanged for many years. The current water fluoride level likely also reflects past developmental exposures. In regard to the outcomes, the inverse association persisted between studies using different intelligence tests, although most studies did not report age adjustment of the cognitive test scores. Fluoride has received much attention in China, where widespread dental fluorosis indicates the prevalence of high exposures. In 2008, the Ministry of Health reported that fluorosis was found in 28 provinces with 92 million residents (China News 2008). Although microbiologically safe, water supplies from small springs or mountain sources created pockets of increased exposures near or within areas of low exposures, thus representing exposure settings close to the ideal, because only the fluoride exposure would differ between nearby neighborhoods. Chinese researchers took advantage of this fact and published their findings, though mainly in Chinese journals and according to the standards of science at the time. This research dates back to the 1980s, but has not been widely cited at least in part because of limited access to Chinese journals. In its review of fluoride, the NRC (2006) noted that the safety and the risks of fluoride at concentrations of 2-4 mglL were incompletely documented. Our comprehensive review substantially extends the scope of research available for evaluation and analysis. Although the studies were generally of insufficient quality, the consistency of their findings adds support to existing evidence of fluoride -associated cognitive deficits, and suggests that potential developmental neurotoxicity of fluoride should be a high research priority. Although reports from the World Health Organization and national agencies have generally focused on beneficial effects of fluoride (Centers for Disease Control and Prevention 1999; Petersen and Lennon 2004), the NRC report examined the potential adverse effects of fluoride at 2-4 mg/L in drinking water and not the benefits or potential risks that may occur when fluoride is added to public water supplies at lower concentrations (0.7-1.2 mg/L) (NRC 2006). In conclusion, our results support the possibility of adverse effects of fluoride exposures on children's neurodevelopment. Future research should formally evaluate dose—response relations based on individual -level measures of exposure over time, including more precise prenatal exposure assessment and more extensive standardized measures of neurobehavioral performance, in addition to improving assessment and control of potential confounders. 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Comparison of children's health and intelligence between the fluorosis areas with and without altering water sources. Lit Inf Prev Med. 1997;3(1):42-43. [in Chinese] Yao LM, Zhou JL, Wang SL, Cui KS, Lin FY. Analysis of TSH levels and intelligence of children residing in high fluorosis areas. Lit Inf Prev Med. 1996;2(1):26-27. [in Chinese] Zhang J, Gung Y, Guo J. Beijing: Captial Institute of Pediatrics Heatlh Research Office; 1985. Children Intelligence Scale Handbook. Zhang JW, Yao H, Chen Y. Effect of high level of fluoride and arsenic on children's intelligence. Chin J Public Health. 1998;17(2):57. [in Chinese] Zhang M, Wang A, Xia T, He P. Effects of fluoride on DNA damage, S -phase cell -cycle arrest and the expression of NF -KB in primary cultured rat hippocampal neurons. Toxicol Lett. 2008;179:1-5. PubMed] Zhao LB, Liang GH, Zhang DN, Wu XR. Effect of a high fluoride water supply on children's intelligence. Fluoride. 1996;29(4):190-192. Articles from Environmental Health Perspectives are provided here courtesy of National Institute of Environmental Health Science h4://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/ 1/11/2016 END WATER FLUORIDATION Index: 1. Dr. Mercola Article related to recent Fluoride studies 2. Camden Smith's original presentation to the BOCC in January 2016 3. Backup materials and studies used as part of Ms. Smith's January 2016 presentation a. FDA memos 1963, 1967 1990, 2000 related to Fluoride usage b. Fluoride in Drinking Water: A Scientific Review of the EPA Standards (summary of the 562 page study with link for you to fully view) c. FDA Fluoride drug fact sheet d. Fluoride Action Network IQ Study Summary 5/3/2016 Mercolaxom Take Control of Your Heafth Since 1997 — Call Toll Free: 877-985-2695 Water Fluoridation Promotes Thyroid Impairment, Study Warns Water Fluoridation Promotes Thyroid Impairment, Study Warns March 10, 2015 525,111 views Disponible en Espanol By Dr. Mercola Fluoride is a toxic drug linked with an array of potentially serious health problems. Most recently, research linking fluoridated water consumption to thyroid dysfunction received attention in both British and American media.1,2,3,4 Evidence also suggests it may contribute to or exacerbate behavioral problems such as ADHD, by way of pineal gland calcification. Despite irrefutable evidence of harm, the United States still adds fluoride to municipal water supplies reaching nearly 211 million Americans. As of 2012, more than 67 percent of Americans receive fluoridated water.5 Of those, more than 11 million people receive fluoride at or above what has been deemed the "optimal" level, according to the US Centers for Disease Control and Prevention (CDC). In the UK, about 6 million Britons receive water with added fluoride. Meanwhile, a growing number of countries—including Germany, Sweden, Japan, the Netherlands, Finland, and Israel6 have ceased this hazardous practice.Z Water Fluoridation Promotes Thyroid Dysfunction, Study Warns Water fluoridation has long been promoted as a safe and effective way to improve dental health—a claim that in reality has no firm basis in science. On the contrary, the evidence clearly suggests there are wide-ranging health hazards associated with fluoride exposure. Story at -a -glance Recent research links fluoridated water consumption to thyroid dysfunction, weight gain, and depression British researchers are now warning that 15,000 people may be needlessly afflicted with hypothyroidism in the UK as a result of drinking fluoridated water Thyroid function was affected starting at a fluoride level of 0.3 mg/L; the US currently recommends a level of 0.7 mg/L Most Popular 1 Why You Need to Eat More Vegetables 2 The Surprising Health Benefits of Extreme Hot and Cold Temperatures 3 An Inside Look Into the Fish Industry Reveals Disturbing Facts That Could Threaten Your Health 4 Peak Fasting — How Long Should You Intermittently Fast? 5 Fast Food Identified as a Significant Source of Hormone -Disrupting Chemicals You Might Also Like 10 Facts About Fluoride You Need to Know The Fluoride Deception: An Interview with Christopher Bryson Why Water Fluoridation Continues, Despite Flying in the Face of Science http://articies.mercola.com/sites/articles/archive/2015/03/10/water-fluoridation-thyroid-dysfunction.aspx 1/6 5/3/2016 Water Fluoridation Promotes Thyroid Impairment, Study Warns British researchers are now warning that 15,000 people may be needlessly afflicted with hypothyroidism in the UK as a result of drinking fluoridated water.$ In areas where fluoride levels in the water registered above 0.3 mg/I, the risk of having a high rate of hypothyroidism was 37 percent greater compared to areas that do not fluoridate. As explained by Vice.com9 and in the featured video above: "The key to a healthy thyroid is iodine, which is generally absorbed through the blood and stored and regulated by the body in the thyroid gland... But because fluoride is more electronegative than iodine, it displaces it in the body, disrupting thyroid function and subsequently impacting hormone levels that keep metabolism in check. Numerous studies (including one from just last year15) have previously confirmed fluoride's ability to promote and exacerbate iodine deficiency�� 11 Recommended Fluoride Levels in US Is Twice the Level at Which Thyroid Function Can Be Affected The US currently recommends a fluoride level of 0.7 mg/L,12 and thyroid dysfunction is also rampant in the US, where an estimated 20 million people are affected,13 so from a public health standpoint, it makes absolutely no sense whatsoever to medicate the entire population with a drug that can either induce or exacerbate this condition. Additional side effects of thyroid dysfunction include weight gain and depression. An equally or more important side effect is harm to the fetus in hypothyroid pregnant women, which can result in lowered IQ and other neurological deficits. Because of all of these effects, the researchers urge city councils to stop adding fluoride to their drinking water. According to lead author Stephen Peckham:14 "1 think itis concerning for people living in those [high fluoride] areas. The difference between the West Midlands, which fluoridates, and Manchester, which doesn't, was particularly striking. There were nearly double the number of [underactive thyroid] cases in the West Midlands. Underactive thyroid is a particularly nasty thing to have and it can lead to other long term health problems. 1 do think councils need to think again about putting fluoride in the water. There are far safer ways to improve dental health." Dr. Spyros Mezitis, an endocrinologist at Lenox Hill Hospital in New York City who did not participate in the study told WebMD:15 "Clinicians in the United States should emphasize to patients this association and should test patients for underactive thyroid. Patients should probably be advised to drink less fluoridated water and consume less fluoridated products, including [fluoridated] toothpaste." Endocrinologist Dr. Terry Davies, who is also a professor of medicine at the Icahn School of Medicine at Mount Sinai, in New York City also agreed, saying that: "This dramatic increase in thyroid dysfunction associated with fluoridation of the water supply adds to previous studies indicating that fluoride has an inhibitory effect on the thyroid gland. [The study] supports the argument that our water supply should be pure water and nothing else." How Is Water Fluoridation in the Public's Best Interest? Many fail to realize that fluoride is indeed a drug, and as such it is grossly inappropriate for it to be indiscriminately added to water supplies, as there's no way to control who gets it, and in what dose. Surely, protecting people from thyroid dysfunction—which can also raise your risk for cardiovascular disease, http://articies.mercola.com/sites/articles/archive/2015/03/10/water-fluoridation-thyroid-dysfunction.aspx 2/6 5/3/2016 Water Fluoridation Promotes Thyroid Impairment, Study Warns osteoporosis, infertility, neurological harm to fetuses and infants, and other health problems—is of greater concern than protecting people from dental caries, which can be very effectively addressed in other, far safer ways... Besides, the science behind fluoride's purported dental benefits is flimsy at best, and has repeatedly failed to stand up to closer scrutiny. Mounting scientific evidence reveals that: • Swallowing fluoride provides relatively little benefit to your teeth. In fact, when fluoride is taken internally, it actually damages your teeth, causing a condition known as dental fluorosis, which now affects 41 percent of American children between the ages of 12 and 14.16 Outwardly visual signs of this condition include pitting and discoloration of your teeth, caused by long- term ingestion of fluoride during early tooth formation. In some areas, fluorosis rates are as high as 70- 80 percent, with some children suffering from advanced forms. Dental fluorosis can be an indication that the rest of your body, such as your bones and internal organs, including your brain, has been overexposed to fluoride as well. According to the World Health Organization (WHO), there is no discernible difference in tooth decay between developed countries that fluoridate their water and those that do not. Moreover, the decline in tooth decay the US has experienced over the last 60 years, which is often attributed to fluoridated water, has likewise occurred in all developed countries—most of which do notfluoridate their water. • Even topical application of fluoride may be largely ineffective. Research published in the journal Langmuir five years ago discovered that the fluorapatite layer formed on your teeth from fluoride is a mere six nanometers thick (about one ten -thousands' the width of a strand of hair), which led the scientists to question whether this ultra-thin layer can actually protect your enamel and provide any discernible benefit, considering the fact that it is quickly eliminated by simple chewing. Other studies have concluded topical fluoride may be helpful. Cavity Prevention 101 As I've discussed in previous articles, the best way to prevent cavities is not by adding fluoride, but by addressing your diet. Scientific American18 recently addressed this issue as well, noting that excessive sugar consumption is at the heart of the problem. According to Dr. Francesco Branca, Director of WHO's Department of Nutrition for Health and Development: "We have solid evidence that keeping intake of free sugars to less than 10 percent of total energy intake reduces the risk of overweight, obesity and tooth decay." One of the keys to oral health is eating a traditional diet rich in fresh, unprocessed vegetables, nuts, and grass- fed meats. By avoiding sugars and processed foods, you prevent the proliferation of the bacteria that cause decay in the first place. Other natural strategies that can significantly improve your dental health is eating plenty of fermented vegetables doing oil pulling with coconut oil. Also make sure you're getting plenty of omega-3 fats. The latest research suggests even moderate amounts of omega-3 fats may help ward off gum disease. My favorite source of high quality omega-3 fat is krill oil. Fluoride Detrimentally Affects Many Tissues in Your Body http://articies.mercola.com/sites/articles/archive/2015/03/10/water-fluoridation-thyroid-dysfunction.aspx 3/6 5/3/2016 Water Fluoridation Promotes Thyroid Impairment, Study Warns 10 Facts About Fluoride Many assume that the fluoride in drinking water (or in any other fluoride supplement) will somehow only affect your teeth. Unfortunately, this is simply not the case. According to one 500 -page scientific review, -1-9- fluoride is an endocrine disruptor that can affect not only your thyroid gland, but also your bones, brain, pineal gland, and even your blood sugar levels. There are more than 100 published studies illustrating fluoride's harm to the brain alone, plus 43 more that directly link fluoride exposure to reduced IQ in children! Studies have also demonstrated that fluoride toxicity, caused by overexposure, can lead to: Increased lead Disrupted synthesis Hyperactivity and/orMuscle disorders absorption of collagen lethargy Bone cancer Increased tumor and Arthritis Skeletal fluorosis and (osteosarcoma) cancer rate J I bone fractures Genetic damage and Damaged sperm and Inactivation of 62 Inhibited formation of cell death increased infertility enzymes and antibodies, and inhibition of more immune system than 100 disruptions The Link Between Fluoride, Pineal Gland Calcification, and ADHD A recent article20 by Frank Granett, R.ph, director of Clinical Pharmacy Operations at Behavioral Center of Michigan Psychiatric Hospital, and author of The American Epidemic and Over Medicating Our Youth, also addresses the issue of fluoride and pineal calcification, which can result in symptoms such as ADHD. He writes, in part: "Located deep within the brain below the corpus callosum, which is the circuit connector for the right and left brain hemispheres, the pineal gland is responsible for the secretion of melatonin, the human body's biological time -clock hormone regulating normal sleep patterns. More importantly, the pineal gland plays a critical role in the enzyme pathway for the production of brain neurotransmitters including serotonin and norepinephrine. Additionally, the body's anti -oxidant defense system is optimized by healthy pineal tissue, which helps eliminate free -radical toxin accumulation in the body." Despite its diminutive size, your pineal gland tends to accumulate significant amounts of fluoride, which http://articies.mercola.com/sites/articles/archive/2015/03/10/water-fluoridation-thyroid-dysfunction.aspx 4/6 5/3/2016 Water Fluoridation Promotes Thyroid Impairment, Study Warns eventually causes it to calcify. Besides ADHD -like symptoms, pineal calcification may also play a role in Alzheimer's and bipolar disease. Considering its effect on neurotransmitters, it's also quite conceivable that it might promote depression and other neurological disorders. Granett also notes that studies have linked pineal calcification to precocious puberty in girls, attributed to abnormal melatonin secretion. "Government agencies complicitin this public-health issue should re-evaluate the dangers fluoride poses in childhood behavioral development," he writes. "Children and adults battling behavioral conditions should adopt an action plan to prevent the onset of pineal -gland calcification." To help decalcify your pineal gland, Granett suggests: • Eliminating sugar, processed foods, and genetically engineered foods • Drinking purified water. To help break up the calcification, take one teaspoon of cold organic apple cider vinegar in water once per day • Consuming raw beets four times per week, as beets contains high amounts of boron that also help break up calcification • Taking an antioxidant supplement • Using non -fluoridated toothpaste To Protect Your Health, Avoid Fluoride No matter which scientific studies you examine or which population trends you view, the rational conclusion is that fluoride's health dangers far outweigh the marginal dental benefits it might offer. Dental caries can be effectively prevented with means otherthan fluoridation, thereby avoiding the adverse effects of fluoride. It's important to realize that fluoride is a cumulative toxin, which over time can lead to serious health concerns, from hypothyroidism to skeletal fluorosis and much more. The neurological effects are particularly disconcerting. As mentioned, 43 human studies21 now link moderately high fluoride exposures with reduced IQ. We cannot afford to ignore such warnings! Water fluoridation needs to stop. The question is how. Despite all the evidence, getting fluoride out of American water supplies has been exceedingly difficult. It's not impossible, however, as evidenced in areas that have successfully abolished water fluoridation. According to the late Jeff Green, National Director of Citizens for Safe Drinking Water, a repeated theme in the cases where communities successfully removed fluoride from their water supply is the shifting of the burden of proof. Rather than citizens taking on the burden of proving that fluoride is harmful and shouldn't be added, a more successful strategy has been to hold those making claims, and the elected officials who rely on them, accountable for delivering proof that the specific fluoridation chemical being used fulfills their health and safety claims, and is in compliance with all regulations, laws, and risk assessments already required for safe drinking water. To learn more, please see this previous article, which discusses these strategies more in-depth. Help End the Practice of Fluoridation There's no doubt about it: fluoride should not be ingested. Even scientists from the EPA's National Health and Environmental Effects Research Laboratory have classified fluoride as a "chemical having substantial evidence of developmental neurotoxicity." Furthermore, according to the Centers for Disease Control and Prevention (CDC), 41 percent of American adolescents now have dental fluorosis — unattractive discoloration and mottling of the teeth that indicate overexposure to fluoride. Clearly, children are being overexposed, and their health and development put in jeopardy. Why? The only real solution is to stop the archaic practice of water fluoridation in the first place. http://articies.mercola.com/sites/articles/archive/2015/03/10/water-fluoridation-thyroid-dysfunction.aspx 5/6 5/3/2016 Water Fluoridation Promotes Thyroid Impairment, Study Warns Fortunately, the Fluoride Action Network has a game plan to END water fluoridation worldwide. Clean pure water is a prerequisite to optimal health. Industrial chemicals, drugs, and other toxic additives really have no place in our water supplies. So please, protect your drinking water and support the fluoride -free movement by making a tax- deductible donation to the Fluoride Action Network today. Internet Resources Where You Can Learn More I encourage you to visit the website of the-luoride Action Network (FAN) and visit the links below: • Like FAN on Facebook, follow on ++or and sign up for campaign alerts. • 10 Facts About Fluoride: Attorney Michael Connett summarizes 10 basic facts about fluoride that should be considered in any discussion about whether to fluoridate water. Also see 10 Facts Handout (PDF). • 50 Reasons to Oppose Fluoridation: Learn why fluoridation is a bad medical practice that is unnecessary and ineffective. Download PDF. • Health Effects Database: FAN's database sets forth the scientific basis for concerns regarding the safety and effectiveness of ingesting fluorides. They also have a Study with the most up-to-date and comprehensive source for studies on fluoride's effects on human health. Together, Let's Help FAN Get the Funding They Deserve In my opinion, there are very few NGOs that are as effective and efficient as FAN. Its small team has led the charge to end fluoridation and will continue to do so with our help! Please make a donation today to help FAN end the absurdity of fluoridation. PtWOJ) FLUORIDEALERT.ORG Fluoride Action Network [+] Sources and References Sort Comments by: Top Rated Newest Oldest Top Poster http://articles. m ercol a.com/sites/articles/archive/2015/03/10/water-fl uoridation-thyroid-dysfuncti on.aspx 6/6 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride Mercolaxom Take Control of Your Heafth Since 1997 — Call Toll Free: 877-985-2695 US Government Admits Americans Have Been Overdosed on Fluoride May 12, 2015 396,144 views Disponible en Espanol By Dr. Mercola The US government has finally admitted they've overdosed Americans on fluoride and, for first time since 1962, are lowering its recommended level of fluoride in drinking water. 1,2,3 About 40 percent of American teens have dental fluorosis,4-a condition referring to changes in the appearance of tooth enamel—from chalky -looking lines and splotches to dark staining and pitting— caused by long-term ingestion of fluoride during the time teeth are forming. In some areas, fluorosis rates are as high as 70-80 percent, with some children suffering from advanced forms. The former recommendation called for a fluoride level of 0.7 to 1.2 milligrams per liter (mg/L) of water. The new upper limit set by the US Department of Health and Human Services (HHS) is 0.7 mg/L, to prevent these visible signs of toxic overexposure. Why Is a Drug Added to Water When the Dose Cannot Be Controlled? It's quite clear that when you add fluoride to drinking water, you cannot control the dose that people are getting, and fluoride is in fact not only a non-essential mineral but a toxic drug. This alone is one of the reasons why fluoride shouldn't be added to drinking water at any level. If a doctor somehow managed to force a patient to take a drug with known toxic effects and failed to Story at -a -glance The US Department of Health and Human Services (HHS) has lowered the recommended level of fluoride in water from 0.7 to 1.2 milligrams per liter (mg/L) of water to 0.7 mg/L, to prevent signs of fluoride overexposure About 40 percent of American teens have dental fluorosis, a condition referring to changes in the appearance of tooth enamel caused by long-term ingestion of fluoride during the time teeth are forming Water fluoridation is inherently unethical. Fluoride is a drug that is added to water for medical purposes (to prevent cavities), but you cannot control the dose people are getting when administering it this way Most Popular Why You Need to Eat More Vegetables 2 The Surprising Health Benefits of Extreme Hot and Cold Temperatures 3 An Inside Look Into the Fish Industry Reveals Disturbing Facts That Could Threaten Your Health 4 Peak Fasting — How Long Should You Intermittently Fast? 5 Fast Food Identified as a Significant Source of Hormone -Disrupting Chemicals You Might Also Like Fluoride: The Toxin So Dangerous - Even CDC Now Warns Against Consumption by Infants http://articles.mercola.com/sites/articles/archive/2015/05/12/fluoride-overdose.aspx 1/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride inform them of the dosage and frequency, and never monitored their health outcome, they would be medically negligent and liable to legal and medical board action. The Fluoride Deception: An Interview with Christopher Bryson Why Water Fluoridation Continues, Despite Yet water utilities administer this drug without a Flying in the Face of Science prescription, at the behest of the government, without any idea of who will get what dose and for how long, and without monitoring for side effects. Fluoride is added to drinking water to, in theory, prevent a disease (tooth decay), and as such becomes a medicine by FDA definition. While proponents claim this is no different than adding vitamin D to milk, fluoride is not an essential nutrient. Moreover, fluoride isn't even approved by the FDA for the prevention of cavities. We now know that at a limit of 0.7-1.2 mg/L causes a great many people to overdose on the drug. Will an upper limit of 0.7 mg/L protect everyone forced to drink fluoridated water? Considering the fact that people also getfluoride from toothpaste, dental rinses, processed foods, and beverages, the chances of overexposure are still present, even at this lowered level. Many Will Still Be at Risk for Overexposure at Lowered Fluoride Level At the previous level, 40 percent of US teens became "collateral damage." What will the allowable damage be at the new level? The HHS said it will evaluate dental fluorosis rates among children in 10 years to assess whether they were correct about this new level. Let's say dental fluorosis goes down to 20 percent. Is 20 percent an acceptable level of harm? How about 10 percent? Who decides what the acceptable level of collateral damage is? Remarkably, the Sacramento Bees reports that: 'Recent unpublished federal research found there's no regional differences in the amount of water kids drink. So it makes sense for the same levels to be used everywhere, health officials said." I'd be very curious to review that study, because I have a hard time imagining that kids everywhere drink the same amount of water! It's also a ludicrous assumption unless every single child is also exposed to the same amount of fluoride from other sources besides drinking water... and weighs the same... and has the same health status... and we know that's simply not the case. According to the HHS, the Environmental Protection Agency (EPA) "uses the 90th percentile of drinking water intake for all age groups to calculate the relative contribution for each fluoride source." What this means is that if you drink more water than the 90th percentile, you are not protected by this reduced level. People most likely to fall into that category include infants receiving formula mixed with fluoridated water, people working outdoors (especially in hot climates), athletes, and diabetics. Dental Fluorosis Is NOT the Only Risk of Water Fluoridation Barbara Gooch, a dentist at the Centers for Disease Control and Prevention (CDC) told NPO that "The only documented risk of water fluoridation is fluorosis, and it is primarily a cosmetic risk. Fluorosis in the milder form is nota health risk." This hints at a really deficient understanding of the available science on fluoride's health effects. Dental fluorosis is the most visible form of fluorosis, but it's far from being "just cosmetic" and of no further concern. It can also be an indication that the rest of your body, such as your bones and internal organs, including your brain, has been overexposed to fluoride as well. In other words, if fluoride is having a visually detrimental effect on the surface of your teeth, you can be virtually http://articles.mercola.com/sites/articles/archive/2015/05/12/fluoride-overdose.aspx 2/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride guaranteed that it's also damaging other parts of your body, such as your bones. Skeletal fluorosis, which isn't visible, is very difficult to distinguish from arthritis. Symptoms indicative of early clinical stage skeletal fluorosis include: • Burning, prickling, and tingling in your limbs • Muscle weakness • Chronic fatigue • Gastrointestinal disorders • Reduced appetite and weight loss The second clinical stage of skeletal fluorosis is characterized by: • Stiff joints and/or constant pain in your bones; brittle bones; and osteosclerosis • Anemia • Calcification of tendons, or ligaments of ribs and pelvis • Osteoporosis in the long bones • Bony spurs may also appear on your limb bones, especially around your knee, elbow, and on the surface of tibia and ulna All of this has been known since the 1930s, so it's rather disingenuous to proclaim that dental fluorosis is the only documented risk of water fluoridation. If 40 percent of American teens have dental fluorosis, how many people suffer from skeletal fluorosis as a result of chronic fluoride overexposure? In one previous study, bone fracture rates also rose sharply with increasing severity of dental fluorosis. Studies have also demonstrated that fluoride toxicity, caused by overexposure, can lead to: Increased lead Disrupted synthesis Hyperactivity and/or Muscle disorders absorption of collagen lethargy FBone cancer Increased tumor and Arthritis Skeletal fluorosis and (osteosarcoma) cancer rate JL bone fractures Genetic damage and Damaged sperm and Inactivation of 62 Inhibited formation of cell death increased infertility enzymes and antibodies, and inhibition of more immune system than 100 disruptions Fluoride Has No Benefit for Teeth When Swallowed You are beyond naive if you believe that fluoride somehow selectively goes to your teeth when you swallow it. Rather, it accumulates throughout your body's bones and tissues. What little benefit fluoride may have is achieved through topical application. Both the CDC and the World Health Organization (WHO) have noted that there is no discernible difference in tooth decay between developed countries that fluoridate theirwater and those that do nota The decline in tooth decay the US has experienced over the last 60 years, which is often attributed to fluoridated water, has likewise occurred in all developed countries, most of which do notfluoridate theirwater. So declining rates of dental decay is not in and of itself proof that water fluoridation actually works. It's also worth noting that well over 99 percent of the fluoride added to drinking water never even touches a tooth; it http://articles.mercola.com/sites/articles/archive/2015/05/12/fluoride-overdose.aspx 3/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride simply runs down the drain, into the environment, where you can be guaranteed it's doing nothing that is beneficial... Source: KK Cheng et al. BMJ 2007.$ Rates of cavities have declined by similar amounts in countries with and without fluoridation. HHS Still Ignores Major Safety Concerns According to Fluoride Action Network9 (FAN), in finalizing its new fluoride recommendation, the HHS has whitewashed a number of safety issues, failing to address recent research showing adverse effects ranging from lowered IQ in children (found in no less than 43 studies), underactive thyroid,10 and ADHD.11 For example, one recent study12 linking fluoridated water to higher prevalence of ADHD created a predictive model showing that every one percent increase in the portion of the US population drinking fluoridated water in 1992 was associated with 67,000 additional cases of ADHD 11 years later, and an additional 131,000 cases 19 years later. FAN points out that the HHS even "resorted to deceit" when it dismissed research showing reductions in IQ. The HHS stated that'A recent meta-analysis of studies conducted in rural China... identified an association between high fluoride exposure (i.e., drinking water concentrations ranging up to 11.5 mg/L) and lower IQ scores... " First of all, there are in all 43 studies reporting a relationship between fluoride exposure and reduced IQ. The study mentioned by the HHS only looked at 27 of them. But more importantly, when you seek to protect an entire population you have to look at the lowest level at which harm becomes apparent, not the highest. By noting only the upper level of the fluoride concentrations found in this study, it appears the HHS was trying to offer misleading reassurance that their recommended level is well beneath any level where risk may be present. But the lowest level at which IQ reductions were noted in that study was 0.88 mg/L, which isn't that far from the new recommended upper limit of 0.7 mg/L. Add fluoride from other sources, and you may very well get into the range of hazard. Interestingly, a number of studies1-114,1-5-6 have specifically shown that children who have moderate or severe dental fluorosis score lower on tests measuring cognitive skills and IQ, suggesting that if 40 percent of our kids have fluorosis, the water fluoridation scheme in the US is likely affecting our children's IQ as well. As noted by FAN: "In addition, in toxicology, it is not the concentration of fluoride (mg/liter) that is the relevant parameter but the dose in mg/day (how much you drink), and such a dose has to be compiled from all sources. In the case of the Chinese children in rural villages in these studies, they did not have two sources that US children commonly have: typically they are not bottle-fed and they do not use fluoridated toothpaste. So, it is likely that some American children are getting higher doses than some of the Chinese children who had their IQ lowered... Because fluoride is an endocrine disruptor and has the potential to lower IQ in children, FAN urges HHS to adopt the Precautionary Principle and end fluoridation now." They Got It Wrong—HHS Does Not Consider the Fact That Fluoride Is an Endocrine Disruptor... According to FAN: HHS also stated in its press release that a report on the toxicology of fluoride by the National Research Council of the National Academies (NRC, 2006��) found no evidence substantial enough to support effects other than severe dental fluorosis at these levels.' What HHS failed to state is that the NRC report of 2006 stated i16 for the first time that fluoride is an 'endocrine disruptor,' which means it has the potential to play havoc with the biology and fate of humans and animals. This is far more significant than severe dental fluorosis." In 2011, FAN submitted a number of concerns to the HHS, and none of them have been adequately addressed, FAN says. These concerns include: http://articies.mercola.com/sites/articles/archive/2015/05/l2lfluoride-overdose.aspx 4/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride Mass medicating the population via the water supply is unethical Any benefits of fluoride are primarily topical, no syste mi c The benefit and safety of ingested fluoride has never been proved by accepted medical standards t Americans will still be over -exposed to fluoride at 0.7 ppm L Infants will not be protected. Babies who receive formula made with fluoridated water will still receive 175 times more fluoride than breast-fed infants African-American children and low-income children will not be protected IL [Fluoride as an endocrine disruptor, which the HHS has not considered or investigated rates of HHS still has not taken into consideration skeletal fluorosis in the US To Protect Your Health, Avoid Fluoride 10 Facts About Fluoride No matter which scientific studies you examine or which population trends you view, the rational conclusion is that fluoride's health dangers far outweigh the marginal dental benefits it might offer. Dental caries can be effectively prevented with means otherthan fluoridation, thereby avoiding the adverse effects of fluoride. It's important to realize thatfluoride is a cumulative toxin, which overtime can lead to serious health concerns, from hypothyroidism to skeletal fluorosis and much more. The neurological effects are particularly disconcerting. Even scientists from the EPA's National Health and Environmental Effects Research Laboratory have classified fluoride as a "chemical having substantial evidence of developmental neurotoxicity." Water fluoridation needs to stop. The question is how. Despite all the evidence, getting fluoride out of American water supplies has been exceedingly difficult. After all, the US government has promoted it for over half a century. Were it to admit that they were wrong all along, and have in fact been poisoning everyone all this time, the ramifications could be enormous. It's not impossible to abolish water fluoridation, however, as evidenced in areas that have successfully done it. http://arti cl es. m ercol a. com /sites/articles/archi ve/2015/05/12/fl uori de-overdose.aspx 5/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride According to the late Jeff Green, national director of Citizens for Safe Drinking Water, a repeated theme in the cases where communities successfully removed fluoride from their water supply is the shifting of the burden of proof. Rather than citizens taking on the burden of proving that fluoride is harmful and shouldn't be added, a more successful strategy has been to hold those making claims, and the elected officials who rely on them, accountable for delivering proof that the specific fluoridation chemical being used fulfills their health and safety claims, and is in compliance with all regulations, laws, and risk assessments already required for safe drinking water. To learn more, please see this previous article, which discusses these strategies more in-depth. The Fluoride Action Network has a game plan to end water fluoridation not only in the US, but worldwide, but they need your support to succeed. Clean pure water is a prerequisite to optimal health. Industrial chemicals, drugs, and other toxic additives really have no place in our water supplies. So, please, protect your drinking water and support the fluoride -free movement by making a tax-deductible donation to the Fluoride Action Network today. Recent Victories in the Fight Against Water Fluoridation There have been a number of recent victories in the fight against water fluoridation that are worth celebrating, including the following: • Clarksburg, West Virginia19 Water Board members voted 2-1 in April to end fluoridation due to the growing number of studies showing negative side effects. The decision by the Clarksburg board end fluoridation for over 25,000 citizens, including residents of Bridgeport and a number of other smaller communities20. Oneida, New York21 On May 5th the Common Council voted 5-1 to reject fluoridation for the third time since 2002. For months, the council has held public hearings and debates on fluoridation, listening to an array of experts on both sides of the issue, including FAN's Dr. Paul Connett and NY Dept. of Health's Dental Representative Jay Kumar, who is a long-time promoter of fluoridation. Despite an aggressive lobbying campaign by the fluoride -lobby, the council and community couldn't be tricked into believing that the practice was safe, effective, or necessary. The decision will protect the water for over 21,000 residents. • Kingsville, Ontario22 This Canadian City Council, representing over 20,000 citizens, passed a motion in April reaffirming its stance in opposition to fluoridation. The issue was raised by the former Deputy Mayor, who urged the council to pass the motion to send a message to the provincial government, which is considering mandating the practice. The community of Lakeshore, Ontario23 also recently publicized their opposition to fluoridation, and will be sending a letter to provincial officials opposing a mandate. Carl Junction, Missouri24 Councilors voted to end fluoridation in April after considering a number of concerns they had regarding the effectiveness and safety of the practice. The community, which is home to approximately 8,000 residents, started fluoridating the water supply in 2005 after voters approved the use of the additive. Carl Junction isn't alone in making this decision. According to a recent article,25 "over the past five years, [at least] seven cities and towns in Missouri have removed fluoride from their municipal water systems, and a half-dozen more have put the matter to vote." • Bennington, Vermont26--Despite aggressive campaigning by a well -organized and well -funded pro - fluoridation coalition, in March residents of this community of 16,000 voted 1,539 to 1,117 in opposition to fluoridation in an advisory referendum vote. This is at least the fifth time Bennington residents have voted down fluoridation since the 1960s. • Gilford, Pennsylvania2L-Gilford Water Authority officials have decided to end fluoridation after more than 60 years of practicing it. The authority sent a letter to water customers stating, "We believe we should not put anything into the water that is not required by regulation to maintain the potability and pH balance of your water." • Sonoma City, California28--In March, City Councilors voted 3-2 to oppose a proposal by the County government to add fluoride to the city's drinking water. The council will be sending a letter of opposition to the Sonoma County Board of Supervisors. http://articies.mercola.com/sites/articles/archive/2015/05/l2lfluoride-overdose.aspx 6/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride Help End the Practice of Fluoridation There's no doubt about it: fluoride should not be ingested. Even scientists from the EPA's National Health and Environmental Effects Research Laboratory have classified fluoride as a "chemical having substantial evidence of developmental neurotoxicity." Furthermore, according to the Centers for Disease Control and Prevention (CDC), 41 percent of American adolescents now have dental fluorosis — unattractive discoloration and mottling of the teeth that indicate overexposure to fluoride. Clearly, children are being overexposed, and their health and development put in jeopardy. Why? The only real solution is to stop the archaic practice of water fluoridation in the first place. Fortunately, the Fluoride Action Network has a game plan to END water fluoridation worldwide. Clean pure water is a prerequisite to optimal health. Industrial chemicals, drugs, and other toxic additives really have no place in our water supplies. So please, protect your drinking water and support the fluoride -free movement by making a tax- deductible donation to the Fluoride Action Network today. Internet Resources Where You Can Learn More I encourage you to visit the website of the Fluoride Action Network (FAN) and visit the links below: • Like FAN on Facebool., follow on Twitter, and sign up for campaign alerts. • 10 Facts About Fluoride: Attorney Michael Connett summarizes 10 basic facts about fluoride that should be considered in any discussion about whether to fluoridate water. Also see 10 Facts Handout (PDF). • 50 Reasons to Oppose Fluoridation: Learn why fluoridation is a bad medical practice that is unnecessary and ineffective. Download PDF. • Health Effects Database: FAN's database sets forth the scientific basis for concerns regarding the safety and effectiveness of ingesting fluorides. They also have a Study Tracker with the most up-to-date and comprehensive source for studies on fluoride's effects on human health. Together, Let's Help FAN Get the Funding They Deserve In my opinion, there are very few NGOs that are as effective and efficient as FAN. Its small team has led the charge to end fluoridation and will continue to do so with our help! Please make a donation today to help FAN end the absurdity of fluoridation. ✓ FLUORIDEALERIORG Fluoride Action Network http://articies.mercola.com/sites/articles/archive/2015/05/12/fluoride-overdose.aspx 7/8 5/3/2016 US Government Admits Americans Have Been Overdosed on Fluoride [+] Sources and References Sort Comments by: Top Rated Newest Oldest Top Poster http://articles.mercola.com/sites/articles/archive/2015/05/12/fluoride-overdose.aspx 8/8 5/3/2016 Mercolaxom Take Control of Your Heafth Since 1997 — Call Toll Free: 877-985-2695 The Fluoride Deception: US Government Ignores Fluoride's Role The Fluoride Deception Continues as US Government Ignores Fluoride's Role as an Endocrine Disruptor June 20, 2015 253,256 views By Dr. Mercola In 2012 more than 67 percent of Americans received fluoridated waterj and of those, more than 11 million people were getting fluoride at or above the "optimal" level of 0.7-1.2 milligrams per liter (mg/L), according to the US Centers for Disease Control and Prevention (CDC). Then, in April this year, the US Department of Health and Human Services (HHS) announced that this "optimal" level of fluoride, recommended since 1962, had in fact been set too high, resulting in 40 percent of American teens showing signs of overexposures --a condition known as dental fluorosis. So, for the first time in nearly 55 years, the US government lowered its recommended level of fluoride in drinking water1,5 to a maximum of 0.7 mg/L. The question is, will this new level protect everyone from overexposure? Considering the fact that virtually all Americans get fluoride from other sources such as toothpaste, dental rinses, processed foods, and beverages, and the fact that fluoride accumulates in your body overtime, chances are this lower level will still pose a health risk for many. The first public experiment was allowed to continue for more than half a century before a reevaluation of the dosage was done. Now, we'll have to wait another decade before they try to determine whether 0.7 mg/L is really "optimal" or not. Remember, fluoride is a toxic drug administered without prescription or dosage control, so really, the optimal dosage of fluoride in water is actually zero... Story at -a -glance The US government has lowered the recommended level of fluoride in water to a maximum of 0.7 mg/L, as the previous level of 0.7-1.2 mg/L resulted in 40 percent of teens showing signs of overexposure Water fluoridation is inherently unethical. Fluoride is a drug that is added to water for medical purposes (to prevent cavities), but you cannot control the dose people are getting when administering it this way Research links fluoridated water consumption to thyroid dysfunction, ADHD, reduced IQ, bone fluorosis, increased bone fracture rates, and endocrine disruption Most Popular 1 Why You Need to Eat More Vegetables 2 The Surprising Health Benefits of Extreme Hot and Cold Temperatures 3 An Inside Look Into the Fish Industry Reveals Disturbing Facts That Could Threaten Your Health 4 Peak Fasting — How Long Should You Intermittently Fast? 5 Fast Food Identified as a Significant Source of Hormone -Disrupting Chemicals You Might Also Like Warning: Fluoride in Drinking Water Is Damaging Your Bones, Brain, Kidneys, and Thyroid http://articies.mercola.com/sites/articles/archive/2015/06/20/fluoride-deception-continues.aspx 1/6 5/3/2016 The Fluoride Deception: US Government Ignores Fluoride's Role Fluoride Is a Toxic Drug Dispensed 10 Facts About Fluoride You Need to Know Without Prescription or Dosage Control The Toxin So Dangerous - Even CDC Now Warns Against Consumption by Infants Fluoride is added to drinking water in an albeit futile attempt to prevent a disease (tooth decay), and as such becomes a medicine by FDA definition—and like most other drugs, there may be side effects. The severity of those side effects depends on your age, size/weight, health status, and of course the amount of water you consume. While proponents claim water fluoridation is no different than adding vitamin D to milk, fluoride is not an essential nutrient that many are deficient in, which is the case with vitamin D. Moreover, fluoride isn't even approved by the FDA for the prevention of cavities! What's worse, it's quite obvious that when you add fluoride to drinking water, you cannot control the dose that people are getting, and this alone is one of the reasons why fluoride should not be added to drinking water at any level. Doing so can have significant consequences, but the health effects are largely hidden in the general disease statistics, since none of the US agencies promoting fluoridation are tracking and correlating the health outcomes of fluoride exposure. What Happens to the Fluoride in Your Body? Approximately 98 percent of the fluoride you consume is absorbed into your blood through your gastrointestinal tract. From there, it enters your body's tissues. On average, about 50 percent of the fluoride you ingest each day gets excreted through your kidneys, so kidney function is another important factor when it comes to the build-up of fluoride and its potentially toxic effects. The remainder accumulates in your teeth and bones,6 pineal gland, and other tissues—including your blood vessels, where it can contribute to calcification. According to a 500 -page long scientific review$ by the National Research Council of the National Academies (NRC), published in 2006, fluoride is an endocrine disruptor that can affect your thyroid functions and even your blood sugar levels. British researchers recently warned that 15,000 Britons may be needlessly afflicted with hypothyroidism as a result of drinking fluoridated water.10 Thyroid dysfunction is also rampant in the US,1 so from a public health standpoint, it makes no sense whatsoever to medicate the entire population with a drug that can either induce or exacerbate this condition. Even more disturbing, 43 human studies -1-2- have linked moderately high fluoride exposures with reduced IQ in children, and over 100 animal studies have linked it to brain damage. Recent research13 has also linked water fluoridation with higher prevalence of ADHD. Using a predictive model, the researchers show that every one percent increase in the portion of the US population drinking fluoridated water in 1992 was associated with 67,000 additional cases of ADHD 11 years later, and an additional 131,000 cases 19 years later. HHS Ignores Fact that Fluoride Is an Endocrine Disruptor Despite massive amounts of evidence of harm, US health authorities such as the Centers for Disease Control and Prevention (CDC) insist that water fluoridation has but one documented risk—dental fluorosis. And they claim dental fluorosis is primarily a cosmetic detriment.'4 This ignores the fundamental fact that dental fluorosis is simply the most visible form of fluorosis. If your teeth are being damaged, you may actually be suffering fluoride damage in areas you cannotsee as well, such as your bones and internal organs. http://articies.mercola.com/sites/articles/archive/2015/06/20/fluoride-deception-continues.aspx 2/6 5/3/2016 The Fluoride Deception: US Government Ignores Fluoride's Role In at least one previous study, bone fracture rates rose sharply with increasing severity of dental fluorosis, indicating that dental fluorosis may in fact be an outward sign of damage occurring inside the body. According to Fluoride Action Network15 (FAN), the HHS whitewashed a number of safety issues when finalizing its new fluoride recommendation, including the impact fluoride has on intelligence. Besides the 43 studies showing water fluoridation lowers IQ, a number of studies16,17,18,19 have specifically shown that children who have moderate or severe dental fluorosis score lower on tests measuring cognitive skills and IQ. This suggests that if 40 percent of our kids have dental fluorosis, water fluoridation is likely affecting our children's IQ as well. Another keyfactor ignored by the HHS is that fluoride is an endocrine disruptor—a finding reported for the first time in the NRC's 2006 report. 20 Endocrine disruptors have the potential to disrupt the biology of both humans and animals, and this is certainly far more significant than severe dental fluorosis! To learn more about why water fluoridation runs counter to good science, common sense, and the public good, please see the following video, which recounts 10 important fluoride facts. I also strongly encourage you to watch the featured interview with Christopher Bryson to get a clear understanding of the true history of water fluoridation. 10 Facts About Fluoride Water Fluoridation Was Invented to Solve an Industrial Pollution Problem Christopher Bryson, an award-winning journalist and former radio producer at the BBC, wrote the book: The Fluoride Deception. Both the book and the interview featured above were published in 2004. The book is based on nearly a decade's worth of research, and it reveals how fluoride—a toxic byproduct of the aluminum industry—ended up being added to drinking water as a dental prophylactic. The commonly repeated history of how water fluoridation came to be states that the practice was spurred on by research from the 1930s, which found that people who drank water containing higher levels of naturally -occurring fluoride tended to have less severe tooth decay. The real story, however, reveals fluoridation was little more than a well -orchestrated PR stunt, designed to sell an inconveniently toxic reality to an unsuspecting public. In his book, Bryson describes the deeply intertwined interests that existed in the 1940s and '50s between the aluminum industry, the US nuclear weapons program, and the dental industry, which resulted in toxic fluoride being declared not only safe, but beneficial to human health. Prior to 1945 when communal water fluoridation in the US took effect, fluoride was in fact known as a protoplasmic poison that alters the permeability of the cell membrane by affecting certain enzymes.21 http://articies.mercola.com/sites/articles/archive/2015/06/20/fluoride-deception-continues.aspx 3/6 5/3/2016 The Fluoride Deception: US Government Ignores Fluoride's Role A 1936 issue of the Journal of the American Dental Association stated that fluoride at the 1 part per million (ppm) concentration is as toxic as arsenic and lead. An editorial published in the Journal of the American Dental Association, October 1, 1944, stated: "Drinking water containing as little as 1.2 ppm fluoride will cause developmental disturbances. We cannot run the risk of producing such serious systemic disturbances. The potentialities for harm outweigh those for good. "Such warnings were not heeded, and today we have even more evidence confirming these conclusions were in fact correct. One of the men responsible for quenching the resistance against water fluoridation was Harold Hodge, who headed up the toxicology department at the University of Rochester. Back in 1957, Harold Hodge was the nation's leading, most trusted scientist, and buried within declassified files of the Manhattan Project and the Atomic Energy Commission, Bryson found proof showing Hodge was tasked with producing medical information about fluoride that could help defend the government against lawsuits over fluoride pollution—an increasingly expensive and legally sensitive problem. Courtesy of his rank and reputation, when Hodge declared fluoride "absolutely safe" at 1 ppm, people believed him, and the naysayers were dismissed. The Importance of Understanding Water Fluoridation Within Its Historical Context Once you understand that the endorsement of fluoride as a dental health prophylactic arose from the need to address increasingly debilitating political and industrial problems relating to fluoride pollution, it becomes easier to see why the US government cannot backpedal and admit the whole thing was a scam. In his 2012 article "Poison is Treatment—Edward Bernays and the Campaign to Fluoridate America, "22 James F. Tracy boldly reveals the PR campaign that created this fake public health measure: "The wide -scale US acceptance of fluoride -related compounds in drinking water and a wide variety of consumer products over the past half century is a textbook case of social engineering orchestrated by Sigmund Freud's nephew and the 'father of public relations' Edward L. Bernays, "he writes. "The episode is instructive, for it suggests the tremendous capacity of powerful interests to reshape the social environment, thereby prompting individuals to unwarily think and act in ways that are often harmful to themselves and their loved ones." It's unrealistic to believe the government will admit to orchestrating such a scheme, as there may be significant legal ramifications. For this reason, getting water fluoridation abolished has proven to be exceedingly difficult. One successful strategy has been to hold those making claims—and the elected officials who rely on them— accountable for producing proof that the specific fluoridation chemical being used fulfills their health and safety claims, and is in compliance with all regulations, laws, and risk assessments already required for safe drinking water. For example, a few years ago, a Tennessee town stopped adding the hydrofluosilicic acid fluoride product they had been using, while still keeping its resolution to fluoridate its water supplies intact (meaning they didn't make a decision on whether it might be harmful). They just haven't been able to find a replacement product that is compliant with existing laws, regulations and safe -water requirements, and they will not add any fluoride product that is not in compliance. To learn more, please see this previous article, which discusses these strategies more in-depth. The Best Cavity Prevention Is Your Diet The best way to prevent cavities is not by adding fluoride, but by addressing your diet. One of the keys to oral health is eating a traditional diet rich in fresh, unprocessed vegetables, nuts, and grass-fed meats. By avoiding sugars and processed foods, you prevent the proliferation of the bacteria that cause decay in the first place. Scientific American23 recently addressed this issue, also noting that excessive sugar consumption is at the heart of the dental caries problem. According to Dr. Francesco Branca, Director of WHO's Department of Nutrition for Health and Development: "We have solid evidence that keeping intake of free sugars to less than 10 percent of total energy intake reduces the risk of overweight, obesity and tooth decay "Other natural strategies that can significantly improve your dental health is eating plenty of fermented vegetables, and doing oil pulling with coconut oil. Also make sure you're getting plenty of omega-3 fats, as research suggests even moderate amounts of omega-3 fats may http://articies.mercola.com/sites/articles/archive/2015/06/20/fluoride-deception-continues.aspx 4/6 5/3/2016 The Fluoride Deception: US Government Ignores Fluoride's Role help ward off gum disease. My favorite source is krill oil. Help End the Practice of Fluoridation There's no doubt about it: fluoride should not be ingested. Even scientists from the EPA's National Health and Environmental Effects Research Laboratory have classified fluoride as a "chemical having substantial evidence of developmental neurotoxicity." Furthermore, according to the Centers for Disease Control and Prevention (CDC), 41 percent of American adolescents now have dental fluorosis — unattractive discoloration and mottling of the teeth that indicate overexposure to fluoride. Clearly, children are being overexposed, and their health and development put in jeopardy. Why? The only real solution is to stop the archaic practice of water fluoridation in the first place. Fortunately, the Fluoride Action Network has a game plan to END water fluoridation worldwide. Clean pure water is a prerequisite to optimal health. Industrial chemicals, drugs, and other toxic additives really have no place in our water supplies. So please, protect your drinking water and support the fluoride -free movement by making a tax- deductible donation to the Fluoride Action Network today. Internet Resources Where You Can Learn More I encourage you to visit the website of the Fluoride Action Network (FAN) and visit the links below: • Like FAN on Facebook, follow on 'Witter, and sign up for campaign alerts. • 10 Facts About Fluoride: Attorney Michael Connett summarizes 10 basic facts about fluoride that should be considered in any discussion about whether to fluoridate water. Also see 10 Facts Handout (PDF). • 50 Reasons to Oppose Fluoridation: Learn why fluoridation is a bad medical practice that is unnecessary and ineffective. Download PDF. • Health Effects Database: FAN's database sets forth the scientific basis for concerns regarding the safety and effectiveness of ingesting fluorides. They also have a with the most up-to-date and comprehensive source for studies on fluoride's effects on human health. Together, Let's Help FAN Get the Funding They Deserve In my opinion, there are very few NGOs that are as effective and efficient as FAN. Its small team has led the charge to end fluoridation and will continue to do so with our help! Please make a donation today to help FAN end the absurdity of fluoridation. P 'I ;_;J00 FLUORIDEALERTARG http://articles. m ercol a.com/sites/articles/archi ve/2015/06/20/fl uori de-decepti on-conti nues.aspx 516 5/3/2016 The Fluoride Deception: US Government IgnoresFluoride's Role Fluoride Action Network [+] Sources and References Sort Comments by: Top Rated Newest Oldest Top Poster http://articies.mercola.com/sites/articles/archive/2015/06/20/fluoride-deception-continues.aspx 6/6 rf J W D O J LL m o ca w z Q � o ._ LL _ �_+ U 0 Q 70 Co U) U p O 7C3 O to co 7C3 cz U O .� 70 ' 7C3 O Q Q) -�► C6 QLO cc: -i:3 cO 4� v (a,��., Cn 70Z — •— C _=3 to .O 70 4� U vR L� 7 +-1 LL O -� W N LL o V C6 m W 0 0 J LL LL 0 H LL W Z W m 0 cc 70 O LL ate-+ C6 U) U 0 a=+ a W L }j ^ ` 7 � O . > co .O V � N O cn M� 4-5 Q O " • +� O U c6 cn CZ 0 �O oda 07 �o.�p� N � O U • � � O +_+ .0 .� :3 0 N LL 7 U 70 70 Co _N U C6 (n LLO N O N p _0 E > N LL p a� 70(6 aj N> U i O Q N i =3O W O O J LL LL 0 (1) H LL W Z W 00 70 LL E OLO 70 O U O LL cc .4 O T C i 70 W L O VJ rr^^ W (6 — � (n (n N — (6 +-' M to Q (� Q — Q (i)'� Q 0 O MU m N C6 N 170 O Q 7 N V L0 c cl 70 70 o O O \> H LL L _ T C Z W U H Z O U W J J 0 U U i � o O 6 L 0 �0 >, O 70 N i >, M i >,LO i O C6 i m O co 0 0 p I ZD PJ i (n 70 C6 Cm LSA O I N C9 � �0 >, O rnr- mL6 N 0 p I ZD PJ i (n 70 C6 Cm LSA O I N C9 � W 0 am W W O 0 J LL Z O w O H LO CN 1H U) Q U •� B fi a� c� �a 0 O f L W o �rs W JR o 5 — CD st "E M U ; C) ILIL U W V) 0 W W O O J LL Z O W D H M, 0 0 Z3 LL N a 0 0 04 t 0 CL E 0 41 .4 a 0 co C) C LLI LLQ 70._ LL — > LJ.I ::3 o (1) _0 (1) vi W0 70 o 4-jW U O C6 � •— U � U LL ca C N .� o a� 0-- N c6 >X 4-- cn 7 �7_ W70'� .� ^ . o N o 4-j O W_� n a� o :3 Co }' v (n O •�°' �� O CIO 4-1 70 O >, J o (D LLcn 4-j o W a Q 70 W 70•� >, N O O .- W � ca Z .U) = o = 'ao W > =o V- P I Ml r P7. a U O n I..L 70 MO W 70 c ca cc c O Q C co Et Q C ,C- W 0 CLX W W V O W (1) 70 O D LL a� U U c� O a� U N 70 O U Q 4� 4-j N O 0- E E W In reply to your � «f±2 *2 July 9 \\� �u \\\\\, >w >, ,� : , . "U9 Out \, :\` � �� . . sodium fluoride, §\, ,\\ \\`« \y \md&:»��yf§ter y\ ^ � \,\>\} : t¥< *� «� j<\� }::� \��!� . 2»< a,+ej, . . as 6. «f±»< ue t:< » > MANow daily `` �y requirement i#2 sodium £\9+f{°« r »\> been established'. 4. There can .\ � g w »a ` r+ : «;, Of >\G+»? any ;9¥ - to zr, . water 22table T:\!\ DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE FOOD AND DRUG ADMINISTRATION WASHINGTON, D.C. 20204 fi— ii'll R -7 This replies to your letter of February 22. Your questions "The United States Food and Drug Administration says that sodium fluoride is necessary for health. Correct?" The answer is "No." Sincerely yours, Jeanne M. Mangels,-- Consumer Inquiries Staff Office of Education and Information (c (I DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service 00, ' Food and Drug Administration Rockville MD 20857 DEC 21 2000 The Honorable Ken Calvert Chairman Subcommittee on Energy and Environment Committee on Science House of Representatives Washington, D.C. 20515-6301 Dear Mr. Chairman: Thank you for the letter of May 8, 2000, to Dr. Jane E. Henney, Commissioner of Food and Drugs, regarding the use of fluoride in drinking water and drug products. We apologize for the delay in responding to you. We have restated each of your questions, followed by our response. 1. If health claims are made for fluoride -containing products (e.g. that they reduce dental caries incidence or reduce pathology from osteoporosis), do such claims mandate that the fluoride -containing product be considered a drug, and thus subject the product to applicable regulatory controls? Fluoride, when used in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or animal, is a drug that is subject to Food and Drug Administration (FDA) regulation. FDA published a final rule on October 6, 1995, for anticaries drug products for over-the-counter (OTC) human use (copy enclosed). This rule establishes the conditions under which OTC anticaries drug products are generally recognized as safe and effective and not misbranded. The rule has provisions for active ingredients, packaging conditions, labeling, and testing procedures that are required by manufacturers in order to market anticaries products. A new drug application (NDA) may be filed for a product containing fluoride that does not meet the provisions stated in the final rule. As you know, the Environmental Protection Agency regulates fluoride in the water supply. Page 2 - The Honorable Ken Calvert 2. Are there any New Drug Applications (NDA) on file, that have been approved, or that have been rejected, that involve a fluoride -containing product (including fluoride -containing vitamin products) intended for ingestion with the stated aim of reducing dental caries? If any such NDA's have been rejected, on what grounds were they rejected? If any such NDA have been approved, please provide the data on safety and efficacy that FDA found persuasive. No NDAs have been approved or rejected for fluoride drugs meant for ingestion. Several NDAs have been approved for fluoride topical products such as dentifrices and gels. Fluoride products in the form of liquid and tablets meant for ingestion were in use prior to enactment of the Kefauver- Harris Amendments (Drug Amendments of 1962) to the Food, Drug, and Cosmetic Act in which efficacy became a requirement, in addition to safety, for drugs marketed in the United States (U.S.). Drugs in use prior to 1962 are being reviewed under a process known as the drug efficacy study implementation (DESI). The DESI review of fluoride -containing products has not been completed. 3. Does FDA consider dental fluorosis a sign of over exposure to fluoride? Dental fluorosis is indicative of greater than optimal ingestion of fluoride. In 1988, the U.S. Surgeon General reported that dental fluorosis, while not a desirable condition, should be considered a cosmetic effect rather than an adverse health effect. Surgeon General M. Joycelyn Elders reaffirmed this position in 1994. 4. Does FDA have any action -level or other regulatory restriction or policy statement on fluoride exposure aimed at minimizing chronic toxicity in adults or children? The monograph for OTC anticaries drug products sets acceptable concentrations for fluoride dentifrices, gels and rinses (all for topical use only). This monograph also describes the acceptable dosing regimens and labeling including warnings and directions for use. FDA's principal safety concern regarding fluoride in OTC drugs is the incidence of fluorosis in Page 3 - The Honorable Ken Calvert children. Children under two years of age do not have control of their swallowing reflex and do not have the skills to expectorate toothpaste properly. Young children are most susceptible to mild fluorosis as a result of improper use and swallowing of a fluoride toothpaste. These concerns are addressed in the monograph by mandating maximum concentrations, labeling that specifies directions for use and age restrictions, and package size limits. Thanks again for contacting us concerning this matter. If you have further questions, please let us know. Si cerely, Melinda K. Plaisier Associate Commissioner for Legislation Enclosure "Final Rule/Federal Register - October 6, 1995 Over -the -Counter Anticaries Drug Products" Web site administrator's note.- To ote:To perform query to access this document Enter: http://www.access.gpo.govlsu_docs/aceslacesl40.html Enter: checkmark for 1995 Volume 60 Enter: On: 10/06/95 Enter. Search terms: anticaries THE NATIONAL ACADEMIES PRESS This PDF is available at http://nap.edu/11571 1 BUY THIS BOOK FIND RELATED TITLES SHARE 000 — Fluoride in Drinking Water: A Scientific Review of EPA's Standards DETAILS 530 pages 16 x 91 PAPERBACK ISBN 978-0-309-10128-81 DOI 10.17226/11571 AUTHORS Committee on Fluoride in Drinking Water, National Research Council Visit the National Academies Press at NAP.edu and login or register to get: – Access to free PDF downloads of thousands of scientific reports – 10% off the price of print titles – Email or social media notifications of new titles related to your interests – Special offers and discounts Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press. (Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences. Copyright © National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards FLUORIDE IN DRINKING WATER A SCIENTIFIC REVIEW OF EPA'S STANDARDS Committee on Fluoride in Drinking Water Board on Environmental Studies and Toxicology Division on Earth and Life Studies NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards Preface In 1986, the U.S. Environmental Protection Agency (EPA) established a maximum -contaminant -level goal (MCLG) of 4 milligrams per liter (mg/L) and a secondary maximum contaminant level (SMCL) of 2 mg/L for fluoride in drinking water. These exposure values are not recommendations for the artificial fluoridation of drinking water, but are guidelines for areas in the United States that are contaminated or have high concentrations of natu- rally occurring fluoride. The goal of the MCLG is to establish an exposure guideline to prevent adverse health effects in the general population, and the goal of the SMCL is to reduce the occurrence of adverse cosmetic con- sequences from exposure to fluoride. Both the MCLG and the SMCL are nonenforceable guidelines. The regulatory standard for drinking water is the maximum contami- nant level (MCL), which is set as close to the MCLG as possible, with the use of the best technology available. For fluoride, the MCL is the same as the MCLG of 4 mg/L. In 1993, a previous committee of the National Research Council (NRC) reviewed the health effects of ingested fluoride and EPA's MCL. It concluded that the MCL was an appropriate interim standard, but that further research was needed to fill data gaps on total exposures to fluoride and its toxicity. Because new research on fluoride is now available and because the Safe Drinking Water Act requires periodic reassessment of regulations for drinking water contaminants, EPA requested that the NRC evaluate the adequacy of its MCLG and SMCL for fluoride to protect public health. In response to EPA's request, the NRC convened the Committee on Fluoride in Drinking Water, which prepared this report. The committee was charged to review toxicologic, epidemiologic, and clinical data on fluoride, Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards xiv PREFACE particularly data published since 1993, and exposure data on orally ingested fluoride from drinking water and other sources. Biographical information on the committee members is provided in Appendix A. This report presents the committee's review of the scientific basis of EPA's MCLG and SMCL for fluoride, and their adequacy for protecting children and others from adverse health effects. The committee consid- ers the relative contribution of various sources of fluoride (e.g., drinking water, food, dental hygiene products) to total exposure, and identifies data gaps and makes recommendations for future research relevant to setting the MCLG and SMCL for fluoride. Addressing questions of economics, risk -benefit assessment, or water -treatment technology was not part of the committee's charge. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the delibera- tive process. We wish to thank the following individuals for their review of this report: Kenneth Cantor, National Cancer Institute; Caswell Evans, Jr., University of Illinois at Chicago; Michael Gallo, University of Medicine and Dentistry of New Jersey; Mari Golub, California Environmental Protection Agency; Philippe Grandjean, University of Southern Denmark; David Hoel, Medical University of South Carolina; James Lamb, The Weinberg Group Inc.; Betty Olson, University of California at Irvine; Elizabeth Platz, Johns Hopkins Bloomberg School of Public Health; George Stookey, Indiana Uni- versity School of Dentistry; Charles Turner, University of Indiana; Robert Utiger, Harvard Institute of Medicine; Gary Whitford, Medical College of Georgia; and Gerald Wogan, Massachusetts Institute of Technology. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by John C. Bailar, University of Chicago, and Gilbert S. Omenn, University of Michigan Medical School. Appointed by the NRC, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The committee gratefully acknowledges the individuals who made pre- sentations to the committee at its public meetings. They include Paul Con - Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards PREFACE xv nett, St. Lawrence University; Joyce Donohue, EPA; Steve Levy, University of Iowa; William Maas, Centers for Disease Control and Prevention; Edward Ohanian, EPA; Charles Turner, Indiana University; and Gary Whitford, University of Georgia. The committee also wishes to thank Thomas Burke, Johns Hopkins University; Michael Morris, University of Michigan; Bernard Wagner, Wagner and Associates; and Lauren Zeise, California Environmen- tal Protection Agency, who served as consultants to the committee. The committee is grateful for the assistance of the NRC staff in prepar- ing the report. It particularly wishes to acknowledge the outstanding staff support from project director Susan Martel. We are grateful for her persis- tence and patience in keeping us focused and moving ahead on the task and her expertise and skill in reconciling the differing viewpoints of committee members. Other staff members who contributed to this effort are James Reisa, director of the Board on Environmental Studies and Toxicology; Kul- bir Bakshi, program director for the Committee on Toxicology; Cay Butler, editor; Mirsada Karalic-Loncarevic, research associate; Jennifer Saunders, research associate; and Tamara Dawson, senior project assistant. Finally, I would like to thank all the members of the committee for their efforts throughout the development of this report. John Doull, M.D., Ph.D., Chair Committee on Fluoride in Drinking Water Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards Contents SUMMARY INTRODUCTION 13 Fluoride in Drinking Water, 14 History of EPA's Regulation of Fluoride, 16 Committee's Task, 18 Committee's Approach, 21 Structure of the Report, 22 MEASURES OF EXPOSURE TO FLUORIDE IN THE UNITED STATES 23 Sources of Fluoride Exposure, 24 Recent Estimates of Total Fluoride Exposure, 54 Total Exposure to Fluoride, 55 Summary of Exposure Assessment, 64 Biomarkers of Exposure, Effect, and Susceptibility, 69 Findings, 81 Recommendations, 87 PHARMACOKINETICS OF FLUORIDE 89 Overview of Fluoride Chemistry, Units, and Measurement, 89 Short Review of Fluoride Pharmacokinetics: Absorption, Distribution, and Elimination, 90 Pharmacokinetic Models, 92 Fluoride Concentrations in Human Bone Versus Water Concentration, 93 Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards WAWA CONTENTS Fluoride Concentrations in Bones after Clinical Studies, 96 Comparative Pharmacokinetics of Rats and Humans, 98 Organofluorine Compounds, 99 Factors Modifying Pharmacokinetics and Their Implications for Potentially Susceptible Populations, 99 Findings, 101 Research Recommendations, 101 4 EFFECTS OF FLUORIDE ON TEETH 103 Enamel Fluorosis, 103 Other Dental Effects, 126 Findings, 127 Recommendations, 130 MUSCULOSKELETAL EFFECTS 131 Chemistry of Fluoride As It Relates to Mineralizing Tissues, 131 Effect of Fluoride on Cell Function, 133 Effects of Fluoride on Human Skeletal Metabolism, 138 Effect of Fluoride on Chondrocyte Metabolism and Arthritis, 177 Findings, 178 Recommendations, 180 REPRODUCTIVE AND DEVELOPMENTAL EFFECTS OF FLUORIDE 181 Reproductive Effects, 181 Developmental Effects, 193 Findings, 204 Recommendations, 204 NEUROTOXICITY AND NEUROBEHAVIORAL EFFECTS 205 Human Studies, 205 Animal Studies, 214 Neurochemical Effects and Mechanisms, 218 Findings, 220 Recommendations, 222 EFFECTS ON THE ENDOCRINE SYSTEM 224 Thyroid Follicular Cells, 224 Thyroid Parafollicular Cells, 236 Parathyroid Glands, 238 Pineal Gland, 252 Other Endocrine Organs, 256 Summary, 260 Recommendations, 266 Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards CONTENTS X1 9 EFFECTS ON THE GASTROINTESTINAL, RENAL, HEPATIC, AND IMMUNE SYSTEMS 268 GI System, 268 The Renal System, 280 Hepatic System, 292 Immune System, 293 Findings, 295 Recommendations, 302 IO GENOTOXICITY AND CARCINOGENICITY 304 Genotoxicity, 304 Carcinogenicity, 316 EPA Guidelines and Practice in Setting MCLGs Regarding Carcinogenicity, 334 Findings, 335 Recommendations, 338 II DRINKING WATER STANDARDS FOR FLUORIDE 340 Current Methods for Setting Standards for Drinking Water, 340 New Risk Assessment Considerations, 342 Fluoride Standards, 345 Findings and Recommendations, 352 REFERENCES Appendixes A Biographical Information on the Committee on Fluoride in Drinking Water, 411 B Measures of Exposure to Fluoride in the United States: Supplementary Information, 416 C Ecologic and Partially Ecologic Studies in Epidemiology, 439 D Comparative Pharmacokinetics of Rats and Humans, 442 E Detailed Information on Endocrine Studies of Fluoride, 447 Copyright National Academy of Sciences. All rights reserved. 354 Fluoride in Drinking Water: A Scientific Review of EPA's Standards FLUORIDE IN DRINKING WATER Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards Summary Under the Safe Drinking Water Act, the U.S. Environmental Protection Agency (EPA) is required to establish exposure standards for contaminants in public drinking -water systems that might cause any adverse effects on human health. These standards include the maximum contaminant level goal (MCLG), the maximum contaminant level (MCL), and the secondary maximum contaminant level (SMCL). The MCLG is a health goal set at a concentration at which no adverse health effects are expected to occur and the margins of safety are judged "adequate." The MCL is the enforceable standard that is set as close to the MCLG as possible, taking into consider- ation other factors, such as treatment technology and costs. For some con- taminants, EPA also establishes an SMCL, which is a guideline for managing drinking water for aesthetic, cosmetic, or technical effects. Fluoride is one of the drinking -water contaminants regulated by EPA. In 1986, EPA established an MCLG and MCL for fluoride at a concentration of 4 milligrams per liter (mg/L) and an SMCL of 2 mg/L. These guidelines are restrictions on the total amount of fluoride allowed in drinking water. Because fluoride is well known for its use in the prevention of dental car- ies, it is important to make the distinction here that EPA's drinking -water guidelines are not recommendations about adding fluoride to drinking water to protect the public from dental caries. Guidelines for that purpose (0.7 to 1.2 mg/L) were established by the U.S. Public Health Service more than 40 years ago. Instead, EPA's guidelines are maximum allowable concentrations in drinking water intended to prevent toxic or other adverse effects that could result from exposure to fluoride. In the early 1990s at the request of EPA, the National Research Council Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards 2 FLUORIDE IN DRINKING WATER (NRC) independently reviewed the health effects of ingested fluoride and the scientific basis for EPA's MCL. It concluded that the MCL was an ap- propriate interim standard but that further research was needed to fill data gaps on total exposure to fluoride and its toxicity. Because new research on fluoride is now available and because the Safe Drinking Water Act requires periodic reassessment of regulations for drinking -water contaminants, EPA requested that the NRC again evaluate the adequacy of its MCLG and SMCL for fluoride to protect public health. COMMITTEE'S TASK In response to EPA's request, the NRC convened the Committee on Fluoride in Drinking Water, which prepared this report. The committee was charged to review toxicologic, epidemiologic, and clinical data on fluoride— particularly data published since the NRC's previous (1993) report—and exposure data on orally ingested fluoride from drinking water and other sources. On the basis of its review, the committee was asked to evaluate independently the scientific basis of EPA's MCLG of 4 mg/L and SMCL of 2 mg/L in drinking water and the adequacy of those guidelines to protect children and others from adverse health effects. The committee was asked to consider the relative contribution of various fluoride sources (e.g., drinking water, food, dental -hygiene products) to total exposure. The committee was also asked to identify data gaps and to make recommendations for future research relevant to setting the MCLG and SMCL for fluoride. Addressing questions of artificial fluoridation, economics, risk -benefit assessment, and water -treatment technology was not part of the committee's charge. THE COMMITTEE'S EVALUATION To accomplish its task, the committee reviewed a large body of research on fluoride, focusing primarily on studies generated since the early 1990s, including information on exposure; pharmacokinetics; adverse effects on various organ systems; and genotoxic and carcinogenic potential. The col- lective evidence from in vitro assays, animal research, human studies, and mechanistic information was used to assess whether multiple lines of evi- dence indicate human health risks. The committee only considered adverse effects that might result from exposure to fluoride; it did not evaluate health risk from lack of exposure to fluoride or fluoride's efficacy in preventing dental caries. After reviewing the collective evidence, including studies conducted since the early 1990s, the committee concluded unanimously that the present MCLG of 4 mg/L for fluoride should be lowered. Exposure at the MCLG clearly puts children at risk of developing severe enamel fluorosis, Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards SUMMARY a condition that is associated with enamel loss and pitting. In addition, the majority of the committee concluded that the MCLG is not likely to be pro- tective against bone fractures. The basis for these conclusions is expanded upon below. Exposure to Fluoride The major sources of exposure to fluoride are drinking water, food, dental products, and pesticides. The biggest contributor to exposure for most people in the United States is drinking water. Estimates from 1992 indicate that approximately 1.4 million people in the United States had drinking water with natural fluoride concentrations of 2.0-3.9 mg/L, and just over 200,000 people had concentrations equal to or exceeding 4 mg/L (the presented MCL). In 2000, it was estimated that approximately 162 mil- lion people had artificially fluoridated water (0.7-1.2 mg/L). Food sources contain various concentrations of fluoride and are the sec- ond largest contributor to exposure. Beverages contribute most to estimated fluoride intake, even when excluding contributions from local tap water. The greatest source of nondietary fluoride is dental products, primarily tooth- pastes. The public is also exposed to fluoride from background air and from certain pesticide residues. Other sources include certain pharmaceuticals and consumer products. Highly exposed subpopulations include individuals who have high con- centrations of fluoride in drinking water, who drink unusually large volumes of water, or who are exposed to other important sources of fluoride. Some subpopulations consume much greater quantities of water than the 2 L per day that EPA assumes for adults, including outdoor workers, athletes, and people with certain medical conditions, such as diabetes insipidus. On a per -body-weight basis, infants and young children have approximately three to four times greater exposure than do adults. Dental -care products are also a special consideration for children, because many tend to use more toothpaste than is advised, their swallowing control is not as well developed as that of adults, and many children under the care of a dentist undergo fluoride treatments. Overall, the committee found that the contribution to total fluoride exposure from fluoride in drinking water in the average person, depending on age, is 57% to 90% at 2 mg/L and 72% to 94% at 4 mg/L. For high- water -intake individuals, the drinking -water contribution is 86% to 96% at 2 mg/L and 92% to 98% at 4 mg/L. Among individuals with an average water -intake rate, infants and children have the greatest total exposure to fluoride, ranging from 0.079 to 0.258 mg/kg/day at 4 mg/L and 0.046 to 0.144 mg/kg/day at 2 mg/L in drinking water. For high -water -intake indi- viduals exposed to fluoride at 4 mg/L, total exposure ranges from 0.294 Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards 4 FLUORIDE IN DRINKING WATER mg/kg/day for adults to 0.634 mg/kg/day for children. The corresponding intake range at 2 mg/L is 0.154 to 0.334 mg/kg/day for adults and children, respectively. Dental Effects Enamel fluorosis is a dose-related mottling of enamel that can range from mild discoloration of the tooth surface to severe staining and pitting. The condition is permanent after it develops in children during tooth for- mation, a period ranging from birth until about the age of 8. Whether to consider enamel fluorosis, particularly the moderate to severe forms, to be an adverse health effect or a cosmetic effect has been the subject of debate for decades. In previous assessments, all forms of enamel fluorosis, includ- ing the severest form, have been judged to be aesthetically displeasing but not adverse to health. This view has been based largely on the absence of direct evidence that severe enamel fluorosis results in tooth loss; loss of tooth function; or psychological, behavioral, or social problems. Severe enamel fluorosis is characterized by dark yellow to brown stain- ing and discrete and confluent pitting, which constitutes enamel loss. The committee finds the rationale for considering severe enamel fluorosis only a cosmetic effect to be much weaker for discrete and confluent pitting than for staining. One of the functions of tooth enamel is to protect the dentin and, ultimately, the pulp from decay and infection. Severe enamel fluorosis compromises that health -protective function by causing structural damage to the tooth. The damage to teeth caused by severe enamel fluorosis is a toxic effect that is consistent with prevailing risk assessment definitions of adverse health effects. This view is supported by the clinical practice of filling enamel pits in patients with severe enamel fluorosis and restoring the affected teeth. Moreover, the plausible hypothesis concerning elevated frequency of caries in persons with severe enamel fluorosis has been accepted by some authori- ties, and the available evidence is mixed but generally supportive. Severe enamel fluorosis occurs at an appreciable frequency, approxi- mately 10% on average, among children in U.S. communities with water fluoride concentrations at or near the current MCLG of 4 mg/L. Thus, the MCLG is not adequately protective against this condition. Two of the 12 members of the committee did not agree that severe enamel fluorosis should now be considered an adverse health effect. They agreed that it is an adverse dental effect but found that no new evidence has emerged to suggest a link between severe enamel fluorosis, as experienced in the United States, and a person's ability to function. They judged that dem- onstration of enamel defects alone from fluorosis is not sufficient to change the prevailing opinion that severe enamel fluorosis is an adverse cosmetic effect. Despite their disagreement on characterization of the condition, these Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards SUMMARY S two members concurred with the committee's conclusion that the MCLG should prevent the occurrence of this unwanted condition. Enamel fluorosis is also of concern from an aesthetic standpoint because it discolors or results in staining of teeth. No data indicate that staining alone affects tooth function or susceptibility to caries, but a few studies have shown that tooth mottling affects aesthetic perception of facial attractive- ness. It is difficult to draw conclusions from these studies, largely because perception of the condition and facial attractiveness are subjective and cul- turally influenced. The committee finds that it is reasonable to assume that some individuals will find moderate enamel fluorosis on front teeth to be detrimental to their appearance and that it could affect their overall sense of well-being. However, the available data are not adequate to categorize moderate enamel fluorosis as an adverse health effect on the basis of struc- tural or psychological effects. Since 1993, there have been no new studies of enamel fluorosis in U.S. communities with fluoride at 2 mg/L in drinking water. Earlier studies indi- cated that the prevalence of moderate enamel fluorosis at that concentration could be as high as 15%. Because enamel fluorosis has different distribu- tion patterns among teeth, depending on when exposure occurred during tooth development and on enamel thickness, and because current indexes for categorizing enamel fluorosis do not differentiate between mottling of anterior and posterior teeth, the committee was not able to determine what percentage of moderate cases might be of cosmetic concern. Musculoskeletal Effects Concerns about fluoride's effects on the musculoskeletal system histori- cally have been and continue to be focused on skeletal fluorosis and bone fracture. Fluoride is readily incorporated into the crystalline structure of bone and will accumulate over time. Since the previous 1993 NRC review of fluoride, two pharmacokinetic models were developed to predict bone concentrations from chronic exposure to fluoride. Predictions based on these models were used in the committee's assessments below. Skeletal Fluorosis Skeletal fluorosis is a bone and joint condition associated with prolonged exposure to high concentrations of fluoride. Fluoride increases bone density and appears to exacerbate the growth of osteophytes present in the bone and joints, resulting in joint stiffness and pain. The condition is categorized into one of four stages: a preclinical stage and three clinical stages that increase in severity. The most severe stage (clinical stage III) historically has been referred to as the "crippling" stage. At stage 11, mobility is not significantly Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards FLUORIDE IN DRINKING WATER affected, but it is characterized by chronic joint pain, arthritic symptoms, slight calcification of ligaments, and osteosclerosis of the cancellous bones. Whether EPA's MCLG of 4 mg/L protects against these precursors to more serious mobility problems is unclear. Few clinical cases of skeletal fluorosis in healthy U.S. populations have been reported in recent decades, and the committee did not find any recent studies to evaluate the prevalence of the condition in populations exposed to fluoride at the MCLG. Thus, to answer the question of whether EPA's MCLG protects the general public from stage II and stage III skeletal fluorosis, the committee compared pharmacokinetic model predictions of bone fluoride concentrations and historical data on iliac -crest bone fluoride concentrations associated with the different stages of skeletal fluorosis. The models estimated that bone fluoride concentrations resulting from lifetime exposure to fluoride in drinking water at 2 mg/L (4,000 to 5,000 mg/kg ash) or 4 mg/L (10,000 to 12,000 mg/kg ash) fall within or exceed the ranges historically associated with stage II and stage III skeletal fluorosis (4,300 to 9,200 mg/kg ash and 4,200 to 12,700 mg/kg ash, respectively). However, this comparison alone is insufficient for determining whether stage II or III skeletal fluorosis is a risk for populations exposed to fluoride at 4 mg/L, because bone fluoride concentrations and the levels at which skeletal fluoro- sis occurs vary widely. On the basis of the existing epidemiologic literature, stage III skeletal fluorosis appears to be a rare condition in the United Sates; furthermore, the committee could not determine whether stage II skeletal fluorosis is occurring in U.S. residents who drink water with fluoride at 4 mg/L. Thus, more research is needed to clarify the relationship between fluoride ingestion, fluoride concentrations in bone, and stage of skeletal fluorosis before any conclusions can be drawn. Bone Fractures Several epidemiologic studies of fluoride and bone fractures have been published since the 1993 NRC review. The committee focused its review on observational studies of populations exposed to drinking water containing fluoride at 2 to 4 mg/L or greater and on clinical trials of fluoride (20-34 mg/ day) as a treatment for osteoporosis. Several strong observational studies in- dicated an increased risk of bone fracture in populations exposed to fluoride at 4 mg/L, and the results of other studies were qualitatively consistent with that finding. The one study using serum fluoride concentrations found no appreciable relationship to fractures. Because serum fluoride concentrations may not be a good measure of bone fluoride concentrations or long-term exposure, the ability to show an association might have been diminished in that study. A meta-analysis of randomized clinical trials reported an elevated risk of new nonvertebral fractures and a slightly decreased risk of vertebral Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards SUMMARY fractures after 4 years of fluoride treatment. An increased risk of bone frac- ture was found among a subset of the trials that the committee found most informative for assessing long-term exposure. Although the duration and concentrations of exposure to fluoride differed between the observational studies and the clinical trials, bone fluoride content was similar (6,200 to more than 11,000 mg/kg ash in observational studies and 5,400 to 12,000 mg/kg ash in clinical trials). Fracture risk and bone strength have been studied in animal models. The weight of evidence indicates that, although fluoride might increase bone volume, there is less strength per unit volume. Studies of rats indicate that bone strength begins to decline when fluoride in bone ash reaches 6,000 to 7,000 mg/kg. However, more research is needed to address uncertainties associated with extrapolating data on bone strength and fractures from animals to humans. Important species differences in fluoride uptake, bone remodeling, and growth must be considered. Biochemical and physiological data indicate a biologically plausible mechanism by which fluoride could weaken bone. In this case, the physiological effect of fluoride on bone qual- ity and risk of fracture observed in animal studies is consistent with the human evidence. Overall, there was consensus among the committee that there is scien- tific evidence that under certain conditions fluoride can weaken bone and increase the risk of fractures. The majority of the committee concluded that lifetime exposure to fluoride at drinking -water concentrations of 4 mg/L or higher is likely to increase fracture rates in the population, compared with exposure to 1 mg/L, particularly in some demographic subgroups that are prone to accumulate fluoride into their bones (e.g., people with renal disease). However, 3 of the 12 members judged that the evidence only sup- ports a conclusion that the MCLG might not be protective against bone fracture. Those members judged that more evidence is needed to conclude that bone fractures occur at an appreciable frequency in human popula- tions exposed to fluoride at 4 mg/L and that the MCLG is not likely to be protective. There were few studies to assess fracture risk in populations exposed to fluoride at 2 mg/L in drinking water. The best available study, from Finland, suggested an increased rate of hip fracture in populations exposed to fluo- ride at concentrations above 1.5 mg/L. However, this study alone is not suf- ficient to judge fracture risk for people exposed to fluoride at 2 mg/L. Thus, no conclusions could be drawn about fracture risk or safety at 2 mg/L. Reproductive and Developmental Effects A large number of reproductive and developmental studies in animals have been conducted and published since the 1993 NRC report, and the Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards FLUORIDE IN DRINKING WATER overall quality of that database has improved significantly. Those studies indicated that adverse reproductive and developmental outcomes occur only at very high concentrations that are unlikely to be encountered by U.S. populations. A few human studies suggested that high concentrations of fluoride exposure might be associated with alterations in reproductive hormones, effects on fertility, and developmental outcomes, but design limitations make those studies insufficient for risk evaluation. Neurotoxicity and Neurobehavioral Effects Animal and human studies of fluoride have been published reporting adverse cognitive and behavioral effects. A few epidemiologic studies of Chi- nese populations have reported IQ deficits in children exposed to fluoride at 2.5 to 4 mg/L in drinking water. Although the studies lacked sufficient detail for the committee to fully assess their quality and relevance to U.S. popula- tions, the consistency of the results appears significant enough to warrant additional research on the effects of fluoride on intelligence. A few animal studies have reported alterations in the behavior of rodents after treatment with fluoride, but the committee did not find the changes to be substantial in magnitude. More compelling were studies on molecular, cellular, and anatomical changes in the nervous system found after fluoride exposure, suggesting that functional changes could occur. These changes might be subtle or seen only under certain physiological or environmental conditions. More research is needed to clarify the effect of fluoride on brain chemistry and function. Endocrine Effects The chief endocrine effects of fluoride exposures in experimental ani- mals and in humans include decreased thyroid function, increased calcitonin activity, increased parathyroid hormone activity, secondary hyperparathy- roidism, impaired glucose tolerance, and possible effects on timing of sexual maturity. Some of these effects are associated with fluoride intake that is achievable at fluoride concentrations in drinking water of 4 mg/L or less, especially for young children or for individuals with high water intake. Many of the effects could be considered subclinical effects, meaning that they are not adverse health effects. However, recent work on borderline hormonal imbalances and endocrine -disrupting chemicals indicated that ad- verse health effects, or increased risks for developing adverse effects, might be associated with seemingly mild imbalances or perturbations in hormone concentrations. Further research is needed to explore these possibilities. Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards SUMMARY 9 Effects on Other Organ Systems The committee also considered effects on the gastrointestinal system, kidneys, liver, and immune system. There were no human studies on drink- ing water containing fluoride at 4 mg/L in which gastrointestinal, renal, hepatic, or immune effects were carefully documented. Case reports and in vitro and animal studies indicated that exposure to fluoride at concentra- tions greater than 4 mg/L can be irritating to the gastrointestinal system, affect renal tissues and function, and alter hepatic and immunologic param- eters. Such effects are unlikely to be a risk for the average individual exposed to fluoride at 4 mg/L in drinking water. However, a potentially susceptible subpopulation comprises individuals with renal impairments who retain more fluoride than healthy people do. Genotoxicity and Carcinogenicity Many assays have been performed to assess the genotoxicity of fluoride. Since the 1993 NRC review, the most significant additions to the database are in vivo assays in human populations and, to a lesser extent, in vitro assays with human cell lines and in vivo experiments with rodents. The results of the in vivo human studies are mixed. The results of in vitro tests are also conflicting and do not contribute significantly to the interpretation of the existing database. Evidence on the cytogenetic effects of fluoride at environmental concentrations is contradictory. Whether fluoride might be associated with bone cancer has been a subject of debate. Bone is the most plausible site for cancer associated with fluoride because of its deposition into bone and its mitogenic effects on bone cells in culture. In a 1990 cancer bioassay, the overall incidence of osteo- sarcoma in male rats exposed to different amounts of fluoride in drinking water showed a positive dose -response trend. In a 1992 study, no increase in osteosarcoma was reported in male rats, but most of the committee judged the study to have insufficient power to counter the evidence for the trend found in the 1990 bioassay. Several epidemiologic investigations of the relation between fluoride and cancer have been performed since the 1993 evaluation, including both individual -based and ecologic studies. Several studies had significant meth- odological limitations that made it difficult to draw conclusions. Overall, the results are mixed, with some studies reporting a positive association and others no association. On the basis of the committee's collective consideration of data from humans, genotoxicity assays, and studies of mechanisms of action in cell systems (e.g., bone cells in vitro), the evidence on the potential of fluoride to initiate or promote cancers, particularly of the bone, is tentative and Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards 10 FLUORIDE IN DRINKING WATER mixed. Assessing whether fluoride constitutes a risk factor for osteosarcoma is complicated by the rarity of the disease and the difficulty of characterizing biologic dose because of the ubiquity of population exposure to fluoride and the difficulty of acquiring bone samples in nonaffected individuals. A relatively large hospital-based case -control study of osteosarcoma and fluoride exposure is under way at the Harvard School of Dental Medicine and is expected to be published in 2006. That study will be an important addition to the fluoride database, because it will have exposure information on residence histories, water consumption, and assays of bone and toenails. The results of that study should help to identify what future research will be most useful in elucidating fluoride's carcinogenic potential. DRINKING -WATER STANDARDS Maximum -Contaminant -Level Goal In light of the collective evidence on various health end points and total exposure to fluoride, the committee concludes that EPA's MCLG of 4 mg/L should be lowered. Lowering the MCLG will prevent children from developing severe enamel fluorosis and will reduce the lifetime accumulation of fluoride into bone that the majority of the committee concludes is likely to put individuals at increased risk of bone fracture and possibly skeletal fluorosis, which are particular concerns for subpopulations that are prone to accumulating fluoride in their bones. To develop an MCLG that is protective against severe enamel fluorosis, clinical stage II skeletal fluorosis, and bone fractures, EPA should update the risk assessment of fluoride to include new data on health risks and better es- timates of total exposure (relative source contribution) for individuals. EPA should use current approaches for quantifying risk, considering susceptible subpopulations, and characterizing uncertainties and variability. Secondary Maximum Contaminant Level The prevalence of severe enamel fluorosis is very low (near zero) at fluo- ride concentrations below 2 mg/L. From a cosmetic standpoint, the SMCL does not completely prevent the occurrence of moderate enamel fluorosis. EPA has indicated that the SMCL was intended to reduce the severity and occurrence of the condition to 15% or less of the exposed population. The available data indicate that fewer than 15% of children will experience moderate enamel fluorosis of aesthetic concern (discoloration of the front teeth) at that concentration. However, the degree to which moderate enamel fluorosis might go beyond a cosmetic effect to create an adverse psychologi- cal effect or an adverse effect on social functioning is not known. Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards SUMMARY 11 OTHER PUBLIC HEALTH ISSUES The committee's conclusions regarding the potential for adverse effects from fluoride at 2 to 4 mg/L in drinking water do not address the lower exposures commonly experienced by most U.S. citizens. Fluoridation is widely practiced in the United States to protect against the development of dental caries; fluoride is added to public water supplies at 0.7 to 1.2 mg/L. The charge to the committee did not include an examination of the benefits and risks that might occur at these lower concentrations of fluoride in drinking water. RESEARCH NEEDS As noted above, gaps in the information on fluoride prevented the committee from making some judgments about the safety or the risks of fluoride at concentrations of 2 to 4 mg/L. The following research will be useful for filling those gaps and guiding revisions to the MCLG and SMCL for fluoride. • Exposure assessment — Improved assessment of exposure to fluoride from all sources is needed for a variety of populations (e.g., different socioeconomic condi- tions). To the extent possible, exposures should be characterized for indi- viduals rather than communities, and epidemiologic studies should group individuals by exposure level rather than by source of exposure, location of residence, or fluoride concentration in drinking water. Intakes or exposures should be characterized with and without normalization for body weight. Fluoride should be included in nationwide biomonitoring surveys and nutri- tional studies; in particular, analysis of fluoride in blood and urine samples taken in these surveys would be valuable. • Pharmacokinetic studies — The concentrations of fluoride in human bone as a function of ex- posure concentration, exposure duration, age, sex, and health status should be studied. Such studies would be greatly aided by noninvasive means of measuring bone fluoride. Information is particularly needed on fluoride plasma and bone concentrations in people with small-to-moderate changes in renal function as well as in those with serious renal deficiency. — Improved and readily available pharmacokinetic models should be developed. Additional cross -species pharmacokinetic comparisons would help to validate such models. • Studies of enamel fluorosis — Additional studies, including longitudinal studies, should be done in U.S. communities with water fluoride concentrations greater than 1 mg/L. Copyright National Academy of Sciences. All rights reserved. Fluoride in Drinking Water: A Scientific Review of EPA's Standards 12 FLUORIDE IN DRINKING WATER These studies should focus on moderate and severe enamel fluorosis in relation to caries and in relation to psychological, behavioral, and social effects among affected children, their parents, and affected children after they become adults. — Methods should be developed and validated to objectively assess enamel fluorosis. Consideration should be given to distinguishing between staining or mottling of the anterior teeth and of the posterior teeth so that aesthetic consequences can be more easily assessed. — More research is needed on the relation between fluoride exposure and dentin fluorosis and delayed tooth eruption patterns. • Bone studies — A systematic study of clinical stage II and stage III skeletal fluoro- sis should be conducted to clarify the relationship between fluoride inges- tion, fluoride concentration in bone, and clinical symptoms. — More studies of communities with drinking water containing fluoride at 2 mg/L or more are needed to assess potential bone fracture risk at these higher concentrations. Quantitative measures of fracture, such as radiologic assessment of vertebral body collapse, should be used instead of self-reported fractures or hospital records. Moreover, if possible, bone fluoride concentrations should be measured in long-term residents. • Other health effects — Carefully conducted studies of exposure to fluoride and emerging health parameters of interest (e.g., endocrine effects and brain function) should be performed in populations in the United States exposed to various concentrations of fluoride. It is important that exposures be appropriately documented. Copyright National Academy of Sciences. All rights reserved. FLUORIDE - sodium fluoride tablet, chewable PureTek Corporation Disclaimer: This drug has not been found by FDA to be safe and effective, and this labeling has not been approved by FDA. For further information about unapproved drugs, click here. Prescribing Information DESCRIPTION Each Fluoride Chewable Tablet 0.5 mg is erythrosine (FD and C Red Dye No. 3) free. Each tablet 0.5 mg (half-strength) contains 0.5 mg F* from 1.1 mg sodium fluoride (NaF). Each tablet for oral administration contains sodium fluoride equivalent to fluoride 0.5 mg and the following inactive ingredients: compressible sugar, croscarmellose sodium, D and C Red No. 27 aluminum lake, FD and C Blue No. 1 aluminum lake, grape flavor, magnesium stearate, mannitol, microcrystalline cellulose. CLINICAL PHARMACOLOGY Sodium fluoride acts systemically (before tooth eruption) and topically (post eruption) by increasing tooth resistance to acid dissolution, by promoting remineralization, and by inhibiting the cariogenic microbial process. INDICATIONS AND USAGE For once daily self -applied systemic use as a dental caries preventive in pediatric patients. It has been established that ingestion of fluoridated drinking water (1 ppm F*) during the period of tooth development results in a significant decrease in the incidence of dental caries. Fluoride Chewable Tablets were developed to provide systemic fluoride for use as a supplement in pediatric patients from 6 months to 3 years of age and older living in areas where the drinking water fluoride content does not exceed 0.6 ppm F*. CONTRAINDICATIONS Fluoride Chewable Tablets 0.5 mg are contraindicated when the fluoride content of drinking water is more than 0.6 ppm F* and should not be administered to pediatric patients under age 6 when the fluoride content of drinking water is 0.3 ppm F* or to pediatric patients under age 3 years. Do not administer Fluoride Chewable Tablets (any strength) to pediatric patients under age 6 months. WARNINGS Prolonged daily ingestion of quantities greater than the recommended amount may result in various degrees of dental fluorosis in pediatric patients under age 6 years, especially in the water fluoridation exceeds 0.6 ppm Read directions carefully before using. Keep out of the reach of children. PRECAUTIONS General Please refer to the CONTRAINDICATIONS, WARNINGS, and OVERDOSAGE sections for overdosage concerns. Use in pediatric patients below the age of 6 months is not recommended by current American Dental Association and American Academy of Pediatrics guidelines. Drug interactions Do not eat or drink dairy products within one hour of fluoride administration. Incompatability of fluoride with dairy foods has been reported due to formation of calcium fluoride which is poorly absorbed. Carcinogenesis, Mutagenesis, Impairment of Fertility In a study conducted in rodents, no carcinogenesis was found in male and female mice and female rats treated with fluoride at dose levels ranging from 4.1 to 9.1 mg/kg of body weight. Equivocal evidence of carcinogenesis was reported for male rats treated with 2.5 mg and 4.1 mg of body weight. In a second study, no carcinogenesis was observed in rats, males or females treated with fluoride up to 11.3 mg/kg of body weight. This dose is at least 400 times greater than the recommended daily dose of Fluoride Chewable Tablets. Fluoride ion is not mutagenic in standard bacterial systems. It has been shown that fluoride ion has potential to induce chromosome aberrations in cultured human and rodent cells at doses much higher than those in which humans are exposed. In vivo data is conflicting. Some studies report chromosome damage in rodents while other studies using similar protocols report negative results. Potential adverse reproductive effects of fluoride exposure inhuman has notbeen adequately evaluated. Adverse effects on reproduction were reported for rats, mice, fox, and cattle exposed to 100 ppm or greater concentration of fluoride in their diet or drinking water. Other studies conducted in rats demonstrated that lower doses of fluoride (5 mg/kg of body weight) did not result in impaired fertility and reproductive capabilities.This dose is approximately 200 times greater than the recommended daily dose of Fluoride Chewable Tablets. Pregnancy Teratogenic Effects: Pregnancy Category B. It has been shown that fluoride crosses the placenta of rats, but only 0.01% of the amount administered is incorporated in fetal tissue. Animal studies (rats, mice, rabbits) have shown that fluoride is not a teratogen. Maternal exposure to 12.2 mg fluoride/kg of body weight (rats) or 13.1 mg/kg of body weight (rabbits) did not affect the litter size or fetal weight and did not increase the frequency of skeletal or visceral malformation. Epidemiological studies conducted in areas with high levels of naturally fluoridated water showed no increase in birth defects. Heavy exposure to fluoride during in utero development may result in skeletal fluorosis which becomes evident in childhood. Nursing Mothers It is not known if fluoride ion is excreted in human milk However, many drugs are excreted in human milk and caution should be exercised when Fluoride Chewable Tablets 0.5 mg are administered to nursing women. Reduced milk production was reported in farm raised fox when the animals were fed a diet containing a high concentration of fluoride (98 —137 mg/kg of body weight). No adverse effects on parturition, lactation, or offspring were seen in rats administered fluoride up to 5 mg/kg of body weight. This dose is at least 200 times greater than the recommended daily dose of Fluoride Chewable Tablets. Pediatric Use The use of Fluoride Chewable Tablets 0.5 mg as a caries preventive in pediatric age groups 6 months to 16 years is supported by evidence from adequate and well-controlled studies on fluoride supplementation frombirth through adolescence. Geriatric Use Ptpblic Health Service b. HUMAN SERVICES DEPARTMENT OF 11EAL, Food and Deug Administiation Rockville MC 20857 NalA The,,"pnorable jo4p,_Hei,,nz' 7 9 States' Senator 1306 Liberty Center 1001 Liberty Avenue Pitrsburgh® Pennsylvania 15222 Dear Senator Heinz: This is in reply to Your lettL.r (-)C !-)eptember 6, 1990, to Veronap ®n behalf of Ms. Bernice O� Berg, Mr. Richard J. Davis, 0 e being listed as an essential Pennsylvania, concerning -,fluorin nutrient. The United States Recommended Daily Allowances (U.S. RDA) are established for vitamins and minerals essential in human nutrition. These nutrients and their recommended levels have been derived by the Food and Dr. published Administration (FDA) from the ed by the Food and "Recommended Dietary Allowances Research Nutrition Board, National Academy of Sciences/National Council (NAS/NRC) and are subject to amendment from time to time by the NAS/NRC as more information on human nutrition becomes available. The National Research Council (loth I Edition 1989) notes that the status of fluorine® as an essential nutrient, has been debated Several studies in rodents have provided conflicting results. These contradictory results did not justify a classification of fluorine as an essential element, according to accepted standard�.,z. Nonetheless, because of its valuable effects On dental health® fluorineis a beneficial element for humans. t list fluorine as an essential nutrient. 1p does no -owf F -_A received _mMa _ry Isil source fr 1 which "tie National Research Council® the so data on essential nutrients, indicated that there was ns' justification to classify fluorine as an essential nutrient. We hope this information is sufficient. If we can be of any further assistance, please let us know. sincerely yours, [high C. Cannon Associate Commissioner for Legislative Affairs Enclosure Constituent®s ltr CC: Richard J. Davis Regional Food and Drug Director Mid -Atlantic Region Fluoride Chewable Tablets 0.5 mg are not indicated for use in geriatric patients. ADVERSE REACTIONS Allergic rash and other idiosyncrasies have rarely been reported. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1 -800 -FDA -1088. OVERDOSAGE Accidental ingestion of large amounts of fluoride may result in acute burning in the mouth and sore tongue. Nausea, vomiting and diarrhea may occur soon after ingestion (within 30 minutes) and are accompanied by salivation, hematemesis and epigastric cramping abdominal pain. These symptoms may persist for 24 hours. If less than 5 mg fluoride/kg body weight (i.e. less than 2.3 mg fluoride/lb body weight) has been ingested, give calcium (e.g., milk) orally to relieve gastrointestinal symptoms and observe for a few hours. If more than 5 mg fluoride/kg body weight (i.e. more than 2.3 mg fluoride/lb body weight) has been ingested, induce vomiting, give orally soluble calcium (e.g. milk, 5% calcium gluconate or calcium lactate solution) and immediately seek medical assistance. For accidental ingestion of more than 15 mg fluoride/kg of body weight (i.e. more than 6.9 mg fluoride/lb body weight), induce vomiting and admit immediately to a hospital facility. DOSAGE AND ADMINISTRATION Dissolve in the mouth or chew before swallowing, preferably at bedtime after brushing teeth. HOW SUPPLIED Chewable tablets containing 0.5 mg fluoride are purple -colored, grape flavor, un -scored, round, debossed "105". Available inbottles of 120's and 1000's. STORAGE Store at Controlled Room Temperature, 20°-25°C (68°-77°F). [See USP Controlled Room Temperature]. *F from sodium fluoride. Inactive Ingredients compressible sugar, croscarmellose sodium, D and C Red No. 27 aluminum lake, FD and C Blue No. 1 aluminum lake, grape flavor, magnesium stearate, mannitol, microcrystalline cellulose. 120 ct Base Label Active Ingredient PerTahlet Fluoride 0.5 mg Inactive Ingredients: compressible, r0 sugar, croscarmellose sodium, D&C Plural Carperalkmn Red No. 27 aluminum lake, FD&C Blue Fernand D, CA 91340 No.1 aluminum lake, gra pe Ilavor, iL magnesium stearate, mannitol, {� microcrystalline cellulose. DOSAGE AND ADMINISTRATION: f1] Dissolve in the mouth or chew before swallowing, preferably at bedtime after brushing teeth. Ill STORAGE: Store at Controlled Room Temperature, 20°-25° C $8°-77° Ff. [See USP Controlled Room r Temperature]. K1 Manufactured by: PureTek Corporation San Fernando, CA 91340 ti 120 ct Inside Label DESCRIPTION: Ea:'I N. A. Ch.." Tar 1. 05 giamyVv11 {FC&C Pec Dye Na. 31 fie,. Each 1ah1+C5 mg Ih.fl Vminlif[.mains 0.5mg "I-1.1 mg aodwa RuuWe INaR. Each mold for oral admidfaw cmassodium N. aide equvil n lnitadidA05mg and NefLlaal+ginanire ingreGenfE:cdnpessihk sugar.tmAtamdwse sOdrrti DG Red No ?I I.m—lake, FDSC 111. INa 1 alumna lab, grape 5avph meiAaaam ¢vara e, mannl mcrocrycal c lliA MNIGEL N UMACOLDGT: sodium Real acts s>raeadcslle Ibefc Q IwLh Amp0.Ylg and POpLAIiy{pada NupDdA[ ay AraISDN resisdn[ems[itldaWuhm,byprulnadigrewinerakeemoa ndhy ihWirg Phe carregenic microbial prpce55 ININATMAND OGAGF for once daily sdf-WitAl secomicwe as a dt" caries pimmiea In ppdmic patiams h has boon aRanishild that ngesDpn OI1Wdidaied dmrksp eater 11 ppm F41 dunng the pencd N hill dwelppmenr results in a sgpn"arr de[reaa in Ne rEcIdem[e ofdwgalcaries. Hppede alTahlel5 per,tl,relp" lo"'T Stam miC Dupnde Nr we a a Aupdemem n pedialr¢ parents iron 6 120 ct Outside Label err mesad In humai mil! Ncs—Er many drugs are eacratedl in lama's mid and ca'r. ' 5hi uld be e[arciad whenFLritle Caewklk hhMk 051X9 are BdmiEglArCd to N'Argq coign Ruauted milk pradumEOA aa9a rPpd190 E1 krm•.aEad hV asM� Rra ITh ware led a d at containing a hgb [oneemralkan OF Ruorde I W 177 mgiYg d bodywerfal. No,&mraa eR&m on part ion, ladaaom, a ""7 ['•ere seen n rale admimcaeredaapride ul m 5,% of hpheephr Thiodows at loam 200 Lma ;for RNn VP re[mmoor-J d dairy dos of FLrEde Chewahle TaVers Pllionc 0!a' The use N Naendg [aepaYa Tehle ; 0S Mg as a Canes prgea aim pod -¢hip age ;'11151 OnPha 016 Year' 6 sawed h!' wdlvice from adequaPeand wA-fair. led RrJ es oTeuudP wpotmerra[mhombnh lhroughaddesrence. Genitrk Dar. 11—idle Ck -bio 0rhfa004 mg ere nil inditped:or use�n peeavic Wx 1000 ct Base Label mamhsb 3yearsdape andcadeEn areas where 05hmumgwa[eluonde come [omen[does acaed08 rIX eppm F•. CDNTIWMORC Illic Rkcrib Clibid* iaWu 05rJaroa"' alAd a1 ha¢ REP TRIPfandsouldA d bradn",lu a pudiaAn RE ppm F1 and should Ai he adruygered mpedialnc pafienrs oder ape6wh¢n the Rdorde comenl of diking wary h47 ppm Per rp pedion. pa$ems Vdar ape3m,s Do Am"film [n NdtridACNAmahe Tadera{arry urm]Ihl to pediatric pats- under age 5munoz. ""'lh TPrdonged Lakyinges-uAN.""'s gfedlgr than Vd [Bien-erde0 8mounl mar faauh n yblDut dAgrAAt d dAnlal lluDEtsd EA-'au"Da[�faE untler aqe 6 years, especia$y f Be pater 111anaadpl il.- a 01 ppm. Read di•echrns..mlihy before us g. Nut art of the reel d children ADYIiISE REACTIONS, Allergic rash and .:her dasynt,gsts haul raffle Aw rgpoRgd. CMI T—r6(pp1r knsreliral M. roar side oll YWm1 edadfa44aa&jFDA■ 7 RODfO' 010. COMM Acadomal inpomon of 1sino amnums0 Runde ma, resiyin anne W ming n ke mouth and cam longue. Nausea, eam9ng antl darrheamay or[ on soon aver inge5tan f wdhin D0 mimmesl ani are appgmpenied W 551ivaDoq hena;empy end epgaaniC crampmq BhddTiM1 pain. TMA; Symrnma may pgfaiR RXloedea.M Ara body been D.e.lenthan tS mg lrapdeAb buoy xelgmf has been ige#ed, grog cokan fe.g. mkt orally W rakeee Ya.Nrohtpiinal a5mpa- ani observe for a few hwm M more dim 5 mg fluwidh% bodymipm iia mpg liters 21 Mg fkmrkd9% body eegh0 has ¢trap EapaAAQ mduca wmnlnp, gyre onaH aduhle calcium te.g. milk 5%rak-gk.—,a CakaRn larrmesdmpnl and PRE=DNS General: Flew refs m CONTMINDICRTM. YMRNINOS.11YERDOSolu emq 31. go ttocenmx IJw III pedatrit palms hPIAx Bre age al 6 monis rs rid reoummemdlk by tirmni. American Dema1 ASsa[ialipnand Amer km AcademyofPildl gaidelkea. DealplrEuradiare, Do oma& dunk dairy prods ms Minn one hour of norlde a]miniMabon. lime mpaabley of fluunde wth dairy foods hu been ,owwodl&,, W VnerrpnRaprid¢, which ES Dcakabsnhed. CambRartuon lilinai ls,nocerrnogmof Farr In � *,din nye and female mice and Wale rata Treated pith fluende of two heels rangirq kom 4,1 to 91 m�Ag 6 body might. E71ngcal eyidente 0 Carcourgeneys avas rPpanPL'oI male rats tetrad Min p.5 mg and I.1 i-medialelqseek medical eaancaree For aCCidemal Enilmoo 01 viallhap 15 mg Nuordw7g of body agipm II.e. moue Van 69 -gfluordn'b bode eeighl ,, mndun warding an] Amid-medlahly m a hospital lacikl DDSAGE AND AOMMISORAT10l Divahee in the mouth or chew befores mwinp,DreferaDN an bedIram she hrwhmp tsoh. NOW SUPPLIED' CR trifle lahlies [ontalnmp 0.5 ma fluoride are parple cdmed,grape lbvm, rn SCored. row, deIrl'1;5' hdLoble in hmllesof 100sand 10M'3 110C.59M 105-n Mull Same al F—Aled Ranm Temmemarrre, 20:45: C JEF FI. ISee 03P Corcidled Room Temperature] IF loon seem ni oodo. NDC 59088-105-73 Rx Only nq d lady weigh'. Ina 4-0 m." aim ygirgg¢n¢55 1ge ibcai in ram hales w femaks imeled with amde up m 11.3 ml %o bad'vamo This dot m m IPa6llr{ [I Amas ;realer Llan BIS rAshmmerdad dally dASA 07 Fluoride CYessahle iahlels Thh—ide mn unm wag— in srardard hanelwl syyemS. N kas been Shownlhal nuonde i,, has pelemialtoind- thipeosDmeaher'a;ma n cuhurgdhPanand robe We it d[aas much Mord., man mw In ranch humans are e[gmed. In -o Lala is conlllnug Some sadmec repel Chromimme caaage in modenta reale ocher ANAEe5 wing simlar [rOICCC15 repo, m,a7ae 95'.4Rn one, ad i'se mprd4ytI,e effect' of k wile =utIn aim -ern leanot .:"""Lan Aaglua- Ad ala affectsm—produepan aero'opened lar raes, m[e,t1r, and aa9le espmsedb ICO pp.nm Beater oancemmtm5411W ile h teir pet on yinong wafer. Rhersludiesconducled k'rmsdern slrated thallMxr doses as m:dride 5 AAA N body ¢boll did rat reed m impend f-hyard reprodu[ime cambion— This duce i5 appremmarely 210Iiii greater than 1h, recommended dairy dose d Fkodde Chee.aMe T6Wma, F.IAP0 ll; Tanrogotic Elko' Pragnantq Cx20%9. N Fae hears Shawn dur flu ride mimes NA p§ceTm d raiz bur only a 01% 'a Bre amwnr admndered G incpplmaod! in Loaf f4w, Animal ""al Irate, mite. rabbiislbaYe 11im Thal nuoMe is mm a1emtNer, Mal-DI0'"Ve lm 131 mq Pwridekq of had, s.epqhl haus[ m 13.1 mpig 61 hodywti"Irablia did nor aNecC Bre Inner sae a Fela1 wagFt and dd not increase 8. hequency of skdeia or ral me floueatil EpidemkApgical studies".ted in areas W- 4h IevKs d na:umlW Nuwdued eater ahosi nn ncrame In bah dafecis Nor. ocpD a to lkaridAdwnpn mA ud—FApnam mar real m akdegl kbtm6am ,COrnese Im as childhood Hillsiag 111Emv k is rat knots EF flumEe imis NDC 59008-$05-73 Rx Only Manufactured by Plural Carperalkmn Pharma PtaneSan Fernand D, CA 91340 Manufactured BY- Plamehk Crvprrapnn Pha ria Pure rk San Fernando. CA 91340 Lice No. 10573 ENA Roy, 01 2401130-1 Active Ingredient: PerTablet Fluoride 0,5 mg Inactive Ingredients: compressible, sugar, croscarmellose sodium, DSPC Red No. 27 aluminum lake, FDW Blue No.1 aluminum lake, grape flavor, magnesium stearate, mannitol, microcrystalline cellulase. NCC 59088-105-64 Rx Only DOSAGE AND ADMINISTRATION: (Frorn 1.1 mg of Sodium Fluoride) Dissolve in the mouth or chew before LA Grape Flavor swallowing, preferably at bedtime — after brushing teeth. r. STORAGE: Store at Controlled Room r Manufactured by: Temperature, 20°-25° C (fib° -77° F) K, PureTek Carparaiinn p San Fernando, C,4 91340 [See LISP Controlled Roam Temperature]_ -`� Manufactured by: Pita nna Pur PureTek Corporation + San Fernando, CA 91340 ` 1000 ct Inside Label DESCRIPTION: Each Fluoride Chewable Tahlm0.5mg is arydrmsine IFW Bed Dye No. 31 free. Each tablet 0.5 rapp (half-mrengthl contains 05 mg F" from 1.1 mg sodium fluoride INw. Each tablet for oral administration conmins sad! ore fluoride equivalent to fluoride 0.5 mg and the following inactive ingredients: compressible sugar, creasas, all o.. sodium, OW fled No. 27 aluminum lake, FYI&C Blue No.1 aluminum lake, grape flavor, magnesium stearate, mannbol, microcrystal- line cellulose. CLINICAL PHARMACOLOGY. Sodium fluoride acts systemically (before tooth eruption) and topically (post eruption) by increasing tooth resiInce to acid dissolution, by promoting remineralization, and by inhib@ing the c8riogenie microbial emotes. INDICATIONS ANO USAGE For once daily sell -applied symemic use as a dental caries preventive in pediatric padenm. It has been able ished that ingestion of fluoridated drinking water (1 ppm Fa) during the period of moth development results in a siggnificant decrease in the incidence of dental es. Fluoride Chewable Tahlem were developed m provide systemic tluoride for use as a supplement in pediatric patients from 6 months to 3 yearsof age and older living In aeaswhere the drinking water fluoride .me In does not exceed 0.6 ppm I 1000 ct Outside Label weight). No adverse effects on parturition, lactation, or offspring were seen in rats admineered fluoride up to 5 mglkg of body weight This dose is at Ieast2IXl times great" than the recommended daily dose of Fluoride Chewable briefs. Pediatric Use: The use of Fluoride Chewable Tablet. 0.5 mg as a c.ri as preventive In pediatric age groups 6 months to 16 yea ra is supported by evilone a from adequate and well-controlled studies on fluoride supplementation from birth through adolescence. Geriatric Use: Fluoride Chewable Tablets n5 mg are not indicated for use in geriatric patients. ADVERSE REACTIONS: Allergic rash and other idiosyncrasies have rely been reported, Call your doctor for medical advice about side effects. You may report side effecm to the IDA at 14M(.1DA-10M. OVERDOSAGE: Accidental ingestion of large amounts of fluoride may result in acute burning in the mouth and scut tongue. Nausea, vomitingg and diarrhea may occur scan after ingestion (within 30 inemsl and are accompanied by s.1fi ion, inch re.us sod .pi "boric cramping abdominal pain. These symptoms may persist for 24 hours. If less than 5 mgfluc idelkg body weight I.e. less than 2.3 m9 fluoridellb hotly weightl has been ingesid, give calcium Ill CONTRAINDICATIONS: fluoride Chewable Table" 0.5 mg are contaidicamd when the fluoride content of drinking water is more than Off f ppm F"andshouldnot beadminlmered to pediatric patients under age 6 when the fluoride content of drinking water is 03 ppm P. or to pediatric patients under age 3ye..a.. Do not administer Flooride Chewable Tablets Jany, strength) to pdiatnc patients under age a months. WARNINGS Prolonged daily ingestion of queequities greater then the mended amount may result in various degrees of dental flue roves in pediatricpatients under ape 6 years, especially 9 the water duo inflation exceeds 0 6 ppm. Read directions carefully before using, Keep out of the mach of children. PRECAUTIONS: Genemh Please reform CANITIAINDICATIONS, WARNINGS, OVERDOSAGE sedans for overdosage concerns. Used pediatric patients below rhe age i months m not recommended by current American Denial Association and American Academy of Pediatrics guidelines. Drug Interactions: Do not eat or drink dairy products within one hour Ie.g., milk) orally to relieve gas0aiinestinal symptoms and observe for a few hours. If more Nan 5 mg flVOrida)kg body weight 0.e, mora than 2.3 mg fluheIII"I11,dy weightl has been ingested, induce vomiting, give orally soluble calcium {e.g. milk 5%oalcium glucm se, or calcium lactate soludool and immediately seek medical assistance. For accidental ingestion m morethan 15 rap fluoridelkg of body weigh lto more than 6.9 mg fluoridellb body weight), induce vomiting and admit immediately to a lam pial facility. DOSAGE AND ADMINISTRATION: Dissolve in the mouth or chew before swallowing, preferably at bedtime after brushing teeth. NOW SUPPLIED: Chewable tablets containin.5 ra g 0p fluoride are purple -se served, grape flavor, um scored, round, debossed "105". Available in bottles of 120s and 10D0's. NGC: 590M 105-14 STORAGE: Store at Controlled Room Temperature, 20°-25° C 168°71°FI (See USP Controlled Aoam Tamperatual 'F from sodium fluoride. of fluoride admmishation. Incompatibility of fluoride with dairy feeds has been reported due to formation of cal ciumfluoride, which is poorlyebsorbed. Carcinogenesis, Mtlzagenesis, Impairment of Fertilfly: In a studq conducted in rodents, no carcinogenesis was found in male and female mice and female rats treated with fluoride at dose levels ranging from 4,1 to 9.1 mi of body weight. Equivocal evidence of cinagenasis was reported for male race treated with 2.5 in and 4.1 mg of body weight. In a second study, no carcinogenesis was observed in rets, males or females treated with guode up to 11.3 mg/kg of hotly weight This dace is abeam 400times greater than the recommended sell m Fluoride Chewable Tablets. Fluoride ion is not mumganic in standard bacirial systems. It hes been shown that fluoride our has potential to induce chromosome e4ahire tons in Cultured human and rodent cells at doses rough higher than those in which humans are exposed. In vivo data is conflicting. Some studies report chromosome damage in rodents while other studies using similar incomes reportnegetive results. Proemial adverse reproductive effects of fluoride exposure in humanshas net been adequately evaluated. Adverse effects on rep duction were eported far rats, mica, fon, and cdle saposed to 100 one or greater concentrations of fluoride in thei`I let or drinking water, Other studies conducted in rats demonstrted that over doses of fluoride 15 or If of body weightl did not result in impaired fertililyand reproductive capa6ilines. This duce is approximately 206 times greater than the recommended daily dose of Fluoride Chewable Tablets. Pregnancy: Terategenic Effects: Pregnancy Category B. It has been shown that fluoride crosses the placerb of rats, but only &.01% of the amount admin istead is mecrpoated in fatal use. Animal studies (rats, mice, rabbit.l have shown that fluoride is not a teatcgen. Maternal exposure to 12,2 mg flupdelhg of body eight (rats) or 13.1 m91k9 of body weight (rabbits) did not affect the liner size or fete) weight and did not increase the frequency of skmeml or visceral malformdons. Epuk emi0logreel studies cooducred in areas with high levels of reaturallyfluoddat al water showed no Increase in birds defects. Heavy exposure to fluoride during in utero development may result In skelaml fluorosis which becomes evident in childhood. Nursing Methods It is not known if flood. ion is excited In human milk. However, many drugs are excrmed in human milk and caution should be exercised when fluoride Chewable Tablets 0.5 of are administered to nursing women. Reduced milk production en the animals were fed a diet containing ahigh din aconce�ntconcentration ofsed fox hfluoride (98-137 ri of body 159088-105-64 Rx Only ChewableFluoride .e (11.1 .9 of Scudiurn Fluoride) Grape I Manufactured by: Pharma Pure PuFerr Cgrpgrat13 _^ San Cin rernantlO, CA 91340 Matafactured By: "'feT"`I.TEr i, Pharma Pure 5an Fernando, CA 91390 rRai 01 20186 1 FLUORIDE sodium fluoride tablet, chewable Product Information . ■ Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:59088-105 Route of Administration ORAL DEA Schedule Active Ingredient/Active Moiety � Ingredient Name SODIUMFLUORIDE (UNII: 8ZYQ1474W7) (FLUORIDE ION - UNII:Q80VPU4080) Inactive Ing re die nts Ingredient Name SUCRO SE (UNII: C 151H8 M554) CRO SCARMELLO SE SODIUM (UNII: M280L1HH48) D&C RED NO. 27 (UNII: 2LRS185U6K) FD&C BLUE NO. 1 (UNII: FBR47K3TBD) MAGNESIUM STEARATE (UNII: 70097M6I30) MANNITOL (UNII: 30WL53L36A) CELLULOSE, MICROCRYSTALLINE (UNII: OP1R32D61U) Product Characteristics Color purple (Light purple) Shape ROUND Flavor GRAPE (Grape flavor) Contains Packaging # Item Code 1 NDC:59088-105-73 2TNDC:59088-105-64 Package Description 120 in 1 BOTTLE, PLASTIC 1000 in 1 BOTTLE, PLASTIC Score Size Imprint Code Basis of Strength Strength FLUORIDE ION 0.5 mg Marketing Start Date Strength no score 7mm 105 Marketing End Date Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date unapproved drug other 06/01/2011 Labeler - PureTek Corporation (785961046) Establishment Name Address ID/FEI Business Operations PureTek Corporation 785961046 manufacture, label, pack, outsourcing human drug compounding, relabel, repack Establishment Name Address ID/FEI Business Operations PureTek Corporation 031678746 manufacture, label, pack, outsourcing human drug compounding, relabel, repack Revised: 5/2011 PureTek Corporation OUR MOST VALUABLE ASSET IS YOU. WITH YOUR HELP, WE CAN CREATE CHANGE. fan newsletter Sign up for our free newsletter for updates on the latest fluoride developments. Find ways to get involved. (#) First Name* Last Name* Email* State/Province Country JOIN HOME (HTTRUFLUORIDEALERT.ORG) // STUDIES (HTTP://FLUORIDEALERT.ORG/ARCHIVE/STUDY) // FLUORIDE & IQ: THE 50 STUDIES (HTTP://FLUORIDEALERT.ORG/STUDIES/BRAIN01/) // JOIN US W DONATE �I t�RQ�DkFJFINORiffcA1b3Q10Fkf6F iu�1N�tTE/D uoridealert.org/fan-tv/) F.A.Q. (http://fluoridealert.org/fag/) N POSU BSC RIPTIONID=2553) Newshtt://fluorldealert.or /news/ N hft ://fluoridealert.or /abouU l u. I H E 5 v M E ttp://www.facebook.com/Fluoride)\ctionNetwork) Fluoride Action Network I By Michael Connett & Tara Blank, PhD I UPDATED April 25, 2016 As of April 2016, a total of 57 studies have investigated the relationship between fluoride and human intelligence, and a total of 38 studies have investigated the relationship fluoride and learning/memory in animals. Of these investigations, 50 of the 57 human studies have found that elevated fluoride exposure is associated with reduced IQ, while 37 of the 39 animal studies (http://www.fluoridealert.orci/studies/brainO2/) have found that fluoride exposure impairs the learning and/or memory capacity of animals. The human studies, which are based on IQ examinations of over 12,000 children, provide compelling evidence that fluoride exposure during the early years of life can damage a child's developing brain. After reviewing 27 of the human IQ studies, a team of Harvard scientists (http://www.fluoridealert.orci/articles/hsph 2012/) concluded that fluoride's effect on the young brain should now be a "high research priority." (Choi, et al 2012). Other reviewers have reached similar conclusions, including the prestigious National Research Council (httr)://www.fluoridealert.org/researchers/nrc/findings/) (NRC), and scientists in the Neurotoxicology Division (http://www.fluoridealert.ora/uploads/epaa mundypdf) of the Environmental Protection Agency (Mundy, et al). In the table below, we summarize the results from the 50 studies that have found associations between fluoride and reduced IQ and provide links to full -text copies of the studies. For a discussion of the 7 studies that did not find an association between fluoride and IQ, click here (http://www.fluoridealert.org/studies/brain07/). Quick Facts About the 50 Studies: (https://npo.networkforciood.ora/Donate/Donate. npoSu bscri ption Id=2553) (http://fluoridealert.myshopify.com/) FAN NEWSLETTER Sign up for our free newsletter for updates on the latest fluoride developments. First Name* Last Name* Email* State/Province Country JOIN QUICK FACTS 91% OF WESTERN EUROPE HAS REJECTED WATER FLUORIDATION (HTTP://WWW.FLUORIDEALERT.ORG/CONTENT/EURO STATEMENTS/) MANY CHILDREN NOW EXCEED RECOMMENDED DAILY FLUORIDE INTAKE FROM TOOTHPASTE ALONE. (HTTP://FLU0RID EALE RIO RG/ISSUES/SO URCES/F- TOOTHPASTE/) FLUORIDE IS NOT A NUTRIENT (HTTP://WWW.FLUORIDEALERT.ORG/STUDIES/ESSEX NUTRIENT . 50 STUDIES HAVE LINKED FLUORIDE WITH REDUCED IQ IN CHILDREN Location of Studies: China (32), India (13), Iran (4), and Mexico (1). (HTTP://WWW.FLUORIDEALERT.ORG/STUDIES/BRAIN Sources of Fluoride Exposure: 41 of the 50 IQ studies involved communities (http://fluoridealert.ora/fan-tv/beciley/)/) where the predominant source of fluoride exposure was water; seven studies investigated fluoride exposure from coal burning. Fluoride Levels in Water: IQ reductions have been significantly associated with RELATED ARTICLES: fluoride levels of just 0.7 to 1.2 mg/L (Sudhir 2009); 0.88 mg/L among children with RELATED VIDEOS: iodine deficiency_(http://www.fluoridealert.ora/studies/thyroid01/) (Lin 1991) Other Rat Studies Link Brain Cell Damage With studies have found IQ reductions at 1.4 ppm (Zhang 2015); 1.8 ppm (Xu 1994); 1.9 Aluminum and Fluoride in Water ppm (Xiang 2003a,b); 0.3-3.0 ppm (Ding 2011); 2.0 ppm (Yao 1996, 1997); 2.1 The Wall Street Joumal October 28. 1992 Rat Studies Link ppm (Das 2016); 2.1-3.2 ppm (An 1992); 2.2 ppm (Choi 2015); 2.3 ppm (Trivedi Brain Cell Damage With Aluminum and Fluoride in Water by 2012); 2.38 ppm (Poureslami 2011); 2.4-3.5 ppm (Nagarajappa 2013); 2.45 ppm Marilyn Chase Staff Reporter ANAHEIM. Calif. -Ateam of (Eswar 2011); 2.5 ppm (Seraj 2006); 2.5-3.5 ppm (Shivaprakash 2011); 2.85 ppm Dr. Wvvan Howard on Fluoride in Drinking Water (Hong 2001); 2.97 ppm (Wang 2001, Yang 1994); 3.1 ppm (Seraj 2012); 3.15 ppm (http://fluoridealert.orci/fan-tv/vXv_van- (Lu 2000); 3.94 ppm (Karimzade 2014); and 4.12 ppm (Zhao 1996). howard/ Fluoride Levels in Urine: About a quarter of the IQ studies have provided data on (http://fluoridealert.org/articlea/w-si- the level of fluoride in the children's urine, with the majority of these studies 1992/) reporting that the average urine fluoride level was below 3 mg/L. To put this level in perspective, a study from England found that 5.6% of the adult population in Summary of 2011 Fluoride Research fluoridated areas have urinary fluoride levels exceeding 3 mg/L, and 1.1% have Evidence of fluoride's detrimental effects on the brain and levels exceeding 4 mg/L. (Mansfield 1999 central nervous system continues to mount. At least four more (http://www.fluoridealert.ora/uploads/mansfield-1999.pdf)) Although there is an Infant Fluoride Exposure Fluoride .org/fan-tv/infant- (http://fluoridealert.org/fan-tv/infant- appalling appalling absence of urinary fluoride data among children in the United States, the exposure/) excess ingestion of fluoride toothpaste total number of such studies at 25. (http://www.fluoridealert.org/contenVtoothpaste-exposure/) among some young children is almost certain to produce urinary fluoride levels that exceed 2 ppm in a (http://fluoridealert.org/articles/2011 review/) portion of the child population. Methodological Limitations Finally, it is worth considering that before any of the studies finding reduced IQ in humans were known in the western world, a team of U.S. scientists at a Harvard- RELATED STUDIES: affiliated research center predicted (based on behavioral effects they observed in Fluoride's Effect on Fetal Brain Ed Begley Jr: Many Studies Link Fluoride to Reduced IQ As both the NRC and Harvard reviews have correctly pointed out, many of the (http://fluoridealert.ora/fan-tv/beciley/)/) fluoride/IQ studies have used relatively simple designs and have failed to adequately control for all of the factors that can impact a child's intelligence (e.g., parental education, socioeconomic status, lead and arsenic exposure). For several reasons, RELATED ARTICLES: however, it is unlikely that these limitations can explain the association between fluoride and IQ. Rat Studies Link Brain Cell Damage With Aluminum and Fluoride in Water First, some of the fluoride/IQ studies have controlled for the key relevant factors, and The Wall Street Joumal October 28. 1992 Rat Studies Link Brain Cell Damage With Aluminum and Fluoride in Water by significant associations between fluoride and reduced IQ were still observed. This fact Marilyn Chase Staff Reporter ANAHEIM. Calif. -Ateam of was confirmed in the Harvard review, which reported that the association between New York scientists said rat studies offer preliminary evidence that aluminum, when administered in dunking water, may be fluoride and IQ remains significant when considering only those studies that controlled linked with behavior changes and damaged for certain key factors (e.g., arsenic, iodine, etc). Indeed, the two studies that (http://fluoridealert.org/articlea/w-si- controlled for the largest number of factors (Rocha Amador 2007 1992/) (htto://http://www.fluorid ea le rt.org/uDloads/rocha amador-2007.pdf); Xiang 2003a.b (http://http://www.fluoridealert.org/uDloads/xiang-2003a.pdf)) reported some of the Summary of 2011 Fluoride Research largest associations between fluoride and IQ to date. Evidence of fluoride's detrimental effects on the brain and central nervous system continues to mount. At least four more studies finding a link between fluoride exposure and decreased Second, the association between fluoride and reduced IQ in children is predicted by, intelligence (IQ) of children were published this year, putting the and entirely consistent with, a large body of other evidence. Other human studies total number of such studies at 25. (http://www.fluoridealert.orci/studies/brainO3/), for example, have found associations (http://fluoridealert.org/articles/2011 review/) between fluoride, cognition, and neurobehavior in ways consistent with fluoride being a neurotoxin. In addition, animal studies have repeatedly found Fluoride & the Brain (http://www.fluoridealert.orci/studies/brainO2/) that fluoride impairs the learning and The most recent Chinese study on fluoride & the brain was costed on PubMed im last week. The study looked at the memory capacity of rats under carefully controlled laboratory conditions. An even effect of fluo de on the hippocampal region of rat bmin, and larger body(httD://www.fluoridealert.org/studies/brain04/) of animal research has found concluded that: "Fluoride may go through the bl od-brain barrier andaccumulate in rat hippocampus, and inhibit the activity of that fluoride can directly damage the brain, a finding that has been confirmed in cholinesterase." studies of aborted human fetuses (http://www.fluoridealert.ora/studies/brain05/) from (http://fluoridealert.org/articles/science- high-fluoride areas. watch01/ Finally, it is worth considering that before any of the studies finding reduced IQ in humans were known in the western world, a team of U.S. scientists at a Harvard- RELATED STUDIES: affiliated research center predicted (based on behavioral effects they observed in Fluoride's Effect on Fetal Brain fluoride -treated animals) that fluoride might be capable of reducing IQ in humans. The human placenta does not prevent the passage of fluoride from a pregnant mother's bloodstream to the fetus. As a (Mullenix 1995) RELATED MISCELLANEOUS CONTENT: result, a fetus can be harmed by fluoride ingested preonancv. Based on research from China, the fetal brain is one of the Summary organs susceptible to fluoride poisoninq. As highlighted by the excerpts Fluoride & the Brain: An Interview with Dr. Phyllis (http://fluoridealert.ora/studies/brain05� When considering their consistency with numerous animal studies, it is very unlikely Mullenix that the 50 human studies finding associations between fluoride and reduced IQ can all 188(4);218, be a random fluke. The question today, therefore, is less whether fluoride reduces IQ, a y Fluoride's Neurobehavioral Effects in Humans & Animals but at what dose, at what time, and how this dose and time varies based on an In addition to studies linking fluoride to reduced IQ in humans, individual's nutritional status, health status, and exposure to other contaminants (e.g., and impaired learning/memory in animals, human and animal studies have also linked fluoride to a variety of other aluminum, arsenic, lead, etc). Of particular concern is fluoride's effect on children born on the neurotoxic effects of fluoride in rat studies. And Phyllis neurobehavioral effects. These studies, which are excerpted to women with suboptimal iodine intake below, provide vet further evidence that fluoride is a neurotoxin. The importance of considering other (httD://www.fluoridealert.org/studies/thyroid01) during the time of pregnancy, and/or Age of Subjects: 6 to 18 (http://fluoridealert.org/studies/brain03� fluoride's effects on infants and toddlers with suboptimal iodine intake themselves. Water According to the U.S. Centers for Disease Control, approximately 12% of the U.S. Water Fluoride Level Average = 2.1 mg/L (S.D. = 1.64 mg/L) Fluoride Affects Learning & Memory in Animals population (http://www.fluoridealert.org/articles/iodine intake/) has deficient exposure Combined Raven's Test for RuralChina (CRT -RC) An association between elevated fluoride exposure and reduced to Iodine. intelligence has now been observed in over 30 studies of human populations. Although a link between fluoride and intelligence might initially seem surprising or random, it is decreasing level of IQ. As fluorosis is a consequence of fluoride actually consistent with a large body of animal research. This STUDIES FINDING ASSOCIATION BETWEEN FLUORIDE & REDUCED IQ: animal research includes the following 37 http://fluoridealert.orci/studies/brainO2 / IQ Study #50: (Das 2016)(htto:Ihvww.ncbi.nim.nih.gov/pubmed/26960765) Citation: Das K, Mondal NK. (2016). Dental fluorosis and urinary RELATED MISCELLANEOUS CONTENT: fluoride concentration as a reflection of fluoride exposure and its impact on IQ level and BMI of children of Laxmisagar, Simlapal Block of Bankura District, W.B., Fluoride & the Brain: An Interview with Dr. Phyllis India. Environmental Monitoring & Assessment Mullenix 188(4);218, The followina interview with Phyllis Mullenix took place on October 18, 1997. The interviewer is Paul Connett. I. Location of Study: West Bengal, India ACADEMIC BACKGROUND Connett: We're talking with Dr. Phyllis Mullenix, who in 1995, published a very important work on the neurotoxic effects of fluoride in rat studies. And Phyllis Size of Study: 149 schoolchildren would you begin by telling us vour (http://fluoridealert.org/content/mullenix- Age of Subjects: 6 to 18 interview/ Source of Fluoride: Water Water Fluoride Level Average = 2.1 mg/L (S.D. = 1.64 mg/L) Type of IQ Test: Combined Raven's Test for RuralChina (CRT -RC) Results: "IQ has anegative significant correlation with dental fluorosis (r -0.253,P<0.01). Dental fluorosis acts as an indicator of decreasing level of IQ. As fluorosis is a consequence of fluoride exposure, so IQ has a negative significant correlation with exposure dose (r=0.343, P<0.01) which was considered as a fluoride input source." (http://fluoridealert.orci/take-action) "IQ values were plotted against the urinary fluoride concentration and it was found that they have a significant negative correlation (r-0.751, P<0.01)." Conclusion "[C]hildren residing in areas with higher than normal water fluoride level demonstrated more impaired development of intelligence and moderate [dental fluorosis]. Millions of children including adults around the world are affected by higher level offluoride concentration through their drinking water and are therefore potentially at risk. It is concluded that for the benefit ofthe future generation, urgent attention should be paid on this substantial public health problem." IQ Study #49: Mondal (2016)(http:/Kluoridealert.orci/studytracker/22507/) Citation: Mondal D, at al. (2016). Inferring the fluoride hydrogeochemistry and effect of consuming fluoride - contaminated drinking water on human health in some endemic areas of Birbhum district, West Bengal. Environmental Geochemistry & Health 38(2):557-76. Location of Study: Birbhum district, India Size of Study: 40 children (20 from endemic fluorosis area; 20 from control area) Age of Subjects: 10 to 14 years old Source of Fluoride: Water Water Fluoride Levels: "Mean F concentration in the study area varies from 0.32 to 13.29 mg/L." Type of IQ Test: Raven Standard Theoretical Intelligence Test Results: "This study indicates that students exposed to high F (children of Junidpur and Nowapara) show an average IQ of 21.17 ± 6.77 in comparison with low -F exposed students (children of Bilaspur, Mohula, Bhalian) having an average IQ of 26.41 ± 10.46.... Statistical analysis (Z test) demonstrates thatthere is a significant (Z = 2.59) difference in IQ among the high- and low -F area student." Conclusion "[S]tudents ofthe study area have less IQ than students of non -contaminated area, demonstrating that consumption of F also has a major role with the intellectual development of children:' IQ Study #48: Khan (2015) (http:ltfluoridealert.org/uploads/khan-2015.pdf) Citation: Khan SA, et al. (2015). Relationship between dental fluorosis and intelligence quotient of school going children in and around Lucknow district: a cross- sectional study. Journal of Clinical & Diagnostic Research 9(11):ZC10-15. Location of Study: Lucknow district, India. Size of Study: 429 schoolchildren Age of Subjects: 6-12 years old Source of Fluoride: Water Results: "In this study, on comparison of children at two locations according to IQ grades [Table/Fig-4], majority ofthe children (74.8%) living in low fluoride area had an IQ grade 2 (definitely above the average in intellectual capacity). None ofthe children from the low fluoride area had an IQ grade 4 and 5 (definitely below average and intellectually impaired). On the other hand, majority of children (58.1 %) from high fluoride area fall under IQ grade 3 (intellectually average). None ofthe children from high fluoride area had an IQ grade 1 (intellectually superior). This difference in IQ grades of children amongstthe two areas was found to be statistically significant (p<0.001)""[I]t is clearly evident thatwith increase in the grade offluorosis, a trend of increase in the IQ grade (decrease in intellectual capacity) was observed indicating a strong correlation between fluorosis grade and IQ grade (Spearman's p=0.766)" Conclusion: "The data from this research may support the hypothesis that excess fluoride in drinking water has toxic effects on the nervous system:' IQ Study #47: Sebastian (2015) (http:llfluoridealert.oro/studytracker/23058/) Citation: Sebastian ST, Sunitha S. 2015. A cross-sectional study to assess the intelligence quotient (IQ) of school going children aged 10-12 years in villages of Mysore district, India with different fluoride levels. Journal ofthe Indian Society of Pedodontics and Preventive Dentistry 33(4):307-11. Location of Study: Mysore district, India Size of Study: 405 schoolchildren (135 children from high fluoride area; 135 children from "normal" fluoride area; 135 chidren from "low" fluoride area) Age of Subjects: 10-12 years old Source of Fluoride: Water Water Fluoride Levels: High -fluoride: 2.2 mg/L; "Normal" Fluoride: 1.2 mg/L; "Low" Fluoride: 0.4 mg/L Type of IQ Test: Raven's colored Progressive Matrices Test Results: "In bivariate analysis, significant relationships were found between water fluoride levels and Intelligence Quotient of school children (P < 0.05). In the high fluoride village, the proportion of children with IQ below 90, i.e. below average IQ was larger compared to normal and low fluoride village. Age, gender, parent education level and family income had no significant association with IQ:' Conclusion: "School children residing in area with higher than normal water fluoride level demonstrated more impaired development of intelligence when compared to school children residing in areas with normal and low water fluoride levels." IQ Study #46: Kundu (2015) (http://fluoridealert.ora/studytracker/22508/) Citation: Kundu H, et al. (2015). Effect offluoride in drinking water on children's intelligence in high and low fluoride areas of Delhi. Journal ofthe Indian Association of Public Health Dentistry 13(2):116-121. April -June. Location of Study: Delhi, India. Size of Study: 200 school children: 100 from low F area and 100 from high F area. Age of Subjects: 8-12 years of age. Equal numbers of male and female children were included in the study. Source of Fluoride: Water Type of Cognitive Tests: Ravens Standardized Progressive Matrices Test Results: "Comparison of mean IQ of children in both high (76.20 ± 19.10) and low F (85.80 ± 18.85) areas showed a significant difference (P= 0.013). Multiple regression analysis between child IQ and all other independent variables revealed that mother's diet during pregnancy (P= 0.001) along with F in drinking water (P= 0.017) were the independent variables with the greatest explanatory power for child IQ variance (r2 = 0.417) without interaction with other variables." Conclusion: "Fluoride in the drinking water was significantly related with the IQ of children. Along with fluoride, mother's diet during pregnancy was also found to be significantly related with IQ of children" IQ Study #45: Choi (2015) (htto://fluoridealert.org/studytracker/20589/) Citation: Choi A, et al. (2015). Association of lifetime exposure to fluoride and cognitive functions in Chinese children: A pilot study. Neurotoxicology & Teratology 47:96-101. Location of Study: Southern Sichuan Province, China. Size of Study: 51 children from elevated fluoride area Age of Subjects: Avg = 7.1 years old Source of Fluoride: Water Urine Fluoride Levels: Mean = 1.64 mg/L; Range = 0.22 to 5.84 mg/L Water Fluoride Levels: Mean = 2.2 mg/L; Range = 1.0 to 4.07 mg/L Confounding Factors: "In this rural community, social differences are limited. The parents or guardians completed a questionnaire on demographic and personal characteristics including the child's sex, age at testing, parity, illnesses before age 3, past medical history of the child and caretakers, parental or guardian age, education and occupational histories, and residential history, and household income. It is known that iron deficiency can impair motor and mental developments in children, iron concentration was therefore considered as a covariate. These potential confounders were used for adjustment in the statistical analysis." "Among possible confounders, both arsenic and lead are known to be low in drinking water in the area." Type of Cognitive Tests: WRAML, WISC-R, WRAVMA Results: "Results of our pilot study showed that moderate and severe dental fluorosis was significantly associated with deficits in WISC-R digit span. Children with moderate or severe dental fluorosis scored significantly lower in total and backward digit span tests than thosewith normal or questionable fluorosis. These results suggest a deficit in working memory. Scores on other tests did not show significant relationships with indices offluoride exposure" Conclusion: "Results of our field study raise a concern about the safety of elevated systemic exposure to fluoride from high concentrations in the drinking water.While topical fluoride treatment confers benefits of reducing caries incidence, the systemic exposure should not be so high as to impair children's neurodevelopment especially during the highly vulnerable windows of brain development in utero and during infancy and childhood and may result in permanent brain injury. We are planning a larger scale study to better understand the dose—effect relationships for fluoride's developmental neurotoxicity in order to characterize the appropriate means of avoiding neurotoxic risks while securing oral health benefits" IQ Study #44: Zhang (2015)(http:/Mluoridealert.orci/studytracker/21075/) Citation: Zhang S, et al. (2015). Modifying Effect of COMT Gene Polymorphism and a Predictive Role for Proteomics Analysis in Children's Intelligence in Endemic Fluorosis Area in Tianjin, China. Toxicological Sciences 144(2):238-45. April. Location of Study: Tianjin City, China Size of Study: 180 children (96 from control area; 84 from "high fluoride" area) Age of Subjects: Avg = 11 years old Source of Fluoride: Water Water Fluoride Levels: High = 1.4 mg/L Control = 0.63 mg/L Urine Fluoride Levels: High = 2.4 + 1.01 mg/L Control = 1.10 + 0.67 mg/L Serum Fluoride Levels: High = 0.18 + 0.11 mg/L Control = 0.06 + 0.03 mg/L Type of IQ Test: Combined Raven's Test for Rural China (CRT -RC) Confounding Factors: "Covariates included the indicator variables for age, gender, educational levels of parents (primary and below, junior high school, senior high school, and above), and continuous variables for drinking water fluoride (mgA) and levels of thyroid hormones (T3, T4, and TSH)." Results: "[T]he present work demonstrated that the IQ scores of children exposed to high fluoride drinking water were significantly lower than those who lived in control area . . .. [O]ur findings further showed that, across the full range of serum and urinary fluoride, children's IQ decreased gradually with the increase offluoride contents in serum and urine, in a dose-dependent manner." Conclusion: "In summary, our data suggestthat the intelligence of children is affected by the COMT gene polymorphism and, in particular, this SNP plays a role in modifying the effect offluoride exposure on cognition. Children with COMT reference allele had a higher risk for cognitive impairments after fluoride exposure. Additionally, proteomics analysis represents early specific markers of developmental fluoride neurotoxicity. Hence, our findings provide certain basis for clarifying the mechanisms and identifying molecular targets of pharmacological interventions for potential delayed therapy." IQ Study #43: Bai (2014) (http://fluoridealert.ora/studytracker/19413/) Citation: Bai Z, et al. (2014) Investigation and analysis ofthe development of intelligence levels and growth of children in areas suffering fluorine and arsenic toxicity from pollution from burning coal. Chinese Journal of Endemiology 33(2):160-163. Location of Study: Shaanxi Province, China. Size of Study: 303 children (120 children from high -fluoride area; 95 from mid -fluoride area, 98 from low -fluoride area) Age of Subjects: 8 to 12 years old Source of Fluoride Coal burning Urine Fluoride Levels: "The median urinary fluoride levels for children 8-12 years old in the areas of significant, minor and no morbidity were, respectively, 1.96, 0.81 and 0.54 mg/L." Results: "The children's urinary fluoride and urinary arsenic levels versus intelligence [quotients] were both negatively correlated (r=-0.560, -0.353, all P<0.05)." Conclusion "Exposures to fluorine and arsenic are deleterious to the development of intelligence and the development of growth in children" IQ Study #42: Wei (2014) (http://www.fluoridealert.ora/uploadstwei-2014.pdf) Citation: Wei N, et al. (2014). The effects of comprehensive control measures on intelligence of school-age children in coal -burning -borne endemic fluorosis areas. Chinese Journal of Endemiology 33(3):320-22. Location of Study: Bijie City, Guizhou Provinc, China. Size of Study: 741 children (104 children from low -fluoride area; 298 children from an endemic fluorosis area with long-term defluoridation measures; 339 children from endemic fluorosis area with short-term defluoridation measures). Age of Subjects: 8-12 years old Source of Fluoride: Coal Urinary Fluoride Levels: Control: 1.34 ± 0.64 mg/L; Long-term defluoridation: 2.33 ± 0.18 mg/L; Short-term defluoridation: 3.03 ± 0.16) mg L. Results: "Above average IQ of children in the control group was 97.1 % (101/104),which was significantly higher than that of long and short treatment groups; after a lengthy treatment, mental retardation detection rate was significantly lower in the low -age group,8-10 year-old children(x2=7.542,P < 0.01). Urinary fluoride content was negatively correlated with the level of IQ (r = -0.553,P < 0.01)." Conclusion: "The intelligence development of children in coal - burning -borne endemic fluorosis area is significantly delayed. After a certain period of comprehensive treatment,the decreased level of cognition is inhibited and the mental retardation in the low -age group is improved:' IQ Study #41: Nagaraiappa (2013) (htto://www.fluoridealort.orci/uploads/naciaraoa[)[)a- 2013.pdf) Citation: Nagarajappa R, et al. (2013). Comparative assessment of intelligence quotient among children living in high and low fluoride areas of Kutch, India: a pilot study. Iranian Journal of Public Health 2(8): 813-818. Location of Study: Kutch District, Gujarat, India Size of Study: 100 children (50 children from high -fluoride area; 50 children from control area) Age of Subjects: 8-10 years old Source of Fluoride: Water Water Fluoride Levels: High Fluoride: 2.4 to 3.5 mg/L; Control: 0.5mg/L. Type of IQ Test: Seguin Form Board Test Results: "Mean scores for average, shortest and total timing category were found to be significantly higher (P<0.05) among children living in Mundra (30.45±4.97) than those living in Bhuj (23.20±6.21). Mean differences at 95% confidence interval for these timings were found to be 7.24, 7.28 and 21.78 respectively." Conclusion: "Chronic exposure to high levels offluoride in water was observed to be associated with lower intelligence quotient." IQ Study #40: Singh (2013) (http://fluoridealert.ora/wo-content/uploads/singh-2013.pdf) Citation: Singh VP, at al. (2014). A correlation between serum vitamin, acetylcholinesterase activity and IQ in children with excessive endemic fluoride exposure in Rajasthan, India. European Academic Journal 2(4):5857-5869. Location of Study: Jaipur, Rajasthan (India) Size of Study: 42 children (70 from high -fluoride area; 72 from control area) Age of Subjects: 9 to 14 year olds Source of Fluoride: Water Levels of Fluoride in Water: High Fluoride = 6.8 mg/L Control area = <1.03 mg/L Confounding Factors: "The subjects were similar in living conditions, parental literacy, socioeconomic status, and health history. Moreover, age and sex matched controls were selected from the [low -fluoride area]." Type of IQ Test: Raven's Test Conclusion: "We observed reduced AChE activity in [the high fluoride area] which may be directly correlate[d] with the reduced intelligence score ofthe subjects" IQ Study #39: Karimzade (2014) (http://fluoridealert.org/wp-content/uploads/karimzade- 2014.pdf) Citation: Karimzade S, at al. (2014). Investigation of intelligence quotient in 9 -12 -year-old children exposed to high- and low -drinking water fluoride in West Azerbaijan province, Iran. Fluoride 47(1):9-14. Location of Study: Poldashi and Piranshahr, West Azerbaijan province, Iran. Size of Study: 39 male children (19 from high -fluoride area; 20 from control area) Age of Subjects: 9 to 12 year olds Source of Fluoride: Water Water Fluoride Levels: High Fluoride = 3.94 mg/L Control = 0.25 mg/L Confounding Factors: No significant differences were found in the potential confounding factors of educational, economic, social, cultural, and general demographic characteristics between the high- and low -F regions. Type of IQ Test: Iranian version of the Raymond B Cattell test Results: "The IQ ofthe 19 children in the high -F region was lower (mean±SD: 81.21±16.17), than that ofthe 20 children in the low -F region (mean±SD: 104.25±20.73, p=0.0004). In the high -F region, 57.8% had scores indicating mental retardation (IQ <70) or borderline intelligence (IQ 70-79), while this figure was only 10% in the low—F region." Conclusions: "The study found that children residing in a region with a high drinking water F level had lower IQs compared to children living in a low drinking water F region (p<0.001). The differences could not be attributed to confounding educational, economic, social, cultural, and general demographic factors." IQ Study #38: Trivedi (2012) (http:/Mluoridealert.ora/wp-content/uploads/trivedi-20124.pdf) Citation: Trivedi MH, et al. (2012). Assessment of groundwater quality with special reference to fluoride and its impact on IQ of schoolchildren in six villages ofthe Mundra Region, Kachchh, Gujurat, India. Fluoride 45(4):377-83. Location of Study: Gujurat, India Size of Study: 84 children (34 from high -fluoride villages, 50 children from control village) Age of Subjects: 6th and 7th grade students Source of Fluoride: Water Water Fluoride Levels: High Fluoride = 2.3 + 0.87 mg/L Control = 0.83 + 0.38 mg/L Urine Fluoride Levels: High Fluoride = 2.69 + 0.92 mg/L Control = 0.42 + 0.23 Confounding Factors: Same socioeconomic status (E on an A-E scale); same attendance status at school (regular students attending more than 80% of classes) Type of IQ Test: Questionnaire prepared by Prof. JH Shah; standardized on the Gujarati population with 97% reliability rate in relation to the Stanford-Binet Intelligence Scale Results: "The average IQ score ofthe 34 students drinking the high F water was significantly lower (p?0.05) than among the 50 students drinking the low F water." Conclusions: "the present investigation concludes that the three villages of Chhasara, Gundala, and Mundra, are F - contaminated villages. Because of high F concentrations in the [groundwater], children in these villages have greater exposure to F that may lead in to low IQ as compared to the nearby villages of Baroi, Zarpara, and Pragpar, which have low F in their [groundwater]." IQ Study #37: Seraj (2012) (http://fluoridealert.org/wp-content/uploads/seraj-2012.pdf) Citation: Seraj B, et al. (2012). Effect of high water fluoride concentration on the intellectual development of children in Makoo/Iran. Journal of Dentistry, Tehran University of Medical Sciences. 9(3): 221-29. Location of Study: Makoo, Iran. Size of Study: 293 children (91 children in control village; 106 children in medium F village; 96 children in high F village) Age of Subjects: 6 to 11 years old Source of Fluoride Exposure: Water Water Fluoride Levels: Control = 0.8+0.3 ppm Medium fluoride = 3.1+0.9 ppm High fluoride= 5.2+1.1 ppm Confounding Factors: Age, gender, child's educational level, mother's educational level, father's educational level, fluorosis Saxena S, et al. (2012). Effect of fluoride exposure on intensity, iodine level in water, lead level in water. IQ Test: Raven's Color Progressive Matrices (RCPM) Results: "The mean IQ scores decreased from 97.77+18.91 for 3(2):144-49. the normal fluoride group to 89.03+12.99 for the Madhya Pradesh, India. medium fluoride group and to 88.58+16.01 for the high 173 children (120 children in three high -F areas and 53 fluoride group (P=0.001)." Conclusion: "Since all potentially confounding factors were School children in the 5th & 6th grades adjusted, the difference in IQ scores may reveal the Water potential effect of high fluoride exposure on the intellectual development of children." IQ Study #36: Saxena (2012) (htto://fluoridealert.ora/wo-content/uploads/saxena-20121.[)dfi Citation: Saxena S, et al. (2012). Effect of fluoride exposure on Group 3 = 1.5-3.0 ppm the intelligence ofschool children in Madhya Pradesh, Control = <1.5 ppm India. Journal of Neurosciences in Rural Practice Group 1 = 7.01±1.02 3(2):144-49. Location of Study: Madhya Pradesh, India. Size of Study: 173 children (120 children in three high -F areas and 53 Control = 2.25+0.28 children from a control group) Age of Subjects: School children in the 5th & 6th grades Source of Fluoride Exposure: Water Water Fluoride Levels: Group 1 =>4.5 ppm Group 2 = 3.1-4.5 ppm Group 3 = 1.5-3.0 ppm Control = <1.5 ppm Urine Fluoride Levels: Group 1 = 7.01±1.02 Group 2 = 4.85+0.50 Group 3 = 3.28+0.48 Control = 2.25+0.28 Confounding Factors: (1) No significant differences in urinary lead, arsenic, or iodine levels between the four groups. (2) No significant differences in gender ratio, socio-economic status, SES, parental education, height/age ratio, and weight/height ratio. (3) Children were excluded ifthey were not lifelong resident ofarea, ifthey had changed their water source since birth, or ifthey had history of congenital or acquired neurological disease and/or head injury. IQ Test: Raven's Standard Progressive Matrices Results: "Reduction in intelligence was observed with an increased water fluoride level (P 0.000). The urinary fluoride level was a significant predictor for intelligence (P 0.000)." Conclusion: "This study indicates that exposure to fluoride is associated with reduced intelligence in children. We have found a significant inverse relationship between intelligence and the water fluoride level, and intelligence and the urinary fluoride level. After adjusting for confounders, urinary fluoride was the significant predictor for intelligence" IQ Study #35: Ding(2011)_(http://fluoridealert.org/studytracker/178701 Citation: Ding Y, et al. (2011). The relationships between low levels of urine fluoride on children's intelligence, dental fluorosis in endemic fluorosis areas in Hulunbuir, Inner Mongolia, China. Journal of Hazardous Materials 186(2- 3):1942-46. Location of study: Hulunbuir, Inner Mongolia, China Size of study: 331 children from four sites Age of Subjects: 7-14 years old Source of Fluoride: Water Water Fluoride Levels: Mianduhe town=0.28+0.03 mg/L Nan district=0.79+0.33 mg/L Donghu district=1.78+0.60 mg/L Zhalainuoercounty=1.82+1.00 mg/ Urine Fluoride Levels: No dental fluorosis = 0.80+0.55 mg/L Questionable fluorosis = 1.13+0.73 mg/L Very mild fluorosis = 1.11+0.74 mg/L Mild fluorosis = 1.31+0.78 mg/L Moderate fluorosis =1.46+0.79 mg/L. Confounding Factors: (1) Sites selected to match social and natural factors like economic situation, educational standard, and geological environments. (2) Schools had similar teaching quality. (3) Sites are not exposed to known neurotoxins (e.g. arsenic) in drinking water, nor are they endemic areas for iodine deficiency disorders. (4) Five children who had not lived in these areas at least 1 year were excluded. IQ Test: CRT-RC3 (Combined Raven's Test for Rural China) Results: Children's IQ was inversely related to urinary fluoride content, (p<0.0001). Each increase in 1 mg/L of urine F was associated with 0.59 point decrease in IQ (p=0.0226). Conclusion: "In conclusion, our study suggested that low levels of fluoride exposure in drinking water had negative effects on children's intelligence and dental health and confirmed the dose -response relationships between urine fluoride and IQ scores as well as dental fluorosis:' IQ Study #34: Poureslami (2011)_(http://fluoridealert.org/wp-content/uploads/poureslami- 2011.pdf) Citation: Poureslami HR, et al. (2011). Intelligence quotient of 7 to 9 year-old children from an area with high fluoride in drinking water. Journal of Dentistry and Oral Hygiene 3(4):61-64. Location of study: Kerman Province, Iran: Koohbanan (high -F) and Baft (low -F) Size of study: 120 children: 60 children per city Age of Subjects: 7-9 years old Source of Fluoride: Water Water Fluoride levels: High -F = 2.38 mg/L Low -F = 0.41 mg/L Confounding Factors: (1) Exclusion criteria: genetic, congenital, or acquired diseases related to the nervous system, past or present. (2) Inclusion criteria (high -F village): signs of grade III TSIDF (total surface index of Dental Fluorosis) or more. (3) Inclusion criteria (low -F village): similar physical and mental health criteria adopted, but children lacked any sign of Dental Fluorosis. (4) Both towns at high altitude. Type of IQ Test Raven's Progressive Matrices Intelligence Test (Persian version) Results: Average IQ of High F group (91.37+16.63) is significantly lower than average IQ of Low -F group (97.80+15.95), p < 0.05. Conclusion: "Based on the findings, chronic exposure to high levels of fluoride can be one ofthe factors that influence intellectual development." IQ Study #33: Eswar (2011) (http://fluoridealert.oratwp-content/uploads/eswar-2011.Pdf) Citation: Eswar P, et al. (2011). Intelligent quotients of 12-14 year old school children in a high and low fluoride village in India. Fluoride 44:168-72. Location of study: Ajjihalli (low F) and Holesirigere (high F) villages, Davangere district, Karnataka, India. Size of study: 133 children total (low F village=65; high F village=68) Age of Subjects: 12-14 years old Source of Fluoride: Water Water Fluoride levels: High F village=2.45 mg/L Low F village =0.29 mg/L Confounding Factors: (1) Children included were continuous residents of study villages since birth; drinking water from same public water supply (1 per village); (2) attended same high school (1 per village). (3) Children with history of trauma or injury to head; affected by congenital or acquired neurological disorders, psychological disorders were excluded. Type of IQ Test Raven's Standard Progressive Matrices Test Results: 63.2% of children in high F area had IQ less than 90, versus 47.7% of children in low F village. (p=0.06). Conclusion: "Though there was a trend in our study towards lower IQ in a greater number of children from high F village than in the low Fvillage, probably the small sample size of the present study failed to establish a statistically significant difference:' IQ Study #32: Shivaprakash (2011) (http://fluoridealert.org/studytracker/17873/) Citation: Shivaprakash PK, et al. (2011). Relation between dental fluorosis and intelligence quotient in school children of Bagalkot district. J Indian Soc Pedod Prev Dent. 29(2):117-20. Location of study: Bagalkot district, Karnataka state, India Size of study: 160 children Age of Subjects: 7-11 years old Source of Fluoride: Water Water Fluoride Levels: high F village = 2.5-3.5 mg/L low F village = < 0.5 mg/L Confounding Factors: (1) Children included in study had normal birth history, were permanent residents in the region of study, had no history of trauma to the head, no history of chronic illness, not on medication. (2) Villages have similar culture, standard of living, and lifestyle habits. Type of IQ Test Raven's Colored Progressive Matrices Test Results: (A) Children with dental fluorosis had lower IQ (66.63+18.09) than those without dental fluorosis (76.36+20.84), p < 0.05. (B) Children with mild dental fluorosis had lower IQ (66.73) than those without dental fluorosis (75.89), p < 0.05. Conclusion: "Previous studies had indicated toward decreased Intelligence in children exposed to high levels of fluoride and our study also confirmed such an effect" IQ Study #31: Sudhir (2009) (http://fluoridealert.orgtwp-content/uploads/sudhir-2009.pdf) Citation: Sudhir KM, et al. (2009). Effect offluoride exposure on Water Fluoride Levels: intelligence quotient (IQ) among 13-15 year old school children of known endemic area offluorosis, Nalgonda Type of IQ Test: District, Andhra Pradesh. Journal ofthe Indian Results: Association of Public Health Dentistry 13:88-94. Location of Study: Nalgonda District, Andhra Pradesh, India Size of Study: 1000 children Age of Subjects: 13-15 years old Source of Fluoride: Water Water Fluoride Levels: Four areas were studied: <0.7 mg/L; 0.7-1.2 mg/L; 1.2- 4.0 mg/L; >4 mg/L Type of IQ Test: Raven's standard progressive matrices Results: "Number of intellectually impaired children were gradually increased with the increase in fluoride concentration in the drinking water." Conclusion: "Findings of this study suggest that overall IQ levels in children's exposed to high fluoride level were significantly lower than the low fluoride areas." IQ Study #30: Li (2009) (http://fluoridealert.ora/wp-content/uploads/11-200911.Ddf) Citation: Li F, et al. (2009). The impact of endemic fluorosis caused bythe burning ofcoal on the developmentof intelligence in children. Journal of Environmental Health 26(4):838-40. Location of study: Xinhua County, Hunan Province, China Size of study: 80 children total: 20 children from "mild" fluorosis area, 20 from "medium" fluorosis area, 20 from "severe" fluorosis area, and 20 from non -fluorosis area. Age of Subjects: 8-12 years old Source of Fluoride: Coal burning Fluoride exposure levels: Urine F (by region): severe = 2.34+1.13 mg/L medium = 1.67+0.66 mg/L mild = 1.24+0.43 mg/L control = 0.96+0.52 mg/L Urine F (by dental fluorosis type): severe = 2.66+1.09 mg/L medium = 2.01+0.80 mg/L mild = 1.64+0.68 mg/L very mild = 1.17+0.48 mg/L suspected = 1.09+0.36 mg/L no fluorosis = 0.87+0.23 mg/L. Confounding Factors: (1) All children were born and raised in the respective areas. (2) Children were excluded ifthey had been diagnosed with physical deformation, developmental disorders, delayed mental development, emotional/behavioral obstacles or challenges, or other forms of mental disorders. Type of IQ Test CRT -RC (Combined Raven's Test for Rural China) Results: — IQ decreased with increasing F level in urine (p < 0.01)— IQ was significantly reduced among children with severe fluorosis as compared to children without fluorosis (p < 0.05) — A trend (albeit not statistically significant) for IQ to decrease with increasing severity of dental fluorosis (NS) and with increasing severity of the region's fluoride poisoning Conclusion: "High exposure to fluoride most definitely has an adverse effect on the development of intelligence in children, in particular on the capability of abstract inference:' IQ Study #29: Rocha-Amador (2007) (http://Huoridealert.org/wp- content/uploads/rocha amador-2007.pdf) Citation: Rocha-Amador D, et al. (2007). Decreased intelligence in children and exposure to fluoride and arsenic in drinking water. Cadernos de Saude Publica 23(Suppl 4):S579-87. Location of study: Durango State, Mexico & San Luis Potosi State, Mexico Size of study: 132 children Age of Subjects: 6 to 10 years old Source of Fluoride Exposure: Water Water Fluoride Levels Lowest F village: 0.8+1.4 mg/L Middle F village: 5.2+0.9 mg/L Highest F village: 9.4+0.9 mg/L Urine Fluoride Levels Lowest F village: 1.8+1.5 mg/L Middle F village: 6.0±1.6 mg/L Highest F village: 5.5+3.3 mg/L Confounding Factors: (1) A multiple regression analysis was used that controlled for blood lead levels, socioeconomic status, mother's education, height -for -age (an index of malnutrition), and transferrin saturation. (2) Each child's waterfluoride level, and urine fluoride level, levels were individually determined. (3) The test examinerwas blinded as to the children's fluoride exposure. IQ Test: Wechsler Intelligence Scale for Children—Revised Mexican Version (WISC-RM) Results: (1) Both fluoride in urine, and fluoride in water, were significantly correlated with IQ, and this correlation remained significant after controlling for lead exposure, socioeconomic status, mother's education, malnutrition, and transferrin. (2) Fluoride's effect on IQ was larger than the effect from arsenic. Conclusion: "We found that exposure to F in urine was associated with reduced Performance, Verbal and Full IQ scores before and after adjusting for confounders. The same pattern was observed for models with F in water as the exposure variable.... The individual effect of F in urine indicated that for each mg increase of F in urine a decrease of 1.7 points in Full IQ might be expected:' IQ Study #28: Wang (2007)_(http://www.fluoridealert.orci/uploads/wana-2007.pdf) Citation: Wang SX, at al. (2007). Arsenic and fluoride exposure in drinking water: children's IQ and growth in Shanyin county, Shanxi province, China. Environmental Health Perspectives 115(4):643-7. Location of study: Shanyin County, Shanxi Province, China Size of study: 720 children: 21-196 per village (3 villages for each of the arsenic groups) Age of Subjects: 8-12 years old Source of Fluoride: Water Water Fluoride Levels: Urine Fluoride levels: High -Arsenic group = 0.9+0.5 mg/L Medium -Arsenic group= 1.7±1.1 mg/L High -Fluoride group = 8.3+1.9 mg/L Control group = 0.5+0.2 mg/L High -Arsenic group = 1.0+1.7 mg/L Medium -Arsenic group =2.8+11.9 mg/l_ High -Fluoride group = 5.1+2.0 mg/L Control group = 1.5+1.6 mg/L Confounding Factors: (1) Arsenic used as variable. Similar manganese levels in water for all groups. (2) All groups lived in rural areas with similar geographic and cultural conditions and a comparable level of socioeconomic development (years of parental education, average income, years of exposure). (3) All children currently attending school. Type of IQ Test CRT -RC (Combined Raven's Test for Rural China) Results: - Average IQ in high -arsenic area (95.1+16.6) is significantly lower than IQ in control area (104.8+14.7). p < 0.05 - The average IQ in high -fluoride area (100.5+15.8) is also significantly lower than average IQ in control area (104.8+14.7). p < 0.05 - Significantly more children with IQ lower than 70 (mental retardation) in high -F area (4%), medium -arsenic area (3.3%), and high -arsenic area (8.3%) as compared to control (0%). Conclusion: "This study indicates that exposure to fluoride in drinking water is associated with neurotoxic effects in children." IQ Study #27: Trivedi (2007) (http://www.fluoridealert.org/uploads/trivedi-2007.pdf) Citation: Trivedi MH, et al. (2007). Effect of high fluoride water on intelligence ofschool children in India. Fluoride 40(3):178-183. Location of study: - High F area: Sachana, Sanand district, Gujarat, India - Medium F area: Chandlodia, Ahmedabad, India Size of study: 190 children (89 in high F area; 101 in medium F area) Age of Subjects: 12-13 years old Source of Fluoride: Water Water Fluoride Levels: High F area=5.55+0.41 mg/L Medium F area=2.01+0.009 mg/L Urine Fluoride Levels: High F area = 6.13+0.67 mg/L Medium F area = 2.30±0.28 mg/L Confounding Factors: (1) The study included only those children who were life-long residents ofthe areas. respective location. (2) The areas have similar nutritional status and both have middle class socioeconomic status (although Sachana is slightly poorer). (3) Iodized salt is used in both areas. Type of IQ Test Questionnaire prepared by Prof. JH Shah; standardized on the Gujarati population with 97% reliability rate in relation to the Stanford-Binet Intelligence Scale Results: (A) Average IQ is lower in High -F area (91.72+1.13) than in Low -F area (104.44+1.23), p<0.001. (B) High F area has 28.09% of children with IQ below normal (over twice the percentage found in lower F area). Conclusion: "In agreement with other studies elsewhere, these findings indicate that children drinking high F water are at risk for impaired development of intelligence." IQ Study #26: Fan (2007) (http://www.fluoridealert.org/uploadstfan-2007.pdf) Citation: Fan Z, et al. (2007). The effect of high fluoride exposure on the level of intelligence in children. Journal of Environmental Health 24(10):802-03. Location of study: Pucheng County, Shaanxi Province, China. Size of study: 79 children (42 children in High F area; 37 children in Confounding Factors: low F area) Age of Subjects: 7-14 years old Source of Fluoride: Water Water Fluoride Levels: — High F area=3.15 mg/L Type of IQ Test — Low F area=1.03 mg/L (water -improvement schemes Results: implemented 14-18 years before study) Urine Fluoride Levels: — High F area group=2.89+1.97 mg/L (range: 1.14-6.09 mg/L); Statistical significance — Low F area group=1.78+0.46 mg/L (range: 1.33-2.35 mg/L) (non-significant difference, likely because Fis consumed from various sources other than water) Confounding Factors: (1) The two areas have common habits and lifestyles in terms of cuisine, economy, culture, education, agricultural goods, etc.. (2) No chemical factories in area. (3) The area does not have an iodine deficiency problem. Type of IQ Test CRT -C2 intelligence module Results: (A) Average IQ in High -F area (96.11 + 12.00) is lower than Low -F area (98.41 + 14.75), although difference is not statistically significant. (B) No child in High -F area has outstanding or excellent intelligence. The respective rates in the Low -F area are 2.7% and 5.4%, respectively. Conclusion: "Exposure to high levels offluoride is likely to cause a certain level of harm to a child's level of intelligence:' IQ Study #25: Serai (2006) (http://fluoridealert.ora/studytracker/147831) Citation: Seraj B, at al. (2006). [Effect of high fluoride concentration in drinking water on children's intelligence]. [Study in Persian] Journal ofDental Medicine 19(2):80-86. Location of study: Iran Size of study: 126 children (85 children from low -F village, 41 children from high -F village) Age of Subjects: Not provided in English abstract (full study is in Persian) Source of Fluoride: Water Water Fluoride Levels: High F village = 2.5 mg/L Low F village = 0.4 mg/L Confounding Factors: The history of illnesses affecting the nervous system, head trauma, birth weight (>2.5kg or < 2.5kg), residental history, age and sex of children were investigated by questionnaires completed by the children's parents. Type of IQ Test Raven's Results: "In the high fluoride area the mean IQ of children (87.9±11) was significantly lower than in the low fluoride area (98.9±12.9) (P=0.025)." Statistical significance ""Based on the findings ofthis study, exposure of children to high levels offluoride may carry the risk of impaired development of intelligence" IQ Study #24: Wang (2005)fhttp://www.fluorideresearch.org/414/files/FJ2008 v41 n4 p344- 348. d Citation: Wang S, at al. (2005). The effects of endemic fluoride poisoning caused by coal burning on the physical development and intelligence of children. Journal of Applied Clinical Pediatrics 20(9):897-898 (republished in Fluoride 2008; 41:344-348). Location of study: Zhijin County, Ghizhou Province, China Size of study: 226 children (176 children in High F area, including 119 children with skeletal fluorosis and 57 children with only dental fluorosis; 50 children in low -F area without skeletal or dental fluorosis) Age of Subjects: 7-12 years old Type of Exposure: Coal burning Urine Fluoride Levels: High F group=1.352±0.457 mg/L (n=144) Lower F group=1.611+0.467 mg/L (n=35) Confounding Factors: (1) Both areas are free from iodine deficiency. (2) Both Size of study: areas have similar standard of living, sanitation, culture, and availability of medical treatment. Type of IQ Test Raven's Standard Theoretical Intelligence Test, Chinese Type of Exposure: version Results: Children from high F (endemic) areas had lower IQ than those from lower F (control) area (p<0.01). Negative correlation between urine F and IQ (p<0.01). Conclusion: "High fluoride burden has a definite effect on the intellectual and physical development of children:' IQ Study #23: Xiang (2003a (http://www.fluorideresearch.org/362miles/FJ2003 v36 n2 P84- 94.pdf)), Xiang, (2003b) (http://www.fluorideresearch.org/363ffiles/FJ2003 v36 n3 p198- 199. d Citation: —Xiang Q, at al. (2003a). Effect offluoride in drinking water on children's intelligence. Fluoride 36: 84-94. — Xiang Q, et al. (2003b). Blood lead of children in Wamiao-Xinhuai intelligence study. Fluoride 36:198- 199. Location of study: Sihong County, Jiangsu Province, China Size of study: 512 children (222 children in high -F village, 290 children in low -F village) Age of Subjects: 8-13 years old Type of Exposure: Water Water Fluoride Levels: High F village=2.47+0.79 mg/L (range=0.57-4.50 mg/L) Low F village=0.36+0.15 mg/L (range=0.18-0.76 mg/L)ln the high -F village, children were subdivided into the following five fluoride water Ievels:Group A<1.0 mg/L; Group B=1.0-1.9 mg/L; Group C=2.0-2.9 mg/L; Group D=3.0-3.9 mg/L; Group E>3.9 mg/L. Urine Fluoride Levels: High F village=3.47+1.95 mg/L Low F village=1.11+0.39 mg/L Confounding Factors: (1) The two villages have similar urine iodine levels (p>0.3), and blood lead levels (p>0.48).(2) Neither village has fluoride pollution from burning coal or other industrial sources. (3) None ofthe residents reported drinking brick tea. (4) Children who had been absent from either village for 2 years or longer, or who had a history of brain disease or head injury were excluded from study. Type of IQ Test CRT -RC (Combined Raven's Test for Rural China) Results: (A) Mean IQ of high F village (92.02±13.00) is lower than low Fvillage (100.41+13.21), p<0.01. (B) Higher drinking water F is significantly associated with higher rates of mental retardation (IQ<70) and borderline intelligence (IQ=70-79), p<0.05. (C) Children's IQs are not related to urinary iodine, family income, or parent's education level. Conclusion: "In endemic fluorosis areas, drinking water fluoride levels greater than 1.0 mg/L may adversely affect the development of children's intelligence." IQ Study #22: Li (2003)_(hftp://www.fluorideresearch.org/412/files/FJ2008 v41 n2 P161- 164.pdf) Citation: Li Y, et al. (2003). Effects of endemic fluoride poisoning on the intellectual development of children in Baotou. Chinese Journal ot'Public Health Management 19(4):337-338 (republished in Fluoride 2008; 41:161-64). Location of study: Baotou, Inner Mongolia, China Size of study: 936 children (720 children from high -F endemic area; 236 children from low -F control area) Age of Subjects: 6-13 years old Source of F exposure: Water Fluoride exposure levels: "The region classified as endemic was designated using the 1981 standards for designation of endemic regions laid out in 1981's Standards for Endemic Fluorosis Prevention and Treatment Work" Type of IQ Test Illustrated version ofthe Chinese Standardized Raven Testforchildren in rural areas Results: (A) Average IQ of children in endemic area (92.07) somewhat lower than that of control area (93.78), NS. (B) Rate of children with low IQ (<69) greater in endemic area (10.38%) than in control area (4.24%) ("high statistical significance", but no p value given). Conclusion: "In our study, we found that the average IQ of children in a fluoride endemic area was somewhat lower than the control, but the result was not statistically significant (p > 0.05). The percentage of children with fluorosis, however, was higher as compared to the control, and this was very significant statistically." IQ Study #21: Shao (2003) (http://www.fluoridealert.org/uploads/shao-2003.pdf) Citation: Shao Q, et al. (2003). Study of cognitive function impairment caused by chronic fluorosis. Chinese Journal of Endemiology 22(4):336-38. Location of study: Bijie City (high F area) and Tongren area (control area), Guizhou Province, China Size of study: 88 adults (49 adults in High -F area; 39 adults in Low -F area) Age of Subjects: Aged 30-50 (High -F area = 42+6 years; Low -F area = 43±6 years) Source of Fluoride Exposure: Water Fluoride exposure levels: Adults in high -F area diagnosed as suffering from fluoride poisoning (as evident by dental and skeletal changes). Water F levels not provided. Confounding Factors: Non -iodine deficient areas. Exclusions of mental disorders caused by mental retardation, brain organic and somatic diseases. All farmers. Similar distribution of age, sex, education level. Type of IQ Test Wechsler Adult Intelligence Scale test for Rural China (WATS-RC); Associated learning (AL) test; Digit Span (DS) test; Similarity test; Speech fluency test (SFT); Comprehension test. Results: (A) Significantly lower operation score on IQ test in high F area (48-54) versus low F area (52-59), p < 0.01. (B) Lower total IQ score in high F area (78-100, average) than in low F area (109-118, average -high), although not statistically significant (C) High F subjects have significantly lower scores on several of the performance tests (speech fluency, recognition, similarity, p <0.01, and digit span, p < 0.05), and this correlates with elevated levels of oxidative stress. Conclusion: "The results suggest that some cognitive function limitations exist in those suffering from chronic fluoride poisoning, and its biologic basis may be related to the levels of SOD and NO [indices of oxidative stress]" IQ Study #20: Wang (2001) (htto://www.fluoridealert.ora/uploads/wane-2001.pdf) Citation: Wang X, et al. (2001). Effects of high iodine and high fluorine on children's intelligence and thyroid function. Chinese Journal of Endemiology20(4):288-90. Location of study: Binzhou and Dezhou, Qingyun County, Shandong Province. China Size of study: 513 children (322 children from school in high iodine/high fluoride area; 193 children from school in lower iodine/lower fluoride area). Age of Subjects: 8-12 years old Source of Fluoride Exposure: Water Water Fluoride Levels: — High iodine/high fluoride area=2.97 mg/L — Lower iodine/lower fluoride area=0.5 mg/L Urine Fluoride Levels: — High iodine/high fluoride = 3.08+1.03 mg/L — Low iodine/low fluoride = 0.82±0.56 mg/L Type of IQ Test CRT -RC (Combined Raven's Test for Rural China) Results: (A) Average IQ is lower in High -F area than in Low -F area (76.67+7.75 vs. 81.67+11.97), although the difference does not reach statistical significance. (B) The rate of extremely low and borderline IQ is higher in the High F areas than in the Low F areas (16.67% vs. 10% and 36.67% vs. 16.67, respectively), although these differencese do not reach statistical significance. Conclusion: "High iodine and high fluorine have certain influence on children's intelligence and thyroid function" IQ Study #19: Hong (2001) (http:/Iwww.fluoridealert.org/uploads/hong-2001.pdf) Citation: Hong F, et al. (2001). Research on the effects offluoride on child intellectual development under different environments. Chinese Primary Health Care 15(3):56- 57 (republished in Fluoride 2008; 41(2):156-60). Location of study: Wukang, Boxing, and Zouping counties, Shangdong Province, China Size of study: 205 children (32 controls; 85 High F; 32 High-F/High Iodine; 28 High F/Low Iodine; 28 Low F/Low Iodine) Age of Subjects: 8-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: — Control area = 0.75 mg/L — High F only = 2.90 mg/L — High F/High I = 2.85 mg/L — High F/Low I = 2.94 mg/L — Low F/Low I = 0.48 mg/L Confounding Factors: —Areas have same geographical features and standard of living. Type of IQ Test Chinese Standardized Raven's Test for Rural areas (CRT -R) Results: (A) Average IQ of High F/Low I group (68.38+19.12) and Low F/Low I group (75.53+6.92) is lower than control group (82.79+8.98), p<0.01. (B) IQ of High F/Low I group is lower than Low F/Low I group, p<0.01. (C) Significant interaction exists between High Fluoride and Low Iodine, p<0.01. (D) IQ ranking of high F groups show significant deficits compared to control, p<0.01. Conclusion: "The IQ results ofthis study show no significant difference between the average IQs of those children from the high fluoride only areas and the high fluoride/high iodine areas, however the resultfrom the high fluoride/low iodine group show statistically significant differences as compared to that of the low fluorideAow iodine group. In short, it appears that the presence or lack of iodine is a more significant factor in both the prevalence ofgoiter and average IQ." IQ Study #18: Lu (2000) (http://www.fluoridealert.org/uploads/lu-2000.pdf) Citation: Lu Y, et al (2000). Effect of high -fluoride water on intelligence of children. Fluoride 33:74-78. Location of study: Tianjin Xiqing District, China Size of study: 118 children (60 children in High -F village; 58 children in Low -F village) Age of Subjects: 10-12 years old Source of Fluoride Exposure: Water Water Fluoride Levels: — High F village = 3.15+0.61 mg/L — Low F village = 0.37±0.04 mg/L Urine Fluoride Levels: — High F village = 4.99+2.57 mg/L — Low F village = 1.43+0.64 mg/L Confounding Factors: (1) Children included in the study are lifelong residents of study area. (2) Villages have similar population size, social, economic and educational backgrounds. (3) Children with congenital or acquired neurological disorders were excluded. Type of IQ Test Chinese Combined Raven's Test, Copyright 2 (CRT -C2) Results: (A) Average IQ of children from High F village (92.27+20.45) is lower than children from Low F village (103.05+13.86), p<0.005. (B) More "retarded" (IQ=<70) and "borderline" intelligence (IQ=70-79) children in high F group (21.6%) than in low F group (3.4%), p<0.005. (C) Significant inverse relationship exists between urinary F and IQ. Conclusion: "The findings ofthis study thus replicate those of earlier studies and suggest that a real relationship exists between fluoride exposure and intelligence." IQ Study #17: Zhang (1998) (htti3://www.fluoridealert.org/uploads/zhang-1998.pdf) Citation: Zhang J, at al. (1998). The effect of high levels of arsenic and fluoride on the development of children's intelligence. Chinese Journal of Public Health 17(2):119. Location of Study: Kuitun region, Urumqi, China Size of Study: 164 children Age of Subjects: 4-10 years old Source of Fluoride Exposure: Water Water Fluoride Levels: For the 4 to 8 year olds, the fluoride level their entire life (including during fetal development) was between 0.49 and 0.81 ppm. The 9 year olds were exposed to high fluoride (level not provided) during fetal development. The 10 year olds were exposed to high fluoride during fetal development and their first year of life. Type of IQ Test: 50 -point evaluation tests created by Japanese researcher, Shigeo Kobayashi Results: No difference in IQ among the 4 to 8 year olds, a slight (non-significant) reduction in IQ among the 9 year olds (who were exposed to fluoride during fetal development), and a significant reduction among the 10 year olds (who were exposed during fetal development and their first year of life). Conclusion: "Even though there were differences in the results from the 10 year-old subjects from the normal comparative group, in contrast to subjects from the high fluoride high arsenic group and the high fluoride group, these results might not be overtly representative as less number of subjects from the high fluoride group has been tested." IQ Study #16: Yao (1997) (http://www.fluoridealert.org/uploads/yao-1997.pdf) Citation: Yao Y, et al. (1997). Comparative assessment ofthe physical and mental development of children in endemic fluorosis area with water improvement and without water improvement. Literature and Information on Preventive Medicine 3(1):42-43. Location of study: Chaoyang City, Liaoning Province, China Size of study: 823 children (326 children from fluorosis area with water improvement; 183 children from fluorosis area without water improvement; 314 children from non -fluorosis area) Age of Subjects: 7-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: - Fluorosis area without water improvements = 2.0 mg/L- Fluorosis with water improvements = 0.33 mg/L (prior to improvement 8 years before study, the F level was 2.0 mg/L)- Non -fluorosis area = 0.4 mg/L Confounding Factors: -All children born locally. - Areas in study have adequate iodine exposure and similar levels of economic development, living conditions, school size, and number of teachers. Type of IQ Test CRT -RC (Combined Raven's Test for Rural China) Results: (A) Children in fluorosis area (without water improvement) have lower average IQ than children in fluorosis area (with water improvement) for all age groups, p<0.01. (B) Children in fluorosis area without water improvement have lower average IQ than children in non -fluorosis area for all age groups, p<0.01. (C) Children born prior to water improvement program in fluorosis area with water improvement have lower average IQ than children in non -fluorosis area, p<0.05. (D) No significant difference in intelligence exists between children born afterwater improvement and children in non -fluorosis area. Conclusion: "These results show thatwater improvement and defluoridation can improve the mental and physical development ofchildren in a fluorosis area." Citation: IQ Study #15: Yao (1996)_(http://www.fluoridealert.org/uploads/vao-1996.pdf) Yao Y, et al. (1996). Analysis on TSH and intelligence level of children with dental Fluorosis in a high fluoride area. Literature and Information on Preventive Medicine 2(1):26-27. Location of study: Chaoyang City, Liaoning Province, China Size of study: 536 children (78 children from high -fluorosis area; 188 children from light -fluorosis area; 270 children from non - fluorosis area) Age of Subjects: 8-12 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High -F area: <11 mg/L Low -F area: 2.0 mg/L Control area: 1.0 mg/L Confounding Factors: (1) Children in each ofthe three areas have adequate iodine exposure as determined through urine analysis. Citation: (2) The three areas have similar economic development, schools, and teachers. Type of IQ Test Raven test—Associative Atlas (Version of Chinese village) Results: (A) Average IQ of children with dental fluorosis in high - fluorosis area and light -fluorosis areas is lower than children in non -fluorosis area, p<0.01. (B) Average IQ of children with dental fluorosis from high -fluorosis area is lowerthan those from light -fluorosis area, p<0.05. (C) Rate of high IQ (>120) is lower in high -fluorosis area (3.85%) and light -fluorosis area group (6.91 %) than non -fluorosis area (10.74%) (no p value given). Conclusion: "The results ofthe intelligence tests show that a high level offluoride influences children's IQ, which is consistent with some previous data. It is worth mentioning that the higher the degree of dental fluorosis, the more negative the impact on the children's intelligence level. This is an issue which merits utmost attention." IQ Study #14: Zhao (1996) (httq://www.fluorideresearch.ora/294/Fles/FJ1996 v29 M p190- 192.odf) Citation: Zhao LB, et al. (1996). Effect of high -fluoride water supply on children's intelligence. Fluoride 29: 190-192. Location of study: Shanxi Province, China Size of study: 320 children (160 children from high -F village; 160 children from lower -F village) Age of Subjects: 7-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High -F village = 4.12 mg/L Lower -F village = 0.91 mg/L Confounding Factors: (1) Similar occupations, living standards, and social customs in the two villages. (2) Only children whose mothers lived in the village during pregnancy were included in study. (3) Parents' educational level was determined (and found to have a significant influence on IQ, p < 0.01). Type of IQ Test "Official intelligence quotient (IQ) tests lasting 40 minutes" Results: Children in High -F village have significantly lower average IQ (97.69+13.00) than children in lower -F village (105.21±14.99), p<0.01. Conclusion: "The results ofthis study indicate that intake of high - fluoride drinking water from before birth has a significant deleterious influence on children's IQ in one oftwo similar villages" IQ Study #13: Wang (1996) (httq://www.fluorideresearch.ora/414/files/FJ2008 v41 M P340- 343. df Citation: Wang G, et al. (1996). A study ofthe IQ levels offour- to seven-year-old children in high fluoride areas. Endemic Diseases Bulletin 11(1):60-6 (republished in Fluoride 2008; 41:340-43). Location of study: Shehezi, Xinjiang Province, China Size of study: 230 children (147 children from High -F village; 83 children from Low -F village) Age of Subjects: 4-7 years old Source of Fluoride Exposure: Water & Coal -Burning Water Fluoride Levels: — All wells = 0.58-8.60 mg/L — High F area = > 1.0 mg/L — Low F area = < 1.0 mg/L Confounding Factors: (1) Children were excluded from study if they had a low intellectual ability due to genetic inheritance, past illness, malnutrition, uses of medication, or other reasons. (2) "Significantly greater' percentage of children with below average head circumference in High F area (18.37%) than in Control area (9.64%) (no p value given). Type of IQ Test Wechler Preschool and Primary Scale of Intelligence (WPPSI) Results: (A) Average Total IQ in High F group (95.64±14.34) is lowerthan in control group (101.23+15.84), p<0.05. (B) Average Performance IQ in High F group (94.33+14.76) is lowerthan in Control group (101.77+18.12), p<0.01. (C) Average Verbal IQ is not significantly different. (D) In High F area, children with below -normal head circumference have lower average IQ (89.07+15.69) than those with normal head circumference (97.13±8.06), p<0.01. Conclusion 'The results show that a high fluoride intake has a clear influence on the IQ of preschool children, manifesting itself primarily as damage to performance intelligence." IQ Study #12: Duan (1995) (http://www.fluoridealert.org/uploads/duan-1995.pdfl Citation: Duan J, et al. (1995). A comparative analysis of the results of multiple tests in patients with chronic industrial fluorosis. Guizhou Medical Journal 18(3):179-180. Location of study: Guiyang, Guizhou Province, China Size of study: 157 adults (72 adults with diagnoses with industrial fluorosis; 43 adults exposed to occupational fluoride but without industrial fluorosis; 42 non -exposed workers) Age of Subjects: 35 to 62 yrs Source of Fluoride Exposure: Occupational exposures Air Fluoride Levels Avg = 2.21 mg/m3 Confounding Factors: Non -exposed workers had similar work conditions, economic status, and lifestyle habits. Type of IQ Test Wechsler Adult Intelligence Scale revised by Prof Gong Yaoxian of Human Medical Sciences University (WAIS - RC) Results: Average IQ of workers with industrial fluorosis was significantly lower (68 to 72) than fluoride -exposed workers without industrial fluorosis (84.5), and IQ of fluoride -exposed workers without fluorosis (84.5) was significantly lower than IQ of non -exposed workers (99.4). Conclusion: "it may be determined that industrial fluorine poisoning has gradually progressive effects on the normal function and metabolism of the adult brain and other aspects of the nervous system. With the progression ofthe course offluorosis, neurological damage gradually worsens, with the degree ofdamage closely related to the length of exposure to fluorine, nail fluorine content, and other factors. Damage from high concentrations offluorine not IQ Study #10: Xu (1994) (http://www.fluoridealert.ora/uploads/xu-1994.odf) Citation: Xu Y, eta I. (1994). The effect of fluorine on the level of intelligence in children. Endemic Diseases Bulletin 9(2):83-84. Location of study: Shandong Province, China Size of study: 330 children (8 groups of21-97 children categorized based on fluoride and iodine content ofwater) Age of Subjects: only affects bones and ligaments, tendons, and other Source of Fluoride Exposure: soft tissue, but is also quite widespread throughoutthe Water Fluoride Levels: entire nervous system. This is of major significance for worker protection and other areas." IQ Study #11: Li (1995) (http://www.fluoridealert.ora/uploads/ii-1995.pdf) Citation: Li XS, et al. (1995). Effect of fluoride exposure on (1) Water iodine level used as variable. (2) Child's pre- intelligence in children. Fluoride 28:189-192. Location of study: Anshu and Zhijin counties, Guizhou Province, China Size of study: 907 children (230 children from severe fluorosis area; Bient-Siman 224 children from medium fluorosis area; 227 children (A) Children in areas with high -fluoride and low -iodine from slight fluorosis area; 226 children from non - have significantly lower IQs than children in areas with fluorosis area) Age of Subjects: 8-13 years old Source of Fluoride Exposure: Coal burning Urine Fluoride Levels — Severe dental fluorosis = 2.69 mg/L — Medium dental (12.82%) than in control group (1.61 %) fluorosis = 2.01 mg/L — Slight dental fluorosis = 1.81 "The number of children whose level of intelligence is mg/L — No dental fluorosis = 1.02 mg/L Confounding Factors: (1) All children of Han nationality.(2) Children were fluoride/iodine, regions of high fluoride only, regions of excluded from study ifthey had congenital or acquired high fluoride/low iodine, againsttheir respective diseases "not related to fluoride." (3) Groups separated by intervals of 6 months in age. Type of IQ Test China Rui Wen's Scaler for Rural Areas Results: Average IQ of children in severe (80.3+12.9) and medium (79.7+12.7) fluorosis areas is lower than the slight (89.7+12.7) and non -fluorosis (89.9+10.4) areas, p<0.01. Conclusion: "A high fluoride intake was associated with a lower intelligence" IQ Study #10: Xu (1994) (http://www.fluoridealert.ora/uploads/xu-1994.odf) Citation: Xu Y, eta I. (1994). The effect of fluorine on the level of intelligence in children. Endemic Diseases Bulletin 9(2):83-84. Location of study: Shandong Province, China Size of study: 330 children (8 groups of21-97 children categorized based on fluoride and iodine content ofwater) Age of Subjects: 8-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: — High Fluoride/High Iodine = 3.9 mg/L — High Fluoride/Low Iodine = 2.0 mg/L — High Fluoride = 1.8 mg/L — Low Fluoride = 0.38-0.5 mg/L — Control Area = 0.8 mg/L Confounding Factors: (1) Water iodine level used as variable. (2) Child's pre- school education history was determined. (3) Parent's literacy was determined. Type of IQ Test Bient-Siman Results: (A) Children in areas with high -fluoride and low -iodine have significantly lower IQs than children in areas with high -fluoride and high -iodine, p < 0.01. (B) More children have low IQ (< 69) in areas with High F/High I (10.53%), High F only (7.32%), and High F/Low I (12.82%) than in control group (1.61 %) Conclusion: "The number of children whose level of intelligence is lower is significantly increased in regions of high fluoride/iodine, regions of high fluoride only, regions of high fluoride/low iodine, againsttheir respective comparative groups.... This could be demonstrative of the fact that fluoride acts to increase the toxicity and worsen the occurrence ofthyroid swelling" IQ Study #9: Li 1994) (http://www.fluoridealert.ora/uploads/ii-1994.pdf) Citation: Li Y, at al. (1994). Effects of high fluoride intake on child mental work capacity: Preliminary investigation into the mechanisms involved. Journal of West China University of Medical Sciences 25(2):188-91 (republished in Fluoride 2008; 41:331-35). Location of study: Sichuan Province, China Size of study: 158 children from two neighboring townships (107 children with various degrees of dental fluorosis; 51 children with no dental fluorosis) Age of Subjects: 12-13 years old Source of Fluoride Exposure: Food contaminated by coal smoke Fluoride Content of Grain: — Children with no dental fluorosis = 0.5 mg/kg- Children with dental fluorosis (HiF1) = 4.7 mg/kg- Children with dental fluorosis (HiF2) = 5.2 mg/kg- Children with dental fluorosis (HiF3) = 31.6 mg/kg Confounding Factors: (1) The areas have similar levels offluoride in water (0.3 mg/L) and air (0.02-0.51 mg/m3) and similar levels of zinc in soil. (2) The areas townships have similar economic and cultural status, lifestyle, dietary habits, basic constituents offood. (3) Age, gender, and grade level ofthe children are kept"as constant as possible." (4) Children with acute or chronic diseases not related to fluoride were excluded from study. Type of IQ Test Mental Work Capacity determined by number of letters found (NLF), rate of error (RE), index of mental capacity (IMC), short-term memory capacity (SMC), visual reaction time (RT). Results: (A) Children with dental fluorosis in mid -exposure group (HiF2) have reduced short-term mental capacity (p<0.05), reduced mental capacity index (p < 0.01), and reduced NLF scores (p<0.01) as compared to children with no fluorosis and children with lower exposure.(B) Children with dental fluorosis in high -exposure group (HiF3) have reduced short-term mental capacity (p<0.01), reduced mental capacity index (p < 0.01), and reduced NLF scores (p<0.01) as compared children with no fluorosis and children with low exposure. Conclusion: "As shown in this study, the mental work capacity (MWC) of the two groups of children with grade 3 dental fluorosis was lower than the two groups with no dental fluorosis.... This indicates that early, long-term exposure to excess fluoride causes deficits in memory, attention, and reaction time, but 12-13 year-old children with only recent exposure show no major effects. Studies [on human fetuses] have already shown that the developing brain is one of the ripest targets for disruption by fluoride poisoning. Given that before six years of age the human brain is in its fastest stage of development, and that around seven and eight basic structural development is completed, therefore the brain is most vulnerable to damage from excess fluoride intake before this age." IQ Study #8: Yana (1994) (http://www.fluoridealert.ora/uploads/vans-1994.pdf) Citation: Yang Y, et al. (1994). The effects of high levels of fluoride and iodine on intellectual ability and the metabolism offluoride and iodine. Chinese Journal of Epidemiology 15(4):296-98 (republished in Fluoride 2008; 41:336-339). Location of study: Shandong Province, China Size of study: 60 children (30 from high -F village, 30 from Low -F village) Age of Subjects: 8-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High F/High Iodine area = 2.97 mg/L Control area = 0.5 mg/L Urine Fluoride Levels: High F/High Iodine area = 2.08+1.03 mg/L Control area = 0.82±0.56 mg/L Type of IQ Test Chinese Comparative Scale of Intelligence Test Results: (A) Children in high F/high iodine area have lower IQ (76.67+7.75) than those in low F area (81.67+11.97), although the difference is not statistically significant.(B) Greater percentage of children have moderately low IQ (<79) in High F/High Iodine area (76.67%) than in control area (36.67%), p<0.01. Conclusion: "An excess of fluoride and a lack of iodine in the same environment has been shown to have a marked effect on child intellectual development, causing a more significant intellectual deficitthan lack of iodine alone." IQ Study #7: An (1992) (http://www.fluoridealert.orn/uploads/an-1992.pdf) Citation: An J, et al. (1992). The effects of high fluoride on the level of intelligence of primary and secondary students. Chinese Journal of Control of Endemic Diseases 7(2):93-94. Location of study: Xingshunxi Town, Guyang County, Inner Mongolia (4 neighboring villages with high fluoride centered around Wubu Ziyao village and 6 neighboring villages with lower fluoride centered around Hada Heshao Village). Size of study: 242 children (121 children from high -F villages and 121 children from the low -F villages) Age of Subjects: 7-16 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High -F villages = 2.1+7.6 mg/L Control villages = 0.6+1.0 mg/L Confounding Factors: (1) Dental fluorosis rates were determined in both areas (90.9% in High -F area vs. 21.5% in Low -F area). (B) Both areas are in the countryside, are 15 km from each other, and share the same Han ethnicity. (C) The geography, culture, education, living standard, and social economic conditions are "very similar." IQ Test: Wechsler Intelligence Scale for Children Results: (A) Children in the High -F villages have significantly lower IQs at each age group studied: 7-10 (p < 0.02); 11-13 (p < 0.01); 14-16 (p < 0.03); 7-16 (p < 0.01). (B) Significantly more children in High -F villages have "critical state" IQ, p < 0.01. (C) When children within the High -F villages are stratified into highest -F (5.2-7.6 mg/L), and lowest -F levels (2.1-3.2 mg/L), the children in the higher -F areas had significantly lower IQ than the lower -F areas (p < 0.05). Conclusion "The results show that the level of intelligence of primary and secondary students from the high fluoride area and that of primary and secondary students from the non - high fluoride area had very significant differences, proving that high fluoride has adverse effects on the mental development of students. The higher the water fluoride is, the lower the level of IQ." IQ Study #6: Lin (1991) (http://www.fluoridealert.orci/uploads/lin-1991.pdf) Citation: Lin Fa -Fu; et al (1991). The relationship of a low -iodine and high -fluoride environmentto subclinical cretinism in Xinjiang. Endemic Disease Bulletin 6(2):62-67 (republished in Iodine Deficiency Disorder Newsletter Vol. 7(3):24-25). Location of study: Hetian prefecture, Xinjiang, China Size of study: 749 children (250 children in High-F/Low Iodine area; 256 children in Low-F/Low-Iodine area; and 243 children in Low F/Low Iodine area) Age of Subjects: 7-14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High F/Low Iodine = 0.88 mg/L Low F/Low Iodine = 0.34 mg/L Control area = n/a Urine Fluoride Levels: High F/Low Iodine = 2.56 mg/L Low F/Low Iodine = 1.34-1.61 mg/L Control area = 1.6 mg/L Confounding Factors: (1) Lower socioeconomic status in all areas. (2) Areas have similar nationalities, habits, customs, and income. IQ Test: CRT -RC (Combined Raven's Test for Rural China) Results: Children from the High F/Low Iodine area have significantly lower IQs (IQ=71) than children from the Low F/Low Iodine area (IQ=77-79; p<0.05), and control area (IQ=96); p<0.01). Conclusion: "The significant differences in IQ among these regions suggests that fluoride can exacerbate central nervous lesions and somatic developmental disturbance caused by iodine deficiency." IQ Study #5: Guo (1991) (httt)://www.fluoridealert.ora/uploads/auo-1991.[)dt) Citation: Guo X, et al. (1991). A preliminary investigation ofthe IQs of 7-13 year old children from an area with coal burning -related fluoride poisoning. Chinese Journal of Endemiology 10(2):98-100 (republished in Fluoride 2008; 41(2):125-28). Location of study: Xinshao County, Hunan Province, China Size of study: 121 children (60 children with mild to severe fluorosis from an endemic area where coal is used as a fuel source; 61 children from a non -endemic area where wood is used as a fuel source) Age of Subjects: 7 to 13 years old Source of Fluoride Exposure: Coal burning (Fluoride levels in water < 0.5 mg/I in both areas) Blood Fluoride Levels: Endemic area=0.1483±0.0473 mg/L Non -endemic area=0.1044±0.0652 mg/L (p<0.01) Confounding Factors: The two areas are neighboring townships with "very similar" economies, cultures, living standards, lifestyles, public health, and education. IQ Test: Chinese Binet IQ Test Results: (A) Children from endemic fluorosis area have lower average IQ (76.7) than children in non -endemic area (81.4), p<0.05. (B) A greater percentage (30%) of children in endemic area have low IQ (<69) than in non - endemic area (11.5%), p<0.05. Conclusion: "In summary, although diminished intellectual ability can resultfrom a multitude offactors (both innate and acquired) that influence neural development and cell division in the cerebrum, the comparison conducted in this study of two areas where the other environment factors are basically the same shows clear differences in IQ, and it [is] probable that this difference is due to a high fluoride environment." IQ Study #4: Chen (1991) (http://www.fluoridealert.orotwp-content/uploads/chen-1991.[)df) Citation: Chen YX, et al. (1991). Research on the intellectual development of children in high fluoride areas. Chinese Journal of Control of Endemic Diseases 6(Suppl):99- IQ Test: 100 (republished in Fluoride 2008; 41:120-24). Location of study: Linyi County, Shanxi Province, China Size of study: 640 children (320 children from High -F village; 320 children from Lower -F village) Age of Subjects: 7 to 14 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High -F village = 4.55 mg/L Lower -F village = 0.89 mg/L Confounding Factors: The occupations, culture, standard of living, lifestyle habits, access to health and transportation facilities are "essentially the same" between the two areas. IQ Test: Rural version of Chinese Standardized Raven Test Results: Average IQ of children in High -F village (100.24+14.52) significantly lower than children in lower -F village (104.03+14.96), p<0.01. Conclusion: "The results of this study indicate that there is significant difference between the intellectual ability ofthe 7-14 year old children from the [fluorosis] endemic area and those of the control, and moreover that the average IQ of the children from the endemic area is clearly lower." IQ Study #3: Sun (1991) (http://www.fluoridealert.oro/uploads/sun-1991.pdf) Citation: Sun M, et al. (1991). Measurement of intelligence by drawing test among the children in the endemic area of AI -F combined toxicosis. Journal of Guiyang Medical College 16(3):204-06. Location of study: Guizhou Province, China: Liupanshui City (endemic fluorosis area) and Guiyang City (non -endemic area) Size of study: 420 children (196 children from endemic fluorosis area; 224 children from non -endemic area) Age of Subjects: 6.5-12 years old Source of Fluoride Exposure: N/A Fluoride exposure levels: N/A Confounding factors: (1) Majority of children offarmers. (2) Children with bone and joint deformities or nervous system symptoms were excluded from study. IQ Test: Drawing test for children (Japanese researcher's Shigeo Kobayashi's 50 -point scoring method). Results: Children from endemic fluorosis area had lower IQ than those from non -endemic area at all ages except <7 (p < 0.05) Excerpt: "From these results, it can be concluded that excessive consumption offluorine and aluminum in the early stage of development directly impacts the development of the human brain, which causes the delayed intellectual development seen in children living in the endemic areas." IQ Study #2: Qin (1990) (http://www.fluoridealert.org/wp-content/uploads/gin-1990.pdf) Citation: Qin LS, Cui SY. (1990). Using the Raven's standard progressive matrices to determine the effects of the level of fluoride in drinking water on the intellectual ability of school-age children. Chinese Journal ofthe Control of Confounding factors: Endemic Diseases 5(4):203-04 (republished IQ Test: in Fluoride 2008; 41:115-19). Location of study: Jing County, Hubei Province, China Size of study: 447 children (141 children from High -F area; 159 children from "normal" F area; 147 children from low -F area) Age of Subjects: 9 to 10.5 years old Source of Fluoride Exposure: Water Water Fluoride Levels: High F = 2.1-4.0 mg/L"Normal" F = 0.5-1.0 mg/LLow F = 0.1-0.2 mg/L Confounding factors: All children had grown up drinking well water in their IQ Test: home village. IQ Test: Raven's Standard Progressive Matrices Results: Children in High F (21.17%) and Low F (23.03%) areas had lower average IQ scores than children in normal F area (28.14%), p<0.01. Conclusion: "All of these finding serve to indicate that both high and low fluoride can affect the normal development and Conclusion: function ofthe cerebrum as well as the entire nervous system causing a decrease in intellectual ability." IQ Study #1: Ren (1989)_(http://www.fluoridealert.org/uploads/ren-1989.pdf) Citation: Ren D, et al. (1989). A study ofthe intellectual ability of 8-14 year-old children in high fluoride, low iodine areas. Chinese Journal of Control of Endemic Diseases 4(4):251 (republished in Fluoride 2008; 41:319-20). Location of study: Shandong Province, China Size of study: 329 children (160 children in High F/low Iodine area: 169 children in Low-F/Low Iodine area) Age of Subjects: 8 to 14 years old Source of Fluoride Exposure: Water Fluoride exposure levels: N/A Confounding factors: Both study groups had low iodine intake. IQ Test: Wechsler Intelligence Test Results: — Average IQ of children in the High Fluoride/Low Iodine group (IQ=64.8) significantly lower than the children in the Low Fluoride/Low Iodine group (IQ = 85.0), p<0.01.- <0.01:The Thepercentage of children with low IQ (<69) significantly greater in High F/Low Iodine group (40.6%) than in Low Fluoride/Low Iodine group (13.6%), p<0.01. Conclusion: "From the results it is evidentthat disrupted child intellectual development is among the effects on the human body from a harmful environment containing both high fluoride and low iodine, and this disruption is clearly much more serious than the effects of iodine deficiency alone:' Tags: Brain (http://fluoridealert.org/tag/brain-2/), Cognitive Function (http://fluoridealert.org/tag/cognitive-function/j, IQ Score (http://fluoridealert.ora/ta(i/intelligence/)