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Backup Documents 09/13-14/2011 Item #10C
• -v �� I U(I\ IVlk%1 /v 10C Fluoridation Facts .0M -k American Dental Association www.ada.org Celebrating 6o Yeara of Water Fluoridation io water nuoriaation. I he answers to the questions that appear in Fluoridation Facts are based on gener- ally accepted, peer - reviewed, scientific evidence. They are offered to assist policy makers and the general public in making informed decisions. The answers are supported by thousands of credible scientific articles, including the more than 350 references within the document. It is hoped that decision- makers will make sound choices based on this body of generally accepted, peer- reviewed science. MBA, Manager and 1R. IMUIR M. 5fvuTTrR,'11LM,'Mn 10, Coordinator, Fluoridation and Preventive Health Activi- ties, Council on Access, Prevention and Interprofession- al Relations. In addition to his legal review, Mr. Mark Rubin, Esq., As- sociate General Counsel, Division of Legal Affairs, made significant contributions to the vision of this booklet. 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 Committee members who contributed to this edition: Ms. Diane Brunson, Dr. Robert N. Crawford, Jr., Dr. Lisa P. Howard, Dr. Jayanth V. 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 a comprehensive review of the extensive literature on fluoridation and fluorides. Readers must also rely on their own review of the literature, including the sources cited herein and any 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. I 10 C `' 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. 211 East Chicago Avenue Chicago, Illinois 60611 -2678 2005 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. Fluoridation Facts 16. Home treatment (filter) systems? 21 2 40. Kidney disease? 38 41. Erroneous health claims? 39 American Dental Association 1 U TABLE OF CONTENTS - ADA Statement Commemorating the 1 SAFETY 22 60th Anniversary of Community Water Fluoridation Question Topic Page ' Executive Summary 4 17. Harmful to humans? 22 18. More studies needed? 23 Introduction 6 19. Total intake? 24 20. Daily intake? 25 21. Prenatal dietary fluoride 26 BENEFITS 10 supplements? 2 2. Body uptake? 26 Question Topic Page 23. Bone health? 27 1. What is fluoride? 10 24 Dental fluorosis? 28 2. How does fluoride help prevent dental decay? 10 25. Prevent fluorosis? 30 3. What is water fluoridation? 11 26. Warning label? 31 4. How much fluoride is in 27• Toxicity? 31 your water? 11 28. Cancer? 32 5. Fluoride additives? 12 29. Enzyme effects? 33 6. Natural vs adjusted? 12 30. Thyroid gland? 34 7. Effectiveness? 13 31. Pineal gland? 34 8. Still effective? 14 32. Allergies? 34 9. Discontinuance? 15 33. Genetic risk? 35 10. Is decay still a problem? 16 34. Fertility? 35 11. Adult benefits? 16 35. Down Syndrome? 35 12. Dietary supplements? 17 36. Neurological impact? 36 13. Fluoride for children? 18 37. Lead poisoning? 37 14. Alternatives? 19 38. Alzheimer's disease? 37 15. Bottled water? 19 39. Heart disease? 38 16. Home treatment (filter) systems? 21 2 40. Kidney disease? 38 41. Erroneous health claims? 39 American Dental Association FLUORIDATION PRACTICE Question Topic 42. Water quality? 40 Page 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 Question Topic 50. Valuable measure? 51. Courts of law? 46 Page 46 47 52. Opposition? 47 53. Internet? 51 54. Public votes? 51 55. International fluoridation? 54 56. Banned in Europe? 54 COST EFFECTIVENESS Question Topic 57. Cost effective? 58. Practical? Fluoridation Facts 56 Page 56 57 E Call to Action 57 References 58 Statements from Five Leading Health 68 Organizations Regarding Community 1998 Consumers' Opinions Water Fluoridation 6. Compendium 69 Figures Opposition Tactics 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 Drinking Water 48 7. Opposition Tactics 50 8. ADA.org - Fluoride and Fluoridation 51 9. Largest Fluoridated Cities 52 10. Tables 1. States Meeting National Goals Dietary Fluoride Supplements 53 18 2. Bottled Water 20 3. Dietary Reference Intakes 25 4. Categories of Dental Fluorosis 28 3 10 EXECUTIVE SUMMARY • Fluoridation of community water supplies is the sin- gle most effective public health measure to prevent dental decay. " Throughout more than 60 years of research and prac- tical experience, the overwhelming weight of credi- 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. More than 100 national and international health, ser- vice and professional organizations recognize the pub- lic health benefits of community water fluoridation for preventing dental decay. Studies prove water fluoridation continues to be ef- fective in reducing dental decay by 20 -40 %, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. Community water fluoridation benefits everyone, es- pecially those without access to regular dental care. It is the most efficient way to prevent one of the most common childhood diseases — dental decay (5 times as common as asthma and 7 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 be- cause of dental - related illness. Community water fluoridation is the adjustment of fluoride that occurs naturally in water to optimal lev- els to protect oral health. 7 ME For most cities, every $1 invested in water fluorida- tion saves $38 in dental treatment costs. Water that has been fortified with fluoride is simi- lar to fortifying salt with iodine, milk with vitamin D and orange juice with vitamin C. • 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 year per person in large communities to approximately $3.00 a year per person in small communities. • More than two- thirds of the population in the United States are served by public water systems that are optimally fluoridated. • In the past five years (2000 through 2004), more than 125 U.S. communities in 36 states have voted to adopt fluoridation. • Fluoridation has been thoroughly tested in the Unit- ed 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. • Be aware of misinformation on the Internet and other junk science related to water fluoridation. • One of the most widely respected sources for in- formation regarding fluoridation and fluorides is the American Dental Association. The ADA main- tains Fluoride and Fluoridation Web pages at http://www.ada.orci/-qoto/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 10 C *+ 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 601h 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 20' century. 1,2 Support for Water Fluoridation Since 1950, the American Dental Association (ADA) 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 continu- ing evaluation of the scientific research on the safety and effectiveness of fluoridation. Since 1950, when the ADA first adopted policy recommending community 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 com- munities served by public water systems.3 The 2005 "ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation" reinforced that po- sition.4 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 ADA's 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- 6 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 enamels,' In the 1920s, Dr. McKay, along with others, suspected that something either in or missing from the drinking water was causing the mottled enamel. Dr. McKay wrote American Dental Association It is 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. 10C 6. Type of Research: How the 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 http: / /www.nlm.nih.ciov /. Fluoridation Facts 7 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, Arizona' 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.' 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.1(' 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.73 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, 10 C � in January 1945. The other three studies were conducted in Newburgh, New York (May 1945); Brantford, Ontario (June 1945) and Evanston, Illinois (February 1947.)73 -1s 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 Disease Control and Prevention 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 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." 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." 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 great public health achievements of the 201h century not- 8 American Dental Association 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.5,20 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.5a0-24 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 -" 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 .21 • 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.27 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 10C 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. "Water fluoridation continues to be effective in reducing dental decay by 20 -4096, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste." 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. ,3 0-33 • 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. - - 9 Fluoridation Facts BENEFITS Q1. 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 Q5. Fluoride additives? p.12 QUESTION 1. What is fluoride? Q6. 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.36 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.37-38 Fluoride is naturally present to some extent in all foods and beverages, but the concentrations vary widely.3e -41 QUESTION 2. How does fluoride help prevent dental decay? Answer. Fluoride protects teeth in two ways - systemically and topically. 10 4 Q 13. Fluoride for children? p. 18 Q 14. Alternatives? P. 19 Q 15. 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.42 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.41 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 - 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 .44 (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.46 In clarifying the effectiveness of water fluorida- tion, John D.B. Featherstone, PhD, Professor and Chair, 10 - -- 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. 1116 "John D.B. Featherstone, PhD, Professor and Chair, Department of Preventive and Restorative Dental Services, 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."' 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.42,"' 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."', 52-51 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 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 fluoridated 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 1St 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.htm1.57 Additionally, the Centers for Disease Control and Prevention's (CDC) fluoridation Web site, "My Water's Fluoride," is available at http: / /apps.nccd.cdc.gov /MWF/ Index.aso.58 For those states that have provided infor- mation to the CDC, the site lists fluoridation status by water system. Fluoridation Facts 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 .36,60 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.61 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. 10C A 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 drinking water 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.61 i+ 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 12 American Dental Association QUESTION 7. 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." • Centers for Disease Control and Prevention. Recom- mendations for Using Fluoride to 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 LW. 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.) 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 .65 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 .66 These findings indicated a continuing need for fluorida- tion although decay levels had declined .61 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 Fluoridation Facts 13 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 1987,28 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 .71 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.74 "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 communities .15-78 14 io 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 -63 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.256 This "halo" or "diffusion" effect results in increased fluoride intake by people in nonfluori- dated communities, providing them increased protection against dental decay. 51,11 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 .81 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 i brought into nonfluoridated communities.86 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 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.9) 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.111-91 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. 13 In Finland, a longitudinal study of Kuopio (fluoridat- ed from 1959 to 1992) and Jyvbskyla (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 programs.94 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." 15 ILI 11 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 I 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 10 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 3 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 1 teeth than ever before. I Another protective benefit for adults is the prevention of root decay. 100,101 -107 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.118 " 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.17' 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- 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 (NHANES III) showed that 22.5% of all adults with natural teeth experienced root decay. This percentage increased markedly with age: 1) in the 18- to 24- year -old age group, only 6.9% experienced root decay; 2) in the 35- to 44- year -old age group, 20.8% experienced root decay; 3) in the 55- to 64- year -old age group, 38.2% showed evidence of root decay; and 4) in the over -75 age group, nearly 56% had root decay.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. 114,115 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 "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." A Swedish study investigating decay activity among adults in optimal and low fluoride areas revealed that not only was decay experience significantly lower in the optimal fluoride area, but the difference could not be explained by differences in oral bacteria, buffer capacity of saliva or salivary flow. The fluoride concentration in the drinking water was solely responsible for decreased decay rates.16 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. 117'116 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. 19-122 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 areas. 123,124 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. 125 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 .10,116 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 .125 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 Fluoridation Facts 17 13 14 15 Approvea Ann American Academy of Pediatric Dentistry Fluoride ion level in drinking water (ppm)* <0.3 ppm 0.3 -06 ppm >0.6 ppm Birth - 6 months None 6 months - 3 years 3- 6years 6 - 16 years 0.25 mg /day ** 0.50 mg /day 1.0 mg /day None None 0.25 mg /day 0.50 mg /day * 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 greatly. 1211,121,131 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 .131 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 areas."' The dietary fluoride supplement schedule is just that - a supplement schedule (Table 1). Recognizing 18 None None None None 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. I The dietary fluoride supplement schedule is just that -a supplement schedule." I 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- entvalues. The newvalues 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.123 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 fluoride 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- 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, El Salvador, Honduras, Nica- ragua, Venezuela, Costa Rica, Jamaica, Mexico, Peru and Uruguay. )132,133 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.13' 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 %.136,137 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."' 10 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.136 Finally, there is general agreement that a high consumption of sodium is a risk factor for hypertension (high blood pressure ).139,140 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 .141 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 .142 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.143 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-us 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 19 Fluoridation Facts IN. Bottled Per Capita Consumption 2000 -2004 Gallo ns Annual Year Per Capita_ % Change 2000 — - 17.2 - 2001 18.7 1 8.7% 2002 20.7 10.8% 2003 22.1 7.0% 2004 1 23.8 1 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. 149,151 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).150 "Individuals who drink bottled water as their 1 primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supply. " 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 householdswith 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. 157 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. 113 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 five brands tested demonstrated significant differences 20 I between the various batches tested of the same brand .154 In evaluating how bottled water consumption affects i fluoride exposure, there are several factors to consider. First isthe 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, I 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,155 bottled water is regulated by the U.S. Food and Drug Administration (FDA) which has established standards for its quality.156 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.15' 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: /Iwww.ada.orci/goto /bottledwater. (Figure 3) Bottled Figure 3. Treatment Systems A MISIIC IR ., http : / /www.ada.org /goto /bottledwater • Does your bottled water contain fluoride? • Does your water filter remove fluoride? 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. Be resourceful. Visit ADA.org today! American Dental Association QUESTION 16. 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.",' 58.159 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. 160,111 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. 162 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. 3 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/cioto /bottledwater. (Figure 3) f,4,A :f: Fluoridation Facts 21 17 18. SAFETY Q 17. Harmful to humans? p. 22 Q25. Prevent fluorosis? p. 30 Q 18. More studies needed? p. 23 Q26. Warning label? p. 31 Q 19. Total intake? p. 24 Q 27• Toxicity? p. 31 Q20. Daily intake? p. 25 Q28. Cancer? p. 32 Q 29. Enzyme effects? p. 33 Q 21. Prenatal dietary p• 26 fluoride supplements? Q30. Thyroid gland? p. 34 Q22. Body uptake? p• 26 Q 31. Pineal Gland? p. 34 Q 23. Bone health? p. 27 Q32. Allergies? p. 34 Q 24. Dental fluorosis? p. 28 Q 33. Genetic risk? p. 35 Q 34. Fertility? p. 35 Q 35. Down Syndrome? p. 35 Q 36. Neurological impact? p.36 Q 37. Lead poisoning? p. 37 Q 38. Alzheimer's disease? p. 37 Q 39. Heart disease? p. 38 Q 40. Kidney disease? p. 38 Q 41. Erroneous health claims? p. 39 QUESTION 17. 1 stantiated by generally accepted scientific knowledge. Does fluoride in the water supply, at the levels recom- i After 60 years of research and practical experience, the pp y' mended for the prevention of dental decay, adversely preponderance of scientific evidence indicates that fluo- ridation of community water supplies is both safe and effective. Answer. The overwhelming weight of scientific evidence indi- ! 'After 60 years of research and practical cates that fluoridation of community water supplies is experience, the preponderance of safe. (See Figure 4.) scientific evidence indicates that fluoridation Fact. � of community water supplies is both For generations, millions of people have lived in ar- safe and effective. ' J 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.161 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. 1611 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- 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 601h 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.17' The World Health Organization, which initially recommended the practice of water fluorida- tion in 1969,171 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. "138 Fol- lowing a comprehensive 1991 review and evaluation of 22 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.84 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 .84,"1 The accumulated dental, medical and public health evi- dence concerning fluoridation has been reviewed and evaluated numerous times by academicians, commit- tees of experts, special councils of government and 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.13$•163 -166 "The verdict of the scientific community is that water fluoridation, at recommended levels, safely provides major I \,_ 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.,1z In April 2002, the EPA announced the results of its preliminary revise /not revise decisions for 68 chemi- i 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 2006.13 The definition of a contaminant is a function of the National Primary Drinking Water Regulations. The EPA Fluoridation Facts 23 19 w 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.84 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.168 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 .12,178 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). 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 10 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 .21, This "halo" or "diffusion" ef- fect results in increased fluoride intake by people in nonfluoridated communities, providing them increased protection against dental decay." -85,116 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 significant.87 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 .116 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. 179 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.123 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 time. 160,161 The fluoride content of fresh solid foods in the Unit- ed States generally ranges from 0.01 to 1.0 part per million .102,179 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- American Dental Association oride concentration and the brewing time.18' 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.1' 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.123 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 DRIs 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 not the 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 I all sources (fluoridated water, food, beverages, fluoride I dental products and dietary fluoride supplements) is set at 0.10 mg /kg /day (milligram per kilogram of body weight per day) for infants, toddlers, and children through eight years of age. For older children and adults, who are no longer at risk for dental fluorosis, the UL for fluoride is set at 10 mg /day regardless of weight. Table 3. Dietary Reference Intakes for Fluoride Food and Nutrition Board of the Institute of Medicine 1997123 Reference Weights Adequate Intake Tolerable Upper Intake Age Group kg (lbs)* (mg /day) (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 Children 4 -8 years 13 (29) 0.7 1.3 22 (48) 1.0 2.2 Children 9 -13 years Boys 14 -18 years 40 (88) 2.0 10.0 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 25 a 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 .42,178 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 Al 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 for a child 3 years of age in a nonfluoridated community is 0.5 mg /day. This provides leeway for some fluoride intake from processed food and beverages, and other sources. Decay rates are declining in many population groups because children today are being exposed to fluoride from a wider variety of sources than decades ago. Many of these sources are intended for topical use only; however, some fluoride is ingested inadvertently by children .1113 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 brushing.' 84.185-189 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. 123 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 10 a 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. 123,190 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. 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. 113 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. 182 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. 12 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 Its, 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 .114-191 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) .11123,199 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. 167 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. 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. 114 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 .115 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. " "' The second study examined the incidence of hip frac- ture rates before and after water fluoridation in Roches- ter, Minnesota .196 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. Fluoridation Facts 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. 203,204 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 .2111 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 .201, The second study was sponsored by the Proctor and Gam- ble Company.209 In both studies, higher than optimal con- 28 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 atthis time fail to establish an association between fluoride and cancer. 1184,210 (+ 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 after the teeth erupt. Because dental fluorosis occurs while teeth are forming under the gums, teeth that have erupted are not at risk for dental fluorosis. It should be noted that many other developmental changes that affect the appear- ance of tooth enamel are not related to fluoride intake. Classification I 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 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) .212 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. 113 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 .14 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% Tota 1 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 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 solution S.215 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 risk of teeth forming with the very mildest form of fluorosis must be weighed against the benefit that the individual's teeth will also have a lower level of dental decay thus saving dental treatment costs, patient discomfort and tooth loss." 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.10 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 Fluoridation Facts 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.215 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 .81 In other words, the majority of dental fluorosis can be associ- ated with other risk factors such as the inappropriate ingestion of fluoride products. 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 ago.84 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 over time.lao,181 The risk of fluorosis can be greatly reduced by following la- bel directions for the use of these fluoride products. 123,157 (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- sis.85,217 Studies of fluoride intake from the diet including foods, beverages and water indicate that fluoride ingestion from these sources has remained relatively constant for over half a century and, therefore, is not likely to be associ- ated with an observed increase in dental fluorosis.1110-182 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 10 topical use only; however, some fluoride is ingested inad- vertently by children .183 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. 189,218,219 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 .220 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.220 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).30,125 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. 122 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. 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 be taken 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, 72 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. " 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 .221 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. 182 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 Fluoridation Facts 31 28 O 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 .121 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) .11123,199 In these communities, daily fluoride intake of 20mg /day would not be uncommon .123 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.221 "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 10C 14 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 .221 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. 84 Studies have been conducted in the United State S,226-231 Japan '232 the United Kingdom,233 -235 Canada 231 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 cancer. 94,163,165,176,206,238 The U.S. Environmental Protection Agency (EPA) fur- ther commented on the safety of appropriate fluoride exposure in the December 5, 1997, Federal Register. 239 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 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 fluoridation.84 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.208 The second study was sponsored by the Proctor and Gamble Company.209 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. 1184,210 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. 14 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 .241 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 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 consequences. 248 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. 11211 The concentrations of fluoride used in laboratory studies to produce significant inhibition of enzymes are hundreds of times greater than the concentration present in body fluids or tissues .222 While fluoride may affect 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 organism.246 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. Fluoridation Facts 33 30. 31. 32. 33. 34. 35. 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 .148 In addition, two studies have explored the associa- tion between fluoridated water and cancer of the thy- roid gland. Both studies found no association between optimal levels of fluoride in drinking water and thyroid cancer. 226,249 In an effort to link fluoride and decreased thyroid func- tion, those opposed to fluoridation cite one small study from the 1950's in which 15 patients who had hyperthy- roidism (an overactive thyroid) were given relative large amounts of sodium fluoride orally or by injection in an ef- fort to inhibit the thyroid's function. The researchers con- cluded 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 ).251 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.251 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 10C 10 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 32. 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 .211 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 .255 There are no confirmed cases of allergy to fluoride, or of any positive skin testing in human or animal mod - eIs.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 .211,211 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 reactions .254 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 .167 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 .258- 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) .265,266 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. 11167 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 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 .117 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 rates .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. 167 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 .214,275 Experienced epidemiologists and dental research- ers from the National Institute of Dental Research and Fluoridation Facts 35 36 37 W 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 .122 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 .216 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 .277 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 .2711 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 .279 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 10C A 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 .2111 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 182 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." "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."" 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 7. 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 arre St. 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 $14,391,255.284 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 al) 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 (ll) compound S.285 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- sion s.288 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 .211 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. Additional information on how to critically review re- search can be found in the Introduction and Figure 1. QUESTION 38. 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 .2811 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 .290 Interestingly, there is evidence that aluminum and fluoride are mutually antagonistic in competing for absorption in the human body.42.29' 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. 37 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. 11292 39 The American Heart Association states: 40 'No evidence exists that adjusting the fluoride content of public water supplies to a level of 41 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. "211 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 .294 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 10 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. 162,192,193 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. 11161 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 dia lysi6.296.297 (Additional information on this topic is available in Ques- tion 22. 38 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 IQ (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 "Of the thousands of credible scientific studies on fluoridation, none has shown health problems associated with the consumption of optimally fluoridated water.' 39 42 43 FLUORIDATION PRACTICE Q42. Water quality? p. 40 Q 43. Regulation? p. 41 Q 44. Standards? p. 42 Q 45. Source of additives? p. 43 Q 46. System safety concerns? p. 43 Q 47. Engineering? p. 44 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 optima 1.36 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 .211 The optimal level is dependent on the annual average of the maximum daily air temperature in a given geographic area .36,11 (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 Q 48. Corrosion? Q 49. Environment? P. 44 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.298 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.t61 In EPA's judgment, the combined weight of hu- man and animal data support the current fluoride drinking water standard. In December 1993, the EPA published a notice in the Federal Registerstating 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. 168 The EPA further commented on the safety of fluo- ride in the December 51 1997, Federal Register."' 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 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 2006.173 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.299 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."' 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 SDWA's passage in 1974 implicitly re- Fluoridation Facts pealed FDA's jurisdiction over drinking water as a 'food' under the 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. 11155 "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. 41 44. 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 bythe 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 world .300 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.301 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. 301 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 42 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.e0 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 treatmen t.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." 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 .305 -3,0 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. American Dental Association Additionally, over time, a number of comprehensive reviews of the health effects of fluoridation have been published. These reviews which support the safety of water fluoridation include many studies conducted in large fluoridated communities which used the silicoflu- orlde additives .71,84,163,165,167,311 -313 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 The two 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 fragrances.314 "To ensure the public's safety, additives used in water fluoridation meet standards of the American i Water Works Association (AWWA) and NSF International (NSF)." 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.","' 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 .315 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- Fluoridation Facts 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 .315 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 10C 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 48. 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. 3 Additional information on this topic may be found in Question 4. A 1999 study31' 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 American Dental Association 30 this study and said there was no credible data to suggest % le" any link between fluoridation and Iead.285 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. 317,318 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 .320 "Under the Washington's State Environmental Protection Act (SEPA), i 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. 11311 There is no evidence that optimally fluoridated wa- ter has any effect on gardens, lawns or plants .322 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 .323 Fluoridation Facts 45 50 51 52 PUBLIC POLICY Q 50. Valuable measure? p. 46 Q 53. Internet? p.51 Q 51. Courts of law? p. 47 Q 54. Public votes? p. 51 Q 52. Opposition? p. 47 Q 55. 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 .7 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. "Former 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.1' 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 10 Q 56. Banned in Europe? p. 54 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.2e 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.27 American Dental Association "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.2e 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.27 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. "No court of last resort has ever determined fluoridation to be unlawful. The highest courts of more than a dozen states have confirmed the constitutionality of fluoridation. " 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 .314 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.3z5 Moreover, the U.S. Supreme Court has denied review of fluoridation cases thirteen times, citing that no substantial federal or constitutional questions were involved .321 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 .321,321 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 interest .328,329 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 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 West favoring 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.333 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 Do You Believe Community Water Should Be Fluoridated? Don't Know 12% 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Adults 10C 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 .342 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 Fluoridated Water, Do You Approve or Disapprove of Fluoridating Drinking Water ?? Approve 78% 70"� Disapprove 10% Don't Know/ 12% Refused 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Parents 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. Individuals who look to the 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 .310 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 0 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 .341 "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. 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. 49 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 10 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 5` 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. 2 50 American Dental Association QUESTION 53. 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.orci/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. FLUORIDATION AT YOUR FINGERTIPS! http: / /www.ada.org /goto /fluoride • 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. Be resourceful. Visit ADA.org today! QUESTION 54. Why does community water fluoridation sometimes lose when it is put to a public vote? 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 in the U.S. have adopted fluo- ridation. Another two have natural optimal levels of fluoride (Figure 9). The remaining six nonfluoridated cities are: Fresno, California; San Jose, California; Col- orado Springs, Colorado; Honolulu, Hawaii; Wichita, Kansas and Portland, Oregon. In 1998, recognizing the ongoing need to improve health and well being, the U.S. Public Health Service revised national health ob- jectives to be achieved by the year 2010. Included un- der oral health was an objective to significantly expand the fluoridation of public water supplies. Specifically, Objective 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 .31 (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 Fluoridation Facts 51 54. Two cities (Jacksonville, Florida and El Paso, Texas) are naturally fluoridated. Seattle Sacramento Oakland San Francisco \ Las 3 • Los Angeles Long Beach O Minneapolis Milwaukee De' Chicago Omaha Denver Kansas City Indianapolis TT St. Louis �J Albuquerque Oklahoma ,*Mesa Phoenix Fort Worth • • Dallas •tsoston New York Philadelphia r • Baltimore Virginia Beach Nashville- Davidson Charlotte • Memphis • • Atlanta I Paso (natural) •Jacksonville (natural) Austin• Houston New Orleans San Antonio • 60 � � Miami Q *Data compiled by the American Dental Association and Centers for Disease Control and Prevention /Division of Oral Health. Information current as of May 2005. 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 .341,343 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 .344 While no court of last resort has ever ruled against fluoridation, community leaders may be swayed by the 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 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 any way. 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. American Dental Association 10 States Meeting the Healthy People 2010 Goal of 75% of the Population Served by Fluoridated Community Water Supplies* J *Data Source: Centers for Disease Control and Prevention /Division of Oral Health. "Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water" 2002. Available at http:/ /www2,cdc.goy /nohss /`Fluoridatic "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:Hwww. ada.org/aoto /fluoride. In the past five years (2000 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 ADA's Division of Legal Affairs, Division of Communications and Department of State Government Affairs. Fluoridation Facts 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 "The value of water fluoridation is recognized internationally ...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. " 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 .131 Thorough inves- tigations of fluoridation have been conducted in Britain and Australia supporting the safety and effectiveness of water fluoridation .163,165,346 Considering the extentto 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- 16,210The 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. 111311 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 .311 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 .3111 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 lone 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 .349 (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. 138.350 American Dental Association 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. 97,109,104,351 -953 Fact. The cost of community water fluoridation can vary in each community depending on the following factors .314 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 .351 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. 17.97104,955 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. 11359 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 saving 5.355 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.358 "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. " American Dental Association The economic importance of fluoridation is under- scored 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 pro- vided by health departments, community health clinics, health insurance premiums, the military and other pub- licly supported medical programs. "' 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. QUESTION 58. 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 .36 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 .357 (Additional information on this topic may be found in Question 44. n April 2003, Surgeon General Richard H. Car - mona issued a National Call to Action to Promote Oral Health. The report was a wake -up call, raising a powerful voice against the silence. It called upon policymakers, community leaders, private industry, health professionals, the media, and the public to af- firm that oral health is essential to general health and well -being and to take action. While the effectiveness of preventive interventions such as community water fluoridation have been persuasively demonstrated, less than half of the fifty states have implemented fluoridation at the level to meet the national health objectives to be achieved by the year 2010. Specifically, Objective 21 -9 states that at least 75% of the U.S. population served by commu- nity water systems should be receiving the benefits of optimally fluoridated water by the year 2010. Fluoridation efforts at the local and state level can be greatly enhanced and the U.S. Healthy People 2010 Objective reached with the efforts of organizations, agencies and individuals who share a commitment to the benefits of community water fluoridation. Technical assistance with fluoridation efforts is available from the Council on Access, Prevention and Interprofessional Relations at ADA. 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Relationship between fluoride concentra- tion in drinking water and mortality rate from uterine cancer in Okinawa Prefecture, Japan. J Epidemiology 1996;6(4):184 -190. 233. Kinlen L. Cancer incidence in relation to fluoride level in water supplies. Br Dent J 1975;138:221 -4. 234. Chilvers C, Conway D. Cancer mortality in England in relation to levels of naturally occurring fluoride in water supplies. J Epidemiol Comm Health 1985;39: 44 -7. 235. Cook- Mozaffari PC, Bulusu L, Doll R. Fluoridation of water supplies and cancer mortality I: a search for an effect in the UK on risk of death from cancer. J Epide- miol Comm Health 1981;35:227 -32. 236. Raman S, Becking G, Grimard M, Hickman JR, McCullough RS, Tate RA. Fluoridation and cancer: an analysis of Canadian drinking water fluoridation and cancer mortality data. Environmental Health Direc- torate, Health Protection Branch. Ottawa, Canada: Authority of the Minister of National Health and Welfare;1977. 237. Richards GA, Ford JM. Cancer mortality in selected New South Wales localities with fluoridated and non - fluoridated water supplies. Med J Aust 1979;2:521 -3. 238. International Agency for Research on Cancer. IARC monographs on the evaluation of the carci- nogenic risk of chemicals to humans, Vol. 27. Switzerland;1982. 239. 62 Fed. Reg. 64297 (Dec. 5, 1997). 240. Clemmesen J. The alleged association between artificial fluoridation of water supplies and cancer: a review. Bulletin of the World Health Organization 1983; 61(5):871 -83. 241. Gelberg KH, Fitzgerald EF, Hwang SA, Dubrow R. Fluoride exposure and childhood osteosar- coma: a case - control study. Am J Public Health 1995;85(12):1678 -83. 242. McGuire SM, Variable ED, McGuire MH, Buckwalter JA, Douglass CW. Is there a link between fluori- dated water and osteosarcoma? J Am Dent Assoc 1991;122(4):38 -45. 243. Mahoney MC, LaBrie DS, Nasca PC, Wolfgang PE, Burnett WS. Population density and cancer mortality differentials in New York State, 1978 -1982. 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Atlanta;June 1987. 256. World Health Organization. Fluorine and fluorides: environmental health criteria 36. Geneva, Switzer - land;1984. 257. Schlesinger E. Health studies in areas of the USA with controlled water fluoridation. In: Fluorides and human health. World Health Organization Monograph Series No. 59. Geneva; 1970:305 -10. 258. Kram D, Schneider EL, Singer L, Martin GR. The effects of high and low fluoride diets on the frequen- cies of sister chromatid exchanges. Mutat Res 1978;57:51-5. 259. Li Y, Dunipace AJ, Stookey GK. Lack of genotoxic effects of fluoride in the mouse bone - marrow micro- nucleus test. J Dent Res 1987;66(11):1687 -90. 260. Li Y, Dunipace AJ, Stookey GK. Effects of fluoride on the mouse sperm morphology test. J Dent Res 1987;66(9):1509 -11. 261. Zeiger E, Gulati DK, Kaur P, Mohamed AH, Revazova J, Deaton TG. Cytogenetic studies of sodium fluoride in mice. Mutagenesis 1994;9(5):467 -71. 262. Li Y, Heerema NA, Dunipace AJ, Stookey GK. Geno- toxic effects of fluoride evaluated by sister- chromatid exchange. Mutat Res 1987;192:191 -201. 263. Dunipace AJ, Zhang W, Noblitt TW, Li Y, Stookey GK. Genotoxic evaluation of chronic fluoride exposure: micronucleus and sperm morphology studies. J Dent Res 1989;68(11):1525 -8. 264. Li Y, Zhang W, Noblitt TW, Dunipace AJ, Stookey GK. Genotoxic evaluation of chronic fluoride expo- sure: sister - chromatid exchange study. Mut Res 1989;227:159 -65. 10 C 'I 267. Martin GR, Brown KS, Singer L, Ophaug R, Jacobson - Kram D. Cytogenic and mutagenic assays on fluoride. In: Fluorides, effects on vegetation, animals and humans. Schupe JL, Peterson HB, Leone NC, eds. Salt Lake City: Paragon Press; 1983:271 -80. 268. Martin GR, Brown KS, Matheson DW, Lebowitz H, Singer L, Ophaug R. Lack of cytogenetic effects in mice or mutations in salmonella receiving sodium fluoride. Mutat Res 1979;66:159 -67. 269. Li Y, Dunipace AJ, Stookey GK. Absence of mutagenic and antimutagenic activities of fluoride in Ames salmonella assays. Mutut Res 1987;120:229 -36. 270. Tong CC, McQueen CA, Brat SV, Williams GM. The lack of genotoxicity of sodium fluoride in a battery of cellular tests. Cell Biol Toxicol 1988;4(2):173 -86. 271. Freni SC. Exposure to high fluoride concentra- tions in drinking water is associated with decreased birth rates. J Toxicology and Environmental Health 1994;42:109 -21. 272. Thomas Sinks, Ph.D., personal communication, November 6, 1992. 273. Lowry R, Steen N, Rankin J. Water fluoridation, still- births, and congenital abnormalities. J Epidemiol Comm Health 2003;57(7):499 -500. 274. Rapaport I. Contribution a Vetude de mongolisme: role pathogenique de fluor. Bull Acad M (Paris) 1953; 140:529 -31. 275. Rapaport I. Oligophrenic mongolienne et caries dentairs. Rev Stomatol Chir Maxillofac 1963;46:207 -18. 276. Berry WT. Study of the incidence of mongolism in relation to the fluoride content of water. Am J Ment Def 1958;62:634 -6. 277. Needleman BL, Pueschel SM, Rothman KJ. Fluorida- tion and the occurrence of Down's Syndrome. New Eng J Med 1974;291:821 -3. 278. Erickson JD, Oakley GP Jr., Flynt JW Jr., Hay S. Water fluoridation and congenital malformations: no asso- ciation. J Am Dent Assoc 1976;93:981 -4. 279. Knox EG, Armstrong E, Lancashire R. Fluoridation and the prevalence of congenital malformations. Comm Med 1980;2:190 -4. 280. Erickson JD. Down syndrome, water fluoridation and maternal age. Teratol 1980;21:177 -80. 281. Mullenix PJ, Denbesten PK, Schunior A, Kernan WJ. Neurotoxicity of sodium fluoride in rats. Neurotoxicol Te rato 1 1995;17(2):169-77. 282. Ross JF, Daaton GP. Neurotoxicology and Teratology 1995;17(6):685 -6. Letter to the editor. 283. Shannon FT, Fergusson DM, Horwood LJ. Exposure to fluoridated public water supplies and child health 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 on the induction of chromosome aberrations in tion predicted to result from use of silicofluorides in human cells and alkylating agents in vitro. 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 I lead(II) in potable water? Hexafluorosilicate and aberrations in human 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 65 286. Centers for Disease Control and Prevention. Surveillance for elevated blood lead levels among children- United States, 1997 -2001. MMWR 2003;52(SS10):1 -21. 287. Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance- United States, 1998 -2001. MMWR 2002;51(SS11):1 -10. 288. Alzheimer's Disease Education & Referral Center. Causes: what causes AD? Available at <http: / /www. alzheimers.org /causes.htm >. Accessed May 6, 2005. 289. Varner JA, Jensen KF, Horvath W, Isaacson RL. Chronic administration of aluminum - fluoride or sodium - fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity. Brain Res 1998;784:284 -98. 290. American Dental Association. Health Media Watch: Study linking fluoride and Alzheimer's under scrutiny. J Am Dent Assoc 1998;129:1216 -8. 291. Kraus AS, Forbes WF. Aluminum, fluoride and the prevention of Alzheimer's Disease. Can J Public Health 1992;83(2):97 -100. 292. US Department of Health, Education and Welfare, National Institutes of Health, Division of Dental Health. Misrepresentation of statistics on heart deaths in Antigo, Wisconsin Pub. No. PPB -47. Bethesda;November 1972. 10 303. NSF International Standard 60 -2002. Drinking water treatment chemicals - health effects. NSF Interna- tional, Ann Arbor, M1;2002. 304. NSF International Standard 61 -2002. Drinking water system components - health effects. NSF International, Ann Arbor, M1;2002. 305. DeEds F, Thomas JO. Comparative chronic toxicities of fluorine compounds. Proc Soc Exper Biol and Med 1933- 34;31:824 -5. 306. McClure FJ. A review of fluorine and its physiological effects. Phys Reviews 1933;13:277 -300. 307. McClure FJ. Availability of fluorine in sodium fluo- ride vs. sodium fluosilicate. Public Health Rep 1950;65(37):1175 -86. 308. Zipkin 1, Likins RC, McClure FJ, Steere AC. Urinary fluoride levels associated with the use of fluoridated water. Public Health Rep 1956;71:767 -72. 309. Zipkin I, Likins RC. Absorption of various fluoride compounds from the gastrointestinal tract of the rat. Amer J Physicol 1957;191:549 -50. 310. McClure FJ, Zipkin I. Physiologic effects of fluoride as related to water fluoridation. Dent Clin N Am 1958:441 -58. 311. Crisp MP. Report of the Royal Commissioner into the fluoridation of public water supplies. Hobart, Tasma- nia, Australia: Government Printers;1968. 293. American Heart Association. Minerals and inorganic 312. Myers DM, Plueckhahn VD, Rees ALG. Report of the substances: fluoridation. Available at <http: / /www. committee of inquiry into fluoridation of victorian americanheart.org /presenter.jhtml ?identifier= 4698 >. water supplies. 1979 -80 Melbourne, Victoria, Australia, Accessed May 6, 2005. FD Atkinson, Government Printer;1980:115 -25. 294. American Heart Association. Risk factors and 313. Ad Hoc Committee for the U.S. Surgeon General coronary heart disease. Available at <http: / /www. Koop, Shapiro JR, Chairman. Report to the Environ- americanheart.org /presenter.jhtml ?identifier= 4726 >. mental Protection Agency on the medical (non - dental) Accessed May 6, 2005. effects of fluoride in drinking water. 1983:1 -9. 295. Geever EF, Leone NC, Geiser P, Lieberman J. Patho- logic studies in man after prolonged ingestion of fluoride in drinking water I: necropsy findings in a community with a water level of 2.5 ppm. J Am Dent Assoc 1958;56:499 -507. 296. US Department of Health and Human Services, Public Health Service. Surgeon General's advisory: treat- ment of water for use in dialysis: artificial kidney treatments. Washington, DC: Government Printing Office 872- 021;June 1980. 297. Centers for Disease Control. Fluoride in a dialysis unit - Maryland. MMWR 1980;29(12):134 -6. 298. 51 Fed. Reg. 11410,11412 (April 2, 1986). 299. Environmental Protection Agency. Safe Drinking Water Act. Basic Information. Available at <http:// www. epa. gov / safewater /sdwa /basicinformation. htmI >. Accessed May 8, 2005. 300. American Water Works Association. Who we are. Available at <http: / /www.awwa.org /About / >. Accessed February 18, 2005. 301. National Sanitation Foundation International. About NSF. Available at <http://www.nsf.org/business/about- NSF/>. Accessed February 18, 2005. 302. American National Standards Institute. About ANSI overview. Available at <http: / /www.ansi.org /about_ ansi/ overview /overview.aspx ?menuid =1 >. Accessed February 18, 2005. 314. Hodges A, Philippakos E, Mulkey D, Spreen T, Murraro R. Economic impact of Florida's citrus indus- try, 1999 - 2000. Gainesville, University of Florida, Institute of Food and Agricultural Sciences. Available at < http:/ /edis.ifas.ufl.edu /BODY_FE307 >. Accessed April 18, 2005. 315. Centers for Disease Control and Prevention. Engineer- ing and administrative recommendations for water fluoridation, 1995. MMWR 1995;44(No.RR -13). 316. Master R, Coplan MJ. Water treatment with silicofluoride and lead toxicity. Int J Environ Studies 1999;56:435 -49. 317. U.S. Environmental Protection Agency. Consumer fact sheet on lead. Available at <http: / /www.epa.gov/ safewater /Icrmr /lead.html >. Accessed on May 8, 2005. 318. U.S. Environmental Protection Agency. Arsenic in drinking water. Available at <http: / /www.epa.gov /safe- water /Icrmr /lead.html >. Accessed on May 8, 2005, 319. Personal correspondence. Stan Hazan. General manager, Drinking Water Additives Certification Program, NSF International to David Spath, California Department of Health Services, Office of Drinking Water. March 30, 2000. Available at <http://www.dentalhealth- foundation .org /documents /NSFLetter.pdf >. Accessed on May 8, 2005, 320. U.S. Environmental Protection Agency, Office of Water, Office of Science and Technology. Fluoride: a regulatory fact sheet. 66 American Dental Association 321. Tacoma - Pierce County Health Department. Tacoma - Pierce County Health Department fluoridation resolution. WAC197 -11 -960 environmental checklist. August 2002. 322. Pollick PF. Water fluoridation and the environment: current perspective in the United States. Int J Occup Environ Health 2004;10:343 -50. 323. Osterman JW. Evaluating the impact of municipal water fluoridation on the aquatic environment. Am J Public Health 1990;80:1230 -5. 324. Safe Water Association, Inc. v. City of Fond du Lac, 184 Wis.2d 365, 516 N.W.2d 13 (Wis. Ct. App. 1994). 325. Block LE. Antifluoridationists persist: the constitu- tional basis for fluoridation. J Public Health Dent 1986;46(4):188 -98. 326. Christoffel T. Fluorides, facts and fanatics: public health advocacy shouldn't stop at the courthouse door. Am J Public Health 1985;75(8):888 -91. 327. McMenamin JP. Fluoridation of water in Virginia: the tempest in the teapot. J Law Ethics Dent 1988;1(1): 42 -6. 328. Roemer R. Water fluoridation: public health responsi- bility and the democratic process. Am J Public Health 1965;55(9):1337 -48. 329. Strong GA. Liberty, religion and fluoridation. J Am Dent Assoc 1968;76:1398 -1409. 330. Easlick KA. An appraisal of objections to fluoridation. J Am Dent Assoc 1962;65:868 -93. 331. American Dental Association, Survey Center. 1998 Consumers' opinions regarding community water fluoridation. Chicago;June 1998. 332. Gallup Organization, Inc. A Gallup study of parents' behavior, knowledge and attitudes toward fluoride. Princeton, NJ: Gallup Organization, Inc.;1991. 333. Newbrun E. The fluoridation war: a scientific dispute or a religious argument? J Public Health Dent 1996;56(5)(Spec Iss):246 -52. 334. Scott DB. The dawn of a new era. J Public Health Dent 1996;56(5)(Spec Iss):235 -8. 335. Park B, Smith K, Malvitz D, Furman L. Hazard vs outrage: public perception of fluoridation risks. J Public Health Dent 1990;50(4):285 -7. 336. Neenan ME. Obstacles to extending fluoridation in the United States. Comm Dent Health 1996;13(Suppl 2):10 -20. 337. Lowry R. Antifluoridation propaganda material -the tricks of the trade. Br Dent J 2000;189(10):528 -30. 338. Mandel I. A symposium of the new fight for fluo- rides. J Public Health Dent 1985;45(3):133 -41. 339. Lang P, Clark C. Analyzing selected criticisms of water fluoridation. J Can Dent Assoc 1981;47(3):i -xii. 340. Lieberman AJ, The American Council on Science and Health. Facts versus fears: a review of the 20 greatest unfounded health scares of recent times. 2nd ed. New York;1997. 341. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113, S.Ct. 2786 (1993). 342. Frazier PJ. Fluoridation: a review of social research. J Public Health Dent 1980;40(3):214 -33. Fluoridation Facts 10 343. Margolis FJ, Cohen SN. Successful and unsuccess- ful experiences in combating the antifluoridationists. Pediatrics 1985;76(1):113 -8. 344. Easley MW. The new antifluoridationists: who are they and how do they operate? J Public Health Dent 1985;45(3):133 -41. 345. Wulf CA, Hughes KF, Smith KG, Easley MW. Abuse of the scientific literature in an antifluoridation pamphlet. Baltimore: American Oral Health Institute;1985. 346. National Health and Medical Research Council. The effectiveness of water fluoridation. Canberra, Austra- lia: Australian Government Publishing Service;1991. 347. Jones S. Water fluoridation in Europe. Paper presented to the British Association for the Study of Community Dentistry, 1996 Spring Scientific Meeting. Dundee, Scotland. 348. Marthaler TM. Water fluoridation results in Basel since 1962: health and political implications. J Public Health Dent 1996 Spec Iss;56(5):265 -70. 349. Meyer J, Marthaler TM, Burgi H. The change from water to salt as the main vehicle for community -wide fluoride exposure in Basle, Switzerland (Editorial). Community Dent Oral Epidemiol 2003;31(6):401 -2. 350. Roemer R. Legislation on fluoridation of water supplies. In: Experience on water fluoridation in Europe. Copenhagen: World Health Organiza- tion;1987:23-36. 351. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness of school - based preventive dental care. Am J Public Health 1985;75(4):382 -91. 352. Federation Dentaire Internationale. Cost - effectiveness of community fluoride programs for caries preven- tion: technical report 13. Chicago: Quintessence;1981. 353. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluorida- tion: 44 Florida communities. J Public Health Dent 1992;52(2):75 -80. 354. Centers for Disease Control and Prevention. Recom- mendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50(No.RR- 14):22. 355. Griffin SO, Jones K, Tomar SL. An economic evalua- tion of community water fluoridation. J Public Health Dent 2001;61(2):78 -86. 356. American Dental Association, Survey Center. 2003 survey of dental fees. Chicago;April 2004. 357. American Water Works Association. Fluoridation of public water supplies. Adopted by the Board of Directors Jan. 25, 1976, reaffirmed Jan. 31, 1982 and revised Jan. 20, 2002. Available at <http: / /www. awwa.org/About/OandC/off icia Idocs /AWWASTAT. cfm >. Accessed April 29, 2005. 358. Centers for Disease Control and Prevention. Water fluoridation and costs of Medicaid treatment for dental decay- Louisiana, 1995 -1996. MMWR 1999;48(34):753 -7. 359 Burt BA, ed. Proceedings for the workshop: cost effec- tiveness of caries prevention in dental public health: results of the workshhop. J Public Health Dent 1989; 56 (5 Spec No): 331 -40. 67 10 C Statements from Five Leading Health Organizations Regarding Community Water Fluoridation AMERICAN DENTAL ASSOCIATION (ADA) "TheAssociation endorses corn munitywaterfIuoridation 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 201h 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. 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 clear that there 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. 1 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. 68 American Dental Association 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 National Kidney Foundation 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 World Health Organization I he 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 hltp;//WWW.ada.org/agio/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 69 ��)��® American Dental Association www.ada.org 211 East Chicago Avenue Chicago, Illinois 60611 -2678 10 Presented by The PROFESSIONALS' STATEMENT Calling for an end to Water Fluoridation "It is time for the US, and the few remaining fluoridating countries, to recognize that fluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. Fluoridation must be ended now." To view the list of signers, or to sign this statement, go to: www.FIuorideAIert.Org 10C Ageraa ;iem #: _i oc- Meei +nc; Date: !P Presented by The PROFESSIONALS' STATEMENT Calling for an end to Water Fluoridation "It is time for the US, and the few remaining fluoridating countries, to recognize that fluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. Fluoridation must be ended now." To view the list of signers, or to sign this statement, go to: www.FIuorideAIert.Org 10C e, the undersigned professionals, come from a variety of disciplines but all have an abiding interest in ensuring that government public health and environmental policies be determined honestly, with full attention paid to the latest scientific research and to ethical principles. KM_tN I C V tN I Make OCf1Ol end water fluo U R G 6aao A The publication in 2006 of a 500 -page review of fluoride's toxicology by a distinguished panel appointed by the National Research Council of the National Academies (NRC, 2006). The NRC report concluded thatthe US Environmental Protection Agency's (EPA) safe drinking water standard for fluoride (i.e. maximum contaminant level goal or MCLG) of 4 parts per million (ppm) is unsafe and should be lowered. Despite over 60 years of fluoridation, the report listed many basic research questions that have not been addressed. Still, the panel reviewed a large body of literature in which fluoride has a statistically significant association with a wide range of adverse effects. These include an increased risk of bone fractures, decreased thyroid function, lowered IQ, arthritic -like conditions, dental fluorosis and, possibly, osteosarcoma. The average fluoride daily intakes ( *) associated with many of these adverse effects are reached by some people consuming water at the concentration Bevels now used for fluoridation -- especially small children, above average water drinkers, diabetics, people with poor kidney function and other vulnerable sub- groups. For example, the average fluoride daily intake associated with impaired thyroid function in people with iodine deficiency (about 12% of the US population) is reached by small children with average consumption of fluoridated water at 1 ppm and by people of any age or weight with moderate to high fluoridated water consumption. Of special note among the animal studies is one in which rats fed water containing 1 ppm fluoride had an increased uptake of aluminum into the brain, with formation of beta- amyloid plaques, which is a classic marker of Alzheimer's disease pathology in humans. Considering the substantial variation in individual water intake, exposure to fluoride from many other sources, its accumulation in the bone and other calcifying tissues and the wide range of human sensitivity to any toxic substance, fluoridation provides NO margin of safety for many adverse effects, especially lowered thyroid function. Note: `Daily intake" takes into account the exposed individual's bodyweight and is measured in mg. of fluoride per kilogram bodyweight. The evidence provided by the US Centers for Disease Control IngreCvention (CDC) in 2005 that 32% of American children have dental fluorosis — an abnormal discoloration and mottling of the enamel. This irreversible and sometimes disfiguring condition is caused by fluoride. Children are now being overdosed with fluoride, even in non - fluoridated areas, from water, swallowed toothpaste, foods and beverages processed with fluoridated water, and other sources. Fluoridated water is the easiest source to eliminate. The American Dental Association's policy change, in November 2006, recommending that only the following types of water be used for preparing infant formula during the first 12 months of life: "purified, distilled, deionized, demineralized, or produced through reverse osmosis. "Thisnew policy, which was implemented to prevent the ingestion of too much fluoride by babies and to lower the risk of dental fluorosis, dearly excludes the use of fluoridated tap water. The burden of following this recommendation, especially for low income families, is reason alone for fluoridation to be halted immediately. Formula made with fluoridated water contains 250 times more fluoride than the average 0.004 ppm concentration found in human breast milk in non - fluoridated areas (Table 2 -6, NRC, 2006). The CDC's concession, in 1999 and 2001, that the predominant benefit of fluoride in reducing tooth decay is TOPICAL and not SYSTEMIC. To the extent fluoride works to reduce tooth decay, it works from the outside of the tooth, not from inside the body. It makes no sense to drink it ant expose the rest of the body to the long term risks of fluoride ingestion when fluoridated toothpaste is readily available. Fluoride's topical mechanism probably explains the fact that, since the 1980s, there have been many research reports indicating little difference in tooth decay between fluoridated and non - fluoridated communities (Leverett, 1982; Colquhoun, 1984; 1985 and 1987; Diesendorf, 1986; Gray, 1987; Brunelle and Carlos, 1990; Spencer,1996; deLiefde, 1998; Locker, 1999; Armfield and Spencer, 2004; and Pizzo 2007). Poverty is the clearest factor associated with tooth decay, not lack of ingested fluoride. According to the World Health Organization, dental health in 12 -year olds in non - fluoridated industrialized countries is as good, if not better, than those in fluoridated countries (Neurath, 2005). In 2000, the publication of the UK government sponsored "York Review," the first systematic scientific review of fluoridation, found that NONE of the studies purportingto demonstrate the effectivenessof fluoridation to reduce tooth decay were of grade A status, i.e. "high quality, bias unlikely" (McDonagh etal., 2000). The publication in May 2006 of a peer - reviewed, case-In r 11 study from Harvard University which found a 5 -7 fold increase i ofeoircoma (a frequently fatal bone cancer) in young men associated with exposure to fluoridated water during their 6th, 7th and 8th years (Bassin et al., 2006). This study was surrounded by scandal as Elise Bassin's PhD thesis adviser, Professor Chester Douglass, was accused by the watchdog Environmental Working Group of attempting to suppress these findings for several yeas. While this study does not prove a relationship between fluoridation and osteosarcoma beyond any doubt, the weight of evidence and the importance of the risk call for serious consideration. The admission by federal agencies, in response to questions from a Congressional subcommittee in 1999 -2000, that the industrial grade waste products used to fluoridate over 90% of America's drinking water supplies (fluorosilicate compounds) have never been subjected to toxicological testing nor received FDA approval for human ingestion (Fox, 1999; Hazan, 2000; Plaisier, 2000; Thurnau, 2000). The publication in 2004 of "The Fluoride Deception" by Christopher i Bryson. This meticulously researched book showed that industrial interests, concerned about liabilities from fluoride pollution and health effects on workers, played a significant role in the early promotion of fluoridation. Bryson also details the harassment of scientists who expressed concerns about the safety and /or efficacy of fluoridation (Bryson, 2004). We call upon Members of Congress (and legislators in other fluoridating countries) to sponsor a new Congressional (or Parliamentary) Hearing on Fluoridation so that those in government agencies who continue to support the procedure, particularly the Oral Health Division of the CDC, be compelled to provide the scientific basis for their ongoing promotion of fluoridation. They must be cross - examined under oath if the public is ever to fully learn the truth about this outdated and harmful practice. We call upon oil medical and dental professionals, members of water departments, local officials, public health organizations, environmental groups and the media to examine for themselves the new documentation that fluoridated water is ineffective and poses serious health risks. It is no longer acceptable to simply rely on endorsements from agencies that continue to ignore the large body of scientific evidence on this matter -- especially the extensive citations in the NRC {2006) report discussed above. The untold millions of dollars that are now spent on equipment, chemicals, monitoring, and promotion of fluoridation could be much better invested in nutrition education and targeted dental care for children from low income families. The vast majority of enlightened nations have done this. It is time for the US, and the few remaining fluoridating countries, to recognize that fluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. Fluoridation must be ended now. To view the list of signers, or to sign this statement, go to: www.FiuorideAie rt. 0r9 a `o u c ' > a O zap d L � Ends A r4►� V Z a 2 _ ..n�f� ^Q*►. -. ov° at { C r • G J �S R _? L" I�It . fy1 �`I ��� `ai .�, � c �{ :.o °�'�m �1KG �• m 'rn o� ;� i � �� a E�'' _� � . �• z'� �� E . +gym; ,w i d E lOC A Strong, Deliberate Statements by the top ;,.edical authorities in our nation based on the latest medical research ♦"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 attemptto use Arrerican Medicd A66Dr water this way is deplorable." - Dr. Charles Gordon Heyd, Past President of the American Medical Association. ♦"I would advise against fluoridation, Side- effects cannot be exclud . In Sweden, the emphasis nowadays is to keep Nobel Prize the environment as clean as possible with regard to pharmacologically active and, thus, potentially toxic Medicine substances." - Dr. Arvid Carlsson, co- winner of the Nobel Prize for Medicine (2000) *"The American Medical Association is NOT prepared to state that no harm will be done to any person by water fluoridation, The AMA has not carried out any research AMA work, either long -term or short-term, regarding the American Medicei Gswc. possibility of any side effects." - Dr. Flanagan, Assistant Director of Environmental Health, American Medical Association. E.P.A. should act immediately to protect the public, not just on ,the cancer data, but on the evidence of bone fractures, TrOER16% arthritis, mutagenicity and other effects." - Dr. William Marcus, Senior Toxicologist at E.P.A. *'Water contains a number of substances WaL are undesirable, and .e jug Stated Dr. F. A. Bull, State Dental Director of Wisconsin, speaking at the Fourth Annual Conference of State Dental Directors Tooth Decay in Fluoridated vs. Unfluoridated Countries 0c Page 1 -.)f Excerpts from the Scientific Literature - Tooth Decay Trends in Western European Countries. : BELGIUM - Unfluoridated Water, Fluoridated Salt: (back to top) "Caries -free childienr increased from 4% to 501X)_ A remarkable decline in dental caries was observed during the 15 -yr period." SOURCEL Carvarho JC, Van Nieuwennu sen JP, D'-oo r e V. i2� 3 ; j. The de c line n dental a;non ^ egian children between 1983 and 1998. C,ornrnunitl Dentistry and Oral Eprderniofo_gy 29: 55 -61. DENMARK - Unfluoridated Water, Unfluoridated Salt: "The paper presents an overview of the oral health situation in Denmark...[Njat €oral oral epidemiological data have been provided since 1972. Partly due to the preventive approach, a general decrease over -tune in the prevalence of dental caries has been documented for children•, and adolescents. For example, in 1972 children in first class had a mean canes experience of 12.4 def -s against 3.9 def -s in 1999 " SOURCE: Petersen PE (199+2). Effectiveness of oral health care —some Danish experiences. Proceedings of the Finnish Dental Socirety 88: 13 -23. +ft FINLAND - Unfluoridated plater, Unfluoridated Salt: "During the 10 years, substantial decreases were seen in the mean numbers of dental visits [from 4.0 to 2.4i and fillings (frorn 2.9 to 1.2) The greatest decrease was seen in the number of fillings made in incisors-` SOURCE: Vehkalahti Ml, Rytomaa i, Heiminen S. 0991). Decline in dental caries and pubiic oral health care of adolescents. Acta Odontologica Scandinavice 49. 323 -8. FRANCE - Unfluoridated Water, Fluoridated Salt: "Epidernioiogical surveys showed a marked decrease of caries prevalence in French children during the last 20 years.,, SOURCE: rObry- Musset AM- (19933). [Epidemiology of dental caries in children] 'Article in Frenchj .Arch Ped;atr 5: 11445.8 GERMANY - Unfluoridated Water, Fluoridated Salt: :,Caries rates are on the decline in the Federal Republic of Germany, too. And, in some cases considerable, increase in the number of children With Caries -free teed} and a clear reduction in the average number of carious teeth has been recorded, above all in kindergartens with preventive dentistry programmes." SOURCE: Gulzow HJ. (1990). [Preventive dentistry in the Federal Republic of Germany] IArticle in German] Ol aiprophidaye 12: 53 -60. ■ i GREECE - Unfluoridated [;later, Unfluoridated Salt, "The percentage of caries -free children for the total examined population increased by 94`% � while the reduction in DMFT index ranged behveen 38 and 70 %. Treatment need vistas significantly lower in 199. 1 compared to 1982 in both dentitions.,, SOURCE: AthanaSSOUIr 1, et al ( 1994) Dental caries changes between 1982 and 1991 in children aged 6 -12 in Athens, Greece. Caries Research 28(5;:378 -82. ■ I ICELAND - Unfluoridated Water, Unfluoridated Salt: "During the last decade: a continuous decrease in dental canes has been observed among schoolchildren in Iceland.. There does not seem to be any single factor responsible for the onset of the caries decline.:, SOURCE: Einaisdottir KG, Bratthall D (19965). Restoring oral health On the rise and fall of dental caries in Iceland. c uropean Journal of Oral Science 104. 459 -69. http://www.fluoridealert.org/health/teeth/caties/who-dmft.aspx 9/6/2011 Tooth Decay in Fluoridated vs. Unfluoridated Countries THE NETHERLANDS - Unfluoridated Water, Unfluoridated Salt: 1 U v Page 2 "According to WHO criteria, 12- year -old children in The ;Netherlands now have a very low caries experience.` SOURCE: Trui.n, GJ, Konig KG, Sronkhorst EM. (1994). Caries prevalence in Belgium and The Netherlands. International Dentistry Journa, 44: 379 -8. EM NORWAY & all SCANDINAVIAN COUNTRIES - Unfluoridated Water, Unfluoridated Salt: "Denmark: iceland, !Norway, and Sweden have ail had a similar decline in dental caries during the last 20 years, although the decline has come later in Iceland. Despite the differences in choice of preventive rnethods, the dental health of children varies little across the frontiers." SOURCE: Kallestal C, et al. ;1999). Caries - preventive methods used for children and adolescents in Denmark, Iceland: Norway and Sweden. Community Dentistry and Ora! cprnernioloa 27: 144 -51 "Despite differences in the dental health care services and the recording and reporting systems: a consistent and similar decline in dental caries is evident for Denmark, Finland, Norway and Sweden during the last two decades " SOURCE: von der Fehr FR. (1994). Caries prevalence in the Nordic countries. International Dentistry Journa144: 371 -8. SWEDEN - Unfluoridated Water, Unfluoridated Salt: "Between 1957 and 1992 the mean dmfs values declined front 7.8 to i .8 The decline was greatest between 1967 and 1980 and then levelled off." SOURCE: Stecksen- Slicks C, Holm AK. (1995y Dental caries, tooth trauma, malocclusion, fluoride usage, toothbrushing and dietary habits in 4- year -old Swedish children: changes between 1967 and 1992. international Journal of Paediatric Dentistry 5. 143 -8 0 SWITZERLAND - Unfluoridated Water, Fluoridated Salt: "Caries prevalence has declined by 70 -84 percent since the late sixties." SOURCE: Ma thale.r TM. (1991). (School dentistry in Zurich Canton changes as a result of caries reduction of 80 to 85 percent! [.Article in German:] Oralprophylaxe 13'. 115 -22. "Surveys of dental caries prevalence were carried out from 1970 -1993 in schoolchildren of the city of Zurich. DfvIFT experience declined by 68 to 80%. while the average draft decreased by 48 -53% (ages 7 to 9) " SOURCE: Steiner M, Menghini G, Curtlovic Z: Marthaler T. ( 1994). ;'r.he caries occurrence in schoolchildren of the city of Zurich in 1970 -1993. A view of prevention in new immigrants± [Article in German]. Schvr,eiz MonatsschrZahnmed 104. 1210 -8. http : / /www.fluofidealert.org/health /teeth /caries /who - dmft.aspx 9/6/2011 it ri 10 Tooth Decay Trends in Fluoridated VS Unfluoridated Countries When the Centers for Disease Control nominated water fluoridation as one of the top 10 public health achievements of the 20th century, it published a graph which showed the reduction of cavities in US children coupled with the increase in water systems that have been fluoridated since the 1960's. The CDC referred to the graph with the statement: "as a result [of watertluoridation], dental caries declined precipitously during the second half of the 20th century." However, what the CDC failed to mention is that similar declines in tooth decay have occurred in virtually every western country, most of which do not fluoridate water W x d v 5 7 z 41 W rn c N N 4 v a �3 a 0 LA- Tooth Decay Trends: Fluoridated vs. Unfluoridated Countries r'ealtrt L)fg3r,IZX1,r1 - rAtp:. xr:A Ml',: GraGn produceC by C ^.• -s Neuratn. FAN 0 = 570 y115 207 2075 Year UNFLUORIDATED --� Austria --a— Belgium - A Denmark Finland — France -�- Germany -� Iceland --a- Italy -,�— Japan Netherlands Norway -� Sweden -- Switzerland �- United Kingdom FLUORIDATED Australia -� Ireland -�- New Zealand -4io-- United States 10 C �± Excerpts from the Scientific Literature — "Universal Decline in Tooth Decay" in Western World Irrespective of Water Fluoridation: "Although the prevalence of caries varies between countries, levels everywhere have fallen greatly in the past three decades, and national rates of caries are now universally low. This trend has occurred regardless of the concentration of fluoride in water or the use of fluoridated salt, and it probably reflects use of fluoridated toothpastes and other factors, including perhaps aspects of nutrition." SOURCE: Cheng KK, et al. (2007). Adding fluoride to water supplies. British Medical Journal 335(7622):699 -702. "In most European countries, where community water fluoridation has never been adopted, a substantial decline in caries prevalence has been reported in the last decades, with reductions in lifetime caries experience exceeding 75%." SOURCE: Pizzo G, et al. (2007). Community water fluoridation and caries prevention: a critical review. Clinical Oral Investigations 11(3):189 -93. "Graphs of tooth decay trends for 12 year olds in 24 countries, prepared using the most recent World Health Organization data, show that the decline in dental decay in recent decades has been comparable in 16 nonfluoridated countries and 8 fluoridated countries which met the inclusion criteria of having (i) a mean annual per capita income in the year 2000 of US$10,000 or more, (ii) a population in the year 2000 of greater than 3 million, and (iii) suitable WHO caries data available. The WHO data do not support fluoridation as being a reason for the decline in dental decay in 12 year olds that has been occurring in recent decades." SOURCE: Neurath C. (2005). Tooth decay trends for 12 year olds in nonfluoridated and fluoridated countries. Fluoride 38:324 -325. "It is remarkable... that the dramatic decline in dental caries which we have witnessed in many different parts of the world has occurred without the dental profession being fully able to explain the relative role of fluoride in this intriguing process. It is a common belief that the wide distribution of fluoride from toothpastes may be a major explanation, but serious attempts to assess the role of fluoridated toothpastes have been able to attribute, at best, about 40 -50% of the caries reduction to these fluoride products. This is not surprising, if one takes into account the fact that dental caries is not the result of fluoride deficiency." SOURCE: Aoba T, Fejerskov O. (2002). Dental fluorosis: chemistry and biology. Critical Review of Oral Biology and Medicine 13:155-70. "A very marked decline in caries prevalence [in Europe) was seen in children and adolescents... The number of edentulous adults in Europe has also been declining considerably." SOURCE: Reich E. (2001). Trends in canes and periodontal health epidemiology in Europe. International Dentistry Journal 51(6 Suppl 1):392 -8. "The caries attack rate in industrialized countries, including the United States and Canada, has decreased dramatically over the past 40 years." SOURCE: Fomon SJ, Ekstrand J, Ziegler EE. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. Journal of Public Health Dentistry 60: 131 -9. "Since the 1960s and 70s, however, a continuous reduction (in tooth decay) has taken place in most 'westernized' countries, it is no longer unusual to be caries - free... During the decades of caries decline, a number of actions have been taken to control the disease, and the literature describes numerous studies where one or several factors have been evaluated for their impact. Still, it is difficult to get a full picture of what has happened, as the background is so complex and because so many factors may have been involved both directly and indirectly. In fact, no single experimental study has addressed the issue of the relative impact of all possible factors, and it is unlikely that such a study can ever be performed." SOURCE: Bratthall D, Hansel - Petersson G, Sundberg H. (1996). Reasons for the caries decline: what do the experts believe? European Journal of Oral Science 104:416 -22. "Caries prevalence data from recent studies in all European countries showed a general trend towards a further decline for children and adolescents... The available data on the use of toothbrushes, fluorides and other pertinent items provided few clues as to the causes of the decline in caries prevalence." SOURCE: Marthaler TM, O'Mullane DM, Vrbic V. (1996). The prevalence of dental caries in Europe 1990- 1995.ORCA Saturday afternoon symposium 1995. Caries Research 30: 237 -55 "The aim of this paper is to review publications discussing the declining prevalence of dental caries in the industrialized countries during the past decades ... (T) here is a general agreement that a marked reduction in caries prevalence has occurred among children in most of the developed countries in recent decades." SOURCE: Petersson GH, Bratthall D. (1996). The caries decline: a review of reviews. European Journal of Oral Science 104: 436 -43. "The regular use of fluoridated toothpastes has been ascribed a major role in the observed decline in caries prevalence in industrialized countries during the last 20 to 25 years, but only indirect evidence supports this claim." SOURCE: Haugejorden O. (1996). Using the DMF gender difference to assess the "major" role of fluoride toothpastes in the caries decline in industrialized countries: a meta- analysis. Community Dentistry and Oral Epidemiology 24: 369 -75. "The marked caries reduction in many countries over the last two decades is thought to be mainly the result of the widespread and frequent use of fluoride- containing toothpaste... There seem to be no other factors which can explain the decline in dental caries, which has occurred worldwide during the same period, in geographic regions as far apart as the Scandinavian countries and Australia/New Zealand." SOURCE: Rolla G, Ekstrand J. (1996). Fluoride in Oral Fluids and Dental Plaque. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Denmark. p 215. "Although difficult to prove, it is reasonable to assume that a good part of the decline in dental caries over recent years in most industrialized countries, notably those Northern European countries without water fluoridation, can be explained by the widespread use of fluoride toothpastes. This reduction in caries has not been paralleled by a reduction in sugar intake..." SOURCE: Clarkson BH, Fejerskov O, Ekstrand J, Burt BA. (1996). Rational Use of Fluoride in Caries Control. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Denmark. p 354. "During the past 40 years dental caries h as been declining in the US, as well as in most other developed nations of the world... The decline in dental caries has occurred both in fluoride and in fluoride - deficient communities, lending further credence to the notion that modes other than water fluoridation, especially dentrifices, have made a major contribution." SOURCE: Leverett DH. (1991). Appropriate uses of systemic fluoride: considerations for the'90s. Journal of Public Health Dentistry 51: 42 -7. "In most European countries, the 12- year -old DMFT index is now relatively low as compared with figures from 1970 -1974. WHO (World Health Organization) data relating to availability of fluoride in water and toothpaste appear reliable. However, these data did not explain differences between countries with respect to the DMFT index of 12 -year- olds." SOURCE: Kalsbeek H, Verrips GH. (1990). Dental caries prevalence and the use of fluorides in different European countries. Journal of Dental Research 69(Spec Iss): 728 -32. "The most striking feature of some industrialized countries is a dramatic reduction of the prevalence of dental caries among school -aged children." 10 10 SOURCE: Binus W, Lowinger K, Walther G. (1989). [Caries decline and changing pattern of dental therapy] [Article in German] Stomatol DDR 39: 322 -6. "The current reported decline in caries tooth decay in the US and other Western industrialized countries has been observed in both fluoridated and nonfluoridated communities, with percentage reductions in each community apparently about the same." SOURCE: Heifetz SB, et al. (1988). Prevalence of dental caries and dental fluorosis in areas with optimal and above - optimal water- fluoride concentrations: a 5 -year follow -up survey. Journal of the American Dental Association 116: 490 -5. "IDluring the period 1979 -81, especially in western Europe where there is little fluoridation, a number of dental examinations were made and compared with surveys carried out a decade or so before. It soon became clear that large reductions in caries had been occurring in unfluoridated areas. The magnitudes of these reductions are generally comparable with those observed in fluoridated areas over similar periods of time." SOURCE: Diesendorf, D. (1986). The Mystery of Declining Tooth Decay. Nature 322: 125 -129. "Even the most cursory review of the dental literature since 1978 reveals a wealth of data documenting a secular, or long term, generalized decline in dental caries throughout the Western, industrialized world. Reports indicate that this decline has occurred in both fluoridated and fluoride- deficient areas, and in the presence and absence of organized preventive programs." SOURCE: Bohannan HM, et al. (1985). Effect of secular decline on the evaluation of preventive dentistry demonstrations. Journal of Public Health Dentistry 45: 83 -89. "The decline in caries prevalence in communities without fluoridated water in various countries is well documented. The cause or causes are, at this time, a matter of speculation." SOURCE: Leverett DH. (1982). Fluorides and the changing prevalence of dental caries. Science 217: 26- 30. Back to top Excerpts from the Scientific Literature - Tooth Decay Trends in Western European Countries: (back to top) BELGIUM - Unfluoridated Water, Fluoridated Salt: (back to top) "Caries -free children increased from 4% to 50%...A remarkable decline in dental caries was observed during the 15 -yr period." SOURCEL Carvalho JC, Van Nieuwenhuysen JP, D'Hoore W. (2001). The decline in dental caries among Belgian children between 1983 and 1998. Community Dentistry and Oral Epidemiology 29: 55 -61. ■ ■ DENMARK - Unfluoridated Water, Unfluoridated Salt: "The paper presents an overview of the oral health situation in Denmark ... I N]ational oral epidemiological data have been provided since 1972. Partly due to the preventive approach, a general decrease over -time in I V V nq the prevalence of dental caries has been documented for children and adolescents. For example, in 1972 children in first class had a mean caries experience of 12.4 def -s against 3.9 def -s in 1990." SOURCE: Petersen PE. (1992). Effectiveness of oral health care - -some Danish experiences. Proceedings of the Finnish Dental Society 88: 13 -23. FINLAND - Unfluoridated Water, Unfluoridated Salt: "During the 10 years, substantial decreases were seen in the mean numbers of dental visits (from 4.0 to 2.4) and fillings (from 2.9 to 1.2). The greatest decrease was seen in the number of fillings made in incisors." SOURCE: Vehkalah6 M, Rytomaa I, Helminen S. (1991). Decline in dental caries and public oral health care of adolescents. Acta Odontologica Scandinavica 49: 323 -8. FRANCE - Unfluoridated Water, Fluoridated Salt: "Epidemiological surveys showed a marked decrease of caries prevalence in French children during the last 20 years." SOURCE: Obry - Musset AM. (1998). [Epidemiology of dental caries in children] [Article in French] Arch Pediatr 5: 1145 -8. GERMANY - Unfluoridated Water, Fluoridated Salt: "Caries rates are on the decline in the Federal Republic of Germany, too. And, in some cases considerable, increase in the number of children with caries -free teeth and a clear reduction in the average number of carious teeth has been recorded, above all in kindergartens with preventive dentistry programmes." SOURCE: Gulzow HJ. (1990). [Preventive dentistry in the Federal Republic of Germany] [Article in German] Oralprophylaxe 12:53-60. GREECE - Unfluoridated Water, Unfluoridated Salt: "The percentage of caries -free children for the total examined population increased by 94% while the reduction in DMFT index ranged between 38 and 70 %. Treatment need was significantly lower in 1991 compared to 1982 in both dentitions." SOURCE: Athanassouli I, et al. (1994). Dental caries changes between 1982 and 1991 in children aged 6- 12 in Athens, Greece. Caries Research 28(5):378 -82. ICELAND - Unfluoridated Water, Unfluoridated Salt: 11TT .0 "During the last decade, a continuous decrease in dental caries has been observed among schoolchildren in Iceland... There does not seem to be any single factor responsible for the onset of the caries decline." SOURCE: Einarsdottir KG, Bratthall D. (1996). Restoring oral health: On the rise and fall of dental caries in Iceland. European Journal of Oral Science 104: 459 -69. THE NETHERLANDS - Unfluoridated Water, Unfluoridated Salt: "According to WHO criteria, 12- year -old children in The Netherlands now have a very low caries experience." SOURCE: Truin GJ, Konig KG, Bronkhorst EM. (1994). Caries prevalence in Belgium and The Netherlands. International Dentistry Journal 44: 379 -8. MIM NORWAY & all SCANDINAVIAN COUNTRIES - Unfluoridated Water, Unfluoridated Salt: "Denmark, Iceland, Norway, and Sweden have all had a similar decline in dental caries during the last 20 years, although the decline has come later in Iceland. Despite the differences in choice of preventive methods, the dental health of children varies little across the frontiers." SOURCE: Kallestal C, et al. (1999). Caries - preventive methods used for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dentistry and Oral Epidemiology 27: 14451. "Despite differences in the dental health care services and the recording and reporting systems, a consistent and similar decline in dental caries is evident for Denmark, Finland, Norway and Sweden during the last two decades." SOURCE: von der Fehr FR. (1994). Caries prevalence in the Nordic countries. International Dentistry Journal 44: 371 -8. SWEDEN - Unfluoridated Water, Unfluoridated Salt: "Between 1967 and 1992 the mean dmfs values declined from 7.8 to 1.8. The decline was greatest between 1967 and 1980 and then levelled off." SOURCE: Stecksen - Blicks C, Holm AK. (1995). Dental caries, tooth trauma, malocclusion, fluoride usage, toothbrushing and dietary habits in 4-year -old Swedish children: changes between 1967 and 1992. International Journal of Paediatric Dentistry 5: 143 -8 SWITZERLAND - Unfluoridated Water, Fluoridated Salt: "Caries prevalence has declined by 70 -84 percent since the late sixties." SOURCE: Marthaler TM. (199 1). [School dentistry in Zurich Canton: changes as a result of caries reduction of 80 to 85 percent) (Article in German Oralprophylaxe 13: 115 -22. I V V +l "Surveys of dental caries prevalence were carried out from 1970 -1993 in schoolchildren of the city of Zurich. DMFr experience declined by 68 to 80 %, while the average dmft decreased by 48 -53% (ages 7 to 9)." SOURCE: Steiner M, Menghini G, Curilovic Z, Marthaler T. (1994). [The caries occurrence in schoolchildren of the city of Zurich in 1970 -1993. A view of prevention in new immigrants] [Article in German]. Schweiz Monatsschr Zahnmed 104: 1210 -8. 1QCn Nag UniversitV of Toronto, Facultv of Dr. Hardy Limeback, BSc, PhD, DDS 'IN Associate Professor and Head, Preventive Dentistry 124 Edward St., Toronto, Ontario, M5G -1G6 Tel(416) 9794929 Fax (416) 979 -4936 hardy.limeback@utoronto.ca April, 2000 To whom it may concern: Why I am now officially opposed to adding fluoride Iuoride to drinking water. Since April of 1999, I have publicly decried the addition of fluoride, especially hydrofluosilicic acid, to drinking water for the purpose of preventing tooth decay. The following summarize my reasons. New evidence for lack of effectiveness of fluoridation in modern times. 1. Modern studies (published in the 1980's 1990's) show dental decay rates are so low in North America that the effects of water fluoridation cannot be measured. Because of the low prevalence of dental decay, water fluoridation studies today must be carefully conducted to correct for mobility of subjects between fluoridated and non - fluoridated areas, access to fluoride from other sources, the lack of blinding and problems with the 'halo' effect. Even when very large sample sizes are used to obtain statistically significant results, the benefit of water fluoridation is not a clinically relevant one (the number of tooth surfaces saved from dental decay per person is less than one half). Recent studies show that halting fluoridation will either result in only a marginal increase in dental decay which cannot be detected or no increase in dental decay at all. 2. The major reasons for the general decline of tooth decay worldwide, both in non - fluoridated and fluoridated areas, is the widespread use of fluoridated toothpaste, improved diets, and overall improved general and dental health (antibiotics, preservatives, hygiene etc). 3. There is now a better understanding of how fluoride prevents dental decay. What little benefit fluoridated water may still provide is derived primarily through topical means (after the teeth erupt and come in contact with fluorides in the oral cavity). Fluoride does not need to be swallowed to be effective. It is not an essential nutrient. Nor should it be considered a desirable 'supplement' for children living in non - fluoridated areas. Fluoride ingestion delays tooth eruption and this may account for some of the differences seen in the past between fluoridated and non - fluoridated areas (i.e. dental decay is simply postponed). No fluoridation study has ever separated out the systemic effects of fluoride. Even if there were a systemic benefit from ingestion of fluoride, it would be miniscule and clinically irrelevant. The notion that systemic fluorides are needed in non - fluoridated areas is an outdated one that should be abandoned altogether. New evidence for potential serious harm from long -term fluoride ingestion. 1. Hydrofluorosilicic acid is recovered from the smokestack scrubbers during the production of phosphate fertilizer and sold to most of the major cities in North America, which use this industrial 10 4 grade source of fluoride to fluoridate drinking water, rather than the more expensive pharmaceutical grade sodium fluoride salt. Fluorosilicates have never been tested for safety in humans. Furthermore, these industrial -grade chemicals are contaminated with trace amounts of heavy metals such as lead, arsenic and radium that accumulate in humans. Increased lead levels have been found in children living in fluoridated communities. Osteosarcoma (bone cancer) has been shown to be associated with radium in the drinking water. Long -term ingestion of these harmful elements should be avoided altogether. 2. Half of all ingested fluoride remains in the skeletal system and accumulates with age. Several recent epidemiological studies suggest that only a few years of fluoride ingestion from fluoridated water increases the risk for bone fracture. The relationship between the milder symptoms of bone fluorosis (joint pain and arthritic symptoms) and fluoride accumulation in humans has never been investigated. People unable to eliminate fluoride under normal conditions (kidney impairment) or people who ingest more than average amounts of water (athletes, diabetics) are more at risk to be affected by the toxic effects of fluoride accumulation. 3. There is a dose - dependent relationship between the prevalence /severity of dental fluorosis and fluoride ingestion. When dental decay rates were high, a certain amount of dental fluorosis was considered an acceptable 'trade off of providing an 'optimum' dose of 1.0 ppm fluoride in the water. However, studies published in the 1980's and 1990's have shown that dental fluorosis has increased dramatically in North America. Infants and toddlers are especially at risk for dental fluorosis of the front teeth since it is during the first 3 years of life that the permanent front teeth are the most sensitive to the effects of fluoride. Children fed formula made with fluoridated tap water are at higher risk to develop dental fluorosis. A relatively small percentage of the children affected with dental fluorosis have the more severe kind that requires extensive restorative dental work to correct the damage. The long -term effect of fluoride accumulation on dentin colour and biomechanics is also unknown. Generalized dental fluorosis of all the permanent teeth indicates that the bone is a major source of the excess fluoride. The effect of this excess amount of fluoride in bone is unknown. Whether stress bone fractures occur more often in children with dental fluorosis has not been studied. 4. A lifetime of excessive fluoride ingestion will undoubtedly have detrimental effects on a number of biological systems in the body and it is illogical to assume that tooth enamel is the only tissue affected by low daily doses of fluoride ingestion. Fluoride activates G- protein and a number of cascade reactions in the cell. At high concentrations it is both mitogenic and genotoxic. Some published studies point to fluoride's interference with the reproductive system, the pineal gland and thyroid function. Fluoride is a proven carcinogen in humans exposed to high industrial levels. No study has yet been conducted to determine the level of fluoride that bone cells are exposed to when fluoride -rich bone is turned over. Thus, the issue of fluoride causing bone cancer cannot be dismissed as being a non -issue since carefully conducted animal and human cancer studies using the exact same chemicals added to our drinking water have not been carried out. The issue of mass medication of an unapproved drug without the expressed informed consent of each individual must also be addressed. The dose of fluoride cannot be controlled. Fluoride as a drug has contaminated most processed foods and beverages throughout North America. Individuals who are susceptible to fluoride's harmful effects cannot avoid ingesting this drug. This presents a medico -legal and ethical dilemma and sets water fluoridation apart from vaccination as a public health measure where doses and distribution can be controlled. The rights of individuals to enjoy the freedom from involuntary fluoride medication certainly outweigh the right of society to enforce this public health measure, especially when the evidence of benefit is marginal at best. 10 44 Based on the points outlined briefly above, the evidence has convinced me that the benefits of water fluoridation no longer outweigh the risks. The money saved from halting water fluoridation programs can be more wisely spent on concentrated public health efforts to reduce dental decay in the populations that are still at risk and this will, at the same time, lower the incidence of the harmful side effects that a large segment of the general population is currently experiencing because of this outdated public health measure. Sincerely, Dr. Hardy Limeback BSc PhD (Biochemistry) DDS Head, Preventive Dentistry References: Water fluoridation less effective in the late 1980's and the 1990's. Water fluoridation cessation studies: 1. Attwood D, Blinkhorn AS. Dental health in school children 5 years after water fluoridation ceased in south -west. Scotland. Dent J. 1991 Feb;41(1):43 -8. 2. Kobayashi S, Kawasaki K, Takagi O, Nakamura M, Fujii N, Shinzato M, Maki Y, Takaesu Y. Caries experience in subjects 18-22 years of age after 13 years' discontinued water fluoridation in Okinawa. Community Dent Oral Epidemiol. 1992 Apr;20(2):81 -3. 3. Kalsbeek H, Kwant GW, Groeneveld A, Dirks OB, van Eck AA, Theuns HM. Caries experience of 15- year -old children in The Netherlands after discontinuation of water fluoridation. Caries Res. 1993;27(3):201 -5. 4. Seppa L, Karkkainen S, Hansen H. Caries frequency in permanent teeth before and after discontinuation of water fluoridation in Kuopio, Finland. Community Dent Oral Epidemiol. 1998 Aug;26(4):256 -62. S. Kunzel W, Fischer T. Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res. 2000 Jan- Feb;34(1):20 -5. 6. Burt BA, Keels MA, Heller KE. The effects of a break in water fluoridation on the development of dental caries and fluorosis. J Dent Res. 2000 Feb;79(2):761 -9. Comparison of fluoridated and non - fluoridated communities 7. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of water fluoridation. J Dent Res. 1990 Feb;69 Spec No:723 -7; discussion 820 -3. 8. Ismail Al, Shoveller J, Langille D, MacInnis WA, McNally M. Should the drinking water of Truro, Nova Scotia, be fluoridated? Water fluoridation in the 1990s. Community Dent Oral Epidemiol. 1993 Jun;21(3):118 -25. 9. Jackson RD, Kelly SA, Katz BP, Hull JR, Stookey GK. Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water. 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Eckerlin, R.H.,Maylin, G.A., and Krook, L. Cornell Vet. 76 403 -404 (1986). Milk production of cows fed fluoride contaminated commercial feed. 126. Balabolkin MI, Mikhailets ND, Lobovskaia RN, Chernousova NV. [The interrelationship of the thyroid and immune statuses of workers with long -term fluorine exposure]. Ter Arkh. 1995;67(1):41 -2. 127. Krishnamachari KA Skeletal fluorosis in humans: a review of recent progress in the understanding of the disease. Prog Food Nutr Sci 1986;10(30:279 -314 128. Tezelman S, Shaver JK, Grossman RF, Liang W, Siperstein AE, Duh QY, Clark OH. Desensitization of adenylate cyclase in Chinese hamster ovary cells transfected with human thyroid - stimulating hormone receptor. Endocrinology. 1994 Mar; 134(3):1561 -9. Fluoride enters the placenta and may cause birth defects 129. Malhotra A, Tewari A, Chawla HS, Gauba K, Dhall K. Placental transfer of fluoride in pregnant women consuming optimum fluoride in drinking water. J Indian Soc Pedod Prev Dent. 1993 Mar; Il(1):1 -3 C 10 C 0 130. Armstrong WD, Singer L, Makowski EL. Placental transfer of fluoride and calcium. Am J Obstet Gvnecol. 1970 Jun 1;107(3):432 -4. 131. Erickson JD. Fluoridation and Down Syndrome. J Dental Res 58a 1979;228. 132. Erickson JD. Down Syndrome, Water Fluoridation, and Maternal Age. Teratology 1980;21(177- 180). 133. Gupta SK, Gupta RC, Seth AK, Chaturvedi CS. Increased incidence of spina bifida occulta in fluorosis prone areas. Acta Paediatr Jpn. 1995 Aug;37(4):503 -6. Fluoride may affect the immune system 134. Loftemus A, Andersson B, Butler J, Ekstrand J. Fluoride augments the mitogenic and antigenic response of human blood lymphocytes in vitro. Caries Res. 1999;33(2):148 -55. 135. Gutierrez J, Liebana J, Ruiz M, Castillo A, Gomez JL. Action of sodium fluoride on phagocytosis by systemic polymorphonuclear leucocytes. J Dent. 1994 Oct;22(5):279 -82. 136. Sutton PR. Is the ingestion of fluoride an immunosuppressive practice? Med Hypotheses. 1991 May;35(1):1 -3. 137. Spittle B. Allergy and hypersensitivity to fluoride. Fluoride 1993 26: 267 -273. 138. Gabler WL, Mugrditchian M, Creamer HR, Bullock WW. Effect of fluoride on movement of concanavalin A- acceptor molecules of human neutrophils. Inflammation. 1989 Jun; 13(3):317-28. 139. Gabler WL, Creamer HR, Bullock WW. Fluoride activation of neutrophils: similarities to formylmethionyl- leucyl- phenylalanine. Inflammation. 1989 Feb; 13(l):47-58. 140. Gabler WL, Hunter N. Inhibition of human neutrophil phagocytosis and intracellular killing of yeast cells by fluoride. Arch Oral Biol. 1987;32(5):363 -6 141. Gomez -Ubric JL, Liebana J, Gutierrez J, Castillo A. In vitro immune modulation of polymorphonuclear leukocyte adhesiveness by sodium fluoride. Eur J Clin Invest. 1992 Oct;22(10):659 -61 142. Lewis A, Wilson CW. Fluoride hypersensitivity in mains tap water demonstrated by skin potential changes in guinea -pigs. Med Hypotheses. 1985 Apr; 16(4):397402 143. Hirano S, Ando M, Kanno S. Inflammatory responses of rat alveolar macrophages following exposure to fluoride. Arch Toxicol. 1999 Aug;73(6):310 -5. 144. O'Shea JJ, Urdahl KB, Luong HT, Chused TM, Samelson LE, Klausner RD. Aluminum fluoride induces phosphatidylinositol turnover, elevation of cytoplasmic free calcium, and phosphorylation of the T cell antigen receptor in murine T cells. J Immunol. 1987 Nov 15 ;139(10):3463 -9 145. Gutierrez J, Liebana J, Ruiz M, Castillo A, Gomez JL. Action of sodium fluoride on phagocytosis by systemic polymorphonuclear leucocytes. J Dent. 1994 Oct ;22(5):279 -82. 10C 14 Why I Am Now Officially Opposed to Adding Fluoride to Drinking Water Dr. Hardy Limeback, BSc, PhD, DDS Associate Professor and Head, Preventive Dentistry University of Toronto I am the Head of Preventive Dentistry at the University of Toronto in Toronto Canada, a professor of dentistry with a PhD in Biochemistry and a practicing dentist with 27 years experience who has done years of funded research in tooth formation, bone and fluoride. I was one of the 12 scientists who served on the US National Academy of Sciences panel that issued the 2006 report, "Fluoride in Drinking Water: A Scientific Review of the EPA's Standards." I would like to outline my arguments thaIfluoridation is ineffective and a harmful public health policy`3 1. Fluoridation is no longer effective. Fluoride in water has the effect of delaying tooth eruption and, therefore, simply delays dental decay (Komarek et al, 2005, Biostatistics 6:145 -55). The studies that water fluoridation works are over 25 years old and were carried out before the widespread use of fluoridated toothpaste. There are numerous modern studies to show that there no longer is a difference in dental decay rates between fluoridated and non - fluoridated areas, a recent one in Australia (Armfield & Spencer, 2004 Community Dental Oral Epidemiology. 32:283 -96). Recent water fluoridation cessation studies show that dental fluorosis (a mottling of the enamel caused by fluoride) declines but there is no corresponding increase in dental decay (e.g. Maupome et a12001, Community Dental Oral Epidemiology 29: 37 -47). Public health services will claim there is still a dental decay crisis. With the national average in Europe of only two decayed teeth per child (World Health Organization data), down from more than 15 decayed teeth in the 1940s and 1950s before fluoridated toothpaste, as much as half of all children grow up not having a single filling. This remarkable success has been achieved in most European countries without fluoridation. The "crisis" of dental decay often mentioned is the result, to a major extent, of sugar abuse, especially soda pop. A 2005 report by Jacobsen of the Center for Science in the Public Interest said that U.S. children consume 40 to 44 percent of their daily refined sugar in the form of soft drinks. Since most soft drinks are themselves fluoridated, the small amount of fluoride is obviously not helping. 10C N The families of these children with rampant dental decay need professional assistance. It appears they are not getting it. Children who grow up in low- income families make poor dietary choices, and cannot afford dental care. Untreated dental decay and lack of professional intervention result in more dental decay. The York review was unable to show that fluoridation benefited poor people to any greater extent than other groups of the population. The York review, and others that followed, including the Systematic Review of the Efficacy and Safety of Fluoridation conducted recently in Australia http://www.nhmrc.gov.au/publications/synoi)ses/eh4Isyn.htm and Heath Canada's review of fluoridated water http: / /www.hc- sc.ge.ca /ewh -semt /pubs /water- eau /2008- fluoride- fluorure /index- eng.php failed to identify even one double- blinded, randomized prospective clinical trial to prove the fluoridation works, after correcting for diet and delay in tooth eruption. This means that the reviewers failed to show the level of evidence for efficacy that is required in North America for a medicine to be approved. Furthermore, most reviews admit that there is not enough evidence for safety, since properly conducted clinical trials were not designed to measure adverse health effects. None of the reviews conducted to date addressed whether fluoridation can reduce the prevalence or severity of early dental decay in nursing infants (baby bottle syndrome). A very large percentage of dentists in North America do not accept patients on government assistance because they lose money treating these patients. In my experience, many dentists support fluoridation because it supposedly absolves them of their responsibility to provide assistance to those who cannot afford dental treatment. Even cities where water fluoridation has been in effect for years are reporting similar dental "crises." In my opinion, Public health officials responsible for community programs are misleading the public by stating that ingesting fluoride "makes the teeth stronger." Fluoride is not an essential nutrient. It does not make developing teeth better prepared to resist dental decay before they erupt into the oral environment. The small benefit that fluoridated water might still have on teeth (in the absence of fluoridated toothpaste use) is the result of "topical" exposure while the teeth are rebuilding from acid challenges brought on by daily sugar and starch exposure (Limeback 1999, Community Dental Oral Epidemiology 27: 62 -71), and this has now been recognized by the Centers for Disease Control. 2. Fluoridation is the main cause of dental fluorosis. Fluoride doses by the end user can't be controlled when only one concentration of fluoride (1 parts per million) is available in the drinking water. Babies and toddlers get too much fluoride when tap water is used to make formula (Brothwell & Pa 10C 4 Limeback, 2003 Journal of Human Lactation 19: 386 -90). Since the majority of daily fluoride comes from the drinking water in fluoridated areas, the risk for dental fluorosis greatly increases (National Academy of Sciences: Toxicological Risk of Fluoride in Drinking Water, 2006). The American Dental Association and the Dental Forum in Ireland have admitted that fluoridated tap water should not be used to reconstitute infant formula. We have tripled our exposure to fluoride since fluoridation was conceived in the 1940s. This has lead to every third child with dental fluorosis (CDC, 2005). Fluorosis is not just a cosmetic effect. The more severe forms are associated with an increase in dental decay (NAS: Toxicological Risk of Fluoride in Drinking Water, 2006) and the psychological impact on children is a negative one. Most children with moderate and severe dental fluorosis, the prevalence of which is higher in fluoridated areas and is not insignificant in terms of proportions of the population affected, seek extensive restorative work costing thousands of dollars per patient. Dental fluorosis can be reduced by turning off the fluoridation taps without affecting dental decay rates (Burt et a12000 Journal of Dental Research 79(2):761 -9). 3. Chemicals that are used in fluoridation have not been tested for safety. All the animal cancer studies were done using sodium fluoride. There is more than enough evidence to show that even this form of fluoride has the potential to promote cancer because it accumulates in the bone and produces levels that are high enough to induce cancer (NAS: Toxicological Risk of Fluoride in Drinking Water, 2006). Some communities use sodium fluoride in their drinking water, but even that chemical is not the same fluoride added to toothpaste. Most cities instead use hydrofluorosilicic acid (or its salt). H2SiF6 is concentrated directly from the smokestack scrubbers during the production of phosphate fertilizer, shipped to water treatment plants and trickled directly into the drinking water. It is industrial grade fluoride contaminated with trace amounts of heavy metals such as lead, arsenic and radium, which are harmful to humans at the levels that are being added to fluoridate the drinking water. In addition, using hydrofluorosilicic acid instead of industrial grade sodium fluoride has an added risk of increasing lead accumulation in children (Masters et al 2000, Neurotoxicology. 21(6): 1091- 1099), probably from the lead found in the pipes of old houses. This could not be ruled out by the CDC in their recent study (Macek et al 2006, Environmental Health Perspectives 114:130 -134). None of these issues have ever been addressed by the various government sponsored reviews. 4. There are serious health risks from water fluoridation. Cancer: Osteosarcoma (bone cancer) has recently been identified as a risk in young boys in a recently published Harvard study (Bassin, Cancer Causes and Control, 2006). The author of this study, Dr. Elise Bassin, acknowledges that perhaps it is the use of these untested and contaminated fluorosilicates mentioned above that caused the over 500% increase risk of bone cancer in young boys. 3 10 C 4 Bone fracture: Drinking on average 1 liter /day of naturally fluoridated water at 4 parts per million increases your risk for bone pain and bone fractures (National Academy of Sciences: Toxicological Risk of Fluoride in Drinking Water, 2006). Since fluoride accumulates in bone, the same risk occurs in people who drink 4 liters /day of artificially fluoridated water at 1 part per million, or in people with renal disease. Additionally, Brits are known for their tea drinking and since tea itself contains fluoride, using fluoridated tap water puts many heavy tea drinkers dangerously close to threshold for bone fracture. Our recently published study on fluoride in bone from fluoridation (Chachra et al, J Dent Res 89(11):1219 -1223, 2010) shows a negative trend in changes that have occurred in the bone of Torontonians who have lived only a portion of their lives in fluoridated Toronto. Fluoridation studies have never properly shown that fluoride is safe in individuals who cannot control their dose, or in patients who retain too much fluoride. Adverse thyroid function: Our National Academy of Sciences report (NAS: Toxicological Risk of Fluoride in Drinking Water, 2006) outlines in great detail the detrimental effect that fluoride has on the endocrine system, especially the thyroid. Fluoridation should be halted on the basis that endocrine function has never been studied in relation to total fluoride intake. Adverse neurological effects: In addition to the added accumulation of lead (a known neurotoxin) in children living in fluoridated cities, fluoride itself is a known neurotoxin. We are only now starting to understand how fluoride affects the brain. Several recent studies suggest that fluoride in drinking water lowers IQ (NAS, 2006). We need to study this more in depth. In my opinion, having served on the NAS Committee in the US for more than 3 years, the evidence that fluoridation is more harmful than beneficial is now overwhelming and cities that avoid thoroughly considering ALL the recent data do so, in my opinion, at risk of future legal action. Dr. Hardy Limeback PhD, DDS Professor and Head, Preventive Dentistry University of Toronto Additional references at: htti)://www.fluoridealert.org/limeback.htm For local information & resources contact Fluoride Free Sacramento at www.FIuorideFreeSacramento.org 4 Fluoridated Water Does Not Prevent Tooth Decay http: / /www.hohstiemed.com /fluoride /nobenefit.html 10C 14 Fluoridated Water Does Not Prevent Tooth Decay by Mark D. Gold I will cover two areas in this section. I will list a selection of information which shows that fluoridation is not helping to prevent dental decay. At the same time, I will comment on how the Dental Trade Organizations have used flawed studies to convince dentists that fluoridation was useful. I will preface those comments with: "ALERT #x" For this discussion, remember that in the U.S., Trade Organizations like the American Dental Association (ADA) recommend that water should be fluoridated to 1 part per million (1 ppm), although they allow for variations depending upon the climate (.7 ppm - 1.2 ppm). Also, please remember that the original studies by H. Trendly Dean on fluoridation which led to the decision to allow fluoridation of municipal water supplies 1. Were worthless by his own criteria. 2. Did not consider other minerals in the water. 3. Did not consider the differences between "natural fluoride" (e.g., CaF) and fluoride waste products (e.g., NaF). 4. Only reported his chosen selection of data -- a subsection of the data gathered. 5. Had little or no statistical analysis. 6. Included no safety experiments except for dental fluorosis. 1. Yiamouyiannis, J. "Water Fluoridation and Tooth Decay: Results From the 1986 -1987 National Survey of U.S. Schoolchildren" Fluoride, Journal of The International Society for Fluoride Research (Volume 23, No. 2; April 1990; pp 55 -67). This study showed, once and for all, that fluoridation of the U.S. water supply was worthless, at best. 1 of 10 9/13/111:21 PM Fluoridated Water Does Not Prevent Tooth Decay hup: / /www.holisticme&com /fluoride /nobenefiLhoW 10 C 10 Summary: Data from dental examinations of 39,207 schoolchildren, aged 5 -17, in 84 areas throughout the United States are analyzed. Of these areas, 27 had been fluoridated for 17 years of more (F), 30 had never been fluoridated (NF), and 27 had been only partially fluoridated or fluoridated for less than 17 years (PF). No statistically significant differences were found in the decay rates of permanent teeth or the percentages of decay -free children in the F, NF and PF areas. However, among 5 -year -olds, the decay rates of the deciduous teeth were significantly lower in F than in NF areas. Table 2 Average- age - adjusted DMFT [Decayed, Missing, Filled Teeth] rates for 39,207 U.S. schoolchildren and 17,336 lofe -long resident schoolchildren in 84 areas throughout the United States. Standard deviations are given in parentheses. ---------- - - - --- Total --------- - - - - -- Life -Long -- Fluoridation No. of No. of DMFT No. of DMFT Status Areas IStudents Students Fluoridated 27 6,272 (0.465} rtially Fluoridated 27 12'578 2.18 (0 465) 642 2.25 5' (0.470) Fonfluoridated 30 13,882 5,422 (� 408) (0.517) As you can see, there are no statistical differences in decayed, mission, or filling teeth for U.S. children aged 5 -17. Yes, there is a stastically significant advantage in DMFT for 5- year -olds. However, by age 6, that advantage disappears. The suspected cause for the one -year, temporary benefit is slightly delayed tooth eruption in fluoridated water drinkers. Whatever the cause, remember, there are no statistically significant difference after age 5. ALERT #1 Recently, Brunelle used the same data to prove a statistically significant advantage in dental decay in fluoridated sections of the U.S. ( "Caries Attack in the Primary Dentition of U.S. Children" J. Dent. Research 69(Special Issue): 180 [Abstr. No. 575], 1990.) However, Brunelle used only one year (5- year -olds) of the data that was gathered in the national survey: 5 to 17 years 9/13/111:21 PM 2 of 10 Fluoridated Water Does Not Prevent Tooth Decay http://www.hofisticmed.CilarobenefiLh 1 old! As was mentioned above, this slight advantage in fluoridation disappears after age 5 and is likely caused by slightly delayed tooth eruption in 5- year -olds. By picking tiny subsections of data collected, a researcher can prove whatever he or she wants! This is not the only time this flawed data analysis technique was used in fluoridation research. Also, this study points to the fact that other studies which relied to a large extent on 5 -year -olds and few older children may also show skewed results. ALERT #2 In another poor study, Brunelle and Carlos used more complete survey data to seemingly "prove" the advantages of fluoridation. ( "Recent Trends in Dental Caries in U.S. Children and the Effect of Water Fluoridation" J. Dental Research, 69(Special Issue): 723 -728, 1990). This time Brunelle used more data than above, but made many other sloppy errors as pointed out by Yiamouyiannis. ■ "It contains extremely serious errors. For example, by a cursory inspection, we found two values that are off by 100% or more. In their Table 9, the DMFS figure for life -long F exposure residents of Region VII should be about 3, not 1.46 as reported. Form their Table 3, the percent of 5- year -olds who have caries is 1.0 %, not the 2.7% that can be calculated from the table. When I pointed out this error to Dr. Carlos he admitted that only 19 out of the 1851 5 -year -olds had caries (19/1851 = 1%), but refused to make the correction." "It fails to report the tooth decay rates for each of the 84 geographical areas surveyed. This covers up the fact that there is no difference in the tooth decay rates of the fluoridated and nonfluoridated areas surveyed. The Brunelle / Carlos study even fails to list the areas studied. As a result, they produce misleading illustrations; for example, their Figure 3 implies that Arizona and New Mexico have the lowest tooth decay rates, when, in fact, not a single area was surveyed in either of the two states." . "It fails to do the statistical analysis (or even provide the data, i.e., the standard deviation and sample number) necessary to determine whether the values found for F and NF areas are significantly different." . "It fails to report the data for the approximately 23,000 schoolchildren who were not life -time residents of either the F or NF areas (the partially fluoridated, PF group).... He goes on to point out other significant flaws in this Brunelle and Carlos 3of10 9/13/111:21 PM Fluoridated Water Does Not Prevent Tooth Decay http: / /www.hofisticmed.com /fluoride /nobenefit.html i0c study. 8. Steelink C., Fowler M, Osborn M et al. Findings and recommendations of subcommittee on fluoridation. City of Tuscon AZ 1992 (PO Box 27210). Also see: Chemical and Engineering News (7/27/92). A study of Tuscon elementary children was performed by Cornelius Steelink, Professor Emeritus, Department of Chemistry, University of Arizona. The study was performed in order to determine the "benefits" of water fluoridation. They compared tooth decay versus fluoride content in a child's neighborhood drinking water for 26,000 elementary school children. Here are the results: "...a positive correlation was revealed. In other words, the more fluoride a child drank, the more cavities appeared in the teeth. He goes on to state: "Since this was an unusual result, our subcommittee looked for other relevant factors. Family incomes was compared to tooth decay. An excellent inverse relation was found for these 26,000 children: the higher the income, the lower the number of decayed teeth. Other anecdotal evidence gathered by our committee included lack of access to dental facilities, poverty, diet, and oral hygiene as contributing factors to tooth decay in this group of children. In the final report, the subcommittee stated that there was no obvious relation of fluoride content in municipal water to the prevention of tooth decay in Tucson, and because there are multiple causes of tooth decay, a decision to fluoridate would still leave pockets of poor dental health in Tucson..... However, when the full Citizens Water Advisory Committee reviewed our report in June 1992, it recommended (on a split vote) that the city council go ahead and fluoridate the water. The principal argument for this vote was: 'Even though fluoridation doesn't appear to be effective, let's rely on the advice of the public health officials. After all, they're the experts. "' I saw a graph with the percentage of tooth decay plotted against fluoride concentration. As soon as it goes over .6 ppm, the decay goes way up. 9. "Influence of social class and fluoridation on child dental health" Community Dentistry and Oral Epidemiology 13 37-41 1985. This study examined the influence of social class (environmental and lifestyle 4of 10 9/13/111:21 PM Fluoridated Water Does Not Prevent Tooth Decay http:// www. holisticmedcq�lHyQt�id�fgobenefit. �4 factors, diet, etc.) and fluoridation on dental health. It showed that dental health as continued to improve equally in both fluoridated and unfluoridated areas and that the level of dental health was strongly related to social class. A similar result (with slightly better teeth in unfluoridated areas) was found in Colquohoun J. "Child dental health differences in New Zealand" Community Health Studies 1185-90 1987. ALERT #3 The last two sections (2,3) show that it is not lack of fluoride that leads to decay but things such as "lack of access to dental facilities, poverty, diet, and oral hygiene." A number of studies were performed by persons interested in keeping the fluoridation myth alive. One way to skew the results was to compare two areas, one fluoridated and one non - fluoridated but not take into account other factors. If a non - fluoridated area with lack of dental facilities, poverty, poor diet and hygiene was compared against a nearby, yet more well -to-do fluoridated area, it becomes very easy to "prove" (wink, wink) that fluoridation is beneficial. This type of nonsense was done several times in order to keep the fluoridation myth alive. One of many studies that have this flaw is: Jackson, D., et al. "Fluoridation in Anglesey 1983: a Clinical Study of Dental Caries" British Dental Journal 1985: 158: 45. The two areas being compared, while adjacent, were vastly different. 10. Ziegelbecker RC, Ziegelbecker R. "WHO data on dental caries and natural water fluoride levels." Fluoride 26 263 -266 1993. and Ziegelbecker R. "Fluoridated water and teeth" Fluoride 14 123 -128 1981 Both of these studies are from large data set showing that there is no correlation between caries and fluoride concentration and no improvement in dental health from fluoride. In the 1981 study, for example, Ziegelbecker made of random sampling of all available data on caries prevalence. He selected 48,000 12 -14 year -old children from 136 community water supplies in seven countries. 11. Diesendorf M. "The mystery of declining tooth decay" Nature 322 125 -129 1986. Summary 5 of 10 9/13/11 1:21 PM Fluoridated Water Does Not Prevent Tooth Decay http://www.hohsticmed.com/fluoride/nobenefithtml Large temporal reductions in tooth decay, which cannot be a ttri bul D C 14 fluoridation, have been observed in both unfluoridated and fluoridated areas of at least eight developed countries over the past thirty years. It is now time for a scientific re- examination of the alleged enormous benefits of fluoridation. Mark Diesendorf, an applied mathmetician, expert in research design, and health researcher at the Human Sciences Program at Austrailian National University showed in this analysis that the decline in dental decay in fluoridated areas has not been greater than in non - fluoridated areas. He used 24 studies of unfluoridated areas to prove this. Diesendorf isn't the only expert to realize the fact that fluoridation is not what lead to the improvement in dental health. In the April 1988 issue of the Journal of the American Dental Association, Stanley Heifetz of the NIDR wrote, "the current reported decline in caries in the U.S. and other Western industrialized countries has been observed in both fluoridated and nonfluoridated communities, with percentage reductions in each community apparently about the same." ALERT #4 There have been numerous studies that have measured improvement in dental health in fluoridated areas. Soon after the publication of these studies, press releases often hail the "enormous dental health improvements due to fluoridation." Had the authors of these studies compared the results to non - fluoridated areas and taken a large sample size (as was done in the Diesendorf and Ziegelbecker studies), there would show no significant improvements in dental health compared to nonfluoridated areas. The moral is to beware fluoridation studies that compare it against nothing and don't account for other factors such as diet. They are nothing more than glorified press releases. 12. Teotia SPS, Teotia M. "Dental caries: a disorder of high fluoride and low dietary calcium interactions" Fluoride 27 April, 1994 (page 61). This was a 20 -year study (1973 -1993) of 400,000 children in India. It shows that the higher the fluoride concentration in water, the more caries occured. In addition, this study shows that adolescents ingesting fluoridated water and a low calcium diet have extremely high rates of fluorosis and dental decay. 13. Imai Y. "Study of the relationship between fluoride ions in drinking water and dental caries in Japan" Japanese Journal of Dental Health 22 144196 1972. 6 of 10 9/13/11 1:21 PM Fluoridated Water Does Not Prevent Tooth Decay http: / /www.hohsticmed.com /fluoride /nobenefit.html This stud of 22 000 Japanese schoolchildren showed that above 0.4 m jen Y � P PP rate increased significantly. When the fluoride concentration was below 0.2 ppm the decay rate also increased significantly. This was thought to be caused by the lack of calcium in the water when the fluoride was less than 0.2 ppm. Needless to say, Japan, like the large majority of countries (including industrialized countries) does not fluoridate their water supply. 8) Colquhoun, J. "Is There a Dental Benefit From Water Fluoride ?" Fluoride Vol. 27, No. 1 13-22,1994. Summary Dental data collected for virtually all New Zealand children, as well as comprehensive data from other countries, indicate no dental benefit from water fluoridation. Claims for a benefit depend on small -scale studies of selected samples of children. The classic fluoridation research is critically re- examined. This study, like the Yiamouyiannis study of 39, 207 US schoolchildren, proves that fluoridation in New Zealand was and is worthless. The data was collected for 98% of all 12 -13 year -old children and 5 year -old children in New Zealand. Here is the table from the study showing the main population centers. Table ---------------- - - - - -- 12 -13 year olds -- - - - - -- 5 year olds - - - - -- No. of Caries- Mean No. of Caries- Mean Center Children free % DMFr Children free % 1MP ON- FLUORIDATED Oristchurch (5822) 7ol0 1.9 (3849) 55°Io 1.8 UORIDATED uckland (11464) 3% 2.0 amilton (2689) 0% 2.3 Palmerston Nth (1025) 1 °% 2.3 ellington (423'n 6T-9 1.8 7unedin (1168} 9% 2.2 (9611) 53% 1.8 (2266) 7% 2.3 (950) 55% 1.8 (3344) 58% 1.6 (994) 56/0 1.5 7 of 10 9/13/11 1:21 PM Fluoridated Water Does Not Prevent Tooth Decay http://www.hohsticmed.COM/flUoride/nobenefiLhtml lOC M This must -read study /report goes on to show the major flaws in so many pro-fluoridation studies. Some notable excerpts: "The New Zealand Department of Health, a long -time advocate of water fluoridation, presented the 12 -13 -year -old data in its annual reports by comparing the combined fluoridated with the combined nonfluoridated areas of New Zealand [Annual Reports, Department of Health, from 1981]. The differences were very small (only I% for the caries -free percentage in each kind of area, and less than half a tooth for the mean number of decayed, missing or filled teeth) but suggested a small benefit from fluoridation. However, the areas being compared were dissimilar, one being mostly urban with higher average incomes, and the other mostly small - town -rural with lower average incomes. When similar kinds of communities were compared, the teeth were actually slightly better in the nonfluoridated areas." "Other New Zealand studies, of small samples of 5 -year -olds 7 -year olds and 9 -year -olds claimed that there was a small but significant benefit resulting from fluoridation. These studies, which were contradicted by the data collected for all 12- and 13 -year -olds, were discussed in my earlier study.... Since then, the authors of the 9 -year olds study and its follow -up have admitted that their low- fluoride sample used for comparison 'probably was biassed towards children of dentally unaware and low socioeconomic parents -- a factor that would tend to increase their caries. "' [See full text for references.] "Recently another small- sample non -blind study has been published, claiming to demonstrate the benefit of fluoridation for the whold of New Zealand [New Zealand Dental Journal 88 9 -13 19921. Samll samples of 5- year -old children were examined, from selected fluoridated and non - fluoridated communities in otago and cantebury provinces. The results claimed up to 60% less tooth decay in the fluoridated communities.... But, when I obtained the School Dental Service data for all 5- year-olds in the fluoridated and nonfluoridated areas of these two provinces... the claimed differences did not exist." [The authors of the study had simply chosen the worst nonfluoridated city to compare again on best fluoridated cities.] He goes on to examine the history of fluoridation research which is full of flawed studies beginning with HT Dean's studies in the 1930s and 1940s. Any student of dental science should read this review. 14. Other o Ray SK, Ghosh S, Tiwari TC et all. "An Epidemiological study of caries and its 8 of 10 9/13111 1:21 PM Fluoridated Water Does Not Prevent Tooth Decay http://www.hohsti pdcom/ff We /nobeq html O o - a relationship to fluoride content of drinking water in rural communities near Varanasi" Indian Journal of Preventive and Social Medicine 12 154 -158 1981. o "Fluoridation of Water ", Chemical and Engineering News, 8/1/88 "Alan S. Gray, former director of the Division of Dental Health Services for the British Columbia Ministry of Health, finds, for example, that the average number of decayed, missing, and filled permanent teeth in British Columbia, where only 11% of the population uses fluoridated water, is lower than in parts of Canada where 40 to 70% of the people drink fluoridated water. School districts in the province with the highest percentage of children with no tooth decay are totally unfluoridated. [See Gray, AS J. Canadian Dent. Assoc. 53:763 (1987).] o Caries incidence in children with 2.0 -3.5 ppm fluuoride in water is the same as that found in 0.20 ppm areas in Tanzania according to several studies. See Community Dental Oral Epidemiology, Volume 14, page 94 -98 and page 99 -103 and Scandinavian Journal of Dental Research, Volume 96, page 385 -389. o There are many other studies which show that fluoridation does not and has never prevented dental decay. Please see the fluoride web page for a listing of other studies. ALERT #5 One other method that is used to make it appear that fluoridation is useful are "defluoridation" studies. When fluoride is removed from the water supply, some studies appear to show a large increase in DMFT rate a few years later. What is usually not said is that the increase is due almost completely to a change in dental practices such that the decay part of DMFT (decayed, missing, filled teeth) does not increase at all. Also, some of the studies are conducted on young children (i.e., five year-olds) and we would expect an increase in decay rate for that age group since tooth eruption is no longer delayed by fluoridation. In addition, pro - fluoridationists sometimes refer to fairly recent small studies purporting to show decreases in DMFS or DMFT. This is irrelevant. It is relatively easy for some researchers to select areas where they know they will get the results they're looking for. As you can see from the above - mentioned extremely large -scale studies, there is no decrease in DMFT, but possible an increase. There are no recent, large -scale studies (i.e., 1985 -1995) which show a decrease in DMFT rates other than the Brunelle studies which are discussed above. 9 of 10 9/13/11 1:21 PM Fluoridated Water Does Not Prevent Tooth Decay Conclusion http://www.holisticmed.com/fluoiide/nobenefit.html 10C A Portland, Oregon rejected fluoridation not long ago. Albany, New York rejected fluoridation recently. Several cities and towns have thrown out fluoridation over the last few years. To conclude, I'll quote Virginia Rosenbaum in an article entitled "U.S. EPA Scientists Warns Nation of Hip Fractures in Elderly Caused By Fluoride" "Fluoridation will be banned in this country. It is in its death throes now. It just hasn't stopped kicking! Like a snake, it keeps twitching for awhile!" There are numerous studies showing detrimental effect from fluoridation (not only cancer and hip fractures), but you won't find those studies listed in any ADA or EPA reviews. 10 of 10 9/13/11 1:21 PM 10C Q Doctors Against Fluoride Statement on drinking water fluoridation The Canadian Association of Physicians for the Environment (CAPE) does not support fluoridation of drinking water for the following reasons: 1) The decline in caries in communities that are fluoridated has been highly significant — but so has the decline that has occurred in non - fluoridated communities. There has, in fact, been a general decline in dental caries throughout the Western world, and the decline in fluoridated cities has not exceeded that in non - fluoridated communities. For example, BC drinking water is 95% non - fluoridated, whereas drinking water in Alberta is 75% fluoridated; yet the two provinces have similar rates of caries. Furthermore, Europe is 98% non - fluoridated, but global European dental health is generally equivalent to or better than that in North America. Whatever the reason for the decline in dental caries, it can not be concluded that it is the result of drinking water fluoridation. 2) The incidence of toxic effects in humans from fluoridation may well have been underestimated. The most serious potential association is with osteosarcoma in boys, which appears to have been loosely associated with age of exposure to fluoride. It is true that the CDC has (as has the original researcher) acknowledged that current data are tentative, but a further larger -scale study is pending from the Harvard School of Dentistry. At the very least, such data are grounds for caution. 3) Animal studies have shown a wide range of adverse effects associated with fluoride. It has been shown to be a potential immunotoxin, embryotoxin, neurotoxin and harmful to bony tissues, including both dental and ordinary bone. In addition, it can damage (inhibit) thyroid function in several species, including humans. Its effect on ecosystem balance has been little researched, but is unlikely to be positive. 4) The intake of fluoride from drinking water is uncontrolled, and can lead to dental fluorosis in children who are inclined to drink large amounts of water. Both natural and artificially flouridated water can cause this effect, which is, of course, simply a visible representation of an effect on the entire bony skeleton. The cost of repairing teeth damaged by fluorosis is not trivial; moderate to severe effects can require $15,000 or more in dental fees. It seems clear that... a) Fluoridation is unlikely to be the cause of the decline in caries in Europe and North America b) The potential for adverse effects is real, and c) current evidence points in the direction of caution. Over the last decade, recommendations with respect to acceptable fluoride exposure have steadily declined, and cautions have increased. Any dental benefit that may accrue from fluoride exposure is fully achieved by controlled topical application of fluoride compounds by trained dental professionals, not by fluoride ingestion. [The analysis of Dr. Hardy Limeback, Head, Preventive Dentistry, at the University of Toronto, further clarifies these points.] On the basis of this "weight of evidence" we believe that fluoridation of drinking water is scientifically untenable, and should not be part of a public health initiative or program. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries Page] of 8 10 0 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 and the 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 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 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 9/6/2011 f� Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries Page 2 of 8 10 C 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 (sue -e -e Lox). 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 concentration recommended for warmer climates (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) (Fi {�,��re_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 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental C rie r Page 3 of 8 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 duriip& tooth development would result in a more acid - resistant mineral. However, laboratory and epidemiologiciresearch suggests that fluoride prevents dental caries predominately On r eruption of the tooth into the mouth, and its actions primarily are topical for both adults and childr1). These mechanisms include 1) inhibition of demineralization, 2) enhancement of remineralization, 3) inhibition of bacterial activity in dental plaque (1). Enamel and dentin are composed of mineral crystals (primarily calcium and phosphate) embedded in an organic protein/lipid 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 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries Page 4 of 8 10 C .4 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 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 disease, osteoporosis and bone fracture, acquired 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 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries Page 5 0 8 10C 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. 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 status 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 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. (HRA)75 -1626. 15. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Ca106 age 6 of .4 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 Services, 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: Newbrun 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. 26. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, 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 1 http://www.cdc.gov/mmwr/preview/mmwrhtmi/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries 10C FIGURE 1. Per+ entage of population residing in areas with fluoridated community water systems and mean cumber of tlt ye+d, mining lbecause of tiariesl, or filled permanent teeth (OMFT). among children age-d 12 years -- € nited States, 1967 --7192 100 90 80 70 60 o 40 30 0 1 Mean DMFT Percentage Drinking Fluoridated Water_.. 1967 1977 1987 5 3 ~u 2 Year Sat.trces: 1. CDC. fluoridation Lensus 1992 Mama, Georgia: US Deptarirrtent of Health and Human Sefv- ices, Pt.iblic Health Service, CDC, Natlonat Center for Prevention Services. Division of viral Health, 1993. 2. Natiortal Center for Health Statistics, Decdayed, missing, and filled teeth anioriql youth 12- 17 ynarg--United Mates. Rockville, tt rtrtanc : U$ Dcpart111erit t f Health, Education,, arici Welfare, Public Health Service. Health Resources Admitiistratiort., 1974. Vital and health statistics, vol 11, no. 141. DHEW publication no. (HRA)75 1626. 3, Nationat Center for Health Statistics, Decayed, missing, and filled teeth among persorls 1 -- 7'4 years - - -- -United States. Hyattsville, Maryland: US Department of health and Human ` rvices, PtIblic Health Service, Office of Health Resemch, Statistics, and Technology, 1981. vitai grid health statistics, hell 11, no� 223, DHHS public atioti no lPHS01 -1T73. d. National ins ittite of Dentat llewarch.Oral hetillh of United States, children: the National Survey of Dernai Caries in l.t,S, School Children, 1986 -- 1987. Bethesda, Maryland. US Department of Health and Human Services, Public Health Service, National lnst tt,ites of Health, IM. Niff pub ieatiop no, 89- 2247. S. CDC, unpubiished data:,. third National Health and Nutrition Examination Survey, 198& 1994, Return to L'op- Page 7 of 8 Disclaimer All MMWR HTMIL versions of articles are electronic conversions from ASCII text into HTN1L. 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Page converted: 10/2111999 HOME I ABOUT MMWR I MMWR SEARCH I DOWNLOADS i RSS i CONTACT POLICY 1 DISCLAIMER I ACCESSIBILITY SAPSil +Mil►LTMI R•PROPLe' , Morbidity and Mortality Weekly Report S i 1' Department of Health Centers for Disease Control and Prevention�% ° w and Human Services 1600 Clifton Rd, MailStop E -90, Atlanta, GA 30333, C. w "F;WA kisfre" i U.S.A http://www.cdc.gov/mmwr/preview/mmwrhtmi/mm4841al.htm 9/6/2011 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries This page last reviewed 5/2/01 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841al.htm 10 Page 8 of 8 -lo 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 10 Recommendations and Reports August 17, 2001 / 50(RR14);1 -42 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page I of 41 1 Fluoride Recommendations Work Group Steven M. Adair, D.D.S., M.S. School of Dentistry Medical College of Georgia Augusta, Georgia William H. Bowen, Ph.D. Caries Research Center University of Rochester Rochester, New York Brian A. Burt, B.D.S., M.P.H., Ph.D. School of Public Health University of Michigan Ann Arbor, Michigan Jayanth V. Kumar, D.D.S., M.P.H. New York Department of Health Albany, New York Steven M. Levy, D.D.S., M.P.H. College of Dentistry University of Iowa Iowa City, Iowa David G. Pendrys, D.D.S., Ph.D. School of Dental Medicine University of Connecticut Farmington, Connecticut R. Gary Rozier, D.D.S., M.P.H. School of Public Health University of North Carolina Chapel Hill, North Carolina Robert H. Selwitz, D.D.S., M.P.H. National Institute of Dental and Craniofacial Research Bethesda, Maryland John W. Stamm, D.D.S., D.D.P.H. School of Dentistry University of North Carolina Chapel Hill, North Carolina George K. Stookey, Ph.D., D.D.S. School of Dentistry Indiana University Indianapolis, Indiana Gary M. Whitford, Ph.D., D.M.D. School of Dentistry Medical College of Georgia Augusta, Georgia Fluoride Recommendations Reviewers Myron Allukian, Jr., D.D.S., M.P.H. Director of Oral Health Boston Public Health Commission Boston, Massachusetts John P. Brown, B.D.S., Ph.D. Department of Community Dentistry University of Texas Health Science Center San Antonio, Texas http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Pau 2 of 41 10C 1 4 Joseph A. Ciardi, Ph.D. National Institute of Dental and Craniofacial Research Bethesda, Maryland D. Christopher Clark, D.D.S., M.P.H. Faculty of Dentistry University of British Columbia North Vancouver, Canada Stephen B. Corbin, D.D.S., M.P.H. Oral Health America Brookeville, Maryland Michael W. Easley, D.D.S., M.P.H. School of Dental Medicine State University of New York Buffalo, New York Caswell A. Evans, D.D.S., M.P.H. County Dental Director Los Angeles, California Lawrence J. Furman, D.D.S., M.P.H. National Institute of Dental and Craniofacial Research Bethesda, Maryland Stanley B. Heifetz, D.D.S., M.P.H. Department of Dental Medicine and Public Health School of Dentistry University of Southern California Los Angeles, California Keith E. Heller, D.D.S., Dr.P.H. School of Public Health University of Michigan Ann Arbor, Michigan Amid I. Ismail, D.D.S., Dr.P.H. School of Dentistry University of Michigan Ann Arbor, Michigan David W. Johnston, B.D.S., M.P.H. School of Dentistry University of Western Ontario London, Canada John V. Kelsey, D.D.S., M.B.A. US Food and Drug Administration Rockville, Maryland James A. Lalumandier, D.D.S., M.P.H. School of Dentistry Case Western Reserve University Hudson, Ohio Stephen J. Moss, D.D.S., M.S. College of Dentistry New York University New York, New York Ernest Newbrun, D.M.D., Ph.D. School of Dentistry University of California, San Francisco San Francisco, California Kathy R. Phipps, Dr.P.H. School of Dentistry Oregon Health Sciences University Portland, Oregon Mel L. Ringelberg, D.D.S., Dr.P.H. State Dental Director State of Florida Department of Health Tallahassee, Florida Jay D. Shulman, D.M.D., M.S.P.H. Baylor College of Dentistry Dallas, Texas Phillip A. Swango, D.D.S., M.P.H. Private dental consultant Albuquerque, New Mexico Gerald R. Vogel, Ph.D. ADA Health Foundation Paffenbarger Research Center Gaithersburg, Maryland James S. Wefel, Ph.D. College of Dentistry University of Iowa Iowa City, Iowa B. Alex White, D.D.S., Dr.P.H. Kaiser - Permanente, Inc. Portland, Oregon Summary Widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries (i.e., tooth decay) in the United States and other economically developed countries. When used http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 3 of 41 10 appropriately, fluoride is both safe and effective in preventing and controlling dental caries. All U.S. residents are likely exposed to some degree to fluoride, which is available from multiple sources. Both health -care professionals and the public have sought guidance on selecting the best way to provide and receive fluoride. During the late 1990s, CDC convened a work group to develop recommendations for using fluoride to prevent and control dental caries in the United States. This report includes these recommendations, as well as a) critical analysis of the scientific evidence regarding the efficacy and effectiveness of fluoride modalities in preventing and controlling dental caries, b) ordinal grading of the quality of the evidence, and c) assessment of the strength of each recommendation. Because frequent exposure to small amounts of fluoride each day will best reduce the risk for dental caries in all age groups, the work group recommends that all persons drink water with an optimal fluoride concentration and brush their teeth twice daily with fluoride toothpaste. For persons at high risk for dental caries, additional fluoride measures might be needed. Measured use of fluoride modalities is particularly appropriate during the time of anterior tooth enamel development (i.e., age <6 years). The recommendations in this report guide dental and other health -care providers, public health officials, policy makers, and the public in the use of fluoride to achieve maximum protection against dental caries while using resources efficiently and reducing the likelihood of enamel fluorosis. The recommendations address public health and professional practice, self -care, consumer product industries and health agencies, and Further research. Adoption of these recommendations could further reduce dental caries in the United States and save public and private resources. INTRODUCTION Dental caries (i.e., tooth decay) is an infectious, multifactorial disease afflicting most persons in industrialized countries and some developing countries (1). Fluoride reduces the incidence of dental caries and slows or reverses the progression of existing lesions (i.e., prevents cavities). Although pit and fissure sealants, meticulous oral hygiene, and appropriate dietary practices contribute to caries prevention and control, the most effective and widely used approaches have included fluoride use. Today, all U.S. residents are exposed to fluoride to some degree, and widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries in the United States and other economically developed countries (1). Although this decline is a major public health achievement, the burden of disease is still considerable in all age groups. Because many fluoride modalities are effective, inexpensive, readily available, and can be used in both private and public health settings, their use is likely to continue. Fluoride is the ionic form of the element fluorine, the 13th most abundant element in the earth's crust. Fluoride is negatively charged and combines with positive ions (e.g., calcium or sodium) to form stable compounds (e.g., calcium fluoride or sodium fluoride). Such fluorides are released into the environment naturally in both water and air. Fluoride compounds also are produced by some industrial processes that use the mineral apatite, a mixture of calcium phosphate compounds. In humans, fluoride is mainly associated with calcified tissues (i.e., bones and teeth) because of its high affinity for calcium. Fluoride's ability to inhibit or even reverse the initiation and progression of dental caries is well documented. The first use of adjusted fluoride in water for caries control began in 1945 and 1946 in the United States and Canada, when the fluoride concentration was adjusted in the drinking water supplying four communities (2 -- 5). The U.S. Public Health Service (PHS) developed recommendations in the 1940s and 1950s regarding fluoride concentrations in public water supplies. At that time, public health officials assumed that drinking water would be the major source of fluoride for most U.S. residents. The success of water fluoridation in preventing and controlling dental caries led to the development of fluoride - containing products, including toothpaste (i.e., dentifrice), mouthrinse, dietary supplements, and professionally applied or prescribed gel, foam, or varnish. In addition, processed beverages, which constitute an increasing proportion of the diets of http: / /www.cdc.gov /mmwr /preview /mmwrhtml /rr5014al .htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 4 of 41 10 C 14 many U.S. residents (6, 7), and food can contain small amounts of fluoride, especially if they are processed with fluoridated water. Thus, U.S. residents have more sources of fluoride available now than 50 years ago. Much of the research on the efficacy and effectiveness of individual fluoride modalities in preventing and controlling dental caries was conducted before 1980, when dental caries was more common and more severe. Modalities were usually tested separately and with the assumption that the method would provide the main source of fluoride. Thus, various modes of fluoride use have evolved, each with its own recommended concentration, frequency of use, and dosage schedule. Health -care professionals and the public have sought guidance regarding selection of preventive modalities from among the available options. The United States does not have comprehensive recommendations for caries prevention and control through various combinations of fluoride modalities. Adoption of such recommendations could further reduce dental caries while saving public and private resources and reducing the prevalence of enamel fluorosis, a generally cosmetic developmental condition of tooth enamel. This report presents comprehensive recommendations on the use of fluoride to prevent and control dental caries in the United States. These recommendations were developed by a work group of 11 specialists in fluoride research or policy convened by CDC during the late 1990s and reviewed by an additional 23 specialists. Although the recommendations were developed specifically for the United States, aspects of this report could be relevant to other countries. The recommendations guide health -care providers and the public on efficient and appropriate use of fluoride modalities, direct attention to fluoride intake among children aged <6 years to decrease the risk for enamel fluorosis, and suggest areas for further research. This report focuses on critical analysis of the scientific evidence regarding the efficacy and effectiveness of each fluoride modality in preventing and controlling dental caries and on the use of multiple sources of fluoride. The safety of fluoride, which has been documented comprehensively by other scientific and public health organizations (e.g., PHS [8], National Research Council [9], World Health Organization [10], and Institute of Medicine [11]) is not addressed. HOW FLUORIDE PREVENTS AND CONTROLS DENTAL CARIES Dental caries is an infectious, transmissible disease in which bacterial by- products (i.e., acids) dissolve the hard surfaces of teeth. Unchecked, the bacteria can penetrate the dissolved surface, attack the underlying dentin, and reach the soft pulp tissue. Dental caries can result in loss of tooth structure, pain, and tooth loss and can progress to acute systemic infection. Cariogenic bacteria (i.e., bacteria that cause dental caries) reside in dental plaque, a sticky organic matrix of bacteria, food debris, dead mucosal cells, and salivary components that adheres to tooth enamel. Plaque also contains minerals, primarily calcium and phosphorus, as well as proteins, polysacchari des, carbohydrates, and lipids. Cariogenic bacteria colonize on tooth surfaces and produce polysaccharides that enhance adherence of the plaque to enamel. Left undisturbed, plaque will grow and harbor increasing numbers of cariogenic bacteria. An initial step in the formation of a carious lesion takes place when cariogenic bacteria in dental plaque metabolize a substrate from the diet (e.g., sugars and other fermentable carbohydrates) and the acid produced as a metabolic by- product demineralizes (i.e., begins to dissolve) the adjacent enamel crystal surface (Fwi_glirc` 1). Demineralization involves the loss of calcium, phosphate, and carbonate. These minerals can be captured by surrounding plaque and be available for reuptake by the enamel surface. Fluoride, when present in the mouth, is also retained and concentrated in plaque. Fluoride works to control early dental caries in several ways. Fluoride concentrated in plaque and saliva inhibits the demineralization of sound enamel and enhances the remineralization (i.e., recovery) of demineralized enamel (12,13). As cariogenic bacteria metabolize carbohydrates and produce acid, fluoride is released from dental plaque in response to lowered pH at the tooth- plaque interface (14). The released fluoride and the fluoride present in saliva are then taken up, along with calcium and phosphate, by de- mineralized http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 5 of 41 10 C 4J enamel to establish an improved enamel crystal structure. This improved structure is more acid resistant and contains more fluoride and less carbonate (12,15 - -19) 1). Fluoride is more readily taken up by demineralized enamel than by sound enamel (20). Cycles of demineralization and remineralization continue throughout the lifetime of the tooth. Fluoride also inhibits dental caries by affecting the activity of cariogenic bacteria. As fluoride concentrates in dental plaque, it inhibits the process by which cariogenic bacteria metabolize carbohydrates to produce acid and affects bacterial production of adhesive polysaccharides (21). In laboratory studies, when a low concentration of fluoride is constantly present, one type of cariogenic bacteria, Streptococcus mutans, produces less acid (22 --25). Whether this reduced acid production reduces the cariogenicity of these bacteria in humans is unclear (26). Saliva is a major carrier of topical fluoride. The concentration of fluoride in ductal saliva, as it is secreted from salivary glands, is low - -- approximately 0.016 parts per million (ppm) in areas where drinking water is fluoridated and 0.006 ppm in nonfluoridated areas (27). This concentration of fluoride is not likely to affect cariogenic activity. However, drinking fluoridated water, brushing with fluoride toothpaste, or using other fluoride dental products can raise the concentration of fluoride in saliva present in the mouth 100- to 1,000 - fold. The concentration returns to previous levels within 1--2 hours but, during this time, saliva serves as an important source of fluoride for concentration in plaque and for tooth remineralization (28). Applying fluoride gel or other products containing a high concentration of fluoride to the teeth leaves a temporary layer of calcium fluoride -like material on the enamel surface. The fluoride in this material is released when the pH drops in the mouth in response to acid production and is available to remineralize enamel (29). In the earliest days of fluoride research, investigators hypothesized that fluoride affects enamel and inhibits dental caries only when incorporated into developing dental enamel (i.e., preeruptively, before the tooth erupts into the mouth) (30,31). Evidence supports this hypothesis (32 -34), but distinguishing a true preeruptive effect after teeth erupt into a mouth where topical fluoride exposure occurs regularly is difficult. However, a high fluoride concentration in sound enamel cannot alone explain the marked reduction in dental caries that fluoride produces (35,36). The prevalence of dental caries in a population is not inversely related to the concentration of fluoride in enamel (37), and a higher concentration of enamel fluoride is not necessarily more efficacious in preventing dental caries (38). The laboratory and epide logic research that has led to the better understandin of how fluoride prevents ental caries indicates tha fluoride's predominant effect is posteruptive and topical that the effect depends on fluoride being in the right amount in the right place at the right time. Fluoride works primarily after teeth have erupted, especially when small amounts are maintained constantly in the mouth, specifically in dental plaque and saliva (37). Thus, adults also benefit from fluoride, rather than only children, as was previously assumed. RISK FOR DENTAL CARIES The prevalence and severity of dental caries in the United States have decreased substantially during the preceding 3 decades (39). National surveys have reported that the prevalence of any dental caries among children aged 12 - -17 years declined from 90.4% in 1971 - -1974 to 67% in 1988- -1991; severity (measured as the mean number of decayed, missing, or filled teeth) declined from 6.2 to 2.8 during this period (40 -43). These decreases in caries prevalence and severity have been uneven across the general population; the burden of disease now is concentrated among certain groups and persons. For example, 80% of the dental caries in permanent teeth of U.S. children aged 5--17 years occurs among 25% of those children (43). To develop and http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the Unit f esc Ite 6 of 41 apply appropriate and effective caries prevention and control strategies, identification and assessment of groups and persons at high risk for developing new carious lesions is essential (44). Caries risk assessment is difficult because it attempts to account for the complex interaction of multiple factors. Although various methods for assessing risk exist, no single model predominates in this emerging science. Models that take multiple factors into account predict the risk more accurately, especially for groups rather than persons. However, for persons in a clinical setting, models do not improve on a dentist's perception of risk after examining a patient and considering the personal circumstances (45). Populations believed to be at increased risk for dental caries are those with low socioeconomic status (SES) or low levels of parental education, those who do not seek regular dental care, and those without dental insurance or access to dental services (45 -47). Persons can be at high risk for dental caries even if they do not have these recognized factors. Individual factors that possibly increase risk include active dental caries; a history of high caries in older siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection with cariogenic bacteria; impaired ability to maintain oral hygiene; malformed enamel or dentin; reduced salivary flow because of medications, radiation treatment, or disease; low salivary buffering capacity (i.e., decreased ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic appliances, or dental prostheses. Risk can increase if any of these factors are combined with dietary practices conducive to dental caries (i.e., frequent consumption of refined carbohydrates). Risk decreases with adequate exposure to fluoride (44, 45). Risk for dental caries and caries experience* exists on a continuum, with each person at risk to some extent; 85% of U.S. adults have experienced tooth decay (48). Caries risk can vary over time - -- perhaps numerous times during a person's lifetime - -- as risk factors change. Because caries prediction is an inexact, developing science, risk is dichotomized as low and high in this report. If these two categories of risk were applied to the U.S. population, most persons would be classified as low risk at any given time. Children and adults who are at low risk for dental caries can maintain that status through frequent exposure to small amounts of fluoride (e.g., drinking fluoridated water and using fluoride toothpaste). Children and adults at high risk for dental caries might benefit from additional exposure to fluoride (e.g., mouthrinse, dietary supplements, and professionally applied products). All available information on risk factors should be considered before a group or person is identified as being at low or high risk for dental caries. However, when classification is uncertain, treating a person as high risk is prudent until further information or experience allows a more accurate assessment. This assumption increases the immediate cost of caries prevention or treatment and might increase the risk for enamel fluorosis for children aged <6 years, but reduces the risk for dental caries for groups or persons misclassified as low risk. RISK FOR ENAMEL FLUOROSIS The proper amount of fluoride helps prevent and control dental caries. Fluoride ingested during tooth development can also result in a range of visually detectable changes in enamel opacity (i.e., light refraction at or below the surface) because of hypomineralization. These changes have been broadly termed enamel fluorosis, certain extremes of which are cosmetically objectionable (49). (Many other developmental changes that affect the appearance of enamel are not related to fluoride [50].) Severe forms of this condition can occur only when young children ingest excess fluoride, from any source, during critical periods of tooth development. The occurrence of enamel fluorosis is reported to be most strongly associated with cumulative fluoride intake during enamel development, but the severity of the condition depends on the dose, duration, and timing of fluoride intake. The transition and early maturation stages of enamel development appear to be most susceptible to the effects of fluoride (51); these stages occur at varying times for different tooth types. For central incisors of the upper jaw, for example, the most sensitive period is estimated at age 15 - -24 months for boys and age 21 - -30 months for girls (51,52). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5Ol4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 7 of 41 10C 10 Concerns regarding the risk for enamel fluorosis are limited to children aged <8 years; enamel is no longer susceptible once its preeruptive maturation is complete (11). Fluoride sources for children aged <8 years are drinking water, processed beverages and food, toothpaste, dietary supplements that include fluoride (tablets or drops), and other dental products. This report discusses the risk for enamel fluorosis among children aged <6 years. Children aged >6 years are considered past the age that fluoride ingestion can cause cosmetically objectionable fluorosis because only certain posterior teeth are still at a susceptible stage of enamel development, and these will not be readily visible. In addition, the swallowing reflex has developed sufficiently by age 6 years for most children to be able to control inadvertent swallowing of fluoride toothpaste and mouthrinse. The very mild and mild forms of enamel fluorosis appear as chalklike, lacy markings across a tooth's enamel surface that are not readily apparent to the affected person or casual observer (53). In the moderate form, >50% of the enamel surface is opaque white. The rare, severe form manifests as pitted and brittle enamel. After eruption, teeth with moderate or severe fluorosis might develop areas of brown stain (54). In the severe form, the compromised enamel might break away, resulting in excessive wear of the teeth. Even in its severe form, enamel fluorosis is considered a cosmetic effect, not an adverse functional effect (8,11,55,56). Some persons choose to modify this condition with elective cosmetic treatment. The benefits of reduced dental caries and the risk for enamel fluorosis are linked. Early studies that examined the cause of "mottled enamel" (now called moderate to severe enamel fluorosis) led to the unexpected discovery that fluoride in community drinking water inhibits dental caries (57). Historically, a low prevalence of the milder forms of enamel fluorosis has been accepted as a reasonable and minor consequence balanced against the substantial protection from dental caries from drinking water containing an optimal concentration of fluoride, either naturally occurring or through adjustment (11,53). When enamel fluorosis was first systematically investigated during the 1930s and 1940s, its prevalence was 12 % - -15% for very mild and mild forms and zero for moderate and severe forms among children who lived in communities with drinking water that naturally contained 0.9 - -1.2 ppm fluoride (53). Although the prevalence of this condition in the United States has since increased (8,58,59), most fluorosis today is of the mildest form, which affects neither cosmetic appearance nor dental function. The increased prevalence in areas both with and without fluoridated community drinking water (8) indicates that, during the first 8 years of life (i.e., the window of time when this condition can develop), the total intake of fluoride from all sources has increased for some children. The 1986 - -1987 National Survey of Dental Caries in U.S. School Children (the most recent national estimates of enamel fluorosis prevalence) indicated that the prevalence of any enamel fluorosis among children was 22 % - -23% (range: 26% of children aged 9 years to 19% of those aged 17 years) (60, 61). Almost all cases reported in the survey were of the very mild or mild form, but some cases of the moderate (l. l %) and severe (0.3 %) forms were observed. Cases of moderate and severe forms occurred even among children living in areas with low fluoride concentrations in the drinking water (61). Although this level of enamel fluorosis is not considered a public health problem (53), prudent public health practice should seek to minimize this condition, especially moderate to severe forms. In addition, changes in public perceptions of what is cosmetically acceptable could influence support for effective caries- prevention measures. Research into the causes of enamel fluorosis has focused on identifying risk factors (62 - -65). Adherence to the recommendations in this report regarding appropriate use of fluoride for children aged <6 years will reduce the prevalence and severity of enamel fluorosis. NATIONAL GUIDELINES FOR FLUORIDE USE PHS recommendations for fluoride use include an optimally adjusted concentration of fluoride in community drinking water to maximize caries prevention and limit enamel fluorosis. This concentration ranges from 0.7 ppm to 1.2 ppm depending on the average maximum daily air temperature of the area (66 - -68). In 1991, PHS also issued policy and research recommendations for fluoride use (8). The U.S. Environmental Protection http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Pa e 8 of 41 10C. Agency (EPA), which is responsible for the safety and quality of drinking water in the United States, sets a maximum allowable limit for fluoride in community drinking water at 4 ppm and a secondary limit (i.e., nonenforceable guideline) at 2 ppm (69, 70). The U.S. Food and Drug Administration (FDA) is responsible for approving prescription and over - the - counter fluoride products marketed in the United States and for setting standards for labeling bottled water (71) and over - the - counter fluoride products (e.g., toothpaste and mouthrinse) (72). Nonfederal agencies also have published guidelines on fluoride use. The American Dental Association (ADA) reviews fluoride products for caries prevention through its voluntary Seal of Acceptance program; accepted products are listed in the ADA Guide to Dental Therapeutics (73). A dosage schedule for fluoride supplements for infants and children aged <16 years, which is scaled to the fluoride concentration in the community drinking water, has been jointly recommended by ADA, the American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) (TaOIe 1) (44, 74, 75). In 1997, the Institute of Medicine published age - specific recommendations for total dietary intake of fluoride ('1_able =). These recommendations list adequate intake to prevent dental caries and tolerable upper intake, defined as a level unlikely to pose risk for adverse effects in almost all persons. FLUORIDE SOURCES AND THEIR EFFECTS Fluoridated community drinking water and fluoride toothpaste are the most common sources of fluoride in the United States and are largely responsible for the low risk for dental caries for most persons in this country. Persons at high risk for dental caries might require more frequent or more concentrated exposure to fluoride and might benefit from use of other fluoride modalities (e.g., mouthrinse, dietary supplements, and topical gel, foam, or varnish). The effects of each of these fluoride sources on dental caries and enamel fluorosis are described. Fluoridated Drinking Water and Processed Beverages and Food Fluoridated drinking water contains a fluoride concentration effective for preventing dental caries; this concentration can occur naturally or be reached through water fluoridation, which is the controlled addition of fluoride to a public water supply. When fluoridated water is the main source of drinking water, a low concentration of fluoride is routinely introduced into the mouth. Some of this fluoride is taken up by dental plaque; some is transiently present in saliva, which serves as a reservoir for plaque fluoride; and some is loosely held on the enamel surfaces (76). Frequent consumption of fluoridated drinking water and beverages and food processed in fluoridated areas maintains the concentration of fluoride in the mouth. Estimates of fluoride intake among U.S. and Canadian adults have ranged from <1.0 mg fluoride per day in nonfluoridated areas to 1--3 mg fluoride per day in fluoridated areas (77 - -80). The average daily dietary fluoride intake for both children and adults in fluoridated areas has remained relatively constant for several years (11). For children who live in optimally fluoridated areas, this average is approximately 0. 05 mg/kg/day (range: 0.02 -- 0.10); for children who live in nonfluoridated areas, the average is approximately half (11). In a survey of four U.S. cities with different fluoride concentrations in the drinking water (range: 0.37 -4.04 ppm), children aged 2 years ingested 0.41 -461 mg fluoride per day and infants aged 6 months ingested 0.21- -0.54 mg fluoride per day (81,82). In the United States, water and processed beverages (e.g., soft drinks and fruit juices) can provide approximately 75% of a person's fluoride intake (83). Many processed beverages are prepared in locations where the drinking water is fluoridated. Foods and ingredients used in food processing vary in their fluoride content (11). As consumption of processed beverages by children increases, fluoride intake in communities without fluoridated water will increase whenever the water source for the processed beverage is fluoridated (84). In fluoridated areas, dietary fluoride intake has been stable because processed beverages have been http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5Ol4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 9 of 41 substituted for tap water and for beverages prepared in the home using tap water (11). O V l A study of Iowa infants estimated that the mean fluoride intake from water during different periods during the first 9 months of life, either consumed directly or added to infant formula or juice, was 0.29 -438 mg per day, although estimated intake for some infants was as high as 1.73 mg per day (85). As foods are added to an infant's diet, replacing some of the formula prepared with fluoridated water, the amount of fluoride the infant receives typically decreases (86). The Iowa study also reported that infant formula and processed baby food contained variable amounts of fluoride. Since 1979, U.S. manufacturers of infant formula have voluntarily lowered the fluoride concentration of their products, both ready -to -feed and concentrates, to <0.3 ppm fluoride (87). Drinking Water Community Water. During the 1940s, researchers determined that 1 ppm fluoride was the optimal concentration in community drinking water for climates similar to the Chicago area (88,89). This concentration would substantially reduce the prevalence of dental caries, while allowing an acceptably low prevalence (i.e., 10 % - -12 %) of very mild and mild enamel fluorosis and no moderate or severe enamel fluorosis. Water fluoridation for caries control began in 1945 and 1946, when the fluoride concentration was adjusted in the drinking water supplying four communities in the United States and Canada (2 -5). This public health approach followed a long period of epidemiologic research into the effects of naturally occurring fluoride in drinking water (53,57,88,89). Current federal fluoridation guidelines, maintained by the PHS since 1962, state that community drinking water should contain 0.7 - -1.2 ppm fluoride, depending on the average maximum daily air temperature of the area. These temperature- related guidelines are based on epidemiologic studies conducted during the 1950s that led to the development of an algebraic formula for determining optimal fluoride concentrations (67,90 - -92). This formula determined that a lower fluoride concentration was appropriate for communities in warmer climates because persons living in warmer climates drank more tap water. However, social and environmental changes since 1962 (e.g., increased use of air conditioning and more sedentary lifestyles) have reduced the likelihood that persons in warmer regions drink more tap water than persons in cooler regions (7). By 1992, fluoridated water was reaching 144 million persons in the United States (56% of the total population and 62% of those receiving municipal water supplies) (93). Approximately 10 million of these persons were receiving water containing naturally occurring fluoride at a concentration of >0.7 ppm. In 11 states and the District of Columbia, >90% of the population had such access, whereas <5% received this benefit in two states. In 2000, a total of 38 states and the District of Columbia provided access to fluoridated public water supplies to >50% of their population (CDC, unpublished data, 2000) Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50 % - -60% (94 - -97). More recent estimates are lower - -- 18 % -- 40% (98,99). This decrease in attributable benefit is likely caused by the increasing use of fluoride from other sources, with the widespread use of fluoride toothpaste probably the most important. The diffusion or "halo" effect of beverages and food processed in fluoridated areas but consumed in nonfluoridated areas also indirectly spreads some benefit of fluoridated water to nonfluoridated communities. This effect lessens the differences in caries experience among communities (100). Quantifying the benefits of water fluoridation among adults is more complicated because adults are rarely surveyed, their fluoride histories are potentially more varied, and their tooth loss or restorations might be caused by dental problems other than caries (e.g., trauma or periodontal diseases). Nevertheless, adults are reported to receive caries- preventive benefits from community water fluoridation (99,101 -103). These benefits might be particularly advantageous for adults aged >50 years, many of whom are at increased risk for http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States P 10 of 41 10 C dental caries. Besides coronal caries, older adults typically experience gingival recession, which results in teeth with exposed root surfaces. Unlike the crowns of teeth, these root surfaces are not covered by enamel and are more susceptible to caries. Because tooth retention among older age groups has increased in recent decades in the United States (39), these groups' risk for caries will increase as the country's population ages. Older adults also frequently require multiple medications for chronic conditions, and many of these medications can reduce salivary output (104). Drinking water containing an optimal concentration of fluoride can mitigate the risk factors for caries among older adults. Studies have reported that the prevalence of root caries among adults is inversely related to fluoride concentration in the community drinking water (105 - -107). Water fluoridation also reduces the disparities in caries experience among poor and nonpoor children (108 -- 111). Caries experience is considerably higher among persons in low SES strata than among those in high SES strata (39,46,112). The reasons for this discrepancy are not well understood; perhaps persons in low SES strata have less knowledge of oral diseases, have less access to dental care, are less likely to follow recommended self -care practices, or are harder to reach through traditional approaches, including public health programs and private dental care (48). Thus, these persons might receive more benefit from fluoridated community water than persons from high SES strata. Regardless of SES, water fluoridation is the most effective and efficient strategy to reduce dental caries (112). Enamel fluorosis occurs among some persons in all communities, even in communities with a low natural concentration of fluoride. During 1930- -1960, U.S. studies documented that, in areas with a natural or adjusted concentration of fluoride of approximately 1.0 ppm in the community drinking water, the permanent teeth of 7 % -- 16% of children with lifetime residence in those areas exhibited very mild or mild forms of enamel fluorosis (53,113,114). Before 1945, when naturally fluoridated drinking water was virtually the only source of fluoride, the moderate and severe forms of this condition were not observed unless the natural fluoride concentration was >2 ppm (53). The likelihood of a child developing the mild forms of enamel fluorosis might be higher in a fluoridated area than in a nonfluoridated area, but prevalence might not change in every community (115,116). The most recent national study of this condition indicated that its prevalence had increased in both fluoridated and nonfluoridated areas since the 1940s, with the relative increase higher in nonfluoridated areas. In communities with drinking water containing 0.7 - -1.2 ppm fluoride, the prevalence was 1.3% for the moderate form of enamel fluorosis and zero for the severe form; thus, few cases of enamel fluorosis were likely to be of cosmetic consequence (8,61). Because combined fluoride intake from drinking water and processed beverages and food by children in fluoridated areas has reportedly remained stable since the 1940s, the increase in fluoride intake resulting in increased enamel fluorosis almost certainly stems from use of fluoride - containing dental products by children aged <6 years (11). Two studies reported that extended consumption of infant formula beyond age 10 -42 months was a risk factor for enamel fluorosis, especially when formula concentrate was mixed with fluoridated water (62, 63). These studies examined children who used pre -1979 formula (with higher fluoride concentrations). Whether fluoride intake from formula that exceeds the recommended amount during only the first 10 - -12 months of life contributes to the prevalence or severity of enamel fluorosis is unknown. Fluoride concentrations in drinking water should be maintained at optimal levels, both to achieve effective caries prevention and because changes in fluoride concentration as low as 0.2 ppm can result in a measurable change in the prevalence and severity of enamel fluorosis (52,117). Since the late 1970s, CDC has provided guidelines and recommendations for managers of fluoridated water supply systems at state and local levels to help them establish and maintain appropriate fluoride concentrations. CDC periodically updates these guidelines; the most recent revision was published in 1995 (68). School Water Systems. In some areas of the United States where fluoridating a community's drinking water was not feasible (e.g., rural areas), the alternative of fluoridating a school's public water supply system was promoted for many years. This method was used when a school had its own source of water and was not http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 11 of 41 10 C t connected to a community water supply system (i.e., stand -alone systems). Because children are at school only part of each weekday, a fluoride concentration of 4.5 times the optimal concentration for a community in the same geographic area was recommended (118) to compensate for the more limited consumption of fluoridated water. At the peak of this practice in the early 1980s, a total of 13 states had initiated school water fluoridation in 470 schools serving 170,000 children (39). Since then, school water fluoridation has been phased out in several states; the current extent of this practice is not known. Studies of the effects of school water fluoridation in the United States reported that this practice reduced caries among schoolchildren by approximately 40% (118 -122). A more recent study indicated that this effect might no longer be as pronounced (123). Several concerns regarding school water fluoridation exist. Operating and maintaining small fluoridation systems (i.e., those serving <500 persons) create practical and logistical difficulties (68). These difficulties have occasionally caused higher than recommended fluoride concentrations in the school drinking water, but no lasting effects among children have been observed (124 - -126). In schools that enroll preschoolers in day care programs, children aged <6 years might receive more than adequate fluoride. Bottled Water. Many persons drink bottled water, replacing tap water partially or completely as a source of drinking water. Water is classified as "bottled water" if it meets all applicable federal and state standards, is sealed in a sanitary container, and is sold for human consumption. Although some bottled waters marketed in the United States contain an optimal concentration of fluoride (approximately 1.0 ppm), most contain <0.3 ppm fluoride (127 -129). Thus, a person substituting bottled water with a low fluoride concentration for fluoridated community water might not receive the full benefits of community water fluoridation (130). For water bottled in the United States, current FDA regulations require that fluoride be listed on the label only if the bottler adds fluoride during processing; the concentration of fluoride is regulated but does not have to be stated on the label (Tat Ie Few bottled water brands have labels listing the fluoride concentration. Determining Fluoride Concentration. Uneven geographic coverage of community water fluoridation throughout the United States, wide variations in natural fluoride concentrations found in drinking water, and almost nonexistent labeling of fluoride concentration in bottled water make knowing the concentration of fluoride in drinking water difficult for many persons. Persons in nonfluoridated areas can mistakenly believe their water contains an optimal concentration of fluoride. To obtain the fluoride concentration of community drinking water, a resident can contact the water supplier or a local public health authority, dentist, dental hygienist, physician, or other knowledgeable source. EPA requires that all community water supply systems provide each customer an annual report on the quality of water, including the fluoride concentration (131). Testing for private wells is available through local and state public health departments as well as some private laboratories. If the fluoride concentration is not listed on the label of bottled water, the bottler can be contacted directly to obtain this information. Fluoride Toothpaste Fluoride is the only nonprescription toothpaste additive proven to prevent dental caries. When introduced into the mouth, fluoride in toothpaste is taken up directly by dental plaque (132 - -134) and demineralized enamel (135,136). Brushing with fluoride toothpaste also increases the fluoride concentration in saliva 100- to 1,000 - fold; this concentration returns to baseline levels within 1--2 hours (137). Some of this salivary fluoride is taken up by dental plaque. The ambient fluoride concentration in saliva and plaque can increase during regular use of fluoride toothpaste (132,133). By the 1990s, fluoride toothpaste accounted for >90% of the toothpaste market in the United States, Canada, and other developed countries (138). Because water fluoridation is not available in many countries, toothpaste might be the most important source of fluoride globally (1). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 12 41 10C Studies of 2--3 years duration have reported that fluoride toothpaste reduces caries experience among children by a median of 15 % - -30% (139 - -148). This reduction is modest compared with the effect of water fluoridation, but water fluoridation studies usually measured lifetime - -- rather than a few years' - -- exposure. Regular lifetime use of fluoride toothpaste likely provides ongoing benefits that might approach those of fluoridated water. Combined use of fluoride toothpaste and fluoridated water offers protection above either used alone (99,149,150). Few studies evaluating the effectiveness of fluoride toothpaste, gel, rinse, and varnish among adult populations are available. Child populations have typically been used for studies on caries prevention because of perceived increased caries susceptibility and logistical reasons. However, teeth generally remain susceptible to caries throughout life, and topically applied fluorides could be effective in preventing caries in susceptible patients of any age (151,152). Most persons report brushing their teeth at least once per day (153,154), but more frequent use can offer additional protection (139,141,155- -158). Brushing twice a day is a reasonable social norm that is both effective and convenient for most persons' daily routines, and this practice has become a basic recommendation for caries prevention. Whether increasing the number of daily brushings from two to three times a day results in lower dental caries experience is unclear. Because the amount and vigor of rinsing after toothbrushing affects fluoride concentration in the mouth and reportedly affects caries experience (157- -160), persons aged >6 years can retain more fluoride in the mouth by either rinsing briefly with a small amount of water or not at all. In the United States, the standard concentration of fluoride in fluoride toothpaste is 1,000 - -1,100 ppm. Toothpaste containing 1,500 ppm fluoride has been reported to be slightly more efficacious in reducing dental caries in U.S. and European studies (161 -164). Products with this fluoride concentration have been marketed in the United States, but are not available in all areas. These products might benefit persons aged >6 years at high risk for dental caries. Children who begin using fluoride toothpaste at age <2 years are at higher risk for enamel fluorosis than children who begin later or who do not use fluoride toothpaste at all (62,63,165-170). Because studies have not used the same criteria for age of initiation, amount of toothpaste used, or frequency of toothpaste use, the specific contribution of each factor to enamel fluorosis among this age group has not been established. Fluoride toothpaste contributes to the risk for enamel fluorosis because the swallowing reflex of children aged <6 years is not always well controlled, particularly among children aged <3 years (171,172). Children are also known to swallow toothpaste deliberately when they like its taste. A child -sized toothbrush covered with a full strip of toothpaste holds approximately 0.75 -4.0 g of toothpaste, and each gram of fluoride toothpaste, as formulated in the United States, contains approximately 1.0 mg of fluoride. Children aged <6 years swallow a mean of 0.3 g of toothpaste per brushing (11) and can inadvertently swallow as much as 0.8 g (138,173 - -176). As a result, multiple brushings with fluoride toothpaste each day can result in ingestion of excess fluoride (177). For this reason, high- fluoride toothpaste (i.e., containing 1,500 ppm fluoride) is generally contraindicated for children aged <6 years. Use of a pea -sized amount (approximately 0.25 g) of fluoride toothpaste <2 times per day by children aged <6 years is reported to sharply reduce the importance of fluoride toothpaste as a risk factor for enamel fluorosis (65). Since 1991, manufacturers of fluoride toothpaste marketed in the United States have, as a requirement for obtaining the ADA Seal of Acceptance, placed instructions on the package label stating that children aged <6 years should use only this amount of toothpaste. Toothpaste labeling requirements mandated by FDA in 1996 (72) also direct parents of children aged <2 years to seek advice from a dentist or physician before introducing their child to fluoride toothpaste. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4aI.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United Stat s O Page .1 f 41 C 1 The propensity of young children to swallow toothpaste has led to development of "child- strength" toothpaste with lower fluoride concentrations (176). Such a product would be a desirable alternative to currently available products for many young children. Clinical trials outside the United States have reported that toothpaste containing 250 ppm fluoride is less effective than toothpaste containing 1,000 ppm fluoride in preventing dental caries (178,179). However, toothpaste containing 500- -550 ppm fluoride might be almost as efficacious as that containing 1,000 ppm fluoride (180). A British study reported that the prevalence of diffuse enamel opacities (an indicator of mild enamel fluorosis) in the upper anterior incisors was substantially lower among children who used toothpaste containing 550 ppm fluoride than among those who used toothpaste containing 1,050 ppm fluoride (181). Toothpaste containing 400 ppm fluoride has been available in Australia and New Zealand for approximately 20 years, but has not been tested in clinical trials, and no data are available to assess whether toothpaste at this concentration has reduced the prevalence of enamel fluorosis in those countries. A U.S. clinical trial of the efficacy of toothpaste with lower fluoride concentrations, required by FDA before approval for marketing and distribution, has not been conducted (182). Fluoride Mouthrinse Fluoride mouthrinse is a concentrated solution intended for daily or weekly use. The fluoride from mouthrinse, like that from toothpaste, is retained in dental plaque and saliva to help prevent dental caries (183). The most common fluoride compound used in mouthrinse is sodium fluoride. Over - the - counter solutions of 0.05% sodium fluoride (230 ppm fluoride) for daily rinsing are available for use by persons aged >6 years. Solutions of 0.20% sodium fluoride (920 ppm fluoride) are used in supervised, school -based weekly rinsing programs. Throughout the 1980s, approximately 3 million children in the United States participated in school -based fluoride mouthrinsing programs (39). The current extent of such programs is not known. Studies indicating that fluoride mouthrinse reduces caries experience among schoolchildren date mostly from the 1970s and early 1980s (184 - -191). In one review, the average caries reduction in nonfluoridated communities attributable to fluoride mouthrinse was 31% (191). Two studies reported benefits of fluoride mouthrinse approximately 2.5 and 7 years after completion of school -based mouthrinsing programs (192,193), but a more recent study did not find such benefits 4 years after completion of a mouthrinsing program (194). The National Preventive Dentistry Demonstration Program (NPDDP), a large project conducted in 10 U.S. cities during 1976- -1981 to compare the cost and effectiveness of combinations of caries- prevention procedures, reported that fluoride mouthrinse had little effect among schoolchildren, either among first -grade students with high and low caries experience (195) or among all second- and fifth -grade students (196). NPDDP documented only a limited reduction in dental caries attributable to fluoride mouthrinse, especially when children were also exposed to fluoridated water. Although no studies of enamel fluorosis associated with use of fluoride mouthrinse have been conducted, studies of the amount of fluoride swallowed by children aged 3--5 years using such rinses indicated that some young children might swallow substantial amounts (191). Use of fluoride mouthrinse by children aged >6 years does not place them at risk for cosmetically objectionable enamel fluorosis because they are generally past the age that fluoride ingestion might affect their teeth. Dietary Fluoride Supplements Dietary fluoride supplements in the form of tablets, lozenges, or liquids (including fluoride- vitamin preparations) have been used throughout the world since the 1940s. Most supplements contain sodium fluoride as the active ingredient. Tablets and lozenges are manufactured with 1.0, 0.5, or 0.25 mg fluoride. To maximize the topical effect of fluoride, tablets and lozenges are intended to be chewed or sucked for 1--2 minutes before being swallowed. For infants, supplements are available as a liquid and used with a dropper. In 1986, an estimated 16% of U.S. children aged <2 years used fluoride supplements (197). All fluoride http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 14 1 10C 4 supplements must be prescribed by a dentist or physician. The prescription should be consistent with the 1994 dosage schedule developed by ADA, AAPD, and AAP (Tahle 1). Because fluoride supplements are intended to compensate for fluoride - deficient drinking water, the dosage schedule requires knowledge of the fluoride content of the child's primary drinking water; consideration should also be given to other sources of water (e.g., home, child care settings, school, or bottled water) and to other sources of fluoride (e.g., toothpaste or mouthrinse), which can complicate the prescribing decision. The evidence for using fluoride supplements to mitigate dental caries is mixed. Use of fluoride supplements by pregnant women does not benefit their offspring (198). Several studies have reported that fluoride supplements taken by infants and children before their teeth erupt reduce the prevalence and severity of caries in teeth (98,199 - -207), but several other studies have not (19,208 - -212). Among children aged 6--16 years, fluoride supplements taken after teeth erupt reduce caries experience (213 - -215). Fluoride supplements might be beneficial among adults who have limitations with toothbrushing, but this use requires further study. A few studies have reported no association between supplement use by children aged <6 years and enamel fluorosis (208,216), but most have reported a clear association (19,62,64,165,170,199 -- 201,209,210,212,217 -- 222 ). In one study, the risk for this condition was high when supplements were used in fluoridated areas (odds ratio = 23.74; 95% confidence interval = 3.43 -- 164.30) (62), a use inconsistent with the supplement schedule. Reports of the frequency of supplement use in fluoridated areas have ranged from 7% to 35% (223 - -228). In response to the accumulated data on fluoride intake and the prevalence of enamel fluorosis, the supplement dosage schedule for children aged <6 years was markedly reduced in 1994 when ADA, AAPD, and AAP jointly established the current schedule (Tabl(Z ;) (73). The risk for enamel fluorosis among children this age attributable to fluoride supplements could be lower, but not enough information is available yet to evaluate the effects of this change. When prescribing any pharmaceutical agent, dentists and physicians should attempt to maximize benefit and minimize harm (229). For infants and children aged <6 years, both a benefit of dental caries prevention and a risk for enamel fluorosis are possible. Although the primary (i.e., "baby ") teeth of children aged 1--6 years would benefit from fluoride's posteruptive action, and some preeruptive benefit for developing permanent teeth could exist, fluoride supplements also could increase the risk for enamel fluorosis at this age (138,223). Professionally Applied Fluoride Compounds In the United States, dentists and dental hygienists have been applying high- concentration fluoride compounds directly to patients' teeth for approximately 50 years. Application procedures were developed on the assumption that the fluoride would be incorporated into the crystalline structure of the dental enamel and develop a more acid - resistant enamel. To maximize this reaction, a professional tooth cleaning was considered mandatory before the application. However, subsequent research has demonstrated that high- concentration fluoride compounds (e.g., those in gel or varnish) do not directly enter the enamel's crystalline structure (230). The compound forms a calcium fluoride -like material on the enamel's surface that releases fluoride for remineralization when the pH in the mouth drops. Thus, professional tooth cleaning solely to prepare the teeth for application of a fluoride compound is unnecessary; toothbrushing and flossing appear equally effective in improving the efficacy of high- concentration fluoride compounds (231). Fluoride Gel and Foam Because an early study reported that fluoride uptake by dental enamel increased in an acidic environment (232), fluoride gel is often formulated to be highly acidic (pH of approximately 3.0). Products available in the United States include gel of acidulated phosphate fluoride (1.23% [12,300 ppm] fluoride), gel or foam of sodium fluoride (0.9% [9,040 ppm] fluoride), and self - applied (i.e., home use) gel of sodium fluoride (0.5% [5,000 ppm] fluoride) or stannous fluoride (0.15% [1,000 ppm] fluoride) (73). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 15 o1 4 10C Clinical trials conducted during 1940 - -1970 demonstrated that professionally applied fluorides effectively reduce caries experience in children (233). In more recent studies, semiannual treatments reportedly caused an average decrease of 26% in caries experience in the permanent teeth of children residing in nonfluoridated areas (191,234 - -236). The application time for the treatments was 4 minutes. In clinical practice, applying fluoride gel for 1 minute rather than 4 minutes is common, but the efficacy of this shorter application time has not been tested in human clinical trials. In addition, the optimal schedule for repeated application of fluoride gel has not been adequately studied to support definitive guidelines, and studies that have examined the efficacy of various gel application schedules in preventing and controlling dental caries have reported mixed results. On the basis of the available evidence, the usual recommended frequency is semiannual (151,237,238). Because these applications are relatively infrequent, generally at 3- to 12 -month intervals, fluoride gel poses little risk for enamel fluorosis, even among patients aged <6 years. Proper application technique reduces the possibility that a patient will swallow the gel during application. Fluoride Varnish High- concentration fluoride varnish is painted directly onto the teeth. Fluoride varnish is not intended to adhere permanently; this method holds a high concentration of fluoride in a small amount of material in close contact with the teeth for many hours. Fluoride varnish has practical advantages (e.g., ease of application, a nonoffensive taste, and use of smaller amounts of fluoride than required for gel applications). Such varnishes are available as sodium fluoride (2.26% [2,600 ppm] fluoride) or difluorsilane (0.1% [1,000 ppm] fluoride) preparations. Fluoride varnish has been widely used in Canada and Europe since the 1970s to prevent dental caries (152,239). FDA's Center for Devices and Radiological Health has cleared fluoride varnish as a medical device to be used as a cavity liner (i.e., to provide fluoride at the junction of filling material and tooth) and root desensitizer (i.e., to reduce sensitivity to temperature and touch that sometimes occurs on root surfaces exposed by receding gingiva) (240); FDA has not yet approved this product as an anticaries agent. Caries prevention is regarded as a drug claim, and companies would be required to submit appropriate clinical trial evidence for review before this product could be marketed as an anticaries agent. However, a prescribing practitioner can use fluoride varnish for caries prevention as an "off - label" use, based on professional judgement (241). Studies conducted in Canada (242) and Europe (243 - -246) have reported that fluoride varnish is efficacious in preventing dental caries in children. Applied semiannually, this modality is as effective as professionally applied fluoride gel (247). Some researchers advocate application of fluoride varnish as many as four times per year to achieve maximum effect, but the evidence of benefits from more than two applications per year remains inconclusive (240,246,248). Other studies have reported that three applications in 1 week, once per year, might be more effective than the more conventional semiannual regimen (249,250). European studies have reported that fluoride varnish prevents decalcification (i.e., an early stage of dental caries) beneath orthodontic bands (251) and slows the progression of existing enamel lesions (252). Studies examining the effectiveness of varnish in controlling early childhood caries are being conducted in the United States. Research on fluoride varnish (e.g., optimal fluoride concentration, the most effective application protocols, and its efficacy relative to other fluoride modalities) is likely to continue in both Europe and North America. No published evidence indicates that professionally applied fluoride varnish is a risk factor for enamel fluorosis, even among children aged <6 years. Proper application technique reduces the possibility that a patient will swallow varnish during its application and limits the total amount of fluoride swallowed as the http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 16 of 41 10 C .4 varnish wears off the teeth over several hours. Fluoride Paste Fluoride - containing paste is routinely used during dental prophylaxis (i.e., cleaning). The abrasive paste, which contains 4,000 -- 20,000 ppm fluoride, might restore the concentration of fluoride in the surface layer of enamel removed by polishing, but it is not an adequate substitute for fluoride gel or varnish in treating persons at high risk for dental caries (151). Fluoride paste is not accepted by FDA or ADA as an efficacious way to prevent dental caries. Combinations of Fluoride Modalities Studies comparing various combinations of fluoride modalities have generally reported that their effectiveness in preventing dental caries is partially additive. That is, the percent reduction in the prevalence or severity of dental caries from a combination of modalities is higher than the percent reduction from each modality, but less than the sum of the percent reduction of the modalities combined. Attempts to use a formula to apply sequentially the percent reduction of an additional modality to the estimated remaining caries increment have overestimated the effect (151, 253). For example, if the first modality reduces caries by 40% and the second modality reduces caries by 30 %, then the calculation that caries will be reduced by a total of 58% (i.e., 40% plus 18% [30% of the 60% decay remaining after the first modality]) will likely be an overestimate. QUALITY OF EVIDENCE FOR DENTAL CARIES PREVENTION AND CONTROL Members of the work group convened by CDC identified the published research in their areas of expertise and evaluated the quality of scientific evidence for each fluoride modality in preventing and controlling dental caries. Evidence was drawn from the most relevant English- language, peer- reviewed scientific publications regarding the current effectiveness of fluoride modalities. Additional references were suggested by reviewers. Members used their own methods for critically analyzing articles. A formal protocol for duplicate review was not followed, but members collectively agreed on the grade reflecting the quality of evidence regarding each fluoride modality. Criteria used to grade the quality of scientific evidence (i.e., ordinal grading) was adapted from the U.S. Preventive Services Task Force Qk)\_l) (254). Grades range from I to III. Community Water Fluoridation Studies on the effectiveness of adjusting fluoride in community water to the optimal concentration cannot be designed as randomized clinical trials. Random allocation of study subjects is not possible when a community begins to fluoridate the water because all residents in a community have access to and are exposed to this source of fluoride. In addition, clinical studies cannot be conducted double -blind because both study subjects and researchers usually know whether a community's water has been fluoridated. Efforts to blind the examiners by moving study subjects to a neutral third site for clinical examinations, using radiographs of teeth without revealing where the subjects live, or including transient residents as study subjects have not fully resolved these inherent limitations. Early studies that led to the unexpected discovery that dental caries was less prevalent and severe among persons with mottled enamel (subsequently identified as a form of enamel fluorosis) were conducted before the caries- preventive effects of fluoride were known (255). In those studies, researchers did not have an a priori reason to suspect they would find either reduced or higher levels of dental caries experience in communities with low levels of mottled enamel. Researchers also had no reason to believe that patients selected where they lived according to their risk for dental caries. In that regard, these studies were randomized, and examiners were blinded. Despite the strengths of early studies of the efficacy of naturally occurring fluoride in community drinking http-//www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 17 of 41 10C water, the limitations of these studies make summarizing the quality of evidence on community water fluoridation as Grade I inappropriate (Tzibie 1). The quality of evidence from studies on the effectiveness of adjusting fluoride concentration in community water to optimal levels is Grade II -1. Research limitations are counterbalanced by broadly similar results from numerous well - conducted field studies by other investigators that included thousands of persons throughout the world (256,257). School Water Fluoridation Field trials on the effect of school water fluoridation were not blindly conducted and had no concurrent controls (118). Thus, the quality of evidence for this modality is Grade II -3. Fluoride Toothpaste Studies that have demonstrated the efficacy of fluoride toothpaste in preventing and controlling dental caries include all of the essential features of well- conducted clinical trials. These include randomized groups, double -blind designs, placebo controls, and meticulous procedural protocols. Taken together, the trials on fluoride toothpaste provide solid evidence that fluoride is efficacious in controlling caries (144). The quality of evidence for toothpaste is Grade I. Fluoride Mouthrinse Early studies of the efficacy of fluoride mouthrinse in reducing dental caries experience were randomized clinical trials (184,185) or studies that used historical control groups rather than concurrent control groups (186 -189). The quality of evidence for fluoride mouthrinse is Grade I. Dietary Fluoride Supplements The only randomized controlled trial to assess fluoride supplements taken by pregnant women provides Grade I evidence of no benefit for their children. Many studies of the effectiveness of fluoride supplements in preventing dental caries among children aged <6 years have been flawed in design and conduct. Problems included self - selection into test and control groups, absence of concurrent controls, high attrition rates, and nonblinded examiners. Because of these flaws, the quality of evidence to support use of fluoride supplements by children aged <6 years is Grade H -3. The well- conducted randomized clinical trials on the effects of fluoride supplements on dental caries among children aged 6--16 years in programs conducted in schools provide Grade I evidence. Fluoride Gel The quality of evidence for using fluoride gel to prevent and control dental caries in children is Grade I. However, data were gathered when dental caries was more prevalent and severe than today. Subjects in earlier studies were probably more representative of persons who now would be characterized as being at high risk for caries. Fluoride Varnish The quality of evidence for the efficacy of high - concentration fluoride varnish in preventing and controlling dental caries in children is Grade I. Although the randomized controlled clinical studies that established Grade I evidence were conducted in Europe, U.S. results should be the same. COST - EFFECTIVENESS OF FLUORIDE MODALITIES http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 18 of 41 10C Of Documented effectiveness is the most basic requirement for providing a health -care service and an important prerequisite for preventive services (e.g., caries - preventive modalities). However, effectiveness alone is not a sufficient reason to initiate a service. Other factors, including cost, must be considered (254). A modality is more cost - effective when deemed a less expensive way, from among competing alternatives, of meeting a stated objective (258). In public health planning, determination of the most cost - effective alternative for prevention is essential to using scarce resources efficiently. Dental - insurance carriers are also interested in cost - effectiveness so they can help purchasers use funds efficiently. Because half of dental expenditures are out of pocket (259), this topic interests patients and their dentists as well. Potential improvement to quality of life is also a consideration. The contribution of a healthy dentition to quality of life at any age has not been quantified, but is probably valued by most persons. Although solid data on the cost - effectiveness of fluoride modalities alone and in combination are needed, this information is scarce. In 1989, the Cost Effectiveness of Caries Prevention in Dental Public Health workshop, which was attended by health economists, epidemiologists, and dental public health professionals, attempted to assess the cost - effectiveness of caries - preventive approaches available in the United States (260). All other things being equal, fluoride modalities are most cost - effective for persons at high risk for dental caries. Because persons at low risk develop little dental caries, limited benefit is gained by adding caries - preventive modalities to water fluoridation and fluoride toothpaste, even those demonstrated to be effective among populations at high risk. Members of the CDC work group reached consensus regarding the populations for which each modality would be expected to have the necessary level of cost - effectiveness to warrant its use. Community Water Fluoridation Health economists at the 1989 workshop on cost - effectiveness of caries prevention calculated that the average annual cost of water fluoridation in the United States was $0.51 per person (range: $0.12 - 45.41) (260). In 1999 dollars, ** this cost would be $0.72 per person (range: $0.17 -- $7.62). Factors reported to influence the per capita cost included . • size of the community (the larger the population reached, the lower the per capita cost); . • number of fluoride injection points in the water supply system; . • amount and type of system feeder and monitoring equipment used; . • amount and type of fluoride chemical used, its price, and its costs of transportation and storage; and . • expertise of personnel at the water plant. When the effects of caries are repaired, the price of the restoration is based on the number of tooth surfaces affected. A tooth can have caries at >1 location (i.e., surface), so the number of surfaces saved is a more appropriate measure in calculating cost - effectiveness than the number of teeth with caries. The 1989 workshop participants concluded that water fluoridation is one of the few public health measures that results in true cost savings (i.e., the measure saves more money than it costs to operate); in the United States, water fluoridation cost an estimated average of $3.35 per carious surface saved ($4.71 in 1999 dollars * *) (260). Even under the least favorable assumptions in 1989 (i.e., cities with populations <10,000, higher operating costs, and effectiveness projected at the low end of the range), the cost of a carious surface saved because of community water fluoridation ranged from $8 to $12 ($11 -417 in 1999 dollars * *) (260), which is still lower than the fee for a one - surface restoration ($54 in 1995 or $65 in 1999 dollars * * *) (261). A Scottish study conducted in 1980 reported that community water fluoridation resulted in a 49% saving in dental treatment costs for children aged 4--5 years and a 54% saving for children aged 11 - -12 years (262). These savings were maintained even after the secular decline in the prevalence of dental caries was recognized (263). The effect of community water fluoridation on the costs of dental care for adults is less clear. This topic http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 10C Page 19 of 1 cannot be fully explored until the generations who grew up drinking optimally fluoridated water are older. School Water Fluoridation Costs for school water fluoridation are similar to those of any public water supply system serving a small population (i.e., <1,000 persons). In 1988, the average annual cost of school water fluoridation was $4.52 per student per year (range: $0.81 -- $9.72) (264). In 1999 dollars, "" this cost would be $6.37 per person (range: $1.14 -- $13.69). Use of this modality must be carefully weighed in the current environment of low caries prevalence, widespread use of fluoride toothpaste, and availability of other fluoride modalities that can be delivered in the school setting. Fluoride Toothpaste Fluoride toothpaste is widely available, no more expensive than nonfluoride toothpaste, and periodically improved. Use of a pea -sized amount (0.25 g) twice per day requires approximately two tubes of toothpaste per year, for an estimated annual cost of $6 - -$12, depending on brand, tube size, and retail source (265). Persons who brush and use toothpaste regularly to maintain periodontal health and prevent stained teeth and halitosis (i.e., bad breath) incur no additional cost for the caries - preventive benefit of fluoride in toothpaste. Because of its multiple benefits, most persons consider fluoride toothpaste a highly cost - effective caries - preventive modality. Fluoride Mouthrinse Public health programs of fluoride mouthrinsing have long been presumed to be cost - effective, especially when teachers can supervise weekly rinsing in classrooms at no direct cost to the program. In other programs, volunteers or hourly workers provide supervision. Under these circumstances, administrators of fluoride mouthrinsing programs have claimed annual program costs of approximately $1 per child ($1.41 in 1999 dollars * * * *) (264). This figure likely is an underestimate because indirect costs are not included (196,266). Fluoride mouthrinsing is a reasonable procedure for groups and persons at high risk for dental caries, but its cost - effectiveness as a universal, population -wide strategy in the modern era of widespread fluoride exposure is questionable (267). Dietary Fluoride Supplements Dietary fluoride supplements prescribed to persons cost an estimated $37 per year. Fluoride supplements in school programs have direct costs of approximately $2.50 per child ($3.52 in 1999 dollars * * * *) for the tablet or lozenge (264); program administrative costs and considerations are similar to those in school mouthrinsing programs. Professionally Applied Fluoride Compounds High- concentration fluoride gel and varnish are effective in preventing dental caries, but because application requires professional expertise, they are inherently more expensive than self - applied methods (e.g., drinking fluoridated water or brushing with fluoride toothpaste). For groups and persons at low risk for dental caries, professionally applied methods are unlikely to be cost - effective (268,269). In the NPDDP study, prophylactic cleaning and gel application costs were $23 per year ($66 in 1999 dollars * * * * *) for semiannual applications, which prevented 0.03 - -0.26 decayed surfaces per year (196). A Swedish study claimed that fluoride varnish was cost - effective, but few supporting data were presented (270). Varnish might be cost - effective in Scandinavian school dental services, in which dental professionals regularly examine and treat each student, but the cost - effectiveness of fluoride varnish in public health programs in the United States remains http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 10 � P e 20 of 4 i undocumented. Whether fluoride varnish or gel would be most efficiently used in clinical programs targeting groups at high risk for dental caries or should be reserved for individual patients at high risk is unclear. Combinations of Fluoride Modalities Because the caries- preventive effects of a combination of fluoride modalities are only partially additive, estimates of the cost - effectiveness when adding a modality (e.g., fluoride mouthrinse for a group already drinking fluoridated water and using fluoride toothpaste) should take into account these smaller, incremental reductions in caries. This consideration is particularly relevant for groups and persons at low risk for caries (253). The scarcity of research on the costeffectiveness of combinations limits the ability to draw more detailed conclusions. RECOMMENDATIONS In developing the recommendations for specific fluoride modalities that address public health and clinical practice and self -care, the CDC work group considered the quality of evidence of each modality's effect on dental caries, its association with enamel fluorosis, and its cost - effectiveness. The strength of the recommendation for each fluoride modality was determined by the work group, which adapted a coding system used by the U.S. Preventive Services Task Force (Bow 22). The work group considered these factors when determining the population for which each recommendation applies ('Fable 4). The work group recognized that some recommendations can only be addressed by health -care industries or agencies and that additional research is required to resolve some questions regarding fluoride modalities. Before promoting a fluoride modality or combination of modalities, the dental -care or other health -care provider must consider a person's or group's risk for dental caries, current use of other fluoride sources, and potential for enamel fluorosis. Although these recommendations are based on assessments of caries risk as low or high, the health -care provider might also differentiate among patients at high risk and provide more intensive interventions as needed. Also, a risk category can change over time; the type and frequency of preventive interventions should be adjusted accordingly. Public Health and Clinical Practice Continue and Extend Fluoridation of Community Drinking Water Community water fluoridation is a safe, effective, and inexpensive way to prevent dental caries. This modality benefits persons in all age groups and of all SES, including those difficult to reach through other public health programs and private dental care. Community water fluoridation also is the most cost - effective way to prevent tooth decay among populations living in areas with adequate community water supply systems. Continuation of community water fluoridation for these populations and its adoption in additional U.S. communities are the foundation for sound caries - prevention programs. In contrast, the appropriateness of fluoridating stand -alone water systems that supply individual schools is limited. Widespread use of fluoride toothpaste, availability of other fluoride modalities that can be delivered in the school setting, and the current environment of low caries prevalence limit the appropriateness of fluoridating school drinking water at 4.5 times the optimal concentration for community drinking water. Decisions to initiate or continue school fluoridation programs should be based on an assessment of present caries risk in the target school(s), alternative preventive modalities that might be available, and periodic evaluation of program effectiveness. Counsel Parents and Caregivers Regarding Use of Fluoride Toothpaste by Young Children, Especially http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 21 of 41 Those Aged <2 Years 10 C 1 Fluoride toothpaste is a cost - effective way to reduce the prevalence of dental caries. However, for children aged <6 years, especially those aged <2 years, an increased risk for enamel fluorosis exists because of inadequately developed control of the swallowing reflex. Parents or caregivers should be counseled regarding selfcare recommendations for toothpaste use for young children (i.e., limit the child's toothbrushing to <2 times a day, apply a peasized amount to the toothbrush, supervise toothbrushing, and encourage the child to spit out excess toothpaste). For children aged <2 years, the dentist or other healthcare provider should consider the fluoride level in the community drinking water, other sources of fluoride, and factors likely to affect susceptibility to dental caries when weighing the risk and benefits of using fluoride toothpaste. Target Mouthrinsing to Persons at High Risk Because fluoride mouthrinse has resulted in only limited reductions in caries experience among schoolchildren, especially as their exposure to other sources of fluoride has increased, its use should be targeted to groups and persons at high risk for caries (see Risk for Dental Caries). Children aged <6 years should not use fluoride mouthrinse without consultation with a dentist or other health -care provider because enamel fluorosis could occur if such mouthrinses are repeatedly swallowed. Judiciously Prescribe Fluoride Supplements Fluoride supplements can be prescribed for children at high risk for dental caries and whose primary drinking water has a low fluoride concentration. For children aged <6 years, the dentist, physician, or other health -care provider should weigh the risk for caries without fluoride supplements, the caries prevention offered by supplements, and the potential for enamel fluorosis. Consideration of the child's other sources of fluoride, especially drinking water, is essential in determining this balance. Parents and caregivers should be informed of both the benefit of protection against dental caries and the possibility of enamel fluorosis. The prescription dosage of fluoride supplements should be consistent with the schedule established by ADA, AAPD, and AAP. Supplements can be prescribed for persons as appropriate or used in school -based programs. When practical, supplements should be prescribed as chewable tablets or lozenges to maximize the topical effects of fluoride. Apply High - Concentration Fluoride Products to Persons at High Risk for Dental Caries High- concentration fluoride products can play an important role in preventing and controlling dental caries among groups and persons at high risk. Dentists and other health -care providers must consider the risk status and age of the patient to determine the appropriate intensity of treatment. Routine use of professionally applied fluoride gel or foam likely provides little benefit to persons not at high risk for dental caries, especially those who drink fluoridated water and brush daily with fluoride toothpaste. If FDA approves use of fluoride varnish to prevent and control dental caries, its indications for use will be similar to those of fluoride gel. Such varnishes have practical advantages for children aged <6 years at high ri sk. Self -Care Know the Fluoride Concentration in the Primary Source of Drinking Water All persons should know whether the fluoride concentration in their primary source of drinking water is below http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 ORecommendations for Using Fluoride to Prevent and Control Dental Caries in the United States a 22 of 4 optimal, optimal, or above optimal. This knowledge is the basis for all individual and professional decisions regarding use of other fluoride modalities (e.g., mouthrinse or supplements). Parents and caregivers of children, especially children aged <6 years, must know the fluoride concentration in their child's drinking water when considering whether to alter the child's fluoride intake. For example, in nonfluoridated areas where the natural fluoride concentration is below optimal, fluoride supplements might be considered, whereas in areas where the natural fluoride concentration is >2 ppm, children should use alternative sources of drinking water. Knowledge of the water's fluoride concentration is also key in public policy discussions regarding community water fluoridation. Frequently Use Small Amounts of Fluoride All persons should receive frequent exposure to small amounts of fluoride, which minimizes dental caries by inhibiting demineralization of tooth enamel and facilitating tooth remineralization. This exposure can be readily accomplished by drinking water with an optimal fluoride concentration and brushing with a fluoride toothpaste twice daily. Supervise Use of Fluoride Toothpaste Among Children Aged <6 Years Children's teeth should be cleaned daily from the time the teeth erupt in the mouth. Parents and caregivers should consult a dentist or other health -care provider before introducing a child aged <2 years to fluoride toothpaste. Parents and caregivers of children aged <6 years who use fluoride toothpaste should follow the directions on the label, place no more than a pea -sized amount (0.25 g) of toothpaste on the toothbrush, brush the child's teeth (recommended particularly for preschool -aged children) or supervise the toothbrushing, and encourage the child to spit excess toothpaste into the sink to minimize the amount swallowed. Indiscriminate use can result in inadvertent swallowing of more fluoride than is recommended. Consider Additional Measures for Persons at High Risk for Dental Caries Persons at high risk for dental caries might require additional fluoride or other preventive measures to reduce development of caries. This additional fluoride can come from daily use of another fluoride product at home or from professionally applied, topical fluoride products. Other preventive measures might include dental sealants and targeted antimicrobial therapies. Parents and caregivers should not provide additional fluoride to children aged <6 years without consulting a dentist or other health -care provider regarding the associated benefits and potential for enamel fluorosis. Persons should seek professional advice regarding their risk status or that of their children. Use an Alternative Source of Water for Children Aged <8 Years Whose Primary Drinking Water Contains >2 ppm Fluoride In some regions in the United States, community water supply systems and home wells contain a natural concentration of fluoride >2 ppm. At this concentration, children aged <8 years are at increased risk for developing enamel fluorosis, including the moderate and severe forms, and should have an alternative source of drinking water, preferably one containing fluoride at an optimal concentration. In areas where community water supply systems contain >2 ppm but <4 ppm fluoride, EPA requires that each household be notified annually of the desirability of using an alternative source of water for children aged <8 years. For families receiving water from home wells, testing is necessary to determine the natural fluoride concentration. Consumer Product Industries and Health Agencies http://www.cdc.gov/mmwr/preview/mmwrhtml/ff50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 23 of 41 10C 4 Label the Fluoride Concentration of Bottled Water Producers of bottled water should label the fluoride concentration of their products. Such labeling will allow consumers to make informed decisions and dentists, dental hygienists, and other health -care professionals to appropriately advise patients regarding fluoride intake and use of fluoride products. Promote Use of Small Amounts of Fluoride Toothpaste Among Children Aged <6 Years Labels and advertisements for fluoride toothpaste should promote use of a pea -sized amount (0.25 g) of toothpaste on a child -sized toothbrush for children aged <6 years. Efforts to educate parents and caregivers and to encourage supervised use of fluoride toothpaste among young children can reduce inadvertent swallowing of excess toothpaste. Develop a Low- Fluoride Toothpaste for Children Aged <6 Years Manufacturers are encouraged to develop a dentifrice for children aged <6 years that is effective in preventing dental caries but alleviates the risk for enamel fluorosis. A "child- strength" toothpaste with a fluoride concentration lower than current products could reduce the risk for cosmetic concerns associated with inadvertent swallowing of toothpaste. Collaborate to Educate Health -Care Professionals and the Public Professional health -care organizations, public health agencies, and suppliers of oral -care products should collaborate to educate health -care professionals and trainees and the public regarding the recommendations in this report. Broad collaborative efforts to educate health -care professionals and the public and to encourage behavior change can promote improved, coordinated use of fluoride modalities. Further Research Continue Metabolic Studies of Fluoride Metabolic studies with animals and humans to determine the influence of environmental, physiological, and pathological conditions on the pharmacokinetics and effects of fluoride should continue. Research in these areas will enhance the knowledge base concerning fluoride use, thereby resulting in more effective and efficient use of fluoride. Identify Biomarkers of Fluoride As an alternative to direct fluoride intake measurement, biomarkers (i.e., distinct biological indicators) should be identified to estimate a person's fluoride intake and the amount of fluoride in the body. Identification of such biomarkers could allow more efficient research. Reevaluate the Method of Determining Optimal Fluoride Concentration of Community Drinking Water The current method of determining the optimal concentration of fluoride in community drinking water, which depends on the average maximum annual ambient air temperature, should be reevaluated because of the social and environmental changes that have occurred since it was adopted in 1962. Research into current consumption patterns of water, processed beverages, and processed foods is also needed. Such research will either validate the current method for determining optimal fluoride concentration in community drinking water or indicate improved methods. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 24 of 41 1 p C Evaluate the Effect of Fluoride Mouthrinse, Fluoride Supplements, and Other Fluoride Modalities on Dental Caries Additional clinical trials are needed to evaluate the current effect of fluoride mouthrinse, supplements, and other modalities on dental caries both individually and in combination. Cohorts of particular interest are groups and persons at high risk for dental caries, including older adults (i.e., those aged >50 years). Such research, as well as studies to determine the effects of new fluoride modalities and various combinations among groups and persons at high risk, could lead to more effective and efficient use of these interventions. Study the Current Cost - Effectiveness of Fluoride Modalities The increasing availability of multiple fluoride modalities and the lower caries prevalence in the United States indicate a need for current cost - effectiveness studies of fluoride modalities, especially logical combinations of regimens in populations with different caries risks. Such research will allow both more efficient use of resources and a better understanding of the additive effects of combined modalities. Conduct Descriptive and Analytic Epidemiologic Studies Descriptive and analytic epidemiologic studies should be conducted to determine the association between dental caries and fluoride exposure from several sources, as well as the current role of community water fluoridation in preventing coronal and root caries among adults. Studies should assess the effect of interruption or discontinuation of water fluoridation; the prevalence of fluorosis associated with different patterns of fluoride use and intake among various populations; and the relationship between objectively measured fluorosis and the aesthetic perceptions of persons, parents, and dentists and other health -care professionals. Studies are needed to refine methods of caries risk assessment. As appropriate, studies should use national, state, and local data. Research addressing these questions will improve understanding of the relationships between fluoride modalities and the benefits and unintended effects of their use. Identify Effective Strategies to Promote Adoption of Recommendations for Using Fluoride Effective strategies should be identified to promote adherence by parents, caregivers, children, adults, and health -care providers to recommendations regarding fluoride use. Such research could result in more effective behavior change, more efficient use of resources, improved caries prevention, and less enamel fluorosis. CONCLUSION When used appropriately, fluoride is a safe and effective agent that can be used to prevent and control dental caries. Fluoride has contributed profoundly to the improved dental health of persons in the United States and other countries. Fluoride is needed regularly throughout life to protect teeth against tooth decay. To ensure additional gains in oral health, water fluoridation should be extended to additional communities, and fluoride toothpaste should be used widely. Adoption of these and other recommendations in this report could lead to considerable savings in public and private resources without compromising fluoride's substantial benefit of improved dental health. References 1. Bratthall D, Hansel Petersson G, Sundberg H. Reasons for the caries decline: what do the experts believe? Eur J Oral Sci 1996;104:416 - -22. 2. 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Caries - inhibiting effects of different modes of Duraphat varnish reapplication: a 3 -year radiographic study. Caries Res 1991 ;25:70 - -3. 250. Skold L, Sundquist B, Eriksson B, Edeland C. Four -year study of caries inhibition of intensive Duraphat application in 11 - -15- year -old children. Community Dent Oral Epidemiol 1994;22:8 - -12. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United Stat1 O C Page 3541 251. Adriaens ML, Dermaut LR, Verbeeck RMH. The use of 'Fluor Protector,' a fluoride varnish, as a caries prevention method under orthodontic molar bands. Eur J Orthod 1990;12:316 - -9. 252. Peyron M, Matsson L, Birkhed D. Progression of approximal caries in primary molars and the effect of Duraphat treatment. Scand J Dent Res 1992 ;100:314 - -8. 253. Marthaler TM. Cariostatic efficacy of the combined use of fluorides. J Dent Res 1990 ;69(special issue): 797--800. 254. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Alexandria, VA: International Medical Publishing, 1996. 255. McKay FS. Relation of mottled enamel to caries. J Am Dent Assoc 1928;15:1429 - -37. 256. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Effects of lifelong consumption of fluoridated water or use of fluoride supplements on dental caries prevalence. Community Dent Oral Epidemiol 1995;23:20 - -4. 257. Murray JJ, Rugg -Gunn AJ. Fluorides in caries prevention. 2nd ed. Boston, MA: Wright -PSG, 1982. (Dental practitioner handbook no. 20). 258. Warner KE, Luce BR. Cost - benefit and cost - effectiveness analysis in health care: principles, practice, and potential. Ann Arbor, Ml: Health Administration Press, 1982. 259. Manski RJ, Moeller JF, Maas WR. Dental services: use, expenditures and sources of payment, 1987. J Am Dent Assoc 1999;130:500 - -8. 260. Burt BA, ed. Proceedings for the workshop: Cost - effectiveness of caries prevention in dental public health, Ann Arbor, Michigan, May 17 - -19, 1989. J Public Health Dent 1989;49(special issue):331 - -7. 261. Brown LJ, Lazar V. Dental procedure fees 1975 through 1995: how much have they changed? J Am Dent Assoc 1998;129:1291 - -5. 262. Downer MC, Blinkhorn AS, Attwood D. Effect of fluoridation on the cost of dental treatment among urban Scottish schoolchildren. Community Dent Oral Epidemiol 1981 ;9:112 - -6. 263. Attwood D, Blinkhom AS. Reassessment of the effect of fluoridation on cost of dental treatment among Scottish schoolchildren. Community Dent Oral Epidemiol 1989;17:79 - -82. 264. Garcia Al. Caries incidence and costs of prevention programs. J Public Health Dent 1989:49(special issue):259 - -71. 265. Anonymous. Which toothpaste is right for you? Consumer Reports 1998;August:11 -4. 266. Doherty NJG, Brunelle JA, Miller AJ, Li S -H. Costs of school -based mouthrinsing in 14 demonstration programs in USA. Community Dent Oral Epidemiol 1984;12:35 - -8. 267. Leverett DH. Effectiveness of mouthrinsing with fluoride solutions in preventing coronal and root caries. J Public Health Dent 1989;49(special issue):310 - -6. 268. van Rijkom HM, Truin GJ, van 't Hof MA. A meta - analysis of clinical studies on the caries - inhibiting effect of fluoride gel treatment. Caries Res 1998;32:83 - -92. 269. Eklund SA, Pittman JL, Heller KE. Professionally applied topical fluoride and restorative care in insured children. J Public Health Dent 2000;60:33 - -8. 270. Petersson LG, Westerberg 1. Intensive fluoride varnish program in Swedish adolescents: economic assessment of a 7 -year follow -up study on proximal caries incidence. Caries Resl994;28:59 - -63. *For this report, the term "caries experience" is used to mean the sum of filled and unfilled cavities, along with any missing teeth resulting from tooth decay. * *US$ 1988 converted to US$ 1999 using the Consumer Price Index for All Urban Customers (CPI - Urban) (all items). More information is available at the U.S. Department of Labor, Bureau of Labor Statistics website at < http : / /stats.bls.gov /cpihome.htm >. Accessed June 25, 2001. * * *US$ 1995 converted to US$ 1999 using CPI -Urban (dental services). More information is available at the U.S. Department of Labor, Bureau of Labor Statistics website at <http:/ /stats.bls.gov /cpihome.htm >. Accessed June 25, 2001. * * * *US$ 1988 converted to US$ 1999 using CPI -Urban (all items). More information is available at the U.S. Department of Labor, Bureau of Labor Statistics website at < http : / /stats.bls.gov /cpihome.htm >. Accessed June 25, 2001. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 0 �aPge 36,ofiq *****US$ 1981 converted to US$ 1999 using CPI-Urban (dental services). More information is available at the U.S. Department of Labor, Bureau of Labor Statistics website at <http://stats.bls.gov/cpihome.htm>. Accessed June 25, 2001. Table I TABLE 1. Recommended dietary fluoride supplement* schedule Sodiumt fluoride 12,2 mg sodium fluotide contains I rnq fluoride ion). 1,0 parts per inillion (plam) 1 rrifilL. Sources: Meskin LH, ed. Caries diagnosis and risk assessrnenl: a feview of preventive strategies and rnanagernent. J Am Dent Assoc 1995,126isuppi)IS-24S. American Academy of Pediatric DenjiStry SpfftiFil iSgUe! reference manual 1994-95, Pecliair Dent 1995;16(special issu0:1-96. American Academy of Pediatrics Committee on Nutrition, Fluoride supplementation for children. inietirn policy recom rn endat ions, Pediatrics 1995,-95.777. RetUrn t0 t0p, Figure I FIGURE 1. The demineralization and rernineralization processes lead to remineralized enamel crystals with surfaces rich in fluoride and lower in solubility Demineralization Fluoride concentration in community drinking water' Age <03 ppm 0.3-0.► ppm >0.6 PPM 0-6 rnonths None None None 6 months-3 years 0.25 rnq/day None None 3-6 years 0.50 mg/day 0,25 nig/day None 6-16 years 1.0 ni 9.1da y 0.50 nigiday None Sodiumt fluoride 12,2 mg sodium fluotide contains I rnq fluoride ion). 1,0 parts per inillion (plam) 1 rrifilL. Sources: Meskin LH, ed. Caries diagnosis and risk assessrnenl: a feview of preventive strategies and rnanagernent. J Am Dent Assoc 1995,126isuppi)IS-24S. American Academy of Pediatric DenjiStry SpfftiFil iSgUe! reference manual 1994-95, Pecliair Dent 1995;16(special issu0:1-96. American Academy of Pediatrics Committee on Nutrition, Fluoride supplementation for children. inietirn policy recom rn endat ions, Pediatrics 1995,-95.777. RetUrn t0 t0p, Figure I FIGURE 1. The demineralization and rernineralization processes lead to remineralized enamel crystals with surfaces rich in fluoride and lower in solubility Demineralization Source. Adapted frorn Featherstone JDB, Pi'eventioa and reversal of dental caries: role of low level fluoride, Community Dent Oral Epidemiol 1999,27:31-40. Reprinted with permission frorn Munksgaard triternational Publishers Ltd., Copenhagen, Denmark, Return _to tU)). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Amd CAQMMI Ae -4. Rorninerafization Gak*un Source. Adapted frorn Featherstone JDB, Pi'eventioa and reversal of dental caries: role of low level fluoride, Community Dent Oral Epidemiol 1999,27:31-40. Reprinted with permission frorn Munksgaard triternational Publishers Ltd., Copenhagen, Denmark, Return _to tU)). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 37 of 41 Table 2 TABLE 2. Recommenced total dietary fluoride intake 10C 0 Age Reference we aht" Adeaivate intake Tolerable uottaer int8ke' kg lb mg /day mglday U -6 months 7 16 0.01 0.7 6 -12 months 9 20 0.5 0.9 1 -3 years 13 29 03 1.3 4--8 years 22 4$ 1.1 2.2 >9 years 40 -I6 88 -166 2.0-M 10.0 �+alues based ora data collected during 1988 -1994 as p {irl: of the third National Health and Nuirition Examination Saurvey. ' Intake that rrraxinially reducer occurrence of dental caries without causing unwanted situ: effects; including moderate enarnel fluorosis. Highest level of nutrient intake that is likely to pose no risks for adverse health effects in ahmost all persons. Source: Adapted from Institute of Medicine, Fluoride. in: Dietary reference intakes for calclum, phosphorus, rnagnesiwn, vitamin D, and fluoride. Washington, DC: National Academy Press, 1997,188-313. Return tom tot). Figure 2 FIGURE 2. Percentage of state populations with access to fluoridated water through public water systems _ Source: CDC, unpublished data, 2000. Return to tcl',. NH N.j MA VT T DE MD l DC http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 10C Table 3 TABLE 3. U.S. Food and Drug Administration (FDA 1 fluoride requirernents'for bottled water par.kaged in the United Mates Maximum fluoride concentration (mgfL) allowed in bottled water Annual average of maximum daily air No fluoride added Fluoride aged to temperature (F} where the battled water to bottled water bottled water is sold at retail X53.7 2.4 1.7 53.8-58.3 2.2 1.5 58.4-63.8 2 1.3 63..9 -70.6 1.:6 1.2 70.7 -79.2 1.6 1 79.3 -90.5 144 0.8 Note: FDA regulations require that fluoride be listed on the label only if the bottler adds fluoride (luring processing; the battler is nott required to list the fluoride conOCIAtratioi), which rriight or might riot be optirnal.. FDA tines not allow imported bottled water with no added fluoride to contain >1.4 trig fluoride,IL or imported 50ttled water with added fluoride to contain >0.8 rnq fluoride /L. Source: US Department of Health and Hurnan Services, Fat i and Drtgj Administration. 21 CFR part 165.110. Bottled water. Federal ReUister 1995,60. 57124 -30. Return to t(>p Table 4 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm Page 3 8 of 41 0 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page 39 of 41 10C TABLE 4. Quality of evidence, strength of recommendation, and target population of recommendation foreach fluoride modality to prevent and control dental caries Quality Strength of evidence of recommendation Target Modality* (grade) (code) population' Ce nimunity water fluoridation 11 -1 A All areas. School water fluoridation 11-3 C Rural, nonftuoridated areas Fluoride toothpaste l A All persons Fluoride mouthrinse I A High risk Fluoride supplements Pregnant women I E None Children aged <6 yeacs 11 -3 C High risk Children aged 616 years 1 to High risk Persons aged >16 years C High risk Fluoride gel l A High risk Fluoride varnish I A High risk Modalities are assumed to be used as directed in terms of dosage and age of user. 'Quality of evidence tot, targeting some modalities to persons at high risk is grade 113 (i.e., representing the opinion of tespected authorities) and is is Cased on considerations of cost - effectiveness that were not included in the studies establishing efficacy or effectiveness. Populations believed to he at iocrea sect risk foF dental caries are those with low socioeco- nomic status or low levels of parental education,. those who do not seek regular dermal care, and these without dental insurance or access to dental services. Individual factors that p:os,sibly increase risk include active dental Caries; a history of high caries experience its older siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection with cariogenic bacteria; irrrpaired agility to maintain oral hygiene; malfor med enamel or dentin, reduced salivary flow because of €viedications, radiation treatmerit, or disease; leer salivary buffering rapacity (i.e., decreased ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic: appliances, or dental prostheses. Risk can in- crease if any of these factors are corr,bined with dietary practices conducive to dental caries ti.e., frequent consumption of refined carbohydrates). Risk decreases with adequate expo- sure to fluoride. { No published studies confirtTi the effectiveness of fluoride supplements in controlling den- tal caries among persons aged >16 years. Return to tor- Box 1 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 106 age 40 A I uux Z. ur"no system usea tor oetermining nm quairty of evioence ror a nuortae mouairry Grade Criteria I Evidence obtained from one or n-sore properly conducted randornized Clinical trials 0.,P,, One using concurrent controls, double-blind design, placebos, valid and reliable measurements, and well-controlled study protocols). 11-1 Evidence obtained from one or- more controlled clinical trials without randomization (i.e., one using systematic subject selection, some type of concurrent controls, valid and reliable measurements, and well- controlled study protocols). 11-2 Evidence obtained front one or more well- designed cohort Or case-control analytic studies, preferably horn more than one center or research group. 11-3 Evidence obtained from cross-sectional comparisons between times and places: studies with historical controls, or dramatic results in uncontrolled experiments (e.g., the results of the introduction of penicillin treatment in the 1940s). Opinions of respected authorities on the basis of clinical experience, desc6plive studies or case reports, or reports of expert cornmittees. Source: US Preventive Services Task Force. Guide to clinical preventive services- 2nd ed. Alexandria, VA: International Medical Publishing, 1996. IZCtLirn to Lol). Box 2 BOX 2. Coding system used to classify recommendations for use of specific fluoride modalities to control dental caries Code Criteria A Good evidence to support the use of the modality, B Fair evidence to support the use of the iytodality. C Lack of evidence to develop a specific recommendation (i.e., the rnodafitv has not been adequately tested) or mixed evidence (i.e., sortie; studies support the use of the modality and some oppose D Fair eviderw.e to reject the use of the modality. E Good evidence to reject the use of the modality. Source- US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Alexandria, VA: International Medical Publishing, 1996. f-US$ 1981 converted to US$ 1999 using g CPI-Urban (dental services). More information is available at the U.S. Department of Labor, Bureau of Labor Statistics website at <http,// ilat,s.bls.gov,,'c.pitiom.e.htrri-.-. Accessed June 25, 2001. Return to ji)p. Disclaimer All MAfWR HT IL 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 ADJWR 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), http-://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Page f 41 10C 4 Washington, DC 20402 -9371; telephone: (202) 512 -1800. Contact GPO for current prices. "Questions or messages regarding errors in formatting should be addressed to Page converted: 8/22/2001 HOME I ABOUT MMWR I MMWR SEARCH I DOWNLOADS I RSS I CONTACT POLICY j DISCLAIMER I ACCESSIBILITY SAW CRsMICLLTMICR-PEOPLE' Morbidity and Mortality Weekly Report �10 Department of Health Centers for Disease Control and Prevention �.JI�I['V •(V and Human Services 1600 Clifton Rd, MailStop E -90, Atlanta, GA 30333, :..��m m aoc +a, U.S.A This page last reviewed 8/22/2001 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr50l4al.htm 9/6/2011 Why I changed my mind about water fluoridation 1 0 V Page 0 11 John C01C uhoiin^ .. 1997 ['ni\ersityof Chica �_,o Press Former Advocate To explain how I came to change my opinion about water fluoridation, I must go back to when I was an ardent advocate of the procedure. I now realize that I had learned, in my training in dentistry, only one side of the scientific controversy over fluoridation. I had been taught, and believed, that there was really no scientific case against fluoridation, and that only misinformed lay people and a few crackpot professionals were foolish enough to oppose it recall how, after I had been elected to a local government in Auckland (New Zealand's largest city, where I practised dentistry for many years and where I eventually became the Principal Dental Officer) I had fiercely — and, I now regret, rather arrogantly — poured scorn on another Council member (a lay person who had heard and accepted the case against fluoridation) and persuaded the Mayor and majority of my fellow councillors to agree to fluoridation of our water supply. A few years later, when I had become the city's Principal Dental Officer, I published a paper in the New Zealand Dental Journal that reported how children's tooth decay had declined in the city following fluoridation of its water, to which I attributed the decline, pointing out that the greatest benefit appeared to be in low - income areas [1]. My duties as a public servant included supervision of the city's school dental clinics, which were part of a national School Dental Service which provided regular six - monthly dental treatment, with strictly enforced uniform diagnostic standards, to almost all (98 percent) school children up to the age of 12 or 13 years. I thus had access to treatment records, and therefore tooth decay rates, of virtually all the city's children. In the study I claimed that such treatment statistics "provide a valid measure of the dental health of our child population" [1]. That claim was accepted by my professional colleagues, and the study is cited in the official history of the New Zealand Dental Association [2]. INFORMATION CONFIDED I was so articulate and successful in my support of water fluoridation that my public service superiors in our capital city, Wellington, approached me and asked me to make fluoridation the subject of a world study tour in 1980 — after which I would become their expert on fluoridation and lead a campaign to promote fluoridation in those parts of New Zealand which had resisted having fluoride put into their drinking water. Before I left on the tour my superiors confided to me that they were worried about some new evidence which had become available: information they had collected on the amount of treatment children were receiving in our school dental clinics seemed to show that tooth decay was declining just as much in places in New Zealand where fluoride had not been added to the water supply. But they felt sure that, when they had collected more detailed information, on all children (especially the oldest treated, 12 -13 year age group) from all fluoridated and all nonfluoridated places [3] — information which they would start to collect while was I away on my tour — it would reveal that the teeth were better in the fluoridated places: not the 50 to 60 percent difference which we had always claimed resulted from fluoridation, but a significant difference nonetheless. They thought that the decline in tooth decay in the nonfluoridated places must have resulted from the use of fluoride toothpastes and fluoride supplements, and from fluoride applications to the children's teeth in dental clinics, which we had started at the same time as fluoridation. Being a keen fluoridationist, I readily accepted their explanation. Previously, of course, we had assured the public that the only really effective way to http://www.fluoride-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation Page 2 of 11 10C 14 reduce tooth decay was to add fluoride to the water supply. WORLD STUDY TOUR My world study tour took me to North America, Britain, Europe, Asia, and Australia [4]. In the United States I discussed fluoridation with Ernest Newbrun in San Francisco, Brian Burt in Ann Arbor, dental scientists and officials like John Small in Bethesda near Washington, DC, and others at the Centers for Disease Control in Atlanta. I then proceeded to Britain, where I met Michael Lennon, John Beale, Andrew Rugg -Gunn, and Neil Jenkins, as well as many other scientists and public health officials in Britain and Europe. Although I visited only pro- fluoridation research centers and scientists, I came across the same situation which concerned my superiors in New Zealand. Tooth decay was declining without water fluoridation. Again I was assured, however, that more extensive and thorough surveys would show that fluoridation was the most effective and efficient way to reduce tooth decay. Such large -scale surveys, on very large numbers of children, were nearing completion in the United States, and the authorities conducting them promised to send me the results. LESSON FROM HISTORY I now realize that what my colleagues and I were doing was what the history of science shows all professionals do when their pet theory is confronted by disconcerting new evidence: they bend over backwards to explain away the new evidence. They try very hard to keep their theory intact — especially so if their own professional reputations depend on maintaining that theory. (Some time after I graduated in dentistry almost half a century ago, I also graduated in history studies, my special interest being the history of science — which may partly explain my re- examination of the fluoridation theory ahead of many of my fellow dentists.) So I returned from my study tour reinforced in my pro - fluoridation beliefs by these reassurances from fluoridationists around the world. I expounded these beliefs to my superiors, and was duly appointed chairman of a national "Fluoridation Promotion Committee." I was instructed to inform the public, and my fellow professionals, that water fluoridation resulted in better children's teeth, when compared with places with no fluoridation. Surprise: Teeth Better Without Fluoridation? Before complying, I looked at the new dental statistics that had been collected while I was away for my own Health District, Auckland. These were for all children attending school dental clinics — virtually the entire child population of Auckland. To my surprise, they showed that fewer fillings had been required in the nonfluoridated part of my district than in the fluoridated part. When I obtained the same statistics from the districts to the north and south of mine — that is, from "Greater Auckland," which contains a quarter of New Zealand's population — the picture was the sameEtooth decay had declined, but there was virtually no difference in tooth decay rates between the fluoridated and non fluoridated places. In fact, teeth were slightly better in the nonfluoridated areas-1I wondered why I had not been sent the statistics for the rest of New Zealand. When I requested them, they were sent to me with a warning that they were not to be made public. Those for 1981 showed that in most Health Districts the percentage of 12- and 13- year -old children who were free of tooth decay - that is, had perfect teeth - was greater in the non - fluoridated part of the district. Eventually the information was published [4]. Over the next few years these treatment statistics, collected for all children, showed that, when similar fluoridated and non - fluoridated areas were compared, child dental health continued to be slightly better in the non - fluoridated areas [5,6]. My professional colleagues, still strongly defensive of fluoridation, now claimed that treatment statistics did not provide a valid measure of child dental health, thus reversing their previous acceptance of such a measure when it had appeared to support fluoridation. I did not carry out the instruction to tell people that teeth were better in the fluoridated areas. Instead, I wrote to my http://www.fluoiide-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation 10 C Pal of 11 American colleagues and asked them for the results of the large -scale surveys they had carried out there. I did not receive an answer. Some years later, Dr John Yiamouyiannis obtained the results by then collected by resorting to the U.S. Freedom of Information Act, which compelled the authorities to release them. The surveys showed that there is little or no differences in tooth decay rates between fluoridated and nonfluoridated places throughout America [7]. Another publication using the same database, apparently intended to counter that finding, reported that when a more precise measurement of decay was used, a small benefit from fluoridation was shown (20 percent fewer decayed tooth surfaces, which is really less than one cavity per child) [8]. Serious errors in that report, acknowledged but not corrected, have been pointed out, including a lack of statistical analysis and a failure to report the percentages of decay - free children in the fluoridated and nonfluoridated areas [7]. Other large -scale surveys from United States, from Missouri and Arizona, have since revealed the same picture: no real benefit to teeth from fluoride in drinking water [9, 10]. For example, Professor Steelink in Tucson, AZ, obtained information on the dental status of all schoolchildren – 26,000 of them – as well as information on the fluoride content of Tucson water [10]. He found: "When we plotted the incidence of tooth decay versus fluoride content in a child's neighborhood drinking water, a positive correlation was revealed. In other words, the more fluoride a child drank, the more cavities appeared in the teeth" [11]. From other lands — Australia, Britain, Canada, Sri Lanka, Greece, Malta, Spain, Hungary, and India — a similar situation has been revealed: either little or no relation between water fluoride and tooth decay, or a positive one (more fluoride, more decay) [12 -17]. For example, over 30 years Professor Teotia and his team in India have examined the teeth of some 400,000 children. They found that tooth decay increases as fluoride intake increases. Tooth decay, they decided, results from a deficiency of calcium and an excess of fluoride [17]. CAUSE OF DECLINE IN TOOTH DECAY At first I thought, with my colleagues, that other uses of fluoride must have been the main cause of the decline in tooth decay throughout the western world. But what came to worry me about that argument was the fact that, in the nonfluoridated part of my city, where decay had also declined dramatically, very few children used fluoride toothpaste, many had not received fluoride applications to their teeth, and hardly any had been given fluoride tablets. So I obtained the national figures on tooth decay rates of five- year -olds from our dental clinics which had served large numbers of these children from the 1930s on [18]. Liel �Iiow that tooth dec_liad started to decline welt befo re we had started to use tluondes Li i Also, the decline has continued after all children had received fluoride all their lives, so the continuing decline could not be because of fluoride. The fewer figures available for older children are consistent with the above pattern of decline [18]. So fluorides, while possibly contributing, could not be the main cause of the reduction in tooth decay. So what did cause this decline, which we find in most industrialized countries? I do not know the answer for sure, but we do know that after the second world war there was a rise in the standard of living of many people. In my country there has been a tremendous increase in the consumption of fresh fruit and vegetables since the 1930s, assisted by the introduction of household refrigerators [19]. There has also been an eightfold increase in the consumption per head of cheese, which we now know has anti -decay properties [19, 20]. These nutritional changes, accompanied by a continuing decline in tooth decay, started before the introduction of fluorides. The influence of general nutrition in protection against tooth decay has been well described in the past [21], but is largely ignored by the fluoride enthusiasts, who insist that fluorides have been the main contributor to improved dental health. The increase in tooth decay in third -world countries, much of which has been attributed to worsening nutrition [22], lends support to the argument that improved nutrition in developed countries contributed to improved dental health. Flawed Studies http://www.fluoride-journal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation O C P44 of 11 The studies showing little if any benefit from fluoridation have been published since 1980. Are there contrary findings? Yes: many more studies, published in dental professional journals, claim that there is a benefit to teeth from water fluoride. An example is a recent study from New Zealand [23], carried out in the southernmost area of the country [23]. Throughout New Zealand there is a range of tooth decay rates, from very high to very low, occurring in both fluoridated and nonfluoridated areas. The same situation exists in other countries. What the pro - fluoride academics at our dental school did was to select from that southern area four communities: one nonfluoridated, two fluoridated, and another which had stopped fluoridation a few years earlier. Although information on decay rates in all these areas was available to them, from the school dental service, they chose for their study the one non - fluoridated community with the highest decay rate and two fluoridated ones with low decay rates, and compared these with the recently stopped fluoridated one, which happened to have medium decay rates (both before and after it had stopped fluoridation). The teeth of randomly selected samples of children from each community were examined. The chosen communities, of course, had not been randomly selected. The results, first published with much publicity in the news media, showed over 50 percent less tooth decay in the fluoridated communities, with the recently defluoridated town in a "middle" position (see left side �of Fig. 2). When I obtained the decay rates for all children in all the fluoridated and all the nonfluoridated areas in that part of New Zealand, as well as the decay rates for all children in the recently defluoridated town, they revealed that there are virtually no differences in tooth decay rates related to fluoridation 'see 0it side of Fig. 2).. When I confronted the authors with this information, they retorted that the results of their study were consistent with other studies. And of course it is true that many similar studies have been published in the dental professional literature. It is easy to see how the consistent results are obtained: an appropriate selection of the communities being compared. There is another factor: most pro - fluoridation studies (including this New Zealand one) were not "blind" — that is, the examiners knew which children received fluoride and which did not. Diagnosis of tooth decay is a very subjective exercise, and most of the examiners were keen fluoridationists, so it is easy to see how their bias could affect their results. It is just not possible to find a blind fluoridation study in which the fluoridated and nonfluoridated populations were similar and chosen randomly. EARLY FLAWED STUDIES One of the early fluoridation studies listed in the textbooks is a New Zealand one, the "Hastings Fluoridation Experiment" (the term "experiment" was later dropped because the locals objected to being experimented on) [24]. I obtained the Health Department's fluoridation files under my own country's "Official Information" legislation. They revealed how a fluoridation trial can, in effect, be rigged [25]. The school dentists in the area of the experiment were instructed to change their method of diagnosing tooth decay, so that they recorded much less decay after fluoridation began. Before the experiment they had filled (and classified as "decayed ") teeth with any small catch on the surface, before it had penetrated the outer enamel layer.After the experiment began, they filled (and classified as "decayed ") only teeth with cavities which penetrated the outer enamel layer. It is easy to see why a sudden drop in the numbers of "decayed and filled" teeth occurred. This change in method of diagnosis was not reported in any of the published accounts of the experiment. Another city, Napier, which was not fluoridated but had otherwise identical drinking water, was at first included in the experiment as an "ideal control" — to show how tooth decay did not decline the same as in fluoridated Hastings. But when tooth decay actually declined more in the non- fluoridated control city than in the fluoridated one, in spite of the instructions to find fewer cavities in the fluoridated one, the control was dropped and the experiment proceeded with no control. (The claimed excuse was that a previously unknown trace element, molybdenum, had been discovered in some of the soil of the control city, making tooth decay levels there unusually low [26], but this excuse is not supported by available information, from the files or elsewhere, on decay levels throughout New Zealand). The initial sudden decline in tooth decay in the fluoridated city, plus the continuing decline which we now know was occurring everywhere else in New Zealand, were claimed to prove the success of fluoridation. These revelations from http://www.fluoiide-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation O C to 5 of 1 I government files were published in the international environmental journal, The Ecologist, and presented in 1987 at the 56th Congress of the Australian and New Zealand Association for the Advancement of Science [27]. When I re- examined the classic fluoridation studies, which had been presented to me in the text books during my training, I found, as others had before me, that they also contained serious flaws [28 -30]. The earliest set, which purported to show an inverse relationship between tooth decay prevalence and naturally occurring water fluoride concentrations, are flawed mainly by their nonrandom methods of selecting data. The later set, the "fluoridation trials" at Newburgh, Grand Rapids, Evanston, and Brantford, display inadequate baselines, negligible statistical analysis, and especially a failure to recognize large variations in tooth decay prevalence in the control communities. We really cannot know whether or not some of the tooth decay reductions reported in those early studies were due to water fluoride. I do not believe that the selection and bias that apparently occurred was necessarily deliberate. Enthusiasts for a theory can fool themselves very often, and persuade themselves and others that their activities are genuinely scientific. I am also aware that, after 50 years of widespread acceptance and endorsement of fluoridation, many scholars (including the reviewers of this essay) may find it difficult to accept the claim that the original fluoridation studies were invalid. That is why some of us, who have reached that conclusion, have submitted an invitation to examine and discuss new and old evidence "in the hope that at least some kind of scholarly debate will ensue" [31]. However, whether or not the early studies were valid, new evidence strongly indicates that water fluoridation today is of little if any value. Moreover, it is now widely conceded that the main action of fluoride on teeth is a topical one (at the surface of the teeth), not a systemic one as previously thought, so that there is negligible benefit from swallowing fluoride [32]. Harm from Fluoridation The other kind of evidence which changed my mind was that of harm from fluoridation. We had always assured the public that there was absolutely no possibility of any harm. We admitted that a small percentage of children would have a slight mottling of their teeth, caused by the fluoride, but this disturbance in the formation of tooth enamel would, we asserted, be very mild and was nothing to worry about. It was, we asserted, not really a sign of toxicity (which was how the early literature on clinical effects of fluoride had described it) but was only at most a slight, purely cosmetic change, and no threat to health. In fact, we claimed that only an expert could ever detect it. HARM TO TEETH So it came as a shock to me when I discovered that in my own fluoridated city some children had teeth like those in Fig. 3. This kind of mottling answered the description of dental fluorosis (bilateral diffuse opacities along the growth lines of the enamel). Some of the children with these teeth had used fluoride toothpaste and swallowed much of it. But I could not find children with this kind of fluorosis in the nonfluoridated parts of my Health District, except in children who had been given fluoride tablets at the recommended dose of that time. I published my findings: 25 percent of children had dental fluorosis in fluoridated Auckland and around 3 percent had the severer (discolored or pitted) degree of the condition [33]. At first the authorities vigorously denied that fluoride was causing this unsightly mottling. However, the following year another Auckland study, intended to discount my finding, reported almost identical prevalences and severity, and recommended lowering the water fluoride level to below 1 ppm [34]. Others in New Zealand and the United States have reported similar findings. All these studies were reviewed in the journal of the International Society for Fluoride Research [35]. The same unhappy result of systemic administration of fluoride has been reported in children who received fluoride supplements [36]. As a result, in New Zealand as elsewhere, the doses of fluoride tablets were drastically reduced, and parents were warned to reduce the amount of fluoride toothpaste used by their children, and to caution them not swallow any. Fluoridationists would not at first admit that fluoridated water contributed to the unsightly mottling — though later, in some countries including New Zealand, they also recommended lowering the level of fluoride in the water. They still insist that the benefit to http://www.fluoiide-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation 1 O C ) 6 of 11 �L teeth outweighs any harm. Figure 3. — Examples of dental fluorosis in 8- and 9 -year old children who grew up in fluoridated Auckland, New Zealand WEAKENED BONES Common sense should tell us that if a poison circulating in a child's body can damage the tooth - forming cells, then other harm also is likely. We had always admitted that fluoride in excess can damage bones, as well as teeth. By 1983 I was thoroughly convinced that fluoridation caused more harm than good. I expressed the opinion that some of these children with dental fluorosis could, just possibly, have also suffered harm to their bones [Letter to Auckland Regional Authority, January 1984]. This opinion brought scorn and derision: there was absolutely no evidence, my dental colleagues asserted, of any other harm from low levels of fluoride intake, other than mottling of the teeth. Six years later, the first study reporting an association between fluoridated water and hip fractures in the elderly was published [37]. It was a large -scale one. Computerization has made possible the accumulation of vast data banks of information on various diseases. Hip fracture rates have increased dramatically, independently of the increasing age of populations. Seven other studies have now reported this association between low water fluoride levels and hip fractures [38 -44]. Have there been contrary findings? Yes; but most of the studies claiming no association are of small numbers of cases, over short periods of time, which one would not expect to show any association [45, 46]. Another, comparing a fluoridated and a nonfluoridated Canadian community, also found an association in males but not in females, which hardly proves there is no difference in all cases [47]. Our fluoridationists claim that the studies which do show such an association are only epidemiological ones, not clinical ones, and so are not conclusive evidence. But in addition to these epidemiological studies, clinical trials have demonstrated that when fluoride was used in an attempt to treat osteoporosis (in the belief it strengthened bones), it actually caused more hip fractures [48 -52]. That is, when fluoride accumulates in bones, it weakens them. We have always known that only around half of any fluoride we swallow is excreted in our urine; the rest accumulates in our bones [53, 54]. But we believed that the accumulation would be insignificant at the low fluoride levels of fluoridated water. However, researchers in Finland during the 1980s reported that people who lived 10 years or more in that country's one fluoridated city, Kuopio, had accumulated extremely high levels of fluoride in their bones — thousands of parts per million — especially osteoporosis sufferers and people with impaired kidney function [55, 56]. After this research was published, Finland stopped fluoridation altogether. But that information has been ignored by our fluoridationists. BONE CANCER? http://www.fluoride-journal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation o C Pa47 of 11 An association with hip fracture is not the only evidence of harm to bones from fluoridation. Five years ago, animal experiments were reported of a fluoride- related incidence of a rare bone cancer, called osteosarcoma, in young male rats [57]. Why only the male animals got the bone cancer is not certain, but another study has reported that fluoride at very low levels can interfere with the male hormone, testosterone [58]. That hormone is involved in bone growth in males but not in females. This finding was dismissed by fluoridation promoters as only "equivocal evidence," unlikely to be important for humans. But it has now been found that the same rare bone cancer has increased dramatically in young human males — teenage boys aged 9 to 19 — in the fluoridated areas of America but not in the nonfluoridated areas [59]. The New Jersey Department of Health reported osteosarcoma rates were three to seven times higher in its fluoridated areas than in its nonfluoridated areas [60]. Once again, our fluoridationists are claiming that this evidence does not "conclusively" demonstrate that fluoride caused the cancers, and they cite small -scale studies indicating no association. One study claimed that fluoride might even be protective against osteosarcoma [61]; yet it included only 42 males in its 130 cases, which meant the cases were not typical of the disease, because osteosarcoma is routinely found to be more common in males. Also, the case - control method used was quite inappropriate, being based on an assumption that if ingested fluoride was the cause, osteosarcoma victims would require higher fluoride exposure than those without the disease. The possibility that such victims might be more susceptible to equal fluoride exposures was ignored. All these counter - claims have been subjected to critical scrutiny which suggests they are flawed [62, 63]. Nonetheless, the pro - fluoride lobbyists continue to insist that water fluoridation should continue because, in their view, the benefits to teeth outweigh the possibility of harm. Many dispute that assessment. OTHER EVIDENCE OF HARM There is much more evidence that tooth mottling is not the only harm caused by fluoridated water. Polish researchers, using a new computerized method of X -ray diagnosis, reported that boys with dental fluorosis also exhibit bone structure disturbances [64]. Even more chilling is the evidence from China that children with dental fluorosis have on average lower intelligence scores [65, 66]. This finding is supported by a recently published animal experiment in America, which showed that fluoride also accumulated in certain areas of the brain, affecting behavior and the ability to learn [67]. Endorsements Not Universal Concerning the oft - repeated observation that fluoridation has enjoyed overwhelming scientific endorsement, one should remember that even strongly supported theories have eventually been revised or replaced. From the outset, distinguished and reputable scientists opposed fluoridation, in spite of considerable intimidation and pressure [68, 69]. Most of the world has rejected fluoridation. Only America where it originated, and countries under strong American influence persist in the practice. Denmark banned fluoridation when its National Agency for Environmental Protection, after consulting the widest possible range of scientific sources, pointed out that the long -term effects of low fluoride intakes on certain groups in the population (for example, persons with reduced kidney function), were insufficiently known [70]. Sweden also rejected fluoridation on the recommendation of a special Fluoride Commission, which included among its reasons that: "The combined and long -term environmental effects of fluoride are insufficiently known" [71]. Holland banned fluoridation after a group of medical practitioners presented evidence that it caused reversible neuromuscular and gastrointestinal harm to some individuals in the population [72]. Environmental scientists, as well as many others, tend to doubt fluoridation. In the United States, scientists employed by the Environmental Protection Agency have publicly disavowed support for their employer's pro - fluoridation policies [73]. The orthodox medical establishment, rather weak or even ignorant on environmental issues, persist in their support, as do most dentists, who tend to be almost fanatical about the subject. In English- speaking countries, http://www.fluoride-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation 10 C PIN 8 of I I unfortunately, the medical profession and its allied pharmaceutical lobby (the people who sell fluoride) seem to have more political influence than environmentalists. REFERENCES 1. Colquhoun J. The influence of social rank and fluoridation on dental treatment requirements. New Zealand Dental Journal 73 146 -148 1977. 2. Brooking TWH. A History of Dentistry in New Zealand. Dunedin. New Zealand Dental Association 1980 pp 214 -215. 3. Hollis MJ, Hunter PB. Official Instructions: Dental health statistics, Form H children. School Dental Service Gazette 41 (3) 19 1980. 4. Colquhoun J. New evidence on fluoridation. Social Science and Medicine 19 1239 -1246 1984. 5. Colquhoun J. Influence of social class and fluoridation on child dental health. Community Dentistry and Oral Epidemiology 13 37 -41 1985. 6. Colquhoun J. 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Australian Dental Journal 36 (2)120- 125 1991. 21. Price WA. Nutrition and Physical Degeneration. Heuber, New York 1939. 22. Smith G. Tooth decay in the developing world: could a vaccine help prevent cavities? Perspectives in Biology and Medicine 31440-453 1988. 23. Treasure ET, Dever JG. The prevalence of caries in 5- year -old children living in fluoridated and non - fluoridated communities in New Zealand. New Zealand Dental Journal 88 9 -13 1992. 24. Ludwig TG. The Hastings fluoridation project. New Zealand Dental Journal 54 165 -172 1958. 55 176 -179 1959. 58 22 -24 1962 (co- author EIF Pearce). 59 298 -301 1963. 61 175 -179 1965. 67 155 -160 1971. 25. Department of Health files on fluoridation in National Archives, Wellington, New Zealand. Copies in possession of author and described in: Colquhoun J. Education and Fluoridation in New Zealand.- An historical study (PhD dissertation, University of Auckland). University Microfilms International, Ann Arbor MI 1987. http://www.fluotide-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation 10 C Page f 11 26. Ludwig TG. Recent marine soils and resistance to dental caries. Australian Dental Journal 8 109 -113 1963. 27. Colquhoun J, Mann R. The Hastings fluoridation experiment: Science or swindle? Ecologist 16 (6) 243 -248 1986 17 (2) 125 -126 1987. 28. Colquhoun J. Flawed foundation: A re- examination of the scientific basis for a dental benefit from fluoridation. Community Health Studies 14 288 -296 1990. 29. Klerer M. The fluoridation experiment. Contemporary Issues 7 119 -143 1956. 30. Sutton PRN. Fluoridation: Errors and Omissions in Experimental Trials. Melbourne University Press, Melbourne 1960. 31. Diesendorf M, Colquhoun J, Spittle B J et at New evidence on fluoridation. Australian and New Zealand Journal of Public Health 21 187 -190 1997. 32. Journal of Dental Research 69 (Special Issue) 606 -613 742 -750 556 -557 1990. 33. Colquhoun J. Disfiguring dental fluorosis in Auckland, New Zealand. Fluoride 17 234 -242 1984. 34. Cutress TW, Suckling GW, Pearce EIF, Ball ME. Defects in tooth enamel in children in fluoridated and non - fluoridated water areas of the Auckland Region. New Zealand Dental Journal 81 12 -19 1985. 35. Colquhoun J. Disfiguring or "white and strong "? Fluoride 23 104 -111 1990. 36. Aasenden R, Peebles TC. Effects of fluoride supplementation from birth on human deciduous and permanent teeth. Archives of Oral Biology 19 321 -326 1974. 37. Jacobsen SJ, Goldberg J, Miles TP et al. Regional variation in the incidence of hip fracture among white women aged 65 years and older. Journal of the American Medical Association 264 500 -502 1990. 38. Cooper C, Wickham CAC, Barker DJR, Jacobsen SJ. Letter. Journal of the American Medical Association 266 513 -514 1991. 39. Jacobsen SJ, Goldberg J, Cooper C, Lockwood SA. The association between water fluoridation and hip fracture among white women and men aged 65 years and older. A national ecologic study. Annals of Epidemiology 2 617- 626 1992. 40. Sowers MFR, Clark MK, Jannausch ML, Wallace RB. A prospective study of bone mineral content and fracture in communities with differential fluoride exposure. American Journal of Epidemiology 133 649 -660 1991. 41. Jacgmin -Gadda H, Commenges D, Dartigues J -F. Fluorine concentration in drinking water and fractures in the elderly. Journal of the American Medical Association 273 775 -776 1995. 42. Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah's elderly population. Journal of the American Medical Association 268 746 -748 1992. 43. Keller C. Fluorides in drinking water. Paper presented at Workshop on Drinking Water Fluoride Influence on Hip Fractures and Bone Health. Bethesda MD, April 10 1991. 44. May DS., Wilson MG. Hip fractures in relation to water fluoridation: an ecologic analysis. Paper presented at Workshop on Drinking Water Fluoride Influence on Hip Fractures and Bone Health. Bethesda MD, April 10, 1991. 45. Cauley JA, Murphy PA, Riley T, Black D. Public health bonus of water fluoridation: Does fluoridation prevent osteoporosis and its related fractures? American Journal of Epidemiology 134 768 1991. Abstract. 46. Jacobsen SJ, O'Fallon WM, Melton III IJ. Hip fracture incidence before and after fluoridation of the public water supply, Rochester, Minnesota. American Journal of Public Health 83 743 -745 1993. 47. Suarez - Almazor ME, Flowerdew G, Saunders LD et al. The fluoridation of drinking water and hip fracture hospitalization rates in 2 Canadian communities. American Journal of Public Health 83 689 -693 1993. 48. Riggs BL, Hodgson SF, O'Fallon WM et al. Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. New England Journal of Medicine 322 802 -809 1990. 49. Kleerekoper M, Peterson E, Philips E et al. Continuous sodium fluoride therapy does not reduce vertebral fracture rate in postmenopausal osteoporosis. Journal of Bone and Mineral Research 4 (Suppl 1) 5376 1989. Abstract. 50. Hedlund LR, Gallagher JC. Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 4 223 -225 1989. 51. Lindsay R. Fluoride and bone - quantity versus quality. New England Journal of Medicine 322 844 -845 1990. 52. Melton LJ. Fluoride in the prevention of osteoporosis and fractures. Journal of Bone and Mineral Research 5 (Suppl 1) S 163 -5 167 1990. http://www.fluoride-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation 10 C Pag *, z of 11 53. 53 Fluorides and Human Health. World Health Organization, Geneva 1970 pp 37-41. 54. 54 Fluorine and Fluorides. World Health Organization, Geneva 1984 pp 152 -153. 55. Alhava EM, Olkkomen H, Kauranen P, Kari T. The effect of drinking water fluoridation on the fluoride content, strength and mineral density of human bone. Acta Orthop6vdica Scandinavica 51413-420 1980. 56. Arnala I, Alhava EM, Kauranen EM. Effects of fluoride on bone in Finland. histomorphometry of cadaver bone from low and high fluoride areas. Acta Orthopadica Scandinavica 56 161 -166 1985. 57. Maurer JK, Cheng MC, Boysen BG, Anderson RL. Two -year carcinogenicity study of sodium fluoride in rats. Journal, National Cancer Institute 82 1118 -1126 1990. 58. Kanwar KC, Parminderjit SV, Kalla NR. In vitro inhibition of testosterone synthesis in the presence of fluoride ions. IRCSMedical Science 11 813 -814 1983. 59. Hoover RN, Devesa S, Cantor K, Fraumeni Jr JF. Time trends for bone and joint cancers and osteosarcomas in the Surveillance, Epidemiology and End Results (SEER) Program, National Cancer Institute. In: Review of Fluoride: Benefits and Risks, Report of the Ad Hoc Committee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. US Public Health Service, 1991. F1-F7. 60. Cohn PD. A brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young males. New Jersey Department of Health, November 8 1992. 61. Gelberg KH, Fitzgerald EF, Hwang S, Dubrow R. Fluoride exposure and childhood osteosarcoma: a case - control study. American Journal ofPuhlic Health 85 1678 -1683 1995. 62. Lee JR. Review of report by K H Gelberg et al. Fluoride 29 237 -240 1996. 63. Yiamouyiannis JA. Fluoridation and cancer. Fluoride 26 83 -96 1993. 64. Chlebna -Sokol D, Czerwinski E. Bone structure assessment on radiographs of distal radial metaphysis in children with dental fluorosis. Fluoride 26 37 -44 1993. 65. Li XS, Zhi JL, Gao RO. Effect of fluoride exposure on intelligence of children. Fluoride 28 189 -192 1995. 66. Zhao LB, Liang GH, Zhang DN, Wu XR. Effect of a high fluoride water supply on children's intelligence. Fluoride 29 190 -192 1996. 67. Mullenix PJ, Denbesten PK, Schunior A, Kernan WJ. Neurotoxicity of sodium fluoride in rats. Neurotoxicology and Teratology 17 169 -177 1995 (Cf. Editorial: Neurotoxicity of Fluoride. Fluoride 29 57 -58 1996). 68. Martin B. Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate. State University of New York Press, Albany NY 1991. 69. Waldbott GL, Burgstahler AW, McKinney HL. Fluoridation: The Great Dilemma. Coronado Press, Lawrence KS 1978. Chapter 18. 70. Nyt fra miljostyrelsen (Newsletter of National Agency of Environmental Protection, Denmark). Special issue (in English), February, 1977. 71. Fluor i karies- forehyggande syfte (Report of Swedish Fluoride Commission). Statens Offentliga Utredningar, Stockholm 1981. English - language summary pp 21 -30. 72. Grimbergen GW. A double blind test for determination of intolerance to fluoridated water (preliminary report). Fluoride 7 146 -152 1974. 73. Hirzy W. Press releases. Fluoride 26 279 -281 1993; Fluoride 30 258 -259 1997. * John Colquhoun School of Education, University of Auckland, Private Bag 92019, Auckland, New Zealand. © 1997 by The University of Chicago Press. All rights reserved. First published in Perspectives in Biology and Medicine 4129 -44 1997 Repri nted with permission in Fluoride, Journal of the International Society for Fluoride Research. Editorial Office: 8 1 A Landscape Road, Mount Eden, Auckland 1004, New Zealand http://www.fluoride-joumal.com/98-31-2/312103.htm 9/7/2011 Why I changed my mind about water fluoridation It e 11 of 11 10C PERSPECTIVES IN BIOLOGY AND MEDICINE The purpose of this quarterly journal is to serve as a vehicle for articles which convey new ideas or stimulate original thought in the biological and medical sciences. Subscription information is available from the publisher: the University of Chicago Press, Journals Division, PO Box 37005, Chicago, IL 60637, USA. International Society for Fluoride Research FLUORIDE 31 (2) 1998, 103 -118 Home I Table cf Goy tents I ISrR Beard S�_bscn) icn Submissions I Announcements Hutor S biect Index http://www.fluoride-journal.com/98-31-2/312103.htm 9/7/2011 10 C http:/ /thyroid. about. com /od/ drsrichkarileeshames /a /fluoride2006 2.htm Fluoridated Water Is Causing Low Thyroid Commentary on 2006 Research Findings By Mary Shomon, About.com Guide Agenda Item #: Meeting Date Updated April 04, 2006 Presented by: Apr 3 2006 That's right! The official word is in. "Fluoride jeopardizes health even at low levels deliberately added to public water supplies. It poses risks for thyroid patient diabetics, kidney patients, high water drinkers, and others." This is one summary of the recent report from a blue- ribbon scientific panel of the National Academy of Sciences National Research Council. (Read about the report now.) NAS panel member Robert Isaacson, a distinguished professor of neurobehavioral science at the State University of New York in Binghamton, said in the Portland Tribune 3/29/06) that the possible effects on the endocrine system and hormones from water fluoridation are "something I wouldn't want to happen to me" The twelve - member NRC fluoride Committee unanimously decided that current maximum allowable fluoride levels must be lowered. So now, it is not just Richard and Karilee Shames and the so- called "small group of anti - fluoridationists" who are trying to warn people about fluoride's effect on the thyroid gland, as well as other body systems. Now, it's some of the top- credentialed people in the country. In doing the research for our books Thyroid Power (HarperCollins 2001) and Feeling Fat, Fuzzy or Frazzled? (Hudson St. /Penguin 2005), it became clear to us years ago that a great many scientists and researchers already knew of fluoride's hazards, but that this information was not getting through to the general public. In fact, a release of July 2, 1997 (from the National Treasury Employees Union which represents 1500 scientists, engineers and other professionals at the Environmental Protection Agency's headquarters in Washington, DC) showed that this Union of Scientists unanimously opposed the practice of adding fluoride to public drinking waters. The University of Colorado Health Sciences Center in 1998 suggested that there are at least 13 million people in this country who have a thyroid problem - but don't know it. The thyroid doctors at Columbia Presbyterian Medical Center in NY estimated in 2000 that at least 20 million people are currently being treated for a thyroid problem. A 2001 article in the Journal of Epidemiology reveals that one of every four menopausal women is suffering from some degree of hypothyroidism. Clearly this is a massive epidemic, and it appears to be getting worse. No longer should people be puzzled over what could be a cause of the enormous epidemic of low thyroid and Hashimoto's thyroiditis. Look no further than the kitchen faucet! Depending upon which side of the fluoride debate you've heard, all this news could come as either a quizzical shock, or a welcome relief. Either way, the next likely thought might be "Why is this news coming out now ?" and perhaps also "What does it mean to me ?" 1 C 4- 1 1.1/1 I wil 1 e/ 4, al' 5 e,CSICa_ Rct) r) e, (=j y/old?stfr) , 6 cb: iNt\W V 617 F de S q ‘4\ 11 yt /0 k -724-1 A 7-- tt.s --Jo Ji cr\l) scr' ( _;17 \Cibriae fi.z, -4 ( 'Pt/ f '40 \I ;d1 6 izz, 164've aJ 10C .40 It is happening now because the overwhelming weight of scientific evidence for public safety has finally turned the tide against the special interest groups. Despite common lore, fluoridation did not come about because of careful professionals' altruistic desire to lessen children's cavities. Christopher Bryson, an award- winning investigative reporter, has recently revealed in shocking detail in his book The Fluoride Deception (Seven Stories Press, 2004) the unsavory story behind the birth of this questionable practice. But aside from all the sordid history, the suppression of scientific concern, and the labeling of dissenters as off - balanced "fluorophobes," what should a sensible person do? Here are three appropriate actions for regular daily life, especially if you are bothered by feeling fat, fuzzy, frazzled, fatigued, depressed, beset by intolerance to heat or cold, annoyed by problems with skin - hair - nails, or suffering with severe constipation, low libido, infertility, or uncomfortable menopause. First, if you are not a thyroid patient, have your thyroid status carefully checked. Insist on more testing than the simple AMA panel of TSH and Free T4. Add a Free T3 and the Thyroid Antibody Panel. You may be one of the millions of people whose fluoride exposure over the years has finally made you low thyroid. Second, if you are already a thyroid sufferer and treatment is not going as well as you would like, consider an enhanced fluoride avoidance program. Stop drinking and cooking with tap water if it is fluoridated. Well- chosen bottled water is preferable. Start buying non - fluoridated tooth paste. It's available at the health food store if you really look closely. Decline the fluoride dental treatments and make sure it is not in your mouth wash. The various other food sources are probably not a significant factor. Third, start speaking out against the unhealthy practice of fluoridation. Don't expect that the Public Health Service will ever willingly admit to the most colossal error ever in the history of government science. The change will instead occur as more and more local communities decide against fluoridating their city water. They will thereby join those whole countries that have rejected or banned the practice, such as Japan, India, Finland, Denmark, Sweden, and Holland. Be guided by the credo of health professionals, "Above all, do no harm." If fluoridated water is now highly suspected of harm, then let's put a moratorium on proceeding further with it. So much for recent news and immediate reactions to it. In an upcoming article we will explain just why fluoride is so injurious to the thyroid gland and what further actions are thereby indicated. Until then........ kindest regards to all and stay healthy. Richard Shames MD and Karilee Shames PhD, RN www.FeelinqFFF.com 7 1,0e 4 lk\ 1. k-'40'. -r);°/-0 D j:C. ■ Nqkyt , im 0 0 ci/ p_e rsOA., 1. 1-7-2 dig 11,2.3 .,...- k ' CO ild( .... ...t r tddonae is k 1 — I a,Ii i ve 1 --k:C,(\°■.( L7 _------ I -..-- \ Cs" vIA I,L -v\i scs.,4421.14,‘4>uoPt4t.---74-5 .,- 1:\1, `L)H -t iph ejs fit V, i INIVI- t ( C ,_ kn i -0- i\ckt 11'<)/1 e„kilm?d(r9 e ki i' ' ,-,714.11-41k 1- i- i'llwA-9 6,4 i ile v • k. ti,‘ ---11- - Vr ,; a.6k...c.ts L_ ,-;6721tAsi-- Iv jr. 1 (..... ,, ,i, -\/- / pit i,,,,,, -76, 5 , l, 5 - ( \- 4 -1r Ct ( ( r- J-- 45 77 utilianyhed ............. 7-7/,s-c, __,... )411te0------ k. • FrbO ike I I do "6 c i -/-TA Caries trends 1992 -1998 in two low- fluori... [Caries Res. 2000 Nov -Dec] - PubMed - NCBI PubMed Display Settings: Abstract Caries Res. 2000 Nov- Dec;34(6):462 -8. Page 1 of 1 10C 44 Caries trends 1992 -1998 in two low- fluoride Finnish towns formerly with and without fluoridation. Seppa L, Karkkainen S, Hausen H. Institute of Dentistry, University of Oulu, Finland. liisa.seppa @oulu.fi Abstract Water fluoridation in Kuopio, Finland, was stopped at the end of 1992. In our previous study, no increase in caries was found in Kuopio 3 years after the discontinuation of water fluoridation. The aim of the present study was to further observe the occurrence and distribution of caries in Kuopio and Jyvaskyla, which was used as the reference town for Kuopio. In 1992, 1995 and 1998 independent random samples of all children aged 3, 6, 9, 12 and 15 years were drawn in Kuopio and Jyvaskyla. The total numbers of subjects examined were 688, 1„484 and 1,530 in 1992, 1995 and 1998, respectively. Calibrated dentists registered caries clinically and radiographically�No indication of increasing caries could be found in the previously fluoridated town uring 1992 -1998. In both towns the mean dmfs and DMFS values either decreased or remained about the same during the observation period. When all study years and both towns were pooled, 25% of the 12- and 15- year -olds with the highest DMFS counts accounted for 79 and 67 %, respectively, of all affected surfaces. The mean numbers of fluoride varnish and sealant applications had markedly decreased in 1993 -1998 compared to 1990- 1992. The fact that no increase in caries was found in Kuopio despite discontinuation of water fluoridation and decrease in preventive procedures suggests that not all of these measures were necessary for each child. P?VIM; 110,9630 I9FIt 1r}Med - indexed f'`:r Ml<_D[JIN'E, Publication Types, McSH Terms, Substances LinkOut - more resources �__ kr1Vnn CCAI-S, CA- C\—C, -0,-) < \',<,,rr\ _ K) L (_'_A3CA- http://www.ncbl.nlm.nih.gov/pubmed/I 1093019?dopt=Abstract 9/8/2011 Patterns of dental caries foil... [Community Dent Oral Epidemiol. 2001] -PubMed -NCBI Page 1 of 1 PubMed 1 0 C Display Settings: Abstract Full Text WWILEY t Community Dent Oral Epidemiol. 2001 Feb;29(1):37-47. Online Patterns of dental caries following the cessation of water fluoridation. Maupome G, Clark DC, Levy SM, Berkowitz J. Faculty of Dentistry, University of British Columbia,Vancouver,Canada.gerardo.maupome @kp.org Abstract OBJECTIVES:To compare prevalence and incidence of caries between fluoridation-ended and still-fluoridated communities in British Columbia, Canada, from a baseline survey and after three years. METHODS: At the baseline(1993/4 academic year)and follow-up(1996/7)surveys, children were examined at their schools. Data were collected on snacking, oral hygiene, exposure to fluoride technologies, and socio-economic level. These variables were used together with D1D2MFS indices in multiple regression models. RESULTS: The prevalence of caries(assessed in 5,927 children, grades 2, 3, 8, 9)decreased over time in the fluoridation-ended community while remaining unchanged in the fluoridated community. While numbers of filled surfaces did not vary between surveys, sealed surfaces increased at both study sites. Caries incidence(assessed in 2,994 life-long residents, grades 5, 6, 11, 12)expressed in terms of D1D2MFS was not different between the still-fluoridating and fluoridation-ended communities. There were, however, differences in caries experienced when D1D2MFS components and surfaces at risk were investigated in detail. Regression models did not identify specific variables markedly affecting changes in the incidence of dental decay. CONCLUSIONS: Our results suggest a complicated pattern of disease following cessation of fluoridation. Multiple sources of fluoride besides water fluoridation have made it more difficult to detect changes in the epidemiological profile of a population with generally low caries experience, and living in an affluent setting with widely accessible dental services. There are, however, subtle differences in caries and caries treatment experience between children living in fluoridated and fluoridation-ended areas. PMlD.111 3562[PubMed-indexed for MEDLINE] Publication Types, MeSH Terms, Substances LinkOut-more resources http://www.ncbi.nlm.nih.gov/pubmed/11153562?dopt=Abstract 9/8/2011 Decline of caries prevalence a... [Community Dent Oral Epidemiol. 2000] -PubMed -NCBI Page 1 of 1 1C 0 PubMed Display Settings: Abstract Full Text wWIIEY 6 Community Dent Oral Epidemiol. 2000 Oct;28(5):382-9. Online Decline of caries prevalence after the cessation of water fluoridation in the former East Germany. KUnzel W, Fischer T, Lorenz R, Bruhmann S. Dental School of Erfurt, Department of Preventive Dentistry, Friedrich-Schiller-University of Jena, Germany. Simionoff@zmkh.ef.uni- jena.de Abstract In contrast to the anticipated increase in dental caries following the cessation of water fluoridation in the cities Chemnitz (formerly Karl-Marx-Stadt)and Plauen, a significant fall in caries prevalence was observed. This trend corresponded to the national caries decline and appeared to be a new population-wide phenomenon. Additional surveys(N=1017)carried out in the formerly-fluoridated towns of Spremberg(N=9042)and Zittau(N232)were carried out in order to support this unexpected epidemiological finding. Pupils from these towns, aged 8/9-, 12/13-and 15/16-years, have been examined repeatedly over the last 20 years using standardised caries-methodological procedures. While the data provided additional support for the established fact of a caries reduction brought about by the fluoridation of drinking water(48%on average), it has also provided further support for the contention that caries prevalence may continue to fall after the reduction of fluoride concentration in the water supply from about 1 ppm to below 0.2 ppm F. Caries levels for the 12-year -olds of both towns significantly decreased during the years 1993-96, following the cessation of water fluoridation. In Spremberg, DMFT fell from 2.36 to 1.45(38.5%)and in Zittau from 2.47 to 1.96(20.6%).These findings have therefore supported the previously observed change in the caries trend of Chemnitz and Plauen. The mean of 1.81 DMFT for the 12-year-olds, computed from data of the four towns, is the lowest observed in East Germany during the past 40 years. The causes for the changed caries trend were seen on the one hand in improvements in attitudes towards oral health behaviour and, on the other hand, to the broader availability and application of preventive measures(F-salt, F- toothpastes, fissure sealants etc.). There is, however, still no definitive explanation for the current pattern and further analysis of future caries trends in the formerly fluoridated towns would therefore seem to be necessary. iiD:1101 4515[PuhMed-indexed for MEDLiNE] Publication Types, MeSH Terms,Substances LinkOut -more resources http://www.ncbi.nlm.nih.gov/pubmed/11014515?dopt=Abstract 9/8/2011 The effects of a break in water fluoridation on t... [J Dent Res. 2000] - PubMed -NCBI Page 1 of I 10C PubMed Display Settings: Abstract ' Fw -10,1 k:Ale J Dent Res. 2000 Feb;79(2):761-9. a Skt;E_ The effects of a break in water fluoridation on the development of dental caries and fluorosis. Burt BA, Keels MA, Heller KE. Department of Epidemiology, School of Public Health, University of Michigan,Ann Arbor 48109-2029, USA.bburt@umich.edu Abstract Durham, NC, fluoridated since 1962, had an 11-month cessation of fluoridation between September, 1990, and August, 1991. The purpose of this study was to assess the effects of this break on the development of caries and fluorosis in children. Study participants were continuously-resident children in Kindergarten through Grade 5 in Durham's elementary schools. There were 1696 children, 81.4%of those eligible, for whom a questionnaire was completed and clinical data recorded. Age cohorts were defined by a child's age at the time that fluoridation ceased. Caries was recorded in children in the Birth Cohort through Cohort 3, and fluorosis for children in Cohorts 1 through 5. Caries was assessed in the primary first and second molars according to the decayed-filled index; fluorosis on the labial surfaces of the upper permanent central and lateral incisors was assessed by the Thylstrup-Fejerskov(TF) index. Mother's education was associated with caries; higher education of the mother had an odds ratio of 0.53(95%CI 0.40, 0.76)for caries in the child. No cohort effects could be discerned for caries. Overall prevalence of fluorosis was 44%. Prevalence in Cohorts 1, 2, 3, 4, and 5 was 39.8%, 32.3%, 33.0%, 62.3%, and 57.1%, respectively. These cohort differences remained statistically significant in regression analysis. It was concluded that while the break had little effect on caries, dental fluorosis is sensitive to even small changes in fluoride exposure from drinking water, and this sensitivity is greater at 1 to 3 years of age than at 4 or 5 years. PM!D:1012%78[PubMed-.indexed for MEDLJNE] Free full text Publication Types, MeSH Terms, Grant Support LinkOut-more resources http://www.ncbi.nlm.nih.gov/pubmed/10728978?dopt=Abstract 9/8/2011 Caries prevalence after cessation of wate... [Caries Res. 2000 Jan-Feb] - PubMed -NCBI Page 1 of 1 1 C 0 PubMed Display Settings: Abstract Full Text Caries Res. 2000 Jan-Feb;34(1):20-5. Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Kunzel W, Fischer T. Department of Preventive Dentistry, Dental School of Erfurt, Friedrich Schiller University of Jena, Germany. Abstract In the past, caries has usually increased after cessation of water fluoridation. More recently an opposite trend could be observed: DMFT remaining stable or even decreasing further. The aim of the present study conducted in La Salud (Province of Habana) in March 1997 was to analyse the current caries trend under the special climatic and nutritional conditions of the subtropical sugar island Cuba, following the cessation, in 1990, of water fluoridation(0.8 ppm F). Diagnostic evaluations were carried out using the same methods as in 1973 and 1982. Boys and girls aged 6-13 years(N =414), lifelong residents in La Salud,were examined. Between 1973 and 1982 the mean DMFT had decreased by 71.4%, the mean DMFS by 73. 3%and the percentage of caries-free children had increased from 26. 3 to 61.6%. In 1997, following the cessation of drinking water fluoridation, in contrast to an expected rise in caries prevalence, DMFT and DMFS values remained at a low level for the 6-to 9-year-olds and appeared to decrease for the 10/11-year-olds (from 1. 1 to 0.8)and DMFS(from 1.5 to 1.2). In the 12/13-year-olds,there was a significant decrease(DMFT from 2.1 to 1.1; DMFS from 3.1 to 1. 5),while the percentage of caries-free children of this age group had increased from 4.8(1973) and 33.3(1982) up to 55.2%. A possible explanation for this unexpected finding and for the good oral health status of the children in La Salud is the effect of the school mouthrinsing programme,which has involved fortnightly mouthrinses with 0.2%NaF solutions(i.e. 15 times/year)since 1990. PMi iD:10601 80[PubMed- indexed for MEDLINE] Publication Types, MeSH Terms,Substances LinkOut-more resources http://www.ncbi.nlm.nih.gov/pubmed/10601780?dopt=Abstract 9/8/2011 [Caries decline in Germany--causes and cons... [Gesundheitswesen. 1997] - PubMed -NCBI Page 1 of 1 10C PubMed Display Settings: Abstract Gesundheitswesen. 1997 Dec;59(12):710-5. [Caries decline in Germany--causes and consequences]. [Article in German] KUnzel W. Poliklinik fur Preventive Zahnheilkunde, Friedrich-Schiller-Universitat Jena. Abstract The reunification of the two German states has resulted in social transformations in Eastern Germany after 1990, in the wake of which disadvantageous effects on oral health were to be expected. Contrary to the predicted caries increase, a caries decline in the juvenile population could be proven by epidemiological comparative studies(n=50612)(decrease between 1983-1989 and 1993-1995 by 34.2%). The caries decline is probably caused by a broader availability of fluorides, a high level of individual dental curative and preventive care(fissure sealings) and by changed oral health behaviour and nutritional habits. Reference is made to a possible tangent between a high level of antibiotics consumption and the virulence of oral pathogenic streptococci. P liD:9 483838[Pub bled-indexed for MEDi_INE] Publication Types, MeSH Terms http://www.ncbi.nlm.nih.gov/pubmed/9483838?dopt=Abstract 9/8/2011 Confirmation of and explanations for elevate... [Neurotoxicology. 2007] - PubMed - NCBI Page 1 of 1 PubMed � O V Display Settings: Abstract Neurotoxicology. 2007 Sep;28(5):1032 -42. Epub 2007 Mar 1.- Confirmation of and explanations for elevated blood lead and other disorders in children exposed to water disinfection and fluoridation chemicals. Caplan MJ, Patch SC, Masters RD, Bachman MS. Intellequity Technology Services Natick, Massachusetts, United States. MYRONCOPLAN @aol.com Abstract Silicofluorides (SiFs), fluosilicic acid FSA) and sodium fluosilicate (NaFSA), are used to fluoridate over 90% of US fluoridated municipal w ter supplies�Living in communities with silicofluoride treated water (SiFW) is associated with two neurotoxic effects: (1 Prevalence of children with elevated blood lead (PbB >10microg /dL) is about double that in non - fluoridated communities Risk Ratio 2, chi2p <0.01). SiFW is associated with serious corrosion of lead- bearing brass plumbing, producing a evated water lead (PbW) at the faucet. New data refute the Ion - evailing belief that PbW contributes little to children's blood lead (PbB), it is likely to contribute 50% or more. (2) SiFW has been shown to interfere with cholinergic function. Unlike the fully ionized state of fluoride (F -) in water treate with sodium fluoride (NaFW), the SiF anion, [SiF6]2- in Si W releases F- in a complicated dissociation process. Small amounts of incompletely dissociated [SiF6]2- or low molecular weight (LMW) silicic acid (SA) oligomers may remain in SiFW. A German PhD study found that SiFW is a more powerful inhibitor of acetylcholinesterase (AChE) than NaFW. It is proposed here that SiFW induces protein mis- folding via a mechanism that would affect polypeptides in general, and explain dental fluorosis, a tooth enamel defect that is not merely "cosmetic" but a "canary in the mine" foretelling other adverse, albeit subtle, health and behavioral effects. Efforts to refute evidence of such effects are analyzed and rebutted. In 1999 and 2000, senior EPA personnel admitted they knew of no health effects studies of SiFs. In 2002 SiFs were nominated for NTP animal testing. In 2006 an NRC Fluoride Study Committee recommended such studies. It is not known at this writing whether any had begun. PIMI 1 420053[PubMed - indexed fir IM "DUNE] McSH Terms, Substances LinkOut - more resources �^ p��UOr. �� Tl eC.►�e -� L�� a neolrokaxi c e4ec}6" �tcll � `-w e �s aM http://www.nebi.nlm.nih.gov/pubmed/17420053 9/12/2011 "STUDIES ON CHOLINERGIC FUNCTION AND MEMORY IN MICE (CHOLINOTOXINS, WOR" ... Page 1 of 2 DigitalCommons@The Texas Medical Center 10 C STUDIES ON CHOLINERGIC FUNCTION AND MEMORY IN MICE (CHOLINOTOXINS, WORKING, REFERENCE MEMORY, RADIAL ARM MAZE) CAREY NAT POPE, The University of Texas Health Science Center at Houston Graduate School of Biomedical Sciences Abstract Considerable evidence suggests that central cholinergic neurons participate in either acquisition, storage or retrieval of information. Experiments were designed to evaluate information processing in mice following either reversible or irreversible impairment in central cholinergic activity. The cholinergic receptor antagonists, atropine and methylatropine were used to reversibly inhibit cholinergic transmission. Irreversible impairment in central cholinergic function was achieved by central administration of the cholinergic- specific neurotoxins, N- ethyl - choline aziridinium (ECA) and N- ethyl - acetylcholine aziridinium (EACA). ECA and EACA appear to act by irreversible inhibition of high affinity choline uptake (proposed rate - limiting step in acetylcholine synthesis). Intraventricular administration of ECA or EACA produced persistent reduction in hippocampal choline acetyltransferase activity. Other neuronal systems and brain regions showed no evidence of toxicity. Mice treated with either ECA or EACA showed behavioral deficits associated with cholinergic dysfunction. Passive avoidance behavior was significantly impaired by cholinotoxin treatment. Radial arm maze performance was also significantly impaired in cholinotoxin- treated animals. Deficits in radial arm maze performance were transient, however, such that rapid and apparent complete behavioral recovery was seen during retention testing. The centrally active cholinergic receptor antagonist atropine also caused significant impairment in radial arm maze behavior, while equivalent doses of methylatropine were without effect. The relative effects of cholinotoxin and receptor antagonist treatment on short-term (working) memory and long -term (reference) memory in radial arm maze behavior were examined. Maze rotation studies indicated that there were at least two different response strategies which could result in accurate maze performance. One strategy involved the use of response algorithms and was considered to be a function of reference memory. Another strategy appeared to be primarily dependent on spatial working memory. However, all behavioral paradigms with multiple trails have reference memory requirements (i.e. information useful over all trials). Performance was similarly affected following either cholinotoxin or anticholinergic treatment, regardless of the response strategy utilized. In addition, rates of behavioral recovery following cholinotoxin treatment were similar between response groups. It was concluded that both cholinotoxin and anticholinergic treatment primarily resulted in impaired reference memory processes. Recommended Citation CAREY NAT POPE, "STUDIES ON CHOLINERGIC FUNCTION AND MEMORY IN MICE (CHOLINOTOXINS, WORKING, REFERENCE MEMORY, RADIAL ARM MAZE)" (January 1, 1985). Texas Medical Center Dissertations (via ProQuest). Paper AA18603231. http: / /digitalcommons. library.tmc.edu /dissertations /AA18603231 http://digitalcommons.library.tmc.edu/dissertations/AA1860323 1 / 9/12/2011 Association of silicofluoride treated water ... [Neurotoxicology. 2000] - PubMed - NCBI Page 1 of 1 PubMed Display Settings: Abstract Neurotoxicology. 2000 Dec;21(6):1091 -100. Association of silicofluoride treated water with elevated blood lead. Masters RD, Coplan MJ, Hone BT, Dykes JE. Foundation for Neuroscience and Society, Dartmouth College, Hanover, NH 03755 -3547, USA. roger.d.masters @dartmouth.edu 10 Abstract Previous epidemiological studies have associated silicofluoride- treated community water with enhanced child blood lead parameters. Chronic, low -level dosage of silicofluoride (SiF) has never been adequately tested for health effects in humans. We report here on a statistical study of 151,225 venous blood lead (VBL) tests taken from children ages 0 -6 inclusive, living in 105 communities of populations from 15,000 to 75,000. The tests are part of a sample collected by the New York State Department of Children's Health, mostly from 1994 -1998. Community fluoridation status was determined from the CDC 1992 Fluoridation Census. Covariates were assigned to each community using the 1990 U.S. Census. Blood lead measures were divided into groups based on race and age. Logistic regressions were carried out for each race /age group, as well as above and below the median of 7 covariates to test the relationship between known risk factors for lead uptake, exposure to SiF- treated water, and VBL >10 microg /dL. RESULTS: For every age /race group, there was a consistently significant association of SiF treated community water and elevated blood lead. Logistic regressions above and below the median value of seven covariates show an effect of silicofluoride on blood lead independent of those covariates. The highest likelihood of children having VBL> 10 microg /dL occurs when they are both exposed to SiF treated water and likely to be subject to another risk factor known to be associated with high blood lead (e.g., old housing). Results are consistent with prior analyses of surveys of children's blood lead in Massachusetts and NHANES III. These data contradict the null hypothesis that there is no difference between the toxic effects of SiF and sodium fluoride, pointing to the need for chemical studies and comprehensive animal testing of water treated with commercial grade silicofluorides. PikgI D:11233 7 55[PubMed - indexed for MI' L LINE; Publication Types, McSH Terms, Substances LinkOut - more resources http: / /www.ncbi.nlm.nih.gov /pubmed /112337559dopt= Abstract 9/12/2011 Dartmouth researcher warns of chemicals added to drinking water Page 1 of 2 1 0 C Dartmouth College Dartmouth News L-. .. 'i..e.5;.J _Jt.; t'i'h Dartmouth researcher warns of chemicals added to drinking water Posted 0315/0.1 In a recent article in the journal NeuroToxicology,a research team led by Roger D.Masters, Dartmouth College Research Professor and Nelson A. Rockefeller Professor of Government Emeritus,reports evidence that public drinking water treated with sodium silicotluoride or fluosilicic acid,known as silicofluorides(SiFs),is linked to higher uptake of lead in children. Sodium fluoride,first added to public drinking water in 1945,is now used in less than 1o%of fluoridation systems nationwide,according to the Center for Disease Control's(CDC) 1992 Fluoridation Census. Instead,SiF's are now used to treat drinking water delivered to 140 million people.While sodium fluoride was tested on animals and approved for human consumption,the same cannot be said for SiFs. Masters and his collaborator Myron J.Coplan,a consulting chemical engineer,formerly Vice President of Albany international Corporation,led the team that has now studied the blood lead levels in over 400,000 children in three different samples.In each case,they found a significant link between SiF- treated water and elevated blood lead levels. "We should stop using silicofluorides in our public water supply until we know what they do,"said Masters.Officials at the Environmental Protection Agency have told Masters and.Caplan that the EPA has no information on health effects of chronic ingestion of SiF-treated water. In their latest study published in a special.December 2000 issue of NeuroToxicology,Masters,Coplan and their team analyzed data on blood levels from more than 150,000 children ages o to 6.These tests were part of a sample collected by the New York State Department of Children's Health,mostly from 1994 to 1998 in comparable non-fluoridated and SiF-treated public drinking water in communities with populations of similar size. Socio-economic and demographic risk factors for high blood lead were also considered using information from the 1990 U.S.Census.The researchers found that the greatest likelihood of children having elevated blood lead levels occurs when they are exposed both to known risk factors,such as old house paint and lead in soil or water,and to SiF-treated drinking water. "Our research needs further laboratory testing," added Masters."This should have the highest priority because our preliminary findings show correlations between SiF use and more behavior problems due to known effects of lead on brain chemistry."Also requiring further examination is German research that shows SiFs inhibit cholinesterase,an enzyme that plays an important role in regulating neurotransmitters. "If SiFs are cholinesterase inhibitors,this means that SiFs have effects like the chemical agents linked to Gulf War Syndrome,chronic fatigue syndrome and other puzzling conditions that plague millions of Americans,"said Masters."We need a better understanding of how SiFs behave chemically and physiologically." Currently, a bill before the New Hampshire House of Representatives would impose more stringent testing on fluoridating chemicals added to public drinking water.On March 7, 2001, Masters and Coplan testified in favor of the bill, HR 754,The Fluoride Product Quality Control Act,at a public hearing. Masters contends that bill's requirement for testing the silicofluorides is vital but needs to be complemented by further research on neurotoxicity and behavior. http://www.dartmouth.edu/—news/releases/2001/mar01/flouride.html 9/12/2011 Dartmouth researcher warns of chemicals added to drinking water Page 2 of 2 10C Masters and Coplan note that their recent studies contain the most extensive empirical evidence of the health and behavioral costs of these chemicals."If further research confirms our findings," Masters added,"this may well be the worst environmental poison since leaded gasoline." Dartmouth has television(satellite uplink)and radio(ISDN)studios available for domestic and international live and taped interviews.For more information,call 603-646-3661 or see our Radio. Television capability webpage. Recent Headlines from Dartmouth News: o Dartmouth helps found a global network of universities [06/04/10] o Dartmouth moves to improve recycling rate [06/02/10] o Class of 1953 Commons dedicated [05/27/10] o Dartmouth's Big Green Bus ready for 6th-annual cross-country educational tour [05/26/10] o Rockefeller Center students to host New Hampshire/Vermont conference on homelessness [05/21/10] o Sign-up to receive Dartmouth News via email http://www.dartmouth.edui—news/releases/2001/mar01/flouride.html 9/12/2011 CHRONIC FLUORINE INTOXICATION, September 18, 1943, 123 (3):150 J Am Med Assoc Page 1 of 2 10C Journal of the Amet -ican Medical Association laln.t. ama- assn.<�rF. CHRONIC FLUORINE INTOXICATION Since Oils oriicle iev. JAM. 1943;123 (� EXCERPT Di, t l7',torInc is st) Nlide.,bread throughout ntirllre th it i small intake ol. the c.lemuai :•, practically ut a� t:idat,l 1 !uc)ricic G are general protoplasmic poiso�J-Nv robably because of their capacity to inodifv the metabolism of cells bv changing the permeal of th e cell membrane. and 1-n inhibiting certain enzyme systems Fbe e -act niechanisvi of such actions is obscai- The sources of Iluorine intoxication are drinking; water containing i part per million or more of fluorine, fluorine compounds used as insecticidal sprays for fruits and vegetables (eryolito and barium fluosilicate) and the mining and conversion of phosphate rock 0 superphosphate, which is used as fertilizer. File fluorine content of phosphate rock i,, about 4 per cent. Yhirino conversion to superphosphate, about 25 per cent o ttie Iffilorine present is volatilized Anil reps- eats a looting, into the . imosphere of approxinlatel.N x,(11,11) tolls of llure fluorine awluea .-' .mother source {It fluorinc intoxication is http://jama.ama-assn.org/content/123/3/150.2. short 9/12/2011 WARNING POTENTIAL FOR At Please see full US PROPER PATIENT SELECTION Prescribim Information. LIMITATIONS OF USE Important Safely Informst*n. sry +_ Boxed WARNING. Potential for Abuse Nt1CYNTAID FIR contains talk Di, t l7',torInc is st) Nlide.,bread throughout ntirllre th it i small intake ol. the c.lemuai :•, practically ut a� t:idat,l 1 !uc)ricic G are general protoplasmic poiso�J-Nv robably because of their capacity to inodifv the metabolism of cells bv changing the permeal of th e cell membrane. and 1-n inhibiting certain enzyme systems Fbe e -act niechanisvi of such actions is obscai- The sources of Iluorine intoxication are drinking; water containing i part per million or more of fluorine, fluorine compounds used as insecticidal sprays for fruits and vegetables (eryolito and barium fluosilicate) and the mining and conversion of phosphate rock 0 superphosphate, which is used as fertilizer. File fluorine content of phosphate rock i,, about 4 per cent. Yhirino conversion to superphosphate, about 25 per cent o ttie Iffilorine present is volatilized Anil reps- eats a looting, into the . imosphere of approxinlatel.N x,(11,11) tolls of llure fluorine awluea .-' .mother source {It fluorinc intoxication is http://jama.ama-assn.org/content/123/3/150.2. short 9/12/2011 F icic acid - Medical Definition and More from Merriam-Webster Word Games Word of the Day New Words & Slang Video k7 %# iMcrri �i Webster , fluosilicic acid fluosilicic acid ? « Quiz Test Yf)tll. %"(W-Aulai-v Arts by Go ogle Take Our 10-Question Quiz K12 Virtual Academy Vtfe Provido Tex")aok,,, & Materials, at No Cost to You! Discover K12. fluo•si•lic•ic acid Our Free Apps Merriam-Webster's Dictionary For iPhone, Mad, and Android Definition of FLUOSILICIC ACID : an unstable corrosive poisonous acid H25iF6 SubrT :A'.) ti' i'j t Page I of 2 10C, Do These \Vords Stminij-) You ,rt)o? i. Top 10 Commonly Confused Words, Vol. 1 t. "Machiavefflaridsirit" and (A 'hole L -A)t) More Top 10 Unusually Long and Interesting Words, Vol. 1 o After Madonna ungraciously received a gift of flowers from a fan ... more http://www.merriam-webster.com/medical/fluosilicic+acid?show--O&t--1315595367 9/9/2011 Sodium fluosilicate - Medical Definition and More from Merriam- Webster Mcl l iani Wei)stet ? * Quiz Test Your 1locahulary Take Our 10- Question Quiz i ,add a lime get a FREE I phone Our Free Apps Merriam- Websters Dictionary For Phone, Mad, and Android `lo ne t Starting at f . � FREC 4 - -' 'Two-year contract required. Other restrictions apply. Word Games Word of the Day New Words & Slang Video k! *# sodium fluosilicate Subrr sodium fluosilicate Ads by Goog;e K12 Virtual Academy t'lte Provide Textbooks & h1iterials, at No Cost to Yost' Discover K12, sodium fluosilicate rg�rxrR Uk Definition of SODIUM FLUOSILICATE : a crystalline salt Na2SiF6 used as an insecticide — called also sodium siiicofiuoride Do These Words Stu►nl) 1 "ou Too? Top 10 Commonly Confused Words, Vol. 1 a 4V " VlachiavelliaWsm" mid (A Whole lot) iVlore Top 10 Unusually Long and Interesting Words, Vol. 1 -` -N "Loathe" After Madonna ungraciously received a gift i of flowers from a fan ... morel, http: / /www.merriam- webster.com/ medical / sodium+ fluosilicate ?show =0 &t= 1315838789 9/12/2011 t'rrlkl late' . Chuiun.lr� ./,AL _. Do These Words Stu►nl) 1 "ou Too? Top 10 Commonly Confused Words, Vol. 1 a 4V " VlachiavelliaWsm" mid (A Whole lot) iVlore Top 10 Unusually Long and Interesting Words, Vol. 1 -` -N "Loathe" After Madonna ungraciously received a gift i of flowers from a fan ... morel, http: / /www.merriam- webster.com/ medical / sodium+ fluosilicate ?show =0 &t= 1315838789 9/12/2011 +r �G .' CA v C—ro r� faol tl http://www.infowars.com/images/fluofidebag.jpg 9/12/2011 10C Ingestion from Water, Supplements and Denfifrice y the mid - 1980x, the prevalence of dental caries in children had de- clined dramatically in the United States and other developed coun- tries, mainly due to the widespread use of fluoride in many forms.1' More recently, concerns have been raised about the in- creased prevalence and severity of dental fluorosis in the United States&6 due to the widespread inges- tion of fluoride from a variety of sources. Local and regional studies in the United States and Canada have found the prevalence of mostly mild dental fluorosis to range from about 20 to 80 percent a' In an effort to help people achieve the "optimal" in- take of ingested fluoride to balance dental caries prevention and dental fluorosis, the recommended dietary fluoride supplementation dosage recently has been reduced in both the United Statee" and Canada.1' In addition, prudent use of small quanti- ties of fluoride dentifrice by preschool -aged children has been widely recommended.'¢16 (Author's note: The optimal level of fluoride intake has never been determined scientifically and has been used only in general terms. Levy and Guha- Chowdhury1° ad- dressed the limitations of current knowledge of "op- timal" fluoride intake levels.) JADA, Vol. 126, December 1995 1625 1 STEVEN M. LEVY, D.D.S., M.P.H.; FRANK J. K, PH.D., M.S.: n ants MARY C. KIRITSYRITSY M.SC., R.D.; JUDY R. HEILMAN. S.S.; JAMES S. WEFEL. PH.D. Fluonde. • Ingestion from Water, Supplements and Denfifrice y the mid - 1980x, the prevalence of dental caries in children had de- clined dramatically in the United States and other developed coun- tries, mainly due to the widespread use of fluoride in many forms.1' More recently, concerns have been raised about the in- creased prevalence and severity of dental fluorosis in the United States&6 due to the widespread inges- tion of fluoride from a variety of sources. Local and regional studies in the United States and Canada have found the prevalence of mostly mild dental fluorosis to range from about 20 to 80 percent a' In an effort to help people achieve the "optimal" in- take of ingested fluoride to balance dental caries prevention and dental fluorosis, the recommended dietary fluoride supplementation dosage recently has been reduced in both the United Statee" and Canada.1' In addition, prudent use of small quanti- ties of fluoride dentifrice by preschool -aged children has been widely recommended.'¢16 (Author's note: The optimal level of fluoride intake has never been determined scientifically and has been used only in general terms. Levy and Guha- Chowdhury1° ad- dressed the limitations of current knowledge of "op- timal" fluoride intake levels.) JADA, Vol. 126, December 1995 1625 ER STORY TABLE Y Few studies have reported comprehensively on fluoride ex- posures or ingestion by children; most of these studies have used retrospective designs, which may limit their validity and util- ity,",' especially in terms of the level of detailed response possi- ble many years after the expo- sure. Little is known about the relative importance of different sources of ingested fluoride among preschool children whose permanent teeth are developing and who are at risk for dental fluorosis. Levy, Kohout, Guha- Chowdhury and colleagues re- cently reported on the frequency distribution of estimated intake of fluoride from water by itself, mixed with infant formula and mixed with other beverages among a group of infants from birth to 9 months of age.1e The 1626 JADA, Vol. 126, December 1995 purpose of this article is to re- port on the relative contribution of fluoride ingested from water, supplements and dentifrices to overall fluoride intake among a group of infants studied longitu- dinally from birth until 9 months of age. METHODS One hundred ninety -two women with newborns were recruited in 1990 from the postpartum wards of two Iowa City hospitals, after they had delivered but before they had left the hospital. 18 This constituted approximately 85 percent of all those invited to participate. Appropriate in- formed.consent procedures were used. The mothers completed a recruitment questionnaire and subsequently completed struc- tured mailed questionnaires con- cerning their infants at 6 weeks and 3, 6 and 9 months of age. The questionnaires focused pri- marily on the children's feeding habits, water sources and intake, as well as use of dietary fluoride supplements and fluoride denti- frice during the time since the previous questionnaire. Non - respondents received a second mailing after three weeks and were contacted by telephone again three weeks later. Participants received tooth- brushes as incentives. Fifty -six mothers did not return any ques- tionnaire after recruitment, 21 returned one of the four, 24 re- turned two, 26 returned three and 65 returned all four. Mothers reported whether their infants had ingested any of these 13 categories of bever- ages and food during the previ- ous week, and if so, the average daily amount ingested: water by itself; - powdered concentrate for- mula reconstituted with water; - liquid concentrate formula reconstituted with water; - ready -to -feed formula; - cow's milk; - breastmilk; - ready -to -drink juices; - beverages reconstituted with water; - other ready- to-drink beverages; - ready - to-feed baby food; - powdered infant cereal recon- stituted with water; - other food made with water; - table food. Total daily water intake was estimated from the reported in- take of water by itself; pow- dered and liquid concentrated formulas reconstituted with water; beverages reconstituted with water; powdered infant ce- reals reconstituted with water; and other food made with water (such as gelatin, pudding, soup). C AGE 6 3 6 9 weeks months months months 4=122) (n =118) (n =98) (n =75) Psrcentile d (minimum) U 0 0 0 25 0.02 0.02 0.0 1 0.03 50 (median) 0.1.4 0.14 0.24 0.14 75 0.46 0.56 0.62 0.49 90 0,83 1..06 0.93 0.80 100 (rnaxilnu111) 1.24 1.57 1.29 1.7 :1 Overall mNan 0.29 0.:3 0.:3� 0.733 (80) (0.32) (0.42) (0. .10 (0.36) Mea ims (S >•) by wntear fltsavicie level (PPm)' <0.3 0.03 0.04 0.03 0.04 (O.OS) ''(0.(36) (0.06) (0.07) 0.3 -0.6 0.20 0_17 0.17 0.1:3 (0.12) (0.08) (0.12) (0:08) -0.6 0.46 0.57 0.64 0.46 (0.3:3) (0.44) (0.36) (0.39) Few studies have reported comprehensively on fluoride ex- posures or ingestion by children; most of these studies have used retrospective designs, which may limit their validity and util- ity,",' especially in terms of the level of detailed response possi- ble many years after the expo- sure. Little is known about the relative importance of different sources of ingested fluoride among preschool children whose permanent teeth are developing and who are at risk for dental fluorosis. Levy, Kohout, Guha- Chowdhury and colleagues re- cently reported on the frequency distribution of estimated intake of fluoride from water by itself, mixed with infant formula and mixed with other beverages among a group of infants from birth to 9 months of age.1e The 1626 JADA, Vol. 126, December 1995 purpose of this article is to re- port on the relative contribution of fluoride ingested from water, supplements and dentifrices to overall fluoride intake among a group of infants studied longitu- dinally from birth until 9 months of age. METHODS One hundred ninety -two women with newborns were recruited in 1990 from the postpartum wards of two Iowa City hospitals, after they had delivered but before they had left the hospital. 18 This constituted approximately 85 percent of all those invited to participate. Appropriate in- formed.consent procedures were used. The mothers completed a recruitment questionnaire and subsequently completed struc- tured mailed questionnaires con- cerning their infants at 6 weeks and 3, 6 and 9 months of age. The questionnaires focused pri- marily on the children's feeding habits, water sources and intake, as well as use of dietary fluoride supplements and fluoride denti- frice during the time since the previous questionnaire. Non - respondents received a second mailing after three weeks and were contacted by telephone again three weeks later. Participants received tooth- brushes as incentives. Fifty -six mothers did not return any ques- tionnaire after recruitment, 21 returned one of the four, 24 re- turned two, 26 returned three and 65 returned all four. Mothers reported whether their infants had ingested any of these 13 categories of bever- ages and food during the previ- ous week, and if so, the average daily amount ingested: water by itself; - powdered concentrate for- mula reconstituted with water; - liquid concentrate formula reconstituted with water; - ready -to -feed formula; - cow's milk; - breastmilk; - ready -to -drink juices; - beverages reconstituted with water; - other ready- to-drink beverages; - ready - to-feed baby food; - powdered infant cereal recon- stituted with water; - other food made with water; - table food. Total daily water intake was estimated from the reported in- take of water by itself; pow- dered and liquid concentrated formulas reconstituted with water; beverages reconstituted with water; powdered infant ce- reals reconstituted with water; and other food made with water (such as gelatin, pudding, soup). C TABLE 2 Mean daily intake 0.13 0.18 0.19 0.1.4 (_SIJ) from supple -- (0.08) (0.08) (0.08) (0.09) merits' * In weeks when' supplements were received t Mean daily intake from supplements - (supplement dosage prescribed)o (proportion of weeks that supplements were received )-( proportion ofdays that supplements were received). In addition to completing a questionnaire at each time point, mothers also completed three -day intake diaries of all beverages and foods that we used to confirm the mothers' answers concerning these cate- gories of ingestion. We contact- ed the mothers by telephone or mail to clarify important dis- crepancies between question- naire and diary responses. No assessment of reliability of sub- ject responses was conducted. Fluoride levels of well water, bottled water and filtered water supplies in homes and child care settings were assayed with a fluoride- specific electrode. Available information obtained from the State of Iowa Health Department reporting monthly fluoride values was used to de- termine fluoride levels in those homes and child care settings using public water supplies. We estimated the amounts of fluo- ride ingested from water at each age by multiplying the amounts of water ingested times the fluoride levels of the water used. At each time point, mothers reported whether their infants received dietary fluoride supple- ments. If so, then they reported the number of weeks that sup- plements were given, the aver- age number of days per week given and the brand and dosage used. From these responses, we calculated an average daily fluoride supplement dosage. If dosage data were not available, we assumed that the then - recommended dosage of 0.25 milligrams of fluoride was used. Mothers also reported whether their infants had any teeth yet, whether the teeth were brushed, the daily frequen- cy of brushing, whether fluoride dentifrice was used, the quanti- ty of dentifrice used (by choosing from among pictures of tooth- brushes with varying quantities of dentifrice)"," and an estimate of the proportion of dentifrice usually ingested. From these re- sponses, we estimated the in- COVER STORY fan& average daily fluoride dentifrice use and ingestion. We analyzed the data using SPSS -PC Plus (SPSS Incor- porated) with descriptive statis- tics generated at each time point for each variable for the whole sample. Here we present selected results according to composite water fluoride levels (individually weighted averages of home, bot- tled water and child care setting sources) categorized as X0.3 parts Per million, 0.3 to 0.6 ppm or >0.6 ppm, according to the dietary fluoride supplement categories for water fluoride levels recently adopted by the American Dental Association, the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.&" The results presented here are for the 122 respondents at 6 weeks of age, 118 at 3 months, 98 at 6 months and 75 at 9 months. This is the same group of children followed longitudi- nally, not different groups at each time period. RESULTS We compared the baseline responses at recruitment of re- spondents with those of non- respondents at the different time points to assess possible non - response bias."` No signifi- cant differences arose between respondents and non- respond- ents in source of water, child care plan, number of adults or children in the family or family income. Only on parent educa- tion did respondents differ sig- nificantly; the mothers and fa- thers of infants remaining in the study at 6 months and 9 months of age had significantly higher levels of education than did the parents of non- respond- ents.11 We also compared 3- month and 6 -month fluoride in- JADA, Vol. 126, December 1995 1627 C AGE VARIABLE g 3 g g wooks months months months 1 Percentage ro ceiving 25 19 23 23 aupplemantw Supplement use, (among users only) NurYlber uf'�uUjects 31 22 22 17 Mean percentage 63 84 82 72 (ST)) cIf weeks in (29) (26) (30) (3 5) period Mean pei-centage 83 86 91 86 (SE)) ofdaym per week"`' (28) (22) (19) (26) Mean daily intake 0.13 0.18 0.19 0.1.4 (_SIJ) from supple -- (0.08) (0.08) (0.08) (0.09) merits' * In weeks when' supplements were received t Mean daily intake from supplements - (supplement dosage prescribed)o (proportion of weeks that supplements were received )-( proportion ofdays that supplements were received). In addition to completing a questionnaire at each time point, mothers also completed three -day intake diaries of all beverages and foods that we used to confirm the mothers' answers concerning these cate- gories of ingestion. We contact- ed the mothers by telephone or mail to clarify important dis- crepancies between question- naire and diary responses. No assessment of reliability of sub- ject responses was conducted. Fluoride levels of well water, bottled water and filtered water supplies in homes and child care settings were assayed with a fluoride- specific electrode. Available information obtained from the State of Iowa Health Department reporting monthly fluoride values was used to de- termine fluoride levels in those homes and child care settings using public water supplies. We estimated the amounts of fluo- ride ingested from water at each age by multiplying the amounts of water ingested times the fluoride levels of the water used. At each time point, mothers reported whether their infants received dietary fluoride supple- ments. If so, then they reported the number of weeks that sup- plements were given, the aver- age number of days per week given and the brand and dosage used. From these responses, we calculated an average daily fluoride supplement dosage. If dosage data were not available, we assumed that the then - recommended dosage of 0.25 milligrams of fluoride was used. Mothers also reported whether their infants had any teeth yet, whether the teeth were brushed, the daily frequen- cy of brushing, whether fluoride dentifrice was used, the quanti- ty of dentifrice used (by choosing from among pictures of tooth- brushes with varying quantities of dentifrice)"," and an estimate of the proportion of dentifrice usually ingested. From these re- sponses, we estimated the in- COVER STORY fan& average daily fluoride dentifrice use and ingestion. We analyzed the data using SPSS -PC Plus (SPSS Incor- porated) with descriptive statis- tics generated at each time point for each variable for the whole sample. Here we present selected results according to composite water fluoride levels (individually weighted averages of home, bot- tled water and child care setting sources) categorized as X0.3 parts Per million, 0.3 to 0.6 ppm or >0.6 ppm, according to the dietary fluoride supplement categories for water fluoride levels recently adopted by the American Dental Association, the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.&" The results presented here are for the 122 respondents at 6 weeks of age, 118 at 3 months, 98 at 6 months and 75 at 9 months. This is the same group of children followed longitudi- nally, not different groups at each time period. RESULTS We compared the baseline responses at recruitment of re- spondents with those of non- respondents at the different time points to assess possible non - response bias."` No signifi- cant differences arose between respondents and non- respond- ents in source of water, child care plan, number of adults or children in the family or family income. Only on parent educa- tion did respondents differ sig- nificantly; the mothers and fa- thers of infants remaining in the study at 6 months and 9 months of age had significantly higher levels of education than did the parents of non- respond- ents.11 We also compared 3- month and 6 -month fluoride in- JADA, Vol. 126, December 1995 1627 C ER STORY TABLE S AOE a 3 a 0 wooks months months months Pesx�sent4l�b 0 (rninimurn) 0 i 0 0 0 25 0.05 0.06 0.11 0.06 50'(roedian) 0.26 0.21 0.29 0.22 75 0.49 0.56 0.68 0.49 90 0.83 1.06 0.98 0.80 100 (maximum) -1.24 1.57 1..65- 1.73 Overcall mean 0.32 0.38 0.42 0.31 (9Ll) (0.32) (0.41) (0.37) (0.36) lo'vol (ppi} <Q_3 0.09 0.07 0.12 0.12 (o -lo) (0.08) (0.11-) (0.14) 0.3 -0.6 0.20 0.19 0.26 0.13 (0.12) (0.11) (0.14) (0.08) _-0.6 0.48 0.60 0.65 0.49 (0.33) (0.41) (0.35) (0.39) take estimates between those responding and those not re- sponding at later time points (six months and nine months).1e Although we found no statisti- cally significant differences, those responding at more time points tended to have a higher estimated fluoride intake.18 Table 1 summarizes the pre- viously reported7s frequency dis- tribution of estimated total fluo- ride intake from water for the total sample at each age check- point. There is substantial vari- ation in intake, with the stand- ard deviations larger than the means. The distributions are skewed; the means are approxi- mately twice as large as the me- dians. The medians were 0.14 mg of estimated ingested fluo- ride daily, except at age 6 1628 DADA, Vol. 126, December 1995 months with median intake of 0.24 mg, while the mean intakes were from 0.29 to 0.38 mg. The maximum individual intakes ranged from 1.24 to 1.73 mg per day. Table 1 also presents the means separately for water fluo- ride levels (weighted average of home, bottled and child -care- setting water sources) and cate- gorizes them as <0.3, 0.3 to 0.6, or >0.6 ppm fluoride. Table 2 summarizes the use of dietary fluoride supplements. Supplement use varied little at the different time points, and there was no apparent increase or decrease over time. Among those who gave their children supplements, the mean percent- ages of weeks (in each time peri- od) that they used supplements were 63 to 84 percent. In the 1 weeks that supplements were used, they were used an average of 83 to 91 percent of the days. Among the children using sup- plements, estimated mean daily fluoride intake from supplements varied only from 0.13 mg at 6 weeks to 0.19 mg at 6 months. No parents reported their in- fants' using fluoride dentifrice before their 9 -month question- naires. At 9 months, 88 percent of the mothers reported that their infants had 1 or more teeth and 56 percent of these said their infants' teeth were being brushed. Among these 37 children, 40 percent had teeth brushed less than once daily, 57 percent brushed once daily and 3 percent brushed twice daily (mean =0.80, SD- 0.36). Thirty percent of those whose teeth were brushed used fluoride den- tifrice (n =11). The estimated quantity of fluoride dentifrice used per brushing varied from less than 0.01 to 0.25 grams (mean =0.08, SD= 0.07). The es- timated quantity of fluoride in- gested daily ranged from less than 0.01 to 0.25 mg (mean= 0.06, SD =0.08). Table 3 summarizes the esti- mated total fluoride intake from water, supplements and denti- frice combined. The results are very similar to, but slightly high- er than, those shown in Table 1 for fluoride intake from water, since most infants received nei- ther fluoride supplements nor dentifrice. There is substantial variation in total estimated fluo- ride intake from these sources, and the distributions are posi- tively skewed (means were greater than medians). There was a fairly consistent trend to- ward increased daily fluoride in- take with increasing age (except at 9 months). However, when ad- justed on the basis of fluoride in- TABLE 4 From supple- meets Range Mean (all) SD (rill) Moan (among 0 -99 0 -100 3 -100 0-98 14 12 i8 12 32 30 36 27 ' 66 80 77 62' take per unit body weight (mil- ligrams of fluoride per kilogram of body weight), fluoride inges- tion remained relatively constant or declined slightly with increas- ing age."-"' Table 3 also presents the means reported separately for the different water fluoride levels (composite of home, bottled and child- care -. setting water). Standard deviations also were higher for those with higher water fluoride levels. Table 4 summarizes the sepa- rate distributions of total com- bined fluoride intake from water, supplements and dentifrice that come from each source separate- ly. The mean percentage of this intake from water varied only slightly, from 82 percent for 6- month -olds to 88 percent for 3- month -olds. Overall, supple- ments and dentifrices contrib- uted little to the fluoride intake. However, among those using supplements or dentifrice, these sources contributed more sub- stantially to fluoride ingestion. For example, supplements con- tributed 12 percent (among 3- month- and 9- month -olds) to 18 percent (among 6- month -olds) of the total fluoride intake from these three sources for the whole sample. However, when consid- ered for only those receiving sup- plements, the percentage contri- butions ranged up to maximums of 98 to 100 percent, and the mean percentage contributions ranged from 52 percent (at nine months) to 80 percent (at three months). Dentifrice ingestion was not reported until the 9- month checkpoint. Among the total sample of 9- month -olds, the mean percentage of fluoride in- take contributed by dentifrice in- gestion was only 2 percent. However, among only users of fluoride dentifrice, dentifrice con- COVER STO tributed up to 46 percent, with a mean of 19 percent. DISCUSSION Sample. There are several fac- tors to consider in interpreting the results of this study. Although the infants in this convenience sample did show a wide range of feeding patterns, water fluoride levels and pat- terns of use of supplements and dentifrice, the sample is not necessarily representative of the broader population of in- fants.18 The values of fluoride intake calculated are estimates only, derived from parents' re- ports that were not validated." And fluoride intake from ready - to- consume infant formulas, juices, baby foods and other foods and beverages was not in- cluded in this study." Also, the ages of the participating infants actually varied by anywhere from a few days to several weeks, which could affect food and beverage intake patterns.18 Furthermore, the numbers of infants for whom we have data varied across the time periods. However, comparisons of base- line data from respondents and non - respondents and of three - and six -month data according to response/non- response at later time points showed few signifi- cant differences. In addition, other analyses (not described in this article) showed similar di- etary patterns and estimated dietary intake for respondents who provided data at all four time points as for the respon- dents overall.18 Individual body weights were not available; thus calculations of fluoride in- take per unit of body weight used only aggregate weights linked to individual fluoride in- take data and, therefore, are only estimates. Is For these and JADA, Vol. 126, December 1996 1629 C Ringo $ — — — 0 -46 p Mean (Sal) 0 0 0 � 2 8D (all) � � Mean (among 19 j users only) take per unit body weight (mil- ligrams of fluoride per kilogram of body weight), fluoride inges- tion remained relatively constant or declined slightly with increas- ing age."-"' Table 3 also presents the means reported separately for the different water fluoride levels (composite of home, bottled and child- care -. setting water). Standard deviations also were higher for those with higher water fluoride levels. Table 4 summarizes the sepa- rate distributions of total com- bined fluoride intake from water, supplements and dentifrice that come from each source separate- ly. The mean percentage of this intake from water varied only slightly, from 82 percent for 6- month -olds to 88 percent for 3- month -olds. Overall, supple- ments and dentifrices contrib- uted little to the fluoride intake. However, among those using supplements or dentifrice, these sources contributed more sub- stantially to fluoride ingestion. For example, supplements con- tributed 12 percent (among 3- month- and 9- month -olds) to 18 percent (among 6- month -olds) of the total fluoride intake from these three sources for the whole sample. However, when consid- ered for only those receiving sup- plements, the percentage contri- butions ranged up to maximums of 98 to 100 percent, and the mean percentage contributions ranged from 52 percent (at nine months) to 80 percent (at three months). Dentifrice ingestion was not reported until the 9- month checkpoint. Among the total sample of 9- month -olds, the mean percentage of fluoride in- take contributed by dentifrice in- gestion was only 2 percent. However, among only users of fluoride dentifrice, dentifrice con- COVER STO tributed up to 46 percent, with a mean of 19 percent. DISCUSSION Sample. There are several fac- tors to consider in interpreting the results of this study. Although the infants in this convenience sample did show a wide range of feeding patterns, water fluoride levels and pat- terns of use of supplements and dentifrice, the sample is not necessarily representative of the broader population of in- fants.18 The values of fluoride intake calculated are estimates only, derived from parents' re- ports that were not validated." And fluoride intake from ready - to- consume infant formulas, juices, baby foods and other foods and beverages was not in- cluded in this study." Also, the ages of the participating infants actually varied by anywhere from a few days to several weeks, which could affect food and beverage intake patterns.18 Furthermore, the numbers of infants for whom we have data varied across the time periods. However, comparisons of base- line data from respondents and non - respondents and of three - and six -month data according to response/non- response at later time points showed few signifi- cant differences. In addition, other analyses (not described in this article) showed similar di- etary patterns and estimated dietary intake for respondents who provided data at all four time points as for the respon- dents overall.18 Individual body weights were not available; thus calculations of fluoride in- take per unit of body weight used only aggregate weights linked to individual fluoride in- take data and, therefore, are only estimates. Is For these and JADA, Vol. 126, December 1996 1629 C ER STORY TABLE a PERCENTILE ESTIMATED F BODY EXPECTED 90 INTAKE FROM WEICiHTi "OPTIMAL - 50 (median) THIS STUDY (KQ) F INTAKE 90 (MO DAY) La montus (MC: /DAY)"'' 50 (tnediTan) 0.22 75 0.4¢3 50 (nie:dian) 0.26 4.8 0.24-0.34 7.5 0.46 5.1 0.26- 0.36 90 0.83 !- .A 0.27 -0.:38 3 monthw r�0 t rxu- cling) 0.21 90 11.06 6 months 50 (median) 0.29 75 0.68 90 0.98 La montus 50 (tnediTan) 0.22 75 0.4¢3 90 ().Ao 6.0 0.:30 -0_ -12 6. 11 0_32 -0-45 6.8 0,34 -0.98 7,6 0.3R -0.53 $..3 0,41-0.57 8.5 0.43 -0.60 8 7 0.44-0.61 9.3 0.47-0,65 * Adapted from Levy and colleagues." Average weight of he ys and girls combined:" Body weight of 6 -week -old infants has been calculated by taking the average of weights of infants aged 4 weeks and tl weeks. Expected range of fluoride intake based on 0.05 =0.07 mg fluoride /kg bady weight traditon- ally being accepted as optimal other reasons, caution is neces- sary in generalizing from the results of this study, and specif- ic assessment of fluoride expo- sures and ingestion must be done at the individual level. Despite these limitations, this report has demonstrated substantial variation in esti- mated total ingestion of fluoride from water, dietary fluoride supplements and dentifrice among children ranging from 6 weeks to 9 months of age. Virtually every child received some fluoride from drinking water, whether only at home or both at home and in the child care setting. Supplements were used by about 25 percent of the children, and only a small per- centage of 9- month -olds ingest- ed fluoride dentifrice. 1630 JADA, Vol. 126, December 1995 Contributions of fluoride sources on ingestion and in- take levels. We evaluated the contributions of the three fluo- ride sources — supplements, dentifrice and water (alone and in food and beverages -to in- gestion and intake levels. Supplements and dentifrice. When we averaged the oontnbu- tions of dietary fluoride supple- ments and fluoride dentifrice over the whole study group, we found that they contributed small absolute quantities of fluo- ride ingestion and small percent- ages of total fluoride intake at each age from 6 weeks to 9 months. However, in the children who ingested supplements or flu- oride dentifrice, absolute quanti- ties of intake from these sources and percentages of total intake i were substantially larger. For some infants, estimated inges- tion of fluoride from supplements and/or dentifrice exceeded that from water and all beverages and foods prepared with water. Thus, all three general sources of fluoride intake— water, supple- ments and dentifrice– should be considered when estimating total fluoride intake. Since children in this study were studied only until 9 months of age, fluoride denti- frice use was not yet nearly uni- versal, as it generally becomes by about age 18 months to 24 months. Fluoride dentifrice was used at 9 months by only about 30 percent of those whose teeth were brushed, as many mothers initially brush without denti- frice until more teeth have erupted. Thus, dentifrice would be a much more important source of fluoride intake at 12 months of age and thereafter. Water. Although infants who had higher fluoride levels in their drinking water generally received more fluoride and clearly had higher mean fluo- ride ingestion than did those with lower water - fluoride lev- els, there was substantial vari- ability at the individual level. Some children ingesting large quantities of water with moder- ate fluoride levels may receive more fluoride than do others in- gesting much smaller quantities of optimally fluoridated water. Ready -to -feed food and bever- ages. It would be desirable also to include fluoride intake from ready - to-feed foods and bever- ages or those prepared without adding water. However, it gen- erally is difficult to estimate fluoride intake from these sources since their levels can vary substantially, especially depending on the water sources E� t _ - Dr. Levy Is a proles- Dr. Kohout Is a pro- ver and graduate fessor. Departrowd program dseotor, of partodond" acrd Department of Doves Matltute for Preventive and Dental Roeearoh. Corr- raedly Derdlelry. College of be tbab W. Co1Ngo of Dentistry. Univerafq of lours, The Unhwershy of Iowa Ctty. lava, bws Clb. lorw rsprlM request. to : used in their Dr. Levy. manufac- ture. 14,16,2422 This does not negate the need for the clinician to estimate a child's total fluoride intake to account for any substantial quantities of ready -to -feed high - fluoride foods or beverages —for instance, ready -to -feed soy - based infant formulas, chicken baby foods, infant grape juices, tea —that the child may be con- suming. Perhaps mean values could be used as estimates for these products' fluoride levels. The optimal intake level. We reported previously that esti- mated daily fluoride intake only from water itself, from water added to beverages and from foods made with water probably exceeded the traditionally accept- ed optimal total daily fluoride in- take of 0.05 to 0.07 mg fluoride per kg of body weight for a sub- stantial percentage of the infants in this study.18 Similar and slight- ly stronger patterns of fluoride intake that exceed optimal fluo- ride intake are evident when in- take from supplements and den- tifrice (Table 3) are included. For example, a total optimal daily flu- oride intake of 0.05 to 0.07 mg fluoride/kg body weight would mean totals (Table 5) of about 0.240.34 mg fluoride for a 6- week -old with mean body weight of 4.8 kg,23 0.30 -0.42 mg fluoride for a mean- weight (6.0 kg) 3- month -old, 0.38 -0.53 mg fluoride for a mean- weight Me. Khrify y re- (7.6 kg) 6- soaruh """'"`' ! month -old and nt Departme of PreveMivo and 0.44 -0.61 mg Common" I' fluoride for a Dentistry. College of -. Dentistry, UnWarafty mean- weight of tows. Iowa City. (8.7 kg) 9- month -old. Mean (and median) fluoride intake in this study from water, supplements and dentifrice (but excluding other dietary fluoride intake) in infants up to 6 months old was within or less than these optimal total daily intake ranges. However, the 75th per- centiles from our data for 6- week -olds, 3- month -olds and 6- month -olds clearly exceeded the ranges for 75th percentiles of expected optimal intake by about 0.10 to 0.27 mg. The 90th percentile of estimated fluoride intake exceeded the expected op- timal daily fluoride intake for all age groups from 6 weeks to 9 months, with the extra amounts being about 0.45 to 0.56 mg for 6 -week -olds, 0.58 to 0.72 mg for 3- month -olds, 0.38 to 0.55 mg for 6- month -olds and 0.11 to 0.31 mg for 9- month -olds. These 90th percentiles of intake for 6 -week- olds and 3- month -olds are more than twice the expected optimal intake, with the proportional dif- ferences somewhat less dramatic for those 6 months or older. Deciding when to use a supplement. With the majority of children having much less decay than in the past, with di- verse sources and variable quantities of ingested fluoride and with the role of systemic fluoride understood to be less important than previously be- lieved, decisions about use of di- COVER STO etary fluoride supplements are more complex than they were in the past. Their use has been questioned` because it increas- es the risk of dental fluorosis, while average reductions in decay are more modest com- pared with those in the past. Therefore, our research group 14,16,20,26 and others9,13,11 have recommended more conserva- tive use of dietary fluoride sup- plements, although continued emphasis on dietary fluoride supplements has also been rec- ommended.36 Specifically, our research group recently recom- mended14 that supplements be "considered a targeted preven- tive regimen instead of being used routinely for the general population of all children living in non - fluoridated areas." When considering use of di- etary fluoride supplements, as- sessment of the patient's caries risk should be a primary consid- eration.14 Although this deter- mination is especially difficult to make for young children, often the "previous caries histo- ry for the child, siblings, and parents; the family's dental knowledge and preventive ori- entation; the child's physical and cognitive status and use of medications; the child's oral preventive behaviors; the child's other fluoride exposures; and possibly results of caries activi- ty tests "14 are important aspects to consider. Monitoring fluoride in- take. The results of this study are consistent with our recent recommendations1' concerning dietary fluoride. Since it is diffi- cult to avoid excessive intake of fluoride by adjusting fluoride in- take via control of food and bev- erage consumption,11 primary emphasis should be on limiting fluoride ingestion from the more JADA, Vol. 126, December 1995 1631 VER STORY Dovrs Imutua for _ Dentstry, and dboo- Dental Researeh, bow, Do" ImtRuts cone or Deemsety. for Dental ReeearoA, unMrNb of Iowa. Celle" of Dentistry, lows env. thdversfhr of awe. aws Dip,. defined sources of supplements and dentifrices. However, manu- facturers of bottled waters, juices and soft drinks; infant formulas; and baby foods should be re- quired to monitor and list the flu- oride levels on their products. 14 Also, "infants receiving substan- tial quantities of infant formula generally should not use powder or liquid concentrate if water flu- oride levels are near optimal or above, since the water fluoride alone might then exceed total, recommended daily levels."" Monitoring dentifrri use. Concerning dentifrice use, the prevention of ingestion of large quantities of fluoride dentifrice by young children should be a major emphasis of the whole dental team within the office, as well as of professional organiza- tions and manufacturers. Use of small, pea -sized quantities of dentifrice by young children; parental responsibility for place- ment of dentifrice and actual brushing, with special attention to dentifrices flavored for chil- dren that may encourage inges- tion" and those with high fluoride concentration; and elim- inating corporate promotion of use of a full strip of dentifrice are all important components of such efforts.l'-1 - "'° In addition, emphasis on future research and acceptance of dentifrices that have a lower- than - conventional 1632 JADA, Vol. 126, December 1996 concentration of fluoride is war - ranted.ml4,16x,31 CONCLUSION It is hoped that by considering all sources of ingested fluoride; making more conservative, indi- vidualized use of dietary fluo- ride supplements; and prudent- ly using fluoride dentifrice, dentists and their patients can best balance caries prevention and the risks of dental fluorosis. Also, because physicians pre- scribe most of the dietary fluo- ride supplements used by in- fants and young children, it is important for dentists and/or other members of the dental team to discuss these considera- tions with their medical col- leagues. ■ Parts of this research were presented at the 1994 annual meetings of the International Association fbr Dental Research and the American Association of Public Health Dentistry. This project was supported in part by USPHS NIDR grants R03- DE09200, R01- DE09661 and P30- DE10126. The authors thank Me. Mary Jo Mohr, Ms. Cindy O'Toole and Ms. Marilyn Pratt. 1. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of water fluoridation. J Dent Res 1990;69 (Special Issue):723 -7. 2. Burt B. Trends in caries prevalence in North American children. Int Dent J 1994; 44(Supplement 1):403 -13. 3. Szpunar SM, Burt BA. Trends in the prevalence of dental fluorosis in the United States: a review. J Public Health Dent 1987;47:71- 9.[published erratum appears in J Public Health Dent 1987;47(3):1667 4. Burt BA. Fluoride -how much of a good thing? Introduction to the symposium. J Public Health Dent 1996;66(1):37 -8. 6. Rosier RG. Prevalence and severity of enamel fluorosis in North American children. J Public Health Dent (In press). 6. Brunelle JA. The prevalence of dental fluorosis in U.S. children, 1987 (Abstract). J Dent Res 1989;68 (Special Iesue):996. 7. Clark DC. Trends in prevalence of dental fluorosis in North America. Community Dent Oral Epidemic] 1994;22:148 -62. 8. American Dental Association. New fluo- ride guidelines proposed. DADA 1994; 126:366. 9. American Dental Association. New fluo- ride schedule adopted. ADA News 1994; May 16:12,14. 10. Committee on Nutrition, American Academy of Pediatrics. Fluoride supplements - tion for children: interim policy recommenda- ioc tions. Pediatr 1996; 96:777. 11. American Academy of Pediatric Dentistry. Second step taken to ratify new fluoride dosage schedule. Pediatr Dent Toddy 1994;July:2. 12. Report of the Canadian workshop on the evaluation of current recommendations con- cerning fluorides. Introduction to the work- shop. Community Dent Oral Epidsmiol 1994;22:140.3. 13. Bawden JW, ed. Changing patterns of fluoride intake. Proceedings of the workshop. J Dent Res 1992;71:1212 -27. 14. Levy SM, Hiritey MC, Warren JW. Sources of fluoride intake in children. J Public Health Dent 1996;b6(1) :89 -62. 16. U.S. Public Health Service, Ad Hoc Subcommittee on Fluoride. Review of fluoride benefits and risks. Washington, D.C.: U.S. Government Printing 016ce, February, 1991. 16. Levy SM, Guha- Chowdhury N. Total fluoride intake and implications for dietary fluoride supplements. J Public Health Dent (In press). 17. Levy SM, Maurice TS, Jakobsen JR. Feeding patterns, water sources and fluoride exposures of infants and 1- year-olds. JADA 1993;124(4):649. 18. Levy SM, Kohout FJ, Guha- Cbowdhury N, Kiritsy MC, Heilman JR, Wahl JS. Inlsnts' fluoride intake Aram drinking water alone, and from water added to ibrmufa, beverages and food. J Dent Res 1996;74(7):1399.1407. 19. Levy SM, Zarei -MZ. Evaluation of Quo - ride exposures in children. ASDC J Dent Child 1991;68:487 -73. 20. Levy SM. Review of fluoride exposures and ingestion. Community Dent Oral Epi. demiol 1994;22:173 -80. 21. Levy SM, Kiritsy MC, Heilman JR, Van Winkle 8, Vukovic 8, Wefel JS. Fluoride lev- els of ready -to -feed juiow and juice drinks (Abstract No. 1043). J Dent Res 1993;72(Spe" Issue):234. 22. Pang PTY, Phillips CL, Bawden JW. Fluoride intake from beverage consumption in a sample of North Carolina children. J Dent Rea 1992;1382 -8. 23. Fomoa SJ, Nelson SE. Size and growth. In: Fomon SJ, ed. Nutrition of normal in- fanta. St. Louis: Mosby;1993:36 -84. 24. Szpunar SM, Burt BA. Fluoride supple- ments: evaluation of appropriate use in the United States. Community Dent Oral Epi- demio11992 0 :148 -64. 26. Levy SM, Muchow G. Provider compli- ance with recommended dietary fluoride sup- plement protocol. Am J Public Health 1992;82:281.3. 26. Horowitz HS. Commentary on and rec- ommendations for the proper uses of fluoride. J Public Health Dent 1996;66(1):67 -62. 27. Levy SM, Maurice TJ, Jakobsen JR. A pilot study of pre- schoolers' use of regular fla- vored dentifrices, and those flavored for chil- dren. Pediatr Dent 1992;14:388-91. 28. Levy SM. A review of fluoride intake from fluoride dentifrice. ASDC J Dent Child 1993;60:116.24. 29. Maurice TJ, Levy SM, Jakobsen JR. Dentifrice use among preschool children. JADA 1998;124(9):67 -60. 30. Beltran ED, Szpunar SM. Fluoride in toothpastes for children: suggestions for change. Pediatr Dent 1988;10:186 -8. 31. Horowitz HS. The need for toothpastes with lower than conventional concentration for preschool -aged children. J Public Health Dent 1992;62:216 -21. �(_ *A11-1i ARTICLE 1 C O V E R S T O R Y THE SCIENCE AND PRACTICE OF CARIES PREVENTION JOHN D.B. FEATHERSTONE, M.SC., PH-EX A B S T R A C T Background and Overview. Dental caries is a bacterially based disease. When it progresses, acid produced by bacterial action on dietary fermentable carbohy- drates diffuses into the tooth and dis- solves the carbonated hydroxyapatite min - eral—a process called demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lacto- bacilli), salivary dysfunction, and dietary carbohydrates are related to caries pro- gression. Protective factors —which include salivary calcium, phosphate and proteins, salivary flow, fluoride in saliva, and antibacterial components or agents — can balance, prevent or reverse dental caries. Conclusions. Caries progression or reversal is determined by the balance between protective and pathological fac- tors. Fluoride, the key agent in battling caries, works primarily via topical mech- anisms: inhibition of demineralization, enhancement of remineralization and inhibition of bacterial enzymes. Clinical Implications. Fluoride in drink- ing water and in fluoride- containing products reduces caries via these topical mechanisms. Antibacterial therapy must be used to combat a high bacterial chal- lenge. For practical caries management and prevention or reversal of dental caries, the sum of the preventive factors must outweigh the pathological factors. lthough the prevalence of dental caries in children has declined markedly over the last 20 years in most countries in the Western world, the disease continues to be a major problem for both adults and children everywhere. The trends in caries in U.S. children during the last 30 years were recently summarized' on the basis of results of four national surveys.2 -5 By the late 1980s, although approximately 75 percent of children aged 5 to 11 years were caries -free, about 70 percent of the 12- to 17- year -olds still had caries. Approximately 25 percent of children and adolescents in the 5- to 17 -year age range accounted for 80 percent of the caries in permanent teeth. By age 17 years, however, 40 percent of the population accounted for 80 per- cent of the caries.1-6 These findings illustrate the need for management of caries by individual risk assessment and for measures more specifically directed to high -risk people and populations. Although these prevalence rates still leave much to be desired, the overall caries prevalence in children has indeed declined in the United States. Smaller epidemiolog- ic studies in recent years indicate, however, that the decline in caries has not continued during the 1990s and that it may have plateaued.- DADA, Vol. 131, July 2000 887 Copyright ©1998 -2001 American Dental Association. All rights reserved. COVER STORY The reasons for the reduc- tions in caries prevalence dur- ing the last 20 years are diffi- cult to pinpoint. Strong evi- dence exists, however, that the near universal use of fluoride - containing products such as dentifrice, mouthrinses and top- ical gels applied in the dental office have been major contribu- tors.'' Earlier caries reductions of 40 to 70 percent (before the 1970s) had resulted from the fluoridation of public water sup- plies in many communities.9 -11 Dental caries in adults also continues to be a major prob- lem, as illustrated by a recent U.S. survey.13 The survey reported that 94 percent of all dentate adults (aged 18 years or older) had evidence of treat- ed or untreated coronal caries. Caries obviously still is a major problem in adults, as well as children, and we need an improved approach to pre- vention and therapy. This arti- cle reviews and summarizes the scientific basis for and practice of successful intervention in the caries process. THE CARIES PROCESS Bacterial plaque and acid production. The caries process is now well - understood; much of it has been described extensively in the dental literature. Some details of the caries process remain to be unraveled, but, in general, we understand the process well enough to initiate better - targeted methods of caries prevention and intervention. The mechanism of dental caries formation is essentially straightforward.' Plaque on the surface of the tooth consists of a bacterial film that produces acids as a byproduct of its metabolism. 14.1' To be specific, certain bacteria within the plaque are acidogenic —that is, they produce acids when they metabolize fermentable carbo- hydrates.12,11,15 These acids can dissolve the calcium phosphate mineral of the tooth enamel or dentin in a process known as demineralization. 11,111 If this process is not halted or re- versed via remineralization- the redeposition of mineral via saliva —it eventually becomes a frank cavity. Dental caries of the enamel typically is first observed clini- cally as a so- called "white -spot lesion." This is a small area of subsurface demineralization beneath the dental plaque. The The mutans streptococci and the lactobacilli, either separately or together, are the primary causative agents of dental caries. body of the subsurface lesion may have lost as much as 50 percent of its original mineral content and often is covered by an "apparently intact surface layer." 19 The surface layer forms by remineralization. The process of demineralization con- tinues each time there is carbo- hydrate taken into the mouth that is metabolized by the bac- teria. The saliva has numerous roles, including buffering (neu- tralizing) the acid and reminer- alization by providing minerals that can replace those dissolved from the tooth during deminer- alization.1,21,21 Any fermentable carbohy- drate (such as glucose, sucrose, fructose or cooked starch) can be metabolized by the acido- genic bacteria and create the aforementioned organic acids as byproducts .12 The acids diffuse through the plaque and into the porous subsurface enamel (or dentin, if exposed), dissociating to produce hydrogen ions as they travel. 17,23 The hydrogen ions readily dissolve the miner- al, freeing calcium and phos- phate into solution, which can diffuse out of the tooth. Most importantly, lactic acid dissoci- ates more readily than the other acids, producing hydrogen ions that rapidly lower the pH in the plaque. 17 As the pH is lowered, acids diffuse rapidly into the underlying enamel or dentin. The two most important groups of bacteria that predom- inantly produce lactic acid are the mutans streptococci and the lactobacilli.l' Each group con- tains several species, each of which is cariogenic. Mutans streptococci include Strep- tococcus mutans and S. sobri- nus. The lactobacilli species also are prolific producers of lactic acid and appear in plaque before caries is clinically observed .14,11 These two groups of bacteria, either separately or together, are the primary causative agents of dental caries. HOW FLUOR113E COMBATS THE CARIES PROCESS The ability of fluoride to pre- vent and arrest caries has been researched extensively. Fluo- ride has three principal topical mechanisms of action: inhibiting bacterial metabo- lism after diffusing into the 888 DADA, Vol. 131, July 2000 Copyright ©1998 -2001 American Dental Association. All rights reserved. bacteria as the hydrogen fluo- ride, or HF, molecule when the plaque is acidified; inhibiting demineralization when fluoride is present at the crystal surfaces during an acid challenge; enhancing remineralization and thereby forming a low - solubility veneer similar to the acid - resistant mineral fluorap- atite, or FAR on the remineral- ized crystals. Inhibiting bacterial metabolism. Several investiga- tors have studied the possible effects of fluoride on oral bacte- ria.z6-z8 The most significant finding reported is that the ion- ized form of fluoride, or F -, can- not cross the cell wall and membrane but can rapidly trav- el into the cariogenic bacterial cells in the unchanged form as HF .26-28 When the pH in the plaque falls as the bacteria produce acids, a portion of the fluoride present in the plaque fluid then combines with hydrogen ions to form HF and rapidly diffuses into the cell, effectively drawing more HF from the outside. 1,26-28 Once inside the cell, the HF dis- sociates, acidifying the cell and releasing fluoride ions that interfere with enzyme activity in the bacterium. For example, fluoride inhibits enolase, an enzyme necessary for the bacte- ria to metabolize carbohydrates. As fluoride is trapped in the cell, the process becomes cumu- lative. In summary, fluoride from topical sources is converted par- tially to HF by the acid that the bacteria produce and diffuses into the cell, thereby inhibiting essential enzyme activity. Inhibiting demineraliza- tion. The mineral of our teeth (enamel, cementum, dentin) COVER STORVmW Figure 1. High - resolution electron microscope Images (magnification approximately ±12,000,000) of individual enamel crystals. The black lines are rows of calcium atoms, which are visualized by this tech- nique. A. Normal enamel crystal showing white patches (arrows), which are calciumsdeficient and carbonate-rich defect regions. B. Deminerallzed crystal from the body of a natural caries lesion showing 'large" hexagonal holes coinciding with the "small" defect regions seen In normal enamel. (Adapted from Featherstone and col - leagues30,31 with permission from Karger, Basel.) and bones is a carbonated hydroxyapatite29 that can be approximately represented by this simplified formula: Calax(Na)X(PO9)s (CO)z (OH),-„(F)„ The substitutions in the hydroxyapatite crystal lattice (the arrangement of atoms and ions in the crystal) occur as the mineral is first laid down dur- ing tooth development, with the carbonate (CO) ion in particu- lar causing major disturbances in the regular array of ions in the crystal lattice.30s1 During demineralization, the carbonate is lost, and during remineral- ization it is excluded from the newly formed mineral. The cal- cium- deficient, carbonate -rich regions of the crystal are espe- DADA, Vol. 131, July 2000 889 Copyright ©1998 -2001 American Dental Association. All rights reserved. OVER STORY X a .! ems.✓ „ .s , � � � ..a. ' ' .. O 5 10 15 20 25 30 TIME (MINUTES) Figure 2. Typical pH curves for normal subjects with normal salivary flow and for subjects with xerostomia (mean for each group) after Ingestion of sucrose. A curve for Ingestion of a sugar -free sweetened product Is shown for comparison. (Reproduced from Featherstone' with permission of the publisher. Copyright 01999, Munksgaard.) cially susceptible to attack by the acid hydrogen ions during demineralization, as has been shown by several investiga- tors.21,29 33 High- resolution lat- tice imaging, which images crystals almost to atomic reso- lution (viewed at about x2,000,000 magnification), was used to illustrate the appear- ance of hexagonal holes in the early stages of enamel crystal dissolution in dental caries (Figure 1), which coincided with the calcium - deficient, carbon- ate- substituted regions of the crystal .311 The carbonated hydroxyap- atite, or CAP, of our teeth is much more soluble in acid than hydroxyapatite, or HAP (HAP = Ca,o(POq)6(OH)2), and that in turn is much more solu- ble than fluorapatite, or FAP (FAP = Ca,JPOJ,F),21 in which the OH- ion in pure hydroxyap- atite is completely replaced by an F" ion. The resulting mineral FAP is highly resistant to disso- lution by acid. Fluoride inhibits demineral- ization. Sound enamel, except in its outer few micrometers, generally contains fluoride at levels of about 20 to 100 parts per million, or ppm, depending on the fluoride ingestion during tooth development .31 Teeth in children who lived in areas with fluoridated drinking water during tooth development have fluoride content toward the higher end of this range. The outer few micrometers of en- amel can have fluoride levels of 1,000 to 2,000 ppm.34 Fluoride in the solution sur- rounding CAP crystals has been shown to be much more effec- tive in inhibiting demineraliza- tion than fluoride incorporated into the crystals at the levels found in enamel.21,31 Ten Cate,Z1 Nelson and colleagues35 and Featherstone and colleagues31,11 found no measurable reduction in the acid solubility of synthet- ic CAP (3 percent CO, by weight, comparable to that of dental enamel mineral) with about 1,000 ppm fluoride incor- porated. Importantly, this means that fluoride incorporat- ed during tooth mineral devel- opment at normal levels of 20 to 100 ppm (even in areas that have fluoridated drinking water or with the use of fluoride sup- plements) does not measurably alter the acid solubility of the mineral. Even when the outer enamel has higher fluoride lev- els, such as 1,000 ppm, it does not measurably withstand acid - induced dissolution any better than enamel with lower levels of fluoride. Only when fluoride is concentrated into a new crys- tal surface during remineraliza- tion is it sufficient to beneficial- ly alter enamel solubility. The fluoride incorporated develop- mentally —that is, systemically into the normal tooth mineral — is insufficient to have a measur- able effect on acid solubility."," In contrast to the lack of effect of fluoride incorporated into the CAP crystals of tooth mineral developmentally, as lit- tle as 1 ppm in the acid solution reduced the dissolution rate of CAP to a rate equivalent to that of HAP.36 Further increas- es in fluoride in the acid solu- tion in contact with the CAP mineral surface decreased the solubility rate logarithmically. These results indicate that if fluoride is present in the aque- ous solution surrounding the crystals, it is adsorbed strongly to the surface of CAP carbonat- 890 DADA, Vol. 131, July 2000 Copyright ©1998 -2001 American Dental Association. All rights reserved. Subjects with Subjects with Subjects normal salivary flow xerostomia who ingested who ingested who ingested a sugar -free sucrose sucrose sweetened product Figure 2. Typical pH curves for normal subjects with normal salivary flow and for subjects with xerostomia (mean for each group) after Ingestion of sucrose. A curve for Ingestion of a sugar -free sweetened product Is shown for comparison. (Reproduced from Featherstone' with permission of the publisher. Copyright 01999, Munksgaard.) cially susceptible to attack by the acid hydrogen ions during demineralization, as has been shown by several investiga- tors.21,29 33 High- resolution lat- tice imaging, which images crystals almost to atomic reso- lution (viewed at about x2,000,000 magnification), was used to illustrate the appear- ance of hexagonal holes in the early stages of enamel crystal dissolution in dental caries (Figure 1), which coincided with the calcium - deficient, carbon- ate- substituted regions of the crystal .311 The carbonated hydroxyap- atite, or CAP, of our teeth is much more soluble in acid than hydroxyapatite, or HAP (HAP = Ca,o(POq)6(OH)2), and that in turn is much more solu- ble than fluorapatite, or FAP (FAP = Ca,JPOJ,F),21 in which the OH- ion in pure hydroxyap- atite is completely replaced by an F" ion. The resulting mineral FAP is highly resistant to disso- lution by acid. Fluoride inhibits demineral- ization. Sound enamel, except in its outer few micrometers, generally contains fluoride at levels of about 20 to 100 parts per million, or ppm, depending on the fluoride ingestion during tooth development .31 Teeth in children who lived in areas with fluoridated drinking water during tooth development have fluoride content toward the higher end of this range. The outer few micrometers of en- amel can have fluoride levels of 1,000 to 2,000 ppm.34 Fluoride in the solution sur- rounding CAP crystals has been shown to be much more effec- tive in inhibiting demineraliza- tion than fluoride incorporated into the crystals at the levels found in enamel.21,31 Ten Cate,Z1 Nelson and colleagues35 and Featherstone and colleagues31,11 found no measurable reduction in the acid solubility of synthet- ic CAP (3 percent CO, by weight, comparable to that of dental enamel mineral) with about 1,000 ppm fluoride incor- porated. Importantly, this means that fluoride incorporat- ed during tooth mineral devel- opment at normal levels of 20 to 100 ppm (even in areas that have fluoridated drinking water or with the use of fluoride sup- plements) does not measurably alter the acid solubility of the mineral. Even when the outer enamel has higher fluoride lev- els, such as 1,000 ppm, it does not measurably withstand acid - induced dissolution any better than enamel with lower levels of fluoride. Only when fluoride is concentrated into a new crys- tal surface during remineraliza- tion is it sufficient to beneficial- ly alter enamel solubility. The fluoride incorporated develop- mentally —that is, systemically into the normal tooth mineral — is insufficient to have a measur- able effect on acid solubility."," In contrast to the lack of effect of fluoride incorporated into the CAP crystals of tooth mineral developmentally, as lit- tle as 1 ppm in the acid solution reduced the dissolution rate of CAP to a rate equivalent to that of HAP.36 Further increas- es in fluoride in the acid solu- tion in contact with the CAP mineral surface decreased the solubility rate logarithmically. These results indicate that if fluoride is present in the aque- ous solution surrounding the crystals, it is adsorbed strongly to the surface of CAP carbonat- 890 DADA, Vol. 131, July 2000 Copyright ©1998 -2001 American Dental Association. All rights reserved. ed apatite (enamel mineral) crystals and thus acts as a potent protection mechanism against acid dissolution of the crystal surface in the tooth's subsurface region. If fluoride is in the plaque fluid at the time that the bacteria generate acid, it will travel with the acid into the subsurface of the tooth and, therefore, adsorb to the crystal surface and protect it against being dissolved. In summary, fluoride present in the water phase at low levels among the enamel or dentin crystals adsorbs to these crystal surfaces and can markedly inhibit dissolution of tooth min- eral by acid."-" Fluoride that acts in this way comes from the plaque fluid via topical sources such as drinking water and fluoride products Fluoride incorporated during tooth development is insufficient to play a significant role in caries protection Fluoride is needed regularly1hroughout life to pro- tect teeth against caries. Enhancing remineraliza- tion. As the saliva flows over the plaque and its components neutralize the acid, raising the pH (Figure 2), demineralization is stopped and reversed. The saliva is supersaturated with calcium and phosphate, which can drive mineral back into the tooth.2139 The partially deminer- alized crystal surfaces within the lesion act as "nucleators," and new surfaces grow on the crystals (Figure 3). These processes constitute remineral- ization —the replacement of mineral in the partially de- mineralized regions of the cari- ous lesion of enamel or dentin (including the tooth root).10,11 Fluoride enhances remineral- ization by adsorbing to the crys- tal surface and attracting calci- COVER STOR Figure 3. High-resolution electron microscope Images (magnification approximately x2,000,000) of Individual enamel crystals that visualize remineralizatlon at the atomic level. The black lines are rows of calcium atoms, which are visualized by this technique. A. Normal enamel crystal dissected from the Inner region of enamel, showing "small' white patches of calclumsleficlent, carbonate-rich regions. B. Crystal on which a "remineralized" surface veneer has been grown after treat- ment with fluoride, calcium and phosphate. (Adapted from Featherstone and colleagues, 198130 with permission from Karger, Basel.) um ions, followed by phosphate ions, leading to new mineral formation. The newly formed "veneer" excludes carbonate and has a composition some- where between HAP and FAP as described above (Figure 4). FAP contains approximately 30,000 ppm F and has a very low solubility in acid. The new DADA. Vol. 131, July 2000 891 Copyright ©1998 -2001 American Dental Association. All rights reserved. bc =. somaCOVER STORY bacterial substances and ACID buffers:10 The saliva compo- Enamel crystal = Partly dissolved nents neutralize the acids pro- carbonated apatite crystal duced by bacterial metabolism in the plaque, raise the pH and reverse the diffusion gradient Remineralization Calcium + for calcium and phosphate. phosphate + fluoride Thereby, they return calcium V and phosphate to the subsur- Ca,o (P0,06 (F)2 = face lesion, where these ions fluorapatitelike --No-- can regrow new surfaces on the coating on crystals Crystal crystal remnants that were pro- nucleus duced by demineralization. These so-called "remineralized" crystals have a veneer of much less soluble mineral. Saliva also Figure 4. Schematic representation of demineralization followed by clears carbohydrates and acids remineralization in the caries process. If remineralization is successful, from the plaque. the final result is a crystal with a surface veneer of"fluorapatitelike" In the case of salivary dys- mineral of low solubility. (Reproduced from Featherstone' with permis- sion of the publisher. Copyright©1999, Munksgaard.) function,'[ all of the above bene- fits of saliva are reduced or eliminated (as is illustrated partially in Figure 2 by the pH Protective Factors Pathological Factors profile of the subjects with Salivary flow and components Reduced salivary function xerostomia). Proteins,antibacterial components Bacteria:mutans streptococci, and agents lactobacilli THE CARIES BALANCE Fluoride,calcium and phosphate Dietary components:frequency Dietary components:protective carbohydrates Fluoride's three extensively studied and documented princi- ipal mechanisms of action rely on the presence of fluoride in saliva, in the plaque at the NO CARIES CARIES tooth surface and in the fluid among the crystals in the sub- surface of the enamel or dentin. Figure 5. The caries balance: a schematic diagram of the balance The clinical effects of fluoride, between pathological and protective factors in the caries process. (Reproduced from Featherstone' with permission of the publisher. therefore, can be optimized by Copyright©1999, Munksgaard.) using delivery methods that bring fluoride to the surface of remineralized crystal now will ubility than the original CAP the tooth and into the plaque behave like low-solubility FAP tooth mineral. Subsequent acid rather than incorporating fluo- rather than the highly soluble challenges must be quite strong ride into the tooth mineral crys- CAP of the original crystal and prolonged to dissolve the tals during tooth development. surface.36 remineralized enamel. These topical delivery methods In summary, fluoride in solu- Saliva and caries. Saliva has are equally applicable to adults tion from topical sources en- a critical role in the prevention and children and include fluo- hances remineralization by or reversal of the caries process; ride in beverages and foods, speeding up the growth of a it provides calcium, phosphate, dental products and drinking new surface on the partially proteins that maintain super- water. The benefits of continu- demineralized subsurface crys- saturation of calcium in the ally providing low levels of fluo- tals in the caries lesion. The plaque fluid, proteins and lipids ride in the saliva and plaque new crystal surface veneer is that form a protective pellicle from the aforementioned topical FAP-like, with much lower sol- on the surface of the tooth, anti- sources are described more fully 892 JADA,Vol. 131,July 2000 Copyright©1998-2001 American Dental Association.All rights reserved. COVER STOR1 ' ' 1 in a recent review article.' showed the posteruptive (topi- urn and phosphate, which are Pathological and protec- cal) effects of fluoride in the derived primarily from saliva tive factors in the caries bal- drinking water. Other studies and plaque fluid. ance. Caries progression, as have illustrated the weak pre- Pathological factors. Patho- opposed to reversal, consists of eruptive effects of fluoride. For logical factors obviously include a delicate balance between the example, in two groups of cariogenic bacteria and the fre- aforementioned factors—name- Okinawa nursing students aged quency of ingestion of ferment- ly, a bacterially generated acid 18 to 22 years, there was no dif- able carbohydrates that sustain challenge and a combination of ference in caries status between these bacteria. The importance demineralization inhibition and those who had received fluori- of mutans streptococci (which reversal by remineralization.'•92 dated water only until about 5 includes S. mutans and S. The balance between pathologi- to 8 years of age (and none sobrinus) in the development of cal factors (such as bacteria and thereafter) and those who had dental caries has been reviewed carbohydrates) and protective never received fluoridated extensively.'2.14,1s.49,50 Numerous factors (such as saliva, calcium, drinking water.94 cross-sectional studies in phosphate and fluoride) is a The cariostatic effects of fluo- humans have shown that great- delicate one that swings either ride are, in part, related to the er numbers of mutans strep- way several times daily in most sustained presence of low con- tococci and lactobacilli in saliva people (Figure 5). centrations of ionic fluoride in or plaque are associated with Protective factors. Saliva is the oral environment,'21,38 high caries rates.'S,25,49,51-54 essential for the protection of Longitudinal studies have the tooth against dental caries shown that an increase over and provides many natural pro- I There is the time in numbers of both of tective factors summarized ear- ! these bacterial groups is lier,9t including calcium, phos- mistaken belief 0'4 associated with caries onset phate, antibacterial components that drilling out and progression.24,55,56 and other proteins with various a caries lesion functions. Extrinsic antibacteri CARIES INTERVENTION al agents such as chlorhexidine and placing a The methods of caries interven- also can be considered as pro- restoration tion can be summarized by join- tective factors in this balance, i eliminates the ing the principal components of as can fluoride from external the caries process with the sources. The mechanisms of bacteria and interventional possibilities action of fluoride described in thereby stops (Table). this article apply primarily to caries Cariogenic bacteria and fluoride from topical sources; high bacterial challenge. systemically incorporated fluo- progression. y y �incor p Dental caries is a transmissible, ride has only a minor role in bacterially generated disease. protecting against dental caries. There is the mistaken belief This conclusion is supported not derived from foods and bever- that drilling out a caries lesion only by laboratory data as ages, drinking water and fluo- and placing a restoration elimi- described previously, but also ride-containing dental products nates the bacteria and thereby by epidemiologic studies. For such as toothpaste. Prolonged stops caries progression. Al- example, a four-year study in and slightly elevated low con- though traditional restorative England found a 27 percent centrations of fluoride in the work may eliminate the bacte- lower caries incidence among saliva and plaque fluid decrease ria at the site of the restoration, children who were 12 years old the rate of enamel demineral- the remainder of the mouth is when water fluoridation began ization and enhance the rate of left untouched, caries continues in their communities, relative remineralization.21,36,38,45-48 For unchecked in the remainder of to the incidence in control sub- example, fluoride at 0.04 ppm the mouth and recolonization jects of the same age in nonfluo- in saliva can enhance reminer- commences rapidly at the ridated areas.93 This was a well- alization. Remineralization of margins.57 conducted study, and it clearly early lesions also requires calci- It is logical, therefore, to use JADA,Vol. 131,July 2000 893 Copyright©1998-2001 American Dental Association.All rights reserved. NEENICOVER STORY TABLE SUMMARY: THE CARIES PROCESS AND METHODS OF CARIES INTERVENTION. CARIES COMPONENT INTERVENTION METHOD Bacteria Antibacterial therapy such as treatment with chlorhexidine gluconate (see text) Carbonated I-Iydroxyapatite Make the mineral less soluble by transforming it to other crystalline forms such as hydroxy- apatite without carbonate (future caries- preventive treatments by specific laser irradia- tion will enable this to be done"'") Fermentable Carbohydrates Reduce the frequency of ingestion; substitute with noncariogenic sweeteners (this method is well-accepted and used in patient education) Recommend use of sugar-free chewing gum, which reduces frequency of fermentable carbo- hydrate ingestion and also enhances reminer- alization Organic Acids Produced by Neutralize the acid by providing extra buffer- Oral Bacteria ing or enhancing saliva; sugar-free gum assists in this as well Saliva Enhance the saliva flow and function Fluoride Exploit its known effects on bacteria, inhibi- tion of demineralization and enhancement of remineralization by using "topical" fluoride delivery by means of dental products, drinking water, beverages and foods antibacterial therapy—such as one-to-one direct correlation tors are in balance, caries does treatment with chlorhexidine between levels of these bacteria not progress. If they are out of gluconate rinse—as a caries- and caries progression.24.49 balance, caries either progresses preventive measure. Although However, it now is well-estab- or reverses. this has been proposed for lished that high levels of Antibacterial therapy for many years58_6°and used in sev- mutans streptococci, high levels caries control. Currently, the eral European countries, an of lactobacilli or both constitute most successful antibacterial antibacterial approach almost a "high bacterial challenge."24 therapy against cariogenic bac- never is used in the United This bacterial challenge can be teria is treatment by chlorhexi- States for the prevention of the balanced by the protective fac- dine gluconate rinse or ge1.47,61 progression of dental caries. tors described earlier, which Chlorhexidine is available by One of the difficulties in per- include salivary components— prescription in the United suading clinicians to use the especially calcium, phosphate States. Studies have shown that antibacterial approach is that and fluoride—and the amount a daily dose of chlorhexidine there have not been rapid and of saliva present.42 rinse for two weeks can accurate methods of determin- Figure 5 illustrates the bal- markedly reduce the cariogenic ing the levels of cariogenic bac- ante between pathological fac- bacteria in the mouth and that, teria in the mouth. Further- tors (including cariogenic bacte- as a result, recolonization takes more, although numerous ria, reduced salivary function place in three to six months studies have indicated that and frequency of use of fer- rather than immediately 58 In mutans streptococci and lacto- mentable carbohydrates) and patients with high levels of bac- bacilli definitely are risk factors protective factors. If these teria, therefore, chlorhexidine for dental caries, there is no pathological and protective fac- treatments at three-month 894 JADA,Vol. 131,July 2000 Copyright©1998-2001 American Dental Association.All rights reserved. ' -COVER STORY -414 C intervals are indicated. probes will be available corn- assess the level of risk of The problem faced by clini- mercially in the near future, caries progression in individ- cians is how to determine, in a and that clinicians will be able ual patients. Studies still are timely fashion, whether the to use them chairside and under way, and there is no bacterial challenge is high, obtain results within a few definitive formula yet avail- medium or low. For many minutes. This will enable clini- able. The status of risk assess- years, commercial "dip slides" cians to determine the quanti- ment was summarized, how- have been available in Europe, tative levels of bacteria in a ever, by the authors of a spe- and they recently became patient's mouth while he or cial supplement to The available in the United she is in the operatory and to Journal of the American States.58 A saliva sample is factor these numbers into an Dental Association in 1995; taken from the patient and overall risk assessment of this publication can be used as incubated on the dip slide; two caries for that patient. It is a guide until more definitive days later, a result is provided envisaged that computer pro- information is available.64 of the levels of S. mutans and grams will be available that Figure 5 represents a basis for lactobacilli bacteria in the will include the assay num- determining caries risk with mouth.58 Although these slides bers, as well as other data. the information currently are a major advance in conven- The practitioner will receive available. ience and are the best tools guidance as to the level of It has been established that available at the time of this high-risk patients include writing, it has been shown those who have a high bacteri- that this technology is not Methods of al challenge, which may con- well-correlated with tradition- rapid chairside sist of a combination of high al bacterial plating. It is antic- numbers of mutans streptococ- ipated that methods of rapid assessment of ci, lactobacilli or both. chairside assessment of bacter- bacterial Although fluoride has excel- ial challenge, based on molecu based lent properties in terms of bal- lar biology, will be available in challenge, ancing caries challenge, if the the future. on molecular challenge is too high, then Several investigators have biology, will be fluoride—even at increased explored the possibility of available in the concentrations, with increased using modern molecular biolo- use or both—cannot balance gy for better and more rapid future. that challenge. Therefore, in methods of bacterial assess- the case of high bacterial chal- ment,62 but they were unable lenge, the bacterial infection to overcome a number of corn- caries risk and what regimen must be dealt with, typically plications. An exciting devel- or regimens to use to prevent with a chlorhexidine rinse, as opment is work by Shi and col- further caries and to reduce well as the enhancement of leagues,63 who recently pub- the bacterial challenge. With salivary action by topical lished a method using species- the new monoclonal antibody delivery of fluoride. These specific monoclonal antibodies probes, the levels of bacteria principles apply equally well that recognize the surface of and success of the intervention to adults and children. cariogenic bacteria. With this could readily be followed over Accurate detection of early technology, it is not necessary time. This is an exciting, inno- caries can increase the relia- to split open the bacterial cells vative tool that may become bility of caries risk assess- to assess the internal DNA or widely used and accepted ment, particularly if those RNA. These probes can be within a few years. measurements are made at tagged either with a fluo- three- or six-month intervals rescent molecule or with a CARIES RISK and caries ro ression can be ASSESSMENT P g marker that can be measured measured. In the case of caries quantitatively in a simple Several studies have attempt- progression, obviously, inter- spectrophotometer. ed to determine risk factors vention is needed either anti- It is anticipated that these that can be reliably used to bacterially, with fluoride or JADA,Vol. 131,July 2000 895 Copyright©1998-2001 American Dental Association.All rights reserved. COZIER STORY 10 C many years is an immuniza- Pulsed laser light with high tion against caries. There are - absorption coefficient many obstacles to the success of immunization, as caries is Removes carious tissue; not a systemic infection that - minimal heat deposition can be dealt with simply by Walls of preparation heated administering a specific anti- Enamel ti to 800-900 c biotic. The infection must be dealt with in the mouth, where Heat conduction the internal body fluids do not Dentin pass and, therefore, the normal Pulp Pulp temperature rise < 4 C immune response is not rele- vant. However, IgA that is pro- duced by the saliva naturally Figure 6. Schematic diagram showing the potential use of specific can interfere with the coloniza lasers for precise removal of carious enamel and modification of the tion of the surface of the tooth surrounding enamel for prevention of further caries progression after by specific bacteria. restoration. The laser would be set first to remove a minimum of cari- ous tissue. Then the walls and base of the cavity preparation would be Recent studies by Ma and treated with the laser to inhibit subsequent caries progression. colleagues 65.66 have illustrated (Reproduced from Featherstone" with the permission of the publisher. Copyright O 2000 Indiana University School of Dentistry.) the effectiveness of specific IgA in the inhibition of recoloniza- with other techniques, some of will become less and less tion of mutans streptococci. which are described in the fol- desirable as a treatment and The next logical step is to use lowing material. will be used only as a final this technology as one of the Caries management by resort when new intervention tools for caries intervention. It risk assessment. As the measures have failed or when is possible to use genetically caries risk assessment people have not participated engineered plants, such as methodologies are refined, we in caries intervention pro- tobacco or alfalfa, to produce will have more definitive bio- grams such as those indicated immunoglobulins.66.67 A study is logical and chemical risk previously. in progress at the University of assessment measures to guide California, San Francisco, to CARIES MANAGEMENT clinical decision making. test IgA that has been pro- TOOLS FOR THE FUTURE g p These measures form the duced using genetically engi- basis for assessing the direc- Several technological advance- neered tobacco plants. At press tion in which the caries bal- ments are currently close to time, the results were not ance is likely to move for a clinical reality and will be known, but if the trial is suc- particular patient. Early embraced if they are proven cessful, this IgA can be applied caries detection, especially in successful. to the teeth after chlorhexidine occlusal surfaces, is an essen- Assessment of bacterial treatment has removed the car- tial part of caries management challenge by chairside iogenic bacteria, with the aim by risk assessment. molecular probes. The use of inhibiting future recoloniza- Caries management by risk of chairside bacterial probes tion by mutans streptococci. assessment now is receiving for assessing a patient's cario- Early caries detection considerable attention, and genic bacterial challenge will and intervention. Successful software programs are being be an essential component of use of the innovative methods developed that will aid practi- caries management by risk described here for caries inter- tioners in assessing risk and assessment. vention will require accurate lead them to the use of cur- Caries immunization. In methods for the early detection rent and new technologies by a program of caries manage- of dental caries in enamel specifying treatments recom- ment by risk assessment, it is and dentin. Early-detection mended for the various risk logical that all available tools methods such as fluorescence, categories.59.6o As we move into should be used. One such tool optical coherence tomography, the future, tooth restorations that has been investigated for electrical impedance and 896 JADA,Vol. 131,July 2000 Copyright©1998-2001 American Dental Association.All rights reserved. COVER STORY : C ultrasonography are likely to laser for use on teeth. This was mineralization-remineraliza- become available for use by cli- the first approval for laser use tion model in the laboratory by nicians in the near future.68 It on dental hard tissues. This up to 85 percent. They have will be possible to detect approval by the FDA was for demonstrated that carbonate is lesions in the occlusal surface this particular laser to be used lost from the CAP mineral of and to determine whether they for the removal of dental caries the tooth during specific laser have progressed into the dentin and the cutting of sound tissue irradiation, making the miner- and, if so, how far. This is not before the placement of restora- al highly resistant to dissolu- possible with current radio- tions. This event has ushered tion by acid. Although they graphic technology. in a new era for lasers in den- have demonstrated in the labo- Once new methods are intro- tistry. Since then, other lasers ratory, using pH cycling mod- duced for the early detection of have been approved for the els, that as little as 20 pulses of caries, they can be used in two same purpose, and additional 100 microseconds each can pro- opposing fashions. Clinicians hard-tissue uses are likely to duce a preventive effect similar with traditional training are be approved in the future, to daily use of fluoride denti- likely to use these methods to including the use of lasers for frice, these promising and intervene physically at an ear- the inhibition of progression of exciting results have not yet her stage with carious dental caries by altering the been tested in human mouths.70 lesions—drilling, filling and composition of surface enamel For practical purposes, it placing restorations. This out- would be desirable to develop a come is of concern, as many laser that can remove carious more restorations would be As innovative tissue and subsequently be placed than may be necessary, used to treat the walls of the which weakens the tooth struc- methods for area from which carious tissue ture. Early detection and inter- early caries is removed to make them vention by placing a restoration 1 intervention resistant to subsequent caries also does not take advantage of challenge71 (Figure 6). Fried the body's natural protective are introduced, and colleagues72 recently pub- mechanisms of inhibition of the need for lished a report on a new CO2 demineralization and enhance- restorations may laser that efficiently removes ment of remineralization via carious tissue. After caries and saliva. be eliminated for a minimal amount of surround- Alternatively, early detection many patients. ing tissue are removed, it will of caries can be used as an be possible to change the laser opportunity to promote re- parameters to perform caries- mineralization via salivary or dentin mineral. preventive treatment on the enhancement, use of topical Kantorowitz and colleagues69 same area. This would be fol- fluoride and chlorhexidine and and Featherstone and col- lowed by placement of a resin- meticulous oral hygiene. In leagues70 have studied the based composite restoration, addition, as innovative meth- effects of lasers on hard tissues thereby inhibiting subsequent ods for early caries interven- for almost 20 years. The overall caries around that restoration. tion are introduced, the need objective of these studies is to For example, if an early oc- for restorations may be elimi- establish the scientific basis for clusal lesion was detected (by nated for many patients, there- the choice of laser parameters the new methods described pre- by preserving the tooth struc- that can be used clinically for viously) that was deemed to be ture and halting or reversing the prevention, removal or beyond hope of remineraliza- progression of dental caries. treatment of caries lesions. tion, this lesion could be con- Caries prevention by Their studies have demonstrat- servatively removed with an laser treatment. In May 1997, ed that specific pulsed carbon appropriate laser. Then the the U.S. Food and Drug dioxide, or CO2, laser treat- surrounding cavity preparation Administration approved the ment of dental enamel can walls could be treated for caries use of an erbium:yttrium- inhibit subsequent carieslike prevention by the laser and a aluminum-garnet, or Er:YAG, progression in a severe de- small conservative restoration JADA,Vol. 131,July 2000 897 Copyright©1998-2001 American Dental Association.All rights reserved. *COVER STORY - 10-c placed. The cavity walls will be health of their patients. • 15.Loesche WJ,Hockett RN,Syed SA.The predominant cultivable flora of tooth surface highly resistant to acid attack plaque removed from institutionalized sub- Dr.Featherstone is a professor and the jects.Arch Oral Biol 1972;17(9):1311-25. and therefore resistant to sec- j chair,Department of Preventive and 16.Featherstone JD.An updated under- ondary caries. Providing bacter- Restorative Dental Sciences and Department standing of the mechanism of dental decay of Dental Public Health and Hygiene, and its prevention.Nutt 1990;14:5-I1. ial intervention via chlorhexi- University of California,San Francisco,707 p Q y 17.Featherstone JD,Rodgers BE.Effect of dine rinse was also part of the Parnassus Ave.,Box 0758,San Francisco, acetic,lactic and other organic acids on the treatment in the same patient, Calif.94143,e-mail"jdbf @itsa.ucsf.edu". formation of artificial carious lesions.Caries Address reprint requests to Dr. Res 1981;15(5):377-85. future caries would be unlikely. Featherstone. 18.Featherstone JD,Mellberg JR.Relative rates of progress of artificial carious lesions SUMMARY AND The author sincerely acknowledges contri- in bovine,ovine and human enamel.Caries CONCLUSIONS butions from numerous colleagues over many Res 1981;15(1):109-14. years to much of the work reviewed here. 19.Silverstone LM.Structure of carious enamel,including the early lesion.Oral Sci The mechanism of dental caries 1.Featherstone JD.Prevention and rever- Rev 1973;3:100-60. is well-established to the point sal of dental caries:role of low level fluoride. 20.ten Cate JM,Duijsters PP.Influence of Community Dent Oral Epidemiol 1999; fluoride in solution on tooth demineralization. where new approaches are 27(1):31-40. II.Microradiographic data.Caries Res 1983; being made for caries preven- 2.Kaste LM,Selwitz RH,Oldakowski RJ, 17(6):513-9. Brunelle JA,Winn DM,Brown LJ.Coronal 21.ten Cate JM,Featherstone JD. tion based on a scientific under- caries in the primary and permanent denti- Mechanistic aspects of the interactions standing of the processes tion of children and adolescents 1-17 years of between fluoride and dental enamel.Crit Rev age:United States,1988-1991.J Dent Res Oral Biol Med 1991;2(3):283-96. involved. Several existing 1996;75:631-41. 22.Geddes DA.Acids produced by human methodologies are available to 3.National Institute of Dental Research, dental plaque metabolism in situ.Caries Res Epidemiology and Oral Disease Prevention 1975;9(2):98-109. enable successful management Program.Oral health of United States chil- 23.Featherstone JD.Diffusion phenomena of dental caries by risk assess- dren:The National Survey of Dental Caries and enamel caries development.In: in U.S.School Children, 1986-1987-national Guggenheim B,ed.Proceedings of the ment. Understanding the bal- and regional findings.Bethesda,Md.:U.S. Cariology Today International Congress, ance between pathological fac- Department of Health and Human Services, September 1983,Zurich,Switzerland.Basel, Public Health Service,National Institutes of Switzerland:Karger; 1984:259-68. tors and protective factors is Health;1989.NIH publication 89-2247. 24.Leverett DH,Proskin HM,Featherstone the key. Beyond the well- 4.The prevalence of dental caries in United JD,et al.Caries risk assessment in a longitu- States children 1979-1980:The National dinal discrimination study.J Dent Res established and currently used Dental Caries Prevalence Survey.Bethesda, 1993;72(2):538-43. methods, some innovative and Md.:U.S.Department of Health and Human 25.Leverett DH,Featherstone JD,Proskin Services,Public Health Service,National HM,et al.Caries risk assessment by a cross- exciting techniques have shown Institutes of Health;1981.NIH publication sectional discrimination model.J Dent Res early research successes that 82-2245. 1993;72(2):529-37. 5.National Center for Health Statistics. 26.Hamilton IR,Bowden GH.Fluoride most likely will be used for Decayed,missing and filled teeth among effects on oral bacteria.In:Fejerskov 0, early caries intervention in the youths,12-17 years:United States,1974. Ekstrand J,Burt BA,eds.Fluoride in den- Vital and Health Statistics,Series 11-No. tistry.Copenhagen,Denmark:Munksgaard; future. These methods include 144.Washington:Government Printing 1996:230-51. fluoride therapy for inhibition of Office;1974.DHEW publication(HRA) 27.Whitford GM,Schuster GS,Pashley 75-1626. DH,Venkateswarlu P.Fluoride uptake by demineralization and enhance- 6.Speechley M,Johnston DW.Some evi- Streptococcus mutans 6715.Infect Immunol ment of remineralization, mole- dente from Ontario,Canada,of a reversal in 1977;18(3):680-7. the dental caries decline.Caries Res 1996; 28.Van Louveren C.The antimicrobial cular probes for the quantita- 30(6):423-7. action of fluoride and its role in caries inhibi- tive detection of cariogenic bac- 7.Jenkins GN.Recent changes in dental Lion.J Dent Res 1990;69:676-81. caries.Br Med J 1985;291(6505):1297-8. 29.LeGeros RZ.Calcium phosphates in oral teria at chairside, computerized 8.Hargreaves JA,Thompson GW,Wagg biology and medicine.In:Myers HM,ed. caries risk assessment pro- BJ.Changes in caries prevalence in Isle of Monographs in oral science.Basel, Lewis children between 1971 and 1981. Switzerland:Karger;1991:1-201. grams,genetically engineered Caries Res 1983;17(6):554-9. 30.Featherstone JD,Nelson DG,McLean IgA for inhibition of recoloniza- 9.Burt BA,Fejerskov O.Water fluorida- JD.An electron microscope study of modifica- tion.In:Fejerskov 0,Ekstrand J,Burt BA, lions to defect regions in dental enamel and tion of cariogenic bacteria, spe- eds.Fluoride in dentistry.Copenhagen, synthetic apatites.Caries Res 1981;15(4): cific lasers for conservative Denmark:Munksgaard;1996:275-90. 278-88. 10.Murray B.Fluorides in caries preven- 31.Featherstone JD,Goodman P,McLean removal of carious tissue and lion.3rd ed.Oxford,England;Boston: JD.Electron microscope study of defect zones specific lasers for the preven- Butterworth-Heinemann;1991. in dental enamel.J Ultrastruc Res 1979;67: 11.Newbrun E.Effectiveness of water flux- 117-23. lion of caries progression. ridatfon.J Public Health Dent 1989;49: 32.Nelson DC,McLean JD.High-resolution The use of these technologies 279-89. electron microscopy of octacalcium phosphate 12.Newbrun E.Cariology.3rd ed.Chicago: and its hydrolysis products.Calcif Tissue Int will require extensive retraining Quintessence;1989:63-87,331-49. 1984;36(2):219-32. of clinical dentists. But it will 13.Winn DM,Brunelle JA,Selwitz RH,et 33.Nelson DG,McLean JD.Direct observa- dramaticall alter the way in al.Coronal and root caries in the dentition of lion of near-atomic details in synthetic and Y Y adults in the United States, 1988-1991.J biological apatite crystallites.In:Fearnhead which dentists diagnose, inter- Dent Res 1996;75:642-51. RW,Suga S,ed.Tooth enamel IV: 14.Loesche WJ.Role of Streptococcus Proceedings of the Fourth International vene, treat and manage caries, mutans in human dental decay.Microbiol Symposium on the Composition,Properties, with major benefits to the oral Rev 1986;50(4):353-80. and Fundamental Structure of Tooth Enamel. 898 JADA,Vol. 131,July 2000 Copyright©1998-2001 American Dental Association.All rights reserved. COVER STORY C Amsterdam,Netherlands:Elsevier Science frices.In:Embery G,Rolla R.eds.Clinical Dent Educ 1997;61(11):895-905. Publishers;1984:47-51. and biological aspects of dentifrices.Oxford, 61.Lagerlof F,Oliveby A.Clinical implica- 34.Robinson C,Kirkham J.Weatherell JA. England:Oxford University Press;1992: tions:new strategies for caries treatment.In: Fluoride in teeth and bone.In:Fejerskov 0, 41-50. 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Calif.Bellingham,Wash.:SPIE Press; and human studies to elucidate the media- 60.Anusavice KJ.Efficacy of nonsurgical 1999:196-203. nism of action of fluoride-containing denti- management of the initial caries lesion.J JADA,Vol. 131,July 2000 899 Copyright©1998-2001 American Dental Association.All rights reserved. 0 w 10 d y u • �+ Em <cr 00 ON cm V r^ H c 9 Nv V G 7 d L Q 6 C ° m C> c O; _ p O cu Sp vuM,eoZ Lmuaci ccaoc UT- m m O u$a, • E o � io -� .. o Y 0o a C ac u - u o c,; V O p Cn C N O O n E Z N T.N .. D' C E. d� -�' N� m Ca[ N m O .. j a0 �'- C° N O O 3 of OI O a0 m S c,v p a v rnF u �°n on m d E ca V) i0 m ^Z E w um yc'timQV umZyy nE�3p,°O�_'ci v m co ,c a> _ c c -U 'o a ONEv` `� ti �,i on-�3= L LE3m� Z °om a°o� U- 3 ., <_ .� d ow uN tio r- �` Em "u 'm t� o Z °E `" V of 01 V V ° 06 0 3 W N u mm m �? -4 CL CL v F m� oFN m u_ ° ai y u E a u u o or- 0� °`3° m E� L o _u o._.. O CL GO (y O m C v cn a 0 v p E O m c �- n_ 3 N E �2: c c n .0 'r- r- , C4 U C E, 0 o � v ° v oZ0. 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V " _ O .c my c u u�t mva,., m °a� V amY _ u9- -m�'�m u a .°� 6 �4-N,4 .: m� 3 c m y�'� � m n„ E pn_ c ° oa m _y 0 a� Ez h�Ym Ud?a'= � vi o -'V, DoE p0 �,.. u c cam° :n % 3 �- m u ct o ak u c to E �a,vim -� bo m sL c U c �n c< .: 7 ,D o�v°rno u v= c eL u eou m v Y Z7 �"" > ��QL ° ° meu`ooE 2�u E mo o -aj „viU ° O �r"pm� _ ai `m C L .L.•+ L - V'_ Q— Q.— a >• 7 c V n n o, c u -u� u.°.�m m 3 L u L m v v C x n V .g E> L m E m C 7 0 .0 V L >, O m O V m amiocmia'"a,oiL�wouo IG V _ ..`V.. =ci :, �?C, 0Vuvtycmiva>>uo .9 m�E`� °u 0u hUSUTU<2 m�A=- °,U°.'; vUYa -ova o` � °' °° n� E E � 3 3 cmi"0 -j 3UalUY5vim cl; C' N O C' t N � c U • E. o- 0 <<o *4% UNITED STATES ENVIRONMENTAL PROTECTION AGENCY ' NATIONAL Rtsx MANAGEMENT RESEARCH t.ASORATOAY j C+FIC.# Irl.OH 462" November 16, 2000 Roger D. Masters Research Professor of Government I)amwuth College Department of Government 6108 Silsby Hall Hanover, New Hampshire 03755 -3547 Dear Professor Masters- 1 GaC1 of 1 WILE of RESEAPC" ANO oEMOMEM F ' ,agenda item # _ �_(= Meeting Date T•, n ?resented by: _ We have received your letter dated September 27, 2000, requesting empirical scientific data we may have on the health effects of fluosil cic acid or sodiwn silicofluoride and manganese neumtoxicity. To anvAw ym drat queaeion on whethw we have in our powession empkiW sciendl c dau on the effecats of lluosilide acid or "an silit:o0wride on health and behavior, out ammor is no. Health effects research is primarily conducted by our National Health and Enviromnental Effects Research Laboratory (NHEERL). We have contacted our colleagues at NHEERL and they report that with the exception of some acute toxicity data, they were unable to fuid any infortusk rt on ttie effects of silicofluoddes on health and bdwvior. In answer to your question on empirical information we may have on manganese neuretoxicity, NHF RL scientists forwarded to us several manuscripts with reference suctions that contain information on the neurotoxicity of manganese. These are enclosed for your information. I apologize for the delay in responding to your request and hope you find the enclosed information useful. Sincerely, �'Z 'e. U'WVVV-� Robert C. Thurnau. Chief Treatment Technology Evaluation Branch Water Supply and Water Resources Division Enclosures http: / /www.fluoi idealert. org/images /letters/EPA- Masters. j pg 9/11/2011 . Q W N W L c0 E p v p u O Y -cc Lc u) Z� v -, O f0 z N Y = m — — N O N = N Q Y L Y ti C U C E = O O = = N w aCr V Y L a_ C v uJ Sr-, m U? 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R °AaRffi �e WE T WE Ws i m `zq D T c o m v S I r � E L O E ° rn a _ - m 2 m i E Wv O T 3 a av ° °v t3d�mumi �'m i m . m a a v .5-U v 3 a m 5 3 "- 2-2 2 ovm3mtsmmm�a i E a"i v y 3 N 3 N 3 m m 9 GG v ir m n u v m C m E E 0 0 O D U w U L S o x o w m o UUIN��DyO '.' 01« m.� c c5 N 'C x 0 Z'.- �naEi >wmEaE DoE m >Y `o E N U1 N> N p Cpp N- N � Zo �.8 o` s E E o c o � a EL T E co n Lwo w 'xm «OR E Eat' w w~ Y o z "K O `o E w a m R E s 2 E c o 8— .n. o« E -o m 3 0 '" o- n m ow o m w 0 0 Q O .Oin f E o oO O E rn aN a .0 -. d 2.$ U $ -o o oq 2 wokw EpO Ed E'owm'w mm a- o°'d o"oa�c'9 E `o2 w wow�'wE-0o'w�c ��> _ _ w �zU) z �Ea�a�a�a�a E o � �T 8 S tC6 u rn m n L 3 d a E a a c c 8 E mom =mWm�� a f,Q uv € ,m m 9 L U c6 O CL Q 0 0 c N C C W U M o E o cc = G Z N 3 N E U a- 0 N > U p 0 f( N co cc v ++ d Q.' �j 0 t v z 0 L Q (LII cu N Q c0 w I0C " m & --,3 m -6 mmo6m6Em fl L9Ag$ as q$i`y4�1O s5o33� °avqu oo�,� mp oam °a9 -8 `gym`_ €amo� "y °��iso „��q ao 8 g �r=LL6;Fm�.a as�aa8 "a; °;�ti €El' nc'° r 11 �. =�wm�y'm =gm�a8=y�5 °Es E-E�`��o3�E�goSQ�u wzA q�n�9Ty Tiomno �yt °c �c -�Sa' E e m u a It oc°�aEZ'NmD�eaz WOior _�,R � °o 5c�via�m.;� ES E 5 n° o�EmmEg�'mm osLm °_- nu 7 fwi$g=exdt4eS�3E�aE =pa'1a °S jL t JEj 33S5g$ 8Jao WvEa ul LL . � K 8$$uaEYij��g� m 0�! G 0, a N C mu E ma Q�t o E'A O C 4pu = ?r O r ad 'p N W K to 2 e m w K•r- R 0-0 E N w V C y !O L U O R E .> w M E m Wiz° Eri Ioc Vice President of EPA's Scientist Union Testifies Against Fluoridation STATEMENT OF Dr. J. WILLIAM HIRZY NATIONAL TREASURYEMPLOYEES UNION CHAPTER 280 BEFORE THE SUBCOMMITTEE ON WILDLIFE, FISHERIES AND DRINKING WATER UNITED STATES SENATE JUNE 29, 2000 Good morning Mr. Chairman and Members of the Subcommittee. I appreciate the opportunity to appear before this Subcommittee to present the views of the union, of which I am a Vice - President, on the subject of fluoridation of public water supplies. Our union is comprised of and represents the professional employees at the headquarters location of the U.S. Environmental Protection Agency in Washington D.C. Our members include toxicologists, biologists, chemists, engineers, lawyers and others defined by law as "professionals." The work we do includes evaluation of toxicity, exposure and economic information for managements use in formulating public health and environmental protection policy. I am not here as a representative of EPA, but rather as a representative of EPA headquarters professional employees, through their duly elected labor union. The union first got involved in this issue in 1985 as a matter of professional ethics. In 1997 we most recently voted to oppose fluoridation. Our opposition has strengthened since then. Summary of Recommendations 1) We ask that you order an independent review of a cancer bioassay previously mandated by Congressional committee and subsequently performed by Battelle Memorial Institute with appropriate blinding and instructions that all reviewers independent determinations be reported to this Committee. 2) We ask that you order that the two waste products of the fertilizer industry that are now used in 90% of fluoridation programs, for which EPA states they are not able to identify any chronic studies, be used in any future toxicity studies, rather than a substitute chemical. Further, since federal agencies are actively advocating that each man woman and child drink, eat and bathe in these chemicals, silicofluorides should be placed at the head of the list for establishing a MCL that complies with the Safe Drinking Water Act. This means that the MCL be protective of the most sensitive of our population, including infants, with an appropriate margin of safety for ingestion over an entire lifetime. 3) We ask that you order an epidemiology study comparing children with dental fluorosis to those not displaying overdose during growth and development years for behavioral and other disorders. 4) We ask that you convene a joint Congressional Committee to give the only substance that is being mandated for ingestion throughout this country the full hearing that it deserves. National Review of Fluoridation The Subcommittees hearing today can only begin to get at the issues surrounding the policy of water fluoridation in the United States, a massive experiment that has been run on the American public, without informed consent, for over fifty years. The last Congressional hearings on this subject were held in 1977. Much knowledge has been Page 1 IOC gained in the intervening years. It is high time for a national review of this policy by a Joint Select Committee of Congress. New hearings should explore, at minimum, these points: 1) excessive and un- controlled fluoride exposures; 2) altered findings of a cancer bioassay; 3) the results and implications of recent brain effects research; 4) the "protected pollutant" status of fluoride within EPA; 5) the altered recommendations to EPA of a 1983 Surgeon Generals Panel on fluoride; 6) the results of a fifty -year experiment on fluoridation in two New York communities; 7) the findings of fact in three landmark lawsuits since 1978; 8) the findings and implications of recent research linking the predominant fluoridation chemical with elevated blood -lead levels in children and anti - social behavior; and 9) changing views among dental researchers on the efficacy of water fluoridation Fluoride Exposures Are Excessive and Un- controlled According to a study by the National Institute of Dental Research, 66 percent of Americas children in fluoridated communities show the visible sign of over - exposure and fluoride toxicity, dental fluorosis (1). That result is from a survey done in the mid- 1980's and the figure today is undoubtedly much higher. Centers for Disease Control and EPA claim that dental fluorosis is only a "cosmetic" effect. God did not create humans with fluorosed teeth. That effect occurs when children ingest more fluoride than their bodies can handle with the metabolic processes we were born with, and their teeth are damaged as a result. And not only their teeth. Childrens bones and other tissues, as well as their developing teeth are accumulating too much fluoride. We can see the effect on teeth. Few researchers, if any, are looking for the effects of excessive fluoride exposure on bone and other tissues in American children. What has been reported so far in this connection is disturbing. One example is epidemiological evidence (2a, 2b) showing elevated bone cancer in young men related to consumption of fluoridated drinking water. Without trying to ascribe a cause and effect relationship beforehand, we do know that American children in large numbers are afflicted with hyperactivity - attention deficit disorder, that autism seems to be on the rise, that bone fractures in young athletes and military personnel are on the rise, that earlier onset of puberty in young women is occurring. There are biologically plausible mechanisms described in peer- reviewed research on fluoride that can link some of these effects to fluoride exposures (e.g. 3,4,5,6). Considering the economic and human costs of these conditions, we believe that Congress should order epidemiology studies that use dental fluorosis as an index of exposure to determine if there are links between such effects and fluoride over - exposure. In the interim, while this epidemiology is conducted, we believe that a national moratorium on water fluoridation should be instituted. There will be a hue and cry from some quarters, predicting increased dental caries, but Europe has about the same rate of dental caries as the U.S. (7) and most European countries do not fluoridate (8). I am submitting letters from European and Asian authorities on this point. There are studies in the U.S. of localities that have interrupted fluoridation with no discernable increase in dental caries rates (e.g., 9). And people who want the freedom of choice to continue to ingest fluoride can do so by other means. Cancer Bioassay Findings In 1990, the results of the National Toxicology Program cancer bioassay on sodium fluoride were published (10), the initial findings of which would have ended fluoridation. But a special commission was hastily convened to Page 2 review the findings, resulting in the salvation of fluoridation through systematic down - grading of the evidence of carcinogenicity. The final, published version of the NTP report says that there is, "equivocal evidence of carcinogenicity in male rats," changed from "clear evidence of carcinogenicity in male rats." The change prompted Dr. William Marcus, who was then Senior Science Adviser and Toxicologist in the Office of Drinking Water, to blow the whistle about the issue (22), which led to his firing by EPA. Dr. Marcus sued EPA, won his case and was reinstated with back pay, benefits and compensatory damages. I am submitting material from Dr. Marcus to the Subcommittee dealing with the cancer and neurotoxicity risks posed by fluoridation. We believe the Subcommittee should call for an independent review of the tumor slides from the bioassay, as was called for by Dr. Marcus (22), with the results to be presented in a hearing before a Select Committee of the Congress. The scientists who conducted the original study, the original reviewers of the study, and the "review commission" members should be called, and an explanation given for the changed findings. Brain Effects Research Since 1994 there have been six publications that link fluoride exposure to direct adverse effects on the brain. Two epidemiology studies from China indicate depression of I.Q. in children (11,12). Another paper (3) shows a link between prenatal exposure of animals to fluoride and subsequent birth of off - spring which are hyperactive throughout life. A 1998 paper shows brain and kidney damage in animals given the "optimal" dosage of fluoride, viz. one part per million (13). And another (14) shows decreased levels of a key substance in the brain that may explain the results in the other paper from that journal. Another publication (5) links fluoride dosing to adverse effects on the brains pineal gland and pre - mature onset of sexual maturity in animals. Earlier onset of menstruation of girls in fluoridated Newburg, New York has also been reported (6). Given the national concern over incidence of attention deficit - hyperactivity disorder and autism in our children, we believe that the authors of these studies should be called before a Select Committee, along with those who have critiqued their studies, so the American public and the Congress can understand the implications of this work. Fluoride as a Protected Pollutant The classic example of EPAs protective treatment of this substance, recognized the world over and in the U.S. before the linguistic de- toxification campaign of the 1940's and 1950's as a major environmental pollutant, is the 1983 statement by EPAs then Deputy Assistant Administrator for Water, Rebecca Hamner (15), that EPA views the use of hydrofluosilicic acid recovered from the waste stream of phosphate fertilizer manufacture as, "...an ideal solution to a long standing problem. By recovering by- product fluosilicic acid (sic) from fertilizer manufacturing, water and air pollution are minimized, and water authorities have a low -cost source of fluoride..." In other words, the solution to pollution is dilution, as long as the pollutant is dumped straight into drinking water systems and not into rivers or the atmosphere. I am submitting a copy of her letter. Other Federal entities are also protective of fluoride. Congressman Calvert of the House Science Committee has sent letters of inquiry to EPA and other Federal entities on the matter of fluoride, answers to which have not yet been received. We believe that EPA and other Federal officials should be called to testify on the manner in which fluoride has been protected. The union will be happy to assist the Congress in identifying targets for an inquiry. For instance, hydrofluosilicic acid does not appear on the Toxic Release Inventory list of chemicals, and there is a remarkable discrepancy among the Maximum Contaminant Levels for fluoride, arsenic and lead, given the relative toxicities of these substances. Surgeon Generals Panel on Fluoride We believe that EPA staff and managers should be called to testify, along with members of the 1983 Surgeon Generals panel and officials of the Department of Human Services, to explain how the original recommendations of Page 3 Ioc the Surgeon Generals panel (16) were altered to allow EPA to set otherwise unjustifiable drinking water standards for fluoride. Kingston and Newburg, New York Results In 1998, the results of a fifty -year fluoridation experiment involving Kingston, New York (un- fluoridated) and Newburg, New York (fluoridated) were published (17). In summary, there is no overall significant difference in rates of dental decay in children in the two cities, but children in the fluoridated city show significantly higher rates of dental fluorosis than children in the un- fluoridated city. We believe that the authors of this study and representatives of the Centers For Disease Control and EPA should be called before a Select Committee to explain the increase in dental fluorosis among American children and the implications of that increase for skeletal and other effects as the children mature, including bone cancer, stress fractures and arthritis. Findings of Fact by Judges In three landmark cases adjudicated since 1978 in Pennsylvania, Illinois and Texas (18), judges with no interest except finding fact and administering justice heard prolonged testimony from proponents and opponents of fluoridation and made dispassionate findings of fact. I cite one such instance here. In November, 1978, Judge John Flaherty, now Chief Justice of the Supreme Court of Pennsylvania, issued findings in the case, Aitkenhead v. Borough of West View, tried before him in the Allegheny Court of Common Pleas. Testimony in the case filled 2800 transcript pages and fully elucidated the benefits and risks of water fluoridation as understood in 1978. Judge Flaherty issued an injunction against fluoridation in the case, but the injunction was overturned on jurisdictional grounds. His findings of fact were not disturbed by appellate action. Judge Flaherty, in a July, 1979 letter to the Mayor of Aukland New Zealand wrote the following about the case: "In my view, the evidence is quite convincing that the addition of sodium fluoride to the public water supply at one part per million is extremely deleterious to the human body, and, a review of the evidence will disclose that there was no convincing evidence to the contrary... "Prior to hearing this case, I gave the matter of fluoridation little, if any, thought, but I received quite an education, and noted that the proponents of fluoridation do nothing more than try to impune (sic) the objectivity of those who oppose fluoridation." In the Illinois decision, Judge Ronald Niemann concludes: "This record is barren of any credible and reputable scientific epidemiological studies and or analysis of statistical data which would support the Illinois Legislatures determination that fluoridation of the water supplies is both a safe and effective means of promoting public health." Judge Anthony Farris in Texas found: "[That] the artificial fluoridation of public water supplies, such as contemplated by {Houston) City ordinance No. 80 -2530 may cause or contribute to the cause of cancer, genetic damage, intolerant reactions, and chronic toxicity, including dental mottling, in man; that the said artificial fluoridation may aggravate malnutrition and existing illness in man; and that the value of said artificial fluoridation is in some doubt as to reduction of tooth decay in man." The significance of Judge Flahertys statement and his and the other two judges findings of fact is this: proponents of fluoridation are fond of reciting endorsement statements by authorities, such as those by CDC and the American Dental Association, both of which have long - standing commitments that are hard if not impossible to recant, on the safety and efficacy of fluoridation. Now come three truly independent servants of j ustice, the j udges in these three cases, and they find that fluoridation of water supplies is not justified. Proponents of fluoridation are absolutely right about one thing: there is no real controversy about fluoridation when the facts are heard by an open mind. Page 4 I am submitting a copy of the excerpted letter from Judge Flaherty and another letter referenced in it that was sent to Judge Flaherty by Dr. Peter Sammartino, then Chancellor of Fairleigh Dickenson University. I am also submitting a reprint copy of an article in the Spring 1999 issue of the Florida State University Journal of Land Use and Environmental Law by Jack Graham and Dr. Pierre Morin, titled "Highlights in North American Litigation During the Twentieth Century on Artificial Fluoridation of Public Water. Mr. Graham was chief litigator in the case before Judge Flaherty and in the other two cases (in Illinois and Texas). We believe that Mr. Graham should be called before a Select Committee along with, if appropriate, the judges in these three cases who could relate their experience as trial judges in these cases. Hydrofluosilicie Acid There are no chronic toxicity data on the predominant chemical, hydrofluosilicic acid and its sodium salt, used to fluoridate American communities. Newly published studies (19) indicate a link between use of these chemicals and elevated level of lead in childrens blood and anti- social behavior. Material from the authors of these studies has been submitted by them independently. We believe the authors of these papers and their critics should be called before a Select Committee to explain to you and the American people what these papers mean for continuation of the policy of fluoridation. Changing Views on Efficacy and Risk In recent years, two prominent dental researchers who were leaders of the pro - fluoridation movement announced reversals of their former positions because they concluded that water fluoridation is not an effective means of reducing dental caries and that it poses serious risks to human health. The late Dr. John Colquhoun was Principal Dental Officer of Aukland, New Zealand, and he published his reasons for changing sides in 1997 (20). In 1999, Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, announced his change of views, then published a statement (21) dated April 2000. I am submitting a copy of Dr. Limebacks publications. We believe that Dr. Limeback, along with fluoridation proponents who have not changed their minds, such as Drs. Ernest Newbrun and Herschel Horowitz, should be called before a Select Committee to testify on the reasons for their respective positions. Thank you for you consideration, and I will be happy to take questions. Page 5 Fluoride is not an essential nutrient. 1999 Letter from the presidents of the National Academy of Science... Page 1 of 3 1p �m Fi..l0RIDE A C T I O N NETWORK Home ...... ............................... About FAN ........ ............................... Latest News ............... . .................... Water Fluoridation 4e, ealth Effects Database ....... ..... .... I ..................... Sources of Fluoride Exposure ........ ............................... Fluoride Pollution ...... ............................... Fluorine Pesticides ............. I ........................ Take Action! ....... ............................... Contact Us ...... ............................... Donate ...... ............................... FAQs «- A ,fir r Letter o e presidents w Academy o .'. Sciences _ a. Institute of Medicine LETTER FROM: Bruce Alberts, Ph.D., President, National Academy of Sciences and Kenneth Shine, President, Institute of Medicine January 12, 1999 Albert W. Burgstahler, Ph.D. and others Professor of Chemistry The University of Kansas 4035 Malott Hall Lawrence, Kansas 66045 Dear Dr. Burgstahler: We apologize for the delay in responding to your letters of October 15, 1997 and February 4, 1998, to each of us individually. At the time we had a very large number of inquiries and comments, and while letters were prepared in response to your letter along with the others, for some reason they did not reach you. The letter that we found in our files is reprinted below. Search: We want to thank you and your co- signers for your October 15, 1997 letter to us Go concerning the Food and Nutrition Board's (FNB) recent report, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. The publication of the report represents the initial report of a major new activity of the FNB: the development of a comprehensive set of reference values for nutrients and food components of possible benefit to health, that may not meet the traditional concept of a nutrient. If adequate scientific data exist that support a health benefit from the inclusion of these components in the diet, reference intakes will be established. In replying to your letter, we have consulted with the Committee that produced the FNB report and asked them to review the important points that you raised concerning their report and the associated workshop, as well as to explain why they have reached the conclusions they reached despite the information you cite. First, let us reassure you with regard to one concern. Nowhere in the report is it stated that fluoride is an essential nutrient. If any speaker or panel member at the September 23rd workshop referred to fluoride as such, they misspoke. As was stated in Recommended Dietary Allowances 10th Edition, which we published in 1989: "These contradictory results do not justify a classification of fluoride as an essential element, according to accepted standards. Nonetheless, because of its valuable effects on dental health, fluoride is a beneficial element for humans." Dr. Vernon Young, Chair of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, stated this at the workshop's conclusion. The adequate intake (AI) of fluoride for infants 0 to 6 months of age is set at 0.01 mg /day. As explained in Chapter I of the report, the average intake of a particular nutrient by full - term infants who are born to well - nourished mothers and exclusively fed human milk has been adopted as the basis for deriving an Al for all nutrients and other food components during the first 6 months of life. Using the human milk -fed infant as the model supports the recommendation that exclusive breast feeding is the preferred method of feeding for http:// www. fluoridealert. org /nas.1998.letter.nutrient.html 9/6/2011 Fluoride is not an essential nutrient. 1999 Letter from the presidents of the National Academy of Science... Page 2 of 3 10C normal fullterm infants for the first 4 to 6 months of life - a recommendation shared by the Canadian Paediatric Society (Health Canada, 1990), the American Academy of Pediatrics (1982), and the Food and Nutrition Board's report Nutrition During Lactation (IOM, 1991). (Infants who are exclusively breast fed for the first six months of life would have a low fluoride intake, and yet scientific evidence showing that these infants are at greater risk for dental caries than formula -fed infants is lacking.) During the second six months of life and thereafter, the AI for fluoride from all sources is set at 0.05 mg /kg /day because it confers a high level of protection against dental caries and is associated with no known unwanted health effects. Although the report acknowledges that most of the anti- caries effect attributed to fluoride occurs by topical exposure, it does not matter whether that exposure is from food, water or dental products. As you state, the prevalence of caries in some countries around the world without water fluoridation has declined over the years. This has been attributed to national dental hygiene programs and the use of fluoride in school -based prevention programs (rinses or tablets), as well as to the use of fluoridated toothpaste. These programs provide both systemic and topical fluoride exposures. In following the model for the development of Tolerable Upper Intake Levels (ULs), as explained in Chapter 3 of the report, moderate enamel fluorosis was considered as the critical adverse effect in children under 9 years of age. As noted by Dean and coworkers some 60 years ago, mild enamel fluorosis was present in some residents of areas where water contained < 2 mgniter of fluoride. At that time the diet, particularly the water, was the only significant source of fluoride so that the daily intake of fluoride could be estimated with reasonable accuracy. The average intake by children at risk was 0.05 mg /kg /day. The prevalences of both dental caries and fluorosis in these communities was low and there is no reason to expect that level of intake (from all sources) to produce different results today. Compared with Dean's findings, recent studies have revealed a higher prevalence of dental fluorosis in the United States and Canada, including a few cases of moderate fluorosis. However, analytical epidemiological studies have repeatedly shown that the major risk factors are ingestion due to the early use of fluoride toothpaste and /or the use of dietary supplements. Thus, the total fluoride intake by some children whose water is fluoridated is now higher than in Dean's time. This is the reason that age - specific intakes for total fluoride, including that from dental products, are based on 0.05 mg /kg /day. To the extent that this intake level is followed, the prevalence of dental fluorosis can be expected to decline while a healthy dentition is maintained. Three recent reviews of the literature, Kaminsky et al., 1990; NRC, 1993; USPHS, 1991, attempted to identify adverse functional effects of fluoride ingestion in adults. Fluoride exposures included those associated with drinking water containing as much as 8 mg /liter of fluoride and the use of dental products. These reviews concluded that evidence linking chronic, high fluoride exposures with adverse effects such as cancer, including osteosarcoma, birth defects, genetic disorders, or bone fractures is either insufficient or highly contradictory. In addition, the majority of animal studies have shown no effect on cancer, birth defects, genetic disorders or bone strength of very high and long -term fluoride exposures. Thus, the primary adverse effects associated with chronic, excess fluoride intake are enamel fluorosis in children through 8 years of age and skeletal fluorosis in adolescents and adults over 8 years of age. In Hodge's 1979 article, he reported that evidence of crippling fluorosis "was not seen in communities in the United States where water supplies contained up to 20 ppm." In such communities daily fluoride intakes of 20 mg would not be uncommon. Fluoride is continuously taken up by newly formed bone and released from older bone being resorbed. As long as intake remains constant, the concentration in bone tends to increase during life. It is not entirely clear why this happens but it may be due to the preferential resorption of bone crystallites that do not contain fluoride. In any event, in the United States and Canada, it is known that the development of skeletal fluorosis, even in earliest stages, has not occurred, even where the water fluoride concentrations have been in excess of 10 ppm. In reviewing Kaj Roholm's classic 1937 report of bone changes among Danish cryolite workers, it was noted that Roholm reported no intake data for fluoride, apparently because the researchers were not able to measure air -borne fluoride. On page 279, Roholm states: "It must be admitted that with respect to the important question of dose, that the observations available are sporadic and to some extent contradictory; in most of the spontaneous intoxications the intaken (his word) quantity of fluoride is not known at http:// www. fluoridealert. org/nas.1998.letter.nutrient.html 9/6/2011 Fluoride is not an essential nutrient. 1999 Letter from the presidents of the National Academy of Science... Page 3 of 3 y 10C all." Later on page 319 Roholm states: "In man the disease (he is referring to crippling skeletal fluorosis) is probably caused by 0.20 -0.35 mg fluoride daily per kg body weight." The reason for this estimate is not given. It is unfortunate that, in the absence of scientific data, these estimates were ever made. Although we are uncertain about the lower level of intake and time of exposure that causes clinically significant skeletal fluorosis, we do know that, at least for U.S. and Canadian citizens, intakes associated with water fluoride concentrations in excess of 10 ppm do not cause clinically significant skeletal fluorosis. Our study was funded entirely by the governments of the United States and Canada. The funding agencies were the National Institute of Health's National Heart, Lung, and Blood Institute; the Agricultural Research Services of the U.S. Department of Agriculture; U.S. Food and Drug Administration; and Health Canada. We thank you and your co- signers for your careful reading of the report and interest in assuring its accuracy and completeness. Given the complexities of the issues the report considers, we are confident that much room remains for further objective inquiry. We have tried to give you some of the reasons for the Committee's conclusions. However, we hope that the report will lead to additional research on which to base dietary reference intakes - for both essential nutrients and other dietary constituents with documented health benefits. Once again, we regret that this reply to your thoughtful letter did not reach you much earlier, when it was prepared. Sincerely, Bruce Alberts, Ph.D. President, National Academy of Sciences Kenneth Shine President, Institute of Medicine See this letter and the correspondence that led to it at o n %.2 t a 2 iet r t /uLv;��. !1 i y��3 or_ :Nti� Fluoride Action Network 1802-338-5577 J.Jni fU JAh Cr3{ http:// www. fluoridealert. org /nas.1998.letter.nutrient.html 9/6/2011 10C / DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service 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? Iused in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or animal,Lis 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. 10C * 4 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. Dkevc_e,'hJnS o NDAs have been a proved 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 10C 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 perform query to access this document Enter:htyr://www.access.gpo.gov/su_docs/aces/aces 140.html Enter:checkmark for 1995 Volume 60 Enter.On:10/06/95 Enter:Search terms:anticaries After 50 Years, Fluoride Supplements have Never been Approved by the FDA FLUORIDE A C T I O N NETWORK Home ....... ............................... About FAN ....... ............................... Latest News ....... ............................... Water Fluoridation ....... ............................... Health Effects Database ...... ............................... Sources of Fluoride Exposure ...... ............................... Fluoride Pollution ....... ............................... Fluorine Pesticides ...... ............................... Take Action! ...... ............................... Contact Us ...... ............................... Donate ....... ............................... FAQs .............I ........................ Search: _ �Go� 1 ag C '. 1 of 2 After '150 Years, FILIC)f ide S,Upplernents !,;?.,ve Nev r been Approved by tfie FICA p4 "tHE SAT NEW JERSEY GENERAL ASSEMBLY John V. Kelly Assemblyman, 36th District Bergen- Essex - Passaic Counties 371 Franklin Avenue, 2nd Floor Nutley, NJ 07110 (973) 667 -6123 Fax (973) 667 -9614 August 14, 2000 Senator Robert Smith, Chairman Environment and Public Works Committee c/o John Pemberton 307 Dirkson Senate Office Building Washington D.C. 20510 -0001 Dear Senator Smith: COMMITTEES Chair Housing Committee New Jersey Fire Safety Commission Member Appropriations Committee Governor's Landlord- Tenant Task Force Ellis Island Advisory Committee In 1992, the New Jersey Department of Health released a study suggesting an association between fluoridated water and osteosarcoma in young males. The New Jersey study was undertaken in response to a national epidemiology study (Hoover 1991) and a National Toxicology program study (1990) linking fluoride and osteosarcoma. Upon receiving this study, I immediately contacted the[American Academy of Pediatric D tistry�AAP and asked them to send me th studies supporting the safety and effectiveness of fluori le upplement)ss (Fortunately, New Jersey has little fluoridated water. As a result, pediatricians in our state prescribe fluoride supplements -- drops for infants and tablets for children.) I was promised the studies - they never came. When I pressed the AAPD, they admitted they had no such studies and informed me the studies could be obtained from th fational Institute of Dental Research (NIDR�T hey assured me they would forward the studies. Again—, they never came. NIDR acknowledged they did not have any studies. The NIDR recommended I obtain the studies directly from the FDA since that agency was responsible for approving these products. After filing a FOIA and waiting six months, I was stunned when I was advised by th FDA at fluoride supplements were not approved by the FDA (emphasis in original). Incredibly, in f ye s, no one has ever bothered submitting a petition to the FDA to have these products approved! http : / /www.fluofidealert.org/fda.htm 9 /7/2011 After 50 Years, Fluoride Supplements have Never been Approved by the FDA 1 GaC2 of 2 The water fluoridation debate has been raging for fifty years. The dose recommended for water fluoridation when adjusted for weight is the same dose recommended for prescription supplements. HoweverEnlio clinical trials have !102P conducted and submitted to the FDA to demonstrate the effectiveness of ingesting fluoride. So, the question remains, if the FDA does not recognize the safety and effectiveness of fluoride supplements, how can we even consider fluoridating water? Toxicology studies and clinical trials of fluoride supplements submitted to the FDA would have been the simplest, clearest and lawful way of demonstrating the safety and effectiveness of ingesting fluoride. There is no reason to debate epidemiology studies. Simply submit fluoride supplement studies to the FDA and we will know whether fluoride is safe and effective. Of course, the reason this has not happened in half a century is because the promoters of fluoride supplements dare not go anywhere near the FDA, fully aware that they could never meet the requirements of demonstrating safety and effectiveness. Rejection by the FDA of petitions for fluoride supplements would be the death knell for water fluoridation, so the FDA and the law are simply ignored. It is my understanding that in 1975, the FDA issued a regulatory letter asking manufacturers to remove fluoride supplements from the market. To date, the FDA has not responded to my inquiry asking for clarification of their actions in 1975. Also, in 19931 petitioned the FDA to enforce the law and remove children's fluoride supplements from the market. The FDA has ignored my repeated requests. At best, fluoride supplements are a waste of precious health care dollars. At worst, they are causing real harm to our infants and children. I urge you to hold hearings on this issue. I also urge you to demand that the FDA enforce the law and remove these unapproved products from the market. Sincerely, 1 John V. Kelly Assemblyman District 36 J K/ki Enc. Fluoride Action Network 1802-338-5577 linfc flUOridealer crc, http : / /www.fluoridealert.org/fda.httn 9/7/2011 EPA's Headquarters Professionals' Union Opposes Fluoridation Why EPA's Headquarters Professionals' Union Opposes Fluoridation mo National Treasury Employees Union Chapter 280 Avlayt Y939 Why EPA's Headquarters f)ofeaoiox/als'Lnioo Opposes Fluoridation by Dr, j. Nx0en Hirzy Senior NcePoeo;Olent,WTEUChm/ier280 of T c ThaV|owinU documents why mx onior. formerly %abona| Federation cfFociera{Empioyooe Local 205O and since April 1988 Chapter 2D1,)o! the National Treasury, EmployoeeUoiontoak the stand it did opposing fluoridation ofdrinking water eupNia*.Our uniunimcomphoodofandeprespntstheapproximata\y15OOaciontiats.}owyers.en0ineoruand otherpmfeeoiono|em',)!oyoeaat EPAHea�quu�em ho�einYVms�ingmn. D�C Thp union first became intenestedinthiu:sooerathe/by accident. Like most Americans, including many physicians and dentists, m��uf our membera had thought. that fluoride'--- only effects were benehdo|' reductions in tooth decay) etc. VVe too believed assurances ofmaf�yundeffoctivnnosuof water fluoridation. For ehisto,yof how drinking water fluoridation began, see 'T!uonde. Tertx an� U�e �nm,: Bon`�'. bfinvea�gahverepo�a,uJno| ����hs and Chna Bryson. Then, ua EPA was engaged in revising it's dnnmnUwa^r/gandadforf 1985.unomployee carne to the union with a complaint he said tie was being forced towrite into the regulation a staternent to the effect that EPA thought it was aN0hitfnr children to have ''funky" te-oth, Itvvau{)R.EPAma,d.beoauae\1unnmdevadthu:oonditiontubeon|yaooamedoeffoct.notanadveme hoy|theffectTheroaaonfnrthiaEPApooidonwaathmtbwoeunderpo|!1.ca!o'eaao/etoSe|itsheahh-booedstandu,dfor0uundont 4mg/htar./t V%at!ovel.EPAknn",thetasignificantnumhe/ofchi!d/endnvelopmodeete1uoevansd+nta.fuoros/s. but since chad deemedtheeffectaooniyuoemeKc.EPAdidn'thavetnaeti1ahea|1h'boeed*kandarduta|mme/|eveltopmvontit VVe tried mSettle Uhmethi:siaaue4uietiy.withinthofamUy.butEPAveeunmbleorunwi|!inyturoa\ute*e/oalpo8hca|proeoure,undwetooktbpnght pvbU: with a union um/cuy Curiae b/iefina lawsuit filed against EPA byapou|ic'nte.*ozO/ourp The union has puNishedon this initial involvernentperiod in dietail (1). Since then our opposition to drinking water fluoridation has grown, based nn the scientific literature douumentingthoinoneuynglyout- of-control exposures to fluoride, the lack of benefit to dental health from ingestion of fluoride and the hazards to human health from ouohingoohon.Thaaohazardaindudeucutetowiuhazand.ouuhaatopanplewithimpaiedNdnoyfunotion.aovvel\saohxmiotoxiu hazards of gene mutations, cancer, reproductive effects, neurotoxicity, bone pathology and dental fluorosis. First, a review of recent naurotnxioity research results. |n1y015. l.|%ery and co-workers (2) showed that rats giver, fluoride m drinking water anieveisthat give rise tu plasma fluo/!d* nonrentrahonoin the range seen /nhomnn* suffer nounc;toxio effects fiat vary, aucoubng+10 when the rats were given the flunhde'ae aduitanima!n.asyounyan:na!n.or through the placenta before birth. T hose exposed before b,thwere born hyperactive and �emamedsot�,ovy�ou�|h�rUveu. Those exposed os young or adult aniona(mdie�ayed depressed ocUvity. Then in1998.(�uanand oo'workem(3) gave doses nimi|ar{o those used by the Muflenix research group to try to uaiderstand the mechanism(s) underlying the eff eoaaoenbythoK8oUenixgroupGuun'agmupfuundtho\yewa,a|keychomixa}aintheb`ain those that form the menihreneof Nair) celis - vvere substantially depleted in rats given fluoride, as cornpared, to those who did not get. fluonde. Another 190-8 publication by Vyn�+,. Jaoyen and uhem WU reported on the brain' and kidney damaging effects in ratsthn were given fluoridem drinking water at the samiaievel deeriied ^optirnal" by pfo-fluoridation groups, namely 1 part per mi||inn(1Ppm) Evenmnropmnounoeddamagawauoeonin*n!malsthatgotthefluoUdminomnjunnbunwilko|uninum.Theeemoultsareanpocim|{y disturbing because of the low �osc, level of flucride that shows the toxx effect n rats -rats are 1 ioie resistant to fi .0110fice than. hunian.s. This latter statement is based on Mullenix's finding that it takes SUIDSWPtially MOrE.; fluoride in the drinking water ofratsthanof humanotn reach, the mamp fluoride level i It is the level in plasnia that detemnin-es how much fluoride is 'seen" by pairticular tissues in. the body. So when rats get 1 ppm in drinking water, their brains and kidneys are expoeeato much less fluoride than hu/nsnSAetting1ppm.yeLtheym/eaxpehenci:g toxic effects. Thus wo are coryipelled 'to consider the likelihood that humans are ox»er|encin8dmmngeto their bramoand �dneyosttho'opbma|'|evo}cf1ppm, in support »fthis concern are results from two opidemio|ogystudies from Clhinx (5.8) that show decreases in I.Q. in children who get n`nmOooridotxaothocmnt,oigmupoofnh3dmnineachstudy.Thooedec/euaoaureabout to1O|.Q. points !n children aged 8to 1 3 years Another troubling brain effect has recently surf.aced. fluoride's interference with the function of "he bmin's pineal gland I he pineal gland produces me{atonmwhich mnxong other m|+a, mediateatke body's internal douk, doing such things as governing the onset ofpuberty, Jenriifer Luke (7) has shown that fluoride acr*: and inhibits its production of melatonin Skeuhw�edinteuan|ma|a that this mhiU!don causes uooa,/.e/ons*' nfs*/ua|matvr,ty.ane�exinepnhedinhumanuaewm||!o 19156, as part of the KincistonlNewburgh study, which is discussed below. In fluoridated Newburgh, young girls experienced earlier onset ofmanutmebon(on average, hy six months) than girls, in non-fluoridated Kingston (d) http://www.fluoiidealert.org/hp-epa.html 9/12/2011 EPA's Headquarters Professionals' Union Opposes Fluoridation Page 2 of 5 10 corn a risk assessment perspective. all these drain effect data are particularly Compelling and disturbing because they are convergent We looked at the cancer' data b,Jth aial'M a$ Weil. ! fie, e are epidemiology Studies that are convergent with whole - animal and single -Cell studies "dealing with the cancer hazard,�, lust as the neuTotoxi :ity research just mentioned all points In the same direct!on. EPA fired the Office of Drinking `Water's chief toxicologist iD iia : t tc.lC'i,a who also was Our local union's treasurer at the 6me, for i efusing t0 rC! ?1a!n S!ie >nt on the cancer risk issue (9). The ii_idge who heard the lawsuit he brought against EPA over the firing made that finding that EPA fired hi n ever his fluoride sJari <. and not for the phony reason put forward by EPA management at his dismissal. Dr. Marcus won his !a`&--.,.!ii and is again at `rlork at EPA. DoCL;f±lentatiOn is available on request, n a x r r }'^ f' F;'1, > >ti? a y.. n 4 t ri^ TI h. type of cancer O pa,.i. u,Zr oilce,rn wi tiioiide. although not tt ea only ype, i5 C C°OS:3r ;ilia, especia iy it sU eS e ! it ^i�ai - �ex ;coiogy F "i 'vn conducted a two -year study (10) irr which rats and mice were given sodium fluoride in drinking water- The Positive result of that study {tit which n 1jIgna _s ! t , uf: other :.? ,,. k .,ne were also observed), particularly in male rats, is convergent with a host Of data ffOn? tests showing fluoride's ability to Cause ni'.ii <tll''ls (a principal 'trigger mechanisni for inducing a Ceii t0 i?$COYe cancerous) {B.U. a, t}, C, d and that :? showing nCrec?5E'S in tJciti 3l'. :Or' i; yo: no men in New Jersey 12; Washington and lowa 13) based on their drinking fluoridated water. it was his analysis, repeated statements about all these and othe! inc iminating Cancer data, and'Ill's requests for an independent, unbiased eValtiat!011 Of then, that got fir. Marcus fared. i)rle Na..1CJ;C'i `s other than Cancer is a concern as `lreli. An exce ?'Sent review of this Issue was published by L iesendorf et al. in 1997 (14', Five ep dernioiogy studies have shovyrn a higher late f hip fracture.. fluoridated f d r unii; d, a � � in rdate ;� s. non- .iuor<aate.� air:m es (15a, b, c, e). Crippling a'x.r F ;. f`itorosis was the endpoint used by EPA to set its primary drinking water standard in 1980, and the ethical deficiencies in that standard Setting process i)rOfTt pteC: Our union to aofr tfle N1 < '< 5 ..'•; :E uE`t ;ii C 1 )OSr31g t e standard in Cotlli, as mentioned above. Regarding the effectiveness of fluoride in ieducing denta +`e . there has cot been any double -blind study of fluoride's e'fectiveness as a Caries preventative There have been many, many small scale, seieCti've publications on this issue that proponents Cite to jListrfy fluoridation, but the largest and most comprehensive study, One done by dentists trained by the Nat!onai institute of Dental Research, on Over 39,000 school Children aged J -11 years, sho,, ;,vs no significant differences (in terms of decayed, missing and filled teeth), among Caries incidences in fluoridated, non - fluoridated and partially fluoridated communities (16). he latest Publication (17) on the fifty-year fluoridation experiment il toJO New York cities, Newburgh an d Kingston, slaws the sarn e thing, to e Only s!gnlfiican difference nil dental health betbveen the two comrnunities as a whole, is that fluoridated Newburgh. N Y. shows about twice tale incidence of dentai fluorosis (the first; visible sign of flLlOride chran;c toxicity,', as seen in non•fluoridated Kingston. r` at1C� , Oil this point Of efticaCV is especially irnpa?fant (18). Dr. C'olqu. Tun was Principal _rental G'..'ver r lokln y 0i:li.Ik Curl's r:ilik !! i i ¢ ' i f,' i( Auckland, the largest City in New Zealand: and a staunch supp'ortei of f uoridatiorl - until he vtas given. the task, of looking at the- world -wide data on fluoridation's effectiveness in preventing cavities. i he patter is titled: "Why I changed fviy Mind !�daut VJ "afar Fluoridation ." In it Colclukloun provides details on stow data were manipulated to support fluoridation in English speaking Countries, especially the U.S and New Zealand. This paper explains why all ethical public health professional was compelled to do a 180 degree turn on fluoridation. Further on the point of the tide turning against drinking water fluoridation, statements are now coining frarn other dentists in the pro- fluoride carr;p v,'ho are starting to bvarn that topical fluoride te.g. fluoride jr i tooth paste) rs the only significantly beneficial 4 ,,ay in 4etiicsl that substance afec s n . n tai health 19, 20, 21). However, if the concentrations of fluoride ir: t he oral cavity ar e sufficient to inhibit bacteria! enzymes and CaLise Other bacte.riostatic effects, then those concentrar:ons are also Capable of producing adverse effects !n n- ;amfnaiian tissue. which likewise relies on enzyme systems, This state,i ;e, t is :lased rot Only on coninnon sense, but also On results of mutation studies which show that fluoride Can Cause Gene. mutations in marntna Tian and lower order tissues at fluoride Corlcentra'trons estimated I,) be present in the mouth from 1' 1, iC73tE ; %a to0t`1 l'.:3`, (22). Fuithei, there were turnars of the Ora! Ca +`fay iseen in qme N i P cancer stLSdy mentioned above. further strengthening Concert over the toxicity of to icaly ap pt` i ed fluoride. de. in any event, a person Can Choose whether to use fluoridated tooth paste or not (although finding non- fluoridated kinds is getting harder and harder), but One Cannot avoid fluoride when it is put into the public vvaier supplies. So, in addMorl t0 Our Concern over the toxicity of fluoride, we note the uncontrolled - and apparently uncOntrcritable - exposures to fiuOnde that are occurring nationwide via drinking water, p•iocessed foods, fluoride pesticide residues and dental ,are products A recent report in'the lay media (23), that, according to the Centers far Disease Control, at l eai} F 2 Percent of Amn ri.ca S children n w have = elan flu;arosi, _ is , ust one indication of this uncontrolled, excess exposure. The finding of nearly '1 percent incidence of dental fluarc,sis among Children in Lin - fluoridated Kingston New fork (17) is another For governmental' and other Organizations to continue to push for more exposure in the face of Current levels of over- exposure Coupled With an increasing C:resCendo of adverse toxicity findings is irrational and irresoonsible at best. Thus, w'e took the stand that a .policy which makes the public water suppiv a vehicle for disseminating this toxic and prophylactically useless (,via ingestion; at any rate) substance is wfong. We have also taken a direct step to protect the employees vve represent from the risks of drinking fluoridated water'. 'Free applied EPA's risk CGn,to! methodology, the Refeie ce Dose, to l'i'e recent nelimtOxiC!ty data. The Reference those is the daily dose, expressed in tnilligrarns of Ch, hemm al per kilogram of body weight that a person can receive over the long term, with reasonable assurance of safety trom adverse effects. Application of this methodology to the Varner et al-(4) data leads to a Reference Dose for flux, ide of O 00010+37 nlgfkg -day. Persons who drink about one quart of fluo! idated water from the p.iblic drinking water supply of the District of Columbia while at Work receive about 0.01 rngikg -day from 'hat source alone. This amount of fluoride is more than 100 times the Reference Dose. Or.. the basis of these results the union filed a grievance, asking that EPA provide un- fluoridated drinking water to its employees. http: / /www.fluoridealert.org/hp- epa.html 9/12/2011 EPA's Headquarters Professionals' Union Opposes Fluoridation 1016 3 of 5 The implication for the general publlc of these calcuiations is clear. Recent, peer- revievved toxicity data, when applied to EPA's standard i- nothod' for controlling risks from toxic chemicals, require an immediate halt to the use of the nations drinking water (eServin a s disposal saes for the toxic waste of the phosphate fertilizer indlustry (24 ). his document was pY li tYBGj on xNe}Pali Oft the r1}a ?O ?ci,'`IaBSu y` L h vl! °E +s Jn;Qf (3F7ci} t!'Y 215 by ( }?r?iBY :Set)tOY `;C -Ycsf<ef7} %. r1r 7', r, more » r t;; r� f• -k .. i/�r,rfa%;? +"tizzy% r ': L. For mot fv.??fn on pleasi. cut; Dr Hirzt/ a- 2� 26 -4683 His f -nail address i's . � ;<<y. ,�1 �,(L'ea:a.u:nr -> ___ _..._ ... _ .....__._. ___._._..__ ...__..___. END NOTE LITERATURE CITATIONS 1. A the '� �� [ �. t o t`. r+ :r f T 4 >. standard. pplying he : AE' crude of ethics to the Environmental P,o iVction � enc and the luonide in drinking :watt tandari . a( on. and H!izy, JNV. Proceedings of the 23rd Aran. Cent. of the National Association, of Environrrental Professionals. 20 -24 June, ,,998. GEN 51-al On -line at rittpff, L P; Cie; r.ar J .:.. 2. Neurotoxicity ofsodlurr fluoride in !ats. Mullenix, P.J., Denbesten, P.K., Schunlor, A. and Kerman, XA,'. J. Neurotoxicol. Teratoi 17 169 -177 3. Influence of chronic fiucrosis on membrane lipids in rat brain Z i Guar?, Y.N Wang: K.Q. X.iao, D.Y, Dal, Y.H. Chen, J1. L-iu, P. S:ndelar and G. Danner, Neurotoxicology and f eraiolocgy 20, 53 7-5,42 998' 4- Chronic ad?rinlstratlon of aluminum- fluoride or sodium - fluoride to rats In crink•'ng Xn /ater alterations in neuronal and n r` r r Varner, +G�1C i i "� Yi. A d i Cr t Brain Research y- Q �s cerebr„vascula, integ,i Va:ne., J.A., en, K,F., ;- ,,,.vat,:, W. An ,saacson, R. ain sear 784 .8 2 8 :99 s; 5. Effect of high fluoride water supply or children?s intelligence. Zhao: L B., Siang G.H : Zhang: D.N., and 'tru. X.R. Fluoride 29 191-1- 192 ;1996) 6- Effect of fluoride exposure on Intc^iiiQe(1cP, li. Ghildrenl. 5., '_hl, J.L , and Liao, R.i0. Fluoride 28 1;1995) 7. Effect- of fluoride on the physiology of the piney }i gland Luke..: A. Caries Research 28 2014 (1994) 8. Ne+; iDurgh- Kingston caries - fluorine study Xiil. Pediatric findings after ten years. Schlesinger, E.R., Overton, G.E.: Chase, H.C., and C`antweli, K T. JAEA, 5:: 296-.386 0956; 9. Memorandurn dated May 1, 1990. Subject. Fluoride Corfererice'to Review the NTP Draft Fluoride Report: From: \�Nrn t.. Marcus. Senior Science Advisor ODW, To Alan B. labs, Acting. Director Criteria & Standards Division ODW. 10. Toxicology Gild carcinogenesis studies of sodium fluoridle in F' 344;N rats and B6113r1 Mice. NTP Report No. 393 1. 1991 ) 11a. Chromosome aberrations, sister chroina id exchanges, unscheduled DNA Synthesis and morphological neopiastic transformation, in Syrian hamnster embryo cells. Tsutsui et al. Cancer Research 44 938 -941 (1984Y 11 b. C;ytotoxicity, cl-irot7Eosorne aberrations and unscheduled DNA, Synthesis in cultured hun -ian diploid fibroblasts. {-sutsui et al. Mutation Research 139 19,3-198 (1984) 11 c. Positive imouse lymphoma assay with and without S -9 activation, positive sister chromatid exchange in Chinese hamster ovary Cells with and without S-9 activation; positive chromosorriP aberration without S-9 activation Toxicology and carcinogenesis Studies of sodium fluoride Iii i=344!N rats and B603F1 mice. NTP report No. 393 1 ;A, .,91). 11d. An increase in the number of Down's syndrome babies born to younger mothers In cities following fluoridation. Science and Public Policy 12 36 -46, (19KV, 12. P, brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young hales. Cohn, P.G. New .Jersey Department of Health (19921 13. Surveillance, epidemiology and end results tSE ER ) program. National Cancer institute in Review of fluoride benefits and risks. Departlrent of Hearth and Human Services. F1 -F7 (1991). 14. New evidence on fluoridation. Diesendorf, M., Colquhoun, J., Spittle, B-1- Everingham, G.N , and Clutterbuck, F.W. Australian and New Zealand J. Punic Healti-i, 21 187 -190; 0.997; i5a. Rectional variation in the incidence of hip fracture: U S..vhite wornen aged 65 years and older. Jacobsen, S.J.; Goldberg, Miles; J1 P et al .IAMB? 264 5000 -1502 i_ 1990) 15b. dip fracture and fluoridation ir, itah ?s eidery population. Danielson, C., Lyon: I.L ,Egger, and Gordenouuh, G.K. JAMy ,68 746_748 (` 91 2,' http://www.fluoiidealert.org/hp-epa.html 9/12/2011 EPA's Headquarters Professionals' Union Opposes Fluoridation 1 GaC4 of 5 15c. The association between water fluoridation and hip fracture an;ong white women and rnen aged 65 yeais and Older: a national ecoiogical study. Jacobsen S .J • Goldberg, ,J., Cooper, C. and Lock -,00d, S.A. Ann. Epidemiol.< 1617-626 11992). 15d. "-luorine concentration is cinnkrng water and fractures in the elderly [letter], jacgmin -G adda; H.. Comnienges, D. and Daitigues, J.F. ,JAMA 2r _775-%76 ( 199!0. 15e, Water fiuoridation and hip fracture iletter; Cooper, C., Wickham, C.A.C., Balker, D.J R. and Jacobson, S .J..JAMA 266 513 -514 i ?991). 16. ` Vater 'uoridatlon and tooth decay Results from the '1086 -1987 national survey of US, school children. Yiarnouyannis, J. Fluoride 23 5r.7-??r i990j`. 17. Recommendations for fiuoride use in children. KUrnar, J.V. and Green, E.L. New York State Dent J (1998) 404;7. 18. Why I changed nay mind about ;mater fluoridation. Colquhoun, J Perspectives in BiN. And Medicine 4" 1 -16 (1997), 19, A re-e :xam nation of the pre - eruptive and post- eruptive mechanism of. the anti - caries effects of fluoride: is there any ant! -canes benefit from swallowing fluoride.% L meback, *?. Community Dent. dial P-Didernnioi. 27 62-`101999). 20. `-iuoride supplements for young children: an analysis C` the literature focussing On benefits and risks. Riordan. F.J. Cornnnunity Ja rt Oral wpidenni CI 2. i 12 -s3 (-'1 999). 21. Prevention and reversal of dental caries: role of low level fluo ide. Featherstone, j.n. Community Dent. Oral Epiderniol 21, 31 -40 (1999). 22, Appendix Appenu;x -, Review cf fl c ( de `eriP titS and rfsK c . Department of . ;lealth and ^tn Ta n Services. i' i a H6 (11991). 23. Some young children get too hush fluoride. Parker -Pope, T VIVaii Street Journal Dec. 21; 1998, 24. Letter frorn Rebecca Nanmer, Deputy Assistant Administrator fnr ;eater, to Leslie Russell re. EPA view on use of by- product fEuosilicic isic) acid as low cost source of fluoride to water authorities. march 30, 1'983. OTHER CITATIONS (This short list does not include the entire literature on fluoride effects) a. Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. Fi eni, S C. J. T oxicol. Environ Health 42 109-11 21 (1994) b, Ameliorative effects of reduced food -horne fluCi "ide on reproduction in silver foxes. Eckerl +n, R.N., Maylin, G.A., Krook, L.; and Carmichael. D.T. Cornell Vet. 78 75-91 (1 :988). c. Milk production of cows fed fluoride c ontarnir;_ated cCn'irnefual feet,,. Eckerlin, R.i -i.. Mayl n, G. A, and Krook, L.:;or hell Vet. 16 403 -464 ('1986). ci. Maternal -fetal transfer of fluoride in oregnantwornen. Calders, R., ChAvine, .J., Fermanian, J , Tertrat, C., and Laurent, A.M. Biol. Neonate 54 263-21.9 (1988). e. Effects of fluoride on screech owl reproduction: teratologicai evaluation, grov.Ah, and blood chemistry in hatchiings. Hoffman, DJ !-at<iee, V H , and'.lfie,ner`er, S.N. Toxicol. Lett. 26 191 -24 % 1 9851 I '-lUarlde 1ntOxiaaiid7r'r !ri dairy i calves. Mayiin, G,A., Eckeilin, R_H., and Krook, L. Cornell Vet. iT 84-98(198T. g. Fluoride inhibition of protein, synthesis. Holland, R.I Cell Biol. int. Rep. 3 0,11 -705 (1-979) h. An Unexpectediy strong hydrogen bond: ab in do caicuiations and spectioscopic studies Of arnide- fluoride systems. Emsiey, ,,1 : „ones, D.J., 1lrlillei, J.M., Gverill, R.E. and Aaddilove R.A. J Ann. Chem Sac. 103 24- 2811981) i. The effect of sodium fluoride on the growth and differentiation of human fetal osteoblasts Sang; X.D., Chang, W L., Li, L Y., Pang, .L.., and Tan, Y•5 Fluoride 21 149 -.158 ;1988) j. Modulation of phosphoinositide hydrolysis by NaF and a;i,Eminum in tat coit!cal slices...'•ope, R.S. J NeurocherTi k. The crystal StrU:;ti.ire of fluonde- inhibited cytoc.hrorne c peroxidase. Edwards, S L., Poulos, C` L.; Kraut, J. J. Bic?. Cheri 259 12984 - 12988 (1984). i. intracellular fluoride alters the kinetic properties of calcium cur tints facilitating the investigation of synaptic events in hippocampal neurons Kay, A. R ,ovules, R., and 14vong, R.K.S. J. Neurosci, 6 2915..2020 (1986) m, Fluoride intoxication a clinical-hytgienic study with a review of the literature and some expe.rirnental investigations. RohClm, IK H.K. Lev ", ;.td (Landon) (193'y http://www.fluofidealert.org/hp-epa.html 9/12/2011 EPA's Headquarters Professionals' Union Opposes Fluoridation 10 a of 5 n 'Fo 1 , sel inclusions caused by the chronic adrmnistration of alurnmurn and sodium. fluoride and their IM, pkations , xx n-:nduceul blood ves�, - i 1 foi dernentia. isaacson, R- L., Varner, JA. and jensen, K F� Ainn. N.Y. Acadl. Sci. 825 11152-166 ( 1997), o. Allergy and hypersensitivity to fluoride S,Pittle, B. Fluoride 26 2;6-'I7.-',7Q 19093', http://www.fluoridealert.org/hp-epa.htmi 9/12/2011 10C ' Ur:ited Stags Office of Preveratiors, EPA 735 -9£i 003 Environmental nrne;atai Prntr.ctic�n Pesticides, and Tcaxic Match 1999 www.e a.g Acjerte.y SL,bstances o� lik i►EPA i i Reco nton � and Management of Pesticide Poisonings , .„......,- i,.r- 1 ,,.., , , ,.,,,..-- 1 9.,..- .... .,,,, , ,„ . , .. .,.... , .., 7 , • 77 I .'',.c 1044-' ¶___--. - - - F 1 1411 Allk `'y of ' l' -,,4 ti 4,- 3 ,, x 1 I Fifth Edition ioc usually considered contraindicated in these poisonings due to the rapid onset of seizures. 3. Seizures. Treatment is primarily supportive, with control of seizures by anticonvulsants, as outlined in Chapter 2. Persons surviving poisoning by in- gestion of DEET have usually recovered within 36 hours or less. 16,11 Sodium fluoride is a crystalline mineral once widely used in the United States for control of larvae and crawling insects in homes, barns, warehouses, and other storage areas. It is highly toxic to all plant and animal liielThe only remaining use permittedy5..for wood treatement Sodium fluosilicate sodium silico fluoride has been used to control ec- toparasites on livestock, as well as crawling insects in homes and work build- ings It is approximately as toxic as sodium fluoride All uses in the U.S. have been cancelled. Sodium fluoaluminate (Cryolite) is a stable mineral containing fluoride. It is used as an insecticide on some vegetables and fruits. Cryolite has very low water solubility, does not yield fluoride ion on decomposition, and presents very little toxic hazard to mammals, including humans. Hydrofluoric acid is an important industrial toxicant, but is not used as a pesticide. Sulfuryl fluoride is discussed in Chapter 16, Fumigants. Sodium fluoride and fluosilicate used as insecticides present a serious haz- ard to humans because of high inherent toxicity, and the possibility that chil- dren crawling on floors of treated dwellings will ingest the material. Absorption across the skin is probably slight, and methods of pesticide use rarely include a hazard of inhalation, but uptake of ingested fluoride by the gut is efficient and potentially lethal. Excretion is chiefly in the urine. Within the first 24 hours of intoxication, renal clearance of fluoride from the blood is rapid. However, patients go on to continue to excrete large amounts of fluoride for several days. This is thought to be due to a rapid binding of fluoride to a body store, probably bone. The subsequent release of fluoride from bone is gradual enough not to cause a recurrence of toxicity. 16, 27 Large loads of ab- sorbed fluoride may potentially poison renal tubule cells, resulting in acute renal failure. Children will have greater skeletal uptake of fluoride than adults, therefore limiting the amount the kidney needs to handle. Despite this, chil- dren are still at great risk because oftheir smaller body mass compared to adults in relation to the amount ingested 27 82 • OTHER INSECTICIDES h The toxic effects of fluoride in mammals are multiple, and all may threaten life. The primary effects from fluoride result from an inhibition of critical intra- cellular enzymes and the direct effect on ionized calcium in extra - cellular fluid. Hypocalcemia commonly occurs .21, 21,29, ao Ingested fluoride is transformed in the stomach to hydrofluoric acid, which has a corrosive effect on the epithelial lining of the gastrointestinal tract. Thirst, abdominal pain, vomiting, and diarrhea are usual symptoms. Hemorrhage in the gastric mucosa, ulceration, erosions, and edema are common signs.'' Absorbed fluoride ion reduces extracellular fluid concentrations of calcium and magnesium. Hypocalcemia sometimes results in tetany.31 Cardiac arrhythmia and shock are often prominent features of severe poisoning. Hypotension and severe arrhythmia, sometimes progressing to ventricular fibrillation, may also occur.2 , '2 These probably result from combinations of effects of fluid and electrolyte disturbances including hyperkalemia-2 and direct actions of fluoride on heart and vascular tissues. Fluoride may directly affect the central nervous system, resulting in headache, muscle weakness, stupor, convulsions, and coma .26,27,28 Respiratory failure and ventricular arrythmias are common causes of death. 26,27 Confirmation of Poisoning A population drinking water with a concentration of 1 mg per liter will have a plasma inorganic fluoride concentration between 0.01 and 0.03 mg per liter28 and rarely above 0. 10 mg per liter. In fatal cases of poisoning, plasma levels of 3.5 mg per liter and higher have been recorded, although survival has been reported in patients with levels as high as 14 mg per liter. 26,28 i1'mllhflenF. F m uWe Toxko s 1. Skin decontamination. Wash skin with soap and water as outlined in Chapter 2. Eye contamination should be removed by prolonged flushing of the eye with copious amounts of clean water or saline. If irritation persists, special- ized medical treatment should be obtained. 2. Gastrointestinal decontamination. If sodium fluoride or sodium fluosilicate has been ingested, consider gastric decontamination as outlined in Chapter 2. If the victim is obtunded or if vomiting precludes oral administration, the airway should be protected by endotracheal intubation, then the stomach should be gently intubated and lavaged with several ounces of one of the liquids named below. Activated charcoal is not likely to be of use because it does not bind the fluoride ion well. Fluoride is not an essential nutrient Page 1 of 1 10 C r 1. F` 1 �.1 r HEALTH EFFECTS: F i_.ti iz is P moil c I? taszsei I fe��dt t�..b F ..i EYIa! iut" r „V r -',:,) DIRECTORY: FAN > Health > lnfa _r fluoride exo%i'.sure > Fluoride is not an essential nutrient I I E A L T I i EFFECTS �— HEALTH Summation - Fluoride is not an essential nutrient: tFFECTS HOMEPAGE "These contradictory results do not justify a classification of fluorine as an essential element; according to -- accepted standards.” Accidents SOUR? E . National Academy . of Sciences 198S,'j. Recommended ommende� Dietary Y Alloy^ ✓ances: 10 ±h Edition. 7 trCiYltTil5: >if7n on Life Sciences, Notional Reseamill l.oLnCl! National Academy Press P. 2315. r?jiwr� V 'fluoride is longer considered an essential factor for human growth and deve� ment.Arthritis �RJ Natl rral Research ((Vwr�(i f: .` 7e�i µ Effects iS 0 it gested Fluor;a: v ri on" a !Academy Bone Disease Press, DC. p. 30. Braid' "First, let us reassure you with regard to one concern. Nowhere in the report is it stated that fluoride is an Cancer essential nutrient. If any speaker or panel member at the September 23rd workshop referred to fluoride as such, they misspoke. As was stated in Recommended Dietary Allowances 10th Edition; which v ✓e Denial Ruorosis published in 1989: 'These contradictory results do not justify a classification of fluoride as an essential elernent. according to accepted standards i�;�?� Standard,- � SC)UR(',E A €bents B, Shine K. (19f8). Letter from Bruce Alberts President, National Acaderny of Sciences and Kenneth Shine, Pre': C4ent, Institut:: of =Medicine to Dr Albert burastahler Nove inber 18 Gastrointestinal 1998 (See letter` Irfa it EY sire i7lr?13.1t1 t, S stem K;dnev Pineal eland Respiratory Drivrolc; Gland Tooth Decay Database Site leap l iossa of Terms B;bilo y2:,,hy Newsletter Useful °.[ill`s auestfor's , Fluoride Action Network 1802-338-5577 1 health @fluoridealert.org € Google Search e Health Pages http:// www. fluoridealert. org /health/infant/essential.html 9/7/2011 New Studies Cast Doubt on Fluoridation Benefits CHEMICAL & Engineering !News May 8,1989 New Studies Cast Doubt on Fluoridation Benefits Page 1 of 2 10C An analysis of national survey data collected by the National Institute of Dental Research (NIDR) concludes that children who live in areas of the U.S. where the water supplies are fluoridated have tooth decay rates nearly identical with those who live in nonfluoridated areas. The analysis was done by John A. Yiamouyiannis, a biochemist and expert on the biological effects of fluoride, who has been an ardent opponent of fluoridation for 20 years. His results are not widely different from those recently found -- but as yet unpublished -- by NICR in analyzing the same data. In the 1986 -87 school year, NIDR examiners looked for dental caries in 39,207 schoolchildren aged five to 17 from 84 different geographical areas. Yiamouyiannis obtained the survey data from NIDR under the Freedom of Information Act. Yiamouyiannis compared decay rates in terms of decayed, missing, and filled permanent teeth. The average decay rates for all the children aged five to 17 were 2.0 teeth for both fluoridated and nonfluoridated areas. When he omitted those children who had ever changed addresses, and thus confined the study to children with an unchanging fluoridation status, the results were nearly the same -- a decay rate of 2.0 for fluoridated areas, and 2.1 for nonfluoridated areas. Decay rates in the individual age groups were sometimes lower in fluoridated areas. sometimes lower in nonfluoridated areas. The differences were never greater than 0.5 teeth. He has submitted his study for publication in the Danish journal Community Dentistry & Oral Epidemiology. He also found that the percentages of decay -free children were virtually the same in fluoridated and nonfluoridated areas, and averaged about 34 %. This analysis included both permanent and deciduous (baby) teeth. NIDR's claim that 50% of the children in the U.S. are decay -free, headlined in newspapers across the country last summer, was based largely on the fact that NIDR analyzed only permanent teeth in children aged five to 17, and a large fraction of these children were not old enough to have many permanent teeth, Yiamouyiannis says. When analyzing the survey data, NIDR compared decay rates in two ways: in terms of the number of decayed, missing, and filled permanent teeth; and in terms of decayed, missing, and filled surfaces of teeth. Both of these methods are widely used today. NIDR found that children who have always lived in fluoridated areas have 18% fewer decayed surfaces than those who have never lived in fluoridated areas. But when NIDR analyzed the data in terms of teeth, the differences were smaller. Janet A. Brunelle, statistician in the epidemiology program at NIDR, tells C &EN the results for teeth "are in a box somewhere" and she does not remember exactly what they are. Brunelle says NIDR is publishing cn;a, the results for surfaces because they are more meaningful. Surface rates give a more complete picture of the extent of decay, she adds, and the decay rate for teeth "is rather low so that there is very little difference in most anything." When asked to comment on Yiamouyiannis' results, Brunelle said she didn't know whether they are valid. In reaction to Yiamouyiannis' new study, the union of professional employees at the Environmental Protection Agency has written a letter to EPA Administrator William K. Reilly. The letter asks him to "immediately suspend (not revoke) EPA's unqualified support for fluoridation" until the agency conducts its own assessment of the risks and benefits of fluoride exposure. The union, Local 2050 of the National Federation of Federal Employees, has been concerned for some time that EPA evaluated fluoride politically, rather than scientifically. The union also believes the safe level of fluoride in drinking water should have been lowered rather than raised in 1986, when EPA increased the maximum allowable contaminant level to 4 ppm from a ranged of 1.4 to 2.4 ppm. Another analysis of decay rates is published in the current issue of the American Journal of Public Health. http://www.fluoridealert.org/media/1989b.html 9/7/2011 New Studies Cast Doubt on Fluoridation Benefits Page 2 of 2 10C Jayanth V. Kumar of the New York State Department of Health examined decay rates in seven to 14 year olds in Newburgh, N.Y. which has been fluoridated since 1945, and in nearby Kingston, which has never been fluoridated. He found that the caries prevalence in Newburgh -- 1.5 decayed, missing, and filled permanent teeth -- is somewhat lower than it is in Kingston (2.0). However, since the 1954 -55 school year, the decay rate has actually declined more in nonfluoridated Kingston than in Newburgh. When asked by C &EN, a spokesman for the American Dental Association said that ADA believes that water fluoridation can reduce tooth decay 18 to 25 %. But as recently as 1988 the association claimed fluoridation reduces decay 40 to 60 %. Return to: Fluorde Action Network's Mema Pane. Fluoride Action Network's Home PUae http:// www. fluoridealert.org/media/1989b.html 9/7/2011 Pao 1 of 1 1 C Tooth Decay Trends: Fluoridated vs. Unfluoridated Countries UNFLUCRIDATED -11:he -ea;th - w47,:ohcccAlat..,:pi nan se; ri a phAuc b C--;'4eurat- !-ANI Belgium 9 - --A—Denmark 8 - Finland France 7 - —4i—Germany o Iceland 6 - f• • to, Italy `6 5 N N Japan Netherlands 4 Norway -E" - • '• 1:1 —4—Sweden 3 3 - ' - Switzerland United Kingdom I- LL FLUORIDATE-0 1 - AL si rat la o Ireland .pt. • "P!!: New Zealand Year United States http://www.fluoridealertorg/health/teeth/caries/who-dmft.gif 9/6/2011 Fluoride and Tooth Decay: Topical Vs Systemic Effects Excerpts from the Scientific Literature - Topical Vs. Systemic: (rack zo t p) "Fluoride is most effective when used topically, after the teeth have erupted." SOURCE. Cheng KK, et ai (2007) adding fluoride to water supplies. British Medicai JOUrnal 33,5f "it ;s now accepted that systen is i,Gride oiays a lirmitted role in caries prevention." : rS O URCE: Pizzo G, Piscorio MR Pizzo JiUliana G. { %: U , Community water fiGEdati On an d Cares preventi on: 0l: a Cri.i a: review. L finical vial investigations , >>.j.10 -03. "the major anticaries benefit of fluoride is topical and not systemic." SOUR= Nationai Rese'aich Council ( 00 ?), Fluotide in Drinking `.rt'ater: A Scientific Revie'w Of EFIA's Standards. Nationai Academies Press; 'Washington D.C. p 11 Pagel of 3 10C "Since the current Scientific thought ht iS that the car ?ost'aric activity of fluoride is nha3inly dt.ie t0 its tvpiCal effeCtS, the need t0 provide systemic fluoride, suprl ?erne;- station fo} Caries prevention is questionable." OURC FE. European Commission. 20051. The Safety of Fitiorine Compounds in Ora,, Hygiene PioductS for I nd i the Age of 6 Years. European Cornimission, Health & C Gnsl.lrner Protection D : reC40rate- General, ;scientific Committee on Consumer Products, September 20. "The results Of from recent epiderniolcialcal and lanoratoiy Studies :an be sure ?nariz'ed by stating that posterupti've (topical) application Of fluoride plays the dornina nt role in Caries prevention.' SOURCE Hell`rvig E, Lennon AM. (12004), Systemic versus topical fluoride, _C_c?rie?S_t'f_G'_seal -ch 38. 258--62 "'Afher, it `,Jas thought that fluoride had to be prese ?t during tooth imine ralisat on to 'improve' the biological w,)atile and the caries resistance' of the teeth, Systemic fluoride aad?nivilsttation was necessary for m5akimunl benefit. Caries reduction therefore had to be balanced against increasing d enl:a !iur,,Iosl :. The 'caries resistance Concept was shovvn to be erroneous 25 years ago, but the new paradigm is not yet fully adopted in public health dentistry, so we still await real breakthroughs in more effective use of fluorides for ;varies prevention.:' SOURCE : Fe erskov C, (2004). Changing paradigrns in conceits Oil dental caries conSegUences fo; oral health care. Curies Research 38, Current e�`idence stronglyr S!1ggeSTS thatftuorides WOriC elfin ?drily by topical rTlesir ;S thrvt. ?gh direct action on the teeth grid dental plaque. Thus ingestion of fluoride is not essential for canes prevention." SOURCE Warren iJ. Lpvy SIVI (12003). Current and future role Of flUOiide in ni. rition �i -. Dental C ` of Agie _Q!ni Nth r_C_o^ 22 5 µ3. f. , ;he majority of benefit frorn fluoride is noti believed to be from its topical, rather than systemic, effects." SC3L E: Broth veil D. i_irneback i -1 ( <'003 . nreastfeedinq is omtecti�ie againsi demal'<uorosis in a nonfluoridated rural area of Ontario, Canada. Journal of Human Lactation 19. 386-90 "For a long tilyle; the systemic effect Of'flUoride vvas regarded to, be most important, resulting in recomnleridetions to use fluoride supplements such as tablets or drops. However, there is increasing evidence that the local effect of fluoride at the stEi #ace of the erupted teeth is by far More important," ;; Oj_ RC;=.: Zimmer S et ai. (12'0031. Rr'C??rm- nendationS for the Use of Fluoride in Caries Prevention. ra/ Hea ;t} Preven, .`vie Senfis`'try 1: 4 5-x1. "By 119,0811 it was therefore possible to propose a paradigm shift concerning the cariostatic rnechanisiris of fluorides in which it `e'r`as argued that the predominant, if not the entire, explanation for how fluoride c'ontro'ls Caries lesion development lies in its topical effect On de- and rernineralization processes taking place at the interface beb.Aileen the tooth surface and the oral fluids This concept has gained wide accerytance. .'Aitch today's knowledge about the rnechanisrTIS Of flu'Ofide acii n, it is important to appreciate that, as fluoride exerts its predominant effect.. at the toothfor ai fluid interface, it is possible for maxim ;m Caries prOCeCtIOn to be obtained without i3'cit the ingestion of fiiEOrldeS 20 any significant extent." SOURCE: Aoba T, ; ejerskov O. t;2002j. Cri +ical_Review of Ora, EL o ;-:Lnd Medic n 13 155 0, ",Fiiucride s predominant effect is posteruptive and topicai." SOURCE, venters for Disease; Control and Pievzention. (20011). €`e�ccrnmen dations for ! sing Fluoride to Prevent and Control Dental Caries in the United States. ;,Worbid.ty and Morfa/ity 1'1 /eekly Report 50 (RRI4): 1 -42. " i'he prevalence of dental Cartes in a popuiatson is not inversely related to the concentration of fluoride in enamel; and a higher concentration of enamel fluoride is not necessarily rnorc? efficacious in preventing dental; caries..' SOURCE: 'Centers f4f i ISed5e � ;OritrGi oriel ' "ventlOr'I i'2001', i R' ^ ndat.^nS for �151n{J 1UOri,Fr tO Prevent and acorn,, e Control Dental Caries in the United States. Morbidity arc; Motia/ity l/i''eek /y Report 50 RR14): 1 42. 'Fluoride incorporated o ring tooth sieve i:7 pn en t is, insufficient ent to p I a y < significant rol e in :cries prG+ eCt ;cn.' SOURCE: r th try i -'70 00. Science is ti f 1' ? Prevention. i i f Ft' �1 r 4 ea ,.ens; ne, .iD s. , i v). T he and P:CfCs.Ue ?. Caries G 1r ".ia/ p, 7e t ;,le,'l+ :far; ue "'.cif . A "SGC1artCf7 131. £3n'- 899. http- / /www.fluoridealert.org/health /teeth /caries /topical- systemic.html 9/9/2011 Fluoride and Tooth Decay: Topical Vs Systemic Effects Page 2 of 3 10C "Current evidence suggests that the predominant beneficial effects of fluoride occur locally at the tooth surface, and that Systemic preei'Llpti've) effects are... of much less imporiance." SOURCE: Formon; S,V Ekstrand; J. Ziegler, E 1200f)) Ruoride intake and Prevalence of Dental Ruorosis: Trends in PlUoride Intake with Special Attention to infants. Joun,al_ci Public Health Itr � cr0 13? - -9 "Fluoride supplementation regimens Suffer from several shortcomings; the First of which may be their derivation from a time when the ma;or effect of fluoride was thous., +ht to be systernlc:. Although evidence that fluoride exerts its effects mainly through topical contact. is great, si.rpplem�entation schen;es Still focus on the ingestion of fluor de." SOaURC,i : Adair I'M' 9rtiU? Overview of the ✓ iStory and current status of fluoride supplementation schedules. Joul—nel of Public 1 %ealth Denti str., . `�9.9 59.252' -8. "The Case is essentiaiiv a risk-benefit issue - fluoride has little pree rumive ls-npact on caries prevention, but presents a clear riS: of T!.i 0 r,_ _. SOURCE-.: hurt BA. x.1999,. ;.fie case for eHminatina the use of dietary fluoride supplements for young children. joilirrfal of 1; irblic ;earth DentiSti-v fig: 260 -274. "UntH recently the nmior caries - inhibitory effect of fluoride -was thought to be due to its incorporation in toroth n;inerai during the development of the tooth pr'or to eruption . There Is now overwhein; ng evidence that t ^e prin,ary caries - preventive mechanisms of action of fluoride are post - eruptive through 'topical' effects for both chilfldren and adults." .'SOURCE.: ;=eatherstone JDB, 01999} Prevention and Reversal of Der ?cal Caries'. Role of I ow Level FIL10ride. C oi nrntvnrt� enL'istr & Arai E ., ;€rem olociy?i 3`140, "If laboratory and epidemuoiogic research suggests that fluoride prevents dental caries predon -i mately after eruption ref the tooth into the mouth, and !ts actions primarily are topical for both adults and children " SOURCE. 0: Fluoride and Tooth Decay: Topical Vs Systemic Effects 1 Ogt of 3 eri,p has COntInUed to accumulate tO support the hypothesis that the anti-Cafies inlechanisrn of fluoride is mainly a topical one." SOURCE: Carlos JR 1983) Comments on Ruor de. journal of YedaWonbcs Winter 135 -136+ "Untii recently most caries preventive programs using fluoride have aimed at incoi- porating fluoride into the dentai enamel. he relaflve 1011, Of etlal'C1el fluoride in canes prevention is now increasingly {questioned, and rased on rat experiments and reeVakiafion of human data, it appears to be of (rii or importance— ±,ra. ny method which places particular eri'`:0asis on incorPnration of bound fluoride Into dental enamol during formation niay be of lirnited irnpoifance." SO, vRCE: i e,e[SKov 0, Tri yi Sfri„1 i , L"i'C en iOI. (1981), Rational Use of Fluorides in Caries Pieverilin I Gi1Cfpt J '5ed on Possible C,ariostatlC Mechanisms. Acta OdontgLc�i Iiu ? ^citlCa 39: Zr+ 11 -249, http : / /www.fluoridealert.org/health/ teeth /caries /topical- systemic.html 9/9/2011 Water Fluoridation & Tooth Decay (C:riw) EucmrptsfnomtheSnientifiuL|beretuna'ReoemdSurvaysofVVatmrF|uovidation/TouthOeuay:(vachtomp) 10 C I Qf 4 "This study assessed the relationsh!p betoveen dental caries and fluorosis at varying fluoride levels |n dhnkioQwsle/ Methods 6ub�lectm were followed Irombi:h with questionnaires every 34 months tn gather information on �uonde|n-ake,42O study ovb.iacts/eceived dental examinations at age 5on pfimary teeth and at age 8useady'emptingpermanen.tteoth_Conclusions. F|uo,nmmpreva|onoeincramaod significantly with higher water fluoride levels: oo\,veve/. caries prevalence did not decline a{QnificanUy.^ SOURCE: Hong L. Levy S. VVanen J. BroffitB. 1280,55>. De,tol caries and fluormda |n relation tuvfu a,floohde |eve|s ADfA4AURYCADRConfenenoe. his stuJympnrtnohmrgoainnon-cav'tated�othaurfacedieAnoneeafta/a4-yoarpenod' NoMuo'ida`anmueoonom!c a��ao, beverage variables were signfficantlyaaeociatedwdth|eaionpnogneso!on.^ SOURCE.: VVarmnJi. Levy Sk8, Brvffitt B. Kpxe||is K4J. (2006). Longitudinal study o!non~cmw�t d carious lesion progression in the phmarydentition. Journal nfPubVoi-ieahrh Dentistry 6O(Z),83-7 ^m the peoe) sudy.8uoridated water did not eeom^u have a positive effect, on dental health, aabnxght have been expa�ogmoconomuniyw�h��aespnod,oca�eep�va}enne.^ 8QURCE� Meyef-i-Lieck ed H, et al. (200% Canes and filuorosis in 6.- and 0-year-oid children residing in three COM'mLinities "Graphs of tooth decay trends fox12 year olds �21'4 countries, prepared using the most recent VVodd Health Organization duta.uhuwthutuhededme/ndmnoa!deooyinpeuantdeoadoehaab*envonporablwm1OncnOuohdatdnuunVrieaend8 fluoridated Countries which me1 the inclusion criteria of having (i)emeen annual per camtainoomemtha year 2O8Oof US$1 0:000 or "Tiore, Ok, a population in 'the year 2000 of greater than 3 rrifliion, and "'ii!) suitable WHO caries data available, TheVVHO data gonot support Fluoridation aa being ereaavn for the decline in dental decay in12 year olds that has been nocu'ongin recent daoados." S0URCE� Nourath C (2005) Tooth decay trends for 12 year olds in non@uondated and fluoridated countries, F."U011do �P,Bmyeuian Survival analysis is presented tu examine theeffect o| fluoride-intake on+he time tooah �o �� eadov��ent the permanent firs, molars in children between 7 and 12 years of age usinig a longitudinal study conducted in Fianders... Ourunalyaisehowanocon,inmngeffectoffluohde-|noukennouneedpvelnpment.^ SOURCE� Komarek A, et al. (2005). A £uyeeian analysis of multivariate dental data. BioVehistics, 6:1145-55 �nUfedma residents /fOum0doted areas 47% had evidence uferosion, in211Yi erosion had progressed to the dentine or Pulp. 1-he corresponding figures in non-fluoriclated areas --were 43M and 2190 respectively... Levels in Ilucinclated and non.- fluoridated areas were n>miiac" SOURCE� Harding MA, *t al(I003).Dema|enosinnin5-year-oid!nah!suhoo!ohSdnannndaaaouatedfoctomopi!cK ^ThaewmunoomnstioaUysignificant diffeencebekmeenDMFTinmun/dPali ties of the same size, regardless /ftho 'Presence or absence offluondeinthe wamrauploly-^ SOURCE. Sale+Pare*@H.BastomJR.(2002).[4nepidemi01wgioalpmf!eof dental caries in12-yoor-old chil}denresiding |n cities with and without fluoridated wmt rmupply in the cenUa/ vvest rn area of the State of Sao Paulo. Brazil] Cadenroa de Saude Pubfica 18: 1281--& "Water fluoridation status of the children's area of residence did notha-ve a significant effect on Early Childhood Caries /E"'.,C O.1 !evelvfoigoifioanuemtheunedjmsted!ogistiureOremoonanalysie.nor*aeit found tobeu confounder of the effect of,ace/ehn|otyonECC prevalence in the mu!tiva//abiemoda[' SOURCE� Shibosk; CH. et ai (2003). 1"he association of early childhood caries and face/01thnicity amon0Ca|ifornia Preschool children- Jouwnal of PublIc Heeith Dentls�r 63( 1) 38-446. � |ongitudnallmppmachdidnutevea|a|owe,oari0000ru/rence|ntheOunridotedUhon|nthe|*w-fiuonUe refeenxecommunity.^ SOURCE. GeppoLesal(20O2). Caries oouv,ren;*ina#uohdate0 and ononDooncla$ed town inFln|snd�uretrospective study using 'longitudinal data from public dental records. ("aries ;:?eseaich 3& 308-314 1 hemugnitu«eof ff uoridatinn'sg effect (s not large inabsolute tem-is, is often riot slabohru|lymQnificmnt Find may not bo of clinical mgn!hoanma.^ SOURCE Looker, D(1Q890 Benefits and Risks, of Water Fluoridation. AnUpdate of the 1988Fadeoa|-Pmvincia!8ub- "or"ify ittee Report Prepared for Ontario Ministry of Heallh and Lo,7g Te!�!M Care http-://www.fluofidealert,org/health/teeth/caiies/fluoridation.aspx 9/9/2011 Water Fluoridation & Tooth Decay (Caries) Page 2 of 4 0 C '?R'lesultsof recent |orge—soaiostudies inutioas+ three countries show thatwhano}mi|eroommuni+ieo are compared and the traditional DMFT index cf dental caries is used, there is no detectable difference in caries pievatence, This has been demonstnatedfu/ schoolchild/en in "he major cities of NmwZeo}and. Australia, the US and e}eevvhere." SOURCE�Oi�nendnr[K3 et (1SS7) New Ev/denceonFluoridation. A:strahanaod New Zealand ici/xne/ofPubiic "Higher fluoride proportions appearecita be associated with lower dfs + DFS. with an estimated difference between fluoridated and non 41uohdund groups of0.6,5 decayed o/ filled surfaces per child, bull. this association was not statistically significant. The o" fedaofMuohdahonon the athe/oi� I tzomeawe,oamuUundnoteta tiancaUy sign ific ant. ^ SOURCEDomumP.eta 19%) The estimation nf caries prevalence in small areae Journal o/ Der, ralRexearcn "lifetime exposure oo fluoridation isassociated with aver-age reduCtmnyuf2Ddmfs and between C1.12 and 0.30DMFSper uhi!d:onpeed with non-exposed uhiid,en.''(Note: DMIFS = Decayed. Miss-rig & Filled Surfaces. There are 128to�h surfaces ma child's mouth "This Study foxndadifferenueo/O. 12mD30 decayed surf aces, out, of128. between children |n fluoridated &unUuohdatedoommuo!deo ) SOURCE: Spenc.pr AJI, et al. (19965). 0�atei fluoridation in Australia. Commur�*v Dpnta/Heaith 1311SuppI 2,1:2-1-37. ���hnmHea�S��oumeyoa�mw the p�vm|en000f baby bo�a�oU decayiaabout tteeUmeo�ena�m�(avo�ge among poor ut ban children, even in communities with ufluoridated water aupply," SOURCE: Von Burg MM et al (1905) Baby Bottle Tooth Decay: A Concern for /V| Muthem Pediatric Nursing 21� 515' 519. ^Ch.�doen attending centers showed nu significant differences yn baby bottle tooth decay) based uo fluoride status fox(he totaoampen/othorvahableo.` SOURCE Barnes GP. et al. (1892). Ethnicity. !ocaUnn. aOe, and Muorida§onfaoom in baby bottle tooth decay and Caries Pmve!esoe of head start children. pubVcHeak//RaPorty 107. 1637-73.apuo" "Am analysis mf national survey data collected bythe 1"'Jauona/ /nv1Wu'uecfDenta/ Roe+o,;h (N0R) concludes that children who live m areas of the U5. where the water supplieaam0uohdntedhnwetoothdooay'atemnee,y}demhcm|wixhthosa who live innon�uondutedo/eaa." SOURCE Hilernan, B. NeW StUdies Cast Doubt on Fluoridation Benefits. Chemicai &En(�fneannyNewo. May 8. "We fou:dthat caries pveveonoeado vary between the geouhemio�mg�noc�Uneo��a�!nthe��|sam�e.however. there were no significant differences bebjveen thr,-,e childien drinking o�tinlally flUoridated water and those drinking aubo;time||y fluoridated wae/." SOURCE Hildebolt CF. et ai 989), Caries prevalences among geochernical regions of Missouri. American ."'ournal of Physical Anthropolcgy 78:7 9- 941. in British Coumbja,,rit�� only 11peroenuf�opopu��onumng�uo�datedwa�xo*mv|n�er�veego DIMIF15' rates thani piovinces with 40-70 percent of the, population drinking fluoridated water. How does one explain this? ISIchool distri�o recently iePorting 'lie highest carkes free rates were totally unfluoriclated." SDURCE: Gray, AS, (1Q87). Fluoridation, T/me for e New Base Line? Journal c4� the Canadian Denta/Association. 10: 703'7,'-;5, "Recent studies and na !ts agree that the differences in dental decay prevaience beNrveen fluoriC."ated and nor,.- fluoridated areua|nQewZea|andamammUFor12'und13-yea'oWuh||doennadomallythemymen�gea*hop/eveomnem- h*einoach�ndofaeu��e,edbyon!y1o'2poroent'andwexeofteohighe/ m the non-Ouohuated part cfohealth diotrict." SOURCE. lColquhoun, J. Child Dental Health Differences in New Zealand. Cornirrjunity Health Studies 6: 853-90, lnt:e inondepidem\duOy'officmUycol!ocmdata8stcmamnmsentedwhiohshowthat. 15yr after nuondadon commencedinAooWan¢NewZea|und.'teewoeeb!!asignifivantui,e|adonbebweenUentalhealthnfchiWvanandthoir social daeo. They also ehmw that treatment levels have cor-itinued to decline in both fluoriclated and unfluoridaiet"i areas, andorere!medt000cia|dausfactorarathorthanto,hmp/onenmeorabuenceofwaerUuoridat!on. When the socioeconomic variable |u allowed for, dentnl health appeals to ba batter in ihe :nfuond/med u/eaa." SOURCE: Co|quhcunJ Influence cf social class and fluoridation on child dental health. Commuoity Dentistry and Oral Epidornio|ogy13:37'41 SEESTVDY Excerpts from the Scientific Literature - Fluoridation & "Baby Bottle Tooth Decay"(baci< to Inv VVater fluorldwion status of the childien's area o� residence did not have a significant effect on Early Childhood Caries (E-CC)et the D 1 level ofoignificmnoe�xtAounncUua�d|o�sn:xo8�aoon analysiu, nor was it found to be a confounder oftha effect of ecoA* hnicity nn EC'C prevalence in the mu|tivariab|emodei'' S0UR("'E @hibuaki CH' et al. ',`2U'0�3}, The association ofearly childhood ouhesand race/ethnicity among 'California preschool children. Jounnal/ofpublici-7aa8hDenhstiyO3(1)�3�4O. http://www.fluoiidealert.org/health/teeth/can'es/fluoridation.aspx 9/9/2011 WataFluoridatioo&ToothQecav(Caries) Page 3 of 4 0 C "Data from Head Statt surveys show the prevalence cf; baby bottle tooth decay isaboyt three Unieutne national average among poor lit children, even in commun�eswbh uMuoAda�dwo�roupp��^ ,8}URCE.Von8ugKKety! (19S5) Baby 8��aTmshDecay. AConoe/n for � A1.1 Mothers Pedia/oc Yuro/ng21�515- ^Ch'ldmn attending centers showed nn significant differences (in baby battle tooth decay) based on fluoride status for the total sample ur other vuhablen.` SOURCE Barnes GP. e\ a|. (1992) Ethn/citv. !ooadon. age. and hvnhdabonfactmrs in baby bottle toot'!', decay and caries prevalence of head, start children Public �"ealhRepmts 10r 1O-7-TJ. "Regardless of water fluoridation, the peva|enoeofS8TD (baby bottle too@ ) decay) remoinod high o(a!|nf the sites au*eyod. More esmopzh needs to be done on the relationship o! fluoridated water and 8BTO. 8OURCE� Kelly M. Brue,d B. (1987). The Prevalence ufBaby Bottle, Tooth Decay Among Two NetiveAmeriouo PoPu\ationa Journal ofPu�./icHaalthDonds,/y47�Q4-A7 Excerpts from the Scientific Literature - Fluoridation Cessation Studies: (ba". K �r) *)m "The prevalence of caries decreased over time in +he fluanclation—ended community while remaining iun&hanged in 'the 8om|dated:ommonity,^ SOURCE: Maupome G, Clai k DC, 'Levy SIM, Berkowitz J. (2001 ). Patterns of dental caries following the cess 3-tion -of water fluoridation Ccvomunit;D*nfiohry and 0e/EPlide/n/oho0y20 37-47. ^T he fact that no increase in caries was found in Kuopio despite discontinuation of water fluoridation and decrease in preventive p,ucodummaoggeu�thu�n/�e!io� these moaoueu were necessary for each ohi!d"^ SOURCE-E.: Seppa L', Karkkainen S, Hausen H. (2000). Caries I rends 1992-1998 in Two Low-Fluo, ide Finnish -1 owns Fonnerly With and wdthoulkF|uoridmtion 'CerieuResearch 34:462-gS8, "In contrast ua the anticipated in, rmameindenm! caries h�|o*iny the ceoea8on/fw�er�oondauonin the mbenChemn�Z and p!mo*n.a�g�fioantfaU|noaries prevalence Was oboewed.^ SOURCE Kun_-e|VKFiocharT' Lorenz R,8ruhmu:nS (J00O) Decline of caries pevaienueafter *.ho cessation ofwater fluofidation in 'the formief East Germiany. Community Dentistly and Ora! FE-Pidemiology .28� 382-9 "in 18&7 following the cessation of drinking watefluo,idatkon.incontraattoanexpeotedhyeinoa,ies prevalence, DMFT and [MFS values remained atalow level for the 6- to8-year-o|ds and appeared to decrease for the 1(V11-yaur-n|da.|n the 12/13-yeapn|da. there was o significant decrease. while the percentage of caries- free children of this age group had increased..." SOURCE.�Kunza|W,FiycherT (2000) Caries prevalence after neeaationofvvatar fluoridation |nLaSa|ud. Cuba. Caries Research J4:2O-5 Recent News Reports -WaterF|woridation&Poverty, mtoN Cincinnati - Fluoridated since 1979 "]fyand regional! medical officials say tooth docayis the oity�s No 1 unmetheolth+cara need \Aviecannct meet the derriand.' says Di. Larry Hill, Cincinnati Health Department dental director. 'It's absolutely xomrtbemNna and a travesty. VVn have kids m this community wjUh severe untreated dental infections. VVe have kids wjih self-esteel-ri orobiems, andwe have kids in severe pain and we have no olace to send their). in Cindnnub People would be shocked m learn hoe bad 'tho Problem has beuume�~ SOURCE: Golv|gE (2002) Cincinnati's dental crisis. The Cmpnnsfi Enquirer October 6 (5e* a/nu*/ Concord, NH - Fluoridated since 1978. "'it's overwhelming,"said Deb Bergschneider. dental clinic coordinator at the Concord cente.!. "Because we semetheuninaure¢w»oaeths{ower(evelnf1heoommun/tyandVhenoogie]ustaotronomics, By the time they get tu us, 1heirmoutho are born-bed out. They are all emer0enuXsituations. it's a severe. severe, orobiem it's sad ^ Boston - Fluoridated since 10T4: "*itha study estimating dsa the xumie/of untreated cavities among Boston students greatly exceeds 'the nationa!overage.puWioheaVho1fida}aapeeUuutoiuonrhannffanoiveoQa/nst*hagtUeysayiuogmwing dental crisia in the city According tostatistics cited in the city's !atestannual health neuort '7he Health of Boston 19-99": Eighteen percent ol children 4 years old and vounger who were seen in the PedlatriC PrOgfarTi at Tufts University School of Dental Medicine in 1995 had babv-bottle 'tooth decay, a painful condition that arises when ababy is given a bottle. of.juice or milk at be(.ftime. Treatment can cost Lip to $4,000 pet, child. About9Opercentof107Bmstonh/gheohnoiatodontsweefoondtnnoeddenta|keatment,auoording|oo unpublished study. That report also estimated that the city's stludents had four times mole untrealled cavities than the national average.. http-//www.fluoiidealert.org/health/teeth/caiies/fluoridation.aspx 9/9/2011 Water Fluoridation & Tooth Decay (Caries) Page 4 of 4 10C SOURCE Kong D. (1999). City to launch battle against dental 'crisis'. Boston Globe November 27. 'ieee Connecticut - Statewide mandatory fluoridation since 1960s: "Dental decay remains the rnost common chronic disease aniong Connecticut's children!. Poof" oral health causes Connecticut c hildren to lose hundreds of thousands of School Clays each gear. One in four Connecticut children is on Medicaid. but t K, of three-' Connecticut children !eceive no d=ental care. At) -d DSS continues to exploit the seriously} stretcl2ed public health providers and the few remaining private pro°��iders. There is an oral health crisis in Connectcul&. SOURCEi Slate R. ;2005✓;. State must fund plant to provide oral health care for the poor. Nero Haven Reg sfer May "e e South Bronx - Fluoridated since 1965: "Bleeding gunCiS; impacted teeth and rGtiltTg t:?eih at° rGUt"!E' matters for ill... Clnil,,i`en 111ab'E' interviewed In the South Bronx. Chiidi "en get used to feeling constant pain. They go to sleep with !t. 'I hey go to school with 4 Sonnetimes their teachers are ala!rrled and try to get therT2 to a Clinic. But iit's all sc; Slow and heavily encunnbered with red tape and waiting lists and rmssi?ntki; lost or canceled vveifare cards, that dental care is after, long delayed . hi`,dren live for rn.ontns with pain that gDOWn -UPS `a OUld f,nd unendurable. The gradual attrition of accepted pain erodes their energy and aspi!ation. I have seen children in New York with teeth that loot: like brownish, broker: Sticks. I have also Shen teen -agars who were missing half their tee=th. But, to me, MOSt shocking is tc: see a child with are abscess that has been inflanned for Meeks and that he has simply lived vllth and accepts aS part of the rout ne of life. Many teachers in this Liman schoois have seen this. It is ahmost c'Un1rnon place. " SOURCE: Kozo/ J. (1 ,9911). Savage !diegc:a;';tres Harper Perennial. Pittsburgh. PA - Fluoridated since 1953: "Nearly half of children in Pittsburgh between 6 and 8 have had cavities, according to a 2002. state Depart!"t ?ent of health report. More than 70 percent of 15 -year -olds in the city have had cavities; the highest percentage in the State. Close to 30 percent of the city's children have i.intreated cavities. That's more than double the state average of 14 Percent" SOURCE. .a+ V i'400•'' _ SrnK yUlf t ec+sh Into h l t" f 7 c. Pi " 5 "v Ur gh rJJ e- PgvlG E y i ebf larr r3. Washington DC - Fluoridated since 1952: Washinngton DC has "orn(,, of the highest decay rates in: children in the country," I'he °typical nebv patent, age 6: has five or Six teeth'vvith cavities -. a'staggering" slumber "' at the Children`s National Medical "'enter. SOL)iRCE noise 5. (2002). Bottled Wpter: Just add Fluo:`de. VK3ii ?%ln ton PoSI March „ (Se'el 21twie) General: ';There was little evidence to snow that vvater rl; oriciatior, has reduced social Inequalities n dental health, SOURC E : o ` e fo r Reviews and : is et ination. (2 01). `V at the 'York P NAesh,' Gn the fl oridation of drinkI n wrater really found. university of York, ea ii 1.11k�vv) "In this study in oral epidemiology, officially collected statistics are presented wlhich show that, .1 `, yr after fluoridation c{ymme>nced in Auckland, News Zealand. there boas still a significani, correlation betvveen dental health of children and their social class. They also show that treatnnent levels have continued to decline ire both fluoridated and unfluoridated areas, acid are related to Social class factor's rather than to the presence or absence of wvater fluoridation . `wJhen the socioe onom;o variable is alloaled for, dental health appears to be. better in the unfluordated areas." SOURCE Colquhoun ; =08:';. Influence of social class aria * luoridation on child dental health. Community Dentisrry and !oral Epidemiology 13 37 -4 http:// www.fluoridealert.oriz/health/teeth /caries /fluoridation.aspx 9/9/2011 NEW EVIDENCE ON FLUORIDATION FLUORIDE 30(3), 1997, pp 179 -185 International Society for Fluoride Research Research Review NEW EVIDENCE ON FLUORIDATION M Diesendorf, J Colquhoun, B J Spittle, D N Everingham and F W Clutterbuck Sydney and Brisbane, Australia; Auckland and Dunedin, New Zealand Reprinted, with permission, from The Australian and New Zealand Journal of Public Health Vol. 21 No. 2 1997 Page I of 6 10C Table of Contents ABSTRACT: A review of recent scientific literature reveals a consistent pattern of evidence — hip fractures, skeletal fluorosis, the effect of fluoride on bone structure, fluoride levels in bones and osteosarcomas — pointing to the existence of causal mechanisms by which fluoride damages bones. In addition, there is a tdence, accepted by some eminent dental researchers and at least one leading US proponent of fluoridation, that there is negligible benefit from ingesting fluoride, and that any (small) benefit from fluoridation comes from the action of fluoride at the surface of the teeth before fluoridated water is swallow Public health authorities in Australia and New Zealand have appeared reluctant to consider openly and frankly the implications of this and earlier scientific evidence unfavourable to the continuation of the fluoridation of drinking water supplies. In recent years, new scientific evidence has emerged which suggests that there are significant risks and negligible benefits from ingesting low levels of fluoride. We outline the evidence that fluoridation of water supplies is harmful to bone, while providing negligible benefits when swallowed. In focussing on the new evidence (mostly since 1989) in just two areas, it is not intended to diminish the importance of earlier evidence for concern about the health hazards of fluoridation: notably dental fluorosis, allergies and intolerance reactions, and genetic damage. These are reviewed elsewhere." Mark Diesendorf is Professor of Environmental Science and Director, Institute for Sustainable Futures, University of Technology, Sydney, PO Box 123, Broadway NSW 2007, Australia. Fax 612 9209 4351. John Colquhoun is an Honorary Research Fellow, School of Education, University of Auckland. Bruce Spittle is Senior Lecturer, Department of Psychological Medicine, University of Otago School of Medical, Dunedin. Douglas Everingham is a retired medical practitioner and former Australian Federal Minister of Health. Frederick Clutterbuck is a medical practitioner in Brisbane. Correspondence to Professor Diesendorf. Fluoride damages bones Since 1990, five major epidemiological studies from three countries — the United States (US), United Kingdom and France — showing a higher rate of hip fractures in fluoridated regions than unfluoridated regions have been reported in leading peer- reviewed journals." Although two of these reports were published as letters, the first was a correction to a http://www.fluoiide-joumal.com/97-30-3/303-179.htm 9/6/2011 NEW EVIDENCE ON FLUORIDATION Page 2 of 6 10C refereed publication and the second was a supplement to a refereed publication about a prospective study which took account of major individual risk factors.10 In addition, a prospective study from the US shows a higher rate of hip fractures in a region naturally fluoridated with four parts per million (ppm) fluoride in drinking water than in a comparison region with 1 ppm." Although there have been a few studies that have found no difference between fluoridated and unfluoridated regions, they have been either limited to small samples, or the women were not exposed to fluoride during the time of their lives when fluoride would be expected to affect bone most, that is, before menopause." The main weight of the recent evidence on hip fractures is consistent with earlier evidence from naturally fluoridated areas that low levels of fluoride ingested for several decades can cause the disease of bones and joints known as osteofluorosis or skeletal fluorosis. Evidence of skeletal fluorosis has been reported in at least nine studies from five countries with fluoride concentrations in drinking water of 0.7 to 2.5 ppm. These studies, and the inadequacies of studies that assert that there is no skeletal fluorosis in the US at fluoride concentrations below 4 ppm, have been reviewed elsewhere.' In three to four decades, when people in areas where water is artificially fluoridated have accumulated fluoride in their bones from birth to old age, the increase in rates of hip fractures and skeletal fluorosis will be larger. Fluoride has been used in high doses (20 to 32 mg a day) for short periods (one to two years) to treat osteoporosis. It is now recognised widely that, while this therapy adds mass to bones, it also damages the bone structure and leads to a higher risk of hip fracture. 134' Bone analyses have shown that elderly women who lived for at least a decade in the town of Kuopio, Finland, with 1 ppm fluoride in its water supply, had high levels of fluoride in bone (typically 900 to 2300 ppm, but for women with impaired kidney function as high as 3890 ppm). 19," These levels are as high as have been reported in patients who have undergone fluoride therapy for osteoporosis." In the US National Cancer Institute's Surveillance, Epidemiology and End Results Program, an increase of 79 per cent was found in the incidence of osteosarcomas in young men living in fluoridated areas of Iowa and Seattle, but not in the unfluoridated areas, where the incidence decreased by 4 per cent.' In fluoridated regions of the State of New Jersey, the incidence of osteosarcoma was three to seven times higher among males aged 10 to 19 years than in unfluoridated regions.' Osteosarcoma is a rare disease and so more evidence is required before any conclusions are drawn. But there is already a strong basis for concern, because the human data are supported by an animal experiment: the US National Toxicology Program has recorded a statistically significant, dose - related increase in the incidence of osteosarcoma in male rats ingesting fluoride."," Thus, there is a consistent pattern of evidence -- hip fractures, skeletal fluorosis, the effect of fluoride on bone structure, fluoride levels in bones, and osteosarcomas -- pointing to the existence of causal mechanisms by which fluoride damages bones. Negligible benefit from fluoride ingestion Recent research on the mechanism . of action of fluoride in reducing the prevalence of dental caries (tooth decay) in humans shows that fluoride acts topically (at the surface of the teeth) and that there is negligible benefit in actually ingesting it.26"' This is supported by experiments on laboratory rats: a slow - release source of fluoride fixed in the mouth reduced dental caries, but when the mouth was bypassed by placing the source under the skin, there was no detectable reduction.29 The lack of observed systemic benefit from ingesting fluoridated water at a concentration 1 ppm is not surprising, since the resulting level of fluoride in the saliva is only around 0.01 ppm.30 http://www.fluoride-joumal.com/97-30-3/303-179.htm 9/6/2011 NEW EVIDENCE ON FLUORIDATION P e of 6 1� The evidence that there is negligible systemic benefit from fluoridation is accepted by eminent dental researchers 16-11 and at least one leading US proponent of fluoridation, Professor Brian Burt.31 Therefore, proponents must come to grips with a serious ethical question: is it right to put fluoride in drinking water and to mislead the community that fluoride must be ingested, when any small benefit is due to the topical action of fluoride on teeth." Alleged benefit from fluoride We say `any small benefit', because the results of recent large -scale studies in at least three countries show that, when similar communities are compared and the traditional DMFT (number of decayed, missing and filled teeth) index of dental caries is used, there is no detectable difference in caries prevalence. This has been demonstrated for schoolchildren in the major cities of New Zealand, Australia, the US and elsewhere.33 -" (When the newer DMFS (number of decayed, missing and filled surfaces) index was used, a 20% reduction was reported for US,39 but, in absolute terms, this is only a fraction of a cavity per child.) Of the many studies used by proponents of fluoridation to claim that there are enormous benefits from fluoridation, not one is a randomised controlled trial. Those that have been re- examined have been found to have serious design flaws.31,40-44 Indeed, hardly any of the many small -scale studies by enthusiasts of fluoridation are `blind' and, in the rare cases when they are, the so- called `control' was selected from a known high -caries area.43 Many studies have also failed to take into account that unfluoridated towns tend to be rural, while fluoridated towns tend to be large cities, and that there is generally more dental caries in rural areas, irrespective of fluoridation status. In general, diet tends to be better in urban areas. Many other studies have had no controls. Their authors have justified their profluoridation conclusions on the basis of large temporal declines in tooth decay. But, it is now known that equally large declines in caries have taken place in unfluoridated areas, 114' and that in several cases this decline commenced before fluoride in any form was used to a significant degree.41,41 However, there is now abundant evidence that topical uses of fluoride, extensively practised in Europe instead of water fluoridation, are effective in controlling tooth decay.49 We agree that their cautious uses in dentistry are justified and provide an alternative to fluoridation which satisfies ethical concerns.32 However, in the past they have been promoted and practised rather irresponsibly — for example, the provision of highly concentrated fluoride toothpastes and mouth rinses to young children who inevitably ingest much of the fluoride. Too often overlooked is the evidence that tooth decay is associated with inadequate diets,50 and that dietary control of caries, without the use of fluoride, is possible." Bias of health authorities In our view, the evidence indicates that fluoridation entails real health risks and at best very small benefits. Therefore, the fluoridation of water supplies should be terminated forthwith. Yet, both in Australia and New Zealand, health authorities appear to be redoubling their efforts to fluoridate the remaining towns that have so far managed to hold fluoridation at bay. The 1991 report on fluoridation by the National Health and Medical Research Council was published just as the first papers reporting the link between fluoridation and hip fractures were being published.52 It acknowledged in its section 6.4 some of the evidence that skeletal fluorosis is a potential health hazard, but created the false impression in its executive summary that there are no health risks. It is the executive summary which is read by decision - makers and the media. The report's profluoridation bias was further demonstrated by its failure to cite any of the studies presenting the evidence against fluoridation published in refereed journals. http://www.fluofide-joumal.com/97-30-3/303-179.htm 9/6/2011 NEW EVIDENCE ON FLUORIDATION Page 4 of 6 10C The 1995 Report to the Minister by the New Zealand Public Health Commission demonstrated similar bias by failing even to cite any of the published papers on hip fractures, skeletal fluorosis or osteosarcomas.53 However, the 1994 New Zealand Public Health Commission report did include some of these references and did acknowledge that: It is possible that there is a small increased risk of hip fracture associated with water fluoridation, though the evidence for this is very inconclusive. More research is required to clarify this issue. A large amount of research has failed to provide evidence that exposure to fluoride causes cancer. However, the possibility of a small increased risk of osteosarcoma (a rare type of bone cancer) in young men cannot be ruled out at this stage. Here again, more research is needed. [From the executive summary; there are similar statements on p. 74 and p 78.]51 But this information, and the references supporting it, were not forwarded officially to the Minister. One of the us (DE), while Federal Minister for Health in Australia from 1972 to 1975, could not get frank answers from his own department on the risks and benefits of fluoridation. Another of us (JC), while convenor of the New Zealand Fluoridation Promotion Committee, observed at first hand how his then fellow proponents of fluoridation kept from the public and decision makers the evidence that fluoridation is less effective than claimed by proponents and is harmful, and then represented the evidence in a misleading way when it was eventually released. All of us have observed attempts by the medical and dental establishment in profluoridation countries to evade the evidence of concern and to suppress and misrepresent scientists, medical practitioners and dentists who attempt to publish evidence against fluoridation.55-57 For these and other reasons, we have no confidence in the impartiality of those institutions of government and the professions which have endorsed fluoridation for decades. Those who have built their careers and professional status on fluoridation cannot credibly assess the evidence against it. We have submitted this short paper for publication in the hope that at least some kind of scholarly debate will ensue. REFERENCES 1. Waldbott GL, Burgstahler AW, McKinney HL. Fluoridation: The Great Dilemma. Coronado Press, Lawrence KS 1978. 2. Diesendorf M. The health hazards of fluoridation: a re- examination. International Clinical Nutrition Review 10 304-21 1990. 3. Yiamouyiannis J. Fluoride: the Aging Factor (3rd edition). Health Action Press, Delaware OH 1993. 4. Jacobsen SJ, Goldberg J, Miles TP et al. Regional variation in the incidence of hip fracture: US white women aged 65 years and older. Journal of the American Medical Association 264 500 -502 1990. 5. Cooper C, Wickham CAC, Barker DJR, Jacobsen SJ. Water fluoridation and hip fracture [letter]. Journal of the American Medical Association 266 513 -514 1991. 6. Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah's elderly population. Journal of the American Medical Association 268 746 -748 1992. 7. Jacobsen SJ, Goldberg J, Cooper C, Lockwood SA. The association between water fluoridation and hip fracture among white women and men aged 65 years and older: a national ecologic study. Annals of Epidemiology 2 617- 626 1992. 8. Jacqmin -Gadda H, Commenges D, Dartigues J -F.. Fluorine concentration in drinking water and fractures in the elderly [letter]. Journal of the American Medical Association 273 775 -776 1995. 9. Cooper C, Wickham C, Lacey RF, Barker DJP. Water fluoride concentration and fracture of the proximal femur. Journal of Epidemiology and Community Health 44 17 -19 1990. 10. Dartigues JF, Gagnon M, Barberger- Gateau P et al. The Paquid epidemiological program on brain aging. Neuroepidemiology 11(Suppl 1) 14 -18 1992. 11. Sowers MFR, Clark MK, Jannausch ML, Wallace RB. A prospective study of bone mineral content and fracture http://www.fluofide-journal.com/97-30-3/303-179.htm 9/6/2011 NEW EVIDENCE ON FLUORIDATION 10 Caje 5 of 6 pi in communities with differential fluoride exposure. American Journal of Epidemiology 133 649 -660 1991. 12. Lee JR. Fluoridation and hip fracture. According to the National Research Council Report: `Health effects of ingested fluoride'. Fluoride 26 274 -277 1993. 13. Hedlund LR, Gallagher JC. Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 4 223 -225 1989. 14. Lindsay R. Fluoride and bone - quantity versus quality (Editorial). New England Journal of Medicine 322 845- 846 1990. 15. Melton LJ. Fluoride in the prevention of osteoporosis and fractures. Journal of Bone and Mineral Research S (Suppl 1) 5163 -167 1990. 16. Riggs BL, Hodgson SF, O'Fallon WM et al. Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. New England Journal ofMedicine 322 802 -809 1990. 17. Fratzl P, Roschger P, Eschberger J et al. Abnormal bone mineralisation after fluoride treatment in osteoporosis: a small -angle x- ray- scattering study. Journal of Bone and Mineral Research 9 1541 -1549 1994. 18. Sogaard CH, Mosekilde L, Richards A, Mosekilde L. Marked decrease in trabecular bone quality after five years of sodium fluoride therapy - assessed by biomechanical testing of iliac crest bone biopsies in osteoporotic patients. Bone 15 393 -399 1994. 19. Arnala I. Bone fluoride, histomorphometry and incidence of hip fracture. University of Kuopio, Kuopio 1983. 20. Arnala I, Alhava EM, Kauranen P. Effects of fluoride on bone in Finland: histomorphometry of cadaver bone from low and high fluoride areas. Acta Orthopaedica Scandinavica 56 161 -166 1985. 21. Baud CA, Lagier R, Bang S et al. Treatment of osteoporosis with NaF, calcium or /and phosphorus, and vitamin D: histological, morphometric and biophysical study of the bone tissue. In: Courvoisier B, Donath A, Baud CA (Eds). Fluoride and Bone. Hans Huber, Berne 1978 pp 290 -292. 22. Hoover RN, Devesa S, Cantor K, Fraumeni Jr JF. Time trends for bone and joint cancers and osteosarcomas in the Surveillance, Epidemiology and End Results (SEER) Program, National Cancer Institute. In: Review of Fluoride: Benefits and Risks. Report of the ad hoc committee on fluoride of the committee to coordinate environmental health and related programs. Department of Health and Human Services, Public Health Service, Washington DC 1991 pp F1 -F7. 23. Cohn PD. A brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young males. New Jersey Department of Health, Trenton NJ 1992. 24. The toxicology and carcinogenesis of sodium fluoride in F344IN rats and B6C3F1 mice (National Toxicology Program technical report 393. Publication No. 90- 2848). National Institutes of Health, Bethesda MD 1990. 25. Maurer JK, Cheng MC, Boysen BG, Anderson RL. Two -year carcinogenicity study of sodium fluoride in rats. Journal of the National Cancer Institute 82 1118 -1126 1990. 26. Margolis HC, Moreno EC. Physicochemical perspectives on the cariostatic mechanisms of systemic and topical fluorides. Journal of Dental Research 69 (special issue) 606 -613 1990. 27. Thylstrup A. Clinical evidence of the role of pre - eruptive fluoride in caries prevention. Journal of Dental Research 69 (special issue) 742 -750 1990. 28. Comments by Fejerskov O, in Whitford GM (compiler). Discussion of Session I: Metabolism of fluoride. Journal of Dental Research 69 (special issue) 556- 557 1990. 29, Mirth DB, Adderly DD, Monell - Torrens E et al. Comparison of the cariostatic effect of topically and systemically administered controlled- release fluoride in the rat. Caries Research 19 466 -474 1985. 30. Oliveby A, Twetman S, Ekstrand J. Diurnal fluoride concentration in whole saliva in children living in a high - and a low - fluoride area. Caries Research 24 44 -47 1990. 31. Debate between John R Lee and Brian A Burt. Fluoride 27 180 -182 1994. 32. Diesendorf M. How science can illuminate ethical debates: a case study on water fluoridation. Fluoride 28 87- 104 1995. 33. Colquhoun J. Child dental health differences in New Zealand. Community Health Studies 1185-90 1987. 34. Gray AS. Fluoridation: Time for a new base line? Journal of the Canadian Dental Association 53 763 -765 1987. 35. Colquhoun J. Is there a dental benefit from fluoridation? Fluoride 27 13 -22 1994. 36, Hildebolt CF, Elvin -Lewis M, Molnar S et al. Caries prevalences among geochemical regions of Missouri. American Journal of Physical Anthropology 78 79 -92 1989. http://www.fluoride-joumal.com/97-30-3/303-179.htm 9/6/2011 NEW EVIDENCE ON FLUORIDATION 10 C Page 606 O 37. Yiamouyiannis JA. Water fluoridation and tooth decay: Results from the 1986 -1987 national survey of US schoolchildren. Fluoride 23 55 -67 1990. 38. Diesendorf M. Have the benefits of water fluoridation been overestimated? International Clinical Nutrition Review 10 292 -303 1990. 39. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water fluoridation. Journal ofDental Research 69 (special issue) 723 -727 1990. 40. Sutton PRN. Fluoridation: Errors and Omissions in Experimental Trials (2nd edition). Melbourne University Press, Melbourne 1960. 41. Diesendorf M. A re- examination of Australian fluoridation trials. Search 17 256 -261 1986. 42. Colquhoun J, Mann R. The Hastings fluoridation experiment: Science or swindle? The Ecologist 16 (6) 243 -248 1986, 17 (2) 125 -126 1987. 43. Diesendorf M. Anglesey fluoridation trials re- examined. Fluoride 22 (2) 1989. 44. Colquhoun J. Flawed foundation: A re- examination of the scientific basis for a dental benefit from fluoridation. Community Health Studies 14 288 -296 1990. 45. Glass RL (Ed). First international conference on the declining prevalence of dental caries. Journal of Dental Research 61 (special issue) 1304 -1383 1982. 46. Leverett DH. Fluorides and the changing prevalence of dental caries. Science 217 26 -30 1982. 47. Diesendorf M. The mystery of declining tooth decay. Nature 322 125 -129 1986. 48. Colquhoun J. Decline in primary tooth decay in New Zealand. Community Health Studies 12 187 -191 1988. 49. Fejerskov O, Ekstrand J, Burt BA (Eds). Fluoride in Dentistry (2nd edition) Munksgaard, Copenhagen 1996. 50. Price WA. Nutrition and Physical Degeneration. Hoeber, New York 1939. 51. Goldsworthy NE. Every doctor a dietitian. Medical Journal of Australia 1285 -286 1960. 52. National Health and Medical Research Council. The Effectiveness of Water Fluoridation. Australian Government Publishing Services, Canberra 1991. 53. Fluoride and Oral Health: the Public Health Commission's advice to the Minister of Health. New Zealand: Public Health Commission, Wellington 1995. 54. Water Fluoridation In New Zealand. - An Analysis and Monitoring Report. New Zealand Public Health Commission, Wellington 1994. 55. Waldbott GL. A Struggle With Titans. Carlton Press, New York I965 56. Varney W. Fluoride in Australia: A Case to Answer. Hale and Iremonger, Sydney 1986. 57. Martin B. Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate. State University of New York Press, Albany 1991 (Chapter 5). FLUORIDE 30 (3), 1997, pp 179 -185 Reprinted, with permission, from The Australian and New Zealand Journal of Public Health in Fluoride Vol. 30 No. 3 1997, published by the International Society for Fluoride Research International Society for Fluoride Research Home I Table of Contents I iSFR Board I Subscription Submissions I Announcements I Authors I Subject Index http://www.fluoiide-joumal.com/97-30-3/303-179.htm 9/6/2011 Communihy Merl Oral EpOemini 1999; 217: 3 1--40 �t'Py" 'YI't F hheitksgai}Rl i45 1'ri >:fecl in Denmark .All r, - {ht, reserved -- - - - - - -- - - - -- -- --------------- - COMMUNITY DENTISTRY -D QRALEPIDEMIOLOGY PSSN 030i -5561 Prevention and reversal of dental John P1 D. 8. Featherstone Francisco, San Francisco; I 6 caries: role of low level fluoride Featherstone JDB: Prevention and reversal of dental caries: role of low level fluo- ride. Community Dent Oral Epidemiol ;1999; 27: 31-40. V< Munksgaard, 1999 Abstract - Dental caries is a bacterially based disease that progresses when acid produced by bacteria! action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the mineral, that is, demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lactobacilli), salivary dys- function, and dietary carbohydrates are related to caries progression. Protective factors which include salivary calcium, phosphate. and proteins, salivary flow, and fluoride in saliva can balance, prevent or reverse dental caries. Fluoride works primarily via topical mechanisms which include (1) inhibition of demineralization at the crystal surfaces inside the tooth, (2) enhancement of remineralization at the crystal surfaces (the resulting reriineralized laver is very- resistant to acid at- Key words: carbonated apatite; dental caries; tack), and (3) inhibition of bacterial enzymes. Fluoride in drinking water and in fluoride; remineralization fluoride- containing products reduces tooth decay via these mechanisms. Low but John D. B. Featherstone, Department of slightly elevated levels of fluoride in saliva and plaque provided from these Restorative Dentistry, Boa 0'58, University of sources help prevent and reverse caries by inhibiting demineralization and enhanc- California at San Francisco, 707 Parnassus ing remineralization. The level of fluoride incorporated into dental mineral- b _ .'avenue, 15 Francisco, CA 94143, USA Tel: X141.4760456 systemic ingestion is insufficient to play a significant role in caries preventioUT e Fax: + 1 415 476 0858 effect of systemically ingested fluoride on caries is minimal luoride "supple:- E -mail: idbf(n ttsa,ucsf.edu tmients" can be best used as a topical delivery system by sucking or chewing tablets Accepted without peer review 9 November or ioze:nges prior to ingestion. 1498 Although the prevalence of dental caries has de- clined markedly over the last 20 years in most countries in the western world the disease is still a major problem for both adults and children. The change in the mean decayed, missing and filled surfaces in permanent teeth (DMFS) is illustrated in Table 1A by results from four surveys carried out in the United States (1-4). Standard errors corresponding to Table 1A show no difference be- tween the last two columns. The DMFS means are grouped for ages 5 -11 years and 12 -17 years. The reduction in decay since the early 1970s is clear. Further, the percentage caries -free children rose during the same period (Table IA). The 1986 --87 re- sult that over 50% of children (over 5 -17 years of age) in the United States were caries free was wide- ly publicized to indicate the caries problem was essentially solved. This statement is unfortunately far from reality. Although approximately 50`3 were caries free on average for the overall age range (5 -- 17 years), it can readily be seen that approximately 70';',) of the 12 -1:- year -olds still had caries. This continues to be borne out by the latest NHANES III survey (1). Further, when the latest available data (1) are examined by individual ages, 51 of 12- year -olds were caries free but only 21 %, of the 17- year -old group were in this category. Approxi- mately 25'/� of children and adolescents in the 5-17 age range accounted for 80 of the caries experi- enced in the permanent teeth. By age 17, however, 40 °/0 of the population accounted for 80% of the caries. Approximately 10`30 of the 5 -17 -year age range had 5-9 DN FT (decayed, missing or filled permanent teeth). Recent smaller epidemiologic studies indicate, however, that the decline in caries has not continued during the 1990s and that it may have leveled out (5). These data clearly show that caries continues to be a major problem, that it in- creases markedly in the teenage years and that we need an improved approach to prevention and therapy. Dental caries in adults also continues to be a 31 k 14 Z0C Featherstone fable I A. Mean DMFS and percentage of children caries free (permanent teeth) in four national surveys in the USA (1-4 Age range NCHS NIDR NIDR NHANF.S Ill (years) 1971 -74 1979 -80 1986 -87 1988 --91 5--11 years Mean DMFS 3.0 2.0 1.2 0.9 5--11 years "'. caries free 44 58 70 74 12 -17 years Mean DMFS 10.4 6.8 4.7 4.4 12 -17 years °% caries free 10 17 2' 33 "Table 1B. Mean DFS ( decaved and filled surfaces), mean DMFS (decayed, inissing and filled surfaces) in dentate US adults, 1988 -91 (6), and mean number of permanent teeth for dentate adults (75) Age range (years) 18-24 25-34 35=14 45 -54 5.5-64 65-74 75+ Mean DFS 9.9 16.5 23.3 29.4 29.2 30.8 25.1 'dean IDMFS 11.::5 23.6 39.5 57.7 69.5 73.1 80.9 Mean t teeth 27.1 26.0 24.3 21.8 193 18.9 16.0 major problem as illustrated by a recent survey in the United States (6). The recently published NHANBS III study (6) included the US adult oral health status over all age ranges. Table 113 shows the trend. for marked increase in caries experience with age. The 18-24 -, and to a lesser extent 25 -34 -, year age groups had the benefit of caries - reducing influences such as fluoride toothpaste during their teenage years (liable 1A), but they still demon- strated substantial levels of decay. Further, 93.8% of dentate adults (all ages, 18 -74 +) had evidence of treated or untreated coronal caries. Caries obvi- ously continues to be a major problem in the adult population. The reasons for the reported reductions in decay during the last 20 years illustrated in Table 1A are difficult to determine precisely, but there is good evidence that the almost universal use of fluoride products such as dentifrice (toothpaste), fluoride mouthrinses, and fluoride topicals in the dental of- fice has been a major contributor (7, 8). Earlier re- ductions in dental caries of 40 °'0 -7030 had resulted from the fluoridation of public water supplies in many communities (9 -12). Until recently the major caries- inhibitory effect of fluoride was thought to be due to its incorporation in tooth mineral during the development of the tooth prior to eruption. This supposed mechanism of action was behind public health efforts and indi- vidual caries- preventive regimens such as the use of fluoride supplements prescribed for children to "strengthen" the teeth during their development. There is now overwhelming evidence that the pri- mary caries- preventive mechanisms of action of fluoride are post eruptive through "topical" effects for both children and adults, .including (a) inhibi- 32 tion of demineralization, (b) enhancement of re- mineralization, and (c) inhibition of bacterial activi- ty in the plaque (13 -19). The purpose of the present paper is to review the mechanisms of action of fluoride with specific reference to the effect of low levels of fluoride in the fluids in the mouth and to relate this information to the use or misuse of the so- called "fluoride supplements". The caries process The basic process of dental decay is simple in con- cept, as first described over 100 years ago. The teeth are covered by bacteria which constitute the dental plaque (20, 21). Certain of the bacteria in dental plaque, such as the mutans streptococci (which includes Streptococcus mutans and S. sobri- nus) and lactobacilli are acidogenic. 'That is, they produce acids when they metabolize fermentable carbohydrates (12, 20, 21). These acids, such as lac- tic, acetic, propionic and formic acid, can dissolve the calcium phosphate mineral of the tooth enamel or dentin (22 -34). If this process is not halted or reversed, the carious lesion progresses, eventually leading to a cavity. Any fermentable carbohydrate such as glucose, sucrose, fructose, or cooked starch, can be metabolized by these bacteria with the evo- lution of organic acids (e.g., acetic, lactic, propion- ic) as by- products (25). The acids diffuse through the plaque and into the porous enamel (or dentin if exposed), dissociating to produce hydrogen ions as they travel (23, 26). The hydrogen ions readily dissolve the mineral, freeing calcium and phos- phate into solution, which can diffuse out of the tooth. This is demineralization, or Loss of mineral as illustrated in Fig. 1. .0 Ph"Devera Fermentable Dr9mic Acids Which woos St.Vfteoaa..d + CmbohydW- --O► Dissdve Tooth MhwW LWOh of eluoors. FAM—. Look, AWJW PNPIONC. F*Mft ACMs 9uc 19WM, W. Dersat Il) w I Dpn�q�on of Tooth PI M Adds Ow C+moara MyOeq OPO" 1 Orwat Crystals LmlsaraC, P -Wowc, asublKh"CYCIUM CYCMm uq PMaWW�batM FOtMk AdW PImp1+rM souks Wm"Te Fig .7. Schematic representation of acid production by plaque bacteria, followed by demineralization of tooth mineral. Dental caries of the enamel is first observed clini- cally as a so- called "white spot lesion ". This is a small area of sub - surface demineralization, beneath the dental plaque. The lesion appears white because the loss of mineral changes the refractive index com- pared with that of the surrounding translucent enamel. The body of the sub - surface lesion may have lost as much as 50 %, of its original mineral and often has an "apparently intact surface laver" over it (27). The surface layer forms by remineralization (redeposition of mineral) as the calcium and phos- phate ions diffuse or travel out of the tooth into the overlying plaque fluid (the fluid between the bacte- ria in the plaque). The process of demineralization continues each time carbohydrate is taken into the mouth and metabolized by the bacteria. The saliva (see below) plays numerous roles including buf- fering (neutralizing) the acid and providing miner- als that can replace those dissolved from the tooth during a demineralization challenge. This replace - merit of mineral is called remineralization as de- scribed further below (17, 18, 22). The nature of tooth mineral The enamel and dentin of a tooth are composed of millions of tiny mineral crystals embedded in a protein /lipid matrix. This combination of inor- ganic and organic components provides two com- plementary hard tissues with sufficient hardness and strength to perform the normal functions of teeth. Hydroxyapatite does not occur during the formation of tooth mineral. Instead, the mineral of Fluoride and dental caries enamel, dentin and bone is best described as a highly substituted carbonated apatite (28 -30). The mineral is related to hydroxyapatite (Ca101(PO4)6(OH)2), but is much more soluble in acid, is calcium deficient (calcium replaced by sodi- um, magnesium, zinc, etc.) and contains between 3 °4, and 6 carbonate by weight, mostly replacing phosphate ions in the crystal lattice (28 -35) (Table 2). Enamel, dentin and bone ini.neral can be ap- proximately represented by the simplified formula: (Cal()- ,, (Na)x(1'O4)6,(CO 3)..(OH)2 -U (F) u ) The substitutions in the hydroxyapatite crystal lat- fice (the arrangement of atoms and ions in the crys- tal) occur as the mineral is first laid down during tooth development, with the carbonate (CO3) ion in particular causing major disturbances in the reg- ular array of ions in the crystal lattice (36, 37). Dur- ing demineralization the carbonate is preferentially lost and during remineralization it is excluded. The calcium- deficient and carbonate -rich regions of the crystal are especially susceptible to attack by the acid hydrogen ions during demineralization as has been shown by several investigators. High resolu- tion lattice imaging, which images crystals almost to atomic resolution (viewed at about 2 000 00OXmagnification), was used to illustrate the appearance of hexagonal holes in the early stages of enamel crystal dissolution in dental car- ies, which coincided with the calcium - deficient and carbonate - substituted regions of the crystal (36 -39). If the OH - ion in pure hydroxyapatite is com- pletely replaced by a fluoride ion (F -) the resulting mineral is flu.orapatite (Calo(PO4)6F21 which is very resistant to dissolution by acid. The solubility dif- ferential is shown schematically in Fig. 2. In summary, dental mineral is readily dissolved by acid unless it can be protected in some way as described below. Rernineralized enamel mineral has a composition more resembling a blend of hy- droxyapatite and fluorapatite and is therefore much less soluble than the original mineral. The crystals of enamel are about 40 nm in dia- Table 2. Approximate composition of enamel and dentin by (Yo weight and by ',%, volume Tissue component F.namei Dentin `56 by weight ;6 by volume `Yo by weight `% by volume Mineral= carbonated hydroxyapatite 96 85 70 47 Protein j lipid 1 3 20 33 Water 3 12 10 20 33 FAR Featherstone S - Fig. 2. Schematic representation of the acid solh+bility ranking of dentally relevant +ninerals (18). meter (about 1 /1000 of a hair's breadth), are ap- proximately perpendicular to the tooth surface, and are clustered into enamel rods about 4 -5 pm in diameter (40). The tiny gaps or pores between the crystals are filled with protein, lipid and water, and allow the passage of small molecules such as lactic acid and ions such as hydrogen and calcium. Mature enamel contains about 1% protein and lipid by weight (3% by volume), and about 12% by vol- ume of water, providing about 15% by volume of diffusible space. Enamel and dentin are best thought of in terms of volume percentage of each component (cable 2) rather than weight percen- tage, in order to give a much clearer picture of the volume fraction (water and proteins) of the tissue available for diffusion of ions and molecules in and out of the tooth. As demineralization progresses the mineral is removed, making the carious enamel more and more porous (27). Fluoride mechanisms of action Fluoride hihibits demineralization when present in solution. Sub- surface sound enamel generally contains fluo- ride at levels of about 20 -100 ppm depending on the fluoride ingestion during tooth development (41). Teeth which develop in a fluoridated drinking water area have a fluoride content toward the higher end of this range. The outer few microme- ters of enamel can have F levels of 1000 -2000 ppm (41). Several investigators have shown that fluoride in the solution surrounding the carbonated apatite crystals is much more effective at inhibiting demin- eralization than fluoride incorporated into the crys- tals at the levels found in enamel (18, 42). Featherstone and co- workers (14, 18, 42, 43) found no measurable reduction in synthetic carbonated apatite (3` %, CO), by weight, comparable to dental 34 10 enamel mineral) solubility with about 1000 ppm F incorporated. Very importantly, this means that fluoride incorporated during tooth mineral devel- opment at normal levels of 20-100 ppm (even in fluoridated drinking water areas or with the use of fluoride supplements) does not alter the solubility of the mineral. Even at higher levels such as 1000 ppm in the outer few micrometers of enamel there is no measurable benefit against acid induced dis- solution. Only when fluoride is concentrated into a new crystal surface during remineralization (see below) is there sufficient to alter solubility benefi- cially However, in laboratory experiments as little as 1 ppm in the acid solution reduced the dissolu- tion rate of carbonated. apatite to that equivalent to hydroxyapatite (14). Further increases in fluoride in the acid solution in contact with the carbonated apatite mineral surface decreased the solubility rate logarithmically. These results indicate that if fluo- ride is present in the solution surrounding the crys- tals it is adsorbed strongly to the surface of carbon- ated apatite (enamel mineral) crystals acting as a potent protection mechanism against acid dissolu- tion of the crystal surface. So, if fluoride is present in the plaque fluid at the time that the bacteria gen- erate acid it will travel with the acid down into the sub - surface of the tooth, adsorb to the crystal sur- face and protect it against being dissolved. Fluoride present in solution at low levels amongst the enamel crystals can markedly inhibit dissolution of tooth mineral by acid (14, 18). This fluoride comes from "topical" sources such as drinking water, and fluoride products, as described below. The fluoride incorporated developmentally into the normal tooth mineral is insufficient to have a measurable effect on acid solubility (18, 44). Fluoride enhances reminerali.zatimz As the saliva flows over the plaque its buffering components (bicarbonate, phosphate and peptides) neutralize the acid produced by the bacteria and the pH rises back towards neutral (Fig, 3), at least when there is normal salivary function. This sloes down and stops the sub- surface dissolution of the mineral. Further, the saliva is "supersaturated " with calcium and phosphate providing a driving force for mineral to go back into the tooth (18, 45). If the chemistry is right at the partially dernrineralized crystal surface within the lesion then a new surface grows on the crystal. The partially dissolved crys- tals act as "nucleators" for rernineralization. Fluo- ride acts to speed up this remineralization process 8 Sugar Free -- &---- Ifi---- &-- --*- -- 6 Normal CL .a 4 Xerostomic 3 2 0 5 10 15 20 25 30 Time, minutes Fla. 3. Typical pH curve in dental plaque (normal) following the ingestion of fermentable carbohydrate, characterized by a fall in p1l due to generation of plaque acids and return to neutral due to buffering by salivary components. Typical pI- l -time curves for a xerostocnic subject and a normal subject with a sugar -free test are shown for comparison. Fig. 4. Schematic representation of the demineralization and remineralization processes which lead to remineralized crys- tals with surfaces rich in fluoride: and of low solubility. by adsorbing to the surface and attracting calcium ions. The newly formed veneer will preferentially take up fluoride from the solution surrounding the crystals and exclude carbonate (18). Consequently this "veneer" will have a composition somewhere between hydroxvapatite and fluorapatite as il- lustrated previously (Fig. 2). Fluorapatite contains approximately 30 000 ppm F. The new surface will be "fluorapatite- like" in its properties so that the crystal will now behave like low solubility fluor - apatite rather than the high solubility carbonated apatite of the original crystal surface (14). Fluoride speeds up this process, acting to bring calcium and phosphate ions together, and is preferentially in- Fluoride and denial caries eluded in the chemical reaction that takes place, producing a lower solubility end - product. This process is shown schematically in Fig. 4. In summary, with respect to remineralization, fluoride present in solution from topical sources therefore enhances remineralization by speeding up the growth of a new surface on the partially demineralized sub- surface crystals in the carious lesion. The new crystal surface veneer is fluorapa- tite -like with much lower solubility than the origi- nal carbonated apatite tooth mineral. Subsequent acid challenges must be very strong and prolonged to dissolve the remineralized enamel. The overall process of demineralization and re- mineralization can be represented by the solubility diagram in Fig. 5. Each of the curved lines repre- sents the position vs pH where enamel mineral (most soluble), hydroxvapatite (HAP) and fluor- apatite (FAP) will dissolve as the pH falls (14, 18). The vertical axis represents the amount of com- bined calcium and phosphate that can be in solu- tion as derived from published solubility products. Since this is a negative logarithm then more calcium and phosphate dissolve as the position moves up the graph. Any set of conditions above each line is supersaturated and may precipitate down to a less soluble mineral form. Anywhere be- low each line is undersaturated and in this case mineral must dissolve. N C2 2 3 a s 6 7 a 9 PH Fi. 5. Solubility isotherms (T (,,, and Tr are total calcium and phosphate concentrations in solution, respectively) for enamel (dotted lint:), hydroxvapatite (solid line =HAP) and tluorapatite (dashed line =FAP) illustrating the log depen- dent ranking of solubility. The arrows trace initial demineral- ization starting from the surface of a sound enamel crystal as the pH falls during a caries challenge, and the subsequent remineralization as the pH rises. In the presence of low levels of fluoride (e.g., 0.1 ppm F in this example) a remineralized veneer of fl uorapatite -like mineral forms on the original crys- tal remnants (as illustrated in Fig. 4). 35 lOC Liu persatu rated — \ pH Rlae � � ` dan a1 anamat •. (carbonat�d- .• ydroxya,aatltJa) P14 real by ro xy' afire t 1UCff aPAtItA + Undgrsaturated ` PH Fi. 5. Solubility isotherms (T (,,, and Tr are total calcium and phosphate concentrations in solution, respectively) for enamel (dotted lint:), hydroxvapatite (solid line =HAP) and tluorapatite (dashed line =FAP) illustrating the log depen- dent ranking of solubility. The arrows trace initial demineral- ization starting from the surface of a sound enamel crystal as the pH falls during a caries challenge, and the subsequent remineralization as the pH rises. In the presence of low levels of fluoride (e.g., 0.1 ppm F in this example) a remineralized veneer of fl uorapatite -like mineral forms on the original crys- tal remnants (as illustrated in Fig. 4). 35 lOC Featherstone FItioride hihibits plaque bacteria Several workers have investigated the possible ef- fects of fluoride on oral bacteria (19, 46, 47). Per- haps the most significant findings in several labo- ratories are that fluoride cannot cross the cell wall and membrane in its ionized form (F-), but can rapidly travel through the cell wall and into the cariogenic bacteria in the form of HF (19, 46, 47). HF forms from H ` and F -- ions as the bacteria pro- duce acids during the metabolism of fermentable carbohydrates. So, as the bacteria produce acid the pH falls (Fig. 3). A portion of the fluoridte present in the plaque fluid then combines with hydrogen ions and rapidly diffuses into the cell, effectively drawing more HF from the outside and so on (Fig. 6). Once inside the cell the HF dissociates again, acidifying the cell and releasing fluoride ions which interfere with enzyme (enolase) activity in the bacterium. Under these circumstances fluoride is trapped in the cell and the process becomes cu- mulative. In summary, fluoride from topical sources is taken up by the bacteria when they produce acid, thereby inhibiting essential enzyme activity. This is the third "topical" mechanistri of action of fluoride against the progression of dental caries. The role of low levels of fluoride in saliva and plaque fluid Over 20 years ago Brown and co- workers predicted that low concentrations of fluoride would enhance remineralization (48). Laboratory studies using a PH-cycling model that simulates the demineraliza- tion and remineralization aspects of the caries pro- H++ F — -c HF Bacterial Cell PH 7 H+ + F - H F PH 4.5 H + +F - HF Fig. 6. Schematic representation of fluoride entering a bacteri- al cell in the form of HF at lower pH values, dissociating, and thereby- providing Hi- and F— ions inside the cell. 36 10C cess showed that when levels of 0.03 ppm fluoride or higher were incorporated in the mineralizing so- lution (artificial saliva in the model) remineraliza- tion was enhanced (14, 49). This laboratory model was developed to mimic caries progression around orthodontic brackets in vivo (49, 50). As the fluoride concentration increased remineralization increased with an optimum being achieved at about 0.08 ppm or above in the calcium phosphate mineraliz- ing solution. Further, the relationship between the logarithm of the fluoride concentration in the min- eralizing solutions and the degree of protection af- forded against caries -like attack was linear. The clinical implication of this finding is that small in- creases in the background level of fluoride in saliva and plaque fluid could provide important caries protection via enhancement of remineralization. Studies have shown that when fluoride products including dentifrice, rinse and gels are used they cause an initial high concentration of fluoride in the saliva and that this falls off with time as the fluoride is cleared from the mouth (51, 52). Very importantly, fluoride can be retained at concentra- tions in the saliva between 0.03 and 0.1 ppm for 2- 6 hours depending on the product and the individ- ual subject (51, 52). In the case of xerostomic sub- jects, because of very low saliva flow, elevated levels of fluoride are maintained in the mouth for many hours (53). Studies by Zero and co- workers showed that a 0.05% sodium fluoride mouthrinse (225 ppm F) used for 1 min could give elevated fluoride levels in saliva for 2 -4 hours and in plaque for much longer times (52). O'Reilly & Featherstone showed that demineralization around orthodontic brackets in vivo could be completely eliminated by the combination of a fluoride - containing dentifrice and a 0.05% NaF rinse daily (50), and Meyerowitz and co- workers found the 0.05% NaF rinse very ef- fective in xerostomic subjects (54). Earlier studies prior to the universal use of fluo- ride dentifrice reported differences in salivary fluoride concentrations between fluoridated and non - fluoridated communities with values in the range of 0.005 -0.01 ppm F. Recent clinical studies (conducted in the late 1980s) which investigated possible caries risk factors in 7- 12- year -old chil- dren in the united States (55, 56) reported mean baseline fluoride concentrations in saliva of 0.02- 0.04 ppm in both fluoridated and non - fluoridated drinking water areas with the fluoride concentra- tion being related to caries status rather than drink- ing water concentration (56). Subsequent similar studies in the 1.990s again reported no differences t1. between mean salivary fluoride levels in 7- 12 -year- old children living in fluoridated and non- fluori- dated communities, with means about 0.05 ppm F in each (57, 58). In the :same study, in which the caries status of the subjects was assessed every 6 months, it was reported that after 2 and 4 years, in this longitudinal caries risk assessment study "chil- dren with high individual salivary fluoride (> 0.075 ppm) were more frequently caries free (P<0.02)" (57, 58). The caries balance Caries progression vs reversal is a delicate balance between the factors described above, namely a bac- terially generated acid challenge and a cornbina- tion of demineralization inhibition and reversal by J remineralization (59). The balance between patho- logical factors (bacteria and carbohydrates) and protective factors (saliva, calcium, phosphate, fluoride) is a delicate one which is tipped either way several times daily in most people. Microbiological components The importance of mutans streptococci (MS) (which includes S. inuuttans and S. sobrinus) in the development of dental caries has been reviewed extensively (12, 20, 21, 60, 61). Numerous cross -sec- tional studies in humans have shown that there is a strong trend for greater numbers of MS and lacto- bacilli (LB) in saliva or plaque to be associated with a high level of caries (20, 56, 60, 62 -64). Longitudi- nal studies have shown that an increase over time in numbers of MS and L,B is associated with the caries on -set and progression (55, 65, 66). Chemical components As described above the large decline in caries prevalence in the United States and other western countries over the past 20 years has been attributed in part to the widespread use of fluoride products and fluoride - containing dentifrices in particular (7, 8, 44). Further, there is considerable evidence that the cariostatic effects of fluoride are, in part, related, to the sustained presence of low concentrations of ionic fluoride in the oral environment (18, 44). There is also abundant evidence that low concen- trations of fluoride decrease the rate of enamel de- mineralization and enhance the rate of remineral- ization (14, 18, 44, 67 -70). Remineralization of early lesions also requires calcium and phosphate, which are primarily derived from saliva and plaque fluid. Several laboratory studies have indicated that the Fluoride and dental caries driving force for remineralization is the degree of supersaturation of the mineralizing fluid (saliva in the mouth) with respect to fluorapatite, hydroxy- apatite, or both (14, 17, 18, 67, 71, 72), and that this is related to the fluoride concentration in the oral fluids. Caries is best depicted as an ever - changing bal- ance between pathological and protective factors (18, 22, 59), as illustrated in Fig. 7. Clinical implications — fluoride delivery systems Fluoride therefore must be considered as one of several protective factors (59). Obviously it is a key one and small adjustments can tip the caries bal- ance illustrated in Fig. 7 one Easy or the other, lead- ing to caries arrestment, reversal, or progression. The frequent delivery of fluoride to the surfaces of the teeth is a very important factor as described in detail above. The topical effects of fluoride are over - riding, and the systemic incorporation of fluoride in the tooth mineral is unfortunately not of major benefit (1.8, 44). This means that we must use this information to deal more effectively with caries in both adults and children. It is well estab- lished that fluoride in drinking water reduces den- tal caries, but does not eradicate it. Fluoride in the drinking water provides fluoride at levels in the mouth which can inhibit demineralization and en- hance remineralization, and tip the caries balance towards protection, provided the challenge is not too great (Fig. 7). Again, as described above, the concentration of fluoride in dental enamel and den- tin provided by fluoridation of drinking water or by natural fluoride levels at about 1. ppm is insuf- ficient to provide protection against caries. The mechanism of action of fluoride in the drinking water is therefore as a topical delivery system. The role of systemically incorporated fluoride is of very limited value. Fluoride - containing products such as dentifrice, Protective Factors rythol.gical F.ct" ahva flow and components Bacteria Proteins, anttbacterials Mutansstreptococei, lactobacilli Fluoride, calcium and IAettry components - phosphate carbohydrates 'etnry components- protectiv Reduced salivary function N ARIES CARIES Fig. 7. Schematic diagram of the balance bet veen protective and pathological factors in caries. 37 al Featherstone mouthrinse and topically applied gels provide car- ies- preventive benefits via the topical mechanisms described above. The effects are all via the mecha- nisms of inhibition of demineralization, enhance- ment of remineralization and action on the bacte- ria. In the case of high bacterial challenge and /or xerostomia or salivary dysfunction, then even high levels of fluoride therapy may be insufficient to balance the effect of the pathological factors, and caries progresses. In each individual person there will be some level of challenge beyond which fluoride is insufficient to swing the balance. Fluo- ride products used frequently can maintain sali- vary fluoride levels in excess of O.0.3 ppm, thereby providing marked caries protection. The biggest problem with the home -use products of course is the need for patient compliance on a daily basis. Fluoride "supplements" and caries prevention For all the reasons described above the so- called fluoride supplements (tablets, lozenges and drops) should not be thought of as providing a dietary supplement that will automatically protect against caries by providing added benefit but rather as a supplement to "inadequate water content of fluo- ride ". This is not the case. To be effective against caries fluoride "supplements" should be thought of as a means to supplement the topical mecha- nisms of fluoride action and not the (minimal) sys- ternic action of fluoride. This was illustrated very clearly by Stephen and co- workers (73) who pro- vided fluoride tablets to children in Scotland to ei- ther swallow or hold in the mouth (sucking or chewing). The groups that dissolved the fluoride in the mouth and thereby "applied" fluoride topically had dramatic caries reductions (approximately 80%) in comparison to the tablet swallowers. If used, then fluoride supplements should be pre- scribed with instructions to chew or suck in order to provide a caries - protective benefit. It has been suggested that when fluoride tablets are swallowed, the fluoride returned via the plas- ma to the saliva may be sufficient to provide a "topical" benefit. Examination of work by Ekstrand and co- workers (74) shows that after ingestion of a fluoride tablet only a transient elevation of fluoride in the plasma occurs and that the levels which ap- pear in saliva as a result of a once a day fluoride tablet ingestion are unlikely to have much, if any, topical benefit. This further illustrates the need to use fluoride supplements directly as a fluoride 38 10 topical delivery mechanism if they are to be effec- tive. Summary and conclusions (1) The anti - caries effects of fluoride are primarily topical for children and for adults. (2) The mechanisms of action of fluoride are (i) inhibition of demineralization at the crystal sur- faces, (ii) enhancement of remineralization at the crystal. surfaces, and (iii) inhibition of bacterial ac- tivity. (3) The systemic benefits of fluoride are minimal. (4) Therapeutic levels of fluoride can be achieved from drinking water and topically applied fluoride products. (5) If used, fluoride "supplements" should be employed as a "topical" delivery system by chew- ing or sucking tablets or lozenges for the maxima n possible time before swallowing. References 1. Kaste LM, Selwitz RI I, Oldakowski .RI, Brunelle )A, Winn DM, 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. 1 National Center for Health Statistics. Vital and health statistics. Series 11. No. 144, Vol. DREW Pub. No. IIRA 7;r -1626. Washington (DC): Government Printing Office; 1974. 3. NIDR. The prevalence of dental caries in United States children: The National Dental Caries Prevalence Surtiev: 1979 -80. NIII Publication No. 82 -3245. National Insti- tutes of Health; 1981. 4. Brunelle JA. Oral health of United States children: The National Survey of Dental caries in US School Children: 1986 --87. Vol. N1H Pub. No. 89 -2247. National Institute of Dental Research; 1989. 5. Speechlev M, Johnston DW. Some evidence from Ontar- io; Canada, of a reversal in the caries decline. Caries Res 1996 ;30:423 -7. 6. Winn DM, Brunelle JA, Selwitz RI I, Kaste LM, Oldakow- ski RJ, Kingman A, et al. 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Rational use of fluorides in caries prevention. Acta Odontol Scand 1981;39:241 -4 45. Moreno EC, Kresak M, Zahradnick RT. Physicochemical aspects of fluoride - apatite systems relevant to the study Of dental caritas. Caries Res 1977;11 :142 -8. 46. Whitford GNI, Schuster GS, Pashley HD, Venkateswarlu P. Fluoride uptake by Streptococcus nnutans 6715. Infect Innmun 1977;18:680 -7. 47. Van Louveren C. The antimicrobial action of fluoride and its role in caries inhibition. J Dent Res 1990 ;69:676 -81, 48. Brown WE, Gregory TM, Chow LC. Effects of fluoride on enamel solubility and cariostasis. Caries Res 1977;11:118 -22. 49. Featherstone JDB, O'Reilly MM, Shariati M, Brugler S. Enhancement of remineralization in vitro and in vivo. fin: Leach SA, editor. Factors relating to demineralization and remineralization of the teeth. Oxford: IRI. Pr; 1986. 50. O'Reilly MM, Featherstone JDB. De- and rennineraliza- tion around orthodontic appliances: an in ;give study. Ain J -- Orthod 1987;92:33 40. 51. Bruun C, Givskov H, Thvlstrup A. Whole saliva fluoride after toothbrushing with NaF and MFP dentifrices with different F concentrations. Caries Res 1984 :;18:282 -8. 52. Zero DT, Raubertas RF, Pedersen AM, Fu J, Hayes AL, Featherstone JDB. Fluoride concentrations in plaque, whole saliva and ductal saliva after applications of home -use fluoride. agents. J Dent Res 1992;71:1768 --75. 39 Featherstone 53. Billings RJ, tileyerowitz C, Featherstone JDB, Espeland MA, Fu J, Cooper LF. Retention of topical fluoride in the mouths of xerostomic subjects. Caries Res 1988;33:306- 10. 54. Meyerowitz C, Featherstone JDB, Billings Rj, Eisenberg AD, Fu J, Shariati M, et al. Use of and infra -oral model to evaluate 0.05`,% sodium fluoride mouthrinse nn radiation - induced hyposalivation. J Dent Res 1991;70:894 --8. 55. Leverett DH, Proskin HM, Featherstone JDB, Adair SM, Eisenberg AD, Mundorff- Shrestha SA, et al. Caries risk assessment in a longitudinal discrimination study. J Dent Res 1993:72:;538 -43. 56. Leverett DH, Featherstone JDB, Proskin HM, Adair SM, Eisenberg AD, Mundorff- Shrestha SA, et al. Caries risk assessment by a cross - sectional discrimination model. j Dent Res 1993;72:529 -37. 57. Shields CP, Moss ME, Featherstone JDB, Proskin HIM, Billings Rj. Chemical analysis of saliva: a longitudinal study. J Dent Res 1995;74:17. 58. Shields CP, Moss ME, Billings Rj, Featherstone. JDB. A longitudinal chernica] analysis of saliva [abstract]. J Dent Res 1997;76(Spec Iss). 59. Featherstone JDB. Clinical implications of early caries de- tection: neon strategies for caries prevention. hr: Stookey GH, Beiswanger B, editors. Indiana Conference 1996: Early Detection 4 Dental Caries. Indiana University; 1996. p. 285 -93. 60. Krasse. B. Biological factors as indicators of future caries. Int Dent 1 19138;38:219-'25. 61. EIle:n P.P. Microbiological assays for dental caries and periodontal disease susceptibility. Oral Sci Rev 1976;8:3 -- :,-, L.l. 62. Alaluusua S, Kieemola- Kujala E, Nystrom M, Evalahti M, Gronroos L. Caries in the primary teeth and salivary S. rnutuns and lactobacillus levels as indicators of caries in permanent teeth. Pediat Dent 19879:126 -30. 63. Klock B, Krasse B. 'Microbial and salivary conditions in 9- to 12- year -old children. Scand J Dent Res 1977;85:56- 6 3. 64. Seppa L, Hausen 1 -L Frequency of initial caries lesions as 40 10 predictor of future caries increment in children. Scand j Dent Res 1988;96:9 - -13. 67. Loesche Wj, Eklund S, Earnest R, Burt BA. Longitudinal investigation of bacteriology of human fissure decay: ep- idemiological studies in molars shortly after eruption. In- fect Imrnun 1984;46:765 -72. 66. Kingman A, Little W, Gomez I, Heifitz SB, Driscoll WS, Sheats R, et al. Salivary levels of Streptococcus ntutans and lactobacilli and dental caries experience in a US adoles- cent population. Community Dent Oral Epidem 1988;16:98 -103. 67. Ten Cate JM, Mundorff- Shrestha SA. Working group re- port: Laboratory models for caries (In vitro and animal models). Adv Dent Res 1995;9:332 =I. 68. Featherstone IDB, Zero DT. Laboratory and human stud- ies to elucidate the mechanism of action of fluoride -con- taining dentifrices. In: Emberry G, Rolla R, editors. Chn- ical and biological aspects of dentifrices. Oxford: Oxford Univ Pr; 1992. p. 41 -50. 69- Arends J, Nelson DG A, Dijkrnan AG, jongebloed WL. Ef- fect of various fluorides on enamel structure and chernis- try. In: Guggenheim B, editor. Cariology Today, Int. Congr., Zurich. Base!, Switzerland: Karger, 1983:245 --58. 70. Zero DT. In situ caries models. Adv Dent Res 1995;9:214 -- 30. 71. Larsen MJ. Chemically induced in vitro lesions in dental enamel. Scand J Dent Ives 1974;82:496 -509. 72. Larsen MJ. An investigation of the theoretical back- ground for the stability of calcium phosphate salts and their mutual conversion in aqueous solutions. Arch Oral Biol 1986;31:757 -61. 73. Stephen KIti, Campbell D. Caries reduction and costbene- fit after 3 years of sucking fluoride tablets daily at school. A double blind trial. British Dent j 1978;144:202 -6. 74. Ekstrand j. Fluoride metabolism. In: Fejerskov O, Ek- strand J, Burt BA, editors. Fluoride in dentistry. Copen- hagen: Munksgaard; 1996. p. 554-)8. 75. Brown LJ, Winn DM, White BA. Dental caries, restora- tion and tooth conditions in U.S. adults, 1988 -1991. j Am Dent Assoc 1996;127:131? -25. 1 Trends In Dental Fluorosis and Dental Caries Prevalences in Newburgh and Kingston, NY JAYANTH V. KUMAR, DDS, MPH, ELMER L. GREEN, DDS, MPH, WILLIAM WALLACE, MS, AND TAIMt CARNAHAN, PHD i Ile r- c Abstract: A study was undertaken in New York Swe to determine the changes in dental fluorosis prevalence from 1955 to 1986 in fluoridated Newburgh and non - fluoridated Kingston childrQ The frequency and severity of dental fluorosis among 884 7- 14 -year-old children were measured by two dentists utilizing Dean's Index. Data regarding residential and fluoride history were obtained from the parents of participants. Among the Newburgh residents, the prevalence of dental fluorosis (very mild to moderate) varied from a low of 5 per cent for the 9-10- year-old group to a high of 9.4 percent for 11-12-year-olds. Except for the 13-14- year-old group, children in non- fluoridated Kingston had the lowest dental fluorosis prevalence Introduction Oral health surveys conducted in the United States and other developed countries have demonstrated that the prev- alence of dental caries in children has declined substantially in recent years." The increased availability of fluoride in many forms appears to be the single most important factor. The use of antibiotics, improved levels of restorative care, and patterns of sugar consumption and snacking have also been thought to contribute to the secular changes.-"' To explain changes in dental caries prevalence in non- fluoridated areas, many investigators have pointed out the effect of systemic fluorides in professionally prescribed supplements and/or the use of fluoridated dentifrices by young children.'•12-1 The increased availability of fluorides in food has also been suggested.13'"21 Singer and his co- workers have indicated that the average daily fluoride intake for infants, two - year-olds, and young male adults is within the accepted range of 0.05 to 0.07 milligram per kilogram body weight and has not significantly changed over the past 30 years.' 2-25 However, studies of fluoride levels of baby formulas and cereals have shown a significant increase in the fluoride content when fluoridated water was used for processing these foods. 12.19.27-29 Additional sources of fluorides are available now that were almost nonexistent when water fluoridation standards were determined. These include fluoride rinses and fluoride dentifrices. Barnhart, et al,30 reported that 2- to 4- year-old children ingested an average of 0.3 gram (gm) of dentifrice or 0.3 milligram (mg) of fluoride per brushing. Fluoride supple- ments are commonly prescribed for children living in non - fluoridated areas. The availability of fluoride from multiple sources has raised questions about the potential for increases in the From the Bureau of Dental Health, New York State Department of Health. Address reprint requests to Jayanth V. Kumar, DDS, MPH, Dental Public Health Epidemiologist, Bureau of Dental Health, New York State Department of Health, Tower Building, Rm 710, Albany, NY 12237. This paper, submitted to the Journal April 22, 1988, was revised and accepted for publication September 26, 1968. Editor's Note: See also related editorial p 561 this issue. ® 1989 American Journal of Public Health 0090-0036/8951,50 IOC rates. A comparison of Dean's Community Fluorosis Indices to the 1955 baseline data obtained from studies conducted after 10 years of fluoridation in Newburgh revealed no changes of consequence among Newburgh residents. However, the changes are apparent for Kingston residents, indicating the availability of fluorides in non- fluoridated areas. The increased risk for dental fluorosispr Kingston residents appears to be from the use of fluoride tablets An analysis of dental caries data revealed that caries prevalenceclined substantially in both fluoridated and non - fluoridated area Am J Public Health 1989; 79:565 -569.) incidence of dental fluorosis. Aasenden and Peebles31 found that 67 per cent of the children who ingested 0.5 mg fluoride from birth to three years of age and 1.0 mg daily thereafter had very mild to mild enamel fluorosis and 14 per cent had moderate fluorosis. In a later report, they suggested that fluorosis might become less noticeable with age.32 Hennon and co- workers33 reported no unacceptable levels of fluorosis among children who resided in communities with 0.6 to 0.8 ppm fluoride in the water and had taken 0.5 mg fluoride supplements from birth to age 3 years. Recently, Soparkar, et a /,34 reported an unexpectedly high proportion of children with enamel fluorosis and the source of fluoride was deter- mined to be prescribed fluoride supplements. Oldak and Leverett35 observed an increased occurrence of dental fluo- rosis in children residing in non - fluoridated communities. Twenty -two per cent of children ages 64 residing in a non - fluoridated community had fluorosis in permanent teeth. This higher than expected level of dental fluorosis was thought to be due to the prior use of dietary fluoride supplements. Recently, Driscoll, et al,36'37 and Segreto, et a1,38 com- pared data on the prevalence of fluorosis with historic data and found no important changes in the prevalence and severity of fluorosis. Although mean fluorosis indices were within the normal range in Rochester, New York, a higher than expected prevalence of very mild categories of fluorosis was reported by Leverett.31 Most epidemiological studies of dental fluorosis have been conducted in the Midwestem States, but baseline data on the frequency and severity of dental fluorosis in New York State are available from the 1955 Newburgh- Kingston Study.00 Therefore, an opportunity existed to determine if the frequency and severity of dental fluorosis had changed over the last 30 years in those two cities. Similarly, changes in dental caries prevalence could also be determined. Studies conducted between 1944 and 1955 in Newburgh indicated that dental caries prevalence declined considerably after fluoridation. In the non- fluoridated King- ston, dental caries prevalence increased during the same period. Another study of 13- and 14- year -old children in Newburgh and Kingston revealed that this trend continued into the early 1%()S.40 I AJPH May 1989, Vol. 79, No. 5 565 KUMAR, ET AL. Methods Between 1955 and 1986, several demographic and so- cioeconomic changes have occurred in both Newburgh and Kingston. Compared to Kingston, Newburgh has: a lower median income, a slightly larger proportion of low income level households, a lower median school years completed, a lower percentage of White population, a slightly higher percentage of unemployed, and a different occupational distribution." The water supply records in Newburgh indi- cate that the level of fluoride in the water was maintained at the recommended 1 ppm established by the US Public Health Service in 1945, except for a three -year period from 1978 to 1981. This reduction in fluoride would affect the teeth of 7- to 14 -year -olds differentially, depending on the stages of devel- opment of the teeth during this time. The city of Kingston has a fluoride content of 0.3 ppm in water." To obtain estimates of prevalences of dental fluorosis and dental caries in the cities of Newburgh and Kingston, children attending grades one through eight in public schools were selected to participate on the basis of a stratified random sampling of clusters. A total of 1,446 children from five elementary and two junior high schools in Newburgh and 694 children from four elementary and two junior high schools in Kingston agreed to participate in clinical examinations. The response rates were 63 per cent for Newburgh and 50 per cent for Kingston. The overall response rates were 72 per cent and 38 per cent for elementary and junior high schools, respec- tively. Dental fluorosis was determined for each child according to the established classification by Dean, in which the child is classified on the basis of the two teeth in the mouth showing the most advanced signs of fluorosis." In order to differen- tiate fluorosis from other enamel defects, the criteria devel- oped by Russell was used.'6 Dental caries was assessed using World Health Organization (WHO) guidelines." A pretested questionnaire was used to obtain residential and fluoride history from the parents of participants. Two dentists, who were not involved in New York State fluoridation or fluoride supplement programs, independently examined approximately equal proportions of participants in Newburgh and Kingston. Examination equipment included a portable chair and a fiber optic light source. The examiners were trained by an outside consultant in applying Dean's classification and were standardized four times during the study. Further, as an attempt to incorporate blindness, children who were not continuous residents of Newburgh and Kingston were also examined. The residential and fluoride history data were not made available to the examiners. The analysis of data is limited to groups of children between ages 7 and 14. Children under age six and over age 15 were excluded because of inadequacies in the sample size. Children with orthodontic bands or only deciduous teeth were also excluded. Estimates of community fluorosis indi- ces and respective standard errors were calculated for comparison purposes using the methods appropriate for stratified cluster sampling. Trends in dental caries preva- lences were determined by comparing age -race adjusted decayed, missing, filled, teeth (DMFT) indices. The relation- ship between fluorosis and dental caries was determined by analysis covariance technique. The adjusted mean scores were derived by treating age as a covariate utilizing the SAS -GLM computer package."' Because a large number of children attending the schools in Newburgh City were from the non - fluoridated town of 10 New Windsor and the recently fluoridated town of New- burgh, the children were separated into distinct groups. As the amount of exposure to fluorides is of particular impor- tance, data analysis is limited to continuous residents of Newburgh and Kingston. For the purpose of this report, 993 children who were not lifetime residents of Newburgh or Kingston cities were excluded from the analysis. Because the prevalence and severity of fluorosis did not differ significantly by ethnic group, sex, or examiners, only summary data are presented. As age - specific fluorosis rates tended to be un- stable, data are presented by two -year age intervals. Results The characteristics of the study population by relevant variables are presented in Table 1. There are smaller pro- portions of White and a generally lower set of socioeconomic indicators in the Newburgh sample and somewhat fewer lifetime residents (14 per cent vs 16 per cent). The frequency and severity of dental fluorosis for the children examined is presented for the two community groups in Table 2. Among the residents of the fluoridated Newburgh City, as well as residents of Kingston, the majority of the detectable dental fluorosis lesions observed were in the very mild category. Among the Newburgh residents, the prevalence of dental fluorosis (very mild to moderate categories) varied from a low of 5 per cent for the 9-10 -year -old group to a high of 9.4 per cent for 11 -12- year -olds. Except for the 13- 14- year -old group, children in the non - fluoridated Kingston had the lowest dental fluorosis prevalence rates. The relation between age and dental fluorosis prevalence was inconsis- tent. When the distribution of the lesions on the worst affected tooth of each child was analyzed, the clinical manifestation of the lesions observed in Newburgh and Kingston was similar (Table 3). A comparison of Dean's community fluorosis indices among the populations reveal that there are no differences in 1986 between Newburgh and Kingston residents (Table 4). Table 4 also compares the Dean's community fluorosis indices to the baseline data obtained from 1955 studies conducted after 10 years of fluoridation in Newburgh and Kingston. Although changes in the prevalence of dental TABLE 1- 4omparison of Dernoyraphic and Socioeconomic Cfaracter- Istics In Newburgh and Kingdon, NY Characteristics Newburgh Kingston Number of 7 -14 year -old Children 3,209 2,611 Per Cent White 47.5 84.8 Median Family income $14,230 $16,573 Per Cent Unskllied (Employed) 24.1 22.0 Per Cent with 4 or More Years of College 7.7 13.0 Low Income Households in Per Cent (Yearly Income Leas than $4,000) 25.1 18.2 Employed Persons 16 years and Over in Per Cent 48.1 51.5 Lifetime Residents 459 425 Per Cent Male 47.7 50.3 Per Cent White' 33.2 79.7 source: US Bureau of the Census: 1900 Census of Populations. General social and Econornlc ClmrecleriMlcs, New York, PC80- 1- C34NY. ' NOTE: The aleck, Hispanic and Asian chikkan were categorized as OBter #fan Whhe populatim: 78.5% and 79% of the Oster than Wh ee popuiadon were Blacks in lk w h and OVidon, respectively. 566 AJPH May 1989, Vol. 79, No. 5 C TABLE 2-- Percentage DlstrllmN of Dental Fluoroels In Newburgh and Kingston Residents by Age Group and Dean's ClesslMaUon Dean's Fluorosis Classification Age Number Questionable Very Mild Mild Moderate Prevalerae Newburgh 7 -8 149 11.4 4.6 2.6 2.0 9.2 9-10 135 12.5 2.2 2.9 0.0 5.1 11 -12 104 12.5 7.6 0.9 0.9 9.4 13-14 71 25.3 5.6 1.4 0.0 7.0 Kingston 7- 8 120 11.6 4.1 0.8 0.0 4.9 9-10 110 11.8 1.8 1.8 0.9 4.5 11 -12 101 13.8 3.9 3.9 0.9 8.7 13-14 94 7.4 8.5 2.1 1.0 11.6 NOTE: Dental fluorosis prevalence is based an very mld to moderate categories of Ruorom. ChWen dassYBed as normal or questionable are viewed as not travep lord* Zero". TABLE 3- 131stributlon of Fluoroafa In 7 to 14 Yew4)ld Children in Newburgh and Kingston According to Clinical WMfaandon Newburgh Kingston Fluorosls % % Generalized Lesions 83 76 Bilateral Symmetry 96 97 Affected Areas (Cuspai Tips Orly) 88 81 Degree of Tooth Affected (Less than 25% of the Tooth) 85 82 TABLE 4- 4omparison of Community fluorosis Indices Along with Standard Errors among Groups by Age and Year of Examine- tion Newburgh Kingston Age (years) 1955 1986 1955 1986 7- 8 0.18 (.04) 0.21 (.05) 0.00 0.16 (.04) 9-10 0.14 (.02) 0.14 (.02) 0.00 0.13 (.03) 11 -12 0.11 (.03) 0.20 (.07) 0.00 0.23 (.05) 13-14 0.00' 0.20 (.05) 0.00 0,19 (.05) 'Newburgh children of this ape group dot not receive fluoridated wabr *wing the NOTE: The 1955 C tmmwtity Fkawis lrwicea for Newburgh and lO goDn residerMs were cakuleled from the frequency and severity of Denlel nwrwis.4e fluorosis are not apparent among Newburgh residents, changes for Kingston residents were detected. A history of the use of fluoride tablets/drops during the first eight years of life from the parental questionnaire may indicate the exposure to a known risk factor. Table 5 shows that approximately 31 per cent of the children in Kingston reported a history of regular use of fluoride tablets/drops compared to 5 per cent for the residents of Newburgh. The odds ratio calculated for the two groups indicated a greater odds of developing dental fluorosis when tablets were taken every day. Over 95 per cent of the children in both groups reportedly use fluoride dentifrices. The effect of other sources of fluoride, such as topical rinses and professional fluoride applications was not examined. A comparison of the data gathered from studies con- ducted in Newburgh and Kingston reveals that caries has declined both in fluoridated and non - fluoridated areas (Figure 1). Figure 2 demonstrates the caries trends in 13- and 10 4 DENTAL FLUOROSIS TRENDS, DENTAL CARIES PREVALENCES TABLE 5- 4111story of Fluoride Tablets0rops Use and the EsdmaMd RelatM Risk with Everyday Use of Tablets/Drops during the First Eight Years of Life Fluoride Tablet/Drops History About About 3 Odds N Every Day Days/Week Occasionally Ratio' Newburgh 459 24 (5 %) 1(0%) 47(10%) 1.7 Kingston 425 133(31%) 16(4%) 46(11%) 3.8 'Irdicelea the ratio of the prevalence of dental fluoroeis among those who reported everyday teblet/dmps use compared to those who did not report tableWdrops use. Odds Ratio (Newburgh) = 3,24 - 28187 = 1.7 (95% CI = -0.5. +3.9) Odds Redo (Kingslon) = 20/133 + 9/230 = 3.8 (95% CI = +.07, +6.9) 14- year -old children. A comparison of dental fluorosis and dental caries prevalence suggests an inverse relationship. Children with very mild to moderate dental fluorosis consistently had lower caries experience (Table 6). The covariate adjusted mean DMFS indices showed that children with very mild to moderate fluorosis had approximately 41 to 54 per cent fewer DMFS, respectively. Discussion Although demographic and socioeconomic changes over a period of four decades have resulted in population differ- ences between Newburgh and Kingston, an analysis of trends in fluorosis prevalence should be still valid. Segreto, et at, have reported that the effect of gender, ethnic group, or family income in dental fluorosis is small compared with the effect of optimal fluoride level in drinking water." The changes in dental caries prevalence in Kingston must be viewed in light of the effect of changes in socioeconomic characteristics and the impact of the availability of other forms of fluoride in non - fluoridated areas. The results indicate that the extent and severity of dental fluorosis among residents in an optimally fluoridated com- munity in a Northeastern State is within the normal range, as specified by Dean. Dean has stated that the mildest forms of dental fluorosis would occur in about 10 per cent of a population that used water containing about 1 ppm of fluoride continuously from birth.S0 Later, he suggested a method to ® KIMSTOW ® NIEWU915W 1941 - 1948 1954 - f955 Ism YBAR OF MrAIG tAT10N FIGURE 1-- Asa - Mace- AdJllsted Dental Carks PrevWeDm (DMFr) for 7- 14- Year4)1d Chfl w is Newburgb and Kingston, NY, 1944416 AJPH May 1989, Vol. 79, No. 5 567 QX�' 1941 - 1948 1954 - f955 Ism YBAR OF MrAIG tAT10N FIGURE 1-- Asa - Mace- AdJllsted Dental Carks PrevWeDm (DMFr) for 7- 14- Year4)1d Chfl w is Newburgb and Kingston, NY, 1944416 AJPH May 1989, Vol. 79, No. 5 567 KUMAR, ET AL. i i i i i i i i i i i i i i i i i i i i i i Is 144 V! 's 'd IN 'Q 'S en � YEAR OF EXAMM71ON FIGURE Zr Denw Colin Prcvalem for 13 and 14-ym M& in Newbwgb and Kinytm, NY, 19" -86 ascertain the public health significance of dental fluorosis utilizing the Community Fluorosis Index (CFI). According to Dean, CFI scores below 0.4 are considered as having no public health significance." Because 99 per cent of the population studied had less than moderate categories of dental fluorosis and the differences over time were negligible, these data suggest that no changes have occurred in the past three decades. This observation is consistent with the recent studies conducted by Segreto, et al, in Texas,39 and by Driscoll, et al,3e.3' in Illinois. The lower community fluorosis indices for all age groups for Newburgh residents compared to those reported elsewhere' for residents of other fluoridated communities could be due to three years of interruption in fluoride availability from water. However, an analysis of the relation between age and fluorosis prevalence did not reveal any consistent effect of this interruption. The 13-14- year -old group that received an uninterrupted supply of fluoride from birth for seven years did not have any more fluorosis than the 7-8- year-old group that received the least amount of fluoride exposure from water. Also, the fact that 16 per cent of Newburgh resident children also reportedly received fluoride tablets may indicate that some of these children received fluoride during the period of interruption in water fluorida- tion. Further, compared to other indices that consider the tooth as a unit, the use of Dean's Community Fluorosis Index based on the child as a unit minimizes the underestimation resulting from interruption in fluoride availability, because any excessive exposure during the development of teeth will affect at least some teeth. This manifestation is considered as fluorosis, no matter whether the child received fluoridation during the development of some teeth or all the teeth. Another possible explanation for the low community flu- TABLE 6 -Dor" Cana Provalenee Accordlnp to Diian's Fkwrosb ClassHlcation Dean's Covariate (Aye) Fhwrosis Adlusted Mean Standard Classification N DMFS Error Normal 704 2.2 0.11 Questionable 113 2.1 0.27 Very Mild 41 1.3 0.47 Mild 19 1.1 0.67 Moderate 7 1.0 1.11 10C orosis indices may be due to differences in the application of the diagnostic criteria. This may have been minimized by not providing the fluoride history to examiners and by the high level of agreement among the examiners. A comparison to an earlier study in Newburgh and Kingston conducted by Russell in 1955 should take into consideration the differences that could have occurred in the application of the diagnostic criteria. The community fluorosis indices reported in 1955 for Newburgh residents were also lower compared to that of other studies.'s However, at that time, only 7— &year -old children had received fluoride in drinking water continuously from birth. The change in the occurrence of very mild to mild categories of dental fluorosis from the original study is noticeable in the non - fluoridated city of Kingston. This increased occurrence of fluorosis in non- fluoridated areas has been reported by other investigators. 4.34.33 In Kingston, the increased occurrence of fluorosis may be attributed to a large extent to the use of fluoride supple- ments. If the use of infant formula was similar in the studied populations and the cases and controls are representative of the population, then an important factor associated with dental fluorosis is the use of fluoride tablets /drops. The fact that this group received fluoride supplements at a higher than the currently recommended dosage may have contributed to an increased risk for developing fluorosis." The higher dental fluorosis rate reported for Kingston when compared to the studies conducted in other non- fluoridated areas is consistent with the variation in the fluoride supplement use in different regions of the country.34 -.3 The findings from the 1983 National Health Interview Survey indicated that the use of fluoride supple- ment was more frequent among White families with high incomes in the Northeastern regions. 53 Dental caries declined substantially both in Kingston and Newburgh, a trend that is consistent with the recent findings from other studies. 11.13 An observation of particular interest is that between the 1940s and 1960s, dental caries increased in the non - fluoridated Kingston in contrast with the fluori- dated Newburgh. As a result of this phenomenon, the caries decline between the 1960s and the 1980s in Kingston appears to be greater in Kingston compared to Newburgh. In spite of this decline in caries in the non - fluoridated area, lower caries prevalence continues to exist in the fluoridated area. How- ever, factors such as differences in the service utilization patterns as evidenced by the comparison of the proportion of filled component of all caries surfaces, interruption in the fluoride availability for Newburgh children, and an increased availability of fluorides for Kingston children complicate the measurement of impact of fluoridation in this study. An analysis of dental caries prevalence, according to Dean's fluorosis classification, revealed that children with very mild to moderate to dental fluorosis had 41 to 54 per cent lower caries prevalence. Driscoll, et al, observed similar differences among children residing in areas where the fluoride is above optimal levels.37 The additional caries inhibitory effect for children with very mild to moderate dental fluorosis observed in the original studies appears to still exist.3i Several researchers have suggested that the logical implication of an inverse relationship between dental caries and dental fluorosis in the development of public policy is that a slightly increased risk for dental fluorosis is prefer- able to a higher risk for dental caries, -17 since the very mild to mild categories of fluorosis are neither an adverse health effect nor esthetically objectionable, whereas dental caries results in pain, suffering, loss of esthetics, and higher costs. 568 AJPH May 1989, Vol. 79, No. 5 1114 ACKNOWLEDGMENTS This study was supported by a grant from the Dental Disease Prevention Activity, Centers for Disease Control, Atlanta. 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Brunelle JA, Miller AJ, Smith JI: DMFS in US children with and without lifelong exposure to water fluoridation. J Dent Res 1983; 62:203 (Abstracts #302). 6. Katz RV, Jensen ME, Meskin LH: Dental caries prevalence in a community of school children: fluoridated vs non - fluoridated. J Dent Res 1983; 62:202 (Abstracts #1298). 7. Stephen KP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC: The cost and effectiveness of school -based preventive dental care. Princeton, NJ: Robert Wood Johnson Foundation, 1985; R- 3203.RWJ. 8. Stamm JW: Is there a need for dental sealants? Epidemiological indica- tions in the 1980s. J Dent Educ 1984; 48(2):9 -17. 9. Graves RC, Stamm J W: Oral health status in the United States: Prevalence of dental caries. J Dent Educ 1985; 49:341 -351. 10, Keene HJ: Global perspectives on the changing prevalence of streptococ- cus mutans in human population. J Dent Res 1984; 63:168 (Abstract #523). 11. Loesche WL: Possible effects of systemic usage of antibiotics for medical purposes on the decline in caries incidence. J Dent Res 1984; 63:168 (Abstract #1526). 12. Ericsson Y, Wei SHY: Fluoride supply and effects in infants and young children. Pediatr Dent 1979; 1:4454. 13. Leverett DH: Fluorides and the changing prevalence of dental caries. Science 1982; 217:26 -30. 14. Infante PF: Dietary fluoride intake from supplements and communal water supplies. Am J Dis Child 1975; 129:835437. 15. Ekstrand J. Ehmebo M: Absorption of fluoride from fluoride dentifrices. Caries Res 1980; 14:96 -102. 16. Marier JR, Rose D: The fluoride content of some foods and beverages. J Food Sci 1966; 31:941-946. 17. Spencer H, Lewin T, Wiatrowski E, Samachson J: Fluoride metabolism in man. Am J Med 1970; 49:807. 18. Ericsson Y, Ribelius W: Wide variation of fluoride supply to infants and their effects. Caries Res 1971; 5:788. 19. Rao GS: Dietary intake and bioavailability of fluoride. Am Rev Nutr 1984; 4:115 -136. 20. Walton JL, Messer LB: Dental caries and fluorosis in breast -fed and bottle -fed children. Caries Res 1981; 15:124137. 21. Singer L, Ophaug RH: Fluoride content of foods and beverages. In: Wei Shy (ed): National Symposium on Dental Nutrition. Iowa City: University of Iowa Press, 1979; 47-62. 22. Singer L, Ophaug RH, Harland BF: Fluoride intake of young male adults in the United States. Am J Clin Nutr 1980; 30:320 -332. 23. Ophaug RH, Singer L, Harland BF: Estimated fluoride intake of six - month -old infants in four dietary regions of the United States. Am 1 Clin Nutr 1980; 33:324327. 24. Ophaug RH, Singer L, Harland BF: Estimated fluoride intake of average two - year -old children in four dietary regions of the United States. J Dent Res 1980; 59:777 -781. 25. Singer L, Ophaug RH: Total fluoride intake of infants. Pediatrics 1979; 63: 160. 26. Taves DR: Is fluoride intake in the United States changing? In: Johansen E, Taves DR, Olsen TO (eds): Continuing Evaluation of the Use of Fluorides. AAAS selected symposium. Boulder, CO, West View Press, 1979;149 -157. 27. Adair SM. Wei SHY: Supplemental fluoride recommendations for infants based on dietary fluoride intake. Caries Res 1978; 12:76 -82. 28. Tinnanoff N, Mueller B: Fluoride content in milk and formula for infants. J Dent Child 1978; 45(1):53 -55. 10C DENTAL FLUOROSIS TRENDS, DENTAL CARIES PREVALENCES 29. McKnight C, Leverett DH, Adair SM, Shields CP: Fluoride content of milk -based and soy -based infant formulas. J Dent Res 1985; 64: 294(Abstract #1075). 30. Barnhart WE, Hiller LK, Leonard G, Michaels SE: Dentifrice usage and ingestion among four age groups. J Dent Res 1974; 53:1317 -1322. 31. Aasenden R, Peebles TC: Effects of fluoride supplementation from birth on deciduous and permanent teeth. Arch Oral Biol 1974; 19:321 -326. 31 Aasenden R, Peebles TC: Effects of fluoride supplementation from birth on dental caries and fluorosis in teenaged children. Arch Oral Biol 1978; 28:111. 33. Hennon DK, Stookey GK, Beiswanger BB: Fluoride - vitamin supple- ments. Effects on dental caries and fluorosis when used in areas with suboptimal fluoride in water supply. J Am Dent Assoc 1977; 95: %5 -971. 34. Soparkar PM, DePaola PF: History of fluoride ingestion among chil- dren diagnosed with and without fluorosis. J Dent Res 1985; 64:226 (Abstract #459). 35. Oldak SB, Leverett DH: Dental fluorosis in a non - fluoridated community. J Dent Res 1984; 62:197 (Abstracts #239). 36. Driscoll WS, Heifetz SB, Horowitz HS, Kingman A, Meyers RJ, Zim- merman ER: Prevalence of dental caries and dental fluorosis in areas with optimal and above - optimal water fluoride concentrations. J Am Dent Assoc 1983; 107:42 -47. 37. Driscoll WS, Heifetz SB, Horowitz HS, Kingman A, Meyers RJ, Zim- merman ER: Prevalence of dental caries and dental fluorosis in areas with negligible, optimal, and above - optimal fluoride concentrations in drinking water. J Am Dent Assoc 1986; 113:29 -33. 38. Segreto VA, Collins EM, Camann D. Smith CT: A current study of mottled enamel in Texas. J Am Dent Assoc 1984; 108:56 -59. 39. Leverett D: Prevalence of dental fluorosis in fluoridated and non- fluoridated communities--a preliminary investigation. J Public Health Dent 1986; 46:184 -187. 40. Ast DB, Smith DJ, Wach B, Cantwell KT: Newburgh- Kingston caries - fluorine study. Combined clinical and roentgenographic dental findings after ten years of fluoride experience. JADA 1956; 52 :314 -325. 41. Ast DB, Fitzgerald B: Effectiveness of water fluoridation. J Am Dent Assoc 1 %2; 65:581 -587. 42. Ast DB, Allaway N, Draker HL: The prevalence of malocclusion, related to dental caries and lost first permanent molars, in a fluoridated city and a fluoride- deficient city. Am J Orthodont 1 %2; 48(2):106 -113. 43. Bureau of the Census: Census of Population. Characteristics of the population. Part 34 New York (PC80.1 -B34). Washington, DC: US Department of Commerce, 1980. 44. New York State Department of Health: Community Water System. Fluoridation Census 1986. Albany, NY: New York State Department of Health, 1986. 45. Dean HT: The investigation of physiological effects by the epidemiological method. In Moulton FR (ed): Fluorine and Dental Health, American Association for the Advancement of Science. Pub. No. 19. Washington, DC: AAAS, 1942; 23 -31. 46. Russell AL: The differential diagnosis of fluoride and non - fluoride enamel opacities. Public Health Dent 1 962; 21:143 -146. 47. World Health Organization: Oral Health Surveys; Basic Methods, 2nd Ed. Geneva: WHO, 1977. 48. Scheaffer RL, Mendenhall W, Ott L: Elementary Survey Sampling. 2nd Ed. N. Scituate, MA: Duxbury Press, 1978. 49. SAS Institute, Inc: Users Guide: Statistics, Version 5 Edition, Cary, NC: SAS Institute, 1985. 50. Dean HT: Chronic endemic dental fluorosis (mottled enamel). JAMA 1936; 107:1269 -1272. 51. Dean HT: Epidemiological studies in the United States. In: Moulton FR (ed): Dental Caries and Fluorine. American Association for the Advance- ment of Science. Lancaster, England: Science Press, 1946; 5:31. 52. Newbrun E: Dietary fluoride supplementation for the prevention of caries. Pediatrics 1978;62 :733 -737. 53. Ismail AI, Burt BA, Hendershot GE, Jack S, Corbin SB: Findings from the Dental Care Supplement of the National Health Interview Survey, 1983. J Am Dent Assoc 1987; 114:617 -621, 54. Singer L, Ophaug RH: Dietary fluoride intakes in the United States. J Dent Res 1986; 65:761 (Abstract #1319). 55. Johnson J, Bawden JW: Fluoride content of commercially available infant formulas. J Dent Res 1986; 65:183 (Abstract #124). 56. American Dental Association. Council on Dental Therapeutics: Accepted Dental Therapeutics. 40th Ed. Chicago: ADA. 1984. 57. Szpunar S, Turt B: Trends in the prevalence of dental fluorosis in the United States: A review. J Public Health Dent 1987; 47(2):71 -79. 58. Horowitz HS: Indexes for measuring dental fluorosis. J Public Health Dent 1986;46(4):179 -183. AJPH May 1989, Vol. 79, No. 5 569 Public Health Focus: Fluoridation of Community Water Systems Pal 104C 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 inrid-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 fi-om 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 1); http: / /www.cdc.gov /mmwr /preview /mmwrhtml/00016840.htm 3/19/2009 1NTR OD U C71 ON great public health achievements of the 20th century not- are retaining their teeth throughout their lifetimes ing that it is a major factor responsible for the decline in due in part to the benefits they receive from water dental decay.'•2 fluoridation. Dental costs for these individuals are Former U.S. Surgeon General David Satcher issued likely to have been reduced and many hours of need- the first ever Surgeon General report on oral health in less pain and suffering due to untreated dental decay May 2000. In Oral Health in America:A Report of the Sur- have been avoided. 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- "Water fluoridation continues to be currence of dental decay in a community.5-20 Additionally, effective in reducing dental decay by 20-40%, Dr. Satcher noted that water fluoridation is a powerful even in an era with widespread availability strategy in efforts to eliminate health disparities among populations. Studies have shown that fluoridation may of fluoride from other sources, such as be the most significant step we can take toward reducing fluoride toothpaste." the disparities in dental decay.5,20-24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called It is important to note that dental decay is caused by on policymakers, community leaders, private industry, dental plaque, a thin, sticky, colorless deposit of bacte- health professionals,the media and the public to affirm ria that constantly forms on teeth.When sugar and oth- that oral health is essential to general health and well be- er carbohydrates are eaten, the bacteria in plaque pro- ing. Additionally,Surgeon General Carmona urged these duce acids that attack the tooth enamel. After repeated groups to apply strategies to enhance the adoption and attacks,the enamel breaks down, and a cavity (hole) is maintenance of proven community-based interventions formed. There are a number of factors that increase an such as community water fluoridation 25 individual's risk for dental decay:27,3°-33 Community water fluoridation is a most valuable • Recent history of dental decay public health measure because: • Elevated oral bacteria count • Optimally fluoridated water is accessible to the en- • Inadequate exposure to fluorides tire community regardless of socioeconomic status, • Exposed roots educational attainment or other social variables.26 • Frequent intake of sugar and sugary foods • Individuals do not need to change their behavior to • Poor or inadequate oral hygiene obtain the benefits of fluoridation. • Decreased flow of saliva • Frequent exposure to small amounts of fluoride • Deep pits and fissures in the chewing surfaces over time makes fluoridation effective through the of teeth life span in helping to prevent dental decay. Exposure to fluoride is not the only measure avail- • Community water fluoridation is more cost effec- able to decrease the risk of decay. In formulating a de- tive than other forms of fluoride treatments or ap- cay prevention program,a number of intervention strat- plications.27 egies may be recommended such as changes in diet and placement of dental sealants.However,fluoride is a Water Fluoridation's Role in Reducing key component in any recommended strategy. Dental Decay Water fluoridation and the use of topical fluoride have Ongoing Need for Water Fluoridation played a significant role in improving oral health. Because of the risk factors for dental decay noted Early studies showed that water fluoridation can re- previously, many individuals and communities still duce the amount of cavities children get in their baby experience high levels of dental decay. Although wa- teeth by as much as 60% and can reduce dental decay ter fluoridation demonstrates an impressive record in permanent adult teeth by nearly 35%. Since that of effectiveness and safety, only 67.3 % of the United time, numerous studies have been published mak- States population on public water supplies receives ing fluoridation one of the most widely studied public fluoridated water containing protective levels of flu- health measures in history. Later studies prove water oride.34 Unfortunately, some people continue to be fluoridation continues to be effective in reducing den- confused about this effective public health measure. tal decay by 20-40%, even in an era with widespread If the number of individuals drinking fluoridated water availability of fluoride from other sources, such as is to increase,the public must be accurately informed fluoride toothpaste.28z9 Increasing numbers of adults about its benefits. Fluoridation Facts Packet Page -906- 9 3. 4. T �,vvll_�l kZ__ 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 Q 5. Fluoride additives? p. 12 QUESTION 1. What is fluoride? Q 6. Natural vs adjusted? p. 12 Q 13. Fluoride for children? P. 18 Q 7. Effectiveness? p. 13 Q 8. Still effective? p. 14 Q 9. Discontinuance? P. 15 Q10. Is decay still a problem? p.16 Q11. 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- curs in its free state in nature, but exists only in com- bination with other elements as a fluoride compound. Fluoride compounds are components of minerals in 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 3'•36 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 14. Alternatives? P. 19 Q 15. Bottled water? P. 19 Q 16. Home treatment p. 21 (filter) systems? 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.42 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 - 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 .44 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 -907- 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. "46 "John D.B. Featherstone, PhD, Professor and Chair, Department of Preventive, and Restorative Dental Services, 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. "' 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 .42,47-51 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 .44,12-54 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 .55 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 fluoridated 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. Flow 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 1St 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 httr)://www.er)a.gov/safewater/dwinfo/index.htmi.E7 Additionally, the Centers for Disease Control and Prevention's (CDC) fluoridation Web site, "My Water's Fluoride," is available at http: / /apps.nccd.cdc.gov /MWF/ Index.aso.58 For those states that have provided infor- mation to the CDC, the site lists fluoridation status by water system. Packet Page -908- 11 " .'W"z41. ' . ' c The EPA does not have the authority to regulate QUESTION 6. private drinking water wells. However, the EPA recom- Is there a difference in the effectiveness between natu- mends that private well water be tested every year. rally occurring fluoridated water (at optimal fluoride While the EPA does not specifically recommend testing levels) and water that has fluoride added to reach the for the level of fluoride, health professionals will need optimal level? this information prior to consideration of prescription of dietary fluoride supplements or to counsel patients Answer. about alternative water sources to reduce the risk of No. The dental benefits of optimally fluoridated water fluorosis if the fluoride levels are above 2 ppm.59 occur regardless of the fluoride's source. (Additional information on this topic may be found in Questions 12, 24,25 and 42. Fact. Always use a state certified laboratory that conducts Fluoride is present in water as "ions" or electrically drinking water tests. For a list of state certified labs,con- charged atoms.36 These ions are the same whether ac- tact the local,county or state water/health department. 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 QUESTION 5. conditions to fluoride-deficient water, the dental ben- What additives are used to fluoridate water supplies in efits are the same as those obtained from naturally fluo- the United States? ridated water. Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all Answer. drinking water sources. Sodium fluoride,sodium fluorosilicate and fluorosilicic acid are the three additives approved for community "Fluoridation is merely an increase of the water fluoridation in the United States. Sodium fluoro- level of the naturally occurring fluoride silicate and fluorosilicic acid are sometimes referred to present in all drinking water sources." 5 as silicofluoride additives. P 9 s Fact. • Some individuals use the term "artificial fluoride- The three basic additives used to fluoridate water in the tion" to imply that the process of water fluoridation is United States are: 1) sodium fluoride which is a white, unnatural and that it delivers a foreign substance into odorless material available either as a powder or crys- a water supply when, in fact, all water sources contain tats;2)sodium fluorosilicate which is a white or yellow some fluoride. Community water fluoridation is a natu- white, odorless crystalline material and 3) fluorosilicic ral way to improve oral health.62 t acid which is a white to straw-colored liquid.3660 (Additional information on this topic may be found in While fluoridation began in 1945 with the use of so- Question 45. dium fluoride, the use of silicofluorides began in 1946 estiono the initiation of"adjusted"water fluoridation, Prior and, by 11951, they were the most commonly used ad- several classic epidemiological studies were conducted ditives. First used in the late 1940s, fluorosilicic acid that compared naturally occurring fluoridated water to is currently the most commonly used additive to fluori- fluoride-deficient water. Strikingly low decay rates were date communities in the U.S. found to be associated with the continuous use of water with fluoride content of 1 part per million.72 "To ensure the public's safety, standards A fluoridation study conducted in the Ontario, Cana- have been established to ensure the safety da, communities of Brantford (optimally fluoridated by adjustment), Stratford (optimally fluoridated naturally) of fluoride additives used in water and Sarnia (fluoride-deficient) revealed much lower de- treatment in the U.S." cay rates in both Brantford and Stratford as compared to nonfluoridated Sarnia. There was no observable dif- To ensure the public's safety, standards have been ference in decay reducing effect between the naturally established to ensure the safety of fluoride additives occurring fluoride and adjusted fluoride concentration used in water treatment in the U.S. Specifically, addi- water supplies, proving that dental benefits were simi- tives used in water fluoridation meet standards of the lar regardless of the source of fluoride.16 American Water Works Association (AWWA) and NSF International (NSF). (6 Additional information on the topic of fluoride addi- tives may be found in Fluoridation Practice Section. 12 Packet Page -909- American Dental Association 10C wl 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 year in large communities to $3.00 per person a year for small communities to operate 1,2. 66 . The return on investment is tremendous — with various studies reporting .$38-$80 in dental treatment cost savings for each dollar invested in community water fluoridation' "2,e,55 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",3" "a. 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 mouth3"9 -32'48. Those fortunate enough to have had access to community water fluoridation experience 40 -60% fewer dental cavities" .32 -aa 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 10 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? f=irst of all, public water systems have been used for the purpose of preventing diseases in the United States since the 184 0'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 caries, 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 -11. 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 adults4s•sc•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 substantial5. The fluoride from saliva not only prevents some cavities from ever starting, but it also repairs early dental decay through a process called remineralization' "e -57 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 sal €vas.55 -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 acidsse 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)"-". 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 -'S' 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 E 1rF be a-;,b ic- I :� :at on It- ch to ry n- he :71 is m 31- m r, 'o 1� of be de 1st +II ill sir of 01 e vl NATURE VOL. 322 10 JULY 1986 The mystery from Mark Diesendorf 1q�6 -- - -COMM of declining tooth:. decay I� Large temporal reductions in tooth decay, which cannot be attributed to fluoridation, have been observed in both unfluoridated and fluoridated areas of at least eight developed countries over the past thirty years. It is now time for a scientific re- examination of the alleged enormous benefits of fluoridation. FLUORIDATION consists of raising the concentration of the fluoride ion F- in water supplies to about 1 part per million (p.p.m.) with the aim of reducing dental caries (tooth decay) in children. In fluori- dated areas, there are now many longi- tudinal (temporal) studies which record large reductions in the incidence of caries'. The results of these and of fixed time sur- veys have led to the 'fluoridation hypothesis', namely that the principal cause of these reductions is fluoridation. Until the early 1980s, there had been comparatively few longitudinal studies of caries in unfluoridated communities. Only a small minority of the studies in fluori- dated areas had regularly examined con- trol populations, and there seemed to be little motivation to study other unfluori- dated communities. But during the period 1979 -81, especially in western Europe where there is little fluoridation, a number of dental examinations were made and compared with surveys carried out a decade or so before. It soon became clear that large reductions in caries had been occurring in unfluoridated areas (see below). The magnitudes of these reduc- tions are generally comparable with those observed in fluoridated areas over similar periods of time. In this article, these reductions are reviewed and attention is also drawn to a second category of caries reduction which cannot be explained by fluoridation. This category is observed in children described by proponents of fluoridation as having been 'optimally exposed', that is, children who have received water fluoridated at about 1 p.p.m. from birth. The observation is that caries is declining with time in 'optimally exposed' children of a given age. In some cases, the magnitudes of these reductions are much greater in per- centage terms than the earlier reductions in the same area which had been attributed to fluoridation. The problem of explaining the two categories of reduction goes well beyond the field of dentistry: contributions from nutritionists, immunologists, bacteriol- ogists, epidemiologists and mathematical Table I Studies reporting large reductions in dental caries in unfluoridated areas Location 'wstratia Brisbane Sydney Denmark Various towns Holland The Hague Various towns Vew Zealand Auckland (parts) Norway Various towns Sweden Various towns North Sweden United Kingdom Bristol Bristol Devon Gloucestershire Isle of Wight North -West England Scotland Shropshire Somerset Somerset United States Dedham, Mass. Norwood, Mass. Massachusetts: sample of schools Ohio Years surveyed 1954, '77 1961, '63, '67 1972, '79 1969,'72,'75,'78 1965, '80 1966, '74, '81 1970, '80 1973, '78, '81 1967, '77 1970, '79 1973,'79 1971''81 Annually from 1964 1971,'90 1969''80 1970, '80 1970,'80 1975 -79 annually 1963 -79 1958, '74 1958, '72, '78 1951, '81 1972, '78 References 2, 3 4 53 38 11 12 54 39 55 56 56 37 37" 57 58 59 10 60 61 40 40 41 62 ' Unpublished communication from J. Tee (1980), Area Dental Officer, Gloucestershire, to R. I. Anderson er al." 1 statisticians, amongst others, may be required. Caries in unfluoridated areas Table I lists over 20 studies which report substantial temporal reductions in caries in children's permanent teeth in unfluori- dated areas of the developed world. In many of these cases, the magnitudes of these reductions are comparable with those observed in fluoridated areas and attributed to fluoridation. Several of these studies give clues as to factors which are unlikely to he the main causes of the reductions. A comparison of the 1954 and 1977 dental health surveys in Brisbane2-3 indicates to a reduction of about 50% in caries, as measured by the number of decayed, missing and filled per- manent teeth (DMFT) per child and averaged over the age groups, in the 23- year period. The 1977 survey distinguished between children who took fluoride tablets regularly, irregularly or not at all. Although there were differences in caries incidences between the three categories (which could reflect factors unrelated to fluoride levels), even the "no tablet" group had on average 40% less caries experience than that recorded in 1954. So fluoride tablets were not the principal cause of the reductions observed in Brisbane. The first Sydney study' showed that children with "naturally sound" teeth increased from 3.8% in 1961 to 20.2% in 1967 and 28% in 1972. The paper, which was titled enthusiastically "The Dental Health Revolution ", was originally used widely to promote fluoridation in Aus- tralia. The authors stated that: "Almost certainly, the availability of fluoride both in tablet form and delivered through town water supplies has been the predominant factor.... These very large reductions rep- resent a modern triumph of preventive health care "'. Yet the major proportion of the reported improvement had already occurred before Sydney was fluoridated in 1968. Moreover, no evidence was pres. ented that fluoride tablets were widely used in the 1960s. Fluoride toothpaste was only introduced into Australia in 19673. Although the index "naturally sound" teeth is unsuitable for more detailed R' COMMENTARY 10 13 Z2y ear s X \ 6 11 yr X\ X, X X10 yr X X �x 4 X 9 yr x�x� X 9 yr x x —x x 2 x7 y\\x�j 1 x X �x —x x x 1963 69 71 72 79 Year Fig. 1 Decline in caries, as measured by DMFT, in Tamworth, Australia, for children in age groups 6 years to 13 years. Data compiled from refs 14, 15. The vertical line cutting graph for each age group denotes year at which maximum possible benefit from fluoridation was reached. Tamworth was fluoridated in 1963. studies which distinguish decayed, miss- ing and filled teeth, the populations , examined were very large (over 9,000 children at each examination) and the results clear -cut. A second Sydney study' used the DMFT index, but was irrelevant for establishing any link with fluoridation, since it reported only on examinations in 1963 and 1982, but not around 1968 when Sydney was fluoridated. As in several other fluorida- tion studies, the key data were either not collected or not reported'. Although the two Sydney papers have an author in com- mon (James S. Lawson, a senior officer of the New South Wales Health Com- mission), the second paper does not even cite the first. This suggests that, once it became clear that the first Sydney study contained evidence unfavourable to fluori- dation, it was a source of embarrassment to some fluoridation proponents who are apparently trying to denigrate it. However, independent confirmation of the large reductions in caries before fluori- dation reported in the first Sydney study" is readily obtained by comparing the results of two survevs'-s separated by 20 years by Barnard, These surveys showed that the mean DIMF index ('I' denotes a permanent tooth which cannot be restored) for school children aged 13 and 14 declined from 11.0 in 1954 -55 to 6.0 in 1972. The four years from 1968, when fluoridation commenced in Sydney, to 1972, would not have contributed sig- nificantly to the decline in caries preva- lence in this age group°. The authors of one of the British studiesiO cited in Table 1 point out that sales of fluoride toothpaste in the United Kingdom were less than 5% of total sales in 1970, but rose to more than 95% of sales in 1977. They quote unpublished annual data from unfluoridated parts of Gloucestershire, collected from 1964 onwards, which show substantial improvements in children's teeth before the use of fluoride toothpaste became significant. Many of the studies in the Netherlands, reviewed by Kalsbeek", were carried out to evaluate the effectiveness of the school lOC VOL. 322 10 JULY 1986 dental health programme. Temporal reductions in DMFTof about 50%u occur- red between 1970 and 1980, whether or not the children had taken part in the dental health education program. Kalsbeek also reviewed the use of fluoride tablets and toothpaste and concluded from the dyta that "factors other than the effects of different fluoride programmes must play a role." The study in the partly fluoridated city of Auckland, New Zealand12, examined the influence of social class (which reflects environmental and lifestyle factors, such as diet) as well as fluoridation on dental health as measured by the levels of dental treatment received by children. The paper showed that treatment levels have con- tinued to decline in both fluoridated and unfluoridated parts of the city and that these reductions are related strongly to social class, there being less caries in the "above average social rank" group than in other children. Thus the main ethical argument for fluoridation, that it should assist the disadvantaged, is not borne out by this study. Fluoridation's benefits On 15 December 1980, the Dental Health Education and Research Foundation, one of the main fluoridation promoting bodies in New South Wales (NSW), issued a press release entitled, "Fluoridation dramatically cuts tooth decay in Tam - worth "i3. This document, which highlight- ed results of a study conducted by the Department of Preventive Dentistry, Sydney University, and the Health Com- mission of NSW, stated in part: Tamworth's water supply was fluoridated in 1963, and the last survey in the area was conducted in August 1979. It shows decay reductions ranging from 71 % in 15•year -olds to 95% in 6- year - olds.... All those surveyed were continuous residents using town water_ The "95 %" reduction actually correspon- ded to a reduction in DMFT from 1.3 in 1963 to 0.1 in 1979[ ", which is 92 %. The press release implied incorrectly that all this reduction was due to fluoridation. However, it has been claimed ever since Each capital city has the majority of the population of its state or territory. t That is, the percentage of population of state /territory which drinks fluoridated water. Data From Annual Reports of Director - General of Health, for example ref. 17. C tt L fr b b 0 rz 0 ti: W st P. 5� T ci A ci e, St dt a of tit of re Pr w' 1 Fi te: P, t (7 S" lai 19 flu wl of the to ha ag ea, is Table 2 Extent of fluoridation in Australia, 1977 and 1983 % Of state % Of state State or Year city fluoridatedt fluoridated i territory Capital city fluoridated" in 1977 in 1983 ACT Canberra 1964 100 100 Tasmania Hobart 1964 74 77 NSW Sydney 1968 81 81 WA Perth 1968 83 83 SA Adelaide 1971 71 70 Victoria Melbourne 1977 0.7 then 73 71 Queensland Brisbane Not 10 5 fluoridated Each capital city has the majority of the population of its state or territory. t That is, the percentage of population of state /territory which drinks fluoridated water. Data From Annual Reports of Director - General of Health, for example ref. 17. C tt L fr b b 0 rz 0 ti: W st P. 5� T ci A ci e, St dt a of tit of re Pr w' 1 Fi te: P, t (7 S" lai 19 flu wl of the to ha ag ea, is I )A6 )oral ,cur- I t ;ram. )ride uded n the rimes i city wined :fleets such lental lental paper con - d and i that gly to in the ) than :thical ;hould ne out Health m, one bodies sued a id' ;hlight- by the ntistry, I Com- dated in i rea was ,s decay , ear -olds ;urveyed -n water. respon- n 1.3 in %. The that all idation. t er since i state imedf 983 ater. Data NATURE VOL. 121- !0 1ULY 1986 the commencement of fluoridation that the maximum possible benefits from fluorida- tion are obtained in children who have drunk fluoridated water from birth. Six - year -olds would have done this by 1969, when, according to the published data15, they had a Dlvt FT index of 0.6. The further reduction in caries in optimally exposed 6- year -olds, observed in years following 1969, cannot be due to fluoridation. Thus, one can say that at best fluorida- tion could have approximately halved the DM FT rate in 6- year -olds between 1963 and 1969. (Since there was no control population, one could also say that at worst fluoridation might have had no effect in that period.) But from 1969 to 1979, caries in 6- year -olds was reduced a further 83 %, by some other factor(s) than fluoridation. Figure I shows that the unknown factors caused in children of each age from 6 years to 9 years similar large reductions in caries. Unfortunately, there are no published data for Tamworth beyond 1979 or in the years between 1972 and 1979, and so it cannot be confirmed whether the large reductions observed 11.15 from 1972 to 1979 in children aged 10 to 15 were also due to these unknown factors. A similar reduction beyond the maximum possible for fluoridation is observed for children of each age from 6 to 9 in the published data from Canberra 16, which cover the period from 1964, the stated year of fluoridation, to 1974. In particular, DMFT rates declined by 50% in 6- year -olds from 1970 to 1974 and by 54% in 7- year -olds from 1971 to 1974. These reductions in optimally exposed children cannot be due to fluoridation. Published post -1974 data are needed to check on further reductions in optimally exposed children aged over 9 years. From 1977 onwards, data have been systematically collected from the school dental services in each Australian state and territory"'. Table 2 shows the degree of fluoridation in each of these states /ter- ritories in 1977 and 1983 and also the dates of fluoridation of the capital cities of these regions. Each of these cities dominates the population of the state or territory in which it lies. The evidence presented in Fig. 2 and Table 2 suggests that states and territories which had been extensively fluoridated for at least 9 years before 1977 (Tasmania, Western Australia and New South Wales) had qualitatively similar large reductions in caries from 1977 to 1983 as a state which was only extensively fluoridated in 1977 (Victoria) and a state which had a small and declining fraction Of fluoridation (Queensland). Although the results of the school dental health sur- vey are recorded by age and state, the data have only been published9•`7''8 so far for ages 6 -13 averaged in each state, or for each age for the whole of Australia. There is evidence that the use of fluoride tooth- COMMENTARY x —x\ x c \ x m 3 Y �x 1977 78 79 8° 81 82 83 Year Fig. 2 Decline in the average number of (per- manent) teeth per child with caries experience in each Australian state and the Australian Capital Territory as observed in school dental services''. 'Caries experience' can be one or more decayed, missing or filled teeth, and con- sists of an average for children aged 6 -13 years. See Table 2 for information on the extent of fluoridation in each state /territory in 1977 and 1983 and the year when the main population centre of each state /territory was fluoridated. x, Victoria; d, Tasmania; •, Queensland; --- SA; , NSW; - -, WA; ACT. paste in Australia reached a high plateau around 1978, so these observed reductions in caries can be due neither to fluoride toothpaste' nor to fluoridated water_ It is to be hoped that similar data on caries reductions in 'optimally exposed" children will be sought in other fluoridated countries. In a region of Gloucestershire, United Kingdom where the main water supply was naturally fluoridated with 0.9 p -p.m. fluoride until 1972, reductions in canes of 51 % were observed in 12 -year- old children between 1964 and 1979t9. Factors other than fluoridated water must have caused these reductions. After 1972, the main water supply was drawn from a bore with less than 0.2 p.p.m. fluoride, so a recent survey of caries there would be of great interest. Benefits overestimated? In some fluoridated areas (for example Tamworth, Australia), temporal reduc- tions in caries have been wrongly credited to fluoridation. The magnitude of these reductions is similar in both fluoridated and unfluoridated areas, and is also gen- erally comparable with that traditionally attributed to fluoridation. Can it be con- cluded that communities which prefer not to fluoridate, either because of concern about potential health hazards2o -n or for ethical reasons (for example compulsory medication; medication with an uncon- trolled dose), do not necessarily face higher levels of tooth decay than fluori- dated communities? In other words, is it reasonable to ask whether it could be gen- erally true that a major part of the benefits 10 ON 127 currently attributed to fluoridation is really due to other causes? Such a hypothesis would seem to be possible in principle because it is well known that fluoridation is neither 'necessary' nor 'sufficient' (the words between inverted commas being used in the formal logic sense) for sound teeth; that is, some children can have sound teeth without fluoridation, and some children can have very decayed teeth even though they consume fluoridated water's. To confirm or refute the hypothesis, it is necessary (but not 'sufficient') to examine the absolute values of caries prevalence in fluoridated and unfluori- dated areas. If it is true that the absolute values of caries prevalence in some unfluoridated areas are comparable with those in some unfluoridated areas of the same country, then the hypothesis is sup- ported (but not proven), and there would be a strong case for the scientific re- examination of the epidemiological studies which appear to demonstrate large benefits from fluoridation. The earliest set of studies comparing caries in fluoridated and unfluoridated areas were time - independent surveys of caries prevalence in areas with 'high' natural levels of fluoride in water supplies, conducted by H. T. Dean and others in the United States''. The surveys purported to show that there is an "inverse relation- ship" between caries and fluoride con- centration. From the viewpoint of modern epidemiology, these early studies were rather primitive. They could be criticized for the virtual absence of quantitative, statistical methods, their nonrandom method of selecting data and the high sensitivity of the results to the way in which the study populations were grouped25. Results running counter to the alleged inverse relationship have been reported from time - independent surveys in naturally fluoridated locations in India', Sweden-g, Japan 29, the United States30 and New Zealand31.63. The Japanese survey19 found a minimum in caries prevalence in communities with water F- concentrations in the range 0.3 -0.4 p.p.m.; above and below this range, canes prevalence increased rapidly. These surveys27 -31 also selected their study regions nonrandomly. But recently Ziegelbecker32 attempted to make a selec- tion close to a random sample by consider - ing'all' available published data on canes prevalence in naturally fluoridated areas. His large data set, which includes Dean's as a sub -set, comprises 48,000 children aged 12 -14 years drawn from 136 com- munity water supplies in seven countries. He found essentially no correlation between caries and log of fluoride con- centration. The surveys27-32 are generally omitted from lists' of studies on the role of fluoridation in caries prevention. V V °n u 4 Age in years COMMENTARY Fig. 3 The variation with age of decayed, miss- ing and filled permanent teeth (DMFT) in fluoridated test towns (x) and unfluoridated control towns (0) in Britain, graphed from data published by the UK Department of Health 33. Note that the rate of increase of DMFT is essentially the same in both groups. Children in the fluoridated areas have an average only one less cavity than children of the same age in the unfluoridated areas. Further evidence can be drawn from Fig. 2. In 1983, the absolute value of caries prevalence in the Australian state of Queensland (which is only 5% fluori- dated) was approximately equal to that in the states of Western Australia (83% fluoridated) and South Australia (70% fluoridated). The classical British fluoridation trials at Watford and Gwalchmai were longi- tudinal controlled studies. In this regard they were better designed than the major- ity of other studies which have been con- ducted around the world. However, as in the case of almost all other surveys, the examinations were not 'blind'. The review of the British trials by the UK Department of Health after 11 years of fluoridation showed that children in fluoridated towns had approximately one less DMFT (that is, essentially one less cavity) than children of the same age in unfluoridated towns (see Fig. 3). The rate of increase in caries with age was the same in both popula- tion533 Thus there are a number of counter- examples to the widely -held belief that "All studies show that communities where water contains about I p.p.m. fluoride have about 50% lower caries prevalence than communities where water has much less than 1 p.p.m. fluoride ". At this point the empirical data presen- ted here may be summarized as follows. In the developed world: (1) there have been large temporal reduc- tions in caries in unfluoridated areas of at least eight countries; (2) there have been large temporal reduc- tions in several fluoridated areas which cannot be attributed to fluoridation, (3) the absolute values of caries preva- lence in several fluoridated areas are com- parable with those in several unfluoridated regions of the same country. Hence there is a case for scientific re- examination of the experimental design and statistical analysis of those studies which appear to prove or "demonstrate" that fluoridation causes large reductions in caries. Indeed the few re- examinations which have already been done confirm that there are grounds for concern. The original justification for fluorida- tion in the United States, Britain, Canada, Australia, New Zealand and several other English- speaking countries was based almost entirely on the North American studies, which were of two kinds. The limi- tations of the first set, the time- indepen- dent surveys conducted in naturally fluori- dated areas of the United States16, have been referred to above. The second set of North American studies consists of five longitudinal studies — carried out at Newburgh, Grand Rapids, Evanston and Brantford (two studies) —which commenced in the mid - 1940s. Only three of them had controls for the full period of the study. These studies were criticized rigorously in a detailed monograph by Sutton34, on the grounds of inadequate experimental design (for example, no `blind' examinations and inadequate baseline measurement), poor or negligible statistical analysis and, in particular, failure to take account of large variations in caries prevalence observed in the control towns. The second edition of Sutton's monograph contains reprints of replies by authors of three of the North American studies and another author, together with Sutton's comments on these replies. It is difficult to avoid the con- clusion that Sutton's critique still stands. Indeed, this was even the view of the pro- fluoridation Tasmanian Royal Com- mission35. Yet, in major, recent reviews of fluoridation, such as that by the British Royal College of Physicians 16, these North American studies are still referred to as providing the foundations for fluoridation, and Sutton's work 31 is not cited. NATURE VOL. 322 10 JULY 1996 An examination has just been comp- leted of the experimental design of all of the eight published fluoridation studies conducted in Australia. One (Tasmania) is a time - independent survey. Four (Townsville, Perth, Kalgoorlie and the second Sydney study) are longitudinal studies with only two examinations of the test group and either no control or only a single examination of a comparison group. The remaining three studies (Tamworth, Canberra and the first Sydney study) have several examinations of the test group, but no comparison group at all. Thus there has not been a single controlled longi- tudinal study in Australia. (M.D., to be published). Moreover, it has been shown above that three of the Australian studies (the first Sydney", Tamworth1 -" and Can - berra16) inadvertently provide evidence that some other factor(s) than fluoridation is /are playing an important role in the decline of caries prevalence. Hence the hypothesis that fluoridation has very large benefits requires re- examination by epidemiologists, mathe- matical statisticians and others outside of the dental profession. The danger of fail- ing to perform scientific research on the mechanisms underlying the large reduc- tions in caries discussed in this paper is that the strong emphasis on fluoridation and fluorides may be distracting attention away from the real major factors. These factors could actually be driving a cyclical variation of caries with time37. It is poss- ible that the condition of children's teeth could return to the poor state observed in the 1950s, even in the presence of a wide battery of F- treatments. Causes of caries reductions Many of the authors who reported the reductions in unfluoridated areas ac- knowledged that the explanation has not yet been determined scientifically "`"'. It is after all much easier to perform a study which measures temporal changes in the prevalence of a multifactorial dis- ease than to identify the causes of such changes. Nevertheless, the authors of some of these studies have speculated that impor- tant causes of the reductions which they observe might be topical fluorides3e.53 (such as in toothpastes, rinses and gels), fluoride tablets4 }8, school dental health programmes°, a lower frequency of sugar intake79, the widespread use of antibiotics which may be suppressing Streptococcus mutans bacteria in the mouth°i, the increase in total fluoride intake from the environment942, or a cyclical variation in time resulting from as yet unknown causes 37. The present overview has revealed that several of the studies contain evidence against some of these proposed factors. We have seen that the Brisbane stud Y3 and P M NA URE VOL. 312 10 JULY 1986 COMMENTARY the Dutch review'' suggest that fluoride tablets may not be important; the Sydney study', one of the British studiesi0 and the I Dutch review'' each provides evidence against fluoride toothpaste; and the Dutch review" found no benefit in their school I dental health education programmes. Although there is evidence that fluoride L toothpaste cannot be an important mechanism of caries reduction in some of the studies reported here, it must be stated C that, unlike the case of fluoridation, there t are also a few well- designed randomised e controlled trials which demonstrate sub - stantial reductions in caries from fluoride e toothpaste"'. Hence, the hypothesis can n be made that topical fluorides sometimes .s improve children's teeth, although they I- are not necessary. So topical fluorides may e comprise one of several factors contribut- e ing to the solution of the scientific problem e of explaining the reduction in tooth decay. Leverett62 has speculated that the caries n reductions in his smaller set of unfluori- dated locations may be due to "an increase in fluoride in the food chain, especially A from the use of fluoridated water in food 1- processing, increased use of infant for- te mulas with measurable fluoride content, c- and even unintentional ingestion of is fluoride dentifrices." This hypothesis can - In not explain the reductions in prefluorida- Jn tion Sydney", or those in unfluoridated sc parts of Gloucestershire which started in at the late 1960sto. The ingestion of fluoride is- toothpastes (and gets) by young children th is well documented and could account for in an intake of about 0.5 mg F- per day in 3e the very young". But the food processing pathway is unlikely to be significant in western Europe where there is hardly any 1 fluoridation, and infant formulas which are made up with unfloridated water will give only small contributions. Thus it appears that Leverett's hypothesis may at best be relevant to a minority of the studies listed in Table 1. Here, the working hypothesis is presen- ted that fluoridation and other systemic uses of fluoride, such as fluoride tablets, have at best a minor effect in reducing caries; that the main causes of the observed reductions in caries are changes in dietary patterns, possible changes in the immune status of populations and, under some circumstances, the use of topical fluorides. Indeed, a promising explanation is that the apparent benefit from fluorides is derived from their topical action. Then, since fluoridated water has a fluoride ion I concentration 10 -' times that of fluoride i toothpaste, its action in reducing caries is likely to be much weaker. It is known that immunity plays a role in the development of caries, as it does with other diseases. Research is currently in progress to try to develop a vaccine against caries" -17. None of the data pres- ented in the present paper provides evidence against immunity as a factor. Dentists often argue against changes in dietary patterns as a major factor, on the , grounds that sugar consumption has remained approximately constant in most developed countries over the past few decades. However, this is a simplistic argu- ment. First, crude industry figures on total sales of sugar in developed countries con- tain no information on the distribution of sugar consumption with age and time of day. The form of sugar ingested -for example in canned food, soft drinks or processed cereals -may also be important. Second, tooth decay is increasing together with increases in sugar and other ferment- able carbohydrates in the diet in several developing countries's• "9. This was also the case with Australian aborigines, even when their water supplies consisted of bores containing fluoride at close to the "optimal" concentration for the local cli- mateso,sl Third, there is more to diet than sugar. For instance, there is some evidence, even conceded occasionally by pro - fluoride bodies52, that certain foods which do not contain fluorides (for example wholegrain cereals, nuts and dairy products) may protect against tooth decay. So the whole question of the relationship between total diet and tooth decay needs much greater input from nutritionists and dietitians. Perhaps the real mystery of declining tooth decay is why so much effort has gone into poor quality research on fluoridation, instead of on the more fundamental ques- tions of diet and immunity. The main body of this research was performed while the author was a prin- cipal research scientist in the CSIRO Division of Mathematics and Statistics, Canberra. ❑ Mark Diesendorj is at the Human Sciences Pro- gram, Australian National University, GPO Box 4, Canberra ACT 2601. Australia, e�11. Murray,l. J.& Rugg -Gun.. A.J. Floodde -Cards Pre- &22, Tsutsui, T., Ide, K. & Maizumi, H. Murat. Res. 140, 43 -48 V 2. I- c-ett. D. H. Science 217, 26 -30 11982). O =' lion 2nd Edn (Wright, Bristol, 19821. (1984), rc,4). lam., P- h1. C., Anderson, R. J., Beal, J. F. & Bradnock, Ile 'yts 2. Kruger, B. 1. Aosr. J. Dent. S9.162-166 (1955). x6, 23. Tsutsui, T., Suzuki, N., Ohmort, M. & Maizumi, H., Molar. t G. Common. Dent .,at Eplde- 5, 67 -72 (1977). lC• X _ 3. N1c Eniery, T. M. & Davies, G- N Community Dem. oral Rrs. 139, 193 -198 (19841. 44. Ekstrand, J. & Ehmebo. M. Caries Res. 141,46-102 (19801; - £pidem. 7, 42 -50 (1979). sc4` 24. Tsutsui, T. Suzuki, N. & Ohmori, M. Cancer Res— 44, Ekstrand, J. & Koch, G., J. Dent Res, 59, 1067 .OE vV , 4. Lawson, 1. S., Brown, J. H- & Oliver, T. 1. Med. J. Aust 1, 938 -941 (1994). (119801. 41 124 -125 (1978). 1<i 25. Diesrndorl, M. Common. HIM Stud 4. 224 -231) ( 1980). 45. Lehner, T. R-ell, M. W. & Caldwell, J. Lancer i, 995 -997 'sCe 5. Burton, V. 1., Rob, M. V. Craig, G. C. & Lawson, J. S. X4 2 -6. McClure, 1-. 1. (ee.i Fluoride Drinking Waiters (US Depart- 119801. a Med. J. Aust 140, 405 -407 11994). mem of Health. Education & Wdfare. Public Health )"e46. McGhee, 1. R. & Michalek, S. M.. Am. Rea Mitrobiol 3S, ;es 6. Sutton, P. R. N..Nfed f Aust 141, 394 -395 11984). Service, Bethesda, Maryland, 1964). KK 595 -638 119811. i5- K, 4 7. Bamard, P. D. NHMRC Spec Rep. Set 8.30 -43 ( National )<i_17. Amrit, T. & Joshi, J. L. Conjere- let. Sac. F?--ride Res., 'j 47. Smith, G. E.. Trends pharmac. Sci. (in the presO. Health & Medical Research Council, Canberra, 1956). New Delhi, November, Abstr. 15 119831. 48, Newbrun, E. Science 217, 418 -423 (19821. ch ''S ,' S. Barnard, P. D., Clements, F. W. Int den,. f 26, 320 -326 28. fonman, B., Commun. dent Oml Elialem. 2 132 -148 ,6 49. Shciham, A. 1rte 1. Epidemiol 13, 142 -147 (1984). (19761. x11 (1974). X50. Barrest, M. J. & Williamson, 1. J. in Aust dent A 17, 37 -50 •'See 9. Carr, L. M. Aust. den,. J. 28. 269 -276 (19831. X -, 29. Imai, Y., Jap. J. Dent, Health 22. 144 -1% (19721. (19721. Of d 10. Anderson, R. 1., Bradnock. G. & James, P. M. C. Br. dent. Zimmermann, E. R., Leone, N. C. & Amold, F. A. J. Ant P�Kl. Brown, T. in Better Health for Aborigines (eds Heizel, B. J. 150, 278 -281 (1981). X30, med Ass. 50. 27 ?- 177 (1955). to al) 97 -101 (University of Queerrsland Press, Brisbane, ,A I. Kalsbeek, H. 1. dent. Res. 61 (Special Issuel, 1321 -1326 W a 31. Hewitt, R. E. T` N Zealand dent J. 4S, 157 -167 (19491. 19741. Bey 03 (1982). Ti 32. Ziagelbecker, R. Fluoride 14. 123 -128 (1981). K,52. Australian Nutrition Foundation, Dent. Outlook n(2).47- t` ?•V1'. Colquhoun, J. Community Dent Oral E P aiemiol 13, 37 -41 p/83. UK Dept of Health, Report No. 12 2, HMSO, Landon 51 (1985). S), i 198 5). (1 %9). r{ 53. Fejeaskuv, O_, Antoft, P. & Gadcllwd, E., L dent. Res. 61 Dental Health Education & Research Foundation, News V4134. Sutton, P. R. N. 1`7uoridattoi: Errors and Omissions in (Special Issue), 1305 - 1310(198'' -). Ith Release, Sydney, IS December 1980. Experimental Trials 22nd con (Melbourne Univmity >054, von der Fehr. F. R. 1. dent. Res. 61 (Special Issue), 1331 - ,ar `' N 14. Barnard, P. D. Dent. Outlook 6(4), 46 -47 (19801. Press. M(Ibournc, 1960). 1335 (19821.55. Mansion, B.. Holm, A. K., 011inen, 1. 'j E I5. Martin, N. D. & Barnard, P. D. Dent, Oudook no. 23, 6 -7 7, ?35. Report ojthe Rawl Commission in,. F7voridanon f Pubhe '4,55. Mattison, B.. Holm, A. K., 011inen, 1. & Grahnea, H. S,ved ics (May, 1970); no. 33, 2 -3 IMay, 1972); no. 41, 6 -7 Wow Supplies(Govcmment Printer, Hobart, Tasmania, dew.J 3.193 - 203(19791. cur (December, 1973). 19691, -ry 56. Andlaw, R. 1., Burchell, C. K. & Tucker, G. J. Caries Rea the 16. Cart, L M. Aust, dent. J 211. 440-"4.(1976). x' 36. Royal College of Physicians, F7aarrde, teeth and Health 16, 257 -264 (19821. IT. Auslratia,Di,.,,o..GeneraI of Health, AnnualRepori 1983- (Pitman Medical. London. 1976). zV57. Mainwaring, P. J. & Naylor, N. M. J dent Res. 60, 1140 th 84, Table 69 (1984); Annual Report 1981 -82, Table 66 F 137. Anderson, R. J., Bradnock, G. Bcal, J. F. & James- P. M. (1981)_ i (1982). Australian Govemment Publishing Servkx, Can. C J. dent Res. 61 (Special Issue), 1311 -1316 (1982), h 58 Mitropoulos, C. M. & Worthington, H- V. J. dent. Am 60, berra. 438. Train, G. J., Plasschatrt• A. J. M., Konig, K. G. & Vogels, o v 1154 (19811. Wn I9. Carr, L. M. A,su. dent. J. 27, 169 -175 (1982). A. L. M. Common. Dent oral Epidrm. 9, 55 -60 (1981). .)w 59. Downer, M. C. J. dent. Res 61, 1336 -1339 (1982).(3 c.Cy 19. Anderson, R, J. Br. dint f 150. 354 -355 (19911 39. Koch, G. 1. dent Rra 61 (Special Issue), 1340 -1345 �Voio. Palmer, J. D. Bi, dens. f 149. 48 -50 (1990). hat O( y,20. Rose, D_ & Marier, 1. R. Envimnmmozii Fluond,, 1977 (1982). "1. Anderson. R. J. Br dent J. 150.218- 221 (1981). (National Research Council of Canada, Ottawa, 1977). )'c 40. Glass. R. L Caries Res. li 415 -450 (19811 'Jt,62. Zaeherl, W. A. & Long, D. M. J. dent. Rex 58. 227 (1979). ice '9,r 21. Waldbott, G. L. Burgstahler• A. W. & McKinney, H. L. x911. De Paola, R F., Soparkar, P. M., Tavares. M., A)lukian Jr. V 63. Hewitt, R. E. T. & Eamcott, D_ F., Dental Caries in New Rvondalmn: the Great Dilemma (Caronado, Lawrence, M. & Peterson• H.. J, dent Ret. 61 (Special Issue , Zealand, pp. 75 -76, 79 (Medical Research Council of )rS. Kansas- 19781. 1356 - 1360(19821. New Zealand, 1955). Ind IF ., 10C .14 324 Research note Tooth decay trends in nonfluoridated and fluoridated countries 324 Fluoride 38(4)324 -325 Neurath November 2005 TOOTH DECAY TRENDS FOR 12 YEAR OLDS IN NONFLUORIDATED AND FLUORIDATED COUNTRIES C Neuratha Canton, NY, USA SUMMARY: Graphs of tooth decay trends for 12 year olds in 24 countries, prepared using the most recent World Health Organization data, show that the decline in dental decay in recent decades has been comparable in 16 nonfluoridated countries and 8 fluoridated countries which met the inclusion criteria of having (i) a mean annual per capita income in the year 2000 of US$10,000 or more, (ii) a population in the year 2000 of greater than 3 million, and (iii) suitable WHO caries data available. The WHO data do not support fluoridation as being a reason for the decline in dental decay in 12 year olds that has been occurring in recent decades. Keywords: Fluoridated countries; Nonfluoridated countries-, Tooth decay trends-, World Health Organization data. INTRODUCTION AND METHOD Tooth decay trends in nonfluoridated and fluoridated countries were studied by preparing graphs using the most recent World Health Organization data from national studies on 12 year old boys and girls.l The criteria required for inclusion of a country were: • a mean annual per capita income in the year 2000 of US$10,000 or more • a population in the year 2000 of greater than 3 million •suitable WHOcariesdataavailable. 9.0 , No countries with appropriate data were excluded. Countries were considered fluoridated when more than 40% of their population had fluoridated water containing about 1 ppm of fluoride and nonfluoridated when less than 10% of their population had such water. For clarity, the nonfluoridated countries were represented in two graphs. RESULTS Figures la, lb, and 2 show that the decline in dental decay in recent decades has been comparable in both nonfluoridated and fluoridated countries. DMFT 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Figure 1a Nonfluoridated countries 0.0 I 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 —Austria —Belgium Denmark -4 Finland x France . Germany • Greece —t Italy Figure 1a. Tooth decay trends, as indicated by the DMFT Index (Decayed, Missing, or Filled Permanent Teeth), for 12 year olds in eight nonfluoriciated countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Italy) using World Health Organization data. aAmerican Environmental Health Studies Project, 82 Judson Street, Canton NY 13617, USA. E -mail: cneurath @AmericanHealthStudies.org 325 Research note Fluoride 38(4)324 -325 November 2005 Figure 1b. Tooth decay trends, as indicated by the DMFT Index (Decayed, Missing, or Filled Permanent Teeth), for 12 year olds in eight nonfluoridated countries (Japan, The Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, The United Kingdom) using World Health Organization data. Figure 2. Tooth decay trends, as indicated by the DMFT Index (Decayed, Missing, or Filled Permanent Teeth), for 12 year olds in eight fluoridated countries (Australia, Canada, Hong Kong, Iceland, Israel, New Zealand, Singapore, The United States of America) using World Health Organization data. lOC Tooth decay trends in nonfluoridated and fluoridated countries 325 Neurath 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 ies 0.0 i 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 —• —Japan a -Netherlands Norway Portugal O Spain -+— Sweden —a— Switzerland - UK 9.0 DMFT Figure 2 8.0 Fluoridated countries 7.0 s.o 5.0 DISCUSSION 4.0 X `lr ► The World Health 3.0 ° Organization data on dental X decay trends in 12 year olds in 2.1 X 24 countries do not support 10 ` fluoridation as being a reason ° for the decline in dental decay o.o that has been occurring in 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 recent decades. -4P-Australia New Zealand --*-Ireland united States -{- Canada X Israel Hong Kong ■ Singapore REFERENCE I WHO Oral Health Country/Area Profile Programme. WHO Headquarters Geneva, Oral Health Programme (NPH), WHO Collaborating Centre. Malmo University Sweden [homepage on the Internet]. Geneva and Malmo: WHO Oral Health Country/Area Profile Programme; [updated 2005 June; cited 2005 Nov]. Oral health profiles for countries listed according to WHO regions [about 7 screens]. Available from: http: / /www.whocollab.od.mah.se /expl /regions.htmi Copyright © 2005 International Society for Fluoride Research. www.fluorideresearch.org Editorial Office: 727 Brighton Road, Ocean View, Dunedin 9051, New Zealand. V The Globe and Mail: Flouridation may not do much for cavities Page 1 of 3 10C 0 April 15, 2010 ' ouridation may not do much for caNitics By MARTIN MITTELSTAEDT From Friday's Globe and Mail The province's widespread fluoridation appeared to offer little advantage over treatment -wary Quebec When it comes to fluoridating drinking water, Ontario and Quebec couldn't be further apart. Ontario has the country's highest rate of adding the tooth - enamel- strengthening chemical into municipal supplies, while Quebec has one of the lowest, with practically no one drinking fluoridated water. But surprisingly, the two provinces have very little difference in tooth -decay rates, a finding that is likely to intensify the ongoing controversy over the practice of adding fluoride to water as a public health measure. Quebeckers have more cavities than people in Ontario, but the difference is slight. Among children 6 to 19, considered the most decay -prone part of the population, the rate in Ontario was lower by less than half a cavity per child. In the 6 -11 age group, Ontario kids have 3.5 per cent fewer cavities than those in Quebec: 1.7 cavities compared to 1.76 in Quebec. In the 12 -19 age group, Ontario youths have 15.8 per cent fewer cavities than those in Quebec: 2.35 cavities compared to 2.79. Details of the cavity rates in the two provinces have been compiled by Statistics Canada in a study it conducted recently into the health status of Canadians. Experts peered into the mouths of more than 5,000 Canadians from 2007 to 2009, tallying the number of cavities and teeth with filings, to try to get an idea of the state of oral health of the nation. After a request from The Globe and Mail for a breakdown of the cavity rates by province, Statistics Canada tabulated the figures for Ontario and Quebec, where it said it had a sufficient number of people to be a representative sample. Statscan said it couldn't compile meaningful data for British Columbia and Alberta, which are in a similar situation. British Columbia has practically no one drinking fluoridated water, while nearly three - quarters of Albertans rely on municipal supplies where the chemical is added. The paper sought the information to see what light it would shed on the effectiveness of fluoridation, which has been touted by the U.S. Centers for Disease Control and Prevention as one of the top 10 great public health achievements of the 20th century, and is endorsed by all dental associations in the country and by Health Canada. http: //license.icopytight.net /user /viewFreeUse .act ?fuid= MTM4MTkwOTE %3D 9/6/2011 The Globe and Mail: Flouridation may not do much for cavities Page 2 of 3 10C But the results showed that if fluoridation is the only major difference between the two provinces, the chemical is preventing fewer than half a cavity per child in Ontario. Health Canada down played the significance of the findings. "While accurate," the data on the children are "an incomplete picture of the tooth decay situation.... [and] cannot be used to form conclusions regarding the efficacy of fluoride use in water," Health Canada said. The federal department said firm conclusions can't be drawn from the Statscan survey because it didn't collect assessments on individual intakes of the chemical. To make a proper assessment, Health Canada said it would need detailed information on whether people in the two provinces differ in their intake fluoride supplements, drink tap water or bottled water, and use fluoridated toothpaste. But fluoridation is one major and obvious difference between the provinces. More than three - quarters of Ontario residents live in areas where municipal water supplies contain the chemical. In Quebec, 94 per cent have water free of the additive, according to figures published by Health Canada in 2007. Since then, Quebec City has voted to stop fluoridating, indicating that the difference between the two provinces is currently even more pronounced. Some critics of fluoridation say the survey does raise questions about the practice. "Fluoridation is no longer effective," contends Hardy Limeback, head of the preventive dentistry program at the University of Toronto, who says adding the chemical to water is "more harmful than beneficial." Although fluoridation is touted as an unalloyed benefit by public health agencies, which estimate it cuts cavity rates by 20 per cent to 40 per cent, many community groups have sprung up across Canada lobbying to stop the practice, which is subject to repeal by local referendums. Some health professionals are worried fluoridation may have under - appreciated risks. While fluoride toughens the outside of teeth to make them more resistant to bacteria - causing decay, a number of medical journal studies have linked exposure to altered thyroid function, and to reduced IQ levels in children, although the intellectual impairments were found at levels of the chemical in water well above those used for municipal supplies. The most worrisome study, by Harvard researchers, appeared in 2006 in the journal Cancer Causes and Control and found that boys aged 7 exposed to high levels of fluoridated water were about four times more likely to develop childhood osteosarcoma. It's a rare bone cancer that felled Canadian icon Terry Fox and almost always leads to amputations. There has also been a worldwide reduction in cavity rates, regardless of whether countries use the chemical, suggesting factors other than adding it to water supplies are at work. One theory is that most people are already getting adequate exposure to fluoride through toothpastes, so the amounts in water aren't making much difference in tooth decay rates. "The parallel reduction in caries [cavities] incidents in countries with a lot of fluoridation and countries with not much fluoridation is quite dramatic," says Warren Bell, former head of the Canadian Association of Physicians for the Environment, a group that questions the practice. Dr. Limeback said factors that might be preventing caries include increased exposure to vitamin D, better oral hygiene, less sugar consumption, and even antibiotics. When fluoridation started 60 years ago, doctors thought swallowing the chemical was beneficial by strengthening teeth from the inside out. Dr. Limeback said more recent research shows that if there is a benefit, it is from the topical application of fluoride to the surface of teeth, which suggests that brushing with a toothpaste is more effective than drinking water containing the chemical. http: //license. icopyright. net /user /viewFreeUse. act ?fuid= MTM4MTkwOTE %3D 9/6/2011 The Globe and Mail: Flouddetioo may not du much for cavities Page 3 of 3 ° The Globe and Mail mc Ali Rights Reserved- Permission granted for ovto5oop�o All �g�o�sa�ed. You may mnaumm�mmc�org�auox�na|pvnn��uoohy�p|n0/=°"°� mwanywmuum�aecn�Gwueynu��o'|ncamuToeSmue�nu�axmgosu��Oute�uo�uemamso/rho�mu*anummii'|nc7xe /copyn&m logo isa registered trademark n[iCopvnym.inc. http://license.icopyiight.net/user/viewFreeUse.act?fuid=MTM4MTkwOTE�/�3D 9/6/2011 Calgary: Fluoridated water is ineffective, unsafe and unethical Page 1 of 2 .>tr n Meeting Date tem O FLUORIDE ACTION _ r NETWORK �, HOME FLUORIDE DANGERS TAKE ACTION NEWS ARCHIVE VIDEO ABOUT FAN FAQ DONATE TODAY L 4rr/o FAN's FREE Newsletter. Join the fight to get our water clean! Enter email address Submit Quen v bk1 Cal uoridated water is ineffective, unsafe and unethical eet o print tlus pw,, Calgary Herald 01/22/2011 Calgary: Fluoridated water is ineffective, unsafe and unethical By Dr. James S. Bed_ ames S—.—B--ecTis a physician and biophysicist (M. D., PhD) and professor emeritus of Medical Biophysics at the University of Calgary. Dr. Beck is the co- author of The Case Against Fluoride, published in September 2010. See original article Calgary is awash in fluoridated water and an intense discussion of it. The issue of fluoridation will be before the city's Standing Policy Committee on Utilities and the Environment. Part of that meeting will be the public consultation mandated by city council. The committee will make a recommendation to council for a decision to stop or continue fluoridation. The decision on fluoridation should rest on the answers to three questions: -Does fluoride in drinking water prevent cavities_ Is fluoride in drinking water safe? -Is adding fluoride to tauter ethical? We have one simple observation and three kinds of population studies to judge by. The simple observation is the striking fall in cavities over the past five decades to the same degree in countries not fluoridated as in countries fluoridated. The population studies compare two large groups, like people of two cities, one fluoridated and the other not; compare one city, in a period before fluoridation is started to the same city after fluoridation began; compare a city that has been fluoridated with the same city after fluoridation has stopped. None of these three experimental designs has shown that fluoridation of the water supply is associated with a lower incidence of cavities. The four large studies of the first kind started in 1945 and are often cited as evidence of effectiveness of fluoridation, but in fact none of them actually did so. Some studies have been said to show that fluoridation is effective, but even those show only very little benefit, if any. One of the better studies, of 39,000 children, found that there was on average six - tenths of a tooth surface less with a cavity in the children with fluoridated water than the children with non - fluoridated water. There are some 128 tooth surfaces in a mouth. Similar studies looking at surfaces showed a lesser benefit or no benefit. It should be noted that these studies did not include in their analyses the well supported fact that fluoride delays eruption of teeth. That is, the teeth come through the gums later. So the teeth of drinkers of fluoridated water are exposed later and less time at a given age then in drinkers of non - fluoridated water. This could well explain a small difference. The second question is more difficult to answer for some effects than for others. And in all cases we won't see an effect unless we look for it, something not often done in countries where fluoridation is practised. And what is found will depend on the dose of fluoride a population gets. A critical uncertainty in fluoridated communities is dosage. The dose is the quantity of the drug swallowed per day, say. The dosage, which is the important thing, is the quantity of the fluoride swallowed per day per unit body weight. With fluoridation the concentration in tap water is controlled. The dose and the dosage are not controlled and will inevitably vary hugely. Athletes, construction workers, diabetics for three examples will drink much more water than persons doing sedentary work in air - conditioned offices. Another problem in looking for health effects is the fact that humans vary in their reactions to drugs. httD: / /www.fluoridealert. org /AlertICanadalAlbertalCal2arv- Fluoridated- water- is- ineffectiv... 9/13/2011 Calgary: Fluoridated water is ineffective, unsafe and unethical It is quite Gear that there are large subsets of large populations that are at greater risk when exposed to fluoride. About half of the fluoride we swallow is excreted through the kidney. People with kidney disease don't excrete it as well. Pagelo� What is not excreted, about half in people who are well, is accumulated in the body, mostly in bone, throughout our entire lives. There is substantial evidence that a higher rate of hip fracture among the elderly is associated with concentrations not much greater than that in fluoridated cities in North America. Associations of fluoridated water with impairment of thyroid function, adverse changes in the cardiovascular system, adverse effects on the development of the reproductive system, on the development of the brain, and on the kidneys have been reported from systematic studies published in peer- reviewed papers in reputable scientific journals. There are hundreds of such papers. An example is the 24 papers about lower IQ by 5 -10 points, in children drinking well water with fluoride levels only slightly higher than what we have in Calgary and with higher levels in the blood. The one adverse effect of fluoridation that is agreed on by proponents and opponents is dental fluorosis. This in its mildest form is a white mottling of the teeth, but it can progress to severe mottling and brown lesions, pitting and fracture. Proponents often dismiss the milder forms of dental fluorosis as an unimportant cosmetic effect, a level of adult arrogance a teenager may find hard to take. The Centers of Disease Control and Prevention in the United States recently reported incidences of dental fluorosis as high as 41 per cent in certain age ranges in that country. The third question is a matter of medical ethics. It is clearly unethical to administer a drug (fluoride as used in water fluoridation is a medication as judged by common sense and court rulings in Canada and the United States) without control of dose, without monitoring by a qualified professional of the effects on the individual taking the drug or without informed consent. Informed consent means consent given by the individual after consultation with a qualified professional who explains the purpose of the drug and its possible side- effects. On all these grounds fluoridation is unethical. It is forced on uninformed people, without monitoring, without control of dose and often to people who object to it. © Copyright (c) The Calgary Herald back I top Fluoride Dangers FAN Sources of Fluoride Dental Fluorosis Other Risks of Fluoride Fluoride's Benefits? Copyright 2007 -2011 Email Fluoride Acton Network News Archive Join the tight to get our water, clean Subscribe to FAN's FREE Newsletter and get the Latest Bulletin Updates Enter email address Contact the Fluoride Action Network: info @fluoddealert.org http: / /www.fluoridealert.orglAlertI CanadalAlbertalCalgary- Fluoridated- water -is- ineffectiv... 9/13/2011 State's dental disaster begins at a tender age I Health I Kentucky.com Pagel of 3 10C State's dental disaster begins at a tender age By Sarah Vos --- svos@herald- leader.com Posted: 12:00am on Nov 9, 2008; Modified: 3:05am on Nov 9, 2008 JENKINS --- Dr. Nikki Stone received her patients in the gym. Her lap formed half the dental chair and an assistant's made the other half. On this October morning, there was a 4- year -old whose two front teeth were rotting, a 3- year -old with six cavities, and another 4-year -old with 10. It's not unusual for Stone to see preschoolers with cavities in all 20 teeth. "These are the kids who haven't been to the dentist at all," Stone said. Stone brings dental care to Head Start preschool programs in four Eastern Kentucky counties. Her work provides a snapshot of how early Kentuckians' dental problems start, how much they hurt the state and its children, and how much more needs to be done. Last fall, almost 60 percent of the 418 children Stone saw at dead Start programs in Letcher, Ferry, Leslie and Knott counties had cavities. Twenty percent had urgent needs -® more than six cavities, pain or infection. Even in a state with measurably bad teeth — Kentucky regularly tops the list of states with the most toothless adults — the high rates of decay are notable. "We're finding lots of disease, little treatment," said Dr. Raynor Mullins of the Center for Oral Health Research at the University of Kentucky; which sponsors the program.. "And we're beginning to understand the magnitude of the problem." Treating kids with urgent needs isn't easy. It requires an operating room and anesthesia and costs $5,000 to $10,000. But not treating them is worse. Kids with tooth decay have a hard time learning. They can't concentrate because of the pain, and they miss class often. Decay in baby teeth can transfer to adult teeth when they come in. In the most severe cases, decay can lead to serious infections and even death. Ear too many urgent cases As the children put their heads in her lap; Stone told them to open their mouths as big as an alligator. She promised the girls that she'd make their smiles sparkle like princesses'. Her voice was high - pitched, a sing -song happy sound as she examined their teeth with a flashlight and then cleaned them with electric toothbrushes decorated with Elmo and Cookie Monster. The kids take those toothbrushes home. Stone wants the experience to be fun for the children. She doesn't force the ones who are scared. She lets them watch their friends and see how painless a dental exam can be. Wben Jacob Barnett, 4, put his head in her lap, Stone's voice dropped. "Urgent," she said to the dental hygienist and the dental assistant who helped her. Jacob's two front teeth were brown with decay and one of them was half -gone. Inside his mouth; she found five more obvious cavities and four teeth with white spots, It's unlikely that Jacob's two front teeth can be saved, Stone said later. They'll have to be pulled, leaving hire with a gap - toothed smile until his adult teeth grow in, http://www.kentucky.com/2008/11/09/58593 I /states - dental - disaster- begins.html 9/8/2011 State's dental disaster begins at a tender age I Health I Kentucky.com �au@C- of 3 On this morning; there are several kids who already have had four front teeth pulled. Pulling teeth gets rid of the decay, but it's an imperfect fix. Baby teeth hold space for the adult teeth, said Judy Skelton, a professor at the Center for Oral Health Research. Without them, it's more likely that the adult teeth will be crowded when they come in and the child will need orthodontic work, she said. In the meantime, the missing teeth make it hard for the children to speak clearly and eat. Fluoride helps, but not enough At the end of the exam, Stone applies a fluoride varnish that she tells the children tastes like a cherry Popsicle. The varnish coats the teeth, protecting them and re- mineralizing soft spots in the enamel. It's the one treatment she can offer kids in the makeshift dental office she brings to the preschools. The problems she finds are noted in reports sent out to parents. The Head Starts contact the parents in the most urgent cases to help them schedule appointments. But even with that help, many of the children don't get the treatment they need. Last year: 78 kids had urgent needs, but only six had all of their problems taken care of, Stone said. Eleven other kids had one or two fillings done, but the majority did not have any work done at all. The fluoride varnish helps some. Stone has seen white spots, precursors to decay, and even small cavities disappear between visits. She hopes that the fluoride, given often enough, will stave off future cavities, But the kids with the worst teeth, those classified as urgent, grow cavities -- an average of four per child in six months, Stone said, One child had 14. Cavities can be contagious Tooth decay can be prevented, but for children like Jacob, it's challenging. The bacteria that cause decay can be passed from one person to another. Young children who have multiple cavities usually have a caregiver who has tooth decay, The more active cavities the caregiver has, the more cavity - causing bacteria lives in their mouths, and the more opportunity there is to transfer it to the child, said Dr. Evlambia "Betty" Harokopakis- Hajishengailis, a professor at the University of Louisville School of Dentistry. Diets high in sugar and carbohydrates, frequent snacks and a lack of dental care contribute to the problem, creating an environment where the bacteria thrive. To prevent decay, these children have to be identified before their first teeth come in, said Harokopakis- Hajishengallis. And their parents have to have their problems treated as well. But the children Stone sees are unlikely to visit the dentist. If they do, it's for an emergency — a painful tooth that has to be pulled — and they tend not to return to have other cavities addressed, Stone said. Part of the problem is that many of the children don't have dental insurance, and their families can't afford to pay for a dental visit. Stone said. In addition, their lives and those of their caregivers are focused on survival. They move often, their phones are disconnected, or they might not have a car to get to appointments, Stone said. Dental care and baby teeth aren't seen as important, In addition, traditional dentists are reluctant to treat very young children, making it hard to find a dentist in the first place. And there are only a few pediatric dentists in Eastern Kentucky, http-//www.kentucky.com/2008/11/09/58593 I /states - dental - disaster- begins.html 9/8/2011 State's dental disaster begins at a tender age I Health I Kentucky. corn 1 [JeCof 3 Stone started going to the Head Starts three years ago as part of an outreach program at UK's Center for Excellence in Rural Health in Hazard. At first; she was so overwhelmed by what she found that she wondered whether the fluoride treatments would work. Navy, having seen some improvement, she tries to give fluoride treatment to everyone. even the babies who cry. "If we can even swipe a little fingerful in there, then we do it, because we know it's making a difference," Stone said. "It's at least molding it at bay." Fj http://www.kentucky.com/2008/11/09/58593 I/states-dental-disaster-begins.htmI 9/8/2011 Kentucky rates second in U.S. in poor oral health - Advances & Insights - UK HealthCare 1P 1�4 tMealthCaret, June 30, 2008 Kentucky rates second in U.S. in What the news prior oral health meallis for you The Centers for Disease Control and Prevention (CDC) ranks Kentucky as the state with the second highest missing teeth rate, falling only a few percentage points behind West Virginia. In an effort to promote better dental health, in July 2007 Kavita R. Mathu -Muju, the Kentucky Cabinet for Health and Family Services DMD, MPH began encouraging physicians to administer topical Pediatric Dentistry fluoride varnish to the teeth of Medicaid - eligible children through age 4. Studies show the fluoride varnish helps Keeping children's teeth strong and prevent early childhood caries (tooth decay) in young healthy children. The application of fluoride varnish at a child's first Fluoride works primarily after teeth have birthday or first tooth eruption will help reduce future erupted into the mouth. It is most critical disease and lessen the occurrence of decay. for infants and children between the ages of 6 months and 16 years to be exposed Tooth decay in children to the proper levels of fluoride. In children, Often referred to as baby bottle tooth decay, decay in when teeth are still forming, fluoride helps infants and children can destroy the teeth. It occurs when to make tooth enamel harder and more sweetened liquids such as milk, formula and fruit juice are resistant to acid and thus decay. left on an infant's teeth for long periods of time. The sugar becomes food for bacteria in the mouth, producing acids " Flitoride ... is that attack the teeth. most Critical for infants acid children bet.%veeii the ages The American Dental Association recommends the of 6 unonths and 16 years." following to prevent tooth decay in infants. • After each feeding, wipe the baby's gums with a clean gauze pad. Begin brushing your child's teeth when the first tooth erupts. Clean and massage gums in areas that remain toothless, and begin flossing when all the baby teeth have erupted, usually by age 2 or 2'/2. • Never allow a child to fall asleep with a bottle containing milk, formula, fruit juice or sweetened liquids. In an effort to ensure that children get the proper levels of fluoride, primary care pediatricians at UK under the leadership of Dr. Kimberly Northrip and with the support and assistance of the UK Division of Pediatric Dentistry have begun applying topical fluoride varnish as part of well -child visits to help deal with the issue of so many Kentucky children with early childhood caries. ,t http: / /ukhealthcare.uky. edu /publications /A Vpedi atrics /fluoride. asp 9/8/2011 Kentucky rates second in U.S. in poor oral health - Advances & Insights - UK HealthCare Page 2 of 4 10C • If a child needs a comforter between regular feedings, at night or during naps, give the child a clean pacifier recommended by your dentist or physician. Never give a child a pacifier dipped in any sweet liquid. • Avoid filling a child's bottle with liquids such as sugar water and soft drinks. Adults benefit from fluoride, too. Topical fluoride from toothpaste, mouthwash or fluoride treatments from the dentist not only helps strengthen teeth as they develop but also helps repair tooth decay in early stages before it becomes visible. • If your local water supply does not contain fluoride, ask your dentist how your child should get it. f=luoridation for Kentucky water • Start dental visits by the child's first birthday. Make sources visits regularly. If you think your child has dental As the research on fluoride in the water problems, take the child to the dentist as soon as indicates, fluoride can be hazardous at possible. high doses. However, fluoride is very safe and effective when used as directed. The Fluoride and fluoridation optimal level of fluoride in the water is 0.7 Fluoride is a naturally occurring mineral found as a to 1.2 parts per million. constituent of minerals in rocks and soil. When rainwater flows over and through the rocks and soil containing The report also recommends drinking fluoride, it dissolves the compounds, resulting in small water contain no more than 2 mg /L of amounts of soluble fluoride in water sources. In most fluoride to protect against cosmetic dental areas, this small amount of fluoride is not enough to effects linked to excess fluoride provide dental benefits, so communities add more fluoride consumption. However, even at this level, to public water supplies in a process referred to as less than 10 percent of the population fluoridation. experiences cosmetic effects. The cosmetic effects of excess fluoride range Most of the wafer that Ainericans drink from slightly noticeable white streaks or contains the recommended amount of spots to more noticeable brown fluoride. discoloration. Known as fluorosis, these defects are most often associated with According to the CDC, fluoride from many sources high levels of naturally occurring fluoride prevents tooth decay. Fluoride can be applied directly to found in well water. teeth through toothpaste, mouth rinses, professionally applied fluoride treatments (such as the fluoride varnish Fluoride basics mentioned above) and dietary supplements prescribed by Fluoride is a mineral that occurs naturally a dentist, physician or other health professional. The in foods and water. It is also often applied widespread availability of fluoride via water fluoridation, directly to the teeth in the form of toothpaste and other sources has resulted in the steady toothpaste or mouthwash that contains decline of dental caries throughout the United States. fluoride. When you visit the dentist, you may get a fluoride treatment in the form of Although some people oppose fluoridation of drinking a gel, foam or varnish. Fluoride helps to water, it is endorsed by the American Dental Association, prevent the development of cavities. the American Medical Association and the World Health Organization, as well as numerous other prestigious Throughout the day, an acid is formed in medical organizations. your mouth from sugars and plaque bacteria. That acid can cause tooth decay Too much fluoride can harm teeth by breaking down the enamel layer on the Despite its benefits, fluoridation can be harmful if teeth, a process called demineralization. overdone. A March 2006 report from the National Our mouth fights tooth decay with http: / /ukhealtheare.uky. edu /publications /AI /pediatrics /fluoride. asp 9/8/2011 Kentucky rates second in U.S. in poor oral health - Advances & Insights - UK HealthCare Research Council found that the U.S. Environmental Protection Agency's standard for the maximum amount of fluoride allowed in drinking water, 4 milligrams of fluoride per liter of water, is too high. At concentrations of 4 mg /L, children are prone to develop severe tooth enamel fluorosis, a condition that causes loss of enamel, discoloration and pitting of the teeth. In 1962, the Public Heath Service recommended that public water supplies contain between 0.7 and 1.2 milligrams of fluoride per liter in an effort to help prevent tooth decay. Most of the water that Americans drink contains the recommended amount of fluoride (0.7 to 1.2 mg /L). Public water in Kentucky According to the CDC, Kentucky ranks number one among U.S. states with 99.8 percent of its population receiving fluoridated water. A few rural areas do not have community water fluoridation, but fluoride dietary supplements can provide fluoride to those who do not have adequate levels in their drinking water. minerals such as fluoride and calcium in our saliva. These minerals are deposited, in a process called remineralization, on the teeth, making them more resistant to acid attacks by interfering with the bacteria's ability to adhere to teeth. The fluoride from saliva is incorporated into the enamel and makes a stronger crystallite. Proper fluoridation of community water supplies increases the amount of fluoride in our saliva and in turn the fluoride interferes with bacteria sticking to teeth resulting in stronger enamel and teeth that are more resistant to bacteria. If your community water does not contain fluoride and if your children have a history of tooth decay, I recommend parents buy water with fluoride in it. If children do not have a history of dental decay, then with proper dental health (dental checkups, proper dental hygiene and limited sticky sugary snacks) purchasing water with fluoride is not necessary. Maintaining good dental health begins in infancy For children under the age of 1, we recommend breast milk as the number one choice for feeding. If a child is formula fed, you should not use tap water, but rather bottled water with no fluoride added. Similar to a well -baby visit, a child should come for their first dental visit at age 1. The dentist will help teach parents what they should know to help their child prevent cavities. We may also recommend a fluoride varnish at that time to help prevent tooth decay. At the UK Division of Pediatric Dentistry we have children age 2 to 4 that we have to take to the operating room to have multiple teeth crowned. Typically, it is for Page 3 of 4 10C http: / /ukhealthcare.uky. edu/ publications /Al/pediatrics /fluoride. asp 9/8/2011 Kentucky rates second in U.S. in poor oral health - Advances & Insights - UK HealthCare a combination of reasons including inappropriate feeding, poor oral hygiene and little or no access to preventive dental care. To prevent tooth decay, parents should begin flossing their children's teeth as soon as the child has back teeth that touch. This could be as early as age 3. In children, the most significant action you can take to prevent tooth decay is to brush at least 2 minutes twice a day. Children over the age of two should use fluoride toothpaste while children under 2 years of age should use non - fluoride toothpaste. Always choose a toothbrush with soft bristles, as the hard bristles can be very damaging. As long as the plaque is removed, both manual and electric toothbrushes are good. I recommend replacing your toothbrush every three to four months. Food intake also becomes very important to prevent tooth decay in children. Try to limit sugary snacks to mealtime only. The most damaging kind of snack is sticky and sugary, such as gummy bears, raisins and dried fruit. If your child eats these types of snacks, bite -size is best. It is also important to limit juice to four to six ounces per day.a Dr Mathu_M� is i� ,�Jediatric dtentist aria an assistar:t Profc -ssor of dentl t ?y al the UK C�!Iege of Der)Vstry,. "e" interests in: i.,de Public health dE; r7ti5tt p' .. Page 4 of 4 10C http - / /ukhealthcare.uky. edu /publi cations /Al/pediatrics /fluoride. asp 9/8/2011 J,%tr0 cr4r- UNITED STATES ENVIRONMENTAL PROTECTION AGENCY ' WASHINGTON, D.C. 20460 ��� anotFF' tiR 3 0 1983 OFFICE OF wnTC H Leslie A. Russell, D.M.D. 363 Walnut Street Newtonville, Mass. 02160 Dear Dr. Russell: Thank you for your letter of March 9, 1983, in regard to t!-:e fluoridation of drinking water. The information available to the Environmental Protection Agency is that fluoridation is a safe and effective means for reducing the occurrence of dental caries. The fluoridation process has been endorsed by several Presidents of the United States and by several Surgeons General, including the current Surgeon General, Dr. C. Everett Koop. A copy of Dr. Koop`s statement on fluoridation is enclosed. Water treatment chemicals, including fluosilicic acid, have been evaluated for their potential for contributing to the contamination of drinking water. The Water Treatment. Chemicals Codex, published by the National Academy of Sciences, prescribes the purity requirements for fluosilicic acid and other fluoridation chemicals. In regard to the use of fluosilicic acid as a source of fluoride for fluoridation, this Agency regards such use as an ideal environmental solution to a long- standing problem. by recovering by- product fluosilicic acid from fertilizer manufacturing, water and air pollution are minimized, and water utilities have a low -cost source of fluoride available to them. I hope this information adequately responds'to your concern. SO_)erely yours, Rebecca Hanmer Deputy Assistant AdministraLor- for Water. Enclosure IOC Sep 12 2011 1:29PM Richard J. Garcia, D.M.D. 239- 455 -4439 page 09/27/2007 00:44 239 - 394 -9274 DR.WELKER 01023 P.001/001 1 Sep OL 2011 2:27PIt Richard J. Garcia, D.M.D. 238- 455 -4438 page i CCDA ALERT ALL DOCTORS, RDHp STAFF ' Y PLEASE PLAN ON ATTEN DING, WE NEED YOUR SUPPORT Board of Collier County Commkoomn meedrs Daft., sept"nbar 20. 2013 • Tuna *Mpm t aa#ias: The Cmnmwon channbas- lawred w the third Floor of VWAdariiniVf tian &OCOn0 at 3301 Lust Tanuami Tray Subject; The Comnttssion wfM vote are wheMerto kW f&wide In our drinking mWer, or tad remora it. The C= sappm is keeping JkwMe M our d RAft voter. Aix l i • �. r I r._ t •ls PLEASE SIGN ASOVE, TEASE SIGN ABODE if my questions call Dr. Garcla 4554M98.or or. Mr le m.2544480 Agenda !tem #: !'U `_ Meeting gate . •? /. ,i Presented by: s� -'cJ�_ , re s l 09/11/2011 19:50 2399923364 HOLZINGER "-CN vl Cu.11 1d :,gHF'M Rirf+ard j. Garcia, D -M.D. 239 -455 -4439 CODA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date- September 13" , 2011 Time: 4:00pm Location: The Gommisslon Chambers - located on the third Floor of the Administration Building at 3301 fast Tamiami Troll. Subject; The Commission will vote on whether to keep fluoride in our drinking water, or to remove it: The CCDAsupport$ keeping fluoride in our drinking water. IF YOU OR ANY OF Y UR STAFF A, IRE UNABLE TO ATTEND P E +E NDICATE YOUR SUPPORT AN. A FAX PAICK TO 155-4439 OR 254 -9575 l 41 M PAGE 01/01 page 1 10 T'' W If any questions call Dr. Garcia 455 -N898 or dr. PH E 2544480 sep.10.2011 05:58 PM 239 394 9153 239 394 1004 Sep 01 2011 2:07PM Richard J. Garcia, D.M.B. 239 - 455-4439 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13*0 2011 Tsrne: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building of 3302 East Tamlomi Trail. Subject: The Commission will vote an whether to keep}iuoride in our drinking water, or to remove it. The CODA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YQUA STAFF ARE UNABLE TO ATTEND PLEAS.g INDICATE YOUR SUPPORT ANR EAS BACK TO 455 -4439 OR 2548575 .r; PLEASE SIGN A30VE j5UEPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE I. SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN A /BnOVE I SUPPORT KEEPING FLUORIDE IN �- PLEASE SIGN ABOVE O 15UP.POftT KEEPING FLUORIDE IN QUR WATER PLEASE SIGN ABOVE If any, questions call Dr. Garcia 455 -0898. or Dr. Prlmero 2544480 PAGE. 1/ 110 C page 1 A 10C CCDA ALERT ALL DOCTORS, RDH, STAFF CT PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13th, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building at 3301 East Tamiami Trail. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove it. The CCDA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTEND PLEASE INDICATE YOUR SUPPORT AND FAX BACK TO 455 -4439 OR 254 -8575 T KEEPING FLUORIDE IN OUR W E SIGN ABOVE I SUPPORT KEEPING FLUORIDE IN OUR WATER lll"` PLEASE SIGN AB I SUPPORT KEEPING FLUORIDE IN OUR WATER I SUPPORT KEEPIN Ark I SUPPORT KEEPING FLUORIDE IN 191WHIM, PLEAS SIGN ABOVE 4-V "U-) ( PLEASE SIGN ABOVE PLEASE SIGN ABOVE If any questions call Dr. Garcia 455 -0898 or Dr. Primero 254 -448 T- Z 09/10/2011 20:43 9412617807 LR MORGAN PAGE100 C SOP 01 2011 1:17PM Richard J. Garola, D.M.D. 239 -455 -4439 Pat* CCDA ALERT Ok ALL DOCTORS, RDM, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Colllar County Commissioners meetIng Data: September 13'", 2011 Time: 400pm Location: The Commission Chambers- lowed on the third Floor of the AdministrWon Budding at 3502 East TomIam/ Trail. Subject: The Cbmmltsion will vote on whether to keep fluoride in our drinking water, or to remove lr. The CCDA supports keeping fluoride In our Otnking water. • • ;� _a� _•l. • 2, AL_ . t C-47 WEWE SIGN ABOVE PLEASE SIGN ABOVE 0 1 SUPPORT 1(EEI jet FG LUORIQE IN OUR WATp r. PLEASE SIGN ABOVE 0 1SUPP99 KE JPlJJG, FLUORIDE IN OUR WATER PLEASE SIGN ABOVE 0 1 SUPPORT KM-ING FLUORIDE IN QUR WATER PLEASE SIGN ABOVE If any questions call Dr. Garcia 45S -MO. or Or. RrJmoro 254 -4490 "r- 09/12/2011 09:33 (FAX) 0 B(7 U.7 CUTA J: VTr II nr L. 91J"1% -L.& I yin Sap 01 2011 l:S3PM Richard J. Garcia, D.M.D. 239 -455 -4439 P. 003/003 Cpace 1'__10 CCDA ALERT ALL DOCTORS, RDH, STAFF _ PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Coliler County Commissioners meeting Date: September 13th, 2011 Time: 4 -Mon Location: The Commission Chambers- Iodated on the third Root of the Admintstrocion Building at 3301 East Tomlaml Trall. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove it. The CCDA supports keeping fluoride in our drinking water. IF YOU OR ANY Qf YOUR STA[F ARE UNABLE TO ATTEND E.LEASE INDICATE YOUR SUPPORT AND FAx BACg IQ 1151-4439-OR 254,852 i SUPPOiR_KEEPING FLUORIPE IN OU.i WATER � �„ :: — PLEASE SIGN ABOVE O EPINGFL4QqtDE1htQIJhWAtER PLEASE SIGN ABOVE Q I SUPPORT KEEPING FLUORIDE IN OU It WATER PLEASE SIGN•ABOVE Q 1 SUPPORT KERING- FLUORIDE IN OU R WATER PLEASE SIGN ABOVE O t SUP-PORT KEEPING FLUOR112E I f$ OUR WAJjR PLEASE SIGN ABOVE If any tiuestions call Dr.'Garda 455.0898, or Dr, Pr1mery 254+4480 09/12/2011 09:33 (FAX) .?tr U1 GulL L: iL... 1\. VIIV. CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT . Board of Collier County Commissioners meeting Date: September 131", 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building ar 3301 East Tomlami Trail. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove It The CCDA supports keeping fluoride in our drinking water. P. 002/003 YOU OR ANY OF YOUR AFF &ffgMHMMM ATTEND PLEAJE INDICATE 11JR SUPPORT AND FAX Shiek TO 4 OR 54 -8575 I SUPPORT KEEPING FLUORIDE IN OUR WATER PL E SIGN ABOVE �1 l 1 SUPPORT KEEPING F RIDE IN OUR WATER PLEASE SI VE ,p I SUPPORT KEEPIN G FLUORIDE IN OUR WATER P N ABOVE I SUPPORT KEEPING FLUORIDE IN OUR WATER 01-� t SUPPORT KEEPING F PLEASE SIGN ABOVE if any questions call 'Dr. *Garcia 4SS -0898, or Dr. Prirnero 254,4480 09/08/2011 10:52 2395978409 WILLIAM AUGHTON DDS PAGE 01/01 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County commissioners meeting Date: September 13*; 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building at 3301 East Tom/omi Trail. Subject: The Commission will vote on. whether to keep fluoride In our drinking water, or to remove it The CCDA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YOU.ILSTAFF AR�UNABLE TO ALTENb PLEASE INDICATE YOUR SUPPORT AMR FAX BACK IQ 455 -4439 OR 254$575 I aged PLEASE SIGN PLEASE 6GN PLEASE SIGN PLEASE SIGN ABOVE If any questions call Dr.'Garcia 455 -0898 or Dr. Primers 254 -4480 FROM : GRIFFITH COSMETIC & FAM DENTAL FAX NO. : 239- 354 -5354 Sep 01 2011 12:23PM Sep. 06 2011 03:03PM i O C Richard J. Garcia, D.M.D. 239 - 455-4439 page CCDA ALERT ALL DOCTORS, RDH, STAFF M PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September W", 2011 Time: 4:40prn Location: The Commission Chambers- located on the third Floor of the AdmwIstrvtion Building of 3301 East Tamiaml ]'roil. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove It. The CCDA supports keeping fluoride In our drinking water. IF YpU OR ANY QF YO ATT END PLEA21 INDICOE YOUR SUPPORT AND FAX OACK TO 455-4,439 OR 254 -8575 • 1 SUPPORT-KEEPING FL RIDE IN OUR WATER PLEASE SIGN AJELQVE CA E SIGN ABOVE S lz% .i PLEASE SIGN PLEASE SIGN ABOV PLEASE SIGN If any questloris call Dr. Garcia 455 -0898 or Dr. PrOnero 254.4480 FROM-: GRIFFITH COSMETIC & FAM DENTAL FAX NO. : 239 -354 -5354 Sep. 06 2011 03:03PM 12ij O Sep o1 2o11 12_23PM Richard J. Garcia, D.M.D. 239- 455 -4439 pag e 1 0-5 CCDA ALERT ALL DOCTORS, RDHp STAFF s PLEASE PLAN ON ATTENDING., WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13th, 2011 Time: 4:00pm Location: The Commission Chambem located an the third Floor of the administration Building at 3301 East Tamlaml Trail. Subject: The Cvmm15Sion will vote on whether to keep fluoride in our drinking water, or to remove It The CCDA supports keeping fluoride In our drinking water. IF YOU OR ANY OF YOUR UAFF ARE UNABLE TO ATTEND PLEASE INDICATE PLEASE SIGN ABOVE I SUPPORT ICE €PING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE Q 1 SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE If any questions call Or-'Garcia 455 -0898 or Dr. Prl,mero 254 -4480 SEP -6 -2011 09:24A FROM:JEREMY DAVEY DMD C239)434 -9039 TO:4554439 P.1 10 Sep 01 2011 11:56AM Richard J. Garcia, D.M.D. 239- 455 -4439 page 1 o CCOA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 130; 2011 Time: 4:00pm Location: The commission Chambers- located on the thft Floor of the Administration Building at 3301 East Tomioml Trail. Subject: The Commission will vote on whether to keep fluorlde in our dunking water, or to remove iG The CCOA supports keeping fluorlde In our drinking water. IM • • • i il 411 ► F-1-3 1!4kZv1.AWfl • • C 24113 PLEASE SIGN ABOVE //. PLEASE SIGN ABOVE If any questions call Or.'Garcia 455 -0898 or Dr. Primero 25444480 mq � Sap 01 2011 1:51PM Richard J. Garcia, n -M.D. 239- -455 -4439 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 131' 2011 Time: 4:00pm Location: Tho Commission Chambers- located on the third Floor of the Administration Building at 33ol East Tomiaml Trail. Pare Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove IL The CCDA supports keeping fluodde in our drinking water. IF YOU OR ANY OF YOUR RAEF ARE UNABLE TO ATTEIND PLEASE INDICATE YOUR SUPPORT AND FAX BACK OR 254 -857 I SUPPOR EEPING FLUORIDE IN OUR WATER PLEASE SIG 14ABOVE 0 PORT E PING FLU0RI.QF IN OUR WATER PLEASE SIGN ABOVE Q 1 SUPPORT KEEPING FLUO.R.IDE IN OVR WATER PLEASE SIGN ABOVE 4 1 SUPP12LT KEEPING FLUORIQLW OUR WATER PLEASE SIGN ABOVE a 1 P RT EEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE If any questions call Dr. Garcla 455 -0898, or Dr. PFlmero 254.4480 09/06/2011 06:47 2395140455 COSMETIC IMPLANT DEN PAGE 01/01 ser 01 2011 i:00PN Richard J. Garcia, D.M.11. 239 -455 -4439 P410 C CCDA' ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13'", 2011 Tirane: 4:00pm Location- The Commission Chambers- located on the third Floor of the Administration Building at 3301 Cost Tomloml Trail. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove /t. The CODA supports keeping fluoride in our drinking water. IF YOU OR ANY OE YQU.O STAFF ARE UNABLE TO ATTEND PLEASL I DID, =E YOUR SUPPORT AND FAX BACK IQ 4S5 -4439 OR 254 -857S 95 G E-11 PLEASE SIGN ABOVE E. PLEASE SIGN ABOVE if any questions call Dr. Garcia 455 -0898 or Djr . Pr1rnero 44480 SEP -6 -2011 08:29A FROM: TO:4554439 Sep 01 2011 1:04PM 'Richard J. Garcia, D.M.D. 239 - 455-443"9 CCDA ALERT ALL DOCTORS, RD-H, STAFF PLEASE F"N ON AT MNDI NG, WE N'E'ED YOUR SUPPORT Board of Collier County CC,om m-lssioners meeting Dam: September 13", 2NI Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the AdmInIstration Building of 3301 East TetnlOml Tra1L P .1 10 V -Subject: . The Commissioa will vote on whetirerta keep f uarid+e in oardrinking water, or to remove It_. The CCOA supporis keeping fivaride in our drinking water, IF YOU OR i%NY OF Y= ETM ARIF UNABiETU END ATT PLI~ fNdTCATE y YOUR SUPPORT AND fAR K Tg4Jr,, n -Qft 2545575 SU P.0 T.IM11F =91DE -10-it S E! F8 C- d . it TFID- FLUORIDE IN ,C " i7 0 wo_ k,: u VVLV ✓L ,." r / �! : *� • I 011S P O KE OR tN R o� i 'ir- (!!S E SIGIN4 ABO ba1 54JEP29I 'K TVG FLUORIDE 11,4 W- W— ltATE --� C ma Jqa ,kc, k SE SIGN aV if anyquestlotisvall •Dr.*Garcia455 -N98; or Dr. PAmers 254.44501 PDA SEP -6 -2011 09:23 FROM:DR GARY LAYTON 12392612670 T0:4554439 Sep 01 2011 1:56PM Richard J_ Garcia, A -M_0. 239 -455 -4439 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Collier County Cott MIS310ners meeting Date: September 10,0 2011 Time: 4:00pm London: The Commission Chambers- located on the third Floor of the Admfnistrattan Building of 3301 East Tomiaml Troll, Pagili O Subject: The Commission will vote on whether to keep fluoride In our drinking water, or to remove It_ The CCDA supports keepingPaorlde in our drinking water, IF YOU OR ANY OF YQUO UAEE ARE UNABLE TO ATTEND PLEAS INDICATE YOUR SUPPORT AND MQMJ2 4SS -4439 OR 254-SS75 PLEASE SIGN ABOVE "I- - �, I SUPPORT KEEPING FLUORIDE IN OUR WAT R LEAS . IGN I SUPPORT KEEPING FLUORIDE IN OUR WATER___ ___ PLEASE S164 Q 1 SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE If any questions call Dr. Garcia 455 -0898 or Dr. Primero 254 -4480 (5) CIap ui cvaa t: -turn Klonara J. ua�cia, u.MFu.23edy654bb -4438p 2 2011 09;OdpagPe1 01 v CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 131h, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third floor of the AdmlMstmtion Building at 3301 East Tarrmlaml Troll. Subject: The Comm/sslon will vote on whether to keep fluoride in our drinking water, or to remove IL The CODA supports keeping fiuorlde in our drinking water. IUOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTEND PLF41i INDICAT AL U.1 i TkIrcims, . ► ; , U PLEASE SIGN ASE SIG"BOVE 'if any questions call Dr.'Garda 455 -0898, or Dr. Primers 2544460 Sep 02 2011 G:57RM (Veil S. Stringer D.D.S. 239 - 597 -9451 p.l Sep 01 2011 2:13PM Richard J. Garcia, D.M.D. 239 - 455 -4439 page 110 C to CCDA ALERT ALL DOCTORS RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13` ; 2011 Time: 4:00pni Location: The Commission Chambers- located on the third Moor of the Administration Building at 3301 East Tomiami Traif. Subject: The Commission will vote on whether to keepfluodde in our drinkln0 water, or to remove /t. The CCDA supports keeping fluoride in our drinking water, IF YOU OR ANY OF YOUR STAFF MI UNABLE TO ATTEND PLEAS INDICATE. it Stringer, DDS, PLLC YOUR SUPPORT ANNFAX BACK TO 455 -4439 OR 254-8575 871 106 Ave. N. Naples, FL 34108 -1851 �vjl SUPPORT KEEPING F E iN QUR WATER PLEASE SIG ROVE O 1 SUPPORT KEEPING FLL ORIDE IN OUR WATER PLEASE SIGN ABOVE O 1 SUPPORT KEEPING FLUORIDE ITV OUR WATER PLEASE SIGN ABOVE O 1 SUPPORT KEEPING FLUORIDE M OUR WATER PLEASE SIGN ABOVE O ! SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE If any questions tall Or. Garda 455 -0698. or Dr. Primero 254 -448a Sep 0711 08:23a DR FRED ECK 12399928644 p.1 Sep 01 2011 12:07PM Richard J. Garcia, D.M.D. 239- 455 -4439 page 11 O C CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 130, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building of 3303 East Tanvami Trait. Subject: The Commission will vote on whether to keep ftuaride in our drinking water, or to remove it. The CCDA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YOUR STAFF ARE UNAQLE TO ATTEND PLEASE INDICATE YOUR SUPPORT AND FAX BACK TO 455 -4439 OR 2548575 1 SUPP(IRT KEEPING FLUORIDE IN OUR WATER P ASE SIGN ABOVE�p�� V I t1PP.ORT KEEPING FLUORIDE IN OUR WATER IVC��tM rJ�: If any questions call Dr. Garcia 455.4898, or Dr. Primero 254 =4450 _ F Smiles By Hale 2395930881 Sep 01 2011 12:24PM Richard 0. Garcia, D.M.O. 239 - 455 -443U CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Coiner County Commissioners meeting Date: September 13th, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Adm fnistro tion auiiding at 3301 East Tamraml rrall. page .1 1 C O . Subject: The Commission will vote on whether to keep fluaride in our drinking water, or to remove 1t. The CCDA supports keepingfiuoride in our drinking water. IF YOU OR ANY OF YQUR STAFF ARE UNABLE TO ATTEND PLEASI INDICATE YOUR SUPPORT AND FAX BACK TO 5-4439 OR 254 -8575 and r%1 In IAIATCQ l' P NO G IN OUR WATER ' PLEASE 516-N :ABOVE PLEASE SIGN ABOVE O 1 SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN ABOVE If any questions 'cal I Dr. .Garcia 455 -0844 or Dr. Prirnero 2544480 yy�M1.. 77-7, x , i'3pCip�La 5 JZa4b'� Sep 01 2011 2:12PM Richard J. Garcia, D.M.D. 239 -455 -4439 10C page 1 CODA ALERT ALL DOCTORS,, RDH, STAFF Y PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT - Board of Coiner county Commissioners meeting Date: September 13`', 2011. Time: 4:Odpm Location: The Commission Chambers- located on the third Floor of the Administration Bu, Jdirig East Tamiaml Trail. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove It the CCDA supports keeping fluoride in our drinking water. 1 SUPPORT KEEPING FLUORIDE IN OU WATER PL SE SIGN ABOVE SUPPORT KEPING FL O ID IN OUR WATER . PLEASE 51 VE I SUPPORT EEPI FLUORID IN 0 R WATER �` r ` P N ABaVE , /,SUPPORT KEEPING FLUORIDE IN OUR 11V &TE R T �'1. SI 130 1 SUPPO E P NG FLUORIDE l UR WA PLEASE SIGN ABO If any questions call Dr. Garcia 40- 0898,or Or. Prirnero 254 =4480 Rf>1' . fn:ni 1107/90/60 lOC CODA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County commissioners meeting Date: September 13M, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Fluor of the Administration Building at 3301 East Tamlami Troll. Subject: The Commission will vote on. whether to keep fluoride In our drinking water, or to remove it. The CODA supports keeping fluoride in our drinking water. 1E YOU OR ANY OF YOUR STAFF ARE UNAB_I.E IQ &HEMD, EASE INDICATE YOUR ,SUPPORT AN,D_ E�j �A X IQ 4554439 OR 254-8575 71 0 C1 Ll PLEASE SrGN(_#BOV PLEASE SIGN XBWE PLEASE SIGN ASO PLEASE SIGN ABOVE ABOVE 0 1 SUPPORT KEEPING FLUORIDE IN OUR WATER PLEASE SIGN if any questions call Dr. Garcia 455 -0898 or Dr. Primero 254 -4480 T aged Q'W'Q `elo.ref) •r pJW431H WWT£: T T 1103 TO Bias Sep; 01 2011 12 :08PM Richard J. Garcia, D.M.D. 239 - 455 -4439 past O C CCDA ALERT All DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 131; 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Suildin9 at 3301 East To/' JQMI Trail. Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove 1G The CCDA supports keeping fluoride In our drinking water. IF YOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTEND PLEASE INDICATE YOUR SUPPORT AND FAX BACK TO 455 -4439 OR 254 -8575 fA ►: EM��� SIGN rkg-� /t7 r lCL E SIGN ABOVE r � PLEASE SIGN ABOVE O 1 SUPPORT KEEPING EIQORQE IN OUR WATER PLEASE SIGN ABOVE If any questions call Dr. Garcia 455 -0898, or Dr. PrI.mero 2544480 Sep 06 11 11:39a 941- 594 -2600 Sep 01 2011 12:01PM Richard J. Garcia, D.M.O. 239- 455 -4439 page 1 CODA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County commissioners meeting Date: September 131' 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building at 3301 East Tomiami Trail, Subject: The Commission will vote on whether to keep fluadde in our drinking w0V,!r,..or to remove it. The CCDA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YOUR STAFF R UNABLE rO ATrEND PLEASE INMATE YOUR SUPPORT AND FAX BACK TO 455 -4439 OR 254 -8575 .M: * PLEASE If any questions call Dr. Garcia 455 -0898,or Dr. Primero 254 -91480 To c (:D SEP -6 -2011 14:00 FROM:GRLLERIR DENTISTRY (239)592 -0254 TO:4554439 1P0 C k• 0 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT . Board of Collier County Commissioners meeting Date: September 13a', 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building at 3301 East Tamlaml Trail. Subject: The Commission will vote on whether to keep fluoride In our drinking water, or to remove lt. The CCOA supports keeping fluoride in our drinking water. IF YOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTEND PLEASE INDICATE YOUR SUPPORT AMD FAN BACK TO 455 -4439 OR 254 -8575 I ZSUPPQRT EEPI FLUORIRE IN OUR W T lB/L" 'R., ef-) 4 PJEASE SIGN ABOVE 3e —/)0 1. E SIGN ABOVE [eI PLEASE SIGN ABOVE 0 i SUPPORT KEEPING F1UOR(DE_iN OUR WATER PLEASE SIGN ABOVE If any question's call Dr. Garcia 455 -0898 or Dr. Primero 254 -4480 T aged a,W-a `eTojeq •r PJeyoTN WE192:TT TTO? TO daS 09/08/2011 00:33 2392628521 JAMES-13 HANSEN IIDM PAGE 1/0 C Sep 01 2011 12r25PM Riohard J. Garcia, D.M.D. 239 -4S5 -4439 pace 1 v CODA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING, WE NEED YOUR SUPPORT Board of Collier County Commissioners meeting Date: September 13 «', 2011 Time: 4:00pm location; The Commission Chambers - located on the third Floor of the Administration Building at 9301 fast Tamiami Trail, Subject: The Commission will vote on whether to keep fluoride In our drinking water, or to remove It The CCDA supports keeping fluoride In our drinking water. IF YOU O ANY OF YOUR 9A.FF ARE UNA0LETQAnMD J!L9ASg IN(21CAyE YOUR SUPPORT AND FAX BACK TO 455.4469 OR 2S4 -8575 N .L 9 O MUPPORT KEEPING UORIdE IN QUR WATERG�� PLEASESIGI,N ABOVE O 1 SUPPORT KFFPlNG FI nnolnc ird n►►a wA. of ZrM,'As PLEASE SIGN ABOVE If any questions call Dr.'Garcia 455 -0898 or Dr. Primero 254-4480 Sep 09 11 08:31 a Godley Family Dentistry 2392610730 Sep 01 2011 12:17PM Richard J. Garcia, D.M.D. 239- 455 -4439 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT Board of Col tier County Commissioners meeting Date: September 130, 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Administration Building at 3301 fost Tomlomi Trail P.1 Fade � O Subject: The Commission will vote on whether to keep fluoride in our drinking water, or to remove it. The CCDA supports keepingfluoride in our drinking water. x PLEASE-S-IGN ABOVE P LEA! G N PLEASE SIGN r01, If any questions call Dr. Garcia 4455 -0898 or Dr. Prirnero 54.4480 R� IF YOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTEND PLEAS) INDICATE .......... 09/08/2011 03:47 2395969743 REED ORTHODONTICS PAGE 01/01 Sep 01 2011 2:1opn Richard J. Garcia, D.H.D. V30-455 -4439 page 1� O, j1 CCDA ALERT ALL DOCTORS, RDH, STAFF PLEASE PLAN ON ATTENDING; WE NEED YOUR SUPPORT . Board of Collier County Commissioners meeting Date: September 13t 2011 Time: 4:00pm Location: The Commission Chambers- located on the third Floor of the Adm(nistration Building at 3301 East Tamloml Trail. Sub)ect: The Commission will vote on whether to keep fluoride in ourdrinking water, or to remove it. The CCDA supports keepingfluorlde in our drinking water. IF YOU OR ANY OF YOUR STAFF ARE UNABLE TO ATTE_ ND pqs D CgTE YOUR SUPPORT AND FAX BACK TO 455 4439 OR 2548575 ®i SUPPD T KEEPING FL ORIDE IN OU WAT L,,.l bmft 0 ASE SIGN ABOVE I SU DRT L RIDE IN OUR WATER PLEAS SIGN ABOVE I SUPPORT KEEPING FLUORIDE IN OUR WATERh' PL SE.SIGNAB E:V I SUPPORT KEEPING FLUORIDE IN OUR WATE PLEAS IGN OVE I S PP T KE PING F UORIDE IN OUR WATE PLEASf SIGN ABOVE if any questions call Dr. Garcia 455 -0898. or Dr. Prirnero 2544480 H , ncnn 73 z > 3 f o = o m a GI m O \ 3 � � ? 3 m m 31- 3 Zmi 13 M .< i ni t m v Z n "< �rX M m Z �' O � W cD a I G Ln rnn rt C) o C 000 o rn 0 a zoo rn o rn > mFnz 3 ai m � rnz �� 3 -I M m cn m � ■ -1 moo 3 . m r. � � � 3 7 �-, 0 m � nD w . 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