Council On Dental Health
and Health Planning
1979

The Council wishes to express its appreciation to Ms. Marian Driscoll for her hard work in developing the White Paper, and to Ms. Darlene Fujii for her organization and coordination of the project, bringing it to publication.

Foreward

The fluoridation of community water supplies has long been recognized as an effective public health measure to protect the population against dental disease.  Numerous studies and extensive research have confirmed the unmatched value of this program.

Despite its proven benefits, fluoridation has undergone a long history of controversy.  In 1979, with over 105,000,000 people receiving fluoridated water, the community of concerned health professionals continues the battle to see universal fluoridation become a reality.

The following document traces the complex history of fluoridation, its discovery, research, proponents, and opponents, most importantly, it offers a long-range strategy for bringing water fluoridation to the entire American population and thereby reducing the threat of dental disease.

A national program for community water fluoridation offers a chance for every  concerned individual to become involved in determining the future of their health.  The White Paper outlines some very basic actions that can and will be taken. Support on the local level is the essential component.  A concerted effort on all parts, will work to provide the protection of fluoridation to all of our country.

Council on Dental Health and Health Planning
American Dental Association

White Paper On Fluoridation

Background

Definition:  Fluoridation is a community health program through which the fluoride level of the public water supply is adjusted to the optimal level for preventing tooth decay without undesirable side effects.  Fluoride is the ionic form of the element fluorine and a constituent of teeth and bones.  Fluoride is ubiquitous, occurring in varying amounts in all water, soil and vegetation.

History:  Nature was fluoridating water supplies for millennia before the role of fluoride in dental caries prevention was discovered.  In some instances, however, nature provided too little fluoride to have any dental benefit; in other, too much, and the result was discolored enamel but little tooth decay.  Thus, controlled fluoridation is not merely the duplication of a natural process, it is an improvement of that process:  the fluoride content of the water supply can be maintained at the desired level.   This level has been established as approximately 1 part fluoride per 1 million parts water (0.7 – 1.2 ppm, depending on the annual average maximum daily air temperature obtained for a minimum of five years – the higher the average temperature, the larger the volume of water consumed and, therefore, the lower the level of fluoride needed in the water to obtain the dental benefits).  Moreover, fluoridation is the most economic and efficacious method for providing fluoride to the individual.  The cost today depends on the size of the community, equipment and source of fluoride used and ranges from $0.08 to $0.28 per capita per year.  Children who drink optimally fluoridated water while their teeth are calcifying, preferably from birth, will have on the average up to two-thirds less tooth decay than those who drink water with less than the optimal amount.  This benefit is life-long, enhancing their adulthood as well as their childhood with better dental health and less pain and suffering – both physical and economic.

The foregoing data were revealed through years of research triggered by the curiosity of a Colorado Springs dentist, Dr. Frederick S. McKay.  As early as 1902, he had been puzzled by two observations:  the teeth of some of his patients had dark stains which he termed “mottled enamel”; they also had little dental decay.  It took 29 years for a number of independent

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investigators to determine that the cause of mottling was a high concentration of fluoride in the drinking water.  The next and obvious question was related to a possible role for fluoride in preventing dental decay without fluorosis, or mottling.

Since thousands of Americans had been living for years in communities whose water supplies contained nearly optimum or higher levels of fluoride naturally, populations were readily available for extensive and exhaustive retrospective and prospective epidemiological research needed to determine not only the dental benefits but also any deleterious effects, dental or systemic.  The research was conducted by a team of scientists, led by Dr. H. Trendley Dean, of the U.S. Public Health Service.  Their comparisons of dental decay rates for persons living in naturally fluoridated areas and in fluoride-deficient areas demonstrated that individuals whose water supplies contained 1 ppm fluoride experienced 60-65 percent less dental decay and little, if any, fluorosis.  Additional studies showed that life-long ingestion of fluoride as high as 8 ppm produced no harmful effects. (1, 2)

By 1945, the safety and effectiveness of fluoridation were so well-established it was decided that controlled study programs were in order.  The first two such studies were initiated that year in Grand Rapids, Michigan, and Newburgh, New York, which adjusted the fluoride content of their water supplies to 1 ppm.  For each community there was a nearby control city of approximately the same demographic make-up but without fluoridation.  Although designed as 10-year projects, the findings they produced after five years, plus the mounting evidence from continuing research on the lack of medical effects of fluoride, supported the efficacy and safety of fluoridation so overwhelmingly that, in 1950, controlled water fluoridation was endorsed by the U.S. Public Health Service and the American Dental Association.  Within the next five years, fluoridation had won the approval of the American Medical Association and virtually all other reputable scientific and health organizations in the United States.  In October, 1958, the World Health Organization joined their ranks and has continued its active support.  In 1969, WHO reaffirmed its support and, in 1970, published Fluorides and Human Health, a comprehensive monograph on the subject of fluoridation and the effects of fluorides on human health, with a chapter devoted to “Fluorides and Dental Health.”  This impartial review, which is representative of dental and medical opinion throughout the world, revealed no evidence of harmful effects from ingestion of fluoride

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at the optimal level.  In 1975, WHO released a statement that “the only sign of physiological or pathological change in life-long users of optimally fluoridated water supplies, after two decades of the practice of fluoridation, is that they suffer less from tooth decay.”  In 1978, the WHO again reaffirmed its support for fluoridation, urging member states to consider fluoridation in their national planning for the prevention and control of oral disease. (3)

In 1952, nearly 8 million persons in 367 communities in the United States were receiving fluoridated water.  This finding, based on a survey conducted by the Council on Dental Health of the American Dental Association, (4) was reported at the Third National Dental Health Conference held during the Association’s annual session that year in St. Louis.  The fact that 40 percent of the new projects had started in the first seven months of 1952 prompted the council’s observation that “If the present rate of acceptance continues, all fluoride-deficient water supplies in the United States may be fluoridated by 1975. (4) However, the strange phenomenon of opposition that plagued other public health measures, such as chlorination of water and pasteurization of milk, surfaced on the horizon – – political horizon, that is.

As of December 31, 1975, the aforementioned target date, U.S. Public Health Service statistics showed that recipients of fluoridated water had indeed increased:  105 million.  (5) Standing alone, this figure looks impressive, but it represents only about 60 percent of the U.S. population on public water supplies and includes more than 10 million persons whose water supplies are naturally fluoridated.  Not only has the glowing 1952 prediction for fluoridation of all U.S. fluoride-deficient water supplies failed to materialize, but, after more than a quarter of a century of hard-won progress, there is an alarming trend toward rejection of the measure.  Alarming, because the opponents comprise a small, but increasingly effective vociferous minority with questionable credentials, whose objective is to deny a proven public health measure to the majority by manipulating the political process.

Identification of opponents:  In the early days, the opponents were organized primarily at the local level, and their efforts were limited, for the most part, to the particular community.  They included individuals who were uninformed or misinformed about this new public health measure and who usually had little training for evaluating scientific information or for

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judging the competency of any spokesman – – pro or con.  Thus, they were readily susceptible to the message of fear and distortion of facts proclaimed by food faddists, cultists and others who traditionally differ with organized medicine, dentistry and public health.  Add to these a few dedicated, self-styled experts whose qualifications for speaking out on such a scientific question as fluoridation were practically nonexistent or whose motivation was self-serving as they themselves have demonstrated through their practices to mislead the public, and the profile of the vociferous minority of opponents of fluoridation emerges.  Their efforts received some assistance from the inactivity of some members of the health professions who were just philosophically opposed to community action programs.

Tactics of opponents:  The opponents’ claims of harm ranged from charges that fluoride was causing stained saucepans, cracked dentures and eroded water pipes to allergic reactions, malaise and damage to the vital organs.  They have claimed that fluoride did not prevent or only postponed tooth decay.  Their charges were made known to the public via the press, personal contacts and community gatherings, and pressure was put on health officials to stop fluoridation – – sometimes, the opponents learned to their embarrassment, before the particular program had ever been put into operation.  At first, opponents were afraid to submit the question to referendums, because they thought they might not be able to defeat fluoridation by putting it to public vote – – but not for long.  It turned out that the political campaign provided an ideal platform for effectively expounding their bizarre claims and scaring and confusing the citizenry.  An additional ruse was to attain ambiguity in the language on the ballot; for example, a “yes” vote could means rejection and vice versa.  The increasing success of their tactics was well demonstrated in the November 1960 elections:  29 out of 35 communities conducting referendums on the question of installing fluoridation rejected the measure. (6) In 1974, in the State of Nebraska alone, fluoridation was defeated in 110 town referendums. (7)

Nor did the opponents overlook the possibility of attack through legal channels:  that it infringed on the rights of the individual under the Constitution, that it constituted socialized medicine, mass medication, and so on.  These charges, too, have been refuted by countless court decisions which have never refuted the constitutionality of fluoridation. (1)

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Sprinkled within the range of charges were proposals that for those who wanted it, fluoride be added to salt, milk or flour, for example, or that fluoride tablets be used.  Some of those alternative forms of fluoride supplements can reduce caries but often are associated with difficulties of administration and of patient compliance.

The Index to Dental Literature, produced by the American Dental Association’s Bureau of Library Services, provides an annual accumulation of fluoride studies.  Major reports themselves continue to be compiled by the BLS in package libraries which may be borrowed from the Bureau.  No public health measure has been researched more nor for a longer period of time than has fluoridation.

In more recent years, the antifluoridation movement “has gone national” through such organizations as the National Health Federation, whose stated purpose of promotion of freedom of choice in health matters has been interpreted by the U.S. Federal Drug Administration as “freedom to promote medical nostrums and devices which violate the law.” (8) The NHF also opposes other public health programs, such as smallpox and polio vaccinations and milk pasteurization while promoting such unproven medical nostrums and practices as laetrile, Krebiozen and naturopathic medicine.  Its opposition may stem not only from its stated purpose as interpreted by the FDA but from the experience of its founder who ran afoul of the law in 1962 for contempt of an earlier U.S. District Court’s order to stop distributing electronic treatment devices found worthless by the FDA.  Several other NHF leaders had similar bread-and-butter interests and received fines or prison sentences for health fraud.  “From its inception,” the FDA report said further, “the Federation has been a front for promoters of unproved remedies, eccentric theories and quackery.”  The NHF maintains its headquarters in Monrovia, California.  Its membership has been estimated at approximately 24,000 and its dues range from $5 for “regular” membership to $1,000 for “perpetual” membership.

The NHF, despite the findings of the National Cancer Institute, has claimed a link between fluoridation and cancer.  The Delaney Amendment to the Federal Food, Drug and Cosmetic Act of 1958 (10) (James J. Delaney, D-NY) states that “no food additive shall be deemed to be safe if it is found to induce cancer when ingested by man or animal, or if it is found, after tests which are appropriate for the evaluation of the

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safety of food additives, to induce cancer in man or animal.” Whether the amendment is applicable to public health practices has not been determined, because the Act relates to commercial or processed foods and drinks.  This factor has not deterred the NHF.  Its assertions are based on interpretations made by Dean Burk, Ph.D., a former biochemist with the National Cancer Institute, and John Yiamouyiannis, Ph.D., a biochemist and the Science Director of the NHF.  (11)

Although their assertions (12) have been refuted by the National Cancer Institute and others, they were entered in the Congressional Record (July and December 1975) by Representative Delaney who also demanded an immediate end to all fluoridation.

In 1975, using the cancer-link theory, the NHF took credit for the defeat of fluoridation in Los Angeles.  The following year brought a dramatic international success: in an interview on Dutch television, February 10, following circulation of a report with Dr. Yiamouyiannis, Dr. Burk charged “fluoridation is a form of public mass murder.”   The report purported to show a connection between fluoridation and cancer resulting in thousands of deaths in the U.S.  At the time, a proposal by the Minister of Health for fluoridating all water supplies throughout Holland was before the Dutch Parliament.  Not only did it fail to be approved, but, by September, the fluoridation programs that had been in operation for years in Rotterdam and other communities were halted by royal decree.

Dr. Burk’s fluoridation odyssey took him on to England where the NHF tactics were the same, but the results more typical of the U.S. experience: overwhelming refutation by scientific studies conducted by the Royal College of Physicians (13) and Oxford University (14); side publicity to the charges, the appearance of a scientific controversy; and confusion on the part of the public.  As a result of all  the furor, there was a reinvestigation of the demographic data that had been used by the statisticians at Oxford and at the National Cancer Institute (12) and University of Rochester (15), all of which also refuted the fluoridation-cancer link charges.  Drs. Richard Doll and Leo Kinlen of Oxford University reported:  “The American evidence when analyzed in detail, is consistent with the British evidence that was examined earlier by one of us.  None of it provides any reason to suppose that fluoridation is associated with an increase in cancer mortality, let alone causes it.” (14)

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The foregoing experience has demonstrated, once again, that scientific research of itself, will not prevent tooth decay.  Recognizing this fact, The Fluoridation Society, a voluntary British organization, has proposed a three-pronged campaign:  political, educational and organizational.  It is to be conducted in collaboration with the British Dental Association, the British Dental Health Foundation and the Health Education Council.

Another tactic of the opponents of fluoridation in the USA is use of the initiative petition to repeal enabling legislation for fluoridation in states where it exists and to prohibit such legislation in others.  The process involves the circulation of a petition to obtain the number of valid signatures of registered voters required by the state in order to have the proposal placed on the election ballot.  Eight states currently have laws intended to provide statewide fluoridation (16) and may be targets for antifluoridation initiatives:  Connecticut, Georgia, Illinois, Michigan, Minnesota, Nebraska, Ohio and South Dakota.  The laws of Georgia, Michigan, Nebraska and Ohio contain provisions that allow a community to exempt itself from compliance if it does not wish to institute the measure.  In Kentucky, a public health regulation requires fluoridation for approval of water supplies.

Identification of proponents:  The proponents of fluoridation comprise a multimillion majority of individuals including Americans who have been consuming fluoridated water for decades, qualified scientists in the United States and abroad who have conducted the research proving the measure’s safety and efficacy and dentists, physicians and other health professionals who are concerned with the total health of the individual and the community.  Their interests are authoritatively expressed through the dental, medical and public health professions plus the national organizations qualified to speak on health issues.  The dental profession is the logical unit in the over all program to assume the leadership role, muster the resources, organize the forces and supervise the delegation of responsibilities and coordination of effort that will be necessary at the national, state and local levels if the tragic trend away from fluoridation is to be reversed.  At the community level, it will be the responsibility of the local dental profession to bring in those who have the expertise and then, under their guidance, assume a leadership role.

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Resources of proponents:  Among the resources of the proponents are the immense body of indisputable scientific evidence supporting the effectiveness of and need for fluoridation; liaison with other national organizations concerned about total health; liaison with federal health agencies; access to sources of funds to support appropriate program or ability to stimulate funding; a communications network within the dental profession from the local to the national level, even the international level; cooperation of local and state health departments; expertise in the development of community programs, regional and national conferences, probably the greatest resource of all, however, is the reality of the fluoridation program itself, i.e., that a profession can offer a safe, inexpensive, cost-effective, easily administered preventive measure at a time when the nation is gravely concerned about inflation and the high costs of health care and is finally awakening to the fact that prevention is more prudent than correction.  Another important resource consists of the dentists who care for the dental needs of congressmen, state legislators, mayors, councilmen and supervisors.  Such patients should be informed of the importance and need to extend communal water fluoridation to areas where it is lacking.

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Framework for the Development
of a National Fluoridation Promotion Program

Background:  The development of a national fluoridation promotion program will require constant two-way communication among the primary parent agencies involved – – the American Dental Association, the Public Health Service and State Health Departments – – so that each will be informed of what is being done and needs to be done.  Consequently, there must be routine, internal communication arrangements within the agencies themselves as well as between the agencies, i.e., to and from the National Advisory Committee on Fluoridation (NACF), state dental societies, the Center for Disease Control (CDC), the Environmental Protection Agency (EPA), the National Center for Health Statistics (NCHS), the National Institute for Dental Research (NIDR), state dental directors and other appropriate groups or individuals. Meeting this need will be expedited by the appointment of a knowledgeable coordinator to help each agency follow through on collecting and circulating appropriate information and initiating action whenever indicated.  This interagency information activity will need to be augmented by the establishment of a fluoridation information clearinghouse, possibly with a toll-free telephone number that will serve as a centralized source for information on all aspects of fluorides and fluoridation.

A major purpose of the gathering of information should be the identification of communities where the timing for political action is favorable as well as unfavorable and where the opponents of fluoridation are considering the initiation of referendums.  Experience has shown that unsuccessful campaigns consume extensive personnel effort, and are expensive and bring on postponement of renewed positive action for at least five years.

Within the ADA, provision has already been made for the addition of a full-time professional person to the staff of the council on dental health and health planning to coordinate the association’s fluoridation program activities.  Among his or her extensive responsibilities will be the provision of assistance to dental societies and other organizations involved in fluoridation campaigns, including personal consultation in the field; recommendations for areas to be researched – – scientific and legal; development and distribution of printed and audiovisual information materials for distribution to the professional and the public; recommending appropriate lobbying for essential funding

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and staffing by HEW for implementing the administration’s expressed assurance of support for fluoridation; exploring application of the techniques developed by the public education program (PEP) of the American Dental Association for the training of spokesmen; establishment of a clearinghouse of information on fluoridation, possibly with a toll-free telephone number, and so on.

It may be that the office of the ADA coordinator could best serve as the central clearinghouse of information.  For example, state dental societies and state dental directors should alert each other to any developments within their states to promote fluoridation of a community water supply or to discontinue a program; to upcoming anniversaries of programs and studies showing results; to any activity on the part of opponents of fluoridation (including newspaper columnists), and so on.  To monitor such developments, the constituent and component dental societies should each have a fluoridation committee in order to provide for automatic reporting from the community to the state level.  The office of the ADA coordinator should be advised immediately of any development and it should circulate any significant information to the NACF and the PHS.  Those agencies, in turn, should keep the ADA office informed, particularly about any developments in the legislative, political or scientific area.  Reporting can be via telephone or by the forwarding of newspaper clippings, copies of letters, memos, bulletins, articles in dental journals, papers presented at meetings and various other information materials.  In other words, lengthy correspondence or documents need not be prepared; the important factor is promptness.

A communications network, as outlined, will also serve for the expeditious transmission of information from the national to the local level.

Other available channels of information that should be utilized are the columns of ADA publications.  The editor should be requested to increase fluoridation coverage in the ADA News and the Journal of the American Dental Association.

Professional education:  Development of the program must begin with re-education and stimulation of the individual dentist both in the community and in the dental school, whose active participation is essential to the success of any fluoridation program.  Individual dentists must be convinced that they need not be familiar with scientific

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reports of laboratory and field investigations on fluoridation to be effective participants in the promotion program and that nonparticipation is overt neglect of professional responsibility.  Initiation of this part of the promotional effort should include the preparation of a short fact sheet for wide distribution.  Important among the facts listed, for example, should be the assurance that professional colleagues, qualified to review and assess the validity of scientific data have and will continue to maintain information on safety, effectiveness and cost of this preventive procedure for immediate response and distribution.

The staff of the American Dental Association offers the greatest potential moving force for education and stimulation of the practicing dentist on a continuing basis.  Through their routine communication with key dental leaders at the state and local levels in connection with the conduct of their respective programs and assignments – – correspondence, travel, planning of meetings and conferences, participation in dental meetings, and so on – – ADA personnel are in a unique position to promote fluoridation with little effort and at no additional expense.  Thus, a first step for the ADA coordinator should be the arrangement of a meeting of ADA department heads to alert them to (1) the renewed effort of the Association in concert with the Public Health Service and other appropriate government agencies and public health officials to assist communities in achieving fluoridation of their public water supplies and (2) the need for their cooperation if the profession is to respond successfully to one of the most exciting challenges of the century in the field of public health:  reversing the increasing triumph of falsehood over truth, of hucksters over scientists and of dental disease over dental health.  The meeting should be carefully structured to present a moving summary of what has happened, what needs to be done, why, and what is planned.  The circulation of a memo will not accomplish the objective of making the staff concerned.  Open, even emotion, discussion is needed.

The meeting should be followed by a communiqué to the constituent and component dental societies, allied and specialty groups and dental schools to alert them to the critical need for a concerted promotion effort, outlining their respective roles and seeking their support.  Information copies should be sent to the Deputy Surgeon General; Public Health Service; the Center for Disease Control; the Environmental Protection Agency; the National Center for Health Statistics; the National Institute for Dental Research; state dental directors and any other appropriate agencies

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and individuals with a covering letter soliciting their cooperation and recommendations.  Copies of the foregoing, with an appropriate covering letter soliciting their support in their respective areas, should be sent also to the Association officers, trustees, council members and department heads.  Copies of all such mailings should be sent routinely to the members of the National Advisory Committee on Fluoridation with the understanding that they should review and comment.

The ADA coordinator should also cooperate with the American Association of Dental Schools in the development and provision of appropriate background materials on fluoridation for continuing education courses.  In addition, the coordinator should encourage dental societies and study clubs to include fluoridation in their programs and should furnish appropriate background materials; should encourage dental schools to expand education of dental students and auxiliaries regarding the metabolism and physiological effects of fluorides and fluoridation; should seek the cooperation of the council on national board examinations to include questions regarding the role of fluorides and the benefits of fluoridation on national board examinations and should stimulate interest in knowledge of fluoridation among physicians, nurses and other health professionals and auxiliaries.  The coordinator should also explore the possibility of an awards program to provide funds for student loans to dental schools that do the most to implement community fluoridation programs each year.

Over the years, seeing the public swayed by the falsehoods and partial truths of unqualified, self-appointed experts, some with disreputable backgrounds, and all using the same emotional tactic of fear, many dentists have been disheartened and become apathetic – understandably.  Once again, the profession must be stimulated to think fluoridation and act accordingly.  Concerted effort on the part of its members can turn around the irrational charges and devious practices of the opponents by enlightening the public to the true facts, thereby changing its attitude from rejection of to demand for fluoridation of its water supplies.  Once a community gains that objective, the improvement in the dental health of its citizens – – physically and economically – – will provide the necessary support for continuation of the program.  The record will speak for itself; the local dental society need only keep it before the public.  Moreover, the image of the dentist will be enhanced by the victory for the community.

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Today, in spite of some of the recent defeats, hope should prevail in the light of some of the successes – – which usually do not receive the publicity that a failure attracts – – and the support that has been indicated by the ADA House of Delegates and the U.S. Department of Health, Education and Welfare as cited in the following paragraphs.

Some demonstrations of success:  The consequences of fluoride-deficient drinking water were learned the hard, dramatic way in Antigo, Wisconsin.  That community had been fluoridating its water supply for 11 years when, in 1960, the opponents convinced the voters to discontinue the program.  Wisconsin public health officials examined nearly all children in the kindergarten, second, fourth and sixth grades to provide a base for future comparison with children in those grades who would not have had the benefits of fluoride.  In 1964, the findings for children in those same grades revealed such dramatic increases in dental decay that the voters reversed their decision and reinstated fluoridation in 1965.  (17)

Results of 11 years of fluoridation, 1965-76, turned out to be the “good news stories of the year” in Winona, Minnesota.  (18) The 15 members of the Winona dental society donated a day and a half plus the services of their dental assistants to a follow-up survey of 3,500 school children, kindergarten through sixth grade, under the guidance of the chief of dental health of the Minnesota Department of Health.  Projected on the total measured dollar benefit minus the total cost of the fluoridation operation, the dramatic decrease revealed by the statistics translated into an estimated annual net savings of $45,767 in dental care for the children.  The findings captured the attention of the Winona Daily News which published feature stories, editorials and letter of commendation.  The comments of the newspaper’s editor-in-chief, Adolph Bremer, point up the importance of a good working relationship between the profession and the media on a continuing basis.

Historically on the area scene, the dental
society has been the pioneer and leader
among the professional groups in communicating
to the public helpful information in its professional
area of responsibility.  We have always tried to
cooperate, for example, in publication of the
children’s dental health week articles.  These
seemed to me to be genuine efforts to provide
useful information in understandable language.
The decade-ago campaign for fluoridation had
our support, not so much because we favored it,
but

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because the dental society had established
credibility with us and with the community.  And
now the stories on the evidence of success were
the good news stories of the year, although parents
may long ago have been convinced of that fact.

The observations made by the publication’s managing editor, Gary Evans, also reflect the mutual benefits to be derived from such a relationship:

We are pleased and thrilled by the results of the
survey report. When newspapers have Citizens
in the community with special expertise, such as
dentists, we should listen to them and their opinions
on professional matters.  The Daily News is a
helpful hand to people.  When a group provides logical
reasoning and credibility on an issue, our paper can
support that group.  Editors cannot be experts in all
fields but should be experts in listening.

Hopefully the dissemination of success stories will greatly increase the active promotion of fluoridation by individual dentists among their patients and their social and political contacts.  They must become increasingly assertive and at least mildly emotional propagandists.

Attaining approval of fluoridation in a small community may be difficult.  However, if it can be attained in a metropolitan area comprising 33 communities in a state where fluoridation was for years a bitter, political issue and in 1969, ranked 47th in the percentage of people on public water supplies receiving fluoridated water, then no water supply should remain fluoride-deficient.  After spearheading amendment of a state statute so that a municipal board of health could order fluoridation, the Massachusetts Citizens Committee for Dental health (MCCDH), a voluntary group of citizens interested in better dental health, studied the feasibility of fluoridating Boston’s water supply which was found to be part of a larger distribution system, the Metropolitan Water District, serving 33 municipalities in a 15-mile radius of Boston.  Under the leadership of the MCCDH, a carefully planned, step-by-step regional program was developed that led to initiation of fluoridation for greater Boston on March 9, 1978.

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This regional approach has application for other fluoride-deficient communities served by a common water supply.

As demonstrated by the foregoing community experiences – – and in many other geographical areas, for example, Tennessee, Indiana, Seattle – – education of the public is the essence of success, and education of the public fall, primarily, to the dentist through the countless opportunities he has for communication on a one-to[one basis:  his patient (particularly a public official or other community leader), his physician, his colleagues at the hospital, his friends and associates at church, at civic, fraternal and social meetings, his children’s friends and so on.  The same holds true for the dentist’s wife whose contacts look to her as a person who should know about developments in the dental field.

Association support:  With regard to support from the Association, the 1977 House of Delegates reaffirmed its commitment to actively promote fluoridation and directed the Council on Dental Health and Health Planning to proceed with the development of an aggressive fluoridation promotion program (Trans, 1977:904).  A National Advisory Committee on Fluoridation has already been appointed as proposed in the initiatives resulting from the 1977 Workshop on Fluoridation (Trans. 1977:319).

Government support:  Strong support of fluoridation by the Carter administration was expressed in the President’s message to the Association’s 1977 House of Delegates that read, in part “I believe now, as I believed then (while Governor of Georgia) that fluoridation is safe and that it is the most effective public health measure available to improve the nation’s dental health and reduce the unnecessary dental health expenditures . . . I assure you that my administration will not shirk its responsibility to help speed the time when all Americans will share in the benefits that modern medicine has made possible.”  In October 1978, at the request of the ADA president, Frank P. Bowyer, Jr., Julius B. Richmond, M.D., Surgeon General and HEW Assistant Secretary for Health, issued a statement reiterating the U.S. Public Health Service’s position regarding fluoridation and urging “health officials and concerned citizens in communities with fluoride-deficient water supplies to act now to see that this deficit is corrected and to ensure the benefits of fluoridation for their community.”

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While the federal government, at the highest levels, has expressed strong support for community fluoridation, a recent action of the Environmental Protection Agency is most disturbing.  Its new regulations regarding standards for drinking water classify all constituents that may affect health, including fluoride, as contaminants.  Since this word connotes danger, the EPA regulations will probably be cited in future arguments against fluoridation.  The PHS and the ADA Washington office should cooperate in an effort to have the language amended.

Research: A vast amount of research on fluoridation has been concerned mostly with proving that the measure is safe and that it reduces the incidence of dental caries.  In addition to continuing the biological and epidemiological research, studies are urgently needed in the areas of behavioral science, law and economics.  Such studies should help anticipate the behavior of opponents of fluoridation and the objections they are likely to raise as well as disclose benefits other than dental that should be stressed.

Health area:  While research to prove the safety and efficacy of fluoridation was, of course, essential, it has been used, out of necessity, in a negative fashion, i.e., fluoridation is not harmful.  It should now be used in a positive way, i.e., that fluoridation is beneficial not only to dental health but that there are other health benefits.  To facilitate research to this end, the scientific literature should be reviewed for the purpose of establishing a continuous and continuing index by name of organ or disease with which a particular study is concerned, because charges made by opponents of fluoridation and questions that are raised by individuals seeking accurate information are often related to an organ or a disease.  Among specific subjects on which further research is needed are fluorides in skeletal biology, in heart disease, in utilization of minimal iron, the combined effects of two or more additives to the drinking water supply; and the long-term effects of multiple sources of fluoride.

Other initiatives recommended in the area of research include the following:

Identification by the ADA of appropriate experts who could evaluate reports, testify at hearings and serve as expert witnesses in court cases.

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Exploration by the ADA and other appropriate agencies of the  possibility of developing a national fluoridation interagency research exchange committee.

Exploration by the ADA of the possibility of an ongoing compilation and review of relevant literature on fluorides
and fluoridation by its editorial staff.

Because of their professional positions and individual qualification, the guidance of the members of the national advisory committee on fluoridation will be invaluable in the implementation of the foregoing initiatives.

Behavioral science:

Why would some persons deny the life-long
health benefits of fluoridation to children?

What kind of mentality would reject the opinion of
those who are qualified by education, training and
experience to recommend on a scientific matter
and accept the advice of an individual whose claims
are shown to be based on pseudoscientific studies,
faulty interpretation of statistics and deliberate
misrepresentation of facts?

Social studies may not produce answers to change the attitudes reflected by the foregoing questions.  However, they might produce guidance on how to cope with the situation in order to overcome the negative effects of the messengers of fear and confusion.

Supplementing the social studies, consideration should be given to the desirability of a national advertising campaign.  Once the promotion program is fairly well organized, the ADA and the PHS might consult in advertising agency.  Perhaps the one involved in the PEP program, to explore the possibility of a national fluoridation promotion campaign, the cost involved and sources of funding.  An ideal kick-off time would be National Children’s Dental Health Week.  In 1979, this activity could be enhanced by involvement in the UNICEF Celebration of The Year of The Child.  The ADA has already approved participation (Trans, 1977:542).  An ideal landmark event during the campaign might be a White House Conference on Fluoridation.

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Law:  In view of the recent attacks on fluoridation as a violation of the principal of a free society, research in the legal area is urgent.  Provision should be made by the ADA for a temporary legal consultant to research court cases and prepare a review on the current legal status of fluoridation.  In turn, there should be research to find legal channels for positive action, i.e., legal ways that could be used to advantage by proponents to effect fluoridation rather than just react to court cases seeking to prevent or discontinue a program.

Economics:  From time to time, studies appear showing the savings in dollars for dental care when a community’s water supply is fluoridated for a substantial period.  Current valid studies are needed and should be encouraged.

If a fluoridation program could be tied in with an access program, such as the Vermont pilot project, the savings in expenditures for life-long dental care and the comfort enjoyed through the retention of natural teeth could be demonstrated dramatically.  (Implemented by the Vermont Dental Society with assistance from the American Dental Association, the Vermont program is a pilot demonstration project for increasing access to dental care for special population groups, including individuals 65 years of age and older.)

Government support:  The ADA will continue to emphasize the need for a visible, active, effective dental unit within the Department of Health, Education and Welfare as the focal point for dental activities in the federal government.  It will also cooperate to its maximum in the initiatives approved by the House of Delegates as follows:

Implement a vigorous lobbying program to obtain increased
funds and staff for additional fluoridation activities by the
U.S. Department of Health, Education and Welfare.  In view
of the recent interest expressed by the Carter administration
in child health and preventive programs, now is an especially
opportune time to seek increased federal support for fluoridation.

Urge HEW to provide the dental staff needed in its regional
offices to make technical assistance available locally for
fluoridation activities.

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Encourage support for fluoridation by the health systems
agencies created under P.L. 93-641, the National Health
Planning and Resources Development Act of 1974.

Encourage inclusion of the words “dental disease” in the
language of P.L. 94-317.

Request that the Environmental Protection Agency designate
a national representative responsible for fluoride regulation
in view of the interim primary water regulations prescribed by
P.L. 93-523, the Safe Drinking Water Act of 1974.

Determine which and how many communities would implement
fluoridation if funds were made available and report the results
to the Center for Disease Control to support a request from
CDC for fluoridation program monies.

Public education:  The fluoridation message reaches the public in a variety of ways:  the press, radio, television, school programs and the private dental office.  While the latter was once held to be the most effective, more recent studies indicate there is no one best way to teach prevention (19, 20).  Appropriate information materials and informed spokesmen must be available

With regard to printed materials, existing items should be reviewed to determine if they are current and appropriate for their respective producers (ADA, PHS, specialty and allied dental organizations, state health departments) and reprinted or replaced.  Consideration should be given to the creation of new materials, such as radio and television spots; patient education materials (bill stuffers, pins recognizing children with perfect check-ups); a wall sign on prevention, emphasizing fluoridation, to be distributed to all ADA members for display in their offices; a program kit for dental societies and other organizations that might include a film and/or slide set, speech, handouts; pocket-sized speaker’s aid card; prototype campaign materials (fact sheet for editors, statements for use in letter-to-the-editor rebuttals, simple fliers for windshields); posters, and so on.

Provision should be made by the ADA for the training and funding of national and regional fluoridation spokesmen.  The techniques developed by PEP should be explored for their application to the training of fluoridation spokesmen.

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the public should be made aware by the ADA of the information clearinghouse, possibly with a toll-free number.

Residents of communities which are now fluoridated should be reminded by the ADA of the value of this public health measure through continuing education efforts.  They may take the benefits of the program for granted, and the ever-ready opponents will take advantage of their complacency.

Media activities relating to fluoridation should be expanded by the ADA and other appropriate agencies.  Staff members of the Bureau of Communications meet with various radio and television representatives and newspaper, magazine and syndicate editors throughout the year in their mutual interest in accuracy of dental coverage and advancement of dental health.  The Bureau staff also suggests subjects for articles, serves as consultants to publishers and writers and, when indicated, provides the ADA’s response to false claims and erroneous statements in the media.  The responses are usually couched in unemotional language common to the scientific community – – “The American Dental Association reiterated its long-standing support of fluoridation “numerous studies have shown there is no evidence of any relation, “investigators have observed.”

In contrast to the charge from an anti-fluoridation pseudoscientist that “fluoridation is a form of public mass murder,” the foregoing types of response give pause to the wisdom of restraint.  The advice of behavioral scientists should be sought with regard to more realistic, convincing rebuttals.

The ADA should explore with dental manufacturers, dealers and suppliers the possibility of including fluoridation promotion messages on their product labels and in their commercial advertisements.

Community activity:  The ADA should encourage all members to support fluoridation through participation in community activities and through patient education in the dental office.  Since community activity is the most important part of an action program, everything done by the ADA and the federal health agencies should be done to encourage, support and strengthen positive and intelligent action at the community and state levels.  The 1979-80 goals of each state dental director, state fluoridation committee or state health department could be determined by means of a questionnaire which would disclose the communities in which a fluoridation campaign is likely to be successful; whether the timing is right for a statewide fluoridation law, whether the opponents of fluoridation will be active and, if so, what countermeasures should be implemented.

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In general, it can be expected that state dental directors, health departments and fluoridation committees will become actively and primarily responsible for promoting fluoridation and that performance will be reflected in the yearly addition to the number of communities which had fluoridation on December 31, 1978.  The National Advisory Committee on fluoridation will assist them in every way possible to reach their goals which will range from 0 to 100 percent.

The ADA should produce a step-by-step manual for the development and conduct of a fluoridation campaign that can be adapted to any community.  Regardless of size, the pattern will be much the same:  gaining the unified support of physicians and other health professionals, community leaders, the women’s auxiliaries to the dental and medical societies, the parent-teachers’ association, church, fraternal and philanthropic groups and the media; anticipating and thwarting the activities of the antifluoridationists; seeking guidance and assistance, if necessary, from the ADA, the PHS and state health department; finding out possible sources of financial support if funds are needed; checking the state law to see if political action may be required, and so on.

The ADA should provide field assistance if needed in a fluoridation campaign or cooperate with the PHS and state health departments in providing such assistance.  A prime concern of all agencies once a fluoridation program is initiated, should be the assurance of surveillance to make certain the fluoride content is maintained at the optimal level.

The ADA should seek a coalition of national health organizations and agencies, dental and nondental, to cooperate in promotion of fluoridation and to encourage their state and/or local units to join in fluoridation campaigns in their respective communities.

Women’s auxiliaries should be encouraged by the ADA to consider fluoridation as a special project in view of their outstanding success in the field of dental health education.

Fluoridation would be an excellent community project for service clubs (Kiwanis, Lions, Rotary) and should be brought to their attention by the ADA, many of whose members belong to one of the groups.

All dental organizations should be reminded by the ADA of the special reasons why, they should support fluoridation and encourage their members’ individual participation in fluoridation campaigns in their respective communities.

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The ADA should encourage the development of grass-roots leadership to implement fluoridation programs by (1) sponsorship, perhaps in collaboration with other appropriate agencies, of national and regional workshops for professional and other leaders from target communities and (2) by appropriate recognition of individuals and communities working to implement fluoridation programs.

The ADA should consider increasing the provision of grants to constituent dental societies for fluoridation activities in target communities.

Start-up grants and technical assistance for target communities should be provided by appropriate government agencies.

International impacts:  Developments in dentistry in other countries have an impact in the United States and vice versa.  The lay press and professional journals herald developments in other countries relating to national health schemes, sugar-free chewing gum, dental laboratory technology and, of course, fluoridation.  Close communication should be maintained with the Federation Dentaire Internationale which serves as a consultant to the World Health Organization and whose request relating to fluorine metabolism information led to the WHO publication, Fluorides and Human Health in 1970.

Sometimes, visiting dentists from abroad can be sources of information on the status of fluoridation in their respective countries.  Similarly, U.S. dentists traveling abroad can carry the message about fluoridation in this country and correct misinformation disseminated by opponents of fluoridation from the U.S.  In view of the fact that the latter take every opportunity to speak out against fluoridation abroad as well as at home and then use any resulting headlines adversely, the Council on Dental Health and Health Planning should take advantage of opportunities to provide traveling U.S. dentists with pertinent, factual information.  To find this kind of emissary, the ADA coordinator should arrange with the ADA Council on International Relations to be advised of requests from ADA members who are planning a trip abroad and want to know if they can do anything for the Association.  It might be desirable to see if they could be of assistance with regard to fluoridation.

References

1. American Dental Association. Fluoridation Facts. pp. 19-23. Chicago, American Dental Association. 1974.

2. First Report of Expert Committee on Water Fluoridation (Technical Report Series No.146) p. 16.  Geneva, Switzerland, World Health Organization.  1958.

3. World Health Organization.  Thirty-First World Health Assembly, FL-101.  July 1978.

4. Phair, W. Philip and Driscoll, Marian F. The Status of Fluoridation Programs in the United States, Its Territories and Possessions. JADA 45:555.  November 1962.

5. U.S. Department of Health, Education and Welfare, Public Health Service. Fluoridation Is For Everyone. DHEW Publication No. (CDC) 77-8334.

6. Terry, Luther L.  The next great areas for teamwork in national health. JADA 63:183.  August 1961.

7.  Ireland, Ralph L. Editorial, Journal of the Nebraska Dental Association 50(4):5. 1974.

8. American Medical Association, Department of Investigation. Data sheet on National  Health Federation. Chicago, American Medical Association. 1966. (Reprinted in ADA News September 2, 1975).

9. ADA News September 22, 1975.  Report by Stephen Barrett.  Physician details NHF’s fight against fluoridation, FDA authority.

10. Federal Food, Drug and Cosmetic Act, Public Law 85-929.  Sec. 409 (348) (c) (3) (a).  September 6, 1958.

11. Yiamouyiannis, J.S. Fluoride and Cancer, National Health Federation Bulletin 21:9.  April 1975.

12. Hoover, R.N., McKay, F.W. and Fraumani, J.F.  Fluoridated drinking waters and the occurrence of cancer.  Journal National Cancer Institute 57:757. October 1975.

13. Royal College of Physicians. Fluoride, Teeth and Health.  London, Pitmans.  1976.

14. Doll, Richard and Kinlen, Leo. Fluoridation of water and cancer mortality in the USA. Lancet  p. 1300.  June 18, 1977.

15. Taves, D.R. Fluoridation and cancer mortality, in Origins of Human Cancer (Cold Spring Harbor Conferences on Cell Proliferation, Vol. 4)  Edited by H.H. Hiatt, J.D. Watson and J.A. Winsten.  P. 357-366.  New York, Cold Spring Harbor Labs. 1977.

16. State Laws. Informal compilation, Center for Disease Control, U.S. Public Health Service, Atlanta.

17. Lemke, C.W. et al. Controlled fluoridation: The dental effects of discontinuation in Antigo, Wisconsin. JADA   80:782-786. April 1970.

18. Winona Daily News.  February 10, 1977. Winona, Minnesota.

19. Bureau of Dental Education, American Dental Association, Patient Education: Use of educational materials in the dental office.  JADA 69:618.  November 1969.

20. Chambers, Davis W.  Patient susceptibility limits to the effectiveness of preventive oral  health education.  JADA 95:1159.  December 1977.

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