As we have reached IFIN #600, and it is a Sunday, I thought it would be an appropriate time for a little reflection. Here is a short essay.
FLUORIDATION: KEY MOMENTS IN ENDING AN INDEFENSIBLE PRACTICE.
There have been many important moments in the long battle to end water fluoridation: the practice of adding a known highly toxic substance into the drinking water of every man, woman and child in the community. Without writing a book on this history it would be impossible to do justice to them all.
In this discussion I will focus on events since 1980 and only on the key moments which have demonstrated fluoridation’s ineffectiveness in fighting tooth decay.
For me the key moment in the MODERN battle to end fluoridation occurred in 1980, when Dr. John Colquhoun, the Principal Dental officer of Auckland, New Zealand, a strong advocate of fluoridation, was asked by his superiors to take a world tour to collect the evidence, which would show, once and for all, that fluoridation was effective at reducing dental decay. The trip took him four months and he went to Australia, Asia, North America and Europe. To his utter chagrin the evidence was not there. Behind the scenes he was told by leading dental researchers that they were not finding the massive reductions in dental decay (60-70%) that zealous advocates of fluoridation had been proclaiming.
On his return to New Zealand Colquhoun compared the dental decay statistics for children in non-fluoridated parts of New Zealand with the fluoridated parts, and he too found little or no difference. If anything the teeth in the non-fluoridated areas were slightly better than the fluoridated areas. When he also found much higher dental fluorosis figures in the fluoridated areas, he decided to go public, knowing that he was risking the level at which his pension would be set (see Colquhoun, 1997 for his own summary) . This was a supreme moment of integrity and courage in my view.
The next key moment came in 1986 when Dr. Mark Diesendorf, from Australia, published an important article in the prestigious British journal Nature (Diesendorf, 1986). In this article he showed that tooth decay was coming down as much in non-fluoridated communities as in fluoridated communities in many countries (Australia, Denmark, Holland, New Zealand, Norway, UK and the US) and that in communities where the anticipated benefits would have been maximized tooth decay continued to decline. Something else, other than fluoridation, would have to be invoked to explain these reductions in tooth decay.
The third key moment came when the National Institute of Dental Research (NIDR) set out to do the largest survey of dental decay ever attempted in the US. They looked at over 39,000 children in 84 communities and the study cost the US taxpayers $3.6 million. When Dr. Yiamouyiannis, a well-known opponent of fluoridation looked at these figures, he found no significant difference in decayed, filled and missing teeth (DMFT) between the children who had lived all their lives in fluoridated and those who lived all their lives in non-fluoridated communities (Yiamouyiannis, 1990). Because Dr. Y was a well-known opponent of fluoridation, advocates were suspicious. However, when the NIDR’s own researchers reported the results (Brunelle and Carlos, 1990), they too found very little difference in decay rates between the two sets of the children. However, this is not how they “spun” the findings in the abstract of their paper. They wrote:
“Children who had always been exposed to community water fluoridation had mean DMFS scores about 18% lower than those who had never lived in fluoridated communities…The results suggest that water fluoridation has played a dominant role in the decline in cries and must continue to be a major prevention methodology.”
Now this may sound impressive until one actually looks at the numbers in question. In table VI they list the DMFS (decayed, missing and filled SURFACES, which is a more sensitive measure of tooth decay than the DMFTs used by Dr. Y) for children aged 5-17 years of age who had lived all their lives in fluoridated and those who lived all their lives in non-fluoridated communities. The average DMFS was 3.39 for the non-fluoridated children and 2.79 DMFS for the fluoridated ones. If one subtracts 2.79 from 3.39 one gets a difference of 0.6 tooth surfaces and this is indeed an 18% (17.7%) difference in decay of tooth surfaces. But in absolute terms it represents a difference of only 0.6 of one tooth surface out of 128 tooth surfaces in a child’s mouth – a saving of less than 0.5% ( 0.47%) of their tooth surfaces. It is highly unlikely that such a minute saving represents either a clinical or statistically significant difference. In fact the authors, for reasons which they leave unexplained, do not present a statistical analysis of their findings.
Why then didn’t fluoridation end at this point? Firstly, we can only assume that the NIDR and the rest of the dental establishment did not want to admit that the policy that they had promoted – with so much hype – for so many years, was actually not effective. Secondly, those outside the dental establishment probably didn’t understand what DMFS stood for and probably didn’t go beyond the abstract. Thirdly, those who did could not get the ear of the mainstream press against the continued hype for fluoridation from high places in the US Government, the medical and dental establishments. These quarters continued their incessant drumbeat, “Fluoridation is safe and effective, safe and effective…” drowning out the voices of reason and caution.
The fourth key moment came in a study, which was based upon dental fluorosis data collected in the same 1986-87 NIDR survey discussed above. Heller et al (1997) reported that the dental fluorosis in optimally fluoridated communities in the US affected 29.9% of the population on at least two teeth. This damage represented a level three times higher than the original goal of the promoters of fluoridation, who thought at 1 ppm they could limit fluorosis to 10% of the children in its mildest form. Thus one of the two planks of fluoridation had failed by a very wide margin. This too could have ended fluoridation, but by this time the dental zealots had braced themselves for these negative findings by describing dental fluorosis as merely a “cosmetic effect”. For these promoters a little damage to the enamel for one third of the population was a price they were prepared to pay for saving 0.47% of the tooth surfaces of the average child!
Later research from several other countries confirms the findings listed above. In 1996 Australian researchers (Spencer et al, 1996) reported a saving of between 0.12 and 0.30 DMFS (i.e. less than 0.1 to 0.23% of the tooth surfaces in a child’s mouth), while finding dental fluorosis rates in fluoridated communities ranging from 40% (Western Australia) to 56% (Southern Australia).
In 1998, Betty de Liefde described a difference in DMFT (decayed, missing and filled TEETH) between children living in fluoridated and non-fluoridated areas in New Zealand of 0.3 (recorded in 1995) as being “clinically meaningless”.
In 1999, Dr. David Locker, in a report commissioned by the Ontario Government, Canada (published in 2001), described the benefit of fluoridation as “not large in absolute terms” and “is often not statistically significant and may not be of clinical significance”. In 2000, the York University team commissioned by the British government, reported an estimated dental fluorosis rate of 48% in optimally fluoridated areas with 12% in a category requiring treatment. Meanwhile, World Health Organization figures available online confirm Diesendorf’s findings from 1986: dental decay rates have been coming down just as fast, if not faster, in non-fluoridated communities as in fluoridated ones. (A graphical summary of this data can be found at http://www.fluoridealert.org/WHO-DMFT.htm)
Even if we ignore all the other health concerns documented since 1990, who in their right mind would advocate a practice which saves at most half a tooth surface while contributing to damaging the enamel of half the population and requiring treatment for more than 1 in 10? But those who make decisions on these matters are usually separated from such rational analysis by the continued mind numbing drumbeat from officials in the US Public Health Service, from the US Surgeon General down to his minions in the State Health Departments, who tell all the waiting newspaper editors and unsuspecting local officials that fluoridation is “safe and effective, “safe and effective”.
That drumbeat became a thunderous explosion when the CDC published its notorious October 22, 1999 MMWR (Mortality and Morbidity Weekly Report) which told the world that fluoridation was “one of the top ten medical achievements of the twentieth century”. Never mind that the report was written by one dentist, did not receive external peer review, was 6 years out of date on its health references, and produced a ridiculously misleading graph which implied that the decline in dental decay in the US from the 60s to the 90s, was correlated with the percentage of the US population drinking fluoridated water, without acknowledging that, according to WHO figures available online, these same reductions (or greater) were occurring in non-fluoridated countries over the same period. However despite its limitations and distortions, this report did represent another key moment in the modern opposition to fluoridation worldwide. This is because the CDC did acknowledge that for over 50 years those promoting fluoridation had got the mechanism of action of fluoride wrong. Concurring with many dental researchers worldwide they admitted that fluoride’s major benefits were topical not systemic. Here is how the report put it:
“Fluoride’s caries-preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid-resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children (1). These mechanisms include 1) inhibition of demineralization, 2) enhancement of remineralization, and 3) inhibition of bacterial activity in dental plaque.” (See http://www.fluoridealert.org/cdc.htm for the full CDC report and our critique of it).
How, one might wonder, would the CDC and other avid promoters of fluoridation wriggle out of this one? If the benefits of fluoridation were topical and all the risks, including the undisputed risk of dental fluorosis, were caused by systemic exposure, why on earth would one put fluoride in the water and guarantee systemic exposure, while achieving very little topical exposure (try drinking a glass of water and see where the water goes before it goes down your throat)? Why not advocate fluoridated toothpaste which is already universally available, which would deliver the fluoride topically but allow it to be spat out before very much systemic exposure has been achieved (unfortunately some fluoride will pass through the gums into the plasma and small children tend to swallow too much toothpaste)?
But wriggle they did. First of all they saw the bonus of saying, because it is topical it confers lifelong benefits, especially for the elderly with receding gums. Secondly, they argued that (George Orwell please stay still!) systemic exposure was the best way to achieve topical exposure! They argue that by swallowing the fluoride it exposes all your tissues to fluoride, including the salivary glands, and thereby allowing the fluoride to re-enter the oral cavity in your saliva, thus bathing your teeth all day long with levels of fluoride at concentrations of 0.016 ppm. Needless to say, this is an incredibly weak argument.
It is highly unlikely that a concentration of 0.016 ppm fluoride does much good in helping to remineralize tooth surfaces or prevent demineralization and it certainly is not high enough to inhibit bacterial activity in the dental plague. A recent study by Dogan et al (2002) confirms the latter thought. They showed that concentrations of fluoride as high as 2.4 ppm fluoride ion (i.e. 0.125 mM NaF) were needed to slightly affect the growth of Streptoccous sobrinus, one of the pathogens thought to cause caries. 2.4 ppm is 150 times higher than the salivary concentration of fluoride (0.016 ppm). The authors found no viable Streptoccous sobrinus at 152 ppm F (8 mM NaF) which is 9500 times higher than salivary concentrations obtained by drinking optimally fluoridated water. Or as the authors put it:
“NaF revealed antimicrobial effects only at concentrations that are significantly higher than oral fluoride concentrations.”
The final straw which should break the camel’s back of fluoridation has been the publication of four studies between 2000 and 2001, which have found no increase in dental decay in communities in Finland (Seppa et al, 2000), Cuba (Kunzel and Fisher, 2000), former East Germany (Kunzel et al, 2000) and Canada (Maupome, 2001), where water fluoridation has been halted. All of these articles are in the mainstream peer-reviewed dental literature.
So those are some of the key milestones since 1980 which show that water fluoridation is not effective. They are not even the most important findings. The health effects of exposure to this toxic substance are more important (but that would take another paper), as is the fact that water fluoridation tramples over the important legal and medical ethic which says that medication should be only given to the individual with their “informed consent”. But if fluoridation is ineffective, why on earth would government officials expose people to ANY health risk and why would they feel secure enough about the practice to remove our right to “informed consent”?
The only defense for those who continue to promote fluoridation is simply to refuse to debate the issue, and instead rely on the drumbeat “safe and effective” and ad hominem attacks on opponents of fluoridation. The hope is that the ordinary citizen will simply trust government officials without checking into the literature themselves and without examining the background of those who are attacked. This defense becomes less and less tenable with the advent of the internet and networks like this which are making the solid scientific information available to all who care to seek it out and read it for themselves. Promotion of fluoridation also became more difficult when people like Dr. Hardy Limeback, former President of the Canadian Association for Dental Research and Head of Preventive Dentistry at the University of Toronto, come out against fluoridation.
How much more satisfactory it is to be on the side of those like Dr. John Colquhoun, Dr. Richard Foulkes and Dr. Hardy Limeback, who have had the courage to come out and say publicly they were wrong about their past support of fluoridation, than to be saddled with allies like Stephen Barrett (self-styled Quackbuster!), Michael Easley (American Council on Science and Health), Tom Reeves (CDC), Mark Greer ( Dental Director of Hawaii Health Department) and other State dental directors whose unwillingness to defend this practice rationally is breathtaking. Here are two outrageous examples of their “irrational defense”.
1) While I was in New Zealand, I had to listen to an health official read this diatribe from Stephen Barrett (“Fluoridation: Don’t let the Poisonmongers Scare You!”), who complains that,
“Although fluoridation is safe and effective in preventing tooth decay, the scare tactics of misguided poisonmongers have deprived many communities of its benefits…The antifluoridationists (“antis”) basic technique is the big lie. Made famous by Hitler, it is simple to use, yet surprisingly effective. It consists of claiming that fluoridation causes cancer, heart and kidney disease, and other serious ailments that people fear….”
Incredibly this disgusting document has been distributed to officials in many communities confronted with efforts to fluoridate their water.
2) Here is what Michael Easley has to say about those wanting to have this issue aired in a public debate:
“Debates give the illusion that a scientific controversy exists when no credible people support the fluorophobics’ view.”
“Like parasites, opponents steal undeserved credibility just by sharing the stage with respected scientists who are there to defend fluoridation.”
“Unfortunately, a most flagrant abuse of the public trust occasionally occurs when a physician or a dentist, for whatever personal reason, uses their professional standing in the community to argue against fluoridation, a clear violation of professional ethics, the principles of science and community standards of practice.”
It is surprising that any democratically elected government official would be seen to be associated with such people or such ideas… or such a practice as fluoridation once the facts are known.
Brunelle, J.A. and Carlos, J.P. (1990). J. Dent. Res 69, (Special edition), 723-727.
CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Mortality and Morbidity Weekly Review (MMWR), 48(41);933-940 October 22, 1999.
Colquhoun, J (1997) “Why I changed my mind on Fluoridation. Perspectives in Biology and Medicine, 41, 1-16. http://www.fluoride-journal.com/98-31-2/312103.htm
Connett, P. and M. Connett (2000). The Emperor Has No Clothes: A Critique of the CDC’s Promotion of Fluoridation. Waste Not #469, 82 Judson Street, Canton, NY 13617. http://www.fluoridealert.org/cdc.htm
De Liefde, B. (1998). The Decline of Caries in New Zealand Over the past 40 Years. New Zealand Dental Journal, 94, 109-113
Diesendorf, M.(1986). The Mystery of Declining Tooth Decay. Nature, 322, 125-129. http://www.fluoridealert.org/diesendorf.htm
Dogan, S. , Günay H., Leyhausen G.and W. Geurtsen (2002). Chemical-biological interactions of NaF with three different cell lines and the caries pathogen Streptococcus sobrinus Clin Oral Invest (2002) 6: 92-97.
Easley, M. (1999). Community Water Fluoridation in America: The Unprincipled Opposition.
Heller KE et al (1997). Dental Caries and Dental Fluorosis at Varying Water Fluoride Concentrations. J of Pub Health Dent, 57;No. 3, 136-143.
Kunzel, W. and T. Fischer (2000). Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res 34(1): 20-5.
Kunzel, W., Fischer, T., Lorenz R., and S. Bruhmann (2000). Decline in caries prevalence after the cessation of water fluoridation in former East Germany. Community Dent. Oral Epidemiol. 28(5): 382-389
Maupome, G. et al. (2001). Patterns of dental caries following the cessation of water fluoridation. Community Dent Oral Epidemiol 29(1): 37-47.
Seppa L, Karkkainen S, and H. Hausen (2000). Caries in the primary dentition, after discontinuation of water fluoridation, among children receiving comprehensive dental care. Community Dent Oral Epidemiol. Aug;28(4):281-8
Spencer, A.J., Slade, G.D. and M. Davies (1996). Water fluoridation in Australia. Community Dental Health. 13, Supplement 2, 27-37.
Sprague, B., Bernhardt and S. Barrett. Fluoridation: Don’t Let the Poisonmongers Scare You! http://www.quackwatch.com/03HealthPromotion/fluoride.html
Yiamouyiannis, J.A. (1990). Water Fluoridation and Tooth decay: Results from the 1986-87 National Survey of U.S. Schoolchildren. Fluoride, 23, 55-67. http://www.fluoridealert.org/DMFTs.htm