I was asked to watch the film “An Inconvenient Tooth.” I take my decision on fluoridation very seriously so I asked my staff and others to provide us answers to the questions raised in the film. The first interview is with Dr. Paul Connett, has been criticized for taking studies out of context and making blatantly false statements. For example, I understand that Professor John Spencer, internationally recognized as Australia’s leading oral health researcher and head of the Australian Research Centre on Population Oral Health (ARCPOH) at Adelaide University, responded to how his research was distorted by Dr. Connett. Professor Spencer states, “Dr Connett misrepresents the study as an analysis of the benefits of water fluoridation which it was not. He also misinterprets the study’s indirect evidence on the benefits of water fluoridation on decay”.
Further, Dr. Connett has been criticized for routinely citing studies that have not been peer-reviewed, distorts their findings, misrepresents legitimate scientific research or draws scientifically invalid conclusions from evidence cited. Dr. Connett even praises Dr. John Yiamouyiannis, a doctor who falsely claimed that HIV does not cause AIDS. I do not find Dr. Connett or his organization, Fluoride Action Network, a credible source of information.
1. No difference in tooth decay between fluoridated versus non-fluoridated countries. The claim that with more fluoride you get less tooth decay has not held up.
FACT: Validated studies show fluoridation works. When comparing communities, you have to look at dental health care, diet, tobacco use, poverty, and whether people are getting their water from the public system or from a well. Valid studies compare tooth decay before and after fluoridation, or between communities that have been matched for “confounders” like access to dental care, income level or percentage of the population on well-water.
FACT: Comparisons of countries can be highly misleading because many countries that do not fluoridate drinking water find other ways to provide fluoride’s benefits to their citizens. For example, Germany and Switzerland rely heavily on fluoridated salt to help residents protect their teeth from decay. A more accurate way to assess the value of fluoridated water is to compare counties or cities within the same U.S. state. Recent studies doing just this in New York and Alaska confirm what has been know for decades — water fluoridation reduces tooth decay.
The 2010 New York study revealed that low-income children where optimally fluoridated water was common needed 33% less fillings, root canals and extractions than low-income children in counties with low levels of optimally fluoridated water.
The 2011 Alaska study showed that kids living in non-fluoridated communities had a 32% higher rate of decayed, missing or filled teeth than kids who lived in communities with optimally fluoridated water.
These studies confirm what over 65 years of research and experience have shown, water fluoridation reduces tooth decay by an additional 25% over and above other factors.
Guide to Community Preventive Services. “Preventing dental caries: community water fluoridation”
Twenty-one studies, eleven of which were published since 1992, qualified for review.
• Decay rates measured before and after water fluoridation: median
decrease of 29.1% among children ages 4 to 17 years when compared with
control groups (21 study arms).
• Decay rates measured after water fluoridation only: median decrease
of 50.7% among children ages 4 to 17 years when compared with control
groups (20 study arms).
• Fluoridation was found to help decrease tooth decay both in
communities with varying decay rates and among children of varying
CDC. “Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries.”
“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%)… Fluoridation reduces enamel caries in adults by 20%-40% and prevents caries on the exposed root surfaces of teeth, a condition that particularly affects older adults.”
The Environmental Protection Agency (Office of Water) did a follow-up assessment of the relationship between fluorosis and dental caries based on the recommendation of the National Research Council’s report “Fluoride in Drinking Water” (2006). They state:
“Early childhood exposure to fluoride in drinking water has been shown to significantly reduce the occurrence of caries.”
The studies that Connett refers to look only at 12 year olds and often are convenience samples rather than comprehensive studies of children of all social and economic conditions in those countries. Many of the countries fluoridate salt and/or have comprehensive universal clinical preventive service programs. Comparing tooth decay in these countries by such a crude measure does not provide evidence of the effectiveness of fluoridation or any other preventive or treatment intervention.
Many additional reviews are listed here: http://www.cdc.gov/
2. No one is doing comprehensive health studies on impacts of fluoridation beyond teeth but literature has well established that fluoride ruins people’s lives, that there is a correlation between fluoride and arthritis, lowered kidney and thyroid functions and brain and bone damage.
Fact: Hundreds of studies and at least a half dozen expert review committees have looked at potential negative health impacts of optimally-fluoridated water. All expert reviews have concluded that there is no credible evidence for any negative health impact of optimally fluoridated water. See: http://www.cdc.gov/
Expert reviews have been conducted by:
(1) United States Public Health Service (1991)
(2) Institute of Medicine (1997)
(3) National Academy of Sciences (1951, 1977, 1993, 2006, 2007)
(4) Australian Government (2007)
(5) University of York / National Health Service, UK (2000)
(6) Fort Collins Technical Committee (2003)
The National Academy of Sciences / National Research Council report of 2006 is often cited as finding negative impacts. But, in fact, this report specifically did not examine optimally fluoridated water of 0.7 ppm but instead looked at higher concentrations of fluoride. They concluded that at 4 ppm there was no negative health impacts except for a potential for severe dental fluorosis. They concluded that at 2 ppm (or almost three times optimal levels), severe dental fluorosis was near zero, and there was no credible evidence for negative health impacts.
3. Drinking water providers with fluoridation are not giving users an “informed consent” option for taking a medication as required by law.
Fact: Water fluoridation is a basic public health preventive service. It has been thoroughly tested in the US court system. The highest courts of more than a dozen states have ruled that water fluoridation is constitutional. http://www.ncbi.nlm.nih.gov/
Fluoridation exists naturally at some level in all water supplies. Consumers of Bull Run water are already drinking fluoride at a concentration of around 0.1ppm. The questions is not whether people are consuming fluoride, but what the optimal level is for people’s health. Unlike medication, fluoride is a naturally-occurring mineral, and there are no negative impacts of fluoridation at optimal levels.
4. Dentists do not have training in toxicology or the neurology.
Fact: Toxicologists and neurologists have weighed in on water fluoridation.
The Agency for Toxic Substances & Disease Registry says:
• “Fluorides are often added to drinking water supplies and to a variety of dental products, including toothpaste and mouth rinses, to prevent dental cavities.”
• “Fluorides are naturally occurring compounds. Low levels of fluorides can help prevent dental cavities.”
• “Cancer Effects: None.”
National Cancer Institute: “Many studies, in both humans and animals, have shown no association between fluoridated water and cancer risk.”
Dr. Damien Fair, OHSU Neurologist, testified at the hearing that “Optimal water fluoridation does not impair brain development.”
The 2006 National Research Council report that CDC has cited as providing evidence of the safety of fluoride in drinking water at the level recommended to prevent tooth decay was prepared by the Committee on Fluoride in Drinking Water established by the Board on Environmental Studies and Toxicology and the report was reviewed by the NRC’s Committee on Toxicology. Several members of the Committee on Fluoride in Drinking Water are toxicologists.
5. The Centers for Disease Control (CDC) only has 30 staffers in one division devoted to the study of oral health in the United States and their job is to promote fluoridation.
Fact: Here is the About Us page for the CDC Oral Health Division, which has a range of goals across the spectrum of oral health issues.
Our Vision: A nation where all people enjoy good oral health that contributes to leading healthy, satisfying lives.
Our Mission: To prevent and control oral diseases and conditions by building the knowledge, tools, and networks that promote healthy behaviors and effective public health practices and programs.
• To prevent and control dental caries (tooth decay) across the life stages.
• To prevent and control periodontal (gum) disease.
• To prevent and control oral and pharyngeal (throat) cancers and their risk factors.
• To eliminate disparities in oral health.
• To promote prevention of disease transmission in dental health care settings.
• To increase state oral health program capacity and effectiveness.
The CDC’s Division of Oral Health (DOH) works to improve the oral health of the nation and reduce inequalities in oral health by—
• Helping states improve their oral health programs.
• Extending the use of proven strategies to prevent oral disease by—
• Encouraging the effective use of fluoride products and community water fluoridation.
• Promoting greater use of school-based and –linked dental sealant programs.
• Enhancing efforts to monitor oral diseases, such as dental caries (tooth decay) and periodontal infections (gum disease).
• Contributing to the scientific knowledge-base regarding oral health and disease.
• Guiding infection control in dentistry.
• Helping states improve their oral health programs.
CDC’s organizational structure includes an Associate Director for Science at each level of the agency and all science and policy statements are subject to review and approval by the higher level. This structure assures that CDC units practice evidence-based science grounded in sound peer-reviewed research and assure a strong science base for public health action. See http://www.cdc.gov/od/science/
In addition, the CDC is simply one organization of many, many health organizations that support fluoridation.
6. The United States “government health services” now admit they got it wrong when they thought that babies had to swallow fluoride. Those same agencies now admit fluoride only works topically and not systemically.
FACT: The CDC states that fluoride works best when small amounts are maintained in the mouth (in dental plaque and saliva) throughout the day. This is why water fluoridation is so effective, compared to tooth-brushing or fluoride supplements that are just taken once a day. Water fluoridation is a lifespan health strategy: Adults benefit from fluoride, not just children.
Water fluoridation works to strengthen teeth and make them resistant to decay during tooth development (systemically), as well as by providing fairly continuous low levels of fluoride in the saliva that neutralizes the acids created by bacteria and also remineralizes teeth (topically).
The CDC says it is safe to mix fluoridated water with formula. For babies who are exclusively formula-fed, if parents are concerned about fluorosis, they can talk to their pediatrician and use fluoridated water part of the time and non-fluoridated water the rest of the time.
7. Scientists at EPA have been fired for being outspoken on fluoride’s toxicity
In 1992 The EPA did incorrectly fire Dr. William Marcus who strongly opposed water fluoridation. He was reinstated and received back pay. The EPA’s mistake, however, does not make Dr. Marcus correct. In fact, his claims that fluoridated water leaches lead from pipes and causes cancer have all been disproven. Adding Fluoride to the water does not increase the risk of cancer as The American Cancer Society makes clear, they state “The EPA has established that optimally fluoridated water does not leach lead from pipes. Following extensive research its scientist found that, “Overall, we conclude that no credible evidence exists to show that water fluoridation has any quantifiable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead(0) or lead(II) compounds.”
Dr. Marcus’s reinstatement is an indication that the EPA did not follow proper administrative procedures, but he was and is clearly wrong about the science.
8. Which side is presenting the more solid scientific case? 24:36
Proponents will not make citations available: opponents who make the science transparent and give all the references 25:09
FACT: References and citations are linked on the www.
Additional sources of scientific information used by the Coalition are:
Community Preventive Services Task Force: http://www.thecommunityguide.
World Health Organization: http://www.who.int/
American Academy of Pediatrics: http://www.healthychildren.
American Dental Association: http://www.ada.org/fluoride.
Pew Center on the States: http://www.ilikemyteeth.org/
National Cancer Institute: http://www.cancer.gov/
National Research Council: http://www.nap.edu/catalog.
9. “…communities of color…. are more likely to live in areas that are fluoridated and also because of all of the different health problems…that black and latinos have already their health conditions get exacerbated…”
Fact: Water fluoridation reduces oral health disparities. “A 2002 study called water fluoridation “the most effective and practical method” for reducing the gap in decay rates between low-income and upper-income Americans. The study concluded, “There is no practical alternative to water fluoridation for reducing these disparities in the United States.”’
Nearly all the major organizations representing people of color in Portland are members of the Everyone Deserves Healthy Teeth Coalition. No organization specifically representing people of color in Oregon opposes fluoridation.
Communities of color and low-income populations are disproportionately affected by dental decay. The Centers for Disease Control and Prevention found that nationally, 16.9% of White children (2-5 years) had untreated tooth decay, while 24.1% of African American and 31.4% of Mexican children (2-5 years) had untreated tooth decay. Water fluoridation decreases tooth decay by 18% – 40%, and has the greatest impact on communities with less access to regular dental treatment.
At 0.7 ppm, children will not be at risk of “high exposure” of fluoride. The NRC concluded that severe dental fluorosis was “close to zero” at water fluoridation levels at or below 2 ppm, which is almost three times the level found in optimally fluoridated water. Most fluorosis in the US is mild, white spotting on the teeth, does not cause any health problems, and is typically only visible by a dentist under close inspection.
10. “if they are really concerned about poor dental care then just donate some money to city government so we can buy tons of toothpaste and so we can pass it all around…”
Fact: Water fluoridation is, by far, the most cost-effective and equitable means of reducing tooth decay. School supplement programs cost about 5 times more than water fluoridation, can be inconsistent, and can be difficult to administer. Individual fluoride supplements cost approximately 70 times as much as water fluoridation.
Current Multnomah County services reach only about ? of school children and cost about $1 million/year, double the annual operating cost of water fluoridation. Water fluoridation would reach the entire population: pre-school kids, school kids, teens, adults, and seniors.
School and community programs are simply unable to reach everybody, and leave kids’ oral health to luck. We’ve invested in these programs, and they are helping, but not going far enough, considering that our children have the fifth worst rate of untreated tooth decay in the nation: 35%.
Water fluoridation costs would be covered by water customers, at about 64 cents/year, less than the cost of a toothbrush.
Current preventive dental programs are funded by grants, co-pays, and insurance reimbursements paid for dental services. The funding is variable, and can’t just be moved around.
Major supporters of this effort include the community foundations, health-care providers, and volunteer dental programs which know, first-hand, how expensive treatment programs can be, how overwhelmed the current services are, and how cost-effective and beneficial water fluoridation would be for the community.
11. Hydrofluorosilicic acid has lead and arsenic in it… and pulls lead out of the pipes
Fact: Fluoride compounds added to drinking water are extremely pure, and fluoride does not affect the amount of lead released from pipes.
The U.S. Environmental Protection Agency (EPA) regulates fluoride and other additives in public drinking water under a Memorandum of Understanding with the U.S. Food and Drug Administration (FDA) signed in 1979.
Fluoride additives must meet strict quality standards that assure the public’s safety. Fluoride additives are subject to a stringent system of standards, testing, and certificates by the American Water Works Association (AWWA) and the National Sanitation Foundation/American National Standards Institute (NSF/ANSI). The annual NSF/ANSI Standard 60 review for fluoride additives considers all ingredients in the product, as well as the manufacturing process, processing aids, shipping containers, and other factors to ensure that there are no contaminants that may pose a health hazard. Standard 60 uses on-site inspections and surprise “spot checks” to confirm that the additives meet the highest standards of quality, safety, and purity.
All fluoride additives are certified as meeting NSF/ANSI Standard 60. There has not been a single fluoride product tested since the initiation of the program in 1988 with a contaminant concentration in excess of its single product allowable concentrations (SPAC). The SPAC is a conservative, protective limit, and is set at ten percent of the maximum concentration allowed by the EPA to account for the possibility of multiple exposure sources.
Optimally fluoridated water that is properly treated does not leach lead out of pipes. This accusation has been thuroughly studied by the EPA and they found that, “Overall, we conclude that no credible evidence exists to show that water fluoridation has any quantifiable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead(0) or lead(II) compounds.” See -Can Fluoridation Affect Water Lead Levels and Lead Neurotoxicity?
A 2003 comprehensive review by Fort Collins Colorado investigating this claim also found that optimally fluoridated water does not leach lead from pipes, they state “There was no evidence that the addition of HFS increased the concentrations of copper, manganese, zinc, cadmium, nickel, or molybdenum. The concentrations of arsenic and lead were below the detection limit for the Fort Collins Water Quality Control Laboratory in both the source water and the finished water and below the maximum contaminant level (MCL) for these naturally occurring elements. There was no evidence that the introduction of HFS changed the pH of the water appreciably.” See = Report of the fort Collins fluoride Technical Study Group – Page 71
12. If you look at the science it is indisputable that fluoride is bad
Fact: Overwhelming evidence compiled over the past 65 years supports the safety and efficacy of water fluoridation. It is one of the most widely studied public health measures in history. See the systematic reviews and data sources noted above.
Water fluoridation has been called one of the greatest public health achievements of the 20th century by the Centers for Disease Control and Prevention. It is a major factor responsible for the decreases in tooth decay over the last century. Water fluoridation is supported by nearly every major health organization, including every Surgeon General for the past 50 years.
To imply that researchers, doctors, dentists, and public health professionals are promoting something “bad” is to call into question the entire medical and public health establishment in this country and around the world and is a flat-out denial of the evidence showing reduced tooth decay (without any adverse health effects) resulting from water fluoridation.
13. Fluoride comes from the industrial processing plant in tanker truck to water treatment plant
Fact: As noted in item #11, Standard 60 uses on-site inspections and surprise “spot checks” to confirm that the additives meet the highest standards of quality, safety, and purity. The annual NSF/ANSI Standard 60 review for fluoride additives considers all ingredients in the product, as well as the manufacturing process, processing aids, shipping containers, and other factors to ensure that there are no contaminants that may pose a health hazard. Because tanker trucks can transfer fluoride additives directly to water treatment facility holding tanks via hoses and sealed couplings, there is virtually no chance that any contamination of the additive will occur.
14. Fluoride shipments come filled with heavy metals, a 34 ppm of lead and fluoride was delivered to a water district down the road.
Fact: Products used for drinking water treatment are evaluated to the criteria specified in the National Science Foundation’s (NSF) Standard 60. 98% of all samples tested had no detectable levels of lead. The average concentration of lead in drinking water has been 0.005 parts per billion (ppb) with 0.6 ppb being the highest concentration detected. This is well below 1.5 ppb single product allowable concentration (SPAC) requirement of NSF 60. The SPAC is a conservative, protective limit, and is set at ten percent of the maximum concentration allowed by the EPA to account for the possibility of multiple exposure sources.
15. Bioaccumulation over a lifetime violates the tenants of toxicology
Fact: There have been a handful of animal studies in labs looking at bioaccumulation of fluorides in snails and fish. The animals were exposed to incredibly high levels of fluoride and these studies did not evaluate optimal water fluoridation levels.
The National Research Council report reviewed high levels (2-4 ppm) of water fluoridation. They found some evidence that, compared to people drinking water fluoridated at 1 ppm, people drinking water fluoridated at 4 ppm for their entire lifetime may possibly be at greater risk for skeletal fluorosis and bone fractures. However, the evidence was mixed and inconclusive. These conditions are very rare in the US, even in areas with naturally high fluoride levels.
16. The National Kidney Foundation withdrew their endorsement of fluoride
The National Kidney Foundation has no position on the optimal fluoridation of water as it is beyond the scope of the foundation’s mission. Although the NKF recommends additional research on the risk and extent of fluoride exposure for patients with chronic kidney disease (CKD), the NKF states, “there is insufficient evidence to validate the concerns regarding persons with CKD, even at fluoride concentrations of 4 mg/L.” A 2007 study published in a leading kidney journal found there were no harmful effects from consuming water at the optimal fluoride level used for public water systems. The National Kidney Foundation has not issued any recommendations calling on people with kidney disease to avoid fluoridated water.