Alison McKellar

79#Mechanic#Street,#Camden,#Maine#04843#
Phone:##(207)#619>1530##!#E>Mail:#:#alisonmckellar@gmail.com#



Dear Mid-Coast Health Professional,
Almost 50 years ago, in an effort to address high rates of tooth decay among children, this
community made a decision to start adding fluoride to our tap water, which originates from Mirror Lake
and serves about half the residents in the towns of Camden, Rockport, Rockland, Thomaston, and small
parts of Owls Head and Warren. After spending some time reviewing the history of the scientific research
and public policies regarding fluoride, I believe its time for our community to re-examine what we have
learned and what has changed in the 44 years since fluoridation began here. I am writing to ask that, as a
local health professional, you take a moment to review the current literature on the subject so as to be
prepared for any questions you might receive from patients in the coming months.
Like most people, I had never thought much about fluoride. Recently, I began to wonder if my 3-year-old
son should start using fluoridated toothpaste. A quick web search will tell you that children under the age
of 2 should not, and the instructions on the back of the tube that I use say that children from 2-6 should
use only a pea-sized amount and be monitored by an adult to minimize swallowing. The label also reads,
"If you accidentally swallow more than used for brushing, seek professional help or contact a poison control center
immediately." Well, even with constant monitoring, my 3 year old accidentally swallows almost all the
toothpaste that goes in his mouth, so I wanted to know exactly how much fluoride he would be likely to
ingest and how much would be too much. At that point, water fluoridation wasn't even on my radar. I
found that a pea-sized amount of typical fluoride toothpaste (1000 ppm fluoride) contains about .25 mg of
fluoride, roughly the same amount of fluoride as 10.5 ounces of our tap water, which averages .8 mg per
liter. This came as a surprise to me, so I wanted to know a little more.
What is fluoride? How much is enough for a 3 year old? How much is too much?
It turns out that these are not easy questions to answer and experts disagree. What we do know is that the
CDC reports that 41% of adolescents (12-15 year olds) now have some form of dental fluorosis, a
permanent staining of the enamel caused by the ingestion of too much fluoride during the years when the
teeth are developing. This is nearly double the figure that was reported 20 years ago and 4-5 times what
was predicted when fluoridation first began.
In 2007, the ADA and the AAP released a warning to parents saying that babies who are exclusively
bottle fed with formula reconstituted with fluoridated water may be at an increased risk for dental
fluorosis. They suggest using fluoride-free or low fluoride water if parents are concerned. Although I was
lucky enough to breastfeed my own children, I know that this is not a reality for some, and buying bottled
water is unrealistic for many low income parents. Further, no pediatrician or maternity nurse ever advised
me that, if I stopped breastfeeding, I should consider mixing my babys formula with fluoride free water.
Even when a lactating mother drinks fluoridated water, her breast milk contains almost no fluoride (about
4 parts per billion), which means that in many cases, bottle fed babies may be getting up to 250 times
as much fluoride as breastfed babies. The ADA and the AAP have generally stated that the permanent
staining of the tooth enamel is only cosmetic, yet there is no scientific consensus on how to categorize
dental fluorosis. Since we know that ingested fluoride is also stored commulatively in other parts of the
body, such as bones and the pineal gland, many experts view dental fluorosis as a biomarker for other
types of fluoride toxicity. To quote Dr. Hardy Limeback, Head of Preventive Dentistry at the University
of Toronto, it is illogical to assume that tooth enamel is the only tissue affected by low daily doses of fluoride
ingestion."
Over the past several months, I have researched this issue extensively. I have consulted countless medical
journals, performed MedLine searches of scholarly, peer-reviewed research, met multiple times with Rick
Knowlton and others from the Maine Water Company, spoken with the Director of the Maine Drinking

Water Program, and read newspaper archives relating to the history of fluoridation in our water district. I
began my research 100% open-minded. In fact, I was swayed in the direction of favoring
fluoridation. After all, I have fluoridated water in my own home and fluoride removal is expensive. Unlike
chlorine, it cannot be removed by a simple Brita filter. I've been drinking it, giving it to my 3 year old, and
even prided myself on my eco-conscious avoidance of bottled water. In general, I tend to side with the
government on most public health measures. I vaccinate my children, etc, etc... Still, after reading the
opinions of many experts on both sides of this issue, it seems like a strange way to prevent tooth decay in
our community, a community in which only 50% of the population is served by municipal water.
As a 29 year old mother of a baby and toddler who grew up in the area, graduated from CHRHS, and
moved back to Camden about 5 years ago, I was a little surprised not to have heard more about
fluoridation in the past. No water bill or newsletter from the water company ever mentioned anything
about the water being fluoridated. New Hampshire recently passed legislation requiring that water
customers be warned that mixing infant formula with tap water could increase the risk of fluorosis, but
here, no such policy is in place. Was I the only one who didnt know that something (a non-nutrient) is
being added to our water for a purely dental benefit? Yet in my discussions with others my age, I've found
that many people who are not old enough to have been a part of the initial debate simply do not know that
our water is fluoridated, much less why. Even some health professionals do not realize that we are a
fluoridated district. Most doctors and nurses I have spoken with havent thought about fluoridation in a
long time, and dont realize that many respected scientists and dentists, who once promoted the
practice, have changed their minds.
It has been almost fifty years since Camden, Rockland, and Thomaston approved fluoridation by a narrow
margin; having twice previously voted the measure down. Although the debate continues, one thing is
very clear to anyone who reviews the Camden Herald and Courier Gazette for the years of 1968 and 1969:
The arguments used to promote it have changed vastly in the 44 years since the practice began
here. I have included copies of health board statements and advertisements promoting fluoridation that
appeared in the Camden Herald and Courier Gazette in 1968 and 1969. At that time, doctors believed that
fluoride worked like an essential nutrient, that its benefit was primarily systemic, and that it would
prevent all sorts of things, from tooth decay to bone fractures to arteriosclerosis. Today, even staunch
advocates of fluoridation recognize that most of those things turned out not to be true, and that fluoride
works much differently than we originally believed.
Fifty years ago, not a single fluoride toothpaste was available, and water fluoridation was considered the
only cost effective way of delivering fluoride to those who wanted it. We now have access to fluoride in
virtually all toothpastes, and its widespread use as a pesticide (as sulfuryl fluoride and cryolite) leads to
high levels of the chemical in unexpected places, such as non-organic grape juice. Since fluoride content
can vary widely, and is not required to be labeled, it is next to impossible for people to figure out how
much they and their children are getting. Few health professionals, including pediatricians and dentists,
have been trained to assess all sources of fluoride in adults and childrens diets, such as tea, certain wheat
products, and mechanically deboned chicken. The AAP supports labeling requirements for fluoride
content in foods and beverages but since fluoride content can vary drastically, there has been little
headway made in this area.
We now know that fluoride is not a nutrient and that its dental benefit is primarily topical. We also know
that most countries, including 97% of Western Europe, have chosen not to fluoridate their water.
Dentists often note the differences they see between fluoridated and non-fluoridated areas, yet data reveals
that many of these differences are socioeconomic. Tooth decay has rapidly decreased worldwide, in
fluoridated and non-fluoridated countries alike, and World Health Organization data show no difference in
tooth decay levels between countries that practice fluoridation and countries that dont.
Very few of us know that the fluoridating agent used here, like in most places, is not naturally occurring
calcium fluoride nor even pharmaceutical grade sodium fluoride, as most people expected it would be. I
have verified with the Maine Water Company that the chemical used is hydrofluorosilicic acid, a
highly corrosive byproduct of the phosphate fertilizer industry. Our fluoride originates in phosphate
fertilizer plants owned by Mosaic Fertilizer Company in Central Florida, and is shipped via railcar to
Borden and Remington in Boston before being transported in a designated tanker truck to us, and is often
contaminated with detectable amounts of arsenic, lead, and other contaminants. It requires its own special
room at the water treatment facility because of its toxicity, and rapidly eats through metal and pavement.
Because it is so acidic, fluoridated water requires treatment with additional amounts of caustic soda
(sodium hydroxide) to normalize the pH of the finished drinking water so that
it doesnt corrode our pipes and leach lead and copper. Still research indicates
a troubling link between fluoridation chemicals and elevated blood lead levels
in children.
Phosphate mining has disastrous implications for Floridians, and the overuse
of phosphate fertilizer has serious implications for drinking water
everywhere. In Florida, phosphate strip mining has been linked to sinkholes,
as well as to the pollution of the Florida aquifer, the primary drinking water
source for many Floridians. To know that we are adding something to the
water that is part of a process that jeopardizes the drinking water of others is
unsettling to me, not to mention the increase in our carbon footprint brought
about by the transporting of the chemicals, and the risk that a spill would
pose to our health and ecosystem.
I wont spell out all the possible areas of concern. As a health professional, you
can easily assess the information for yourself and I am including a copy of a
Scientific American article from 2007 which provides a nice overview of the
evolution of this debate and the way that fluoride works, as well as a few
other abstracts and articles from my research that illustrate some of the
things I mentioned earlier. I plan to write a letter to the city councils of the five
town water district, but wanted to also reach out to the dental and medical
community to get your thoughts on this important issue.
Thank you for taking the time to review this letter and some of the material
I've included. I have printed everything at my own expense and have
conducted all my research mainly while breastfeeding my now 9 month old son over the
past few months. I would be eager to speak with you or provide additional
copies of any of this information. I can be reached by email or phone.

Sincerely,

Alison McKellar

(207) 619-1530
alisonmckellar@gmail.com


74 SCI ENTI FI C AMERI CAN Januar y 2008
PUBLIC HEALTH
L
ong before the passionate debates over cig-
arettes, DDT, asbestos or the ozone hole,
most Americans had heard of only one
environmental health controversy: uoridation.
Starting in the 1950s, hundreds of communities
across the U.S. became embroiled in heated bat-
tles over whether uoridesionic compounds
containing the element fluorineshould be
added to their water systems. On one side was
a broad coalition of scientists from government
and industry who argued that adding uoride
to drinking water would protect teeth against
decay; on the other side were activists who con-
tended that the risks of uoridation were inad-
equately studied and that the practice amount-
ed to compulsory medication and thus was a
violation of civil liberties.
The advocates of uoride eventually carried
the day, in part by ridiculing opponents such as
the right-wing John Birch Society, which called
uoridation a communist plot to poison Amer-
ica. Today almost 60 percent of the U.S. popu-
lation drinks uoridated water, including resi-
dents of 46 of the nations 50 largest cities. Out-
side the U.S., uoridation has spread to Canada,
the U.K., Australia, New Zealand and a few
other countries. Critics of the practice have gen-
erally been dismissed as gadies or zealots by
mainstream researchers and public health agen-
cies in those countries as well as the U.S. (In
other nations, however, water uoridation is
rare and controversial.) The U.S. Centers for
Disease Control and Prevention even lists water
uoridation as one of the 10 greatest health
achievements of the 20th century, alongside
vaccines and family planning.
Now, though, scientic attitudes toward uo-
ri da tion may be starting to shift in the country
where the practice began. After spending more
than two years reviewing and debating hun-
dreds of studies, a committee of the National
Research Council (NRC) released a report in
2006 that gave a tinge of legitimacy to some
longtime assertions made by antiuoridation
campaigners. The report concluded that the En-
vironmental Protection Agencys current limit
KEY CONCEPTS
I Researchers are intensify-
ing their scrutiny of uo-
ride, which is added to
most public water sys-
tems in the U.S. Some
recent studies suggest
that overconsumption of
uoride can raise the risks
of disorders affecting
teeth, bones, the brain
and the thyroid gland.
I A 2006 report by a com-
mittee of the National
Research Council recom-
mended that the federal
government lower its cur-
rent limit for uoride in
drinking water because of
health risks to both chil-
dren and adults.
The Editors
New research indicates that a cavity-ghting
treatment could be risky if overused
By Dan Fagin
Second Thoughts about
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2007 SCI ENTI FI C AMERI CAN, I NC.
www. Sci Am. com SCI ENTI FI C AMERI CAN 75
for uoride in drinking waterfour milligrams
per liter (mg/L)should be lowered because of
health risks to both children and adults. In chil-
dren, consistent exposure to uoride at that lev-
el can discolor and disgure emerging perma-
nent teetha condition called dental uorosis.
In adults, the same uoride level appears to in-
crease the risk of bone fracture and, possibly, of
moderate skeletal uorosis, a painful stiffening
of the joints. Most uoridated water contains
much less uoride than the EPA limit, but the sit-
uation is worrisome because there is so much
uncertainty over how much additional uoride
we ingest from food, beverages and dental prod-
ucts. What is more, the NRC panel noted that
uoride may also trigger more serious health
problems, including bone cancer and damage to
the brain and thyroid gland. Although these ef-
fects are still unproved, the panel argued that
they deserve further study.
The largest long-running investigation of the
effects of uoride is the Iowa Fluoride Study, di-
p TOO MUCH OF A GOOD
THING: Fluoride is in many
foods, beverages and
dental products. The
ubiquity of the cavity-
ghting chemical can
result in overconsump-
tion, particularly among
young children.
2007 SCI ENTI FI C AMERI CAN, I NC.
76 SCI ENTI FI C AMERI CAN Januar y 2008
rected by Steven M. Levy of the University of
Iowa College of Dentistry. For the past 16 years
Levys research team has closely tracked about
700 Iowa children to try to tease out subtle ef-
fects of uoridation that may have been over-
looked by previous studies. At the same time,
Levy is also leading one of the most extensive
efforts ever to measure uoride concentrations
in thousands of productsincluding foods,
drinks and toothpastesto develop credible es-
timates of typical uoride intake.
It is a maddeningly complex area of research
because diets, toothbrushing habits and water
uoridation levels vary so much and also be-
cause genetic, environmental and even cultural
factors appear to leave some people much more
susceptible to the effects of uorideboth pos-
itive and negativethan others. Despite all the
uncertainties, however, Levy and some other
uoride researchers have come around to the
view that some children, especially very young
ones, are probably getting more uoride than
they should. Most of those scientists, including
Levy, still support water uoridation as a proved
method of controlling tooth decay, especially in
populations where oral hygiene is poor. But the
researchers also believe that in communities
with good dental care the case for uoridation
is not as strong as it used to be. Instead of just
pushing for more uoride, we need to nd the
right balance, Levy says.
The Advent of Fluoride
Framed toothpaste advertisements from more
than half a century ago hang on the walls of
Levys conference room. One touting Pebeco
Toothpaste reads: Do you want your teeth to
ache and get ugly? Another asserts that Col-
gate Chlorophyll Toothpaste Destroys Bad
Breath. They are artifacts of the preuoride
era, when tooth decaycalled caries in the par-
lance of dentistrywas pervasive and tooth-
pastes were marketed with questionable medi-
cal claims.
The introduction of uoride changed all that.
In 1945 Grand Rapids, Mich., became the rst
city to uoridate its water supply. Ten years lat-
er Procter & Gamble introduced Crest, the rst
uoridated toothpaste, which contained stan-
nous uoride (a compound with one atom of tin
and two of fluorine). Colgate-Palmolive fol-
lowed in 1967 by modifying its Colgate brand
with what has become one of the dominant cav-
ity-ghting ingredients in toothpastes: sodium
monouorophosphate. Instead of sticking with
the uoride salts found in toothpastes and fa-
[TRENDS]
FLUORIDATION ACROSS AMERICA
Water uoridation has spread across the
U.S. since its introduction in 1945. In 2002,
the latest year for which data are available,
Americans receiving uoridated water rep-
resented 67 percent of all people supplied
by public water systems and 59 percent of
the total population. Fluoridation is most
prevalent in the District of Columbia (100
percent) and Kentucky (99.6 percent) and
least common in Hawaii (8.6 percent) and
Utah (2.2 percent).
[THE AUTHOR]
Dan Fagin is an associate profes-
sor of journalism and director of
the Science, Health and Environ-
mental Reporting Program at New
York University. A former environ-
mental and science writer for
Newsday, his articles on cancer
epidemiology won the AAAS
Science Journalism Award in 2003.
Fagin is co-author of Toxic Decep-
tion (Common Courage Press,
1999) and is working on a book
about gene-environment interac-
tions and the childhood cancer
cluster in Toms River, N.J.
5
9
%
of the U.S. population
received uoridated w
ater
in 2002
WA
OR
ID
MT
WY
NV
CA
UT
AZ
CO
NM
TX
AK
OK
KS
NE
SD
ND
MN
ME
NY
VT
NH
MA
NJ
DE
MD
CT
RI
PA
WI
MI
IL
IN
OH
WV
VA
KY
TN
IA
MO
AR
LA
MS
FL
AL
GA
SC
NC
HI
PERCENTAGE OF STATE POPULATIONS RECEIVING FLUORIDATED WATER, 2002
< 25% 25%49% 50%75% >75%
Total U.S. population
Supplied by public water systems*
Receiving fluoridated water
FLUORIDATION RISING IN THE U.S.
300
200
100
0
1945 1965 1985 2002
Year
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*Data on public water systems not available before 1964
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2007 SCI ENTI FI C AMERI CAN, I NC.
www. Sci Am. com SCI ENTI FI C AMERI CAN 77
vored by dentists in ofce treatments, most wa-
ter suppliers eventually switched to the cheaper
option of uoridating with silicouorides such
as hexauorosilicic acid, a by-product of a fer-
tilizer manufacturing process in which phos-
phate ores are treated with sulfuric acid.
By the 1970s and 1980s America was awash
in various forms of uoride, and uoridation
had become the cornerstone of preventative
dentistry in most English-speaking countries.
Exactly why and how much caries incidence de-
creased during the same period is a matter of
erce debate, but the consensus among dental
researchers is that the decline was steep and that
uoride deserved much of the credit.
That was the culture in which Levy got his
start in public health dentistry in the mid-1980s.
Colgate-Palmolive funded his early research,
which had the effect of encouraging more uo-
ride use in dental ofces. But as American den-
tists began to see fewer cavities and more uo-
rosis on the teeth of their young patients, Levy
started to wonder whether children were get-
ting too much of a good thing. There was a
transition in my own thinking from more uo-
ride is denitely our goal to making sure we un-
derstand where the right balance is between
caries and uorosis.
Fluorides role in causing one disease and de-
terring another is rooted in the uorine ions pow-
erful attraction to calcium-bearing tissues in the
body. In fact, more than 99 percent of ingested
uoride that is not quickly excreted ends up in
bones and teeth. Fluoride inhibits cavities through
two separate mechanisms. First, uoride that
touches the enamelthe hard, white outer layer
of the teethbecomes embedded in the crystal-
line structures of hydroxylapatite, the main min-
eral component of teeth and bones. The uorine
ions replace some of the hydroxyl groups in the
hydroxylapatite molecules of the enamel, and this
substitution makes teeth slightly more resistant
to the enamel-dissolving acid excreted by bacte-
ria in the mouth as they consume food remnants.
Second, the uoride on the surface of teeth serves
as a catalyst that enhances the deposition of cal-
cium and phosphate, making it easier for the body
to continually rebuild the enamel crystals that the
bacteria are dissolving.
Fluoride has a very different effect, however,
when large doses are ingested by young children
whose permanent teeth are still developing and
have not yet erupted. The key proteins in early
tooth formation are called amelogenins, which
regulate the formation of hydrox ylapatite crys-
Debating the Effects
The U.S. Centers for Disease Control and
Prevention has hailed uoridation as one
of the 10 greatest public health achieve-
ments of the 20th century, claiming that
the addition of the chemical to drinking
water has been one of the main reasons
for the decline in tooth decay over the
past three decades (measured here by the
number of decayed, missing or lled
teeth in 12-year-olds). Rates of tooth
decay have also plunged, however, in
many countries where public water sys-
tems are not uoridated. In some of
these nations, uoride added to foods,
beverages and dental products may
account for part of the decline.
Fluorides role in combating tooth decay is rooted in the ions powerful
attraction to enamel, the hard, white outer layer of the teeth.
[FOCUS ON TEETH]
p With Fluoride
The topical application of uoride to the
teeth has two effects. First, the uoride
ions replace some of the hydroxyl groups in
the hydroxylapatite molecules, creating
uorapatite crystals that are slightly more
resistant to the enamel-dissolving acid ex-
creted by the bacteria. Second, the uoride
on the surface of teeth serves as a catalyst
that enhances the deposition of calcium
and phosphate, thus remineralizing dam-
aged enamel and combating decay.
FIGHTING CAVITIES
p Without Fluoride
The primary mineral in enamel is hydroxylap-
atite, a crystal composed of calcium, phos-
phorus, hydrogen and oxygen. When food
remnants become lodged between teeth,
bacteria consume the sugars and excrete lac-
tic acid, which can lower the pH of the mouth
enough to dissolve the hydroxylapatite. If
the rate of dissolution is higher than the rate
of remineralizationthe deposition of calci-
um and phosphate ions from saliva onto the
enamelthen cavities will form in the teeth.
Enamel
Gums
Acid excreted
by bacteria
Blood
vessels
Fluoride ions
applied to teeth
Calcium ions
Phosphate ions
Fluoride ions
Food
remnant
Calcium and
phosphate ions
Enhanced
deposition of
calcium and
phosphate
Fluoridated
U.S.
Australia
New Zealand
Unfluoridated
Belgium
Finland
Italy
TOOTH DECAY INDEX
(number of decayed, missing
or filled teeth in 12-year-olds)
2005 1975


8
7
6
5
4
3
2
1
0
Year
1985 1995
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2007 SCI ENTI FI C AMERI CAN, I NC.
78 SCI ENTI FI C AMERI CAN Januar y 2008
tals. As a crystal matrix forms, the amelogenins
break down and are removed from the matur-
ing enamel. But when some children consume
high doses of fluoride, which is absorbed
through the digestive tract and delivered by the
bloodstream to the developing teeth, the bio-
chemical signaling goes awry and the proteins
remain inside the budding tooth longer than
usual, thereby creating gaps in the crystalline
enamel structure. As a result, when a uorosed
tooth nally erupts it is often unevenly colored,
with some portions whiter than othersa visu-
al effect caused by light refracting off the po-
rous enamel. In more severe cases, the surface
of the tooth is pitted and the stains are brown.
Nutrition and genetics can inuence the risk of
uorosis, but the most important factor by far
is the amount of uoride ingested.
With grant money from the National Insti-
tute of Dental and Craniofacial Research, Levy
set out to determine how much uoride children
consume and how it affects their teeth and
bones. There is no universally accepted optimal
level for daily intake of uoridethat is, a level
that maximizes protection against tooth decay
while minimizing other risksbut the range
most often cited by researchers is 0.05 to 0.07
milligram of fluoride per kilogram of body
weight per day. In the early 1990s, when the
children in Levys study were infants, he found
that more than a third of them were ingesting
enough uoridemostly via water-based infant
formula, baby foods and juice drinksto put
them at a high risk of developing mild uorosis
in their permanent teeth. That fraction dropped
only slightly as their diet changed during their
toddler yearsa critical period for enamel for-
mation in preemergent teeth. Typical uoride
ingestion stayed high during the toddler years,
in part because toothpaste replaced formula as
a key source. Although both children and adults
are supposed to spit out their toothpaste after
brushing, Levy had found in an earlier study
that toddlers on average actually swallowed
more than half of their toothpaste.
By the time the Iowa children were nine
years old and their permanent front teeth had
emerged, it was obvious that the earlier expo-
sures to uoride had literally left their mark.
The front teeth of children who had been in the
high-intake group as infants and toddlers were
more than twice as likely to show the telltale
staining of uorosis than the teeth of children
who had ingested less uoride when they were
younger. And as their diet broadened, so did
their sources of uoride. Tests performed in
[AREA OF CONCERN]
p Normal Bone Formation
Scientists have focused on uorides effects on bone because so much of the chemical is stored there.
Studies have shown that high doses of uoride can stimulate the proliferation of bone-building osteo-
blast cells, raising fears that the chemical may induce malignant tumors. Fluoride also appears
to alter the crystalline structure of bone, possibly increasing the risk of fractures.
IS FLUORIDE WEAKENING BONE?
Compact
bone
Spongy
bone
Periosteum
Marrow
Existing bone
Blood
vessels
Osteoblasts forming
new bone
Layer of new
weak bone
p Effects of Excessive Fluoride
Scientic
attitudes
toward
uoridation
may be
starting
to shift in
the country
where the
practice
began.
Proliferation of
osteoblasts
Fluoride
ions
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2007 SCI ENTI FI C AMERI CAN, I NC.
www. Sci Am. com SCI ENTI FI C AMERI CAN 79
Levys lab found, for example, that many kinds
of juice drinks and soda pop contain enough
fluo ride (generally about 0.6 mg/L) so that
drinking a little more than a liter a day would
put a typical three-year-old at the optimal in-
take level, without counting any other daily
sources.
Dozens of food items tested by Levys team
contained even higher concentrations of uo-
ride: an average of 0.73 mg/L in cranberry-juice
cocktail, 0.71 mg/L in ice pops, 0.99 mg/L in
beef gravy and 2.10 mg/L in canned crabmeat,
for example. In most cases, the uoride came
from water added during processing, although
higher levels also got into grapes and raisins via
pesticides, into processed chicken products via
ground-up bone, and into tea leaves via absorp-
tion from soil and water.
Levy found that exposure to fluoridated
drinking water was an even more important risk
factor for uorosis. Iowa children who lived in
communities where the water was uoridated
were 50 percent more likely to have mild uoro-
sis on at least two of their eight permanent front
teeth at nine years of age than children living in
nonuoridated areas of the state (there was a 33
percent prevalence in the former versus 22 per-
cent in the latter). Similar results appeared in
the NRC report, which found that infants and
toddlers in fluoridated communities ingest
about twice as much uoride as they should.
Furthermore, the committee noted that adults
who drink above-average amounts of water, in-
cluding athletes and laborers, are also exceed-
ing the optimal level for uoride intake.
But enamel uorosis, except in the severest
cases, has no health impact beyond lowered
self-esteem: the tooth marks are unattractive
and do not go away (although there are mask-
ing treatments). The much more important
question is whether uorides effects extend be-
yond altering the biochemistry of tooth enamel
formation. Says longtime uoride researcher
Pamela DenBesten of the University of Califor-
nia, San Francisco, School of Dentistry: We
certainly can see that uoride impacts the way
proteins interact with mineralized tissue, so
what effect is it having elsewhere at the cellular
level? Fluoride is very powerful, and it needs to
be treated respectfully.
Fluoride and Bone
Bone is an obvious place to look for uorides
ngerprints because so much uoride is stored
there. What is more, studies of patients with
osteoporosisa bone disease that increases the
risk of fractureshave shown that high doses
of uoride can stimulate the proliferation of
bone-building osteoblast cells, even in elderly
patients. The exact mechanism is still unknown,
but uoride appears to achieve this by increas-
ing the concentrations of tyrosine-phosphory-
lated proteins, which are involved in biochemi-
cal signaling to osteoblasts. As with tooth
enamel, however, uoride not only stimulates
bone mineralization, it also appears to alter the
crystalline structure of boneand in this case,
the effects are not merely aesthetic. Although
uoride may increase bone volume, the strength
of the bone apparently declines. Epidemiologi-
cal studies and tests on lab animals suggest that
high uoride exposure increases the risk of bone
fracture, especially in vulnerable populations
such as the elderly and diabetics. Although
those studies are still somewhat controversial,
nine of the 12 members of the NRC panel con-
cluded that a lifetime of exposure to drinking
water fluoridated at 4 mg/L or higher does
indeed raise the risk of fracture. The committee
noted that lower uoridation levels may also
increase the risk, but the evidence is murkier.
As the Iowa children in his study enter ado-
lescence, Levy hopes that analyses of the
strength of their spine, hips and overall skeleton
will point to possible connections between uo-
ride intake and bone health. He presented some
preliminary data in 2007, nding little differ-
ence in the mineral content of the bones of 11-
year-olds based on how much uoride they had
ingested as young children. As they go through
adolescence, however, Levy thinks that
trends may emerge.
The even bigger question looming over
the uoride debate is whether these known
cellular effects in bones and teeth are clues
that uoride is affecting other organs and
triggering other diseases besides uorosis.
The biggest current debate is over osteosar-
comathe most common form of bone can-
cer and the sixth most prevalent cancer in
children. Because uoride stimulates the pro-
duction of osteoblasts, several researchers
have suggested that it might induce malignant
tumors in the expanding cell population. A
1990 study conducted by the U.S. govern-
ments National Toxicology Program found
a positive dose-response relation for osteo-
sarcoma incidence in male rats exposed to
different amounts of uoride in drinking wa-
ter (all those amounts, as is typical for ani-
SIGNS OF
FLUOROSIS
When young children consume
large amounts of uoride, the
chemical can disrupt the develop-
ment of their permanent teeth.
When the teeth emerge, their
enamel may be discolored (top)
or, in more severe cases, disg-
ured (bottom). Researchers have
found that this condition, called
dental uorosis, is more common
in communities where the drink-
ing water is uoridated.
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2007 SCI ENTI FI C AMERI CAN, I NC.
80 SCI ENTI FI C AMERI CAN Januar y 2008
mal studies, were far above the actual expo-
sures found in uoridated communities). But
other animal studies as well as most epidemio-
logical studies in human populations have been
ambiguous at best.
The latest dustup over uoride and osteosar-
coma was instigated by a young researcher
named Elise B. Bassin of the Harvard School of
Dental Medicine. Bassin collected information
about uoride exposures among 103 osteosar-
coma patients and 215 matched control subjects
and concluded that uoride is a risk factor for
the cancer among boys (the results were ambig-
uous for girls). Bassins report appeared in 2006
in the journal Cancer Causes and Control; in
the same issue, however, her dissertation advis-
er at Harvard, Chester Douglass, wrote a com-
mentary warning readers to be especially cau-
tious in interpreting her ndings because, he
said, better data, still unpublished, contradict
them. Antiuoridationists and some envi-
ronmental groups quickly rushed to
Bassins defense, demanding that Har-
vard investigate Douglass, professor
and chair of epidemiology at the den-
tal school, for allegedly misrepresent-
ing Bassins work and for having a con-
ict of interest because he is editor in
chief of a newsletter for dentists funded by
Colgate. The universitys investigation of Doug-
lass, completed in 2006, concluded that there
was no misconduct or conict of interest.
Clashes over the possible neurological effects
of uoride have been just as intense. Phyllis
Mullenix, then at the Forsyth Institute in Bos-
ton, set off a restorm in the early 1990s
when she reported that experiments on
lab rats showed that sodium uoride
can accumulate in brain tissue and af-
fect animal behavior. Prenatal expo-
sures, she reported, correlated with hy-
peractivity in young rats, especially
males, whereas exposures after birth had
the opposite effect, turning female rats
into what Mullenix later described as
couch potatoes. Although her research
was eventually published in Neurotoxicology
and Teratology, it was attacked by other
scientists who said that her methodolo-
gy was awed and that she had used un-
realistically high dosages. Since then,
however, a series of epidemiological
studies in China have associated high
uoride exposures with lower IQ, and
research has also suggested a possible
mechanism: the formation of aluminum uo-
ride complexessmall inorganic molecules that
mimic the structure of phosphates and thus in-
uence enzyme activity in the brain. There is
also some evidence that the silicouorides used
in water uoridation may enhance the uptake
of lead into the brain.
The endocrine system is yet another area
where some evidence exists that uoride can
have an impact. The NRC committee conclud-
ed that uoride can subtly alter endocrine func-
tion, especially in the thyroidthe gland that
produces hormones regulating growth and me-
tabolism. Although researchers do not know
how uoride consumption can inuence the
thyroid, the effects appear to be strongly inu-
enced by diet and genetics. Says John Doull,
professor emeritus of pharmacology and toxi-
cology at the University of Kansas Medical Cen-
ter, who chaired the NRC committee: The thy-
roid changes do worry me. There are some
things there that need to be explored.
The Controversy Continues
The release of the NRC report has not triggered
a public stampede against uoridation, nor has
it prompted the EPA to quickly lower its uoride
limit of 4 mg/L (the agency says it is still study-
ing the issue). Water suppliers who add uoride
typically keep levels between 0.7 to 1.2 mg/L,
far below the EPA limit. About 200,000 Ameri-
cansand several million people in China,
India, the Middle East, Africa and Southeast
Asiadrink concentrations higher than the lim-
it, but their excess uoride comes from natural-
ly occurring runoff from uoride-containing
rocks and soils near water sources.
The report is, however, prompting some re-
searchers to wonder whether even 1 mg/L is too
much in drinking water, in light of the growing
recognition that food, beverages and dental
products are also major sources of uoride, es-
pecially for young children. The NRC commit-
tee did not formally address the question, but
its analyses suggest that lower water uorida-
tion levels may pose risks, too. What the com-
mittee found is that weve gone with the status
quo regarding uoride for many yearsfor too
long, reallyand now we need to take a fresh
look, Doull says. In the scientic community,
people tend to think this is settled. I mean, when
the U.S. surgeon general comes out and says this
is one of the 10 greatest achievements of the
20th century, thats a hard hurdle to get over.
But when we looked at the studies that have
A FLUORIDE DIET
The optimal range for daily intake
of uoridethe level that maxi-
mizes protection against tooth
decay but minimizes other risks
is generally considered to be 0.05
to 0.07 milligram for each kilo-
gram of body weight. Consuming
foods and beverages with large
amounts of uoride can put a diet
above this range. Below are typi-
cal trace levels of uoride, mea-
sured in parts per million (ppm),
found in foods and drinks tested
at the University of Iowa College
of Dentistry.
3.73 ppm Brewed black tea
2.34 ppm Raisins u
2.02 ppm White wine
1.09 ppm Apple-
avored
juice drink
0.91 ppm Brewed
coffee
0.71 ppm Tap water
(U.S.-wide
average)
0.61 ppm Chicken soup
broth
0.60 ppm Diet Coke
(U.S.-wide
average)
0.48 ppm Hot dog
0.46 ppm Grapefruit
juice
0.45 ppm Beer u
0.45 ppm Baked russet
potatoes
0.35 ppm Cheddar cheese
0.33 ppm Flour
tortillas
0.32 ppm Creamed corn
(baby food)
0.23 ppm Chocolate
ice cream u
0.13 ppm Brewed
chamomile tea
0.03 ppm Milk (2%) D
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2007 SCI ENTI FI C AMERI CAN, I NC.
www. Sci Am. com SCI ENTI FI C AMERI CAN 81
been done, we found that many of these ques-
tions are unsettled and we have much less infor-
mation than we should, considering how long
this [uoridation] has been going on. I think
thats why uoridation is still being challenged
so many years after it began. In the face of igno-
rance, controversy is rampant.
Some longtime uoride researchers, however,
remain unimpressed by the evidence of effects
beyond teeth and bones, and they continue to
push for an expansion of water uoridation in
the U.S. and elsewhere. Their view remains the
ofcial position of the American Dental Asso-
ciation and the U.S. Public Health Service. We
feel there are enough communities out there
with high caries rates to justify additional uo-
ridation, says Jayanth V. Kumar, director of
oral health surveillance and research at the New
York State Department of Health and a member
of the NRC panel who dissented from some of
its ndings. He acknowledges, however, that
the argument for water uoridation is not as
strong in afuent areas with good nutrition and
dental care. Today it depends on what the car-
ies level is in the community. If the disease is
low, the return on investment [for uoridation]
may not be all that great.
Opponents of uoridation, meanwhile, have
been emboldened by the NRC report. What
the committee did was very, very important, be-
cause its the rst time a truly balanced panel
has looked at this and raised important ques-
tions, says Paul Connett, a chemistry professor
at St. Lawrence University and the executive di-
rector of the Fluoride Action Network, one of
the most active antiuoridation groups world-
wide. I absolutely believe its a scientic turn-
ing point because now everythings on the table.
Fluoride is the most consumed drug in the U.S.,
and its time we talked about it. g
T
he risks of uoride were known long before its benets. Starting in the rst decade of the 20th century, a
dentist named Frederick McKay traveled the American West investigating reports of what was then known
as Colorado Brown Stain. With a collaborator, G. V. Black, dean of the Northwestern University Dental School,
McKay discovered that children born in Colorado Springs, Colo., had stained teeth, but adults who moved
there did not. They hypothesized that young children whose permanent teeth had not yet erupted or developed
enamel faced the highest risk of developing the stain. McKay, who guessed that the stain was caused by some
unknown compound in the local drinking water, also noticed a curious fact: the mottled teeth were surprisingly
resistant to decay.
The cause remained a mystery until 1930, when McKay went to Arkansas to investigate reports of tooth
staining in Bauxite, a company town owned by the Aluminum Company of America (Alcoa). Worried that alu-
minum might be blamed, Alcoas chief chemist, H. V. Churchill, tested the local water and discovered some-
thing McKay had never suspected: high levels of naturally occurring uoride. McKay quickly tested other sus-
pect water supplies and found that wherever uoride levels were hightypically 2.5 milligrams per liter or
higherColorado Brown Stain was prevalent. A new disease entered the
lexicon: uorosis.
Spurred by Churchills and McKays discoveries, a researcher named
Henry Trendley Dean, head of the dental hygiene unit at the National
Institute of Health (which later changed its name to the National Insti-
tutes of Health), tried to determine how much uoride was enough to
trigger uorosis. By the late 1930s he had concluded that levels below
1 mg/L would pose little risk. Dean remembered that McKay had
found that uorosed teeth were resistant to decay, and so he began
pushing for a citywide test of a revolutionary idea: deliberately add-
ing uoride to water at levels that would deter cavities without trig-
gering uorosis. He got his wish in 1945 in Grand Rapids, Mich.,
and Dean went on to become uoridations leading advocate as the
rst director of the newly formed National Institute of Dental Re-
search from 1948 until his retirement in 1953. D.F.
t COLORADO DENTIST Frederick McKay,
whose investigations led to the discovery
of uorides effects on teeth.
[BACKGROUND]
FLUORIDE HISTORY
MORE TO
EXPLORE
Patterns of Fluoride Intake from
Birth to 36 Months. Steven M.
Levy, John J. Warren, Charles S.
Davis, H. Lester Kirchner, Michael J.
Kanellis and James S. Wefel in Jour-
nal of Public Health Dentistry, Vol. 61,
No. 2, pages 7077; June 2001.
Patterns of Fluoride Intake from
36 to 72 Months of Age. Steven M.
Levy, John J. Warren and Barbara
Broftt in Journal of Public Health
Dentistry, Vol. 63, No. 4, pages 211
220; December 2003.
Timing of Fluoride Intake in Rela-
tion to Development of Fluorosis
on Maxillary Central Incisors.
Liang Hong, Steven M. Levy,
Barbara Broftt, John J. Warren,
Michael J. Kanellis, James S. Wefel
and Deborah V. Dawson in Commu-
nity Dentistry and Oral Epidemiology,
Vol. 34, No. 4, pages 299309;
August 2006.
Age-Specic Fluoride Exposure in
Drinking Water and Osteosarco-
ma. Elise B. Bassin, David Wypij,
Roger B. Davis and Murray A.
Mittleman in Cancer Causes and Con-
trol, Vol. 17, No. 4, pages 421428;
May 2006.
Caution Needed in Fluoride and
Osteosarcoma Study. Chester W.
Douglass and Kaumudi Joshipura in
Cancer Causes and Control, Vol. 17,
No. 4, pages 481482; May 2006.
Fluoride in Drinking Water:
A Scientic Review of EPAs
Standards. National Academy
of Sciences, 2006. Available at
www.nap.edu/catalog.
php?record_id=11571
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2007 SCI ENTI FI C AMERI CAN, I NC.
STATEMENT BY DR. HARDY LIMEBACK
by Dr. Hardy Limeback PhD, DDS
Associate Professor and Head, Preventive Dentistry
University of Toronto
I am the Head of Preventive Dentistry at the University of Toronto in Toronto Canada , a
professor with a PhD in Biochemistry and a practicing dentist who has done years of funded
research in tooth formation, bone and fluoride. I was one of the 12 scientists who served on the
National Academy of Sciences panel that issued the 2006 report, Fluoride in Drinking Water: A
Scientific Review of the EPAs Standards.
I would like to outline my arguments that fluoridation is an ineffective and harmful public health
policy.
1. Fluoridation is no longer effective .
Fluoride in water has the effect of delaying tooth eruption and, therefore, simply delays dental
decay (Komarek et al, 2005, Biostatistics 6:145-55). The studies that water fluoridation work are
over 25 years old and were carried out before the widespread use of fluoridated toothpaste .
There are numerous modern studies to show that there no longer is a difference in dental
decay rates between fluoridated and non-fluoridated areas, the most recent one in Australia
(Armfield & Spencer, 2004 Community Dental Oral Epidemiology. 32:283-96). Recent water
fluoridation cessation studies show that dental fluorosis (a mottling of the enamel caused by
fluoride) declines but there is no corresponding increase in dental decay (e.g. Maupome et al
2001, Community Dental Oral Epidemiology 29: 37-47).
Public health services will claim there is still a dental decay crisis. With the national average in
Europe of only two decayed teeth per child (World Health Organization data), down from more
than 15 decayed teeth in the 1940s and 1950s before fluoridated toothpaste, as much as half of all
children grow up not having a single filling. This remarkable success has been achieved in most
European countries without fluoridation. The crisis of dental decay often mentioned is the
result, to a major extent, of sugar abuse, especially soda pop. A 2005 report by Jacobsen of the
Center for Science in the Public Interest said that U.S. children consume 40 to 44 percent of their
daily refined sugar in the form of soft drinks. Since most soft drinks are themselves fluoridated,
the small amount of fluoride is obviously not helping.
The families of these children with rampant dental decay need professional assistance. Are they
getting it? Children who grow up in low-income families make poor dietary choices, and cannot
afford dental care. Untreated dental decay and lack of professional intervention result in more
dental decay. The York review was unable to show that fluoridation benefited poor people.
Similarly, early dental decay in nursing infants (baby bottle syndrome) cannot be prevented with
water fluoridation. The majority of dentists in the U.S. do not accept Medicaid patients because
they lose money treating these patients. I would think the same is true for dentists in Europe .
Dentists support fluoridation programs because it absolves them of their responsibility to provide
assistance to those who cannot afford dental treatment. Even cities where water fluoridation has
been in effect for years are reporting similar dental crises.
Public health officials responsible for community programs are misleading the public by stating
that ingesting fluoride makes the teeth stronger. Fluoride is not an essential nutrient. It does not
make developing teeth better prepared to resist dental decay before they erupt into the oral
environment. The small benefit that fluoridated water might still have on teeth (in the absence of
fluoridated toothpaste use) is the result of topical exposure while the teeth are rebuilding from
acid challenges brought on by daily sugar and starch exposure (Limeback 1999, Community
Dental Oral Epidemiology 27: 62-71), and this has now been recognized by the Centers for
Disease Control.
2. Fluoridation is the main cause of dental fluorosis .
Fluoride doses by the end user cant be controlled when only one concentration of fluoride (1
parts per million) is available in the drinking water. Babies and toddlers get too much fluoride
when tap water is used to make formula (Brothwell & Limeback, 2003 Journal of Human
Lactation 19: 386-90). Since the majority of daily fluoride comes from the drinking water in
fluoridated areas, the risk for dental fluorosis greatly increases (National Academy of Sciences:
Toxicological Risk of Fluoride in Drinking Water, 2006). The American Dental Association and
the Dental Forum in Ireland has admitted that fluoridated tap water should not be used to
reconstitute infant formula.
We have tripled our exposure to fluoride since fluoridation was conceived in the 1940s. This has
lead to every third child with dental fluorosis (CDC, 2005). Fluorosis is not just a cosmetic
effect. The more severe forms are associated with an increase in dental decay (NAS:
Toxicological Risk of Fluoride in Drinking Water, 2006) and the psychological impact on
children is a negative one. Most children with moderate and severe dental fluorosis seek
extensive restorative work costing thousands of dollars. Dental fluorosis can be reduced by
turning off the fluoridation taps without affecting dental decay rates (Burt et al 2000 Journal of
Dental Research 79(2):761-9).
3. Chemicals that are used in fluoridation have not been tested for safety .
All the animal cancer studies were done on pharmaceutical-grade sodium fluoride. There is more
than enough evidence to show that even this fluoride has the potential to promote cancer. Some
communities use sodium fluoride in their drinking water, but even that chemical is not the same
fluoride added to toothpaste. Most cities instead use hydrofluorosilicic acid (or its salt). H2SiF6
is concentrated directly from the smokestack scrubbers during the production of phosphate
fertilizer, shipped to water treatment plants and trickled directly into the drinking water. It is
industrial grade fluoride contaminated with trace amounts of heavy metals such as lead, arsenic
and radium, which are harmful to humans at the levels that are being added to fluoridate the
drinking water. In addition, using hydrofluorosilicic acid instead of industrial grade sodium
fluoride has an added risk of increasing lead accumulation in children (Masters et al 2000,
Neurotoxicology. 21(6): 1091- 1099), probably from the lead found in the pipes of old houses.
This could not be ruled out by the CDC in their recent study (Macek et al 2006, Environmental
Health Perspectives 114:130-134).
4. There are serious health risks from water fluoridation .
Cancer: Osteosarcoma (bone cancer) has recently been identified as a risk in young boys in a
recently published Harvard study (Bassin, Cancer Causes and Control, 2006). The author of this
study, Dr. Elise Bassin, acknowledges that perhaps it is the use of these untested and
contaminated fluorosilicates mentioned above that caused the over 500% increase risk of bone
cancer.
Bone fracture: Drinking on average 1 liter/day of naturally fluoridated water at 4 parts per
million increases your risk for bone pain and bone fractures (National Academy of Sciences:
Toxicological Risk of Fluoride in Drinking Water, 2006). Since fluoride accumulates in bone, the
same risk occurs in people who drink 4 liters/day of artificially fluoridated water at 1 part per
million, or in people with renal disease. Additionally, Brits are known for their tea drinking and
since tea itself contains fluoride, using fluoridated tap water puts many heavy tea drinkers
dangerously close to threshold for bone fracture. Fluoridation studies have never properly shown
that fluoride is safe in individuals who cannot control their dose, or in patients who retain too
much fluoride.
Adverse thyroid function: The recent National Academy of Sciences report (NAS: Toxicological
Risk of Fluoride in Drinking Water, 2006) outlines in great detail the detrimental effect that
fluoride has on the endocrine system, especially the thyroid. Fluoridation should be halted on the
basis that endocrine function in the U.S. has never been studied in relation to total fluoride
intake.
Adverse neurological effects: In addition to the added accumulation of lead (a known
neurotoxin) in children living in fluoridated cities, fluoride itself is a known neurotoxin. We are
only now starting to understand how fluoride affects the brain. Several recent studies suggest that
fluoride in drinking water lowers IQ (NAS, 2006), we need to study this more in depth.
In my opinion, the evidence that fluoridation is more harmful than beneficial is now
overwhelming and policy makers who avoid thoroughly reviewing recent data before introducing
new fluoridation schemes do so at risk of future litigation.

Response to British Medical Journal article: Adding Iluoride to water supplies. Cheng et al.
BMJ.2007; 335: 699-702 (6 October)
http://www.bmj.com/rapid-response/2011/11/01/Iluoridation-time-reevaluate

Fluoridation: Time to reevaluate 19 October 2007

Bill Osmunson DDS, MPH,
Cosmetic Comprehensive Dentist
Bellevue, Washington 9804


The BMJ needs to be commended Ior Iurther opening the scientiIic debate on Iluoridation. For the Iirst 25 years oI dental practice I
promoted the addition oI Iluoride to water, in part because I thought I could 'see the diIIerence between those on Iluoridated water
and those without. UnIortunately, I was actually comparing socioeconomics rather than Iluoridation. As more patients have come in
requesting extensive cosmetic dentistry, sometimes costing tens oI thousands oI dollars to correct their dental Iluorosis, I decided it
was time to look at the sources, dosage, eIIicacy, and beneIits oI ingested Iluoride. Looking at the current literature was like a knee in
the gut.1

FLUORIDE EXPOSURE: Clearly Iluoride exposure has increased over the last 60 years. Dental Iluorosis is up 50 to a third oI
children. More dental and medical products and medications contain Iluoride. Permitted residue levels Irom Iluoride based pesticides
and post-harvest Iumigants (ProFume, Dow Agro Chemical) have signiIicantly increased in just the last decade. Mechanically
deboned meat can be much higher in bone/Iluoride content. Grape products and some tea have high levels oI Iluoride. Apparently no
agency is the legal intermediary, the doctor, responsible Ior monitoring the public`s total exposure to Iluoride. Some people are more
sensitive to chemicals and unable to excrete excess Iluoride. Synergistic eIIects Irom groups oI chemicals are relatively unknown. It
appears any beneIit oI Iluoride is Irom a topical application and not Irom ingested Iluoride.

BENEFITS OF FLUORIDATION: 'Evidence Ior whether an intervention works when applied in the community at large is reIerred to
as its eIIectiveness. . . . EIIectiveness studies more accurately reIlect results that may be expected Irom the implementation oI
interventions.2 II Iluoride actually provides a 'liIe time reduction oI dental decay, certainly aIter 60 years oI Iluoridation we should
see clear evidence oI eIIectiveness. UnIortunately, comparing developed countries Iinds all have reduced dental decay to similar levels
regardless oI Iluoridation. Comparing states within the USA based on the percentage oI the population Iluoridated Iinds no improved
dental health or reduction oI decay regardless oI the percentage Iluoridated. Comparing similar states such as Washington State (59
Iluoridated) with Oregon State (19 Iluoridated) actually Iinds slightly better dental health in the less Iluoridated Oregon. Comparing
counties within states Iinds similar oral health, with similar socioeconomics, regardless oI Iluoridation.3 Studies on Iluoridation have
not included the conIounding Iactor oI delayed tooth eruption or looked at liIe time beneIits.4

It is a Ilawed assumption to expect Iluoridated children with Iewer cavities will "thereIore" have a liIe time oI Iewer cavities. Several
studies have actually Iound an increase in dental decay and tooth loss with Iluoridation. Without clear, undisputed, liIe time beneIits
Irom Iluoridation, any risk or expense is unacceptable. Communities have stopped Iluoridation with no increase in dental decay.5 The
experiment oI Iluoridation is currently being promoted without good scientiIic and ethical review oI continued liIe time beneIits.

The US National Academy oI Sciences 2006 report conIirmed potential beneIits Irom Iluoridation are during the development oI the
tooth, up to about age 8. It makes no sense to have a liIetime uncontrolled dose oI Iluoride Ior everyone when the potential beneIits are
only up to age 8. LiIetime exposure must be considered.

DENTAL RISKS OF FLUORIDATION: As a Cosmetic Dentist, it is not uncommon to have patients receive gorgeous porcelain
veneers to correct their dental Iluorosis, white and brown damage Irom too much ingested Iluoride. Costs range Irom several hundred
dollars to well over $25,000 and need to be retreated every 10 to 20 years Ior liIe time costs which may exceed $100,000 per person.
With a third oI children having dental Iluorosis, the true costs Ior cosmetic damage to teeth alone is in the trillions oI dollars. A side
eIIect seldom raised by cosmetic dentists. Certainly most will not seek treatment, but the public liability Ior damage is signiIicant.
Public Health Dentists seldom provide cosmetic dentistry and thereIore under rate the increased dental damage Irom Iluoridation.

MEDICAL RISKS OF FLUORIDATION: Many committees reviewing Iluoridation are composed oI Dentists. It is not in the purview
oI Dentistry to diagnose thyroid, hormonal, skeletal, kidney, liver, brain, skeletal disorders or cancers outside the oral cavity.
Epidemiologists, Toxicologists and Medical ProIessionals unwisely rely on their Dental counterparts to diagnose saIety Ior body
organs Irom Iluoridation and Dentists would be practicing outside their scope oI training and licensure to appropriately weigh the
gravity oI medical side eIIects. Historic ground was covered in the USA when scientists opposed to Iluoridation were permitted on the
National Academy oI Science 2006 report to the US Environmental Protection Agency which unanimously Iound the EPA`s
Maximum Contaminant Level was not protective.6

The US Center Ior Disease Control and American Dental Association have cautioned inIants should not be given Iluoridated water or
Iluoridated water be used Ior making inIant Iormula.7 More than 3 out oI 4 inIants receive Iormula. Consider that all are medicated
with Iluoridation, yet the water is not saIe Ior our most vulnerable, our babies. We are now asking moms to haul their inIant, its Iood,
toys, clothes, and now water. Parents in third world countries can usually boil their water to make it saIe Ior inIants, but many
communities consciously put chemicals in the public water which can`t even be boiled out or traditional Iilters used to make it saIe Ior
inIants.

The biggest problem in the US scientiIic community is the Iear Universities, Medical and Dental Associations and Journals have in
permitting discussion, debate and scientiIic review oI Iluoridation. One state medical association requested $50,000 Ior a short private
presentation oI concerns. Others permit review only by their legal counsel. The BMJ should be commended Ior their willingness to do
what Iew other scientists are willing to do, open scientiIic discussion.

Bill Osmunson DDS, MPH Aesthetic Dentistry oI Bellevue billsmilesoIbellevue.com

1. The CDC also reIerences Horowitz and Ismail 1996, Johnston 1994, Ripa 1990, Stookey and Beiswanger 1995, however all these
reviewed topical application oI Iluoride, not the addition oI Iluoride to water. http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm

2. http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm

3. National Survey oI Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm

http://www.cdc.gov/oralhealth/waterIluoridation/Iactsheets/statesstats2002.htm---(No longer there)

The National Survey oI Children's Health 2003. Rockville, Maryland: U.S. Department oI Health and Human Services, 2005

U.S. Department oI Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau

http://www.doh.wa.gov/cIh/OralHealth/Documents/SmileSurvey2005FullReport.pdI---(No longer there)

http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdI#search'Oregon20Decay20experience

BRFSS 2002 http://www.dhs.state.or.us/dhs/ph/chs/brIs/02/orahea/dentvisi.shtml---(No longer there)
http://apps.nccd.cdc.gov/brIss/display.asp?stateWA&catOH&yr2004&qkey6610&grp0&SUBMIT4Go Sample size OR 3509
and WA 12,926 2004 data

National Survey oI Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm U.S. Department oI Health and Human
Services, http://www.Iluoridationcenter.org/papers/2002/cdcmmwr022102.htm---(No longer there)

http://quickIacts.census.gov/qId/states/41000.html

4. Our analysis shows no convincing eIIect oI Iluoride-intake on caries development." Komarek A, et al. (2005). A Bayesian analysis
oI multivariate doubly-interval-censored dental data. Biostatistics 6:145-55.

5. Kugel (sp) and Fischer 1997, Sepp et al. 1998

6. www.nap.edu/catalog/11571.html Fluoride in Drinking Water: A ScientiIic Review oI EPA`s Standards 2006

7. http://www.cdc.gov/Iluoridation/saIety/inIantIormula.htm www.ada.org see also Pizzo G, et al Community water Iluoridation
and caries prevention: a critical review, Clin Oral Investig. 2007 Feb 27.

Competing interests: None


(Typo corrections and links checked and updated with permission. K. Case, April 2012)


Vol. 60, No. 3, Summer 2000 131
R E V I E W & C O MME N T A R Y
Fluoride Intake and Prevalence of Dental Fluorosis:
Trends in Fluoride Intake with Special Attention to Infants
Samuel J. Fomon, MD; Jan Ekstrand, DDS, PhD; Ekhard E. Ziegler, MD
Abstract
Background: Although the predominant beneficial effect of fluoride occurs
locally in the mouth, the adverse effect, dental fluorosis, occurs by the systemic
route. The caries attack rate in industrializedcountries, including the Unitedstates
and Canada, has decreased dramatically over the past 40 years. However, the
prevalence of dental fluorosis in the United States has increased during the last
30 years both in communities with fluoridated water and in communities with
nonfluoridated water. Dental fluorosis is closely associated with fluoride intake
during the period of tooth development. Methods: We reviewed the major
changes in infant feeding practices that have occurred since 1930 and the
changes in fluoride intakes by infants and young children associated with changes
in feeding practices. Results and Conclusions: Based on this review, we
conclude that fluoride intakes of infants and children have shown a rather steady
increase since 1930, are likely to continue to increase, and will be associated with
further increase in the prevalence of enamel fluorosis unless intervention meas-
ures are instituted. Recommendations: We believe the most important measures
that should be undertaken are ( I ) use, when feasible, of water low in fluoride for
dilution of infant formulas; (2) adult supervision of toothbrushing by children
younger than 5 years of age; and (3) changes in recommendations for admini-
stration of fluoride supplements so that such supplements are not given to infants
and more stringent criteria are applied for administration to children.
Key Words: dental fluorosis, fluoride supplements, fluoridated dentifrices, formula
fluoride. [J Public Health Dent 2000;60(3): 131 -91
Current evidence suggests that the
predominant beneficial effects of fluo-
ride occur locally at the tooth surface,
and that systemic (preeruptive) effects
are of much less importance (1-5). Be-
cause fluoride intake at intervals
throughout the day is an important
factor in limiting the prevalence and
severity of dental caries in erupted
teeth, fluoridation of community
drinking water has been and contin-
ues to be a useful public health meas-
ure. In addition, the widespread use of
fluoridated dentifrices has provided
effective topical application of fluoride
to erupted teeth.
Although the predominant benefi-
cial effect of fluoride occurs locally in
the mouth, the adverse effect, dental
fluorosis, occurs by the systemic route.
From the beginning of tooth formation
until tooth eruption, fluoride appears
able to exert an adverse effect on den-
tal enamel at a number of develop-
mental stages (6,7). Of the several
mechanisms proposed for the adverse
effect on tooth development, the most
likely is that fluoride has an effect on
cell function, either through interac-
tions with the developing ameloblasts
or the intracellular matrix (8). Dental
fluorosis is characterized by an in-
creasing porosity (hypomineraliza-
tion) of the subsurface enamel, caus-
ing the enamel to appear opaque. The
clinical features include changes rang-
ing from barely discernible fine white
lines running across the teeth to en-
tirely chalky white teeth (8). In ad-
vanced stages, the enamel may be-
come so porous that the outer layers
break down and the exposed porous
subsurface becomes discolored.
The caries attack rate in industrial-
ized countries, including the United
States and Canada, has decreased dra-
matically over the past 40 years (9). On
the other hand, based on changes in
the earlier community fluorosis index
and in the more recent index of Thyl-
strup and Fejerskov (lo), the preva-
lence of dental fluorosis in the United
States has increased during the last 30
years, both in communities with
fluoridated water and in communities
with nonfluoridated water (1,11-18).
Because dental fluorosis is closely
associated with fluoride intake during
the period of tooth development (19),
we reasoned that a review of trends in
fluoride intake over the past 70 years
would be useful in predicting future
trends in dental fluorosis. Thus, the
purpose of thi s communication is to
review trends since 1930 in fluoride
intakes by infants and young children.
We shall put particular emphasis on
review of data on fluoride intake by
infants because major changes in in-
fant feeding practices over the past 70
years have been associated with age-
related changes in fluoride intake, and
we believe that these changes have not
been generally recognized.
General Considerations
Because the beneficial action of fluo-
ride in caries prevention is a local ef-
fect within the mouth, the exposure to
fluoride throughout the life span is a
major factor in prevention of dental
caries, and, i f a choice is to be made
between decreasing incidence of den-
tal caries and increasing incidence of
Send correspondence and reprint requests to Dr. Fomon, Department of Pediatrics, University of Iowa Hospitals and Clinics, 200 Hawkins Drive,
Iowa City, IA 52242-1083. E-mail: samfomon@aol.com. Dr. Ekstrand is affiliated with the Department of Basic Oral Sciences, School of Dentisw,
Karolinska Institute, Huddinge, Sweden. Dr. Ziegler is with the Department of Pediatrics, University of Iowa. The presentation is an updated and
expanded version of a paper presented at the Dietary Fluoride Supplement Workshop, Chicago, IL, Jan 31-Feb 1,1994. Manuscript received:
9/14/99; returned to authors for revision: 4/19/00; accepted for publication: 6/5/00.
Comparison of hydrouorosilicic acid and pharmaceutical
sodium uoride as uoridating agentsA costbenet
analysis
J. William Hirzy
a,
*, Robert J. Carton
b
, Christina D. Bonanni
a
, Carly M. Montanero
a
,
Michael F. Nagle
a
a
American University, Department of Chemistry, 4400 Massachusetts Ave., N.W., Washington, DC,. USA
b
4 Glenwood Terrace, Averill Park, NY, USA
e nv i r onme nt a l s c i e nc e & p ol i c y x x x ( 2 0 1 3 ) x x x x x x
a r t i c l e i n f o
Article history:
Received 30 March 2012
Received in revised form
14 January 2013
Accepted 15 January 2013
Keywords:
Fluoride
Arsenic
Cancer
Fluoridation
Costbenet analysis
a b s t r a c t
Water uoridation programs in the United States and other countries which have themuse
either sodium uoride (NaF), hydrouorosilicic acid (HFSA) or the sodium salt of that acid
(NaSF), all technical grade chemicals to adjust the uoride level in drinking water to about
0.71 mg/L. In this paper we estimate the comparative overall cost for U.S. society between
using cheaper industrial grade HFSA as the principal uoridating agent versus using more
costly pharmaceutical grade (U.S. Pharmacopeia USP) NaF. USP NaF is used in toothpaste.
HFSA, a liquid, contains signicant amounts of arsenic (As). HFSA and NaSF have been
shown to leach lead (Pb) fromwater delivery plumbing, while NaF has been shown not to do
so. The U.S. Environmental Protection Agencys (EPA) health-based drinking water stan-
dards for As and Pb are zero. Our focus was on comparing the social costs associated with
the difference in numbers of cancer cases arising fromAs during use of HFSAas uoridating
agent versus substitution of USP grade NaF. We calculated the amount of As delivered to
uoridated water systems using eachagent, andused EPAUnit Risk values for As to estimate
the number of lung and bladder cancer cases associated with each. We used cost of cancer
cases published by EPA to estimate cost of treating lung and bladder cancer cases. Com-
mercial prices of HFSA and USP NaF were used to compare costs of using each to uoridate.
We then compared the total cost to our society for the use of HFSA versus USP NaF as
uoridating agent. The U.S. could save $1 billion to more than $5 billion/year by using USP
NaF in place of HFSAwhile simultaneously mitigating the pain and suffering of citizens that
result fromuse of the technical grade uoridating agents. Other countries, such as Ireland,
NewZealand, Canada and Australia that use technical grade uoridating agents may realize
similar benets by making this change. Policy makers would have to confront the uneven
distribution of costs and benets across societies if this change were made.
# 2013 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Chemistry, American University, 4400 Massachusetts Ave., N.W., Washington, DC 20016, USA.
Tel.: +1 202 885 1780; fax: +001 202 8851752.
E-mail addresses: whirzy@american.edu, hirzyinbox@gmail.com (J.W. Hirzy).
ENVSCI-1173; No. of Pages 6
Please cite this article in press as: Hirzy, J.W., et al., Comparison of hydrouorosilicic acid and pharmaceutical sodium uoride as uoridating
agentsA costbenet analysis. Environ. Sci. Policy (2013), http://dx.doi.org/10.1016/j.envsci.2013.01.007
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/envsci
1462-9011/$ see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.envsci.2013.01.007
1362 VOLUME 120
|
NUMBER 10
|
October 2012 t Environmental Health Perspectives
Review
A recent report from the National Research
Council (NRC 2006) concluded that adverse
effects of high fluoride concentrations in
drinking water may be of concern and that
additional research is warranted. Fluoride may
cause neurotoxicity in laboratory animals,
including effects on learning and memory
(Chioca et al. 2008; Mullenix et al. 1995). A
recent experimental study where the rat hip-
pocampal neurons were incubated with vari-
ous concentrations (20 mg/L, 40 mg/L, and
80 mg/L) of sodium uoride in vitro showed
that fluoride neurotoxicity may target hip-
pocampal neurons (Zhang M et al. 2008).
Although acute fluoride poisoning may be
neurotoxic to adults, most of the epidemio-
logical information available on associations
with childrens neurodevelopment is from
China, where fluoride generally occurs in
drinking water as a natural contaminant, and
the concentration depends on local geologi-
cal conditions. In many rural communities
in China, populations with high exposure to
uoride in local drinking-water sources may
reside in close proximity to populations with-
out high exposure (NRC 2006).
Opportunities for epidemiological stud-
ies depend on the existence of comparable
population groups exposed to dierent levels
of fluoride from drinking water. Such cir-
cumstances are difficult to find in many
industrialized countries, because uoride con-
centrations in community water are usually
no higher than 1 mg/L, even when uoride
is added to water supplies as a public health
measure to reduce tooth decay. Multiple epi-
demiological studies of developmental uo-
ride neurotoxicity were conducted in China
because of the high uoride concentrations
that are substantially above 1 mg/L in well
water in many rural communities, although
microbiologically safe water has been acces-
sible to many rural households as a result of
the recent 5-year plan (20012005) by the
Chinese government. It is projected that all
rural residents will have access to safe public
drinking water by 2020 (World Bank 2006).
However, results of the published studies have
not been widely disseminated. Four studies
published in English (Li XS et al. 1995; Lu
et al. 2000; Xiang et al. 2003; Zhao et al.
1996) were cited in a recent report from the
NRC (2006), whereas the World Health
Organization (2002) has considered only two
(Li XS et al. 1995; Zhao et al. 1996) in its
most recent monograph on uoride.
Fluoride readily crosses the placenta
(Agency for Toxic Substances and Disease
Registry 2003). Fluoride exposure to the devel-
oping brain, which is much more susceptible
to injury caused by toxicants than is the mature
brain, may possibly lead to permanent damage
(Grandjean and Landrigan 2006). In response
to the recommendation of the NRC (2006),
the U.S. Department of Health and Human
Services (DHHS) and the U.S. EPA recently
announced that DHHS is proposing to change
the recommended level of uoride in drinking
water to 0.7 mg/L from the currently recom-
mended range of 0.71.2 mg/L, and the U.S.
EPA is reviewing the maximum amount of
uoride allowed in drinking water, which cur-
rently is set at 4.0 mg/L (U.S. EPA 2011).
To summarize the available literature,
we performed a systematic review and meta-
analysis of published studies on increased
uoride exposure in drinking water associated
with neurodevelopmental delays. We speci-
cally targeted studies carried out in rural
China that have not been widely disseminated,
thus complementing the studies that have
been included in previous reviews and risk
assessment reports.
Methods
Search strategy. We searched MEDLINE
(National Library of Medicine, Bethesda, MD,
USA; http://www.ncbi.nlm.nih.gov/pubmed),
Embase (Elsevier B.V., Amsterdam, the
Netherlands; http://www.embase.com), Water
Resources Abstracts (Proquest, Ann Arbor,
MI, USA; http://www.csa.com/factsheets/
water-resources-set-c.php), and TOXNET
(Toxicology Data Network; National Library
of Medicine, Bethesda, MD, USA; http://tox-
net.nlm.nih.gov) databases to identify studies
of drinking-water fluoride and neurodevel-
opmental outcomes in children. In addition,
we searched the China National Knowledge
Infrastructure (CNKI; Beijing, China; http://
www.cnki.net) database to identify stud-
ies published in Chinese journals only. Key
Address correspondence to A.L. Choi, Department
of Environmental Health, Harvard School of Public
Health, Landmark Center 3E, 401 Park Dr., Boston,
MA 02215 USA. Telephone: (617) 384-8646. Fax:
(617) 384-8994. E-mail: achoi@hsph.harvard.edu
Supplemental Material is available online (http://
dx.doi.org/10.1289/ehp.1104912).
We thank V. Malik, Harvard School of Public Health,
for the helpful advice on the meta-analysis methods.
is study was supported by internal institutional
funds.
e authors declare they have no actual or potential
competing nancial interests.
Received 30 December 2011; accepted 20 July 2012.
Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis
Anna L. Choi,
1
Guifan Sun,
2
Ying Zhang,
3
and Philippe Grandjean
1,4
1
Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA;
2
School of Public Health, China
Medical University, Shenyang, China;
3
School of Stomatology, China Medical University, Shenyang, China;
4
Institute of Public Health,
University of Southern Denmark, Odense, Denmark
BACKGROUND: Although uoride may cause neurotoxicity in animal models and acute uoride
poisoning causes neurotoxicity in adults, very little is known of its eects on childrens neuro-
development.
OBJECTIVE: We performed a systematic review and meta-analysis of published studies to investigate
the eects of increased uoride exposure and delayed neurobehavioral development.
METHODS: We searched the MEDLINE, EMBASE, Water Resources Abstracts, and TOXNET
databases through 2011 for eligible studies. We also searched the China National Knowledge
Infrastructure (CNKI) database, because many studies on uoride neurotoxicity have been pub-
lished in Chinese journals only. In total, we identied 27 eligible epidemiological studies with high
and reference exposures, end points of IQ scores, or related cognitive function measures with means
and variances for the two exposure groups. Using random-eects models, we estimated the stan-
dardized mean dierence between exposed and reference groups across all studies. We conducted
sensitivity analyses restricted to studies using the same outcome assessment and having drinking-
water uoride as the only exposure. We performed the Cochran test for heterogeneity between stud-
ies, Beggs funnel plot, and Egger test to assess publication bias, and conducted meta-regressions to
explore sources of variation in mean dierences among the studies.
RESULTS: e standardized weighted mean dierence in IQ score between exposed and reference
populations was 0.45 (95% condence interval: 0.56, 0.35) using a random-eects model.
us, children in high-uoride areas had signicantly lower IQ scores than those who lived in low-
uoride areas. Subgroup and sensitivity analyses also indicated inverse associations, although the
substantial heterogeneity did not appear to decrease.
CONCLUSIONS: e results support the possibility of an adverse eect of high uoride exposure on
childrens neurodevelopment. Future research should include detailed individual-level information
on prenatal exposure, neurobehavioral performance, and covariates for adjustment.
KEY WORDS: fluoride, intelligence, neurotoxicity. Environ Health Perspect 120:13621368
(2012). http://dx.doi.org/10.1289/ehp.1104912 [Online 20 July 2012]
Conrmation of and explanations for elevated blood lead and
other disorders in children exposed to water disinfection and
uoridation chemicals
Myron J. Coplan
a,
*
, Steven C. Patch
b
, Roger D. Masters
c
, Marcia S. Bachman
a
a
Intellequity Technology Services Natick, Massachusetts, United States
b
Environmental Quality Institute, University of North Carolina in Asheville, United States
c
Dartmouth College Institute for Nuroscience and Society, United States
Received 23 February 2006; accepted 12 February 2007
Available online 1 March 2007
Abstract
Silicouorides (SiFs), uosilicic acid (FSA) and sodium uosilicate (NaFSA), are used to uoridate over 90% of US uoridated municipal
water supplies. Living in communities with silicouoride treated water (SiFW) is associated with two neurotoxic effects: (1) Prevalence of children
with elevated blood lead (PbB > 10 mg/dL) is about double that in non-uoridated communities (Risk Ratio 2, x
2
p < 0.01). SiFW is associated
with serious corrosion of lead-bearing brass plumbing, producing elevated water lead (PbW) at the faucet. New data refute the long-prevailing
belief that PbW contributes little to childrens blood lead (PbB), it is likely to contribute 50% or more. (2) SiFW has been shown to interfere with
cholinergic function. Unlike the fully ionized state of uoride (F-) in water treated with sodium uoride (NaFW), the SiF anion, [SiF6]2- in SiFW
releases F- in a complicated dissociation process. Small amounts of incompletely dissociated [SiF6]2- or low molecular weight (LMW) silicic acid
(SA) oligomers may remain in SiFW. A German PhD study found that SiFW is a more powerful inhibitor of acetylcholinesterase (AChE) than
NaFW. It is proposed here that SiFW induces protein mis-folding via a mechanism that would affect polypeptides in general, and explain dental
uorosis, a tooth enamel defect that is not merely cosmetic but a canary in the mine foretelling other adverse, albeit subtle, health and
behavioral effects. Efforts to refute evidence of such effects are analyzed and rebutted. In 1999 and 2000, senior EPApersonnel admitted they knew
of no health effects studies of SiFs. In 2002 SiFs were nominated for NTP animal testing. In 2006 an NRC Fluoride Study Committee
recommended such studies. It is not known at this writing whether any had begun.
# 2007 Elsevier Inc. All rights reserved.
Keywords: Elevated blood lead; Silicouoride; Fluosilicate; Brass corrosion; Enzyme inhibition; Fluorosis
1. Introduction
Chronic ingestion of water bearing 1 ppm of uoride ion
(F

) from NaF was thought harmless to humans when

municipal water uoridation began in 1945. NaFSA was
substituted in 1947 and endorsed in 1950 by the US Public
Health Service without prior animal testing because rats grew
just as fast, their teeth got as much F

as from NaF, and a

community could save 4 cents per year per resident (McClure,
1950).
FSA (H
2
SiF
6
) and NaFSA, its sodium salt (Na
2
SiF
6
), share
the [SiF
6
]
2
anion, a uoride complex herein called silico-
uoride (SiF) which dissociates in water, releasing F

. The
dissociation was predicted to be virtually complete at 1 ppm
of F

so that SiFW would be just like NaF treated water

(NaFW). Today, 92% of US uoridated drinking water is SiFW
(CDC, 1993). Senior EPA personnel have found no evidence
SiFW was ever tested for adverse health effects (Fox, 1999;
Thurnau, 2000). In 2002, SiFs were nominated for animal
tests (NTP, 2002) that had not begun as of July 2006.
The NRC report, Fluoride in Drinking Water. . .A
Scientic Review of EPAs Standards (NRC, 2006) empha-
sizes the importance of such testing with questions about
NeuroToxicology 28 (2007) 10321042
* Corresponding author. Tel.: +1 508 653 6147; fax: +1 508 655 3677.
E-mail addresses: MYRONCOPLAN@aol.com (M.J. Coplan),
patch@unca.edu (S.C. Patch), Roger.D.Masters@Dartmoth.edu
(R.D. Masters), maribac@aol.com (M.S. Bachman).
0161-813X/$ see front matter # 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.neuro.2007.02.012
Community Dent Oral Epidemiol 2000; 28: 3829 Copyright C Munksgaard 2000
Printed in Denmark . All rights reserved
ISSN 0301-5661
W. Knzel
1
, T. Fischer
1
, R. Lorenz
2
and
S. Brhmann
2
Decline of caries prevalence after
1
Dental School of Erfurt, Department of
Preventive Dentistry, Friedrich-Schiller-
University of Jena,
2
Public Health Services of
the cessation of water uoridation
Spremberg and Zittau, Germany
in the former East Germany
Knzel W, Fischer T, Lorenz R, Brhmann S: Decline of caries prevalence after
the cessation of water uoridation in the former East Germany. Community Dent
Oral Epidemiol 2000; 28: 3829. C Munksgaard, 2000
Abstract In contrast to the anticipated increase in dental caries following the
cessation of water uoridation in the cities Chemnitz (formerly Karl-Marx-Stadt)
and Plauen, a signicant fall in caries prevalence was observed. This trend corre-
sponded to the national caries decline and appeared to be a new population-wide
phenomenon. Additional surveys (N1017) carried out in the formerly-uori-
dated towns of Spremberg (N9042) and Zittau (N6232) were carried out in
order to support this unexpected epidemiological nding. Pupils from these
towns, aged 8/9-, 12/13- and 15/16-years, have been examined repeatedly over
the last 20 years using standardised caries-methodological procedures. While the
data provided additional support for the established fact of a caries reduction
brought about by the uoridation of drinking water (48 % on average), it has
also provided further support for the contention that caries prevalence may contin-
ue to fall after the reduction of uoride concentration in the water supply from
about 1 ppm to below 0.2 ppm F. Caries levels for the 12-year-olds of both towns
signicantly decreased during the years 199396, following the cessation of water
uoridation. In Spremberg, DMFT fell from 2.36 to 1.45 (38.5 %) and in Zittau from
2.47 to 1.96 (20.6%). These ndings have therefore supported the previously ob- Key words: caries prevalence; cessation;
children; East Germany; water uoridation
served change in the caries trend of Chemnitz and Plauen. The mean of 1.81 DMFT
for the 12-year-olds, computed from data of the four towns, is the lowest ob-
Walter Knzel, Dental School of Erfurt and
WHO Collaborating Centre for the
served in East Germany during the past 40 years. The causes for the changed caries
Prevention of Oral Diseases, Nordhuser Str.
trend were seen on the one hand in improvements in attitudes towards oral
78, D 99089 Erfurt, Germany
health behaviour and, on the other hand, to the broader availabilty and application
Tel: 49 361 741 1209
of preventive measures (F-salt, F-toothpastes, ssure sealants etc.). There is, how-
Fax: 49 361 741 1109
e-mail: Simionoff/zmkh.ef.uni-jena.de
ever, still no denitive explanation for the current pattern and further analysis of
future caries trends in the formerly uoridated towns would therefore seem to
Submitted 5 January 1999; accepted
be necessary. 7 February 2000
Long-lasting discontinuities or a nal cessation of
water uoridation have, hitherto, usually resulted
in a caries increase in the juvenile population (1, 2,
3). In contrast to this repeated nding (4, 5, 6), it
emerged that in Chemnitz (formerly Karl-Marx-
Stadt), caries prevalence actually continued to
decrease (7), the DMFT-index falling signicantly
between 1991 and 1995, from 2.5 to 1.9. A similar
statistical trend was observed in the F-poor control
town Plauen, where water uoridation had ceased
382
in 198485 due to a necessary reconstruction of the
water supply system. By 1995, the relatively high
DMFT of 3.5 for 12-year-olds seen in 1983 had de-
creased to 2.0.
This unexpected trend, shown for the rst time
after cessation of water uoridation (CWF), oc-
curred at a time when there was a population-wide
decline in dental caries. This caries decline, which
became evident in the highly industrialised coun-
tries of the western hemisphere at the end of the
7/16/13 4:10 PM Caries prevalence after cessation of wate... [Caries Res. 2000 Jan-Feb] - PubMed - NCBI
Page 1 of 1 http://www.ncbi.nlm.nih.gov/pubmed/10601780
Caries Res. 2000 Jan-Feb;34(1):20-5.
Caries prevalence after cessation of water fluoridation in La Salud, Cuba.
Knzel W, Fischer T.
Department of Preventive Dentistry, Dental School of Erfurt, Friedrich Schiller University of Jena, Germany.
Abstract
In the past, caries has usually increased after cessation of water fluoridation. More recently an
opposite trend could be observed: DMFT remaining stable or even decreasing further. The aim of the
present study conducted in La Salud (Province of Habana) in March 1997 was to analyse the current
caries trend under the special climatic and nutritional conditions of the subtropical sugar island Cuba,
following the cessation, in 1990, of water fluoridation (0.8 ppm F). Diagnostic evaluations were carried
out using the same methods as in 1973 and 1982. Boys and girls aged 6-13 years (N = 414), lifelong
residents in La Salud, were examined. Between 1973 and 1982 the mean DMFT had decreased by
71.4%, the mean DMFS by 73. 3% and the percentage of caries-free children had increased from 26.
3 to 61.6%. In 1997, following the cessation of drinking water fluoridation, in contrast to an expected
rise in caries prevalence, DMFT and DMFS values remained at a low level for the 6- to 9-year-olds
and appeared to decrease for the 10/11-year-olds (from 1. 1 to 0.8) and DMFS (from 1.5 to 1.2). In
the 12/13-year-olds, there was a significant decrease (DMFT from 2.1 to 1.1; DMFS from 3.1 to 1. 5),
while the percentage of caries-free children of this age group had increased from 4.8 (1973) and 33.3
(1982) up to 55.2%. A possible explanation for this unexpected finding and for the good oral health
status of the children in La Salud is the effect of the school mouthrinsing programme, which has
involved fortnightly mouthrinses with 0.2% NaF solutions (i.e. 15 times/year) since 1990.
PMID: 10601780 [PubMed - indexed for MEDLINE]
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PubMed
7/16/13 4:14 PM The effects of a break in water fluoridation on t... [J Dent Res. 2000] - PubMed - NCBI
Page 1 of 1 http://www.ncbi.nlm.nih.gov/pubmed/10728978
J Dent Res. 2000 Feb;79(2):761-9.
The effects of a break in water fluoridation on the development of dental caries
and fluorosis.
Burt BA, Keels MA, Heller KE.
Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA.
bburt@umich.edu
Abstract
Durham, NC, fluoridated since 1962, had an 11-month cessation of fluoridation between
September, 1990, and August, 1991. The purpose of this study was to assess the effects of this
break on the development of caries and fluorosis in children. Study participants were continuously-
resident children in Kindergarten through Grade 5 in Durham's elementary schools. There were 1696
children, 81.4% of those eligible, for whom a questionnaire was completed and clinical data recorded.
Age cohorts were defined by a child's age at the time that fluoridation ceased. Caries was recorded
in children in the Birth Cohort through Cohort 3, and fluorosis for children in Cohorts 1 through 5.
Caries was assessed in the primary first and second molars according to the decayed-filled index;
fluorosis on the labial surfaces of the upper permanent central and lateral incisors was assessed by
the Thylstrup-Fejerskov (TF) index. Mother's education was associated with caries; higher education
of the mother had an odds ratio of 0.53 (95% CI 0.40, 0.76) for caries in the child. No cohort effects
could be discerned for caries. Overall prevalence of fluorosis was 44%. Prevalence in Cohorts 1, 2, 3,
4, and 5 was 39.8%, 32.3%, 33.0%, 62.3%, and 57.1%, respectively. These cohort differences
remained statistically significant in regression analysis. It was concluded that while the break had little
effect on caries, dental fluorosis is sensitive to even small changes in fluoride exposure from drinking
water, and this sensitivity is greater at 1 to 3 years of age than at 4 or 5 years.
PMID: 10728978 [PubMed - indexed for MEDLINE]
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PubMed
7/16/13 4:24 PM Physiologic conditions affect toxici... [J Environ Public Health. 2013] - PubMed - NCBI
Page 1 of 2 http://www.ncbi.nlm.nih.gov/pubmed/23840230
J Environ Public Health. 2013;2013:439490. doi: 10.1155/2013/439490. Epub 2013 Jun 6.
Physiologic conditions affect toxicity of ingested industrial fluoride.
Sauerheber R.
Department of Chemistry, University of California, San Diego, La Jolla, CA 92037, USA ; STAR Tutoring Center, Palomar
Community College, San Marcos, CA 92069, USA.
Abstract
The effects of calcium ion and broad pH ranges on free fluoride ion aqueous concentrations were
measured directly and computed theoretically. Solubility calculations indicate that blood fluoride
concentrations that occur in lethal poisonings would decrease calcium below prevailing levels. Acute
lethal poisoning and also many of the chronic effects of fluoride involve alterations in the chemical
activity of calcium by the fluoride ion. Natural calcium fluoride with low solubility and toxicity from
ingestion is distinct from fully soluble toxic industrial fluorides. The toxicity of fluoride is determined by
environmental conditions and the positive cations present. At a pH typical of gastric juice, fluoride is
largely protonated as hydrofluoric acid HF. Industrial fluoride ingested from treated water enters
saliva at levels too low to affect dental caries. Blood levels during lifelong consumption can harm
heart, bone, brain, and even developing teeth enamel. The widespread policy known as water
fluoridation is discussed in light of these findings.
PMID: 23840230 [PubMed - in process] PMCID: PMC3690253 Free PMC Article
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