Water fluoridation controversy

Water fluoridation controversy refers to the debate surrounding the health benefits of public authorities fluoridating water supplies. Calcium fluoride is a naturally-occurring mineral found in all water sources, such as lakes, rivers, groundwater and oceans. Community water fluoridation is the process of artificially increasing fluoride levels in drinking water supplies with the stated of improving oral health. This is usually done by the addition of sodium fluoride, sodium fluorosilicate, or fluorosilicic acid.

Advocates of water fluoridation say that fluoridation is similar to fortifying salt with iodine, milk with vitamin D and orange juice with vitamin C and say it is an effective way to prevent tooth decay and improve oral health over a lifetime, for both children and adults.

Those opposed to public fluoridation of drinking water say that water fluoridation can have negative health effects such as dental fluorosis which outweighs the purported benefits of water fluoridation. Some opponents claim that releasing fluoride compunds into a municipal water takes away individual choice as to the substances a person ingests and amounts to mass medication. Some suggest water fluoridation is part of a scheme to dispose of a toxic industrial byproduct.

Common arguments against water fluoridation

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Tap water in cities may have fluoride compounds added in an effort to reduce dental decay. However, opponents object to being forced to ingest these compounds based on freedom of choice and health concerns

Adding fluoride compounds to municipal water supplies takes away individual choice of medication

Some opponents of water fluoridation object to adding fluoride to the water supply because it takes away individual choice as cities usually only have one source of water. Thus, they do not approve of the social or political implications of adding fluoride to the public's water supplies. Even though water fluoridation may improve dental health of the general public, these people value an individual's choice to pursue medical treatment and argue that water fluoridation is "compulsory mass medication" because it does not allow proper consent.

On the other hand, other commentators argue that because of the negative health effects of fluoride exposure, mandatory fluoridation of public water supplies is a "breach of ethics" and a "human rights violation."

Many groups oppose adding fluoride compounds to municipal water supplies primarily on health concerns and a general objection about being forced to ingest a substance introduced in the water supply.

Fluoride is not essential

Some opponents of water fluoridation argue that fluoride is neither a vitamin nor an essential nutrient. They state that overall health does not rely on fluoride and that dental health can be improved through other methods, such as modifying diet. Consequently, they argue, there is no need to promote fluoride as important to healthy growth and development.

Water fluoridation has been rejected by many countries through the world

Although somewhat prevalent in the United States, most of Western Europe does not add fluoride to its water supply. In spite of this, the prevalence of dental decay has decreased in both Western Europe and the United States. Some countries had water fluoridation but then abruptly stopped the practice. These countries, including Canada, the former East Germany, Cuba and Finland, have continued to see drops in the incidence of tooth decay. Based on this evidence, opponents conclude that factors other than fluoride decrease tooth decay.

Water fluoridation is not effective

Opponents point to a study by the National Institute of Dental Research showing little difference in tooth decay rates among children in fluoridated and non-fluoridated communities. In the study's results, the difference between the children exposed to water fluoridation and those who were not was very small, between 0.12 and 0.30 DMFS (Decayed Missing and Filled Surfaces).

Some detractors of water fluoridation support concentrated topical methods to deliver fluoride, as seen in these fluoride trays often used in dentistry.

Opponents also argue that in the instances that fluoride prevents tooth decay, the effects are merely topical. Therefore, fluoridating water is unnecessary and ineffective. Instead, they argue, direct applications of fluoride to teeth as done in dental offices and with fluoridated toothpastes should be the recommended methods.

Opponents point out that dental decay continues to exist in water fluoridated communities. They reason that if fluoride is effective, then there would be no more tooth decay. While, in theory, the poorest members of society would be aided the most by fluoridinated water, baby bottle tooth decay (BBTD) and tooth decay in general is still prevalent in those social groups. Opponents conclude that, in light of the continuing dental health problem, water fluoridation is unable to successfully increase health standards and thus should not be used.

Finally, opponents argue that the general decline of tooth decay is the result of factors beside water fluoridation, including toothpaste with fluoride, improved diets, and overall improved general and dental health.

Fluoride causes health problems

There are some opponents of fluoridation who believe fluoride causes negative health effects such as dental fluorosis and other problems. They argue that having a lethal chemical in the water is reckless and leads to many health problems in the general public.

Teeth as seen in dental fluorosis caused by excessive fluoride.

These persons point to research which they say supports the notion that fluoride causes chromosomal damage and interferes with DNA repair. They point to animal studies that they say demonstrate that rats fed for one year with 1 ppm fluoride in their water had detrimental changes to their kidneys and brains, an increased uptake of aluminum in the brain, and the formation of beta amyloid deposits, a characteristic of Alzheimers disease. Further, it is argued by some opponents that fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.

At high doses, fluoride has many side effects. Animal studies demonstrate that fluoride can damage the male reproductive system in a various number of species. Consequently, fluoride is considered dangerous by these groups.

Reliance on EPA Scientists and Nobel Prize winners who oppose water fluoridation

Many opponents of water fluoridation rely on experts opposing water fluoridation.

On April 1998 Chapter 280 of the National Treasury Employees Union, the EPA union of scientists voted to oppose water fluoridation of drinking water supplies. The union is comprised of and represents the approximately 1500 scientists, lawyers, engineers and other professional employees at EPA Headquarters in Washington, D.C.[1]

"I would advise against fluoridation. Individual prophylaxis (treatment) is preferable on principle grounds and is as equally effective," says Dr. Arvid Carlsson of Sweden, co-winner of the 2000 year's Nobel Prize for medicine.[2]

Government and industry collusion

Some opponents point to a government and/or industry collusion that has influenced research to further its own political goal.

Key players

• Francis Cowles Frary, Director of Research at the Aluminum Company of America from 1918, [3] was grappling with the issue of fluoride emissions from aluminum smelters. In 1935 Frary made suggestions to Gerald Cox, a researcher at the Mellon Institute, that fluoride might make strong teeth.

• Gerald Judy Cox, a researcher at the Mellon Institute in the 1930s held a fellowship from the Aluminum Company of America. Cox reported that fluoride gave rats cavity-resistant teeth and in 1939 made the first public proposal to add fluoride to public water supplies.

• Oscar R. Ewing was a top Wall Street lawyer for the Aluminum Company of America. As Federal Security Agency administrator in 1950 for the Truman administration, with jurisdiction over the Public Health Service, Ewing endorsed public water fluoridation for the United States.[4]

Other theories involve large industrial companies wanting to rid themselves of fluorine "waste products". Some argue that fluoride is a waste product that is unusable and expensive to dispose of properly. Because of this expense, industrial companies desiring to protect their profits release "millions of tons of waste fluoride into the environment." As a result, these opponents of water fluoridation say, "it is now clear that the one utterly relentless force behind fluoridation is American 'big industry' ".

In other cases, the particular theories involves the secret development of the atomic bomb during World War II. The argument usually involves characterizing research as flawed or edited for the public in order to avoid public concern over military research. As some have put it, "The science of fluoridating public drinking water systems has been, from day one, shoddy at best . . . . the basis of that science was rooted in protecting the U.S. Atomic bomb program from litigation."

Some other theories rest on the dental community as a whole. Some believe that a secret, Masonic society of dentists with 26,000 members around the world influence fluoridation policy for their own goals.

Common Arguments Advocating Water Fluoridation

(See Medical approval" for a list of health organizations.)

Groups opposing water fluoridation believe that individuals should be able to decide the chemicals they ingest in their drinking water rather than the government.

Advocates for water fluoridation argue that any risks posed by water fluoridation are outweighed by the benefits. The Centers for Disease Control and Prevention (CDC) has listed water fluoridation as one of the ten greatest achievements in public health of the 20th century. In 2000, a report by the Surgeon General of the United States titled "Oral Health in America" stated, "Community water fluoridation remains one of the great achievements of public health in the twentieth century." Various international groups, including the World Health Organization (WHO) and the International Association for Dental Research (IADR) support water fluoridation as a safe and effective method to fight tooth decay. These organizations respond to arguments by water fluoridation opponents similarly.

Optimal oral health care includes fluoride

Fluoridation proponents believe that research has shown that fluoride has a positive effect on overall dental health. During tooth development, fluoride binds to the hydroxyapatite crystals present in enamel and makes the enamel more resistant to demineralization by acids. As a result, some organizations, such as the American Dental Hygiene Association, classify fluoride as a nutrient necessary for proper tooth development. In addition, organizations, including the CDC and WHO, promote increasing the accessibility of fluoridated water.

Water fluoridation is not needed by everyone

Though water fluoridation is promoted by many health organizations and is considered the least costly method of dispersing fluoride, other methods of dispersal are possible. The World Health Organization is currently researching the use of fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe.

Nonetheless, the most important concern of health organizations is the incidence of dental fluorosis, a sign of overexposure to fluoride. In many instances, natural fluoride levels in water are much higher than desired. These areas do not need fluoride added to water supplies, and health organizations endorse providing alternate water sources or adjusting the fluoride levels to deliver the proper amount for dental health instead.

Water fluoridation is effective

Scientific and health organizations criticize opponents of water fluoridation for trying to engage in "polling practices" with research. When a group opposing water fluoridation claims an award-winning researcher or dental expert agrees with them, the argument is supposed to be more convincing to the general public. In response, researchers emphasize that voting or polling is not how scientific progress is made. Thorough review of methodology and design of multiple studies over time lead researchers to conclusions. Even in the critical analysis of these studies, content is the focus, rather than the researcher who led the study.

An example of rampant decay. Health organizations do not expect to completely eliminate all tooth decay using only fluoride.

Coincidentally, if voting determined scientific thought, then fluoridation would be considered safe and effective since the majority of health and scientific organizations approve of its use. The Centers for Disease Control and Prevention published in its Morbidity and Mortality Weekly Report (MMWR) that starting or continuing water fluoridation decreased the incidence of tooth decay by 29%, and that stopping water fluoridation increased the incidence of tooth decay in some communities. Other organizations also see a clear link between desired fluoride levels in water and a decrease in tooth decay.

In addition, since oral health is affected by many factors, fluoride alone would be unable, nor would it be expected, to eradicate the disease. The social groups that would be more likely to benefit from water fluoridation are those living in poorer conditions, and an important factor to decrease dental health disparities may be water fluoridation programs. Nonetheless, it is understood that these communities suffer from various problems which would impede oral health, such as lack of access to dental care and poorer oral hygiene education. Water fluoridation is only a single factor to improve dental health.

Another criticism of water fluoridation opponents given is their reference to research seeming to support their view. Generally, those studies are criticized by the majority of scientific researchers on basic principles, such as the methodology used. More problematic is the accusation that some anti-fluoridation research is published in journals, such as "Fluoride", that are deceptively made to appear peer-reviewed.

There are safe levels for fluoride use

Advocates of water fluoridation agree that fluoride in high concentrations produces harmful effects to the body. Nonetheless, they argue that almost any substance is harmful because toxicity is based on the amount of exposure. In defending water fluoridation, the American Dental Association points out that vitamin A, vitamin D, iron, iodine, aspirin, and water are potentially harmful if given in certain amounts. As is true for all vitamins and minerals, recommended dosages for fluoride represent levels which maximize health benefits and minimize adverse effects.

The greatest concern with fluoride overexposure is dental fluorosis. Fluorosis is undesireable because, in severe cases, it discolors teeth, causes surface changes to the enamel, and makes oral hygiene more difficult. Government agencies, such as the Center for Disease Control and Prevention, keep records on the prevalence of fluorosis in the general public. Also a concern, skeletal fluorosis is a disease in which fluoride deposits into bone, causing joint stiffness, joint pain, and sometimes changes in bone shape. For skeletal fluorosis to occur, chronic, high level exposure to fluoride is required. A mild form of skeletal fluorosis, osteosclerosis, is seen when levels of fluoride reach 5 parts per million (ppm) and the time of exposure lasts for 10 years.

Schedule for Fluoride Prescription Age < 0.3 ppm 0.3 - 0.6 ppm >0.6 ppm Birth - 6 months 0 0 0 6 months - 3 years .25 mg 0 0 3 years - 6 years .50 mg .25 mg 0 6 years - 16 years 1.0 mg .50 mg 0 Dosages are in milligrams F/day; 1.0 ppm = 1 mg/liter.

In order to best prevent fluorosis, health organizations have created guidelines restricting the amount of fluoride exposure. The Environmental Protection Agency limits the maximum amount of fluoride in drinking water to 4.0 milligrams per liter of water and recommends water supplies to contain between 0.7 and 1.2 milligrams of fluoride per liter. The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis. When there is a fluoride deficiency in water (usually below 0.6 ppm), fluoride supplements are sometimes needed to encourage healthy dental development. There are accepted recommended guidelines on the amount of fluoride to prescribe, which depend on the fluoride levels in the drinking water and on the age of the child.

Moreover, health organizations have affirmed the currently accepted belief that recommended levels of fluoride does not contribute to the many diseases water fluoridation detractors accuse fluoride of causing. The Centers for Disease Control and Prevention and the National Cancer Institute have both issued statements that water fluoridation is not believed to cause osteosarcomas. Cancer in general is not believed to be caused from water fluoridation.

There is no clear link between Alzheimer's disease and water fluoridation. A study in 1998 suggested a possible relationship between fluoride exposure and Alzheimer's disease. Research groups point out that the study contained methodological limitations, which prevent a definitive conclusion on the subject. As a result, research and health agencies currently believe fluoride is not a risk factor for Alzheimer's disease, and instead age and family history are the most important risk factors. Moreover, there is some research that suggests Alzheimer's disease can be prevented with water fluoridation because of the competition between aluminum and fluoride absorption. Nonetheless, this research is also limited by design and no definitive conclusion can be made.

Other health concerns, such as kidney disease, Down syndrome, lead poisoning, heart disease, decreased fertility rates, and inhibition of biologic enzymes, are not believed to be attributed to water fluoridation.

Water fluoridation is sometimes compared to fortifying milk with Vitamin D.

Ethical questions

Frequently, health agencies confront the ethics of water fluoridation along the lines of two topics. They address the issues of whether fluoridation violates people's consent to pursue medical treatment and whether fluoridation should be easily accessible to everyone.

Many advocates of fluoridation do not consider it a violation of people's right to consent to medical treatment. They usually argue that fluoridation is not a form of mass medication because fluoride is naturally present in all water systems. In their view, fluoridation is a modification of a naturally present substance in water that helps resist dental decay. Frequently, the comparison is made to the fortication of other types of foods, such as adding vitamins to breakfast cereals and baby foods.

In addition, they propose that preventing broad, easy access to fluoride is unethical. Since the populations which benefit most from water fluoridation are children and those in poorer communities, fluoridation is considered an avenue to relieve some of the health disparities between socio-economic groups. Fluoridation is defended further by its relative low cost. In the United States, the cost can be as low as 31 cents per person. As a result, many health organizations defend fluoridation and do not consider it a violation of ethical principles.

The ethical challenges by fluoridation opponents cannot be sufficiently addressed using scientific research alone.

Court cases

United States

Fluoridation has spawned many court cases. Anti-fluoride activists have sued municipalities, claiming that their rights to consent to medical treatment, privacy, and due process are infringed by mandatory water fluoridation. Individuals have sued municipalities for a number of illnesses that they blamed on fluoridation of the city's water supply. A substantial majority of courts have held in favor of cities in such cases, finding no or only a tenuous connection between health problems and widespread water fluoridation. To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.

Early cases

A flurry of cases were heard in numerous state courts in the 1950s during the early years of water fluoridation. State courts consistently held in favor of allowing fluoridation to continue, analogizing fluoridation to mandatory vaccination and the use of other chemicals to clean the public water supply, both of which had a long-standing history of acceptance by courts.

In 1952, a Federal Regulation was adopted that stated in part, "The Federal Security Agency will regard water supplies containing fluorine, within the limitations recommended by the Public Health Service, as not actionable under the Federal Food, Drug, and Cosmetic Act."

The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case. The court noted, "we think the weight of well-reasoned modern precedent sustains the right of municipalities to adopt such reasonable and undiscriminating measures to improve their water supplies as are necessary to protect and improve the public health, even though no epidemic is imminent and no contagious disease or virus is directly involved . . . . To us it seems ridiculous and of no consequence in considering the public health phase of the case that the substance to be added to the water may be classed as a mineral rather than a drug, antiseptic or germ killer; just as it is of little, if any, consequence whether fluoridation accomplishes its beneficial result to the public health by killing germs in the water, or by hardening the teeth or building up immunity in them to the bacteria that causes caries or tooth decay. If the latter, there can be no distinction on principle between it and compulsory vaccination or inoculation, which, for many years, has been well-established as a valid exercise of police power."

In the 1955 case Froncek v. City of Milwaukee, the Wisconsin Supreme Court affirmed the ruling of a circuit court which held that "the fluoridation is not the practice of medicine, dentistry, or pharmacy, by the City" and that "the legislation is a public health measure, bearing a real, substantial, and reasonable relation to the health of the city."

The Supreme Court of Ohio, in 1955's Kraus v. City of Cleveland, said, "Plaintiff's argument that fluoridation constitutes mass medication, the unlawful practice of medicine and adulteration may be answered as a whole. Clearly, the addition of fluorides to the water supply does not violate such principles any more than the chlorination of water, which has been held valid many times."

Fluoridation consensus

As cases continued to be brought in state courts, a general consensus developed that fluoridation, at least from a legal standpoint, was acceptable. In 1973's Beck v. City Council of Beverly Hills, the California Court of Appeal, Second District, said, "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question." (citations omitted)

Contemporary challenges

Though courts have consistently rejected arguments against fluoridation, advocates continue to challenge the spread of fluoridation. For instance, in 2002, the city of Watsonville, California chose to disregard a California law mandating fluoridation of water systems with 10,000 or more hookups, and the dispute between the city and the state ended up in court. The trial court and the intermediate appellate court ruled in favor of the state and its fluoridation mandate, however, and the Supreme Court of California declined to hear the case in February of 2006. Since 2000, courts in Washington, Maryland, and Texas have reached similar conclusions.

Medical approval

The growing use of bottled water, which usually does not have enough fluoride as recommended for dental health, may contribute to fluoride deficiencies.

External links

• The Fluoride Deception - on Google video