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Water fluoridation controversy

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Water fluoridation controversy refers to debate surrounding the health benefits of water fluoridation of public water supplies by public authorities. 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 adjusting fluoride levels in drinking water supplies with the intention of improving oral health.[1] This is usually done by the addition of sodium fluoride, sodium fluorosilicate, or fluorosilicic acid.[1]

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.

Many groups continue to question the practice of water fluoridation despite the current stance of the medical and dental research communities. The various groups do not necessarily agree with one another, but they share some arguments against water fluoridation, including several key issues. Those opposed to public fluoridation of drinking water say that water fluoridation can have negative health effects (such as dental fluorosis) which outweigh the purported benefits of water fluoridation. Some opponents claim that releasing fluoride compounds into 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. Sometimes the medical and dental research communities send mixed messages, like fluoridation is good for young children - except there are concerns over excessive consumption in very young children when reconstituting baby formula according to a 2006 National Research Council report.

History

File:Ppeak-s.jpg
Pike's Peak mountain where dental fluorosis was first studied.
(For more information, see "History of water fluoridation".)

Community water fluoridation owes its origin in part to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into the "Colorado stain," which is now known as dental fluorosis.[2] In 1909, children from the Pikes Peak region had some degree of stain or mottling on their teeth. Despite having a negative impact on the physical appearance of their teeth, the children with stained or mottled teeth also had fewer cavities than other children. McKay brought the problem to the attention of Dr. G.V. Black, who later became known as the father of modern U.S. dentistry, and Black's interest into the Colorado stain led to greater interest throughout the dental profession. In 1931, researchers finally concluded that the cause of the Colorado stain was a high concentration of fluoride ions in the region's drinking water.

Photograph of Dr. G.V. Black (left) and Dr. McKay (right) studying the "Colorado Brown Stain".

Studies led by Dr. H. Trendley Dean determined that the optimal level of fluoride that minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 part per million (ppm).[3][4] In 1939, Dr. Gerald J. Cox conducted laboratory tests on fluoride and released a report that was the first publication recommending the addition of fluoride to drinking water to improve oral health.[5]

In the 1940s, four widely-cited studies were conducted. The researchers investigated cities that had both fluoridated and unfluoridated water. The first pair was Muskegon, Michigan and Grand Rapids, Michigan, making Grand Rapids the first community in the world to modify its fluoride levels in drinking water to benefit dental health on January 25, 1945.[6] Kingston, New York was paired with Newburgh, New York.[7] Oak Park, Illinois was paired with Evanston, Illinois. Sarnia, Ontario was paired with Brantford, Ontario, Canada.[8] The research found a decrease in the incidence of tooth decay in cities which had added fluoride to water supplies. Since these results were published, fluoride has gained acceptance in the scientific community as potentially beneficial to oral health, and various governments throughout the world have fluoridated water, salt, and/or other food items.

The history of opposition to water fluoridation is difficult to verify. Some opponents of water fluoridation say their concerns and protests have been muted by the scientific community since the inception of water fluoridation research.[9] These charges include omitting research that contradicts the safety of fluoride and constructing biased research in favor of fluoridation. On the other hand, some say the history of their opposition to fluoride began with fighting a conspiracy between the dental establishment and industrial companies.[10]

Role in oral health

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

There are some groups which consider fluoride neither a vitamin nor an essential nutrient and claim that is the same belief held by the medical community.[11] Fluoridation oponents believe that excellent dental health can be maintained through alternative methods, such as modifying diet by consuming less sugar, chewing xylitol gum as is done in Europe, and good dental hygiene through flossing and brushing the teeth - even with fluoride toothpaste. They argue that since the effects of fluoride is primarily topical, there is no need to actually consume fluoride. Furthermore, the benefits of fluoridated water does not outweigh the costs of systemic harm on the body. Consequently, they argue that there is no need to fluoridate the community drinking water.

Despite these claims, dental research has shown that fluoride has a positive effect on dental health. During tooth development, fluoride binds to the hydroxyapatite crystals present in enamel and makes the enamel more resistant to demineralization by acids.[12] As a result, some organizations, such as the American Dental Hygiene Association, classify fluoride as a nutrient necessary for proper tooth development.[13] In addition, organizations, including the CDC and WHO, promote increasing the accessibility of fluoridated water.[14][15]

Use throughout 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.[16] 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.[17] Based on this evidence, opponents conclude that factors other than fluoride decrease tooth decay.

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. In areas with complex water sources, water fluoridation is more difficult and more costly. Thus, other methods to fluoride are supported in those cases. The World Health Organization is currently assessing the effects of affordable fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe.[18]

Moreover, a major 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.[19]

Effectiveness

Frequently, 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).[20]

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.[21] 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.[22]

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.[23]

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

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.[24] 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.[15] 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.

Safety

There are some opponents of fluoridation who believe fluoride is a poison that can lead to death or, more commonly, dental fluorosis in instances of overdose. 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.[25] 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,[26] an increased uptake of aluminum in the brain, and the formation of beta amyloid deposits, a characteristic of Alzheimers disease.[27] Further, it is argued by some opponents that fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.[28]

Theses groups further emphasize that an overdose of fluoride is associated with liver damage, kidney function, and fluorosis in children.[29] At high doses, fluoride has many side effects. Animal studies demonstrate that fluoride can damage the male reproductive system in various species.[30] Consequently, fluoride is considered dangerous by these groups.

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.[31] 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.[32] As is true for all vitamins and minerals, recommended dosages for fluoride represent levels which maximize health benefits and minimize adverse effects.[33]

The greatest concern with fluoride overexposure is dental fluorosis. Fluorosis is undesirable because, in severe cases, it discolors teeth, causes surface changes to the enamel, and makes oral hygiene more difficult.[34] Government agencies, such as the Center for Disease Control and Prevention, keep records on the prevalence of fluorosis in the general public.[35] 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.[36] 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.[32]

Schedule for Fluoride Prescription[37]
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.[38] The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.[39] When fluoride levels in water are low (usually below 0.6 ppm), fluoride supplements are sometimes prescribed 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.[37]

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.[40] [41] Cancer in general is not believed to be caused from water fluoridation.[42] [43]

There is no clear link between Alzheimer's disease and water fluoridation.[32] A study in 1998 suggested a possible relationship between fluoride exposure and Alzheimer's disease.[44] 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.[45] 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.[46] Nonetheless, this research is also limited by design and no definitive conclusion of this effect 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.[32]

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

Reliance on experts

Many fluoridation opponents rely on experts opposing water fluoridation to validate their argument of the dangers of fluoride. People, such as scientists and Nobel prize winners, are exemplified as a large knowledgeable group that have stated their opposition against water fluoridation.[47] [48]

In response, 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. Researchers emphasize that voting or polling is not how scientific progress is made.[49] 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.

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.[49]

Ethics

Some opponents of water fluoridation accept the health benefits of fluoride, but 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.[50]

On the other hand, other commentators argue that because of the negative health effects of minimal fluoride exposure, mandatory fluoridation of public water supplies is a "breach of ethics" and a "human rights violation."[51] Since the ethical challenges by fluoridation opponents extends beyond scientific research alone, court cases have also addressed the issue in relation to the law and human rights. See Court cases below.

Frequently, health agencies confront the ethics of water fluoridation along the lines of two topics. They address the issues of consent and providing fluoridated water as a method of improving dental care for low-income persons.

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.[32] 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 fortification of other types of foods, such as adding vitamins to breakfast cereals and baby foods.[52]

In addition, proponents 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.[53] Fluoridation is defended further by its relative low cost. The Canadian Task Force On Preventive Health Care describes water fluoridation as "the single most effective, equitable and efficient means of preventing coronal and root dental caries."[54] In the United States, the cost can be as low as 31 cents per person, per year.[55] As a result, many health organizations defend fluoridation and do not consider it a violation of ethical principles.

Mixed industry messages

According to an ADA Bulletin 'November 9, 2006' - 'research was cited that raised the possibility that infants could receive a greater than optimal amount of fluoride from reconstituted baby formula.' and that 'If using a product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride' [56].

Recent developments led the ADA to develop the interim guidance. Last spring, the National Research Council released a report on naturally occurring fluoride in drinking water. While not the major focus of the report, research was cited that raised the possibility that infants could receive a greater than optimal amount of fluoride from reconstituted baby formula. Then, on Oct. 14, the FDA said bottlers could claim that fluoridated water can reduce the risk of dental cavities or tooth decay, but that this claim could not be used on water marketed to infants. If using a product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride.

Government and industry conspiracy

Some opponents point to a government conspiracy that has modified scientific research to further its own political goal. The origin of this conspiracy is frequently attributed to right-wing conspiracy theories as alluded to in Dr. Strangelove in 1964. In other cases, the particular conspiracy 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."[57]

File:DrstrangeloveCover.jpg
The movie Dr. Strangelove includes a character who is outspokenly against fluoridation

Other conspiracy theories involve large industrial companies wanting to rid themselves of fluorine "waste products".[58] 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."[59] 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' ".[60]

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.[61]

In spite of this, a large majority of government agencies and medical organizations support water fluoridation in locations needing fluoride supplementation and agree that it is a safe practice. (See Medical approval for a list of health organizations.) 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.[62] 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."[63] 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.[15][64]

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.[65] 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.[66] To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.[67]

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."[68]

The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case.[69] 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."[69]

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."[70]

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."[71]

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)[66]

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.[72] Since 2000, courts in Washington,[73] Maryland,[74] and Texas[75] have reached similar conclusions.

Republic of Ireland

In Ryan v. Attorney General (1965), the Supreme Court held that water fluoridation did not infringe the plaintiff's right to bodily integrity.[76] However, the court found that such a right to bodily integrity did exist, despite the fact that it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.

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.[77]

More than 100 national and international health service agencies and professional organizations recognize the benefits of community water fluoridation in preventing dental decay.[78] Some of them include:

Pop culture references

References

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  64. ^ a b International Association for Dental Research policy statements, including water fluoridation, page accessed March 3, 2006.
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  66. ^ a b Beck v. City Council of Beverly Hills, 30 Cal. App. 3d 112, 115 (Cal. App. 2d Dist. 1973) ("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)). Cite error: The named reference "beck" was defined multiple times with different content (see the help page).
  67. ^ Pratt, Edwin, Raymond D. Rawson & Mark Rubin, Fluoridation at Fifty: What Have We Learned, 30 J.L. Med. & Ethics 117, 119 (Fall 2002)
  68. ^ 17 Fed. Reg. 6743 (July 23, 1952).
  69. ^ a b 273 P.2d 859, 862-63 (Okl. 1954) (available at FindLaw for Legal Professionals)
  70. ^ 69 N.W.2d 242, 252 (Wis. 1955)
  71. ^ 127 N.E.2d 609, 613 (Ohio 1955)
  72. ^ Jones, Donna "Supreme Court turns down Watsonville's appeal to keep fluoride out of its water." Santa Cruz Sentinal. February 10, 2006.
  73. ^ Parkland Light & Water Co. v. Tacoma-Pierce County Bd. of Health, 90 P.3d 37 (Wash. 2004)
  74. ^ Pure Water Committee of W. MD., Inc. v. Mayor and City Council of Pure Water Comm. of W. MD., Inc. v. Mayor and City Council of Cumberland, MD. Not Reported in F.Supp.2d, 2003 WL 22095654 (D.Md. 2003)
  75. ^ Espronceda v. City of San Antonio, Not Reported in S.W.3d, 2003 WL 21203878 (Tex.App.-San Antonio 2003)
  76. ^ Ryan v. A.G. IESC 1; IR 294 (3 July, 1965) — text of the Irish Supreme Court's judgement
  77. ^ Smith, Michael. "Bottled Water Cited as Contributing to Cavity Comeback", from the MedPage Today website, page accessed 29 April, 2006.
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