Water fluoridation controversy

Water fluoridation opposition refers to activism against the addition of fluoridation chemicals to public water supplies.

Opposition to water fluoridation arises from concern over the lack of quality research demonstrating its efficacy and safety, evidence that it may cause serious health problems, and a general resistance to the idea of compulsory 'mass medication' which takes away an individual's right to choose.
Most major medical and dental research associations maintain that water fluoridation is a safe and effective way to prevent tooth decay and improve oral health.

A review conducted by the Centre for Reviews and Dissemination conclusion that the "evidence about reducing inequalities in dental health (using water fluoridation) was of poor quality, contradictory and unreliable" and noted that overall the studies they reviewed did support a decrease in dental decay from fluoridated water

Efficacy of water fluoridation

A recent review of the evidence from the University of York, published in 2000, examined 30 studies. The researchers concluded that the quality of evidence in most studies was poor, also expressing concern over the "continuing misinterpretations of the evidence." Of the studies examined, there were mixed conclusions on the effectiveness of water fluoridation - the majority found some improvement, some showed no difference, some actually showed an increase in decay. The study did find an increase in cosmetic fluorosis, but no evidence of any link between fluoride and cancer, Down syndrome, or bone fractures. It reserved caution however. A BBC story reviewing the review article, suggested that because of the poor evidence it said no firm conclusions should be drawn, and more evidence is needed.

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

Those that question the effectiveness of water fluoridation 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, and suggest that the continued prevalence of tooth decay among low-income groups demonstrates the ineffectiveness of fluoridation. One study by the National Institute of Dental Research showed 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 exposed, was very small, between 0.12 and 0.30 DMFS (Decayed Missing and Filled Surfaces). 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.

Water fluoridation opponents also argue that the decline of tooth decay over the last thirty years may be the result of factors other than fluoride, including improved oral hygiene, diet, and overall health.

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.

Some research shows the effects of fluoridation to be merely topical, indicating that fluoridating water is unnecessary and ineffective.

Safety

The issue of flouride toxicology has been brought into question by opponents. The Green Party, a UK political party, even refer to fluoride as a poison. They say water fluoridation violates Article 35 of the European Charter of Fundamental Rights, and the UK poisons act of 1972 which bans fluorosilicates. Because it believes that fluoride is a poison they say it also violates Articles 3 and 8 of the Human Rights Act, and also Articles 3 and 8 of the Convention because governments are forbidden from harming its citizens. Where children are involved - indeed, specifically targeted - such an act also raise issues under the United Nations Convention on the Rights of the Child.
There are a lot of conflicting reports as to the safety of water fluoridation. This issue was covered in the University of York's review concluding that "The evidence about reducing inequalities in dental health was of poor quality, contradictory and unreliable." Because of these conflicting reports and the numerous websites that point to these safety concerns, many question whether fluoridation should be legal until some of these issues are resolved. Some of the concerns raised include:

• A weakening of bones, leading to an increase in hip and wrist fracture.

• A lowering of IQ.

• Chromosomal damage and interference with DNA repair.
• According to the National Cancer Institute fluoride is an equivocal carcinogen. Available data is conflicting, but osteosarcoma (a rare bone cancer) has been shown to be associated with fluoride exposure, including fluoridated water, in humans and animals.
• A study using rats that were fed for one year with 1 ppm fluoride in their water. They were shown to have 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 Alzheimer's disease. However another study found no link 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 of this effect can be made. Other studies claim that age and family history are the most important risk factors concerning alzheimers..

• In animal studies, fluoride has been shown to inhibit melatonin production and promote precocious puberty. Fluoride may have an analogous inhibitory effect on human melatonin production, as fluoride accumulates readily in the human pineal gland, the brain organ responsible for melatonin synthesis. Further, fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.

• A study showing that overdose of fluoride have been associated with liver damage, impaired kidney function, and fluorosis in children.

• Animal studies demonstrate that fluoride can damage the male reproductive system in various species.

Concentration of fluoride

File:Fluorosis-severe.jpg

Discoloration of teeth as seen in dental fluorosis caused by excessive fluoride.

Although anti-fluoridation advocates do not want water fluoridation at all, they also raise concern over the concentration of fluoride that is currently being used. Concentration is measured in parts per million or the equivalent measurement: milligrams per liter (mg/L). The United States Environmental Protection Agency(EPA) provide guidelines on the level of fluoride to add to the water under the Safe Drinking Water Act and its amendments (1974, 1986, and 1996). These include the maximum contaminant level goal (MCLG), the maximum contaminant level (MCL), and the secondary maximum contaminant level (SMCL). The MCLG of a substance is defined as the maximum level of a contaminant in drinking water at which no known or anticipated adverse effect on the health of persons would occur, and which allows an adequate margin of safety. After the MCLG has been found, "the MCL is then set as close to the MCLG as feasible, which the Safe Drinking Water Act defines as the level that may be achieved with the use of the best available technology, treatment techniques, and other means which EPA finds are available(after examination for efficiency under field conditions and not solely under laboratory conditions) are available, taking cost into consideration." The SMCL is a nonenforceable secondary standard taking into account cosmetic or aesthetic considerations. In 1986 the EPA established an MCLG and MCL for fluoride at a concentration of 4 milligrams per liter (mg/L) and an SMCL of 2 mg/L. In 2006 the National Research Council conducted a report entitled Fluoride in Drinking Water: A Scientific Review of EPA’s Standards The committee concluded that the current MCLG of 4 mg/L should be lowered to better protect people from the health risks associated with high natural fluoride levels. They now advocate a level of 0.7–1.2 mg/L.
Opponents would argue that there is no safe level of fluoride.

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. Fluoride content of local water supply is in ppm.

Both sides of the argument agree that fluoride in high concentrations is harmful to the body. However advocates of fluoride 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 even water are potentially harmful if given in excessive amounts.

Another concern cited in respect of 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. 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. The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.

Ethics

One aspect of opposition to water fluoridation regards the social or political implications of adding fluoride to public water supplies. Setting aside the claim that water fluoridation may improve dental health, such an act would violate an individual's right to pursue free choice of, or form of, medical treatment and it is argued that water fluoridation is "compulsory mass medication" because it does not allow proper consent.

It is also argued 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." Litigation, both pro and con, has been a frequent outcome of public water fluoridation.

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. Opponents argue that the form of fluoride found in naturally fluoridated water supplies is not the same as the form used to artificially fluoridate water. Likewise, opponents argue that the pharmacy grade fluoride used in many studies to support fluoride as a tooth decay preventative is not the grade used to fluoridate water (although this raises the question of whether the grade of fluoride used to fluoridate water is effective, and also if we can rely on studies that support fluoride use, since they don't use the same fluoride that is in the public water supply). Frequently, those who promote water fluoridation make the comparison to the fortification of other types of foods, such as adding vitamins to breakfast cereals and baby foods.

The precautionary principle

In an analysis published in the March 2006 issue of the Journal of Evidence Based Dental Practice, the authors examine the water fluoridation controversy in the context of the precautionary principle. The authors note that while the precautionary principle is "often criticized as antiscientific," it is based on the notion that:

[I]f there is uncertainty, yet credible scientific evidence or concern of threats to health, precautionary measures should be taken. In other words, preventive action should be taken on early warnings even though the nature and magnitude of the risk are not fully understood.

The authors note that “The need for precaution arises because the costs of inaction in the face of uncertainty can be high, and paid at the expense of sound public health.”

In determining whether the precautionary principle should be applied to fluoridation, the authors note that:

• There are other ways of delivering fluoride besides the water supply;

• Fluoride does not need to be swallowed to prevent tooth decay;

• Tooth decay has dropped at the same rate in countries with, and without, water fluoridation;

• People are now receiving fluoride from many other sources besides the water supply;

• Studies indicate fluoride’s potential to cause a wide range of adverse, systemic effects;

• Since fluoridation affects so many people, “one might accept a lower level of proof before taking preventive actions.”

Opposition from health authorities

In 2005, eleven environmental protection agency EPA employee unions, representing over 7000 environmental and public health professionals of the Civil Service, called for a halt on drinking water fluoridation programs across the USA and asked EPA management to recognize fluoride as posing a serious risk of causing cancer in people. The unions acted on an apparent cover-up of evidence from Harvard School of Dental Medicine linking fluoridation with an elevated risk of osteosarcoma in boys, a rare but fatal bone cancer. [3]

In addition, over 1,700 health industry professionals, including doctors, dentists, scientists and researchers from a variety of disciplines are calling for an end to water fluoridation in an online petition to Congress. [4]

Their petition highlights eight recent events that they say mandates a moratorium on water fluoridation, including a 500-page review of fluoride’s toxicology that was published in 2006 by a distinguished panel appointed by the National Research Council of the National Academies. [5] While the NRC report did not specifically examine artificially fluoridated water, it concluded that the U.S. Environmental Protection Agency's safe drinking water standard of 4 parts per million (ppm) for fluoride is unsafe and should be lowered. Despite over 60 years of water fluoridation in the U.S, there are no double-blind studies which prove fluoride's effectiveness in tooth decay. The panel reviewed a large body of literature in which fluoride has a statistically significant association with a wide range of adverse effects.

Several prominent dental researchers and government advisors who were leaders of the pro-fluoridation movement have announced reversals of their former positions after they concluded that water fluoridation is not an effective means of reducing dental caries and that it poses serious risks to human health. The late Dr. John Colquhoun was Principal Dental Officer of Auckland, New Zealand. In an article titled, "Why I changed my mind about water fluoridation", he published his reasons for changing sides. [6]

Dr. Hardy Limeback, BSc, PhD, DDS was one of the 12 scientists who served on the National Academy of Sciences panel that issued the aforementioned report, Fluoride in Drinking Water: A Scientific Review of the EPA's Standards. Dr. Limeback is an associate professor of dentistry and head of the preventive dentistry program at the University of Toronto. He detailed his concerns in an April 2000 letter titled, "Why I am now officially opposed to adding fluoride to drinking water". [7]

In a presentation to the California Assembly Committee of Environmental Safety and Toxic Materials, Dr. Richard Foulkes, B.A., M.D., former special consultant to the Minister of Health of British Columbia, revealed:

The [water fluoridation] studies that were presented to me were selected and showed only positive results. Studies that were in existence at that time that did not fit the concept that they were "selling," were either omitted or declared to be "bad science." The endorsements had been won by coercion and the self-interest of professional elites. Some of the basic "facts" presented to me were, I found out later, of dubious validity. We are brought up to respect these persons in whom we have placed our trust to safeguard the public interest. It is difficult for each of us to accept that these may be misplaced.[8]

Despite widespread concern by scientists and private citizens, government agencies such as the CDC and WHO continue to support water fluoridation as being a safe and effective means of reducing dental decay.

Critical reviews

In the United Kingdom, the Department of Health funded a systematic review in 1999, which looked at all of the evidence so far published, into the efficacy and safety of adding fluoride to drinking water. This work was carried out at the University of York. They concluded:

We were unable to discover any reliable good-quality evidence in the fluoridation literature world-wide.

What evidence we found suggested that water fluoridation was likely to have a beneficial effect, but that the range could be anywhere from a substantial benefit to a slight disbenefit to children's teeth.

This beneficial effect comes at the expense of an increase in the prevalence of fluorosis (mottled teeth). The quality of this evidence was poor.

An association with water fluoride and other adverse effects such as cancer, bone fracture and Down's syndrome was not found. However, we felt that not enough was known because the quality of the evidence was poor.

The evidence about reducing inequalities in dental health was of poor quality, contradictory and unreliable.

Since the report was published in October 2000 there has been no other scientifically defensible review that would alter the findings of the York review. As emphasised in the report, only high-quality studies can fill in the gaps in knowledge about these and other aspects of fluoridation. Recourse to other evidence of a similar or lower level than that included in the York review, no matter how copious, cannot do this.

— Centre for Reviews and Dissemination, University of York

The report was checked by the Medical Research Council (UK) after publication.

In January 2008 Scientific American posted significant concerns about the use of fluoride.

Use throughout the world

Main article: Water fluoridation § International status

Water fluoridation is used in the United States, United Kingdom, Canada, and Australia, among other countries. The following developed nations previously fluoridated their water, but stopped the practice, with the years when water fluoridation started and stopped in parentheses:

• German Federal Republic (1952-1971)
• Sweden (1952-1971)
• Netherlands (1953-1976)
• Czechoslovakia (1955-1990)
• German Democratic Republic (1959-1990)
• Soviet Union (1960-1990)
• Finland (1959-1993)
• Japan (1952-1972)

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 the former East Germany and Cuba, have continued to see drops in the incidence of tooth decay. Based on this evidence, opponents conclude that water fluoridation is unnecessary.

Though water fluoridation is promoted by 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 fluoridation methods 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.

Moreover, a concern of health organizations is the incidence of dental fluorosis, a sign of overexposure to fluoride. Severe cases of dental fluorosis are characterized by black and brown stains, cracking, and pitting of the teeth. In many instances, natural fluoride levels in water are much higher than desired. These areas do not need fluoride added to water supplies. Excessive levels of fluoride in drinking water can lead to skeletal fluorosis - a crippling bone disease. In these high fluoride areas, some health organizations endorse providing alternative water sources, or removing fluoride from the water. .

More than 100 national and international NGOs, health agencies, and professional organizations advocate water fluoridation as a means of preventing dental decay. including the American Dental Association, the Australian Dental Association, the British Dental Association, the Canadian Dental Association and the World Health Organization

Court cases

United States

Fluoridation has been the subject of many court cases. Anti-fluoride activists have sued municipalities, asserting 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 believe were caused by fluoridation of the city's water supply. So far, the 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 across the U.S. 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

In 1973, 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."

Contemporary challenges

Advocates continue to make contemporary challenges to 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.

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. 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.

External links

• Fluoride Action Network
• A Bibliography of Scientific Literature on Fluoride
• Boning Up on Fluoride - from Eugene Weekly
• All Party Parliamentary Group Against Fluoridation (UK)
• Article on the use of fluoridated water in baby formula
• Centers for Disease Control
• Senior doctors allege lack of evidence on fluoride safety, article in The Guardian, October 5 2007
• Keepers of the Well