Does it represent untapped potential?
Or will it allow problems to trickle in?
Ashley Gardner, August 19, 2002
Fluoride has become the hot topic of public debate in Texarkana as city governments on both sides of the state line consider whether to fluoridate the city's water supply.
The debate has been going on since Grand Rapids, Mich., became the first city to fluoridate its water supply in 1945.
Both proponents and opponents of fluoridation argue their perspectives vehemently. Each side can point to reams of data supporting their side of the argument, or in some cases mixed messages.
About 58 percent of Americans live in communities that have artificially fluoridated drinking water.
Europe is 98 percent fluoride free, and for much of the West Coast (California, Oregon and Washington) resistance to fluoridation has been growing. Even in places like San Antonio, which recently voted to fluoridate its water supply, the public was split on the issue, passing the measure by at 52.6 to 47.4 percent margin.
What follows is a look at several sides of the debate.
A majority of Americans live in communities that have enacted fluoridation, which is touted by the American Dental Association (ADA) and the American Medical Association (AMA) as a safe means of preventing tooth decay.
"Community water fluoridation is supported by virtually every major medical association," said Dr. Maria Lopez Howell, spokesperson for the ADA and a practicing dentist.
The ADA is a whole-hearted supporter of fluoridation, Howell said. Fluoride occurs naturally in water and air and has been dubbed by the ADA as nature's cavity fighter.
According to a statement from the U.S. Surgeon General, "Community water fluoridation is a cost-effective, practical and safe means for reducing and controlling tooth decay."
Surgeon General Dr. David Satcher concluded in April 1999 that fluoridated drinking water is one of the top 10 public health achievements of the 20th century, Howell said.
The agencies believe fluoridation is an economical means of fighting tooth decay and saves millions in dental repairs.
According to a report from the Centers for Disease Control and Prevention (CDC) published in August 2001, fluoride is both a safe and effective when used at its optimal level in drinking water of 0.7 to 1.2 parts per million.
Dental studies have been conducted on almost every aspect of fluoridation. Many of them support the position that fluoride prevents tooth decay.
For example, the study, "An Economic Evaluation of Community Water Fluoridation," published in the Journal of Public Health Dentistry concluded the effects of fluoridated drinking supplies may reach farther than the bounds of the city limit.
Scientists found children living in nonfluoridated communities in states that were highly fluoridated received the benefits of living close to the fluoridated area through contact with products containing fluoride.
The 12-year-olds in the study had less decay than 12-year-olds living in a state with a low rate of fluoridation.
Another study with similar findings was conducted by the CDC and the University of Georgia.
The study, "Quantifying the Diffused Benefit from Water Fluoridation," published in the March issue of Community Dentistry and Oral Epidemiology, found that 12-year-old children living in states that were more than 55 percent fluoridated have 26 percent fewer decayed tooth surfaces per year than their counterparts living in states with lower than 25 percent fluoridation.
The study states that children living in fluoridated areas would typically have one fewer cavity than children living in nonfluoridated areas. Based on the cost of dental care and maintenance for one tooth, savings could be $175.
The CDC recommends frequent exposure to small amounts of fluoride each day to best prevent dental caries, an infectious disease that results in tooth decay.
The ADA has staunchly supported fluoridation since 1950 as being a cost-effective public health measure for preventing dental caries. Fluoride supplements and fluoridation are recommended by many in the dental community.
"As a dentist in the trenches fighting tooth decay on a daily basis, I can't for the life of me understand why there'd be any opposition to community water fluoridation," Howell said.
Local dentist, Dr. Neil Carmony, explained how fluoride improves the strength of teeth.
"Fluoride works topically in a major sense. It mineralizes the teeth; it makes them hard. A harder tooth is more resistant to tooth decay," he said.
Fluoride also benefits children as their permanent teeth are forming.
"When a child is born, their permanent tooth buds are just starting to form," Carmony said.
If children are exposed to the optimal amount of fluoride at the right time, their teeth will be stronger and more resistant to decay, improving the overall health of the children.
The downside of fluoridation is this: Overexposure to fluoride when teeth are forming can cause dental fluorosis, a developmental condition in which tooth enamel has white lines or spots. In more severe cases of fluorosis, the tooth may pit, develop brown spots and fracture.
There has been a rise in dental fluorosis, Howell said, but to counteract the rise, the concentration of fluoride in supplements has been lowered. She, for one, doesn't think the rise is a result of community water fluoridation.
Carmony doesn't think dental fluorosis will be a problem in Texarkana if the amount of fluoride put into the water is monitored correctly. When asked about the safety of fluoride, Carmony said this, "I have five kids, and I gave all my children fluoride vitamins." He said he would no longer prescribe fluoride supplements in most cases if Texarkana decides to fluoridate its water supply.
Howell recommends taking questions about fluoride to a professional.
"If you have any questions, talk to your family dentist, someone you trust."
She believes fluoridation critics are not using "sound science," and claims that fluoride is linked to cancer and skeletal fluorosis are wrong. She asks, "Wouldn't we be seeing a higher incidence in these areas if those findings were true, and the fact is, we're not."
Howell says she doesn't believe it is possible that anyone could drink enough fluoridated water to do themselves harm.
"A human would hurt themselves with water toxicity before they'd feel the effects of fluoride toxicity."
Water fluoridation has been in practice since the 1940s but not everyone is singing its praises.
There have been numerous studies on fluoridation since 1970 alone, but many of those findings are not in agreement or substantial in scope. Some are quite critical of fluoridation.
Some of the studies produced evidence that fluoride accumulates in bone, causing skeletal fluorosis. It has been linked to cancer and a high rate a dental fluorosis.
Scientists and experts who oppose fluoridation say the effects of fluoride ingestion over a lifetime haven't been studied enough to conclude it is safe for daily consumption, even in small amounts. Many believe the longterm ingestion of fluoride is unnecessary, that fluoride is a toxic substance serving no nutritional need.
In the 1960s a study was conducted in Finland to assess the longterm effects that fluoride consumption has on the bone.
The study determined that while fluoride benefited the teeth, it had a tendency to build up in the bones, which could cause adverse effects over time. One of the possibilities is skeletal fluorosis, a condition in which bones accumulate so much fluoride that in severe cases the vetebra fuse with crippling effects. Finland abandoned efforts to enact fluoridation after the results of that study.
The opposition also links fluoride to cancer.
A study conducted by the U.S. National Toxicology Program determined fluoride may have caused cancer in four male rats out of 261 rats that were exposed to high amounts of fluoride over a two-year period. Four of the rodents developed osteosarcoma, a rare bone cancer.
In 1991, the National Cancer Institute reported a 50 percent higher rate of osteosarcomas in males at least 19 years old who drank fluoridated water than those who did not. Those findings were published in the article, "Fluoride the Aging Factor," in the Townsend Letter for Doctors and Patients in 1995.
Dr. Bob Carton, an environmental scientist and former employee of the Environmental Protection Agency, believes fluoride is poisoning the nation.
"It's a great human experiment," he argues. "We should be stopping this right now. You don't continue to experiment on people while you do the studies on this."
The book "Emergency Toxicology" defines fluoride as a general protoplasmic poison and states that the minimum toxic or lethal dose hasn't been determined but ingesting more than 30 mg/kg can be fatal.
The FDA mandated a policy that required toothpaste containing fluoride to display a poison warning label. The label reads "if you accidentally swallow more than the amount used for brushing teeth, seek professional help or contact the Poison Control Center immediately." The mandate was prompted by more than 11,000 calls a year to poison control centers and three fluoride-related deaths.
Less lethal side effects of too much fluoride consumption include nausea; vomiting; tremors; faintness; sores on lips and in the mouth; white, black or brown discolorations on the teeth; or dental fluorosis.
Another question raised by fluoridation critics is the possibility of overdose. How is the amount of fluoride ingested by children and adults controlled when the public water supply is fluoridated?
Dr. James Presley, Ph.D. in medical history and a Texarkana resident, has attended three world conferences of the International Society for Fluoride Research and is a founder of Friends United for a Safe Environment (FUSE).
Presley brings up the point that everyone drinks different amounts of water and there is no way to control the amount of fluoride people receive through a fluoridated water supply and the other products containing fluoride, including sodas, juices, toothpaste and mouth wash.
"Common sense raises a central concern about promoters' harebrained logic: There is absolutely no way to control the dose," he said.
"Diabetic patients and athletes, many of whom are children or youth, may consume enormous quantities (of fluoridated water), ensuring they get overdosed," Presley said.
The CDC in August 2001 issued a report that indicated the number of cavities in a population is not "inversely related" to how much fluoride is concentrated in the enamel, and a higher concentration of enamel fluoride is not necessarily more effective in preventing cavities. The report also suggest that the fluoride in saliva, as it is secreted after ingestion, is not of high enough concentration to affect cariogenic activity.
In a report published in the professional journal NeuroToxicology 21, R.D. Masters of the Foundation for Neuroscience and Society at Dartmouth College, and three other researchers with similar credentials concluded: "The congruent statistical findings from three populations totaling almost 400,000 children indicate an urgent need for further study of the possible links between exposure to sodium silicofluoride or fluosilic acid and increased lead uptake as well as the behavioral dysfunctions associated with lead neurotoxicity."
Dr. David Kennedy, past president of the International Academy of Oral Medicine and Toxicology, said fluoridating public water is, among other flaws, a racist policy.
"Black and minority children will develop substantially more dental fluorosis at the same dosage level as the Caucasian population," he said. "Research also found a much greater increase in dangerously high lead levels in blood in the Black and Hispanic populations exposed to silicofluoride treated drinking water."
This position is based on data extracted from a sample collected by the New York State Department of Children's Health between 1994-1998.
The CDC and the ADA caution parents to monitor their children's fluoride intake because the first six years of life are an important period for tooth development and overexposure to fluoride during this time could result in dental fluorosis.
"Children need to be supervised while brushing their teeth," Howell said.
The CDC and ADA recommend that children under 6 years should use only a pea-sized amount of toothpaste.
Critics of fluoridation say proponents of fluoridation are twisting old studies and ignoring fresher information. They say proponents use endorsements, not science, to validate their case. That's why, Presley says, voting bodies work to convince other public bodies, like local school boards, to pass resolutions and take official positions-even though fluoridation hardly qualifies as an education issue.
Fluoridation: Other viewpoints
While much of the information and opinion on fluoridation are polarizing, some carries additional weight by virtue of its institutional status.
The EPA, for example, acknowledged in a 1998 document, "In the United States, there are no Federal safety standards which are applicable to drinking water additives, including those intended for use in fluoridating water."
Voluntary product standards were developed by a "consortium of representatives from utilities, government, manufacturers and the public health community" (some of which, critics argue, have a vested economic interest in fluoridation). The consortium's first report, "Standard 60: Drinking Water Treatment Chemicals - Health Effects," came out in 1988.
A 1999 EPA letter to U.S. Rep. Ken Calvert, chairman of the Subcommittee on Energy and the Environment, stated: "The Safe Drinking Water Act prohibits the EPA from requiring the addition of any substance (including fluoride) to drinking water for preventative health care purposes unrelated to contamination. As a consequence, state or local authorities determine whether or not to fluoridate their water supply."
In other words, the federal government has washed its hands of this issue.
At one point, until 1997 when the EPA asked to have its name removed, the American Dental Association Website listed the EPA as an organization that endorsed fluoridation programs.
In an enclosure to the same letter, the EPA, when asked about toxicity test data, said it is "not able to identify chronic (ongoing) studies" for sodium fluorosilicate and hydrofluorosilic acid, two of the chemicals used to fluoridate water supplies.
In correspondence to Rep. Calvert in December 2000, the FDA wrote: "Fluoride, when used in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or animal, is a drug that is subject to Food and Drug Administration regulation." A few sentences later it adds, "As you know, the EPA regulates fluoride in the water supply."
This response to Rep. Calvert's inquiries goes on to state that no New Drug Applications have been approved or rejected for fluoride drugs meant for ingestion.
When Calvert asked if the FDA considered fluoriosis a sign of overexposure to fluoride, the response was, "Dental fluorosis is indicative of greater than optimal ingestion of fluoride. In 1988, the U.S. Surgeon General reported that dental fluorosis, while not a desirable condition, should be considered a cosmetic effect rather than an adverse health effect. Surgeon General M. Joycelyn Elders reaffirmed this position in 1994."
Even the acknowledged experts in the fluoridation debate find a broad range of science issues to bicker about when it comes to determining what, if any, is a safe level of fluoride to put into the public water.
In April 1983, a group of 15 scientists and health experts met for two days in a U.S. Surgeon General's Ad Hoc Committee on the Non-Dental Effects of Fluoride. The transcript of that meeting indicated every bit as much disagreement as agreement on even the most minute of details. Even when there was general agreement, the specific reasons for that agreement were often different.
When it comes to fluoride, everything from race, age and other substances in the water, such as lead, other available sources of fluoride and economic and hygienic factors, play important roles in determining how its addition into a water system may affect the general public or special populations.
Dr. Jay R. Shapiro, then the director of the National Institutes of Health Clinical Center, asked during the hearing he led: "There are good things for doing it (fluoridation) certainly as far as the teeth are concerned. Our problem is how much is good. If you look at the non-dental effects, is any of it good? Is it a little good? Do we have the information? How do you get the information?
"Somebody says what you are doing here is going to sit on the books for the next 35 years. If no one has dealt with this question to this point, then I think we ought to grapple with it somehow."
Dr. Michael Kleerekoper of the Bone and Mineral Division of Henry Ford Hospital in Detroit had a problem with the cost of fluoridation being passed on to the consumer, even though households generally pay for the water they use.
"But you are not allowing them to say what their water should be." said Kleerekoper. "There is a difference. They are paying for the water they want. If you turn around and say, now I want you to have this water. I want you to buy Borden milk rather than whatever milk, and you want them to pay the difference."
Dr. Stanley Wallach, chief of Medical Service at the Veterans Administration Medical Center testified that, "You would have to have rocks in your head, in my opinion, to allow your child much more than two parts per million."
And Dr. Shapiro again, "I have a summary from the United Nations Environment Program, International Labor Organization and World Health Organization in which they did a summary on environmental health criteria for fluorine and fluorides and they say about the same thing. Osteosclerosis occurs only as a result of long years of excessive fluoride ingestion characterized by Stage I changes of this similar grading system, roughing and blurring of bones, then to finally Stage III where there is increased density and periosteal thickening.
"This progression from State I to Stage III apparently only occurs in industrial fluorosis. The lowest exposure they quote that will ultimately result in osteosclerosis lies in the range of five to eight milligrams of fluoride per day."
Finally, near the end of the debate, Dr. Robert Marcus, assistant professor of Medicine at Palo Alto Veterans Administration Medical Center raises this concern: "I would like to establish another point which I think is important in terms of how somebody who might not be on this committee would read the report because it would seem to me that there would be two options, depending on how the report were written.
"One would be that the committee was very concerned about potential hazards associated with fluoride and we singled out a group of individuals-that is children below the age of nine-for special, additional protection and I can see that somebody who might be on the outside of the fluoridation lobby would use that as food for his fodder.
"On the other hand, another interpretation could be, depending on how it was written, that this committee was by and large unimpressed by real dangers associated with fluoride. We are being fairly cautious with children, but we are actually relaxing our concerns about everybody above the age of nine or people whose teeth have already erupted."
He goes on, "My impression from talking with most of the people around the room is that the second case is a more accurate representation of the views of this committee, and I think it would be a very good idea to formulate whatever the conclusions are in a way that could not be used like what happened in that newspaper article."
A few statements later, James Carlos, D.D.S., M.P.H., and the associated director for the National Caries Program at the National Institute of Dental Research, piped up: "I think it might be well worth considering how you phrase the recommendation, the rationale for the recommendation very carefully in terms of potential adverse effect.
"The reason is that we have on record the Surgeon General, the American Medical Association, the American Dental Association all saying that there is no adverse health effects. I think, in the case of dental fluorosis, we can't find any data to the contrary; however, I certainly accept and I think most people do that there may well be and we just haven't found it yet and that would be true of the other things you are speaking of as well. It is potential."
Dr. Marcus: "I don't think that is the sense of the committee. I think that the sense of committee is that the cosmetic effect represents an adverse health effect, that this is psychologically damaging. People walk around covering their mouths."
Dr. Shapiro: "I think the Surgeon General left a big loophole, frankly, when he raised this cosmetic issue. I think he, in effect, was saying there is still some room for doubt as to whether what we are saying is the best really that can be said."
Dr. Carlos: "There is more study needed in the matter."
Dr. Shapiro: "That is right and I would seize on that, expressing the concern of the committee that we don't have all the answers."
Just as these doctors did almost 20 years ago, many in the public are still struggling to make sense out of the wide range of viewpoints. Even those who might lean strongly toward fluoridation might be troubled by other aspects of the debate.
Some see it as local government stepping in as it should to improve the quality of life; others see it as local leadership injecting itself intrusively into a domain where it doesn't belong. Some feel the public has a right to vote on the issue; others suggest it is the role of government to look out for the greater public interest.
Make of it what you will. The debate is far from over. If fluoride doesn't get you, interpretive science or information overload just might.
The debate on fluoridation will go on regardless of what Texarkana decides on the issue. Numerous studies on the subject haven't succeeded in changing the minds of the people who feel the most strongly about it. Absent some irrefutable evidence to the contrary, a majority of Americans will continue to drink water that's been fluoridated.
The question that remains is will Texarkana residents be added to that list.