1. I have been researching the literature on fluoride for just over three years. I approached this issue with an open mind. If I had any bias when I set out it was that those who were opposed to fluoridation were `crackpots’.
2. However, the more I have read the more concerned I have become over the dangers posed by fluoride and the very poor science underpinning its supposed efficacy in protecting children’s teeth. How we ever allowed such a toxic substance into the drinking water is staggering. Even though fluoride’s toxicity is rated higher than lead, the US Environmental Protection Agency’s (EPA) maximum contaminant level for lead in water is 15 ppb (parts per billion) whereas the level allowed for fluoride is 4,000 ppb. The recommended level for artificial fluoridation of the drinking water of 1 part per million (1 ppm = 1,000 ppb) was established in 1945, and it hasn’t been changed since, even though today we (and our children) are getting fluoride from many other additional sources, including toothpaste, other dental products, mouthwashes, processed food, some vitamin tablets, and beverages.
The benefits to teeth are questionable.
3. The key initial studies which purported to show that fluoride was a benefit to teeth, conducted in Grand Rapids, Michigan (1945), Newburgh, New York (1945), Evanston, Illinois (1947), and Brantford, Ontario, Canada (1945), were of a very dubious scientific quality. This is fully and thoroughly documented by Dr. Philip Sutton in his book, “The Greatest Fraud: Fluoridation” (1). While the science was dubious, the confidence of the US Public Health Service (PHS) was enormous. In April 1951, before any single fluoridation trial had been completed, the US Surgeon General, Leonard Scheele, was telling a Senate Subcommittee on Appropriations, “During the past year our studies progressed to the point where we could announce an unqualified endorsement of the fluoridation of the public water supplies as a mass procedure for reducing tooth decay by two thirds” (2). Subsequent Surgeon Generals have continued to act as cheerleaders for this procedure. Their passionate promotion bears little relation to the quality of the science involved in fluoridation, either to its efficacy or to its safety. Another Surgeon General, Thomas Parran, stated, “I consider water fluoridation to be the greatest single advance in dental health made in our generation” (3). Such an opinion sharply contrasts with that of former US EPA scientist, Dr. Robert Carton, who after he examined the evidence declared, “Fluoridation is a scientific fraud, probably the greatest fraud of the century” (4).
4. According to Dr. John Lee, a bone specialist from California, “Certain crucial errors common to fluoride studies that claim benefit have been identified and, when applied to any or all fluoridation trials claiming to prove benefit, are sufficient to nullify them. I challenge fluoridationists to find just one trial that can stand a critical review in the light of the errors I describe. If they cannot, they should use their authority to help rid our water supply of this useless toxin” (5).
5. Lee continues, “It is important to understand that in health matters, everything is interrelated and multifactorial. This presents a challenge to all health research: the factor being studied is just one factor among many that may confound the study. If the other factors can not be held constant (or their presence be kept equal in all groups being observed), the role of the single factor being studied can be confused… In the case of dental caries, the various factors include oral sugar and other fermentable carbohydrates, lysine and other amino acids, calcium and other minerals, vitamins, fiber, saliva flow and oral pH, dental hygiene, sunlight, genetic or constitutional factors, immune factors, use of antibiotics which may inhibit plague bacteria and others” (5). Lee lists the statistical misinterpretations common to the “fluoridation trials”: a) using “percent reductions” instead of “rate of change” of decay; b) selection bias; and c) outright fudging of the data (5).
6. Why were these early studies so poorly designed? In some cases it may simply have been the result of over-zealous promotion. For example, in the Grand Rapids, Michigan, study the control city was dropped six years into the study, supposedly because they wanted the children in this city to get the benefits as well. In the case of Hastings, New Zealand, this study was unmistakably fraudulent. Here the control city of Napier was dropped after only two years and the method of diagnosing tooth decay was changed during the course of the study, which quite artificially inflated the drop in decay. This change in diagnosis was made without this being stated in the final report (6). I am not aware of any double blind examination to investigate the efficacy of water fluoridation (i.e. one in which neither investigator nor subject is aware of which subjects have been exposed and which have not).
7. Meanwhile, considerable evidence has accumulated that the state of children’s permanent teeth in non-fluoridated communities, as measured by their DMFT (decayed, missing and filled teeth) values, is just as good as (if not better than) those in fluoridated communities. For example, in 1995 the teeth of the children in fluoridated Newburgh were again compared to those in still unfluoridated Kingston (this study started in 1945) and there was little difference in the DMFT values across the 7-14 years age range. If an average is taken the children in unfluoridated Kingston had slightly better DMFT values. However, there was one big difference: the average levels of dental fluorosis was about twice as high in fluoridated Newburgh as it was in unfluoridated Kingston (7). Dental fluorosis is a mottling of the teeth. In its mildest form it consists of white patches or streaks. As the severity increases the color of the patches changes from white to yellow, to orange and then to brown. In its severest form dental fluorosis results in loss of tooth enamel and extreme brittleness. The only known cause of dental fluorosis is exposure to fluoride and the rates are increasing. The argument used by the pro-fluoride authors of the Newburgh-Kingston study is that the improvement in DMFTs in non-fluoridated Kingston is due to exposure to fluoride from other sources: fluoridated toothpaste, beverages and processed food. If we accept this argument at face value then it completely undermines the need to add fluoride to the drinking water since a better result (i.e. slightly better DMFTs and less dental fluorosis) was achieved in Kingston without fluoridation.
8. In 1986-87 a survey was conducted by the National Institute for Dental Research (NIDR) at a cost of $3.6 million to the US taxpayer. The raw data from this study had to be pried out of this institution by Dr. John Yiamouyiannis using the Freedom of Information Act. From this data he was able to show that there was little difference in the DMFT values for approximately 40,000 children, whether they grew up in fluoridated, non-fluoridated or partially fluoridated communities (8). Pro-fluoridationists have argued that this data (or a sub-set of it) indicates 25% lower DMFT in fluoridated communities. Even if we take this argument at face value, with current DMFT values (about 2.0 or less) this represents less than half a tooth. Hardly an achievement to compensate for the increase in dental fluorosis which goes hand in hand with the measure and possibly other more serious health effects discussed below. According to Dr. Hardy Limeback, the Head of Preventive Dentistry at the University of Toronto, fluoridation of water, “has contributed to the birth of a multi-billion dollar industry of tooth bleaching and cosmetic dentistry. More money is being spent now on the treatment of dental fluorosis than what would be spent on dental decay if water fluoridation were halted” (9).
9. Another large and important study was carried out in New Zealand. What makes this work important is that under the New Zealand National Health Service plan every child between the ages of 12 and 13 years has his or her teeth examined, so here we are looking at a complete set of data, not a selected sample. Again, it was found that the teeth of children in non-fluoridated cities were slightly better than those in the fluoridated cities, and again the levels of dental fluorosis was much higher in the fluoridated cities (10).
10. In Europe, where nearly all the countries remain unfluoridated, the average DMFTs for the children are actually lower (i.e. better) than those for children in the US. Moreover, Ireland, the only country in Europe with significant fluoridation (about 73% of the population drink fluoridated water), rates sixth in a table of national average DMFTs in Europe (11).
11. How can this be? People in the US have been told again and again that children drinking fluoridated water have far better teeth than those who don’t. What explains this conflict between claim and reality? What emerges from impartial study is that the quality of children’s teeth in industrialized countries has been steadily improving from the 1930s to the 1990s, independent of whether fluoride has been added to the water supply or not. Thus, unless a control community was chosen extremely carefully–which they were not–improvements were erroneously assigned to fluoride addition rather than to the overall improvement that was taking place in both fluoridated and non-fluoridated communities.
12. Proponents of water fluoridation argue that these overall improvements in children’s teeth in non-flouridated communities have been caused by the introduction of fluoridized toothpaste and other sources (see paragraph 7). However, these improvements (i.e. lower DMFT scores) occurred before the introduction of fluoridized toothpaste and other dental products, and they have continued long after the supposed benefits of both the use of water fluoridation and dental products would have been maximized (12,13). John Colquhoun, using a simple but very elegant graph (see Figure), has shown that there has been little change in the steady downward movement in DMFTs over the period 1930-1990 in New Zealand’s 5-year olds as a consequence of the addition of fluoride or the introduction of fluoridized toothpaste (14). As Lee observes, “A decline in the rate of decay rates after fluoridation is relatively meaningless unless one knows the rate of change prior to fluoridation” (5).
13. John Colquhoun’s work is both revealing and inspiring. In the 1960’s and 1970’s in New Zealand as both local councilor and Principal Dental Officer for the city of Auckland (New Zealand’s largest city) he had been an avid promoter of fluoridation. He was so successful in fact that in 1980 he was asked by his superiors to take a 4-month sabbatical and tour the world in order to collect supporting evidence for the efficacy of water fluoridation. He did so. He visited Australia, the US, Canada, the UK, and several other countries in Europe and Asia. From talking behind the scenes with dental researchers he found, to his chagrin, that the evidence was not there. When he returned to New Zealand and examined the national statistics the evidence was not there either. He might have left the issue to rest at this point had it not been for the fact that his colleagues were discovering high levels of dental fluorosis in the fluoridated cities. He had the courage to change his mind on the issue and began publicly working for a halt to fluoridation. His position is well summarized in his paper, “Why I Changed My Mind on Fluoridation” (14). He later joined Mark Diesendorf and several other authors, including a former Minister of Health from Australia, to write another important paper, “New Evidence on Fluoridation” (15).
14. In May 1998, I had the privilege of making a videotaped interview with Dr. Colquhoun in his Auckland home less than a year before he died. Seldom have I been so impressed with the integrity of anyone as I was with Dr. Colquhoun. I simply cannot believe that any dentist or scientist who watches this taped interview with an open mind could continue to promote fluoridation. (This taped interview can be obtained from GG Video, 82 Judson Street, Canton, NY 13617).
15. Some of the reasons offered for the decline in tooth decay have included: a) a better standard of living; b) better education; c) better dental hygiene; d) more refrigeration; e) more fresh fruits and vegetables in diet; f) more cheese in diet; g) exposure to antibiotics in processed food; and h) less exposure to environmental lead.
16. The theory behind fluoride’s purported benefit to teeth is that the fluoride ion displaces the hydroxide ion from the calcium hydroxyapatite in the tooth enamel, forming the substance calcium fluorapatite, which is more resistant to acid attack. A second suggestion is that fluoride kills some of the decay causing bacteria in the mouth by poisoning their enzymes (16). However, these mechanisms pose three huge questions, which have plagued this matter for over 50 years.
1) Can you poison the enzymes in the oral bacteria, without poisoning some of the enzymes in the rest of the body? Nearly every single chemical reaction in the body is steered by enzymes (enzymes are biological catalysts).
2) As far as the tooth is concerned, can you strengthen the enamel on the outside of the tooth without damaging the tooth cells on the inside? In other words, will chemical intervention with the enamel on the surface of the tooth be accompanied by biological interference with the enzymes which lay down that enamel?
3) What will this constant exposure to fluoride do to our bones? They, too, contain calcium hydroxyapatite. Will the formation of calcium fluorapatite in our bones make them more or less vulnerable to fracture? Does fluoride poison the enzymes involved in bone growth and turnover? Are there any other ways fluoride could damage bone growth and structure?
17. The large increase in dental fluorosis in both fluoridated and non-fluoridated communities testifies to the fact that an unacceptably high number of children are now being overdosed on fluoride. In a NIDR study of nearly 40,000 children in the US it was found that the incidence of dental fluorosis increased in a dose-related fashion with the level of fluoride in the drinking water. It was found that
- at less than 0.3 ppm, 13.5% of the children had dental fluorosis,
- between 0.3 to 0.7 ppm, 21.7% had fluorosis,
- between 0.7 to 1.2 ppm, 29.9 % had fluorosis,
- and above 1.2 ppm, 41.4 % had fluorosis.
It was also found that each category of severity (based on Dean’s classification) increased in a similar dose related fashion (17). Putting these numbers into perspective, it means that for every three children who might have their tooth enamel strengthened by the addition of fluoride to drinking water at 0.7 to 1.2 ppm, approximately one child will have its tooth enamel damaged by dental fluorosis.
18. Moreover, the fact that children today are getting dental fluorosis in non-fluoridated areas means other exposures to fluoride can also cause this same damage. Pendrys et al (18) have shown that there is a significant difference in the incidence of dental fluorosis in non-fluoridated areas, between children who brush their teeth twice a day with fluoridated toothpaste and those who brush just once a day. Thus, in conjunction with efforts to eliminate fluoridation of the drinking water, a major effort has to be made to force toothpaste manufacturers to make available non-fluoridated versions of each of their major brands. In Canada, there is a non-fluoridated version of Pepsodent, and Boots, the largest chain of pharmacies in the UK, also has a brand which contains no fluoride. In the US, one usually has to go to health food stores or to catalogs to find a brand without fluoride.
19. To argue that dental fluorosis is merely a “cosmetic effect,” as some US government agencies do, is a blatant example of “linguistic detoxification” (19). In actual fact, dental fluorosis indicates that fluoride has interfered with the enzymes laying down the tooth enamel. Thus dental fluorosis is the visible flag of fluoride’s toxicity. This observation should raise the question, what other enzymes and processes in the body are being affected by fluoride for which we do not have a visible flag? Up until 1983 dental fluorosis was defined as an adverse health effect due to overexposure to fluoride. It was redefined as a “cosmetic effect” to accommodate the US EPA’s Recommended Maximum Contaminant Level [RMCL] of 4 .0 mg/L for fluoride in drinking water. According to Bette Hileman,
RCML’s are set to “prevent known or anticipated adverse health effects with an adequate margin of safety… A special committee convened by the Surgeon General in 1983 to guide EPA in setting its fluoride standard wrote in the first draft of its report that moderate to severe dental fluorosis per se is a health effect. The second draft, presented to the Surgeon General in September 1983, said that moderate to severe dental fluorosis is only a cosmetic effect–the position long held by political advocates of fluoridation. This rationale allowed EPA to ignore dental fluorosis in setting the RMCL for fluoride” (20, p 34).
20. Many researchers now agree that fluoride’s benefits (if they exist) come largely from topical application and not from systemic exposure (i.e. ingestion) (21). Despite this recognition of the primacy of topical application, and the knowledge of a marked increase in dental fluorosis, there are still many doctors who are prescribing fluoride tablets for pregnant women and young babies, i.e. before the baby’s teeth have erupted. Another concern is that women who bottle feed their babies and who live in fluoridated communities are not being adequately warned that they should be using non-fluoridated bottled water, not tap water, to make up the formula.
21. Underlining the concerns in paragraph 20, is the fact that fluoride levels in mothers’ milk is naturally very low, averaging approximately 0.01 ppm (22, p 301), which is one hundred times lower than fluoridated tap water. Even when the mother herself is drinking fluoridated water, very little of it gets passed on in her breast milk. One has to wonder then, if fluoride is necessary for healthy tooth development, how it was that God (or evolutionary forces) “failed” in this important development by limiting the supply of fluoride to the newly born baby. Why is it that human milk provides the baby with such low levels of fluoride if much higher levels are deemed necessary for healthy teeth? Who is correct: “God” or the US Public Health Service?
The threat to our bones.
22. If we now turn from teeth to bones, it is shocking to see how little investigation of the long term effect of fluoride on bones has been undertaken. For example, there has been no comprehensive attempt to determine the levels of fluoride in the bones of people living in the US. This, despite the fact that we know the following:
1) fluoridation has continued for over 50 years;
2) approximately half of the fluoride we ingest each day is deposited in our bones;
3) there is a steady accumulation of fluoride in our bones over our lifetime;
4) serious bone diseases have occurred to people with excessive exposure, especially in workers in the aluminum industry and in areas of countries like India and China; and
5) we are being exposed to more sources of fluoride today than we were in the 1940s and 1950s.
By now, if American health authorities had done their job properly we should have had a wealth of data. We should know the bone levels as a function of many variables: location, fluoridation, hardness of water supply, diet, disease status, smoking, etc. We have practically nothing. Instead, when American agencies consider what levels may cause bone damage they go back to studies carried out with cryolite (the mineral used in the smelting of aluminum) workers in Denmark in 1937. Even though Kaj Roholm’s study is a classic (23), it should not substitute today for a comprehensive study of the bones of the American people. According toa 1993 report from the Agency for Toxic Substances and Disease Registry (ATSDR),
“Fluoride is found in all bone, with the concentration depending on total fluoride exposure. The amount varies among different bones. Levels of fluoride in human bone are generally determined by biopsy of the iliac crest bone, and are generally reported as ppm of bone ash. Normal bone contains 500-1,000 ppm fluoride… Bone from people with preclinical skeletal fluorosis… contains 3,500-5,500 ppm… The fluoride concentration in bone increases with age. In a group of five people ages 64-85 who had lived for at least 10 years in an area with water containing 1 ppm fluoride, the average fluoride concentration of the iliac crest bone was 2,250 ppm of bone ash” (24, pp. 53-54).
It is extraordinary to me that a leading US agency should be relying on measurements made on “five people”. The sad truth of the matter is that the US PHS has spent many more millions of dollars promoting fluoridation than it has on investigating the effect that fluoridation has had on the American people.
23. Belatedly, an investigation has been carried out comparing the fluoride levels in the iliac crest bone in citizens in Montreal (non-fluoridated) and Toronto (fluoridated). The initial results of this study by Dr. Limeback and colleagues have been reported to the annual meeting of the International Association for Dental Research in 1999. These results indicate that the levels are about twice as high in the bones of the Toronto residents. This is a disturbing finding, since Toronto was only fluoridated in 1963. We have yet to have any human being on this planet exposed to artificially fluoridated water for a lifetime. We have little idea what levels of fluoride will be in the bones of someone who lives into their 60s, 70s, 80s or 90s who has had lifetime exposure to fluoridated water as well as all the other sources we are exposed to today. It is incredible that despite the importance of this Canadian study its funding has been discontinued. If governmental authorities in fluoridated countries wish to retain any semblance of credibility on this issue, these type of studies need to be carried out with greater intensity, not less. The fear is that the increases in dental fluorosis in our children today may foreshadow the damage to their bones that will come in the future.
24. Meanwhile, there are numerous studies in the published literature (four published in the Journal of the American Medical Association alone) which demonstrate an association between water fluoridation, or naturally occurring fluoride, and increased hip fractures in the elderly, particularly women who were exposed to fluoride prior to menopause (25-30). In 1993 the ATSDR made the following comment on the published studies on hip fractures:
“The weight of evidence from these experiments suggests that fluoride added to water can increase the risk of hip fractures in both elderly women and men… If this effect is confirmed, it would mean that hip fracture in the elderly replaces dental fluorosis in children as the most sensitive endpoint of fluoride exposure” (24, pp. 56-57).
Yet another study (this one from Finland) has just been published which demonstrates a correlation between increased hip fracture rates in elderly women and naturally occurring fluoride (31). While there are other smaller studies which have not found this correlation (32-34), and some critics have stressed the weaknesses inherent in the “ecological” methodology used (study group and control are distinguished by geographical location and not by the actual doses received by individuals), the weight of evidence indicates an association between hip fracture and exposure to fluoride. Does it make sense to protect our teeth (possibly) when we are young, and then break our bones (possibly) when we are old? By whom should such a trade-off be made? This is not a trivial issue. According to Harold Slavkin, Director of the National Institute of Dental and Cranofacial Research (formerly the NIDR), “About one-half of the people with hip fractures end up in nursing homes, and in the year following the fracture, 20 per cent of them die” (35).
25. Another set of findings which has been outrageously downplayed in my view is a possible association between water fluoridation (or fluoride exposure) and osteosarcoma (bone cancer) in young males. Of particular interest in this matter is a little known comment which was made by an early reviewer of the medical examinations of the children studied during the Newburgh-Kingston fluoridation trial (36). This comment was picked up by the authors of a National Academy of Sciences report in 1977, and further amplified:
“There was an observation in the Kingston-Newburgh (Ast et al, 1956) study that was considered spurious and has never been followed up. There was a 13.5% incidence of cortical defects in bone in the fluoridated community but only 7.5% in the non-fluoridated community… Caffey (1955) noted that the age, sex, and anatomical distribution of these bone defects are `strikingly’ similar to that of osteogenic sarcoma. While progression of cortical defects to malignancies has not been observed clinically, it would be important to have direct evidence that osteogenic sarcoma rates in males under 30 have not increased with fluoridation” (my emphasis) (37).
Continue to Part 2: Fluoride: Impact on enzymes, endocrine system and brain