LOVELAND UTILITIES COMMISSION Special Fluoride Meeting September 30, 2014 - 4:00 p.m. Police and Courts Building 810 East 10th Street
AGENDA
4:00 pm CALL TO ORDER The purpose of this special meeting is to provide a forum for public input regarding the City’s current water fluoridation policy. The Commission does not anticipate taking any formal action or formulating any recommendation tonight.
4:05 pm STAFF REPORTS 1. City of Loveland Fluoride History – Chris Matkins Following the presentation the Loveland Utilities Commission (LUC) will have approximately 10-15 minutes to ask questions.
2. Overview of EPA and Health and Human Services (HHS) Center for Disease Regulations and State Standards – Corinne Allen-Ziser Following the presentation the LUC will have approximately 10-15 minutes to ask questions.
5:05pm INFORMATION ITEMS 3. Fluoridation Presentation – Larry Sarner Following the presentation the LUC will have approximately 10-15 minutes to ask questions.
6:05 pm 4. Fluoridation Presentation – John Meaders Following the presentation the LUC will have approximately 10-15 minutes to ask questions.
CITIZEN REPORTS 7:05 pm 5. Open-Microphone for Citizen Comments (3 minute limit per citizen) Please enter the stage from the left and exit on the right. Prior to making your comments, provide your full name, address, and state whether or not you are a Loveland Water Utility customer. Please do not interrupt the speakers while they are making comments.
8:05 pm ADJOURN
The City of Loveland is committed to providing an equal opportunity for citizens and does not discriminate on the basis of disability, race, age, color, national origin, religion, sexual orientation or gender. The City will make reasonable accommodations for citizens in accordance with the Americans with Disabilities Act. For more information, please contact the City’s ADA Coordinator at [email protected] or 970-962-3319.
The password to the public access wireless network (colguest) is accesswifi. 1 Overview of Police and Courts Facility
Projection Screen Projection Screen
Podium
Citizen Citizen Seating Seating Begin Line for Citizen LUC Board Comments
2 3 1 4 1 5 1 6 1 7 2 8 2 Attachment A
Community Water Fluoridation
Presented by: Corinne Allen-Ziser September 30, 2014 Loveland Utilities Commission
Community Water Fluoridation
Rules EPA HHS State Additives
Why Water Fluoridation?
Evidence-Based Public Health
9 2 What is Fluoride?
Fluoride is a natural element found in the earth
Fluoride is found in all natural water sources
Optimally fluoridated water is not toxic or harmful.
Not all communities have sufficient naturally occurring fluoride for cavity protection
Community Water Fluoridation is the adjustment of natural water fluoride for the prevention of cavities
EPA (Environmental Protection Agency)
EPA focuses on safe water and contaminant levels that result in unfavorable health outcomes National Primary Drinking Water Regulation (4.0 mg/L) Enforceable upper limit; based on MCGL; potential adverse health effect with chronic exposure National Secondary Drinking Water Regulation (2.0 mg/L) Cosmetic; non-enforceable limit; focus on natural levels The Colorado Primary Drinking Water Regulations (5 CCR 1003-1) require: Surface Water: Annual testing Ground Water: Once every 3 years
10 2 HHS (Department of Health & Human Services Centers for Disease Control)
Recommended Optimum Level
1945 – 1.0 mg/L Dental research consensus
1962 - 0.7 to 1.2 mg/L US PHS Standards, temperature-dependent
2011 - 0.7 mg/L US HHS PROPOSED Recommendation
Benefits begin at 0.5 mg/L
No significant increased benefit above optimal levels
CDC recommends control range 0.1 mg/L below to 0.1 mg/L above optimum level
Fluoride Additives Standards
American Water Works Association Specifies product quality as purchased Sodium Fluoride Sodium Fluorosilicate Fluorosilic Acid
NSF/ANSI 60-2005 Specifies purity and product integrity in distribution (National Safety Foundation/American National Standards Institute)
11 2 Colorado Fluoridation Program
Water fluoridation is a state program, not a federal program Local decision Participating water systems: Sample/test levels daily (CDC & AWWA recommended) Send monthly reports to the State Send monthly split samples to the State Lab State recommends a control range of 0.1 mg/L below to 0.2 mg/L above target level Equipment inspections every 3 years Equipment grants
For the best prevention of tooth decay… frequent exposure to low concentrations of fluoride
12 2 Ideal Public Health Measure
No compliance required – do not have to DO anything – just drink and use the water
Benefits everyone – young & old
Safe
No access to care issues
Inexpensive
True cost savings
In Perspective
Nearly all Dental Disease is 100% Preventable
Cavities (tooth decay): the most common chronic disease of childhood
Tooth decay remains a chronic, infectious disease across all age groups
Oral Health has been linked to multiple systemic conditions and chronic diseases
13 2 Is it Safe? Does Fluoride Over 65 years of Cause……. research and (insert awful disease studies have here) shown no causal Cancer Heart Disease relationship Thyroid Disease between optimal Osteoporosis Kidney Disease fluoride and any Low IQ of these “Mushy Brain” problems. Male Pattern Baldness Socialist Tendencies
Strength of the Evidence Over 65 years of research and studies
Water fluoridation
1. Evidence by multiple systematic reviews Increasing confidence 2. Evidence by a systematic How do you review decide if it 3. Evidence by a peer reviewed study is opinion 4. Evidence by a non-peer reviewed or science? study
5. Evidence by “person-who”
14 2 Summary: Community Water Fluoridation
Local decision in Colorado
Water system participation in state program
Prevention/reduction of cavities
Benefits all members of the community – young, old, rich, poor, tall, short
Supported by decades of research
Economical (cost-savings)
Oral Health Unit Colorado Department of Public Health & Environment [email protected] 303-692-2470
Contact Us
15 2 16 2 Attachment B Oral Health Program Prevention Services Division Colorado Department of Public Health and Environment 4300 Cherry Creek Dr. S. Denver, CO 80246
P
Community Water Fluoridation
FACTS Community water fluoridation remains the safest, most effective method for preventing and reducing tooth decay in people of all ages. The U.S. Centers for Disease Control and Prevention (CDC) named fluoridation one of the 10 great public health interventions of the 20th Century. More than 65 years of research has shown water fluoridation to be safe and effective. Community Water Fluoridation is supported by numerous scientific organizations, including: o American Dental Association (ADA) o Centers for Disease Control and Prevention (CDC) o American Medical Association (AMA) o American Academy of Pediatrics o American Public Health Association o World Health Organization (WHO) o American Water Works Association (AWWA) http://www.dentalwatch.org/fl/orgs.html Community Water Fluoridation reduces dental decay by about 25%. Despite widespread availability of fluoride from other sources, community water fluoridation accounts for approximately 25% of the individual reduction in dental cavities. A 2005 Colorado study showed that community water fluoridation contributed to an annual savings of $149 million in avoided dental treatment, about $61 per person. The average cost to fluoridate for one year is $1-3 per person. Fluoride is a naturally occurring element in all water sources. Not all communities have enough naturally occurring fluoride to effectively prevent and reduce tooth decay, so they add it.
SAFETY The overwhelming weight of scientific evidence has consistently demonstrated that fluoridation of community water supplies is safe. According to the CDC and numerous independent scientific studies conducted over 65 years, there is no association between water fluoridation and any adverse health effect or systemic disorder, including but not limited to an increased risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, immune disorders, lowered intelligence, renal disorders, Alzheimer disease, or allergic reactions. According to the ADA, it is safe to use fluoridated water to mix infant formula. If the baby is only fed formula, using fluoridated water may increase the chance of mild dental enamel fluorosis which is a difficult to see cosmetic concern and does not pose a health risk. Dental enamel fluorosis will not result in cavities or other dental problems. 17 2 RECOMMENDATIONS
On Jan. 7, 2011, the Environmental Protection Agency (EPA) and the U.S. Department of Health and Human Services (HHS) issued a joint statement regarding proposed changes to the level of fluoride in drinking water necessary for the prevention of dental decay. The proposed recommendation, based on emerging research and proliferation of other fluoride products, lowers the recommended level of fluoride in drinking water to a single static level of 0.7 mg/L, from the previous range of 0.7 – 1.2 mg/L. CDPHE will wait for a final HHS recommendation before making recommendations to Colorado water operators. Until then, CDPHE supports the current recommendation by the HHS for optimal fluoride levels. The decision to optimally fluoridate community water supplies is made locally in Colorado. CDPHE serves as an advisor when requested to do so by the community. CDPHE named oral health a top 10 winnable battle, with a goal of 75 percent of Coloradans served by community water systems that optimally fluoridate water by 2016. Approximately 72% of Coloradans on a public water system have access to water with adequate fluoride levels for the prevention of dental cavities. 74% of people in the United States are served by public water systems which provide optimally fluoridated water.
FOR MORE INFORMATION
CDC (Centers for Disease Control) Community Water Fluoridation
http://www.cdc.gov/fluoridation/index.htm
ADA (American Dental Association)
http://www.ada.org/fluoride.aspx
PEW Charitable Trusts (Children’s Dental Campaign)
http://www.pewtrusts.org/en/research-and-analysis/q-and-a/2011/11/11/water-fluoridation-frequently-asked- questions
http://www.ilikemyteeth.org/
Fluoride Science
http://www.fluoridescience.org/
Colorado Department of Public Health & Environment
https://www.colorado.gov/pacific/cdphe/community-water-fluoridation
Contact us:
303-692-2470
18 2 Attachment C
Water Fluoridation Frequently Asked Questions
The Pew Children’s Dental Campaign supports water fluoridation because it’s one of the most cost-effective strategies for states and communities to improve the oral health of their residents. Although a number of communities in the U.S. have been fluoridating their public water systems for more than 60 years, this strategy re-entered the spotlight in the wake of recent announcements from federal health officials about fluoride.
This FAQ is meant to answer many key questions about the benefits of fluoridation and address the federal announcements.
Q: What is fluoride and how does it benefit dental health? A: Fluoride is a mineral that exists naturally in nearly all water supplies. Research proves that at a certain level in drinking water, fluoride prevents tooth decay. This optimal level is reached when a public water system adjusts—either increasing or lowering—the level of fluoride.
Q: I recently found the website of a group that opposes fluoridation. This group claims that the connection between fluoridation and cavity prevention isn’t solid. Is that true? A: No, it is not true. There is solid, consistent evidence supporting fluoride’s role in cavity prevention. Studies show that fluoridation reduces tooth decay by 18 to 40 percent. Two studies released in 2010 strengthened the already substantial evidence that fluoridated water prevents cavities.
Q: Does fluoride in drinking water protect only the teeth of children or does it benefit everyone? A: People of all ages benefit from drinking water that is optimally fluoridated. Oral health is important throughout a person’s life. In the 1950s, before water fluoridation was common, most people over the age of 65 had lost their teeth. Now, after decades of widespread fluoridation, more seniors are keeping most or all of their teeth. Between 1972 and 2001, the rate of edentulism—losing all of one’s teeth—dropped 26 percent among lower-income seniors and fell 70 percent among upper-income seniors.
Q: What do leading medical and health organizations say about drinking water that is optimally fluoridated? A: The American Academy of Pediatrics, the American Dental Association, the American Medical Association and many other respected medical or health organizations recognize the health benefits of fluoridation. The U.S. Centers for Disease Control and Prevention called water fluoridation “one of 10 great public health achievements of the 20th century.”
19 2 Q: Federal health officials recently recommended that public water systems reduce the level of fluoride in drinking water. Exactly what was the recommendation and why was this new level set? A: In January 2011, the U.S. Department of Health and Human Services (HHS) recommended that the optimal level of fluoride in public water systems should be 0.7 milligrams per liter (mg/L) of water. This is a change from the previous recommendation that the optimal level would vary by a region’s climate (average temperatures) within the range of 0.7 to 1.2 mg/L. This new recommendation by HHS recognizes these scientific findings: 1) Americans today are getting fluoride from more sources than they were when the original level was set, and 2) the water intake of children does not vary by climate or region. This new fluoride level demonstrates that federal health officials are periodically reviewing research and relying on the best science to update—if and when appropriate—their recommendations on fluoridated water.
Q: Are many communities planning on completely removing fluoride from water because of the recent federal announcement on the fluoride level? A: Many communities are reviewing their fluoride levels and planning to adjust those levels to meet the new recommendation. There is no sign that many communities either want or plan to remove fluoride entirely. HHS and leading health experts do not support removing fluoride from water to a level below the recommended level because this would deprive people of cavity protection. In fact, the American Dental Association welcomed HHS’ new fluoride level and said that water fluoridation remains “one of our most potent weapons in disease prevention.” In Grand Rapids, Michigan—the first U.S. city that optimally fluoridated its water system—the city’s daily newspaper wrote an editorial noting that the new HHS recommendation “should not feed the flawed notion . . . that fluoride must be removed entirely from drinking water. ”
Q. What impact will the new fluoride level have on Americans who are served by a public water system that’s fluoridated? A: The new optimal fluoride level that federal health officials have recommended will have a positive impact. First, it will continue to protect teeth by helping to reduce tooth decay. Second, the new level will minimize the chances of fluorosis, a condition that typically causes a minor discoloration of teeth that is usually visible only to a dentist. The new HHS recommendation reflects the fact that Americans today receive fluoride from more sources (toothpaste, mouth rinses and other products) than they were getting several decades ago.
Q: How many Americans receive water that is optimally fluoridated? A: Roughly 72 percent of Americans whose homes are connected to a community water system receive fluoride-adjusted water. Some communities have been doing so for over 60 years.
Q: Water fluoridation helps to prevent tooth decay, but is that really a concern in the U.S. anymore? A: Yes, it remains a concern. Although dental health has improved for many Americans, tooth decay remains the most common chronic childhood disease—five times more prevalent than asthma. Tooth decay causes problems that often last long into adulthood, affecting kids’ schooling and their ability to get jobs as adults.
20 2 Q: If I use fluoridated toothpaste, am I getting enough fluoride to protect against decay? A: No. The benefits from water fluoridation build on those from fluoride in toothpaste. Studies conducted in communities that fluoridated water in the years after fluoride toothpastes were widely used have shown a lower rate of tooth decay than communities without fluoridated water. The author of a 2010 study noted that research has confirmed “the most effective source of fluoride to be water fluoridation.” Water fluoridation provides dental benefits to people of all ages and income groups without requiring them to spend extra money or change their daily routine.
Q: Do any states have laws guaranteeing residents’ access to fluoridated water? A: Twelve states and the District of Columbia have laws designed to ensure access to fluoridated water. Forty-three of the 50 largest cities in the U.S. fluoridate their drinking water. Research shows that every $1 invested in water fluoridation saves $38 in unnecessary dental costs.
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21 2 22 2 Attachment D
Myths and Facts About Water Fluoridation (Updated March 17, 2011)
Myths Facts 1. Adding fluoride Fluoride occurs naturally in water. The term “fluoridated water” to water is like simply means that the fluoride level in a water system has been forcing people to adjusted to a certain level—or optimal level—to prevent tooth take medication. decay. Most water systems in the U.S. are fluoride-deficient without this adjustment. Fluoride is not a medication. It is a mineral essential for human life based on its role in metabolism and other cell functions. Fluoride in drinking water has two beneficial effects: preventing tooth decay and contributing to healthy bones.1 U.S. court decisions have rejected the argument that fluoride is a “medication” that should not be allowed in water. The American Journal of Public Health summarized one of these rulings, noting that “fluoride is not a medication, but rather a nutrient found naturally in some areas but deficient in others.”2 Adding fluoride to water is like any other treatment to improve the quality of drinking water. It is based on public officials making a decision that is informed by sound research—not driven by fear. Those who prefer not to drink from a public water system can do so. Maintaining an optimal amount of fluoride in water is based on the principle that decisions about public health should be based on what is healthy for the entire community, not based on the fears of a few individuals who have extreme opinions about their drinking water.
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2. There is little There is a clear difference between the health of communities that difference in the fluoridate their drinking water and those that do not. Fluoridation dental health of prevents tooth decay and improves dental health. people in communities with Studies consistently show that water fluoridation reduces tooth fluoridated water decay by 18 to 40 percent.3 compared to those A study of two similar, adjacent communities in Arkansas showed in communities that residents without access to fluoridated water had twice as many without it. cavities as those with access to fluoridated water.4 Children on Medicaid in less fluoridated counties in New York State require 33 percent more treatments for tooth decay than those in counties where most water systems are optimally fluoridated.5 Texas saves $24 per child, per year in Medicaid expenditures for children because of the cavities averted by drinking fluoridated water.6 The benefits of fluoridation are long-lasting. A recent study of U.S. adults found that those born in counties with fluoridation lose fewer teeth than those born in fluoride-deficient counties.7 International studies across the United States, Australia, Britain, Canada, Ireland, and New Zealand showed 15 to 40 percent less tooth decay in optimally fluoridated communities compared to fluoride- deficient communities.8 The Centers for Disease Control and Prevention named fluoridated water as one of “10 great public health achievements” of the 20th century.”9
24 2 3. Fluoridation Fluoridated water is safe. Claims that it causes cancer or other life- causes cancer and threatening illnesses are unproven. other serious health problems. The National Cancer Institute has stated: “Many studies, in both humans and animals, have shown no association between fluoridated water and risk for cancer.”10 In 2006, a panel of the National Research Council—an arm of the National Academies of Science—found no convincing evidence of a causal link between fluoridation and cancer.11 A leading spokesperson for the Centers for Disease Control and Prevention notes that “60 years of research has shown that there’s no persuasive evidence that points to any harm from community water fluoridation.”12 Fluoridation opponents cite an “exploratory” Harvard study in the mid-1990s associating fluoride with osteosarcoma, a rare bone cancer. The author herself described the study as having “limitations.” In addition, the principal investigator of the study has stated that further analysis does not support this association.13 The overwhelming evidence shows the benefits of water fluoridation far outweigh any perceived risk. A 2006 study by the Australian National Health and Medical Research Council examined 408 studies on fluoridation, and concluded that water fluoridation offers clear benefits without solid evidence of negative health effects.14 At least 100 million Americans have been drinking fluoridated water for many decades. 72 percent of the U.S. population served by community systems has fluoridated water.15 Without fluoridated water, children face a much higher rate of tooth decay and the potential for related dental diseases can have lasting effects on their health, schooling and future. The risk we must avoid is that of allowing our children to grow up without water fluoridation.
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4. There are better Water fluoridation provides dental benefits to people of all age and ways of delivering income groups without requiring them to spend extra money or fluoride than change their daily routine. adding it to water. The CDC notes that fluoride is most effective when provided in “the right amount in the right place at the right time,”16 and there’s no better way to ensure that than fluoridated water. A 2003 study of fluoridation in Colorado concluded that “even in the current situation of widespread use of fluoride toothpaste,” water fluoridation “remains effective and cost saving” at preventing cavities.17 Studies conducted in communities that fluoridated water in the years after fluoride toothpastes were widely used have shown a lower rate of tooth decay than communities without fluoridated water.18 For low-income individuals who are at higher risk of dental problems, fluoride rinses are a costly expense, which is why these products are not the “easy” answer that opponents of fluoridation claim they are. Water fluoridation is the least expensive and most effective solution.
5. Fluoridated Fluoridated water is safe for babies and young children. water isn’t safe for babies. The American Academy of Pediatrics and the American Medical Association support water fluoridation.19 Fluoridated water can be safely used to reconstitute infant formula. The only issue for parents of infants to consider is enamel fluorosis— a minor, cosmetic condition that produces faint white markings on permanent teeth as they are forming (from birth through age 8). The risk of dental fluorosis is low. Even when it occurs, fluorosis is barely noticeable—if noticed at all.20 Mothers who rely on reconstituted infant formula should consult with their pediatricians about options other than using fluoridated water. Some pediatricians may recommend alternatives to fluoridated water, while others may tell parents to continue using fluoridated water. The CDC concludes the vast majority of fluorosis cases are mild, and fluorosis can also occur in communities without fluoridated water.21 Fluoridated water has stood the test of time, serving U.S. communities since 1945.22 Today, over 195 million people (72 percent of Americans on public water supplies) drink fluoridated water.23 Tens of millions, many of whom are now parents themselves, were given formula reconstituted with fluoridated water when they were infants.
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6. Tooth decay is Tooth decay is the most common childhood disease, five times more no longer a prevalent than asthma. problem in the Tooth decay affects nearly 60 percent of children.24 United States. Tooth decay causes problems that often last long into adulthood— affecting kids’ schooling, access to healthcare, the ability to get jobs and even national security. o California children missed 874,000 school days in 2007 due to dental problems.25 o A study of seven Minneapolis-St. Paul hospitals showed that patients made over 10,000 trips to the emergency room because of dental health issues, costing more than $4.7 million.26 o An estimated 164 million hours of work are missed during a year because of dental problems or treatments.27 In addition, poor dental health worsens a person’s future job prospects. A 2008 study confirmed a widely held but little-discussed prejudice: People who are missing front teeth are viewed as less intelligent, less desirable and less trustworthy than people without a gap in their smile.28 o In a 2008 study of the armed forces, 52 percent of new recruits were categorized as Class 3 in “dental readiness”—meaning they had oral health problems that needed urgent attention and would delay overseas deployment.29 Between 1994 and 2004, tooth decay increased by 15 percent among kids ages two to five.30
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7. Fluoridating Water fluoridation saves money. water is an For most cities, every $1 spent on water fluoridation returns $38 in expensive burden savings.31 to communities or states in this time The average cost for one dental filling is $120, compared to less than $1 per person, per year to fluoridate water for a community of 20,000 of recession. residents or more.32 A study by the Texas Department of Health found that fluoridated water saved $24 per child, per year in state Medicaid costs.33 Researchers estimated that fluoridation saved Colorado nearly $149 million in 2003 by preventing unnecessary treatment costs. These savings averaged about $61 per person.34 A 1999 study compared Louisiana communities that were fluoridated with those that were not. The study found that low-income children in non-fluoridated communities were three times more likely than those in communities with fluoridated water to receive dental treatment in a hospital operating room.35 Like other public works, which continue to be funded even during economic downturns, fluoridation is an investment that provides huge economic returns to communities, once implemented, year after year.
8. Most countries Millions of people in Great Britain, Spain and Ireland drink in Western Europe fluoridated water. And millions of other Europeans receive fluoride don’t fluoridate through salt or milk. their water so why should we? Whether the vehicle is water, salt or something else, millions of Europeans are receiving fluoride’s protection to prevent tooth decay.36 In some Western European countries, the large number of separate water sources used for drinking water makes water fluoridation very difficult logistically.37 Several of these countries use salt fluoridation as an alternative, demonstrating that they recognize the public health value of fluoride.38 After the fall of communism in Czechoslovakia, school-based dental programs were discontinued and water fluoridation ended in most of the country. According to a study, “Subsequent surveys indicated an increasing [decay] prevalence after these changes.”39 In 2009, the European Archives of Paediatric Dentistry published an analysis of 59 studies and concluded that "water fluoridation is effective at reducing caries in children and adults. With the exception of dental fluorosis, no association between adverse effects and water fluoridation has been established."40 An estimated 405 million people in 60 countries worldwide enjoy the benefits of fluoridated water.41
28 2 Sources:
1 National Research Council. “Earth Materials and Health: Research Priorities for Earth Science and Public Health.” National Academies Press. 2007. 2 Readey v. St. Louis County Water Co., supranote 25 at 628, 631 for the court's statement that it could not assume that the addition of 0.5 parts per million of fluoride to water that already contained 0.5 parts per million would result in infringement of any constitutional rights; Roemer, Ruth. “Water Fluoridation PH Responsibility and the Democratic Process.” American Journal of Public Health. Vol. 55 (9), 1965. (2) Chapman v. City of Shreveport, supra note 25 at 146. 3 Centers for Disease Control and Prevention. Public Health Service report on fluoride benefits and risks. Journal of the American Medical Association 1991; 266(8):1061–1067. 4 Mouden, L. “Fluoride: The Natural State of Water.” Arkansas Dentistry; Summer 2005; 77(2): 15-16. 5 Kumar, J. “Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation Under Contemporary Conditions”. Public Health Reports. Vol. 125, 2010. 6 Texas Department of Oral Health Website. www.dshs.state.tx.us/dental/pdf/fluoridation.pdf Accessed August 1, 2010. 7 M. Neidell, K Herzog, S Glied, “The Association Between Community Water Fluoridation and Adult Tooth Loss,” American Journal of Public Health, in press. 8 U.S. Department of Health and Human Services (USDHHS). Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. Washington: U.S. Department of Health and Human Services, Public Health Service; 1991. 9 “Ten Great Public Health Achievements – United States, 1900-1999,” Centers for Disease Control and Prevention, April 2, 1999; accessed on July 13, 2010 at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm . 10 National Cancer Institute Website. Water Fluoridation Fact Sheet. http://www.cancer.gov/cancertopics/factsheet/Risk/fluoridated-water Accessed July 28, 2010. 11 National Research Council. Carcinogenicity of fluoride. In: Subcommittee on Health Effects of Ingested Fluoride, editor. Health Effects of Ingested Fluoride. Washington DC: National Academy Press, 1993. 12 Dr. Bill Bailey, CDC Podcast 7/17/2008. http://www2c.cdc.gov/podcasts/player.asp?f=9927#transcript 13 CDC Water Fluoridation Homepage. http://www.cdc.gov/fluoridation/65_years.htm Accessed August 2, 2010. 14 National Health and Medical Research Council (Australia) (2007). "A systematic review of the efficacy and safety of fluoridation" (PDF). http://www.nhmrc.gov.au/PUBLICATIONS/synopses/_files/eh41.pdf. 15 CDC Water Fluoridation Homepage. http://www.cdc.gov/fluoridation/65_years.htm. Accessed August 2, 2010. 16 CDC Fluoridation Website. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm Accessed August 10, 2010. 17 Report of the Fort Collins Fluoride Technical Study Group, (April 2003) 58. 18 ADA Fluoridation Facts, 2005, p. 10. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf. Accessed August 2, 2010. 19 ADA Website. www.ada.org/4052.aspx. Accessed August 2, 2010. 20 ADA Fluoridation Facts, 2005, p. 28. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf. Accessed August 2, 2010. 21 ADA Fluoridation Facts, 2005, p. 29. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf. Accessed August 2, 2010. 22 ADA Fluoridation Facts, 2005, p. 1. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf 23 CDC. Water Fluoridation: Nature’s Way to Prevent Tooth Decay. 2006, p. 2. www.cdc.gov/fluoridation/pdf/natures_way.pdf 24 Pew Center on the States. http://www.pewcenteronthestates.org/initiatives_detail.aspx?initiativeID=42360 25 Nadereh Pourat and Gina Nicholson, “Unaffordable Dental Care Is Linked to Frequent School Absences,” Health Policy Research Brief. (UCLA Center for Health Policy Research, Los Angeles, California) November 2009. 6 p. 26 Advanced Dental Hygiene Practitioners Frequently Asked Questions. NNDHA Spring 2008, p. 8. http://www.nddha.org/DH%20FAQ.pdf 28 M. Willis, C. Esqueda, and R. Schact, “Social Perceptions of Individuals Missing Upper Front Teeth,” Perceptual and Motor Skills, 106 (2008): 423–435. 29 Thomas M. Leiendecker, Gary C. Martin et al., “2008 DOD Recruit Oral Health Survey: A Report on Clinical Findings and Treatment Need,” Tri-Service Center for Oral Health Studies, (2008) 1 (accessed August 19, 2010).
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30 B. Dye, et al., “Trends in Oral Health Status: United States, 1988-1994 and 1999-2004,” Vital Health and Statistics Series 11, 248 (2007), Table 5, http://www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf (accessed December 4, 2009). 31 Centers for Disease Control and Prevention, “Cost Savings of Community Water Fluoridation,” August 9, 2007, http://www.cdc.gov/fluoridation/fact_sheets/cost.htm (accessed August 7, 2009). 32 National median fee for a two-surface amalgam (silver) filling among general dentists. (Procedure code D2150, amalgam, two surfaces, primary or permanent.) See American Dental Association, “2007 Survey of Dental Fees”; Centers for Disease Control and Prevention, Division of Oral Health, “Cost Savings of Community Water Fluoridation” (August 9, 2007), http://www.cdc.gov/fluoridation/fact_sheets/cost.htm (accessed August 7, 2009). 33 Texas Department of Health, “Water Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid),” Report to Texas Legislature. May 2000, http://www.dshs.state.tx.us/dental/pdf/fluoridation.pdf (accessed August 2, 2010). 34 O’Connell J.M. et al., “Costs and savings associated with community water fluoridation programs in Colorado,” Preventing Chronic Disease (November 2005), accessed on March 12, 2011 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/. 35 “Water Fluoridation and Costs of Medicaid Treatment for Dental Decay – Louisiana, 1995-1996,” Morbidity and Mortality Weekly Report, (U.S. Centers for Disease Control and Prevention), September 3, 1999, accessed on March 11, 2011 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4834a2.htm. 36 T. Marthaler and G. Pollak, “Salt fluoridation in Central and Eastern Europe,” Schweiz Monatsschr Zahnmed (August 2005), Vol. 115, http://www.zahnaerzte.ch/doc/doc_download.cfm?uuid=9553209DD9D9424C4C98A160B35CD8DE&&IRACER_A UTOLINK&& (accessed March 14, 2011); A.E. Villa, “Milk Fluoridation for the Prevention of Dental Caries,” World Health Organization, 2009, pp. 93-105, http://whqlibdoc.who.int/publications/2009/9789241547758_eng.pdf (accessed on February 2, 2011). 37 ADA Fluoridation Facts, p. 54. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf 38 ADA Fluoridation Facts, p. 19. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf 39 T. Marthaler and G. Pollak, pp. 671-672. 40 Guidelines on the use of fluoride in children: An EAPD policy document. European Archives of Pediatric Dentistry, 10 (3), 2009, p. 130. 41 The British Fluoridation Society, The UK Public Health Association, The British Dental Association, The Faculty of Public Health of the Royal College of Physicians. “One in a million—the facts about water fluoridation.” Manchester, England, 2004.
30 2 Attachment E
Water Fluoridation & Safety
Virtually any substance — even many vitamins and minerals — has the potential to cause adverse health effects if it is consumed in unusually high levels. This is true for calcium, fluoride and other minerals. The major arguments that anti-fluoride activists make about safety are based on poorly designed studies or misinterpretations of data. This document provides summaries from more than a dozen reports and studies that strengthen the case that fluoridated water is safe.
National Research Council (2006)
Anti-fluoride groups raise fears about fluoride by misrepresenting a 2006 report by the National Research Council (NRC). The focus of the NRC’s report was on people living in areas of the U.S. with natural levels of fluoride in water that are at least three or four times higher than the level recommended for fluoridating a public water system.
Nothing in the NRC report casts doubt on the safety of fluoride at the recommended optimal level. In fact, the NRC explicitly stated that its concerns “do not apply at the lower water fluoride levels commonly experienced by most U.S. citizens.”
In March 2013, Dr. John Doull, who chaired the NRC committee, stated, “I do not believe there is any valid scientific reason for fearing adverse health conditions from the consumption of water fluoridated at the optimal level.”
http://sboh.wa.gov/Meetings/2010/06-09/docs/Tab16i-Fluoridation_CDC_Statement.pdf
Journal of Dental Research (2011)
A peer-reviewed study analyzed hundreds of bone samples and found no link between fluoride levels and osteosarcoma, a rare bone cancer. The researchers from Harvard University, the Medical College of Georgia and the National Cancer Institute (NCI) examined bone samples over an eight-year period from patients with osteosarcoma and a control group. The NCI approved the design of the study, which examined actual fluoride levels in bone — a more reliable method than relying on patients’ self- reporting. http://jdr.sagepub.com/content/early/2011/07/23/0022034511418828.abstract
World Health Organization (2004)
The director of the World Health Organization’s oral health program co-wrote this study that reviewed the use of different forms of fluoride to prevent tooth decay. Among other conclusions, the study found, “There is no credible evidence that water fluoridation is associated with any adverse health effects.” http://www.who.int/water_sanitation_health/dwq/chemicals/fluoride.pdf
Platform for Better Oral Health in Europe (2012)
1
31 2 This report concluded that fluoridated water “is safe, cost-effective and has a demonstrable long term benefit to population dental health. Notwithstanding reports from anti-fluoridationist groups, over the last 50 years, the fluoridation of water has been a significant method” to help prevent tooth decay. http://www.oralhealthplatform.eu/proposed-2020-targets-better-oral-health-europe
The Fluoride Technical Study Group, Fort Collins, Colo. (2003)
“In the literature reviewed, doses appropriate for caries reduction were not shown to negatively impact thyroid function. Studies in which humans received doses significantly higher than the optimum fluoride intake for long periods of time showed no negative impact on thyroid function.” http://www.healthdistrict.org/fluoridereport/executivesummary.pdf
Australian Study on Chronic Kidney Disease (2007)
“There is no consistent evidence that the retention of fluoride in people with stage 4 or 5 [chronic kidney disease] who consume optimally fluoridated drinking water results in any negative health consequences. Animal studies have demonstrated that rats with compromised kidney function that are exposed to the level of fluoride that is commonly encountered by human populations (1 ppm in drinking water) do not develop any clinically adverse extraskeletal physiological, biochemical or genetic outcomes.” http://www.ada.org/4383.aspx
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32 2 Attachment F
What Respected Organizations and Experts Say About Water Fluoridation
Academy of General Dentistry:
“Fluoride makes the entire tooth structure more resistant to decay and promotes remineralization, which aids in repairing early decay before damage is even visible. Studies have confirmed the most effective source of fluoride to be water fluoridation.”1
“Instead of drilling holes to fix cavities, dentists would rather educate the public on how to avoid developing tooth decay in the first place. Drinking tap water to receive fluoride is safe, and it's easier on your wallet than going to the dentist for a filling.”2
American Academy of Pediatrics:
“Fluoride plays a very important role in the prevention of dental caries. Although the primary mechanism of action of fluoride in preventing dental caries is topical, systemic mechanisms are also important.”3
“Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. In short, fluoridated water is the cheapest and most effective way to deliver anticaries benefits to communities.”4
American Academy of Pediatrics (New York State Chapter):
“Community water fluoridation is safe, effective and necessary to prevent chronic dental disease in pediatric populations.”
“Dental decay is a common but preventable, chronic disease. It is our youngest children who are at the greatest risk for developing early dental disease while not having access to a dental care home. ... Without community water fluoridation the incidence of this disease and its attendant complications will increase.”5
American Academy of Family Physicians:
“Fluoridation of public water supplies is a safe, economical, and effective measure to prevent dental caries.”6
1
33 2 American Academy of Physician Assistants:
“Primary prevention keeps disease from occurring at all by removing its causes. Examples of primary prevention include . . . giving immunizations for many communicable diseases, and counseling patients to adopt healthy lifestyles … Examples include chlorination and fluoridation of the water supply …”7
“Fluoride substantially decreases caries rates. … All children should receive fluoride through systemic water fluoridation or dietary supplements.”8
American Association for the Advancement of Science:
“… fluoridation of community water supplies is repeatedly demonstrating that it is an effective public health measure for the mass partial control of dental cavities, and … [AAAS is] on record as endorsing fluoridation of community water supplies as a method for advancing dental public health, as this 121st meeting of the AAAS.”9
American Association of Oral and Maxillofacial Surgeons:
“Community water fluoridation, which adjusts the fluoride in water to a level sufficient for preventing and controlling tooth decay, reduces tooth decay by 30–50%.
“Although great progress has been made, nearly 28% of public water systems do not have the capacity to deliver—and approximately 100 million Americans do not have access to— optimally fluoridated water. Many communities need support to upgrade or purchase new water systems and fluoridation equipment.”10
American Association of Public Health Dentistry:
“… it has been shown that children with the greatest dental need and who are at highest risk for tooth decay benefit the most from water fluoridation.”
The resolution also stated: “The Association recommends that federal, state, and local agencies and organizations promote water fluoridation as the foundation for better oral health.”11
American Council on Science and Health:
“Fluoride is harmless at the levels necessary for maximum (dental) benefits. Thousands of studies on fluorides and fluoridation have been completed in the last 50 years — more than 3,700 since 1970 alone. Over 50 peer-reviewed epidemiological studies have dealt with the claim that fluoridation increases cancer risk. None has substantiated the claim.”12
American Dental Association:
“Studies conducted throughout the past 65 years have consistently shown that fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. Simply by drinking water, children and adults can benefit from fluoridation's cavity protection whether they are at home, work or school.”13
2
34 2 American Dental Education Association: “ADEA supports and encourages fluoridation of community water supplies and the use of topical fluoride. Community water fluoridation is safe, practical, and the most cost-effective measure for the prevention of dental caries.”14
American Dental Hygienists’ Association: “Good scientific evidence supports the use of community water fluoridation and the use of fluoride dental products for preventing tooth decay for both children and adults. “Adjusting the level of fluoride in drinking water first used fluoride as a preventative for tooth decay in Grand Rapids, Michigan. Fluoridation of drinking water has been used successfully in the United States for more than 50 years.”15
American Dietetic Association: “The American Dietetic Association reaffirms that fluoride is an important element for all mineralized tissues in the body. Appropriate fluoride exposure and usage is beneficial to bone and tooth integrity and, as such, has an important, positive impact on health throughout life.”16
American Federation of Teachers: “The good news is that tooth decay and other oral diseases are preventable. The combination of dental sealants and fluoride has the potential to nearly eliminate tooth decay in school-age children.”17
American Medical Association: “The AMA urges state health departments to consider the value of required statewide fluoridation (preferably a comprehensive program of fluoridation of all public water supplies, where these are fluoride deficient), and to initiate such action as deemed appropriate.”18 AMA has also encouraged physicians to “become involved” in the fluoridation issue by determining “whether municipal water supplies are optimally fluoridated and … working with public health agencies to take corrective action if suboptimal fluoridation is found.”19
American Osteopathic Association: “The American Osteopathic Association supports the fluoridation of fluoride-deficient public water supply.”20
American Public Health Association: “[The U.S. Department of Health and Human Services] announced proposed recommendations to simplify the recommended optimal level for community water systems to 0.7 mg/L fluoride … APHA continues to support community water fluoridation as a sound public health preventive measure. APHA is supportive of the process of updating recommendations for optimal fluoride concentrations in water based on today’s conditions.”21
3 35 2
American Society for Clinical Nutrition:
“… the American Society for Clinical Nutrition agrees that fluoridation of community water supplies to an optimum level wherever the natural level is less than optimum is a safe, economical, and effective measure to improve dental health by improving nutrition.”22
American Water Works Association:
“… community water fluoridation at optimal levels is beneficial for preventing tooth decay.
“The goal of community water fluoridation is to achieve the desired oral health benefit while minimizing potential health risks. That is why water providers undergo thorough and extensive training to safely apply fluoride in the amount recommended by the world’s most respected public health authorities.”23
Association of California Water Agencies:
“ACWA is a diverse state wide organization representing nearly 450 public water agencies that collectively supply 90% of the water delivered in California for domestic, agricultural and industrial uses. California enjoys some of the highest water quality in the world.
“… ACWA reaffirms its support for water fluoridation and strongly believes that its benefits need to be continued to communities served by centralized water systems.”24
Association of State & Territorial Dental Directors:
“Community water fluoridation remains the cornerstone of dental caries prevention in the United States and has been demonstrated to be safe, cost-effective and beneficial through every stage of life and for all people, regardless of age, race, ethnicity or socio-economic status.”25
Audrey F. Manley, M.D., M.P.H., Surgeon General under President Bill Clinton:
“Water fluoridation continues to be the cornerstone of community oral disease prevention. The benefits of fluoridation are available, on average, for little more than $0.50 per person per year, and even less, in large communities.”26
Australian Dental Association:
“Drinking fluoridated water several times a day is the ideal way to give your teeth a quick fluoride treatment.
“… Fluoride from fluoridated water is found in saliva and provides a wonderful, low concentration fluoride treatment for your teeth.”27
4
36 2 The Bower Foundation: “The most inexpensive way to deliver the benefits of fluoride to all residents of a community is through water fluoridation. For most cities, every dollar invested in public water fluoridation saves $38 in dental treatment costs.”28
British Dental Association: “The BDA is pleased with [a program to expand fluoridation in southwest England] because it is likely to encourage consultation on similar schemes in other parts of the country where fluoride could help address the poor dental health of the population. “A recent European summary of the latest scientific evidence reiterated the view that water fluoridation is a safe and effective method of reducing oral health inequalities.”29
British Dental Health Foundation: “Fluoride was added to the Birmingham supply in 1964 and the difference in dental health compared to the neighbouring population in non-fluoridated Sandwell was stark. When Sandwell's water was fluoridated in 1987 it transformed levels of oral health, putting a poor borough amongst the top ten areas for dental health in the country.”30
British Medical Association: “The BMA remains committed to the fluoridation of mains water supplies, after appropriate public consultation, on the grounds of effectiveness, safety and equity.”31
Canadian Dental Association: “Fluoride is added to public drinking water to protect all members of the community from tooth decay. Community water fluoridation is a safe and effective way of preventing tooth decay at a low cost.”32
Canadian Public Health Association “In 1945, Brantford, Ontario became the first Canadian community to test water fluoridation, thereby achieving a 54% reduction in decay experienced by 8-year-olds.” “In Quebec, for instance, less than 7% of the population has access to fluoridated water. A study of the oral health of children between 1990 and 1999 found that kindergarten children in Quebec had 40% more cavities than children in Ontario and the United States, and that tooth decay affects 56% of Quebec children in Grade 2.”33
Centers for Disease Control and Prevention: The CDC named the “fluoridation of drinking water” as one of “10 great public health achievements” of the 20th century.34
5 37 2 C. Everett Koop, M.D., Surgeon General under President Ronald Reagan:
“… I encourage the dental profession in communities which do not enjoy the benefits of an optimally fluoridated drinking water supply to exercise effective leadership in bringing the concentration to within an optimum level.”35
Children’s Dental Health Project:
“Water fluoridation is particularly beneficial during childhood and in adolescence when cavity experience first begins. Not only do children who drink fluoridated water have fewer cavities but their cavities are smaller and less deep when they do occur.”36
Children’s Hospital of Denver, Colorado:
In 2008, this hospital was ranked in the top 10 children’s hospitals in the U.S.37
“From a public health perspective, to improve the oral health of the people of Colorado the first important step is to fluoridate those public water systems that are as yet non-fluoridated.”
Council of State Governments:
“… states need to reduce expenditures in Medicaid budgets and studies have proven that communities benefiting from fluoridated water use fewer Medicaid dollars to treat dental decay.
“… simply by drinking water, everyone, especially those without access to regular dental care, can benefit from fluoridation’s cavity protection whether they are at home, work or school.”38
David Satcher, M.D., Ph.D., Surgeon General under President Bill Clinton:
“Other evidence of the benefits of fluoridation comes from studies of populations where fluoridation has ceased. Examples in the United States, Germany, and Scotland have shown that when fluoridation is withdrawn and there are few other fluoride exposures, the prevalence of caries increases. In Wick, Scotland, which began water fluoridation in 1969 but stopped it in 1979, the caries prevalence in 5- to 6-year-olds with limited exposure to other sources of fluoride increased by 27 percent between 1979 and 1984. This was despite a national decline in caries …”39
Early Head Start National Resource Center:
“Fluoride is the most effective agent to prevent tooth decay. It can be added to community water supplies, as needed, and occurs naturally in some areas.”
“… Early Head Start staff and parents should be aware that purchased bottled water usually does not contain enough fluoride to prevent tooth decay.”40
Ernie Mueller, Alaska’s former Commissioner of Environmental Conservation:
“I followed [the fluoridation issue] through my 35-year career in water and wastewater research, supervision and management. … What is disturbing is that the inflammatory and
6
38 2 misleading rhetoric used by some of the opponents of fluoridation frightens many people who may not have personal knowledge of the issue.”41
Florida Public Health Institute:
”Fluoride reduces the ability of bacteria to produce acid and promotes the remineralization of enamel, thereby preventing a cavity from continuing to form. Community water fluoridation is a proven cost-effective intervention that optimizes fluoride content in public water systems to promote oral health. Florida’s Department of Health supports Community Water Fluoridation.”42
GreenFacts.org (international organization with a board of scientific advisers):
“The numerous studies carried out in many countries on populations consuming fluoridated drinking water did not show any consistent evidence of an association between the consumption of controlled fluoridated drinking water and increased frequency of cancer.”43
Idaho Medical Association:
“The IMA has historically taken a leadership role in public health and safety issues. Its proactive support for polio immunization, public water fluoridation, civil defense planning, cigarette warning labels, use of seat belts, child abuse reporting, motorcycle helmet use, day care licensing, cigarette taxes, minimum drinking age, and immunization of schoolchildren has positively impacted the quality of life and health of all Idahoans.”44
Indiana State Department of Health:
“Despite the fact that thousands of studies, analyses, and experiments have shown fluoridation to be safe and effective, some insist that it cease until all doubts about its safety have been resolved. Of course, it is impossible to prove the absolute safety of anything. But in the case of fluoridation, opponents are constantly making new allegations, none of which are supported by science.”45
Indian Health Service (U.S. Dept. of Health and Human Services):
“An effective community water fluoridation program should be the cornerstone of all public oral health programs.”46
“Recent studies have found a smaller difference in the caries prevalence between optimally fluoridated and fluoride-deficient communities. In American Indian/Alaska Native populations the expected reductions in disease may be even greater, given the high caries rates.”47
International Agency for Research on Cancer:
“Fluoridation of drinking-water was introduced in the USA in 1950, and thus the studies in the USA encompass periods of observation of 20 years or more. … The studies have shown no consistent tendency for people living in areas with high concentrations of fluoride in the water to have higher cancer rates than those living in areas with low concentrations or for cancer mortality rates to increase following fluoridation.”
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39 2
“Since a large number of comparisons were made, some would be expected by chance alone to show differences. However, no consistent difference has been seen, and there have been as many significant negative associations between fluoridated water supplies and cancer incidence or mortality as there have been positive associations.”
“… Epidemiological studies have shown no association between the presence of fluorides in drinking-water and the incidence of Down’s syndrome.”48
International Association of Dental Research:
“The International Association for Dental Research (IADR), considering that dental caries (tooth decay) ranks among the most prevalent chronic diseases worldwide . . . and taking into account that over 50 years of research have clearly demonstrated its efficacy and safety; and noting that numerous national and international health-related organizations endorse fluoridation of water supplies; fully endorses and strongly recommends the practice of water fluoridation for improving the oral health of nations.”49
Irish Forum on Fluoridation:
Note: The Forum on Fluoridation was appointed by Ireland’s government to study the impact of water fluoridation on the Irish people. The Forum published its report in September 2002. The very first conclusion of this report is below:
“Water fluoridation has been very effective in improving the oral health of the Irish population, especially of children, but also of adults and the elderly.”50
Joseph Thompson, M.D., Surgeon General of the State of Arkansas:
“Water fluoridation was trumpeted by the CDC as one of the most important health measures of the 20th century. Now that we are in the 21st century, every community and water system not currently providing this benefit to their residents and customers needs to step up and help their community and its residents.”51
Linus Pauling, winner of the Nobel Prize (1954) and National Medal of Science (1974):
Note: Opponents of water fluoridation often label fluoride as “toxic” or “poison.” Linus Pauling debunked this assertion in a 1967 article by writing:
“In this respect, fluoride ion is similar to many other substances, such as vitamin D, that are harmful in large amounts but are required in small amounts for life and good health of human beings.”52
8
40 2 Roughly 20 years before he died, Pauling co-founded the Linus Pauling Institute. The Institute has issued this statement on fluoride: “Although its role in the prevention of dental caries (tooth decay) is well established, fluoride is not generally considered an essential mineral element because humans do not require it for growth or to sustain life. However, if one considers the prevention of chronic disease (dental caries) an important criterion in determining essentiality, then fluoride might well be considered an essential trace element.”53
Massachusetts Dental Society: “…we also have come to realize that the issue of fluoride, to some, is less about science and more about emotion. The groups and individuals questioning the safety of fluoride tend to forget that many dentists are parents, too. Why would we advocate for water fluoridation if we believed that it would be compromising our own children’s health in any way?”54
Michigan Department of Community Health: “Community water fluoridation has proven to be safe through both practical experience and research. During the past 40 years, over 4,000 studies have measured and confirmed the safety of fluoride. Community water fluoridation has been studied more thoroughly than any other public health measure.”55
Michigan State Medical Society: “The Michigan State Medical Society, in cooperation with the Michigan Association of Public Health and Preventive Medicine Physicians, is urging citizens and public water facilities throughout the state not to misinterpret the new [federal] recommendations regarding the fluoridation of municipal water.” “… the FDA believes that reducing the level of fluoride in municipal water will help reduce the occurrence of dental fluorosis, a harmless discoloration (mottling) that can occur with higher levels of exposure to fluoride. Fluoridation of water can decrease cavities by up to 40% if available to children during the first 7 years of their lives. The value of fluoridation has been thoroughly established as safe and effective.”56
Mississippi State Department of Health: “Water fluoridation is an effective, safe and inexpensive way to prevent tooth decay. … In Mississippi, the cost of water fluoridation is usually between one and two dollars per person per year and saves $16-$19 per person per year in dental treatment costs.”57
National Consumers League: “Bottled water consumption has doubled over the past decade and as a result, the exposure to fluoride from tap water, which can not only prevent tooth decay, it can repair tooth decay, has been reduced as well.”
9 41 2 “Oral health is a critical component of overall health, and we need to spread the word about the importance of brushing with fluoridated toothpaste twice a day, drinking tap water wherever possible, and seeing the dentist twice a year. The benefits will pay off exponentially.”58
National Council Against Health Fraud:
“Antifluoridationists who point out that fluoride can produce adverse effects deliberately fail to mention that the concentrations that produce adverse effects [are] higher than the concentration produced by properly maintained fluoridation systems.”
“… NCAHF believes that the factions that keep alive the antifluoridation movement are a major detriment to the health and well-being of the public.”59
National Dental Association:
“As a result of water fluoridation half of all children ages 5 to 17 have never had a cavity in their permanent teeth. Despite the overwhelming evidence of the value of water fluoridation 34% of the population still does not have access to fluoridated water. Water fluoridation would save over $1.5 billion per year.”60
National Fluoride Information Centre (United Kingdom):
Note: Many anti-fluoridation activists tell the public that “Europe doesn’t fluoridate.” Although it is true that water fluoridation is not common in Europe, this argument is very misleading because there are other ways, such fluoridating salt and milk, that many European countries provide fluoride to their citizens:
“Salt fluoridation was introduced in Switzerland in 1955 and it is now estimated that fluoridated salt is available to nearly 200 million people worldwide, including Europe, Central and South America and the Caribbean. It is the preferred method of fluoridation on mainland Europe and is widely available in France, Germany, Switzerland, Austria, Belgium, Spain, Czech Republic and Slovakia.”61
In addition, millions of Irish and English drink fluoridated water:
“Five and a half million people in England drink artificially fluoridated water. In these areas the children have among the lowest levels of tooth decay in the country. Recent independent research at the University of York has confirmed the benefits of fluoridation. Fluoridation works best in large towns with a simple water supply and where the children have high amounts of dental decay. People living in Birmingham and Newcastle have been drinking fluoridated water for more than 30 years.”62
National Institute of Dental and Craniofacial Research:
“Although dental caries remains a public health worry, it is no longer the unbridled problem it once was, thanks to fluoride.”63
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National PTA (Parent-Teacher Association):
“PTA involvement laid the groundwork for cooperative partnerships with medical associations and health organizations in the decades to come. … [PTA also worked] to educate members about other immunizations and treating water with fluoride to prevent rampant dental problems.”64
Nevada State Medical Association:
“… the NSMA and its component medical societies support legislative efforts to promote community water fluoridation at optimal levels to decrease the incidence of dental caries.”65
Oklahoma State Department of Health:
“It is recommended that all public water systems in Oklahoma be fluoridated to provide this cost-effective oral disease prevention measure to residents throughout Oklahoma.”66
Oral Health America:
“Oral Health America enthusiastically supports community water fluoridation. Fluoridated water supplies give Americans, especially those most vulnerable, equal access to one of the most celebrated public health measures of our time. Fluoridation brings healthy mouths to life.”67
Oregon Medical Association:
“OMA recognizes the health benefits of fluoridation and has long stood in support of fluoridating public water supplies.”
“OMA reaffirms its support for fluoridation of all public water supply systems …”68
Pew Center on the States:
“Fluoride counteracts tooth decay and strengthens the teeth by fighting harmful acids and drawing calcium back into the teeth. Community water fluoridation can reduce tooth decay in children by up to 60 percent, and it costs as little as $1 per person, per year.
“Research shows that community water fluoridation offers perhaps the greatest return-on- investment of any dental care strategy. The reduction in just the costs of filling and extracting diseased teeth (not counting reductions in lost work time and dental pain) more than makes up for the cost of fluoridation.”
Public Health Law Research (Temple University):
“Fluoride is a mineral that has been proven effective at preventing tooth decay.”
11
43 2 “… In the judgment of a Community Guide expert panel, there is significant evidence to support water fluoridation as an effective public health intervention aimed at reducing tooth decay.”69
Richard H. Carmona, M.D., Surgeon General under President George W. Bush:
“Water fluoridation is a powerful strategy in our efforts to eliminate differences in health among people and is consistent with my emphasis on the importance of prevention.
“… Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for both children and adults.”70
Robert Wood Johnson University Hospital:
“Fluoride, either applied topically to erupted teeth, or ingested orally (called systemic fluoride) during tooth development, helps to prevent tooth decay, strengthen tooth enamel, and reduce the harmful effects of plaque.”71
Tennessee Department of Health:
“Fluoride is naturally occurring and present in all bodies of water (rivers, lakes, springs, and wells) to some degree. Water fluoridation is the adjustment of the natural level of fluoride to a level that is optimal for oral health.
“… More than 60 years of research supports the fact that community water fluoridation is both safe and effective.”72
Texas Department of State Health Services:
“The wide implementation of community water fluoridation in Texas has resulted in substantial savings in publicly financed dental care under the Texas Healthy Steps (EPSDT-Medicaid) program. Further savings may be made by implementing community water fluoridation in areas where it is lacking and feasible.”73
United Methodist Health Ministry Fund:
“Since 1998, the Health Fund has offered grants to fund the start-up costs of community water fluoridation due to fluoridation's time-proven oral health benefits, safety, and practicality. Persons living in communities with fluoridated water enjoy 20 to 40% less tooth decay than those in areas without adequate fluoride.”74
U.S. Task Force on Community Preventive Services:
“The Task Force on Community Preventive Services recommends community water fluoridation based on strong evidence of effectiveness in reducing tooth decay.”75
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Utah Health Department:
“The nationwide goal to prevent cavities through community water fluoridation is similar to previous public health efforts to prevent other common health problems. These include adding iodide to salt to prevent thyroid problems, adding iron to infant formula to prevent anemia, adding Vitamin D to milk to prevent rickets, adding niacin to flour and other foods to prevent pellagra, and adding folic acid to cereal grains products to prevent birth defects.
“Each of these public health efforts represents situations where a nutritional additive is provided to everyone or to large target populations since it is impossible to individually identify and effectively treat the significant number of people who are at risk.”76
Vermont Medical Society:
“… frequent exposure to small amounts of fluoride enhances developing enamel and encourages remineralization, replacing minerals that bacteria dissolve from the enamel surface of teeth.”
“… the Vermont Medical Society endorses fluoridation as an important community commitment to the oral health of its children and adults and it affirms the value of continuing fluoridation in community water systems.”77
Washington State Public Health Association:
“… the benefits of fluoridation of water in the prevention of dental disease have been scientifically substantiated.”
“… the Washington State Public Health Association actively endorses and strongly supports fluoridation of the public water systems in the State of Washington.”78
WebMD.com:
“Fluoride helps prevent tooth decay by making the tooth more resistant to acid attacks from plaque bacteria and sugars in the mouth. It also reverses early decay. In children under six years of age, fluoride becomes incorporated into the development of permanent teeth, making it difficult for acids to demineralize the teeth. Fluoride also helps speed remineralization as well as disrupts acid production in already erupted teeth of both children and adults.”79
Wisconsin Oral Health Coalition:
“… community water fluoridation is a significant cost containment measure available for dental caries prevention in communities throughout Wisconsin, costing an average of approximately 50 cents per person per year while reducing the need for expensive treatment …”80
World Health Organization:
“Fluoride is being widely used on a global scale, with much benefit. Millions of people worldwide use fluoridated toothpaste. They benefit from fluoridated water, salt fluoridation or other forms of fluoride applications …”81
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Sources:
1 C.H. Chu, BDS, PhD, MAGD, ABGD, lead author of a 2010 study is quoted in: “Advocacy: Drinking Tap Water May Help You Avoid Dentist’s Drill,” Academy of General Dentistry, March 2010, accessed on February 11, 2011 at http://www.agd.org/public/oralhealth/Default.asp?IssID=303&Topic=F&ArtID=7363#body. 2 Cynthia Sherwood, DDS, FAGD, a spokesperson for the Academy of General Dentistry is quoted at: “Advocacy: Drinking Tap Water May Help You Avoid Dentist’s Drill,” Academy of General Dentistry, March 2010, accessed on February 11, 2011 at http://www.agd.org/public/oralhealth/Default.asp?IssID=303&Topic=F&ArtID=7363#body. 3 “Protecting All Children’s Teeth (PACT),” a training module by the American Academy of Pediatrics, accessed on Jan. 20, 2011 at http://www.aap.org/oralhealth/pact/ch6_intro.cfm. 4 “Preventive Oral Health Intervention for Pediatricians,” Pediatrics, Vol. 122, No. 6, December 2008, pp. 1387-1394, accessed on Jan. 20, 2011 at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/6/1387. 5 Letter to New York City Councilman Peter Vallone from the New York State Chapter of the American Academy of Pediatrics, February 9, 2011. 6 “Fluoridation of Public Water Supplies,” a policy statement of the American Academy of Family Physicians, accessed on January 24, 2011 at: http://www.aafp.org/online/en/home/clinical/clinicalrecs/guidelines/fluoridation.html. 7 “A Practical Approach to Prevention,” American Academy of Physician Assistants, 2009, accessed on February 2, 2011 at http://web1.aapa.org/aapaconf2009/syllabus/9144BergeisenPrevention.doc.pdf. 8 Wanda C. Gonsalves, M.D., “Incorporating Oral Health into Primary Care: The Role of the Physician Assistant,” May 30, 2010, posted on the website of the American Academy of Physician Assistants, accessed on February 2, 2011 at http://web1.aapa.org/10ACSyllabi/1193OralHealthGonsalves.pdf. 9 “Fluoridation of Community Water Supplies,” a resolution approved on December 30, 1954 by the AAAS Council, accessed on February 18, 2011 at http://archives.aaas.org/docs/resolutions.php?doc_id=245. 10 Letter to Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, June 3, 2010. (Note: The letter was signed by the American Association of Oral and Maxillofacial Surgeons and 13 other medical and health organizations.) The letter was accessed on February 18, 2011 at http://www.aaoms.org/docs/govt_affairs/issue_letters/ppaca.pdf. 11 This resolution was adopted in March 2010 by the American Association of Public Health Dentistry, accessed on January 31, 2011 at http://www.aaphd.org/default.asp?page=Resolution%20on%20Community%20Water%20Fluoridation%20(CWF).html. 12 Dr. Michael W. Easley, “Fluoridation: A Triumph of Science Over Propaganda,” American Council on Science and Health, October 1, 1996, accessed on January 21, 2011 at http://www.acsh.org/healthissues/newsid.724/healthissue_detail.asp. 13 “Flouride & Fluoridation,” American Dental Association, accessed on Jan. 12, 2011 at http://www.ada.org/fluoride.aspx. 14 “ADEA Policy Statements,” approved by the 2010 ADEA House of Delegates, accessed on February 18, 2011 at http://www.adea.org/about_adea/governance/Pages/PolicyStatements.aspx. 15 “Fluoride Facts,” American Dental Hygienists’ Association, accessed on January 21, 2011 at http://www.adha.org/oralhealth/fluoride_facts.htm. 16 “Position of the American Dietetic Association: The Impact of Fluoride on Health,” Journal of the American Dietetic Association (2005), Vol. 105. 17 “Linking Children’s Health to Education,” American Federation of Teachers, accessed on January 31, 2011 at http://www.aft.org/issues/childhealth/. 18 Submitted and approved as Resolution 9 by the AMA House of Delegates in 1986. The language was reaffirmed by AMA’s House of Delegates in 1996 and 2006. Accessed on January 21, 2011 at http://www.ama- assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/accreditation-collaboration/ada- council.shtml. 19 This statement on fluoridation was approved by the American Medical Association in 1991 and reaffirmed in 2001. Accessed on January 21, 2011 from the AMA website at http://www.ama-assn.org/ama/pub/physician- resources/clinical-practice-improvement/clinical-quality/accreditation-collaboration/ada-council.shtml. 20 “Fluoridation,” Resolution H268-A, was approved in both 2004 and 2009 by the American Osteopathic Association’s House of Delegates, accessed on February 18, 2011 at http://www.osteopathic.org/inside- aoa/about/leadership/Documents/2010-policy-compendium.pdf. 21 “APHA Reaffirms Its Support for Community Water Fluoridation,” a press release by the American Public Health Association, January 11, 2011, accessed on January 18, 2011 at http://www.apha.org/about/news/pressreleases/2011/water+fluoridation+response.htm. 22 “Resolution on fluoridation of drinking water,” adopted by the American Society for Clinical Nutrition on May 2, 1985, published by the American Journal of Clinical Nutrition, accessed on March 11, 2011 at
14
46 2 http://www.ajcn.org/content/43/3/480.full.pdf. (Note: In 2005, the American Society for Nutrition was created by the merger of the American Society for Clinical Nutrition, the American Society for Nutritional Science and the Society for International Nutrition.) 23 “AWWA backs best science on fluoridation,” a statement by the American Water Works Association, January 7, 2011, accessed on February 10, 2011 at http://www.awwa.org/publications/breakingnewsdetail.cfm?itemnumber=55972. 24 Letter from ACWA to the U.S. Centers for Disease Control and Prevention, February 11, 2011. 25 “ASTDD Statement in response to the recent Department of Health and Human Services and Environmental Protection Agency fluoridation announcements,” Association of State & Territorial Dental Directors, accessed on January 13, 2011 at: http://www.astdd.org/. 26 “Surgeon General’s Statement on Community Water Fluoridation, 1995,” from the website of the U.S. Centers for Disease Control and Prevention, accessed on January 27, 2011 at: http://www.cdc.gov/fluoridation/fact_sheets/sg95.htm. 27 “Fluoride FAQ's,” Australian Dental Association, Inc., accessed on February 18, 2011 at http://www.ada.org.au/oralhealth/fln/flfaqs.aspx#FLdismedcon. 28 “Mississippi Public Water Fluoridation Program Phases I – IV,” The Bower Foundation, accessed on March 3, 2011 at http://www.bowerfoundation.org/htdocs/case_studies/investing/water_fluoridation.html. 29 The comments of BDA’s Scientific Adviser, professor Damien Walmsley are from: “BDA commends go-ahead for fluoridation,” a press release by the British Dental Association, February 11, 2011, accessed on February 18, 2011 at http://www.bda.org/news-centre/press-releases/30700-bda-commends-go-ahead-for-fluoridation.aspx. 30 This quote by Dr. Nigel Carter, chief executive for the British Dental Health Foundation is from: “Foundation Urges More Water Fluoridation After High Court Ruling, UK,” Medical News Today, February 15, 2011, accessed on March 2, 2011 at http://www.medicalnewstoday.com/articles/216530.php. 31 “Fluoridation of water,” British Medical Association, January 12, 2010, accessed on February 18, 2011 at http://www.bma.org.uk/health_promotion_ethics/environmental_health/Fluoriwater.jsp. 32 “Your Oral Health,” Canadian Dental Association, accessed on February 18, 2011 at http://www.cda- adc.ca/en/oral_health/faqs_resources/faqs/fluoride_faqs.asp. 33 “Fighting the Good Fight: Fluoridation of Drinking Water,” 12 Great Achievements, Canadian Public Health Association, (2010), accessed on March 12, 2011 at http://cpha100.ca/12-great-achievements/fighting-good-fight-fluoridation- drinking-water. 34 “Ten Great Public Health Achievements – United States, 1900-1999,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, April 2, 1999, Vol. 48, No. 12, 241-243, accessed on January 25, 2011 at http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm. 35 Letter from C. Everett Koop, M.D., to John W. Hernandez, Jr., deputy administrator of the Environmental Protection Agency, July 30, 1982. 36 “Public Health Officials Reconfirm Value of Water Fluoridation While Adjusting Recommended Levels,” press release by the Children’s Dental Health Project, January 10, 2011, accessed on March 12, 2011 at http://www.cdhp.org/press_release/public_health_officials_reconfirm_value_water_fluoridation_while_adjusting_recom mended. 37 “US News Again Ranks The Children’s Hospital in Top 10,” The Children’s Hospital of Denver, Colorado, accessed on March 11 at http://www.thechildrenshospital.org/news/pr/2008news/USNews-2008.aspx. 38 “The Council of State Governments Resolution on Community Water Fluoridation,” adopted on May 10, 2006; accessed on February 17, 2011 at http://www.csg.org/knowledgecenter/docs/CommunityWaterFluoridation.pdf. 39 Oral Health in America: A Report of the Surgeon General, U.S. Department of Health and Human Services & U.S. Public Health Service, 2000, accessed on January 26, 2011 at http://silk.nih.gov/public/[email protected]. 40 “Early Head Start Tip Sheet No. 18,” Early Head Start National Resource Center (May 2004), accessed on March 12, 2011 at http://www.ehsnrc.org/Publications/English%20Tip%20Sheets/TIP_SHEET_18.PDF. 41 Ernie Mueller, “Some fluoride opponents are making misleading statements,” Juneau Empire, April 6, 2004. 42 “Florida Oral Health Policy 101 – Prevention,” Florida Public Health Institute, accessed on March 9, 2011 at http://floridaoralhealth.com/FloridaOralHealthPolicy101/Prevention.aspx. 43 “5.1: Has Fluoride Exposure Caused Cancer?” Scientific Facts on Fluoride, GreenFacts.org, (2005), accessed on February 11, 2011 at http://www.greenfacts.org/en/fluoride/fluorides-2/05-effects-humans.htm#1. 44 “IMA’s History: A Legacy of Leadership,” Idaho Medical Association, accessed on March 14, 2011 at http://www.idmed.org/d/history. 45 “Questions and Answers about Fluoridation,” Indiana State Department of Health, accessed on March 11, 2011 at http://www.in.gov/isdh/24525.htm. 46 “Community Water Fluoridation,” Oral Health Program Guide, Indian Health Service, 2007, accessed via http://www.ihs.gov/index.cfm. 47 ibid.
15 47 2
48 “Fluorides,” International Agency for Research on Cancer – Summaries & Evaluations, 1987, accessed on January 21, 2011 at http://www.inchem.org/documents/iarc/suppl7/fluorides.html. 49 “Fluoridation of Water Supplies,” a policy statement adopted by the International Association for Dental Research, 1979, (statement updated in 1999). 50 Forum on Fluoridation 2002, a report to the Minister of Health and Children, September 2002, accessed on March 1 at http://www.dohc.ie/publications/pdf/fluoridation_forum.pdf?direct=1. 51 “Fluoridation necessary,” letter to the editor of the Arkansas Democrat-Gazette by Joseph W. Thompson, M.D., published on May 21, 2009. 52 “The Fluoridation of Drinking Water,” a statement by Linus Pauling, Ph.D., November 29, 1967, accessed on January 21, 2011 at http://www.quackwatch.org/03HealthPromotion/fluoridepauling.html. 53 “Fluoride,” from the Micronutrient Information Center at The Linus Pauling Institute (Oregon State University), accessed on January 19, 2011 at http://lpi.oregonstate.edu/infocenter/minerals/fluoride/. 54 “Block to preventive health is discouraging to dentists,” letter by Dr. John P. Fisher, president of the Massachusetts Dental Society, The Boston Globe, October 10, 2010, accessed at http://www.boston.com/bostonglobe/editorial_opinion/letters/articles/2010/10/10/springfield_suffers_without_fluori dated_water_supply/. 55 Susan Deming, “Community Water Fluoridation Fact Sheet,” Michigan Department of Community Health, accessed on February 17, 2011 at http://www.michigan.gov/documents/mdch/Microsoft_Word_- _Community_Water_Fluoridation_Fact_Sheetedit_218186_7.pdf. 56 “New Fluoridation Recommendations Not a Cause for Concern,” press release by the Michigan State Medical Society, February 18, 2011, accessed on March 12, 2011 at http://www.msms.org/AM/Template.cfm?Section=News_Releases&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID= 17153. 57 “Mississippi Fact Sheet: Community Water Fluoridation and Oral Health,” Mississippi State Department of Health, accessed on March 2, 2011 at http://msdh.ms.gov/msdhsite/_static/resources/3817.pdf. 58 Sally Greenberg, “Drink up! Tape water key to dental health,” Savvy Consumer blog, National Consumers League, January 19, 2011, accessed on February 11, 2011 at http://savvyconsumer.wordpress.com/2011/01/19/drink-up-tap- water-key-to-dental-health/. 59 William T. Jarvis, Ph.D, “Fluoridation,” National Council Against Health Fraud, (February 1, 2002), accessed Jan. 14, 2011 at http://www.ncahf.org/articles/e-i/fluoride.html. 60 “Position on Water Fluoridation,” National Dental Association (2009), accessed on March 14, 2011 at http://www.ndaonline.org/index.php?option=com_content&view=article&id=54:water-flouridation&catid=34:position- statements&Itemid=59. 61 “Salt: The Facts,” National Fluoride Information Centre, accessed on February 1, 2011 at http://www.fluorideinformation.com/guide_to_fluoride/salt. 62 “Water Fluoridation and Children,” National Fluoride Information Centre, accessed on February 1, 2011 at http://www.fluorideinformation.com/images/leaflet_items/Binder1.pdf. 63 “The Story of Fluoridation,” National Institute of Dental and Craniofacial Research, 2010, accessed on February 3, 2011 at http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm. 64 Speaker Notes from “A Walk Through PTA History,” July 16, 2010, accessed on January 31, 2011 at http://www.pta.org/history_workshop_speaker_notes.pdf. 65 “Water Fluoridation,” Resolution 1997-28, adopted in 1997 by the Nevada State Medical Association. See: Nevada State Medical Association: Policy Compendium – 2008-2009, accessed on March 9, 2011 at http://www.nsmadocs.org/PDF_08/Compendium-2009.pdf.(Note: This resolution was reaffirmed by NSMA in 2003.) 66 “Community Water Fluoridation Program,” Oklahoma State Department of Health, accessed on February 18, 2011 at http://www.ok.gov/health/Child_and_Family_Health/Dental_Health_Service/Community_Water_Fluoridation_Program/i ndex.html. 67 E-mail communication from Liz Rogers, Vice President of Oral Health America, sent to the Pew Center on the States at 3:00 pm on Monday, February 28, 2011. 68 Resolutions A-80 and A-91, adopted by the Oregon Medical Association, accessed on March 9, 2011 at http://www.theoma.org/Page.asp?NavID=434. (Note: Resolution A-80 was reaffirmed by OMA’s Resolution A-85.) 69 “Water Fluoridation,” Public Health Law Research, November 14, 2009, accessed on February 22, 2011at http://www.publichealthlawresearch.org/public-health-topics/oral-health/evidence-brief/water-fluoridation. 70 Statement of the United States Surgeon General, July 2004, accessed at http://www.nidcr.nih.gov/OralHealth/Topics/Fluoride/StatementWaterFluoridation.htm. 71 “Fluoride,” Robert Wood Johnson University Hospital, accessed on March 9, 2011 at http://www.rwjuh.edu/health_information/adult_oralhlth_flouride.html. 72 “Fluoride Facts and Fiction,” Tennessee Department of Health, accessed on February 2, 2011 at http://health.state.tn.us/oralhealth/facts_fiction.html.
16
48 2 73 “Water Fluoridation Costs in Texas: Texas Healthy Steps (EPSDT-Medicaid),” Texas Department of Health (May 2000), a study authorized by House Concurrent Resolution 145 of the 75h Texas Legislature, accessed on January 25, 2011 at www.dshs.state.tx.us/idcu/health/dpn/issues/dpn62n04.pdf. 74 Health Fundamentals, an e-newsletter by the United Methodist Health Ministry Fund, September 3, 2004, accessed on March 3, 2011 at http://www.healthfund.org/newsletters/hfn09032004.php. 75 “Preventing Dental Caries: Community Water Fluoridation,” a summary of the Task Force’s recommendations, accessed on March 3, 2011 at http://www.thecommunityguide.org/oral/fluoridation.html. 76 “Statement on Community Water Fluoridation,” Utah Department of Health (January 2007), accessed on March 10, 2011 at http://www.health.utah.gov/oralhealth/pdf/Fluoridation07.pdf. 77 “Fluoridation in Community Water Systems,” a resolution by the Vermont Medical Society, approved on February 2, 2006, http://www.vtmd.org/sites/all/themes/vms/documents/policies/2005/dental.pdf, accessed on March 9, 2011. 78 “Fluoridation of Public Water Systems,” Resolution 99-04, Washington State Public Health Association, adopted on October 4, 1999, accessed on March 10, 2011 at http://www.wspha.org/resources/Documents/Resolution%2099-04.pdf. (Note: This resolution reaffirmed a 1968 resolution on fluoridation that was adopted by WSPHA.) 79 “Oral Health Guide,” WebMD.com, accessed on January 27, 2011 at http://www.webmd.com/oral- health/guide/fluoride-treatment. 80 “Resolution Regarding Community Water Fluoridation,” Wisconsin Oral Health Coalition, adopted on September 23, 2004, accessed on March 12, 2011 at http://www.chawisconsin.org/documents/OH3resolution207.pdf. 81 “Oral Health: Risks to oral health and intervention,” World Health Organization, accessed on January 21, 2011 at http://www.who.int/oral_health/action/risks/en/index1.html.
17 49 2 50 2 51 3 52 3 Attachment A
53 3 54 3 Attachment B 2010-2014 Ave F- (ppm) Days Online Monthly F- Bckgrd (ppm) Days Offline Monthly Bckgrd Aug 2010 0.84 31 26.04 0 0.00 Sep 2010 0.81 30 24.30 0 0.00 Oct 2010 0.83 24 19.92 0.17 7 1.16 Nov 2010 0.00 0 0.00 0.16 30 4.80 Dec 2010 0.00 0 0.00 0.18 31 5.58 Jan 2011 0.00 0 0.00 0.20 31 6.20 Feb 2011 0.00 0 0.00 0.20 28 5.60 Mar 2011 0.00 0 0.00 0.20 31 6.20 Apr 2011 0.56 6 3.36 0.21 24 5.04 May 2011 0.00 0 0.00 0.18 31 5.58 Jun 2011 0.63 30 18.90 0.18 0 0.00 Jul 2011 0.63 31 19.53 0.26 0 0.00 Aug 2011 0.65 31 20.15 0.23 0 0.00 Sep 2011 0.63 30 18.90 0.18 0 0.00 Oct 2011 0.63 24 15.18 0.16 7 1.13 Nov 2011 0.00 0 0.00 0.20 30 6.00 Dec 2011 0.00 0 0.00 0.17 31 5.27 Jan 2012 0.00 0 0.00 0.20 31 6.20 Feb 2012 0.00 0 0.00 0.18 29 5.22 Mar 2012 0.00 0 0.00 0.19 31 5.89 Apr 2012 0.00 0 0.00 0.17 30 5.10 May 2012 0.00 0 0.00 0.16 31 4.96 Jun 2012 0.00 0 0.00 0.14 30 4.20 Jul 2012 0.00 0 0.00 0.13 31 4.03 Aug 2012 0.00 0 0.00 0.13 31 4.03 Sep 2012 0.00 0 0.00 0.13 30 3.90 Oct 2012 0.00 0 0.00 0.13 31 4.03 Nov 2012 0.00 0 0.00 0.14 30 4.20 Dec 2012 0.00 0 0.00 0.15 31 4.65 Jan 2013 0.00 0 0.00 0.15 31 4.65 Feb 2013 0.00 0 0.00 0.17 28 4.76 Mar 2013 0.00 0 0.00 0.15 31 4.65 Apr 2013 0.00 0 0.00 0.16 30 4.80 May 2013 0.00 0 0.00 0.16 31 4.96 Jun 2013 0.00 0 0.00 0.14 30 4.20 Jul 2013 0.49 21 10.24 0.14 10 1.40 Aug 2013 0.50 31 15.50 0.12 0 0.00 Sep 2013 0.46 30 13.80 0.14 0 0.00 Oct 2013 0.45 31 13.95 0.15 0 0.00 Nov 2013 0.44 30 13.20 0.13 0 0.00 Dec 2013 0.46 31 14.26 0.15 0 0.00 Jan 2014 0.48 31 14.88 0.19 0 0.00 Feb 2014 0.46 28 12.88 0.19 0 0.00 Mar 2014 0.47 31 14.57 0.19 0 0.00 Apr 2014 0.50 30 15.00 0.18 0 0.00 May 2014 0.52 31 16.12 0.20 0 0.00 Jun 2014 0.64 30 19.20 0.20 0 0.00
55 3 Explanation of Raw Data (all from Forms 380 submitted by LWD to CDPHE)
1. The first column is the daily average of fluoride exposure reaching end- users, just on those days when the plant was fluoridating.
2. The second column is the number of days when the plant was fluoridating.
3. The third column is the total fluoridation exposure provided to end-users while the plant was fluoridating. (column 1 x column 2)
4. The fourth column is the daily average background level, just for those days when the plant was not fluoridating.
5. The fifth column is the number of days when the plant was not fluoridating.
6. The sixth column is the total fluoridation exposure provided to end-users while the plant was not fluoridating. (column 4 x column 5)
Summary & Conclusions for FY2011-2014
A. The Loveland treatment plant’s fluoridation system was offline for 2.3 of the last 4 fiscal years.
B. For those days that the Loveland treatment plant’s fluoridation system was offline, customers received an average background fluoridation exposure of 0.17ppm.
C. After coming back online, apparently for good in July 2013, the daily average of fluoride exposure reaching end-users was just 0.49ppm.
D. The daily average of fluoride exposure reaching end-users in July had risen to 0.72ppm, which is close to their target optimal level of 0.70ppm.
56 3 Attachment C
Fluoride Use in Caries Prevention in the Primary Care Setting Melinda B. Clark, Rebecca L. Slayton and SECTION ON ORAL HEALTH Pediatrics 2014;134;626; originally published online August 25, 2014; DOI: 10.1542/peds.2014-1699
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/134/3/626.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
57 Downloaded from pediatrics.aappublications.org by guest on September 21, 2014 3 Guidance for the Clinician in Rendering Pediatric Care
CLINICAL REPORT Fluoride Use in Caries Prevention in the Primary Care Setting
Melinda B. Clark, MD, FAAP, Rebecca L. Slayton, DDS, PhD, abstract and SECTION ON ORAL HEALTH Dental caries remains the most common chronic disease of childhood KEY WORDS fl fl fl in the United States. Caries is a largely preventable condition, and fluo- enamel uorosis, uoride, uoride varnish, formula mixing, systemic fluoride supplements, toothpaste, water fluoridation ride has proven effectiveness in the prevention of caries. The goals of fl ABBREVIATIONS this clinical report are to clarify the use of available uoride modalities AAP—American Academy of Pediatrics for caries prevention in the primary care setting and to assist pediatri- ADA—American Dental Association cians in using fluoride to achieve maximum protection against dental CDC—Centers for Disease Control and Prevention EPA—Environmental Protection Agency caries while minimizing the likelihood of enamel fluorosis. Pediatrics 2014;134:626–633 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Dental caries (ie, tooth decay) is an infectious disease in which acid Academy of Pediatrics has neither solicited nor accepted any produced by bacteria dissolves tooth enamel. If not halted, this process commercial involvement in the development of the content of will continue through the tooth and into the pulp, resulting in pain and this publication. tooth loss. This activity can further progress to local infections (ie, The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. dental alveolar abscess or facial cellulitis), systemic infection, and, in Variations, taking into account individual circumstances, may be rare cases, death. Dental caries in the United States is responsible for appropriate. many of the 51 million school hours lost per year as a result of dental- related illness, which translates into lost work hours for the parent or adult caregiver.1 Early childhood caries is the single greatest risk factor for caries in the permanent dentition. Good oral health is a necessary part of overall health, and recent studies have demon- strated the adverse effects of poor oral health on multiple other chronic conditions, including diabetes control.2 Therefore, the failure to prevent caries has health, educational, and financial consequences at both the individual and societal level. Dental caries is the most common chronic disease of childhood,1 with www.pediatrics.org/cgi/doi/10.1542/peds.2014-1699 59% of 12- to 19-year-olds having at least 1 documented cavity.3 Caries doi:10.1542/peds.2014-1699 is the “silent epidemic” that disproportionately affects poor, young, and Accepted for publication Jun 9, 2014 minority populations.1 The prevalence of dental caries in very young All clinical reports from the American Academy of Pediatrics children increased during the period between the last 2 national sur- automatically expire 5 years after publication unless reaffirmed, veys, despite improvements for older children.4 Because many children revised, or retired at or before that time. do not receive dental care at young ages, and risk factors for dental PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). caries are influenced by parenting practices, pediatricians have a Copyright © 2014 by the American Academy of Pediatrics unique opportunity to participate in the primary prevention of dental caries. Studies show that simple home and primary care setting pre- vention measures would save health care dollars.5 Development of dental caries requires 4 components: teeth, bacteria, carbohydrate exposure, and time. Once teeth emerge, they may become colonized with cariogenic bacteria. Thebacteriametabolizecarbohydrates
626 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org58 by guest on September 21, 2014 3 FROM THE AMERICAN ACADEMY OF PEDIATRICS and create acid as a byproduct. The acid reduces enamel demineralization; and white striations or opaque areas dissolves the mineral content of enamel (3) it inhibits bacterial metabolism and that are not readily noticeable to (demineralization) and, over time with acid production.9 The mechanisms of the casual observer. Although this repeated acid attacks, the enamel sur- fluoride are both topical and systemic, type of fluorosis is of no clinical face collapses and results in a cavity in but the topical effect is the most im- consequence, enamel fluorosis has the tooth. Protective factors that help to portant, especially over the life span.10 been increasing in frequency over remineralize enamel include exposing the last 2 decades to a rate of the teeth to fluoride, limiting the fre- RISK OF FLUOROSIS approximately 41% among adoles- quency of carbohydrate consumption, cents because fluoride sources are The only scientifically proven risk of choosing less cariogenic foods, prac- more widely available in varied fluoride use is the development of forms.17 Moderate and severe forms ticing good oral hygiene, receiving reg- fluorosis, which may occur with fluo- of enamel fluorosis are uncommon ular dental care, and delaying bacterial ride ingestion during tooth and bone in the United States but have both colonization. If carious lesions are iden- development. Fluorosis of permanent fi an aesthetic concern and potentially ti ed early, the process can be halted or teeth occurs when fluoride of sufficient a structural concern, with pitting, reversed by modifying the patient’sin- quantity for a sufficient period of time is dividual risk and protective factors. ingested during the time that tooth brittle incisal edges, and weakened Certain American Academy of Pediatrics enamel is being mineralized. Fluorosis groove anatomy in the permanent (AAP) publications (Oral Health Risk As- is the result of subsurface hypomin- 6-year molars. sessment Timing and Establishment of eralization and porosity between In 2001, the AAP endorsed the guidelines the Dental Home6 and Bright Futures: the developing enamel rods.11 This from the Centers for Disease Control Guidelines for Health Supervision of risk exists in children younger than and Prevention (CDC), “Recommen- Infants, Children, and Adolescents7)dis- 8years,andthemostsusceptible dations for Using Fluoride to Prevent cuss these concepts in greater depth period for permanent maxillary in- and Control Dental Caries in the United and provide targeted preventive an- cisor fluorosis is between 15 and States.”15 Dental and governmental ticipatory guidance. The Medical Ex- 30 months of age.12–14 The risk of organizations (American Dental Associ- penditure Panel Survey demonstrated fluorosis is influenced by both the ation [ADA], American Academy of Pe- that 89% of infants and 1-year-olds dose and frequency of exposure to diatric Dentistry, the Department of have office-based physician visits an- fluoride during tooth development.15 Health and Human Services, and the nually, compared with only 1.5% who Recent evidence also suggests that CDC) have more recently published have dental visits.8 For primary pre- individual susceptibility or resis- guidelines on the use of fluoride, but vention to be effective, it is imperative tance to fluorosis includes a ge- current AAP publications do not reflect that pediatricians be knowledgeable netic component.16 these newer evidence-based guidelines. about the process of dental caries, After 8 years of age, there is no further Table 1 provides a simple explanation fl prevention of the disease, and avail- risk of fluorosis (except for the third of uoride use for patients at low and fl able interventions, including uoride. molars) because the permanent tooth high risk of caries. Fluoride is available from many sources enamel is fully mineralized. The vast The present report has 2 goals: (1) to and is divided into 3 major categories: majority of enamel fluorosis is mild or assist pediatricians in using fluoride to tap water (and foods and beverages very mild and characterized by small achieve maximum protection against processed with fluoridated water), home administered, and professionally applied. There has been substantial public and TABLE 1 Summary of Fluoride Modalities for Low- and High-Risk Patients professional debate about fluoride, and Fluoride Modality Low Caries Risk High Caries Risk myriad information is available, often Toothpaste Starting at tooth emergence (smear of Starting at tooth emergence (smear of with confusing or conflicting messages. paste until age 3 y, then pea-sized) paste until age 3 y, then pea-sized) Fluoride varnish Every 3–6 mo starting at tooth Every 3–6 mo starting at tooth The widespread decline in dental caries emergence emergence in many developed countries, including Over-the-counter Not applicable Starting at age 6 y if the child can the United States, has been largely at- mouth rinse reliably swish and spit fl Community water Yes Yes tributable to the use of uoride. Fluoride fluoridation has 3 main mechanisms of action: (1) it Dietary fluoride Yes, if drinking water supply is not Yes, if drinking water supply is not promotes enamel remineralization; (2) it supplements fluoridated fluoridated
PEDIATRICS Volume 134, Number 3, September 2014 627 Downloaded from pediatrics.aappublications.org59 by guest on September 21, 2014 3 dental caries while minimizing the used. Ingestion of excessive amounts of dental health professionals in a variety likelihood of enamel fluorosis; and (2) fluoride can increase the risk of fluoro- of settings.23 The concentration of fluo- to clarify the advice that should be sis. This excess can be minimized by ride varnish is 22 600 ppm (2.26%), and given by pediatricians regarding fluo- limiting the amount of toothpaste used the active ingredient is sodium fluoride. ride in the primary care setting. and by storing toothpaste where young The unit dose packaging from most children cannot access it without pa- manufacturers provides a specificmea- CURRENT INFORMATION rental help. sured amount (0.25 mg, providing 5 mg fl fl REGARDING FLUORIDE USE IN Use of fluoride toothpaste should begin of uoride ion). The application of uo- CARIES PREVENTION with the eruption of the first tooth. ride varnish during an oral screening is fl of benefittochildren,especiallythose The following information aims to as- When uoride toothpaste is used for who may have limited access to dental sist pediatricians in achieving maxi- children younger than 3 years, it is care. Current American Academy of Pe- mum protection against dental caries recommended that the amount be diatric Dentistry recommendations for for their patients while minimizing the limited to a smear or grain of rice size children at high risk of caries is that likelihood of enamel fluorosis. Sources (about one-half of a pea). Once the child fluoride varnish be applied to their teeth of ingested fluoride include drinking has turned 3 years of age, a pea-sized 20,21 every 3 to 6 months.24 The 2013 ADA water, infant formula, fluoride tooth- amount of toothpaste should be used. guideline recommends application of paste, prescription fluoride supplements, Young children should not be given fluoride varnish at least every 6 months fluoride mouth rinses, professionally water to rinse after brushing because to both primary and permanent teeth in applied topical fluoride, and some their instinct is to swallow. Expec- those subjects at elevated caries risk.25 foods and beverages.18 torating without rinsing will both reduce the amount of fluoride swal- The US Preventive Services Task Force lowed and leave some fluoride in the recently published a new recommenda- Fluoride Toothpaste saliva, where it is available for uptake tion that primary care clinicians apply fl Fluoride toothpaste has consistently been by the dental plaque. Parents should uoride varnish to the primary teeth of proven to provide a caries-preventive be strongly advised to supervise their all infants and children starting at the effect for individuals of all ages.15,19 In child’s use of fluoride toothpaste to age of primary tooth eruption (B rec- fl 26 the United States, the uoride concen- avoid overuse or ingestion. ommendation). tration of over-the-counter toothpaste High-concentration toothpaste (5000 In most states, Medicaid will pay phy- ranges from 1000 to 1100 ppm. In some fl ppm) is available by prescription only. sicians for the application of uoride other countries, toothpastes containing fl The active ingredient in this toothpaste varnish. Information regarding uoride 1500 ppm of fluoride are available. A is sodium fluoride. This agent can be varnish application reimbursement and 1-inch (1-g) strip of toothpaste translates recommended for children 6 years and which states currently provide payment to 1 or 1.5 mg of fluoride, respectively. older and adolescents who are at high can be found on the AAP Web site Apea-sizedamountoftoothpasteis risk of caries and who are able to (http://www2.aap.org/oralhealth/docs/ approximately one-quarter of an inch. expectorate after brushing. Dentists OHReimbursementChart.pdf) and the Therefore, a pea-sized amount of tooth- may also prescribe this agent for Pew Charitable Trusts Web site (http:// paste containing 1000/1100 ppm of adolescents who are undergoing or- www.pewstates.org/research/analysis/ fluoride would have approximately 0.25 fl thodontic treatment, as they are at reimbursing-physicians-for- uoride- mg of fluoride, and the same amount of increased risk of caries during this varnish-85899377335). Because state reg- toothpaste containing 1500 ppm of fluo- fl time.22 ulations vary regarding whether uoride ride would have approximately 0.38 mg varnish must be applied within the fl fl of uoride. Most uoride toothpaste in context of a preventive care code, this fl Fluoride Varnish the United States contains sodium uo- information should be determined fl ride, sodium mono uorophosphate, or Fluoride varnish is a concentrated before billing. stannous fluoride as the active ingre- topical fluoride that is applied to the dient. Parents should supervise children teeth by using a small brush and sets Indications for Use younger than 8 years to ensure the on contact with saliva. Advantages of In the primary care setting, fluoride proper amount of toothpaste and effec- this modality are that it is well tolerated varnish should be applied to the teeth tive brushing technique. Children youn- by infants and young children, has of all infants and children at least once ger than 6 years are more likely to a prolonged therapeutic effect, and can every 6 months and preferably every 3 ingest some or all of the toothpaste be applied by both dental and non- months, starting when the first tooth
628 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org60 by guest on September 21, 2014 3 FROM THE AMERICAN ACADEMY OF PEDIATRICS erupts and until establishment of a den- beyond daily use of fluoridated toothpaste Guidelines for Use tal home. for children at low risk of caries.28,29 CDC recommendations regarding fluo- ride supplementation are provided in Instructions for Use Dietary Fluoride Supplements Table 2. Supplements can be prescribed Fluoride varnish must be applied by Dietary fluoride supplements should be in liquid or tablet form. Tablets are a dentist, dental auxiliary professional, considered for children living in com- preferable for children old enough to physician, nurse, or other health care munities in which the community water chew, because they gain an additional professional, depending on the prac- is not fluoridated or who drink well topical benefit to the teeth during the tice regulations in each state. It should water that does not contain fluoride.26 chewing process. Liquid supplements not be dispensed to families to apply at Because there are many sources of are recommended for younger children home. Application of fluoride varnish is fluoride in the water supply and in and should ideally be added to water most commonly performed at the time processed food, it is essential that all or put directly into the child’smouth. of a well-child visit. Teeth are dried with potential sources of fluoride be as- Addition of the fluoride supplement to a 2-inch gauze square, and the varnish sessed before prescribing a dietary milk or formula is not recommended is then painted onto all surfaces of the supplement, including consideration of because of the reduced absorption of teeth with a brush provided with the differing environmental exposures (eg, fluoride in the presence of calcium.31 varnish. Children are instructed to eat dual homes, child care). As a general The risk of mild fluorosis can be mini- soft foods and not to brush their teeth guideline, if the primary source of water mized by health care providers verify- on the evening after the varnish ap- is fluoridated tap or well water, the child ing that there are no other sources of plication to maximize the contact time will not require fluoride supplementa- fluoride exposure before prescribing of the varnish to the tooth. The following tion, even if he or she primarily drinks systemic fluoride supplements. day, they should resume brushing twice bottled water, because the teeth are fl daily with uoridated toothpaste. exposed to fluoride through cooking and Other Sources of Fluoride brushing. The risk of fluorosis is high if Fluoride is present in processed foods fluoride supplements are given to Over-the-Counter Fluoride Rinse and beverages and may be naturally achildconsumingfluoridated water.30 fl occurring in some areas of the coun- Over-the-counter uoride rinse pro- Information about the fluoridation levels try. The presence of fluoride in juices vides a lower concentration of sodium in many community water systems can fl and carbonated beverages does not uoride than toothpaste or varnish. be found on the CDC Web site entitled counteract the cariogenic nature of The concentration is most commonly My Water’sFluoride(http://apps.nccd. fl these beverages. 230 ppm (0.05% sodium uoride). Ex- cdc.gov/MWF/Index.asp). Not all commu- pert panels on this topic have con- nities report this information to the CDC; fl cluded that over-the-counter uoride therefore, it may be necessary to con- Reconstitution of Infant Formula rinses should not be recommended for tact the local water department to de- In a study of infant feeding practices, children younger than 6 years because termine the level of fluoride in the 70% to 75% of mothers who fed their of their limited ability to rinse and spit community water. Well water must be infants formula used tap water to and the risk of swallowing higher-than- tested for fluoride content before pre- reconstitute the powdered formula.32 fl 27 recommended levels of uoride. A scribing supplements; such testing is According to CDC data from 2012, teaspoon (5 mL) of over-the-counter available in most states through the approximately 67% of US households fl uoride rinse contains approximately state or county public health laboratory. using public water supplies received 1mgoffluoride. For children younger than 6 years, this type of rinse provides an additional, low-dose topical fluoride TABLE 2 Fluoride Supplementation Schedule for Children application that may assist in the pre- Age Fluoride Ion Level in Drinking Watera vention of enamel demineralization. <0.3 ppm 0.3–0.6 ppm >0.6 ppm However, the evidence for an anticaries Birth–6 mo None None None effect is limited. The daily use of a 6 mo–3y 0.25 mg/db None None 0.05% sodium fluoride rinse may be of 3–6y 0.50 mg/d 0.25 mg/d None benefitforchildrenolderthan6years 6–16 y 1.0 mg/d 0.50 mg/d None Source: Centers for Disease Control and Prevention.43 who are at high risk of dental caries; a 1.0 ppm = 1 mg/L. however, there is no additional benefit b 2.2 mg of sodium fluoride contains 1 mg of fluoride ion.
PEDIATRICS Volume 134, Number 3, September 2014 629 Downloaded from pediatrics.aappublications.org61 by guest on September 21, 2014 3 optimally fluoridated water (between or accessing the Web site My Water’s call the ethics of community water 0.7 and 1.2 ppm).33 Fluoride (http://apps.nccd.cdc.gov/MWF/ fluoridation into question, but courts Index.asp). have consistently held that it is legal and ADA Evidenced-Based Clinical appropriate for a community to adopt Recommendations Recommended Concentration a fluoridation program.37 Opponents In 2011, the ADA Council on Scientific Water fluoridation was initiated in the also express concern about the quality Affairs examined the existing evidence United States in the 1940s. In January and source of fluoride, claiming that fl and made 2 recommendations. The 2011, the US Department of Health and the additives ( uorosilicic acid, sodium first recommendation supported the Human Services proposed a change to fluoride, or sodium fluorosilicate), in continued use of optimally fluoridated lower the optimal fluoride level in their concentrated form, are highly toxic water to reconstitute powdered and drinking water. The proposed new rec- and are byproducts of the production of liquid infant formula, being cognizant ommendation is 0.7 mg of fluoride per phosphate fertilizer and may include of the small risk of fluorosis in per- liter of water to replace the previous other contaminants, such as arsenic. The fl manent teeth. The second recom- recommendation, which was based on quality and safety of uoride additives mendation stated that if there was climate and ranged from 0.7 mg/L in the are ensured by Standard 60 of the Na- concern about the risk of mild fluo- warmest climates to 1.2 mg/L in the tional Sanitation Foundation/American rosis, the formula could be recon- coldest climates.36 The change was National Standards Institute, a program stituted with bottled (nonfluoridated) recommended because recent studies commissioned by the Environmental water.18 It should be noted that most showed no variation in water con- Protection Agency (EPA), and testing has bottled water has suboptimal levels of sumption by young children based on been conducted to confirm that arsenic fluoride and that fluoride content is climate and to adjust for an overall in- or other substances are below the levels not listed unless it is added. crease in sources of fluoride (foods and allowed by the EPA.38 Finally, there have beverages processed with fluoridated been many unsubstantiated or disproven water and fluoridated mouth rinses claims that fluoride leads to kidney dis- Community Water Fluoridation and toothpastes) in the American diet. ease, bone cancer, and compromised IQ. Community water fluoridation is the More than 3000 studies or research practice of adding a small amount of Evidence Supporting Community papers have been published on the fluoride to the water supply. It has been Water Fluoridation subject of fluoride or fluoridation.39 Few heralded as 1 of the top 10 public health Despite overwhelming evidence sup- topics have been as thoroughly re- achievements of the 20th century by the porting the safety and preventive bene- searched, and the overwhelming weight CDC.34 Community water fluoridation is fits of fluoridated water, community of the evidence—in addition to 68 years a safe, efficient, and cost-effective way water fluoridation continues to be a of experience—supports the safety to prevent tooth decay and has been controversial and highly emotional issue. and effectiveness of this public health shown to reduce tooth decay by 29%.35 Opponents express a number of con- practice. It prevents tooth decay through the cerns, all of which have been addressed provision of low levels of fluoride ex- or disproven by validated research. The Naturally Occurring Fluoride in posure to the teeth over time and only scientifically documented adverse Drinking Water provides both topical and systemic effect of excess (nontoxic) exposure to The optimal fluoride level in drinking exposure. It is estimated that every fluoride is fluorosis. An increase in the water is 0.7 to 1.2 ppm, an amount that dollar invested in water fluoridation incidence of mild enamel fluorosis has been proven beneficial in reducing saves $38 in dental treatment costs among teenagers has been cited as tooth decay. Naturally occurring fluo- (http://www.cdc.gov/fluoridation/bene- areasontodiscontinuefluoridation, ride may be below or above these levels fits/). Currently, although more than even though this condition is cosmetic in some areas. Under the Safe Drinking 210 million Americans live in commu- with no detrimental health outcomes. Water Act (Pub L No. 93-523 [1974]), the nities with optimally fluoridated water, Recent opposition has sometimes cen- EPA requires notification by the water there are more than 70 million others tered on the question of who decides supplier if the fluoride level exceeds 2 with public water systems who do not whether to fluoridate (elected/public ppm. In areas where naturally occur- have access to fluoridated water.33 The officials or the voters), possibly reflect- ring fluoride levels in drinking water fluoridation status of a community ing a recent trend of distrust of the US exceed 2 ppm, people should consider water supply can be determined by government. Many opponents believe an alternative water source or home contacting the local water department fluoridation to be mass medication and water treatments to reduce the risk of
630 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org62 by guest on September 21, 2014 3 FROM THE AMERICAN ACADEMY OF PEDIATRICS
fluorosis in young children.40 Well wa- SUGGESTIONS FOR PEDIATRICIANS is a resource for oral health practice ter should be tested for the level of tools (http://www2.aap.org/oralhealth/ 1. Know how to assess caries risk. As fluoride; this testing is most commonly PracticeTools.html). recommended by the AAP’s Oral performed through the health de- Health Risk Assessment Timing and 4. Advocate for water fluoridation in partment. Establishment of the Dental Home6 the local community. Public water fl and Bright Futures: Guidelines for uoridation is an effective and safe Fluoride Toxicity Health Supervision of Infants, Chil- method of protecting the most vul- fl Toxic levels of uoride are possible, dren, and Adolescents,7 pediatri- nerable members of our population particularly in children, as a result of cians should perform oral health from dental caries. Pediatricians are fl ingesting large quantities of uoride risk assessments on all children at encouraged to advocate on behalf fl supplements. The toxic dose of ele- preventive visits beginning at 6 of public water uoridation in their fl fl mental uoride is 5 to 10 mg of uoride months of age. An oral health risk communities and states. For addi- 41 fl per kilogram of body weight. Lethal assessment tool has been developed tional information and water uori- doses in children have been calculated by the AAP/Bright Futures and en- dation facts and detailed questions to be between 8 and 16 mg/kg. When dorsed by the National Interprofes- and answers, see http://www.ada. prescribing sodium fluoride supple- sional Initiative on Oral Health. This org/sections/newsAndEvents/pdfs/ ments, it is recommended to limit the fl tool can be accessed at http://www2. uoridation_facts.pdf, http://www. quantity prescribed at one time to no fl aap.org/oralhealth/RiskAssessment- cdc.gov/ uoridation/, and http:// more than a 4-month supply. Parents Tool.html. There are currently no www.ilikemyteeth.org. should be advised to keep fluoride validated early childhood caries risk products out of the reach of young LEAD AUTHORS assessment tools. The aforemen- children and to supervise their use. Melinda B. Clark, MD, FAAP tioned tool is a guide to help clini- Rebecca L. Slayton, DDS, PhD cians counsel patients about oral Fluoride Removal Systems health and best identify risk. SECTION ON ORAL HEALTH EXECUTIVE There are a number of water treatment 2. Know how to assess a child’sexpo- COMMITTEE, 2011–2012 systems that are effective in the removal Adriana Segura, DDS, MS, Chairperson sure to fluoride and determine the of fluoride from water,42 including re- Suzanne Boulter, MD, FAAP verse osmosis and distillation. Parents need for topical or systemic supple- Melinda B. Clark, MD, FAAP 43 Rani Gereige, MD, FAAP should be counseled on the use of these ments. fl David Krol, MD, MPH, FAAP and activated alumina filters in the 3. Understand indications for uoride Wendy Mouradian, MD, FAAP home and, should they choose to use varnish and how to provide it. Fluo- Rocio Quinonez, DMD, MPH one that removes fluoride, the potential ride varnish can be a useful tool in Francisco Ramos-Gomez, DDS effect on their family’soralhealth. the prevention of early childhood car- Rebecca L. Slayton, DDS, PhD fi Martha Ann Keels, DDS, PhD, Immediate Past Commonly used home carbon lters ies. Additional training on oral Chairperson (eg, Brita [Brita LP, Oakland, California], screenings, fluoride varnish indica- PUR [Kaz USA, Incorporated, South- tions and application, and office LIAISONS borough, MA]) do not remove fluoride. implementation can be found in the Joseph Castellano, DDS – American Academy of These can be recommended for families Smiles for Life Curriculum Course 6: Pediatric Dentistry Sheila Strock, DMD, MPH – American Dental who are concerned about heavy metals Caries Risk Assessment, Fluoride Var- Association Liaison or other impurities in their home water nish and Counseling44 at www.smiles- supply but who wish to retain the forlifeoralhealth.org. In addition, the STAFF benefits of fluoridated water. AAP Children’sOralHealthWebsite Lauren Barone, MPH
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37. Burt B, Eklund S. Dentistry, Dental Practice, 40. ADA Division of Communications. For the 43. Centers for Disease Control and Prevention. and the Community. 6th ed. St. Louis, MO: dental patient: infants, formula and fluo- Recommendations for using fluoride to prevent Elsevier Saunders; 2005 ride. J Am Dent Assoc. 2007;138(1):132 and control dental caries in the United States. 38. Centers for Disease Control and Pre- 41. Shulman JD, Wells LM. Acute fluoride toxicity MMWR Recomm Rep. 2001;50(RR-14):1–42 vention. Community water fluoridation. En- from ingesting home-use dental products in www.cdc.gov/mmwr/preview/mmwrhtml/ gineering. water fluoridation additives fact children, birth to 6 years of age. J Public rr5014a1.htm. Accessed May 20, 2014 sheet. Available at: www.cdc.gov/fluoridation/ Health Dent. 1997;57(3):150–158 44. Douglass AB, Clark MB, Maier R, et al. factsheets/engineering/wfadditives.htm. 42. Van Winkle S, Levy SM, Kiritsy MC, Heilman Smiles for Life: A National Oral Health Accessed May 20, 2014 JR, Wefel JS, Marshall T. Water and formula Curriculum. 3rd ed. Leawood, KS: Society of 39. Cheng KK, Chalmers I, Sheldon TA. Adding fluoride concentrations: significance for Teachers of Family Medicine; 2010. Avail- fluoride to water supplies. BMJ. 2007;335 infants fed formula. Pediatr Dent. 1995;17 able at: www.smilesforlifeoralhealth.com. (7622):699–702 (4):305–310 Accessed May 20, 2014
PEDIATRICS Volume 134, Number 3, September 2014 633 Downloaded from pediatrics.aappublications.org65 by guest on September 21, 2014 3
Fluoride Use in Caries Prevention in the Primary Care Setting Melinda B. Clark, Rebecca L. Slayton and SECTION ON ORAL HEALTH Pediatrics 2014;134;626; originally published online August 25, 2014; DOI: 10.1542/peds.2014-1699 Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/134/3/626.full.ht ml References This article cites 31 articles, 13 of which can be accessed free at: http://pediatrics.aappublications.org/content/134/3/626.full.ht ml#ref-list-1 Citations This article has been cited by 1 HighWire-hosted articles: http://pediatrics.aappublications.org/content/134/3/626.full.ht ml#related-urls Post-Publication One P3R has been posted to this article: Peer Reviews (P3Rs) http://pediatrics.aappublications.org/cgi/eletters/134/3/626
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org66 by guest on September 21, 2014 3 AttachmentSPECIAL REPORT D Fluoridation Update 2014
MYRON ALLUKIAN JR., DDS, MPH CHLOE WONG, BA Dr. Allukian is a nationally recognized expert on fuoridation and dental public health. He is the president of the Massachusetts Coalition for Oral Health, and was the dental director for the City of Boston for 34 years. He is also a past president of the American Public Health Association and a member of the Institute of Medicine, National Academy of Sciences. Ms. Wong is a 2018 DMD candidate at Harvard School of Dental Medicine. Abstract not have fuoridation, and of these, 170,000 residents in 60 com- his year, more than 4 million people living in 140 munities do not have a public water supply. communities in Massachusetts will have the health In 2012, more than 210 million Americans—about 74.6 per- cent of the U.S. population on a public water supply—lived in and economic benefits of community water fluo- T fuoridated communities.1 (See Table 2.) The Healthy People ridation. However, Massachusetts is ranked only 37th in 2020 national objective is 79.6 percent. Although community water fuoridation has been used since 1945, it is still being chal- the country for fluoridation, with just 62 percent of the lenged in Massachusetts and nationwide. population on a public water supply living in fluoridated All of the 30 largest cities in the United States are fuori- dated with the exception of Portland, Oregon, where a public communities. Nationally, more than 210 million Ameri- vote in May 2013 defeated fuoridation 60.6 percent to 39.4 per- cans, about 74.6 percent of the U.S. population on a cent, although the Portland City Council supported it 5 to 0.2 In Massachusetts, fve of the 25 largest cities and towns are not community water supply, live in fluoridated communities. fuoridated. (See Table 3.) Although we have had community water fuoridation for nearly 70 years, fuoridation is still being challenged nationally Fluoridation Quality Award for Massachusetts and locally. In 2013, there were at least seven challenges in fuori- Fluoridation quality in Massachusetts has been very well main- dated communities in Massachusetts to discontinue fuoridation. tained, thanks to the state’s Departments of Public Health and Fortunately, these challenges did not prevail and these communi- Environmental Protection, as well as individual fuoridating water ties remain fuoridated. systems. Massachusetts is the only state to have received the State On a daily basis, the public is being misinformed about the Fluoridation Quality Award eight years in a row, beginning in 2006. safety and effectiveness of fuoridation by the Internet and social It is awarded by the U.S. Centers for Disease Control and Preven- media (see “Community Water Fluoridation on the Internet and tion (CDC), Association of State & Territorial Dental Directors, and Social Media” on page 32). Oral health professionals must do American Dental Association (ADA), and recognizes fuoridating a better job of educating their patients and community leaders systems that maintain fuoridation quality at optimal fuoride levels. whether they live in fuoridated or non-fuoridated communities. One of the goals of Healthy People 2020—the U.S. National Why So Many Fluoridation Challenges? Health Objectives to increase the quality and years of healthy life Fluoridation is being challenged in Massachusetts and nation- and to eliminate health disparities—is to have 79.6 percent of wide because a vocal minority has been adept at confusing and the U.S. population living in fuoridated communities by the year scaring the public on the safety and effectiveness of fuoridation. 2020. Unfortunately, it appears unlikely that Massachusetts will A recent study of the Internet and social media showed that a reach this goal. We can do better. major anti-fuoridation website had more than 133,000 hits per month—5 to 60 times the monthly traffc on leading pro- Introduction fuoridation websites.3 In Massachusetts, more than 4 million people, about 62 percent* The public is being misled daily on the Internet. Anti- of the population on a public water supply, live in 140 fuori- fuoridationists continue to mislead, misinform, and scare the pub- dated communities—ranking Massachusetts 37th in the nation. lic with poorly done studies or misinterpreted results of studies (See Table 1.) About 2.5 million residents in 150 communities do conducted by reputable individuals, organizations, or institutions.
*Based on the current number of people on public water supplies and the Massachusetts population estimate from the Massachusetts Department of Public Health 24 Journal of the Massachusetts Dental Society 67 3
Journal Summer 2014.indd 24 8/6/2014 3:37:36 PM Table 1. The 140 Massachusetts Public Water Systems Receiving Water Fluoridation Fluoridated at 1 ppm: 1 part fluoride per million parts water (PPM) or mg/L
Year of 2010 Year of 2010 Year of 2010 City/Town Start-Up Population City/Town Start-Up Population City/Town Start-Up Population
Acton 1970 21,924 Hull 1953 10,293 Somerset 1969 18,165 Acushnet 2007 10,303 Ipswich 1971 13,175 Somerville* 1978 75,754 Amherst 1987 37,819 Lawrence 1983 76,377 Southborough* 1996 9,767 Andover 1969 33,201 Lexington* 1978 31,394 Southbridge 1971 16,719 Aquinnah (WHA Part) 1996 80(E) Lincoln 1971 6,362 Stoneham* 1978 21,437 Arlington* 1978 42,844 Longmeadow 1989 15,784 Stoughton (Part)* 2004 26,962 Ashburnham 1957 6,081 Lowell 1982 106,519 Sturbridge 1990 9,268 Athol 1952 11,584 Lynn 1983 90,329 Sudbury 1960 17,659 Attleboro 1973 43,593 (Lynnfield Center) 1959 Swampscott* 1978 13,787 Bedford* 1978 13,320 Lynnfield (Fl)* 1972 11,596 Swansea 1969 15,865 Belchertown (Part) 1987 243(E) Malden* 1978 59,450 Taunton 1981 55,874 Belmont* 1978 24,729 Manchester by-the-Sea 1983 5,136 Templeton 1951 8,013 Berlin (Sp Mall Only) 1997 - Mansfield 1997 23,184 Tewksbury 1983 28,961 Beverly 1952 39,502 Marblehead* 1978 19,808 Topsfield 1953 6,085 Billerica 1992 40,243 Marlborough* 1982 38,499 Tyngsboro 1987 11,292 Boston* 1978 617,594 Medford* 1978 56,173 Wakefield* 1978 24,932 Bourne (Otis Ang) 1960 1,000(E) Medway 1953 12,752 Walpole 1977 24,070 Bridgewater (MCI) 1989 2,230 Melrose* 1978 26,983 Waltham* 1978 60,632 Brookline* 1978 58,732 Middleton 1951 8,987 Watertown (Fl)* 1971 31,915 Burlington 1993 24,498 Millis 1983 7,891 Wayland 2000 12,994 Cambridge (Fl)* 1974 105,162 Milton* 1978 27,003 Wenham 1967 4,875 Canton* 1978 21,561 Nahant* 1978 3,410 Wellesley* 1987 27,982 Charlton** 150(E) Natick 1997 33,006 Westborough 1974 18,272 Charlton (Part) 1996 150(E) New Bedford 2007 95,072 Westfield (White Oak Sh)** - Chelsea* 1978 35,177 Needham (Fl)* 1971 28,886 Westford 1994 21,951 Cohasset 1956 7,542 Newbury (Part) 1969 1,000(E) Westminster 1968 7,277 Concord 1970 17,668 Newburyport 1969 17,416 West Newbury 1969 4,235 Danvers 1951 26,493 Newton (Fl)* 1963 85,146 Weston (Fl)* 1973 11,261 Dartmouth (Part) 2007 34,032 Norfolk (Part) 1977 40(E) Westport (Part) 1975 1,000(E) Dedham* 1977 24,729 North Andover 1975 28,352 Westwood* 1977 14,618 Dighton (Part) 1971 2,200(E) North Attleboro 2002 28,712 Weymouth 1972 53,743 Dover (Part) 1997 159(E) Northborough* 2001 14,155 Wilmington (Part)* 2009 1,000(E) Dracut 1982 29,457 North Reading 1971 14,892 Winchester (Fl)* 1956 21,374 Dudley (Part)** 45(E) Norwood* 1978 28,602 Winthrop* 1978 17,497 Duxbury 1987 15,059 Oak Bluffs 1991 4,527 Woburn* 1978/2008 38,120 Essex 1970 3,504 Orange (Part) 1975 120(E) Worcester (Part) 1995 250(E) Everett* 1978 41,667 Oxford 1987 13,709 Fall River 1973 88,857 Peabody* 1983 51,251 Total Population 4,049,549 Fitchburg 1975 40,318 Pelham (Part) 1987 309(E) Natural & Adjusted Framingham (Fl)* 1970 68,318 Pembroke 1969 17,837 Franklin 1970 31,635 Plainville (Part) * Members of the Massachusetts Water Resources Freetown*** 1978/2007 5,000(E) Quincy* 1978 92,271 Authority (MWRA) fluoridated in 1978 (old MDC) Gardner 1987 20,228 Reading* 1970 24,747 ** Naturally fluoridated at 0.7 or higher ppm. Gloucester 1981 28,789 Revere* 1978 51,755 *** Public water system that began receiving fluoridated water in two different years Groveland 1995 6,459 Rockport (Part Natural) 1984 6,952 (Part) - Communities partially fluoridated. Check with Hamilton 1956 7,764 Royalston (Part) (Sric)** 400(E) local water department/board of health. Hardwick-EHS** 150(E) Rutland 1985 7,973 (Fl) - Fluoridating prior to MDC Haverhill 1971 60,879 Salem 1952 41,340 (E) - Estimated population served Prepared by: Massachusetts Department of Public Hingham 1953 22,157 Saugus* 1978 26,628 Health—Office of Oral Health Holden 1995 17,346 Scituate 1954 18,133 For additional information, email Oral.Health@state. Holliston 1970 13,547 Seekonk 1952 13,722 ma.us or go to www.mass.gov/dph/oralhealth. Holyoke 1970 39,880 Sharon 1953 17,612 Updated January 2014 Hudson 1985 19,063 Shrewsbury 1953 35,608
Vol. 63/No. 2 Summer 2014 25 68 3
Journal Summer 2014.indd 25 8/6/2014 3:37:36 PM Table 2. Number of People Templeton Duxbury in the United States Who Live In Templeton, fuoridation was chal- In 2013, Duxbury Fluoride Choice, a in Fluoridated Communities, lenged four years in a row at town meet- residents group, proposed an article re- 1 1945–2012 ings, but the challenge was soundly de- questing the Selectmen to petition the feated each time. As a matter of fact, a state legislature to put the discontinua- Year Number of People dental hygienist who educated the com- tion of fuoridation up for a vote on the 1945 231,930 munity about the benefts of fuorida- 2014 election ballot. The Selectmen voted tion the frst two years was elected to unanimously to recommend approval of a 1950 1,578,578 the Templeton Board of Health in 2013. town meeting warrant to end fuoridation. 1955 26,278,820 At the third town meeting in May 2013, However, the Board of Health responded three warrants—to add a fuoride warn- to this action and the petition was defeated 1960 41,179,694 ing to water bills, to discontinue fuori- 89 to 16 at the 2013 annual town meet- 1965 58,369,355 dation, and to adopt a bylaw requiring ing. Again, it took an intense educational town meeting approval for community effort to show the community that the ar- 1970 83,725,771 water fuoridation—were all defeated by guments against fuoridation had no merit 1975 94,627,294 voice vote. This could not have been ac- or substance. complished without the dedication and 1980 106,170,149 hard work of well-intentioned dental and Wayland 1985 120,100,100 (estimate) health professionals who live or work in After much discussion at its September the community. 2013 meeting, the Wayland Board of 2008 195,545,109 Fluoridation was again brought Health voted to decrease the fuoride level 2010 204,283,554 up at town meetings in 2014, asking to 0.7 ppm—the recommended fuoride for a fluoridation warning to be sent level proposed in 2011 by the U.S. Depart- 2012 210,655,401 to all residents and to change state law ment of Health and Human Services—but so that fluoridation is decided by town it has not yet been fnalized. Table 3. Five of the 25 Most Highly meetings, not boards of health. The cur- Populated Massachusetts Cities and Towns That Are Not Fluoridated rent fluoridation law, which gives local 2014 boards of health authority to order fuori- By mid-2014, at least 11 fuoridated com- City/Town Population* dation, was based on the recommenda- munities have had their fuoridation status tion of a Special Legislative Commis- questioned or challenged: Amherst, Cam- Barnstable 45,167 sion on Dental Health supported by a bridge, Cohasset, Gloucester, Hingham, Brockton 94,316 comprehensive fact-finding report.4 In Hull, Longmeadow, Newburyport, Oak May 2014, the two warrants were de- Bluffs, Rockport, and Templeton. In the Chicopee 55,333 feated by margins of about 3 to 1 and town meetings in Longmeadow and Tem- Springfield 153,155 2.5 to 1. pleton, the communities voted to keep fuo- ridation. In the other nine communities, no Worcester 181,631 Lincoln action had been taken as of early August. Total 529,602 In 2013, a few Lincoln residents peti- tioned the Selectmen to include a war- Massachusetts Challenges *Population estimates from the 2010 U.S. Census Bureau rant for a public vote to discontinue flu- 2004–2012 oridation at their March town meeting. Between 2004 and 2012, a number of com- Health professionals, community leaders, Prior to the town meeting, a Lincoln munities in Massachusetts became partially and public health and dental communi- resident and Harvard Medical School or completely fuoridated. (See Table 5.) ties need to better educate patients and the professor wrote a guest commentary In 2007, New Bedford (population: public. for the Lincoln Journal stating that 95,072) implemented fuoridation after a fluoridation appears neither necessary communitywide vote. Although the pre- Massachusetts Challenges nor effective, is unsafe, and provides un- vious mayor supported fuoridation, the in 2013 and 2014 controlled drug delivery. Subsequently, new mayor initially opposed it. There was In 2013, fuoridation was challenged or the deans of Harvard Medical School, an intense educational effort so the com- questioned in at least seven Massachusetts Harvard School of Dental Medicine, munity would vote in their best interest. communities. (See Table 4.) In fve of these and Harvard School of Public Health In 2009, Amesbury (population: communities—Athol, Duxbury, Lincoln, signed a letter stating that fluoridation 16,535) discontinued fuoridation because Longmeadow, and Templeton—it was is a safe and effective public health mea- of problems, claiming they had diffculty soundly voted in town meetings to not sure for people of all ages. The majority processing the fuoride into the water sup- discontinue fuoridation. In each circum- voice vote at the Lincoln town meeting ply; no other fuoridated community has stance, it took an intense educational ef- was in favor of continuing fluoridation. experienced similar problems. fort to update the community on the most It took an intense educational effort to In 2011, Groveland (population: recent science and benefts of community update the community on the science, 6,530) had an election ballot to discontinue water fuoridation so they would vote in safety, and benefits of fluoridation and fuoridation, but it was soundly defeated— their best interest. to discredit the negative information. probably because one of the town’s den-
26 Journal of the Massachusetts Dental Society 69 3
Journal Summer 2014.indd 26 8/6/2014 3:37:36 PM Table 4. Contested Fluoridated Communities in Massachusetts, 2013 poor, rural communities, and some were conducted as far back as 19 years ago. Year Year City/Town Population* Result Also, the original study designs may not Fluoridated Contested have adequately controlled for intervening Athol 11,584 1952 2009 Town Meeting: Positive variables (e.g., parents’ education, socio- 2013 Town Meeting: Positive economic status, pollution) that could in- Duxbury 15,059 1985 2013 Town Meeting: Positive (89–16) fuence IQ level. These studies have been Lincoln 6,362 1971 2013 Town Meeting: Positive severely criticized. There have been two Longmeadow 15,784 1989 2013 Town Meeting: Positive formal reviews—one that delineates the Scituate 18,133 1954 2013 Board of Health: Positive weaknesses in these studies7 and another Templeton 8,013 1951 2011 Town Meeting: Positive (190–64) that concludes that the biological plausi- 2012 Town Meeting: Positive bility for a link between fuoridated water 2013 Town Meeting: Positive and IQ has not been established.8 Wayland 12,994 2000 2013 Board of Health: The anti-fuoridationists have used Reduce F Concentration (3–1) this paper worldwide to convince the pub- Total 87,929 lic that fuoridation at the recommended level negatively affects IQ. No credible *Population estimates from the 2010 U.S. Census Bureau study conducted in the United States has confrmed this fnding. In fact, a reputable Table 5. Newly Fluoridated Communities 2004–2012 study showed that fuoridation had no Year City/Town Population Status neurotoxic effect or signifcant health ef- Fluoridated fect on rats even at levels up to 230 times Stoughton 29,962 2004 Partial the recommended concentration,9 and an New Bedford 95,072 2007 Complete earlier study showed that fuoride causes Dartmouth 34,032 2007 Partial no harm to children.10 Freetown 5,000 (estimate) 2007 Partial Interestingly, the mean fuoride level Woburn 20,615 (estimate) 1978 Partial through MWRA of controls (areas with low fuoride concen- 38,120 2008 Complete tration) in the Chinese studies was 0.7 ppm, Wilmington 1,000 (estimate) 2009 Partial which is the new proposed recommended Total 203,186 fuoride level in the United States. Thus, their data can be interpreted such that Source: Massachusetts Department of Public Health—Office of Oral Health those living in a community at the recom- tists regularly educated his patients about that the recommended fuoride level is be- mended fuoride level (0.7 ppm) will have fuoridation (Dr. David Archibald to me, ing lowered because fuoride is potentially a higher IQ, which is the opposite of what personal communication, Spring 2011). dangerous, which is not true. the authors of this study and anti-fuorida- In 2012, the Mansfeld (population: The previous recommended fuoride tionists are claiming. In a media statement, 23,284) Board of Health requested an up- level had ranged from 0.7 to 1.2 ppm de- the authors of this meta-analysis said: date on fuoridation information and con- pending on the mean annual temperature tinued to fuoridate. of the community over a fve-year period. “These results do not allow us to make However, recent studies demonstrate that any judgment regarding possible levels of New Proposed Fluoride Level water ingestion is the same regardless of risk at levels of exposure typical for water In 2011, the U.S. Department of Health climate temperatures, and thus this range fuoridation in the [United States]. On the and Human Services (DHHS) proposed a was eliminated and the recommended level other hand, neither can it be concluded new recommended fuoride level, 0.7 ppm, is a single number.5 that no risk is present. We therefore rec- for fuoridating communities. At a 2011 ommend further research . . .”11 press conference held in conjunction with Anti-Fluoridation Activities the Environmental Protection Agency In their efforts to convince the public Lancet Neurology Article (EPA), the EPA announced that it would that fuoridation is a health hazard, anti- In February 2014, the article “Neuro- study the maximum contaminant fuo- fuoridationists have relied on question- behavioural Effects of Developmental Tox- ride level in naturally fuoridated com- able studies and articles to back up their icity” by Grandjean and Landrigan was munities, which at that time was 4 ppm. claims. Here are the major studies/articles published in Lancet Neurology.12 This ar- This created a lot of confusion, and anti- they use to misinform the public: ticle quoted the Harvard IQ study—which fuoridationists used this confusion to Grandjean co-authored—and included scare the public against fuoridation. Harvard IQ Studies fuoride in a list of fve toxic chemicals As of August 1, 2014, the new rec- A 2012 paper, which was a meta-analysis that may have a neurotoxic effect on the ommended fuoride level of 0.7 ppm for of 27 cross-sectional studies in naturally world population, especially in developed community water fuoridation has not high-fuoridated communities in China, countries. been fnalized by the DHHS. Once fnal- Iran, and Mongolia, stated a possible re- Surprisingly, the only study the au- ized, it is expected that anti-fuoridation- lationship between fuoridation and lower thors reference to support the addition ists will attempt to convince the public IQ.6 However, these studies were done in of fuoride to their list is Choi et al.’s
Vol. 63/No. 2 Summer 2014 27 70 3
Journal Summer 2014.indd 27 8/6/2014 3:37:36 PM IQ study,6 of which Grandjean is a co- spective study conducted by a doctoral the word “mild” to scare and confuse the author—making this a self-citation. (The student showing an increase in the risk of public and will show pictures of severe many faws in the IQ study are described osteosarcoma in boys living in fuoridated fuorosis. in the previous section.) It’s interesting to communities. At the time the article was Parents who feed infants dry infant note that Dr. Landrigan, the Lancet Neu- written, the study had not yet been pub- formula reconstituted with fuoridated rology article’s co-author, was quoted in lished or submitted for peer review, and water and who are concerned about the the Atlantic as saying:13 had several limitations as stated by the possibility of their child having very mild author. This exploratory analysis was sub- fuorosis should contact their child’s pe- “Fluoride is very much a two-edged sequently published, and again the author diatrician. Concerned parents can use bot- sword. . . . There’s no question that, delineated the study’s limitations. tled water to reconstitute infant formula at low doses, it’s benefcial. . . . The doctoral student’s analysis was or use fuoridated water intermittently. I think it’s very good to have part of a larger, ongoing, prospective study [fuoride] in toothpaste.” done by Harvard researchers in the same Dental Fluorosis department with bone assays of a much Fluorosis may occur in non-fuoridated New Neurotoxicity Studies larger sample size. The larger, comprehen- or fuoridated communities. Very mild or Two recent comprehensive, prospective, sive study showed no relationship between questionable fuorosis is not new, and may and well-controlled studies have shown no fuoride and osteosarcoma.16 In spite of be due to various sources of fuoride, such neurotoxic effect from fuoridation. One, that conclusion, anti-fuoridationists con- as toothpaste consumption or unnecessary which was reported at the 2014 American tinue to claim that fuoridation causes fuoride prescriptions. Cases of mild or Association for Dental Research meeting, cancer or osteosarcoma. moderate fuorosis in the United States usu- showed no signifcant impact between ally only occur when very young children prenatal or postnatal fuoride and cogni- National Research Council Report ingest large amounts of fuoride toothpaste tive development in the frst three years of In 2006, the Report of the National Re- over long periods in non-fuoridated or life for children (E. Angeles Martinez-Mier search Council, Fluoride in Drinking Wa- fuoridated communities, or when children to me, personal communication, April 24, ter: A Scientifc Review of EPA’s Standards, consume prescribed systemic fuoride pills 2014). The other found that fuoridation recommended lowering the maximum or drops despite living in fuoridated com- is not neurotoxic for either children or permissible fuoridated levels (4 ppm) of munities.19 It is recommended that children adults, and does not have a negative effect naturally fuoridated communities.17 The age 6 years and younger have supervision on IQ.14 report’s appendix included a number of when brushing their teeth, use no more allegations against fuoride from known than a pea-size amount of fuoride tooth- Osteosarcoma Study anti-fuoridationists. Although Study paste, and use toothpaste that has no more In 2005, the article “Fluoridation, Can- Committee Chair John Doull, MD, PhD, than 1,000 ppm of fuoride.20 cer: Did Researchers Ask the Right Ques- has stated multiple times that this report is The anti-fuoridationists continue to tions?” was published in the Wall Street not applicable to community water fuori- alarm the public by saying that 41 percent Journal.15 The article reported on a retro- dation in the United States, anti-fuorida- of American adolescents have some form tionists continue to use it to scare or mis- of fuorosis and by implying that it is due lead the public about water fuoridation. to fuoridation. There are no known, cred- To quote Dr. Doull: ible negative health effects of fuoride at Helpful Resources the recommended levels. Anti-fuorida- on Fluoridation “I do not believe there is any valid sci- tionists do not say that very mild fuorosis, Massachusetts Department of Public entifc reason for fearing adverse health which may occur, is usually imperceptible Health: www.mass.gov/eohhs/gov/ conditions from the consumption of to the untrained eye and is not noticeable departments/dph/programs/ water fuoridated at the optimal level.”17 by most individuals unless they are trained community-health/oral-health/ oral health professionals. community-water-fuoridation.html Infant Formula and Fluoridation As part of their campaign, anti-fuo- U.S. Centers for Disease Control Thanks to anti-fuoridationists, there is ridationsists will show pictures of severe and Prevention (available in confusion in the public’s eye regarding fuorosis, which includes brown mottling multiple languages): the use of fuoridated water to reconsti- and pitting of teeth, without indicating the www.cdc.gov/fuoridation/ tute dry infant formula. As a result, New level of fuorosis. Severe fuorosis occurs in Hampshire passed a law in 2012 requiring countries like India, where water is natu- American Dental Association: fuoridated communities to warn residents rally fuoridated at over 10 to 20 ppm, and http://www.ada.org/en/public- that infants under six months old who ex- is very rare in the United States, as we do programs/advocating-for-the-public/ clusively consume infant formula recon- not have any communities that are natu- fuoride-and-fuoridation/ stituted with fuoridated water may have rally fuoridated at such high levels. ada-fuoridation-resources an increased chance for dental fuorosis. American Academy of Pediatrics: The CDC information on infant formula Cancer 18 www.ilikemyteeth.org/fuoridation/ uses the term “mild fuorosis,” which is For years, anti-fuoridationists have al- usually imperceptible to the untrained eye, leged that cancer is a possible side effect of whereas the anti-fuoridationists eliminated fuoridation. However, there are no repu-
28 Journal of the Massachusetts Dental Society 71 3
Journal Summer 2014.indd 28 8/6/2014 3:37:36 PM table studies that demonstrate this.21 As a • Have familiarity with credible 4. More dentists, dental hygienists, and result of anti-fuoridation activity in 2011, studies that reaffrm the science other oral health advocates need to the California State Carcinogen Identif- behind fuoridation become involved in their local com- cation Committee held hearings to deter- • Educate their patients, the public, munities, local boards of health, and mine whether fuoride should be added to and community leaders continually local school boards. Out of the 351 the list of known carcinogens under the about the safety and benefts of boards of health in Massachusetts, Safe Drinking Water and Toxic Enforce- fuoridation—it is a never-ending only four oral health professionals ment Act. After lengthy hearings and data professional responsibility serve on their local board. We can, and we must, do better to educate our collection, they determined that fuoride 2. In fuoridated communities, dental patients and the public on the safety is not a carcinogen. The Food and Drug providers—including dental stu- and effcacy of fuoridation. ■ Administration (FDA) in their hearing tes- dents—should tell each of their pa- timony stated, “We have determined that tients during a treatment plan and/or Acknowledgments the available data do not support a con- recall visit: “We are fortunate to live in The authors would like to thank Lynn clusion that exposure to fuoride in FDA- a fuoridated community, as we have Ann Bethel, RDH, MPH, former director regulated products causes cancer.”22 less tooth decay, infections, and lower of the Offce of Oral Health, Massachu- dental bills.” The ADA, American Medical Associa- setts Department of Public Health, for her 3. In non-fuoridated communities, tion, American Public Health Association, assistance. dental providers—including dental American Cancer Society, National Cancer students—should tell each of their Institute, and more than 100 other credible patients during a treatment plan and/ References national and international organizations all 1. U.S. Centers for Disease Control and Preven- or recall visit: “It is unfortunate that tion. 2013. 2012 water fluoridation statistics. recognize the public health benefts of fuo- your/our community is not fuoridated, Available from: http://www.cdc.gov/fluoridation/ ridation to prevent tooth decay. as you/we have more unnecessary statistics/2012stats.htm. tooth decay, infections, and higher 2. City of Portland, Oregon. Auditor’s Office. 2013 referendum petition log: measure 26-151. Recommendations dental bills.” Available from: http://www.portlandonline. 1. Oral health professionals must: Dental schools and dental hy- com/auditor/index.cfm?c=62541&a=451949. • Be aware of the anti-fuoridation giene schools should also have their Accessed 9 Apr 2014. arguments and tactics used to students educate their patients about 3. Mertz A, Allukian M. Social media and com- munity water fluoridation. J Mass Dental Soc. scare or mislead the public fuoridation in this manner. 2014;63(2):32-36. Continued on page 30
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Vol. 63/No. 2 Summer 2014 29 72 3
Journal Summer 2014.indd 29 8/6/2014 3:37:36 PM 4. Commonwealth of Massachusetts. Report of 11. Choi AL, Grandjean P. Statement on fluoride 19. Pendrys DG. Risk of enamel fluorosis in non- the Special Commission of the condition of paper. 2012. Available from: http://www.hsph. fluoridated and optimally fluoridated popula- dental health and of measures to eliminate harvard.edu/news/files/2012/07/Media- tions: considerations for the dental professional. dental decay including fluoridation of commu- Statement_Fluoride-9-12-12-Revised2.pdf. JADA. 2000;131(6):746-755. nity water supplies. December 1967. House- 12. Grandjean P, Landrigan PJ. Neurobehavioural 20. Pendrys DG, Haugejorgen O, Bardsen A, Wang No. 3902. Boston (MA): Wright & Porter effects of developmental toxicity. Lancet Neurol. NJ, Gustavsen F. The risk of enamel fluorosis Printing Co. Legislative Printers; 1968. 2014;13(3):330-338. and caries among Norwegian children: implica- 5. Department of Health and Human Services. 13. Hamblin J. The toxins that threaten our tions for Norway and the United States. JADA. Proposed HHS recommendation for fluoride brains. The Atlantic. 2014 Mar 18. Available 2010;14(4):401-414. concentration in drinking water for prevention from: http://www.theatlantic.com/features/ 21. Public Health England (PHE). Water fluoridation: of dental caries. Available from: http://www. archive/2014/03/the-toxins-that-threaten-our- health monitoring report for England 2014— gpo.gov/fdsys/pkg/FR-2011-01-13/pdf/ brains/284466/. executive summary. London (UK): Wellington 2011-637.pdf. 14. Broadbent J, Thomson WM, Ramrakha S, Mof- House; 2013. 6. Choi, AL, Sun G, Zhang Y, Grandjean P. De- fitt T, Zeng J, Foster LA, Poulton R. Community 22. Woodcock J, Landa M. Selection of fluoride velopmental fluoride neurotoxicity: a system- water fluoridation and intelligence: prospective for consideration for listing by the carcinogen atic review and meta-analysis. Environ Health study in New Zealand. Am J Public Health. Perspect. 2012;120(10):1362. identification committee. 2011. Available from: 20 Dec 2013. E-View Ahead of Print. Available http://oehha.ca.gov/prop65/public_meetings/ 7. Bazian Ltd. Independent critical appraisal of from: http://ajph.aphapublications.org/doi/ CIC101211/comments/FDACDER_fl.pdf. selected studies reporting an association abs/10.2105/AJPH.2013.301857. Accessed 9 Apr 2014. between fluoride in drinking water and IQ: 15. Begley S. Fluoridation, cancer: Did researchers a report for South Central Strategic Health ask the right questions? Wall Street Journal. Authority. London (UK): Bazian Ltd.; 2009. 2005 Jul 22: B1. 8. Scientific Committee on Health and Environ- 16. Kim FM, Hayes C, Williams PL, Whitford GM, MORE INFORMATION mental Risks (SCHER). Critical review of any Joshipura KJ, Hoover RN, Anderson HC. An new evidence on the hazard profile, health assessment of bone fluoride and osteosarcoma. Additional effects, and human exposure to fluoride and J Dental Res. 2011;90(10):1171-1176. information the fluoridating agents of drinking water. 2011. 17. National Research Council. National Research Available from: http://ec.europa.eu/health/ on the status of Council Report of the National Academy of scientific_committees/environmental_risks/docs/ fluoridation in Science’s report. Fluoride in drinking water: a scher_o_122.pdf. scientific review of EPA’s standards. 2006. Massachusetts, 9. Whitford GM, Whitford JL, Hobbs SH. Available from: http://www.nap.edu/ including a map of fluoridated Appetitive-based learning in rats: lack of effect openbook.php?record_id=11571. of chronic exposure to fluoride. Neurotoxicol- communities, is availabled in the ogy and Teratology. 2009;31(4):210-215. 18. U.S. Centers for Disease Control and Preven- tion. Community water fluoridation. Overview: extended version of this article in the 10. Shannon FT, Fergusson DM, Horwood LJ. infant formula and fluorosis. Available from: digital JOURNAL. Read it at www.mass Exposure to fluoridated public water supplies http://www.cdc.gov/fluoridation/safety/ and child health and behavior. New Zealand dental.org/publications/journal. infant_formula.htm. Med J. 1986;99(803):416-418.
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Journal Summer 2014.indd 30 8/6/2014 3:37:37 PM Figure 1. Fluoridation Map of Massachusetts Communities Figure Massachusetts CommunitiesFluoridation Map of 1. 1
Journal of the Massachusetts Dental Society 74 3 Table 6. National and International Organizations that Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay Academy of Dentistry International British Fluoridation Society Academy of General Dentistry Canadian Dental Association Academy for Sports Dentistry Canadian Dental Hygienists Association Alzheimer’s Association Canadian Medical Association America’s Health Insurance Plans Canadian Nurses Association American Academy of Family Physicians Canadian Paediatric Society American Academy of Nurse Practitioners Canadian Public Health Association American Academy of Oral and Maxillofacial Pathology Child Welfare League of America American Academy of Orthopaedic Surgeons Children’s Dental Health Project American Academy of Pediatrics Chocolate Manufacturers Association American Academy of Pediatric Dentistry Consumer Federation of America American Academy of Periodontology Council of State and Territorial Epidemiologists American Academy of Physician Assistants Delta Dental Plans Association American Association for Community Dental Programs FDI World Dental Federation American Association for Dental Research Federation of American Hospitals American Association for Health Education Hispanic Dental Association American Association for the Advancement of Science Indian Dental Association (U.S.A.) American Association of Endodontists Institute of Medicine American Association of Oral and Maxillofacial Surgeons International Association for Dental Research American Association of Orthodontists International Association for Orthodontics American Association of Public Health Dentistry International College of Dentists American Association of Women Dentists March of Dimes Birth Defects Foundation American Cancer Society National Association of Community Health Centers American College of Dentists National Association of County and City Health Officials American College of Physicians–American Society National Association of Dental Assistants of Internal Medicine National Association of Local Boards of Health American College of Preventive Medicine National Association of Social Workers American College of Prosthodontists National Confectioners Association American Council on Science and Health National Dental Assistants Association American Dental Assistants Association National Dental Association American Dental Association National Dental Hygienists’ Association American Dental Education Association National Down Syndrome Congress American Dental Hygienists’ Association National Down Syndrome Society American Dietetic Association National Foundation of Dentistry for the Handicapped American Federation of Labor and Congress National Head Start Association of Industrial Organizations National Health Law Program American Hospital Association National Healthy Mothers, Healthy Babies Coalition American Legislative Exchange Council Oral Health America American Medical Association Robert Wood Johnson Foundation American Nurses Association Society for Public Health Education American Osteopathic Association Society of American Indian Dentists American Pharmacists Association Special Care Dentistry American Public Health Association Academy of Dentistry for Persons with Disabilities American School Health Association American Association of Hospital Dentists American Society for Clinical Nutrition American Society for Geriatric Dentistry American Society for Nutritional Sciences The Children’s Health Fund American Student Dental Association The Dental Health Foundation (of California) American Water Works Association U.S. Department of Defense Association for Academic Health Centers U.S. Department of Veterans Affairs Association of American Medical Colleges U.S. Public Health Service Association of Clinicians for the Underserved Health Resources and Services Administration (HRSA) Association of Maternal and Child Health Programs Centers for Disease Control and Prevention (CDC) Association of State and Territorial Dental Directors National Institute of Dental and Craniofacial Research (NIDCR) Association of State and Territorial Health Officials World Federation of Orthodontists Association of State and Territorial Public Health Nutrition Directors World Health Organization Permission is hereby granted to reproduce and distribute this Fluoridation Facts Compendium in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 312-440-2879
Vol. 63/No. 2 Summer 2014 75 3 76 3 Attachment E ! Oral!Health! A!healthy!mouth!is!more!than!just!a!nice!smile.!Good!oral!health!helps!us!eat,!drink,!speak!and! express!emotions.!Even!though!diseases!of!the!mouth!(oral!diseases)!are!nearly!100!percent! preventable,!Colorado!kids!miss!about!7.8!million!school!hours!every!year!because!of!mouth! pain.!!Safe,!inexpensive!preventive!measures!such!as!water!fluoridation!and!dental!sealants!are! available,!but!many!children!lack!access!to!these!interventions,!and!cavities!are!still!the!most! common!chronic!disease!of!childhood.!Nationally,!the!number!of!children!between!ages!2!and!5! with!cavities!has!increased!15!percent!during!the!past!decade.!An!estimated!42!percent!of! workingKage!Coloradans!and!approximately!67!percent!of!Colorado!adults!over!65!years!of!age! !do!not!have!dental!benefits.!Access!to!regular!preventive!care!and!interventions!is!necessary!to! help!Colorado!win!the!battle!against!oral!diseases.!! ! Why!is!this!important?! Oral!health!is!an!essential!part!of!overall!health.!Everyone!can!be!affected!by!oral!disease,!even!people!without! teeth.!Poor!oral!health!can!escalate!into!far!more!serious!problems!later!in!life.!CavityKcausing!bacteria!can!be! passed!from!parents!to!children.!Children!without!dental!sealants!(protective!tooth!coatings)!and!communities! without!fluoride!in!their!water!are!unprotected!and!at!a!higher!risk!of!tooth!decay!at!every!age.! Periodontal!disease!(gum!disease)!is!linked!to!cardiovascular!disease,!diabetes!and!stroke.!Medications!to! control!chronic!diseases!can!cause!a!dry!mouth,!leading!to!fastKgrowing!cavities.!People!with!illKfitting!dentures! are!at!risk!for!nutritional!deficiencies!and!poor!quality!of!life.! Where!are!we?!
! Where!do!we!want!to!be?! By!2016,! 75!percent!or!more!of!the!population!served!by!community!water!systems!receives!optimally! fluoridated!water;! increase!to!4.6!percent!the!percentage!of!Colorado!infants!who!get!a!dental!checkup!by!age!1!year;! Increase!to!39!percent!the!percentage!of!Colorado!thirdKgraders!who!have!dental!sealants!on! permanent!molars.! !! !! ! Clean!Air!!!!!Clean!Water!!!!!Infectious!Disease!Prevention!!!!!Injury!Prevention! Mental!Health!and!Substance!Abuse!!!!!Obesity!!!!!Oral!Health!!!!!Safe!Food!!!!!Tobacco!!!!!Unintended!Pregnancy! ! !!!! ! 77 3 ! What!is!being!done?! Most!oral!diseases!in!Colorado!can!be!eliminated!if!the!Colorado!Department!of!Public!Health!and!Environment! supports!the!development!of!more!schoolKbased!sealant!programs!in!targeted!schools!and!varnish!for! young!children;! provides!fluoridation!support!and!training!locally!to!water!engineers;! provides!fluoridation!equipment!grants;! works!with!local!public!health!agencies!to!provide!oral!health!promotion!and!linkages!to!dental! providers;! streamlines!data!collection!(surveillance)!for!youth!and!adults!to!identify!areas!of!need!and!focus! resources!to!address!disparities;! works!with!partners!to!align!oral!health!projects!across!the!state!to!improve!oral!health!literacy!and! link!resources!to!underserved!populations.! ! HighFrisk!groups! Colorado!kids!miss!an!estimated!900,000!days!of!school!every!year!due!to!mouth!pain.!This!increases!the! achievement!gap,!making!it!difficult!for!children!to!perform!as!well!as!their!peers.!This!nationwide!trend,! reported!in!2007!by!the!Department!of!Health!and!Human!Services,!is!especially!true!for!poor!and!minority! children.!They!continue!to!suffer!the!most!from!dental!decay!and!receive!less!preventive!care,!such!as!tooth! sealants!(Colorado!Oral!Health!Survey).!! ! Almost!a!third!of!Hispanic!children!in!Colorado!have!untreated!cavities!and/or!decay.!Hispanic!adults!have! similar!rates.!More!than!40!percent!of!AfricanKAmerican!adults!have!lost!five!or!more!teeth!because!of!cavities.!! ! LowKincome!children!who!visit!a!dentist!by!age!1!year!are!less!likely!to!get!cavities!and!need!expensive!dental! procedures!or!emergency!room!visits.!Regular!dental!visits!reduce!average!dental!costs!by!nearly!40!percent.! ! ! Underlying!causes! Poor!oral!health!has!many!causes.!At!the!start!of!life,!parents!can!transmit!cavityKcausing!bacteria!directly!to! Krisk!children!use!their!Medicaid!and/or!CHP+!dental!benefits.! Approximately!42!percent!of!Colorado!adults!do!not!have!dental!insurance;!an!estimated!67!percent!of! Coloradans!over!age!65!do!not.!Many!areas!of!Colorado!do!not!have!dentists!or!hygienists,!and!many!of!them! do!not!accept!Medicaid!or!CHP+!or!treat!young!children.!Finally,!oral!health!care!must!be!part!of!primary! prevention!for!every!Coloradan.!The!following!factors!impact!oral!health:! Our$mouths:!Bacteria,!acidKbase!level!(pH),!saliva!flow,!chronic!diseases!affecting!the!mouth! Our$children:!Regular!dental!exams,!brushing!twice!a!day!with!fluoridated!toothpaste!and!flossing! Our$families:! !nutrition,!daily!habits,!income!and!composition! Our$community:!Community!water!fluoridation,!resources!for!oral!health,!providers!who!accept!new! patients!and!patients!with!Medicaid!or!CHP+,!social!and!cultural!attitudes!toward!oral!care! ! ! ! ! !
!! !! ! Clean!Air!!!!!Clean!Water!!!!!Infectious!Disease!Prevention!!!!!Injury!Prevention! Mental!Health!and!Substance!Abuse!!!!!Obesity!!!!!Oral!Health!!!!!Safe!Food!!!!!Tobacco!!!!!Unintended!Pregnancy! ! !!!! ! 78 3 Attachment F June 2012
NSF Fact Sheet on Fluoridation Chemicals
Introduction This fact sheet provides information on the fluoride containing water treatment additives that NSF has tested and certified to NSF/ANSI Standard 60: Drinking Water Chemicals - Health Effects. According to the latest Association of State Drinking Water Administrators Survey on State Adoption of NSF/ANSI Standards 60 and 61, 47 U.S. states require that chemicals used in treating potable water must meet Standard 60 requirements. If you have questions on your state's requirements, or how the NSF/ANSI Standard 60 certified products are used in your state, you should contact your state's Drinking Water Administrator.
Water fluoridation is the practice of adjusting the fluoride content of drinking water. Fluoride is added to water for the public health benefit of preventing and reducing tooth decay and improving the health of the community. The U.S. Centers for Disease Control and Prevention is a reliable source of information on this important public health intervention. For more information please visit www.cdc.gov/fluoridation/.
NSF certifies three basic products in the fluoridation category:
1. Fluorosilicic Acid (aka Fluosilicic Acid or Hydrofluosilicic Acid). 2. Sodium Fluorosilicate (aka Sodium Silicofluoride). 3. Sodium Fluoride.
NSF Standard 60 Products used for drinking water treatment are evaluated to the criteria specified in NSF/ANSI Standard 60. This standard was developed by an NSF-led consortium, including the American Water Works Association (AWWA), the American Water Works Association Research Foundation (AWWARF), the Association of State Drinking Water Administrators (ASDWA), and the Conference of State Health and Environmental Managers (COSHEM). This group developed NSF/ANSI Standard 60, at the request of the US EPA Office of Water, in 1988. The NSF Joint Committee on Drinking Water Additives continues to review and maintain the standard annually. This committee consists of representatives from the original stakeholder groups as well as other regulatory, water utility and product manufacturer representatives.
Standard 60 was developed to establish minimum requirements for the control of potential adverse human health effects from products added directly to water during its treatment, storage and distribution. The standard requires a full formulation disclosure of each chemical ingredient in a product. The standard requires testing of the treatment chemical products, typically by dosing these in water at 10 times the maximum use level, so that trace levels of contaminants can be detected. An evaluation of test results is required to determine if any contaminant concentrations have the potential to cause adverse human health effects. The standard sets criteria for the establishment of single product allowable concentrations (SPAC) of each respective contaminant. For contaminants regulated by the U.S. EPA, this SPAC has a default level not to exceed ten-percent of the regulatory level to provide protection for the consumer in the unlikely event of multiple sources of the contaminant, unless a lower or higher number of sources can be specifically identified. To address the health effects of the substances, Standard 60 requires that if EPA has not established a Maximum Contaminant Level for a substance, then the toxicology review and evaluation procedures contained in Annex A of NSF 60 should be followed to establish a SPAC. 79 3 June 2012
All the three NSF certified products, Sodium fluoride, Sodium fluorosilicate, and Fluorosilicic acid, all dissociate to sodium, fluoride, and silicate ions in water. Sodium, fluoride, and silicates all have toxicological studies, fluoride has an MCL regulatory level, and silicate has an NSF maximum usage assessment. Fluorosilicates do not need a toxicological assessment specifically for the fluorosilicate ion, because it does not exist in potable water at the fluoride concentrations and pH levels of public drinking water (Finney WF, Wilson E, Callender A, Morris MD, Beck LW. Reexamination of hexafluorosilicate hydrolysis by fluoride NMR and pH measurement. Environ Sci Technol 2006;40:8:2572).
NSF Certification NSF also developed a testing and certification program for these products, so that individual U.S. states and waterworks facilities would have a mechanism to determine which products were appropriate for use. The certification program requires annual unannounced inspections of production and distribution facilities to ensure that the products are properly formulated, packaged, and transported with safe guards against potential contamination. NSF also requires annual testing and toxicological evaluation of each NSF Certified product. NSF Certified products have the NSF Mark, the maximum use level, lot number or date code and production location on the product packaging or documentation shipped with the product.
The use of this standard and the associated certification program have yielded benefits in ensuring that drinking water additives meet the health objectives that provide the basis for public health protection. NSF maintains listings of companies that manufacture and distribute treatment products at www.nsf.org. These listings are updated daily and list the products at their allowable maximum use levels. In recognition of the important safeguards that NSF Standard 60 provides to public drinking water supplies, 47 U.S. States and 9 Canadian Provinces and Territories require drinking water treatment chemicals to comply with the requirements of the standard.
Treatment products that are used for fluoridation are addressed in Section 7 of NSF/ANSI Standard 60. The products are allowed to be used up to concentrations that result in a maximum use level of 1.2 mg/L fluoride ion in water. The NSF standard requires that the treatment products added to drinking water, as well as any impurities in the products, are supported by toxicological evaluation. The following text explains the rationale for the allowable levels established in the standard for 1) fluoride, 2) silicate, and 3) other potential contaminants that may be associated with fluoridation chemicals.
Fluoride NSF/ANSI Standard 60 requires, when available, that the US EPA regulated maximum contaminant level (MCL) be used to determine the acceptable level for a contaminant. The EPA MCL for fluoride ion in water is 4 mg/L. The NSF Standard 60 single product allowable concentration (SPAC) for fluoride ion in drinking water from NSF Certified treatment products is 1.2 mg/L, or less than one-third of the EPA’s MCL. Based on this the allowable maximum use level (MUL) for the NSF Certified fluoridation products are:
1. Fluorosilicic Acid: 6 mg/L. 2. Sodium Fluorosilicate: 2 mg/L. 3. Sodium Fluoride: 2.3 mg/L.
2 80 3 June 2012
Silicate There is no EPA MCL for silicate in drinking water. When an MCL does not exist for a contaminant, NSF/ANSI Standard 60 provides criteria to conduct a toxicological risk assessment of the contaminant and the development of a SPAC. NSF has established a SPAC for silicate at 16 mg/L. A fluorosilicate product, applied at its maximum use level, results in silicate drinking water levels that are substantially below the 16 mg/L SPAC established by NSF. For example, a sodium fluorosilicate product dosed at a concentration into drinking water that would provide the maximum concentration of fluoride allowed (1.2mg/L) would only contribute 0.8 mg/L of silicate – or 5 percent of the SPAC allowed by NSF 60.
Potential Contaminants The NSF toxicology review for a chemical product considers all chemical ingredients in the product as well as the manufacturing process, processing aids, and other factors that have an impact on the contaminants present in the finished drinking water. This formulation review identifies all the contaminants that need to be analyzed in testing the product. For example, fluosilicic acid is produced by adding sulfuric acid to phosphate ore. This is typically done during the production of phosphate additives for agricultural fertilizers. The manufacturing process is documented by an NSF inspector at an initial audit of the manufacturing site and during each annual unannounced inspection of the facility. The manufacturing process, ingredients, and potential contaminants are reviewed annually by NSF toxicologists, and the product is tested for any potential contaminants. A minimum test battery for all fluoridation products includes metals of toxicological concern and radionuclides.
Many drinking water treatment additives, including fluoridation products, are transported in bulk via tanker trucks to terminals where they are transferred to rail cars, shipped to distant locations or transferred into tanker trucks, and then delivered to the water treatment plants. These tanker trucks, transfer terminals and rail cars are potential sources of contamination. Therefore, NSF also inspects, samples, tests, and certifies products at rail transfer and storage depots. It is always important to verify that the location of the product distributor (the company that delivers the product to the water utility) matches that in the official NSF Listing for the product (available at www.nsf.org).
NSF has compiled data on the level of contaminants found in all fluoridation products that have applied for, or have been listed by, NSF. The statistical results in Table 1 (attached) include the test results for these products, as well as the annual monitoring tests from the period 2000 to 2006. This includes 245 separate samples analyzed during this time period. The concentrations reported represent contaminant levels that would be expected when the product is dosed into water at the Maximum Use Level (MUL). Lower product doses would produce proportionately lower contaminant concentrations (e.g. a 0.6 mg/L fluoride dose would produce one half the contaminant concentrations listed in Table 1.)
Table 1 documents that there is no contamination of drinking water from the fluoridation products NSF has tested and certified. NSF issued previous summaries of contaminant levels in fluoridation products for earlier reporting periods in 1999 and 2003. While some contaminant levels in those earlier periods were slightly higher than the current data for certain contaminants, there has not been a single fluoride product tested since the initiation of the program in 1988 with a contaminant concentration in excess of its corresponding SPAC. The documented reduction of impurities for this most current time period is due, at least in part, to the
3 81 3 June 2012 effectiveness of NSF/ANSI Standard 60 and the NSF certification program for drinking water treatment additives, and demonstrates the effectiveness of the program. The reduction in impurities is further attested to by an article in the Journal of the American Water Works Association entitled, “Trace Contaminants in Water Treatment Chemicals.”1
Arsenic The results in Table 1 indicate that the most common contaminant detected in these products is arsenic, which is detected in 43% of the product samples. This means that levels of arsenic in 57% of the samples were non-detectable. Products were tested at 10 times their maximum use level in accordance to NSF/ANSI Standard 60. All detections were at levels below the Single Product Allowable Concentration (SPAC) if the product is added to drinking water at (or below) its maximum use level. The SPAC, as defined in NSF/ANSI Standard 60, is one tenth of the US EPA’s MCL. The current MCL for arsenic is 10 ppb, the highest detection of arsenic from a fluoridation chemical was 0.6 ppb (shown on Table 1), and the average concentration was 0.12 ppb. The highest concentration of 0.6 ppb was detected because NSF/ANSI standard 60 requires testing the chemical at 10 times its maximum use level to detect these trace levels of contaminants.
Figure A
Arsenic was not detectable in Arsenic was detected in 43% of 57% of Fluoride products. 57% 43% fluoride products; however, the highest recorded arsenic level was 6% of the US EPA MCL.
Arsenic Results (% of USEPA MCL) 100%
75%
50%
25%
6.0 2.9 1.2 0% Max. Ave. Ave. of All Result Detection Samples
1 Brown, R., et al., “Trace Contaminants in Water Treatment Chemicals: Sources and Fate.” Journal of the American Water Works Association 2004: 96:12:111. 4 82 3 June 2012
Copper The second most common contaminant found, and on a much less frequent basis, is copper, and 97% of all samples tested had no detectable levels of copper. The average concentration of copper has been 0.02 ppb with 2.6 ppb being the highest concentration detected. This is well below the 130 ppb SPAC requirement of NSF 60.
Figure B
97% of Fluoride products 97% 3% of Fluoride products contain do not contain measurable measurable Copper, but the amounts of Copper. 3% highest level recorded was only 0.2% of the USEPA Action Level.
Copper Results (% of USEPA AL) 5%
4%
3%
2%
1%
0.2 0.05 0.002 0% Max. Ave. Ave. of All Result Detection Samples
5 83 3 June 2012
Lead The third most common contaminant found is lead. It occurs on a much less frequent basis, and 98% of all samples tested had no detectable levels of lead. The average concentration of lead has been 0.005 ppb with 0.6 ppb being the highest concentration detected. This is well below the 1.5 ppb SPAC requirement of NSF 60.
Figure C
98% of Fluoride products 98% 2% of Fluoride products contain do not contain measurable measurable Lead, but the highest amounts of Lead. 2% level recorded was only 4% of the USEPA Action Level of 15ppb.
Lead Results (% of USEPA AL)
100%
75%
50%
25%
4.0 1.6 0.03 0% Max. Ave. Ave. of All Result Detection Samples
6 84 3 June 2012
Radionuclides Fluoridation products are also tested for radionuclides. All samples tested have not had any detectable levels of alpha or beta radiation.
Summary In summary, the majority of fluoridation products as a class, based on NSF test results, do not add measurable amounts of arsenic, lead, other heavy metals, or radionuclide contamination to drinking water.
Additional information on fluoridation of drinking water can be found on the following web sites:
American Water Works Association (AWWA) Fluoridation Chemical Standards http://www.awwa.org/Bookstore/producttopicsresults.cfm?MetaDataID=121&navItemNumber=5093
American Water Works Association (AWWA) position http://www.awwa.org/Advocacy/pressroom/fluoride.cfm
American Dental Association (ADA) http://www.ada.org/public/topics/fluoride/index.asp
U.S. Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/fluoridation
Table 1 Percentage Mean Mean Maximum NSF/ANSI US EPA of Samples Contaminant Contaminant Contaminant Standard 60 Maximum with Concentration Concentration Concentration Single Contaminant Detectable in all samples in detectable in detectable Product or Action Levels (ppb) samples (ppb) samples (ppb) Allowable Level Concentration Antimony 0% ND ND ND 0.6 6 Arsenic 43% 0.12 0.29 0.6 1 10 Barium <1% 0.001 0.3 0.3 200 2000 Beryllium 0% ND ND ND 0.4 4 Cadmium 1% 0.001 0.08 0.12 0.5 5 Chromium <1% 0.001 0.15 0.2 10 100 Copper 3% 0.02 0.68 2.6 130 1300 Lead 2% 0.005 0.24 0.6 1.5 15 Mercury <1% 0.0002 0.04 0.04 0.2 2 Radionuclides 0% ND ND ND 1.5 15 – alpha pCi/L Radionuclides 0% ND ND ND 0.4 4 – beta mrem/yr Selenium <1% 0.016 1.95 3.2 5 50 Thallium <1% 0.0003 0.04 0.06 0.2 2
7 85 3 June 2012
Abbreviations used in this Fact Sheet
ANSI – American National Standards Institute
AWWA – American Water Works Association
AWWARF – American Water Works Association Research Foundation
ASDWA – Association of State Drinking Water Administrators
COSHEM – Conference of State Health and Environmental Managers
EPA – U.S. Environmental Protection Agency
MCL – maximum contaminant level mrem/yr – millirems per year – measurement of radiation exposure dose
MUL – Maximum use level
NSF – NSF International (formerly the National Sanitation Foundation) ppb – parts per billion
PCi/L – pico curies per liter – concentration of radioactivity
SPAC – Single Product Allowable Concentration
8 86 3 Attachment G MYTHS & FACTS Responses to common anti-fluoride claims
For more information, go to iLikeMyTeeth.org
THE TRUTH 23321(17¶6&/$,0 THE FACTS
Fluoride occurs naturally in ³)OXRULGHGRHVQ¶WEHlong in x ,W¶VDOUHDG\WKHUH)OXRULGHH[LVWVQDWXUDOO\LQYLUWXDOO\ all water supplies and even in water, though rarely at the GULQNLQJZDWHU´ various brands of bottled water. If the people making this statement truly believed it, they optimal level to protect teeth. would no longer drink water or grape juice ² or eat shellfish, meat, cheese or other foods that contain trace levels of fluoride. x :KDW¶VDWLVVXHLVWKHDPRXQWRIIOXRULGHLQZDWHU There are proven benefits for public health that come from having the optimal level of fluoride in the water ² just enough to protect our teeth. In 2011, federal health officials offered a new recommended optimal level for water fluoridation: 0.7 parts per millLRQ7KDW¶VRXUJRDO getting just enough to help all of us keep our teeth longer.
87 Numerous scientific studies ³$GGLQJIOXRULGHLVlike forcing x Fluoride is not a medication. It is a mineral, and when present at the right level, fluoride and reviews have recognized SHRSOHWRWDNHPHGLFDWLRQ´ in drinking water has two beneficial effects: preventing tooth decay and contributing to fluoride as an important healthy bones. nutrient for strong healthy x 86FRXUWGHFLVLRQVKDYHUHMHFWHGWKHDUJXPHQWWKDWIOXRULGHLVD³PHGLFDWLRQ´WKDW teeth. should not be allowed in water. The American Journal of Public Health summarized one RIWKHVHUXOLQJVQRWLQJWKDW³IOXRULGHLVQRWDPHGLFDWLRQEXWUDWKHUDQXWULHQWIRXQG naturally in some DUHDVEXWGHILFLHQWLQRWKHUV´ x There are several examples of how everyday products are fortified to enhance the health of Americans ² iodine is added to salt, folic acid is added to breads and cereals, and Vitamin D is added to milk.
Fluoridation is one of the ³2XUFLW\FRXQFLOcan save x A community that stops fluoridating or never starts this process will find that local most cost-effective health money by ending fluoridation residents end up spending more money on decay-related dental problems. Evidence strategies ever devised. RIRXUZDWHUV\VWHP´ shows that for most cities, every $1 invested in fluoridation saves $38 in unnecessary treatment costs. x A Texas study confirmed that the state saved $24 per child, per year in Medicaid expenditures because of the cavities that were prevented by drinking fluoridated water. x A Colorado study showed that water fluoridation saved the state nearly $149 million by 3 avoiding unnecessary treatment costs. The study found that the average savings were roughly $61 per person. THE TRUTH 23321(17¶6&/$,0 THE FACTS
Fluoridation is a public health ³)OXRULGDWLRQLVDµIUHHGRP of x )OXRULGHH[LVWVQDWXUDOO\LQYLUWXDOO\DOOZDWHUVXSSOLHVVRLWLVQ¶WDTXHVWLRQRIFKRRVLQJWR measure where a modest FKRLFH¶LVVXH3HRSOHVKRXOG get fluoride. The only question is whether people receive the optimal OHYHOWKDW¶V documented to prevent tooth decay. community-wide investment choose when or if they have benefits everyone. IOXRULGHLQWKHLUZDWHU´ x It is completely unrealistic to make water fluoridation a person-by-person or household- by-household choice. The cost efficiency comes from a public water system fluoridating its entire supply.
x Maintaining an optimal amount of fluoride in water is based on the principle that decisions about public health should be based on what is healthy for the entire community, not based on a handful of individuals whose extreme fears are not backed by the scientific evidence.
x Fluoridation is not a local issue. Every taxpayer in a state pays the price for the dental problems that result from tooth decay. A New York study found that Medicaid enrollees in counties where fluoridation was rare needed 33% more fillings, root canals, and extractions than those in counties where fluoridated water was much more prevalent.
Fluoridated water is the best ³:HDOUHDG\FDQJHWIOXRULGHLQ x The benefits from water fluoridation build on those from fluoride in toothpaste. Studies ZD\WRSURWHFWHYHU\RQH¶V WRRWKSDVWHVRZHGRQ¶WQHHGLW conducted in communities that fluoridated water in the years after fluoride toothpastes 88 teeth from decay. in our drinking wDWHU´ were common have shown a lower rate of tooth decay than communities without fluoridated water.
x The CDC reviewed this question in January 2011. After looking at all the ways we might get fluoride ² including fluoride toothpaste ² the CDC recommended that communities fluoridate water at 0.7 parts per million. Any less than that puts the health of our teeth at risk.
x Fluoride toothpaste alone is insufficient, which is why pediatricians and dentists often prescribe fluoride tablets to children living in non-fluoridated areas.
Very high fluoride ³)OXRULGDWLRQFDXVHVIOXRURVLV x Nearly all cases of fluorosis are mild ² faint, white specks on teeth ² that are usually so concentrations can lead to a and fluorosis can make teeth subtle that only a dentist will notice this condition. Mild fluorosis does not cause pain, and it does not affect the health or function of the teeth. condition called fluorosis. EURZQDQGSLWWHG´ Nearly all fluorosis in the U.S. x The pictures of dark pitted teeth that anti-fluoride opponents circulate show severe cases and of fluorosis, a condition that is almost unheard of in the U.S. Many of these photos are is mild. This condition does from India, and the reason is natural fluoride levels over there that are dramatically not cause pain, and does not ³2QH-third of all children now higher than the level used in the U.S. to fluoridate public water systems. Common sense affect the health or function of KDYHGHQWDOIOXRURVLV´ shows how misleading these photos are. Think about it: Do one-WKLUGRIWKHFKLOGUHQ¶V the teeth. teeth yoXVHHORRNEURZQDQGSLWWHG"1RWKH\GRQ¶W
3 x In 2011, the CDC proposed a new level for fluoridation ² 0.7 parts per million ² that is expected to reduce the likelihood of fluorosis while continuing to protect teeth from decay. THE TRUTH 23321(17¶6&/$,0 THE FACTS
Getting enough fluoride in ³)OXRULGHLVHVSHFLDOO\WR[LFIRU x According to the American Academy of Pediatrics optimal exposure to fluoride is childhood will determine the VPDOOFKLOGUHQ´ important to infants and children. The use of fluoride for the prevention and control of strength of our teeth over our cavities is documented to be both safe and effective. entire lifetime. x Medical experts disagree with opponents¶³WR[LF´ claim. In fact, the American Academy of Family Physicians recommends that parents consider using dietary fluoride supplements for children at risk of tooth decay from ages 6 months through age 16 if their ZDWHULVQ¶WIOXRULGDWHG x Children who drink fluoridated water as their teeth grow will have stronger, more decay resistant teeth over their lifetime. A 2010 study confirmed that the fluoridated water consumed as a young child makes the loss of teeth (due to decay) less likely 40 or 50 years later when that child is a middle-aged adult.
Children who swallow ³7heUH¶VDZDUQLQJODEHO on x The warning label simply reflects the fact that toothpaste contains roughly 1,000 times as toothpaste are at increased fluoride toothpaste that tells much fluoride per milligram as fluoridated water. Even so, the American Dental risk of mild fluorosis. \RXWRµNHHSRXWRIUHDFKRI Association (ADA) believes the warning label on toothpaste exaggerates the potential for negative health effects from swallowing toothpaste. The ADA has stated WKDW³DFKLOG FKLOGUHQ¶, so fluoride in water could not absorb enough fluoride from toothpaste to cause a serious probOHP´DQGQRWHG must also be a danger´
89 WKDWIOXRULGHWRRWKSDVWHKDVDQ³H[FHOOHQWVDIHW\UHFRUG´ x 0DQ\YLWDPLQODEHOVKDYHVLPLODUVWDWHPHQWV ³.HHSRXWRIUHDFKRIFKLOGUHQ´7KDW¶V because almost anything has the potential for negative health effects if LW¶Vleft in the hands of unsupervised, young children.
Fluoridated water is safe for ³)OXRULGDWHGZDWHULVQ¶WVDIHto x The evidence does not support what anti-fluoride groups say. The American Dental babies and young children. use IRUEDELHV´ Association cRQFOXGHVWKDW³LWLVVDIHWRXVHIOXRULGDWHGZDWHUWRPL[LQIDQWIRUPXOD´DQG encourages parents to discuss any questions they may have with their dentists and pediatricians. x Although using fluoridated water to prepare infant formula might increase the chance that a child develops dental fluorosis, nearly all instances of fluorosis are a mild, cosmetic condition. Fluorosis nearly always appears as very faint white streaks on teeth. The effect is usually so subtle that only a dentist would notice it during an examination. Mild fluorosis does not cause pain, nor does it affect the function or health of the teeth. x A 2010 study examined the issue of fluorosis and infant formula, and reached the FRQFOXVLRQWKDW³QRJHQHUal recommendations to avoid use of fluoridated water in UHFRQVWLWXWLQJLQIDQWIRUPXODDUHZDUUDQWHG´ 7KHUHVHDUFKHUVH[DPLQHGWKHFRQGLWLRQ¶V LPSDFWRQFKLOGUHQDQGFRQFOXGHGWKDW³the effect of mild fluorosis was not adverse and
3 could even be favorable.´ THE TRUTH 23321(17¶6&/$,0 THE FACTS
Although AmericaQV¶WHHWK ³7RRWKGHFD\LVQRORQJHUD x Tooth decay is the most common chronic health problem affecting children in the U.S. It are healthier than they were SUREOHPLQWKH8QLWHG6WDWHV´ is five times more common than asthma. Tooth decay causes problems that often last several decades ago, many long into adulthood ² DIIHFWLQJNLGV¶ability to sleep, speak, learn and grow into happy and healthy adults. people still suffer from decay ² and the overall impact it x California children missed 874,000 school days in 2007 due to toothaches or other dental problems. A study of seven Minneapolis-St. Paul hospitals showed that patients made has on their lives. over 10,000 trips to the emergency room because of dental health issues, costing more than $4.7 million.
x PRRUGHQWDOKHDOWKZRUVHQVDSHUVRQ¶VIXWXre job prospects. A 2008 study showed that people who are missing front teeth are viewed as less intelligent and less desirable by employers.
x In a 2008 study of the armed forces, 52% of new recruits were categorized as Class 3 in ³GHQWDOUHDGLQHVV´ ² meaning they had oral health problems that needed urgent attention and would delay overseas deployment.
Leading health and medical ³)OXRULGDWLRQFDXVHVFDQFHU x The American Academy of Family Physicians, the Institute of Medicine and many other organizations agree: and other serious health respected authorities endorse water fluoridation as safe. The Centers for Disease 90 fluoridated water is both SUREOHPV´ Control and Prevention reports that ³panels of experts from different health and scientific fields have provided strong evidence that water fluoridation is safe and effective.´ safe and effective. x More than 3,200 studies or reports had been published on the subject of fluoridation. Even after all of this research, the best that anti-fluoride groups can do is to claim that fluoride could cause or may cause one harm or another. The\FDQ¶WJREH\RQG speculating because the HYLGHQFHVLPSO\GRHVQ¶WEDFNXSWKHir fears.
x The cancer claim is part of a pattern. According to the American Council on Science and +HDOWK³+LVWRULFDOO\DQWL-fluoride activists have claimed, with no evidence, that IOXRULGDWLRQFDXVHVHYHU\WKLQJIURPFDQFHUWRPHQWDOGLVHDVH´
x A 2011 Harvard study found no link between fluoride and bone cancer. This study reviewed KXQGUHGVRIERQHVDPSOHVDQGWKHVWXG\¶VGHVLJQZDVDSSURYHGE\WKH National Cancer Institute. The study is significant because the National Research Council reported that if there were any type of cancer that fluoride might possibly be linked to, it would probably be bone cancer (because fluoride is drawn to bones). The fact that this Harvard study found no link to bone cancer strengthens confidence that fluoride is unlikely to cause any form of cancer.
x Opponents usually cite a 2006 study when they raise the cancer issue, but they omit the fact that the author of this study called it ³DQH[SORUDWRU\DQDO\VLV´,QVWHDGRI measuring 3 the actual fluoride level in bone, this 2006 study relied on estimates of fluoride exposures that could not be confirmed, which undermines the reliability of the data. THE TRUTH 23321(17¶6&/$,0 THE FACTS
Dozens of studies and more ³)OXRULGDWLRQGRHVQ¶WUHGXFH x An independent panel of 15 experts from the fields of science and public health reviewed than 60 years of experience WRRWKGHFD\´ numerous studies and concluded that fluoridation reduces tooth decay by 29%. have repeatedly shown that x An analysis of two similarly sized, adjacent communities in Arkansas showed that fluoridation reduces tooth residents without access to fluoridated water had twice as many cavities as those with decay. access to fluoridated water. x In New York, Medicaid recipients in less fluoridated counties required 33% more treatments for tooth decay than those in counties where fluoridated water was prevalent. x The benefits of fluoridation are long-lasting. A recent study found young children who consumed fluoridated water were still benefiting from this as adults in their 40s or 50s. x The Centers for Disease Control and Prevention recognizes fOXRULGDWLRQ¶VHIIHFWLYHQHVV in preventing tooth decay and citHGIOXRULGDWHGGULQNLQJZDWHUDVRQHRIWKH³JUHDW SXEOLFKHDOWKDFKLHYHPHQWVRIWKHWKFHQWXU\´ x The European Archives of Pediatric Dentistry published an analysis of 59 studies that conclXGHGWKDW³ZDWHUIOXRULGDWLRQLVHIIHFWLYHDWUHGXFLQJ>GHFD\@LQFKLOGUHQDQGDGXOWV´
Millions of people living in ³(XURSHDQFRXQWULHVKDYH x EuropHKDVXVHGDYDULHW\RISURJUDPVWRSURYLGHIOXRULGH¶VEHQHILWVWRWKHSXEOLFWater 91 Europe are receiving the rejected fluoridation, so why fluoridation is one of these programs. Fluoridated water reaches 12 million Europeans, benefits of fluoride. should we fluoridate water?´ mostly residents of Great Britain, Ireland and Spain. Fluoridated milk programs reach millions of additional Europeans, mostly in Eastern Europe. x Salt fluoridation is the most widely used approach in Europe. In fact, at least 70 million Europeans consume fluoridated salt, and this method of fluoridation reaches most of the population in Germany and Switzerland. These two countries have among the lowest rates of tooth decay in all of Europe. x Italy has not tried to create a national system of water fluoridation, but the main reasons are cultural and geological. First, many Italians regularly drink bottled water. Second, a number of areas in Italy have water supplies with natural fluoride levels that already reach the optimal level that prevents decay. x Technical challenges are a major reason wh\IOXRULGDWHGZDWHULVQ¶WZLGHVSUHDG in Europe. In France and Switzerland, for example, water fluoridation is logistically difficult because of the terrain and because there are tens of thousands of separate sources for drinking water. This is why Western Europe relies more on salt fluoridation, fluoride rinse programs and other means to get fluoride to the public. 3 THE TRUTH 23321(17¶6&/$,0 THE FACTS
Community water fluoridation ³7KHUHDUHVWDWHVZLWKDKLJK x Water fluoridation plays a critical role in decay prevention, but other factors also influence is proven to reduce decay, rate of water fluoridation that decay rates. Researchers often call WKHVHIDFWRUVDV³FRQIRXQGLQJIDFWRUV´ Someone EXWLWLVQ¶WWKHRQO\IDFWRUWKDW have higher decay rates than who ignores confounding factors is violating a key scientific principle. A SHUVRQ¶VLQFRPH level is a confounding factor in tooth decay because low-income Americans are more at affects the rate of tooth states where water fluoridation risk for decay than upper-income people. This makes sense because income status decay. is less common.´ shapes how often a person visits a dentist, their diet and nutrition, and other factors.
x Comparing different states based solely on fluoridation rates ignores key income differences. For example, West Virginia and Connecticut reach roughly the same percentage of their residents with fluoridated water ² 91 percent and 90 percent, respectively. Yet the percentage of West Virginians living below the poverty line is nearly double the percentage of those living in Connecticut. West Virginians are also more likely to get their drinking water from wells, which are not fluoridated to the optimal level.
x ,W¶VPLVOHDGLQJWRFRPSDUHVWDWHVZLWKRXWFRQVLGHULQJRWKHUFRQIRXQGLQJIDFWRUV$PXFK more reliable approach is to compare residents of the same state who share similar traits, such as income levels. A 2010 study of New York counties did just this and found that people living in areas with fluoridated water needed fewer fillings and other corrective dental treatments. 92
Community water fluoridation ³There are better ways of x $VWXG\RIIOXRULGDWLRQLQ&RORUDGRFRQFOXGHGWKDW³HYHQLQWKHFXUUHQWVLWXDWLRQRI is the most cost-effective way delivering fluoride than adding widespread use of fluoride toothpDVWH´ZDWHUIOXRULGDWLRQ³UHPDLQVHIIHFWLYHDQGFRVW VDYLQJ´DWSUHYHQWLQJFDYLWLHV to protect oral health. it to water.´ x Studies conducted in communities that fluoridated water in the years after fluoride toothpastes were widely used have shown a lower rate of tooth decay than communities without fluoridated water.
x The co-author of a 2010 study stated that research confirms the ³WKHPRVWHIIHFWLYH VRXUFHRIIOXRULGHWREHZDWHUIOXRULGDWLRQ´
x Water fluoridation is inexpensive to maintain and saves money down the road. The typical cost of fluoridating a local water system is between 40 cents and $2.70 per person, per year ² less than the cost of medium-sized latte from Starbucks.
x For low-income individuals who are at higher risk of dental problems, fluoride rinses are a costly expense, ZKLFKLVZK\WKHVHSURGXFWVDUHQRWWKH³HDV\´DQVZHUWKDWRSSRQHQWVRI fluoridation claim they are. 3 THE TRUTH 23321(17¶6&/$,0 THE FACTS
Water fluoridation has been ³7KH1DWLRQDO5HVHDUFK x The NRC raised the possibility of health concerns about areas of the U.S. where the one of the most thoroughly &RXQFLO¶V 2006 report said that natural fluoride levels in well water or aquifers are unusually high. These natural fluoride studied subjects, and the fluoride can have harmful levels are two to four times higher than the level used to fluoridate public water systems. evidence shows it is safe and HIIHFWV´ x The National Research Council itself explained that its report was not an evaluation of effective. the safety of water fluoridation. x The Centers for Disease Control and Prevention reviewed the NRC report and statHG³7KH report addresses the safety of high levels of fluoride in water that occur naturally, and does not TXHVWLRQWKHXVHRIORZHUOHYHOVRIIOXRULGHWRSUHYHQWWRRWKGHFD\´
Anti-fluoride groups cite ³6WXGLHVVKRZWKDWIOXRULGHLV x The foreign studies that anti-fluoride activists cite involved fluoride levels that were at PDQ\³VWXGLHV´WKDWZHUH linked to lower IQ scores in least double or triple the level used to fluoridate drinking water in the U.S. It is poorly designed, gathered FKLOGUHQ´ irresponsible to claim these studies have any real meaning for our situation in the U.S. unreliable data, and were not x British researchers who evaluated these studies from China and other countries found peer-reviewed by ³EDVLFHUURUV´7KHVHUHVHDUFKHUVSRLQWHGRXWthat the lower IQs could be traced to other independent scientists. factors, such as arsenic exposure, the burning of high-fluoride coal inside homes and the eating of contaminated grain. 93 Much of the fluoride used to ³)OXRULGHLVDE\-product from x Much of the fluoride used to fluoridate water is extracted from phosphate rock, and so is fluoridate public water the phosphate fertilizer phosphoric acid²an ingredient in Coke and Pepsi. After fluoride is extracted from systems is extracted from industry." phosphate rock, much of that rock is later used to create fertilizers that will enrich soil. Opponents use this message a lot, maybe because they want to create the false phosphate rock. impression that fluoride comes from fertilizer. x Corn produces several useful by-products, including corn oil, cornstarch and corn syrup. Fluoride is one example of many by-products that help to improve the quality of life or health.
A Summary of Key Sources:
1DWLRQDO5HVHDUFK&RXQFLO³(DUWK0DWHULDOVDQG+HDOWK 5HVHDUFK3ULRULWLHVIRU(DUWK6FLHQFHDQG3XEOLF+HDOWK´1DWLRQDO$FDGHPLHV3UHVV
5HDGH\Y6W/RXLV&RXQW\:DWHU&RVXSUDQRWHDWIRUWKHFRXUW¶VVWDWHPHQWWKDWLWFRXOGQRWDVVXPHWKDWWKHDGdition of 0.5 parts per million of fluoride to water that DOUHDG\FRQWDLQHGSDUWVSHUPLOOLRQZRXOGUHVXOWLQLQIULQJHPHQWRIDQ\FRQVWLWXWLRQDOULJKWV 5RHPHU5XWK³:DWHU)OXRULGDWLRQ3+5HVSRQVLELOLW\DQGWKH'HPRFUDWLF3URFHVV´ American Journal of Public Health. Vol. 55 (9), 1965. (2) Chapman v. City of Shreveport, supra note 25 at 146.
ADA Fluoridation Facts, 2005. http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf. 3 American Dental Association Website. www.ada.org/4052.aspx.
U.S. Centers for Disease Control and Prevention. ³:DWHU)OXRULGDWLRQ 1DWXUH¶V:D\WR3UHYHQW7RRWK'HFD\´2006, www.cdc.gov/fluoridation/pdf/natures_way.pdf Pew Center on the States. http://www.pewcenteronthestates.org/initiatives_detail.aspx?initiativeID=42360
1DGHUHK3RXUDWDQG*LQD1LFKROVRQ³8QDIIRUGDEOH'HQWDO&DUH,V/LQNHGWR)UHTXHQW6FKRRO$EVHQFHV´+HDOWK3ROLF\5HVHDUFK%ULHI 8&/$&HQWHUIRU+HDOWK3ROLF\5HVHDUFK Los Angeles, California) November 2009.
$PHULFDQ'HQWDO$VVRFLDWLRQ³6WDWHPHQWRQ)'$7RRWKSDVWH:DUQLQJ/DEHOV´ -XO\ http://www.ada.org/1761.aspx.
Advanced Dental Hygiene Practitioners Frequently Asked Questions. NNDHA Spring 2008, p. 8. http://www.nddha.org/DH%20FAQ.pdf
01HLGHOO.+HU]RJDQG6*OLHG³7KH$VVRFLDWLRQ%HWZHHQ&RPPXQLW\:DWHU)OXRULGDWLRQDQG$GXOW7RRWK/RVV´$PHULFDQ-RXUQDORI3XEOLF+HDOWK
0:LOOLV&(VTXHGDDQG56FKDFW³6RFLDO3HUFHSWLRQVRI,QGLYLGXDOV0LVVLQJ8SSHU)URQW7HHWK´3HUFHSWXDODQG0RWRU6NLlls, 106 (2008): 423±435.
Thomas M. LeLHQGHFNHU*DU\&0DUWLQHWDO³'2'5HFUXLW2UDO+HDOWK6XUYH\ $5HSRUWRQ&OLQLFDO)LQGLQJVDQG7UHDWPHQW1HHG´7Ui-Service Center for Oral Health Studies, (2008) 1 (accessed August 19, 2010).
%'\HHWDO³7UHQGVLQ2UDO+HDOWK6WDWXV 8QLWHd States, 1988-1994 and 1999-´9LWDO+HDOWKDQG6WDWLVWLFV6HULHV 7DEOH http://www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf (accessed December 4, 2009).
National Cancer Institute Website. Water Fluoridation Fact Sheet. http://www.cancer.gov/cancertopics/factsheet/Risk/fluoridated-water Accessed July 28, 2010.
Dr. Bill Bailey, CDC Podcast 7/17/2008. http://www2c.cdc.gov/podcasts/player.asp?f=9927#transcript
1DWLRQDO+HDOWKDQG0HGLFDO5HVHDUFK&RXQFLO $XVWUDOLD ³$V\VWHPDWLFUHYLHZRIWKHHIILFDF\DQGVDIHW\RIIOXRULGDWLRQ´ 3') http://www.nhmrc.gov.au/PUBLICATIONS/synopses/_files/eh41.pdf.
Centers for Disease CRQWURODQG3UHYHQWLRQ³ Water Fluoridation´ Homepage. http://www.cdc.gov/fluoridation/65_years.htm. 94 Centers for Disease Control and Prevention. ³Public Health Service report on fluoride benefits and risks.´ Journal of the American Medical Association 1991; 266(8).
0RXGHQ/³)OXRULGH 7KH1DWXUDO6WDWHRI:DWHU´$UNDQVDV'HQWLVWU\ 6XPPHU -16.
.XPDU-³*HRJUDSKLF9DULDWLRQLQ0HGLFDLG&ODLPVIRU'HQWDO3URFHGXUHVLQ1HZ Texas Department of Oral Health Website. www.dshs.state.tx.us/dental/pdf/fluoridation.pdf. U.S. Department of Health and Human Services (USDHHS). Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. Washington: U.S. Department of Health and Human Services, Public Health Service; 1991. ³Ten Great Public Health Achievements ± United States, 1900- ´&HQWHUVIRU'LVHDVH&ontrol and Prevention, 1999, http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm. Guidelines on the use of fluoride in children: An EAPD policy document. European Archives of Pediatric Dentistry, 10 (3), 2009. The British Fluoridation Society, The UK Public Health Association, The British Dental Association, The Faculty of Public Health RIWKH5R\DO&ROOHJHRI3K\VLFLDQV³2QHLQD million²WKHIDFWVDERXWZDWHUIOXRULGDWLRQ´0DQFKHVWHU(QJODQG National median fee for a two-surface amalgam (silver) filling among general dentists. (Procedure code D2150, amalgam, two surfaces, primary or permanent.) See American Dental $VVRFLDWLRQ³6XUYH\RI'HQWDO)HHV´ &HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ'LYLVLRQRI2UDO+HDOWK³&RVW6DYLQJV RI&RPPXQLW\:DWHU)OXRULGDWLRQ´ $XJXVW 3 http://www.cdc.gov/fluoridation/fact_sheets/cost.htm. CDC Fluoridation Website. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. Report of the Fort Collins Fluoride Technical Study Group, (April 2003). Attachment H Fluoridation Provides the NUTRIENT Fluoride “Although its role in the prevention of dental caries (tooth decay) is well established, fluoride is not generally considered an essential mineral element because humans do not require it for growth or to sustain life. However, if one considers the prevention of chronic disease (dental caries) an important criterion in determining essentiality, then fluoride might well be considered an essential trace element.” http://lpi.oregonstate.edu/infocenter/minerals/fluoride/ AI (Adequate Intake) from Academy of Nutrition and Dietetics Fluoride: Not Just in Your Toothpaste Fluoride provides health benefits throughout a person’s life, especially for bones and teeth. Fluoride helps harden tooth enamel and so helps protect your teeth from decay. It also may offer some protection from osteoporosis, or brittle bone disease, by helping to strengthen your bones. Consuming too little fluoride may cause tooth enamel to weaken and put you at greater risk of cavities. http://www.eatright.org/Public/content.aspx?id=6442474377 95 3 96 3 Attachment I Campaign For Dental Health ILikeMyTeeth.org Savings from Water Fluoridation: What the Evidence Shows Research shows that community water fluoridation offers perhaps the greatest return- oninvestment of any public health strategy. The reduction in just the costs of filling and extracting diseased teeth and time lost from work to get care—not counting reduction in dental pain and discomfort—more than makes up for the cost of fluoridation. In recent decades, the evidence showing savings has grown: • For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs.1 • A Texas study confirmed that the state saved $24 per child, per year in Medicaid expenditures for children because of the cavities that were prevented by drinking fluoridated water.2 • A 2010 study in New York State found that Medicaid enrollees in less fluoridated counties needed 33 percent more fillings, root canals, and extractions than those in counties where fluoridated water was much more prevalent.3 As a result, the treatment costs per Medicaid recipient were $23.65 higher for those living in less fluoridated counties.4 • Researchers estimated that in 2003 Colorado saved nearly $149 million in unnecessary treatment costs by fluoridating public water supplies—average savings of roughly $61 per person.5 • A 1999 study compared Louisiana parishes (counties) that were fluoridated with those that were not. The study found that low-income children in communities without fluoridated water were three times more likely than those in communities with fluoridated water to need dental treatment in a hospital operating room.6 • By reducing the incidence of decay, fluoridation makes it less likely that toothaches or other serious dental problems will drive people to hospital emergency rooms (ERs)—where treatment costs are high. A 2010 survey of hospitals in Washington State found that dental disorders were the leading reason why uninsured patients visited ERs.7 • Scientists who testified before Congress in 1995 estimated that national savings from water fluoridation totaled $3.84 billion each year. 1 97 3 Sources: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 “Cost Savings of Community Water Fluoridation,” U.S. Centers for Disease Control and Prevention, accessed on March 14, 2011 at http://www.cdc.gov/fluoridation/fact_sheets/cost.htm. 2 “Water Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid),” Texas Department of Oral Health Website (2000), www.dshs.state.tx.us/dental/pdf/fluoridation.pdf, accessed on August 1, 2010. 3 Kumar J.V., Adekugbe O., Melnik T.A., “Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation Under Contemporary Conditions,” Public Health Reports, (September-October 2010) Vol. 125, No. 5, 647-54. 4 The original figure ($23.63) was corrected in a subsequent edition of this journal and clarified to be $23.65. See: “Letters to the Editor,” Public Health Reports (November- December 2010), Vol. 125, 788. 5 O’Connell J.M. et al., “Costs and savings associated with community water fluoridation programs in Colorado,” Preventing Chronic Disease (November 2005), accessed on March 12, 2011 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/. 6 “Water Fluoridation and Costs of Medicaid Treatment for Dental Decay – Louisiana, 1995-1996,” Morbidity and Mortality Weekly Report, (U.S. Centers for Disease Control and Prevention), September 3, 1999, accessed on March 11, 2011 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4834a2.htm. 7 Washington State Hospital Association, Emergency Room Use (October 2010) 8-12, http://www.wsha.org/files/127/ERreport.pdf, accessed February 8, 2011. 8 Michael W. Easley, DDS, MP, “Perspectives on the Science Supporting Florida’s Public Health Policy for Community Water Fluoridation,” Florida Journal of Environmental Health, Vol. 191, Dec. 2005, accessed on March 16, 2011 at http://www.doh.state.fl.us/family/dental/perspectives.pdf. 2 98 3 Attachment J FLUORIDATION HELPS MINORITIES AND POOR Many studies have documented strong benefits from CWF exposure during childhood on a child's oral health, but our evidence suggests that the benefits may be even larger than previously believed because prior studies may not have captured the full benefits from CWF. Furthermore, CWF appears to have led to a lasting improvement in racial and economic disparities in oral health. Lower-educated individuals and Blacks have seen disproportionate improvements when compared with higher-educated individuals and with Whites, respectively, which suggests that the “universal coverage” provided by CWF may have reduced disparities in oral health." “The Association Between Community Water Fluoridation and Adult Tooth Loss,” Matthew Neidell, PhD, Karin Herzog, BA, and Sherry Glied, PhD American Journal of Public Health: October 2010, 100(10):1980-1985. Conclusions: This study suggests that the benefits of CWF may be larger than previously believed and that CWF has a lasting improvement in racial/ ethnic and economic disparities in oral health. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009.189555 99 3 100 3 Attachment K ENERGY, TRANSPORTATION, AND ENVIRONMENT Resolution ETE-13-02 RECOGNIZING THE IMPORTANCE OF COMMUNITY WATER FLUORIDATION WHEREAS, the National Black Caucus of State Legislators (NBCSL) recognizes the importance of oral health to the overall health and well-being of children and adults; WHEREAS, dental disease, which may affect the teeth, gums, or other tissues and parts of the mouth, is the most common chronic childhood disease in the United States and is five times more prevalent than asthma; WHEREAS, optimally fluoridated water reduces rates of tooth decay among children and adults by between 18 and 40 percent; WHEREAS, for 65 years, community water fluoridation has distinguished itself as a safe and cost-effective way to prevent tooth decay and has been shown to reduce disparities in tooth decay rates that exist by race, ethnicity, and income; WHEREAS, the Centers for Disease Control and Prevention (CDC) has recognized water fluoridation as one of the 10 greatest public health achievements of the 20th century and estimates that for most cities, each dollar spent on water fluoridation saves $38 in dental costs and related treatment; WHEREAS, more than 204 million people in the United States are served by community water supplies containing enough fluoride to protect teeth; WHEREAS, leading health organizations, including the American Academy of Pediatrics, the American Dental Association, the American Medical Association, the National Dental Association, and the Hispanic Dental Association, have recognized the health benefits of community water fluoridation; WHEREAS, after examining more than 2.2 million cancer death records and 125,000 cancer case records in counties using fluoridated water, the National Research Council found no indication of increased cancer risk associated with fluoridated drinking water; WHEREAS, even though more Americans have access to community water fluoridation than ever before, coverage is uneven, and less than 50 percent of those on public water supplies receive recommended fluoride levels; and WHEREAS, only 20 states currently receive CDC oral health infrastructure grants for prevention activities such as community water fluoridation. THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) recognizes the importance of community water fluoridation as a safe, cost-effective public health intervention proven to prevent tooth decay and reduce oral health disparities; BE IT FURTHER RESOLVED, that the NBCSL urges state and local governments to implement and maintain optimal levels of water fluoridation in public water supplies; BE IT FURTHER RESOLVED, that the NBCSL calls for further studies to be done on the long-term health and effectiveness of water fluoridation to gain more information on the issue, and allow for improved distribution; | 37 ENERGY, TRANSPORTATION, AND ENVIRONMENT RESOLUTION101 ETE-13-02 3 ENERGY, TRANSPORTATION, AND ENVIRONMENT Resolution ETE-13-02 BE IT FURTHER RESOLVED, that the NBCSL calls upon the United States Congress to provide full funding for Centers for Disease Control and Prevention (CDC) oral health infrastructure grants to all 50 states as authorized by the Patient Protection and Affordable Care Act (PPACA) of 2010; and BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, the Vice President of the United States, the Secretary of the U.S. Department of Health and Human Services, the United States Surgeon General, and the Director of the Centers for Disease Control and Prevention, members of the United States House of Representatives and the United States Senate, and other federal and state government officials as appropriate. SPONSOR: Representative Alan Williams (FL) Committee of Jurisdiction: Energy, Transportation, and Environment Policy Committee Certified by Committee Chair: Representative Dee Dawkins-Haigler (GA) Ratified in Plenary Session: Ratification Date is December 7, 2012 Ratification is certified by: Representative Barbara W. Ballard (KS), President 38 | RESOLUTION102 ETE-13-02 ENERGY, TRANSPORTATION, AND ENVIRONMENT3 Attachment L * Fluoride in water helps to prevent and can even reverse tooth decay. * Many studies, in both humans and animals, have shown no association between fluoridated water and cancer risk. Recently, researchers examined the possible relationship between fluoride exposure and osteosarcoma in a new way: they measured fluoride concentration in samples of normal bone that were adjacent to a person’s tumor. Because fluoride naturally accumulates in bone, this method provides a more accurate measure of cumulative fluoride exposure than relying on the memory of study participants or municipal water treatment records. The analysis showed no difference in bone fluoride levels between people with osteosarcoma and people in a control group who had other malignant bone tumors. http://www.cancer.gov/cancertopics/factsheet/Risk/fluoridated-water 103 3 104 3 Attachment M From PEW: 105 3 106 3 Attachment N WORLD PICTURE Here's the world picture from the New Zealand National Fluoride Information Service: "Countries with widespread water fluoridation programs include Australia, the United States of America, Canada, the United Kingdom, Ireland, Spain, Israel, Brazil, Brunei, Chile, Argentina, Colombia, Hong Kong, South Korea, Singapore and Malaysia. Countries with limited water fluoridation programs include Vietnam, Fiji, Papua New Guinea, and South Korea. “Several countries are unable to introduce water fluoridation programs due to technical, financial or sociocultural reasons. As an alternative, both salt and milk have been found to be reliable and convenient vehicles for increasing fluoride intake to an optimal level for hard to reach and low socio-economic communities. Studies have found them to be as effective as community water fluoridation schemes. “Some European, Latin American, and Caribbean countries, including France, Switzerland, Germany, Costa rica, Colombia and Jamaica currently use fluoridated salt schemes. Mexico and most Latin American and Caribbean countries (apart from Argentina, Brazil, Chile and French Guyana) have or have had salt fluoridation programs. “A smaller number of countries currently have fluoridated milk programs, including Bulgaria, Chile, China, Peru, Russia, Thailand and the United Kingdom “Some country regions have optimal amounts of naturally occurring fluoride which provides good protection for oral health. examples of countries supplied with naturally fluoridated water at or around the optimum level needed to prevent dental decay include the United Kingdom (estimated 329,000 people), United States of America (estimated 10,078,000 people) Canada (estimated 300,000 people) and Australia (estimated 144,000 people). “It is estimated that 39.5 million people around the world have access to naturally fluoridated water at the optimal level although variations from one community to another over time make it difficult to calculate an accurate total." 107 3 108 3 Attachment O Institute for Science in Medicine COMMUNITY WATER FLUORIDATION THE PROBLEM Tooth decay continues to be the most common disease of mankind, having long caused misery and can even lead to life-threatening infections. One of the top public health achievements has been community water fluoridation (CWF), which now provides a safe, effective and economical way to help prevent tooth decay. Despite CWF’s phenomenal success, a small but vocal move- ment of anti-fluoridation activists have, since the 1950s, spread unfounded fears among the public about it, with the result that some communities have opted to stop fluoridating their drink- ing water. Their destructive activities have manufactured a fake “scientific controversy” which ultimately results in a decline in dental health, lost productivity, and increased financial burdens on individuals and the health care systems. BACKGROUND Fluoride is necessary for developing and maintaining strong bones and teeth. In 1998, the Insti- tute of Medicine classified fluoride a “nutrient” because of its important role in sustaining health.1 Community water fluoridation (CWF) is the adjustment of the naturally-occurring fluoride content in drinking water for optimal health benefit. Worldwide, communities that fluoridate drinking water do so within the range of 0.6 to 1.2 ppm (parts per million).2,3,4,5,6 At this concen- tration, there is a wide margin of safety.7 Today in the United States, with many consumer prod- ucts from toothpastes to fruit juices containing fluoride, a lower concentration of 0.7 ppm was proposed in 2011. It isn’t until concentrations reach 4.0 ppm or greater that communities are re- quired by the US Environmental Protection Agency to remove excessive naturally-occurring fluoride from drinking water.8 It should be noted that no communities in the United States add fluoride to drinking water to levels that exceed 1.2 ppm. CWF is a safe, economical and effective way to deliver fluoride. Scientific studies have es- tablished that CWF lowers the rate of tooth decay by 20-40% in children, over and above the ef- fect of topical fluoride products.9 Moreover, it benefits all residents of a community, regardless of socio-economic status.10 Fluoridation is one of the most cost-effective health strategies; for most communities, every $1 invested in CWF saves $38 to $80 in dental treatment.11,12,13 CWF has been documented to eliminate millions of dollars in welfare medical costs, days lost at school and work, and in dental and emergency room visits.14 In 1995, fluoridation was estimated to be saving Americans an estimated $3.8 billion per year.15 For example, according to a Texas study ISM Policy Statement! Community Water Fluoridation! Page 1 of 9 109 3 published in 2000, CWF saved Medicaid $24 per child per year.16 Research done in New Zea- land determined that CWF is cost effective for communities of 1,000 or more inhabitants.17 The fluoride obtained from systemic sources actually becomes part of the tooth structure as baby teeth and permanent teeth develop under the gums of infants and children.18 These teeth are then considerably stronger and resist dental decay much better once they have erupted into the mouth. This protection, gained from getting fluoride from systemic sources, generally stays with the teeth throughout life. Systemic sources of fluoride also benefit older children and adults. Fluoride from food and drink eventually ends up in a person’s saliva. The fluoride in saliva constantly bathes the teeth so that the teeth are protected continuously through exposure to small amounts of fluoride. For those older children and adults fortunate enough to live in fluoridated communities, this constant protection of the teeth by saliva containing small amounts of fluoride is substantial. Through a process called remineralization, some very small cavities are not only prevented from getting larger, they actually can "heal" or repair themselves because of the action of these low levels of fluoride present in the saliva. Fluoride in saliva also inhibits attachment, metabolism, and repro- duction of the bacteria implicated in the decay process, such that it inhibits the ability of these bacteria to produce enamel-destroying acids.11,19,20,21 CWF helps the elderly protect teeth that are at additional risk because of decreased saliva production and increased root exposure.22 A recent increase in the incidence of tooth decay has been linked to the reliance on bottled water that does not contain sufficient fluoride content to promote dental health.23,24 Antifluoridationists activists are small in number but tend to be very vocal. Since CWF’s in- ception in 1945, they have made hundreds of invalid criticisms.25 CWF has been a favorite target of conspiracy theorists; it has been charged with being a secret plot of Nazis, Communists, the Illuminati, the Centers for Disease Control and Prevention (CDC), the fertilizer industry, and many other groups.26,27 The anti-fluoridation movement’s allegations of harm from CWF are not scientifically sub- stantiated. In particular, toxicity and carcinogenicity of fluoridation at the levels used in CWF have been ruled out by reliable scientific studies. The National Cancer Institute (NCI) states that CWF poses no increased risks for cancer.28 The CDC has also concluded that there is “no credi- ble evidence” for such a link.29 Fluoride’s only identified side-effect has been mild dental fluoro- sis — an almost unnoticeable cosmetic concern — and one where CWF makes only a small contribution.30,31,32,33 Worldwide, some 400 million people have optimally fluoridated drinking water, with ap- proximately 70% of the US, 90% of Australians, and 10% of the UK population having access.34,35,36 While studies indicate that most people favor CWF,37,38 this public health measure is not always implemented or retained. In January 2012, a prominent anti-fluoridation organiza- tion claimed 38 communities in the United States, Canada and New Zealand, together represent- ing a population of 2,892,500, had been “freed from forced fluoridation” in just over a year.39 The safety of CWF has been comprehensively reviewed by numerous public-health authori- ties and scientific institutions.40 These include the US Public Health Service,41 World Health Or- ISM Policy Statement! Community Water Fluoridation! Page 2 of 9 110 3 ganization,42 NCI,28 CDC,43 National Research Council,44 and National Health and Medical Re- search Council (Australia).45 None has ever identified any health risk with the levels of fluoride provided by CWF. As Consumers Union, another supporter of CWF, has aptly concluded: The simple truth is that there’s no “scientific controversy” over the safety of fluoridation. The practice is safe, economical, and beneficial. The survival of this fake controversy represents one of the major triumphs of quackery over science in our generation.46 US courts have also recognized that there is no scientific controversy over the safety and ef- ficacy of CWF. No appellate court – state or federal – has ever ruled that fluoridation of local water systems is an unconstitutional exercise of government power. Moreover, because fluoride is scientifically classified as a naturally-occurring mineral nutrient, like calcium or iron, courts have also consistently found that adjusting fluoride levels in water cannot be legally character- ized as “mass medication.”47,48,49 DISCUSSION For a democratic society to make sound decisions about CWF, the debate that occurs should be reliably informed; scientific evidence and reasoning should be indispensable in making public health policy. Yet every year, some communities needlessly forego CWF, with resulting declines in dental health. Policy makers may see CWF as a place to trim public expenditures, especially when faced with local anti-fluoridation activists clamoring for an end to CWF, but it is a penny- wise, pound-foolish decision for the community. Decades of sound research and experience with CWF have made certain conclusions clear and inescapable. Individuals can receive lifetime benefits from CWF, in improved quality of life, employ- ment opportunities, and in the dental care savings (not only for the initial treatment for caries, but in the subsequent need for caps, root canals, tooth loss, dentures, etc.). Poor communities are es- pecially impacted negatively by the lack of CWF. No health risks have been identified with the levels of fluoride provided by CWF. Moreover, researchers continue to monitor changes in diet, climate, and life styles in order to insure the ideal levels of fluoride are present in drinking water. Courts have repeatedly ruled that CWF neither interferes with constitutional freedoms nor is “mass medication” of a population. Since it already occurs in water naturally, CWF is an ad- justment of that level. Water treatment should be determined by what is best for the community as a whole. The primary source of fluoride (hydrofluorosilicic acid) is irrelevant; when added to water, this chemical breaks down into fluoride ions, sand and water. Water-treatment engineers have an excellent record of ensuring safe drinking water. CWF is practical and economical for most communities. Where it is not, there are alterna- tive sources of fluoride, but these are considerably more expensive than CWF and require more individual effort than CWF. Reliance on alternative sources of fluoride puts many children at risk. ISM Policy Statement! Community Water Fluoridation! Page 3 of 9 111 3 The astounding success of CWF may make citizens and policymakers complacent about the seriousness of tooth decay and its costs to the community. It is short-sighted to bow to the de- mands made by anti-fluoridation activists solely on fiscal grounds. It is a sound investment for states and municipalities to establish, maintain, or modernize fluoridation equipment. Anti-fluoridation activists use many conventional propaganda techniques, such as the “Big Lie.” The Internet allows false claims about fluoridation to reach a wide audience. Emotionally- charged claims undermine the public’s confidence in the proven safety and effectiveness of CWF and have led some communities to reject scientific arguments supporting CWF. The public can be misled about CWF when the media, in attempting to provide “balanced” reporting on the “controversy,” frequently give weight to the views of antifluoridationists that are not warranted by the scientific facts of the matter. NEEDED POLICY To help protect the public’s dental health, policymakers need to maintain community water fluoridation (CWF) and expand it to underserved communities. • In order to optimize the dental health of citizens, all communal water systems need to im- plement CWF as recommended by recognized public health authorities. • States, NGOs, and insurance companies should financially assist local communities to create and maintain facilities for optimal fluoridation of drinking water. • The National Institutes of Health and the US Public Health Service need to begin a wide- spread program of public education, emphasizing the benefits, cost-effectiveness and safety of CWF. • State health departments, local health officials, and dental and medical societies need to de- termine the level of fluoride in local water supplies, while educating their states and commu- nities about appropriate fluoride supplementation and the need for CWF. Educators should encourage parents to supervise their children’s use of toothpaste. • State and local dental and medical societies and other health authorities should be prepared to counter unfounded health claims about fluoridation as they arise. While the false claims made by the anti-fluoridation movement need to be addressed, the public especially needs to become familiar with the significant benefits of CWF and its excellent safety record. • State and local dental/medical societies need to make a priority of reintroducing CWF where the anti-fluoridation movement has stopped this vital public health measure. Citizens in these communities need to be made aware that they are not benefitting from the protections of CWF. • All bottled water sold for drinking purposes should be required to contain optimal levels of fluoride. Bottled water labels should be required to state the fluoride concentration. • Media should be mindful that their content is used by voters and policy makers to decide public health issues. Whenever a story touches on CWF, reporters and editors should fact- ISM Policy Statement! Community Water Fluoridation! Page 4 of 9 112 3 check with reliable and authoritative sources, and balance the story in accordance with the weight of the facts. • Policy makers should seek out scientifically reliable information and opinion, and base decisions about CWF accordingly. Approved by ISM Board of Directors 22 January 2012 ISM Policy Statement! Community Water Fluoridation! Page 5 of 9 113 3 FURTHER READING Campaign for Dental Health. “Possible responses to common anti-fluoride claims.” Myths & Facts Sheet [online], 2011. Pew Center on the States. “Savings from water fluoridation: what the evidence shows.” [online] 2010. Jason M. Armfield. “When public action undermines public health: a critical examination of an- tifluoridationist literature.” Australia and New Zealand Health Policy [online], 2007 Dec 9; 4:25. C. Albert Young. “A systematic review of the efficacy and safety of fluoridation.” Evidence- Based Dentistry, 2008 Jun; 9(2):39-43. Committee on Fluoride in Drinking Water, National Research Council. Fluoride in Drinking Wa- ter: A Scientific Review of EPA’s standards. Washington: National Academies of Science, 2006. (ISBN 978-0-309-10128-8) National Cancer Institute. “Fluoridated water: questions and answers.” NCI Fact Sheet [online], reviewed 29 Jun 2005. American Dental Association. Fluoridation Facts. Chicago: The Association, 2005. British Fluoridation Society, UK Public Health Association, British Dental Association & Fac- ulty of Public Health. One in a Million: The Facts About Water Fluoridation. Oldham, UK: The Society, 2nd edition, 2004 Jun. US Centers for Disease Control and Prevention. “Recommendations for using fluoride to prevent and control dental caries in the United States.” Morbidity & Mortality Weekly Report. 2001 Aug 17; 50(RR14):1-42. Michael W. Easley. “Opposition to community water fluoridation and connections to the ‘alterna- tive medicine’ movement.” Scientific Review of Alternative Medicine. 2001; 5(1):24-31. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General (Rockville, MD: National Institutes of Health, 2000):158-166. Division of Oral Health, National Center for Chronic Disease Prevention. “Achievements in public health, 1900-1999: fluoridation of drinking water to prevent dental caries.” Morbidity and Mortality Weekly Report, 1999 Oct 22; 48(41):933-940. Michael W. Easley. “A symposium on the new fight for fluorides, part I: The new antifluorida- tionists: who are they and how do they operate?” Journal of Public Health Dentistry, 1985 Summer; 45(3):133-141. Stephen J. Barrett & Sheldon Rovin, eds. The Tooth Robbers: A Pro-Fluoridation Handbook. Philadelphia: Stickley, 1980. ISM Policy Statement! Community Water Fluoridation! Page 6 of 9 114 3 References 1 Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes: A Risk Assessment Model For Establishing Upper Intake Levels For Nutrients (Washington: National Academies Press, 1998):20,22,23,28. (ISBN 0-309-06348-5) 2 National Institute of Dental and Craniofacial Research (2000), op. cit., supra, p.160. 3 National Health and Medical Research Council. “The Efficacy and Safety of Fluoridation.” NHMRC Public Statement, 2007 [online]. http://www.nhmrc.gov.au/_files_nhmrc/file/media/media/rel07/Fluoride_Flyer.pdf 4 British Medical Association. “Fluoridation of water.” BMA Policy, 2010 Jan 12 [online]. http:// www.bma.org .uk/health_promotion_ethics/environmental_health/Fluoriwater.jsp 5 Clarkson J, McLoughlin J & O’Hickey S. “Water fluoridation in Ireland—a success story.” Journal of Dental Research, 2003 May; 82(5):334-337. [abstract] 6 Health Canada. It’s Your Health: Fluoride and Human Health (Ottawa, Canada: Minister of Health, rev. 2010). (ISBN 978-1-100-17147-0) http://www.hc-sc.gc.ca/hl-vs/alt_formats/pacrb-dgapcr/pdf/iyh-vsv/environ/fluor- eng.pdf 7 Dodes JE, “Fluoridation in the 21st Century.” In Lehr JH and Keeley J, eds., Water Encyclopedia: Domestic, Municipal, and Industrial Water Supply and Waste Disposal (Hoboken, NJ: Wiley, 2005), 2:254-256. (ISBN 978-0-471-73686-8) 8 National Research Council (2006), op. cit., supra. 9 Brunelle JA & Carlos JP. “Recent trends in dental caries in U.S. children and the effect of water fluoridation,” Journal of Dental Research, 1990 Feb; 69(Spec Iss):723-727; discussion, 820-823. [abstract] 10 National Institute of Dental and Craniofacial Research (2000), op. cit., supra, p.162. 11 Division of Oral Health, Centers for Disease Control and Prevention. “Cost savings of community water fluoridation.” CDC Fact Sheet, 2009 Sep 1 [online]. http://www.cdc.gov/fluoridation/fact_sheets/cost.htm 12 Centers for Disease Control and Prevention. An ounce of prevention…what are the returns? (Atlanta, GA: US Department of Health and Human Services, 2nd edn., 1999), p. 10. ftp://ftp.cdc.gov/pub/Publications/mmwr/ other/ozprev.pdf 13 Centers for Disease Control and Prevention, “Public health focus: fluoridation of community water systems,” Morbidity & Mortality Weekly Report, 1992 May 29; 41(21):372-375,381. 14 Berg JH & Slayton RL. Early Childhood Oral Health (New York: Wiley-Blackwell, 2009), p. 44. (ISBN 978-0-8138-2416-1) 15 Silverstein SC. Testimony before the US Congressional Biomedical Research Caucus. Washington: 1995 Feb 10. Regarding a finding by the Federation of American Societies of Experimental Biology. 16 Texas Department of Health, “Water fluoridation costs in Texas: Texas Health Steps (EPSDT-Medicaid),” 2000 May. 17 Wright JC, Bates MN, Cutress T & Lee M. “The cost-effectiveness of fluoridating water supplies in New Zealand,” The Australian and New Zealand Journal of Public Health, 2001 Apr; 25(2):170-178. [abstract] 18 Newbrun E, ed. Fluorides and Dental Caries: Contemporary Concepts for Practitioners and Students (Springfield, IL: Thomas, 1986, 3rd edn.). (ISBN 0398051968) 19 Lambrou D, Larsen MJ, Fejerskov O & Tachos G, “The effect of fluoride in saliva on remineralization of dental enamel in humans,” Caries Research, 1981; 15(5):341-345. [abstract] ISM Policy Statement! Community Water Fluoridation! Page 7 of 9 115 3 20 Jones S, Burt BA, Petersen PE & Lennon MA. “The effective use of fluorides in public health,” Bulletin of the World Health Organization, 2005 Sep; 83(9):670-676. 21 American Dental Association (2005), op. cit., supra. 22 National Institute of Dental and Craniofacial Research (2000), op. cit., supra, p.161. 23 Smith M. “Bottled water cited as contributing to cavity comeback,” MedPage Today, 2005 Sep 19 [online]. http://www.medpagetoday.com/PrimaryCare/DentalHealth/1756 24 Division of Oral Health, Centers for Disease Control and Prevention. “Bottled water and fluoride.” CDC Fact Sheet, 2011 Jan 7 [online]. http://www.cdc.gov/fluoridation/fact_sheets/bottled_water.htm 25 Bernhardt M & Sprague B, “The poisonmongers,” in Barrett & Rovin, eds., op. cit., supra, pp. 3-4. 26 Easley MW (2001), op. cit., supra. 27 Bowers B. “Truth about fluoride doesn't include Nazi myth.” PolitiFact Florida, 2011 Oct 6 [online]. http:// www.politifact.com/florida/statements/2011/oct/06/critics-water-fluoridation/truth-about-fluoride-doesnt- include-nazi-myth/ 28 National Cancer Institute (2005), op. cit., supra. 29 National Center for Chronic Disease Prevention (1999), op. cit., supra. 30 Holloway PJ. “Government should meet commitment made in white paper” [letter], British Medical Journal, 2001 Jun 16; 322(7300):1486. 31 American Dental Association (2005), op. cit., supra, pp. 28-31. 32 Lewis DW & Banting DW, “Water fluoridation: current effectiveness and dental fluorosis,” Community Dentistry and Oral Epidemiology, 1994 Jun; 22(3):153-158. [abstract] 33 Division of Oral Health, Centers for Disease Control and Prevention. “Dental fluorosis.” CDC Fact Sheet, 2011 Jan 6 [online]. http://www.cdc.gov/fluoridation/safety/dental_fluorosis.htm 34 British Fluoridation Society et al. (2001), op. cit., supra. 35 Victoria Department of Health, “Water fluoridation in Victoria and Australia,” Victorian Government Health Information, 2011 Mar 10 [online]. http://www.health.vic.gov.au/environment/fluoridation/flumap.htm 36 Division of Oral Health, Centers for Disease Control and Prevention, “2008 water fluoridation statistics,” CDC Fact Sheet, 2010 Aug 9 [online]. http://www.cdc.gov/fluoridation/statistics/2008stats.htm 37 Mummery WK, Duncan M & Kift R. “Socio-economic differences in public opinion regarding water fluoridation in Queensland.” Australian and New Zealand Journal of Public Health, 2007 Aug; 31(4):336-339. [abstract] 38 American Dental Association (2005), op. cit., supra, p. 48. 39 Fluoride Action Network. “Cities that voted against fluoridation.” News, 2011 Nov (rev 2012 Jan) [online, accessed 2012 Jan 14]. http://www. fluoridealert.org/breaking_news.aspx 40 Division of Oral Health, Centers for Disease Control and Prevention, “Scientific reviews: assessing the weight of the evidence,” CDC Fact Sheet, 2010 Jan 29 [online]. http://www.cdc.gov/fluoridation/safety/systematic.htm 41 Ad Hoc Subcommittee on Fluoride, US Public Health Service. Review of Fluoride: Benefits and Risks. Report, 1991 Feb. http://www.health.gov/environment/ReviewofFluoride/default.htm ISM Policy Statement! Community Water Fluoridation! Page 8 of 9 116 3 42 Fawell J, Bailey K, Chilton J, Dahi E, Fewtrell L & Magara Y. Fluoride in Drinking-Water. (London: IWA Publishing, 2006). [ISBN 9781900222969] http://www.who.int/water_sanitation_health/publications/fluoride_ drinking_water_full.pdf 43 Division of Oral Health, Centers for Disease Control and Prevention. “Community water fluoridation: overview.” CDC Fact Sheet, 2011 Jan 19. http://www.cdc.gov/fluoridation/ 44 Division of Oral Health, Centers for Disease Control and Prevention. “National Academy of Sciences on fluoride in drinking water: what is the National Academy of Sciences and why is its opinion important?” CDC Fact Sheet, 2011 Jan 7. http://www.cdc.gov/fluoridation/safety/nas.htm 45 Young (2007), op. cit., supra. 46 Botta JR. “Fluoridation: the cancer scare,” Consumer Reports, 1978 Jul, 43:392-396. Also, “The attack on fluoridation: six ways to mislead the public,” ibid., 1978 Aug; 43:480-482. This series of articles was the subject of a libel action, with summary judgment for defendant affirmed, Yiamouyiannis v. Consumers Union of the United States (2nd Circuit, 1980), 619 F2d 932. http://174.123.24.242/leagle/xmlResult.aspx?xmldoc= 19801551619F2d932_11387.xml 47 Block LE. “Antifluoridationists persist: the constitutional basis for fluoridation.” Journal of Public Health Dentistry, 1986 Sep; 46(4):188-198. [abstract] 48 Safe Water Association v. City of Fond du Lac (Wisc App 1994), 184 Wis2d 365, 516 NW2d 13. http:// www.actionpa.org/fluoride/lawandcourts/wi-fond-du-lac.html 49 American Dental Association (2005), op. cit., supra, p. 47. Copyright 2012 by Institute for Science in Medicine, Inc. Permission to reproduce in its entirety is hereby granted, provided that it is not altered, not distributed for commercial purposes, and this notice is included. All other rights are reserved. Institute for Science in Medicine, Inc. (ISM) is an international, educational and public-policy institute, incorporated in the State of Colorado, and recognized as a 501(c)(3) organization for US federal tax purposes. ISM Policy Statement! Community Water Fluoridation! Page 9 of 9 117 3 118 3 Attachment P Institute for Science in Medicine WHITE PAPER THE ANTI-FLUORIDATIONIST THREAT TO PUBLIC HEALTH PREPARED BY JOHN E. DODES, DDS, FISM AND MICHAEL W. EASLEY, DDS, MPH, FISM APRIL 2012 119 3 Institute for Science in Medicine (ISM) is an international, educational and public-policy or- ganization comprised of health care professionals, scientists, and researchers who agree that the best science available should be used to determine health policy and to establish a standard of care that both protects and promotes the public health. We necessarily oppose policies which erode a science-based standard of care and thereby significantly expose the public to fraudulent, worthless, or harmful medical practices and products. Copyright 2012 by Institute for Science in Medicine. Permission to reproduce in its entirety is hereby granted, provided that it is not altered, not distributed for commercial purposes, and this notice is in- cluded. All other rights are reserved. 120 3 White Paper: The Anti-Fluoridationist Threat to Public Health Declared by the Centers for Disease Control and Prevention to be one of the ten greatest public- health achievements of the Twentieth Century,1 community water fluoridation has been under attack by a small band of critics since its inception. The scientific consensus over fluoridation’s health benefits, safety, social justice, and economies has been firmly established over six decades of widespread use in the United States and elsewhere. Nevertheless, anti-science critics have never relented in their opposition — recycling previously disproven charges of harm, inventing new ones out of whole cloth, misrepresenting scientific facts and research, exaggerating risks, understating benefits, inappropriately invoking the precautionary principle, and accusing public health officials of corruption, conspiracy, and ‘mass medication’ of whole populations. Background Tooth decay is the most common disease of all mankind. Decay and loss of teeth due to de- cay can affect general health, especially for the elderly, and adversely impact an individual’s emotional and social well-being. Fluoride is a micro-nutrient essential to the development and maintenance of teeth and bones. Fluoride-fortified teeth are significantly resistant to dental car- ies. Community water fluoridation (CWF) is an adjustment to the amount of fluoride that occurs naturally in all water supplies to a safe level that is optimal for dental health and safe for overall health. Scientific studies have established that CWF lowers the rate of tooth decay by 20-40% in children, over and above the effect of toothpaste and other sources of fluoride.2 Moreover, it benefits all residents of a community, regardless of age and socio-economic status.3 CWF is re- markably economical for community water systems serving 1,000 people or more. For such communities, every dollar spent on CWF on average saves $38 to $80 per year in dental treatment.4,5 To look at it another way, for the cost of a single small tooth restoration, an individ- ual can be protected for life. Thousands of reliable scientific studies have established the safety of CWF at the levels of optimal fluoridation. After decades of observation and examination, reviews by major scientific organizations have found there is no epidemiological evidence for any other threat to public or individual health associated with CWF. In the United States, 62.2% of the population has access to public water supplies that are op- timally fluoridated. Over 360 million people worldwide, in approximately 60 countries enjoy the benefits of fluoridated drinking water. Dr C. Everett Koop, a former US Surgeon General, has stated, “Fluoridation is the single most important commitment that a community can make to the oral health of its citizens.” Yet in spite of overwhelming scientific evidence and greatly improved dental health, opposi- tion to CWF persists. This opposition has had success in delaying the adoption of CWF in some April 2012 Page 1 121 3 White Paper: The Anti-Fluoridationist Threat to Public Health communities, and even causing others to abandon it, depriving tens of thousands of citizens of optimal dental health and putting a heavy financial burden on the community’s health care re- sources. Because of this threat to public health, the tactics of the anti-fluoridationists warrant ex- amination and exposure. Tactics of the Anti-fluoridation Movement Misrepresenting the Conclusions of Valid Research The National Research Council (NRC) is a group of distinguished experts that issues inde- pendent reports to improve government, decision making and public policy. In 2006, the NRC issued a report on fluoride.6 Anti-fluoride groups often cite the NRC’s report when they try to raise fears about community water fluoridation, but these groups’ statements misrepresent the NRC’s findings.7 Although the report’s title cites “drinking water,” the NRC produced a sum- mary of its report, reiterating the focus of its concern, i.e. people living in areas of the United States with natural levels of fluoride in water that are at least double or triple the level used to fluoridate a public water system. As the NRC itself stated, “it is important to note that the safety and effectiveness of the practice of water fluoridation was outside the scope of this report and is not evaluated.” 8 Citing Strange, Far-Fetched Case Studies to Attack Fluoridation The New York State Coalition Opposed to Fluoridation (NYSCOF) has cited bizarre case studies of people that are in no way representative of normal behavior or normal conditions. These case studies are not scientifically relevant to whether Americans drink fluoridated water. Here are some examples of the case studies that are presented with fearful headlines by NYSCOF. April 2012 Page 2 122 3 White Paper: The Anti-Fluoridationist Threat to Public Health • In 2009, NYSCOF posted a press state- ment that quoted its president saying that “even water fluori- dation will cause arthritic-like symptoms in susceptible indivi- duals….” 9 However, NYSCOF provided no evidence connecting fluoridated water to arthritis. One of the ar- ticles that the group cited to back up its claim was from a French medical journal. That article described a bizarre case study that had nothing to do with whether Americans drink fluoridated water. It was about a woman who brushed her teeth 18 times a day and swallowed the toothpaste, con- suming a tube of toothpaste every two days.10 It is irresponsible to attack water fluoridation with a case study that (a) does not involve fluoridated water, and (b) is not representative of normal behavior. It is also instructive to note that while fluoride levels in water fluoridation do not exceed 1.0 parts per million, the fluoride levels in toothpastes range from 1100 to 1500 parts per million depending on the brand. • In 2010, NYSCOF cited the case of a 53-year-old British woman in a Facebook post head- lined, “Fluoride Damages Bones, Studies Show.” Unless people read the full article, they never learn what a bizarre lifestyle this woman had, drinking six cups of high-fluoride “brick tea” and brushing her teeth 8-10 times each day.11 Ordinary Americans do not drink that type of tea, and they do not brush their teeth every two hours they’re awake. Presenting this woman’s case as a reason to fear water fluoridation in the United States is misleading.12 Engaging in Misleading Spin about Europe and Fluoride Fluoridation.com, an anti-fluoride website managed by Canadian activist Elke Babiuk, contends that “99% of western continental Europe has rejected, banned, or stopped fluoridation due to en- vironmental, health, legal, or ethical concerns.”13 There is no citation for this statement, and this assertion is a classic example of spin. Based on this language, one would conclude that virtually nobody in Western Europe regularly receives systemic forms of fluoride. The reality is very dif- ferent. April 2012 Page 3 123 3 White Paper: The Anti-Fluoridationist Threat to Public Health First, the insertion of the word “continental” is a way of ignoring that millions of Irish and British people drink water that is optimally fluoridated. In fact, fluoridated water is provided to 12 million Europeans, mostly reaching residents of Great Britain, Ireland, Spain and other countries.14 Second, this statement by Fluoridation.com obscures the fact that fluoride is widely used in Europe. In fact, at least 70 million Europeans consume fluoridated salt, and this method of fluoridation reaches most of the population in Germany and Switzerland. These two countries have among the lowest rates of tooth decay in all of Europe.15 Fluoridated milk programs reach millions of additional Europeans.16 Italy has not tried to create a national system of water fluoridation, but there are logical rea- sons for this. Firstly, many Italians regularly drink bottled water. Secondly, a number of areas in Italy have water supplies with natural fluoride levels that already reach the optimal level that prevents decay.17 Misrepresenting the Positions of Governmental or Health Organizations In 2012, a group called the New York State Coalition Opposed to Fluoridation (NYSCOF) claimed in an Internet article that the U.S. Department of Health and Human Services (HHS) “recommends avoiding fluoridated water when making infant formula.”18 The hyperlink con- tained within this statement takes readers to yet another article by NYSCOF that makes the same inaccurate claim.19 NYSCOF asserted that its source for this assertion is a video commentary re- corded by Dr Howard Koh, HHS’s Assistant Secretary for Health in 2011. But in the video, Dr Koh did not warn parents against using fluoridated water for infant formula.20 This is what he actually said: Parents and caregivers can use fluoridated water for preparing infant formula. How- ever, if the child is exclusively consuming infant formula reconstituted with fluori- dated water, there is an increased potential for mild dental fluorosis. The majority of fluoride comes from the water used to mix the formula. Some parents may choose to use low-fluoride bottled water some of the time to mix infant formula. This HHS message suggests another option for parents who may be concerned about fluoro- sis, but it is a far cry from telling parents to avoid fluoridated water. Incidentally, nearly all fluorosis in the United States is a mild, cosmetic condition that doesn’t affect the health or func- tion of the teeth. In most cases, only a dentist will detect the condition because the faint white streaks on teeth are so subtle. Painting an Inaccurate Picture of Dental Fluorosis One typical way that anti-fluoride activists raise fears about safety is by talking about a con- dition called dental fluorosis. They don’t mention that nearly all fluorosis in the United States is a mild, cosmetic condition that is so subtle that only a dentist is usually able to detect it and only April 2012 Page 4 124 3 White Paper: The Anti-Fluoridationist Threat to Public Health when the teeth are completely dry. Mild fluorosis does not cause pain, and it does not affect the health or function of the teeth. Here are two examples of how opponents misrepresent what fluorosis is: • The Fluoride Action Net- work (FAN), a web-based anti-fluoridation organiza- tion, has cited the incidence of fluorosis in India and other nations to raise con- cern about water fluorida- tion. Yet FAN neglects to inform readers that the cause of this condition is not fluoridated water.21 In fact, the process of adjust- ing fluoride in public water systems is extremely rare in India.22 The problem is that several regions of India have geological conditions that make the natural fluoride levels between four and 15 times higher than the level used to fluoridate water in the United States.23 Moreover, some excessive lev- els of fluoride in India’s ground water is the result of widespread unabated industrial pollu- tion. India’s leading health officials do not blame the practice of what is called “fluoridation.” In fact, the director of India’s Institute of Public Health publicly endorsed water fluoridation.24 Skeletal fluorosis is a condition that is virtually unheard of in the United States. • The leader of NYSCOF posted a statement on the web about fluoridation in which he de- clared that a study links dental fluorosis to bone fractures.25 The Chinese study he cited was about fluorosis “from drinking traditional brick-tea.”26 Although brick tea is consumed in many areas of China, it is virtually unheard of the United States. Brick tea has a concentra- tion of fluoride that is between three and 10 times higher than the level recommended to fluoridate drinking water in the United States.27 This study was described in an anti-fluoride publication called Fluoride, which does not have the same rigorous standards for peer review and integrity that are required of full-fledged scientific journals. For example, the World Health Organization’s guidelines recommend that a study’s methodology be “clearly defined” and the procedures used in a study “should be described in detail.”28 The article in Fluoride is only three and a half pages long, and most of one page consists of photographs. Few details are provided of the methodology or procedures used by the Chinese researchers. The article states that the children had “a known regular consumption” of brick tea, but there is no way April 2012 Page 5 125 3 White Paper: The Anti-Fluoridationist Threat to Public Health to determine how much brick tea was consumed by the children who were studied — or for how many years they consumed such tea. Leaving Out Critical Facts • An anti-CWF group cited a study about a city in Cuba that ceased fluoridation, presenting it as proof that fluoridation offers no benefits.29 It’s true that decay rates fell for children in this city after CWF ended in 1990, but the anti-fluoride group ignored a crucial point that could well have influenced these rates — that very same year, this city started a weekly, fluoride mouth-rinsing program in its schools.30 Effective mouth-rinsing programs generally cost sig- nificantly more per person than CWF. • Citizens for Safe Drinking Water (www.nofluoride.com) has posted anti-fluoridation quotes on its website, claiming that these statements “are made by the top medical authoriti- es…based on the latest medical research.” But several of these quotes are more than 40 years old and, therefore, are not based on the latest research. The group even cites a quote from an American Medical Association leader, without revealing that he was AMA’s president in the 1930s — many years before fluoridation was first tried in the United States.31 The American Medical Association has since endorsed CWF as an effective public health strategy. Using a “Rhetorical Question” to Create Fear One example of anti-fluoride propaganda seeks to raise a major health concern, claiming a link be- tween fluoride and fibromyalgia, without offering any credible evi- dence to back it up. Instead, this article engages in guesswork: Is it possible that some cases of fibromyalgia are actually cases of fluoride poisoning? Again, it is a possibility. … The problem is, there is no actual research to determine a solid connection between fluoride and fibromy- algia…32 Saying something is “possible” is a poor reason for raising a concern that is not backed by scientific evi- dence. People who suffer from April 2012 Page 6 126 3 White Paper: The Anti-Fluoridationist Threat to Public Health fibromyalgia deserve our compassion, not our wild speculations about their illness. The article was written by a woman who is described as a writer “with a special interest in health-related topics.” Yet there is no indication that she holds a medical degree or has any expertise in this par- ticular field. Holding Extreme Views About Health and Medicine Several of the leading voices in the anti-fluoride movement have expressed radical views that place them at odds with the scientific and medical community. • Mike Adams, editor of NaturalNews.com, is a vocal opponent of water fluoridation. In 2009, he launched an online petition endorsing a health reform plan for the United States that in- cluding a provision preventing state medical boards from being able to license “who can or cannot practice medicine.” 33 Adams also attacks vaccines. In 2011, he wrote, “Vaccines make you stupid. The chemical adjuvants added to vaccines actually cause neurological dam- age and interfere with healthy cognitive function.” 34 • Dr. Joseph Mercola is a leading opponent of fluoridation who claims it “causes teeth to rot and crumble.” 35 In 2010, Dr Mercola posted a series of lengthy interviews with Paul Con- nett, leader of the FAN, and kicked off these interviews by declaring his intent “to remove fluoride from the water supply of the United States.” 36 In 2011, the website Quackwatch re- ported, “Many of Mercola’s articles make unsubstantiated claims and clash with those of leading medical and public health organizations.” Quackwatch also reports these claims in- clude articles opposing immunization and promoting dietary supplements.37 For instance, Mercola’s website has warned women against getting mammograms to screen for breast can- cer. Instead, Mercola encourages women to use thermograms – digital images of skin tem- peratures – as a tool for detecting cancer and other health conditions. Since 2005, Mercola has received at least three letters from the Food and Drug Administration, ordering him to stop making certain claims about thermograms or other products promoted on his website. The FDA has concluded that the broad claims made by the Illinois physician do not accu- rately reflect the medical evidence about thermograms. The Chicago Tribune reported that “science has yet to back his claims” about the Med2000, a thermographic camera that Mer- cola promotes.38 According to the American Cancer Society, “no study has ever shown that [a thermogram] is an effective screening tool for finding breast cancer early. It should not be used as a substitute for mammograms.” 39 • John Yiamouyiannis, a PhD chemist whose anti-fluoride articles are still cited by FAN, co- wrote a book making the false claim that the virus HIV does not cause AIDS.40 Yiamouyian- nis also predicted that people who received childhood vaccinations would have a higher rate of AIDS—another assertion that is at odds with the evidence.41 Yiamouyiannis died at age 58 of cancer. He had neglected symptoms of rectal cancer, and then, rejecting standard treat- ment, he opted for IV vitamin C and laetrile at a Mexican clinic. Many years ago, Consumer April 2012 Page 7 127 3 White Paper: The Anti-Fluoridationist Threat to Public Health Reports criticized the junk science behind Yiamouyiannis’s attacks on fluoridation,42 but FAN continues to praise him as an expert on the subject.43 • Stanley Monteith, MD, is a retired orthopedic surgeon. He has a syndicated program called Radio Liberty that airs on over 50 stations. A long-time member of the John Birch Society, Monteith’s favorite issues include a “secret cabal” that controls the United States, the “New World Order,” promoting belief in the supernatural, and a conspiracy to reduce the world’s population to 500 million using fluoridation which he claims lowers sperm production.44 In 2004, he published the book Hidden Agenda: The Fluoride Deception (Training Manual for Parents, Physicians, and Dentists). • Mehmet Oz, MD, reaches a TV audience of millions with the Dr. Oz Show. Oz recommends individuals purchase reverse osmosis filters, as his family has done, for the purpose of re- moving fluoride from drinking water. Oz also promotes Joseph Mercola (see above) and many discredited health care practices, such Reiki and acupuncture; he even claims that ho- meopathy is “worth considering.” 45 As a practicing cardiothoracic surgeon, Oz brought a “radical energy healer” into his operating room to reduce patients’ anxiety stemming from their repressed “birth trauma.” 46 • Paul H. Connett, a retired professor of chemistry at St. Lawrence University, authored The Case Against Fluoride: How Hazardous Waste Ended Up in Our Drinking Water and the Bad Science and Powerful Politics That Keep It There (2010). Connett is the head of the family- operated FAN. At the end of 2011, fewer than 200 of America’s 150,000 dentists had signed Connett’s “Professionals’ Statement to End Fluoridation.” 47 Connett considers fluoridation to be forced medication and repeats many of the usual anti-fluoridation arguments. He often frames his opposition to fluoride in the form of questions, such as “What parent in their right mind would put the interest of their children’s teeth…above the interest of their brains?” He also claims that with fluoridation, “There’s no adequate margin of safety.” 48 In an unguarded moment with an interviewer, Connett recently stated, “All these liberal commentators around the world immediately jump in and use the fact that the Tea Party is involved to slam us as being crazy conspiracy theorists. We might be wrong, but we’re not looney.” 49 • Christopher Bryson is a reporter whose book, The Fluoride Deception, purports to link wa- ter fluoridation to the Manhattan Project at Los Alamos. In an interview aired on Democracy Now, Bryson stated, “The post-war campaign to fluoridate drinking water was less a public health innovation than a public relations ploy sponsored by industrial users of fluoride- including the government’s nuclear weapons program.” 50 The studies Bryson refers to are of poor quality and don’t hold up to scientific scrutiny. He refers to fluoride as “rat poison.” • Hardy Limeback is a Canadian dentist who teaches the University of Toronto and who has opposed fluoridation since 1998. He seems to have changed his support for fluoridation after losing a bid for the presidency of the Canadian Dental Association. He repeatedly makes the scientifically unfounded claim that, “In Canada, we are now spending more money treating dental fluorosis than we do treating cavities.” 51 He often asserts that fluoride has cumulative April 2012 Page 8 128 3 White Paper: The Anti-Fluoridationist Threat to Public Health toxic effects that can be ‘catastrophic,’ although he cites scientific evidence that actually does not support his assertions. • Carol Kopf appears to be principal voice behind the New York Coalition Opposed to Fluori- dation (NYSCOF). A Long Island housewife without any health-related training, Kopf pep- pers the internet with unscientific articles under her actual name and the nom de plume “Sally Stride.” She bombards newspapers with letters to the editor in response to almost any men- tion of fluoridation. It also appears that she is the ghost writer for attorney Paul Beeber, titu- lar head of NYSCOF. Conclusions For decades, a small, but vocal, movement of anti-fluoridation activists has spread unfounded fears among the public about community water fluoridation, with the result that some communi- ties have opted to stop this beneficial and cost-effective public health measure. While the value of fluoride is gaining gradual acceptance, overcoming the misinformation promoted by those op- posed to fluoridation is a long and difficult process. The anti-fluoridationists’ fake scientific controversy has resulted in reduced dental health, needless pain, suffering, and lost productivity, with substantially increased financial burdens on individuals and our health care system. The anti-fluoridation movement employs classic propaganda methods, such as misrepresenta- tion, fear mongering, false analogies and outright lies to further their political goals. As William Jarvis, past executive director of the National Council Against Health Fraud, has said: These charges seem to grow out of a mentality of distrust. Anti-fluoridation groups are led by many of the same people who oppose immunization, pasteurization, sex education, mental health programs, and other public health advances. Most are closely connected with sellers of alternatives to medically accepted products and services. Fluoridation is safe, effective, efficient, socially equitable, and environmentally sound public health policy for the prevention of the most common disease afflicting children and adults. It is imperative that the optimal fluoridation of community water systems continue throughout the United States and, indeed, the world. April 2012 Page 9 129 3 White Paper: The Anti-Fluoridationist Threat to Public Health Sources 1 Division of Oral Health, National Center for Chronic Disease Prevention. “Achievements in public health, 1900- 1999: fluoridation of drinking water to prevent dental caries.” Morbidity and Mortality Weekly Report, 1999 Oct 22; 48(41):933-940. 2 Brunelle JA & Carlos JP. “Recent trends in dental caries in U.S. children and the effect of water fluoridation,” Journal of Dental Research, 1990; 69(Special Issue):723-727. 3 National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon Gen- eral (Rockville, MD: National Institutes of Health, 2000):158-166 at 162. 4 Griffin SO, Jones K & Tomar SL. “An economic evaluation of community water fluoridation,” Journal of Public Health Dentistry, 2001; 61(2):78-86. Cited in Fluoridation Facts, 2005, American Dental Association, http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf 5 “Savings from Water Fluoridation: What the Evidence Shows,” The Pew Center On The States. http://www.ilikemyteeth.org/wp-content/uploads/2010/11/Savings-from-Fluoridation.pdf 6 Committee on Fluoride in Drinking Water, National Research Council. Fluoride in Drinking Water: A Scientific Review of EPA’s standards. Washington: National Academies of Science, 2006. (ISBN 978-0-309-10128-8) 7 New York State Coalition Opposed to Fluoridation (NYSCOF), “Fluoride damages the thyroid, study reveals,” 2009 Jun 14 (http://journals.gagazine.com/nyscof/fluoride-damages-the-thyroid-study-reveals/). See also point #4 in The Lillie Center, “About dental fluorosis, fluoridated water, and fluorides,” 2010 Feb 4 (http://spotsonmyteeth.com/about-dental-fluorosis-fluoridated-water-and-fluorides/), accessed 2012 Jan 11. 8 Committee on Fluoride in Drinking Water, op. cit. 9 NYSCOF, “Fluoride linked to arthritis, study shows,” 2009 Aug 26. (http://voices.yahoo.com/fluoride-linked- arthritis-study-shows-4139607.html?cat=5) 10 Roos J, Dumolard A, Bourget S, Grange L, Rousseau A, Gaudin P, Calop J & Juvin R. “[Osteofluorosis caused by excess use of toothpaste],” Presse Médicale, 2005 Nov 19; 34(20 pt 1):1518-1520 [article in French] [ab- stract] 11 It is reasonable to conclude that this British woman had consumed brick tea because the fluoride level reported in the tea is only reached by brick tea; the level reported (7.6 mg./L) is more than triple the fluoride level found in green, black and oolong teas. See: Micronutrient Information Center, The Linus Pauling Institute, Oregon State University, “Tea” (http://lpi.oregonstate.edu/infocenter/phytochemicals/tea/), accessed 2011 Oct 26. 12 NYSCOF, “Fluoride damages bones, studies show,” Facebook, 2010 Nov 1 (http://www.facebook.com/topic.php? uid=252199261811topic=16302), accessed 2011 Oct 5. 13 Fluoridation.com, “Fluoridation status of some countries” (http://www.fluoridation.com/c-country.htm), ac- cessed 2012 Jan 12. 14 The British Fluoridation Society, “The extent of water fluoridation in the UK and worldwide,” (http://www. bfsweb.org/facts/wf_uknworld/f_wf_uknworld.htm), accessed 2011 Nov 17. O’Mullane D, Whelton HP, Costelloe P, Clarke D, McDermott S & McLoughlin J. “The results of water fluorida- tion in Ireland,” Journal of Public Health Dentistry, 1996 Dec; 56(5):259-264. [DOI] Cheng KK, Chalmers I & Sheldon TA. “Adding fluoride to water supplies,” British Medical Journal, 2007 Oct 6; 335(7622):699-702 at 700. [DOI] 15 Marthaler T, Gillespie G & Goetzfried F. “Salt fluoridation in Europe and in Latin America – with potential worldwide,” Wirthschaft, 2011 Mar, pp. 12-25. April 2012 Page 10 130 3 White Paper: The Anti-Fluoridationist Threat to Public Health 16 Ibid. 17 Pizzo G, Piscopo MR, Pizzo I & Giuliana G. “Community water fluoridation and caries prevention: a critical review,” Clinical Oral Investigations, 2007 Sep; 11(3):189-193. [DOI] 18 NYSCOF, “Top 20 fluoride news stories of 2011,” 2012 Feb 1. (http://www.sacbee.com/2012/02/01/4231040/ top-20-fluoride-news-stories-of.html) 19 NYSCOF, “HHS: All infant formulas contain fluoride; avoid mixing with fluoridated water,” 2011 Mar 10. (http: //www.prnewswire.com/news-releases/hhs-all-infant-formulas-contain-fluoride-avoid-mixing-with-fluoridated- water-117760088.html) 20 Koh HK, “HHS: Proposed guidelines on fluoride in drinking water,” Medscape Today, 2011 Mar 8. (http://www. medscape.com/viewarticle/738322) 21 Fluoride Action Network, “Skeletal fluorosis: new reports from India,” (http://www.fluoridealert.org/ fluorosis- india.htm), accessed 2011 Nov 2. 22 Lennon MA, Whelton H, O’Mullane D & Ekstrand J. “Fluoride: rolling revision of the WHO guidelines for drinking-water quality” [draft report] (World Health Organization, 2004 Sep). See Tables 1 and 2 which list the countries with laws or policies to fluoride-adjust their public water systems. Warning: this document is labeled “not for citation”. 23 Many groundwater sources in India have detectable, natural fluoride levels ranging from 5 to 23 milligrams per liter. See Box 2 in: World Health Organization, “Water Sanitation and Health (WSH): Fluoride,” (http://www. who.int/water_sanitation_health/naturalhazards/en/index2.html), accessed 2011 Oct 25. 24 Ramachandra SS, Ramachandra SS & Rao M. “Need for community water fluoridation in areas with suboptimal fluoride levels in India,” Perspectives in Public Health, 2010 Sep; 130(5):211-212. [DOI] 25 Citizens for Safe Water, “Paul Beeber weighs in on fluoridation,” 2007 Jul 16 (http://www.cfsw.us/2007/07/17/ paul-beeber-weighs-in-on-fluoridation/), accessed 2012 Feb 9. 26 Cao J, Liu J-W, Tang L-L, Sangbu D-Z, Yu S, Zhou S, Yu Y & Qu H-Y. “Dental and early-stage skeletal fluorosis in children induced by fluoride in brick-tea,” Fluoride, 2005; 38(1):44-47. 27 Micronutrient Information Center, op. cit. 28 World Health Organization, “Research policy: recommended format for a research protocol.” (http://www. who. int/rpc/research_ethics/format_rp/en/index.html) 29 NYSCOF, “When fluoridation ends – so do cavities,” 2001 Jan 24. (http://www.orgsites.com/ny/nyscof/_pgg7. php3), accessed 2012 Mar 30. 30 Künzel W & Fischer T. “Caries prevalence after cessation of water fluoridation in La Salud, Cuba,” Caries Re- search, 2000 Jan-Feb; 34(1):20-25. [DOI] 31 Citizens for Safe Drinking Water, “Respected medical professionals and scientists are warning of long-term health consequences” (http://www.nofluoride.com/), accessed 2011 Oct 27. 32 Roberts K. “Fluoridation as a potential cause for fibromyalgia symptoms,” Top Secret Writers (http://www. topsecretwriters.com/2011/12/fluoridation-fibromyalgia-symptoms/), accessed 2012 Mar 30. 33 “The Health Revolution Petition” (http://www.healthrevolutionpetition.org/), accessed 2011 Dec 20. 34 Adams M. “Flu shot fantasies: how influenza vaccines halt flu infections (even when they don’t),” NaturalNews.com, 2011 Dec 20. (http://www.naturalnews.com/034452_flu_shots_vaccines_immunity. html) 35 Mercola J. “CDC covering up serious hazards of water fluoridation,” Mercola.com, 2007 Aug 20. (http://articles.mercola.com/sites/articles/archive/2007/08/20/cdc-covering-up-serious-hazards-of-water-fluoridat ion.aspx), accessed 2012 Jan 3. April 2012 Page 11 36 “Dr. Mercola interviews Dr. Paul Connett on Fluoride (Part 1 of 5),” 2010 Jun 22. (http://www.youtube.com/ watch?v=UpPv290z2-Y) 131 3 White Paper: The Anti-Fluoridationist Threat to Public Health 37 Barrett S. “FDA orders Dr. Joseph Mercola to stop illegal claims,” Quackwatch.org, (May 26, 2011), http://www.quackwatch.com/11Ind/mercola.html. 38 Tsouderos T. “FDA warns doctor: stop touting camera as disease screening tool,” The Chicago Tribune, 2011 Apr 25. 39 Ibid. 40 Peter Duesberg & John Yiamouyiannis. AIDS: The Good News Is That HIV Doesn’t Cause It (Delaware, OH: Health Action Press, 1995). 41 Yiamouyiannis J. [excerpt from] “Fluoride: the aging factor,” Fluoride Action Network. (http://www. fluoridealert.org/aging-factor.htm), accessed 2012 Mar 30. Barrett SJ. “Dr. John Yiamouyiannis, fluoridation opponent, dead at 58,” Quackwatch.org, 2005 Feb 25. (http:// www.quackwatch.com/11Ind/yiamouyiannis.html) 42 Botta JR. “Fluoridation: the cancer scare,” Consumer Reports, 1978 Jul; 43:392-396. Also, “The attack on fluoridation: six ways to mislead the public,” ibid., 1978 Aug; 43:480-482. This series of articles was the subject of a libel action, with summary judgment for defendant affirmed, Yiamouyiannis v. Consumers Union of the United States (2nd Circuit, 1980), 619 F2d 932. (http://174.123.24.242/leagle/xmlResult.aspx?xmldoc= 19801551619F2d932_11387.xml) 43 Fluoride Action Network. “In honor of Dr. John Yiamouyiannis (1943-2000),” (http://www.fluoridealert.org/In- Honor-of-Dr--John-Yiamouyiannis.aspx) [online] 2000 Oct 11. [accessed January 4, 2012] 44 “The population control agenda - Dr. Stanley Monteith M.D.” (http://www.youtube.com/watch?v= 5I8A- LoZCurE) [accessed 2012 Mar 30] 45 Oz M. “4 treatments for headaches,” O Magazine, 2009 Nov. [accessed 2012 Mar 30] 46 Julie Motz. Hands of Life: From the Operating Room to Your Home, An Energy Healer Reveals the Secrets of Using Your Body’s Own Energy Medicine for Healing, Recovery, and Transformation (Bantam, 1998). 47 Fluoride Action Network. “Professionals’ statement to end fluoridation,” [online] (http://www.fluoridealert.org/ professionals-statement.html) [accessed 2012 Mar 30] 48 Mercola J. “25 studies prove this reduces your IQ,” [online] 2011 Dec 3. (http://articles.mercola.com/sites/ articles/archive/2011/12/03/paul-connett-fluoride.aspx) [accessed 2012 Mar 30] 49 Resnick B. “What do we know about fluoride,” The Atlantic [online], 2012 Feb 9. 50 Democracy Now! “The fluoride deception: how a nuclear waste byproduct made its way into the nation’s drink- ing water,” [online] 2004 Jun 17. (http://www.democracynow.org/2004/6/17/the_fluoride_deception_how_ a_nu- clear) [accessed 2012 Mar 30] 51 Forbes B. “Top fluoride expert apologizes for pushing poison,” The Tribune [Mesa, Arizona], 1999 Dec 5. April 2012 Page 12 132 3 133 4 134 4 Attachment A 9/24/2014 Let's Begin 1. Government is . . . 2. Has nothing but LOVE for our Children since they want to stop dental caries. 3. The corollary of course is . . . 4. Adding Fluoride to our water supply must be a loving, caring practice without any problems and anyone who opposes it's use . . . DEMONIZATION Doctor Strange Love - Strangelovians Tin-foil hat wearing kooks afraid of a little mind control. 135 4 1 9/24/2014 The Case Against Fluoride – Great Book by Paul Connett, PhD Director, Fluoride Action Network FluorideALERT.org Introduction I’m not much of an Expert in anything of REAL importance save for Court Testimony in Drug cases – I've spent most of the last 30 years as a beat cop and retired as a sergeant for the CHP. (BS CJ/ Dean's List/ Medal Valor/Officer of the year) 136 4 2 9/24/2014 Outline of my presentation 1. The efficacy of Fluoride. 2. Margin of Safety is loss. 3. Its use cancels my Right of Choice. 4. Maybe there are Better alternatives to fight tooth decay. For a Retired Cop to stand here and attempt to give a lesson in Biology or Medicine would make this Comedy Central. 137 4 3 9/24/2014 I'm not! 1. Dr. Paul Connett SAYS: There is not one human system that needs fluoride. 2. You can’t control who gets the medicine. 3. It violates the individual’s right to informed consent to medicine. 4. You can’t control the DOSE people get. 138 4 4 9/24/2014 5. There is not a single process inside the body that needs fluoride to function properly, however 6. Fluoride is a known toxic substance that interferes with many fundamental biochemical functions In other words: it doesn’t do any good to swallow fluoride and it has the potential to cause harm 7. 1 ppm fluoride (1 mg/liter) is NOT small. It is 250 times the level in mothers milk in a non-fluoridated community (0.004 ppm, NRC , 2006, p. 40) 8. A bottle-fed baby in a fluoridated community is getting 250 times the fluoride dose that nature intended! 139 4 5 9/24/2014 7) 1 ppm fluoride (1 mg/liter) is NOT small. It is 250 times the level in mothers milk in a non-fluoridated community (0.004 ppm, NRC , 2006, p. 40) 8) A bottle-fed baby in a fluoridated community is getting 250 times the fluoride dose that nature intended! 9. The fluoridating chemicals used are not the pharmaceutical grade chemicals used in dental products, but are arsenic- contaminated industrial waste products obtained from the fertilizer industry. 10. The dental lobby has controlled this debate for far too long. There are more tissues in the body than teeth. 140 4 6 9/24/2014 As I stated, I'm a retired State Trooper and except for delivering a baby on the side of the Freeway and a few failed resuscitation attempts, my knowledge of medicine is limited. FACT: The vast majority of countries do NOT FLUORIDATE their water 141 4 7 9/24/2014 Having spent most of my life running away from cops or running with them, I tend to look at this issue from the point of view of an INVESTIGATOR. As a Public Servant my JOB was to investigate criminal activity. For example: DUI 142 4 8 9/24/2014 Cellular Phones were not around when I began wearing a gun-belt and BADGE! Cell Phones arrived and with them citizens began reporting crime on the Example: Collisions, DUI, Violence Roadway. A Road Cop's discernment improves in time and also their ability to sort through the Sleepy or Distracted DRIVER. Positioning your Cruiser behind or to the side (white dooring) should cause the driver to start paying attention. 143 4 9 9/24/2014 What is the point? DUTY! Should I just jump off the Freeway at the closest exit to a Coffee shop for a warm donut? Possibly!! Do we as public servants have a DUTY to INVESTIGATE further once a problem is called to our attention? 144 4 10 9/24/2014 I always gave it my best effort to investigate. Witness Contact information, willingness to testify in court The number of citizens reporting this same vehicle Houston, we have a problem! The Information package I put together for you is an example of a citizen calling POLICE dispatch and giving an ERRANT VEHICLE report! 145 4 11 9/24/2014 97% of Western European populations now drink Non-Fluoridated Water Austria* Italy Belgium Luxembourg Denmark Netherlands Finland Northern Ireland France* Norway Germany* Scotland Greece Sweden Iceland Switzerland* *Some fluoridate their salt According to WHO data tooth decay in 12-year-olds is coming down as fast in F as NF countries World Health Organization 146 4 12 9/24/2014 SOURCE: World Health Organization. (Data online) Just when we believe the Science is settled, Pythagoras and then Galileo tells us the earth is ROUND! A debate can destroy a beautiful theory. 147 4 13 9/24/2014 DEBATE A series of studies since 1980 indicate that the notion that swallowing fluoride reduces tooth decay is very weak Between 1980 and 1990 A number of articles began to appear in major journals indicating that there was very little difference in tooth decay between fluoridated and non-fluoridated communities 148 4 14 9/24/2014 This prompted the NIDR (now: NIDCR) to conduct the largest survey of tooth decay ever carried out in the U.S. Leverett in Science, 1982 Diesendorf in Nature, 1986* Gray, 1987 Colquhoun* NIDR survey The teeth of over 39,000 children in 84 communities were examined. 149 4 15 9/24/2014 Yiamouyiannis Using the FOIA Dr. John Yiamouyiannis obtained the DMFT (Decayed, Missing and Filled permanent TEETH), data for children aged 5-17 His plot of the data showed no statistical difference between children from N-F and F communities NIDR - Yiamouyiannis, 1990 150 4 16 9/24/2014 NIDR - Brunelle and Carlos (1990) Brunelle and Carlos increased sensitivity by factor of five (approximately) by comparing DMFS (Decayed, Missing and Filled permanent SURFACES - 5 surfaces to most teeth, 4 in the cutting teeth) Decayed Missing and Filled surfaces (DMFS) There are 4 surfaces to the top six and bottom six cutting teeth and 5 surfaces on all the other teeth. 128 tooth surfaces in all. 151 4 17 9/24/2014 The largest US survey of tooth decay 3.4 2.8 DMFS DMFS NF F Brunelle and Carlos, 1990 3.4 2.8 DMFS DMFS NF F Average difference (for 5 - 17 year olds) in DMFS = 0.6 tooth surfaces (5 surfaces to a tooth) 152 4 18 9/24/2014 Not only was this saving very small (0.6 of one tooth surface) but it was not even shown to be statistically significant! Warren et al. (2009) (the “Iowa” study) 153 4 19 9/24/2014 Warren et al., 2009, measured tooth decay as a function of individual exposure to fluoride. They found NO relation between tooth decay and amount of fluoride ingested. “These findings suggest that achieving a caries-free status may have relatively little to do with fluoride intake…” Supporting document Warren et al., 2009* 154 4 20 9/24/2014 Debate CDC (1999) Fluoride’s predominant benefit is TOPICAL not systemic CDC, MMWR , 48(41); 933-940, Oct 22, 1999* (Morbidity and Mortality Weekly Report) “Fluoride’s caries-preventive properties initially were attributed to changes in enamel during tooth development... However, laboratory and epidemiologic research suggest that fluoride prevents dental caries predominantly after eruption of the tooth into the mouth, and its actions primarily are topical…” 155 4 21 9/24/2014 If fluoride works on the outside of the tooth not from inside the body Why swallow fluoride and expose every tissue of the body to a toxic substance, when you can brush it on your teeth and spit it out? And why put it in the drinking water and force it on people who don’t want it? Debate The U.S. National Research Council published the results of its 3-year review of fluoride’s toxicity (NRC, 2006) 156 4 22 9/24/2014 National Research Council (2006) The purpose of the National Research Council is to help improve public policy, understanding, and education in matters of science, technology, and health. To accomplish this purpose, the Council promotes the increase and dissemination of knowledge in the natural and social sciences, mathematics, and engineering and the use of this knowledge to benefit the public welfare. 157 4 23 9/24/2014 NRC found that fluoride could cause many harmful effects in the body in countries with high natural levels of fluoride in their water. Independent scientists have argued that there is NO ADEQUATE MARGIN OF SAFETY to protect everyone drinking fluoridated water from some of these harmful effects. 158 4 24 9/24/2014 An exposure analysis in Chapter 2 of the NRC report shows that subsets of population drinking F -water (including bottle-fed infants) are exceeding EPA’s safe reference dose (0.06 mg/kg/day) John Doull (chairman, NRC, 2006 Review) “What the committee found is that we’ve gone with the status quo regarding fluoride for many years—for too long really—and now we need to take a fresh look . . . In the scientific community people tend to think this is settled. I mean, when the U.S. Surgeon General comes out and says this is one of the top 10 greatest achievements of the 20th century, that’s a hard hurdle to get over. But when we looked at the studies that have been done, we found that many of these questions are unsettled and we have much less information than we should, considering how long this [fluoridation] has been going on.” Scientific American, Jan 2008 pages 74–81. 159 4 25 9/24/2014 Osteosarcoma Bassin found that young boys exposed to fluoridated water in their 6th,7th or 8th years, had a 5-7 fold increase in developing osteosarcoma by the age of 20, compared to non-exposed boys. Her 2006 study has never been refuted. The study promised by Douglass (Kim et al., 2011) failed to do so. Supporting documents located in A Case Against Fluoride: Bassin et al., 2006* Kim et al., 2011* 160 4 26 9/24/2014 Debate CDC (2010) Confirms that American kids are being hugely over- exposed to fluoride Dental Fluorosis Early promoters thought that at 1 ppm F they could reduce tooth decay and limit dental fluorosis to 10% of children in its very mild form. 161 4 27 9/24/2014 Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004 November 2010: CDC update on fluorosis by Beltrán-Aguilar et al. See supporting document* Impacts up to 25% of tooth surface Very Mild Dental Fluorosis 162 4 28 9/24/2014 Impacts up to 50% of tooth surface Mild Dental Fluorosis Impacts 100% of tooth surface Moderate- Severe Dental Fluorosis 163 4 29 9/24/2014 See also CDC (2005) An earlier report from the CDC found that Black and Hispanic Americans had higher rates of dental fluorosis (especially the more serious categories) than White Americans. See supporting document CDC, 2005, Table 23.* A KEY QUESTION When fluoride is damaging the baby’s growing tooth cells (causing dental fluorosis) what is it doing to the BABY'S other developing tissues? 164 4 30 9/24/2014 Debate There is extensive evidence that fluoride damages the brains of animals and humans Over 40 animal studies show that prolonged exposure to fluoride can damage the brain. 19 animal studies report that mice or rats ingesting fluoride have an impaired capacity to learn and remember. 12 studies (7 human, 5 animal) link fluoride with neurobehavioral deficits 3 human studies link fluoride exposure with impaired fetal brain development 37 out of 43 published studies show that fluoride lowers IQ 165 4 31 9/24/2014 To access any of these brain studies 1) Go to FluorideALERT.org 2) Click on RESEARCHERS 3) Search: Health Data Base 4) Or Search: Brain Effects Or go direct to: FluorideALERT.org/issues/health/brain Varner et al. (1998) Gave rodents 1 ppm fluoride in their water for one year. The exposed rodents had Kidney damage Brain damage A greater uptake of aluminum into the brain and Beta amyloid deposits which are characteristic of Alzheimer’s disease. 166 4 32 9/24/2014 Xiang et al. (2003 a,b) . Compared children in two villages (<0.7 ppm versus 2.5 - 4.5 ppm F in water) . Controlled for lead exposure and iodine intake, and other key variables . NOTE: Both lead exposure and low iodine also lower IQ. . Found a drop of 5-10 IQ points across the whole age range No protection for range of exposure A child drinking TWO liters of water at 1 ppm would get a higher DOSE (2 mg/day) than one of the Chinese children drinking ONE liter of water at 1.9 ppm (1.9 mg/day) 167 4 33 9/24/2014 11 of the 37 IQ studies found an association between lowered IQ and fluoride levels in the urine Xiang finds an association between lowered IQ and PLASMA fluoride levels Xiang et al., 2011* 168 4 34 9/24/2014 Debate Choi et al. (2012)* The Harvard Review of IQ Studies Harvard meta-analysis of 27 studies Choi et al (the team included Philippe Grandjean) did a meta-analysis of 27 studies comparing IQ in “high” versus “low” fluoride villages . The study was published in Environmental Health Perspectives (published by NIEHS) They acknowledge that there were weaknesses in many of the studies, however… 169 4 35 9/24/2014 the results were remarkably consistent In 26 of the 27 studies there was lower average IQ in the “high” versus “low” fluoride villages. Average IQ lowering was about 7 IQ points. Choi et al. 2012 The Harvard scientists concluded that further investigation of fluoride’s lowering of IQ should be a “high research priority” 170 4 36 9/24/2014 Dr. Philippe Grandjean “Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain. The effect of each toxicant may seem small, but the combined damage on a population scale can be serious, especially because the brain power of the next generation is crucial to all of us.” (Harvard Press Release) Other health concerns 1) First symptoms of fluoride’s poisoning of the bone are identical to arthritis. No investigation in any fluoridated country. 2) Li et al (2001).* Doubling of hip fracture at 1.5 ppm? 3) Fluoride used to lower thyroid function in hyperthyroid patients Galletti and Joyet (1958)* 171 4 37 9/24/2014 Other health concerns 4) Bachinskii et al (1985) Thyroid function lowered at 2.3 ppm. 5) Fluoride accumulates in human pineal gland. Lowers melatonin levels in animals and shortens time to puberty (Luke 1997, 2001*). No attempt to reproduce these findings in any fluoridated country. Summary 1) Most countries don’t fluoridate their water but there is no difference in tooth decay in 12-year- olds between those that do and those that don’t (WHO figures) 2) Fluoridation is a clumsy form of medicine (You can’t control the dose or who gets it). 3) It violates the individual’s right to informed consent to medicine 172 4 38 9/24/2014 Summary 4) The evidence that swallowing fluoride actually reduces tooth decay is very weak. Warren et al (2009) could find no relationship between the amount of fluoride swallowed by children and tooth decay. 5) Even major promoters of fluoridation (e.g. CDC) admit that fluoride’s predominant action is TOPICAL not SYSTEMIC, i.e. it works on the outside of the tooth not from inside the body Summary 6) For those who want fluoride, fluoridated toothpaste is readily available. There is no need to swallow it and there is no need to force it on people that don’t want it. 7) American kids are being over-exposed to fluoride. 41% of American children aged 12-15 have some form of dental fluorosis (CDC, 2010). 8) It is reckless to assume – without very careful study – that while fluoride is damaging the growing tooth cells it is not harming other tissues in the child’s developing body. 173 4 39 9/24/2014 Summary 9) Nature has given us a very good idea about how much fluoride the baby should get. The level of fluoride in mothers milk is EXTREMELY LOW: 0.004 ppm (NRC, 2006, p.40) 10) It is reckless to give a bottle-fed baby about 200 times the level of fluoride that nature intended. 11) The evidence that fluoride can damage the developing brain is extensive Summary 12) Studies from China indicate that lower IQs are associated with a) levels of fluoride in water b) level of fluoride in their urine and c) levels of fluoride in their plasma 13) One estimate of the threshold for this effect (1.9 ppm) offers no adequate margin of safety to protect all our children from either the range of doses or the range of sensitivity expected in a large population. 14) A small shift in IQ can have devastating consequences at the population level. 174 4 40 9/24/2014 Summary 15) There is no question that given a sufficient dose, fluoride can harm many human tissues (brain, bone, teeth, thyroid, kidney etc.) (NRC, 2006). 16) There is no adequate margin of safety to protect all our citizens drinking uncontrolled amounts of fluoridated water and getting fluoride from many other sources. 17) It is reckless to expose our population in this way, when alternatives are readily available. Summary 18) It impacts all of us. I know there is an Errant Vehicle on the Hwy so I buy expensive Fluoride removal equipment for my family and me. What about low-income families who cannot afford alternative water supplies. 19) I am astounded this practice has continued for over 65 years a) without approval of the FDA, b) without a single randomized clinical trial to demonstrate Fluoride's effectiveness and c) with so many crucial health questions unanswered. 175 4 41 9/24/2014 Better Alternatives If you want fluoride, use fluoridated toothpaste (96% of toothpaste sold in the U.S. is fluoridated) Better still use XYLITOL toothpaste. Xylitol toothpaste has been used for over 30 years in Finland Give Xylitol mints (not chewing gum) to kids in school (e.g. Wichita, Kansas). Give free toothbrushes and free toothpaste to low-income families (e.g. Scotland - ChildSmile) Better Alternatives Education: Teaching mothers about baby bottle tooth decay – cause & prevention Most of tooth decay is concentrated in low- income families - EDUCATION Low-income families need better diet and better dental EDUCATION LESS SUGAR! MORE BRUSHING! Less sugar means less tooth decay and less OBESITY…less diabetes, fewer heart attacks (education = a good investment!) 176 4 42 9/24/2014 Modern studies show that tooth decay does NOT go up when fluoridation stopped Recent studies indicate that Dental Caries has not gone up after Fluoridation Stopped 1. Former East Germany Kunzel, W. & Fischer, T. (1997). Rise and fall of caries prevalence in German towns with different F concentrations in drinking water. Caries Res 31(3): 166-73 2. Cuba Kunzel, W. & Fischer, T. (2000). Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res 34(1): 20-5. 3. Canada Maupome, G. et. al (2001). Patterns of dental caries following the cessation of water fluoridation. Community Dent Oral Epidemiol 29(1): 37- 47. 4. Finland Seppa, L. et. al (2000). Caries trends 1992-98 in two low-fluoride Finnish towns formerly with and without fluoride. Caries Res 34(6): 462-8. 177 4 43 9/24/2014 Fluoridation violates the Precautionary Principle The precept that an action should not be taken if the consequences are uncertain and potentially dangerous Precautionary Principle Criteria for application. 1. Is there published evidence of harm? YES – 36 IQ studies 2. Is this effect serious? YES 178 4 44 9/24/2014 Precautionary Principle Criteria for application. 3. Is the benefit being pursued very significant? No. – A fraction of one permanent tooth surfaced saved. 4. Are there alternative cost-effective solutions available? YES – Toothpaste, Xylitol, Education, Scotland – Smile program Conclusion Finally, I applaud this Commission, the LUC, for giving their valuable time to present this Community Forum. If only our U.S. Congress would see it is their DUTY to do the same perhaps their approval rating would not be in the single digits. 179 4 45 9/24/2014 It is time to get dentistry out of the PUBLIC WATER supply and back into the dental office. 180 4 46 Attachment B Open Letter to Honorable Yael German, Minister of Health, Israel June 25, 2014 Dear Honorable Minister German, We applaud your decision to end mandatory fluoridation in Israel and we look forward to the time that there is an outright ban on this reckless practice. Your position is a model for the public health community both in Israel and in our respective communities. It is sound, based on the current literature and the need to protect the health of citizens from unnecessary ingestion of fluoride. It is unfortunate that in making the best decision for the health and welfare of your citizens that you have been subjected to criticism and bullying as noted in the June 22rd article, Backlash against Health Minister Yael German for her decision to stop fluoridation, published in The Jerusalem Post (Siegel- Itzkovich). Professor Paul Connett, co-author of The Case Against Fluoride (Chelsea Green, 2010), is willing to travel to Israel and publicly debate any of those who are organizing against you. However, in our experience the pro-fluoridation advocates are unable to defend their position in open public debate. This is not through a lack of debating skills on their part but rather the fact that science simply does not support their claims that swallowing fluoride is safe or that it dramatically reduces tooth decay. The following facts and arguments underline the inappropriateness of this outdated practice: Delivering any medicine via the water supply is reckless Fluoridation violates all principles of modern pharmacology. Once added to water there is no way of controlling the dose or the people who get the medicine – it goes to everyone regardless of age, weight, health, need or nutritional status. Moreover, it violates the individual’s right to informed consent to medical treatment. (http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000445.htm). Swallowing fluoride is particularly inappropriate Fluoride is not a nutrient. Not one biochemical process in the body needs fluoride. Underlining this fact is the exceedingly low level of fluoride in mother’s milk (0.004 ppm, NRC, 2006, p.40). Formula-fed infants in fluoridated communities (at 0.7 to 1.2 ppm) receive 175 to 300 times more fluoride than a breast-fed infant. Making matters worse is the fact that fluoride is known to have toxic properties at low doses (NRC 2006, Barbier et al., 2010; Varner et al., 1998). It also accumulates in the bone and builds up there over a lifetime. Early signs of fluoride poisoning of the bone (skeletal fluorosis) are identical to arthritis and lifelong accumulation can make bones brittle and more prone to fracture. Dental fluorosis While we do not see the crippling effects of skeletal fluorosis observed in countries like India and China, which have areas of high natural levels of fluoride, children in fluoridated countries are 181 4 experiencing a very high prevalence of dental fluorosis. According to the CDC (2010) 41% of American children aged 12-15 have dental fluorosis. Black and Mexican American children have significantly higher rates of the more severe forms of dental fluorosis (CDC, 2005, Table 23). Fluoridation promoters acknowledge that dental fluorosis indicates over-exposure to fluoride but refuse to admit other harm. A review of the toxicology of fluoride by the U.S. National Research Council of the National Academies in 2006 revealed that fluoride is an endocrine disruptor and causes many health problems at levels close to the exposure levels in fluoridated communities. This panel also reported that bottle-fed babies are exceeding the EPA’s safe reference dose when drinking fluoridated water (NRC, 2006, p85). Fluoride impacts the brain Many animal and human studies indicate that fluoride is a neurotoxin (www.FluorideAlert.org/issues/health/brain). In 2012, a team that included Harvard University researchers reviewed 27 studies that showed an association between fairly modest exposure to fluoride and lowered IQ in children (Choi et al., 2012). In nine of these studies the so-called “high fluoride” village had fluoride levels less than 3 ppm. Such levels provide no adequate margin of safety to protect all children –especially the most vulnerable- from lowered IQ when drinking fluoridated water. An incredible lack of oversight Fluoridation is designed to treat a disease but has never been approved by the Food and Drug Administration (FDA); it classifies fluoride as an “unapproved drug.” How strong is the evidence that swallowing fluoride reduces tooth decay? Fluoridation advocates claim that it is very strong. However, if you look at the actual science it is a different story. The effectiveness of swallowing fluoride to reduce tooth decay has never been demonstrated via a randomized controlled trial (RCT), the gold standard of epidemiology (McDonagh et al., 2000). Two key U.S. studies – both government funded and by pro-fluoridation researchers – have failed to produce convincing evidence of benefit. A very large study, administered by the U.S. National Institute for Dental Research, examined the permanent teeth of 39,000 children (aged 5-17) from 84 communities. The average saving in Decayed Missing and Filled Surfaces (DMFS) when comparing children in fluoridated and non-fluoridated communities was 0.6 of a tooth surface out of 128 tooth surfaces, and this was not shown to be statistically significant (Brunelle and Carlos, 1990). Even if it were, the average saving is remarkably small considering what risks are being taken to achieve this result. As part of the “Iowa Fluoride Study,” where children’s tooth decay and fluoride intake has been tracked from birth, researchers examined the relationship between tooth decay and individual exposure to fluoride from all sources, including water, food and dental products. They were attempting to find the so-called “optimal dose” needed to reduce tooth decay, however they concluded that, “achieving a caries-free status may have relatively little to do with fluoride intake…” (Warren et al., 2009). The most likely explanation for the weak evidence of benefit Even fluoridation advocates have acknowledged that the predominant benefit of fluoride is topical, not 182 4 systemic (CDC, 1999). In other words, fluoride works on the outside of the tooth not from inside the body. This acknowledgement removes the whole rationale for fluoridating water and forcing people who don’t want it to ingest it. Most countries don’t fluoridate their water The vast majority of countries (including 97% of Europe) neither fluoridate their water nor their salt. However, WHO figures indicate that tooth decay in 12-year-olds is coming down as fast in non- fluoridated countries as fluoridated ones (http://fluoridealert.org/issues/caries/who-data/ ). Tooth decay in low-income families can be reduced by safer means Many countries have been able to reduce tooth decay in low-income families using cost-effective programs without water fluoridation. The Scottish Childsmile program involves a) teaching tooth- brushing in nursery schools; b) advising parents on better diets; c) annual check-ups and d) fluoride varnishes where necessary. The number of 12-year-olds without caries has increased to over 70% using these methods and in the process costs have been cut by half (BBC Scotland, 2013). Added benefit of emphasizing education Making education, not fluoridation, the center of the fight against tooth decay has the added advantage of attacking the cause of obesity, an issue which threatens to cost health services billions of dollars over coming decades. Please see Signatory Page 183 4 REFERENCES for: Open Letter to Honorable Yael German, Minister of Health, Israel Barbier O, Arreola-Mendoza L, Del Razo LM. 2010. Molecular mechanisms of fluoride toxicity. Chemico-Biological Interactions, 188(2):319-33. BBC News Scotland. 2013. Nursery toothbrushing saves £6m in dental costs. November 9. Brunelle JA, Carlos JP. 1990. Recent trends in dental caries in U.S. children and the effect of water fluoridation. Journal of Dental Research, 69(Special edition):723-727. Excerpts at http://fluoridealert.org/studies/nidr-dmfs/ CDC 1999 (Centers for Disease Control and Prevention). Achievements in public health, 1900- 1999: Fluoridation of drinking water to prevent dental caries. Mortality and Morbidity Weekly Review (MMWR) 48(41): 933-940. October 22. CDC 2005 (Centers for Disease Control and Prevention). Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis–United States, 1988-1994 and 1999-2002. MMWR Surveillance Summaries, 54(3):1-43. CDC 2010 (Centers for Disease Control and Prevention). Beltrán-Aguilar, Barker L, Dye BA. 2010. Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004. NCHS Data Brief Number 53. November. Choi AL, Sun G, Zhang Y, Grandjean P. 2012. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environmental Health Perspectives, 120(10):1362–1368. Connett P, Beck J and Micklem S. 2010. The Case Against Fluoride. White River Junction, Vermont: Chelsea Green Publishing. McDonagh MS, Whiting PF, Wilson PM, et al. 2000. Systematic Review of Water Fluoridation. British Medical Journal, 321(7265):855–59. Note: The full report that this paper summarizes is commonly known as the York Review and is available at http://www.york.ac.uk/inst/crd/fluorid.htm NRC 2006 (National Research Council of the National Academies). Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. Washington, DC: The National Academies Press. Siegel-Itzkovich J 2014. Backlash against Health Minister Yael German for her decision to stop fluoridation. The Jerusalem Post. June 22. Varner JA, Jensen KF, Horvath W, Isaacson RL. 1998. Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity. Brain Research, Feb 16;784(1-2):284-98. Warren JJ, Levy SM, Broffitt B, et al. 2009. Considerations on optimal fluoride intake using dental fluorosis and dental caries outcomes – a longitudinal study. Journal of Public Health Dentistry, 69(2):111-5. 184 4 Signatories: Open Letter to Honorable Yael German, Minister of Health, Israel Sincerely, Paul Connett, PhD, Director, Fluoride Action Network, USA Mary Lou Andersen, MS, Bellingham, Washington Eve-Marie Arcand, DMD, Sherbrooke, Québec, Canada Douglas Amell, ND, Moose Jaw, Saskatchewan, Canada Alexander J. Audette, R.Ac., TCMP, B.Eng.(Chem), Guelph, Ontario, Canada David M. Augenstein, MSc, PEng, Akron/Canton, Ohio John Bain, DDS, Farmington, Arkansas Kellie Barnes, MOMT, MPT, Portland, Oregon Jane Beck, BSc, MBBS, Thames, New Zealand James S. Beck, MD, PhD, Professor Emeritus of Medical Biophysics, University of Calgary, Canada; Co-author, Case Against Fluoride (Chelsea Green, 2010) Bobbie Beckman, DDS, Bassano del Grappa, Italy Kathleen Bernardi, RDH, King City, Ontario, Canada Rosemary R. Bishop, MS (Health Ed), Pensacola, Florida Jo Thomas Blaine, L.Ac, San Diego, California Zuzka Borovjakova, CNP (Certified Nutritional Practitioner), Toronto, Ontario Barry Breger, MD, Montreal, Québec, Canada Gene Burke, BA, Woodland Hills, California Roger Burt, MS (psychology), Portland, Oregon Robert Button BScPharm, RPh, CDE, CRE, Dryden, Ontario, Canada David Buttorff, Louisville, Kentucky Elizabeth Caliva, PE, MS, Encinitas, California Neil J. Carman, PhD, Austin, Texas Page: 1 185 4 Leo Cashman, MA, Executive Director of DAMS Inc. (Dental Amalgam Mercury Solutions), USA Anthony Cipolla, DDS, Williamsport, Pennsylvania Griffin Cole, DDS, President, International Academy of Oral Medicine & Toxicology, Austin, Texas John J. Collins, DC, Newberg, Oregon Michael Connett, JD, Los Angeles, California Gerald W Cooper, PENG, B Eng, MBA, Toronto, Canada Karl Cox, PhD, Brighton, Sussex, UK Michael Czajka, PhD candidate (Chemistry), Melbourne, Victoria, Australia Lady Carla Davis, MPH, Queensland, Australia Catherine L. Deptula, DVM, BS, Brandon, Florida Robert C Dickson, MD, CCFP, FCFP, Calgary, Alberta, Canada Michael F. Dolan, PhD, Amherst, Massachusetts Dr Jayne LM Donegan, MBBS DRCOG DCH DFFP MRCGP MFHom, London, UK Aviva (Zack) Dycian, DMD, Ramat HaSharon, Israel Irucka Embry, M.Eng., BS, Nashville, Tennessee Hart Nadav Feuer, PhD, Agricultural Sciences, University of Bonn, Germany Gerald A Fillmore, DDS, MS, Orthodontist (retired), Gridley, California Laurence Fisher, BDS, Wellington, New Zealand Naomi H. Flack, BS, EdM, Palm Beach Gardens, Florida Gary Fortinsky, DDS, Toronto, Ontario, Canada Matt Freedman, Chiropractic Physician, Eugene, Oregon Brenda L. Gallie, Professor, University of Toronto, Ontario, Canada Elsa Noeline Gannaway, MA. Dip Ed., Wellington, New Zealand Page: 2 186 4 Michael Godfrey, MBBS, Tauranga, New Zealand Sara Gold, DAMS International (Dental Amalgam Mercury Solutions) – Israel Activist, Certified Energy Health Practitioner, Betar Illit, Israel Dorothy Goldin Rosenberg, MES, PhD, Toronto, Canada Yarden Goldstein, DDS, Tel Aviv, Israel Anna Goodwin, MD (Medical Oncologist), Hamilton, New Zealand Michael Gossweiler, DDS Indianapolis, Indiana Stephanie Grootendorst, DC, DACNB, Chiropractic Physician, Diplomate Chiropractic Neurology, Portland, Oregon Ian Gregson, Wellington Chapter, Weston A Price Foundation, New Zealand Ronald A. Greinke, PhD, Medina, Ohio Sophie Guellati-Salcedo, PhD, Miami, Florida Chris Gupta, P.Eng., London, Ontario, Canada MC Hagerty, RN, BSN, MA, Carlsbad, California Merilyn Haines, B App Sc Med Lab Tech, Brisbane, Queensland, Australia Kathryn Hall, RN, Berkeley, California Gerald F Harris BSc, BEd, Peterborough, Ontario, Canada William Harris, MD, Honolulu, Hawaii Leslie C. Hatcher RN, BSN, Southlake, Texas Simeon Hein, PhD, Institute for Resonance, Boulder, Colorado James M. Heltzel, DMD, Las Vegas, Nevada Nancy R. Heltzel, RDH, KOHP, Las Vegas, Nevada David R. Hill, PEng, CEng, FBCS, Professor Emeritus, Calgary, Alberta, Canada J. William Hirzy, PhD, Washington, DC Vic Hummert, Author, Lafayette, Louisiana Page: 3 187 4 David W Horwood, MAgSc, Melbourne, Victoria, Australia Professor C. Vyvyan Howard, MD, PhD, University of Ulster, Northern Ireland; Past President, International Society of Doctors for the Environment Cheryl Hughes, RN, Cove, Texas Ann Huntsman, RN, MS, Cupertino, California April Hurley, MD, Santa Rosa, California Lisa Intemann, PhD, BA, BAppSc, DipSocSc, Port Macquarie, NSW, Australia Bo H Jonsson, MD, PhD, Department of clinical neuroscience, Karolinska Institutet, Stockholm, Sweden Susan Kanen, BS (Whistleblower to lead in drinking water Washington DC), Anchorage, Alaska Barry S. Kendler, PhD, FACN, CNS, Professor of Nutrition, University of Bridgeport, Connecticut David Kennedy, DDS, Past President, International Academy of Oral Medicine and Toxicology, San Diego, California George Knorr, Professor of Physics Emeritus, University of Iowa, Iowa Robert Kopitzke, PhD (Statistics), Fort Collins, Colorado Stephen M. Koral, DMD, Boulder, Colorado Deborah Landowne, CCH, RSHom(NA) Classical Homeopathy, San Rafael, California Neima Langner, MD, FRCP(C) Community Medicine and Public Health, Ottawa, Ontario, Canada Isabella Leviyev, Physician Assistant, Queens, New York Louisa Liberman, PhD, Hillsborough, North Carolina Hardy Limeback, PhD, DDS, Former Head, Preventive Dentistry, University of Toronto; Past President, Canadian Association for Dental Research; Member of the 2006 National Research Council panel which reviewed the toxicology of fluoride; Mississauga, Ontario, Canada Mel Litman, MD and Maya Litman, BA, B.Ed, Metar, Israel Dennis Lobstein, MTCM, PhD, Los Angeles, California Theresa Lynch, Ed. D., Charlottesville, Virginia Page: 4 188 4 Douglas J. Mackenzie, MD, Santa Barbara, California Peter Mackinlay, Dip Arch, A G Inst Tech, B Arch, Geelong, Victoria, Australia Joy Margulies, RN, BS (community health), Arverne, New York Elizabeth McDonagh BSc(Hons), Cert. Ed., Doncaster, South Yorkshire, UK Lisa McLaurin, RN, CCRN, Castaic, California James D. McNabb, MD, CNS, Austin, Texas Philip Michael, MB, BCh, DCH, DRCOG, MICGP, Hon Sec IDEA, Bandon, Co Cork, Ireland Spedding Micklem, D.Phil (Oxon), Edinburgh, Scotland; Co-author, Case Against Fluoride (Chelsea Green, 2010) Howard W. Mielke, PhD (Environmental Pharmacology), New Orleans, Louisiana Deborah E. Moore, PhD, Executive Director, Second Look, Worcester, Massachusetts Tatyana Moore, CPA, Syracuse, New York John J Mulrooney DC, Portland, Oregon Janet Nagel, Ed.D (Public health educator, ret.), Greensboro, North Carolina Ted Ninnes, MA, MSc, PhD, Kawhia, New Zealand Bill Osmunson DDS, MPH, Portland, Oregon Eugene L. Packer, DC, N.Easton, Massachusetts Ian E Packington MA (Oxon) Cert Tox (Barts), York, UK Dr Geoff Pain, Monbulk, Victoria, Australia Gilles Parent, ND, Co-author, Fluoridation: Autopsy of a Scientific Error, 2010. Québec, Canada Professor Stephen Peckham, BSc, MA(Econ), University of Kent; Director, Centre for Health Services Studies, Canterbury, UK Doug Piltingsrud, PhD (Inorganic chemistry), Eyota, Minnesota Michael Pinkerton, Doctor of Chiropractic, Petaluma, California Page: 5 189 4 Christian Pires, Systems Engineer, Portalegre, Portugal Betsy Ramsay, Journalist, Teacher, Author, Jerusalem, Israel Hagen Rampes, BSc MBChB FRCPsych, London, UK Elizabeth W. Reed, PhD, Oak Ridge, Tennessee James W. Reeves, PhD, Lafayette, Louisiana David W Regiani, DDS, MIAOMT, Founding member, Past president of the International Academy of Oral Medicine and Toxicology, Ortonville, Michigan Curtis Rexroth MA, DC, CCN, Moline, Illinois Robert H Riffenburgh, PhD, MS, PStat, FASA, FRSS, San Diego, California; Author, Statistics in Medicine, 3rd Edition (Elsevier, 2012). Cynthia L. Rochen, BSN, BSAg, Silver Spring, Maryland Terry Rose, BSc., BDS, Otago New Zealand Michael Ross, LHP, Toronto, Ontario, Canada Troy Ross, MD, MPH, Reno, Nevada Teresa Rouse, BSN, RN, CRRN, Green City, Missouri Jean Ryan, BSc, Nutrition and Dietetics, RN, Brisbane, Queensland, Australia John A. Ryan, MBBS, MSc, Nutrition, FRACGP, DCH, FAMAC (Acupuncture), FACNEM, Brisbane, Queensland, Australia Holly Satvika, RN, FNP-BC, Asheville, North Carolina Andrew W. Saul, PhD, Editor, Orthomolecular Medicine News Service, Rochester, New York Michael B Schachter, MD, Certified Nutrition Specialist (CNS), Suffern, New York Judy Schriebman, Certified Classical Homeopath, RSHom(NA), San Rafael, California Karilee Shames PhD, RN, Sebastopol, California Richard Shames, MD, Sebastopol, California Nestor B Shapka, DDS, Bonnyville, Alberta, Canada Page: 6 190 4 Ruth W. Shearer, PhD (toxicologist, retired), Lacey, Washington Davorin K. Skender, BSE, Bloomington, Indiana Rick Smith, Network Manager (CAAS), Providence, Rhode Island Kristine L. Soly, MD, FACC, Holistic Cardiologist, Crossville, Tennessee Joerg Spitz, MD, PhD, Schlangenbad, Germany Carol Vander Stoep, RDH, BSDH, OMT, Austin, Texas Kathleen Thiessen, PhD, Senior Scientist, Oak Ridge Center for Risk Analysis, Tennessee Sheldon Thomas, Director ‘Clear Water Legacy’, Retired Manager of Water Distribution, Hamilton, Ontario, Canada William Thornton, ND, DC, Santa Monica, California Eric Turk, PhD (Neuroscience), North Hills, California Shimon Tsuk, M.Sc., Kiryat Ono, Israel Ruth Tudor, RN, Olympia, Washington Hilary C. Walton, PhD in Evolutionary Behavioral Ecology, Cleveland OH Barbara Warren, RN, MS, Albany, New York Joy Warren, BSc. (Hons, Env. Sc.), Certificate in Health and Nutrition, West Midlands, UK Declan Waugh, Environmental Scientist, Cork, Ireland Charles Weber, MS (soil science), Hendersonville, North Carolina John J. West, CET, LAFT, Wallingford, Vermont Donna Westfall, Former Councilmember, Crescent City, California Raymond R. White, PhD (Biology), San Francisco, California Shirley Williams, RN, Bellingham, Washington Mae W. Woo, DDS, Billings, Montana Loty Zilberman, Chemical Engineer, MSc, Ghivataiim, Israel Page: 7 191 4 192 4 Attachment C !"# $ % &' '' ( % 193 4 ! ""#$ 194 !! " " !### % &' ( !)*#+ $$ % % & ' !## , ( ) '%)- ! $# ($ ** % %+'' ,!### --)#-. # / ( " !(")#. 4 Attachment D !" #$% &'((%%% ()**( + ,-.-,. /% 195 4 196 4 197 4 198 4 199 4 200 4 201 4 202 4 203 4 204 4 205 4 206 4 207 4 208 4 209 5 210 5