Scientific knowledge in controversy: the social dynamics of the fluoridation debate Brian Martin with a commentary by Edward Groth III Published in 1991 by State University of New York Press, Albany The version here differs from the published version in a number of details of expression, a different format, different page numbering (151 instead of 274 pages) and omission of the index. Contents 1. Introduction 1 2. Arguments 9 3. Coherent viewpoints 27 4. The struggle over credibility 40 5. Professional attack 66 6. A corporate connection? 84 7. Making a decision 94 8. Studying the controversy 106 The fluoridation controversy: which side is science on? by Edward Groth III 122 Appendix: Fluoridation around the world 137 Acknowledgments Albert Burgstahler, Edith Waldbott, and many others (too numerous to mention) plied me with valuable information through correspondence. Gay Antonopoulos obtained copies of many publications for me through interlibrary loans. I thank the individuals listed in chapter 3 for their generosity in being interviewed. Discussions with Mark Diesendorf and Evelleen Richards provided me with insights. I received a large number of valuable corrections and comments on the earlier drafts from Albert Burgstahler, Brian Burt, John Colquhoun, Mark Diesendorf, Edward Groth III, Michael A. Lennon, Pam Scott, John Small, Donald Taves, and several anonymous reviewers. I especially thank Edward Groth III for his mammoth correspondence and for writing the commentary. 1 Introduction The 1 August 1988 issue of Chemical & fluoridation are given little space and little Engineering News contained an article that credence. caused a sensation in the long-running The Chemical & Engineering News article controversy over fluoridation. “Fluoridation of represented a dramatic contrast to the usual Water,” a special report written by associate dismissal of antifluoridation views. The article editor Bette Hileman,1 surveyed the arguments generated news stories around the country and both for and against the measure. overseas, and led to a large volume of Fluoridation is the addition of the element correspondence in later issues. Not surpris- fluorine — called “fluoride” when in an ingly, opponents of fluoridation were ionized form — to public water supplies as a delighted with the article; supporters were measure to help prevent tooth decay in dismayed. More significantly, many corre- children. Hileman’s article outlined the spondents congratulated Bette Hileman and standard view that fluoridation greatly reduces Chemical & Engineering News for raising tooth decay, but also presented criticisms of both sides of the issue for public discussion. this view. It described evidence both for and against claims that fluoridation may be A BRIEF HISTORY involved in health problems, such as kidney disease, hypersensitive reactions, and cancer. The use of fluoride to prevent tooth decay was It also recounted some of the methods used in promoted by various individuals in Europe in the ardent promotion of fluoridation. the 1800s.4 But the key events on the road to Hileman had not been involved in the fluoridation occurred later and in the United fluoridation debate that has raged for decades. States. In writing the article, she studied the issue and Frederick McKay, a dentist, first noticed consulted both supporters and opponents of staining of teeth in his Colorado patients in fluoridation. 1901. The colors ranged from white, yellow, The ideas in her article were not new, and and brown to black. In serious cases, there was most of the evidence had been canvassed also pitting of the enamel. Unlike most others repeatedly in other forums. Why, then, did it who had noticed this mottling, McKay was cause such an impact? The reason is that never intrigued by it and, over the next three before had such a major scientific publication decades, he pursued its origins. He noticed presented both sides to the debate in such an that, whereas people who had lived in a extensive treatment. In particular, never before particular community from birth had stained in recent decades had a major professional teeth, newcomers to the district did not. association, such as the American Chemical Further investigation convinced McKay that Society, publisher of Chemical & Engineering water supplies were responsible. News, given the scientific criticisms of It was not until 1931 that chemical analysis fluoridation such credibility.2 provided an answer to what was causing the In the English-speaking countries at least, discoloration: fluoride. H. V. Churchill, chief fluoridation has long been virtually untouch- chemist at the Aluminum Company of able for “serious scientists.” Opponents of America, supervised tests on water samples fluoridation have been categorized as cranks, and, with McKay’s help, established a usually right-wing, and akin to those who connection between fluoride in drinking water think the earth is flat.3 In most dental, medical, and mottled teeth. At about the same time, and scientific journals, the arguments against researchers M. C. Smith, E. M. Lantz, and H. 2 Scientific knowledge in controversy V. Smith in Arizona were able to produce 1945. The water supply in control city, mottling in the teeth of rats by feeding them Muskegon, also in Michigan, remained fluoride. Also in the same year, H. Velu unfluoridated. In the same year and in New reported the fluoride-mottling link based on York State, Newburgh’s water was fluori- work in Morocco and Tunisia. dated, while Kingston served as the control. McKay had long observed that mottled Other important early studies involved teeth, although unsightly, seemed to be more fluoridation of the water supplies in Evanston, resistant to decay. Discovery of the fluoride Illinois, and Brantford, Ontario. Oak Park, connection finally stimulated the United States Illinois, and Sarnia, Ontario, served as the Public Health Service (USPHS) to investigate respective controls. the issue. Led by H. Trendley Dean, USPHS At the time, it was thought that fluoride scientists (mainly dentists) carried out surveys acted by being incorporated into the growing of decay in towns with different fluoride levels enamel of children’s teeth. Hence, it would and also carried out experiments with animals. take quite a few years to see the full effect of A range of levels of fluoride led to the fluoridation. The trials were planned to last ten severe mottling observed by McKay and or fifteen years. But after only a few years, the others. Severe mottling was widespread at five reported reductions in tooth decay were quite parts per million (ppm) and above, but less striking. common at lower concentration.5 Investigators The proponents of fluoridation — in looked to see whether there was a concentra- particular, a few enthusiastic advocates such as tion that avoided most mottling while Wisconsin dentist John G. Frisch and providing the benefits of reduced tooth decay. Wisconsin dental administrator Francis Bull The level judged to be optimal in this regard — were impatient with delay. Their lobbying was 1.0 ppm. was aimed especially at administrators in the Only a small fraction of water supplies have USPHS, the most influential body in the high levels of fluoride naturally. Most have public health field. H. Trendley Dean, whose less than 0.2 ppm, a concentration too small to work helped lay the ground for fluoridation, provide much impact on decay. In 1939, it was was not a supporter of rapid implementation, first proposed to add fluoride to waters that preferring to wait for the full results of the naturally have low fluoride levels. Fluoride fluoridation trials. Along with others, his view would be added to bring the concentration to was influential in maintaining the USPHS’s about 1.0 ppm. cautious stand throughout the 1940s. The proposal struck a chord with a small The high-pressure tactics of Frisch, Bull, number of dentists and public health officials and others eventually won out. The top in the United States who began campaigning administrators of the USPHS apparently vigorously for fluoridation. Many others were overruled Dean,6 and, in 1950, the USPHS more cautious, including national health endorsed fluoridation. Shortly afterward, two administrators and USPHS scientists who were key professional bodies — the American still studying the dental effects of fluoride. In Dental Association (ADA) and the American 1945, the first of a number of trials was begun. Medical Association (AMA) — also expressed In these studies, two cities with similar support. characteristics were selected. Both had low In the United States, however, decisions natural levels of fluoride in the water. One city concerning public water supplies are made at had fluoride added to its water supply, while the level of states, cities, or towns. The the other’s water remained unfluoridated. USPHS endorsement did not force any Rates of tooth decay in the cities were community to fluoridate, but it did provide monitored by periodic examination of vital authoritative backing for local individuals children’s teeth. and groups that pushed for it. The first study involved Grand Rapids, The endorsements by the USPHS, ADA, Michigan, where water was fluoridated in and AMA were based on the claim that Introduction 3 fluoridation resulted in massive reductions in From the United States, the message about tooth decay, typically quoted as 50 to 60 fluoridation was sent around the industrialized percent, with no associated health risks, and at world. Dental and medical authorities, after little cost to the community. At the time, investigation, usually endorsed the measure. In dental decay was widespread, and many several countries — especially Australia, dentists felt unable to cope with it. Many Canada, Ireland, and New Zealand — the people had all their teeth removed at an early pattern has been similar to that of the United age due to decay. In this environment, States: there has been widespread adoption of fluoridation was an attractive proposition. fluoridation in the face of strenuous opposi- During the 1950s, a large number of tion.