Analysis Controversy

Adding fluoride to water supplies

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39318.562951.BE (Published 04 October 2007) Cite this as: BMJ 2007;335:699

Fluoridation: Time to reevaluate

The BMJ needs to be commended for further opening the scientific
debate on fluoridation. For the first 25 years of dental practice I
promoted the addition of fluoride to water, in part because I thought I
could “see” the difference between those on fluoridated water and those
without. Unfortunately, I was actually comparing socioeconomics rather
than fluoridation. As more patients have come in requesting extensive
cosmetic dentistry, sometimes costing tens of thousands of dollars to
correct their dental fluorosis, I decided it was time to look at the
sources, dosage, efficacy, and benefits of ingested fluoride. Looking at
the current literature was like a knee in the gut.1

FLUORIDE EXPSURE: Clearly fluoride exposure has increased over the
last 60 years. Dental fluorosis is up 50% to a third of children. More
dental and medical products and medications contain fluoride. Permitted
residue levels from fluoride based pesticides and post-harvest fumigants
(ProFume, Dow Agro Chemical) have significantly increased in just the last
decade. Mechanically deboned meat can be much higher in bone/fluoride
content. Grape products and some tea have high levels of fluoride.
Apparently no agency is the legal intermediary, the doctor, responsible
for monitoring the public’s total exposure to fluoride. Some people are
more sensitive to chemicals and unable to excrete excess fluoride.
Synergistic effects from groups of chemicals are relatively unknown. It
appears any benefit of fluoride is from a topical application and not from
ingested fluoride.

BENEFITS OF FLUORIDATION: “Evidence for whether an intervention
works when applied in the community at large is referred to as its
effectiveness. . . . Effectiveness studies more accurately reflect results
that may be expected from the implementation of interventions.”2 If
fluoride actually provides a “life time” reduction of dental decay,
certainly after 60 years of fluoridation we should see clear evidence of
effectiveness. Unfortunately, comparing developed countries finds all
have reduced dental decay to similar levels regardless of fluoridation.
Comparing states within the USA based on the percentage of the population
fluoridated finds no improved dental health or reduction of decay
regardless of the percentage fluoridated. Comparing similar states such as
Washington State (59% fluoridated) with Oregon State (19% fluoridated)
actually finds slightly better dental health in the less fluoridated
Oregon. Comparing counties within states finds similar oral health, with
similar socioeconomics, regardless of fluoridation.3 Studies on
fluoridation have not included the confounding factor of delayed tooth
eruption or looked at life time benefits.4

It is a flawed assumption to expect fluoridated children with fewer
cavities will "therefore" have a life time of fewer cavities. Several
studies have actually found an increase in dental decay and tooth loss
with fluoridation. Without clear, undisputed, life time benefits from
fluoridation , any risk or expense is unacceptable. Communities have
stopped fluoridation with no increase in dental decay.5 The experiment
of fluoridation is currently being promoted without good scientific and
ethical review of continued life time benefits.

The US National Academy of Sciences 2006 report confirmed potential
benefits from fluoridation are during the development of the tooth, up to
about age 8. It makes no sense to have a lifetime uncontrolled dose of
fluoride for everyone when the potential benefits are only up to age 8.
Lifetime exposure must be considered.

DENTAL RISKS OF FLUORIDATION: As a Cosmetic Dentist, it is not
uncommon to have patients receive gorgeous porcelain veneers to correct
their dental fluorosis, white and brown damage from too much ingested
fluoride. Costs range from several hundred dollars to well over $25,000
and need to be retreated every 10 to 20 years for life time costs which
may exceed $100,000 per person. With a third of children having dental
fluorosis, the true costs for cosmetic damage to teeth alone is in the
trillions of dollars. A side effect seldom raised by cosmetic dentists.
Certainly most will not seek treatment, but the public liability for
damage is significant. Public Health Dentists seldom provide cosmetic
dentistry and therefore under rate the increased dental damage from
fluoridation.

MEDICAL RISKS OF FLUORIDATION: Many committees reviewing
fluoridation are composed of Dentists. It is not in the perview of
Dentistry to diagnose thyroid, hormonal, skeletal, kidney, liver, brain,
skeletal disorders or cancers outside the oral cavity. Epidemiologists,
Toxicologists and Medical Professionals unwisely rely on their Dental
counterparts to diagnose safety for body organs from fluoridation and
Dentists would be practicing outside their scope of training and licensure
to appropriately weigh the gravity of medical side effects. Historic
ground was covered in the USA when scientists opposed to fluoridation were
permitted on the National Academy of Science 2006 report to the US
Environmental Protection Agency which unanimously found the EPA’s Maximum
Contaminant Level was not protective.6

The US Center for Disease Control and American Dental Association
have cautioned infants should not be given fluoridated water or
fluoridated water be used for making infant formula.7 More than 3 out of
4 infants receive formula. Consider that all are medicated with
fluoridation, yet the water is not safe for our most vulnerable, our
babies. We are now asking mom’s to haul their infant, it’s food, toys,
clothes, and now water. Parents in third world countries can usually boil
their water to make it safe for infants, but many communities consciously
put chemicals in the public water which can’t even be boiled out or
traditional filters used to make it safe for infants.

The biggest problem in the US scientific community is the fear
Universities, Medical and Dental Associations and Journals have in
permitting discussion, debate and scientific review of fluoridation. One
state medical association requested $50,000 for a short private
presentation of concerns. Others permit review only by their legal
counsel. The BMJ should be commended for their willingness to do what few
other scientists are willing to do, open scientific discussion.

Bill Osmunson DDS, MPH
Aesthetic Dentistry of Bellevue
bill@smilesofbellevue.com

1. The CDC also references Horowitz and Ismail 1996, Johnston 1994,
Ripa 1990, Stookey and Beiswanger 1995, however all these reviewed topical
application of fluoride, not the addition of fluoride to water.
http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm

2. http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm

3. National Survey of Children's Health.
http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm.

http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats...

The National Survey of Children's Health 2003. Rockville, Maryland:
U.S. Department of Health and Human Services, 2005

U.S. Department of Health and Human Services, Health Resources and
Services Administration, Maternal and Child Health Bureau

http://www.doh.wa.gov/cfh/Oral_Health/Documents/SmileSurvey2005FullRepor...

http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdf#search='Oregon%20Decay%20experience‘

BRFSS 2002
http://www.dhs.state.or.us/dhs/ph/chs/brfs/02/orahea/dentvisi.shtml
http://apps.nccd.cdc.gov/brfss/display.asp?state=WA&cat=OH&yr=2004&qkey=...
Sample size OR 3509 and WA 12,926 2004 data

http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats...

National Survey of Children's Health.
http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm
U.S. Department of Health and Human Services,
http://www.fluoridationcenter.org/papers/2002/cdcmmwr022102.htm

http://quickfacts.census.gov/qfd/states/41000.html

4. Our analysis shows no convincing effect of fluoride-intake on
caries development." Komarek A, et al. (2005). A Bayesian analysis of
multivariate doubly-interval-censored dental data. Biostatistics 6:145-55.

5. Kugel (sp) and Fischer 1997, Seppä et al. 1998

6. www.nap.edu/catalog/11571.html; Fluoride in Drinking Water: A
Scientific Review of EPA’s Standards 2006

7.http://www.cdc.gov/fluoridation/safety/infant_formula.htm;
www.ada.org; see also Pizzo G, et al Community water fluoridation and
caries prevention: a critical review, Clin Oral Investig. 2007 Feb 27.

Competing interests:
None

Competing interests: No competing interests
19 October 2007
Bill Osmunson DDS, MPH
Cosmetic Comprehensive Dentist
Bellevue, Washington 9804
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