ArticlePDF Available

The fluoride debate

January 2014

Authors:

Paul Connett

The American Environmental Health Studies Project, Inc

Ken Perrott

AgResearch

No caption available

…

No caption available

…

No caption available

…

No caption available

…

+22

No caption available

…

Figures - uploaded by Ken Perrott

Content may be subject to copyright.

Content uploaded by Ken Perrott

Content may be subject to copyright.

THE FLUORIDE

DEBATE

PAUL CONNETT AND KEN PERROTT

Contents

Introduction - Ken Perrott .......................................................................................................... 3

First article: Paul Connett - October 30, 2013 ........................................................................... 5

Ken Perrott - October 30, 2013 .................................................................................................. 9

Paul Connett - November 4, 2013............................................................................................ 18

Ken Perrott - November 7, 2013 .............................................................................................. 36

Why I Support fluoridation: Ken Perrott - November 11, 2013 .............................................. 46

Paul Connett - November 14, 2013.......................................................................................... 52

Ken Perrott -November 17, 2013 ............................................................................................. 56

Paul Connett - November 21, 2013.......................................................................................... 65

Ken Perrott - November 25, 2013 ............................................................................................ 78

Paul Connett - December 2, 2013 ............................................................................................ 90

Ken Perrott - December 9, 2013 ............................................................................................ 103

Paul Connett - December 12, 2013 ........................................................................................ 119

Ken Perrott- December 16, 2013 ........................................................................................... 135

Paul Connett - December 25, 2013 ........................................................................................ 150

Ken Perrott - 1 December 30, 2013 ....................................................................................... 161

Closing statement: Paul Connett - January 22, 2014 ............................................................. 176

Final article – Ken Perrott - 23 January 23, 2014 .................................................................. 196

Introduction - Ken Perrott

This is a collection of articles written by Paul Connett and Ken Perrott in their exchange of

opinions on the fluoridation of drinking water and related issues. While loosely titled The

Fluoride Debate this was in no way meant to be a debate in the gladiatorial sense. It was not

about “winners” and “losers.” Our intention was to discuss the science in a format

encouraging good faith discussion and intelligent participation from commenters.

I leave it to readers to decide how successful, or otherwise, we have been in this.

Introducing the authors

The authors in this "debate' have similar academic and professional backgrounds. Both have

PhDs in chemistry, worked as research chemists and are now retired. Neither of us have done

original research on fluoridation specifically, although both have become involved in the

public discussion of it since there retirements.

Paul Connett is an executive director of the Fluoride Action Network and campaigns

throughout the world against fluoridation. He is, together with James Beck & H. Spedding

Micklem, author of the book "The Case Against Fluoride." Paul has made several speaking

tours in New Zealand as part of his campaign and will have another tour in February, 2014.

Ken Perrott is a retired research chemist. These days he writes a blog, Open Parachute

(http://openparachute.wordpress.com/), which deals issues related to science, human rights,

philosophy and religion. Many of his articles have argued against pseudoscience and the

misrepresentation of science. He has written a number of articles on scientific issues related

to fluoridation (see http://openparachute.wordpress.com/fluoridation/)

Format of debate

The exchange occurred as posts on the blog Open Parachute. Paul originally proposed it as 5

pairs of articles with Paul starting and raising specific arguments against fluoridation

followed by my reponse.– Paul Connett’s specific argument first with my response second. I

thought this would be a convenient size for a series of blog articles.

Paul's first article went live on October 30, 2013. Without the discipline of an external

moderator the series ended up a longer than originally planned - we ended up with 8 pairs of

articles, with my final closing article posted on January 23, 2014.

Responding to requests from commenters about my own personal, rather than scientific,

motivations I also posted an extra article Why I support fluoridation on November 11.

Inevitably its content was also debated.

Editing of articles

The articles here are basically the same as originally posted in the debate. I have corrected

some typos and added reference lists to my own articles recognising that the hot links

provided in a blog article may not be suitable for all readers of this document. I have avoided

editing or altering Paul's articles except for a few minor issues like adjusting image size..

Comment discussions

Many others, representing both sides of the "debate," participated in this exchange through

the comments section of each article. Some commenters were very well informed, often with

professional experience related to fluoridation. There were almost 2000 comments in total

with many of them containing useful information and citations. Unfortunately it is not

feasible to include the comment discussion here but I urge interested readers to browse

through them on-line.

Links to debate

You can easily find original blog articles, together with comments, at the link Fluoride

Debate (http://openparachute.wordpress.com/fluoride-debate/)

Advice to readers

Such lengthy articles, and so many of them, might be intimidating to some readers. My

advice is to browse, read the articles that interest you or cover issues of interest. I imagine

only the most dedicated reader would start at the beginning and read to the end.

Any reader wishing to make contact with me can do so via my About me blog page

(http://openparachute.wordpress.com/about-me/).

First article: Paul Connett - October 30,

2013

This is part 1 of a five-part series of internet exchanges on the fluoridation debate between

Paul Connett (USA) and Ken Perrott (NZ).

1. Fluoridation is a poor medical practice.

2. The evidence that swallowing fluoride reduces tooth decay is very weak. Better

alternatives for fighting tooth decay

3. The large database that indicates that fluoride can impact the brain of animals and humans.

4. Other health concerns and the lack of an adequate margin of safety to protect everyone

drinking fluoridated water.

5. Key moments since 1990 that should have forced an end to fluoridation.

Paul Connett is co-author of The Case Against Fluoride (Chelsea Green, 2010) and executive

director of the Fluoride Action Network (www.FluorideALERT.org ) Paul’s cv and list of

publications is attached.

Part 1. Fluoridation is a poor medical practice

Introduction. Using the public water supply to deliver medical treatment is a very unusual

practice. In fact it has only been done only once before and that was a short trial in which

iodine was added to the drinking water to help fight hypothyroidism. However this was

quickly abandoned when it was found that some people were being over-exposed to iodine.

Since then fluoridation has been the only example. The reasons for not using the water to

deliver medical treatment are fairly obvious.

1) It is impossible to control the dose people get. Once a chemical is added to the water to

treat people (as opposed to treating the water to make it safe or palatable to drink) it is

impossible to control the dose people get. People drink very different amounts of water. In

short, engineers at the water works can control the concentration added to the water (mg/liter)

but no one can control the total dose (mg/day) individuals receive.

2) It is totally indiscriminate. It goes to everyone regardless of age, regardless of health or

nutritional status. Of particular concern is that it goes to people with poor kidney function

who are unable to clear the fluoride from their bodies via the kidneys as effectively as others.

It thus accumulates in their bones more rapidly. It also goes to people with low or borderline

iodine intake, which makes them more vulnerable to fluoride’s impact on the thyroid gland.

In general, according to studies done in India, people with poor diet (low protein, low

calcium and low vitamin intake) are more vulnerable to fluoride’s toxic effects.

3) It violates the individual’s right to informed consent to medical treatment. This is a

very important medical ethic which is fully described on the website of the American

Medical Association (www.AMA.org). It is very surprising that so many medical doctors

standby while the community does to everyone what they are not allowed to do to a single

patient.

The above arguments would apply to any medicine added to the drinking water but there are

other aspects to the fluoride ion, which makes it particularly unsuitable for addition to the

drinking water.

4) Fluoride is NOT a nutrient. There is not one single biochemical process in the body that

has been shown to require fluoride for normal function (we will see later that fluoride’s

predominant action on teeth is topical not systemic). However,

5) There are many biochemical processes that are harmed by fluoride (given a sufficient

dose). These include the inhibition of many enzymes. This is the reason that some of the

earliest opponents of fluoridation were biochemists like Professor James Sumner from

Cornell University, who won the Nobel Prize for his work on enzyme chemistry. More

recently fluoride has been shown to activate G-proteins and interfere with the cell’s

messaging systems. It can also cause oxidative stress. An excellent summary of fluoride’s

biochemistry can be found in the article “Molecular Mechanisms of Fluoride Toxicity” by

Barbier et al, 2010.

6) The levels of fluoride in mothers’ milk is extremely low. This level, on average for a

woman in a non-fluoridated community, is 0.004 ppm (NRC, 2006, p.40). This means that a

bottle-fed baby in a fluoridated community (at 1 ppm) will get about 250 times more fluoride

than a breast fed baby in a non-fluoridated community. Bearing in mind the fact that life

emerged from the sea where the average level of fluoride is about 1.4 ppm, and thus there

was no impediment for nature to use fluoride when developing human metabolism, her

verdict appears to be that the baby a) does not need fluoride and b) that it may be harmed by

fluoride. In my view, it is more likely that nature knows more about what the baby needs than

a bunch of dentists from Chicago or public health officials in Washington, DC.

7) Fluoridation has always been a trade-off between lowered tooth decay and dental

fluorosis but a key question was never satisfactorily answered. When the fluoridation

trials began in 1945 it was known that the trade-off was that approximately 10% of the

children would develop dental fluorosis in its mildest form (this was a mottling or

discoloration of the tooth enamel). While the mechanism whereby fluoride caused this effect

was not known it was known to be a systemic effect. In other words it was caused by fluoride

interfering with biochemistry during the development of the tooth cells. The question that

was not answered before the US Public Health Service endorsed fluoridation in 1950, was:

“What other tissues in the body may be interfered with at the same time that fluoride was

interfering with the laying down of the tooth enamel?” Were the baby’s bone cells also being

impacted? How about brain cells? How about the cells of the glands in the endocrine system?

Sadly, very little has been done in fluoridated countries to answer these questions since

fluoridated was started. However, proponents do acknowledge that the appearance of dental

fluorosis means that a child was over-exposed to fluoride before the permanent teeth have

erupted. Meanwhile, in 2010 the CDC reported that 41% of American children aged 12-15

have dental fluorosis, with 8.6% having the mild form (with up to 50% of the enamel

impacted) and 3.6% with moderate or severe dental fluorosis (100% of the enamel impacted).

In later arguments in this debate I will be presenting evidence that fluoride is capable of

harming other developing tissues.

8) The fluoridating chemicals used to fluoridate the water supply are not the

pharmaceutical grade chemicals as used in dental products. Most of the chemicals used

are obtained from the phosphate fertilizer industry’s wet scrubbing systems (see Chapter 3,

The Case Against Fluoride). One of the problems with this source is that it is contaminated

with a number of other toxic chemicals including arsenic. Arsenic is a known human

carcinogen and as such for the US Environmental Protection Agency (EPA) there is no safe

level. The EPA’s maximum contaminant level goal (MCLG) for drinking water is thus set at

zero. Proponents will argue that after the dilution of these bulk chemicals by about 180,000 to

1, the level of arsenic is negligible. However it is not zero and thus this practice will

inevitably increase cancer rates in the population. As there are other delivery systems which

are cost-effective and do not involve the use of these industrial grade chemicals, increasing

the cancer rate even by a small amount is not acceptable.

9) Worldwide fluoridation is not a common practice. Proponents will often imply that

fluoridating the drinking water is a common practice. It is not. Most countries do not

fluoridate their water. 97% of the European population is not forced to drink fluoridated

water. Four European countries have salt fluoridation (Germany, France, Switzerland and

Austria), but the majority of European countries have neither fluoridated water nor

fluoridated salt, yet according to World Health Organization (WHO) data available online

(measured as DMFT in 12-year-olds) tooth decay rates in 12-year-olds have declined as

rapidly over the period 1960 to the present in non-fluoridated countries as fluoridated ones

and there is little difference in tooth decay rates today (see Cheng et al, 2007). The reasons

that European spokespersons have given for not fluoridating their water are usually twofold:

a) they do not want to force fluoride on people who don’t want it and b) there are still many

unresolved health issues (see a list of statements by country

athttp://fluoridealert.org/studies/caries01 ).

10) Typically fluoridation is promoted via endorsements not via sound science. When the

US Public Health Service (PHS) endorsed fluoridation in 1950, before a single trial had been

completed and before any meaningful health studies had been published, it clearly was not

the result of solid scientific research. However the PHS endorsement set off a flood of

endorsements from other health agencies and professional bodies (see Chapters 9 and 10 in

The Case Against Fluoride). Most of these came between 1950 and 1952. These

endorsements were not scientific but simply reflected a subservience of public policy to the

US government. However, promoters of fluoridation for over 60 years have used these

endorsements very effectively with the general public as if they were coming from scientific

bodies reflecting thorough and comprehensive scientific research. Very seldom is this the

case. Hopefully, in these exchanges with Ken Perrott we will both focus on what the primary

science actually says and not what some “authority” has to say about the matter.

References:

Barbier et al., 2010. Molecular Mechanisms of Fluoride Toxicity. Chem Biol Interact.

188(2):319-33http://www.ncbi.nlm.nih.gov/pubmed/20650267

CDC, 2010. Beltrán-Aguilar,Prevalence and Severity of Dental Fluorosis in the United

Stateshttp://www.cdc.gov/nchs/data/databriefs/db53.htm

Cheng et al. 2007. Adding fluoride to water supplies. BMJ 335:699

http://www.bmj.com/content/335/7622/699?tab=responses

Connett, P., Beck, J and Micklem HS. The Case Against Fluoride. Chelsea Green, White

River Junction, Vermont, 2010.

NRC, 2006. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards (2006)

http://www.nap.edu/catalog.php?record_id=11571

Ken Perrott - October 30, 2013

Paul’s first article appears to be a general overview and not detailed consideration of the ten

points he makes. I will be similarly brief in my response to each point. Paul may wish to go

deeper into specific issues in later contributions and I will respond in more detail then.

The medical argument

Paul’s first 3 arguments rely on defining fluoridation as a medical treatment. This is a

common anti-fluoridationist approach. I have no wish to argue about that definition as it is

really just a matter of semantics. You could use a weak definition of “medicine” which can

include practically anything in your diet the body uses and may tolerate over a wide range of

intake without harm. Or a tighter definition implying a drug with some sort of marked effect

in the body and requiring relatively careful control of intake. But whatever definition is used

should be openly declared and applied consistently.

Opponents of fluoridation usually apply their definitions of “medicine” inconsistently and the

argument becomes a classic bait and switch tactic. It uses a weak definition of “medicine” to

capture fluoride and then switches to a tight definition to argue that use of fluoride requires

rigid controls. This presents them with a number of problems because a weak definition of

“medicine” must also include “natural” as well as “artificial” fluoride at natural levels in

water a food. (A weak definition may also include many other elements – perhaps even water

itself). There is no such thing as a “fluoride-free” water supply. If we exclude natural levels

of fluoride (and most other elements) from our definition of “medicine” then why should we

treat levels for artificially fluoridated water any differently?

Connett’s point 1: Why should we not be concerned about controlling the dose of natural

levels of fluoride (or many of the other elements we consume) while only be concerned about

the fluoride added as a “top up?” The are no differences between the “artificial” and “natural”

fluoride anions in drinking water. In reality most elements like this have a sufficiently wide

range of concentrations and intakes for efficacy that it is just ridiculous to treat them like

powerful drugs which need accurate dosage.

Connett’s point 2: Similarly why make charges of indiscriminate intake only for artificially

added F and not for natural levels of F and other elements? The small number of people, if

any, who may have problems with fluoridation levels of F will also have the same problems

with natural levels of F. Such people, if they real exist, will need individual responses to

either natural or artificial levels of F and possibly other elements. These people will need

individual responses whether their water supply is artificially fluoridated or not.

Connett’s point 3: Why demand “informed consent” for situations where natural levels of

fluoride have been “topped up” and not require it for natural levels of fluoride – which in

some situations may actually be higher than for fluoridated water supplies.

Is fluoride a nutrient?

Connett’s point 4: This also reduces to semantics – how should “nutrient” be defined? Paul

restricts his definition only to elements involved in “biochemical processes” – a definition

confidently excluding the role of F in bioapatites – bones and teeth. Yet bones and teeth are

important to organisms – so the strengthening of bioapatites, and the reduction of their

solubility, by incorporation of fluoride is important.

Perhaps we can agree that F is at least a beneficial element, even if we can’t reach agreement

on the use of terms like “nutrient” and “essential.”

Biochemical processes and fluoride

Connett’s point 5: It is easy to cite literature references showing negative effects of fluoride

but we should not ignore the conditions used. Most such studies refer to much higher

concentrations than used in water fluoridation and this is also true for the review by Barbier

et al, 2010 Connett cites.

Let’s not forget that community water fluoridation describes “topping up” fluoride

concentrations to about 0.7 ppm F. Yet reviews of negative effects on biochemical process

will quote studies which have used 50 ppm, 100 ppm or even greater concentration of F in

drinking water. Opponents of fluoridation often seem completely oblivious of these huge

differences in concentration when they present a long list of claims about the ill effects of

fluoridation.

Another confusion readers often have with such reviews is the use of different units. The

sensible reader must often apply a few conversion factors when checking the fluoride

concentrations used in the reviewed studies. 1 mM = 19 ppm (or mg/L) for fluoride.

It is possible to find similar evidence of harmful effects of essential elements when present in

high concentrations. Selenium is an example of such an essential element. This graph

illustrates the situation for fluoride and is common to many elements.

Diagram from Ethan Seigel’s blog Starts with a Bang (see Weekend Diversion: Fluoridated

Water: Science, Scams and Society).

I am not denying the usefulness of these studies of negative effects of fluoride. Researchers

and policy makers should continuously assess research findings for their relevance to the

fluoridation issue and guidelines used in regulations. But this assessment must be critical and

intelligent – not simply a search to confirm biases.

Health authorities should not be swayed by populist naive interpretations of research.

Naturalistic fallacies

Connett’s point 6: Sure, organisms evolve to fit the parameters of their environment. But to

say “it is more likely that nature knows more about what the baby needs than a bunch of

dentists from Chicago or public health officials in Washington, DC” is really not a good way

of deciding this issue. Do we really want to argue that the situations in which marine animals

evolved are the best to aim for in a society which has undergone so much cultural and

intellectual evolution? Are we to reject the idea that society should task experts to consider

possible approaches for our future by the argument that “nature knows best” and give up all

rights for humanity to improve its condition? Do we really think that the environment that

ancestral species experienced millions of years ago are necessarily the best for us today?

Modern humans live in environments offering a range of natural dietary fluoride intakes. We

know that very low or very high intakes present problems for our bones and teeth. We should

not avoid the problems this presents by saying “nature knows best.”

The very low levels of F in breast milk may have more to do with the inorganic role of F in

animal bodies than any wisdom that “nature” has.

Fluorosis

Proponents of fluoridation do acknowledge dental fluorosis in a negative, although minor,

aspect of fluoridation.

Connett’s point 7: Opponents of fluoridation will often quote high values of the incidence of

fluorosis which ignore the fact that much of it is “questionable” and/or “very mild.” These

grades are really only cosmetic and usually can only be detected by a professional.

Opponents may also hide the fact that the incidence of fluorosis for children living in

fluoridated may often be the same as, or only slightly greater than, the incidence for children

living in non-fluoridated areas.

The graphs below shows the situation reported for New Zealand in the 2009 New Zealand

Oral health Survey (see Our Oral Health).

See Wikipedia for a brief description of Dean’s Fluorosis Index.

Health experts have generally concluded that the apparent rise in the incidence of fluorosis is

caused by increases in other forms of fluoride intake, such as from eating toothpaste, and not

from fluoridated water.

Fluorosis could well have been a normal feature of teeth and bones for a very long time.

Remember many areas of the world are high in natural forms of fluoride and the body does

not seem to have a process for fine regulation of blood and plasma fluoride concentrations.

Perhaps we should consider very mild and questionable levels of fluoride as cosmetically

perfectly acceptable. Considering the natural variation in fluoride intakes some people might

argue that “nature knows best.”

Nature of fluoridating chemicals

Connett’s point 8: Anti-fluoridationists make wild claims about fluoridation chemicals.

“They are industrial waste products, loaded with heavy metals and fluorosilicates are toxic

and/or untested for toxicity!”

Claims of contamination with toxic elements are easily, and often, made but are never

justified with any evidence. So let's look at the reality.

By-products that are used are not waste products – and surely we should aim for the efficient

use of natural resources. The purchaser of any product will sensibly make sure it is suitable

for their requirements – and these are rigidly defined for water treatment chemicals.

Suppliers are required to provide certificates of analysis and maximum values for

contaminants in chemicals used for water treatment. Those regulations are determined from

the maximum concentrations of contaminants allowed in the finished water for human

consumption. Safety factors are also involved as well as allowance for contribution from

other sources.

The table below contains analytical data for contaminants taken from the certificate of

analysis for the last batch of fluorosilicic acid used in the Hamilton, New Zealand, water

treatment plant (see FSA column). I compare the data with the maximum allowed impurity

levels of fluorosilicic acid defined in the regulations (Impurity limits column) and with an

example of the contaminant concentrations in finished water (Drinking water column).

1. These concentrations are extremely low, meaning that the final concentrations in the

finished water are insignificant.

2. For comparison, column one provides the maximum permissible concentrations

allowed for fluorosilicic acid used for water treatment ( NZ Water and Wastes

Association Standard for “Water Treatment Grade” fluoride, 1997. ).

3. The NSF, which regularly monitors contaminants in water treatment chemicals says in

this year’s NSF Fact sheet on fluoridation:

“In summary, the majority of fluoridation products as a class, based on NSF test

results, do not contribute measurable amounts of arsenic, lead, other heavy metals,

radionuclides, to the drinking water.”

And the NZ Waste Water Association’s report says:

“Commercially available hydrofluorosilicic acid, sodium fluoride and sodium

silicofluoride are not known to contribute significant quantities of contaminants that

adversely affect the potability of drinking water.”

Brown, Cornwall & McPhee, 2004 say in their review paper, Trace contaminants in

water treatment chemicals: sources and fate:

“Coagulant chemicals are the main source of trace metal contamination in water

treatment.”

4. Some people seem to think that simply quoting concentration of contaminant species

is proof of contamination – irrespective of the actual magnitudes. I have seen speakers

flash up a slide listing heavy metal contents without bringing notice to the actual

concentrations. That is silly. Our environment, no matter how “natural,” will always

contain some amount of contaminant chemicals – it is the actual amount that is

important – not that it can be, or is, measured.

Toxic Element

Impurity

limits*

FSA**

Drinking water**

Sb (ppm)

<0.09

As (ppm)

132

0.4

<0.002

Cd (ppm)

0.11

<0.001

Cr (ppm)

660

0.8

<0.001

Hg (ppm)

< 0.05

<0.001

Ni (ppm)

264

< 1

<0.001

Pb (ppm)

132

0.8

<0.001

* Maximum acceptable contamination.

** From Certificate of Analysis

***For Gear Island Treatment Plant, Greater Wellington region.

There are several points to make.

Arsenic in community water supplies

Paul raises the problem of arsenic and this provides an opportunity to put the contaminants in

fluorosilicic acid into context. The table shows that As levels are typically very low in

fluorosilicic acid used for water treatment (0.4 ppm As). In my article “Hamilton – the water

is the problem, not the fluoride! ” I show that in the local Hamilton, New Zealand, situation

the source water from the Waikato River is the major source of As in the finished water –

several orders of magnitude greater than for than from treatment chemicals.

Anti-fluoridationists often rely on a recent paper by Hirzy et al. (2013) for their claims about

As in fluorosilicic acid and its effect on the incidence of cancer. Hirzy has since

acknowledged errors in his calculations and described himself as embarrassed by them and

his mistake about cancers. A petition to the EPA which used his data to argue against use of

fluorosilicic acid in water treatment was rejected partly because of these errors (see Anti-

fluoridation study flawed – petition rejected).

Fluoridation data around the world

Connett’s point 9: Yes, a few countries do not fluoridate their water community supplies for

political reasons, but decisions against water fluoridation can depend on a range of factors

including size and centrality of water treatment plants, widespread use of bottled water,

naturally sufficient water fluoride concentrations, etc.

Paul refers to a plot used by Cheng et al (2007) – which is similar to this one:

This and similar plots are much beloved but anti-fluoridation propagandists. But while the

plots do show improvements in oral health for countries irrespective of fluoridation they say

nothing about the effect of fluoride. Simple comparison of countries obscures all sorts of

effects such as differences in culture, history, social and political policies, etc. Such plots are

also influenced by changes and differences in dental treatment and measurement techniques.

However, there are some within country data within the WHO data set Cheng et al used

which can give a better idea of the beneficial effects of fluoridation. This plot shows the

results for the WHO data for Ireland. A clear sign that fluoridation has played a beneficial

role.

Political and scientific arenas.

Connett’s point 10: The debates around fluoridation involve both scientific and political

issues. Inevitably this leads to the separate issues being mixed. I find, for example, that

attempts to discuss the ethical aspects always get diverted into differences in understanding

of the science. For example the paper Ethics of Artificial Water Fluoridation in Australia by

Niyi Awofeso is meant to be a description of the ethical issues. However, it assumes

mistaken ideas about the science – that fluorosilicate species are present in fluoridated

drinking water. Without the correct science it is so easy to end up with invalid ethics.

Appeal to authority is also a problem. Connett does this, for example, in his reference to Prof.

James Summer, Nobel prize winner. Similarly wild claims are often made about Nobel prize

winners and “top scientists” opposing community water fluoridation – these are really not

valid arguments.

I feel that opponents of fluoridation commonly rely more on confirmation bias than critical

and objective assessment when referring to the scientific literature.

There is also a reliance on conspiracy theories and poisoning of the well. We have seen

personal attacks on scientists and health authorities in New Zealand when they have spoken

up to defend the science. Childish name calling, accusations of being paid to make incorrect

claims, charges of being “shills” for industry, etc. This is simply “playing the man and not the

ball” and makes good faith discussion of the science impossible.

This even gets into peer-reviewed scientific literature. The authors of the paper Connett refers

to, Cheng et al 2007, do this when they accused one side, that of health authorities, of

“questionable objectivity.” Pots and kettles?

All of these problems are probably inevitable for an issue like this where political and

ideological interests operate. But they are an anathema to proper scientific consideration.

Professor Gluckman, the NZ Prime Ministers Chief advisor on Science commented that

fluoridation controversies were an example of science being a proxy for values/political

issues. This leads to misrepresentation of the science, cherry picking of data, and relying on

confirmation bias and google for literature searches. Ideology and values are the motivating

factors but a caricature of science is used in the debate.

Good faith discussion of the scientific issue around fluoridation requires much more

objectivity than is usually demonstrated by the opponents of fluoridation.

References

Awofeso, N. (2012). Ethics of Artificial Water Fluoridation in Australia. Public Health

Ethics 5(2): 1-12.

Barbier, O., Arreola-Mendoza, L., Del Razo, L. M. (2010). Molecular Mechanisms of

Fluoride Toxicity. Chem Biol Interact. 188(2): 319-33

Brown, R. A., Cornwell, D. A., Macphee, M. J. (2004) Trace contaminants in water

treatment chemicals: sources and fate. American Water Works Association, Journal 96(12):

111-125.

Cheng, K. K., Chalmers, I, and Sheldon, T. (2007). Adding fluoride to water supplies. BMJ

(Clinical research ed.) 335(7622): 699-702.

Hirzy, J. ., Carton, R. J., Bonanni, Montanero, C. D., Carly M. & Nagle, M. F. (2013).

Comparison of hydrofluorosilicic acid and pharmaceutical sodium fluoride as fluoridating

agents—A cost–benefit analysis. Environmental Science & Policy 29: 81-86. - See also

Hirzy, J. ., Carton, R. J., Bonanni, Montanero, C. D., Carly M. & Nagle, M. F. (2013).

Corrigendum to “Comparison of hydrofluorosilicic acid and pharmaceutical sodium fluoride

as fluoridating agents—A cost–benefit analysis” [Environ. Sci. Policy 29 (2013) 81–86].

Ministry of Health. 2010. Our Oral Health: Key findings of the 2009 New Zealand Oral

Health Survey. Wellington: Ministry of Health.

New Zealand Water & Wastes Association (1997): Standard for “Water Treatment Grade”

fluoride. Auckland. 21 pp.

NSF (2013). NSF Fact sheet on fluoridation products. 7 pp.

WHO data for Ireland. See http://www.mah.se/CAPP/Country-Oral-Health-Profiles/EURO/

Paul Connett - November 4, 2013

Fluoride debate: Paul responds to Ken’s response to part 1 of his argument against

fluoridation, “Fluoridation is a poor medical practice.”

Ken writes: Paul’s first article appears to be a general overview and not detailed

consideration of the ten points he makes. I will be similarly brief in my response to each

point. Paul may wish to go deeper into specific issues in later contributions and I will respond

in more detail then.

Paul responds: I certainly do, but before I do this Ken I would like to make two reasonable

requests. First, please drop the term anti-fluoridationist, which I find offensive. It makes

opposition to fluoridation sound like some mental disease! I am a scientist who opposes water

fluoridation based upon my 17-year review of the scientific literature. So please use the more

respectful and neutral term “opponent of fluoridation.” Secondly, please stick to addressing

my arguments without going into the opinions and arguments of others, especially the more

extreme views. I am not responsible for all the arguments used by all the opponents of

fluoridation, just as you are not responsible for all the views of all the proponents of

fluoridation. To digress into these will simply confuse the arguments between ourselves and

waste time and space.

My arguments 1,2 and 3 (You can’t control dose, who gets

the medicine and it violates the individual’s right to

informed consent).

Ken, you have problems with my referring to water fluoridation as “medical treatment”

without carefully defining the term. So here is what I consider to be a commonly understood

definition of medicine or medical treatment. A medicine is a substance defined by its

intended purpose, in other words it is a substance used “to treat or prevent a disease.”

In the case of water fluoridation the purpose of adding fluoride ions (or fluoride compounds

which release fluoride ions) to the water is “to treat or prevent dental disease.” That makes

water fluoridation a medical treatment. Unlike all the other chemicals added to water the

fluoridating chemicals are not used to treat the water but are added to treat people. For

example, unlike chlorine, they are not added to make the water safe to drink but are simply

using the water supply as a delivery system for human treatment– and as I have argued – this

is a very clumsy delivery system for such treatment because a) you can’t control the dose

delivered; b) you can’t control who gets the treatment and c) you are violating the

individual’s right to informed consent to any kind of human treatment.

You say that this discussion it is matter of semantics. It is not. In fact in it is a matter of law.

In most countries if you make a claim that a substance prevents or treats disease then it’s

classified as a drug or medicine and it has to go through rigorous clinical testing for safety.

This has never happened for fluoride. In fact the US Food and Drug Administration classifies

fluoride for ingestion as an “unapproved drug.” This means that in the U.S. fluoride intended

for ingestion has never been subjected to the double blind randomized clinical trials (RCT)

for either efficacy or safety that are required of all other drugs. Nor is the FDA tracking side

effects from patients or doctors, despite the fact that many individuals claim to be highly

sensitive to fluoride’s toxic effects. The same professional and regulatory neglect appears to

have occurred in all other fluoridated countries, including New Zealand.

As far as fluoride being a “mineral” found naturally in water or food, that does not exclude it

from being classified as a medicine and needing regulation. For example Sulfites occur

naturally in foods and even in tap water but the FDA controls how this ‘natural’ inorganic

compound is used in the food industry because it produces asthma in 5% of the population (

http://edis.ifas.ufl.edu/fy731 andhttp://www.itmonline.org/arts/sulfa.htm ).

Ken, as far as lack of control of dosage is concerned you say that it does not matter because

“most elements like this have a sufficiently wide range of concentrations and intakes for

efficacy that it is just ridiculous to treat them like powerful drugs which need accurate

dosage.”

It is interesting that you focus on efficacy here and not on fluoride’s harmful effects. In fact,

there is very little margin of safety between the dose (poorly defined as it is) that supposedly

reduces tooth decay and the doses that have been documented to cause harm – both in the

short term and over a lifetime of exposure. This point is often obscured by proponents

because they prefer to discuss the matter in terms of concentration (mg/liter) rather than dose

(mg/day). The former can be controlled the latter cannot.

People drink very different quantities of water. High water consumers can easily exceed the

doses that have been documented to cause harm in human studies.

Let’s take a specific example to make this point clear. Xiang et al (2003a,b) found that the

threshold level that reduced IQ in his study of Chinese children was 1.9 parts per million

(ppm) or mg/liter. Let’s do a rough calculation of dose.

If these children were drinking two liters of water a day their dose was 3.8 mg/day (2 liters x

1.9 mg/liter); if they were drinking one liter per day their dose was 1.9 mg/day and if they

were drinking half a liter of water per day their dose was 0.95 mg/day. Let’s round this off

and say that the range in doses for these children was between 1 and 4 mg/day.

A child drinking water at 1 ppm would exceed these doses drinking from one to four liters

per day. So some children in fluoridated communities will exceed these harmful doses,

especially when you remember the other sources of fluoride that they are getting. There can

be no doubt that these other sources can be quite large because as you yourself have admitted,

these other sources probably explain why dental fluorosis rates in the US are four times

higher than expected (41% versus 10%, CDC, 2010).

So there is no margin of safety here – even if we restrict ourselves to a consideration of just

the range of doses expected in a large population. But as anyone who has studied toxicology

knows we can’t stop there.

When we are extrapolating from the lowest observable dose causing harm in a small study

group to define a safe dose for a large population we have to introduce a safety factor to take

into account the wide variation in response to any toxic substance in the whole population.

This factor is referred to as the intra-species variation safety factor. Its default value is 10. In

other words if we were a regulatory agency doing its job we would have to divide the range

of doses that caused harm (in this case 1-4 mg/day) by 10 to get a dose that we can

confidently state is safe for the whole population. Thus we would not any child in the

population to get a dose higher than 0.1 mg/day –and certainly not higher than 0.4 mg/day –

in other words we would not want them drinking more than one large glass of water per day –

to make sure that no child is exceeding a dose that could cause a lowering of IQ! Remember

our task in public health is not just to protect the average child. We have to worry about the

most vulnerable child.

I would also remind you that when the US National Research Council reviewed the

toxicology of fluoride in water they concluded that several subsets of the US population were

exceeding the US EPA’s safe reference dose for fluoride (the so-called ISIS value) of 0.06

mg/kg/day. This included high water consumers and bottle fed infants. See Figure 2.8 in their

report (NRC, 2006).

Ken the way you deal with the other clumsy aspects of using the water supply to deliver

medical treatment is that you argue that there is no difference between “naturally” fluoridated

water and “artificially” fluoridated water and because of this lack of difference you argue that

we shouldn’t worry about a) the fact that artificially fluoridated water is going

indiscriminately to everyone and b) we shouldn’t worry that it violates the individual’s right

to informed consent to medication.

First of all. There are some key differences between naturally fluoridated water and

artificially fluoridated water. Usually when fluoride occurs naturally in the water it is

accompanied by large concentrations of ions like calcium. The presence of the calcium can

reduce the uptake of fluoride in the stomach and GI tract. No such protection is offered when

the fluoridating chemicals are added to soft water.

Second, the average level of fluoride in most water supplies is about 0.1 ppm. This is about

an order of magnitude lower than 0.7 to 1.2 ppm used in artificial fluoridation. That is not a

small difference.

However, you raise an interesting point with this argument – what should we be doing about

natural levels of fluoride in our water supplies?

It is clear that naturally occurring fluoride has caused a lot of health problems. Not only are

millions of people being impacted by naturally occurring fluoride in areas which are endemic

for both dental and skeletal fluorosis in India and China but more recent studies have shown

that more subtle harm is occurring in their soft tissues as well, including lowered thyroid

function, reproductive problems and lowered IQ. So I am not saying that naturally occurring

fluoridated water is OK. The latter – depending on the level – may well be bad.

What I am arguing is that it is not wise to expose the whole population to deliberately

elevated levels of fluoride in the water supply and we should not be forcing these increased

levels on people who don’t want it increased, especially when there are more rational and

acceptable delivery systems (which I will discuss later).

Ken I do not find your argument for ignoring the violation of the individual’s right to

informed consent to this deliberate medical treatment convincing. You write: “Why demand

‘informed consent’ for situations where natural levels of fluoride have been ‘topped up’ and

not require it for natural levels of fluoride – which in some situations may actually be higher

than for fluoridated water supplies.”

If water is “treated” in order to “treat” people, then the people “treated” should be asked to

give their informed consent to that “treatment.” If the water is “untreated” then there is no

need to ask for their informed consent. However, in areas with fluoride levels above 0.1 ppm

I believe that people should be warned about the potential harm that those natural levels may

cause. Such warnings should be given especially to parents who bottle-feed their babies.

Just because fluoride occurs naturally does not make fluoride safe, just as naturally occurring

arsenic is not safe. Looking to the future, as more and more scientists accept that modest

levels of fluoride can cause harm, we might find ourselves being forced to lower the level of

naturally occurring fluoride in water that is considered safe.

Currently, most of the world, including the World Health Organization has set a safe drinking

water standard of 1.5 ppm. The US is the odd one out with a ridiculously high safety standard

of 4 ppm. This was set in 1986, and according to whistle-blower at the US EPA, was set this

high because of political pressures. In 2006, a US National Research Council panel

concluded that this standard was not protective of health and recommended that the EPA

perform a new health risk assessment to determine a safer drinking water standard (NRC,

2006). After 7 years this agency has still has not done this.

When regulatory agencies finally get to revisit the safe drinking water standard in the US and

other countries – and do it free of political pressures from those who promote water

fluoridation – we might find ourselves in a similar predicament that authorities have found

with arsenic.

Because arsenic is a known human carcinogen the EPA has set the maximum contaminant

level goal (MCLG) for arsenic at zero. This is the “ideal” level to protect the whole

population from increased cancer risk. However, it is not a federally enforceable “standard,”

instead, as the name (MCLG) implies, it is the ideal “goal.” The actual standard, or maximum

contaminant level (MCL) is set at 10 ppb (10 parts per billion or 0.01 ppm). This is a

compromise between the ideal and the costs to communities for getting close to this ideal

goal. It would be prohibitively expensive to remove the arsenic down to zero.

With fluoride we might find ourselves in a similar situation. We might find that the

background levels of exposure to fluoride from dental products, pesticides and the diet

already exceeds the safe reference dose to protect against developmental harm. Thus the

MCLG for fluoride in water would have to be set at zero. However, like arsenic the costs of

doing this would be prohibitive and a compromise would have to be sought. Such a

compromise might yield an MCL at around 0.1 ppm (note this is still 25 times higher than the

level in mothers milk). Ironically, US water engineers were recommending an MCL of 0.1

ppm in 1939, because of concerns about dental fluorosis! But removing fluoride to this level

would be very expensive for some communities and political forces might push for a higher

value. However, regardless of the final MCL value, if the MCLG was set at zero, it would be

very clear that society could no longer tolerate the deliberate addition of fluoride to the water

supply supposedly to fight tooth decay.

In my opening statement I singled out three subsets of the population that shouldn’t be

getting fluoridated water: bottle-fed babies, people with poor kidney function and people with

outright or borderline iodine deficiency. Ken chose not to comment on the latter two groups.

In my view we should be concerned about both groups whether they are drinking naturally

occurring fluoride or artificially fluoridated water.

I believe that my first three arguments stand. Fluoridating the whole public water supply is a clumsy and

reckless because you can neither control the dose nor who gets the treatment and it is unethical way of

delivering human treatment because you have denied the right of the individual to informed consent.

Since most dental researchers and even promoters of fluoridation like the Oral Health

Division of the Centers for Disease Control and Prevention (CDC, 1999, 2001) concede that

the predominant benefit as far as protecting the teeth is concerned, is topical (rather than

systemic) i.e. fluoride works on the surface of the tooth enamel and not from inside the body.

A more rational way of delivering this treatment would be to brush fluoridated toothpaste

directly onto the teeth. This way you would minimize exposure to other tissues and not force

it on people who don’t want it.

Argument 4. Is fluoride a nutrient?

Ken writes:

Connett’s point 4: This also reduces to semantics – how should “nutrient” be defined? Paul

restricts his definition only to elements involved in “biochemical processes” – a definition

confidently excluding the role of F in bioapatites – bones and teeth. Yet bones and teeth are

important to organisms – so the strengthening of bioapatites, and the reduction of their

solubility, by incorporation of fluoride is important.

What Ken has glossed over here is the fact that humans can have perfectly healthy teeth and

bones without fluoride. Moreover, he does not acknowledge that at the same level that

fluoride interacts with bioapatites it damages those bioapatites. It is highly questionable

whether the hardening effect on bones warrants interference with the bone’s structure or the

surrounding cells. This is what Dr. Hardy Limeback, one of the panel members of the NRC

(2006) wrote about fluoride and bone:

Bone can ACCUMULATE up to 2500 ppm fluoride with fluoridation (we showed that in our

Toronto vs Montreal study). The osteoclast cells are exposed to these huge concentrations

(because they dissolve bone keeping the dissolved mineral under their dorsal surface through

the use of hemidesmosome attachments and then they release that dissolved mineral into the

bone extracellular fluid where nearby osteoblasts can also be exposed). In fact one of the

theories why there is apoptosis of osteoclasts is the poisonous conditions they have to endure

remodeling bone. It is also the reason there is a biologically-supported rationale for the bone

cancer inducing effects of fluoride (personal correspondence, Nov 1, 2013).

As far as fighting tooth decay is concerned the most significant involvement of fluoride is the

interaction with the surface of the enamel. You do not have to swallow the fluoride to have

this interaction. In fact, even promoters of fluoridation now concede that it is this topical

action, which is the predominant action of fluoride (CDC, 1999, 2001). Here the fluoride ion

is interacting with a mineral. Such an interaction doesn’t warrant the title of a “nutrient” and

certainly not an essential nutrient.

Ken suggests that, “Perhaps we can agree that F is at least a beneficial element, even if we

can’t reach agreement on the use of terms like ‘nutrient’ and ‘essential.’”

Maybe Ken but you are now a long way from justifying the addition of this substance to the

drinking water. I would argue that if used topically fluoride is a “beneficial element

(substance)” in the same way that sun tan lotion is a “beneficial substance” when applied to

the skin to protect us from damaging ultraviolet light or antiseptics are “beneficial

substances” when added to soap to kill bacteria. But this does not make these substances

nutrients and no one in their right mind would want to swallow them. Nor should they want

to deliberately swallow fluoride.

5. Biochemical processes and fluoride

Ken writes,

“ Connett's point 5: It is easy to cite literature references showing negative effects of fluoride

but we should not ignore the conditions used. Most such studies refer to much higher

concentrations than used in water fluoridation and this is also true for the review by Barbier

et al, 2010 Connett cites.

Let’s not forget that community water fluoridation describes “topping up” fluoride

concentrations to about 0.7 ppm F. Yet reviews of negative effects on biochemical process

will quote studies which have used 50 ppm, 100 ppm or even greater concentration of F in

drinking water. Opponents of fluoridation often seem completely oblivious of these huge

differences in concentration when they present a long list of claims about the ill effects of

fluoridation.”

First of all in biochemistry and toxicology it is not at all unusual – especially in animal

experiments – to use high concentrations to probe toxic effects. The alternative of using

lower concentrations is you are forced to use a very large number of animals in order to tease

out an effect. This is very expensive. Furthermore, in the case of fluoride it is well known that

you have to give 5 to 10 times as much fluoride to rats to reach the same plasma level as you

need in humans.

I should add that there have been some animal studies where the level of fluoride used that

has caused harm is very low indeed. This is particularly true in chronic studies. For example,

Varner et al, 1998 fed rats 1 ppm in water for one year and found kidney damage, visible

brain damage, a greater uptake of aluminium into the brain, and beta-amyloid deposits which

have been associated with Alzheimer’s disease.

As far as human studies are concerned Ken should know it is the not the highest doses that

cause harm which is of concern, but the lowest doses. For example, in the meta-analysis of 27

IQ studies carried out by the team from Harvard University (Choi et al., 2012), 26 of the

studies found a lowered IQ in high fluoride villages compared to low fluoride villages (an

average lowering of 7 IQ points). It is true that the range of the fluoride levels went as high as

11.5 ppm. However, the relevant fact is that in eight of the studies the high fluoride village

had less than 3 ppm of fluoride in the well water. That leaves no adequate margin of safety to

protect all our children drinking water at 0.7 ppm and getting fluoride from other sources. See

also the discussion of Xiang et al (2003a,b) above where he found a threshold of 1.9 ppm.

Ken adds, “Another confusion readers often have with such reviews is the use of different

units. The sensible reader must often apply a few conversion factors when checking the

fluoride concentrations used in the reviewed studies. 1 mM = 19 ppm (or mg/L) for fluoride.”

Others may be confused by this but I am not and I do not understand why Ken brought this

issue up.

Ken also adds, “Health authorities should not be swayed by populist naive interpretations of

research.”

If Ken is directing that comment to me (or to the contents of the book I co-authored with two

other scientists, The Case Against Fluoride), I find his comment insulting, especially to my

co-authors who are meticulous in such matters. If he is directing it towards others, I see no

reason for bringing it up in this exchange.

6. Naturalistic fallacies

Ken writes:

“Connett’s point 6: Sure, organisms evolve to fit the parameters of their environment. But to