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The fluoride debate

Authors:
  • The American Environmental Health Studies Project, Inc

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THE FLUORIDE
DEBATE
PAUL CONNETT AND KEN PERROTT
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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
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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
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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/).
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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.
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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
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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
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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
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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.
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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.
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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?
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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.
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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.”
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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)
40
<0.09
-
As (ppm)
132
0.4
<0.002
Cd (ppm)
40
0.11
<0.001
Cr (ppm)
660
0.8
<0.001
Hg (ppm)
26
< 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
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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
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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.
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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
agentsA costbenefit 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 agentsA 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/
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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
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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.
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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.
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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
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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:
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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
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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
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
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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 the with inorganic role of F in
animal bodies than any wisdom that “nature” has.
I think Ken has not appreciated the thrust of my argument here. So let me attempt to restate
the case.
In your response Ken you have attempted to downplay any significance in the fact that the
level of fluoride in mothers’ milk is naturally so low (0.004 ppm, NRC, 2006, p.40). I am
surprised that you feel this way. Let me explain.
What levels of fluoride that end up “naturally” in our ground or surface water is a vagary of
geology over which “nature” (or biological evolution) has little control. However, biological
evolution has had control over how much fluoride it has inserted into normal biological
functions. In the earliest days of evolution there was plenty of fluoride available in the sea
(average 1.4 ppm) for nature to use in the biology of aquatic creatures but it did not to do so.
Yes the fluoride may well have been sequestered in the shells or bones of these creatures and
made shark’s teeth stronger, but no use was found in either the structure or function of
enzymes, proteins, membranes, fats, nucleic acids or any of the other components of active
biochemistry. Nor have the fluoride ions unlike many other ions (e.g. potassium sodium
calcium or chloride ions) been used in messaging systems. By the time we reach the mammal
we still find no use made of this ion in biochemistry.
So, when we look at the baby’s first meal and we find very little fluoride there (0.004 ppm,
NRC, 2006, p.40), it appears entirely consistent with the notion that the baby does not need
fluoride for healthy development.
Moreover, this very low level in mothers’ milk might mean that nature deliberately kept the
fluoride away from the mammalian baby’s delicate tissues during early development, which
again is consistent with the known toxicity of fluoride. The fluoride ion is incompatible with
many biological functions.
Is it not reckless then to knowingly expose the bottle-fed baby to 175-300 times more
fluoride than the breast-fed baby? Especially, when we know that fluoride can harm at least
one developing tissue (the growing tooth cells) at very low levels and cause the condition
known as dental fluorosis.
It is particularly disturbing that very few studies probing the possibility of subtle effects of
fluoride on other developing tissues in the baby before this practice was launched in 1945, or
endorsed by the US Public Health Service in 1950.
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Even when some warning signals emerged during the early trials they were cavalierly ignored
by those hell-bent on promoting this practice. For example, when Schlesinger et al.,
published the results of the Newburgh-Kingston trial in 1956 they reported that young girls in
the fluoridated community were menstruating 5 months earlier on average than the girls in
the non-fluoridated community, and that the young boys were experiencing about twice as
many cortical bone defects in the fluoridated community compared with the non-fluoridated
community. However, no follow-up studies were recommended (see Chapters 9 and 10, The
Case Against Fluoride). These red flags were ignored then just as the studies indicating a
lowering of IQ associated with fairly modest levels of fluoride exposure, are being ignored or
downplayed by proponents today.
7. Fluorosis
Ken argues that, “Proponents of fluoridation do acknowledge dental fluorosis is a negative,
although minor, aspect of fluoridation.”
Paul’ response: Ken you may consider dental fluorosis to be a minor consideration, but that
does not apply to all those children especially teenagers who are afflicted with this
condition. Even mild fluorosis can be psychologically damaging.
Ken adds:
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.”
Paul’s response: What the CDC reported in 2010, was that 41% of American children aged
12-15 had some form of dental fluorosis over and above the questionable category. Of this
41%:
28.5% were in the very mild category, which according to Dean ranged from small white
patches on the cusp of the tooth up to 25% of the enamel (of the affected teeth) impacted.
8.6% were in the mild category where between 26 and 50% of the enamel (of the affected
teeth) is impacted. In testimony before Congress Dean testified that he did not believe that
any mild dental fluorosis was an acceptable trade-off for lowered tooth decay.
3.6% were in the moderate or severe category where 100% of the enamel (of the affected
teeth) is impacted.
Thus 12.2% of these cases are thus in the unacceptable categories. Moreover, these numbers
are an average of children living in both fluoridated and non-fluoridated areas and thus it is
reasonable to anticipate that the numbers in the fluoridated areas are significantly higher. In a
review of the data collected in 1986-87 by the National Institute of Dental Research, Heller et
al (1997) reported:
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13.5% dental fluorosis prevalence in communities less than 0.3 ppm fluoride in their water
21.7 % dental fluorosis prevalence in communities with 0.3 <0.7ppm fluoride in their
water
29.9% dental fluorosis prevalence in communities with 0.7 1.2 ppm fluoride in their water
41.4% dental fluorosis prevalence in communities with >1.2 ppm fluoride in their water.
Thus as far as the US figures are concerned it is not true that the dental fluorosis rates in non-
fluoridated areas are the same or very close to the rates in fluoridated areas as Ken states. It is
clear that the level of fluoride in the water remains a key factor. It is also the factor, which is
most amenable to mitigation by a public policy change, i.e. lowering the level of fluoride
added or ending water fluoridation altogether.
8. Nature of fluoridating chemicals
In this section Ken goes way beyond my stated concerns. I stated that the chemicals used are
not pharmaceutical grade. That they are waste products from the phosphate fertilizer industry
and that they contain arsenic, which is a known human carcinogen and thus will
UNNECESSARILY increase cancer rates in fluoridated communities.
Ken writes:
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 certificate of analysis
for the last batch of fluorosilicic acid used in the Hamilton, New Zealand, water treatment
plant (see FSA column)…
Paul’s response. I will jump over Ken’s table here and focus on responding to the
contaminant over which I expressed my concern: arsenic.
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Ken writes: 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. Zany (sic) 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).
Paul’s response: As Ken has singled out a close colleague of mine Dr. J. William Hirzy, a
former senior scientist at the US EPA I have asked him to respond to his comments. I
should add that to his credit Dr. Hirzy was very quick to admit his mistake and apologize for
it. However, it is not to the credit to the promoters of fluoridation to use this single mistake to
throw out the rest of his important analysis and argument.
Dr. Hirzy writes:
November 1, 2013
Regarding arsenic contamination of fluorosilicic acid (FSA).
Perrott’s citation of “a certificate of analysis” (emphasis added) showing 0.4 ppm arsenic is
not evidence of routine low levels of that contaminant in FSA. Based on 19 certificates of
analysis from acid suppliers Cargill and Mosaic (including two reporting only “complies with
NSF Std. 60”), 11 laboratory analyses from the Denver, Colorado water authority and 3
analyses from the City of Escondido California, the mean arsenic level in these 33 samples
was 41.4 ppm. Upper and lower 95% confidence limits were 123 and 15.8 ppm, respectively.
These values derived from assuming the two “complies with NSF Std 60” samples contained
arsenic at ½ the Std. 60 allowable level of 380 ppm, namely 190 ppm. Without those two
“Std. 60” samples, the mean and 95% upper and lower confidence limit values were 31.9,
62.3 and 15.5 ppm, respectively.
With respect to Perrott’s comments about the error in my paper comparing use of
pharmaceutical grade sodium fluoride (U.S.P. NaF) and “by-product” fluorosilicic acid, my
finding of the difference in lung and bladder cancer risks between the two agents was not
challenged by the U.S. Environmental Protection Agency (USEPA).
Fluorosilicic acid with 30 ppm arsenic poses 100 fold higher risk for these cancer types than
does U.S.P. NaF, whether one considers lifetime exposures or only annual exposures.
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Perrott's claim that contaminant levels are rigidly defined and safety factors offer additional
protection is hollow. Arsenic levels in water permitted under the “safety factor” provided by
NSF Std. 60 actually allows for 1200 fold higher cancer rates that use of U.S.P. NaF would
cause another finding in my paper not challenged by USEPA.
Furthermore the City of Wellington, Florida proudly announced in its Annual Drinking Water
Quality Report for 2009 “…that arsenic is added to the drinking water (approximately 1.1
micrograms per liter) as part of the fluoridation process…”, which is well over the NSF Std.
60 permissible level. Who is minding the store? Of what real value is that standard?
For Perrott to claim, regarding the permitted arsenic levels that, “These concentrations are
extremely low, meaning that the final concentrations in the finished water are
insignificant…” ignores basic toxicology insofar as low levels of chronic exposure to arsenic
have been shown in my paper and not challenged by USEPA to result in 100 to 1200 fold
higher cancer rates than would be caused by use of U.S.P. NaF. Likewise, NSF’s assertion
quoted by Perrott, viz. “…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….” is also a meaningless attempt at reassuring
the public that upon dilution, FSA’s contaminant levels can cause no harm. In USEPA’s
response to the referenced petition the Agency notes that measurable levels of arsenic were
detected in fluoridated water during monitoring from 2007 to 2011, with mean and maximum
levels being 0.15 ppb and 0.6 ppb as reported by NSF. So much for NSF’s public relations
declaration of “no measurable amounts of arsenic…in drinking water.” At 0.15 ppb arsenic,
the difference in cancer rates between FSA and U.S.P. NaF is actually more than 200 fold
twice as high as the levels shown in my paper.
Perrott’s citation of a similar public relations declaration by the New Zealand Waste Water
Association is likewise without merit.
Recent calculations on the cohorts of people in the Unites States who have been exposed to
0.15 ppb arsenic since 1965, 1967, 1975, 1989, and 1992, using USEPA’s risk and cost data
(which were used in my referenced paper and not challenged by that agency in its response to
the referenced petition) show that by 2020, there is an expected increase of 2000 lung/bladder
cancers in these cohorts attributable to arsenic in drinking water, costing $7 billion in 2001
dollars.
If Perrott’s claim that using the phosphate industry’s waste acid for ingestion in fluoridated
water is merely an “efficient use of natural resources” is valid, then why not use neutralized
FSA in fluoridated tooth paste and mouth wash?
The “efficient use of natural resources,” viz. FSA in the U.S. is reflected in sale of about
280,000 tons of 23% assay FSA in 20111, which at an average price of $2000/ton,2 resulted in
transfer of taxpayers’ cash of over $500,000,000 to phosphate producers in 2011 alone. And
over 99 percent of that purchased phosphate waste was, and is now, flushed down toilets,
shower drains, and the like.
30
Water fluoridation, especially with FSA in the U.S., is not at all about improving dental
health; it is rather about U.S. taxpayers paying phosphate producers billions of dollars for the
privilege of having our public drinking water systems used to dispose of an acid that would
otherwise have to be managed in a hazardous waste facility, and thereby improving the
bottom lines of phosphate producers.
J. William Hirzy, Ph.D.
References
1. USGS Minerals Yearbook 2011.
Fluorsparhttp://minerals.usgs.gov/minerals/pubs/commodity/fluorspar/myb1-2011-fluor.pdf
accessed 11/01/2013
2. http://www.scribd.com/doc/18235930/NYC-Fluoridation-Costs-2008-Feb-2-2009-Letter-
Page-1 accessed 11/01/2013
9. Fluoridation data around the world
Ken writes:
“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’s response:
It is not just a few countries but the vast majority of countries that do not fluoridate their
water. About 30 countries have some cities fluoridated, but only 10 have more than 50% of
their populations drinking artificially fluoridated water.
Your explanations for why the vast majority of countries do not fluoridate reads more like
self-serving political spin than the reality. On our website we have offered explanations from
spokespersons from many of the countries that have stopped or never started to fluoridate
their water (see 50 Reasons to Oppose Fluoridation). There are two main reasons given: a)
they do not want to force fluoridated water on people who don’t want it and b) they are not
satisfied that all the health concerns have been addressed. From what I can see none of them
give the explanations that you have offered. Perhaps you can provide statements from some
of the non-fluoridated countries that support the claims you have made in their name.
In response to the plots of tooth decay versus time as presented by Paul by Cheng et al
(2007), Ken writes:
“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
31
policies, etc. Such plots are also influenced by changes and differences in dental treatment
and measurement techniques.”
Paul’s response:
Certainly many factors influence tooth decay. There is bound to be a lot of noise in a large
data-set. However, what is striking to me and others is that the presence of fluoride in the
drinking water does not appear to rise above this noise. On the face of it the relationship
between fluoridation and tooth decay appears to be weak at best. Especially compared to two
other relationships, which are very strong: the relationship between fluoride levels in water
and dental fluorosis and the relationship between tooth decay and income levels.
Ken writes:
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.
Paul responds:
Since being invited by the Irish government to testify before its Fluoridation Forum panel in
2000, I have not been impressed with the objectivity on this issue by the pro-fluoridation
dental researchers there. Thus I would not exclude the researchers’ bias influencing this
result.
Ireland has had mandatory fluoridation since 1963. If this comparison between the Republic
of Ireland and Northern Ireland was legitimate it would have been more impressive and more
appropriate to have compared the health status of the two populations. Like many fluoridated
countries (including Australia, Canada, New Zealand) very few health studies (if any) have
been conducted in Ireland comparing the health of fluoridated and non-fluoridated
communities. Particularly absent are studies that have used the severity of dental fluorosis as
a biomarker of exposure to investigate various health and development problems in children,
such as bone defects and fractures, onset of puberty, thyroid function and lowered IQ.
10. Political and scientific arenas.
Ken wrote the following in response to my comment about the way that many proponents of
fluoridation use endorsements of fluoridation by government agencies and professional
bodies to win their case for fluoridation with the general public instead of using the primary
scientific literature. I am glad that Ken has not done that in his responses.
Ken adds:
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
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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.
My response: This comment does not respond to my concerns here. I will leave Professor
Awofeso to respond.
Ken writes: “Appeal to authority is also a problem. Connett does this, for example, in his
reference to Prof. James Summer, Nobel prize winner.”
Paul responds: I think this is a very weak argument. I simply pointed out that some of the
earliest opponents of fluoridation were biochemists who had used fluoride to poison enzymes
in their experiments. James Sumner was a distinguished example. Citing the fact that he won
a Noble prize for his work on enzyme chemistry simply underlines the fact that he knew
something about the subject.
Ken writes:
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.
Paul responds: If Ken is referring to me here then let him give specific examples to which I
can respond. If he is referring to others I think they are out of place in this exchange with me.
We made a point in our book, and also in public presentations, to disavow the more nutty
conspiracy theories espoused by some opponents of fluoridation. We do not believe that the
evidence that Hitler used fluoride in the concentration camps sufficient to convince a
historian. Meanwhile, in our view it is offensive to the many well-intentioned dentists and
others who promote fluoridation to be associated with such a horrendous person. Nor do we
believe that fluoridation is an attempt to dumb down or limit the world’s population.
However, promoters of fluoridation should not be surprised that some people are trying to
come up with a rational explanation for why certain governments are behaving so
irrationally promoting this practice. They continue to do so long after the science has shown
that swallowing fluoride does not reduce tooth decay, that there are many risks involved and
that there are clearly alternative ways of fighting tooth decay, which have been demonstrated
in the vast majority of countries, which do not choose to force their populations to drink
artificially fluoridated water.
33
Ken writes: 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?
Paul responds: Hardly. Cheng et al 2007 actually question the objectivity of both sides in
this debate. However, sadly, they were not out of place questioning the objectivity of
spokespersons for many health agencies in fluoridated countries, especially in Australia,
Canada, Ireland, the UK and the US. It is one thing for individuals who believe strongly in
fluoridation to present one-sided arguments in favor of fluoridation, but as tax-payers we
have the right to expect that health officials (who are paid by the taxpayer) would present the
case objectively. Frequently they do not and resort to outrageous spin tactics. For example,
Queensland Health officials, when the government there was about to introduce mandatory
fluoridation in 2007, claimed that there was a 65% less tooth decay in children from
fluoridated Townsville compared to non-fluoridated Brisbane. However, when the data was
checked it was discovered they had a) cherry picked the data (they reported the tooth decay
for one age only, 7-year olds) and b) by presenting the data as a relative saving rather than an
absolute saving they deliberately misled the public into thinking that the saving was highly
significant when it wasn’t. The difference amounted to 0.17 of one tooth surface! If they had
chosen the data for 9-year olds the saving was 0.10 of one tooth surface with a relative saving
of 20%. To make matters worse they showed two photos: one for a child that had grown up in
a fluoridated community (here the teeth were perfect) and one from a child from a non-
fluoridated community (here the teeth were atrocious).
Ken writes:
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.
34
Good faith discussion of the scientific issue around fluoridation requires much more
objectivity than is usually demonstrated by the opponents of fluoridation.
Paul responds: Again I am not sure if Ken is aiming this criticism at me or the book I co-
authored. If he is then I request that he shows examples from this text or my public
presentations that support his claims.
I entered this exercise hoping that we could have an exchange in which we would have a
“good faith discussion of the scientific issues.” I am certainly prepared to do that and I urge
Ken to do the same. It would help if he stuck to addressing the arguments I raise and not to
muddy the waters with the arguments, beliefs and behavior of others.
Postscript.
I am traveling in Europe at the moment and it might be a few days before I have put together
part 2 of my side of this exchange titled, “The evidence that swallowing fluoride reduces
tooth decay is very weak.” Those who want a head start on this can consult chapters 6-8 in
The Case Against Fluoride.
Meanwhile, I would like to leave this suggestion for Ken and other promoters of fluoridation
to consider. It is partly based on the arguments of Dr. J. William Hirzy above. Let’s assume
for the sake of this argument that you prevail Ken and persuade us that swallowing
fluoridated water works and was actually superior to applying fluoridated toothpaste directly
to the teeth. Here is a way that you could secure that goal more effectively, more precisely
and without infringing on the individual’s right to informed consent to medical treatment and
without giving up the central dogma of fluoridation.
Why not make one-liter bottles of fluoridated water freely available in dental offices,
pharmacies, clinics and supermarkets? These could be provided free for low-income families.
In this way, you could afford use pharmaceutical grade sodium fluoride (because you would
only need much smaller quantities); you could control the dose by telling people to drink only
one bottle a day and you would not be forcing it on people who didn’t want it. Nor would you
be wasting large quantities of industrial grade fluoride in other applications such as flushing
the toilet nor would you be putting most of it into the environment.
Back to you Ken.
References:
CDC, 1999. Centers for Disease Control and Prevention, “Achievements in Public Health,
19001999: Fluoridation of Drinking Water to Prevent Dental Caries,” Mortality and
Morbidity Weekly Review 48, no. 41 (October 22, 1999): 93340
,http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm.
CDC, 2001. Centers for Disease Control and Prevention, “Recommendations for Using
Fluoride to Prevent and Control Dental Caries in the United States,” Morbidity and Mortality
35
Weekly Report 50, no. RR14 (August 17, 2001): 1
42,http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
CDC, 2010. Beltrán-Aguilar,Prevalence and Severity of Dental Fluorosis in the United States
http://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
Choi AL, Sun G, Zhang Y, Grandjean P. 2012. Developmental fluoride neurotoxicity: a
systematic review and meta-analysis. Environ Health Perspect 120:13621368.
See also
Anna L. Choi, Philippe Grandjean, Guifan Sun, Ying Zhang, 2012. Developmental Fluoride
Neurotoxicity. Choi et al. Respond. Environ. Health Perspect. 121:a70a70
(2013).http://dx.doi.org/10.1289/ehp.1206192R [Online 1 March 2013]
Connett, P., Beck, J and Micklem HS. The Case Against Fluoride. Chelsea Green, White
River Junction, Vermont, 2010.
K. E. Heller, S. A. Eklund, and B. A. Burt, “Dental Caries and Dental Fluorosis at Varying
Water Fluoride Concentrations,” Journal of Public Health Dentistry 57, no. 3 (1997): 13643.
NRC, 2006. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards (2006)
http://www.nap.edu/catalog.php?record_id=11571
E. R. Schlesinger, D. E. Overton, H. C. Chase, and K. T. Cantwell, “Newburgh-Kingston
Caries-Fluorine Study XIII. Pediatric Findings After Ten Years,” Journal of the American
Dental Association 52, no. 3 (1956): 296306.
J. A. Varner, K. F. Jensen, W. Horvath, and R. L. Isaacson, “Chronic Administration of
Aluminum-Fluoride and Sodium-Fluoride to Rats in Drinking Water: Alterations in Neuronal
and Cerebrovascular Integrity,” Brain Research 784, no. 12 (1998): 28498. Extended
excerpts athttp://www.fluoride-journal.com/98-31-2/31291-95.htm.
Q. Xiang, Y. Liang, L. Chen, et al., “Effect of Fluoride in Drinking Water on Children’s
Intelligence,” Fluoride 36, no. 2 (2003): 84
94,http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf .
Q. Xiang, Y. Liang, M. Zhou, and H. Zang, “Blood Lead of Children in Wamiao-Xinhuai
Intelligence Study” (letter), Fluoride 36, no. 3 (2003):19899
http://www.fluorideresearch.org/363/files/FJ2003_v36_n3_p198-199.pdf .
36
Ken Perrott - November 7, 2013
I think Paul’s response illustrates some of the problems in discussions of the fluoridation
issue. He shows a selective approach to data, indulges in unwarranted extrapolation from
research and misinterprets scientific knowledge to fit his own agenda. In the interests of
maintaining interest by avoiding repetition, I will just select a few of the more obvious
examples in my response.
It is pointless to continue debating definitions of fluoride as a medicine as I have said the
argument is largely semantic. people who wish to pursue the argument should do so in a court
of law.
Irish oral health data.
Paul dismisses the data I presented showing the difference between fluoridated and
unfluoridated areas in Ireland because he “would not exclude the researcher’s bias
influencing the result!” That is an incredible statement because the source of the Irish data in
my plot was exactly the same as that used in the plot of Cheng et al (2007) which Paul and
many other campaigners against fluoridation constantly use to argue that fluoride does not
contribute to the observed improvement of dental health!
In the figure below I have added the data for Ireland from Cheng et al’s diagram to illustrate
this. Cheng et al used the mean WHO values for Ireland (the dotted line), (and only two data
points for each country) while I simply used the data for both people from fluoridated and
unfluoridated areas.
37
I am not impressed by Paul’s contradictory attitudes to the same data set. It displays a biased
attitude driven by his wish to conclude that fluoridation has not had a beneficial effect on oral
health.
I am also amazed that Paul should argue that with the Irish data it “would have been more
impressive and more appropriate to have compared the health status of” the Republic of
Ireland and Northern Ireland.
Surely comparison of the data from unfluoridated and fluoridated areas within a country
introduces far fewer confounding factors than comparison of data for separate countries.
History, culture, ethnic differences, differences in dental practice and assessments, and many
other factors would contribute.
Paul shows some awareness of the problem of confounding factors when he refers to the
noise in a large data set specifically in referring to Cheng et al’s original plots. Yet he seems
to want to increase this noise, the influence of confounding factors, in the case of Ireland and
rejects an example where confounding factors have been reduced. He then implies that it is
the researchers who are “biased!”
The idea that somehow inter-country comparisons should have less noise than comparisons
made within a country seems so obviously wrong to me I was pleased to find I am not the
only person who sees this problem. Robyn Whyman in his report Does delayed tooth
eruption negate the effect of water fluoridation? puts it well:
“Studies that appropriately compare the effectiveness of water fluoridation do not compare
poorly controlled inter-country population samples. They generally compare age, sex, and
where possible ethnicity matched groups from similar areas. Inter-country comparisons of
health status, including oral health status, are notoriously difficult to interpret for cause and
effect, because there are so many environmental, social and contextual differences that need
to be considered.”
Contamination of fluorosilicic acid
Here Paul handed over to William Hirzy who rejected the data I presented for Hamilton city,
NZ, as atypical because the arsenic (As) concentration was so low.
See my article Anti-fluoridation study flawed petition rejected for some background to
Hirzy, his paper and the petition he organised. One of our commenters, Steve Slott, has
brought to my attention that Hirzy is a long time avowed antifluoridationist and is employed
by Connett as the paid lobbyist for Connett’s antifluoridationist group, FAN.”
In the table below I include data from 2 other certificates of analysis in these cases
Australian produced material. I also include my own data from a batch I analysed about 10
years ago when I was researching the chemical. This suggests the Hamilton sample is not that
atypical, for our region anyway.
38
Concentrations (ppm) of contaminants in several different batches of fluorosilicic acid
Toxic
Element
Impurity
limits*
Hamilton
City**
Incitec
08
Incitec
09
Own
Anal
Sb
40
<0.09
<2
<2
As
132
0.4
2.2
<2
2
Cd
40
0.11
<2
<1
<1
Cr
660
0.8
<2
<2
5
Hg
26
<0.05
<1
<0.1
Ni
264
<1
<2
<1
Pb
132
0.8
<2
<2
0.3
As you can see all the samples have a very low As concentration. Much lower than required
by regulations for such materials used in water treatment. These samples do have a lot less As
contamination than the ones Hirzy used in his study (typical value of 30 ppm). Maybe this
represents the choice of samples in both cases, or maybe there are more sources of
fluorosilicic acid in the US and some products have higher contamination of As. The fact that
there are fewer plants producing fluorosilicic acid in New Zealand and Australia could be a
reason for the apparently higher quality here.
I have no way of assessing the range of As contamination in US sourced samples so don’t
know how representative Hirzy’s choices are. The NSF analyses water treatment chemicals
and state in their last Fact Sheet on Fluoridation Products (2013) that only 43% of the
fluoridation chemicals would have produced a detectable amount of As in the finished water
(actually, because of the standard methods required detectable in water at 10 times its
maximum use level). The bar graph below shows the amounts of As measured in surveyed
samples as a percentage of the USEPA regulated maximum contaminant level (MCL).
Similarly, Brown et al. (2004) (Trace contaminants in water treatment chemicals: sources
and fate, American Water Works Association Journal. 96: 12, 111-125) identified the
coagulation chemicals used in water treatment as far more likely to introduce contaminants
than the fluoridation chemicals.
Hirzy may object because the NSF measured contaminants in terms of the finished water
concentrations and not that in the concentrated chemicals. The finished water concentrations
were then compared to the regulated MCL. But that will simply reflect his objection to the
current MCL values.
This raises an interesting issue and identifies a problem with Hirzy’s approach in his
campaign to substitute pharmaceutical grade NaF for fluorosilicic acid in water treatment. If
the real issue for Hirzy was the As concentration he should instead have campaigned to lower
the currently accepted regulations for level of contamination in fluoridation chemicals. Surely
39
that would have satisfied his concern about the role of As in cancers and possibly been
more acceptable to authorities. If the current approved levels are too high let’s get them
lowered whatever chemical is used.
It is also interesting that the fluorosilicic acid used in Hamilton contained As contamination
similar to those of the pharmaceutical grade NaF Hirzy used (typical value 0.76 ppm). He
should be happy to advocate the use of material with our levels of purity in the US if his only
concern is the As levels.
Perhaps we should be selling our fluorosilicic acid to the US if they cannot produce material
to such standards.
Hirzy’s bandwagon is the possibility of cancers resulting from As in fluoridation chemicals. I
appreciate where he is coming from and have no wish to debate that issue it is outside my
area of expertise. I can only comment that in our own situation (Hamilton City, NZ) the
Waikato River source water has about 3 times the recommended maximum concentration of
As for human consumption (see Hamilton the water is the problem, not the fluoride!). This
is reduced by about 80% during treatment but still remains a bigger source of As
contamination than the fluoridation chemicals by several orders of magnitude. it would be
very silly to be concerned with contamination of the fluoridation chemicals and ignore the
natural contamination of the source water.
40
Hirzy’s political activism
Finally Hirzy’s activist bias concerns me in that it could interfere with proper assessment of
the risks. It certainly makes it difficult not to be suspicious about his claims. Out of hand he
rejects the NSF conclusions as “a meaningless attempt at reassuring the public.” He also
similarly rejects the conclusions of the NZ Water and Wastes Association as being “without
merit.” This is derogatory to honest and active scientific and technical workers who have
made the analyses, assessed the risks and drawn conclusions. Question the regulations if you
must (and no regulations are permanent) but please do that using evidence, not by “poisoning
the well” with such claims. Play the ball, not the man. Hirzy would object to his own work
being flippantly rejected in such a way.
His use of the silly conspiracy theory that fluoridation is a way of disposing of industrial
waste also raises questions of his credibility. And he is biased to claim that regulations have
no “real value” because they were violated by one treatment plant!
Normal role of F in bioapatites
Paul seems to reject the concept that F is a normal constituent of apatites, including
bioapatites. He argues that it is possible to have bones and teeth without fluoride. and says
“that at the same level that fluorides interact with bioapatites it damages those bioapatites.”
But in the real, natural world, and not the extreme conditions of the laboratory, absolutely
“pure” minerals don’t exist. Isomorphous substitution is normal and ubiquitous. Apatites only
exist as end members like hydroxyapatite in unusual or laboratory situations. Fluoride and
carbonate are very commonly incorporated into bioapatite by isomorphous substitution as
are some common cations.
In reality no bones or teeth are “fluoride free.” Which is just as well because they would have
higher solubility and reduced strength and hardness. Sure, this might mean that it is normal
for a proportion of people to have teeth with “questionable” or “very mild” forms of
fluorosis. But that is a cosmetic issue (if at all noticeable) and does no harm. It has probably
been a simple fact about our teeth through our whole evolution.
For the vast majority of people who have dental fluorosis (recognised by a professional) it is
usually classified as “questionable” or “mild.” Real health concerns should only be raised for
severe dental fluorosis. Yet anti-fluoride activists lump all those grades together and pretend
that dental fluorosis is a much bigger problem than it really is.
“Topical” mechanism
We will deal with the mechanism of the beneficial role of fluoride on teeth in later articles so
I will just respond briefly to Paul’s brief reference to the issue in his last article here. He
claims the US Centers for Disease Control and Prevention (CDC) agrees “that the
predominant benefit as far as protecting teeth is concerned is topical (rather than systemic).”
41
(Actually, he says “concedes” and not “agrees” but this word is ideologically loaded). That is
correct as far as it goes but we should remember that this is referring to existing teeth
ingested fluoride still has a beneficial role with bones and pre-erupted teeth. The word
“predominant” is important. So I can’t help recognise the bait and switch tactic when, in his
book, he drops the word “predominant” in his chapter summary and he says:
“For many years, fluoride was believed to act systemically to prevent caries tooth decay
by being incorporated into the enamel of the developing teeth. However, it is now known to
act topicallythat is, at the surface of the tooth. Thus, the main reason for ingesting fluoride
has disappeared . . .”
Again and again I find anti-fluoride people using this tactic to deny any mechanism but
“topical.” They thereby purposely deny any of the known beneficial effects of ingested
fluoride.
This bait and switch tactic is compounded by another bait and switch where the “topical”
referring to the reactions occurring at the tooth surface because of fluoride in saliva and
biofilms becomes a new “topical” referring only to methods of application such as
toothpaste and dentrifices. This tactic enables them to deny the beneficial roles of fluoride
transferred from water to saliva during drinking, as well as that ingested.
Anti-fluoride activists pushed this misrepresentation hard during recent hearings on
fluoridation at the Hamilton City Council in NZ. It had its effect when the Council took on
itself to issue a leaflet giving oral health advice. This repeated the “topical” misinformation.
Health and dental experts were publicly very critical of the leaflet and Hamiltonians felt
embarrassed by the Council’s hubris.
Fluoridated toothpaste only complements, does not substitute for, this regular “top up” of
saliva F during drinking and eating.
Perhaps we should be referring to “surface” mechanisms rather than “topical” ones as the
latter is so easily seen as applying only to application methods.
Extrapolation from high concentration animal studies
I think Paul’s confidence in unsupported extrapolation from higher concentration animal
studies is very cavalier. Paul claims:
“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.”
He doesn’t support this with a citation but I suspect that would only be to a similar assertion
in Fluoride Alert or a sister web site, with no, or poor, literature reference.
The US National Research Council report Fluoride in Drinking Water A Scientific Review
of EPA’s Standards discussed the contradictory data used for attempting to show a ratio
between humans and rats for blood plasma levels and concluded:
42
“Dunipace et al. (1995) concluded that rats require about five times greater water
concentrations than humans to reach the same plasma concentration. That factor appears
uncertain, in part because the ratio can change with age or length of exposure. In addition,
this approach compares water concentrations, not dose. Plasma levels can also vary
considerably both between people and in the same person over time (Ekstrand 1978).”
I am suspicious of attempts to use comparison of blood plasma F levels for such justifications
because of the huge range and variability of these levels. This sort of speculation seems to
fuel the frequent use of the word “might” in Paul’s article (and attempts to convert such
logical possibilities to realities) and in the end leads to the speculation being present as a fact
(Paul’s “well-known” and the simple FANNZ declaration).
But Paul at least refers to one study on rats using drinking water with F concentrations closer
to those of fluoridated water Varner et al (1998). Unfortunately I could not get the full text
of this paper and the link Paul provides to http://www.fluoride-journal.com does not allow
access to mere mortals like me. In my search I was amazed how links promising full text of
papers like this often just take one back to Fluoride Alert and their in-house interpretation.
The abstract mentions changes in cerebrovascular and neuronal integrity for AlF3, and to a
smaller extent for NaF. As I can’t access the discussion to understand he possible
significance of these small changes I won’t comment further on this.
Why do countries not fluoridate
Paul describes my consideration of the various reasons behind the decisions of countries not
to fluoridate their community water supplies as “more like self-serving political spin than
reality!” That is rather harsh considering he then goes on to claim only 2 main reasons
freedom of choice and health concerns. Using his own article as a reference!
No, I won’t respond by selecting personal statement from citizens of the non-fluoridated
countries as he asks. But here is an outline of the situation with fluoridation throughout the
world taken from a recent issue of the newsletter of the New Zealand National Fluoride
Information Service. It gives a pretty detailed picture:
Countries with widespread water fluoridation programmes 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 programmes
include Vietnam, Fiji, Papua New Guinea, and South Korea.
Several countries are unable to introduce water fluoridation programmes 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
43
and most Latin American and Caribbean countries (apart from Argentina, Brazil, Chile and
French Guyana) have or have had salt fluoridation programmes.
A smaller number of countries currently have fluoridated milk programmes, 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.
Reasons for not fluoridating water supplies and/or using alternative ways of overcoming
fluoride deficiencies are simply not restricted to attitudes towards freedom of choice and
health concerns, although they may have been deciding factors for a few countries. This is
another instance where opponents of fluoridation are making widespread simplistic claims
(like Europe bans use of fluorosilicic acid) based on only a few facts, and ignoring (or hiding)
the details.
We should also remember that despite different decisions by governments and local
authorities about implementation of fluoridation all the reputable national and international
health bodies do accept the scientific consensus of the beneficial role of fluoride in oral
health. It is this endorsement which is more relevant to us than the specific technical, political
or social decisions made in other countries.
Political activism
I am glad Paul rejects extremism among anti-fluoride activists. However this does not seem
to stop him cooperating with extreme conspiracy theorists like Alex Jones and Vinny
Eastwood to produce videos. (Have a look at Cyber bullying of science, which includes a
recent video of Eastwood’s attacking scientists and science, to get an idea of how silly these
people can be). People do notice such associations and draw their own conclusions. Paul
appears to give some justification of “the more nutty conspiracy theories espoused by some
opponents of fluoridation.” He says “promoters of fluoridation should not be surprised that
some people are trying to come up with a rational explanation for why certain governments
are behaving so irrationally promoting this practice.” Well that is his perspective and it is a
minority one. I certainly don’t accept such justifications because I, and many others, have no
trouble understanding the decisions to fluoridate.
Misrepresentation of the facts is a real problem among activists of all persuasions. That is
understandable because ideological and political convictions and motivations can distract
44
even the most honest people. Paul presents an example of an image that illustrates this for
some supporters of fluoridation.
This image seemed to create a lot of controversy among local Facebook pages and I got the
blame because it was posted on this blog. I have been assuring complainants that it is not my
image and I do not support its implied message. It seems to have been taken from a document
prepared under the Queensland Health logo. I cannot find a source and no-one seems to be
able to give a citation. It is not on the Queensland Health web site. All Internet references
seem to be in documents and sites of fluoridation opponents indicating that it has backfired
as a propaganda exercise for fluoridation. I gather it may have been prepared to send to
selected Australian members of parliament at some stage.
Paul has sent me a copy of the document which interested readers can download.
But here is the trouble for those living in glasshouses who wish to throw stones. This sort of
misrepresentation is probably more common among opponents of fluoridation. The figure
below, for example, is from a document of the “Queenslanders for Safe Water” website
which ironically included and criticised the Queensland Health photos! (Thanks to
commenter Steve Slott for the link). It uses photos of extreme skeletal and dental fluorosis to
argue against fluoridation.
This, and the Queensland Health photos, are extreme exaggerations used to promote a
message. Reasonable people should condemn that tactic. But isn’t this, in essence, the same
tactic used by Paul and other opponents of fluoridation when they extrapolate from animal
studies at high concentrations, characterise the relatively common very mild and
“questionable” cosmetic fluorosis as if it were severe, use the “topical” mechanism to argue
that fluoridated water has no influence, wildly exaggerate the concentration of toxic
contaminants in fluoridation chemicals, persistently and inappropriately describes fluoride a
poison and a neurotoxin, misrepresent the reasons why some countries do not fluoridate their
water supplies and deny data illustrating a beneficial effect of fluoride on oral health as
“biased?”
References
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.
National Fluoridation Information Service (2013): Newsletter. #6 May 2013.New Zealand
National Fluoride Information Service. 8 pp
National Fluoridation Information Service (2011): Does Delayed Tooth Eruption Negate The
Effect of Water Fluoridation? National Fluoridation Information Service Advisory June
2011, Wellington, New Zealand. 14 pp.
45
National Research Council. (2006) Fluoride in Drinking Water: A Scientific Review of EPA's
Standards. Washington, DC: The National Academies Press.
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.
46
Why I Support fluoridation: Ken Perrott -
November 11, 2013
So far, our exchange has only covered some arguments against fluoridation and responses to
those arguments. Some readers feel we should have started with me advancing the arguments
for fluoridation. For example one commenter, Alison, said
“readers haven’t had the opportunity to see the basic arguments favoring fluoridation as you
see them. . . . we are genuinely perplexed about why this practice has continued and honestly
and sincerely trying to further or understanding.”
Paul Connett made a similar remark in his last article:
“promoters of fluoridation should not be surprised that some people are trying to come up
with a rational explanation for why certain governments are behaving so irrationally
promoting this practice.”
I can’t understand why anyone should be perplexed or think fluoridation is irrational. But I
am happy to give my reasons for supporting fluoridation but remember it is a personal
perspective as I can’t speak for everyone who supports it. My perspective derives from
several issues that are important to me the science, defence of science against anti-science
elements, social concerns and the provisional nature of knowledge.
Scientific acceptance of fluoridation
New Zealand agriculture dependent on science and correction of deficient micro-elements. Photo credit: Farm Forestry NZ
47
We have many advantages in New Zealand, despite our social, economic and political
problems. The climate, our scenery, our people (who are generally open-minded, liberal and
accepting), agriculture and food. But our agriculture and food, and the rest that depends on
these, has only really been possible because of the application of science to solve problems
with the land we inherited.
New Zealanders accept the need to correct nutrient and micro-element deficiencies because
we realise their importance to our place in the world. The correction of cobalt deficiencies in
our central volcanic region of the North Island/Te Ika-a-Māui had huge economic returns. We
also took steps to correct other important deficiencies like molybdenum, copper and
selenium. Discovery of the role of fluoride in oral health, and that we had a deficiency which
needed correction, was hardly a surprise to us. Nor did most of us find the solution unusual.
In the mid-1960s I worked at Soil Bureau, DSIR, outside Wellington, and remember some of
the early discussions around fluoridation there was some debate then about the possible role
of the micro-element molybdenum, rather that fluoride, in limiting tooth decay. Later my
research developed further into the nature of phosphate and it’s reactions in soil and the
fluoride story really made sense. I became aware that the primary minerals of phosphate in
soils were apatites which had fluoride as a natural constituent. This small amount of fluoride
imparted important properties to the apatites lowering their solubility and increasing their
hardness which helped prevent weathering losses.
So it is understandable I could see how fluoride improved oral health (bones and teeth are
bioapatites). In my research reading I also found many dental research papers were very
useful. Looking back I can, for example, remember the discovery like of the role of fluoride
in inhibiting dissolution of apatites by a surface reaction in partly acidulated rock phosphate
fertilisers. This parallels similar discoveries about the role of surface reactions of fluoride in saliva
inhibiting tooth mineralisation and reducing tooth decay.
So the efficacy of fluoridation as a social health measure was a no-brainer as far as I was
concerned. But about 10 years ago I had a sort of road to Damascus moment about the
political issues when working on a research project involving fluorosilicic acid. My analysis
of this material (the same used in New Zealand for water fluoridation) revealed the
concentrations of contaminants like arsenic were very low contrasting sharply with the
claims of activists campaigning against fluoridation (whose story I had sort of accepted till
then). That left me with a healthy respect for evidence, and a corresponding suspicion of
ideologically motivated activists, in these sorts of public debates involving scientific issues.
Defence of science
I guess most scientific researchers have, at some stage, to meet the activity of anti-science
sympathisers and activists. Evolutionary biologists have a permanent battle defending their
science against creationists. There has been huge political pressure imposed on climate
scientists. Surprisingly, even scientific researchers in agriculture periodically face this
problem. Quacks selling snake oil seem to be able to find a market with farmers selling
48
alternative fertilisers, etc., just as they can on health issues. Ideology also intrudes, with
debates over organic farming and use of chemicals in agriculture.
Often these conflicts are not simply black and white. The last two examples are complex.
There is a role for organic farming and there is certainly need to lower chemical inputs into
agriculture. These issues get sensibly debated and have their own scientific support. But
agricultural scientists have often had to face the problem of more highly motivated and
ideologically driven detractors with more extreme views.
These anti-science people and groups can often be very effective politically and will skilfully
use the mass media and the new social media blogs, Twitter and Facebook. Very few
scientists have experience with, or a liking for, this form of public relations and easily lose
such media debates. Scientists don’t willingly get their hands dirty in such public relations
battles. It is interesting to speculate why but that is a subject for another time. One barrier I
was aware of during my career was the limits and control placed on individual researchers by
their institution. Institutional politics often over-ride the freedom of researchers to defend
their work and take part in social debates about it. institutions encourage scientists to keep
their heads down when attacked and not retaliate. The institutional fear of such social
engagement possibly results from fears of legal action.
I am now retired and this has at least one advantage freedom from institutional constraints.
Mind you, if a retired scientist is involved with paid consulting, advocacy or lobbying, then
they have another form of constraint which is probably more direct and rigid than that
imposed by a research institute. Because consulting, advocacy and lobbying usually need
prior commitment to an idea, product or policy - payment is made for endorsement or
justification and not research.
In my case I have not had to rely on such extra income so have had the freedom to explore
my interests, and express my opinion without censorship or control. I have enjoyed the
freedom to read and research ideas and to follow my nose in a way intensive paid research
does not allow because it is so focused.
Inevitably I have been attracted to some of the more controversial areas controversial
politically, not necessarily scientifically. Such as the religion-science conflict, evolution,
climate change and, more recently, fluoridation. I have participated in on-line debates on
these issues, and about 7 years ago started this blog. None of this would have been possible
while I was employed, or if I had got into paid consulting or advocacy during my retirement.
Despite my interest in the chemistry around the fluoridation issue I did not get involved in
any public discussion until earlier this year. My city, Hamilton, held a referendum in 2006
which overwhelmingly supported fluoridation. I was aware the issue was coming up again
and assumed we would have another referendum this year. That was OK by me but, like
many Hamiltonians, I was shocked to hear in June that the local council had decided to stop
fluoridation without a referendum. Yes, they held hearings beforehand and had last year
reversed their decision to send the issue to referendum again but most citizens were just not
aware of this going on. Many of us felt it was done behind our backs.
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In New Zealand decisions on fluoridation are left to local councils because they are the
ones managing the treatment plants. Most councils really don’t feel they should be making
those decisions that this should be the responsibility of central government and health
ministries. However, that is the way it is.
While other decisions on water treatment don’t go to referendum, or get decided by councils,
fluoridation attracts controversy there have been regular campaigns by activists opposing
fluoridation. I don’t think citizens think councils should make decisions about health and
science that is not their job. Councils should instead reflect the views of the community on
such issues. Personally, I think if a community opposes fluoridation that should be enough.
While I accept that the person in the street does not understand the science (why should they)
and may be prone to chemophobia or misinformation, if they are so inclined it should not be
imposed.
In the end sensible citizens will take advice on such issues from scientific and health experts
not local council politicians.
So I guess my interest in the political issue was sparked off by what I saw as a violation of
democratic rights. As I reacted and started to comment on line and write to councillors about
the injustice I became more and more aware of just how badly the science around this issue
was being distorted by anti-fluoride campaigners. So, we had a repeat of the evolution and
climate change debates. There was a battle about the science behind fluoridation and I had to
get involved.
As with these other issues a strong motivation for me is the integrity of science. The need to
challenge and expose distortions about the science. But fluoridation is also an ethical and
social health issue which raises a human rights motivation for me. In particular I find some of
the hostility towards fluoridation repugnant because it demonstrates a complete lack of
understanding of what life is like for the economically and socially disadvantaged in our
society. In fact, it often demonstrates a complete lack of empathy for their situation.
Social concerns
This not the place for discussing the details (and that is very difficult anyway) but I come
from a socially deprived background and have some understanding of what it is like for
people caught in such social and economic traps. I believe more people are actually in that
situation than political activists, or politicians in general, realise. Partly because socially and
economically disadvantaged people are usually incapable of advocating for their interests,
and partly because the rest of society prefers to turn a blind eye, or to otherwise deny the
problem.
But these problems exist, and they affect all of us. If a section of society cannot reach its
potential for social, economic and psychological reasons that affects us all. It often means
more people dependent on state social and financial help. Fewer people getting the education
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and becoming the experts needed to make our society better. These problems increase the
health costs which end up being paid by us all through our taxes.
Social health policies, like fluoridation, are actually very cost-effective. They help reduce
what the whole of society must pay in their absence. Probably more important from my
perspective, they are humanitarian. They help rescue children and adults from otherwise
hopeless situations.
Poor oral health is a huge burden for the individual. Toothache is unbearable for children,
who do not have the power to ease their situation. In later life the inevitable cosmetic
consequences affect the individual socially. Destroying their confidence, inhibiting their
employment and other social opportunities.
Believe me, I am just as big an advocate for personal freedom of choice as the next person.
But in the real world this needs to be balanced against social good. To dogmatically stress
one at the cost of the other is just political extremism. And this is rejected by most people in
today’s democratic, empathetic and pluralistic society. Most people accept that social health
programmes benefit the whole of society, financially and ethically.
Provisional nature of knowledge
I have not dealt here with any of the many arguments used against fluoridation. This was
meant to be a positive article, dealing with the argument for this practice. I expect it will
bring out many of the arguments against fluoridation in the comments and response and I can
respond to them then.
I don’t wish to ignore the criticisms of fluoridation far from it. But I do want to make my
own judgements on them intelligently and critically. I think that is the correct scientific
approach. And my own experience has taught me that criticisms can be wrong, ideologically
motivated or just plain untrue. The example of the claimed contaminants in hydrofluoric acid
illustrates this.
I also recognise that humans are not really a rational species, more a rationalising one.
Confirmation bias is a natural result of the very human activity of pattern seeking. We are all
prone to logical fallacies, selective viewing, and biased interpretation. Scientists are no
exception, but at least the scientific ethos of demanding evidence, checking ideas against
reality and submitting conclusions and theories to the critique of one's peers help to reduce
(but not eliminate the problems),
Ideology and strong convictions get in the way of intelligent and critical assessments.
Personally I think this problem is rife among anti-fluoride activists. They are a socially and
ideologically diverse group but philosophies of alternative health, alternative medicine and
treatments, opposition to establishment ideas for its own sake, conspiracy theories of one sort
or another and a long-term component of extreme right-wing politics are all present. In
saying that I am not denying the many honest and sensible people who may have concerns
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about fluoridation for one reason or another. Hopefully it is the latter group which will
engage in discussion here.
I am definitely ready to honestly assess the criticisms and arguments made by opponents of
fluoridation especially if presented in good faith and a non-hostile way. One thing that a
career in scientific research teaches is that we are often wrong. Discovery is about making
mistakes, discovering one has been wrong, seeking further evidence and adjusting one’s ideas
and theories. I can recall situations where experimental results have proven me wrong and I
felt enthused because that mistake, and my discovery of it, opened things up to new
discoveries. In effect, whether we personally intend it or not, scientists do experiments with
the express purpose of proving themselves wrong. After all, the best experimental evidence
one can offer for a dearly loved theory is one that would test it properly and show it wrong if
that is the case.
That is why I have chosen the name Open Parachute (“your mind doesn’t work if it is
closed”) for the blog and adopted the slogan - “if you have not changed your mind in the last
few years check your pulse, you may not be alive.”
I am certainly open to changing my mind about fluoridation. But that change will need
evidence, good evidence. And honest, intelligent interpretation of that evidence.
So criticise what I have written here. Present your arguments against fluoridation. But please
do so in good faith. I am not going to be convinced by name calling or hostility. Unwarranted
extrapolation from studies done at high concentration are a dime a dozen and worthless in
this debate. And misrepresentation of the literature is counter-productive because I do like to
check. I have seen too many examples of distorted interpretation and misinformation to take
such assurances on trust any more.
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Paul Connett - November 14, 2013
I think your opening statement certainly gives us a perspective from where you are coming
on this issue Ken and that is helpful.
I am very glad that you put “having an open mind” and “relying on science” as your key tools
for resolving controversial issues like fluoridation. I believe that once you have got over
some negative impressions that you have had with some people opposed to fluoridation, that
you will find that having an open mind and relying on the best science will inevitably lead
you to rejecting fluoridation and to see it as the misguided practice it is. But we shall see.
As far as the case you present I find it very, very short on science. Basically you argue that
fluoride is needed to react with our bio-apatites and make them stronger, less soluble and in
the case of teeth less vulnerable to tooth decay. You offer no scientific evidence that
interaction with the bones is beneficial and can be achieved without damage to the bone or
the connective tissue.
Your case as far as the teeth are concerned seems to boil down to the need to put fluoride in
the drinking water so after passing through the whole body it ends up in our saliva and that
this is the delivery system which reduces tooth decay. Two questions: 1) Why do you feel
that this is more rational and suitable than treating the tooth enamel more directly with topical
treatments like fluoridated toothpaste? 2) If you reject topical treatment for some reason and
you insist the fluoride must be swallowed to be effective why don’t you use a more
appropriate way of delivering fluoridated water, i.e. in one liter bottles at 1 ppm and prepared
with pharmaceutical grade sodium fluoride?
I asked this latter question at the end of section 1A but in your response you did not answer.
So may I ask it again? Would not this delivery system provide, 1) a better control of the dose,
2) a far better control over the purity of the chemical used and 3) would not force this human
treatment on people who don’t want it. Nor would it involve giving up on the central dogma
of water fluoridation. Surely this would be a win-win situation for everyone?
On the ethical front, you stress the need to help disadvantaged children. No argument there
from me. But what if your chosen method actually further disadvantages these children and
their families? What for example are parents in low-income families supposed to do if they
don’t want their children to drink fluoridated water? Haven’t you trapped these families with
this policy? Moreover, are you not aware of the extensive literature from India that fluoride’s
toxic effects are more serious for people with poor nutrition (low protein, low vitamins and
low calcium see the early work from Pandit et al., 1940 and the more recent animal studies
from Chinoy, NJ see the FAN bibliography for full citations,
http://fluoridealert.org/researchers/fan-bibliography/)? Aren’t children in disadvantaged
communities more likely to have poor nutrition?
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Scotland, which has no fluoridation, has found a simple and cost-effective alternative way of
fighting tooth decay as this recent BBC Scotland report indicates (
http://fluoridealert.org/news/nursery-toothbrushing-saves-6m-in-dental-costs/):
“A scheme to encourage nursery children to brush their teeth has saved more than £6m in
dental costs, according to a new study.
Childsmile involves staff at all Scottish nurseries offering free supervised toothbrushing every
day.
Glasgow researchers found that the scheme had reduced the cost of treating dental disease in
five-year-olds by more than half between 2001 and 2010.
The programme was launched in 2001 and costs about £1.8m a year.
It emphasises the importance of toothbrushing and helps parents establish a healthy diet from
the earliest stage.
A number of nurseries and schools in targeted areas also provide fluoride varnish and
toothbrushing in primary one and two.
An evaluation, funded by the Scottish government and carried out by Glasgow University,
found that fewer children needed dental extractions, fillings or general anaesthetics as a
result of the programme.
‘Less toothache’
There was also said to be a drop in the number of children needing hospital treatment for
dental problems, freeing up operating theatres.
Public Health Minister Michael Matheson said: “This is an amazing achievement and shows
just how much can be saved from a very simple health intervention.
“This has seen less tooth decay in children which means less toothache, fewer sleepless
nights and less time off school.
“By this simple measure, NHS costs associated with the dental disease of five-year-old
children have decreased dramatically.
“More children can just be treated routinely in the dental chair because they need less
invasive treatments, so fewer fillings and fewer extractions, and many more children with
much better oral health than we have seen in many years.”
For the second time you state your concerns about, “Unwarranted extrapolation from studies
done at high concentration” which you say are “a dime a dozen and worthless in this debate.”
Last time you brought this up I responded by showing that several human IQ studies were not
done at high concentrations. For example, in nine of the 27 IQ studies reviewed by Choi et al
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(2012), the high fluoride village was at 3 ppm or less. I also went into more detail on the
study by Xiang et al. (2003a,b) who found a threshold at 1.9 ppm for this effect.
In my discussion on this point I stressed the difference between concentration and dose and
the need to consider a margin of safety calculation to protect for the full range of expected
sensitivity or vulnerability in a large population when extrapolating from a small human
study of a fairly homogeneous population. Thus extrapolating from Xiang’s study we find
that there is absolutely no margin of safety to protect either for the range of exposure to
fluoride in an American or NZ population or for the full range of sensitivity expected in any
large heterogeneous population. This latter calculation is particularly important for your
major concern disadvantaged children because that is almost certainly where you will find
the most vulnerable in this regard.
When we embarked on this exercise I thought that this was going to be an exchange between
yourself and me, but I am finding that you do not want to restrict yourself to my arguments
but want to argue against all the arguments thrown at you by people opposed to fluoridation.
That has a place of course but it was not what I was expecting. In my view it serves to
distract and muddy the waters.
I wish you had taken a more disciplined approach and focused entirely on the arguments I
have put forward. In this respect it is unfortunate that when you were educating yourself on
this issue you did not take advantage of reading the book I co-authored with two other
scientists, James Beck, MD, PhD and Spedding Micklem, DPhil (Oxon). There we spelled
out the case in a cool, calm and collected way with every argument backed up with citations
to the scientific literature. As you know but your readers may not I sent you a pdf copy of
this text. By so doing, I had hoped that we could keep this debate tightly focused; that I could
defend my own arguments (and there is plenty enough of those) and not have to keep
considering those of others.
Your readers might also not know that shortly after this book was published (Oct 2010) I was
invited in early 2011 to meet with staff of the Ministry of Health in Wellington. About 20
people were there from the Ministry and some of their advisers. I carefully went through the
arguments in the book and asked them at the end of my presentation to provide a written
response to the book showing where I was wrong and providing the science that supported
their critique. I added that if they could not do this with all the resources and personnel at
their disposal then they should not continue to promote this practice. After nearly 3 years I
still have not received that written critique. Meanwhile, personnel from this Ministry,
including the Minister himself, continue to promote the practice and even accuse opponents
of distorting the scientific arguments with no specific examples to which someone like
myself could respond.
Blanket condemnation of opponents gets us nowhere. Nor does it help to keep knocking
down straw dummies. The debate will only be seriously engaged when the proponents begin
to put forward and defend the studies that have convinced them that fluoridation is both
effective and safe and safe for everyone. This is what opponents like myself have done.
55
This was what I was expecting from you Ken when you got the opportunity to put forward
your case. Surprisingly, you gave no scientific citations at all. Hopefully, these will come
later.
Rather than take up any more space at this point I will wait for part 2 of your case, where I
hope you will present some science to support this practice.
While you are doing this I will prepare my response to your response to my section 1A.
References
Choi et al., 2012. Developmental fluoride neurotoxicity: a systematic review and meta-
analysis. Environ Health Perspect 120:13621368.
Pandit et al., 1940, Endemic Fluorosis in South India, Indian Journal of Medical Research 28,
no. 2: 53358.
Q. Xiang, Y. Liang, L. Chen, et al., “Effect of Fluoride in Drinking Water on Children’s
Intelligence,” Fluoride 36, no. 2 (2003): 8494,
http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf .
Q. Xiang, Y. Liang, M. Zhou, and H. Zang, “Blood Lead of Children in Wamiao-Xinhuai
Intelligence Study” (letter), Fluoride 36, no. 3 (2003):198
99,http://www.fluorideresearch.org/363/files/FJ2003_v36_n3_p198-199.pdf .
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Ken Perrott -November 17, 2013
First this issue of science and citations? Yes, my last article was general and concentrated on
the philosophy of science and social aspects both of which are important to me and central
to why I support fluoridation. But Paul seems not to have appreciated or understood my first
section on scientific aspects so I will develop part of that, the nature of fluorine in apatites,
further here. I will throw in a few citations just to keep Paul and my other critics happy (more
on the use of citations later).
Apatites contain structural fluoride
I briefly referred to the nature of apatites and the occurrence of fluoride as a natural
constituent. Paul seems not to get this as he again refers to fluoride as something external,
and not a natural, normal, part of apatites. He is mistaken in his belief that I claim “that
fluoride is needed to react with our bio-apatites and make them stronger, less soluble and in
the case of teeth less vulnerable to tooth decay.” (My stress).
I don’t claim that at all. I argue that apatites, including bioapatites, are not pure end
members such as hydroxylapatite, but naturally (and normally) contain species like F and
carbonate as part of their structure. isomorphous substitution of these species for phosphate
and oxygen occur during formation of the apatite compounds. This isomorphous substitution
of F for O strengthens the apatite and lowers its solubility compared with the hydroxylapatite
end member. Carbonate substitution for phosphate can have an opposite effect things are
never simple so there is a balancing act which makes isomorphous substitution of fluoride
even more important. The bioapatites in our body contain both F and carbonate as normal,
natural components (see figure below). The incorporation of ions like fluoride into
bioapatites can change their solubility product by several orders of magnitude according to
Driessens (1973). Planer at al (1975) attributes the improved stability of bone to "the
isomorphous substitution of fluoride in the apatite structure.”
(None of this denies the negative effects of excessive fluoride intake on our bones and teeth).
This is why Wopemka and Pasteris (2005) argue “the apatite phase in bone should not be
called hydroxylapatite.” This is also the reason why there are “limitations to the use of the
stoichiometric mineral hydroxylapatite as a mineral model for the inorganic phase in bone.”
57
I second this and find unfortunate the simplification we often see in more general texts where
bioapatites are discussed as if they were the end members hydroxylapatite or fluoroapatite
rather than an intermediate hydroxyl-carbonate-fluoroapatite of somewhat variable
composition.
The fluoride we ingest is involved in the formation of bioapatites right from the beginning.
This is why we see increased risks of weakened bones and teeth when dietary fluoride intake
is insufficient. It can also be lost from actively growing bones and other bioapatites when
fluoride intake is reduced. See Kurland et al (2007) for an example of the reverse of fluorosis
(probably caused by surreptitious ingestion of toothpaste) once fluoride inputs had been
reduced.
Understanding the complex nature of bioapatites and the effect of composition on structure
and strength is important to appreciating the role of ingested fluoride on producing healthy
bones and teeth. Unfortunately this aspect is often neglected, or purposely overlooked or
hidden, when attention is concentrated on the mechanism of surface reactions of fluoride with
existing teeth in inhibiting tooth decay.
However, some researchers are stressing that the beneficial effect of fluoride arises from
effects of ingested, or systemic, fluoride on pre-eruptive teeth as well as surface reactions on
existing teeth. Newbrun (2004), for example, stressed in a review of the systemic role of
fluoride and fluoridation on oral health:
“The role of systemic fluoride in caries prevention is neither “minimal” nor “of borderline
significance.” On the contrary, it is a major factor in preventing pit and fissure caries, the
most common site of tooth decay. Maximal caries-preventive effects of water fluoridation are
achieved by exposure to optimal fluoride levels both pre- and posteruptively.”
I will now discuss those surface reactions.
Topical confusion once again
Having dealt with this issue twice now (admittedly only briefly) I am surprised Paul could
interpret my understanding of the beneficial role of fluoride on teeth as requiring:
“the need to put fluoride in the drinking water so after passing through the whole body it
ends up in our saliva and that this is the delivery system which reduces tooth decay.”
I have never claimed that at all. Still, local anti-fluoride activists accuse me of this despite
my many specific refutations. Paul’s characterisation of the “topical mechanism” is common
among such activists and, as I said in a previous article, an example of a bait and switch
fallacy.
Earlier this year I wrote about the so-called “topical” mechanism and the way it was being
misrepresented by anti-fluoride activists in two articles - Fluoridation topical confusion and
Topical confusion persists. I will just repeat myself a bit here to clarify.
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The US Center for Disease Control describes this “topical” or surface mechanism in its report
Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United
States:
. . drinking fluoridated water, brushing with fluoride toothpaste, or using other fluoride
dental products can raise the concentration of fluoride in saliva present in the mouth 100-to
1,000-fold. The concentration returns to previous levels within 12 hours but, during this
time, saliva serves as an important source of fluoride for concentration in plaque and for
tooth remineralization.”
So let us be clear, they are referring (in the case of fluoridated water) to fluoride ions
transferring from the water (or food) to saliva (and biofilms on the teeth). There is no
assumption that the salivary fluoride must come only from ingested fluoride after “passing
through the whole body. The latter, of course happens, but contributes a smaller amount.
There are literature reports that this lower concentration can also contribute to the “topical”
mechanism but I am not myself advocating that as necessary.
The diagram below portrays this the fluoride is going directly from the drink and food into
the saliva:
Tooth decay occurs because when the pH at the tooth surface is lowered (this happens when
bacteria decompose sugars and other carbohydrates) some of the calcium and phosphate in
the bioapatite at the tooth surface dissolves mineralisation. With time the pH increases and
the reaction is reversed calcium and phosphate ions at the tooth surface reform as a solid
hydroxylapatite surface phase (remineralisation). The acidity (or pH) is an important factor in
the dissolution and precipitation of apatites.
When fluoride is present at the tooth surface a fluorohydroxyapatite is formed in the surface
phase. This is “harder” it doesn’t dissolve as readily. Consequently the incorporation of
fluoride into the tooth surface reduces mineralisation and enhances remineralisation. It
inhibits tooth decay.
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Fluoride in fluoridated water and food does this very effectively. Because we drink and eat
often, dietary forms of fluoride help to maintain a useful concentration of saliva fluoride over
time.
Topical application methods (toothpastes and dentrifices) are a supplement to fluoridated
water and dietary fluoride, but not a substitute partly because they are not applied as often
(if at all). However, dentrifices and dentist’s fluoride treatments may cause formation of CaF2
globules on the tooth surface (because of the high F concentration) which then slowly release
their F over time to maintain saliva concentrations at an appropriate level (see the review
article Mechanisms of Action of Fluoride for Caries Control by Buzalaf, Pessan, Honório,
and ten Cate JM (2011)).
The “topical” or surface mechanism which operates with fluoridated water is effective
because it is regular (much more regular that topical application methods) and this helps
maintain fluoride concentrations in saliva and tooth biofilms are effective levels.
Incidentally, this is also a reason water fluoridation is an effective social health policy. It
means that the whole population can and does access the “topical mechanism” without
thinking about it (as is required with toothpaste, mouth rinse and dentist fluoride treatments).
In summary, science supports both a systemic and a surface (“topical”) role for the
beneficial effects of fluoridated water.
Benefits for bones
Paul asks for “scientific evidence that interaction [of fluoride] with the bones is beneficial.”
As I described above that question actually misrepresents the situation. It is not the
interaction with bones that is important but incorporation into bones during their formation
and growth. Fluoride does not have to “react with our bioapatites,” as Paul puts it. The
fluoride is a component of the bioapatites - See first figure above.
There are numbers of scientific papers that can be cited to show a beneficial role for fluoride
in bones. I will just refer here to Li et al (2001) (full text here) because it does offer a useful
graphic demonstration of that beneficial effect in this case of the overall incidence of bone
fractures. Figure 2 from this paper below shows that the incidence of fractures is lowest at
concentrations similar to that used for water fluoridation, with increased incidence at both
lower and higher concentrations.
Incidentally, one of our commenters Kurt Ferre draws attention to the fact Paul Connett is
aware of this paper at least he referred to it in his 50 reasons to oppose fluoridation where
Paul notes:
One very important study in China, which examined hip fractures in six Chinese villages,
found what appears to be a dose-related increase in hip fracture as the concentration of
fluoride rose from 1 ppm to 8 ppm (Li 2001) offering little comfort to those who drink a lot of
fluoridated water.
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Actually the study did not show what Paul claims “a dose-related increase in hip fracture
as the concentration of fluoride rose from 1 ppm to 8 ppm.” The particular data relates to
overall fractures, and not hip fractures. And rather than demonstrating “a dose-related
increase” it just shows a significant increase in the 4.32 7.97 ppm group when compared
with the 1.00 a 1.06 ppm group.
But really he should have mentioned the significant increased incidence of fractures in the
0.25 0.34 ppm group (to the same incidence as at 8 ppm) as this is consistent with a
beneficial role for fluoride at around 1 ppm. It demonstrates the negative effects of deficient
intake of fluoride.
This brings us to the next issue the selective approach to scientific literature and use of
citations.
Approaching the literature purposely or objectively
One thing that sticks out like a sore thumb when Paul and other opponents of fluoridation cite
research papers is the predominance of studies from China and India. And the journal
Fluoride, which is not considered a high quality journal by the scientific community, is often
cited.
Just on the possibility of chance we might expect a better representation of countries of origin
of the research, and of journals. I believe this demonstrates a selective approach to the
literature.
If you wish to promote a pet theory or way-out idea it is possible to find a “scientific” citation
to support it. All you need is Google and a fair bit of confirmation bias. The latter is a normal
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problem for all of us if we have a strong commitment to an idea we can usually find some
handy citations to support it (and ignore those that don’t). On top of that we can interpret
those papers (or more likely just their titles or abstracts who bothers to read the full text?) to
fit in with our ideas.
It is just so easy to make any argument look “sciency” using citations these days. And who
bothers checking them? A good proportion of readers seem to be convinced just by the
presence of citations. (Or unimpressed by the lack of them Paul described my last article as
"very, very short on science” because “surprisingly you gave no scientific citations at all.”)
So citations do get thrown around a lot in this discussion often in a meaningless and
thoughtless way. As for their interpretation in my articles Fluoridation are we dumping
toxic metals into our water supplies? and Fluoridation it does reduce tooth decay I give
examples from the local anti-fluoride activist web site FANNZ where cited sources are
claimed to say the opposite of what they do say! (It always pays to check citations from
ideologically motivated sources like this I certainly do now).
Fortunately working scientists usually have the discipline of peer review and continual
critique of their findings and idea by their scientific community. This encourages an ethos of
objectivity and consideration of all the relevant literature not just the cherry-picked stuff.
Yes, this is difficult and never works perfectly but that discipline certainly helps.
An honest approach requires one to approach the scientific literature more objectively and
intelligently than anti-fluoridation activists (or activists in general) do. A conscientious
approach requires that readers critically assess studies, recognise problems and realise the
need to get an overall picture not a selected one.
I won't deal with the IQ issue, and attempts of fluoridation opponents to implicate fluoride in
the “dumbing down” of the population, at this stage because Paul has indicated he will be
covering it in a future article. But here are a few comments on the paper of Xiang et al (2003)
which illustrates how Paul places a lot of confidence in a cherry-picked citation.
1. Why did the authors choose to publish in the journal Fluoride?” It is certainly not
considered of high quality. It is actually rather suspect because of the ideological
commitment of the editors. This gives the impression that even suspect papers will be
published if the story is right. My point is that if I had some credible findings in
fluoride chemistry and wished to present a paper to the scientific community for their
consideration Fluoride is the last journal I would choose.
2. If I was reviewing this paper for publication I would certainly call on the assistance of
a skilled statistician as reviewer and would probably recommend changes as a result. I
would ask the authors to clarify their figure 1 and its interpretation as well as
explaining the meaning and significance of their “BMC” and “BMCL” and an
estimation of the errors in their values.
3. Xiang’s paper is a minor piece of evidence surely it should be objectively considered
together with all other publications in this area of research. The fact that it is taken in
isolation (except for a few other low quality Chinese studies), and nothing of higher
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quality or from different regions is considered, makes me suspicious. After all, a
number of countries with highly qualified scientists (and activists claiming negative
effects) have had many years to look at possible health effects from fluoridation. The
fact that more credible papers are not produced is hardly good evidence for the claims
made by anti-fluoride activists. Why would they rely on low quality research if better
research supporting their claims was available?
Yet Paul uses Xiang’s paper to authoritatively claim it had “found a threshold at 1.9 ppm for
this effect.” (What effect he refers to is unclear.) How reliable is that figure of 1.9 ppm
(actually 1.85 or 2.32 ppm F in the paper) considering the huge variation in the data points
of the Figure 1? (Unfortunately the paper is not a lot of use in explaining that figure
reviewers should have paid more attention.)
This is the problem. Papers are selected and then values are pulled out of them to make
assertions or claims that really are not warranted and certainly not by a balanced reading of
the literature.
Disadvantaged children
Having experienced the reality of social disadvantage I am still cynical of many people who
claim sympathy. Too often as a child I was blamed for problems I had no control over or told
things would be OK when I knew they wouldn’t. My experience showed me that most of
those social workers, teachers and health practitioners just had no concept of the reality of my
position. How could they unless they had experienced it themselves.
Things are probably a lot better today but I am still cynical of many of these assertions.
I feel the same cynicism and helplessness when opponents of fluoridation like Paul Connett
agree on “the need to help disadvantaged children” - and then follow that declaration with
arguments about hypothetical situations showing absolutely no idea of the reality of life for
disadvantaged children.
Paul suggests my advocacy of fluoridation policies will trap families. "What for example are
parents in low-income families supposed to do if they don’t want their children to drink
fluoridated water? he asks. Well, if he really cared what about the children suffering
horribly from toothache whose parents really don’t have the luxury, the interest or feelings of
choice, to think about the details of the water supply they use? It is the plight of those
children which sparks my empathy.
Sure, there are a few disadvantaged or low-income families who face decisions involving
priority of freedom of choice over social policy. The Catholic families who must find
resources to send their children to fee-charging Catholic schools and not secular public
schools. Or the religious fundamentalists who refuse to use public hospitals. These people do
find the resources if their specific minority freedom of choice issue is really important
enough to them. We don’t deny the advantages of secular schools and public hospitals to the
rest of society just because of the ideological foibles of a small minority.
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The resources required to avoid a public water supply are much smaller and should not be
used as an argument to deny the advantages of a social health policy to the rest of society.
Yes, children from disadvantaged backgrounds may well have problems with bad nutrition as
well as poor oral health. So let us help them. Let us not deny them the beneficial effects of a
well-established beneficial social oral health policy on the pretence that it might enhance
issues related to poor nutrition. Let’s not even worry about such a cynical diversion why
not do something about that poor nutrition instead?
I find the idea of refusing a beneficial social health policy to children because somebody has
it in their head that it might enhance the problems of poor nutrition very cynical and anti-
human. It shows a complete lack of empathy for socially and economically disadvantaged
families and their children. It is an argument for standing by and doing nothing. And I am not
impressed by Paul’s reliance on reports from India where high natural levels of fluoride do
present problems a situation very different to those in New Zealand and the US considering
the fluoridation issue.
Sorry if I come across harshly on this issue it is important to me, raises strong feelings in
me and I have seen too many examples of false concern and complete lack of empathy to
suppress those feelings. I just think people who raise hypothetical “freedom of choice” issues
to oppose beneficial social health policies really have no idea of what it is like for
disadvantaged children and their families or any empathy for their situation.
Nature and focus of debate
I think Paul and I have different concepts of what an exchange of scientific opinion should be
like. We discussed this in our initial negotiations and our different approaches were obviously
not resolved.
Paul expressed a wish that our exchange be focused on his own arguments, and indeed be
limited to, and focused on, the issues raised in his book. I rejected this, arguing this was a
discussion between equals. We each have our own points to make, our own data, experience
and arguments, and we should do so. Anyway this is a public exchange with involvement of
readers who are following the articles and commenting on the issues raised. We are really
both aiming our arguments at our readers, not each other.
I do not think either of us should require that the other has one arm tied behind their back in
entering an exchange like this. I certainly could not, in good faith, enter into such an
“exchange” or “debate.”
Paul was kind enough to send me an electronic copy of his book I thank him for this. I may
review the book (which was highly recommended to me by a few local anti-fluoride activists)
when I can find time. The book has also been useful for me in making specific criticisms of
his arguments. But at no time have I agreed to limit my part of the exchange to the book.
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I can appreciate Paul is proud of his book and therefore wishes to promote it. I can also
understand why local opponents of fluoridation also promote the book. But he cannot
legitimately demand that my part of the exchange be limited in the way he suggests. It is not
my job to sell his book.
A general comment on the use of books in science. Books rarely get the degree of peer
review of journal articles, can often be dominated by authors’ biases or hobby horses, and are
generally somewhat dated in their content. Hence researchers prefer citing research papers to
books. Again, while it is understandable Paul should promote his book to health authorities
and experts in NZ, surely he can appreciate that researchers might not give it the same
authority they give research papers. Or have the same high opinion of the books the authors’
naturally have.
In fact, along these lines, I understand that local researchers suggested that Paul submit his
work on fluoride, or the reviews of others’ research, to a reputable journal for peer review
and publication. I understand he has not responded positively to that suggestion yet.
References
Mechanisms of Action of Fluoride for Caries Control In Fluoride and the Oral Environment,
Monographs in oral science ; v. 22. Pp 97-114.
Centers for Disease Control and Prevention (2001) Recommendations for Using Fluoride to
Prevent and Control Dental Caries in the United States: Vol. 50(No. RR-14): 42 pp.
Driessens, F. C. M. (1973). Fluoride Incorporation and Apatite Solubility. Caries Res
7(4):297314.
Kurland, E. S., Schulman, R. C., Zerwekh, J. E., Reinus, W. R., Dempster, D. W. & Whyte,
Michael P. (2007) Case Report: Recovery From Skeletal Fluorosis (an Enigmatic, American
Case). J Bone Miner Res. 22(1): 163-170.
Li, Y, Liang, C., Slemenda, C W, et al. (2011), "Effect of long-term exposure to fluoride in
drinking water on risks of bone fractures." Journal of bone and mineral research: the official
journal of the American Society for Bone and Mineral Research. 16(5): 932-939
Newbrun, E.(2004), Systemic Benefits of Fluoride and Fluoridation. Journal of Public Health
Dentistry. 64: 35-39
Posner, A.S., Eanes, E.D., Harper, R.A. & Zipkin, I. (1975). X-ray diffraction analysis of the
effect of fluoride on human bone apatite. Archives of Oral Biology 8(4): 549570.
Wopemka, B. & Pasteris, J. D. (2005) A mineralogical perspective on the apatite in bone.
Materials Science and Engineering: C, 25(2): 131-143
Xiang, Q et al. (2003) “Effect of Fluoride in Drinking Water on Children’s Intelligence,”
Fluoride 36(2): 8494,http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf
65
Paul Connett - November 21, 2013
I am going to ignore most of the personal criticisms in Ken’s response to my critique of his
opening statement and focus largely on the science and scientific studies in question.
1. Different interpretations of the Li et al. (2001) paper
I am very familiar with the Li et al. (2001) paper on bone fractures in the elderly in six
Chinese villages with fluoride concentrations in well water ranging from about 0.25 to 8 ppm.
In fact, I reviewed a pre-publication copy of this paper sent to me by the lead author as part of
my invited peer review of the York Report (McDonagh et al., 2000).
Had Ken taken advantage of my sending him the full pdf text of our book he would have
quickly seen that the charge he levels at me of selectively using the Li et al (2001) text on
bone fractures from China is grossly inaccurate.
Instead of relying on the misleading commentary of pro-fluoridation activist Kurt Ferre, he
could have read Chapter 17 of our book (The Case Against Fluoride, CAF), where we
covered both parts of Li’s paper. The part Ken and Ferre cover, shows a U-shaped curve for
all fractures combined. This shows a minimum for fracture rate at the village at 1 ppm. It
could be argued as Ken does that at 1 ppm fluoride may confer some benefit in
strengthening of elderly bones after a lifetime of exposure. However, such an argument is
somewhat muted by the second part of Li’s paper that deals with hip fractures, which is the
most critical bone fracture for elderly people, since about half of the elderly never regain an
independent existence after such a fracture. In this part of the study there is no U-shape i.e.
no apparent protection offered by fluoride against hip fracture and the hip fracture
prevalence appears to increase in a linear fashion above 1 ppm (actually maybe from 0.25
ppm).
This systematic increase becomes more apparent when one checks our re-plot of the data
see Figure 17.2 on p.179.
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Please note I say replot because the graphs provided by Li et al (2001), including the one
used by Ken, are not real plots at all. They are only illustrative. The points on the x-axis
neither represent an average of the fluoride concentration in each village nor the estimated
dose (mg/day) calculated by the authors, the six data points are simply evenly spaced out to
illustrate which village is being represented for the fracture data on the y-axis. In the case of
Figure 17.1 it makes little difference when one puts in the average dose in mg/day, but in the
case of Figure 17.2 it makes a big difference and shows up this “apparent” linear trend more
clearly.
While Ken is correct when he says that the only individual village to show a statistically
significant increase in hip fractures is village 6, based on our replot the increases in villages 4
and 5 appear to be “real,” even though they are not statistically significant individually. In
fact, the data for the whole set of villages appear consistent with a linear regression.
Statistical significance is not the final word on whether a data point or data set is real or not.
In our view, a linear increase in fracture rate for villages 3 through 6 (and maybe even
villages 1-6) looks a more reasonable interpretation of the data than a threshold (i.e. a sudden
tripling of the hip fracture rates) at village 6, the interpretation that Ken prefers.
It is unfortunate that Ken uses an inaccurate commentary from Ferre to mischaracterize what
we did here.
2. Other studies of fluoride and the bone
However, there is a great deal of literature available on fluoride’s impact on the bone (see the
references to Chapter 17, CAF). Ken will need more than the Li et al (2001) paper to
establish that there is an overall benefit to the elderly bone when people are exposed for a
lifetime to an approximate ten-fold increased exposure to fluoride via artificially fluoridated
water. This is especially true for people with poor kidney function and high water drinkers
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(miners in Western Australia drink between 10 and 12 liters of water a day). Can you provide
more studies that support the possibility that fluoride protects the elderly bone Ken?
Nor is it just the bones of the elderly that is in question. I am still waiting to see Ken’s
response to the finding in the Schlesinger et al (1956) study of the second fluoridation trial
(Newburgh-Kingston, NY, 1945-55) in which they reported a statistically significant increase
in the prevalence of cortical bone defects (the ratio was about 2 to 1) in children in the
fluoridated community versus the non-fluoridated community. The cortical bone is the
outside lamellar structure of the bone whose integrity is important in resisting fractures. We
discuss Schlesinger’s work in CAF (p.96).
I am not aware of any health agency in any fluoridated country comparing fracture rates in
children in fluoridated versus non-fluoridated communities or even examining fracture rates
in children as a function of the severity of dental fluorosis. Scientists did this in Mexico
(Alarcón-Herrera et al., 2001) and found an increase in fractures as the severity of dental
fluorosis increased (see P.169, CAF). No attempt has been made to reproduce this result or
conduct a similar study in any of the fluoridated countries.
3. Fluoride’s topical action and saliva
As far as the mechanism of fluoride’s topical mechanism on the teeth is concerned, Ken
quotes the CDC from 2001,
. . drinking fluoridated water, brushing with fluoride toothpaste, or using other fluoride
dental products can raise the concentration of fluoride in saliva present in the mouth 100-to
1,000-fold. The concentration returns to previous levels within 12 hours but, during this
time, saliva serves as an important source of fluoride for concentration in plaque and for
tooth remineralization.”
I went back to this CDC Oral Health Division statement from 2001 and found the sentences
that preceded Ken’s quote most revealing. These preceding sentences read:
“Saliva is a major carrier of topical fluoride. The concentration of fluoride in ductal saliva,
as it is secreted from salivary glands, is low approximately 0.016 parts per million (ppm) in
areas where drinking water is fluoridated and 0.006 ppm in nonfluoridated areas (27). This
concentration of fluoride is not likely to affect cariogenic activity. However, drinking
fluoridated water, brushing with fluoride toothpaste…
These few sentences further strengthen Ken’s arguments that it is fluoride delivered directly
into the mouth that provides the saliva with concentrations, which may or may not do
something and not, the meager concentrations reached systemically through the salivary
gland, a position I erroneously attributed to him. My apologies.
As the CDC states the concentration of fluoride delivered by the saliva gland “is not likely to
affect cariogenic activity.” However, if it is the fluoride levels reached when fluoridated
water has entered the mouth that is the key dynamic for fighting tooth decay, then I think this
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weakens the need to force people to drink fluoridated water. Maybe we should be suggesting
that people swish with fluoridated bottled-water and then spit it out! I also have to wonder
why we are giving fluoridated water to babies before their teeth have erupted.
Let me ask for the third time how Ken feels about an alternative delivery system for
fluoridated water. This would involve using fluoridated bottled-water in one-liter
bottles at 0.7 1.2 ppm. These could be made freely available in dental offices
(supermarkets, pharmacies or clinics). With this approach one could a) use
pharmaceutical grade sodium fluoride; b) could control the dose and c) avoid not
forcing it on people who don’t want it. Nor does it involve giving up the central
paradigm of the fluoridation program.
As far as the rest of the 2001 CDC quote is concerned I think the Oral Health Division is
using a slight of hand here by mixing up a discussion of fluoride in food and water with the
fluoride in toothpaste. That 100-1000 fold increase might take place when toothpaste
containing 1000 or even 1500 ppm is used but is hardly likely with water at 0.7- 1.2 ppm.
I think the CDC put the “cat among the pigeons” among both fluoridation opponents and
proponents when it admitted in 1999 that:
“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…” (CDC, 1999).
It maybe that the CDC Oral Health Division in its 2001 paper was scrambling to salvage
some kind of role for fluoridated water, sufficient to justify continuing its long-time support
and promotion of the fluoridation program, despite its admission of the predominance of a
topical effect. However, It would have been better if, in 1999, the CDC had changed the
focus of its efforts from delivering fluoride systemically to delivering it topically, as well as
addressing other key issues of diet, regular brushing and providing early interventions for
children of low-income families.
In the latter respect I do not understand why Ken completely ignored the exciting news that I
provided from unfluoridated Scotland, where they are having great success with teaching
toothbrushing to infants as well providing better diets and earlier interventions.
As far as the mechanisms that Ken offers for a topical benefit derived from fluoridated water
directly to the saliva in the mouth (and not via systemic exposure), he discussed “fluoride
ions transferring from the water (or food) to saliva (and biofilms on the teeth).”
My experience when drinking water is that it hits the tongue, the back of the top front teeth
and the palate before it swiftly goes down the gullet (unless it is deliberately swished). It
seems to me that the fluoride ions have little opportunity to form a biofilm on any teeth other
than the back of the front teeth. Nor is there much time to mix with the saliva. But this is only
conjecture based on simple personal observations on my part and if Ken has a study that
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shows the level of fluoride in the saliva is dramatically increased immediately after someone
has swallowed a glass of water that would be very helpful.
4. The work of Xiang et al (2003) on IQ
Ken suggests that I am “cherry picking” the data by “singly pulling out the Xiang et al. study
from 2003.” In actuality, I gave that as a specific example of a human study where effects
were found at concentrations very close to the level at which we artificially fluoridate (0.7 to
1.2 ppm). This was in response to Ken’s claim that he was not impressed by all the high
concentration animal studies that have found fluoride causes harm. I cited Xiang in the larger
context of 37 (out of 46 human studies that have found an association between fluoride
exposure and lowered IQ.) These studies come from India, Iran, Mexico and China, with the
majority coming from China. 27 of them were reviewed by a Harvard team (Choi et al.,
2012). Of these 27 studies 26 found a lowering of IQ (average of 7 IQ points). These results
are remarkably consistent even though they have been performed in several different
countries and many different parts of China. However, proponents of fluoridation have
dismissed them on the basis that in two of these studies the range in the high fluoride village
went up to 11.5 ppm. However, I pointed out that nine of the studies found a lowering of IQ
at or less than 3 ppm, which offers no adequate margin of safety for a whole population
drinking water in the range 0.7 to 1.2 ppm. So I wasn’t cherry picking here. We have to see
Xiang’s work in the context of all these other studies as well as the other studies that show
that fluoride is a neurotoxicant (discussed below). I chose Xiang’s study because it is one of
the better studies. It controlled for more potential co-founders than others (including lead and
iodine intake). Recently, Xiang has confirmed that as far as arsenic was concerned there were
higher levels in the low fluoride village, so clearly arsenic was not a factor in the lower IQs
found in the high fluoride village.
Yes, there are weaknesses in many of these IQ studies but the greatest “weakness” is the fact
that countries that practice water fluoridation have made virtually no attempt to reproduce
them or pursue the matter in any way. That is why, as Ken complains, I have not quoted
studies from a wider range of countries: apart from a small early study in NZ (Shannon et al.,
1986) and small behavioral study in the US (Warren et al., 1998) there aren’t any. At the very
least these studies from China, India, Iran and Mexico represent a serious red flag on this
practice and the health agencies in fluoridated countries are ignoring this red flag.
In his further attempt to downplay Xiang’s 2003 study Ken asks
“Why did the authors choose to publish in the journal Fluoride?” It is certainly not
considered of high quality. It is actually rather suspect because of the ideological
commitment of the editors. This gives the impression that even suspect papers will be
published if the story is right.”
I discuss these derogatory comments about Fluoride and its editors, and the double standard
that Ken and other proponents of fluoridation exercise on this matter below, here I would like
to discuss more about Xiang’s work.
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5. Xiang and the journal Environmental Health
Perspectives
Xiang almost certainly chose to publish in the journal Fluoride because it has probably given
more coverage to the possibility that fluoride affects the brain of animals and lowers IQ in
humans than any other journal in the world.
That being said if Ken is going to make judgments based on what journal the article appears
in, then he might be interested by the fact that in 2010 Xiang et al submitted an updated
version of their work to one of the leading environmental health journals, Environmental
Health Perspectives, which is published by the National Institute of Environmental Health
Sciences (NIEHS) a division of the National Institute of Health (NIH). After peer review this
journal agreed to publish Xiang’s work and posted a pre-publication copy on the internet (see
Xiang et al., 2010).
However, Xiang was asked to withdraw his article for the technical reason that some of the
material had already been published by this team (and that was the Fluoride article from
2003). But the key fact from the point of view of this discussion is that despite Ken’s
criticisms Xiang’s work was peer-reviewed by this prestigious journal and was found
acceptable for publication.
The update from Xiang was very important for this discussion and it is a pity that this was
withheld from the mainstream scientific community. Xiang found that the lowering of IQ in
his study correlated with the fluoride levels in the children’s plasma. This greatly strengthens
Xiang’s finding by moving from a population (or ecological) study closer to a study based on
individual exposure. Xiang finally published this part of his finding in Fluoride (Xiang et al.,
2011).
Despite all of this, Ken considers Xiang’s paper “a minor piece of evidence” and argues that,
“it should be objectively considered together with all other publications in this area of
research. The fact that it is taken in isolation (except for a few other low quality Chinese
studies), and nothing of higher quality or from different regions is considered, makes me
suspicious. After all, a number of countries with highly qualified scientists (and activists
claiming negative effects) have had many years to look at possible health effects from
fluoridation. The fact that more credible papers are not produced is hardly good evidence for
the claims made by anti-fluoride activists. Why would they rely on low quality research if
better research supporting their claims was available?”
First of all, I argue that this study by Xiang is part of a large body of work that indicates that
fluoride can damage the brain and I have summarized this large body of work previously (and
it can be found atwww.FluorideAlert.org/issues/health/brain )
So when Ken argues that “Papers are selected and then values are pulled out of them to make
assertions or claims that really are not warranted and certainly not by a balanced reading of
the literature.”
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I must ask Ken what “balanced reading of the literature” on fluoride’s potential to damage the
brain are you talking about? I have cited a large body of work and it almost all goes in one
direction: fluoride is a potent neurotoxicant. Can you cite an extensive body of literature Ken
that points in the opposite direction?
6. Fluoridated countries are not doing studies on key
health concerns
Sadly, as I have already indicated the health agencies in those countries that support and
promote fluoridation show absolutely no inclination to study their populations with respect to
this effect, i.e. lowered IQ.
In fact the scientist who published one of the earliest animals studies on fluoride and animal
behavior, Dr. Phyllis Mullenix, was fired after her paper was accepted for publication
(Mullenix et al., 1995). Mullenix was the chairperson of the first toxicology department in
any dental school in the US. She was hired specifically to look at the neurological effects of
the chemicals used in dentistry. However, when she found changes in animal behavior related
to fluoride exposure and published it, she was told that her work was “no longer relevant to
dentistry.” I would argue that her work conflicted with dental establishment’s determination
to continue the fluoridation program at all costs. The treatment meted out to Mullenix did not
go unnoticed by members of the research community, who have treated doing research on
fluoride like touching the third rail as far their careers were concerned.
In addition to their lack of interest in pursuing the lowering of IQ, neither health agencies nor
those “highly qualified scientists” Ken talks about, have been inclined to fully investigate
many other serious concerns such as lowered thyroid function, accumulation in the pineal
gland (Luke 1997, 2001), arthritis rates in fluoridated populations, bone fractures in children
(discussed above), earlier onset of puberty, behavioral problems in children and the plight of
those who claim to be highly sensitive to fluoride’s toxicity.
All these concerns cry out for attention and certainly the attention of those critical of the
epidemiology of studies conducted in those countries that are investigating some of these
issues because they are legitimately concerned about what naturally fluoridated water is
doing to their citizens. I have expressed my own thoughts on the reason for this lack of
attention, but I would be interested in Ken’s thoughts on this overwhelming lack of scientific
interest in investigating fluoridation’s potential health effects in the many years since the US
Public Health Service endorsed fluoridation in 1950? Why in fluoridated countries are we
getting an endless stream of studies on teeth but virtually none on other tissues in the body?
7. What other authorities are saying about fluoride as a
neurotoxicant
Meanwhile, I am not the only scientist who is expressing concerns about fluoride’s
neurological affects. According to the report by US National Research Council (NRC, 2006):
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“A few epidemiologic studies of Chinese populations have reported IQ deficits in children
exposed to fluoride at 2.5 to 4 mg/L in drinking water. Although the studies lacked sufficient
detail for the committee to fully assess their quality and relevance to U.S. populations, the
consistency of the results appears significant enough to warrant additional research on the
effects of fluoride on intelligence.” p.8
(Note from PC: this comment was based on a review of only five of these IQ studies, there
have now been 42.)
“On the basis of information largely derived from histological, chemical, and molecular
studies, it is apparent that fluorides have the ability to interfere with the functions of the brain
and the body by direct and indirect means.” p.222
“histopathological changes similar to those traditionally associated with Alzheimer’s disease
in people have been seen in rats chronically exposed to AlF.” p.212
“Fluorides also increase the production of free radicals in the brain through several different
biological pathways. These changes have a bearing on the possibility that fluorides act to
increase the risk of developing Alzheimer’s disease.” p.222
“More research is needed to clarify fluoride’s biochemical effects on the brain.” p.222
“The possibility has been raised by the studies conducted in China that fluoride can lower
intellectual abilities. Thus, studies of populations exposed to different concentrations of
fluoride in drinking water should include measurements of reasoning ability, problem
solving, IQ, and short- and long-term memory.” p.223
“Studies of populations exposed to different concentrations of fluoride should be undertaken
to evaluate neurochemical changes that may be associated with dementia. Consideration
should be given to assessing effects from chronic exposure, effects that might be delayed or
occur late-in-life, and individual susceptibility.” p.223
EPA researchers listed fluoride among those chemicals for which there was substantial
evidence of developmental neurotoxicity” (W. Mundy et
al.http://www.epa.gov/ncct/toxcast/files/summit/48P%20Mundy%20TDAS.pdf
The EPA headquarters scientists made this request to the U.S. Senate in 2000 (Hirzy 2000):
“We ask that you order an epidemiology study comparing children with dental fluorosis to
those not displaying (fluoride) overdose during growth and development years for behavioral
and other disorders.”
And according to Dr. Philippe Grandjean, one of the authors of the Choi et al (2012) study:
“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)
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As such it seems reckless to me and many others that we should knowingly increase the
whole population’s exposure to this neurotoxicant by putting it into the public water supply.
Meanwhile, according to my son Michael Connett, who is the special project director at FAN,
and compiled FAN’s Health Database, research on fluoride and the brain in animals has been
rolling in at a steady pace over the past year with over a dozen new studies, including
some at notably low doses. One such study that is worthy to have on the radar is a study on
mice by Liu et al, 2013. It reports that exposure to fluoride in drinking water (at 5 and 10
ppm) 4 weeks after weaning not only impaired cognition, but caused “anxiety- and
depression-like behavior” as well. Here’s an excerpt from the discussion:
“Almost all existing epidemiological surveys on areas with high-fluoride drinking water have
focused on cognition; however, our data suggest the need for a large-scale epidemiological
survey to investigate whether drinking water with high levels of fluoride can lead to human
emotional behavior changes. In summary, we found developmental fluoride exposure through
drinking water 1) caused cognitive impairment and 2) led to anxiety- and depression-like
behavior in adult mice. Therefore, consideration should be given to the neurotoxicity of
fluoride used to combat dental caries, and attention should be paid to the concentration and
dosage of fluoride, especially in young children. Our data suggest that excessive fluoride
intake should be avoided to prevent its adverse effects.”
So the weight of evidence that fluoride impacts both the brain of animal and humans keeps
piling up. About the only animal study that proponents can produce that has not found an
effect is one performed by Whitford et al., 2009, who used behavioral tests on rats. They
found no neurotoxic effects in their study setting. The study is limited because the rats were
not dosed in utero or even during earliest post-natal development, but only after they had
been weaned, which roughly translates to adolescence in rats.
Even if this had been a strong animal study, it is one of a small minority that found no
evidence of neurotoxicity of fluoride. So, taking the scientific evidence on this topic as a
whole, the weight of evidence from both animal and human studies is that fluoride is a
developmental neurotoxicant.
8. The journal Fluoride and the ISFR
In his commentary on Xiang’s IQ paper Ken chose to do what a number of proponents of
fluoridation do and that is to try and trash the journal Fluoride. He claims that Fluoride “is
certainly not considered of high quality. It is actually rather suspect because of the
ideological commitment of the editors.”
Why is it Ken you see proponents’ support of fluoridation as being “scientific” and
opponents’ opposition to fluoridation as being “ideological”? Isn’t it possible that opponents
of fluoridation are opposed for scientific reasons?
Fluoride is the only journal in the world, which is completely devoted to research on fluoride
in many different areas of study (geological, biological, biochemical, toxicological,
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epidemiological, medical and dental to name a few). To its discredit the US National Institute
of Health (NIH) has refused to cover the contents of this journal in PubMed, thus depriving
many researchers valuable information on fluoride’s toxicity. This has been particularly true
of depriving the mainstream medical community (many of whom use PubMed as their
primary research tool) knowing about the extensive database indicating that fluoride is a
neurotoxicant. It has done this despite covering the contents of far lesser journals and even
trade magazines.
There have been three editors of Fluoride since it began its quarterly publication in 1968: Dr.
George Waldbott, Dr. John Colquhoun and Dr. Albert Burgstahler (who passed away a few
weeks ago). You would be correct in asserting that each of these editors was opposed to
fluoridation, however that opposition was rooted in science not some ill-defined ideology. I
think you can get a glimpse of the caliber of both Dr. George Waldbott and Professor Albert
Burgstahler in the book they co-authored “Fluoridation: The Great Dilemma.” (Coronado
Press, Lawrence, Kansas, 1978).
I met Dr. John Colquhoun (briefly before he died in 1998) and videotaped an interview with
him during to trip to NZ. I count this interview one of the great moments of my scientific
career. Never have I been more impressed by someone’s character than I was by John. He
had been an avid promoter of fluoridation both as the chief dental officer of Auckland and as
a city councillor. When during a world tour in 1980 (he went to Australia, Asia, North
America and Europe) he found that talking behind the scenes to leading dental researchers
that they were not finding much of difference between tooth decay in fluoridated and non-
fluoridated communities and found the same in “confidential reports” from the NZ dental
authorities on his return, he had the enormous courage and scientific integrity to come out
publicly against water fluoridation and spent the rest of his life trying to right the wrong he
had done. But while he was at the reins he never hesitated to allow pro-fluoridation voices
and articles to be published in Fluoride.
I worked with professor Albert Burgstahler for many years and I can vouch for his scientific
integrity. In fact for me he represented one of the pinnacles of scientific integrity and that is
why FAN named an annual award in his name.
I never met Dr. Waldbott, but I know that his position was that neither the journal nor its
supporting organization (the International Society for Fluoride Research, ISFR) should adopt
a formal opposition to fluoridation (and its membership included both pro and anti-
fluoridation scientists), but to publish as much science as they could on the subject and as
far as water fluoridation was concerned from both sides and to let the chips fall where they
may. He and his successors also believed that if the science was aired fully and openly it
would lead most independent scientists to an anti-fluoridation position.
9. The double standard
Unfortunately, none of the dental journals have adopted the same openness on this issue. By
and large they do not entertain any anti-fluoridation editorial or even a review that conflicts
75
with their mantra that fluoridation is “safe and effective.” So I think Ken is exercising a
double standard here.
I should also point out that there have been several occasions where dental journals have
gone out of their way to publish papers that have provided an “ideological” as opposed to a
“scientific” support for one side of a controversial matter. Take the example of osteosarcoma.
In 1991, shortly after the 1990 NTP animal study had found an association in male rats
between fluoride exposure and osteosarcoma, the Journal of the American Dental Association
(JADA) rushed to give prominence (i.e. the front cover was devoted to it) to an article, in
which the authors clearly reveal their bias in favor of fluoridation. In this very small
epidemiological study they proposed that far from causing osteosarcoma fluoride was
actually protective against it (see P.187 in The Case Against Fluoride, CAF).
I think the following comments reveal a greater sensitivity to the need to protect the
fluoridation program than protecting a few young boys from a life threatening disease:
“An incorrect inference implicating systemic fluoride carcinogenicity and its removal from
our water systems would be detrimental to the oral health of most Americans, particularly
those who cannot afford to pay for increasingly expensive restorative dental care . . .Because
of its strengthening action, fluoride has been widely accepted as the responsible agent for the
dramatic declines in the tooth decay rates of U.S. children and adolescents . . . A disruption in
the delivery of fluoride through municipal water systems would increase decay rates over
time . . . Linking of fluoride ingestion and cancer initiation could result in a large-scale
defluoridation of municipal water systems under the Delaney clause. (McGuire et al., 1991,
quoted on p. 187, CAF).
In my view the commentary (above) plus the JADA editors’ choice to give it this article full-
front page coverage is an example of “ideology” not science at work. The authors and the
journal both had a need to protect the fluoridation program at all costs even if it meant
downplaying the concerns about the fate of the young boys in question. I will pick up the
osteosarcoma story again in a later submission.
10. A request to Ken
Finally, Ken I think it would save us all a lot of time if putting the rhetoric and your general
disdain for the opponents of fluoridation to one side you would be kind enough to list the
primary studies that you have read that have most convinced you that fluoridation is both
safe for the bottle-fed baby and for the adult over lifelong exposure.
References
Alarcón-Herrera et al., 2001. “Well Water Fluoride, Dental Fluorosis, Bone Fractures in the
Guadiana Valley of Mexico,” Fluoride 34, no. 2 (2001): 13949.
http://www.fluorideresearch.org/342/files/FJ2001_v34_n2_p139-149fig.pdf
76
CDC, 1999. Centers for Disease Control and Prevention, “Achievements in Public Health,
19001999: Fluoridation of Drinking Water to Prevent Dental Caries,” Mortality and
Morbidity Weekly Review 48, no. 41 (October 22, 1999): 933
40,http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm
CDC, 2001. Centers for Disease Control and Prevention, “Recommendations for Using
Fluoride to Prevent and Control Dental Caries in the United States,” Morbidity and Mortality
Weekly Report 50, no. RR14 (August 17, 2001): 1
42,http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
Choi AL, Sun G, Zhang Y, Grandjean P. 2012. Developmental fluoride neurotoxicity: a
systematic review and meta-analysis. Environ Health Perspect 120:13621368.
Connett, P., Beck, J and Micklem HS. The Case Against Fluoride. Chelsea Green, White
River Junction, Vermont, 2010.
Harvard School of Public Health. (2012). Impact of fluoride on neurological development in
children. July 25. Available online at:http://www.hsph.harvard.edu/news/features/fluoride-
childrens-health-grandjean-choi/
Hirzy, 2000. Statement of Dr. J. William Hirzy, National Treasury Employees Union Chapter
280 before the Subcommittee on Wildlife,
Fisheries and Drinking Water, United States Senate. June 29, 2000.
Li, Y et al., 2001. “Effect of Long-Term Exposure to Fluoride in
Drinking Water on Risks of Bone Fractures,” Journal of Bone and Mineral Research 16, no. 5
(2001): 93239.
Liu F. et al., 2013 (online) (hard copy 2014). “Fluoride exposure during development affects
both cognition and emotion in mice.” Physiology & Behavior 124 (2014) 17.
Luke, J, 1997, “The Effect of Fluoride on the Physiology of the Pineal Gland,” PhD thesis,
University of Surrey, Guildford, UK, 1997. Excerpts at http://fluoridealert.org/studies/luke-
1997/ and a complete copy of Dr. Luke’s dissertation can be downloaded
athttp://www.fluoridealert.org/wp-content/uploads/luke-1997.pdf (with the author’s
permission).
Luke, J, 2001. “Fluoride Deposition in the Aged Human Pineal Gland,” Caries Research 35,
no. 2 (2001): 12528.
McDonagh et al., 2000. “Systematic Review of Water Fluoridation,” British Medical Journal
321, no. 7265 (2000): 85559,http://www.bmj.com/cgi/content/full/321/7265/855 Note: The
full report that this paper summarizes is commonly known as the York Review and is
accessible athttp://fluoridealert.org/re/york.review.2000.pdf
77
McGuire et al, 1991. “Is There a Link between Fluoridated Water and Osteosarcoma?”
Journal of the American Dental Association 122, no. 4 (1991): 3845.
Mullenix, PJ et al., 1995. “Neurotoxicity of Sodium Fluoride in Rats,” Neurotoxicology and
Teratology 17, no. 2 (1995): 16977.
Morgan, L. et al. 1998, “Investigation of the Possible Associations between Fluorosis,
Fluoride Exposure, and Childhood Behavior Problems,” Pediatric Dentistry 20, no. 4 (1998):
24452.
NRC, 2006. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards (2006)
http://www.nap.edu/catalog.php?record_id=11571
NTP, 1990. National Toxicology Program, “NTP Technical Report on the Toxicology and
Carcinogenesis Studies of Sodium Fluoride (CAS no. 7682-49-4) in F344/N Rats and
B6C3F1 (Drinking Water Studies),” Technical Report 393, NIH publ. no. 91-2848, National
Institutes of Health, Public Health Service, U.S. Department of Health and Human Services,
Research Triangle Park, NC, 1990.
E. R. Schlesinger, D. E. Overton, H. C. Chase, and K. T. Cantwell, “Newburgh-Kingston
Caries-Fluorine Study XIII. Pediatric Findings After Ten Years,” Journal of the American
Dental Association 52, no. 3 (1956): 296306.
Shannon, FT et al., 1986. “Exposure to Fluoridated Water Supplies and Child Behaviour,”
New Zealand Medical Journal 99, no. 803 (1986):41618.
Waldbott, GL, Burgstahler, AW and H. L. McKinney, Fluoridation: The Great Dilemma
(Lawrence, Kansas: Coronado Press, 1978).
Whitford, GM et al. 2009. “Appetitive-based Learning in Rats: Lack of Effect of Chronic
Exposure to Fluoride,” Neurotoxicology and Teratology 31, no. 4 (2009): 21015.
Q. Xiang, Y. Liang, L. Chen, et al., “Effect of Fluoride in Drinking Water on Children’s
Intelligence,” Fluoride 36, no. 2 (2003): 84
94,http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf
Q. Xiang, Y. Liang, M. Zhou, and H. Zang, “Blood Lead of Children in Wamiao-Xinhuai
Intelligence Study” (letter), Fluoride 36, no. 3 (2003):198
99,http://www.fluorideresearch.org/363/files/FJ2003_v36_n3_p198-199.pdf
Xiang, Q. et al., 2010. “Serum Fluoride Level and Children’s Intelligence Quotient in Two
Villages in China.” Environmental Health Perspectives. EHPonline.org
Xiang, Q. et al. 2011. “Analysis of children’s serum fluoride in relation to intelligence scores
in a high and low fluoride village in
China.”http://www.fluorideresearch.org/444/files/FJ2011_v44_n4_p191-194_sfs.pdf
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Ken Perrott - November 25, 2013
It is a pity that Paul Connett chose to ignore the ethical question of balancing personal choice
and social good because he took my comments on this as a personal criticism of him. They
were not meant to be. I am happy to discuss the science but, in the end, science cannot make
ethical and values decisions for us. Yes, it can, and should, inform those decisions but
pretending they are only about science does a disservice to science and to ethics.
Unfortunately science is often used in these sort of debates as a proxy for values issues.
Professor Gluckman pointed that out in his statement What is in the water? An excellent
article by Tania Ritchie in Science and Society outlines the dangers of this approach (see The
fluoridation debate: why we all lose when we pretend it’s just about science). She shows how
using science as a proxy backs people into pseudoscientific corners (and that is certainly an
issue for these opposing fluoridation). It also places an impossible demand of certainty on
science (“prove to me beyond doubt that fluoride at optimal concentrations is completely safe
if in doubt leave it out”). And concentration on the science often disguises poor ethical
positions. She concludes:
“Using good science to counter bad science is productive. Using good science to tell us what
will happen if we make a certain decision is also, of course, vital. But pretending science can
tell us what decision we should make, or trying to counter ethical concerns with science, will
never be helpful.”
Well, for the moment I guess I am opting for “using good science to counter bad science”
but I hope we can return to these ethical issues at some stage.
Nature of bioapatites and systemic role for fluoride
Paul seems not to have taken on board my description of the structural role of fluoride in
apatites and the recognised beneficial role of ingested fluoride. (Perhaps he considered that
section was somehow a personal criticism and should be ignored.)
Mind you, I keep coming across that problem with other anti-fluoride activists. They wish to
talk only about topical application of fluoride, and ignore completely the beneficial effects of
ingested fluoride. This seems to create reading, hearing and comprehension problems for
them. So I get accused of advocating that suntan lotion should be drunk or similar attempts at
humour!
However, it is a critical feature of this debate so I will just start this response by briefly
repeating a few things.
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Fluoride is a normal, natural component of bioapatites. In the real world these don’t
exist as end-member compounds such as hydroxylapatite or fluoroapatite. They are
more correctly described as hydroxyl-fluoro-carbonate-apatites.
Accumulation of fluoride, together with calcium and phosphate, in our bioapatites is a
normal part of development. This is beneficial because it helps strength our bones and
teeth, and lowers their solubility.
Both insufficient fluoride, or excess fluoride in our bioapatites can cause problems.
Excessive dietary intake can result in excessive fluoride in our bones and teeth.
Insufficient intake may also cause our bioapatites to be weaker and more prone to
dissolve. When dietary intake of fluoride is reduced fluoride can be lost from bones
and calcified tissues.
The scientific literature reports that fluoride has a systemic role benefitting bones and
pre-erupted teeth
Surface mechanisms for reducing tooth decay
We seem to be making a little progress here with the so-called “topical” mechanism but
only a little and very grudgingly. Paul has apologised for misrepresenting my explanation of
the surface mechanism for the action of fluoridated water in countering tooth decay in
existing teeth. He acknowledges that I was discussing the transfer of fluoride to saliva from
water during drinking water, and not the smaller concentrations coming from the salivary
glands after ingestion.
In this I was simply reporting what I have read in the scientific literature. But Paul will still
have none of that. He concedes that fluoride in saliva “may or may not do something” and
presents his own “simple personal observations” to claim that there is little chance of
drinking water mixing with saliva. Not the first time I have heard this argument and it
always brings a picture to mind of a committed anti-fluoride activist drinking their water
through a tube down the throat. I leave it to readers to observe their own drinking behaviour
and decide if drinking water has little chance of mixing with saliva or transferring ions to
saliva.
So it is one step forward and another step back. Made worse by his assertion (from personal
experience) “that the fluoride ions have little opportunity to form a biofilm on any teeth other
than the back of the front teeth.” Of course the fluoride does not form a biofilm. It and other
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ions in the water and saliva do, however, transfer to, and diffuse through, existing biofilms
(plaque) on the teeth.
There are quite a few reports of the effect of regular consumption of fluoridated water
increasing the F concentrations in saliva and plaque both after ingestion (e.g. Cury & Tenuta
2008, Martínez-Mier 2012) and directly Featherston 2000, Bruun & Thylstrup 1984). (Yes, I
realise that the CDC sates that the ingested fluoride delivered to saliva “is not likely to affect
cariogenic activity” and this is echoed by other writers. However, there still seem to be
workers who argue this does contribute and I am aware of laboratory experiments showing
the mechanism can work at very low fluoride concentrations. But this is a detail I will leave
to the experts it doesn’t affect the current exchange).
Loaded language and scientific knowledge
Paul again refers to advances of scientific knowledge in a sneering way. He claims that the
CDC “admitted” that research indicated the prevention of dental caries by fluoride occurs by
a topical mechanism in existing teeth. He also speculates that the CDC “was scrambling to
salvage some kind of role for fluoridated water . . . Despite its admission of the
predominance of the topical effect.” Can somebody with research experience in chemistry
really see scientific progress as some sort of winning-out over a conspiracy to ignore the
“truth?”
Mary Byrne, a local anti-fluoridation spokesperson, shows a similar apparent
misunderstanding of the nature of scientific knowledge when she describes, disparagingly,
this progress in understanding as scientists being “wrong for fifty years.” She keeps repeating
this even though her error has been explained to her.
These characterisations are like saying Newton was wrong with his laws of motion or that he
was somehow hiding the truth and Einsteinian relativity is simply a case of scientists being
forced to “admit”, or “concede” they were wrong as if they had hidden something!
Use of loaded language like this has a political purpose which interferes with proper
understanding of the science.
The journal Fluoride
Paul describes my comments about the journal Fluoride, and its editors, as “derogatory,” and
accuses me of “double standards.” I think that shows a sensitivity and inability to consider
my comments objectively. Not surprising, as Paul has some “irons in the fire” on this issue.
I said that “if I had some credible findings in fluoride chemistry and wished to present a
paper to the scientific community for their consideration Fluoride is the last journal I would
choose.” This isn’t completely hypothetical because I have published a few papers on
fluoride chemistry. So how do I decide where to publish my work?
Firstly, my fluoride work was relevant to pedology and soil chemistry so it was natural to
consider soil science journals. This was the audience to aim for and our work was of direct
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relevance to readers of those journals. I doubt that many of our intended audience or their
institutes subscribed to, or read, Fluoride.
But, today if I were considering a general journal and had a look at Fluoride what would I
find. First of all the website (where I would go to judge the journal’s scope, requirements and
refereeing policy) seriously, does this show a credible scientific society or editorial office?
This is what greets you as the home page for the Fluoride journal (http://www.fluorideresearch.org/)
That extremely amateurish web page puts me off perhaps there are other general journals
dealing with fluoride (contrary to Paul’s claim). Let us see if Journal of Fluoride Chemistry
is better? See the difference?
Home page for the Journal of Fluorine Chemistry
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Secondly, a quick skim of accepted papers in Fluoride indicates many are related to areas
where fluoride toxicity is a problem because natural levels are high or excessive. The quality
of many of these papers appears poor, a common problem where there are many authors
whose main language is not English. It has a predominantly “third World” appearance. This
would also raise a flag about possibly low standards of editorial review. Have a look at the
list of contents for one of the 2007 issues.
None of these factors would attract me as a working and publishing scientist concerned at
establishing a publication record in high quality and credible journals.
However, if I was a non-English speaker with routine work which I might find difficulty
publishing elsewhere, and especially if that work was related to areas where natural fluoride
levels were high, I would probably consider the journal. With the realisation in the back of
my mind that I would probably have no luck with submission to a more reputable journal.
Now, I am not being “personal” or “derogatory” in making that realistic evaluation. Nor do
I think there are “double standards’ in choosing a good journal for publication. Good work
deserves a good journal for publication.
Paul effectively concedes this in referring to attempts by Xiang et al to get their work
published in a more reputable journal. He laments the fact that this journal would not include
material already published in Fluoride (standard procedure in the publishing world) as
amounting to Xiang’s material being “withheld from the mainstream scientific community.”
(Paul obviously agrees that Fluoride does not have a good standing in the mainstream
scientific community). The lesson being that Xiang should have gone for the reputable
journal first time around. Why publish in a journal which does not give access to “the
mainstream scientific community” if one’s work is good enough to get published in a
reputable journal
That is a sensible question not a derogatory one.
Connett’s relation with Fluoride
It is instructive to look at Paul Connett’s own publications in Fluoride. He claims to have
researched the issue for 17 years and I would expect that at least some of his research papers
would have ended up in this journal.
A simple search for the name Connett showed me a couple of guest editorials often co-
authored with editors of the journal (see for example Professionals moblize to end water
fluoridation and Misplaced trust in official reports), a book review (co-authored with editors
of the journal), reports of the International Fluoride Society (IFS owner of Fluoride)
conferences. There were abstracts of papers or posters presented at IFS conferences authored
by Paul, Ellen and Michael Connett but no sign of formal papers for these. (I hope Paul will
correct me and provide links if I have missed papers with full text.)
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This at least tells me that Paul is on excellent terms with those editing and running this
journal. Not surprising when one looks at the names in the editorial board of the journal, the
western contributors to the journal and the names on the advisory board of Paul’s activist
organisation Fluoride Alert.
Another thing that stands out for me about the editorial and advisory boards is the large
number of retired, former, emeritus academics (around 17 from a glance). In the past I have
also noticed this about the organisations and petitions of climate change climate
contrarians/deniers/pseudosceptics. As a retired scientist myself I can appreciate how such
issues can become hobbies, and avenues for social involvement and personal standing for
people who formerly relied on their employment and professional standing for such things. I
can also appreciate that retirement often also means loss of contact with current research and
findings. This increases my suspicions of the journal and organisation.
There was one normal looking journal paper by Michael Connett Vulvar paget’s disease:
recovery without surgery following change to very low-fluoride spring and well water. My
impression is this was simply an anecdotal history for one person probably not normally
acceptable in a scientific journal (unless at least written by the practicing medical person
handling the case). A quick search of Google Scholar shows this to be Michael’s sole
scientific paper perhaps not surprising as he is not a scientist. He is the Special Projects
Director for the Fluoride action network, an attorney in Philadelphia, PA, and received his
law degree from Temple Law School in 2011. But now has a scientific publication record!
(Note for non-scientists wishing to show a scientific publication record. There are plenty of
anecdotal stories on the internet by people claiming sensitivity to fluoride. Hell, the other day
I read the personal account of one person with skeletal fluorosis which cleared up
immediately he stopped drinking tap water! You could select your own “case history,” write
it up as a scientific paper and submit to Fluoride. Mind you, your paper might not be all that
visible to the “mainstream scientific community”).
Looking at Fluoride, Fluoride Alert and the International Society for Fluoride Research I get
a strong impression of a group who take in each other’s laundry but at the same time give
publication space for some third world scientists who may not meet the standards of more
reputable journals.
Paul gave it away when he reported to us that “the US National Institute of Health (NIH) has
refused to cover the contents of this journal in PubMed.” Surely that tells us something about
how this journal is considered by the science community (and please if one has to resort to
conspiracy theories to explain this the argument is surely already lost.)
Bones, hip fractures and the literature
Kurt Ferre’s comment about misrepresentation of the Li et al (2001) paper referred to Paul’s
note on it in Fluoride Alert (Reason 29 of 50 reasons to oppose fluoridation). Here Paul did
describe the data as relating to hip fractures and not over all fractures. OK, Paul in chapter 17
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of his book may have been more specific but that is not what Kurt referred to. (By the way, I
am still plodding through Paul’s book on chapter 9 at the moment).
Paul claims I “prefer” an “interpretation” of the Li et al (2001) paper that there is a
“sudden” appearance of hip fracture at a higher concentration rather than a linear increase
from low concentrations. He is wrong I don’t prefer any specific interpretation. I was
merely pointing out what can be drawn from the statistical analysis of the data.
One of our commenters has already noted that Paul’s argument for his own interpretation of
the data here amounts to special pleading where he has to ignore, or denigrate, the statistical
analysis. He is pleading when he writes that increases “appear to be ‘real’ even though they
are not statistically significant individually.” Or that the data “appear consistent with a
linear regression. Statistical significance is not the final word on whether a data point or
data set is real or not.”
These were the sort of statements I would put red lines through when I was reviewing papers
submitted for publication.
However, this is a digression. The interpretation of the increase at higher concentrations is
not important. The fact is neither overall fractures or hip fractures showed an increase at
fluoride concentrations considered optimum for oral health.
It was clear to me when I originally read and wrote about Li et al’s (2001) paper (see - Is
fluoride an essential dietary mineral? ) that the increased incidence of overall fractures at
concentrations below optimum did not refer to hip fractures. The authors specifically brought
that to readers attention - “the data show a somewhat different pattern for hip fractures in
relation to the water fluoride levels. . . Instead, the prevalence of hip fractures was stable
until the water concentration reached 1.452.19 ppm.” They qualified this with However, it
may not be appropriate to conclude that the risk of hip fracture is more sensitive to the water
fluoride concentration as compared with overall fractures, because the number of hip
fractures in the present study is relatively small.” And they did conclude that “our results on
hip fractures support previous findings that fluoride around 1 ppm in drinking water does not
increase the risk of hip fracture.”
This diagram by Ethan Seigel (which I reproduced in an article earlier this year (see Getting a
grip on the science behind claims about fluoridation) was clearly taking on board Li et al’s
work when perhaps it should not have been so specific.
But of course the issue of hip fractures does not rest with the work of Li et al alone. I wrote
about this specifically in Fluoridation: the hip fracture deception where I also mentioned the
recent paper of Näsman et al (2013) “Estimated Drinking Water Fluoride Exposure and Risk
of Hip Fracture: A Cohort Study showing no significant correlation of hip fractures with
fluoride in drinking water at the optimum concentrations.
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Miscellaneous
Delivery systems: It seems I must respond to Paul’s suggestion of “an alternative delivery
system for fluoridated water” selling fluoridated bottled water. I guess that already happens
in many places but I did not take his suggestion seriously because he is offering it as a
substitute for already existing social health policies. That is not my area of expertise but I can
understand how fluoridated water and fluoridated salt are effective as social policies for
overcoming problems where the natural fluoride levels are deficient. Surely bottled water in
the corner of a “supermarket, pharmacy or clinic” hardly measures up as a social health
policy? Fluoridated salt seems to me to be a more credible alternative to water fluoridation.
Having said that, bottled water is culturally preferred in some countries and is attractive to
some age groups in others. There are suggestions, therefore, that fluoridation of bottled water
should be encouraged. New Zealand and Australia recently brought in regulations allowing
this.
Inference from high concentrations: Paul has objected to my criticism that he often relies
on extrapolation from laboratory or epidemiological studies where higher than optimum
fluoride concentrations were used. He responded by discussing Xiang et al (2003) and argued
that some of the studies covered by Choi et al (2012) did include lower concentrations.
However, there is still a tendency to then fall back on all the studies to give extra weight to
his assertions, rather than just rely on the low concentration studies. I think the image below
prepared by fellow New Zealander Andrew Sparrow helps put this issue into context. High
fluoride cases in Choi et al (2012) were almost all completely out of the zone for optimum
fluoridation of drinking water.
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Appeal to authority with declarations: This tactic is used a lot by anti-fluoride activists.
The poster below is a recent example from Fluoride Free NZ. The inclusion of a citation
gives it some authority but can anyone find that paper? No one at Fluoride free could yet
they were promoting a claim using the citation!
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The Journal of Dental Medicine is now defunct and I could find no abstracts or full text on
the internet. However, I did find a description athttp://slweb.org - a well-known anti-fluoride
activist site. This claimed adverse reactions, affecting “the dermatologic, gastro-intestinal
and neurological systems,” to fluoride in 1% of the group studied! I would have liked to
check out the statistical analysis used in the study as this seems a very small response. Was
1% significantly different to zero in this study?
What the hell Fluoride Free NZ doesn’t care. They went ahead with a poster and its
promotion anyway. As a political activist group they are concerned more with moulding
public opinion than the facts.
Paul might argue this case is a diversion he is not responsible for. But my