Water Fluoridation: Myths, Conspiracies, and Outright Lies

While having an online discussion with an anti-fluoridation friend of mine, she offered up this video to vindicate her position.  It includes interviews with 15 fluoridation authorities (doctors, dentists, and other professionals) essentially calling for the elimination of water fluoridation.  The video was produced by FluorideAlert.org, also called The Fluoride Action Network (FAN), according to their mission statement:

The Fluoride Action Network (FAN) seeks to broaden awareness about the toxicity of fluoride compounds among citizens, scientists, and policymakers alike. FAN not only provides comprehensive and up-to-date information, but remains vigilant in monitoring government agency actions that impact the public's exposure to fluoride.  [1]

They seek to "broaden awareness about the toxicity of fluoride among... scientists."  Part of the scientific method is to attempt to remove inherent biases when conducting experiments and analyzing data.  With the intention of influencing scientists to insert biases such as, "fluoride is toxic" they are invalidating any scientific research which they fund or are involved with.  They "remain vigilant in monitoring government agency actions" a statement which panders to the conspiratorial mode of thinking.

Water fluoridation has been a rather hot button issue lately here in Portland.  The city's drinking water already contains naturally occurring fluoride, but not enough to be considered effective at fighting cavities.  Portland is also the last remaining metropolitan area in the US to have unfluoridated water.  Late last year the City Council approved adding fluoride to the city's drinking water, effective March 2014, without calling for a citywide ordinance vote [2].  Opponents quickly rallied and gathered over 30,000 signatures to force a referendum and put the issue to a citywide vote in May 2013 [3].  In this essay, I want to examine the facts behind fluoridation.  I will explore the claims made in this video by dissecting them using empirical evidence.

The introduction of the video begins with old newsreel footage consisting of various proclamations about fluoridation's health benefits.  Quickly, the black and white footage switches to a talking head, "We're not dealing with a benign substance." "There's much too much risk and far too much benefit." proclaims another.  This continues with switching between the positive newsreel footage on fluoridation and back to short quips from "the experts".  "The dental community has no idea of the toxicology of fluoride." says a man with a mustache wearing scrubs.  Well, your average dentist may or may not be aware of the toxicology of fluoride, but there have been several studies to determine the negative health effects of fluoride.  The only clear and substantiated detrimental effect of fluoride at the commonly recommended dosage is dental fluorosis, which can alter the appearance of children's teeth (the most vulnerable period of exposure being between one and four years old with the risk ending around age eight), being mostly mild with minor aesthetic effects [4].  Every substance can be toxic at certain levels, a lethal dose of fluoride for most people is between 5 to 10 grams and can cause gastrointestinal distress at about a tenth of that dose.  Chlorine, another commonly added chemical to drinking water, is lethal after 30 minutes 430 ppm (parts per million) when in gaseous form [5].  The current recommended amount of fluoride in water is 0.7 to 1 ppm [6].  When it comes to the actual causes of dental fluorosis, it is estimated that fluoridated water, directly or indirectly, accounts for around 40% of cases with around 60% being caused by other sources (namely toothpaste) [7].

The introduction continues with various blanket statements being issued.  One female expert, a Dr. Phyllis Mullenix, states, "Fluoride is a neurotoxin."  Directly after a computer generated graphic of a brain rotates around.  The graphic is obviously provided to lend some sort of credence to the claim being made.  A metadata analysis systematically reviewing water fluoridation compiled 32 studies which examined possible health risks such as Down's syndrome, mortality, senile dementia, goitre, and IQ.  The quality of these studies were low (bias, lack of controls, and so forth).  None of the studies had a prospective follow up or incorporated any form of blinding. While 22 studies mentioned potential confounding factors, only six used an analysis that controlled for them.  Only 3 of the 32 studies found any significant effects (one found increased incidents of Alzheimer's, one found decreased incidents of impaired mental functioning [lower mental retardation rates], the third study found that the combination of low iodine and high fluoride concentrations [probably well above the recommended fluoridation level] was associated with goitre and learning difficulties) and all can be discounted because of their poor quality [8].  There are no quality studies which supports the notion that "Fluoride is a neurotoxin."  Fluoride is naturally occurring in water, food and is commonly used in toothpastes and other dental hygiene products.  The idea that fluoride is a neurotoxin is ludicrous.  The overwhelming scientific consensus is that fluoridated water has an overall positive effect on health [9].

The title to the next section of the video is "Fluoridation & Medical Ethics" and begins with a litany of experts essentially saying "Fluoride is a medicine/drug which is being introduced into the water supply to treat dental caries, unlike chlorine which is specifically introduced to treat/cleanse the water, not to treat the consumer of the water.  It violates medical ethics because it is not specifically tailored to the individual."  This is definitely a part of the video where if moves into an ethical grey area.  As far as medical ethics are concerned, what they say in the video is true, fluoridation is not specifically tailored to the individual.  You have to weigh the positive effects with the negative effects and try to arrive at a conclusion which benefits the most people.  But, when you remove the conspiratorial thinking and examine the scientific consensus that says, "Water fluoridation is safe, reduces dental cavities, is inexpensive, and easy to implement." [11] the ethical question becomes less and less, "They're introducing a harmful chemical into our water supply." and more "Why are we not introducing water fluoridation?"  Because a group of individuals, counter to scientific evidence, believe that it is harmful?  Ethically, it seems to me that in most circumstances not introducing fluoridated water is more unethical than introducing it, given its proven effectiveness and lack of harm.  It closes the gap between the prevalence of dental caries between rich and poor children.  Less and less people here in Portland have access to proper health and dental care.  Go and ask your dentist what they think of water fluoridation and try to shed your own biases and conclusions.  Ethical questions are difficult, should be discussed, and should be informed by good science and reasoning.  And by all means, I urge you to examine the evidence and see through the conspiratorial/bias ridden haze that surrounds this issue and come to your own conclusion as to whether water fluoridation is ethical or not.

The next section is entitled "Do We Need Fluoride?".  The answer is unequivocally no.  Our bodies do not need to imbibe or process fluoride in order to survive.  The fact that the body doesn't need fluoride does not make water fluoridation superfluous.  We do not need to imbibe chlorine, but it has obvious positive health effects when added to our drinking water.  Chlorine is presently an important chemical for water purification (such as water treatment plants), in disinfectants, and in bleach. Chlorine in water is more than three times as effective as a disinfectant against Escherichia coli than an equivalent concentration of bromine, and is more than six times more effective than an equivalent concentration of iodine [10].  Once again, the scientific consensus is "water fluoridation is safe, reduces dental cavities, is inexpensive, and easy to implement." [11].  The section ends with Earl Baldwin of the British House of Lords stating "... it is not in the category of a vitamin and apart from everything it's miles more toxic than any vitamin."  As stated above, fluoride at recommended fluoridation levels is not toxic.  Any substance is toxic at certain levels.  Niacin (Vitamin B3) produces side effects like gastrointestinal complaints, such as dyspepsia (indigestion), nausea and liver toxicity fulminant hepatic failure, have also been reported.  These can manifest at dosages of 1.5 - 6 g per day [12].  Vitamin B3 is one of the 40 to 80 essential human nutrients.

Next up is "Does Fluoride Need to Be Swallowed?" and we are subjected to the drum beat of experts "The effects of fluoride are topical and it does not need to be swallowed."  One expert boldly illustrates the notion "If you want to apply suntan lotion to avoid sunburn, you don't swallow the suntan lotion."  While the analogy is entertaining, the effectiveness of water fluoridation is proven.  Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%-60% (94-97). More recent estimates are lower- 18%-40% (98-99) [9] the lowering of the figures is speculated to be related to the increase of fluoridated toothpaste and other fluoridated products.

"Do Most Countries Fluoridate Water?"  The answer really has no bearing whatsoever on the efficacy and safety of water fluoridation.  I'll report the answer dutifully however; It is a logical fallacy to think that because any particular country fluoridates their water, does not fluoridate it's water, or has rejected water fluoridation outright that therefore water fluoridation is safe or unsafe. Countries that have over half of their water fluoridated include the US, Singapore, Hong Kong, Ireland, most of Canada, Australia, New Zealand, Brazil, and Chile.  Most European countries have rejected water fluoridation and the list includes: Austria, Belgium, Denmark, Finland, France, Germany, Luxembourg, Netherlands, Northern Ireland, Norway, Italy, Sweden, and Switzerland [13].

"Is There Less Tooth Decay In Fluoridated Countries?"  Lower rates of tooth decay are uncorrelated with water fluoridation rates but the answer is much more complicated than that.  Africa has low rates of dental carries, but Africans typically consume less refined sugars in their diet [14], have poor access to health care, and also have large areas where fluoride occurs naturally in groundwater at high levels [18].  India also has large areas of the country where natural groundwater fluoride levels are higher than recommended.  Some European countries that have banned fluoridated water instead add it to their salt and its effectiveness is measured to be on par with water fluoridation [24].  Many European countries have universal health care.  France rejects water fluoridation, is rated low in the prevalence of dental caries [15], and listed in the WHO's 2000 ranking of health care systems as number one in the world [16].  Italy too, rejects water fluoridation, is rated low in the prevalence of dental caries, and ranked as the number two health care system in the world.  66% of residents in the US receive fluoridated water [17], our health care system is ranked 38th (behind Saudi Arabia, Costa Rica, and Morocco) with the highest rank of expenditure per capita in the world, we consume copious amounts of refined sugars in our diets, and yet we still have a low rating for prevalence of dental caries.  Research shows that drinking optimally fluoridated water is one of the safest and most cost-effective public health measures for preventing, controlling, and in some cases reversing, tooth decay [19].

"How Much Fluoride are We Ingesting?"  Fluoride occurs naturally in groundwater at normal levels between 0.01 ppm and 0.3 ppm.  Food contains fluoride at differing variables.  This handy chart shows the levels of fluoride in commonly eaten foods [20].  A study by the Journal of Public Health Dentistry contradicts the idea that it is even possible to roughly calculate and optimize your fluoride intake.

With widespread water fluoridation and countless fluoride-containing products available, quantifying the intakes of fluoride is much more complex than it was several decades ago. In fact, obtaining data from the Iowa Fluoride Study necessary for estimates of total fluoride intake has been extremely complex. For example, fluoride concentrations varied considerably within the same product category depending on site of manufacture and distribution pattern, and many children utilized multiple sources of water, often varying in fluoride concentration [21].

While this may sound troubling, the same study also called into question the idea that there is even an "optimal" level of dental fluorosis to avoid.

It should be emphasized that while almost all of the fluorosis cases in the present study were mild, the level of esthetic concern among individual cases likely also varied considerably so that, as demonstrated in a previous study, an “optimal” fluoride level to avoid fluorosis may differ depending on the threshold used to define fluorosis. This is important because as reported in a recent article, mild fluorosis was associated with higher quality-of-life measures, which suggests that avoiding all fluorosis may not be warranted [21].

"Are Kids Being Overdosed?"  This section once again highlights the video's intention of omitting evidence which runs counter to their claim.  They even have the audacity to do it directly on-screen.  A graphic displays a 2005 press release from the CDC [22] and highlights only the following sentence: one-third of children and adolescents 6 to 19 years had enamel fluorosis of their teeth.  The full press release statement shown, on-screen mind you, is:

About one-third of children and adolescents 6 to 19 years had enamel fluorosis of their teeth, although most was very mild. Enamel fluorosis happens when the teeth absorb too much fluoride as they develop beneath the gums. In its mildest form, fluorosis shows up as white spots on the teeth. Moderate to severe fluorosis, where teeth are discolored and sometimes pitted, was found in less than 4 percent of children and adolescents.

We are then bombarded by pictures of severe dental fluorosis, with no statement that only 4 percent of children and adolescents have moderate to severe fluorosis.  The study which prompted the press release also reports:

The milder forms of enamel fluorosis typically are not noticeable; however, more severe levels might be objectionable for cosmetic reasons. Historically, a low prevalence of the milder forms of fluorosis has been accepted as a reasonable and minor consequence balanced against the substantial protection afforded by dental caries from the use of fluoridated drinking water and foods, beverages, and oral care products that contain fluoride [23].

The video continues and attempts to make some sort of tenuous connection between dental fluorosis and harm to other bodily systems and areas.  "To do that, impacting the enamel cells in the teeth, means that it can also impact cells elsewhere in the body." states the same "enlightened" expert who told us that fluoride is a nuerotoxin.  "What's happening in the teeth is very likely happening in the bone as well.", says another expert.  According to a systematic review by the Australian National Health and Research Council of 20 potentially relevant studies concluded that water fluoridation at levels aimed at preventing dental caries, and possibly at somewhat higher naturally occurring levels, appears to have little effect on fracture risk - either protective or deleterious [4].  Of course, there are dubious studies which hint at countering this conclusion but they are all of poor quality and can be dismissed.  The video goes on, spiraling further outward, attacking the American Dental Association and calling into question the basic efficacy of the field of dentistry.

The video then refers to a report entitled "Fluoride In Drinking Water" by the National Academy of Sciences [25] which is hailed to be "one of the best reports to find out what Fluoride is doing to the rest of the body."  The study makes plenty of key points, all of which are not discussed in the video.

• Addressing questions of artificial fluoridation, economics, risk-benefit assessment, and water-treatment technology was not part of the committee’s charge. (p. 2)
• The committee only considered adverse effects that might result from exposure to fluoride; it did not evaluate health risk from lack of exposure to fluoride or fluoride’s efficacy in preventing dental caries. (p. 2)
• The report makes no concrete claims to any negative effects of fluoride at the normal accepted levels of fluoridation other than dental fluorosis.  It continually calls for more studies to be conducted.
• It calls for more studies and concern over possible negative human effects based off of animal studies in which rats were given extremely large (10 mg for 30 days in one) dosages of fluoride.  The average rat weighs 550 grams while the average human in North America weighs 80.7 kg.  Toxicity is weight dependent.  That's 10 times the recommended human dosage to an animal that weighs 146 times less.
• It references the already mentioned above study linking lower IQ scores to fluoride that can be discounted because of its poor quality.  It even states: Without detailed information about the testing conditions and the tests themselves, the committee was unable to assess the strength of the studies. (p. 208)

The producers of the video either ignored the non-supportive contents of the study, totally misunderstood what the term "suggestive evidence" means and proper scientific method, or deliberately cited the study to lend authoritative support to the medical claims being made in the video and expected the audience not to read or properly investigate the study in question.  The first two are mistakes out of ignorance while the third imparts willful misfeasance, although the first two are more probable considering the callous disregard of scientific thinking shown thus far in this video.

"Should Infants Drink Fluoridated Water?"  There are several studies which show that mother's breast milk is healthier for infants than reconstituted baby formula [26].  An expert in the video states "I think the ADA's recent statement on warning against adding fluoridated water to baby formula is a watershed decision."  While searching for the actual ADA press release which contained this statement, I found numerous false leads and even the Boston local news website which is flashed in the video which contained no links to the actual press release.  The following is from the ADA Fluoride and Infant Formula FAQ:

If fluorosis occurs when teeth are developing, is it okay to use fluoridated water to reconstitute infant formula?

Yes, it is safe to use fluoridated water to mix infant formula. If your baby is primarily fed infant formula, using fluoridated water might increase the chance for mild enamel fluorosis, but enamel fluorosis does not affect the health of your child or the health of your child’s teeth. Parents and caregivers are encouraged to talk to their dentists about what’s best for their child [27].

Its here where the video begins to reiterate many of the topics that I have already debunked and since I've lost my patience, I will begin to close.  Water fluoridation is currently in an information positive feedback loop as the type described in Micheal Shermer's book Why People Believe Weird Things: Pseudoscience, Superstition, and Other Confusions of Our Time.  The amount of misinformation on the internet regarding water fluoridation is astounding.  The misinformed people feed in misinformation which perpetuates the feedback loop cycling ever onward.  It's time to throw a wrench in the gears.

Sources:
[1] http://www.fluoridealert.org/about/team/
[2] http://www.huffingtonpost.com/2012/09/12/portland-fluoride-water-oregon_n_1878515.html
[3] http://www.koinlocal6.com/news/local/story/Portland-City-Council-moves-fluoride-vote-up-to/xUEcBKZbxE-6f8JufBsJfg.cspx
[4] http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/Eh41_Flouridation_PART_A.pdf
[5] http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947361183
[6] http://www.reuters.com/article/2011/01/08/us-usa-fluoride-idUSTRE7064CM20110108
[7] http://medicinaoral.com/medoralfree01/v14i2/medoralv14i2p103.pdf
[8] http://www.bmj.com/content/321/7265/855
[9] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
[10] http://en.wikipedia.org/wiki/Chlorine#Public_sanitation.2C_disinfection.2C_and_antisepsis
[11] http://www.who.int/oral_health/media/en/orh_cdoe_319to321.pdf
[12] http://en.wikipedia.org/wiki/Niacin#Toxicity 
[13] http://en.wikipedia.org/wiki/Fluoridation_by_country
[14] http://www.freysmiles.com/blog/view/what-countries-have-the-lowest-prevalence-of-cavities
[15] http://www.who.int/oral_health/media/en/orh_figure6.pdf
[16] http://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems (a note on this source: criticisms of this ranking have been raised however, most stem from criticism of the United States' ranking raised from US sources)
[17] http://www.cdc.gov/fluoridation/statistics/2010stats.htm
[18] http://en.wikipedia.org/wiki/File:Groundwater-fluoride-world.svg
[19] http://www.ada.org/2467.aspx
[20] http://www.nal.usda.gov/fnic/foodcomp/Data/Fluoride/fluoride.pdf
[21] http://onlinelibrary.wiley.com/doi/10.1111/j.1752-7325.2008.00108.x/full
[22] http://www.cdc.gov/media/pressrel/r050825.htm
[23] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm
[24] http://www.ncbi.nlm.nih.gov/pubmed/7546135
[25] http://www.nap.edu/catalog.php?record_id=11571
[26] http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/
[27] http://www.ada.org/4052.aspx#reconstitute