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What they said
'There is not a single scientific, or laboratory, study from anywhere in the world which proves that fluoridation reduces tooth decay in humans. There are, however, hundreds of published scientific papers which show that water fluoridation is dangerous to human, animal, plant and aquatic life ...' The British National Pure Water Association
'Fluoridation of water at optimal levels (levels given).... remains the most effective and socially equitable means of achieving community-wide exposure to the caries-preventive effects of fluoride ... Communities that have ceased water fluoridation have demonstrated an increase in caries (decay) experience' The Australian National Health and Medical Research Council
The issue at a glance
In October 2005 the Queensland health inquiry chief, Peter Forster, urged the State Government to investigate introducing fluoride to drinking water because the state could no longer afford to pay for free dental care.
The Queensland Government has rejected all previous proposals to fluoridate the state's water supply, however, Premier Beattie has now offered councils $6 million to set-up fluoride plants in water treatment facilities. Mr Beattie has given councils five years to take up the offer or face fluoridation being forced on them.
The proposal has met with significant popular support and has been endorsed by the Queensland president of the Australian Dental Association. There are, however, a number of lobby groups, and others, who remain completely opposed to the introduction of fluoride to the state's water supply.
On November 8, 2005, the Local Government Association of Queensland called on Queensland's councils to ignore the State Government's moves to force them to put fluoride in their water supplies.
Background Some background information about fluoride and fluoridation
Fluoride exists fairly abundantly in the earth's crust and can enter groundwater by natural processes; the soil at the foot of mountains is particularly likely to be high in fluoride from the weathering and leaching of bedrock with a high fluoride content.
According to 1984 guidelines published by the World Health Organization (WHO), fluoride is an effective agent for preventing dental caries if taken in 'optimal' amounts. But a single 'optimal' level for daily intake cannot be agreed because the nutritional status of individuals, which varies greatly, influences the rate at which fluoride is absorbed by the body. A diet poor in calcium, for example, increases the body's retention of fluoride.
Water is a major source of fluoride intake. The 1984 WHO guidelines suggested that in areas with a warm climate, the optimal fluoride concentration in drinking water should remain below 1 mg/litre (1ppm or part per million), while in cooler climates it could go up to 1.2 mg/litre. The differentiation derives from the fact that we perspire more in hot weather and consequently drink more water. The guideline value (permissible upper limit) for fluoride in drinking water was set at 1.5 mg/litre, considered a threshold where the benefit of resistance to tooth decay did not yet shade into a significant risk of dental fluorosis. (The WHO guideline value for fluoride in water is not universal: India, for example, lowered its permissible upper limit from 1.5
ppm (parts per million) to 1.0 ppm in 1998)
In many countries, fluoride is purposely added to the water supply, toothpaste and sometimes other products to promote dental health. It should be noted that fluoride is also found in some foodstuffs and in the air (mostly from production of phosphate fertilizers or burning of fluoride-containing fuels), so the amount of fluoride people actually ingest may be higher than assumed.
It has long been known that excessive fluoride intake carries serious toxic effects. But scientists are now debating the extent of the benefits fluoride confers.
When fluoride was first used to fight dental cavities in the 1940s, its effectiveness was defended on two grounds:
* Fluoride has been claimed to inhibit enzymes that breed acid-producing oral bacteria whose acid eats away tooth enamel. While this observation is valid, some scientists now believe that the harmful impact of fluoride on other useful enzymes outweighs the beneficial effect on caries prevention.
* Fluoride ions are also claimed to bind with calcium ions, strengthening tooth enamel as it forms in children. However, many researchers now consider this more of an assumption than fact, because of conflicting evidence from studies in India and several other countries over the past 10 to 15 years.
Regarding hazards, there is now general agreement that excessive fluoride intake leads to loss of calcium from the tooth matrix, aggravating cavity formation throughout life rather than remedying it, and so causing dental fluorosis (molting and staining of the tooth surface). Further, severe, chronic and cumulative overexposure can cause incurable crippling of skeletal fluorosis, a weakening of the structure of the bone.
Water fluoridation is the act of adding fluoride ions to water in order to reduce tooth caries in the general population. Fluoride was first introduced into water supplies in the United States in the late 1940s after it was claimed that regions with naturally occurring fluoride had a lower incidence of caries (decays). Many North American municipalities now fluoridate their water supplies, claiming this practice is effective in reducing tooth decay, is safe and is cost-effective. As of 2000, around two-thirds of United States citizens have access to fluoridated drinking water
Unlike North America, less than 2% of Europe's population has fluoridated water. Sweden banned fluoridation in 1971 by mandate of their Supreme Court; the Netherlands banned it constitutionally in 1976. West Germany rejected it in 1971; Norway in 1975; Denmark in 1977; France in 1980. In Switzerland, only Basel's water was fluoridated, and that was stopped in April 2003 on the advice of their Health and Social Commission. Finland maintains an 'experimental program' covering only 1.5% of its people. Most European countries have other modes of delivery such as salt and milk fluoridation.
Chile rejected fluoridation in 1977. India and Egypt have naturally occurring fluoride in their water. These two countries suffer from excessive fluoride and India, in particular, removes the fluoride from some of its water supplies. Australia has fluoridation in all but one state, Queensland.
Internet information
The on-line encyclopedia Wikipedia has a detailed entry titled 'Water fluoridation controversy'. This supplies clear background information and a detailed summary of the arguments for and against fluoridation as well as a good list of Internet sources and an index of some of the most recent research. The entry is a very good place from which to begin your consideration of this issue. It can be found at http://en.wikipedia.org/wiki/Water_fluoridation_controversy
In 1997, David R Hill, Professor Emeritus, The University of Calgary, Alberta, Canada, published a detailed report titled, 'Fluoride: risks and benefits'. This is a scholarly consideration of the scientific and ethical arguments offered in support of fluoridation which attempts to show their inadequacies. It can be found at http://www.fluoridation.com/calgaryh.htm
The Fluoride Debate is a very well researched site opposed to fluoridation. Despite its clear stance on the issue, it is a conscientious attempt to answer the arguments put by the American Dental Association. It presents the pro fluoride case in significant detail and then attempts to counter these arguments via research findings of apparently equal validity.
The site can be found at http://www.fluoridedebate.com/
The American Dental Association has produced a booklet titled 'Fluoridation Facts'. It is a detailed account of a wide range of arguments and research supporting the fluoridation of water supplies. It can be found at http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf
In 2005 the British Dental Journal published an article by Dr Joe Mullen titled 'The History of Water Fluoridation'. It gives a reasonably detailed, if uncritical, overview of the steps leading up to the current degree of acceptance of fluoridation. Though the article favours fluoridation, it is not strident in the presentation of its arguments. It can be found at http://www.nature.com/bdj/journal/v199/n7s/full/4812863a.html
Arguments against fluoridating Queensland's water supply
1. Fluoride is a toxic substance which can damage human health
Fluoride is a known toxin. It is more toxic than lead and only slightly less poisonous than arsenic. It is described by manufacturers' safety data as a 'hazardous waste' which it is illegal to dump at sea. Fluoride is a cumulative poison of which only about half of what is ingested is excreted. The rest is stored, mainly in the bones, where it increases the density but changes the internal architecture of the bone. It can make bones more brittle and prone to fracture. Fluoride has been linked to an increased risk of osteoporosis.
Fluoride exposure can disrupt the synthesis of collagen and lead to the breakdown of collagen in bone, tendon, muscle, skin, cartilage, lungs, kidney and trachea. Fluoride can also kill red blood cells and damage gastric mucosa, resulting in the symptoms of 'Irritable Bowel Syndrome'.
Fluoride can also confuse the immune system and cause it to attack the body's own tissues, and so increases the tumour growth rate in cancer prone individuals.
2. Fluoride's impact on dental health is problematic
It has been claimed that large-scale studies of the official school dental data of children in the United States, New Zealand and Canada show that there is no difference in the incidence of decayed, missing and filled teeth between fluoridated and non-fluoridated areas.
In 1990 Dr John Colquhoun in New Zealand conducted a study on 60,000 school children and found no difference in tooth decay between fluoridated and non-fluoridated areas. He additionally found that a substantial number of children in fluoridated areas suffered from dental fluorosis, mottling of the tooth enamel.
The British National Pure Water Association is reported to have asked the United Kingdom Department of Health to cite one scientific or laboratory study from anywhere in the world which proves that fluoridation reduces tooth decay in humans. They have failed to do so.
The British National Pure Water Association has stated, 'There is not a single scientific, or laboratory, study from anywhere in the world which proves that fluoridation reduces tooth decay in humans. There are, however, hundreds of published scientific papers which show that water fluoridation is dangerous to human, animal, plant and aquatic life ...'
3. Many of the experiments demonstrating fluoride's supposed effectiveness and safety have been flawed
Repeated claims have been made that many of the early studies of populations naturally exposed to fluoride do not demonstrate what the original researchers claimed. One of the complicating factors is that naturally occurring fluoride in water supplies is frequently found as a compound with calcium. A number of researchers have suggested that many of the favourable effects observed were the result of the calcium rather than the fluoride.
It has also been noted that a number of the trial studies conducted with American populations deliberately exposed to fluoride, exaggerated the benefits supposedly received, did not run for as long as was originally intended and finally ignored the improvements in dental health in control populations which had not been exposed to fluoridated water.
Dr Richard Foulkes who had recommended that Canada fluoridate its water supply in 1973 is claimed to have later discovered that the statistics that his researchers had based their findings on were largely falsified. By 1992 Dr Foulkes had concluded, 'I now hold a different view. ... the fluoridation of community water supplies can no longer be held to be either safe or effective in the reduction of dental caries ... Therefore, the practice should be abandoned.'
4. No population should undergo compulsory mass medication
Critics of water fluoridation argue that it violates the individual's right to informed consent to medication. In no other circumstance can a patient be compelled to take a medication or have a medical treatment against his or her will, yet fluoridation of public water supplies compulsorily medicates those dependent on that water.
There is also concern that no attempt is or can be made to gauge the effect of the medication on any given individual. This is particularly concerning as nutritional status and other types of exposure to fluoride can dramatically influence the effect that the substance has on individuals drinking fluoridated water.
Mass medication in this manner also ignores the fact that some people are more vulnerable to the toxic effects of fluoride than are others.
In summary it has been claimed, 'The use of fluoridation as a prophylactic medical intervention without the fully informed consent of the public violates numerous articles of international conventions aimed at the protection of human rights with respect to State-sponsored medical interventions and health care, and undoubtedly constitutes medical malpractice.'
5. Those who wish to use fluoride can chose to use fluoridated toothpaste
It has repeatedly been claimed that those who wish to treat their teeth with fluoride are able to do so without authorities having to put fluoride in the water which people drink.
The most obvious source of fluoride available to people voluntarily is through fluoridated toothpastes. If a person wishes to take fluoride systemically (that is, internally) rather than topically (that is, applied directly to the surface of the teeth) it is possible to get fluoride tablets. In many countries in Europe, fluoride is available in salt and in milk. Unlike fluoridated water, ingesting fluoride in either milk or salt is completely within the control of the individual who wishes to undertake the treatment.
6. Any dental health benefits to be derived from fluoride are through topical application
The American Dental Association and other proponents of the fluoridation of water claim that fluoride 'prevents tooth decay systemically when ingested during tooth development.' This claim has been disputed as the result of a variety of studies conducted in different parts of the world.
The United States Center for Disease Control and Prevention has stated in a report released in 1999-2000 'Fluoride's caries-preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid-resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children.'
This is a significant claim as it means that whatever beneficial effects fluoride has occur when it is applied directly to teeth rather than when it is ingested and thereby incorporated into teeth and bones as they form. This suggests that delivery modes such as toothpaste or fluoride-added chewing gum would be more effective than fluoride added to drinking water.
7. The ongoing cost of fluoridation is too great a burden on councils
Greg Hallam, the executive director of the Local Government Association of Queensland (LGAQ), has stated that water fluoridation was an issue which polarised shires. Mr Hallam questioned the accuracy of the State government figures of large support for fluoridation, and the costing of $6 million to implement it.
Mr Hallam said an LGAQ poll conducted last year found that the level of support for it was 'dreadful' and the cost was about $80 million.
On November 8, 2005, the LGAQ has called on Queensland's councils to ignore the State government's moves to force them to put fluoride in their water supplies.
Toowoomba Councillor, Joe Ramia, has argued, '$6 million won't do much. It is costly and costly to maintain.'
Councillor Ramia said council had not formally considered adding fluoride to water, nor was it likely to any time soon unless the State Government offered to make a more substantial investment.
Arguments in favour of fluoridating Queensland's water supply
1. Fluoride is not harmful in the quantities added to water supplies
It is generally claimed that at the levels recommended for human consumption, 1ppm (one part per million), fluoride has no adverse effects on human health.
The British Government commissioned research by the York National Health Service Centre for Reviews and Dissemination in 2000. The Centre concluded, 'Worldwide, 39 million people consume naturally fluoridated water and a further 317 million consume water with added fluoride, many for 40 years or more. Any adverse health effects would by this time have emerged in the general population and have been reported and incorporated into studies of its effects. The review can therefore be added to those others published over the past fifteen years that provide reassurance on the safety and efficacy of fluoridation programs.'
Drawing on research from 1991, the United States National Cancer Institute stated in 2000, '...scientists at the National Cancer Institute evaluated the relationship between the fluoridation of drinking water and the number of deaths due to cancer in the US during a 36 year period, and the relationship between water fluoridation and the number of new cases of cancer during a 15 year period. After examining more than 2.2 million cancer deaths records and 125,000 cancer case records in countries using fluoridated water, the researchers concluded that there was no indication of increased cancer risk associated with fluoridated drinking water.'
2. Fluoride has been shown to be effective in improving dental health
In a recent scientific review of 113 articles from 23 countries (59 of which were conducted in the United States) it was claimed that water fluoridation reduced dental decay by 40 to 49 percent in the primary dentition or baby teeth and by 50 to 59 percent in the permanent teeth or adult teeth.
In a further scientific review of studies conducted from 1976 through 1981, reductions in dental decay in fluoridated communities were 30 to 60 percent in the primary dentition or baby teeth, 20 to 40 percent in the mixed dentition (both baby and adult teeth - children aged 8 to 12), 15 to 35 percent in permanent dentition or adult teeth ( adolescents aged 14-17) and 15 to 35 percent in the permanent dentition (adults and seniors).
In 1999 the Australian National Health and Medical Research Council stated, 'Fluoridation of water at optimal levels (levels given).... remains the most effective and socially equitable means of achieving community-wide exposure to the caries-preventive effects of fluoride ... Communities that have ceased water fluoridation have demonstrated an increase in caries (decay) experience.'
3. The 'halo' effect explains improved dental health in areas without fluoridated water
The first community water fluoridation studies, which were begun in the mid-1940s, demonstrated that reductions in childhood dental caries attributable to such fluoridation were approximately 50%-60%. More recent estimates of such reductions are lower, at 18%-40%. This decrease may be attributable to the benefit that comes from the increasing use of fluoride from other sources, of which the widespread use of fluoride toothpaste is probably the most important.
Further, many studies have demonstrated that there has been an improvement in dental health, often of equal magnitude, among people living in non-fluoridated areas compared with similar populations living in fluoridated areas.
It has been claimed that the diffusion or 'halo' effect of beverages and food processed in fluoridated areas, but consumed in non-fluoridated areas, indirectly spreads some benefit of fluoridated water to non-fluoridated communities. This effect lessens the differences in caries experience between communities.
4. Queensland has the worst dental health in the nation
With the lowest fluoridation rate in Australia, Queensland has the nation's worst dental health with an average of 45 per cent of children with tooth decay, compared with 35 per cent nationally.
This marked difference in decay rates is seen by many as a compelling reason why fluoride should be introduced into the drinking water in Queensland. It would appear that reduced access to fluoride may be the reason why so many more Queenslanders suffer from dental caries compared with those living in other states.
5. Fluoride is a cost-effective means of improving dental health
Health economists at a 1989 workshop on cost-effectiveness of caries prevention calculated that the average annual cost of water fluoridation in the United States was $0.51 per person. In 1999 dollars, this cost would be $0.69 per person.
Even under the least favourable assumptions in 1989, the cost of a tooth surface saved due to community water fluoridation ranged from $8 to $12 ($10.88-$16.32 in 1999 dollars). Even this is a far lower cost than the fee for a one surface restoration of $54 per tooth surface in 1989 and $65 per tooth surface in 1999.
A study conducted in Scotland showed that community water fluoridation resulted in a 49% saving in dental treatment costs for children aged 4-5 years and a 54% saving for children aged 11-12 years. The effect of community water fluoridation on costs of dental care among adults is less clear.
6. Ingestion of fluoride benefits adult as well as forming teeth
It has been claimed that quantifying the benefits of water fluoridation among adults is more complicated, because adults are more rarely surveyed, their fluoride history is potentially more varied, and their tooth loss or restorations may be due to dental problems other than caries (e.g., trauma or periodontal disease).
Nevertheless, adults have been found to receive caries-preventive benefits from community water fluoridation. These benefits may be particularly advantageous for adults aged over 50 years, many of whom are at increased risk of dental caries. Beside coronal caries, older adults typically experience gum recession, which results in teeth with exposed root surfaces.
Drinking water containing an optimal concentration of fluoride can mitigate the risk factors for caries among older adults.
In 1999, the United States Center for Disease Control and Prevention, stated, 'Although early studies focused mostly on children, water fluoridation also is
effective in preventing dental caries amongst adults. Fluoridation reduces
enamel caries in adults by 20-40% and prevents caries on the exposed root
surfaces of teeth, a condition that particularly affects older adults.'
7. Fluoridating water is of particular benefit to those living in less wealthy areas.
A major advantage to public health which is claimed for fluoridated water is that water fluoridation benefits persons living in lower socio-economic areas.
Typically, where water is not fluoridated, the caries experience is considerably higher for persons living in lower socio-economic areas relative to those living in high socio-economic groups.
The reasons for this discrepancy are generally not well understood. It has been suggested that perhaps persons in low socio-economic areas have more limited knowledge of oral diseases, have poorer access to dental care, are less likely to follow recommended self-care practices, or are harder to reach through traditional approaches, including public health programs and private dental care.
Thus, these persons appear to derive more benefit from fluoridated water than persons from higher socio-economic areas. It is argued that not fluoridating water discriminates against the less wealthy whose dental health is very hard to guarantee in any other way.
Further implications
If the State Government retains its support for the fluoridation of Queensland water, it seems highly likely that over time Queensland councils will be compelled to fluoridate the water supplies they administer. There appears to be popular support running at a level of approximately 70% for the state's water supply to be treated in this manner.
The Local Government Association of Queensland has argued that before fluoridation proceeds there should be a region by region referendum to gauge the level of popular acceptance for the measure. However, even this would not be sufficient unless it were preceded by genuine, informed public debate.
Fluoridation of water supplies appears to have become an accepted public health measure in many areas of Australia. The extent of this acceptance is indicated by the fact that there has been discussion about altering the laws re adulteration in New South Wales so that fluoride can be added to bottled water, perhaps compulsorily.
However, the extent of medical debate on the efficacy of the treatment, its potential toxicity and the ethical questions provoked by compulsory mass medicating appear to indicate that it is an issue that should be re-examined.
The prevailing orthodoxy within Australia and much of the United States is that the fluoridation of public water supplies is a good thing, however, this is far from the view everywhere. The refusal of many European countries to fluoridate their water supplies and, more concerning, the decision by a number to cease fluoridation after years of adherence to the practice, indicates that the orthodoxy could stand renewed scrutiny.
Newspaper sources used in the compilation of this outline
In a departure from our usual practice, there is no package of clippings offered with this outline. Instead, we have cached all but three of the newspaper items, either in their original form or as caches on third-party sites. If you click on any of the underlined headlines below, you will be taken to the news item online.
The Australian
October 7, page 5, news item (with statistics on decay figures state-to-state) by Clare Pirani, `Fluoride theory proves watertight'.
October 25, page 13, editorial, `Gnashing of teeth'.
October 21, page 15, editorial, `Biting the bullet'.
October 21, page 8, news item by Sean Parnell, 'Rot sets in as councils revolt on fluoride bill'. NOTE: Listed items may still be available on the Web. To search for them, cut and paste any headline into the search-box below (or type the headline in exactly) then click the search button. The search opens in a NEW WINDOW.
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