Water fluoridation controversy
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Water fluoridation controversy refers to the debate surrounding the health benefits of public authorities fluoridating water supplies. Calcium fluoride is a naturally-occurring mineral found in all water sources, such as lakes, rivers, groundwater and oceans. Community water fluoridation is the process of artificially adjusting fluoride levels in drinking water supplies with the intention of improving oral health.<ref name="amwafactsheet">American Water Works Association website, "Fact Sheets: Drinking Water Fluoridation", page accessed March 3, 2006.</ref> This is usually done by the addition of sodium fluoride, sodium fluorosilicate, or fluorosilicic acid.<ref name="amwafactsheet">American Water Works Association website, "Fact Sheets: Drinking Water Fluoridation", page accessed March 3, 2006.</ref>
Advocates of water fluoridation say that fluoridation is similar to fortifying salt with iodine, milk with vitamin D and orange juice with vitamin C and say it is an effective way to prevent tooth decay.
Those opposed to public fluoridation of drinking water say that water fluoridation can have negative health effects (such as dental fluorosis) which outweigh the purported benefits of water fluoridation.
[edit] History
- (For more information, see "History of water fluoridation".)
Community water fluoridation owes its origin in part to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into the "Colorado stain," which is now known as dental fluorosis.<ref name="csdshistory">History of Dentistry in the Pikes Peak Region,Colorado Springs Dental Society webpage, page accessed 25 February, 2006.</ref> In 1909, children from the Pikes Peak region had some degree of stain or mottling on their teeth. Despite having a negative impact on the physical appearance of their teeth, the children with stained or mottled teeth also had fewer cavities than other children. McKay brought the problem to the attention of Dr. G.V. Black, who later became known as the father of modern dentistry, and Black's interest into the Colorado stain led to greater interest throughout the dental profession. In 1931, researchers finally concluded that the cause of the Colorado stain was a high concentration of fluoride ions in the region's drinking water.
Studies led by Dr. H. Trendley Dean determined that the optimal level of fluoride which minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 part per million (ppm).<ref>Dean, H.T. "Classification of mottled enamel diagnosis." Journal of the American Dental Association, 21, 1421 - 1426, 1934.</ref><ref>Dean, H.T. "Chronic endemic dental fluorosis." Journal of the American Dental Association, 16, 1269 - 1273, 1936.</ref> In 1939, Dr. Gerald J. Cox conducted laboratory tests on fluoride and released a report which was the first published paper suggesting adding fluoride to drinking water in order to improve oral health.<ref>Cox, G.J., M.C. Matuschak, S.F. Dixon, M.L. Dodds, W.E. Walker. "Experimental dental caries IV. Fluorine and its relation to dental caries. Journal of Dental Restoration, 18, 481-490, 1939. Copy of original paper can be found here.</ref>
In the 1940s, four widely-cited studies were conducted. The researchers investigated cities that had both fluoridated and unfluoridated water. The first pair was Muskegon, Michigan and Grand Rapids, Michigan, making Grand Rapids the first community in the world to modify its fluoride levels in drinking water to benefit dental health on January 25, 1945.<ref name="mntmichigan">After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities. Medical News Today website, accessed 26 February, 2006.</ref> Kingston, New York was paired with Newburgh, New York.<ref>Ast, D.B., D.J. Smith, B. Wacks, K.T. Cantwell. "Newburgh-Kingston caries-fluorine study XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride experience." Journal of the American Dental Association, 52, 314-25, 1956.</ref> Oak Park, Illinois was paired with Evanston, Illinois. Sarnia, Ontario was paired with Brantford, Ontario, Canada.<ref>Brown, H., M. Poplove. "The Brantford-Sarnia-Stratford Fluoridation Caries Study: Final Survey, 1963." Canadian Journal of Public Health,56, 319–24, 1965.</ref> The research found a decrease in the incidence of tooth decay in cities which had added fluoride to water supplies. Since these results were published, fluoride has gained acceptance in the scientific community as potentially beneficial to oral health, and various governments throughout the world have fluoridated water, salt, and/or other food items.
The history of opposition to water fluoridation is difficult to verify. Some opponents of water fluoridation say their concerns and protests have been muted by the scientific community since the inception of water fluoridation research.<ref>Voices of Opposition have been Suppressed since early days of Fluoridation,Fluoride Alert webpage, page accessed 26 February, 2006.</ref> These charges include omitting research that contradicts the safety of fluoride and constructing biased research in favor of fluoridation. On the other hand, some say the history of their opposition to fluoride began with fighting a conspiracy between the dental establishment and industrial companies.<ref>Fluorides and Fluoridation: How We Got Fluoridated, page accessed 26 February, 2006.</ref>
[edit] Common arguments against water fluoridation
Many groups continue to question the practice of water fluoridation despite the current stance of the medical and dental research communities. The various groups do not necessarily agree with one another, but they share some arguments against water fluoridation, including several key issues.
[edit] Fluoride is not essential
Water fluoridation considered neither a vitamin nor an essential nutrient by the medical community.<ref>Is Fluoride A Nutrient?,PFPC The Fluoride Education Project webpage, page accessed 23 February, 2006.</ref> They point out that excess fluoride has been scientifically linked to liver damage, kidney function, and fluorosis in children. <ref>PubMed NCBI Dose-effect relationship between drinking water fluoride levels and damage to liver and kidney functions in children.</ref> They insist that excellent dental health can be maintained through other methods, such as modifying diet by consuming less sugar, chewing xylitol gum as is done in Europe, and good dental hygiene through flossing and brushing the teeth - even with fluoride toothpaste. They argue that fluoride is primarily effective topically. They say that the benefit that fluoridated water has through washing over the teeth doesn't outweigh the costs that ingesting it imposes on the body, in their mind, and can be done individually if one is so inclined. Consequently they argue that there is no need to fluoridate the community drinking water.
[edit] Water fluoridation is not used by many countries throughout the world
Although somewhat prevalent in the United States, most of Western Europe does not add fluoride to its water supply. In spite of this, the prevalence of dental decay has decreased in both Western Europe and the United States.<ref>Health Effects: Tooth Decay Trends in Fluoridated vs. Unfluoridated Countries,Fluoride Alert webpage, page accessed 22 February, 2006.</ref> Some countries had water fluoridation but then abruptly stopped the practice. These countries, including the former East Germany, Cuba and Finland, have continued to see drops in the incidence of tooth decay.<ref>Cavities Not Increasing, But Decreasing, When Fluoridation Stops,Fluoride Alert webpage, page accessed 22 February, 2006.</ref> Based on this evidence, opponents conclude that factors other than fluoride decrease tooth decay.
[edit] Water fluoridation is not effective
Opponents point to a study by the National Institute of Dental Research showing little difference in tooth decay rates among children in fluoridated and non-fluoridated communities. In the study's results, the difference between the children exposed to water fluoridation and those who were not was very small, between 0.12 and 0.30 DMFS (Decayed Missing and Filled Surfaces).<ref>The "Fuzzy Math" of Fluoride Promotion, No Fluoride website, Paul Connett, accessed 18 February, 2006.</ref>
Opponents also argue that in the instances that fluoride prevents tooth decay, the effects are merely topical.<ref>Health Effects: Fluoride & Tooth Decay (Caries), Fluoride Alert website, accessed 18 February, 2006.</ref> Therefore, fluoridating water is unnecessary and ineffective. Instead, they argue, direct applications of fluoride to teeth as done in dental offices and with fluoridated toothpastes should be the recommended methods.
Opponents point out that dental decay continues to exist in water fluoridated communities. They reason that if fluoride is effective, then there would be no more tooth decay. While, in theory, the poorest members of society would be aided the most by fluoridinated water, baby bottle tooth decay (BBTD) and tooth decay in general is still prevalent in those social groups. Opponents conclude that, in light of the continuing dental health problem, water fluoridation is unable to successfully increase health standards and thus should not be used.<ref>Facts about Fluoridation, Fluoride Alert website, accessed 22 February, 2006.</ref>
Finally, opponents argue that the general decline of tooth decay is the result of factors beside water fluoridation, including toothpaste with fluoride, improved diets, and overall improved general and dental health.<ref>Why I am now officially opposed to adding fluoride to drinking water, Second Look website, Hardy Limeback, accessed 22 February, 2006.</ref>
[edit] Fluoride is toxic
There are some opponents of fluoridation who believe fluoride is a poison that can lead to death or, more commonly, dental fluorosis in instances of overdose. They argue that having a lethal chemical in the water is reckless and leads to many health problems in the general public.
These persons point to research which they say supports the notion that fluoride causes chromosomal damage and interferes with DNA repair.<ref>Health Effects: Fluoride's Mutagenicity (Genotoxicity), Fluoride Alert website, accessed 18 February, 2006.</ref> They point to animal studies that they say demonstrate that rats fed for one year with 1 ppm fluoride in their water had detrimental changes to their kidneys and brains,<ref>Health Effects: Fluoride & the Kidneys, Fluoride Alert website, accessed 18 February, 2006.</ref> an increased uptake of aluminum in the brain, and the formation of beta amyloid deposits, a characteristic of Alzheimers disease.<ref>Health Effects: Fluoride & the Brain, Fluoride Alert website, accessed 18 February, 2006.</ref> Further, it is argued by some opponents that fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.<ref>Diseases: Question 25, Fluoride Debate website, accessed 19 February, 2006.</ref>
At high doses, fluoride has many side effects. Animal studies demonstrate that fluoride can damage the male reproductive system in various species.<ref>The reproductive effects of fluoride intake, Fluoridation.com website, accessed 18 February, 2006.</ref> Consequently, fluoride is considered dangerous by these groups.
According to the United States National Research Council, "several lines of information indicate an effect of fluoride exposure on thyroid function"<ref>Fluoride in Drinking Water: A Scientific Review of EPA's Standards (2006), [1] website, accessed July 21, 2006.</ref> - particularly among individuals with an iodine deficiency.
Fluoride's potential to impair thyroid function is most clearly illustrated by the fact that -- up until the 1970s -- European doctors used fluoride as a thyroid-suppressing medication for patients with hyperthyroidism (over-active thyroid). Fluoride was utilized because it was found effective at reducing the activity of the thyroid gland - even at doses as low as 2 mg/day.
The United States National Research Council reports that, "in humans, effects on thyroid function were associated with fluoride exposures of 0.05-0.13 mg/kg/day when iodine intake was adequate and 0.01-0.03 mg/kg/day when iodine intake was inadequate."<ref>Fluoride in Drinking Water: A Scientific Review of EPA's Standards (2006), [2] website, accessed July 21, 2006.</ref> This is of particular concern considering the widespread problem of hypothyroidism (under-active thyroid) in the United States. Symptoms of hypothyroidism include obesity, lethargy, depression, and heart disease.<ref>HEALTH EFFECTS: Fluoride & the Thyroid, [3] website, accessed July 21, 2006.</ref>
Drinking water fluoridation has been linked to osteosarcoma in young boys.<ref>New Study Is One of Many Linking Fluoride to Cancer (2006)</ref> Elise Bassin, PhD and colleagues reported their findings in the peer-reviewed Harvard Medical School journal, "Cancer Causes and Control" May 2006 issue.
[edit] EPA scientists and Nobel Prize winners who oppose water fluoridation
On April 1998 Chapter 280 of the National Treasury Employees Union, the EPA union of scientists voted to oppose water fluoridation of drinking water supplies. The union is comprised of and represents the approximately 1500 scientists, lawyers, engineers and other professional employees at EPA Headquarters in Washington, D.C.[4]
"I would advise against fluoridation. Individual prophylaxis (treatment) is preferable on principle grounds and is as equally effective," says Dr. Arvid Carlsson of Sweden, co-winner of the 2000 year's Nobel Prize for medicine.[5]
[edit] Water fluoridation is compulsory mass medication
Some opponents of water fluoridation accept the health benefits of fluoride, but do not approve of the social or political implications of adding fluoride to the public's water supplies. Even though water fluoridation may improve dental health of the general public, these people value an individual's choice to pursue medical treatment and argue that water fluoridation is "compulsory mass medication" because it does not allow proper consent.<ref>The Fluoride Debate: Question 34, Fluoride Debate website, accessed 23 February, 2006.</ref>
On the other hand, other commentators argue that because of the negative health effects of minimal fluoride exposure, mandatory fluoridation of public water supplies is a "breach of ethics" and a "human rights violation."<ref>Fluoride Primer: Fluoridation is a serious breach of ethics, International Institute of Concern for Public Health website, accessed 22 February, 2006.</ref>
[edit] Government and industry conspiracy
Some opponents point to a government conspiracy that has modified scientific research to further its own political goal.
The origin of this conspiracy is frequently attributed to right-wing conspiracy theories as alluded to in Dr. Strangelove in 1964. In other cases, the particular conspiracy involves the secret development of the atomic bomb during World War II. The argument usually involves characterizing research as flawed or edited for the public in order to avoid public concern over military research. As some have put it, "The science of fluoridating public drinking water systems has been, from day one, shoddy at best . . . . the basis of that science was rooted in protecting the U.S. Atomic bomb program from litigation."<ref>Fluoride, Teeth, And the Atomic Bomb, Flordiation.com website, Joel Griffiths and Chris Bryson, accessed 18 February, 2006.</ref>
Other conspiracy theories involve large industrial companies wanting to rid themselves of fluorine "waste products".<ref>Water Fights: Believe it or not, the fluoridation war still rages — with a twist you may like - efforts to have cities no longer fluoridate water, FindArticles.com website, Jay Nordlinger, accessed 22 February, 2006.</ref> Some argue that fluoride is a waste product that is unusable and expensive to dispose of properly. Because of this expense, industrial companies desiring to protect their profits release "millions of tons of waste fluoride into the environment."<ref>Fluoride: Commie Plot or Capitalist Ploy, Fluoride Alert website, Joel Griffiths, accessed 18 February, 2006.</ref> As a result, these opponents of water fluoridation say, "it is now clear that the one utterly relentless force behind fluoridation is American 'big industry' ".<ref>Fluoride: A Protected Pollutant, Flordiation.com website, Dr. F. B. Exner, accessed 18 February, 2006.</ref>
Some other theories rest on the dental community as a whole. Some believe that a secret, Masonic society of dentists with 26,000 members around the world influence fluoridation policy for their own goals.<ref>Delta Sigma Delta: Dentistry's secret society, Fluoride.org.uk website, accessed 22 February, 2006.</ref>
[edit] Response by government agencies and medical organizations
- (See Medical approval" for a list of health organizations.)
In the United States, Australia, and most other Anglophone nations, a large majority of government agencies and medical organizations support water fluoridation in locations needing fluoride supplementation and agree that it is a safe practice. The Centers for Disease Control and Prevention (CDC) has listed water fluoridation as one of the ten greatest achievements in public health of the 20th century.<ref>CDC, website, "Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries," page accessed 4 March, 2006. Overview of list can be found here.</ref> In 2000, a report by the Surgeon General of the United States titled "Oral Health in America" stated, "Community water fluoridation remains one of the great achievements of public health in the twentieth century."<ref>Reports of the Surgeon General, hosted by the National Library of Medicine, page accessed 4 March, 2006. The document, "Oral Health in America: A Report of the Surgeon General" can be found here (in pdf format).</ref> Various international groups, including the World Health Organization (WHO) and the International Association for Dental Research (IADR) support water fluoridation as a safe and effective method to fight tooth decay.<ref name="whostatement">World Health Organization website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref><ref name="iadrstatement">International Association for Dental Research policy statements, including water fluoridation, page accessed March 3, 2006.</ref> These organizations respond to arguments by water fluoridation opponents similarly.
[edit] Optimal oral health care includes fluoride
Dental research has shown that fluoride has a positive effect on overall dental health. During tooth development, fluoride binds to the hydroxyapatite crystals present in enamel and makes the enamel more resistant to demineralization by acids.<ref>Ross, Michael H., Gordon I. Kaye, and Wojciech Pawlina, Histology: a Text and Atlas, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2002), p. 453. ISBN 0-683-30242-6.</ref> As a result, the American Dental Hygiene Association classifies fluoride as a nutrient necessary for proper tooth development.<ref>Nutritional Factors in Tooth Development and Maintenance, American Dental Hygiene Association website, page accessed 4 March, 2006.</ref> In addition, organizations, including the CDC and WHO, promote increasing the accessibility of fluoridated water.<ref>"Populations Receiving Optimally Fluoridated Public Drinking Water", from the CDC website, page accessed 4 March, 2006.</ref><ref name="whostatement">World Health Organization website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref>
[edit] Alternative methods of fluoridation
Though water fluoridation is promoted by many health organizations and is considered the least costly method of dispersing fluoride, other methods of dispersal are possible. The World Health Organization is currently assessing the effects of affordable fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe.<ref>WHO World Oral Health Report (in pdf format), from the World Health Organization website, accessed on 4 March, 2006.</ref>
[edit] Regulation of naturally high levels of fluoride
A major concern of health organizations is the incidence of dental fluorosis, a sign of overexposure to fluoride. In many instances, natural fluoride levels in water are much higher than desired. These areas do not need fluoride added to water supplies, and health organizations endorse providing alternate water sources or adjusting the fluoride levels to deliver the proper amount for dental health instead.<ref>"World Water Day 2001: Oral health", World Health Organization website, page 4, page accessed March 4, 2006.</ref>
[edit] Water fluoridation is effective
Scientific and health organizations criticize opponents of water fluoridation for trying to engage in "polling practices" with research. When a group opposing water fluoridation claims an award-winning researcher or dental expert agrees with them, the argument is supposed to be more convincing to the general public. In response, researchers emphasize that voting or polling is not how scientific progress is made.<ref name="uwfdeception">"Impact of Fluoridation of the Municipal Drinking Water Supply: Review of the Literature", hosted on the University of West Florida website, page accessed 4 March, 2006.</ref> Thorough review of methodology and design of multiple studies over time lead researchers to conclusions. Even in the critical analysis of these studies, content is the focus, rather than the researcher who led the study.
The Centers for Disease Control and Prevention published in its Morbidity and Mortality Weekly Report (MMWR) that starting or continuing water fluoridation decreased the incidence of tooth decay by 29%, and that stopping water fluoridation increased the incidence of tooth decay in some communities.<ref>Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries: A Report on Recommendations of the Task Force on Community Preventive Services (in pdf format), from the Morbidity and Mortality Weekly Report (MMWR) produced by the CDC, page accessed 4 March, 2006.</ref>
In addition, since oral health is affected by many factors, fluoride alone would be unable, nor would it be expected, to eradicate the disease. The social groups that would be more likely to benefit from water fluoridation are those living in poorer conditions, and an important factor to decrease dental health disparities may be water fluoridation programs.<ref name="whostatement">World Health Organization website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref> Nonetheless, it is understood that these communities suffer from various problems which would impede oral health, such as lack of access to dental care and poorer oral hygiene education. Water fluoridation is only a single factor to improve dental health.
Another criticism of water fluoridation opponents given is their reference to research seeming to support their view. Generally, those studies are criticized by some scientific researchers on basic principles, such as the methodology used. More problematic is the accusation by pro-fluoridationists that some anti-fluoridation research is published in journals, such as "Fluoride", that are deceptively made to appear peer-reviewed.<ref name="uwfdeception">"Impact of Fluoridation of the Municipal Drinking Water Supply: Review of the Literature", hosted on the University of West Florida website, page accessed 4 March, 2006.</ref>
[edit] There are safe levels for fluoride use
Advocates of water fluoridation agree that fluoride in high concentrations produces harmful effects to the body. Nonetheless, they argue that almost any substance is harmful because toxicity is based on the amount of exposure.<ref>Is fluoride poisonous?, from the Austrialian Dental Association website, page accessed 18 March, 2006.</ref> In defending water fluoridation, the American Dental Association points out that vitamin A, vitamin D, iron, iodine, aspirin, and water are potentially harmful if given in certain amounts.<ref name="adafluoridationfacts">Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.</ref> As is true for all vitamins and minerals, recommended dosages for fluoride represent levels which maximize health benefits and minimize adverse effects.<ref>Towards Better Oral Health in Children, from the Scottish Executive website, page accessed 18 March, 2006.</ref>
The greatest concern with fluoride overexposure is dental fluorosis. Fluorosis is undesirable because, in severe cases, it discolors teeth, causes surface changes to the enamel, and makes oral hygiene more difficult.<ref>Enamel Fluorosis, from the American Academy of Pediatric Dentistry website, page accessed 18 March, 2006.</ref> Government agencies, such as the Center for Disease Control and Prevention, keep records on the prevalence of fluorosis in the general public.<ref>Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis --- United States, 1988--1994 and 1999--2002, from the CDC website, page accessed 18 March, 2006.</ref> Also a concern, skeletal fluorosis is a disease in which fluoride deposits into bone, causing joint stiffness, joint pain, and sometimes changes in bone shape.<ref>Water-related diseases: Fluorosis, from the World Health Organization website, page accessed 18 March, 2006.</ref> For skeletal fluorosis to occur, chronic, high level exposure to fluoride is required. A mild form of skeletal fluorosis, osteosclerosis, is seen when levels of fluoride reach 5 parts per million (ppm) and the time of exposure lasts for 10 years.<ref name="adafluoridationfacts">Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.</ref>
Dosages are in milligrams F/day; 1.0 ppm = 1 mg/liter. | ||||||||||||||||||||||||
In order to best prevent fluorosis, certain health organizations have created guidelines restricting the amount of fluoride exposure. The Environmental Protection Agency limits the maximum amount of fluoride in drinking water to 4.0 milligrams per liter of water and recommends water supplies to contain between 0.7 and 1.2 milligrams of fluoride per liter.<ref>ToxFAQs for Fluorine, Hydrogen Fluoride, and Fluorides, from the Agency for Toxic Substances and Disease Registry (ATSDR) website, page accessed 18 March, 2006.</ref> The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.<ref>Fluoride, from the Agency for World Health Organization website, page accessed 18 March, 2006.</ref> When fluoride levels in water are low (usually below 0.6 ppm), fluoride supplements are sometimes prescribed to encourage healthy dental development. There are accepted recommended guidelines on the amount of fluoride to prescribe, which depend on the fluoride levels in the drinking water and on the age of the child.<ref name="aapdschedule">Fluoride Therapy (in pdf format), from the American Association of Pediatric Dentistry website, page accessed 18 March, 2006.</ref>
Moreover, some health organizations have opined the currently accepted belief that recommended levels of fluoride does not contribute to the many diseases water fluoridation detractors accuse fluoride of causing. The Centers for Disease Control and Prevention and the National Cancer Institute have both issued statements that water fluoridation is not believed to cause osteosarcomas.<ref>CDC Statement on Water Fluoridation and Osteosarcoma, from the CDC website, page accessed 18 March, 2006.</ref><ref name="nciosteosarcomas">National Cancer Institute website, "Fluoridated Water: Questions and Answers", page accessed March 3, 2006.</ref> Cancer in general is not believed to be caused from water fluoridation.<ref>Knox, E.G. "Fluoridation of water and cancer: a review of the epidemiological evidence", hosted on the British Official Publications Collaborative Reader Information Service website, page accessed 18 March, 2006. Full text can be found here</ref><ref>"Inorganic Fluorides Used In Drinking-water and Dental Preparations", by the International Agency on Research for Cancer website, page accessed 18 March, 2006.</ref>
The American Dental Association proclaims that there is no clear link between Alzheimer's disease and water fluoridation.<ref name="adafluoridationfacts">Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.</ref> A study in 1998 suggested a possible relationship between fluoride exposure and Alzheimer's disease.<ref>Varner, J.A., K.F. Jensen, W. Horvath, R.L. Isaacson. "Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity", abstract from PubMed website, page accessed 18 March, 2006.</ref> Research groups point out that the study contained methodological limitations, which prevent a definitive conclusion on the subject. As a result, research and health agencies currently believe fluoride is not a risk factor for Alzheimer's disease, and instead age and family history are the most important risk factors.<ref>Causes", by the Alzheimer's Disease Education and Referral (ADEAR) Center website, a division of the National Institute of Aging, page accessed 18 March, 2006.</ref> Moreover, there is some research that suggests Alzheimer's disease can be prevented with water fluoridation because of the competition between aluminum and fluoride absorption.<ref>Kraus, A.S. and W.F. Forbes. "Aluminum, fluoride and the prevention of Alzheimer's disease.", abstract from PubMed website, page accessed 18 March, 2006.</ref> Nonetheless, this research is also limited by design and no definitive conclusion can be made.
The American Dental Association denies that other health concerns, such as kidney disease, Down syndrome, lead poisoning, heart disease, decreased fertility rates, and inhibition of biologic enzymes, can be attributed to water fluoridation.<ref name="adafluoridationfacts">Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.</ref>
[edit] Ethical questions
Frequently, health agencies confront the ethics of water fluoridation along the lines of two topics. They address the issues of consent and providing fluoridated water as a method of improving dental care for low-income persons.
Many advocates of fluoridation do not consider it a violation of people's right to consent to medical treatment. They usually argue that fluoridation is not a form of mass medication because fluoride is naturally present in all water systems.<ref name="adafluoridationfacts">Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.</ref> In their view, fluoridation is a modification of a naturally present substance in water that helps resist dental decay. Frequently, the comparison is made to the fortification of other types of foods, such as adding vitamins to breakfast cereals and baby foods.<ref name="bmastatment">British Medical Association website, statement on water fluoridation, page accessed March 3, 2006.</ref>
In addition, proponents propose that not fluoridating municipal water is unethical. Since the populations which the proponents allege benefit most from water fluoridation are children and those in poorer communities, proponents consider fluoridation to be an avenue to relieve some of the health disparities between socio-economic groups.<ref>"The Ethics of Water Fluoridation" publication (in pdf format), from the British Fluoridation Society website, page accessed March 19, 2006.</ref> Fluoridation is defended further by its relative low cost. The Canadian Task Force On Preventive Health Care describes water fluoridation as "the single most effective, equitable and efficient means of preventing coronal and root dental caries."<ref>Lewis DW and Ismail AI. Prevention of dental caries. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 408-17. Page accessed August 13, 2006.</ref> In the United States, the cost can be as low as 31 cents per person, per year.<ref name="RingelbergCost">Ringelberg, M. L., S. J. Allen, L. J. Brown. "Cost of fluoridation: 44 Florida communities.", abstract from PubMed website, page accessed 19 March, 2006.</ref> As a result, some health organizations defend fluoridation and do not consider it a violation of ethical principles.
[edit] Court cases
[edit] United States
Fluoridation has spawned many court cases. Anti-fluoride activists have sued municipalities, claiming that their rights to consent to medical treatment, privacy, and due process are infringed by mandatory water fluoridation.<ref>Cross, D. W., R. J. Carton. "Fluoridation: a violation of medical ethics and human rights.", abstract from PubMed website, page accessed 19 March, 2006.</ref> Individuals have sued municipalities for a number of illnesses that they blamed on fluoridation of the city's water supply. A substantial majority of courts have held in favor of cities in such cases, finding no or only a tenuous connection between health problems and widespread water fluoridation.<ref name="beck">Beck v. City Council of Beverly Hills, 30 Cal. App. 3d 112, 115 (Cal. App. 2d Dist. 1973) ("Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question." (citations omitted)).</ref> To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.<ref>Pratt, Edwin, Raymond D. Rawson & Mark Rubin, Fluoridation at Fifty: What Have We Learned, 30 J.L. Med. & Ethics 117, 119 (Fall 2002)</ref>
[edit] Early cases
A flurry of cases were heard in numerous state courts in the 1950s during the early years of water fluoridation. State courts consistently held in favor of allowing fluoridation to continue, analogizing fluoridation to mandatory vaccination and the use of other chemicals to clean the public water supply, both of which had a long-standing history of acceptance by courts.
In 1952, a Federal Regulation was adopted that stated in part, "The Federal Security Agency will regard water supplies containing fluorine, within the limitations recommended by the Public Health Service, as not actionable under the Federal Food, Drug, and Cosmetic Act."<ref>17 Fed. Reg. 6743 (July 23, 1952).</ref>
The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case.<ref name="dowell">273 P.2d 859, 862-63 (Okl. 1954) (available at FindLaw for Legal Professionals)</ref> The court noted, "we think the weight of well-reasoned modern precedent sustains the right of municipalities to adopt such reasonable and undiscriminating measures to improve their water supplies as are necessary to protect and improve the public health, even though no epidemic is imminent and no contagious disease or virus is directly involved . . . . To us it seems ridiculous and of no consequence in considering the public health phase of the case that the substance to be added to the water may be classed as a mineral rather than a drug, antiseptic or germ killer; just as it is of little, if any, consequence whether fluoridation accomplishes its beneficial result to the public health by killing germs in the water, or by hardening the teeth or building up immunity in them to the bacteria that causes caries or tooth decay. If the latter, there can be no distinction on principle between it and compulsory vaccination or inoculation, which, for many years, has been well-established as a valid exercise of police power."<ref name="dowell">273 P.2d 859, 862-63 (Okl. 1954) (available at FindLaw for Legal Professionals)</ref>
In the 1955 case Froncek v. City of Milwaukee, the Wisconsin Supreme Court affirmed the ruling of a circuit court which held that "the fluoridation is not the practice of medicine, dentistry, or pharmacy, by the City" and that "the legislation is a public health measure, bearing a real, substantial, and reasonable relation to the health of the city."<ref>69 N.W.2d 242, 252 (Wis. 1955)</ref>
The Supreme Court of Ohio, in 1955's Kraus v. City of Cleveland, said, "Plaintiff's argument that fluoridation constitutes mass medication, the unlawful practice of medicine and adulteration may be answered as a whole. Clearly, the addition of fluorides to the water supply does not violate such principles any more than the chlorination of water, which has been held valid many times."<ref>127 N.E.2d 609, 613 (Ohio 1955)</ref>
[edit] Fluoridation consensus
As cases continued to be brought in state courts, a general consensus developed that fluoridation, at least from a legal standpoint, was acceptable. In 1973's Beck v. City Council of Beverly Hills, the California Court of Appeal, Second District, said, "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question." (citations omitted)<ref name="beck">Beck v. City Council of Beverly Hills, 30 Cal. App. 3d 112, 115 (Cal. App. 2d Dist. 1973).</ref>
[edit] Contemporary challenges
Though courts have consistently rejected arguments against fluoridation, advocates continue to challenge the spread of fluoridation. For instance, in 2002, the city of Watsonville, California chose to disregard a California law mandating fluoridation of water systems with 10,000 or more hookups, and the dispute between the city and the state ended up in court. The trial court and the intermediate appellate court ruled in favor of the state and its fluoridation mandate, however, and the Supreme Court of California declined to hear the case in February of 2006.<ref>Jones, Donna "Supreme Court turns down Watsonville's appeal to keep fluoride out of its water." Santa Cruz Sentinal. February 10, 2006.</ref> Since 2000, courts in Washington,<ref>Parkland Light & Water Co. v. Tacoma-Pierce County Bd. of Health, 90 P.3d 37 (Wash. 2004)</ref> Maryland,<ref>Pure Water Committee of W. MD., Inc. v. Mayor and City Council of Pure Water Comm. of W. MD., Inc. v. Mayor and City Council of Cumberland, MD. Not Reported in F.Supp.2d, 2003 WL 22095654 (D.Md. 2003)</ref> and Texas<ref>Espronceda v. City of San Antonio, Not Reported in S.W.3d, 2003 WL 21203878 (Tex.App.-San Antonio 2003)</ref> have reached similar conclusions.
[edit] Republic of Ireland
In Ryan v. Attorney General (1965), the Supreme Court held that water fluoridation did not infringe the plaintiff's right to bodily integrity.<ref>Ryan v. A.G. IESC 1; IR 294 (3rd July, 1965) — text of the Irish Supreme Court's judgement</ref> However, the court found that such a right to bodily integrity did exist, despite the fact that it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.
[edit] Pop culture references
- In Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb, General Jack D. Ripper states that fluoridation is a communist plot: "Do you realize that fluoridation is the most monstrously conceived and dangerous Communist plot we have ever had to face?" [6]
- In the Justice League Unlimited episode "Question Authority", the Question, a conspiracy obsessed vigilante, is being tortured for information when he claims that fluoridation does not in fact prevent tooth decay, but does render one's teeth visible by spy satellite.
[edit] Medical approval
The following medical organizations have expressed approval of water fluoridation:
- American Academy of Pediatric Dentistry<ref>Policy on Use of Fluoride (in pdf format) from the American Academy of Pediatric Dentistry website, page accessed April 13, 2006.</ref>
- American Association of Public Health Dentistry<ref>American Association of Public Health Dentistry website, page accessed March 3, 2006.</ref>
- American Dental Hygienists Association<ref>American Dental Hygienists Association website, "Public health", page accessed March 3, 2006.</ref>
- American Dental Association<ref>American Dental Association website, page accessed March 3, 2006.</ref>
- American Public Health Association<ref>American Public Health website, "Fluoridation", page accessed March 3, 2006.</ref>
- American Water Works Association<ref name="amwafactsheet">American Water Works Association website, "Fact Sheets: Drinking Water Fluoridation", page accessed March 3, 2006.</ref>
- Australian Dental Association<ref>Australian Dental Association website's policy on water fluoridation (in pdf format), page accessed March 3, 2006.</ref>
- British Dental Association<ref>British Dental Association website on a water bill vote, page accessed March 3, 2006.</ref>
- British Medical Association<ref name="bmastatment">British Medical Association website, statement on water fluoridation, page accessed March 3, 2006.</ref>
- Canadian Dental Association<ref>Canadian Dental Association policy on water fluoridation (in pdf format), page accessed March 3, 2006.</ref>
- Canadian Dental Hygienists Association<ref>Canadian Dental Hygienists Association position statement on water fluoridation (in pdf format), page accessed March 3, 2006.</ref>
- Centers for Disease Control and Prevention (CDC)<ref>CDC website, page accessed March 3, 2006.</ref>
- European Academy of Paediatric Dentistry<ref>"Guidelines on the use of fluoride in children: an EAPD policy document", hosted on the European Academy of Paediatric Dentistry website, page accessed April 29, 2006.</ref>
- FDI World Dental Federation<ref>Policy statement (in pdf format) from the FDI World Dental Federation on various fluoride therapy, including water fluoridation, page accessed March 3, 2006.</ref>
- International Association for Dental Research<ref name="iadrstatement">International Association for Dental Research policy statements, including water fluoridation, page accessed March 3, 2006.</ref>
- National Cancer Institute<ref name="nciosteosarcomas">National Cancer Institute website, "Fluoridated Water: Questions and Answers", page accessed March 3, 2006.</ref>
- National Institute of Dental and Craniofacial Research<ref>National Institute of Dental and Craniofacial Research website, "The Story of Fluoride", page accessed March 3, 2006.</ref>
- World Health Organization<ref name="whostatement">World Health Organization website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref>
The Massachusetts Coalition for Oral Health, a pro-fluoridation organization, maintains a list of more than one hundred national and international organizations that it says advocate community water fluoridation to prevent dental decay.<ref>National and International Organizations that Support Fluoride, from the Massachusetts Coalition for Oral Health website, page accessed March 19, 2006.</ref>
[edit] References
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