This article responds to Ken Perrott’s article Fluoride debate Part 1: Perrott. The later was a response to Paul’s original article Fluoride debate Part 1: Connett.
Fluoride debate: Paul responds to Ken’s response to part 1 of his argument against fluoridation, “Fluoridation is a poor medical practice.”
Ken writes: Paul’s first article appears to be a general overview and not detailed consideration of the ten points he makes. I will be similarly brief in my response to each point. Paul may wish to go deeper into specific issues in later contributions and I will respond in more detail then.
Paul responds: I certainly do, but before I do this Ken I would like to make two reasonable requests. First, please drop the term anti-fluoridationist, which I find offensive. It makes opposition to fluoridation sound like some mental disease! I am a scientist who opposes water fluoridation based upon my 17-year review of the scientific literature. So please use the more respectful and neutral term “opponent of fluoridation.” Secondly, please stick to addressing my arguments without going into the opinions and arguments of others, especially the more extreme views. I am not responsible for all the arguments used by all the opponents of fluoridation, just as you are not responsible for all the views of all the proponents of fluoridation. To digress into these will simply confuse the arguments between ourselves and waste time and space.
My arguments 1,2 and 3 (You can’t control dose, who gets the medicine and it violates the individual’s right to informed consent).
Ken, you have problems with my referring to water fluoridation as “medical treatment” without carefully defining the term. So here is what I consider to be a commonly understood definition of medicine or medical treatment. A medicine is a substance defined by its intended purpose, in other words it is a substance used “to treat or prevent a disease.”
In the case of water fluoridation the purpose of adding fluoride ions (or fluoride compounds which release fluoride ions) to the water is “to treat or prevent dental disease.” That makes water fluoridation a medical treatment. Unlike all the other chemicals added to water the fluoridating chemicals are not used to treat the water but are added to treat people. For example, unlike chlorine, they are not added to make the water safe to drink but are simply using the water supply as a delivery system for human treatment– and as I have argued – this is a very clumsy delivery system for such treatment because a) you can’t control the dose delivered; b) you can’t control who gets the treatment and c) you are violating the individual’s right to informed consent to any kind of human treatment.
You say that this discussion it is matter of semantics. It is not. In fact in it is a matter of law. In most countries if you make a claim that a substance prevents or treats disease then it’s classified as a drug or medicine and it has to go through rigorous clinical testing for safety. This has never happened for fluoride. In fact the US Food and Drug Administration classifies fluoride for ingestion as an “unapproved drug.” This means that in the U.S. fluoride intended for ingestion has never been subjected to the double blind randomized clinical trials (RCT) for either efficacy or safety that are required of all other drugs. Nor is the FDA tracking side effects from patients or doctors, despite the fact that many individuals claim to be highly sensitive to fluoride’s toxic effects. The same professional and regulatory neglect appears to have occurred in all other fluoridated countries, including New Zealand.
As far as fluoride being a “mineral” found naturally in water or food, that does not exclude it from being classified as a medicine and needing regulation. For example Sulfites occur naturally in foods and even in tap water but the FDA controls how this ‘natural’ inorganic compound is used in the food industry because it produces asthma in 5% of the population ( http://edis.ifas.ufl.edu/fy731 and http://www.itmonline.org/arts/sulfa.htm ).
Ken, as far as lack of control of dosage is concerned you say that it does not matter because “most elements like this have a sufficiently wide range of concentrations and intakes for efficacy that it is just ridiculous to treat them like powerful drugs which need accurate dosage.”
It is interesting that you focus on efficacy here and not on fluoride’s harmful effects. In fact, there is very little margin of safety between the dose (poorly defined as it is) that supposedly reduces tooth decay and the doses that have been documented to cause harm – both in the short term and over a lifetime of exposure. This point is often obscured by proponents because they prefer to discuss the matter in terms of concentration (mg/liter) rather than dose (mg/day). The former can be controlled the latter cannot.
People drink very different quantities of water. High water consumers can easily exceed the doses that have been documented to cause harm in human studies.
Let’s take a specific example to make this point clear. Xiang et al (2003a,b) found that the threshold level that reduced IQ in his study of Chinese children was 1.9 parts per million (ppm) or mg/liter. Let’s do a rough calculation of dose.
If these children were drinking two liters of water a day their dose was 3.8 mg/day (2 liters x 1.9 mg/liter); if they were drinking one liter per day their dose was 1.9 mg/day and if they were drinking half a liter of water per day their dose was 0.95 mg/day. Let’s round this off and say that the range in doses for these children was between 1 and 4 mg/day.
A child drinking water at 1 ppm would exceed these doses drinking from one to four liters per day. So some children in fluoridated communities will exceed these harmful doses, especially when you remember the other sources of fluoride that they are getting. There can be no doubt that these other sources can be quite large because as you yourself have admitted, these other sources probably explain why dental fluorosis rates in the US are four times higher than expected (41% versus 10%, CDC, 2010).
So there is no margin of safety here – even if we restrict ourselves to a consideration of just the range of doses expected in a large population. But as anyone who has studied toxicology knows we can’t stop there.
When we are extrapolating from the lowest observable dose causing harm in a small study group to define a safe dose for a large population we have to introduce a safety factor to take into account the wide variation in response to any toxic substance in the whole population. This factor is referred to as the intra-species variation safety factor. Its default value is 10. In other words if we were a regulatory agency doing its job we would have to divide the range of doses that caused harm (in this case 1-4 mg/day) by 10 to get a dose that we can confidently state is safe for the whole population. Thus we would not any child in the population to get a dose higher than 0.1 mg/day –and certainly not higher than 0.4 mg/day – in other words we would not want them drinking more than one large glass of water per day – to make sure that no child is exceeding a dose that could cause a lowering of IQ! Remember our task in public health is not just to protect the average child. We have to worry about the most vulnerable child.
I would also remind you that when the US National Research Council reviewed the toxicology of fluoride in water they concluded that several subsets of the US population were exceeding the US EPA’s safe reference dose for fluoride (the so-called ISIS value) of 0.06 mg/kg/day. This included high water consumers and bottle fed infants. See Figure 2.8 in their report (NRC, 2006).
Ken the way you deal with the other clumsy aspects of using the water supply to deliver medical treatment is that you argue that there is no difference between “naturally” fluoridated water and “artificially” fluoridated water and because of this lack of difference you argue that we shouldn’t worry about a) the fact that artificially fluoridated water is going indiscriminately to everyone and b) we shouldn’t worry that it violates the individual’s right to informed consent to medication.
First of all. There are some key differences between naturally fluoridated water and artificially fluoridated water. Usually when fluoride occurs naturally in the water it is accompanied by large concentrations of ions like calcium. The presence of the calcium can reduce the uptake of fluoride in the stomach and GI tract. No such protection is offered when the fluoridating chemicals are added to soft water.
Second, the average level of fluoride in most water supplies is about 0.1 ppm. This is about an order of magnitude lower than 0.7 to 1.2 ppm used in artificial fluoridation. That is not a small difference.
However, you raise an interesting point with this argument – what should we be doing about natural levels of fluoride in our water supplies?
It is clear that naturally occurring fluoride has caused a lot of health problems. Not only are millions of people being impacted by naturally occurring fluoride in areas which are endemic for both dental and skeletal fluorosis in India and China but more recent studies have shown that more subtle harm is occurring in their soft tissues as well, including lowered thyroid function, reproductive problems and lowered IQ. So I m not saying that naturally occurring fluoridated water is OK. The latter – depending on the level – may well be bad.
What I am arguing is that it is not wise to expose the whole population to deliberately elevated levels of fluoride in the water supply and we should not be forcing these increased levels on people who don’t want it increased, especially when there are more rational and acceptable delivery systems (which I will discuss later).
Ken I do not find your argument for ignoring the violation of the individual’s right to informed consent to this deliberate medical treatment convincing. You write: “Why demand ‘informed consent’ for situations where natural levels of fluoride have been ‘topped up’ and not require it for natural levels of fluoride – which in some situations may actually be higher than for fluoridated water supplies.”
If water is “treated” in order to “treat” people, then the people “treated” should be asked to give their informed consent to that “treatment.” If the water is “untreated” then there is no need to ask for their informed consent. However, in areas with fluoride levels above 0.1 ppm I believe that people should be warned about the potential harm that those natural levels may cause. Such warnings should be given especially to parents who bottle-feed their babies.
Just because fluoride occurs naturally does not make fluoride safe, just as naturally occurring arsenic is not safe. Looking to the future, as more and more scientists accept that modest levels of fluoride can cause harm, we might find ourselves being forced to lower the level of naturally occurring fluoride in water that is considered safe.
Currently, most of the world, including the World Health Organization has set a safe drinking water standard of 1.5 ppm. The US is the odd one out with a ridiculously high safety standard of 4 ppm. This was set in 1986, and according to whistle-blower at the US EPA, was set this high because of political pressures. In 2006, a US National Research Council panel concluded that this standard was not protective of health and recommended that the EPA perform a new health risk assessment to determine a safer drinking water standard (NRC, 2006). After 7 years this agency has still has not done this.
When regulatory agencies finally get to revisit the safe drinking water standard in the US and other countries – and do it free of political pressures from those who promote water fluoridation – we might find ourselves in a similar predicament that authorities have found with arsenic.
Because arsenic is a known human carcinogen the EPA has set the maximum contaminant level goal (MCLG) for arsenic at zero. This is the “ideal” level to protect the whole population from increased cancer risk. However, it is not a federally enforceable “standard,” instead, as the name (MCLG) implies, it is the ideal “goal.” The actual standard, or maximum contaminant level (MCL) is set at 10 ppb (10 parts per billion or 0.01 ppm). This is a compromise between the ideal and the costs to communities for getting close to this ideal goal. It would be prohibitively expensive to remove the arsenic down to zero.
With fluoride we might find ourselves in a similar situation. We might find that the background levels of exposure to fluoride from dental products, pesticides and the diet already exceeds the safe reference dose to protect against developmental harm. Thus the MCLG for fluoride in water would have to be set at zero. However, like arsenic the costs of doing this would be prohibitive and a compromise would have to be sought. Such a compromise might yield an MCL at around 0.1 ppm (note this is still 25 times higher than the level in mothers milk). Ironically, US water engineers were recommending an MCL of 0.1 ppm in 1939, because of concerns about dental fluorosis! But removing fluoride to this level would be very expensive for some communities and political forces might push for a higher value. However, regardless of the final MCL value, if the MCLG was set at zero, it would be very clear that society could no longer tolerate the deliberate addition of fluoride to the water supply supposedly to fight tooth decay.
In my opening statement I singled out three subsets of the population that shouldn’t be getting fluoridated water: bottle-fed babies, people with poor kidney function and people with outright or borderline iodine deficiency. Ken chose not to comment on the latter two groups. In my view we should be concerned about both groups whether they are drinking naturally occurring fluoride or artificially fluoridated water.
In your response Ken you downplayed any significance in the fact that the level of fluoride in mothers’ milk was naturally so low (0.004 ppm, NRC, 2006, p.40). I am surprised that you feel this way. Let me explain my understanding of this issue more carefully.
The levels of fluoride that end up “naturally” in our ground or surface water is a vagary of geology over which “nature” (or biological evolution) has little control. However, biological evolution has had control over how much fluoride it has inserted into normal biological functions. In the earliest days of evolution there was plenty of fluoride available in the sea (average 1.4 ppm) for nature to use in the biology of aquatic creatures but it did not to do so. Yes the fluoride may well have been sequestered in the shells or bones of these creatures and made shark’s teeth stronger, but no use was found in either the structure or function of enzymes, proteins, membranes, fats, nucleic acids or any of the other components of active biochemistry. Nor have the fluoride ions –unlike many other ions (e.g. potassium sodium, calcium or chloride ions) been used in messaging systems. By the time we reach the mammal we still find no use made of this ion in biochemistry.
So, when we look at the baby’s first meal and we find very little fluoride there, it appears entirely consistent with the notion that the baby does not need fluoride for healthy development. So why give it to them? Moreover, it might mean that nature deliberately kept the fluoride away from the baby’s delicate tissues during early development, which again is consistent with what we know about the toxicity of fluoride. Simply put: the fluoride ion is incompatible with many biological functions.
Is it not reckless then to knowingly expose the bottle-fed baby to 175-300 times more fluoride than the breast-fed baby? Especially, when we know that fluoride can harm at least one developing tissue in the baby –the growing tooth cells – at very low levels and cause the condition known as dental fluorosis. What makes us believe that while the fluoride is damaging processes in the growing tooth it is not doing the same to the growing bone. Afterall the teeth grow out of the bone.
It is particularly disturbing that very few studies probing the possibility of subtle effects of fluoride on other developing tissues in the baby before this practice was launched in 1945, or endorsed by the US Public Health Service in 1950.
Even when some warning signals emerged during the early trials they were cavalierly ignored by those hell-bent on promoting this practice. For example, when Schlesinger et al., 1956, published the results of the Newburgh-Kingston trial in 1956 they reported that young girls in the fluoridated community were menstruating 5 months earlier on average than the girls in the non-fluoridated community, and that the young boys were experiencing about twice as many cortical bone defects in the fluoridated community compared with the non-fluoridated community. However, no follow-up studies were recommended (see Chapters 9 and 10, The Case Against Fluoride). These red flags were ignored then just as the studies indicating a lowering of IQ associated with fairly modest levels of fluoride exposure, are being ignored or downplayed by proponents today.
I believe that my first three arguments stand. Fluoridating the whole public water supply is a clumsy and reckless because you can neither control the dose nor who gets the treatment and it is unethical way of delivering human treatment because you have denied the right of the individual to informed consent.
Since most dental researchers and even promoters of fluoridation like the Oral Health Division of the Centers for Disease Control and Prevention (CDC, 1999, 2001) concede that the predominant benefit as far as protecting the teeth is concerned, is topical (rather than systemic) i.e. fluoride works on the surface of the tooth enamel and not from inside the body. A more rational way of delivering this treatment would be to brush fluoridated toothpaste directly onto the teeth. This way you would minimize exposure to other tissues and not force it on people who don’t want it.
Argument 4. Is fluoride a nutrient?
Ken writes:
Connett’s point 4: This also reduces to semantics – how should “nutrient” be defined? Paul restricts his definition only to elements involved in “biochemical processes” – a definition confidently excluding the role of F in bioapatites – bones and teeth. Yet bones and teeth are important to organisms – so the strengthening of bioapatites, and the reduction of their solubility, by incorporation of fluoride is important.
What Ken has glossed over here is the fact that humans can have perfectly healthy teeth and bones without fluoride. Moreover, he does not acknowledge that at the same level that fluoride interacts with bioapatites it damages those bioapatites. It is highly questionable whether the hardening effect on bones warrants interference with the bone’s structure or the surrounding cells. This is what Dr. Hardy Limeback, one of the panel members of the NRC (2006) wrote about fluoride and bone:
Bone can ACCUMULATE up to 2500 ppm fluoride with fluoridation (we showed that in our Toronto vs Montreal study). The osteoclast cells are exposed to these huge concentrations (because they dissolve bone keeping the dissolved mineral under their dorsal surface through the use of hemidesmosome attachments and then they release that dissolved mineral into the bone extracellular fluid where nearby osteoblasts can also be exposed). In fact one of the theories why there is apoptosis of osteoclasts is the poisonous conditions they have to endure remodeling bone. It is also the reason there is a biologically-supported rationale for the bone cancer inducing effects of fluoride (personal correspondence, Nov 1, 2013).
As far as fighting tooth decay is concerned the most significant involvement of fluoride is the interaction with the surface of the enamel. You do not have to swallow the fluoride to have this interaction. In fact, even promoters of fluoridation now concede that it is this topical action, which is the predominant action of fluoride (CDC, 1999, 2001). Here the fluoride ion is interacting with a mineral. Such an interaction doesn’t warrant the title of a “nutrient” and certainly not an essential nutrient.
Ken suggests that, “Perhaps we can agree that F is at least a beneficial element, even if we can’t reach agreement on the use of terms like ‘nutrient’ and ‘essential.’”
Maybe Ken but you are now a long way from justifying the addition of this substance to the drinking water. I would argue that if used topically fluoride is a “beneficial element (substance)” in the same way that sun tan lotion is a “beneficial substance” when applied to the skin to protect us from damaging ultraviolet light or antiseptics are “beneficial substances” when added to soap to kill bacteria. But this does not make these substances nutrients and no one in their right mind would want to swallow them. Nor should they want to deliberately swallow fluoride.
5. Biochemical processes and fluoride
Ken writes,
“ Connet’s point 5: It is easy to cite literature references showing negative effects of fluoride but we should not ignore the conditions used. Most such studies refer to much higher concentrations than used in water fluoridation and this is also true for the review by Barbier et al, 2010 Connett cites.
Let’s not forget that community water fluoridation describes “topping up” fluoride concentrations to about 0.7 ppm F. Yet reviews of negative effects on biochemical process will quote studies which have used 50 ppm, 100 ppm or even greater concentration of F in drinking water. Opponents of fluoridation often seem completely oblivious of these huge differences in concentration when they present a long list of claims about the ill effects of fluoridation.”
First of all in biochemistry and toxicology it is not at all unusual – especially in animal experiments – to use high concentrations to probe toxic effects. The alternative of using lower concentrations is you are forced to use a very large number of animals in order to tease out an effect. This is very expensive. Furthermore, in the case of fluoride it is well known that you have to give 5 to 10 times as much fluoride to rats to reach the same plasma level as you need in humans.
I should add that there have been some animal studies where the level of fluoride used that has caused harm is very low indeed. This is particularly true in chronic studies. For example, Varner et al, 1998 fed rats 1 ppm in water for one year and found kidney damage, visible brain damage, a greater uptake of aluminium into the brain, and beta-amyloid deposits which have been associated with Alzheimer’s disease.
As far as human studies are concerned Ken should know it is the not the highest doses that cause harm which is of concern, but the lowest doses. For example, in the meta-analysis of 27 IQ studies carried out by the team from Harvard University (Choi et al., 2012), 26 of the studies found a lowered IQ in high fluoride villages compared to low fluoride villages (an average lowering of 7 IQ points). It is true that the range of the fluoride levels went as high as 11.5 ppm. However, the relevant fact is that in eight of the studies the high fluoride village had less than 3 ppm of fluoride in the well water. That leaves no adequate margin of safety to protect all our children drinking water at 0.7 ppm and getting fluoride from other sources. See also the discussion of Xiang et al (2003a,b) above where he found a threshold of 1.9 ppm.
Ken adds, “Another confusion readers often have with such reviews is the use of different units. The sensible reader must often apply a few conversion factors when checking the fluoride concentrations used in the reviewed studies. 1 mM = 19 ppm (or mg/L) for fluoride.”
Others may be confused by this but I am not and I do not understand why Ken brought this issue up.
Ken also adds, “Health authorities should not be swayed by populist naive interpretations of research.”
If Ken is directing that comment to me (or to the contents of the book I co-authored with two other scientists, The Case Against Fluoride), I find his comment insulting, especially to my co-authors who are meticulous in such matters. If he is directing it towards others, I see no reason for bringing it up in this exchange.
6. Naturalistic fallacies
Ken writes:
“Connett’s point 6: Sure, organisms evolve to fit the parameters of their environment. But to say “it is more likely that nature knows more about what the baby needs than a bunch of dentists from Chicago or public health officials in Washington, DC” is really not a good way of deciding this issue. Do we really want to argue that the situations in which marine animals evolved are the best to aim for in a society which has undergone so much cultural and intellectual evolution? Are we to reject the idea that society should task experts to consider possible approaches for our future by the argument that “nature knows best” and give up all rights for humanity to improve its condition? Do we really think that the environment that ancestral species experienced millions of years ago are necessarily the best for us today?
Modern humans live in environments offering a range of natural dietary fluoride intakes. We know that very low or very high intakes present problems for our bones and teeth. We should not avoid the problems this presents by saying “nature knows best.”
The very low levels of F in breast milk may have more to do the with inorganic role of F in animal bodies than any wisdom that “nature” has.
I think Ken has not appreciated the thrust of my argument here. So let me attempt to restate the case.
In your response Ken you have attempted to downplay any significance in the fact that the level of fluoride in mothers’ milk is naturally so low (0.004 ppm, NRC, 2006, p.40). I am surprised that you feel this way. Let me explain.
What levels of fluoride that end up “naturally” in our ground or surface water is a vagary of geology over which “nature” (or biological evolution) has little control. However, biological evolution has had control over how much fluoride it has inserted into normal biological functions. In the earliest days of evolution there was plenty of fluoride available in the sea (average 1.4 ppm) for nature to use in the biology of aquatic creatures but it did not to do so. Yes the fluoride may well have been sequestered in the shells or bones of these creatures and made shark’s teeth stronger, but no use was found in either the structure or function of enzymes, proteins, membranes, fats, nucleic acids or any of the other components of active biochemistry. Nor have the fluoride ions –unlike many other ions (e.g. potassium sodium calcium or chloride ions) been used in messaging systems. By the time we reach the mammal we still find no use made of this ion in biochemistry.
So, when we look at the baby’s first meal and we find very little fluoride there (0.004 ppm, NRC, 2006, p.40), it appears entirely consistent with the notion that the baby does not need fluoride for healthy development.
Moreover, this very low level in mothers’ milk might mean that nature deliberately kept the fluoride away from the mammalian baby’s delicate tissues during early development, which again is consistent with the known toxicity of fluoride. The fluoride ion is incompatible with many biological functions.
Is it not reckless then to knowingly expose the bottle-fed baby to 175-300 times more fluoride than the breast-fed baby? Especially, when we know that fluoride can harm at least one developing tissue (the growing tooth cells) at very low levels and cause the condition known as dental fluorosis.
It is particularly disturbing that very few studies probing the possibility of subtle effects of fluoride on other developing tissues in the baby before this practice was launched in 1945, or endorsed by the US Public Health Service in 1950.
Even when some warning signals emerged during the early trials they were cavalierly ignored by those hell-bent on promoting this practice. For example, when Schlesinger et al., published the results of the Newburgh-Kingston trial in 1956 they reported that young girls in the fluoridated community were menstruating 5 months earlier on average than the girls in the non-fluoridated community, and that the young boys were experiencing about twice as many cortical bone defects in the fluoridated community compared with the non-fluoridated community. However, no follow-up studies were recommended (see Chapters 9 and 10, The Case Against Fluoride). These red flags were ignored then just as the studies indicating a lowering of IQ associated with fairly modest levels of fluoride exposure, are being ignored or downplayed by proponents today.
7. Fluorosis
Ken argues that, “Proponents of fluoridation do acknowledge dental fluorosis is a negative, although minor, aspect of fluoridation.”
Paul’ response: Ken you may consider dental fluorosis to be a minor consideration, but that does not apply to all those children – especially teenagers – who are afflicted with this condition. Even mild fluorosis can be psychologically damaging.
Ken adds:
“ Opponents of fluoridation will often quote high values of the incidence of fluorosis which ignore the fact that much of it is “questionable” and/or “very mild.” These grades are really only cosmetic and usually can only be detected by a professional. Opponents may also hide the fact that the incidence of fluorosis for children living in fluoridated may often be the same as, or only slightly greater than, the incidence for children living in non-fluoridated areas.”
Paul’s response: What the CDC reported in 2010, was that 41% of American children aged 12-15 had some form of dental fluorosis over and above the questionable category. Of this 41%:
28.5% were in the very mild category, which according to Dean ranged from small white patches on the cusp of the tooth up to 25% of the enamel (of the affected teeth) impacted.
8.6% were in the mild category where between 26 and 50% of the enamel (of the affected teeth) is impacted. In testimony before Congress Dean testified that he did not believe that any mild dental fluorosis was an acceptable trade-off for lowered tooth decay.
3.6% were in the moderate or severe category where 100% of the enamel (of the affected teeth) is impacted.
Thus 12.2% of these cases are thus in the unacceptable categories. Moreover, these numbers are an average of children living in both fluoridated and non-fluoridated areas and thus it is reasonable to anticipate that the numbers in the fluoridated areas are significantly higher. In a review of the data collected in 1986-87 by the National Institute of Dental Research, Heller et al (1997) reported:
13.5% dental fluorosis prevalence in communities less than 0.3 ppm fluoride in their water
21.7 % dental fluorosis prevalence in communities with 0.3 – <0.7 ppm fluoride in their water
29.9% dental fluorosis prevalence in communities with 0.7 – 1.2 ppm fluoride in their water
41.4% dental fluorosis prevalence in communities with >1.2 ppm fluoride in their water.
Thus as far as the US figures are concerned it is not true that the dental fluorosis rates in non-fluoridated areas are the same or very close to the rates in fluoridated areas as Ken states. It is clear that the level of fluoride in the water remains a key factor. It is also the factor, which is most amenable to mitigation by a public policy change, i.e. lowering the level of fluoride added or ending water fluoridation altogether.
8. Nature of fluoridating chemicals
In this section Ken goes way beyond my stated concerns. I stated that the chemicals used are not pharmaceutical grade. That they are waste products from the phosphate fertilizer industry and that they contain arsenic, which is a known human carcinogen and thus will UNNECESSARILY increase cancer rates in fluoridated communities.
Ken writes:
Connett’s point 8: Anti-fluoridationists make wild claims about fluoridation chemicals. “They are industrial waste products, loaded with heavy metals and fluorosilicates are toxic and/or untested for toxicity!”
Claims of contamination with toxic elements are easily, and often, made but are never justified with any evidence. So lets look at the reality.
By-products that are used are not waste products – and surely we should aim for the efficient use of natural resources. The purchaser of any product will sensibly make sure it is suitable for their requirements – and these are rigidly defined for water treatment chemicals.
Suppliers are required to provide certificates of analysis and maximum values for contaminants in chemicals used for water treatment. Those regulations are determined from the maximum concentrations of contaminants allowed in the finished water for human consumption. Safety factors are also involved as well as allowance for contribution from other sources.
The table below contains analytical data for contaminants taken from certificate of analysis for the last batch of fluorosilicic acid used in the Hamilton, New Zealand, water treatment plant (see FSA column)…
Paul’s response. I will jump over Ken’s table here and focus on responding to the contaminant over which I expressed my concern: arsenic.
Ken writes: Arsenic in community water supplies
Paul raises the problem of arsenic and this provides an opportunity to put the contaminants in fluorosilicic acid into context. The table shows that As levels are typically very low in fluorosilicic acid used for water treatment (0.4 ppm As). In my article “Hamilton – the water is the problem, not the fluoride! ” I show that in the local Hamilton, New Zealand, situation the source water from the Waikato River is the major source of As in the finished water – several orders of magnitude greater than for than from treatment chemicals.
Anti-fluoridationists often rely on a recent paper by Hirzy et al. (2013) for their claims about As in fluoroslicic acid and it’s effect on the incidence of cancer. Zirny (sic) has since acknowledged errors in his calculations and described himself as embarrassed by them and his mistake about cancers. A petition to the EPA which used his data to argue against use of fluorosilicic acid in water treatment was rejected partly because of these errors (see Anti-fluoridation study flawed – petition rejected).
Paul’s response: As Ken has singled out a close colleague of mine –Dr. J. William Hirzy, a former senior scientist at the US EPA – I have asked him to respond to his comments. I should add that to his credit Dr. Hirzy was very quick to admit his mistake and apologize for it. However, it is not to the credit to the promoters of fluoridation to use this single mistake to throw out the rest of his important analysis and argument.
Dr. Hirzy writes:
November 1, 2013
Regarding arsenic contamination of fluorosilicic acid (FSA).
Perrott’s citation of “a certificate of analysis” (emphasis added) showing 0.4 ppm arsenic is not evidence of routine low levels of that contaminant in FSA. Based on 19 certificates of analysis from acid suppliers Cargill and Mosaic (including two reporting only “complies with NSF Std. 60”), 11 laboratory analyses from the Denver, Colorado water authority and 3 analyses from the City of Escondido California, the mean arsenic level in these 33 samples was 41.4 ppm. Upper and lower 95% confidence limits were 123 and 15.8 ppm, respectively. These values derived from assuming the two “complies with NSF Std 60” samples contained arsenic at ½ the Std. 60 allowable level of 380 ppm, namely 190 ppm. Without those two “Std. 60” samples, the mean and 95% upper and lower confidence limit values were 31.9, 62.3 and 15.5 ppm, respectively.
With respect to Perrott’s comments about the error in my paper comparing use of pharmaceutical grade sodium fluoride (U.S.P. NaF) and “by-product” fluorosilicic acid, my finding of the difference in lung and bladder cancer risks between the two agents was not challenged by the U.S. Environmental Protection Agency (USEPA).
Fluorosilicic acid with 30 ppm arsenic poses 100 fold higher risk for these cancer types than does U.S.P. NaF, whether one considers lifetime exposures or only annual exposures.
Perrotts’ claim that contaminant levels are rigidly defined and safety factors offer additional protection is hollow. Arsenic levels in water permitted under the “safety factor” provided by NSF Std. 60 actually allows for 1200 fold higher cancer rates that use of U.S.P. NaF would cause – another finding in my paper not challenged by USEPA.
Furthermore the City of Wellington, Florida proudly announced in its Annual Drinking Water Quality Report for 2009 “…that arsenic is added to the drinking water (approximately 1.1 micrograms per liter) as part of the fluoridation process…”, which is well over the NSF Std. 60 permissible level. Who is minding the store? Of what real value is that standard?
For Perrott to claim, regarding the permitted arsenic levels that, “These concentrations are extremely low, meaning that the final concentrations in the finished water are insignificant…” ignores basic toxicology insofar as low levels of chronic exposure to arsenic have been shown in my paper – and not challenged by USEPA – to result in 100 to 1200 fold higher cancer rates than would be caused by use of U.S.P. NaF. Likewise, NSF’s assertion quoted by Perrott, viz. “…In summary, the majority of fluoridation products as a class, based on NSF test results, do not contribute measurable amounts of arsenic, lead, other heavy metals, radionuclides, to the drinking water….” is also a meaningless attempt at reassuring the public that upon dilution, FSA’s contaminant levels can cause no harm. In USEPA’s response to the referenced petition the Agency notes that measurable levels of arsenic were detected in fluoridated water during monitoring from 2007 to 2011, with mean and maximum levels being 0.15 ppb and 0.6 ppb as reported by NSF. So much for NSF’s public relations declaration of “no measurable amounts of arsenic…in drinking water.” At 0.15 ppb arsenic, the difference in cancer rates between FSA and U.S.P. NaF is actually more than 200 fold – twice as high as the levels shown in my paper.
Perrott’s citation of a similar public relations declaration by the New Zealand Waste Water Association is likewise without merit.
Recent calculations on the cohorts of people in the Unites States who have been exposed to 0.15 ppb arsenic since 1965, 1967, 1975, 1989, and 1992, using USEPA’s risk and cost data (which were used in my referenced paper and not challenged by that agency in its response to the referenced petition) show that by 2020, there is an expected increase of 2000 lung/bladder cancers in these cohorts attributable to arsenic in drinking water, costing $7 billion in 2001 dollars.
If Perrott’s claim that using the phosphate industry’s waste acid for ingestion in fluoridated water is merely an “efficient use of natural resources” is valid, then why not use neutralized FSA in fluoridated tooth paste and mouth wash?
The “efficient use of natural resources,” viz. FSA in the U.S. is reflected in sale of about 280,000 tons of 23% assay FSA in 20111, which at an average price of $2000/ton,2 resulted in transfer of taxpayers’ cash of over $500,000,000 to phosphate producers in 2011 alone. And over 99 percent of that purchased phosphate waste was, and is now, flushed down toilets, shower drains, and the like.
Water fluoridation, especially with FSA in the U.S., is not at all about improving dental health; it is rather about U.S. taxpayers paying phosphate producers billions of dollars for the privilege of having our public drinking water systems used to dispose of an acid that would otherwise have to be managed in a hazardous waste facility, and thereby improving the bottom lines of phosphate producers.
J. William Hirzy, Ph.D.
References
1. USGS Minerals Yearbook 2011. Fluorspar http://minerals.usgs.gov/minerals/pubs/commodity/fluorspar/myb1-2011-fluor.pdf accessed 11/01/2013
2. http://www.scribd.com/doc/18235930/NYC-Fluoridation-Costs-2008-Feb-2-2009-Letter-Page-1 accessed 11/01/2013
9. Fluoridation data around the world
Ken writes:
“Connett’s point 9: Yes, a few countries do not fluoridate their water community supplies for political reasons, but decisions against water fluoridation can depend on a range of factors including size and centrality of water treatment plants, widespread use of bottled water, naturally sufficient water fluoride concentrations, etc.”
Paul’s response:
It is not just a few countries but the vast majority of countries that do not fluoridate their water. About 30 countries have some cities fluoridated, but only 10 have more than 50% of their populations drinking artificially fluoridated water.
Your explanations for why the vast majority of countries do not fluoridate reads more like self-serving political spin than the reality. On our website we have offered explanations from spokespersons from many of the countries that have stopped or never started to fluoridate their water (see 50 Reasons to Oppose Fluoridation). There are two main reasons given: a) they do not want to force fluoridated water on people who don’t want it and b) they are not satisfied that all the health concerns have been addressed. From what I can see none of them give the explanations that you have offered. Perhaps you can provide statements from some of the non-fluoridated countries that support the claims you have made in their name.
In response to the plots of tooth decay versus time as presented by Paul by Cheng et al (2007), Ken writes:
“while the plots do show improvements in oral health for countries irrespective of fluoridation they say nothing about the effect of fluoride. Simple comparison of countries obscures all sorts of effects such as differences in culture, history, social and political policies, etc. Such plots are also influenced by changes and differences in dental treatment and measurement techniques.”
Paul’s response:
Certainly many factors influence tooth decay. There is bound to be a lot of noise in a large data-set. However, what is striking to me – and others – is that the presence of fluoride in the drinking water does not appear to rise above this noise. On the face of it the relationship between fluoridation and tooth decay appears to be weak at best. Especially compared to two other relationships, which are very strong: the relationship between fluoride levels in water and dental fluorosis and the relationship between tooth decay and income levels.
Ken writes:
However, there are some within country data within the WHO data set Cheng et al used which can give a better idea of the beneficial effects of fluoridation. This plot shows the results for the WHO data for Ireland. A clear sign that fluoridation has played a beneficial role.
Paul responds:
Since being invited by the Irish government to testify before its Fluoridation Forum panel in 2000, I have not been impressed with the objectivity on this issue by the pro-fluoridation dental researchers there. Thus I would not exclude the researchers’ bias influencing this result.
Ireland has had mandatory fluoridation since 1963. If this comparison between the Republic of Ireland and Northern Ireland was legitimate it would have been more impressive and more appropriate to have compared the health status of the two populations. Like many fluoridated countries (including Australia, Canada, New Zealand) very few health studies (if any) have been conducted in Ireland comparing the health of fluoridated and non-fluoridated communities. Particularly absent are studies that have used the severity of dental fluorosis as a biomarker of exposure to investigate various health and development problems in children, such as bone defects and fractures, onset of puberty, thyroid function and lowered IQ.
10. Political and scientific arenas.
Ken wrote the following in response to my comment about the way that many proponents of fluoridation use endorsements of fluoridation by government agencies and professional bodies to win their case for fluoridation with the general public instead of using the primary scientific literature. I am glad that Ken has not done that in his responses.
Ken adds:
The debates around fluoridation involve both scientific and political issues. Inevitably this leads to the separate issues being mixed. I find, for example, that attempts to discuss the ethical aspects always get diverted into differences in understanding of the science. For example the paper Ethics of Artificial Water Fluoridation in Australia by Niyi Awofeso is meant to be a description of the ethical issues. However, it assumes mistaken ideas about the science – that fluorosilicate species are present in fluoridated drinking water. Without the correct science it is so easy to end up with invalid ethics.
My response: This comment does not respond to my concerns here. I will leave Professor Awofeso to respond.
Ken writes: “Appeal to authority is also a problem. Connett does this, for example, in his reference to Prof. James Summer, Nobel prize winner.”
Paul responds: I think this is a very weak argument. I simply pointed out that some of the earliest opponents of fluoridation were biochemists who had used fluoride to poison enzymes in their experiments. James Sumner was a distinguished example. Citing the fact that he won a Noble prize for his work on enzyme chemistry simply underlines the fact that he knew something about the subject.
Ken writes:
I feel that opponents of fluoridation commonly rely more on confirmation bias than critical and objective assessment when referring to the scientific literature.
There is also a reliance on conspiracy theories and poisoning of the well. We have seen personal attacks on scientists and health authorities in New Zealand when they have spoken up to defend the science. Childish name calling, accusations of being paid to make incorrect claims, charges of being “shills” for industry, etc. This is simply “playing the man and not the ball” and makes good faith discussion of the science impossible.
Paul responds: If Ken is referring to me here then let him give specific examples to which I can respond. If he is referring to others I think they are out of place in this exchange with me.
We made a point in our book, and also in public presentations, to disavow the more nutty conspiracy theories espoused by some opponents of fluoridation. We do not believe that the evidence that Hitler used fluoride in the concentration camps sufficient to convince a historian. Meanwhile, in our view it is offensive to the many well-intentioned dentists and others who promote fluoridation to be associated with such a horrendous person. Nor do we believe that fluoridation is an attempt to dumb down or limit the world’s population. However, promoters of fluoridation should not be surprised that some people are trying to come up with a rational explanation for why certain governments are behaving so irrationally promoting this practice. They continue to do so long after the science has shown that swallowing fluoride does not reduce tooth decay, that there are many risks involved and that there are clearly alternative ways of fighting tooth decay, which have been demonstrated in the vast majority of countries, which do not choose to force their populations to drink artificially fluoridated water.
Ken writes: This even gets into peer-reviewed scientific literature. The authors of the paper Connett refers to, Cheng et al 2007, do this when they accused one side, that of health authorities, of “questionable objectivity.” Pots and kettles?
Paul responds: Hardly. Cheng et al 2007 actually question the objectivity of both sides in this debate. However, sadly, they were not out of place questioning the objectivity of spokespersons for many health agencies in fluoridated countries, especially in Australia, Canada, Ireland, the UK and the US. It is one thing for individuals who believe strongly in fluoridation to present one-sided arguments in favor of fluoridation, but as tax-payers we have the right to expect that health officials (who are paid by the taxpayer) would present the case objectively. Frequently they do not and resort to outrageous spin tactics. For example, Queensland Health officials, when the government there was about to introduce mandatory fluoridation in 2007, claimed that there was a 65% less tooth decay in children from fluoridated Townsville compared to non-fluoridated Brisbane. However, when the data was checked it was discovered they had a) cherry picked the data (they reported the tooth decay for one age only, 7-year olds) and b) by presenting the data as a relative saving rather than an absolute saving they deliberately misled the public into thinking that the saving was highly significant when it wasn’t. The difference amounted to 0.17 of one tooth surface! If they had chosen the data for 9-year olds the saving was 0.10 of one tooth surface with a relative saving of 20%. To make matters worse they showed two photos: one for a child that had grown up in a fluoridated community (here the teeth were perfect) and one from a child from a non-fluoridated community (here the teeth were atrocious). 
Ken writes:
All of these problems are probably inevitable for an issue like this where political and ideological interests operate. But they are an anathema to proper scientific consideration.
Professor Gluckman, the NZ Prime Ministers Chief advisor on Science commented that fluoridation controversies were an example of science being a proxy for values/political issues. This leads to misrepresentation of the science, cherry picking of data, and relying on confirmation bias and google for literature searches. Ideology and values are the motivating factors but a caricature of science is used in the debate.
Good faith discussion of the scientific issue around fluoridation requires much more objectivity than is usually demonstrated by the opponents of fluoridation.
Paul responds: Again I am not sure if Ken is aiming this criticism at me or the book I co-authored. If he is then I request that he shows examples from this text or my public presentations that support his claims.
I entered this excercise hoping that we could have an exchange in which we would have a “good faith discussion of the scientific issues.” I am certainly prepared to do that and I urge Ken to do the same. It would help if he stuck to addressing the arguments I raise and not to muddy the waters with the arguments, beliefs and behavior of others.
Postscript.
I am traveling in Europe at the moment and it might be a few days before I have put together part 2 of my side of this exchange titled, “The evidence that swallowing fluoride reduces tooth decay is very weak.” Those who want a head start on this can consult chapters 6-8 in The Case Against Fluoride.
Meanwhile, I would like to leave this suggestion for Ken and other promoters of fluoridation to consider. It is partly based on the arguments of Dr. J. William Hirzy above. Let’s assume for the sake of this argument that you prevail Ken and persuade us that swallowing fluoridated water works and was actually superior to applying fluoridated toothpaste directly to the teeth. Here is a way that you could secure that goal more effectively, more precisely and without infringing on the individual’s right to informed consent to medical treatment and without giving up the central dogma of fluoridation.
Why not make one-liter bottles of fluoridated water freely available in dental offices, pharmacies, clinics and supermarkets? These could be provided free for low-income families. In this way, you could afford use pharmaceutical grade sodium fluoride (because you would only need much smaller quantities); you could control the dose by telling people to drink only one bottle a day and you would not be forcing it on people who didn’t want it. Nor would you be wasting large quantities of industrial grade fluoride in other applications such as flushing the toilet nor would you be putting most of it into the environment.
Back to you Ken.
References:
CDC, 1999. Centers for Disease Control and Prevention, “Achievements in Public Health, 1900–1999: Fluoridation of Drinking Water to Prevent Dental Caries,” Mortality and Morbidity Weekly Review 48, no. 41 (October 22, 1999): 933–40, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm.
CDC, 2001. Centers for Disease Control and Prevention, “Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States,” Morbidity and Mortality Weekly Report 50, no. RR14 (August 17, 2001): 1–42, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
CDC, 2010. Beltrán-Aguilar,Prevalence and Severity of Dental Fluorosis in the United States http://www.cdc.gov/nchs/data/databriefs/db53.htm
Cheng et al. 2007. Adding fluoride to water supplies. BMJ 335:699
http://www.bmj.com/content/335/7622/699?tab=responses
Choi AL, Sun G, Zhang Y, Grandjean P. 2012. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect 120:1362–1368.
See also
Anna L. Choi, Philippe Grandjean, Guifan Sun, Ying Zhang, 2012. Developmental Fluoride Neurotoxicity. Choi et al. Respond. Environ. Health Perspect. 121:a70–a70 (2013). http://dx.doi.org/10.1289/ehp.1206192R [Online 1 March 2013]
Connett, P., Beck, J and Micklem HS. The Case Against Fluoride. Chelsea Green, White River Junction, Vermont, 2010.
K. E. Heller, S. A. Eklund, and B. A. Burt, “Dental Caries and Dental Fluorosis at
Varying Water Fluoride Concentrations,” Journal of Public Health Dentistry 57, no. 3 (1997): 136–43.
NRC, 2006. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards (2006) http://www.nap.edu/catalog.php?record_id=11571
E. R. Schlesinger, D. E. Overton, H. C. Chase, and K. T. Cantwell, “Newburgh-Kingston Caries-Fluorine Study XIII. Pediatric Findings After Ten Years,” Journal of the American Dental Association 52, no. 3 (1956): 296–306.
J. A. Varner, K. F. Jensen, W. Horvath, and R. L. Isaacson, “Chronic Administration of Aluminum-Fluoride and Sodium-Fluoride to Rats in Drinking Water: Alterations in Neuronal and Cerebrovascular Integrity,” Brain Research 784, no. 1–2 (1998): 284–98. Extended excerpts at http://www.fluoride-journal.com/98-31-2/31291-95.htm.
Q. Xiang, Y. Liang, L. Chen, et al., “Effect of Fluoride in Drinking Water on Children’s Intelligence,” Fluoride 36, no. 2 (2003): 84–94, http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf .
Q. Xiang, Y. Liang, M. Zhou, and H. Zang, “Blood Lead of Children in Wamiao-Xinhuai Intelligence Study” (letter), Fluoride 36, no. 3 (2003):198–99, http://www.fluorideresearch.org/363/files/FJ2003_v36_n3_p198-199.pdf .
Anyone wanting to follow the debate and/or check back over previous articles in the debate can find the list of articles at Fluoride Debate.
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