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May / June 2003

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OPINION - Confusing Cause and Effect


Incorporating

Founder : Len Abrams
Water Policy International

Contents

Introduction
The debate
The effects of fluoridation
The case of China
The case of Rand Water in South Africa
A violation of rights?
Conclusion
Links

 

Introduction

Fluoride is a natural mineral occurring in all water sources and is also one of the most commonly used industrial chemicals. High-octane petrol is refined by hydrofluoric acid, freezers and air-conditioners require fluorocarbons and chlorofluorocarbons, and computer screens, fluorescent light bulbs, semiconductors, plastics, herbicides, and fluoride toothpaste all make use of this chemical. However approved and utilized in industry, fluoride stirs heated controversy when it is added to public water.

Fluoridation is the practice of adding fluoride to public water in order to reduce dental decay, especially in young children. Usually a compound containing or producing fluoride is added to water in order to reach a level of one milligram of fluoride ion per litre (1 part per million). A Maximum Contaminant Level (MCL) was set in 1986 by the EPA at 4 ppm to avoid skeletal fluorosis, a bone-decaying disease. Fluoridation has been under scrutiny for the past 50 years and has come under severe criticism from many quarters in the last decade. Critics of fluoridation say that past research is biased or has been shown to be false and outdated by recent research, while proponents of fluoridation cite their own research and insist that fluoridation has proven itself useful and safe in preventing dental decay. Both sides have creditable supporters, and the issue has no straightforward solution. Aside from the question of whether fluoridation is a scientifically proven health benefit to people or not, another debate revolves around whether the rights of individuals are violated when they are forced to partake of fluoridated water. Some have gone so far in protest as to acquire their own sources for unfluoridated water, and many feel that because fluoride is so easily attainable and its benefits so hotly disputed, the public water supply should be free of fluoride.


The debate

By 1992 nearly 60% of Americans drank from fluoridated water systems. Fluoridation began in the US in 1945 and has since been implemented in almost every major city. In Europe, the 1980 European Water Quality Directive imposed a maximum amount of fluoride that water could contain, and many countries have fluoridated their water systems. Where piped water is unavailable, many have turned to salt fluoridation to provide a fluoridated water source. Over thirty countries have utilized this including Switzerland, Columbia, Jamaica, Costa Rica, Mexico, France, Spain and Germany.

In Britain, over three million people have dental fluorosis. While only 10% of the UK has fluoridated water systems, many organisations are advocating further fluoridation. The British Fluoridation Society sees fluoridation as a way to prevent tooth decay and aid the lower classes who experience its worst consequences. They affirm that over half of all the health authorities in England have recommend public fluoridation since 1985, yet none have been heeded. And while admitting that some dental fluorosis is inevitable with the fluoridation of water, they say that mild fluorosis is detectable only by dentists and severe fluorosis is a rare occurrence in the UK. But the National Pure Water Association, an anti-fluoridation organisation based in Britain, disputes this analysis of fluoridation and campaigns against further fluoridation in the UK.

The American Dental Association has published a booklet and many articles on the usefulness and benefits of fluoridation. The ADA claims that fluoride, when ingested, systemically prevents tooth decay while teeth develop, and topically when applied to mature teeth. Fluoride is said to strengthen teeth and make them decay-resistant as it is absorbed onto the surface of teeth: enamel is made less soluble, plaque organisms reduce their ability to produce acid, and tooth enamel undergoes remineralisation in areas where acids have demineralised it. The ADA supports community water fluoridation and recommends dietary fluoride supplements for children aging from six months to sixteen years old living in non-fluoridated areas. The ADA's booklet and facts are well documented and cite various studies that support its claims, yet it has also undergone criticism, and The Health Way House (HWH), an organisation out of San Marco, California, has published a full systematic rebuttal of the booklet titled 'The Fluoride Debate: A Response to the American Dental Association's Booklet Fluoridation Facts'. In response to the ADA's claim that fluoride is a natural element found in water, the HWH notes that 90% of public drinking water is fluoridated with industrial grade hazardous wastes captured in the air pollution-control scrubber systems of the phosphate fertilizer industry, called silicofluorides. They also quote a NY Times article where cancer research scientist Dr. Ludwik Gross states that fluorine is a toxic poison and harmful, even when ingested in minimal amounts.

The effects of fluoridation

Pictures of dental fluorosisThe harmful effects of fluoride are, again, disputed. Dental fluorosis is the most common harmful effect of fluoride, and occurs during the early development of teeth. It is usually complete by the end of a child's fifth year and results in the discoloring of teeth. Once enamel has finished developing, dental fluorosis cannot occur and the EPA in conjunction with the US Surgeon General has declared that fluorosis is no more than a cosmetic effect; teeth may in fact be stronger having undergone fluorosis. In a mild case, fluorosis is hardly detectable and appears as slight mottling of the teeth. In a severe case, fluorosis leaves permanent dark patches on teeth. The National Institute of Dental Research completed a survey in 1987 concluding that 22% of children examined had dental fluorosis, 94% of whom had moderate cases. The ADA as well as the National Center for Fluoridation Policy and Research asserts that the trade off between mild fluorosis and severe dental decay is well worth it. The US Centers for Disease Control reports that fluoridation has an 80:1 cost benefit ratio: for every $1 spent on fluoridation, $80 are saved in dental treatment costs. But these figures are highly disputed by others. Professor Sheldon of the National Alliance for Equity in Dental Health chaired the Advisory Panel for the British government's review of water fluoridation. The review of fluoridation was conducted by the NHS Centre for Reviews and Dissemination, and the research is noteworthy because it was completed by an independent research group conforming to the highest international scientific standards. After misleading press releases were made by the British Dental Association, British Medical Association, National Alliance for Equity in Dental Health and the British Fluoridation Society, Professor Sheldon responded to correct the misleading briefings. He says that while water fluoridation is effective at reducing dental caries, the studies were of moderate quality and the estimated benefit, described as 'massive', was only about 15%. Dental fluorosis was found at high levels and effects were more than cosmetic. The cost-effectiveness of water was inconclusive as was the overall safety of fluoridation. Sheldon notes that the rigor of this review resulted in less conclusive results than previous studies. Despite the abundance of studies carried out over past decades, the review team felt that reliable evidence fit to inform public policy was sparse and inadequate. Fluoridation could not be determined as veritably safe and more research is necessary to inform any kind of responsible public policy.

Other critics of fluoridation do not speak so softly. Fluoridation has been labeled 'A 50 Year Old Blunder and Cover-up', and has been thought responsible for numerous adverse health effects. If water is fluoridated in order to ensure that people receive an adequate amount of fluoride, what happens when too much water is ingested? The amount of water the public drinks is obviously uncontrollable and some people will invariably consume large amounts. Some claim that excessive fluoride accumulates in the biosphere and increasingly shows up in soil, food, and water without any deliberate fluoride addition. Because no disease can be shown to be caused by its deficiency, fluoride cannot be an essential nutrient to humans, yet neither have fluorosis and other unwanted effects been sufficiently linked to fluoride to convince the public that fluoridation is a bad idea.

The case of China

In September of 2001, a conference took place in China sponsored by the Chinese Ministry of Health and the World Health Organization (WHO). In the largest conference of the society, 200 scientists from China and almost 100 from 15 other countries met to discuss widespread fluorosis in China. Out of a population of 100 million, 43 million have dental fluorosis and 2.4 million, skeletal fluorosis. Fluoride poisoning comes from naturally high fluoride in drinking water, burning of fluoride-rich coal, and fluoride in food. Levels of fluoride in water are estimated to range from 1.5 to 9 ppm. In the US, the Department of Health and Human Services (DHHS) estimated in 1991 that individuals in communities where 1 ppm fluoride was in the water were ingesting 1.58 to 6.6 mg per day. These startlingly high figures have been connected to increasing number of hip fractures in the elderly. Many scientists and dentists support these connections, and this has led to increased opposition to fluoridation. The Fluoride Action Network (FAN) was formed in 2001 by like-minded activists and scientists with the goal to end fluoridation and minimize exposure to fluoride. They specifically aim to refute claims made by the ADA and Centers for Disease Control regarding the safety of fluoride. The group originated from an Internet newsletter from Paul Connett, a Professor of Chemistry at St. Lawrence University in Canton, New York, who became increasingly distressed at what he considered misleading and dangerous information spreading about the benefits of fluoridation.

The case of Rand Water in South Africa

In September 2000 the Department of Health legislated in respect of fluoridation of potable water in South Africa. Fluoridating potable water is considered by some as being unconstitutional in that the use of fluoridated water is forced on consumers who have no choice in the matter. During the past 5 years water boards, and Rand Water in particular, made several submissions to the appropriate ministries. A key aspect of these submissions is that Rand Water sought indemnity from the Department of Health against any claims arising from the fluoridation of water that may give rise to possible health implications or impact on the environment or industrial water users. The Department of Health responded that any claims regarding possible health implications or impact on the environment on industrial water users must be made against the Minister of Health.

The most common-sense reasoning to date for not fluoridating drinking water supplies, especially in developing countries. Editor

Fluoride, in the correct concentration, is effective in protecting teeth and is especially necessary in children within the 1 to 10 year age group. The rationale for supplementing potable water with fluoride is that South Africans, particularly those in rural areas who do not use fluoridated toothpaste, would benefit. Given that most people in rural areas do not receive piped water the benefit will not reach the target population. Furthermore only 0,65 % of the water produced by Rand Water is used for drinking purposes. This equates to 19 000 m3 of the 3 000 000 m3 sold daily, which means that 99,35% or R25 000 of the direct costs (chemical costs per day) is not effectively utilised for the intended purpose. The question thus arises, how cost effective is this method of augmenting dietary fluoride intake? Rand Water will introduce 1 500 kg of fluoride daily into potable water.

Approximately 1000kg of fluoride per day will find its way into water streams. This may have long-term negative consequences on the water environment. The cost of de-fluoridation can amount to as much as R5.50/m3 if reverse osmosis is used and the cost of using alternative methods of removing fluoride from water such as the use of activated aluminia is estimated at R1.80 m3 Who will be expected to pay this cost?

Rand Water does not consider fluoridation of water as the highest priority for South Africa. In fact, the total estimated national cost of R30 million per annum should rather be used to extend the provision of free water to South Africans. Based on Rand Water’s experience the R30 million could extend water provision to some 300 000 unserved consumers. Considering the above costs and the large sector of the targeted population, that will not be reached through water fluoridation, the question raised is whether alternative methods of fluoride augmentation such as supplementing milk, sugar, salt, maize meal have been thoroughly investigated. These may have a much better chance of reaching the target population, especially if fluoridated foods are subsidised such that it is cheaper than non-fluoridated foods. (See the full article)

A violation of rights?

Another issue involved in the fluoride debate regards the autonomy of individuals. This question is related but separate to the scientific disputes over the benefits of fluoridation. It is related because it is taken into account along with the results of scientific research in determining public policy. But it is separate because aside from the benefits or harm that fluoridation might bring, a moral question exists pertaining to the way in which individuals retain their freedom. Bioethics is the examination of the moral questions and problems that result from biological and scientific research and involve the well being of humanity. If science concludes that something is beneficial to the human body, should the government legislate and require people to have it? No one ostensibly desires the government to enforce children to eat their daily dose of broccoli, but some fear that we are moving this way. This question would remain even if fluoridation were universally agreed upon to be healthy. Everyone agrees that vegetables are healthy, but people want their freedom to stick to junk food. Many groups opposed to fluoridation argue that the public should not be forced to pay for something they do not want, or do not even know they are getting. Sources for fluoride are numerous and easily attainable without fluoridating drinking water.

This plea is intensified by the contradictory conclusions of fluoridation research. Many label the research of the past 50 years as obsolete, but others cite it as building evidence of benefits. Science, to any student of history, is notoriously fickle in its conclusions. What will our research show 50 years from now? If we judge on past examples, the majority of what is thought to be credible now will be consigned to the rubbish bin in the following generation. Unfortunately, the moral side of the debate rarely makes it into the public discussion. The premises are quietly assumed and the legislation passes mostly unnoticed. Public ignorance of fluoridation 'benefits' is one of the pro-fluoridation groups main arguments for it. They cite studies showing tooth decay is worse among the lower classes, classes that would greatly benefit from fluoride in their public water-poor people hardly have the luxury of concerning themselves with fluoride supplements. Thus fluoridation becomes a type of aid program to the less privileged, and this benefits everyone because less public money will have to be spent on tooth decay. For those against fluoridation regardless of its benefits, this begs the question because the government should not intrude on personal freedom in the first place; they would object to public money being spent on dental care anyway. But most people against fluoridation do not reject the limiting of personal autonomy per se. The problem is the uncertainty of the benefits of fluoride. What 50 years ago promised to rid the next generation of much lamented dental decay has come under shadows of doubt.

Conclusion

The endemic problem in China is converse to that of the rest of the world-they know they have too much fluoride. The debate continues over how much fluoride is too much and whether water fluoridation is an acceptable way of delivering fluoride to communities. Perhaps the most perplexing element of the discussion is the depth of support on both sides. Many agencies still support and endorse fluoridation with research in-hand, while increasing opposition unites to oppose and discontinue it. It seems the most fair-minded, informed opinions assert that the benefits of fluoride, both financial and medical, are as of yet inconclusive and require further high-standard, independent scientific research. Unfortunately, as many people already drink fluoridated water, the research cannot be conducted too quickly. In the meantime, representatives of communities ought to make the debate known to their people and pressure health organisations for further research.

 


Written by Jerry Owen


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