Response to British Medical Journal article: Adding fluoride to water supplies. Cheng et al. BMJ.

2007; 335: 699-702 (6 October) http://www.bmj.com/rapid-response/2011/11/01/fluoridation-time-reevaluate

Fluoridation: Time to reevaluate

Bill Osmunson DDS, MPH, Cosmetic Comprehensive Dentist Bellevue, Washington 9804

19 October 2007

The BMJ needs to be commended for further opening the scientific debate on fluoridation. For the first 25 years of dental practice I promoted the addition of fluoride to water, in part because I thought I could see the difference between those on fluoridated water and those without. Unfortunately, I was actually comparing socioeconomics rather than fluoridation. As more patients have come in requesting extensive cosmetic dentistry, sometimes costing tens of thousands of dollars to correct their dental fluorosis, I decided it was time to look at the sources, dosage, efficacy, and benefits of ingested fluoride. Looking at the current literature was like a knee in the gut.1 FLUORIDE EXPOSURE: Clearly fluoride exposure has increased over the last 60 years. Dental fluorosis is up 50% to a third of children. More dental and medical products and medications contain fluoride. Permitted residue levels from fluoride based pesticides and post-harvest fumigants (ProFume, Dow Agro Chemical) have significantly increased in just the last decade. Mechanically deboned meat can be much higher in bone/fluoride content. Grape products and some tea have high levels of fluoride. Apparently no agency is the legal intermediary, the doctor, responsible for monitoring the publics total exposure to fluoride. Some people are more sensitive to chemicals and unable to excrete excess fluoride. Synergistic effects from groups of chemicals are relatively unknown. It appears any benefit of fluoride is from a topical application and not from ingested fluoride. BENEFITS OF FLUORIDATION: Evidence for whether an intervention works when applied in the community at large is referred to as its effectiveness. . . . Effectiveness studies more accurately reflect results that may be expected from the implementation of interventions.2 If fluoride actually provides a life time reduction of dental decay, certainly after 60 years of fluoridation we should see clear evidence of effectiveness. Unfortunately, comparing developed countries finds all have reduced dental decay to similar levels regardless of fluoridation. Comparing states within the USA based on the percentage of the population fluoridated finds no improved dental health or reduction of decay regardless of the percentage fluoridated. Comparing similar states such as Washington State (59% fluoridated) with Oregon State (19% fluoridated) actually finds slightly better dental health in the less fluoridated Oregon. Comparing counties within states finds similar oral health, with similar socioeconomics, regardless of fluoridation.3 Studies on fluoridation have not included the confounding factor of delayed tooth eruption or looked at life time benefits.4 It is a flawed assumption to expect fluoridated children with fewer cavities will "therefore" have a life time of fewer cavities. Several studies have actually found an increase in dental decay and tooth loss with fluoridation. Without clear, undisputed, life time benefits from fluoridation, any risk or expense is unacceptable. Communities have stopped fluoridation with no increase in dental decay.5 The experiment of fluoridation is currently being promoted without good scientific and ethical review of continued life time benefits. The US National Academy of Sciences 2006 report confirmed potential benefits from fluoridation are during the development of the tooth, up to about age 8. It makes no sense to have a lifetime uncontrolled dose of fluoride for everyone when the potential benefits are only up to age 8. Lifetime exposure must be considered. DENTAL RISKS OF FLUORIDATION: As a Cosmetic Dentist, it is not uncommon to have patients receive gorgeous porcelain veneers to correct their dental fluorosis, white and brown damage from too much ingested fluoride. Costs range from several hundred dollars to well over $25,000 and need to be retreated every 10 to 20 years for life time costs which may exceed $100,000 per person. With a third of children having dental fluorosis, the true costs for cosmetic damage to teeth alone is in the trillions of dollars. A side effect seldom raised by cosmetic dentists. Certainly most will not seek treatment, but the public liability for damage is significant. Public Health Dentists seldom provide cosmetic dentistry and therefore under rate the increased dental damage from fluoridation. MEDICAL RISKS OF FLUORIDATION: Many committees reviewing fluoridation are composed of Dentists. It is not in the purview of Dentistry to diagnose thyroid, hormonal, skeletal, kidney, liver, brain, skeletal disorders or cancers outside the oral cavity. Epidemiologists, Toxicologists and Medical Professionals unwisely rely on their Dental counterparts to diagnose safety for body organs from fluoridation and Dentists would be practicing outside their scope of training and licensure to appropriately weigh the gravity of medical side effects. Historic ground was covered in the USA when scientists opposed to fluoridation were permitted on the National Academy of Science 2006 report to the US Environmental Protection Agency which unanimously found the EPAs Maximum Contaminant Level was not protective.6

The US Center for Disease Control and American Dental Association have cautioned infants should not be given fluoridated water or fluoridated water be used for making infant formula.7 More than 3 out of 4 infants receive formula. Consider that all are medicated with fluoridation, yet the water is not safe for our most vulnerable, our babies. We are now asking moms to haul their infant, its food, toys, clothes, and now water. Parents in third world countries can usually boil their water to make it safe for infants, but many communities consciously put chemicals in the public water which cant even be boiled out or traditional filters used to make it safe for infants. The biggest problem in the US scientific community is the fear Universities, Medical and Dental Associations and Journals have in permitting discussion, debate and scientific review of fluoridation. One state medical association requested $50,000 for a short private presentation of concerns. Others permit review only by their legal counsel. The BMJ should be commended for their willingness to do what few other scientists are willing to do, open scientific discussion. Bill Osmunson DDS, MPH Aesthetic Dentistry of Bellevue bill@smilesofbellevue.com 1. The CDC also references Horowitz and Ismail 1996, Johnston 1994, Ripa 1990, Stookey and Beiswanger 1995, however all these reviewed topical application of fluoride, not the addition of fluoride to water. http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm 2. http://www2.nidcr.nih.gov/sgr/sgrohweb/chap7.htm 3. National Survey of Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htm---(No longer there) The National Survey of Children's Health 2003. Rockville, Maryland: U.S. Department of Health and Human Services, 2005 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau http://www.doh.wa.gov/cfh/Oral_Health/Documents/SmileSurvey2005FullReport.pdf---(No longer there) http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdf#search='Oregon%20Decay%20experience BRFSS 2002 http://www.dhs.state.or.us/dhs/ph/chs/brfs/02/orahea/dentvisi.shtml---(No longer there) http://apps.nccd.cdc.gov/brfss/display.asp?state=WA&cat=OH&yr=2004&qkey=6610&grp=0&SUBMIT4=Go Sample size OR 3509 and WA 12,926 2004 data National Survey of Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm U.S. Department of Health and Human Services, http://www.fluoridationcenter.org/papers/2002/cdcmmwr022102.htm---(No longer there) http://quickfacts.census.gov/qfd/states/41000.html 4. Our analysis shows no convincing effect of fluoride-intake on caries development." Komarek A, et al. (2005). A Bayesian analysis of multivariate doubly-interval-censored dental data. Biostatistics 6:145-55. 5. Kugel (sp) and Fischer 1997, Sepp et al. 1998 6. www.nap.edu/catalog/11571.html Fluoride in Drinking Water: A Scientific Review of EPAs Standards 2006

7. http://www.cdc.gov/fluoridation/safety/infant_formula.htm www.ada.org see also Pizzo G, et al Community water fluoridation and caries prevention: a critical review, Clin Oral Investig. 2007 Feb 27. Competing interests: None

(Typo corrections and links checked and updated with permission. K. Case, April 2012)