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Fluoride in your drinking water: History, Science, and Policy

ENV H 472 A - ENVIRONMENTAL RISK AND SOCIETY Class 12

Steven G. Gilbert, PhD, DABT www.toxipedia.org


SOT Fluoride - History 02/11/10

Issues
Should public water be fluoridated? Benefits reduced dental carries Risks dental fluorosis bone disease Dose - Response

Mild fluorosis

Severe fluorosis
SOT Fluoride - History 02/11/10

Fundamental Issue

Science meets Policy


Ethical, legal, social, political, scientific considerations Engage Public? Role of government agencies? Local National International?

SOT Fluoride - History 02/11/10

History of Fluoride
1899 - Sodium Fluoride -- Herbert H Baldwin reported symptoms of acute toxicity (e.g. gastrointestinal upset) doses as low as 0.1-0.3 mg/kg. 1909 Colorado stain (fluorosis) Frederick McKay, observed children in the Pikes Peak region had of stain or mottling on their teeth but fewer cavities

1931 G.V. Black (father of modern dentistry) and others concluded fluoride ion in the water was the cause
SOT Fluoride - History 02/11/10

History of Fluoride
1939 Gerald J. Cox first publication recommending the addition of fluoride to drinking water to improve oral health at 1 ppm level 1940s - several paired city studies conclude fluoride in drinking water is beneficial 1945, January 25 - Grand Rapids, Michigan first community in the world to add fluoride to its drinking water to benefit dental health 1940s Fluorine used in bomb making (University of Rochester Harold Hodge)
SOT Fluoride - History 02/11/10

Stannous Fluoride
1951, Joseph C. Muhler and Harry G. Day of Indiana University reported that stannous fluoride as a tooth decay preventive and the university first sold the technology to Procter & Gamble to use in Crest toothpaste.

SOT Fluoride - History 02/11/10

CDCs Recommendation
Nature's Way to Prevent Tooth Decay

...fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children
CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October 22.
SOT Fluoride - History 02/11/10

How Fluoride Works


Teeth are generally composed of hydroxyapatite and carbonated hydroxyapatite; when fluoride is present, fluorapatite is created. Fluorosis cannot occur once the tooth has erupted into the oral cavity. Topical fluoride encourages fluorapatite which is beneficial because it is more resistant to dissolution by acids (demineralization).
SOT Fluoride - History 02/11/10

Dental Fluorosis with Optimal Fluoride


67% of US people exposed to fluoridated water most large cities 1997 - 29.9% of US children living in fluoridated communities have dental fluorosis on (Heller et al, 1997). 2005 - CDC dental fluorosis effects 1 in 3 American kids - up 9% since 1986-87.

2006 - ADA & CDC offers interim guidance on infant formula and fluoride
SOT Fluoride - History 02/11/10

Ethical Issues
Individual vs Public Health? Fluoridation of public water is "compulsory mass medication" Individual Consent? Legal human rights choice? Improves dental care for low-income people. Not mass medication because fluoride is natural. Similar to fortifying foods with vitamins
SOT Fluoride - History 02/11/10

MCLG-MCL
MCLG maximum contaminant level goal - level of a contaminant in drinking water below which there is no know or expected risk to health - non-enforceable public health goal MCL maximum contaminant level - highest level of a contaminant allowed in drinking water - enforceable standard - set as close as feasible to the MCLG; technology and costs are considered
SOT Fluoride - History 02/11/10

SMCL
SMCL secondary maximum contaminant level - non-enforceable guideline for managing drinking water for aesthetic, cosmetic (e.g., tooth discoloration), or technical effects

SOT Fluoride - History 02/11/10

History
1986
MCLG and MCL set at 4 mg/L to protect against crippling skeletal fluorosis SMCL set at 2 mg/L to reduce occurrence and severity of objectionable enamel fluorosis.

1993
MCL reviewed by NRC in 1993 4 mg/L is appropriate as an interim MCL More research needed on fluoride intake, enamel fluorosis, bone strength and fractures, and carcinogenicity.

SOT Fluoride - History 02/11/10

National Academy of Sciences - Tasks


Review toxicologic, epidemiologic, and clinical data on fluoride, particularly data conducted since 1993 NRC report Review exposure data on orally ingested fluoride from drinking water and other sources (e.g., food, toothpaste) Evaluate the scientific basis of the MCLG and SMCL and their adequacy to protect children and others from adverse health effects. Consider relative contribution of various fluoride sources to total exposure. Identify data gaps and recommend research relevant to setting the MCLG and SMCL.
SOT Fluoride - History 02/11/10

Exposure
Drinking Water Contribution to Total Exposure Drinking Water Natural Sources - 2.0-3.9 mg/L (1.4 million people exposed) 57% - 90% for average individual 86% - 96% for high-water intake individual - 4mg/L (200,000 people exposed) 72% - 94% for average individual 92% - 98% for high-water intake individual Drinking Water Artificial Sources - PHS recommends 0.7-1.2 mg/L (162 million people exposed) 41% - 83% for average individual 75% - 91% for high-water intake individual
SOT Fluoride - History 02/11/10

Enamel fluorosis
Enamel fluorosis is a dose-related mottling of enamel ranging from mild discoloration to severe dark stains and pitting in children (0 to 8 years). Permanent condition. Historically, condition considered cosmetic because it is not associated with tooth loss, loss of tooth function, or psychological, behavioral, or social problems. Cause: receiving too much fluoride during tooth development. Committee separated severe from moderate fluorosis.
Severe: mottling with enamel pitting and/or loss Moderate: mottling but no enamel pitting or loss
SOT Fluoride - History 02/11/10

Severe Enamel Fluorosis

SOT Fluoride - History 02/11/10

Severe Enamel Fluorosis


Severe Enamel Fluorosis in Children in the United States

Source: Selwitz et al. (1995, 1998)

SOT Fluoride - History 02/11/10

NAS Recommendations
New risk assessment should be performed on fluoride. The assessment should include new data on health risks, better estimate of total exposure to fluoride, and updated approaches to risk assessment. Key end points for the risk assessment are severe enamel fluorosis, bone fracture, and stage II skeletal fluorosis. Committees conclusions about the adverse effects at the MCLG and SMCL do not address the lower concentrations of exposure that occur with water fluoridation.
SOT Fluoride - History 02/11/10

ADVERSE EFFECTS OF 4ppm FLUORIDE


Enamel damage with severe fluorosis PROVEN Increased fractures in susceptible groups PROBABLE Skeletal fluorosis (stage II) POSSIBLE

SOT Fluoride - History 02/11/10

APPROPRIATE RESPONSE??
Precautionary principle (Wingspread, 1998)
1. Take anticipatory action to prevent harm 2. Burden of proof on proponents, not public 3. Must examine all alternatives (do nothing) 4. Process transparent & stakeholders involved

Evidence based risk assessment (Guzelian, 2005)


1. Research-based evidence vs expert opinion 2. Strength of evidence vs weight of evidence 3. Hazard, probability and causality. Hill criteria
SOT Fluoride - History 02/11/10

WHATS NEXT??
A comprehensive analysis of all the effects of fluoride (adverse, beneficial, incidence, severity, reversibility etc.) Move from reasonable assurance of no harm to a risk/benefit analysis (MOA and dose response).

SOT Fluoride - History 02/11/10

Effective versus Toxic Conc.


LOAEL=20mg/day (crippling skeletal fluorosis)
Intake = 2L/day

Severe Dental Fluorosis

Safety factor=2.5X

4
ppm in drinking water

MCL=4ppm 2.5-4ppm IQ deficits in Chinese studies

?
2

2.5ppm=threshold for severe dental fluorosis SCL=2ppm: 4-15% mod. dental fluorosis

?
1ppm=target level of water fluoridation

1
0

Prevalence (%) 02/11/10 SOT Fluoride - History

Effective versus Toxic Dose


0.20
4ppm (1L/d, 20 kg child)

0.15
4ppm (2L/d, 70kg adult) Average dietary intake Age 0-2 yrs Fluoride 0.71.1 ppm

1ppm child 10kg 1L/d

Dose (mg/kg/day)

0.10
Crippling Skel. Flsis at 40 yr (NRC 77) EPA RfD Optimal theraputic dose range

1ppm child 20 kg 1L/d 1ppm adult 2L/d 1ppm adult 1L/d

0.05

0
STANDARDS THERAPUTIC/DIETARY RANGE TOTAL INTAKES
SOT Fluoride - History 02/11/10

Fluoridated vs. Unfluoridated

Figure 2: Tooth Decay Trends for 12 Year Olds: Fluoridated Vs. Unfluoridated Countries. Data from World Health Organization. (Graph by Chris Neurath).

SOT Fluoride - History 02/11/10

More Findings from NAS


The MCL should be lowered (EPA directed to do a new risk assessment). Bone fluoride concs from lifetime exposure at 2 ppm (SMCL) fall within or exceed levels associated with stage II (mod.) or stage III (sev.) skeletal fluorosis The SCML (2ppm) does not completely protect against moderate enamel fluorosis. (Moderate enamel fluorosis might have psychological or social effects.)
SOT Fluoride - History 02/11/10

More Findings from NAS


The possibility has been raised by the studies conducted in China that fluoride can lower intellectual abilities. (2.5-4 ppm) Fluoride affects normal endocrine function or response; fluoride is an endocrine disruptor in the broad sense of altering normal endocrine function or response.

SOT Fluoride - History 02/11/10

Not for infants


In November 2006, the American Dental Association and CDC began recommending to parents that infants from 0 through 12 months of age should have their formula prepared with water that is fluoride-free, or contains low levels of fluoride to reduce the risk of fluorosis

SOT Fluoride - History 02/11/10

US vs Europe
The U.S. Centers for Disease Control listed water fluoridation as one of the ten great public health achievements of the 20th century. Most European countries have experienced substantial declines in tooth decay without its use, primarily due to the introduction of fluoride toothpaste in the 1970s. Fluoridation may be more justified in the U.S. because of socioeconomic inequalities in dental health and dental care??
SOT Fluoride - History 02/11/10

More Information
Web Sites
Toxipedia Fluoride
http://www.toxipedia.org/display/toxipedia/Fluoride Wikipedia - http://en.wikipedia.org/wiki/Fluoride

The Controversy - http://en.wikipedia.org/wiki/Water_fluoridation_controversy

Anti fluoridation groups -- Fluoride Action Network - http://www.fluoridealert.org/ - www.fluorideACTION.net Pro fluoridation -- CDC on Water Fluoridation
http://www.cdc.gov/fluoridation/

American Dental Association Fluoridation Facts 2005 - http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf American Dental Association Fluoridation http://www.ada.org/public/topics/fluoride/
SOT Fluoride - History 02/11/10

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