From the Townsend Letter for Doctors & Patients
Fluoride Controversy Continues: An Update Part 1
by Gary Null, PhD, and Martin Feldman, MD
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Most Americans associate the fluoride in their drinking water with positive images of tooth protection, strong bones and a government that cares about their dental needs. So it may come as a surprise that water fluoridation, long portrayed as a safe and effective way to prevent tooth decay, is in fact a fraud that has led to the deaths of hundreds of thousands of Americans and a weakened immune system in tens of millions more.
In recent years research has shown that fluoridation is neither essential to good health nor protective of teeth. What it does is poison the body. "We would not purposely add arsenic to the water supply. And we would not purposely add lead. But we do add fluoride," said the late Dr. John Yiamouyiannis in a 1995 interview. "The fact is that fluoride is more toxic than lead and just slightly less toxic than arsenic."1
The fluoride added to public drinking water is not a pharmaceutical, but rather a crude industrial waste product of the aluminum and fertilizer industries. (Fluoride is one of industry's major pollutants; in 1989 155,000 tons annually were released into the air2 and 500,000 tons were disposed of in our lakes, rivers and oceans.3) Waste fluoride is toxic enough to be used as rat poison.
How did Americans learn to love an environmental hazard? This phenomenon can be attributed to a carefully planned marketing program that began even before Grand Rapids, Michigan, became the first community to officially fluoridate its drinking water in 1945.4 As a result of this ongoing campaign, many American communities have enthusiastically followed Grand Rapids' example. Approximately 162 million Americans were receiving fluoridated water at the end of 2000; they represented 65.8% of the 246 million Americans on public water supply systems and 57.6% of the US population.5,6 Of the 50 largest cities in the United States, 43 have fluoridated water.7
With this three-part series, we examine whether water fluoridation is the safe and beneficial process the US government and the American Dental Association claim it to be. In Part 1, we discuss the research on dental decay rates, the government's position on fluoridation, the thin margin of safety that exists for fluoride, and our increasing exposure to fluoride from multiple sources. In Part 2, we will present studies showing that water fluoridation and fluoride exposure are associated with disorders such as dental fluorosis, skeletal fluorosis, bone fractures, cancer and reduced intelligence. And in Part 3, we will discuss the fluoride accidents that occur at water facilities, the steps a person can take to reduce the risk of a fluoride overdose, one city's decision to reject a fluoridation proposal, and the difficulties of challenging an entrenched system such as water fluoridation.
How to Market a Toxic Waste
Fluoride's toxicity was recognized as far back as the 1850s, at the start of the Industrial Revolution, when iron and copper factories discharged it into the air and poisoned plants, animals and people.8
By the 1920s rapid industrial growth had exacerbated the problems of industrial pollution, and fluoride was one of the biggest. Medical writer Joel Griffiths explains that "it was abundantly clear to both industry and government that spectacular US industrial expansion and the economic and military power and vast profits it promised would necessitate releasing millions of tons of waste fluoride into the environment."9
In the early 1930s the Aluminum Company of America (Alcoa) took a proprietary interest in this issue because fluoride is a major waste product of aluminum production. The company wanted to know how much fluoride exposure people could tolerate without getting mottled, discolored teeth.10
This question was addressed that same year, when H. Trendley Dean, head of the Dental Hygiene Unit of the National Institutes of Health, conducted research in Texas and claimed that "fluoride levels of up to 1.0 ppm (part per million) in drinking water did not cause mottled enamel; if the fluoride exceeded this level, however, fluorosis would occur."11 He proposed that fluoridating water at the magic threshold of 1 ppm would prevent tooth decay while avoiding damage to bones and teeth.12 He recommended further studies to determine whether his hypothesis was true.
Government and industry strongly supported water fluoridation,13 and overwhelming acceptance allowed them to proceed hastily. A clinical trial of fluoridation in Grand Rapids was supposed to take 15 years, during which time health benefits and hazards would be studied. In 1946, however, just one year into the experiment, six more US cities adopted the process. By 1947, 87 more communities were treated; popular demand was the official reason for this unscientific haste.
The Fluoride Myth Doesn't Hold Water
The big hope for fluoride was that it would protect children's developing teeth against cavities. Rates of dental caries were supposed to plummet in areas where water was treated. Yet decades of experience and worldwide research have contradicted this expectation numerous times. Here are just a few examples:
In 1986/87, the largest study on fluoridation and tooth decay ever conducted found no statistically significant differences in dental decay between fluoridated and unfluoridated cities. The study encompassed 39,000 schoolchildren aged 5 to 17 living in 84 areas around the country. A third of the places were fluoridated, a third were partially fluoridated, and a third were not.14 The benefit to fluoridated communities, if any, amounts to 0.6 fewer decayed tooth surfaces per child, which is less than 1% of the tooth surfaces in a child's mouth.15
In British Columbia, only 11% of the population drinks fluoridated water, as opposed to 40% to 70% in other Canadian regions. However, British Columbia has the lowest rate of tooth decay in Canada. In addition, the lowest rates of dental caries within the province are found in areas that do not have fluoridated water supplies.16
A 1999 New York State Department of Health study of 3,500 7 to 14 year-olds shows that children in fluoridated Newburgh, New York, have no less tooth decay but significantly more dental fluorosis than children from Kingston, New York, which has never been fluoridated. Since 1945, children of the two towns have been examined periodically in order to demonstrate that fluoridation reduces tooth decay. "This new research shows the experiment has failed," the report concludes.17
In contrast to the anticipated increase in dental caries following the cessation of water fluoridation in the German cities of Chemnitz (formerly Karl-Marx-Stadt) and Plauen, a significant fall in caries prevalence was observed. This trend corresponded to the national caries decline and appeared to be a new population-wide phenomenon.18
A follow-up of a study of the town of Kuopio, Finland, six years after fluoridation was discontinued found no increase in dental caries. The authors conclude that fluoridation was unnecessary to begin with.19
A study comparing prevalence and incidence of caries in 2,994 lifelong residents of British Columbia, Canada, in grades 5, 6, 11 and 12 found no difference in caries incidence between the still-fluoridating and fluoridation-ended communities.20
In 1997, following the cessation of drinking water fluoridation in La Salud, Cuba, caries prevalence remained at a low level for the 6- to 9-year-olds and appeared to decrease for the 10- to 11-year-olds. Among the 12- to 13-year-olds, there was a significant decrease; the percentage of caries-free children of this age group had increased from 4.8% (1973) and 33.3% (1982) up to 55.2%.21
In Durham, North Carolina, a town that has fluoridated its water since 1962, an 11-month break in fluoridation (in 1990 and 1991) had little effect on the development of caries in those studied continuously resident children in kindergarten through fifth grade.22
A 1998 study conducted in New Zealand found that when the timing of various forms of fluoride supplementation is correlated with the decline in caries, the decline continues beyond the time of maximum population coverage with fluoridated water and fluoridated toothpaste. The authors call for a reassessment of the fluoride effect.23
Interestingly, a number of research studies show that the rate of dental caries has declined in countries that do not fluoridate their drinking water (other forms of fluoride, such as fluoridated toothpastes, may be used). These studies looked at the prevalence of dental caries in countries such as Belgium, Norway, Denmark, Iceland, Sweden, France and Greece (or certain cities within them) during different periods of time between the 1960s and 1990s.24-28 Several other studies report a decline in the prevalence of dental caries in Europe in general.29,30
A 1999 study of water fluoridation in Italy shows that parents socioeconomic status, the area of residence and children's consumption of sweets are more significant predictors of dental caries than is fluoride consumption. The authors conclude that universal fluoridation is an inadequate approach and the decision to fluoridate or defluoridate water requires careful epidemiological consideration.31
Some former supporters are beginning to question the need for fluoridation altogether. One longtime advocate of water fluoridation who now opposes the process is Hardy Limeback, PhD, DDS, head of preventive dentistry at the University of Toronto. In early 2000 he wrote, "Since April of 1999, I have publicly decried the addition of fluoride, especially hydrofluosilicic acid, to drinking water for the purpose of preventing tooth decay." As his reasons, he cites new evidence of fluoridation's lack of effectiveness in modern times and new evidence that the long-term ingestion of fluoride may cause potential serious harm.32
A 1999 literature review conducted by Dr. Limeback indicates that fluoride prevents dental caries primarily through a topical effect. Swallowing fluoridated water is ineffective and unnecessary. Dr. Limeback concludes that everyone working in the dental health field must "examine more closely the risks and benefits of fluoride in all its delivery forms."33
Dr. Limeback also notes: "Dental decay rates in North America are so low that water fluoridation provides little to no benefit whatsoever these days. In fact, studies show that when you turn the water fluoridation taps off and look for dental decay rates, they don't move whatsoever. There is no increase in dental decay when you stop fluoridating."34 Fluorosis occurs on two or more teeth in 30% of children in areas where the water is fluoridated, and not all in its mildest form.35
Much like Dr. Limeback, dentist and public health official Dr. John Colquhoun, formerly one of New Zealand's most prominent pro-fluoridation advocates and educators, has revised his opinion of the process. In a letter published in 1999, Dr. Colquhoun explains how he came to recognize over the years that water fluoridation provided no benefit and that children's dental health is slightly better in nonfluoridated areas than in fluoridated ones.36
Another noteworthy opponent of fluoridation is Chapter 280 of the National Treasury Employees Union, which represents professional employees such as scientists, lawyers and engineers at the Environmental Protection Agency's headquarters in Washington, DC. Senior vice president William Hirzy, PhD, reports that the union's differences with the EPA over its drinking water standard for fluoride began in 1985 and have only grown since that time.37
Dr. Hirzy states, "Since then our opposition to drinking water fluoridation has grown, based on the scientific literature documenting the increasingly out-of-control exposures to fluoride, the lack of benefit to dental health from ingestion of fluoride and the hazards to human health from such ingestion. These hazards include acute toxic hazard, such as to people with impaired kidney function, as well as chronic toxic hazards of gene mutations, cancer, reproductive effects, neurotoxicity, bone pathology and dental fluorosis."38
A Disregard for Evidence
Despite the scientific evidence, US government agencies continue to support water fluoridation and plan for its expansion. The US Department of Health and Human Services named water fluoridation one of the top achievements in health and well-being in the 20th century, citing decreases of 40% to 70% in dental cavities among children in the second half of the century.39 And in 1999, the Centers for Disease Control and Prevention (CDC), part of Health and Human Services, identified fluoridation as one of the 10 great public health achievements of the 20th century.40
The benefits of water fluoridation also were extolled in the first-ever report on oral health from the US Surgeon General. The 2000 report states, "Community water fluoridation, an effective, safe, and ideal public health measure, benefits individuals of all ages and socioeconomic strata."41 The National Institute of Dental and Craniofacial Research, part of the National Institutes of Health, states that it "continues to support water fluoridation as a safe and effective method of preventing tooth decay in people of all ages. One significant advantage of water fluoridation is that anyone, regardless of socioeconomic level, can enjoy its benefits during their daily lives at work, school, play simply by drinking fluoridated water or beverages prepared with fluoridated water."42
The American Dental Association also is a strong supporter of fluoridation. The organization states that it has "endorsed fluoridation of community water supplies as safe and effective for preventing tooth decay for more than 40 years," and refers to "overwhelming evidence of fluoridation's safety and efficacy."43 Because fluoride is found in nearly all sources of drinking water in the U.S. anyway, says the ADA, fluoridation is "the 20th-century adaptation of a naturally occurring process. Fluoridation is a form of nutritional supplementation that is not unlike the addition of vitamins to milk, breads and fruit drinks; iodine to table salt; and both vitamins and minerals to breakfast cereals, grains and pastas."44
Given the support for fluoridation, it should come as no surprise that the U.S. government wants to extend the process to more of the approximately 100 million Americans who currently do not drink fluoridated water. The Department of Health and Human Services' Healthy People 2010 plan, which sets health goals for the country, "calls for at least 75% of the population served by community water systems to receive optimal levels of fluoride. The current level is 65.8%. To reach this goal, approximately 22.5 million more people must gain access to fluoridated water through public water systems."45
One would assume that government agencies supporting fluoridation are current on the research, but that may not be the case. Paul Connett, PhD, a professor of chemistry at St. Lawrence University (NY) who has studied fluoridation and who helped found the Fluoride Action Network (www.fluoridealert.org), says that when the CDC named water fluoridation one of the top 10 public health achievements of the 20th century, the agency was six years out of date on the health studies. Needless to say, a huge, prestigious agency of the US government "shouldn't be more than six weeks out of date," he says, when it comes to using a known toxic substance in public drinking water.46
The US government and other fluoridation proponents also have been wrong for many years about fluoride's mechanism of action in teeth, adds Dr. Connett. The government, dentists and doctors have long told people that you must swallow fluoride to receive its benefits and that children need the substance before their teeth have erupted. Now, however, the CDC says that the benefit of fluoridation is predominately topical, affecting the teeth after they have erupted. "They've been wrong all these years on something as basic as how fluoride is supposed to help," says Dr. Connett.47
A 2000 article in the Journal of the American Dental Association admits that the fluoride that is swallowed and incorporated into teeth is "insufficient to have a measurable effect" on reducing cavities.48 Fluoride works primarily at the topical level, such as by inhibiting the demineralization of a tooth's crystal surfaces, enhancing remineralization of the crystal surfaces and inhibiting bacterial enzymes. Fluoride that is ingested systemically has minimal effect on dental caries.49
A Thin Margin of Safety
Only a small margin separates supposedly beneficial fluoride levels from amounts that are known to cause adverse effects. Dr. James Patrick, a former antibiotics research scientist at the National Institutes of Health, describes the predicament:
"[There is] a very low margin of safety involved in fluoridating water. A concentration of about 1 ppm is recommended . In several countries, severe fluorosis has been documented from water supplies containing only 2 or 3 ppm. In the development of drugs we generally insist on a therapeutic index (margin of safety) of the order of 100; a therapeutic index of 2 or 3 is totally unacceptable, yet that is what has been proposed for public water supplies."50
Other countries argue that even 1 ppm is not a safe concentration. Canadian studies, for example, imply that children under age 3 should have no fluoride whatsoever. The Journal of the Canadian Dental Association states, "Fluoride supplements should not be recommended for children less than 3 years old."51 Since these supplements contain the same amount of fluoride as water does, they are basically saying that these young children should not drink fluoridated water under any circumstances.
According to a report by the National Pure Water Association in the UK,52 the figures reported by European researcher Kaj Roholm in a 1937 study53 provide a good indication of how much fluoride is safe. Roholm found that some cyrolite workers developed crippling skeletal fluorosis in a very short time at levels of 0.2 to 0.35 milligrams of fluoride per kilogram of body weight. However, when a toxicologist applied these figures to a typical range of body weights (100 to 229 pounds) to set a maximum intake level, he failed to convert the figures from kilograms to pounds and mistakenly said that the amounts of fluoride that would cause crippling skeletal fluorosis were 20 mg to 80 mg per day. The National Research Council's Board on Environmental Studies and Toxicology finally corrected this error in its Health Effects of Ingested Fluoride in 1993. At that time the figure was changed from 20 to 80 mg per day to 10 to 20 mg per day. (One quart of water with a fluoride concentration of 1 ppm contains 1 milligram of fluoride.)
Based on the corrected data, says the National Pure Water Association, "the amount needed to cause crippling fluorosis in a 100 to 229 lb person was reckoned to be 10 to 20 mg per day for 10 to 20 years. Since fluorides accumulate in a linear fashion, the crippling dosage of 10 mg per day for 10 years is the same as 5 mg per day for 20 years, and so on. If we extrapolate this to a normal lifetime with fluoridated water, this is the same as 2.5 to 5 mg per day for 40 to 80 years. But we should note that, for persons with kidney disease, the risk is greater because less fluoride will be eliminated by their malfunctioning kidneys.55
"It is also important to note that these figures are for crippling fluorosis, the last stage. It will take only four years at 10 mg per day, or 16 years at 2.5 mg per day, before a 100-pound individual can expect to experience phase 2, musculoskeletal fluorosis, with chronic joint pain and arthritic symptoms with or without osteoporosis."56
The National Pure Water Association concludes that "the only safe limit for fluoride is none."57
Even if we were to assume that low concentrations are safe, there is no way to control how much fluoride different people consume. Some take in a lot more than others.58 For example, laborers, athletes, diabetics and people living in hot or dry regions (in fluoridated areas) all can be expected to drink more water, and therefore more fluoride, than others. Due to such wide variations in water consumption, it is impossible to scientifically control the dosage of fluoride a person receives from the water supply.59 But we do know that a person who drinks six 8-ounce glasses of water fluoridated at 1 ppm will ingest 1.5 milligrams of fluoride.
Incidentally, 90% of the fluoride added to our drinking water is no longer sodium fluoride. Today's fluoride is an industrial waste that is complexed with silica or sodium, and the resulting free fluoride ions are quickly absorbed in the gastrointestinal tract. By contrast, fluoride bound to calcium is less readily absorbed.60
Other Sources of Fluoride
Another concern is that drinking water is not the only source of fluoride. It is also contained in toothpastes and in foods processed with fluoride. In the United States, these include nearly all bottled drinks and canned foods.61
Once fluoride is added to water, you get the "multiplier effect" as that water is used to process or dilute foods and beverages, explains Dr. Connett. Add this exposure to the fluoride found in today's dental products, pesticide and fertilizer residues and pollution (an ignored source), he says, and "we are overdosed with fluoride in this country." But despite the new sources of fluoride exposure we face today, the US government has never adjusted the level of fluoridation it claims to be "optimal" meaning it will reduce dental caries but will not cause too much dental fluorosis since that level was set at 1 ppm in 1945. "They're still saying that 1 ppm is optimal in 2002," says Dr. Connett. "It's just scientific poppycock."62
Some sources of fluoride are:
Toothpaste. In the 1950s fluoridated toothpastes were required to carry warnings saying they were not to be used in areas where water was already fluoridated.63 Although that statement no longer exists on toothpaste products, the Food and Drug Administration has required fluoride toothpastes to carry the following warning since 1997: "If you accidentally swallow more than used for brushing, seek professional help or contact a poison control center immediately."64 The reason for that statement is, of course, the fluoride content of the products. Fluoridated toothpastes may contain as much as1,000 ppm of fluoride or even more, while fluoridated drinking water has 1 ppm.
The amount of fluoride ingested by children during toothbrushing was the subject of a 1999 study in England. Researchers studied 30-month-old children who used toothpaste containing either 1,450 or 400 ppm of fluoride. The mean amount ingested per brushing was 0.42 mg and 0.10 mg, respectively. The researchers stated: "It is essential that parents of children aged less than 7 years apply a small (pea-sized) amount of fluoride toothpaste on the toothbrush and discourage swallowing."65
A recent study of fluoridated and nonfluoridated communities in Brazil proved that fluoride toothpaste contributes to dental fluorosis. In the study, children who started using fluoride before the age of 3 were 4.43 times more likely to have dental fluorosis than those who started using it after the age of 3.66
Another study suggests that fluoride toothpaste may not have played as large a part in the decline of dental caries in industrialized countries as believed. The researchers found no evidence to support the hypothesis that the more frequent use of fluoride toothpastes by girls than boys has reduced the relative age-specific D(M)FT gender difference, and that this difference should decrease as children age and are exposed to more fluoride toothpaste. They concluded that "the gender difference in fluoride exposure due to toothbrushing frequency is too small to matter, that the study lacked power, or that the role of fluoride toothpastes in the caries decline has been overrated."67
Fruit juices. Researchers writing in The Journal of Clinical Pediatric Dentistry have found that fruit juices contain significant amounts of fluoride. In one analysis of a variety of popular juices and juice blends, 42% of the samples had more than l ppm of fluoride. Some brands of grape juice contained much higher levels of up to 6.8 ppm.68
The authors cite the common use of fluoride-containing insecticide in the growing of grapes as a factor in these high levels, and they suggest that the fluoride content of beverages be printed on their labels along with the other nutritional information provided to consumers.69 Considering how much juice some children ingest, and their tendency to insist on particular brands they consume day after day, this seems to be a prudent idea.
Other beverages. In a 1999 study, researchers found that the fluoride levels of 332 soft drinks ranged from 0.02 to 1.28 ppm, with a mean level of 0.72 ppm. Fluoride levels exceeded 0.60 ppm in 71% of the products. To reduce the risk of dental fluorosis, they concluded, "dental and medical practitioners should be cautious about prescribing dietary fluoride supplements to preschool-aged children in nonfluoridated areas who consume large quantities of carbonated soft drinks."70
Similarly, researchers who examined the fluoride content of 45 carbonated and juice drinks from two communities in Texas one fluoridated, one not concluded that even people in low-fluoride communities face the risk of fluorosis from the fluoride consumption in beverages as well as the water supply and fluoride therapy.71
Prepared baby foods. A 1997 article in the Journal of the American Dental Association warns that some baby foods contain such high levels of fluoride that babies who eat the food risk dental fluorosis.72 Infants who eat large quantities of dry infant cereals reconstituted with fluoridated water could ingest substantial quantities of fluoride from this source, the study shows. "Children should also be monitored to make sure that they do not ingest too much fluoride from other sources such as fluoride dentifrice, dietary fluoride supplements or fluoridated water ."73
Infant formulas. Babies who are only partially breastfed or fed formulas in the first 10 months of life have a highly variable intake of fluoride, depending largely on the amount of fluoride in the water used to dilute the concentrated liquid or powdered formula products, according to a 1999 study. The researchers note that infant feeding practices have changed greatly since the 1960s, and prolonged exposure to high intakes of fluoride during infancy is much more common now than in the past.74
Foods cooked in fluoridated water. Cooking can greatly increase a food's fluoride content. Peas, for example, contain 12 micrograms of fluoride when raw and 1,500 micrograms after they are cooked in fluoridated water, a tremendous difference.
Other sources. In addition to pesticides and insecticides, fluoride also is an ingredient in pharmaceuticals and aerosols.
Gary Null, PhD
Gary Null, PhD, has authored 50 books on health and nutrition and numerous articles published in leading magazines. Null holds a PhD in human nutrition and public health science from the Union Graduate School. He maintains a Web site at www.garynull.com that presents research articles on optimizing health through nutrition, lifestyle factors and alternative medicine.
Martin Feldman, MD, is assistant clinical professor of neurology at Mount Sinai Medical School in New York City. He practices complementary medicine.
1. Gary Null interview with Dr. John Yiamouyiannis, March 10, 1995. His statement is referenced in the Clinical Toxicology of Commercial Products, Fifth Ed., Williams and Wilkins.
2. "Summary review of health effects associated with hydrogen fluoride acid related compounds," EPA Report Number 600/8-29/002F, December 1988.
3. Yiamouyiannis J. Lifesaver's Guide to Fluoridation, Safe Water Foundation, Delaware, OH, 1983, 1.
4. Griffiths, Joel. Fluoride: commie plot or capitalist ploy. Covert Action 1992 Fall; 42:30.
5. Fluoridation statistics 2000: status of water fluoridation in the United States. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. From www.cdc.gov/OralHealth/factsheets/fl-stats-us2000.htm.
6. Populations receiving optimally fluoridated public drinking water United States, 2000. MMWR Weekly 2002 Feb 22; 51(07):144-7.
7. Community water fluoridation: surgeon general's statement, 2001. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. From www.cdc.gov/OralHealth/factsheets/fl-surgeon2001.htm.
8. Griffiths, op. cit., 27.
9. Griffiths, op. cit., 28.
13. Griffiths, op. cit.
14, Yiamouyiannis J. Water fluoridation and tooth decay: results from the 1986-1987 national survey of U.S. schoolchildren. Fluoride 1990 Apr; 23(2):55-67.
15. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of water fluoridation. J Dent Res 1990 Feb; 69 Spec No:723-7; discussion 820-3.
16. Gray AS. Canadian Dental Association Journal 1987 Oct: 76-83.
17. Kumar JV, Swango PA. Fluoride exposure and dental fluorosis in Newburgh and Kingston, New York: policy implications. Community Dent Oral Epidemiol 1999 Jun; 27(3):171-80.
18. Kunzel W, Fischer T, Lorenz R, Bruhmann S. Decline of caries prevalence after the cessation of water fluoridation in the former East Germany. Community Dent Oral Epidemiol 2000 Oct; 28(5):382-9.
19. Seppa L, Karkkainen S, Hausen H. Caries trends 1992-1998 in two low-fluoride Finnish towns formerly with and without fluoridation. Caries Res 2000 Nov-Dec; 34(6):462-8.
20. Maupome G, Clark DC, Levy SM, Berkowitz J. Patterns of dental caries following the cessation of water fluoridation. Community Dent Oral Epidemiol 2001 Feb; 29(1):37-47.
21. Kunzel W, Fischer T. Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res 2000 Jan-Feb; 34(1):20-5.
22. Burt BA, Keels MA, Heller KE. The effects of a break in water fluoridation on the development of dental caries and fluorosis. J Dent Res 2000 Feb; 79(2):761-9.
23. de Liefde B. The decline of caries in New Zealand over the past 40 years. N Z Dent J 1998 Sep; 94(417):109-13.
24. Carvalho JC, Van Nieuwenhuysen JP, D'Hoore W. The decline in dental caries among Belgian children between 1983 and 1998. Community Dent Oral Epidemiol 2001 Feb; 29(1):55-61.
25. Kallestal C, Wang NJ, Petersen PE, Arnadottir IB. Caries-preventive methods used for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol 1999 Apr; 27(2):144-51.
26. Obry-Musset AM. Epidemiology of dental caries in children. (Article in French) Arch Pediatr 1998 Oct; 5(10):1145-8.
27. Stecksen-Blicks C, Holm AK. Dental caries, tooth trauma, malocclusion, fluoride usage, toothbrushing and dietary habits in 4-year-old Swedish children: changes between 1967 and 1992. Int J Paediatr Dent 1995 Sep; 5(3):143-8.
28. Athanassouli I, Mamai-Homata E, Panagopoulos H, Koletsi-Kounari H, Apostolopoulos A. Dental caries changes between 1982 and 1991 in children aged 6-12 in Athens, Greece. Caries Res 1994; 28(5):378-82.
29. Marthaler TM, O'Mullane DM, Vrbic V. The prevalence of dental caries in Europe 1990-1995. ORCA Saturday afternoon symposium 1995. Caries Res 1996; 30(4):237-55.
30. Reich E. Trends in caries and periodontal health epidemiology in Europe. Int Dent J 2001; 51(6 Suppl 1):392-8.
31. Angelillo IF, Torre I, Nobile CG, Villari P. Caries and fluorosis prevalence in communities with different concentrations of fluoride in the water. Caries Res 1999; 33(2):114-22.
32. Limeback H, BSc, PhD, DDS. Why I am now
officially opposed to adding fluoride to drinking water. April 2000.
33. Limeback H. A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride? Community Dent Oral Epidemiol 1999 Feb; 27(1):62-71.
34. Gary Null interview with Dr. Hardy Limeback, January 30, 2001.
35. Heller KE, Eklund SA, Burt BA. Dental caries and dental fluorosis at varying water fluoride concentrations. J Public Health Dent 1997 Summer; 57(3):136-43.
36. Colquhoun J. Why I changed my mind about water fluoridation. Perspect Biol Med 1997 Autumn; 41(1):29-44.
37. Hirzy W, PhD. Why EPA's headquarters professionals' union opposes fluoridation. May 1, 1999. From the Fluoride Action Network, at www.fluoridealert.org/hp-epa.htm.
39. Top achievements in health and well being
in the 20th century. Department of Health & Human Services Accountability
Report, Fiscal Year 1999.
40. CDC releases new guidelines on fluoride
use to prevent tooth decay. Press release. Centers for Disease Control and
Prevention, Atlanta, GA. August 17, 2001.
41. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. >From www.nidcr.nih.gov/sgr/execsumm.htm.
42. Statement on water fluoridation. National
Institute of Dental and Craniofacial Research, National Institutes of Health,
43. American Dental Association statement on water fluoridation efficacy and safety. June 29, 2000. From www.ada.org/prof/prac/issues/statements/fluoride2.html.
44. Fluoride and fluoridation. American Dental Association Web site. Document updated May 20, 2002. From www.ada.org/public/topics/fluoride/artcl-02.html.
45. Water fluoridation: background information. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Document updated May 29, 2002. From www.cdc.gov/OralHealth/factsheets/fl-background.htm.
46. Gary Null interview with Dr. Paul Connett, July 24, 2002.
48. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000 Jul; 131(7):887-99.
49. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999 Feb; 27(1):31-40.
50. Statement by Dr. James Patrick before Congressional Subcommittee, August 4, 1982.
51. Fluoride recommendations released. Canadian Conference on the Evaluation of Current Recommendations Concerning Fluorides, April 9-11, 1992. J Can Dent Assoc 1993 Apr; 59(4):330, 334-6.
52. Skeletal fluorosis. National Pure Water Association, Campaign for Safe Drinking Water, Wakefield, UK. From www.npwa.freeserve.co.uk/skeletal.htm.
53. Roholm K. Fluorine intoxication. A clinical-hygienic study, Nyt Nordisk, Copenhagen and H K Lewis, London, 1937, 281-2.
54. National Academy of Sciences. Health Effects of Ingested Fluoride, National Academy Press, Washington, DC, 1993, 59.
55. Skeletal fluorosis, op. cit. National Pure Water Association.
58. Exner FB and Waldbott GL. Fluoride Poisoning in the Fluoridated Cities. Part II of The American Fluoridation Experiment. Edited by J Rorty. Devin-Adair Company, NY, 1957, 43.
59. Federal Register, December 24, 1975.
60. Lee JR. Hip fractures and fluoride revisited: a critique. Editorial. Fluoride 2000 Feb; 33(1):1-5.
61. Hileman B. Fluoridation of water. Chemical & Engineering News 1988 Aug 1; 66:33.
62. Gary Null interview with Dr. Paul Connett, July 24, 2002.
63. Waldbott GL, Burgstahler A, McKinney HL. Fluoridation: The Great Dilemma, Coronado Press Inc., Lawrence, KS, 1978, 307-8.
64. ADA statement on FDA toothpaste warning labels. American Dental Association, July 19, 1997. From www.ada.org/prof/prac/issues/statements/fluoride.html
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66. Pereira AC, Da Cunha FL, Meneghim M de C, Werner CW. Dental caries and fluorosis prevalence study in a nonfluoridated Brazilian community: trend analysis and toothpaste association. Fluoride 2000 May; 33(2):86-7.
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