To fluoridate or not to fluoridate? That is the question — UPDATE: Port Angeles water fluoridation in a toss-up. Citizens to make binding decision in late 2017

Courtesy of George Hodan

Research commentary by Giovanni Roverso — Updated 15 Nov. 2016

For the second time within the last year Port Angeles water fluoridation is in a toss-up. Residents will make a final binding vote on the issue on Nov. 7 2017 following a flip-flop of the city council’s position on the matter.

Port Angeles Mayor Patrick Downie changed his vote to “against” in Aug. 2016, after months of outcry from some voices in the community according to the Peninsula Daily News. Downie then proposed a measure which the city council approved to stop adding fluoride to Port Angeles water immediately until the decision is reached; this resulted in an ethics charge filed against him to be dropped.

In Jan. 2016 the city council had voted 4-3 to continue water fluoridation for another decade despite a Nov. 2015 survey in which 56% of Port Angeles public water users expressed their desire to halt water fluoridation, compared to 41% who would continue it.

Scaling the multi-faceted fluoride iceberg

This is my take on the fluoride debate after just several weeks of research, so take it with a pinch of salt as you should any source on the issue, fluoridated salt if you see fit.

Scientific research can be a bit technical. Fluorides are molecular fluorine compounds. Many of these molecules, like the element fluorine which they contain, are highly biologically active, effectively making them a kind of drug or medication. Fluorides are usually measured in terms of milligrams per liter (mg/l) or parts per million (ppm).

As seen in the previous section, mass water fluoridation is an ethics issue due to the impossibility of individual consumers’ informed consent. This basically means that the choice to reject water fluoridation can’t be given to individuals. If people don’t want to drink fluoridated tap water, they are forced to look for other sources or to purchase expensive filtration systems.

Various health organizations recommend an optimal level of water fluoridation to help protect people from tooth decay, but it’s actually impossible to control individual dosages considering people can get fluorine compounds from countless other sources which then accumulates in the body over time. Over the years these organizations have continued lowering the recommended water fluoridation levels due to safety and liability concerns. The World Health Organization and U.S. Public Health Administration’s latest adjustment in 2015 set the maximum recommended level at .7 ppm, down from 1 ppm previously.

Even the use of fluoridation as a health solution at all is highly controversial. Fluorides are said to protect your teeth, but when enough information is taken into consideration some flags and possible risk factors come to light. How much information is enough depends on who you talk to.

Fluoride compounds can sometimes be found in food, soil and even the air due to a variety of reasons.

Other beverages besides water can contain them too: several carbonated drinks, tea (naturally) and certain fruit juices for example. In fact, the 1991 Journal of Clinical Pediatric Dentistry found 42% of tested fruit juices had levels of fluoride higher than 1 ppm. The highest concentration was found in the juice of white grapes. Removing the skins before pressing however, produced juice with very little fluoride, indicating a possible connection with pesticide use.

Considering over-exposure in fluoridated communities is difficult to control, higher-risk population segments are endangered. These segments include people with reduced kidney function like babies and young children who also consume lots of water relative to their size. Other people with kidney damage or reduced functionality due to old age are at risk too, more so because they drink more water than the average person.  Some people are even just naturally hypersensitive to fluorine compounds and must minimize contact with them.

Other population segments people suffer over-exposure at their workplace, for example those who work in or around the production of aluminum, magnesium, petrochemicals, coal, glass, tile or brick will have higher exposures to fluoride and/or other elements that could act together with fluoride, that is synergistically, to do more damage.

Key aspects to investigate include fluoride effectiveness in tooth and bone protection, fluoride safety, fluoride biological effects and routes of action, and fluorine sources and forms.

Health concerns regarding fluoride consumption over time easily arise when considering that the original use of fluoride compounds was as a pesticide and is still used as such today as seen above.

When applied to a surface, fluoride acts topically. After being swallowed, fluoride acts systemically through the bloodstream. From the bloodstream fluoride ends up in saliva, producing a topical effect on teeth. This is the primary route of action for fluorides and prime motivator for pro-fluoridationists. Systemic fluoride also tends to collect over time in certain tissues like bones and certain organs like the pineal gland which is involved in hormone production and can interfere with healthy with regular thyroid function, research suggests.

Water fluoridation also appears to be somewhat pointless when major health organizations openly admit that fluoride has no significant systemic effect on tooth strength outside of the development phase of permanent teeth in children. To add to the confusion there have actually been cases in which excessive fluorine caused severe negative effects on people’s teeth later on in life.

Fluoride research is also not evenly thorough and consistently conducted from study to study, making comparative research difficult. Bias can also influence the parties involved while conducting and interpreting research.

Anti-fluoridationists overstate risks, pro-fluoridationists understate risks

A quick web search about fluoride safety results in more questions than answers. The massive amount of information and factors involved require a deep long look at available sources, many of which stink of bias whichever side of the debate they are on.

Anti-fluoridation pages often have a knack of mixing in wild speculation and rumor with legitimate questions and research. The worst cases will say that it all started in Nazi Germany when fluoride was used to sterilize and pacify Jews and that the World Health Organization is the devil, works for the New World Order and wants to control your mind, so “hide ya wife and hide ya kids.”

Some concern is definitely reasonable, but let’s not get carried away, especially when an abundance of peer-reviewed research can be used to disprove all sorts of wild claims. If fluoride is so bad for you for example, how is there no known statistical difference in mortality rate between fluoridated and non-fluoridated communities? That is of course up for debate but most research yields negative results.

Pro-fluoridation pages generally seem more well-groomed and refined than the opposition and assure viewers that it’s safe and effective, with decades of research to back them up. Some big fish like the World Health Organization, the U.S. Centers for Disease Control and Prevention and the American Dental Association identify with this position. It’s clear though, they have taken a side; they want to save your children’s teeth and really prefer you don’t think about any under-explored research avenues too much.

Everyone knows fluoride is safe, please move along

The American Dental Association’s 2005 edition of “Fluoridation Facts,” available on their website, is reassuring. Almost too reassuring.

“While opponents of fluoridation have questioned its safety and effectiveness, none of their charges have ever been substantiated by generally accepted science. With the advent of the Information Age, a new type of ‘pseudo-scientific literature’ has developed. The public often sees scientific and technical information quoted in the press, printed in a letter to the editor or distributed via an Internet Web page. Often the public accepts such information as true simply because it is in print. Yet the information is not always based on research conducted according to the scientific method, and the conclusions drawn from research are not always scientifically justifiable. In the case of water fluoridation, an abundance of misinformation has been circulated. Therefore, scientific information from all print and electronic sources must be critically reviewed before conclusions can be drawn.”

Fair enough, after all there’s a saying, “a lie can travel halfway around the world while the truth is putting on its shoes,” but, some safety claims are based on promising preliminary research which deserves to be fleshed out for certainty’s sake.

The CDC does not seem to have any more doubts though: “The safety and effectiveness of fluoride at levels used in community water fluoridation have been thoroughly reviewed by multinational scientific and public health organizations (U.S., Canada, Australia, New Zealand, Great Britain, and by the World Health Organization) using evidence-based reviews and expert panels.

The safety and effectiveness of community water fluoridation continues to be supported by scientific evidence produced by independent scientists and summarized by panels of experts. The independent, non-governmental Community Preventive Services Task Force has noted that the research evidence does not demonstrate that community water fluoridation results in any unwanted health effects other than dental fluorosis, a condition that causes primarily cosmetic changes in the appearance of tooth enamel.”

Coverup?

Some high profile scientists, doctors and dentists do stand out with a belief that there could be potential risks which are not being taken seriously enough. Is research that goes against the grain discouraged?

“Fluoridation presents unacceptable risks to public health, and the government cannot prove its claims of safety,” former EPA senior scientist Robert J. Carton, PhD, has said, “EPA has attempted to silence scientists who do not follow the party line.”

Carton has made some serious allegations: “in April 1985, a person writing standards for EPA actually told me, in private, that he was lying. He said he was told to lie, and that he had to do what he had to do to keep his job.”

Philippe Granjean, M.D., who is widely accused of overemphasizing fluoride risks, stated in 1985: “fluoride toxicity has been a ‘faux pas’ for many years, and anybody discussing this topic would be suspected to belong to the antifluoridation movement. Thus, the recently published Environmental Health Criteria 36 on Fluorine and Fluorides (WHO, 1989) only superficially discusses chronic toxicity, while beneficial effects and safety margins are dealt with in detail. As Temporary Adviser I was present at most of the Task Group meeting when the document was finalized. In accordance with the official fluoridation policy, information which could cast any doubt on the advantage of fluoride supplements was left out by the Task Group.”

Is Granjean just another loose cannon or did he do the public a service? The convoluted, but it’s definitely not an idea that should be completely thrown out of the window, however crazy that that may sound. After all, money interests and reputations can be touchy and socio-political pressure can be exerted to protect them.

The curious Mullenix case

The case of Dr. Phyllis Mullenix deserves its own paragraph. She worked  at Forsythe Dental Center, in Bostonin the eighties and nineties, as toxicology department head under supervision of fluoride toxicology expert Harold Hodge and Forsythe Director Jack Hein. Her job was to head up this department to look at the environmental impact and the toxicity of products that are used by dentists and the dental community with a novel computer-based approach she had become known for.

Hodge had been chief of fluoride toxicology studies for the University of Rochester division of the Manhattan Project in the forties and one of the founders of the Society of Toxicology. He had a defining influence on the adoption of fluoride in the U.S. as a caries preventative, it’s alleged. Hein, who encouraged Mullenix to do toxicology research on fluoride had also previously been a student of Hodge’s.

After Hodge’s death in 1990 and Hein’s retirement in 1991, the encouraging environment changed. Mullenix got a paper on fluoride submitted for peer review in 1994 which got published in 1995. The paper was supposed to garner the interest necessary to get funding for more in-depth research.

The paper indicated that high-dose fluoride in the diet of rats could cause accumulation in parts of the brain when administered in over time, hyperactivity disorder when administered to the mother prenatally, and hypoactivity disorder when administered postnatally.

Her research garnered a lot of attention, negative attention. In fact she was reprimanded by a large group of people representing various agencies and corporate interests via teleconference for having submitted the research for peer-review, a standard practice that had never been a problem with her previous, less controversial research. She was denied further funding and was she was fired from Forsythe before her paper even got published. Mullenix said the reasons given for her firing was that she “didn’t get enough funds to do [her] research, number one; number two, the projects [she] worked on were not ‘dentally related.’ Then also that they weren’t interested in that kind of science, to look into the safety of fluoride. They didn’t consider that, well, as they put it, that’s not ‘their idea of science.’”

Several videos of Mullenix can be found on YouTube, and an extensive interview between her and the founder of the anti-fluoridation Fluoride Action Network can be found on their website.

RESEARCH WANTED

Recent research committees such as the U.S. National Academies of Science Research Committee (NRC 2006) and the E.U. Scientific Committee on Health and Environmental Risks (SCHER 2010), were tasked on shedding more light on common questions regarding fluoridation. The panels indicated that that the quality and quantity of studies and data available is lacking for there to be a very high degree of certainty regarding safety of systemic fluoridation and dental fluorosis in a variety of cases.

I must premise that in 2013 John Doull, MD, PhD, and Chair of the National Research Council stated: “I do not believe there is any valid, scientific reason for fearing adverse health conditions from the consumption of water fluoridated at the optimal level.”

Nonetheless the NRC’s 2006 report indicates that more research needs to be done on fluoride concentrations in human bone especially in the post-menopausal women and the elderly, and in soft tissues (e.g., brain, thyroid, kidney) following chronic exposure. The report also found research on aluminofluoride complexes to be lacking and deserving of more attention.

The following are some of the more interesting recommendations made in the NRC 2006 report (complete text available for free online):

  • “More studies are needed on fluoride concentrations in soft tissues (e.g., brain, thyroid, kidney) following chronic exposure. More research is needed on bone concentrations of fluoride, especially in people with altered renal function, as well as other potentially sensitive populations (e.g., the elderly, postmenopausal women, people with altered acid-balance), to better understand the risks of musculoskeletal effects in these populations.
  • “The biological effects of aluminofluoride complexes should be researched further, including the conditions (exposure conditions and physiological conditions) under which the complexes can be expected to occur and to have biological effects.
  • “The possibility has been raised by the studies conducted in China that fluoride can lower intellectual abilities. Thus, studies of populations exposed to different concentrations of fluoride in drinking water should include measurements of reasoning ability, problem solving, IQ, and short-and long-term memory. Care should be taken to ensure that proper testing methods are used, that all sources of exposure to fluoride are assessed, and that comparison populations have similar cultures and socioeconomic status.
  • “Studies of populations exposed to different concentrations of fluoride should be undertaken to evaluate neurochemical changes that may be associated with dementia. Consideration should be given to assessing effects from chronic exposure, effects that might be delayed or occur late-in-life, and individual susceptibility
  • “Further effort is necessary to characterize the direct and indirect mechanisms of fluoride’s action on the endocrine system and the factors that determine the response, if any, in a given individual. [The endocrine system is comprised of all the major hormone producing glands in the body, including the thyroid and the pineal gland.]
    Better characterization of exposure to fluoride is needed in epidemiology studies investigating potential endocrine effects of fluoride. Important exposure aspects of such studies would include the following:

    • collecting data on general dietary status and dietary factors that could influence the response, such as calcium, iodine, selenium, and aluminum intakes
    • characterizing and grouping individuals by estimated (total) exposure, rather than by source of exposure, location of residence, fluoride concentration in drinking water, or other surrogates
    • reporting intakes or exposures with and without normalization for body weight (e.g., mg/day and mg/kg/day), to reduce some of the uncertainty associated with comparisons of separate studies
    • addressing uncertainties associated with exposure and response, including uncertainties in measurements of fluoride concentrations in bodily fluids and tissues and uncertainties in responses (e.g., hormone concentrations)
    • reporting data in terms of individual correlations between intake and effect, differences in subgroups, and differences in percentages of individuals showing an effect and not just differences in group or population means.
  • “The effects of fluoride on various aspects of endocrine function should be examined further, particularly with respect to a possible role in the development of several diseases or mental states in the United States. Major areas for investigation include the following:
    • thyroid disease (especially in light of decreasing iodine intake by the U.S. population);
    • nutritional (calcium deficiency) rickets;
    • calcium metabolism (including measurements of both calcitonin and PTH);
    • pineal function (including, but not limited to, melatonin production); and
    • development of glucose intolerance and diabetes.”

The SCHER 2010 report states:

“Exposure assessment is the critical requirement here. Improving the assessment needs: 1) New biomarkers for long-term fluoride exposure. 2) Standardized methods for exposure assessment that add together all routes of exposure. 3) Better information on fluoride in food and bioavailability of fluoride. 4) Epidemiological studies, taking advantage of the existing mother-child cohorts to investigate the role of fluoride intake in dental fluorosis and dental health.”

Clearly there is a lot of research to cover, all of which would be impossible in this commentary, so I’ll stick to a couple main research topics over the next two sections, the effects of fluorosis on mineralized tissues and the dangerous potential of aluminofluoride compounds.

Fluorosis is primarily cosmetic?

Let’s think about fluorosis, the supposed only negative effect of low-dose fluoride.

Dental fluorosis is due to an excessive systemic exposure to fluoride during tooth development (between birth and eight years of age), with white discoloration in milder forms and brown stains and pitting in the worst cases.

A 2010 study found that fluorosis rates have nearly doubled since the eighties in the U.S.; in fact 40.7% of adolescents aged 12-15 were found to have dental fluorosis between 1999 and 2004. Only a very small portion of cases were moderate or severe though, which is good news considering that severe cases can actually mean teeth can chip more and get cavities more easily. Such cases are usually due to accidental overdoses

Still, could mild dental fluorosis also indicate mild skeletal fluorosis, and might it be dangerous at some point? The WHO has also stated that fluoride accumulates (fluorosis) in bone tissue progressively over many years.

Bones with even moderate fluorosis have been found to be more prone to breakage than average, among other issues.

In 1970 the WHO said: “At higher levels of ingestion – from 2 to 8 [ppm] daily, skeletal fluorosis may arise […] Whereas dental fluorosis is easily recognized, the skeletal involvement is not clinically obvious until the advanced stage of crippling fluorosis […] early cases may be misdiagnosed as rheumatoid or osteo arthritis (sic).” Is that concerning?

A quick calculation based on 2015 Port Angeles public utility district water fluoridation data, water is kept at concentrations between .8 and .96 mg/l or ppm. So, going by the 1970 WHO data, Port Angeles residents are in the skeletal fluorosis risk-zone after drinking just two and a half liters a day, and that’s without considering any other common fluoride source like swallowed toothpaste, tea, etc.

Recent statements from the WHO have played its earlier conclusions down, saying fluorosis occurs only at acute high-level fluoride exposures, and not at recommended levels.

Unsurprisingly the ADA went one step further in its 2005 report, stating that low-dose fluoride is essential to keep bones from demineralizing in at-risk population segments. The NRC 2007 report also chimed in attesting to fluoride’s contribution to bone mineralization and bone matrix integrity.

The conclusions seem to stem from a 2000 study by Phipps et al. sampling almost 1000 individuals which concluded, “this is the first prospective study with adequate power to examine the risk of specific fractures associated with fluoride on an individual rather than a community basis. Our results show that long term exposure to fluoridation [at 1 ppm] may reduce the risk of fractures of the hip and vertebrae in older white women. Because the burden of osteoporosis is largely due to fractures of the hip, this finding may have enormous importance for public health.”

The research is somewhat reassuring, but considering the possible implications, more research would still be helpful in low-fluoride dose cases that factors in secondary sources especially so as to determine the threshold between enough and too much consumption.

Synergy — can fluoride cause harm when combined with other elements like aluminum?

In the past few decades, some research has been done indicating that molecules containing fluoride and certain other elements, especially aluminum and barium, could have a synergistic effect. Such an effect occurs when the combined action is greater than the sum of each element acting separately.

The most interesting interaction seems to be that of fluoride and aluminum.

According to a 1988 paper by Martin, et. al., of the more than 60 metals on the periodic chart, the Al3+ ion binds with fluoride most strongly.

Research has shown that aluminum can have a role in the formation of amyloid plaques in the brain which are the cause of Alzheimer’s dementia.

A 2009 study on rats by Tanzeer, et. al., showed that when rats are given fluoride in combination with aluminum, it produces toxic results on the rat brain at high concentrations over time. In this experiment it was shown that aluminum can cross the blood-brain barrier more easily thanks to fluorine.

It would seem safe to assume that the effect of fluoride on people who are exposed to aluminum routinely could have serious implications.

A 1998 study on rats by Varner, et. al., showed that in rats accidentally fed a large quantity of aluminum, those given water with low amounts of sodium fluoride suffered significant damage, resulting in kidney disease, dementia, and an elevated mortality rate compared to non-fluoridated controls (40% compared to 10% mortality rate).

Mullenix has pointed out that the scientific community’s understanding of chemical signaling in cells is thanks to the use of aluminum fluoride complexes which were used to alter important cell functions.

Are people really exposed to significant amounts of fluoride and aluminum though?

“Besides vaccines, aluminum is found in a number of baked goods, processed cheeses, and teas. In one study, food was found to supply 25 times more aluminum systemically than public drinking water. Recent studies have shown very high levels in a number of commonly used feeding and intravenous parenteral solutions used in pediatrics,” according to a 2009 peer-reviewed paper by Blaylock, et. Al, “aluminum not only accumulates in the brain but produces inflammation, generates free radicals, and interferes with neuronal tubular function.”

“Sources of human exposure to aluminum include drinking water, tea, food residues, infant formula, aluminum-containing antacids or medications, deodorants, cosmetics, and glassware,” a 2002 Strunecka and Patocka study also reports, according to NRC 2006.

According to Greger JL of the Department of Nutritional Sciences, University of Wisconsin, “most adults consume 1-10 mg aluminum daily from natural sources. Intake of aluminum from food additives varies greatly (0 to 95 mg Al daily) among residents in North America, with the median intake for adults being about 24 mg daily. Generally, the intake of aluminium from foods is less than 1% of that consumed by individuals using aluminium-containing pharmaceuticals.”

Aluminum can also be found in water.

“Aluminum in drinking water comes both from the alum used as a flocculant or coagulant in water treatment and from leaching of aluminum into natural water by acid rain” (Agency for Toxic Substances and Disease Registry 1999; Li 2003).

Concerningly, a 1985 study by Pitter, et. al., found that drinking water contains a substantial fraction of fluoro-aluminum complexes rather than free fluoride.

An interesting result of the Tanzeer study was that, “fluoride and aluminum have a strong tendency to form a complex, and even if their ingestion is from different sources, they have a tendency to form the complex in vivo.” The ATSDR 1999 findings also indicated aluminofluorides “can occur when a person ingests both a fluoride source (e.g., fluoride in drinking water) and an aluminum source.”

“As well, with the increasing prevalence of acid rain, metal ions such as aluminum become more soluble and enter our day-to-day environment; the opportunity for bioactive forms of aluminum fluoride to exist has increased in the past 100 years” (Li 2003; Shu et al. 2003; Wong et al. 2003).

It is clear once again that more research needs to be undertaken.

Wrapping up

When I started looking into fluoride research I had doubts. Now, after relatively just scratching the surface, while I have some significant reassurances, I still have way too many doubts.

I’m glad fluoride keeps teeth from decaying, but I don’t think I’m willing to put up with the risks of a slow over-dose.

I had my mom ask my old dentist about fluoride in Italy. He said there’s plenty of fluoride available from other sources—though Italy does have some in the water naturally. That seems reasonable. As long as people brush at least once a day, floss regularly and get regular cleanings isn’t that plenty enough?

Also, if caries are such a problem with kids, maybe we should bump up free dental cleaning for affordable care act users to twice a year, for example. There could also be better dental education, with schools involving parents, for example. The wrong diet also plays a role in dental decay, as well as in fluorosis. There should be better education on what foods to should be avoided to minimize tooth decay.

If fluoride is so safe, why aren’t we seeing more in-depth studies where they’re needed to ease doubters’ worries? Why are there still so many questions after 70+ years of research? Organizations can give assurances all they want, but an exhaustive range of data is what’s needed for true consumer confidence.

Is it even ethical to continue medicating against the will of the majority?

I hope the fluoridation level will at a minimum be lowered in fluoridated communities soon across the U.S. to decrease any risks. As mentioned previously, water was kept at concentrations between .8 ppm and .96 ppm for Port Angeles. This data was provided by Craig Fulton, Port Angeles director of public works and utilities in Nov. 2015. The Washington State Department of Health still has to update its standard to the new, lower .7 ppm limit recommendation. Fulton said levels were intentionally kept on the lower end of the the recommended range in Washington State, which is between .8 ppm and 1.3 ppm.