Friday, April 10, 2015

Pretty Smiles

We have to be careful when we make decisions for others, or when we criticize others for making decisions with which we don't agree.

For example, putting fluoride in a water supply from which everyone in a community drinks - when other options are available, when controversy exists about its safety, when some people simply do not want the chemical added to their water - may be unhealthy, imprudent, and unethical.

Concern is reasonable in a community whose members have a variety of health issues, some known and some not known, that the fluoridation of its water supply may not have a net benefit. Yet there seems to be pressure to convince communities to add fluoride to its water supply. Dentists and doctors, citing scientific research, have written how important water fluoridation is for dental health. Special interests, present but invisible, use “Science” in an attempt to coerce public opinion and overwhelm common sense without addressing the complexities.

If the fluoridation issue was only about healthy teeth and pretty smiles, there is compelling scientific evidence to contradict the scientific evidence that shows the safety, efficiency, and necessity of adding fluoride to drinking water. This alone might cause concern in the minds of those who would be drinking the water. But it's not about healthy teeth and pretty smiles as much as it is about people making decisions for themselves and their families.

Authoritative fluoride promotion expresses concern for the welfare of the community: “We know what's best for you,” is implied. Other assurances are issued from some levels of government but even the federal government cannot make fluoridation of local water supplies mandatory. It appears that the intention is to control public policy.

Fluoride, usually in the form of hydrofluorosilicic acid (HFSA), a cheap waste product of phosphate fertilizer production, is added to water supplies to reduce the incidence of dental caries - cavities - in people who drink the water. It has been done in various places in the United States since 1945 when sodium fluoride, a pharmaceutical grade chemical, was used. By most accounts it appears to be effective at reducing the incidence of cavities.By 2008, over 195,000,000 Americans were drinking fluoridated water.

The Environmental Protection Agency (EPA) approved of the use of HFSA in place of sodium fluoride for water fluoridation in 1980 without prior animal or human studies. It based its decision on HFSA's low cost and the “longstanding problem” it perceived as air and water contamination from fertilizer manufacturing. In some expert opinions this “two birds with one stone” solution amounted to a “double whammy” on human health.

Hydrofluorosilicic acid, the fluoride compound used in over 90% of American communities that employ fluoridation, contains about 30 parts per million of arsenic and may be responsible for leaching lead into water from pipe fittings. HFSA is a good lead solvent and was associated with elevated children's blood lead levels in Washington, D.C. in the 2001-2004 period. The EPA's maximum water contaminant level for arsenic is 10 parts per billion and for lead, 15 parts per billion. Arsenic is a known human carcinogen and lead profoundly harms children's neurological development. A 1992 research project in northern Mexico proposed an interaction between fluoride and arsenic with the possibility that fluoride is partly to blame for signs and symptoms that usually are attributed to arsenic alone, since they often occur together and both harmfully affect enzyme activity in metabolic energy production pathways.

Sodium fluoride, which is found in many commercially available toothpastes, contains virtually no arsenic and no heavy metals. According to the EPA, sodium fluoride is not appropriate for water fluoridation.

As pointed-out in an April 2013 petition to the EPA, 99% of the water treated with HFSA flushes toilets, washes clothes, bathes bodies, and waters lawns and as such is an inefficient way to apply fluoride to human teeth where it has its effect. It may be more a profitable way that the fluorochemical industry has of disposing of a hazardous waste than it is an efficient dental treatment.

According to a 2010 report, the global fluorochemical market was expected to exceed 2.6 million tons by 2015. In 2006, at a considerably lower production rate, the fluorochemical market was valued at $16 billion with water fluoridation accounting for about 5%, or roughly $750 million.

The U.S. is the largest consumer of fluorochemicals in the world. Fluorochemicals are used in refrigerants, electronics, water repellants, and aluminum smelting. Teflon and Scotchguard are made using fluorchemicals. Fluorides are used also in the manufacture of drugs including statins, antidepressants, and antibiotics. Dupont, 3-M, and Merck are among the biggest participants in the fluorochemical economy. The American Chemical Society (ACS), headquartered in Washington, D.C., owner of a Title 36 Congressional Charter, is a powerful lobbying group representing Dupont, 3-M, Merck, Dow, Exxon, and Procter and Gamble, among many others. In 2015 a former Dupont executive became the CEO of the ACS. A goal of the ACS, of course, is to establish public policy supportive of its industry.

In the 1970's, with the U.S. Public Health Service (USPHS), Procter and Gamble sponsored a study of fluoride's carcinogenicity but did not find a statistically significant relationship between fluoride and cancer.

The Safe Drinking Water Act, the federal law that ensures quality drinking water in the U.S.,  prohibits the EPA “...from requiring the addition of any substance to drinking water for preventive health care purposes...” according to the 2013 petition. Adding fluoride, either in the hazardous waste form or the pharmaceutical grade form, is considered a local matter.

According to the FDA, “Fluoride, when used in the diagnosis, cure, mitigation, treatment or prevention of disease in man or animal is a drug that is subject to Food and Drug Administration (FDA) regulation.” But HFSA has not been evaluated or approved by the FDA - no new drug applications to study HFSA for ingestion have ever been received by FDA.

In 2006 the National Academies of Science suggested that EPA update its recommendations on fluoride exposure based on what appeared to be an increase in the incidence of dental and bone fluorosis over the previous decades. In 2010 the Department of Health and Human Services (HHS) reviewed “the best available information” on the incidence of cavities, the incidence of fluorosis, exposure of adults and children to various sources of fluoride, and data from the EPA, resulting in a downward revision of the EPA's recommended standard of 0.7 to 1.2 milligrams per liter to 0.7 milligrams per liter, the value at the low end of the range. Note that the recommended revision was downward from an acceptable range to the concentration at the low end of the range of EPA's previous standard. It's not known if EPA has implemented the revision.

Dental fluorosis, considered a developmental defect, is caused by ingesting fluoride while teeth are developing. Fluorosis starts to occur at fluoride concentrations in water at 1 part per million, according to The Chemistry of Mature Enamel. It is characterized by white lacy markings on teeth in its mild form to pitting and mottling with brown discoloration of the enamel in more severe cases. The greatest risk is to children up to 8 years of age, but in the period 1999-2004 the incidence of fluorosis in 12 to 15 year olds was 41%. The CDC has blamed the increase in incidence of fluorosis on the availability of fluoride-containing toothpastes and other dental treatments, and the consumption of food prepared with fluoride-containing water. By the 1990's, 90% of commercial toothpastes contained fluoride. Some antibiotics contribute to fluorosis at lower levels of fluoride ingestion.

Dental caries is a bacterial infection of teeth in which acids from bacteria dissolve the tooth's enamel, resulting in pain, tooth loss, and possibly systemic infection. These bacteria live in the plaque that forms around teeth and sticks to tooth enamel. The more sugar that enters the environment of the mouth, the happier and more active the bacteria become.

According to the Centers for Disease Control and Prevention (CDC), “Fluoride's predominant effect is... topical and depends on fluoride being in the right amount in the right place at the right time.” This statement seems to recommend the use of fluoride-containing toothpaste when brushing teeth after eating, but CDC still recommends water fluoridation calling it “one of the ten great public health achievements of the 20th century”. Though we often hear that fluoride “prevents” cavities, experts insist that fluoride technically doesn't prevent cavities – it promotes re-mineralization of enamel that's been dissolved by bacterial acids. Thus, fluoride's beneficial effect is observed when it's applied topically as opposed to systemically by ingestion.

Cavities are no small problem. The World Health Organization recognizes dental caries as a major health concern related to diabetes, cardiovascular disease, cancer, and lung disease by risk factors that are considered “modifiable”. An odd thing about the incidence of cavities is that it is very low in poor, non-industrialized countries but in developed, industrialized countries it is high especially in poor, socioeconomically disadvantaged areas. Risk factors for dental caries include - in addition to low income - high sugar consumption, smoking and other tobacco use, and low (acidic) salivary pH. They're “modifiable” because we can choose to eat less sugar or stop smoking cigarettes, for example. Usually cavities are a sign of poor health in general not an isolated health problem.

A 1999 Polish study found that a variety of factors influence a child's risk for caries, including genetics, and that prevention should be individualized to match the risk. The study found that high caries-risk children benefitted most from chewing fluoride gum.

Chewing gum sweetened with xylitol has benefits to oral health including reduction of plaque formation and gum-tissue inflammation, and in increasing re-mineralization of tooth enamel.  American Dental Association (ADA) research questions xylitol's benefits, however, quoting the study's author as saying “The best evidence for preventing tooth decay is still brushing with fluoride toothpaste and eating less sugar.”

Fluoride isn't safe - it's relatively safe and relatively toxic. It is not an essential nutrient in the human diet. The pharmaceutical compound sodium fluoride is a drug regulated by the FDA and requires a doctor's prescription (except in toothpaste or mouthwash). Ingested either from the water supply or in a pill as prescribed, fluoride interferes with magnesium absorption. It's generally acknowledged that many people are magnesium deficient, even that magnesium deficiency is endemic in the U.S. According to the U.S. Department of Agriculture, 57% of the U.S. population does not meet the U.S. RDA for dietary intake of magnesium. The more magnesium deficient one is the greater is one's absorption of fluoride. Taking magnesium supplements may reduce fluoride absorption. Fluoride also inhibits iodine absorption and, because of the chemical similarity between the two, the former competes with the latter in the sensitive metabolism of the thyroid gland and its hormones. Because of the way in which it can interfere with thyroid metabolism, fluoride is considered a “hormone disruptor”. Fluoride is excreted from the body by the kidneys. If one has kidney problems, one must filter fluoride from the water before drinking it. Fluoride accumulates in bone and soft tissues. Fluoride has an affinity for aluminum, which is abundant in the environment and in prepared food, and which has been implicated as a causal factor in the development of Alzheimer's disease.

Chronic ingestion of fluoride at 4 parts per million or more can cause serious neurological and musculoskeletal health problems, and at lower concentrations it has other unwanted and unanticipated effects. In research to explore the effect of fluoride ingestion on postmenopausal women, it was found consistently that fluoride increased bone mass but also increased the incidence of bone fracture. Research performed by a former researcher from the National Cancer Institute (NCI) demonstrated an increased risk of cancer in those ingesting fluoridated water, research that was contested by the NCI and the U.S. Public Health Service (USPHS) in a famous court case in the 1970's.

It doesn't seem reasonable to assume that fluoride does not have harmful effects on the human body along a continuum of concentrations before side effects manifest, especially if the body's ability to detoxify it is compromised in some way. It may be that we don't recognize yet some health problems as fluoride-related.

Fluoride occurs naturally in many water supplies in the U.S. In some areas, for example in the Southwest, naturally occurring fluoride is present in water at high concentrations and must be reduced for drinking. In Rifle, Colorado, where artificial water fluoridation is an issue, the naturally occurring fluoride content of public water is 0.33 milligrams per liter, which is about half of the most recent recommendation of 0.70 milligrams per liter made by the U.S. Department of Health and Human Services.

Researchers have discovered that living at a relatively high altitude improves enamel production in the same way that fluoride does and that its effects may be additive to fluoride's. This observation was made on dental patients at an elevation of 4300 feet above sea level. Rifle's elevation is 5350 feet above sea level.

Some European countries have rejected fluoridation of public drinking water on the principle that doing so amounts to the indiscriminate medication of a population. Under the terms of the 1999 European Biomedical Convention, “Fluoridation as a practice is clearly unethical.” The Convention established “the individual's right to informed consent on any personal intervention”.

Informed consent” is a voluntary agreement between a patient and her or his doctor for participation in a research project, or for a diagnostic or therapeutic procedure, the patient having been informed thoroughly of the purpose, methods, benefits, and risks. “The patient must be put in a position, through the use of terms he or she can understand, to weigh up the necessity or usefulness of the aim and methods of the intervention against its risks and the discomfort or pain it will cause.” In some opinions, in the case of water fluoridation informed consent does not occur and fluoridation, therefore, is medical malpractice.

A classic paper in support of water fluoridation titled the Newburgh-Kingston Caries-Fluorine Study: Final Report, published in the Journal of the American Dental Association in 1956, announced that water fluoridation presented no risk to human health, and that those who opposed it were “... chiefly food faddists, cultists, chiropractors, misguided and misinformed persons who are ignorant of the scientific facts on the ingestion of water fluorides, and, strange as it may seem, even among a few uninformed physicians and dentists.” According to Graham and Morin, in a paper published in the Journal of Land Use and Environmental Law in 1999, this sentiment “...set the tone of ADA and USPHS activists and others promoting this practice in the face of growing opposition from eminent scientists and physicians... there has always been learned and respectable opposition to artificial fluoridation of public water supplies, and all attempts to deny it can only be characterized as irresponsible.” Graham and Morin say further that “...the lowest rates of tooth decay in children occur in areas where the fluoride level is about 0.2-0.4 ppm, which is the normal level in most parts of the world.” And finally, “...trial judges over the past twenty years have repeatedly found, after hearing experts, that fluoridation is injurious to public health”.

World renowned cancer research scientist Dean Burk, head of cytochemistry at NCI, testified before congress in 1976:

The scientific and medical status of artificial fluoridation of public water supplies has now advanced to the stage of the possibility of socially imposed mass murder on an unexpectedly large scale involving tens of thousands of cancer deaths of Americans annually.

In response the USPHS criticized Burk's methods and the NCI, for whom he'd worked for 30 years, attacked his epidemiological work. Eventually, NCI convinced Congress that there was no association between fluoridation and cancer.

(Dean Burk earned his first Ph.D at the age of 20, co-discovered biotin, taught biochemistry at the medical school at Cornell University, and co-authored research with Nobel laureate Otto Warburg, with whom he was a close friend. Burk had a remarkable professional career.)

Other important lawsuits against mandatory fluoridation have been decided in favor of plaintifs who sought injunctions against the procedure. Three notable cases, in Pittsburg, Alton (Illinois), and Houston, in the '70's and '80's all found that research demonstrated that fluoridation was associated with an increased risk of cancer and that the proposed benefit was not worth the risk. The finding of the Judge in the Houston case was unequivocal:

...the artificial fluoridation of public water supplies, such as is contemplated by [Houston] City Ordinance No.80-2530 may cause or contribute to the cause of cancer, genetic damage, intolerant reactions, and chronic toxicity, including dental mottling, in man; that the said artificial fluoridation may aggravate malnutrition and existing illnesses in man; and that the value of said artificial fluoridation is in some doubt as to the reduction of tooth decay in man.

Subsequently, the Texas Court of Appeals found that injecting fluoride into the city's water was harmful. But these decisions (and judges' rulings in Pittsburgh and Alton) were not enough to prevent the state from exercising what is called “police power” to proceed with fluoridation. Police power is the legal authority of states to act in the interest of the “health, safety, morals, and general welfare of the public”. It gives the states the power to force people to do what it thinks is best for them and to overturn a judge's decision.

Having learned their lesson in court, “pro-fluoridation activists” from the ADA and the USPHS decided on a different tactic for future defenses of its program: avoid court and the decisions of a judge who probably would not know enough about science to make the "right" decision.

Graham and Morin believe that, eventually, the practice of artificially fluoridating water supplies will be discontinued. Meanwhile it is important to maintain the legal history of the issue because, as they say, "time is the solvent of truth".