Facts about Fluoridation

Fluoride Action Network
March 2002

• 98% of western Europe has rejected fluoridation. This includes: Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, Netherlands, Norway, Sweden, the majority of Switzerland (97%), and the majority of the United Kingdom (90%).

• Fluoride is the only chemical added to drinking water for the purpose of medication (i.e. to prevent tooth decay). All other treatment chemicals are added to treat the water (i.e. to improve the water's quality and safety - which fluoride does not do). This is one of the reasons why much of Europe has rejected fluoridation. For instance:

In Germany, "The argumentation of the Federal Ministry of Health against a general permission of fluoridation of drinking water is the problematic nature of compuls[ory] medication."

In Belgium, it is "the fundamental position of the drinking water sector that it is not its task to deliver medicinal treatment to people. This is the sole responsibility of health services."

In Luxembourg, "In our views, drinking water isn't the suitable way for medicinal treatment and that people needing an addition of fluoride can decide by their own to use the most appropriate way."

• All fluoride products designed for ingestion (i.e. fluoride supplements) are available by prescription only. Amazingly, no fluoride products designed for ingestion have ever been approved as safe or effective by the US Food & Drug Administration.¹ The only fluoride products which the FDA has approved, are products designed for topical - not systemic - application (i.e. fluoridated toothpaste).

Fluoride's Benefits are Primarily TOPICAL not SYSTEMIC

• When water fluoridation began 50 years ago, it was believed that fluoride needed to be ingested in order to be effective. This, however, is no longer the view of the dental establishment, which now generally concedes that fluoride's benefits are derived primarily from topical application.² According to the US Centers for Disease Control, "[L]aboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children."
• While fluoride's benefits are primarily topical, it's risks (as discussed below) are primarily systemic (i.e. when swallowed).
• The chemical used to fluoridate water is an industrial waste product from the phosphate fertilizer industry. It is an unprocessed hazardous waste, contaminated with a number of toxins, particularly arsenic.³
• The industrial chemicals used to fluoridate 91% of fluoridated water in the US (fluosilicic acid & sodium silicofluoride) have never been tested for either safety or effectiveness. According to a recent letter from the US Environmental Protection Agency (EPA), "to answer your question on whether we have in our possession empirical scientific data on the effects of fluosilicic acid or sodium silicofluoride on health and behavior, the answer is no."

(Friends of the Earth UK, a prominent environmental health group in England, has called upon the British Government to conduct studies on these fluoridation chemicals, and that these studies should be carried out "before fluoridation could be contemplated.")

• New evidence suggests that fluoridation is either unnecessary or doesn't work. Cavities have declined at similarly impressive rates throughout the entire western, industrialized world over the past half century. This decline has occurred irrespective of a country's fluoridation status. Western Europe, which is 98% unfluoridated, has experienced the same decline in cavities as the heavily fluoridated US, and today enjoys the SAME low level of tooth decay.⁴
• The largest dental survey ever conducted in the US found virtually no difference in dental decay between children living in fluoridated vs. unfluoridated areas. The study, which was conducted by the National Institute of Dental Research (NIDR), found that the average difference in tooth decay (0.6 tooth surfaces) between children living in fluoridated vs unfluoridated areas amounted to LESS than 0.5% of the 128 total tooth surfaces in a child's mouth.⁵
• 5 peer reviewed studies published in the last 2 years have found that dental decay DOES NOT increase when communities stop fluoridation.⁶

Pit & Fissure Decay - Prevented by Sealants, not Fluoride

• The dental community concedes that fluoride is largely ineffective at preventing the most common type of cavity - Pit & Fissure Decay - which accounts for upwards of 85% of dental decay now experienced in the US.⁷ Pit & fissure decay is decay that occurs in the crevices of a tooth's chewing surface.
• The rhetoric supporting fluoridation is increasingly centered around the notion that fluoridation benefits the poorest in society the most. This claim flies in the face of the experience of most US inner cities over the past 50 years. Despite the fact that nearly all large US cities have been fluoridated for decades, dental decay is currently rampant in virtually all poor urban areas. (Read about the situation in fluoridated Boston.)
• One of the major dental health problems experienced in poor communities is a debilitating condition known as "baby bottle tooth decay" which is also referred to as "early childhood caries." This condition, which results from excessive consumption of sweetened liquids at a young age, is NOT prevented by water fluoridation. According to data from Head Start surveys "the prevalence of baby bottle tooth decay is about three times the national average among poor urban children, even in communities with a fluoridated water supply."⁸
• The real "oral health crisis" in the US is not lack of fluoridation, but lack of private dental insurance among the poor, and underinvestment in Medicaid by the Government. According to a recent report from the Surgeon General, roughly 85% of US dentists do not treat Medicaid patients due to Medicaid's low rates of reimbursement.⁹
• Fluoride is a very toxic substance, which is why it is the active ingredient in a number of pesticides. Just over 2 grams of fluoride (roughly a teaspoon) is enough to kill a 160 pound adult, while just 300 mg is enough to kill a 20 pound child. (10) In the US, people have died, and many have become sick, when faltering fluoridation equipment has pumped excess fluoride into the water.
• Poor nutrition exacerbates the toxic effects of fluoride exposure, which is a further reason why it's wrong to target poor communities with fluoridation (as poor nutrition is more prevalent in low income communities). According to the Agency for Toxic Substances and Disease Registry, "Existing data indicate that subsets of the population may be unusually susceptible to the toxic effects of fluoride and its compounds. These populations include the elderly, people with deficiencies of calcium, magnesium and/or vitamin C, and people with cardiovascular and kidney problems."¹¹
• Total fluoride exposure has increased substantially since the early days of fluoridation.¹² When fluoridation first began, exposure to fluoride from sources other than fluoridated water, was minimal. Today that is not the case. People now receive fluoride from a whole host of sources, including pesticide residues, fluoridated dental products, mechanically deboned meat, fluoride air pollution, and processed foods & beverages prepared with fluoridated water (e.g. soda, juice, beer, cereal, etc). It has now reached the point where most people receive the "optimal" 1 mg/day of fluoride (which fluoridated water was designed to deliver) WITHOUT ever drinking a glass of fluoridated water.
• Despite the increase in total fluoride exposure, the concentration of fluoride added to drinking water (0.7-1.2 mg/L) as prescribed by the US Government, is still the same as it was back in the 1940s.
• Due to the increase in total fluoride exposure, there has been a major increase in the rate of dental fluorosis found among American children. According to the US Government, approximately 1 in 3 children living in fluoridated areas have fluorosis on at least 2 teeth.¹³ Dental fluorosis is the first visible sign that fluoride has poisoned enzymes in the body.
• When a parent feeds a child infant formula reconstituted with fluoridated water, they are exceeding the fluoride dosage recommendations of the American Dental Association (ADA). According to the ADA, infants under 6 months of age should receive NO fluoride supplementation, while infants between the age of 6 months and 3 years should receive no more than 0.25 milligrams per day. Ingestion of fluoridated infant formula will exceed these limits and significantly increase the child's risk of developing dental fluorosis.¹⁴
• The level of fluoride found naturally in women's breast milk - which is where one would expect to find high levels of fluoride if it were necessary for the development of healthy teeth (which it is not) - is 100 times lower (0.01 mg/L) than the level of fluoride added to municipal water (1.0 mg/L).^15,16
• Approximately half of the fluoride we ingest each day accumulates in our bodies, primarily in the bones, but also in soft tissues.¹⁷
• High levels of naturally occurring fluoride causes a crippling bone disease known as skeletal fluorosis.¹⁸ Skeletal fluorosis, in its extreme form, currently affects millions of people living in India, China, and other poorer countries where nutritional deficiencies (e.g. lack of calcium) exacerbate fluoride's toxic effects.¹⁹
• Skeletal fluorosis comes in varying degrees of severity depending on nutritional status and level of exposure. The earliest symptoms are characterized by joint pain that is difficult, if not impossible, to distinguish from arthritis. According to a review on fluoridation by Chemical & Engineering News: "Because some of the clinical symptoms mimic arthritis, the first two clinical phases of skeletal fluorosis could be easily misdiagnosed [as arthritis]."²⁰ The World Health Organization states that "early cases [of skeletal fluorosis] may be misdiagnosed as rheumatoid or osteo arthritis."²¹

It is estimated that approximately 40 million Americans suffer from arthritis, the most common type being osteoarthritis.

• Fluoride stimulates abnormal bone development. Clinical trials published in the New England Journal of Medicine and Journal of Bone and Mineral Research²² report that high dose fluoride treatment increases bone mass but that the newly formed bone is "structurally unsound".²³ Thus, instead of reducing hip fracture, the studies found that high doses of fluoride increase hip fracture.
• There is concern that "low" doses of fluoride, taken over long periods of time (e.g. fluoridated water), may also increase the rate of hip fracture. 19 recent studies have investigated the relationship between low levels of fluoride in water and hip fracture, with over half of the studies finding an association.²⁴
• A 1995 study in the journal Neurtoxicology and Teratology, found that fluoride accumulated in the brain of rats and produced age-specific behavioral deficits typical of most neurotoxic agents.²⁵ In the study, fluoride induced damage to the hippocampal region of the brain. Damage to the hippocampal region has been linked to hyperactivity and cognitive deficits. Based on the results, the lead author of the study, Dr. Phyllis Mullenix, has come out and advised against water fluoridation.
• 5 recent peer reviewed studies from China have found an association between elevated fluoride exposure and decreased IQs in children - an effect that would be expected based on Mullenix's research.²⁶ According to a May 2000 review by Greater Boston Physicians for Social Responsibility:

"Studies in animals and human populations suggest that fluoride exposure, at levels that are experienced by a significant proportion of the population whose drinking water is fluoridated, may have adverse impacts on the developing brain. Though no final conclusions may be reached from available data, the findings are provocative and of significant public health concern."

• In the late 1990s, a British scientist discovered that fluoride accumulates to very high levels (avg = 9000 ppm) in the crystallized tissue of the human pineal gland. A subsequent animal study found that fluoride interferes with the pineal gland's production of melatonin, a hormone which helps regulate the onset of PUBERTY. In the study, animals dosed with fluoride had reduced levels of melatonin metabolites in their urine and had earlier onsets of puberty than the controls.²⁷
• Up until the 1950s, European doctors used fluoride to reduce the activity of the thyroid gland for people suffering from overactive thyroid (hyperthyroidism).²⁸ The daily dose of fluoride which people are now receiving in fluoridated communities (1.6 to 6.6 mg/day)²⁹ actually exceeds the dose of fluoride which was found to depress the thyroid gland (2.3 to 4.5 mg/day).³⁰

Hypothyroidism (under-active thyroid) is currently one of the most common medical problems in the United States. Synthroid, the drug doctors prescribe to treat hypothyroidism, was the fourth most prescribed drug in the US in the year 2000. Symptoms of hypothyroidism include depression, fatigue, weight gain, muscle and joint pains, increased cholesterol levels, and heart disease.

• A recent study published in the journal Brain Research found that 1 PPM fluoride in water facilitated the uptake of aluminum into the brain of rats, producing the type of brain tangles (amyloid deposits) that are associated with alzheimers disease and other types of dementia.³¹
• An epidemiological study published in the December 2000 issue of the journal Neurotoxicology, found that fluoridated water was associated with elevated levels of lead in children's blood.³² The study's findings parallel the findings of an earlier study published in the September 1999 issue of the International Journal of Environmental Studies.³³ Lead in the blood is associated with a variety of neurological problems, including reduced intelligence, aggression and hyperactivity.
• Dozens of laboratory studies have found that fluoride is a mutagen - a classification which frequently indicates that a substance is carcinogenic (i.e. that it causes cancer).³⁴ A cancer bioassay conducted by the National Toxicology Program found that rats dosed with fluoride had a statistically significant increase in bone tumors (osteosarcomas), which were not found among the controls. The initial review of the study also reported that the fluoride-dosed animals had tumors of the thyroid, oral cavity and rare tumors of the liver; however these tumors were later downgraded under conspicuous and controversial circumstances. According to Dr. William Marcus, the Chief Toxicologist at EPA's Office of Drinking Water, the downgrading of the tumors was politically motivated and not scientifically defensible.³⁵
• A recent epidemiological study conducted by a scientist from the US Public Health Service found that female infertility was associated with elevated levels of fluoride (> 3ppm) in drinking water. The study concluded that more emphasis needs to be given to the effects on health from total fluoride exposure - not just exposure from fluoridated drinking water.³⁶
• In light of the recent research indicating health risks from low level fluoride exposure, the Union of Scientists and Professionals at EPA Headquarters has voted to oppose fluoridation³⁷ and has called upon Congress to issue a "national moratorium" on the fifty year old policy. According to the Vice President of the Union, Dr. J. William Hirzy,

"In summary, we hold that fluoridation is an unreasonable risk. That is, the toxicity of fluoride is so great and the purported benefits associated with it are so small - if there are any at all - that requiring every man, woman and child in America to ingest it borders on criminal behavior on the part of governments."

• After years of overlooking the problems with fluoride & fluoridation, the environmental community is finally beginning to address the issue. In September of 2001, the Sierra Club announced that:

"There are now valid concerns regarding the potential adverse impact of fluoridation on the environment, wildlife, and human health. The Sierra Club therefore supports giving communities the option of rejecting mandatory fluoridation of their water supplies. To protect sensitive populations, and because safer strategies and methods for preventing tooth decay are now available, we recommend that these safer alternatives be made available and promoted."

• In the last two years, the national Green Parties of both England and Ireland have launched campaigns to ban water fluoridation in their respective countries. According to the Irish Greens:

"Our objections to water fluoridation are based on a number of factors:

1. We disagree with mass medication on ethical grounds. In our view freedom of choice ought to be an integral part of health care;
2. All studies show that we are not fluoride deficient. In fact, studies carried out in this country show that we have an excess of fluoride which is a toxic substance, in our bodies;
3. There is now a scientific consensus that fluoride does not work systemically, but rather topically and therefore does not need to be ingested;
4. The increase in fluorosis, which is a manifestation of fluoride toxicity, is a real cause of concern;
5. The many reports from all over the world which link fluoride with other health effects."

• Meanwhile, a growing number of communities across the United States are voting down fluoridation proposals. Since 1999, 51 communities in the US have voted against fluoridation, while recent attempts to pass mandatory statewide fluoridation bills have failed in Hawaii, Oregon, Pennsylvania, and Washington.
• And lastly, in the summer of 2001, Dr. Arvid Carlsson, the recent winner of the Nobel Prize in Medicine (2000), advised Canadian communities not to fluoridate their water. According to Carlsson:

"I would advise against fluoridation. Individual prophylaxis (treatment) is preferable on principle grounds and is as equally effective. Fluoridation of water supplies would treat people who may not benefit from the treatment. Side-effects cannot be excluded and, thus, some people might only have negative effects without any benefit."

References

1 | Fluoride Never Approved as Safe & Effective by FDA:

1. Food & Drug Administration. (2000). Letter from Melinda K. Plaisier, Associate Commissioner for Legislation, FDA, to Congressman Ken Calvert. Dec 21, 2000. (See pdf file of letter at http://www.citizens.org/Food_Water_Safety/Fluoridation/Materials/fda_response.pdf
2. Kelly, J.V. (2000). Letter to Senator Robert Smith, Chairman of Environment and Public Works Committee, U.S. Senate, August 14, 2000. (for text see http://www.fluoridealert.org/fda.htm)

2 | Fluoride's Topical Vs. Systemic Effects:

1. Burt, B.A. (1994). Letter. Fluoride, 27, 180-181.
2. Carlos, J.P. (1983). Comments on Fluoride. J. Pedodontics. Winter, 135-136.
3. CDC. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Mortality and Morbidity Weekly Review. August 17, 50(RR14):1-42.
4. CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Mortality and Morbidity Weekly Review (MMWR), 48(41);933-940 October 22, 1999. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4841a1.htm
5. Featherstone, J.D.B. (1987) The Mechanism of dental decay. Nutrition Today, May/June, 10.
6. Featherstone J.D.B. (1999) Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol. 27:31-40.
7. Featherstone, J.D.B. (2000). The Science and Practice of Caries Prevention. Journal of the American Dental Association. 131, 887-899.
8. Fejerskov, O. et al (1981) Rational use of fluorides in caries prevention. Acta. Odontol. Scand., 241-249.
9. Levine, R.S., (1976). The action of fluoride in caries prevention: a review of current concepts. Brit. Dent. J. 140, 9-14.
10. Locker, D. (1999). Benefits and Risks of Water Fluoridation. An Update of the 1996 Federal-Provincial Sub-committee Report. Prepared for Ontario Ministry of Health and Long Term Care.
11. Limeback, H. (1999). A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any caries benefit from swallowing fluoride? Community. Dent. Oral Epidemiol. 27, 62-71.

3 | Arsenic Levels in Fluoridation Chemicals:

Hazan, Stan (2000). Letter to Florida Department of Health from Stan Hazan, General Manager, Drinking Water Additives Certification Program, National Sanitation Foundation International. 24 April 2000. http://www.fluoridealert.org/NSF-Letter.pdf

4 | Cavities Declining throughout Western Industrialized World, Irrespective of Fluoridation:

1. Diesendorf, M.(1986). The Mystery of Declining Tooth Decay. Nature, 322, 125-129.
2. WHO (Online). WHO Oral Health Country/Area Profile Programme. Department of Noncommunicable Diseases Surveillance/Oral Health. WHO Collaborating Centre, Malmö University, Sweden. http://www.whocollab.od.mah.se/euro.html
3. Haugejorden O. (1996). Using the DMF gender difference to assess the "major" role of fluoride toothpastes in the caries decline in industrialized countries: a meta-analysis. Community Dent Oral Epidemiol 24(6):369-75.
4. Petersson GH, Bratthall D. (1996). The caries decline: a review of reviews. Eur J Oral Sci 104(4(Pt 2)):436-43.
5. Reich E. (2001). Trends in caries and periodontal health epidemiology in Europe. Int Dent J. 51(6 Suppl 1):392-8.

DMFT (Decayed, Missing & Filled teeth) Status for 12 year olds by Country - WHO Data -
World Health Organization Data

Data from: WHO Oral Health Country/Area Profile Programme Department of Noncommunicable Diseases Surveillance/Oral Health WHO Collaborating Centre, Malmö University, Sweden http://www.whocollab.od.mah.se/euro.html

5 | NIDR's National Survey on Dental Health (Largest Dental Survey Ever Conducted in US):

1. Brunelle, J.A. and Carlos, J.P. (1990). Recent trends in dental caries in U.S. children and the effect of water fluoridation. J. Dent. Res 69, (Special edition), 723-727. (Read correspondence on this study).
2. Hileman, B. (1989). New Studies Cast Doubt on Fluoridation Benefits. Chemical and Engineering News, 67 (19) May 8. http://www.fluoridealert.org/NIDR.htm
3. Yiamouyiannis, J.A. (1990). Water Fluoridation and Tooth decay: Results from the 1986-87 National Survey of U.S. Schoolchildren. Fluoride, 23, 55-67. http://www.fluoridealert.org/DMFTs.htm

6 | Fluoridation Cessation Studies:

1. Burt BA, Keels MA, Heller KE. (2000). The effects of a break in water fluoridation on the development of dental caries and fluorosis.J Dent Res Feb;79(2):761-9.
2. Kunzel, W., Fischer, T., Lorenz R., Bruhmann, S. (2000). Decline in caries prevalence after the cessation of water fluoridation in former East Germany. Community Dent. Oral Epidemiol. 28(5): 382-389.
3. Kunzel, W. and T. Fischer (2000). Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res 34(1): 20-5.
4. Maupome, G. et al. (2001). Patterns of dental caries following the cessation of water fluoridation. Community Dent Oral Epidemiol 29(1): 37-47.
5. Seppa, L., Karkkaimen, S. and Hausen, H. (2000) Caries trends 1992-98 in two low-fluoride Finnish towns formerly with and without fluoride. Caries Res 34(6): 462-8.

7 | Fluoride Ineffective at Preventing Pit & Fissure Decay:

1. Loe, H. (1984). Hearings: Subcommittee of the Committee on Appropriations, House of Representatives. Dr. Harald Loe, Director of the National Institute of Dental Research.

"Let me begin by saying that fluorides are most effective in preventing decay on the smooth surfaces of teeth. However, the chewing surfaces of posterior are not smooth. They have crevices and pits and it is our experience that fluorides don't really get access to these pitted areas."

2. The Oral Health of California's Children: A Neglected Epidemic. Selected Findings and Recommendations from the California Oral Health Needs Assessment of Children, 1993-1994.

"Fluoride primarily protects the smooth surfaces of teeth, and sealants protect the pits and fissures (grooves), primarily on the chewing surfaces of the back teeth. Although pit and fissure tooth surfaces only comprise about 15% of all permanent tooth surfaces, they were the site of 83% of tooth decay in U.S. children in 1986-87."

3. Gray, AS. (1987). Fluoridation: Time For A New Base Line? Journal of the Canadian Dental Association. No. 10.

"The type of caries now seen in British Columbia's children of 13 years of age, is mostly the pit and fissure type. Knudsen in 1940, suggested that 70 percent of the caries in children was in pits and fissures. Recent reports indicate that today, 83 percent of all caries in North American children is of this type. Pit and fissure cavities aren't considered to be preventable by fluorides, they are prevented by sealants."

4. Journal of the American Dental Association. (1984). Preserving the perfect tooth. Editorial. Vol. 108.

"It is estimated that 84% of the caries experience in the 5 to 17 year-old population involves tooth surfaces with pits and fissures. Although fluorides cannot be expected appreciably to reduce our incidence of caries on these surfaces, sealants can."

5. Pinkham, JR, ed. (1999). Pediatric Dentistry Infancy Through Adolescence. 3^rd Edition. WB Saunders Co.

"[E]namel surfaces with pits and fissures receive minimal caries protection from either systemic or topical fluoride agents."

6. Public Health Reports. (1993). Toward Improving the Oral Health of Americans. Vol. 108, No. 6. Nov. - Dec.

"Fluoridation and the use of other fluorides have been successful in decreasing the prevalence of dental caries on the smooth surfaces of teeth. Unfortunately, these efforts have much less effect on dental caries that occur in the pits and fissures of teeth (particularly on the biting surfaces of teeth) where more than 85 percent of dental caries now occur."

8 | Fluoridation doesn't Prevent Baby Bottle Tooth Decay:

1. Barnes GP et al. Ethnicity, Location, Age, and Fluoridation Factors in Baby Bottle Tooth Decay and Caries Prevalence of Head Start Children. Public Health Reports; 107: 167-73, 1992.
2. Von Burg MM et al. Baby Bottle Tooth Decay: A Concern for All Mothers. Pediatric Nursing; 21:515-519, 1995.

9 | Lack of Dentists Accepting Medicaid Patients:

Guiden, M. (1990). Dental Health for kids moves to the forefront. State Health Notes 19(280). Forum for State Health Policy Leadership, National Conference of State Legislatures. July 6. (Cited in: U.S. Department of Health & Human Services. (U.S. DHHS) (2000). Oral health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health & Human Services. National Institute of Dental and Craniofacial Research, National Institutes of Health. http://www.nidcr.nih.gov/sgr/execsumm.htm)

10 | Fluoride Acute Toxicity Data:

1. University of Pennsylvannia School of Dental Medicine. (2001). Can Fluoride Cause Harm? InteliHealth Dental. See http://www.intelihealth.com/IH/ihtDNT/WSDNT000/24982/25474/307684?d=dmtContent
2. Hodge, H.C. and Smith, F.A. (1965). Fluorine Chemistry Vol. IV. Academic Press, New York.
3. Gleason, M.N., Gosselin, R.E., Hodge, H.C., & Smith, R.P. (1969). Clinical Toxicology of Commercial Products. 3^rd Ed. Williams & Wilkins, Baltimore.

11 | Nutritional Deficiences Exacerbate Fluoride's Toxicity:

1. Agency for Toxic Substances and Disease Registry (ATSDR) (1993). Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (F). U.S. Department of Health & Human Services, Public Health Service. ATSDR/TP-91/17.
2. Marier J, Rose D. (1977). Environmental Fluoride. National Research Council of Canada. Associate Committe on Scientific Criteria for Environmental Quality. NRCC No. 16081. (Report available online at: http://www.fluoridealert.org/NRC-fluoride.htm)
3. Teotia M, Teotia SP, Singh KP. (1998). Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India: year 2000. Indian J Pediatr. 65(3):371-81.
4. Teotia SPS, et al. (1984). Environmental Fluoride and Metabolic Bone Disease, An Epidemiological Study (Fluoride and Nutrition Interactions) Fluoride. 17(1): 14-22.

12 | Total Fluoride Exposure on the Increase:

1. Fomon SJ, Ekstrand J, Ziegler EE. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. J Public Health Dent. 60(3):131-9.
2. Mascarenhas AK. (2000). Risk factors for dental fluorosis: a review of the recent literature. Pediatr Dent. 22(4):269-77.
3. Marier JR. (1977). Some current aspects of environmental fluoride. Sci Total Environ 8(3):253-65.

13 | 29.9% of US Children in Fluoridated Areas have Dental Fluorosis on 2 teeth:

Heller KE et al (1997). Dental Caries and Dental Fluorosis at Varying Water Fluoride Concentrations. J of Pub Health Dent, 57; No. 3, 136-143.

14 | Infant Formula Reconstituted with Fluoridated Water Increases Risk for Dental Fluorosis:

1. Pendrys, DG. (2000). Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional. J Am Dent Assoc. Vol. 131 No. 6: 746-55.
2. Fomon SJ, Ekstrand J, Ziegler EE. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. J Public Health Dent. 60(3):131-9.
3. Mascarenhas AK. (2000). Risk factors for dental fluorosis: a review of the recent literature. Pediatr Dent. 22(4):269-77.
4. Pendrys DG, Katz RV. (1998). Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers' decision to reduce the fluoride concentration of infant formula. Am J Epidemiol Vol. 148 No. 10: 967-74.
5. Lewis DW, Limeback H. (1996). Comparison of recommended and actual mean intakes of fluoride by Canadians. J Can Dent Assoc. Vol. 62 No. 9: 708-9, 712-5.
6. Clark DC, et al. (1994). Influence of exposure to various fluoride technologies on the prevalence of dental fluorosis. Community Dent Oral Epidemiol Vol. 22 No. 6: 461-4.
7. Pendrys DG et al. (1994). Risk factors for enamel fluorosis in a fluoridated population. Am J Epidemiol Vol. 140 No. 5: 461-71.

See also:

8. Buzalaf MA, et al. (2001). Fluoride content of infant formulas prepared with deionized, bottled mineral and fluoridated drinking water. ASDC J Dent Child. Vol. 68 No. 1: 37-41.
9. Fomon SJ, Ekstrand J. (1999). Fluoride intake by infants. J Public Health Dent Vol. 59 No. 4: 229-34.
10. Levy SM, et al. (2001). Patterns of fluoride intake from birth to 36 months. J Public Health Dent 61(2):70-7.
11. Van Winkle S, et al. (1995). Water and formula fluoride concentrations: significance for infants fed formula. Pediatr Dent. Vol. 17 No. 4: 305-10.

15 | Fluoride Levels in Women's Breast Milk 100 times Lower than in Fluoridated Water:

Institute of Medicine. (1997). Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. National Academy Press.

16 | Fluoride is Not an Essential Nutrient (No disease, including tooth decay, has ever been linked to a fluoride deficiency):

National Research Council (1993). Health Effects of Ingested Fluoride. National Academy Press, Washington DC. See page 30.

17 | An average of 50% of Ingested Fluoride Accumulates in the Body:

National Research Council (1993). Health Effects of Ingested Fluoride. National Academy Press, Washington DC. See page 131.

18 | See UNICEF's Report on Fluoride:

UNICEF Water, Environment & Sanitation. Fluoride in water: An overview. Waterfront December 1999 http://www.unicef.org/programme/wes/info/fluor.htm

19 | Calcium Deficiency Exacerbates the Toxic Effects of Fluoride on Bone:

1. Teotia M, Teotia SP, Singh KP. (1998). Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India: year 2000. Indian J Pediatr. 65(3):371-81.
2. Li G, Ren L. (1998). [Effects of excess fluoride on bone turnover under conditions of diet with different calcium contents] [Article in Chinese] Zhonghua Bing Li Xue Za Zhi. 26(5):277-80.

20 | Chemical & Engineering News Review of Fluoridation:

Hileman, B. (1988). Fluoridation of water. Questions about health risks and benefits remain after more than 40 years. Chemical and Engineering News. August 1, 1988, 26-42. http://www.fluoridealert.org/hileman.htm

21 | WHO: Early Stages of Skeletal Fluorosis can be Misdiagnosed as Osteo- and Rhematoid-Arthritis:

World Health Organization. (1970). Fluorides and Human Health. pp 32, 239-240

22 | Clinical Trials Examining the Effectiveness of Fluoride Therapy for the treatment of Osteoporosis:

1. Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. J Bone Miner Res Apr;4(2):223-5.
2. Riggs, B.L. et al (1990). Effect of Fluoride treatment on the Fracture Rates in Postmenopausal Women with Osteoporosis. N. Eng. J. Med., 322, 802-809.
3. Bayley TA, et al. (1990). Fluoride-induced fractures: relation to osteogenic effect. J Bone Miner Res Mar;5 Suppl 1:S217-22.

23 | New England Journal of Medicine Editorial Discussing Fluoride & Bone:

Lindsay, R. (1990). Fluoride and Bone - Quantity Versus Quality. Editorial. New England Journal of Medicine. Vol. 322. No. 12. March 22. http://www.fluoridealert.org/NEJM-bone.htm

24 | Water Fluoride/Hip Fracture Studies:

a) Studies Reporting an Association between water fluoride (<4 ppm) & hip fracture:

1. Cooper, C., C. Wickham, et al. (1990). "Water fluoride concentration and fracture of the proximal femur." J Epidemiol Community Health 44: 17-19.

Cooper, C., C. Wickham, et al. (1991). "Water fluoridation and hip fracture." JAMA 266: 513-514 (letter, a reanalysis of data presented in 1990 paper).

"We found a significant positive correlation between fluoride levels and discharge rates for hip fracture. This relationship persisted for both women and men...Using an appropriately weighted regression model, there appears to be a positive ecologic association between fluoride levels of county water supplies and fracture discharge rates. This ecologic association is consistent with a recently published study and others currently in progress."

2. Danielson, C., J. L. Lyon, et al. (1992). "Hip fractures and fluoridation in Utah's elderly population." Journal of the American Medical Association 268(6): 746-748.

"We found a small but significant increase in the risk of hip fracture in both men and women exposed to artificial fluoridation at 1 ppm, suggesting that low levels of fluoride may increase the risk of hip fracture in the elderly."

3. Hegmann, K.T. et al (2000) the Effects of Fluoridation on Degenerative Joint Disease (DJD) and Hip Fractures.Abstract #71, of the 33^rd Annual Meeting of the Society For Epidemiological research, June 15-17, 2000. Published in a Supplement of Am. J. Epid.

"The only age adjusted rate achieving statistical significance was the age-specific rate for hip fracture among women 75-84 years, with a RR = 1.43 (95% CI, 1.02-1.84). The rate of hip fracture among women aged 85+ approached significance with a RR = 1.42 (CI, 0.98 - 1.87)."

4. Jacobsen, S., J. Goldberg, et al. (1992). "The association between water fluoridation and hip fracture among white women and men aged 65 years and older; a national ecologic study." Annals of Epidemiology 2: 617-626.

"There was a small statistically significant positive association between fracture rates and fluoridation. The relative risk (95% confidence interval) of fracture in fluoridated counties compared to nonfluoridated counties was 1.08 (1.06 to 1.10) for women and 1.17 (1.13 to 1.22) for men."

5. Jacobsen, S., J. Goldberg, et al. (1990). "Regional variation in the incidence of hip fracture: US white women aged 65 years and olders." J Am Med Assoc 264(4): 500-2.

"The results from the ecological regression analysis suggest that soft and fluoridated water, poverty, reduced sunlight exposure, and rural location all increase the risk of hip fracture."

6. Jacqmin-Gadda, H. (1995). "Fluorine concentration in drinking water and fractures in the elderly." JAMA 273: 775-776 (letter).

Jacqmin-Gadda, H., A. Fourrier, et al. (1998). "Risk factors for fractures in the elderly." Epidemiology 9(4): 417-423. (An elaboration of the 1995 study referred to in the JAMA letter).

"We found a higher risk of hip fractures for subjects exposed to fluorine concentrations over 0.11 mg per liter but without a dose-effect relation."

7. Keller, C. (1991) Fluorides in drinking water. Unpublished results. Discussed in Gordon, S.L. and Corbin, S.B,(1992) Summary of Workshop on Drinking Water Fluoride Influence on Hip Fracture on Bone Health. Osteoporosis Int. 2, 109-117.

"In general, with increasing dose of fluoride in the drinking water the hip fracture ratio also increased."

8. Kurttio, P., N. Gustavsson, et al. (1999). "Exposure to natural fluoride in well water and hip fracture: A cohort analysis in Finland." American Journal of Epidemiology 150(8): 817-824.

"[A]mong younger women, those aged 50-64 years, higher fluoride levels increased the risk of hip fractures."

9. Li Y, et al. (2001). Effect of long-term exposure to fluoride in drinking water on risks of bone fractures. J Bone Miner Res.16(5):932-9.

"The prevalence of hip fractures was highest in the group with the highest water fluoride...It is concluded that long-term fluoride exposure from drinking water containing > or =4.32 ppm increases the risk of overall fractures as well as hip fractures."

10. May, D.S. and Wilson, M.G. Hip fractures in relation to water fluoridation: an ecologic analysis. Unpublished data, discussed in Gordon, S.L. and Corbin S.B.,(1992), Summary of Workshop on Drinking Water Fluoride Inflruenbce on Hip Fracture on Bone Health. Osteoporosis Int. 2, 109-117.

"As the percentage of individuals exposed to fluoridated water increased within a county, the hip fracture rate generally rose for both sexes...Adjustment for county latitude and longitude produced higher correlation values and significance for females and males."

11. Sowers, M., M. Clark, et al. (1991). "A prospective study of bone mineral content and fracture in communities with differential fluoride exposure." American Journal of Epidemiology 133: 649-660.

"Residence in the higher-fluoride community was associated with a significantly lower radial bone mass in premenopausal and postmenopausal women, an increased rate of radial bone mass loss in premenopausal women, and significantly more fractures among postmenopausal women."

b) Studies Reporting No Association between water fluoride & hip fracture:

1. Cauley, J., P. Murphy, et al. (1995). "Effects of fluoridated drinking water on bone mass and fractures: the study of osteoporotic fractures." J Bone Min Res 10(7): 1076-86.
2. Feskanich D., et al. (1998). Use of toenail fluoride levels as an indicator for the risk of hip and forearm fractures in women. Epidemiology 9(4): 412-6.

While this study didn't find an association between water fluoride and hip fracture, it did find an association - albeit non-significant 1.6 (0.8-3.1) - between fluoride exposure and elevated rates of forearm fracture.

3. Hillier, S., C. Copper, et al. (2000). "Fluoride in drinking water and risk of hip fracture in the UK: a case control study." The Lancet 335: 265-2690.

Read critique of this study at http://www.fluoride-journal.com/00-33-1/331-1.pdf

4. Jacobsen, S.J. et al (1993). Hip Fracture Incidence Before and After the Fluoridation of the Public Water Supply, Rochester, Minnesota. American Journal of Public Health, 83, 743-745.
5. Karagas,M.R. et al (1996). "Patterns of Fracture among the United States Elderly: Geographic and Fluoride Effects." Ann. Epidemiol. 6 (3), 209-216.

As with Feskanich (1998) this study didn't find an association between fluoridation & hip fracture, but it did find an association between fluoridation and distal forearm fracture, as well as proximal humerus fracture. "Independent of geographic effects, men in fluoridated areas had modestly higher rates of fractures of the distal forearm and proximal humerus than did men in nonfluoridated areas."

6. Lehmann R. et al (1998). Drinking Water Fluoridation: Bone Mineral Density and Hip Fracture Incidence. Bone, 22, 273-278.
7. Phipps, K. R. (2000). Community water fluoridation, bone mineral density and fractures: prospective study of effects in older women. British Medical Journal, 321: 860-4.

As with Feskanich (1998) and Karagas (1996), this study didn't find an association between water fluoride & hip fracture, but it did find an association between water fluoride and other types of fracture - in this case, wrist fracture. "There was a non-significant trend toward an increased risk of wrist fracture." For a critique of this study, see http://www.fluoridealert.org/phipps.htm

8. Suarez-Almazor, M., G. Flowerdew, et al. (1993). "The fluoridation of drinking water and hip fracture hospitalization rates in two Canadian communities." Am J Public Health 83: 689-693.

Interestingly, while the authors of this study conclude that there is no association between fluoridation and hip fracture, their own data reveals a different picture. Namely, a statistically significant increase in hip fracture for men living in the fluoridated area. According to the authors, "although a statistically significant increase in the risk of hip fracture was observed among Edmonton men, this increase was relatively small (RR=1.12)."

25 | Neurotoxic Effects of Sodium Fluoride:

Mullenix, P. et al (1995).Neurotoxicity of Sodium Fluoride in Rats Neurotoxicology and Teratology, 17, 169-177. (Read statement from lead author of this study, Dr. Phyllis Mullenix, at http://www.fluoridealert.org/pmullenix2.htm)

26 | Chinese Studies Concerning Relationship between Fluoride & Decreased IQ:

1. Li, X.S., (1995). Effect of Fluoride Exposure on Intelligence in Children. Fluoride, 28:4, 189-192
2. Li Y, Li X, Wei S. (1994). [Effect of excessive fluoride intake on mental work capacity of children and a preliminary study of its mechanism] Hua Hsi I Ko Ta Hsueh Hsueh Pao Jun;25(2):188-91.
3. Lin Fa-Fu; et al (1991). The relationship of a low-iodine and high-fluoride environment to subclinical cretinism in Xinjiang. Iodine Deficiency Disorder Newsletter. Vol. 7. No. 3.
4. Lu, Y. et al (2000). Effect of high-fluoride water on intelligence of children. Fluoride, 33, 74-78.
5. Zhao, L.B. et al (1996). Effect of high-fluoride water supply on children's intelligence. Fluoride, 29, 190-192.

See also:

Spittle, B. (2000). Fluoride and Intelligence (Editorial). Fluoride Vol. 33 No. 2: 49-52. http://www.fluoride-journal.com/00-33-2/332-49.pdf

27 | Fluoride & Pineal Gland:

1. Luke, J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildord.
2. Luke, J. (2001). Fluoride Deposition in the Aged Human Pineal Gland. Caries Res. 35:125-128.

28 | European Doctors Used Fluoride to Treat Hyperthyroidism:

1. Stecher, P, et al. (1960). The Merck Index of Chemicals and Drugs. Merck & Co., Inc, Rathway NJ.
2. Waldbott, G.L., Burgstahler, A.W. and McKinney, H.L. Fluoridation: The Great Dilemma. Coronado Press, Inc., Lawrence, Kansas, 1978.

See also:

3. Schuld, A. (1999). Fluoride-Iodine Antagonism: Some History. Parents for Fluoride Poisoned Children. See http://www.fluoridealert.org/f-iodine.htm

29 | US Government Data on Total Fluoride Intake (1.6-6.6 mg/day) in Fluoridated Communities:

DHHS (1991). Review of Fluoride: Benefits and Risks, Report of the Ad Hoc Committee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. Department of Health and Human Services, USA.

30 | Study Discussing Dosage of Fluoride (2.3-4.5 mg/day) Found to Depress Thyroid Gland:

Galletti, P. & Joyet, G. (1958). Effect of Fluorine on Thyroidal Iodine Metabolism in Hyperthyroidism. Journal of Clinical Endocrinology; 18:1102-1110 http://www.fluoridealert.org/galletti.htm

31 | Brain Research Study Reporting that Fluoride Administers the Uptake of Aluminum into the Brain:

Varner, J.A. et al (1998). "Chronic Administration of Aluminum-Fluoride and Sodium-Fluoride to Rats in Drinking Water: Alterations in Neuronal and Cerebrovascular Integrity" Brain Research, 784, 284-298.

32 | Epidemiological Studies Reporting Association Between Fluoridated Water and Elevated Blood Lead Levels in Children:

Masters, R. et al. (2000). Association of Silicofluoride Treated Water with Elevated Blood Lead. Neurotoxicology. 21:6, 1091-1099.

33 | Another Epidemiological Study Reporting Association Between Fluoridated Water and Elevated Blood Lead Levels in Children:

Masters, R.D. and Coplan, M. (1999). "Water treatment with Silicofluorides and Lead Toxicity" International Journal of Environmental Studies. September.

34 | Fluoride is a Mutagen:

Department of Health and Human Services (1991). Review of fluoride benefits and risks. Appendix H. H1-H6.

35 | EPA's Dr. William Marcus Discussing his Objections to the NTP's Downgrading of the Tumors:

1. Marcus, W. (1990). Memorandum from Dr. William Marcus,to Alan B. Hais, Acting Director Criteria & Standards Division ODW, US EPA, DATED MAY 1, 1990, and subsequent memos. These can be viewed on the web at http://www.fluoridealert.org/marcus.htm
2. Marcus, W. (1995). Radio Interview with Dr. Gary Null. March 10.See www.fluoridealert.org/ifin-19.htm

36 | Study Finding Decreased Female Fertility in Areas with Elevated Fluoride in the Water:

Freni SC. (1994). Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. J Toxicology and Environmental Health 42:109-121.

37 | Statement from EPA Headquarters Union on Why they Oppose Fluoridation:

Hirzy, J.W. (1999). Why the EPA's Headquarters Union of Scientists Opposes Fluoridation. Press release from National Treasury Employees Union, May 1, 1999. (for text see http://www.fluoridealert.org/HP-Epa.htm)