Opposition to water fluoridation refers to activism against the fluoridation of public water supplies. The controversy occurs mainly in English-speaking countries, as Continental Europe does not practice water fluoridation, although some continental countries fluoridate salt.^[1] At the recommended concentration of 0.7 – 1.2 mg/L (0.7 for hot climate, 1.2 in cool climates) the only apparent side-effect appears to be dental fluorosis, but those organizations and individuals opposed raise concerns that the intake is not easily controlled, and that children, small individuals, and others may be more susceptible to health problems. Those opposed also argue that water fluoridation imposes ethical issues,^[2] may cause serious health problems,^[3][4][5] is not effective enough to justify the costs.^[6] Opposition to fluoridation has existed since its initiation in the 1940s.^[1] During the 1950s and 1960s, some opponents of water fluoridation suggested that fluoridation was a communist plot to undermine public health.^[7] Sociologists have typically viewed opposition to water fluoridation as irrational, while critics of this position have argued that this rests on an uncritical attitude toward scientific knowledge.^[1]

[edit] Ethics

Many who oppose water fluoridation consider it to be a form of compulsory mass medication. They argue that consent of all water consumers cannot be achieved, nor can water suppliers accurately control the exact levels of fluoride that individuals receive, nor monitor their response. It is also argued that, because of the alleged negative health effects of such level of fluoride exposure, mandatory fluoridation of public water supplies is a breach of ethics and a human rights violation.

In the United Kingdom the Green Party refers to fluoride as a poison, claims that water fluoridation violates Article 35 of the European Charter of Fundamental Rights, is banned by the UK poisons act of 1972, violates Articles 3 and 8 of the Human Rights Act and raises issues under the United Nations Convention on the Rights of the Child.^[8]

Water fluoridation has also been criticized by Cross and Carton for violating the Nuremberg Code and the Council of Europe's Biomedical Convention of 1999.^[2] Dentistry professor David Locker and philosopher Howard Cohen argued that the moral status for advocating water fluoridation is "at best indeterminate" and could even be considered immoral because it infringes upon autonomy based on uncertain evidence, with possible negative effects.^[9]

[edit] The precautionary principle

In an analysis published in the March 2006 issue of the Journal of Evidence Based Dental Practice, the authors examine the water fluoridation controversy in the context of the precautionary principle. The authors note that:

• There are other ways of delivering fluoride besides the water supply;
• Fluoride does not need to be swallowed to prevent tooth decay;
• Tooth decay has dropped at the same rate in countries with, and without, water fluoridation;
• People are now receiving fluoride from many other sources besides the water supply;
• Studies indicate fluoride’s potential to cause a wide range of adverse, systemic effects;
• Since fluoridation affects so many people, “one might accept a lower level of proof before taking preventive actions.”^[10]

[edit] Potential health risks

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Fluoride's adverse effects depend on total fluoride dosage from all sources. At the commonly recommended dosage, the only clear adverse effect is dental fluorosis, which can alter the appearance of children's teeth during tooth development; this is mostly mild and is unlikely to represent any real effect on public health.^[11] Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation.^[11] A major Australian study found no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma^[11], and other adverse effects lack sufficient evidence to reach a confident conclusion.^[12] Several studies cited by opponents of community fluoridation have found associations, consistently finding that osteosarcoma rates are significantly higher in male children with raised fluoride levels.^[13]

Constant ingestion of high levels of fluoride can cause adverse effects including severe dental fluorosis, skeletal fluorosis, and weakened bones; the WHO has a guideline of 1.5 mg/L.^[14] In 2006, a 12-person U.S. National Research Council (NRC) committee reviewed the health risks associated with fluoride in the water^[15] and unanimously concluded that the maximum contaminant level of 4 mg/L should be lowered. Although it did not comment on water fluoridation's safety, three of the panel members expressed their opposition to water fluoridation after the study^[16][17][18] and the chair, John Doull, suggested that the issue should be reexamined.^[3] Because the report recommended lowering the MCL, opponents argue that fluoridation has a lower margin of safety than previously realized.^[19]

Because water fluoridation provided is not individually controlled, opponents express concern for vulnerable populations such as children, nutritionally deficient individuals, and renally-impaired individuals. The National Research Council states that children have a higher daily average intake than adults per kg of bodyweight.^[15]:23 Those who perspire heavily or have kidney problems consume more water and thus also have a greater intake. Of the following health problems, osteosarcoma, a rare bone disease affecting male children, is strictly associated with the recommended dosage of fluoride. The weight of the evidence does not support a relationship.^[20] However, a study performed as a doctoral thesis, which is described as the most rigorous yet by the Washington Post, found a relationship among young boys,^[21] but then the Harvard professor who advised the doctoral students determined that the results were not highly correlative enough to have evidentiary value; the professor then was investigated but exonerated by the federal government's Office of Research Integrity (ORI).^[22]

An epidemiological connection between silicofluorides, an industrial byproduct which is used to fluoridate much of the U.S. water, and lead was observed in a 2000 study.^[23] A 2006 U.S. CDC-funded study was unable to replicate the results,^[24] which the original researchers responded to in a 2007 rebuttal.^[25] Aside from the lead connection, concerns are raised as to whether silicofluorides might have different effects on the body than sodium fluorides, and silicofluorides have not been rigorously tested for safety.^[25]

[edit] Efficacy

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The available evidence shows that water fluoridation is effective in reducing cavities (see effectiveness section of the main article). The most comprehensive systematic review found that fluoridation was statistically associated with a decreased proportion of children with cavities (the median of mean decreases was 14.6%, the range −5 to 64%), and with a decrease in decayed, missing, and filled primary teeth (the median of mean decreases was 2.25 teeth, the range 0.5 to 4.4 teeth),^[12] which is roughly equivalent to preventing 40% of cavities.^[26] The review found that the evidence was of moderate quality: many studies did not attempt to reduce observer bias, control for confounding factors, report variance measures, or use appropriate analysis.^[12] The effect is largely due to the topical effect of fluoride ions in the mouth rather than the systemic effect of ingestion.^[27]

Fluoridation opponents have challenged the efficacy of fluoridation,^[4] although their arguments have been accused of bias.^[28] A large study of water fluoridation's efficacy was conducted by the National Institute of Dental Research in 1988, which officially found "20 percent fewer decayed tooth surfaces" corresponding to "less than one cavity per child".^[4] Opponents argued that the study had errors, and the data was reanalyzed by fluoridation opponent John A. Yiamouyiannis, whose results indicated no statistically significant difference in tooth decay rates among children in fluoridated and nonfluoridated communities.^[4][29] Conversely, fluoridation proponents argued that Yiamouyiannis' work had errors.^[30]

In 1986 fluoridation opponent Mark Diesendorf pointed out the substantial declines in tooth decay in nonfluoridated European countries.^[31] Although fluoridation may still be a relevant public health measure among the poor and disadvantaged, it may be unnecessary for preventing tooth decay, particularly in industrialized countries where tooth decay is rare.^[27]

[edit] Statements against

Since 1985, the United States Environmental Protection Agency (EPA) headquarters' union has expressed concerns about fluoride. In 2005, eleven EPA employee unions, representing over 7000 environmental and public health professionals of the Civil Service, called for a halt on drinking water fluoridation programs across the USA and asked EPA management to recognize fluoride as posing a serious risk of causing cancer in people. Among the union's concerns are what they contend is a cover-up of evidence from Harvard School of Dental Medicine linking fluoridation with an elevated risk of osteosarcoma in boys, a rare but fatal bone cancer.^[32] However, the professor accused of the cover-up was exonerated by the federal Office of Research Integrity.^[33]

In addition, over 1,730 health industry professionals, including one Nobel prize winner in medicine (Arvid Carlsson), doctors, dentists, scientists and researchers from a variety of disciplines are calling for an end to water fluoridation in an online petition to Congress.^[34] The petition signers express concern for vulnerable groups like "small children, above average water drinkers, diabetics, and people with poor kidney function," who they believe may already be overdosing on fluoride.^[34] Another concern that the petition signers share is, "The admission by federal agencies, in response to questions from a Congressional subcommittee in 1999-2000, that the industrial grade waste products used to fluoridate over 90% of America's drinking water supplies (fluorosilicate compounds) have never been subjected to toxicological testing nor received FDA approval for human ingestion."^[34] The petition was sponsored by the Fluoride Action Network of Canton, New York, the most active anti-fluoridation organization in North America.^{[citation needed]}

Dr. Hardy Limeback, BSc, PhD, DDS was one of the 12 scientists who served on the National Academy of Sciences panel that issued the aforementioned report, Fluoride in Drinking Water: A Scientific Review of the EPA's Standards. Dr. Limeback is an associate professor of dentistry and head of the preventive dentistry program at the University of Toronto. He detailed his concerns in an April 2000 letter titled, "Why I am now officially opposed to adding fluoride to drinking water".^[6]

In a presentation to the California Assembly Committee of Environmental Safety and Toxic Materials, Dr. Richard Foulkes, B.A., M.D., former special consultant to the Minister of Health of British Columbia, revealed:

The [water fluoridation] studies that were presented to me were selected and showed only positive results. Studies that were in existence at that time that did not fit the concept that they were "selling," were either omitted or declared to be "bad science." The endorsements had been won by coercion and the self-interest of professional elites. Some of the basic "facts" presented to me were, I found out later, of dubious validity. We are brought up to respect these persons in whom we have placed our trust to safeguard the public interest. It is difficult for each of us to accept that these may be misplaced.^[35]

On April 15, 2008, the United States National Kidney Foundation (NKF) updated their position on fluoridation for the first time since 1981.^[36] The foundation's position stated, however, that there is insufficient evidence to recommend fluoride-free drinking water for patients with renal disease, and did not voice opposition to water fluoridation.^[37]

The International Chiropractors Association opposes mass water fluoridation, considering it "possibly harmful and deprivation of the rights of citizens to be free from unwelcome mass medication."^[38]

[edit] Use throughout the world

Water fluoridation is used in the United States, United Kingdom, Ireland, Canada, and Australia, and a handful of other countries. The following developed nations previously fluoridated their water, but stopped the practice, with the years when water fluoridation started and stopped in parentheses:

• Federal Republic of Germany (1952–1971)
• Sweden (1952–1971)
• Netherlands (1953–1976)
• Czechoslovakia (1955–1990)
• German Democratic Republic (1959–1990)
• Soviet Union (1960–1990)
• Finland (1959–1993)
• Japan (1952–1972)^{[citation needed]}

In 1986 the journal Nature had a commentary, "Large temporal reductions in tooth decay, which cannot be attributed to fluoridation, have been observed in both unfluoridated and fluoridated areas of at least eight developed countries."^[39]

In areas with complex water sources, water fluoridation is more difficult and more costly. Alternative fluoridation methods have been proposed, and implemented in some parts of the world. The World Health Organization (WHO) is currently assessing the effects of fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe. The WHO supports fluoridation of water in some areas, and encourages removal of fluoride where fluoride content in water is too high. ^[40]

[edit] History

The use of fluorides for prevention of dental caries (cavities) was discussed in the 19th century in Europe.^[41][42] The first occurrence of fluoridated drinking water was found in Germany's Nazi concentration camps during world war II, which were maintained partly by I.G. Farben.^[43]. After the discovery in early controlled trials that water fluoridation reduced cavities, health organizations and agencies in the U.S. began to recommend that water be fluoridated.

The first large confrontation and defeat occurred in Wisconsin in 1950. Persistent objections arose then, where opponents questioned the ethics, safety, and efficacy of fluoridation.^[44] New Zealand was the second country to fluoridate, and similar controversies arose there.^[42] Fears about fluoride were likely exacerbated by the reputation of fluoride compounds as insect poisons and by early literature which tended to use terms such as "toxic" and "low grade chronic fluoride poisoning" to describe mottling from consumption of 6 mg/L of fluoride prior to tooth eruption, a level of consumption not expected to occur under controlled fluoridation.^[45] When voted upon, the outcomes tend to be negative, and thus fluoridation has had a history of gaining through administrative orders in North America.^[44] Theories for why the public tends to reject fluoridation include "alienation from mainstream" society, but evidence for that is weak. Another interpretation is confusion introduced during the referendum.^[44] Some studies of the sociology of opposition to water fluoridation have been criticized for having an uncritical attitude toward scientific knowledge.^[1]

Outside of North America, water fluoridation was adopted in European countries, but in the late 1970s and early 1980s, Denmark and Sweden banned fluoridation when government panels found insufficient evidence of safety, and the Netherlands banned water fluoridation when "a group of medical practitioners presented evidence" that it caused negative effects in a percentage of the population.^[4]

[edit] Conspiracy theories

Anti-public health flier issued in May 1955 by the Keep America Committee, alleging a conspiracy theory that water fluoridation is a communist plot.

Water fluoridation has frequently been the subject of conspiracy theories. During the "Red Scare" in the United States during the late 1940s and 1950s, and to a lesser extent in the 1960s, activists on the far right of American politics routinely asserted that fluoridation was part of a far-reaching plot to impose a socialist or communist regime. They also opposed other public health programs, notably mass vaccination and mental health services.^[46] Their views were influenced by opposition to a number of major social and political changes that had happened in recent years: the growth of internationalism, particularly the UN and its programs; the introduction of social welfare provisions, particularly the various programs established by the New Deal; and government efforts to reduce perceived inequalities in the social structure of the United States.^[47]

Some took the view that fluoridation was only the first stage of a plan to control the American people. Fluoridation, it was claimed, was merely a stepping-stone on the way to implementing more ambitious programs. Others asserted the existence of a plot by communists and the United Nations to "deplete the brainpower and sap the strength of a generation of American children". Dr. Charles Bett, a prominent anti-fluoridationist, charged that fluoridation was "better THAN USING THE ATOM BOMB because the atom bomb has to be made, has to be transported to the place it is to be set off while POISONOUS FLUORINE has been placed right beside the water supplies by the Americans themselves ready to be dumped into the water mains whenever a Communist desires!" Similarly, a right-wing newsletter, the American Capsule News, claimed that "the Soviet General Staff is very happy about it. Anytime they get ready to strike, and their 5th column takes over, there are tons and tons of this poison "standing by" municipal and military water systems ready to be poured in within 15 minutes."^[7]

This viewpoint led to major controversies over public health programs in the US, most notably in the case of the Alaska Mental Health Enabling Act controversy of 1956.^[48] In the case of fluoridation, the controversy had a direct impact on local programs. During the 1950s and 1960s, referendums on introducing fluoridation were defeated in over a thousand Florida communities. Although the opposition was overcome in time, it was not until as late as the 1990s that fluoridated water was drunk by the majority of the population of the United States.^[46]

The communist conspiracy argument declined in influence by the mid-1960s, becoming associated in the public mind with irrational fear and paranoia. It was lampooned in Stanley Kubrick's 1964 film Dr. Strangelove, in which the character General Jack D. Ripper initiates a nuclear war in the hope of thwarting a communist plot to "sap and impurify" the "precious bodily fluids" of the American people with fluoridated water. Similar satires appeared in other movies, such as 1967's In Like Flint, in which a character's fear of fluoridation is used to indicate that he is insane. Even some anti-fluoridationists recognized the damage that the conspiracy theorists were causing; Dr. Frederick Exner, an anti-fluoridation campaigner in the early 1960s, told a conference: "most people are not prepared to believe that fluoridation is a communist plot, and if you say it is, you are successfully ridiculed by the promoters. It is being done, effectively, every day ... some of the people on our side are the fluoridators' 'fifth column'."^[7]

[edit] Court cases

[edit] Republic of Ireland

In Ryan v. Attorney General (1965), the Supreme Court of Ireland held that water fluoridation did not infringe the plaintiff's right to bodily integrity.^[49] However, the court found that such a right to bodily integrity did exist, despite the fact that it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.

[edit] United States

Fluoridation has been the subject of many court cases wherein activists have sued municipalities, asserting that their rights to consent to medical treatment and due process are infringed by mandatory water fluoridation.^[2] Individuals have sued municipalities for a number of illnesses that they believe were caused by fluoridation of the city's water supply. In most of these cases, the courts have held in favor of cities, finding no or only a tenuous connection between health problems and widespread water fluoridation.^[50] To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.^[51]

[edit] See also

• Hexafluorosilicic acid
• Fluoride therapy

[edit] References

[edit] Further reading

• Freeze RA, Lehr JH (2009). The Fluoride Wars: How a Modest Public Health Measure Became America's Longest-Running Political Melodrama. Wiley. ISBN 0-470-44833-4. 
• Review Of Fluoride: Benefits And Risks. Report Of The Ad Hoc Subcommittee On Fluoride. Diane Pub Co. 1992. ISBN 0-7881-0729-1. 
• Fawell, John Wesley (2006). Fluoride in drinking-water. Geneva: World Health Organization. ISBN 92-4-156319-2. 
• Bryson, Christopher (2004). The Fluoride Deception. New York: Seven Stories Press. ISBN 1583225269. 

[edit] External links

• Fluoride Action Network
• Water fluoridation at the Open Directory Project
• Interview with Christopher Bryson, from Democracy Now!, June 17, 2004