When the public questions fluoridation, the best response is patience combined with scientific evidence
By Cathleen Terhune Alty, RDH
The use of fluoridation and fluoride stirs up a good bit of controversy. The pro and con sides are polarized and passionate, and it's hard to doubt the sincerity of the people on both sides. Both groups believe they're enlightened crusaders fighting for the public good. Few dental materials (outside of amalgam) have created such a firestorm. The Internet is alive with opinions on both sides-passion and fear reign over science, science is stifled to line the pockets of corporate interests, anecdotes substitute for scientific data, government is overreaching. Both sides face ridicule and eye rolling and are met with inflexibility and closed minds.
Much of the fluoride controversy rages over water fluoridation. Fluoride advocates say it's safe, cost effective, and has effectively reduced children's dental decay. Antifluoridationists say ingestion of fluoride in water is unethical and should be illegal because people are being mass medicated without concern for individual dosage, medical supervision, or informed consent.
As dental health professionals, we're faced with making informed decisions based on the available clinical evidence, and evaluating the benefits and potential harm. We need to be able to explain this position to people so they can make their own informed choices about what they will do with their bodies or their children's bodies. Questioning the safety and efficacy of fluoride, and evaluating the reasoning and research behind why we're using this product on this patient at this time is important. Questioning isn't wrong; good research should always stand up to scrutiny or be dismissed when discovered to have incorrect, unprovable, or unreproducible data.
Holding fluoride up for professional, scientific scrutiny is important because the public is asking questions and wants answers. Knowing the public's concerns and arguments, listening with respect even when we disagree, and sharing scientific evidence so people can have a broader context on which to base their decisions is part of our job. Doing this with civility, respect, and professionalism takes research and patience.
A bit of fluoridation history
It's been about 70 years since water fluoridation began in Grand Rapids, Michigan. Water fluoridation started as an experiment to discover if fluoride in the public water supply would reduce the amount of tooth decay. The hypothesis that fluoride could arrest tooth decay came about from anecdotal clinical evidence. In 1901, brown stains on children's teeth were observed clinically, and a debate ensued about what was causing it-radiation, iron, heredity, the drinking water?
Water testing was performed, but the testing instruments weren't sensitive enough to detect if there was something in the water making the teeth mottled and brown. Many areas of the country had pockets of population with brown stained teeth, such as Colorado Springs and Hereford, Texas. In 1931, H. V. Churchill, the chief chemist at Alcoa, ran tests in Bauxite, Arkansas, on the local drinking water with sensitive testing equipment. He was able to reliably detect a large amount of fluoride in the water. The children in Bauxite had the brown stain but very low rates of tooth decay. The brown, mottled teeth condition was named dental fluorosis.
The U.S. Public Health Service took notice of the positive effects of dental fluorosis and compiled data to show how caries resistance and brown stained enamel went hand-in-hand. The media reported the findings, and the public began to demand adding fluoride to drinking water across the country. Grand Rapids, Michigan, was the first to volunteer for a study, adding fluoride to the water supply in 1945, closely followed by seven other cities in the U.S. and Canada.
When the study concluded in 1959, Grand Rapids saw a 55.5% caries reduction in children. Even before the study was complete, early results were promising. The other cities that added fluoride in Illinois, New York, and Ontario also reported success. It wasn't long before other communities petitioned for fluoride to be added to their local drinking water. It was inexpensive, easy for communities to add, tasteless, and appeared to be effective. So where was the controversy?
According to an article posted at the Chemical Heritage Foundation library, the first person to publically protest was Alexander Y. Wallace in Stevens Point, Wisconsin. Calling fluoride a poison, he wrote letters and garnered support from local civic groups to reject fluoridated water. When the city council lost the referendum to add fluoride to the water, it was reported the council secretly added fluoride to the local drinking water anyway. The scheme was discovered and created an uproar.
A second vote for fluoridation was defeated as the now distrustful public chose to ignore the evidence-based data. The exposed deceit and doubt that was planted in the minds of the public along with the cold war paranoia of a government desiring a medicated, controlled, and docile public have cast a shadow on fluoride use ever since. It has been labeled a communist plot; it is said that conspiracy theories have grown in size, scope, and sophistication over the last 70 years.
Today's protesters of fluoridated water use similar arguments, calling water fluoridation mass medication without consent and a human rights violation, citing overreaching government interference, flawed and suppressed evidence, corporate greed, lack of unbiased scientific data, and lack of definitive studies showing the benefit of fluoridation. Some people question whether the government has the duty to protect public health at the cost of overriding public will.
With the recent rise of individual medicine (the idea that one size does not fit all when it comes to health care) and informed choice, fluoride continues to breed controversy. Dr. J. William Hirzy, senior vice president of the EPA Headquarters Union, states, "We hold that water fluoridation is an unreasonable risk." He has called for a moratorium on water fluoridation. The National Research Council (NRC) has stated that fluoride safety literature is lacking, and the margin between toxic and therapeutic dose is "very narrow."
The praises of fluoridated water are equally passionate. It's been hailed by the Centers for Disease Control and Prevention as one of the 10 great public health achievements of the 20th century. The CDC has proclaimed, "Fluoride is safe and effective in preventing and controlling dental caries when used appropriately." The American Dental Association (ADA) endorsed water fluoridation as safe and effective in the 1950s, and continues to champion the impressive results
seen over 70 years of evidence. The ADA states, "Today, studies prove water fluoridation continues to be effective in reducing tooth decay by 20% to 40%, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste."
Most professional dental organizations have praise for water fluoridation, including the American Association of Pediatric Dentistry (AAPD). The American Medical Association (AMA) chooses to walk the thin line between the two camps by stating, "We are not prepared to state that fluoridated water is safe, nor have we done any research to determine any negative effects of water fluoridation."
In researching the facts, it's clear that both sides are adamant and entrenched in their positions and attempts to stifle the opposition by name calling and ad hominem attacks do not keep communication lines open. The water fluoridation discussion is very active on the web as concerned individuals and institutions debate the real question of its use: Do the benefits outweigh the dangers?
Water fluoridation backlash has reached into the dental office and has many patients questioning all fluoride, whether it's professionally applied or for home use, such as toothpaste and mouth rinse. Topical fluoride treatments have a scientifically/statistically strong anticaries effect on children and are often considered win-win procedures. Many hygienists routinely apply topical fluoride to children's teeth at the preventive recall visit. The positives are huge: Most insurance plans cover it for children; it's fairly easy to apply; the research says it's safe and effective; our production goes up; the dentist is pleased; children have fewer cavities; the parents spend less; and everyone is happy.
But routine doesn't mean right. It's important to consider a patient's caries susceptibility, other fluoride exposure (water, toothpaste, rinse, lozenges, etc.), and diet before performing a "routine" fluoride treatment. If a patient is not at risk for caries, there is a question whether topical in-office fluoride treatment is necessary. Where can hygienists find good information to make informed, balanced, evidence-based decisions when it comes to caries susceptibility and topical fluoride use?
Many caries-risk assessment tools are available to help with the decision. The ADA offers several resources to help clinicians decide how to balance the fluorosis negatives of fluoride with the anticaries positives. They advocate frequent caries risk assessment along with analysis of overall fluoride source intake. Printable caries-risk assessment forms are available online from the ADA, AAPD, and other professional and commercial websites.
Factors increasing risk for developing caries may include active caries in the last 12 months, poor oral hygiene, quantity and/or quality of restorations, defects in tooth morphology, active GERD, medications, physical and/or mental disabilities, and cariogenic diet. It's also important to evaluate overall fluoride intake of a child, which requires some detective work. How much fluoride is in the drinking water? Contact local government authorities to find out fluoride content of the water, or ask a parent if the child is drinking bottled water with or without fluoride. What about home care? Are fluoride toothpaste and/or fluoride-containing mouth rinses being used? How often? How much? Any dietary fluoride supplements being used at home? How confident is the parent that the child is expectorating the paste or rinse instead of swallowing some of it? Is the child receiving any fluoride at school or a public-health clinic?
In 2014, the AAPD released "Guideline on Fluoride Therapy." They performed a thorough review of scientific fluoride literature, initially finding over two million papers. This was narrowed to 45 manuscripts that had "full examination and analysis" in order to revise fluoride guidelines. Dental professionals can download and print chairside guides from the ADA or AAPD to make good clinical decisions.
Fluoride isn't the only cavity fighter in town. Nonfluoride therapies include oral xylitol and topical chlorhexidine products. The ADA says these "may serve as adjunct therapeutics for preventing, arresting or even reversing dental caries." Of course, reduced sugar consumption and placement of sealants are known to help decrease decay. But some of the newer products are being tested for clinical efficacy. Highest rated in the ADA report was a three-month interval application of chlorhexidine-thymol varnish for root caries. Many of the protocols were found to have lacking evidence of their efficacy and will require more clinical trials. But lack of evidence does not necessarily mean they're not effective.
This article represents an overview of the fluoride controversy and hopefully will compel dental professionals to review the pros and cons, opinions, and facts in depth to get a broad perspective of the issues. As dental professionals, we are able to use science and expert opinions to guide our decisions. We can help patients sort through it by educating, not dictating. Informed decisions are good decisions, even when we personally and professionally disagree. The science isn't perfect, but it's the best we have. RDH
Cathleen Terhune Alty, RDH, is a frequent contributor who is based in King George, Va.
Suggested websites to review
• "Achievements in Public Health 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries" October 22, 1999.
• American Dental Association - Fluoride Facts 2005.
• American Dental Association - Fluoride Clinical Guidelines. November 2013.
• Chemical Heritage Foundation. "Pipe Dreams: America's Fluoride Controversy." Jesse Hicks. Summer 2011.
• Des Moines Water Works. 10 Facts about Fluoridation. Stephen Slott, DDS.
• Health Risks of Water Fluoridation Raise Concerns - Public Radio International. "Living on Earth" program. February 21, 2014.
• Connett P. A review of "The case against fluoride: How hazardous waste ended up in our drinking water and the bad science and powerful politics that keep it there."
• World Health Organization. Benefit-Harm Assessments. March 27, 2003.
• Fluoride Action Network .fluoridealert.org/
• Hirzy JW. June 29, 2000 Statement to Subcommittee of Wildlife, Fisheries and Drinking Water.