Feb. 8, 2001
[Introduction from Dr. Russell.] I have enclosed a summary article I wrote after reviewing much of the fluoride literature. This is a fairly brief article but lists the important aspects of fluoride, its known toxicity, dental effects, adverse health effects, synergistic effects with heavy metals, etc.
References are listed at the end. Note that Physicians for Social Responsibility lists fluoride as a developmental neurotoxin in their new publication "In Harms Way" pg 94.
Cindy Russell, M.D.
Water fluoridation has been, and continues to be one, of the most highly controversial issues in the history of dentistry. Since the 1950's, many communities in the U.S and abroad have fluoridated their water in an effort to reduce tooth decay. Currently about 49 % of the U.S. population is artificially fluoridated (hydrofluorosilicic acid, sodium silicofluoride and sodium fluoride) and 7 % have natural water fluoridation (calcium fluoride) (CDC). Japan and most of Europe have stopped water fluoridation due to reports of adverse health effects.
Recent studies have shed new light on the mechanism of action of fluorides cariostatic effects (topical vs systemic), and on the increasing amounts of fluoride we are currently exposed to in food and juices. There are numerous articles, including epidemiological and basic research, which point to adverse human and environmental health effects of long term bioaccumulation of what are considered "optimal" levels of fluoride in our water.
I have reviewed many of the studies on both sides of the argument and believe that in light of these new findings we should not be fluoridating our water but instead we should carefully re-address the science, ethics and risk/benefit ratio of water fluoridation.
There is ample evidence of an increasing rate of dental fluorosis (white/brown spots on the teeth) due to excess ingested fluoride(1-4, 9, 10). Because of this the Canadian Dental Asociation issued a recent advisory to stop fluoride supplements for children under the age of 7(74).
In addition, a growing body of evidence links increased hip fracture rates with water fluoridation (22, 26, 38-54). Some basic research articles suggest subtle neurologic effects of fluoride in doses 5-10 times that of "optimal" exposure (55). Clinical studies have demonstrated other
neurologic disorders including decreased intelligence (32-34, 55, 57, 60).
There is also a recent large epidemiological study from Dartmouth indicating fluoride increases aluminum and lead levels in our water supplies and blood levels due to a leaching effect on water pipes (17).
Approximately 20,000 tons of fluorides are dumped into the US ecosystem each year from fluoridated water that is flushed down the toilet and used in the garden. The same concentration of fluoride used to fluoridate our water (1ppm) is lethal to freshwater salmon. Levels of 0.2
ppm have been found to affect upstream migration of endangered salmon species in the Columbia River, contributing to increased mortality (62, 63, 64, 65, 66, 67).
Given the widespread use of fluoridated water in public water supplies, the benefits and risks will affect large numbers of people. The risks could thus pose a significant public health problem. As with lead, mercury, pesticides like DDT, PCB's and many other bioaccumulative toxins, many of which we are exposed to daily, it took many years to discover the association between the agent and chronic toxicity. It takes even longer to even attempt to reduce or stop the human and environmental exposure.
Why the Decision to Fluoridate?
Currently only 16% of California water supplies are fluoridated as compared to about 50% nationwide. In 1994 Pollick et al. wrote an unpublished and unreviewed study called the Report of the California Oral Health Needs Assessment 1993-1994, which supported water fluoridation.
The authors, using their study, lobbied Legislators for the passage of AB733, the state mandate calling for 167 cities and water districts to add fluoride to their water. The mandate passed handily, and since 1995 California cities have one by one been going through the process of
deciding whether or not to fluoridate their water supply. Santa Cruz recently rejected fluoride, while Mountain View voted for fluoride.
Doubts recently cast on the document supporting water fluoridation. The City of Escondido near san Diego was in the process of deciding whether or not to fluoridate their water and asked for an independent review of the California Oral Health Needs Assessment, the document that was the basis for the 1995 California mandate to fluoridate water. The analysis was performed by the internationally renowned Senes Oak Ridge Inc, Center for Risk Assessment in Tennessee. The study focused on the relationship between prevalence of dental caries and such factors as use of fluoridated water, use of fluoride supplements, use of dental sealants, prevalence of specific feeding practices and occurrence of Baby Bottle Tooth Decay. The Senes report concluded, "The results of the study as reported by Pollick et al. (1994 ) do not support its primary conclusion,
namely that increased fluoridation of public water supplies and increased supplementation of fluoride in nonfluoridated areas are warranted. The differences in caries incidence with fluoridation status as reported by Pollick et al. (1994) are probably due to other factors, primarily economic status and presence or absence of dental sealants."
Who opposes water fluoridation?
In 1997 the union of EPA toxicologists, biologists, chemists and other professionals at EPA headquarters in Washington, D.C. voted unanimously to sponsor the California Safe Drinking Water Initiative to reverse the 1995 California State Legislative mandate to fluoridate water
in cities with populations greater than 10,000. The EPA professionals made this recommendation after reviewing the body of evidence over the last 11 years, including animal and human epidemiological studies indicating a causal link between fluoridation and genetic damage, neurologic impairment, bone pathology , osteosarcoma and other adverse health effects such as
Dr. Hardy Limeback, President of the Canadian Association of Dental Research, called for an end to water fluoridation in a statement made in April, 1999. He stated that experts all over the world were concerned after reviewing the literature and finding no evidence that ingesting fluoride protects the teeth. Health concerns included accumulation and cytotoxicity of fluoride in bone.
Dr. John Colquhoun, Principle Dental Officer for the City of Aukland, New Zealand was an articulate and successful proponent of water fluoridation for many years throughout New Zealand. After a world study tour and examining carefully complete statistics for New Zealand he found that there were fewer cavities and more children ages 12-13 cavity free in the non-fluoridated part of New Zealand. He re-examined the statistics, called colleagues all over the world, and reviewed large-scale studies. In 1997 he came to the conclusion that water fluoridation had little or no effect on cavity prevention but had health consequences. His careful review of the data showed a decline in tooth decay since the 1930's before any fluoride products were used. It was felt that improved nutrition, which has been well described, contributed to the improved dental health (68, 69, 70)
Mechanism of Dental Decay and Fluoride Benefit
Dental decay occurs when the oral bacteria feed on carbohydrates and produce acids such as lactic and acetic as by products of metabolism. These acids diffuse in the tooth substance and dissolve calcium and phosphate from the subsurface minerals leading to cavity formation. This is
termed demineralization. As saliva travels over the tooth it can neutralize the acid and allow for remineralization of the calcium and phosphorous. The cariostatic mechanism of fluoride has yet to be fully understood, while others question if there is indeed any cariostatic effect. Fluoride reportedly has two topical effects on cavity prevention.
Remineralization is enhanced by fluoride in the oral cavity. Fluoroapatite-like material that precipitates on the surface of the crystals allegedly makes the enamel more resistant to attack by acids. In addition, it is felt there is a direct antibacterial effect of fluoride by enzyme inhibition (11)
It was always assumed that fluoridated drinking water had a systemic effect by incorporation into the dental enamel. Most dental researchers today believe the mechanism of fluoride is due to a topical effect (23). Limeback (12) states that teeth that develop in the presence of fluoride have higher levels of fluoride in the enamel and dentine.
Recent studies by Li (13) showed that teeth exposed to years of fluoridated water had elevated levels of fluoride in the enamel but the fluoride content in the enamel surfaces, where the process is dynamic, showed no significant increase in fluoride. Limeback reviewed 13 articles commonly cited in support of the pre-eruptive effect of fluoride and found that all had design flaws, including not separating topical vs systemic benefits (12).
Water Fluoridation and Salivary Fluoride Levels
Examining saliva concentrations with ingestion of fluoridated water shows approximate levels of 0.01 ppm which would give negligible if any benefit in cavity prevention (14). Studies of ingestion of fluoride supplements show serum and salivary levels peak at 30 minutes and therefter decline to a baseline level of 0.02 ppm after 1 to 2 hours, thus also of negligible benefit (12). Limeback cautions that it is no longer acceptable to use fluoride supplements on large
populations due to the risks of dental fluorosis from excess ingestion (12).
Do Studies Show Fluoride Reduces Tooth Decay?
There are over 113 studies that report a caries reduction with fluoridation of the water (1, 2). Current studies indicate, however, that the effectiveness of water fluoridation has decreased as the benefits of other forms of fluoride have been used e.g. fluoridated toothpaste, mouth rinses and fluoride treatments to teeth (3). Fluoride is now found in many foods and beverages, see below. Newbrun concludes fluoridation reduces cavity formation in only 15-35% of adult teeth (3).
Others disagree as to the true benefits of fluoridation because most of the caries seen are of the pit and fissure type which are not affected by fluoride (24). Yiamouyiannis analysis of data from the National Institute of Dental Research examining 39,207 U.S. School children showed no difference in tooth decay in the fluoridated vs. non- fluoridated communities. The Diseased, Missing or Filled Teeth (DMFT) per child was identical at 2.0. The percentage of decay free children in the fluoridated, non-fluoridated and partially fluoridated areas was similar at 34%, 35% and 31%, respectively (9). Heller used the same data and found similar decay free rates in fluoridated and non-fluoridated groups (10)
Fluoride in our Food: The "Halo" effect of Water Fluoridation
As communities fluoridate their water supply, we are exposed to the higher levels of fluoride in the environment. Fluoride is not only discharged into sewage treatment plants and rivers, it is incorporated into foods and beverages made in cities that are fluoridated. Banting estimates
dental fluorosis is 60% attributed to other fluoride sources and 40% from water fluoridation (4). Independent lab analysis of fluoride concentrations of ready to eat products showed that 42% of 43 fruit juices contained more than 1ppm of fluoride. Pure fruit juices, especially grapes, contained high levels of fluoride (up to 6.8 ppm), thought to be due to the fluoride containing pesticides widely used on grapes (5). A select list from Stannard (5) is shown in Table 1. It also includes an independent evaluation (7). It is noted that children's ingestion of fluoride from
fruit juices can be substantial and a factor in the development of fluorosis (6)
Fluoride concentrations in select food products (from Stannard (5))
Product Name Company Location Fluoride concentration
(ppm or mg/L)
Grape Beverage Tropicana Bradenton, FL 0.47 Apple Juice Ocean Spray, Middleboro, MA 0.78 Coca Cola Classic various locations 0.98 Grape Juice Welch's Concord, MA 1.28 Apple 100% Minute Maid Houston, TX 1.30 Fruit Loops (solid) Kelloggs Battle Creek MI 2.1 mg/kg Graduate Berry Punch Gerber Fremont, MI 3.0 White Grape Gerber Fremont, MI 6.80
Overdosing on Fluoride: Dental Fluorosis Is An Increasing Problem
Dental fluorosis is a well documented undesirable tooth affect that results from ingestion of too much fluoride in the preeruptive phase of tooth development (10). Dental fluorosis is characterized by chaulky white spots or striations on the teeth and in severe forms pitting with brown stains occur. Fluorosis is not just cosmetic but may require bonding. It is defined as a hypomineralization of enamel and has greater surface and subsurface porosity than is found normally. The disorder increases with higher levels of fluoride intake (15, 16). Optimal levels of water fluoridation (0.7-1.2 ppm) still produce mild fluorosis.
Dental fluorosis has increased substantially in countries where fluoridation is practiced. Fluorosis is found in 22% of the population in the US overall (1) and in optimally (0.7-1.2 ppm) fluoridated communities over 66% have visible signs of fluorosis (10). Levy reviews the relatively high amount of fluoride in mouth rinses, professional and self applied gels and supplements (8). Because of this overexposure many dentists are concerned about ingestion of fluoridated toothpaste's (approximately 1 mg per application) and dispensing fluoride supplements.
What Is Natural Fluoride?
Fluoride is a halogen, and like its family members (chlorine, iodine and bromine) it forms strong bonds with other elements. Fluoride compounds come in many forms. Calcium fluoride, leached from rocks, can be found in some natural water supplies. It is poorly absorbed from the gut
(20-30%) unlike the synthetic fluoride compounds sodium fluoride and hydrofluosilic acid used to fluoridate water supplies and prescribed as tablets which are 85-95% absorbed from the gut(16).
Is Fluoride a Nutrient?
No. Despite billions of years of evolution, fluoride like many heavy metals (lead, mercury) is not used in any biological process in plants, animals or humans. It is not a required trace mineral or vitamin as the proponents of fluoride would have you believe. There is a reason fluoride is not found in biological systems, it is toxic to our natural enzymatic processes, see below.
What Fluoride Compounds are used in our Water Supply?
Fluoride compounds used in our water supply are of three types: fluorosilicic acid, sodium fluorosilicate and sodium fluoride. Fluorosilic acid and sodium fluorosilicate, used in about 50% of our water supplies, are toxic industrial pollutants, by-products of the fertilizer, aluminum
and 50 other manufacturing processes. These industries capture large amounts of fluorine gas in scrubbers, store the resultant waste in settling ponds and then sell the untreated hazardous waste to cities. This permits them to avoid the high cost of disposing of the hazardous materials in
proper disposal facilities.
These fluoride wastes also contain small amounts of other hazardous materials including lead, arsenic, mercury, cadmium, nickel, and radionuclides. No analysis for these materials are done prior to their shipment to municipal water fluoridation facilities. All studies done on fluoride safety have been done with medical grade sodium fluoride in distilled water. No testing has been done with the actual chemicals added, in the water being treated. Further, no clinical studies have ever tested silicofluorides for safety or efficacy.
It is interesting to note that sodium fluoride and sodium fluosilicate were once widely employed as insecticides, especially on grapes. Sodium fluoride is still widely used to control pests such as
cockroaches and termites.
FluorideToxicity and Metabolism
Fluoride is a halogen compound that has a toxicity rating between lead and arsenic (18). It bioaccumulates in humans. Fluorosilicates used to artificially fluoridate our water are rapidly absorbed, unlike the calcium fluoride found naturally in some water supplies. Once ingested only 50% of the fluoride is excreted by the kidneys (16, 25, 26). 99% of the absorbed fluoride is incorporated into calcified tissue i.e. bone, teeth (16).
Fluoride is strongly bound to apatite and calcium phosphate compounds in bone where it accumulates. Thus, over a lifetime fluoride can accumulate in bone at high levels (22). 1% is stored in soft tissues such as the brain (27) specifically in the pineal gland which is not protected by the blood brain barrier (21).
Fluoride is a "general protoplasmic poison", at least four major functional derangements are well recognized: 1) enzyme inhibition of cellular respiration and glycolosis, 2) hypocalcemia, 3) cardiovascular collapse, 4) specific organ damage (18, 58). A study in the Journal Chemical Society in 1985 describes how fluoride disrupts hydrogen bonding between biomolecules.
The most important weak hydrogen bonds are between amides in DNA (20).
Fluorides are toxic to plants.
"Fluoride compounds which enter the air as waste products from the manufacture of phosphates, steel, aluminum, and other industrial processes, act as cumulative poisons, entering the leaf through the stomata and causing collapse of leaf tissue, apparently by inhibiting enzymes concerned with cellulose synthesis. Thousands of acres of florida citrus groves have been damaged by fluorides discharged from phosphate fertilizer plants." (75)
Chronic Toxicity of Fluoride
Skeletal and dental fluorosis are established manifestations of chronic fluoride toxicity (30, 31) In China, 43 million dental fluorosis cases and 2,370,000 skeletal fluorosis cases may have occurred because of exposure to fluoride emissions and drinking contaminated water (36).
Several studies focusing on neurologic effects have shown chronic exposure to cause symptoms of fatigue, headache, decreased concentration, memory disturbances, motor in coordination and depression (32, 33, 34).
Bone Effects of Fluoride: Arthritis and Hip Fractures
The effect of fluorides on bone is considered by most authorities to be toxic. Fluorides are retained preferentially in bone incorporating into the hydroxyapatite and altering the structure of the crystals. Fluoride decreases the mechanical competence of the bone (54). Human skeletal fluorosis is well documented (36). Preclinical skeletal fluorosis is asymptomatic but shows increased bone mass on x-ray.
It was felt in the 1980's that fluorides ability to increase bone density may help women with osteoporosis, however, the opposite was discovered. Four clinical trials demonstrated that when fluoride was administered in an effort to treat osteoporosis and prevent hip fractures that although bone density improved, the hip fracture rate increased along with symptoms of joint pain in those women treated with fluoride. The chairman of the FDA advisory committee at the time was quoted as saying "The FDA should quietly forget about fluoride."
The National Research Council in 1993 (16) reviewed these 3 U.S. studies (37, 38, 39) and one European study of "osteoporosis" therapy (40) using sodium fluoride in doses of 50-80 mg daily, equivalent to 5-10 times the daily fluoride intake of persons living in fluoridated communities.
They report that in all three US studies there was an increase in hip fracture rates as well as peripheral fractures (42, 53). Fluoride was found neither safe nor effective as a treatment for osteoporosis (53).
The NRC also reviewed 10 studies comparing fracture rates in fluoridated and non fluoridated communities. Three studies did not show any increase in fractures (50, 51, 52), however seven (43, 44, 45, 46, 47, 48, 49) found a significant increase in hip fracture incidence. Chronic ingestion of fluoride may produce mild skeletal fluorosis in our population. This is now being studied in Canada. The severity of symptoms of skeletal fluorosis correlate with the level and duration of exposure of fluoride. In phase 1 there is sporadic pain and stiffness of joints, x-rays show osteosclerosis of the pelvis and vertebral column.
In phase 2 there is chronic joint pain and stiffness and increased osteoscerosis in cancellous bones. Phase 3 is characterized by crippling fluorosis with deformities of the spine and major joints, calcification of the ligaments of the neck and vertebral column and muscle wasting. According to the NCR Report "Crippling skeletal fluorosis might occur in people who have ingested 10-20 mg of fluoride daily for 10-20 years" (16).
In 1952 Soriano from Spain reported 28 cases of a crippling bone disorder called periostitis deformans in humans who drank wine containing high doses of fluoride (up to 15 ppm). This was presumably from the fluoride containing pesticides used on the grapes. Radiologically there was 1) osteoscerosis with osteoporosis 2) almond sized periostoses which simulate bone tumors 3) osteophytes that invade tendons and ligaments. Bone bioassays show levels of above 4,000 ppm. He stated that the diagnosis could go unrecognized or incorrectly diagnosed as chronic polyarthritis or rheumatoid disease (22).
Neurotoxic Effects of Fluoride
High doses of chronic fluoride exposure are known clinically to cause neurologic symptoms such as generalized malaise, decreased concentration, decreased memory, depression, and headaches (32, 33, 34). It is known that fluoride can cross the blood brain barrier especially in utero and that it deposits in the pineal gland (21, 27, 61). There has been very little investigation into the link between fluoride and CNS effects at lower exposure. Recent research by Phyllis Mullenix, Ph.D. has shown cognitive and behavioral effects on rats with serum levels of 5-10 ppm
fluoride (55). These levels are lower than those found in some dental fluoride treatments.
In 1995 Dr. Mullenix, a neuropsycopharmacologist and head of the Toxicology Department at Harvard's' Forsyth Dental Center for 12 years, published the first laboratory study demonstrating the neurotoxicity of sodium fluoride in rats. She was asked to study fluoride and expected to
find nothing. In study after study she found that brain function was vulnerable to fluoride, the effects on behavior depended on age of exposure and that fluoride accumulates in brain tissue. Prenatal exposure caused hyperactivity while adult rats exposed to fluoride exhibited "couch potato syndrome". The authors state "Experience with other developmental toxins prompts expectations that changes in behavioral function will be comparable across species." Her work has been honored in the Yearbook of Oncology for the predictability and applicability of her basic science research to clinical medicine working with childhood leukemia patients.
Dr. Mullenix was dismissed from her position as chairman immediately after publishing
her work.. A subsequent lawsuit ended in a settlement with sealed results.
Li in 1995 published a study showing reduced intelligence in children in China with moderate or severe fluorosis (57). Zhao in 1996 compared two villages in China and found statistically significant lowering of IQ in children living in the village with high water fluoride (7-8 IQ
points) (60). Both studies demonstrate that IQ is lower in all age groups in the high fluoride population suggesting neurological damage in early development.
Effects With Lead and Aluminum
Fluoride forms complex ions with many metal ions and due to its corrisivity has been found to leach lead from water pipes and increase levels of lead in children's blood. A recent study was published in the August, 1999 issue of the International Journal of Environmental Studies by
Professor Emeritus Roger Masters at Dartmouth College(17), who describes the findings after analyzing over 280,000 Massachusetts children.
They found that silicofluorides - the fluoride compound most widely used in treating public water supplie - are associated with an increase in children's lead blood levels. Children in 30 communities that use these chemicals were over twice as likely to have over 10 micrograms per
deciliter of blood lead. The correlation with blood levels is especially serious because lead poisoning is associated with higher rates of learning disabilities, hyperactivity, substance abuse and crime.
Lead levels dropped in two community water systems by half after fluoride was discontinued. When the town of Thurmont, Maryland banned water fluoridation with hydrofluosilic acid in 1994 the lead levels went from a high of 130 ppb to 31 ppb and the average blood level went from 9.26 ppb to 7.11.
Lead levels in the water dropped from 32 ppb to 17 ppb when the Tacoma Public Utilities in Washington state temporarily discontinued using fluoride in the public water system due to a drought in the summer of 1992
Dr. Karl Jensen reported long term studies (52 weeks) with rats given aluminum fluoride at 0.5 ppm or sodium fluoride at 2.1 ppm (current water fluoridation level is 1ppm). In both treated groups, the aluminum levels in the brain were elevated relative to controls. The researchers
speculate that fluoride in water may complex with the aluminum in food and enable it to cross the blood brain barrier. Neurotoxic effects similar to alzheimer's were seen in the brain tissue.
They are concerned that fluoride may enhance the bioavailability of aluminum in the brain.(35)
To Fluoridate or Not to Fluoridate?
Despite the fact that fluoridation has enjoyed overwhelming scientific endorsement in the past, most of the world has rejected fluoride. The reason is that the long term environmental and health effects of fluoride are insufficiently known (71-73). In my opinion, recent evidence has taken us beyond that. The bioaccumulative, toxic and synergistic aspects of fluoride are worrisome for humans and ecosystems.
Newer reviews of the literature point to a marginal if any improvement in dental caries. I urge you to reconsider your position on this important public health issue. The potential hazards far outweigh the possible benefits and reasonable alternatives to reduce cavities exist other than water fluoridation.
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