Exerpted from the Cleveland Plain Dealer Sunday Supplement
March 26, 2000
Does fluoridated water help prevent
toothdecay? Or does it cause illness?
Story by FRAN HENRY Photos by BRYNNE SHAW
She speaks softly, in pleasant, confident tones. Sharon Schnall embodies calm and patience. She works at it.
"You don't want people to think you're nuts;' she says. That's a good idea for a person engaged in a movement historically linked with the notion of crackpot.
Over the past two years, Schnall, a Bainbridge Township homemaker and the mother of two, has evolved into an anti-fluoride activist. Although she doesn't think water fluoridation is a communist plot, a la General Jack Ripper in the 1964 film Dr. Strangelove, Schnall believes that it's a health hazard, a contention currently under investigation by the U.S. House of Representatives Science Committee. The inquiry is in the letter-writing stage, says committee staffer Jeff Lungren, and may be the subject of hearings.
"I don't think the issue is about tooth decay anymore;" says Schnall. "I personally don't believe that fluoride is an essential element to prevent tooth decay, and if it were, I still think there's too much out there, and it's linked to other illnesses."
She says thousands of studies in medical journals worldwide document links between long-term fluoride ingestion and myriad illnesses and conditions, including thyroid disorders, cancer, mental retardation, osteoporosis, birth defects, infertility, organ failure, lead poisoning and learning disabilities, and an increased incidence of hip fractures in the elderly.
What's more, she says, research shows no connection between water fluoridation and a reduced cavity rate.
Fluoride proponents maintain that fluoride prevents decay both topically and systemically through its presence in the saliva and plaque, says Dr. William Bowen, of the University of Rochester's Center for Oral Biology. Communities that fluoridate aim for 0.7 to 1.2 parts per million, the optimum concentration recommended by the U.S. Public Health Service.
The proponents flat out dismiss studies that find danger in long-term consumption of fluoride.
"There's misinformation, distortion of what studies say and creation of unnecessary fear;" says Scott Presson, oral health expert for the Centers for Disease Control and Prevention, the federal agency with primary responsibility for oral health nationwide. "What the CDC will do is continue to evaluate emerging science. For now, our view and that of other major health organizations is that fluoride is a safe and effective [decay] preventive measure."
The government stands by its original measure of fluoride's safety, says Thomas Reeves, national fluoridation engineer for the CDC. That measure was a 1943 study of Bartlett, Texas, where the natural fluoride level is eight times the recommended one part per million. (Fluoride, a naturally occurring element in the earth's crust, is found in all water to various degrees. Fluoridation of any water supply involves adjusting the level of fluoride, either bringing it up to a certain level or lowering the level, such as in Bartlett.) The only long-term complication of drinking Bartlett water, says Reeves, was widespread dental fluorosis, which is mottling of the tooth enamel.
Despite pockets of anti-fluoride activity, particularly in California, Pennsylvania, New York, Massachusetts and Washington, fluoridation has flourished in this country since January 1945, when Grand Rapids, Michigan, became the first city to add fluoride to its water system. Every U.S. surgeon general since 1945 has endorsed the practice, which the CDC calls one of the 10 great public health achievements of the century.
Yet in an October 22, 1999, report, the CDC noted that since community water fluoridation began, the prevalence of cavities has declined in U.S. communities both with and without fluoridated water. The CDC attributes the decline to the presence of fluoride in foods and beverages and the widespread use of fluoridated toothpaste.
The American Dental Association concedes that tooth decay is still a significant oral health problem, but says it would be more so if artificial fluoridation (the addition of fluoride to drinking water) were discontinued. According to the EPA, more than 84 percent of U.S. children, 96 percent of U.S. adults, and 99.5 percent of Americans 65 years of age and older have experienced tooth decay.
"The wonderful thing about fluoridated water is that it's passive prevention;" says Dr. John Stamm, an ADA spokesman. "There's no overt expenditure, no behavior involved"
Before fluoridated toothpaste was introduced, he says, the entire population profited from fluoridated water. Now the chief beneficiary of fluoridated water is the low-income population, says Dr. Jayanth V Kumar, assistant director of the New York State Health Department. His studies of cavity rates in fluoridated and unfluoridated communities reveals, he says, that fluoridation is of particular benefit to low-income people, who presumably don't practice good dental hygiene and don't receive regular dental care.
But it is this very lack of choice that galls the opposition. "The water is the people's water. It's held in trust by the people we elect. It's not the American Dental Association's water, or the government's water. Just don't mess with the water;" says Jeff Green, director of Citizens for Safe Drinking Water of San Diego, California.
"Even if you think fluoride is good;" says Eleanor Krinsky, of the New York State Coalition Against Fluoridation, "it shouldn't be in our drinking water. Even if you can't decide if the studies are right on either side, don't force people to ingest fluoride. If you want fluoride, there are lots of optional ways to get it."
Krinsky is being selfish, says Dr. Michael Easley, also an ADA spokesman and the former chief of dental health in Ohio. "If she doesn't want fluoride in her water, she can buy bottled water. Is it more fair for poor kids to be left out there with no protection? In this country we do what is best for most people."
About 61 percent of the U.S. population is served by fluoridated public water systems, says Thomas Reeves, national fluoridation engineer for the CDC. The recent additions of the water supplies of Los Angeles, Phoenix, and Augusta and Portland, Maine, ensure that by 2010, 75 percent of the population will be served by fluoridated water supplies, meeting goals outlined in the federal government's Healthy People 2010 plan for disease prevention.
Ten states, including Ohio since 1969, require fluoridation of water supplies that serve communities over 5,000. In the other 40 states, fluoridation is determined state by state, city by city. In Ohio, the state pays start-up costs for fluoridation programs, says Dr. Mark Siegel, director of Ohio's Bureau of Oral Health, but the ongoing cost of buying fluoride is borne by the municipalities.
The Cleveland Water Department fluoride bill is $220,000 a year, says Cleveland Water Commissioner Julius Ciccia, out of a total yearly budget of $200 million.
Siegel says fluoridation is cost-effective. While the average filling in Ohio costs $65, he says, water fluoridation costs "about 50 cents per person, per year, $37.50 for a lifetime of protection."
The trend toward universal fluoridation seems to be well accepted by the American population. According to a 1998 Gallup Poll sponsored by the ADA, 70 percent of those individuals surveyed nationally agreed that water systems should be fluoridated.
Sharon Schnall is convinced that the American public would be far less supportive if the broadcast and print media reported more widely on the opposition. As it is, she says, fluoride's public image is shaped by dental hygiene commercials and ads that tout fluoride's benefits.
Schnall admits that she herself accepted fluoridation without question until about two years ago, when she happened upon a magazine article about a plan in Phoenix, Arizona, to stop fluoridation. She says she was shaken to discover that water fluoridation has critics.
"My immediate reaction was to investigate discontinuing the [children's] fluoride supplements;' which the American Dental Association recommends for children whose water source is unfluoridated, as is the Schnall family's well water.
"As a parent, you feel extra cautious; says Schnall, who has a master's degree in business administration from Case Western Reserve University. So she put her research skills to work looking for tarnish beneath fluoride's highly polished public image.
Her research began at a health food store, where she found books about fluoridation. As she began to believe that objections to fluoride were well-founded, she called scientists and organizations cited in footnotes, and explored the Internet to find Web sites addressing the subject of fluoridation (See Sidebar, "Untangling the Web of Information").
Schnall decided it would be in her family's best interest to minimize their exposure to fluoride: no fluoride toothpaste and no fluoride supplements for the children, ages 3 and 5. And she had their well water tested for fluoride. "It was clear;" she notes, free of fluoride, and therefore safe to drink.
Schnall became an anti-fluoride activist and shares anti-fluoride research and news with about 100 online correspondents, including friends, family and fellow activists. She feels she is helping to compensate for the lack of information in the mainstream press. She says she was particularly disappointed when the union that represents EPA scientists, chemists, biologists and other professional staff at EPA headquarters in Washington, D.C., called for an immediate halt to fluoridation of drinking water supplies in 1997, and the story went generally unreported, a contention supported by online research of newspaper tiles.
The union, the National Treasury Employees, Chapter 280, is arguably fluoridation's most credible opposition in the United States.
The union's position is that EPA research proves "fluoride delivered through the water doesn't prevent cavities" says Dr. William Hirzy, senior vice president of the union. Although he has been a full-time union officer for 10 years, Hirzy also has the title of senior scientist in the EPA's risk assessment division in the Office of Pollution Prevention and Toxics.
"There's virtually no [water fluoridation] in continental Europe where the [cavity] rate is the same as in the U.S.," notes Hirzy. (As an alternative to water fluoridation, many countries, including France, Switzerland, Colombia, Jamaica, Costa Rica, Mexico, Spain and Germany, put fluoride in salt, says the ADA. But water is a preferable medium, notes Kumar, because "the concentration of fluoride in water compared to alternative forms of fluoride delivery is lower, and, therefore, safer." )
Hirzy says EPA scientists have provided the federal government with data that demonstrates a causal link between fluoridation and cancer, genetic damage, neurologic impairment, bone pathology and lowered IQ, but it has been ignored, he says, because of fear of liability.
"The government and certain elements in the private sector, like the ADA he says, "have a tremendous interest in keeping up the pronouncement that fluoride is good for the teeth and if you drink [fluoridated water], it will be good for your teeth."
"They're riding a tiger that's hard to get off."
However, two prominent fluoride proponents have ended their ride. In November 1999, Dr. Hardy Limeback, who for many years was chief spokesman for the Canadian Dental Association, and as such, the leading fluoride proponent in Canada, began to work to unify anti-fluoride activists worldwide into one organization, AGAINST F, the Association of Groups Against Ingestion and Nutritive Systemic Therapy with Fluoride.
Dr. John Colquhoun, an avid fluoridationist in the Seventies in his capacity as principal dental officer for the city of Auckland, New Zealand, became actively opposed to fluoridation in the Eighties.
Eventually, says Hirzy, who also teaches chemistry at American University it Washington, D.C., the govern ment will "have to tell the electorate why [they] haven' followed science"
The motto of the National Center fog Fluoridation Policy & Research, founded by ADA spokesman Easley, is "Fluoridation: Nature though of it first." The anti fluorida tionists beg to differ. Althougl fluoride is found in smal traces on the earth's surface they note that while food grade fluoride is used in tooth paste, the form used in water fluoridation is a toxic byprod uct of the phosphate fertilize industry.
Only "because it has commercial value;" the fertilizer industry prefers to call it co-product, says Mike Coates director of transportation and regulatory compliance for Lucier Chemicals, the compa that sells 1,200 pounds of liquid and powdered fluoride to the Cleveland Water Department yearly.
It is produced, he explains, when fluorine gas is removed from the steam emitted during the process in which phosphate rock and sulfuric acid produce phosphate fertilizer. Phosphate rock, which is the mineral apatite, contains 3 percent to 7 percent fluoride.
"As the fluorine rises out of the big pressure cooker and goes up the [steam] column, it's knocked down with little water jets, which is the scrubber. When the water mixes with the fluorine gas, the molecules of fluorine can be collected in a storage tank"
If the fluorine gas were emitted into the atmosphere, it would be considered a toxic emission, subject to action by the EPA.
Using harvested forms of fluoride for fluoridation purposes sidesteps the usual costs of disposing of toxic waste, says Hirzy. Instead of the $250 million to $300 million a year cost of disposal, he says, "Human bodies are used as the disposal site."
The pro-fluoride camp has a distinctly different take on the transaction.
"They'd be stupid if they didn't sell fluoride," says Easley, the ADA spokesman and University of Buffalo professor. "We reward companies for being efficient. So it's a byproduct, it's a poison, but not in the amount we put in the water. Poison is a relative term. It means nothing."
One part fluoride per million parts water is a safe concentration, says Dr. James Simmelink, director of research for the CWRU School of Dentistry. "There are two extremes of fluoride. At high levels it's poison and at low levels it's beneficial to the teeth. People who want to push the negative side don't make that clear."
But the critics maintain that danger lies in the American diet containing multiple sources of fluoride, including foods and beverages produced in fluoridated areas.
"Right now American children are being overdosed," says Dr. Paul Connett, a chemistry professor at St. Lawrence University in Canton, New York, and coeditor of Waste Not, a journal of resource management with an anti-fluoride agenda.
In addition to the fluoride in the water, he says, the presence of fluoride in foods, from soft drinks to cereals to produce grown in fluoridated areas, has been well established.
The November 1999, Journal
of the American Dental Association reported that the fluoride
levels of a majority of soft drinks exceeded 0.60 parts per million;
a July 1996 article reported on the high fluo-ride level in fruit
juices; and a July 1997 article reported that young children
who consume ready-to-eat baby foods, particularly those containing
chicken, are "ingesting more fluoride than they need:"
Dental fluorosis ranges in severity from subtle white flecks in the tooth enamel to a pronounced brown staining, depending on the level of overexposure to fluoride. The condition was first noted in 1901 in Colorado Springs, Colorado, where it was called "Colorado Brown Stain;" but could not be studied until 1931 when technology to analyze water became available. Then the National Institutes of Health initiated research that con-firmed the connection between fluoride and dental fluorosis.
The incidence of dental fluorosis among U.S. children has increased from 10 percent to 22 percent in the past 25 years, says the ADA. And some studies report even higher rates. The American Academy of Pediatric Dentistry cites a study at the Indiana University School of Dentistry that found fluorosis increased from 18 percent in 1992 to 33 percent in 1994, and another study, in July 1998, that found fluorosis in 69 percent of children from high socioeconomic-status families whose parents had college degrees and lived in fluoridated-water communities.
In response to the rise in fluorosis, the ADA and the pediatric dentistry group suggested a reduction in fluoride supplement dosage, and pediatricians were encouraged by the academy to warn parents to carefully supervise children's tooth-brushing because studies have shown that children often swallow tooth-paste instead of spitting it out. Since 1997, toothpaste tubes have carried warnings discouraging toothpaste swallowing. Tooth-paste flavored to appeal to children exacerbates the problem.
"This is a legitimate area of concern;' says Simmelink of the CWRU School of Dentistry. "Very young children with a fluoridated water supply don't need more [fluoride.]"
It's time, says Dr. John Stamm, ADA spokesman, to offer a pediatric fluoride toothpaste with lower concentrations of fluoride, something "already being done in Europe."
An even bigger issue separating the camps is the implication of dental fluorosis.
Fluoride proponents say fluorosis is merely a cosmetic problem, while the antifluoride camp says cosmetics is the least of it. In an e-mail letter being circulated among anti-fluoridationists, Limeback calls fluorosis "the tip of the iceberg" of fluoride-related health problems.
"In fluorosis,'' says Professor Connett, "you are looking at interference with the laying down of calcium. It's something you can see. If it's doing this to teeth, what is it doing to enzymes we can't see? Practically all the thousands of chemical reactions that take place in the body are catalyzed by enzymes. And it's known that many enzymes are poisoned in test tubes at one part per million fluoride or less.
"Dental fluorosis is a waning that something else is going on."
The pro-fluoride camp rejects the contention that fluoride disrupts enzyme action. One part fluoride per million, says Dr. Gary Whitford, toxicology specialist at the University of Georgia Medical College, "is really too low to have an effect on any enzyme I know of."
"The National Academy of Science, the World Health Organization and other reputable, cool-headed scientists have done large-scale reviews [of fluoride research] and so far" he says, "they've found that optimally fluoridated water or fluoridated toothpastes are beneficial and not harmful.
The pro-fluoride camp doesn't dispute the anti-fluoridationists' allegation that fluoride is a poison. However, explains Simmelink, diluting fluoride to one part per one million parts water makes it safe.
Fluoride's main poisonous effect, Simmelink continues, is that it binds with calcium, which is necessary for muscles to work. "If you ingest a toxic level and manage to keep it down - you'd probably throw up - your muscles can't expand and contract properly so you can't breathe."
Obviously, says the ADA's Stamm, the sides are caught in a standoff.
"We've all engaged each other in the past and tried hard to persuade each other, but the evidence appears to be that we haven't persuaded each other very much.
"On both sides a certain level of futility sets in that we're never going to persuade the other side . ... There's the feeling that not much is going to change;" Stamm says.
Easley, Stamm's fellow ADA spokesman, is blunt about why he's given up on talking to the anti-fluoridationists.
"They're flat-Earthers" he says. "I don't bother trying to convince them. They're uneducable. They'll remain opposed despite the facts."
Even labeling toothpaste with poison warnings, says Easley, was a bad idea. "It inordinately scares people."
Nor does he support any discussion of fluoridation. "Don't do the article" he advises. "It will only scare people. Just bringing it up makes people think there's something wrong with it"
Fran Henry is a Plain Dealer
features writer who formerly was the editor of the Health &
Fitness section. She can be reached at 216/999-4806 or fhenry@
copyright Cleveland Plain Dealer 2000