The
Case Against Fluoride
At a public meeting held on
October 17, 2009, in Yellow Springs, Ohio, a community that was considering
halting its fluoridation program, Paul Connett gave a twenty-minute
presentation on the scientific arguments against the practice. After a county
health commissioner and local dentist responded, a woman in the audience said,
“Whether this practice is safe or not, or beneficial or not, I want freedom of
choice. It is my right to choose what substances I put into my body, not some
governmental agency’s.”
This woman echoed what many
opponents of fluoridation have believed and articulated for over sixty years:
Government has no right to force anyone to take a medicine. Thus, while in the
effort to end this practice worldwide it is helpful to provide scientific
evidence that the program is neither effective nor safe, this commonsense
position remains the crux of the argument against fluoridation.
The Need for Informed Consent
Every doctor knows, or
should know, that he or she cannot force an individual to take medicine without
that patient’s informed consent. Doctors must tell their patients the benefits
of any medicine prescribed and warn of any possible side effects. After they
have done this, it is the patient—and only the patient—who should make the
final decision as to whether to take the medicine.
This is what the American
Medical Association (AMA) has to say about informed consent:
Informed consent is more
than simply getting a patient to sign a written consent form. It is a process
of communication between a patient and physician that results in the patient’s
authorization or agreement to undergo a specific medical intervention.
In the communications
process, you, as the physician providing or performing the treatment and/or
procedure (not a delegated representative), should disclose and discuss with
your patient:
- the patient’s diagnosis, if known;
- the nature and purpose of a proposed treatment
or procedure;
- the risks and benefits of a proposed treatment
or procedure;
- alternatives (regardless of their cost or the
extent to which the treatment options are covered by health insurance);
- the risks and benefits of the alternative
treatment or procedure; and
- the risks and benefits of not receiving or
undergoing a treatment or procedure.
In turn, your patient
should have an opportunity to ask questions to elicit a better understanding
of the treatment or procedure, so that he or she can make an informed decision
to proceed or to refuse a particular course of medical intervention.
This communications
process, or a variation thereof, is both an ethical obligation and a legal
requirement spelled out in statutes and case law in all fifty states of the
United States.
By violating the individual
patient’s right to informed consent, fluoridation allows decision makers,
without medical qualifications, to do to the whole community what an individual
doctor is not allowed to do to his or her individual patients.
Counterargument 1: It Is Unethical Not to
Fluoridate
Proponents respond to this
ethical argument by turning it upside down. They argue that it is unethical to
deprive children of a benefit that might reduce pain and help them lead
healthier lives, especially children from low-income families.
However, by not putting
fluoride in the water, you are not depriving anyone of access to fluoride: It
is available in tablet form and in fluoridated toothpaste. (For a discussion
about topical versus systemic benefits, see chapters 2 and 6.)
From an economic
perspective, avoiding fluoride in water is an expensive business, whether it
involves purchasing bottled water for cooking and drinking or the use of
distillation equipment or reverse osmosis systems. Thus, low-income families
are disproportionately burdened by fluoridation since by and large they cannot
afford avoidance measures.
In the United States,
dental decay is concentrated in poor and minority families. Fifty-five years
after fluoridation began, the U.S. surgeon general stated in his 2000 report,
Oral Health in America: “There are profound and consequential disparities in
the oral health of our citizens. Indeed, what amounts to a ‘silent epidemic’ of
dental and oral diseases is affecting some population groups. Those who suffer
the worst oral health are found among the poor of all ages, with poor children
and poor older Americans particularly vulnerable. Members of racial and ethnic
minority groups also experience a disproportionate level of oral health
problems.”
The motivation for
targeting poor children for extra help is highly laudable, but adding fluoride
to the drinking water to do so is misguided. In fact, it makes an inequitable
situation even worse. This is because in Western countries the children most
likely to suffer from poor nutrition come from low-income families, and we will
see in chapter 13 that people with inadequate diets are those most vulnerable
to fluoride’s toxic effects. In our view, children from low-income families are
the very last children who should be exposed to ingested fluoride.
Counterargument 2: No One Is “Forced” to
Drink the Water
Proponents of fluoridation
further counter the notion that fluoridation in the public water system
violates the individual’s right to informed consent to medication by arguing
that fluoridated water is only delivered to the tap and no one is actually
forced to drink it.
This argument certainly
does not apply to low-income families. Their economic circumstances do force
them to drink the water coming out of the tap. Thus, a program that is billed
as equitable is actually inequitable, since families of low income are trapped
by a practice that may cause them harm (see chapters 11, 13–19).
Moreover, even for families
with the means to buy bottled water for drinking and cooking, or equipment to
remove the fluoride at the tap, it is very difficult to avoid fluoride once it
has been put in the community’s water supply. It will be in every glass of
water and cup of coffee or tea consumed in town—at work and in friends’ homes.
It will also be in the water that is used to water the garden and in the shower
and bath water.
Counterargument 3: Fluoride Is a Nutrient,
Not a Drug
Proponents have tried to
muddy the waters in the argument of violation of informed consent and
unacceptability of “mass medication” by insisting that fluoride is not a
medicine or drug, but a nutrient. We examine the evidence for their claims.
Is Fluoride an Essential Nutrient?
There is little or no
evidence that fluoride is an essential nutrient. To demonstrate that a
substance is an essential nutrient one has to demonstrate that some disease
results from depriving an animal or a human of this substance. This has never
been done for fluoride (see chapter 12).
In a 1998 letter by Bruce
Alberts, president of the National Academy of Sciences, and Kenneth Shine,
president of the Institute of Medicine, to Professor Albert Burgstahler, editor
of the journal Fluoride and several other scientists, in response to their
complaint to the National Academy about the Institute of Medicine’s inclusion
of fluoride in the list of nutrients in its report Dietary Reference Intakes for
Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, the following quote
appeared:
First, let us reassure you
with regard to one concern. Nowhere in the report is it stated that fluoride is
an essential nutrient. If any speaker or panel member at the September 23rd
workshop referred to fluoride as such, they misspoke. As was stated in
Recommended Dietary Allowances 10th Edition, which we published in 1989: “These
contradictory results do not justify a classification of fluoride as an
essential element, according to accepted standards. Nonetheless, because of
its valuable effects on dental health, fluoride is a beneficial element for
humans.”
What Alberts and Shine do
not discuss here is whether the supposed benefits of this “beneficial element”
are obtained from some internal biological process or via some nonbiological
interaction of the fluoride with the surface of the tooth enamel. This is a
crucial difference when considering water fluoridation, since the former would
necessitate swallowing fluoride and the latter would not (see chapter 2).
While there is no solid
scientific evidence supporting the notion that fluoride is a nutrient,
strenuous attempts have been made by a number of proponents throughout the
history of fluoridation to try to establish this notion in the public mind. In
chapter 26 we examine these efforts, in particular the effort by Harvard
researcher Dr. Frederick Stare and the aid given to him by the sugar and food
lobbies.
Is Fluoride a Drug?
In a letter sent in
December 2000 to Congressman Kenneth Calvert, chairman of the Subcommittee on
Energy and the Environment, of the Committee on Science, the U.S. Food and Drug
Administration (FDA) stated, “Fluoride, when used in the diagnosis, cure,
mitigation, treatment, or prevention of disease in man or animal, is a drug
that is subject to Food and Drug Administration regulation.” The National
Association of Pharmacy Regulatory Authorities in Canada lists “sodium
fluoride” and “fluoride and its salts” as drugs.
According to Cheng et al.
in an article appearing in the British Medical Journal, “The legal definition
of a medicinal product in the European Union (Codified Pharmaceutical Directive
2004/27/EC, Article 1.2) is any substance or combination of substances
‘presented as having properties for treating or preventing disease in human
beings."
Both the Centers for
Disease Control and Prevention (CDC) and the American Dental Association
(ADA), the main proponents of fluoridation in the United States, describe
dental caries (tooth decay) as a “chronic infectious disease” and recommend
fluoride to prevent the disease.
If fluoride is a drug or
medicinal product, fluoridation is medication delivered on a massive scale.
An Unapproved Drug
In a June 3, 1993, letter
to FDA commissioner Dr. David Kessler, former New Jersey assemblyman John V.
Kelly wrote, “The Food and Drug Administration Office of Prescription Drug
Compliance has confirmed, to my surprise, that there are no studies to
demonstrate either the safety or effectiveness of these drugs [fluorides],
which FDA classified as unapproved new drugs.”
It goes without saying that
it would be highly questionable to deliver any drug via the public water
system—let alone fluoride, which the FDA calls an unapproved drug. The
designation “unapproved drug” means that it has not gone through rigorous
trials to establish either its effectiveness or its safety. This designation
also puts into question the ethics and legality of school nurses and teachers
administering fluoride pills and/or rinses to students in U.S. schools located
in non-fluoridated areas.
Other Arguments
Violating the modern
medical ethic of informed consent is not the only feature of fluoridation that
makes it a poor medical practice. In a recent videotaped interview, Earl Baldwin,
a member of the British House of Lords and one of the advisory board members
for the York Review, the UK-sponsored review of fluoridation, explained why
he thought fluoridation was a bad idea: “What physician do you know, who in his
or her right mind, would treat someone he does not know and has never met, with
a substance that’s meant to do change in their bodies, with the advice: ‘Take
as much, or as little, as you like, but take it for a lifetime because it may
help someone’s teeth’?”
Independent observers have
been saying similar things since the inception of fluoridation, but these
arguments have fallen largely on deaf ears. This is not because the reasoning
lacks merit, but because those who promote fluoridation have the power to
ignore both common sense and scientific argument. We examine the strategies and
tactics used in the promotion of fluoridation in chapter 23. In the following
sections we examine some of the commonsense arguments of opponents such as Earl
Baldwin in more detail.
No Control over Who Gets the Medicine
For those who promote
fluoridation, one of its attractions is that it delivers fluoride to everyone
indiscriminately. But for opponents this is one of its greatest weaknesses.
When fluoride is added to the water supply, it goes to everyone, including
those most vulnerable to fluoride’s known toxic effects. These include
above-average water consumers; the very young; the very old; those with
diabetes; those with low thyroid function or kidney disorder; and those with an
inadequate diet, including those suffering from outright or borderline iodine
deficiency (see chapter 16). Also, as we indicated above, it goes to families
of low income who cannot afford avoidance measures.
No Control of Dose
A critical problem with
delivering a medicine via the water supply is that there is no control over the
dose. Dr. Arvid Carlsson discussed this issue in a letter he wrote in February
2009:
Fluoridation is an obsolete
practice. It goes against all principles of modern pharmacology. The use of the
public drinking water supply to administer the same dose of fluoride to
everyone, from the infant to those who consume copious amounts of water (such
as diabetics), goes against all principles of science because individuals
respond very differently to one and the same dose and there are huge variations
in the consumption of this drug.
Concentration versus Dose (from water and
other sources)
Proponents of fluoridation
stress how well engineers can control and monitor the concentration of the fluoridating
agent added to the water supply. However, controlling concentration, measured
in the case of fluoride in milligrams per liter (mg/liter), is not the same as
controlling dose, which is measured in milligrams consumed per day (mg/day).
If someone drinks 1 liter
of water containing fluoride at 1 mg/liter (i.e., 1 ppm, which is the
concentration at which it is administered), they will ingest 1 mg of fluoride.
If they drink 2 liters, they will receive 2 mg of fluoride, and so on. The dose
gets larger the more water is drunk; and the larger the dose, the more likely
it will cause harm. This is particularly serious for a substance like fluoride,
which is known to be highly toxic at moderate to high doses, which accumulates
in the bone, and for which there is little, if any, margin of safety to protect
the most vulnerable against known health risks (see chapter 20).
We also receive fluoride
from sources other than the water supply, and this amount varies from
individual to individual. Thus, it is the total dose from all sources we should
be concerned about.
To determine potential
harm, we also have to take into account the body weight of the consumer. We
discuss the difference between dose and dosage below.
Dose versus Dosage
The dose of aspirin or any
other drug considered safe for a grown-up is not a safe dose for a baby.
Similarly, a safe dose of fluoride for an adult cannot be considered safe for a
baby. Thus it is alarming when one discovers that, over the course of the day,
bottle-fed babies can receive nearly as much fluoride as an adult who drinks 1
liter of fluoridated water. According to the U.S. Environmental Protection
Agency in a 2008 article on why children may be especially sensitive to
pesticides, “In relation to their body weight, infants and children eat and
drink more than adults.”14 The way toxicologists determine the safe dose for
different ages is to adjust for the average body weight of the age range in
question.
According to the EPA’s 1986
calculation of a safe drinking water standard, a safe daily dose of fluoride
for a 70-kg (154-lb) adult is supposed to be 8 mg per day.15 In chapter 20, we
challenge the faulty reasoning that led to this high figure. But in the
meantime, if we adjust this figure of 8 mg per day for body weight, that would
mean that only 0.8 mg per day would be safe for a 7-kg (15-lb) infant (i.e., a
ten times lower dose because the baby’s body weight is ten times lower). Even
that dose may be too high for a baby, however, because a baby’s developing
tissues, particularly the brain, are much more vulnerable to toxic agents than
an adult’s. An infant is not simply a miniature adult.
Dose divided by a person’s
body weight is called dosage and is measured in milligrams per kilogram of body
weight per day (mg/kg/day). The safe dose for an adult divided by an adult’s
body weight (assumed to be 70 kg) is called the reference dose, or RfD.
Strictly speaking, we should call this a reference dosage, but people seldom
do. Note the different units here. If we are talking about dose, we are
speaking about mg/day, but if we are talking about a reference dose, or
dosage, we are speaking about mg/kg/day. This is a big difference.
Now let’s look at a
real-life example of using a reference dose. The EPA lists IRIS reference doses
for a number of toxic substances. IRIS stands for Integrated Risk Information
System; it is used for health-risk assessments. The EPA’s RfD for fluoride
listed in IRIS is 0.06 mg/kg/day.
It is worrying to see that
this IRIS RfD is easily exceeded by a baby consuming formula made with
fluoridated water. For example, a 10-kg infant drinking each day 1 liter of
water containing fluoride at 1 ppm will get a dosage of 0.10 mg/kg/day (1
mg/day divided by 10 kg). That is almost twice the IRIS RfD.
It was after the 2006 U.S.
National Research Council report made it clear that bottle-fed babies were
exceeding the IRIS RfD that the ADA finally recommended to its membership, in
November 2006, that they advise their patients not to use fluoridated water to
make baby formula. The CDC followed suit, but neither has made much of an
effort to get this information to parents.
Different Responses to Same Dose
It is well known that there
is a very wide range of sensitivity across the human population to any drug or
toxic substance. Some people will be very resistant, while others will be very
vulnerable or sensitive to the same substance. Most of us will have an average
tolerance; however, we can anticipate that the most sensitive will be at least
ten times more vulnerable than the average responder. Those who promote
fluoridation gloss over the insufficient margin of safety to protect all
citizens, especially the most sensitive, from the known adverse health effects
of fluoride (see chapters 13 and 20).
Warnings, Help, and Compensation
One thing that is generally
accepted about water fluoridation is that where it is implemented, the rates of
dental fluorosis (mottling and discoloration of the enamel; see chapter 11) in
children will rise. Very little warning is being given about this, especially
to low-income families who bottle-feed their babies with formula made with
fluoridated tap water. Nor is any financial help being provided to those
families whose children are so affected. It can cost up to $1,000 to treat a
fluorosed tooth with veneers—more when the veneers have to be replaced in
subsequent years.
According to the CDC, 32
percent of American children are affected by dental fluorosis. While most of
those children have the very mild condition, those with the mild, moderate, or
severe condition make up about 10 percent of the total, and many of those may
need treatment (see chapter 11). Ten percent being affected would mean some
32,000 children in a city of one million needing cosmetic treatment that few
families can afford. Public and media concern is growing on this issue; for
example, see the transcript of a TV news clip from CBS in Atlanta, Georgia,
broadcast in March 2010.
Mandatory Fluoridation
The imposition of
fluoridation on individuals without their informed consent becomes even more
egregious when legislation is introduced to mandate the practice for whole
states, provinces, or countries. While we do not consider that a local
referendum is ethically satisfactory, since the medicine we take should not be
determined by our neighbors, such a process may allow discussion,
deliberation, and the opportunity for people to express their concerns—at least
at the local level. When the practice of adding fluoride to the public water
system becomes mandatory at the state, provincial, or even national level, the
vast majority of the population has little idea of what is going on, either
during the passage of the legislation or subsequently, when the measure is
enforced. Informed citizens are usually dispersed in large jurisdictions and
have few resources to match the lobbying power of either the national dental
associations or governmental health bodies hell-bent on introducing this measure.
Those who hold the ethical requirement of informed consent to be the final
argument on this matter will continue to battle at the national and international
levels to insist on this principle being recognized. But in practice, in
today’s world, local democracy—when it is allowed to operate—probably offers
citizens a greater chance of protecting themselves against forced fluoridation.
A number of legislatures
have introduced mandatory fluoridation legislation in various states within
countries and sometimes for the whole country. These include the states of
Victoria and Queensland in Australia; the states of California, Connecticut,
Georgia, Illinois, Indiana, Louisiana, Michigan, Minnesota, Nebraska, Nevada,
Ohio, and Tennessee (as well as Washington, D.C.) in the United States; and the
countries of Singapore and the Republic of Ireland. As we write, efforts to
introduce mandatory fluoridation are under way in the U.S. states of New
Jersey, Oregon, and Pennsylvania.
Mandatory fluoridation
measures violate the principle of the crucial role of community participation
in health measures outlined in the Ottawa Charter for Health Promotion.
Mandatory fluoridation also violates the Council of Europe’s Convention on
Human Rights and Biomedicine, whose article 5 states, “An intervention in the
health field may only be carried out after the person concerned has given free
and informed consent to it. This person shall beforehand be given appropriate
information as to the purpose and nature of the intervention as well as on its
consequences and risks. The
person concerned may freely withdraw at any time.”
No local, state, or federal
government—no matter how well intentioned—has the right to force anyone to take
a medicine for a disease that is neither contagious (in a communal sense) nor
life threatening.
Summary
Fluoridation—the deliberate
addition of fluoride to the public water supply—is a poor medical practice
because it violates the principle of informed consent to medication. It is
indiscriminate and offers no control over the dose received by an individual.
It makes inadequate allowance for differing sensitivity to toxic effects, or
for the size and body mass of recipients; this last point is particularly
important for young children who may receive proportionately much higher
dosages than adults at a time when their bodies are far more vulnerable to
toxic agents. Fluoride used in the fluoridation of drinking water is considered
to be a drug, not a nutrient. It is chronically toxic at moderate doses. As a drug,
it has not been rigorously tested and has not been approved by the U.S. FDA.
Fluoridation increases the chances that a child will develop fluorosis of the
permanent teeth, which can be disfiguring and require expensive cosmetic
treatment in a minority of cases. The notion that fluoridation is equitable is
misplaced for two reasons: Children from low-income families are more likely to
have poor nutrition, making them more vulnerable to fluoride’s toxic effects;
and low-income families are least able to afford avoidance measures.
