The Fluoride Debate

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TABLE OF CONTENTS

INTRODUCTION

HISTORY/
ENVIRONMENT

CENSORSHIP

THE FLUORIDE
DEBATE

BENEFITS
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8

ALTERNATIVES
Question 9
Question 10
Question 11
Question 12


SAFETY
Question 13
Question 14

OVERDOSE
Question 15
Question 16
Question 17

DISEASES
Question 18
Question 19
Question 20
Question 21
Question 22
Question 23
Question 24
Question 25
Question 26
Question 27
Question 28
Question 29
Question 30
Question 31
Question 32
Question 33

PUBLIC
POLICY

Question 34
Question 35
Question 36
Question 37
Question 38
Question 39
Question 40

COST
EFFECTIVENESS
Question 41
Question 42
Question 43

CONCLUSION

DISEASES

Question 19.
What is dental fluorosis?

ADA's Fluoridation Facts Short Answer
Dental fluorosis is a change in the appearance of teeth and is caused when higher than optimal amounts of fluoride are ingested in early childhood while tooth enamel is forming. The risk of dental fluorosis can be greatly reduced by closely monitoring the proper use of fluoride products by young children.

ADA's Fluoridation Facts Long Answer
Dental fluorosis is caused by a disruption in enamel formation which occurs during tooth development in early childhood.104 Enamel formation of permanent teeth, other than third molars (wisdom teeth), occurs from about the time of birth until approximately five years of age. After tooth enamel is completely formed, dental fluorosis cannot develop even if excessive fluoride is ingested.131 Older children and adults are not at risk for dental fluorosis. Dental fluorosis only becomes apparent when the teeth erupt. Because dental fluorosis occurs while teeth are forming under the gums, teeth that have erupted are not at risk for dental fluorosis.

Dental fluorosis has been classified in a number of ways. One the most universally accepted classifications was developed by H. T. Dean in 1942; its descriptions can be easily visualized by the public (See Table 3).

In using Dean's Fluorosis Index, each tooth present in an individual's mouth is rated according to the fluorosis index in Table 3. The individual's fluorosis score is based upon the severest form of fluorosis recorded for two or more teeth.

Very mild to mild fluorosis has no effect on tooth function and may make the tooth enamel more resistant to decay. This type of fluorosis is not readily apparent to the affected individual or casual observer and often requires a trained specialist to detect. In contrast, the moderate and severe forms of dental fluorosis are generally characterized by esthetically (cosmetically) objectionable changes in tooth color and surface irregularities. Most investigators regard even the more advanced forms of dental fluorosis as a cosmetic effect rather than a functional adverse effect.74

The EPA, in a decision supported by the U.S. Surgeon General, has determined that objectionable dental fluorosis is a cosmetic effect with no known health effects.97 Little research on the psychological effects of dental fluorosis on children and adults has been conducted, perhaps because the majority of those who have the milder forms of dental fluorosis are unaware of this condition.54 In a 1986-7 national survey of U.S. school children conducted by the National Institute of Dental Research, dental fluorosis was present in 22.3% of the children examined using Dean's Index.54 These children were exposed to all sources of fluoride (fluoridated water, food, beverages, fluoride dental products and dietary supplements). The prevalence of the types of fluorosis were:

  • Very mild fluorosis 17.0%
  • Mild fluorosis 4.0%
  • Moderate fluorosis 1.0%
  • Severe fluorosis 0.3%
  • Total cases of fluorosis 22.3%

The incidence of moderate or severe fluorosis comprised a very small portion (6%) of the total amount of fluorosis. In other words, 94% of all dental fluorosis is the very mild to mild form of dental fluorosis (See Figure 2).

As with other nutrients, fluoride is safe and effective when used and consumed properly. The recommended optimum water fluoride concentration of 0.7 to 1.2 ppm was established to maximize the decay preventive benefits of fluoride, and the same time minimize the likelihood of mild dental fluorosis.54

As with all public health measures, the benefits and risks of community water fluoridation have been examined. The benefits of water fluoridation are discussed extensively in the Benefits section of this document and the safety of water fluoridation is discussed in great detail in the remainder of this Safety section. In assessing the risks in regards to dental fluorosis, scientific evidence shows it is probable that approximately 10% of children consuming optimally fluoridated water, in the absence of fluoride from all other sources, will develop very mild dental fluorosis.133

As defined in Table 3, very mild fluorosis is characterized by small opaque, paper-white areas covering less than 25% of the tooth surface. The risk of teeth forming with the very mildest form of fluorosis must be weighed against the benefit that the individual's teeth will also have a lower rate of dental decay thus saving dental treatment costs.4, 5 In addition, the risk of fluorosis may be viewed as an alternative to having dental decay, which is a disease that may cause cosmetic problems much greater than fluorosis (See Figure 2).134

In 1994, a review of five recent studies indicated that the amount of dental fluorosis attributable to water fluoridation was approximately 13%. This represents the amount of fluorosis that might be eliminated if community water fluoridation was discontinued.52 In other words, the majority of dental fluorosis can be associated with other risk factors such as the inappropriate ingestion of fluoride products.

Additional discussion on this topic may be found in Question 20.

The type of fluorosis seen today remains largely limited to the very mild and mild categories, although the prevalence of enamel fluorosis in both fluoridated and nonfluoridated communities in the United States is higher than it was when original epidemiological studies were done approximately 60 years ago. Because fluoride intake from water and the diet appears not to have increased since that time, the additional intake by children at risk for dental fluorosis is believed to be caused by consumer's inappropriate use of fluoride-containing dental products. As the ADA has recommended, the risk of fluorosis can be greatly reduced by following label directions for the use of these fluoride products.74, 96

Repeat of Question 19.
What is dental fluorosis?

Opposition's Response

In 1954, proponents openly admitted that dental fluorosis was the result of chronic low-grade poisoning from excess fluoride ingestion. (See 19-1: "Metabolism of Fluoride in Man," from Industrial Medicine & Surgery, 23:431-2, Sept. 1954). It is not just a "cosmetic effect" — it is the first sign that your child has been overdosed with a poison.

66.4% of US schoolchildren in so-called "optimally" fluoridated communities have teeth that display the permanent visible signs of fluoride-overdose. Dental fluorosis: white spots, staining, chalky and brittle enamel. (K.E. Heller,et al, Journal of Public Health Dentistry, Vol. 57: No. 3, Summer 1997.) (See Overdose section).

"Fluorosis — An abnormal condition caused by excessive intake of fluorine, as from fluoridated drinking water, characterized chiefly by mottling of the teeth." (The American Heritage Stedman's Medical Dictionary, 1995).

For 35 years it has been known that African-American children have twice the prevalence of dental fluorosis as white children and tends to be more severe. (See 19-2: "Health Effects of Ingested Fluoride" from National Academy Press, Washington, D.C.,1993. Also see 19-3, 19-4 and 19-5: H.T. Dean's 1942 Classification and Criteria of dental fluorosis, "Dental Fluorosis — How it Happens," and photos of fluorosed teeth).

Dr. F. J. McClure, National Institutes of Health, states that "the first specific symptom of fluorine injury to the child is the appearance of hypocalcified enamel known as mild mottled enamel."

Classification of fluorosis is based on the two teeth most affected. If the two teeth are not equally affected, the classification given is that of the less involved tooth. The tooth with the worst fluorosis is not even scored. (See 19-6: "Oral Health of US Children," 1986-87 National Survey).

Sixty-nine percent of children examined from a suburb of Boston had dental fluorosis. They were from high-socioeconomic-status families. Thirteen percent of these children were moderate-to severe. (See 19-7: "Your Family," — a study published in Pediatric Dentistry, 20:4, 1998).

Eighty-one percent of 12-14 year-olds in "optimally fluoridated (1 ppm)" Augusta, Georgia had dental fluorosis. Moderate-to severe was found in 14% of these children. ("Health Effects of Ingested Fluoride," National Academy Press, Washington, D.C., 1993, pp. 37, 44, 45.)

A study of 708 children aged 5 to 19 in fluoridated Asheville, North Carolina, found that 75% had fluorosis. (See 19-10: "Pediatrics," from Pediatric Dentistry 17:19, Jan./Feb. 1995).

H. Trendley Dean, (D.D.S.) Dental Research of Council of American Dental Association, public health expert on mottling stated: "I don't want to recommend any fluoridation where you get any mild (mottling)." (Congressional Hearings (Delaney Committee) p.1652.) Dean is known as "the father of fluoridation." Today, in some areas, dental fluorosis is found in epidemic proportions, and many children are suffering from not just mild fluorosis, but from moderate to severe!

"Opinions differ as to what traces of fluoride can do, but all agree that they do damage to the teeth and that damage is serious. It can be far worse than the worst neglected decay." (Dr. F. B. Exner, (M.D.) Fellow of American College Radiology, Seattle, Washington.)

"I believe that fluorine does, in a mild way, retard caries, but I also believe that the damage it does is far greater than any good it may appear to accomplish. It even makes the teeth so brittle and crumbly they can be treated only with difficulty, if at all." (See 10-9: Copy of Dentist's Letter from "The Town Without a Toothache," George W. Heard, 3/15/54).

"There are several areas in the United States where the water has a natural fluorine content of 1 ppm. I am practicing in such an area. In 1937, after moving from Michigan to eastern New Mexico, I was impressed by the number of attractive young persons who were disfigured by defective teeth, which defects on cursory notice looked like severe decay. I had never before seen dental fluorosis. I asked several of the patients what was wrong with their teeth and the reply was invariable, "Texas teeth"." (Dr. D. C. Badger, (M.D.) in American Journal of Diseases of Children, July 1949.)

A recent study in Europe looked at X-rays of children with dental fluorosis and children who did not have fluorosis. The bone structure of the children with fluorosis was different from that of the normal children. The largest deviations from normal were seen in younger children and boys. (Fluoride, Journal of the International Society for Fluoride Research, Jan. 1993, pp. 37-44.)

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