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Water Fluoridation (2012-2014)
1 Lel • .. . , _ [1, 14()- 11Z- . ..-.:-. .--.. , -,-- :- ..- .,_ ,' .' - at the SC1entific gt ; -_ _.. • . } Evidence ,: , __ ,',, 1 -..'ip:6' r.,,,, ,--::-...-45p:,,cfeEKoN, ..... , , \ , -. :\, ,,, ....... - ----'-'-',' , .k . , - .._. L. --i - - . -NOV -2012 --, 11 26 .. RECEIVED . _ _ ._ CITY,CLERK'S'OFFICE . _ . THE CASE AGAINST . ' ' . U. o r 1. . . . ,, . . . , , . . • . „.. _ . , . ... . . • How Hazardous Waste Ended Up in Our Drinking Water, ' Iand the Bad Science and . Powerful Politics I That Keep It There l 'r` 1 \c/ \\ ` . PAUL CONNETT, PhD JAMES BECK, MD, PhD I H. S. MICKLEM, DPhil 1 t - Take a Closer Look at Your Drinking Water I "Sweden rejected,fluoridation in the 1970s,and in this,excellent, book these threescientists have confirmed the wisdom of. . that decision Ourchildren:'have°not":suffered greater,tooth decay;, ' as World Health Organization figures attest;:and inturn,our_: . citizens have not'borne the other hazards fluoride may=cause." —DR. ARVID CARLSSON,Nobel;Laure ate in Medicine or Physiology(2000) " When the V.S. Public Health Service endorsed water fluoridation in '1950,its safety was still unproven.Now,six decades later and after most countries.have. rejected the practice,more.than 70 percent of Americans (as well as 200 Mil- lion people worldwide) drink fluoridated water."Disturbingly, the Center for • • Disease Control and the American Dental Association continue to promote it • despite increasing evidence that it is not only;unnecessary, but also .poten- tially hazardous to human health: In this timely and important book, Cornett Beck, and Micklern:carefully investigate the science behind water fluoridation—concluding that endorse= merits from dental and medical establishments do not mean a public-health measure is effective or safe.At once painstakingly documented and also high• ly readable, The Case Against Fluoride brings new research to light—including links between fluoride and harm to the brain,bones, and endocrine system— arguing that the evidence of fluoridation reducing tooth decay,the very reason it is added to drinking water,is surprisingly weak. "Alfred North Whitehead said the scientific method means leaving'options open for revision.'An ancient Roman adage says that'whatever touches all must be approved by all.'These characterizations of science and democracy are the reasons for " reading this book. Especially if you and your family are drinking administratively mandated fluoridated water." —RALPH NADER $24.95 USD/ISBN 9781603582872 CHELSEA GREEN PUBLISHING ISBN 978-1-60358-287-2 PO Box 428•White River Junction,VT 05001 5 2 4 9 5 802-295-6300•www.chelseagreen.com , no. �,. Cover design by irr� g Jennifer Carrow Cover art by wor, 'h I tTM Peter Dazeley 9 781603 582872 PRINTED ONRECYCLED PAPER and Steve Gorton • • " November 19,2012 Renton City Council Subject: Documentation for the Committee of the Whole, Nov 26 Dear Renton City Council members, Mayor Law and staff, In anticipation of next week's Committee of the Whole on water fluoridation, I am bringing you more documentation because I fear that the amount of information that Dr. Bill Osmunson will have to present in 15 minutes will be rather overwhelming to grasp without more background information, both of the science and the politics of fluoridation. Honestly,this topic is huge and highly complex, but I am extremely grateful that you have delegated this time to hear an opposing view and the science behind it. The documentation I'm bringing is eight copies of the book, "The Case Against Fluoride: How Hazardous Waste Ended up in Our Drinking Water and the Bad Science and Powerful Politics That Keep It There" by Dr. Paul Connett, PhD, Dr.James Beck, MD, PhD and H.S. Michlem, DPhil. This book is particularly relevant because it is absolutely packed with references to the fluoride studies it discusses to make its "case against fluoride". No publication supporting fluoridation has yet emerged with even a fraction of the referenced science in this book,although they have had 60 years to write one. Please ask those who promote fluoridation to provide you with scientific references to published studies to support their claim that fluoride is safe, particularly to the developing brain of fetuses and infants. A Freedom of Information Request to the CDC revealed that the Oral Health Division has acted alone in its review of fluoridation,that not a single profession outside of the dental experts participated in determining the safety of fluoridation--no toxicologists, no endocrinologists, no neurologists were involved. In other words,the Oral Health Division's claim that fluoride is safe is referring only to teeth since the Oral Health Division has no professional capacity to determine the safety to other organs. Please review these chapters: 15-Fluoride and the Brain(pg 148),20-Margin of Safety(pg 201),and 21- The Precautionary Principle(pg 213). There has been a number of studies finding harm to the brain since this book's publication,such as the Harvard study that I brought to you two weeks ago. The health of babies'brains trumps teeth---every time,all the time. In the last decade,tons of new science has emerged that show harm to the developing brain from fluoride. When science shows us something new---something we did not realize before---we must alter old policies and practices, as we did with tobacco,asbestos and lead. There is nothing more valuable to our future than our future children's brains. The precautionary principle states that we must give highest priority to protecting fetuses and babies,especially of the poor who are unable to avoid fluoride in tap water. Sincerely and appreciatively, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 Y i E 'll ,71y-')\-i� T . rC ,( '_., , .<, ares. Building a Database of Developmental Neurotoxicants: Evidence from Human and Animal Studies "I C�7• T�1 W. Mundy', S. Padilla', T. Shafer', M. Gilbert', J. Breier1'2, J. Cowden', K. Crofton', D. Herr', K. Jensen', K. Raffaele3, N. Radio4, and K. Schumacher5! s O -N) 'Neurotoxicology Div. U.S. EPA, RTP, NC 27711; 2Curriculum in Toxicology, Univ. of N.C. at Chapel Hill, Chapel Hill, NC, 27514; 3 NCEA/ORD, U.S. EPA; �,,A roc Washington, DC, 20460;4Cellumen, Inc., Pittsburgh, PA. 15238; U.S.SEPA, Region 7, Kansas City, KS, 66101. ;' rat Profec` • Introduction Evidence: Criteria for Assessment and Endpoints Chemicals with Substantial Evidence of Developmental Neurotoxicity (n=100) EPA's program for the screening and prioritization of chemicals for a) We included only mammalian studies. , developmental neurotoxicity makes it essential to assemble a list of chemicals -no in vitro studies were included. - that are toxic to the developing mammalian nervous system.Listed chemicals will b) We included only studies with the pure chemical(or reasonably so). 2-Ethoxyethyl Acetate Diazepam Naltrexone be used to evaluate the sensitivity,reliability,and predictivepower of alternative -no mixture studies were included. Actbenzolars-methyl Cytosine Arabinoside Nicotine developmental neurotoxicity assays.To establish this list,a erature review was -no human studies were included wherein there was exposure to more than one AAMdicarlba Delmm than to ( Me'mylaxoxymettanol conducted for over 400 compounds that have been suggested to be compound. Allethrin o, Diazinon ©Methylmercury -no formulations were included. Aluminum(cl or lactate) Dieldrin ozone developmental neurotoxicants,neurotoxicants,or developmental toxicants. c) We included only studies where the exposure took place during pregnancy or Amino-nicoenamide(s-1 Diethylstilbestrol '•.,' Paraquat Compounds were assigned one of three groups based on the strength of the during the period before weaning. Aminopterin Diphenylhydantoin Parathion(ethyl) evidence for developmental neurotoxicity: Amphesenine(d-) Epidermal Growth Factor, PBDEs p ty: d) We included only studies in which the administered dose was below 5 grams/kg. Arsenic Ethanol --,') PCBs(generic( (1) no evidence:either there were no reports that met our criteria for evidence,or e) Where knowledge was available,we considered only studies where the Aspartame Ethylene thiourea '" Penicillamine there were reports which showed no developmental neurotoxicity; administered dose would not be lethal to the offspring. Azaoyddine(5-) Ffourouracl1(5-) Permethrin (2) minimal evidence:one report onlyor multiple reports from onlyone laboratory; f) We did not include any case reports. • Benomyl FFluoiidm Pnylala ine(d etate p p p In studies where the chemical was administered during gestation,to the extent Benzene Fluoride Phenylalanine dil2lne(d,p or g) 9Bloalteth„n ,• • !• Grlseofolvin.-�.' Phthalate,d1 -(2 O3 substantial evidence:re ports from more than one labordto possible,we looked for a litter-based statistical design. Bicit„-n-butyltin)oxide !- Haloperiodol! Propylthiouracil p ry• h) If only acute pharmacological effects were reported(either during dosing or shortly Blsphenol A / .Hatd hone` Reenolddvlt.Msatretinoln The chemicals in the latter group will be especially useful for vetting protocols that thereafter),we did not Include that study. Bromodeoxyuridine(5-) s--_-Keptaachlor Salicylate Butylated Hydroxy Anlsol Hexachlorobenzene Tezele have been proposed as screens for developmental neurotoxicity. Endpoints assessed included,but were not limited to: Butylated hydroxytoiuene Hexachlorophene Telluriumurium(salts) Cadmium Hydroxyurea Terbutaline This presentation hes been reviewed by the Natrona!Healthand Enomementer Effects Research Laboratory and approved.Approval ® Head Circumference ® Grip Strength Caffeine Imminodiproprionitrile 5DPN) Thalidomide does not dotty that the contents reflect tha News nfine Agency. ® Brain Weight ® Negative Geotaxis Carbamazepine Ketamine THC ® Exencephaly ® Startle Response carbaryl Lead Toluene carbon monoxide Undone Trlamclnolone Approach ® Brain Morphology ® Righting Reflex chlordeeone LSD Trlhuryltln chloride Motor Activity ® Neurochemical Levels Chlordiazepoxide Maneb trichlorfon Chlorine dioxide Medroxyprogesterone Trichloroethylene ® Learning and Memory ® Receptor Affinity/Number chlorpromazine Meplvacaine Ttlethyliead n Chlorpyrifos Methadone Triethyltin Collect lists 1 CocaineMethanol Teblu Calcemimltl Methimazole T,yprypan blue Chemicals with Minimal Evidence ofI Colchicine Methyiparahion Urethane • of putative Cypermethrin Monosodium Glutamate Valpraate Developmental Neurotoxicity (nz100) Dexamethasone MPTP lrina„aline DNT chemicals (n=400) Diamorphine hydrochloride Nalozona . ',t4 »t ...*.....',.'4,,--=:04`..2;,-.:1:2.--- -;_,,,,;,'" -ty,' 1,1,1-Trichloroethane Dlaminotoluene(2,5-) Lidocaine s — 5 XAS Abamectin Dichloromethane(methylene chlo„de) Malathion Sample Paragraph„ C'onsylt EPAREIdoeumentsi - Acephate Dlchlorvos(DDVP) Mancozeb COI rsult C-11tICtit( "'' Acetamlprld mcroropnos Maytansin AetlnomyeieO Dlfiuoromethylomlthlne Min " Amicarbezone(MKH 3585) Dimethaate Methyl Ethyl Ketone DEXAMETHASONE -• Astemizole Dinoseb MNDA CAS Number.50-02-2 Formula: �O•ra t. Atorvastatin Diphenhydramine Mollnate /•\ Atrazine Disulfoton Naled Dexamethasone is synthetic member of the glucocorticold class of steroid hormones.It is • Azinphos methyl Emamectin n-Hexane used to treat Inflammation and autoimmune conditions(e.g.,rheumatoid arthritis),and to counteract side- BAS 510(Boseand) Endoxulphan Nickel carbonyl effects of chemotherapy In cancer patients.Synthetic glucecorticolds,Including dexamethasone,are also BAD 070H Endrin Perchlorate administered to women at risk for preterm labor to advance fetal maturation and reduce neonatal Bltenthrin EPTC(S-Ethyl dlpropylhlocarbamete) Phorate(BAB 22511 morbidity and mortality. • Bismuth Ribromophenate Ergotamine Picrotoxin Numerous studies In animals have shown neurodevelopmental effects of perinatal -.-'Assess Documentation- Brominated veg oil Ethoxyethanol(2-) Primidone dexamethasone treatment In rodents.Doses 010.2-3 mgfkg(which encompasses the therapeutic range Busulfan Ethylene dubromide Profenoros in humans)given to the pregnant dam during gestation or to the offspring postnatally alter neurogenesis ©iseuss 1 cliE Evidence Ca,bnlaran Ethylene aside Prohloconazole and differentiation(Bohn,1984;Carlos et al.,1992),decrease brain size and brain weight(DeKoskey et ;>-e. ,..,., ,,. : :s Carbon disulfide Etofenproz Selenium compounds al.,1982;Carlos et al.,1992;Ferguson and Holson,1999),and alter locomotor activity and learning and `-'^'#.'a,?',:'',:' �eP re are.manuserl•tr - z�','”• Chlordane Fenamlphos simvastatin memory behavior(DeKoskey et al.,1982;VIcedomini et al,1988;Ferguson et al.,2001:Kreider et al., ---• •'mac•-`0,I'l.',,-r+_p< L. •--.,r..fL-..->c.a�p4-n. `,.t''"a o%r.,-.", -- ehlordlmetorm Fenitrothlan Sptrodicloten 2005a).Relatively low doses(0.05-0.2 mg/kg)have also been shown to result in long-lasting changes In ehlorfenapyr Fenvalerate succamir neurotransmitter systems and Intracellular signaling(Kreider et al.,2005b;Kreider et al.,2008;Slotkin et Each chemical was assigned to one of three categories: ! chlorite,sodium FK33-024(Synthetic enkephalin) Terbufos al.,2008).Effects of dexamethasone,Including decreased brain weight and hippocampal damage,have 1. No available evidence existed•exclude from C1-943(Antipsychotic) - Flufenacet(thlafluamlde) tert-Butylhydroquinone,2- also been observed In nonhuman primates(reviewed In Coe and Lubach,2005). clodinarop-propargyl Formaldehyde Tetrachleethylene Human developmental neurotoxicity is associated with perinatal exposure to - manuscript. Clothienidin Glufoslnate ammonium Tetracycline dexamethasone.Prenatal dexamethasone is routinely administered to mothers at risk for preterm delivery coumaphos Glyphosate trimeslum Thiamethoxam to reduce mortality and the incidence of respiratory distress syndrome and intraventricular hemorage in 2. Minimal evidence existed:put in table in manuscript. . cyiuthrin Hexachoroplatinate(Na) Tributes(DEP) premature Infants.Postnatal dexamethasone treatment In preterm Infants is also used to reduce the risk 3. Substantial evidence existed•write a descriptive Cyhalathan Imidacloprid T„ethylene glycol dimethyl ether and severity of chronic lung disease.A preponderance of epidemlologic and clinical evidence,however, p Cymoxanli Ivermectin Trlmethadone Indicates that both pre-and post-natal exposure to dexamethasone can result In an Increased risk for paragraph for manuscript. Danazol Lasofoxlfene Triphenyl phosphate cerebral palsy,decreased brain size,and long-term effects on cognition and behavior(reviewed In Baud, DDT Levoalphaacetylmethadol VM-20(Tenlpostde) 2004;Purdy,2004;Purdy and Wiley,2004;Sloboda et al.,2005). *Registration Eligibility Decision Documents(available online or via Freedom of Information Act) Dextromoramide VP-18-217(Etoposide) O.) Tooth Decay Trends in Fluoridated and Non-Fluoridated Countries WHO data on DMFT in 12 year olds* 8 444 Non-Fluoridated" 0 ,4ap4h Fluoridated 5- a t- t, aerIra is a_ eer l him Moiled Cates fre/400, 2— _ - i 03 u Ci 1 1970 1980 1990 X00 2010 Years 1970 through 2010 'World Health Organizabon(WHOI.Collaborating Centre for Education.Training,and Research in Oral Health,Matnad University Swedenhttp-i:w.va•.mah sciCAPPi'accessed June 10 2012). No water or salt fluoridation 1 ( Dental Fluorosis Rates in the United States: 1950 through 2004 1999-2004 N 50 41% 45 National Average for 12-15 year olds = 40 :a. 35 .rte 0 30' 25 •-• 20 1986-1987 Q. 15 - - 23% National Average for C to 1960 12-15 year olds 10% Children in Fluoridated Communities a. 1953 1980 1970 1980 1993 2000 2010 Years 1950 through 2004 FJcitran FD,ct al 12010).Prevalence and Severity of Dental Fluorosis in the United States,1999-2004. NCHS Data Brief No.53.Figure 3. National Research Council.11993).Health Effects of Ingested Fluoride.National Academy Press. Washington DC.p-4-5. From "50 Reasons to Oppose Fluoridation" The other reasons can be found at: http://www.fluoridealert.org/articles/50-reasons/ "� I Introduction of Fluoridated Water and Fluoride Toothpaste and Tooth Decay Rate of 5-year-old Children in New Zealand 10 - -100 0 �.. Tooth Decay A a. 9 ....ii Fluoridated Water .0 4.4.. Fluoridated Toothpaste o G v V u 7 — — 70 o. s 'o e 6 — ®f? a' aid ea I.- v e 5 - - sa o z ei u a: • 4 — — 40 t O f d i. 3 — — 30 c av 0 7• 2 — Zb Z - - 10 ss --....marirrr 0 1 *.0 e F I 1 1 I 1930 1940 1950 1900 15170 19010 1990 Years 1930 through 1990 Colquhoun J.(1997).Why i changed my mind about fluoridation.Perapecaves In Biology and Medicine 41(11;29-44 From "50 Reasons to Oppose Fluoridation" The other 44 reasons can be found at: http://www.fluoridealert.org/articles/50-reasons/ 20)The highest doses of fluoride are going to bottle-fed babies. Because of their sole reliance on liquids for their food intake, infants consuming formula made with fluoridated water have the highest exposure to fluoride, by bodyweight, in the population. Because infant exposure to fluoridated water has been repeatedly found to be a major risk factor for developing dental fluorosis later in life (Marshall 2004; Hong 2006; Levy 2010), a number of dental researchers have recommended that parents of newborns not use fluoridated water when reconstituting formula (Ekstrand 1996; Pendrys 1998; Fomon 2000; Brothwell 2003; Marshall 2004). Even the American Dental Association (ADA), the most ardent institutional proponent of fluoridation, distributed a November 6, 2006 email alert to its members recommending that parents be advised that formula should be made with "low or no-fluoride water." Unfortunately, the ADA has done little to get this information into the hands of parents. As a result, many parents remain unaware of the fluorosis risk from infant exposure to fluoridated water. 36)There is no margin of safety for several health effects. No one'can deny that high natural levels of fluoride damage health. Millions of people in India and China have had their health compromised by fluoride. The real question is whether there is an adequate margin of safety between the doses shown to cause harm in published studies and the total dose people receive consuming uncontrolled amounts of fluoridated water and non-water sources of fluoride. This margin of safety has to take into account the wide range of individual sensitivity expected in a large population (a safety factor of 10 is usually applied to the lowest level causing harm). Another safety factor is also needed to take into account the wide range of doses to which people are exposed. There is clearly no margin of safety for dental fluorosis (CDC, 2010) and based on the following studies nowhere near an adequate margin of safety for lowered IQ (Xiang 2003a,b; Ding 2011; Choi 2012); lowered thyroid function (Galletti &Joyet 1958; Bachinskii 1985; Lin 1991); bone fractures in children (Alarcon-Herrera 2001) or hip fractures in the elderly(Kurttio 1999; Li 2001). All of these harmful effects are discussed in the NRC (2006) review. 37) Low-income families penalized by fluoridation.Those most likely to suffer from poor nutrition, and thus more likely to be more vulnerable to fluoride's toxic effects, are the poor, who unfortunately, are the very people being -- targeted by new fluoridation programs.While at heightened risk, poor families are least able to afford avoiding fluoride once it is added to the water supply. No financial support is being offered to these families to help them get alternative water supplies or to help pay the costs of treating unsightly cases of dental fluorosis. 38) Black and Hispanic children are more vulnerable to fluoride's toxicity.According to the CDC's national survey of dental fluorosis, black and Mexican-American children have significantly higher rates of dental fluorosis than white children (Beltran-Aguilar 2005, Table 23). The recognition that minority children appear to be more vulnerable to toxic effects of fluoride, combined with the fact that low-income families are less able to avoid drinking fluoridated water, has prompted prominent leaders in the environmental-justice movement to oppose mandatory fluoridation in Georgia. In a statement issued in May 2011, Andrew Young, a colleague of Martin Luther King, Jr., and former Mayor of Atlanta and former US Ambassador to the United Nations, stated: "I am most deeply concerned for poor families who have babies: if they cannot afford unfluoridated water for their babies'milk formula, do their babies not count? Of course they do. This is an issue of fairness, civil rights, and compassion. We must find better ways to prevent cavities, such as helping those most at risk for cavities obtain access to the services of a dentist...My father was a dentist. I formerly was a strong believer in the benefits of water fluoridation for preventing cavities. But many things that we,began to do 50-or more years ago we now no longer do, because we have learned further information that changes our practices and policies. So it is with fluoridation." 39) Minorities are not being warned about their vulnerabilities to fluoride.The CDC is not warning black and Mexican-American children that they have higher rates of dental fluorosis than Caucasian children (see#38). This extra vulnerability may extend to other toxic effects of fluoride. Black Americans have higher rates of lactose intolerance, kidney problems and diabetes, all of which may exacerbate fluoride's toxicity. 40)Tooth decay reflects low-income not low-fluoride intake. Since dental decay is most concentrated in poor communities, we should be spending our efforts trying to increase the access to dental care for low-income families. The highest rates of tooth decay today can be found in low-income areas that have been fluoridated for many years. The real"Oral Health Crisis"that exists today in the United States, is not a lack of fluoride but poverty and lack of dental insurance. The Surgeon General has estimated that 80% of dentists in the US do not treat children on Medicaid. July 7,2014 Renton City Council Minutes Page 204 help educate children and families about this chronic health issue and to provide and promote healthy activity opportunities and nutritional information. The two elliptical machines were installed adjacent to the playground at Gene Coulon Memorial Beach Park to encourage visitors to exercise. This is an easy way for parents to exercise and still be able to watch their children. Setting a good example of activity for your children is a great way to create and keep healthy habits from youth through adulthood. There are plans for additional outdoor exercise equipment to be installed in other parks in the near future. If you are interested in learning more about the "I"CANN initiative, please visit www.valleymed.org/icann. AUDIENCE COMMENT Diane Dobson (Renton) expressed concern about the increase in criminal Citizen Comment: Dobson— activity among the homeless population residing along the only residential Homelessness on Cedar River neighborhood (N. Riverside Dr.) adjacent to the Cedar River Trail. She Trail remarked that she has consistently reported this activity to the police department to no avail. She requested that Council urge bicycle patrol officers to patrol this stretch of the trail more frequently and to cite and arrest anyone committing crimes. Ms. Dobson also stated that she finds it ironic that the City recently accepted responsibility for a parcel of land to be named the Kenyon- Dobson Park,yet cannot maintain the half mile stretch of trail near her home. Mayor Law stated that he will be meeting with the Police and Community Services departments to review this issue. He added that the City will provide a response to her concerns. Citizen Comment:Adams- Audrey Adams (Renton) suggested that the City could spend the$80,000 it Fluoride costs to annually fluoridate the water supply more efficiently by purchasing and providing fluoride tablets and other dental products to people who request them. She added that some of the money could also be spent to educate children about the benefits of dental hygiene. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 6/23/2014. Council concur. 6/23/2014 CAG: 14-083, Maplewood City Clerk reported bid opening on 6/26/2014 for CAG-14-083, Maplewood Creek& Madsen Creek Creek and Madsen Creek Sediment Basin Cleaning Project 2014;four bids; Sediment Basin Cleaning engineer's estimate$75,472.88;and submitted staff recommendation to award Project 2014,Sierra Pacific the contract to the low bidder,Sierra Pacific Construction, in the amount of Construction $75,123.57. Council concur. CAG: 14-089,S 132nd St Sewer City Clerk reported bid opening on 7/1/2014 for CAG-14-089,S. 132nd St. Extension,A Advanced Septic Sewer Extension project;six bids; engineer's estimate$254,752;and submitted Services staff recommendation to award the contract to the low bidder,A Advanced Septic Services, Inc., in the amount of$213,447.44. Council concur. Annexation:Alpine Nursery, Community and Economic Development Department submitted King County 160th Ave SE&SE 146th PI Boundary Review Board Closing Letter for the proposed Alpine Nursery Annexation and recommended approval of the annexation. Council concur. (See page 206 for ordinance.) June 16, 2014 Renton City Council Minutes Page 186 their neighborhood park, located at SE 4th and Zillah PI.SE. Residents of each neighborhood are encouraged to bring their favorite potluck dish and attend their picnic to get to know their immediate and surrounding neighbors and meet City representatives. AUDIENCE COMMENT Tom Carpenter(King County)submitted a packet of information and stated that Citizen Comment: Carpenter— he had presented similar information to Council regarding the 154th PI. 154th PI SE/156th Ave SE SE/156th Ave.SE arterial corridor at a prior Council meeting. He stated that he Arterial Corridor was pleased to learn at that time the City had already been engaging with King County regarding joint planning in unincorporated areas. He noted, however, that he believes the County has responded to the City indicating that resource availability is limited. He urged Council to keep joint planning with King County an important objective. Additionally, Mr.Carpenter shared the background histories of the Four Creeks Unincorporated Area Council (Four Creeks)and the Community Alliance Reach Out and Engage (CARE) non-profit organizations,and noted that both organizations are heavily involved in the planning of the East Renton Plateau. He suggested that the City could engage with the community by hosting the 154th/156th arterial topic at on the Four Creeks or CARE monthly meetings. Citizen Comment:Adams— Audrey Adams(Renton) stated that she believes she has a solution regarding Fluoridation the issue of fluoridation. She remarked that a medical journal recently declared fluoride to be a neuro-toxicant in the same category as lead,arsenic, and mercury. She provided an analogy indicating that not everyone reacts the same way to medical prescriptions. She also stated that people have the freedom of choice to decide whether or not they will take prescriptions. Ms.Adams indicated that she will provide the solution to the fluoride issue at a future meeting. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 6/9/2014. Council concur. 6/9/2014 CAG: 14-078,Sewer Radio City Clerk reported bid opening on 6/10/2014 for CAG-14-078,Sewer Radio Panel Relocation and Lift Panel Relocation and Lift Station Improvements project;three bids; engineer's Station Improvements, Equity estimate$166,440; and submitted staff recommendation to award the contract Builders to the low bidder, Equity Builders, LLC, in the amount of$145,799.25. Refer to Utilities Committee for discussion of funding. CAG: 14-079,Sunset City Clerk reported bid opening on 6/10/2014 for CAG-14-079,Sunset Community Low Impact Community Low Impact Development Retrofit Stormwater Green Connection: Development Retrofit Harrington Ave. NE and Harrington Ave. NE Water Main Replacement project; Stormwater Green nine bids; engineer's estimate$1,302,442;and submitted staff Connection: Harrington Ave recommendation to award the contract to the low bidder, Northwest Cascade, NE& Harrington Ave NE Water Inc., in the amount of$1,101,142.55. Council concur. Main Replacement, Northwest Cascade Court Case:Capital One NA vs. Court Case filed by Capital One, N.A., represented by Bishop, Marshall & Estate of Donald O. Carlile& Weibel, P.S.,Attorneys for Plaintiff,vs.The Estate of Donald O.Carlile, City of City of Renton,CRT-14-003 Renton,et al, regarding the collection of debts. Refer to City Attorney and Insurance Services. May 20, 2013 Renton City Council Minutes Page 167 ORDINANCE#5690 An ordinance was read amending Section 4-1-160, of Chapter 1,Administration CED:School Impact Fees and Enforcement,of Title IV(Development Regulations), of City Code, adding a Waiver, Payment Under new Subsection 4-1-160.E.4., Regarding School Impact Fees Waiver, Payment Protest&Appeals Under Protest,and Appeals. MOVED BY BRIERE,SECONDED BY ZWICKER, COUNCIL ADOPT THE ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. ORDINANCE#5691 An ordinance was read authorizing the issuance and sale of a Limited Tax Finance: QECB Bond, General Obligation (LTGO) bond of the City of Renton in the principal amount of Streetlight Replacement not to exceed$3,200,000 for the purpose of financing streetlight improvements as part of a Green Community Program; providing the form of the bond;and authorizing the sale of the bond. MOVED BY BRIERE,SECONDED BY ZWICKER,COUNCIL ADOPT THE ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. NEW BUSINESS Councilmember Palmer invited everyone to attend the City's Memorial Day Community Event: Memorial event scheduled for Monday, May 27, at 1 p.m.at Veteran's Memorial Park, Day Event located on the corner of S. 3rd St.and Main Ave.S. Mr. Covington added that the event is coordinated by VFW Post 1263,and it will include a wreath laying ceremony to honor all five branches of military service. He encouraged everyone to attend the event to honor veterans who have served both at home and abroad, and especially for those who have fallen in the line of duty. Council President Corman remarked that there are plenty of memorial tiles left, and asked how someone would go about getting a tile engraved. Mayor Law remarked that citizens can contact the City, and information regarding the process will be distributed at the Memorial Day event. He also remarked that the City is currently repairing some of the memorial tiles, and the administration will brief Council on this topic at the next Council meeting. Community Event: Meadow Councilmember Persson announced that there is a fundraising event scheduled Crest Playground Fundraising for Friday,June 7,from 5:30 p.m.to 8:30 p.m. at the Renton Community Event Center. He stated that there will be a presentation by Tony Ventrella,and the goal is to raise money to help close the$100,000 funding gap needed to add a couple pieces of optional play equipment at the Meadow Crest Accessible Playground. He stated that the event is free to attend, but encouraged everyone to pre-register by calling 425-430-6700 or by signing up on the City's website. Community Event: Kiwanis Mayor Law remarked that on Saturday, May 18,50 volunteers from local Park Clean-up Event churches and high schools did a tremendous job pruning,weeding, and cleaning up Kiwanis Park. He stated that these local partnerships along with dedicated City employees really make a difference in the community. AUDIENCE COMMENT Audrey Adams (Renton) remarked that the public comment period during Citizen Comment: Adams— Council meetings may not be the best forum for voicing her concerns about Water Fluoridation water fluoridation,and asked for help in determining key people and organizations in the community to contact. Ms.Adams also stated that she will contact the Council Liaison to schedule appointments with individual Councilmembers to discuss a recent study on this issue. May 20, 2013 Renton City Council Minutes Page 168 Citizen Comment:Green Jeannie Green Crooke (Renton)expressed support for the removal of fluoride Crooke—Water Fluoridation, from the City's water supply. She also stated that she supports the additional Smart Meters&Cedar River door at the Cedar River library. Additionally, Ms. Green Crooke noted that she Library recently traveled through Oregon,California,and Arizona and remarked that areas with smart meters appeared to have fewer birds. ADJOURNMENT MOVED BY PERSSON,SECONDED BY PRINCE,COUNCIL ADJOURN. CARRIED. Time 7: p.m. ida Bonnie I.Walton, CMC, City Clerk Jason Seth, Recorder May 20, 2013 May 13, 2013 Renton City Council Minutes Page 143 Ms.Timmons reported that Issaquah's service area within Renton allows single- family units only,and that the Issaquah School District has requested a fee of $3,738,which is an increase from last year of$170. She reported that the Kent School District is requesting a continuation of last year's fees of$5,486 per new single-family unit and$3,378 for new multi-family units. She also reported that the Renton School District has requested a fee of$6,395 per new single-family unit,which is an increase from last year of$3, and$1,308 per new multi-family unit,which is an increase of$34. Ms.Timmons stated that staff is recommending the adoption of legislation to approve the interlocal agreements, authorize the imposition of the fees,amend the fee amounts,and authorize provisions for waiver of claims for refunds, payments under protest, and appeals. Public comment was invited. Gwen Escher-Derdowski(Kent), Planning Administrator for the Kent School. District,expressed support for the district's Capital Facilities plan. She stated that the Kent School District is the fourth largest district in the state and serves residents in Covington, Kent, Renton,Auburn, Maple Valley,SeaTac, Black Diamond, and unincorporated King County.She also pointed out that the Kent School District makes a voluntary reduction to their impact fee formula,and without this adjustment the fee for single-family units would be$10,000 and for multi-family units it would be$7,500. MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL CLOSE THE PUBLIC HEARING. CARRIED. (See page 144 for Finance Committee report.) AUDIENCE COMMENT Paul Ouellette(Renton)expressed concern that the administration may not be Citizen Comment: Ouellette— pressing the issue of adding an additional entrance to the Cedar River Library Cedar River Library with the King County Library System (KCLS). He also noted that KCLS has stated • that the pedestrian bridge is not ADA compliant,and pointed out that the bridge is not a ramp it is just a walking surface. Citizen Comment: Beedon— Dave Beedon(Renton) questioned whether the City believed the interlocal Cedar River Library agreement with KCLS should be updated to reflect what is currently happening at the Cedar River Library site. Council President Corman remarked that updating the interlocal agreement should be considered. Mayor Law stated that the administration will review the matter. Citizen Comment:Adams— Audrey Adams(Renton) requested that the City independently test the sodium Water Fluoridation fluoride added to the water supply. She explained that Utah recently passed a law calling for independent testing of fluoride after it was discovered that elements of arsenic, lead, mercury, and beryllium were found in the fluoride. and not listed on the product's Certificate of Analysis provided by the manufacturer. Citizen Comment: McOmber— Howard McOmber(Renton) remarked that Renton has great volunteers who Various Comments are trying to achieve wonderful things. He noted that the Renton Ecumenical Association of Churches (REACH) Center of Hope day shelter for homeless women and children opens on May 17, 2013 in the basement of City Hall. Mr. McOmber also advocated for affordable housing in the Renton Highlands. February 25,2013 Renton City Council Minutes Page 49 Concluding, Mr. Covington stated that in order to remain true to the commitment the City made by Council direction to provide a public forum, sometimes a situation occurs were citizens have more information than Council. He stated that KCLS is providing another presentation next month and Council will review the plans after that information is received by the City. Responding to Ms. Robinson's question, Mr.Covington clarified that some agencies have expressed concern about predatory fish and the size of the shadow the building creates over the water. He explained that these agencies are not happy with the idea that a refurbished building would retain its same size and shape. He emphasized, however, it is not known at this time if the agencies could force a design change. Citizen Comment: Ouellette— Paul Ouellette (Renton) expressed disappointment with the report provided to Waterline Smart Meter the Utilities Committee regarding waterline smart meter installations. He Installation stated that although the City has FCC approval to install the meters,the effects the meters have on birds was not studied. He remarked that smart meters interfere with a bird's inherent navigation system which makes the birds avoid areas where the meters are installed. Citizen Comment: Keyes— David Keyes(Renton) requested that the upcoming presentation from KCLS Cedar River Library regarding the design of the Cedar River library be held in a room large enough to accommodate the amount of citizens interested in the subject,and it allows for the meeting to be recorded. He also requested that any information provided to the City by KCLS be made available to the public as soon as the City receives it. Additionally, Mr. Keyes requested that the City demand KCLS provide the schematic design cost estimate at the same time the design is submitted. Citizen Comment: Livengood— Elaine Livengood (Renton)stated that after conducting research on the Internet Waterline Smart Meter regarding the waterline smart meter systems she has concerns about billing Installation and radio frequency radiation issues. She explained that although the FCC has given blanket approval for the systems the World Health Organization has classed radio frequency waves as a Class 2.b. carcinogen. She stated that some states have opt-out policies, but pointed out that it would probably do little good to be the only house in.a neighborhood that opted-out of the program. MOVED BY CORMAN,SECONDED BY PRINCE,COUNCIL EXTEND THE AUDIENCE COMMENT PERIOD. CARRIED. Citizen Comment: Rouchex— Dana Rouchex(Renton)stated that one of the most distressing elements of the Cedar River Library proposed Cedar River library design is the relocation of the entryway. She remarked that the entry was originally designed as an elegant solution to unite the two halves of the City and to encourage visitors to engage with the Cedar River. Ms. Rouchex stated that she would like to see KCLS offer another design proposal. Citizen Comment:Watt— Paul Watt(Renton) explained that after researching the topic of water Water Fluoridation fluoridation on the internet he found a lot of scientific evidence opposing its use, but not much evidence supporting it. He also expressed concern that China sells the product but does not use it in their water supply. Mr. Watt suggested that the money spent on fluoride could be used to supplement the salary of a firefighter or police officer. February 25,2013 Renton City Council Minutes Page 50 Citizen Comment: Greene Jeanie Greene Crook(Renton) asked Council to respect the wishes of the 76 Crook—Cedar River Library percent of Renton voters who voted to save the Cedar River library. She explained that voters believed the building would be refurbished, not demolished and rebuilt; and that the entryway would remain at mid-span on the bridge deck. Noting that the Fairwood library has been remodeled three times, Ms. Greene Crook stated that this is an indicator of how KCLS builds libraries too small. Citizen Comment: Ossenkop— Kathy Ossenkop (Renton)stated that she was shocked to learn that KCLS Cedar River Library proposes to reduce the Cedar River library from 22,400 square feet to 16,000 square feet. She remarked that she paid for the original building and is now being asked to pay to rebuild it. Ms.Ossenkop stated that she believes KCLS is ignoring citizen input, and although representatives from the Muckleshoot Tribe are encouraging increased light to the river,the City is in the unique position to continue to utilize the full 22,400 square foot building. Citizen Comment: Beedon— Dave Beedon (Renton) echoed the concerns voiced by previous speakers Cedar River Library regarding the Cedar River library. He remarked that he did not understand the motives behind the design decisions KCLS is making. He also expressed support for Mr. Keyes'suggestion to hold the upcoming KCLS meeting in a room large enough to accommodate everyone interested in attending and that has recording capabilities. Citizen Comment: Keyes— Jeanie Keyes(Renton)stated that the Cedar River library has been in place for Cedar River Library many years and should be grandfathered in as far as new codes are concerned. She stated that it should just be fixed up and not completely remodeled. She also expressed concern that KCLS had recently thrown a large number of books in the garbage. Ms. Keyes stated that there are numerous charitable organizations that could use the books. Citizen Comment:Torres— Shannan Torres(King County) expressed concern that the City was adding Water Fluoridation & fluoride to the water supply. She stated that she has researched fluoride on Waterline Smart Meter the internet and determined it is a toxic waste. Additionally, Ms.Torres Installation remarked that she is a gardener who opposes the use of the waterline smart meters. She stated that she sleeps near 24 meters and the constant transmission of signals is detrimental to her health. She urged Council to stop installing the meters. Mr. Covington emphasized that Renton's water is safe to drink. He explained that although people continue to debate the benefits of fluoride in drinking water,the City relies on national,state,and local public health agencies to be the experts on how and why fluoride is added to the water supply. He reiterated his point from last week's Council meeting that some people may be I affected by the water, but for the general population it is safe to drink. Library: Cedar River Library Council President Corman stated that he would like to see KCLS resolve the issue regarding the design of the Cedar River library. He remarked that he would like to know what it would take to build a library that would satisfy the community. He stated that KCLS should let the City know if there are issues hindering their ability to accomplish the desired design elements,and that if there are any funding issues,they should at least be discussed. February 25,2013 Renton City Council Minutes Page 55 AUDIENCE COMMENT Phyllis Forister(Renton) stated that KCLS is not being responsive to citizen Citizen Comment: Forister— comments regarding the design of the Cedar River library. She remarked that Cedar River Library she believes the interlocal agreement with KCLS should be redone because citizens want the library remodeled not rebuilt. Further,she expressed disappointment that Council did not have the same information the public had about the proposed design. Council President Corman clarified that Council did not have the information because.it was assumed that KCLS would work with citizens to develop an acceptable proposal. He noted that did not happen,and reiterated his expectation that KCLS must change direction so that a consensus with the community can be achieved. Councilmember Persson stated that several people had talked about the library building being demolished. He pointed out that Council had never discussed anything but a full remodel of the building. He stated that he does not want to see the building demolished,and he believes that KCLS will provide clarification. Citizen Comment: Storwick— Sandra Storwick(Kirkland)expressed concern regarding wireless radiation from Waterline Smart Meter waterline smart meters. She stated that according to an article she read on the Installation internet, Health Canada has admitted that their safety guidelines regarding microwave radiation is based only on thermal or heating effects and not on radio frequencies. She explained that many illnesses are now being attributed to wireless radiation,and urged Council to look further into this issue. Citizen Comment: Carlyle— Nancy Carlyle (Kirkland) expressed concern that smart meters are effecting the Waterline Smart Meter bird and wildlife populations near her home. She stated that the Installation disappearance of the animals should be viewed as a warning that something is wrong. Ms.Carlyle remarked that she read an article on the internet regarding wireless radiation, and stated that she cannot trust the FCC. She urged Council to stop installing the meters for a few months to see if the birds come back. Council President Corman remarked that he is intrigued by this topic,and noted that he has had his own home studied by an electrical engineer that specializes in RF radiation. He remarked that there had been concern in the past about cellular phone antennas,and high-voltage wires, but he is skeptical that the meters would add that much more radiation to the amount that is already present in the environment. Citizen Comment:Greene Jeanie Greene Crook(Renton)stated that she has a health condition and is very Crook—Water Fluoridation concerned about fluoride in the water supply. She asked if public health agencies would consider establishing a grant program that would provide funds to people who are affected by fluoride to install reverse osmosis machines in their homes. Citizen Comment: Rouchex— Dana Rouchex(Renton) requested that the City test the fluoride that is being Water Fluoridation ' added to the water supply. She stated that some foreign countries have put out a lot of poor-quality products over the years,and have had issues with public safety. • RENTON CITY COUNCIL Regular Meeting February 11,2013 Council Chambers Monday, 7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RANDY CORMAN,Council President;GREG TAYLOR; RICH ZWICKER;TERRI COUNCILMEMBERS BRIERE; ED PRINCE; DON PERSSON; MARCIE PALMER. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; MARK BARBER,Senior Assistant City Attorney; BONNIE WALTON, City Clerk; GREGG ZIMMERMAN, Public Works Administrator; CHIP VINCENT, Community and Economic Development Administrator;TERRY HIGASHIYAMA, Community Services Administrator; IWEN WANG,Administrative Services Administrator; LESLIE BETLACH, Parks Planning& Natural Resources Director; LYS HORNSBY, Utility Systems Director; FIRE&EMERGENCY SERVICES ADMINISTRATOR MARK PETERSON, DEPUTY CHIEF BILL FLORA and DEPUTY CHIEF ERIK WALLGREN, Fire & Emergency Services Department;COMMANDER KATIE MCCLINCY, Police Department. SPECIAL PRESENTATION Fire and Emergency Services Administrator Mark Peterson recognized Fire: Employee Recognition Administrative Secretary I Kathy Michelsohn, Firefighter(EMT) Dave Laha, Firefighter Al Koskovich,and Lieutenant Stephen Rawson as the department's 2012 employees of the year. He reviewed each person's achievements respectively,and expressed appreciation for their outstanding contributions to the department. Additionally, Mr. Koskovich expressed appreciation for the honor,and remarked that he is accepting the award not as an individual, but as a fire service team member. AUDIENCE COMMENT Paul Ouellette(Renton) expressed concern regarding the recent installation of Citizen Comment: Ouellette— smart meters on the waterline system in the Rolling Hills neighborhood. He Alleged Effect of Waterline stated that since the new meters were installed bird activity has decreased by Smart Meters on the Bird 90 percent. He remarked that 52 communities in British Columbia have asked Population that a moratorium be placed on the installation of smart meters pending further investigation of this phenomenon. He stated that the City has plans to install as many as 18,000 meters and each meter transmits four radio signals a day at a frequency of 900 Megahertz. Mr.Ouellette explained that this is a very high frequency that affects small birds and animals. MOVED BY PRINCE,SECONDED BY ZWICKER, COUNCIL REFER THE TOPIC OF THE ALLEGED EFFECT OF WATERLINE SMART METERS ON THE BIRD POPULATION TO THE UTILITIES COMMITTEE. CARRIED. Citizen Comment:Tabak— Judy Tabak(Renton) repeated her request from last week that Council peruse Water Fluoridation the website,fluorideactionnetworktv.com. She read a list of European countries that do not fluoridate their water, and a list of American cities that have either recently stopped adding fluoride or voted to not add fluoride to their water supplies. She remarked that she and other residents are waiting for Council to take action on this issue. } February 11,2013 Renton City Council Minutes Page 38 Citizen Comment: Lawless— Lee Lawless(Renton)stated that property owners in his neighborhood are Property Easement Dispute having an easement dispute with one homeowner in the Shamrock annexation area. He explained that a homeowner blocked access to a 50-year old access easement. Mayor Law clarified that the easement in question may have been granted by King County prior to the area being annexed to the City. He stated that Fire and Public Works personnel have studied the issue and determined that the blocked route poses no direct safety issue. Mayor Law also remarked that staff has determined that this is a civil issue and not something the City can resolve. Chief Administrative Officer Jay Covington added that staff is still determining whether this was in fact a public easement or an agreement developed between the property owners. Mr.Covington also stated that the City is working with the property owner believed to have blocked the road; however, the City has no intention at this time to establish a public right-of-way at this location. MOVED BY ZWICKER,SECONDED BY PRINCE,COUNCIL REFER THIS ISSUE OF PROPERTY EASEMENT RIGHTS TO THE ADMINISTRATION. CARRIED. Council President Corman encouraged Mr. Lawless to seek legal advice and not wait for the City to resolve the issue. Citizen Comment:Adams— Audrey Adams(Renton)stated that her request to have the sodium fluoride the Water Fluoridation City adds to the water supply independently tested was still outstanding. She expressed concern that adding sodium fluoride to the water supply would harm the City's water aquifer. Ms.Adams also remarked that the sodium fluoride bags state that the product is to be used for industrial purposes only,and asked Council what the term industrial means to them. Mayor Law stated that the Administration has previously presented both sides of this issue to Council,and that the City is not in a position to research or argue the validity of whether fluoride is right for all people. He added that he is aware the topic is controversial; however,the City relies on outside government agencies like the King County Public Health Department and the Center for Disease Control to provide advice concerning matters of public health. He also expressed concern that weekly one-sided testimony could potentially be misleading to the public,or could be viewed as a strong assertion that the City is doing something wrong. He invited Utility Systems Director Lys Hornsby to provide Council with an update on this issue. Ms. Hornsby asserted that the study referenced by the citizen,suggesting that children in high-fluoride areas have lower!Qs than children in low-fluoride areas,was actually referring to areas where fluoride was found in strengths of ten milligrams per liter of water. She reported that Renton only adds 0.8 milligrams of fluoride per liter of water;which is considered optimum for preventing tooth decay. She stated that scientists conducting the study admitted that it did not apply to water fluoridation as it is used in the United States. February 11, 2013 Renton City Council Minutes Page 39 • Ms. Hornsby also asserted that a study regarding heart health and fluoride mentioned by the citizen at a previous Council meeting was referring to the use of radioactive fluoride 18(18F)that is commonly administered in PET(Positron Emission Tomography)scans to detect arterial sclerosis;and was not referring to heart damage from fluoridated water. She remarked that federal agencies responsible for researching heart health and fluoride have found no link between fluoridated water and heart disease. Ms. Hornsby explained that there is no reason for the City to independently test the sodium fluoride because it is being used for its intended purpose. She explained that all Material Data Safety Sheets have disclaimers stating that the manufacturer does not warranty a product that is not used correctly. She also pointed out that the sodium fluoride, regardless of its country of origin, must meet the United States Environmental Protection Agency's"Standard 60" regulations. She added that in addition to meeting the standards,fluoride manufactures are also subject to on-site inspections and spot inspections. Ms. Hornsby stated that it would be very expensive for European cities to fluoridate their water supplies because they are served by thousands of small water systems. She explained that Europeans use fluoridated salt and milk as ways to add fluoride to their populations. Ms. Hornsby also remarked that although a few American cities are opting out of adding or reaffirming the use of fluoride, more cities continue to add or reaffirm its use than not. Chief Administrative Officer Covington emphasized that the City certainly wants to allow people the opportunity to speak to Council, but there comes a point in time when the things that are being said can have, in effect,almost the same impact as someone running into a crowded theater and yelling fire. He clarified for the record that the fluoride added by the City is diluted by two to three billion gallons of water. He pointed out that fluoride, like anything taken in sufficient, intensified,concentrated quantities,can cause harm. He stated that this why the sodium fluoride bags say for industrial use only; it is not meant to be taken home and eaten. Mr.Covington also emphasized that the City's water supply is potable water, not pure water. He explained that due to government regulations a number of different chemicals and additives are added to the water supply in order to ensure that it is safe for the majority of the population to drink. He acknowledged that there may be a portion of the population that is sensitive to one or more of these additives, but reiterated that for the vast majority of the public it is perfectly safe to drink. Concluding, Mr. Covington emphasized that the City,and Council as policy makers, rely heavily on state,federal, and local agencies to make recommendations regarding public health and safety issues. He stressed that all of these public health agencies have weighed in on the topic and determined fluoride to be safe. He also emphasized that the City is charged to follow the guidelines recommended by these agencies. Additionally, Ms. Hornsby stated that Renton's groundwater supply currently provides water to approximately three quarters of the population. She stated that as the City limits expand, more and more of the water will be coming from outside sources that are already fluoridated. • February 11,2013 Renton City Council Minutes Page 40 Ms. Hornsby explained that even if the City ended the practice of adding fluoride to its water supply,the water would still contain some fluoride because the water derived from multiple sources. Ms. Hornsby also stated that the data used to determine how much fluoride could be added to the water supply is not old data,as it was based on advice from the federal government from 2011. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 2/4/2013. Council concurs. 2/4/2013 CAG: 10-156, Extension of Community Services Department recommended approval of Addendum#3 to Landscape Maintenance CAG-10-156,with Canber Corporation, in the amount of$104,274 per year,to Services, Canber Corporation extend landscape maintenance services for an additional three years, expiring 12/31/2015. Council concur. Community Services: Urban Community Services Department recommended approval of a Washington Forest Restoration,WA DNR State Department of Natural Resources Urban Forestry Restoration grant that Urban Forestry Restoration will provide free labor with an estimated value of$15,000 for use of Grant Washington Conservation Corps (WCC) crews to assist in the restoration of declining urban forests for the purpose of improving water quality that eventually impacts Puget Sound. Refer to Finance Committee. Community Services: MOU Community Services Department recommended approval of a Memorandum of with Various Agencies, Understanding with the cities of Auburn, Bellevue, Bothell, Burien,Covington, Establish Joint Human Services Des Moines, Federal Way, Issaquah, Kenmore, Kent(lead), Kirkland, Mercer Program Island, Redmond,Sammamish,SeaTac,Shoreline,Tukwila,and Woodinville for planning,funding,and implementation of a joint human services application and funding program. Renton's share of the fee is$1,000. Council concur. (See page 41 for resolution.) Police: Increase Patrol Police Department requested authorization to increase the number of patrol Vehicles&Assignments vehicles by one for the Patrol Operations Division at a cost of$45,000,to allow assigning two officers per patrol car,and to provide for a spare vehicle pool with five retired vehicles. Refer to Finance Committee. Utility: Emergency Sale of Utility Systems Division recommended approval of an Emergency Sale of Water Water, Coal Creek Utility agreement with the Coal Creek Utility District that establishes the terms for District determining the availability and quantity of surplus water for sale to the district in the case of an emergency. Refer to Utilities Committee. MOVED BY CORMAN,SECONDED BY PERSSON,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Finance Committee Chair Briere presented a report recommending Finance Committee concurrence in the staff recommendation to approve the extension of a two- Finance: Extension of GIS year Limited Term Geographic Information Systems(GIS)Analyst position by Analyst Position one year,to February 28,2014,to allow for completion of work plan items with costs to be paid from the Enterprise GIS project budget. MOVED BY BRIERE,SECONDED BY PERSSON,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. February 11, 2013 Renton City Council Minutes Page 41 Finance:Conversion of Finance Committee Chair Briere presented a report recommending approval of Business Analyst to Systems the staff recommendation to approve the conversion of one Business Systems Analyst/Programmer Position Analyst position (grade A23)to Systems Analyst/Programmer position (grade A21),effective February 16, 2013,to provide application and programming support in addition to business process analysis. MOVED BY BRIERE,SECONDED BY PERSSON,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. RESOLUTIONS AND The following resolution was presented for reading and adoption: ORDINANCES RESOLUTION#4167 A resolution was read authorizing the Mayor and City Clerk to enter into a Community Services: MOU Memorandum of Understanding with the cities of Kent,Auburn, Bellevue, with Various Agencies, Bothell, Burien, Covington, Des Moines, Federal Way, Issaquah, Kenmore, Establish Joint Human Services Kirkland, Mercer Island, Redmond,Sammamish,SeaTac,Shoreline,Tukwila,and Program Woodinville for planning,funding,and implementation of a joint human services application and funding program. MOVED BY BRIERE,SECONDED BY ZWICKER,COUNCIL ADOPT THE RESOLUTION AS READ. CARRIED. AUDIENCE COMMENT Jeanie Green Crooke (Renton) submitted a partial newsletter by local natural Citizen Comment: Green medicine advocate Dr.Jonathan V. Wright that highlighted his support of the Crooke—Water Fluoridation Harvard Study regarding fluoride and the lowering of the IQ of children. Mr.Covington reiterated that City staff reviewed the study, not the opinions of people who reviewed the study,and that the study actually refers to those water systems that had high levels of fluoride, not low-level systems like Renton's,where only 0.8 milligrams of fluoride are maintained in the water supply. ADJOURNMENT MOVED BY ZWICKER,SECONDED BY PERSSON,COUNCIL ADJOURN. CARRIED. Time 7:57 p.m. Bonnie I.Walton,CMC, City Clerk Jason Seth, Recorder February 11, 2013 r. Jonathan V. Wrigh�, � � aol3 i?(.44.144; diart.. &&-Atei 1; NUTRITION 4 , ' HEALING, Green Medicine'" Vol. 19, Issue 10 • January 2013 SPECIAL EDITION Nutritional Research Reviews: Seven surprising natural-health interventions you NEED to know NOW By Jonathan V. Wright, M.D. very month, I review from come the standard of care for the very few people, if any (includ- fifty to one-hundred fifty re- vast majority of practicing MDs ing me) who can read a scientific search papers. These papers and DOs. So, while a good por- research paper at that speed. The are typically about natural sub- tion of the research I'm review- subjects are, naturally, technical stances and natural energies and ing every month is made up of and dense, and the authors,while how they function in our bodies to the latest studies they are defi- skilled at scientific research, are maintain health, or "go wrong" in nitely not all of it. There's always, frequently not as talentedat Eng- disease. And while a small portion some research from decades past. lish composition. Then there are of the research I'm reviewing does Fortunately, if you know where the countless figures and tables mention patent medicines (some- to look, there's a rich history of found in many research papers, times called drugs or pharmaceu- legacy research...stretching all the which often require not only ticals) those molecules are never way back to the early 1900's...on reading glasses but magnifying found in Nature—and are only vitamins, minerals, amino acids, glasses to decipher. patentable for that reason. They essential fatty acids, botanicals, Fortunately, medical and scien- have very limited uses and applica- and other natural-to-planet Earth tific journals know this too,and re- rions inhuman..bodies. _. . substancesandenergies. . quire-almost every research article Unfortunately, as the twen- You've probably noticed the to be published with an"abstract," tieth century evolved into the term "reviewed"whenever I write which summarizes the findings pre- "Century of Patent Medicines" about monthly research reading. sented in the full report.This makes natural medicine took a back That's because, even though a deciding which reports to read in seat in many research circles. fifth.grade reading speed test— full slightly easier. But,as useful as Promoted by mammoth patent repeated under close supervision ,. abstracts are, they often leave out medicine companies—and their as the teacher didn't believe it key details. And, especially when bloated advertising campaigns— found that my reading speed was writing about natural substances, patent medicines have, sadly, be- 800 words per minute, there are they are often quite inaccurate.For example:Confusing horse estrogen IN THIS ISSUE: with human estrogen, identifying Why there's much to fear from frankenfoods 5 alpha tocopherol as "vitamin E" when it's only one of several vita- The toxic danger lurking in your drinking water 6 min E fractions, writing as if the - The amino-acid answer to prostate problems ' 6 (continued on next page) • GMO foods. Maybe we'll get in your State. If we can't get rid of eat any corn chips, corn flakes, it done next year right here in the stuff entirely, at the very least soy products, and other likely- Washington State;we're working we have a right to know if it's in GMO'ed foods unless the label on it! Hope you're doing the same our food! In the meantime, don't on the package says "No GMO!" RESEARCH REPORT#5 The toxic danger lurking in your drinking water Unless you've followed this a significant level of an IQ-de- tell anyone asking this question to next toxic topic closely, you stroying toxin? And then using read the well-documented booklet probably don't know how bad even more in their toothpaste? (it's also cheap!) Prevent Tooth it really is. This fluoridation re- And why didn't your local Decay the Sweet Natural Way, search can't be written off as the newspapers or radio or TV stations which was written by Lane Lenard, work of some "rabid, kooky anti- lead with big black headlines about Ph.D. and me. It's available mostly fluoridationists." It comes to us these shocking findings?"(The word at the Tahoma Clinic Dispensary, straight from the Harvard School "shocking" is 'way overused, but from a few dentists, and maybe of Public Health.' y in this case it's The research reports it re- These Harvard researchers iden- With just a little bit of research the views prove that xylitol in chewing tified twenty-seven reliable research media could have added to those gum (or toothpaste) does a better reports about fluoride and found non-existent news stories that the job than fluoride, anytime! And it that twenty-six of the twenty-seven union of approximately 1500 sci- tastes a lot better,too! came to the same conclusion: entists, engineers,.and lawyers at Fluoride in amounts commonly the U.S. Environmental Protection There's a longer article about found in water supplies in these Agency condemned dumping toxic the researched health hazards of United States is significantly de- fluoride. into anyone's drinking fluoridation coming in Nutrition creasing our children's IQ by ap- water way back in 1999.6 (Yes,fif- er Healing within a few months. proximately seven—that's 7—IQ teen years ago!) Much thanks to www.fluoride- points! (Sorry about the "bold- Oh, and one more thing. You alert.org for posting an excel- face," want to make sure no one can hear it now: "Whatever can lent article on this topic which misses that research finding.) we do to prevent tooth decay if (among other things) accurately Do you really want your chil- there's no fluoride in the water debunked the critics of this Har- dren drinking water that contains anymore?" My suggestion is to yard study! RESEARCH REPORT#6 The amino-acid answer to prostate problems e next "golden oldie" is from fects in 2058 BC. None of that "it "The value of the Glycine-Al- 1958. The research describes a works for 17 years until the patent anine-Glutamic Acid mixture for treatment for the symptoms of en- runs out" stuff. Copy Nature! relief of symptoms of benign pros- larged prostate (BPH) that worked In this case, the researchers tatic hypertrophy was suggested by then, and it, of course, still works reported that a combination of a chance observation made by one now. As you read last month, if three amino acids...glycine, ala- of us, and an associate.A group of a food, a nutrient, or a group of nine, and glutamic acid...reduced allergic patients were being given nutrients had beneficial effects in or eliminated the symptoms of an amino acid mixture and during human bodies in 1958,it will have BPH.7 Let's let the researchers— the course of treatment one of the the same effects in 2058 AD, and clinical practitioners all—tell how patients volunteered the informa- will still—if we have a time ma- they discovered this remedy intion that all of his urinary symp- chine handy—have had those ef- their own words: toms had disappeared. This led 6 Nutrition&Healing January 2013 www.wrightnewsletter.com F Relative Toxicity . .6 . 1 • . 5= Extreme' Toxic t ti .!.-sysii,..,:51,..,..s.!iiil!sr > „,,,„„...........„.„....,....„,..„,..4.,,„...„,,,„ 5 ,.,..„ .,...„...„........„...„ ., ,,, ,.,,,,,,,,,,,_7;;,k., ,:„,,,t,.::.i.„,, rl y � i� at s. � teYfii L„ ,f , „ 4.= Ve Toxic 4 --1 ..,.,...,,,,L5:?_f-',..f5 ,-:;,.„-it...--...,,,-,,.--::,-.-,f,:;;:t rSt Y � T L 44 e L . ,....;::,,,,,:t?,;:,...,i.tc::,,,,-;:;:,:,,:.,,,p_;;:..4:..::::p4.,;„ -3 11111144241:5N4"441V ...4,_.4 -_ c i _ at _ r • 4.t 'h ; Y ▪ im. fi_� ' - 'N� I. x. ...„,„„,,,......„,:„....„,„,,„:„.„,, ...:,-:,;-,-..;,:,:::„:.::::::,,-.,:-...„,,,,,,. :::,...,‘„,„„„„,,,,,..„,..„:„...„, Mfr,: € ' x •�, cf` Te ;== ” - .cmc,�' _ __ _• _ r Pit?" �▪ 41 _ _ Lead • Fluoride Arsenic • • . Source:Clinical Toxicology of Commercial . Products T/D50 data - 1984 . . I • . , a 1, . Relative Toxicity 6 -"/ ----- • 5= Extremely Toxic ti,,, Y-- :::,'„,,,z.,,..„.„,,,,,.,„.,,,,,_„,„, ,., , : = Yom.$s3{.-'' ,3.K.3,-,,,,,A.,,,,T,..,,N,:i-sz-: *•35, g ,, ='j`.: ,•i4-, lir'5a ° �ma ��rrgl a f �ZhYTPL 'v'S07, ` ,g -b �- 4= Ve Toxic 4 -...,;--7-'we3,,,Pfik,',4-3,-1-zsZli'.Zi..0,,,,,,,,§ ..,,•ii,',..,g,,, ,,..g,g' ..z-F,-=:- -MAW . F{. � �t ” i 3 - teg_ - ".- _ z L - 4. r 1 ~", j. rK ate' 4C6 } : _„ ,...v,:,,.,..-,,,,,,;5,,,,..:4•0,44,-ce' ^ 5 fy fit Fvy�' __ - _ _ _ 3_ _ - c s'v. _ p� xs-fJ gip. _ :'E'�:T.',^ a.,” A� "'_2 .../--;,i:,'Agig,:t:ffi-Y.d;;tiV:,LVN � t - �f-' t •,•-•,444,51 � �' am` " r=J'v 5 v n��Wy Il. Y = J� t ��h yy _ r4 I• _ _ _- t,.....45,?:,!'",---r t _ s`_ n3 ji ,v yy q 1. L' yy - - v_ _ SE _ _� _ v+� .1:1A _:�k4 ..:44,,,, __ d.- - ;.:1,i),,,,,i,,--. � Waiat - — .,g_y' -- -_ - -.amu -'Ya._ _ - s-b:, .;,r :=;c• � 0 r Lead Fluoride Arsenic .. Source:Clinical Toxicology of Commercial Products LD50 data - 1984 • • Relative Tii NE El6 1 5— Extremel Toile �q = :107,115,14 „,,,„„_„„:,74„....: t v5 -11 „,-..„-,,,.,,,,„,„-„..„.„,- .4.,ry11V.,55`t ,.yf .. ,..„01 ,,,., r,$;l vl,tA'�4,.T..V.V.'.,-' '--_ yk Y.Yi-a'�.2- G4>� )r�y�;'• 3 ll 14= Ye Toxic 7 t: ; , � lii{L... ,. 51-1 3 { ti ^b 3 4 ,,... k „ ...i. :,.....,_ ,.....„ ,,,,,.-„,,,,„,,,:„,.„.„-.,„,„.,,,,„ ,...„......,„,,,,,,,,,,,-:,,,„,..4,4 .14044. ill--:1;'1.i.f.l.i,i'.1:':::::.,i'.:':;'i''i'l":::-...''.1,;:i-;;1.-Iiiiiii.'iii-1- i 3 h Yg _ } - -eft_ • _ _ _ kr? . i--,'si.:.:,:ii t:.4',e.-7t,-14:A*::;': =ii 9 p@ �j v S- t •. Fes{ [4,- :{vy£,.'y-;' A i+Ca CYN,, S ',7-,-.,,,:-,27,-,...4-;"--1.-.1 .-a-4",. 15 rf _ _ iv �'•Lf".`cam �h 1 _ _ _ t 4s ,,S fr ii::;;;'?"4=*!:`,.:Acf-',7i,::ilil FA6*-1 K1y,v l•” 0 "''''''''';-''''"'''..":' '.,---41:1..i114t:;.7.;:,!..,,,..1..,,E...,.„ .,._, ... ... .... .. Lead Fluoride Arsenic Source:Clinical Toxicology of Commercial ... 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In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses, is added to make sure the water stays clean on-its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton,Hill,Talbot Hill,and West Hill,ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. • • r Renton's Drinking Water r Source of Renton's Drinking Water Renton's drinking water comes from three sources: fire downtown wells, located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs,a small springs located at the southern city limit;and from the Maplewood welifield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a "sole source"by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses,is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill,and West Hill, ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean, but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide, and ammonia from the raw water. Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. • t.i I oi' Renton's Dr king Water Source of Renton's Drinking Water Renton's drinking water comes from three sources: five downtown wells, located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs,a small springs located at the southern city limit;and from the Maplewood wellfield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a "sole source"by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine, which destroys bacteria and viruses, is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill,and West Hill,ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. . J • Reny ii 's Drinking Water Source of Renton's Drinking Water Renton's drinking water comes from three sources: five downtown wells,located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs,a small springs located at the southern city limit;and from the Maplewood wellfield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses, is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill,and West Hill, ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean, but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. Renton's D i kg Water Source of Renton's Drinking Water Renton's drinking water comes from three sources: five downtown wells, located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs,a small springs located at the southern city limit;and from the Maplewood weilfield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses,is added to make surethe water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill, and West Hill,orho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water. Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. (n R nto es Drinking Water Source of Renton's Drinking Water Renton's drinking water comes from three sources: five downtown wells,,located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs, a small springs located at the southern city limit;and from the Maplewood welifield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses,is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill,and West Hill,ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. • , . .._ .� Renton's Drinking Water Source of Renton's Drinking Water Renton's drinking water comes from three sources: five downtown wells, located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook.Springs,a small springs located at the southern city limit;and from the Maplewood welifield located in the Maplewood Golf Course.As Renton's primary water source,the Cedar Valley Aquifer has been designated a"sole source" by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine,which destroys bacteria and viruses, is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,-sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay.In the areas of Renton Hill,Talbot Hill,and West Hill,ortho polyphosphates are added to the water to reduce corrosion of the iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese, hydrogen sulfide,and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. J Renton's DrEnkina Water Source of Renton's Drinking Water Renton's drinking water comes from three sources:five downtown wells, located in Liberty and Cedar River Parks,which draw water from the Cedar Valley Aquifer;Springbrook Springs,a small springs located at the southern city limit;and from the Maplewood welifieid located in the Maplewood Golf Course.As Renton's primary water source, the Cedar Valley Aquifer has been designated a"sole source" by the U.S. Environmental Protection Agency.This means no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. In 2007,our combined water sources produced 2.92 billiion gallons of water. The water pumped from the downtown wells and Springbrook Springs sources is very clean and needs minimal treatment. Chlorine, which destroys bacteria and viruses, is added to make sure the water stays clean on its way to the customers. Because our water is naturally soft,sodium hydroxide is added to stop corrosion of plumbing. Fluoride is also added to prevent tooth decay. In the areas of Renton Hill,Talbot Hill,and West Hill,ortho polyphosphates are added to the water to reduce corrosion ofthe iron water pipes found in these neighborhoods. The Maplewood wells water is also very clean,but because of its natural mineral content and pH, it must first be treated before it can be co-mingled with the water from the other sources.This treatment process consists of the removal of manganese,hydrogen sulfide, and ammonia from the raw water.Chlorine is added for secondary disinfection and fluoride to prevent tooth decay. • Our Water Quality is !gyp to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and,furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank? These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points,the groundwater contained in our aquifer.is only 23•feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It ishighly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank? These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. • Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer,with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow failing on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank?These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No ' one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. • Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley AQuifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank?These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinkingwater and our quality of life. tall'a• ' r Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate-the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. • Fed by rain and snow falling on the aquifer and higher adjacent ground,the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank? These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. -iia���}i1• }f Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points,the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank?These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. Our Water Quality is Up to You • Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer,with the rest coming from Springbrook Springs -a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source" by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank?These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean.The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural deansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. e ^. .c=ti ' 'tet=11'`..E' 'x _' '• .] Our Water Quality is Up to You Water: it is one of our most valuable resources. We need it to drink, cook, bathe, and survive. Yet we take it for granted. Each day we dump dangerous chemicals onto the ground that could potentially get into our water supply and affect our water quality. Our Underground Water Source Approximately 87 percent of Renton's water is supplied by the Cedar Valley Aquifer, with the rest coming from Springbrook Springs - a source located in south Renton. As Renton's primary water source, the Cedar Valley Aquifer has been designated a "sole source by the U.S. Environmental Protection Agency. This means that no federal financial assistance can be given to a project which might contaminate the aquifer and create a public health hazard. The aquifer is an underground layer of sand and gravel running 3 1/2 miles long, and furnishing Renton residents with an average of 7.3 million gallons of water each day. At some points, the groundwater contained in our aquifer is only 23 feet below ground, making it very sensitive to pollutants. Fed by rain and snow falling on the aquifer and higher adjacent ground, the aquifer is also replenished by groundwater flow from the Cedar Valley. It is highly permeable, and contaminants reaching these recharge areas could potentially find their way into our drinking water. Protecting Our Aquifer We drink what we pour out. The most obvious pollutants come from fuel tank spills, street run-off, septic tanks, and storm sewers. But we present one of the greatest dangers to the aquifer. How often have we used pesticides to maintain the beauty of our northwest lawns? Or dumped unwanted chemicals into the ground? How about chemicals used to unclog a stubborn drain that are then flushed into a septic tank? These are everyday examples of how we, as residents, control the purity of our own water. Clean Water Tomorrow Takes Actions Today The City has already taken steps to keep our water supply clean. The small portion of earth we can control seriously affects us, our children, our neighbors, and our city for years to come. No one expects us to change old habits overnight. But each step forward brings us closer to a solution. What can you do? It is simple. If you are using a pesticide, make sure it is natural. If you need to dispose of unwanted chemicals, make sure they are properly stored and handled. Avoid products marked "danger," "flammable," or "corrosive," which usually indicate hazardous material, and substitute natural cleansers, such as vinegar and baking soda. Take action to save the quality of our drinking water and our quality of life. J J February 4,2013 Renton City Council Minutes Page 30 Concluding, Ms.Gant provided an overview of current tolls in the State, including the Tacoma Narrows Bridge,the SR 167 HOT lanes,and the SR 520 bridge. She stated that the 1-405 dual express toll lanes being constructed on the north end,the Columbia River crossing, and the SR 99 tunnel have all been authorized to have tolls,and the State is considering tolling the 1-90 bridge,the SR 509 extension,the SR 167 extension,and potentially portions of the 1-5 corridor. Responding to Council inquiries, Ms. Gant acknowledged that there could be increases in traffic along SR 900 and in downtown Renton due to the tolling of I- 90. She added that the degree of impact would not be estimated until the environmental assessment study was completed. ADMINISTRATIVE REPORT Chief Administrative Officer Jay Covington reviewed a written administrative report summarizing the City's recent progress towards goals and work programs adopted as part of its business plan for 2012 and beyond. One item noted was: * To foster strong and healthy neighborhoods,the City of Renton announces the Neighborhood Project Grant Program for 2013. The grants are available to organized neighborhood associations with defined boundaries in the City of Renton that have been officially recognized by the City. Eligible projects include physical improvements that build or enhance a feature of the neighborhood or benefit the general public. The grants range from $3,000 to$5,000 per project,with the actual amount based on a project's merit as determined by the Renton City Council after considering the recommendation of a staff-level interdepartmental team. Applications are available on the City's website at www.rentonwa.gov,and are due by 5 p.m.on Friday, March 8, 2013. * The City of Renton Neighborhood Program will host the 9th annual "Neighbor to Neighbor"forum on Saturday, February 9 from 8 to 11:30 a.m. at the Renton Senior Activity Center, located at 211 Burnett Ave. N. All who are interested in their community are welcome to attend. For questions and to RSVP please contact the City at 425-430-6595. AUDIENCE COMMENT Judy Tabak(Renton) suggested that Council view a video regarding fluoride on Citizen Comment:Tabak— the website,fluorideactionnetworktv.com. She remarked that experts cited in Water Fluoridation the book, "The Case Against Fluoride,"speak about the issue in the video. She stated that the cities of Santa Fe,Albuquerque,and Wichita Falls have all ended the practice of adding fluoride to their water supplies. Ms.Tabak also displayed two tubes of toothpaste,one containing fluoride and one that did not,and read the warning label from the tube that contained fluoride. Citizen Comment: Martinez— Mark Martinez(Renton)expressed concern regarding the crosswalk on Duvall Poorly Lit Crosswalk on Duvall Ave. NE near Hazen High School. He explained that there is no stop light at the Ave NE &Water Fluoridation crosswalk,just lights in the road that are activated when someone pushes the button to cross. He stated that it is difficult to see the high school kids early in the morning when he is driving to work, and requested that the City consider installing a traffic light at this location. Additionally, Mr. Martinez stated that he believes the City's spends approximately$60,000 to fluoridate the water. He explained that this estimate , includes the cost of the fluoride and other costs associated with adding it to the February 4, 2013 Renton City Council Minutes Page 31 water supply. Mr. Martinez remarked that in his opinion the funds would be better spent supplementing the salary of an additional firefighter or police officer. • Citizen Comment:Adams— Audrey Adams(Renton) remarked that both requests she has submitted asking Water Fluoridation & Renton that the City independently test the sodium fluoride added to the City's water Heart Month supply have been denied. She stated that if the City gave her a sample of the sodium fluoride she would pay to have it tested. Ms.Adams also stated that the warnings on the sodium fluoride bags state that the product is harmful if swallowed and is for industrial use only. Additionally, Ms.Adams shared a personal story of the recent loss of her sister- in-law and of her brother's triple heart bypass surgery. She stated that an issue unique to her brother was that he had calcified plaque in his arteries. She explained that both her brother and sister-in-law had been on fluoridated water for over 30 years, and after doing research on the internet,she had found studies that concluded that increased fluoride uptake in coronary arteries may be associated with an increased cardiovascular risk. Citizen Comment: Greene Jeanie Greene Crooke(Renton) stated that Ms.Adams had enlightened her on Crooke—Water Fluoridation the subject of water fluoridation. She expressed concern about fluoride's effect on the health of young children. She remarked that she would prefer to have fluoride taken out of the City's water supply. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 1/28/2013. Council concur. 1/28/2013 Finance: Business Analyst to Administrative Services Department requested authorization to convert a Systems Analyst/Programmer Business Analyst position to a Systems Analyst/Programmer position. Refer to Position Conversion Finance Committee. Finance: Limited Term GIS Administrative Services Department recommended approval to extend the Analyst Position Extension Limited Term GIS(Geographic Information Systems)Analyst position for one year(until 2/28/2014)to complete implementation of the four-year Enterprise GIS plan. Refer to Finance Committee. Transportation: Operating Transportation Systems Division recommended approval of an Operating Permit&Agreement, Pro- Permit and Agreement with Pro-Flight Aviation, Inc. acknowledging a sublease Flight Aviation agreement between Renton Gateway Center, LLC and Pro-Flight Aviation, Inc. in order to operate an aircraft maintenance facility at the airport. Refer to Transportation (Aviation)Committee. Utility: Harrington Ave NE Utility Systems Division recommended approval of a contract with CH2MHILL in Green Connections,CH2MHILL the amount of$212,704 for final engineering design of the Harrington Ave. NE Green Connections project. Council concur. MOVED BY CORMAN,SECONDED BY BRIERE,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. January 28,2013 Renton City Council Minutes Page 22 Citizen Comment:Adams— Audrey Adams (Renton)stated that she hopes to convince the City to begin Water Fluoridation independently testing the sodium fluoride that is added to the water supply. She explained that she does not have a high level of confidence that the product is being tested properly because of the product origin listed in the Certificate of Analysis (CoA). Ms.Adams also quoted sections of the CoA and related Material Data Safety Sheet(MSDS), and remarked that the manufacture has shifted all responsibility regarding safety to the City. She added that chronic exposure to sodium fluoride may cause dental or skeletal fluorosis,and there are higher rates of hip fractures in fluoridated areas compared to non- fluoridated areas. Citizen Comment:Tabak— Judy Tabak (Renton) expressed concern regarding the effect fluoride may have Water Fluoridation on her grandchildren, and on the food she grows in her gardens. She stated that she read a book entitled, "The Case Against Fluoride," and suggested that Council also read it. Ms.Tabak read several passages from the book and urged Council to become more informed on the issue. Citizen Comment: McOmber— Howard McOmber(Renton) stated that he believes there is cause to re- Water Fluoridation. evaluate the reasons why fluoride is added to the City's water supply. He remarked that if adding sodium fluoride to the water is found to not be an improvement,then the practice should be discontinued. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 1/14/2013. Council concur. 1/14/2013 Appointment: Planning Mayor Law reappointed Michael Chen to the Planning Commission for a three- Commission year term expiring 1/31/2016. Council concur. City Clerk: Quarterly Contract City Clerk submitted quarterly contract list for period 10/31/2012 to List, 10/1/2012- 12/31/2012 12/31/2012, and expiration report for agreements expiring 1/1/2013 to 6/30/2013. Information. Court Case:Alleged Court Case filed by Dorsie Williams v. City of Renton, represented by Raymond Negligence Due to Broken L. Connell,Attorney for Plaintiff, alleging City negligence due to a broken Sidewalk,Williams, CRT-13- sidewalk resulting in a fall and injury. Refer to City Attorney and Insurance 001 Services. CAG: 11-189, Cedar River Community Services Department submitted CAG-11-189,Cedar River Park Parking Lot Lighting, Parking Lot Lighting project; and requested approval of the project, Transportation Systems commencement of a 60-day lien period,and release of retained amount of $11,983.06 to Transportation Systems, Inc.,contractor, if all required releases are obtained. Council concur. CAG:09-081, Basic Life Fire and Emergency Services Department recommended approval of Support Services, King County Amendment#6 to CAG-09-081, accepting$1,229,898 from King County for basic life support services for 2013 to be divided amongst the City-$916,361, King County Fire District#25-$105,875,and King County Fire District#40- $207,662. Council concur. January 14, 2013 Renton City Council Minutes Page 12 Fire: Employee&Citizen Fire and Emergency Services Administrator Mark Peterson presented a Recognition Certificate of Appreciation to Joey Juaregui for his quick actions following a vehicular accident that occurred on 10/11/2012. Chief Peterson explained that Mr.Juaregui drove up to the accident scene, noted that the injured driver was pinned inside the burning vehicle, and used a fire extinguisher from his own vehicle to put the fire out. Chief Peterson remarked that Juaregui's actions saved the driver's life. Additionally, Chief Peterson announced that Firefighter Jeff Vollandt was promoted to Lieutenant on 7/1/2012. He stated that Lt.Vollandt was hired by King County Fire District in 1992 and became a Renton Firefighter in 1993. Chief Peterson praised Lt.Vollandt's work ethic, and acknowledged the sacrifices his family made during the promotional process. Lt.Vollandt introduced members of his family, and thanked Council and the administration for his promotion. ADMINISTRATIVE REPORT Chief Administrative Officer Jay Covington reviewed a written administrative report summarizing the City's recent progress towards goals and work programs adopted as part of its business plan for 2013 and beyond. One item noted was: * Due to dangerously low temperatures,the City of Renton is partnering with Catholic Community Services to keep the Severe Weather Shelter(SWS) open at Renton Harambee Center(316 S.3rd St.). The SWS will open nightly at 8:30 p.m. Monday January 14,Tuesday January 15, and Wednesday January 16,closing at 7 a.m. Separate sleeping areas have been prepared for men,women, and families with children. Registration is required at the door and, as with all shelters, rules for the health and safety of clients,staff, and the broader community will apply. AUDIENCE COMMENT Audrey Adams (Renton)shared a story about a woman she met who has to buy Citizen Comment:Adams— bulk non-fluoridated water because drinking fluoridated water causes her to Water Fluoridation experience stomach aches and headaches. She stated that a report from 2006 found that fluoride impairs cognitive functions in adults. Ms.Adams also made the following requests: 1)conduct an independent study of the sodium fluoride before it is diluted in the City's water supply to determine if it contains any contaminants,2) provide her with a copy of the Certificate of Analysis (COA)from the most recent shipment of sodium fluoride, 3.) provide her with a copy of the most recent Material Data Safety Sheet(MSDS) regarding sodium fluoride,and 4) provide her with an empty sodium fluoride bag. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 1/7/2013. Council concur. 1/7/2013 Finance: Utility Billing Administrative Services Department submitted a request from The Rock Wood Adjustment Request,The Rock Fired Pizza for a utility bill adjustment due to a water leak and recommended Wood Fired Pizza granting the adjustment in the amount of$7,180.40. Refer to Finance Committee. December 10,2012 Renton City Council Minutes Page 382 Citizen Comment:Tabak— Judy Tabak(Renton) requested a clarification regarding Councilmember Councilmember Appointment Persson's appointment to a state forensics board. She asked if he was stepping &Water Fluoridation down from his Council position. She also expressed concern regarding water fluoridation. Mr. Persson explained that he is not leaving the Council,and has been nominated for a position on the state's Forensics Investigations Council. He remarked that the board meets once a month and focuses on policy and procedures regarding law enforcement issues. EXECUTIVE SESSION & MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL RECESS INTO EXECUTIVE ADJOURNMENT SESSION FOR APPROXIMATELY 15 MINUTES TO DISCUSS.PERSONNEL ISSUES (RCW 42.30.110.1.g.)WITH NO OFFICIAL ACTION TO BE TAKEN AND THAT THE COUNCIL MEETING BE ADJOURNED WHEN THE EXECUTIVE SESSION IS ADJOURNED. CARRIED. Time: 7:52 p.m. Executive session was conducted. There was no action taken. The executive sessio nd the Co cil meeting adjourned at 8:10 p.m. .i t4., Jaso A. Seth, Deputy City Clerk Li Li-Wong, Recorder December 10, 2012 December 10, 2012 Renton City Council Minutes Page 379 CED:Suburban (Sound)Cities Deanna Dawson, Executive Director,stated that Suburban Cities Associations Association (SCA)was founded in the 1970s to help cities with populations under 150,000 act locally and partner regionally to create vital, livable communities through advocacy,education, leadership, mutual support, and networking. She remarked that Renton is one of the most active cities in the 35-member consortium. Ms. Dawson reviewed the memberships and appointments of Renton officials, and remarked that Mayor Law currently serves as the SCA Board of Directors President and has been nominated to serve as President once again for 2013. She also noted that Mayor Law serves on the Executive Board of the Puget Sound Regional Council,and Council President Zwicker serves on the Public Issues Committee. Ms. Dawson stated that SCA provides support to member cities through committee appointments and staffing; policy research, analysis,and advocacy; training and education;and providing networking opportunities. She also announced that SCA has changed its name from Suburban Cities Association to Sound Cities Association due to results taken from the 2012 Membership Survey, and will work to build upon policy successes, raise the organization's public profile, and try to get more members involved in the association. AUDIENCE COMMENT Ruthie Larson (Renton) questioned which process allows City Hall to revoke Citizen Comment: Larson—Aid programs passed by a vote of the people. She also asked where ambulances Car Transports are located throughout the City. Mayor Law remarked that the vehicles are at multiple locations including near Renton High School and in the Renton Highlands. Chief Administrative Officer Covington clarified that the action the City took in order to begin charging insurance companies when patients are transported in City vehicles does not change current dispatching procedures. Administrative Services Administrator Wang added that the cost to bill insurances companies is$21 per transport and is accounted for in revenue projections. Citizen Comment:Adams— Audrey Adams(Renton) stated that she believesit is no accident that state and Water Fluoridation federal agencies have passed off their responsibilities concerning water fluoridation to local jurisdictions. She remarked that the Washington State Board of Pharmacy has declared fluoride a drug,and explained how there are no safeguards in place to protect children from this drug. She noted that she has submitted her comments to the City electronically. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 12/3/2012. Council concur. 12/3/2012 • Appointment:Airport Advisory Mayor Law reappointed Alfred Banholzer to the Airport Advisory Committee, Committee Washington Pilots'Association—Green River Chapter position,for a three-year term expiring on 5/7/2015. Council concur. December 3,2012 Renton City Council Minutes Page 367 allergies and through fluoride avoidance was able to regain the use of 90 percent of foods. Ms. Peters added that the quickest way she regressed was through fluoride exposure,and pointed out that it is nearly impossible to travel or eat out because fluoride is everywhere. She stated that she is able to survive because she lives in an un-fluoridated household. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 11/26/2012. Council concur. 11/26/2012 Utility:Sewer Oversizing City Clerk submitted request from Gladco Development for reimbursement in Reimbursement Request, the amount of$3,840.09 for oversizing the sewer mains installed upstream of Gladco Development the new Liberty High School Lift Station. Refer to Utilities Committee. CED: Funding Allocation Community and Economic Development Department recommended approval Recommendations, Renton of the Renton Lodging Tax Advisory Committee recommendation to allocate Lodging Tax Advisory $120,000 to the Renton Chamber of Commerce to fund the Renton Visitors Committee Connection,$102,000 to the Renton Community Marketing Campaign administered by Saunderson Marketing Group, and additional marketing campaign expenses in the amount of$49,000. Council concur. CAG: 12-038,Scope of Work Transportation Systems Division recommended approval of Supplemental No. 1 Change for Taxiway Bravo to CAG-12-038,with Reid Middleton, Inc., in the amount of$259,476 for a Rehabilitation, Reid Middleton change in scope of work regarding the Airport's Taxiway Bravo Rehabilitation project. Refer to Transportation (Aviation) Committee. CAG: 11-156, Hardie Ave SW— Utility Systems Division recommended approval of Addendum No. 1 to CAG-11- SW 7th St Storm System 156, Hardie Ave.SW—SW 7th St.Storm System Improvement project,with Improvement,SAIC Energy SAIC Energy, Environment&Infrastructure, LLC, in the amount of$694,178 for Environmental & final design services. Council concur. Infrastructure MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Council President Zwicker reported that the Committee of the Whole heard Committee of the Whole presentations on the subject of fluoridation of the City's water supply and Utility:Water Fluoridation recommends that the referral be closed. MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Councilmember Briere remarked that she believes this to be an issue that should be brought up at the county or state level. She encouraged everyone interested in this issue to continue their efforts but at a higher level. Councilmember Taylor agreed with Ms. Briere and remarked that he believes the issue could be put to a vote of the people. Councilmember Corman remarked that he needs more time to digest the information,and agrees that the issue should be taken to the state level. _ • • COMMITTEE OF THE WHOLE APPROVED BY G OMMITTEE.REPORT . CITY COUNCIL. . • • December:3 2012 . ;.. Water Fluoridation_ :. (Referred Septe"mber 24; 2012);' .. , , - The Committee of the Whole has heard presentations:on:the subject of fluoridation of the Ci y'S.water supply'.andrecommends that the referral be closed: ' Rich-Zwicker;..Council�Pre ident , ' • - cc`, Gregg Zimmerman , Lys Hornsby Abdoul"Gafour Ray.Sled Teresa.Phelan Terry.Higashiyam• • • • Water Fluoridation.doc\. ' , rev 01/09 bh December 3, 2012 Renton City Council Minutes Page 366 Citizen Comment: Larson— Ruthie Larson(Renton) recalled that there had been a City-wide vote regarding Emergency Medical Transport the use of Aid cars in Renton,and remarked that she did not understand why User Fee that service was going away. She stated that improving fire department equipment over the years and training fire personnel as Emergency Medical Technicians helped keep insurance rates low in Renton. Ms. Larson added that she believes insurance rates will increase for people who frequently need transport and they will now have to pay the$600 plus$14 per mile fee for transport. She stated that she thinks the new fee is a bad idea. Citizen Comment:White— Jon White (Bellevue) remarked that he had expressed concerns regarding the Title IV(Development proposed height limitations for Accessory Dwelling Units (ADUs) at the Regulations) Docket#D-91, 11/26/2012 Council meeting. He stated that Community and Economic Accessory Dwelling Units Development Administrator Vincent submitted a memorandum in response to his concerns. Mr.White presented four scenarios demonstrating his belief that Mr.Vincent's response was erroneous. He requested that the matter be remanded back to the Planning Commission to allow for further review and additional public comment. Citizen Comment: McOmber— Howard McOmber(Renton)stated that he grew up believing that fluoride was Water Fluoridation safe because that is what he had always been told. He remarked that cigarettes had once been promoted as safe,and everyone now knows them to be harmful. Mr. McOmber suggested stopping fluoridation of the water supply and using the$80,000 to address other budget issues. He also remarked that he has an older grandson who has autism, and when he was diagnosed the rate for children born with autism was about 1 in 1,400. He noted that the current rate is 1 in 166. Citizen Comment:Adams— Keith Adams(Renton)stated that his son has autism and spoke in rebuttal to Water Fluoridation the fluoride endorsers who presented information at the 11/26/2012 Committee of the Whole meeting. Mr.Adams read a prepared statement indicating that more than 4,000 professionals in various occupations have signed a statement calling for an end to water fluoridation. He remarked that these professionals believe that the benefits of fluoridation do not warrant the significant health risks. Citizen Comment:.Larkin— Alli Larkin (Des Moines) read a prepared statement from Dr. Bill Osmunson Water Fluoridation expressing opposition to water fluoridation. Additionally, Ms. Larkin shared stories regarding the effects of fluoridation on animals in Colorado and California. Citizen Comment:Adams— Audrey Adams(Renton)stated that the promoters of fluoridation gave strong Water Fluoridation endorsements, but lacked the science and study references that Dr. Bill Osmunson brought to Council at the 11/26/2012 Committee of the Whole meeting. She remarked that reverse osmosis systems are expensive and do not remove 100 percent of the fluoride in tap water. She stated that someone trying to avoid fluoride will pay roughly 60 to 1,000 times more for bottled water. Ms.Adams also asserted that minority children are especially vulnerable to the effects of fluoride because they are less able to avoid drinking fluoridated water. Citizen Comment: Peters— Olemara Peters(Redmond) remarked that she believes her body provides Water Fluoridation signals in the form of'headaches and other symptoms to let her know that fluoride is a toxicant. She stated that she addressed these issues as food RENTON CITY COUNCIL Regular Meeting December 3, 2012 Council Chambers Monday, 7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER, Council President;TERRI BRIERE; ED PRINCE; DON PERSSON; COUNCILMEMBERS MARCIE PALMER; RANDY CORMAN; GREG TAYLOR. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; LAWRENCE J. WARREN,City Attorney; BONNIE WALTON, City Clerk; GREGG ZIMMERMAN, Public Works Administrator;TERRY HIGASHIYAMA, Community Services Administrator; NANCY CARLSON, Human Resources Administrator; IWEN WANG,Administrative Services Administrator; CHIP VINCENT,Community and Economic Development Administrator; PREETI SHRIDHAR, Deputy Public Affairs Administrator; KELLY BEYMER, Parks&Golf Course Director; LESLIE BETLACH, Parks Planning&Natural Resources Director;SUZANNE DALE ESTEY, Economic Development Director;JAMIE THOMAS, Fiscal Services Director; DEPUTY CHIEF ERIK WALLGREN, Fire& Emergency Services Department; COMMANDER PAUL CLINE, Police Department. SPECIAL PRESENTATION Community Services Administrator Terry Higashiyama reported that two years Community Services: First ago the City began the process to build an accessible playground for children Financial Northwest with physical and mental challenges. She stated that with the help of many Foundation community partners and a$65,000 grant from King County,this project has come closer to reality. She introduced Gary Kohlwes,Gary Faull, and Joann Lee from the First Financial Northwest Foundation. Mr. Kohlwes remarked that the foundation was created after First Savings Bank of Renton went public in 2007, and was established for the purpose of giving back to the greater Renton community. He remarked that the accessible ' playground is an example of the type of project that brings the community together and that the foundation delights in supporting. He presented a check in the sum of$150,000 to Mayor Law. Mayor Law expressed appreciation for the foundation's contribution to the project. He thanked First Savings Bank and the First Financial Northwest Foundation for their partnership and continued support, and remarked that the funds are going to a great cause. • AUDIENCE COMMENT Monica Richter, M.D. (Mercer Island)stated that she is a pediatrician and a Citizen Comment: Richter— strong supporter of water fluoridation. She remarked that respected experts in Water Fluoridation the field of dentistry believe fluoride to be safe and effective in preventing cavities. She stated that she is speaking on behalf of children in low-income households who often do not receive adequate medical and dental care, and explained that these children may not have access to fluoride. Dr. Richter urged Council to continue to fluoridate the City's water supply. December 3,2012 Renton City Council Minutes Page 367 allergies and through fluoride avoidance was able to regain the use of 90 percent of foods. Ms. Peters added that the quickest way she regressed was through fluoride exposure,and pointed out that it is nearly impossible to travel or eat out because fluoride is everywhere. She stated that she is able to survive because she lives in an un-fluoridated household. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 11/26/2012. Council concur. 11/26/2012 Utility:Sewer Oversizing City Clerk submitted request from Gladco Development for reimbursement in Reimbursement Request, the amount of$3,840.09 for oversizing the sewer mains installed upstream of Gladco Development the new Liberty High School Lift Station. Refer to Utilities Committee. CED: Funding Allocation Community and Economic Development Department recommended approval Recommendations, Renton of the Renton Lodging Tax Advisory Committee recommendation to allocate Lodging Tax Advisory $120,000 to the Renton Chamber of Commerce to fund the Renton Visitors Committee Connection,$102,000 to the Renton Community Marketing Campaign administered by Saunderson Marketing Group, and additional marketing campaign expenses in the amount of$49,000. Council concur. CAG: 12-038,Scope of Work Transportation Systems Division recommended approval of Supplemental No. 1 Change for Taxiway Bravo to CAG-12-038,with Reid Middleton, Inc., in the amount of$259,476 for a Rehabilitation, Reid Middleton change in scope of work regarding the Airport's Taxiway Bravo Rehabilitation project. Refer to Transportation (Aviation) Committee. CAG: 11-156, Hardie Ave SW— Utility Systems Division recommended approval of Addendum No. 1 to CAG-11- SW 7th St Storm System 156, Hardie Ave.SW—SW 7th St.Storm System Improvement project,with Improvement,SAIC Energy SAIC Energy, Environment& Infrastructure, LLC, in the amount of$694,178 for Environmental & final design services. Council concur. Infrastructure MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Council President Zwicker reported that the Committee of the Whole heard Committee of the Whole presentations on the subject of fluoridation of the City's water supply and Utility: Water Fluoridation recommends that the referral be closed. MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Councilmember Briere remarked that she believes this to be an issue that should be brought up at the county or state level. She encouraged everyone interested in this issue to continue their efforts but at a higher level. Councilmember Taylor agreed with Ms. Briere and remarked that he believes the issue could be put to a vote of the people. Councilmember Corman remarked that he needs more time to digest the information,and agrees that the issue should be taken to the state level. CITY OF RE '---"4 C►TY OF RENT.N DEC 0 3 2012 Howard J. McOmber Sr RECEIVED NOV 3 , 475 Olympia Ave NE 212 Renton, WA 98056 CITY CLERK'S OFFICE RE, IVSD December 3, 2012 - CITy RK'S OFFICE Mayor Law, Renton City Council Members, Dear Friends, I attended the city meetings last week with you and heard Audrey and the others concerning sodium fluoride being put in our drinking water. And, I heard everyone's concern about our very tight city budget. Don Persson and I are old enough to remember when the major advertiser on the television and radio was the tobacco industry pushing cigarettes. In those days the anti smoking people claimed that cigarette smoke was linked to cancer and all sorts of negative things. The tobacco industry spent a lot of money hiring lobbyists, and scientists, and public relations people who did a good job explaining to America that there was no scientific basis for these anti smoker's claims about negatives in cigarette smoke. They kept the anti smokers at bay for many years. Eventually though the anti smokers finally convinced the American people that cigarette smoke was indeed INJURIOUS to our health. Then step by step the government stopped cigarette advertising on the TV and radio. Then the attorney generals from the states, and others took the tobacco industry to court and won a huge settlement from the tobacco companies for the damage that cigarette smoke had done to people all of those years. The people who were responsible for advertising to, and providing the cigarettes were punished severely for what they did. BUT no one was forced to buy cigarettes.Neither I nor my family ever bought a single pack. People had to choose to go buy cigarettes. But it still came back big time on the tobacco companies. The people and the organization that is responsible for putting sodium fluoride in our drinking water are you. Everyone else has neatly said that they only"advised"you to put the chemical in the drinking water. Everyone on every level at the presentations last week were very careful to point out that the decision to put this very"harmful rat poison"in the water is you. They were all covering their flanks big time!! If it comes out that the people who are against sodium fluoride prevail and it is shown that sodium fluoride is indeed as harmful as they claim I don't have to tell you who is going to be mounting a huge campaign including law suits to punish the people responsible for all of the damages caused. There is the issue of the budget. It costs about$80,000.00 a year to put sodium fluoride in the drinking water. I would like to suggest that perhaps you look into the wisdom of funding this questionable procedure... In light of the concerns now raised both at the committee of the whole and the council meeting, and also in the interest of our tight budget,the city leaders might consider placing a moratorium on adding sodium fluoride to the drinking water. That would be a saving to the budget until more studies and research can be done to assure the public health safety. You have the absolute right, as very well pointed out by both sides last week to stop the flow of sodium fluoride into the water until you have had the medical questions for which you alone are responsible, resolved. I like you am not a doctor or a research scientist, I am though a Renton City resident and tax payer and I am certain that neither you nor I want to be paying the costs that will surely come against the city if these anti sodium fluoride people are right. Unlike the cigarette issue,the people of Renton are all furnished the drinking water by the city and we have no choice but to drink the water as we have all been doing for many years. I am just interested, as you all are, in doing the right and prudent thing. I think that now the safety of this procedure has been raised and attested to by very competent researchers and scientists in open and recorded public meetings; and now that you and all of us have been put on public notice that there is a very dangerous threat to the public's health;. I suggest that in the interest of safety the city cease putting sodium fluoride in the water. Sincerely, Howard J. McOmber Sr. F b r Jason Seth From: Bonnie Walton Sent: Tuesday, November 27, 2012 3:13 PM To: Jason Seth Subject: FW: Dr. Moffett Burgess' response to Councilmember Corman's questions Fyi... Bw From: Lys L. Hornsby Sent: Tuesday, November 27, 2012 3:07 PM To: ORG CITY_COUNCIL Cc: Bonnie Walton; Julia Medzegian; Jay B Covington Subject: Dr. Moffett Burgess' response to Councilmember Corman's questions Councilmembers, I am sending you a response that I received from Dr. Moffett Burgess relating the questions that Councilmember Corman asked at the COW Fluoridation Presentation on November 26, 2012 as follows: Thanks so much for the opportunity to talk to the Council yesterday. I want to be sure the Council, and in particular Councilmember Corman,get complete answers to the questions he posed. • Some of the health concerns raised appear to have come from a 2006 report on fluoride by the National Research Council. It is important to clarify that the NRC raised the possibility of health concerns in U.S. communities where the natural fluoride levels in well water or aquifers are unusually high.These natural fluoride levels are dramatically higher than the level used to fluoridate public water systems. In addition,the NRC itself explained that its report was not an evaluation of water fluoridation. The Centers for Disease Control and Prevention wrote that the NRC's findings "are consistent with CDC's assessment that water is safe and healthy at the levels" used for fluoridating community water systems. • Some concerns were raised about the impact of fluoridation on IQ. This line of questioning comes in response to a Harvard review that looked at studies done in areas of China where fluoridation is 10 times that found in optimally fluoridated US cities. The study found a small difference in 10 between those children raised in optimally fluoridated water and those in areas endemic with high concentrations of fluoride. However; it concluded, "The IQs of adults in the area were also measured and the intellectual ability and even life expectancy of people in the (high-fluoride)endemic region appeared to be higher than the non-endemic region".The researches themselves clarified that the study has no relevance to fluoridation in the US. Related News • Here is some information on Fluorine vs. Fluoride: http://www.fluoridedebate.com/question0l.html Thanks again for allowing me to present information on water fluoridation and advocate for the health of the citizens of Renton. 1 I sincerely appreciate and trust in the dedication of the council to serve its citizens well. Moffett Burgess • Dental Director Public Health Seattle and King County 2 November 26,2012 Renton City Council Minutes Page 353 Citizen Comment:Adams— Audrey Adams (Renton)stated that she was disappointed with the earlier Water Fluoridation Committee of the Whole meeting because she did not believe that equal time had been given to the anti-fluoridation group. She stated that Dr.Osmunson was the only person allowed to speak against fluoridation while four people were allowed to speak in favor of the issue. She questioned whether a Chief Dental Officer was qualified to have the expertise to determine the systemic effects to long-term exposure to fluoride. Ms.Adams asked that the pro- fluoride group provide Council references to the 3,000 studies they mentioned in their presentation. Citizen Comment: Peters— Olemara Peters (Redmond)shared her experiences to food allergies and other Water Fluoridation intolerances, and stated that she had lost the use of 90%of the kinds of food she could eat. She remarked that she must avoid fluoridated water and foods prepared with it,and noted that regular water filters do not remove fluoride from water. Citizen Comment:John— David John, M.D. (Mercer Island) remarked that Council is left with a choice Water Fluoridation regarding water fluoridation after hearing both sides of the issue. He shared his experiences working in research and urged Council to ask the pro-fluoride group to produce just one of the 3,000 reports they mentioned so it could be reviewed. Dr.John stated that New Hampshire requires annual public notification to communities that fluoridate their water, and the Center for Disease Control has recommended that fluoride not be given to babies. Citizen Comment:White— John White (Bellevue) expressed concern regarding the potential impacts of the Title IV(Development height restriction of Docket#D-91 regarding Accessory Dwelling Units(ADUs). Regulations) Docket#D-91, He stated that current code allows ADUs to be up to 30 feet in height,and the Accessory Dwelling Units proposed change limits the height of the ADU to the height of the primary Review dwelling. Mr.White remarked that he would prefer the limit to be no more than five feet nine and a half inches taller than the primary building. He explained that this number is half the allowable height for a one-story building as defined by the International Residential Code. He presented two potential • scenarios under the proposed code that would not mathematically allow an ADU to have the same roofline height as the primary dwelling. MOVED BY CORMAN,SECONDED BY BRIERE,.COUNCIL ALLOW THE SPEAKER THREE ADDITIONAL MINUTES TO CONCLUDE HIS COMMENTS. CARRIED. Concluding, Mr.White urged Council to review his proposal to allow the additional five feet nine and a half inches of height. Referring to the previous examples he presented, Mr. White stated that a person standing on the street would not notice the difference in rooflines. Councilmember Corman stated that Mr.White had made some good points, but the docket was very close to being approved. Councilmember Prince added that Mr.White could apply for an administrative variance for his project. Mr.White acknowledged that a variance could work,but the$1,200 cost to a homeowner could be avoided by tweaking the code amendment as he has proposed. RENTON.CITY COUNCIL Regular Meeting November 26,2012 Council Chambers Monday,7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER,Council President; GREG TAYLOR; RANDY CORMAN; MARCIE COUNCILMEMBERS PALMER; DON PERSSON; ED PRINCE;TERRI BRIERE. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; GARMON NEWSOM,Assistant City Attorney; BONNIE WALTON,City Clerk; IWEN WANG, Administrative Services Administrator; GREGG ZIMMERMAN, Public Works Administrator; CHIP VINCENT, Community and Economic Development Administrator; NANCY CARLSON, Human Resources Administrator;TERRY HIGASHIYAMA,Community Services Administrator;TIM WILLIAMS, Recreation Director; LYS HORNSBY, Utility Systems Director;JAMIE THOMAS, Fiscal Services Director;TOM PUTHOFF, Recreation Coordinator; FIRE& EMERGENCY SERVICES ADMINISTRATOR MARK PETERSON and DEPUTY CHIEF ERIK WALLGREN, Fire& Emergency Services Department;COMMANDER DAVE LEIBMAN, Police Department. SPECIAL PRESENTATION Community Services Administrator Terry Higashiyama introduced Recreation Renton Youth Council Coordinator Tom Puthoff. Recognition Mr. Puthoff shared the history of the Renton Youth Council, and stated that the council is involved in projects that include drunk-driving awareness and education,alcohol and tobacco compliancy checks at local businesses,and volunteering at the Salvation Army. He remarked that the council also attends leadership training conducted by their peers on subjects as varied as dating violence,substance abuse,eating disorders, and other issues affecting teens. Concluding, Mr. Puthoff stated that students cleaned up the beaches at Lake Wenatchee as a service project during their last weekend leadership training event. He added that applications are available on the City's website, and the youth council is open to students in grades six to twelve. Councilmember Persson thanked the Renton Youth Council for the outstanding service they provide to the community. AUDIENCE COMMENT Beatrice Clark(Renton)explained that when she received a copy of emails Citizen Comment:Clark— requested through a public records request, a portion had been redacted. She Discrepancies with Emails further explained that after making a complaint the City provided a copy of the emails without the redactions. Ms. Clark stated that she has found discrepancies between the two sets of emails and requested clarification on this matter. Citizen Comment: Richter— Monica Richter, M.D. (Mercer Island) stated that she is a pediatrician and a Water Fluoridation strong supporter of water fluoridation. She remarked that she believes the benefits of fluoridating water outweigh the risks. Dr. Richter also remarked that she prescribes fluoride to patients who live in areas who do not have fluoridated water. , - -. . Report f ohte , . Fairbanks• uo FI ride Task Fore April 25, 2011 Prepared for the Fairbanks City Council r v r Fairbanks, Alaska A r _ r ff y � �v__._._.,,�,.,�....� _ � �_.s._.�._,...._.. .,.....,..,�_�.�a.:.�,y._-.a�.. _.b.,, Contents Chapter 1: Introduction 4 Chapter 2: Recommendations 6 Chapter 3: History 8 Chapter 4: Legal and Ethical Issues 14 Chapter 5: Exposure 16 Chapter 6: Efficacy 30 Chapter 7:Adverse Effects 39 Chapter 8: Socioeconomic Issues 45 Chapter 9: Cost 46 References 47 Appendix A: Resolution Establishing Task Force 53 Fairbanks Fluoride Task Force Report 3 Chapter 1 x` ' Introduction Y • In response to concerns expressed by community members, on February 8,2010, the Fairbanks City Council passed a resolution (Appendix A) establishing a committee charged with the responsibility to examine evidence related to fluoridation of public water supplies and to provide the City Council with a report containing analysis and recommendations. The committee was to obtain documentation provided by both proponents and opponents of fluoridation and to supplement this documentation with information from other appropriate sources.The committee was to make its final report to the City Council by early July,2010, but the committee was unable to meet this deadline due to the complexity of the assignment and the schedules of the committee members. The committee, referred to in this report as the Fairbanks Fluoride Task Force (FFTF), is composed of the following members: Paul Reichardt, Ph.D. (Chair) Bryce Taylor, D.D.S. Professor of Chemistry Emeritus Dentist University of Alaska Fairbanks Fairbanks Richard Stolzberg, Ph.D. Joan Braddock, Ph.D. Professor of Chemistry Emeritus Professor of Microbiology Emeritus University of Alaska Fairbanks University of Alaska Fairbanks Rainer Newberry, Ph.D. Beth Medford, M.D. Professor of Geochemistry Tanana Valley Clinic University of Alaska Fairbanks Fairbanks The FFTF met for the first time on March 4,2010, and continued to hold public meetings approximately twice a month through March 8,2011. At the invitation of the FFTF,both proponents and opponents of fluoridation of the Fairbanks water system (operated by Golden Heart Utilities) made presentations at the March 16,2010, meeting. Public testimony was received at each of the ten public meetings during the period March 16,2010, through June 22, 2010. Numerous comments and pieces of information were submitted to the FFTF electronically. Members of the FFTF supplemented this information with relevant articles from the professional literature and results of personal interviews and research. All documents and information received by the FFTF during the period in which public testimony was being accepted are cited on the References section of the FFTF website (www.ci.fairbanks.ak.us/ boardscommissions/fluoridetaskforce/fluoridetaskforcereferencematerials.php). While FFTF members considered the entire body of information submitted and collected, only some of the materials listed on the References website were used in preparing this report. Those materials are listed as references at the end of this report.There is a massive amount of relevant information on this topic. For example, Fairbanks Fluoride Task Force Report 4 in 2008, C. A.Yeung did a review of the efficacy and safety of fluoridation that began with over 5,000 relevant citations. The approach the FFTF took to assessing and using this information was to rely on reviews and studies published between 2000 and 2008 to assess the evidence for and against fluoridation of drinking water as it existed up to 2008 and to supplement this body of literature with key professional articles published in the last several years. Although the FFTF examined all aspects of water fluoridation, it focused most of its review of the literature on exposure of individuals to fluoride, the efficacy of fluoridated water in caries prevention, and the risks associated with consumption of fluoride.While the task force's major concerns were about populations exposed to 0.7 to 1.2 parts per million (ppm) fluoride in their water supplies, it did examine and consider evidence related to populations receiving both higher and lower concentrations of fluoride in their drinking water.The FFTF's review and analysis of relevant information was organized around the topics that became the chapters of this report. After a series of discussions and work sessions in which all members voiced their observations and concerns about each of the topics, assignments were made to individual task force members for lead responsibility in producing an initial draft of each chapter. The entire task force was subsequently engaged in the process of chapter revision that led to a draft report,which went out for public review and comment. After consideration of comments submitted electronically as well as at two public hearings (March 29 and 31,2011), the task force made corrections and edits at its meeting on April 5, 2011. The subsequent final report (including recommendations)will be submitted to the City Council. Some technical terms and abbreviations are used throughout this report. In an attempt to make the report more readable for the general public, a few key definitions are given below: concentration: the relative content of a component, often expressed as amount in a given volume (e.g.,ppm) DMFS:decayed, missing, and filled surfaces in permanent teeth DMFT: decayed, missing, and filled permanent teeth dmft: decayed, missing, and filled deciduous (baby) teeth dose: measured quantity of an agent to be taken at one time g(gram):0.001 kg kg(kilogram): a basic unit of mass and weight equal to 2.2 pounds mg(milligram): 0.001 g L(liter):a basic unit of volume equal to about a quart LD50(lethal dose,50%): dose of a toxin required to kill 50%of a group of test organisms ppm(parts per million): a unit of concentration, defined for this report as one mg/L Fairbanks Fluoride Task Force Report 5 • • Chapte • rz • #, Recommendation The Fairbanks Fluoride Task Force makes a set of four recommendations. We anticipate that the community's focus will be on Recommendation#1, but as a committee we feel strongly that Recommendations 2, 3, and 4 should be implemented along with Recommendation#1 as part of a cohesive plan to address dental health issues in our community. 1. Primarily because (1) the ground water used for Fairbanks public water contains an average of 0.3 ppm fluoride, and (2) higher concentrations of fluoride put non-nursing infants at risk, the task force recommends that supplemental fluoridation of the Fairbanks public water supply be terminated. The task force further recommends that the Fairbanks community be,informed of possible dental health implications from not fluoridating the water. Rationale:Not fluoridating Fairbanks water will reduce the fluoride content from 0.7 ppm to 0.3 ppm,which is the fluoride concentration of the raw water used by Golden Heart Utilities (GHU).This will reduce,but not eliminate,the risk of significant incidence and severity of fluorosis, especially fluorosis associated with the use of GHU water to prepare infant formula. Doing so will also address ethical concerns raised during the task force's public testimony. However, the effect of this reduction in fluoride concentration on the caries rate in the Fairbanks community, while most likely small,is unknown and unpredictable. Those who depend on 0.7 ppm fluoride in tap water for their dental health need to be informed of the possible adverse consequences to their dental health caused by reducing the fluoride content of Fairbanks tap water from 0.7 ppm to 0.3 ppm and of the measures that can be taken to address these possible adverse consequences. The task force has made this recommendation to terminate fluoridation of GHU water with full knowledge of and respect for the positions of the American Dental Association (ADA), the Centers for Disease Control and Prevention(CDC;part of the U.S. Department of Health and Human Services), the World Health Organization, and the Alaska Department of Public Health in support of fluoridation of public water supplies.While the task force members agree that water fluoridation may be an important element of an effective dental health program in many communities, the majority of members are not convinced that it is necessary in Fairbanks because of the fluoride content of the city's ground water and the alternate sources of fluoride available in the community. Five task force members,with various degrees of conviction, support this recommendation,while one member(Dr.Taylor) supports continuing fluoridation at 0.7 ppm. 2. The Fairbanks City Council's decision-making process on fluoridation should involve representatives of the Fairbanks North Star Borough government. Rationale:At least 25% of area residents who receive GHU water reside outside the city limits. 3. Local dentists and physicians should be encouraged to provide their patients with up-to-date information on the benefits and risks associated with fluoride. Rationale:If nothing else, the recent notice that the secretary of the U.S. Department of Health and Human Services has proposed a new recommendation on fluoridation of public water supplies Fairbanks Fluoride Task Force Report 6 indicates that the citizenry should be informed about the state of contemporary research findings and analysis related to the role of fluoride in dental health.All of the members of the task force went into this project with incomplete and in some cases incorrectinformation about the issue.We suspect that we are not unique in that respect. 4. The Fairbanks City Council should encourage the local school system to review and modify, as appropriate,its approach to promoting good dental health practices. Rationale:The local schools have an excellent opportunity to help all families in the community to learn about and to implement good dental health practices,which can include optional opportunities at school for topical fluoride treatment(in the form of rinses and tooth brushing, for example) as well as techniques for minimizing unnecessary and/or unwanted exposure to fluoride. Fairbanks Fluoride Task Force Report 7 • Chapter .. . • •' '•'.History of Fluoridation OfPublic Water-Supplies Fairbanks A version of Fairbanks City Code dated July 1, 1959,contained a section (Article III, Section 10.301) that authorized and directed the Municipal Utilities System to develop and implement a fluoridation plan that fulfilled the requirements of the Alaska Department of Health. A slightly rewritten version of Article III, Section 10.301 of the City Code was adopted on January 12, 1960, and on August 21, 1962, the mandated fluoridation of city water was implemented in the city of Fairbanks. In 1996, the city water plant was sold by the Municipal Utilities System to Golden Heart Utilities (GHU). The fluoridation program continued under the auspices of GHU, and in 1999 the rewritten Fairbanks General Code (FGC 82-1) continued the mandate for fluoridation under the administration of Golden Heart Utilities. The present version of the Fairbanks City Code retains the language of Section 82-1 as it existed in 1999. The only formal attempts to discontinue the fluoridation program took place in 2008. On February 25 of that year a proposed ordinance to prohibit the addition of fluoride to the GHU water supply failed in a vote of the City Council. In July 2008, a city resident submitted an application for an initiative proposing that FGC 82-1 be repealed and reenacted to read: Fluoride should not be added to City community water systems.Water utilities that own or operate community water distribution systems in the City shall not add fluoride,in any form,to the water system.All water utilities owning or operating community water systems in the City shall conduct periodic water quality testing. The required signatures were not submitted by the deadline of August 12, so the initiative did not go on the October ballot. The city took no additional action on the fluoridation issue until February 8, 2010,when the City Council passed Resolution No. 4398, establishing a task force to research issues related to the fluoridation of the municipal water supply. United States In the early 1900s, research,largely by dentist Frederick McKay and Dr. G. V. Black of the Northwestern University Dental School, documented that many residents in several areas of the western U.S. had mottled teeth and, in severe cases,brown stains ("Colorado brown stain") on their permanent teeth. McKay also noticed that the mottled teeth were resistant to decay. By the 1930s it had been determined that these conditions (today known as fluorosis) were caused by high concentrations of fluoride (ca. 4-14 ppm) in drinking water. In the ensuing years, Dr. H. Trendley Dean conducted a series of epidemiological studies and reported that (1) fluoride concentrations of up to 1.0 ppm in drinking water did not cause the more severe forms of dental fluorosis and(2) a correlation existed between fluoride levels in drinking water and reduced incidence of dental decay Fairbanks Fluoride Task Force Report 8 • (Dean et al., 1941). Dean's work led Dr. Gerald Cox and associates to publish in 1939 the first paper in which fluoridation of public water supplies was proposed (Cox et al., 1939). In the 1940s, four classic, community-wide studies were carried out to evaluate the addition of sodium fluoride as a caries-reduction strategy in Grand Rapids, MI; Newburgh, NY; Brantford, Ontario; and Evanston,IL. Based on the overwhelmingly positive evaluations of these pilot studies by scientists and dental professionals,water fluoridation programs were instituted in a number,of large U.S. cities in the following two decades. In addition, alternative methods of administering fluoride to combat caries, were developed, the most notable being the introduction of fluoridated toothpaste in 1955. However, as water fluoridation programs spread, so did opposition to the practice. In 1965, the first lawsuit in the U.S. contesting the legality of fluoridation of public water supplies was settled by the New York State Supreme Court,which denied the plaintiff's case"at least until some proof is advanced that fluoridation hasharmful side effects" (Graham and Morin, 1992, p. 215). In the ensuing years a number of lawsuits contesting fluoridation of public water supplies have been pursued, but in no case have the plaintiffs been successful in stopping the practice (see Legal/Ethical Issues, chapter 4). the relevant federal, state, and professional organizations have endorsed and promoted the fluoridation of public water supplies for the past.fifty years. As a result, in 2008, forty-six of the country's fifty largest cities provided fluoridated water, and approximately 60%of the U.S. population consumed fluoridated water (Fagin, 2008). The U.S. Public Health Service (USPHS) has set a goal of"at least 75%of the U.S. population served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2010" (U.S. Department of Health and Human Services.[HHS],2000, p. 205). However, the actions of communities on this front are mixed. One summary(Juneau Fluoride Study Commission, 2006) indicates that from 1998 to 2005 approximately two hundred communities in the U.S. moved to fluoridated water or decided to retain it while approximately one hundred chose to discontinue the practice. The situation in Alaska,where the fluoridation'of public water systems is encouraged by the Alaska Department of Public Health (www. hss.state.ak.us/dph/targets/ha2010/PDFs/13_Oral_Health.pdf), roughly mirrors the national picture. In 2006, 64%of the Alaska population received fluoridated water, up from 47%in 1993 (Whistler, 2007). However, today's statewide figure may be below that of 2006 because Juneau discontinued its fluoridation program in January 2007. International According to the British Fluoridation Society(British Fluoridation Society, 2010), over 400 million people in sixty countries were served by fluoridated public water supplies in 2004. Countries and geographic regions with extensive water fluoridation programs include the U.S.,Australia, Brazil, Canada, Chile, Columbia, Ireland, Israel,Malaysia, New Zealand, Hong Kong, Singapore, Spain, and the United Kingdom. However, especially during the period of 1970 to 1993,Japan and a number of European Countries (Federal Republic of Germany, Sweden, Netherlands, Czechoslovakia, German Democratic Republic,USSR, and Finland) discontinued water fluoridation programs. In 2003, Basel, Switzerland, ended its water fluoridation program, and in 2004 Scotland rejected plans to fluoridate water supplies. Fairbanks Fluoride Task Force Report 9 In most or all of these situations, dental health continued to improve following cessation of water fluoridation (Ziegelbecker, 1998), presumably due to factors including enhanced dental hygiene programs, fluoride-containing table salt,fluoridated toothpaste, and improved diets. There are data to support the contention that in recent years caries rates in many areas have declined irrespective of the concentrations of fluoride in water supplies.World Heath Organization (WHO) data(Peterson, 2003: Fig. 7) indicate substantial declines in DMFT among twelve-year-olds in developed countries (from about 4.7 to about 2.5) during the period 1980 to 1998 but little change among this age group in developing countries (from about 1.8 to about 2.3). Nevertheless, the World Health Organization continues to consider community water fluoridation to be an effective method to prevent dental caries in adults and children. However, it recognizes that other approaches,including fluoridated salt and milk fluoridation, have"similar effects" (www.who.int/oral_health/strategies/cont/en/index.html). It also recognizes the value of fluoridated toothpasteand fluoride-containing mouth rinses and gels. For Alaska communities, perhaps the most relevant international situation is that in the neighboring country of Canada. According to the Health Canada website (www.hc-sc.gc.ca), each Canadian municipality retains the authority to decide on fluoridation of its water supply; in 2005, 43%of the Canadian population was served by fluoridated water supplies (Federal-Provincial-Territorial Committee on Drinking Water,2009). The Guidelines for Canadian Drinking Water Quality set a maximum allowable fluoride concentration of 1.5 ppm in drinking water, a level at which Health Canada believes there are no undue health risks (Health Canada,2010). Although Canadian provincial and territorial governments regulate the quality of drinking water in their jurisdictions, Health Canada has recommended to communities wishing to fluoridate their water supplies that"the optimal concentration of fluoride in drinking water to promote dental health has been determined to be 0.7 mg/L" (Health Canada, 2010). The Controversy From the very beginning of efforts to implement water fluoridation programs in 1945, there has been controversy(Connett et al., 2010). By the 1950s the sides were pretty well drawn. On one side were dentists and scientists from government and industry,who promoted the addition of fluoride to drinking water as a protection against dental decay. On the other side were mostly activists who contended that water fluoridation was essentially compulsory mass medication, thus a violation of individual rights, and that the risks of fluoridation had not been studied adequately. The advocates of fluoridation won the argument,in part by ridiculing the unlikely arguments of some of the opponents (e.g., the John Birch Society,which contended that fluoridation was a communist plot to poison the citizens of the USA). A series of court cases from the mid-1960s through the mid-1980s established that local and state governments have the constitutional authority to implement fluoridation programs. These decisions were based largely on the principle that the`government interest in the health and welfare of the public generally overrides individual objections to health regulation" (American Dental Association [ADA], 2005,pp. 47-49). In light of these decisions,the argument against"compulsory mass medication"has emphasized ethical rather than legal issues (see, for example, Bryson, 2004). Fairbanks Fluoride Task Force Report io During this same period, a number of scientific investigations into potential adverse effects of drinking fluoridated water were undertaken. None of these studies produced results that were generally accepted as demonstrating serious adverse health effects of water containing"optimal levels" of fluoride ion (0.7 to 1.2 ppm). However, a number.of them raised significant questions about potential risks by showing some adverse health effects at fluoride concentrations of greater than 2 ppm (for example, Kurttio et al., 1999; Freni, 1994). Around the turn of the century, a comprehensive review of the scientific literature related to water fluoridation was undertaken under the auspices of York University in the United Kingdom. The report from this review(McDonagh et al., 2000), often referred to as the York Report, noted the generally poor quality of the evidence for both beneficial and adverse effects of fluoridation.The resulting uncertainties about the benefits and risks of consuming fluoridated water fueled the controversy in that it allowed each side to discount the opposition's arguments because of the"poor quality" of the evidence on which positions were based.While there are many examples of the arguments put forward by the two sides, two representative accounts are an antifluoridation article by Colquhoun (1998) and a profluoridation article by Armfield(2007). Another key review of the effects of fluoride in drinking water was published by the U.S. National Academy of Sciences in 2006 (National Research Council,2006). This review and associated recommendations were focused on EPA standards for drinking water (Maximum Contaminant Level, MCL, of 4 ppm and Secondary Maximum Contaminant Level, SMCL, of 2 ppm) and did not directly address the USPHS regulations on the lower concentrations in fluoridated public water supplies in the U.S. (0.7 to 1.2 ppm). Nevertheless, the report contains information and data relevant to the safety of fluoridated water. Evidence in the scientific literature led the review committee to conclude that water containing 4 ppm fluoride "puts children at risk for developing severe enamel fluorosis" and was "not likely to be protective against bone fracture" (National Research Council, 2006,p. 2). This review also contains analyses of a number of other adverse health effects that have been alleged to be related to fluoride ingestion,but the authors found that these allegations were either not supported by good evidence or required further study before any meaningful conclusions could be drawn. As with the York Report,the uncertainties about the risks of fluoride-containing water (compounded,in this case,by uncertainties about how conclusions based on consideration of fluoride concentrations of 2 ppm or higher relate to lower concentrations) have given both advocates and opponents of fluoridation data and arguments that they have selectively employed in supporting their opposing positions. As time has gone on,particularly since the publication of the York and National Research Council reports, a number of professionals with expertise in dental health and toxicology have joined the opposition to fluoridation.They include dental researchers who were originallysupporters of fluoridation (e.g., Colquhoun, 1998; Limeback, 2000), dentists (e.g., Osmunson,2010a), and EPA employees (e.g.,Thiessen, 2006, 2009a, 2009b,2010; Hirzy, 2000).A"Professionals' Statement to End Fluoridation" (www.fluoridealert.org/prof statement.pdf) had over three thousand signers as of July 2010 (although many of the signers are not identified with respect to their areas of expertise, so it is not clear that all these"professionals"have expertise in relevant areas). However, professional and governmental organizations remain supportive of water fluoridation, and to our knowledge, the majority of dental health practitioners in the United States continue to support it. Fairbanks Fluoride Task Force Report �� There is no shortage of information; the literature search for a recent review of the efficacy and safety of fluoridation turned up over five thousand citations..However, after application of exclusion/ inclusion criteria related to the quality of the research and after review of the full text of each remaining article, the author of the review selected just seventy-seven citations for inclusion (Yeung, 2008).Why has so much of the fluoridation literature been deemed to be of less than high quality? There are at least four difficulties inherent in these studies:' 1. as with all epidemiological studies, those focused on the safety and efficacy of water fluoridation are complicated by a multitude of confounding variables (e.g.,Taubes, 2006), not the least of which is the tremendous variability in water consumption and related fluoride dose of individuals (EPA,2004); 2. in many cases the data cannot be interpreted without the application of sophisticated statistical methods, and even then statistical correlations do not necessarily imply causative relationships (e.g., Sigfried,2010); 3. some of the alleged adverse effects of fluoride are associated with very rare conditions (e.g., osteosarcoma), making it difficult to detect small, but potentially significant, differences in study populations; 4. the results from studies with laboratory animals are often not complicated by confounding variables, but their relevance to humans and the concentrations of fluoride in public water supplies is often difficult to determine (Hayes, 2008,pp. 330-332). In recent years, the difficulties associated with critical evaluation of research findings and associated conclusions have been exacerbated by the widespread use of the internet as a medium for distributing information and opinions. The opponents of fluoridation in particular have used the internet to advance their arguments and point of view.Although many of these sites contain useful information and cogent arguments, the sites and the information on them are not uniformly of high quality. In many instances it is difficult to evaluate the quality of material posted on websites focused on fluoride and fluoridation without a fairly thorough knowledge of the peer-reviewed literature. While these scientific issues continue to be debated, it appears that within the general public the major concern is related to ethics, not quality of the research on benefits and adverse effects of water fluoridation. Thus, many opponents of water fluoridation would remain opposed to"mass medication" even if the safety and efficacy of the practice were clearly documented. So, today the controversy continues unabated. The situation is described quite well in a recent journal article: Plans to add fluoride to water supplies are often contentious. Controversy relates to potential benefits of fluoridation, difficulty in identifying harms,whether fluoride is a medicine, and the ethics of a mass intervention.We are concerned that the polarised debates and the way that evidence is harnessed and uncertainties glossed over make it hard for the public and professionals to participate in consultations on an informed basis. (Cheng et al.,2007,p. 699) Fairbanks Fluoride Task Force Report 12 Findings Throughout the United States, and in many countries around the world, the incidence of tooth decay has decreased significantly over the past several decades. Although claims have been made that adding fluoride to drinking water has been one of the main reasons for this decline, the data indicate that in many countries and communities progress in preventing caries has been made without fluoridated water. For many years professional organizations and federal, state (including Alaska), and local governments in the United States have promoted the fluoridation of public water supplies, and these organizations and relevant government agencies still strongly support the practice. However, there has also been opposition to the practice since its inception in the 1940s. Although it appears that most dental practitioners and researchers still support fluoridation of municipal water supplies, it also seems that the number of practitioners and researchers who oppose the practice has increased.At this time the claims most often cited by opponents of fluoridation of water supplies are: • lack of definitive evidence for efficacy, • evidence indicating risk of adverse effects, and • ethical issues related to mass medication. Fairbanks Fluoride Task Force Report 13 ;,. Chapter 4 • 'Legal, and Ethical issues _ As indicated by testimony to the Fairbanks Fluoride Task Force, legal and ethical issues are perhaps the biggest concerns of the local residents who are opposed to fluoridation of Fairbanks'public water supply. The testimony received by the task force was overwhelmingly against fluoridation. During the ten task force meetings at which public testimony was invited, sixty-two testimonies were presented by thirty individuals (at the extremes eighteen individuals presented testimony just once, and one individual submitted testimony on six different occasions). 'Ihe positions of the testifying individuals, as described by themselves or ascertained by the task force from the nature of the testimonies,were twenty-six against fluoridation, three in favor, and one with no clearly stated opinion. 'The major concerns voiced by the opponents of fluoridation were: 1. toxic and harmful effects of fluoride; 2. lack of high-quality evidence that fluoride in public water supplies effectively prevents dental caries; 3. unethical aspects of"mass medication,"including lack of informed consent; 4. fluoridation of public water supplies interferes with freedom of choice,infringes on individual rights, and results from an overreach of governmental powers; and 5. the risk that fluoridation of public water supplies may do more harm than good. While testimony and evidence on all five of these concerns were presented to the task force, concerns 3, 4, and 5 were highlighted for the task force by both the frequency and passion of testimonies related to them. They have also been voiced in the larger debate over water fluoridation. the"mass medication"argument is that fluoridation of public water supplies administers medication to an unaware and in some cases,unwilling public (see,for example,www.fluoridedebate.com/question34. html; Cross and Carton,2003). The"individual rights"concern (#4) is related to the previous concern in that it questions governmental authority to implement the "mass medication" (Cross and Carton, 2003). The concern that water fluoridation may do more harm than good brings into the argument the "first, do no harm"precept of medical ethics. This precept basically says that in a given situation it may be better to do nothing if the action to be taken may cause more harm than good. The legal concerns brought to the task force were considered in light of a rather lengthy history of legal challenges to fluoridation of public water supplies (Graham and Morin, 1999). Although fluoridation has been challenged numerous times in at least thirteen states, and while cases decided primarily on procedural grounds have been won and lost by both proponents of and opponents to fluoridation, no final ruling in any of these cases has stopped a proposed fluoridation program or ruled in favor of elimination of an existing program (Block, 1986;ADA,2005; Pratt et al.,2002). In the process, the U.S. Supreme Court has declined to review fluoridation cases at least thirteen times (ADA,2005). In contrast to the legal question,which has repeatedly been addressed by the courts, the ethical issues remain problematic. On the one hand, opponents of fluoridation cite concerns about the propriety of forced"mass medication"and the integrity of at least some of the individuals and organizations that promote the practice (see, for example, Bryson, 2004; Cheng et al.,2007; Connett et al., 2010). On Fairbanks Fluoride Task Force Report 14 • the other hand, some proponents have argued that those who potentially have the most to gain from fluoridation of public water supplies—the economically and educationally disadvantaged and those with limited access to proper health care—do not have a voice in the development of health policies and practices unless those in power are looking out for their interests (McNally and Downie, 2000). Cohen and Locker (2001), observe that the conflict between beneficence of water fluoridation and autonomy remains unresolved and that"there appears to be no escape from this conflict of values, which would exist even if water fluoridation involved benefits and no risks" (p. 578). Further, they argue that although recent studies indicate that water fluoridation continues to be beneficial, critical analysis indicates that the quality of evidence provided by these studies is generally poor.Thus, they argue that from an ethical standpoint, past benefits of fluoridation cannot be used to justify continuation of the practice, and they call for new guidelines that"are based on sound, up-to-date science and sound ethics" (p. 579). Fairbanks Fluoride Task Force Report 15 • il .Chapter 5. _ . • • exposure Fluorine,which exists in its elemental form as fluorine gas, is one of the most reactive elements. Its chemical reactivity is.characterized by its propensity to accept electrons and to undergo,reduction to the fluoride ion.While elemental fluorine is found in just one form;the fluoride ion exists in a number of compounds,including the common minerals fluorite and especially fluorapatite. Fluorine is also found in a group of compounds called"organic fluorides,"compounds in which fluorine is chemically bonded to carbon. Some pharmaceuticals, consumer products, and pesticides are organic fluorides. Concerns about the safety and efficacy of artificially fluoridated water revolve around one species, the fluoride ion—often referred to in this report as fluoride. Fluoride is easily absorbed in the human alimentary tract, is distributed to most—if not all—tissues, and is cleared from the blood and tissues by uptake into bone and by excretion (Whitford, 1996; National Research Council,2006). It is capable of inhibiting certain enzymes (Scott, 1983, p. 166; National Research Council,2006) and of affecting bacterial metabolism,including reducing the capability of plaque-forming bacteria to produce acid(Featherstone,2000;Jones et al., 2005),which is the bacterial product responsible for caries. Given that fluoride has these biochemical properties, it is not surprising to find that it is toxic. The acute toxic dose of fluoride is 5 to 10 grams for a 155-pound person (Hodge and Smith, 1965; ADA, 2005).More precise determinations of toxicity have been performed with pure chemicals and laboratory rats, and these studies indicate, for example, that sodium fluoride is about ten times less toxic than sodium cyanide and about fifty times more toxic than sodium chloride (table salt). The fluoride-containing compound of most interest in the Fairbanks situation is sodium fluorosilicate, the compound that Golden Heart Utilities (GHU) uses to fluoridate the water it distributes. Sodium fluorosilicate is toxic;for rats its LD50 is 125 mg/kg(that is when laboratory rats were given single doses of 125 mg of sodium fluorosilicate per kg of body weight,50%of the test animals died). According to the National Institute of Health's TOXNET website (http://toxnet.nlm.nih.gov/cgi- bin/sis/search/a?dbs+hsdb:@term+@DOCNO+770), the acute toxic dose of sodium fluorosilicate for a human is between 3.5 and 35 grams. However, the low concentration of this compound in treated water(around 1.5 mg per liter) ensures that there is no acute toxicity threat associated with the treated GHU water. Nevertheless, concerns have been voiced about risks related to the use of sodium fluorosilicate in water fluoridation programs. In particular, a correlation was reported between use of sodium fluorosilicate to fluoridate water in various locales in the state of New York and levels of lead in the blood of children residing in these communities (Masters and Coplin, 1999;Masters et al., 2000). However, this correlation was not verified in a subsequent study(Macek et al.,2006). Furthermore, a causative link between the use of sodium fluorosilicate and elevated lead levels in blood of children who consume the fluoridated water would require that sodium fluorosilicate incompletely dissociates when it dissolves in water, a proposition put forward by Westendorf(1975) but which is inconsistent with the best contemporary evidence (Urbansky, 2002). Fairbanks Fluoride Task Force Report 16 Because fluoride is found in a number of common minerals,it is not surprising to find that it is naturally present in water. The concentration of fluoride in the oceans is approximately 1.3 ppm (Turekien, 1969). In the United States,fluoride concentrations in wells, lakes, and rivers range from below detection to 16 ppm (National Research Council,2006). For example, Lake Michigan's fluoride level is 0.17 ppm,wells in Arizona have concentrations up to 7 ppm, and groundwater in Bauxite, Arkansas,has up to 14 ppm fluoride (ADA,2005). In Alaska, a voluminous DEC data sheet(Alaska Department of Environmental Conservation, 2010) demonstrates that although many natural water systems around the state have undetectable levels of fluoride, one area (Wales) has 2 ppm fluoride in groundwater, and several sources of groundwater in the Fairbanks area have from 0.1 to 0.3 ppm fluoride. Several independent studies of domestic,commercial, and monitoring wells in the greater Fairbanks area show that fluoride is present at concentrations ranging from 0.1 to 1.6 ppm (Fig. 5.1; USGS,2001;.Mueller,2002;Verplanck et al., 2003). 90 80 - r= 70 _ 81 wells from the greater Fairbanks area E0) 60 - E 50 - } o 40 - a, <C_, E 30 20 - 4 - 10 - Fd 1.4' a n n n r, o 01 O'Z 03 0•1)‘ 05) O3 on 05s 05 1 11 1.' 13 1•11 fluoride concentration in well.water(ppm) Figure 5.1.Histogram of fluoride concentrations in 81 wells in the Fairbanks area.The median value is between 0.2 and 0.3 ppm,and the bulk of values are between 0.1 and 0.7 ppm.Wells in metamorphic rocks contain the higher fluoride concentrations;those tapping the sedimentary aquifer have values of 0.2 to 0.4 ppm.Data from USGS,2001;Mueller, 2002;Verplanck et al.,2003;and Alaska Department of Environmental Conservation,2010). Wells employed for Fairbanks city water are at depths greater than 100 feet below the surface and tap the sedimentary aquifer of the Fairbanks floodplain. The several hundred feet of sediment is essentially uniform in mineralogy and mineral compositions, hence, by reaction with groundwater it creates water with an essentially constant composition. The fluoride content of raw water from these wells has been tested numerous times between 1987 and 2008 yielding an average fluoride concentration of 0.34 ± 0.1 ppm (Fig. 5.2). Given the constant substrate for groundwater in the Fairbanks floodplain,there is every reason to consider this fluoride concentration to be the same for a very long time to come. Fairbanks Fluoride Task Force Report 17 0.6 Fairbanks City average: 0.34± .1 ppm well water, before 0.5 - — treatment 13 0.4 — CU I� P ji _ ti 0.3 - FA EPS Q. �.'� i a — - 0.2 c j* ' r AA, x_, Vit. li " ire,'• 1 'rF lit ,.n " 0 time (1987 2008) Figure 5.2.Fluoride concentrations in Fairbanks municipal raw well water prior to treatment and fluoridation.Each bar represents a single measurement.Based on checks of fluoride standards,the uncertainty of a given measurement is approximately o.05 ppm.Data supplied by GHU. A major source of exposure to fluoride for many Americans, including those who receive GHU water, is drinking water. While this exposure is clearly related to the concentration of fluoride in the water, it is important to distinguish between concentration and dose;The amount of fluoride (dose) an individual receives from drinking water depends on the concentration of fluoride in the water and the amount of water consumed.Thus an individual who drinks one liter of water containing OS ppm fluoride receives the same dose of fluoride as another individual who drinks two liters of water containing 0.25 ppm. Various surveys have found that the amount of drinking water consumed by individuals varies considerably. For example, an EPA report(2004) states that the results from surveys done in the 1990s indicate that very young children consume an average of about 0.3 liter of drinking water per day and adults about 1 liter, as opposed to earlier.EPA and WHO estimates of 1 liter and 2 liters, respectively. More importantly, the ranges of consumption are enormous: among the study subjects, infants less than one year old had water consumptions ranging from 0.03 liter to 15 liters, and the range among adults was from 0.1 liter to over 4 liters. The situation is further complicated by the fact that certain metal ions present in many water supplies can react with fluoride ions (before consumption) in a way that alters the uptake of fluoride from drinking water by humans (Institute of Medicine,2000;Urbansky,2002). For example, in seawater about one-half of the total fluoride is actually present as the MgF+ complex ion (Bethke; 1996). Therefore, it is very difficult to determine how much fluoride any individual actually consumes from drinking water on a daily basis. Furthermore, "average consumption"is meaningful for a relatively small segment of the population (see Fig. 5.3 for one representation of the situation). Fairbanks Fluoride Task Force Report 18 30 .012 25 a I l - - ■infants v a a 20 cc Q = o-. ° ¢ infant f° 15 mean o_ o o 4 ♦ infants 541 all � 0 0.025 0.05 0.075 0.1 0.125 0.15 0.175 mg F/kg body weight/day for 1 ppm F tap water Figure 5.3.Fluoride consumption from tapwater distribution for total population(dark,solid curve)and for infants (dashed curve).Note that only a small proportion of the population receives the target dose from tap water and that a large proportion of infants receive a dose considerably higher than the target dose.Graph constructed from data in EPA(woo). Agencies of the U.S. federal government, taking into account information that documents the adverse effects of human consumption of large doses of fluoride, have issued regulations and recommendations on the concentrations of fluoride ion in drinking water. The U.S. Environmental Protection Agency (EPA) has set a maximum contaminant level(MCL) for fluoride at 4 ppm and a secondary maximum contaminant level(SMCL) of 2 ppm (to provide a margin of safety against development of fluorosis from exposure to fluoride in drinking water—see Chapter 7). In 1962 the U.S. Public Health Service adopted standards that call for fluoride concentrations between 0.7 ppm and 1.2 ppm in public water supplies that have been"artificially fluoridated" or have"adjusted"levels of fluoride. This range of concentrations was selected based on estimates of water consumption that take into account differences based on climate and the assumption that people in warmer climates drink more tap water than do residents in cooler climates. In January 2011,just as the Fairbanks task force was finalizing the first draft of its report and recommendations,two federal agencies initiated formal processes to change policy and regulations related to fluoride exposure. In early January, the secretary of the U.S. Department of Health and Human Services (HHS) issued.a notice that HHS was seeking public comment on a proposed new recommendation that communities that are fluoridating or choose to fluoridate their public water Fairbanks Fluoride Task Force Report 19 supplies adjust the fluoride concentration to 0.7 ppm(http://www.hhs.gov/news/press/2011pres/01/ pre_pub_frn_fluoride.html). This recommendation is based on the considerations that(1) scientific evidence indicates that water fluoridation is effective in preventing dental caries, (2) fluoride in drinking water is now just one of several sources of fluoride, (3) the prevalence and severity of dental fluorosis has increased in recent years, and (4) the water consumption of children and adolescents is independent of ambient temperatures. At this writing, the HHS action is limited to initiating the public comment period and does not constitute a formal change in the HHS recommendation. A few weeks later, the EPA initiated a"Registration Review" of the pesticide sulfuryl fluoride.This chemical, used for controlling insect pests in a variety of stored agricultural products, breaks down during application to release fluoride ions.Although the fluoride residue from sulfuryl fluoride contributes negligibly to the fluoride exposure of individual humans, this proposal is based on the EPA's assessment that"aggregate fluoride exposure is too high for certain identifiable subpopulations in the United States,in particular children under the age of seven who live in areas with higher fluoride concentrations in drinking water resulting from natural background sources" (EPA,2011; Office of Pesticide Programs,2011). Under the Federal Food, Drug, and Cosmetic Act, EPA must withdraw sulfuryl fluoride under these circumstances, and the action initiated at this point(invitation for public comment) is the first step in the withdrawal process. The exposure of a given individual in the Fairbanks area to fluoride from drinking water is very difficult to assess because of the various sources of drinking water available in the area. However, for the purposes of this report,we will focus on individuals who are served by the Golden Heart Utilities water system. This distribution includes about 30,000 people (approximately 6,500 hookups) in the city of Fairbanks and an additional 10,000 to 25,000 individuals (approximately 2,200 hookups, including several water delivery services) in the surrounding area served by College Utilities. Until January of 2011 the drinking water supplied to these individuals contained, on average, 1.0 ppm fluoride. The GHU records examined by the task force demonstrated that over an extended period of time, the range of fluoride concentration in the distributed water was from 0.8 to 1.1 ppm.The variability in the concentration of fluoride was probably due to measurement uncertainties and to the fluctuation in fluoride concentration in the feed water for the GHU process—averaging 0.3 ppm but ranging from 0.2 to 0.4 ppm (Fig. 5.2). In response to the HHS action described in the previous paragraph, in January of 2011 GHU reduced the concentration of fluoride in distributed water from 1.0 ppm to 0.7 ppm.Thus the GHU fluoridation,process presently raises the fluoride concentration from about 0.3 ppm in the groundwater to 0.7 ppm in the distributed water. The process used by GHU to produce water containing 0.7 ppm fluoride is one of the two most common approaches used elsewhere in the United States.A calculated amount of sodium fluorosilicate (SFS) is added to the raw water in a rather sophisticated treatment process. The SFS originates at KC Industries in Mulberry, Florida,where it is manufactured and purified as a byproduct from the domestic phosphate fertilizer industry. Each lot of SFS is analyzed and verified as meeting or exceeding American Water Works Association standards of purity before it is shipped. The material used by GHU is shipped from Florida by truck and container ship to Univar in Anchorage then,by truck to Fairbanks. Univar has on record the certificates of assurance for the purity of each lot of SFS that it receives (R. Holland,personal communication).A member of the Fairbanks Fluoride Task Force conducted a laboratory analysis of a sample of SFS provided by GHU and found it to be impressively pure (Table 5.1) relative to typical laboratory chemicals.When used in the fluoridation Fairbanks Fluoride Task Force Report 20 process, the calculated concentrations of metal ions added from the SFS are in the parts per trillion range,well below limits set by the EPA.While there are no guarantees against accidents in which fluoride levels in distributed water could rise to a dangerous point, the GHU fluoridation process is well run and has controls in place to provide a high level of assurance of safe operation. Each year since 2006 GHU has received a"Water Fluoridation Quality Award"from the Alaska Oral Health Program (Alaska Division of Public Health). The fluoride concentration in drinking water is measured three times each day, and the concentrations of eleven metals and radionuclides are analyzed on schedules that range from every three to nine years. Table 5.1a.Major elemental components of a random sample of KC Industries'sodium fluorosilicate° Element Weight% Element Weight% Silicon 14.8 Fluorine 60.3 Sodium 24.9 Chlorine 0.24 Table 5.113.Trace elements in a random sample of KC Industries'sodium fluorosilicate° Element ppm Element ppm Aluminum 25 Arsenic <4 Barium <5 Bromine 132 Cobalt <1 Chromium <1 Copper <5 Iron 35 Iodine 35 Nickel <2 Phosphorous 34 Lead <1 Antimony <5 Thorium <0.5 Vanadium <1 Tungsten <2 Zinc <2 Table 5.1c.Approximate concentrations of elements added to Fairbanks water after the fluoride concentration has been adjusted to 0.7 ppm Element ppm Element ppm Silicon o.1 Fluorine 0.4 Sodium 0.2 Chlorine 0.002 Element pptb Element pptb Aluminum 21 Arsenic <4 Barium <4 Bromine 11 Cobalt <1 Chromium <1 Copper <4 Iron 28 Iodine 28 Nickel <1 Phosphorous 28 Lead <1 Antimony <4 Thorium <0.4 Vanadium <1 Tungsten <1 Zinc <2 a.Analysis by XRF at the University of Alaska Fairbanks,Advanced Instrumentation Lab;R.Newberry,analyst b.ppt=parts per trillion Fairbanks Fluoride Task Force Report 21 Exposure of individuals to fluoride from dental products was not an issue when fluoridation of public water supplies was first introduced in the 1940s. Fluoridated toothpaste became commercially available in 1955, and it rapidly became widely accepted as an agent for caries prevention. However, inadvertent intake of fluoride from toothpaste can be a problem, especially with children who may have poor control of the swallowing reflex. Detailed studies of fluoride ingested by children from swallowing toothpaste have led to ingestion estimates ranging from 0.1 to 0.4 mg per brushing (Ophaug et al., 1985; Levy and Zarei-M. 1991; Rojas-Sanchez et al., 1999). A USPHS report (Institute of Medicine,2000) summarized the findings by concluding that an average of about 0.3 mg of fluoride is introduced with each episode of tooth brushing in young children.Additional, and highly variable, amounts of fluoride may be ingested by individuals who take fluoride supplements (e.g., drops) or receive topical fluoride application by dental professionals. Many foods and beverages contain detectable amounts of fluoride. The USDA National Fluoride Database on the fluoride content of a wide range of beverages and foods (USDA, 2004) contains an extensive list. Some representative entries from the USDA database are displayed in Table 5.2. Table 5.2.Fluoride concentrations in selected foods and beverages available in the United States.Adapted from USDA National Fluoride Database of Selected Beverages and Foods(2004)and Lalumandier and Ayers(2000). Food or Beverage Mean(ppm) Standard Deviation Range(ppm) Dairy Products 0.25 0.38 0.02-0.82 Grain and Cereals 0.42 0.40 0.08-2.01 Potatoes 0.49 0.26 0.210-0.84 Leafy Vegetables 0.27 0.25 0.21-0.84 Fruits 0.06 0.03 0.02-0.08 Sugar and 0.28 0.27 0.02-0.78 Substitutes Tea(brewed) 3.7 0.6 2.6-5.3 Soda Pop or Cola 0.5 0.1 0.05-0.8 Bottled Water' NA NA 0.02-0.94 a.An analysis of bottled water available in Scotland found some European bottled waters to contain nearly 6 ppm(MacFayden et al.,1982). Part of the variation in fluoride concentrations in foods reflects differences in plant metabolism (for example, tea leaves seem to sequester higher concentrations of fluoride than do the leaves of lettuce or kale). However, one notable aspect of the range of fluoride concentrations in prepared foods is what is called the"halo effect"-the result of the use of fluoridated water to prepare foods and beverages (Griffin et al.,2001).Thus, the fluoride content of processed foods and beverages reflects, in large part, the fluoride concentrations in the water used in their processing. While the halo effect is manifested in a variety of products,perhaps the most obvious is bottled water, a product of special interest to residents of communities with fluoridated water supplies because it provides an alternative to tap water. The fluoride content of bottled water is regulated by law(see National Research Council, 2006), and it can contain up to 2.4 ppm fluoride with no requirement for a statement of fluoride content on the label,unless fluoride has been added. The large range of Fairbanks Fluoride Task Force Report 22 allowable concentrations of fluoride and the lack of a requirement for notification of fluoride content clearly compromises the utility of bottled water (as opposed to distilled water) as an alternative to fluoridated community water. A final source of fluoride, or at least fluorine in some form, is from the air.This is largely due to trace amounts of pesticides and other industrial chemicals in the atmosphere. For the most part the fluoridated substances in the air are organic fluorides (as are some medications such as Prozac and Ciprofloxacin) rather than the fluoride ion found in water, dental products,foods, and beverages. Although our knowledge of the fate of fluorine from organic fluorides as the result of metabolism in the human body is very limited, it seems unlikely that the"fluoride"that comes from atmospheric sources adds significantly to the fluoride ion burden in humans. Various estimates of the total fluoride exposure of individuals in the United States have been made, but the most comprehensive.effort is probably that of an NRC committee (National Research Council, 2006).Tables 5.3 through 5.5,below,were constructed by the Fairbanks Fluoride Task Force from data in that report.The NRC committee's estimates of fluoride exposure from water were based on estimates of water consumption (EPA, 2000),which had been used in many of the studies considered by the committee. Because updated estimates of water consumption are now available (EPA,2004), the task force substituted the updated estimates of water consumption and repeated the calculations used to construct Tables 5.3 through 5.5. The results are displayed in Tables 5.6 through 5.8. Table 5.3.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with 1.0 ppm fluoride, based on water intakes estimated in NRC(2006) Population water' toothpasteb background foodb pesticides&airb total exposure' %from water Nursing infant .026o .0046 .0019 .033 79 Non-nursing Infant .o86o .0114 .0019 .099 87 1-2 year old .0314 , .0115 .0210 .0020 .066 48 3-5 year old .0292 .0114 .0181 .0012 .060 49 6-12 year old .0202 .0075 .0123 .0007 .041 49 13-19 year old .0152 .0033 .0097 .0007 .029 52 20-49 year old .0196 .0014 .0114 .0006 .033 59 5o+year old .0208 .0014 .0102 .0006 .033 63 a.Assuming all water,tap plus other,at 1.0 ppm b.NRC(2006),Table 2-9 c.NRC(2006),Table 2-11 Fairbanks Fluoride Task Force Report 23 Table 5.4.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with 0.7 ppm fluoride, based on water intakes estimated in NRC(2006) Population water' toothpasteb background foodb pesticides&airb total exposure' %from water Nursing infant .0182 .0046 .0019 .025 73 Non-nursing Infant .0602 .0114 .0019 .074 81 1-2 year old .0220 .0115 .0210 .0020 .056 39 3-5 year old .0204 .0114 .0181 .0012 .051 40 6-12 year old .0141 .0075 .0123 .0007 .035 40 13-19 year old .o1o6 .0033 .0097 .0007 .024 44 20-49 year old .0138 .0014 .0114 .0006 .027 51 5o+year old .0146 .0014 .0102 .0006 .027 54 a.Calculated from Table 5.3,assuming all water,tap plus other,at o.7ppm NRC(2006) b.NRC(2006),Table 2-9 c.NRC(2006),Table 2-11 Table 5.5.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with o.3 ppm fluoride, based on water intakes estimated in NRC(2006) Population water' toothpasteb background food" pesticides&air" total exposure' %from water Nursing infant .0078 .0046 .0019 .014 56 Non-nursing Infant .0258 .0114 .0019 .039 66 1-2 year old .0094 .0115 .0210 .0020 .044 20 3-5 year old .0088 .0114 .0181 .0012 .040 22 6-12 year old .0061 .0075 .0123 .0007 .027 23 13-19 year old .0046 .0033 .0097 .0007 .018 26 20-49 year old .0059 .0014 .0114 .0006 .019 31 5o'year old .0062 .0014 .0102 .0006 .018 34 a.Calculated from Table 5.3,assuming all water,tap plus other,at o.3Ppm b.NRC(2006),Table 2-9 c.NRC(2006),Table 2-11 Table 5.6.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with 1.0 ppm fluoride, based on water intakes estimated by EPA in 2004 Population water' toothpasteb background food" pesticides&air" total exposure %from water Nursing infant .017 .0046 .0019 .024 71 Non-nursing Infant .055 .0114 .0019 .068 81 1-2 year old .029 .0115 .0210 .0020 .064 45 3-5 year old .026 .0114 .0181 .0012 .057 46 6-12 year old .017 .0075 .0123 .0007 .038 45 13-19 year old .014 .0033 .0097 .0007 .028 5o 20-49 year old .018 .0014 .0114 .0006 .032 56 5o'year old .018 .0014 .0102 .0006 .030 6o a.Calculated from Table 5.3,assuming all water,tap plus other,at 1.oppm b.NRC(2006),Table 2-9 Fairbanks Fluoride Task Force Report 24 Table 5.7.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with 0.7 ppm fluoride, based on water intakes estimated by EPA in 2004 Population water' toothpastes background foodb pesticides&airb total exposure %from water Nursing infant .012 .0046 .0019 .019 63 Non-nursing Infant .039 .0114 .0019 .052 75 1-2 year old .020 .0115 .0210 .0020 .055 36 3-5 year old . .018 .0114 .o181 .0012 . .049 ' ' 37 6-12 year old .012 .0075 .0123 .0007 .033 36 13-19 year old .010 .0033 .0097 .0007 .024 42 20-49 year old .013 .0014 .0114 .0006 .026 50 50'year old .013 .0014 .0102 .0006 .025 52 a.Calculated from Table 5.4,assuming all water,tap plus other,at o.7ppm b.NRC(2006),Table 2-9 Table 5.8.Estimated fluoride exposure(mg/kg body weight/day)of U.S.populations on water with o.3 ppm fluoride, based on water intakes estimated by EPA in 2004 Population water' toothpaste" background food" pesticides&air" , total exposure %from water Nursing infant .0051 .0046 .0019 .012 43 Non-nursing Infant .017 .0114 .0019 .030 57 1-2 year old .0087 .0115 .0210 .0020 .043 20 3-5 year old .0078 .0114 .0181 .0012 .039 20 6-12 year old .0051 .0075 .0123 .0007 .026 20 13-19 year old .0042 .0033 .0097 .0007 .018 23 20-49 year old .0054 .0014 .0114 .0006 .019 28 5o+year old .0054 .0014 .0102 .0006 .018 3o a.Calculated from Table 5.5,assuming all water,tap plus other,at 0.3 ppm b.NRC(2006),Table 2-9 Several things must be kept in mind when interpreting the data in these tables: • The average intakes of water are based on two different estimates of water consumption (NRC, 2006; EPA,2004). The following pairs of tables allow direct comparison of the overall estimated exposures based on the differences in estimates of water intake: Tables 5.3 and 5.6,Tables 5.4 and 5.7,Tables 5.5 and 5.8. • The range of water intakes among individuals is quite large. • For simplicity of calculation,the estimated intake of fluoride from water assumes that all water has the fluoride concentration indicated in each table.This clearly is not the case for someone who uses several sources of water (for example,well, public system, and bottled) on a regular basis.This assumption, coupled with the range of fluoride concentrations in commercial bottled water, injects quite a bit of uncertainty into the results of these calculations. • The estimated amounts of fluoride ingested by individuals from toothpaste are for individuals who regularly brush twice daily with fluoridated toothpaste and whohave control over swallowing. • Estimates of intakes from food (and beverages) are really just educated guesses because of variability in diets and in the magnitude of the halo effect. Despite the limitations on the validity of the estimates of exposure, the data in the tables can be evaluated in light of recommendations made by relevant organizations of health professionals.There Fairbanks Fluoride Task Force Report 25 have been a number of recommendations through the years, and the situation is complicated by the fact that some recommendations are interms of mg per individual per day and others in terms of mg per kg per day. In the opinion of the task force, the key recommendations on fluoride are: • Adequate daily intake (Institute of Medicine, 1997): 0.0014 mg/kg/day for infants.0-6 months 0.06 mg/kg/day for infants 7-12 months 0.05 mg/kg/day for other children and all adults • Upper limits: Agency for Toxic Substances and Disease Registry(ATSDR): 0.023 mg/kg/day Environmental Protection Agency(EPA,2010): 0.06 mg/kg/day Institute of Medicine tolerable upper intake (Institute of Medicine, 1997): 0.1 mg/kg/day for newborns through age 8 0.15 mg/kg/day for ages 9 through adult The ATSDR limit (MRL, minimal risk level) is an estimate of the daily human exposure to sodium fluoride that is likely to be without appreciable risk of adverse noncancer health effects (set,in the case of sodium fluoride,by the lowest level of fluoride judged to be correlated with increased bone fracture rates and then divided by a"safety factor"of ten). The ATSDR"upper limit" of 0.023 mg/ kg/day for fluoride cited in this report takes into account the fluoride content of sodium fluoride for which the ATSDR has set an MRL of 0.05 mg/kg/day.The EPA limit ("reference dose")is based on a "no observed adverse effect level"for mottling of the teeth. The Institute of Medicine limits (tolerable upper intake limits, or UL's),which were also endorsed by the American Dental Association in 1994 and the American Dietetic Association in 2000, are set to minimize the risk of dental fluorosis but are at or near those that have been associated with mild (Institute of Medicine, 1997) or even crippling (National Research Council, 1993) skeletal fluorosis.While these upper limit recommendations have been used in formulation of a number of public health programs, the opponents of fluoridation have often critiqued and questioned the propriety of the recommendations and have called for lower limits for exposure to fluoride (see,for example, Connett et al., 2010). The problems associated with using these guidelines to develop public policy is perhaps best illustrated by the observation that the adequate daily intakes recommended by the Institute of Medicine for individuals greater than six months of age are equal to or greater than upper limits recommended by the ATSDR and the EPA. The relationships between estimated fluoride exposures of several subpopulations of Fairbanks residents consuming drinking water with 0.7 or 0.3 ppm fluoride can be analyzed with the aid of Figs. 5.4 and 5.5 (derived from Tables 5.7 and 5.8,respectively). In analyzing these data,it is important to keep in mind that the numbers represent"average"individuals and that the consumption of drinking water varies widely among individuals (Fig. 5.1).In the existing scenario (0.7 ppm fluoride in drinking water, Fig. 5.4),it is apparent that nursing infants (NI) are estimated to be exposed to daily fluoride doses well below those established by ATSDR, EPA, and IOM;those over twenty-years of age (20+YR) have exposure well below EPA and IOM upper limits and about at the limit'recommended by ATSDR. However, non-nursing infants (NNI) and one to five year-olds receive daily doses significantly above the ATSDR recommendation, marginally below that recommended by EPA, and significantly below that recommended by IOM. In contrast,while drinking water with 0.3 ppm fluoride does place non-nursing infants and one to five year-olds at risk of exceeding ATSDR upper limits, the exposure of other age groups remains below the ATSDR recommendation. Furthermore, no age group risks exposure greater than the recommended upper limits of the EPA or IOM (Fig. 5.5). Fairbanks Fluoride Task Force Report 26 0.06 o.05 >. . to - -6 Y 0.04 = E . - 'ac.?".': 0Other ' uui = -- OFood a0.03 -,,7=.2,i• ,'.. ': '.r3,.. Toothpaste X -. W !, El Water • __' - .. li 0.02 - Y rj ";i^W, - S 0.01 a- t5 �, ! - ..r ,,tom ;y, 0 .-—.. ._. U,. _ ._ NI NNI 1-2YR 3-5 YR 20+YR Population Subgroup Figure 5.4.Estimates of fluoride exposure of individuals with 0.7 ppm fluoride in drinking water(data from Table 5.7) o.o6 0.05 >' re v Y 0.04 MI . E d - ❑Other En --- -- OFood et. 0.03 X :.i ::::]::]].:-.]::: Toothpaste W N - - - --- _ DWater 73 O • 0.02 1__________ 001 - - - NI NNI 1-2YR 3-5 YR 20+YR Population Subgroup Figure 5.5.Estimates of fluoride exposure of individuals with 0.3 ppm fluoride in drinking water(data from Table 5.8). NI=nursing infant,NNI=non-nursing infant. Fairbanks Fluoride Task Force Report 27 r In addition to the officially defined upper and lower limits for exposure to fluoride, there has been a widely accepted"optimal intake"of fluoride of 0.05 to 0.07 mg/kg/day. The optimal intake was thought to be a narrow range of doses that provide protection from caries but do not cause dental fluorosis. However,recently the concept of an"optimal"intake has been called into question because of(1) the overlap in fluoride intakes of groups of children who are caries-free and groups of children diagnosed with fluorosis and(2) the high variability in individual fluoride intakes (Warren et al.,2009). Because the Fairbanks Fluoride Task Force had concerns about exposure of infants to fluoride and about the uncertainties associated with estimates of drinking water consumption,we performed some independent calculations.The results of the calculations for infants are displayed in Table 5.9.While the values in Table 5.9 are not identical with corresponding entries in Tables 5.3 through 5.5, the task force judges that they are sufficiently consistent, given the uncertainties and assumptions involved. Table 5.9.Average fluoride intake per day by non-nursing infants(mg/kg/day) Age I ppm F in water 0.7 ppm F in water 0.3 ppm F in water upper limit Birth 0.164 0.115 0.049 0.023,'0.10b 1 mo. 0.161 0.113 0.048 0.023,a0.1ob 2 mo. ; 0.179 0.125 0.054 0.023,a0.10b 4 mo. 0.130 0.091 0.039 0.023,a0.10b 8 mo. 0.089 0.064 0.027 0.023,'0.10b 10 mo. 0.070 0.049 0.021 0.023,'0.10b 12 mo. 0.065 0.045 0.019 0.023,'0.10b a.ATSDR b.IOM(1997) Findings 1. The problematic relationship between fluoride concentration in drinking water and"fluoride dose," due to varying amounts of water consumed by individuals and to other sources of ingested fluoride, severely complicates attempts to determine both health risks and benefits associated with 0.7 ppm fluoride in drinking water. In particular, commonly available foods and beverages contain from high (greater than 2 ppm) to negligible levels of fluoride, and fluoridated toothpaste is variably used and swallowed.We believe that these factors grossly complicate interpretation of drinking water studies and explain why the numerous studies conducted have come to a variety of conclusions that, in some cases, are quite different. 2. The concentration of fluoride in raw Fairbanks city water averages 0.3 ppm and is adjusted to 0.7 ppm in the treatment process. Because removing the fluoride from the raw water is impractical, the City of Fairbanks does not seem to have a realistic option for"fluoride free" city water(for a discussion of fluoride-removal processes see Fawell et al., 2006).Whatever benefits and detriments are caused by fluoride in drinking water will continue to a smaller degree if Fairbanks city water is no longer fluoridated. 3. Fluoride concentrations in Fairbanks area well water vary from 0.1 to greater than 1.0 ppm. Thus, some well water in the Fairbanks area contains more fluoride than fluoridated city water. Fairbanks Fluoride Task Force Report 28 4. Fluoridation of Fairbanks city water has ramifications throughout the surrounding area because of the distribution of GHU water by College Utilities and several suppliers of trucked water. 5. The practice of fluoridation as carried out in Fairbanks has sufficient safeguards to protect public health beyond whatever health effects are associated with 0.7 ppm fluoride. The chemical employed is of sufficient purity and the manner in which it is added and monitored meets or exceeds standard practices. 6. An analysis of the estimates in Tables 5.3 through 5.8 and Figures 5.4 and 5.5 indicates that two segments of the Fairbanks area population must be considered separately with respect to professional recommendations on upper limits of fluoride exposure: (1) the average consumer of GHU water(fluoride concentration of 0.7 ppm)who is greater than five years of age is projected to consume less than the daily upper limits set by the EPA and IOM and just about at the upper limit set by ATSDR, and (2) children less than six years of age (with the exception of nursing infants) are projected to have total fluoride exposures that remain below the upper limits set by TOM and EPA but exceed those of ATSDR. It appears that drinking water with a fluoride concentration of 0.3 ppm would bring total fluoride exposure for those over 20 years of age well below even the most stringent of the recommendations of upper limits (ATSDR) and would significantly reduce concerns about overexposure of infants and young children. However, due to the tremendous variability in amount of drinking water consumed by individuals, the fluoride exposures of significant portions of the population are not adequately represented by the average values. 7. Nevertheless,the estimates of Table 5.9 highlight additional concerns about fluoride exposure of non-nursing infants in their first year. The use of fluoridated water to make up infant formula leads to levels of fluoride consumption that exceed recommended upper limits.While the magnitude of the problem obviously declines with a decline in fluoride concentration in the water used to make up formula, the most conservative of the upper limits of fluoride exposure would be approached or exceeded even when using GHU well water(fluoride concentration averaging 0.3 ppm) to which no fluoride has been added.While bottled water would seem to be the water of choice, the data of Table 5.2 indicate that not all bottled waters available in the United States would provide this level of protection. The use of bottled water for this purpose is further complicated by the absence of information about fluoride content on the labels of most bottled water.The only certainty for consumers seems to be that the distilled water sold in supermarkets has an undetectable concentration of fluoride. Fairbanks Fluoride Task Force Report 29 Efficacy of Community‘Water Fluoridation. 4 ; Evaluation of Efficacy Before 2000 The addition of fluoride was effective in reducing caries in those municipalities that were the subject of reports in the primary dental literature during the mid-twentieth century. The Ft. Collins report gives the historical background that led to widespread fluoridation of public water systems: In 1901, a Colorado Springs dentist recognized that his patients with teeth with a brown stain or mottled dental enamel also had a very low prevalence of cavities(also called caries) (Centers for Disease Control and Prevention [CDC], 1999b).At this time in history,extensive dental caries were common, so this observation and its subsequent correlation with high amounts of fluoride ion in the water supply(2.0-12.0 milligrams per liter, mg/L)proved to be significant.Another dentist, H.T.Dean,DDS,took this information and conducted a survey of dental caries in relation to natural concentrations of fluoride in drinking water of 21 U.S. cities(Committee to Coordinate Environmental Health and Related Programs,USPHS [USPHS], 1991,pp. 18-19; CDC, 1999a,p. 934).Dean observed that at a concentration of 1 mg/L,fluoride would significantly reduce caries while causing a low incidence of mottled enamel, now called fluorosis, of the mostly very mild type.Beginning in 1945 and 1946,community trials were conducted over 13-15 years in four pairs of cities in the U.S. and Canada.These studies found a 50-70% reduction of caries in children following addition of fluoride(in the form of sodium fluoride) to community water supplies at 1 mg/L.The incidence of mild fluorosis remained low(CDC, 1999a,p. 936). Some of the early studies were criticized for lacking appropriate controls, not applying randomization,and not controlling for potential examiner bias (Sutton, 1960). However, the large effect sizes in these trials,along with replication of these findings in subsequent studies, led to the acceptance of community water fluoridation as a public health approach to caries prevention. (Fluoride Technical Study Group,2003) Many reviews and meta-analyses,which combine the results of several studies that address a set of related research hypotheses, support the hypothesis that water fluoridation reduces the incidence of caries.The York Report(McDonagh et al., 2000) is a systematic review made to assess the evidence of the positive and negative effects of population-wide drinking water fluoridation strategies to prevent caries. It is a summary of 254 studies published from the mid-1960s to mid-1999,which were chosen for relevance from over 3,000 studies identified in the literature. The authors of the York Report identified five objectives to make their assessment. Their first objective was to answer the question: "What are the effects of fluoridation of drinking water supplies on the incidence of caries?" Of the 254 studies, twenty-six were relevant to this question. They are optimistic about the caries reductions caused by water fluoridation,yet cautious. The best available evidence suggests that fluoridation of drinking water supplies does reduce caries prevalence,both as measured by the proportion of children who are caries free and by Fairbanks Fluoride Task Force Report 30 the mean change in dmft/DMFT score.The studies were of moderate quality(level B),but of limited quantity.The degree to which caries is reduced,however,is not clear from the data available.The range of the mean difference in the proportion(%) of caries-free children is—5.0 to 64%,with a median of 14.6%. . . .The range of mean change in dmft/DMFT score was from 0.5 to 4.4,with a median of 2.25 teeth. . . .It is estimated that a median of six people need to receive fluoridated water for one extra person to be caries-free. . . .'The best available evidence from studies following withdrawal of water fluoridation indicates that caries prevalence increases, approaching the level of the low fluoride group.Again,however,the studies were of moderate quality(level B), and limited quantity.The estimates of effect could be biased due to poor adjustment for the effects of potential confounding factors. (McDonagh et al.,2000,p.xii) Their second objective was to answer the question: "If water fluoridation is shown to have beneficial effects,what is the effect over and above that offered by the use of alternative interventions and strategies?" Of the 254 studies, nine conducted after 1974 were relevant to this question. Again, their summary statement is positive toward the extra benefits of water fluoridation in the presence of other sources of fluoride: In those studies completed after 1974, a beneficial effect of water fluoridation was still evident in spite of the assumed exposure to non-water fluoride in the populations studied.The meta- regression conducted for Objective 1 confirmed this finding. (McDonagh et al.,2000,p.xii). A summary of observed effects of fluoridation on caries in children is presented in Figs. 6.1 and 6.2 (McDonagh et al.,2000, pp. 12-13). An examination of twenty-one studies, half of which were published between 1990 and 2000, came to a similar conclusion, although without as many caveats: "According to Community Guide rules of evidence, strong evidence shows that CWF(community water fluoridation) is effective in reducing the cumulative experience of dental caries within communities" (Truman et al.,2002, p. 28; see http:// wwwthecommunityguide.org/index.html for more about Community Guide). A meta-analysis of twenty studies concluded that fluoride prevents caries among adults of all ages (Griffin et al., 2007). Some details are worth noting.Water fluoridation was responsible for preventing 27%of the caries. Self- and professionally applied topical fluoride was responsible for the remaining 73%reduction. For studies published after 1980, fluoride from all sources annually averted 0.29 carious coronal and 0.22 carious root surfaces per person.The authors point out the value of all types of fluoride for low-income adults and the elderly,who may not be receiving routine dental care. Note that the York Report(McDonagh et al.,2000) does not support this conclusion. An epidemiological study in the United Kingdom addressed the question of differences in effect of water fluoridation over a range of socioeconomic groups (Riley et al., 1999).They conclude that water fluoridation reduced dental caries more in materially deprived wards than in affluent wards. In addition, the introduction of community water fluoridation substantially reduced inequalities in dental health. This conclusion is supported to an extent in the York Report(McDonagh et al.,2000,p.xii), although with considerable caution due to the low quality of the evidence and the general lack of variance Fairbanks Fluoride Task Force Report 31 Adriasola(1959) Ast(1951) Beal(1971) :.-- Beal(1981) DHSS(1969)Scotland DHSS(1969)Wales DHSS(1969)England Gray(1999) Guo(1984) Kunzel(1997) Adriasola(1959) ,Beal(1981) Beal(1981) DHSS(1969) ;ar� '..m.r.;, Guo(1984) Guo(1984) Kunzel(1997) Kunzel(1997) =� Adriasola(1959) Beal(1981) DHSS(1969)England - s DHSS(1969)Wales Guo(1984) Kunzel(1,997) DHSS(1969)England 1:4 ° -=p' '1 DHSS(1969)Wales : l Guo(1984) >4= Kunzel(1997) Brown(1965) --=-°1 Brown(1965) 1 -20 0 20 40 60 80 Favours non-fluoridated Favours fluoridated O 5 year olds n 8 year olds 0 12 year olds ® 15 year olds IN 9-12 year olds IN 12-14 year olds Figure 6.1.The mean difference of the change in the proportion(Z)of caries-free children in the exposed(fluoride)group compared with the control group(low fluoride),for all ages extracted(color coded by age),for studies in which fluoridation was initiated after the baseline survey(McDonagh et al.,2000,p.12) Fairbanks Fluoride Task Force Report 32 Beal(1981) Guo(1984) Kunzel(1997) Beal(1981) Beal(1981) Guo(1984) Guo(1984) Kunzel(1997) T Kunzel(1997) Beal(1981) Guo(1984) Kunzel(1997) Guo(1984) Kunzel(1997) Brown(1965) Brown(1965) -1 0 1 3 5 Favours non-fluoridated Favours fluoridated El 5 year olds El 8 year olds 0 12 year olds IN 15 year olds 0 9-12 year olds ll 12-14 year olds Figure 6.2.Change in dmft/DMFT Score(mean difference and 95%Cl)(McDonagh et al.,2000,p.13) Fairbanks Fluoride Task Force Report 33 estimates in the fifteen studies.To objective 3, "Does water fluoridation result in a reduction of caries across social groups and between geographical locations, bringing equity?", their response was There appears to be some evidence that water fluoridation reduces the inequalities in dental health across social classes in 5 and 12 year-olds,using the dmft/DMFT measure.This effect was not seen in the proportion of caries-free children among 5 year-olds.The data for the effects in children of other ages did not show an effect.The small quantity of studies, differences between these studies, and their low quality rating, suggest caution in interpreting these results. McDonagh et al.,2000,p.xii) It is apparently difficult to design and execute good studies to test the hypothesis that fluoridation of public water systems decreases the incidence of caries. Questions have been raised on a regular basis about the design and analysis of studies investigating the efficacy of municipal water fluoridation for the reduction of caries incidence. Concerns about experimental design and examiner bias were raised long ago (Sutton, 1960). The York Report(McDonagh et al., 2000), a meta-analysis of 214 studies published before 2000, presented relatively positive results for efficacy,with many caveats. In particular, they note the general lack of analysis, lack of control for potentially confounding factors, and the lack of any measure of variance for the estimates of decay. The difficulties of an accurate analysis and interpretation of data from a large and carefully designed longitudinal trial have been pointed out,with the observation made that"our analysis shows no convincing effect of fluoride- intake on caries development"in the permanent first molars in children between 7 and 12 years of age (Komarek et al., 2005,p. 145). Equally important to the critical evaluation of the efficacy of water fluoridation to prevention of caries is "The Mystery of Declining Tooth Decay,"which was reported in the journal Nature(Diesendorf, 1986). He notes in summary that"large temporal reductions in tooth decay,which cannot be attributed to fluoridation,have been observed in both unfluoridated and fluoridated areas of at least eight developed countries over the past thirty years" (p. 125). The magnitude of the reductions observed in unfluoridated areas were generally comparable with those observed in fluoridated areas over similar periods. In his discussion of the why's of the reductions, the author emphasized the literature that suggests changes in diet, immunity, and perhaps topical fluoride exposure with time are more likely candidates than fluoridated municipal water. The magnitude of the decrease in tooth decay is demonstrated in World Health Organization data,which was put into graphical form (Fig. 6.3) for the antifluoridation Fluoride Action Network(FAN) (Osmunson,2010b). The European experience has been one of generally decreasing DMFT scores.This is reported for fluoridated regions, nonfluoridated regions, and regions where fluoridation has been discontinued. In East Germany, the introduction of water fluoridation in Spremberg and Zittau brought about caries reduction averaging 48%. Surprisingly, caries levels for the twelve-year-olds of both towns significantly decreased following the cessation of water fluoridation (Kunzel et al.,2000). In Spremberg, DMFT fell from 2.4 to 1.4 (-40 %) and in Zittau from 2.5 to 2.0 (-20%). In Tiel (The Netherlands),where water fluoridation was discontinued in 1973, DMFS scores varied somewhat less consistently. The mean DMFS score increased between 1968/1969 and 1979/1980 from 10.8 to 12.7 (+18%) and then decreased to 9.6 (-26%) in 1987/1988. Overall the mean DMFS score decreased by 11%from 1968/1969,when water was fluoridated,to 1987/1988,when the town water had been Fairbanks Fluoride Task Force Report 34 UNFLU0RIDATED Tooth Decay Trends: Fluoridated vs. Unfluoridated Countries Data from the World Health Organization,http://www.whocollab_od.mah.se/ +- Austria Graph produced by Chris Neurath,FAN --Ls-_ Belgium 9 -,k- Denmark • —..- Finland 8 -X France a• 7 - `� --0- Germany Iceland E Y 6 $-El— Italy a °' S - —A— Japan LL -n-- Netherlands nds 4 - -� -- Norway Sweden ▪ 3 - \\S\ -�- Switzerland -0- United Kingdom FLUORIDATED Australia B -0- Ireland 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 New Zealand Year _... United States Figure 6.3.Tooth decay trends internationally in countries with fluoridated vs.unfluoridated water unfluoridated for fourteen years. In Culemborg,where the water was never fluoridated, the mean DMFS score decreased from 27.7 in 1968/1969 to 7.7 in 1987/1988. 'This decrease of 72%occurred with no fluoridation of the public water supply(Kalsbeek et al., 1993). Presuming the application of existing preventive measures, the question as to whether water fluoridation would have had an additional effect if it had been continued cannot be answered,because no communities in The Netherlands now fluoridate water. Evaluation of Efficacy After z000 A recent review of community water fluoridation and caries prevention considers only recent data (Pizzo et al.,2007).Using MEDLINE as the primary database, the authors reviewed articles published from January 2001 to June 2006.They conclude that community water fluoridation is not necessary for caries prevention in modern, industrialized societies. Because the primary cariostatic action of fluoride occurs after tooth eruption, the use of topical fluoride is a more effective approach in communities where caries levels have become low. This line of thought is noted in a recent analysis published in the British Medical Journal(Cheng et al.,2007).'Ihe average number of decayed, missing, and filled teeth in twelve-year-old children in a number of European countries is near 1.5, and half of children have no cavities. There is no correlation in the downward trends with degree of Fairbanks Fluoride Task Force Report 35 • water fluoridation. Pizzo and coworkers are cautious,however, and these cautions may be germane in Fairbanks. They state that"water fluoridation may still be a relevant public health measure in populations where oral hygiene conditions are poor,lifestyle results in high caries incidence, and access to a well-functioning oral health care system is limited" (p. 192). An evaluation of three reviews culled from fifty-nine publications published between 2000 and 2008 resulted in positive support for the effectiveness of water fluoridation in prevention of dental caries (Parnell et al.,2009).Two of the reviews have been discussed previously and they include mostly older literature (McDonagh et al., 2000; Griffin et al., 2007). The third review(National Health and Medical Research Council,2007) identified one systematic review(Truman et al.,2002) and one cessation study(Seppa et al.,2000) published since the York Report(McDonagh et al., 2000). As noted above, the Truman study was strongly positive toward water fluoridation. In contrast, the Seppa study showed no evidence of increased caries when a previously fluoridated town reverted to nonfluoridated water. Parnell et al. concluded that the two new studies do not change the findings of the York Report that"the existing body of evidence strongly suggests that water fluoridation is beneficial at reducing dental caries" (p. 143). A recent, somewhat indirect, study makes an association between lack of water fluoridation and inclusion of Nevada youth in the high caries prevalence group (Ditmyer et al.,2010). For adolescents in the study group (the 30%highest DMFT scores, DMFT > 4.0),27.3%lived in a water-fluoridated community. For the control group (caries free,DMFT score = 0), 64.7%lived in a water-fluoridated community. Thus, participants living in nonfluoridated communities were almost twice as likely to be in the highest DMFT group as those living in fluoridated communities. Discussions of efficacy may sometimes revolve around the mode of action of fluoride in optimally fluoridated water. The theoretical mechanism by which fluoride prevents caries has undergone significant revision since the introduction of community water fluoridation. The original systemic theory was that fluoride had to be ingested to incorporate into tooth mineral during its development (Dean et al., 1942). By the 1970s, doubts emerged regarding the exclusively pre-eruptive effect of fluoride. Numerous clinical studies suggested that fluoride action is predominantly post-eruptive (topical).While there are conflicting results, most recent epidemiological and laboratory studies indicate that topical application of fluoride plays the dominant role in caries prevention (CDC 2001; Hellwig and Lennon,2004). Fluoride's effect depends on its being in the right amount in the right place at the right time. It works primarily after teeth have erupted, especially when small amounts are maintained constantly in the mouth, specifically in dental plaque and saliva.The fluoride in saliva aids in enamel remineralization in enamel lesions by inducing apatite formation from calcium and phosphate ions present in saliva (Fejerskov et al., 1981). The effectiveness of toothpaste in decreasing the prevalence of caries is particularly clear.When introduced into the mouth, fluoride in toothpaste is taken up directly by dental plaque and demineralized enamel. Brushing with fluoride toothpaste increases the fluoride concentration in saliva 100- to 1,000-fold for one to two hours. Some of this salivary fluoride is taken up by dental plaque. The ambient fluoride concentration in saliva and plaque can increase during regular use of fluoride toothpaste (CDC, 2001). Fairbanks Fluoride Task Force Report 36 In its recommendations, the CDC (2001) makes a strong argument supporting the topical mode of action in caries prevention. That said, they report that people living in communities with optimally fluoridated water who also use topical fluoride on a regular basis have a lower incidence of caries than people who use only optimally fluoridated drinking water or who only use topical fluoride. Thus the mode of action has been established in the modern literature as predominantly topical.Yet the epidemiological evidence, at least as reported a decade ago by CDC, still shows an empirical effect for fluoride in drinking water. Drinking fluoridated water prevents caries. When fluoridated water is the main source of drinking water,a low concentration of fluoride is routinely introduced into the mouth. Some of this fluoride is taken up by dental plaque; some is transiently present in saliva,which serves as a reservoir for plaque fluoride; and some is loosely held on the enamel surfaces.Frequent consumption of fluoridated drinking water and beverages and food processed in fluoridated areas maintains the concentration of fluoride in the mouth. (CDC 2001) Thus, although the mode of action for fluoride in drinking water was initially thought to be systemic, its true action is predominantly topical in caries prevention, as is the action of the fluoride present in toothpaste, supplements, mouth rinse, and professionally applied gels and varnishes. Publications and a federal proposal made even in the past year show that the jury is very much'out' with respect to questions about the efficacy of community water fluoridation at 1 ppm fluoride and about the benefit-to-risk assessment. • A proponent of community water fluoridation has recently written of the existing uncertainties associated with the efficacy of community water fluoridation (Newbrun,2010). These include the effect of reducing the concentration of fluoride below 1 ppm, the expected result of discontinuing community water fluoridation in a community, and the role of socioeconomic factors in the importance of continuing water fluoridation. • On January 7,2011, the U.S.Department of Health and Human Services (HHS) announced a proposal recommending that water systems practicing fluoridation adjust their fluoride content to 0.7 ppm, as opposed to the previous temperature-dependent optimal levels ranging from 0.7 ppm to 1.2 ppm (http://www.hhs.govinews/press/2011pres/01/20110107a.html, accessed January 27,2011). • An opponent of community water fluoridation has noted the 15%difference in the proportion of caries-free children reported in the York Report and the 20%to 40%reduction in tooth decay reported by the American Dental Association (Thiessen, 2009a). She has no apparent objection to the numerical accuracy. However, she does put these values in context: "which would translate to < 1 decayed, missing, or filled permanent tooth (DMFT) in older children and adolescents (based on U.S. data from CDC 2005). Is this adequate justification for imposing inadequately characterized risks?" (Thiessen,2009a,p. 3). Findings 1. There has never been a double blind, randomized, long-term study of the effectiveness of community water fluoridation on decreasing the incidence of caries. Nor has there been a comparable study on the effect of discontinuing water fluoridation on the incidence of caries. Fairbanks Fluoride Task Force Report 37 2. The degree of caries reduction due to community water fluoridation was large and significant in the first decades that it was done. In recent decades, the degree of caries reduction attributed to community water fluoridation has decreased as other sources of fluoride have come into common use and as effective dental health measures have become more prevalent. The relative importance of water fluoridation is currently much smaller, more variable among populations, and perhaps unknowable. 3. The problematic relationship between fluoride concentration in drinking water and"fluoride dose" (due to varying amounts of water consumed by individuals and to other sources of ingested fluoride) severely complicates attempts to determine both health risks and benefits associated with 1 ppm fluoride in drinking water. In particular, at this time commonly available foods and beverages range from high (greater than 2 ppm) to negligible fluoride content, and fluoridated toothpaste is variably swallowed.We believe that these factors grossly complicate interpretation of drinking water studies and explain why the numerous studies conducted have come to a variety of different conclusions: 4. Studies of the relative effectiveness of community water fluoridation among socioeconomic groups give contradictory results. Dietary habits, dental hygiene, and intervention by health/dental providers are independent factors that confound the investigation of the efficacy of fluoridation of water on caries prevalence. Fairbanks Fluoride Task Force Report 38 Chapter 7 x Adverse Effects . • Introduction ,. Fluoride can clearly lead to adverse health effects in humans. However, as for most chemicals, the dose that one is exposed to is a critical factor in determining the effect(s). For example, many drugs with therapeutic benefit are toxic at higher-than-recommended doses. Further, some drugs may have a very narrow window of therapeutic benefit. That is, the dose at which the drug provides benefit may be only slightly lower than the dose leading to ill effects.We focused primarily on studies that examined the effects on humans of drinking water with fluoride concentrations of less than 2 ppm (or 2 mg/L). In Fairbanks (Golden Heart Utilities), the water is fluoridated to a concentration of 0.7 ppm.One challenge in understanding possible adverse effects is that, depending on water consumption and other possible sources of fluoride exposure (such as toothpaste or heavy tea consumption),individuals may be exposed to widely different doses of fluoride. Another challenge is that the average expected dose may also vary by age (an infant receiving most nutrition from formula reconstituted with fluoridated water vs. an infant who is breast fed),health (for example,patients with kidney problems vs. people with normal kidney function), or other confounding factors. In this section we rely heavily on several comprehensive review studies. Notably,we frequently cite the 2006 National Research Council(NRC) report by the Committee on Fluoride in Drinking Water, Fluoride in Drinking Water:A Scientific Review of EPA's Standards. Although the purpose of this well- researched report was to determine if the Environmental Protection Agency's drinking water standard of 4 ppm maximum allowable concentration for fluoride protects the public from harmful effects of fluoride, the report also provides valuable information about possible effects of drinking water containing lower concentrations of fluoride,such as those found in Golden Heart Utilities water. We supplemented information from this report with other comprehensive reviews and with refereed literature,particularly those papers published since the NRC report came out in 2006. • Dental Fluorosis Dental fluorosis,a mottling and/or pitting of the tooth surface due to fluoride exposure, develops in children during tooth formation when exposure to excess fluoride leads to disruption of the crystalline-enamel structure. Fluoride has a strong affinity for developing pre-eruptive enamel,leading to integration of fluoride into the crystal lattice.Teeth appear to be most susceptible to fluorosis at early maturation stages,which vary for different tooth types. For example, central incisors of the upper jaw are most susceptible at age 15 to 24 months for boys and age 21 to 30 months for girls (Fluoride Recommendations Work Group, 2001). Infants primarily ingesting formula reconstituted with fluoridated water, even at concentrations recommended for municipal systems, may receive doses of fluoride that could lead to more than mild fluorosis or possibly other adverse health effects from fluoride. For example, a recent study(Levy et Fairbanks Fluoride Task Force Report 39 al.,2010) found that participants with fluorosis of permanent incisors (generally rated as mild) had significantly greater intake of fluoride from reconstituted powdered infant formula or other beverages with added water than those without fluorosis. The clinical implication suggested by the authors is that avoiding ingestion of formula or other drinks mixed with fluoridated water can reduce the likelihood of fluorosis. Due to the increased risk of fluorosis for non-nursing infants, in 2007 the American Dental Association (ADA) made an interim recommendation that infant formula be reconstituted with water that is fluoride-free or containing low levels of fluoride (ADA, http://www.ada.org/1767.aspx). In January 2011, the ADA rescinded the interim recommendation and issued a new recommendation based on research by the ADA's Council on Scientific Affairs (Berg et al.,2011). The new recommendations"for infants who consume reconstituted infant formula as the main source of nutrition"are (1) "Continue use of liquid or powdered concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risk for enamel fluorosis" and (2) "Use ready-to-feed formula or liquid or powdered concentrate formula reconstituted with water that is either fluoride-free or has low concentrations of fluoride when the potential risk for enamel fluorosis is a concern."These"evidence-based"recommendations were ranked by the ADA as being"based on lower levels of evidence" (ADA, http://ebd.ada.org/contentdocs/ADA_Evidence- based_Infant_Formula_Chairside_Guide.pdf). The results of fluoride exposure on developing teeth range from mild discoloration to highly stained and pitted teeth, depending on the concentration of fluoride and to a certain degree the susceptibility of the individual (NRC,2006; Fagin,2008). Severe enamel fluorosis characterized by pitting results in teeth that are very susceptible to dental caries. Severe fluorosis is estimated to occur at a rate of about 10%among children drinking water at the current EPA maximum allowable fluoride concentration (4 ppm) (NRC,2006).The incidence of severe dental fluorosis is near zero where fluoride in water is below 2 ppm (NRC,2006). But fluoride ingestion at levels commonly used to fluoridate water(1 ppm) can lead to mild to moderate levels of fluorosis. In its mildest form, fluorosis leads to opaque areas on the teeth. Estimates in the literature on the incidence of fluorosis vary,but it can be expected that at least 30%of school-aged children who consume water with between 0.7 and 1.2 ppm fluoride will have very mild or more severe dental fluorosis (Heller et al., 1997).A more recent study reported that the incidence of fluorosis has increased since the 1980s, and an analysis of data from 1999 to 2004 found that the prevalence of dental fluorosis in adolescents aged 12 to 15 is 41% (Centers for Disease Control and Prevention,2010b).This condition has not been linked to other adverse health effects (Fagin,2008). However, even mild fluorosis is considered by some to be of cosmetic concern. Since fluorosis cannot be reversed, treatment requires costly cosmetic dentistry where teeth are coated to hide the effects. For slightly older children(16 to 36 months), fluorosis risk increases with higher fluoridated toothpaste ingestion.To avoid fluorosis,it is recommended that ingestion of toothpaste should be reduced through parental supervision and using only a small smear of toothpaste when brushing(Levy et al.,2010). There are challenges to determining the relationship between fluorosis and dental caries. One challenge is consistent diagnosis of mild dental fluorosis,which is subjectively rated using various rating scales. Another challenge is that there is some evidence that fluoride delays the eruption of permanent teeth, thus affecting studies comparing caries rates in children of different age groups Fairbanks Fluoride Task Force Report 40 exposed to varying fluoride concentrations (NRC,2006).A final challenge that affects all studies linking water fluoridation to both positive and negative health effects is that the concentration in water can lead to widely different individual doses, depending on water consumption and exposure to other sources of fluoride. Bone Effects and Skeletal Fluorosis Since about 50%of ingested fluoride not excreted is deposited in bone, and 99%of the fluoride in a human body is contained in the skeleton (cited in Bassin et al.,2006), a number of studies have examined the effects of fluoride on bone. Ingestion of fluoride at very high concentrations results in thickened bone and can lead to bone deformities (skeletal fluorosis). Debilitating skeletal fluorosis is rare in the U.S. (NRC,2006), and there is no evidence that ingestion of fluoride at levels used to treat drinking water leads to significant skeletal fluorosis. However, exposure to fluoride at relatively high concentrations has been linked to an increased risk of bone fractures because fluoride incorporation, while increasing bone density, also leads to a decrease in bone strength. The Committee on Fluoride in Drinking Water(NRC,2006) found that people consuming drinking water containing 4 ppm or greater fluoride over their lifetime had an increased risk of bone fractures. However, they could not reach a conclusion about the relationship between consumption of water containing lower concentrations of fluoride and risk of bone fractures. There are a number of studies on the relationship between fluoride consumption and bone fractures. Interestingly, since fluoride is known to increase bone density, treating patients at risk of osteoporosis with fluoride was once a clinically accepted strategy. However, studies suggesting, at best, no protection against fractures and a high level of side effects have led to a decline in fluoride treatment (Vestergaard et al., 2008). Studies are confounded by factors that include the possibility that fluoride may affect different bones differently(NRC, 2006). Two comprehensive reviews of the literature have concluded that there is no clear association between hip fractures (either positive or negative) or osteoporosis and water fluoridation (McDonagh et al., 2000;Yeung, 2008). Overall, the data suggesting an increased risk of bone fractures in populations drinking fluoridated water in the concentration range recommended for drinking water are not conclusive. Cancer The potential link between fluoride and cancer, most specifically osteosarcoma, is an area of recent controversy. Since fluoride incorporates readily into developing bone and increases the proliferation of osteoblasts, it has been hypothesized that there could be a link between fluoride and osteosarcoma. Published studies have drawn different conclusions about whether or not there is a relationship, in part complicated by the relative rarity of this type of cancer. But several.studies have indicated a potential link, including a 1990 study conducted by the U.S. National Toxicology Program (Bucher et at, 1991). In this study,where rats were exposed to high levels of fluoride, there appeared to be a relationship between osteosarcoma frequency in male rats and the level of exposure to fluoride. A more recent paper by Bassin et al. (2006) on humans used a case-control approach to assess the patient history of 103 patients with osteosarcoma matched with 215 controls.The authors concluded "our exploratory analysis found an association between fluoride exposure in drinking water during Fairbanks Fluoride Task Force Report 41 childhood and the incidence of osteosarcoma among males but not consistently among females." Interestingly, Dr. Bassin's PhD supervisor, Chester Douglass,,challenged the data in a rebuttal published in the same issue of the journal that the Bassin et al. paper appeared (Douglass and Joshipura,2006). In that rebuttal he suggested that a paper was forthcoming with more extensive data that would show no link.To date, no such paper has been published. Our task force committee chair contacted Dr. Douglass by e-mail to try to get more information. Dr. Douglass was not forthcoming with information, only stating that: "A paper has been submitted to a scientific journal for publication. Thank you for your interest."A literature search in late November 2010 did not find a publication on this topic by Dr. Douglass. While the Bassin paper is intriguing, the authors admit that the results are in contrast to several other case control studies (see Bassin et al., 2006) that found no link between fluoride consumption and osteosarcoma. They were careful to outline limitations to their preliminary study, including lack of data on actual consumption of fluoride by their subjects,lack of data on other potential unidentified factors, and selection bias.The authors cautiously referred to their study as "exploratory" and urged that"further research is required to confirm or refute this observation."Unfortunately, as of 2010 it appears that no more comprehensive studies have been published that might shed light on a possible link between fluoride consumption and osteosarcoma.We find that although there may be such a link, the data published to date suggesting a link are limited and published studies are conflicting in their conclusions. This conclusion is supported by comprehensive reviews of the literature (Yeung, 2008;McDonagh et al.,2000),which both concluded that there is no clear association between water fluoridation and overall cancer incidence and mortality. Other Effects Endocrine Effects:Fluoride exposure has been shown to affect some endocrine glands and may function as an endocrine disruptor. Although fluoride is generally not thought to accumulate in soft tissues, there is evidence that it may accumulate in the thyroid where exposure can lead to decreased thyroid function.According to the NRC's Fluoride in Drinking Water report(2006), many effects of low-dose fluoride exposure may be"subclinical effects, meaning there are no adverse health effects." However, they also point out that"borderline hormonal imbalances"might lead to an increased risk of adverse health effects. Their report concluded that studies to date on the effects of fluoride on endocrine function have limitations and that further research is needed to explore the possible connections between fluoride, particularly at low doses, and endocrine function. Additional research is important since there is some indication that concentrations of fluoride in drinking water of 4 ppm or less may affect endocrine function in"young children" or in"individuals with high water intake." Neurotoxicity and Neurobehavioral Effects:A number of studies have reported changes to the nervous system following fluoride exposure that could lead to functional effects. Of the neurobehavioral studies, epidemiological studies suggesting a link between fluoride exposure and cognitive abilities are of particular interest. For example, several Chinese studies have consistently reported lower IQs in children drinking water containing 2.5 to 4 ppm fluoride (e.g., see NRC, 2006). The mechanism of the action of fluoride on IQis not clear (Tang et al., 2008) but could be related to changes in membrane lipids in brain cells or to effects of fluoride on thyroid activity. It is unclear how the Chinese studies relate to U.S. populations, since U.S. populations are generally Fairbanks Fluoride Task Force Report 42 exposed to drinking water with less than 2.5 ppm and there may be other confounding factors affecting the Chinese communities studied. Although the NRC's Fluoride in Drinking Water committee (2006) did not include neurological effects on their list of adverse effects not protected by the current EPA maximum allowable concentration for fluoride in drinking water, they did strongly advise that because of the "consistency of the results"in studies, such as those conducted on Chinese populations, additional research on the effects of fluoride on intelligence and on other neurological processes is warranted. A literature search conducted in December 2010 did not find published results that provide new information. It appears that there is reasonably good evidence that fluoride in drinking water at concentrations above 4 ppm may have neurological effects, including an effect on cognitive abilities. But the effects, if any, at lower concentrations of fluoride are not clear. Effects on Other Organ Systems: Other systems that may be affected by fluoride exposure include the gastrointestinal system, kidneys,liver, and immune system.The NRC committee (2006) found a lack of well-documented studies on humans exposed to drinking water at 4 ppm or less for all of these systems.They concluded that the risk of adverse effects was likely to be low for most individuals drinking water with fluoride at 4 ppm but that there is a possibility of adverse effects in particular subpopulations such as those with renal impairment. In an apparent response to the possibility of an increased risk of adverse health effects for renal-impaired patients, the National Kidney Foundation recently changed its position on fluoridated water from"safe"to"takes no position" and"further research is needed" (www.kidney.org/atoz/pdf/Fluoride_Intake_in_CKD.pdf). Findings 1. The problematic relationship between fluoride concentration in drinking water and"fluoride dose" (due to varying amounts of water consumed by individuals and to other sources of ingested fluoride) severely complicates attempts to determine,both health risks and benefits associated with 1 ppm fluoride in drinking water. In particular, at this time commonly available foods and beverages range from high (greater than 2 ppm) to negligible fluoride content, and fluoridated toothpaste is variably swallowed.We believe that these factors grossly complicate interpretation of drinking water studies and explain why the numerous studies conducted have come to a variety of different conclusions. 2. The only commonly agreed-upon adverse effect related to drinking water with 1 ppm fluoride is mild dental fluorosis.Although debate continues concerning the quality of the studies, there are a large number that report deleterious effects from elevated fluoride in drinking water. On the other hand, numerous communities around the world use drinking water with natural fluoride concentrations of 1 ppm with no obvious ill effects, aside from mild dental fluorosis. 3. A fluoride concentration in water of 4 ppm is not protective for several adverse effects, including bone effects. That means that at best there is only a safety factor of about six for persons drinking Fairbanks water fluoridated to 0.7 ppm. 4. Although there may be a link between fluoride and osteosarcoma, the data published to date suggesting a link are limited and published studies are conflicting in their conclusions. 5. Fluoridated water is not recommended for all consumers. Recently several organizations have expressed concern about using fluoridated water to reconstitute infant formula. Consequently,the American Dental Association has recommended that parents of infants who primarily consume Fairbanks Fluoride Task Force Report 43 reconstituted formula consult with their health care providers about the potential risks of using fluoridated water to make up infant formula.Despite those recommendations and cautions, pediatricians in the Fairbanks area(polled by committee member Dr. Medford)were not aware of these recommendations.The National Kidney Foundation has also changed its position on fluoridated water from"safe"to"takes no position"and"further research is needed." 6. Research on possible adverse effects of drinking fluoridated water(at concentrations less than 2 ppm) on the endrocrine glands, nervous system, or other organ systems has showed mixed results,with many studies showing no effects. However, studies involving extensive review of the literature (e.g.,McDonagh et al.,2000; NRC,2006) recommend that more high-quality research is warranted. . Fairbanks Fluoride Task Force Report 44 `Chapter8 Socioeconomic Issues •, .. One of the public policy arguments put forward for fluoridation of public water supplies has been that it reduces disparities in dental health among populations. 'The argument goes that, if fluoridated water reduces the incidence of caries, it seems reasonable that the availability of fluoridated water for an entire community should provide particular benefit to those with the greatest risk of developing caries.This argument has been strongly put forward by professional organizations and government officials, including former U.S. Surgeon General David Satcher who "noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations" (ADA, 2005, p. 46). For decades it has been noted that members of lower socioeconomic categories have significantly higher rates of caries than those who are more fortunate (Kozol, 1992; CDC,2010a), so fluoridation should provide particularly valuable benefits to these groups. The refereed literature contains numerous reports that support(for example, Riley et al., 1999;Jones and Worthington, 2000) and refute this proposal(for example, Bradnock et al., 1984; Carmichael et al., 1989). McDonough et al. (2000) could reach no clear consensus on whether this public policy argument is valid, and shortly thereafter Cohen and Locker(2001) concluded that there is"little evidence that water fluoridation has reduced social inequalities in dental health" (p. 579). However, the most recent reviews of the matter tend to be guardedly positive (Cheng et al.,2007; Pizzo et al., 2007; Parnell et al., 2009; Newbrun, 2010). Newbrun's review provides a good example of the dilemma. It cites evidence in support of the proposition but concludes by stating, "whether fluoridation reduces disparities in caries is a continuing research question." Arguments that members of lower socioeconomic groups disproportionately benefit from fluoridation of public water supplies raise questions about the existence of evidence that these groups also bear elevated risk of adverse effects from consuming fluoridated water.While the task force could find no good evidence on this topic, it does note that there is documentation that breast-feeding rates among mothers from lower socioeconomic groups are lower than those of their more affluent counterparts (Scanlon et al., 2010).Thus the task force's concerns about the exposure of formula-fed infants to fluoride (see Chapter 5) are particularly directed toward those from lower socioeconomic groups. Finding Although claims are made both that the detriments and the benefits of fluoridated water are greater for those in lower socioeconomic status, documentation of this is not conclusive. Fairbanks Fluoride Task Force Report 45 , pt�e+r 9 ¢ The proponents of water fluoridation continue to tout its cost effectiveness. For example, both the Centers for Disease Control and Prevention (CDC,2010a) and the American Dental Association (ADA, 2005) claim that the fluoridation of public water supplies in the United States costs between approximately$0.50 and$3.00 per person per year and provides something on the order of$40 per person in annual benefits (decreased costs of dental care) for every dollar invested. However,both costs and benefits are very difficult to identify and quantify in any generally agreed upon and reliable way, so there is widespread disagreement about the legitimacy of any of these estimates: In Fairbanks, the only clearly quantifiable cost of the water fluoridation program is the annual GHU expenditure for sodium fluorosilicate,which is $10,000 to $12,000 per year. The additional indirect costs to GHU for handling the material, adding it to the water, and monitoring the concentration of fluoride in the distributed water are difficult to estimate but are probably negligible in that these duties are incorporated into the work schedules of employees who dedicate the majority of their time and effort to other responsibilities. Similarly,while there are real costs associated with the purchase, operation, and maintenance of equipment used in the fluoridation process, those costs have never been documented but are probably modest. If GHU discontinues its fluoridation process, it will have to adjust its protocol for conditioning the distributed water.While the task force didnot investigate the projected costs of the required changes (mostly focused on maintenance of an appropriate pH), it seems likely that they will not be significant. No attempts have been made to quantify indirect medical and dental costs or benefits resulting from the fluoridation of Fairbanks water. Finding There is little in the way of reliable data that can be used to estimate the cost of fluoridating Fairbanks'water or the net savings or costs associated with discontinuing the existing fluoridation process. Fairbanks Fluoride Task Force Report 46 References Alaska Department of Environmental Conservation(2010). "07-01-2010 Fluoride Information Request(Raw Water)."Online at www.ci.fairbanks.ak.us/boardscommissions/fluoridetaskforce/ fluoridetaskforceexposure.php. American Dental Association(ADA) (2005).Fluoridation Facts. Chicago:ADA. Armfield,J.M. (2007).When Public Action Undermines Public Health:A Critical Examination of Anifluoridationist Literature.Australia and New Zealand Health Policy 4:25ff. Agency for Toxic Substances and Disease Registry(ATSDR). Online at http://www.atsdr.cdc.gov/mrls/index. html.Accessed March 14,2011. Bassin, E. B.,Wypij,D.,Davis, R.B.,and Mittleman,M.A. (2006).Age-specific Fluoride Exposure in Drinking Water and Osteosarcoma(United States). Cancer Causes Control 17:421-428. DOI 10.1007/ s10552-005-0500-6. Berg,J., C. Gerweck,P. P. Hujoel, R. King,D.M. Krol,J. Kumar, S. Levy,H. Pollick, G.M.Whitford, S. Strock, K.Aravamudhan,J.Frantsve-Hawley,and D.M.Meyer(2011). Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis.J.Am. Dent.Assoc. 142:79-87. Bethke, C.M. (1996). Geocheinical Reaction Modeling.New York: Oxford Press. Block,L. E. (1986).Antifluoridationists Persist:The Constitutional Basis for Fluoridation.J. Public Health Dent. 46(4):188-198. Bradnock, G.,Marchment,M., and Anderson, R. (1984). Social Background,Fluoridation and Caries Experience in 5 Year Old Population.Br.Dent.J. 156:127-131. British Fluoridation Society(2010). One in a Million-The Facts About Water Fluoridation (2nd ed.).Manchester, UK:British Fluoridation Society.Online at www.bfsweb.org/onemillion/onemillion.htm. Bryson, C. (2004). The Fluoride Deception.New York: Severn Stories Press. Bucher,J. R., Hejtmancik,M. R.,Toft,J.D.II, Persing, R. L., Eustis, S.L., and Haseman,J. K. (1991). Results and Conclusions of the National Toxicology Program's Rodent Carcinogenicity Studies with Sodium Fluoride.Int.J. Cancer 48:733-737. Carmichael, C., Rugg-Gunn,A.,and Ferrell, R. (1989).The Relationship Between Fluoridation, Social Class and Caries Experience in 5 Year Old Children in Newcastle and Northumberland in 1987.Br.Dent.J. 167:57-61. Centers for Disease Control and Prevention(CDC) (2010a). Community Water Fluoridation: Cost Savings of Community Water Fluoridation.Online at www.cdc.gov/fluoridation/fact_sheets/cost.htm. Centers for Disease Control and Prevention(CDC) (2010b). Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004.NCHS Data Brief No.53. Online at www.cdc.gov/nchs/data/databriefs/ db53.pdf Centers for Disease Control and Prevention(CDC) (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States.Morbidity and Mortality Weekly Report 50(RR14):1-42. Centers for Disease Control and Prevention(CDC) (1999a). Fluoridation of Drinking Water to Prevent Dental Caries.Morbidity and Mortality Weekly Report 48(41):933-940. Centers for Disease Control and Prevention(CDC) (1999b).Water Fluoridation and Costs of Medicaid Treatment for Dental Decay-Louisiana, 1995-6.Morbidity and Mortality Weekly Report 48(34):753-757. Cheng,K.K.,Chalmers,K.,and Sheldon,T A. (2007).Adding Fluoride to Water Supplies.BMJ335:699-702. Cohen,H., and Locker,D. (2001).The Science and Ethics of Water Fluoridation.J. Can.Dent.Assoc. 67(10):578-580. Colquhoun,J. (1998).Why I Changed My Mind about Water Fluoridation.Fluoride 31(2):103-118. Fairbanks Fluoride Task Force Report - 47 • Committee to Coordinate Environmental Health and Related Programs,United States Public Health Service (1991). Review of Fluoride:Benefits and Risks: Report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs,U.S. Public Health Service, Department of Health and Human Services. Online at http://health.gov/environment/ReviewofFluoride/. Connett,P.,Beck,J., and Micklem, H. S. (2010). The Case Against Fluoride.White River Junction,VT: Chelsea Green Publishing. Cox, G.J.,Matuschak,M. C.,Dixon, S. F.,Dodds,M. L., and Walker,W. E. (1939). Experimental Dental Caries IV.Fluorine and Its Relation to Dental Caries.J.Dent.Res. 57:481-490. Cross,D.W., and Carton, R.J. (2003).Fluoridation:A Violation of Medical Ethics and Human Rights.Int.J. Occup. &Environ.Health 9(1):24-29. Dean,H.T.,Arnold, F.A., and Elvove, E. (1942).Domestic Water and Dental Caries.Public Health Report 57:1155-1179. Dean, H.T.,Arnold Jr., F.A., and Elvove, E. (1941).Domestic Water and Dental Caries.Public Health Report 56:761-792. Diesendorf,Mark(1986).The Mystery of Declining Tooth Decay.Nature,July 10,pp. 125-29. Ditmyer,Marcia,Dounis,Georgia,Mobley, Connie, and Schwarz, Eli(2010).A Case-control Study of Determinants for High and Low Dental Caries Prevalence in Nevada Youth. BMC Oral Health 10:24. Online at www.biomedcentral.com/1472-6831/10/24. Douglass, C.W, and Joshipura, K. (2006). Caution Needed in Fluoride and Osteosarcoma Study. Cancer Causes Control 17:481-482. Environmental Protection Agency(EPA) (2000). Estimated Per Capita Water Ingestion in the United States (EPA 822-R-00-008). Online at waterepa.gov/action/.../2005_05 06_criteria_drinkingpercapita_Textpdf. Environmental Protection Agency(EPA) (2004). Estimated Per Capita Water Ingestion and Body Weight • in the United States-An Update. (EPA-822-R-00-001). Online at www.epa.gov/waterscience/criteria/ drinking/percapita/2004 pdf. Environmental Protection Agency(EPA) (2010).Fluorine(Soluble Fluoride) (CASRN 7782-41-4). Online at www.epa.gov/iris/subst/0053.htm. Environmental Protection Agency(EPA) (2011). EPA proposes to withdraw sufuryl fluoride tolerances (http:// vvvv-w.epa.gov/pesticides/sulfuryl-fluoride/evaluations.html) Fagin,D. (2008). Second Thoughts About Fluoride. Sci.Am. 298(1):74-81. Fawell,J.,Bailey,K., Chilton,J.,Dahi, E.,Fewtrell,L., and Magara,Y. (2006).Fluoride in Drinking-water. World Health Organization. London:IWA Publishing. Featherstone,J.D.B. (2000).The Science and Practice of Caries Prevention.J.Am.Dent.Assoc. 131(7):887-899. Federal-Provincial-Territorial Committee on Drinking Water(2009). Fluoride in Drinking Water-Draft For Public Consultation. Online at www.hc-sc.gc.ca/ewh-semt/consult/ 2009/fluoride-fluorure/draft-ebauche- eng.php). Fejerskov,0.,Thylstrup,A., and Larsen,M.J. (1981). Rational Use of Fluoride in Caries Prevention:A Concept Based on Possible Cariostatic Mechanisms.Acta Odontol Scand.39:241-249. Fluoride Recommendations Work Group (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States.Morbidity and Mortality Weekly Report 50 (RR14):1-42. Online at http://vwvw.cdc.gov/mmwr/preview/mmwrhtml/rr5014al.htm. Fluoride Technical Study Group (2003). Report of the Fort Collins Fluoride Technical Study Group. Online at http://www.healthdistrict.org/fluoridereport/FTSG.htm. Freni, S. C. (1994). Exposure to High Fluoride Concentrations in Drinking Water is Associated with Decreased Birth Rates.J. Toxicol.Environ.Health 42:109-121. Fairbanks Fluoride Task Force Report 48 Graham, R.J.,and Morin;P-J. (1999). Highlights in North American Litigation During the Twentieth Century on Artificial Fluoridation of Public Water Supplies.J.Land Use and Environmental Law 14(2):195-247. Griffin, S. 0., Gooch,B. F.,Lockwood, S.A., and Tomar, S. L. (2001). Quantifying the Diffused Benefit from Water Fluoridation in the United States; Community Dent. Oral Epidemiol. 29:120-129. Griffin, S. 0., Regnier, E.,Griffin,P.M.,and Huntley, V. (2007). Effectiveness of Fluoride in Preventing Caries in Adults.J.Dent.Res. 86:410-415. DOI 10.1177/154405910708600504. Hayes,A.W., ed. (2008).Principles and Methods of Toxicology(5t''ed.). New York:Informa Healthcare USA. Health Canada(2010).Fluoride and Human Health. Online at www.hc-sc.gc.ca/hl-vs/iyh-vsv/environ/fluor- eng.php#prov. Heller, K. E., Eklund, S.A.,and Burt,B.A. (1997).Dental Caries and Dental Fluorosis at Varying Water Fluoride Concentrations.J.Public Health Dentistry 57:136-143. Hellwing, E.,and Lennon,A.M. (2004). Systemic Versus Topical Fluoride. Caries Res. 38:258-262. Hirzy,J.W. (2000). Statement Before the Subcommittee on Wildlife,Fisheries and Drinking`Water,United States Senate,June 29,2000. Online at www.fluoridealert.org/HirzyTestimony.pdf. Hodge,H. C., and Smith,F.A. (1965).Biological Properties of Inorganic Fluorides. In Fluorine Chemistry, Simons,H. H.,ed.,pp. 1-42.New York:Academic Press. Iida,H., and Kumar,J.V. (2009).The Association Between Enamel Fluorosis and Dental Caries in U.S. Schoolchildren.J.American Dental Association 140:855-862. Institute of Medicine(1997).Dietary Reference Intakes for Calcium,Phosphorus,Magnesium,Vitamin D,and Fluoride. Report of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes.Washington,DC:National Academies Press. Institute of Medicine(2000).Dietary Reference Intakes.Washington,DC:National Academies Press. Jones, C.,and Worthington, H. (2000).Water Fluoridation, Poverty, and Tooth Decay in 12-year-old Children.J.Dent. 28:389-393. Jones, S.,Burt,B.A., Petersen, P. E.,and Lennon,M.A. (2005).The Effective Use of Fluorides in Public Health.Bull. World Health Organization 83(9):670-676. Juneau Fluoride Study Commission(2006). Report to Assembly of the City and Borough of Juneau,July 11,2006. Online at www.ci.fairbanks.ak.us/boardscommissions/fluoridetaskforce/ fluoridetaskforceotherreferencesJuneaudocs.php. Kalsbeek, H., Kwant,J.W., Groeneveld,J.,Backer Dirks,J.,van Eck,A.M.J., and Theuns, H.M. (1993). Caries Experience of 15 Year Old Children in the Netherlands After Discontinuation of Water Fluoridation. Caries Res.27:201-205. Komarek,Arnost,Lesaffre, Emmanuel, Harkanen,Tommi,Declerck,Dominique,and Virtanen,Jorma I. (2005). A Bayesian Analysis of Multivariate Doubly-Interval-Censored Dental Data.Biostat 6(1):145-155. DOI 10.1093/biostatistics/kxh023. Kozol,J. (1992). Savage Inequalities:Children in America's Schools.New York: Crown Publishers. Kiinzel,W.,Fischer,T.,Lorenz,R., and Bruhmann, S. (2000).Decline of Caries Prevalence After the Cessation of Water Fluoridation in the Former East Germany. Community Dent. Oral Epidemiol.28:382-9. Kurttio, P., Gustaysson,N., Vartaninen,T., and Pekkanen,J. (1999). Exposure to Natural Fluoride in Well Water and Hip Fracture.A Cohort Analysis in Finland.Am.J.Epidemiol. 150:817-824. Lalumandier,J.A., and Ayers,L.W. (2000). Fluoride and Bacterial Content of Bottled Water Versus Tap Water up to 1 ppm.Arch.Fain.Med. 9:246-250. Levy, S.M., and Zarei-M, Z. (1991). Evaluation of Fluoride Exposures in Children.J. Dent. Child. 58(6):467-473. Levy, S.M.,Broffitt,B.,Marshall,T.A., Eichenberger-Gilmore,J.M., and Warren,J.J. (2010).Associations Between Fluorosis of Permanent Incisors and Fluoride Intake from Infant Formula, Other Dietary Sources and Dentifrice During Early Childhood.J.American Dental Association 141:1190-1201. Fairbanks Fluoride Task Force Report 49 Limeback,H. (2000).Why I Am Now Officially Opposed to Adding Fluoride to Drinking Water. Online at www.fluoridealert.org/limeback.htm. Macek,M.D.,Matte,T. D., Sinks,T.,and Malvitz,D.M. (2006). Blood Lead Concentrations in Children and Method of Fluoridation in the United States, 1988-1994.Environ.Health Perspect. 114(1):130-13. MacFayden, E. E.,McNee, S. G., and Weeman,D.A. (1982).Fluoride.Content of Some Bottled Spring Waters.Br.Dent.J. 53:423-424. Masters, R. D., and Coplan,M.J. (1999).Water Treatment with Silicofluorides and Lead Toxicity.Int.J. Environ. Stud. 56:435-449. Masters, R. D., Coplan,M.J., Hone,B.T.,and Dykes,J. E. (2000).Association of Silicofluoride Treated Water with Elevated Blood Lead.NeuroToxicity 21(6):1091-1100. McDonough,M.,Whiting,P., Bradley,M., Cooper,J., Sutton,A., Chestnutt,I.,Misso, K.,Wilson, P.,Treasure, E., and Kleinjen,J. (2000).A Systematic Review of Public Water Fluoridation. National Health Service Centers for Reviews and Dissemination.York,UK:University of York.DOI 10.1136/ bmj.321.7265.855. McNally,M., and Downie,J. (2000).'The Ethics of Water Fluoridation.J. Can.Dent.Assoc. 66(11):592-593. Mueller, S. H. (2002).A Geochemical Characterization of Groundwater Near Fairbanks,Alaska,with Emphasis on Arsenic Hydrogeochemistry.MSc. thesis,University of Colorado,Boulder. National Health and Medical Research Council(Australia) (2007).A Systematic Review of the Efficacy and Safety of Fluoridation. Online at www.nhmrc.gov.au/publications/synopses/eh4lsyn.htm National Research Council(NRC)(1993).Health Effects of Ingested Fluoride.Washington,DC:National Academies Press. National Research Council(NRC)(2006).Fluoride in Drinking TWVaterA Scientific Review of EPA's Standards. Washington,DC: National Academies Press. Online at www.nap.edu/catalog/11571.html. Newbrun, E. (2010).What We Know and Do Not KnowAboutFluoride.J.Pub.Health And Dentistry pp. 1-7. (Invited review presented at National Oral Health Conference, Portland, OR,April 21,2009). DOI 10.1111/j.1752-7325.2010.00171.x. Ophaug, R. H., Singer,L., and Harland,B. F. (1985).Dietary Intake of 6-months and 2-year-old Children in Four Dietary Regions of the United States.J. Clin.Nutr. 42(4):701-707. Office of Pesticide Programs (OPP) (2011). Sulfuryl Fluoride-Revised Human Health Risk Assessment for Fluoride to Incorporate New Hazard and Exposure Information. Online at www.regulations. gov/#documentDetail;D=EPA-HQOPP-2005-0174-0113. Osmunson,W. (2010a). Letter#1 to Fairbanks Fluoride Task Force. "03-02-2010 Osmunson Letter to FTC-Fluoridation,Drugs,and Human Subject Research."Online at www.ci-.fairbanks.ak.us/ boardscommissions/fluoridetaskforce/fluoridetaskforceotherreferences.php. Osmunson,W. (2010b).Letter#4 Effectiveness of Fluoridation,to Fairbanks Fluoridation Task Force."03- 13-2010 Dr. Osmunson Letter-Effectiveness of Fluoridation."Online at http://www.ci.fairbanks.ak.us/ boardscommissions/fluoridetaskforce/fluoridetaskforceefficacy.php. Parnell, C.,Whelton,H.,and O'Mullane,D. (2009).Water Fluoridation.•Eur.Arch.Paediatr.Dent. Sep; 10(3):141-8. Peterson,P. E. (2003).Fluoride in Drinking Water.The World Oral Health Report 2003: Continuous Improvement of Oral Health in the 21st Century-The Approach of the WHO Global Oral Health Programme(WHO/NMH/NPH/ORH/03.2). Geneva:WHO Global Oral Health Program. Online at http://www.who.int/oral_health/publications/report03/en/. Pizzo, Giuseppe,Piscopo,Maria R., Pizzo,Ignazio, and Giuliana, Giovanna(2007). Community Water Fluoridation and Caries Prevention:A Critical Review. Clin. Oral.Invest. 11:189-193.DOI 10.1007/ s00784-007-0111-6. Pratt,Jr., E., Rawson, R.D., and Rubin,M. (2002). Fluoridation at Fifty:What Have We Learned?J.Law Med.Ethics Fall 30(3) Supp1:117-121. Fairbanks Fluoride Task Force Report 50 Riley,J. C.,Lennon,M.A.,and Ellwood, R. P. (1999).The Effect of Water Fluoridation and Social Inequalities on Dental Caries in 5-year-old Children.Int.J.Epidemiol.28(2):300-305.DOI 10.1093/ ije/28.2.300. Rojas-Sanchez,F.,Kelly, S.A.,Drake, K.M.,Eckert,G.J., Stookey,G.K.,and Dunipace,A.J.(1999).Fluoride Intake From Foods,Beverages and Dentifrice by Young Children in Communities With Negligibly and Optimally Fluoridated Water.A Pilot Study. Community Dent. Oral Epidemiol.27(4):288-297. Scanlon, K. S., Grummer-Strawn,L.,Chen,J.,Molinari,N., and Perrine, C. G. (2010). Racial and Ethnic Differences in Breastfeeding Initiation and Duration by State-National Immunization Survey,United States,2004-2008.Morbidity and Mortality Weekly 59(11):327-334. Scott,T. (1983). Concise Encyclopedia of Biochemistry.Berlin:Walter DeGruyter&Co. Seppa, L.,Karkkainen, S., and Hausen, H. (2000). Caries Trends 1992-1998 in Two Low-Fluoride Finnish Towns Formerly With and Without Fluoridation. Caries Res. 34:462-468.. Sigfried,T. (2010). Odds Are,It's Wrong. Science News 177(7):26ff. Sutton, P. (1960).Fluoridation:Errors and Omissions in Experimental Trials(2nd Ed.).Melbourne:Melbourne University Press. Tang, Qin-ging,Du,Jun,Ma, Heng-hui,Jiang, Shao jun, and Zhou,Xiao-jun(2008).Fluoride and Children's Intelligence:A Meta-analysis.Biol. Trace Elem. Res.DOI 10.1007/s12011-008-8204-x. Humana Press Inc. Taubes, G. (2006). Epidemiology Faces its Limits. Science 269:164-169. 'Thiessen, K.M. (2006).Water Fluoridation: Suggested Issues for Consideration.Unpublished manuscript, 6 pp.,"05-27-2010'Thiessen-EPA Comments."Online at www.ci.fairbanks.ak.us/boardscommissions/ fluoridetaskforce/fluoridetaskforcereviews.php). Thiessen, K.M. (2009a). Comments on Fluoride in Drinking Water.Unpublished manuscript, 15 pp.,"11-27- 2009 Thiessen-Water Fluoridation Suggested Issues for Consideration."Online at www.ci.fairbanks.ak.us/ bo ardscommissions/fluoridetaskforce/fluoridetaskforcetoxicityadverseeffects.php. 'Thiessen, K.M. (2009b). Comments in Response to Announcement of Chemicals Selected by OEHHA for Consideration for Listing by the Carcinogen Identification Committee and Request for Relevant Information on the Carcinogenic Hazards of These Chemicals.Unpublished manuscript, 15 pp., "12-15- 2009 Thiessen-Comments Responding to CA EPA Carcinogen Listings." Online at www.ci.fairbanks. ak.us/boardscommissions/fluoridetaskforce/fluoridetaskforcereviews:php. Thiessen,K.M. (2010). Comments on the Need for Revision of the NPDWR for Fluoride.Unpublished manuscript,22 pp.,"15-27-2010 Thiessen-EPA comments."Online at www.ci.fairbanks.ak.us/ boardscommis Bions/fluoridetaskforce/fluoridetaskforcereviews.php. Truman,B.,I, Gooch,B.F., Sulemana,I., Gift,H. C.,Horowitz,A.M., Evans, C.A.,Griffin, S. 0., and Carande, K.,V(2002). Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries(Structured abstract).Amer.J.Preventive Medicine 23:21-54. Turekian, K. K. (1969).The Oceans, Streams, and Atmosphere.In Handbook of Geochemistry,vol. 1, K. H. Wedepohl, ed., New York: Springer-Verlag. Urbansky, E.T. (2002). Fate of Fluorosilicate Drinking Water Additives. Chem. Rev. 102:2837-2854. U.S. Department of Agriculture(USDA) (2004).USDA National Fluoride Database of Selected Beverages and Foods-2004.Online at www.nal.usda.gov/fnic/foodcomp/Data/Fluoride/fluoride.pdf. U.S. Department of Health and Human Services(HHS) (2000).Healthy People 2000. With Understanding and Improving Health and Objectives for Improving Health(2"d ed.).Washington,DC:U.S. Government Printing Office. U.S. Geological Survey(USGS) (2001). Ground-Water Studies in Fairbanks,Alaska-A Better Understanding of Some of the United States'Highest Natural Arsenic Concentrations. (Fact Sheet FS- 111-01). Online at http://pubs.usgs.gov/fs/fs-0111-01/fs-0111-01.pdf. Fairbanks Fluoride Task Force Report 51 U.S. Public Health Service(USPHS) (1991). Review of Fluoride: Benefits and Risks: Report of the Subcommittee on Fluoride of the EHPC.Washington,DC: Public Health Service,Department of Health and Human Services. Verplanck, P.I.,Mueller, S. H.,Youcha, E. K., Goldfarb, R.J., Sanzolone, R. F.,McCleskey, R. B., Briggs, P. H., Roller,M.,Adams,M., and Nordstrom,D. K. (2003). Chemical Analyses of Ground and Surface Waters, Ester Dome, Central,Alaska,2000-2001. Open File Report 03-244.U.S. Geological Survey. Vestergaard, P.,Jorgensen,N. R., Schwarz,P., and Mosekilde,L. (2008). Effects of Treatment with Fluoride on Bone Mineral Density and Fracture Risk:A Meta-analysis. Osteoporosis Intern. 19:257-268. Warren,J.J.,Levy, S.M.,Broffitt, B., Cavanaugh,J. E.,Kanellis,M.J., and Weber-Gasparoni, K. (2009). Considerations on Optimal Fluoride Intake Using Dental Fluorosis and Dental Caries Outcomes—A Longitudinal Study.J. Public Health Dent. 69(2):111-115. Westendorf,J. (1975). The Kinetics of Acetylcholinesterase Inhibition and the Influence of Fluoride and Fluoride Complexes on the Permeability of Erythrocyte Membranes. Ph.D. dissertation,University of Hamburg, Hamburg, Germany. Whistler,B.J. (2007).Alaska Oral Health Plan:2008-2012.Juneau,AK: Section of Women's, Children's and Family Health, Division of Public Health,Alaska Department of Health and Social Services. Whitford, G.M. (1996). The Metabolism and Toxicity of Fluoride(2❑d Rev. ed.).Monographs in Oral Science, vol. 16.New York: Krager. Young, C.A. (2008).A Systematic Review of the Efficacy and Safety of Fluoridation.Evid.Based Dent. 9(2):39-43. Ziegelbecker R. (1998). Fluoridation in Europe.Fluoride 31(3):171-174. Fairbanks Fluoride Task Force Report 52 ` `•' y; ;Appendix A,. k �, -. f iE. Resolution ti' ; f , a e = 4l `F.' � _..,=-s,. _�. . .. Y .., ..ea.:. a s,, x•Y:_ __, a'..r -'_...r -..1 - _ `'..`Z ,. .-F_' .a,S= r... .. _ . ..x,. c�•_ z.a- .__ Introduced By: Council Member Cleworth Introduced: February 8, 2010 RESOLUTION NO. 4398 A RESOLUTION ESTABLISHING A TASK FORCE TO RESEARCH CURRENT POLICY REGARDING FLUORIDATION OF THE MUNICIPAL WATER SUPPLY. WHEREAS, the health and security of Fairbanks citizens are a primary concern of the City Council; and WHEREAS, the use of fluoride in the City's water supply was established in 1960 (FGC Sec. 82-1) as a way to enhance dental care; and WHEREAS, this practice has raised questions regarding potential long-term effects caused by the use of fluoride; and WHEREAS, it is advisable to periodically reanalyze this policy to make sure the potential benefits outweigh any potential side effects associated with fluoridation; and WHEREAS, the amount of research available on this subject is voluminous and often extremely technical. NOW, THEREFORE, BE IT RESOLVED, that a committee is formed consisting of the six individuals listed below to research documentation provided by both proponents and opponents of fluoridation through public hearings and to supplement this information with any other sources deemed appropriate. A final report along with analysis and recommendations will be presented to the City Council no later than early July. Legal notifications and assistance will be given by the City Clerk's office. The committee consists of individuals having extensive backgrounds in chemistry, biology, dentistry, and medicine, who have expressed a strong interest in objectively analyzing research regarding fluoridation. Committee Chair: Dr. Paul Reichardt, former Provost, Dean, and Professor at UAF, with a Ph.D. in Organic Chemistry; Dr. Dick Stolzberg: Professor Emeritus of Chemistry at UAF, with a Ph.D. in Chemistry, who has done extensive research in the field of analytical chemistry; Dr. Rainer Newberry: Professor in Geochemistry, Mineralogy, and Economic Geology, with a Ph.D. in Economic Geology; Fairbanks Fluoride Task Force Report 53 Dr. Bryce Taylor: Doctorate of Dental Surgery, formerly serving in public health with the TCC, now in private practice; Dr. Joan Braddock: Most recently Dean of the College of Natural Science and Mathematics, with a Master's Degree in Microbiology and a Ph.D. in Oceanography; Dr. Beth Medford: Board Certified Pediatrician with a background in biochemistry; formerly at Eielson AFB b- ten g prival practice. fr Terry Strle, ity Mayor AYES: - Roberts, Eberhart, Gatewood, Bratcher,Cleworth,Stiver NAYS: Nona ABSTAIN: ABSENT: ADOPTED: February 08,2010 ATTEST: APPROVED AS TO FORM: `money H•renden, CMC, City Clerk Paul J. 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Y"`p P,l!1T•,"ji'rr'!f_},_1 A.'ini 1]:j:: >'`'C•:iiJ''-o_]'c '. - __ 'I,J�r:7r?l'J•�-.;,is'i'_rl':- �.vk`i�%�1,}".%,•t'I i.,J1'/ �] a7"17.'rfl i._I'i'°!'t',+� 'lisl:Y,}j;�,i'.I ,il..�yt � 1 'ff,ffil.l]_ll.�Jr:�� ) .i'I 7 s'. ( 4Ff'.`rrT1c]aqOb,t-% i- -- f5�1 "+t�U- 'f41•}�i• q'c 1 ,i,, N,K _ - i�l f}•i ly[S 1,.'„4•;17:-? C,.i ? .l1 :Frl� +li'— ',Fro .,r`;1.- 'ul4l �;Pi_'ul ri c f r'f:�n r ' , (- f f �;-tit J(i)b -1.;{J J];,'1 lL'. kt ., z Lf)c ! p ii; k z rn'�J. J s/4 /1,) r%+gi Yt� l�} "� 1 y 11 Z.:. J. 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""���.!a�r,�'k�i��i'� 1 ;��• •� � � �a pee I7 ewed ienc£ ' K. z �Y g r f � � DtllQr Slgni _ratesG4nf�IbUCO ,D Connor,iZegrsJative Liaison,Department of State Gov ',ernment Affairs,lMls-Helen Ristic PhD,Director ence Information,;Co uncil:on Scientific`Affairs and Mr Chakwan Siew, Ph,D.,..Senior.Director..Research:!and • Laboratories,Councii on Scientific Affairs. • A special thanks to the National Fluoridation Advisory Committee members who contributed to this edition: Ms. Diane Brunson, Dr. Robert N. Crawford,Jr.,Dr.Lisa P Howard, Dr. Jayanth V. Kumar, Dr. Ernest Newbrun, Mr.Thomas G.Reeves and Dr.Michael S.Swartz. DISCLAIMER This publication is designed to answer frequently asked questions about community water fluoridation, based on a summary of relevant published articles. It is not intended to be a comprehensive review of the extensive literature on fluoridation and fluorides. Readers must also rely on their own review of the literature, including the sources cited herein and any subsequent published,for a complete understanding of these issues. ©2005 American Dental Association This publication may not be reproduced in whole or in part without the express written permission of the American Dental Associa- tion except as provided herein. • • • eF2 r'f� G: . ADA American Dental Associations America's leading advocate for oral health ADA Statement Commemorating the 60t''Anniversary of `u; Community Water Fluoridation Sixty years ago,Grand Rapids,Michigan became the world's first city to adjust the level of fluoride in its water supply. Since that time, fluoridation has dramatically improved l the oral health of tens of millions of Americans. Community water fluoridation is the single most effective public health measure to prevent tooth decay. Additionally,the r F Centers for Disease Control and Prevention proclaimed community water fluoridation as one of 10 great public health achievements of the 20th century. Fluoridation of community water supplies is simply the precise adjustment of the existing naturally occurring fluoride levels in drinking water to an optimal fluoride level recommended by the U.S.Public Health Service(0.7—1.2 parts per million)for the prevention of dental decay. Based on data from 2002,approximately 170 million people (or over two-thirds of the population)in the United States are served by public water systems that are fluoridated. Studies conducted throughout the past 60 years have consistently indicated that 444 fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. It is the most efficient way to prevent one of the most • common childhood diseases—tooth decay (5 times as common as asthma and 7 times as common as hay fever in 5-to17-year-olds). 4Early studies, such as those conducted in Grand Rapids,showed that water fluoridation tHr. • reduced the amount of cavities children get in their baby teeth by as much as 60%and _ • reduced tooth decay in permanent adult teeth nearly 35%. Today,studies prove water fluoridation continues to be effective in reducing tooth decay by 20-40%,even in an era with widespread availability of fluoride from other sources,such as fluoride toothpaste. The average cost for a community to fluoridate its water is estimated to range from approximately$0.50 a year per person in large communities to approximately$3.00 a year per person in small communities. For most cities,every$1 invested in water fluoridation saves$38 in dental treatment costs. The American Dental Association continues to endorse fluoridation of community water supplies as safe and effective for preventing tooth decay. This support has been the Association's position since policy was first adopted in 1950. The ADA's policies regarding community water fluoridation are based on the overwhelming weight of peer- • reviewed,credible scientific evidence. The ADA,along with state and local dental societies,continues to work with federal,state,local agencies and community coalitions • to increase the number of communities benefiting from water fluoridation. 2005 211 East Chicago Avenue Chicago,Illinois 60611-2678 Permission is hereby granted to reproduce and distribute this ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation in its entirety, without modification.To request any other copyright permission please contact the American Dental Association at 1-312 110-2879. N e C' Fluoridation Facts 1 fir l a'1'4.'00�° s i�� �Y dit tt i` 4 f r -a. 't',. vA•x... f f t€' A' , t , „ 4 ,� n .itE ?t ^cam - v .1144 " s. �. `',_. TL --_ _ a_.w e a...O...!..,s...�.. - -- :�:.s..m.++H"d'' rl. e`°i' 7.2.117-7,...,.. r: x. ... :! ,` '. 3 ACf: .., TABLE OF CONTENTS ADA Statement Commemorating the 1 SAFETY 22 60th Anniversary of Community Water Fluoridation Question Topic Page Executive Summary 4 17. Harmful to humans? 22 18. More studies needed? 23 Introduction 6 19. Total intake? 24 20. 'Daily intake? 25 21. Prenatal dietary fluoride 26 BENEFITS 10 supplements? 22. Body uptake? 26 Question Topic Page 23. Bone health? 27 1. What is fluoride? 10 .24. Dental fluorosis? 28 2. How does fluoride help 25. Prevent fluorosis? 30 prevent dental decay? 10 3. What is water fluoridation? 11 26. Warning label? 31 4. How much fluoride is in 27. Toxicity? 31 your water? 11 28. . Cancer? 32 5. Fluoride additives? 12 29. Enzyme effects? 33 6. Natural vs adjusted? 12 30. Thyroid gland? 34 7. Effectiveness? 13 31. Pineal gland? 34 8. Still effective? 14 32. Allergies? 34 9. Discontinuance? 15 33. Genetic risk? 35 10. Is decay still a problem? 16 34. Fertility? 35 11. Adult benefits? 16 35. Down Syndrome? 35 12. Dietary supplements? 17 36. Neurological impact? 36 13. Fluoride for children? 18 37. Lead poisoning? 37 14. Alternatives? 19 38. Alzheimer's disease? 37 15. Bottled water? 19 39. Heart disease? 38 16. Home treatment(filter)systems? 21 40. Kidney disease? 38 41. Erroneous health claims? • 39 2 American Dental Association FLUORIDATION PRACTICE 40 Call to Action 57 Question Topic Page References 58 42. Water quality? 40 StatementsfromFive Leading Health 68 43. Regulation? 41 Organizations Regarding Community 44. Standards? 42 Water Fluoridation 45. Source of additives? 43 Compendium 69 • 46. System safety concerns? 43 47. Engineering? 44 48. Corrosion? 44' 49. Environment? 45 Figures 1. Reviewing Research 7 2. Effectiveness List 13 PUBLIC POLICY 46 3. ADA.org-Bottled Water 20 Question Topic Page 4. Safety List 23 50. Valuable measure? 46 " 5. 1998 Consumers'Opinions 48 51. Courts of law? 47 6. Approval of Fluoridating 48 Drinking Water 52. Opposition? 47 7. Opposition Tactics 50 53. Internet? 51 8. ADA.org-Fluoride and 51 54. Public votes? 51 Fluoridation 55. International fluoridation? 54 9. Largest Fluoridated Cities 52 56. Banned in Europe? 54 10. States Meeting National Goals 53 Tables COST EFFECTIVENESS 56 1. Dietary Fluoride Supplements 18 Question Topic Page • 2. . Bottled Water 20 57. Cost effective? 56 3. Dietary Reference Intakes 25 . 58. Practical? 57 4. 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",:,'','-';' -- -'''!'•'-''' ,. --- * - _--!'-_ - ----' -,:',-'- '': „., ,.' :'-- -'':- .-_,'''':.. --. 'f'":',--'i"-,,'-,''''''';-',--,-, ' -'::: ,:1-:''',..----'---.I'-._l' -', 1 i-':''.-- '',---- ._-'--.-.-'--.:',-------'i-:-- '-',1;,4':''- - _.._._........—___....,,_ • '. INTRODUCTION ince 1956,the American Dental Association(ADA)has anced conclusions based on their research findings and published Fluoridation Facts. Revised periodically, have published their results in refereed (peer-reviewed) Fluoridation Facts answers frequently asked questions professional journals that are widely held or circulated. about community water fluoridation. In this 2005 edition Studies showing the safety and effectiveness of water issued as part of the 60th Anniversary celebration of corn- fluoridation have been confirmed by independent sci- munity water fluoridation; the ADA Council on Access, entific studies conducted by a number of nationally and Prevention and Interprofessional Relations provides up- internationally recognized scientific investigators. While dated information for individuals and groups interested opponents of fluoridation have questioned its safety and in the facts about fluoridation.The United States now has effectiveness, none of their charges has ever been sub- over 60 years of practical experience with community wa- stantiated by generallyaccepted science. ter fluoridation. Its remarkable longevity is testimony to With the advent of the Information Age,a new type of fluoridation's significance as a public health measure. In "pseudo-scientific literature" has developed. The public recognition of the impact that water fluoridation has had often sees scientific and technical information quoted in on the oral and general health of the public, in 1999,the the press, printed in a letter to the editor or distributed Centers for Disease Control and Prevention named fluori- via an Internet Web page. Often the public accepts such dation of drinking water as one of ten great public health information as true simply because it is in print.Yet the achievements of the 20th century.1,2 information is not always based on research conducted according to the scientific method, and the conclusions Support for Water Fluoridation drawn from research are not always scientifically justifi- Since 1950,the American Dental Association (ADA) has able. In the case of water fluoridation, an abundance continuously and unreservedly endorsed the optimal of misinformation has been circulated. Therefore, sci- fluoridation of community water supplies as a safe and entific information from all print and electronic sources effective public health measure for the prevention of must be critically reviewed before conclusions can be dental decay. The ADRs policy is based on its continu- drawn. (See Figure 1.) Pseudo-scientific literature may ing evaluation of the scientific research on the safety peak a reader's interest but when read as science, it can and effectiveness of fluoridation. Since 1950, when the be misleading. The scientific validity and relevance of ADA first adopted policy recommending community claims made by opponents of fluoridation might be best water fluoridation, the ADA has continued to reaffirm viewed when measured against criteria set forth by the its position of support for water fluoridation and has U.S.Supreme Court. strongly urged that its benefits be extended to corn- 6-Additional information on this topic may be found in munities served by public water systems.3 The 2005 Question 52. "ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation" reinforced that po- History of Water Fluoridation sition.4 Fluoridation is the most effective public health Research into the beneficial effects of fluoride began measure to prevent dental decay for children and adults, in the early 1900s. Frederick McKay, a young dentist, reduce oral health disparities and improve oral health opened a dental practice in Colorado Springs, Colo- over a lifetime.5 rado, and was surprised to discover that many local The American Dental Association, the U.S. Public residents exhibited brown stains on their permanent Health Service, the American Medical Association and teeth. Dr. McKay could find no documentation of the the World Health Organization all support community condition in the dental literature and eventually con- water fluoridation. Other national and international vinced Dr. G.V. Black,dean of the Northwestern Univer- health, service and professional organizations that rec- sity Dental School in Chicago, to join him in studying ognize the public health benefits of community water the condition. Through their research, Drs. Black and fluoridation for preventing dental decay are listed on McKay determined that mottled enamel, as Dr. Black the inside back cover of this publication. termed the condition, resulted from developmental imperfections in teeth. (Mottled enamel is a historical Scientific Information on Fluoridation term. Today, this condition is called dental or enamel The ADA's policies regarding community water fluorida- fluorosis.) Drs. Black and McKay wrote detailed de- tion are based on generally accepted scientific knowledge. scriptions of mottled enamel.6'7 This body of knowledge is based on the efforts of nation- In the 1920s, Dr. McKay, along with others,suspected ally recognized scientists who have conducted research that something either in or missing from the drinking using the scientific method, have drawn appropriate bal- water was causing the mottled enamel. Dr. McKay wrote 6 American Dental Association M1.. , ,.. r+�,a --r .' '' r , ;S"g� Y[ems ,3+� r -t' .,�.nes-+ r'ae ",� ,d -. + '+l '. y �y." f� ��., ea � *�� ,r Y � i- # ° " .rE.� .,,,,,,,,,,.::(1. a :"i u�'f .!:.-...'":7--.. .� P 'j 4' f ' 3 ' 'n ,°!.. 'h G' f f.0.``" N S "Lt fi tg '' ':'.F "245 .. ' Mi,{,g� y, kit ..f p v., .. s�r� ."" is ka. Figure 1. Key Elements In Reviewing Research It is important to review information about fluoreda & _Type ofResearch How the research is conducted`is tion with a critical eye Listed below are key elements -relevant. Research conducted in vitro-(outside the to consider when~reviewing enformateonaboutfluore = living body andin a laboratory environment)may ;`dation tesQPTPFZnC. A. ,- .0-e, -T6'te ,1 , e ,reseAr9ibtnducte& in vivo(in a living human orother animal) 1 Credentials-'The authors background-and- cre , a = dentials should reflect expertise in_-the area of 'j 7 :Research Model A good study will try to repli research undertaken: 9„cite real life situations-as close as possible `For' w t example results from animal studies using high z: Date=The year of the publication should be ap I doses,,of fluoride that are infected rather than parent The informationshould be relatively cur provided rn dnnkmg wafer should be-cautiously rentitii : :,974 :k611E9 - 9ied'OtY11Pg*oap- -ardinthrpTetdsucF,6idie§aA4h101fY:-66esiP1 the,test of time and scientific scrutiny A=review able-as`a predictor ofeffects of ihuman`ex of existing-literature can provide insight',into posure to low concentrations of fluoride such`as whether the results:of older studies have-,:been ` `'those used to fluoridate water- superseded by subsequent.studies >_ 8 :Peer Review -Publications-,presenting_scientific 3: Accuracy If the information`s a review of other :' ..information should be: peer revi• ewed to help ,,._,--7.„,,:--::-.:-;,,7.-,--,_,--!.,-_-::- .,--,:.:,::_. -,:-..::.,_,,- --.'i-:=--.: = studies it should be.;accurate-and representative _ ensure that scientifically sound articles are_pub of'the original research Information quoted di Iished .Peer review involves evaluation and'rat rectly from other sources should be_quoted„in its ng of the scientific and technical meet of an ar entirety "ticle by'otherqualified_scientists 4: Statistical Methods The methods used to aria g Weight of Evidence Conclusions from one partic lyze ilii data should be generally accepted and ular study or on_e particular researcher should be appropriate ;:weighed against▪the bulk of°established genii ally accepted, peer reviewed science hNo single 5 Comparability The research, should be applica 'study by itself,is conclusive If=other researchers ble to community water fluoridation and use an have-not been able to--replicate the results_of.a- appropriate-type and amount of fluoride Many particular study or the work of one researcher research projects investigate the use of fluoride ▪ the results of that study or'body-of research at much higher levels than recommended for • should be viewed with some skepticism community_water fluoridation For example the results of a study using a concentration of 125 `' 10=Easily Accessible• Reputable studies=on fluori parts per million (ppm) fluoride are-not compa dation are typically published in peer=reviewed rable to research#endings regarding water fluori l journals and other vehicles thatrar▪e easily obtain dated at 0 7 to 1 2 ppm table through a medical/dental library or through ;PubMed a service of=the National Library'of • Medicine which_can be'accessed yea the Internet at http:Jww:nlm nehgov/ Fluoridation Facts 7 �' _ i t'":7.1` - '`�"•4.ek i'" FPEIISec2fxn„+'9y„v ,� .,. -10„ " i se.. '3' h' • a •F '& _._. _ aem#e, rr ? rs "`�x $ sem+ ar"� fir ;". w; ing that it is a major factor responsible for the decline in due in part to the benefits they receive from water dental decay.1,2 fluoridation. Dental costs for these individuals are Former U.S. Surgeon General David Satcher issued likely to have been reduced and many hours of need- the first ever Surgeon General report on oral health in less pain and suffering due to untreated dental decay May 2000. In Oral Health in America:A Report of the Sur- have been avoided. geon General, Dr. Satcher stated that community water fluoridation continues to be the most cost-effective, prac- tical and safe means for reducing and controlling the oc- Water fluoynda#ion continues to be currence of dental decay in a community.5,20 Additionally, effective to reducing dental decay by 20.40% , Dr. Satcher noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among even`(n an era'with widespread avarlab�hty populations. Studies have shown that fluoridation may of fluortdefrom other`sources,such as be the most significant step we can take toward reducing fluoride toothpaste the disparities in dental decay.5,2°24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called It is important to note that dental decay is caused by on policymakers, community leaders, private industry, dental plaque, a thin, sticky, colorless deposit of bacte- health professionals, the media and the public to affirm ria that constantly forms on teeth.When sugar and oth- that oral health is essential to general health and well be- er carbohydrates are eaten, the bacteria in plaque pro- ing. Additionally,Surgeon General Carmona urged these duce acids that attack the tooth enamel. After repeated groups to apply strategies to enhance the adoption and attacks, the enamel breaks down, and a cavity (hole) is maintenance of proven community-based interventions formed. There are a number of factors that increase an such as community water fluoridation 25 individual's risk fordental decay:27,3°-33 Community water fluoridation is a most valuable • Recent history of dental decay public health measure because: • Elevated oral bacteria count • Optimally fluoridated water is accessible to the en- • Inadequate exposure to fluorides tire community regardless of socioeconomic status, • Exposed roots educational attainment or other social variables.26 • Frequent intake of sugar and sugary foods - Individuals do not need to change their behavior to • Poor or inadequate oral hygiene obtain the benefits of fluoridation. • Decreased flow of saliva • Frequent exposure to small amounts of fluoride - Deep pits and fissures in the chewing surfaces over time makes fluoridation effective through the of teeth life span in helping to prevent dental decay. Exposure to fluoride is not the only measure avail- • Community water fluoridation is more cost effec- able to decrease the risk of decay. In formulating a de- tive than other forms of fluoride treatments or ap- cay prevention program,a number of intervention strat- plications.27 egies may be recommended such as changes in diet and placement of dental sealants. However,fluoride is a Water Fluoridation's Role in Reducing key component in any recommended strategy. Dental Decay Water fluoridation and the use of topical fluoride have Ongoing Need for Water Fluoridation played a significant role in improving oral health. Because of the risk factors for dental decay noted Early studies showed that water fluoridation can re- previously, many individuals and communities still . duce the amount of cavities children get in their baby experience high levels of dental decay. Although wa- teeth by as much as 60%and can reduce dental decay ter fluoridation demonstrates an impressive record in permanent adult teeth by nearly 35%. Since that of effectiveness and safety, only 67.3 % of the United time, numerous studies have been published mak- States population on public water supplies receives ing fluoridation one of the most widely studied public fluoridated water containing protective levels of flu- health measures in history. Later studies prove water oride.36 Unfortunately, some people continue to be fluoridation continues to be effective in reducing den- confused about this effective public health measure. tal decay.by 20-40%, even in an era with widespread If the number of individuals drinking fluoridated water availability of fluoride from other sources, such as is to increase,the public must be accurately informed fluoride toothpaste.28'29 Increasing numbers of adults about its benefits. are retaining their teeth throughout their lifetimes Fluoridation Facts 9 • ". _ BENEFITS • Q 1. What is fluoride? p.10 Q 6. Natural vs adjusted? p.12 Q 13. Fluoride for children? p.18 Q 2. How does fluoride help p.10 Q 7. Effectiveness? p.13 Q 14. Alternatives? p.19 prevent dental decay? Q 8. Still effective? p.14 Q 15. Bottled water? p.19 Q 3. What is water p.11 fluoridation? Q 9. Discontinuance? p.15 Q 16. Home treatment p.21 Q 4. How much fluoride is p.11 Q 10. Is decay still a problem? p.16 (filter)systems? • in your water? Q 11. Adult benefits? p.16 Q 5. Fluoride additives? p.12 Q 12. Dietary supplements? p.17 QUESTION 1. Fact. What is fluoride? Systemic fluorides are those ingested into the body. During tooth formation, ingested fluorides become in- Answer. corporated into tooth structures. Fluorides ingested Fluoride is a naturally occurring compound that can help regularly during the time when teeth are developing prevent dental decay. (preeruptively) are deposited throughout the entire tooth surface and provide longer-lasting protection Fact. than those applied topically.42 Systemic fluorides can The fluoride ion comes from the element fluorine. also give topical protection because ingested fluoride 1- Fluorine is an abundant element in the earth's crust is present in saliva, which continually bathes the teeth in the form of the fluoride ion. As a gas, it never oc- providing a reservoir of fluoride that can be incorporat- e' curs in its free state in nature, but exists only in com- ed into the tooth surface to prevent decay. Fluoride also bination with other elements as a fluoride compound. becomes incorporated into dental plaque and facilitates 3. Fluoride compounds are components of minerals in further remineralization.43 Sources of systemic fluoride 4, rocks and soil. Water passes over rock formations and in the United States include fluoridated water, dietary dissolves the fluoride compounds that are present, re- fluoride supplements in the forms of tablets, drops or leasing fluoride ions. The result is that small.amounts lozenges and fluoride present in food and beverages. .of fluoride are present in all water sources. Gener- ally, surface water sources such as lakes, rivers and streams have.very low levels of fluoride. For example, �iFluortde protects'teeth`rn two waysA k • Lake Michigan's fluoride level is 0.17 ppm.35 As water F systemically and topically ` � moves through the earth, it contacts fluoride-contain- ' W,,. 's ' ., s . . . I 4 r ,� , £_ .j✓ ing minerals and carries away fluoride ions. The con • - centration of fluoride in groundwater varies according . While it was originally believed that fluoride's action to such factors as the depth at which the water is was exclusively systemic or preeruptive, by the mid- found and the quantity of fluoride bearing minerals,in 1950s, there was growing evidence of both systemic the area.36 In the United States, the natural level of and topical benefits of fluoride exposure.44 fluoride in ground water varies from very low levels to 6-Additional information on this topic may be found in over 4 ppm. The fluoride level of the oceans ranges Question 11. from 1.2 to 1.4 ppm.37,38 Fluoride is naturally present Topical fluorides strengthen teeth already present in to some extent in all foods and beverages, but the the mouth (posteruptively). In this method of delivery, concentrations vary widely.39-41 fluoride is incorporated into the surface of teeth making them more decay-resistant. Topically applied fluoride provides local protection on the tooth surface. Topical fluorides include toothpastes, mouthrinses and profes- sionally applied fluoride foams, gels and varnishes. QUESTION 2. As mentioned-previously, systemic fluorides also pro- How does fluoride help prevent dental decay? vide topical protection. Low levels of fluoride in saliva and plaque from sources such as optimally fluoridated Answer. water can. prevent and reverse the process of dental Fluoride protects teeth in two ways—systemically and decay.45 In clarifying the effectiveness of water fluorida- topically. tion, John D.B. Featherstone, PhD, Professor and Chair, • 10 American Dental Association f • • ' • :?!;+;5:-' 'r1^' : • 4z ,'• • Cuestxions 1•r16 - s .e, . • y Department of Preventive and Restorative Dental Ser- For clarity, the following terms and definitions are vices, University of California San Francisco, noted: "... used in this booklet: There is irrefutable evidence in numerous studies that Community water fluoridation is the adjustment of fluoride in the drinking water works to reduce dental the natural fluoride concentration in water up to the caries in populations. This is still the case."66 level recommended for optimal dental health (a range of 0.7 to 1.2 ppm). Other terms used interchangeably in this booklet are water fluoridation, fluoridation and op- John D B Featherstone,PhD, Professo.rir: timally fluoridated water. Optimal levels of fluoride may -+ and Char Department of Preventive and be present in the water naturally or by adjusted means. Restorative-Dental Services University of Additional information on this topic may be found in Calrfornra San Tfaheiedor,ifolethtijilate is Question 6. irrefutable evidence cri numerous studies that Sub-optimally fluoridated water is water that natural- fluor►de'.in kiligyirOier*orkktifil reduce ly contains less than the optimal level (below 0.7 ppm) dental'carres in populations s t of fluoride. Other terms used interchangeably in this booklet are nonfluoridated water and fluoride-deficient water. • The remineralization effect of fluoride is important. Flu- oride ions in and at the enamel surface result in fortified enamel that is not only more resistant to decay (loss of QUESTION 4. minerals or demineralization), but enamel that can repair How much fluoride is in your water? or remineralize early dental decay caused by acids from decay-causing bacteria.42,4751 Fluoride ions necessary for remineralization are provided by fluoridated water as well Answer. as various fluoride products such as toothpaste. If your water comes from a public/community water The maximum reduction in dental decay is achieved supply,the options to learn the fluoride level of the wa- when fluoride is available preeruptively (systemically) ter include contacting the local water supplier or the for incorporation during all stages of tooth formation local/county/state health department, reviewing your and posteruptively (topically) at the tooth surface. Wa Consumer Confidence Report(CCR)and using the Inter- ter fluoridation provides both types of exposure."a,ez-a4 net based "My Water's Fluoride." If your water source is a private well,it will need to be tested and the results obtained from a certified laboratory. QUESTION a. Fact" What is water fluoridation? The fluoride content of the local public or community wa- ter supply can be obtained by contacting the local water Answer. supplier or the local/county/state health department. Water fluoridation is the adjustment of the natural fluo- In 1999, the U.S. Environmental Protection Agency ride concentration of fluoride-deficient water to the (EPA) began requiring water suppliers to put annual level recommended for optimal dental health. drinking water quality reports into the hands of its cus- tomers. Typically available around July 15L each year, Fact. these Water Quality Reports, or Consumer Confidence Based on extensive research, the United States Public Reports (CCRs), may be mailed to your home, placed Health Service (USPHS) established the optimum con- in the local newspaper or made available through the centration for fluoride in the water in the United States Internet.56 To obtain a copy of the report, contact the in the range of 0.7 to 1.2 parts per million. This range local water supplier. The name of the water system (of- effectively reduces dental decay while minimizing the ten not the name of the city) can be found on the water occurrence of dental fluorosis.The optimum level is de- bill. If the name of the public water system is unknown, pendent on the annual average of the maximum daily contact the local health department. air temperature in the geographic area.55 There are two sites on the Internet that supply in- One milligram per liter (mg/L) of fluoride in water is formation on water quality. The online source for identical to one part per million (ppm). At 1 ppm, one water quality reports or CCRs is the EPA web site at part of fluoride is diluted in a million parts of water. Large http://www.eoa.gov/safewater/dwinfo/index.html.0 numbers such as a million can be very difficult to visual- Additionally, the Centers for Disease Control and ize. While not exact,the following comparisons can be of Prevention's (CDC) fluoridation Web site, "My Water's assistance in comprehending one part per million: Fluoride," is available at htto://apos.nccd.cdc.gov/MWF/ 1 inch in 16 miles Index.asp 58 For those states that have provided infor- 1 minute in 2 years mation to the CDC, the site lists fluoridation status by 1 cent in$10,000 water system. Fluoridation Facts 11 � a.k b - -'1 - _ x €'�, ` a i- '� k. �'o ams �,,� ' • The EPA does not have the authority to regulate QUESTION 6. private drinking water wells. However, the EPA recom Is there a difference in the effectiveness between natu- mends that private well water be tested every year. rally occurring fluoridated water (at optimal fluoride While the EPA does not specifically recommend testing levels) and water that has fluoride added to reach the for the level of fluoride, health professionals will need optimal level? this information prior to consideration of prescription of dietary fluoride supplements or to counsel patients about alternative water sources to reduce the risk of Answer. fluorosis if the fluoride levels are above 2 ppm.59 No. The dental benefits'of optimally fluoridated water Additional information on this topic may be found in occur regardless of the fluoride's source. Questions 12,24,25 and 42. Fact. • Always use a state certified laboratory that conducts Fluoride is present in water as "ions" or electrically drinking water tests.59 For a list of state certified labs,con charged atoms.36 These ions are the same whether ac- tact the local,county or state water/health department. quired by water as it seeps through rocks and sand or added to the water supply under carefully controlled conditions. When fluoride is added under controlled QUESTION 5. conditions to fluoride-deficient water, the dental ben- What additives are used to fluoridate water supplies in efits are the same as those obtained from naturally fluo the United States? ridated water. Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all Answer. drinking water sources. Sodium fluoride,sodium fluorosilicate and fluorosilicic acid are the three additives approved for communityuoridation:is merelan increase of water fluoridation in the United States. Sodium fluoro y' ' 'x level of the naturally occurring fluoride silicate and fluorosilicic acid are sometimes referred to G; r� 5. presentln all drinking water sources as silicofluoride additives. 6. Fact. The three basic additives used to fluoridate water in the Some individuals use the term "artificial fluorida 7. tion" to imply that the process of water fluoridation is United States are: 1) sodium fluoride which is a white, unnatural and that it delivers a foreign substance into odorless material available either as a powder or crys` a water supply when, in fact, all water sources contain tals;2) sodium fluorosilicate which is a white or yellow- some fluoride. Community water fluoridation is a natu- white, odorless crystalline material and 3) fluorosilicic ral wayto improve oral healthy acid which is a white to straw-colored liquid.as, (Additional information on this topic may be found in u While fluoridation began in 1945 with the use of so Question 45. dium fluoride, the use of silicofluorides began in 1946 Prior to the initiation of"adjusted"water fluoridation, and, by 1951, they were the most commonly used ad several classic epidemiological studies were conducted ditives.61First used in the late 1940s, fluorosilicic acid that compared naturally occurring fluoridated water to is currently the most commonly used additive to fluori fluoride-deficient water. Strikingly low decay rates were date communities in the U.S. found to be associated with the continuous use of water with fluoride content of 1 part per million.12 �.� `� To ensureythe�publrc's�safety standards - A fluoridation study conducted in the Ontario, Cana- liave been established to ensure the afety da, communities of Brantford (optimally fluoridated by of fluoride additives used in water adjustment), Stratford (optimally fluoridated naturally) and Sarnia (fluoride-deficient) revealed much lower de- treatrnenfim cay rates in both Brantford and Stratford as compared ' "} to nonfluoridated Sarnia. There was no observable dif- To ensure the public's safety, standards have been ference in decay-reducing effect between the naturally established to ensure the safety of fluoride additives occurring fluoride and adjusted fluoride concentration used in water treatment in the U.S. Specifically, addi water supplies, proving that dental benefits were simi- tives used in water fluoridation meet standards of the lar regardless of the source of fluoride. 16 American Water Works Association (AWWA) and NSF International (NSF). Additional information on the topic of fluoride addi- tives may be found in Fluoridation Practice Section. 12 American Dental Association Q i � f v5• e 7 a F 3 TXs a . ENE a .; +; V =s �. ,�: 19z ' r � ■ a , s; �xBFIaS , ' • ,,,. ..� .. ,., ..r,r .'4. .., :- ^ _._ --.c .. .. .,_..... : . .. .. _ s. fi'•x.a�,«e, fig... _ .. .�, . •�. • `.fir,. � rY^Z"i■ ��, • r,,v QUESTION 7 After 14 years of fluoridation in Evanston, Illinois, Is water fluoridation effective in helping to prevent den- 14-year-olds had 57% fewer decayed, missing or filled tal decay? teeth than the control group in Oak Park, Illinois, who drank water low in fluoride.65 Answer. In 1983, a study was undertaken in North Wales Overwhelming evidence exists to prove the effective- (Great Britain) to determine if the decay rate of fluori- ness of water fluoridation. Water fluoridation is a very dated Anglesey continued to be lower than that of non- effective method for preventing dental decay for chil- fluoridated Arfon, as had been indicated in a previous dren, adolescents and adults. Continued assessment, survey conducted in 1974. Decay rates of life-long resi- however, is important as the patterns and extent of dents in Anglesey, aged 5, 12 and 15, were compared dental decay change in populations. with decay rates of identically aged residents in nonflu- oridated Arfon. Study results demonstrated that a de- Fact. cline in decay had occurred in both communities since The effectiveness of water fluoridation has been docu- the previous survey in 1974. However, the mean decay mented in scientific literature for over 60 years. (See rate of the children in fluoridated Anglesey was still 45% Figure 2.) Even before the first community fluoridation lower than that of those living in nonfluoridated Arfon.66 program began in 1945,'epidemiologic data from the These findings indicated a continuing need for fluorida- 1930s and 1940s revealed lower number of cavities in children consuming naturally occurring fluoridated wa- although decay levels had declined.67 ter compared to children consuming fluoride-deficient In the United States, an epidemiological survey of water."•12 Since that time, thousands of studies have nearly 40,000 schoolchildren was completed in 1987.29 been done which continue to prove fluoride's effective- Nearly 50% of the children in the study aged 5 to 17 ness in decay reduction. years were decay-free in their permanent teeth, which In Grand Rapids, Michigan, the first city in the world was a major change from a similar survey in 1980 in to fluoridate its water supply, a 15-year landmark study which approximately 37% were decay-free. This dra- showed that children who consumed fluoridated water matic decline in decay rates was attributed primarily from birth had 50-63%less dental decay than children who to the widespread use of fluoride in community water had been examined during the original baseline survey completed in nonfluoridated Muskegon,Michigan 63 supplies, toothpastes, supplements and mouthrinses. Ten years after fluoridation.in Newburgh, New York, Although decay rates had declined overall, data also 6- to 9-year-olds had 58% less dental decay than their revealed that the decay rate was 25% lower in children counterparts in nonfluoridated Kingston, New York, with continuous residence in fluoridated communities which was fluoride-deficient. After 15 years, 13- to 14- when the data was adjusted to control for fluoride ex- year-olds in Newburgh had 70% less decay than the posure from supplements and topical treatments. children in Kingston.66 A controlled study conducted in 1990 demonstrated that average dental decay experience among schoolchil- Figure 2. Effectiveness,of Community dren who were lifelong residents of communities with Water Fluoridation low fluoride levels in drinking water was 61-100% high- Ceniers`for Disease Control and==Prevention Recom ; er as compared with dental decay experience among -,:tridiidationSlcifiUsingpilprideiTttiPreventand Control`: schoolchildren who were lifelong residents of a com- Dental Canesrn.the United States MMWR 2001 50 munity with an optimal level of fluoride in the drinking '(No RR=14),(Guidelines on the_use of_fluoride) water.68 In addition, the findings of this study suggest that community water fluoridation still provides signifi- Horow�tz HS The effectiveness.of communityywa cant public health benefits and that dental sealants can ter fluoridation'in the United States J Pub1ic Health play a significant role in preventing dental decay. Dent 1996 56(5 Spec Noj 253 8=(A review of fifty Using data from the dental surveys in 1991-2 and years ofiwater fldondation) 1993-4, a British study predicted that on average,water Murray JJ Efficacy of preventivea'gents for dental' fluoridation produces a 44% reduction in dental decay caries Ganes Res 1993 27(Supp[1)2 8a 4 review of in 5-year-old children. The study further demonstrated s udies conducted from 1976 through 1987 ) that children in lower socioeconomic groups derive Newbrun E ,Effectweness of water fJuondation an even greater benefit from water fluoridation with J Public`Health Dent 1989 49(5):279 89 (The analysis K an average 54% reduction in dental decay. Therefore, ofthe results of 793 studies m 23'countrie's) children with the greatest dental need benefit the most Ripa[W A half century of communitywaterfluorida from water fluoridation.69 _tion mthe United States;review and commentary._J' In 1993,the results of 113 studies in 23 countries were Public Health Dent 1993 53(7}17 44 (The-analysts of compiled and analyzed. (Fifty-nine out of the 113 stud ears-----—rfluohdation) ies analyzed were conducted in the United States.) This YY review provided effectiveness data for 66 studies in pri mary teeth and for 86 studies in permanent teeth. Taken Fluoridation Facts 13 4a0,14.'"- '15A;".41 sY . �1ti!� 1 ' t % `I'- e� `4".c' �r a . ,44 together,the most frequently reported decay reductions QUESTION 8. observed were: With other forms of fluoride now available,is water flu- 40-49% for primary teeth or baby teeth;and oridation still an effective method for preventing dental 50-59% for permanent teeth or adult teeth. decay? In a second review of studies conducted from 1976 through 1987,28 when data for different age groups were Answer, separated, reductions in dental, decay in fluoridated Although other forms of fluoride are available,persons communities were: in nonfluoridated communities continue to demon- 30-60% in the primary dentition or baby teeth; strate higher dental decay rates than their counterparts 20-40% in the mixed dentition*(aged 8 to 12); in communities with water fluoridation 68.",72,79-8a (*A mixed dentition is composed of both baby teeth and adult teeth.) Fact. 15-35% in the permanent dentition or adult teeth In the 1940s, children in communities with optimally (aged 14 to 17);and fluoridated drinking water had reductions in decay rates 15-35% in the permanent dentition (adults and of approximately 60% as compared to those living in • seniors). nonfluoridated communities. At that time, drinking wa- A comprehensive analysis of the 50-year history ter was the only source of fluoride other than fluoride of community water fluoridation in the United States that occurs naturally in foods. • further demonstrated that the inverse relationship be- Recent studies reveal that decay rates have declined tween higher fluoride concentration in drinking water in naturally or adjusted fluoridated areas and nonfluo- and lower levels of dental decay discovered a half-cen- ridated areas as well. One factor is the high geographic tury ago continued to be true." mobility of our populations. In other words,it is becom- Baby bottle tooth decay is a severe type of early child- ing increasing difficult to study large numbers of people hood decay that seriously affects babies and toddlers in in one location who have a history of consuming only some populations. Water fluoridation is highly effective fluoridated or nonfluoridated water. 8in preventing decay in baby teeth,especially in children from low socioeconomic groups,72 In a 1998 review of 9, the effectiveness of methods currently used to prevent Even trian era4wrth widespread avadabr/rfy ,` . this type of decay,water fluoridation received the high- iqouire*,stlichei prove est rating. For very young children, water fluoridation water;fluorrdatron continuessto be effective is the only means of prevention that does not require a m,re'duCrn dents(deco by 20 40% dental visit or motivation of parents and caregivers.73 In 2001, the National Institutes of Health (NIH) held - a consensus development conference, "Diagnosis and A second factoris the universal availability of fluo- Management of Dental Caries Throughout Life." As part ride from other sources including food, beverages, den- of the Consensus Statement issued at the conclusion of tal products (toothpaste, rinses, professionally applied the conference, the panel noted that water fluoridation foams, gels and varnish) and dietary supplements.84 is widely accepted as both effective and of great impor- Foods and beverages processed in optimally fluoridated tance in the primary prevention of tooth decay,74 cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods } and beverages are consumed not only in the city where Children withhthe greatestdentaneed"benefit' -` processed, but may be distributed to and consumed in m the ost.fromwaterfluoridatron The US Task * nonfluoridated areas 256 This "halo" or"diffusion" effect Forcestionglyrecommended thatcommundyY - results in increased fluoride intake by people in nonfluori- waterfluorrdationbea»cluded as partofa dated communities, providing them increased protection against dental decay,527186 As a result of the widespread coin prehensrveyopulatron based strategyto availability of thesevarious sources of fluoride, the dif prevent or control tooth decayrn communrtres''_ t== ference between decay rates in fluoridated areas and nonfluoridated areas is somewhat less than several de- • cades ago but it is still significant 87 Failure to account A systematic review of published studies conducted for the diffusion effect may result in an underestimation in 2001 by a team of experts on behalf of the U.S. Task of the total benefit of water fluoridation especially in ar- Force on Community Preventive Services found that flu- eas where large quantities of fluoridated products are oridation was effective in reducing tooth decay among brought into nonfluoridated communities 86 populations. Based on strong evidence of effectiveness, Even in an era with widespread availability of fluo- the Task Force strongly recommended that community ride from other sources, studies prove water fluorida- water fluoridation be included as part of a comprehen- tion continues to be effective in reducing dental decay sive population-based strategy to prevent or control by 20-40%.28.29 tooth decay in communities 75-78 14 American Dental Association ,� f • � :r f ° °Px' ,B'ENE`FITS .. • QUESTION 9. on the city of Galesburg, Illinois, a community whose What happens if water fluoridation is discontinued?. public water supply contained naturally occurring fluoride at 2.2 ppm. In 1959, Galesburg switched its Answer. community water source to the Mississippi River. This Over time, dental decay can be expected to increase if alternative water source provided the citizens of Gales water fluoridation in a community is discontinued,even burg a sub optimal level of fluoride at approximately if topical products such as fluoride toothpaste and fluo 0.1 ppm. During the time when the fluoride content ride rinses are widely used. was below optimal levels, data revealed a 10% de- crease in the number of decay-free.14-year-olds(oldest Fact. group observed), and a 38% increase in dental decay. The following paragraphs provide a summary of key his- Two years later, in 1961, the water was fluoridated at torical studies that have been conducted on the discon- the recommended level of 1.0 ppm.92 tinuation of water fluoridation. There have been several studies from outside the Antigo, Wisconsin began water fluoridation in June United States that have reported no increase in den- 1949,and ceased adding fluoride to its water in Novem- tal decay following the discontinuation of fluoridation. ber 1960. After five and one-half years without opti- However, in all of the cases reported, the discontinua- mal levels of fluoride, second grade children had over tion of fluoridation coincided with the implementation 200% more decay, fourth graders 70% more, and sixth of other measures to prevent dental decay. graders 91% more than those of the same ages in 1960. For example, in La Salud, Cuba a study on dental Residents of Antigo re-instituted water fluoridation in decay in children indicated that the rate of dental de- October 1965 on the basis of the severe deterioration of cay did not increase after fluoridation was stopped in their children's oral health.88 1990. However, at the time fluoridation was discontin- Because of a government decision in 1979, fluorida- ued a new topical fluoride program was initiated where tion in the northern Scotland town of Wick was discon- all children received fluoride mouthrinses on a regular tinued after eight years. The water was returned to its basis and children two to five received fluoride varnish sub-optimal, naturally occurring fluoride level of 0.02 once or twice a year.93 ppm. Data collected to monitor the oral health of Wick In Finland, a longitudinal study of Kuopio (fluoridat- children clearly demonstrated a negative health effect ed from 1959 to 1992)and Jyvaskyla(low levels of natu- from the discontinuation of water fluoridation. Five ral fluoridation) showed little differences in decay rates years after the cessation of water fluoridation, decay in between the two communities. This was attributed to a permanent (adult) teeth had increased 27% and decay number of factors.The populations are extremely simi- in primary (baby) teeth increased 40%.This increase in lar in terms of ethnic background and social structure. decay occurred during a period when there had been Virtually all children and adolescents used the govern- a reported overall reduction in decay nationally and ment-sponsored, comprehensive, free dental care. The when fluoride toothpaste had been widely adopted.89 dental programs exposed the Finnish children to intense These data suggest that decay levels in children can be topical fluoride regimes and dental sealant programs. expected to rise where water fluoridation is interrupted The result was that the effect of water fluoridation ap- or terminated, even when topical fluoride products are peared minimal. Because of these unique set of factors, widely used, it was concluded these results could not be replicated In a similar evaluation, the prevalence of decay in in countries with less intensive preventive dental care 10-year-old children in Stranraer, Scotland increased 94 after the discontinuation 'of water fluoridation, result- programs, ing in a 115% increasein the mean cost of restorative No significant decrease in dental decay was seen dental treatment for decay and a 21% increase in the after fluoridation was discontinued in 1990 in Chemniz mean cost of all dental treatment. These data support and Plauen which are located in what was formerly East the important role water fluoridation plays in the re- Germany. The"intervening factors in this case include duction of dental decay.9° improvements in attitudes toward oral health behav- A U.S.study of 6-and 7-year-old children who had re- fors, broader availability and increased use of other sided in optimally fluoridated areas and then moved to preventive measures including fluoridated salt, fluoride the nonfluoridated community of Coldwater, Michigan, toothpaste and dental sealants.95 revealed an 11% increase in decayed, missing or filled A similar scenario is reported from the Netherlands. tooth surfaces(DMFS) over a 3-yearperiod from the time A study of 15-year-old children in Tiel (fluoridated 1953 the children moved.These data reaffirm that relying only to 1973) and Culemborg (nonfluoridated) was conduct- on topical forms of fluoride is not an effective or prudent ed comparing dental decay rates from a baseline in public health practice 28'91 Decay reductions are greatest 1968 through 1988. The lower dental decay rate in Tiel where water fluoridation is available in addition to topical after the cessation of fluoridation was attributed in part fluorides,such as fluoride toothpaste and fluoride rinses.. to the initiation of a dental health education program, Finally, a study that reported the relationship be- free dietary fluoride supplements and a greater use of tween fluoridated water and decay prevalence focused professionally applied topical fluorides.96 Fluoridation Facts 15 6.,74,,..,!:-::::,:-.3$, _ - V .. .� _ � -�"' -s...Y�: �s'.E,.k't�.� �'.....x:.-vE�x ,>- _: ' `=`se+€�l'=`i Fx9'y� �. ' _ 'd --- - QUESTION 10. problems or the cost of services by other health care Is dental decay still a serious problem? providers.102 Again, the goal must be prevention rather than repair. Fluoridation is presently the most cost-ef- fectiveAnswer. method for the prevention of dental decay for Yes.Dental decay or tooth decay is an infectious disease residents of a community in the United States.103'104 that continues to be a significant oral health problem. Fact. QUESTION '�7 Dental decay is, by far, the most common and costly Do adults benefit from fluoridation? oral health problem in all age groups.97 It is one of the principal causes of tooth loss from early childhood Answer. through middle age.9899 Decay continues to be problem- Fluoridation plays a protective role against dental de- atic for middle-aged and older adults, particularly root caythroughout life,benefiting both children and adults. decay because of receding gums. Older adults may ex In fact,inadequate exposure to fluoride places children perience similar or higher levels of dental decay than do and adults in the high risk category for dental decay. - children.100 In addition to its effects in the mouth,dental g g y decay can affect general well-being by interfering with Fact. an individual's ability to eat certain foods and by impact- While the early fluoridation trials were not designed to ing an individual's emotional and social well-being by study the possible benefits fluoridation might have for causing pain and discomfort. Dental decay, particularly adults,by the mid-1950s,there was growing evidence of in the front teeth, can detract from appearance,thus af- both systemic and topical benefits of fluoride exposure. fecting self-esteem and employability. It soon became evident that fluoridation helped prevent decay in adults,too.46 Fluoride has both a systemic and �15 M'Decaj`continues to°be problematic for '- topical effect and is beneficial to adults in two ways.The first is through the remineralization process in enamel, 10. middle-agednd aolder adults,particularly 4, in which eearlydecaydoes not enlarge, and can even re- root decay because of rceding gums "' , ,� _ t == verse, because of frequent exposure to small amounts 11. • - -; 1 :` _'- of fluoride. Studies have clearly shown that the avail- 12. Despite a decrease in the overall decay experience of ability of topical fluoride in an adult's mouth during the initial formation of decay can not only stop the decay U.S. schoolchildren over the past two decades, dental process, but also make the enamel surface more resis- decay is still a significant oral health problem, especial- tant to future acid attacks. Additionally,the presence of ly in certain segments of the population.The 1986-1987 systemic fluoride in saliva provides a reservoir of fluo- National Institute of Dental Research (NIDR) survey of ride ions that can be incorporated into the tooth surface approximately 40,000 U.S. school children found that to prevent decay.63 25% of students ages 5 to 17 accounted for 75% of the &-Additional information on this topic may be found in decay experienced in permanent teeth 97 Despite prog- • Question 2. ress in reducing dental decay, individuals in families living below the poverty level experience more dental / ' decay than those who are economically better off.20 "People in the United States are liwngr ALL° Some of the risk factors that increase an individual's risk ` longer`and retamrng more of therrnatural' ' for decay are inadequate exposure to fluoride, irregular ';'''''':::- .,--,•--'--,-''`.;-'y,Nteeth than ever before "„ ' a4 dental visits, deep pits and fissures in the chewing sur �l ''°r ., -4` r { 3 v,F g - faces of teeth, inadequate flow of saliva,frequent sugar intake and very high oral bacteria counts. Another protective benefit for adults is the prevention Dental decay is one of the most common childhood of root decay.100=105-107 Adults with gum recession are at diseases—five times as common as asthma and seven risk for root decay because the root surface becomes ex- times as common as hay fever in 5- to 17-year-olds. posed to decay-causing bacteria in the mouth. Studies Without fluoridation, there would be manymore than have demonstrated that fluoride is incorporated into the the estimated 51 million school hours lost per year in structure of the root surface, making it more resistant to this country because of dental-related illness."'" decay.118-112 In Ontario, Canada, lifelong residents of the In addition to impacting emotional and social well- naturally fluoridated (1.6 ppm) community of Stratford being,the consequences of dental disease are reflected had significantly lower root decay experience than those in the cost of its treatment. According to the Centers living in the matched, but nonfluoridated,community of for Medicare and Medicaid Services, the nation's total Woodstock.171 bill (including private and public spending) for dental People in the United States are living longer and retain- services in 2003 was estimated to be$74.3 billion. This ing more of their natural teeth than ever before. Because figure does not include indirect expenses of oral health older adults experience more problems with gum reces- 16 American Dental Association .`p "x � r'gaK as _ '41 . :.. '"E E 4 F,a•'*x� , • `wF , A 3 •• k a.• t a • ' m" t .,�kti'••" RB�EN F;1TSI • • sion, the prevalence of root decay increases with age. A explained by differences in oral bacteria,buffer capacity large number of exposed roots Or a history of past root of saliva or salivary flow. The fluoride concentration in decay places an individual in the high risk category for de- the drinking water was solely responsible for decreased cay.3° Data from the 1988-1991 National Health and Nutri- decay rates.16 tion Examination Survey(NHANES III)showed that 22.5% Water fluoridation contributes much more to overall of all adults with natural teeth experienced root decay. health than simply reducing dental decay: it prevents This percentage increased markedly with age: needless infection, pain, suffering and loss of teeth; 1) in the 18-to 24-year-old age group,only 6.9% improves the quality of life and saves vast sums of experienced root decay; money in dental treatment costs.26 Additionally, fluori- 2) in the 35-to 44-year-old age group,20.8% dation conserves natural tooth structure by preventing experienced root decay; the need for initial fillings and subsequent replacement 3) in the 55-to 64-year-old age group,38.2% fillings.117118 showed evidence of root decay;and (+Additional information on this topic may be found in 4) in the over-75 age group,nearly 56%had root Question 2. decay.13 In addition to gum recession,older adults tend to ex- perience decreased salivary flow, or xerostomia, due to op�* the.use of medications or medical conditions."4'115 In- QUESTION e2 adequate flow of saliva places an individual in the high Are dietary fluoride supplements effective? risk category for decay.30 This decrease in salivary flow • can increase the likelihood of dental decay because sa- Answer. liva contains calcium, phosphates and fluorides — all For children who do not live in fluoridated communi- necessary for early repair of dental decay. ties,dietary fluoride supplements are an effective alter- There are data to indicate that individuals who have native to water fluoridation for the prevention of dental consumed fluoridated water continuously from birth decay.19-122 receive the maximum protection against dental decay. However,teeth present in the mouth when exposure to Fact. water fluoridation begins also benefit from the topical Dietary fluoride supplements are available only by pre- effects of exposure to fluoride. In 1989, a small study scriptiori in the United States and are intended for use by in the state of Washington suggested adults exposed children living in nonfluoridated areas to increase their to fluoridated water only during childhood had similar fluoride exposure so that it is similar to that received by decay rates as adults exposed to fluoridated water only children who live in optimally fluoridated areas.123.124 Di- after age 14. This study lends credence to the topical etary fluoride supplements are available in two forms: and systemic benefits of water fluoridation. The topical drops for infants aged six months or older,and chewable effects are reflected in the decay rates of adults exposed tablets for children and adolescents.124 Fluoride supple- to water fluoridation only after age 14. The study also ments should only be prescribed for children living in demonstrates that the preeruptive, systemic effects of nonfluoridated areas. The correct amount of a fluoride fluoridation have lifetime benefits as reflected in the de- supplement is based on the child's age and the existing cay rates of adults exposed to fluoridation only during fluoride level in the drinking water.725 Because fluoride childhood. The same study also noted a 31% reduction is so widely available, it is recommended that dietary of dental disease (based on the average number of de- fluoride supplements be used only according to the rec- cayed or filled tooth surfaces) in adults with a continu- ommended dosage schedule and after consideration of ous lifetime exposure to fluoridated water as compared all sources of fluoride exposure 3°•126 For optimum ben- to adults with no exposure to water fluoridation.10 efits, use of supplements should begin at six months of age and be continued daily until the child is at least 16 years old.125 The current dietary fluoride supplement 'Water fluoridation coi tributes much more schedule is shown in Table 1 on the next page. :to overall health than slmply'reducrng dental i The relatively higher cost and need for compliance F = over an extended period of time is a major procedural =rt prevents�needless��nfectrora earn, and economic disadvantage of community-based fluo- suffering and loss of teefh,-improves the„ ride supplement programs,one that makes them imprac- gualhty of life addsaves vast sures of money tical as an alternative to water fluoridation as a public in dental treatmentcosts _�- health measure. In a controlled situation, as shown in a 6 r study involving children of health professionals,fluoride supplements achieve effectiveness comparable to that of A Swedish study investigating decay activity among water fluoridation. However, even with this highly edu- adults in optimal and low fluoride areas revealed that cated and motivated group of parents,only half continued not only was decay experience significantly lower in the to give their children fluoride tablets for the necessary optimal fluoride area, but the difference could not be number of years.127 Additional studies have verified that Fluoridation Facts 17 ms's,c Table 1. Dietary Fluoride Supplement Schedule 1994125 Approved`by the American Dental Association American Academy of Pediatrics American Academy of Pediatric Dentistry , ;Age s�} {Fluonde'ion level inadr(nk�n water('" ml* <0.3 ppm 0.3-0.6 ppm >0.6 ppm Birth—6 months None None None 6 months—3 years 0.25 mg/day** None None 3—6 years 0.50 mg/day 0.25 mg/day None 6—16 years 1.0 mg/day 0.50 mg/day None *1.0 part per million(ppm)=1 milligram/liter(mg/L) **2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary greatly.128,129,130 In- that children will receive fluoride from other sources dependent reports from several countries, including the (food and beverages) even in nonfluoridated areas,the United States, have demonstrated that community-wide amounts in the table reflect the additional amount of trials of fluoride supplements in which tablets were dis- fluoride intake necessary to achieve an optimal anti- tributed for use at home were largely unsuccessful be- cavity effect. cause of poor compliance.731 While total costs for the purchase of supplements <W - ' r . 1 and administration of a program are small (compared l The3d;.etary'fl *- ,yuoridesupplementschedule with the initial cost of the installation of water fluori- er Is just that a supplement schedule 13. dation equipment), the overall cost of supplements per a,.. child is much greater than the per capita cost of corn- 14. munity fluoridation.'D4 In addition, community water The dietary fluoride supplement schedule should not be fluoridation provides decay prevention benefits for the viewed as recommending the absolute upper limits of 15. entire population regardless of age, socioeconomic sta- the amount of fluoride that should be ingested each day. tus, educational attainment or other social variables.26 In 1997, the Food and Nutrition Board of the Institute This is particularly important for families who do not of Medicine developed the Dietary Reference Intakes, a have access to regular dental services. comprehensive set of reference values for dietary nutri- ((Additional information on this topic may be found in ent values.The new values present nutrient requirements Questions 4,,13,24 and 25. to optimize health and, for the first time, set maximum- level guidelines to reduce the risk of adverse effects from excessive consumption of a nutrient. In the case of fluo- ride, levels were established to reduce dental decay with- • QUESTION 13. out causing moderate dental fluorosis.123 Does the ADA recommend fluoride for children under For example, the dietary fluoride supplement sched- six years of age? ule recommends that a two-year-old child living in a non-fluoridated area (where the primary water source Answer. contains less than 0:3 ppm fluoride) should receive 0.25 Yes. The ADA recognizes that lack of exposure to fluo- mg of supplemental fluoride per day.This does not mean ride places individuals of any age at risk for dental decay. that this child should ingest exactly 0.25 mg of fluoride Fluoride exposure may_take many forms including wa- per day. On the contrary, a two-year-old child could re- ter fluoridation and dietary fluoride supplements. ceive important anti-cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- Fact. verse effects on health. This child would most probably For children who live in nonfluoridated communities, be receiving fluoride from other sources (foods and bev- dietary fluoride supplements are an effective alterna- erages) even in a non-fluoridated area and the recom- tive to water fluoridation to help prevent dental decay. mendation of 0.25 mg of fluoride per day takes this into Dietary fluoride supplements are available only by pre- account. In the unlikely event the child did not receive scription and are intended for use by children living in any extra fluoride from food and beverages,the 0.25 mg nonfluoridated areas to increase their fluoride exposure per day could be inadequate fluoride supplementation to so that it is similar to that experienced by children who achieve an optimal anti-cavity effect. live in optimally fluoridated areas.124 The following statement is correct. "The dosage has The dietary fluoride supplement schedule is just been lowered two different times as evidenced of too that — a supplement schedule (Table 1). Recognizing much fluoride has appeared." Rather than being a prob- 18 American Dental Association s `� •- C BENEFITS lem,as those opposed to the use of fluoride might imply, Saltfluoridation-has several disadvantages that do this is evidence that the ADA is doing the right thing.The not exist with water fluoridation. Challenges occur with ADA continually reviews available scientific evidence,and implementation of salt fluoridation when there are mul- revises its statements based on the most current scien- tiple sources of drinking water in an area. The natural tific information. In 1994, a Dietary Fluoride Supplement fluoride level of each source must be determined and,if Workshop cosponsored by the ADA, the American Acad- the level is optimal or excessive,'fluoridated salt should emy of Pediatric Dentistry and the American Academy of not be distributed in that area.138 Finally,there is general Pediatrics was held in Chicago.Based on a review of scien- agreement that a high consumption of sodium is a risk tific evidence,a consensus was reached on a new dosage factor for hypertension (high blood pressure).139'740 Peo- schedule developed in recognition that numerous sources ple who have hypertension or must restrict their salt in- of topical and systemic fluoride are available today that take may find salt fluoridation an unacceptable method were not available many years ago.125 The revised dietary of receiving fluoride. fluoride supplement schedule appears as Table 1. (+Additional information on this topic may be found in Question 56. Fluoridated milk has been suggested as another alterna- tive to community water fluoridation in countries outside QUESTION 14. the U.S. WHO has supported milk fluoridation feasibil- In areas where water fluoridation is not feasible be- ity projects in the United Kingdom, People's Republic of cause of engineering constraints, are alternatives to China,Peru and Thailand.141 Studies among small groups water fluoridation available? of children have demonstrated a decrease in dental de- cay levels resulting from consumption of fluoridated milk; Answer. - however,these studies were not based on large-scale sur- ' Yes. Some countries outside the United States that do veys. More research is needed before milk fluoridation not have piped water supplies capable of accommodat- can be recommended as an alternative to water or salt _ing community water fluoridation have chosen to use fluoridation.142 The rationale,for adding fluoride to milk salt fluoridation. is that this method "targets" fluoride directly to children, but the amount of milk consumed by children is quite Fact. variable, more so than water. Concerns have been raised Salt fluoridation is used extensively in a number of 'about decreased widespread benefits due to the slower countries in Europe (examples: France, Hungary, Ger- absorption of fluoride from milk than from water and the many, Spain and Switzerland) and Central and South considerable number of persons, especially adults, who America (examples: Boliva, Colombia, Cuba, Domini- do not drink milk for various reasons.143 The monitoring can Republic, Ecuador, El 'Salvador, Honduras, Nica- of fluoride•content in milk is technically more difficult than ragua, Venezuela, Costa Rica, Jamaica, Mexico, Peru for drinking water because there are many more dairies and Uruguay.)132'133 The Pan American Health Organi- than communal water supplies. In addition, because fluo- zation (PAHO), a regional divisionof the World Health ridated milk should not be sold in areas having natural or Association (WHO), with. responsibilities for health adjusted fluoridation, regulation would be difficult, and matters in North, South and Central America as well established marketing patterns would be disrupted.42 , as the Caribbean has been active in developing strate- . gies to implement decay prevention programs in the regions of the Americas using both water and salt fluoridation.133,134 QUESTION 15. Studies evaluating the effectiveness of salt fluoridation Can the consistent use of bottled water result in indi- outside the U.S. have concluded that fluoride delivered viduals`missing the benefits of 'optimally fluoridated via salt may produce decay reductions similar to that of water? optimally fluoridated water.135 An analysis of published results of studies from some countries shows that, for Answer. 12-year-old children, the initial level of decay reduction Yes.The majority of bottled waters on the market do not due to salt fluoridation is between 35%and 80%.136,137 contain optimal levels(0.7-1.2 ppm)of fluoride.144-148. An advantage of iiat dt require a centralized piped waterfluoridatsonystem.sthThisit isoes of parnoFact. . ticular use in many developing countries that do not Individuals who drink bottled water as their primary have such water systems: When both domestic salt and source of water could be missing the decay preventive bulk salt (used by commercial bakeries, restaurants, in- effects of optimally fluoridated water available from stitutions,and industrial food'production) is fluoridated, their community water supply. the decay-reducing effect may be comparable to that of The consumption of bottled water in the United States water fluoridation over an extended period of time.136 has been growing by at least one gallon per person each On the other hand, when only domestic salt is fluori- - year-more.than doubling in the last ten years. Consump- dated,the decay-reducing effect may be diminished.135 tion.rates for the past five years are shown in Table 2.14 Fluoridation Facts 19 • 1�' F � � �}. ��,-. �'- �{��'��1�1�`"�J"����3^•'� ' S b�Yw ,.L,}� •° �'�,$ �`4 4S F Table 2. U.S. Bottled Water Market149 between the various batches tested of the same brand.154 r i In evaluating how bottled water consumption affects . Per Capita.Consumption 2000 2004 fluoride exposure, there are several factors to consider. t 1 Gallons k,,Annual -- = First is the'amount of bottled water consumed during the Year Per Capita %Change day. Second is whether bottled water is used for drink- 2000 17.2 ing, in meal preparation and for reconstituting soups, juices and other drinks.Third is whether another source 2001 18.7 8.7% of drinking water is accessed during the day such as an 2002 20.7 10.8% optimally fluoridated community water supply at day- care,school or work. 2003 22.1 7.0% A final important issue is determining the fluoride 2004 23.8 7.6% content of the bottled water. While drinking water is reg- ulated by the U.S. EPA,155 bottled water is regulated by In 2004,total U.S. sales of bottled water surpassed 6.8 the U.S. Food and Drug Administration (FDA) which has established standards for its quality. billion gallons, an 8.6% advance over 2003 with whole- ()Additional information on this topic may be found in sale dollar sales reaching a record of approximately$9.2 Question 43. billion. This category includes sparkling and non-spar- Bottled water is defined as water that is intended for kling water,domestic and imported water,water in single- human consumption sealed in bottles or other containers serve bottles and larger packages as well as vended and with no added ingredients except that it may optionally direct delivered waters. U.S. residents now drink more contain safe and suitable antimicrobial agents. The FDA bottled water annually (23.8 gallons per person in 2004) has established maximum allowable levels for physical, than any other beverage with the exception of carbonated chemical, microbiological, and radiological contaminants soft drinks.145050 In 2004, consumption of carbonated soft drinks fell for the sixth straight year after several decades in the bottled water quality standard regulations.The FDA of uninhibited growth (53.7 gallons per person in 2004 l has also approved standards for the optional addition of 16 compared to 54.8 gallons per person in 1999).150 fluoride. Effective in 1996,FDA regulations require flux- ride content of bottled water to be listed on the label only if fluoride is added during processing.157 If the fluoride "lndivrduals whol dank bottled water''as their level is not shown on the label of the bottled water, the company can be contacted,or the water can be tested to primary source of wafer could be missingobtain this information. the decay preventive effects'of optimally For additional information on bottled water and fluo- fluoridated ,:6I0f-aVi*Oble from her exposure, page - ride view the ADAs Web "Bottled Water, cormmun�ty watersupply'> Home Water Treatment Systems and Fluoride Exposure" Y ; at http://www.ada.org/goto/bottledwater. (Figure 3) Figure 3. Bottled Water/Home Water In 1994,a small study at two community health centers Treatment Systems in Rhode Island showed that 55% of the total households responding used only bottled water for drinking while 59% A MISSING INGREDIENT.? of the households with children reported using only bottled {http//vvwrw ada org/goto/botf' ledwa water for drinking. The vast majority of these bottled wa- ters had less than optimal levels of fluoride. While most of • Does your bottled water contain fluoride? the patient population of the health centers was either on • Does your water filter remove fluoride? public assistance(60%) or uninsured (20%),families spent their limited resources to purchase bottled water. It was ADA American Dental Association® reported that 52%of children on public assistance and 35% of the uninsured children used bottled water.151 America's leading advocate for oral health The fluoride content of bottled water can vary greatly. www.ada.org A 1989 study of pediatric dental patients and their use of bottled water found the fluoride content of bottled water Many ADA resources are at your fingertips 24/7/365. from nine different sources varied from 0.04 ppm to 1.4 Order a library book or products online, read JADA ppm.152 In a 1991 study of 39 bottled water samples,34 articles,discuss important topics with colleagues,find had fluoride levels below 0.3 ppm. Over the two years helpful information on professional topics from u c do the study was conducted, six products showed a two-to Cation to X-rays and recommend our dental education animations,stories and games to your patients. four-fold drop in fluoride content.153 A similar study of five national brands of bottled water conducted in 2000, y t f r 3 P 7 dav1 4,,7 `; z i showed that significant differences in fluoride concentra Be resourceful 1/�sit ADA'org'today! Yiy� g �_ . ,�,., ,a ,,.�r;�.w . x ��:,�• tion existed between the five brands and that three of the five brands tested demonstrated significant differences 20 American Dental Association c � 9 ?P x .. � A . Lowr • 5PY'v k E r 'L. • n x ' .BENF ITS k r QUESTION 16. Notes Can home water treatment systems (e.g.water filters) affect optimally fluoridated water supplies? Answer. Yes. Some types of home water treatment systems can reduce the fluoride levels in water supplies potentially decreasing the decay-preventive effects of optimally -fluoridated water. Fact. There are many kinds of home water treatment systems including water filters (for example: carafe filters,faucet filters, under the sink filters and whole house filters), reverse osmosis systems, distillation units and water softeners. There has not been a large body of research regarding the extent to which these treatment systems affect fluoridated water. Available research is often con- flicting and unclear. However, it has been consistently documented that reverse osmosis systems and distilla- tion units remove significant amounts of fluoride from the water supply.41'158'159 On the other hand, repeated studies regarding water softeners confirm earlier re- search indicating the water softening process caused no significant change in fluoride levels.16o,161 With water filters,the fluoride concentration remaining in the water depends on the type and quality of the filter being used, the status of the filter and the filter's age. Some acti- vated carbon filters containing activated alumina may remove significant amounts of the fluoride.162 Each type of filter should be assessed individually.159 Individuals who drink water processed by home wa- ter treatment systems as their primary source of water ' could be losing the decay preventive' effects of opti- mally fluoridated water available from their community , water supply. Consumers using home water treatment systems should have their water tested at least annu- ally to establish the fluoride level of the treated water. More frequent testing may be needed. Testing is avail- able through local and state public health departments: Private laboratories may also offer testing for fluoride levels in water. Information regarding the existing level of fluoride in a community's public water system can be obtained by asking a local dentist,contacting your local or state health department,or contacting thelocal water supplier. (-Additional information on this topic may be found in Question 4. 'For additional information on home water treatment systems and fluoride exposure,view the ADRs Web page "Bottled Water, Home.Water Treatment Systems and Flu- oride Exposure" at http://www.ada.org/goto/bottledwater. (Figure 3) - Fluoridation Facts 21 P's _ t :., it n M 9.V'7:-: 4c'$c+, r.N::7f r i - 1' - y _ xs.3 y l',4 hu"r """'!n K'S y r4 , ,..,- ai a.'ii '1a$;+tuts¢i}. Y„ s 4 •i` ;4:.:!":.,11 .._.�._.._. '..�....__::t..w.:;, :r f ,';--4.==:;-;: ,. ` k , ....- 6__ «. sS:44 t%4 �'t{, . . :.,'°-. .. Of.-is ' '4141iA". i...' ..f.'`.....,'moi? V. . SAFETY Q 17. Harmful to humans? p.22 Q 25. Prevent fluorosis? p.30 Q 34. Fertility? p.35 Q 18. More studies needed? p.23 Q 26. Warning label? p.31 Q 35. Down Syndrome? p.35 Q 19. Total intake? p.24 Q 27. Toxicity? p.31 Q 36. Neurological impact? p.36 Q 20. Daily intake? p.25 Q 28. Cancer? p.32 Q 37. Lead poisoning? p.37 Q 21. Prenatal dietary p 26 Q 29. Enzyme effects? p.33 Q 38. Alzheimer's disease? p.37 fluoride supplements? Q 30. Thyroid gland? p.34 Q 39. Heart disease? p.38 Q 22. Body uptake? p.26 Q 31. Pineal Gland? p.34 Q 40. Kidney disease? p.38 Q 23. Bone health? p.27 Q 32. Allergies? p.34 Q 41. Erroneous health p.39 claims? Q 24. Dental fluorosis? p.28 Q 33. Genetic risk? p.35 QUESTION 'I7 stantiated by generally accepted scientific knowledge. Does fluoride in the water su I at the levels recom After 60 years of research and practical experience, the pp y' preponderance of scientific evidence indicates that fluo- mended for the prevention of dental decay, adversely ridation of community water supplies is both safe and 17. affect human health? effective.169 pp 18. . Answer. ' The overwhelming weight of scientific evidence indi- 'After`SOayears o`fresearch and practical -= cates that fluoridation of community water supplies is experience the xpreponderance of safe. (See Figure 4.) scientific.et idernce indicates that fluoridation Fact. of community water supplies rs both For generations, millions of people have lived in ar >> k"I' 0, r -Safe'and effective ' - eas where fluoride is found naturally in drinking water ' in concentrations as high or higher than those recom- Many organizations in the U.S. and around the ' mended to prevent dental decay. Research conducted world involved with health issues have recognized the among these persons confirms the safety of fluoride value of community water fluoridation. The American in the water supply.84,163-166 In fact, in August 1993,the Dental Association (ADA) adopted its original resolu- National Research Council, a branch of the National tion in support of fluoridation in 1950 and has repeat- Academy of Sciences, released a report prepared edly reaffirmed its position publicly and in its House for the Environmental Protection Agency (EPA) that of Delegates based on its continuing evaluation of the confirmed that the currently allowed fluoride levels safety and effectiveness of fluoridation.3 The 2005 in drinking water do not pose a risk for health prob- "ADA Statement Commemorating the 60" Anniver- lems such as cancer, kidney failure or bone disease.167 sary of Community Water Fluoridation" reinforced that Based on a review of available data on fluoride tox- position.4 The American Medical Association's (AMA) icity, the expert subcommittee that wrote the report House of Delegates first endorsed fluoridation in 1951. concluded that the EPA's ceiling of 4 ppm for naturally In 1986,and again in 1996,the AMA reaffirmed its sup- occurring fluoride in drinking water was "appropri- port for fluoridation as an effective means of reducing ate as an interim standard."167 Subsequently, the EPA dental decay.170 The World Health Organization, which announced that the ceiling of 4 ppm would protect initially recommended thepractice of water fluoride- against adverse health effects with an adequate mar- ' tion in 1969,171 reaffirmed its support for fluoridation gin of safety and published a notice of intent not to in 1994 stating that: "Providing that a community has revise the fluoride drinking water standard in the Fed- a piped water supply, water fluoridation is the most eral Register.168 effective method of reaching the whole population, As with other nutrients,fluoride is safe and effective so that all social classes benefit without the need for when used and consumed properly. No charge against active participation on the part of individuals."138 Fol- the benefits and safety of fluoridation has ever been sub- lowing a comprehensive 1991 review and evaluation of 22 American Dental Association 1111 r 3 4:4'.1" . '' 1,d x sa'33'...i.,„:24,43' �'t. 1m .;e ., + '-{ .` °tinfi":34 4%' 4 it a , l' '14: '. :: -,,`::..---.7-i : !F `5 F '4'F -4'° ;;-4 ,fe, ,r, 1,-;.."!i-,?,.:.„ '. • ,vim £v r x i.,..ya+^:4,. '.3 E*ea* likr '.. � ' Tt d[+p�`a e , �. V<.4::.',.%.- ''A'":'.4';"; :3 ` .•a€r ,$ � ., � x:% '`: �-Ouesfion24"0":4k,'').4%1:134:1-."'"3;',.4.41 - ' .r't.,` £ -.r7S4R4•. "'*e _- _ - _ ...� `w0..��i' b 9 q — Figure 4. Safety of Community tees of experts, special councils of government and Water Fluoridation most of the world's major national and internation ' al health organizations. The verdict of the scientific Institiite of Medicine Food aril Nutrition Board community is that water fluoridation, at recommend Dietary reference intakes for calcium'phospho ed levels, safely provides major oral health benefits. rus magnesiurri vitamin D acid fluontle Report The question of possible secondary health effects of th'i Standing Corcirnittee;.on- the Scientific caused by fluorides consumed in optimal Concentra uation of Dietary'Reference Intakes Wash tions throughout life has been the object of thorough Eval <ington:DC 'NationalAcademy`Press;1997 medical investigations which have failed to show any impairment of general health throughout life.138163-166 National Research Council Health effects of in 43'gestedoride Report of Subcommittee on :fiu -;.Health'Effects of�Ingestedthe Fluoride Washing The verdicf of the scient�frc community- ton,DC National Academy Press 1993 .ts that'water fluondation,at recommended levels;.safely provides major 'US Department of Health and Human Services - oral hC.-'-,P,,;-,-i,ltht:-t--+&`!Pt.,,irrqi-,-1q-7vi.1..1v,'::1',,-$',Vf;+,'s;r;A,1-,;,,,,i,:,;,- ;!.:.F1.:-',,'_V-,',;4' ,:, ,'.:.3PUbliCTHeOlfW.SetiiC6:.peyiewinfIllArjdOber = ; :efits and',risks Report of the Ad Hoc?:Subcommrt tee on`FluorideIWashington DC February 1991: In scientific research,there is no such thing as "final knowledge." New information is continuously emerg- World-Health:'Organization Fluorides and h_n ; ing and being disseminated. Under the Safe Drinking `'man`health Monograph series no 59 Geneva, Water Act (SDWA), the U. S. Environmental Protection Switzerland 1970 Agency (EPA) must periodically review the existing Na- tional Primary Drinking Water Regulations (NPDWRs) "not less often-than every 6 years." This review is a the public health benefits and risks of fluoride,the U.S. routine part of the EPA's operations as dictated by the Pubc Health Service reaffirmed its support for fluori- SDWA.172 dation and continues to recommend the use of fluoride In April 2002, the EPA announced the results of its to prevent dental decay.84 preliminary revise/not revise decisions for 68 chemi- Recent statements by five leading health authorities cal NPDWRs. Fluoride was one of the 68 chemicals re viewed. The EPA determined that it fell under the "Not on community water fluoridation can be found in the Appropriate for Revision at this Time" category, but not- back of this publication. ed that it planned to ask the National Academy of Sci- National and international health, service and pro- ence (NAS) to update the risk assessment for fluoride. fessional organizations that recognize the public health The NAS had previously completed a review of fluoride benefits of community water fluoridation for prevent- for EPA approximately 12 years ago which was pub- ing dental decay are listed on the inside back cover of lished as "Health Effects of Ingested Fluoride" in 1993 this publication. . by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the Sub- QUESTION 1 . • committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data pub- Are additional studies being conducted to determine lished since 1993 and exposure data on orally ingest- the effects of fluorides in humans? ed fluoride from drinking water and other sources (e.g., food, toothpaste, mouthrinses). Based on this Answer. review the Subcommittee will evaluate the scien- Yes. Since its inception, fluoridation has undergone tific and technical basis of the EPA's maximum con- a nearly continuous process of reevaluation. As with taminant level (MCL) of 4 milligram per liter (mg/L other areas of science,additional studies on the effects or ppm) and secondary maximum contaminant level of fluorides in humans can provide insight as to how to (SMCL) of 2 mg/L for fluoride in drinking water. The make more effective choices for the use of fluoride. The Subcommittee will advise the EPA on the adequacy American Dental Association and the U.S.Public Health of its fluoride MCL and SMCL to protect children and Service support this on-going research. others from adverse health effects and identify data gaps and make recommendations for future research Fact. relevant to setting the MCL and SMCL for fluoride. For more than 60 years, thousands of reports have The Subcommittee began its work in November 2002 been published on all aspects of fluoridation.B4,167 The and is currently projected to complete the project in accumulated dental, medical and public health evi- early 2006.173 dence concerning fluoridation has been reviewed and The definition of a contaminant is a function of the evaluated numerous times by academicians, commit- National Primary Drinking Water Regulations. The EPA Fluoridation Facts 23 -.u7,,.� - - - -- -U 3-` ,>'7+�7.9 v";" "' -` '� - "!�y,-, As4� ••�t,. -p '.f J s:a ' ' considers a contaminant to be ANYTHING found in wa- dental fluorosis in the Bartlett residents, the study in- ter that may be harmful to human health. The EPA has dicated that long term consumption of dietary fluoride designated 90 microorganisms, minerals and chemicals (resident average length of fluoride exposure was 36.7 as contaminants.174,175 years), even at levels considerably higher than recom- While research continues,the weight of scientific evi- mended for decay prevention, resulted in no clinically dence indicates water fluoridation is safe and effective significant physiological or functional effects.166 in preventing dental decay in humans.B4 Fluoride in Food Additional information on this topic may be found in Foods and beverages commercially processed (cooked Questions 7, 8,and 42. or reconstituted) in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and QUESTION 19. bev- erages are consumed not only in the city where pro- cessed,.but may be distributed to and consumed in Does the total intake of fluoride from air, water and nonfluoridated areas.26 This "halo" or "diffusion" ef- food pose significant health risks? fect results in increased fluoride intake by people in nonfluoridated communities, providing them increased Answer. protection against dental decay.71'85•86 As a result of the The total intake of fluoride from air, water and food, widespread availability of these various sources of in an optimally fluoridated community in the United fluoride, the difference between decay rates in fluo- States,does not pose significant health risks. ridated areas and nonfluoridated areas is somewhat less than several decades ago but still significant.B7 Fact. Failure to account for the diffusion effect may result in Fluoride from the Air an underestimation of the total benefit of water fluo- The atmosphere normally contains negligible concen- ridation especially in areas where a large amount of trations Of airborne fluorides. Studies reporting the lev- fluoridated products are brought into nonfluoridated 19. els of fluoride in air in the United States suggest that communities.86 ambient fluoride contributes little to a person's overall Water and water-based beverages are the chief source 20. fluoride intake.779.180 of dietary fluoride intake. Conventional estimates are that approximately 75% of dietary fluoride comes from Fluoride from Water water and water-based beverages.179 In the United States, the natural level of fluoride in The average daily dietary intake of fluoride (ex- ground water varies from very low levels to over 4 ppm. pressed on a body weight basis) by children residing in Public water systems in the U.S. are monitored by the optimally fluoridated (1 ppm) communities is 0.05 mg/ Environmental Protection Agency (EPA),which requires kg/day; in communities without optimally fluoridated that public water systems not exceed fluoride levels of 4 water, average intakes for children are about 50% low- ppm.7fi8 The optimal concentration for fluoride in water er.123 Dietary fluoride intake by adults in optimally fluo- in the United States has been established in the range ridated (1 ppm)areas averages 1.4 to 3.4 mg/day,and in of 0.7 to 1.2 ppm. This range will effectively reduce den- nonfluoridated areas averages 0.3 to 1.0 mg/day.123 tal decay while minimizing the occurrence of mild den- In looking at the fluoride content of food and bever- tal fluorosis. The optimal fluoride level is dependent on ages over time, it appears that fluoride intake from di- the annual average of the maximum daily air tempera- etary sources has remained relatively constant. Except ture in the geographic area.36 for samples prepared or cooked with fluoridated wa- Children living in a community with water fluori- ter, the fluoride content Of most foods and beverages dation get a portion of their daily fluoride intake from is not significantly different between fluoridated and fluoridated water and a portion from dietary sources nonfluoridated communities. When fluoridated water which would include food and other beverages. When is used to prepare or cook the samples, the fluoride considering water fluoridation, an individual must con- content of foods and beverages is higher as reflected sume one liter of water fluoridated at 1 part per million in the intake amounts noted in the previous paragraph. (1 ppm) to receive 1 milligram (1 mg) of fluoride.42.178 This difference has remained relatively constant over Children under six years of age, on average, consume time.180.161 less than one-half liter of drinking water a day.178 There- The fluoride content of fresh solid foods in fore,children under six years of age would consume,on the United States generally ranges from 0.01 to average, less than 0.5 mg of fluoride a day from drink- 1.0 part per million.102.179 It has long been known that ing optimally fluoridated water(at 1 ppm). fish, such as sardines, may contribute to higher A ten-year comparison study of long-time residents dietary fluoride intake if the bones are ingested of Bartlett and Cameron, Texas, where the water sup- as fluoride has an affinity for calcified tissues. plies contained 8.0 and 0.4 parts per million of fluo- Additionally, brewed teas may also contain fluoride ride, respectively, included examinations of organs, concentrations of 1 ppm to 6 ppm depending on bones and tissues. Other than a higher prevalence of the amount of dry tea used, the water fluo- 24 American Dental Association t 4SAFETY k ride concentration and the brewing time.182 The fluo- been set by the National Academy of Sciences since ride value for unsweetened instant tea powder appears 1941. The new values present nutrient requirements to very high when reported as a dry powder because this optimize health and, for the first time, set maximum- product is extremely concentrated. However,when one level guidelines to reduce the risk of adverse effects teaspoon of the unsweetened tea powder is added to from excessive consumption of a nutrient. Along with an eight ounce cup of tap water,the value for prepared calcium, phosphorous, magnesium and vitamin D, DRIs instant tea is similar to the values reported for regular for fluoride were established because of its proven ef- brewed tea.179 fect on dental decay. Unveiled in 2004, the National Fluoride Database is As demonstrated in Table 3, fluoride intake in the a comprehensive, nationally representative database of United States has a large range of safety. the fluoride concentration in foods and beverages con- The first DRI reference value is the Adequate In- sumed in the United States. The database for fluoride take (Al) which establishes a goal for intake to sustain was designed for use by epidemiologists and health re- a desired indicator of health without causing side ef- searchers to estimate fluoride intake and to assist in the fects. In the case of fluoride, the Al is the daily intake investigation of the relationships between fluoride in- level required to reduce dental decay without causing take and human health. The database contains fluoride moderate dental fluorosis. The Al for fluoride from all values for beverages, water, and some lower priority sources (fluoridated water, food, beverages, fluoride foods.779 dental products and dietary fluoride supplements) is set at 0.05 mg/kg/day (milligram per kilogram of body weight per day). Using the established Al of 0.05 mg/kg,the amount of QUESTION 20. fluoride for optimal health to be consumed each day has How much fluoride should an individual consume each been calculated by gender and age group(expressed as day to reduce the occurrence of dental decay? average weight). See Table 3 in this Question. The DRIs also established a second reference value Answer. for maximum-level guidelines called tolerable upper The appropriate amount of daily fluoride intake var- intake levels (UL). The UL is higher than the Al and is ies with age and body weight.As with other nutrients, not the recommended level of intake. The UL is the es- fluoride is safe and effective when used and consumed timated maximum intake level that should not produce properly. unwanted effects on health. The UL for fluoride from all sources (fluoridated water, food, beverages, fluoride Fact. dental products and dietary fluoride supplements) is set In 1997,the Food and Nutrition Board of the Institute of at 0.10 mg/kg/day(milligram per kilogram of body weight Medicine developed a comprehensive set of reference per day)for infants,toddlers,and children through eight values for dietary nutrient intakes.123 These new refer- years of age. For older children and adults,who are no ence values,the Dietary Reference Intakes(DRI), replace longer at risk for dental fluorosis, the UL for fluoride is the Recommended Dietary Allowances(RDA)which had set at 10 mg/day regardless of weight. Table 3. Dietary Reference Intakes for Fluoride Food.and Nutrition Board of the Institute:of Medicine.1997'P I 151; g` .F � Reference Weights Adequate Intake .Tolerintakepper j /day) Infants 0-6 months 7 (16) 0.01 0.7 Infants 7-12 months 9 (20) 0.5 0.9 Children 1-3 years 13 (29) 0.7 1.3 Children 4-8 years 22 (48) 1.0 2.2 Children 9-13 years 40 (88) 2.0 10.0 Boys 14-18 years 64(142) 3.0 10.0 Girls 14-18 years 57 (125) 3.0 10.0 Males 19 years and over 76 (166) 4.0 10.0 Females 19 years and over 61 (133) 3.0 10.0 * Value based on data collected during 19.88-94 as part of the Third National Health and Nutrition Examination Survey (NHANES Illi in the United States.123 Fluoridation Facts 25 E7-77777757:77, 77. _" -` 1t'''✓*7" 4. a , 4` tom,-3t'''i 1 Using the established ULs for fluoride, the amount of fluoride toothpaste on a young child's toothbrush at of fluoride that may be consumed each day to reduce each brushing. Also, young children should be super- the risk of moderate dental fluorosis for children under vised while brushing and taught to spit out, rather than eight, has been calculated by gender and age group(ex- swallow, the toothpaste. Consult with your child's den- pressed as average weight). (See Table 3.) tist or physician if you are considering using fluoride As a practical example,daily intake of 2 mg of fluoride toothpaste before age two. is adequate for a nine to 13-year-old child weighing 88 /Additionl information on this topic may be found in pounds (40 kg). This was calculated by multiplying 0.05 Question 25. mg/kg/day(Al)times 40 kg(weight)to equal 2 mg. At the It should be noted that the amounts of fluoride dis- same time,that 88 pound (40kg) child could consume 10 cussed here are intake,or ingested,amounts.When flu- mg of fluoride a day as a tolerable upper intake level. oride is ingested,a portion is retained in the body and a Children living in a community with water fluori- portion is excreted.This issue will be discussed further dation get a portion of their daily fluoride intake from in Question 22. fluoridated water and a portion from dietary sources which would include food and other beverages. When considering water fluoridation, an individual must con- sume one liter of water fluoridated at 1 part per million QUESTION 21. (1 ppm) to receive 1 milligram (1 mg) of fluoride.42,178 Is there a need for prenatal dietary fluoride supplemen- Children under six years of age, on average, consume tation? less than one-half liter of drinking water a day.18 There- fore,children under six years of age would consume,on Answer. average, less than 0.5 mg of fluoride a day from drink- There is no scientific basis to suggest any need to fin- ing optimally fluoridated water(at 1 ppm). crease a woman's daily fluoride intake during preg- If a child lives in a nonfluoridated area, the dentist or nancy or breastfeeding to protect her health. At this physician may prescribe dietary fluoride supplements. As time, scientific evidence is insufficient to support the shown in Table 1 "Dietary Fluoride Supplement Schedule recommendation for prenatal fluoride supplementation 21. 1994" (See Question 12),the current dosage schedule rec- for decay prevention for infants.123,190 22 ommends supplemental fluoride amounts that are below the Al for each age group. The dosage schedule was de- Fact. 23. signed to offer the benefit of decay reduction with margin The Institute of Medicine has determined that, "No of safety to prevent mild to moderate dental fluorosis. For data from human studies document the metabolism example,the Al for a child 3 years of age is 0.7 mg/day. of fluoride during lactation. Because fluoride concen- The recommended dietary fluoride supplement dosage trations in human milk are very low (0.007 to 0.011 for a child 3 years of age in a nonfluoridated community is ppm) and relatively insensitive to differences in the 0.5 mg/day. This provides leeway for some fluoride intake fluoride concentrations of the mother's drinking water, from processed food and beverages,and other sources. fluoride supplementation during lactation would not Decay rates are declining in many population groups be expected to significantly affect fluoride intake by because children today are being exposed to fluoride the nursing infant or the fluoride requirement of the from a wider variety of sources than decades ago. mother."123 Many of these sources are intended for topical use only; The authors of the only prospective, randomized, however, some fluoride is ingested inadvertently by double blind study to evaluate the effectiveness of children.183 Inappropriate ingestion of fluoride can be prenatal dietary supplementation have concluded that prevented, thus reducing the risk for dental fluorosis the data do not support the hypothesis that prenatal without jeopardizing the benefits to oral health. fluoride has a strong decay preventive effect.190 More- For example, it has been reported in a number of over, prenatal dietary fluoride supplementation will studies that young children inadvertantly swallow an not have an affect on the baby's permanent teeth be- average of 0.30 mg of fluoride from fluoride toothpaste cause permanent teeth do not begin to develop during at each brushing.184,185-189 If a child brushes twice a day, pregnancy.191 0.60 mg may be ingested inappropriately. This may slightly exceed the Adequate Intake (Al) values from Ta- ble 3.The 0.60 mg consumption is 0.10 mg higher than the Al value for children 6 to 12 months and is 0.10 mg QUESTION 22. lower than the Al for children from 1-3 years of age.123 When fluoride is ingested,where does it go? Although toothpaste is not meant to be swallowed,chil- dren may consume the daily recommended Adequate Answer. Intake amount of fluoride from toothpaste alone. In or- Much of the fluoride is excreted. Of the fluoride retained, der to decrease the risk of dental fluorosis,the American almost all is found in calcified (hard) tissues, such as Dental Association since 1992 has recommended that bones and teeth. Fluoride helps to prevent dental decay parents and caregivers put only one pea-sized amount when incorporated into the teeth. 26 American Dental Association • SAFETY Fact. QUESTION 23. . After ingestion of fluoride, Such as drinking a glass of Will the ingestion of optimally fluoridated water over a optimally fluoridated water,the-majority of the fluoride lifetime adversely affect bone health? is absorbed from the stomach and small intestine into the blood stream.192 This causes a short term increase Answer. in fluoride levels in the blood. The fluoride levels in- No, the ingestion of optimally fluoridated water does • crease quickly and reach a peak concentration within not have an adverse effect on bone health.194-'98,203-209 20-60 minutes.793 The concentration declines rapidly, •usually within three to six hours following peak ley- Fact. •. els, due to the uptake of fluoride by calcified tissues The weight of scientific evidence does not provide an and efficient removal of fluoride by the kidneys.182 Ap- proximately 50% of the fluoride absorbed each day by adequate basis for altering public health policy regard young or middle-aged adults becomes associated with ing fluoridation because of bone health concerns. A hard tissues within 24 hours while virtually all of the number of investigations have studied the effects on remainder is excreted in the urine. Approximately 99% bone structure of individuals residing in communi of the fluoride present in the body is associated with ties with optimal and higher than optimal Concentra hard tissues.192 tions of fluoride in the drinking water. These studies Ingested or systemic fluoride becomes incorporated have focused on whether there exists a possible link into forming tooth structures. Fluoride ingested regularly between fluoride and bone fractures. Additionally, the during the time when teeth are developing is deposited passible association between fluoride and bone cancer throughout the entire surface of the tooth and contrib has been studied. utes to long lasting protection against dental decay." In 1991, a workshop, co-sponsored by the Nation (t Additional information on this topic may be found in al Institute of Arthritis and Musculoskeletal and Skin Question 2. Diseases and the then National Institute of Dental Re- An individual's age and stage of skeletal devel- search, addressed the potential relationship of hip frac- opment will affect the rate of fluoride retention.The ture and bone health in humans to fluoride exposure amount of fluoride taken up by bone and retained in from drinking water. Meeting at the National Institutes the body is inversely related to age. More fluoride is of Health, researchers examined historic and contem- retained in young bones than in the bones of older porary research on fluoride exposure and bone health. adults.183•192,193 At that time, participants concluded there was no basis According to generally accepted scientific knowl- for altering current public health policy regarding cur- edge, the ingestion of optimally fluoridated water does rent guidelines for levels of fluoride in drinking water. not have an adverse effect on bone health.184-'98 Evidence Recommendations were made regarding additional re- of advanced skeletal fluorosis, or crippling skeletal search in several areas.'94 fluorosis, "was not seen in communities in the United In 1993, two studies were published demonstrating States where water supplies contained up to 20 ppm that exposure to fluoridated water does not contribute (natural levels of fluoride)."'23''99 In these communities, to an increased risk for hip fractures. One study looked daily fluoride intake of 20 mg/day would not be uncom- at the risk of hip fractures in residents of two similar mon.123 Crippling skeletal fluorosis is extremely rare in communities in Alberta, Canada.195 In this study, re- the United States and is not associated with optimally searchers compared a city with fluoridated drinking fluoridated water; only 5 cases have been confirmed water optimally adjusted to 1 ppm to a city whose during the last 35 years.123 residents drank water containing naturally occurring 6.Additional information on this topic may be found in fluoride at a concentration of only 0.3 ppm. No signifi- Question 23. cant difference was observed in the overall hip frac- The kidneys play the major role in the removal of ture hospitalization rates for residents of both cities. fluoride from the body. Normally kidneys are very ef- "These findings suggest that fluoridation of drinking ficient and excrete fluoride very rapidly. However, de- water has no impact, neither beneficial nor deleteri- creased fluoride removal may occur among persons ous,on the risk of hip fracture."95 with severely'impaired kidney function who may not The second study examined the incidence of hip frac- be on kidney dialysis.167 No cases of dental fluorosis ture rates before and after water fluoridation in Roches- or symptomatic skeletal fluorosis have been reported ter, Minnesota.196 Researchers compared the hip fracture among persons with impaired kidney function; how- rates of men and women aged 50 and older from 1950 ever, the overall health significance of reduced fluoride to 1959 (before the city's water supply was fluoridated removal is uncertain and continued follow-up is recom- in 1960)with the ten-year period after fluoridation.Their mended especially for children with impaired kidney findings showed that hip fracture rates had decreased, . function.64 and that the decrease began before fluoridation was in- 6-Additional information on this topic may be found in troduced, and then continued. These data demonstrate Question 40. no increase in the risk of hip fracture associated with water fluoridation. Fluoridation Facts 27 An ecological study conducted in eastern Germany centrations of sodium fluoride(25, 100 and 175 ppm)were compared the incidence of hip fractures for adults living consumed by rats and mice.When the NTP and the Proctor in Chemnitz (optimally fluoridated) and Halle (fluoride- and Gamble studieswere combined, a total of eight indi- deficient). The results suggested the consumption of vidual sex/species groups became available for analysis. optimally fluoridated water reduced the incidence of hip Seven of these groups showed no significant evidence of fractures in elderly individuals, especially women over malignant tumor formation.One group,male rats from the 84 years of age 200 NTP study, showed "equivocal" evidence of carcinoge- The ingestion of optimally fluoridated water does not nicity,which is defined by NTP as a marginal increase in have an adverse effect on bone health.194-198,20° Exposure neoplasms—i.e.,osteosarcomas (malignant tumors of the to fluoride at levels considered optimal for the prevention bone)—that may be chemically related. The Ad Hoc Sub- of dental decay appears to have no significant impact on committee on Fluoride of the U.S. Public Health Service bone mineral density or risk of bone fracture.201-205 Some combined the results of the two studies and stated:"Taken studies have reported hip fracture risk increased slightly, together,the two animal studies available at this time fail to decreased slightly or was unchanged in fluoridated areas establish an association between fluoride and cancer."84,210 compared to nonfluoridated areas. A recent systematic j+)Additional information on this topic may be found in review of these studies concluded there was no clear as- Question 28. sociation with water fluoridation and hip fracture 206 Exposure to rflu"orideat levels .: . : .. QUESTION 24. consideredoptimpifor`the,prevention_.of- What is dental fluorosis? -dentandeca a earsto`haveno>si odbonefmineratide ns or-`=„'( a' Answer, rrsk of bone fracture ” 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 24. While a number of studies reported findings at a enamel is forming. The risk of dental fluorosis can be population level, both the Hillier and Phipps studies greatly reduced by closely monitoring the proper use examined risk on an individual rather than a commu- of fluoride products by young children. nity basis taking into account other risk factors such as medications, age of menopause, alcohol consumption, Fact. smoking, dietary calcium intake and physical activity. Dental fluorosis is caused by a disruption in enamel for- Using these more rigorous study designs, Hillier and mation which occurs during tooth development in early Phipps reported no change or lower hip fracture risk in childhood related to a higher than optimal intake of flu- those drinking fluoridated water.203204 oride .782 Enamel formation of permanent teeth, other In Bone Health and Osteoporosis:A Report of the Sur- than third molars (wisdom teeth), occurs from about the geon General issued in 2004,fluoride is listed as a nutri- time of birth until approximately five years of age. After ent that has potentially beneficial effects on bone207 tooth enamel is completely formed, dental fluorosis can- Lastly, the possible association between fluoride and not develop even if excessive fluoride is ingested 217 Older bone cancer has been studied. In the early 19905, two children and adults are not at risk for the development of studies were conducted to evaluate the carcinogenicity of dental fluorosis. Dental fluorosis becomes apparent only sodium fluoride in laboratory animals.The first study was after the teeth erupt.Because dental fluorosis occurs while conducted by the National Toxicology Program (NTP) of teeth are forming under the gums,teeth that have erupted the National Institute of Environmental Health Sciences 208 are not at risk for dental fluorosis. It should be noted that The second study was sponsored by the Proctor and Gam- many other developmental changes that affect the appear- ble Company.209 In both studies, higher than optimal con- ance of tooth enamel are not related to fluoride intake. Table 4. Dental Fluorosis Classification by H.T. Dean-1:422'2 '..}''I 1'--� -L,- -- � �> it j : --1.� :'--- z -.. i a,,, ��- d ti,�'_-s..n� 'tc. «a Classification' r,i-; , r,, 00 —DescriptLo tii,ii amM . `' z ,.. _.�- .,._. �''` 7In y� Normal Smooth,glossy,pale creamy-white translucent surface Questionable A few white flecks or white spots Very Mild Small opaque,paper-white areas covering less than 25%of the tooth surface Mild Opaque white areas covering less than 50%of the tooth surface Moderate All tooth surfaces affected;marked wear on biting surfaces; brown stain may be present Severe All tooth surfaces affected;discrete or confluent pitting;brown stain present 28 American Dental Association s 7,.4• 4,7-4.7.1:J-'b ".y -vim �,. ,` - V*, ! '(:.;h. . 7:1ei, a."-.7,.-, s. �4Y##r`-4 i. ,., ,z�• g',M k.::i %,,'.'- SAFETY 7"'":.'1''" --T-' or. .,,,.` o '.A,r*S33 '.� ; 4 '. , • , _ aFP` - Dental fluorosis has been classified in a number of sources including water, infant formula, foods, foods ways.One of the most universally accepted classifications and drinks prepared with fluoridated water as well as was developed by H.T. Dean in 1942;its descriptions can dietary supplements and the ingestion of fluoride tooth- be easily visualized by the public(see Table 4).212 paste making it difficult to pinpoint the effect any one In using Dean's Fluorosis Index, each tooth present item had on the development of fluorosis. As part of the in an individual's mouth is rated according to the fluo- most recent National Health and Nutrition Examination rosis index in Table 4.The individual's fluorosis score is Survey (NHANES) 1999-2002, new fluorosis data has based upon the severest form of fluorosis recorded for been collected as a representative sample of the U.S. two or more teeth. Dean's Index, which has been used population. By comparing NIDR and the latest NHANES for more than 60 years, remains popular for prevalence data, researchers will be able to determine trends in the studies in large part due to its simplicity and the ability prevalence and severity of dental fluorosis in the past 15 to make comparisons with findings from a number of years and examine if changes in exposure to systemic earlier studies.213 fluorides such as infant formulas,toothpaste and dietary Very mild to mild fluorosis has no effect on tooth fluoride supplements have had some effect.214 function and may make the tooth enamel more resis- Using the same NIDR study, researchers looked at chil- tent to decay. These types of fluorosis are not readily dren aged 12-14 years who had never received dietary apparent to the affected individual or casual observ- fluoride supplements and had only lived in one home. er and often require a trained specialist to detect. In Through their analysis, they found that approximately contrast, the moderate and severe forms of dental 2% of U.S. school children may experience perceived es- fluorosis, characterized by esthetically (cosmetically) thetic problems which could be attributed to the currently objectionable changes in tooth color and surface ir- recommended levels of fluoride in drinking water. They regularities, are typically easy to detect. Most investi- reported that dental fluorosis in the esthetically important gators regard even the more advanced forms of dental front teeth occurs less often and is less severe than when fluorosis as a cosmetic effect rather than a functional looking at all teeth in an individual. While the researchers adverse effect.123 The U.S. Environmental Protection were not able to provide a cost estimate associated with Agency, in a decision supported by the U.S. Surgeon the treatment of this fluorosis, they did note that such General, has determined that objectionable dental estimates are frequently an overestimation of the actual fluorosis is a cosmetic effect with no known health ef- costs.Additionally, any change recommended to the cur- fects.168 Little research on the psychological effects of rent fluoridation policy would need to be weighed against dental fluorosis on children and adults has been con- fluoridation's lifetime benefits and the feasibility and as- ducted, perhaps because the majority of those who sociated costs of alternative solutions.215 have the milder forms of dental fluorosis are unaware As with other nutrients, fluoride is safe and effective of this condition.84 when used and consumed properly.The recommended In a 1986-7 national survey of U.S. school children optimum water fluoride concentration of 0.7 to 1.2 ppm conducted by the National Institute of Dental Research was established to maximize the decay preventive ben- (NIDR), dental fluorosis was present in 22.3% of the efits of fluoride, and the same time minimize the likeli- children examined using Dean's Index.84 These children hood of mild dental fluorosis 64 were exposed to a variety of sources of fluoride (fluori- dated water, food, beverages, fluoride dental products - 'The:rfsk Offteeth formmg'with the very and dietary supplements). The prevalence of the types - mildest form'of fluorosis rnust be weighed of dental fluorosis observed was: .'-', .,,.7,J:1",'!". :: agamst;'theenefith'at the individual s teeth Very mild fluorosis 17.0% - ' Mild fluorosis 4.0% will also have a lower level`of dental decay Moderate fluorosis 1.0% ,thus saving dental treatrnentcosts patient i Severe fluorosis 0.3% discomfortand tooth'loss - Total 22.3% I , - -, -1' , The incidence of moderate or severefluorosis com- The benefits and risks of community water fluoridation prised a very small portion (6%) of the total amount of have been examined and are discussed extensively in the fluorosis.In other words,94%of all dental fluorosis was Benefits Section and the safety of water fluoridation is the very mild to mild form of dental fluorosis. discussed in great detail in the remainder of this (Safety) This survey conducted by NIDR remains the only Section of this document. In assessing the risks of den- source of national data regarding the prevalence of den- tal fluorosis, scientific evidence indicates it is probable tal fluorosis. In a study that compared this data with data that approximately 10% of children consuming optimally recorded by H. Trendley Dean in the 1930s, it was de- fluoridated water,in the absence of fluoride from all other termined that the greatest increase in fluorosis from the sources,will develop very mild dental fluorosis.10 As de- 1930s to the 1980s appeared in the group with subopti- fined in Table 4, very mild fluorosis is characterized by mally fluoridated water. During the last ten years of this small opaque,paper-white area covering less than 25%of period, children were exposed to fluoride from multiple the tooth surface.The risk of teeth forming with the very Fluoridation Facts 29 • "WA " ro ss 1 S - � ; - • ii �a � .+ y vs� -r5k Ty a fl, 7 :*' a:'* ^i -'ti'il xt•E C aa� ,ark F,r',�Fi,-. ..,^.� c�w, .C.,. . 5e ., s, _ _ - .5 s+ F. .`"x .fia �,: sC.�rr.""•tS:•t *` :� •, . • - mildest form of fluorosis must be weighed against the topical use only;however,some fluoride is ingested inad- benefit that the individual's teeth will also have a lower vertently by children.183 Inappropriate ingestion of topical level of dental decay thus saving dental treatment costs, fluoride can be minimized,thus reducing the risk for den- patient discomfort and tooth loss.11'12 In addition,the risk tal fluorosis without reducing decay prevention benefits. .of fluorosis may be viewed as an alternative to having Since 1992, the American Dental Association (ADA) dental decay,which is a disease that may cause cosmetic has required manufacturers of toothpaste to include the problems much greater than dental.fluorosis.216. phrase"Use only a pea-sized amount(of toothpaste)for In 1994,a review of five recent studies indicated that children under six"on fluoride toothpaste labels with the the amount of dental fluorosis attributable to water flu- ADA Seal of Acceptance. The rationale for choosing six oridation was approximately 13%. This represents the years of age for the toothpaste label is based on the fact amount of fluorosis that.might be eliminated if com- that the swallowing reflex is not fully developed in chil- • munity water fluoridation was discontinued.85 In other dren of preschool age and they may inadvertently swal- words, the majority of dental fluorosis can be associ- low toothpaste during brushing. In addition,the enamel ated with other risk factors such as the inappropriate formation of permanent teeth is basically complete at ingestion of fluoride products. six and so there is a decreased risk of fluorosis. Because (Additional information on this topic may be found in dental fluorosis occurs while teeth are forming under the Question 25. gums, individuals whose teeth have erupted are not at The type of fluorosis seen today remains largely limited risk for dental fluorosis. to the very mild and mild categories; however,the preva- Additional information on this topic may be found in lence of dental fluorosis in both fluoridated and nonfluo- Question 24. ridated communities in the United States is higher than it Numerous studies have established a direct relation- was when the original epidemiological studies were con- ship between young children brushing with more than ducted approximately 60 years ago.94 The inappropriate a pea-sized amount of fluoride toothpaste and the risk use of fluoride-containing dental products is the largest of very mild or mild dental fluorosis in both fluoridated risk factor for increased fluorosis as fluoride intake from and nonfluoridated communities.18°,218.218 It was noted food and beverages has remained constant over time.1B0'181 that 34%of the dental fluorosis cases in a nonfluoridated 25. The risk of fluorosis can be greatly reduced by following la- community were explained by children having brushed 6. bel directions for the use of these fluoride products.123.167 more than once per day during the first two years of life. Additional information on this topic may be found in In the optimally fluoridated community, 68% of the fluo- 27. Question 25. • rosis cases were explained by the children using more than a pea-sized amount of toothpaste during the first • year of life 220 Parents and caregivers should put only one pea-sized amount of fluoride toothpaste on a young QUESTION 25. child's toothbrush at each brushing. Young children What can be done to reduce the occurrence of dental should be supervised while brushing and taught to spit fluorosis in the U.S.? out, rather than swallow,the toothpaste. Consult with • your child's dentist or physician if you are considering Answer. • using fluoride toothpaste before age two. The vast majority of dental fluorosis in the United Additionally, it has been shown that 65% of the fluo- States can be prevented by limiting the ingestion of rosis cases in a nonfluoridated area were attributed to topical fluoride products (such as toothpaste) and the fluoride supplementation under the pre-1994 protocol. appropriate use of dietary fluoride supplements with- Thirteen percent of fluorosis cases in a fluoridated com- out denying young children the decay prevention ben- munity could be explained by a history of taking dietary efits of community water fluoridation. fluoride supplements inappropriately.220 Dietary fluoride supplements should be prescribed as recommended in Fact. the dietary fluoride supplement schedule approved by During the period of enamel formation in young children the American Dental Association, the American Acade- (before teeth appear in the mouth),inappropriate ingestion my of Pediatrics and the American Academy of Pediatric of high levels of fluoride is the risk factor for dental fluoro- Dentistry in 1994(see Table 1).3°125 Fluoride supplements sis 85.217 Studies of fluoride intake from the diet including should only be prescribed for children living in nonfluori- foods,beverages and water indicate that fluoride ingestion dated areas. Because of many sources of fluoride in the from these sources has remained relatively constant for diet, proper prescribing of fluoride supplements can be over half a century and,therefore,is not likely to be associ- complex. It is suggested that all sources of fluoride be ated with an observed increase in dental fluorosis.180182 evaluated with a thorough fluoride history before sup= j)Additional information on this topic may be found in plements are prescribed for a child.122 That evaluation Question 19. should include testing of the home water supply if the Dental decay has decreased because children today are fluoride concentration is unknown. being exposed to fluoride from a wider variety of sources -&Additional information on this topic may be found in than decades ago.Many of these sources are intended for Question 42. 30 American Dental Association , , - a r. , ■ < y Parents, caretakers and health care professionals The ADA warning labels were adopted to help reduce should judiciously monitor use of all fluoride-contain- the risk of mild dental fluorosis. This type of fluorosis ing dental products by children under age six. As is the is not readily apparent to the affected individual or ca- case with any therapeutic product, more is not always sual observer and often requires a trained specialist to better. Care should be taken to adhere to label directions detect. Dental fluorosis only occurs when more than the on fluoride prescriptions and over-the-counter products optimal daily amount of fluoride is ingested. (e.g. fluoride toothpastes and rinses). The ADA recom- Additionally,to ensure children's safety,the ADA lim- mends the use of fluoride mouthrinses,but not for chil- its the total amount of fluoride allowed in any one tube dren under six years of age because they may swallow of ADA-Accepted toothpaste. the rinse. These products should be stored out of the Since 1997, the U.S. Food and Drug Administration reach of children. (FDA) has required the label language, "If you acci- Finally, in areas where naturally occurring fluoride dentally swallow more than used for brushing, seek levels in ground water are higher than 2 ppm,consum- .professional help or contact a poison control center im- ers should consider action to lower the risk of dental mediately" on all fluoride toothpastes sold in the U.S. fluorosis for young children. (Adults are not affected The new FDA labels are consistent with the ADA because dental fluorosis occurs only when develop- statements, with the exception of the poison control ing teeth are exposed to elevated fluoride levels.) warning. Families on community water systems should contact The ADA Council on Scientific Affairs believes that their water supplier to ask about the fluoride level. the last sentence on the label could unnecessarily fright- Consumers with private wells should have the source en parents and children and that this portion of the label tested yearly to accurately determine the fluoride con- overstates any demonstrated or potential danger posed tent. Consumers should consult with their dentist re- by fluoride toothpastes. garding water testing and discuss appropriate dental The ADA notes that a child could not absorb enough health care measures. In homes where young children fluoride from one tube of toothpaste to cause a seri- are consuming water with a fluoride level greater than ous problem and that the excellent safety record on 2 ppm, families should use an alternative primary fluoride toothpaste argues against any unnecessary water source, such as bottled water, for drinking and regulation.221 cooking. It is also important to remember that the ADA ,recommends dietary fluoride supplements only for children living in areas with less than optimally fluori- dated water. QUESTION 27. Additional information on this topic may be found in Is fluoride, as provided by community water fluoride- Questions 4, 12 and 42. tion,a toxic substance? Answer. No:Fluoride, at the concentrations found in optimally QUESTION 26. fluoridated water,is not toxic according to generally ac- Why is there a warning label on a tube of fluoride tooth- cepted scientific knowledge. paste? Fact. Answer. Like many common substances essential to life and The American Dental Association originally required good health — salt, iron, vitamins A and D, chlorine, manufacturers to place a label on fluoride toothpaste oxygen and even water itself—fluoride can be toxic in in 1991 to ensure proper use and therefore reduce the excessive quantities. Fluoride in the much lower con- risk of dental fluorosis. centrations(0.7 to 1.2 ppm) used in water fluoridation is not harmful or toxic. Fact. Acute fluoride toxicity occurring from the ingestion In 1991, the American Dental Association (ADA) began of optimally fluoridated water is impossible.1B2 The requiring toothpaste manufacturers to include the follow- amount of fluoride necessary to cause death for a hu- ing language on all ADA-Accepted toothpastes: "Do not man adult (155 pound man) has been estimated to be swallow. Use only a pea-sized amount for children under 5-10 grams of sodium fluoride, ingested at one time.222 six. To prevent swallowing, children under six years of This is more than 10,000-20,000 times as much fluoride age should be supervised in the use of toothpaste." as is consumed at one time in a single 8 ounce glass of optimally fluoridated water. :-',i Chronic fluoride toxicity may develop after 10 or t To ensure children srrsafety,the ADA hmlts l° more years of exposure to very high levels of fluoride, thearoount of fluoride allowed in;, t levels not associated with optimal fluoride intake in ADA=Accepted toothpaste "'_-= _ ;;i drinking water. The primary functional adverse effect associated with long term excess fluoride intake is Fluoridation Facts 31 as + w + v r 5s r } r ti r r r � € t 1 T,„ Z rt ' *Y. t r � % S h '1.. • - r - ; • skeletal fluorosis. The development of skeletal fluoro- At one time, high concentrations of fluoride additives sis and its severity is directly related to the level and were used in insecticides and rodenticides.36 Today fluo- duration of fluoride exposure. For example,the inges- ride additives are rarely used in pesticides because more tion of water naturally fluoridated at approximately 5 effective additives have been developed.183 ppm for 10 years or more is needed to produce clinical While large doses of fluoride may be toxic, it is im- signs of osteosclerosis(a mild form of skeletal fluorosis portant to recognize the difference in the effect of a that can be seen as a change in bone density on x-rays) massive dose of an extremely high level of fluoride in the general population. In areas naturally fluoridat- versus the recommended amount of fluoride found ed at 5 ppm, daily fluoride intake of 10 mg/day would in optimally fluoridated water. The implication that not be uncommon.123 A survey of X-rays from 170,000 fluorides in large doses and in trace amounts have people in Texas and Oklahoma whose drinking water the same effect is completely unfounded. Many sub- had naturally occurring fluoride levels of 4 to 8 ppm stances in widespread use are very beneficial in small revealed only 23 cases of osteosclerosis and no cases amounts, but may be harmful in large doses—such as of crippling skeletal fluorosis.223 Evidence of advanced salt,chlorine and even water itself. skeletal fluorosis, or crippling skeletal fluorosis, "was not seen in communities in the United States where water supplies contained up to 20 ppm (natural levels of fluoride)."123.199 In these communities, daily fluoride QUESTION 28. intake of 20mg/day would not be uncommon.123 Crip- Does drinking optimally fluoridated water cause or ac- piing skeletal fluorosis is extremely rare in the United celerate the growth of cancer? States and is not associated with optimally fluoridated water; only 5 cases have been confirmed during the Answer. last 35 years.123 According to generally accepted scientific knowledge, /)Additional information on this topic may be found in there is no association between cancer rates in humans Question 20. and optimal levels of fluoride in drinking water.225 The Agency for Toxic Substances and Disease Regis- n' try (ATSDR) prepares toxicological profiles for various Fact. 29. hazardous substances most commonly found at facili- Since community water fluoridation was introduced in ties on the CERCLA National Priorities List (Superfund 1945, more than 50 epidemiologic studies in different Sites). The Toxicological Profile for Fluorides,Hydrogen populations and at different times have failed to dem- Fluoride and Fluorine was revised in 2003. The ATSDR onstrate an association between fluoridation and the states that existing data indicates that subsets of the risk of cancer.84 Studies have been conducted in the population may be unusually susceptible to the toxic ef- United States,226-231 Japan,232 the United Kingdom,233236 fects of fluoride and its compounds at high doses.How- Canada236 and Australia.237 In addition, several indepen- ever, there are no data to suggest that exposure to the dent bodies have conducted extensive reviews of the low levels associated with community water fluoride- scientific literature and concluded that there is no rela- tion would result in adverse effects in these potentially tionship between fluoridation and cancer.84,163,166,176,206,238 susceptible populations.224 The U.S. Environmental Protection Agency (EPA) fur- ther commented on the safety of appropriate fluoride exposure in the December 5, 1997, Federal Register.239 a< '•::� t - mac::': .The po:ssibility of!adverse :'s In a notice of a final rule relating to fluoride additives; health effects from contmuouslow the EPA stated, "...the weight of evidence from more '"4'',%eve/;consurrijitionoffluorideryover-lgng "' than 50 epidemiological studies does not support the periods has been studied;extensively As with . hypothesis of an association between fluoride expo- sure and increased cancer risk in humans. The EPA is other nutrients fluoride,s.s,`afe and effect,ve. in agreement with the conclusions reached by the Na- :1,;:'=;,; when used"a`nd consumed_properly" s== r tional Academy of Sciences(NAS)." •' `` Despite the abundance of scientific evidence to the contrary, claims of a link between fluoridation and in- The possibility of adverse health effects from con- creased cancer rates continue. This assertion is largely tinuous low level consumption of fluoride over long based on one study comparing cancer death rates in ten periods has been studied extensively. As with other large fluoridated cities versus ten large nonfluoridated nutrients, fluoride is safe and effective when used and cities in the United States.The results of this study have consumed properly. No charge against the benefits and been refuted by a number of organizations and research- safety of fluoridation has ever been substantiated by ers.240 Scientists at the National Cancer Institute analyzed generally accepted scientific knowledge. After 60 years the same data and found that the original investigators of research and practical experience, the preponder- failed to adjust their findings for variables, such as age ance of scientific evidence indicates that fluoridation of and gender differences,that affect cancer rates. A review community water supplies is both safe and effective. by other researchers pointed to further shortcomings in 32 American Dental Association '�'r�se�_A`4,.;a44 •''. l.,./e !�'•'�� '�" :'b3kT'�'�` a� tPF 'n i."'',, i��'p � ��..w-"'W.;43.--‘..;:' �� , �� ,,s 3 G v �. '..1.%A,.; �, Q�,g� .q s E�' S�a .A.• Vt..;;.■"s� "�'p � ..hi 4. M'_a�'�a✓'�'. �. s :i ,F .=„.5.. . • . r _ _ fd' -Ra�l.4 .o'„C''5,e9.4A'• 'i%.ms's',°.-,]7. c.t a A asx 1 R�».�, 01 R ai �.; aw '�+"''yr:t: kF o the study.The level of industrialization in the fluoridated ' for cancer in the fluoridated and nonfluoridated coin- cities was much higher than the nonfluoridated cities. munities. For example, this analysis did not control Researchers noted that a higher level of industrialization for differences in urbanization, socioeconomic status, is usually accompanied by a higher incidence of cancer. geographic region, occupations, industries, diet, medi- While the researchers noted that the fluoridated cities did cal practices or tobacco use between the fluoridated have higher cancer rates over the twenty year study,the and nonfluoridated communities. Thus any attempt to rate of increase in the nonfluoridated cities was exactly interpret cancer risk between these communities with the same (15%) as the fluoridated cities. Following fur- this number of uncontrolled variables is scientifically ther reviews of the study,the consensus of the scientific inappropriate. community continues to support the conclusion that the incidence of cancer is unrelated to the introduction and (—,--4--'','./!.',,=',"' - , 1, duration of water fluoridation.84 "ThA e merican Cancer Society states i In the early 1990s, two studies using higher than Scientific studies-showno connection ,-- optimal levels of fluoride were conducted to evaluate -rir 4' , r. betwee_n cancer rates�in humans acid adding the carcinogenicity of sodium fluoride in laboratory "- 4 .,:. - fluoride to-drinkingwater. animals.The first study was conducted by the National \,, {.. ,. ; Toxicology Program (NTP) of the National.Institute of Environmental Health Sciences.208 The second study In a document entitled "Fluoride and Drinking Water was sponsored by the Proctor and Gamble Company.209 Fluoridation,"the American Cancer Society states, "Sci- In both studies, higher than optimal concentrations of entific studies show no connection between cancer rates sodium fluoride (25, 100 and 175 ppm)were consumed in humans and adding fluoride to drinking water."225 by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual sex/species groups became available for anal- ysis. Seven of these groups showed no significant QUESTION 29. evidence of malignant tumor formation. One group, Does fluoride, as provided by community water fluori- male rats from the NTP study,showed "equivocal" evi- dation,inhibit the activity of enzymes in humans? dence of carcinogenicity,which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas Answer. (malignant tumors of the bone) —that may be chemi- Fluoride,in the amount provided through optimally flu- cally related. The Ad Hoc Subcommittee on Fluoride oridated water,has no effect on human enzyme activity of the U.S. Public Health Service combined the results according to generally accepted scientific knowledge. of the two studies and stated: "Taken together,the two animal studies available at this time fail to establish an Fact. association between fluoride and cancer."84.210 Enzymes are organic compounds that promote chem- Since that time, a number of studies have examined ical change in the body. Generally accepted scientific the hypothesis that fluoride is a risk factor for bone can- knowledge has not indicated that optimally fluoridat- cer. None of these studies reported an association be- ed water has any influence on human enzyme activity. tween optimal levels of fluoride in drinking water and There are no available data to indicate that, in humans cancer of the bone.241-244 drinking optimally fluoridated water, the fluoride af- j�Additional information on this topic may be found in fects enzyme activities with toxic consequences.248 Question 23. The World Health Organization report, Fluorides and In a 1990 study, scientists at the National Cancer In- Human Health states, "No evidence has yet been pro- stitute evaluated the relationship between fluoridation vided that fluoride ingested at 1 ppm in the drinking of drinking water and cancer deaths in the United States water affects intermediary metabolism of food stuffs, during a 36 year period, and the relationship between vitamin utilization or either hormonal or enzymatic fluoridation and the cancer rate during a 15 year period. activity."24' After examining more than 2.3 million cancer death re- The concentrations of fluoride used in laboratory cords and 125,000 cancer case records in counties using studies to produce significant inhibition of enzymes fluoridated water, the researchers saw no indication of a are hundreds of times greater than the concentration cancer risk associated with fluoridated drinking water.84 present in body fluids or tissues.222 While fluoride may In 2001, researchers from Japan analyzed data on affect enzymes in an artificial environment outside of cancers taken from the International Agency for Re- a living organism in the laboratory, it is unlikely that ad- search on Cancer World Health Organization in 1987, equate cellular levels of fluoride to alter enzyme activi- 1992 and 1997 and concluded that fluoridation may ties would be attainable in a living organism.245 The two increase the risk for numerous types of cancers.245 primary physiological mechanisms that maintain a low However, the methodology used in this analysis was concentration of fluoride ion in body fluids are the rapid inherently flawed as there are major and obvious dif- excretion of fluoride by the kidneys and the uptake of ferences in a number of factors relevant to the risk fluoride by calcified tissues. Fluoridation Facts 33 _ -, ..',+ s"z`�•- �a _`._ -. `` A' �'!i., ria" 'r'St +a a- . X12 ,.t. r w, } �_ ix ''# ' QUESTION 30. . tion in the pineal gland. The purpose of the study was Does the ingestion of optimally fluoridated water ad- to discover whether fluoride accumulates in the pineal versely affect the thyroid gland or its function? gland of older adults. This limited study, conducted on only 11 cadavers whose average age at death was 82 Answer. years, indicated that fluoride deposited in the pineal There is no scientific basis that shows fluoridated wa- gland was significantly linked to the amount of calcium ter has an adverse effect on the thyroid gland or its in the pineal gland. It would not be unexpected to see function. higher levels of calcium in the pineal gland of older indi- viduals as this would be considered part of a normal ag- Fact. ing process. As discussed in Question 22,approximately In an effort to determine if fluoride in drinking water of 99%of the fluoride present in the body is associated with fects the function, shape and size of the thyroid gland, hard or calcified tissues.192 The study concluded fluoride researchers conducted a study comparing one group levels in the pineal gland were not indicators of long of people who consumed water that contained natural term fluoride exposure.252 fluoride levels of 3.48 ppm and one group who con- The same researcher has theorized in unpublished sumed water with extremely low fluoride levels of 0.09 reports posted on the Internet that the accumulation of ppm. The researchers noted that all study participants fluoride in children's pineal gland leads to an earlier on had been residents of their respective communities for set of puberty. However,the researcher notes that there more than 10 years. The researchers concluded that is no verification that fluoride accumulates in children's prolonged ingestion of fluoride at levels above optimal pineal glands. Moreover, a study conducted in New- to prevent dental decay had no effect on thyroid gland burgh (fluoridated) and Kingston (non fluoridated), New size or function. This conclusion was consistent with York found no statistical significance between the onset earlier animal studies.248 of menstruation for girls living in a fluoridated verses In addition, two studies have explored the associa non fluoridated area.253 tion between fluoridated water and cancer of the thy • - 30 roid gland. Both studies found no association between optimal levels of fluoride in drinking water and thyroid QUESTION ��. 31. cancer.226'249 In an effort to link fluoride and decreased thyroid func- Can fluoride,at the levels found in optimally fluoridated 32. tion, those opposed to fluoridation cite one small study drinking water,alter immune function or produce aller- from the 1950's in which 15 patients who had hyperthy- gic reaction (hypersensitivity)? 33. roidism (an overactive thyroid) were given relative large amounts of sodium fluoride orally or by injection in an ef- Answer. 34' fort to inhibit the thyroid's function. The researchers con- There is no scientific evidence of any adverse effect cluded that efforts to treat hyperthyroidism with fluoride on specific immunity from fluoridation, nor have there 35. been anyconfirmed reports of allergic reaction.254 was successful only occasionally among persons sub- P g jected to massive doses of fluoride. This study does not support claims that low fluoride levels in drinking water Fact. would cause hypothyroidism(an underactive thyroid)25° There is no scientific evidence linking problems with immune function such as HIV or AIDS (acquired im- mune deficiency syndrome) with community water fluoridation.255 QUESTION 31. There are no confirmed cases of allergy to fluoride, Does water fluoridation affect the pineal gland causing or of any positive skin testing in human or animal mod- the early onset of puberty? els.254 A committee of the National Academy of Sciences evaluated clinical reports of possible allergic responses Answer. to fluoride and reported, "The reservation in accepting Generally accepted science does not suggest that wa- (claims of allergic reaction) at face value is the lack of ter fluoridation causes the early onset of puberty. similar reports in much larger numbers of people who have been exposed to considerably more fluoride than Fact. was involved in the original observations."39 The World The pineal gland is an endocrine gland located in the Health Organization also judged these cases to repre- brain which produces melatonin.251 Endocrine glands sent "a variety of unrelated conditions" and found no secrete their products into the bloodstream and body evidence of allergic reactions to fluoride.255.257 tissues and help regulate many kinds of body functions. A 1996 review of the literature on fluoride and white The hormone, melatonin, plays a role in sleep, aging cell function examined numerous studies and conclud- and reproduction. ed that there is no evidence of any harmful effect on A single researcher has published one study in a peer- specific immunity following fluoridation nor any con- reviewed scientific journal regarding fluoride accumula- firmed reports of allergic reactions.254 34 American Dental Association i. .. ' -�� " tart _ . , .. s •. - 3 - . SAFETY QUESTION 33. QUESTION 34. Is fluoride, as provided by community water fluorida- Does fluoride at the levels found in water fluoridation tion,a genetic hazard? affect human reproduction,fertility or birth rates? Answer. Answer. Following a review of generally accepted scientific There is no credible, scientific evidence that fluorida- knowledge, the National Research Council of the tion has an adverse effect on human reproduction,fer- National Academy of Sciences supports the conclu- tility or birth rates. sion that drinking optimally fluoridated water is not a genetic hazard.'67 Fact. ' Very high levels of fluoride intake have been associated Fact. with adverse effects on reproductive outcomes in many Chromosomes are the DNA-containing bodies of cells animal species. Based on these findings,it appears that that are responsible for the determination and transmis- fluoride concentrations associated with adverse repro- sion of hereditary characteristics. ,Genes are the func- ductive effects in animals are far higher (100-200 ppm) tional hereditary unit that occupies a fixed location on than those to which human populations are exposed. a chromosome. Many studies have examined the pos- Consequently, there is insufficient scientific basis on sible effects of fluoride on chromosome damage. While which to conclude that ingestion of fluoride at levels there are no published studies on the genotoxic (dam- found in community water fluoridation (0.7 — 1.2 ppm) age to DNA) effect of fluoride in humans, numerous would have adverse effects on human reproduction.167 studies have been done on mice.167 These studies have - One human study compared county birth data with shown no evidence that fluoride damages chromo- county fluoride levels greater than 3 ppm and attempt- somes in bone marrow or sperm cells even at fluoride ed to show an association between high fluoride lev- levels 100 times higher than that in fluoridated water.258- els in drinking water and lower birth rates.27' However, 264 Another independent group of researchers reported 'because of serious limitations in design and analysis, a similar lack of fluoride-induced chromosomal damage the investigation failed to demonstrate a positive cor- to human white blood cells,which are especially sensi- relation.272 • tive to agents which cause genetic mutations. Not only A study examining the relative risk of stillbirths and did fluoride fail to damage chromosomes, it protected congenital abnormalities (facial clefts and neural tube them against the effect of a known mutagen (an agent defects)found no evidence that fluoridation had any ef- that causes changes in DNA)?65.266 The genotoxic effects fect of these outcomes.273 . of fluoride were also studied in hamster bone marrow The National Research Council (NRC) of the National cells and cultured hamster ovarian cells. Again,the re- Academy of Sciences (NAS) supports the conclusion sults supported the conclusion that fluoride does not that drinking optimally fluoridated water is not a genetic cause chromosomal damage, and therefore, was not hazard.'67 a genetic hazard.267 In further tests, fluoride has not (+Additional information on this topic may be found in caused genetic mutations in the most widely used bac- Question 33. terial mutagenesis assay (the Ames test) over a wide range of fluoride levels.267-270 The National Research Council (NRC) of the Nation- al Academy of Sciences supports the conclusion that QUESTION 35. drinking optimally fluoridated water is not a genetic Does drinking optimally fluoridated water cause hazard. In a statement summarizing its research, the an increase in the rate of children born with Down NRC states,"in vitro data indicate that: Syndrome? 1) the genotoxicity of fluoride is limited primarily to doses much higher than those to which humans Answer. are exposed, There is no known association between the consump- 2) even at high doses, genotoxic effects are not al- tion of optimally fluoridated drinking water and Down ways observed,and Syndrome. 3) the preponderance of the genotoxic effects that have been reported are of the types that probably Fact. are of no or negligible genetic significance."167 This question originally arose because of two studies The lowest dose of fluoride reported to cause chro- published in 1956 and 1963 by a psychiatrist. Data col- mosomal changes in mammalian cells was approxi- lected in several Midwest states in 1956 formed the mately 170 times that found normally found in human basis for his two articles published in French journals, cells in areas where drinking water is fluoridated,which purporting to prove a relationship between fluoride in indicates a large margin of safety.167 the water and Down Syndrome.274.275 Experienced epidemiologists and dental research- ers from the National Institute of Dental Research and Fluoridation Facts 35 ._ ,4 <.-_ - - ... z..«�..,....... a-r.•'.;. - ^.�.w .ne " .___ ._:,a ...f1...-.'% #..m --F'" F.}.'1V .,v-3 <•i� '}T4_5�. . .b;.n,¢. 0 .._-, staff members of the National Institute of MentaliHealth partly on one 1995 study in which rats were fed fluoride have found serious shortcomings in the statistical pro- at levels up to 125 times greater than that found in opti- cedures and designs of these two studies. Among the mally fluoridated water.281 The study attempted to dem- most serious inadequacies is the fact that conclusions onstrate that rats fed extremely high levels of fluoride were based on the fluoridation status of the commu- (75 ppm to 125 ppm in drinking water) showed behav- nities where the mothers gave birth, rather than the ior-specific changes related to cognitive deficits. status of the rural areas where many of the women In addition, the experiment also studied the off- lived during their pregnancies.222 In addition,the num- spring of rats who.were injected two to three times a ber of Down Syndrome cases found in both fluoridat- day with fluoride during their pregnancies in an effort ed and nonfluoridated communities were much lower to show that prenatal exposure resulted in hyperactiv- than the rates found in many other parts of the United ity in male offspring. States and the world,that casting doubt on the validity However, two scientists who reviewed the 1995 of findings. study282 have suggested that the observations made The following paragraphs provide a summary of nu- can be readily explained by mechanisms that do not merous studies that have been conducted which refute involve neurotoxicity. The scientists found inadequa- the conclusions of the 1956 studies. cies in experimental design that may have led to in- A British physician reviewed vital statistics and records valid conclusions. For example, the results of the from institutions and school health officers, and talked experiment were not confirmed by the use of control with public health nurses and others caring for children groups which are an essential feature of test valida- with Down Syndrome. The findings noted no indication of any relationship between Down Syndrome and the tion and experimental design. In summary the scien- tists of fluoride in water consumed by the mothers 278 tists stated, "We do not believe the study by Mullenix These findings were confirmed by a detailed study of et al. can be interpreted in any way as indicating the approximately 2,500 Down Syndrome births in Massa- potential for NaF (sodium fluoride) to be a neurotoxi- chusetts. A rate of 1.5•cases per 1,000 births was found cant." Another reviewer182 noted, "...it seems more in both fluoridated and nonfluoridated communities, likely that the unusually high brain fluoride concen 36. providing strong evidence that fluoridation does not in trations reported in Mullenix et al. were the result of 37. crease the risk of Down Syndrome.277 some analytical error." Another large population-based study with data Fe- 38. lating to nearly 1.4 million births showed no association h between water fluoridation and the incidence of con "A seven year studyCOmparedlthe'health genital malformations including Down Syndrome.278 and behavror of chrldren from bath through_ �", In 1980, a 25-year review of the prevalence of con six years of age m communities wrfh genital malformations was conducted in Birmingham, England. Although Birmingham initiated fluoridation optimally fluoridated water. The results in 1964, no changes in the prevalence of children born suggested that there was no evidence with Down Syndrome occurred since that time.279 to rn'dreate�that ex osure o o timall F A comprehensive study of Down Syndrome, births fluoridated water had any detectableryeffect' was conducted in 44 U.S. cities over a two-year period. j on chrldren s health or b"ehavror i �: Rates of Down Syndrome were comparable in both flu- oridated lu oridated and nonfluoridated cities.28° A seven-year study compared the health and be- havior of children from birth through six years of age QUESTION 36. in communities with optimally fluoridated water with Does ingestion of optimally fluoridated water have any those of children the same age without exposure to neurological impact? optimally fluoridated water. Medical records were re- viewed yearly during the study. At age six and seven, Answer. child behavior was measured using both, maternal There is no generally accepted scientific evidence es- and teacher ratings. The results suggested that there tablishing a causal relationship between consumption was no evidence to indicate that exposure to opti of optimally fluoridated water and central nervous sys- mally'fluoridated water had any detectable effect on tem disorders, attention deficit disorders or effects on children's health or behavior. These results did not intelligence. differ even when data was controlled for family social background.283 Fact. The research conducted by Mullenix et al discussed in There have been claims that exposure to fluoride pres- this question has not been replicated by other researchers. ents a neurotoxic (harmful or damaging to nerve tis- ( Additional information on how to critically review re- sue) risk or lowered intelligence. Such claims are based search can be found in the Introduction and Figure 1. 36 American Dental Association 1 a _ • a ._.1 'i- 4,'N„I , "X.r,?e,%• ,,';d.'r., r 14:'-''.:";.•44 -7,-1,V;:.•;„!, .4, s 4,,0,4,7,,,, ...)..",,,„...\ ,, : 4'.1I.,,L5' �g'ty ' pC� . • l5O1§ ; ' ' s o ` H i»# , . 4 ,"" SAIF-ET Y e+x • .: 2 ,, ' s s .th? # A :S. a, `q"-V3 e K - ,.6i.> D, f- QUESTION 37 adult lead exposure are occupational. Adult blood lead Does drinking fluoridated water increase the level of levels have continued to decline over the last ten years lead in the blood or cause lead poisoning in children? due largely to improved prevention measures in the workplace and changes in.employment patters 287 It Answer. should be noted that since the 1970s, while blood lead Generally accepted scientific evidence has not shown levels have continued to decline, the percentage of the , any association between water fluoridation and blood population receiving optimally fluoridated water has lead levels. continued to increase.34 The research conducted by Masters et al discussed in Fact. this question has not been replicated by other researchers. One set of researchers has claimed that the silicofluo- jfAdditional information on how to critically review re- ride additives used in community water fluoridation search can be found in the Introduction and Figure 1. may be responsible for acidic drinking water which - . leaches lead from plumbing systems thereby increas- ing lead uptake by children.They go on to theorize that QUESTION 38. communities that use the silicofluorides have greater numbers of children with high levels of lead in their Does drinking optimally fluoridated water cause Alzheim- blood than nonfluoridated communities and that the er's disease? results of the use of silicofluorides are reflected in these communities' residents exhibiting higher rates Answer. of learning disabilities, attention deficit disorders, vio Generally accepted science has not demonstrated an lent crimes and criminals who were using cocaine at association between drinking optimally fluoridated wa- ter and Alzheimer's disease. the time of arrest.284 From his research, Masters has claimed to be able to Fact. predict the estimated cost of increased prison popula- The exact cause of Alzheimer's disease has yet to be tions due to water fluoridation. For example, in a 2003 identified. Scientists have identified the major risk fac- appearance before the Palm Beach County (Florida) tors for Alzheimer's as age and,family 'history. Sci- Commission, Masters stated that if the county fluoridat- entists believe that genetics may play a role in many ed with silicofluorides, they could expect an additional Alzheimer's cases. Other possible risk factors that are 819 violent crimes per year directly related to water being studied are level of education, diet, environment fluoridation with a minimum additional annual cost of and viruses to learn what role theymight play in the imprisonment of$14,391,255.284 development of this disease.288 Scientists from the Environmental. Protection A study published in 1998289 raised concerns about Agency (EPA) have reviewed the basic science that the potential relationship between fluoride and AI- was the foundation for the claim that silicofluorides zheimer's disease. However,several flaws in the experi- leach lead from plumbing systems and found that mental design preclude any definitive conclusions from many of the chemical assumptions made and statisti- being drawn29° cal methods ,utilized' in the original ecological study Interestingly, there is evidencethat aluminum and were scientifically unjustified. They went on to state fluoride are mutually antagonistic in competing for that the research was inconsistent with accepted absorption in the human body.42'29' While a conclusion scientific knowledge and the authors of the original cannot be made that consumption of fluoridated wa- studies (Masters et al) failed to identify or account ter has a preventive effect on Alzheimer's, there is no for these inconsistencies. Overall, the EPA scientists generally accepted scientific knowledge to show con- concluded that "no credible evidence exists to show sumption of optimally fluoridated water is a risk factor that water fluoridation has any quantitatable effects for Alzheimer's disease. on the solubility, bioavailability, bioaccumulation, or reactivity of lead (0) or lead (II) compounds.285 According to the Centers for Disease Control and Prevention, the average blood lead levels of young children in the U.S. have continued to decline Since the 1970s primarily due to the phase-out of leaded gaso- line and the resulting decrease in lead emissions. The primary remaining sources of childhood lead exposure are deteriorated leaded paint, house dust contaminated - by leaded paint and soil contaminated by both leaded paint and decades of industrial and motor vehicle emis- ' sions.286 Approximately 95% of the primary sources of Fluoridation Facts 37 �� � s SE• � � � A J ' � •.� �6'�+�4`'e: i - - tfi „i d' '3%�' �' ,'.✓'d �' j, --a 4 a Ca f€w '�dkr', x4413 3 €r `� of T-• ,a. -- . - �� --- y a. i•" .:Aibi: `*Y-A' _- t ems`-', ".' V;TAAr QUESTION 39. QUESTION 40. Does drinking optimally fluoridated water cause or con- Is the consumption of optimally fluoridated water harm- tribute to heart disease? ful to kidneys? Answer. Answer. • Drinking optimally fluoridated water isnot a risk factor The consumption of optimally fluoridated water has for heart disease. not been shown to cause or worsen human kidney disease. Fact. This conclusion is supported by results of a study Fact. conducted by the National Heart and Lung and Blood Approximately 50% of the fluoride ingested daily is re- Institute of the National Institutes of Health. Research- moved from the body by the kidneys.182,192,'93 Because ers examined a wide range of data from communities the kidneys are constantly exposed to various fluoride that have optimally fluoridated'water and from areas concentrations, any health effects caused by fluoride with insufficient fluoride.The final report concluded would likely manifest themselves in kidney cells. How- that: ever, several large community-based studies of people "Thus,the evidence from comparison of the health with long-term exposure to drinking water with fluoride of fluoridating and nonfluoridating cities, from concentrations up to 8 ppm have failed to show an in- medical and pathological examination of persons crease in kidney disease.'66,253,295 exposed to'a lifetime of naturally occurring fluo In a report issued in 1993 by the National Research rides or persons with high industrial exposures, Council,the Subcommittee on Health Effects of Ingest- and from broad national experience with fluorida- tion all consistently indicate no adverse effect on ed Fluoride stated that the threshold dose of fluoride in cardiovascular health."292 drinking water which causes kidney effects in animals is approximately 50 ppm-more than 12 times the max- 39 = imum level allowed in drinking water by the Environ- . American Heart Association states mental Protection Agency. Therefore, they concluded 40. JVp`eurdence exists thatadjusting the fluoride that "ingestion of fluoride at currently recommended content of public water supplies to a leve!of concentrations is not likely to produce kidney toxicity 4t. in humans."'e' about on'e part per m�/hon has anyharmful. Many people with kidney failure depend on hemo- ct.on the,cardiovascur system effect �,^. la ls� dialysis (treatment with an artificial kidney machine) for their survival. During hemodialysis, the patient's The American Heart Association states: "No evidence blood is exposed to large amounts of water each exists that adjusting the fluoride content of public water week (280-560 quarts). Therefore, procedures have supplies to a level of about one part per million has any been designed to ensure that the water utilized in the harmful effect on the cardiovascular system."293 The process contain a minimum of dissolved substances American Heart Association identifies aging, male sex, that could diffuse indiscriminately into the patient's heredity, cigarette and tobacco smoke, high blood cho bloodstream.296 Since the composition of water var- lesterol levels, high blood pressure, physical inactivity, ies in different geographic locations in the United obesity and diabetes mellitus as major risk factors for States, the U.S. Public Health Service recommends cardiovascular disease 294 dialysis units use techniques such as reverse osmosis A number of studies have considered trends in ur and de ionization to remove excess iron, magnesium, ban mortality in relation to fluoridation status. In one aluminum, calcium, and other minerals, as well as study, the mortality trends from 1950-70 were studied fluoride, from tap water before the water is used for • for 473 cities in the United States with populations of dialysis.286,287 25,000 or more. Findings showed no relationship be- (Additional information on this topic is available in Ques- tween fluoridation and heart disease death rates over tion 22. the 20-year period.228 In another study, the mortality rates for approximately 30 million people in 24 fluori- dated cities were compared with those of 22 nonfluo- ridated cities for two years. No evidence was found of any harmful health effects, including heart disease,at- tributable to fluoridation.As in other studies,crude dif- ferences in the mortality experience of the cities with fluoridated and nonfluoridated water supplies were explainable by differences in age, gender and race composition227 38 American Dental Association �^� ��:};ai+. a•s-t••i� �,•� '. �'s , _.��•�'������� �� =sow � �.r •"G &t'�`��" "�A.?'" � ..�L���*� �A�yf�. • s .,��g '� � �i�. -�F� � -��ar �a�,.s�"4. �., j :5 t7+ •"t�'�. �"S:�'+.��' ,.•e^-�•w'� %* ', �• 3 �* a* SAF'EY: QUESTION 41. What are some of the erroneous health claims made moi; Of the thousands=of credible scientffrc against water fluoridation? = studies,on fluoridation,none has shown" ='A rvhealth problems associated with the Answer consurrmpt�on of opturially fluoridated water. From sources such as the Internet, newsletters, and r"''' ... 4 w t. personal anecdotes in e-mails, community water fluo- ridation is frequently charged with causing all of the • following adverse health effects: Notes • AIDS • Allergic Reactions(loss of hair,skin that burns and peels after contact with fluoridated water) • Alzheimer's disease • Arthritis • Asthma • Behavior Problems(attention deficit disorders) • Bone Disease(osteoporosis—increased bone/hip fractures) • Cancer(all types including osteosarcoma or bone • cancer) • Chronic Bronchitis • Colic(acute abdominal pain) • Down Syndrome - Emphysema • Enzyme Effects(gene-alterations) • Flatulence(gas) • Gastrointestinal Problems(irritable bowel syndrome) • Harmful Interactions with Medications • Heart Disease • Increased Infant Mortality • Kidney Disease • Lead Poisonings • Lethargy(lack of energy) • Lower IQ(mental retardation) • Malpositioned Teeth • Pineal Gland (early puberty)(chronic insomnia) • Reproductive Organs(damaged sperm) (reduced fertility) • Skin Conditions (redness,rash/welts,itching) • Sudden Infant Death Syndrome(SIDS) • Thyroid Problems(goiter and obesity due to hy- pothroidism) AND • Tooth Decay Fact. As discussed throughout this booklet,the overwhelming weight of credible scientific evidence has consistently in- dicated that fluoridation of community water supplies is safe and effective. The possibility of any adverse health effects from continuous low-level consumption of fluo- ride has been and continues to be extensively studied. It has been determined that approximately 10% of dental fluorosis is attributable to water fluoridation.This type of very mild to mild fluorosis has been determined to be a cosmetic effect rather than an adverse health effect. Of the thousands of credible scientific studies on fluorida- tion, none has shown health problems associated with the consumption of optimally fluoridated water. Fluoridation Facts - 39 • - - ic. "ap'3`�€a�"', � r�y 3'�"" -as-7 , as • FLUORIDATION PRACTICE Q 42. Water quality? p.40 Q 45. Source of additives? p.43 Q 48. Corrosion? p.44 Q 43. Regulation? p.41 Q 46. System safety concerns? p.43 Q 49. Environment? p.45 Q 44. Standards? p.42 Q 47. Engineering? p.44 QUESTION 42. level exceeds 2.0 mg/L. The SMCL, while not federally Will the addition of fluoride affect the quality of enforceable, is intended to alert families that regular drinking water? consumption of water with natural levels of fluoride greater than 2.0 mg/L by young children may cause Answer. moderate to severe dental fluorosis in the developing Optimal levels of fluoride do not affect the quality permanent teeth, a cosmetic condition with no known of water. All ground and surface water in the United adverse health effect.298 The notice to be used by water States contain some naturally occurring fluoride. systems that exceed the SMCL must contain the follow ing points: Fact. 1. The notice is intended to alert families that children Nearly all water supplies must undergo various water under nine years of age who are exposed to levels of treatment processes to be safe and suitable for hu- fluoride greater than 2.0 mg/liter may develop dental man consumption. During this process, more than 40 fluorosis. chemicals/additives are typically used including alumi- 2..Adults are not affected because dental fluorosis oc- 42. curs only when developing teeth are exposed to el- num sulfate, ferric chloride, ferric sulfate, activated car- bon, lime,soda ash and, of course, chlorine. Fluoride is evated fluoride levels. 4'' 3. The water supplier can be contacted for information added only to water that has naturally occurring levels lower than optimal,36 on alternative sources or treatments that will insure Fluoridation is the adjustment of the fluoride concen the drinking water would meet all standards (includ tration of fluoride-deficient water supplies to the recom- mended range of 0.7 to 1.2 parts per million of fluoride The 1993 National Research Council report, "Health for optimal dental health.The U.S. Environmental Protec- Effects of Ingested Fluoride," reviewed fluoride toxicity tion Agency (EPA) recognizes that fluoride in children's and exposure data for the EPA and concluded that the drinking water at levels of approximately 1.0 ppm reduc- current standard for fluoride at 4.0 mg/L(set in 1986)was es the number of dental cavities.298 The optimal level is appropriate as an interim standard to protect the public dependent on the annual average of the maximum daily health.1fi7 In EPA's judgment,the combined weight of hu- air temperature in a given geographic area.38,55 man and animal data support the current fluoride drinking (+Additional information on this topic may be found in water standard. In December 1993, the EPA published a Questions 3 and 6. notice in the Federal Register stating the ceiling of 4 mg/L Under the Safe Drinking Water Act, the EPA has es- would protect against adverse health effects with an ad- tablished drinking water standards for a number of sub- equate margin of safety and published a notice of intent stances,including fluoride, in order to protect the public's not to revise the fluoride drinking water standards.'68 health.There are several areas in the United States where The EPA further commented on the safety of fluo- the ground water contains higher than optimal levels of ride in the December 5, 1997, Federal Register.239 In a naturally occurring fluoride. Therefore, federal regula- notice of a final rule relating to fluoride additives the tions were established to require that naturally occurring EPA stated, "There exists no directly applicable scien- fluoride levels in a community water supply not exceed tific documentation of adverse medical effects at levels a concentration of 4.0 mg/L.298 Under the Safe Drinking of fluoride,below 8 mg/L (0.23mg/kg/day)." The EPA's Water Act,this upper limit is the Maximum Contaminant Maximum Concentration Limit(MCL) of 4.0 mg/L(0.114 Level ,(MCL) for fluoride. Under the MCL standard, if the mg/kg/day) is one half that amount, providing an ade- naturally occurring level of fluoride in a public water sup- quate margin of safety. ply exceeds the MCL (4.0 mg/L for fluoride), the water Under the Safe Drinking Water Act (SDWA), the EPA supplier is required to lower the level of fluoride below must periodically review the existing National Primary the MCL.This process is called defluoridation. Drinking Water Regulations (NPDWRs) "not less often The EPA has also set a Secondary Maximum Con- than every 6 years." This review is a routine part of the taminant Level (SMCL) of 2.0 mg/L, and requires con- EPA's operations as dictated by the SDWA. NPDWRs, or sumer notification by the water supplier if the fluoride primary standards,are legally enforceable standards that 40 American Dental Association • ,=,...k1.44.=.-..� .2r .. - .•-� sE � , �S`�' s�'t����r��e.•"� % r w i #.' o.r tom' r"� "i:�.� wee, '�_� k .r r �� A' � 6 �.�e�4 d • . .•" war cy'`e!,g r 'aa- ''' '41.5,14,.i' „£.4 S!* ''f 3' ''it,: v, f�,y i ..ry'+`.. ' 0 �.. -4 £” , .. . . , r.S €�„ '•¢,`y A . , t ,gyp . .€t:�Y `` QueStlonS, 2.49 xu/�' 7�" f 'M'+¢20'�{1�-. .. •'�f��.. • Rw°._ A4 • F g'#0'i:g�"`}�'�r`'.�lj„<,X.�t r..T�Ee apply to public water systems. Primary standards protect pealed FDA's jurisdiction over drinking water as a 'food' public health by limiting the levels of contaminants in under the Federal Food,Drug and Cosmetic Act(FFDCA). drinking water. Under the agreement, EPA enjoys exclusive regulatory In April 2002, the EPA announced the results of its authority over drinking water served by public water preliminary revise/not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re supplies, including any additives in such water. FDA re- viewed. The EPA determined that it fell under the "Not tains jurisdiction over bottled drinking water under Sec- Appropriate for Revision at this Time” category,but not- tion 410 of the FFDCA and over water(and substances in ed that it planned to ask the National Academy of Sci- water) used in food or food processing once it enters the ence (NAS) to update the risk assessment for fluoride. food processing establishment."155 The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 f „r I".-- s by the National Research Council. 'From time to trmefstates and` At the request of the NAS, the National Researchcommunities have had'to deal with Council's Committee on Toxicology created the Sub- " legislation or ballot initiatives armed at ; _ committee on Fluoride in Drinking Water to review regcrmg`the approval ofthe'FD�4before toxicologic, epidemiologic, and clinical data published since 1993 and exposure data on orally ingested fluo `'any agent can,be added to Community water ride from drinking water and other sources (e.g., food, systems 'OnLthe sur-fa`ce this may,appear toothpaste, dental rinses). Based on this review the to,'be a,'common sense approach Subcommittee will evaluate the scientific and technical `However its only real purposeIsco defeat basis of the EPA's maximum contaminant level (MCL) of effgrts`to provide water fluor`rdatron k, ;, 4 milligram per liter(mg/L or ppm) and secondary maxi- 1 Ma 0k . - _ That rs because it-would require mum contaminant level (SMCL) of 2 mg/L for fluoride in „---:,----_---- -,7 :3,,,,:;:.1 drinking water and advise EPA on the adequacy of its the FDA which oes NOT regulate fluoride MCL and SMCL to protect children and others 4, watersyster»s T tD approve any,water a; from adverse health effects. Additionally, the Subcom- additive. By mistakenly(andfperhaps craftily) mittee will identify data gaps and make recommenda- naming{the wrongfedeiral agency, tions for future research relevant to setting the MCL and the probable outcomeas tostop or , SMCL for fluoride. - ' f The Subcommittee began its work in November 'TLprevent water fluorrdat�on 2002 and is currently projected to complete the project ” "' in early 2006.173 From time to time, states and communities have had to deal with legislation or ballot initiatives aimed at re- quiring the approval of the FDA before any agent can QUESTION 43. be added to community water systems. Often referred Who regulates drinking water additives in United States? to as the Fluoride Product Quality Control Act, Water Answer. Product Quality Ordinance or Pure Water Ordinance,the The United States Environmental Protection Agency legislation is specifically used by those opposed to wa regulates drinking water additives. ter fluoridation as a tool to prevent water systems from providing community water fluoridation. Often this leg- Fact islation does not mention fluoride or fluoridation.Those In 1974, Congress passed the original Safe Drinking supporting this type of legislation may claim that they Water Act (SDWA) which protects the public's health by are not against water fluoridation but are proponents regulating the nation's public drinking water supply.299 The SDWA,as amended in 1986 and 1996,299 requires of pure water and do not want anything added to water the U.S. Environmental Protection Agency (EPA) ensure that has not been approved by the FDA. the public is provided with safe drinking water.155 On the surface, this may appear to be a "common On June 22,1979,the U.S.Food and Drug Administra- sense" approach. However, its only real purpose is to tion (FDA) and the EPA entered into a Memorandum of defeat efforts to provide water fluoridation. That is be- Understanding (MOU) to clarify their roles and respon- cause it would require the FDA—which does NOT reg- sibilities in water quality assurance. The stated purpose ulate water systems — to approve any water additive. of the MOU is to "avoid the possibility of overlapping jurisdiction between the EPA and FDA with respect to By mistakenly (and perhaps craftily) naming the wrong control of drinking water additives. The two agencies federal agency,the probable outcome is to stop or pre- agreed that the SDWA's passage in 1974 implicitly re- vent water fluoridation. Fluoridation Facts 41 y - - 4 v�' t s ¢ x T ' „� l A i, - % tea, -°.'� r 3-E40 • 'i,t '^iak -+id i ..,. EBF ' • QUESTION 44. no soluble materials or organic substances in quanti- What standards have been established to ensure .the ties capable of producing deleterious or injurious ef- safety of fluoride additives used in community water fects on the health of those consuming water that has fluoridation in the United States? been properly treated with the [fluoride compound]." Certified analyses of the additives must be furnished Answer. by the manufacturer or supplier.60 The three fluoride additives used in the U.S. to fluori- NSF Standard 60 ensures the purity of drinking wa date community water systems (sodium fluoride, so- ter additives. NSF Standard 61 provides guidance for dium fluorosilicate, and fluorosilicic acid) meet safety equipment used in water treatment plants. The NSF/ standards established by the American Water Works ANSI Standards were developed by a consortium of Association(AWWA)and NSF International (NSF). associations including NSF, AWWA, the Association of State Drinking Water Administrators and the Con- Fact. ference of State Health and Environmental Manag- Additives used in water treatment meet safety stan ers with support from the EPA. In part,they establish dards prepared in response to a request by the Environ minimum requirements for the control of potential mental Protection Agency (EPA) to establish minimum adverse human health effects from products added to requirements to ensure the safety of products added to water for its treatment.303'304 water for its treatment, thereby ensuring the public's Fluoride additives, like all of the more than 40 addi- health. Specifically, fluoride additives used in water tives typically used in water treatment, are "industrial fluoridation meet standards established by the Ameri grade" additives. The water supply is an industry and can Water Works Association (AWWA) and NSF Inter all additives used at the water plant are classified as in- national (NSF). Additionally, the American National dustrial grade additives. Examples of other "industrial Standards Institute (ANSI) endorses both AWWA and grade" additives which are commonly used in water NSF standards for fluoridation additives and includes plant operations are chlorine (gas), ferrous sulfate, hy- its name on these standards. drochloric acid,sulfur dioxide and sulfuric acid.36 The American Water Works Association is an interna Sometimes antifluoridationists express the view that 44. the are not reallyopposed to fluoridation, but are op- tional nonprofit scientific and educational society dedi- y pp 45. cated to the improvement of drinking water quality and posed to the use of"industrial grade"fluoride additives. supply. AWWA is the authoritative resource for knowl- They may even go so far as to state that they would sup- 46. edge, information, and advocacy to improve the quality port fluoridation if the process was implemented with and supply of drinking water in North America and be- pharmaceutical grade fluoride additives that were ap- yond. Founded in 1881, AWWA is the largest organiza- proved by the Food and Drug Administration (FDA). On tion of water supply professionals in the world.300 the surface, this may appear to be a "common sense" NSF International, a not-for-profit, non-governmental approach. In fact,this is usually a ploy whose only real organization, is the world leader in standards develop- purpose is to stop fluoridation. The EPA, not the FDA, ment, product certification, education, and risk-man- regulates additives in drinking water. agement for public health and safety. For 60 years, NSF !, Additionl information on this topic may be found in has been committed to public health,safety,and protec- Question 43. tion of the environment. NSF is widely recognized for The claim is sometimes made that no studies on its scientific and technical expertise in the health and safety exist on the additives used in water fluoridation. environmental sciences. Its professional staff includes The scientific community does not study health effects engineers, chemists, toxicologists, and environmental of concentrated additives as put into water; studies are health professionals with broad experience both in pub- done on the health effects of the treated water. While lic and private organizations 301 sodium fluoride was the first additive used in water The American National Standards Institute (ANSI) is fluoridation, the use of silicofluoride additives (sodium a private, non-profit organization that administers and fluorosilicate and fluorosilicic acid) began in the late coordinates the U.S. voluntary standardization and con- 1940s. By 1951, silicofluorides had become the most formity assessment system. The Institute's mission is to commonly used fluoride additives in water fluorida- enhance both the global competitiveness of U.S. business tion.61 Many of the early studies on the health effects of and the U.S. quality of life by promoting and facilitating fluoridation were completed in communities that were voluntary consensus standards and conformity assess- using the silicofluoride additives, most generally fluo- ment systems,and safeguarding their integrity.302 rosilicic acid.3°6-31° However, at that time, the additives The purpose of AWWA standards for fluoride ad- used to fluoridate were not always identified in research ditives is to provide purchasers, manufacturers and reports. As the body of research on fluoridation grew, suppliers with the minimum requirements for fluoride it became evident that there was no adverse health ef- additives, including physical, chemical, packaging, fects associated with water fluoridation regardless of shipping and testing requirements. In part,the AWWA which fluoride additive was used. standards for fluoride additives state, "The [fluorideAdditional information on this topic may be found in compound] supplied under this standard shall contain Question 5. 42 American Dental Association 414 anctr.q'f_ �m• - _, 44 #w.,4;t -' 'L$' a"'f.f i - `:*'- "F` `.a a'�,•9 rt,R'" 'A".'.Tl44�4�, f.!?..; .s ot"- n' e • F° 4-6m .eRACyy�,C4 ;{Ys,, %. xAv°ersFarwr+'v'sw;#f 4. 4 •i." r d , -- • Additionally, over time, a number of comprehensive reviews of the health effects of fluoridation have been �- To ensure thepublics safety additives used in• published. These reviews which support the safety of water fluoridation meet standards of the American < water fluoridation include many studies conducted in Water Works"Association(AWWA)and NSF large fluoridated communities which used the silicoflu- ` International(NSF) oride additives.71,64,163,165,167,311-313 \ , Beyond the foundation that has been established through the overwhelming weight of credible, peer- Fluoride additives are valuable byproducts produced reviewed scientific evidence, there is over 60 years of as a result of producing phosphate fertilizer. To ensure practical experience that lends additional credence to the public's safety, additives used in water fluoridation the science that concludes that fluoridation is safe. meet standards of the American Water Works Associa- tion (AWWA)and NSF International (NSF). (+Additional information on this topic may be found in Question 44. QUESTION 45. What is the source of the additives used to fluoridate water supplies in the United States? QUESTION 46. Answer. Does the process of water fluoridation present unusual Fluoride additives used in the United States are derived safety concerns for water systems and water operators? from the mineral apatite. Answer. Fact. No. With proper planning, maintenance and monitor- The three fluoride additives used in the United States ing,water fluoridation is a safe process. for water fluoridation (sodium fluoride, sodium fluoro- silicate, and fluorosilicic acid) are derived,from apatite Fact. which is a type of limestone deposit used in the produc- Water plant facilities and water plant personnel per- tion of phosphate fertilizers. Apatite contains 3-7%fluo- form a valuable public service by carefully adjusting ride and is the main source of fluorides used in water the level of fluoride in water to improve the oral health fluoridation.36 of the community. Facilities and personnel are subject During processing, apatite is ground up and treated to a number of regulations designed to ensure safety. with sulfuric acid, producing phosphoric acid (the main The Occupational Safety and Health Administration ingredient in the production of phosphate fertilizer) plus (OSHA) provides guidelines for the safety of employ- a solid and two gases. The solid, calcium sulfate (also ees in the workplace.66•315 Additionally, the American known as gypsum) is the material used to form drywall Water Works Association publishes detailed guidance or sheetrock. The two gases, hydrogen fluoride and on safety and safe working conditions for water plant silicon tetrafluoride, are captured in water to form fluo- personnel. Furthermore, the Centers for Disease Con- rosilicic acid which today is the most commonly used trol and Prevention has established safety procedures fluoride additive in the United States.60 designed specifically for water plant operators in The two remaining fluoride additives(sodium fluoride charge of implementing fluoridation.315 Adherence to and sodium fluorosilicate) are derived from fluorosilicic these guidelines helps to ensure continuous levels of acid. Sodium fluoride is produced when fluorosilicic optimally fluoridated drinking water while maintain- acid is neutralized with caustic soda. Fluorosilicic acid is ing water operator safety. neutralized with sodium chloride or sodium carbonate As part ofthesafety procedures, water plant per- to produce sodium fluorosilicate.36 sonnel receive training on the management of the From time to time opponents of fluoridation al- chemicals/additives in water plants. While the optimal lege that fluoridation additives are byproducts of the fluoride concentration found in drinking water has phosphate fertilizer industry in an effort to infer the been proven safe, water plant operators and engi- additives are not safe. Byproducts are simply materi- neers may be exposed to much higher fluoride levels als produced as a result of producing something else when handling fluoride additives at the water treat- - they are by no means necessarily bad, harmful or ment facility.36 Fluoride additives present comparable waste products. In the chemical industry, a byproduct risks as other chemicals/additives in common use is anything other than the economically most important at water treatment facilities, such as hypochloride, product produced. Byproducts may have certain char- quick-lime, aluminum sulfate, sodium hydroxide and acteristics which make them valuable resources. For ferrous sulfate. In fact,the fluoride additives are much example, in addition to orange juice, various byprod- less dangerous than chlorine gas commonly used in ucts are obtained from oranges during juice produc- water plant operations. tion that are used in cleaners, disinfectants, flavorings Today's equipment allows water treatment personnel and fragrances.314 to easily monitor and maintain the desired fluoride con- Fluoridation Facts 43 centration.Automatic monitoring technology is,available solution feeders (metering pumps). By design, and with that can help to ensure that the fluoride concentration of proper maintenance and testing, water systems limit the the water remains within the recommended range. amount of fluoride that can be added to the system (i.e., It is important that the water treatment operators re- the use of a day tank that only holds one day's supply of sponsible for monitoring the addition of fluoride to the fluoride) so prolonged over-fluoridation becomes a me- water supply be appropriately trained and that the equip- chanical impossibility.36 ment used for this process is adequately maintained.316 As with any mechanical equipment, water fluoridation equipment should be tested, maintained and replaced as needed. With over 60 years of experience and thou- QUESTION 48. sands of water systems in operation, there have been Will fluoridation corrode water pipes or add lead,arse- remarkably few untoward incidents. nic and other toxic contaminants to the water supply? Answer. Allegations that fluoridation causes corrosion of water QUESTION 47 delivery systems are not supported by current scientific Does fluoridation present difficult engineering problems? evidence.36 Furthermore, the concentrations of con- taminants in water as a result of fluoridation do not ex- Answer. ceed, but, in fact, are well below regulatory standards No. Properly maintained and monitored water fluo- set to ensure the public's safety. ridation systems do not present difficult engineering problems. Fact. Water fluoridation has no impact on the acidity or pH of Fact. drinking water and will not cause lead and copper to be With proper planning and maintenance of the system, leached from water pipes. Corrosion of pipes by drink- fluoride adjustment is compatible with other water ing water is related primarily to dissolved oxygen con- • 47• treatment processes. Today's equipment allows water centration, pH, water temperature, alkalinity,-hardness, treatment personnel to easily monitor and maintain the salt concentration, hydrogen sulfide content and the 48' desired fluoride concentration. Automatic monitoring presence of certain bacteria. Under some water quality 49 technology is available that can help to ensure that the conditions, a small increase in the acidity of drinking fluoride concentration of the water remains within the water that is already slightly acidic may be observed af- recommended range. ter treatment with alum, chlorine, fluorosilicic acid or When added to community water supplies the con- sodium florosilicate. In such cases,further water treat- centrated fluoride additives become greatly diluted. ment is indicated by water plant personnel to adjust the For example, fluorosilicic acid is diluted approximately pH upward to neutralize the acid.This is part of routine 180,000 times to reach the recommended range of 0.7 water plant operations. Note that the Water Quality Re- to 1.2 parts per million. At 1 ppm, one part of fluoride port or Consumer Confidence Report that all water sys- is diluted in a million parts of water. Large numbers tems send to customers on a yearly basis, lists the pH such as a million can be difficult to visualize. While not of the system's finished water and compares that level exact, the following comparisons can be of assistance against the standard set at a pH of 7.0(neutral)or higher in comprehending one part per million: indicating that the water leaving the plant is non-acidic. 1 inch in 16 miles (&Additional information on this topic may be found in 1 minute in 2 years Question 4. 1 cent in$10,000 A 1999 study316 charged that fluorosilicic acid and so- dium silicofluoride did not disassociate completely when € "r added to water systems and may be responsible for low- "'Because theref�s more than 60'years of '" er pH levels of drinking water,leaching lead from plumb- experience with water fluoridation there.isfr ing systems and increasinglead uptake by children. cons►derable guidance on sound engineering - In response to the study, scientists from the U.S. En- r4.to design, construct, operaste and vironmental Protection Agency (EPA) have reviewed the mrntarn waterfluorrdation systerras basic science that was the foundation for the claim that ,,rd. ? silicofluorides leach lead from water pipes and found that many of the chemical assumptions made in the Because there is more than 60 years of experience original research were scientifically unjustified. Fluoride with water fluoridation,there is considerable guidance on additives do disassociate very quickly and completely . sound engineering practices to design,construct, operate releasing fluoride ions into the water. The research was and maintain water fluoridation systems. Fluoride addi- inconsistent with accepted scientific knowledge and the • tives are introduced to the water supply as liquids,but are authors of the original studies failed to identify or account measured by two basic types of devices, dry feeders or for these inconsistencies. The EPA scientists discounted 44 American Dental Association • },� a - `` , +? t '�.r.on6 &'lt'!'+ 'e*r}sq• a a�.'1 �3'�X •sw r. *' ,S.'� � F �. a rk y:+ `$`5 ,.a. '' ;Ai . ' .4 .c91 Y' . "� �.. : xt F .. R `' fi sr h ry.i'..` c• - r x . � n 4 a F RIDAT°IO•N►PRACTICE • this study and said there was no credible data to suggest motes any link between fluoridation and lead.285 Fluorosilicic acid is the additive used to fluoridate the vast majority of community water systems in the U.S. Be- cause it is a natural substance derived from apatite which is mined from the earth, fluorosilicic acid may contain minute amounts of contaminants such as lead and arse- nic. However, existing regulations and standards require that these contaminants, including arsenic and lead, be at levels considered safe by the EPA when the fluorosilicic acid is diluted to produce optimally fluoridated water.317.3'9 Evidence of testing by the fluoride additive manufacturer documents that the concentrations of these contaminants do not exceed,but,in fact,are well below regulatory stan- dards set to ensure the public's safety. Most batches of the — additive do not contain any detectable amount of either lead or arsenic. On average, the concentration of arsenic and lead in optimally fluoridated drinking water created using fluorosilicic acid is less than 0.1 part per billion 319 QUESTION 49. Does fluoridated water harm the environment? Answer. Scientific evidence supports the fluoridation of public water supplies as safe for the environment and benefi- cial for people. Fact. The U.S. Environmental Protection Agency (EPA) has set an enforceable Federal drinking water standard for fluoride at 4.0 mg/L. As long as the 4.0 mg/L standard is not exceeded, State and local authorities determine whether or not to fluoridate.32o Under,`the Washrngtons State EnvironmentalProtection_Act(SEPA) ad study'concluded that there are'no probable significant adverse environmental impacts Under the Washington's State Environmental Protec- tion Act(SEPA),a study was conducted in Tacoma-Pierce County to investigate the environmental consequences of adding optimal levels of fluoride to drinking water. Noting that the amount of fluoride in the water does not reach levels that are harmful to plants or animals, the SEPA study concluded that there are "no probable significant adverse environmental impacts."321 There is no evidence that optimally fluoridated wa- ter has any effect on gardens, lawns or plants.322 A comprehensive literature review conducted in 1990 revealed absolutely no negative environmental impacts as a result of water fluoridation. Historically, issues surrounding problems with fluoride and the en- vironment have involved incidents related to industrial pollution or accidents.323 Fluoridation Facts 45 �„ - - ,� F+ � i ,.vu •' ice. _.";_7!? n.�; ._}e $ aryn. • Y °' ,.3•v1t'e as • PUBLIC POLICY Q 50. Valuable measure? p.46 Q 53. Internet? p.51 Q 56. Banned in Europe? p.54 Q 51. Courts of law? p.47 Q 54. Public votes? p.51 Q 52. Opposition? p.47 Q 55. International fluoridation?p.54 QUESTION 50. t kap 1 �j a, 'Farmer U S Surgeon iGeneral David Is water fluoridation a valuable public health measure? Satcher noted that water fluoridation Is a. Answer. powerful strategy iia=efforts to eliminate ;:€'', Yes. Water fluoridation is a public health measure that health disparntres among populations ' J�< benefits people of all ages, is safe and is a community public health program that saves money. In 1999,the Centers for Disease Control and Preven- Fact. tion named fluoridation of drinking water one of ten Throughout decades of research and more than 60 years great public health achievements of the 20th century of practical experience, fluoridation of public water sup- noting that it is a major factor responsible for the de- plies has been responsible for dramatically improving the cline in dental decay.1,2 Former U.S. Surgeon General public's oral health status. Former Surgeon General of the David Satcher, issued the first ever Surgeon General United States,Dr. Luther Terry,called fluoridation as vital a 50. report on oral health in May 2000. In Oral Health in public health measure as immunization again disease,pas America:A Report of the Surgeon General, Dr. Satcher 51. teurization of milk and purification of water. Another for stated that community water fluoridation continues to mer U.S. Surgeon General Dr. C. Everett Koop stated that be the most cost-effective, practical and safe means 52. fluoridation is the single most important commitment that for reducing and controlling the occurrence of dental a community can make to the oral health of its citizens. decay in a community. Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts "F.ormer.US Surgeon General Dr C'Everett }= to eliminate health disparities among populations. Koopstated that;fluor�datron is' Studies have shown that fluoridation may be the most the stnglermost!mp""octant comr fitment significant step we can take toward reducing the dis- that community can make to the . parities in dental decay.21-24 In the 2003 National Call to .r ,, Action to Promote Oral Health, U.S. Surgeon General oral health oftts citizens � � Richard Carmona called on policymakers, community leaders, private industry, health professionals, the me- In 1994, the U.S. Department of Health and Human dia and the public to affirm that oral health is essential Services issued a report which reviewed public health to general health and well being.Additionally,Surgeon achievements. Along with other successful public health General Carmona urged these groups to apply strat- measures such as the virtual eradication of polio and re- egies to enhance the adoption and maintenance of ductions in childhood blood lead levels,fluoridation was proven community-based interventions such as com- lauded as one of the most economical preventive values in munity water.fluoridation.25 the nation." A policy statement on water fluoridation reef- Community water fluoridation is a most valuable firmed in 1995 by the U.S. Public Health Service(USPHS) public health measure because: stated that water fluoridation is the most cost-effective, • Optimally fluoridated water is accessible to the entire practical and safe means for reducing the occurrence community regardless of socioeconomic status, edu- of dental decay in a community.18 In 1998, recognizing cational attainment or other social variables;26 the ongoing need to improve health and well being, the • Individuals do not need to change their behavior to USPHS revised national health objectives to be achieved obtain the benefits of fluoridation. by the year 2010. Included under oral health was an ob- • Frequent exposure to small amounts of fluoride over jective to significantly expand the fluoridation of public time makes fluoridation effective through the life water supplies. Specifically, Objective 21-9 states that at span in helping to prevent dental decay. least 75% of the U.S. population served by community • Community water fluoridation is more cost ef- water systems should be receiving the benefits of opti- fective than other forms of fluoride treatments or mally fluoridated water by the year 2010.19 applications.27 46 American Dental Association ,. x ' -E.'' -" +.,J.'. . s. cad 4 agyr v'w '' M. .. : esti:!,,r,.."..-:;44,i,``e•tseY lis ^`e ,x. � Ir ���. d .^„ w`sY �� a'' � 2 ',$, 'e"• s_�..n r. �S'�-e��-s�Ze�, ti ` ��� - �'sS��. • +,�.: er p" `�r.`y4 j:k. "s�`��� �� �„' *.�'a $'w* � � s� L �,(�i.x re�• s,� fP S x :W`Ea r �' •: a �est � �� ,y 4A`7& .f.4 to+ s.r�x e 4}p ,n�s{Y° '"'e_e _t 4_ac�,tn.aa-.,� r`Egr'y _ A '4''^,;r a s .s 'ea'- Quest�ons��56 `� `"C.. ,,•*.,r•9 .I A Mex. ' s 5- t QUESTION 51. Fluoridation is the adjustment of a naturally occur- Has the legality of water fluoridation been upheld by ring element found in water in order to prevent dental the courts? decay. Courts have consistently ruled that water fluo- ridation is not a form of compulsory mass medication or socialized medicine.325-325-33° Fluoridation is simply Answer. the adjustment of a naturally occurring element found Yes. Fluoridation has been thoroughly tested in the in water in order to prevent dental decay. In fact, water United States' court system, and found to be a proper that has been fortified with fluoride is similar to forti- means of furthering public health and welfare. No court fying salt with iodine, milk with vitamin D and orange of last resort has ever determined fluoridation to be juice with vitamin C—none of which are medications. unlawful. Moreover,fluoridation has been clearly held not to be an unconstitutional invasion of religious free- dom or other individual rights guaranteed by the First, To`ADAs knowledge netfin`al ruling rn any �. Fifth or Fourteenth Amendments to the U.S. Constitu- ,of those(cas'':,,1"'-.4_ ,„rs has found fluoridation to;be tion. And while cases decided primarily on procedurald grounds have been won and lost by both pro and anti anything utsafe and effective fluoridation interests,to ADA's knowledge no final rul- ing in any of those cases has found fluoridation to be In recent years, challenges to fluoridation have anything but safe and effective. been dismissed for a variety of reasons, including that plaintiffs admitted they could not establish injury by x:,MYcoart of last resort has ever virtue of fluoridation, and that state law supporting r mined;fluondation to be un'la'wful fluoridation prevailed over local attempts to oppose dete fluoridation. Interestingly, pro and anti fluoridation The Highest courts of morethan a;dozen interests have each won and lost legal challenges re- states:'have,confrmed the constrtutionattty garding which state or local agency has regulatory ,of fluoridation authority over fluoridation, which of course varies by ✓ � . state and locality. State law variances have also led to different rulings on other issues, such as whether Fact. downstream end users of fluoridation must be given During the last sixty years, the legality of fluoridation in an opportunity to vote on whether to fluoridate.While the United States has been thoroughly tested in our court cases decided primarily on procedural grounds have systems. Fluoridation is viewed by the courts as a proper been won and lost by both pro and anti fluoridation means of furthering public health and welfare 324 No court interests, to ADA's knowledge no final ruling in any of of last resort has ever determined fluoridation to be un- those cases has found fluoridation to be anything but lawful. The highest courts of more than a dozen states safe and effective. have confirmed the constitutionality of fluoridation.325 In 1984,the Illinois Supreme Court upheld the constitution- ality of the state's mandatory fluoridation law, culminat- ing 16 years of court action at a variety of judicial levels.326 QUESTION 52. Moreover, the U.S. Supreme Court has denied review of Why does opposition to community water fluoridation fluoridation cases thirteen times,citing that no substantial continue? federal or constitutional questions were involved 325 It has been the position of the American courts that Answer. a significant government interest in the health and wel- Fluoridation is considered beneficial by the overwhelm- fare of the public generally overrides individual objec- ing majority of the health and scientific communities tions to public health regulation.333 Consequently, the as well as the general public. However,a small faction courts have rejected the contention that fluoridation continues to speak out against fluoridation of municipal • ordinances are a deprivation of religious or individual water supplies. Some individuals may view fluoride- freedoms guaranteed under the Constitution.325.327 In tion of public water as limiting their freedom of choice; reviewing the legal aspects of fluoridation, the courts other opposition can stem from misinterpretations or have dealt with this concern by ruling that: (1)fluoride inappropriate extrapolations of the science behind the. is a nutrient, not a medication, and is present naturally fluoridation issue. in the environment; (2) no one is forced to drink fluo- ridated water as alternative sources are available; and Fact. (3) in cases where a person believes that fluoridation A vast body of scientific literature endorses water fluo- interferes with religious beliefs,there is a difference be- ridation as a safe means of reducing the incidence of tween the freedom to believe, which is absolute, and dental decay. Support for fluoridation among scientists the freedom to practice beliefs,which may be restricted and health professionals, including physicians and den- in the public's interest 326.329 tists, is nearly universal. Recognition of the benefits of Fluoridation Facts 47 —'� ' -Tye 5114 41„ig '.j 3 e`sn.:" -1441m4'021M-M '14m.......�_..s �x-..., � � t+c.. *` "€ � fluoridation by the American Dental Association, the tinues today with over 60 years of practical experience American Medical Association, governmental agencies showing fluoridation to be safe and effective. An article and other national health and civic organizations con- that appeared in the local newspaper shortly after the tinues as a result of published, peer-reviewed research. first fluoridation program was implemented in Grand (See Compendium at back of booklet.) Rapids, Michigan, noted that the fluoridation program The majority of Americans also approves of water was slated to commence January 1 but did not actually fluoridation. In June 1998,the Gallup Organization con- begin until January 25. Interestingly, health officials in ducted a national survey of just over 1,000 adults on their Grand Rapids began receiving complaints of physical attitudes toward community water fluoridation. When ailments attributed to fluoridation from citizens weeks asked, "Do you believe community water should be fluo- before fluoride was actually added to the water.342 ridated?",70%answered yes, 18%answered no and 12% Since that time, antifluoridation leaders and orga- responded don't know (Figure 5). Results characterized nizations have come and gone, but their basic beliefs by U.S. Census Region showed the level of support for have remained the same.These include:fluoride is tox- community water fluoridation to be relatively constant is and causes numerous harmful health effects;fluoride throughout the United States,with 73% in the Northeast, does not prevent dental decay; fluoridation is costly; 72% in the Midwest, 68% in the South and 70% in the and fluoridation interferes with freedom of choice and West favoring community waterfluoridation.331 These re- infringes on individual rights. sults are consistent with a December 1991 Gallup survey While the arguments against fluoridation have re- that asked 1,200 parents, "Whether or not you presently mained relatively constant over the years, the antifluo- have fluoridated water, do you approve or disapprove of ridationists have used different approaches that play fluoridating drinking water?" More than three-quarters upon the popular concerns of the public at the time. For (78%) of the responding parents approved, 10% disap- example, in the 1950s fluoridation was a Communist proved and 12% answered don't know or refused to an- plot. With America's growing concern for environmen- swer the question (Figure 6). Disapproval ranged from tal issues in the 1960s,fluoridation was pollution. After 4% in communities where water was fluoridated to 16% the Vietnam War in the 1970s, the antifluoridationists in communities where it was not.332 capitalized on the popularity of conspiracy theories by 52. Of the small faction that opposes water fluoridation portraying fluoridation as a conspiracy between the for philosophical reasons, freedom of choice probably U.S. government,the dental-medical establishment and stands out as the most important single complaint.333 industry. As Americans became more concerned about Some individuals are opposed to community action on their health in the 1980s, antifluoridationists claimed any health issue, others because of environmental or fluoridation caused AIDS and Alzheimer's disease. In economic arguments and some because they are mis- the 1990s, claims of hip fractures and cancer were de- informed. signed to resonate with aging baby boomers. With the Opposition to fluoridation has existed since the initis new millennium, overexposure and toxicity, in associa- ation of the first community programs in 1945 and con- tion with lead and arsenic poisoning, have surfaced as Figure 5. 1998 Consumers'Opinions Figure 6. Approval of Fluoridating Regarding Community_Water Fluoridation331 Drinking Water332 Do You Believe Community Water Should Whether or Not You Presently Have Fluoridated Be Fluoridated?-.'YWater Do You Approve or,;Disapprove of Fluoridating DrinkingWater?7 _ 77777Yes s. 70% Approve L 78% No --- 18% Disapprove =- 10% Don't Know �4t==•xv" 120�o Dant Know/ 12% Refused 11111111 1 1 1 0 10% 20% 30% 40% 50% 60% 70% 80% 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Adults Percent of Parents 48 American Dental Association • ,. * , BLl SPO ICY ;`-'4` ... �. �•� � .�" -.�.€: ��a:: ��w'S� r��A3. r � -... � �'. Y' �' •..a*y�s` Ewe ' c ',�, v, ar. common themes. None of these approaches has ever In 1993 the U.S.Supreme Court issued a landmark de- really disappeared, but are often recycled as antifluo- cision that many view as likely to restrict the use of junk ridationists choose which approach will have the most science in the federal courts and in those state courts effect on the intended audience.333 which adopt this reasoning. The Court determined that Antifluoridationists have eagerly embraced technol- while "general acceptance" is not needed for scientific ogy such as videos and the Internet to spread their mes- evidence to be admissible, federal trial judges have the sage to the public. These two venues have allowed the task of ensuring that an expert's testimony rests on a small faction of antifluoridationists to be linked across reasonable foundation and is relevant to the issue in the country and around the world and promote their question. According to the Supreme Court, many con- message economically. siderations will bear on whether the expert's underlying A number of opposition videos are available from na reasoning or methodology is scientifically valid and ap- tional antifluoridation organizations. These economical plicable in a given case. The Court set out four criteria ly-priced videos make it affordable for every campaign to bring an antifluoridationist to the community via local judges could use when evaluating scientific testimony: cable access television. However,it has been the Internet (1) whether the expert's theory or technique can be (and that has breathed new life into the antifluoridation effort. has been)tested,using the scientific method, The Internet has brought the antifluoridation message . (2) whether it has been subject to peer review and pub- into voters'homes. With just a click of the mouse,search lication (although failing this criteria alone is not nec- engines can locate hundreds of Web sites denouncing essarily grounds for disallowing the testimony), fluoridation,which may give the impression that this is a (3) its known or potential error rate and the existence and one-sided argument. Individuals who look to the Internet maintenance of standards in controlling its operation as a source of reliable information may fail to recognize and that these sites often contain personal opinion rather (4) whether it has attracted widespread acceptance within than scientific fact. Newspaper stories, press releases a relevant scientific community, since a known tech- and letters to the editor are often posted as documenta- nique that has been able to attract only minimal sup- tion of the "science" behind antifluoridationists' claims. port may properly be viewed with skepticism. All too often,the public accepts this type of information - The scientific validity and relevance of claims made by as true simply because it is in print. opponents of fluoridation might be best viewed when The techniques used by antifluoridationists are well measured against these criteria.341 known and have been discussed at length in a number of published articles that review the tactics used by an- tifluoridationists.325.333.335-339 Examples of a few of the °- "° '�":" - "•"" techniques can be viewed in Figure 7 on the next page. Opinions are seldom unanimous on-; anyIn fact there may, be no such;thrng as finalknowledge 'Reputable scrence rs based on the k since new information rs l contrnuousy scientific method of testing hypotheses rn; emerging- and:being drssemd.'A inates such, ways that canlbe reproduced and verrfied;tiy th'e benefit evrdenc'e must be continuelly others,junk Science-Which often p"rovrdes weighed against risk evidence =too simple answers to complex questions, Health',professionals`decision makers and often cannot be substantiated' s _ the public should becooperat►ng'partners rn;the quest for accountability where .' "Junk science," a term coined by the press and used 'ill'decisions are based on proven benefits over the past decade to characterize data derived frommeasured against vernfled asks ' x atypical or questionable scientific techniques, also can play a role in provoking opposition to water fluorida- tion. In fact, decision makers have been persuaded to Opinions are seldom unanimous on any scientific sub- postpone action on several cost-effective public health ject. In fact,there may be no such thing as "final know) measures after hypothetical risks have made their way into the public media.340 Junk science impacts public edge," since new information is continuously emerging and being disseminated. As such, the benefit evidence policy and costs society in immeasurable ways. More people, especially those involved in policy decisions, must be continually weighed against risk evidence.Health need to be able to distinguish junk science from legiti- professionals, decision makers and the public should be mate scientific research. Reputable science is based on cooperating partners in the quest for accountability where the scientific method of testing hypotheses in ways that decisions are based on proven benefits measured against can be reproduced and verified by others;junk science, verified risks 335 which often provides too-simple answers to complex 6-Additional information on this topic may be found in questions,often cannot be substantiated. the Introduction and Figure 1. Fluoridation Facts 49 4' -H . #Y ¢ al .a9a0� FCr 4f,rsia, sr ' ukr-i , ,, tr •� A i3zR3,.aaasrt, • • :Figure'? Opposition Tactics t. k„...;,..k..,.._ } � ,' ?rargetrneg Politicians erid `' ,_ Claimed that fourteen Nobel -Prize winners have = Ct►aii €uilii Lea+dei opposed or expressed reservations about fluori ':,-.-_7..t'_-5--_2-,'-_.---1,:;=5,,='_--._f',,--.;'_:1t•'.,_,::,-_,i-`'--,.,'--,.-c,---i-.-,;-',_i,.:";:-,,;,'--.%T-_,---7.-7,-=,.:.,-,1:-u;-1-::.,:,':-:_J:_.:-;,,-:::':.',:„.;=„,--:_--:,.▪i'-:Z'-.-i,:,,;„i:-,::;'':,f:,-,:..--''-i,_:.-- Cntifluoridation Web sites contain draft letters to be dation It should-be noted that the vast:majority -_ sent to newspaper publishers water ..departments • of these individuals=were awarded their prizes from and community public_ofticials warning them of their ▪ 1929--through 1958 ,v liability'should they support or;endorse water fluo sdation,:Leaders--are urged to remain neutral and �tateiiierits 9ut'n1F99text _ One< of the;_-most repeated antifluoridation state allow fluoridation decisions to be°put to a public vote merits is Fluoride:;is a toxic chemical Dont let _- therefore relieving;the leaders of'any and all respon them put rt in our water :This statement ignores si,bilrty in the matter Antifiuoridationists,use the time the scientific principle that toxicity is related,'to gained to.-conduct a public referendum to bombard dosage andrnot just to exposure;to a substance the public_with misinformation designed to turn pub ,,Examples of,other substances that can-be harmful :: iicopinion'againstfluoridation ▪ in the wrong amounts but beneficial in the correct Unproven Cl ares amounts are"salt vitamins A and D iron,`Iodine,as Antifluondationists have" repeatedly claimed-fluo pine and even water itself -,: ridation^causes an entire laundry.list.:of human SII ln: another example a ,press release -from the nesses including AIDS Alzheimers disease cancer ! New_'York State Coalition Opposed to Fluoridation' ;' Down Syndrome; genetic darriage heart disease (NIYSCOF)posted-on the Internet in°August;2001 and a ain in March 2005 stated Fluoridation;is based - ,_:_,-,,:,',';_::,=::;.,:'--1:,!:i:1_--:„:-7;:.:--.-f:..-:E--'_.1' lower intelligence; kidney tlrs- and osteoporosis 9. (hip factures) These a)legations"'are:often repeated ▪ -= more on unproven theories=than scientific evidence so frequently during campaigns'that the public as according to a revised dental textbook by-leaders in 53. sumes they must`bo-true;Their-appearance in:print n the field The press release also includes`a number 54. even if only in letters to the editor of thelocal news of items quoted from the textbook The American paper reinforces_the allegations credibility With Dental Association contacted the_textbook author`s just a small_amount of doubt established;::the.op - who_immediately wrote a letter responding to the position slogan 'if in doubt,,vote it out; may-ring_ press release Drs Brian A `Burt and Dr Stephen A y true with'voters ▪ Eklund responded The NYSCOF article takes a se= • nes of disconnected quotes from our textbook(Burt Innuendo BA Eklund SE The Dentist Dental Practice and The statement Fifty years ago physicians and den ,the.Community 5i°:edition Philadelphia _Saunders,_;; ---1-1-ests posed for cigarette ads is an examplp.„.,-91_,i nu 199,9) and puts its own interpretation on them The endo or more specifically_guilt-'by association Even ` .result is to,portray Drs Burt-and,•Eklund as being op -` though fluoridation is riot-mentioned individuals are posed to fluo_ridation which is most definitely not expected_to make the connection that:the medical the case community changed its position on smoking so_,_it is possible health professionals are wrong about fluori • ®viitg Targets- ; dation too: In venues ranging from the media to the courts • opponents have been known to-shift their_:theories`V_ utdated studies acid Statements of_opposition frequently and mid=stream=-This of - frimtri 'Experts` ten appears=to occur when one of their originally Antifluoridation.Web sites often offer a:list of're _ advanced points of_opposition has been:unveiled spected medical professionals and scientists who as being without merit Some examples -A parent have spoken out_against fluoridation One of those s- who told the-media_that he would need`to move -` often quoted is Dr Charles Gordon Neyd who isnot his family out of town because of past allergies ed to be-,•a•Past President of they-American Medical to,fluoride..had,to change f is position after_f was' `- Association (AMA) What is not disclosed rs'the disclosed that the family had previously lived in a source of the quote or that Dr Heyd was President fluoridated_tommunity ,and; oppo'nentsfiling -:re ,_ of the AMA in 1936 almost ten years-before wa • peated amendments to their legal complaints m ter.fluoridation trials began His decades old quote one:.case moving from an al_l out,attack to the_posi certainly--does not represent the, • TO -11' � ..•+9 f 4-7'1s .s • uw o r�Cn`t - •. _ ' P. ' QLICY~b x ," Rzti._ ,�: ;-. ., '• rr "'' _ r� I•.. s-::..7 � 0 .* � iP � _ . '' �.t .'!-. � , 7,,,.,,...:4,iJ ��F°f ,. QUESTION 53. QUESTION 54. Where can reliable information about water fluoride- Why does community water fluoridation sometimes tion be found on the Internet and World Wide Web? lose when it is put to a public vote? Answer. Answer. The American Dental Association,as well as other rep- Voter apathy or low voter turnout due the vote being utable health and science organizations, and govern- held as a special election or in an "off"year,confusing ment agencies have sites on the Internet/Web that pro- ballot language (a "no" vote translates to support for vide information on fluorides and fluoridation. These fluoridation),blurring of scientific issues,lack of leader- sites provide information that is consistent with gener- ship by elected officials and a lack of political campaign ally accepted scientific knowledge. skills among health professionals are some of the rea- sons fluoridation votes are sometimes unsuccessful. Fact. The Internet and World Wide Web are evolving as ac- Fact. cessible sources of information. However, not all "sci- Despite the continuing growth of fluoridation in this ence" posted on the Internet and World Wide Web country over the past decades, millions of Americans is based on scientific fact. Searching the Internet for do not yet receive the protective benefits of fluoride in "fluoride" or "water fluoridation" directs individuals their drinking water. Centers for Disease Control and to a number of Web sites. Some of the content found Prevention (CDC) data from 2002 indicate, only two- in the sites is scientifically sound. Other less scientific thirds (67.3%) of the population served by public water sites may look highly technical, but contain information systems have access to fluoridated water.34 Forty-two based on science that is unconfirmed or has not gained of the 50 largest cities in the U.S. have adopted fluo- widespread acceptance. Commercial interests, such as ridation. Another two have natural optimal levels of the sale of water filters,may also be promoted. fluoride (Figure 9). The remaining six nonfluoridated One of the most widely respected sources for infor- cities are: Fresno, California; San Jose, California; Col- mation regarding fluoridation and fluorides is the Ameri- orado Springs, Colorado; Honolulu, Hawaii; Wichita, can Dental Association's (ADA) Fluoride and Fluoridation Kansas and Portland, Oregon. In 1998, recognizing the Web site at http:www.ada.org/goto/fluoride (Figure 8). ongoing need to improve health and well being, the From the ADA Web site individuals can link to other Web U.S. Public Health Service revised national health ob- sites, such as the Centers for Disease Control and Pre- jectives to be achieved by the year 2010. Included un- vention, National Institute of Dental and Craniofacial Re- der oral health was an objective to significantly expand search, Institute of Medicine, National Cancer Institute, the fluoridation of public water supplies. Specifically, and state/local health departments for more information Objective 21-9 states that at least 75% of the U.S. popu- about fluoride and water fluoridation. lation served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2010.19 Although water fluoridation reaches Figure 8. Fluoride and Fluoridation Web-Page some residents in every state, 2002 data indicates that FLUORIDATION AT YOUR FINGERTIPSI only 24 states are providing these benefits to 75% or http//www ada org/goto/fluoride more of their residents.34 (Figure 10). Social scientists have conducted studies to exam- • ADA Fluoridation Resources ine why fluoridation fails when put to a public vote. • Fluoridation Facts Online Among the factors noted are lack of funding, public • ADA Fluoridation News Stories and professional apathy,the failure of many legislators • ADA Policy and Statements and community leaders to take a stand because of per- • Links to Additional Fluoridation Web Sites ceived controversy, low voter turnout and the difficulty faced by an electorate in evaluating scientific informa- /C.D�. American Dental Association® tion in the midst of emotional charges by opponents. Unfortunately, citizens may mistakenly believe their America's leading advocate for oral health water contains optimal levels of fluoride when, in fact, www.ada.org it does not. Many ADA resources are at your fingertips 24/7/365. •, r i Order a library book or products online, read JADA ; Clevr umn ese-of eotioallyeharged 4scare articles,discuss important topics with colleagues,find helpful information on professional topics from accredi- - i propaganda by'flu0/'ide opponents creates tation to X-rays and recommend our dental education fear confusion.'and doubt within animations stories and games to your patients a comrnunity when voters consider the" }T . - use of fluoridation Be resourceful Visit ADA org today) Fluoridation Facts 51 if Alg . . ri:P inn s. Vie), -,*fir `4:g G 1 a w ,r 0.. - aL • Figure 9. Forty-Two of the Fifty Largest Cities in the U.S. are Supplied with Fluoridated Water* Two cities(Jacksonville,FlondEI oa and PasTxa es)are naturally fluoridated'; Seattle O ' ii Minneapolis illi • ...„ eBoston Milwaukee j a Detroit Cleveland NewYork Chicago Philadelphia Sacramento Omaha Columbus • ' p Oakland • • •Baltimore ® Indiana Indianapolis Washington San Francisco Denver Kansas City p )(jj Las Vegas St.Louis \I} • =Virginia Beach Nashville-Davidson Los Angeles Tulsa • Charlotte • • Long Beach Albuquerque Oklahoma City a emphis ••Mesa Phoenix Atlanta • Fort Worth ••Dallas 54' El Paso(natural) Jacksonville(natural) / Austin• Houston New Orleans San Antonio • • 0 O QMiami d . °aA O�o^o43b V Datacompiled bythe American Dental Aocaion and Centers forDisease ControlandPrevention/DivisionoOralriitlo h Informaion arrant as of May 2005 ;' V ` r x4 ,'1- ;14-,-_'„:,. 6-i—,. `„ .410' -. 2 x . 11 ?!! }-• ti;3v4 -- a_ a _ j .. i . - . ,,n_ :ter.-, -. Clever use of emotionally charged "scare" propa- knows of no cases in which community leaders have ganda by fluoride opponents creates fear, confusion been found liable for their pro-fluoridation efforts. In and doubt within a community when voters consider no instance has fluoridation been discontinued be- the use of fluoridation.342,343 Defeats of referenda or the cause it was proven harmful in any way.343-345 discontinuance of fluoridation have occurred most of- Adoption of fluoridation is ultimately a decision of ten when a small, vocal and well organized group has state or local decision makers, whether determined used a barrage of fear-inspiring allegations designed by elected officials, health officers or the voting pub- to confuse the electorate. In addition to attempts to in- lic. Fluoridation can be enacted through state legisla- fluence voters, opponents have also threatened corn- tion, administrative regulation or a public referendum. munity leaders with personal litigation.344 While no While fluoridation is not legislated at the federal level, court of last resort has ever ruled against fluoridation, it is legislated at the state and local level. As with any community leaders may be swayed by the threat of liti- pubic health measure, a community has the right and gation due to the cost and time involved in defending obligation to protect the health and welfare of its citi- even a groundless suit, not to mention threats of po- zens, even if it means overriding individual objections litical fallout. The American Dental Association (ADA) to implement fluoridation. 52 American Dental Association • :..--: - , —. , . . _ I r[ r..H:/•-•,•:.z.: +ter... _ t • ;:v1-,,:,..-: ,.:. .. ..- ,•: :-. .:. „. ,• ,.,. , _, t, ...... , ,.. , . ,. .;•• , :„ , •p5 _ ' ,:P'UBLICnOLICy Figure 10. State Fluoridation Status :- States'Nleeting the.Healthy People 2010 Goal of 75%of the Population'.r. ' Served by,Fluoridated Community Water Supplies,- ' ar0 �i �a mx lifits..14,,,i, .402, ii„. isili, eo4t, , ,,,ilift „ . C,IP( off 0, I I' ' I Over 75%of population served by fluoridated �'c.'oQD. D community water supplies __7 - r'i ,z-77...ma,k 7,,Z',7 -ji z 77 41 t " " '-„ 3 -; ” - 731 p„ DataSource CentersforD,sease;Control-and Pevention/Division,of Oral ofUSPopulaton on Public WaterSuPly SstemsReceivin 'Fluoridated Water"2002 Available athttp//www2 cdc qov/notess/FluondationVasp. ,. ,. P _-. TiL44' ,y,- ,;4', -,--'--i`,.-s.,':?, ,' p L.';',1,1" -5i . . Yz t i ti. ,%i., ?J+I',4',2 2. .,,,,9;. ! ,,,,--E''' . n i: _:, f.__: -,., .;,, v_'•,;;;;``;`,;';.'-: _;,==_::- through 2004), more than 125 communities in 36 ' :'In the.past five years,(2000'through 2004) states have decided to provide the benefits of fluori- ..;:moreIlia n 125aori.muri,ities:in 36 states:have,. dation for their residents.The size of these water sys- i,.decided'to provide theabenefrts of fluoridation tems/communities varies greatly - from those with : for their residents , r a few thousand residents to the Metropolitan Water c'17':: :.;:,_ ,..' ..,y Ti-1'-' . ,.._:: =I-:-:,„:.-irk,tiv 9 District of Southern California which will provide flu- oridated water to more than 18 million people. Each spring as part of the yearly Community Water Technical assistance with fluoridation efforts is avail- Fluoridation Awards program, the ADA, Association able from the Council on Access, Prevention and Inter- of State and Territorial Dental Directors and the CDC professional Relations at the ADA. Additional support Division of Oral Health compile a list of water sys- for fluoridation is available from ADA's Division of Legal tems/communities in the United States that have ad- Affairs, Division of Communications and Department of opted community water fluoridation in the past year. State Government Affairs. This list is posted on the ADA Web site at http://www. ada.org/goto/fluoride. In the past five years (2000 Fluoridation Facts 53 } -� --*• �-^�^-_-^^�^xmr ,•w^ r dhw,ra µ: ; r3;; 3 QUESTION 55. tries construct their own water quality regulations within Is community water fluoridation accepted by other the framework of the 1980 European Water Quality Direc- countries? tive. The Directive provides maximum admissible con- centrations for many substances,one of which is fluoride. Answer. The Directive does not require or prohibit fluoridation, Over 405 million people in more than 60 countries it merely requires that the fluoride concentration in worldwide enjoy the benefits of fluoridated water.'" water does not exceed the maximum permissible con centration.342 Many fluoridation systems that used to operate in Eastern and Central Europe did not function properly ;�• : and, when the Iron Curtain fell in 1989-90, shut down .'';recogn¢ed rntemationally Consmdenng the,,;,, because ofobsolete technical equipment and lack of e�rtent to:whmchluondatmon has already been knowledge as to the benefits of fluoridated water.348 Wa- } 1 �, rm4 r Jt s Ay.n - - �• g mrrmpleented#h'roughout the world the lack?:: { ter fluoridation is not practical in some European coun- of,documentatmon of adverse;health effec#s'ms„ tries because of complex water systems with numerous 4 ti �remarkable testrmonyEtq�mtsEsafety ias�y ' water sources. As an alternative to water fluoridation, r F ', ;_,° many European countries have opted for the use of fluo- ride supplements or salt fluoridation. Fact. Basel, Switzerland is one such example. Those op- The value of water fluoridation is recognized interna- posed to water fluoridation claimed a large victory when tionally. Countries and geographic regions with exten- sive water fluoridation include the U.S., Australia, Brazil, facts are that Basel was the lone city with fluoridated Canada, Chile, Columbia, Ireland, Israel, Malaysia, New water surrounded by communities that used fluoridated Zealand, People's Republic of China (Hong Kong only), salt. In the mid 90s, trade barriers that had prevented Singapore and the United Kingdom.132 Thorough inves fluoridated salt from being sold to those living in Basel tigations of fluoridation have been conducted in Britain fell and soon it was evident that residents were receiv 55, ing fluoride from salt as well as through drinking water. and Australia supporting the safety and effectiveness of Theovernment voted to cease water fluoridation in 56. water fluoridation.183,165,348 Considering the extent to which g fluoridation has already been implemented throughout 2003 in light of availability and use of fluoridated salt in the world, the lack of documentation of adverse health the community. Basel, Switzerland did not stop fluori- effects is remarkable testimony to its safety.84,163-'67'210 The dating. Officials simply chose another type of fluoride- World Health Organization (WHO) and the Pan American tion-salt fluoridation.348 Health Organization have endorsed the practice of water (Additional information on this topic may be found in fluoridation since 1964. In 1994, an expert committee of Question 14. WHO published a report which reaffirmed its support of fluoridation as being safe and effective in the prevention No European country,h`as imposed of dental decay, and stated that "provided a community p a: on`water4 fluoridation t �t has a piped water supply,water fluoridation is the most Y1' „ ban' effective method of reaching the whole population, so that all social classes benefit without the need for active participation on the part of individuals."138 In many parts Again, no European country has imposed a "ban" of the world,fluoridation is not feasible or a high priority, on water fluoridation, it has simply not been imple- usually due to the lack of a central water supply,the exis- mented for a variety of technical, legal, financial or tence of more life threatening health needs or the lack of political reasons. trained technical personnel or sufficient funds for start- Political actions contrary to the recommendations up and maintenance costs. of health authorities should not be interpreted as a negative response to water fluoridation. For example, although fluoridation is not carried out in Sweden and the Netherlands, both countries support World Health QUESTION 55. Organization's recommendations regarding fluoridation Is community water fluoridation banned in Europe? as a preventive health measure, in addition to the use of fluoride toothpastes, mouthrinses and dietary fluoride Answer. supplements.138,35° No country in Europe has banned community water fluoridation. Fact. The claim that fluoridation is banned in Europe is frequently used by fluoridation opponents. In truth, European coun- 54 American Dental Association .4---1,--,-- t... ry ' ar '•.- i } n14r v € a sr 'rs , � { s` � 041.61-cCL:1 C Ya f � st�- , ■ � a# x °. 1y i3� �t.K� a y . sr • r, _. .,' 4 • 47 C ot.es Fluoridation Facts 55 _ t t ' fis _ *'y 4 ^_..:re .*i a 3 'fit4 `'i 1 �a 14. COST EFFECTIVENESS Q 57. Cost effective? p.56 Q58. Practical? p.57 QUESTION 57 School-based dental disease prevention activities Is water fluoridation a cost-effective means of prevent- (such as fluoride mouthrinse or tablet programs), pro- ing tooth decay? fessionally applied topical fluorides and dental health education are beneficial but have not been found to Answer. be as cost-effective in preventing dental decay as com- yes.Fluoridation has substantial lifelong decay preven- tive effects and is a highly cost-effective means of pre- most cost-effective and practical form of preventing venting tooth decay in the United States,regardless of decay in the United States and other countries with es socioeconomic status.97,1o31o4,351-353 tablished municipal water systems."•97•104,355 Because of the decay-reducing effects of fluoride, Fact. the need for restorative dental care is typically lower The cost of community water fluoridation can vary in in fluoridated communities. Therefore, an individual each community depending on the following factors.354 residing in a fluoridated community will typically 1. Size of the community(population and water usage); have fewer restorative dental expenditures during a 2. Number of fluoride injection points where fluoride lifetime. Health economists at a 1989 workshop con- 57. additives will be added to the water system; cluded that fluoridation costs approximately $3.35 3. Amount and type of equipment used to add and per tooth surface when decay is prevented, mak 58' monitor fluoride additives; ing fluoridation "one of the very few public health 4. Amount and type of fluoride compound used,its price, procedures that actually saves more money than it and its costs of transportation and storage;and costs."355 Considering the fact that the national aver- 5. Expertise of personnel at the water plant. age fee359 for a two surface amalgam (silver) restora- The annual cost for a U.S.community to fluoridate its tion in a permanent tooth placed by a general dentist water is estimated to range from approximately$0.50 is $101.94*, fluoridation clearly demonstrates signifi- per person in large communities to approximately cant cost savings.356 $3.00 per person in small communities.355 In a study conducted in Louisiana,Medicaid-eligible children (ages 1-5) residing in communities without fluoridated water were three times more likely than 1 For'most cities every$?,invested m sx� Medicaid-eligible children residing in communities water fluortdatron saves$38 rn dental A, with fluoridated water to receive dental treatment in a treatment costs � , hospital and the cost of dental treatment per eligible child was approximately twice as high. In addition to community water fluoridation status, the study took It can be calculated from these data that the average into account per capita income, population and num- lifetime cost per person to fluoridate a water system is ber of dentists per county.358 less than the cost of one dental filling. When it comes to the cost of treating dental disease, everyone pays. Not just those who need treatment, but the entire conn- munity-through om munity-through higher health insurance premiums and rs underscored by the fact that y higher taxes. For most cities, every $1 invested in wa- ter a the Cost of treating dental d/sease rs pard4,1 ter fluoridation saves $38 in dental treatment costs.355 ,' Inot oalyby the affected individual, Cutting dental care costs by decreasing dental decay is also by_the general+public through services something a community can do to improve oral health provided-by health departments,,,cpriamu lth�clrnnrty and save money for everyone. With the escalating cost res' � +} Ieahealth insurance/�remrums,£ ; of health care, fluoridation remains a preventive mea- the m►litary and other publicly supported , sure that benefits members of the community at mini mal cost.25 Fluoridation is a community public health .: measures that saves money. �. .1 •. . ".r,'= ` .b- :, .' tt 56 American Dental Association _ «x �.` 's. sv'ro,. ...h � 3 ro��S"4 r'#r FE.k'vsle '.,`..'. - - c {,.,. , .�• a , � �.�.s' . 4,',C ,^.' ,. ,. . .. �„.. om - A4 • The economic importance of fluoridation is under- QUESTION 58. scored by the fact that frequently the cost of treating Why fluoridate an entire water system when the vast dental disease is paid not only by the affected individual, majority of the water is not used for drinking? but also by the general public through services pro- vided by health departments, community health clinics, Answer. health insurance premiums,the military and other.pub It is more practical to fluoridate an entire water supply licly supported medical programs.103 than to attempt to treat individual water sources. Indirect benefits from the prevention of dental decay may include: Fact. • freedom from dental pain It is technically difficult, perhaps impossible, and cer- • a more positive self image tainly more costly to fluoridate only the water used for - fewer missing teeth drinking.Community water that is chlorinated,softened, • fewer cases of malocclusion aggravated by or in other ways treated is also used for watering lawns, tooth loss • washing cars and for most industrial purposes.The cost • fewer teeth requiring root canal treatment of additives for fluoridating a community's water supply • reduced need for dentures, bridges and implants is inexpensive on a per capita basis;therefore, it is prac- • less time lost from school or work because of tical to fluoridate the entire water supply. dental pain or visits to the dentist pp y These intangible benefits are difficult to measure Fluoride is but one of more than 40 different chemi- economically, but are extremely important.97257 cals/additives that may be used to treat water in the United States. Most are added for aesthetic or conve- *The survey data should not be interpreted as con- nience purposes such as to improve the odor or taste, stituting a fee schedule in any way, and should not be prevent natural cloudiness or prevent staining of clothes used for that purpose. Dentists must establish their or porcelain.36 own fees based on their individual practice and market The American Water Works Association, an interna considerations. tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply, supports the practice of fluoridation of public water supplies.357 Additionalinformation on this topic may be found in Question 44. • '°CALL TO ACTION: n Apn! 2003 Surgeon General Richard H °Car nity water systems should be receiving the benefits of mona;issued ,a National Call to Action to Promote optimally fluoridated water by the,year2070- Oral Health The report was awake up'call,lra sing Fluonda#lon efforts at the local and state level can a powerful voice against the silence t caked upon r be greatly enhanced enc.'the U S Healthy People 2010 policymakers community leaders private'industry Objective- reached with the:efforts, of organizations __ health professionals the:media and the public to of agencies and individuals who share'a commitment t firm that oral health is essential to general health and the benefits of community water fluoridation well being and to take action Technical assistance with fluoridation efforts_is ,. Whsle the effectiveness of preventive-mtetventlons available from the council°on Access Prevention and such as community water fluondatwn" have been Interprofessional Relations;at ADA Additional sup persuasively demonstrated les's than half of the fifty port,for fluontlation'is available from ADAs Division i states have implemented fluoridation at.the level to of Legal Affairs,'Divisss.ion of Communications and De meet the-national health'objectives to be>achieved by partment of__State Governrn:ment-Affairs the year 2010 Specifically, Objective 21-9rsiates'that atleast 75%of the U S population served by comm-14.7.r: Fluoridation Facts • 57 I i REFERENCES 1. Centers for Disease Control and Prevention.Ten great 19. US Department of Health and Human Services. pubic health achievements-United States, 1990-1999. Healthy People 2010.2nd ed.With understanding MMWR 1999;48(12):241-3. and improving health and objectives for improving health.2 vols.Washinton,DC:US Government Print- 2. Centers for Disease Control and Prevention.Fluo- ing ing Office;November 2000. ridation of drinking water to prevent dental caries. MMWR 1999;48(41):933-40. 20. US Department of Health and Human Services.Oral health in America:a report of the Surgeon General. , 3. Operational policies and recommendations regarding Rockville,MD:US Department of Health and Human community water fluoridation(Trans. 1997:673). Services,National Institute of Dental and Craniofacial 4. ADA statement commemorating the 60th anniversary Research,National Institutes of Health;2000. of community water fluoridation.2005. 21. Burt BA.Fluoridation and social equity.J Public 5. US Department of Health and Human Services, Health Dent 2002;62(4):195-200. Public Health Service.Surgeon General statement 22. Slade GD,Spencer AJ,Davies MJ,Stewart JF. on community water fluoridation.Washington,DC; Influence of exposure to fluoridated water on socio- December 3,2001. economic inequalities in children's caries experience. 6. McKay FS.Mottled enamel:the prevention of its Community Dent Oral Epidemiol 1996;24:89-100. further production through a change of the water 23. Riley JC.Lennon MA.Ellwood RP.The effect of water supply at Oakley,Ida.J Am Dent Assoc 1933;20(7): fluoridation and social inequalities on dental caries in 1137-49. 5-year-old children.Int Epidemiol 1999;28:300-5. 7. McClure FJ.Water fluoridation:the search and the 24. Jones CM,Worthington H.The relationship between victory.Bethesda,Maryland:National Institute of water fluoridation and socioeconomic deprivation Dental Research;1970. on tooth decay in 5-year-old children.Br Dent J 1999;186(8):397-400. 8. Smith MC,Lantz EM,Smith HV. The cause of mottled enamel,a defect of human teeth.University 25. U.S.Department of Health ardpromote Human oral Services.hea . S of Arizona,College of Agriculture,Agriculture Exp. Apart e call Healtho action ando umanees,Ph. is Station.Technical Bulletin 32 1931:253-82. Department af Human Services,Public Health Service,Centers for Disease Control and 9. Churchill HV.The occurrence of fluorides in some Prevention and the National Institutes of Health, waters of the United States.J Am Water Works Assoc National Institute of Dental and Craniofacial Research. 1931;23(9):1399-1407. NIH Pub.No.03-5303.Rockville,MD;May 2003. 10. Dean HT.Chronic endemic dental fluorosis.JAMA 26. Horowitz HS.The effectiveness of community water 1936;107(16):1269-73. fluoridation in the United States.J Public Health Dent 1996;56(5)(Spec Iss):253-8. 11. Dean HT.Endemic fluorosis and its relation to dental 27. Milgrom P Reisine S.Oral health in the United States: caries.Public Health Rep 1938;53(33):1443-52. the post-fluoride generation.Ann Rev Public Health 12. Dean HT,Arnold FA,Elvove E. Domestic water and 2000;21:403-36. dental caries.Public Health Rep 1942;57(32):7155-79. 28. Newbrun E.Effectiveness of water fluoridation. 13. Cox GJ, Matuschak MC, Dixon SF, Dodds ML, J Public Health Dent 1989;49(5):279-89. Walker WE.Experimental dental caries IV. Fluorine 29. Brunelle JA,Carlos JP. Recent trends in dental caries and its relation to dental caries.J_Dent Res 1939; in U.S.children and the effect of water fluoridation. (571:481-90. J Dent Res 1990;69(Spec Iss):723-7. 14. Dean HT,Arnold Jr FA, Knutson JW.Studies on 30. American Dental Association,Council on Access mass control of dental caries through fluoridation Prevention and Interprofessional Relations.Caries of the public water supply. Public Health Rep 1950; diagnosis and risk assessment:a review of preven- 65(43):1403-8. tive strategies and management.J Am Dent Assoc 15. Ast DB,et al.Newburgh-Kingston caries-fluorine study: 1995;126(Suppl). final report.J Am Dent Assoc 1956;52(3):290-325. 31. Marini BR Levy SM,Warren JJ,Bergus GR,Marshall 16. Brown HK,Poplove M.The Brant-ford-Sarnia-Stratford TA,Broffitt B.Medically administered antibiotics, dietary habits,fluoride intake and dental caries expe- j fluoridation caries study:final survey,1963.Med Sery rience in the primary dentition.Community Dent Oral J Can 1965;21(7):450-6. Epidemiol 2003;31:40-51. 17. US Department of Health and Human Services.For 32. Dye BA,Shenkin JD,Odgen CL,Marshall TA,Levy a healthy nation:returns on investment in public SM,Kanellis MJ.The relationship between healthful health.Washington,DC:US Government Printing eating practices and dental caries in children aged Office;August 1994. 2-5 years in the United States, 1988-1944.J Am Dent 18. US Department of Health and Human Services, Assoc 2004;135:55-66. Public Health Service.Surgeon General statement 33. Tinanoff N,Palmer CA.Dietary determinants of dental on community water fluoridation.Washington, caries and dietary recommendations for preschool chil- DC;December 14, 1995. dren.J Public Health Dent 2000;60(3):197-206. � I 1 � i 58 American Dental Association 41 34. National Oral Health Surveillance System.Water supply ; 54. Singh KA,Spencer AJ.Relative effects of pre-and statistics 2002.Available at<http://www.cdc.gov/nohss/ post-eruption water fluoride on caries experience by FSSupplyStats.htm>.Accessed April 18,2005. surface type of permanent first molars.Community 2004;32:435-46.idemiol E 35. City of Chicago,Department of Water Management, i Dent Oral p Bureau of Water Supply,Water Quality Division,Water } 55. US Department of Health,Education and Welfare, Purification Laboratories.Comprehensive chemi- Public Health Service.Public Health Service drinking cal analysis,March 2005.Available at<http://egov. water standards.Washington,DC.Revised 1962. cityofchicago.org/webportal/COCWebPortal/COC_ 56. US Environment Protection Agency,Ground ATTACH/march2005.pdf>.Accessed May 23,2005. ! Water and Drinking Water.Consumer confidence 36. US Department of Health and Human Services, i reports:final rule.Available at<http://www.epa.gov/ Centers for Disease Control,Dental Disease Preven- ! ogwdw000/ccr/ccrfact.html>.Accessed April 28,2005. tion Activity.Water fluoridation:a manual for engineers and technicians.Atlanta;September 1986. 57. US Environment Protection Agency,Ground Water and Drinking Water.Local drinking water information. 37. Thompson TG,Taylor HJ.Determination and occur- I Available at<http://www.epa.gov/safewater/dwinfo/ rence of fluorides in sea water.Industrial Engineering i index.html>.Accessed April 28,2005. Chem March 15, 1933. 4 38. Bell ME,Ludwig TG.The supply of fluorine to man:2. 58. Centers for Disease Control and Prevention,Oral Health Resources.My water's fluoride.Available at<http:// Ingestion from water.In:Fluorides and human health. apps.nccd.cdc.gov/MWF/Index.asp>.Accessed April 28, World Health Organization Monograph Series No.59. 2005- Geneva;1970:18. w j 59. Environmental Protection Agency.Private drinking 39. Safe Drinking Water Committee,National Research water wells.Available at<http://www.epa.gov/safewa- Council.Drinking water and health.National Academy ter/privatewells/index2.html>.Accessed May 8,2005. of Sciences.Washington,DC;1977. j 40. Largent E.The supply of fluorine to man: 1.Intro- 60. American Water Works Association.AWWA standard duction.In:Fluorides and human health.World for sodium fluoride(ANSI/AWWA B701-99),March 1, 2000;AWWA standard for sodium fluorosilicate(ANSI/ Health Organization Monograph Series No.59. Geneva;1970:17-8. AWWA B702-99),March 1,2000 and AWWA standard for fluorosilicic acid(ANSI/AWWA B703-00),September 41. Levy SM,Kiritsy MC,Warren JJ.Sources of 1,2000. fluoride intake in children.J Public Health Dent 1995;55(1):39-52. 61. Maier FJ.Manual of water fluoridation practice. New York:McGraw-Hill Book Company, Inc.;1963. 42. Newbrun E.Fluorides and dental caries,3rd ed.Spring- field,Illinois:Charles C.Thomas,publisher;1986. 62. Horowitz HS.Letter to the editor.Am J Public Health 1997;87(7):1235-6. 43. Lambrou D,Larsen MJ,Fejerskov 0,Tachos B.The effect of fluoride in saliva on remineralization of 63. Arnold FA Jr.,Likins RC,Russell AL,Scott DB. dental enamel in humans.Caries Res 1981;15:341-5. Fifteenth year of the Grand Rapids fluoridation study. 44. Newbrun E.Systemic benefits of fluoride and fluori J Am Dent Assoc 1962;65:780-5. dation.J Public Health Dent 2004;64(Spec Iss):35-9. i 64. Ast DB,Fitzgerald B.Effectiveness of water fluorida- 45. Featherstone JD.The science and practice of caries tion.J Am Dent Assoc 1962;65:581-7. prevention.J Am Dent Assoc 2000;131:887-99. 65. Blayney JR,Hill IN.Fluorine and dental caries:find- 46. Featherstone JD.Fluoridation works.Letter to the ings by age group.J Am Dent Assoc 1967;74(2)(Spec editor.The Salt Lake Tribune.November 3,2000. Iss):246-52. 47. Backer-Dirks 0,Kunzel W,Carlos JP.Caries-preventive 66. Jackson D,James PM,Thomas FD.Fluoridation in water fluoridation.In:Progress in caries prevention. Anglesey 1983:a clinical study of dental caries.Br Ericsson Y,ed.Caries Res 1978;12(Suppl 1):7-14. I DentJ 1985;158(2):45-9. 48. Silverstone LM.Remineralization and enamel caries: ? 67. Jackson D.Has the decline of dental caries in English new concepts.Dent Update 1993;May:261-73. G children made water fluoridation both unnecessary and uneconomic?Br Dent J 1987;162(5):170-3. 49_ Featherstone JD.The mechanism of dental decay. Nutrition Today 1987;May-Jun:10-6. 68. Selwitz RH,Nowjack-Raymer RE,Kingman A,Driscoll 50. Fejerskov 0,Thylstrup A,Larsen MJ.Rational use I WS.Dental caries and dental fluorosis among school- of fluorides in caries prevention.Acta Odontol Scan I children who were lifelong residents of communities 1981;39:241-9. I having either low or optimal levels of fluoride in drinking water.J Public Health Dent 1998;58(1):28-35. 51. Silverstone LM,Wefel JS,Zimmerman BF,Clarkson BH,Featherstone MJ.Remineralization of natural 69. Jones CM,Taylor GO,Whittle JG,Evans D,Trotter and artificial lesions in human dental enamel in vitro. ( DR Water fluoridation,tooth decay in 5 year olds,and Caries Res 1981;15:138-57. social deprivation measured by the Jarman score: { analysis of data from British dental surveys.BMJ 52. Hargreaves JA.The level and timing of systemic 1997;315:514-7. exposure to fluoride with respect to caries resistance. J Dent Res 1992;71(5):1244-8. 70. Murray JJ.Efficacy of preventive agents for dental caries.Caries Res 1993;27(Suppl 1):2-8. 53. Singh KA,Spencer AJ,Armfield BA.Relative effects t of pre-and posteruption water fluoride on caries 71. Ripa LW.A half-century of community water fluorida- experience of permanent first molars.J Public Health tion in the United States:review and commentary. Dent 2003;63(1):11-19. J Public Health Dent 1993;53(1):17-44. Fluoridation Facts 59 F._ a k:- :::-I"--- '. �� '�:7-fir 7h _ 4 ,dr��t���; , 72. Evans DJ,Rugg-Gunn AJ,Tabari ED,Butler T.The 87. National Institute of Dental Research.Statement on effect of fluoridation and social class on caries effectiveness of water fluoridation.Bethesda;December experience in 5-year-old Newcastle children in 1994 1989. compared with results over the previous 18 years. 88. Lemke CW,Doherty JM,Arra MC.Controlled fluorida- Comm Dent Health 1996;13:5-10. tion:the dental effects of discontinuation in Antigo, 73. Ismail Al. Prevention of early childhood caries. Wisconsin.J Am Dent Assoc 1970;80:782-6. Community Dent Oral Epidemiol 1998;26(Suppl 1): 89. Stephen KW,McCall DR,Tullis Jl.Caries prevalence 49-61. in northern Scotland before,and 5 years after,water 74. NIH consensus statement 2001.Diagnosis and defluoridation.Br Dent J 1987;163:324-6. , management of dental caries throughout life.March 90. Attwood D,Blinkhorn AS.Dental health in school- 26-28;18(11:1-30. children 5 years after water fluoridation ceased in 75. Centers for Disease Control and Prevention.Promot- west Scotland.Int Dent) 1991;41(1):43-8. ing oral health:interventions for preventing dental 91. Burt BA,Eklund SA,Loesche WJ.Dental benefits of caries,oral and pharyngeal cancers,and sport-related limited exposure to fluoridated water in childhood. craniofacial injuries:a report on recommendations of J Dent Res 1986;61(11):1322-5. the Task Force on Community Preventive Services. 92. Way RM.The effect on dental caries of a change from MMWR 2001;50(No.RR-21):1-12. a naturally fluoridated to a fluoride-free communal 76. Task Force on Community Preventive Services. water.J Dent Child 1964;31:151-7. Recommendations on selected interventions to 93. Kunzel W,Fischer T.Caries prevalence after cessation ' prevent dental caries,oral and pharyngeal cancers, of water fluoridation in La Salud,Cuba.Caries Res and sports-related craniofacial injuries.Am J Prey 2000;34(11:20-5. Med 2002;23(1S):16 20. 94. Seppa L,Hausen H,Karkkainen S,Larmas M.Caries 77. Truman BI,Gooch BF,Sulemana I,Gift HC,Horowitz occurrence in a fluoridated and a nonfluoridated AM,Evans,Jr CA,Griffin SO,Carande-Kulis VG.Task town in Finland:a retrospective study using longi- Force on Community Preventive Services.Reviews of tudinal data from public dental records.Caries Res evidence on interventions to prevent dental caries,oral 2002;36(5):308-14. ' and pharyngeal cancers,and sports-related craniofa- 95. Kunzel W,Fischer T,Lorenz R,Bruhmann S.Decline tial injuries.Am J Prey Med 2002;23(1S):21-54. of caries prevalence after the cessation of water 78. Gooch BF,Truman BI,Griffin SO,Kohn WG,Sule- fluoridation in the former East Germany.Community mana I,Gift HC,Horowitz AM,Evans,Jr CA.A Dent Oral Epidemiol 2000;28(5):382-9. comparison of selected evidence on interventions to 96. Kalsbeek H,Kwant GW,Groeneveld A,Dirks OB,van prevent dental caries,oral and pharyngeal cancers, Eck AA,Theuns HM.Caries experience of 15-year-old , and sports-related craniofacial injuries.Am J Prey children in The Netherlands after discontinuation of Med 2002;23(1S):55-80. water fluoridation_Caries Res 1993;27(3):201-5. 79. Spencer AJ,Slade GD,Davies M.Water fluoridation in 97. US Department of Health and Human Services,Public Australia.Comm Dent Health 1996;13(Suppl 2):27-37. Health Service.Toward improving the oral health 80. Gray MM,Davies-Slowick J.Changes in the percent- of Americans:an overview of oral status,resources age of 5-year-old children with no experience of on health care delivery.Report of the United States decay in Dudley towns since the implementa- Public Health Service Oral Health Coordinating tion of fluoridation schemes in 1987.Br Dent J Committee.Washington,DC;March 1993. I 2001;190(11:30-2. 98. Niessen LC,Weyant RJ.Causes of tooth loss in a 81. Lee M,Dennison PJ.Water fluoridation and dental veteran population.J Public Health Dent 1989;49(1): caries in 5-and 12-year-old children from Canterbury 19-23. and Wellington.New Zealand Dent J 2004;100(1): 99. Phipps KR,Stevens VJ.Relative contribution of 10-15. caries and periodontal disease in adult tooth loss 82. Giticrist JA,Brumley DE.Community fluoridation for an HMO dental population.J Public Health Dent status and caries experience in children.J Public 1995;55(41:250-2. Health Dent 2001;61(3):168-71. 100.Griffin SO,Griffin PM,Swann JL,Zlobin N.Estimat- ing rates of new root caries in older adults.J Dent Res 2004;83(8):634-8. poverty and tooth decay in 12-year-old children. J Dent 2000;28:389-93. 101. Gift HC.Oral health outcomes research:Challenges and opportunities.In Slade GD,ed.,Measuring Oral Health 84. US Department of Health and Human Services,Public and Quality of Life.Chapel Hill,NC:Department of Health Service.Review of fluoride:benefits and risks. Dental Ecology,University of North Carolina 1997: Report of the Ad Hoc Subcommittee on Fluoride. 25-46. Washington,DC;February 1991. 102.Centers for Medicare&Medicaid Services,Office 85. Lewis DW,Banting OW.Water fluoridation:current of the Actuary,National Health Statistics.Table ' effectiveness and dental fluorosis.Community Dent 10:Expenditures for health services and supplies Oral Epidemiol 1994;22:153-8. under public programs,by type of expenditure and 86. Griffin SO,Gooch BF,Lockwood SA,Tomar SL.Quan- program:calendar year 2003. tifying the diffused benefit from water fluoridation in 103.White BA,Antczak-Bouckoms AA,Weinstein MC. the United States.Community Dent Oral Epidemiol Issues in the economic evaluation of community 2001;29:120-9. water fluoridation.J Dent Educ 1989;53(111:646-57. 60 American Dental Association ,----*-2i---r 7-- :'-'-' -.-7-,'''''.-_-'-`,-:%--' -,--'----:', :_',-'?111r1.-.-_-7------=:- -t------''--7'-'.-2:`ri'qiiMVRt',:lit-_-_-:-:-.,_-__-__,--___-___,--__ __:--„v_t_.-: ±4±- -----,-_--. ._,F,__- . 1._._.. . .. :.,.. . ,,. _ _.,:... .,...____ ___.;_...,:;_, _.„.;_._, _ _.4..T _,:-: _,-5- -;-,_z, ---_: _,.,;...tz--,--;--,.,-,-;w-rinzls-eqp-t- -:-i--1--,c,--ti, --7,: {---'1 ,-1,-- -- -._;_ii.,ii-:.:---_-,---_- --t,=. :,,, 74 � - -__-__---:,_1:::',i!;". --7.. :7,7:1REFERENCES • ' ` 7744_ 104.Garcia Al.Caries incidence and costs of prevention 123.Institute of Medicine,Food and Nutrition Board. programs.J Public Health Dent 1989;49(51:259-71. Dietary reference intakes for calcium,phosphorus, 105.Brustman BA.Impact of exposure to fluoride- magnesium,vitamin D and fluoride.Report of the adequate water on root surface caries in elderly. Standing Committee on the Scientific Evaluation of Gerodontics 1986;2(61:203-7. Dietary Reference Intakes.Washington,DC:National Academy Press;1997. 106.Burt BA,Ismail Al,Eklund SA.Root caries in an opti- mally fluoridated and a high-fluoride community.j 124. Horowitz HS.The role of dietary fluoride supple- Dent Res 1986;65(9):1154-8. ments in caries prevention.J Public Health Dent 1999;59(4):205-10. 107.Brown LJ,Wall TP Lazar V.Trends in caries among adults 18 to 45 years old.J Am Dent Assoc 125. Preface:Dosage Schedule for Dietary Fluoride 2002;133(7):827-34. Supplements.J Public Health Dent 1999;59(4):203-4. 108.Mellberg JR,Ripa LW.Fluoride in preventive { 126.Levy SM,Guha-Chowdhury N.Total fluoride intake dentistry:theory and clinical applications.Chicago: and implications for dietary fluoride supplementation. Quintessence;1983:41 80. J Public Health Dent 1999;59(4):211-23. 127.Arnold FA,McClure FJ,White CL.Sodium fluoride 109.McGuire S.A review of the impact of fluoride on } adult caries.J Clin Dent 1993;4(1):11-13. i tablets for children.Dental Progress 1960;1(1):8-12. i 1 110. Grembowski D,Fiset L,Spadafora A. How fluorida- 128.Hamasha AA,Levy SM,Broffitt B,Warren JJ.Patterns { tion affects adult dental caries:systemic and topical { of dietary fluoride supplement use in children from effects are explored.J Am Dent Assoc 1992;123: birth to 96 months of age.J Public Health Dent 49-54. 1 2005;65(1):7-13. 111.Stamm JW,Banting DW,lmrey PB.Adult root caries 129. Levy SM,Warren JJ,Broffitt B.Patterns of fluoride { survey of two similar communities with contrast- intake from 36 to 72 months of age.J Public Health ' ing natural water fluoride levels.J Am Dent Assoc Dent 2003;63(4):211-20. 1990;120:143-9. 130. Levy SM,Warren JJ,Davis CS,Kirchner HL,Kanellis 112.Newbrun E.Prevention of root caries.Gerodont MJ,Wefel JS.Patterns of fluoride intake from birth to 1986;5(1):33-41. { 36 months.J Public Health Dent 2001.;61(21:70-7. 113.Brown LJ,Winn DM,White BA.Dental caries,restora- 131. Newbrun E.Systemic fluorides:an overview.J Can tion and tooth conditions in U.S.adults,1988-1991. Dent Assoc 1980;1:31-7. J Am Dent Assoc 1996;127:1315-25. 132.The British Fluoridation Society,The UK Public 114.Papas AS,Joshi A,MacDonald SL,Maravelis-Spla- l Health Association,The British Dental Association, gounias L,Pretara-Spanedda F Curro FA.Caries I The Faculty of Public Health of the Royal College of prevalence in xerostomic individuals.J Can Dent Physicians.One in a million-the facts about water Assoc 1993;59(2):771-9. fluoridation.Manchester,England;2004.Available at r <http://www.bfsweb.org/onemillion.html>.Accessed 115.Jones JA.Root caries:prevention and chemotherapy. May 23,2005. Am J Dent 1995;8(6):352-7. • 133.Estupinan-Day S.International perspectives and prac- j 176.Wiktorsson A,Martinsson T,Zimmerman M.Salivary levels of lactobacilli,buffer capacity and salivary tical applications on fluorides and fluoridation. flow rate related to caries activity among adults in J Public Health Dent 2004;64(Spec Iss 1):40 3. communities with optimal and low water fluoride 134.Horowitz HS.Decision-making for national programs concentrations.Swed Dent J 1992;16:231-7. of community fluoride use.Community Dent Oral 117.Anusavice KJ.Treatment regimens in preventive and Epidemiol 2000;28:321-9. restorative dentistry.J Am Dent Assoc 1995;126: 135.Marthaler TM,Mejia R,Vines JJ.Caries-preventive 727-43. { salt fluoridation.Caries Res 1978;12(Suppl 1):15-21. I I 118.Hoperaft MS,Morgan MV.Exposure to fluoridated 136. Kunzel W.Systemic use of fluoride-other methods: drinking water and dental caries experience in Austra- i salt,sugar,milk,etc.Caries Res 1993;27(Suppl 1):16-22. Ilan army recruits,1996.Comm Dent Oral Epidemiol 137.Estupinan-Day SR,Baez R,Horowitz H,Warpeha R, 2003;31(1):68-74. Sutherland B,Thamer M.Salt fluoridation and dental 119.Horowitz HS.The future of water fluoridation and caries in Jamaica.Community Dent Oral Epidemiol other systemic fluorides.J Dent Res 1990;69(Spec '{ 2001;29(4):247-52. Iss):760-4. 138.World Health Organization.Fluorides and oral health. 120.Driscoll WS.The use of fluoride tablets for the Report of a WHO Expert Committee on Oral Health prevention of dental caries.In:International work- Status and Fluoride Use.WHO Technical Report shop on fluorides and dental caries prevention. Series 846.Geneva;1994. Baltimore,University of Maryland;1974:25-111. 139. Bergmann KE,Bergmann RL.Salt fluoridation and 121.Aasenden R,Peebles TC.Effects of fluoride supple- i general health.Adv Dent Res 1995;9(2):138-43. mentation from birth on human deciduous and 140.Chobanian AV,Bakris GL,Black HR,Cushman WC, permanent teeth.Arch Oral Biol 1974;19:321-6. Green LA,Izzo JL Jr,Jones DW,Materson BJ,Oparil 122.Margolis FJ,Reames HR,Freshman E,Macauley CD, S,Wright JT Jr,Roccella EJ.Joint National Committee Mehaffey H.Fluoride:ten year prospective study of on Prevention,Detection,Evaluation,and Treatment deciduous and permanent dentition.Am J Dis Child of High Blood Pressure. National Heart,Lung,and 1975;129:794-800. Blood Institute;National High Blood Pressure Fluoridation Facts 61 I � it ' ' Education Program Coordinating Committee.Seventh 160.Full CA,Wefel JS.Water softener influence on anions ' report of the joint national committee on prevention, and cations. Iowa Dent J 1983;69:37-9. detection,evaluation,and treatment of high blood 161.Robinson SN,Davies EH,Williams B.Domestic water pressure.Hypertension 2003;42(6):1206-52. treatment appliances and the fluoride ion. Br Dent J 141.World Health Organization.Development of a milk 1991;171:91-3. fluoridation scheme for prevention of dental caries 162.Jobson MD,Grimm SE 3rd, Banks K,Henley G.The preliminary assessment of feasibility.Geneva;2001. effects of water filtration systems on fluoride:Wash- 142.Pakhomov GN.Objectives and review of the inter- ington,D.C.metropolitan area.ASDC J Dent Child national milk fluoridation program.Adv Dent Res 2000;67(5):302,304,350-4. 1995;9(2):110-1. 163.Fluoride,teeth and health. Royal College of Physi- 143. Burt BA,Marthaler TM.Fluoride tablets,salt fluoride- clans.Pitman Medical,London;1976. tion and milk fluoridation.In:Fluoride in Dentistry, 164.Johansen E,Taves D,Olsen T,eds.Continuing 2nd ed.Fejerskov 0,Ekstand J and Burt B,eds. evaluation of the use of fluorides.AAAS Selected Munksgaard,Copenhagen;1996:291-310. Symposium 11.Boulder,Colorado:Westview 144. Lindemeyer RG,Fitz LG,and Pikarski JD.Fluoride: Press;1979. surprising factors in bottled water. Penn Dent J(Phila) 165.Knox EG. Fluoridation of water and cancer:a review ' 1996;63(11:13-7. of the epidemiological evidence.Report of the ' 145.Van Winkle S,Levy SM,Kiritsy MC,Heilman JR, Working Party. London:Her Majesty's Stationary Wefel JS and Marshall T.Water and formula fluoride Office:1985. concentrations:significance for infants fed formula. 166.Leone NC,Shimkin MB,Arnold FA,et al.Medical Pediatr Dent 1995 Jul-Aug;17(4):305-10. aspects of excessive fluoride in a water supply. Public ' 146.Wisconsin Department of Agriculture,Trade and Health Rep 1954;69(10):925-36. Consumer Protection.State of Wisconsin bottled 167. National Research Council.Health effects of ingested drinking water sampling and analysis test results. fluoride.Report of the Subcommittee on Health June 1993. Effects of Ingested Fluoride.Washington,DC:Nation- 147.Chan JT,Liu CF and Tate WH.Fluoride concentration al Academy Press;1993. in milk,tea and bottled water in Houston.J Gt Houst 168.58 Fed.Reg.68826,68827(Dec.29, 1993). Dent Soc 1994;66(41:8-9. 169. US Department of Health and Human Services,Public ' 148.Johnson SA,DeBiase C.Concentration levels Health Service.Facts on the ATSDR toxicological ' of fluoride in bottled drinking water.J Dent Hyg profile for fluorides,hydrogen fluoride,and fluorine. , 2003;77(3):161-7. CDC Atlanta,GA;May 15,1998. , 149. Beverage Marketing Corportation.Bottled water 170.American Medical Association.H-440.945 and H- strengthens position as no.2 beverage,reports Bever- 440.972.In:American Medical Association Policy age Marketing.Press Release dated April 25,2005. Compendium.Chicago:American Medical Associa- Available at<http://www.beveragemarketing.com>. tion;1998:633,637. Accessed April 29,2005. 171.Fluoridation and dental health.World Health Organi- 150. Beverage Marketing Corportation.US soft drink sales zation(WHA22.30);July 23,1969. up slightly in 2004,Beverage Marketing Corpora- 172. United States Environmental Protection Agency, tion reports.Press Release dated March 14,2005. Office of Water.Fact Sheet:Announcement of Available at<http://www.beveragemarketing.com>. completion of EPA's review of existing drinking water Accessed April 29,2005. standards(EPA 815-F-03-001).June 2003. 151.Weissman AM.Bottled water use in an immigrant 173. National Academyof Science Project Title:Toxicologic community:a public health issue?Am J Public Health Risk of Fluoride in Drinking Water.Available at<http:// 1997;87(8)1379-80. www4.nas.edu/cp.nsf/Projects%20_13y%20_PIN/BEST-K- 152_ 152_Flaitz CM,Hill EM,Hicks MJ.A survey of bottled water 02-05-A7OpenDocument>.Accessed May 5,2005. usage by pediatric dental patients:implications for 174.US Environment Protection Agency,Ground Water dental health.Quintessence Int 1989;20(11):847-52. and Drinking Water.List of drinking water contami- 153.Tate WH,Chan JT.Fluoride concentrations in bottled nants and MCLs.Available at<http://www.epa. and filtered waters.Gen Dent 1994;42(4):362-6. gov/safewater/mcl.html>.Accessed April 28,2005. 154.Bartels D,Haney K,Khajotia SS.Fluoride concen- 175. US Environment Protection Agency,Ground Water trations in bottled water.Oklahoma Dent Assoc J and Drinking Water.Drinking water glossary.Avail- 2000:18-22. able at<http://www.epa.gov/safewater/glossary. 155.44 Fed.Reg.42775-78(July 20, 1979). htm#clink>.Accessed April 28,2005. 156.21 CFR 165.Sec.765.110. 176.Hodge HC,Smith FA.Occupational fluoride exposure. J Occup Med 1977;19:12-39. 157.60 Fed.Reg.57079(November 13,1995). 177. Committee on Biologic Effects of Atmospheric Pollut- 158_Maier FJ.Manual of water fluoridation practice.New ants.Biologic effects of atmospheric pollutants: York:McGraw-Hill Book Company,Inc.:1963. fluorides.Washington D.C.,National Academy of Sciences 1971:5-9. 159.ADA Division of Science on behalf of the ADA Council on Scientific Affairs.Tap water filters.J Am Dent 178.Rugg-Gunn AJ. Nutrition and dental health.New Assoc 2003;134(2):226-7. York:Oxford University Press:1993. 62 American Dental Association ° REFERENCRS { 179.US Department of Agriculture,Agricultural Research { 198.Cauley JA,Murphy PA,Riley TJ,Buhari AM.Effects Service,Beltsville Human Nutrition Research Center, I of fluoridated drinking water on bone mass and frac- Nutrient Data Laboratory.USDA national fluoride I tures:the study of osteoporotic fractures.J Bone Min database of selected beverages and foods-2004. i Res 1995;10(7):1076-86. Available at<http://www.nal.usda.govtfnic/foodcomp/ 199.Hodge HC.The safety of fluoride tablets or drops.In: Data/Fluoride/Fluoride.html>.Accessed May 6,2005. Continuing evaluation of the use of fluorides.Johan- 180.Pendrys DG,Stamm JW.Relationship of total fluoride sen E,Tavaes DR,Olsen TO,eds.Boulder,Colorado: intake to beneficial effects and enamel fluorosis. Westview Press;1979:253-75. J Dent Res 1990;69(Spec Iss):529-38. 200. Lehmann R,Wapniarz M,Hofman B,Peiper B, 181.Jackson RD,Brizendine EJ,Kelly SA,Hinesley R, Haubitz I,Allolio B.Drinking water fluoridation:bone Stookey GK,Dunipace AJ.The fluoride content of { mineral density and hip fracture incidence.Bone foods and beverages from negligibly and optimally f 1998;22(3):273-8. fluoridated communities.Community Dent Oral Epidemiol 2002;30(5):382-91. j 201. Phipps KR,Orwoll ES,Bevan L.The association between water-borne fluoride and bone mineral 182.Whitford GM.The metabolism and toxicity of fluo- density in older adults.J Dent Res 1998;77(9):1739-48. ride,2nd rev.ed. Monographs in oral science,Vol. 16. Basel,Switzerland:Karger;1996. I 202.Demos LL,Kazda H,Cicuttini FM,Sinclair MI,Fairley CK.Water fluoridation,osteoporosis,fractures-recent 183. Levy SM,Maurice TJ,Jakobsen JR.Feeding patterns, developments.Aust Dent J 2001;46(2):80-7. water sources and fluoride exposures of infants and 1-year-olds.J Am Dent Assoc 1993;124:65-9. I 203. Hillier S,Cooper C,Kellingray S,Russell G,Hughes 184.Levy SM.Review of fluoride exposures and ingestion. f H,Coggon D.Fluoride in drinking water and risk of Community Dent Oral Epidemiol 1994;22:173-80. hip fracture in the UK:a case-control study.Lancet 2000;355(9200):265-9. 185.Barnhart WE,Hiller LK,Leonard GJ,Michaels SE. 204. Phipps KR,Orwoll ES,Mason JD,Cauley JA.Commu- price usage and ingestion among four age { nity water fluoridation,bone mineral density,and groups.J Dent Res 1974;53(6):1317-22. fractures:prospective study of effects in older 186.Ericsson Y,Forsman B.Fluoride retained from mouth- women.Br Med J 2000;321(7265):860-4. rinses and dentifrices in preschool children.Caries I 205.Jones G,Riley M,Couper D,Dwyer T.Water fluorida- Res 1969;3:290-9. tion,bone mass and fracture:a quantitative overview 187. Bruun C,Thylstrup A.Dentifrice usage among Danish of the literature.Aust N ZJ Public Health. 1999;23(1): children.J Dent Res 1988;67(8):1114-7. G 34-40. 188.Ekstrand J,Ehmebo M.Absorption of fluoride from 206. University of York Centre for Reviews and Dissemina- fluoride dentifrices.Caries Res 1980;14:96-102. ; tion.CRD Reportl8-Systematic review of the efficacy 189.Levy SM.A review of fluoride intake from fluoride and safety of the fluoridation of drinking water.2000. dentifrice.J Dent Child 1993;60(21:115-24. Executive Summary.Available at<http://www.york. 190.Leverett DH,Adair SM,Vaughan BW,Proskin HM, I ac.uk/inst/crd/reportl8.htm>.Accessed April 28,2005. Moss ME.Randomized clinical trial of effect of Arena- j 207. US Department of Health and Human Services. Bone tal fluoride supplements in preventing dental caries, health and osteoporosis:a report of the Surgeon Caries Res 1997;31:174-79. General.Rockville,MD: US Department of Health and 191.American Dental Association.ADA guide to dental ` Human Services,Office of the Surgeon General 2004: therapeutics.Third Edition.Chicago;2003. I Chapter 7,Table 7-5:166. 192.Whitford GM.The physiological and toxicological 208. Bucher JR,Hejtmancik MR,Toft JD II,Persing RL, { characteristics of fluoride.J Dent Res 1990;69(Spec Eustis SL,Haseman JK.Results and conclusions of the National Toxicology Program's rodent carcino- Iss):539 49. genicity studies with sodium fluoride.IntJ Cancer 193.Whitford GM.Intake and metabolism of fluoride. 1991;48:733-7. Adv Dent Res 1994;8(1):5-14. 209. Maurer JK,Cheng MC,Boysen BG,Anderson RL. 194.Gordon SL,Corbin SB.Summary of workshop on ! Two-year carcinogenicity study of sodium fluoride in drinking water fluoridation influence on hip fracture I rats.J Natl Cancer Inst 1990;82:1118-26. { on bone health.Osteoporosis Int 1992;2109-17. 210. Banting DW.The future of fluoride.An update one 195.Suarez-Almazor ME,Flowerdew G,Saunders LD, year after the National Toxicology Program Study. Soskolne CL,Russell AS.The fluoridation of drink- J Am Dent Assoc. 1991;122(8):86-91. ing water and hip fracture hospitalization rates in two Canadian communities.Am J Public Health 211. Horowitz HS.Indexes for measuring dental fluorosis. 1993;83(5):689-93. J Public Health Dent 1986;46(4):179-183 196.Jacobsen SJ,O'Fallon WM,Melton LJ.Hip fracture 1 212.Dean HT.The investigation of physiological effects by incidence before and after the fluoridation of the j the epidemiological method.In:Moulton FR,ed.Fluo- public water supply,Rochester,Minnesota.Am J { rine and dental health.American Association for the Public Health 1993;83(5):743-5. Advancement of Science,Publication No.19.Wash- 197.Karagas MR,Baron JA,Barrett JA,Jacobsen SJ. j ington DC;1942 23 31. Patterns of fracture among the United States elderly: 213.Kumar JV,Swango PA,Opima PN,Green EL.Dean's geographic and fluoride effects.Ann Epidemiol fluorosis index:an assessment of examiner reliability. 1996;6(3):209-16. { J Public Health Dent.2000;60(1):57-9. { Fluoridation Facts 63 i � 214. Beltran-Aguilar ED,Griffin SO,Lockwood SA.Preva- 232.Tohyama E.Relationship between fluoride concentra- lence and trends in enamel fluorosis in the United tion in drinking water and mortality rate from uterine States from the 1930s to the 1980s.J Am Dent Assoc cancer in Okinawa Prefecture,Japan.J Epidemiology 2002;133:157-65. 1996;6(4)184-190. 215.Griffin SO,Beltran ED,Lockwood SA,Barker LK. 233. Kinlen L Cancer incidence in relation to fluoride level Esthetically objectionable fluorosis attributable to in water supplies.Br Dent J 1975;138:221-4. water fluoridation.Community Dent Oral Epidemiol 234.Chilvers C,Conway D.Cancer mortality in England 2002;30(3):199-209. in relation to levels of naturally occurring fluoride in 216.Horowitz HS.Fluoride and enamel defects.Adv Dent water supplies.J Epidemiol Comm Health 1985;39: Res 1989;3(2):143-6. 44-7. 217.Pendrys DG.Dental fluorosis in perspective.J Am 235.Cook-Mozaffari PC,Bulusu L,Doll R.Fluoridation of Dent Assoc 1991;122:63-6. water supplies and cancer mortality I:a search for an 218.Stookey GK.Review of fluorosis risk of self-applied effect in the UK on risk of death from cancer.J Epide topical fluorides:dentifrices,mouth rinses and gels. miol Comm Health 1981;35:227-32. Community Dent Oral Epidemiol 1994;22(3):181-6. 236. Raman S,Becking G,Grimard M,Hickman JR, 219.Pendrys DG,Katz RV,Morse DE.Risk factors for McCullough RS,Tate RA.Fluoridation and cancer:an enamel DG,Kfluorosis inR a no r e DE.Ridsk factors population. analysis of Canadian drinking water fluoridation and Am J Epidemiol n anon{8):808 15. cancer mortality data.Environmental Health Direc- torate,Health Protection Branch.Ottawa,Canada: 220.Pendrys DG.Risk of enamel fluorosis in nonfluo- Authority of the Minister of National Health and ridated and optimally fluoridated populations: Welfare;1977. considerations for the dental professional.J Am Dent 237.Richards GA,Ford JM.Cancer mortality in selected Assoc 2000;131(6):746-55. New South Wales localities with fluoridated and non- 221.American Dental Association.ADA statement on FDA fluoridated water supplies.Med J Aust 1979;2:521-3. toothpaste warning labels.Available at<http://www. 238.International Agency for Research on Cancer. ada.org/prof/resources/positions/statements/fluoride. IARC monographs on the evaluation of the carci- asp>. Accessed May 8,2005. nogenic risk of chemicals to humans,Vol.27. 222.Hodge HC,Smith FA.Biological properties of inor- Switzerland;1982. ganic fluorides.In:Fluorine chemistry.Simons HH, 239.62 Fed.Reg.64297(Dec.5,1997L ed. New York:Academic Press;1965:1-42. 240.Clemmesen J.The alleged association between 223.Stevenson CA,Watson AR.Fluoride osteosclerosis. artificial fluoridation of water supplies and cancer: American Journal of Roetgenology,Radium Therapy a review. Bulletin of the World Health Organization and Nuclear Medicine 1957;78(1)13-18. 1983;61(5):871-83. 224.Agency for Toxic Substances and Disease Registry 241.Gelberg KH,Fitzgerald EF,Hwang SA,Dubrow (ATSDR).Toxicological Profile for fluorine,hydrogen R.Fluoride exposure and childhood osteosar- fluoride,and fluorides.Atlanta,GA:US Department coma:a case-control study.Am J Public Health of Health and Human Services,Public Health Service. 1995;85(12):1678-83. 2003.Available at<http://www.atsdr.cdc.gov/toxpro- 242.McGuire SM,Venable ED,McGuire MH,Buckwalter files/tp1l.html>.Accessed April 28,2005. JA,Douglass CW.Is there a link between fluori- 225. American Cancer Society.A statement on fluoride dated water and osteosarcoma?J Am Dent Assoc and drinking water fluoridation by Clark W Heath,Jr. 1991;122(41:38-45. MD,Vice President of Epidemiology and Surveillance 243.Mahoney MC,LaBrie DS,Nasca PC,Wolfgang PE, Research of American Cancer Society;February 17,1998. Burnett WS.Population density and cancer mortality 226.Hoover RN,McKay FW,Fraumeni JF.Fluoridated differentials in New York State,1978-1982.Int J Epide- drinking water and the occurrence of cancer.J Nati miol 1990;19(3):483-90. Cancer Inst 1976;57(4):757-68. 244. Hrudey SE,Soskolne CL,Berkel J,Fincham S.Drink- 227.Erickson JD.Mortality in selected cities with fluori- ing water fluoridation and osteosarcoma.Can J dated and non-fluoridated water supplies.New Eng Public Health 1990;81(6):415-6. J Med 1978;298(20):1112-6. 245.Takahashi K,Akiniwa K,Narita K.Regression analysis 228.Rogot E,Sharrett AR,Feinleib M,Fabsitz RR.Trends of cancer incidence rates and water fluoride in the in urban mortality in relation to fluoridation status. U.S.A.based on IACR/IARC(WHO)data(1978-1992). Am J Epidemiol 1978;107(2):104-12. International Agency for Research on Cancer.J Epide- 229. Chilvers C.Cancer mortality and fluoridation of water miol 2001;11(4):170-9. supplies in 35 US cities.Int J Epidemiol 1983;12(4): 246.Kaminsky LS,Mahoney MC,Leach J,Melius J,Miller 397-404. MJ.Fluoride:benefits and risks of exposure.Crit Rev 230.Mahoney MC,Nasca PC,Burnett WS,Melius JM. Oral Biol Med 1990;1:261-81. Bone cancer incidence rates in New York State:time 247.Jenkins G,Venkateswarlu P Zipkin I.Physiological trends and fluoridated drinking water.Am J Public effects of small doses of fluoride.In:Fluorides and Health 1991;81(4):475-9. human health.World Health Organization Monograph 231.Cohn PD,New Jersey Department of Health,New Series No.59.Geneva;1970:163-224. Jersey Department of Environmental Protection and 248.Leone NC,Leatherwood EC,Petrie IM,Lieberman L. Energy.An epidemiologic report on drinking water Effect of fluoride on thyroid gland:clinical study. and fluoridation.Trenton,NJ;1992. J Am Dent Assoc 1964;69:179-80. 64 American Dental Association AREFERENCES 249.Kinlen L.Cancer incidence in relation to fluoride level 267.Martin GR,Brown KS,Singer L,Ophaug R,Jacobson- in water supplies.Br Dent J.1975;138(6):221-4, I Kram D.Cytogenic and mutagenic assays on fluoride. In:Fluorides,effects on vegetation,animals and 250.Galletiodine i PM,JoyetlisG.Effect of fluorine on thyroidal humans.Schupe JL,Peterson HB,Leone NC,eds.Salt iodine metabolism in hyperthyroidism.J Clin Endo- crinology. ndocrinology.'1958;18:1102-10. Lake City:Paragon Press;1983:271-80. 251. Britannica Concise Encyclopedia.Pineal gland.Available 268. Martin GR,Brown KS,Matheson DW,Lebowitz H, at<http://www.britannica.com/ebc/article?tocld=9375298 Singer L,Ophaug R.Lack of cytogenetic effects in &query=pineal%20gland&ct=>.Accessed December 29, 1 mice or mutations in salmonella receiving sodium 2004. ! fluoride.Mutat Res 1979;66:159-67. 252.Luke J.Fluoride deposition in the aged human pineal I 269.Li Y Dunipace AJ,Stookey GK.Absence of mutagenic gland.Caries Res 2001;35:125-28. and antimutagenic activities of fluoride in Ames 253.Schlesinger ER,Overton DE,Chase HC,Cantwell salmonella assays.Mutut Res 1987;120:229-36. { KT.Newburgh-Kingston caries-fluorine study XIII: j 270.Tong CC,McQueen CA,Brat SV,Williams GM.The pediatric findings after ten years.J Am Dent Assoc lack of genotoxicity of sodium fluoride in a battery of 1956;52:296-306. cellular tests.Cell Biol Toxicol 1988;4(2):173-86. 254.Challacombe SJ.Does fluoridation harm immune 271.Freni SC.Exposure to high fluoride concentra- function?Comm Dent Health 1996;13(Suppl 21:69-71. tions in drinking water is associated with decreased 255.US Department of Health and Human Services, birth rates.J Toxicology and Environmental Health Centers for Disease Control,Dental Disease 1994;42:109-21. Prevention Activity.Update of fluoride/acquired 272.'Thomas Sinks,Ph.D.,personal communication, immunodeficiency syndrome(AIDS)allegation.Pub. November 6,1992. No.FL-133.Atlanta;June 1987. 273.Lowry R,Steen N,Rankin J.Water fluoridation,still- 256.World Health Organization.Fluorine and fluorides: births,and congenital abnormalities.J Epidemiol environmental health criteria 36.Geneva,Switzer- f Comm Health 2003;57(7):499-500. land;1984. 274.Rapaport I.Contribution a 1'etude de mongolisme: 257.Schlesinger E.Health studies in areas of the USA role pathogenique de fluor. Bull Acad M (Paris) 1953; with controlled water fluoridation.In:Fluorides and 140:529-31. human health.World Health Organization Monograph f Series No.59.Geneva;1970:305-10. i 275. Rapaport I.Oligophrenic mongolienne et caries 258. Kram D,Schneider EL,Singer L,Martin GR.The dentairs.Rev Stomatol Chir Maxillofac 1963;46:207-18. effects of high and low fluoride diets on the frequen- { 276. Berry WT.Study of the incidence of mongolism in cies of sister chromatid exchanges.Mutat Res ( relation to the fluoride content of water.Am J Ment 1978;57:51-5. j Def 1958;62:634-6. 259.Li Y,Dunipace AJ,Stookey GK.Lack of genotoxic 277. Needleman BL,Pueschel SM,Rothman KJ.Fluoride- effects of fluoride in the mouse bone-marrow micro- tion and the occurrence of Down's Syndrome.New nucleus test.J Dent Res 1987;66(11):1687-90. ; Eng J Med 1974;291:821-3. 260.Li V.Dunipace AJ,Stookey GK.Effects of fluoride 278.Erickson JD,Oakley GP Jr.,Flynt JW Jr.,Hay S.Water on the mouse sperm morphology test.J Dent Res fluoridation and congenital malformations:no asso- 1987;66(91:1509-11. ciation.J Am Dent Assoc 1976;93:981-4. 261.Zeiger E,Gulati DK,Kaur I?Mohamed AH,Revazova 279.Knox EG,Armstrong E,Lancashire R.Fluoridation J,Deaton TG.Cytogenetic studies of sodium fluoride and the prevalence of congenital malformations. in mice.Mutagenesis 1994;9(5):467-71. Comm Med 1980;2:190-4. 262.Li Y, Heerema NA,Dunipace AJ,Stookey GK.Geno- j 280.Erickson JD.Down syndrome,water fluoridation and toxic effects of fluoride evaluated by sister-chromatid maternal age.Teratol 1980;21:177-80. exchange.Mutat Res 1987;192:191-201. I 281.Mullenix PJ,Denbesten PK,Schunior A,Kernan WJ. 263.Dunipace AJ,Zhang W,Noblitt TW,Li Y Stookey GK. Neurotoxicity of sodium fluoride in rats.Neurotoxicol Genotoxic evaluation of chronic fluoride exposure: Teratol 199517(2):169-77. micronucleus and sperm morphology studies.J Dent Res 1989;68(111:1525-8. 282.Ross JF,Daston GP.Neurotoxicology and Teratology 1995;17(6):685-6.Letter to the editor. 264. Li Y,Zhang W,Noblitt TW,Dunipace AJ,Stookey GK.Genotoxic evaluation of chronic fluoride expo- 283.Shannon FT,Fergusson DM,Horwood U .Exposure sure:sister-chromatid exchange study.Mut Res I to fluoridated public water supplies and child health ,, 1989;227:159-65. j and behaviour.N Z Med J 1986;99(803):416-8. 265.Obe G,Slacik-Erben R.Suppressive activity by fluo- 284.Masters R.Estimated cost of increased prison popula- ride on the induction of chromosome aberrations in tion predicted to result from use of silicofluorides in human cells and alkylating agents in vitro. Mutat Res Palm Beach County. Presented to Palm Beach County 1973;19:369-71. I Commission,August 26,2003. 266.Slacik-Erben R,Obe G.The effect of sodium fluoride 285. Urbansky ET,Schock MR.Can fluoridation affect on DNA synthesis,mitotic indices and chromosomal lead(11)in potable water?Hexafluorosilicate and aberrations in human leukocytes treated with Tremni- fluoride equilibria in aqueous solution.Int J Environ mon in vitro.Mutat Res 1976;37:253-66. # Studies 2000;57:597-637. f ; f Fluoridation Facts 65 . I _ i 1 286.Centers for Disease Control and Prevention. 303. NSF International Standard 60-2002. Drinking water 1 Surveillance for elevated blood lead levels treatment chemicals-health effects.NSF Interna- among children-United States,1997-2001.MMWR tional,Ann Arbor,MI;2002. 2003;52(SS10):1-21. 304. NSF International Standard 61-2002. Drinking water 287.Centers for Disease Control and Prevention.Adult system components-health effects.NSF International, blood lead epidemiology and surveillance-United Ann Arbor,MI,2002. , States,1998-2001.MMWR 2002;51(SS11):1-10. 305.DeEds F,Thomas JO.Comparative chronic toxicities 288.Alzheimer's Disease Education &Referral Center. of fluorine compounds.Proc Soc Exper Biol and Med Causes:what causes AD?.Available at<http://www. 1933-34;31:824-5. alzheimers.org/causes.htm>.Accessed May 6,2005. 306.McClure FJ.A review of fluorine and its physiological 289.Varner JA,Jensen KF,Horvath W,Isaacson RL. effects.Phys Reviews 1933;13:277-300. Chronic administration of aluminum-fluoride or 307.McClure FJ.Availability of fluorine in sodium fluo- sodium-fluoride to rats in drinking water:alterations ride vs.sodium fluosilicate.Public Health Rep ` in neuronal and cerebrovascular integrity. Brain Res 1950;65(37):1175-86. 1998;784:284-98. 308.Zipkin I,Likins RC,McClure FJ,Steere AC. Urinary 290.American Dental Association.Health Media Watch: fluoride levels associated with the use of fluoridated Study linking fluoride and Alzheimer's under scrutiny. water.Public Health Rep 1956;71:767-72. J Am Dent Assoc 1998;129:1216-8_ • 309.Zipkin 1,Likins RC.Absorption of various fluoride 291.Kraus AS,Forbes WF.Aluminum,fluoride and the compounds from the gastrointestinal tract of the rat. , prevention of Alzheimer's Disease.Can J Public Amer J Physicol 1957;191:549-50. Health 1992;83(21:97-100. 310. McClure FJ,Zipkin I.Physiologic effects of fluoride 292. US Department of Health,Education and Welfare, as related to water fluoridation.Dent Clin N Am , National Institutes of Health,Division of Dental 1958:441-58. Health.Misrepresentation of statistics on heart 311.Crisp MF?Report of the Royal Commissioner into the deaths in Antigo,Wisconsin Pub. No.PPB-47. fluoridation of public water supplies.Hobart,Tasma- Bethesda;November 1972. nia,Australia:Government Printers;1968. 293.American Heart Association.Minerals and inorganic 312.Myers DM,Plueckhahn VD,Rees ALG.Report of the substances:fluoridation.Available at<http://www. committee of inquiry into fluoridation of victorian americanheart.org/presenter.jhtml?identifier=4698>. water supplies.1979-80 Melbourne,Victoria,Australia, Accessed May 6,2005. FD Atkinson,Government Printer;1980:115-25. , 294.American Heart Association. Risk factors and 313.Ad Hoc Committee for the U.S.Surgeon General . coronary heart disease.Available at<http://www. Koop,Shapiro JR,Chairman. Report to the Environ- ! americanheart.org/presenter.jhtml?identifier=4726>. mental Protection Agency on the medical(non-dental) Accessed May 6,2005. effects of fluoride in drinking water. 1983:1-9. 295.Geever EF,Leone NC,Geiser P,Lieberman J.Patho- 314.Hodges A,Philippakos E,Mulkey D,Spreen T, logic studies in man after prolonged ingestion of Murraro R.Economic impact of Florida's citrus indus- fluoride in drinking water I:necropsy findings in a try,1999-2000.Gainesville,University of Florida, community with a water level of 2.5 ppm.J Am Dent Institute of Food and Agricultural Sciences.Available Assoc 1958;56:499-507. at<http://edis.ifas.ufl.edu/BODY_FE307>.Accessed ' 296. US Department of Health and Human Services,Public April 18,2005. Health Service.Surgeon General's advisory:treat- 315.Centers for Disease Control and Prevention.Engineer- ment of water for use in dialysis:artificial kidney ing and administrative recommendations for water treatments.Washington,DC:Government Printing fluoridation,1995.MMWR 1995;44(No.RR-13). Office 872-021;June 1980. 316.Master R,Coplan MJ.Water treatment with 297.Centers for Disease Control.Fluoride in a dialysis silicofluoride and lead toxicity.Int J Environ unit-Maryland.MMWR 1980;29(121:134-6. Studies1999;56:435-49. � r 298.51 Fed.Reg.11410,11412(April 2,1986). 317. U.S.Environmental Protection Agency.Consumer 299.Environmental Protection Agency.Safe Drinking fact sheet on lead.Available at<http://www epa.gov/ safewater/Icrmr/lead_html>.Accessed on May 8,2005. Water Act.Basic Information.Available at<http:// www.epa.gov/safewater/sdwa/basicinformation. 318. U.S.Environmental Protection Agency.Arsenic in html>.Accessed May 8,2005. drinking water.Available at<http://www.epa.gov/safe- water/Icrmr/lead.html>.Accessed on May 8,2005. 300.American Water Works Association.Who we are. Available at<http://www.awwa.org/About/>.Accessed 319. Personal correspondence.Stan Hazen.General February 18,2005. manager,Drinking Water Additives Certification Program,NSF International to David Spath,California 301. National Sanitation Foundation International.About Department of Health Services,Office of Drinking Water. NSF.Available at<http://www.nsforg/business/about_ March 30,2000.Available at<http://www.dentalhealth- NSF/>. Accessed February 18,2005. foundation.org/documents/NSFLetterpdf>.Accessed on 302.American National Standards Institute.About ANSI May 8,2005. overview.Available at<http://www.ansi.org/about_ 320.U.S.Environmental Protection Agency,Office of ansi/overview/overview.aspx?menuid=1>.Accessed Water,Office of Science and Technology.Fluoride: February 18,2005. a regulatory fact sheet. 66 American Dental Association � z REFERENCES I � 321.Tacoma-Pierce County Health Department.Tacoma- 343. Margolis FJ,Cohen SN.Successful and unsuccess- Pierce County Health Department fluoridation ful experiences in combating the antifluoridationists. resolution.WAC197-11-960 environmental checklist. I Pediatrics 1985;76(1)113-8. August 2002. II 344.Easley MW.The new antifluoridationists:who are 322.Pollick PF Water fluoridation and the environment: i they and how do they operate?J Public Health Dent current perspective in the United States.Int J Occup 1985;45(3):133-41. Environ Health 2004;10:343-50. 345.Wulf CA,Hughes KF,Smith KG,Easley MW.Abuse of 323.Osterman JW.Evaluating the impact of municipal the scientific literature in an antifluoridation pamphlet. water fluoridation on the aquatic environment.Am J Baltimore:American Oral Health Institute;1985. Public Health 1990;80:1230-5. 1 346. National Health and Medical Research Council.The 324. Safe Water Association,Inc.v.City of Fond du Lac, effectiveness of water fluoridation.Canberra,Austra- 184 Wis.2d 365,516 N.W.2d 13(Wis.Ct.App.1994). I Iia:Australian Government Publishing Service;1991. 325.Block LE.Antifluoridationists persist:the constitu- 347.Jones S.Water fluoridation in Europe. Paper tional basis for fluoridation.J Public Health Dent presented to the British Association for the Study 1986;46(4)188-98. of Community Dentistry, 1996 Spring Scientific . Meeting. Dundee,Scotland. 326.Christoffel T. Fluorides,facts and fanatics:public 348. Marthaler TM.Water fluoridation results in Basel health advocacy shouldn't stop at the courthouse door.Am J Public Health 1985;75(8):888-91. since 1962:health and political implications.J Public Health Dent 1996 Spec Iss;56(5):265-70. 327.McMenamin JR Fluoridation of water in Virginia:the 349. Meyer J,Marthaler TM,Burgi H.The change from tempest in the teapot.J Law Ethics Dent 1988;1(1):42-6. water to salt as the main vehicle for community-wide 328.Roemer R.Water fluoridation:public health responsi- fluoride exposure in Basle,Switzerland(Editorial). bility and the democratic process.Am J Public Health j Community Dent Oral Epidemiol 2003;31(6):401-2. 1965;55(91:1337-48. f! 350. Roemer R. Legislation on fluoridation of water 329.Strong GA.Liberty,religion and fluoridation.J Am supplies.In:Experience on water fluoridation in Dent Assoc 1968;76:1398-1409. ! Europe.Copenhagen:World Health Organize- 330.Easlick KA.An appraisal of objections to fluoridation. tion;1987:23 36. J Am Dent Assoc 1962;65:868-93. 351. Klein SF Bohannan HM,Bell RM,Disney JA,Foch 331.American Dental Association,Survey Center. 1998 CB,Graves RC.The cost and effectiveness of school Consumers'opinions regarding community water based preventive dental care.Am J Public Health fluoridation.Chicago;June 1998. ! 1985;75(4):382-91. 332.Gallup Organization,Inc.A Gallup study of parents' 352.Federation Dentaire Internationale.Cost-effectiveness of community fluoride programs for caries preven- behavior,knowledge and attitudes toward fluoride. Princeton,NJ:Gallup Organization,Inc.;1991. tion:technical report 13.Chicago:Quintessence;1981. 333. Newbrun E.The fluoridation war:a scientific dispute } 353.Ringelberg ML,Allen SJ,Brown L.J.Cost of fluorida or a religious argument?J Public Health Dent tion:44 Florida communities.J Public Health Dent 1996;56(5)(Spec Iss):246-52. 1992;52(2):75-80. 354.Centers for Disease Control and Prevention.Recom- 334.Scott DB.The dawn of a new era.J Public Health mendations for using fluoride to prevent and Dent 1996;56(5)(Spec Iss):235 8. control dental caries in the United States.MMWR 335.Park B,Smith K,Malvitz D,Furman L.Hazard vs 2001;50(No.RR-14):22. outrage:public perception of fluoridation risks. 355.Griffin SO,Jones K,Tomar SL.An economic evalua- I J Public Health Dent 1990;50(4):285-7. ! tion of community water fluoridation.J Public Health 336. Neenan ME.Obstacles to extending fluoridation in the Dent 2001;61(21:78-86. United States.Comm Dent Health 1996;13(Suppl 2):10-20. 356.American Dental Association,Survey Center.2003 337.Lowry R. Antifluoridation propaganda material-the j survey of dental fees.Chicago;April 2004. tricks of the trade.Br Dent J 2000;189(10):528-30. f 357.American Water Works Association.Fluoridation 338. Mandel I. A symposium of the new fight for fluo- 1 of public water supplies.Adopted by the Board of rides. J Public Health Dent 1985;45(3):133-41. Directors Jan.25,1976,reaffirmed Jan.31, 1982 339.Lang F Clark C. Analyzing selected criticisms of f and revised Jan.20,2002.Available at <http://www. water fluoridation.J Can Dent Assoc 1981;47(3):1 xii. awwa.org/About/OandC/officialdocs/AWWASTAT. f cfm>.Accessed April 29,2005. 340.Lieberman AJ,The American Council on Science and { 358.Centers for Disease Control and Prevention.Water Health.Facts versus fears:a review of the 20 greatest f fluoridation and costs of Medicaid treatment unfounded health scares of recent times.2nd ed.New for dental decay-Louisiana, 1995-1996.MMWR York;1997. 1999;48(34):753-7. 341.Daubert v.Merrell Dow Pharmaceuticals,Inc.,509 359 Burt BA,ed.Proceedings for the workshop:cost effec- ! U.S.579, 113,S.Ct.2786(1993)_ tiveness of caries prevention in dental public health: 342.Frazier PJ.Fluoridation:a review of social research. results of the workshhop.J Public Health Dent 1989; J Public Health Dent 1980;40(3):214-33. 56(5 Spec No):331-40. Fluoridation Facts 67 *'*.- ,. .. s F ed c- r „F -�s. :e�„3 �*" _ *-' 1"." . ,it a t.t q "•y. r•`'i sa °`:'r"+�. tP.• ++ a r' � 2'11; a rX ,i� '� aR � 7 h �` e 4 q f a r• „e:144.* e ° •, x .sR `�' �' -e a q a r� -� �s3, a '- F re'" - l f!;4:111` tea„€';, 'P t mss' ",• i "Avi.evwa,rt Statements from Five Leading Health Organizations Regarding Community Water Fluoridation AMERICAN DENTAL ASSOCIATION (ADA) U.S.SURGEON GENERAL "The Association endorses community water fluoridation "A significant advantage of water fluoridation is that as a safe, beneficial and cost-effective public health all residents of a community can enjoy its protective measure for preventing dental caries. This support has benefit — at home, work, school or play — simply by been the Association's policy since 1950." drinking fluoridated water or beverages and foods —ADA Operational Policies and Recommendations prepared with it...Water fluoridation is a powerful Regarding Community Water Fluoridation strategy in our efforts to eliminate differences in health (Trans.1997:673). among people and is consistent with my emphasis on the importance of prevention...Fluoridation is the single CENTERS FOR DISEASE CONTROL most effective public health measure to prevent tooth AND PREVENTION (CDC) decay and improve oral health over a lifetime, for both "During the 20th century, the health and life expectancy children and adults. of persons residing in the United States improved While we can be pleased with what has already been dramatically. To highlight these advances, MMWR will accomplished,it is clear that there is much yet to be done. profile 10 public health achievements in a series of reports Policymakers, community leaders, private industry, published through December 1999 (Fluoridation of health professionals, the media, and the public should drinking water was chosen as one of these achievements affirm that oral health is essential to general health and profiled in the October 22,1999 MMWR).Fluoridation and well being and take action to make ourselves, our safely and inexpensively benefits both children and families, and our communities healthier. I join previous adults by effectively preventing tooth decay, regardless Surgeons General in acknowledging the continuing of socioeconomic status or access to care. Fluoridation public health role for community water fluoridation in has played an important role in the reductions in tooth enhancing the oral health of all Americans." decay (40%-70% in children) and of tooth loss in adults —Surgeon General Richard H.Carmona,Statement (40%-60%)." on Community Water Fluoridation, —CDC,Morbidity and Mortality Weekly Report. July 28,2004. "Ten Great Public Health Achievements-United States 1900-1999" April 1999. NATIONAL INSTITUTE OF DENTAL &CRANIOFACIAL RESEARCH (NIDCR) "The National Institute of Dental and Craniofacial AMERICAN MEDICAL ASSOCIATION(AMA) Research continues to support water fluoridation as a "The AMA recognizes the important public health safe and effective method of preventing tooth decay in benefits of drinking properly fluoridated water and people of all ages. Community water fluoridation is a encourages its member physicians and medical societies public health effort that benefits millions of Americans. to work with local and state health departments, dental For more than half a century, water fluoridation has societies, and concerned citizens to assure the optimal helped improve the quality of life in the U.S. through fluoridation of community drinking water supplies." reduced pain and suffering related to tooth decay, —AMA Letter to the American Dental Association, reduced tooth loss, reduced time lost from school and March 10, 1995. work,and less money spent on dental care." — NIDCR: Statement on Water Fluoridation, June 2000. 68 American Dental Association if::,''-;;; t'4‘. 3,',':;':!."1111n �rs..n 4. 4. � m '* " "4ykAst ,� S ;CAx °p 4 Y'tZ,�1,�. s ' * . ` __; .72. »13 e � °-"* �'_ ' '' e a r 4 +F' 6 #s" 1.re `«"' .7.1%-'14411.5.4..:'4 r_ *r :"� S'R aY,s". tS;'• q1.' e aha .m ';x - '+i7, :.'4.9r.i '"i," .*. "r: e y .; S' iq..c• • "x �;a"T .i. 2h}„ t,}x,✓' G s+h�5't€.0 a..���4�.ae .1,4,1t,.7.44))51,-(4.1.4.,...-,,,t l r. [ COMPENDIUM National and International Organizations Association of State and Territorial Health Officials That Recognize the Public Health Benefits of Association of State and Territorial Public Health Nutrition Directors Community Water Fluoridation for Preventing British Fluoridation Society Dental Decay Canadian Dental Association Academy of Dentistry International Canadian Dental Hygienists Association Academy of General Dentistry Canadian Medical Association Academy for Sports Dentistry Canadian Nurses Association Alzheimer's Association Canadian Paediatric Society America's Health Insurance Plans Canadian Public Health Association American Academy of Family Physicians Child Welfare League of America American Academy of Nurse Practitioners Children's Dental Health Project American Academy of Oral and Maxillofacial Pathology Chocolate Manufacturers Association American Academy of Orthopaedic Surgeons Consumer Federation of America American Academy of Pediatrics Council of State and Territorial Epidemiologists American Academy of Pediatric Dentistry Delta Dental Plans Association American Academy of Periodontology FDI World Dental Federation American Academy of Physician Assistants Federation of American Hospitals American Association for Community Dental Programs Hispanic Dental Association American Association for Dental Research Indian Dental Association(U.S.A.) American Association for Health Education Institute of Medicine American Association for the Advancement of Science International Association for Dental Research American Association of Endodontists International Association for Orthodontics American Association of Oral and Maxillofacial Surgeons International College of Dentists American Association of Orthodontists March of Dimes Birth Defects Foundation American Association of Public Health Dentistry National Association of Community Health Centers American Association of Women Dentists National Association of County and City Health Officials American Cancer Society National Association of Dental Assistants American College of Dentists National Association of Local Boards of Health American College of Physicians-American Society National Association of Social Workers of Internal Medicine National Confectioners Association American College of Preventive Medicine National Council Against Health Fraud American College of Prosthodontists National Dental Assistants Association American Council on Science and Health National Dental Association American Dental Assistants Association National Dental Hygienists'Association American Dental Association National Down Syndrome Congress American Dental Education Association National Down Syndrome Society American Dental Hygienists'Association National Eating Disorders Association American Dietetic Association National Foundation of Dentistry for the Handicapped American Federation of Labor and Congress National Head Start Association of Industrial Organizations National Health Law Program American Hospital Association National Healthy Mothers,Healthy Babies Coalition American Legislative Exchange Council National Kidney Foundation American Medical Association Oral Health America American Nurses Association Robert Wood Johnson Foundation American Osteopathic Association Society for Public Health Education American Pharmacists Association ' Society of American Indian Dentists American Public Health Association Special Care Dentistry American School Health Association Academy of Dentistry for Persons with Disabilities American Society for Clinical Nutrition American Association of Hospital Dentists American Society for Nutritional Sciences American Society for Geriatric Dentistry The Children's Health Fund American Student Dental Association The Dental Health Foundation(of California) American Veterinary Medical Association American Water Works Association U.S.Department of Defense Association for Academic Health Centers U.S.Department of Veterans Affairs U.S.Public Health Service Association of American Medical Colleges Centers for Disease Control and Prevention(CDC) Association of Clinicians for the Underserved National Institute of Dental and Craniofacial Research(NIDCR) Association of Maternal and Child Health Programs World Federation of Orthodontists Association of State and.Territorial Dental Directors World Health Organization The list above was current at the time Fluoridation Facts went to press.As organizations and entities continue to be added to the Compen- dium,the most current Compendium can be viewed on ADA.org at http://www.ada.org/goto/ffcomoendium. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Compendium in its entirety,without modification.To request any other copyright permission please contact the American Dental Association at 1-312-440-2879. Fluoridation Facts 69 FLUORIDATION IS: NOT SAFE NOT EFFECTIVE NOT APPROVED NOT FREEDOM OF CHOICE November 2012 Presentation to the Bill Osmunson DDS,MPH Washington Action for Safe Water,President (1-101 Aesthetic,Comprehensive and Neuromuscular Dental Practitioner, (.;� ... ' Educator,Author,Lecturer and Nutritionist www.teachingsmiles.com 425.455.2424 1418-112th Ave Ste 200 Bellevue,WA 98004 UNDER WHO'S DEA LICENSE DO WATER SYSTEMS FLUORIDATE PUBLIC WATER? "The Washington State Department of Health (DOH) does not dispense fluoride. Rather, the DOH regulates water systems that choose to add fluoride to water. Therefore, DOH does not operate under any DEA license for the dispensing of fluoride. " Victor Colman,JD Sr. Policy Advisor DOH does not determine how much total fluoride is safe or how much total fluoride is desired. or approve substances intended to prevent disease. The WA legislature has authorized water districts to fluoridate, but authorization does not exempt FDA CDER approval, customary and general Federal and State laws for approval, manufacturing and dispensing, legal intermediary or patient consent. 1 FDA CDER HAS OVERSIGHT JURISDICTION with experts to evaluate the safety and efficacy. CONGRESS-DEFINES DRUGS: "Articles intended for use in the . . . prevention of disease . . . . 21 USC 321 (g)(1)(B), WA Board of Pharmacy "Fluoride is a legend (prescription) drug. . . ." FDA testified to Congress that fluoride is a drug. Congressional Investigation 2001 Why do EPA Scientists, say "NO" to Fluoridation? "In summary, We hold that fluoridation is an unreasonable risk: That is, the toxicity of fluoride is so great and the purported benefits associated with it are so small - if there are any at all — that requiring every man, woman and child in America to ingest it borders on criminal behavior on the part of governments." -Dr.J. William Hirzy, Senior Vice-President,'Headquarters Union, -US Environmental Protection Agency,March 26,2001 "The process by which EPA arrived at the RMCL for fluoride is scientifically irrational and displays an unprofessional review of relevant scientific data." Amicus to the US Court of Appeals,DC Circuit,Natural Resources Defense Council,Inc.,v EPA Civ.No.85=1839 ' http://www.fluoridealert.org/health/epa/n rdc/union-brief1986.pdf 2 Why has 90+% of European governments and dental associations rejected, banned, or stopped fluoridation? . . . environmental, health, legal, and ethical concerns Austria REJECTED:"toxic fluorides"NOT added Belgium REJECTED:encourages self-determination—those who want fluoride should get it themselves. F products banned Finland STOPPED:"...do not favor or recommend fluoridation of drinking water.There are better ways of providing the fluoride our teeth need.'A recent study found..."no indication of an increasing trend of caries...." Germany STOPPED:A recent study found no evidence of an increasing trend of caries Denmark REJECTED:"...toxic fluorides have never been added to the public water supplies in Denmark." Norway REJECTED:"...drinking water should not be fluoridated" Sweden BANNED:"not allowed".No safety data available! Netherlands REJECTED:Inevitably,whenever there is a court decision against fluoridation,the dental lobby pushes to have the judgment overturned on a technicality or they try to get the laws changed to legalize it.Their tactics didn't work in the vast majority of Europe. Hungary STOPPED:for technical reasons in the'60s.However,despite technological advances,Hungary remains unfluoridated. Japan REJECTED:"...may cause health problems...."The 0.8-1.5 mg regulated level is for calcium-fluoride,not the hazardous waste by-product which is added with artificial fluoridation. Israel SUSPENDED mandatory fluoridation until the issue is reexamined from all aspects.:June 21,2006"The labor,welfare and health Knesset committee" China BANNED:"not allowed"AND the USA purchases China's fluoride for fluoridation. France <35%fluoridated Salt,and not in commercial foods Ireland 74%Fluoridated UK 9%Fluoridated More than 70 Cities in the USA have stopped or rejected fluoridation since 2010 Most European dental associations no longer recommend fluoride supplements. Zimmer 2003 HOW MUCH FLUORIDE DO TEETH NEED? "The enamel has more fluoride near the surface. . . But not much higher statistically." Comprehensive Preventive Dentistry Limeback H.Editor.Wiley-Blakwell.2012 fi • Ez • American Dental Association(Paffenbarger a= A3 Research Center grant request) x "After 60 years of community .1i 5. _ - , 1. 2.00 ," - water fluoridation we still do not fi know how much fluoride is i °ieto* codr ao. required to prevent caries." 14.0=0 has more C.mraenear tM)Mace as a rear of p¢s 010402 exposure.but e,tIxls are trot much higher tteittinlly. i,Mrirdfrao Thiry Mal.20gj. - http://www.ada.org/prc.aspx#efficacv 3/3/12 Acc. 3 WITH INCREASED FLUORIDE WE GET INCREASED TOXIC FLUOROSIS BUT NOTA SIGNIFICANT DIFFERENCE IN CARIES EXPERIENCE lida, H., and Kumar,J.V. 2009.The association between enamel fluorosis and dental caries in CONFOUNDING FACTORS U.S.schoolchildren. JADA 140:855-862. € PROBLEMS WITH F-RESEARCH • A. Not one Double Blinded Prospective •t zo, Randomized Controlled Trial a p:m ,. x • B. Socioeconomic status usually not Permanent teeth in children(ages 7-77) controlled 1 1. C. Inadequate Sample Size —w. D. Difficulty in diagnosing decay • 50 amt - • E. Delay in tooth eruption F. Diet:Vitamin D,calcium,strontium, vw l total and frequency of sugar. to • G. Total exposure of Fluoride,(Water, v 30 as Toothpaste,Foods,Medicines) `oH. Oral hygiene 4 20 s -- • I. Not evaluating Life time benefit i • J. Estimating or assuming subject • - actually drinks the fluoridated water. 0 = K. Dental treatment expenses a 0.3.0.7 03-12 i L.L. Breast feeding and infant formula Water fluoride concentration(mg4.) k M. Bias,fraud or gross errors. F• N. Genetics NRC 2006 FOUND EPA"NOT PROTECTIVE" WITH CaF MCLG EPA RESPONSE: EPA declares fluoride safer and increases RfD by 33%. EPA ignores all infants and ignores 10%drinking the most water. 1:1 margin of safety 3.3 Above the black line ,. Ingesting too Much mp.d+r JJ/ 8. 'd l� b P ( e O.5 'I Sb.i 4to c7 7v•11 9;N4: aro ` Atte Range to Meas Figure 84.Total Daily fluoride Intake Estimates Relative to the Proposedin;90th Percentile Drinking Water Intake Data for Consumers Only and the Mean Drinking Water �e.fa ����+ (0.87 rug/LI 4 w g .2:«:,..„,,, :7 , . The FDA warns: .:7 ,f CrCSU� "do not swallow." t .,, our& ,� A pea size of toothpaste - 25 mg of fluoride, �° � l has 0. - u � thes x same as onewater glass m � ton moi^$-13 tf-- „,,,,t ali4als.i-eattr5 - /arsitn - n v Lt a mash a6 ;fit allat . r� i g.o1'6e R i ii , f cr aalf 4 r Vit; ;# dtn 1 « ' 1 U'�-ms €� :,,,,,,,,-c,,,___,_ f ®guage EFA — ;,in 2007,the t7S-Potsi on Coi troi'Centers'rep rted 24,087 exposures involving toothpaste with fluoride.emedicine National Research Council unanimous agreement: EPA' s MCL for Fluoride is too high. Concerns: •Tooth Damage B I S KS •Rheumatoid. and Osteoarthritic-like Pain •Bone Cancer Dental Fluorosis White Spots •Bone Fractures - '� - �4. ,� , Expecting any •Thyroid Reduction ,” -:L.,;_:,,_,;__-, chemical • Diabetes treatment to • Obesity ,z .` be safe for •Kidney damageY everyone is 0.-,.. naive. -Reproductive problems -Lower IQ and increased Mental Retardation •Allergies (overactive immune system) -Gastrointestinal disorders For references See NRC 2006 report,http://www.nationalacademies.org/morenews/20060322.html www.fluoridalert.org and contact Bill@smilesofbellevue.com 5 FREEDOM All treatment or research requires informed consent "PARQ" or "SOAP." Standard of care. -Universal Declaration of Human Rights 1948 •Declaration of Helsinki (Nuremberg Trial) -Belmont Report (US Public Health Tuskegee Syphilis Study) -Federal and state laws Individual,freedom to choose. I do not give my consent. If a person wants fluoride, swallow a pea size of toothpaste, mouthwash, foods high in fluoride, tea, fluoridated salt, etc. Fluoridation of water is practiced under police powers invested in public health authorities for the purpose of stopping highly contagious and lethal diseases, i.e. quarantine authority. BRAINS ARE MORE IMPORTANT THAN TEETH Economic and social correlates of IQ IQ CO 75-90 90-110 110-125 US population distribution 5 20 50 20 5 Unemployed more than 1 month out of year(men) 12 2 Divorced in 5 years 21 9 Lives in poverty 30 2 Ever incarcerated (men) 7 0 Chronic welfare recipient(mothers) 31 0 High school dropout 55 0 Values are the percentage of each IQ sub-population, among,non-Hispanic whites only, fitting each descriptor. Herrnstein &Murray(1994) pp. 171, 158, 163, 174, 230, 180, 132, 194, 247-248, 194, 146 respectively. 6 Choi(2012) Anna L.Choi,Guifan Sun,Ying Zhang,Philippe Grandjean (Harvard School of Public Health FUNDED) Developmental Fluoride Neurotoxicity:A Systematic Review and Meta-Analysis "Background:Although fluoride may cause neurotoxicity in animal models and acute fluoride poisoning causes neurotoxicity in adults, very little is known of its effects on children' s neurodevelopment." 27 human studies % $'4.4 aawen 14100:410) 9.404 s "Fluoride crosses the placenta. analMB fa,NH . y Y4tl , °,$` .-0i2„n Y anal 9W1 SPaw 423(461,4 to 413 G 41,1991 Iwo 4M(46g4.011326 Fluoride exposure to the t........, �;a, �_ 464(1 D:,fi]Z)x23 f. 14...1331 Ii 344 YL d1U 326 M4141112 111444N .—!!T 4471010.43113.E developing brain . . . may possibly D"A' 4 6 4"(42y43c)323 3'nn 6.1934 1I1.111a2 --a—. 4s3F1451102)491 Yap 34,4 .1(W 9aKoq 41'3µ31,D0»236 lead to damage of apermanent °n"' 466(414452)4U 9 wng a.4.1654 l 4 439(433,0i3)333 al.4.16541.3 054(431,0311422 11 mann a.lw3 63.10 ---k� a44(4.r6aa1)4n nature. bmgnd.WAS. nikvq 4.17(465,32»306 - 14Kat ZOO Tay4 ._4 462(414,425)320 - _ Nab 442031 9uip9 - 424(425.4331214 Wangx0.20E along 464(141,02)230 __ 1141.-X01 I ha. —t.. 413(43,044)an T 1314213 Am.. H 454(4.&.4.40)4,52 { 648.445X06 i1344 413(423.460)403 a 31/41.033 `1344 iE— 422(4.44403).4 Fin dol.2001 31444 4 417(451.522)2.75 1744 e14.2441 Sa 4261044.000 444 114x,2'+03 114+4 .34,50A61.)233 ` Received:30 December 2011;Accepted:20 July 1.1449420o N4a antwGe,'227 469 2012;Online:20 July 2012 '0:74:::::::07,,`,,'3-exo) tiw 4•5(4.34,034)461961 us ;, Environmental Health Perspectives On-Line Federal Government Journal `;'{ 741' 'Ll 'F Y(_.T'._-_.Z21:-.1".L.........;';,; ., Xiang (2003 &2005) compared IQ and fluoride serum concentrations. 8 IQ point loss throughout the entire population. Vis`; 1--/-- -----N, "-\ a 3t i�i3i , .41 i i P i tX64 x-'k4x60_, 3 4103 it llfal l' } 1117," t 1 -,t, _- a ¢ -- -i )410 10 �„.... ,,w,,, ,.�h ' Ftwel Kewary( bhutinaraltldmn 01Q in Wnnien mi XiamivitIn What is your fluoride serum concentration? What should it be to reduce dental caries? (Optimal?) What should it be to prevent risk? (Safe?) With low iodine intake? With synergistic toxins? With damaged.kidneys? For infants and children? 7 PEW Charitable Trust's 5 Criticisms of Choi (2012): "Does not raise valid concerns about water fluoridation. . . . NEUROTOXICITY IS A VALID CONCERN: Brains are More Important than Teeth 1. PEW claims "Given very small IQ difference (0.45) it's possible that arsenic levels, school quality, nutrition, parents' educational levels . . . Very little IQ difference." Harvard School of Public Health News (July 20, 2012) "The average loss in IQ was reported as a standardized weighted mean difference of 0.45, which would be approximately equivalent to seven /Q points . . . . Some studies suggested that even slightly increased fluoride exposure could be toxic to the brain. . . . "Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain,"Grandjean says. "The effect of each toxicant may seem small, but the combined damage on a population scale can be serious, especially because the brain power of the next generation is crucial to all of us." 8. PEW Charitable Trust's Criticisms of Choi (2012): 2. Pew claims, "Unusually high natural fluoride levels (China CDC studies). . ." a.Of the 20 studies evaluating water fluoride concentration, 12 had fluoride content of less than 4 ppm, within the EPA MCLG. b.7 studies with fluoride levels 2.1-4 ppm. c.4 studies at levels 1.8-2.0 ppm.(Xiang 2004;Yao 1997;Yao 1996;Xu 1994) d.One study with 0.88 ppm. (Lin 1991 sponsored by UNICEF) e.ln the USA many ingest a great deal of fluoride from other sources. Total exposure is very high. f.USA Urine and serum fluoride often similar to Choi studies. 3. PEW claims, The actual exposures of the individual children are not known . . . PEW and Critics have not read the studies. Li (2004) "It is concluded that fluoride is toxic to neurodevelopment. . . urine samples were 3.58 mg F/L ±.1.47 and.controls 0.18-2.6 mg F/L statistically significant (p<0.01)." Tang (2008) "Children who live in a fluorosis area have five times ' . higher odds of developing low IQ. . . ." Rocha-Amador (2007) "The individual effect of F in urine indicated that for each mg increase of F in urine a decrease of 1.7 points in Full IQ" Xiang (2003 & 2005) 8 IQ point drop with 0.08 ppm blood serum fluoride concentration, controls 0.04 ppm. 9 5. PEW rejects 26 human studies finding harm, based on: "A 2009 animal study. . No evidence of learning deficits . . ." The overwhelming evidence is rapidly growing, fluoridation contributes to brain damage. Especially for: Infants, children, � e;��throuotUthe�� .. Those with kidney problems, 01 fom1950gh2004 It')d States Diabetics, 41 ..:, low iodine intake, 12.1S'v""• High altitude, low selenium, With synergistic contaminants 9 _ 19861967 etc. ..,� eaawto�MFt.ariareea .. t .. 'erre aaw'.. t`mm- two axe ... on .. .,tar.f45G1nroU042W4' • Wen P.A.YYC-'%'.w.m�sa w�r9dtanti.�w.waww+eama,+rt-�v+Ue.aeiav@.cn t'aw. 1,,c�•.. 0.^.ail. 10 • FLUORIDATION DECREASES IQ IN THE USA Ranking the 50 states on their whole population fluoridated finds triple the number of mentally retarded (half a SD, 8 IQ lower) in the more fluoridated states. FLUORIDATION'S ERECT ON MENTAL RETARDATION 1992 350 44 • • 300 {{{ X200 , ge 150 7 1.2966k..46302 50 - f 0.0 20.0 40,0 60.0 80.0 100.0 94 of state population fluoridated http:llapps.nced.cdc.aovlgiscvhlmap.aspx htfp:l/apps.nced.cdc.govinohsslFluoridationV.asp http:l/pubs.usgs.gov/circf20041circ12e8lhtdocsttable05.html http:I/www.cdc.govlmmwRlpreview/mmwrhtmll00040023.htm • INCREASED LEAD IN BLOOD Pocia2uScadLeal /uerTeEloolLa'd N WSn-Chidra,35 18 IES.-ClulAol 517 • 6 6 Differences in fluoride exposure. 7• l �6 ..". ..a t;i 99 05-� �:SEat SsI'�NI WOG.,onenue3 GI ' \NW �' ^3 ♦ g:raj YthYrS J I\_\ I\_\ \ m 1 \ 30$'P- ark L'oem wwt Bat !bast tat remdOev RncaDAt #k{. 'v:' • - . tS Coplan,Neurotoxicology.2007 For NHANES III Children 3-5, lsor l' }1szrs :`1503. mean blood lead is significantly associated with fluoridation status(DF 3,F 17.14,p<.0001)and race(DF 2,F 19.35,p< FIGURE 1:Martinez-Mier EA,Soto-Rojas AE.(2010).Differences in .0001)as well as for poverty income ratio(DF 1,F 66.55,p< exposure and biological markers of fluoride among White and African .0001).Interaction effect between race and fluoridation status: American children.Journal of Public Health Dentistry 70:234-40. DF 6,F;3.333,p<.0029; Fluoridation chemicals added to water are a contaminated industrial grade product and may contain: Arsenic, Lead, Mercury, Beryllium,Vanadium,Cadmium, Radium,Silicon, Bauxite,and Radioactive Materials National Salutation Foundation 11 Blood Lead levels in Fluoridated-areas 2X higher for Whites and 6X higher for Blacks Confirmation of and explanations for elevated blood lead and other disorders in children exposed to water disinfection and fluoridation chemicals.CoolanMJ,Patch SC, Masters RD,6achman MS.Neurotoxicology.2007 Sep;28(5):1032-42.Epub 2007 Mar 1."Prevalence of children with elevated blood lead (PbB>10mug/dL)is about double that in non-fluoridated communities" When FSA was added "lead concentrations spiked to over 900ppb" Effects of fluoridation and disinfection agent combinations on lead leaching from leaded-brass parts,Maas RP,Patch SC,Christian AM, Coolan MJ. Neurotoxicology.2007 Sep;28(5):1023-31.Epub 2007 Jun 30 Water treatment with silcofluorides and lead toxicity. Masters RD,Coplan M.1999 International Joumal'of Environmental Science 56:435-449. Association of silicofluoride treated water with elevated blood lead. Masters RD,Coplan MJ,Hone BT,Dykes JF.2000 Neurotoxicology21(6):1091-1100. Blood lead concentrations in children and method of water fluoridation in the United States,1988-1994. Macek MD,Matte TD,Sinks T,Malvitz DM. Environ Health Perspect.2006 Jan;114(1):130-4. Dental School Did not find an increased blood lead level except for older homes. Lead from Leaded auto gas,canned foods,and lead pipes have decreased. t i h - - A ;Z:y9 joiffiNtar Mother' s Milk: most samples, #1F fluoride is not detected Mean 0.004 ppm F NRCp.33 Early Childhood Caries (ECC), is not due to an inadequate ingestion of fluoride while these teeth were developing which occurs in utero &/or during the first few months of life. [ECC is generally caused by sleeping with a bottle of milk,juice or sugared pacifier.] http://www.ada.org/3034.aspx http://64.177.90.157/pfpc/htmlif-_iniood.html 12 ,___,,,,,,••,--,--i7 ,7777.77-71,1,•-'74T4 a.--L-'?.. 1.--.: -,. "i'45i-t4r, ,W-fial-44:344, .4;,•-4,,,,.'ps,, ,,,!:;A:,;-,W-44,1-„kf ,'1,.•,-'' ',,--`, , -' ',.' ' --2-- q-:',‘ : -, --_-' 4-"''';',4---'-'3',,,_g-',7'-'-..T--',..--i--:-.,r.r,i,,-', -', , ,:.,-t'..!.;• :,--,-;:-,-„-. . . ",,;--,:i- 7_-._ .-,--2..-:,•-• :i,--....,i-w:::;,:,,,,, ';-,‘,,,"-':',:f#:i-,"::! ":,- ..-„,,. , . , 1- , --:q -..!,.-.,":, 4 s4,, , le--.z r 4. :...'*F4 ',"i' ;,e,:f,W - - L.Ii,. --r,,,_-_ - ,.:::'--i".• Dental • Fluorosis .----'----k,sT,:- -,,,,A,,,,,,,::,i;--,-,,,,,5-. .L_.',''f- ,_-, -,- Ci:,-f f,,,,,,,;-,:1--•e,,, ir.„-,.,,,,,, $12,000 Treatment ',\'C„-,,':. 2:- ''r' r-7-';:.,:-;",;c':7:';'1,:l.:,. --r..':'::;0.•..' ,,!,:'1' '-',:.'-,'V,„,•, .'t, Lifetime $50,000 to $100,000 damage. La' H.,a-4 Kertx,.W.213 MI ava...I beam tnr,ni Unsi rid tirroJorui US.tftifit#1.40,JACA1-03£55-la ‘ #____,...-- , •- 1 i - ...............,.....1. P477771' , . . c.. -F .,., •.,...„....,/ ,.., i. 13 i ii i i http://wwwsmilesbysoileau.com - ...• _,-....., .,..,,,....,..A ................ Cosmetic treatment Cost $16,000-$24,000- • - - r.-Y0.17:‘,_ t. .. -,-.7r.`A jri;,i ' r;:. i==,.1-7.- '_...;;-.--,kt. -w--.. --it - • 7af i,,• ',-..* -' ' r'-''-e-i',.. 'I','' -F,' r g ,r4 .... rAl „. : ,,, ., . .141.. •7=7_3.4 , ,,t_.. ',c,,..,.".---,.._,—.1 '',4=c,1,' , ..,--=,---".:7=3Y:— =•' -''-. ,-e, ' . ''.. -`,- --;.".'''''' '''.-1-'-':' , '-'—,'' • ' . 1; .-' . ',.' ';', ?:-- ',. _,''•''' ''1'•''",''kids have . „.,-1 CDC reports 41%Pf flUdrosiv. -..- - - • . — -,----7 ... , .,.. . 20,•-_ =, -- " '''',:tt--47f- , . ,•, - . , it.-•,•#,-• - ------.------ I .. , ' ' , :a, ?%-•- „ ,' " '-' '''''' :;-•'a•-:-..:. '. t'- `Kii gi• ..,, ••.; - ,a, ,,, ,.•!-. I4it— f... '.a.,...._--.i': • • - 'Avakitki-t•._At.-..aae.•a'•-a.. I ', - 4.„ y_!,-..:.--* , -.::-: --i ., . . Photos Courtesy of Dr. Stephen J.Markus 13 CUSP FRACTURES .• :r 4:.� 'r OONPLETETOOTH FRACTIRE ° 't - '' Fbpl cation Fluuridafed(F) -*A- � ,-.fi r,',1 ' i ' / . _ . D TWrH%4 FRACTURESzE 3 .i'3 r , 1, v� '' 1 —,-4,', :.,:1 .tea' '','''',,itP ,_,:tex,;,,1,..:F/A 0.,__',%-'.. . I' 1 2 • 3 = Y O%F 1936F 85%F Geurtsen Quintessence 2003 VTr Patel PatelPrim Dental Care 1995 Bader Corn Dent Oral Epi 1996 and 2001 and JADA 2004 Vieira Eur J Oral Sci 2006 Fennis Int J Prosth 2002 Osmunson Fluoride 2007 Comparing 50 states , • Fluoridation is not effective. - ,-i AMID FLD.,, ,00.o 30.0 -- (Population Fluoridated 70.0 I. 150.0 - , t ',1 ' --- High For rich , the0.o i I r childrenreporting 40.0 ! 1 sprocIVreeccelkrrit 30-0 1heENl 20.0 —....—%Lenrirswrrte . 10.0 children r Or the poor 00 goocarerocellerrt , 1 r 7•13 19 25 31.37 43 49 6D S7"A712^s _LirttearCY High • Higher income = better teeth "Caregivers'assessments of their children's OHS(oral health status)and their clinically . determined restorative treatment needs were statistically associated"(above 2 yrs of age). Divans K et al.Examining the accuracy of caregivers'assessments of young children's oral health status.(Nov. 2012 JADA 143(11)p1237–1245. http:llmchb,hrsa.govloralhealth/nortraitllcct.htm National Survey of Children's Health. very little common cause variation U.S.Department of Health and Human Services,Health Resources and Services Administration,Maternal and Child Health Bureau. The National Survey of Children's Health 2003.Rockville,Maryland:U.S.Department of Health and Human Services,2005 http:llwww.cdc.aov/oralheahhhvatertluoridation/fact sheetslstates stats2002,htm http://pubs.usqs.qov/circ/2004/circ1268/htdocs/table05.html 14 . . . . .,... Coiquhoun J.Perspectives in Biology and Medicine 41,1,Autumn 1997 ..- , http://www.fluoride-joumal.com/98-31-2/312103-f.htm r-- -1V--• ,' ' -,01'. --; zl ,...-, •x; '. -,.'-._ .. . p&v.,. c.1,L IV ' th:,.-.. , -, ,,-..', • I fae :.: .-: -. -_-_ .rilA-....s.,:,, : ., ';'t•--k..i. c - .---:D-4i4--' ri't-'•'.-, ,;:': r'r'1,4'4% ''rr -: ' -- '-:-• :ill 1'..e(12,,,, .:N:.j:.--) -: • , - , <-±-a, >., , : 0,-,17, ILI -- - • •• .1 2;1::. ,j, '1..•;; IC 111" •i , ':_!., ' '', :- ':.: __.•' ,,'.„ , :•:A ,. . ."-. .. .. ,., ...... ,, . . .... 0 3,54,0'. ' .11146 190 060' 1.9.46d566ri. 9.56 2000 2010 Huge caries crushing "UNKNOWN" Before Fluoridation Fluoridation makes no difference in the - incidence or prevalence of dental caries. Novae Earridairs Warr lbatib9re(%pcputaira teret.1,1 —Ragft3 ..---:.Grrraly 1AFLUOM.110. ......6 ma)rolIrel.md Tooth Decay Trends: Fluoridated vs.Unfluoridated Countries Diai: —Wald —M00% aespn wake...WC--sa...,,,FAN ——ri_IVIr.di ..--..Sega A 9 --..-Daina* •••••••S.#,til ••••OM 8- -C \ -,,,-Fintnd : Dar lie gen Sall Caoriiatim(Xpapetalmceren9 . i N ,-.4.-From ' .---- •••••••••...••Caltil •••••Fr...U(4044Q bli r-q!“1 -a-Germany N;\ \, -0.-ialancl .:S S----------- •-• ../ . : 10 [..:',';:.:.::•S ::::.'l'''....:::' ':-.::', .'.:1:21 .N...\,,........ .. 9 4. If AV:4,.;,..4„-;.*:;•-i::::.Zt;4.„ 334:.,.].;.::,:,,,:5 —.5.,:txt:rtand . 1. IM 1.47(1 1g9 1 WS MO 1991 Va3 M. • IInatand Uto.. I0( 1,V, 1.3 015 .1_.., H. MI IS 2230 MO .,,,,,—..".,,,,z.. : leandraarin 12pairolis In[mem thiarcalaties. Year -6-Un1od States Fluoridated vs. Unfluoridated Countries. Chen et al,BMJ 5 October 2007 Tooth Decay Trends for 12 Year Olds: Data from World Health Organization.(Graph by Chris Neurath). http://www.fluoridealert.org/health/teethicaries/who-drnft.html .. . , 15 Oregon has better dental health with less cost Oregon Washington Population fluoridated 19% 59% • Decay % 6-8 yr. olds 57%* • 59%** Any permanent teeth extracted 60%**** 63% "Very Good/Excellent Teeth" 58%*** 51% Low Income Children Dental expenses $176/child/yr. $180/child/yr•**** Median income $42,593 $48,185 Preventive dental visit 45% 60%(within 12 rho Low income) Delay in tooth eruption --- 5% compared to Oregon Bachelor's Degree 25.1% 27.7% English spoken 88% 88% Race similar +1% Hispanic +1% Black "•*National Survey of Children's Health. i r r.. v eu •""Portland vs Vancouver Maupome 2007 J PHD U.S.Department of Health and Human Services,htto://www.cdc.gov/oralheatth/watedluoridationlfact sheets/states stats2002.htm BRFSS 2002 http://www.dhs.state.or.us/dhslphlchs/brfsl021orahealdentvisi.shtml ""itto:l/apes.nccd.cdcyov/brfss/display.asa?state=WA&cat--OH&yi 20D48ukey-6610&qrp=0&SUBMIT4Go Sample size OR 3509 and WA 12,926 2004 data "http://www.doh.wagov/cftt/Oral_HeahhlDocuments/SmileSurvev2005FultReoort.ps[ IMplhwomcdc.govifluoridationffact_sheets/states_stats2002.htm http://quickfacts.census.gov/gfd/states/41000.html r,«.,u,..,.,..•n....�.�.s: .e......r�.•e..roae•,r,.a,..........•nve.m w°.,. Washington Counties di lercear,d %pof people Fluoridated % of Washington fluoridated 46% in 1996 59% in 2007 100 9J Until FDA CDER approval, 70MMN fluoridating cities are 60°o Rt oridated manufacturing and- marketing anNNW �o unapproved, misbranded, MM. —Flevdcalesefice adulterated, off-label substanceMINI' —; aries which the FDA says is an 10 ,- "illegal" drug. g g• 1 6 11 16 21 26 31 36 Leroux, et al Univ.WA (ngtees J Dent Res'1996 16 • • • • • OPPOSED � S E M ENT T ca FoodRIDATION and Dg Admmist 6IRSA RgensryenaonaAa emy f eneral C (Deferring Regulatory Action) American College of Dentists.... Washington Board of Pharmacy ' • http://www.ada.org/4051.aspx (Prescription Drug) Washington Action for Safe Water American Academy of Environmental Medicine • Orthomolecular Medicine EPA Employees Union Holistic Dental Association International Academy of Oral Medicine&Toxicology(IAOMT) Nutritional Therapy Association Oregon Association of Acupuncture and Oriental Medicine . ' Oregon Chiropractic Association • League of United Latin American Citizens(LULAC) Sierra Club lf/ Willamette Riverkeepers... • ff NO POSITION • Washington Board of Pharmacy w American Academy of Allergy,Asthrraan• - - American Academy of Neurology American Cancer Society???? • American Diabetes Association American Kidney Fund • American Lung Association ' American Society of Nephrology American Thyroid Association ' National Kidney Foundation Oregon Association of Naturopathic Physicians The Endocrine Society.. Oregon Physicians for Social Responsibility... "The idea that ... the consumption of fluoridated water, will make teeth `stronger.'and more resistant to decay has been largely abandoned in many countries." Comprehensive Preventive Dentistry(2012) Wiley-Blackwell,A Dental School Textbook. The City of Renton needs to have in writing on file: A.Toxicological review demonstrating safety of fluoride products used' for all individuals, ages, subpopulations, health status. A.FDA CDER approval or exemption for efficacy and safety B.Washington Board of Pharmacy license or exemption C.EPA SDWA approval or exemption D.Under who's drug license is,fluoride dispensed. • E.Documented evidence of patient consent. 17 Largest survey of children's tooth decay, 39,207 children, 2 reports: A. No benefit (2 cavities with or without fluoridation) B. <0.5% of caries reduction (Brunelle 1990) 120 - y: .. ... -. .. .. 100 4. -. . . .. • 1 40 i --fT .. ... • .. .. .... L4 128 TOOTH SURFACES NO FLUORIDATION FLUORIDATION Brunelle JA, Carlos JP (1990) Recent trends in dental caries in U.S. children and the effect of water fluoridation. JDR.69(Special edition):723-727 Yiamouyiannis JA,Water Fluoridation and tooth decay:results from the 1986-87 National survey of U.S. schoolchildren;wete'rFluoridatibrr and Tooth Decay.p57-67, Vol23;No':2 ;Komarek AE(2005).A Bayesian Analysis of Multivariate Doubly-Interval-Censored Dental Data,"Biostatistics.6(1):145-55.(Delay in tooth eruption needs to be considered) Washington Legislature has authorized fluoridation, but did not exempt Federal Oversight by the FDA CDER with NDA. Under who's DEA license is fluoridated water prescribed? Washington Board of Pharmacy; "Fluoride is a legend drug regulated under chapter 69.41 RCW. RCW 69.41.010 defines a `legend drug'as drugs `which are required by state law or regulation of the state board of pharmacy to be dispensed on prescription only or are restricted to use by practitioners only.'In WAC 246-883-020(2), the Board specified that`legend drugs are drugs which have been designated as legend drugs under federal law and are listed as such in the 2002 edition of the Drug Topics Red Book."'State of Washington Department of Health Board of Pharmacy June 4, 2009 letter to Bill Osmunson DDS; The above-referenced Board letter continues, "While RCW 69.41.010 restricts the dispensing of prescription drugs to practitioners, the legislature has authorized water districts to fluoridate their water supplies in RCW 57.08.012." 18 By law: FLUORIDE IS A POISON EXEMPT WHEN REGULATED AS A DRUG. The Food, Drug, and Cosmetics Act (FDCA) and RCW 69.41.010(9) define a drug as an article: "... intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animal." 21 U.S.C. 321 (g)(1)(B). Dental caries is a disease, and fluoridation is intended to prevent caries. The WA Board of Pharmacy, "fluoride is a legend drug?' The FDA CDER has confirmed the ingestion of fluoride is an unapproved drug which are illegal drugs. FDA Confirms: F- is an Unapproved Drug "A search of the Drugs@FDA database . . . does not indicate that sodium fluoride, silicofluoride, or hydrofluorosilicic acid has been approved . . . .'.2009 Best regards,Drug Information SH,Division of Drug Information,Center for Drug Evaluation and Research,Food and Drug Administration FDA CDER ADVISES: "Manufacturers of unapproved drugs are usually fully aware that their drugs are marketed illegally, yet they continue to circumvent the law and put consumers' health at risk." http://www.nabo.net/publications/assets/OR082008.pdf Oregon Board of Pharmacy 8/08 Newsletter 19 Although the 1955 court held that fluoridation is a public health measure (Froncek v.City of Milwaukee), Since 1955 drug laws have become more precise. 1962 Kefauver-Harris Amendments to ensure efficacy and safety 1962 Consumer Bill of Rights(Pres.JF Kennedy)the right to safety, be informed,to chose and be heard. 1966 Fair Packaging and Honest Labeling 1974 Safe Drinking WaterAct(EPA) 1981 Human Subjects Protection 1988 FDA Act 1988 Prescription Drug Marketing Act 1990 Safe Medical Devices Act 1997 FDA Modernization Act 1997"Protection of Children"(Executive Order 13045) 1998 Pediatric Rule 2002 The Best Pharmaceuticals for Children Act&Office of Combination Products 2005 Drug Safety Board FDA REGULATES SUBSTANCES WHICH TREAT PEOPLE EPA REGULATES SUBSTANCES WHICH TREAT WATER "The Safe Drinking Water Act prohibits the deliberate addition of any substance to drinking water for health- related purposes other than disinfection of the water." FOIA Request HQ-FOI-01418-10 "No national primary drinking water regulation may require the,addition of any substance for preventive health care purposes unrelated to contamination of drinking water. " 42 USC 300g-1(b)(11): Wisconsin has agreed to abide by and enforce the SDWA in order to receive Federal funding 20 CDC: Ingestion of fluoride is not likely to reduce tooth decay CDC(1999).Achievements in Public Health,1900-1999:Fluoridation of Drinking Water to Prevent Dental Caries.MMWR,48(41);933-940,October 22 CDC: "It is not CDC' s task to determine what levels of fluoride in water are safe." htto://www.cdc.gov/fluoridation/safety.htm 5/26/2012 MANY HAVE EXCESS FLUORIED IN SERUM. CDC: "Normal serum fluoride levels are <20 mcg/L (0.02 ppm) but varies substantially. . ."http://www.bt.cdc.gov/agent/sulfurvlfluoride/casedef.aso Taves (`66) normal <0.013 ppm Sowers controls 0.05 ppm (4th quartile) Sandhu controls 0.042 ppm and tumors at 0.072 ppm (Xiang 0.064 ppm) Zang controls 0.04 ppm and 8 IQ loss 0.08 ppm Rathe controls 0.025 ppm and stones at 0.12 ppm Hossney (2003) Mother's Milk most samples-none detected The American Dental Association Does Not have Jurisdiction To the Superior Court of the State of California Case No. 718228, Demurrer(October 22, 1992).the ADA said, "The American Dental Association (ADA) owes no legal duty of care to protect the public form allegedly dangerous products . . . Dissemination of information relating to the practice of dentistry does not create a duty of care to protect the public from potential injury." 21 • American Dental Association White Paper — 1979 On Fluoridation Excerpt, Pg. 10-11 "Individual dentists must be convinced that they need not be familiar with scientific reports of laboratory and field investigations on fluoridation to be effective participants in the a promotion program and, that nonparticipation is overt neglect of professional responsibility." "Our analysis shows no convincing effect of fluoride-intake on caries development. A Bayesian analysis of multivariate doubly-interval-censored dental data" Fluoridation delays tooth eruption. ARNO"ST KOMA"REK.,EMMANUEL LESAFFRE Biostatistical Centre,Katholieke Universiteit Leuven,Kapucijnenvoer35,B-3000 Leuven,Belgium amostkomarek@medkuleuven.ac.be • TOMMI HA RKA"NEN National Public Health Institute,Mannerheimintie 166,FIN-00300 Helsinki,Finland DOMINIQUE DECLERCK School of Dentistry,Katholieke Universiteit Leuven,Kapucijnenvoer 7,B-3000 Leuven,Belgium JORMA 1.VIRTANEN J'4 Institute of Dentistry,University of Helsinki,PO Box 41,FIN-00014 Helsinki,Finland Biostatistics(2005),6,1,pp.145-155 4 doi:10.1093/biostatistics/kxh023 l /� ti .ems 22 1 .. A number of recent cessation studies show that ,stopping fluoridation does literally nothing to increase overall dental decay. Komarek et al,A Bayesian analysis of multivariate doubly-interval-censored dental data, , Biostatistics 2005 6 pp 145-155 Copy Available. .2. Modern studies find difficulty in measuring the benefits of fluoridation (no difference between fluoridated and non- fluoridated communities) Studies by: Brunelle,Angelilo,Clark,Ismail,Slade, Kumar and in Australia by Armfield JM.SpencerAJ 2004,a very large study found No difference in dental decay in permanent teeth. 3. Not taking into account delayed tooth eruption makes early fluoridation studies'over-estimates of the benefits".... Fluoride added to drinking water may have simply delayed caries in the past. Hardy Limeback DMD, PhD Even those flawed studies found 0.6 ppm F better than 1.0ppm.Edward&Stric . • b Fluoride and The Brain Low iodine and high Fluoride exert "severe damage to the human body" 0.8 ppm Iodine and 1-3 mg/L fluoride in urine.Yang Y 1994 • The lowering of IQ by 8 to 10 points 1 Lu Y,Sun ZR,Wu LN,Wang X,Lu W,Liu SS.Effect of high-fluoride water on intelligence in children.Fluoride 2000;33:74-8. o. 2 Li XS,Zhi JL,Gao RO.Effect of fluoride exposure on intelligence in children. _ < J..- - Fluoride 1995;28:189-92. -- 3 Zhao LB,Liang GH,Zhang DN,Wu XR.Effect of a high fluoride water supply 1 ~J on children's intelligence.Fluoride 1996;29:190-2. 21.6% retardation with fluoride 3.14ppm vs 3.4% in control with fluoride 0.37 ppm Tianjin,Fluoride Vol.33 No.2 49052 2000,Editorial 49 Fluoride 33(2)2000 http://www.fluoride-journal.com/00-33-2/332-49.pcif Fluoride and low iodine on learning/memory in rats. Wang et al,2004 23 "Since April of 1999, I have publicly decried the addition of fluoride, especially hydrofluosilicic acid, to drinking water for the purpose of preventing tooth decay." See details http://www.slweb.org/limeback.html " VIA Hardy Limeback,BSc,PhD,DDS Associate Professor and Head, Preventive Dentistry ' University of Toronto ' 4 :.111-4 -- "I am quite convinced that water fluoridation, . in a not-too-distant future, will be consigned to medical history." -Dr.Arvid Carlsson, Winner,Nobel Prize for Medicine(2000). "Fewer fillings had been required in the nonfluoridated part of my district than in the fluoridated part." 1997 John Colquohoun PhD,DDS http://www.slweb.org/colquhoun.html Decay is not the result of fluoride deficiency. Aoba T,Fejerskov O.(2002).Dental fluorosis:chemistry and biology. Critical Review of Oral Biology and Medicine 13:155-70. • ADA awarded Kentucky with "50 Year Award" for (100%) fluoridation/ 2003 42% were edentulous, #1 in USA (2002 Mortality Weekly Report) "With 1 .6 to 4ppm fluoride in the water, 50% or more past age 24 have false teeth because of fluoride damage." JADA 1944 Connecticut (87.5%water fluoridated) Detroit-^ ` Boston all report a crisis with decay and all have water fluoridation. http://www.fortwavne.com/mld/newssentinel/7521679.htm?template=contentModu les/printstorv.isp http://www.enquirer.com/editions/2002/10/06/loc special report.html http://www.fluoridealertoraff-boston.htm http://www.ncbi.nlm.nih.00v/entrez/aueryfcoi?cmd=Retrieve&db=pubmed&dopt=Abstract&list uids=13678102&query h1=1 http://wwwnhregistencom/site/news.cfm?newsid=14472801&BRD=1281&PAG=461&dept_id=517515&rfi=8&xb=kasan • 24 GENERAL AGREEMENT Dental caries can be painful and expensive. Dental caries are not caused by inadequate fluoride. Too much fluoride increases risk of harm. Fluoridation is controversial. A poor diet and lack of daily clean are significant causes of caries. Topical fluoride has benefit No prospective randomized controlled trials. Most developed countries world wide do not fluoridate water. Fluoride is more toxic than lead. Why did Portland Council Vote to Fluoridate? A million dollar marketing program . . . Endorsements and false information. • From 2002 to 2007:Survey results show-_. Oregon's oral hcafth.is headed in The'wrong -The-2007=Srnde'Survey reports the,oral health of Oregon s -- school dNdren worsened In every maipr.measwernent f om 2�=�ey<Mmes waz�n«duntod Fluoride does not TREAT cavities. o Oregon (not Portland) -49% 41% i a° hncrruse !manse lacks caries treatment --- .. .AGoady,,. .-4Iud,s .' Rampant-.• :.atnueated:"i,'Wrter' -- !heed e' ..mvtty In decay -_decry. Ft oddation Graph modified to include Water Fluoridation 25 • The FDA CDER has not approved fluoride in bottled water;however,the City of Renton should at least use the standard set up by the FDA office of food labeling and nutrition. Remember,it was those wanting to maintain fluoridation who raised the issue of bottled water. Certainly they should not object to the same standards of bottled water for public water. A new law was passed by Congress to fast track health claims for FOOD. The same law firm defending the tobacco company pushed through the FDA food section a"NOTIFICATION"to the FDA of their intent to make a health care claim,circumventing the FDA CDER. Neither the food section of the FDA,nor the FDA CDER were presented with the science or risks of the health claim for rigorous scientific review. In effect,proponents of fluoride have NOT been able to meet the FDA CDER scientific standards of efficacy and safety,so they circumvented the FDA CDER using a new law designed to make a health claim for food by simply notifying the FDA they were going to make the claim. Apparently(based on FOI information),the FDA CDER was prevented from drug regulatory enforcement and provided minimal input. Two changes required by the FDA included the word"may"and the water not be marketed to infants.The claim language is:"Drinking fluoridated water may reduce the risk of[dental caries or tooth decay]."In addition,the health claim is not intended for use on bottled water products specifically marketed for use by infants. The City of Milwaukee should at least follow the exact terms of bottled water as required by the food division of the FDA and use the word"may"when referring to the possible benefits of fluoride. Second the City should not market the product to infants. To sell(market)fluoridated water to everyone and claim it is"safe"for everyone(specifically includes infants),violates even the food and labeling section of the FDA and has not had rigorous scientific scrutiny by the FDA CDER. To sell(market)fluoridated water as"proven"effective when even the food section of the FDA only permitted the word, "MAY"is misrepresentation. ENDORSEMENTS OR SCIENCE Ask endorsers of fluoridation to provide their science, prospective randomized controlled trials. Ask endorsers for FDA CDER,and WBOP approval or documented exemption for manufacturing, marketing, dispensing and administering fluoridated water. Ask endorsers for prospective randomized controlled trials of exposure, dosage, effectiveness, safety and ethics. Ask endorsers for evidence based analysis. Under who's DEA license is the fluoridated water dispensed? 26 , Spittleal (2011) ". . . the only assuredly safe level is zero." Prystupaj2] (2011) Conclusion: . . . Based on an analysis of the affects of fluoride demonstrated consistently in the literature, safe levels have not been determined nor standardized. Mounting evidence, presents conflicting value to its presence in biological settings and applications." f1]Spittle B,Neurotoxic Effects of Fluoride,Fluoride 2011;44(3)117-124 http://www.fluorideresearch.org/443/files/FJ2011_v44_n3_p11 7-124_pq.pdf [2]Prystupa J,Fluorine-A current literature review.An NRC and ATSDR based review of safety standards for exposure to fluorine and fluorides.Toxicology Mechanisms and Methods,2011;21(2):103-170. figure 1:Changes in moon notional Decayed F:lbsing Filled Teeth(OMIT)stoles for 12 year olds from piofied Member States between the 1923s end fin.:decade of 2094[WHO 2022b] 5 — I 7r OMFTScore In1980-1990 4 -- iii!' '-- IIDM,FTScoreIn2000-2009 i # ,.:,-.;, -0. x y 2 14 2 4 6i c ' a S? '$ SI R t U. LL u LL LL LL >W N LL LL 'L. o u N o o 0 0 0 °' o o o "' � r- F=%on fluoridated water Notes c,co Fluoride salt data incomplete •Ireland:WAFT score for children receiving fluoridated water at home since birth •DMFT score for Poland in 2003 was ascertained from examination of 180 children in Gdansk region DMFT score in UK in 2008-2009 is for England only Better Oral Health European Platform 9/2012 Patel R, • 27 r 11/28/2012 Public Health`iq Scatcle&King Count)^ Community Water Fluoridation Moffett Burgess, PhD, DDS W -' X 7 A -, s s I s r 4 Acknowledgement _- --arfment of Health, ' -€ Bureau of Dental Health for parts of this presentation. Public Health ki Seattle S.Xing Count}',1.011 The Centers for Disease Control & Prevention (CDC) identifies community water fluoridation as one of 10 great public health achievements of the 20th century. Fluoridation prevents tooth decay safely and effectively. . Public Health community supports fluoridation 1 11/28/2012 • Fluoridation is effective. • Fluoridation is safe. • Fluoridation is legal. Public Health Seattle&King County�1 • Fluoride is a naturally occurring mineral and the 13th most abundant element • Fluoride is incorporated into the tooth enamel which becomes stronger and more resistant to decay Fluoride Public Health Senalc&King County�1 2 11/28/2012 :•;F.rr,; r€ 4- Public Health:(,l " Dental canes(tooth'decay)il.s the h° Seattle&Xing Countyliall ': single most common4chronlc , h childhood°disease`¢ ,5°' ,, • Infection ✓ 1. 7:;`,4"4-1),,r,. .,..,, - ter ., • Extreme pain ;�:riVK: .A ' '` • Difficultyconcentrating 9 .. : . • Missed school hours ' F • Difficulty in chewing ._. Poor weight gain/nutrition ' issues �- • Predictor of future cavities �� • Costly treatment s The problem: Tooth decay 5 F'.,;-1.',:: :`-%-,:7.77., -;, Tooth Decay-t 2010 Smile Survey weTr- s 4 - ' w' Kindergarten and 3rd grade =K ' -, WA State King County Community water N=5,733 N=4,000 fluoridation Caved es (Treated and 49% 40% reaches 80% of Untreated) King County residents Fluoride makes a difference Public Health ill Seattle&King County Ili,_ 3 4 14 11/28/2012 . �� Tooth Decay t � , ..r -674 a 47° Wj• # ., 2010 Smile Survey King County F , Kindergarten and 3rd grade ▪ t ' . s ' �- r Race Income Language ?_ l#4 1 ' White Higher English ' ' 30% 29% 33% Minority Low Not English Disparities by 50% 57% 56% Race, Income, Language Fluoridation addresses disparities Public Health 11-11 Seattle&King County mal Public Health.La Seattle&King County NM 1 •• Fluoridated communities have 25- - h, t ,l .. -- 40% less tooth decay-depending . /_j�, moi, . : on the population studied ':-'N.:,‘:...''-:'-'''i' - 's:-:ti„--,--- • Water fluoridation is the single >� 4'f 4,;'1 . most effective intervention to vi'--.11,0:',„--:k-.,,'4:--, , 7 j S1 :_ prevent cavities :»> _ "'"- .<.'' -'' `.:»..lt ' Saves money: every dollar spent on water fluoridation avoids on average $38 -$42 in dental care ✓ Fewer fillings, longer lasting teeth • Equitable: age, income, race, language, ethnicity • Benefits last a lifetime Fluoridation is effective 4 11/28/2012 a Six Year Review of Drinking Water Standards,Fluoride,2011 Public Health kg Seattle&King County a Health Canada Report on Fluoride and Human Health(Dec 2010) a Australian Review of Efficacy and Safety of Fluoridation(2007) a Research Council,USA(1993,2006) *World Health:Organization(1994,1996,2006) a U.S.Guide to Community Preventive Services(2002) a U.S.Surgeon General's Report(2000) • Agency for Toxic Substances and Disease Registry,US Public Health Service(1991,2003) a International Programme on Chemical Safety,WHO(2002) • Forum on Fluoridation,Ireland(2002) a Medical Research Council,UK(2002) a University of York,UK(2000) a Institute of Medicine,USA(1999) a National Health and Medical Research Council,Australian Government(2007) Independent reviews supporting efficacy & safety • Renton is in compliance with ANSI (American National Standards Institute) 60 Water Quality Standard • Sensitivity/allergy to fluoride products such as toothpaste or fluoride treatments are from the other components in the product and not from the fluoride • Fluoridation is safe Public Health Seattle Sc King County u� 5 • 11/28/2012 . : Normal Questionable Very Mild Mild Moderate Severe What fluorosis looks like Public Health Eg Seattle&King County IMO • Describes range of cosmetic changes in teeth • Fluorosis occurs with swallowing too much fluoride A • The primary cause is from swallowing • It0-0;., toothpaste • Only occurs while teeth are developing • Occurs in BOTH fluoridated & non- fluoridated communities What about fluorosis? Public Health ill Seattle Sr King County nal 6 11/28/2012 8 3 7 6 4:A686—A � 1 g 1 2 4 1 Menathel Mimiis',. Si a 2 D 1 2 3 Fluaddo Concontmtion in Water(porn) 6 Fluoridation is a balanced approach Public Health b•,� Seattle&King County AWM What is fluoridation? • Adjustment and monitoring of fluoride in drinking water to ensure that it stays at a desired level • Allowed up to 4 ppm only in non-adjusted systems • 0.8 ppm in Renton • EPA has recently proposed 0.7 ppm Public Health 1•f'! Seatdc&Ring County l�l 7 11/28/2012 Public Health HI Seattle&King County JIM t `Source Y Parts perp l Q tPt�„M) Drinking-water.=Adjusted 7 �.2 Drinking water--Allowed y <4 f z Water ;_not allowed -_ ' >4 aOcean water n i n 1- Fluoride toothpaste 1 000 1500 Fluoride rinses 230 daily rinse . 900 weekly rinse> 9 040'foam t Fluoride:•treatmrents 12 500 APF gel 22 500.varnish Fluoride supplements _ 25 1 0 Water fluoridation ensures safest fluoride levels Community Water Fluoridation Regulatory Standards Meets the standards (wide margins) Scientific Reviews 16 reviews since 1990, Health No health concerns Esthetics Cosmetic benefit Tooth decay/ Enamel fluorosis Environmental safety No negative effect Less tooth decay for children and Benefits adults'7'particularly seniors; Cost effective Public Health HI Seaccle&King County: 8 - 11/28/2012 Public Health kii Seattle&King County IMM Endorsed for efficacy and safety ,44. x- �' by numerous scientific and t professional organizations: nom= t',:,:.:!:>--..*: ` r • US Public Health Service t • American Medical Association --# • -- -, . American Dental Association �,r , 7' • World Health Organization sw `, * • International Association for Dental ,, r >0Research 44. ,' • American Water Works Association ... and many other scientific and professional organizations concerned with oral health and overall health. Health organizations support fluoridation Public Health"[ Seattle&Klug County Mal - • Health professionals and ! ru,,-,,.. 5 scientific organizations - support fluoridation! ,-„,::;6,-,..--, Renton's residents are -i _ ` among the 205 million residents in the United States that receive water fluoridation's benefits Health professionals & public support 9 11/28/2012 Renton residents support fluoridation A majority of the citizens of ,, ,., Renton voted in 1985 to fluoridate the community voTwater supply. *** _ � Fluoridation in Renton began in 1987. Fluoridation is legal PuH Seattleblic&Ring County • Fluoridation is effective. • Fluoridation is safe. • Fluoridation is legal. Keep water fluoridation in Renton Public Health Seattle&Ring County�1 10 ao4r STATE OF WASHINGTON DEPARTMENT OF HEALTH • PO Box 47890•Olympia,Washington 98504-7890 Tel:(360)236-4501 •FAX:(360)586-7424• TDD Relay Service: 1-800-833-6388 August 2012 STATEMENT ON COMMUNITY WATER FLUORIDATION Community water fluoridation began in the United States over sixty-five years ago. Fluoridated water systems serve nearly two-thirds of the U.S.population and sixty-five percent of Washington State.Evidence shows that water fluoridation is the most cost- . effective,practical,and safe means for reducing tooth decay.People who drink fluoridated water at recommended levels retain healthier teeth and have less tooth decay than those without access to fluoridated water. Tooth decay is a preventable infectious bacterial disease process that begins in infancy and continues throughout life. Early exposure to optimally fluoridated water improves dental health.Fluoride is a safe and naturally occurring element that benefits the enamel of developing teeth when it is ingested. When in contact with teeth in the mouth,it helps to repair early signs of tooth decay,harden exposed root surfaces,and slows decay-causing bacteria in adults and children.Fluoride benefits teeth for all ages. Public health provides prevention measures to all citizens,regardless of age,race, gender,or • income.Community water fluoridation is the most effective way to deliver the benefits of fluoride to everyone.The Surgeon General of the United States and over one hundred national and international organizations endorse water fluoridation.The U.S. Centers for Disease Control and Prevention recognizes the fluoridation of drinking water as one of ten great public health achievements of the twentieth century. Community water fluoridation is a Healthy People 2020 goal.The Department of Health supports water fluoridation as a sound population-based public health measure. The department supports communities in their efforts to maintain and fluoridate community water supplies. Maxine Hayes, ,MPH State Health Officer irk%140 I F f r^r, Y9 f - a ��' {t,�,'^.s *^'3 9�,cTt a` ^ra z. - .7: k - J Ni } , 1 - K„ s 7 ,i F 3+ �T - t +y r {y ` ,r pp F .......� ....,. .., , .,,�.,„..s_...._ _ _ .,,,i ..? u .w.r.,.i 4,.� ..,,... ,,:.: .5k�....+i:L_t o -Z�1":01; �u �,t ...._.,: ..,n>..,.w.. ,';, T Vii:Tel - . '.!k WASE-IINGTON STATE DENTAL ASSOCIATION 126 NW Canal Street Seattle;WA 98107 November.1, 2012 Phone: 20 43.9266 The_Honorable Rich•Zwicker i FAX 206.4 Council Presiders vvww.wsda.org City of.Renton 1055 S. Grady Way Renton, WA 98057 Dear President Zwicker: Onbehalf of the Washington State Dental Association, I am writing to support the r� Pp continued practice of optimallyfluoridating the City of Renton's water supply. Support for,community Water fluoridation can be found among more than 100 national,and international health organizations including the Centers for Disease Control and Prevention and the World Health Organization. 1 Water fluoridation is one of the safestand most equitable methods for delivering 1 fluoride to all members of a community regardless.of social or economic status. iFluoride is a naturally occurring mineral found in all water supplies that when set to optimal levels is effective in reducing dental decay by 20-40 percent. The average 1 cost.:for a;community to fluoridate its water system is as low as $0.50 per person, per year. Community water fluoridation has received strong support from key policy makers in Washington state. In an official statement released in 2006, State Health Officer Maxine Hayes said that the "Department of Health supports water fluoridation as a E sound population-based public health measure,and...supports communities inE their efforts to fluoridate community water.supplies." After 60 years of research, fluoridated water systems are continually proven to be i one of the best tools for communities to efficiently improve their overall oral health. Former U.S. Surgeon General Dr. C. Everett Koop called fluoridation "the single most important commitment that a community can make to the oralhealth of its citizens." It is my-hope-that the-City of Renton continue.to-provide its citizens this Dr,Rodney B.Wentworth valuable resource. t President The Washington State Dental Association has provided all Renton city Council. Dr.Danny G.WarnerThe with the American Dental Association's Fluoridation Facts Booklet.I President-elect encourage all council members to review the material in the book to gain a better [jr.David M.Minahan understanding of the truths and benefits of fluoridated water. Vice President Resp ctfully submitted, t Dr.Bryan C.Edgar ��/� Secretary-Treasurer 40,E /t./� ~' E Dr,Douglas P.Walsh Dr..Danny G. Warner ' 1 immediate Past President President Mr.Stephen A.-Hiardyrnon i Executive Director . COLLABOBATiON, youth King Council of human Services ao' _ rvPa�- Enhancing the quality,availability and accessibility of human services for South King County Joy �o°_ (206)462.6644 • www.skchs.org 4800 South 188th Street,Suite 232,SeaTac,WA 98188 CITY OF RENTON November 21, 2012 NOV 2 6 2.012 Renton City Council 1055 S.Grady Way RECEIVED Renton,WA 98057 CITY CLERK'S OFFICE Dear Councilmembers Briere, Corman, Palmer, Persson, Prince,Taylor and Zwicker: The South King Council of Human Services supports community water fluoridation because it is effective in preventing tooth decay and related negative health impacts, especially in low-income communities where other prevention services are less readily available. We ask the Renton City Council to ensure that this important health measure is not compromised in Renton. For over 25 years,South King Council of Human Services has worked to ensure that the people of South King County continue to have access to the basic building blocks of a strong society: health care, housing and human services. As a membership organization of nonprofit agencies, community leaders and concerned residents, we work to support one another cooperatively in building a strong safety net. We all know that there are precious few resources available to support safety net services in our communities right now,so when a significant measure to promote good health is also very cost-effective, we see it as a great benefit for everyone. Community water fluoridation saves$38 in dental care costs for every$1 invested. It also reduces tooth decay by 25 to 40 percent. Because it is available through the City's water system,fluoridation reduces the health disparities in tooth decay rates that exist by race, ethnicity and income. Tooth decay affects overall health for people of all ages. It interferes with a child's ability to eat, sleep and perform well in school. It can limit opportunities for employment and in life. For seniors, it can lead to poor nutrition and health complications. Many people end up seeking treatment for dental disease in hospital emergency rooms,which imposes higher health costs on everyone. Community water fluoridation has been studied for over 60 years and the evidence clearly shows that fluoride is safe and effective. We urge you to keep the residents of Renton among the nearly 205 million Americans who receive the health benefits of community water fluoridation. Sincerely,:' ' Nathan Phillips,SKCHS Director CITY OF RENTON NOV 262012. November 23, 2012 RECEIVED CITY CL RK'S OFFICE Renton City Council Olatid 1055 S. Grady Way Renton, WA 98057 ATTN: Terri Briere, Randy Corman, Marcie Palmer, Don Persson, Ed Prince, Greg Taylor and Rich Zwicker Dear Members of the City Council: Health is one of the most precious gifts of life. As a society and as leaders in our local communities, we should support efforts to promote better health. At Renton Area Youth & Family Services (RAYS), we strive to strengthen the lives of children, youth and families who are affected by conflict, substance abuse and poverty. We know that health is an important part of overcoming these challenges. We support community water fluoridation because it has been clearly shown over more than 60 years to provide significant oral health benefits to people of all ages. It is safe and effective, reducing tooth decay by as much as 40 percent. It is also extremely cost- effective, saving$38 in dental costs for every$1 invested in fluoridation, according to the national Centers for Disease Control and Prevention (CDC). Community water fluoridation is important because oral health has a significant impact on overall health. Young children with untreated tooth decay may have difficulty eating, sleeping and concentrating in school. Poor oral health can compromise the chances of success in life for anyone. We urge the City of Renton to continue to provide this important health benefit, which is available to everyone who utilizes the City's water system. Respectfully, (Dtegeh-4-1Z---- g10 L Richard Brooks, MA Executive Director Renton Area Youth and Family Services y 1 � 4 Renton Pediatric As ciates. PS 4 � y Stuart Shorr,MD,FAAP Connie Patulot,MD Linda Wiseman,MD,FAAP r v 4 MAP Nicole Lauinger,MD FAAP Daniel Friedman,MD FAAP C ' • - ,1 ‘0,14%,„ � %,„ Peyton Caunt,MD, g , l,' E,' ~� ��; "� Yass Moinpour,MD MAP Staci Scott,ARNP Shawna Hood,ARNP ,a ,' Ann Nelms,Practice Administrator CITY OF RENTON NOV 26 2012 November 20, 2012 RECEIVED Renton City Council CITY CLERK'S OFFICE 1055 S. Grady Way Renton, WA 98057 • Dear Council Members Briere, Zwicker, Prince, Persson, Palmer, Corman, and Taylor: I am a Board Certified Pediatrician. I have practiced in Renton since 1983 and in Tukwila before than since 1975. I have had the opportunity first hand to observe the improvement in children's dental health for those patients of mine who lived in the Renton community since the beginning of water fluoridation in the late 1980's. These children have had a significant reduction in cavities and other dental problems. At a time when more than 100 million Americans lack dental insurance, fluoridation offers an easy inexpensive strategy that benefits everyone. Fluoride toothpaste alone is insufficient to accomplish this goal. A 2010 survey of hospitals in Washington State found that dental disorders were the leading reason why uninsured patients visited Emergency Rooms. The American Academy of Pediatrics has noted that water fluoridation is a cost effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. I urge the council members to continue to support fluoridation for the Renton Community. This is a very important public health necessity. Thank you. Sincerely, Stuart S. Shorr, M.D. 4033 Talbot Rd S.,Suite 200 24837 104`h Ave SE,Ste#102 Renton,WA 98055 Kent,WA 98030 Phone: (425)271-5437 Fax: (425)656-4212 y:Valley Family . Medicine Residency CITY OF RENTON UW Medicine VALLEY NOV 2.6 2012 . MEDICAL,CENTER RECEIVED _._........ ... ..__. ,.� _ .CITY_CL-ERK'S'OFFICE ._—_.----- November —_— .November 15,2012 Renton City Council 1055 S.Grady Way Renton,WA 98057 • Dear Renton City Councilmembers, We are writing to express our support for community water fluoridation. It is an important public health measure that benefits everyone who drinks the water provided by the City of Renton. More than 60 years of scientific evidence clearly demonstrates that water fluoridation is safe and effective.Today, nearly two-thirds of Americans.,including the people of Renton,receive the proven health benefits of water fluoridation every day. Because it is available through the City's water system,community water fluoridation reduces the disparities in the rate of tooth decay that exist by income,race and ethnicity. Dental disease affects people of all ages. It interferes with a child's ability to eat,sleep and perform well in school. It can limit employment opportunities for-adults: And for seniors,dental disease can result in poor'nutrition and health complications. Dental disease can negatively impact overall health and too often,people end up seeking treatment for dental disease in hospital emergency rooms. The good news is that dental disease is preventable. Community water fluoridation is a proven,low-cost tool for preventing this disease across the entire population.Medical and health experts agree that community water fluoridation is beneficial and helps to promote good oral health. We urge you to protect the oral health and overall health of the residents of Renton by continuing to support water fluoridation. From the physicians of the Valley Family Medicine Clinic: ( -e://4/t14744 144, Z. 62— (Prk(4 4001444- 14----- Tony Pedro a,MD Dan Herman,MD Gary Kelsb D CO I ...A. C\--)3'.---- -IND (..... \_�C // i PO Jon Neher,M. Ginger Allen,MD Tanya Riz/o,MD r `lam oris,Rosellini,MDAII Jan Carlton,MD Teresa Wallace,MD .,., . Pw/e--( /- Jon Wooi Heather Rudisill,MD Belinda Fu,MD Residency Administration MIS VPC 401 3915 Talbot Rd.5,Suite 401 Renton,WA 98055 425.656.4287 FAX 425.656.5395 valleyfamilymedicine.org November 19,2012 Renton City Council Minutes Page 345 D-91: Accessory Dwelling Units Review—Amend code to limit the size of the Accessory Dwelling Units(ADUs)to either 800 square feet or 75%of the square footage of the primary unit,whichever is less. Also,to include ADUs in the calculation for maximum lot coverage and limit the height of ADUs to the same height as the primary dwelling unit. D-92: Hotel in Commercial Office—Amend the Renton Municipal Code to allow hotel uses in all areas zoned Commercial Office. D-93: Redevelopment and Existing Structures—Require existing dwellings in the R-10 and R-14 zones to comply with the Residential Design Guidelines and off-street parking requirements if they are retained as part of a new development. Amend the Residential Design Guidelines to provide clear and specific standards in the R-10 and R-14 zones. D-94: Technical Amendments—Make a series of amendments which do not change policies, but provide clarity and consistency to the Renton Municipal Code. The Committee further recommended that the ordinances regarding these matters be presented for first reading. MOVED BY PRINCE,SECONDED BY BRIERE,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Finance Committee Finance Committee Chair Briere presented a report recommending approval of Finance:Vouchers Claim Vouchers 316481-316997,five wire transfers and one payroll run with benefits withholding payments totaling$5,404,704.14, and payroll vouchers including 725 direct deposits and 61 payroll checks totaling$1,670,391.57. MOVED BY BRIERE,SECONDED BY TAYLOR,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. AUDIENCE COMMENT Audrey Adams(Renton) expressed appreciation for the opportunity to provide Citizen Comment:Adams— Council with information regarding water fluoridation at the next Committee of Water Fluoridation the Whole meeting. She submitted a book with three chapters highlighted regarding whether or not fluoride is safe for a developing brain. She noted that the Center for Disease Control (CDC) revealed that the Oral Health Division acted alone it its review of fluoridation. She explained that the claim that I fluoride is safe refers only to teeth and not to brains. She stated that new science has emerged in the past decade, and when science changes then policies must also change. NEW BUSINESS Council President Zwicker called for the nomination and election of the 2013 Council:2013 Council Council President and President Pro tern. President(Corman) & MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL ELECT COUNCILMEMBER President Pro Tern (Persson) • RANDY CORMAN AS THE 2013 COUNCIL PRESIDENT,AND COUNCILMEMBER Election DON PERSSON AS THE 2013 COUNCIL PRESIDENT PRO TEM. CARRIED. Councilmember Taylor abstained. Randy Corman was declared 2013 Council President,and Don Persson was declared 2013 Council President Pro tern. Council: Committee on MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL ANNOUNCE COMMITTEE Committees ON COMMITTEES MEMBERS AS COUNCIL PRESIDENT ZWICKER, PRESIDENT- ELECT CORMAN,AND PRESIDENT PRO TEM-ELECT PERSSON. CARRIED. November 5,2012 Renton City Council Minutes Page 334 Council: Nominations of 2013 Council President Zwicker remarked that under the New Business portion of the Council President and November 19 agenda Council will have the opportunity to announce President Pro Tern nominations for 2013 Council President and President Pro Tern. Community Events:Acacia Councilmember Taylor announced that he had the opportunity to attend the Foundation Event,Zambian Acacia Foundation Friendship Dinner that was established in 2005 in order to Independence Day enhance cross-cultural understanding,the Zambian Independence Day Celebration,Somali Youth and Celebration at the Renton Community Center,and the Gates Foundation Family Club Documentary Homeless Strategy Convening. He also noted that the Somali Youth and Family Presentation &Gates Club were able to present the second and final documentary showcasing their Foundation Homelessness community at Carco Theatre. Mr.Taylor explained that the club had received a Strategy Convening State Arts Commission grant to develop the two documentaries. Fire: First Response Vehicle MOVED BY BRIERE,SECONDED BY PERSSON,COUNCIL REFER THE TOPIC OF Options FIRE AND EMERGENCY FIRST RESPONSE VEHICLE OPTIONS TO THE PUBLIC SAFETY COMMITTEE. CARRIED. Public Safety:Valley Corn MOVED BY PERSSON,SECONDED BY ZWICKER, COUNCIL REFER THE TOPIC OF • CAD/Radio System Upgrades VALLEY COM CAD/RADIO SYSTEM UPGRADES TO THE PUBLIC SAFETY COMMITTEE. CARRIED. AUDIENCE COMMENT Audrey Adams (Renton) expressed appreciation for having been given an Citizen Comment:Water opportunity to provide a review on water fluoridation at the November 26 Fluoridation .(o A Committee of the Whole meeting. She thanked Council for not being close- l IVD1I a minded about the topic and noted that there will be an opportunity to hear tole ( both sides of the issue at the meeting. Ms.Adams remarked that a recent rp p� Harvard School of Public Health study reviewed 27 studies from around the world on fluoride's effect on brain development. She remarked that the overall determination was that there is a potential neurodevelopmental risk from exposure to fluoride. EXECUTIVE SESSION & MOVED BY ZWICKER,SECONDED BY CORMAN, COUNCIL RECESS INTO ADJOURNMENT EXECUTIVE SESSION FOR APPROXIMATELY 45 MINUTES TO DISCUSS LABOR NEGOTIATIONS (RCW 42.30.140.4.a.)AND PERSONNEL ISSUES(RCW 42.30.110.1.g.)WITH NO OFFICIAL ACTION TO BE TAKEN AND THAT THE COUNCIL MEETING BE ADJOURNED WHEN THE EXECUTIVE SESSION IS ADJOURNED. CARRIED. Time: 8:40 p.m. Executive session was conducted. There was no action taken. The executive session and the Council meeting adjourned at 9:25 p.m. • cdaGtr Bonnie I.Walton, CMC,City Clerk Jason Seth, Recorder November 5,2012 26-11."14 ". /a November 5, 2012 Renton City Council Subject: Harvard Study Finds Neurodevelopmental (Brain) Risk from Fluoride Dear Renton City Council members, Mayor Law and staff, I am very appreciative that the Committee of the Whole will be hearing the topic of water fluoridation on Monday, November 26 at 6:00pm and that Dr. Bill Osmunson will be addressing you for 15 minutes at this meeting. If this changes for any reason, please let me know. In preparation of this meeting, I have attached a new study from the Harvard School of Public Health. This 2012 study was published in the Environmental Health Perspectives,a division of the National Institute of Health. This study reviewed 27 studies from around the world on fluoride's effect on brain development. The Harvard researchers concluded that, "The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment"and said, "Thus,children in high-fluoride areas had significantly lower IQ scores than those who lived in low fluoride areas." Please ask those who promote fluoridation to provide you with scientific references to current published studies of equal caliber that show zero negative effect on IQ or brain development from fluoride. Endorsements,without rigorous and current science to back up claims of safety, is merely marketing. Endorsements,from any person,agency or entity, are not a substitute for scientific studies. Babies' brains are more important than teeth. To justify the addition of any drug or chemical to the water supply, no matter what the possible benefits might be---especially when tap water is unavoidable by the poor--the precautionary principle must supersede any policy mandate such as fluoridation in order to give the highest regard to the protection of brain development of fetuses and babies. "The precautionary principle...states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is harmful, the burden of proof that it is not harmful falls on those taking the action. This principle allows policy makers to make discretionary decisions in situations where there is the possibility of harm from taking a particular course or making a certain decision when extensive scientific knowledge on the matter is lacking."(Wikipedia) Sincerely and appreciatively, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 Review Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis Anna L. Choi,1 Guifan Sun,2 Ying Zhang,3 and Philippe Grandjean1' 1Department of Environmental Health,Harvard School of Public Health,Boston,Massachusetts,USA;2School of Public Health,China Medical University,Shenyang,China;'School of Stomatology,China Medical University,Shenyang,China;°Institute of Public Health, University of Southern Denmark,Odense,Denmark Registry 2003).Fluoride exposure to the devel- BACKGROUND:Although fluoride may cause neurotoxicity in animal models and acute fluoride oping brain,which is much more susceptible poisoning causes neurotoxicity in adults,very little is known of its effects on children's neuro- to injury caused by toxicants than is the mature development brain,may possibly lead to permanent damage OBJECTIVE:We performed a systematic review and meta-analysis of published studies to investigate (Grandjean and Landrigan 2006). In response the effects of increased fluoride exposure and delayed neurobehavioral development. to the recommendation of the NRC (2006), METHODS:We searched the MEDL1NE,EMBASE,Water Resources Abstracts,and TOXNET the U.S. Department of Health and Human databases through 2011 for eligible studies.We also searched the China National Knowledge Services (DHHS) and the U.S.EPA recently Infrastructure(CNKI)database,because many studies on fluoride neurotoxicity have been pub- announced that DHHS is proposing to change lished in Chinese journals only.In total,we identified 27 eligible epidemiological studies with high the recommended level of fluoride in drinking and reference exposures,end points of IQ scores,or related cognitive function measures with means water to 0.7 mg/L from the currently recom- and variances for the two exposure groups.Using random-effects models,we estimated the stan- mended range of 0.7-1.2 mg/L,and the U.S. dardized mean difference between exposed and reference groups across all studies.We conducted sensitivity analyses restricted to studies using the same outcome assessment and having drinking- EPA is reviewing the maximum amount of water fluoride as the only exposure.We performed the Cochran test for heterogeneity between stud- fluoride allowed in drinking water,which cur- ies,Begg's funnel plot,and Egger test to assess publication bias,and conducted meta-regressions to rently is set at 4.0 mg/L(U.S.EPA 2011). explore sources of variation in mean differences among the studies. To summarize the available literature, RESULTS:The standardized weighted mean difference in IQ score between exposed and reference we performed a systematic review and meta- populations was—0.45 (95% confidence interval:—0.56,—0.35)using a random-effects model. analysis of published studies on increased .Thus,children in high-fluoride areas had significantly lower IQ scores than those who lived in low- fluoride exposure in drinking water associated fluoride areas.Subgroup and sensitivity analyses also indicated inverse associations,although the with neurodevelopmental delays.We specifi- substantial heterogeneity did not appear to decrease. cally targeted studies carried out in rural CONCLUSIONS:The results support the possibility of an adverse effect of high fluoride exposure on China that have not been widely disseminated, children's neurodevelopment.Future research should include detailed individual-level information thus complementing the studies that have on prenatal exposure,neurobehavioral performance,and covariates for adjustment. been included in previous reviews and risk KEY WORDS: fluoride, intelligence,neurotoxicity.Environ Health Perspect 120:1362-1368 assessment reports. (2012). http://dx.doi.org/10.1289/ehp.1104912[Online 20 July 2012] Methods Search strategy. We searched MEDLINE A recent report from the National Research of fluoride from drinking water. Such cir- (National Library of Medicine,Bethesda,MD, Council (NRC 2006) concluded that adverse_ cumstances are difficult to find in many USA;http://www.ncbi.nlm.nih.gov/pubmed), effects of high fluoride concentrations in industrialized countries,because fluoride con- Embase (Elsevier B.V., Amsterdam, the drinking water may be of concern and that centrations in community water are usually Netherlands;http://www.embase.com),Water additional research is warranted.Fluoride may no higher than 1 mg/L, even when fluoride Resources Abstracts (Proquest,Ann Arbor, cause neurotoxicity in laboratory animals, is added to water supplies as a public health MI, USA; http://www.csa.com/factsheets/ including effects on learning and memory measure to reduce tooth decay.Multiple epi- water-resources-set-c.php), and TOXNET (Chioca et al.2008;Mullenix et al. 1995).A demiological studies of developmental fluo- (Toxicology Data Network;National Library recent experimental study where the rat hip- ride neurotoxicity were conducted in China of Medicine,Bethesda,MD,USA;http://tox- pocampal neurons were incubated with vari- because of the high fluoride concentrations net.nlm.nih.gov) databases to identify studies ous concentrations (20 mg/L, 40 mg/L, and that are substantially above 1 mg/L in well of drinking-water fluoride and neurodevel- 80 mg/L) of sodium fluoride in vitro showed water in many rural communities, although opmental outcomes in children. In addition, that fluoride neurotoxicity may target hip- microbiologically safe water has been acces- we searched the China National Knowledge pocampal neurons (Zhang M et al. 2008). sible to many rural households as a result of Infrastructure(CNKI; Beijing, China;http:// Although acute fluoride poisoning may be the recent 5-year plan (2001-2005) by the www.cnki.net) database to identify stud- neurotoxic to adults, most of the epidemio- Chinese government. It is projected that all ies published in Chinese journals only. Key logical information available on associations rural residents will have access to safe public with children's neurodevelopment is from drinking water by 2020 (World Bank 2006). Address correspondence to A.L.Choi,Department China, where fluoride generally occurs in However,results of the published studies have of Environmental Health,Harvard School of Public drinking water as a natural contaminant,and not been widely disseminated. Four studies Health,Landmark Center 3E,401 Park Dr.,Boston, the concentration depends on local geologi- published in English(Li XS et al. 1995; Lu MA)02215 USA.Telephone:(617) Fax: (617)384-8994.E-mail:achoi@hsph.harvard.edu cal conditions. In many rural communities et al. 2000;Xiang et al. 2003; Zhao et al. Supplemental Material is available online(http:// in China, populations with high exposure to 1996) were cited in a recent report from the dx.doLorg/10.1289/ehp.1104912). fluoride in local drinking-water sources may NRC (2006), whereas the World Health We thank V.Malik,Harvard School ofPublic Health, reside in close proximity to populations with- Organization (2002)has considered only two for the helpful advice on the mem-analysis methods. out high exposure(NRC 2006). (Li XS et al. 1995; Zhao et al. 1996) in its This study was supported by internal institutional Opportunities for epidemiological stud- most recent monograph on fluoride. funds. The authors declare they have no actual or potential ies depend on the existence of comparable Fluoride readily crosses the placenta competing financial interests. population groups exposed to different levels (Agency for Toxic Substances and Disease Received 30 December 2011;accepted 20 July 2012. 1362 VOLUME 1201 NUMBER 10 I October 2012 • Environmental Health Perspectives Fluoride neurotoxicity 4F' words included combinations of"fluoride"or study)to heterogeneity among the studies.The Wechsler Intelligence tests(3 studies;An et al. "drinking water fluoride," "children," "neu- scoring standard for the Combined Raven's 1992;Ren et al. 1989;Wang ZH et al. 1996), rodevelopment" or"neurologic" or"intelli- Test—The Rural edition in China(CRT-RC) Binet IQ test(2 studies; Guo et at 1991;Xu gence"or"IQ."We also used references cited test classifies scores of_< 69 and 70-79 as et al. 1994),Raven's test(2 studies;Poureslami in the articles identified.We searched records low and marginal intelligence, respectively et al. 2011; Seraj et al. 2006),Japan IQ test for 1980-2011. Our literature search iden- (Wang D et al. 1989). We also used the (2 studies; Sun et al. 1991; Zhang JW et al. tified 39 studies, among which 36.(92.3%) random-effects models to estimate risk ratios 1998), Chinese comparative intelligence test were studies with high and reference expo- for the association between fluoride exposure (1 study; Yang et al. 1994), and the mental sure groups, and 3 (7.7%) studies were based and a low/marginal versus normal Raven's test work capacity index(1 study;Li Yet al. 1994). on individual-level measure of exposures.The score among children in studies that used the Because each of the intelligence tests used is latter showed that dose-related deficits were CRT-RC test (Wang D et al. 1989). Scores designed to measure general intelligence,we found, but the studies were excluded because indicating low and marginal intelligence(5 69 used data from all eligible studies to estimate our meta-analysis focused on studies with the and 70-79, respectively) were combined as the possible effects of fluoride exposure on high-and low-exposure groups only. In addi- a single outcome due to small numbers of general intelligence. tion, two studies were published twice, and children in each outcome subgroup. In addition, we conducted a sensitivity the duplicates were excluded. analysis restricted to studies that used similar Inclusion criteria and data extraction. Results tests to measure the outcome (specifically, the The criteria for inclusion of studies included Six of the 34 studies identified were exduded CRT-RC,Wechsler Intelligence test,Binet IQ studies with high and reference fluoride expo- because of missing information on the num- test,or Raven's test),and an analysis restricted sures,end points of IQ scores or other related ber of subjects or the mean and variance of the to studies that used the CRT-RC. We also cognitive function measures,presentation of a outcome[see Figure 1 for a study selection flow performed an analysis that excluded studies mean outcome measure, and associated mea- chart and Supplemental Material, Table S1 with co-exposures including iodine and arsenic, sure of variance [95% confidence intervals (http://dx.doi.org/10.1289/ehp.1104912)for or with non-drinking-water fluoride exposure (CIs) or SEs and numbers of participants]. additional information on studies that were from coal burning. Interpretations of statistical significance are excluded from the analysis]. Another study Pooled SMD estimates. Among the based on an alpha level of 0.05. Information (Trivedi et al. 2007) was excluded because 27 studies, all but one study showed included for each study also included the first SDs reported for the outcome parameter were random-effect SMD estimates that indicated author,location of the study,year of publica- questionably small (1.13 for the high-fluoride an inverse association, ranging from—0.95 tion, and numbers of participants in high- group, and 1.23 for the low-fluoride group) (95% CI:—1.16,—0.75) to—0.10 (95% CI: fluoride and low-fluoride areas.We noted and and the SMD (-10.8; 95%CI:—11.9,—9.6) recorded the information on age and sex of was> 10 times lower than the second small- Total abstracts identified children, and parental education and income est SMD (-0.95; 95% CI:—1.16,—0.75)and from literature search if available. 150 times lower than the largest SMD (0.07; (n=39) Statistical analysis. We used STATA 95%CI:—0.083,0.22)reported for the other (version 11.0;StataCorp,College Station,TX, studies,which had relatively consistent SMD USA) and available commands (Stern 2009) estimates.Inclusion of this study in the meta- Duplicate records for the meta-analyses.A standardized weighted analysis resulted with a much smaller pooled removed mean difference (SMD)was computed using random-effects SMD estimate and a much (n=2) both fixed-effects and random-effects models. larger 12 (-0.63; 95% CI: —0.83, —0.44, I2 The fixed-effects model uses the Mantel— 94.1%) compared with the estimates that Studies excluded Haenszel method assuming homogeneity excluded this study(-0.45; 95% CI:—0.56, because they did not among the studies, whereas the random- —0.34,12 80%) (see Supplemental Material, meet inclusion criteria effects model uses the DerSimonian and Laird Figure S1). Characteristics of the 27 studies In=3) method, incorporating both a within-study included are shown in Table 1 (An et al. 1992; and an additive between-studies component of Chen et al. 1991; Fan et al.2007; Guo,et al. variance when there is between-study hetero- 1991;Hong et al.2001;Li FH et al.2009;Li Studies for retrieval of geneity(Egger et al 2001).The estimate of the X-I et al.2010;Li XS 1995;Li Yet al. 1994; detailed information between-study variation is incorporated into Li Yet aL 2003;Lin et al.1991;Lu et at 2000; (n=34) both the SE of the estimate of the common Poureslami et al. 2011;Ren et al. 1989;Seraj effect and the weight of individual studies, et al. 2006; Sun et al. 1991; Wang G et al. which was calculated as the inverse sum of 1996;WangSH et al.2001;WangSX et al. Studies with > missing information the within and between study variance.We 2007;Wang ZH et at 2006;Xiang et al.2003; on outcomes evaluated heterogeneity among studies using Xu et al. 1994; Yang et al. 1994;Yao et al. (n=6) the F statistic,which represents the percentage 1996,1997;Zhang JW et at 1998;Zhao et al. of total variation across all studies due to 1996).Two of the studies included in the anal- Studies excluded due between-study heterogeneity (Higgins and ysis were conducted in Iran(Poureslami et al. > to questionably small Thompson 2002).We evaluated the potential 2011;Seraj et al.2006);the other study cohorts standard deviations for publication bias using Begg and Egger were populations from China. Two cohorts (O=1) tests and visual inspection of a Begg funnel were exposed to fluoride from coal burning plot (Be :yand Mazumdar 1994;Egger et al. (Guo et al. 1991;Li XH et al.2010);otherwise Studies included in 1997).We also conducted independent meta- populations were exposed to fluoride through meta-analysis regressions to estimate the contribution of drinking water. The CRT-RC was used to (°=27) study characteristics (mean age in years from measure the children's intelligence in 16 stud- the age range and year of publication in each ies. Other intelligence measures included the Figure 1.Flow diagram of the meta-analysis. Environmental Health Perspectives • VOLUME 120 1 NUMBER 101 October 2012 1363 ,r ny aF' ic 'or.-' Choi el al. -0.25, 0.04) (Figure 2). The study with a although the difference did not appear to be the two covariates. The overall test of the positive association reported an SMD esti- significant.Heterogeneity,however,remained covariates was significant(p=0.004). mate of 0.07 (95% CI:-0.8, 0.22). Similar at a similar magnitude when the analyses were When the model was restricted to the results were found with the fixed-effects SMD restricted(Table 2). 16 studies that used the CRT-RC,the child's estimates. The fixed-effects pooled SMD Sources of heterogeneity. We performed age(but not year of publication)was a signifi- estimate was-0.40 (95% CI: -0.44,-0.35), meta-regression models to assess study char- cant predictor of the SMD.The R2 of 65.6% with a p-value<0.001 for the test for homo- acteristics as potential predictors of effect. of between-study variance was explained by geneity. The random-effects SMD estimate Information on the child's sex and paren- the two covariates, and only 47.3% of the was-0.45 (95% CI:-0.56, -0.34) with an tal education were not reported in > 80% residual variation was attributable to hetero- /2 of 80% and homogeneity test p-value of the studies, and only 7% of the studies geneity. The overall test of both covariates in < 0.001 (Figure 2). Because of heterogeneity reported household income. These variables the model remained significant(p= 0.0053). (excess variability) between study results,we were therefore not included in the models. On further restriction of the model to exclude used primarily the random-effects model for Among the two covariates, year of publica- the 7 studies with arsenic and iodine as co- subsequent sensitivity analyses,which is gen- tion (0.02; 95% CI: 0.006, 0.03), but not exposures and fluoride originating from coal erally considered to be the more conserva- mean age of the study children (-0.02; 95% burning(thus including only the 9 with fluo- tive method (Egger et al. 2001).Among the CI:-0.094, 0.04),was a significant predictor ride exposure from drinking water), neither restricted sets of intelligence tests, the SMD in the model with all 27 studies included. /2 age nor year of publication was a significant for the model with only CRT-RC tests and residual 68:7% represented the proportion predictor,and the overall test of covariates was drinking-water exposure (and to a lesser of residual between-study variation due to less important(p=0.062),in accordance with extent the model with only CRT-RC tests) heterogeneity. From the adjusted R2, 39.8% the similarity of intelligence test outcomes and was lower than that for all studies combined, of between-study variance was explained by the source of exposure in the studies included. Table 1.Characteristics of epidemiological studies of fluoride exposure and children's cognitive outcomes. No.in high- No.in Age Study exposure reference range Fluoride exposure Outcome Reference location group group (years) Assessment Range measure Results Ren et al. Shandong, 160 169 8-14 High-/ Not specified Wechsler Children in high-fluoride region had lower IQ scores 1969 China low-fluoride Intelligence villages testa Chen et al. Shanxi, 320 320 7-14 Drinking 4.55 mg/L(high); CRT-RCb The average IQ of children from high-fluoride area 1991 China water 0.89 mg/L(reference) were lower than that of the reference area Guo et al. Hunan, 60 61 7-13 Fluoride in 118.1-1361.7 mg/kg Chinese Average IQ in fluoride coal-burning area was lower . 1991 China coal burning (coal burning area); Binete than that in the reference area Control area used wood Lin et al. Xinjiang, 33 86 7-14 Drinking 0.88 mg/L(high); CRT-RCb Children in the high-fluoride(low-iodine)area had 1991 China water 0.34 mg/L(reference) lower IQ scores compared with the children from the reference fluoride(low-iodine)areas Sun et al. Guiyang, 196 224 ' 6.5-12 Rate of Fluorosis:98.36% Japan 10 Mean I0 was lower in all age groups except s 7 years 1991 China fluorosis (high);not specified testa in the area with high fluoride and aluminum(limited • (reference) to high-fluoride population only) An et al. Inner 121 121 7-16 Drinking 2.1-7.6 mg/L(high); Wechsler IQ scores of children in high-fluoride areas were 1992 Mongolia, water 0.6-1.0 mg/L Intelligence significantly lower than those of children living in China (reference) testa reference fluoride area Li Yet al. Sichuan, 106 49 12-13 Burning of 4.7-31.6 mg/kg(high); Child Early,prolonged high fluoride intake causes a 1994 China high-fluoride 0.5 mg/kg(reference) mental work decrease in the child's mental work capacity coal to cook capacity grain in high- fluoride area Xu et al. Shandong, 97 32 8-14 Drinking 1.8 mg/L(high); Binet- Children had lower IQ scores in high-fluoride area 1994 China water 0.8 mg/L(reference) Simone than those who lived in the reference area. Yang et al. Shandong. 30 30 8-14 Well water 2.97 mg/L(high); Chinese The average 10 scores was lower in children from 1994 China 0.5 mg/L(reference) comparative high-fluoride and-iodine area than those from the intelligence reference area,but the results were not significant testi Li XS et al. Guizhou, 681 226 8-13 Urine,Dental 1.81-2.69 mg/L(high); CRT-RCb Children living in fluorosis areas had lower 111 scores 1995 China Fluorosis 1.02 mg/L(reference); than children living in nonfluorosis areas Index DFI 0.8-3.2(high); DR<0.4(reference) Wang G Xinjiang, 147 83 4-7 Drinking >1.0-8.6 mg/L(high); Wechsler Average IQ score was lower in children in the high- et al.1996 China water 0.58-1.0 mg/L Intelligence fluoride group than those in the reference group (reference) testa Yao et al. Liaoning, 266 270 8-12 Drinking 2-11 mg/L(high); CRT-RCb Average IQ scores of children residing in exposed fluoride 1996 China water 1 mg/L(reference) areas were lower than those in the reference area Zhao et al. Shanxi, 160 160 7-14 Drinking 4.12 mg/L(high); CRT-RCb Children living in high-fluoride and-arsenic area had 1996 China water 0.91 mg/L(reference) significantly lower 10scores than those living in the reference fluoride(and no arsenic)area Yao et al. Liaoning, 188 314 7-14 Drinking 2 mg/L(exposed); CRT-RCb 10 scores of children in the high-fluoride area were 1997 China water 0.4 mg/L(reference) lower than those of children in the reference area Continued 1364 VOLUME 1201 NUMBER 10 I October 2012 • Environmental Health Perspectives Fluoride neurotoxicity ' L'4t Although official reports of lead concentra- tests did not indicate significant (p < 0.05) Discussion tions in the study villages in China were not departures from symmetry. Findings from our meta-analyses of 27 stud- available,some studies reported high percent- Pooled risk ratios. The relative risk (RR) ies published over 22 years suggest an inverse age (95-100%) of low lead exposure (less of a low/marginal score on the CRT-RC test association between high fluoride exposure and than the standard of 0.01 mg/L) in drinking- (< 80) among children with high fluoride children's intelligence. Children who lived in water samples in villages from several study exposure compared with those with low areas with high fluoride exposure had lower IQ provinces (Bi et al. 2010; Peng et al. 2008; exposure(16 studies total)was 1.93 (95%CI: scores than those who lived in low-exposure or Sun 2010). 1.46, 2.55;P 58.5%).When the model was control areas.Our findings are consistent with Publication bias. A Begg's funnel plot restricted to 9 studies that used the CRT-RC an earlier review(Tang et al. 2008),although with the SE of SMD from each study plotted and included only drinking-water fluoride ours more systematically addressed study selec- against its corresponding SMD did not show exposure (Chen et al. 1991; Fan et al. 2007; tion and exclusion information, and was more clear evidence of asymmetry, although two Li XH et al. 2010; Li XS et al. 1995; Li Y comprehensive in a) including 9 additional studies with a large SE also reported relatively et al. 2003; Lu et al.2000;Wang ZH et at studies, b)performing meta-regression to esti- large effect estimates,which may be consis- 2006;Yao et al. 1996, 1997),the estimate was mate the contribution of study characteristics tent with publication bias or heterogeneity similar (RR= 1.75; 95% CI: 1.16, 2.65; P as sources of heterogeneity, and c) estimating (Figure 3). The plot appears symmetrical for 70.6%).Although fluoride exposure showed pooled risk ratios for the association between studies with larger SE, but with substantial inverse associations with test scores, the fluoride exposure and a low/marginal Raven's variation in SMD among the more precise available exposure information did not allow test score. studies, consistent with the heterogeneity a formal dose-response analysis. However, As noted by the NRC committee (NRC observed among the studies included in the dose-related differences in test scores occurred at 2006), assessments of fluoride safety have analysis.Begg(p=0.22)and Egger(p=0.11) a wide range of water-fluoride concentrations. relied on incomplete information on potential Table 1.Continued. No.in high- No.in Age Study exposure reference range Fluoride exposure Outcome Reference location group group (years) Assessment Range measure Results Zhang JW Xinjiang, 51 52 4-10 Drinking Not specified Japan IQ Average IQ scores of children residing in high-fluoride et al.1998 China water Test"' and-arsenic area were lower than those who resided in the reference area . Lu et al. Tianjin, 60 58 10-12 Drinking 3.15 mg/L(high); CRT-RC" Children in the high-fluoride area scored significantly 2000 China water 0.37 mg/L(reference) lower IQ scores than those in the reference area Hong et al. Shandong, 85 32 8-14 Drinking 2.90 mg/L(high); CRT-RC" Average ID scores were significantly lower in high- 2001 China water 0.75 mg/L(reference) fluoride group(and-iodine)than the reference group Wang SH Shandong, 30 30 8-12 Drinking 2.97 mg/L(high); CRT-RCb No significant difference in IQ scores of children in et al.2001 China water 0.5 mg/L(reference) the high-fluoride/high-iodine and reference fluoride/ low-iodine areas Li Yet al. Inner 720 236 6-13 Fluorosis Endemic vs.control CRT-RC" Average IQ of children in high-fluorosis area was 2003 Mongolia, regions defined by the lower than that in the reference area China Chinese Geological Office Xiang et al. Jiangsu, 222 290 8-13 Drinking 0.57-4.5 mg/L(high); CRT-RC" Mean ID score was significantly lower in children who 2003 China water 0.18-0.76 mg/L lived in the high-fluoride area than that of children (reference) in the reference exposure area(both areas also had arsenic exposure) Seraj et al. Tehran, 41 85 Not Drinking 2.5 mg/L(high); Raven9 The mean ID of children in the high-fluoride area 2006 Iran specified water 0.4 mg/L(reference) was significantly lower than that from the reference fluoride area Wang ZH Shanxi, 202 166 8-12 Drinking 5.54±3.88 mg/L CRT-RCb The IQ scores of children in the high-fluoride group et al.2006 China water (high);0.73±0.2B were significantly lower than those in the reference mg/L(reference) group Fan et al Shaanxi, 42 37 7-14 Drinking 1.14-6.09 mg/L(high); CRT-RCb The average IQ scores of children residing in the 2007 China water 1.33-2.35 mg/L high-fluoride area were lower than those of children (reference) residing in the reference area Wang SX Shanxi, 253 196 8-12 Drinking 3.8-11.5 mg/L(water,high); CRT-RCb Mean ID scores were significantly lower in the high- et al.2007 China water and 1.6-11 mg/L(urine,high); fluoride group than from the reference group in the urine 0.2-1.1 mg/L(water, fluoride/arsenic areas reference); 0.4-3.9 mg/L(urine, reference) Li et al. Hunan, 60 20 8-12 Coal burning 1.24-2.34 mg/L(high); CRT-RC" Mean ID was lower in children in coal-burning areas 2009 China 0.962 mg/L(reference) compared to those in the reference group Li FH et al. Henan, 347 329 7-10 Drinking 2.47±0.75 mg/L(high) CRT-RC" No significant difference in IQ scores between 2010 China water children in the exposed and reference groups Poureslami Iran 59 60 6-9 Drinking 2.38 mg/L(high); Raven9 Children in the high-fluoride group scored significantly et al.2011 Water 0.41 mg/L(reference) lower than those in reference group aWechsler Intelligence Scale(Lin and Zhang 1986)."CRT-RC,Chinese Standardized Raven Test,rural version(Wang G et a1.1989).'Chinese Binet Test(Wu 1936)."Japan test(Zhang J et al.1985).9Binet-Simon Test(Binet and Simon 1922).(Chinese comparative intelligence test(Wu 1983).9Raven test(Raven et al.2003). Environmental Health Perspectives • VOLUME 120 1 NUMBER 10 I October 2012 1365 4. , ,4r Choi et al. risks. In regard to developmental neuro- difference was not significant. The exposed development at exposures much below those toxicity, much information has in fact been groups had access to drinking water with fluo- that can cause toxicity in adults (Grandjean published, although mainly as short reports ride concentrations up to 11.5 mg/L (Wang 1982). For neurotoxicants such as lead and in Chinese that have not been available to SX et al. 2007); thus, in many cases concen- methylmercury, adverse effects are asso- most expert committees.We carried out an trations were above the levels recommended ciated with blood concentrations as low as extensive review that includes epidemiological (0.7-1.2 mg/L; DHHS) or allowed in pub- 10 nmol/L. Serum fluoride concentrations studies carried out in China.Although most lic drinking water (4.0 mg/L; U.S. EPA) in associated with high intakes from drinking reports were fairly brief and complete informa- the United States (U.S.EPA 2011).A recent water may exceed 1 mg/L, or 50 µmol/L- don on covariates was not available,the results cross-sectional study based on individual-level more than 1,000 times the levels of some other tended to support the potential for fluoride- measure of exposures suggested that low lev- neurotoxicants that cause neurodevelopmental mediated developmental neurotoxicity at rela- els of water fluoride(range,0.24-2.84 mg/L) damage. Supporting the plausibility of our tively high levels of exposure in some studies. had significant negative associations with chil- findings, rats exposed to 1 ppm (50 pmol/L) We did not find conclusive evidence of publi- dren's intelligence (Ding et al. 2011). This of water fluoride for 1 year showed morpho- cation bias,although there was substantial het- study was not included in our meta-analysis, logical alterations in the brain and increased erogeneity among studies.Drinking water may which focused only on studies with exposed levels of aluminum in brain tissue compared contain other neurotoxicants,such as arsenic, and reference groups,thereby precluding esti- with controls(Varner et al. 1998). but exclusion of studies including arsenic and mation of dose-related effects. The estimated decrease in average IQ asso- iodine as co-exposures in a sensitivity analy- The results suggest that fluoride may be a ciated with fluoride exposure based on our sis resulted in a lower estimate, although the developmental neurotoxicant that affects brain analysis may seem small and may be within the measurement error of IQ testing.However,as Study Location SMD(95%CI) %Weight research on other neurotoxicants has shown,a Ren et al.1989 Shandong -; -0.75(-0.97,-0.52) 4.22 shift to the left of IQ distributions in a popu- Chen et a1.1991 Shanxi '--- -0.261-0.41,-0.10) 4.66 lation will have substantial impacts, especially Guo et a1.1991 Hunan • ii'. -- -0.44(-0.80,4.08) 3.26 among those in the high and low ranges of the Lin et a1.1991 Xinjiang :_:... -0.64(-1.01,-028) 3.23 Sun et al.1991 Guiyang -0.95(-1.16,-0.75) 4.36 IQ distribution(Bellinger 2007). An et a1.1992 I Mongoliai -0.57(4.83,-0.31) 3.98 Our review cannot be used to derive an Li Y et al.1994 Sichuan -0.40(-0.74,-0.06) 3.39 exposure limit, because the actual exposures Xu et al.1994 Shandong 3. -0.93(-1.35,-0.52) 291 of the individual children are not known. Yang et a1.1994 Shandong :: -0.50(-1.01,0.02) 2.36 Li XS et a1.1995 Guizhou -0.55(-0.70,-0.39) 4.68 Misclassification of children in both high- Wang 0 et a1.1996 Xinjiang -0.38(-0.65,-0.10) 3.88 and low-exposure groups may have occurred Yao et al.1996 Liaoning -0.34(-0.51,-0.17) 4.57 if the children were drinking water from other Zhao et al.1996 Shanxi .:' -0.54(-0.76,-0.31) 4.22 sources(e.g.,at school or in the field). Yao et a1.1997 Liaoning • -#.= -0.431-0.61,-025) 4.49 Zhang JW et a1.1998 Xinjiang -0.17(-0.55,0.22) 3.09 The published reports clearly represent Lu et a1.2000 Tianjin --T- -0.621-0.98,-0.25) 320 independent studies and are not the result Hong et al.2001 Shandong -0.44(-0.85,-0.03) 2.94 of duplicate publication of the same studies Wang SH et a1.2001 Shandong 4 -0.50(-1.01,0.02) 236 Li Y et al.2003 !Mongolia rg -0.101-0.25,0.04) 4.71 (we removed two duplicates). Several studies Xiang et al.2003 Jiangsu -.- , -0.64(-0.82,-0.46) 4.52 (Hong et al.2001;Lin et al. 1991;Wang SH Seraj et al.2006 Tehran -� • -0.89(-1.28,-0.50) 3.08 et al.2001;Wang SX et al.2007;Xiang et al. Wang ZH et al.2006 Shanxi -0.27(-0.47,-0.06) 434 Fan et a1.2007 Shaanxi f -0.17(-0.61,0.27) 2.75 2003; Zhao et al. 1996) report other expo- Wang SX et al.2007 Shanxi --LE- -0.26(-0.44,-0.07) 4.46 sures, such as iodine and arsenic, a neuro- Li FH et al.2009 Hunan if -0.43(-0.94,0.08) 2.38 toxicant, but our sensitivity analyses showed Li XH et al.2010 Henan g 0.07(-0.08,0.22) 4.69 similar associations between high fluoride Poureslami et a1.2011 Iran -0.41(-0.77,-0.04) 3.25 exposure and the outcomes even after these Overall(12=80.0%,p=0.000) <> -0.45(-0.56,-0.34) 100.00 studies were excluded.Large tracts of China 1 I I I -1.5 -1 0 0.5 1 0 Figure 2.Random-effect standardized weighted mean difference(SMD)estimates and 95%Cls of child's intelligence score associated with high exposure to fluoride.SMs for individual studies are shown as solid 0.05 • diamonds(•),and the pooled SMD is shown as an open diamond(0).Horizontal lines represent 95%Cls c 0.10 ° ° ,a ° 0 �, 0 0 for the study-specific SMDs. w 0 ,/o° ° 0.15 ° Table 2.Sensitivity analyses of pooled random-effects standardized weighted mean difference(SMD) co o • estimates of child's intelligence score with high exposure of fluoride. 0.20 00 0 ° 0 Available p-Value 025 studies for test of ° ° Model analysis SMD(95%Cl) /2 heterogeneity -1 -0.5 0 1.Exclude nonstandardized testsa 23 -0.44(-0.54,-0.33) 77.6% <0.001 SMD 2.Exclude non-CRT-RC Testsb 16 -0.36(-0.48,-0.25) 77.8% <0.001 Figure 3. Begg's funnel plot showing individual 3.Exclude studies with other exposures(iodine,arsenic)° 9 -0.29(-0.44,-0.14) 81.8% <0.001 studies included in the analysis according to or non-drinking-water fluoride exposures random-effect standardized weighted mean differ- °Mental work capacity(Li Y et al.1994);Japan IQ(Sun et al.1991;Zhang JW et al.1998);Chinese comparative scale ence(SMD)estimates(x-axis)and the SE(se)of of intelligence test(Yang et al.1994).bWechsler intelligence test(An et al.1992;Ren et al.1989;Wang G et al.1996); each study-specific SMD(y-axis).The solid verti Chinese Binet ID(Guo et al.1991);Raven(Poureslami et al.2011;Seraj et at 2005);Binet-Simon(Xu et al.1994).'Iodine cal line indicates the pooled SMD estimate for all (Hong et al.2001;Lin et al.1991;Wang SH et al.2001);arsenic[Wang SX et al.2007;Xiang et al.2003;Zhao et al.1996; studies combined and the dashed lines indicated (Zhang JW et at 1998 was already excluded,see note a)].°Fluoride from coal burning[Li FH et al.2009(Guo et at 1991 pseudo 95%confidence limits around the pooled and Li V et a1.1994 were already excluded;see notes a and b)]. SMD estimate. 1366 VOLUME 120 I NUMBER 10 1 October 2012 • Environmental Health Perspectives 'i t"f a7 ar Fluoride neurotoxicity .,r 2;_ have superficial fluoride-rich minerals with Prevention 1999;Petersen and Lennon 2004), Higgins JP,Thompson SG.2002.Quantifying heterogeneity in a little, if any,likelihood of contamination by the NRC report examined the potential meta-analysis.Stat Med 21:1539-1558. • other neurotoxicants that would be associ- adverse effects of fluoride at 2-4 mg/L Hong F,Cao Y,Yang D,Wang H.2001.A study of fluorine g effects on children's intelligence development under ated with fluoride concentrations in drinking in drinking water and not the benefits or different environments.Chin Prim Health Care 15:56-57. water. From the geographic distribution of potential risks that may occur when fluoride Available:htp://www.fluoridealertorg/chinese/[accessed 20 August 2012]. the studies, it seems unlikely that fluoride- is added to public water supplies at lower Li FH,Chen X,Huang RJ,Xie YP.2009.Intelligence impact of attributed neurotoxicity could be attributable concentrations(0.7-1.2 mg/L)(NRC 2006). children with endemic fluorosis caused by fluoride from to other water contaminants. In conclusion,our results support the possi- coal burning[in Chinese].J Environ Health 26(4):338-340. Still, each of the articles reviewed had bility of adverse effects of fluoride exposures on Li XH,Hou GQ,Vu B,Yuan s,Liu Y,zi L,et al.2010. Investigation and analysis of children's intelligence and deficiencies,in some cases rather serious ones, children's neurodevelopment.Future research dental fluorosis in high fluoride area[in Chinese].J Med that limit the conclusions that can be drawn. should formally evaluate dose-response rela- Pest Control 26(31:230-231. However, most deficiencies relate to the dons based on individual-level measures of uXS,Zhi JL Gao R0.1995.Effect of fluoride exposure on Intel)i- • gence in children.Fluoride 28(41:189-192. reporting of where key information was miss- exposure over time, including more precise Li Y,Jing X,Chen D,in L,Wang Z.2003.The effects of endemic ing. The fact that some aspects of the study - prenatal exposure assessment and more eaten- fluoride poisoning on the intellectual development of children were not reported limits the extent to which sive standardized measures of neurobehavioral in Baotou.Chin J Public Health Manag 19(4[:337-338. Available:http://www.fluoridealert.org/Chinese/[accessed the available reports allow a firm conclusion. performance, in addition to improving assess- 20 August 2012]. Some methodological limitations were also ment and control of potential confounders. Li Y,Li X,Wei S.1994.Effect of excessive fluoride intake on noted. Most studies were cross-sectional, but mental work capacity of children and a preliminary study of its mechanism.J West China Univ Med Sci 25(2[:188-191. this study design would seem appropriate REFERENCES Available:http:l/www.fluoridealert.org/chinese/[accessed in a stable population where water supplies 20 August 2012]. and fluoride concentrations have remained Agency for Toxic Substances and Disease Registry.2003. Lin C,Zhang H.1986.Wechsler Children Intelligence Scale.Revised Toxicological Profile for Fluorides,Hydrogen Fluoride,and Edition in China.Beijing:Beijing Normal University Press. unchanged for many years.The current water Fluorine(Update).Available:http://www.atsdr.cdc.gov/ Lin FF,Ai HT,Zhao HX,Lin J,Jhiang JY,Maimaiti,et al.1991. fluoride level likely also reflects past develop- toxprofiles/tpll.pdf[accessed 5 April 2010]. High fluoride and low iodine environment and subclinical mental exposures.In regard to the outcomes, An JA,Mei SZ,Liu AP,Fu Y,Wang CF.1992.Effect of high level cretinism in Xinjiang[in Chinese].Endem Dis Bull 6[21:62-67. of fluoride on children's intelligence[in Chinese].Chin J Lu Y,Sun ZR,Wu LN,Wang X,Lu W,Liu SS.et a1.2000.Effect of the inverse associationersisted between stud- Control Endem Dis 7(21:93-94. high-fluoride water on intelligence in children[in Chinese]. ies using different intelligence tests, although Begg CB,Mazumdar M.1994.Operating characteristics of Fluoride 33121:74-78. most studies did not report age adjustment of a rank correlation test for publication bias.Biometrics Mullenix PJ,Denbesten PK,Schunior A,Kernan WJ.1995. the co tive test scores. 50:1086-1101. Neurotoxicity of sodium fluoride in rats.Neurotoxicol Bellinger DC.2007.Interpretation of small effect sizes in occu- Teratol 17:169-177. • Fluoride has received much attention in national and environmental neurotoxicity:individual ver- NRC(National Research Council).2006.Fluoride in Drinking China, where widespread dental fluorosis sus population risk.Neurotoxicology 28245-251. Water:A Scientific Review of EPA's Standards.Washington, Bi WJ,Zheng X,Lan TX.2010.Analysis on test results of drink- DC:National Academies Press. indicates the prevalence of high exposures. ing water's quality in Janan Railway Bureau from 2005- Peng YP,Zou J,Yang OF,Li XH,Wu K.2008.Analysis of water In 2008, the Ministry of Health reported 2009[in Chinese].Prey Med Trib 16(61:463-485. quality from homemade wells in Leshan downtown that fluorosis was found in 28 provinces with Binet A,Simon T.1922.The Measurement of the Mental during 2004-2006[in Chinese].J Occup Health Damage. Development of the Child(translated into Chinese by Jie 23(41:219-221. 92 million residents (China News 2008). FP).Shanghai:Commercial Press. Petersen PE,Lennon MA.2004.Effective use of fluorides for the Although microbiologically safe, water sup- Centers for Disease Control and Prevention.1999.Achievements prevention of dental caries in the 21st century.the WHO plies from small springs or mountain sources in public health,1990-1999:fluoridation of drinking water to approach.Community Dent Oral Epidem 32(51:319-321. created pockets of increased exposures near prevent dental caries.MMWR 48(41[:933-940. Poureslami HR,Horri A,Atash R.2011.High fluoride exposure Chen YX,Han F,Zhou Z,Zhang H,Jiao X,Zhang S,et al.1991. in drinking water:effect on children's IQ,one new report or within areas of low re-exposures, thus rep highIntJ Pedlar Dent21(suppl 11:47. P P Research on intellectual development children in senting exposure settings close to the ideal, fluoride areas.Chin J Control Endem Dis 6(suppl):99-100. Raven J,Raven.IC,Court JH.2003.Manual for Raven's because only the fluoride exposure would dif- Available:http://www.fluoridealertorg/chinese/[accessed Progressive Matrices and Vocabulary Scales.San Antonio, 20 August2012]. TX:Harcourt Assessment. fer between nearby neighborhoods. Chinese China News.2008.Twenty-eight provinces were affected by Ren DL,Li K,Lin D.1989.An investigation of intelligence researchers took advantage of this fact and fluorosis in China[in Chinese].Available:http://news. development of children aged 8-14 years in high-fluoride published their findings, though mainly in gq•com/a/20081216/001707.htm[accessed 3 July 2012]. and low-iodine areas.Chin J Control Endem Dis 4:251. Chioca LR,Raupp IM,Da Cunha C,Losso EM,Andreatini R. Available:http://www.fluoridealertorg/chinese/[accessed Chinese journals and according to the Stan- 2008.Subchronic fluoride intake induces impairment 20 August 2012]. dards of science at the time. This research in habituation and active avoidance tasks in rats.Eur J Seraj B,Shahrabi M,Falahzade M,Falahzade FP,Akhondi N. dates back to the 1980s, but has not been Pharma col 579:196-201. 2006.Effect of high fluoride concentration in drinking Ding Y,Gao Y,Sun H,Han H,Wang W,Ji X,et al.2011.The water on children's intelligence.J Dental Med 19121:80-86. widely cited at least in part because of limited relationships between low levels of urine fluoride on chil- [abstract in English].Available:http://joumals.tums.ac.ir/ access to Chinese journals. dren's intelligence,dental fluorosis in endemic fluorosis upload_files/pdf/J2530.pdf[accessed 24 August2012]. In its review of fluoride,the NRC(2006) area in Hulunbuir,Inner Mongolia,China.J Hazard Mater Stern JAC.2009.Meta-analysis in Stats:An Updated Collection 186:1942-1946. from the Stats Journal.College Station,TX:Stata Press. noted that the safety and the risks of fluoride at Egger M,Davey Smith G,Altman DC.2001.Systematic Reviews Sun LY.2010.Survey of drinking water quality in Jintang County concentrations of 2-4 mg/L were incompletely in Health Care:Meta-Analysis in Context.London:BMJ [in Chinese].J Occup Health Damage 25(51:277-280. documented. Our comprehensive review Publishing. Sun MM,Li SK,Wang YF,Li FS.1991.Measurement of intelli- substantially extends the scope of research Egger M,Davey Smith 6,Schneider M,Minder C.1997.Bias in gence by drawing test among the children in the endemic meta-analysis detected by a simple,graphical test.BMJ area of Al-F combined toxicosis[in Chinese].J Guiyang available for evaluation and analysis.Although 315:629-634.. Med College 16131:204-206. the studies were generally of insufficient Fan ZX,Dai HY,Bai AM,Li P0,Li T,LI GD,et al.2007.Effect Tang nn,Du J,Ma HH,Jiang SJ,Zhou XJ.2008.Fluoride and quality, the consistency of their findings of high fluoride exposure in children's intelligence[in children's intelligence:a meta-analysis.Bio Trace Elam Chinese].J Environ Health 24(101:802203. Res 126:115-120. adds support to existing evidence of fluoride- Grandjean P.1982.Occupational fluorosis through 50 years: Trivedi MH,Verna RJ,Chinoy NJ,Patel RS,Sathawara NG. associated cognitive deficits, and suggests clinical and epidemiological experiences.Am J Ind Med 2007.Effect of high fluoride water on intelligence of school that potential developmental neurotoxicity 3(2):227-336 children in India.Fluoride 40(31:178-183. of fluoride should be a hi h research Grandjean P.,LandriganP.2006.Developmental neurotoxicity of U.S.EPA.2011.EPA and HHS Announce New Scientific g industrial chemicals.lancet368(9553):2167 2178. Assessments and Actions on Fluoride:Agencies Working priority.Although reports from the World Guo XC,Wang R,Cheng C,Wei W,Tang L,Wang Q,et al.1991. Together to Maintain Benefits of Preventing Tooth Decay Health Organization and national agencies A preliminary exploration of IQ of 7-13 year old pupils in a while Preventing Excessive Exposure.Available:http:// have generally focused on beneficial effects fluorosis area with contamination from burning coal.Chin yosemite.epa.gov/opa/admpress.nsf/bd4379a92ceceeac85 J Endemiol 10:98-100.Available:http://www.fluoridealert 25735900400c27/86964af577c37ab285257811005a841710pen of fluoride (Centers for Disease Control and org/chinese/[accessed20August2012]. Document[accessed 7 January 2011]. Environmental Health Perspectives • VOLUME 1201 NUMBER 10 I October 2012 1367 ilv•Aa ,N.; w ' Choi et al. • Varner JA,Jensen KF,Horvath W,Isaacson RL 1998.Chronic World Bank.2006.Water Quality Management:Policy and Yao LM,Deng Y,Yang SY,Zhou JL,Wang SL,Cui JW.1997. administration of aluminum-fluoride or sodium-fluoride to Institutional Considerations.Available:http!/siteresources. Comparison of children's health and intelligence between rats in drinking water.alterations in neuronal and cerebro- worldbank.org/INTEAPREGTOPENVIRONMENT/Resources/ the fluorosis areas with and without altering water vascular integrity.Brain Res 784:284-298. China WPM_final_lo_res.pdf[accessed 13 June 2012]. sources[in Chinese].Lit Id Prey Med 3(11:42-43. Wang D,Di M,Qian M.1989.Chinese Standardized Raven Test, World Health Organization.2002.Fluorides.Geneva:World Yao LM,Zhou JL Wang SI,Cui KS,Lin FY.1996.Analysis of Rural Version.Tianjin,China:Tianjin Medical University. Health Organization.Available:http://whglibdoc.who.int/ TSH levels and intelligence of children residing in high Wang G,Yang D,Jia F,Wang H.1996.Research on intelligence ehc/WHO_EHC_227.pdf[accessed 5 September 2012]. fluorosis areas[in Chinese].Lit Inf Prey Med 2(11:26-27, quotient of 4-7 year-old children in a district with a high Wu TM.1936.Second revision of Chinese-Binet Intelligence Zhang J,Gung Y,Guo J.1985.Children Intelligence Scale level of fluoride.Endem Dis Bull 11:60-62.Available:http:// Test Shanghai:Commercial Press(in Chinese[. Handbook.Beijing:Captial Institute of Pediatrics Heatlh www.fluoridealertorg/chinese/[accessed 20 August 2012]. Wu T.1983.The Chinese Comparative Intelligence Test Research Office. Wang SH,Wang LF,Hu PY,Guo SW,Law SH.2001.Effects of Guidebook.3rd ed.Beijing:Beijing University Press. Zhang JW,Van H,Chen Y.1998.Effect of high level of fluoride high iodine and high fluorine on children's intelligence and Xiang Q,Liang Y,Chen L,Wang C,Chen B,Chen X,et al.2003. and arsenic on children's intelligence[in Chinese].Chin J thyroid function[in Chinese].Chin J Endemiol 20(41:288-290. Effect of fluoride in drinking water on children's intel- Public Health 17(21:57. Wang SX,Wang ZH,Cheng XT,Li J,Sang ZP,Zhang XD,et al. ligence.Fluoride 36(2):84-94. Zhang M,Wang A,Xia T,He P.2008.Effects of fluoride on DNA 2007.Arsenic and fluoride exposure in drinking water:chil- Xu YL,Lu CS,Zhang XN.1994.Effect of fluoride on children's damage,S-phase cell-cycle arrest and the expression dren's IQ and growth in Shanyin County,Shanxi Province, intelligence[in Chinese].Endem Dis Bull 2:83-84. of NF-KB in primary cultured rat hippocampal neurons. • China.Environ Health Perspect 115:643-647. Yang Y,Wang X,Guo X,Hu P.1994.Effects of high iodine and Toxicol Lett 179:1-5. Wang ZH,Wang SX,Zhang XD,Li J,Zheng XT,Hu CM,et al. high fluorine on children's intelligence and the metabolism Zhao LB,Liang OH,Zhang DN,Wu XR.1996.Effect of a high 2006.Investigation of children's growth and development of iodine and fluorine.Chin J Pathol 15(51:296-298. fluoride water supply on children's intelligence.Fluoride under long-term fluoride exposure[in Chinese;abstract in Available:http://www.fluoridealertorg/chinese/[accessed 29(41:190-192 English].Chin J Control Endem Dis 21(41:239-241. 20 August2012]. • • C i 1368 VOLUME 120 I NUMBER 101 October 2012 • Environmental Health Perspectives hfia Me*egun From: 'Barry Conger, DDS'<bfc01 @comcast.net> Sent: Thursday, October 25,2012 9:36 AM To: Council Cc: bfc01@comcast.net Subject: water fluoridation Dear Renton City Councilmen, My name is Barry Conger. I have lived in Renton since 2003.My current address is 1217 N 32nd Street, Renton, WA 98056. I am writing to express my support for continuing Renton's mandate to fluoridate its public water supply which was discussed and approved by city officials and leaders in 1985. I have been a licensed dentist since 1983 and have been an active advocate and proponent of fluoridated water for 30 years.I renovated an old building in the Renton downtown area in 2003 and built a dental practice, 4th and Morris Dentistry,which continues to serve the residents of Renton.Although I retired from active private practice in 2010, I have continued working as a dentist through humanitarian efforts in six Central American countries and Haiti, as well as supporting the U.S.Army by providing dental readiness to our service men and women both before and after military deployments. This background has allowed me to see how lucky the children of Renton have been to grow up with a community fluoridated water supply.During my career in Renton, our dental staff invited classes of First and Second graders into our office as well as visiting elementary schools in the Kennydale and Renton Highlands areas. Our message always included how well fluoride works and how important it is to good dental care. We gave them little yellow hardhats marked"Fluoride"and let them throw black ping pong balls marked "Toothbugs"at each other to watch them bounce off. It sometimes got out of hand but they got the point! Most of the children of Central America do not have the luxury of fluoride and their dental health certainly reflects this. Many of our young servicemen I have seen from other areas of our own country,where community leaders were not as proactive as the leaders of Renton were in 1985, bear the dental handicaps of non- fluoridated water even today.Many of them face a lifetime of missing teeth and expensive adult dental work. The benefits of fluoridated water are as important today as ever. It is the only effective delivery system available. The lower socioeconomic families of Renton do not get regular fluoride treatments in dental offices and the compliance of daily fluoride tablets is just not that effective.Those who do not wish fluoride can easily and economically use one of the many bottled water companies for their drinking and cooking needs. I urge every member of the Renton City Council to unanimously vote to continue our safe, effective and economical fluoridated water supply. Thank you in advance for your support. Barry Conger,DDS This email request originated from the following link:http://rentonwa.gov/government/default.aspx?id=3212 Jason Seth From: Jay B Covington Sent: Thursday, November 15, 2012 10:04 AM To: Don Persson; Ed Prince; Greg Taylor; Julia Medzegian; Marcie Palmer; Randy Corman; Rich Zwicker; Terri Briere Cc: Denis Law; Lys L. Hornsby; Bonnie Walton Subject: FW: Nov 5-Testimony& Documents on Fluoridation Attachments: 2012 11-5+Renton Council Ltr&Attachments 11-5-12.docx; 2012 11-5 Harvard Fluoride Neurotoxicity Abstract Summary July 2012.docx; 2012 11-05 Harvard Developmental Fluoride Neurotoxicity Study-July 2012.pdf Council, For your information From: Audrey Adams [mailto:audrey55Ca�comcast.netl Sent:Thursday, November 15, 2012 9:38 AM To: Jay B Covington Cc: Lys L. Hornsby; Gregg A. Zimmerman Subject: Nov 5 -Testimony&Documents on Fluoridation Mr. Covington, The attached is my letter and documents that I brought to the Renton City Council on November 5, so they have already been distributed in hard copy to the Council. Sorry it took so long to get this to you (computer troubles), but thought it might be easier for you if you had an electronic copy to be consistent with the others that I have submitted. I will be bringing more information this Monday in preparation for the Committee of the Whole on November 26 at 6pm. Dr. Osmunson has 15 minutes to present his Power Point on water fluoridation that is near impossible to adequately present in 60 minutes, so I wanted to make sure that the Council has some background information ahead of time. Dr. Osmunson will only be able to touch the tip of the iceberg on the 26th, but that 15 minutes is none-the-less extremely precious and we are so very grateful for this opportunity. Thank you, Audrey Adams 425-271-2229 1 November 5,2012 Renton City Council Subject: Harvard Study Finds Neurodevelopmental (Brain) Risk from Fluoride Dear Renton City Council members, Mayor Law and staff, I am very appreciative that the Committee of the Whole will be hearing the topic of water fluoridation on Monday, November 26 at 6:00pm and that Dr. Bill Osmunson will be addressing you for 15 minutes at this meeting. If this changes for any reason, please let me know. In preparation of this meeting, I have attached a new study from the Harvard School of Public Health. This 2012 study was published in the Environmental Health Perspectives,a division of the National Institute of Health. This study reviewed 27 32studies from around the world on fluoride's effect on brain development. The Harvard researchers concluded that, "The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment" and said, "Thus, children in high-fluoride areas had significantly lower IQ scores than those who lived in low fluoride areas." Please ask those who promote fluoridation to provide you with scientific references to current published studies of equal caliber that show zero negative effect on IQ or brain development from fluoride. Endorsements,without rigorous and current science to back up claims of safety, is merely marketing. Endorsements,from any person,agency or entity,are not a substitute for scientific studies. Babies' brains are more important than teeth. To justify the addition of any drug or chemical to the water supply, no matter what the possible benefits might be---especially when tap water is unavoidable by the poor---the precautionary principle must supersede any policy mandate such as fluoridation in order to give the highest regard to the protection of brain development of fetuses and babies. "The precautionary principle...states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is harmful, the burden of proof that it is not harmful falls on those taking the action. This principle allows policy makers to make discretionary decisions in situations where there is the possibility of harm from taking a particular course or making a certain decision when extensive scientific knowledge on the matter is lacking."(Wikipedia) Sincerely and appreciatively, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 EIWIRONMENTAL HEAL111 1 PERSPECTIVE Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis October 1, 2012 Anna L.Choi,'Guifan Sun,'Ying Zhang,3 and Philippe Grandjean" 'Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA;'School of Public Health, China Medical University, Shenyang, China;3School of Stomatology, China Medical University, Shenyang, China; 'Institute of Public Health, University of Southern Denmark, Odense, Denmark Abstract Background: Although fluoride may cause neurotoxicity in animal models and acutefluoride poisoning causes neurotoxicity in adults, very little is known of its effects on children's neurodevelopment. Objective: We performed a systematic review and meta-analysis of published studies to investigate the effects of increased fluoride exposure and delayed neurobehavioral development. Methods: We searched the MEDLINE, EMBASE, Water Resources Abstracts, and TOXNET databases through 2011 for eligible studies. We also searched the China National Knowledge Infrastructure (CNKI) database, because many studies on fluoride neurotoxicity have been published in Chinese journals only. In total, we identified 27 eligible epidemiological studies with high and reference exposures, end points of IQ scores, or related cognitive function measures with means and variances for the two exposure groups. Using random-effects models, we estimated the standardized mean difference between exposed and reference groups across all studies.We conducted sensitivity analyses restricted to studies using the same outcome assessment and having drinking-water fluoride as the only exposure. We performed the Cochran test for heterogeneity between studies, Begg's funnel plot, and Egger test to assess publication bias, and conducted meta-regressions to explore sources of variation in mean differences among the studies. Results: The standardized weighted mean difference in IQ score between exposed and reference populations was—0.45 (95% confidence interval:—0.56, —0.35) using a random-effects model. Thus, children in high-fluoride areas had significantly lower IQ scores than those who lived in low-fluoride areas. Subgroup and sensitivity analyses also indicated inverse associations, although the substantial heterogeneity did not appear to decrease. Conclusions: The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment. Future research should include detailed individual-level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment. Key words: fluoride, intelligence, neurotoxicity. Environ Health Perspect 120:1362-1368 (2012). http://dx.doi.org/10.1289/ehp.1104912 [Online 20 July 2012] Address correspondence to A.L. Choi, Department of Environmental Health, Harvard School of Public Health, Landmark Center 3E,401 Park Dr., Boston, MA 02215 USA.Telephone: (617)384-8646. Fax: (617)384-8994. E-mail: achoi@hsph.harvard.edu Supplemental Material is available online(http://dx.doi.org/10.1289/ehp.1104912). We thank V. Malik, Harvard School of Public Health,for the helpful advice on the meta-analysis methods. This study was supported by internal.institutional funds. The authors declare they have no actual or potential competing financial interests. Received 30 December 2011;Accepted 20 July 2012; Online 20 July 2012. National Institute of Health,Environmental Health Perspectives http://ehp.niehs.nih.gov/2012/10/developmental-fluoride-neurotoxicity-a-systematic-review-and-meta-analysis/ Office.of the Directora 401 Fifth Avenue;Suite 1300 Public Health Seattle,WA 98104-1818 Seattle:.&King County 206-296-4600 Fax 206-296-0166. Tr(Re0),:.711: • www.kingcounty.gov/health:: November 9, 2012 Honorable Rich Zwicker Councilmember Renton City Council 1055 South Grady Way Renton, WA 98057 Dear Councilmember Zwicker: As Health Officer for King County and every city within its borders, I wish to express my support for community water fluoridation and to commend you for undertaking this issue. Fluoridation of community water supplies is the single most effective public health measure to prevent dental decay—leading the Centers for Disease Control and Prevention to recognize water fluoridation as one of the ten greatest public health achievements of the 20th century. Community water fluoridation benefits everyone, especially those without regular access to dental care. Studies show that fluoridated communities have about 30 percent less tooth decay. Community water fluoridation costs about$1 per person per year—and saves $38 for every dollar invested, helping to lower health care costs. The City of Renton's water was fluoridated by a vote of the people in 1985, with the majority of citizens supporting fluoridation. The City of Renton's water supply has been fluoridated since 1987, providing strong preventive oral health benefits for 25 years. Public Health supports water fluoridation as a safe, economical way to increase the oral,health of people in King County. In addition to Public Health, the following federal agencies and national/international organizations support water fluoridation: • • The U.S. Environmental Protection Agency (EPA) Responsible for the safety and quality of drinking water in the United States. • The U.S. Food and Drug Administration (FDA) Responsible,for approving prescription and over-the-counter fluoride products marketed in the United States and for setting standards for labeling bottled water and over-the-counter fluoride products., • The Centers for Disease Control and Prevention (CDC) The nation's health protection agency responsible for saving lives, protecting people from health threats, and saving money through prevention. • NSF International (a not-for-profit, non-governmental organization) World leader in standards development, product certification, education and risk-management for public health and safety. • American Water Works Association An international non-profit scientific and education society dedicated to the improvement of drinking water quality and supply. As your Health Officer, I urge councilmembers to support the continuation of community water fluoridation in the City of Renton. Sincerely, David Fleming, MD Director and Health Officer • • 1,4 - RECEIVED - • . NOV 0 7 2012 Renton City Council • November 1. 2012 Rich Zwicker. President Renton City Council 1055 South Grady Way Renton" WA 98057 • Dear Mr Zwicker: • • Fluoridation of community water supplies has been proclaimed by the Centers for Disease Control and Prevention as one of the ten great public health achievements of the 20' century. According to the best available scientific evidence, fluoridation is safe, effective and economical in preventing tooth decay Today. •• three in four Americans benefit from fluoridated water. representing more than 204 million people. Renton citizens have enjoyed the decay-preventing benefits of fluoridation for almost 30 years. Community water fluoridation saves money. On an individual basis, the lifetime cost of fluoridation is less than the cost of one dental filling. For communities, every $1 invested in water fluoridation saves $38 in dental treatment costs Water fluoridation is a crucial investment for Renton Studies have shown that community water fluoridation prevents at least 25 percent of tooth decay in children • .and adults. even with the widespread use of fluoride-containing products such as toothpaste. Simply by drinking water. people can benefit from fluoridation's cavity protection —regardless of age; education. race or socio-economic status As a dentist practicing in Renton. my first concern is my patients' health. When I see new patients, I can • always tell who grew up with fluoridated water as their teeth are stronger and they have fewer cavities. Fluoride toothpaste and fluoridated water deliver a one-two punch in the fight against cavities. The bottom line is that community water fluoridation remains the single most effective public health measure to . prevent tooth decay. That is why the Seattle-King County Dental Society (SKCDS). the American Dental Association (ADA) and more than 100 other organizations support community water fluoridation We urge the Renton City Council to continue providing this public health benefit Sincerely. • • Princy S Rekhi. DDS � President Cc . Renton.Cit.youncii members " • l • ,9 L� t tri P e-LSnt + 3 - ' Tap in to3 �, rr;;k � _ t� :. .• `i _—'� Your Health 10 Reasons to Fluoridate Public Water Single most effective public health measure to prevent tooth decay. The Centers for Disease Control and Prevention (CDC) has proclaimed community water fluoridation one of 10.great public health achievements of the 20th century. Natural. Fluoride is already present in all water sources, even the oceans. Water fluoridation is simply the adjustment of fluoride that occurs naturally to a recommended level for preventing tooth decay. Similar to fortifying other foods and beverages.Water that has been fluoridated is similar to fortifying salt with iodine, milk with vitamin D, orange juice with calcium and bread with folic acid. Prevents dental disease. It is the most efficient way to prevent one of the most common childhood diseases—dental decay. An estimated 51 million school hours are lost each year due to dental- related illness. Protects all ages against cavities. Studies show that community water fluoridation prevents at least 25 percent of tooth decay in children and adults, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. Safe and effective. For more than 65 years, the best available scientific evidence consistently indicates that community water fluoridation is safe and effective. • • . Saves money.The average lifetime cost per person to fluoridate a water supply is less than the cost • of one dental filling. For most.cities, every$1 invested in water fluoridation saves$38 in dental treatment costs. • Recognized by more than 100 organizations. The American Dental Association.(ADA) as well as the Centers for Disease Control and Prevention, the American Medical Association,the World Health Organization and more than 125 national and international organizations recognize the public health benefits of water fluoridation for preventing dental decay. Availability of fluoridation continues to grow. In2010, 73.9 percent of the U.S. population on public water systems(204.3 million people) received fluoridated water.This is an increase of almost nine percent from 2000. The Healthy People 2020 goal is for 79.6 percent of the population on public water systems to have access to fluoridated water. Endorsed by the American Dental Association. One of the most widely respected sources for • information regarding fluoridation and fluoride is-the American Dental Association. Learn more on the ADA's website at ADA.org/fluoride. For more information,visit ADA org/fluoride P2012.American Dental Association.All Rights Reserved. • July 2012 • • u,v :$0.45 0 �? i., i • US POSTAGE s i FIRST-CLASS 4, ._ 06250008181719 3 • • 98121 Seattle King County =,, Dental Society s ; 2201 Sixth Avenue,Suite 1210 Seattle,Washington 98121-1857 • • Ms. Marcie Palmer Renton City Council 1055 South Grady Way Renton,WA 98057 e `160E;73232= • • ���ssareoA /8n t1 STATE OF WASHINGTON DEPARTMENT OF HEALTH PO Box 47890• Olympia,Washington 98504-7890 Tel:(360)236-4501 •FAX:(360)586-7424•TOD Relay Service:1-800-833-6388 August 2012 STATEMENT ON COMMUNITY WATER FLUORIDATION Community water fluoridation began in the United States over sixty-five years ago. Fluoridated water systems serve nearly two-thirds of the U.S.population and sixty-five percent of Washington State.Evidence shows that water fluoridation is the most cost- effective,practical,and safe means for reducing tooth decay. People who drink fluoridated water at recommended levels retain healthier teeth and have less tooth decay than those without access to fluoridated water. Tooth decay is a preventable infectious bacterial disease process that begins in infancy and continues throughout life.Early exposure to optimally fluoridated water improves dental health.Fluoride is a safe and naturally occurring element that benefits the enamel of developing teeth when it is ingested.When in contact with teeth in the mouth,it helps to repair early signs of tooth decay,harden exposed root surfaces,and slows decay-causing bacteria in adults and children. Fluoride benefits teeth for all ages. Public health provides prevention measures to all citizens,regardless of age,race,gender,or • income. Community water fluoridation is the most effective way to deliver the benefits of fluoride to everyone.The Surgeon General of the United States and over one hundred national and international organizations endorse water fluoridation.The U.S. Centers for Disease Control and Prevention recognizes the fluoridation of drinking water as one of ten great public health achievements of the twentieth century. Community water fluoridation is a Healthy People 2020 goal.The Department of Health supports water fluoridation as a sound population-based public health measure. The department supports communities in their efforts to maintain and fluoridate community water supplies. Maxine Hayes, ,MPH State Health Officer 0 • • .- F Y Y• 2 . . t Y . 4 ry z ll ,�., : .. tilFluoridation ' ° , t {- . Tap in to >-'" • ;, ,ter . tf ;�. _:� Your Health 10 Reasons 'to Fluoridate Public Water Single most effective public health measure to prevent tooth decay.The Centers for Disease Control and Prevention (CDC) has proclaimed community water fluoridation one of 10.great public health • achievements of the 20th century. Natural. Fluoride is already present in all water sources, even the oceans. Water fluoridation is simply the adjustment of fluoride that occurs naturally to a recommended level for preventing tooth decay. Similar to fortifying other foods and beverages.Water that has been fluoridated is similar to fortifying salt with iodine, milk with vitamin D, orange juice with calcium and bread with folic acid. Prevents dental disease. It is the most efficient way to prevent one of the most common childhood diseases—dental decay. An estimated 51 million school hours are lost each year due to dental- related illness. Protects all ages against cavities. Studies show that community water fluoridation prevents at least 25 percent of tooth decay in children and adults, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. Safe and effective. For more than 65 years. the best available scientific evidence consistently indicates that community water fluoridation is safe and effective. • Saves money.The average lifetime cost per person to fluoridate a water supply is less than the cost of one dental filling. For most.cities, every$1 invested in water fluoridation saves $38 in dental treatment costs. • Recognized by more than 100 organizations. The American Dental Association (ADA)as well as the Centers for Disease Control and Prevention, the American Medical Association,the World Health Organization and more than 125 national and international organizations recognize the public health benefits of water fluoridation for preventing dental decay. Availability of fluoridation continues to grow. in•2010, 73.9 percent of the U.S. population on public water systems(204.3 million people) received fluoridated water.This is an increase of almost nine percent from 2000. The Healthy People 2020 goal is for 79.6 percent of the population on public water systems to have access to fluoridated water. • • Endorsed by the American Dental Association. One of the most widely respected sources for information regarding fluoridation and fluoride is the American Dental Association. Learn more on the ADA's website at ADA.org/fluoride. • For more information,visit ADA org_/fluoride 11 2012.American Dental Association.All Rights Reserved. July 2012 • • tlyH C . WA(ACO $0.45 P SNOV:2Q-12 US POSTAGE 11$ �.•�. . FIRST-CLASS '.-?? 062S0008181719 i-....r, • Seattle King County 981211I Dental Society , ; .:•�L 2201 Sixth Avenue,Suite 1210 Seattle,Washington 98121.1857 Ms.Marcie Palmer Renton City Council 1055 South Grady Way Renton,WA 98057 E30.37qy3:::E.4.•' 1�Jli J1JJ 13I1lfli!{�11ili�l l�lf ll/II11��1{{Ifl F1J1J 1�71141f i�J • aux 5s5� > T e40q; rq ,AA' VALLE�f`�gy yy � y e 4 a sN r i 7 g 's.. � �._J`-- dt di3� { I I 1 �f -,�{�I, $t���r [ _� rt ... .-� G - Ilse • • November 14,2012 To: 'Renton City-Council,Committee of the Whole From., Kathryn Beattie;.MD Senior Vice President of Medical Affairs Valley Medical Center Re: Water Fluoridation • It.was brought to our attention that the City of Renton received a request to discontinue its fluoridation, of city drinking water and the CityCouncil will be considering this request at the-Committee of the Whole on November 26. We support the position of the American Academy Of P'ediatrics,,the American Academy of Pediatric.Dentistry,.the American Dental Association,the US Department.of Health and Human Services-and the.US Environmental Protection Agency that.finds."tooth decay is the most common chronic disease of-childhood-and water fluoridation is beneficial for reducing and controlling tooth decay and promoting oral health in.children and adults.The recommended 0.7 milligrams per-liter providesenough fluoride to.prevent tooth decay in children and adults while limiting the possibility for children to develop dental fluorosis,a mild change in the appearance of tooth enamel." Optimal water fluoridation aids:in improved health for our community and prevention of costly decay and we feel as the primary provider of healthcare in Renton it important:not to discontinue its use.- M/S se.M/5 VMC 1-01.9 400-S 43rd 5t. PO Box 50010 Renton,WA 98058-5010 425.228.3450 FAx.425.656:4202 valleymed.org P7.7 — .-.. '' 37 -9 4-- 1:071,..-;:-7.77:'--_ e 4 f 'N ,",3-r.. x s- —,-,-,,. .`.7.7.7N711:.7..17- 7-7,1741 H L LL,-i.,„;,':.... .mom T ,i....c, . .r a..y1, ....= )f': ._f.e U: rYi'd 5 a3- -- , ;', { w?+.. +5.. 7 .,„ ,k., \t- _ f WASHINGTON STATE DENTAL ASSOCIATION 126 NW Canal Street Seattle,WA 98107 November 1, 2012 F X: 206.448,1 6 FAX:206.441.9266 The Honorable Rich Zwicker Council President www.wsda.org City of Renton 1055 S. Grady Way Renton, WA 98057 Dear President Zwicker: On behalf of the Washington State Dental Association, I am writing:to support the continued practice of optimally fluoridating the City of Renton's water supply. Support for community Water.fluoridation can be found among more than 100 national and international health organizations including the Centers for I Disease Control and Prevention and the World Health Organization. Water fluoridation is one of the safest and most equitable methods for delivering fluoride to all members Of a community regardless of social_or economic status. Fluoride is a naturally occurring mineral found in all water supplies that when set to optimal levels.is effective in reducing dental decay by 20-40 percent. The.average ; cost for a.cornmunity to fluoridate its water system is as low as $0.50 per person, per year. Community water fluoridation has received strong,support from key policy makers in Washington state. In an official statement released in 2006, State Health Officer Maxine Hayes said that the "Department of.Health supports water fluoridation as a sound population-based public health measure, and...supports communities in their efforts to fluoridate,community water supplies." I After 60 years of research, fluoridated water systems are continually proven to be one of the best tools for communities to efficiently improve their overall oral health. Former:U.S. Surgeon General Dr..C. Everett Koop called fluoridation "the single most important commitment that a community can make to the oral health of its citizens." It is my hope-that.the City of Renton continue to provide its citizens this Dr,Rodney B.Wentworth valuable resource. President The Washington State Dental Association has provided all Renton City Council 1 Dr.Danny 6.Warner President-elect members with the American Dental.Associations Fluoridation Facts Booklet. I encourage all council members to review the material in the book to gain a better Dr..David.M.Mina hen understanding of the truths and benefits of fluoridated water. - Vice President t Resp ctfullyss/u�bmitted, DSe $cyann�.Tree Edgar ` ' /" 5ecretaasurEr Dr,Douglas P.Walsh Dr. Danny G. Warner Immediate Past President President Mr.Stephen A.Hardymon Executive Director I I Review Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis Anna L. Choi,1 Guifan Sun,2 Ying Zhang,3 and Philippe Grandjean1•4 • • 1Department of Environmental Health,Harvard School of Public Health,Boston,Massachusetts,USA;2School of Public Health,China Medical University,Shenyang,China;3School of Stomatology,China Medical University,Shenyang,China;'Institute of Public Health, University of Southern Denmark,Odense,Denmark Registry 2003).Fluoride exposure to the devel- oping brain,which is much more susceptible tty poisoning causes'neurotoicicin adults vry li ettle is known,of its effects on children s neuro to injury caused by toxicants than is the mature development brain,may possibly lead to permanent damage Oajscr a We performed a systematic renew and meta`analysts of published studiesao investigate (Grandjean and Landrigan 2006).In response the effects of increased fluoride exposure and delayed-neurobehavioral development to the recommendation of the NRC (2006), METHODS We searched the MEDLINE EM BASE Water Resources Abstracts'and TOXNET the U.S—Department of Health and Human databases through 2011 for eligible studies We also searched',the China National Knowledge',' Services (DHHS) and the U.S. EPA recently Infrastructure(CNKI)database because many studies'`on fluoride neurotoxicity have been pub -' announced that DHHS is proposing to change `lished,itr Chinese,journals only In total we identified 27 eligible epidemiological studies wuh_l igh' the recommended level of fluoride in drinking and reference exposures end pointsof IQ scores or related cognitive funcnoii measures with rrieans-[ water to 0.7 mg/L from the currently recom- and variances,tor'the two exposure groups:,Using random effects models we estimated the scan- mended range of 0.7-1.2 mg/Land the U.S. r dardized-meandifference between-exposed and referenee groups-across all'studies We conducted- , sensitivity analyses restncted to studies using the same outcome-assessment,and having drinking EPA is reviewing the maximum amount of wafer fluonde as the only exposure Weperformed the'Cochran`test for,heterogenetty_between_stud fluoride allowed in drinking water,which cur- ies,Begg s funnel plot and Egger test to assess"publication bias ai>d conduetedmeta regressions to-' rently is set at 4.0 mg/L(U.S.EPA 2011). ,explore sources of variation in mean differences among the L To summarize the available literature, RF$ULTS The standardized:weighted=mean difference ari IQ score between_exposed and reference_ we performed a systematic review and meta- o ulations was,-0 45 95%confidence interval 0: 6 -0 3� usin a=random=effects model :` analysis of published studies on increased Thus children;in high fluoride areas;had srgriificantly,lower IQscores than those who lived in low fluoride exposure in drinking water associated fluonde"areas Subgroup and sensitivity analyses also indicated i nverse,associations,although the. with neurodevelopmental delays.We specifi- substanual heterogeneity didnot appeal to decrease cally targeted studies carried out in rural CONCLUSIONS The resulrs��supporr rh�"e--possibility of an-=adverse-effect ofhigh-fluonde exposure on China that have not been widely disseminated, children's neurodevelopment Future_research-should'include detailed individual level information. thus complementing the studies that have on prenatal exposure,neurobehavioral performance and covanates for adjustment been included in previous reviews and risk KEY WORDS fluoride intelligence;'neurotoxicity.Environ'Health Perspect 120 1362 1368.,', assessment reports. i{2012) littp?/14clacitg/.1,0.1289/elii;t1049,1-2.,[gnliiie-20My'2012k,',;Zic Methods Search strategy. We searched MEDLINE A recent report from the National Research of fluoride from drinking water. Such cir- (National Library of Medicine,Bethesda,MD, Council (NRC 2006) concluded that adverse cumstances are difficult to find in many USA;http://www.ncbi.nlm.nih.gov/pubmed), effects of high fluoride concentrations in industrialized countries,because fluoride con- Embase (Elsevier B.V., Amsterdam, the drinking water may be of concern and that centrations in community water are usually Netherlands;http://www.embase.com),Water additional research is warranted.Fluoride may no higher than 1 mg/L, even when fluoride Resources Abstracts'(Proquest, Ann Arbor, cause neurotoxicity in laboratory animals, is added to water supplies as a public health MI, USA; http://www.csa.com/factsheets/ including effects on learning and memory measure to reduce tooth decay. Multiple epi- water-resources-set-c.php), and TOXNET (Chioca et al.2008; Ivlullenix et al. 1995).A demiological studies of developmental fluo- (Toxicology Data Network; National Library recent experimental study where the rat hip- ride neurotoxicity were conducted in China of Medicine,Bethesda,MD,USA;http://tox- pocampal neurons were incubated with vari- because of the high fluoride concentrations net.nlm.nih.gov) databases to identify studies ous concentrations (20 mg/L, 40 mg/L, and that are substantially above 1 mg/L in well of drinking-water fluoride and neurodevel- 80 mg/L) of sodium fluoride in vitro showed water in many rural communities, although opmental outcomes in children. In addition, that fluoride neurotoxicity may target hip- microbiologically safe water has been acces- we searched the China National Knowledge pocampal neurons (Zhang M et al. 2008). sible to many rural households as a result of Infrastructure (CNKI; Beijing, China;http:// Although acute fluoride poisoning may be the recent 5-year plan (2001-2005) by the www.cnki.net) database to identify stud- neurotoxic to adults, most of the epidemio- Chinese government. It is projected that all res published in Chinese journals only. Key logical information available on associations rural residents will have access to safe public with children's neurodevelopment is from drinking water by 2020 (World Bank 2006). Address correspondence to A.L.Choi,Department China, where fluoride generally occurs in However,results of the published studies have of Environmental Health,Harvard School of Public T drinking water as a natural contaminant,and not been widely disseminated. Four studies HMAealth02,215 LandmarUSA.k Centerle3E,401 Park Dr.,Boston, ephone:(617) 384-8646.Fax: the concentration depends on local geologi- published in English (Li XS et al. 1995; Lu (617)384-8994.E-mail:achoi@hsph.harvard.edu cal conditions. In many rural communities et al. 2000; Xiang et al. 2003; Zhao et al. Supplemental Material is available online(http:// in China, populations with high exposure to 1996)were cited in a recent report from the dx.doi.org/10.1289/ehp.1104912). fluoride in local drinking-water sources may NRC (2006), whereas the World Health We thank V.Malik,Harvard School of Public Health, reside in close proximity to populations with- Organization (2002)has considered only two for the helpful advice on the meta-analysis methods. out high exposure(NRC 2006). (Li XS et al. 1995; Zhao et al. 1996) in its This study was supported by internal institutional funds. Opportunities for epidemiological stud- most recent monograph on fluoride. The authors declare they have no actual or potential ies depend on the existence of comparable Fluoride readily crosses the placenta competing financial interests. population groups exposed to different levels (Agency for Toxic Substances and Disease Received 30 December 2011;accepted 20 July 2012. 1362 VOLUME 1201 NUMBER 10 I October 2012 • Environmental Health Perspectives ' Fluoride neurotoxicity words included combinations of"fluoride"or study)to heterogeneity among the studies.The Wechsler Intelligence tests(3 studies;An et al. "drinking water fluoride," "children," "neu- scoring standard for the Combined Raven's 1992;Ren et al. 1989;Wang ZH et al. 1996), rodevelopment" or"neurologic" or "intelli- Test—The Rural edition in China (CRT-RC) Binet IQ test(2 studies; Guo et al. 1991;Xu gence"or"IQ"We also used references cited test classifies scores of<_ 69 and 70-79 as et al. 1994),Raven's test(2 studies;Poureslami in the articles identified.We searched records low and marginal intelligence, respectively et al. 2011; Seraj et al. 2006),Japan IQ test for 1980-2011. Our literature search iden- (Wang D et al. 1989). We also used the (2 studies; Sun et al. 1991; Zhang JW et al. tified 39 studies, among which 36 (92.3%) random-effects models to estimate risk ratios 1998), Chinese comparative intelligence test were studies with high and reference expo, for the association between fluoride exposure (1 study;Yang et al. 1994), and the mental sure groups,and 3 (7.7%)studies were based and a low/marginal versus normal Raven's test work capacity index(1 study;Li Y et al. 1994). on individual-level measure of exposures.The score among children in studies that used the Because each of the intelligence tests used is latter showed that dose-related deficits were CRT-RC test (Wang D et al. 1989). Scores designed to measure general intelligence, we found, but the studies were excluded because indicating low and marginal intelligence(<_69 used data from all eligible studies to estimate our meta-analysis focused on studies with the and 70-79, respectively) were combined as the possible effects of fluoride exposure on high-and low-exposure groups only. In addi- a single outcome due to small numbers of general intelligence. tion, two studies were published twice, and children in each outcome subgroup. In addition, we conducted a sensitivity the duplicates were excluded. Results analysis restricted to studies that used similar Inclusion criteria and data extraction, tests to measure the outcome(specifically, the The criteria for inclusion of studies included Six of the 34 studies identified were excluded CRT-RC,Wechsler Intelligence test,Binet IQ studies with high and reference fluoride expo- because of missing information on the num- test,or Raven's test),and an analysis restricted sures,end points of IQ scores or other related ber of subjects or the mean and variance of the to studies that used the CRT-RC. We also cognitive function measures,presentation of a outcome[see Figure 1 for a study selection flow performed an analysis that excluded studies mean outcome measure, and associated mea- chart and Supplemental Material, Table Si with co-exposures including iodine and arsenic, sure of variance.'[95% confidence intervals (http://dx.doi.org/10.1289/ehp.1104912)for - or with non-drinking-water fluoride exposure (CIs) or SEs and numbers of participants]. additional information on studies that were from coal burning. Interpretations of statistical significance are excluded from the analysis].Another study Pooled SMD estimates. Among the based on an alpha level of 0.05. Information (Trivedi et al. 2007) was excluded because 2T-studies, all but one study showed included for each study also included the first SDs reported for the outcome parameter were random-effect Sr. mates that indicated author,location of the study,year of publica- questionably small (1.13 for the high-fluoride an inverse associaton, ranging from—0.95 tion, and numbers of participants in high- group, and 1.23 for the low-fluoride group) (95% CI:—1.16,—0.75) to—0.10 (95% CI: fluoride and low-fluoride areas.We noted and and the SMD (-10.8; 95% CI:—11.9,—9.6) ,, _ _ -_ recorded the information on age and sex of was> 10 times lower than the second small- P, Total abstracts identified =} children, and parental education and income est SMD (-0.95; 95%CI:—1.16,—0.75) and v from literature search if available. • 150 times lower than the largest SMD (0.07; (n=39) f Statistical analysis. We used STATA 95%CI:—0.083,0.22)reported for the other '` (version 11.0;StataCorp,College Station,TX, studies,which had relatively consistent SMD - USA) and available commands (Stern 2009) estimates.Inclusion of this study in the meta- Duplicate records for the meta-analyses.A standardized weighted analysis resulted with a much smaller pooled ,.;) removed :--..i mean difference (SMD) was computed using random-effects SMD estimate and amuck =K (n=2) both fixed-effects and random-effects models. larger 12 (-0.63; 95% CI: —0.83, —0.44 IZ m_ The fixed-effects model uses the Mantel— 94.1%) compared with the estimates that Studies excluded Haenszel method assuming homogeneity excluded this study(-0.45; 95% CI:—0.56, -7,;;'` because they did not ` among the studies, whereas the random- —0.34,Iz 80%) (see Supplemental Material, ..*:::-AW,-,:',--Z.7�a"M r" =y meet inclusion criteria `e effects model uses the DerSimonian and Laird Figure Si). Characteristics of the 27 studies (n=3) • method, incorporating both a within-study included are shown in Table 1 (An et al. 1992; h'zt ,,..?„,q . "� Y and an additive between-studies component of Chen et al. 1991; Fan et al. 2007; Guo et al a "' r ` variance when there is between-study hetero- 1991;Hong et al.2001;Li FH et al.2009 Li Studies for retrieval of u •.x, f. M ti` geneity(Egger et al.2001).The estimate of the. XH et al. 2010;Li XS 1995;Li Yet al. 1994; r detailed information between-study variation is incorporated into Li Yet al.2003;Lin et al.1991;Lu et al.2000; (n=34) both the SE of the estimate of the common Poureslami et al. 2011; Ren et al. 1989;Seraj 2 i _���_ _ effect and the weight of individual studies, et al. 2006; Sun et al. 1991;Wang G et al. "; z Studies with ili which was calculated as the inverse sum of 1996;Wang SH et al.2001;Wang SX et al =-_ missing information the within and between study variance. We 2007;Wang ZH et al.2006;Xiang et al.2003; & .' on outcomes evaluated heterogeneity among studies using Xu et al. 1994; Yang et al. 1994;Yao et al. ` �5 (n 61 the 11 statistic,which represents the percentage 1996, 1997;Zhang JW et al. 1998;Zhao et al. •Vs 5 of total variation across all studies due to 1996).Two of the studies included in the anal- e 3 -. eaSt,-;-.; - Studies excluded due between-study heterogeneity (Higgins and ysis were conducted in Iran(Poureslami et a!. ' to questionably small Thompson 2002).We evaluated the potential 2011;Seraj et al.2006);the other study cohorts _ standard deviations for publication bias using Begg and Egger were populations from China. Two cohorts (0 1) tests and visual inspection of a Begg funnel were exposed to fluoride from coal burning ';' ' y "` -_ plot(Begg and Mazumdar 1994; Egger et a1. (Guo et al.1991;Li XH et al.2010);otherwise E£ Studies included in 1997).We also conducted independent meta- populations were exposed to fluoride through meta-analysis regressions to estimate the contribution of drinking water. The CRT-RC was used to E In=27) - --- f.R study characteristics (mean age in years from measure the children's intelligence in 16 stud- �._r..w.�li--w---- _-•-•- �:.?*. ..,....w.. the age range and year of publication in each ies. Other intelligence measures included the Figure 1.Flow diagram of the meta-analysis. Environmental Health Perspectives • VOLUME 120 I NUMBER 10 I October 2012 1363 • Choi et al. -0.25, 0.04) (Figure 2). The study with a although the difference did not appear to be the two covariates. The overall test of the positive association reported an SMD esti- significant.Heterogeneity,however,remained covariates was significant(p=0.004). mate of 0.07 (95% CI:-0.8, 0.22). Similar at a similar magnitude when the analyses were When the model was restricted to the results were found with the fixed-effects SMD restricted(Table 2). 16 studies that used the CRT-RC,the child's estimates. The fixed-effects pooled SMD Sources of heterogeneity. We performed age(but not year of publication)was a signifi- estimate was-0.40 (95% CI:-0.44,-0.35), meta-regression models to assess study char- cant predictor of the SMD.The R2 of 65.6% with a p-value<0.001 for the test for homo- acteristics as potential predictors of effect. of between-study variance was explained by geneity. The random-effects SMD estimate Information on the child's sex and paren- the two covariates, and only 47.3% of the was-0.45 (95% CI:-0.56,-0.34) with an tal education were not reported in > 80% residual variation was attributable to hetero- I2 of 80% and homogeneity test p-value of the studies,.and only 7% of the studies geneity.The overall test of both covariates in < 0.001 (Figure 2). Because of heterogeneity reported household income. These variables the model remained significant(p=0.0053). (excess variability) between study results,we were therefore not included in the models. On further restriction of the model to exclude used primarily the random-effects model for Among the two covariates, year of publica- the 7 studies with arsenic and iodine as co- subsequent sensitivity analyses,which is gen- tion (0.02; 95% CI: 0.006, 0.03), but not exposures and fluoride originating from coal erally considered to be the more conserva- mean age of the study children (-0.02; 95% burning(thus including only the 9 with fluo- tive method (Egger et al. 2001).Among the CI:-0.094, 0.04),was a significant predictor ride exposure from drinking water), neither restricted sets of intelligence tests, the SMD in the model with all 27 studies included. I2 age nor year of publication was a significant for the model with only CRT-RC tests and residual 68.7% represented the proportion predictor,and the overall test of covariates was drinking-water exposure (and to a lesser of residual between-study variation due to less important(p=0.062),in accordance with extent the model with only CRT-RC tests) heterogeneity. From the adjusted R2, 39.8% the similarity of intelligence test outcomes and was lower than that for all studies combined, of'between-study variance was explained by the source of exposure in the studies included. Table 1.Characteristics of epidemiological studies of fluoride exposure and children's cognitive outcomes. No.in high- No.in Age - • Study exposure reference range Fluoride exposure Outcome Reference location group group (years) Assessment Range measure Results Ren et al Shandong 160 169 8 14 High/ Not specfied M Wechsler Children in high fluoride region find lower,ID scores 1989 China= low fluoride Intelligence ' z Chen et al. Shanxi, 320 320 7-14 Drinking 4.55 mg/L(high); CRT-RC° The average IQ of children from high-fluoride area 1991 China water 0.89 mg/L(reference) were lower than that of te reference area .Guo-et al Hunan_;' 60 61- 7 13 Fluoride iii'; 1181 13617 mg%kg Chinese :Average 10"in fluoride.coal burni g area we's i1991 China__ - coal-burning? (coal burning area) Binete thanthat in the;reference area �_,_- - Control'ar'ea:used,wood Lin et al. Xinjiang, 33 86 7-14 NDrinking 0.88 mg/L(high); CRT-RCb Children in the high-fluoride(low-iodine)area had 1991 China water 0.34 mg/L(reference) lower IQ scores compared with the children from the reference fluoride(low-iodine)areas 'Sun et al Gwyang 196 224 6 5-12 Rate of Fluorosis 98.36%-,; Japan IQ aMean;IQ was lower rn all age groups except-<7 years,. 21991 China `- fluorosis (high)not specified test's in the areawith high filuoride and.aluminum(limited „__ - k. .,- r (reference} .n.r to high fluoridepopulation only);; , , An et al. Inner 121 121 7-16 Drinking 2.1-7.6 mg/L(high); Wechsler ID scores of children in high-fluoride areas were 1992 Mongolia, water 0.6-1.0 mg/L Intelligence significantly lower than those of children living in China (reference) ' testa reference fluoride area 1-iYetal Sichuan 106 49 1213 Burnmgof 474316mg/kg(high) Child nEftly,prolongedhighfluoriderntakecausesa 1994 China:'- ,:tefr:',Kgifffe high fluoride_ 0 5 mg/kg(reference) marital work decrease i thelchdd s mental work capacity y > coal to cook capacity °� grammhigh' ! _ LLV fluoride ar _ 4, _ Xu et al. Shandong, 97 32 8-14Drinking 1.8 mg/L(high); Binet- Children had lower ID scores in high-fluoride area , 1994 China water 0.8 mg/L(reference) Simone than those who lived in the reference area. Yang et al' Shandong i 30 30 8-14 ell water 2 97 mg/L(high} :, Chinese The average IQ scores was lower in children,from X1994 China ` _ 05 mg/L_(reference} comparative :high fluonde and iodine area,than those from the i telhgence •-4reference area but the results were not significant Li XS et al. Guizhou, 681 226 8-13 Urine,Dental 1.81-2.69 mg/L(high); CRT-RCb Children living in fluorosis areas had lower IQ scores 1995 China Fluorosis 1.02 mg/L(reference); than children living in nonfluorosis areas Index DFI 0.8-3.2(high); DFI<0.4(reference) Wang G .y.,•• Xrnpang X1.47 83 4-7 Drinking S >1 0-S 6 mg/L(higfi) Wechsler °Average IQscorewas-lower in-children m the high et al 1996 China;' water 0 58 1,0 mg/L Intelligence --fluonde group than those m the,reference group .$ _�._ (reference) testa r ___ ra.a Yao et al. Liaoning, 266 270 8-12 Drinking 2-11 mg/L(high); CRT-RCb Average ID scores of children residing in exposed fluoride 1996 China water 1 mg/L(reference) areas were lower than those in the reference area *Zhao et al'° Shan160 160 -7 14- Drinking 412mg/I(high) ' CRT-RCb a Childien hying rn high fluoride and arsenic area had .1996 China°'il vvater 0 911mg/L-,Irefe'rence) =significantly lower IQ"scores than those living rn the Yao et al. Liaoning, 188 314 7-14 Drinking 2 mg/L(exposed); CRT-RCb. ID scores of children in the high-fluoride area were 1997 China water 0.4 mg/L(reference) lower than those of children in the reference area Continued 1364 VOLUME 1201 NUMBER 10!October 2012 • Environmental Health Perspectives Fluoride neurotoxicity Although official reports of lead concentra- tests did not indicate significant (p < 0.05) Discussion tions in the study villages in China were not departures from symmetry. Findings from our meta-analyses of 27 stud- available,some studies reported high percent- Pooled risk ratios. The relative risk(RR) ies published over 22 years suggest an inverse age (95-100%) of low lead exposure (less of a low/marginal score on the CRT-RC test association between high fluoride exposure and than the standard of 0.01 mg/L) in drinking- (< 80) among children with high fluoride children's intelligence. Children who lived in water samples in villages from several study exposure compared with those with low areas with high fluoride exposure had lower IQ provinces (Bi et al. 2010; Peng et al. 2008; exposure(16 studies total)was 1.93 (95%CI: scores than those who lived in low-exposure or Sun 2010). 1.46, 2.55;I22 58.5%).When the model was control areas. Our findings are consistent with Publication bias. A Begg's funnel plot restricted to 9 studies that used the CRT-RC an earlier review(Tang et al. 2008), although with the SE of SMD from each study plotted and included only drinking-water fluoride ours more systematically addressed study selec- against its corresponding SMD did not show exposure(Chen et al. 1991; Fan et al.2007; tion and exclusion information,and was more clear evidence of asymmetry, although two Li XH et al. 2010; Li XS et al. 1995; Li Y comprehensive in a) including 9 additional studies with a large SE also reported relatively et al. 2003; Lu et al. 2000;Wang ZH et al. studies, b) performing meta-regression to esti- large effect estimates, which may be concis- 2006;Yao et al. 1996, 1997),the estimate was mate the contribution of study characteristics tent with publication bias or heterogeneity similar (RR= 1.75; 95% CI: 1.16, 2.65; J2 as sources of heterogeneity, and c) estimating (Figure 3). The plot appears symmetrical for 70.6%).Although fluoride exposure showed pooled risk ratios for the association between studies with larger SE, but with substantial inverse associations with test scores, the fluoride exposure and a low/marginal Raven's variation in SMD among the more precise available exposure information did not allow test score. studies, consistent with the heterogeneity a formal dose-response analysis. However, As noted by the NRC committee (NRC observed among the studies included in the dose-related differences in test scores occurred at 2006), assessments of fluoride safety have analysis.Begg(p=0.22)and Egger(p=0.11) a wide range of water-fluoride concentrations. relied on incomplete information on potential Table 1.Continued. No.in high- No.in Age Fluoride exposure Study exposure reference range Outcome Reference location group group (years) Assessment Range measure Results .Zhang JW Xmhang cs51 52 4 10 Drinking Not specified Japan IQ :'Average l0 scores of;'chlldren residing-in high fluoride `et al 1998, Cfirna water Testd Land arsenic area were lower than thosewho resided- fn hejeference area Lu et al. Tianjin, 60 58 10-12 Drinking 3.15 mg/L(high); CRT-RCb Children in the high-fluoride area scored significantly 2000 China water 0 37 mg/L(reference) lower IQ scores than those in the reference area ;Hong et at°,_ Shandong 85 32 8 14 Drinking 2 90 mg/L(high) CRT RCb Average 10 scOres,were significantly lower in,hrgh Ya 0001 China`;„ 4-_' water 075mg/L{refer"erice) fluonde:group(and iodine);thanahereferencegroup .. Wang SH Shandong, 30 30 8-12 Drinking 2.97 mg/L(high); CRT-RCb No significant difference in ID scores of children in et al.2001 China water 0.5 mg/L(reference) the high-fluoride/high-iodine and reference fluoride/ low-iodine areas -Lr Y et al Inner „'. 720 236 6-13 Fluorosis Endemic vs control CRT RCb Average'10 of children m high,fluorosis areas 2003 lvlongolia regions defined liy the lower than that imthe reference area a_�a w 4 China Chuiese Geological- r z r- - �� Office Xiang et al. Jiangsu, 222 290 8-13 Drinking 0.57-4.5 mg/L(high); CRT-RCb Mean IQ score was significantly lower in children who 2003 China water 0.18-0.76 mg/L lived in the high-fluoride area than that of children (reference) in the reference exposure area(both areas also had arsenic exposure) `Serat et al°- Tehran; -41 85 Not Drinking 2 5°mg/L(high) Raven° -_ -The mean7Q of children in the high fluoride area • :2.006 Iran x specified 'water .0 4 mg/h(reference) was srgmficantly lower than that from the reference N _ fluoride area _ Wang ZH Shanxi, 202 166 8-12 Drinking 5.54±3.88 mg/L CRT-RCb The IQ scores of children in the high-fluoride group et al.2006 China water (high);0.73±0.28 were significantly lower than those in the reference mg/L(reference) group fan et al Shaanxi 42 37 7 14 Drinking 1 14 6 09 mg/L(high) GRT RGb The average IQ scores of children residin mi the ;2007 China s - twater 133 2 35 mg/L hig) fluoride area were lower than those of children .r= _ - r reference r tesidi mithe referencearea - t Wang SX Shanxi, 253 196 8-12 Drinking 3.8-11.5 mg/L(water,high); CRT-RCb Mean ID scores were significantly lower in the high- et al.2007 China water and 1.6-11 mg/L(urine,high); fluoride group than from the reference group in the urine • 0.2-1.1 mg/L(water, fluoride/arsenic areas reference); 0.4-3.9 mg/L(urine, reference) .Lr et al Hunan 60 20 8 12 'Coal burning T24 2 34 mg/L{high) CRT RCb Mean I0 was lower in childrenln coel burning areas ;2009 China,„ s<< :,, ,OMai_„- hex_ 0962_mg/Lfreference). .. _t___compared_toihose,lnthereferericegroup-,_i_,�_ 4a; Li FH et al. Henan, 347 329 7-10 Drinking 2.47±0.75 mg/L(high) CRT-RCD No significant difference in IQ scores between 2010 China water children in the exposed and reference groups 1?oureslamr; 0:00F1TEtgli5VAPPW,60 6-9 Dnnkmg 2 38 mg/L(high) Raven° ,Children lnxhe high fluondegroup scored sigmfican3ly et al 2011 , Wates-- 0 41 mg/L(reference) lower than those 1n reference group 8Wechsler Intelligence Scale(Lin and Zhang 1986).°CRT-RC,Chinese Standardized Raven Test rural version(Wang Get al.1989).'Chinese Binet Test(Wu 1936)."Japan test(Zhang J et al.19851.'Binet-Simon Test(Binet and Simon 1922).(Chinese comparative intelligence test(Wu 1983).9Raven test(Raven et al.2003). Environmental Health Perspectives • VOLUME 120 I NUMBER 101 October 2012 1365 Choi et al. risks. In regard to developmental neuro- difference was not significant. The exposed development at exposures much below those toxicity, much information has in fact been groups had access to drinking water with fluo- that can cause toxicity in adults (Grandjean published, although mainly as short reports ride concentrations up to 11.5 mg/L(Wang 1982). For neurotoxicants such as lead and in Chinese that have not been available to SX et al.2007); thus, in many cases concen- methylmercury, adverse effects are asso- most expert committees. We carried out an trations were above the levels recommended elated with blood concentrations as low as extensive review that includes epidemiological (0.7-1.2 mg/L; DHHS) or allowed in pub- 10 nmol/L. Serum fluoride concentrations studies carried out in China.Although most lie drinking water (4.0 mg/L; U.S. EPA) in associated with high intakes from drinking reports were fairly brief and complete informa- the United States (U.S.EPA 2011).A recent water may exceed 1 mg/L, or 50 pmol/L- tion on covariates was not available,the results cross-sectional study based on individual-level more than 1,000 times the levels of some other tended to support the potential for fluoride- measure of exposures suggested that low ley- neurotoxicants that cause neurodevelopmental mediated developmental neurotoxicity at rela- els of water fluoride(range, 0.24-2.84 mg/L) damage. Supporting the plausibility of our Lively high levels of exposure in some studies. had significant negative associations with chil- findings, rats exposed to 1 ppm (50 Nmol/L) We did not find conclusive evidence of publi- dren's intelligence (Ding et al. 2011). This of water fluoride for 1 year showed morpho- cation bias,although there was substantial het- study was not included in our meta-analysis, logical alterations in the brain and increased erogeneity among studies.Drinking water may which focused only on studies with exposed levels of aluminum in brain tissue compared contain other neurotoxicants, such as arsenic, and reference groups,thereby precluding esti- with controls(Varner et al. 1998). but exclusion of studies including arsenic and mation of dose-related effects. The estimated decrease in average IQ asso- iodine as co-exposures in a sensitivity analy- The results suggest that fluoride may be a ciated with fluoride exposure based on our sis resulted in a lower estimate, although the developmental neuroroxicant that affects brain analysis may seem small and may be within the measurement error of IQ testing.However,as Study Location SMD(95%CI) %Weight research on other neurotoxicants has shown,a' °Fegetal`1989„' ,, Shaniong -+ =_ _O.5,)-097-052), 4.22- shift to the left of IQ distributions in a popu- Chen et al 1991 Shanxi -r- - -1)26(-0.41,-0.10) 4.66 lation will have substantial impacts, especially Guo et aI'1991 Hunan -=�- --0.44(-0 80'0 08) 3 26 among those in the high and Iow ranges of the Lin et al 1991 Xinjiang • .: -0.64(7151,-028) 323 ;Sun et x1:..7991 Guiyang, -+- - 0.95( 1 76-0 75) IQ distribution(Bellinger 2007). An et al.1992 I Mongolia +,_ -0.57(-0.83_-0.31) 3.98 Our review cannot be used to derive an tiVatat 1994' Sichuan • (4454:41.00!) 339x` exposure limit, because the actual exposures Xu et a1.1994 Shandong - . .a-0.93(-135,-0.52) 2.91 of the individual children are not known. is Yang,'etal...199'5 Shandong 70,-02) 236; Misclassification of children in both hi h Li XS et al.1995 Guizhou i'!!!!!!!! !!!.. -±-L 0.55(-0.70,-0.39) 4.68 g °Wang G atat 1998 ' Xmpang ;,+^; )3.38(-065°-010) _ y,3.88`:;; and low-exposure groups may have occurred Yao et al.1996 Liaoning - ,-0.34(-051,-0.17) 4.57 if the children were drinking water from other i`Zhaoetal;1996 Shanxi--_ --+- • Yao et al.1997 Liaoning -0.43(-0.61,-025) 4.49 sources(e.g. at school or in the held). p published The reports clearlyrepresent ZhangJVtletal 1998:, Xmpaog- ! X0.17(-055;_0.22) .:,-309--`� Lu et al.2000 Tianjin -0.62(-098,-025) 320 independent studies and are not the result , EHongatat 2001 Shandong • 0441 085 X03) 294.x; of duplicate publication of the same studies Wang SH et al 2001 Shandong -0.50(-1.01,0.02) 236 !!Li Y ef'x1.2003 I Mongolia 0:10( 0,25;0.04)„ 4 71 , (we removed two duplicates). Several studies Xiang et 81.2003 Jiangsu -0.64(-0.82,-0.46) 452 (Hong et al.2001;Lin et al. 1991;Wang SH Serajet,al 2006 Tehran_,"_ x;891:'1.28, 050) 308. et al.2001;Wang SX et al.2007;Xiang et al. Wang ZH et al.2006 Shanxi -+ ' -0.27(-0.47,-0.06) 434 2003; Zhao et al. 1996) report other expo- Wang • -0:171-061;0.27) 375 Wang Si et al.2007 ShanxiV.,!!!!!!,:!,.!•:!_,;!!!!-!!!!,.!,, -•. -026(-0.44,-0.07) 4.46 sures, such as iodine and arsenic, a neuro- :,U FH et el 2009 - Hunan • A),43(-0:94,0.08) 2386 toxicant, but our sensitivity analyses showed Li XH et al.2010 Henan 0.07(-058,0.22) 4.69 • similar associations between high fluoride Poureslarniµeta1.2011?,rt Iran • -0;41(--077-004) 325? exposure and the outcomes even after these overall(/2=Bork,p=0.000) -0.45(-0.56,-0.34) 100.00 studies were excluded. Large tracts of China -1.5 -1 0 0.5 1 0 Figure 2.Random-effect standardized weighted mean difference(SMD)estimates and 95%Cls of child's intelligence score associated with high exposure to fluoride.SMs for individual studies are shown as solid diamonds(•),and the pooled SMD is shown as an open diamond(0).Horizontal lines represent 95%Cis 010 for the study-specific SMDs. h ° Table 2.Sensitivity analyses of pooled random-effects standardized weighted mean difference(SM DI o =. estimates of child's intelligence score with high exposure of fluoride. Available p-Value 025 studies for test of i Model analysis SMD(95%CI) /2 heterogeneity 1 -0.5 0 1.Exclude nonstandardized testsa 23 -0.44(-0.54,-0.33) 77.6% <0.001 • SMD 2.Excludenon-CRT-RCTests5 . 16 -0.36)-0.48,-D.25) 77.8% <0.001 Figure 3. Begg's funnel plot showing individual 3.Exclude studies with other exposures(iodine,arsenicr 9 -0.29)-0.44,-0.14) 81.8% <0.001 studies included in the analysis according to or non-drinking-water fluoride exposures random-effect standardized weighted mean differ- °Mental work capacity(Li Yet al.1994);Japan IQ(Sun et al.1991;Zhang JW et al.1998);Chinese comparative scale ence(SMD)estimates(x-axis)and the SE(se)of of intelligence test(Yang et al.1994).bWechsler intelligence test(An et al.1992;Ren et al.1989;Wang G et a1.1996); each study-specific SMD(y-axis).The solid verti- Chinese Binet IQ(Guo et al.1991);Raven(Poureslami et al.2011;Seraj et al.2006);Binet-Simon(Xu et al.1994).'Iodine cal line indicates the pooled SMD estimate for all (Hong et al.2001;Lin et al.1991;Wang SH et al.2001);arsenic[Wang SX et al.2007;Xiang et al.2003;Zhao et al.1996; studies combined and the dashed lines indicated (Zhang JW et al.1998 was already excluded,see note a)].°Fluoride from coal burning[Li FH et a1.2009(Guo et al.1991 pseudo 95%confidence limits around the pooled and Li Y et al.1994 were already excluded;see notes a and b)]. SMD estimate. 1366 VOLUME 1201 NUMBER 101 October 2012 • Environmental Health Perspectives t. Fluoride neurotoxicity . have superficial fluoride-rich minerals with Prevention 1999;Petersen and Lennon 2004), Higgins JP,Thompson SG.2002.Quantifying heterogeneity in a little, if any, likelihood of contamination by the NRC report examined the potential meta-analysis.Stat Med 21:1539-1558. Hong F,Cao Y,Yang D,Wang H.2001.A study of fluorine other neurotoxicants that would be associ- adverse effects of fluoride at 2-4 mg/L effects on children's intelligence development under ated with fluoride concentrations in drinking in drinking water and not the benefits or different environments.Chin Prim Health Care 15:56-57. water. From the geographic distribution of potential risks that may occur when fluoride Available:http://www.fluoridealert.org/chinese/[accessed uthe studies, it seems unlikelythat fluoride- is added topublic water supplies at lower 20Aen X, 0121. PP Li FH,Chen X,Huang RJ,Xie YP.2009.Intelligence impact of attributed neurotoxicity could be attributable concentrations(0.7-1.2 mg/L)(NRC 2006). children with endemic fluorosis caused by fluoride from to other water contaminants. In conclusion,our results support the possi- coal burning[in Chinese].J Environ Health 26(41:338-340. Still, each of the articles reviewed had bility of adverse effects of fluoride exposures on Li XH,Hou GQ,Yu B,Yuan CS,Liu Y,Zn's ig L,et al.2010. InvestigatioeV and analysis of children's intelligence and deficiencies,in some cases rather serious ones, children's neurodevelopment. Future research dental fluorosis in high fluoride area[in Chinese].J Med that limit the conclusions that can be drawn. should formally evaluate dose-response rela- Pest Control 26(31:230-231. However, most deficiencies relate to the tions based on individual-level measures of Li XS,eZhi JL,Gas RD.1995.Effect of fluoride exposure on intelli- re ortin of where keyinformation was miss- exposure over time, includingmoreprecise JincXiCchildren.FluWan2.2003.T92. P g P Li Y,Jing X,Chen D,Lin L,Wang Z.2003.The effects of endemic ing. The fact that some aspects of the study prenatal exposure assessment and more exten- fluoride poisoning on the intellectual development of children were not reported limits the extent to which sive standardized measures of neurobehavioral in Baotou.Chin J Public Health Ma nag 19(41:337-338. Available:http://www.fluoridealert.org/chinese/[accessed the available reports allow a firm conclusion. performance, in addition to improving assess- 20 August 20121. Some methodological limitations were also ment and control of potential confounders. Li Y,Li X,Wei S.1994.Effect of excessive fluoride intake on noted. Most studies were cross-sectional, but mental work capacity of children and a preliminary study of its mechanism.J West China Univ Med Sci 25)2):188-191. this study design would seem appropriate REFERENCES Available:http://www.fluoridealert.org/chinese/[accessed in a stable population where water supplies 20 August 2012]. and fluoride concentrations have remained Agency for Toxic Substances and Disease Registry.2003. Lin C,Zhang H.1986.Wechsler Children Intelligence Scale.Revised Toxicological Profile for Fluorides,Hydrogen Fluoride,and Edition in China.Beijing:Beijing Normal University Press. unchanged for many years.The current water Fluorine(Update).Available:http://www.atsdr.cdc.gov/ Lin FF,Ai HT,Zhao HX,Lin J,Jhiang JY,Maimaiti,et al.1991. fluoride level likely also reflects past develop- toxprofiles/tp11.pdf[accessed 5 April 2010]. High fluoride and low iodine environment and subclinical mental exposures. In regard to the outcomes, An JA,Mei SZ,Liu AP,Fu Y,Wang CF.1992.Effect of high level cretinism in Xinjiang[in Chinese].Endem Dis Bull 6(21:62-67. of fluoride on children's intelligence[in Chinese].Chin J Lu Y,Sun ZR,Wu LN,Wang X,Lu W,Liu SS.et al.2000.Effect of the inverse association persisted between stud- Control Endem Dis 7(2):93-94. high-fluoride water on intelligence in children[in Chinese]. ies using different intelligence tests, although Begg CB,Mazumdar M.1994.Operating characteristics of Fluoride 33(21:74-78. most studies did not report age adjustment of a rank correlation test for publication bias.Biometrics Mullenix PJ,Denbesten PK,Schunior A,Kernan WJ.1995. the co itive test scores. 50:1086-1101. Neurotoxicity of sodium fluoride in rats.Neurotoxicol Bellinger DC.2007.Interpretation of small effect sizes in occu- Teratol 17:169-177. Fluoride has received much attention in pational and environmental neurotoxicity:individual ver- NRC(National Research Council).2006.Fluoride in Drinking China, where widespread dental fluorosis sus population risk.Neurotoxicology 28:245-251. Water:A Scientific Review of EPA's Standards.Washington, Bi WJ,Zheng X,,Lan TX.2010.Analysis on test results of drink- DC:National Academies Press. indicates the prevalence of high exposures. ing waters quality in Janan Railway Bureau from 2005- Peng YP,Zou J,Yang DF,Li XH,Wu K.2008.Analysis of water In 2008, the Ministry of Health reported 2009[in Chinese].Prey Med Trib 16(61:483-485. quality from homemade wells in Leshan downtown that fluorosis was found in 28 provinces with Binet A,Simon T.1922.The Measurement of the Mental during 2004-2006[in Chinese].J Occup Health Damage. 92 million residents (China News 2008). Development of the Child(translated into Chinese by Jie 23(4)219-221. FP).Shanghai:Commercial Press. Petersen PE,Lennon MA.2004.Effective use of fluorides for the Although microbiologically safe,water sup- Centers for Disease Control and Prevention.1999.Achievements prevention of dental caries in the 21st century:the WHO plies from small springs or mountain sources in public health,1990-1999:fluoridation of drinking water to approach.Community Dent Oral Epidem 32(51:319-321. prevent dental caries.MMWR48(41):933-940. Poureslami HR,HordA,Atash R.2011.High fluoride exposure created pockets of increased exposures near Chen YX,Han F,Zhou Z,Zhang H,Jiao X,Zhang S,et al.1991. in drinking water:effect on children's IQ,one new report or within areas of low exposures, thus re re- p highInt J Pediatr Dent 21(suppl 11:47. P repre- on the intellectual development of children in senting exposure settings close to the ideal, fluoride areas.Chin J Control Endem Dis 6(suppl).99-100. Raven J,Raven JC,Court JH.2003.Manual for Raven's because only the fluoride exposure would dif- Available:http://www.fluoridealert.org/chinese/[accessed Progressive Matrices and Vocabulary Scales.San Antonio, 20 August 2012]. TX:Harcourt Assessment fer between nearby neighborhoods. Chinese China News.2006.Twenty-eight provinces were affected by Ren DL,Li K,Lin D.1989.An investigation of intelligence researchers took advantage of this fact and fluorosis in China[in Chinese].Available:http://news. development of children aged 8-14 years in high-fluoride published their findings; though mainly in qq.com/a/20081216/001707.htm[accessed 3 July 2012]. and low-iodine areas.Chin J Control Endem Dis 4:251. Chioca LR,Raupp IM,Da Cunha C,Louse EM,Andreatini R. Available:http://www.fluoridealert.org/chinese/[accessed Chinese journals and according tO the Stan- 2008.Subchronic fluoride intake induces impairment 20 August 2012]. dards of science at the time. This research in habituation and active avoidance tasks in rats.Eur J Seraj B,Shahrabi M,Falahzade M,Falahzade FP,Akhondi N. dates back to the 198Os, but has not been Pharmacol 579:196-201. 2006.Effect of high fluoride concentration in drinking Ding Y,Gao V.Sun H,Han H,Wang W,Ji X,et al.2011.The water on children's intelligence.J Dental Med 19(21:80-86. widely cited at least in part because of limited relationships between low levels of urine fluoride on chil- [abstract in English].Available:http://journals.tums.ac.ir/ access to Chinese journals. g upload_files/pdf/,J2530.pdf[accessed 24 August 2012]. dren's intelli ence,dental fluorosis in endemic fluorosis In its review of fluoride,the NRC (2006) area in Hulunbuir,Inner Mongolia,China.J Hazard Mater Stern JAC.2009.Meta-analysis in State:An Updated Collection College 186:1942-1946. from the Stata Journal. Station,TX:State Press. noted that the safety and the risks of fluoride at concentrations of 2-4mg/L were incompletely Egger M,Davey Smith G,Altman O6.2001.Systematic Reviews Sun LY.2010.Survey of drinking water quality in Jintang County g P y in Health Care:Meta-Analysis in Context.London:BMJ [in Chinese].J Occup Health Damage 25(51:277-289. . documented. Our comprehensive review Publishing. Sun MM,Li SK,Wang YF,U FS.1991.Measurement of intelli- substantially extends the scope of research Egger M,Davey Smith G,Schneider M,Minder C.1997.Bias in gence by drawing test among the children in the endemic meta-analysis detected by a simple,graphical test.BMJ area of Al-F combined toxicosis[in Chinese].J Guiyang available for evaluation and analysis.Although 315:629-634. Med College 16(31:204-206. the studies were generally of insufficient Fan ZX,Dai HY,Bai AM,Li P0,Li T,LI GD,et al.2007.Effect Tang QQ,Du J,Ma HH,Jiang SJ,Zhou XJ.2008.Fluoride and quality, the consistency of their findings of high fluoride exposure in children's intelligence[in children's intelligence:a meta-analysis.Bio Trace Elem Chinese].J Environ Health 24(101:802-803. Res 126:115-120. adds support to existingevidence of fluoride-PPGrandjean P.1982.Occupational fluorosis through 50 years: Trivedi MH,Verma RJ,Chinoy NJ,Patel RS,Sathawara NG. associated cognitive deficits, and suggests clinical and epidemiological experiences.Am J Ind Med 2007.Effect of high fluoride water on intelligence of school that potential developmental neurotoxicity 3(21:227-336. children in India.Fluoride 40131:178-183. Grandjean P,Landrigan P.2006.Developmental neurotoxicity of U.S.EPA.2011.EPA and HHS Announce New Scientific of fluoride should be a high research industrial chemicals.Lancet 366195531:2167-2178. Assessments and Actions on Fluoride:Agencies Working priority. Although reports from the World Guo XC,Wang R,Cheng C,Wei W;Tang L,Wang Q,et al.1991. • Together to Maintain Benefits of Preventing Tooth Decay Health Organization and national agencies A preliminary exploration of ID of 7-13 year old pupils in a while Preventing Excessive Exposure.Available:http:// fluorosis area with contamination from burning coal.Chin yosemite.epa.gov/opo/admpress.nsf/bd4379a92ceceeac85 have generally focused on beneficial effects J Endemiol 10:98-100.Available:http://www.fluoridealert. 25735900400c27/86964af577c37ab285257811005a6417!Open of fluoride (Centers for Disease Control and org/chinese/[accessed 20 August 2012]. Document[accessed 7 January 2011]. Environmental Health Perspectives • voLUME 1201 NUMBER 101 October 2012 1367 r £v 4' ' 1 Choi et al. Varner JA,Jensen KF,Horvath W,Isaacson RL.1998.Chronic World Bank.2006.Water Duality Management:Policy and Yao LM,Deng Y,Yang SY,Zhou JL,Wang SL,Cui JW.1997. administration of aluminum-fluoride or sodium-fluoride to Institutional Considerations.Available:http://siteresources. Comparison of children's health and intelligence between rats in drinking water:alterations in neuronal and cerebro- worldbank.org/INTEAPREGTOPENVIRONMENT/Resources/ the fluorosis areas with and without altering water vascular integrity.Brain Res 764:284-298. China WPM_final_lo_res.pdf[accessed 13 June 2012]. sources[in Chinese].Lit Inf Prey Med 3(11:42-43. Wang D,Di M,Dian M.1989.Chinese Standardized Raven Test, World Health Organization.2002.Fluorides.Geneva:World Yao LM,Zhou JL,Wang SL,Cui KS,Lin FY.1996.Analysis of Rural Version.Tianjin,China:Tianjin Medical University. Health Organization.Available:http://whglibdoc.who.intl TSH levels and intelligence of children residing in high Wang G,Yang D,Jia F,Wang H.1996.Research on intelligence ehc/WHO_EHC_227.pdf[accessed 5 September 2012]. fluorosis areas[in Chinese].Lit Inf Prev Med 2(1):26-27. quotient of 4.7 year-old children in a district with a high Wu TM.1936.Second revision of Chinese-Binet Intelligence Zhang J,Gung Y,Guo J.1985.Children Intelligence Scale level of fluoride.Endem Dis Bull 11:60-62.Available:http:// Test Shanghai:Commercial Press(in Chinese). Handbook.Beijing:Captial Institute of Pediatrics Heatlh www.fluoridealert.org/chinese/[accessed 20 August 2012]. Wu T.1983.The Chinese Comparative Intelligence Test Research Office. Wang SH,Wang LF,Hu PY,Guo SW,Law SH.2001.Effects of Guidebook.3rd ed.Beijing:Beijing University Press. Zhang JW,Yao H,Chen Y.1998.Effect of high level of fluoride high iodine and high fluorine on children's intelligence and Xiang D,Liang Y,Chen L,Wang C,Chen B,Chen X,et al.2003. and arsenic on children's intelligence[in Chinese].Chin J thyroid function[in Chinese].Chin J Endemiol 20(4):288-290. Effect of fluoride in drinking water on children's intel- Public Health 17(2):57. Wang SX,Wang ZH,Cheng XT,Li J,Sang ZP,Zhang XD,et al. ligence.Fluoride 36(2):84-94. Zhang M,Wang A,Xia T,He P.2008.Effects of fluoride on DNA 2007.Arsenic and fluoride exposure in drinking water:chil- Xu YL,Lu CS,Zhang XN.1994.Effect of fluoride on children's damage,S-phase cell-cycle arrest and the expression dren's ID and growth in Shanyin County,Shanxi Province, intelligence[in Chinese].Endem Dis Bull 2:83-84. of NF-KB in primary cultured rat hippocampal neurons. • China.Environ Health Perspect 115:643-647. Yang Y,Wang X,Guo X,Hu P.1994.Effects of high iodine and Toxicol Lett 179:1-5. Wang ZH,Wang SX,Zhang XD,Li J,Zheng XT,Hu CM,et al. high fluorine on children's intelligence and the metabolism Zhao LB,Liang GH,Zhang DN,Wu XR.1996.Effect of a high 2006.Investigation of children's growth and development of iodine and fluorine.Chin J Pathol 15(51:296-298. fluoride water supply on children's intelligence.Fluoride under long-term fluoride exposure[in Chinese;abstract in Available:http://www.fluoridealert.arg/chinese/[accessed 29(4):190-192. English].Chin J Control Endem Dis 21(41:239-241. 20 August 2012]. • • • 1368 VOLUME 120 I NUMBER 101 October 2012 • Environmental Health Perspectives („.-----'- •A io*: P 1/2- . .40._;.• .Fi:'.-.012W4In.r-rs-'Z. 1., ,' ,,,,,' 7.,--1/2.1-...1.`r.`:'''',. .--, '...;,- • 17177.17$,, :,‘,4,•:,-,';:. ..,:,.i.,.:0k4ii,Aleitt_foi4,ri.-AN -'•',--•.:ikItAti...:•4',r-— -%1/2''''. 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DEDICATION This 2005 edition of Fluoridation Facts is dedicated to Dr. Herschel Horowitz, talented researcher, renowned dental epidemiologist and tireless advocate of community water fluoridation. ABOUT FLUORIDATION ACKNOWLEDGMENTS ACKNOWLEDGMENTS , . ",Y; c, 1)) riPi.?:.;:grtar ;; tiglargifl In.'0) -T'-)0!fitilie41,LreiriV iiiY07;..141(5)1-02)K1, i . 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DISCLAIMER This publication is designed to answer frequently asked questions about community water fluoridation, based on a summaryof relevant published articles. It is not intended to be a comprehensive review of the extensive literature on fluoridation and fluorides. Readers must also rely on their own review of the literature,including the sources cited herein and any subsequent published,for a complete understanding of these issues. ©2005 American Dental Association This publication may not be reproduced in whole or in part without the express written permission of the American Dental Associa- tion except as provided herein. - -- 1 . ADA American Dental Association' <<=: i America's leading advocate for oral health ADA Statement Commemorating the 60t''Anniversary of r"'i Community Water Fluoridation a ,,.,. Sixty years ago,Grand Rapids,Michigan became the world's first city to adjust the level ` . of fluoride in its water supply. Since that time,fluoridation has dramatically improved ff: the oral health of"tens of millions of Americans. Community water fluoridation is the h,- single most effective public health measure to prevent tooth decay. Additionally,the €i Centers for Disease Control and Prevention proclaimed community water fluoridation as I J one of 10 great public health achievements of the 20th century. i IN s._ . Fluoridation of community water supplies is simply the precise adjustment of the i.,, existing naturally occurring fluoride levels in drinking water to an optimal fluoride level t - t[., recommended by the U.S.Public Health Service(0.7—1.2 parts per million)for the t" prevention of dental decay. Based on data from 2002,approximately 170 million people (or over two-thirds of the population)m the United States are served by public water systems that are fluoridated. 011. ,h`= Studies conducted throughout the past 60 years have consistently indicated that tkto fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. It is the most efficient way to prevent one of the most common childhood diseases—tooth decay(5 times as common as asthma and 7 times as 1,- ,, common as hay fever in 5-to17-year-olds). Early studies, such as those conducted in Grand Rapids, showed that water fluoridation :__3 reduced the amount of cavities children get in their baby teeth by as much as 60%and reduced tooth decay in permanent adult teeth nearly 35%. Today,studies prove water fiLW- fluoridation continues to be effective in reducing tooth decay by 20-40%,even in an era with widespread availability of fluoride from other sources,such as fluoride toothpaste. 6' The average cost for a community to fluoridate its water is estimated to range from approximately$0.50 a year per person in large communities to approximately$3.00 £ ayearperperson in small communities. For most cities,every$1 invested in water , r, fluoridation saves$38 in dental treatment costs. ;. The American Dental Association continues to endorse fluoridation of community b' water supplies as safe and effective for preventing tooth decay. This support has been ., the Association's position since policy was first adopted in 1950. The ADA's policies regarding community water fluoridation arc based on the overwhelming weight of peer- reviewed,credible scientific evidence. The ADA,along with state and local dental 9 societies,continues to work with federal,state,local agencies and community coalitions to increase the number of communities benefiting from water fluoridation. '•.s � 2005 Se. e= 211 East Chicago Avenue Chicago;Illinois 60611-2678 •{ 'i Permission is hereby granted to reproduce and distribute this ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation in its entirety, .' without modification.To request any other copyright permission please contact the American Dental Association at 1-312 440-2879. • :ri M` Fluoridation Facts 1 s 5 i �,V-k-..-41.;.•„„i'':4; `' `` e S ,y�" t; a�' a r Al4° 4.f.'-, a "l f.x Spa 7.-tt ' em -_- =.9.-'�Lr.r"_:. a 5''ti`� X•a -,^�,`.�.ri c' ..,•-?„ :�.,.,n... Y - - - ..... '-. .. TABLE OF CONTENTS ADA Statement Commemorating the 1 SAFETY 22 60th Anniversary of Community Water Fluoridation Question Topic Page Executive Summary 4 17. Harmful to humans? 22 18. More studies needed? 23 Introduction 6 19. Total intake? 24 20. Daily intake? 25 21. Prenatal dietary fluoride 26 BENEFITS 10 supplements? 22. Body uptake? 26 Question Topic Page 23. Bone health? 27 1. What is fluoride? 10 24. Dental fluorosis? 28 2. How does fluoride help 25. Prevent fluorosis? 30 prevent dental decay? 10 3. What is water fluoridation? 11 26. Warning label? 31 4. How much fluoride is in 27. Toxicity? 31 your water? 11 28. Cancer? 32 5. Fluoride additives? 12 29. Enzyme effects? 33 6. Natural vs adjusted? 12 30. Thyroid gland? 34 7. Effectiveness? 13 31. Pineal gland? 34 8. Still effective? 14 32. Allergies? 34 9. Discontinuance? 15 33. Genetic risk? 35 10. Is decay still a problem? 16 34. Fertility? 35 11. Adult benefits? 16 35. Down Syndrome? 35 12. Dietary supplements? 17 36. Neurological impact? 36 13. Fluoride for children? 18 37. Lead poisoning? 37 14. Alternatives? 19 38. Alzheimer's disease? 37 15. Bottled water? 19 39. Heart disease? 38 16. Home treatment(filter)systems? 21 40. Kidney disease? 38 41. Erroneous health claims? 39 2 American Dental Association {" ` 3 u # 6 f a5'' �[ ¢ •..�s ,....:!:`,;.„ ."r,.' A , 'F Sx 1"...�,,..2. .. '," . v A t ``.t ar,:-%s ?- X "' . ..F.1 FLUORIDATION PRACTICE 40 Call to Action 57 Question Topic Page References 58 42. Water quality? 40 Statements from Five Leading Health 68 43. Regulation? 41 Organizations Regarding Community 44. Standards? 42 Water Fluoridation 45. Source of additives? 43 Compendium 69 46. System safety concerns? 43 47. Engineering? 44 48. Corrosion? 44 . 49. Environment? 45 Figures 1. Reviewing Research _ 7 2. Effectiveness List 13 PUBLIC POLICY 46 3. ADA.org-Bottled Water 20 Question Topic Page 4. Safety List 23 50. Valuable measure? 46 5. 1998 Consumers'Opinions 48 51. Courts of law? 47 6. Approval of Fluoridating 48 52. Opposition? 47 Drinking Water 7. Opposition Tactics 50 53. Internet? 51 8. ADA.org-Fluoride and 51 54. Public votes? 51 Fluoridation 55. International fluoridation? 54 9. Largest Fluoridated Cities 52 56. Banned in Europe? 54 10. States.Meeting National Goals 53 Tables COST EFFECTIVENESS 56 1. Dietary Fluoride Supplements 18 Question Topic Page 2. Bottled Water 20 57. Cost effective? 56 3. Dietary Reference Intakes 25 58. Practical? 57 4. Categories of Dental Fluorosis 28 Fluoridation Facts 3 „ f ; Ii I _ 4 EXECUTI ,VE• • MSU ` r ' • Fluoridation of community water.supplies is thesln • For mos#;clues every $1' invested m water fluonda le most.'effective ublic_.health,measure to revent tion sa•ves$38 in dental treatment costs 1:-:':• _''.1j::'''.---'..:”: 9 • P p , ( dental decay • Water'that has been fortified with fluoride is slml , E Throughout more'than 60 ears of research and- rac - 'la`r to_forti in 'saltzwith Iodine;=milk`with-vitamin J,▪• '' tical experience; the overwhelming weight of credi D• 'and orange juice with"•vitamin'C G ,;ble'scientific evidence has consistently indicated:that ," fluoridation•of comm_unity water su•pplies is sef_e:: ;,....!2.,� Simply by drinking water peopVle can benefit:from fluoridations cavity protection whether,,they are at • The Centers for, Disease Control and Prevention:has 2 home work or school 77 { proclaimed, community water fluoridation (along a with vaccinations and infectious;disease;control_)_as The average costfor a co'mmunityto fluoridate its wa - one of ten great,public health achievements of the ter. is estimated to range,"'from approximately$0:50 a 20" Century year'per personin large communities to:approximately 1'' - ;$3.00 a year per'person in small•communities . -- I r • More than 100 national and international'-•health; ser r vice,and professional organizations recognize the pub , • 'More than two thirds of-the population in the United, f- = lic health benefits of corrtrnunity water fluoridation for ,State s are served:by,public water systems that are P f preventing dental decay7. , ptimally fluoridated i h p s e' ast7.five years (2000 through 2004) ,more • Studies rove water fluoridation continues to.be of • ln"th p 1fective in reducing dental decay by 20 40% ,even in: than 125 U S communities in-36 states have voted_ I 1.-.':''':--1'''''''-;"' an.-era`with widespread availability of.fluoride from to adopt'flu•oridation rces,such as-fluoride toothpa ti . ste r " other.so • • l • :Fluoridation has=been thoroughly tested in'the Unit-, ,' , •j Community water fluoridation,benefits everyone; es "' ed States' court'system; and found to be a proper ( •_ - pedally those'u'vithout access to regular, dental care: j l f li • ir k L. e�a,l rr • -- - _ -} -=F i} 1 [r rr, 1 !CC , Y , z I ` ,I ; 1 'r r , l: r ' k {{ 'G ;r ,i + - , 1 -E50� a fi; r- 1 011i „ t Ir, d '44 r'rr t {f, r r' ''r�, r 1- f y I 11� u - #L . s , 4 1 • '11�� i - INTRODUCTION ince 1956,the American Dental Association(ADA)has anced conclusions based on their research findings and published Fluoridation Facts. Revised periodically, have published their results in refereed (peer-reviewed) Fluoridation Facts answers frequently asked questions professional journals that are widely held or circulated. about community water fluoridation. In this 2005 edition Studies showing the safety and effectiveness of water issued as part of the 60"Anniversary celebration of com- fluoridation have been confirmed by independent sci- munity water fluoridation, the ADA Council on Access, entific studies conducted by a number of nationally and Prevention and Interprofessional Relations provides up- internationally recognized scientific investigators. While dated information for individuals and groups interested opponents of fluoridation have questioned its safety and in the facts about fluoridation.The United States now haseffectiveness, none of their charges has ever been sub- over 60 years of practical experience with community wa- stantiated by generally accepted science. ter.fluoridation. Its remarkable longevity is testimony to With the advent of the Information Age,a new type of fluoridation's significance as a public health measure. In "pseudo-scientific literature" has developed. The public recognition of the impact that water fluoridation has had often sees scientific and technical information quoted in on the oral and general health of the public, in 1999, the the press, printed in a letter to the editor or distributed Centers for Disease Control and Prevention named fluori- via an Internet Web page. Often the public accepts such dation of drinking water as one of ten great public health information as true simply because it is in print.Yet the achievements of the 20'h century.1,2 information is not always based on research conducted according to the scientific method, and the conclusions Support for Water Fluoridation drawn from research are not always scientifically justifi- Since 1950,the American Dental Association (ADA) has able. In the case of water fluoridation, an abundance continuously and unreservedly endorsed the optimal of misinformation has been circulated. Therefore, sci- fluoridation of community water supplies as a safe and entific information from all print and electronic sources effective public health measure for the prevention of must be critically reviewed before conclusions can be dental decay. The ADRs policy is based on its continu- drawn. (See Figure 1.) Pseudo-scientific literature may ing evaluation of the scientific research on the safety peak a reader's interest but when read as science, it can and effectiveness of fluoridation. Since 1950, when the be misleading. The scientific validity and relevance of ADA first adopted policy recommending community claims made by opponents of fluoridation might be best water fluoridation, the ADA has continued to reaffirm viewed when measured against criteria set forth by the its position of support for water fluoridation and has U.S.Supreme Court. strongly urged that its benefits be extended to corn- 6Additional information on this topic may be found in munities served by public water systems.3 The 2005 Question 52. "ADA Statement Commemorating the 60'h Anniversary of Community Water Fluoridation" reinforced that po- History of Water Fluoridation sition.4 Fluoridation is the most effective public health Research into the beneficial effects of fluoride began measure to prevent dental decay for children and adults, in the early 1900s. Frederick McKay, a young dentist, reduce oral health disparities and improve oral health opened a dental practice in Colorado Springs, Colo- over a lifetime.5 rado, and was surprised to discover that many local The American Dental Association, the U.S. Public residents exhibited brown stains on their permanent Health Service, the American Medical Association and teeth. Dr. McKay could find no documentation of the the World Health Organization all support community condition in the dental literature and eventually con- water fluoridation. Other national and international vinced Dr. G.V. Black,dean of the Northwestern Univer- health, service and professional organizations that rec- sity Dental School in Chicago, to join him in studying ognize the public health benefits of community water the condition. Through their research, Drs. Black and fluoridation for preventing dental decay are listed on McKay determined that mottled enamel, as Dr. Black the inside back cover of this publication. termed the condition, resulted from developmental imperfections in teeth. (Mottled enamel is a historical Scientific Information on Fluoridation term. Today, this condition is called dental or enamel The ADAs policies regarding community water fluoride- fluorosis.) Drs. Black and McKay wrote detailed de- tion are based on generally accepted scientific knowledge. scriptions of mottled enamel.6•7 This body of knowledge is based on the efforts of nation- In the 1920s, Dr. McKay,along with others,suspected ally recognized scientists who have conducted research that something either in or missing from the drinking using the scientific method, have drawn appropriate bal- water was causing the mottled enamel. Dr. McKay wrote 6 American Dental Association -- c_^'. r- sr--xr� pec' 7'F,�'�33' �•, �rty "'� ie-` _ --r k'# .�,�:�y �{ -r,°c 1 " 4• • to the Surgeon General in 1926 indicating that he had in January 1945. The other three studies were conducted identified a number of regions in Colorado, New Mexico, in Newburgh, New York (May 1945); Brantford, Ontario Arizona, California,'Idaho, South Dakota, Texas and Vir- (June 1945) and Evanston, Illinois (February 1947.)13-16 ginia where mottled enamel existed. Also in the late 20s, The astounding success of these studies firmly estab- Dr. McKay made another significant discovery — these lished fluoridation as a practical and safe public health stained teeth were surprisingly resistant to decay.' measure to prevent dental decay that would quickly be Following additional studies completed in the early embraced by other communities. 1930s in St. David,Arizonas and Bauxite,Arkansas,9 it The history of water fluoridation is a classic example of was determined that high levels of naturally occurring a curious professional making exacting clinical observa- fluoride in the drinking water were causing the mottled tions which led to epidemiologic investigation and even- enamel. In Arizona, researchers scrutinized 250 resi- tually to a safe and effective community-based public dents in 39 local families and were able to rule out he- health intervention which even today remains the corner- reditary factors and environmental factors, except for stone of communities'efforts to prevent dental decay. one -fluoride in the water which occurred naturally at levels of 3.8 to 7,15 ppm, In Bauxite, H. V, Churchill, chief chemist with the Aluminum Company of America The Centers far DiseaseNControl 3r d (later changed to ALCOA), was usinga new method P� " f , k 1'7,-42 � 9 ���� 'Prevention named fluorrdat�on of drtnking� of spectrographic analysis in his laboratory to look at wte ,one of ten great public healthy -3 the possibility that the water from an abandoned deep achievements o 'tpe 20th century noting that ' well in the area might have high levels of aluminum = r y containing bauxite that was causing mottled teeth. it is a malar factor responsible for then What he found was that the water contained a highf f' decline in dental decay' 1 ,' 4' level of naturally occurring fluoride (13.7 ppm). When ==- -_-- Dr. McKay learned of this new form of analysis and Dr. Churchill's findings, he forwarded samples of water Water Fluoridation as a Public from areas where mottled enamel was commonplace Health Measure to Dr. Churchill. All of the samples were found to have Throughout decades of research and more than sixty high levels of fluoride when compared to waters tested years of practical experience, fluoridation of public from areas with no mottled enamel.' water supplies has been responsible for dramatically During the 1930s, Dr. H. Trendley Dean, a dental of- improving the public's oral health. In 1994, the U.S. ficer of the U.S. Public Health Service, and his associ- Department of Health and Human Services issued a ates conducted classic epidemiological studies on the report which reviewed public health achievements. geographic distribution and severity of fluorosis in Along with other successful public health measures the United States.10 These early studies were aimed at such as the virtual eradication of polio and reductions evaluating how high the fluoride levels in water could in childhood blood lead levels, fluoridation was laud- be before visible, severe dental fluorosis occurred. By ed as one of the most economical preventive inter- 1936, Dean and his staff had made the critical discovery ventions in the nation.1' A policy statement on water that fluoride levels of up to 1.0 part per million (ppm) in fluoridation reaffirmed in 1995 by the USPHS stated the drinking water did not cause the more severe forms that water fluoridation is the most cost-effective, prac- of dental fluorosis. Dean additionally noted a correla- tical and safe means for reducing the occurrence of tion between fluoride levels in the water and reduced dental decay in a community,18 In 1998, recognizing incidence of dental decay.11•12 the ongoing need to improve health and well being, In 1939,Dr.Gerald J.Cox and his associates at the Mel- the USPHS revised national health objectives to be Ion Institute evaluated the epidemiological evidence and achieved by the year 2010. Included under oral health conducted independent laboratory studies. While the is- was an objective to significantly expand the fluorida- sue was being discussed in the dental research commu- tion of public water supplies. Specifically, Objective nity at the time,they were the first to publish a paper that 21-9 states that at least 75% of the U.S. population proposed adding fluoride to drinking water to prevent served by community water systems should be receiv- dental decay.13 In the 1940s, four classic, community- ing the benefits of optimally fluoridated water by the wide studies were carried out to evaluate the addition of year 2010.19 sodium fluoride to fluoride-deficient water supplies.The In 1999,the Centers for Disease Control and Preven- first community water fluoridation program, under the tion named fluoridation of drinking water one of ten direction of Dr. Dean, began in Grand Rapids, Michigan, great public health achievements of the 20th century not- 8 American Dental Association >44' t. :1 -J.',F y .. . '%• `p i '= t j''',"'' , 'i"'q �."1 tat'- `- s` ' ! .n4 ^i .,'a�tem°ft j' 5 "'. FSS �' L ,• ,• �} .,. n b ''''''"-'‘'4-';' -.,'„fii„k. 'bw�.. j--1 r. '''.4.2.' t• is•'. ,. ,. . , 4e _ . : «•t17;•. .',: � .", �&, II f INT R0DUCif:FON �' f `fir ing that it is a major factor responsible for the decline in due in part to the benefits they receive from water dental decay.'`2 fluoridation. Dental costs for these individuals are Former U.S. Surgeon General David Satcher issued likely to have been reduced and many hours of need- the first ever Surgeon General report on oral health in less pain and suffering due to untreated dental decay May 2000. In Oral Health in America:A Report of the Sur- have been avoided. geon General, Dr. Satcher stated that community water fluoridation continues to be the most cost-effective, prac / , tical and safe means for reducing and controlling the oc- W'aterfluoridation contrnuestto be ,'''::' '''i currence currence of dental decay in a community.5.2° Additionally, effective m reducing dental decay by�,20 4O%' ? Dr. Satcher noted that water fluoridation is a powerful `q '- v < ;even in an era w:th widespread availability, strategy in efforts to eliminate health disparities among „ t - , .; populations. Studies have shown that fluoridation may of fluoryde1rl r fothersources such as 1 i. be the most significant step we can take toward reducing = , fluoride toothpaste ' `` the disparities in dental decay.5,2024 �.. _ ,;, _ ,,„, :F . - 5t.,.,--.:,,,-.:.:-. ;..J In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called It is important to note that dental decay is caused by on policymakers, community leaders, private industry, dental plaque, a thin, sticky, colorless deposit of bacte- health professionals, the media and the public to affirm ria that constantly forms on teeth.When sugar and oth- that oral health is essential to general health and well be- er carbohydrates are eaten, the bacteria in plaque pro- ing. Additionally,Surgeon General Carmona urged these duce acids that attack the tooth enamel. After repeated groups to apply strategies to enhance the adoption and attacks,the enamel breaks down, and a cavity (hole) is maintenance of proven community-based interventions formed. There are a number of factors that increase an such as community water fluoridation.25 individual's risk for dental decay:27,3°_33 Community water fluoridation is a most valuable • Recent history of dental decay public health measure because: • Elevated oral bacteria count • Optimally fluoridated water is accessible to the en- • Inadequate exposure to fluorides tire community regardless of socioeconomic status, • Exposed roots educational attainment or other social variables.26 • Frequent intake of sugar and sugary foods • •Individuals do not need to change their behavior to • Poor or inadequate oral hygiene obtain the benefits of fluoridation. • Decreased flow of saliva • Frequent exposure to small amounts of fluoride - Deep pits and fissures in the chewing surfaces over time makes fluoridation effective through the of teeth life span in helping to prevent dental decay. Exposure to fluoride is not the only measure avail- • Community water fluoridation is more cost effec- able to decrease the risk of decay. In formulating a de- tive than other forms of fluoride treatments or ap- cay prevention program,a number of intervention strat- plications.27 egies may be recommended such as changes in diet and placement of dental sealants. However,fluoride is a Water Fluoridation's Role in Reducing key component in any recommended strategy. Dental Decay Water fluoridation and the use of topical fluoride have Ongoing Need for Water Fluoridation played a significant role in improving oral health. Because of the risk factors for dental decay noted Early studies showed that water fluoridation can re- previously, many individuals and communities still duce the amount of cavities children get in their baby experience high levels of dental decay. Although wa- teeth by as much as 60%and can reduce dental decay ter fluoridation demonstrates an impressive record in permanent adult teeth by nearly 35%. Since that of effectiveness,and safety, only 67.3 % of the United time, numerous studies have been published mak- States population on public water supplies receives ing fluoridation one of the most widely studied public fluoridated water containing protective levels of flu- health measures in history. Later studies prove water oride.34 Unfortunately, some people continue to be fluoridation continues to be effective in reducing den- confused about this effective public health measure. tal decay by 20-40%, even in an era with widespread If the number of individuals drinking fluoridated water availability of fluoride from other sources, such as is to increase,the public must be accurately informed fluoride toothpaste.28,29 Increasing numbers of adults about its benefits. are retaining their teeth throughout their lifetimes Fluoridation Facts 9 .y. --r i4 k ' s Fx_ s-- P p a', 'e a i .�3 7: �. _.,,,.. �., r* 45rk--, - � $ l 5 z taN:z.s `5 S4 1 ,. s S �' -ak `fix ' �,. `.:V�t ^i,v'� �,, • € ,�, iT �'.4 ^k4.-k-, -tr- N. 'a 3' fi.' {4"T !. ' a t -i ; a .-�- f --r tSFi$a,a 1'4h. , ..>� . v � �v 'f'.t . "€� s s k � . BENEFITS Q 1. What is fluoride? p.10 Q 6. Natural vs adjusted? p.12 Q 13. Fluoride for children? p.18 Q 2. How does fluoride help p.10 Q 7. Effectiveness? p.13 0 14. Alternatives? p.19 prevent dental decay? Q 8. ' Still effective? p.14 Q 15. Bottled water? p.19 Q 3. What is water p.11 fluoridation? Q 9. Discontinuance? p.15 Q 15. Home treatment p.21 Q 4. How much fluoride is p:11 Q 10. Is decay still a problem? p.16 (filter)systems? in your water? Q 11. Adult benefits? p.16 Q 5. Fluoride additives? p.12 Q 12. Dietary supplements? p.17 QUESTION 1. Fact. What is fluoride? Systemic fluorides are those ingested into the body. During tooth formation, ingested fluorides become in- Answer. corporated into tooth structures. Fluorides ingested Fluoride is a naturally occurring compound that can help regularly during the time when teeth are developing prevent dental decay. (preeruptively) are deposited throughout the entire tooth surface and provide longer-lasting protection Fact. than those applied topically.42 Systemic fluorides can The fluoride ion comes from the element fluorine. also give topical protection because ingested fluoride i. Fluorine is an abundant element in the earth's crust is present in saliva, which continually bathes the teeth in the form of the fluoride ion. As a gas, it never oc- providing a reservoir of fluoride that can be incorporat- 2' curs in its free state in nature, but exists only in corn- ed into the tooth surface to prevent decay. Fluoride also s bination with other elements as a fluoride compound. becomes incorporated into dental plaque and facilitates Fluoride compounds are components of minerals in further remineralization.43 Sources of systemic fluoride 4. rocks and soil. Water passes over rock formations and in the United States include fluoridated water, dietary dissolves the fluoride compounds that are present, re- fluoride supplements in the forms of tablets, drops or leasing fluoride ions. The result is that small amounts lozenges and fluoride present in food and beverages. of fluoride are present in all water sources. Gener- ally, surface water sources such as lakes, rivers and I ,w : , a ,j r 4 3 :� streams have very low levels of fluoride. For example, Fluoride protects teeth in t'v ways zi,- Lake Michigan's fluoride level is 0.17 ppm.35 As water systemtcally'and topically,, 4 , moves through the earth, it contacts fluoride-contain- �- "5`. , :_ 4 ing minerals and carries away fluoride ions. The con- centration of fluoride in groundwater varies according While it was originally believed that fluoride's action to such factors as the depth at which the water is was exclusively systemic or preeruptive, by the mid- found and the quantity of fluoride bearing minerals in 1950s, there was growing evidence of both systemic the area.36 In the United States, the natural level of and topical benefits of fluoride exposure.44 fluoride in ground water varies from very low levels to0Additional information on this topic may be found in over 4 ppm. The fluoride level of the oceans ranges Question 11. from 1.2 to 1.4 ppm.37,38 Fluoride is naturally present Topical fluorides strengthen teeth already present in to some extent in all foods and beverages, but the the mouth (posteruptively). In this method of delivery, concentrations vary widely.39-41 fluoride is incorporated into the surface of teeth making them more decay-resistant. Topically applied fluoride provides local protection on the tooth surface. Topical fluorides include toothpastes, mouthrinses and profes- sionally applied fluoride foams, gels and varnishes. QUESTION 2. As mentioned previously, systemic fluorides also pro- How does fluoride help prevent dental decay? vide topical protection. Low levels of fluoride in saliva and plaque from sources such as optimally fluoridated Answer. water can prevent and reverse the process of dental Fluoride protects teeth in two ways-systemically and decay.45 In clarifying the effectiveness of water fluorida- topically. tion, John D.B. Featherstone, PhD, Professor and Chair, 10 American Dental Association .. Awa of r., �, r rsrs+g'4.: . ,`....:'.4t'....1.07.1110.,..•, 4,., a - % . t, ,• 5Y 3'F'€�. a s's !E€`€ R -$did #;�'+� ''•, ,,. ap..' tb � :-,n f ..o-.t3'xy ,, �4.:.. R ,p5 . .'y.{f. 4' d S'� ..'^a '.F' =•T''- k. 14 :S, `, _::;. ». „.''';' ''',._,',11,Z- A t t• '; ',:.„W.,..-,-....,, '.' v .KEN °Questions 1 16` ...',,..-„.,:..i? i...:,:.,,,,, , , ,: ,r r .. c., .„ ....a .. �.L.*,C.:4:e; � i�N', *t .� i 4. c.I' .11'g. R' 5,., n - _ . S `�.F. ,..�� ���% 'sem+. ,'4 t;. e' Department of Preventive and Restorative Dental Ser- For clarity, the following terms and definitions are vices, University of California San Francisco, noted: "... used in this booklet: There is irrefutable evidence in numerous studies that Community water fluoridation is the adjustment of fluoride in the drinking water works to reduce dental the natural fluoride concentration in water up to the caries in populations. This is still the case."46 level recommended for optimal dental health (a range of 0.7 to 1.2 ppm). Other terms used interchangeably in John D B Featherstone PhD Professor this booklet are water fluoridation, fluoridation and op- .! ry timally fluoridated water. Optimal levels of fluoride may ; and Chair,Department of Preventwe and; a be present in the water naturally or by adjusted means. Restorative Dental Services Unrve'rsrty of 6 Additional information on this topic may be found in ' Cahfornra SankkFrancisco noted There rs Question 6. irrefutable evrdencernnumerous studies that Sub-optimally fluoridated water is water that natural- fluonde in the dnnkrng watertworks to reduce` '` ly contains less than the optimal level (below 0.7 ppm) dental canes-.“7.,'24:: POpopulations i i',n�, of fluoride. Other terms used interchangeably in this = _ booklet are nonfluoridated water and fluoride-deficient , , . , ..... water. The remineralization effect of fluoride is important. Flu- oride ions in and at the enamel surface result in fortified enamel that is not only more resistant to decay (loss of QUESTION 4. minerals or demineralization), but enamel that can repair How much fluoride is in your water? or remineralize early dental decay caused by acids from decay-causing bacteria,42,4751 Fluoride ions necessary for remineralization are provided by fluoridated water as well Answer. as various fluoride products such as toothpaste. If your water comes from a public/community water The maximum reduction in dental decay is achieved supply,the options to learn the fluoride level of the wa- when fluoride is available preeruptively (systemically) ter include contacting the local water supplier or the for incorporation during all stages of tooth formation local/county/state health department, reviewing your and posteruptively (topically) at the tooth surface. Wa Consumer Confidence Report(CCR)and using the Inter- ter fluoridation provides both types of exposure.aa,sz-54 net based "My Water's Fluoride." If your water source is a private well,it will need to be tested and the results obtained from a certified laboratory. QUESTION 3. Fact. What is water fluoridation? The fluoride content of the local public or community wa- ter supply can be obtained by contacting the local water Answer. supplier or the local/county/state health department. Water fluoridation is the adjustment of the natural fluo- 1999, the U.S. Environmental Protection Agency ride concentration of fluoride-deficient water to the (EPA) began requiring water suppliers to put annual level recommended for optimal dental health. drinking water quality reports into the hands of its cus- tomers. Typically available around July 1st each year, Fact. these Water Quality Reports, or Consumer Confidence Based on extensive research, the United States Public Reports (CCRs), may be mailed to your home, placed Health Service (USPHS) established the optimum con- in the local newspaper or made available through the centration for fluoride in the water in the United States Internet.56 To obtain a copy of the report, contact the in the range of 0.7 to 1.2 parts per million. This range local water supplier. The name of the water system (of- effectively reduces dental decay while minimizing the ten not the name of the city) can be found on the water occurrence of dental fluorosis.The optimum level is de- bill. If the name of the public water system is unknown, pendent on the annual average of the maximum daily contact the local health department. air temperature in the geographic area.55 There are two sites on the Internet that supply in- One milligram per liter (mg/L) of fluoride in water is formation on water quality. The online source for identical to one part per million (ppm). At 1 ppm, one water quality reports or CCRs is the EPA web site at part of fluoride is diluted in a million parts of water. Large http://www.epa.gov/safewater/dwinfo/index.htm1.57 numbers such as a million can be very difficult to visual- Additionally, the Centers for Disease Control and ize. While not exact,the following comparisons can be of Prevention's (CDC) fluoridation Web site, "My Water's assistance in comprehending one part per million: Fluoride,” is available at http://apps.nccd.cdc.gov/MWF/ 1 inch in 16 miles Index.asp.58 For those states that have provided infor- 1 minute in 2 years mation to the CDC, the site lists fluoridation status by 1 cent in$10,000 water system. Fluoridation Facts 11 Y .' 6rt*": ' "ifs:¥ ., , -i n . y la - :�'" t`l"ry ;•,a d v v "� k `,4e#.;v l' . .' '. G - ' I -__<.,.�... 'l ' -------I _ • X - �. A . . . • t r -- "'N, 4"-'�. t4 rsix��.. - .. : . '. - L The EPA does not have the authority to regulate QUESTION 6. private drinking water wells. However, the EPA recom Is there a difference in the effectiveness between natu- mends that private well water be tested every year. rally occurring fluoridated water (at optimal fluoride While the EPA does not specifically recommend testing levels) and water that has fluoride added to reach the for the level of fluoride, health professionals will need optimal level? this information prior to consideration of prescription of dietary fluoride supplements or to counsel patients Answer. about alternative water sources to reduce the risk of No. The dental benefits of optimally fluoridated water fluorosis if the fluoride levels are above 2 ppm.59 occur regardless of the fluoride's source. Additional information on n this topic may be found in Questions 12,24,25 and 42. Fact. Always use a stategcertified laboratory that conducts Fluoride is present in water as "ions" or electrically drinking water tests. For a list of state certified labs,con charged atoms.36 These ions are the same whether ac- tact the local,county or state water/health department. quired by water as it seeps through rocks and sand or added to the water supply under carefully controlled conditions. When fluoride is added under controlled QUESTION J. conditions to fluoride-deficient water, the dental ben- What additives are used to fluoridate water supplies in efits are the same as those obtained from naturally fluo the United States? ridated water. Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all Answer. drinking water sources. Sodium fluoride,sodium fluorosilicate and fluorosilicic ,:.1:i,'";:1!1' 1' - n ) , „�� i�'��rti,��, _ f acid are the three additives approved for,community "Fluoridation is merely an increase of the` water fluoridation in the United States. Sodium fluoro ' level of the naturally occurring fluoride V silicate and fluorosilicic acid are sometimes referred to ''11:15:!,,j ' r ' 4 5 presentspt -011 dnnk�ng water,sources ,! as silicofluoride additives. \'..., ,, , 'l--.. Er e,-; , ;0 6 Fact. Some individuals use the term "artificial fluorida- The three basic additives used to fluoridate water in the7. tion" to imply that the process of water fluoridation is United States are: 1) sodium fluoride which is a white, unnatural and that it delivers a foreign substance into odorless material available either as a powder or crys a water supply when, in fact, all water sources contain tals;2) sodium fluorosilicate which is a white or yellow some fluoride. Community water fluoridation is a natu- white, odorless crystalline material and 3) fluorosilicic ral wayto improve oral health.62 acid which is a white to straw-colored liquid.36'60 (.Additional information on this topic may be found in While fluoridation began in 1945 with the use of so Question 45. dium fluoride, the use of silicofluoridesbegan in 1946 Prior to the initiation of"adjusted"water fluoridation, and, by 1951, they were the most commonly used ad several classic epidemiological studies were conducted ditives.61 First used in the late 1940s, fluorosilicic acid that compared naturally occurring fluoridated water to is currently the most commonly used additive to fluori fluoride-deficient water. Strikingly low decayrates were date communities in the U.S.36,61 found to be associated with the continuous use of water # with fluoride content of 1 part per million.12 y To,ensureihe pubhes safety standards A fluoridation study conducted in the Ontario, Cana- have'been established to ensure thesafety da, communities of Brantford (optimally fluoridated by s -„ adjustment), Stratford (optimally fluoridated naturally) 1-. o€fluoride additsves used rn water -�4 ' and Sarnia (fluoride-deficient) revealed much lower de- r,,wr 'i treaty ientin the u./.st"� # ca rates in both Brantford and Stratford as compared �'" g'" "`' to nonfluoridated Sarnia. There was no observable dif- To ensure the public's safety, standards have been ference in decay-reducing effect between the naturally established to ensure the safety of fluoride additives occurring fluoride and adjusted fluoride concentration used in water treatment in the U.S. Specifically, addi water supplies, the proving'that dental source of fluoride.ben6efits were simi- tives used in water fluoridation meet standards of the lar regardless of the American Water Works Association (AWWA) and NSF International (NSF). Additional information on the topic of fluoride addi- tives may be found in Fluoridation Practice Section. 12 American Dental Association * " ,; � �a- " rte1f---1 n+ r ��. '�� p �,�'a Z:l! � t ' & a . { a `v i , ,4 f 7 ° t4 € 3,ENE1F1TSa. s � a c3 S," QUESTION 7 After 14 years of fluoridation in Evanston, Illinois, Is water fluoridation effective in helping to prevent den- 14-year-olds had 57% fewer decayed, missing or filled tal decay? teeth than the control group in Oak Park, Illinois, who drank water low in fluoride.65 Answer. In 1983, a study was undertaken in North Wales Overwhelming evidence exists to prove the effective- (Great Britain) to determine if the decay rate of fluori- ness of water fluoridation. Water fluoridation is a very dated Anglesey continued to be lower than that of non- effective method'for preventing dental decay for chil- fluoridated Arfon, as had been indicated in a previous dren, adolescents and adults. Continued assessment, survey conducted in 1974. Decay rates of life-long resi- however, is important as the patterns and extent of dents in Anglesey, aged 5, 12 and 15, were compared dental decay change in populations. with decay rates of identically aged residents in nonflu- oridated Arfon. Study results demonstrated that a de- Fact. cline in decay had occurred in both communities since The effectiveness of water fluoridation has been docu- the previous survey in 1974. However, the mean decay merited in scientific literature for over 60 years. (See rate of the children in fluoridated Anglesey was still 45% Figure 2.) Even before the first community fluoridation • lower than that of those living in nonfluoridated Arfon.66 program began in 1945, epidemiologic data from the These findings indicated a continuing need for fluorida- 1930s and 1940s revealed lower number of cavities in children consuming naturally occurring fluoridated wa tion although decay levels had declined.67 ter compared to children consuming fluoride-deficient In the United States, an epidemiological survey of water.11•12 Since that time, thousands of studies have nearly 40,000 schoolchildren was completed in 1987.29 'been done which continue to prove fluoride's effective- Nearly 50% of the children in the study aged 5 to 17 ness in decay reduction. years were decay-free in their permanent teeth, which In Grand Rapids, Michigan, the first city in the world was a major change from a similar survey in 1980 in to fluoridate its water supply, a 15-year landmark study which approximately 37% were decay-free. This dra- showed that children who consumed fluoridated water matic decline in decay rates was attributed primarily from birth had 50-63%less dental decay than children who to the widespread use of fluoride in community water had been examined during the original baselinesurveysupplies, toothpastes, supplements and mouthrinses. completed in nonfluoridated Muskegon,Michigan. Ten years after fluoridation in Newburgh, New York, Although decay rates had declined overall, data also 6 to 9-year-olds had 58% less dental decay than their revealed that the decay rate was 25% lower in children counterparts in nonfluoridated Kingston, New York, with continuous residence in fluoridated communities which was fluoride-deficient. After 15 years, 13-to 14- when the data was adjusted to control for fluoride ex- year-olds in Newburgh had 70% less decay than the posure from supplements and topical treatments. children in Kingston.64 A controlled study conducted in 1990 demonstrated that average dental decay experience among schoolchil- Figure 2. Effectiveness of Community dren who were lifelong residents of communities with Water Fluoridation low fluoride levels in drinking water was 61-100% high- --Centers=for Disease_Control and'Preventiion Recom er as compared with dental decay experience among mendations for Usirigfluoride toTreventand Control schoolchildren who were lifelong residents of a com- :DentalCaries_in;the United States MMWR 2001'50 munity with an optimal level of fluoride in the drinking 'SNo RR-14) 1Guidelines on the use offluoride) water.66 In addition, the findings of this study suggest . that community water fluoridation still provides signifi- Horowit" tS The effectiveness-=of community wa cant public health benefits and that dental sealants can ter fluorldaUon in the-United States J Public Health; play a significant role in preventing dental decay. Dent 3996 56(5 Spec No)253 8 (A review of fifty` Using data from the dental surveys in 1991-2 and years ofv✓a#er fluoridation) 1993-4, a British study predicted that on average,water Murray JJ Efficacy of-preventiveagents for dental:; fluoridation produces a 44% reduction in dental decay canes Earies Res1993,27(Suppi_9)2-8(A review of= in 5-year-old children. The study further demonstrated studiesconductedfrom 1976 through'1987 ) that children in lower socioeconomic groups derive Newbrun E Effectiveness of _watery fluoridation an even greater benefit from water fluoridation with J Public`Health Dent 1989 49(5)279 89 (The analysis = an average 54% reduction in dental decay. Therefore, of the results of713studies in 23 countries} children with the greatest dental need benefit the most Ripa LW A half century of cornmunitywater fluorida from water fluoridation.69 tion n th"e"UnitedStates review andreolnmentary J.: In 1993,the results of 113 113 studies in 23 countries were i Public Health Dent 1993 53(1)17 44 1The:analysis of compiled and analyzed. (Fifty-nine out of the 113 stud fi ears ofwaterfluorida#ion) ies analyzed were conducted in the United States.)This y review provided effectiveness data for 66 studies in pri- mary teeth and for 86 studies in permanent teeth.Taken Fluoridation Facts • 13 Lit .i.t:. a ,r.....ux�^:�i-4 "��"0'f•.h".��.' Na. slut=y,ft '2' ' together,the most frequently reported decay reductions QUESTION 8. observed were: With other forms of fluoride now available,is water flu- 40-49% for primary teeth or baby teeth;and oridation still an effective method for preventing dental 50-59% for permanent teeth or adult teeth. decay? In a second review of studies conducted from 1976 through 1987,28 when data for different age groups were Answer. - separated, reductions in dental decay in fluoridated Although other forms of fluoride are available,persons communities were: , in nonfluoridated communities continue to demon- 30-60% in the primary dentition or baby teeth; _ strate higher dental decay rates than their counterparts 20-40% in the mixed dentition*(aged 8 to 12); in communities with water fluoridation.68•78-7479-83 (*A mixed dentition is composed of both baby teeth and adult teeth.) Fact. 15-35% in the permanent dentition or adult teeth In the 1940s, children in communities with optimally (aged 14 to 17);and fluoridated drinking water had reductions in decay rates 15-35% in the permanent dentition(adults and of approximately 60% as compared to those living in seniors). nonfluoridated communities. At that time, drinking wa- A comprehensive analysis of the 50-year history ter was the only source of fluoride other than fluoride of community water fluoridation in the United States that occurs naturally in foods. further demonstrated that the inverse relationship be- Recent studies reveal that decay rates have declined tween higher fluoride concentration in drinking water in naturally or adjusted fluoridated areas and nonfluo- and lower levels of dental decay discovered a half-cen- ridated areas as well. One factor is the high geographic tury ago continued to be true?' mobility of our populations. In other words,it is becom- • Baby bottle tooth decay is a severe type of early child- ing increasing difficult to study large numbers of people hood decay that seriously affects babies and toddlers in in one location who have a history of consuming only some populations. Water fluoridation is highly effective fluoridated or nonfluoridated water. 8 in preventing decay in baby teeth, especially in children from low socioeconomic groups.72 In a 1998 review of lk1 g, the effectiveness of methods currently used to prevent 'Even m an era wrt'h_vuldesp'r`ead availability this type of decay,water fluoridation received the high of fluoride,frorr othersources;studies prove - est rating. For very young children, water fluoridation water fluorida_tion:contin ues_to be effective s is the onlymeans of prevention that does not require a2044,6,%!- -7,.,,,-,:-. q in reducrng dental£decay Iiy " - 73 63 f A Y. at" ,:- 9. dental visit or motivation of parents and caregivers. ,,�MM,', a x;,. , ___ ,- ,_,,, F�����,> In 2001, the National Institutes of Health (NIH) held a consensus development conference, "Diagnosis and A second factor is the universal availability of fluo- Management of Dental Caries Throughout Life." As part ride from other sources including food, beverages, den- of the Consensus Statement issued at the conclusion of tal products (toothpaste, rinses, professionally applied the conference, the panel noted that water fluoridation foams, gels and varnish) and dietary supplements.B6 is widely accepted as both effective and of great impor- Foods and beverages processed in optimally fluoridated tance in the primary prevention of tooth decay.74 cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods F : , , , a„ and beverages are consumed not only in the city where Children withithe greatest dental need1benefit_3 processed, but may be distributed to and consumed in theostfrom waterfluondation Th me US ,Task nonfluoridated areas 256 This"halo" or"diffusion" effect Force strongly recommended that�commattO results in increased fluoride intake by people in nonfluori- •Waterfluondation$be ncludedaspartofa # dated communities, providing them increased protection r . -,,:,,, ,,,E-5,,,r)",^,-,;',.::_ i, against dental decay.52,2',86 As a result of the widespread comprehensive population based straegy tos 1 I ,, availability of these various sources of fluoride, the dif- pieventorcontrol tooth decay'in.communities" =_ ference between decay rates in fluoridated areas and :'.'21':2,1'2:-,41,.'v 'T' �' °-�'X{•1i -i74'4liqQ � >, ' a�"41,', ` nonfluoridated areas is somewhat less than several de- cades ago but it is still significant 82 Failure to account A systematic review of published studies conducted for the diffusion effect may result in an underestimation in 2001 by a team of experts on behalf of the U.S. Task of the total benefit of water fluoridation especially in ar- Force on Community Preventive Services found that flu- eas where large quantities of fluoridated products are oridation was effective in reducing tooth decay among brought into nonfluoridated communities.66 populations. Based on strong evidence of effectiveness, Even in an era with widespread availability of fluo- the Task Force strongly recommended that community ride from other sources, studies prove water fluoride- water fluoridation be included as part of a comprehen- tion continues to be effective in reducing dental decay sive population-based strategy to prevent or control by 20-40%.28.29 tooth decay in communities 75-76 14 American Dental Association • ,,.5,,. ,si{ €, `• 4 ,..t" ,€ ,. r c # rl ¢s° 3 ■ Ja, r• „A+ r --i• G �■ . •at i r, •" BENEFITS •.{L • r. a u , a 3 a2. • �. _.. ♦ .. r x r e n , „�n .. . R 'x ' QUESTION 9. on the city of Galesburg, Illinois, a community whose What happens if water fluoridation is discontinued? public water supply contained naturally occurring fluoride at 2.2 ppm. In 1959, Galesburg switched its Answer. community water source to the Mississippi River. This Over time, dental decay can be expected to increase if alternative water source provided the citizens of Gales water fluoridation in a community is discontinued,even burg a sub optimal level of fluoride at approximately if topical products such as fluoride toothpaste and fluo 0.1 ppm. During the time when the fluoride content ride rinses are widely used. was below optimal levels, data revealed a 10% de- crease in the number of decay-free 14-year-olds(oldest Fact group observed), and a 38% increase in dental decay. • The following paragraphs provide a summary of key his- Two years later, in 1961, the water was fluoridated at torical studies that have been conducted on the discon- the recommended level of 1.0 ppm.92 tinuation of water fluoridation. There have been several studies from outside the Antigo, Wisconsin began water fluoridation in June United States that have reported no increase in den- 1949,and ceased adding fluoride to its water in Novem= tal decay following the discontinuation of fluoridation. ber 1960. After five and one-half years without opti- However, in all of the cases reported, the discontinua- mal levels of fluoride, second grade children had over tion of fluoridation coincided with the implementation 200% more decay, fourth graders 70% more, and sixth of other measures to prevent dental decay. graders 91%more than those of the same ages in 1960. For example, in La Salud, Cuba a.study on dental Residents of Antigo re-instituted water fluoridation in decay in children indicated that the rate of dental de- October 1965 on the basis of the severe deterioration of cay did not increase after fluoridation was stopped in their children's oral health.88 1990. However, at the time fluoridation was discontin- Because of a government decision in 1979,fluoride- ued a new topical fluoride program was initiated where tion in the northern Scotland town of Wick was discon- all children received fluoride mouthrinses on a regular tinued after eight years. The water was returned to its basis and children two to five received fluoride varnish sub-optimal, naturally occurring fluoride level of 0.02 once or twice a year.93 ppm. Data collected to monitor the oral health of Wick In Finland, a longitudinal study of Kuopio (fluoridat- children clearly demonstrated a negative health effect ed from 1959 to 1992)and Jyvaskyla(low levels of natu- from the discontinuation of water fluoridation. Five ral fluoridation) showed little differences in decay rates years after the cessation of water fluoridation, decay in between the two communities. This was attributed to a permanent (adult)' teeth had increased 27% and decay number of factors. The populations are extremely simi- in primary (baby) teeth increased 40%.This increase in lar in terms of ethnic background and social structure. decay occurred during a period when there had been Virtually all children and adolescents used the govern- a reported overall reduction in decay•nationally and ment-sponsored, comprehensive, free dental care. The when fluoride toothpaste had been widely adopted.89 dental programs exposed the Finnish children to intense These data suggest that decay levels in children can be topical fluoride regimes and dental sealant programs. expected to rise where water fluoridation is interrupted The result was that the effect of water fluoridation ap- or.terminated, even when topical fluoride products are peared minimal. Because of these unique set of factors, widely used. it was concluded these results could not be replicated In a similar evaluation, the prevalence of decay in in countries with less intensive preventive dental care 10-year-old children in Stranraer, Scotland increased 96 after the discontinuation of water fluoridation, result- programs. ing in a 115% increase in the mean cost of restorative No significant decrease in dental decay was seen dental treatment for decay and a 21% increase in the after fluoridation was discontinued in 1990 in Chemniz mean cost of all dental treatment. These data support and Plauen which are located in what was formerly East the important role water fluoridation plays in the re- Germany. The intervening factors in this case include duction of dental decay.9° improvements in attitudes toward oral health behav- A U.S.study of 6-and 7-year-old children who had re- ' iors, broader availability and increased use ofother sided in optimally fluoridated areas and then moved to preventive measures including fluoridated salt,fluoride the nonfluoridated community of Coldwater, Michigan, toothpaste and dental sealants.95 revealed an 11% increase in decayed, missing or filled A similar scenario is reported from the Netherlands. tooth surfaces(DMFS) over a 3-year period from the time A study of 15-year-old children in Tiel (fluoridated 1953 the children moved.These data reaffirm that relyingonly to 1973) and Culemborg (nonfluoridated) was conduct- on topical forms of fluoride is not an effective or prudent ed comparing dental decay rates from a baseline in public health.practice.28,9' Decay reductions are greatest 1968 through 1988. The lower dental decay rate in Tiel where water fluoridation is available in addition to topical after the cessation of fluoridation was attributed in part fluorides,such as fluoride toothpaste and fluoride rinses. to the initiation of a dental health education program, Finally, a study that reported the relationship be- free dietary fluoride supplements and a greater use of tween fluoridated water and decay prevalence focused professionally applied topical fluorides.96 Fluoridation Facts 15 U � � • ��. QUESTION ®. problems or the cost of services by other health care Is dental decay still a serious problem? providers.102 Again, the goal must be prevention rather than repair. Fluoridation is presently the most cost-ef- Answer. fective method for the prevention of dental decay for Yes.Dental decay or tooth decay is an infectious disease residents of a community in the United States.103004 that continues to be a significant oral health problem. Fact. QUESTION 11. Dental decay is, by far, the most common and costly Do adults benefit from fluoridation? oral health problem in all age groups.97 It is one of the principal causes of tooth loss from early childhood Answer. through middle age.9e,99 Decay continues to be problem- Fluoridation plays a protective role against dental de- atic for middle-aged and older adults, particularly root caythroughout life,benefiting both children and adults. decay because of receding gums. Older adults may ex- In fact,inadequate exposure to fluoride places children perience similar or higher levels of dental decay than do and adults in the high risk category for dental decay. children.100 In addition to its effects in the mouth,dental decay can affect general well-being by interfering with Fact. an individual's ability to eat certain foods and by impact- While the early fluoridation trials were not designed to ing an individual's emotional and social well-being by study the possible benefits fluoridation might have for causing pain and discomfort. Dental decay, particularly adults,by the mid-1950s,there was growing evidence of in the front teeth, can detract from appearance,thus af- both systemic and topical benefits of fluoride exposure. fecting self-esteem and employability. It soon became evident that fluoridation helped prevent decay in adults,too.44 Fluoride has both a systemic and -- ' J Decay contJnues to be problematic for�,,_ �f topical effect and is beneficial to adults in two ways.The first is through the remineralization process in enamel, 10. middle-aged and older adults particularly +' a n in which early decay does not enlarge,and can even re- 11. rootrlecay because'ofreceding gums verse, because of frequent exposure to small amounts =' ._' '� of fluoride. Studies have clearly shown that the avail- 12. ability of topical fluoride in an adult's mouth during the Despite a decrease in the overall decay experience of initial formation of decay can not only stop the decay U.S. schoolchildren over the past two decades, dental process, but also make the enamel surface more resis- decay is still a significant oral health problem, especial- tant to future acid attacks. Additionally,the presence of ly in certain segments of the population.The 1986-1987 systemic fluoride in saliva provides a reservoir of fluo- National Institute of Dental Research (NIDR) survey of ride ions that can be incorporated into the tooth surface approximately 40,000 U.S. school children found that to prevent decay.63 25% of students ages 5 to 17 accounted for 75% of the 6-Additional information on this topic may be found in decay experienced in permanent teeth.97 Despite prog- Question 2. ress in reducing dental decay, individuals in families living below the poverty level experience more dental decay than those who are economically better off.20 "People rn the United-States are Irving Some of the risk factors that increase an individual's risk longer and retarnrngmore ofktherr natural for decayare inadequate exposure to fluoride, irregular teeth than ever before dental visits, deep pits and fissures in the chewing sur- faces ur faces of teeth, inadequate flow of saliva,frequent sugar intake and very high oral bacteria counts. Another protective benefit for adults is the prevention Dental decay is one of the most common childhood of root decay.100,105.107 Adults with gum recession are at diseases—five times as common as asthma and seven risk for root decay because the root surface becomes ex- times as common as hay fever in 5- to 17-year-olds. posed to decay-causing bacteria in the mouth. Studies Without fluoridation, there would be many more than have demonstrated that fluoride is incorporated into the the estimated 51 million school hours lost per year in structure of the root surface, making it more resistant to this country because of dental-related illness.101 decay.116-112 In Ontario, Canada, lifelong residents of the In addition to impacting emotional and social well- naturally fluoridated (1.6 ppm) community of Stratford being,the consequences of dental disease are reflected had significantly lower root decay experience than those in the cost of its treatment. According to the Centers living in the matched, but nonfluoridated,community of for Medicare and Medicaid Services, the nation's total Woodstock.171 bill (including private and public spending) for dental People in the United States are living longer and retain- services in 2003 was estimated to be$74.3 billion. This ing more of their natural teeth than ever before. Because figure does not include indirect expenses of oral health older adults experience more problems with gum reces- 16 American Dental Association .c,! y rag €I 'a. i' h `' i't } M w -a au^ rz4 yr€g. � r •F 4a` 4-:Pi iii € � �`�G+� .Kv.,'k� ,r €��, ��� G ''i 1 . R; � � � �C�•�S4`r�.�p 'Yx.�. ��r � iii y!'a V a a .}' ,� ft,' -..•.:,•:-•,•:'' 'Y sion, the prevalence of root decay increases with age. A explained by differences in oral bacteria, buffer capacity large number of exposed roots or a history of past root of saliva or salivary flow. The fluoride concentration in decay places an individual in the high risk category for de- the drinking water was solely responsible for decreased cay.30 Data from the 1988-1991 National Health and Nutri- decay rates.176 tion Examination Survey(NHANES III)showed that 22.5% Water fluoridation contributes much more to overall of all adults with natural teeth experienced root decay. health than simply reducing dental decay: it prevents This percentage increased markedly with age: needless infection, pain, suffering and loss of teeth; 1) in the 18-to 24-year-old age group,only 6.9% improves the quality of life and saves vast sums of experienced root decay; money in dental treatment costs.26 Additionally, fluori- 2) in the 35-to 44-year-old age group,20.8% dation conserves natural tooth structure by preventing experienced root decay; the need for initial fillings and subsequent replacement 3) in the 55-to 64-year-old age group,38.2% fillings.117•718 showed evidence of root decay;and (&Additional information on. this topic may be found in 4) in the over-75 age group,nearly 56%had root Question 2. decay.73 In addition to gum recession,older adults tend to ex- perience decreased salivary flow, or xerostomia, due to the use of medications or medical conditions.14•15 In- QUESTION 12., adequate flow of saliva places an individual in the high Are dietary fluoride supplements effective? risk category for decay.3°This decrease in salivary flow can increase the likelihood of dental decay because sa- Answer. liva contains calcium, phosphates and fluorides — all For children who do not live in fluoridated communi- necessary for early repair of dental decay. ties,dietary fluoride supplements are an effective alter- There are data to indicate that individuals who have native to water fluoridation for the prevention of dental consumed fluoridated water continuously from birth decay.179-122 receive the maximum protection against dental decay. However, teeth present in the mouth when exposure to Fact. water fluoridation begins also benefit from the topical Dietary fluoride supplements are available only by pre- effects of exposure to fluoride. In 1989, a small study scription in the United States and are intended for use by in the state of Washington suggested adults exposed children living in nonfluoridated areas to increase their to fluoridated water only during childhood had similar fluoride exposure so that it is similar to that received by decay rates as adults exposed to fluoridated water only children who live in optimally fluoridated areas.123,124 Di- after age 14. This study lends credence to the topical etary fluoride supplements are available in two forms: and systemic benefits of water fluoridation. The topical drops for infants aged six months or older,and chewable effects are reflected in the decay rates of adults exposed tablets for children and adolescents.124 Fluoride supple- to water fluoridation only after age 14. The study also ments should only be prescribed for children living in demonstrates that the preeruptive, systemic effects of nonfluoridated areas. The correct amount of a fluoride fluoridation have lifetime benefits as reflected in the de- supplement is based on the child's age and the existing cay rates of adults exposed to fluoridation only during fluoride level in the drinking water.125 Because fluoride childhood. The same study also noted a 31% reduction is so widely available, it is.recommended that dietary of dental disease (based on the average number of de- fluoride supplements be used only according to the rec- cayed or filled tooth surfaces) in adults with a continu- ommended dosage schedule and after consideration of ous lifetime exposure to fluoridated water as compared all sources of fluoride exposure.3°,126 For optimum ben- to adults with no exposure to water fluoridation."0 efits, use of supplements should begin at six months of age and be continued daily until the child is at least 16 years old.125 The current dietary fluoride supplement :'Water-fluoridation contr;butes much more schedule is shown in Table 1 on the next page. #o overall health than simply i-educuig dental The relatively higher cost and need for compliance '=decay rt preJentet eedless infection,parn over an extended period of time is a major procedural and economic disadvantage of community-based fluo- "suffenngand loss of teeth,improves the ride supplement programs,one that makes them imprac quality`of life and saves vastsums of money, tical as an alternative to water fluoridation as a public ' rn dental treatment costs health measure. In a controlled situation, as shown in a --.= -. 1',t ,.'',: . study involving children of health professionals,fluoride supplements achieve effectiveness comparable to that of A Swedish study investigating decay activity among water fluoridation. However, even with this highly edu- adults in optimal and low fluoride areas revealed that cated and motivated group of parents,only half continued not only was decay experience significantly lower in the to give their children fluoride tablets for the necessary optimal fluoride area, but the difference could not be number of years.127 Additional studies have verified that Fluoridation Facts 17 • Table . Dietary Fluoride Supplement Schedule 1994125 Approved by the American Dental Association American Academy,of Pediatrics American Academy of Pediatric Denfi�try <0.3 ppm 0.3-0.6 ppm >0.6 ppm Birth—6 months None None None 6 months—3 years 0.25 mg/day** None None 3—6 years 0.50 mg/day 0.25 mg/day None 6—16 years 1.0 mg/day 0.50 mg/day None * 1.0 part per million(ppm)=1 milligram/liter(mg/L) **2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary greatly.1213,129,130 In- that children will receive fluoride from other sources dependent reports from several countries, including the (food and beverages) even'in nonfluoridated areas,the United States, have demonstrated that community-wide amounts in the table reflect the additional amount of trials of fluoride supplements in which tablets were dis- fluoride intake necessary to achieve an optimal anti- tributed for use at home were largely unsuccessful be- cavity effect. cause of poor compliance.131 While total costs for the purchase of supplements and administration of a program are small (compared `Tlae"d►etary,fluor►deesupplementschedule ; with the initial cost of the installation of water fluori- 1sjust that asupP lerneht schedule '3 Ts.,+' � 13. dation equipment), the overall cost of supplements per Y child is much greater than the per capita cost of conn- 14. munity fluoridation.104 In addition, community water The dietary fluoride supplement schedule should not be fluoridation provides decay prevention benefits for the viewed as recommending the absolute upper limits of 15. entire population regardless of age, socioeconomic sta- the amount of fluoride that should be ingested each day. tus, educational attainment or other social variables.26 In 1997, the Food and Nutrition Board of the Institute This is particularly important for families who do not of Medicine developed the Dietary Reference Intakes, a have access to regular dental services. comprehensive set of reference values for dietary nutri- Additional information on this topic may be found in ent values.The new values present nutrient requirements Questions 4, 13,24 and 25. to optimize health and, for the first time,set maximum- level guidelines to reduce the risk of adverse effects from excessive consumption of a nutrient. In the case of fluo- ride, levels were established to reduce dental decay with- QUESTION 13. out causing moderate dental fluorosis.123 Does the ADA recommend fluoride for children under For example, the dietary fluoride supplement sched- six years of age? ule recommends that a two-year-old child living in a non-fluoridated area (where the primary water source Answer, contains less than 0.3 ppm fluoride) should receive 0.25 Yes. The ADA recognizes that lack of exposure to fluo- mg of supplemental fluoride per day.This does not mean ride places individuals of any age at risk for dental decay. that this child should ingest exactly 0.25 mg of fluoride Fluoride exposure may take many forms including wa- per day. On the contrary, a two-year-old child could re- ter fluoridation and dietary fluoride supplements. ceive important anti-cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- Fact. verse effects on health. This child would most probably For children who live in nonfluoridated communities, be receiving fluoride from other sources (foods and bev- dietary fluoride supplements are an effective alterna- erages) even in a non-fluoridated area and the recom- tive to water fluoridation to help prevent dental decay. mendation of 0.25 mg of fluoride per day takes this into Dietary fluoride supplements are available only by pre- account. In the unlikely event the child did not receive scription and are intended for use by children living in any extra fluoride from food and beverages,the 0.25 mg nonfluoridated areas to increase their fluoride exposure per day could be inadequate fluoride supplementation to so that it is similar to that experienced by children who achieve an optimal anti-cavity effect. live in optimally fluoridated areas.124 The following statement is correct. "The dosage has The dietary fluoride supplement schedule is just been lowered two different times as evidenced of too that — a supplement schedule (Table 1). Recognizing much fluoride has appeared." Rather than being a prob- 18 American Dental Association • • BENEFITS lem,as those opposed to the use of fluoride might imply, Salt fluoridation has several disadvantages that do this is evidence that the ADA is doing the right thing.The not exist with water fluoridation. Challenges occur with ADA continually reviews available scientific evidence, and implementation of salt fluoridation when there are mul- revises its statements based on the most current scien- tiple sources of drinking water in an area. The natural tific information. In 1994, a Dietary Fluoride Supplement fluoride level of each source must be determined and,if Workshop cosponsored by the ADA,the American Acad- the level is optimal or excessive,fluoridated salt should emy of Pediatric Dentistry and the American Academy of not be distributed in that area.138 Finally,there is general Pediatrics was held in Chicago.Based on a review of scien- agreement that a.high consumption of sodium is a risk tific evidence,a consensus was reached on a new dosage factor for hypertension (high blood pressure).139•140 Peo- schedule developed in recognition that numerous sources ple who have hypertension or must restrict their salt in of topical and systemic fluoride are available today that take may find salt fluoridation an unacceptable method were not available many years ago.125 The revised dietary of receiving fluoride. fluoride supplement schedule appears as Table 1. Additional information on this topic may be found in Question 56. Fluoridated milk has been suggested as another alterna- tive to community water fluoridation in countries outside QUESTION 14. the U.S. WHO has supported milk fluoridation feasibil- In areas where water fluoridation is not feasible be- ity projects in the United Kingdom, People's Republic of cause of engineering constraints, are alternatives to China, Peru and Thailand.141 Studies among small groups water fluoridation available? of children have demonstrated a decrease in dental de- cay levels resulting from consumption of fluoridated milk; Answer. however,these studies were not based on large-scale sur- Yes. Some countries outside the United States that do veys. More research is needed before milk fluoridation not have piped water supplies capable of accommodat- can be recommended as an alternative to water or salt ing community water fluoridation have chosen to use fluoridation.742 The rationale for. adding fluoride to milk salt fluoridation. is that this method "targets" fluoride directly to children, but the amount of milk consumed by children is quite Fact. variable, more so than water. Concerns have been raised Salt fluoridation is used extensively in a number of about decreased widespread benefits due to the slower countries in Europe (examples: France, Hungary, Ger- absorption of fluoride from milk than from water and the many, Spain and Switzerland) and Central and South considerable number of persons, especially adults, who America (examples: Boliva, Colombia, Cuba, Domini- do not drink milk for various reasons.'43 The monitoring can Republic, Ecuador, El Salvador, Honduras, Nice- of fluoride content in milk is technically more difficult than ragua, Venezuela, Costa Rica, Jamaica, Mexico, Peru for drinking water because there are many more dairies and Uruguay.)132.133 The Pan American Health Organi- than communal water supplies. In addition, because fluo- zation (PAHO), a regional division of the World Health ridated milk should not be sold in areas having natural or Association (WHO), with responsibilities for health adjusted fluoridation, regulation would be difficult, and matters in North, South and Central America as well established marketing patterns would be disrupted.42 as the.Caribbean has been active in developing strate- gies to implement decay prevention programs in the regions of the Americas using both water and salt fluoridation.133.134 QUESTION 15. Studies evaluating the effectiveness of salt fluoridation Can the consistent use of bottled water result in indi- outside the U.S. have concluded that fluoride delivered viduals missing the benefits of optimally fluoridated via salt may produce decay reductions similar to that of water? optimally fluoridated water.735 An analysis of published results of studies from some countries shows that, for Answer. 12-year-old children, the initial level of decay reduction Yes.The majority of bottled waters on the market do not due to salt fluoridation is between 35%and 80%.136.137 contain optimal levels(0.7-1.2 ppm)of fluoride.144-148 An advantage of salt fluoridation is that it does not require a centralized piped water system.This is of par- Fact. ticular use in many developing countries that do not Individuals who drink bottled water as their primary have such water systems. When both domestic salt and source of water could be missing the decay preventive bulk salt (used by commercial bakeries, restaurants, in- effects of optimally fluoridated water available from stitutions, and industrial food production) is fluoridated, their community water supply. the decay-reducing effect may be comparable to that of The consumption of bottled water in the United States water fluoridation over an extended period of time.136 has been growing by at least one gallon per person each On the other hand, when only domestic salt is fluori- year-more than doubling in the last ten years. Consump- dated,the decay-reducing effect may be diminished.135 tion rates for the past five years are shown in Table 2.14 Fluoridation Facts 19 tie• ,y�;,�. �n r. �.it4 R s € S* aj v i`�iy 't± .Y t r - .}'• �T+i k w'"Y-d ny _ -k M L m.3 ' C}.wN t, ,.�.' E�'X m.a G - r. Table 2. U.S. Bottled Water Market149 between the various batches tested of the same brand.154 2,-per Capita umption 2g01)7,2094,:.:- In evaluating how bottled water consumption affects Cons br y {ons�,r. fluoride exposure, there are several factors to consider. -,[1h4.4!&104t4, First is the amount of bottled water consumed during the Year Per Capita %Change day. Second is whether bottled water is used for drink- 2000 17.2 ing, in meal preparation and for reconstituting soups, juices and other drinks.Third is whether another source 2001 18.7 8.7% of drinking water is accessed during the day such as an 2002 20.7 10.8% optimally fluoridated community water supply at day- care,school or work. 2003 22.1 7-.0% A final important issue is determining the fluoride 2004 23.8 7.6% content of the bottled water. While drinking water is reg- ulated by the U.S. EPA,155 bottled water is regulated by In 2004,total U.S.sales of bottled water surpassed 6.8 the U.S. Food and Drug Administration (FDA) which has billion gallons, an 8.6% advance over 2003 with whole established standards for its quality.156 sale dollar sales reaching a record of approximately$9.2 iJe Additional information on this topic may be found in billion. This category includes sparkling and non-spar- Question 43. Bottled water is defined as water that is intended for kling water,domestic and imported water,water in single human consumption sealed in bottles or other containers serve bottles and larger packages as well as vended and with no added ingredients except that it may optionally direct delivered waters. U.S. residents now drink more contain safe and suitable antimicrobial agents. The FDA bottled water annually (23.8 gallons per person in 2004) has established maximum allowable levels for physical, than any other beverage with the exception of carbonated chemical, microbiological, and radiological contaminants soft drinks.149,15° In 2004, consumption of carbonated soft in the bottled water quality standard regulations.The FDA drinks fell for the sixth straight year after several decades has also approved standards for the optional addition of of uninhibited growth (53.7 gallons per person in 2004 fluoride.156 Effective in 1996,FDA regulations require fluo- 16. compared to 54.8 gallons per person in 1999).150 ride content of bottled water to be listed on the label only if fluoride is added during processing.157 If the fluoride level is not shown on the label of the bottled water, the �''Indrwduals who drink bottledwater as th `;eirk4` ., .. _ company can be contacted, or the water can be tested to pr�mar-y source of.`water could bewrriissingj'rt L obtain this information, ythe decay prEyentive effects of optimally For additional information on bottled water and fluo f%uoridafeah%vater.available froh),Me1,i;-'::';"` ride exposure,view the ADRs Web page "Bottled Water, Home Water Treatment Systems and Fluoride Exposure" ' community wate'rsupply' x at http://www.ada.org/goto/bottledwater. (Figure 3) Figure 3. Bottled Water/Home Water In 1994,a small study at two community health centers Treatment Systems in Rhode Island showed that 55% of the total households responding used only bottled water for drinking while 59% A MISSING{INGREDIENT? of the households with children reported using only bottled http water for drinking. The vast majority of these bottled wa- ters had less than optimal levels of fluoride. While most of • Does your bottled water contain fluoride? the patient population of the health centers was either on • Does your water filter remove fluoride? public assistance(60%) or uninsured (20%),families spent their limited resources to purchase bottled water. It was ADA American Dental Association® reported that 52%of children on public assistance and 35% of the uninsured children used bottled water.751 America's leading advocate for oral health The fluoride content of bottled water can vary greatly. www.ada.org A 1989 study of pediatric dental patients and their use of bottled water found the fluoride content of bottled water Many ADA resources are at your fingertips 24/7/365. from nine different sources varied from 0.04 ppm to 1.4 Order a library book or products online, read JADA ppm.152 In a 1991 study of 39 bottled water samples,34 articles,discuss important topics with colleagues,find had fluoride levels below 0.3 ppm. Over the two years helpful information on professional topics from accredi- the study was conducted,six products showed a two-to Cation to X-rays and recommend our dental education animations,stories and games to your patients. four-fold drop in fluoride content.153 A similar study of five national brands of bottled water conducted in 2000, showed that significant differences in fluoride concentra- tion oncentra tion existed between the five brands and that three of the five brands tested demonstrated significant differences 20 American Dental Association � , :w •r-• x B_EN'EFITS • e QUESTION 16. Notes Can home water treatment systems (e.g.water filters) affect optimally fluoridated water supplies? Answer. Yes. Some types of home water treatment systems can reduce the fluoride levels in water supplies potentially decreasing the decay-preventive effects of optimally fluoridated water. Fact. There are many kinds of home water treatment systems including water filters (for example: carafe filters,faucet filters, under the sink filters and whole house filters), reverse osmosis systems, distillation units and water softeners. There has not been a large body of research regarding the extent to which these treatment systems affect fluoridated water. Available research is often con- flicting and unclear. However, it has been consistently documented that reverse osmosis systems and distilla- tion units remove significant amounts of fluoride from the water supply."'758159 On the other hand, repeated studies regarding water softeners confirm earlier re- search indicating the water softening process caused no significant change in fluoride levels.160,161 Withwater filters,the fluoride concentration remaining in the water depends on the type and quality of the filter being used, the status of the filter and the filter's age. Some acti- vated carbon filters containing activated alumina may remove significant amounts of the fluoride.162 Each type of filter should be assessed individually.159 Individuals who drink water processed by home wa- ter treatment systems as their primary source of water could be losing the decay preventive effects of opti- mally fluoridated water available from their community water supply. Consumers using home water treatment systems should have their water tested at least annu- ally to establish the fluoride level of the treated water. More frequent testing may be needed. Testing is avail- able through local and state public health departments. Private laboratories may alsooffer testing for fluoride levels in water. Information regarding the existing level of fluoride in a community's public water system can be obtained by asking a local dentist,contacting your local or state health department,or contacting the local water supplier. (Additional information on this topic may be found in Question 4. For additional information on home water treatment systems and fluoride exposure,view th'e ADAs Web page "Bottled Water, Home Water Treatment Systems and Flu- oride Exposure" at http://www.ada.org/goto/bottledwater. (Figure 3) Fluoridation Facts 21 al SAFETY Q 17. Harmful to humans? p.22 Q 25. Prevent fluorosis? p.30 Q 34. Fertility? p.35 Q 18. More studies needed? p.23 Q 26. Warning label? p.31 Q 35. Down Syndrome? p.35 Q 19. Total intake? p.24 Q 27. Toxicity? p.31 Q 36. Neurological impact? p.36 Q 20. Daily intake? p.25 Q 28. Cancer? p.32 Q 37. Lead poisoning? p.37 Q 21. Prenatal dietary p P6 Q 29. Enzyme effects? p.33 Q 38. Alzheimer's disease? p.37 fluoride supplements? Q 30. Thyroid gland? p.34 Q 39. Heart disease? p.38 Q 22. Body uptake? p.26 Q 31. Pineal Gland? p.34 Q 40. Kidney disease? p.38 Q 23. Bone health? p.27 Q 32. Allergies? p.34 Q 41. Erroneous health p.39 claims? Q 24. Dental fluorosis? p.28 Q 33. Genetic risk? p.35 QUESTION 17 stantiated by generally accepted scientific knowledge. Does fluoride in the water supply,at the levels recom- After 60 years of research and practical experience, the mended for the prevention of dental decay, adversely preponderance of scientific evidence indicates that fluo 17 affect human health? ridation of community water supplies is both safe and effective.'69 18. Answer. ,k t - ?: q, St, ,' - ,00Z4 The overwhelming weight of scientific evidence indi- ' 'After,60 years of research'and1practical M cates that fluoridation of community water supplies is r 1'experien0Ratzle preponderance of` -, safe. (See Figure 4.) sclentificyewdence indreates that fluoridation s' w of community water supplies is both z Focgenerations, millions of people have lived in ar '-K,'.', 0'','!''''11'.' f i a' '1'!dr a xsafetand effective " r, eas where fluoride is found naturally in drinking water ` " w `" ' "` in concentrations as high or higher than those recom- Many organizations in the U.S. and around the mended to prevent dental decay. Research conducted world involved with health issues have recognized the among these persons confirms the safety of fluoride value of community water fluoridation. The American in the water supply.84,163-166 In fact, in August 1993,the Dental Association (ADA) adopted its original resolu- National Research Council, a branch of the National tion in support of fluoridation in 1950 and has repeat- Academy of Sciences, released a report prepared edly reaffirmed its position publicly and in its House for the Environmental Protection Agency (EPA) that of Delegates based on its continuing evaluation of the confirmed that the currently allowed fluoride levels safety and effectiveness of fluoridation.3 The 2005 in drinking water do not pose a risk for health prob- "ADA Statement Commemorating the 60th Anniver- lems such as cancer, kidney failure or bone disease.167 sary of Community Water Fluoridation" reinforced that . Based on a review of available data on fluoride tox- position.4 The American Medical Association's (AMA) icity, the expert subcommittee that wrote the report House of Delegates first endorsed fluoridation in 1951. concluded that the EPA's ceiling of 4 ppm for naturally In 1986,and again in 1996,the AMA reaffirmed its sup- occurring fluoride in drinking water was "appropri- port for fluoridation as an effective means of reducing ate as an interim standard."167 Subsequently,the EPA dental decay.170 The World Health Organization, which announced that the ceiling of 4 ppm would protect initially recommended the practice of water fluorida- against adverse health effects with an adequate mar- tion in 1969,171 reaffirmed its support for fluoridation gin of safety and published a notice of intent not to in 1994 stating that: "Providing that a community has revise the fluoride drinking water standard in the Fed- a piped water supply, water fluoridation is the most eral Register.168 effective method of reaching the whole population, As with other nutrients, fluoride is safe and effective so that all social classes benefit without the need for when used and consumed properly. No charge against active participation on the part of individuals."136 Fol- the benefits and safety of fluoridation has ever been sub- lowing a comprehensive 1991 review and evaluation of 22 American Dental Association -�. .t r .• " E;? . ray s. ' ?•" 1.:;)•.i.04,71?.?„* t:1 ,, " r pt, � Z •..: �P. "�: z. - • �.f �Ouestions'17 41x � ° °;v Figure 4. Safety of Community tees of experts, special councils of government and Water Fluoridation - most of the world's major national and internation- al health organizations. The verdict of the scientific InstituteofMedicine_FoodandNutritionBoard community is that water fluoridation, at recommend- Dietary reference Intakes for calcium;-phospho ed levels, safely provides major oral health benefits. rus magnesium vitamin D aril fluoride Report The question of possible secondary health effects of the`Standing Committee on ahe::_Scientific caused by fluorides consumed in optimal concentra- Evaluation ofwDietar Reference Makes Wash tions throughout life has been the object of thorough Ington DC National Academy�Press 1.997 medical investigations which have failed to show any impairment of general health throughout life.136,163-166 National Research Council Health effects of in gested fluoride Report of the Subcommittee on 4 . Health,Effects of Ingested Fluoride Washing The1 verdief of the`saentrfic community , ton DC National Academy Press 1993 h,,i is that waterfluondation,at recommended levels,=safely=provides major ' ; US Department of Health and'Human Services w f° oral health benefits Public.'Health,Service Review of fluoride ben Q, , " r r ;,� efits and risks Report of t1i*Ad Floc-Subcommit ;:"tee on Fluoride:Washington,DC February 1997 In scientific research,there is no such thing as "final knowledge." New information is continuously emerg- World`,Health.Organiiation v$luorides and nu ing and being disseminated. Under the Safe Drinking man health Monograph-series no 59 Geneva, Water Act (SDWA), the U. S. Environmental Protection Switzerland 1970 Agency(EPA) must periodically review the existing Na- tional Primary Drinking Water Regulations (NPDWRs) "not less often than every 6 years." This review is.a thepublic health benefits and risks of fluoride,the U.S. routine part of the EPA's operations as dictated by the Public Health Service reaffirmed its support for fluori- SDWA.172 dation and continues to recommend the use of fluoride In April 2002, the EPA announced the results of its to prevent dental decay.84 preliminary revise/not revise decisions for 68 chemi- Recent statements by five leading health authorities cal NPDWRs. Fluoride was one of the 68 chemicals re on community water fluoridation can be found in the viewed. The EPA determined that it fell under the "Not of this publication. Appropriate for Revision at this Time" category,but not- backed that it planned to ask the National Academy of Sci- National and international health, service and pro- ence (NAS) to update the risk assessment for fluoride. fessional organizations that recognize the public health The NAS had previously completed a review of fluoride benefits of community water fluoridation for prevent- for EPA approximately 12 years ago which was pub- ing dental decay are listed on the inside back cover of lished as "Health Effects of Ingested Fluoride" in 1993 this publication. by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the QUESTION `��e Sub- committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data pub- Are additional studies being conducted to determine lished since 1993 and exposure data on orally ingest- the effects of fluorides.in humans? ed fluoride from drinking water and other sources (e.g., food, toothpaste, mouthrinses). Based on this AnsWef. review the Subcommittee will evaluate the scien- Yes. Since its inception, fluoridation has undergone tific and technical basis'of the EPA's maximum con- a nearly continuous process of reevaluation. As with taminant level (MCL) of 4 milligram per liter (mg/L other areas of science,additional studies on the effects or ppm) and secondary maximum contaminant level of fluorides in humans can provide insight as to how to (SMCL) of 2 mg/L for fluoride in drinking water. The make more effective choices for the use of fluoride. The Subcommittee will advise the EPA on the adequacy American Dental Association and the U.S.Public Health of its fluoride MCL and SMCL to protect children and • Service support this on-going research. others from adverse health effects and identify data gaps and make recommendations for future research Fact. relevant to setting the MCL and SMCL for fluoride. For more than 60 years, thousands of reports have The Subcommittee began its work in November 2002 been published on all aspects of fluoridation.84,167 The and is currently projected to complete the project in accumulated dental, medical and public health evi- early 2006.173 deuce concerning fluoridation has been reviewed and The definition of a contaminant is a function of the evaluated numerous times by academicians, commit- National Primary Drinking Water Regulations. The EPA Fluoridation Facts 23 . • rivet . rt- a€ # ,,,A,4,-;;:,,,,,5,,t-a., s. N y� considers a contaminant to be ANYTHING found in wa- dental fluorosis in the Bartlett residents, the study in- ter that may be harmful to human health. The EPA has dicated that long-term consumption of dietary fluoride designated 90 microorganisms, minerals and chemicals (resident average length of fluoride exposure was 36.7 as contaminants."4.176 - years), even at levels considerably higher than recom- While research continues,the weight of scientific evi- mended for decay prevention, resulted in no clinically dence indicates water fluoridation is safe and effective significant physiological or functional effects.166 in preventing dental decay in humans.84 Fluoride in Food Additional information on this topic may be found in Foods and beverages commercially processed (cooked Questions 7, 8,and 42. or reconstituted) in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and 19. bev- erages are consumed not only in the city where pro- QUESTIONcessed, but may be distributed to and consumed in Does the total intake of fluoride from air, water and nonfluoridated areas.26 This "halo" or "diffusion" ef- food pose significant health risks? fect results in increased fluoride intake by people in nonfluoridated communities, providing them increased Answer. protection against dental decay.71•85'86 As a result of the The total intake of fluoride from air, water and food, widespread availability of these various sources of in an optimally fluoridated community in the United fluoride, the difference between decay rates in fluo- States,does not pose significant health risks. ridated areas and nonfluoridated areas is somewhat less than several decades ago but still significant.87 Fact. Failure to account for the diffusion effect may result in Fluoride from the Air an underestimation of the total benefit of water fluo- The atmosphere normally contains negligible concen- fluo- ridation especially in areas where a large amount of trations of airborne fluorides. Studies reporting the lev- fluoridated products are brought into nonfluoridated 19. els of fluoride in air in the United States suggest that communities.86 ambient fluoride contributes little to a person's overall Water and water-based beverages are the chief source 20. fluoride intake.173,183 of dietary fluoride.intake. Conventional estimates are that approximately 75% of dietary fluoride comes from Fluoride from Water water and water-based beverages.179 . In the United States, the natural level of fluoride in The average daily dietary intake of fluoride (ex- ground water varies from very low levels to over 4 ppm. pressed on a body weight basis) by children residing in Public water systems in the U.S. are monitored by the optimally fluoridated (1 ppm) communities is 0.05 mg/ Environmental Protection Agency (EPA), which requires kg/day; in communities without optimally fluoridated that public water systems not exceed fluoride levels of 4 water, average intakes for children are about 50% low- ppm.7fi8 The optimal concentration for fluoride in water er.123 Dietary fluoride intake by adults in optimally fluo- in the United States has been established in the range ridated (1 ppm) areas averages 1.4 to 3.4 mg/day,and in of 0.7 to 1.2 ppm. This range will effectively reduce den- nonfluoridated areas averages 0.3 to 1.0 mg/day.123 tal decay while minimizing the occurrence of mild den- In looking at the fluoride content of food and bever- tal fluorosis. The optimal fluoride level is dependent on ages over time, it appears that fluoride intake from di- the annual average of the maximum daily air tempera- etary sources has remained relatively constant. Except ture in the geographic area.36 for samples prepared or cooked with fluoridated wa- Children living in a community with water fluori- ter, the fluoride content of most foods and beverages dation get a portion of their daily fluoride intake from is not significantly different between fluoridated and fluoridated water and a portion from dietary sources nonfluoridated communities. When fluoridated water which would include food and other beverages. When is used to prepare or cook the samples, the fluoride considering water fluoridation, an individual must con- content of foods and beverages is higher as reflected sume one liter of water fluoridated at 1 part per million in the intake amounts noted in the previous paragraph. (1 ppm) to receive 1 milligram (1 mg) of fluoride,42.178 This difference• has remained relatively constant over Children under six years of age, on average, consume time.180'181 less than one-half liter of drinking water a day.178 There- The fluoride content of fresh solid foods in fore,children under six years of age would consume,on the United States generally ranges from 0.01 to average, less than 0.5 mg of fluoride a day from drink- 1.0 part per million.102.179 It has long been known that ing optimally fluoridated water(at 1 ppm). fish, such as sardines, may contribute to higher A ten-year comparison study of long-time residents dietary fluoride intake if the bones are ingested of Bartlett and Cameron, Texas, where the water sup- as fluoride has an affinity for calcified tissues. plies contained 8.0 and 0.4 parts per million of fluo- Additionally, brewed teas may also contain fluoride ride, respectively, included examinations of organs, concentrations of 1 ppm to 6 ppm depending on bones and tissues. Other than a higher prevalence of the amount of dry tea used, the water fluo- 24 American Dental Association A1` ;""42.•,7,f1. `-:/4e144%-.4:'.. :Y '1'.. .R , .i '4 ,4h'je ..•. , ., `' ti� �. s is ..;,'''`..%t; �E. u �' ``'>xiyi. sa i. r -.s.: a; ,, J .. ," S A F;E T Y : r ride concentration and the brewing time.182 The fluo- been set by the National Academy of Sciences since ride value for unsweetened instant tea powder appears 1941. The new values present nutrient requirements to very high when reported as a dry powder because this optimize health and, for the first time, set maximum- product is extremely concentrated. However,when one level guidelines to reduce the risk of adverse effects teaspoon of the unsweetened tea powder is added to from excessive consumption of a nutrient. Along with an eight ounce cup of tap water, the value for prepared calcium, phosphorous, magnesium and vitamin D, DRIs instant tea is similar to the values reported for regular for fluoride were established because of its proven ef- brewed tea.179 fect on dental decay. Unveiled in 2004, the National Fluoride Database is As demonstrated in Table 3, fluoride intake in the a comprehensive, nationally representative database of United States has a large range of safety. the fluoride concentration in foods and beverages con- The first DRI reference value is the Adequate In- sumed in the United States. The database for fluoride take (Al) which establishes a goal for intake to sustain was designed for use by epidemiologists and health re- a desired indicator of health without causing side ef- searchers to estimate fluoride intake and to assist in the fects. In the case of fluoride,the Al is the daily intake investigation of the relationships between fluoride in- level required to reduce dental decay without causing take and human health. The database contains fluoride moderate dental fluorosis. The Al for fluoride from all values for beverages, water, and some lower priority sources (fluoridated water, food, beverages, fluoride foods.179 dental products and dietary fluoride supplements) is set at 0.05 mg/kg/day (milligram per kilogram of body weight per day). Using the established Al of 0.05 mg/kg,the amount of QUESTION 20. fluoride for optimal health to be consumed each day has How much fluoride should an individual consume each been calculated by gender and age group (expressed as day to reduce the occurrence of dental decay? average weight). See Table 3 in this Question. The DRIs also established a second reference value Answer. for maximum-level guidelines called tolerable upper The appropriate amount of daily fluoride intake var- intake levels (UL). The UL is higher than the Al and is ies with age and body weight.As with other nutrients, not the recommended level of intake. The UL is the es- fluoride is safe and effective when used and consumed timated maximum intake level that should not produce properly. unwanted effects on health. The UL for fluoride from all sources (fluoridated water, food, beverages, fluoride Fact. dental products and dietary fluoride supplements) is set In 1997,the Food and Nutrition Board of the Institute of at 0.10 mg/kg/day(milligram per kilogram of body weight Medicine developed a comprehensive set of reference per day)for infants,toddlers,and children through eight values for dietary nutrient intakes.123 These new refer- years of age. For older children and adults,who are no ence values,the Dietary Reference Intakes(DRI), replace longer at risk for dental fluorosis, the UL for fluoride is the Recommended Dietary Allowances(RDA)which had set at 10 mg/day regardless of weight. Table 3. Dietary Reference Intakes for Fluoride L . ._ • he Institute of.Medicine 199723 "4 :, Footl and Nutrmon Board oft k :', eta a- n-- Tolerable Upper 1 -z, ' Reference Weights AdequatelntakexIntakes ';_, r i Age-Group �-kg(lb's)*: , lh'(mg%day) - '- A i ,r, 1 7 Img/day) Z, Infants 0-6 months 7 (16) 0.01 0.7 Infants 7-12 months 9 (20) 0.5 0.9 Children 1-3 years 13 (29) 0.7 1.3 Children 4-8 years 22 (48) 1.0 2.2 Children 9-13 years 40 (88) 2.0 10.0 Boys 14-18 years 64(142) 3.0 10.0 Girls 14-18 years 57 (125) 3.0 10.0 Males 19 years and over .76 (166) 4.0 10.0 Females 19 years and over 61 (133) 3.0 10.0 * Value based on data collected during 1988-94 as part of the Third National Health and Nutrition Examination Survey (NHANES Ill)in the United States.123 Fluoridation Facts 25 111 Using the established ULs for fluoride, the amount of fluoride toothpaste on a young child's toothbrush at of fluoride that may be consumed each day to reduce each brushing. Also, young children should be super- the risk of moderate dental fluorosis for children under vised while brushing and taught to spit out, rather than eight,has been calculated by gender and age group(ex- swallow, the toothpaste. Consult with your child's den- pressed as average weight). (See Table 3.) tist or physician if you are considering using fluoride As a practical example,daily intake of 2 mg of fluoride toothpaste before age two. is adequate for a nine to 13-year-old child weighing 88 (+Additional information on this topic may be found in pounds (40 kg). This was calculated by multiplying 0.05 Question 25. mg/kg/day(Al)times 40 kg(weight)to equal 2 mg. At the It should be noted that the amounts of fluoride dis- same time,that 88 pound (40kg)child could consume 10 cussed here are intake,or ingested,amounts.When flu- mg of fluoride a day as a tolerable upper intake level. oride is ingested,a portion is retained in the body and a Children living in a community with water fluori- portion is excreted.This issue will be discussed further dation get a portion of their daily fluoride intake from in Question 22. fluoridated water and a portion from dietary sources which would include food and other beverages. When considering water fluoridation, an individual must con- sume one liter of water fluoridated at 1 part per million QUESTION 21. (1 ppm) to receive 1 milligram (1 mg) of fluoride.42'178 Is there a need for prenatal dietary fluoride supplemen- Children under six years of age, on average, consume tation? less than one-half liter of drinking water a day.18 There- fore,children under six years of age would consume,on Answer. average, less than 0.5 mg of fluoride a day from drink- There is no scientific basis to suggest any need to fin- ing optimally fluoridated water(at 1 ppm). crease a woman's daily fluoride intake during preg- If a child lives in a nonfluoridated area, the dentist or nancy or breastfeeding to protect her health. At this physician may prescribe dietary fluoride supplements. As time, scientific evidence is insufficient to support the shown in Table 1 "Dietary Fluoride Supplement Schedule recommendation for prenatal fluoride supplementation 21. 1994" (See Question 12),the current dosage schedule rec- for decay prevention for infants.123•19D ,, ommends supplemental fluoride amounts that are below the Al for each age group. The dosage schedule was de- Fact. 23. signed to offer the benefit of decay reduction with margin The Institute of Medicine has determined that, "No of safety to prevent mild to moderate dental fluorosis. For data from human studies document the metabolism example,the Al for a child 3 years of age is 0.7 mg/day. of fluoride during lactation. Because fluoride concen- The recommended dietary fluoride supplement dosage trations in human milk are very low (0.007 to 0.011 for a child 3 years of age in a nonfluoridated community is ppm) and relatively insensitive to differences in the 0.5 mg/day. This provides leeway for some fluoride intake fluoride concentrations of the mother's drinking water, from processed food and beverages,and other sources. fluoride supplementation during lactation would not Decay rates are declining in many population groups be expected to significantly affect fluoride intake by because children today are being exposed to fluoride the nursing infant or the fluoride requirement of the from a wider variety of sources than decades ago. - mother."123 - Many of these sources are intended for topical use only; The authors of the only prospective, randomized, however, some fluoride is ingested inadvertently by double blind study to evaluate the effectiveness of children.163 Inappropriate ingestion of fluoride can be prenatal dietary supplementation have concluded that prevented, thus reducing the risk for dental fluorosis the data do not support the hypothesis that prenatal without jeopardizing the benefits to oral health. fluoride has a strong decay preventive effect190 More- For example, it has been reported in a number of over, prenatal dietary fluoride supplementation will studies that young children inadvertantly swallow an not have an affect on the baby's permanent teeth be- average of 0.30 mg of fluoride from fluoride toothpaste cause permanent teeth do not begin todevelopduring at each brushing.184,185-189 If a child brushes twice a day, pregnancy.191 0.60 mg may be ingested inappropriately. This may slightly exceed the Adequate Intake (Al)values from Ta- ble 3.The 0.60 mg consumption is 0.10 mg higher than the Al value for children 6 to 12 months and is 0.10 mg QUESTION 22. lower than the Al for children from 1-3 years of age.123 When fluoride is ingested,where does it go? Although toothpaste is not meant to be swallowed,chil- dren may consume the daily recommended Adequate Answer. Intake amount of fluoride from toothpaste alone. In or- Much of the fluoride is excreted. Of the fluoride retained, der to decrease the risk of dental fluorosis,the American almost all is found in calcified (hard) tissues, such as Dental Association since 1992 has recommended that bones and teeth. Fluoride helps to prevent dental decay parents and caregivers put only one pea-sized amount when incorporated into the teeth. 26 American Dental Association • SAFETY • Fact. QUESTION 23. After ingestion of fluoride, such as drinking a glass of Will the ingestion of optimally fluoridated water over a optimally fluoridated water,the majority of the fluoride lifetime adversely affect bone health? is absorbed from the stomach and small intestine into the blood stream.192 Thiscauses a short term increase Answer. in fluoride levels in the blood. The fluoride levels in- No, the ingestion of optimally fluoridated water does crease quickly and reach a peak concentration within not have an adverse effect on bone health.194_198'203-205 20-60 minutes.193 The concentration declines rapidly, usually within three to six hours following peak lev- Fact. els, due to the uptake of fluoride by calcified tissues The weight of scientific evidence does not provide an and efficient removal of fluoride by the kidneys.182 Ap- adequate basis for altering public health policy regard- proximately 50% of the fluoride absorbed each day by ing fluoridation because of bone health concerns. A young or middle-aged adults becomes associated with number of investigations have studied the effects on hard tissues within 24 hours while virtually all of the bone structure of individuals residing in communi- remainder is excreted in the.urine. Approximately 99% ties with optimal and higher than optimal Concentra of the fluoride present in the body is associated with hard tissues.'92 tions of fluoride in the drinking water. These studies Ingested or systemic fluoride becomes incorporated have focused on whether there exists a possible link into forming tooth structures. Fluoride ingested regularly between fluoride and bone fractures. Additionally, the during the time when teeth are developing is deposited possible association between fluoride and bone cancer throughout the entire surface of the tooth and contrib has been studied. utes to long lasting protection against dental decay.42 In 1991, a workshop, co-sponsored. by the Nation- / Additional information on this topic may be found in al Institute of Arthritis and Musculoskeletal and Skin Question 2. Diseases and the then National Institute of Dental Re- An individual's age and stage of skeletal devel- search, addressed the potential relationship of hip frac- opment will affect the rate of fluoride retention.The ture and bone health in humans to fluoride exposure amount of fluoride taken up by bone and retained in from drinking water. Meeting at the National Institutes the body is inversely related to age. More fluoride is of Health, researchers examined historic and contem- retained in young bones than in the bones of older porary research on fluoride exposure and bone health. adults.183•'92,'93 At that time, participants concluded there was no basis According to generally accepted scientific knowl- for altering current public health policy regarding cur- edge, the ingestion of optimally fluoridated water does rent guidelines for levels of fluoride in drinking water. not have an adverse effect on bone health.194-'98 Evidence Recommendations were made regarding additional re- of advanced skeletal fluorosis, or crippling skeletal search in several areas.'94 fluorosis, "was not seen in communities in the United In 1993, two studies were published demonstrating States where water supplies contained up to 20 ppm that exposure to fluoridated water does not contribute (natural levels of fluoride)."123.'99 In these communities, to an increased risk for hip fractures. One study looked daily fluoride intake of 20 mg/day would not be uncom- at the risk of hip fractures in residents of two similar mon.'23 Crippling skeletal fluorosis is extremely rare in communities in Alberta, Canada.195 In this study, re- the United States and is not associated with optimally searchers compared a city with fluoridated drinking fluoridated water; only 5 cases have been confirmed water optimally adjusted to 1 ppm to a city whose during the last 35 years.123 residents drank water containing naturally occurring (Additional information on this topic may be found in fluoride at a concentration of only 0.3 ppm. No signifi- Question 23. cant difference was observed in the overall hip frac- The kidneys play the major role in the removal of ture hospitalization rates for residents of both cities. fluoride from the body. Normally kidneys are very ef- "These findings suggest that fluoridation of drinking ficient and excrete fluoride very rapidly. However, de- water has no impact, neither beneficial nor deleteri- creased fluoride removal may occur among persons ous,on the risk of hip fracture."195 with severely impaired kidney function who may not The second study examined the incidence of hip frac- be on kidney dialysis.167 No cases of dental fluorosis ture rates before and after water fluoridation in Roches- or symptomatic skeletal fluorosis have been reported ter, Minnesota.'96 Researchers compared the hip fracture among persons with impaired kidney function; how- rates of men and women aged 50 and older from 1950 ever, the overall health significance of reduced fluoride to 1959 (before the city's water supply was fluoridated removal is uncertain and continued follow-up is recom- in 1960)with the ten-year period after fluoridation.Their mended especially for children with impaired kidney findings showed that hip fracture rates had decreased, function.84 and that the decrease began before fluoridation was in- /.Additional information on this topic may be found in troduced, and then continued. These data demonstrate Question 40. no increase in the risk of hip fracture associated with water fluoridation. Fluoridation Facts 27 it An ecological study conducted in eastern Germany centrations of sodium fluoride(25, 100 and 175 ppm)were compared the incidence of hip fractures for adults living consumed by rats and mice.When the NTP and the Proctor in Chemnitz (optimally fluoridated) and Halle (fluoride- and Gamble studies were combined, a total of eight indi- deficient). The results suggested the consumption of vidual sex/species groups became available for analysis. optimally fluoridated water reduced the incidence of hip Seven of these groups showed no significant evidence of fractures in elderly individuals, especially women over malignant tumor formation.One group,male rats from the 84 years of age.200 NTP study, showed "equivocal" evidence of carcinoge- The ingestion of optimally fluoridated water does not nicity, which is defined by NTP as a marginal increase in have an adverse effect on bone health:194-198,20° Exposure neoplasms—i.e.,osteosarcomas (malignant tumors of the to fluoride at levels considered optimal for the prevention bone)—that may be chemically related. The Ad Hoc Sub- of dental decay appears to have no significant impact on committee on Fluoride of the U.S. Public Health Service bone mineral density or risk of bone fracture 2°1-205 Some combined the results of the two studies and stated: "Taken studies have reported hip fracture risk increased slightly, together,the two animal studies available at this time fail to decreased slightly or was unchanged in fluoridated areas establish an association between fluoride and cancer."94.21° compared to nonfluoridated areas. A recent systematic (Additional information on this topic may be found in review of these studies concluded there was no clear as- Question 28. sociation with water fluoridation and hip fracture206 y .L S' _ 4 "k. _ "tExposure to fluoride'at levels"'' QUESTION 24 considered optimal for the,prevention of yh v What is dental fluorosis? 4ental decay-appears`to have no significant 6,':'''','.., h � J $ impact1on bone mineral•density or Answer. f , Y ,1 `,,risk of bone fracture " z.'w� Dental fluorosis is a change in the appearance of teeth h„ lj , e,"'aa, gte and is caused when higher than optimal amounts of fluoride are ingested in early childhood while tooth 24. While a number of studies reported findings at a enamel is forming. The risk of dental fluorosis can be population level, both the Hillier and Phipps studies greatly reduced by closely monitoring the proper use examined risk on an individual rather than a commu- of fluoride products by young children. nity basis taking into account other risk factors such as medications, age of menopause, alcohol consumption, Fact. smoking, dietary calcium intake and physical activity. Dental fluorosis is caused by a disruption in enamel for- Using these more rigorous study designs, Hillier and mation which occurs during tooth development in early Phipps reported no change or lower hip fracture risk in childhood related to a higher than optimal intake of flu- those drinking fluoridated water.203,204 oride .182 Enamel formation of permanent teeth, other In Bone Health and Osteoporosis:A Report of the Sur- than third molars (wisdom teeth), occurs from about the geon General issued in 2004,fluoride is listed as a nutri- time of birth until approximately five years of age. After ent that has potentially beneficial effects on bone 207 tooth enamel is completely formed, dental fluorosis can- Lastly, the possible association between fluoride and not develop even if excessive fluoride is ingested211 Older bone cancer has been studied. In the early 1990s, two children and adults are not at risk for the development of studies were conducted to evaluate the carcinogenicity of dental fluorosis. Dental fluorosis becomes apparent only sodium fluoride in laboratory animals.The first study was after the teeth erupt.Because dental fluorosis occurs while conducted by the National Toxicology Program (NTP) of teeth are forming under the gums,teeth that have erupted the National Institute of Environmental Health Sciences.208 are not at risk for dental fluorosis. It should be noted that The second study was sponsored by the Proctor and Gam- many other developmental changes that affect the appear- ble Company.209 In both studies, higher than optimal con- ance of tooth enamel are not related to fluoride intake. a Table 4.4. Dental F,luoros_ is Classification by H.T. Dean-1942312 ` } s ,--i:,;,11,%,,t4,--_,,,,,,-----__ ., :,f, '.., r- k l ' 5 yi "Clssficationatma � _ Crteria-DesrptioofEnamel a, . 'f., .. -r i; i. vr, '?t" _ . Normal Smooth,glossy,pale creamy-white translucent surface Questionable A few white flecks or white spots Very Mild Small opaque,paper-white areas covering less than 25%of the tooth surface Mild Opaque white areas covering less than 50%of the tooth surface Moderate All tooth surfaces affected;marked wear on biting surfaces;brown stain may be present Severe All tooth surfaces affected;discrete or confluent pitting;brown stain present 28 American Dental Association foe. t x . �1 • i ♦ i ..w. *'M1FSAFET Dental fluorosis has been classified in a number of sources including water, infant formula, foods, foods ways.One of the most universally accepted classifications and drinks prepared with fluoridated water as well as was developed by H.T. Dean in 1942; its descriptions can dietary supplements and the ingestion of fluoride tooth- be easily visualized by the public(see Table 4).212 paste making it difficult to pinpoint the effect any one In using Dean's Fluorosis Index, each tooth present item had on the development of fluorosis. As part of the in an individual's mouth is rated according to the fluo- most recent National Health and Nutrition Examination rosis index in Table 4.The individual's fluorosis score is Survey (NHANES) 1999-2002, new fluorosis data has based upon the severest form of fluorosis recorded for been collected as a representative sample of the U.S. two or more teeth. Dean's Index, which has been used population. By comparing NIDR and the latest NHANES for more than 60 years, remains popular for prevalence data, researchers will be able to determine trends in the studies in large part due to its simplicity and the ability prevalence and severity of dental fluorosis in the past 15 to make comparisons with findings from a number of years and examine if changes in exposure to systemic earlier studies.213 fluorides such as infant formulas,toothpaste and dietary Very mild to mild fluorosis has no effect on tooth fluoride supplements have had some effect.214 function and may make the tooth enamel more resis- Using the same NIDR study, researchers looked at chil- tant to decay. These types of fluorosis are not readily dren aged 12-14 years who had never received dietary apparent to the affected individual or casual observ- fluoride supplements and had only lived in one home. er and often• require a trained specialist to detect. In Through their analysis, they found that approximately contrast, the moderate and severe forms of dental 2% of U.S. school children may experience perceived es- fluorosis, characterized by esthetically (cosmetically) thetic problems which could be attributed to the currently objectionable changes in tooth color and surface ir- recommended levels of fluoride in drinking water. They regularities, are typically easy to detect. Most investi- reported that dental fluorosis in the esthetically important gators regard even the more advanced forms of dental front teeth occurs less often and is less severe than when fluorosis as a cosmetic effect rather than a functional looking at all teeth in an individual. While the researchers adverse effect.123 The U.S. Environmental Protection were not able to provide a cost estimate associated with Agency, in a decision supported by the U.S. Surgeon the treatment of this fluorosis, they. did note that such General, has determined that objectionable dental estimates are frequently an overestimation of the actual fluorosis is a cosmetic effect with no known health ef- costs. Additionally, any change recommended to the cur- fects.168 Little research on the psychological effects of rent fluoridation policy would need to be weighed against dental fluorosis on children and adults has been con- fluoridation's lifetime benefits and the feasibility and as- ducted, perhaps because the majority of those who sociated costs of alternative solutions.215 have the milder forms of dental fluorosis are unaware As with other nutrients, fluoride is safe and effective of this condition.84 when used and consumed properly. The recommended In a 1986-7 national survey of U.S. school children optimum water fluoride concentration of 0.7 to 1.2 ppm conducted by the National Institute of Dental Research was established to maximize the decay preventive ben- (NIDR), dental fluorosis was present in 22.3% of the efits of fluoride, and the same time minimize the likeli- children examined using Dean's Index.84 These children hood of mild dental fluorosis 84 were exposed to a variety of sources of fluoride (fluori- dated water, food, beverages, fluoride dental products e The nsk of teeth forinmgwith the very and dietary supplements): The prevalence of the types w of dental fluorosis observed was: rnildest�=form::of fluorosis,m!JO:tie?weighed:"_,''•' Very mild fluorosis 17.0% against the beneftahathe iridiv►dua/s teeth Mild fluorosis 4.0% will also have a lower level of dental decay Moderate fluorosis 1,0% Mustdental treatment costs':patient Severe fluorosis 0.3% discomfort and tooth loss"- Total 22.3% :_,_ The incidence of moderate or severe fluorosis corn- The benefits and risks of community water fluoridation prised a very small portion (6%) of the total amount of have been examined and are discussed extensively in the fluorosis. In other words,94%of all dental fluorosis was Benefits Section and the safety of water fluoridation is the very mild to mild form of dental fluorosis. discussed in great detail in the remainder of this (Safety) This survey conducted by NIDR remains the only Section of this document. In assessing the risks of den- source of national data regarding the prevalence of den- tal fluorosis, scientific evidence indicates it is probable tal fluorosis. In a study that compared this data with data that approximately 10% of children consuming optimally recorded by H. Trendley Dean in the 1930s, it was de- fluoridated water,in the absence of fluoride from all other termined that the greatest increase in fluorosis from the sources,will develop very mild dental fluorosis.10 As de- 1930s to the 1980s appeared in the group with subopti- fined in Table 4, very mild fluorosis is characterized by mally fluoridated water. During the last ten years of this small opaque,paper-white area covering less than 25%of period, children were exposed to fluoride from multiple the tooth surface.The risk of teeth forming with the very Fluoridation Facts 29 Y,., „� yam -+� a" mildest form of fluorosis must be weighed against the topical use only;however,some fluoride is ingested inad- benefit that the individual's teeth will also have a lower vertently by children.783 Inappropriate ingestion of topical level of dental decay thus saving dental treatment costs, fluoride can be minimized,thus reducing the risk for den- patient discomfort and tooth loss.",12 In addition,the risk tal fluorosis without reducing decay prevention benefits. of fluorosis may be viewed as an alternative to having Since 1992, the American Dental Association (ADA) dental decay,which is a disease that may cause cosmetic has required manufacturers of toothpaste to include the problems much greater than dental fluorosis 276 phrase"Use only a pea-sized amount(of toothpaste)for In 1994, a review of five recent studies indicated that children under six"on fluoride toothpaste labels with the the amount of dental fluorosis attributable to water flu- ADA Seal of Acceptance. The rationale for choosing six oridation was approximately 13%. This represents the years of age for the toothpaste label is based on the fact amount of fluorosis that might be eliminated if com- that the swallowing reflex is not fully developed in chil- munity water fluoridation was discontinued.85 In other dren of preschool age and they may inadvertently swal- words, the majority of dental fluorosis can be associ- low toothpaste during brushing. In addition,the enamel ated with other risk factors such as the inappropriate formation of permanent teeth is basically complete at ingestion of fluoride products. six and so there is a decreased risk of fluorosis. Because Additional information on this topic may be found in dental fluorosis occurs while teeth are forming under the Question 25. gums, individuals whose teeth have erupted are not at The type of fluorosis seen today remains largely limited risk for dental fluorosis: to the very mild and mild categories; however,the preva- Additional information on this topic may be found in lence of dental fluorosis in both fluoridated and nonfluo- Question 24. ridated communities in the United States is higher than it Numerous studies have established a direct relation- was when the original epidemiological studies were con- ship between young children brushing with more than ducted approximately 60 years ago.64 The inappropriate a pea-sized amount of fluoride toothpaste and the risk use of fluoride-containing dental products is the largest of very mild or mild dental fluorosis in both fluoridated risk factor for increased fluorosis as fluoride intake from and nonfluoridated communities.189,218,218 It was noted food and beverages has remained constant over time.180,181 that 34%of the dental fluorosis cases in a nonfluoridated 25' The risk of fluorosis can be greatly reduced by following la- community were explained by children having brushed 6. bel directions for the use of these fluoride products.123.16' more than once per day during the first two years of life. Additional information on this topic may be found in In the optimally fluoridated community, 68% of the fluo- 27. Question 25. rosis cases were explained by the children using more than a pea-sized amount of toothpaste during the first year of life 220 Parents and caregivers should put only one pea-sized amount of fluoride toothpaste on a young QUESTION 25. child's toothbrush at each brushing. Young children What can be done to reduce the occurrence of dental should be supervised while brushing and taught to spit fluorosis in the U.S.? out, rather than swallow,the toothpaste. Consult with your child's dentist or physician if you are considering Answer. using fluoride toothpaste before age two. The vast majority of dental fluorosis in the United Additionally, it has been shown that 65% of the fluo- States can be prevented by limiting the ingestion of rosis cases in a nonfluoridated area were attributed to topical fluoride products (such as toothpaste) and the fluoride supplementation under the pre-1994 protocol. appropriate use of dietary fluoride supplements with- Thirteen percent of fluorosis cases in a fluoridated com- out denying young children the decay prevention ben- munity could be explained by a history of taking dietary efits of community water fluoridation. fluoride supplements inappropriately.220 Dietary fluoride supplements should be prescribed as recommended in Fact. the dietary fluoride supplement schedule approved by During the period of enamel formation in young children the American Dental Association, the American Acade- (before teeth appear in the mouth),inappropriate ingestion my of Pediatrics and the American Academy of Pediatric of high levels of fluoride is the risk factor for dental fluoro- Dentistry in 1994(see Table 1)30.125 Fluoride supplements sis 85,2" Studies of fluoride intake from the diet including should only be prescribed for children living in nonfluori- foods,beverages and water indicate that fluoride ingestion dated areas. Because of many sources of fluoride in the from these sources has remained relatively constant for diet, proper prescribing of fluoride supplements can be over half a century and,therefore,is not likely to be associ- complex. It is suggested that all sources of fluoride be ated with an observed increase in dental fluorosis.186-182 evaluated with a thorough fluoride history before sup- --Additional information on this topic may be found in plements are prescribed for a child.122 That evaluation Question 19. should include testing of the home water supply if the Dental decay has decreased because children today are fluoride concentration is unknown. being exposed to fluoride from a wider variety of sources Additional information on this topic may be found in than decades ago.Many of these sources are intended for Question 42. 30 American Dental Association • If 1 • • . t - � �' 'SA°FETY Parents, caretakers and health care professionals The ADA warning labels were adopted to help reduce should judiciously monitor use of all fluoride-contain- the risk of mild dental.fluorosis. This type of fluorosis ing dental products by children under age six.As is the is not readily apparent to the affected individual or ca- case with any therapeutic product, more is not always sual observer and often requires a trained specialist to better. Care should be taken to adhere to label directions detect. Dental fluorosis only occurs when more than the on fluoride prescriptions and over-the-counter products optimal daily amount of fluoride is ingested. (e.g. fluoride toothpastes and rinses). The ADA recom- Additionally,to ensure children's safety,the ADA lim- mends the use of fluoride mouthrinses,but not for chil- its the total amount of fluoride allowed in any one tube dren under six years of age because they may swallow of ADA-Accepted toothpaste. the rinse. These products should be stored out of the Since 1997, the U.S. Food and Drug Administration reach of children. (FDA) has required the label language, "If you acci- Finally, in areas where naturally occurring fluoride dentally swallow more than used for brushing, seek levels in ground water are higher than 2 ppm,consum- professional help or contact a poison control center im- ers should consider action to lower the risk of dental mediately" on all fluoride toothpastes sold in the U.S. fluorosis for young children. (Adults are not affected The new FDA labels are consistent with the ADA because dental fluorosis occurs only when develop- statements, with the exception of the poison control ing teeth are exposed to elevated fluoride levels.) warning. Families on community water systems should contact The ADA.Council on Scientific Affairs believes that their water supplier to ask about the fluoride level. the last sentence on the label could unnecessarily fright- Consumers with private wells should have the source en parents and children and that this portion of the label tested yearly to accurately determine the fluoride con- overstates any demonstrated or potential danger posed tent. Consumers should consult with their dentist re- by fluoride toothpastes. garding water testing and discuss appropriate dental The ADA notes that a child could not absorb enough health care measures. In homes where young children fluoride from one tube of toothpaste to cause a seri- are consuming water with a fluoride level greater than ous problem and that the excellent safety record on 2 ppm, families should use an alternative primary fluoride toothpaste argues against any unnecessary water source, such as bottled water, for drinking and regulation.221 cooking. It is also important to remember that the ADA recommends dietary fluoride supplements only for children living in areas with less than optimally fluori- dated water. QUESTION 27. Additional information on this topic may be found in Is fluoride, as provided by community water fluorida- Questions 4, 12 and 42. tion,a toxic substance? Answer. No. Fluoride, at the concentrations found in optimally QUESTION 26. fluoridated water,is not toxic according to generally ac- Why is there a warning label on a tube of fluoride tooth- cepted scientific knowledge. paste? Fact. Answer. Like many common substances essential to life and The American Dental Association originally required good health — salt, iron, vitamins A and D, chlorine, manufacturers to place a label on fluoride toothpaste oxygen and even water itself—fluoride can be toxic in in 1991 to ensure proper use and therefore reduce the excessive quantities. Fluoride in the much lower con- risk of dental fluorosis. centrations(0.7 to 1.2 ppm) used in water fluoridation is not harmful or toxic. Fact. Acute fluoride toxicity occurring from the ingestion In 1991, the American Dental Association (ADA) began of optimally fluoridated water is impossible.182 The requiring toothpaste manufacturers to include the follow- amount of fluoride necessary to cause death for a hu- ing language on all ADA-Accepted toothpastes: "Do not man adult (155 pound man) has been estimated to be swallow. Use only a pea-sized amount for children under 5-10 grams of sodium'fluoride, ingested at one time.222 six. To prevent swallowing, children under six years of This is more than 10,000-20,000 times as much fluoride age should be supervised in the use of toothpaste." . as is consumed at one time in a single 8 ounce glass of optimally fluoridated water. Chronic fluoride toxicity may develop after 10 or F_ "To e>sure ch5ldren's;safety the ADA Lmits _ ,_..,�._t-.,� _ more years of exposure to very high levels of fluoride, .' 7-tiie total amount df fluoride allowed n „s levels not associated with optimal fluoride intake in _ADA Accepted toothpaste drinking water. The primary functional adverse effect associated with long term excess fluoride intake is Fluoridation Facts 31 'a ,WA,;,-;',".,,,,,,# alT 1 x SF '�$ "G*{t is,�,6T y�, 1C 14,��m°°� � �u -.�. f .., s g• f'I 9'3 i. 4A •..a JF'1• (:':,„ wq.' } i < c*T Fs 1- uts .PyS� y t , 4 { „R €r +A•�h '' #' a,i. i ALT .3. skeletal fluorosis. The development of skeletal fluoro- At one time, high concentrations of fluoride additives sis and its severity is directly related to the level and were used in insecticides and rodenticides.36 Today fluo- duration of fluoride exposure. For example,the inges- ride additives are rarely used in pesticides because more tion of water naturally fluoridated at approximately 5 effective additives have been developed.183 ppm for 10 years or more is needed to produce clinical While large doses of fluoride may be toxic, it is im- signs of osteosclerosis(a mild form of skeletal fluorosis portant to recognize the difference in the effect of a that can be seen as a change in bone density on x-rays) massive dose of an extremely high level of fluoride in the general population. In areas naturally fluoridat- versus the recommended amount of fluoride found ed at 5 ppm, daily fluoride intake of 10 mg/day would in optimally fluoridated water. The implication that not be uncommon.123 A survey of X-rays from 170,000 fluorides in large doses and in trace amounts have people in Texas and Oklahoma whose drinking water the same effect is completely unfounded. Many sub- had naturally occurring fluoride levels of 4 to 8 ppm stances in widespread use are very beneficial in small revealed only 23 cases of osteosclerosis and no cases amounts, but may be harmful in large doses—such as of crippling skeletal ffuorosis.223 Evidence of advanced salt,chlorine and even water itself= skeletal fluorosis, or crippling skeletal fluorosis, "was not seen in communities in the United States where water supplies contained up to 20 ppm (natural levels of fluoride)."123.799 In these communities, daily fluoride QUESTION 28. intake of 20mg/day would not be uncommon=123 Crip- Does drinking optimally fluoridated water cause or ac- piing skeletal fluorosis is extremely rare in the United celerate the growth of cancer? States and is not associated with optimally fluoridated water; only 5 cases have been confirmed during the Answer. last 35 years.123 According to generally accepted scientific knowledge, 6Additional information on this topic may be found in there is no association between cancer rates in humans Question 20. and optimal levels of fluoride in drinking water.225 The Agency for Toxic Substances and Disease Regis- $' try (ATSDR) prepares toxicological profiles for various Fact. 29 hazardous substances most commonly found at facili- Since community water fluoridation was introduced in ties on the CERCLA National Priorities List (Superfund 1945, more than 50 epidemiologic studies in different Sites). The Toxicological Profile for Fluorides,Hydrogen populations and at different times have failed to dem- Fluoride and Fluorine was revised in 2003. The ATSDR onstrate an association between fluoridation and the states that existing data indicates that subsets of the risk of cancer.84 Studies have been conducted in the population may be unusually susceptible to the toxic ef- United States,226-23' Japan,232 the United Kingdom 233235 fects of fluoride and its compounds at high doses. How- Canada236 and Australia.237 In addition, several indepen- ever, there are no data to suggest that exposure to the dent bodies have conducted extensive reviews of the low levels associated with community water fluorida- scientific literature and concluded that there is no rela- tion would result in adverse effects in these potentially tionship between fluoridation and cancer.84,163,166,176,206,236 susceptible populations.224 The U.S. Environmental Protection Agency(EPA)fur- ther commented on the safety of appropriate fluoride c� ,, ',“ ,+w;t,,;, ' ,i,r�, .4 exposure in the December 5, 1997, Federal Register.239 . The posslb,Iltyof adverse J'. In a notice of a final rule relating to fluoride additives; ,`,11 -b1:froin.contirnuous,/ow -i-r� the EPA stated, "...the weight of evidence from more :,s-:`}leve!c onsumpt,on oftf%uorideover long j5 than 50 epidemiological studies does not support the '"" ., ` "'" " ' ' '" " i : hypothesis of an association between fluoride expo- :-:perioii"stilus=been:studied;extensiv`ely�:4's=Wlth�:�; "'''" sure and increased cancer risk in humans. The EPA is ''-Bother nutrients fluorrdeasysafe and effective' :y;:"; in agreement with the conclusions reached by the Na- when used and consumed proper ly ' tional Academy of Sciences(NAS)." 1' ::�'' n, .,,.;N, W.`,4-, -41,P,'4'`.. Despite the abundance of scientific evidence to the contrary, claims of a link between fluoridation and in- The possibility of adverse health effects from con- creased cancer rates continue. This assertion is largely tinuous low level consumption of fluoride over long based on one study comparing cancer death rates in ten periods has been studied extensively. As with other large fluoridated cities versus ten large nonfluoridated nutrients, fluoride is safe and effective when used and cities in the United States.The results of this study have consumed properly. No charge against the benefits and been refuted by a number of organizations and research- safety of fluoridation has ever been substantiated by ers.240 Scientists at the National Cancer Institute analyzed generally accepted scientific knowledge. After 60 years the same data and found that the original investigators of research and practical experience, the preponder- failed to adjust their findings for variables, such as age ance of scientific evidence indicates that fluoridation of and gender differences,that affect cancer rates. A review community water supplies is both safe and effective. by other researchers pointed to further shortcomings in 32 • American Dental Association µ „ the study.The level of industrialization in the fluoridated for cancer in the fluoridated and nonfluoridated com- cities was much higher than the nonfluoridated cities. munities. For example, this analysis did not control Researchers noted that a higher level of industrialization for differences in urbanization, socioeconomic status, is usually accompanied by a higher incidence of cancer. geographic region, occupations, industries, diet, medi- While the researchers noted that the fluoridated cities did cal practices or tobacco use between the fluoridated have higher cancer rates over the twenty year study,the and nonfluoridated communities. Thus any attempt to rate of increase in the nonfluoridated cities was exactly interpret cancer risk between these communities with the same (15%) as the fluoridated cities. Following fur- this number of uncontrolled variables is scientifically ther reviews of the study,the consensus of the scientific inappropriate. community continues to support the conclusion that the incidence of cancer is unrelated to the introduction and / 1 duration of water fluoridation.84 >- 'The Amercan Cancer Socrety states; In the early 1990s, two studies using higher than 'Scientrfic stuafies show no connectron optimal levels of fluoride were conducted to evaluate be?wee"rl cancer rates_rn humans and adding the carcinogenicity of sodium fluoride in laboratory w k fluo,-deto drinking water animals.The first study was conducted by the National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences.208 The second study In a document entitled "Fluoride and Drinking Water was sponsored by the Proctor and Gamble Company.209 Fluoridation,"the American Cancer Society states, "Sci- In both studies, higher than optimal concentrations of entific studies show no connection between cancer rates sodium fluoride(25, 100 and 175 ppm)were consumed in humans and adding fluoride to drinking water."225 by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual sex/species groups became available for anal- ysis. Seven of these groups showed no significant QUESTION 29. evidence of malignant tumor formation. One group, Does fluoride,as provided by community water fluori- male rats from the NTP study,showed "equivocal" evi- dation,inhibit the activity of enzymes in humans? dence of carcinogenicity,which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas Answer. (malignant tumors of the bone) —that may be chemi- Fluoride,in the amount provided through optimally flu- cally related. The Ad Hoc Subcommittee on Fluoride oridated water,has no effect on human enzyme activity of the U.S. Public Health Service combined the results according to generally accepted scientific knowledge. of the two studies and stated: "Taken together,the two animal studies available at this time fail to establish an Fact. association between fluoride and cancer."84.210 Enzymes are organic compounds that promote chem- Since that time, a number of studies have examined. ical change in the body. Generally accepted scientific the hypothesis that fluoride is a risk factor for bone can- knowledge has not indicated that optimally fluoridat- cer. None of these studies reported an association be- ed water has any influence on human enzyme activity. tween optimal levels of fluoride in drinking water and There are no available data to indicate that, in humans cancer of the bone.241-244 drinking optimally fluoridated water, the fluoride af- (-Additional information on this topic may be found in fects enzyme activities with toxic consequences.246 Question 23. The World Health Organization report, Fluorides and In a 1990 study, scientists at the National Cancer In- Human Health states, "No evidence has yet been pro- stitute evaluated the relationship between fluoridation vided that fluoride ingested at 1 ppm in the drinking of drinking water and cancer deaths in the United States water affects intermediary metabolism of food stuffs, during a 36 year period, and the relationship between vitamin utilization or either hormonal or enzymatic fluoridation and the cancer rate during a 15 year period. activity."24' After examining more than 2.3 million cancer death re- The concentrations of fluoride used in laboratory cords and 125,000 cancer case records in counties using studies to produce significant inhibition of enzymes fluoridated water,the researchers saw no indication of a are hundreds of times greater than the concentration cancer risk associated with fluoridated drinking water.84 present in body fluids or tissues.222 While fluoride may In 2001, researchers from Japan analyzed dataon affect enzymes in an artificial environment outside of cancers taken from the International Agency for Re- a living organism in the laboratory,it is unlikely that ad- search on Cancer World Health Organization in 1987, equate cellular levels of fluoride to alter enzyme activi- 1992 and 1997 and concluded that fluoridation may ties would be attainable in a living organism.246 The two increase the risk for numerous types of cancers.265 primary physiological mechanisms that maintain a low However, the methodology used in this analysis was concentration of fluoride ion in body fluids are the rapid inherently flawed as there are major and obvious dif- excretion of fluoride by the kidneys and the uptake of ferences in a number of factors relevant to the risk fluoride by calcified tissues. Fluoridation Facts 33 s "' tee'} . s • - QUESTION 30. tion in the pineal gland. The purpose of the study was Does the ingestion of optimally fluoridated water ad- to discover whether fluoride accumulates in the pineal versely affect the thyroid gland or its function? gland of older adults. This limited study, conducted on only 11 cadavers whose average age at death was 82 Answer. years, indicated that fluoride deposited in the pineal There is no scientific basis that shows fluoridated wa- ter has an adverse effect on the thyroid gland or its in the pineal gland. It would not be unexpected to see function. higher levels of calcium in the pineal gland of older indi- viduals as this would be considered part of a normal ag- Fact. ing process. As discussed in Question 22,approximately In an effort to determine if fluoride in drinking water af- 99%of the fluoride present in the body is associated with fects the function,shape and size of the thyroid gland, hard or calcified tissues.192 The study concluded fluoride researchers conducted a study comparing one group levels in the pineal gland were not indicators of long of people who consumed water that contained natural term fluoride exposure 252 fluoride levels of 3.48 ppm and one group who con- The same researcher has theorized in unpublished sumed water with extremely low fluoride levels of 0.09 reports posted on the Internet that the accumulation of ppm. The researchers noted that all study participants fluoride in children's pineal gland leads to an earlier on had been residents of their respective communities forset of puberty. However,the researcher notes that there more than 10 years. The researchers concluded that is no verification that fluoride accumulates in children's prolonged ingestion of fluoride at levels above optimal pineal glands. Moreover, a study conducted in New to prevent dental decay had no effect on thyroid gland burgh (fluoridated) and Kingston (non fluoridated), New size or function. This conclusion was consistent with York found no statistical significance between the onset earlier animal studies.248 of menstruation for girls living in a fluoridated verses In addition, two studies have explored the associa- fluoridated area 253 tion between fluoridated water and cancer of the thy- 30 roid gland. Both studies found no association between optimal levels of fluoride in drinking water and thyroid QUESTION 32.31. cancer.226,249 In an effort to link fluoride and decreased thyroid func- Can fluoride,at the levels found in optimally fluoridated 32. tion, those opposed to fluoridation cite one small study drinking water,alter immune function or produce eller- from the 1950's in which 15 patients who had hyperthy- gic reaction (hypersensitivity)? 33. roidism (an overactive thyroid) were given relative large amounts of sodium fluoride orally or by injection in an ef- Answer. 34' fort to inhibit the thyroid's function. The researchers con- There is no scientific evidence of any adverse effect 35. cluded that efforts to treat hyperthyroidism with fluoride on specific immunity from fluoridation, nor have there was successful only occasionally among persons sub- been any confirmed reports of allergic reaction 254 jected to massive doses of fluoride. This study does not support claims that low fluoride levels in drinking water Fact. would cause hypothyroidism(anunderactive thyroid)250 There is no scientific evidence linking problems with immune function such as HIV or AIDS (acquired im- mune deficiency syndrome) with community water fluoridation.255 QUESTION 31. There are no confirmed cases of allergy to fluoride, Does water fluoridation affect the pineal gland causing or of any positive skin testing in human or animal mod- the early onset of puberty? els.254 A committee of the National Academy of Sciences evaluatedclinical reports of possible allergic responses Answer. to fluoride and reported, "The reservation in accepting Generally accepted science does not suggest that wa- (claims of allergic reaction) at face value is the lack of ter fluoridation causes the early onset of puberty. similar reports in much larger numbers of people who have been exposed to considerably more fluoride than Fact. was involved in the original observations."39 The World The pineal gland is an endocrine gland located in the Health Organization also judged these cases to repre- brain which produces melatonin.251 Endocrine glands sent "a variety of unrelated conditions" and found no secrete their products into the bloodstream and body evidence of allergic reactions to fluoride 256.252 tissues and help regulate many kinds of body functions. A 1996 review of the literature on fluoride and white The hormone, melatonin, plays a role in sleep, aging cell function examined numerous studies and conclud- and reproduction. ed that there is no evidence of any harmful effect on A single researcher has published one study in a peer- specific immunity following fluoridation nor any con- reviewed scientific journal regarding fluoride accumula- firmed reports of allergic reactions.254 34 American Dental Association • •) \' SAFETY QUESTION 33. QUESTION 34. Is fluoride, as provided by community water fluorida- Does fluoride at the levels found in water fluoridation tion,a genetic hazard? affect human reproduction,fertility or birth rates? Answer. Answer. Following a review of generally accepted scientific There is no credible, scientific evidence that fluorida- knowledge, the National Research Council of the tion has an adverse effect on human reproduction,fer- National Academy of Sciences supports the conclu- tility or birth rates. sion that drinking optimally fluoridated water is not a genetic hazard.167 Fact. Very high levels of fluoride intake have been associated Fact. with adverse effects on reproductive outcomes in many Chromosomes are the DNA-containing bodies of cells animal species. Based on these findings,it appears that that are responsible for the determination and transmis- fluoride concentrations associated with adverse repro- sion of hereditary characteristics. Genes are the func- ductive effects in animals are far higher (100-200 ppm) tional hereditary unit that occupies a fixed location on than those to which human populations are exposed. a chromosome. Many studies have examined the pos- Consequently, there is insufficient scientific basis on sible effects of fluoride on chromosome damage. While which to conclude that ingestion of fluoride at levels there are no published studies on the genotoxic (dam- found in community water fluoridation (0.7— 1.2 ppm) age to DNA) effect of fluoride in humans, numerous would have adverse effects on human reproduction.'67 studies have been done on mice.167 These studies have One human study compared county birth data with shown no evidence that fluoride damages chromo- county fluoride levels greater than 3 ppm and attempt- somes in bone marrow or sperm cells even at fluoride ed to show an association between high fluoride lev- levels 100 times higher than that in fluoridated water.258- els in drinking water and lower birth rates.271 However, 264 Another independent group of researchers reported because of serious limitations in design and analysis, a similar lack of fluoride-induced chromosomal damage the investigation failed to demonstrate a positive cor- to human white blood cells,which are especially sensi- relation.272 tive to agents which cause genetic mutations. Not only A study examining the relative risk of stillbirths and did fluoride fail to damage chromosomes, it protected congenital abnormalities (facial clefts and neural tube them against the effect of a known mutagen (an agent defects)found no evidence that fluoridation had any ef- that causes changes in DNA)285,266 The genotoxic effects fect of these outcomes.273 of fluoride were also studied in hamster bone marrow The National Research Council (NRC) of the National cells and cultured hamster ovarian cells. Again,the re- Academy of Sciences (NAS) supports the conclusion sults supported the conclusion that fluoride does not that drinking optimally fluoridated water is not a genetic cause chromosomal damage, and therefore, was not hazard.'67 a genetic hazard.267 In further tests, fluoride has not (Additional information on this topic may be found in caused genetic mutations in the most widely used bac- Question 33. terial mutagenesis assay (the Ames test) over a wide range of fluoride levels.267-27° The National Research Council (NRC) of the Nation- al Academy of Sciences supports the conclusion that QUESTION 35. - drinking optimally fluoridated water is not a genetic Does drinking optimally fluoridated water cause hazard. In a statement summarizing its research, the an increase in the rate of children born with Down NRC states,"in vitro data indicate that: Syndrome? 1) the genotoxicity of fluoride is limited primarily to doses much higher than those to which humans Answer. are exposed, There is no known association between the consump- 2) even at high doses, genotoxic effects are not al- tion of optimally fluoridated drinking water and Down ways observed,and Syndrome. 3) the preponderance of the genotoxic effects that have been reported are of the types that probably Fact. are of no or negligible genetic significance."167 This question originally arose because of two studies The lowest dose of fluoride reported to cause chro- published in 1956 and 1963 by a psychiatrist. Data col- mosomal changes in mammalian cells was approxi- lected in several Midwest states in 1956 formed the mately 170 times that found normally found in human basis for his two articles published in French journals, cells in areas where drinking water is fluoridated,which purporting to prove a relationship between fluoride in indicates a large margin of safety.767 the water and Down Syndrome.274'275 Experienced epidemiologists and dental research- ers from the National Institute of Dental Research and 35 Fluoridation Facts 45 b I. '< ' , V ,,� Y� .° M t •� �.�,• t -, 4,V �-+-0 _sc ti'A' ‘, C^ .. .._ay „A . i .3°.,1 4 V : ry y �S' &SjC4�Vn+F +,._ q<v. fi . _ staff members of the National Institute of Mental Health partly on one 1995 study in which rats were fed fluoride have found serious shortcomings in the statistical pro- at levels up to 125 times greater than that found in opti- cedures and designs of these two studies. Among the mally fluoridated water.281 The study attempted to dem- most serious inadequacies is the fact that conclusions onstrate that rats fed extremely high levels of fluoride were based on the fluoridation status of the commu- (75 ppm to 125 ppm in drinking water) showed behav- nities where the mothers gave birth, rather than the ior-specific changes gelated to cognitive deficits. status of the rural areas where many of the women In addition, the experiment also studied the off- lived during their pregnancies.222 In addition,the num- spring of rats who were injected two to three times a ber of Down Syndrome cases found in both fluoridat- day with fluoride during their pregnancies in an effort ed and nonfluoridated communities were much lower to show that prenatal exposure resulted in hyperactiv- than the rates found in many other parts of the United ity in male offspring. States and the world,that casting doubt on the validity However, two scientists who reviewed the 1995 of findings. study282 have suggested that the observations made The following paragraphs provide a summary of nu- can be readily explained by mechanisms that do not merous studies that have been conducted which refute involve neurotoxicity. The scientists found inadequa- the conclusions of the 1956 studies. cies in experimental design that may have led to in- A British physician reviewed vital statistics and records valid conclusions. For example, the results of the from institutions and school health officers, and talked experiment were not confirmed by the use of control with public health nurses and others caring for children groups which are an essential feature of test valida- with Down Syndrome. The findings noted no indication of any relationship between Down Syndrome and the tion and experimental design. In summary the scien level of fluoride in water consumed by the mothers27fi tists stated, "We do not believe the study by Mullenix These findings were confirmed by a detailed study of et al. can be interpreted in any way as indicating the approximately 2,500 Down Syndrome births in Massa- potential for NaF (sodium fluoride) to be a neurotoxi- chusetts. A rate of 1.5 cases per 1,000 births was found cant.” Another reviewer-182 noted, "...it seems more in both fluoridated and nonfluoridated communities; likely that the unusually high brain fluoride concen- 36' providing strong evidence that fluoridation does not in trations reported in Mullenix et al. were the result of 37. crease the risk of Down Syndrome.277 some analytical error." Another large population-based study with data re- 38. lating to nearly 1.4 million births showed no association .,; xi between water fluoridation and the incidence of con 'A seven year,studyrcompa-ed the health genital malformations including Down Syndrome.278 ,•=•. .e -.- . -- - '_h `° ;�F::and behavior.of.c1�'ildren:from'birth:;tlrough°;;,? In 1980, a 25-year review of the prevalence of con- ,:' " genital malformations was conducted in Birmingham, ":="` six years of`age„inrcommunities with England. Although Birmingham initiated fluoridation --' 1".:,~optimally fluor►dated water The results in 1964, no changes in the prevalence of children born ,' 'suggested that there was no,evidence r'-'.' with Down Syndrome occurred since that time.279 '' to indjcate that exposure to optu�ally A comprehensive study of Down Syndrome births 1 fluori ated*water had a"ny detectable effect, was conducted in 44 U.S. cities over a two-year period. ;" , "�E" a�'{ '-' r . h ° ,' °f , on childrens heslth�or,behavior ���# Rates of Down Syndrome were comparable in both flu ''' .-'4' rr'; „' i _{ oridated and nonfluoridated cities 280 A seven-year study compared the health and be- havior of children from birth through six years of age QUESTION 36. in communities with optimally fluoridated water with Does ingestion of optimally fluoridated water have any those of children the same age without exposure to neurological impact? optimally fluoridated water. Medical records were re- viewed yearly during the study. At age six and seven, Answer. child behavior was measured using both maternal There is no generally accepted scientific evidence es- tablishing a causal relationship between consumption was no evidence to indicate that exposure to opti- of optimally fluoridated water and central nervous sys- mally fluoridated water had any detectable effect on tem disorders,attention deficit disorders or effects on children's health or behavior. These results did not intelligence. differ even when data was controlled for family social background.283 Fact. The research conducted by Mullenix et al discussed in There have been claims that exposure to fluoride pres- this question has not been replicated by other researchers. ents a neurotoxic (harmful or damaging to nerve tis- /Additional information on how to critically review re- sue) risk or lowered intelligence. Such claims are based search can be found in the Introduction and Figure 1. 36 American Dental Association `vim SAFETY s e.. ' QUESTION 37. adult lead exposure are occupational. Adult blood lead Does drinking fluoridated water increase the level of levels have continued to decline over the last ten years lead in the blood or cause lead poisoning in children? due largely to improved prevention measures in the workplace and changes in employment patters.287 It Answer. should be noted that since the 1970s, while blood lead Generally accepted scientific evidence has not shown levels have continued to decline, the percentage of the any association between water fluoridation and blood population receiving optimally fluoridated water has lead levels. continued to increase.34 The research conducted by Masters et al discussed in Fact. this question has not been replicated by other researchers. One set of researchers has claimed that the silicofluo- j-Additional information on how to critically review re- ride additives used in community water fluoridation search can be found in the Introduction and Figure 1. may be responsible for acidic drinking water which leaches lead from plumbing systems thereby increas- ing lead uptake by children.They go on to theorize that QUESTION 38. communities that use the silicofluorides have greater numbers of children with high levels of lead in their Does drinking optimally fluoridated water cause Alzheim- blood than nonfluoridated communities and that the er's disease? results of the use of silicofluorides are reflected in these communities' residents exhibiting higher rates Answer. of learning disabilities, attention deficit disorders, vio Generally accepted science has not demonstrated an lent crimes and criminals who were using cocaine at association between drinking optimally fluoridated wa- the time of arrest.286 ter and Alzheimer's disease. From his research, Masters has claimed to be able to Fact. predict the estimated cost of increased prison popula- The exact cause.of Alzheimer's disease has yet to be tions due to water fluoridation. For example, in a 2003 identified. Scientists have identified the major risk fac- appearance before the Palm Beach County (Florida) tors for Alzheimer's as age and family history. Sci- Commission, Masters stated that if the county fluoridat- entists believe that genetics may play a role in many ed with silicofluorides, they could expect an additional Alzheimer's cases. Other possible risk factors that are 819 violent crimes per year directly related to water being studied are level of education, diet, environment fluoridation with a minimum additional annual cost of and viruses to learn what role.they might play in the imprisonment of$14,391,255.284 development of this disease.288 Scientists from the Environmental Protection A study published in 1998289 raised concerns about Agency (EPA) have reviewed the basic science that the potential relationship between fluoride and AI- was the foundation for the claim that silicofluorides zheimer's disease. However,several flaws in the experi- leach lead from plumbingsystems and found that mental design preclude any definitive conclusions from many of the chemical assumptions made and statisti- being drawn.29° cal methods utilized in the original ecological study Interestingly, there is evidence that aluminum and were scientifically unjustified. They went on to state fluoride are mutually antagonistic in competing for that the research was inconsistent with accepted absorption in the human body.42'291 While a conclusion scientific knowledge and the authors of the original cannot be made that consumption of fluoridated wa- studies (Masters et al) failed to identify or account ter has a preventive effect on Alzheimer's, there is no for these inconsistencies. Overall, the EPA scientists generally accepted scientific knowledge to show con- concluded that."no credible evidence exists to show sumption of optimally fluoridated water is a risk factor that water fluoridation has any quantitatable effects for Alzheimer's disease. on the solubility, bioavailability, bioaccumulation, or reactivity of lead (0) or lead (II) compounds.285 According to the Centers for Disease Control and Prevention, the average blood lead levels of young children in the U.S. have continued to decline since the 1970s primarily due to the phase-out of leaded gaso- line and the resulting decrease in lead emissions. The primary remaining sources of childhood lead exposure are deteriorated leaded paint, house dust contaminated . by leaded paint and soil contaminated by both leaded paint and decades of industrial and motor vehicle emis- sions.288 Approximately 95% of the primary sources of Fluoridation Facts 37 --o- ..n'.`� .` ::w. a_--,.. u���.nMr' __ "F"a°, ;P .� n5 3� :, "� 6 ^�:"; 'E i,. e 7. E• . , .. QUESTION 39. QUESTION 40. Does drinking optimally fluoridated water cause or con- Is the consumption of optimally fluoridated water harm- tribute to heart disease? ful to kidneys? Answer. Answer. Drinking optimally fluoridated water is not a risk factor The consumption of optimally fluoridated water has for heart disease. not been shown to cause or worsen human kidney disease. Fact. This conclusion is supported by results of a study Fact. conducted by the National Heart and Lung and Blood Approximately 50% of the fluoride ingested daily is re- institute of the National Institutes of Health. Research- moved from the body by the kidneys.'82,192093 Because ers examined a wide range of data from communities the kidneys are constantly exposed to various fluoride that have optimally fluoridated water and from areas concentrations, any health effects caused by fluoride with insufficient fluoride.The final report concluded would likely manifest themselves in kidney cells. How- that: ever, several large community-based studies of people "Thus,the evidence from comparison of the health with long-term exposure to drinking water with fluoride of fluoridating and nonfluoridating cities, from concentrations up to 8 ppm have failed to show an in- medical and pathological examination of persons crease in kidney disease.'66,253,295 exposed to a lifetime of naturally occurring fluo In a report issued in 1993 by the National Research rides or persons with high industrial exposures, Council,the Subcommittee on Health Effects of Ingest- and from broad national experience with fluorida ed Fluoride stated that the threshold dose of fluoride in tion all consistently indicate no adverse effect on cardiovascular health."292 drinking water which causes kidney effects in animals is approximately 50 ppm-more than 12 times the max- imum level allowed in drinking water by the Environ- 39. "The A"mer�can`HeartAssociat►on States mental Protection Agency, Therefore, they concluded that "ingestion of fluoride at currently�'No evidence ex�ststhat adjusting the`fluQr�de"- 9 recommended concentrations is not likely to produce kidney toxicity content ofoublia water supp'te'S to a levelof ,67 41. about one part per rnillion has nyIra rmfu! in humans." Many people with kidney failure depend on hemo- effect„ona the;cardiovascularrsystem1 , G�., � 2:'1',' � � dialysis (treatment with an artificial kidney machine) for their survival. During hemodialysis, the patient's The American Heart Association states: "No evidence blood is exposed to large amounts of water each exists that adjusting the fluoride content of public water week (280-560 quarts). Therefore, procedures have supplies to a level of about one part per million has any been designed to ensure that the water utilized in the harmful effect on the cardiovascular system,"293 The process contain a minimum of dissolved substances American Heart Association identifies aging, male sex, that could diffuse indiscriminately into the patient's heredity cigarette and tobacco smoke, high blood cho bloodstream.296 Since the composition of water var- lesterol levels, high blood pressure, physical inactivity, ies in different geographic locations in the United obesity and diabetes mellitus as major risk factors for States, the U.S. Public Health Service recommends cardiovascular disease.294 dialysis units use techniques such as reverse osmosis A number of studies have considered trends in ur- and de-ionization to removeexcess iron, magnesium, ban mortality in relation to fluoridation status. In one aluminum, calcium, and other minerals, as well as study, the mortality trends from 1950-70 were studied fluoride, from tap water before the water is used for for 473 cities in the United States with populations of dialysis.296,297 25,000 or more. Findings showed no relationship be- &*Additional information on this topic is available in Ques- tween fluoridation and heart disease death rates over tion 22, the 20-year period.226 In another study, the mortality rates for approximately 30 million people in 24 fluori- dated cities were compared with those of 22 nonfluo- ridated cities for two years. No evidence was found of any harmful health effects, including heart disease, at- tributable to fluoridation.As in other studies,crude dif- ferences in the mortality experience of the cities with fluoridated and nonfluoridated water supplies were explainable by differences in age, gender and race composition.227 38 American Dental Association SAFETY • QUESTION 41. '= Y What are some of the erroneous health claims made Of,tfie thousands of credible sctentlfic f against water fluoridation? ( , studres on fluor�dat7on,Jnone has shown,, r ', 9 Vic, 3 aa- .. health Problems associated wtth the' ,x s Answer: , zconsumpt�on of,optimally fluoridated:water From sources such as the Internet, newsletters, and personal anecdotes in e-mails,community water fluo- ridation is frequently charged with causing all of the following adverse health effects: • AIDS Notes • Allergic Reactions(loss of hair,skin that burns and peels after contact with fluoridated water) • Alzheimer's disease • Arthritis • Asthma • Behavior Problems(attention deficit disorders) • Bone Disease(osteoporosis—increased bone/hip fractures) • • Cancer(all types including osteosarcoma or bone cancer) • Chronic Bronchitis • Colic(acute abdominal pain) • Down Syndrome • Emphysema • • Enzyme Effects(gene-alterations) • Flatulence(gas) • Gastrointestinal Problems(irritable bowel syndrome) • Harmful Interactions with Medications • Heart Disease • Increased Infant Mortality • Kidney Disease • Lead Poisonings • Lethargy(lack of energy) • Lower IQ(mental retardation) • Malpositioned Teeth • Pineal Gland (early puberty)(chronic insomnia) • Reproductive Organs(damaged sperm)(reduced fertility) • Skin Conditions(redness,rash/welts,itching) • Sudden Infant Death Syndrome(SIDS) • Thyroid Problems(goiter and obesity due to hy- pothroidism) AND Tooth Decay Fact. As discussed throughout this booklet,the overwhelming weight of credible scientific evidence has consistently in- dicated that fluoridation of community water supplies is safe and effective. The possibility'of any adverse health effects from continuous low-level consumption of fluo- ride has been and continues to be extensively studied. It has been determined that approximately 10% of dental fluorosis is attributable to water fluoridation.This type of very mild to mild fluorosis has been determined to be a cosmetic effect rather than an adverse health effect. Of the thousands of credible?scientific studies on fluorida- tion, none has shown health problems associated with the consumption of optimally fluoridated water. Fluoridation Facts 39 } - y * 1 � i # rse 7"a ", .;. 0 -%.,'14 'wr�.�- �+¢# • r _ :,a+ AGw P: - FLUORIDATION PRACTICE Q 42. Water quality? p.40 Q 45. Source of additives? p.43 Q 48. Corrosion? p.44 Q 43. Regulation? p.41 Q 46. System safety concerns? p.43 Q 49. Environment? p.45 Q 44. Standards? p.42 Q 47. Engineering? p.44 QUESTION 42. level exceeds 2.0 mg/L. The SMCL, while not federally Will the addition of fluoride affect the quality of enforceable, is intended to alert families that regular drinking water? consumption of water with natural levels of fluoride greater than 2.0 mg/L by young children may cause Answer. moderate to severe dental fluorosis in the developing Optimal levels of fluoride do not affect thequalitypermanent teeth, a cosmetic condition with no known of water. All ground and surface water in the United adverse health effect.298 The notice to be used by water States contain some naturally occurring fluoride. systems that exceed the SMCL must contain the follow- ing points: Fact. 1. The notice is intended to alert families that children Nearly all water supplies must undergo various water under nine years of age who are exposed to levels of treatment processes to be safe and suitable for hu- fluoride greater than 2.0 mg/liter may develop dental man consumption. During this process, more than 40 fluorosis. chemicals/additives are typically used including alumi- 2. Adults are not affected because dental fluorosis oc- 42. num sulfate, ferric chloride, ferric sulfate, activated car curs only when developing teeth are exposed to el- bon, lime,soda ash and, of course, chlorine. Fluoride is evated fluoride levels. 4'' 3. The water supplier can be contacted for information added only to water that has naturally occurring levels lower than optimal28 on alternative sources or treatments that will insure Fluoridation is the adjustment of the fluoride concen- drinking water would meet all standards (includ- tration of fluoride-deficient water supplies to the recom- ing the SMCL). mended range of 0.7 to 1.2 parts per million of fluoride The 1993 National Research Council report, "Health for optimal dental health.The U.S. Environmental Protec- Effects of Ingested Fluoride," reviewed fluoride toxicity tion Agency (EPA) recognizes that fluoride in children's and exposure data for the EPA and concluded that the drinking water at levels of approximately 1.0 ppm reduc- current standard for fluoride at 4.0 mg/L(set in 1986)was es the number of dental cavities 298 The optimal level is appropriate as an interim standard to protect the public dependent on the annual average of the maximum daily health.1fi7 In EPAs judgment,the combined weight of hu- air temperature in a given geographic area.38,88 man and animal data support the current fluoride drinking /. Additional information on this topic may be found in water standard. In December 1993, the EPA published a Questions 3 and 6. notice in the Federal Register stating the ceiling of 4 mg/L Under the Safe Drinking Water Act, the EPA has es- would protect against adverse health effects with an ad- tablished drinking water standards for a number of sub- equate margin of safety and published a notice of intent stances, including fluoride, in order to protect the public's not to revise the fluoride drinking water standards.168 health.There are several areas in the United States where The EPA further commented on the safety of fluo- the ground water contains higher than optimal levels of ride in the December 5, 1997, Federal Register.239 In a naturally occurring fluoride. Therefore, federal regula- notice of a final rule relating to fluoride additives the tions were established to require that naturally occurring EPA stated, "There exists no directly applicable scien- fluoride levels in a community water supply not exceed tific documentation of adverse medical effects at levels a concentration of 4.0 mg/L.298 Under the Safe Drinking of fluoride below 8 mg/L (0.23mg/kg/day)." The EPA's Water Act,this upper limit is the Maximum Contaminant Maximum Concentration Limit(MCL) of 4.0 mg/L(0.114 • Level (MCL) for fluoride. Under the MCL standard, if the mg/kg/day) is one half that amount, providing an ade- naturally occurring level of fluoride in a public water sup- quate margin of safety. ply exceeds the MCL (4.0 mg/L for fluoride), the water Under the Safe Drinking Water Act (SDWA), the EPA supplier is required to lower the level of fluoride below must periodically review the existing National Primary the MCL.This process is called defluoridation. Drinking Water Regulations (NPDWRs) "not less often The EPA has also set a Secondary Maximum Con- than every 6 years." This review is a routine part of the taminant Level (SMCL) of 2.0 mg/L, and requires con- EPA's operations as dictated by the'SDWA. NPDWRs, or sumer notification by the water supplier if the fluoride primary standards,are legally enforceable standards that 40 American Dental Association �. ; . • `�. •Questions 42-49 apply to public water systems. Primary standards protect pealed FDA's jurisdiction over drinking water as a 'food' public health by limiting the levels of contaminants in under the Federal Food, Drug and Cosmetic Act(FFDCA). drinking water. Under the agreement, EPA enjoys exclusive regulatory • In April 2002, the EPA announced the results of its authority over drinking water served by public water preliminary revise/not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re supplies, including any additives in such water. FDA re- viewed. The EPA determined that it fell under the "Not tains jurisdiction over bottled drinking water under Sec- Appropriate for Revision at this Time" category,but not- tion 410 of the FFDCA and over water(and substances in ed that it planned to ask the National Academy of Sci- water) used in food or food processing once it enters the ence (NAS) to update the risk assessment for fluoride. food processing establishment."'S5 • The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 by the National Research Council. From time to time,states and At the request of the NAS, the National Research communrt�es have had to deal with Council's Committee on Toxicology created the Sub- .;:;legrslatign.or.,:ballOt,�rltiatives,,almed:at�e ; .•::. committee on Fluoride in Drinking Water to review .�� ..•_-.-�•. .- `a-•• �,..- ,-` ,. ,-.'.'.:',--: toxicologic, epidemiologic, and clinical data published arequir<»g;the'approval'of the FDA before;;' since 1993 and exposure data on orally ingested fluo- zany agent can be added to community water:: ride from drinking water and other sources (e.g., food, systems On{the surface, this may appears i toothpaste, dental rinses). Based on this review the ,' � I 3 rh p � o be a;corrmmon sense,approach Subcommittee will evaluate the scientific and technical ` �,However rts;only real purpose issto_defeat , basis of the EPA's maximum contaminant level (MCL) of ;; effgrts to provide water,fluondat�on 4 milligram per liter(mg/L or ppm)and secondary maxi- - t- .<: ;',_i•_ . mum contaminant level (SMCL) of 2 mg/L for fluoride in ;Thefis.,beCauseatwould'require ;::,; rr,_ the.FDA drinking water and advise EPA on the adequacy of its which does NQ,Tregulate. fluoride MCL and SMCL to protect children and others „+ water systems to-approve anyywaterl' from adverse health effects. Additionally, the Subcom- mittee ubcom mittee will identify data gaps and make recommenda- namin the wron federal a�enc tions for future research relevant to settingthe MCL and 9 9'' gp y_. +` t SMCL for fluoride. +` theproba6;leroufcome:istostop=or prevent water fluoridation` • The Subcommittee began its work in November g 2002 and is currently projected to complete the project in early 2006.13 From time to time,states and communities have had to deal with legislation or ballot initiatives aimed at re- quiring the approval of the FDA before any agent can QUESTION 43. be added to community water systems. Often referred Who regulates drinking water additives in United States? to as the Fluoride Product Quality Control Act, Water Product Quality Ordinance or Pure Water Ordinance,the Answer. The United States Environmental Protection Agency legislation is specifically used by those opposed to wa regulates drinking water additives. ter fluoridation as a tool to prevent water systems from providing community water fluoridation. Often this leg- Fact islation does not mention fluoride or fluoridation.Those In 1974, Congress passed the original Safe Drinking supporting this type of legislation may claim that they Water Act(SDWA)which protects the public's health by are not against water fluoridation but are proponents regulating the nation's public drinking water supply.299 of pure water and do not want anything added to water The SDWA,as amended in 1986 and 1996,299requires the U.S. Environmental Protection Agency (EPA) ensure that has not been approved by the FDA. the public is provided with safe drinking water.755 On the surface, this may appear to be a "common On June 22,1979,the U.S.Food and Drug Administra- sense" approach. However, its only real purpose is to tion (FDA) and the EPA entered into a Memorandum of defeat efforts to provide water fluoridation. That is be- Understanding (MOU) to clarify their roles and respon- cause it would require the FDA-which does NOT reg- sibilities in water quality assurance. The stated purpose ulate water systems - to approve any water additive. of the MOU is to "avoid the possibility of overlapping jurisdiction between the EPA and FDA with respect to By mistakenly (and perhaps craftily) naming the wrong control of drinking water additives. The two agencies federal agency, the probable outcome is to stop or pre- agreed that the SDWA's passage in 1974 implicitly re- vent water fluoridation. Fluoridation Facts 41 - - - ',+ •d „ S t.,4,,:!..:40? r yam . z.7 ' _ r`,.:',,,,`"`-'7',z ,_----1--:-_, _ fi *, } a . ..� _ 4. .!':.:1,-fr-4 :7,1,---4.- QUESTION 44. no soluble materials or organic substances in quanti- What standards have been established to ensure the ties capable of producing deleterious or injurious of safety of fluoride additives.used in community water fects on the health of those consuming water that has fluoridation in the United States? been properly treated with the [fluoride compound]." Certified analyses of the additives must be furnished Answer. by the manufacturer or supplier.60 The three fluoride additives used in the U.S. to fluori- NSF Standard 60 ensures the purity of drinking wa date community water systems (sodium fluoride, so- ter additives. NSF Standard 61 provides guidance for dium fluorosilicate, and fluorosilicic acid) meet safety equipment used in water treatment plants. The NSF/ standards established by the American Water Works ANSI Standards were developed by a consortium of Association(AWWA)and NSF International(NSF). associations including NSF, AWWA, the Association of State Drinking Water Administrators and the Con- Fact. ference of State Health and Environmental Manag- Additives used in water treatment meet safety stan ers with support from the EPA.IIn part, they establish dards prepared in response to a request by the Environ minimum requirements for the control of potential mental Protection Agency(EPA) to establish minimum adverse human health effects from products added to requirements to ensure the safety of products added to water for its treatment.303.304 water for its treatment, thereby ensuring the public's Fluoride additives, like all of the more than 40 addi health. Specifically, fluoride additives used in water tives typically used in water treatment, are "industrial fluoridation meet standards established by the Ameri- grade" additives. The water supply is an industry and can Water Works Association (AWWA) and NSF Inter all additives used at the water plant are classified as in- national (NSF). Additionally, the American National dustrial grade additives. Examples of other "industrial Standards Institute (ANSI) endorses both AWWA and grade" additives which are commonly used in water NSF standards for fluoridation additives and includes plant operations are chlorine (gas), ferrous sulfate, by its name on these standards. drochloric acid,sulfur dioxide and sulfuric acid.36 The American Water Works Association is an interna- Sometimes antifluoridationists express the view that ' they are not really opposed to fluoridation, but are op- tional nonprofit scientific and educational society dedi- 45, cated to the improvement of drinking water quality and posed to the use of"industrial grade"fluoride additives. supply. AWWA is the authoritative resource for knowl- They may even go so far as to state that they would sup- 46. edge, information, and advocacy to improve the quality port fluoridation if the process was implemented with and supply of drinking water in North America and be- pharmaceutical grade fluoride additives that were ap- yond. Founded in 1881, AWWA is the largest organiza- proved by the Food and Drug Administration (FDA). On tion of water supply professionals in the world.30° the surface, this may appear to be a "common sense" NSF International, a not-for-profit, non-governmental approach. In fact, this is usually a ploy whose only real organization, is the world leader in standards develop- purpose is to stop fluoridation. The EPA, not the FDA, ment, product certification, education, and risk-man- regulates additives in drinking water. agement for public health and safety. For 60 years, NSF (Additional information on this topic may be found in has been committed to public health,safety, and protec- Question 43. tion of the environment. NSF is widely recognized for The claim is sometimes made that no studies on its scientific and technical expertise in the health and safety exist on the additives used in water fluoridation. environmental sciences. Its professional staff includes The scientific community does not study health effects engineers, chemists, toxicologists, and environmental of concentrated additives as put into water; studies are health professionals with broad experience both in pub- done on the health effects of the treated water. While lic and private organizations.301 sodium fluoride was the first additive used in water The American National Standards Institute (ANSI) is fluoridation, the use of silicofluoride additives (sodium a private, non-profit organization that administers and fluorosilicate and fluorosilicic acid) began in the late coordinates the U.S. voluntary standardization and con- 1940s. By 1951, silicofluorides had become the most formity assessment system. The Institute's mission is to commonly used fluoride additives in water fluorida- enhance both the global competitiveness of U.S. business tion.61 Many of the early studies on the health effects of and the U.S. quality of life by promoting and facilitating fluoridation were completed in communities that were voluntary consensus standards and conformity assess- using the silicofluoride additives, most generally fluo- ment systems,and safeguarding their integrity.302 rosilicic acid.3°531° However, at that time, the additives The purpose of AWWA standards for fluoride ad- used to fluoridate were not always identified in research ditives is to provide purchasers, manufacturers and reports. As the body of research on fluoridation grew, suppliers with the minimum requirements for fluoride it became evident that there was no adverse health ef- additives, including physical, chemical, packaging, fects associated with water fluoridation regardless of shipping and testing requirements. In part,the AWWA which fluoride additive was used. standards for fluoride additives state, "The [fluoride (Additional information on this topic may be found in compound] supplied under this standard shall contain Question 5. 42 American Dental Association • ' .r F. OR?IDATI ON PRACTICE Additionally, over time, a number of comprehensive err ;; :-..� reviews of the health effects of fluoridation have been 'To ensure the publics;safety additive"s usedin a published. These reviews which support the safety of 4 ,water fluondafion'meet:standardofs the American`f water fluoridation include many studies conducted in ;Water Works Association(AWWA)and NSF large fluoridated communities which used the silicoflu- oride ilicoflu oride additives.71,84,163,165.167.311-313 Beyond the foundation that has been established through the overwhelming weight of credible, peer- Fluoride additives are valuable byproducts produced reviewed scientific evidence, there is over 60 years of as a result of producing phosphate fertilizer. To ensure practical experience that lends additional credence to the public's safety, additives used in water fluoridation the science that concludes that fluoridation is safe. meet standards of the American Water Works Associa- tion (AWWA)and NSF International (NSF). (b Additional information on this topic may be found in Question 44. QUESTION 45. What is the source of the additives used to fluoridate water supplies in the United States? QUESTION 46. Answer. Does the process of water fluoridation present unusual Fluoride additives used in the United States are derived safety concerns for water systems and water operators? from the mineral apatite. Answer. Fact. No. With proper planning, maintenance and monitor- The three fluoride additives used in the United States ing,water fluoridation is a safe process. for water fluoridation (sodium fluoride, sodium fluoro- silicate, and fluorosilicic acid) are derived from apatite Fact. which is a type of limestone deposit used in the produc- Water plant facilities and water plant personnel per- tion of phosphate fertilizers. Apatite contains 3-7%fluo- form a valuable public service by carefully adjusting ride and is the main source of fluorides used in water the level of fluoride in water to improve the oral health fluoridation.36 of the community. Facilities and personnel are subject During processing, apatite is ground up and treated to a number of regulations designed to ensure safety. with sulfuric acid, producing phosphoric acid (the main The Occupational Safety and Health Administration ingredient in the production of phosphate fertilizer) plus (OSHA) provides guidelines for the safety of employ- a solid and two gases. The solid, calcium sulfate (also ees in the workplace.66,315 Additionally, the American known as gypsum) is the material used to form drywall Water Works Association publishes detailed guidance or sheetrock. The two gases, hydrogen fluoride and on safety and safe working conditions for water plant silicon tetrafluoride, are captured in water to form fluo- personnel. Furthermore, the Centers for.Disease Con- rosilicic acid which today is the most commonly used trol and Prevention has established safety procedures fluoride additive in the United States.60 designed specifically for water plant operators in The two remaining fluoride additives(sodium fluoride charge of implementing fluoridation.375 Adherence to and sodium fluorosilicate) are derived from fluorosilicic these guidelines helps to ensure continuous levels of acid. Sodium fluoride is produced when fluorosilicic optimally fluoridated drinking water while maintain- acid is neutralized with caustic soda. Fluorosilicic acid is ing water operator safety. neutralized with sodium chloride or sodium carbonate As part of the safety procedures, water plant per- to produce sodium fluorosilicate.36 sonnel receive training on the management of the From time to time opponents of fluoridation al- chemicals/additives in water plants. While the optimal. lege that°fluoridation additives are byproducts of the fluoride concentration found in drinking water has phosphate fertilizer industry in an effort to infer the been proven safe, water plant operators and engi- additives are not safe. Byproducts are simply materi- neers may be exposed to much higher fluoride levels als produced as a result of producing something else when handling fluoride additives at the water treat- - they are by no means necessarily bad, harmful or ment facility.36 Fluoride additives present comparable waste products. In the chemical industry, a byproduct risks as other chemicals/additives in common use is anything other than the economically most important at water treatment facilities; such as hypochloride, product produced. Byproducts may have certain char- quick-lime, aluminum sulfate, sodium hydroxide and acteristics which make them valuable resources. For ferrous sulfate. In fact,the fluoride additives are much example, in addition to orange juice, various byprod- less dangerous than chlorine gas commonly used in ucts are obtained from oranges during juice produc- water plant operations. tion that are used in cleaners, disinfectants,flavorings Today's equipment allows water treatment personnel and fragrances.314 to easily monitor and maintain the desired fluoride con- Fluoridation Facts 43 cu � gF :44-zt s 1, centration.Automatic monitoring technology is available solution feeders (metering pumps). By design, and with that can help to ensure that the fluoride concentration of proper maintenance and testing, water systems limit the the water remains within the recommended range. amount of fluoride that can be added to the system (i.e., It is important that the water treatment operators re- the use of a day tank that only holds one day's supply of sponsible for monitoring the addition of fluoride to the fluoride) so prolonged over-fluoridation becomes a me- water supply be appropriately trained and that the equip- chanical impossibility.36 ment used for this process is adequately maintained 316 As with any mechanical equipment, water fluoridation equipment should be tested, maintained and replaced as needed. With over 60 years of experience and thou- QUESTION 48. sands of water systems in operation, there have been Will fluoridation corrode water pipes or add lead,arse- remarkably few untoward incidents. nic and other toxic contaminants to the water supply? Answer. Allegations that fluoridation causes corrosion of water QUESTION 47. delivery systems are not supported by current scientific Does fluoridation present difficult engineering problems? evidence 36 Furthermore, the concentrations of con- taminants in water as a result of fluoridation do not ex- Answer. ceed, but, in fact, are well below regulatory standards No. Properly maintained and monitored water fluo- set to ensure the public's safety. ridation systems do not present difficult engineering problems. Fact. Water fluoridation has no impact on the acidity or pH of Fact. drinking water and will not cause lead and copper to be With proper planning and maintenarice of the system, leached from water pipes. Corrosion of pipes by drink- fluoride adjustment is compatible with other water ing water is related primarily to dissolved oxygen con- 47• treatment processes. Today's equipment allows water centration, pH, water temperature, alkalinity, hardness, treatment personnel to easily monitor and maintain the salt concentration, hydrogen sulfide content and the 48' desired fluoride concentration. Automatic monitoring presence of certain bacteria. Under some water quality 49 technology is available that can help to ensure that the conditions, a small increase in the acidity of drinking fluoride concentration of the water remains within the water that is already slightly acidic may be observed af- recommended range. ter treatment with alum, chlorine, fluorosilicic acid or When added to community water supplies the con- sodium florosilicate. In such cases,further water treat- centrated fluoride additives become greatly diluted. ment is indicated by water plant personnel to adjust the For example, fluorosilicic acid is diluted approximately pH upward to neutralize the acid.This is part of routine 180,000 times to reach the recommended range of 0.7 water plant operations. Note that the Water Quality Re- to 1.2 parts per million. At 1 ppm, one part of fluoride port or Consumer Confidence Report that all water sys- is diluted in a million parts of water. Large numbers tems send to customers on a yearly basis, lists the pH such as a million can be difficult to visualize. While not of the system's finished water and compares that level exact, the following comparisons can be of assistance against the standard set at a pH of 7.0(neutral)or higher in comprehending one part per million: indicating that the water leaving the plant is non-acidic. 1 inch in 16 miles (Additional information on this topic may be found in 1 minute in 2 years Question 4. 1 cent in$10,000 A 1999 study316 charged that fluorosilicic acid and so- dium silicofluoride did not disassociate completely whenadded to water may systems and be responsible for low- er pH levels of drinking water, leaching lead from plumb plumb- bieriatiefida4eitith)wateigflildildatioititier&isrr ing systems and increasing lead uptake by children. considerable guidance on sound engrneering,E . In response to the study, scientists from the U.S. En- practices to design iccoristruct,operate sand ', vironmental basic science rotehat was tion Agencythe (EPA) EP fohave undation for the reviewed m that marntaln water fluonr%atIon"systems r= . ,l.k a i, r1...- w,..,4 _w_ silicofluorides leach lead from water pipes and found that many of the chemical assumptions made in the Because there is more than 60 years of experience original research were scientifically unjustified. Fluoride with water fluoridation,there is considerable guidance on additives do disassociate very quickly and completely sound engineering practices to design,construct,operate releasing fluoride ions into the water. The research was and maintain water fluoridation systems. Fluoride addi- inconsistent with accepted scientific knowledge and the tives are introduced to the water supply as liquids,but are authors of the original studies failed to identify or account measured by two basic types of devices, dry feeders or for these inconsistencies. The EPA scientists discounted 44 American Dental Association • rTh .FL--cJORIDATIONPRACTICE this study and said there was no credible data to suggest Notes • any link between fluoridation and lead.285 Fluorosilicic acid is the additive used to fluoridate the vast majority of community water systems in the U.S. Be- cause it is a natural substance derived from apatite which is mined from the earth, fluorosilicic acid may contain minute amounts of contaminants such as lead and arse- nic. However, existing regulations and standards require that these contaminants, including arsenic and lead, be at levels considered safe by the EPA when the fluorosilicic acid is diluted to produce optimally fluoridated water.3"•3'3 Evidence of testing by the fluoride additive manufacturer documents that the concentrations of these contaminants do not exceed,but,in fact,are well below regulatory stan- dards set to ensure the public's safety. Most batches of the additive do not contain any detectable amount of either lead or arsenic. On average, the concentration of arsenic and lead in optimally fluoridated drinking water created • using fluorosilicic acid is less than 0.1 part per billion 319 QUESTION 49. • Does fluoridated water harm the environment? Answer. Scientific evidence supports the fluoridation of public water supplies as safe for the environment and benefi- cial for people. Fact. The U.S. Environmental Protection Agency (EPA) has set an enforceable Federal drinking water standard for fluoride at 4.0 mg/L. As long as the 4.0 mg/L standard is not exceeded, State and local authorities determine whether or not to fluoridate.3zo `Under the Washingt6n s State `3EtiVitoffit ental i:OtectionrAct( EPA), ,'i astucly concluded that;ti ere are"no probable' s►gn+ficant adverse environmental impacts Under the Washington's State Environmental Protec- tion Act(SEPA),a study was conducted in Tacoma-Pierce County to investigate the environmental consequences of adding optimal levels of fluoride to. drinking water. Noting that the amount of fluoride in the water does not reach levels that are harmful to plants or animals, the SEPA,study concluded that there are "no probable significant adverse environmental impacts."32' There is no evidence that optimally fluoridated wa- ter has any effect on gardens, lawns or plants.322 A comprehensive literature review conducted in 1990 revealed absolutely no negative environmental impacts as a result of water fluoridation. Historically, issues surrounding problems with fluoride and the en- vironment have involved incidents related to industrial pollution or accidents.323 Fluoridation Facts 45 t ' k ft * 7}V '� " `'r� 6 e•`QA v' s ,`t - • PUBLIC POLICY Q 50. Valuable measure? p.46 Q 53. Internet? p.51 Q 56. Banned in Europe? p.54 Q 51. Courts of law? p.47 Q 54. Public votes? p.51 Q 52. Opposition? p.47 Q 55. International fluoridation?p.54 QUESTION 50. "Former U S SurgeonGeneral David i ap Is water fluoridation a valuable public health measure? s k „ Satcherinoted that water fluoridation is-a, Answer. 1�,5••,j �powerful strategy in efforts to min eliate !. Yes.Water fluoridation is a "' public health measure that ' health d►sparrt�es�among`populat�ons�, benefits people of all ages,is safe and is a community public health program that saves money. Fact. In 1999,the Centers for Disease Control and Preven- tion named fluoridation of drinking water o Throughout decades of research and more than 60 years one of ten great public health achievements of the 20 century of practical experience, fluoridation of public water sup noting that it is a major factor responsible for the de plies has been responsible for dramatically improving the cline in dental decay.12 Former U.S. Surgeon General public's oral health status. Former Surgeon General of the David Satcher, issued the first ever Surgeon General United States,Dr. Luther Terry,called fluoridation as vital a 50. report on oral health in May 2000. In Oral Health in public health measure as immunization again disease,pas America:A Report of the Surgeon General, Dr. Satcher 51. teurization of milk and purification of water. Another for stated that community water fluoridation continues to mer U.S. Surgeon General Dr. C. Everett Koop stated that be the most cost-effective, practical and safe means 52. fluoridation is the single most important commitment that for reducing and controlling the occurrence of dental a community can make to the oral health of its citizens. decay in a community. Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts ?;.`{,kFormer,.US. Sufgeon;General Dr.0 Everett.; -.`. to eliminate health disparities among populations. Koop stated that fluorldai►on 1s Studies have shown that fluoridation may be the most • sr 4-thesrnglemostimpokrtantcommtment ;: ;<: significant step we can take toward reducing the dis- I 4:„ parities in dental decay.21-24 In the 2003 National Call to that a communitycan make lb the'"',3 ,rt Action to Promote Oral Health, U.S. Surgeon General oral health of►ts c:t►zens g art' { , i Lr al Ml, Richard Carmona called on policymakers, community leaders, private industry, health professionals, the me- In 1994, the U.S. Department of Health and Human dia and the public to affirm that oral health is essential Services issued a report which reviewed public health to general health and well being.Additionally,Surgeon achievements. Along with other successful public health General Carmona urged these groups to apply strat- measures such as the virtual eradication of polio and re- egies to enhance the adoption and maintenance of ductions in childhood blood lead levels,fluoridation was proven community-based interventions such as corn- lauded as one of the most economical preventive values in munity water fluoridation.25 the nation:17 A policy statement on water fluoridation reaf- Community water fluoridation is a most valuable firmed in 1995 by the U.S. Public Health Service(USPHS) public health measure because: stated that water fluoridation is the most cost-effective, • Optimally fluoridated water is accessible to the entire practical and safe means for reducing the occurrence community regardless of socioeconomic status, edu- of dental decay in a community.18 In 1998, recognizing cational attainment or other social variables;26 the ongoing need to improve health and well being, the • Individuals do not need to change their behavior to USPHS revised national health objectives to be achieved obtain the benefits of fluoridation. by the year 2010. Included under oral health was an ob- • Frequent exposure to small amounts of fluoride over jective to significantly expand the fluoridation of public time makes fluoridation effective through the life water supplies. Specifically, Objective 21-9 states that at span in helping to prevent dental decay. least 75% of the U.S. population served by community • Community water fluoridation is more cost ef- water systems should be receiving the benefits of opti- fective than other forms of fluoride treatments or mally fluoridated water by the year 2010.19 applications.27 • 46 American Dental Association =R x • Questionsu3056 ' QUESTION 51. Fluoridation is the adjustment of a naturally occur- Has the legality of water fluoridation been upheld by ring element found in water in order to prevent dental the courts? decay. Courts have consistently ruled that water fluo- ridation is not a form of compulsory mass medication or socialized medicine.325,328,33° Fluoridation is simply Answer. the adjustment of a naturally occurring element found Yes. Fluoridation has been thoroughly tested in the in water in order to prevent dental decay. In fact, water United States court system, and found to be a proper that has been fortified with fluoride is similar to forti- means of furthering public health and welfare. No court fying salt with iodine, milk with vitamin D and orange of last resort has ever determined fluoridation to be juice with vitamin C—none of which are medications. unlawful. Moreover,fluoridation has been clearly held not to be an unconstitutional invasion of religious free- dom or other individual rights guaranteed by the First, '' ` To,4DAs knowledge no;-.final r'uling►n any Fifth or Fourteenth Amendments to the U.S. Constitu of those cases has fqund fluoridation to be tion. And while cases decided primarily on procedural .. = grounds have been won and lost by both pro and anti anything but$safe.and effective; �i ni � .. d "'`rye, ,' ., .';�i„=,...-rte .£..•;'� fluoridation interests,to ADA's knowledge no final rul- ing in any of those cases has found fluoridation to be In recent years, challenges to fluoridation have anything but safe and effective. been dismissed for a variety of reasons, including that plaintiffs admitted they could not establish injury by ' ``--No court oflast esorthas eves ;` virtue of fluoridation, and that state law supporting Q z-'determined'fluotidatiori:to be;unlawful.',:'` fluoridation prevailed over.local attempts to oppose = fluoridation. Interestingly, pro and anti fluoridation :., The,highest courts of more'than'a`dozen; interests have each won and lost legal challenges re- states,have confirmed the constitutionality `;H garding which state or local agency has regulatory of,fluoridation. authority over fluoridation, which of course varies by state and locality. State law variances have also led to different rulings on other issues, such as whether Fact. downstream end users of fluoridation must be given During the last sixty years, the legality of fluoridation in an opportunity to vote on whether to fluoridate. While the United States has been thoroughly tested in our court cases decided primarily on procedural grounds have systems. Fluoridation is viewed by the courts as a proper been won and lost by both pro and anti fluoridation means of furthering public health and welfare.324 No court interests,to ADA's knowledge no final ruling in any of of last resort has ever determined fluoridation to be un- those cases has found fluoridation to be anything but lawful. The highest courts of more than a dozen states safe and effective. have confirmed the constitutionality of fluoridation.325 In 1984,the Illinois Supreme Court upheld the constitution- ality of the state's mandatory fluoridation law, culminat- ing 16 years of court action at a variety of judicial levels 326 QUESTION 52 Moreover, the U.S. Supreme Court has denied review of Why does opposition to community water fluoridation fluoridation cases thirteen times,citing that no substantial continue? federal or constitutional questions were involved 325 It has been the position of the American courts that Answer. a significant government interest in the health and wel- Fluoridation is considered beneficial by the overwhelm- fare of the public generally overrides individual objec- ing majority of the health and scientific communities tions to public health regulation.333 Consequently, the as well as the general public. However,a small faction courts have rejected the contention that fluoridation continues to speak out against fluoridation of municipal ordinances are a deprivation of religious or individual water supplies. Some individuals may view fluoride- freedoms guaranteed under the Constitution.325.327 In tion of public water as limiting their freedom of choice; reviewing the legal aspects of fluoridation, the courts other opposition can stem from misinterpretations or have dealt with this concern by ruling that: (1)fluoride inappropriate extrapolations of the science behind the is a nutrient, not a medication, and ispresent naturally fluoridation issue. in the environment; (2) no one is forced to drink fluo- ridated water as alternative sources are available; and Fact. (3) in cases where a person believes that fluoridation A vast body of scientific literature endorses water fluo- interferes with religious beliefs,there is a difference be- ridation as a safe means of reducing the incidence of tween the freedom to believe, which is absolute, and dental decay. Support for fluoridation among scientists the freedom to practice beliefs,which may be restricted and health professionals, including physicians and den- in the public's interest.326,326 tists, is nearly universal. Recognition of the benefits of Fluoridation Facts 47 R : A c a n e a,- et" t e 3 • : _ fluoridation by the American Dental Association, the tinues today with over 60 years of practical experience American Medical Association, governmental agencies showing fluoridation to be safe and effective. An article and other national health and civic organizations con- that appeared in the local newspaper shortly after the tinues as a result of published, peer-reviewed research, first fluoridation program was implemented in Grand (See Compendium at back of booklet.) Rapids, Michigan, noted that the fluoridation program The majority of Americans also approves of water was slated to commence January 1 but did not actually fluoridation. In June 1998,the Gallup Organization con- begin until January 25. Interestingly, health officials in ducted a national survey of just over 1,000 adults on their Grand Rapids began receiving complaints of physical attitudes toward community water fluoridation. When ailments attributed to fluoridation from citizens weeks asked, "Do you believe community water should be fluo- before fluoride was actually added to the water.342 ridated?",70%answered yes, 18%answered no and 12% Since that time, antifluoridation leaders and orga- responded don't know (Figure 5). Results characterized nizations have come and gone, but their basic beliefs by U.S. Census Region showed the level of support for have remained the same.These include:fluoride is tox- community water fluoridation to be relatively constant is and causes numerous harmful health effects;fluoride throughout the United States,with 73%in the Northeast, does not prevent dental decay; fluoridation is costly; 72% in the Midwest, 68% in the South and 70% in the and fluoridation interferes with freedom of choice and West favoring community water fluoridation.331 These re- infringes on individual rights. sults are consistent with a December 1991 Gallup survey While the arguments against fluoridation have re- that asked 1,200 parents, "Whether or not you presently mained relatively constant over the years, the antifluo- have fluoridated water, do you approve or disapprove of ridationists have used different approaches that play fluoridating drinking water?" More than three-quarters upon the popular concerns of the public at the time. For (78%) of the responding parents approved, 10% disap- example, in the 1950s fluoridation was a Communist proved and 12% answered don't know or refused to an- plot. With America's growing concern for environmen- swer the question (Figure 6). Disapproval ranged from tal issues in the 1960s,fluoridation was pollution. After 4% in communities where waterwas fluoridated to 16% the Vietnam War in the 1970s, the antifluoridationists in communities where it was not.332 capitalized on the popularity of conspiracy theories by 52. Of the small faction that opposes water fluoridation portraying fluoridation as a conspiracy between the for philosophical reasons, freedom of choice probably U.S. government,the dental-medical establishment and stands out as the most important single complaint.333 industry. As Americans became more concerned about Some individuals are opposed to community action on their health in the 1980s, antifluoridationists claimed any health issue, others because of environmental or fluoridation caused AIDS and Alzheimer's disease. In economic arguments and some because they are mis- the 1990s, claims of hip fractures and cancer were de- informed. signed to resonate with aging baby boomers. With the Opposition to fluoridation has existed since the initi- new millennium, overexposure and toxicity, in associa- ation of the first community programs in 1945 and con- tion with lead and arsenic poisoning, have surfaced as Figure 5. 1998 Consumers'Opinions Figure 6. Approval of Fluoridating Regarding Community Water Fluoridation337 Drinking Water332 = Whether;or Not-You Presently Have Flluoridate& Do You Believe.Community Water Should Be Fluoridated?, Water Do•You Approve'9r Disapprove of Fluoridating,Drinking Water?? Yes - 70% Approve �v_- k '''= " ' 78% No 18% Disapprove Don't Know 12% Don Refused I 12% I:Eti"M? I I 1 1 I I 1 I 1 I I I I I I I 0 10% 20% 30% 40% 50% 60% 70% 80% 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Adults Percent of Parents 48 American Dental Association .c � s iii 5 'n r. q r. "lt""vk,s'' x ki, s • ' • a as r Sea ff`` " s• Y �.a i! a'' '` ,. :ice � „�,x a s.:;. ,�-, • ,�_. a,rs• i9 x. - ., '"Sq, � .. " .�:� {=� ,' a¢rw•,' .“ a P .?-; s. •4..w. `C. :¢ '.!r• .",n. . common themes. None of these approaches has ever In 1993 the U.S.Supreme Court issued a landmark de- really disappeared, but are often recycled as antifluo- cision that many view as likely to restrict the use of junk ridationists choose which approach will have the most science in the federal courts and in those state courts effect on the intended audience.333 which adopt this reasoning. The Court determined that Antifluoridationists have eagerly embraced technol- while "general acceptance" is not needed for scientific ogy such as videos and the Internet to spread their mes- evidence to be admissible, federal trial judges have the sage to the public. These two venues have allowed the task of ensuring that an expert's testimony rests on a small faction of antifluoridationists to be linked across reasonable foundation and is relevant to the issue in the country and around the world and promote their question. According to the Supreme Court, many con- message economically. siderations will bear on whether the expert's underlying A number of opposition videos are available from na reasoning or methodology is scientifically valid and ap- tional antifluoridation organizations. These economical plicable in a given case. The Court set out four criteria ly-priced videos make'it affordable for every campaign to bring an antifluoridationist to the community via local judges could use when evaluating scientific testimony: cable access television. However,it has been the Internet (1) whether the expert's theory or technique can be(and that has breathed new life into the antifluoridation effort. has been)tested,using the scientific method, The Internet has brought the antifluoridation message (2) whether it has been subject to peer review and pub- into voters'homes. With just a click of the mouse,search lication (although failing this criteria alone is not nec- engines can locate hundreds of Web sites denouncing essarily grounds for disallowing the testimony), fluoridation,which may give the impression that this is a (3) its known or potential error rate and the existence and one-sided argument. Individuals who look to the Internet maintenance of standards in controlling its operation as a source of reliable information may fail to recognize and that these sites often contain personal opinion rather (4) whether it has attracted widespread acceptance within than scientific fact. Newspaper stories, press releases a relevant scientific community, since a known tech- and letters to the editor are often posted as documenta- nique that has been able to attract only minimal sup- tion of the "science" behind antifluoridationists' claims, port may properly be viewed with skepticism. All too often,the public accepts this type of information The scientific validity and relevance of claims made by as true simply because it is in print. opponents of fluoridation might be best viewed when The techniques used by antifluoridationists are well measured against these criteria 341 known and have been discussed at length in a number of published articles that review the tactics used by an- tifluoridationists.325,333,335-339 Examples of a few of the techniques can be viewed in Figure 7 on the next page. .•y' r "Oprnionsare seldom unanimous on ` any scientific subject In fact there may` be'no such thing as 'final.knowledge, Reputable science rs based on thg since new information rs continuously scientific method of testing hypotheses{in , emerging and being drsseminatea`As such, ways that can be reproduced and verified kr = ▪ the benefit evidence must be continually- others junk screncea which often provides weighedagarrist risk evrdeuce too simple answers to complex,questions Health professrorrals decision makers and ' often cannot be substantiated e public should be cooperating partners` - z • the the quest for accountabrlrty inhere are based on roven benefits'', "Junk science," a term coined by the press and used � decisions P over the past decade to characterize data derived from measured agaifrg'cl- nbed risks atypical or questionable scientific techniques, also can E m —' _g •--.--- �v`` play a role in provoking opposition to water fluorida- tion. In fact, decision makers have been persuaded to Opinions are seldom unanimous on any scientific sub- postpone action on several cost-effective public health jest. In fact,there may be no such thing as "final knowl- measures after hypothetical risks have made their way into the public media.34° Junk science impacts public edge," since new information is continuously emerging policy and costs society in immeasurable ways. More and being disseminated. As such, the benefit evidence people, especially those involved in policy decisions, must be continually weighed against risk evidence.Health need to be able to distinguish junk science from legiti- professionals, decision makers and the public should be mate scientific research. Reputable science is based on cooperating partners in the quest for accountability where the scientific method of testing hypotheses in ways that decisions are based on proven benefits measured against can be reproduced and verified by others;junk science, verified risks 335 which often provides too-simple answers to complex (+Additional information on this topic may be found in questions,often cannot be substantiated. the Introduction and Figure 1. Fluoridation Facts 49 4. PUBLIC POLIC;Y-, QUESTION 53. QUESTION 54. Where can reliable information about water fluoride- Why does community water fluoridation sometimes tion be found on the Internet and World Wide Web? lose when it is put to a public vote? Answer. Answer. The American Dental Association,as well as other rep- Voter apathy or low voter turnout due the vote being utable health and science organizations, and govern- held as a special election or in an "off"year,confusing ment agencies have sites on the Internet/Web that pro- ballot language (a "no" vote translates to support for vide information on fluorides and fluoridation. These fluoridation),blurring of scientific issues,lack of leader- sites provide information that is consistent with gener- ship by elected officials and a lack of political campaign ally accepted scientific knowledge. skills among health professionals are some of the rea- • sons fluoridation votes are sometimes unsuccessful. Fact. The Internet and World Wide Web are evolving as ac- Fact. cessible sources of information. However, not all "sci- Despite the continuing growth of fluoridation in this ence" posted on the Internet and World Wide Web country over the past decades, millions of Americans is based on scientific fact. Searching the Internet for do not yet receive the protective benefits of fluoride in "fluoride" or "water fluoridation" directs individuals their drinking water. Centers for Disease Control and to a number of Web sites. Some of the content found Prevention (CDC) data from 2002 indicate, only two- in the sites is scientifically sound. Other less scientific thirds (67.3%) of the population served by public water sites may look highly technical, but contain information systems have access to fluoridated water.34 Forty-two based on science that is unconfirmed or has not gained of the 50 largest cities in the U.S. have adopted fluo- widespread acceptance. Commercial interests, such as ridation. Another two have natural optimal levels of the sale of water filters,may also be promoted. fluoride (Figure 9). The remaining six nonfluoridated One of the most widely respected sources for infor- cities are: Fresno, California; San Jose, California; Col- mation regarding fluoridation and fluorides is the Ameri- orado Springs, Colorado; Honolulu, Hawaii; Wichita, can Dental Association's (ADA) Fluoride and Fluoridation Kansas and Portland, Oregon. In 1998, recognizing the Web site at http:www.ada.org/goto/fluoride (Figure 8). ongoing need to improve health and well being, the From the ADA Web site individuals can link to other Web U.S. Public Health Service revised national health ob- sites, such as the Centers for Disease Control and Pre- jectives to be achieved by the year 2010. Included un- vention, National Institute of Dental and Craniofacial Re- der oral health was an objective to significantly expand search, Institute of Medicine, National Cancer Institute, the fluoridation of public water supplies. Specifically, and state/local health departments for more information Objective 21-9 states that at least 75%of the U.S. popu- about fluoride and water fluoridation. lation served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2010.19 Although water fluoridation reaches Figure 8. Fluoride and Fluoridation Web Page some residents in every state, 2002 data indicates that ` FLUORIDATION AT.YOURFINGERTIPS! only 24 states are providing these benefits to 75% or --- -- //www ada org/got-/fluo de more of their residents.34 (Figure 10). A _ x Social scientists have conducted studies to exam- • ADA Fluoridation Resources ine why fluoridation fails when put to a public vote. • Fluoridation Facts Online Among the factors noted are lack of funding, public • ADA Fluoridation News Stories and professional apathy,the failure of many legislators • ADA Policy and Statements and community leaders to take a stand because of per:- - er=• Links to Additional Fluoridation Web Sites ceived controversy, low voter turnout and the difficulty faced by an electorate in evaluating scientific informa- tion in the midst of emotional charges by opponents. Unfortunately, citizens may mistakenly believe their America's leading advocate for oral health water contains optimal levels of fluoride when, in fact, www.ada.org it does not. Many ADA resources are at your fingertips 24/7/365. _3`_ _, +.. : `, Order a library book or products online, read JADA "Elev`eE`Use,bf e?nOtiOriall&hafged;scare articles, discuss important topics with colleagues,find p foP y oPP a9ndb as fluoride onents creates helpful information on professional topics from accredi- tation to X-rays and recommend our dental education F fear confusion.and'doubt'within F G' ' ' animations,stories and games to your patients. kF r,, " ont:r a communifyiiilen voters csider the, Be resourceful Visit ADA org today) , use of fluoridation Fluoridation Facts 51 • 'fir.�'°'� n -:;!,...71.714 Ss ,i . _. t � x . " - ,� ' ' .... ,-1,,,-,,..-,F:.,.. �� 4 A . txau :. -4,' te ,. µ,53 fc ... . � �� ?'.u79 � .„:fi' .. , - . Figure 9. Forty-Two of the Fifty Largest Cities in the U.S. are Supplied with Fluoridated Water* 4,j1 ,tI,N ` g:'L'j yi"�O1; Tht .t-s•, ,q.. 4g 'aY.,,[$2., ' P,;b+T' ii '2, o4%�Y^III'peil i� e r,Vi * Two cities(Jacksonville,Florida and EI Paso Texas)are naturally fluoridated)A i�l , „xr _, t ,x 4 • Seattle Illa d • IIIIIm Minneapolis • • •Boston Milwaukee Detroit a Cleveland New York Chicago Philadelphia Omaha Sacramento Columbus • Oakland • •Baltimore l' _ Denver Kansas Ci Indianapolis as San Francisco • City Washington Las Vegas St.Louis • Nashville-Davidson •Virginia Beach Los Angeles Tulsa • Charlotte • • —kt• • • Memphis Long Beach Albuquerque Oklahoma City • ••Mesa • Phoenix Fort Worth Atlanta ••Dallas 54. El Paso(natural) •Jacksonville(natural) Austin• Houston New Orleans San Antonio • • 0O •Miami Q . C2 \� O'�o^o'Dbl.' ';i;r r t rr7'�-a --k dT� I ' --x O ' i,C "ivy r7 T'7 s i '^ . '{.3- -_ 7.ji7L a x"'' -.s �� T'.;�",'.xF- a�',',, �i T �'rl-'fix'$ �r n�, ,YPA �„•,T 113*a,compled'by-the;Arrepican Dsrttal As_ocratron and-enters for Disease Control-and Prevenporieir ion+of;Oral Health w f!„ lnfor'rnationcu ntlasofMay2005;,, ir l,_ -- '}!l�' r,'','. .i 1 z - -4'9V;' 11,-t"ikt: ,:''. --'. ,i,: ” K-vr_ �i...-�..,x. a4-`, .Y4a--,_ `,`n3tek;k' 3 -VV. .'°wtia ,r..- ,',: ,s,,. , ..a x.,.1,0- .-....=.,..z 4?,2._ ;..;-st_ x,.-T4'':s' Clever use of emotionally charged "scare" propa- knows of no cases in which community leaders have ganda by fluoride opponents creates fear, confusion been found liable for their pro-fluoridation efforts. In and doubt within a community when voters consider no instance has fluoridation been discontinued be- the use of fluoridation.342,343 Defeats of referenda or the cause it was proven harmful in any way.343-345 discontinuance of fluoridation have occurred most of- Adoption of fluoridation is ultimately a decision of ten when a small, vocal and well organized group has state or local decision makers, whether determined used a barrage of fear-inspiring allegations designed by elected officials, health officers or the voting pub- to confuse the electorate. In addition to attempts to in- lic. Fluoridation can be enacted through state legisla- fluence voters, opponents have also threatened com- tion, administrative regulation or a public referendum. munity leaders with personal litigation.344 While no While fluoridation is not legislated at the federal level, court of last resort has ever ruled against fluoridation, it is legislated at the state and local level. As with any community leaders may be swayed by the threat of liti- pubic health measure, a community has the right and gation due to the cost and time involved in defending obligation to protect the health and welfare of its citi- even a groundless suit, not to mention threats of po- zens, even if it means overriding individual objections litical fallout. The American Dental Association (ADA) to implement fluoridation. 52 American Dental Association `'� PUBLIC POLICY " Figure 10. State Fluoridation Status s p l; • '-'''.',..:Y''''''-11-;'1: W . _ ,-f ,Ty " •,y v 1,r�,w it _, "I ," -' p l'r -, - 1_ 5 i Ir �' v it - ;' States Meeting the`Healthy People 2010 Goal of 75%ofath'e Population _' Served,byiFluorm idated Comunity Water Supplies {' . ..,,_.... ,.„„,„:,.,,,=_:,_,, , . „ ,: ,,, ,,,. ,:7..,„,,.,„,,t , „,,,,„.,1_,,:,„,„,,„,„,,„:„1„.„,,:,,...,ii,„,,,.„'„ nu„.a....„„„ „:,,:,..:.FT' A4',r. -y � a ',::': ':.:; '.''''::1 S ::''''':7':::;T: -:: 4 .L'',.'''-''__,':- IF..-.414t‘r\k_ 1111 1111111 d O �p� d 114b�'4 0, r`e'- t''I Over 75%of population served by fluoridated • Beo..,V° -- community water supplies r "r"T r r4 -]-�'.�11j',•3.ts,e_ z- j ac` i 7^;YJy.. r °i � 3 t 7'Sx.�z ',k i. sx`,�7( '� ,� -^-kr k d - y4 f 1 - ,'Data Source Centers for;pisease Controliand Prevention/Dlvlsion of Oral°Health Percentage of U S Population on ati� Public Water Supply�.Systems Receiving Fluoridated Water' 2002 Available at http//www2,�dc:oov/nohss/Fliioridationilaspl 3,. .ti..cry `_-- .z ;e q,- ^`sem•,,,.. .w --- , ==Az a w__ a,-...,-, _' (5i __ _ - _ _ s -.: = n: through 2004), more than 125 communities in 36 In the past five years(2000tlirough 2004), states have decided to provide the benefits of fluori- rnore than 125 communities in 36 states�have dation for their residents.The size of these water sys- decidedto provide the benefits of flu oridation„ri tems/communities varies greatly — from those with for their residents a , a few thousand residents to the Metropolitan Water -1.X.:A t. ,"I,,,: ;T g.. .;.,. . ., „ u°r!. .__ .7 c.k`-'_", '' District of Southern California which will provide flu- oridated water to more than 18 million people. Each spring as part of the yearly Community Water Technical assistance with fluoridation efforts is avail- Fluoridation Awards program, the ADA, Association able from the Council on Access, Prevention and Inter- of State and Territorial Dental Directors and the CDC professional Relations at the ADA. Additional support Division of Oral Health compile a list of water sys- for fluoridation is available from ADA's Division of Legal tems/communities in the United States that have ad- Affairs, Division of Communications and Department of opted community water fluoridation in the past year. State Government Affairs. This list is posted on the ADA Web site at http://www. ada.org/goto/fluoride. In the past five years (2000 Fluoridation Facts 53 ...,., -. ..,:_ :„ L - � n::',.1--_.- Z - t - 0F ** X, a s ,» t • t QUESTION 55. tries construct their own water quality regulations within Is community water fluoridation accepted by other the framework of the 1980 European Water Quality Direc countries? tive. The Directive provides maximum admissible con= centrations for many substances,one of which is fluoride. Answer. The Directive does not require or prohibit fluoridation, Over 405 million people in more than 60 countries it merely requires that the fluoride concentration in worldwide enjoy the benefits of fluoridated water.132 water does not exceed the maximum permissible con centration.347 Many fluoridation systems that used to operate in , - -- rj F ,�J;::•,, Eastern and Central Europe did not function properly ' a The value of tnraterfiluondatlon is -:'-'-4-:6'.E:-.a ,_,;;, : ,- ::___ .. ,;,_;:_ and, when the Iron Curtain fell in 1989-90, shut down reeogrnzedpriternationally k;pnsider►ngttie es �, :._ . because of obsolete technical equipment and lack of extent:,to,�whIch flupridation has alreadyrbeen`;` knowledge as to the benefits of fluoridated water,348 Wa- implemented�throughout the world the lack t ter fluoridation is not practical in some European coun- $of docurneritItron�`of adverse health effects,s, �' tries because of complex water systems with numerous ,1-1.-,,,`. .i.:',',, i,,I,i; water sources. As an alternative to water fluoridation, ,;,,,,t,-,. remarkable..testrmony to its safety m . 1, , : { ,: •,, ,_,. _z_,_,„-0,. z _. many European countries have opted for the use of fluo ride supplements or salt fluoridation. Fact. Basel, Switzerland is one such example. Those op- The value of water fluoridation is recognized interna- posed to water fluoridation claimed a large victory when tionally. Countries and geographic regions with exten- sive water fluoridation include the U.S., Australia, Brazil, facts are that Basel was the lone city with fluoridated Canada, Chile, Columbia, Ireland, Israel, Malaysia, New water surrounded by communities that used fluoridated Zealand, People's Republic of China (Hong Kong only), salt. In the mid 90s, trade barriers that had prevented Singapore and the United Kingdom.132 Thorough inves fluoridated salt from being sold to those living in Basel tigations of fluoridation have been conducted in Britain fell and soon it was evident that residents were receiv ss. ing fluoride from salt as well as through drinking water. and Australia supporting the safety and effectiveness of 56. water fluoridation.163165.346 Considering the extent to which The government voted to cease water fluoridation in fluoridation has already been implemented throughout 2003 in light of availability and use of fluoridated salt in the world, the lack of documentation of adverse health the community. Basel, Switzerland did not stop fluori- effects is remarkable testimony to its safety.84,163.167,210The dating. Officials simply chose another type of fluorida World Health Organization (WHO) and the Pan American tion—salt fluoridation.349 Health Organization have endorsed the practice of water (Additional information on this topic may be found in fluoridation since 1964. In 1994, an expert committee of Question 14. WHO published a report which reaffirmed its support of ,. `,Y 1 fluoridation as being safe and effective in the prevention y g No rEuropean country has imposed h 'Y of dental decay, and stated that "provided a community1:, -,f4%.1',4,:'.'31:: ,, t a ban on water fluorrdat,on, .-14, has a piped water supply, water fluoridation is the most t �, A- effective method of reaching the whole population, so ''' ry""°f< ' .. �r' i .,.~ ` t> ',a'd ,. = °�Mr� that all social classes benefit without the need for active participation on the part of individuals."738 In many parts Again, no European country has imposed a "ban" of the world,fluoridation is not feasible or a high priority, on water fluoridation, it has simply not been imple- usually due to the lack of a central water supply,the exis- mented for a variety of technical, legal, financial or tence of more life threatening health needs or the lack of political reasons. trained technical personnel or sufficient funds for start- Political actions contrary to the recommendations up and maintenance costs. of health authorities should.not be interpreted as a negative response to water fluoridation. For example, although fluoridation is not carried out in Sweden and the Netherlands, both countries support World Health QUESTION 56. Organization's recommendations regarding fluoridation Is community water fluoridation banned in Europe? as a preventive health measure, in addition to the use of fluoride toothpastes, mouthrinses and dietary fluoride Answer. supplements.136,350 No country in Europe has banned community water fluoridation. Fact. The claim that fluoridation is banned in Europe is frequently used by fluoridation opponents. In truth, European coun- 54 American Dental Association v • tl PUBLIC POLICY Notes Fluoridation Facts 55 . a 4 Yto' ry w ��'� ...Ti ?tr ;',147.2e: , COST EFFECTIVENESS . Q 57. Cost effective? p.56 Q 58. Practical? p.57 QUESTION 57 School-based dental disease prevention activities Is water fluoridation a cost-effective means of prevent- (such as fluoride mouthrinse or tablet programs), pro ing tooth decay? fessionally applied topical fluorides and dental health education are beneficial but have not been found to Answer. be as cost-effective in preventing dental decay as corn- Yes. Fluoridation has substantial lifelong decay preven- tive effects and is a highly cost-effective means of pre- most cost-effective and practical form of preventing venting tooth decay in the United States,regardless of decay in the United States and other countries with es socioeconomic status.97.103.104•351-353 tablished municipal water systems."•97.104.355 Because of the decay-reducing effects of fluoride, Fact. the need for restorative dental care is typically lower The cost of community water fluoridation can vary in in fluoridated communities. Therefore, an individual each community depending on the following factors.354 residing in a fluoridated community will typically 1. Size of the community(population and water usage); have fewer restorative dental expenditures during a 2. Number of fluoride injection points where fluoride lifetime. Health economists at a 1989 workshop con 57. additives will be added to the water system; eluded that fluoridation costs approximately $3.35 3. Amount and type of equipment used to add and per tooth surface when decay is prevented, mak- 58' monitor fluoride additives; ing fluoridation "one of the very few public health 4. Amount and type of fluoride compound used,its price, procedures that actually saves more money than it and its costs of transportation and storage;and costs."355 Considering the fact that the national aver 5. Expertise of personnel at the water plant. age fee359 for a two surface amalgam (silver) restora- The annual cost for a U.S.community to fluoridate its tion in a permanent tooth placed by a general dentist water is estimated to range from approximately$0.50 is $101.94*, fluoridation clearly demonstrates signifi- per person in large communities to approximately cant cost savings.356 $3.00 per person in small communities.355 In a study conducted in Louisiana,Medicaid-eligible children (ages 1-5) residing in communities without fluoridated water were three times more likely than For mostcrtres every$9nvestealrn "y Medicaid-eligible children residing in communities ,.a_r,,water,flgoricJation.saves;$38�n dentalw_,..` , with fluoridated water to receive dental treatment in a hospital and the cost of dental treatment per eligible ;;x`-x _ _=tceatrrienfcosts:"; • child was approximately twice as high. In addition to community water fluoridation status, the study took It can be calculated from these data that the average into account per capita income, population and num- lifetime cost per person to fluoridate a water system is ber of dentists per county.355 less than the cost of one dental filling. When it comes to the cost of treatingdental disease, pays. 3 - i ease, everyone p y • _r:' _:r.:.. ' _.°;... ,ya _ Y ::. t:. . Not just those who need treatment, but the entire corn 'economric importance of fluorrdatton"xfV-r. munity-through higher health insurance premiums and IS!underscored by the factrthat frequentlyy �? higher taxes. For most cities, every $1 invested in wa- the cost oftreatrngdental diseasefispard .+z ter fluoridation saves $38 in dental treatment costs.355 • not oily by the affectedaindrwdua"1, but r ;:;',j Cutting dental care costs by decreasing dental decay is a""Iso by the general publrc through servrcesY'. .` something a community can do to improve oral health roigcl*/ti .l ealtti•;dep#1.7.m"e nts',cor and save money for everyone. With the escalating cost ,4• health clinics, health insurance premiums,' of health care, fluoridation remains a preventive mea- sure ea sure that benefits members of the community at mini mal cost.25 Fluoridation is a community public health medical progra""ins sr measures that saves money. 56 American Dental Association Questions 57-58 The economic importance of fluoridation is under- QUESTION 58. • scored by the fact that frequently the cost of treating Why fluoridate an entire water system when the vast dental disease is paid not only by the affected individual, majority of the water is not used for drinking? but also by the general public through services pro- vided by health departments, community health clinics, Answer. health insurance premiums,the military and other pub It is more practical to fluoridate an entire water supply licly supported medical programs.103 than to attempt to treat individual water sources. y Indirect benefits from the prevention of dental decay may include: Fact. • freedom from dental pain It is technically difficult, perhaps impossible, and cer- • a more positive self image tainly more costly to fluoridate only the water used for • fewer missing teeth drinking.Community water that is chlorinated,softened, • fewer cases of malocclusion aggravated by or in other ways treated is also used for watering lawns, tooth loss washing cars and for most industrial purposes.The cost • fewer teeth requiring root canal treatment of additives for fluoridating a community's water supply • reduced need for dentures,bridges and implants is inexpensive on a per capita basis;therefore,it is prac- • less time lost from school or work because of tical to fluoridate the entire water supply. dental pain or visits to the dentist Fluoride is but one of more than 40 different chemi- These intangible benefits are difficult to measure cals/additives that may be used to treat water in the economically, but are extremely important. United States. Most are added for aesthetic or conve- *The survey data should not be interpreted as con- nience purposes such as to improve the odor or taste, stituting a fee schedule in any way, and should not be prevent natural cloudiness or prevent staining of clothes used for that purpose. Dentists must establish their or porcelain.36 own fees based on their individual practice and market The American Water Works Association, an interna considerations. tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply, supports the practice of fluoridation of public water supplies.367 Additional information on this topic may be found in • Question 44. #CALL TO •ACTION �'n April 2003 Surgeon,.General Richard H -Car ntty,water'systems should tie`receiving the benefitsof r r. . , jmona issued a National Call'to Action to Promoter optimally fluoridated water by,the year 2010: ,1 Oral Health The reportwas a wake=ups call raising Fluoridation efforts at the local:and state level can t- a'powerful`voice.against,the-silence Itcalled`_upon be-_greatly enhanced°and the:U,S:,Healthy People 2010? ' '-policymakers community .leaders private it dustryObjective reached with.`the efforts of organizations 'health professionals,.the media,and the=public-to of agencies and individuals who share a commitment-to firm that oral health.is essential to-'-g;p-i-,e.f,,a,_lhealth and the benefits-of community water fluoridation tis fa '.:. - - '•'• ' ... - ` y- - = r'r well being and to take:action. " Technical assistance with fluoridation efforts is r While;the effectiveness of,preventive interventions av_ailable=from the Council on•Access Prevention and such as .community'.watef.fluoridation have been Interprofessional .Relations at°ADA. Additional sup pqropsNor demonstrated,.less than half of thefifty port,for'fluoridation;is`available_from ADRs Division states have implemented fluor'idation'at the level to of Legal A(fairs,_Division of Communications and De- , meet the national health,objectives to be-achieved by partment of-State.Go"vernment Affairs it :, the year 2010 Specifically', Objective 21,9 states that .at least 75%o of the U S:population served by.commuY • Fluoridation Facts 57 :REFERENCES ' 1. Centersfor Disease Control and Prevention:Ten great . 19: US Department of Health and Human Services. . pubic health achievements-United States,1990-1999. Healthy People 2010.2nd ed.With understanding ' MMWR 19.99;48(12):241-3. and improving health and objectives for improving 2. Centers'for Disease Control-and Prevention.Fluo health_-2 vols.Washinton,DC:US Government:Print " ridation of:drinking water to prevent dental caries. ing OfFice;November 2000. . MMWR 1999;48(41):933-40. 20. US Department of Health and Human Services.Oral - health in America:a report of the Surgeon'General. • 3. Operational policies and recommendations regarding_ Rockville,MD:US Department of Health'and`Human _ • community-Water fluoridation(Trans.1997:673). Services,National Institute of Dental and Craniofacial 4.• ADA statement commemorating the 60th anniversary, Research,National Institutes of Health;2000.. ' of community water fluoridation.2005. 21_" Burt BA.Fluoridation.and social equity.J Public - 5. US Department of,Health and Human Services, Health Dent 2002;62{4):195 200. " ' ' • Public Health Service:Surgeon General statement - ' 22. Slade GD,Spencer AJ,Davies MJ,Stewart JE • • • . on community water fluoridation.Washington,DC; . Influence-of exposure to fluoridated water on socio- • • December3,2001.• economic inequalities in children's caries experience. 6. McKay FS.Mottled enamel:the prevention of its Community Dent Oral Epidemiol 1996;24:89-100. " - . • further production through a change ofthe.water 23. Riley JC._Lennon MA.Ellwood RR The effect of water supply at Oakley,'Ida._J Am Dent-Assoc 1933;20(7): • fluoridation and social inequalities on dental caries in -1137-49. 5-year-old children.Int Epidemiol 1999;28:300,-5. " - ' 7. McClure FJ.Water fluoridation:the search and the 24: Jones CM,Worthington H.The relationship between victory.Bethesda,Maryland:National Institute-of water fluoridation and socioeconomic deprivation, V Dental Research;1970. - - on tooth decay in 5-year-old children.Br-DentJ • . . 1999;186(8):397-400. 8. Smith MC,Lantz EM,Smith HV. The cause of` 25. U.1 Department of Health and Human Services: • mottled enamel,-a defect of humen,teeth.University A national call to action to promote oral health.US of Arizona,.College of Agriculture,Agriculture Exp. Department of Health and Human Services,Public • Station.Technical Bulletin 32 1931:253-82. Health Service,Centers for Disease Control and 9.. Churchill HV.The occurrence of fluorides in some Prevention and the National Institutes of Health, waters of the United States.J Am Water Works Assoc National Institute of Dental and Craniofacial Research. 1931;23(9):1399-1407. NIH Pub.No.03-5303.Rockville,MD;May2003. 10. Dean HT.Chronic endemic dental fluorosis.JAMA 26. Horowitz HS.The effectiveness.of community water • 1936;107(16):1269-73. - fluoridation in the United States.J Public HealthDent • 1996;56(5)(Spec lss):253-8. • 11. Dean HT.Endemic fluorosis and its relation to dental • • caries.Public.Health Rep 1938;53133):1443-52. 27. Milgrom P Reisine S.Oral health in the United States; the post-fluoride generation:Ann Rev Public Health . 12. Dean HT,'Arnold FA,Elvove E.Domestic water and 2000;21:403-36. dental caries,Public Health Rep 1942;57(32):1155-79. 28, Newbrun E.Effectiveness of water fluoridation. " • 13. Co*GJ, Matuschak MC,Dixon SF,Dodds ML, ' J Public Health Dent 1989;49(5):279-89: . • ' , • Walker WE.Experimental dental caries IV.Fluorine 29. Brunelle JA,CarlosJP.Recent trends in dental caries " ' . and its relation to dental caries.J.Dent Res 19.39; in U.S.children and the effect of water fluoridation. • (571:481-90.' J'Dent Res 1990;69(Spec Iss);723-7. • , 14.'Dean HT,Arnold Jr FA,Knutson JW.Studies on 30. American Dental Association,Council on Access - • mass control of dental caries through fluoridation Prevention and Interprofessional Relations:Caries of the public water supply.Public Health Rep 1.950; diagnosis and risk assessment a review of prevent - V 65(43):1403-8. - - tive strategies and management.J Am Dent Assoc: 15. Ast DB,et al.-Newburgh-Kingston caries-fluorine study: 1995;126(Suppl). . final report.J Am Dent Assoc 1956;52(3):290-325. 31. Marin BP Levy SM,Warren JJ,Bergus GFS,Marshall - " V " 16. Brown HK,Poplove M.The Brantford-Samia-Stratford TA,Broffitt B.Medically administered antibiotics,' • fluoridation caries study:final survey,1963.Med Sent dietary habits,fluoride intake and dental caries expe- J Can 1965;21(7):450 6. rience'in the primary dentition.Community Dent Oral Epidemiol 2003;31:40-51. . - 17. US Department of Health and Human Services.For 32. Dye BA,Shenkin JD,Odgen CL,Marshall TA,Levy , . a healthy nation:returns on investment in public. SM,Kanellis MJ.The relationship between healthful health.Washington,DC:US Government Printing , eating practices and dental caries in children aged Office;August 1994. 2-5 years in the United States,1988-1944.J Am Dent " 18. US Department of Health and Human Services, Assoc 2004;135:55-66. Public Health Service.Surgeon General statement 33. Tinanoff N,Palmer CA.Dietary determinants of dental on community`water fluoridation.Washington, caries and dietary recommendations for preschool chil- • DC:December 14,1995. dren.J Public Health Dent 2000;60(3):197-206. American'Dental'Association / ^1 _ _i . 34. National Oral'Health Surveillance System.Water supply 54. Singh KA,Spencer AJ.Relative effects of pre and • - statistics 2002.Available at<http://www.cdc.gov/nohss/ ,. post-eruption water fluoride on caries experience by . FSSupplyStats.htm>.Accessed ApriI.18,2005." 1 , surface type of permanent first molars.Community . .; 35. City of Chicago,Department of Water Management, Dent Oral Epidemiol 2004;32:435-46. • Bureau of Water Supply,Water Quality Division,Water 55. US Department of Health,Education and Welfare, Purification Laboratories.Comprehensive chemi- Public Health Service.Public Health Service drinking cal analysis,March 2005.Available at<http://egov. water standards.Washington,DC.Revised 1962. cityofchicago org/webportaV0O0WebPortaVCOC_ • 56. US Environment Protection A en Ground. ATTACH/rnarch2005.pdf>.Accessed May 23,2005. g �" • Water and Drinking Water.Consumer confidence 36. US Department of Health and Human Services, reports:final rule.Available at<http1//www.epa.gov/ Centers for Disease Control,Dental Disease Preven- . S ogwdw000/ccr/ccrfact.html>.Accessed April 28,2005. I tion Activity:Water fluoridation:a manual for 57. US Environment Protection Agency,Ground Water engineers and technicians.Atlanta;September 1986. ,and Drinking Water. Local drinking water information. ' - 37. Thompson TG,Taylor HJ.Determination and occur , Available at<http:/twww.epa.gov/safewater/dwinfo/. . rence of fluorides in sea water.Industrial Engineering . , index.html>.Accessed.April 28,2005. . Chem March 15, 1933. 38. Bell ME,Ludwig TG.The supply of fluorine to man:2. 58. Centers for Disease Control and Prevention,Oral Health Resources.My water's fluoride.Available at<http:// • Ingestion from water.In:Fluorides and human health. World Health Organization Monograph Series No.59. 2pe .nccd.cdc.gov/M1NF/Index.asp>.Accessed April 28, 2005. Geneva;1970:18. - 39. Safe Drinking Water Committee,National Research 59. Environmental Protection Agency.Private drinking , Council.Drinking water and health.National Academy water wells.Available at<http: Icepa.gov/safewa. of Sciences.Washington,DC;1977_ • ter/privatewells/index2.html>.Accesessed-May 8,2005. • 40. Largent E..The supply of fluorine to man:1.Intro- 60. American Water Works Association.AWWA standard duction.In:Fluorides and human health.World • for sodium fluoride(ANSVAWWA B701-99),March 1, • ., Health Organization Monograph Series No.59. 2000;• AW WA standard for sodium fluorosilicate(ANSI/ . Geneva;1970:17-8. AWWA 8702-99),March 1,2000 and AWWA standard for fluorosilicic acid(ANSI/AWWA 8703-00),September 41: Levy SM,Kiritsy MC,Warren JJ. Sources of 1,2000. fluoride.intake in children.J Public Health Dent 1995;55(11:39-52. 61: Maier FJ:Manual of water fluoridation practice.New York: McGraw-Hill Book Company,Inc.;1963. 42. Newbrun E.Fluorides and dental caries,3rd ed.Spring- field,Illinois:'Charles C.Thomas,publisher;1986. 62. Horowitz HS.Letter to the editor.Am J Public Health • 43. Lambrou D,Larsen MJ,Fejerskov 0,Tachos B. The 1997;87(71:1235-6. effect of fluoride in saliva on remineralization of 63. Arnold FA Jr.,Likins RC,Russell AL,Scott De. dental enamel in humans.Caries Res 1981;15:341-5. i Fifteenth year of the Grand Rapids fluoridation study. 44. Newbrun E.Systemic benefits of fluoride and fluori- J Am Dent Assoc 1962;65:780-5. dation.J Public Health Dent 2004;64(Spec Iss1:35-9. 64. Ast DB,Fitzgerald B.Effectiveness of waterfluorida- tion.45. Featherstone JD.The science and practice of caries ; J Am Dent Assoc 1962;65;581-7. prevention.J Am Dent Assoc 2000;131:887-99. 1 65: Blayney JR,Hilt IN.Fluorine and dental caries:find- 46. Featherstone JD.Fluoridation works.Letter to the ings by age group.J Am Dent Assoc 1967;74(2)(Spec • editor.The Salt Lake Tribune. November 3,2000. E . Iss)246-52. . 47. Backer-Dirks O,Kunzel W,Carlos JP.Caries-preventive 66. Jackson D,James PM, Thomas FD.Fluoridation in water fluoridation.In:Progress in caries prevention. " Anglesey 1983:.a clinical study of dental'caries.Br Ericsson V.ed.Caries Res 1978;12(Suppl-1):7-14. Dent J 1985;158(2):45-9: . . 48. Silverstone LM.Remineralization and enamel caries: ' 67. Jackson D.Has the decline of dental caries in English new concepts.Dent Update 1993;May:261-73. children made water fluoridation both unnecessary 49. Featherstone JD.The mechanism of dental decay. ( and uneconomic?Br Dent J 1987;162(51:170-3. Nutrition Today 1987;May-Jun:10-6. 68. Selwitz RH,Nowjack-Raymer RE,Kingman A,Driscoll 50. Fejerskov 0,T.hylstrup A, Larsen MJ.Rational use i WS.Dental caries and dental fluorosis among school- of fluorides in caries prevention.Acta Odontol Scan children who were lifelong residents of communities 1981;39:241-9. •having either low or optimal levels of fluoride in drinking water.J Public Health Dent 1998;58(1):28.35. 51. Silverstone LM,Wefel JS,Zimmerman BF,Clarkson BH,Featherstone MJ.Remineralization of natural i 69. Jones CM,Taylor GO,Whittle JG,Evans D,Trotter and artificial lesions in human dental enamel in vitro. DP Water fluoridation,tooth decay in 5 year olds.and Caries Res 1981;15:138-57. social deprivation measured by the Jarman score: 52. Hargreaves JA.The level and timing of systemic analysis of data from British dental surveys. BMJ exposure to fluoride with respect to caries resistance. 1997;315:514-7. J Dent Res 1992;71(51:1244-8. 70. Murray JJ.Efficacy of preventive agents for dental 53. Singh KA,Spencer AJ,Armfield BA.Relative effects caries.Caries Res 1993;27(Suppl 11:2-8. of pre-and posteruption water fluoride on caries 71. Ripa LW.A half-century of community water fluorida- experience of permanent first molars.J Public Health ' tion in the United States: review and commentary. Dent 2003;63(1):11-19. I J Public Health Dent 1993;53(1):17-44. _ _.__.___________ ___- __ ... . _ ..._.____ _ ___.-__ _ .___ _ _ .. ._.- . __ _____ ______- _ __. . .______--____.______. Fluoridation Facts 59 - � 4 72. Evans DJ,Rugg-Gunn AJ,Tabari ED,Butler T.The 87. National Institute of Dental Research.Statement on effect of fluoridation and social class on caries effectiveness of water fluoridation.Bethesda;December experience in 5-year-old Newcastle children in 1994 1989. compared with results over the previous 18 years. 88. Lemke CW,Doherty JM,Arra MC.Controlled fluorida- Comm Dent Health 1996;13:5-10. tion:the dental effects of discontinuation in Antigo, 73. Ismail Al.Prevention of early childhood caries. Wisconsin.J Am Dent Assoc 1970;80:782-6. Community Dent Oral Epidemiol 1998;26(Suppl 1): 89. Stephen KW,McCall DR,Tullis JI.Caries prevalence 49-61. in northern Scotland before,and 5 years after,water 74. NIH consensus statement 2001.Diagnosis and defluoridation.Br Dent J 1987;163:324-6. management of dental caries throughout life.March 90. Attwood D,Blinkhorn AS.Dental health in school- 26-28;18(1):1-30. children 5 years after water fluoridation ceased in 15. Centers for Disease Control and Prevention.Promot south-west Scotland.Int Dent J 1991;41(1):43-8. ing oral health:interventions for preventing dental 91. Burt BA,Eklund SA,Loesche WJ.Dental benefits of caries,oral and pharyngeal cancers,and sport-related limited exposure to fluoridated water in childhood. craniofacial injuries:a report on recommendations of J Dent Res 1986;61(11):1322-5. the Task Force on Community Preventive Services. 92. Way RM.The effect on dental caries of a change from MMWR 2001;50(No.RR-21):1-12. a naturally fluoridated to a fluoride-free communal 76. Task Force on Community Preventive Services. water.J Dent Child 1964;31:151-7. Recommendations on selected interventions to 93. Kunzel W,Fischer T.Caries prevalence after cessation prevent dental caries,oral and pharyngeal cancers, of water fluoridation in La Salud,Cuba.Caries Res and sports-related craniofacial injuries.Am J Prey 2000;34(1):20-5. Med 2002;23(1S):16-20. 94. Seppa L,Hausen H,Karkkainen 5,Larmas M.Caries 77. Truman BI,Gooch BF,Sulemana I,Gift HC,Horowitz occurrence in a fluoridated and a nonfluoridated AM,Evans,Jr CA,Griffin SO,Carande-Kulis VG.Task town in Finland:a retrospective study using longi- Force on Community Preventive Services.Reviews of tudinal data from public dental records.Caries Res evidence on interventions to prevent dental caries,oral 2002;36(5):308-14. and pharyngeal cancers,and sports-related craniofa- 95. Kunzel W,Fischer T,Lorenz R,Bruhmann S. Decline cial injuries.Am J Prey Med 2002;23(1S):21-54. of caries prevalence after the cessation of water 78. Gooch BF,Truman BI,Griffin SO,Kohn WG,Sule- fluoridation in the former East Germany.Community mana I,Gift HC,Horowitz AM,Evans,Jr CA.A Dent Oral Epidemiol 2000;28(5):382-9. comparison of selected evidence on interventions to 96. Kalsbeek H,Kwant GW,Groeneveld A,Dirks OB,van prevent dental caries,oral and pharyngeal cancers, Eck AA,Theuns HM.Caries experience of 15-year-old and sports-related craniofacial injuries.Am J Prey children in The Netherlands after discontinuation of Med 2002;23(1S):55-80. water fluoridation.Caries Res 1993;27(3):201-5. 79. Spencer AJ,Slade GD,Davies M.Water fluoridation in 97. US Department of Health and Human Services,Public Australia.Comm Dent Health 1996;13(Suppl 2):27-37. Health Service.Toward improving the oral health 80. Gray MM,Davies-Slowick J.Changes in the percent- of Americans:an overview of oral status,resources age of 5-year-old children with no experience of on health care delivery.Report of the United States decay in Dudley towns since the implementa Public Health Service Oral Health Coordinating tion of fluoridation schemes in 1987.Br Dent J Committee.Washington,DC;March 1993. 2001;190(1):30-2. 98. Niessen LC,Weyant RJ.Causes of tooth loss in a 81. Lee M,Dennison PJ.Water fluoridation and dental veteran population.J Public Health Dent 1989;49(1): caries in 5-and 12-year-old children from Canterbury 19-23. and Wellington.New Zealand Dent J 2004;100(1): 99. Phipps KR,Stevens VJ.Relative contribution of 10-15. caries and periodontal disease in adult tooth loss 82. Gillcrist JA,Brumley DE.Community fluoridation for an HMO dental population.J Public Health Dent status and caries experience in children.J Public 1995;55(41:250-2. Health Dent 2001;61(3):168-71. 100.Griffin SO,Griffin PM,Swann JL,Zlobin N.Estimat- ing rates of new root caries in older adults.J Dent 83. Jones CM,Worthington H.Water fluoridation, Res 2004;83(8):634-8. poverty and tooth decay in 12-year-old children. J Dent 2000;28:389-93. 101. Gift HC.Oral health outcomes research:Challenges and opportunities.In Slade GD,ed.,Measuring Oral Health 84-. US Department of Health and Human Services,Public and Quality of Life.Chapel Hill,NC:Department of Health Service.Review of fluoride:benefits and risks. Dental Ecology,University of North Carolina 1997: Report of the Ad Hoc Subcommittee on Fluoride. 25-46. Washington,DC;February 1991. 102.Centers for Medicare&Medicaid Services,Office 85. Lewis DW,Banting DW.Water fluoridation:current of the Actuary,National Health Statistics.Table effectiveness and dental fluorosis.Community Dent 10:Expenditures for health services and supplies Oral Epidemiol 1994;22:153-8. under public programs,by type of expenditure and 86. Griffin SO,Gooch BF,Lockwood SA,Tomar SL.Quan- program:calendar year 2003. tifying the diffused benefit from water fluoridation in 103.White BA,Antczak-Bouckoms AA,Weinstein MC. the United States.Community Dent Oral Epidemiol Issues in the economic evaluation of community 2001;29:120-9. water fluoridation.J Dent Educ 1989;53(11):646-57. 60 American Dental Association REFERENCES - 104.Garcia Al.Caries incidence and costs of prevention 123.Institute of Medicine,Food and Nutrition Board. programs.J Public Health Dent 1989;49(5):259-71. Dietary reference intakes for calcium,phosphorus, . 105.Brustman BA Impact of exposure to fluoride magnesium,vitamin D and:fluoride.Report of the adequate water on root surface caries in elderly. Standing Committee.on the Scientific Evaluation of Gerodontics 1986;2(6)203-7. . Dietary Reference Intakes.Washington,DC:National - Academy Press;1997. 106.Burt BA;Ismail Al,Eklund SA.Root caries in an opti- mally fluoridated and a high-fluoride community.J 124. Horowitz HS.The role of dietary fluoride supple Dent Res 7986;65(9):1154 8. ments in caries prevention.J Public Health-Dent 9 1999;59(4):205-10. 107.Brown LJ,Wall TP Lazar V.Trends in caries - . amohg.adults 18 to 45 years old.J Am Dent Assoc • 125.Preface:Dosage Schedule for Dietary Fluoride I _ 2002;133(7):827-34. Supplements.J Public Health Dent 1999;59(4):203-4. 108.Mellberg JR,Ripa LW.Fluoride in preventive 126.Levy SM,Guha-Chowdhury N.Total fluoride intake . dentistry:theory and clinical applications.Chicago: and implications for dietary fluoride supplementation. Quintessence;1983:414i0. •J Public Health Dent 1999;59(4):211-23. 109.McGuire S.A review of the impact,of fluoride on 1 127.Arhold FA,McClure FJ,White CL.Sodium fluoride adult caries.J Clin Dent 1993;4(1):11-13. tablets for children.Dental Progress 1960;1(1):8-12. - 110:Grembowski D,Fiset L,Spadafora A.How fluorida- 128.Hamasha AA,Levy SM,Broffitt B,Warren JJ.Patterns • tion affects adult dental caries:systemic and topical of dietary fluoride supplement use in children from ' effects are explored.J Am Dent Assoc 1992;123: birth to 96 months of a_ge.J Public Health Dent . 49-54. 2005;65(1):7-13. • 111.Stamm JW,Banting DW,Imrey PB.Adult root caries - 129.Levy SM,Warren JJ,Broffitt B.Patterns of'fluoride survey of two similar communities with contrast- ' intake from 36to'72 months of age.J Public,Health ing natural water fluoride,levels.J Am Dent Assoc Dent 2003;63(4):211-20. 1990;120:143-9. i 130.Levy SM,Warren JJ,Davis CS,KirchnerHL,Kanellis 112.Newbrun E.Prevention of root caries.Gerodont MJ,Wefel JS.Patterns of fluoride intake from birth to 1986;5(1):33-41. 36 months.J Public Health Dent 2001;61(2):70-7. 113.Brown LJ,Winn DM,White BA.Dental caries;restora- 131. Newbrun E.Systemic fluorides:an overview.J Can tion and tooth conditions in U.S.adults,1988-1991. r Dent Assoc 1980;1:31-7. J Am Dent Assoc 1996;127:1315-25. ' 132.The British Fluoridation Society,The UK Public 114.Papas AS,Joshi A,MacDonald SL,Maravelis-Spla- Health Association,The British Dental Association, gounias L,Pretara-Spanedda F Curro FA.Caries 1 The Faculty of Public Health of the Royal College of prevalence in xerostomic individuals.J Can Dent Physicians.One in a million-the facts about water • Assoc 1993;59(2):171-9. _ fluoridation.Manchester;England;2004.Available at '115.Jones JA.Root caries:prevention and chemotherapy. <http://www.bfsweb.org/onemillion.html>.Accessed Am J Dent'1995;8(6):352 7. May 23,2005. 116.Wiktorsson A,Martinsson T,Zimmerman M.Salivary 133.Estupinan-Day S.International perspectives and prat- levels of lactobacilli,buffer capacity and salivary tical applications on fluorides and fluoridation. flow rate related to caries activity among adults in J Public Health Dent 2004;64(Spec Iss 1):40-3. communities with optimal and low water fluoride 134.Horowitz HS.Decision-making for national programs concentrations.Swed Dent J 1992;16:231-7. of'cornmunity fluoride use:Community Dent Oral 117.Anusavice KJ.Treatment regimens in preventive and Epidemiol 2000;28:321-9. " restorative dentistry_J Am Dent Assoc 199.5;126: 135.Marthaler TM,"Mejia R,"Vines JJ.Caries-preventive ' 727-43. salt fluoridation.Caries Res 1978;12(Suppl.1):15-21. 118.Hoperaft MS,Morgan MV.Exposure to fluoridated 136. Kunzel W.Systemic use of fluoride-other methods: drinking water and dental caries experience in Austra- salt,sugar,milk,etc.Caries Res 1993;27(Suppl 1):16-22. " Ilan army recruits,1996.Comm Dent Oral Epidemiol 137.Estupinan-Day SR,Baez 1 ,Horowitz H,Warpeha R, 2003;31(1):68-74. ` Sutherland B,Thamer M.Salt fluoridation and dental 119.Horowitz HS.The future of water fluoridation and caries in Jamaica.Community Dent Oral Epidemiol other systemic fluorides.J Dent Res 1990;69(Spec 2001;29(4):247-52. Iss):760-4. 138.World Health Organization.Fluorides and oral health. 120.Driscoll WS.The use of fluoride tablets for the Report of a WHO Expert Committee on Oral Health prevention of dental caries.In:International work-- Status and Fluoride Use.WHO Technical Report shop on fluorides and dental-caries prevention. ' Series 846.Geneva;1994. Baltimore,University of Maryland;1974:25-111. - 139.Bergmann KE,Bergmann RL.Salt fluoridation and 121.Aasenden R,Peebles TC.Effects of fluoride supple- general health.Adv Dent Res 1995;9(2):138-43. mentation from birth on human deciduous and 140.Chobanian AV,Bakris GL,Black HR,Cushman WC, permanent teeth.Arch Oral Biol 1974;19:321-6. I Green LA,lzzo JL Jr,Jones DW,Materson BJ,Oparil • 122.Margolis FJ,Reames HR,'Freshman E,Macauley CD, S,Wright JT Jr,Roccella EJ.Joint National Committee Mehaffey H.Fluoride:ten year prospective study of - - on Prevention,Detection,Evaluation,and Treatment . . deciduous and permanent dentition.Am J Pis Child i of High Blood Pressure.National Heart,Lung,and 1975;129:794-800. I Blood Institute;National High Blood Pressure Fluoridation Facts 61 •` • Education Program Coordinating Committee-Seventh 160.Full CA,Wefel JS.Water softener influence_on anions -- report:of the joint national committee on prevention, . . . and cations.-Iowa Dent-J 1983;69:37-9. •- - . detection;evaluation;and treatment of high blood 161.Robinson SN,Davies`EH;Williams B.Domestic water " ' - .. .pressure.Hypertension 2003;42(6):120652:, . - ' treatm"entappliances and the fluoride ion.Bi Deni J •-141.World Health Organization.Development of a milk 1991;17i:91-3.. -' - ` , • fluoridation scheme for prevention of dental caries 162.Jobson MD,Grimm SE 3rd,Banks K,Henley'G.The .. -preliminary assessment of feasibility.Geneva:2001.., effects of:water filtration systems on fluoride:Wash 142.Pakhoinov GN.Objectives and review of the inter ington,D.C.metropolitan area,ASDC J Dent Child ' national milk fluoridation program.Adv Dent Res - 2000;67(51:302,304,350-4_ - - 1995;9(2):;110-1. 163.Fluoride,teeth and health.Royal College of Fhy si- 143.Burt BA;Marthaler TM.Fluoride tablets,salt fluorida- ' cians.Pitman Medical,London:1976. - _ tion and milkfluoridation.In:Fluoride in Dentistry,_ 164.Johansen E,Tave's D;Olsen T,eds.Continuing. 2nd ed.Fejerskov 0,Ekstand J and Burt B,eds. - evaluation ofthe;use of fluorides.AAAS Selected Munksgaard,Copenhagen;1996:291-310. -- - - Symposium 11:Boulder,Colorado:Westview - 144.LindemeyerRG,Fitz LG,and Pikarski JD.Fluoride: Press;1979. .. _ surprising factors'in bottled water.Penn bentJ.(Phila) - 1'65.Knox EG.Fluoridation of water and'cancer a review ' 1996;63(108-7.: ' - of the epidemiological evidence.Report of the-. 145.Van Winkle S,Levy SM,Kiritsy MC,Heilman JR; ,• • - Working Party London Her Majesty's Stationary.- - - ' Wefel,JS and Marshall T.Water and formula fluoride Office;1985: concentrations:significance for infants fed formula •_ 166.Leone NC,Shimkin MB,Arnold FA,et al.Medical • ' Pediatr Dent 1995 Jul-Aug;17(4):305-10_ - aspects of excessive fluoride in a water supply,Public - 146.Wisconsin Department of Agriculture,Trade arid- • Health Rep 1954;69(10):925-36. • . _ - , Consumer Protection.State of Wisconsin bottled- 167.National Research Council:Health effects'of ingested, drinking water sampling and analysis test results. fluoride.Repoi-t of the Subcommittee On Health - June 1993. - - - Effects of-Ingested Fluoride.Washin_gton,'DC:Nation- • 147.Chan JT,Liu CF-and Tate WH.;Fluoride concentration al AcademyPress;1993. - in milk,tea and bottled water in Houston.J Gt Houst 168.58 Fed.Reg_68826,68827(Dec.29, 1993). - Dent,Soc•1994;66(4):8-9.. - u ,. 169.US Department Health and Human 5ervices,Public; - 148.Johnson SA,DeBiase C.Concentration levels Health Service:Facts on the ATSDR toxicological of fluoride in bottled drinking water.J Dent Hyg -' profile for fluorides,hydrogen fluoride,•and fluorine. 2003;77(3);:161-7. - CDC Atlanta,GA;May 15,1998. ' 149.Beverage Marketing Corportation.Bottled water '170.American"Medical Association.H-440.945 and H strengthens position as no.2 beverage,reports Bever- 440.972_In:American Medical Association Policy age Marketing.Press Release dated April 25,2005, 'Compendium.Chicago:American Medical Associa- Available at<http://www.beveragemarketing.com>. tion;1998:633,637. - • - Accessed April 29;2005: 171.Fluoridation and dental health.,World Health Organi- I 150.Beverage Marketing Corportation.US soft drink sales zation(WHA22.30);July 23,1969. . . , up slightly in 2004,Beverage Marketing Corpora • 172.UnitedStatesEnvironmental Protection Agency, ' tion reports.Press Release dated March 14,2005. 9" �'" Available at-<http:/(www.beveragemarketing:com>. Office of Water.Fact Sheet:-Annou existing drinking Accessed fApril'29,2005. completion of EPA's review of Water•• •, _ standards(EPA 81.5-F-03-001).June 2003. 151.Weissman AM.Bottled water use in an immigrant ' 173.National Academy of Science Project Title:Toxicologic community:a public health issue?.Am J Public'Health_- Risk of Fluoride in Drinking Water.Available at<http:// 1997;87(8):1379 80.www4.nas.edu/cp.nsf/Projects%20_by%20_PIN/BEST-K-, 152.Flaitz CM,Hill EM,Hicks MJ.A survey of bottled water. 02-05-A7OpenDocument>.Accessed May 5,2005, usage by pediatric dental patients:implications for 174:US Environment Protection Agency,Ground Water dental health.Quintessence Int 1989;20(1.1):847-52. and Drinking Water.List of drinking water contami • - 153.Tate WH,Chan JT Fluoride concentrations in bottled nants and MCLS:Available.at<httpJ/www.epa, and,filtered waters.Gen Dent 1994;42(4):362-6. - gov/safewater/mcl.html>.Accessed April 28,2005. 154.Bartels D,Haney K,Khajotia SS.Fluoride concen- ,175.US Environment Protection Agency,Ground Water _ trations in bottled water.Oklahoma Dent AssocJ - - and Drinking,Water.Drinking water glossary Avail- ' 2000:18;21 • able at<http://www-epa.gov/safewater/glossary. - - 155.44 Fed.Reg.42775-78(July 20,1979). hfm#clink>,Accessed April 28,2005: 156.21 CFR 165:Sec:165.110. • 176.Hodge HC;Sinith'FA.Occupational fluoride exposure.• J Occup Med;1977;19:12-39: ' - 157.60 Fed.Reg.57079(November 13,1995). 177.Committee on Biologic Effects of,Atmospheric Pollut 158.Maier FJ.Manual of water fluoridation practice:New ants.Biologic effects of atmospheric pollutants: - York:McGraw-Hill Book Company,Inc.;1963,--- fluorides.Washington D.C.,National Academy of 159.ADA Division of Science on behalf of the ADA Council Sciences 1971:5 9:, on Scientific Affairs.Tap water filters.J Am Dent •178.Rugg-Gunn AJ.Nutrition and dental health.New ' Assbc 2003;134(2):226-7. - • York:Oxfor'd.University Press;1993. 62.. - •- . American'Dental'Association • f _ _ , ` REFERENCES I i 179.US Department of Agriculture,Agricultural Research {II 198.Cauley JA,Murphy PA,Riley TJ,Buhari AM.Effects Service,Beltsville Human Nutrition Research Center, i of fluoridated drinking water on bone mass and frac- Nutrient Data Laboratory.USDA national fluoride j tures:the study of osteoporotic fractures.J Bone Min database of selected beverages and foods-2004. 4 Res 1995;10(7):1076-86. Available at<http://www.naLusda.gov/fnic/foodcomp/ 199.Hodge HC.The safety of fluoride tablets or drops.In: Data/Fluoride/Fluoride.html>.Accessed May 6,2005. Continuing evaluation of the use of fluorides.Johan- 180.Pendrys DG,Stamm JW.Relationship of total fluoride sen E,Tavaes DR,Olsen TO,eds.Boulder,Colorado: intake to beneficial effects and enamel fluorosis. Westview Press;1979:253-75. J Dent Res 1990;69(Spec Iss):529-38. 200. Lehmann R,Wapniarz M,Hofman B,Peiper B, 181.Jackson RD,Brizendine EJ,Kelly SA, Hinesley R, Haubitz I,Allolio B.Drinking water fluoridation:bone Stookey GK,Dunipace AJ.The fluoride content of mineral density and hip fracture incidence.Bone foods and beverages from negligibly and optimally 1998;22(3):273-8. fluoridated communities.Community Dent Oral Epidemiol 2002;30(5):382-91. t 201.Phipps KR,Orwoll ES,Bevan L.The association between water-borne fluoride and bone mineral 182.Whitford GM.The metabolism and toxicity of fluo- density in older adults.J Dent Res 1998;77(9):1739-48. ride,2nd rev.ed.Monographs in oral science,Vol. 16. Basel,Switzerland:Karger;1996. R 202.Demos LL,Kazda H,Cicuttini FM,Sinclair MI,Fairley CK.Water fluoridation,osteoporosis,fractures-recent 183. Levy SM,Maurice TJ,Jakobsen JR.Feeding patterns, developments.Aust Dent J 2001;46(2):80-7. water sources and fluoride exposures of infants and 1-year-olds.J Am Dent Assoc 1993;124:65-9. I 203.Hillier S,Cooper C,Kellingray S,Russell G,Hughes H,Coggon D.Fluoride in drinking water and risk of 184.Levy SM.Review of fluoride exposures and ingestion. hip fracture in the UK:a case-control study.Lancet Community Dent Oral Epidemiol 1994;22:173-80. I 2000;355(9200):265-9. 185.Barnhart WE,Hiller LK,Leonard GJ,Michaels SE. 204.Phipps KR,Orwoll ES,Mason JD,Cauley JA.Commu- price usage and ingestion among four age nity water fluoridation,bone mineral density,and groups.J Dent Res 1974;53(6):1317-22. fractures:prospective study of effects in older 186.Ericsson Y,Forsman B.Fluoride retained from mouth- women.Br Med J 2000;321(7265):860-4. rinses and dentifrices in preschool children.Caries 205.Jones G,Riley M,Couper D,Dwyer T Water fluoride- Res 1969;3:290-9. tion,bone mass and fracture:a quantitative overview 187.Bruun C,Thylstrup A.Dentifrice usage among Danish of the literature.Aust N ZJ Public Health.1999;23(1): children.J Dent Res 1988;67(8):1114-7. 34-40. 188.Ekstrand J,Ehmebo M.Absorption of fluoride from i 206.University of York Centre for Reviews and Dissemina- fluoride dentifrices.Caries Res 1980;14:96-102. tion.CRD Reportl8-Systematic review of the efficacy 189.Levy SM.A review of fluoride intake from fluoride j and safety of the fluoridation of drinking water.2000. dentifrice.J Dent Child 1993;60(2):115-24. Executive Summary.Available at<http://www.york. 190.Leverett DH,Adair SM,Vaughan BW,Proskin HM, ; ac.uk/inst/crd/reportl8.htm>.Accessed April 28,2005. Moss ME.Randomized clinical trial of effect of prena- 1 207.US Department of Health and Human Services. Bone tal fluoride supplements in preventing dental caries. ) health and osteoporosis:a report of the Surgeon Caries Res 1997;31:174-79. General.Rockville,MD:US Department of Health and 191.American Dental Association.ADA guide to dental Human Services,Office of the Surgeon General 2004: Chapter 7,Table 7-5:166. therapeutics.Third Edition.Chicago;2003. 192.Whitford GM.The physiological and toxicological 208. Bucher JR,Hejtmancik MR,loft JD II,Persing RL, characteristics of fluoride.J Dent Res 1990;69(Spec Eustis SL,Haseman JK.Results and conclusions of Iss):539 49. the National Toxicology Program's rodent carcino- genicity studies with sodium fluoride.Int J Cancer 193.Whitford GM.Intake and metabolism of fluoride. 1991.48:733-7. Adv Dent Res 1994;8(1):5-14. 209.Maurer JK,Cheng MC,Boysen BG,Anderson RL. 194.Gordon SL,Corbin SB.Summary of workshop on F Two-year carcinogenicity study of sodium fluoride in drinking water fluoridation influence on hip fracture rats.J Natl Cancer Inst 1990;82:1118-26. on bone health.Osteoporosis Int 1992;2:109-17. M 195.Suarez-Almazor ME,Flowerdew G,Saunders LD, 210.Ranting DW.The future of fluoride.An update one year after the National Toxicology Program Study. Soskolne CL,Russell AS.The fluoridation of drink- J Am Dent Assoc. 1991;122(8):86-91. ing water and hip fracture hospitalization rates in two Canadian communities.Am J Public Health 211.Horowitz HS.Indexes for measuring dental fluorosis. 1993;83(5):689-93. { J Public Health Dent 1986;46(4):179-183 196.Jacobsen SJ,O'Fallon WM,Melton LJ.Hip fracture I 212. Dean HT.The investigation of physiological effects by incidence before and after the fluoridation of the ( the epidemiological method.In:Moulton FR,ed.Fluo- public water supply,Rochester,Minnesota.Am J d rine and dental health.American Association for the Public Health 1993;83(5):743-5. ! Advancement of Science,Publication No. 19.Wash- 197.Karagas MR,Baron JA,Barrett JA,Jacobsen SJ. ington DC;1942:23-31. Patterns of fracture among the United States elderly: 213.Kumar JV,Swango PA,Opima PN,Green EL.Dean's geographic and fluoride effects.Ann Epidemiol i fluorosis index:an assessment of examiner reliability. 1996;6(3):209-16. J Public Health Dent.2000;60(1):57-9. { Fluoridation Facts 63 ,--, / 214. Beltran-Aguilar ED,Griffin SO,Lockwood SA.Preva-. . 232.Tohyama E.Relationship between.fltioride concontra- - . Ience and trends in enamel fluorosis in the United ,' tion in drinking water and mortality rate from uterine States from the 1930s to the 1980s.J Am Dent Assoc - cancer in Okinawa Prefecture,Japan.'J Epidemiology . 2002;133:157-65. 1996;6(4):184-190: ' 215.Griffin SO;Beltran ED,Lockwood SA,Barker LK. • 233.Kinlen L Cancer incidence in relation to fluoride level ' • Esthetically objectionable fluorosis attributable to , • in water supplies.Br Dent J 1975;138:221-4. water fluoridation.Community Dent Oral Epidemiol 234.Chilvers C,Conway D.Cancer mortality in England 2002;30(31:199-209. in relation to levels of naturally occurring fluoride in 216.Horowitz HS.Fluoride and enamel defects.Adv Dent water supplies.J Epidemiol Comm Health 1985;39: Res 1989;3(2):143-6. 44-7. 217. Pendrys DG.Dental fluorosis in perspective.J Am 235.Cook-Mozaffari PC,Bulusu L,Doll R.Fluoridation of Dent Assoc 1991;122:63-6. water supplies and cancer mortality.1:a search for an •218.Stookey GK Review of fluorosis risk of self-applied effect in the UK on risk of death from cancer.J Epide- 218. fluorides:dentifrices,'motithrinses and gels. miol Comm Health 1981;35:227-32. Community Dent Oral,Epidemiol 1994;22(3):181-6. 236. Raman S.Becking G.Grimard M,Hickman JR, • 219. Pendrys DG,Katz RV,Morse DE.Risk factors for McCullough RS,Tate RA.Fluoridation and cancer:an enamel fluorosis in a no D . d population. analysis of Canadian drinking water fluoridation'and Am J Epidemiolorosiianonridate cancer mortality data.Environmental Health Direc- torate,Health Protection Branch.Ottawa,Canada: 220.Pendrys DG.Risk of enamel fluorosis in nonfluo- Authority of the Minister of National Health and'- ridated and optimally fluoridated populations: Welfare;1977. . ' considerations for the-dental professional.J Am Dent 237.Richards GA,Ford JM.Cancer mortality in selected Assoc 2000;131(6):746-55. • New South Wales localities with fluoridated and non- 221.American Dental Association.ADA statement on FDA fluoridated water supplies.Med J Aust 1979;2:521-3.- ' ' • toothpaste warning labels.Available at<http://www. 238.International Agency for Research on Cancer. ada_org/prof/resources/positions/statements/fluoride. IARC monographs on the evaluation of the carci • - asp>: Accessed May 8,2005. nogenic risk of chemicals to humans,Vol.27. 222. Hodge HC,Smith FA.Biological properties of inor- Switzerland:1982. L ._ .. garlic fluorides.In:Fluorine chemistry.Simons HH, 239.62 Fed.Reg.64297(Dec.5, 1997). - ed.New York:Academic Press;1965:1.42. 1 - 240.Clemmesen J.The alleged association between - i y-- 223.Stevenson CA,,Watson AR.Fluoride osteosclerosis. artificial fluoridation of water supplies and cancer: . American Journal of Roetgenology,Radium Therapy a review. Bulletin of the World Health Organization,. and Nuclear Medicine 1957;78(1):13-18. 1983;61(5):871-83. . { 224.Agency for Toxic Substances and Disease Registry 241.Gelberg KH,Fitzgerald EF,Hwang ISA,Dubrow (ATSDR).Toxicological Profile for fluorine,hydrogen R.Fluoride exposure and childhood osteosar- . fluoride,and fluorides.Atlanta.GA:US Department corria:a case-control study.AmJ Public Health of Health and Human Services,Public Health Service. 1995;85(121:1678-83. 2003.Available at<ht1p://www.atsdr.cdc.gov/toxpro- 242. McGuire SM,Vanable ED,McGuire MH,Buckwalter fileshpll.html>.Accessed April 28,2005. JA,Douglass CW. Is there a link between fluori- . 225. American Cancer Society.A statement on fluoride dated water and osteosarcoma?J Am Dent Assoc- + • and drinking water fluoridation by Clark W Heath,Jr. ' 1991;122(41:38-45. MD,Vice President of Epidemiology and Surveillance Research of American Cancer Society;February 17.1998. 243.Burn Mahoney MC,La latae DS, Nasca PC,Wolfgang Burnett WS.Population density and cancer mortality 226.Hoover RN,McKay FW,Fraumeni JF.Fluoridated . differentials in New York State,-1978-1982. Int J Epide- drinking water and the occurrence of cancer.J Natl miol 1990;19(3):483-90. - • Cancer Inst 1976;57(4):757 68: 244.Hrudey SE,Soskolne CL,Berkel J.Fincham S.Drink- 227.Erickson JD.Mortality in selected cities with fluori- ing water fluoridation and osteosarcoma.Can J dated and non-fluoridated water supplies.New Eng Public Health 1990;81(6):415-6. ' ' J Med 1978;298(20)1112-6. 245.Takahashi K,Akiniwa K,Narita K. Regression analysis 228.Rogot E,Sharrett AR,Feinleib M,Fabsitz RR.Trends. of cancer incidence rates and water fluoride in the in urban mortality in relation to fluoridation status. U.S.A. based on IACR/IARC(WHO)data(1978-1992). Am J Epidemiol 1978;107(2):104-12. International Agency for Research on Cancer.J Epide- - 229. Chilvers C.Cancer mortality and fluoridation of water miol 2001;11(4):170-9. supplies in 35 US cities.Int J Epidemiol 1983;12(4): 246.Kaminsky LS,Mahoney MC,Leach J,Melius J,Miller 397-404. MJ.Fluoride:benefits and risks of exposure.Crit Rev 230. Mahoney MC, Nasca PC,Burnett WS,Melius JM. Oral Biol Med 1990;1:261-81. Bone cancer incidence rates in New York State:time 247.Jenkins G,Venkateswarlu P Zipkin I.Physiological • trends and fluoridated drinking water.Am J Public effects of small doses of fluoride.In:Fluorides and Health 1991;81(4):475-9. human health.World Health Organization Monograph 231.Cohn PD,New Jersey Department of Health,New Series No.59.Geneva:1970:163.224. • ) Jersey Department of'Environmental Protection and 248. Leone NC,Leatherwood EC,Petrie IM,Lieberman L. - Energy.An epidemiologic report on drinking water Effect of fluoride on thyroid gland:clinical study. .and fluoridation.Trenton,NJ;1992. J Am Dent Assoc 1964;69:179-80. II 64 _ L" _ Amrsrican Dental Association ' REFERENCES 249.Kinlen L.Cancer incidence in relationto fluoride level 267.Martin GR,Brown KS,Singer L,Ophaug R,Jacobson-, in water supplies.Br Dent J.1975;138(6):221=4. • .Kram D:-Cytogenic and mutagenic assays-on fluoride. 250.Galletti"PM,doyet G.Effect of fluorine on;ttiyroidal In:Fluorides,effects on vegetation,animals and • iodine metabolism in.hyperthyroidism.J Clin_ Endo- • hurrians•Schupe JL,Peterson HB Leone NC,eds.Salt crinology.`1958.18:1102-10. Lake City:.Paragon Press;1983:271-80. - 251- Britannica Concise Encyclopedia.Pineal gland.Available 268.Mai-tin GR,Brown KS,Matheson DW,Lebowitz H, at<http://www.britannica.com/ebc/article?tocld=9375298 Singer L;Ophaug R.Lack of cytogenetic effects in - &query=pineal%20gland&ct=>.Accessed December 29, mice or mutations in salmonella receiving sodium 2004. , fluoride.Mutat Res 1979;66:159-67. 252.Luke).Fluoride deposition in the aged human pineal 269.Li Y Dunipace.AJ,Stookey GK.Absence of mutagenic ' gland_Caries Res 2001;35:125-28. ' V and antimutagenic activities of fluoride_in Ames - 253.Schlesinger ER,Overton DE,Chase HC,Cantwell . salmonella assays.Mutut Res 1987;120:229-36. , KT Newburgh-Kingston caries-fluorine study XIII:- 270.Tong CC,McQueen CA,Brat SV,Williams G_M.The . pediatric'findings after ten years.J Am Dent Assoc lack of genotoxicity of sodium fluoride in a battery of , 1956;52:296=306. - . cellular tests.Cell Biol Toxicol'1988;4(2):173-86. . • . 254.Challacombe SJ.Does fluoridation harm:immune 27.1.Freni SC.Exposure to high fluoride concentra- , function?Comm Dent Health 1996;13(Supp1 2):69771: • tions in drinking water is associated with decreased ' 255.US Department of Health and Human Services, • birth rates.J Toxicology and Environmental Health ' Centers for Disease Control,Dental Disease - 1994;42:109-21. . - Prevention Activity.Update of fluoride/acquired" - - 272.Thomas Sinks,Ph.D.,personal communication, . , immunodeficiencysyndrome(AIDS)allegation.Pub. November 6,1992. - No.FL-133:Atlanta June 1987. - - - 273.Lowry R,Steen N,Rankin J.Water fluoridation,still- v. 256.World Health Organization.Fluorine and fluorides: births,and congenital abnormalities.J Epidemiol • environmental health criteria 36.Geneva,Switzer- Comm Health 2003;57(7):495-500. land;1984. . - . • -- ' 257.Schlesinger E.Health studies in areas of the USA 274.Rapaport I.Contribution a 1'etude de mongolisme: with controlled water fluoridation.In:Fluorides.and : 140:5229-319-31 role enique de fluor.Bull Aced M(Paris) 1953; . . human'health.World Health Organization Monograph , Series No;59.Geneva;1970:305-10. ' ' 275.Rapaport I.Oligophrenic mongolienne et caries 258.Kram D,Schneider EL,Singer L,Martin GR. The - dentairs:Rev Stomatol Chir Maxillofac 1963;46:207-18. .' effects of high and low fluoride diets on thefirequen- 276.Berry WT Study of the incidence of mongolism in cies of sister chromatid exchanges.Mutat Res relation to the fluoride content of water.Am J Ment • 1978;57:51-5. - . Def 1958;62:634-6. " 259.Li Y,Dunipace AJ,Stookey GK.Lack of genotoxic 277.Needleman BL,Pueschel SM,Rothman KJ.Fluoride- effects of fluoride in the mouse bone marrow micro- tion and the occurrence of Down's Syndrome--New nucleus test.J Dent Res 1987;66(11):1687-90. - Eng J Med 1974;291:821-3. • 260.Li Y,Dunipace AJ,Stookey GK.Effects offluoride 278.Erickson JD,Oakley GP Jr.,Flynt JW Jr.,Hay S.Water on the mouse sperm morphology test.J=Dent Res fluoridation and congenital malformations:no asso- 1987;66(9):1,509-11. • - ' elation.J Am Dent Assoc 1976;93:981-4: - 261.Zeiger E,Galati DK,Kaur F Mohamed AH,Revazova 279.Knox EG,Armstrong E,Lancashire R.Fluoridation J,Deaton TG.Cytogenetic studies of sodium-fluoride 'and the prevalence of congenital malformations. in mice.Mutagenesis 1994;9(5):467=71. Comm Med 1980;2:190:4. 262.Li Y,Heerema NA,Dunipace AJ,'Stookey GK.Geno-. 280.Erickson JD_Down syndrome,water fluoridation and toxic effects of fluoride evaluated by sister-chromatid maternal age..Teratol.1980;21:177-80. exchange Mutat Res 1987;192:191-201. "- . 281.Mullenix PJ,Denbesten'PK,Schunior A,Kernan WJ. 263.Dunipace AJ,Zhang W,Noblitt TW,Li V'Stookey GK. Neurotoxicity of sodium fluoride in rats.Neurotoxicol Genotoxic evaluation of chronic fluoride exposure: Teratol 1995;17(2):169-77. micronucleus and sperm morphology studies.J Dent ' Res 1989;68(11):1525-8. 282.Ross JF,Duston GR Neurotoxicology and Teratology 1995;17(6):685-6.Letter to the editor.. 264. Li V.Zhang W,Noblitt TW,Dunipace AJ,Stookey GK.Genotoxic evaluation of chronic fluoride expo., 283.Shannon FT Fergusson DM,Horwood LJ.Exposure sure:sister-chromatid exchange study.Mut-Res' .to fluoridated public water supplies and child health 1989;227:159 65: and behaviour.N Z Med J 1986;99(803):416-8. 265.Obe G,Slacik-Erben R.Suppressive activity by fluo- 284.Masters R.Estimated cost of increased prison popula- ride on the induction of chromosome aberrations in tion predicted to result from use of silicofluorides in human cells and alkylating agents in vitro.Mutat Res Palm Beach County. Presented to Palm Beach County ' 1973;19:369-71. - Commission,August 26,2003. . - 266.Slacik-Erben R,Obe G.The effect of sodium fluoride 285.Urbansky ET,Schock MR.Can fluoridation affect on DNA synthesis,mitotic indices and chromosomal leed(II)in potable water?Hexafluorosilicate and aberrations in human.leukocytes treated with Tremni- fluoride equilibria in aqueous solution.Int J Environ mon in vitro.Mutat Res 1976;37:253-66. Studies 2000;57:597-637. :,, . Fluoridation Facts 65 , 286.Centers for Disease Control'and Prevention _ • 303.NSF International Standard 60-2002.Drinking"water. Surveillance for elevated blood lead levels" . treatment chemicals-health effects.NSF Interne-among children-United States,1997-2001.MMWR: tional,Ann Arbor,M1;2002. . 2003;52(SS10):1 21: ., 304, NSF International Standard 61-2002.Drinking water -. • 287.Centers for Disease Control and Prevention.Adult. - system components:-health effects.NSF International, blood lead epidemiology and surveillance-United Ann Arbor,MI,2002. - States,1998-2001.MMWR 2002;51(SS11):1710.- 305.DeEds F,Thomas JO.Comparative chronic toxicities 288.Alzheimer's Disease Education&Referral Center. of fluorine compounds.Proc Soc Exper Biol and Med Causes:what causes AD? Available at<http://www. 1933-34;31:824-5. -- alzheimers.org/causes.htm>.Accessed May 6,2005. 306.McClure FJ.A review of fluorine and its physiological' - 289.Varner JA,Jensen KF,Horvath W,Isaacson RL 4: . effects_Phys Reviews 1933;13:277-300. - • . Chronic administration of aluminum-fluoride.or., 307.McClure FJ.Availability of fluorine in sodium fluo- sodium-fluoride to rats,in drinking water:alterations ride vs.sodium fluosilicate.Public Health Rep in neuronaland cerebrovascular.integrity.Brain Res 1950;65(37):1175-86. 1998,784.284 98. 308;Zipkin I,Likins RC,McClure FJ,Steere AC:Urinary, , ' _ 290.American Dental Association.Health.Media Watch: ` fluoride levels associated with the'use of fluoridated - Study linking-luoride and Aliheimer's underscrutiny water.Public Health Rep 1956;71:767-72. - " • J Am Dent Assoc 1998;129:1216-8. 309.Zipkin I,Likiris RC.Absorption of various fluoride ' 291.Kraus AS,Forbes WF.Aluminum,fluoride and the _ compounds from the gastrointestinal tract of the rat. ' prevention of Alzheimer's Disease.Can J,Public Amer J Physical 1957;191:549-50. . Health 1992;83(2):97-100. 310.McClure FJ,Zipkin I.Physiologic effects of fluoride ' - 292. US Department of Health,Education and Welfare,. ' as related to Water fluoridation.Dent Clin N Am National Institutes of Health,Division of Dental 1958:441-58_ - Health_Misrepresentation of statistics•on heart 311_Crisp MR Report of the Royal Commissioner into the deaths in Antigo,Wisconsin Pub:No::PPB-47. Bethesda;Noverriber 1972. fluoridation of public water supplies:Hobart;?rima- nia,Australia:Government Printers:1968. - 293..American Heart Association.Minerals and inorganic 312..Myers DM;Plueckhahn VD,Rees ALG.Report of the • ' substances:-fluoridation.Available at<http://www. committee of inquiry into fluoridation of victorian americanheart.org/presenter.jhtml?identifier=4698>. 'water supplies.1979-80 Melbourne,Victoria,Australia, Accessed May6,2005. - FD Atkinson,Government Printer;1980:115-25. • 294.American Heart Association.Risk factors and 313.Ad Hoc Committee for the U.S.Surgeon General ' . coronary heart disease.Available at<http://www. Koop,Shapiro JR,Chairmen.Report to the Environ- americanheart.org/presenter.jhtml?identifier=4726>. - mental Protection Agency on the medical(non-dental) Accessed May 6,2005. effects of fluoride in drinking water. 1983:1-9. - 295.Geever EF,Leone NC,Geiser F Lieberman J.Patho- 314.Hodges A,Philippakos E,Mulkey D,Spreen T; - logic studies in man after prolonged ingestion of- Murraro R.Economic impact of Florida's citrus Indus- fluoride in drinking water I:necropsy findings in a try,1999-2000.Gainesville,University of Florida,.: " community with a water level of 2.5 ppm.J Am Dent • Institute of Food and•AgriculturalSciences.Available • Assoc 1958;56:499-507. -• at<http://edis.ifas.ufl.edu/BODY_FE397>.rAccessed 296.US Department of Health and Human Services,Public April 18,2005, Health'Service.Stireon.Generai's advisory:treat-- -315.Centers for Disease Control and Prevention.Engineer- ment of water for use in dialysis:artificial kidney ing and administrative recommendations for water treatments.Washington,DC:Government Printing - fluoridation,1995.MMWR 1995;44(No.RR-13). Office 872-021;June 1980. 316.Master R,Caplan MJ.Water treatment with 297.Centers for Disease Control.Fluoride in a dialysis silicofluoride_and lead toxicity.IntJ Environ . unit-Maryland.MMWR 1980;29(12):134-6. Studies1999;56:435-49. 298.51 Fed.Reg_11410,11412(April 2,1986). 317.U.S.Environmental Protection Agency.Consumer fact sheet On lead.Available at<http://www.epa.gov/ 299.Environmental Protection-Agency.Safe Drinking . • safewater/lcrmr/lead.html>:Accessed on.Mey 8,2005. Water Act.Basic Information.Available at<http:// www.epa.gov/safewater/sdwa/basicinformation.. 318.LIS.Environmental Protection Agency.Arsenic in '• html>.Accessed May 8,2005. drinking`water w. Available et<http://wwepe.gov/safe- water/lcrmr/lead.html>.Accessed on May 8,2005. . 300.American Water Works Association.Who we are. - • ' Available at<http://www.awwa.org/A'bout/>.Accessed 319. Personal correspondence.Stan Hazan..General February 18;2005_ manager,Drinking Water Additives Certification - Program,NSF Intemational to David Spath,California 301. National Sanitation Foundation International.About - Department of Health Services,Office of Drinking Water. ' NSF.Available at<http://www.nsforg/business/about_ • March 30,2000.Available at<iittp://www.dentaihealth- NSF/>_ Accessed February 18,2005. foundation.org/documents/NSFLetter.pdf>.Accessed on 302.American National Standards Institute.About ANSI May 8,2005:- - overview.Available at<http://www.ansi.org/about_ 320.U.S.Environmental Protection Agency,Office of - ansi/overview/overMiew.aspx?menuid=1>.Accessed - Water,Office of Science and Technology_Fluoride: February 18,2005. - 'a regulatory fact sheet. 66' American Dental Association ,t, .4ti:4•,7- n.1 REFERENCES: E • • • 4 Statements from Five Leading Health .Organizations Regarding Community Water Fluoridation AMERICAN DENTAL ASSOCIATION(ADA) U.S.SURGEON GENERAL "The Association endorses community water fluoridation "A significant advantage of water fluoridation is that as a safe, beneficial and cost-effective public health all residents of a community can enjoy its protective measure for preventing dental caries. This support has benefit at home, work, school or play – simply by been the Association's policy since 1950." drinking fluoridated water or' beverages and foods —ADA Operational Policies and Recommendations prepared with it...Water fluoridation is a powerful Regarding Community Water Fluoridation strategy in our efforts to eliminate differences in health (Trans.1997:673). among people and is consistent with my emphasis on the importance of prevention...Fluoridation is the single CENTERS FOR DISEASE CONTROL most effective public health measure to prevent tooth AND PREVENTION (CDC) decay and improve oral health over a lifetime, for both "During the 20th century, the healthand life expectancy children and adults. of persons residing in the United States improved While we can be pleased with what has already been dramatically. To highlight these advances, MMWR will accomplished,it is clear that there is much yet to be done. profile 10 public health achievements in a series of reports Policymakers, community leaders, private industry, published through December 1999 (Fluoridation of health professionals, the media, and the public should drinking water was chosen as one of these achievements affirm that oral health is essential to general health and profiled in the October 22,1999 MMWR).Fluoridation and well being and take action to make ourselves, our safely and inexpensively benefits both children and families, and our communities healthier. l join previous adults by effectively preventing tooth decay, regardless Surgeons General in acknowledging the continuing of socioeconomic status or access to care. Fluoridation public health role for community water fluoridation in has played an important role in the reductions in tooth enhancing the oral health of all Americans." decay (40%-70% in children) and of tooth loss in adults —Surgeon General Richard H.Carmona,Statement (40%-60%)." on Community Water Fluoridation, —CDC,Morbidity and Mortality Weekly Report. July 28,2004. "Ten Great Public Health Achievements-United States 1900-1999" April 1999. NATIONAL INSTITUTE OF DENTAL &CRANIOFACIAL RESEARCH (NIDCR) "The National Institute of Dental and Craniofacial AMERICAN MEDICAL ASSOCIATION(AMA) Research continues to support water fluoridation as a "The AMA recognizes the important public health safe and effective method of preventing tooth decay in benefits of drinking properly fluoridated water and people of all ages. Community water fluoridation is a encourages its member physicians and medical societies public health effort that benefits millions of Americans. to work with local and state health departments, dental For more than half a century, water fluoridation has societies, and concerned citizens to assure the optimal helped improve the quality of life in the U.S. through fluoridation of community drinking water supplies." reduced pain and suffering related to tooth decay, —AMA Letter to the American Dental Association, reduced tooth loss, reduced time lost from school and March 10, 1995. work,and less money spent on dental care." — NIDCR: Statement on Water Fluoridation, June 2000. 68 American Dental Association r • i - r x •. f x "f e.� . r.:t£' • Y , ♦. . •s•6` ."• • .- '/ ''r - , r . i • • • .. .et • ;.Yx a r. . e. • . COMPENDIUM National and International Organizations Association of State and Territorial Health Officials That Recognize the Public Health Benefits of Association of State and Territorial Public Health Nutrition Directors Community Water Fluoridation for Preventing Dental DecayBritish Fluoridation Society Canadian Dental Association Academy of Dentistry International Canadian Dental Hygienists Association Academy of General Dentistry Canadian Medical Association • Academy for Sports Dentistry Canadian Nurses Association Alzheimer's Association Canadian Paediatric Society America's Health Insurance Plans Canadian Public Health Association American Academy of Family Physicians Child Welfare League of America American Academy of Nurse Practitioners Children's Dental Health Project American Academy of Oral and Maxillofacial Pathology Chocolate Manufacturers Association American Academy of Orthopaedic Surgeons Consumer Federation of America American Academy of Pediatrics Council of State and Territorial Epidemiologists American Academy of Pediatric Dentistry • Delta Dental Plans Association American Academy of Periodontology FDI World Dental Federation • American Academy of Physician Assistants Federation of American Hospitals American Association for Community Dental Programs Hispanic Dental Association American Association for Dental Research Indian Dental Association(U.S.A.) American Association for Health Education Institute of Medicine American Association for the Advancement of Science International Association for Dental Research American Association of Endodontists International Association for Orthodontics American Association of Oral and Maxillofacial Surgeons International College of Dentists American Association of Orthodontists March of Dimes Birth Defects Foundation American Association of Public Health Dentistry National Association of Community Health Centers American Association of Women Dentists National Association of County and City Health Officials American Cancer Society National Association of Dental Assistants American College of Dentists National Association of Local Boards of Health American College of Physicians—American Society National Association of Social Workers of Internal Medicine National Confectioners Association American College of Preventive Medicine National Council Against Health Fraud American College of Prosthodontists National Dental Assistants Association American Council on Science and Health National Dental Association American Dental Assistants Association National Dental Hygienists'Association American Dental Association National Down Syndrome Congress American Dental Education Association National Down Syndrome Society American Dental Hygienists'Association National Eating Disorders Association American Dietetic Association National Foundation of Dentistry for the Handicapped American Federation of Labor and Congress National Head Start Association of Industrial Organizations National Health Law Program American Hospital Association National Healthy Mothers,Healthy Babies Coalition American Legislative Exchange Council National Kidney Foundation • American Medical Association Oral Health America American Nurses Association Robert Wood Johnson Foundation American Osteopathic Association Society for Public Health Education American Pharmacists Association Society of American Indian Dentists American Public Health Association Special Care Dentistry American School Health Association Academy of Dentistry for Persons with Disabilities American Society for Clinical Nutrition American Association of Hospital Dentists American Society for Geriatric Dentistry American Society for Nutritional Sciences The Children's Health Fund American Student Dental Association The Dental Health Foundation(of California) American Veterinary Medical Association U.S.Department of Defense American Water Works Association Association for Academic Health Centers U.S.Department of Veterans Affairs U.S.Public Health Service Association of American Medical Colleges Centers for Disease Control and Prevention(CDC) Association of Clinicians for the Underserved National Institute of Dental and Craniofacial Research(NIDCR) Association of Maternal and Child Health Programs World Federation of Orthodontists Association of State and Territorial Dental Directors World Health Organization The list above was current at the time Fluoridation Facts went to press.As organizations and entities continue to be added to the Compen- dium,the most current Compendium can be viewed on ADA.org at htta://www.ada.org/goto/ffcompendium. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Compendium in its entirety,without modification.To request any other copyright permission please contact the American Dental Association at 1-312-440-2879. Fluoridation Facts 69 RENTON CITY COUNCIL Regular Meeting September 24, 2012 Council Chambers Monday, 7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the • Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER, Council President; GREG TAYLOR; RANDY CORMAN; MARCIE COUNCILMEMBERS PALMER; DON PERSSON; ED PRINCE;TERRI BRIERE. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; LAWRENCE J. WARREN,City Attorney;JASON SETH, Deputy City Clerk; NANCY CARLSON, Human Resources& Risk Management Administrator; CHIP VINCENT, Community and Economic Development Administrator;TERRY HIGASHIYMA, Community Services Administrator; GREGG ZIMMERMAN, Public Works • Administrator; PETER RENNER, Facilities Director; KELLY BEYMER, Parks&Golf Course Director;SONJA MEJLAENDER, Community Relations& Events Coordinator; COMMANDER KATIE MCCLINCY, Police Department. SPECIAL PRESENTATION Community Relations and Events Coordinator Sonja Mejlaender presented a Community Services: Renton report for the 27th Anniversary of Ikea Renton River Days which ran from July River Days Wrap-Up 27 to 29. She shared a new video marketing the event,and stated that this year's theme was"Duck into Fun." She summarized event costs from 2007 to 2012,and noted that the overall cost to the City varies year-to-year dependent upon the features for that year's festival. Ms. Mejlaender introduced Parks& Golf Course Director,and festival board member, Kelly Beymer. Ms. Beymer reported that the annual kick-off event was held at the Luther's Table restaurant in downtown Renton. She remarked that the kick-off festival also included the Duck Hunt III,explaining that there were 30 rubber ducks that were in host locations in the Highlands and Cascade neighborhoods, the Rainier Ave. corridor,and downtown areas. She added that participants had to donate non-perishable food items at the food bank booth to receive their final stamp. Ms. Beymer summarized festival highlights and new activities like the alternative energy car show, and a surprise 40-person flash mob dance routine. She noted that all of the activities and events for children are free. Ms. Beymer recognized event sponsors and highlighted attractions including the Wenatchee Youth Circus, Lee's Martial Arts Break-A-Thon fundraiser that raised $15,300 for Communities in Schools of Renton;the art market,quilt exhibit,400 performing artists,and the 27th Annual Teen Summer Musical,"Guys and Dolls." She also reported that Renee Hart was recognized for her multi-year volunteer service helping to operate the two entertainment stages. Ms. Beymer reported that the Renton Rotary Club raised$21,000 for local charities by selling 4,300 rubber ducks for the annual Rubber Ducky Derby. Ms. Beymer also reported that there were 121 entries, and 2,466 participants in the River Days parade. She noted that Renton businessman and philanthropist Bob Bridge was the parade's Grand Marshal. September 24,2012 Renton City Council Minutes _ Page 265 61 Concluding, Ms. Beymer reported that 99%of those surveyed stated that they would attend the event again. She thanked the volunteers,service clubs,youth and faith groups, and City employees who helped make the event a success. She also thanked all of the sponsors and pointed out that Ikea is confirmed to be the title sponsor for 2013. Mayor Law remarked that year-after-year Renton River Days draws thousands of people to Renton. He expressed gratitude to the sponsors,festival board members,and volunteers who contributed to the success of the event. He also remarked that not only did everyone have a good time, but$80,000 was raised that went back into the community. ADMINISTRATIVE REPORT Chief Administrative Officer Jay Covington reviewed a written administrative report summarizing the City's recent progress towards goals and work programs adopted as part of its business plan for 2012 and beyond. Item noted included: * Thousands of transit riders will see changes to their King County Metro bus routes starting September 29. These revisions include the start of the Metro RapidRide C and D lines,five new bus routes,two re-numbered routes, 17 discontinued routes and changes to over 50 other routes. Metro routes within the City of Renton will not be impacted by any of these service changes. Also,the Ride Free Area in downtown Seattle will end and passengers will be required to pay on entry for all trips in King County. Route changes and Metro's online trip planner can be accessed by visiting the King County website. Transportation: Projects Public Works Administrator Gregg Zimmerman reported that currently there Update are over$40 million in transportation projects being constructed on City streets. He stated that the Rainier Ave.S. project is the largest of the projects and is on time and on budget, and should be completed by early 2014. He pointed out that anyone who wishes to view detailed information about any of the projects can visit the City's website. Mr.Zimmerman also reported that the Garden Ave./S. Lake Washington Blvd. intersection project is at 55%completion at this time. He indicated that intersection repaving has been completed,and the project should be finished by early November. He remarked that this project is also on time and on budget. Mr.Zimmerman added that the traffic signal installation project at NE 4th St. and Whitman Ave.NE has commenced and should be completed by early 2013. Responding to Council inquiries, Mr.Zimmerman stated that updated photographs, computer assisted graphics, and other details will be posted to the City's website in order to provide citizens with an idea of what the completed projects will look like. He remarked that projected travel time improvements will also be included on the City's website. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 9/17/2012. Council concur. 9/17/2012 MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. September 24,2012 Renton City Council Minutes Page 266 UNFINISHED BUSINESS Utilities Committee Chair Taylor presented a report recommending forwarding Utilities Committee the issue of water fluoridation to the Committee of the Whole for a Utility: Water Fluoridation presentation from City staff and the proponent. • MOVED BY TAYLOR,SECONDED BY CORMAN, COUNCIL CONCUR IN THE �S 1 COMMITTEE REPORT.* t ilk?/' - Councilmember Taylor explained that in 1984 a petition to fluoridate the City's lY water supply was brought forth by a citizens group. He stated that the issue was put on the ballot and residents voted to add fluoridation to the water supply. Mr.Taylor further explained that the Committee has learned that Council has the authority to change that decision without going back to the voters. He indicated that the full Council should hear the arguments regarding this topic before a recommendation is made. *MOTION CARRIED. EXECUTIVE SESSION & MOVED BY ZWICKER,SECONDED BY PRINCE,COUNCIL RECESS INTO EXECUTIVE ADJOURNMENT SESSION FOR APPROXIMATELY 30 MINUTES TO DISCUSS LABOR NEGOTIATIONS (RCW 42.30.140.4.a.)WITH NO OFFICIAL ACTION TO BE TAKEN AND THAT THE COUNCIL MEETING BE ADJOURNED WHEN THE EXECUTIVE SESSION IS ADJOURNED. CARRIED. Time: 8:09 p.m. Executive session was conducted. There was no action taken. The executive sess7 and the Co it eeting adjourned at 8:07 p.m. I( J/ J a n Seth, Deputy City Clerk Jason Seth, Recorder September 24, 2012 RENTON My COUNCIL COMMITTEE MEETING rAI.ENDAR Office of the City Clerk COUNCIL COMMITTEE MEETINGS SCHEDULED AT CITY COUNCIL MEETING September 24, 2012 COMMITTEE/CHAIRMAN DATE/TIME AGENDA COMMITTEE OF THE WHOLE MON., 10/1 Impact Fees Update (Zwicker) 5:45 p.m. . COMMITTEE OF THE WHOLE MON., 10/1 Meet& Greet with Renton School District (Zwicker) 6 p.m. *7TH FLOOR CONFERENCING CENTER* COMMUNITY SERVICES (Palmer) FINANCE MON., 10/1 Vouchers; (Briere) 5:15 p.m. Emerging Issues in Revenue Streams • PLANNING & DEVELOPMENT THURS., 9/27 Galloway at the Highlands Final Plat (Prince) 3 p.m. Permit Fees Appeal *Council Chambers* PUBLIC SAFETY MON., 10/1 CANCELED (Persson) TRANSPORTATION (AVIATION) THURS., 9/27 CANCELED (Corman) UTILITIES (Taylor) NOTE: Committee of the Whole meetings are held in the Council Chambers unless otherwise noted. All other committee meetings are held in the Council Conference Room unless otherwise noted. July 9, 2012 Renton City Council Minutes Page 205 Citizen Comment:Adams- Audrey Adams(Renton)stated that she had provided Council with a summary Fluoridated Water of 92 studies questioning the safety of fluoridated water. She explained the concept of the precautionary principle, and stated that if the principle was applied to the issue of fluoridated water,the significance of this issue would be elevated. Ms.Adams also shared information regarding a court case involving a union scientist who was fired from the Environmental Protection Agency(EPA) because he believed fluoride to be unsafe. She noted that he won the case and was able to win his job back. MOVED BY TAYLOR,SECONDED BY CORMAN, COUNCIL ALLOW MS.ADAMS A FEW ADDITIONAL MINUTES TO CONCLUDE HER COMMENTS. CARRIED. Concluding, Ms.Adams acknowledged that there are opposing views on this topic, but remarked that she has nothing to gain except knowing that she believes she is doing the right thing by informing Council of the issue. She added that the precautionary'principle would set a higher standard than just proving that something is unsafe, and should be applied since the City is using public water as an avenue to introduce a drug to the population. Councilmember Corman remarked that Council is listening to Ms.Adams' concerns,and that information regarding fluoride has changed immensely over the past 30;years. He stated that he believes this is an issue that should probably go back to the voters at some time in the future. Council President Zwicker remarked that, as mentioned by Ms.Adams,there are two sides to the issue,and that he believes changes can be made without going back to the voters. He suggested that a briefing to the Utilities Committee would provide an opportunity for Ms.Adams to present her /e) `��° information in a precise manner, and it would also give City staff an opportunity �( U"`� to weigh-in on the topic. ,kel l e5 MOVED BY ZWICKER,SECONDED BY TAYLOR, COUNCIL REFER THE TOPIC OF FLUORIDATION TO THE UTILITITES COMMITTEE. CARRIED. Councilmember Palmer requested that the Committee of the Whole be briefed on the topic after the Utilities Committee had reviewed the issue. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 6/25/2012. Council concur. 6/25/2012 City Clerk: 2012 Population City Clerk reported the official population of the City of Renton as of 4/1/2012 to be 93,910 as calculated by the State of Washington Office of Financial Management. Information. CAG: 12-081,2012 Street City Clerk reported bid opening on 6/26/2012 for CAG-12-081, 2012 Street Patch & Overlay with Curb Patch &Overlay with Curb Ramps project;four bids; engineer's estimate Ramps, Lakeside Industries $1,211,399.84; and submitted staff recommendation to award the contract to the low bidder, Lakeside Industries, in the amount of$1,272,052.20 along with Change Order#1 in the amount of-$145,926.49. The total amount of the contract after the change order will be$1,126,125.71. Refer to Transportation (Aviation) Committee. RENTON CITY COUNCIL Regular Meeting July 9, 2012 Council Chambers Monday, 7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER, Council President; GREG TAYLOR; RANDY CORMAN; MARCIE COUNCILMEMBERS PALMER; DON PERSSON; ED PRINCE;TERRI BRIERE. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; MARK BARBER,Senior Assistant City Attorney; BONNIE WALTON, City Clerk; CHIP VINCENT, Community and Economic Development Administrator; GREGG ZIMMERMAN, Public Works Administrator; IWEN WANG,Administrative Services Administrator; FIRE& EMERGENCY SERVICES ADMINISTRATOR MARK PETERSON and DEPUTY CHIEF ERIK WALLGREN, Fire&Emergency Services Department; COMMANDER DAVE LEIBMAN, Police Department. AUDIENCE COMMENT Lori Madson (Renton)shared her history of working to achieve a city-wide Citizen Comment: Madson- fireworks ban. She remarked that due to budget cuts the Fire and Police Enforcement of City-Wide departments are no longer able to effectively enforce the ban. Ms. Madson Fireworks Ban emphasized that the City has a zero-tolerance policy regarding fireworks,and requested the number of fireworks-related citations written for this year and the previous two years. Mayor Law acknowledged that there are limited resources for enforcing the ban, and asked Fire&Emergency Services Administrator Mark Peterson to summarize the department's response to this year's Fourth of July event. Discussion ensued regarding whether or not lighting a large explosive device is a felony, and police officer comments regarding enforcement strategies. Councilmember Corman requested that the administration address Ms. Madson's concerns regarding fireworks ban violations and police officer comments. Fire & Emergency Services Administrator Mark Peterson reported that the department worked with Valley Communications in preparation of the increase in calls for service due to fireworks complaints. He emphasized that the department has limited resources and had to use on-duty fire apparatuses and personnel. He added that all five Fire Inspectors were on duty that night,and they made 47 contacts,confiscated over 50 pounds of fireworks,and issued one$100 and five$500 citations. Chief Peterson reported that while the enforcement efforts were on-going the department also responded to over 136 calls for service including,five motor vehicle accidents,five automatic fire alarm calls,a water craft rescue, 22 Emergency Medical Services responses, and five medic responses. Concluding,Chief Peterson reported that there were no fireworks injuries or loss or damage due to fireworks within Renton city limits. He noted that although there were some fireworks set off within the city,the offenders were usually gone before the Fire Department could get to their location. RENTON CITY COUNCIL COMMITTEE MEETING I AIENDAR Office of the City Clerk COUNCIL COMMITTEE MEETINGS SCHEDULED AT CITY COUNCIL MEETING July 9, 2012 COMMITTEE/CHAIRMAN DATE/TIME AGENDA COMMITTEE OF THE WHOLE MON., 7/16 Business Plan; (Zwicker) 5 p.m. Council Communications *7TH FLOOR CONFERENCING CENTER* COMMUNITY SERVICES MON., 7/16 2012 Neighborhood Grants (second (Palmer) 4:30 p.m. round) FINANCE MON., 7/16 Vouchers; (Briere) 3:30 p.m. Emerging Issues in Revenue Streams; Utility Billing Adjustment Request from Milt's Trucking; Utility Billing Adjustment Request from J&J Renton LLC PLANNING & DEVELOPMENT THURS, 7/12 Title IV (Development Regulations), (Prince) 3:30 p.m. Docket#8 PUBLIC SAFETY MON., 7/16 CANCELED (Persson) TRANSPORTATION (AVIATION) THURS., 7/12 2012 Street Patch & Overlay Project Bid (Corman) 4:30 p.m. Award; Taxiway Bravo Contract with Reid Middleton; Emerging Issues in Transportation UTILITIES (Taylor) NOTE: Committee of the Whole meetings are held in the Council Chambers unless otherwise noted. All other committee meetings are held in the Council Conference Room unless otherwise noted. July 9, 2012 Renton City Council Minutes Page 206 Finance: Utility Billing Administrative Services Department submitted a request from Milt's Trucking Adjustment, Milt's Trucking for a utility billing adjustment due to a water leak and recommended granting the adjustment in the amount of$2,769.95. Refer to Finance Committee. Finance: Utility Billing Administrative Services Department submitted a request from J&J Renton, LLC Adjustment,J&J Renton LLC for a utility billing adjustment due to a water leak and recommended granting the adjustment in the amount of$15,150.89. Refer to Finance Committee. Community Services: 2012 Community Services Department reported submission of one grant application Neighborhood Grant Program for the 2012 Neighborhood Grant Program (second round), and recommended granting the project in the amount of$17,202. Refer to Community Services Committee. Airport:Taxiway Bravo Transportation Systems Division recommended approval of a contract with Reid Rehabilitation, Reid Middleton Middleton, Inc. in the amount of$215,742 for construction management and inspection services for the Taxiway Bravo Rehabilitation project. Refer to Transportation (Aviation)Committee. Airport: Maintenance Transportation Systems Division recommended approval of a grant agreement Dredging&Shoreline with the Washington State Department of Transportation to accept$50,000 for Mitigation,WA Transportation the Maintenance Dredging and Shoreline Mitigation project. Council concur. Grant MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Finance Committee Chair Briere recommended approval of Claim Vouchers Finance:Vouchers 312972-313239,four wire transfers,and one payroll run with benefit withholding payments totaling$3,529,855.76, and payroll vouchers including 766 direct deposits and 158 payroll checks totaling$1,610,612.17. MOVED BY BRIERE,SECONDED BY CORMAN, COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. . NEW BUSINESS MOVED BY PERSSON,SECONDED BY ZWICKER, COUNCIL REFER THE TOPIC OF Police:Social Media Policy SOCIAL MEDIA IN THE POLICE DEPARTMENT TO THE PUBLIC SAFETY COMMITTEE. CARRIED. Community Event:South Councilmember Palmer announced that she had attended the South County County Council of Human Council of Human Services annual luncheon two weeks ago. She remarked that Services Annual Luncheon Councilmember Taylor was awarded the Human Services and Equity Award for an Individual, and Luther's Table,a Renton restaurant,was awarded a President's Award. Community Event: Boy Scout Mayor Law recognized the scouts of Boy Scout Troop 438 of Bellevue who were Troop 438 in the audience. ADJOURNMENT MOVED BY PRINCE, SECONDED BY ZWICKER, COUNCIL ADJOURN. CARRIED. Time: 7:30 p.m. )efl4V t:d. Gtiater,-- Bonnie I.Walton,CMC,City Clerk Jason Seth, Recorder July 9, 2012 aaki -.4f2A-2 Of 7-9-ga1.2 From: Jay B Covington Sent: Monday, July 09, 2012 7:24 PM To: Ed Prince; Terri Briere; Randy Corman; Rich Zwicker; Don Persson; Greg Taylor; Marcie Palmer; Denis Law Cc: Bonnie Walton; Julia Medzegian; Gregg A. Zimmerman; Lys L. Hornsby; Preeti Shridhar Subject: Fw: Fluoridation-Precautionary Principle& EPA Union Opposition Attachments: 2012 7-09+Renton Council Ltr&Attachments 7-09-12.docx; 2012 7-09 EPA's Professionals' Union Opposes Fluoridation 7-9-12.docx Follow Up Flag: Follow up Flag Status: Flagged Mayor and Council, Per Ms Adams request, I'm forwarding the attached information. Sent via my Blackberry(pardon the spelling errors) From: Audrey Adams To: Jay B Covington Cc: Lys L. Hornsby; Gregg A. Zimmerman Sent: Mon Jul 09 18:18:17 2012 Subject: Fluoridation - Precautionary Principle &EPA Union Opposition Mr. Covington, Please forward the attachments to the Council. Thank you! Audrey Adams 1 July 9,2012 Renton City Council Subject: Precautionary Principle & EPA Union Opposition Dear Renton City Council members and Mayor Law By now you have had a great deal of exposure from the anti-fluoridation perspective: And there has always been an abundance of views, particularly from our federal and state health agencies,that either enthusiastically support,or seem to support,artificial water fluoridation. So far, I have presented only a tiny fraction of the evidence of harm, putting the Council in the awkward position of listening to a mere mother and child advocate on scientific information that neither you nor me can be expected to fully understand. In the last weeks I have given you (not a complete list): 6/04 Testimony to Wash State Supreme Court describing my son's harm from fluoridated water 6/11 DVD video "Professional Perspectives on Water Fluoridation" Link to 4,000+Professional signers of"Professionals Statement Calling for End to Fluoridation" List of 130 Professional signers in Washington State who believe fluoridation is not safe 6/18 Comparison and toxicity descriptions of Calcium Fluoride vs.Sodium Fluoride Renton's MSDS sheet which outlines"Chronic Toxicity", "Health Rating"and a disclaimer 6/25 Dr. Bill Osmunson's document highlighting 92 referenced studies showing harm to the brain 7/2 Fact-finding email request to Lys Hornsby focusing on water quality testing&health outcomes 7/9 "EPA Headquarters Professionals' Union Opposes Fluoridation" May 1, 1999 Today I am sending only the above mentioned EPA Professionals' Union statement which ends stating, "The implication for the general public of these calculations is clear. Recent,peer-reviewed toxicity data, when applied to EPA's standard method for controlling risks from toxic chemicals, require an immediate halt to the use of the nation's drinking water reservoirs as disposal sites for the toxic waste of the phosphate fertilizer industry" Fortunately,we don't need to understand every detail of the effects of fluoridation,good and bad, because of the Precautionary Principle which is what I believe Council members would already embrace. "The precautionary principle or precautionary approach states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is harmful, the burden of proof that it is not harmful falls on those taking the action. This principle allows policy makers to make discretionary decisions in situations where there is the possibility of harm from taking a particular course or making,a certain decision when extensive scientific knowledge on the matter is lacking."(Wikipedia) Sincerely and appreciatively, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 Why EPA's Headquarters Professionals' Union Opposes Fluoridation National Treasury Employees Union - Chapter 280 May 1, 1999 Why EPA's Headquarters Professionals'Union Opposes Fluoridation by Dr. J. William Hirzy Senior Vice President, NTEU Chapter 280 The following documents why our union, formerly National Federation of Federal Employees Local 2050 and since April 1998 Chapter 280 of the National Treasury Employees Union, took the stand it did opposing fluoridation of drinking water supplies. Our union is comprised of and represents the approximately 1500 scientists, lawyers, engineers and other professional employees at EPA Headquarters here in Washington, D.C. The union first became interested in this issue rather by accident. Like most Americans, including many physicians and dentists, most of our members had thought that fluoride's only effects were beneficial = reductions in tooth decay, etc. We too believed assurances of safety and effectiveness of water fluoridation. For a history of how drinking water fluoridation began, see "Fluoride, Teeth and the Atomic Bomb", by investigative reporters Joel Griffiths and Chris Bryson. Then, as EPA was engaged in revising its drinking water standard for fluoride in 1985, an employee came to the union with a complaint: he said he was being forced to write into the regulation a statement to the effect that EPA thought it was alright for children to have "funky" teeth. It was OK, EPA said, because it considered that condition to be only a cosmetic effect, not an adverse health effect. The reason for this EPA position was that it was under political pressure to set its health-based standard for fluoride at 4 mg/liter. At that level, EPA knew that a significant number of children develop moderate to severe dental fluorosis, but since it had deemed the effect as only cosmetic, EPA didn't have to set its health-based standard at a lower level to prevent it. We tried to settle this ethics issue quietly, within the family, but EPA was unable or unwilling to resist external political pressure, and we took the fight public with a union amicus curiae brief in a lawsuit filed against EPA by a public interest group. The union has published on this initial involvement period in detail (1). Since then our opposition to drinking water fluoridation has grown, based on the scientific literature documenting the increasingly out-of-control exposures to fluoride, the lack of benefit to dental health from ingestion of fluoride and the hazards to human health from such ingestion. These hazards include acute toxic hazard, such as to people with impaired kidney function, as well as chronic toxic hazards of gene • mutations, cancer, reproductive effects, neurotoxicity, bone pathology and dental fluorosis. First, a review of recent neurotoxicity research results. In 1995, Mullenix and co-workers (2) showed that rats given fluoride in drinking water at levels that give rise to plasma fluoride concentrations in the range seen in humans. suffer neurotoxic effects that vary according to when the rats were given the fluoride - as adult animals, as young animals, or through the placenta before birth. Those exposed before birth were born hyperactive and remained so throughout their lives. Those exposed as young or adult animals displayed depressed activity. Then in 1998, Guan and co-workers (3) gave doses similar to those used by the Mullenix research group to try to understand the mechanism(s) underlying the effects seen by the Mullenix group. Guan's group found that several key chemicals in the brain - those that form the membrane of brain cells -were substantially depleted in rats given fluoride, as compared to those who did not get fluoride. . Another 1998 publication by Varner, Jensen and others (4) reported on the brain- and kidney damaging effects in rats that were given fluoride in drinking water at the same level deemed "optimal" by pro-fluoridation groups, namely 1 part per million (1 ppm). Even more pronounced damage was seen in animals that got the fluoride in conjunction with aluminum. These results are especially disturbing because of the low dose level of fluoride that shows the toxic effect in rats -rats are more resistant to fluoride than humans. This latter statement is based on Mullenix's finding that it takes substantially more fluoride in the drinking water of rats than of humans to reach the same fluoride level in plasma. It is the level in plasma that determines how much fluoride is "seen" by particular tissues in the body. So when rats get 1 ppm in drinking water, their brains and kidneys are exposed to much less fluoride than humans getting 1 ppm, yet they are experiencing toxic effects. Thus we are compelled to consider the likelihood that humans are experiencing damage to their brains and kidneys at the 'optimal' level of 1 ppm. In support of this concern are results from two epidemiology studies from China (5,6) that show decreases in I.Q. in children who get more fluoride than the control groups of children in each study. These decreases are about 5 to 10 I.Q. points in children aged 8 to 13 years. Another troubling brain effect has recently surfaced: fluoride's interference with the function of the brain's pineal gland. The pinealgland produces melatonin which, among other roles, mediates the body's internal clock, doing such things as governing the onset of puberty. Jennifer Luke (7) has shown that fluoride accumulates in the pineal gland and inhibits its production of melatonin. She showed in test animals that this inhibition causes an earlier onset of sexual maturity, an effect reported in humans as well in 1956, as part of the Kingston/Newburgh study, which is discussed below. In fluoridated Newburgh, young girls experienced earlier onset of menstruation (on average, by six months) than girls in non-fluoridated Kingston (8). From a risk assessment perspective, all these brain effect data are particularly compelling and disturbing because they are convergent. We looked at the cancer data with alarm as well. There are epidemiology studies that are convergent with whole- ti • animal and single-cell studies (dealing with the cancer hazard), just as the neurotoxicity research just mentioned all points in the same direction. EPA fired the Office of Drinking Water's chief toxicologist, Dr. William Marcus, who also was our local union's treasurer at the time, for refusing to remain silent on the cancer risk issue (9). The judge who heard the lawsuit he brought against EPA over the firingmade that finding _that EPA fired him over his fluoride work and not for the phony reason put forward by EPA management at his dismissal. Dr. Marcus won his lawsuit and is again at work at EPA. Documentation is available on request. The type of cancer of particular concern with fluoride, although not the only type, is osteosarcoma, especially in males. The National Toxicology Program conducted a two- year study (10) in which rats and micewere given sodium fluoride in drinking water: The positive result of that study (in which malignancies in tissues other than bone were also observed), particularly in male rats, is convergent with a host of data from tests showing fluoride's ability to cause mutations (a principal 'trigger' mechanism for inducing a cell to become cancerous) (e.g.11a, b,'c, d and data showing increases in osteosarcomas in young men in New Jersey 12, Washington and Iowa 13) based on their drinking fluoridated water. It was his analysis, repeated statements about all these and other incriminating cancer data, and his requests for an independent, unbiased evaluation of them that got,Dr. Marcus,fired. Bone pathology other than cancer is a concern as well. An excellent review of this issue was published by Diesendorf et al.. in 1997 (14). Five epidemiology studies have shown a higher.rate of hip fractures in fluoridated vs. non-fluoridated communities (15a, b, c, d, e). Crippling skeletal fluorosis was the endpoint used by EPA to set its primary drinking water standard in 1986, and the ethical deficiencies in that standard setting process prompted our union to join the Natural Resources Defense Council in opposing the standard in court, as mentioned above. Regarding the effectiveness of fluoride in reducing dental cavities, there has not been any double-blind study of fluoride's effectiveness as a caries preventative. There have been many, many small scale, selective publications on this issue that proponents cite to justify fluoridation, but the largest and most comprehensive study, one done by dentists trained by the National Institute of Dental Research, on over 39,000 school children aged 5-17 years, shows no significant differences (in terms of decayed, missing and filled,teeth) among caries incidences in fluoridated, non-fluoridated and partially fluoridated communities (16). The latest publication (17) on the fifty-year fluoridation experiment in two New York cities, Newburgh and Kingston, shows the same thing. the only significant difference in dental health between the two communities as a whole is that fluoridated Newburgh, N.Y. shows about twice the incidence of dental fluorosis (the first, visible sign of fluoride chronic toxicity) as seen in non-fluoridated Kingston. John Colquhoun's publication on this point of efficacy is especially important (18). Dr. Colquhoun was Principal Dental Officer for Auckland, the largest city in New Zealand, and a staunch supporter of fluoridation - until he was given the task of looking at the world-wide data on fluoridation's effectiveness in preventing cavities. The paper is titled, "Why I changed My Mind About Water Fluoridation." In it Colquhoun provides details on how data were manipulated to support fluoridation in English speaking countries, especially the U.S. and New Zealand. This paper explains why an ethical public health professional was compelled to do a 180 degree turn on fluoridation. Further on the point of the tide turning against drinking water fluoridation, statements are now coming from other dentists in the pro-fluoride camp who are starting to warn that topical fluoride (e.g. fluoride in tooth paste) is,the only significantly beneficial way in which that substance affects dental health (19, 20, 21). However, if the concentrations of fluoride in the oral cavity are sufficient to inhibit bacterial enzymes and cause other bacteriostatic effects, then those concentrations are also capable of producing adverse effects in mammalian tissue, which likewise relies on enzyme systems. This statement is based not only on common sense, but also on results of mutation studies which show that fluoride can cause gene mutations in mammalian and lower order tissues at fluoride concentrations estimated to be present in the mouth from fluoridated tooth paste (22). Further, there were tumors of the oral cavity seen in the NTP cancer study mentioned above, further strengthening concern over the toxicity of topically applied fluoride. In any event, a person can choose whether to use fluoridated tooth paste or not (although finding non-fluoridated kinds is getting harder and harder), but one cannot avoid fluoride when it is put into the public water supplies. So, in addition to our concern over the.toxicity of fluoride, we note the uncontrolled - and apparently uncontrollable - • exposures.to fluoride that are occurring nationwide via drinking water, processed foods, fluoride pesticide residues and dental care products. A recent report in the lay media (23), that, according to the Centers for Disease Control, at least 22 percent of America's children now have dental fluorosis, is just one indication of this uncontrolled, excess exposure. The finding of nearly 12 percent incidence of dental fluorosis among children in un-fluoridated Kingston New York (17) is another. For governmental and other organizations to continue to push for more exposure in the face of current levels of over- exposure coupled with an increasing crescendo of adverse toxicity findings is irrational and irresponsible at best. Thus, we took the stand that a policy which makes the public water supply a vehicle for disseminating this toxic and prophylactically useless (via ingestion, at any rate).substance is wrong. We have also taken a direct step to protect the employees we represent from the risks of drinking fluoridated water. We applied EPA's risk control methodology, the Reference Dose, to the recent neurotoxicity data The Reference Dose is the daily dose, expressed in milligrams of chemical per kilogram of body weight, that a person can receive over the long term with reasonable assurance of safety from adverse effects. Application of this methodology to the Varner et al.(4) data leads to a Reference Dose for fluoride of 0.000007 mg/kg-day. Persons who drink about one quart of fluoridated water from the public drinking water supply of the District of Columbia while at work receive about 0.01 mg/kg-day from that source alone. This amount of fluoride is more than 100 times the Reference Dose. On the basis of these results the union filed a grievance, asking that EPA provide un-fluoridated drinking water to its employees. • The implication for the general public of thesecalculations is clear. Recent, peer- reviewed toxicity data, when applied to EPA's standard method for controlling risks from toxic chemicals, require an immediate halt to the use of the nation's drinking water reservoirs as disposal sites for the toxic waste of the phosphate fertilizer industry (24). *Read an interview with Dr. Hirzy concerning the NTP's Fluoride Cancer study *Read Dr. Hirzy's June 2000 Testimony to the US Senate This document was prepared on behalf of the National Treasury Employees Union Chapter 280 by Chapter Senior Vice-President J. William Hirzy, Ph.D. For more information please call Dr. Hirzy at 202-260-4683. His E-mail address is <hirzy.john@epa.gov> END NOTE LITERATURE CITATIONS 1. Applying the NAEP code of ethics to the Environmental Protection Agency and the fluoride in drinking water standard. Carton, R.J. and Hirzy, J.W. Proceedings of the 23rd Ann. Conf. of the National Association of Environmental Professionals. 20-24 June, 1998. GEN 51-61. On-line at http//:www.rvi.net/-fluoride/naep.htm 2. Neurotoxicity of sodium fluoride in rats. Mullenix, P.J., Denbesten, P.K., Schunior, A. and Kernan, W.J. Neurotoxicol. Teratol. 17 169-177 (1995) 3. Influence of chronic fluorosis on membrane lipids in rat brain. Z.Z. Guan, Y.N. Wang, K.Q. Xiao, D.Y. Dai, Y.H. Chen, J.L. Liu, P. Sindelar and G. Dallner, Neurotoxicology and Teratology 20 537-542 (1998). 4. Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity. Varner, J.A., Jensen, K.F., Horvath, W. And Isaacson, R.L. Brain Research 784 284-298 (1998). 5. Effect of high fluoride water supply on children?s intelligence. Zhao, L.B., Liang, G.H., Zhang, D.N., and Wu, X.R. Fluoride 29 190-192 (1996) 6. Effect of fluoride exposure on intelligence in children. Li, X.S., Zhi, J.L., and Gao, R.O. Fluoride 28 (1995). 7. Effect of fluoride on the physiology of the pineal gland. Luke, J.A. Caries Research 28 204 (1994). 8. Newburgh-Kingston caries-fluorine study XIII. Pediatric findings after ten years. Schlesinger, E.R., Overton, D.E., Chase, H.C., and Cantwell, K.T. JADA 52 296-306 (1956). 9. Memorandum dated May.1, 1990. Subject: Fluoride Conference to Review the NTP Draft Fluoride Report; From: Wm. L. Marcus, Senior Science Advisor ODW; To: Alan B. Hais, Acting Director Criteria & Standards Division ODW. 10. Toxicology and carcinogenesis studies of sodium fluoride in F344/N rats and B6C3F1 mice. NTP Report No. 393 (1991). 11a. Chromosome aberrations, sister chromatid exchanges, unscheduled DNA synthesis and morphological neoplastic transformation in Syrian hamster embryo cells. Tsutsui et al. Cancer Research 44 938-941 (1984). 11 b. Cytotoxicity, chromosome aberrations and unscheduled DNA synthesis in cultured human diploid fibroblasts. Tsutsui et al. Mutation Research 139 193-198 (1984). 11c. Positive mouse lymphoma assay with and without S-9 activation; positive sister chromatid exchange in Chinese hamster ovary cells with and without S-9 activation; positive chromosome aberration without S-9 activation. Toxicology and carcinogenesis studies of sodium fluoride in F344/N rats and B6C3F1 mice. NTP Report No. 393 (1991). 11d. An increase in the number of Down's syndrome babies born to younger mothers in cities following fluoridation. Science and Public Policy 12 36-46 (1985). 12. A brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young males. Cohn, P.D. New Jersey Department of Health (1992). 13. Surveillance, epidemiology and end results (SEER) program. National Cancer Institute in Review of fluoride benefits and risks. Department of Health and Human Services. F1-F7 (1991). 14. New evidence on fluoridation. Diesendorf, M., Colquhoun, J., Spittle, B.J., Everingham, D.N., and Clutterbuck, F.W. Australian and New Zealand J. Public Health. 21 187-190 (1997). 15a. Regional variation in the incidence of hip fracture: U.S. white women aged 65 years and older. Jacobsen, S.J., Goldberg, J., Miles, ,T.P. et al. JAMA 264 500-502 (1990) 15b. Hip fracture and fluoridation in Utah?s elderly population. Danielson, C., Lyon, J.L., Egger, M., and Goodenough, G.K. JAMA 268 746-748 (1992). 15c. The association between water fluoridation and hip fracture among white women and men aged 65 years and older: a national ecological study. Jacobsen, S.J., Goldberg, J., Cooper, C. and Lockwood, S.A. Ann. Epidemiol.2 617-626 (1992). 15d. Fluorine concentration is drinking water and fractures in the elderly [letter]. Jacqmin-Gadda, H., Commenges, D. and Dartigues, J.F. JAMA 273 775-776 (1995). 15e. Water fluoridation and hip fracture [letter]. Cooper, C., Wickham, C.A.C., Barker, D.J.R. and Jacobson, S.J. JAMA 266 513-514 (1991). 16. Water fluoridation and tooth decay: Results from the 1986-1987 national survey of U.S. school children. Yiamouyannis, J. Fluoride 23 55-67 (1990). 17. Recommendations for fluoride use in children. Kumar, J.V. and Green, E.L. New York State Dent. J. (1998) 40-47. 18. Why I changed my mind about water fluoridation. Colquhoun, J. Perspectives in Biol. And Medicine 41 1-16(1997). 19. A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride? Limeback, H. Community Dent. Oral Epidemiol. 27 62-71 (1999). • 20. Fluoride supplements for young children: an analysis of the literature focussing on benefits and. risks. Riordan, P.J. Community Dent. Oral Epidemiol. 27 72-83 (1999). 21. Prevention and reversal of dental caries: role of low level fluoride. Featherstone, J.D. Community Dent. Oral Epidemiol. 27 31-40 (1999). 22. Appendix H. Review of fluoride benefits and risks. Department of Health and Human Services. H1-H6 (1991). 23. Some young children get too much fluoride. Parker-Pope, T. Wall Street Journal Dec. 21, 1998. 24. Letter from Rebecca Hanmer, Deputy Assistant Administrator for Water, to Leslie Russell re: EPA view onuse of by-product fluosilicic (sic) acid as low cost source of fluoride to water authorities. March 30, 1983. OTHER CITATIONS (This short list does not include the entire literature on fluoride effects) a. Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. Freni, S.C. J. Toxicol. Environ. Health 42 109-121 (1994) b. Ameliorative effects of reduced food-borne fluoride on reproduction in silver foxes. Eckerlin, R.H., Maylin, G.A., Krook, L., and Carmichael, D.T. Cornell Vet. 7875-91 (1988). c. Milk production of cows fed fluoride contaminated commercial feed. Eckerlin, R.H., Maylin, G.A., and Krook, L. Cornell Vet. 76 403-404 (1986). d. Maternal-fetal transfer of fluoride in pregnant women. Calders, R., Chavine, J., Fermanian, J., Tortrat, D., and Laurent, A.M. Biol. Neonate 54 263-269 (1988). e. Effects of fluoride on screech owl reproduction: teratological evaluation, growth, and blood chemistry in hatchlings. Hoffman, D.J., Pattee, O.H., and Wiemeyer, S.N. Toxicol. Lett. 26 19-24 (1985). f. Fluoride intoxication in dairy calves. Maylin, G.A., Eckerlin, R.H., and Krook, L. Cornell Vet. 77 84-98 (1987). g. Fluoride inhibition of protein synthesis. Holland, R.I. Cell Biol. Int. Rep. 3 701-705 (1979). h. An unexpectedly strong hydrogen bond: ab initio calculations and spectroscopic studies of amide-fluoride systems. Emsley, J., Jones, D.J., Miller, J.M., Overill, R.E. and Waddilove, R.A. J. Am. Chem. Soc. 103 24-28 (1981). i. The effect of sodium fluoride on the growth and differentiation of human fetal osteoblasts. Song, X.D., Zhang, W.Z., Li, L.Y., Pang, Z.L., and Tan, Y.B. Fluoride 21 149-158 (1988). j. Modulation of phosphoinositide hydrolysis by NaF and aluminum in rat cortical slices. Jope, R.S. J. Neurochem: 51 1731-1736 (1988). k. The crystal structure of fluoride-inhibited cytochrome c peroxidase. Edwards, S.L., Poulos, T.L., Kraut, J. J. Biol. Chem. 259 12984-12988 (1984). I. Intracellular fluoride alters the kinetic properties of calcium currents facilitating the investigation of synaptic events in hippocampal neurons. Kay, A.R., Miles, R., and Wong, R.K.S. J. Neurosci. 6 2915-2920 (1986). m. Fluoride intoxication: a clinical-hygienic study with a review of the literature and some experimental investigations. Roholm, K. H.K. Lewis Ltd (London) (1937). n. Toxin-induced blood vessel inclusions caused by the chronic administration of aluminum and sodium fluoride and their implications for dementia. Isaacson, R.L., Varner, J.A., and Jensen, K. F. Ann. N.Y. Acad. Sci. 825 152-166 (1997). o. Allergy and hypersensitivity to fluoride. Spittle, B. Fluoride 26 267-273 (1993) RENTON CITY COUNCIL Regular Meeting June 18,2012 Council Chambers Monday,7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER,Council President;TERRI BRIERE; ED PRINCE; DON PERSSON; COUNCILMEMBERS MARCIE PALMER; RANDY CORMAN; GREG TAYLOR. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON,Chief Administrative Officer; LAWRENCE J.WARREN, City Attorney; BONNIE WALTON, City Clerk; IWEN WANG, Administrative Services Administrator;CHIP VINCENT,Community and Economic Development Administrator; NANCY CARLSON, Human Resources Administrator;SUZANNE DALE ESTY, Economic Development Director; KELLY BEYMER, Parks&Golf Course Director; MEHDI SADRI, Information Technology Director; DEPUTY CHIEF ERIK WALLGREN, Fire& Emergency Services Department; CHIEF KEVIN MILOSEVICH, Police Department. PUBLIC HEARING This being the date set and proper notices having been posted and published in Annexation: Windstone V, accordance with local and State laws, Mayor Law opened the public hearing to North of Sunset Blvd N & East consider proposed R-4(residential four dwelling units per net acre)zoning and of Jericho Ave NE final annexation for the Windstone V Annexation;4.3 acres located south of NE 16th St., if extended,west but not abutting 148th Ave.SE, north of NE Sunset Blvd., and east of Jericho Ave. NE,if extended. Associate Planner Angie Mathias reported that the King County Boundary Review Board issued a closing letter approving this annexation on 5/16/2012. She stated that tonight's hearing is the second of two required public hearings • regarding zoning. She explained that the area was pre-zoned in 1996 as R-5, which is a zoning designation that no longer exists. Ms. Mathias reported that the site consists of single-family residences and vacant land,and there are no regulated slopes. She noted that there is a Class IV waterway that runs along the eastern boundary known as Greenes Stream. Ms. Mathias stated that the existing King County zoning is R-4(four dwelling units per gross acre),and reported that the City's Comprehensive Plan designates the site as eligible for residential low density zoning. She recommended that the area be zoned R-4(four dwelling units per net acre). Responding to Council inquiries, Ms. Mathias stated that the City uses net density and the County uses gross density. She explained that the setback for Greenes Stream and street right-of-ways will be subtracted from the total amount of land that can be developed. Ms. Mathias also noted that surrounding developments are zoned R-4. There being no public comment, it was MOVED BY ZWICKER,SECONDED BY CORMAN,COUNCIL CLOSE THE PUBLIC HEARING. CARRIED. MOVED BY PRINCE,SECONDED BY CORMAN, COUNCIL APPROVE THE FIRST READING OF THE ORDINANCES REGARDING THE WINDSTONE V ANNEXATION. CARRIED. (See page 191 for ordinances.) June 18, 2012 • Renton City Council Minutes Page 188 AUDIENCE COMMENT Steve Holman (King County)stated that he was surprised that Council was Citizen Comment: Holman- considering delaying the West Hill annexation vote again. He remarked that he West Hill Annexation believes the area has a lot of potential for economic development. Mr. Holman stated that people in West Hill are looking for better fire and police protection, and urged Council to allow these residents the right to participate as full Renton citizens. Citizen Comment: Ferguson- Dian Ferguson (Tukwila)urged Council to allow the West Hill annexation vote to West Hill Annexation occur as scheduled. She stated that the support West Hill residents give to Renton does not get enough attention, and explained that residents shop, eat, and conduct business in Renton. Ms. Ferguson emphasized that people in West Hill are mostly concerned with police and fire protection, and jump-starting economic development. She also expressed concern that delaying the vote could mean losing state tax dollars. Citizen Comment: Cheryl Scheuerman (Renton)stated that she is a City resident who lives at the Scheuerman-West Hill base of West Hill and has not seen a greater level of police or street Annexation maintenance crews presence compared to other areas. She explained that she is the manager of Skyway Water&Sewer District and praised the City Utility Division staff for working together to lobby for a utility tax in the area that will help close the funding gap. Ms.Scheuerman stated that West Hill residents have a unique relationship with Renton,and explained that they work, play, and eat in Renton, and their children attend the Renton School District. She urged that the election go forward. Citizen Comment: Rice-West Stefanie Rice (Renton)stated that she works in Skyway and is the President of Hill Annexation the West Hill Business Association. She remarked that having grown up in Renton she had heard rumors about West Hill regarding safety issues, and stated that they are not true. She also stated that delaying the vote is a slap in the face to all who worked so hard to get the issue on the ballot. Ms. Rice pointed out that the area has park volunteers and neighborhood block watches, which will continue after annexation. She also reiterated that many West Hill residents already work, play, shop,and eat in Renton. Citizen Comment:Witt-West Paul Witt(Renton) urged Council to not move forward with the election at this • Hill Annexation time. He explained that current City residents are not allowed to vote on the issue, and emphasized that Council has a duty and responsibility to vote in the best interests of those they currently represent. Mr.Witt stated that taking on any revenue-negative responsibility during these tough economic times will lead to immediate demands on staff and City programs that will cause reductions in service levels to current residents. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 6/11/2012. Council concur. 6/11/2012 CAG: 12-083, Liberty Lift City Clerk reported bid opening on 6/12/2012 for CAG-12-083, Liberty Lift Station, Equity Builders Station project;six bids;engineer's estimate$329,991.39; and submitted staff recommendation to award the contract to the low bidder, Equity Builders, LLC, in the amount of$362,554.50. Refer to Utilities Committee for discussion of funding. • June 18, 2012 Renton City Council Minutes Page 189 Attorney:Tax Related Administrative Services Department recommended amending RMC 5-23-7B to Examinations&Audits,Code clarify the time limitation for tax/fee audits as the audit year plus six previous Amendment years. Council concur. (See page 191 for ordinance.) Finance: Project#63, Administrative Services Department recommended approval of an addendum Community Connectivity for Project#63 to the Community Connectivity Consortium agreement,to Consortium, KC-RCECC provide additional fiber optic cable from the north side of NE 4th St. approximately 150' west from Monroe Ave. NE to King County Regional Communications and Emergency Coordination Center, KC-RCECC. Council concur. (See page 191 for resolution.) Community Services: Fee Community Services Department recommended waiver of all fees and charges Waiver Request, Renton River associated with the 2012 Renton River Days activities as requested by the Days Renton River Days Board of Directors. Council concur. MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Council President Zwicker stated that West Hill annexation vote is currently Committee of the Whole scheduled for the 11/6/2012 ballot. He remarked that if the vote is affirmative Annexation:West Hill Election it will require the City to develop a plan to take in the area. He explained.that there had been some thought previously that Council could decide whether or not to take the area in after an affirmative vote, however, it had been clarified by the City Attorney that if the vote is affirmative the City is required to annex. Mr.Zwicker further explained that if the proposed Committee of the Whole Committee report is approved by Council the election will be postponed and left open for further discussion as to when it will be re-submitted to the ballot. He emphasized that if the report is not approved,the election will proceed as scheduled. Council President Zwicker presented a Committee of the Whole Committee report regarding deliberations on West Hill annexation timelines and options. The report stated, "With the consideration of the projected City 2013-2014 budget challenge,the Committee of the Whole wishes to further delay the annexation election until the first Tuesday after the first Monday of November in the year the Council determines that the City's financial condition improves or other long-term financing tools become available to bridge the annexation • funding gap. Therefore,the Committee recommends that Council adopt a resolution requesting King County to remove the item from the November 2012 election and rescind the prior resolution requesting an election." MOVED BY PERSSON,SECONDED BY PALMER, COUNCIL CONCUR IN THE COMMITTEE REPORT.* Councilmember Corman requested clarification between approving this Committee report and leaving the measure on the ballot. He explained that neither option provides a date certain as to when the area will actually be taken in by the City. Mayor Law affirmed Mr. Corman's statement, and remarked that the biggest difference is if the report is approved,Council could reset the election at a later date which would preserve the state annexation sales tax credit. He stated that if the issue goes to a vote in November and is not approved,the annexation sales tax credit could be lost. June 18, 2012 Renton City Council Minutes Page 190 Mayor Law also stated that with this report, if the annexation election is approved by voters,the administration is comfortable knowing that the funding issues will be worked out prior to effectuating the annexation. He added that the administration will not propose annexing the area until the City can afford to do so. Councilmember Corman summarized the issue by stating that approving the report would keep in place the state annexation sales tax credit but delays the vote, and if the economy brightens Council may be able to set a date for the election in the future. Mayor Law remarked that the issue has been discussed for a long time,and if the annexation election is positive,the City will need to find a way to take West Hill in at some point in time. • ROLL CALL: FOUR NOES:ZWICKER, BRIERE, PRINCE,TAYLOR; THREE AYES: PALMER, PERSSON, CORMAN. *MOTION FAILED. Discussion ensued regarding address and zip code changes for persons living in the annexation area presuming the November 2012 election is positive. • Finance Committee Finance Committee Chair Briere recommended approval of Claim Vouchers Finance:Vouchers 312556-312971,two wire transfers and one payroll run with benefit withholding payments totaling$10,069,079.30, and payroll vouchers including 743 direct deposits and 77 payroll checks totaling$1,649,855.09. MOVED BY BRIERE,SECONDED BY PERSSON, COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Transportation (Aviation) .Transportation (Aviation) Committee Chair Corman presented a report Committee recommending concurrence in the staff recommendation to approve the lease Lease:Addendum, Northwest rate increase to the Northwest Seaplanes, Inc. lease, LAG-95-001,and authorize Seaplanes, LAG-91-005 the Mayor and City Clerk to sign the lease addendum. MOVED BY CORMAN,SECONDED BY ZWICKER, COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Airport: Operating Permit& Transportation (Aviation)Committee Chair Corman presented a report Agreement,Clean Craft recommending concurrence in the staff recommendation to approve the Detailing sublease from Bosair, LLC to Clean Craft Detailing, Inc.and authorize the Mayor and City Clerk to sign the Operating Permit and Agreement with Clean Craft Detailing, Inc. ' MOVED BY CORMAN,SECONDED BY PALMER, COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Lease: Addendum,Aerodyne, Transportation (Aviation)Committee Chair Corman presented a report LAG-84-006 recommending concurrence in the staff, recommendation to approve the lease rate increase and authorize the Mayor and City Clerk to sign the lease addendum to Aerodyne, LLC's lease, LAG-84-006. MOVED BY CORMAN,SECONDED BY PALMER, COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. June 18,2012 Renton City Council Minutes - Page 191 RESOLUTIONS AND The following resolution was presented for reading and adoption: ORDINANCES RESOLUTION#4148 A resolution was read authorizing the Mayor and City Clerk to enter into an • Finance: Project#63, addendum to the Community Connectivity Consortium's Project Agreement Community Connectivity Template Policy, between the City of Renton and the Cities of Auburn, Bellevue, Consortium, KC-RCECC Kirkland,Seattle,and King County, Renton School District, University of Washington, and Valley Communications. MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL ADOPT THE RESOLUTION AS READ. CARRIED. The following ordinances were presented for first reading-and referred to the 6/25/2012 Council meeting for second and final reading: Annexation:Windstone V, An ordinance was read annexing approximately 4.3 acres generally located North of Sunset Blvd N & East south of NE 16th St., if extended,west of but not abutting 148th Ave.SE, north of Jericho Ave NE of NE Sunset Blvd., and east of Lyons Pl. NE,if extended,Windstone V Annexation. MOVED BY PRINCE,SECONDED BY BRIERE,COUNCIL REFER THE ORDINANCE FOR SECOND AND FINAL READING ON 6/25/2012. CARRIED. Annexation:Windstone V, R-4 An ordinance was read establishing the zoning classification for approximately Zoning 4.3 acres,generally located south of NE 16th St., if extended,west of but not abutting 148th Ave.SE, north of NE Sunset Blvd., and east of Lyons PI. NE, if extended,from R-4(Residential-four dwelling units per gross acre) King County zoning to R-4(Residential-four dwelling units per net acre)zoning; Windstone V Annexation. MOVED BY PRINCE, SECONDED BY BRIERE, COUNCIL REFER THE ORDINANCE FOR SECOND AND FINAL READING ON 6/25/2012. CARRIED. Attorney:Tax Related An ordinance was read amending Section 5-23-7 of Chapter 23, Examinations, Examinations&Audits, Code Records Preservation,Successor Liability, and Public Disclosure, of Title V Amendment (Finance and Business Regulations),of City Code, by clarifying the intent of the limitation on actions. MOVED BY ZWICKER,SECONDED BY BRIERE,COUNCIL REFER THE ORDINANCE FOR SECOND AND FINAL READING ON 6/25/2012. CARRIED. NEW BUSINESS Further discussion ensued regarding the West Hill annexation election Annexation:West Hill including, if the election results are negative there is a possibility that the state annexation sales tax credit will be lost unless the annexation is re-commenced prior to 2015,and the annexation sales tax credit is essential to funding the annexation. Community Event: "Queen, Councilmember Taylor reported that he attended an anti-domestic violence it's a new day,"Anti-Domestic event entitled "Queen, it's a new day." He stated that the event provided a Violence Event two-day make-over for 100 women who have been abused, broken,or forgotten to show them their worth. He stated that the women were given new work clothes,shoes, massages, and an overnight stay at a nice hotel. AUDIENCE COMMENT Audrey Adams(Renton) explained that calcium fluoride in naturally occurring Citizen Comment:Adams- and comparatively benign, and noted that Renton adds sodium fluoride to its Fluoridated Water water supply. She remarked that sodium fluoride is synthetic,does not occur naturally,and is more harmful than calcium fluoride. Ms.Adams stated that the City paid $7,600 for 10,000 pounds of sodium fluoride. She remarked that she believes a 50 pound bag contains the equivalent of 2,600 lethal adult doses of the chemical. June 18,2012 Renton City Council Minutes Page 192 EXECUTIVE SESSION& MOVED BY ZWICKER,SECONDED BY CORMAN, COUNCIL RECESS INTO ADJOURNMENT EXECUTIVE SESSION FOR APPROXIMATELY 30 MINUTES TO DISCUSS PERSONNEL(RCW 42.30.110.1.f.)WITH NO OFFICIAL ACTION TO BE TAKEN AND THAT THE COUNCIL MEETING BE ADJOURNED WHEN THE EXECUTIVE SESSION IS ADJOURNED. CARRIED. Time: 7:53 p.m. Executive session was conducted. There was no action taken. The executive session and the Council meeting adjourned at 8:44 p.m. Bonnie I.Walton,CMC, City Clerk Jason Seth, Recorder June 18, 2012 • RENTO""''TY COUNCIL COMMITTEE MEETING r"a'ENDAR Office of the City Clerk COUNCIL COMMITTEE MEETINGS SCHEDULED AT CITY COUNCIL MEETING June 18, 2012 COMMITTEE/CHAIRMAN DATE/TIME AGENDA COMMITTEE OF THE WHOLE MON., 6/25 Regional Committee Updates; (Zwicker) 5:30 p.m. Emerging Issues in Economic Development &Transportation *7TH FLOOR CONFERENCING CENTER* • COMMUNITY SERVICES MON., 6/25 CANCELED (Palmer) FINANCE (Briere) PLANNING & DEVELOPMENT (Prince) PUBLIC SAFETY (Persson) TRANSPORTATION (AVIATION) (Corman) UTILITIES MON., 6/25 Release of Utility Easements at Renton (Taylor) 4:30 p.m. Village; Yellow Pages Opt-Out Program; Liberty Lift Station Bid Award Funding NOTE: Committee of the Whole meetings are held in the Council Chambers unless otherwise noted. All other committee meetings are held in the Council Conference Room unless otherwise noted. J. • CALCIUM FLUORIDE 7VS. SODIUM FLUORIDE ' (CaF2) O (NaF) , 3 . O • Chemical Hazard Label <—> • Chemical Hazard Label Blue = health risks/toxicity (NONE) Blue = health risks (HIGHLY TOXIC) Red= flammability &Yellow=reactivity Scale of 1-4, with 4 the highest • Naturally occurring in hard water <==> • Never occurs naturally • Naturally occurring in wells & underground water <==> • Synthetic waste product of the nuclear, aluminum & (some, not all); seawater is high in calcium phosphate fertilizer industries (without purification) • Fluoride is neutralized (made safe) by calcium <=> • Contains virtually no calcium to bond with fluoride • Calcium +Fluoride create strong bond, producing a <==> • Lacking calcium, Sodium Fluoride mixes very well hard material that doesn't mix well with water with water, making it suitable for water fluoridation Solubility in water: 15 ppm Solubility in water: 40,000 ppm ' • Passes through body UNABSORBED, dramatically C—� • Very well absorbed in the body, causing systemic reducing fluoride's toxicity toxicity to organs (up to 85 times more toxic) • NOT USED TO FLUORIDATE in Washington • ADDED TO PUBLIC WATER in Washington iAN' • Virtually all studies demonstrating the safety of <==> • The safety & efficacy of Sodium Fluoride to treat fluoridation use the less toxic Calcium Fluoride dental caries in humans is scientifically unsupported • Rivers & aquifers are mostly soft water, containing - <---> • Highly toxic Sodium fluoride is used to medicate virtually no protective calcium in Western Wash. people yet has not been approved for use by the FDA • REGULATED BY EPA—EPA sets the maximum • NOT REGULATED BY EPA—The SDWA(Safe naturally occurring CaF2 levels, and if too high �� Drinking Water Act) prohibits EPA from regulating regulates the REMOVAL of Calcium Fluoride artificially added Sodium Fluoride l FROM CITY OF RENTON (via public information request) Renton: Invoice for Sodium Fluoride-2/8/12 10,000 lbs(200-50 lb bags) x $0.76/Ib($38/bag) = $7,600.00 Sodium Fluoride Toxicity calculations(from Richard D. Sauerheber, Ph.D. Chemistry): The recognized single oral acute(fatal) dose in mammals is 125 mg/Kg body weight(Merck Index#8368) For an average adult of 70 Kg a lethal dose would be 8.8 grams. Small children have been reported killed after ingesting only 1 gram of sodium fluoride. 50 lb bag contains 22.7 Kg or 22,700 grams of sodium fluoride,so each bag contains: 2,600 lethal adult doses or 22,700 lethal childrens' doses 10,000 lbs contain 4,500 Kg or 4,540,000 grams of sodium fluoride,so the total shipment contained: 520,000 lethal adult doses or 4,540,000 lethal childrens'doses Renton: MSDS(Material Safety Data Sheet)Toxicological Information 11.2,Chronic toxicity states: "Oral route,after prolonged exposure, rat/mouse,target organ: skeleton/thyroid/testes/kidney, liver, 1 mg/kg,observed effect." and "Fetotoxic and fertility effects" (Definition of fetotoxic: "pertaining to anything that is poisonous to a fetus") • CASA D E Ef LrCECC CUSTOMER NO. x � COLUMBIA DATE NUMBER 03486 G•' ; 1 2/8/12: J 563065 Page 1 of 1 ,. 'a.r Par 6900 Fox Ave South `'°" DATE SHIPPED DUE DATE. Seattle,WA 98108 USA 2/8/12 1 3/9/12 Phone:(206)763-2350 Fax:(206)763-7523 o CITY OF RENTON 8 CITY OF RENTON CALL BILL WALKER 1-2 HR '- 3555 NE 2ND ST P BEFORE 0 T RENTON,WA 98056-4192 CALL 111R PRIOR TO DELIVERY o o BEHIND REC CENTER IN PARK CCTF-1715 MAPLE VALLEY HWY • RENTON,WA 98057-3900 CUSTOMER ORDER NUMBER F.O.B. SHIPPED VIA SALES AGENT TERMS 190064 100 CD Kevin Rock Net 30 Days UNITS PACKAGE DESCRIPTION TOTAL QUANTITY UNIT PRICE AMOUNT 200.00 50#BAG SODIUM FLUORIDE JAPA 50# BAG 10000.00# 0.7600/# 7,600.00 I 666100T1 Merchandise Total 7,600.00 I • Invoice Energy Surcharge - 25.00 I Cascade Columbia Distribution TOTAL 7,625.00 PLEASE REMiT TO: P.O Box 24745 - - - Seattle,WA 98124-0745 - PLEASE PAY THIS AMOUNT gimagEsil IMPORTANT-Returnable containers will be charged end must be paid for.Such payment will be refunded alfuU price,provided containers are received by us in good reasonable condition vrithtn 60 days from date of invoice,freight prepaid,tagged with shipper's name.No discount allowed on containers-Interest vol be charged at the tate of 1%per month is charged an all balances or portions of balances that are more than 30 days past due. Intim event that it becomes necessary to Involve a third party to effect collection of this account,Purchaser agrees to pac tin maximum Mance charge allowed by taw on all invoices not paid within terms.attorneys teas,and all other collection fees.Seller strati retain a sece34 Interest in all of the goods sold rereunderuntil the purchase price is fully paid. In the event that any such payment is not made promptly when due,the seller strati have all the rights and remedies of a secured credfda*under the Uniform Commercial Code with respect to the goods delivered to Purchaser and products and services into which they mayhave been incoperalcdin adddtian to any other rights and re ales available under applicable law: Sodium Fluoride Material Safety Data Sheet • — _ JFC4 OfCf�fD77it3i�7 _ �— 11.1 Acute toxicity: Inhalation: • Oral:LDS=52-250 mg/kg,rat. Dermal:LI)to=-300 mg/kg, mouse. ` Irritation: e Rabbit,slight irritant(skin). -1, • Rabbit,irritant(eyes). Sensitization:No data Comments: • Chronic exposure may entail dental or skeletal fluorosis. • The carcinogenic effect found in animals is not demonstrated in humans. • Risk of toxic effect on reproduction. /11.2 Chronic toxicity; • Oral route,after prolonged exposure,rat/mouse,target organ:skeleton/thyroid/testes/ kidney,liver,-1 mg/kg,observed effect. • Ambiguous carcinogenic effect. • Ambiguous mutagenic effect. • Fetotoxic and fertility effects. 1t3 Carcinogenic Designation:None. 12.1 Acute ecotoxicity: • Fish,Sarno gairdneri,LCA,,96 hour(s), 112 Mg/I. • ;Crustaceans,Daphnia magna,ECS,48 hour(s), 213 mg(I Conditions:Fresh water. • • Crustaceans,Mysidopsis bahia,ECS,,96 hour(s).23mg/l • Conditions:Salt water: • Algae,Scene desmus sp.EC50,96 hour(s).95 mg/1. 122 Chronic ecotoxicity: • Fish,Salmo gairdneri,LC50,21 days,from 5.9-10.3 mg/i. • • Crustaceans,Daphnia magna,NOEC,21 days, 8.1 mg/i. 12.3 Mobility: • Air-mobility as solid aerosols. • • Water/soil-considerable solubility and mobility. • Soil/sediments-adsorption on mineral soil constituents. Conditions:slightly acid pH(Fluorides). MSOS No.NAF-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides,LLC A subsidiary of Solvay Chemicals,Inc. Ali Rights Reserved. Page 7/10 wrsv.solvaychemicals.us 1.800.765.8292 Sodium Fluoride • Material Safety Data Sheet 16.1 Ratings: . (i4 NAL FIRE PROTECTION ASSOCIATION) ..'--:----4 Health=03 Flammability=0 instability=0 Special=None H IRDOUS MATERIAL INFORMATION SYSTEM) ealth=3 ire=0 Reactivity=0 PPE=Supplied by User;dependent on local conditions 162 Other Information: The previous information is based upon our current knowledge and experience of our product and is not exhaustive.it applies to the product as defined by the specifications.In case of combinations or mixtures,one must confirm that no new hazards are likely to exist.In any case,the user is not J exempt from observing all legal,administrative and regulatory procedures relating to the product, personalZ. hygiene,and integrityof the work environment. Y9 (Unless noted to the contrary,the technical ' orrnation applies only to pure product). To our actual knowledge, the information contained herein is accurate as of the date of this document.However;neither Solvay fluorides,LIG nor any of Its affiliates makes any warranty, ..w express or implied, or accepts any liability in connection with this information or its use. This information is for use by technically skilled persons at their own discretion and risk and does not relate to the use of this product in combination with any other substance or any other process.This is not a license under any patent or other proprietary right. The user alone must finally determine suitability of any information or material for any contemplated use, the manner of use and whether any patents are infringed.This information gives typical properties only and is not to be used for specification purposes. - ' .demarks and/or other Solvay Fluorides,LLG products referenced herein are either trademarks or registered trademarks of Solvay Fluorides, LW or its affiliates,unless otherwise indicated. 16.3 Reason for revision: Supersedes edition: Solvay Fluorides Inc. MSDS dated 5/6/2003 Purpose of revision: Change Company name and MSDS format • MSDS No.NAF-1103 Revised 11-13-03 CITY OF RENTON June 18,2012 JUN:2 0 2012 RECEIVED Renton City Council CITY CLERK'S OFFICE Subject: Comparison & Toxicity of Calcium Fluoride vs. Sodium Fluoride Dear Renton City Council members and Mayor Law, Water fluoridation is a process, not a chemical. Fluoride does not exist alone, it must combine with or attach to something else. Understanding what Renton adds to its prized and pure aquifer water is paramount to understanding what effects"fluoridation" might have on Renton residents,good or bad. So last week I requested a few documents to discover detailed information about the water fluoridation chemicals that are used in Renton. Many thanks to Lys Hornsby for responding so quickly. The handouts I brought to the Council this evening were: • 1) Calcium Fluoride vs.Sodium Fluoride side-by-side comparison sheet 2) Sodium Fluoride Toxicity calculations 3) Renton's 2/8/12 Invoice for Sodium Fluoride($7,600) 4) Renton's MSDS, Item 11.2 Chronic toxicity 5) Renton's MSDS, Item 16.1 Health Ratings and 16.2 Other Info (Disclaimer) No discussion about water fluoridation is relevant unless it is clear which chemical is used because the toxicity is so variable. According to the invoice, Renton uses Sodium Fluoride. However, nearly all studies showing the safety of fluoridation use the much less toxic, naturally-occurring Calcium Fluoride. Please refer to the Calcium vs.Sodium Fluoride side-by-side comparison that I created and note the Chemical Hazard Labels for each--Calcium Fluoride is rated 0(no toxicity)while Sodium Fluoride is rated 3 (highly toxic). Sodium Fluoride never occurs naturally and is a synthetic by-product(waste) of the nuclear, aluminum and phosphate fertilizer industries. It isnot purified prior to delivery to cities. To put this in perspective, I have submitted toxicity calculations of Renton's Sodium Fluoride with the expert assistance of Richard Sauerheber, Ph.D. Chemistry. Based on the recognized single oral acute • dose in mammals of 125 mg/Kg body weight(Merck Index, Rahway, N.J., 1976, p. 1114, index entry #8368), a fatal dose of Sodium Fluoride for an average adult weighing 70 Kg is 8.8 grams. Small children, however, have suffered fatal doses after ingesting as little as 1 gram of Sodium Fluoride. Fifty pounds is 22,700 grams,so a 50 pound bag of Sodium Fluoride contains between 2,600 to 22,700 lethal doses, depending on the size of the individual or child. One ton of Calcium Fluoride would be needed to produce approximately the same number of lethal doses as 50 pounds of Sodium Fluoride. The invoiced shipment Renton received on 2/18/12---a total of 10,000 pounds--contained enough poisonous material to kill roughly 500,000 adults or 4.5 million small children,without dilution of course. From the description at the top of the invoice, it appears that this material is stored near the Community Recreation Center and next to the Cedar River. I would not want this level of responsibility on my shoulders. I hope the security surrounding this material protects against targeted acts of violence. CALCIUM FLUORIDE ( )‘ ; VS. SODIUM FLUORIDE (CaF2) ' "0- ,; 0 (NaF) .,,l/ • Chemical Hazard Label <—> • Chemical Hazard Label Blue = health risks/toxicity (NONE) Blue = health risks (HIGHLY TOXIC) Red = flammability & Yellow = reactivity Scale of 1-4, with 4 the highest • Naturally occurring in hard water <=> • Never occurs naturally • Naturally occurring in wells & underground water <—> • Synthetic waste product of the nuclear, aluminum & (some, not all); seawater is high in calcium phosphate fertilizer industries (without purification) • Fluoride is neutralized (made safe) by calcium <=> • Contains virtually no calcium to bond with fluoride • Calcium + Fluoride create strong bond, producing a <==> • Lacking calcium, Sodium Fluoride mixes very well hard material that doesn't mix well with water with water, making it suitable for water fluoridation Solubility in water: 15 ppm Solubility in water: 40,000 ppm • Passes through body UNABSORBED, dramatically .<=> • Very well absorbed in the body, causing systemic reducing fluoride's toxicity toxicity to organs (up to 85 times more toxic) • NOT USED TO FLUORIDATE in Washington <===> • ADDED TO PUBLIC WATER in Washington • Virtually all studies demonstrating the safety of <=> • The safety & efficacy of Sodium Fluoride to treat fluoridation use the less toxic Calcium Fluoride dental caries in humans is scientifically unsupported • Rivers & aquifers are mostly soft water, containing • Highly toxic Sodium fluoride is used to medicate virtually no protective calcium in Western Wash. people yet has not been approved for use by the FDA • REGULATED BY EPA—EPA sets the maximum • NOT REGULATED BY EPA—The SDWA(Safe • naturally occurring CaF2 levels, and if too high <=> Drinking Water Act) prohibits EPA from regulating regulates the REMOVAL of Calcium Fluoride artificially added Sodium Fluoride . • I, cusTaraER3 y.• •' CZ l4.f-f ��BEA�: DATE NUMBER • CUSTOMER NO. ;ris o G ` C� y D L S i fZ f 6.k V V � l.t*z• �. 03488 2/8/12 563065 COMPANY I� ~ Page 1 of 1 ':s .s : 6900 Fox Ave South DATE SHIPPED bUE DATE. Seattle,WA 98108 USA 2/8/12 3/9/12 Phone:(206)763-2350 Fax:(206)763-7523 • o CITY OF RENTON H CITY OF RENTON CALL BILL WALKER 1-2 HR 0 3555 NE 2ND ST p BEFORE T RENTON, WA 98056-4192 CALL 1HR PRIOR TO DELIVERY 0 o BEHIND REC CENTER IN PARK CCTF--171514APLE VALLEY I-II' • RENTON,WA 98057-3900 CUSTOMER ORDER NUMBER F.O.B. SHIPPED VIA SALES AGENT TERMS 190064 100 CD Kevin Rock Net 30 Days UNITS PACKAGE DESCRIPTION. TOTAL QUANTITY UNIT PRICE AMOUNT ' 200.00 50#BAG SODIUM FLUORIDE JAPA 50# BAG 10000.00# 0.7600/# 7,600.00 1 66610011 • I Merchandise Total 7,600.00 I Invoice Energy Surcharge • 25.00 I • • • • • Cascade Columbia Distribution TOTAL 7,625.00 PLEASE REMIT TO: P.O Box 24745 • Seattle,WA 98124-0745 • PLEASE PAY THIS AMOUNT IMPORTANT-Returnable containers will be charged end must be paid for.Such payment will be refunded at full price,provided containers are received by us in good reasonable condition within 6D days from date of Invoice,freight prepaid.tagged with shipper's name, No discount allowed on containers. Interestr6ll be charged at the rate of 1%per month Is charged on ell balances or portions of balances that are more than 30 days past due. In the event that it becomes necessary to involve a third party to effect collection of this account,Purchaser agrees to pay.the maximum finance charge allowed by law on all invoices not paid within terms,attorneys fees,and all other collection fees. Seller shall retain a security interest in all of the goods sold hereunder until the purchase price is fully paid. in the event that any such payment is not made promptly when due,the seller shall have all the rights and remedies of a secured creditor under the Uniform Commercial Code with respect to the goods delivered to Purchaser and products and services into which they may have been Incoporated in adddition to any other rights and remedies available under applicable lam I . STRAIGHT BILL OF LADING CUSTOMER PORTLAND-14200 SW T UALATIN-SHERWOOD RD SHERWOOD,OR 97140 BlLDATE Al> CASCADE SEATTLE-6900 FOX AVE S. 2EILOA E• '0 i• :;4.� � pp �y+,�� SEATTLE.WA 98108 3" -• COLt,f'EbktY5tL�: SEATTLE PH:(206)282-6334 FAX:(206)282-6330 y PORTLAND PH:(503)625-5293 FAX:(503)625-4335 Bn.NO, •• COMPANY E C L SPOKANE PH:(877)625.5293 6306a� •'�' : '} by4 F'cG 4r Page I of' 1 cAscAbE: COLUMBIA CITY OF RENTON :S i CITY OF RENTON CALL BILL WALKER 1-2 HR DISTRIBUTION O 3555 NE 2ND ST iH FOR CHEMICAL L t I BEFORE EMERGENCY D RENTON,WA 98056-4192 1p, CALL IHR PRIOR TO DELIVERY T, 425-430-7400 SPILL,LEAK BEHIND REC CENTER IN PARK FIRE, •O' 1,1 i CCTF--1715 MAPLE VALLEY HVtrY EXPOSURE.OR A: ACCIDENT r :•CUST.MO;f', •''•• •;CU,S�'PI7N0_;.•,: : !:;'+::' ,;•,:•:::QtderDafe, - •Wk(SECOC:_::4. •:CQNSIONEEORDERt;0._ CALL: _ - CHEMTREC DAY 03488 190064 2/3/2012 100 OR NIGHT :SHIPDATF..�::: ....::. :..:.... •••._ :-, -$H!t?VIA.'•:'` ::•.:r • -- ..REb1At�K' ,2. -:,_ 24 930D - •- - ---- •FOB �T'ERtis• BDO-4 2/8/2012 CASCADE DELIVERY DELIVERED N3 KR QUANTITY QUANTITY QUANTITY PACKAGING HM DESCRIPTION NET GROSS . FRT ORDERED SHIPPED BACKORDER WEIGHT WEIGHT CLS 200 200 0 50#BAG X UN1690,SODIUM FLUORIDE 10000.00 10200.00,. 666100T1 6.1,PG111,ERG 154 SODIUM FLUORIDE JAPA 50#.BAG Lot Number. Pac:aoinq: Qtv: _ SO-F-13 50 A BAG 200 Total Weights(LBS): 10000.00 10200,00 DELIVER BETWEENN 7-7:30AM • EARLY MORNING DELIVERIES ONLYIIII , . Call either CRAIG 425-766-1866 or Venessa(425)430-7411 prior to delivery LIFTGATE REQUIRED • • • SHIPPER'S CERTIFICATION This is to certify that the above neme erials are groperlyclassified, =Carrier Name,If different . described,padraged,marked and labeled and are iaproper-cont•onto nspori Jion-according to the applicable regulations of DOT. /'��.�� . , Sigr:ature: r"„- - Drivers Signature l . Date• LOAD INFO PULLED BY: : CHECKED a 11 .— 1 L- 2-'P'-.I BY: Customer Signature UNLOAD ARRIVE: DEPART: ----------_-------.—.---.__.__..__--._._ TIME _ Customer Print Name ' Date i / a 1 PLACARDS OFFERED: ON TRUCK: Signature here by confirms receipt of quantity stated in order and • agrees to comply with the terms set forth on the back of Ibis Form. c' Sodium Fluoride • 1W Material Safety Data Sheet Chemical: Sodium Fluoride NFPA: H=3 F=0 1=0 S=None HMIS: H=3 F=0 R=0 PPE=Supplied by user; MSDS Number; NAF-1103 dependent on conditions mij Effective Date; 13 November 2003 Issued by: • Solvay Chemicals,Inc.Regulatory Affairs Department Not valid three years after effective date or after issuance of superseding MSDS,whichever is earlier.French or Spanish translations of this MSDS may be available.Check www.solvaychemicals.us or call Solvay Fluorides,LLC to verify the latest version or translation availability. Material Safety Data Sheets contain country specific regulatory information.Therefore,the MSDS's provided are for use only by customers of Solvay Fluorides,LLC in North America.If you are Iodated in a country other than Canada,Mexico or the United States,please contact the Solvay Group company in your country for MSDS information applicable to your location. = prnyali:drodu _ r= y.f._ 1.1 Product Name: Sodium Fluoride Chemical Name: Sodium fluoride Synonyms: None • Chemical Formula: NaF Molecular Weight 42 • CAS Number: 7681-49-4 EINECS Number: 231-667-8 Grade/Trade Names: Coarse Blends,Granular,Powder,USP,Coarse,Crystal 1.2 Recommended Uses:Welding and fluxing agents;metallurgy;glass industry; dental application;water fluoridation • 1.3 Supplier: ' Solvay Fluorides,LW PO BOX 27328 Houston,TX 77227-7328 3333 Richmond Ave.Houston,Texas 77098 1.4 Emergency Telephone Numbers • Emergencies(USA):1-800-424-9300(CHEMTREC1 Transportation Emergencies(INTERNATIONAUMARITIME);1-703-527-3887(CHEMTREC5) • Transportation Emergencies(CANADA):1-613-996-6666(CANUTEC) Transportation Emergencies(MEXICO-SETIO): 01-800-00-214-00(MEX.REPUBLIC) 525-559-1588(Mexico City and metro area) - 1 (1) 1 SolVay MSDS No.NAF-1103 Revised 11-13-03 Respornible Care' Copyright 2003,Solvay Fluorides,LLC Fluorides canarx s:yot sv�t A subsidiary of Solvay Chemicals,Inc. All ww.sRights ReserveychemId. A Subsidiary of Solvay Chemicals, Inc. . Page 1/10 w�nvsolvaychemfcels.t>s 1.800365.8292 t . • Sodium Fluoride • Material Safety Data Sheet Ham -__--=�-=�_��zA= �=_;,.�.�-_ate_•^-�_�-.��-v-:=._i3- ��:".:�.�_____—_ .=-��_ �—� INGREDIENTS FORMULA WI.PERCENT CAS# Sodium Fluoride NaF 97.00 7681-49-4 Sodium Fluorosilicale Na2SiFe 5.2.50 16893-85-9 Water H2O S 0.50 7732-18-5 a r Emergency Overview: • Hazardous product for the human health and the aquatic environment. • Presents hazards from its ionizing fluorine. • In case of decomposition,releases hydrogen fluoride. DEM 3.1 Route of Entry: Inhalation:Yes Skin:Yes Ingestion:Yes 3.2 Potential Effects of exposure: • Irritating to the mucous membranes,eyes and skin. • Risk of cardiac and nervous disorders. • Fatalities have been observed after a single dose of 5 grams or more taken by an adult weighing 70 kg. • Chronic exposure to the product can cause bone or dental fluorosis Inhalation: • Nose and throat irritation. • Cough. • At high concentrations, risk of hypocalcemia with nervous problems(tetany)and cardiac arrhythmia. • .In case of repeated or prolonged exposure:risk of sore throat,nose bleeds, • • chronic bronchitis. Eyes: - • Severe eye irritation,watering and redness. • Risk of temporary eye lesions. • Skin contact: • Irritation. • in case of repeated contact: risk of burns. • ingestion: • Severe Irritation of the mouth,throat,esophagus and stomach. • Abundant salivation. • Nausea,vomiting,abdominal cramps and diarrhea. a Risk of hypocalcaemia with nervous disorders(tetany)and cardiac rhythm disorders. • Risk of convulsions,loss of consciousness,deep coma and cardiopulmonary arrest. • Risk of general symptoms having a severe prognosis. . Carcinogenicity:See section 11.3 MSPS No.NAF-1103 Revised-11-13-03 Copyright 2003,Solvay fluorides,LLC A subsidiary of Solvay Chemicals.Inc. All Rights Reserved. Page 2/10 wwwsolvaychemicals.us 1.800.765.8292 • Sodium: Fluoride • Material Safety Data Sheet dea`s_Qrs 4.1 General Recommendations:Strict hygiene during and at the end of working shifts. Inhalation: • Remove the subject from dusty environment. • • Administer oxygen orcardlopulmonary resuscitation if necessary, • Consult a physician in case of respiratory symptoms. Eyes: r9 Consult an ophthalmologist immediately in all cases. • Take to hospital immediately. • Flush eyes with running water for 5 minutes,while keeping the eyelids wide open. • Rinse the eyes with calcium gluconate(1%solution in'physiological serum) M (10m1 of calcium gluconate 10% In 90 ml of physiological serum)for 10 minutes. (Continue a calcium gluconate drip into eyes...then drop-wise while transporting.)if 1%calcium gluconate is not available continue flushing with water. • In the case ofdifficulty opening the lids,administer an analgesic eye wash. Do not use oily drops,ointment,or HF skin bum treatments). Skin: • Remove contaminated shoes,socks and clothing,while washing the affected skin with running water for 5 minutes. Double-bag all contaminated clothing for disposal. • Immediately apply calcium gluconate gel(2.5%)and massage into the affected area using rubber gloves;continue to massage while repeatedly applying gel until 15 minutes after pain is relieved. • If fingers/finger nails are touched,even if there is no pain,dip them in a bath of 5%calcium gluconate for 15 to 20 minutes. • Apply water longer(15 minutes)if calcium gluconate is not available. • Provide clean clothing. • Consult a physician in cases of persistent pain or redness. • Ingestion: General recommendations • Consult a physician immediately in ail cases. • Take to hospital. If the subject Is completely conscious: • Rinse mouth with fresh water. • Give a 1%aqueous calcium gluconate solution to drink. • If the subject presents nervous,respiratory or cardiovascular disorders: • administer oxygen, • Administer classical resuscitation measures. • If the subject is unconscious: • NEVER GIVE ANYTHING BY MOUTH TO AN UNCONSCIOUS PERSON. 4.2 Medical Treatment/Notes to Physician:See Section 4.1. ru1SOS No.NAF-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides,t10 A subsidiary of Solvay Chemicals,Inc. All Rights Reserved. Page 3/10 www.solvaychemIcals.us 1.800.765.8292 . • Sodium Fluoride Material Safety Data Sheet NEM • • -� Yom- - r _ • ttlr-e Sodium Fluoride Material Safety Data Sheet • 7.3 Specific Uses:See Section 1.2. 7.4 Other precautions: • Warn people about the hazards of sodium fluoride. • Avoid dust and formation of dust clouds. • Follow the protective measures given in section 8. 7.5 Packaging: • • Paper th E. • Drums lined linedwiwithPPE..E �8 �pa_su_r�C: �A.is`I,:Pi�rsi��alP�ratec�t�on=x.� .�=�• �w==�==•=- 8.1 Exposure Limit Values:~� Authorized Iimit•Ilalues 'FLIP ACRIH9-IDSA(2002) OSHA PEL• NIOSH REL(1994) Fluorides 2.5 mg/m3(as F) 2.5 mg/m3(as F) 2.5 mg/m3(as F) ACGIH5 and TLVa are registered trademarks of the American Conference of Governmental Industrial Hygienists. 8.2 Exposure Controls: • • Follow the protective measures given in section 7. • Maintain employee exposures to levels below the applicable exposure limits. 8.2.1 Occupational Exposure Controls: 8.2.1.1 Ventilation:Provide local ventilation suitable for the dust risk. 8.2.1.2 Respiratory protection: • Self-contained breathing apparatus in medium confinement/insufficient oxygen/in case of large uncontrolled emissions/in all circumstances when the mask and cartridge do not give adequate protection. • Use only respiratory protection that conforms to international/national standards. • Use only NIOSH-approved respirators. • Comply with OSHA respiratory protection requirements. • 8,2.1.3 Hand protection;Protective gloves-chemical-resistant(PVC,neoprene,rubber). 8.2.1.4 Eye protection:Dustproof goggles. 8.2.1.5 Skin protection: • Overalls, • Apron/boots of PVC,neoprene,rubber in case of dust. 8.3 Other precautions: • Do not smoke,eat or drink in the working area. • Take off contaminated clothing immediately after work. • Provide shower and eyewash stations. • Consult the industrial hygienist or the safety manager for the selection of personal protective equipment suitable for the working conditions. • . Maintain adequate supply of antidote gel,calcium gluconate. MSDS No.NAF-1103 Revised 11-13-03 • - Copyright 2003,Solvay Fluorides,LLC • A subsidiary of Solvay Chemicals,Inc. M Rights Reserved.. - • Page 5/10 wvAv.solvaychemlcals.us 1.800.765.8292 Sodium Fluoride Material Safety Data Sheet •cti^-`:.^.`r----r"_--_:!'�_^:�:_...�_.-=r...�._._ _ aL`?=^.-..�4�_=:c=`_^�.-..__.'_�_.=ami='ir_^{:�:i?:=:_.-�.=:=� 9.1 Appearance:Crystalline powder. • Color:White. Odor:Odorless. 9.2 Important Health,Safety and Environmental information: pH:9,2 at 20°C(68°F)1%solution. Change of state: Melting point:995°C(1823°F). Boiling point:1695°C(3083°F). • Decomposition Temperature: No data. Flash Point:Not applicable. Flammability:Not applicable, Explosive Properties:No data. Oxidizing Properties:Not applicable. • Vapor pressure:1.33 hPa. Relative Density: Specific gravity(H2O=1):2.5-2.6. Solubility: Water:42 Oat 20°C(68°F). Fat:No data. • Partition coefficient Not applicable. Viscosity:Not applicable. Vapor Density(air=1):Not applicable. • Evaporation Rate:Not applicable. 9.3 Other Information: Granulometry:90%>1 mm. . ���:�tabili�jr=anc�Reaci�irE. _--.--�--�-s. - � -.---=_�j�- _ _��• Stability:Stable under certain conditions(see below). 10.1 Conditions to avoid:Moisture. 10.2 Materials and substances to avoid: • Strong acids-reacts. • Glass-reacts. 10.3 Hazardous decomposition products:Hydrogen fluoride. 10.4 Hazardous Polymerization:Will not occur. MSDS No.NAF-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides.LLC A subs!diary of Solvay Chemicals,Inc. All Rights Reserved. Page 6/10 wvwvsolvaychemicals.us 1.800.785.8292 Sodium Fluoride Material Safety Data Sheet 11.1 Acute toxicity: Inhalation: Oral:LDS=62-250 mg/kg,rat. Dermal:LID to=-300 mg/kg, mouse. • Irritation: • Rabbit,slight irritant(skin). • Rabbit,irritant(eyes). • Sensitization:No data Otani • Comments: • Chronic exposure may entail dental or skeletal fluorosis. • The carcinogenic effect found in animals is not demonstrated iii humans. • Risk of toxic effect on reproduction. 11.2 Chronic toxicity: • Oral route,after prolonged exposure,rat/mouse,target organ:skeleton/thyroid 1 testes/ kidney,liver,-1 mg/kg,observed effect. • Ambiguous carcinogenic effect. • Ambiguous mutagenic effect. • Fetotoxic and fertility effects. 11.3 Carcinogenic Designation:None. 12.1 Acute ecotoxicity: • Fish,Salmo gairdneri, LOW,96 hour(s),112 mg/i. • Crustaceans, Daphnia magna,ECS,48 hour(s), 213 mg/.1 Conditions:Fresh water. • • Crustaceans, Mysidopsis bahia, ECS,96 hour(s),23mg/I • Conditions:Salt water. • Algae,Scene desmus sp.EC50,96 hour(s),95 mg/!. 12.2 Chronic ecotoxicity: • Fish,Salmo gairdneri, LC50,21 days,from 5.9-10,3 mg/l, + Crustaceans, Daphnia magna,NOEC,21 days, 8.1 mg/i. 12.3 Mobility: • Air-mobility as solid aerosols. • • Water/soil-considerable solubility and mobility. ' • Soil/sediments-adsorption on mineral soil constituents. Conditions:slightly acid pH(Fluorides). • MSDS No.NAP-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides, MC A subsidiary of Solvay Chemicals,Inc. All Rights Reserved. Page 7110 vrvnvsolvaychemicals,us 1.800.765.8232 • Sodium Fluoride Material Safety Data Sheet ' Oil 12.4 Degradation Abiotic:Water/soil-complexation/precipitation of inorganic materials. Degradation products:aluminum/iron/calcium/phosphate complexes and/or precipitates as a function of pH(Fluorides). Biotic:not applicable(inorganic compound). 124 Potential for bioaccumulation:Bioconcentration: log Po/w. (icompound). • ANotccumulatiapplicableon into vegetableonizableinorganic leafs(Fluorides). 12.6 Other adverse effects/Comments: • Harmful for aquatic organisms. • Nevertheless,hazard for the aquatic environment is limited due to product properties: low chronic toxicity. • Product fate is highly depending on environmental conditions:pH,temperature, oxidoreductive potential,mineral and organic content of the medium,... Zt�3 D1 p�osaICorsiderators = =_ 13.1 Waste treatment: • • Consult current federal,state and local regulations regarding the proper disposal of this material, • • Dispose of the product at a landfill authorized for Industrial waste. 13.2 Packaging treatment:Consult current federal,state and local regulations regarding the proper disposal of emptied containers. 13.3 RCRA Hazardous Waste:Not Listed. TWISpOt lnfor• a�ib-ns�—_..��r�,:y • Mode DOT IMDG IATA UN Number UN 1690 UN.1690 UN 1690 • Class(Subsidiary) 6.1 6.1 6.1 Proper Shipping Name Sodium Fluoride Sodium Fluoride Sodium Fluoride Hazard label(Subsidiary) Poison Placard[Subsidiary) Poison 1690 Packing Group HI ill Ill Reportable quantity 1000 lbs. MFAG Emergency Info ERG:154 EmS:6.1-04 ERG Code:6L • • MSPS No.NAF-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides,LLC A subsidiary of Solvay Chemicals,Inc. All Fights Reserved. Page 8110 W wsotvaychemicals.us 1.800.765.8292 • Sodium Fluoride Material Safety Data Sheet • --.W= >zs-..-'••-�• ty.r---_..._`_.r.��.::.a—•ti_-_:'.=-uta::__._=-- ��i _.x-.,v�k:v:v:_•ax:_. -�:-.-�_`_`_-'r"`L,y"zf.:.xcn. ...... .........=„cam— National Regulations(US) TSCA Inventory 8(b):Yes. . • SARA Title III Sec.302/303 Extremely Hazardous Substances(40 CFR 355):No, • SARA Title Ill Sec.311/312(40 CFR 370):No. SARA Title IiI Sec.313 Toxic Chemical Emissions Reporting(40 CFR 372):No. CERCLA Hazardous Substance(40 CFR Part 302): Listed:Yes,Reportable Quantity 1,000 lbs. State Component Listing: State Comment g= CA Airborne Contaminants&Emissions Inventory CA Hazardous Substance List CT. Hazardous Materials Survey IL Chemical Safety Act IL Toxic Substances Disclosure-to Employees Act IN Occupational Health&Safety Standards-Air KY Occupational Health&Safety Standards-Air LA Spill Reporting MA Oil and Hazardous Materials List MA Right to Know Substance List MN' Hazardous Substance List NJ Right to Know Substances List NJ Spill Tax List NC Exposure limits for Air Contaminants NY Release Reporting; List of Hazardous Substances PA Right to Know RI Right to Know National Regulations(Canada) Canadian DSL Registration:DSL WHMIS Classification: D2A-Very Toxic Material: This product has been classified in accordance with the hard criteria of the Controlled Products Regulations,and the MSDS contains all the information required by the Controlled Products Regulations. Labeling according to Directive 1999/45/EC. Category _ll phrase Symbols T Toxic. Phrases R 25 Toxic if swallowed. 32 Contact with acids liberates very toxic gas. 36 Irritating to eyes and skin. Phrases S 22 Do not breathe dust. 36 Wear suitable protective clothing. 45 In case of accident or if you feel unwell,seek medical advice immediately show the label where possible. MSDS No.NAF-1103 Revised 11-13-03 Copyright 2003,Solvay Fluorides,LLC A subsdiery of Solvay Chemicals,inc. All Rights Reserved. Page 9/10 vrWiW.solvaychemlcals.us 1.800.705.8292 1, • Sodium Fluoride Material Safety Data Sheet -- -_- -Wit__^r�•:..-.��.a`- -__ -" -- _- - -.............. -- •. ^-` - -�., •_'- -^ ,kms."�:__�'.� _--.•----_•-- • 16.1 Ratings: - NFPA(NATIONAL FIRE PROTECTION ASSOCIATION) Health=03 Flammability=0 Instability=0 Special=None HMIS(HA7.11RIDOUS MATERIAL INFORMATION SYSTEM) Health=3 Fire=0 Reactivity=0 PPE=Supplied by User;dependent on local conditions 16.2 Other Information: The previous information is based upon our current knowledge and experience of our product'and is not exhaustive.It applies to the product as defined by the specifications.In case of combinations or mixtures,one must confirm that no new hazards are likely to exist.In any case,the user is not exempt from observing all legal,administrative and regulatory procedures relating to the product, personal hygiene,and integrity of the work environment.(Unless noted to the contrary,the technical information applies only to pure product). - To our actual knowledge,the information contained herein is accurate as of the date of this document. However, neither Solvay Fluorides,LLC nor any of its affiliates makes any warranty, express or implied,or accepts any liability in connection with this information or its use.This information is for use by technically skilled persons.at their own discretion and risk and does not relate to the use of this product in combination with any other substance or any other process,Thls Is not a license under any patent or other proprietary right.The user alone must finally determine suitability of any information or material for any contemplated use,the manner of use and whether any patents are infringed.This information gives typical properties only and is not to be used for specification purposes. • Trademarks and/or other Solvay Fluorides,LLC products referenced herein are either trademarks or registered trademarks of Solvay Fluorides,ILO or its affiliates,unless otherwise indicated. • 16.3 Reason for revision: • Supersedes edition: Solvay Fluorides Inc.MSDS dated 5/6/2003 Purpose of revision:Change Company name and MSDS format • MSDS No.NAF-7103 Revised 11-13-03 Copyright 2003,Solvay Fluorides,LLC A subsidiary of Solvay Chemicals,Inc. All Rights Reserved. Page 10/10 vovmsotvaychemlcals.us 1.800-765.8292 \ 1 5 J ' RENTON CITY COUNCIL Regular Meeting June 11,2012 Council Chambers Monday,7 p.m. MINUTES Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER, Council President;TERRI BRIERE; ED PRINCE; DON PERSSON; COUNCILMEMBERS RANDY CORMAN; GREG TAYLOR. MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL EXCUSE COUNCILMEMBER MARCIE PALMER. CARRIED. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; LAWRENCE. J.WARREN, City Attorney; BONNIE WALTON, City Clerk; GREGG ZIMMERMAN, Public Works Administrator; CHIP VINCENT, Interim Community and Economic Development Administrator; DEPUTY CHIEF ERIK WALLGREN, Fire & Emergency Management Services Department;COMMANDER CLARK WILCOX, Police Department. . PROCLAMATION A proclamation by Mayor Law was read declaring June 15, 2012 to be"Elder Elder Abuse Awareness Day- Abuse Awareness Day" in the City of Renton, and encouraging all citizens to join June 15,2012 in this special observance. MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL CONCUR IN THE PROCLAMATION. CARRIED. ' AUDIENCE COMMENT Dian E. Ferguson (Tukwila),speaking on behalf of the West Hill Business Citizen Comment: Ferguson— Association and the West Hill "YES" Community, expressed concern about the Proposed West Hill possible postponement of the vote on West Hill Annexation,and asked Council Annexation to allow the election to take place in November. She stated that they have been working hard on their public education campaign, and that the uncertainty of date makes it difficult for them to proceed. Ms. Ferguson acknowledged that the cost of annexation will not be fully compensated, but believed that there are alternate ways to pursue the funding. She reiterated that Renton will gain benefit in the long term if the Skyway and West Hill area becomes part of the city. Ms. Ferguson concluded by urging Council to understand the importance of moving the vote forward. Councilmember Corman remarked that Council plans a serious discussion about the potential postponement. He explained that the initial understanding was that the City Council could still make a decision on whether or not to accept the annexation after the vote,and the City Attorney has now advised that might . not be the case. He further explained the administration's concerns about the budget and the related legislative uncertainty. Mr.Corman expressed appreciation for the West Hill residents' participation in the annexation. Ms. Ferguson responded that they have been talking to the people who are actively working on the campaign and speaking with political leaders. She commented that there might be different interpretations of the law regarding the annexation process. June 11,2012 Renton City Council Minutes Page 181 Citizen Comment: Bean— Paula Bean (Renton)complained of'noise disturbances from the roosters in her Noise Complaint neighborhood, and asked for help to solve the problem. Mayor Law referred Ms. Bean to Police Commander Clark Wilcox to address her concerns. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. Council: Meeting Minutes of Approval of Council meeting minutes of 6/4/2012. Council concur. 6/4/2012 Utility: Release of Easement City Clerk submitted City-initiated request for release of easements on behalf of Request, Renton Properties, Renton Properties, LLC(PID 723160-0542, Recording#20060216000604); RVA RVA Office, & RVA Center Office, LLC(PID 723200-0020, Recording#20060317000391);and RVA Center, LLC(PID 192305-9043, Recording#20060317000390)for the 2006 Renton Village Storm System project in order to designate smaller easement areas,to classify the new easements as Class B with no compensation due,and waive all filing and processing fees. Refer to Utilities Committee. CAG: 12-078, Earlington City Clerk submitted bid opening on 6/5/2012 for CAG-12-078, Earlington Sewer Sanitary Sewer Replacement, Replacement Phase II project;six bids;engineer's estimate$704,014.92; and Shoreline Construction submitted staff recommendation to award the contract to the low bidder, Shoreline Construction,Co., in the amount of$714,844.47. Council concur. Lease:Addendum,Aerodyne, Transportation Systems Division recommended approval of an addendum to LAG-84-006 airport lease LAG-84-006,with Aerodyne, LLC, increasing the total ground lease to$0.62 per square foot per year plus leasehold tax,which is an annual increase of$4,065.02,through 8/31/2014. Refer to Transportation (Aviation) Committee. Lease:Addendum, Northwest Transportation Systems Division recommended approval of an addendum to Seaplanes, LAG-91-005 airport lease LAG-91-005,with Northwest Seaplanes, Inc., increasing the total ground lease to$0.62 per square foot per year plus leasehold tax,which is an annual increase of$23,124.41,through 12/31/2017. Refer to Transportation (Aviation) Committee. Airport:Operating Permit& Transportation Systems Division recommended approval of an Operating and Agreement, Clean Craft Permit Agreement with Clean Craft Detailing, Inc.,and the related sublease Detailing between Bosair, LLC and Clean Craft Detailing, Inc.,for the purpose of allowing Clean Craft Detailing, Inc.to operate their aircraft detailing business at the airport. Refer to Transportation(Aviation) Committee. MOVED BY ZWICKER,SECONDED BY CORMAN, COUNCIL APPROVE THE CONSENT AGENDA AS PRESENTED. CARRIED. UNFINISHED BUSINESS Community Services Committee Vice-Chair Prince presented a report Community Services recommending concurrence in Mayor Law's appointment of Mr. David Basco to Committee the Airport Advisory Committee(Renton Hill Neighborhood -primary position), Appointment:Airport Advisory for a term expiring on May 7, 2015. Committee MOVED BY PRINCE,SECONDED BY TAYLOR,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. June 11, 2012 Renton City Council Minutes Page 182 RESOLUTIONS AND The following ordinance was presented for second and final reading: ORDINANCES ORDINANCE#5664 An ordinance was read amending Section 1-3-1 of Chapter 3, Remedies and Attorney:Gross Penalties,of Title I (Administrative)of Ordinance No.4260 entitled "Code of Misdemeanors, Code General Ordinances of the City of Renton,Washington", correcting Subsection Amendment 1-3-1B to include gross misdemeanors. MOVED BY PERSSON,SECONDED BY ZWICKER, COUNCIL ADOPT THE ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. NEW BUSINESS. Councilmember Persson shared his observations and appreciation regarding Community Event: Renton the recent barbecue event provided by the Renton High School Alumni High School Alumni Association to recognize the Renton High School senior graduates. Association Barbecue AUDIENCE COMMENT Audrey Adams (Renton) stated that she is involved in Washington Action for Citizen Comment:Adams— Safe Water,which promotes the removal of fluoride in water. She pointed out Fluoridated Water that more than 4,000 professionals,who are at great risk to their profession and livelihood speaking against fluoridation, have studied and signed a statement calling for an end to water fluoridation,and among the professionals, 130 are from Washington State. Ms.Adams highlighted a few items in the statement. ADJOURNMENT MOVED BY ZWICKER,SECONDED BY PRINCE,COUNCIL ADJOURN. CARRIED. Time:7:27 p.m. 'J. �- Bonnie I.Walton, CMC, City Clerk Li Li-Wong, Recorder June 11, 2012 RENTON CITY COUNCIL COMMITTEE MEETING CALENDAR Office of the City Clerk COUNCIL COMMITTEE MEETINGS SCHEDULED AT CITY COUNCIL MEETING June 11, 2012 COMMITTEE/CHAIRMAN DATE/TIME AGENDA COMMITTEE'OF THE WHOLE WED., 6/13 ' - - : _ : a :. : - - _ _ - - (Zwicker) CANCELED *Knowles Education Center, 300 SW 7th St., Renton* MON., 6/18 West Hill Annexation 5:30 p.m. COMMUNITY SERVICES (Palmer) FINANCE MON:, 6/18 Vouchers; (Briere) 4:30 p.m. Emerging Issues in Revenue Streams PLANNING & DEVELOPMENT THURS., 6/14 Title IV (Development Regulations) Docket (Prince) 3:00 p.m. #8 • PUBLIC SAFETY MON., 6/18 CANCELED (Persson) TRANSPORTATION (AVIATION) THURS., 6/14 Lease Addendum with Northwest (Corman) 4:00 p.m. Seaplanes; Operating Permit &Agreement with Clean Craft Detailing; Lease Addendum with Aerodyne, LLC; Emerging Issues in Transportation UTILITIES (Taylor) NOTE: Committee of the Whole meetings are held in the Council Chambers unless otherwise noted. All other committee meetings are held in the Council Conference Room unless otherwise noted. From: Jay B Covington Sent: Monday, June 11, 2012 7:14 PM To: Bonnie Walton; Don Persson; Ed Prince; Greg Taylor; Julia Medzegian; Marcie Palmer; Randy Corman; Rich Zwicker; Terri Briere Cc: Gregg A. Zimmerman; Denis Law; 'audrey55@comcast.net Subject: FW: Renton City Council meeting 6/11/12 Attachments: 2012 6-11 Renton City Council.docx; 2012 6-11 Professional Signers in WA(130 as of 6-11-12).docx; 1 Professionals Stmt to End Fluoridation in PDF.pdf Council, I am forwarding this information at the.request of Ms Adams. The Mayor has asked staff to prepare background materials for your information that will provide a history of the decisions made regarding fluoridation of Renton's water supply. Jay Covington Chief Administrative Officer City of Renton From: Audrey Adams [mailto:audrey55C8comcast.net] Sent: Monday,June 11, 2012 5:52 PM To: Jay B Covington Subject: Renton City Council meeting 6/11/12 Mr. Covington, Attached and below is the topic of my public comment tonight. I fully recognize that it is too late to give this to the Council before the meeting, but after the meeting is just fine. Thank you for helping me save trees by not printing hard copies. Audrey Adams • June 11, 2012 Subject: Over 4,000 Professionals Call for an End to Water Fluoridation Dear Renton City Council members and Mayor Law, I am not alone in my desire to end water fluoridation. More than 4,000 professionals who have studied water fluoridation and who now believe that it should be stopped have signed a statement calling for an end to water fluoridation. Over 130 of these professionals are from Washington state. 1 0 1• In many cases these professionals are coming out of the closet against fluoridation at significant risk to their continued employment or standing in their professional organizations. Professionals who speak against it are not paid (with very rare exceptions) and are often risking their livelihood by putting their name on the line. This is in sharp contrast to the professionals who promote fluoridation who are paid specifically to do so. See the Professionals Statement and the signers online at http://www.fluoridealert.org/statement-august-2007.html By viewing this list online you can click on the links for many of these professionals, especially national and international signers,to see who they are and what their accomplishments are. The Professionals Statement is attached in PDF format as well. Tonight I am also bringing 10 copies of the DVD video"Professional Perspectives on Water Fluoridation" produced by Fluoride Action Network. I have received permission from Paul Connett of FAN to reproduce this video. You may view it online at http://www.fluoridealert.org/videos.aspx if you would prefer. I am happy to provide as many copies of this DVD as you like. My primary goal is to protect children. These professionals have many reasons to denounce water fluoridation,the negative effects of too much fluoride now being consumed by children is just one, but perhaps is the greatest concern. These professionals have done their homework---read the scientific studies themselves on both sides---and are now courageously making a stand. I am so thankful to them...and to you,for listening with an open mind. Sincerely, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 PS: Please let me know what type of information you would like me to bring to you in the future. • • 2 June 11,2012 Renton City Council Subject: Over 4,000 Professionals Call for an End to Water Fluoridation Dear Renton City Council members and Mayor Law, I am not alone in my desire to end water fluoridation. More than 4,000 professionals who have studied water fluoridation and who now believe that it should be stopped have signed a statement calling for an end to water fluoridation. Over 130 of these professionals are from Washington state. In many cases these professionals are coming out of the closet against fluoridation at significant risk to their continued employment or standing in their professional organizations. Professionals who speak against it are not paid (with very rare exceptions) and are often risking their livelihood by putting their name on the line. This is in sharp contrast to the professionals who promote fluoridation who are paid specifically to do so. See the Professionals Statement and the signers online at http://www.fluoridealert.org/statement- august-2007.html By viewing this list online you can click on the links for many of these professionals, especially national and international signers,to see who they are and what their accomplishments are. The Professionals Statement is attached in PDF format as well. Tonight I am also bringing 10 copies of the DVD video"Professional Perspectives on Water Fluoridation" produced by Fluoride Action Network. I have received permission from Paul Connett of FAN to reproduce this video. You may view it online at http://www.fluoridealert.org/videos.aspx if you would prefer. I am happy to provide as many copies of this DVD as you like. My primary goal is to protect children. These professionals have many reasons to denounce water fluoridation,the negative effects of too much fluoride now being consumed by children is just one, but perhaps is the greatest concern. These professionals have done their homework---read the scientific studies themselves on both sides---and are now courageously making a stand. I am so thankful to them...and to you,for listening with an open mind. Sincerely, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 • 425-271-2229 PS: Please let me know what type of information you would like me to bring to you in the future. Professionals' Statement Calling for an End to Water Fluoridation http://wvvw.fluoridealert.org/statement-august-2007.html 4,038 Signers by-degree as of February 2, 2012: • 687 Nurses (RN, MSN, BSN, ARNP, APRN, LNC, RGON) • 518 MD's (includes MBBS) . • 561 DC's (Doctor of Chiropractic, includes M Chiro)' •481 PhD's-includes DSc, Doctor of Science; EdD (Doctor of Education); DrPH (Doctor of Public Health) • 331 Dentists (DDS, DMD, BDS) • 165 ND's (Doctor of Naturopathic Medicine) • 95 Lawyers (JD, LLB, Avvocato) • 89 Pharmacists (Pharm.D, B. Pharm, DPh, RPH) • 96 RDHs (Registered Dental Hygienist); also DH, RDHAP, EFDA, RDAEF, and RDN • 62 Acupuncturists (LAc- Licensed Acupuncturist, and, MAc-Master Acupuncturist) •43 DO's (Doctor of Osteopathic Medicine) •27 Veterinarians (DMV, VMD, BVMS) • 17 OD (Doctor of Optometry). • 18 PA-C (Physician Assistant-Certified); also MPAS and RPA-C • Signers include: •Arvid Carlsson, Nobel Laureate for Physiology or Medicine, 2000 •Vyvyan Howard, MD, PhD, Past President, International Society of Doctors for the Environment(ISDE) • Ingrid Eckerman, MD, MPH, President, Swedish Doctors for the Environment(LFM), Stockholm, Sweden • Raul Montenegro, PhD, Right Livelihood Award 2004 (known as the Alternative Nobel Prize), President of FUNAM, Professor of Evolutionary Biology, National University of Cordoba, Argentina •The current President and six past Presidents of the International Academy of Oral Medicine and Toxicology •Three scientists from the Environmental Protection Agency (EPA) Headquarters Union in Washington D.C. *William Marcus, PhD, Former chief toxicologist of the EPA Water Division, Boyds, MD •Three members of the National Research Council committee who wrote the landmark 2006 report: Fluoride in Drinking Water:A Scientific Review of EPA's Standards(Hardy Limeback, PhD, DDS; Robert L. Isaacson, PhD; Kathleen M. Thiessen, PhD) •The Board of Directors, American Academy of Environmental Medicine •Two advisory board members of the UK government sponsored "York Review" •Andy Harris, MD, former national president, Physicians for Social Responsibility, Salem, OR • Theo Colborn, PhD, co-author, Our Stolen Future • Lubomyr Romankiw, PhD, awarded the Perkin Medal (1993), the highest honor given in the US industrial chemical industry • Lynn Margulis, PhD, a recipient of the National Medal of Science • Ken Cook and Richard Wiles, President and Executive Director, Environmental Working Group (EWG) • Ron Cummins, Director, Organic Consumers Association • Magda Aelvoet, MD, Former Minister of Public Health, Leuven, BELGIUM • Doug Everingham, former Federal Health Minister(1972-75), Australia • Peter Montague, PhD, Director of Environmental Health Foundation • Ted Schettler, MD, Science Director, Science and Environmental Health Network • • Stephen Lester, Science Director, Center for Health, Environment, and Justice • Lois Gibbs, Executive Director, Center for Health, Environment, and Justice, Goldman Prize Winner(1990), Falls Church, VA. • Rosalie Bertell, PhD, Regent of the Board, International Physicians for Humanitarian Medicine, Geneva, Switzerland, Retired President, International Institute of Concern for Public Health, Toronto, Canada • FIVE Goldman Prize winners (2006, 2003, 1997,1995, 1990) • Sam Epstein, MD, author, "Politics of Cancer" and Chairman,Cancer Prevention Coalition • Pat Costner, retired Senior Scientist, Greenpeace International • Jay Feldman, Executive Director,Beyond Pesticides • Sandra Duffy, Board President, Consumers for Dental Choice •Joseph Mercola, Doctor of Osteopathic Medicine, http://www.mercola.com, Chicago, IL • Michael W. Fox, DSc, PhD, BVM, MRCVS (former vice president of The Humane Society of the US, former vice president of Humane Society International and the author of more than 40 adult and children's books on animal care, animal behavior and bioethics), http://www.twobitdog.com/DrFox/, Minneapolis, MN • Leo Cashman, Executive Director of DAMS (Dental Amalgam Mercury Syndrome) • Chris Bryson, author, The Fluoride Deception • Environmental leaders from over 30 countries, and • Legendary folksinger, songwriter and activist, Pete Seeger • Professional Signers in Washington State (130 as of 6/11/12) *Helen Abay, RDH, BS, Lynnwood,WA *Sheila Adkins, RN, Prosser,WA *Rebecca Allen, RN, Shoreline,WA Mary Lou Andersen, MS (biology), LPN, CHT, Nurse, Nutritionist, Bellingham,WA *Julie Anderson,ARNP, Seattle,WA *Maryann Andonian, RDH, BA, Battle Ground,WA *Denel Andreas, ND,Seattle,WA *Nathan Banks, DC, Redmond,WA *James Bentz, DC,Anacortes,WA *Toni Best, DC, Redmond,WA *Jeffrey T. Bland, PhD, (the father of functional medicine)Seattle,WA *Colleen Bolander, RN,Woodinville,WA Russ Borneman, DDS,Anacortes,WA *Jon Burke, PhD(Clinical Psychologist), Union,WA *Valerie Burke, RN, MSN, Union,WA Blair B. Burroughs,JD, Burroughs&Baker P.C., Seattle,WA *Mikayla Byers, DC,Auburn,WA *Paul Byers, DC,Auburn,WA *Janell Chandler, DC,Vancouver,WA *Wenliang Chen, PhD,Vancouver,WA *Beverly Clark, RN, BSN, Seattle,WA Lawrence A. Clayman, BS, DC, Roxbury Spine and Wellness Clinic, Seattle,WA *Ann Clifton, RN, Olympia,WA *Kevin Conroy, ND, Port Angeles,WA *Louis Cook, DC, DesMoines,WA *Deborah Cummings,OT(Occupational Therapist), LMP, Snohomish,WA *James Robert Deal,JD, Lynnwood,WA Armand V. DeFelice, DDS, Spokane,WA *Resa Delany, PA-C (Physician Assistant-Certified), Shelton,WA *Beth DiDomenico, ND, Family Practice, Federal Way,WA • *Kenneth Dunning,MS, Mount Vernon,WA *Richard Edlich, MD, PhD, Brush Prairie,WA Roger Eichman, DDS(retired), Nordland,WA *Dwight Erickson, DC, Diplomate American Board of Disability Analysts, Colville,WA *Sylvia Ericson, MS, Certified Nutritionist Washington state, Mountlake Terrace,WA *Daniel Eschbach, DC, Bellingham,WA Diana L. Estberg, PhD, Chemistry(retired), Port Angeles,WA Gerald N. Estberg, PhD, Professor Emeritus in Physics, University of San Diego, CA, resident Port Angeles,WA *Gayle Eversole, PhD, DHom, MH, NP, ND,Spokane,WA *Shannon Fisher, RD,Tacoma,WA Paul Framson, PhD, Seattle,WA *Sharon Frederick, RN,Tacoma,WA *Robert Gabriel, PhD, Olympia,WA *Erwin Gemmer, DC, Silverdale,WA *Jill Goetsch, RN, MSN, Kirkland,WA *Brandy Gove, RD,CD,CNSD, Shoreline,WA *Sharon Greene,BSN, RN, MS, Pateros,WA C.Jess Groesbeck, MD, Preventive Medicine, Mount Vernon,WA James A.Gruber,former water superintendent, Lakeview Park Water Assoc(retired after 24 yrs), Soap Lake,WA *Lois Gruber, RN (retired), Seattle,WA *Jose Gude,MD, Seattle,WA *John B. Hallawell, DC, Harbor,WA *Michael Hanson, PhD,Shoreline,WA *Loraine Harkin, ND,Yakima,WA *Ruth Hawkinson, RN, Colbert,WA • *Joan Hill, ND, RN, Seattle, WA *Holly Hochstadt, DC, Seattle,WA *Cynthia Hodges,JD, LL.M, MA, Edmonds,WA Debra Hopkins, DDS,Tacoma,WA *Marlie Hostetter, RN, Redmond,WA *Becki Hoyt, RN, Lynnwood, WA *Charles W. Huffine, MA(Sociology), Pullman,WA Shirley Jacobson, MSc (Nursing), USPHS Nurse Corps(retired), Bellingham,WA *Duane Jones, DDS, Federal Way,WA *Lynn Jonsson, PhD,Tacoma,WA Eloise Kailin, MD, Sequim,WA *Elton Kerr,MD, FACOG, FRSM, Pasco,WA *Marga Kerr, RN, BS, Pasco,WA Dietrich Klinghardt, MD, Seattle,WA *Vernita C. Kontz, RN, BS, College Place,WA *Brice Kovarik, DC, BS, Lynnwood,WA *Michael Kucher, PhD, University of Washington(Tacoma),Seattle,WA *Grace Lasker, PhD, MS, Kirkland,WA *Alli Larkin, President, Board of Commissioners, King County Water District 54, Des Moines,WA Todd Lawson, DMD,Aesthetic Dentistry of Bellevue,WA *Susan D. Liddel-Jones, RN, BS, Nurse-Educator, Renton,WA *Joanne Loudin, PhD(Psychotherapist), Fox Island,WA *Cheryl Malcham, RD(Nutritionist), Mercer Island,WA Avery N. Martin, BS, DC, Mt.Vernon,WA *Matt McCann, DC, Marysville,WA • *Ben McCay, DC, Lynnwood,WA *John McLean,Water System Manager(#5829)in the state of Washington, Camano Island,WA *Mary Meier, RN, Seattle,WA *Donald Miller, MD, Professor of Surgery, Univ of Wash School of Medicine; author Fluoride Follies, Seattle,WA *Matthew Miller, DC, Vancouver,WA *Joshua Minks, BSN, Bothell,WA *Bill Misner, PhD,Author:What Should I Eat?A Food-Endowed Prescription For Well Being, Spokane,WA Jeffrey Morris, PhD(Economics), Sound Resource Management, Olympia,WA *Richard Morrison, PhD, Bellingham,WA *Jon R. Mundall, MD, Dipl.ABCMT, CNS, Connell,WA • *Michelle Murphy, Sr. Electrical Engineer, Mental Health Advocate for Washington State, Richland,WA *Cheryl Murray, RN, Newcastle,WA *Fred Neil,DC, Bellingham,WA Helene R. (Vaughn) Newbaker, RN, DC (retired), Sedro Woolley,WA *Sheryl Nixon, RN,Toledo,WA • *Chris Nubbe, MA(Environmental Engineering), BS (Civil Engineering), Olympia,WA *Lalania Olsby, RN, Seattle,WA *Ann Olsen, LM, CPM (Licensed Midwife and Certified Professional Midwife), Enumclaw,WA *Mike Pagan, CMPT, CCCE, PT(Physical Therapist), Seattle,WA *Lisa Paulk, RN,Arlington,WA *Margaret Piela, RN, Nutritional Counselor, Certified Herbalist, Sammamish,WA *Wendy Phillips Piret, BS USNA 93', Pediatric Craniosacral Therapist, Licensed Brain Gym Practioner, Mercer Is,WA *Terry K. Poth, DC, Bellingham,WA Jody Prusi, RDH, dental hygienist, Seattle,WA • *Danielle Reilly, BSN, RN, Bellevue,WA *Jennifer Ricker, DC, BA, Edmonds,WA *Elizabeth Rosendahl, RN,Tacoma,WA Darryl W. Roundy, DC, Gig Harbor,WA *Judith Royse, BSRDH, Spanaway,WA Paul G. Rubin, DDS, Seattle,WA *Jessica P.Saepoff, DDS, Issaquah,WA *David Schorno,Waste Water treatment Operator group II, Sedro-Woolley,WA *Ruth W.Shearer, PhD, Lacey,WA • *John Sheridan, MAT(Education), Issaquah,WA *Barara Simons, PA-C (Primary Care Physician Assistant), Freeland,WA *Lucy Smith, ND, Shoreline,WA Mark Stahl, DDS, Seattle,WA *Katie Stamwitz, DC, Hoquiam,WA *Gerald Steel, MS, PE, Esq., Olympia,WA *Robert Stephan, DDS, BS, FAPD, Nine Mile Falls,WA *Crystal Tack, ND, LAc, Sequim,WA *Carol Taylor, PhD(Computer Science), Spokane,WA J. Miranda R.Taylor, LAc, MTCM, Licensed Acupuncturist, Master of TCM, Gesundheit Acupuncture PLLC, Seattle *Christine Walker, RD(Registered Dietitian), MS (Nutrition and Dietetics), CD(Certified Dietitian), Bonney Lake,WA *Stephen Walsh, MS (Mathematical Statistics), Research Scientist, Richland,WA *Lee Whitmer, OD, Chattaroy,WA Richard S.Wilkinson, MD,Yakima,WA *Carla Witham, ROH, Bellingham,WA *Keith Wollen, PhD, Port Angeles,WA *Linda Zachariah,JD, Bellevue,WA THE STATEMENT: We, the undersigned professionals, come from a variety of disciplines but all have an abiding interest in ensuring that government public health and environmental policies be determined honestly, with full attention paid to the latest scientific research and to ethical principles. EIGHT recent events make action to end water fluoridation urgent. 1. The publication in 2006 of a 500-page review of fluoride's toxicology by a distinguished panel appointed by the National Research Council of the National Academies (NRC, 2006). The NRC report concluded that the US Environmental Protection Agency's (EPA) safe drinking water standard for fluoride (i.e. maximum contaminant level goal or MCLG) of 4 parts per million (ppm) is unsafe and should be lowered. Despite over 60 years of fluoridation, the report listed many basic research questions that have not been addressed. Still, the panel reviewed a large body of literature in which fluoride has a statistically significant association with a wide range of adverse effects. These include an increased risk of bone fractures, decreased thyroid function, • lowered IQ, arthritic-like conditions, dental fluorosis and, possibly, osteosarcoma. The average fluoride daily intakes (*) associated with many of these adverse effects are reached by some people consuming water at the concentration levels now used for fluoridation -- especially small children, above average water drinkers, diabetics, people with poor kidney function and other vulnerable sub-groups. For example, the average fluoride daily intake associated with impaired thyroid function in people with iodine deficiency (about 12% of the US population) is reached by small children with average consumption of fluoridated water at 1 ppm and by people of any age or weight with moderate to high fluoridated water consumption. Of special note among the animal studies is one in which rats fed water containing 1 ppm fluoride had an increased uptake of aluminum into the brain, with formation of beta-amyloid plaques, which is a classic marker of Alzheimer's disease pathology in humans. Considering the substantial variation in individual water intake, exposure to fluoride from many other sources, its accumulation in the bone and other calcifying tissues and the wide range of human sensitivity to any toxic substance, fluoridation provides NO margin of safety for many adverse effects, especially lowered thyroid function. * Note: "Daily intake"takes into account the exposed individual's bodyweight and is measured in mg. of fluoride per kilogram bodyweight. 2. The evidence provided by the US Centers for Disease Control and Prevention (CDC) in 2005 that 32% of American children have dental fluorosis—an abnormal discoloration and mottling of the enamel. This irreversible and sometimes disfiguring condition is caused by fluoride. Children are now being overdosed with fluoride, even in non-fluoridated areas, from water, swallowed toothpaste, foods and beverages processed with fluoridated water, and other sources. Fluoridated water is the easiest source to eliminate. 3. The American Dental Association's policy change, in November 2006, recommending that only the following types of water be used for preparing infant formula during the first 12 months of life: "purified, distilled, deionized, demineralized, or produced through reverse osmosis." This new policy, which was implemented to prevent the ingestion of too much fluoride by babies and to lower the risk of dental fluorosis, clearly excludes the use of fluoridated tap water. The burden of following this recommendation, especially for low income families, is reason alone for fluoridation to be halted immediately. Formula made with fluoridated water contains 250 times more fluoride than the average 0.004 ppm concentration found in human breast milk in non- fluoridated areas (Table 2-6, NRC, 2006). 4. The CDC's concession, in 1999 and 2001, that the predominant benefit of fluoride in reducing tooth decay is TOPICAL and not SYSTEMIC. To the extent fluoride works to reduce tooth decay, it works from the outside of the tooth, not from inside the body. It makes no sense to drink it and expose the rest of the body to the long term risks of fluoride ingestion when fluoridated toothpaste is readily available. Fluoride's topical mechanism probably explains the fact that, since the 1980s, there have been many research reports indicating little difference in tooth decay between fluoridated and non- fluoridated communities (Leverett, 1982; Colquhoun, 1984; 1985 and 1987; Diesendorf, 1986; Gray, 1987; Brunelle and Carlos, 1990; Spencer,1996; deLiefde, 1998; Locker, 1999; Armfield and Spencer, 2004; and Pizzo 2007- see citations). Poverty is the clearest factor associated with tooth decay, not lack of ingested fluoride. According to the World Health Organization, dental health in 12-year olds in non-fluoridated industrialized countries is as good, if not better, than those in fluoridated countries (Neurath, 2005). 5. In 2000, the publication of the UK government sponsored "York Review," the first systematic scientific review of fluoridation, found that NONE of the studies purporting to demonstrate the effectiveness of fluoridation to reduce tooth decay were of grade A status, i.e. "high quality, bias unlikely" (McDonagh et al., 2000). 6. The publication in May 2006 of a peer-reviewed, case-controlled study from Harvard University which found a 5-7 fold increase in osteosarcoma (a frequently fatal bone cancer) in young men associated with exposure to fluoridated water during their 6th, 7th and 8th years (Bassin et al., 2006). This study was surrounded by scandal as Elise Bassin's PhD thesis adviser, Professor Chester Douglass, was accused by the watchdog Environmental Working Group of attempting to suppress these findings for several years (see video). While this study does not prove a relationship between fluoridation and osteosarcoma beyond any doubt, the weight of evidence and the importance of the risk call for serious consideration. 7. The admission by federal agencies, in response to questions from a Congressional subcommittee in 1999-2000, that the industrial grade waste products used to fluoridate over 90% of America's drinking water supplies (fluorosilicate compounds) have never been subjected to toxicological testing nor received FDA approval for human ingestion (Fox, 1999; Hazan, 2000; Plaisier, 2000; Thurnau, 2000). 8. The publication in 2004 of"The Fluoride Deception" by Christopher Bryson. This meticulously researched book showed that industrial interests, concerned about liabilities from fluoride pollution and health effects on workers, played a significant role in the early promotion of fluoridation. Bryson also details the harassment of scientists who expressed concerns about the safety and/or efficacy of fluoridation (see Bryson interview). We call upon Members of Congress (and legislators in other fluoridating countries)to sponsor a new Congressional (or Parliamentary) Hearing on Fluoridation so that those in government agencies who continue to support the procedure, particularly the Oral Health Division of the CDC, be compelled to provide the scientific basis for their ongoing promotion of fluoridation. They must be cross-examined under oath if the public is ever to fully learn the truth about this outdated and harmful practice. We call upon all medical and dental_professionals, members of water departments, local officials, public health organizations, environmental groups and the media to examine for themselves the new documentation that fluoridated water is ineffective and poses serious health risks. It is no longer acceptable to simply rely on endorsements from agencies that continue to • 1 • ignore the large body of scientific evidence on this matter-- especially the extensive citations in the NRC (2006) report discussed above. The untold millions.of dollars that are now spent on equipment, chemicals, monitoring, and promotion of fluoridation could be much better invested in nutrition education and targeted dental care for children from low income families. The vast majority of enlightened nations have done this (see statements). • It is time for the US, and the few remaining fluoridating countries, to recognize that fluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. Fluoridation must be ended now. The . : PROFESSIONALS'' STATEMENT • Calling for an end to Water- Fluoridation '‘it is time for the US, and the few remaining fluoridating countries, to recognize t at� g ifluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. • Fluoridation must be ended now." Signed by`over"�2,^000 medical, scientific,and environmental health professionals as of: • • 'JANUARY,2009 To view the:.listof signers, or to sign this statement, go to: www:FluorideAIert. Orgj We, the undersignea professionals, come from a variety of disciplines but all have an abiding interest in ensuring that government public health and environmental policies be determined honestly, with • full attention paid to the latest scientific research and to ethical principles. Ws,„;:;,t,11„, ✓ 0 CENT i;E _?: i ',,--.:-, S • ,c° - �"y� :--- ,--*-4.4. -;„,.,,-;..; ‘...;',.,--;,,,,,i-eit,—,„ ,„,„;?,.t•:.,:-•,,,,;:: ,;,,,,,.., ,,„,, ,,:,:,,,,,.,-,.:--,.::::,z:,:.:, • •.:, 0 :0,,,, v,• 3 ,,°Y ra s fis ., If r, CY:r 0E s •. ,} y th ,-,..--!'*fr,,,,%F.44.0":44-.4; '4,Tr-----....qt,'1,,,,iv,,'; : i-,:-.1.,:-...114.-.,;-:,11-', ,,,':-.,...-: ,,,:::: .,,,-. , , , ,i.ilt, „i„,.„,.. itt ? A.,,,.:::0-,:„7,,,,c;:,..., j� '•� +4" i � � � � #h 5+'.y,kssp^'A:.-ri"=�'`�. 1Ka�«b...Y ...-,C. f t � -a ", ,, The publication in 2006 'of a 500-page review of fluoride's °•o ' :' • 'a - '74^; � ' toxicology by a distinguished panel appointed by the National -' '11J40-$41,,,-..,1)E Research Council of the National Academies (NRC, 2006). The ,„ •.. ,- e :NRC report concluded that the US Environmental Protection Agency's ,,' 1 - ` (EPA) safe drinking water standard for fluoride (i.e. maximum '' �"� ' :contaminant level goal or MCLG) of 4 parts per million .(ppm) is oQT1tv '* unsafe and should be lowered.Despite over 60 years of fluoridation, a tip ' ,.`- 1,,,,: ',. the report listed many basic research questions that have not been o ; ,, _ ,� '. addressed. Still, the panel reviewed a large body of literature in a -Z,1: , which fluoride has a statistically significant association with a wide range of adverse o effects:These include an increased risk of bonefractures,decreased thyroid function, ' gam lowered IQ, arthritic-like conditions, dental fluorosis and, possibly, osteosarcoma: , ' The average fluoride daily intakes (1 associated with many of these adverse k-: �� � ; ' effects are reached by some people consuming water at the concentration levels a ' -` `1 4 now used for'fluoridation -= especially small children, above average water E4% drinkers, diabetics;people with poor kidney function and other vulnerable sub- - groups. For example, the average fluoride daily intake associated with.impaired n ' thyroid function in eo le with iodine deficiency ° � y �� � � _ Y P p (about 12/o of the US population) • r is reached by small children with average consumption of fluoridated water at a �,. x 1 ppm and by people•of.any age; or weight.with moderate to high fluoridated •Q z- �• d3�'+t� .ff 0 _,� _-' water consumption. Of special note among the animal studies is one in which rats . f-_� fed water containing 1 ppm' fluoride had an increased uptake of aluminum into �a '" the brain, With formation of beta-amyloid plaques, which is a classic marker of °" J' • '' Alzheimer's disease pathology in humans: Considering the substantial variation o 1 in individual water intake, exposure to fluoride from many other sources, its }` accumulation in thebone and 'other calcifying tissues and the wide range.of '1� human:: sensitivityto toxic.'substance, fluoridation anyprovides NO margin of safety. for many'adverse effects, especially. lowered thyroid function. ," `,a * Note: `"Daily intake"takes`into account the exposed individual's bodyweight and is rer‘Atr-- measured in mg. of fluoride perkilogram bodyweight. • x t ' 4-,--144:70 f i'¢; }. ,i1:7,;;;;; :7'. ' 4." T- he eviden ovided by the US Centers for.D se.Control and Prevention (CDC) k, t- in 2005 than "s2% of American children have dental fluorosis —; •. 'f A �� an abnormal .discoloration and mottling, of the enamel. This ,�' �' �,��r�. i- rreversible and sometimes.disfiguring.condition is"caused by ,,: . ,. fl- uoride._Children are now being.overdosed_with fluoride, even °Y= y> Fki;; l',::;-.;.41t.:.,-.A.,4£ . �t in non-fluoridated area_s, from .water, swallowed,toothpaste, ' '� $ ' 1Yq ' �.,, .-b,-. foods and beverages professed ,with`fluoridated,water, and rt-t,,,,,,, 4 -. > '" � fi " other sources.Fluoridated water is the easiest source;to eliminate. '_.. �. ; e, x The'American Dental Association's policy change,in November_ 2006, recommending o , 3 that only the following types.of water;be used for preparing,infant formula during a the first 12 months of life: purified;'distilled, deionized,.demineralized, or produced 13 through otic which;wasim plementedto prevent g p Y, p ^*.71"'; 5-: .•' the ingestion of too much fluoride. by babies and. to lower the risk of / _ dental fluorosis,clearly excludes the use of fluoridated tap water.The ^�^ x �, ... t ,, `' - t,' - ,, burden of following this'recommendation,especially for low income Yl.. a ` : (f ,: , families, is reason alone for-fluoridation to be halted immediately. �3 :$4,41,:.,. .-....7:''F-X;;:' q i .�, y 3 9 3 ' i " i j_ VFormula made with fluoridated water contains:250 times more ;o �c i ,:,:',>,,,,,,7:-.„i,-.',..: :fluoride than.the average 0.004 ppm concentration.found.in human '-a °r '� , -. "breast milk in non-fluoridated areas (Table 2-6, NRC, 2006). � te, ;`zi **-SitU."-'il ,,,,,,, ,..;. :-;-1.,:,,,Aii,07"' , ' 1 The CDC's•concession, in 1999 and 2001, thatthe predominant benefit of fluoride in reducing tooth decay is TOPICAL and not SYSTEMIC. To the extent fluoride a > " . •P. works to reduce tooth decay, it works' from the outside of the _ v � } _ Y tooth, not from inside the body. It makes no sense to drink it and : <a �a ; a i expose the rest of the body to the long term risks.of fluoride ,;N . a, p ingestion when fluoridated toothpaste' is readily available. t �� -.n $•- .NA.1.,„,,,. ...".:*..Z .,:' k.: ; I f Wyk ` Tl• y Fluorides topical mechanism probably explains the fact ` t = t,. that,' h �. , ', a ,, ,. since the 1980s, there' have been many research ,T a a reports indicating little difference, 'in tooth decay between N i, . F fluoridated and non-fluoridated communities (Leverett, 1982, '" ` _'. " (' V :14 ,gf V Colquhoun, 1984; 1985 and 1987• Diesendorf, 1986• Gray, o a i 7 1987;. Brunelle and Carlos, 1990; Spencer,1996, deLiefde, 1998; Locker, 1999; 4 �, v-s'A Armfield and Spencer, 2004; and Pizzo 2007). Poverty is the clearest factor i= . - a, ' associated with tooth decay, not lack of ingested fluoride. According to the World '�" ..� =' Health Or anization, dental,health in 12- ear olds in non-fluoridated industrialized r .., g 12-y ear � : ;`<.c countries is as good, if not better, than those in fluoridated countries (Neurath, 2005). c, ' In 2000, the publication of the UK government sponsored "York Review,"the y� first systematic scientific review of fluoridation,found that NONE of the studies purportingtodemonstratetheeffectivenessoffluoridationtoreducetoothdecay ,: were of grade A status,i.e."high quality,bias unlikely"(McDonagh et a1.,2000). ,4w,,,, 3; 4, iittregM-:41,:,: - Thee publicc�,"'`'"D in May 2006 of. a peer-revio ,d case-controlled study from Harva Jniversity,which found a; 5-7 fo• , ncrease in osteosarcoma $' ,:• 6 fi, (a frequently.fatal bone'cancer) in young men associated with exposure to ,;. ` °.' ‘''At fluoridated wate•r.during their 6th,.7th and.8th'years (Bassin et al., 2006). This " „ ` ' study was surrounded..by scandal as Elise. Bassin's PhD thesis adviser, Professor ! , ' a: Chester Douglass,was accused by the watchdog Environmental Working Group.of le P, attempting to suppress these findings for several yeas. While this study does not '' " r7 f' prove a relationship between fluoridation and osteosarcomabeyond any doubt, ���, the weight of evidence and the importance of the risk call for serious consideration. . 3 Yr . , The admission by federal agencies, in 'response to questions from `. a Congressional subcommittee . in1999-2000,... that . the ' industrial grade. waste . products' ,used to fluoridate' over: 90% of. America's . •"' drinking 'water supplies (fluorosilicate- compounds) have never •. be ',... • 1 subjected to toxicological testing nor'.received'.FDA' approval for human_ ingestion (Fox, 1999 Hazan 2000, Plaisier 2000 Thurnau, 2000). ,,„..•:,.; - 8 . .tsa- The :publication in 2004 of . "The Fluoride. ',Deception" by Christopher Bryson. This meticulously -researched book showed that industrial interests, `' concerned about liabilities from fluoride pollution " and health effects on. 1:1workers, played a significant ":role in the early promotion of fluoridation: 4 Bryson also details ' the" harassment of scientists who expressed concerns . about the safety and/or efficacy. of . fluoridation (Bryson, 2004). if M , x ii a a We call upon Members of Congress (and legislators in other fluoridating countries) to sponsor a new Congressional (or Parliamentary) Hearing on Fluoridation so that those in government agencies who continue to support the procedure, particularly the Oral Health Division of the CDC, be compelled to provide the scientific basis for their ongoing promotion of fluoridation. They must be cross-examined under oath if the public is ever to fully learn the truth about this outdated and harmful practice. We call upon all medical and dental professionals, members of water departments, local officials, public health organizations, environmental groups and the media to examine for themselves the new documentation that fluoridated water is ineffective and poses serious health risks. It is no longer acceptable to simply rely on endorsements from agencies that continue to ignore the large body of scientific evidence on this matter -- especially the extensive citations in the NRC (2006) report discussed above. The untold millions of dollars that are now spent on equipment, chemicals, monitoring, and promotion of fluoridation could be much better invested in nutrition education and targeted dental care for children from low income families. The vast majority of enlightened nations have done this. It is time for the US, and the few remaining fluoridating countries, to recognize that fluoridation is outdated, has serious risks that far outweigh any minor benefits, violates sound medical ethics and denies freedom of choice. Fluoridation must be ended now. Signed by over 2,000 medical, scientific,. andenvironmental health professionals as.of ` , JAN• UARY 2009 - , . . • • .. To view the list of signers, or tosignthis statement, go to: www.`Fl:uorideAlert.,Org RENTON CITY COUNCIL Regular Meeting June 4, 2012 Council Chambers• Monday, 7 p.m. MINUTES . Renton City Hall CALL TO ORDER Mayor Law called the meeting of the Renton City Council to order and led the Pledge of Allegiance to the flag. ROLL CALL OF RICH ZWICKER, Council President;TERRI BRIERE; ED PRINCE; DON PERSSON; COUNCILMEMBERS MARCIE PALMER; RANDY CORMAN;GREG TAYLOR. CITY STAFF IN ATTENDANCE DENIS LAW, Mayor;JAY COVINGTON, Chief Administrative Officer; LAWRENCE J.WARREN,City Attorney; BONNIE WALTON, City Clerk; GREGG ZIMMERMAN, Public Works Administrator; IWEN WANG,Administrative Services Administrator; PREETI SHRIDHAR,Communications Director;SUZANNE DALE ESTY, Economic Development Director; DEPUTY CHIEF ERIK WALLGREN, Fire& Emergency Services Department;COMMANDER PAUL CLINE, Police Department. SPECIAL PRESENTATION King County Councilmember Reagan Dunn reported that King County will likely King County: Councilmember. face$20 million in budget cuts for 2013. He remarked that the County Reagan Dunn-State of the Executive believes most of these cuts can be absorbed through administrative County Address efficiencies and should not impact the court system or law enforcement. Mr. Dunn reported that he introduced anti-gang and human trafficking legislation this year. He stated that the anti-gang legislation will prohibit persons convicted of gang-related crimes from entering known gang areas,and it also makes intimidating someone trying to leave a gang or forcing someone into joining a gang a gang-related offense. Mr. Dunn also stated that the human trafficking legislation provides$750,000 from unspent Veterans and Human Services levy funds for enforcement, prevention,and intervention of human trafficking in King County. Mr. Dunn reported that METRO Rapid Ride F Line between Renton and Burien will begin in the fall of 2013. He stated that METRO Route 149, Renton to Enumclaw,was converted to Route 907 DART(Dial-a-Ride Transit) service to save operating costs. He also reported that METRO Route 240, Renton to Bellevue, has changed from 30 minute to 15 minute intervals during peak service, and this line was extended to Eastgate Park&Ride and Bellevue College. On the issue of the proposed sports arena, Mr. Dunn remarked that the Mayor of Seattle and the King County Executive were briefed on the issue and will be briefed again in the near future. He remarked that there are members of the County Council who support and oppose the idea, and that he would like to see an independent study conducted before making a decision. He noted that most • people would like to see basketball and hockey teams in Seattle, but questions remain about the timing and location for the proposed arena. Concluding, Mr. Dunn reported that he is the chair of the King County Flood Control District Executive Committee, and the committee has authorized funds to remove the 25-mile wall of sandbags along the Cedar River. He remarked that the bags should be removed by the end of this summer. June 4,2012 Renton City Council Minutes Page 172 .M Responding to Council inquiries, Mr. Dunn remarked that extending the Rapid Ride F Line to The Landing is a critical component of Renton's transit needs. He • recommended that he and Councilmember Palmer speak with the head of METRO to see if that can happen. He also remarked that Renton, along with Bellevue, have occasionally been mentioned as possible locations for the proposed sports arena, and stated that the City of Seattle has not done a lot in terms of investing in capacity for new infrastructure in the SODO district. Mr. Dunn added that he is concerned about blocking access to the Port of Seattle, and he is open-minded about Renton being a possibility for a new facility. ADMINISTRATIVE REPORT Chief Administrative Officer Jay Covington reviewed a written administrative report summarizing the City's recent progress towards goals and work programs adopted as part of its business plan for 2012 and beyond. Items noted were: * The eleventh season of the Renton Farmers Market at the Piazza will run June 5 to September 25. The downtown market will be open 3 to 7 p.m. and will feature chef demonstrations, kids'activities, live entertainment, tips from Master Gardeners,free parking for up to two hours,and a pedestrian-friendly environment. Mayor Law will officially ring the bell at the Renton Farmers Market at the Piazza at 2:45 p.m.on June 5 to kick off the season. • * The second season of the Farmers Market at Valley Medical Center, located in the parking lot adjacent to the Professional Center at 4011 Talbot Rd.S., will run June 10 to September 16 from 12 to 4 p.m. * The Renton Housing Authority is opening its Section 8 Housing Choice Voucher Wait List June 4 to 15 or until 2,000 pre-applications are received. There are a total of 315 vouchers,and this wait list is for when current families give up their vouchers. Please visit www.rentonhousing.org for more information. AUDIENCE COMMENT Dr. Mary Alice Heuschel (Renton), Renton School District Superintendent, Citizen Comment: Heuschel- reported that the community suffered a terrible tragedy in the loss of Renton's Leadership& Lindbergh High School student Jessica Scholl. She stated that the support and Partnership with the Renton partnership with the City is exceptionally outstanding,and that this partnership School District allowed the district to dispatch their own crisis team to support the thousands of students at Lindbergh High School,their families,and other students and staff impacted by the homicide. Dr. Heuschel stated that the Renton School District was able to process fear,frustration, anger,shock,disbelief,and other emotions by providing appropriate and accurate information,and maintaining communications. She thanked Mayor Law and Council for their leadership and partnership during this difficult time. Dr. Heuschel also expressed appreciation for recent assistantance on the district's 3-year plan. Mayor Law expressed his appreciation for Dr. Heuschel's kind words,and stated that the City also values its partnership with the school district. CONSENT AGENDA Items listed on the consent agenda are adopted by one motion which follows the listing. At the request of Councilmember Persson,Consent Agenda Item 6.f. • was removed for separate consideration. June 4, 2012 Renton City Council Minutes Page 173 Council: Meeting Minutes of Approval of Council meeting minutes of 5/21/2012. Council concur. 5/21/2012 Appointment:Airport Advisory Mayor Law appointed David Basco to the Airport Advisory Committee,West Hill Committee Neighborhood-primary(position previously held by Roger Lewis),for a term expiring 5/7/2015. Refer to Community Services Committee. Appointment:Airport Advisory Mayor Law reappointed the following individuals to the Airport Advisory Committee Committee, each for a three year-term expiring on 5/7/2015: Marlene Mandt (Kennydale neighborhood-primary), Robert Dempster(Aircraft Owners/Pilots' Association-primary), Karen Stemwell (Aircraft Owners/Pilots'.Association- alternate),and Ulf Goranson (Airport-At-Large-primary). Council concur. Attorney:Gross Misdemeanor City Attorney Department recommended amending City Code by correcting a Citation Correction, Code reference in Renton Municipal Code (RMC) 1-3-1.B. regarding gross Amendment misdemeanors. Council concur. (See page 174 for ordinance.) Annexation:Windstone V, Community and Economic Development Department submitted King County North of Sunset Blvd N & East Boundary Review Board Closing Letter regarding the Windstone V Annexation, of Jericho Ave NE and recommended a public hearing be set on 6/18/2012 to consider approving the annexation and zoning. Council concur. CAG: 11-091, 2011 Street Transportation Systems Division submitted CAG-11-091, 2011 Street Patch& Patch &Overlay with Curb Overlay with Curb Ramps project;and requested approval of the project,final Ramps, Lakeridge Paving pay estimate in the amount of$137,391.79,commencement of a 60-day lien Company period,and release of retained amount of$54,405.35 to Lakeridge Paving Company, LLC,contractor, if all required releases are obtained. Council concur. CAG: 11-127, Cascade Utility Systems Division submitted CAG-11-127,Cascade Interceptor Interceptor Rehabilitation, Rehabilitation project,and request approval of the project,final pay estimate in SunCoast Environmental NW the amount of$1,095,commencement of a 60-day lien period, and release of retained amount of$7,877.06 to SunCoast Environmental NW, Inc.,contractor, if all required releases are obtained. Council concur. MOVED BY ZWICKER,SECONDED BY CORMAN,COUNCIL APPROVE THE CONSENT AGENDA MINUS ITEM 6.f. CARRIED. Separate Consideration Item Community Services Department requested authorization to waive City Center 6_f. Parking Garage fees in the total amount of$6,000 for volunteers working at the Community Services:City 2012 Renton Farmers Market and the 2012 Return to Renton Benefit Car Show. Center Parking Garage Fee Refer to Finance Committee. Waivers Councilmember Persson remarked that Council has traditionally waived these fees,and recommended that the item be approved at tonight's meeting because the Farmers Market opens tomorrow. MOVED BY PERSSON,SECONDED BY TAYLOR,COUNCIL APPROVE CONSENT AGENDA ITEM 6.f.AS COUNCIL CONCUR. CARRIED. UNFINISHED BUSINESS Finance Committee Chair Briere recommended approval of Claim Vouchers Finance Committee 312226-312555,five wire transfers, and one payroll run with benefit • Finance:Vouchers withholding payments totaling$3,756,384.61,and payroll vouchers including 735 direct deposits and 67 payroll checks totaling$1,576,006.29. MOVED BY BRIERE,SECONDED BY TAYLOR,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. I, June 4,2012 Renton City Council Minutes Page 174 Lease: Rent Reduction, Barajas Finance Committee Chair Briere presented a report recommending Arias dba RiverRock Grill& • concurrence in the staff recommendation to authorize an addendum to the Alehouse, LAG-03-003 lease and concession agreement with Barajas Arias dba RiverRock Grill and Alehouse at Maplewood Golf Course to reduce the rent percentage for a period of one year,commencing June 2012 through June 2013. The Committee further recommended that the Mayor and City Clerk be authorized to sign the addendum. MOVED BY BRIERE,SECONDED BY TAYLOR,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. Community Event: NW Folklife Councilmember Taylor reported that he had been invited to attend a planning Festival,Somali Youth and meeting for Seattle's annual Northwest Folklife Festival in order to provide Family Club Attendance input on how to include more communities of color in the festivities. Mr. Taylor stated that he identified the Somali Youth and Family Club, and with help through King County Councilmember Julia Patterson's office,was able to secure funding for two 57 passenger coaches to transport individuals to the festival. He noted that 153 people were able to attend the event. Continuing, Mr.Taylor explained how the Somali community was also selected for a new program called the Folklife Community Arts Engagement and Mentorship project. He stated that grant funding is being utilized to hire a project coordinator to create two documentaries showcasing the community. Mr.Taylor stated that the goal of the project is to promote the Somali culture, and create partnerships and connections throughout the greater community. RESOLUTIONS AND The following ordinance was presented for first reading and referred to the ORDINANCES 6/11/2012 Council meeting for second and final reading: Attorney:Gross Misdemeanor An ordinance was read amending Section 1-3-1 of Chapter 3, Remedies and Citation Correction, Code Penalties, of Title I (Administrative),of City Code, correcting Subsection 1-3-1.B. Amendment to include gross misdemeanors. MOVED BY PERSSON,SECONDED BY BRIERE, COUNCIL REFER THE ORDINANCE FOR SECOND AND FINAL READING ON 6/11/2012. CARRIED. The following ordinances were presented for second and final reading: ORDINANCE#5661 An ordinance was read amending Section 3-4-3 of Chapter 4,Administrative Attorney:Administrative Services Department, of City Code, revising the duties of the Administrative Services Administrator Duties, Services Administrator relating to recent changes in the department. MOVED Code Amendment BY BRIERE,SECONDED BY TAYLOR,COUNCIL ADOPT THE ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. ORDINANCE#5662 An ordinance was read amending Title V(Finance and Business Regulations), of Attorney:Tax Related City Code, by adding a new Chapter 23, "Examinations, Records Preservation, Examinations&Audits, Code Successor Liability,and Public Disclosure,"clarifying the Administrative Services Amendment Administrator's authority to examine and audit records; also adding successor liability and public disclosure. MOVED BY BRIERE,SECONDED BY TAYLOR, COUNCIL ADOPT THE ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. ORDINANCE#5663 An ordinance was read amending Section 6-10-1 of Chapter 10,Criminal Code, Attorney: Criminal of Title VI (Police Regulations), of City Code, adopting by reference State Prosecutions,Code statutes. MOVED BY PERSSON,SECONDED BY CORMAN,COUNCIL ADOPT THE Amendment ORDINANCE AS READ. ROLL CALL. ALL AYES. CARRIED. June 4,2012 Renton City Council Minutes - Page 175 NEW BUSINESS MOVED BY ZWICKER,SECONDED BY TAYLOR, COUNCIL CANCEL THE 7/2/2012 Council:Cancel 7/2/2012& AND 7/23/2012 COUNCIL MEETINGS. CARRIED. 7/23/2012 Council Meetings CED: Food Trucks in Public Council President Zwicker remarked that he had received correspondence from Right-of-Way Barbara Pagarian regarding the issue of food trucks. He recommended that this topic be revisited. MOVED BY ZWICKER,SECONDED BY BRIERE, COUNCIL REFER THE TOPIC OF FOOD TRUCKS IN PUBLIC RIGHT-OF-WAYS TO THE COMMITTEE OF THE WHOLE. CARRIED. AUDIENCE COMMENT Audrey Adams(Renton)stated that her son was diagnosed at an early age with • en Comment:Adams- having a severe intolerance to fluoridated water. She remarked that she does oridated Water not receive water from the City of Renton, but would like to inform Council of the dangers of fluoridation. Ms.Adams asked Council to have an open-mind about the subject,and submitted a copy of testimony on the topic that she provided to the Washington State Supreme Court in 2010. Councilmember Corman shared that his daughter is also intolerant of fluoride, and stated that Council takes the issue seriously. He added that the City reduced the amount of fluoride in its water supply by half within the last year. ADJOURNMENT MOVED BY ZWICKER,SECONDED BY CORMAN,COUNCIL ADJOURN. CARRIED. Time: 7:43 p.m. Bonnie I.Walton, CMC,City Clerk Jason Seth, Recorder • June 4, 2012 RENTON CITY COUNCIL COMMITTEE MEETING CALENDAR Office of the City Clerk COUNCIL COMMITTEE MEETINGS SCHEDULED AT CITY COUNCIL MEETING June 4, 2012 COMMITTEE/CHAIRMAN DATE/TIME AGENDA COMMITTEE OF THE WHOLE MON., 6/11 West Hill Annexation (Zwicker) 6 p.m. WED., 6/13 Renton School Board Meet&Greet 6 p.m. *Knowles Education Center, 300 SW 7th St., Renton* ,.04111 COMMUNITY SERVICES MON., 6/11 Basco Appointment to the Airport (Palmer) 5:45 p.m. Advisory Committee FINANCE (Briere) PLANNING & DEVELOPMENT • (Prince) PUBLIC SAFETY (Persson) TRANSPORTATION (AVIATION) • (Corman) UTILITIES MON., 6/11 CANCELED (Taylor) NOTE: Committee of the Whole meetings are held in the Council Chambers unless otherwise noted. All other committee meetings are held in the Council Conference Room unless otherwise noted. June 4, 2012 Renton City Council Dear Council members, I have been waiting a long time to talk with you about fluoridation. It all started with my autistic son. This was not a journey I chose,but one that chose me. My intent is to inform,not to lay blame. We all share equal responsibility for protecting the children of our community and in doing this,educating my city leaders, I am fulfilling some of my civic responsibility. I intend to bring something new for you to ponder on a semi-regular basis. It is my sincere hope that you will tell me what information you would like to hear about. Fluoridation is,at best,a boring topic. At worst, it is highly.controversial and emotional. Somewhere in the middle is where I'd like us to travel, specifically,toward a scientific conclusion even though none of us are scientists. My only expectation is that you listen with an open mind to a mother who has been forced to open her own mind to literally hundreds of things I once thought impossible(such as me speaking in public). Attached is a list of my volunteer accomplishments(that I can remember)to give you some shred of evidence that I am not a lunatic and that you can be assured that,at the very least, my passion has always been to improve the lives of children,especially those with special needs. Also attached is my letter to the Washington State Supreme Court in 2010 that explains why this issue is so important to me. Thank you for your service to the great community of Renton. Sincerely, Audrey Adams 10939 SE 183rd Ct Renton,WA 98055 425-271-2229 1,C: eot:GYk'c'1 meur:ye Renton Schools PTA-served on executive boards and committees for 19 years in nearly every capacity Thompson PTA 1988-1991 Benson PTA 1988-1997(Golden Acorn award) Nelson PTA 1995-1999 Lindbergh PTA 1997-2003 Renton PTA Council 1988-2006(Lifetime Achievement award) Founded Summer Kindergarten for children with special needs(1991-1993) • Published The Link Newsletter(for parents of students in special education)1996-2007 Renton Special Education Advisory Board 2001-2007 Superintendent&Principal Hiring Committees(3) Various Curriculum,Restructuring,Budget and Levy committees Renton Truancy Advisory Board State,King Co&Other Autism Society of Washington,Treasurer 1992-1996 Presenter, ASW Conferences Wash State Autism Task Force(appointed by Gov-letter of rec.by Gary Kohlwes)..1995(?) Wash State Parks Fee Committee 2004-2008 King County Referral Registry Advisory Board 2007-2009 Wash State Developmental Disabilities Core Project Committee 2006 Wash State Dev.Disabilities Support Intensity Scale Training Project 2008 Highline Community College Achieve Bridge Transition Advisory Board 2005-2006 Life Before Autism Bank Officer, IT Trainer,Bookkeeper Greatest Achievements Mom Advocate for children A Page 1 of 2 Audrey Adams 10939 SE 183rd Ct, Renton,WA 98055 425-271-2229 audrey55@comcast.net January 15,2010 To the Washington Supreme Court: This letter regards the case of the City of Port Angeles v.Our Water-Our Choice and Protect Our Waters,v.Washington Dental Service Foundation LLC,Case No. 82225-5. I am competent to testify,age 54,and make this affidavit under oath and penalty of perjury. My son Kyle Adams,age 24,has autism and suffers from pain,severe headaches and other symptoms when exposed to chemicals in his food,in the air or in his water. He works as an office assistant at a local Community College,but cannot do his job after chemical exposures. He must be protected from such exposures,but water is the hardest to avoid. His sensitivity to chemicals is sogreat that he cannot drink fluoridated water and cannot shower in fluoridated water without suffering a severe headache that lasts for hours. Someone wearing perfume will cause his heart rate to skyrocket(demonstrated by accident in the doctor's office). A tiny bit of yellow dye#5 in white cake will cause him to,scream and run as if pursued by killer bees. Preservatives will cause him to break out in a red sweat and will guarantee a wild ride for all those around him. His doctor-ordered chemical and dietary avoidance regimen is complex,time-consuming and expensive,but necessary.- After exposure to chemicals,including fluoridated tap water,the intensity of his pain creates behaviors that make him appear many times more autistic—because he cannot talk, cannot listen,cannot cope- until the pain subsides. After exposure,his wild and erratic behavior makes him appear violent,but his normal self is a very gentle man,happy in his home,loving his job,enjoying playing the piano and showing tons of love to his family. Even with the use of a chlorine filter on the showerhead,Kyle's headache,body pain and reduced function follow shortly after the shower. Moving his shower to the evening moves the pain to the evening and into the night,with screams,sweating,rapid heartbeat and violent bed-pounding,shaking our house like an earthquake. Visits to locations that do not fluoridate,but do chlorinate(with no chlorine filter)have shown that these severe reactions are not present with chlorine alone. He has no negative reactions to water as God made it. Providing fluoride-free water is very expensive and labor-intensive. My tap water costs me $0.0042 per gallon,but fluoride-free water at the grocery store is$0.45/gal to refill jugs or $1.00 to$3.00 per gallon off the shelf—a mind-blowing 100-700 times more expensive! Page 2 of 2 My son's greatest impediment to a livable life is pain,not autism. Similar reactions to chemicals are very common in the autistic population and,unfortunately,those that are the most out of control have parents who do not yet know that their fluoridated water could be causing their child's wild behavior. It took me almost two decades to fully discover this, partly because his intolerance to chemicals continues to increase and worsen as he ages. One might think that we should move to a non-fluoridated area,but Kyle's job took many years to cultivate and was tailor-made for him,with his unique abilities and disabilities in mind. It is in the heart of,and surrounded by,fluoridated water districts.He travels to work on Metro Access(a transportation service for disabled persons)which only serves areas in King County that are served by regular buses,an area almost entirely fluoridated. The chemical drug fluoride can intensify pain and increase autistic symptoms due to their inefficient detoxification system. The cause of autism is unknown,but most experts agree that genetic vulnerability+environmental exposures=the behavioral symptoms labeled "autism". In the 1980's autism affected 1 in 2,000—now it's 1 in 110. Countless parents have reported improvement of their child's behavior and school success by reducing their child's toxic load and providing chemical-free food and fluoride-free water. Every medication has a risk,including fluoride,but only one medication is delivered to everyone regardless of health status,regardless of vulnerability,regardless of consent, regardless of dose and regardless of individual tolerance. Our babies,children and vulnerable populations need our utmost protection and conservatism from ALL chemicals. It is unconscionable to add a toxic drug to something so basic to survival as water when there is any chance whatsoever that doing so might harm even a single child and make that water undrinkable and unusable to those with chemical intolerances. There is simply no drug that is safe for everyone. No chemical or drug is benign,not even fluoride. As a person with a developmental disability,a serious medical condition,and completely reliant on others to protect him,the refusal of public servants to recognize the toxicity and harm of fluoridation threatens every aspect of Kyle's right to life,liberty and happiness. • As I said before,I am 54 and competent to testify. I make this affidavit under oath and penalty of perjury. Respectfully submitted, Audrey A. , 11 10939 SE 183`'Ct Renton,WA 98055 425-271-2229 audrey55@comcast.net March 19,2012 Renton City Council Minutes Page 79 Public Safety Committee Public Safety Committee Chair Persson presented a report recommending Fire: Fire Station 17,Fire concurrence with the staff recommendation to approve a Memorandum of District 40 MOU Understanding with Fire Protection District 40 for the City to provide project management services for the reconstruction of Fire Station 17 at 14810 Petrovitsky Rd., Renton,WA. The cost of this service will be five percent of the total construction cost,including change orders. The Committee further recommended that the Mayor and City Clerk be authorized to sign the agreement. MOVED BY PERSSON,SECONDED BY PALMER,COUNCIL CONCUR IN THE COMMITTEE REPORT. CARRIED. NEW BUSINESS Councilmember Corman clarified that the City Attorney's opinion released last Executive:Citizen Petition week that the downtown library petition was illegal meant that it was not Regarding Downtown Library binding by the Revised Code of Washington(RCW),and did not mean that submitting the petition was breaking the law. City Attorney Warren affirmed Mr.Corman's clarification. AUDIENCE COMMENT Audrey Adams(Renton)shared her experiences living in unincorporated King Citizen Comment:Adams- County and the benefits of having been recently annexed to Renton. She also Various Topics praised Council for working well together. Concluding,Ms.Adams stated that v •Glovi'l blaT she has been hesitant to bring an issue to Council's attention and hinted that �Q she would reveal this issue at a future Council meeting. Citizen Comment:McOmber- Howard McOmber(Renton), Highlands Community Association,stated that Renton Highlands Library Highlands residents are very delighted with the design work on the new Highlands library. He remarked that the new library will be just as busy as the current library it will replace. ADJOURNMENT MOVED BY ZWICKER,SECONDED BY PRINCE,COUNCIL ADJOURN. CARRIED. Time: 8:22 p.m. ,d l-te ^ , Bonnie I.Walton,CMC,City Clerk Jason Seth, Recorder March 19,2012