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HomeMy WebLinkAboutWater Fluoridation (2012-2014) 1
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at the SC1entific gt ;
-_ _.. • . } Evidence
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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"
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Moiled Cates fre/400,
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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
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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
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NUTRITION
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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
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Renton's DrinkingWater
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.
•
•
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
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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
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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. Ewe ;City Attorney
Ordinance No. 4398
Page 2 ,
Fairbanks Fluoride Task Force Report 54
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Celebrating 6o Year).
of Water Fluoridatzon
ADA American Dental fPokrs::1)hcei:tion®
America's leading advocate
•
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.
I ,
_
ABOUT FLUORIDATION : c,7,� ACKNOWLEDGMENTS ~
Plc)) •1:JI'.'.1;1r1'::��1r
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,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
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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. Categories of Dental Fluorosis 28
Fluoridation Facts 3
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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
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a F 3 TXs a . ENE a .; +; V
=s �. ,�: 19z ' r � ■ a , s; �xBFIaS , '
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,,,. ..� .. ,., ..r,r .'4. .., :- ^ _._ --.c .. .. .,_..... : . .. .. _ s. fi'•x.a�,«e, fig... _ .. .�, .
•�.
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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
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_- _ - _ ...� `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
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_.";_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
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'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
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60 American Dental Association
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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,.•,-'' ',,--`, , -' ',.'
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4
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•
Fluorosis
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$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
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.,..,,,....,..A
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Cosmetic treatment Cost $16,000-$24,000- •
- -
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t. .. -,-.7r.`A
jri;,i ' r;:. i==,.1-7.- '_...;;-.--,kt. -w--.. --it - • 7af
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''.. -`,- --;.".'''''' '''.-1-'-':' , '-'—,'' • ' . 1; .-' . ',.' ';', ?:-- ',. _,''•''' ''1'•''",''kids have . „.,-1
CDC reports 41%Pf
flUdrosiv. -..- - - • . — -,----7
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,•,
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., .
. 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--
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ri't-'•'.-, ,;:': r'r'1,4'4% ''rr -: ' --
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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—
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Tony Pedro a,MD Dan Herman,MD Gary Kelsb D
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Jon Neher,M. Ginger Allen,MD Tanya Riz/o,MD
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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].
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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
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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 �?
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._ 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
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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
•
•
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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
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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
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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
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•
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1368 VOLUME 120 I NUMBER 101 October 2012 • Environmental Health Perspectives
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' eC lebrating.6o Years
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•
'''' of Water Fluoridation
V-, •
ADA American Dental Association®
America's leading advocate for oral health
•
_ .
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
, .
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D:;Director of-Sci
Affairs and Mr.
Chakwan STew, Ph.D., Senior Director, Research-;and
Laboratories,Council on Scientific
A special thanks to the National Fluoridation Advisory
Committee memberswhocontributedto this- edition:
Ms. Diane Brunson,-'DCRobert 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 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
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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
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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:
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-
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�..
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,. ,. . , 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
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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!
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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
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• . . 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. " •
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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.
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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
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The'American Dental Association's policy change,in November_ 2006, recommending
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a the first 12 months of life: purified;'distilled, deionized,.demineralized, or produced
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;o �c i ,:,:',>,,,,,,7:-.„i,-.',..: :fluoride than.the average 0.004 ppm concentration.found.in human
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' 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