Fluoride debate: Why I support fluoridation – Response from Connett

This is Paul Connett’s response to Ken Perrott’s article – Fluoride debate: Why I support fluoridation.

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I think your opening statement certainly gives us a perspective from where you are coming on this issue Ken and that is helpful.

I am very glad that you put “having an open mind” and “relying on science” as your key tools for resolving controversial issues like fluoridation. I believe that once you have got over some negative impressions that you have had with some people opposed to fluoridation, that you will find that having an open mind and relying on the best science will inevitably lead you to rejecting fluoridation and to see it as the misguided practice it is. But we shall see.

As far as the case you present I find it very, very short on science. Basically you argue that fluoride is needed to react with our bio-apatites and make them stronger, less soluble and in the case of teeth less vulnerable to tooth decay. You offer no scientific evidence that interaction with the bones is beneficial and can be achieved without damage to the bone or the connective tissue.

Your case as far as the teeth are concerned seems to boil down to the need to put fluoride in the drinking water so after passing through the whole body it ends up in our saliva and that this is the delivery system which reduces tooth decay. Two questions: 1) Why do you feel that this is more rational and suitable than treating the tooth enamel more directly with topical treatments like fluoridated toothpaste?  2) If you reject topical treatment for some reason and you insist the fluoride must be swallowed to be effective why don’t you use a more appropriate way of delivering fluoridated water, i.e. in one liter bottles at 1 ppm and prepared with pharmaceutical grade sodium fluoride?

I asked this latter question at the end of section 1A but in your response you did not answer. So may I ask it again?  Would not this delivery system provide, 1) a better control of the dose, 2) a far better control over the purity of the chemical used and 3) would not force this human treatment on people who don’t want it. Nor would it involve giving up on the central dogma of water fluoridation. Surely this would be a win-win situation for everyone?

On the ethical front, you stress the need to help disadvantaged children. No argument there from me. But what if your chosen method actually further disadvantages these children and their families? What for example are parents in low-income families supposed to do if they don’t want their children to drink fluoridated water? Haven’t you trapped these families with this policy? Moreover, are you not aware of the extensive literature from India that fluoride’s toxic effects are more serious for people with poor nutrition (low protein, low vitamins and low calcium – see the early work from Pandit et al., 1940 and the more recent animal studies from Chinoy, NJ – see the FAN bibliography for full citations, http://fluoridealert.org/researchers/fan-bibliography/)? Aren’t children in disadvantaged communities more likely to have poor nutrition?

Scotland, which has no fluoridation, has found a simple and cost-effective alternative way of fighting tooth decay as this recent BBC Scotland report indicates ( http://fluoridealert.org/news/nursery-toothbrushing-saves-6m-in-dental-costs/):

 “A scheme to encourage nursery children to brush their teeth has saved more than £6m in dental costs, according to a new study.

Childsmile involves staff at all Scottish nurseries offering free supervised toothbrushing every day.

Glasgow researchers found that the scheme had reduced the cost of treating dental disease in five-year-olds by more than half between 2001 and 2010.

The programme was launched in 2001 and costs about £1.8m a year.

It emphasises the importance of toothbrushing and helps parents establish a healthy diet from the earliest stage.

A number of nurseries and schools in targeted areas also provide fluoride varnish and toothbrushing in primary one and two.

An evaluation, funded by the Scottish government and carried out by Glasgow University, found that fewer children needed dental extractions, fillings or general anaesthetics as a result of the programme.

‘Less toothache’

There was also said to be a drop in the number of children needing hospital treatment for dental problems, freeing up operating theatres.

Public Health Minister Michael Matheson said: “This is an amazing achievement and shows just how much can be saved from a very simple health intervention.

“This has seen less tooth decay in children which means less toothache, fewer sleepless nights and less time off school.

“By this simple measure, NHS costs associated with the dental disease of five-year-old children have decreased dramatically.

“More children can just be treated routinely in the dental chair because they need less invasive treatments, so fewer fillings and fewer extractions, and many more children with much better oral health than we have seen in many years.”

For the second time you state your concerns about, “Unwarranted extrapolation from studies done at high concentration” which you say are “a dime a dozen and worthless in this debate.”

Last time you brought this up I responded by showing that several human IQ studies were not done at high concentrations. For example, in nine of the 27 IQ studies  reviewed by Choi et al (2012), the high fluoride village was at 3 ppm or less. I also went into more detail on the study by Xiang et al. (2003a,b) who found a threshold at 1.9 ppm for this effect.

In my discussion on this point I stressed the difference between concentration and dose and the need to consider a margin of safety calculation to protect for the full range of expected sensitivity or vulnerability in a large population when extrapolating from a small human study of a fairly homogeneous population. Thus extrapolating from Xiang’s study we find that there is absolutely no margin of safety to protect either for the range of exposure to fluoride in an American or NZ population or for the full range of sensitivity expected in any large heterogeneous population. This latter calculation is particularly important for your major concern – disadvantaged children – because that is almost certainly where you will find the most vulnerable in this regard.

When we embarked on this exercise I thought that this was going to be an exchange between yourself and me, but I am finding that you do not want to restrict yourself to my arguments but want to argue against all the arguments thrown at you by people opposed to fluoridation. That has a place of course but it was not what I was expecting. In my view it serves to distract and muddy the waters.

I wish you had taken a more disciplined approach and focused entirely on the arguments I have put forward. In this respect it is unfortunate that when you were educating yourself on this issue you did not take advantage of reading the book I co-authored with two other scientists, James Beck, MD, PhD and Spedding Micklem, DPhil (Oxon). There we spelled out the case in a cool, calm and collected way with every argument backed up with citations to the scientific literature. As you know – but your readers may not – I sent you a pdf copy of this text. By so doing, I had hoped that we could keep this debate tightly focused; that I could defend my own arguments (and there is plenty enough of those) and not have to keep considering those of others.

Your readers might also not know that shortly after this book was published (Oct 2010) I was invited in early 2011 to meet with staff of the Ministry of Health in Wellington. About 20 people were there from the Ministry and some of their advisers. I carefully went through the arguments in the book and asked them at the end of my presentation to provide a written response to the book showing where I was wrong and providing the science that supported their critique. I added that if they could not do this with all the resources and personnel at their disposal then they should not continue to promote this practice. After nearly 3 years I still have not received that written critique.  Meanwhile, personnel from this Ministry, including the Minister himself, continue to promote the practice and even accuse opponents of distorting the scientific arguments – with no specific examples to which someone like myself could respond.

Blanket condemnation of opponents gets us nowhere. Nor does it help to keep knocking down straw dummies. The debate will only be seriously engaged when the proponents begin to put forward and defend the studies that have convinced them that fluoridation is both effective and safe – and safe for everyone. This is what opponents like myself have done. This was what I was expecting from you Ken when you got the opportunity to put forward your case. Surprisingly, you gave no scientific citations at all.  Hopefully, these will come later.

Rather than take up any more space at this point I will wait for part 2 of your case, where I hope you will present some science to support this practice.

While you are doing this I will prepare my response to your response to my section 1A.

References

Choi et al., 2012. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect 120:1362–1368.

Pandit et al., 1940, Endemic Fluorosis in South India, Indian Journal of Medical Research 28, no. 2: 533–58.

Q. Xiang, Y. Liang, L. Chen, et al., “Effect of Fluoride in Drinking Water on Children’s Intelligence,” Fluoride 36, no. 2 (2003): 84–94, http://www.fluorideresearch.org/362/files/FJ2003_v36_n2_p84-94.pdf .

Q. Xiang, Y. Liang, M. Zhou, and H. Zang, “Blood Lead of Children in Wamiao-Xinhuai Intelligence Study” (letter), Fluoride 36, no. 3 (2003):198–99, http://www.fluorideresearch.org/363/files/FJ2003_v36_n3_p198-199.pdf .

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Anyone wanting to follow the debate and/or check back over previous articles in the debate can find the list of articles at Fluoride Debate.

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