Yes, this is the absolute, guaranteed, final statement from Paul Connett in this exchange. It responds to Ken Perrott’s last article Fluoride debate: Ken Perrott’s closing response to Paul Connett?
For Paul Connett’s original article see – Fluoride debate Part 1: Connett.
A final attempt to bring this debate back to science.
The structure of this posting.
Part A. A few introductory comments
Part B. Ken’s claim that the Hastings trial was not “fraud” but bad science
Part C. Major issues that have been avoided or poorly addressed
- The difference between concentration and dose
- The need for a Weight of Evidence analysis – especially on fluoride’s impact on the brain
- The need for a Margin of Safety Analysis when harm has been found at a certain level
- A margin of safety analysis for lowered IQ
- Bottle-fed babies: a special case
- Osteosarcoma: politics versus science
PART D. A response to some of the issues raised in Ken’s last posting – Ken Perrott’s closing response to Paul Connett? December 30, 2013 not covered in Parts A-C.
PART E. A Summary of the key arguments against fluoridation
PART A. Introductory comments
A.1) Attacking the messenger instead of dealing with the message
A lot of time was wasted in Ken’s final posting Ken Perrott’s closing response to Paul Connett? December 30, 2013 in attacking the Fluoride Action Network, FAN-NZ and other opponents of fluoridation. In my view, Ken would have served his pro-fluoridation position better by providing solid scientific references to support the proponents’ claims of effectiveness and safety. I address some of the specific issues he raises in part D below.
A.2) There are some important unresolved issues, which I have raised in earlier posts but not fully addressed by Ken. I will cover these in Part C.
B.1 The Hastings-Napier Fluoridation Trial Fraud
Let me summarize the bare bones of the issue here.
The Hastings Napier trial was meant to have Hastings as the fluoridated community and Napier as the control. In other words it was going to be cross-sectional study – comparing tooth decay in two cities at the same point in time after one had been fluoridated and the other had not. Shortly into the experiment the control city was dropped, thus the study became a longitudinal one. In this case comparing the tooth decay in one city (Hastings) at the beginning and end of the trial.
For such a comparison to be valid, there must be no change in key parameters during the trial. However, there was a change in one of the key parameters in this trial and it was a major parameter – the method of diagnosing and treating tooth decay. This was less stringent at the end than it was at the beginning. Thus the drop in tooth decay attributed to fluoridation was part, or all, the result of making the diagnosis and treatment of tooth decay less stringent.
What convinces me the final report was a fraud was that the authors did not mention the change in diagnosis when claiming the drop in tooth decay was due to fluoridation. In my view this was more than an oversight or just “bad science” as Ken argues. As this trial was used to promote fluoridation throughout NZ it is a very serious matter indeed.
Ken makes three points that do not pertain to the central fraud discussed above and completely ignores the “smoking gun” letter from NZ Dental Director G.H. Leslie.
First, Ken says that the method of changing the diagnosis of tooth decay was applied throughout NZ and not just locally. Ken argues:
“My own family remembers this change in dental technique by the school dental service because it was country-wide – not restricted to Hastings as Colquhoun, and Paul, imply. There goes the conspiracy theory and Paul’s claim of a scientific fraud.”
No it doesn’t. Whether the diagnosis and treatment of tooth decay was changed locally or nationally, the authors of the report should have acknowledged this very important change in their report. Their failure to do so – and claiming that their study showed that fluoridation was a great success – was a fraud. What legitimate researchers should have done was to instruct the nurses not to change the way teeth were treated in Hastings (regardless of what was happening in the rest of NZ). In this way they could have maintained the same situation with this key parameter at the beginning and the end of the trial. But they didn’t.
Ken’s second point was to argue about why the control city was dropped. However, whether the control city was dropped for bogus or legitimate reasons the central charge remains the same. The resulting longitudinal study in Hastings was a fraud because of the fundamental change that was made and not announced by the authors.
Ken’s third point is his citation of paper by Akers (2008) to convince us that it wasn’t a swindle but bad science. But Akers’ comment is certainly not a rebuttal, if anything it is a confirmation.
Here is the quote from Akers:
“The changing of NZSDS [NZ School Dental Service] diagnostic criteria for caries and the cessation of the NZSDS nurses’ practice of prophylactic restoration of fissures further confused interpretations. While later antifluoridationists justifiably claimed that the changed diagnostic criteria contributed to the fall in caries (Colquhoun, 1999), their “science or swindle” questioning of methodology and findings (Colquhoun and Mann, 1986; Colquhoun, 1998; Colquhoun and Wilson, 1999) simplified confounding variables and dismissed international evidence supporting community water fluoridation as one factor in declining community caries incidence (de Liefde, 1998).”
Readers will note that Akers does not claim that the diagnostic wasn’t changed. He admits that it was and he acknowledges that, “antifluoridationists justifiably claimed that the changed diagnostic criteria contributed to the fall in caries”
Whether there were other confounding factors not acknowledged by Colquhoun, the charge of fraud centers around the important change in diagnostic that was not acknowledged by the authors of the report.
Ken also ignored the incriminating evidence presented in the letter from G.H. Leslie, the Director of Dental Health for NZ that I quoted in my previous post.
There is no doubt about the validity of this letter. This “smoking gun” letter was obtained by Colquhoun who used the Official Information Act 1982 to obtain all the files pertaining to the Hastings-Napier trial from Department of Health files (1951-1973) now held in National Archives, Wellington. This letter from Leslie was found in those files and was reprinted in the paper by Colquhoun and Wilson (1990).
Here is the letter again:
12, October 1962
I have delayed acknowledging receipt of Dr. Roche’s letter to you and replying to your minute in the hope that I would by now be able to give a positive reply to your enquiry. I still cannot.
No one is more conscious than I am of the need for proof of the value of fluoridation in terms of reduced treatment. It is something which has been concerning me for a long time. It is only a matter of time before I will be asked questions and I must have an answer with meaning to a layman or I am going to be embarrassed and so is everyone else connected with fluoridation. But it is not easy to get. On the contrary it is proving extremely difficult. Mr. Espia is conferring with Mr. Bock and Mr. Ludwig and I am hopeful that in due course they will be able to make a practical suggestion.
I will certainly not rest easily until a simple method has been devised to prove the equation fluoridation = less fillings
Division of Dental Health
According to Colquhoun and Wilson (1990) what was concerning Leslie in 1962 (which was 8 years into the 10-year Hastings trial) was that the Hastings tooth decay statistics showed little difference between those exposed to fluoridation in Hastings and the rest of unfluoridated New Zealand. In other words, fluoridation wasn’t working.
Miraculously, two years after this letter was written, the Fluoridation Trial report showed that the Hastings trial was a great success!
In conclusion, I can find no evidence of a published rebuttal of the conclusion that this Hastings trial amounted to fraud. Certainly Colquhoun’s co-author Professor Robert Mann is not aware of one and I have checked with him.
PART C: Elaboration of some key issues so far not satisfactorily resolved
C.1) The difference between concentration and dose
In our exchanges Ken has never commented on the key difference between concentration (mg/liter) and dose (mg/day). This question is important because leading proponents, organizations and agencies that promote or defend fluoridation often blur this key distinction in a self-serving manner.
For example, the American Dental Association (ADA) denied the relevance of the National Research Council’s groundbreaking review on the toxicology of fluoride in drinking water (NRC, 2006), to water fluoridation – on the day it was published – because they argued that the NRC panel only found harm in the range of 2 – 4 ppm and in the U.S. we fluoridate in the range of 0.7 – 1.2 ppm. The Oral Health Division of the Centers for Disease Control and Prevention (CDC) made similar claims six days later as did the Australian Government’s NHMRC Report in 2007.
One of several things wrong with this argument by the ADA, CDC and NHMRC is that above-average water drinkers in communities with 0.7 – 1.2 ppm could easily get higher doses than some of the below-average water drinkers in the communities at 2 ppm and even 4 ppm. In short, the concentrations may be different but the doses overlap – and it is the dose that can cause harm.
Fluoridation proponents continue to make the same claims today when they argue that we can ignore the studies that have found a lowering of IQ associated with fluoride exposure (Choi et al, 2012) because they were carried out at higher concentrations than the levels we use in water fluoridation programs. The weaknesses of such arguments will become clear in my margin of safety analysis based on 5 of the studies in the Choi review below.
C.2) The need for a “weight of evidence” analysis – especially on fluoride’s impact on the brain.
In toxicology we seldom have a definitive study about the risks or safety of a particular substance sufficient to resolve a dispute to everyone’s satisfaction, especially to the satisfaction of those with special interests. That is why some bodies favor the application of the Precautionary Principl, (Tickner and Coffin, 2006) into which we go into in some detail in chapter 21 of The Case Against Fluoride… .
Less controversially many regulatory agencies settle for a “weight of evidence” analysis where they carefully balance all the studies – including both human and animal, as well as epidemiological, clinical, and biochemical – before they conclude one way or the other whether a particular chemical is going to cause harm to any specific population.
I have provided a list of studies on the brain from which the “weight of evidence” suggests that fluoride is a neurotoxin and could well be lowering the IQ of children. Ken has yet to produce any studies that would outweigh this conclusion. Here is that list again:
In over 100 animal studies that we have examined, at least 40 show that prolonged exposure to fluoride can damage the brain
At least 19 animal studies report that mice or rats ingesting fluoride have an impaired capacity to learn and remember
At least 12 studies (7 human, 5 animal) link fluoride with neurobehavioral deficits
3 human studies link fluoride exposure with impaired fetal brain development, and we are not aware of any that don’t
37 out of 43 published studies show that fluoride lowers IQ, of which 27 were part of a meta-analysis conducted by a team from Harvard (Choi et al. 2012)
The full citations to all these studies can be accessed at www.fluoridealert.org/issues/health/brain
With respect to the lowering of IQ several of the studies are strengthened by the fact that the lowering of IQ was inversely related to urine fluoride levels (Xiang et al., 2003 and Ding et al, 2011). In addition, Xiang et al (2011) showed that the lowering of IQ was inversely related to plasma fluoride levels. In other words the lowering of IQ can be related to individual exposure to fluoride.
The NRC (2006) report had a whole chapter on this matter and so do we, in The Case Against Fluoride…, but the proponents of fluoridation have done their level best to ignore, downplay or distract attention from this landmark NRC review as well as the updated discussion in our book, and most recently the systematic review by Choi et al (2012).
As far as the IQ studies are concerned, at the time the NRC (2006) reviewed the matter there were only five IQ papers available to them. Even so, the NRC panel – while pointing out some weaknesses in these studies – commented on the consistency of the results and recommended more research. But none has been published in the U.S. or any other fluoridated country in the 7 years plus since the NRC recommendation was made.
Thanks to translations made available by the Fluoride Action Network of studies previously published in China, and several new studies from Mexico, Iran and India, there are now 43 IQ studies available. 37 of these indicate a statistically significant lowering of IQ associated with fluoride exposure. The Harvard team reviewed 27 of these studies (Choi et al, 2012) and found a lowering of IQ in 26 studies, with an average lowering of about 7 IQ points.
Ken is rightfully concerned about the well-being of children from low-income families, but is he willing to put the questionable benefit from fluoridation above the possibility of harm to their neurological and mental development? Especially when other countries have achieved success with alternative approaches. Why force whole populations –especially low-income families who cannot afford avoidance measures – to take such risks?
C.3) The need for a “Margin of Safety” Analysis when harm has been found at a certain level
This analysis is critical when you are considering rejecting the relevance of a study based on the dose levels used, or concentrations in the case of fluoridation proponents.
It is important to remember that in any large population we can anticipate a very large range of sensitivity to any toxic substance. Like most other human traits such sensitivity follows a normal distribution curve (the famous bell-shaped curve). Most people cluster around the average – the bulge of the bell – and will have an average response but at the tails of this curve – the lips of the bell – we will have people who are very sensitive at one end and very resistant at the other. Typically toxicologists assume some people are going to be at least 10 times more sensitive than the average person. This is used to generate a default safety factor of 10 (sometimes referred to as the “intra-species variation” safety factor). This default value is only dropped to a smaller value than 10 if the population in the study group is very large.
Thus if we find harm in a small human study and wish to determine the level that would protect everyone in a large population from that harm this is what we do. We take the dose (mg/day), which has been found to cause no harm (the so-called no observable adverse effect level or NOAEL) and divide that dose by 10 to give a safe dose for the most sensitive individual in the population. Frequently we don’t have a NOAEL and so we have to use a LOAEL (the lowest observable adverse effect level) and divide that by 100. Sometimes this process is corrupted and it is the LOAEL not the NOAEL that is divided by 10. The method used by Xiang (2003 a) is a variant on this method, but it usually arrives at similar end points. It uses all the data in a study to find the dose-response curve, not just the NOAEL and LOAEL.
Applying these calculations in a real world situation is called a Margin of Safety Analysis and shockingly it is very seldom considered by people who promote fluoridation. They simply use the very crude and highly misleading approach of comparing the concentration used in the study group with the concentration of the fluoride in the water of the fluoridated population, as discussed above in C.1.
C.4 A margin of safety analysis for lowered IQ
Ken has reasonably questioned how Xiang determined the threshold value that I used in the Margin of Safety analysis in a previous posting. In rechecking Xiang’s explanation I find it is rather complicated, even though he appears to have used a methodology advocated by the US EPA. I have no problem with Ken raising this question but I do have a problem with the way he has used this one detail as a way of avoiding the main exercise. That main exercise is how one goes about determining a safe dose for everyone in a large population when one has evidence that there is harm in a small study group.
I am going to repeat the margin of safety analysis for lowered IQ without using Xiang’s threshold value of 1.9 ppm. Instead, I will start with the nine studies where IQ was lowered at a fluoride level less than 3 ppm.
Of these nine studies I have used five of the six where the result is statistically significant . The sixth is a study by Lin et al (1991), which I have excluded because it is complicated by the iodine levels involved. These five studies had levels where IQ was lowered in the high-fluoride village at 1.8; 2; 2.38; 2.5 and 2.9 ppm. See Table 1.
Here is a step-by-step explanation of my margin of safety analysis.
Step a) As our starting point I choose the study that found a lowering of IQ at the lowest concentration. That was 1.8 ppm.
Step b) Our next task is to estimate the reasonable dose range this represents for the children in the study group – which of course, will depend on how much water they drink and how much they get from other sources. We assume (correctly, we believe) that very few of these rural Chinese children use fluoridated toothpaste and that their daily dose comes largely from the water.
- If they drank 2 liters of water per day at 1.8 mg/liter (i.e. 1.8 ppm) their daily dose would be (2 L x 1.8 mg/L) = 3.6 mg/day.
- If they drank 1 liter of water per day their daily dose would be 1.8 mg/day
- If they drank 0.5 liters of water per day their daily dose would be approx 0.9 mg/day.
In other words a reasonable estimate of the range of the dose leading to a lowered IQ was approximately 0.9 – 3.6 mg/day.
Step c) Our third task is to determine a safe dose to protect all the infants and children from lowered IQ in a large population.
From this range the LOAEL is 0.9 mg/day. We do not have a NOAEL so we have to divide the LOAEL by 10. So the NOAEL = 0.09mg/day.
To protect every child (including the most vulnerable) we have to divide the NOAEL by a further factor of 10. This is being very conservative, but it is the standard procedure unless one has data from a large population study.
Thus we would not want any child in a large population ingesting more than 0.009 mg/day of fluoride to protect against lowered IQ (NOAEL divided by 10). This translates into 9 ml of water fluoridated at 1 ppm . Here is the calculation. 9 ml = 0.009 Liters. 0.009 L x 1 mg/L = 0.009 mg/day
Of course this is a rather crude measure because the subjects in this study were children, whose weight (and hence perhaps tolerance of fluoride) varies according to age and other factors. We shall refine this shortly in relation to infants.
Conclusion. Based upon the five statistically significant IQ studies that found a lowering of IQ at less than 3 ppm a responsible regulatory authority would not allow water fluoridation. Little wonder then that fluoridation promoters are doing everything they can to criticize these IQ studies.
Note: this is an analysis based on the data available. Of course there are things we don’t know which can affect the interpretation. For example we don’t know that post-natal fluoride consumption is the most important variable: it might be prenatal exposure.
C.5) Bottle-fed babies: a special case
Let me return to the issue that got me involved in this matter 17 years ago: the level of fluoride in mothers’ milk. I do not believe Ken has provided a convincing explanation as to why we should ignore this issue.
The level of fluoride in mothers’ milk is very low. For a woman in a non-fluoridated area it is about 0.004 ppm (NRC, 2006, p.40), although a range of values has been reported.
There are certain realities about the fluoride ion which make it incompatible for a lot of biochemistry – always given the important caveat of the concentration levels reached – and these are its ability to seek out positive centers like metal ions and hydrogen bonds – both critical for biochemical structure and function.
These fundamental attractions can easily explain fluoride’s known ability to inhibit enzymes, help to switch on G-proteins non-specifically, and possibly cause oxidative stress. These interactions are so fundamental that we should not be at all surprised if many ailments may be caused by fluoride. It was the American Medical Association (before fluoridation began) that used old-fashioned terminology when it stated that fluoride was a “general protoplasmic poison” in its warning not to rush into water fluoridation in a 1943 editorial in JAMA.
So let us briefly extend the margin of safety analysis to bottle-fed babies.
Here we have to take into account the extra problem of the baby’s small bodyweight. To take bodyweight into account we use a different measure of exposure: i.e. dosage instead of dose.
Dose is measured in mg/day, dosage is measured in mg/kilogram bodyweight/day.
If we consider that the ‘safe’ dose we have determined (0.009 mg/day) and apply that to 20 kg child, then we would say the safe dosage was 0.00045 mg/kg/day (0.009 mg/day divided by 20 kg). Then the safe dose for a 7 kg baby would be 0.00315 mg/day. (7 kg x 0.00045 mg/kg/day = 0.00315 mg/day).
A breast fed baby (with mothers milk at 0.004 ppm) drinking 800 ml a day would get 0.004 mg/L x 0.8 L = 0.0032 mg/day which is very close to the level we have determined is safe. So based on these calculations, the fluoride that naturally occurs in breast milk does not pose a risk of lowering the IQ in babies.
A bottle-fed baby (with water at 0.7 ppm) drinking 800 ml a day would get 0.7 mg/L x 0.8 Liters = 0.56 mg/day. This is 0.56/0.00315 = approx 180 times higher than the safe level to protect against lower IQ.
A bottle-fed baby (with water at 1.2 ppm) drinking 800 ml a day would get 1.2 mg/L x 0.8 Liters = 0.96 mg/day. This is 0.96/0.00315 = approx 300 times higher than the safe level to protect against lower IQ.
So whether by accident or by evolutionary “design” mothers’ milk is protective against lowered IQ but formula made up with fluoridated water (0.7-1.2 ppm) is not. The latter delivers a daily dose of fluoride, that is a factor of 180-300 times too high for a 7 kg baby.
C.6) Osteosarcoma: politics versus science
This is another issue to which Ken has not responded. It also one of the 10 “Ugly Facts,” which I feel should have ended the fluoridation experiment. This ugly fact occurred in 2001 when Elise Bassin, a dentist completing her doctoral thesis at the Harvard Dental School, found in a carefully conducted matched case-control study, that young boys exposed to fluoridated water (at 1 ppm) in their 6th to 8th years had an associated 5-7 fold increased risk of succumbing to osteosarcoma. Osteosarcoma is a rare but frequently fatal bone cancer.
Her study was first hidden (politics) from the public and scientific community, but was eventually published in 2006. Despite published promises from her thesis adviser that his larger study would refute her finding (politics), his study when it was finally published in 2011 entirely failed to do so (Kim et al., 2011).
So what we have here is an unrefuted study that indicates that a few young boys may be losing their lives by drinking fluoridated water. I am really amazed that promoters of fluoridation can take this issue so lightly. The small number involved should not justify turning a blind eye to this. As John Colquhoun asked in my videotaped interview with him in 1997 how much tooth decay saved would be an adequate exchange for “one death of a teenage boy from osteosarcoma” http://fluoridealert.org/fan-tv/colquhoun/
I am also disturbed that the Pew Charitable Trusts (a multibillion dollar foundation that is actively campaigning in support of fluoridation) would mischievously claim that the Kim et al (2011) study has put the matter to rest when it clearly has not.
The issue of fluoride and osteosarcoma has a long and fascinating history. There is a lot of politics involved, which is not surprising because if this connection was proven it would spell the end of fluoridation. We go into this sixty year history in some detail in Chapter 18 of our book, The Case Against Fluoride… A timeline can be found on the FAN website at http://fluoridealert.org/studies/cancer05/ where full citations of the references can be found. Space forbids including it all here so we will jump to 2001.
2001. Even though Bassin’s thesis advisor Professor Chester Douglass had signed off on her thesis, in the three years that elapsed after her research was successfully defended he did not inform his peers, the NRC panel or his funders of this dramatic finding (politics). Instead he kept insisting when asked that his “own” study found no relation between osteosarcoma and fluoridation, without indicating that his own graduate student had found the opposite to be the case (and with better methodology).
Douglass knew of course that if this connection between fluoridation and osteosarcoma was established it would end fluoridation, and stated as much in a paper he had co-authored ten years earlier (McGuire et al.,1991).
2005. Eventually Bassin’s doctoral thesis was found in one of the Harvard libraries in 2005. The Environmental Working Group charged Douglass with academic misconduct for hiding this finding and asked the NIH (which had funded the study) to investigate. The investigation was handed over to Harvard. A committee appointed by the Harvard Dental and Medical Schools investigated the matter and in a short 4-paragraph statement exonerated Douglass, finding that he did not “deliberately” hide these findings. Harvard refused repeated requests for them to provide the basis for this decision.
2006. Bassin’s findings were finally published in the journal Cancer Causes and Control (Bassin et al., 2006). In the same issue of the journal a letter was published from Douglass that stated that his larger study would show that Bassin’s thesis did not hold (Douglass and Joshipura, 2006). Douglass told the NRC panel that this larger study would be available in the Summer, 2006. But it did not appear for five years.
Meanwhile, Douglass’ promise of a study in a letter was used by the NHMRC (2007); Health Canada (2011) and health authorities in the UK as if it was an actual peer-reviewed and published study (more politics).
2011. Eventually the Douglass paper was published in 2011, but oddly enough not in a cancer journal but in a dental journal, although it had nothing to do with teeth (Kim et al., 2011). The study has many weaknesses, but the key fact is that it did not refute Bassin’s findings. Nor could it possibly do so. Because the biometric of exposure was the accumulated fluoride levels in the bones. As the authors themselves admitted, there is no way such levels could be used to determine the exposure to fluoride during the critical age window of vulnerability found by Bassin (the 6th to 8th years).
Conclusion: a well-researched study found a possible relationship between exposure to fluoridated water – at a specific age range in young boys – and a rare but frequently fatal bone cancer. Despite promises to the contrary, which were greedily gobbled up and repeated ad nauseam by promoters and supporters of fluoridation, this study has never been refuted.
It may be that fluoridation is killing a few – not many – young boys each year from this cancer. This is not fearmongering on my part. It is the current state of affairs as far as legitimate scientific research is concerned.
As with the lowering of IQ we are talking about serious albeit unproven risks here. When even prominent promoters of fluoridation have acknowledged that the predominant benefit of fluoride is topical and not systemic (CDC, 1999 and 2001), it remains puzzling – at least from a scientific point of view – why promoters are willing to take these risks. Especially, when it is clear that tooth decay is being reduced in the vast majority of countries that fluoridate neither their water, nor their salt, nor their milk.
There are alternatives, including education on dental hygiene, education for better diets (especially pregnant women and young children) and targeted topical treatments for the most vulnerable populations as currently being practiced in Scotland.
Here I address some of the issues presented in Ken’s Final Posting Ken Perrott’s closing response to Paul Connett? December 30, 2013 not covered in Parts A-C.
Ken’s comments are in bold and blue.
D.1) Correcting some misrepresentations
This is Ken’s title for a super-gish-gallop of complaints and accusations, some trivial, some contentious, some correct and a few that raise important issues. Some deserve or require response. It seems rather a pity to end the exchange, which in some ways has been interesting and informative on such a ding-dong and largely negative note. I shall try to conclude with something a bit more positive.
D.2)…I would be perfectly happy to see New Zealand switch to fluoridated salt.
Certainly fluoridated salt would be an improvement over fluoridated water because it would give citizens a choice on whether they wanted to increase their ingestion of fluoride or not
D.3) “Maybe the most empathetic solution is that society as a whole compensate this small number of people [who have increased sensitivity to fluoride, PC] in some way to aid them with their predicament.”
I am sure that those with this predicament are grateful for Ken’s empathy but probably believe, like I do, that the chances of the NZ government compensating them for a condition it does not recognize and is not willing to study is next to nil. So perhaps he might agree that a better way to relieve their symptoms would be simply to stop fluoridating the water.
D.4) Paul criticises public funding of an information service in New Zealand set up specifically to facilitate a “weighted evidence approach” towards fluoridation research.
My concern here is the use of taxpayer money (about 1 million dollars) to support the promotion of fluoridation rather than presenting a balanced view of the evidence. Yes, I was confused by the similar names; my mistake.
The citizens of NZ have reason to be grateful that a counterbalancing site has been set up. Its mission statement is worth reading because it clarifies why it came into being and how the organizers perceive their role:
“The New Zealand Fluoridation Information Service has evolved from frustration that useful, factual information about fluoridation has become almost impossible for the public and even professionals to sort out. NZFIS’ main goal is to facilitate full public and scientific examination of this public policy, which has become obscured by biased or inept media treatment (or lack thereof), by political rhetoric, and because of the obfuscation surrounding important information.
Probably the best that independent people can do, who are interested in this controversial issue, is to read the material on both sites and make their own judgment.
D.5) Paul is still confused about the graphic I introduced early in this exchange showing data for fluoridated and unfluoridated areas of the Irish Republic.
My apologies. I should have checked back.
D.6) He (Paul) has already lost that argument (about fluoridation cessation studies not leading to increased tooth decay) and he is desperately clutching at his remaining straws…
I have acknowledged that Ken had raised some valid arguments pertaining to the effects of ending water fluoridation but he takes this a little too far. Here is the background: proponents have argued that ending fluoridation would be a disaster as far as tooth decay was concerned. We have cited four modern studies that indicate that tooth decay did not increase when fluoridation was halted in Cuba, former East Germany, Finland and British Columbia, Canada.
Ken responded that in two of these studies other measures were taken which might have explained why tooth decay did not increase. I in turn argued that if this was the case it shows that there are alternatives to fluoridation that work, removing the need to force this practice on people who don’t want it.
In checking one of the other studies from British Columbia (Maupomé et al, 2001 and Clark et al, 2006) I came across a study commissioned by the City of Toronto Public Health Board. This study examined the very issue of what would happen if fluoridation was ceased in Toronto (Azarpazhooh, 2006) and in the process carefully examined all the cessation studies available at that time. I think you can gauge from the fact that this pro-fluoridation board would not publicly release this report, that the results were not favorable to a pro-fluoridation position. After a great deal of effort the group Canadians Opposed to Fluoridation finally obtained this report and it can be accessed from their site.
D.7) He (Paul) again avoids the importance of including social good in ethical considerations of social health policies like fluoridation.
I have no problem with entertaining the idea that a social good may over-ride individual preference (e.g. seat belts are a good example, and so is smoking in public). But I do not think that this notion applies in the case of water fluoridation. For those like Ken who believe it does, there are three hurdles in my view that they have to cross.
If they wish to force a practice on the whole population, against the express wishes of many, they at least need to demonstrate three things:
a) They must be sure that the good they are attempting to achieve is substantial and has been demonstrated with near certainty. We agree that no RCTs have been done to establish certainty and I think we may agree that the effect found in less rigorous studies has not, since the advent of fluoridated toothpaste, been all that impressive in absolute terms.
b) They must be sure that the good they are trying to achieve outweighs any harm that it may cause. In this case we have the undisputed increase in dental fluorosis, which can cause psychological harm when it reaches the moderate and severe levels, as well as being very costly to treat. In addition we have several distinct risks, which – largely due to a lack of will to seek evidence to corroborate or disprove them – should be seriously considered. These include impairment of brain development and IQ; long tem bone damage including some forms of arthritis; small increases in cancer deaths due to fluoride itself or arsenic contamination of the fluoridating chemicals; and (cf D3 above) production of sensitivity reactions in some individuals.
c) They can demonstrate that there are no other cost-effective approaches that can achieve the same aims (primarily the reduction of tooth decay among low-income families). This is hard to demonstrate because many countries have achieved the same reduction in tooth decay without fluoridation. And I have also cited the targeted Scottish program, which appears cost-effective and has achieved remarkable results with the children of low-income families using fluoride only for topical application.
I think it is fair to say that none of the three hurdles has been cleared or even seriously attempted during this debate.
D.8) Paul’s emotional (or political) obsession with individual choice often comes though in the most unlikely places. Why should he use the term “forced fluoridation” in a polite scientific exchange?…. There is always a choice for those prepared to make the effort to satisfy their convictions.
Ken objects to the “impolite” word “forced” in connection with water fluoridation. Okay, someone like me, or like him I guess, living in a fluoridated community can install a reverse osmosis filter (expensive), avoid eating out or visiting friends (restrictive) and refrain from eating prepared foods (hmm). But let’s see what “forced” means to low-income families who are supposedly the main beneficiaries of the program. They can’t necessarily afford bottled water for drinking and cooking, and they can’t afford reverse osmosis units. They are trapped by this program. If these families do not share Ken’s belief that this program is doing them good, and may even be causing them harm, there is little they can do.
If these same families cannot afford bottled-water to make up baby formula, then they may be forced to give their babies about 200 times more fluoride than nature provides. In this situation they are worse off than children from middle-income and higher-income families because fluoride’s toxic effects strike hardest on those with poor nutrition, low calcium, low protein, low vitamins and low or borderline iodine.
Let me introduce an idea about fairness into this discussion: the idea of “disproportionate imposition.” Clearly if you remove fluoride from the community’s water supply or add it, you are going to make some people happy and others unhappy. But let’s look at the “disproportionate imposition” involved here. For those who don’t want it – and it is added – they have to go at the least to the expense and inconvenience that I have discussed above . At the worst, they may be unable to avoid it at all. In contrast, those who do want it – and it is removed from the public water supply – merely have to content themselves with fluoridated toothpaste, which they are probably using already – if they insist on ingesting fluoride they can drink fluoridated bottle-water or take sodium fluoride tablets.
I think the imposition to both sets of people is dramatically different. Thus at the very least – and on top of all the other arguments – this practice is unfair because of this disproportionate imposition factor. The idea that fluoridation is a social good is quite fallacious.
D.8) I am surprised Paul has taken the approach of blaming practically every illness or change on fluoride.
I do not do this and we didn’t do it in our book. But it is a standard technique used by proponents of fluoridation. They ridicule the position of the opponents of fluoridation by claiming that we assert that every disease known to man is caused by fluoride. They sometimes include nymphomania, which is an invention entirely of their own making, to add to the ridicule.
Certainly there are some specific health concerns, most of which have been discussed at some length in this exchange. Those concerns deserve to be taken seriously because there are scientific reasons for postulating that fluoride may be involved in some way and to some extent in their pathogenesis. The case for investigating them is much enhanced by the fact that millions of people are having their total fluoride exposure increased by fluoridation. Ken goes on to list these concerns, though he doesn’t really need to at this stage, but then he just dismisses them as a mere tactic of non-scientific activists! Later he drags obesity into the discussion and his argument, if there is one, then becomes unintelligible to me. But let’s just look at the first on his list: arthritis.
Arthritis is of concern because the first symptoms of fluoride’s poisoning of the bone in endemic fluorosis areas are symptoms just like arthritis. We have argued that with arthritis reaching epidemic proportions in several fluoridated countries it would be a responsible thing for health agencies there to investigate whether there is any relationship between long-term exposure to fluoridated water and increased arthritis risk. It is not an unreasonable hypothesis. It is testable and one can reasonably argue that it should be tested. No fluoridated country has done so. I don’t think anyone is naïve enough to claim that all arthritis is associated with fluoride. Certainly I would never advocate anything so silly.
D.9) Paul insists on using the authority fallacy – out of context quotations from authoritative figures.
An example in his last article was that by David Locker. Perhaps he is not aware he is doing this – it seems to be an instinctive reaction for anti-fluoridation activists. He should appreciate that the world is never as simple as implied by such quotes. I see his resort to such fallacies as a weakness, not a strength.
I often quote the late David Locker. It is interesting that he, who has been pro-fluoridation reached a similar conclusion to my own, namely that today there seems to be not much of a significant benefit that can be associated with fluoridation (e.g. Brunelle and Carlos, 1990) or ingesting fluoride (e.g Warren et al., 2009).
For those who would like to see more of David Locker’s views on this subject I would encourage them to view a TV program featuring a three-way debate/discussion featuring David, myself and a representative of the Canadian Dental Association. The program (22 minutes in length) is a little rushed but still shows that you can have a civilized discussion on this with people who fundamentally disagree. http://fluoridealert.org/fan-tv/water-fluoridation-medical-hot-seat-debate/
I think David by occupying a middle position was key to the success of this program. Sadly he has since passed away at far too young an age.
It is ironic that Ken should complain about “anti-fluoridation activists” quoting authoritative figures because that strategy has been absolutely central to the promotion of fluoridation since the 1950s. They have used an endless list of endorsements from professional bodies, surgeon generals, Benjamin Spock, US Presidents – you name it. All this as a substitute for actual science!
D.10) Nature of Fluoride Action Network
If Ken wants to play pro-fluoridation activist rather than scientist, that’s fine by me.
He may convince himself and the rest of the world that FAN is a terrible organization, but that does not affect the scientific cases for and against fluoridation, which is what this debate is supposed to be about.
However I do urge readers, rather than taking Ken’s views of FAN at face value, to go to our homepage at (www.FluorideAlert.org) click on “researchers” top right, explore from there and draw their own conclusions.
PART E. Summary: The Key Arguments Against Fluoridation
Based upon all the above I believe that my key arguments against fluoridation remain largely untouched. Here they are again.
E.1) Fluoride is not an essential nutrient. There is no need to swallow it or put it in the drinking water.
E.2) It is bad medical practice – you cannot control the dose or who gets the fluoride. It goes to everyone, for a lifetime with no individual monitoring for side effects or the accumulated dose in the bones.
E.3) It is an unethical practice – you are forcing fluoridation on people who don’t necessarily want it.
E.4) It is a reckless practice. It is reckless for several reasons but particularly because it involves giving bottle-fed babies about 200 times more fluoride than breast-fed babies.
E.5) The evidence that swallowing fluoride reduces tooth decaysignificantly in today’s conditions is weak. Ken failed to address the many epidemiological studies that I cited (and we discussed in our book in chapters 6-8), most of which were conducted by pro-fluoridation scientists or pro-fluoridation agencies, that suggested that very little absolute benefit comes from swallowing fluoride. I singled out two studies. These were the studies by Brunelle and Carlos (1990) and Warren et al. (2009).
Both these studies were funded by the US taxpayer and both were conducted by pro-fluoridation researchers. So if there were any bias involved it would not have been in favor of the anti-fluoridation position. One study was very large and the other was small but very precise in its scope and nature.
Brunelle and Carlos (1990). This was the largest survey of tooth decay ever undertaken in the U.S. The teeth of 39,000 children from 84 communities were examined. The authors compared the Decayed Missing and Filled Surfaces (DMFS) for children who had always lived in a fluoridated community with children who had never lived in a fluoridated community. The average difference in tooth decay of the permanent teeth was 0.6 of one tooth surface and even this small saving was not shown to be statistically significant.
Warren et al., (2009). This study was part of the U.S. government funded “Iowa Study” where children’s tooth decay has been tracked from birth. The authors were attempting to find the so-called “optimal dose” needed by a child to reduce tooth decay. But they couldn’t find that dose. In fact, they could not find a clear relationship between tooth decay and the amount of fluoride ingested on a daily base. The authors concluded that, “These findings suggest that achieving a caries-free status may have relatively little to do with fluoride intake…”
E.6) Those countries in Europe that have opted not to fluoridate their water or their salt show little evidence that this decision has ruined their children’s teeth.
Ken argues that even though they don’t have fluoridated water, many use fluoridated salt and milk. In actuality, the majority of European countries fluoridate neither their water nor their salt. The only country that still has even a small amount of fluoridated milk in a few schools is the UK. Bulgaria and a few other former-communist countries experimented with fluoridated milk, but it has never been given to more than a miniscule percentage of European kids. Furthermore, with both fluoridated salt and fluoridated milk you are offering the individual a choice in the matter.
These countries have found alternative ways of fighting tooth decay, which do not involve forcing people to swallow fluoride who don’t want to. Those alternatives include early education for better dental hygiene, better diets, reduced sugar consumption, and targeted preventive measures (including topical treatments) for children from low-income families.
E.7) The admission by leading promoters of fluoridation like the CDC (1999, 2001) that the predominant action of fluoride is topical not systemic probably explains the findings in both E.5) and E.6) above.
E.8) There is a growing amount of evidence emerging that documents health effects at levels which offer no adequate margin of safety to protect everyone drinking fluoridated water, including the potential to lower IQ.
In the case study margin of safety analysis for lowered IQ (see C.4), I estimate that to protect every child drinking fluoridated water at 1 ppm, he or she should drink no more than 9 ml of water. The same analysis indicates that a breast fed baby is just about at the safe level to prevent lowered IQ, but a bottle fed baby will be getting 180 – 300 times above the safe level if its formula is made up with water at 0.7 and 1.2 ppm respectively (see C.6).
E.9) There is an unrefuted study that young boys drinking fluoridated water in their 6th to 8th years have an associated 5-7 fold increase of succumbing to osteosarcoma by the age of 20. As this rare bone cancer is frequently fatal, it is a shocking but real possibility that several young boys may be killed by this practice each year.
E.10) Since the U.S. Public Health Service endorsed water fluoridation in 1950 very little serious scientific attention has been directed into investigating both short and long term health effects of ingesting fluoride. Inexplicably the U.S. Food and Drug Administration has never regulated fluoride for ingestion and its official classification of fluoride is an “unapproved drug.” The U.S. National Research Council review of 2006 reveals many important but unanswered questions about ingested fluoride. The NRC also concluded that certain subsets of the population are exceeding the EPA’s reference dose for fluoride (the IRIS level) drinking water at 1 ppm fluoride; this includes bottle-fed infants and people with poor kidney function. The NRC recommended that the EPA Office of Water perform a new risk assessment to determine a new and safer MCLG (maximum contaminant level goal) for fluoride in drinking water. After nearly 8 years this new risk assessment has not been done. If determined honestly a new MCLG would almost certainly force an end to water fluoridation. Politics not science is keeping this practice afloat in the U.S.
Overall Conclusion. It is time to end water fluoridation worldwide. The very small and questionable benefits do not justify the huge risks being taken. New Zealand would be a good place to start the process. If it did so it would not make the U.S. health agencies that have doggedly promoted this practice for over 60 years very happy. However, NZ has shown itself capable of bucking the tide on other international issues in which the U.S. has held a strong contrary position. It would be refreshing for at least one fluoridating country to admit that it has made a mistake with this policy and set out to return scientific integrity to the center of its public health policies.
I thank Ken for sharing this debating platform with me. Of course we have disagreed on many things, which one would expect in any debate –but hopefully readers of all persuasions will have found enough to engage their interest.
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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.