A SCIENTIFIC CRITIQUE OF THE FLUORIDATION FORUM REPORT, IRELAND 2002.
Conclusions and Recommendations
In our view, the Fluoridation Forum had several tasks. It first had to demonstrate that fluoridation was effective at reducing tooth decay in Ireland. It then had to address all the concerns that have been expressed about fluoride's harmful effects at the daily doses experienced in optimally fluoridated communities as well as the lifetime cumulative dose. If, after addressing these two tasks, there was uncertainty in either or both of the outcomes, then it had to offer some kind of balancing analysis which would demonstrate that any benefit found outweighed any possible health risks, with a sufficiency to overcome concerns about margin of safety considerations for a whole population.
Particular consideration should have been given to individuals who are likely to exhibit a wide range in sensitivity to any toxic substance, and who are also likely to experience a considerable range of exposure to fluoride from water and other sources, a sizeable number of whom are unable to avoid fluoridated water.
Some would argue, that no matter how strong the benefit and how weak the evidence of harm, the individual should still have the right to exercise "informed consent" in this matter and the Irish (or any) government should not be allowed to override this important human right, by enforcing medication on all. We agree with this ethical position. However, our main concern with this report is that the Forum has failed to demonstrate a significant benefit to teeth and failed to fully, or even partially, address many of the health concerns that have been raised.
Even the few concerns that the Forum authors did address were tackled inadequately and unscientifically. They ignored many studies, even ones that were actually presented to them in person, and those they didn't ignore they addressed superficially. In particular, they failed to use a "weight of evidence" approach which, in our view, is critical in a situation where a whole population is being exposed to a toxic substance, and where damage may not be realized until nearly a full lifetime of exposure. To wait until all the evidence is in simply means that a whole population will have received a lifetime of exposure. This is taking governmental arrogance to a whole new level of disdain.
In our view adding fluoride to the drinking water of every man, woman and child in society is akin to building a dam above a village. If something goes wrong with the dam it could flood the village. If those supporting fluoridation are wrong in their claims of safety millions of people could be adversely affected. That is why it is essential that those who review this policy leave no stone unturned in case there are flaws in the promoters' arguments. In toxicological terms that means taking into account every piece of scientific evidence however remotely relevant. The Forum should have examined biochemical studies; animal testing; clinical studies; all the evidence gleaned from countries which have high natural levels of fluoride (China, India and countries in Africa); the fluoride levels in the tissues and particularly the bones of people living in fluoridated communities, and epidemiological studies. These studies should be assessed for any need for caution. Those in charge, like the Minister of Health and Children, are appointed to look for red flags not to avoid them. That's their duty as public health officials. If they are unwilling to do their duty then they shouldn't be putting fluoride, and certainly not untested industrial grade hexafluorosilicic acid, into the drinking water of their citizens.
Unfortunately, the Forum authors, like many government sponsored report authors before them, have not chosen the careful approach. Instead of looking under every stone, they have left whole mountains unscaled. They have missed out many important studies and lines of enquiry. Moreover, where red flags have been waved, instead of proper scrutiny and research, they have simply looked for other studies to nullify them. Their aim appears to have been not to study the evidence, but to find ways to get around it. In short, they are approaching this task in the same manner the chemical industry has defended a whole host of toxic substances in the past (e.g. tetraethyl lead, DDT, PCBs, dioxins and furans).
Underlining the Forum's failure to take its charge of protecting the public seriously, is their failure to address the fact that the industrial grade chemical (hexafluorosilicic acid) used to fluoridate Ireland's water has never been tested in long term toxicological studies. This is especially inexplicable in light of the fact that Masters and Coplan have shown (1999, 2000) that there is an association between the uptake of lead (from various sources) into children's blood and the use of these same fluoridating chemicals in the United States. Moreover, these same authors have found an association between their use and indices of violent and anti social behavior, which is entirely consistent with this greater uptake of lead.
What is particularly shocking about the Fluoridation Forum's failure, and other previous government sponsored reports, is the relatively simple task of extrapolating from solid clinical data to predict a serious outcome for the bones from lifetime exposure to fluoride. If one simply calculates, as we have done, the cumulative dose used in clinical studies for the treatment of patients with osteoporosis, from the administered daily dose (20-40 mg per day for 1 - 4 years) which resulted in the unintended increase in hip fracture rates, it is not difficult to conclude that these cumulative doses will be exceeded during lifetime exposure by people living in fluoridated communities (1.6 to 6.6 mg per day for 70 years or more).
Instead of doing these kind of calculations on cumulative doses, the fluoridation forum authors obscured the issue in two ways: 1) they continued to describe the clinical experience as "high dose" trials without acknowledging that the trials only ran for short (compared to lifetime) periods (1-4 years), and 2) failed to underline the significance of the fact that approximately 50% of every daily dose of fluoride accumulates in the bones. Such an accumulation cries out for cumulative dose calculations.
Perhaps, the clearest evidence that the practice and promotion of fluoridation has always been a non-scientific venture, is the fact that no government endorsing this practice, including the Irish government, has ever felt fit to call for, or financially support, the careful monitoring of fluoride levels in the bones of their citizenry. This, even while they have poured money into studies of dental caries and dental fluorosis and even money into studying the psychology of people who oppose fluoridation. The fluoridation forum fell into line once again by failing to call for the obvious.
Because the Fluoridation Forum has failed to demonstrate either the efficacy of fluoridation or its safety, or convincingly demonstrate that this is an issue over which the government still has the right to overrule the individual's right to "informed consent" to medication, it is time for the Irish government to halt this practice.
Fortunately, there is plenty of evidence in the dental literature that where communities have stopped fluoridation in recent years in Finland, Cuba, former East Germany and Canada, that tooth decay has not increased, but actually continued to decrease. Nor does halting fluoridation deprive anyone of fluoride who is capable of brushing their teeth, since fluoridated toothpaste is universally available. We would further argue that the money saved by the Irish government in halting this practice would be far better spent targeting vulnerable individuals and communities with better education in oral hygiene, free toothbrushes and toothpaste, better dietary information and better dental treatment services.
It is time for the Irish government to have the political courage to admit that this practice was, is, and always will be wrong. They will win far more respect taking this high road, than the low road of dragging science and common sense through the mud in a report like this.
1) The historical, geographical and political context of the report.
2) Membership of panel.
3) Protecting health or protecting policy? Evidence of bias.
4) Health concerns and key studies omitted. A critique of Chapter 11.
4.1 Dental fluorosis.
4.2 The Alarcon-Herrera study.
4.3 Tolerable Daily Intakes (TDIs).
4.4 TDIs without uncertainty factors.
4.5 A huge mistake: a TDI which is enough to kill.
4.6 Margin of safety.
4.7 Bioaccumulation and the pineal gland.
4.8 Second-hand science: Reviews of reviews.
4.9 Key issues and key studies omitted.
4.10 Fluoride and bone.
4.11 Failure to take into account total dose.
4.12 Failure to use weight of evidence approach.
4.13 Failure to discuss the Precautionary Principle.
4.14 Failure to address Paul Connett's "50 Reasons".
4.15 The use of hexafluorosilicic acid instead of sodium fluoride (Chapter 10).
5) Inadequacies of dental analysis.
5.1 Dental decay.
5.2 Dental fluorosis.
5.3 Dental fluorosis and infant feeding.
5.4 Estimations of early childhood exposure to fluoride.
5.5 Conclusion of the the forumâs dental analysis.
Appendix 1. Biographical notes on signatories.
Appendix 2. Dr Paul Connett's "50 Reasons to Oppose Fluoridation".
Appendix 3. Responses to the York Review.
Appendix 4. A chronological listing of animal, clinical and endemic studies of fluoride and bone, with quotations.
Appendix 5. A chronological listing of the epidemiological hip fracture studies.
Appendix 6. References.
1) The historical, geographical and political context of the report.
Ireland is one of the very few countries in the world which has water fluoridation mandated at the national level. This policy was enacted in 1963. As a consequence Ireland is one of a mere handful of countries worldwide with the majority of its citizens drinking water which has fluoride added. Virtually every country in Europe has abandoned the practice, some after lengthy trials.
In the 1990's there were attempts by the UK government to extend fluoridation into Northern Ireland beyond two suburbs of Belfast. This effort led to very widespread opposition across the political spectrum. The end result was that 25 out of the 26 councils in Northern Ireland rejected the proposal. The widespread and vocal opposition to fluoridation in the North raised questions from jurisdictions in the South. Eleven County Councils have gone on record as opposing the forced fluoridation of their local water supplies by central government.
In recent years citizens, Irish environmental and public health organizations, increasing numbers of dentists, and the media have raised many questions about the practice. These include:
1) Is it necessary to have the water fluoridated when fluoridated toothpaste is universally available?
2) Why is it that countries which do not fluoridate their water have teeth just as good if not better than those that do?
3) Why is it that when communities stop fluoridating their water, tooth decay does not go up but continues to go down, as it has been in most industrialized countries since World War II? 4) Why are the fluoridating chemicals used industrial waste products, and not pharmaceutical grade?
5) Is the prevalence of a number of health problems in Ireland - such as irritable bowel syndrome, osteoporosis, osteoarthritis, hip fracture, bone cancer, Alzheimers disease - related to lifelong exposure and bio-accumulation of fluoride?
6) Why has the government not systematically studied a possible relationship among these diseases and exposure to fluoride?
7) Why does the government feel that they can force fluoride on its people, even when some of these questions have not been fully answered?
8) Does any government have the right to override the citizen's right to "informed consent" to medication?
Because of these and other questions being raised, and the very unsatisfactory answers from the central government, a number of prominent politicians began to call for an end to fluoridation.
Eventually, this accumulating pressure forced a response from Mr. Micheal Martin, the Minister for Health and Children, who set up the Fluoridation Forum to review the policy. Key activists questioned whether this panel was created in an effort to protect the health of the Irish people, or to protect government policy.
2) Membership of the panel.
We note that of the 20 Forum panel members (listed p 14-15 of report), at least 10 work for the Irish government (national or regional), 2 are well known for their promotion of fluoridation (Professor John Clarkson and Professor Denis O'Mullane), and none specialize in toxicology. The fact that there was no one on the panel with specialist knowledge on toxicology goes a long way to explain how such an elementary mistake (see section 4.5) of presenting the tolerable daily intake for fluoride as 10 mg/kg/day, which is twice the acutely toxic (even lethal) dose, went unspotted, not once but twice!
3) Protecting health or protecting policy? Evidence of bias.
a) Use of conclusory statements.
Several times in the text, it is stated AS FACT that fluoridation reduces dental decay. Since this was presumably one of the points the panel was supposedly investigating, it is inappropriate to repeat this as a statement of fact, rather than a conclusion reached through an impartial examination of the evidence.
b) Chapter 7.
In Chapter 7, the Forum addresses the status of fluoridation worldwide. One can only describe their discussion as a "positive spin" on this matter. Instead of admitting that most countries in Europe do not fluoridate their water (e.g. Austria, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Greece, Italy, Luxemburg, the Netherlands, Norway, Portugal and Sweden) they go to pains to inflate the number of countries around the world that do. Without citing a reference they tell us that "Approximately 317 million people in 39 countries benefit from artificially fluoridated water".
Without a citation it would be foolhardy to accept this number at face value. We can only assume it is based upon lists prepared by the British Fluoridation Society (BFS), since the BFS is the most commonly cited source for these statistics. However, it should be noted that the BFS list includes countries like Switzerland, New Guinea, and Fiji, which have only one city fluoridated, and other countries like Cuba and the Czech Republic which have stopped fluoridation, and countries like the Philippines where only the US military bases are fluoridated. In our view, it would be more appropriate to provide three lists:
(i) Those countries where the majority of citizens are drinking fluoridated water (i.e. Australia, Ireland, possibly Israel, New Zealand, Singapore and the United States). This list is a mere handful of the fluoridated countries listed by the BFS.
(ii) Those countries where 10% or more are drinking fluoridated water (e.g Canada, and the UK). This list is also very short.
(iii) Cities in otherwise unfluoridated countries which are fluoridated, e.g Basel in Switzerland.
Presented this way, it would become very clear to Irish citizens that they are in a very distinct minority worldwide and are a part of the 2% of Europe which is still fluoridated.
Other statements in this chapter do not stand up to scrutiny, and appear to be an attempt to minimize other countries outright rejection of water fluoridation. For example, their claim that, "The Government in the Netherlands did not persist with water fluoridation because it was unable to supply fluoridated and non-fluoridated water to adjacent towns depending on the decision reached by communities sharing the same water supply" is incorrect. It was not technical limitations that halted fluoridation in Netherlands, but a Supreme Court ruling on June 22, 1973, which stated that fluoridation had "no legal basis." When some politicians tried to amend the law to create a legal basis for fluoridation, "it became clear that there was not enough support from Parliament for this amendment and the proposal was withdrawn." These are the words of the Netherlands' Office of Drinking Water, January 26, 2002. (See letter at http://www.fluoridationfacts.com/c-netherlands.htm)
Likewise, the Forum's description of the Swedish battle over fluoridation is also very misleading. According to the Forum,
"A body established by the Swedish government advised that water fluoridation should proceed. A bill was prepared but not enacted."
Such a description gives little indication of the vigorous and articulate nature of the scientific opposition to fluoridation in Sweden. In fact, it is interesting to note that the scientist who led the successful opposition in Sweden was Dr. Arvid Carlsson who won the Nobel Prize for Medicine in 2000. According to Carlsson's written testimony to the Swedish Government in 1978,
"Water fluoridation also goes against leading principles of pharmacotherapy, which is progressing from a stereotyped medication of the type of 1 tablet 3 times a day to a much more individualized therapy as regards both dosage and selection of drugs. The addition of drugs to the drinking water means exactly the opposite of an individualized therapy. Not only in that the dose cannot be adapted to individual requirements. It is, in addition, based on a completely irrelevant factor, namely consumption of drinking water, which varies greatly between individuals and is, moreover, very poorly surveyed."
For this and other reasons, Carlsson stated in his testimony "I am quite convinced that water fluoridation, in a not-too-distant future, will be consigned to medical history."