To fluoridate or not to fluoridate

Decades after the rest of Australian capital cities, Brisbane is to add fluoride to the city’s fluoride-free public water supply. Prior to 2007, only local government which controlled each local area water supply could make this decision after direct consultation with its community. A fluoridated water community could co-exist beside a non fluoridated community.

During compulsory amalgamation of the regional councils during 2007, the state government transferred control of water to the state. One of the reasons for this is seen in the immediate decision to fluoridate the state’s water supply. It will also make it easy to transfer or sell the people’s water supply in the future.

Mandatory fluoridation has been supported by political parties in an ad hoc fashion until the majority of state politicians united in 2008 to pass the bill to allow fluoride to be added to water that was once described as one of the “safest” and cheapest tap waters in the world.

Instead of spending a dollar or more to drink bottled water, anyone of any economic status could drink “safe” public or private tap water at a cost of a cent or two. All this has changed. Without a mandate, politicians acting as though they have majority support and believing they act in the best interests of the community have rushed through a decision that could have been the next election issue. In political time, an 18-month delay is miniscule, and government could have received a clear mandate: to fluoridate or not to fluoride.

Queensland State Premiers have had different positions on mandatory fluoridation; in 2005 Premier Beattie was anti fluoridation; in 2007 Premier Bligh was pro fluoridation. During the term of Lord Mayor Soorley, in 1997 the Brisbane City Council established a task force to consider the fluoridation issue. After six months the 17-person panel representing all sections of the community, including the Australian Dental Association (ADA) and Australian Medical Association (AMA), reached the conclusion it “would not support the introduction of water fluoridation until the recommended Australian research has been carried out” as it found a credible or non ambiguous collection of data and research did not exist.

The taskforce also expressed concern about the lack of scientific research on the lifetime effects of an accumulation of fluoride in the body, noting this is unaddressed in 1997 despite a statement in the 1991 National Health and Medical Research Council (NHMRC) Working Group report that “it was imperative that public health recommendations in the future be based on accurate knowledge of the total fluoride intake of Australians (NHMRC 1991, Section 8.3)”. This statement is repeated in the NHMRC report 1999 (p 183).

Perhaps lack of reliable studies accounts for Queensland Health (QH) stating as fact, on its page “common fluoride myths” (PDF 163KB) that global studies reveal no evidence of any link between water fluoridation and cancer/allergies/arthritis/bone fractures/health risks for babies and excessive dental fluorosis.

Total fluoride intake is the issue. Natural fluoride occurs in some foods and waters. In some parts of the world naturally occurring fluoride presents a serious health risk to the population. QH says the World Health Organization (WHO) endorses fluoridated water: however, the WHO also warns “fluorosis remains a problem in areas (of) where the natural concentrations of fluoride is high”.

Fluoride is present in foods and drinks when these are manufactured in areas where natural or non natural fluorides are in the water supply. Queenslanders already drink fluoride. It is in beer, wine, bottled water, even tea leaves. From December 2008, it will be in the tap water too.

QH recommends the maximum daily dose of fluoride be 0.8ppm. For a 50kg adult, this equates to approximately 1.2 litres of tap water or five glasses of fluoridated liquid. The 1999 NHMRC report adds that cooking with FW adds 0.5mg/l to a product that already includes fluoride, for example pasta, vegetables, soup, fish, chicken, baby food, infant formula. A fact QH states is “fluoridated water can be safely used to reconstitute infant formula, and the risk of dental fluorosis is low”. This assumes the level is at 0.15ppm and baby has no other fluoride source through juices, tinned food, dessert, soft drink, cordial. (NHMRC 1999). As dietary consumption of fluoride is non discretionary, an overdose is unavoidable and the real dose ingested cannot be measured or monitored.

As mandatory fluoridation of a nation’s food chain eliminates real choice on ingestion, control over non discretionary sources to prevent over dosing is the only avenue available. This is an area in which health professionals take the most interest and for good reason according to the 1999 NHMRC report p182 which states “The public perception of fluoridation as a health benefit may be endangered if the prevalence of fluorosis continues to increase at its current rates”. As fluorosis is the sign, or canary in the tunnel, that the population is consuming too much fluoride the concern is appreciated.

On page 189 the report further states the increase in more severe cases of fluorosis “has social and economic costs which need to be weighed against the marginal reduction in caries experience”. The report also expresses concern that children with mild degrees of fluorosis (TSIF Index ranges from 0-7) can be affected psychologically and the trend towards fluorosis increasing is “undesirable as it places dental professionals at increased risk of litigation”.

Fluorosis can affect anyone and reveals itself in the teeth as dental fluorosis (mottled teeth) and in the bones as skeleletal fluorosis. As this is where 90 per cent of fluoride concentrates during infancy, it is ideal to prevent this symptom developing in young children, our canaries, by finding a means to reduce their levels of fluoride intake. For this reason the ADA, which in 1962 described fluoride as harmless as mother’s milk, now advises parents to supervise intake until six years of age by the use of low fluoride toothpastes and to prevent swallowing it and to avoid toothpaste with infants under the age of 18 months.

After these warnings, the ADA advises parents to “encourage your child to drink fluoridated water as much as possible”. Advice to adults is also clearer. As the quantity of fluoridated adult toothpaste covering the head of the brush may contain the equivalent of a 1mg fluoride tablet or four glasses of 1ppm water, toothpaste tubes are now labeled with a warning to not swallow. For similar reasons mouth rinse which may contain 230ppm and the gel used at the dental surgery which may contain 10,000ppm is clearly labeled. Health professionals are obviously concerned.

Symptoms of fluorosis will vary depending on the degree of exposure to fluorides. Dean’s fluorosis index from 0 to 5 is easy for the lay person to follow.

Level 1 is “questionable” fluorosis where mottling is a few white specks to an occasional white spot on a tooth; level 2 “very mild” is where the tip is snow capped and less than 25 per cent of the tooth is affected; level 3 “mild” is where white striations cover up to 50 per cent of the tooth; level 4 “moderate” is where most teeth have brown to yellow stains on the surface and minute pitting; while level 5 is “severe” where teeth are smoky white, stained brown to black and pitted.

The WHO says the adverse affects of fluorosis ranges from mild dental fluorosis to crippling skeletal fluorosis as the level and period of exposure increases. The ADA says severe fluorosis is remedied with crowns or dentures.

QH says “The only known side effect of optimal water fluoridation is a slight increase in dental fluorosis levels” and says nothing about the affect of more than optimal levels. Mallinckrodt Chemicals (USA) states on its factsheet about handling the sodium fluoride and monofluoride it produces: these man-made chemicals are toxins which cause symptoms including fluorosis/mottled teeth and bone damage in people over exposed to these fluorides.

QH proclaims it is a myth to believe “Water fluoridation is banned in Europe”. True, it is not banned but the statement is a convenient omission of a simple truth: Europe does not endorse the fluoridated water agenda.

Europe gives many reasons for its position: personal choice and responsibility; angst about legislated fluoridation; concern that studies do not prove man-made fluorides are “safe”; and the influence of evidence in recent studies. For example Basel in Switzerland de-fluoridated its water in 2003 after 41 years. Norway again said “No” in 2000. The Pasteur Institute influenced the government so that no artificial fluorides are added to water in France. The same occurs in Sweden after advice from the Nobel Medical Institute.

Perhaps Europe simply believes the WHO when it says there is insufficient benefit to warrant mandatory fluoridation in a developed country which has ready access to clean water, good diet and appropriate oral hygiene practice. Perhaps other strategies to target the economically deprived are indeed our appropriate option.

Meanwhile of the countries that rushed to fluoridate after the successful US-led marketing of the product, Canada and Ireland Health now recommend reducing fluoridated water levels to 0.7ppm along with the measures advised by the ADA, in an attempt to control fluorosis levels to a publicly acceptable level. Hong Kong which never had fluorosis prior to fluoridated water is reducing its levels. Towns in the USA have also reduced optimal levels as studies by the Centre for Disease control (CDC) released study results showing (1999-2002) 40 per cent aged six to eleven have fluorosis, (1999-2004) 41 per cent aged 12 to 15 have fluorosis.

In 1990 a study of 12-year-olds in Perth, Western Australia reveals 40 per cent are affected with fluorosis. One concern of this study was “a need for studies to measure community acceptance of mild dental fluorosis” and to lower exposure and fluorosis levels through education about the danger posed by toothpastes. A study of 10-year-olds in 2000 reveals that this education has been a success as fluorosis levels reduced to 22 per cent.

Queensland with all the benefits of the wisdom of hindsight is to fluoridate South East Queensland at 0.8ppm, not the lower 0.5ppm level the Brisbane City Council taskforce report said that the WHO recommended for a sub- tropical city. For QH, as the governments marketing machine, it is not a case of to fluoridate or not to fluoridate; it is a case of retaining the hearts of the masses with clever propaganda like its “common fluoride myths” when the real issue at stake is just what level is a “safe” level for our children and our children’s children.