WHY MASS MEDICATION WITH FLUORIDE MUST STOP NOW! Alliance for Natural Health International Position Paper September 2012

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1 ANH International The Atrium, Curtis Road Dorking, Surrey RH4 1XA United Kingdom e: t: +44 (0) f: +44 (0) ANH-Intl Regional Offices WHY MASS MEDICATION WITH FLUORIDE MUST STOP NOW! Alliance for Natural Health International Position Paper September 2012 Background Around 60 years ago, scientists discovered that fluoride could be used to reduce the prevalence of dental caries (tooth decay). Tooth decay is actually an infectious disease caused by bacteria (especially Streptococcus mutans) that convert sugary and starchy food residues in the mouth into acids, which then destroy the enamel of teeth to produce cavities. Severe cases will lead to loss of teeth, and recent research has shown an association between poor oral health, including dental caries, and increased risk of heart disease, 1 the main killer disease in most Western societies. The Alliance for Natural Health International (ANH- Intl) is strongly opposed to the fluoridation of public drinking water, for the following main reasons: Safety concerns There is continuing scientific debate about the risks involved with lifetime exposure to fluoride in public drinking water. 2 While there have been several studies suggesting an increased risk of hip fractures, cancer and other serious health concerns among certain groups exposed to fluoride in drinking water, there is general agreement that dental fluorosis is the most sensitive adverse effect. Dental fluorosis causes white flecks or spots to appear in the teeth, with pitting of the enamel in severe cases, accompanied by brown stains, It is also generally agreed that levels of exposure to fluoride from all sources (including drinking water, toothpastes, mouthwashes, processed foods, tea, etc.) may induce mild to moderate dental fluorosis in significant sectors of the population, especially children under the age of 8 years. 1 de Oliveira C, Watt R, Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. BMJ. 2010; 340:c McGrady MG, Ellwood RP, Pretty IA. The water fluoridation debate. Dent Update 2011;38:12-14,16-18,20-2. Promoting natural and sustainable healthcare through the use of good science and good law Registered address: 10 Milton Court, Ravenshead, Nottingham NG15 9BD, UK. A Not-For-Profit Company, Limited by Guarantee, Reg no

2 Damage to the permanent teeth, even in mild to moderate cases of dental fluorosis, is more than cosmetic in effect. It can be psychologically damaging to children and adolescents, 3 and it may represent a marker for damage to other calcium- rich areas of the body, especially the skeletal structure. There are other suggestions that fluoride exposure in drinking water may disrupt the endocrine (hormonal) system. Risk of excessive fluoride exposure is greater in areas in which drinking water fluoridation occurs, since background exposure to fluoride in these areas tends to be higher. In a risk analysis of fluoride in drinking water undertaken by the European Commission s Scientific Committee on Health and Environmental Risks (SCHER) 4 published in 2011, the state of the science was summarised as follows: Systemic exposure to fluoride through drinking water is associated with an increased risk of dental and bone fluorosis in a dose- response manner without a detectable threshold. Limited evidence from epidemiological studies points towards other adverse health effects following systemic fluoride exposure, e.g. carcinogenicity, developmental neurotoxicity and reproductive toxicity; however the application of the general rules of the weight- of- evidence approach indicates that these observations cannot be unequivocally substantiated. The precautionary principle While it is clear that risks are incurred as a result of exposure to fluoride, it must be accepted that scientific studies to- date are unable to accurately predict what the effect of lifetime exposure to fluoride from all sources is likely to be among different individuals. Typically, in such situations of uncertainty, the precautionary principle is applied. In this case, it would necessitate the cessation of drinking water fluoridation schemes, given that topical application of fluoride products in toothpastes, mouthwashes and other oral hygiene products is another viable strategy for fluoride application that does not require systemic exposure. The National Research Council (2006), in its extensive risk assessment on fluoride, 5 identified the following population groups as being particularly susceptible to adverse effects for fluoride: young children, diabetes patients, kidney disease patients, the elderly, hypersensitive individuals, pregnant or lactating mothers and individuals deficient in specific micronutrients, such as calcium, magnesium, iodine and selenium. These groups appear to have been unaccounted for in the setting of both Upper Safe Levels and reference intakes in both the USA and Europe. 6 3 Macpherson, LM, Conway DI, Gilmour WH, et al. Photographic assessment of fluorosis in children from naturally fluoridated Kungsbacka and non- fluoridated Halmstad, Sweden. Acta Odonto. Scand 2007;65: Scientific Committee on Health and Environmental Risks (SCHER). Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water 16 May NRC (National Research Council, US), Fluoride in Drinking Water: A Scientific Review of EPA s Standards. National Academies Press, Washington, DC. 6 Verkerk RH. The paradox of overlapping micronutrient risks and benefits obligates risk/benefit analysis. Toxicology 2010;278:

3 Also, most of the earlier studies upon which fluoridation programmes have been based were undertaken predominantly during the 1940s in the USA, when fluoride in drinking water was the only source of exposure to fluoride. 6 Since this time, a raft of other sources of fluoride have emerged, including a wide range of foods and beverages, toothpaste and other oral hygiene products, infant formulae and fluoride supplements. 6 Recent campaigns to encourage people, including children, to spit don t rinse after using toothpaste, are likely to lead to even higher levels of fluoride absorption, and yet there are no adequate studies which attempt to evaluate how this altered behaviour might affect more susceptible individuals. Forms of fluoride Most health authorities that have evaluated the risks of fluoridation have not distinguished between the different forms of fluoride that have been subject to the various studies. For example, calcium fluoride, the principal form of naturally occurring fluoride in mineral waters, is very poorly absorbed by the body, and most of what is ingested is excreted. Synthetic fluorides, in contrast, such as the hexafluorosilicic acid that is generally added to municipal fluoridation schemes, are almost completely absorbed. Many of the older studies were undertaken using less bioavailable forms of fluoride, such as sodium fluoride. Risk vs benefit However one approaches the sometimes conflicting science on fluoride risks and benefits, the margin between the dosage that aims to reduce the incidence of dental caries, and that which causes harm through dental fluorosis, is very narrow. In fact, with respect to more sensitive individuals, overlap has been found in groups with both dental fluorosis and dental caries. 7 This means that simple variations of intake of drinking water between individuals, along with variations in intake of fluoride from other sources and variations in individual susceptibility, will cause a significant proportion of the population to be exposed to harmful levels of fluoride. 5 At the very least, endemic dental fluorosis will be the result. 7 The figure below demonstrates just how narrow this margin is, with endemic fluorosis being common among children exposed to just twice the 1 mg/l level that is the typical target for most water fluoridation programmes. 6 7 Levy SM. Review of fluoride exposures and ingestion. Community Dent Oral Epidemiol 1994;22:

4 Figure 1. The narrow margin between fluoride concentration in drinking water and that which results in moderate dental fluorosis (Dean s index > 0.6). [Source: Verkerk (2010) 4, based on data from Dean et al (1942) 8 and IOM (1997) 9 ]. Health authorities views The EU s Scientific Committee on Health and Environmental Risks (SCHER), 4 the European Food Safety Authority (EFSA), 10 the US s Institute of Medicine, and other health authorities, are agreed that exposure levels in excess of 0.05 mg of fluoride per kg body weight (F/kg bw) will trigger adverse effects in a proportion of the population. In infants during the critical period of tooth eruption and enamel formation, the threshold is likely to be as low as 0.01 mg F/kg bw/day. 5 SCHER identified a particular risk of over- exposure to fluoride in children under 6 years of age, as explained in the following extract: For younger children (1-6 years of age) the UL was exceeded when consuming more than 1 L of water at 0.8 mg fluoride/l (mandatory fluoridation level in Ireland) and assuming the worst case scenario for other sources. For infants up to 6 months old receiving infant formula, if the water fluoride level is higher than 0.8 mg/l, the intake of fluoride exceeds 0.1 mg/kg/day, and this level is 100 times higher than the level found in breast milk (less than mg/kg/day). 8 Dean HT, Arnold FA, Elvove E. Domestic water and dental caries. Pub Health Rep 1942;57; IOM, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Institute of Medicine. National Academies Press, Washington, DC. 10 European Food Safety Authority (EFSA). Tolerable Upper Levels of Intake for Vitamins and Minerals Fluoride: pp EFSA, Parma, Italy. 4

5 ANH- Intl considers it both completely unacceptable that the most vulnerable groups in society, namely children, are exposed to such risks. In addition, other more susceptible groups, such as foetuses, diabetics and those with kidney disease, are likely to be excessively exposed in areas where drinking water is fluoridated. This will be particularly the case where exposure from drinking water is combined with that from other sources. Exposure and dosing Given the very narrow, and sometimes even non- existent, margin between the dosage required to reduce the rate of dental caries and that which causes harm, it is unacceptable that systemic exposure via drinking water is selected as the delivery system for fluoride. Drinking water consumption rates vary greatly between individuals, and particularly between age groups and according to activity. For example, very active individuals may regularly consume well over 3 litres of drinking water per day. Informed consent Most surveys undertaken of populations in which fluoridation is being contemplated have shown that significant numbers of residents are deeply concerned about the health risks. In areas that have long been fluoridated, residents are generally unable to influence municipal authorities to cease fluoridation. Pro- fluoridation authorities have also tended to emphasise the perceived benefit of fluoridation programmes, namely the reduction of dental caries rates in children, while not publicising the known risks. These authorities tend to avoid raising the long- existing scientific controversies, which relate as much to studies on benefit as they do to risk. Such communication is misleading and prevents members of the public from exercising informed consent. Alternatives to mass medication The debate over whether to fluoridate or not fluoridate the public water supply would be much more complex if alternatives that ensure that vulnerable groups are not over- exposed did not exist. Good evidence suggests that oral hygiene education, good toothbrushing habits, reduction of consumption of sugary and starchy foods, and even topical use of fluoride products is extremely effective at dealing with dental caries Axelsson P, Nyström B, Lindhe J. The long- term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol. 2004; 31(9):

6 Legal rights (and wrongs) The right of governments to apply, without the consent of the public, an unregistered medicine to the water supply for a clearly medicinal purpose prevention of the preventable disease known as dental caries is opaque at the very least. While ANH- Intl continues to investigate this area, the evidence gathered to- date would suggest that governments that impose fluoridation on their populations, especially to children and the unborn, may be acting negligently given the known risks, and may be violating fundamental human rights. Within the European Union (EU), Ireland and the UK are the only two Member States that have seen fit to fluoridate the public water supply. In Ireland, around 75% of drinking water supplies are fluoridated, while in the UK it is currently around 15%. However, in the UK, there is mounting pressure on water authorities to fluoridate given requirements stipulated within the Health and Social Care Act The European Commission, despite having commissioned the risk evaluation by SCHER, currently appears content to allow individual Member States to make their own decisions about fluoridation, despite clear evidence from SCHER that a significant proportion of children, at the very least, will be harmed. This situation appears to be in breach of the European Commission s duties obligated under the Treaty on the Functioning of the European Union (the Lisbon Treaty ) (Article 169) in which it is required to ensure a high level of consumer protection. Furthermore, the European Commission has determined that the use of fluorosilicates by private water companies, despite the fact that these chemicals have never been registered either as medicinal products (under Directive 2001/83/EC) nor are they authorised as active substances for inclusion in biocidal products (under Directive 98/8/EC). Accordingly, it appears that the use of fluorosilicates in drinking water is illegal. More information: ANH Europe Clean Drinking Water campaign page: europe.org/campaigns/clean- drinking- water Scientific Committee on Health and Environmental Risks (SCHER). Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water 16 May df European Food Safety Authority (EFSA). Tolerable Upper Levels of Intake for Vitamins and Minerals Fluoride: pp