Aesthetic Dentistry of Bellevue

Fluoride suggestions: Do not drink fluoridated water. Use fluoride toothpaste only if at high risk for dental decay. If fluoridated toothpaste is used, be sure to spit it out, rinse and spit it out again.

Fluoridation Summary: The “Stake holders” promoting fluoridation should be required to provide scientific evidence as to the efficacy, toxicology, ethics, total intake from all sources and legality of adding hydrofluorsalicic acid to water.

Our total intake of fluoride from all sources is too much and even without fluoridation needs to be reduced. Most of the world has rejected fluoridation because it no longer appears to reduce dental decay1, is not safe, and individual dosage is increasing from increases in foods, beverages, and medications. Without benefit, with increasing risks, and dosage from all sources too high, most prudent reduction of fluoride intake is a cessation of water fluoridation. The National Research Council 2006 outlines concerns, “Some say Fluoridation has serious problems with no benefits:

Infringement on freedom of choice Hilman 1988; Cross and Carton 2003
Causes adverse health effects which outweigh benefits (Colquhoun 1997)
Safety of the Chemicals are in question
Toxicity database on silicofluorides is sparse (Coplan and Masters 2001)
Individual variations in exposure
Major benefits are topical, not systemic. (Zero 1992; Rolla 1996; Featherstone 1999;
Limeback 1999; Clarson 2000; CDC 2001; Fejerskov 2004” 2

Although the CDC suggested fluoridation was one of the 10 great public health achievements of the 20th century, the CDC then continues “fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children.”3 Topical benefits of fluoride require higher concentrations than found in fluoridated water.

The source of fluoridation is not medical grade fluoride and contains contaminants such as lead, arsenic, beryllium, vanadium, cadmium, mercury, radium radionuclides, silicon, and bauxite. Although these other contaminants are in small quantities, even these small amounts are significant. Lead levels are elevated in the blood of those drinking silicofluoride treated water.4 The EPA has maximum contaminant level goals for lead and arsenic at “0 ppm” and fluoridation contaminates our water above EPA MCL goals. Naturally occurring fluoride as calcium and magnesium fluorides are relatively insoluble, while sodium fluorosilicates and hydrofluorosilicic acids are highly soluble.

Fluoride benefits appear to be topical, not systemic.5

  1. “In summary, we hold that fluoridation is an unreasonable risk. That is, the toxicity of fluoride is so great and the purported benefits associated with it are so small – if there are any at all – that requiring every man, woman and child in America to ingest it borders on criminal behavior on the part of governments.” EPA scientists and lawyers.6
  2. Excellent scientists in most developed countries world wide have rejected, banned or suspended fluoridation: China, Austria, Belgium, Finland, Germany, Denmark, Norway, Sweden, Netherlands, Hungary, Japan, and June 21, 2006 Israel suspended mandatory fluoridation until the issue is reexamined from all aspects. Ontario reduced fluoridation from 1 ppm to 0.6 ppm.
  3. Most industrialized countries have never fluoridated nor have they used significant fluoride from other sources, yet they have reduced dental decay just as much as the USA. The graph below shows 14 countries who on good scientific grounds have said “NO” to fluoridation and 4 countries which have fluoridated. Over a 30 year period, all countries have reduced decay about the same amount. Some have given the option of fluoridated salt (freedom of choice) and the option is often refused. The American Dental Association continues to blindly assert, “studies prove water fluoridation continues to be effective in reducing tooth decay by 20-40%.”7 If the ADA were correct, we should see a benefit for fluoridating countries, but we do not. The references provided by the ADA show up to a 0.6 out of 88 to 128 tooth surface reduction in tooth decay (about half a percent) if confounding factors are not included. If confounding factors are included we may actually be experiencing an increase in the life time incidence of decay in fluoridated areas.



  4. When the percentage of fluoridated people in each state increases (graph on the left), so does the percentage of people with six or more missing teeth. There appears to be no life long reduction in dental decay with fluoridation and possibly an increase in tooth loss from fluoridation.


  5. In 2003, the ADA awarded Kentucky with a “50 Year Award” for virtually 100% fluoridation for 50 years. In 2002 the CDC reported Kentucky with the highest percentage of people without any teeth, 42%.8 Fluoridation does not benefit those without teeth and does not appear to have helped prevent their tooth loss.
  6. A number of recent cessation studies show that stopping fluoridation does literally nothing to increase overall dental decay.9
  7. . Scientific studies are mixed, some showing an increase in dental decay with
    fluoridation10 and others showing a decrease.11 Socioeconomics, a huge variable, is seldom included. “Not taking into account delayed tooth eruption makes early fluoridation studies “over-estimates of the benefits”.... Fluoride added to drinking water may have simply delayed caries in the past.” Hardy Limeback DMD, PhD Even those flawed studies found 0.6 ppm fluoridation was better than 1.0ppm. Edward & Strickler
  8. The graph below12 has all 50 US states listed in order of the percentage of residents on public water who are fluoridated, the least at 3% and the greatest at 99+% (black line). The pink line represents the percentage of poor children’s parents who report their child to have very good/excellent teeth. The yellow line represents the same for wealthy children. A state could fluoridate at 3% or 99% and have the same dental health. What are your goals for the percentage of children with healthy teeth? Suppose you choose 55% of the poor and 82% of the wealthy? Now look on the chart to find how much you need to fluoridate to achieve these results. Consistent with published studies, fluoridation does not appear to improve dental health. Without benefits, mass medication makes no sense.



  9. The next two graphs compare Washington and Oregon and the change in fluoridation and dental decay, 1992 and 200213. Both states have similar confounding factors of language, elevation, race, and slightly higher education in Washington. Washington has a 12% higher mean socioeconomic level and thus should have better Oral Health. Washington has three times the percentage of residents fluoridated than Oregon and even with higher socioeconomics has now surpassed Oregon’s decay rate.

    Where is the “20-40% proven benefit”14 from fluoridation suggested by the American Dental Association? Other studies by Spencer, de Liefde, Angelilo, Clark, Ismail, Slade, Kumar, Armfield, and Spencer have found clinically meaningless results and benefits from fluoridation. Biostatisticians Rek et.al, in 2005 reported, “Our analysis shows no convincing effect of fluorideintake on caries development. A Bayesian analysis of multivariate doubly-interval-censored dental data”15 Other studies actually found Increases in tooth decay with elevated fluoride levels and indeed consistent with the trend now experienced in Washington.16



    When comparing fluoridated and non fluoridated groups of people, several confounding factors must be included which promoters of fluoridation seldom consider. Poor people have more decay and socioeconomics is a significant confounding factor. Bellingham’s decay rate cannot be reasonably compared to Seattle’s decay rate because Seattle has three times the mean income level. Another major factor is the delay in tooth eruption found in fluoridated areas which skews the data.17 For a life time benefit, studies must consider how long the teeth have been exposed in the mouth, not just the age of the subject. A 13 year old on fluoride with exfoliating primary molars and unerupted second molars will have a lower incidence of decay than a non-fluoridated child of the same age who has had their teeth for a year.

    It makes no sense to mass medicate people with a drug which no longer shows any benefit.
  10. Fluoride is not a nutrient, it is a drug. Read a fluoridated toothpaste label. The absence of fluoride does not cause any disease. Decay is not the result of fluoride deficiency.18
  11. "Fluoride works topically" not systemically CDC 200119
  12. The evidence for fluoride varnish (topical application) reducing decay is "fair". The evidence for the benefits of fluoride ingestion is "incomplete." NIH Consensus Development Conference 2001.
  13. Fluoridation does not prevent bottle decay, pit and fissure decay, or decay from bad habits such as soda pop, diet, poor hygiene or meth. At best, fluoride was thought to simply reduce one of the symptoms of poor diet and oral hygiene.
  14. Sometimes promoters of fluoridation will show emotional pictures of little children with decayed front teeth. This “bottle decay” is due to juice/milk in a bottle at night and naps and is not prevented with fluoridation.
  15. For 25 years I observed patients from fluoridated areas who had good teeth and nonfluoridated areas with bad teeth. I was convinced with my own eyes I clinically “saw” the benefits of fluoridation. With a more studied evaluation, I was seeing the effects of
    socioeconomics rather than fluoridation.

B. Risks from Fluoridation appear to be significant:

  1. When presented to impartial Courts20, the finding of fact has consistently found fluoridation to be hazardous and Governments even in time of war have restrictions on medicating people.21 The FDA has never approved any substance for water fluoridation and in 1974 agreed under the SDWA that the EPA is responsible for drinking water because water is not a food.22 The EPA is involved with the removal of fluoride, not the addition of fluoride and in US House Hearings, 2001, provided the position the EPA is prohibited and lacks authority to require the addition of anything for the treatment of humans.23 The circle leaves no one at the switch, monitoring all sources of fluoride intake, monitoring efficacy, monitoring side effects and risks. Anyone who claims the 2006 NRC report has nothing to do with water fluoridation, has not read the NRC report. The scientists’ advice to the EPA that 4ppm fluoride in water is too high means the level needs to be reduced theoretically somewhere between 0 and 3 ppm. The margin of safety between 1 ppm and 4 ppm was not significant and lowering MCLG below 4 ppm provides no margin of safety for sensitive individuals on fluoridation. Read the NRC report (Footnote #2).
  2. Fluoridation does cause harm to the Public Health. Fluoride at fluoridation levels does indeed cause damage to teeth and bones and is an enzymatic reactor, a contributing factor in various pathologies.
    • Dental fluorosis has significantly increased and no one disputes the damage fluoride and fluoridation causes to teeth. Two thirds of children show some signs of too much fluoride.24 Life time costs for repairs can exceed $100,000 per person.
      Parents often pay about $14,000 for treatment of dental fluorosis with expected 10-15 year longevity. Example below.

                
    • As Cosmetic Dentists we enjoy the financial benefits of treating fluoridation’s damage. If children on fluoridation had a reduction in decay, the benefits might outweigh the risks. No Dentist disagrees with the risks of fluoridation and the tremendous cosmetic costs, coverage born for retreatment by Dental Insurance.
    • Increased bone fractures, especially in the elderly25. NRC 2006
    • Evidence is fair that fluoridation decreases thyroid activity (thyroxin the 4th most common Rx and increases obesity), decreases intelligence26, increases mental retardation27, increases violent behavior28, increases bone cancer, increases kidney damage and much more. Not everyone has the same risks.29

      The National Research Council (2006 p. 26) reports: (inserted comments)

      • “Endocrine Effects: The chief endocrine effects of fluoride exposures in experimental animals and humans include

      • decreased thyroid function, (synthyroid is the1st to 5th most common Rx; low BMR, obesity, skin disorders)
      • increased calcitonin activity,
        (opposite parathyroid, reduces Calcium in blood, enhances Ca excretion)
      • increased parathyroid hormone activity,
        (increases blood Ca level, from bone & kidney)
      • secondary hyperparathyroidism,
        (When Ca blood level too low due to low Vit D or low Ca absorption)
      • impaired glucose tolerance, and
        (Diabetes, 7%, sixth leading killer. Six fold increase since 1958, $132 B)
      • possible effects on timing of sexual maturity.” NRC 2006 p.26
  3. Read the Crest toothpaste label, flexible wording required by the FDA. "Drug Facts. Do not swallow. If more than used for brushing (a pea size) is accidentally swallowed, get medical help or contact a poison control center right away." A pea size of Crest contains
    0.5mg or less of fluoride. The same amount of fluoride as two glasses of Seattle water. Certainly fluoridated water districts should at least warn young residents not to drink more than two glasses of Seattle water.



  4. Household water filters do not remove fluoride.
  5. As with all medications, some individuals have very little tolerance and significant side effects. Mass medication of everyone regardless of their need, tolerance, side effects or desire makes no sense.
  6. Last weeks National Academy of Science 550 page report on fluoride, lists numerous studies which should and have not been done to determine fluorides risk/safety.30 We have failed to have due diligence and precaution.

C. Recommended Dose and Dosage:

There is NO recommended Daily Allowance for Fluoride because fluoride is a drug, not a nutrient. “AI” or the American Dental Associations suggested “Adequate Intake” to reduce dental decay:31

  1. Infant’s AI is 0.01 mg/day through six months. This would be one hundredth of a liter (10 ml) of Seattle water mixed in formula. A tablespoon of Seattle water contains about 0.02mg of fluoride, twice the AI. The Washington Department of Health should warn parents not to use Seattle Water to mix infant formula. Soy Formula also contains fluoride. (Even water from reverse osmosis contains 0.05 ppm) Nature provided an infant with significant protection, 100 to 200 times less fluoride than formula mixed with Seattle water. Why are not Public Health agencies, water districts and those responsible for fluoridating providing parents with warnings? For children 6 mo to 3 years, one cup of Seattle Water provides the AI of 0.25mg/da. 3 years to 6 years AI is two cups of water. Why are parents not being warned to stop their children from drinking water/beverages/foods/soups in excess of these levels? Who is at
    the switch?
  2. The American Academy of Pediatrics in May 1998 Pediatrics, recommended no prescription fluoride before the age of 6 months and only one cup of water (0.25 mg) from 6 mo. to 3 yr. of age.32 If a child is thirsty and has had their glass of fluoridated water/beverage/soup, what does a parent tell their child? Do not drink more water, this water is not safe? The wealthy can afford
    bottled water, the poor find it an expensive burdon.
  3. Adults from foods and beverages without fluoridated water frequently, if not usually exceed AI levels by two and three times. Examples can be provided.
  4. The total fluoride intake from all sources is almost never considered and hard to determine.
  • Almost all foods contain fluoride.
  • Recent increases in pesticides such as Cryolite (52% fluoride) for example in lettuce from 7mg/Kg residue to 180 mg/Kg residue and make testing of foods in the past incomplete.
  • Post Harvest fumigants (2004 and 2005) permitting huge amounts of sulfurylfluoride residue (Profume, i.e. Vikane) in most foods. For example up to 900 ppm residue in dried egg33 almost the same concentration as toothpaste. No credible estimates have been made on total fluoride ingestion with these new increases and sources of fluoride.
  • Medications34 and several have had to be taken off the market.35 Toothpaste and dental visits, add significant fluoride intake and significant economic gain for most dental offices. (Twice a year for 500 people generates over $30,000.) The topical use of fluoride varnish does have fair evidence of benefit in reducing dental decay.
  • Even the National Organic Standards permits over 1,000 ppm in bone meal.36

Fluoridation is controversial. Remember, the people who claim fluoridation is safe are also the people who tell us the mercury we place in our teeth is too toxic for the sewers and trash, yet is safe implanted in our bodies three inches from our brains. Although their claim is to protect the public health, please note that when asked in court, the American Dental Association represents, “Dissemination of information relating to the practice of dentistry does not create a duty of care to protect the public from potential injury.”37 I am proud of my Profession, but in just a few instances our pride and profit stand in the way of good science and ethics. Fluoridation is a moment in Public Health history which we will not remember with pride.

Other links which should be viewed:

1 SDWA Section 1412 (b)(11)

2 http://www.nap.edu/catalog/11571.html, Fluoride in Drinking Water: A Scientific Review of EPA’s Standards

3 CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October 22.

4 Masters, R.D. et al, Association of Silicofluoride Treated Water with Elevated Blood Lead, NeuroToxicology 2000

5 Brunelle, Angelilo, Clark, Ismail, Slade, Kumar and in Australia by Armfield JM. Spencer AJ 2004, a very large study found No difference in dental decay in permanent teeth.

6 Dr. J. William Hirzy, Sr. VP, Headquarters Union, USEPA, March 26, 2001.

7 http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp 7/13/06

8 2002 CDC Mortality Weekly Report.

9 Komarek et al, A Bayesian analysis of multivariate doubly-interval-censored dental data, Biostatistics 2005 6 pp 145-155

10 Binbin W, Baoshan Z, Hongying W, Yakun P, Yuehua T. (2005). Dental caries in fluorine exposure areas in China. Environ Geochem Health. 27(4):285-8. See: http://tinyurl.com/765m2

11 www.ada.org

12 http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm National Survey of Children's Health. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Maryland: U.S. Department of Health and Human Services, 2005
http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htm

13 Fluoridation 2002 = 58.9% http://www.cdc.gov/fluoridation/fact_sheets/states_stats2002.htm Washington Fluoridation 1992 = 53.2%
http://www.fluoridationcenter.org/papers/2002/cdcmmwr022102.htm
http://www.doh.wa.gov/cfh/Oral_Health/Documents/SmileSurvey2005FullReport.pdf
http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdf#search='Oregon%20Decay%20experience‘
http://quickfacts.census.gov/qfd/states/41000.html

14 http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp 7/13/06

15 ARNO?ST KOMA´ REK* , EMMANUEL LESAFFRE Biostatistical Centre, Katholieke Universiteit Leuven, Kapucijnenvoer 35, B-3000 Leuven, Belgium arnost.komarek@med.kuleuven.ac.be TOMMI HA¨ RKA¨ NEN National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland DOMINIQUE DECLERCK School of Dentistry, Katholieke Universiteit Leuven, Kapucijnenvoer 7, B-3000 Leuven, Belgium
JORMA I. VIRTANEN Institute of Dentistry, University of Helsinki, PO Box 41, FIN-00014 Helsinki, Finland Biostatistics (2005), 6, 1, pp. 145–155 doi: 10.1093/biostatistics/kxh023

16 A few recent studies: Awadia AK, et al. (2002). Caries experience and caries predictors - a study of Tanzanian children consuming drinking water with different fluoride concentrations. Clinical Oral Investigations (2002) 6:98-103) Binbin W, et al. (2005). Dental caries in fluorine exposure areas in China. Environmental Geochemistry and Health 27:285-8.) Budipramana ES, et al. (2002). Dental fluorosis and
caries prevalence in the fluorosis endemic area of Asembagus, Indonesia. International Journal of Paediatric Dentistry 12(6):415-22. Ekanayake L, Van Der Hoek W. (2002). Dental caries and developmental defects of enamel in relation to fluoride levels in drinking water in an arid area of sri lanka. Caries Research 36(6):398-404. Grobleri SR, et al. (2001). Dental fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. International Journal of Paediatric Dentistry 11(5):372-9.

17 Ainsworth NJ. (1933). Mottled teeth. British Dental Journal 55: 233-250. Campagna L, et al. (1995). Fluoridated drinking water and maturation of permanent teeth at age 12. Journal of Clinical Pediatric Dentistry 19(3):225-8. Feltman R, Kosel G. (1961). Prenatal and postnatal ingestion of fluorides - Fourteen years of investigation - Final report. Journal of Dental Medicine 16: 190- 99. Freitas JA, et al. (1971). Influence of fluoridation in the chronology of eruption of permanent teeth. Estomatologia e Cultura 5: 156-165.
Krook L, et al. (1983). Dental fluorosis in cattle. Cornell Veterinarian 73(4):340-62.
Kunzel VW. (1976). [Cross-sectional comparison of the median eruption time for permanent teeth in
children from fluoride poor and optimally fluoridated areas] Stomatol DDR. 5:310-21.
Lemmon JR. (1934). Mottled enamel of teeth in children. Texas State Journal of Medicine 30: 332-336.
Leroy R, et al. (2003). The effect of fluorides and caries in primary teeth on permanent tooth emergence.
Community Dentistry and Oral Epidemiology 31(6):463-70.
Limeback, H. (2002). Systemic Fluoride: Delayed Tooth Eruption and DMFT vs Age Profiles. abstract
presented at IADR/AADR/CADR 80th General Session. San Diego, California. March 6-9.
Roholm K. (1937). Fluoride intoxication: a clinical-hygienic study with a review of the literature and some
experimental investigations. H.K. Lewis Ltd, London.
Virtanen JI, et al. (1994). Timing of eruption of permanent teeth: standard Finnish patient documents.
Community Dentistry and Oral Epidemiology 22(5 Pt 1):286-8.
See also: Nadler GL. (1998). Earlier dental maturation: fact or fiction? Angle Orthod. 68(6):535-8.

18 Aoba T, Fejerskov O. (2002). Dental fluorosis: chemistry and biology. Critical Review of Oral Biology and Medicine 13: 155-70.

19 CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October 22.

20 J and Morin, P, Highlights in North American Litigation During the Twentieth Century on Artificial Fluoridation of Public Water Supplies, J. Land Use & Envtl.L. Vol. 14.2, Spring 1999, p.195-248 Contact Jack Grahm for details, 418.888.5049, graham@megaquebec.net Graham

21 The Court ruled even under emergency conditions of war the Government cannot force an individual to be medicated with a substance which has not been specifically approved for the purpose and manor it is intended. Case regarding AVA, a non FDA approved anthrax drug. Doe v. Rumsfield 2003 U.S. Dist. LEXIS 22990

22 http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Summary p. 22

23 SDWA Section 1412 (b)(11)

24 Heller, K et al, Dental Caries and Dental Fluorosis at Varying Water Fluoride Concentrations, NIDR, 1997, Vol 57, No 3. p.135

25 Danielson, C, et al, Hip Fractures and Fluoridation in Utah’s Elderly Population, JAMA Aug 12, 1992

26 The lowering of IQ by 8 to 10 points 1 Lu Y, Sun ZR, Wu LN, Wang X, Lu W, Liu SS. Effect of highfluoride water on intelligence in children. Fluoride 2000; 33:74-8.
2 Li XS, Zhi JL, Gao RO. Effect of fluoride exposure on intelligence in children. Fluoride 1995;28:189-92.
3 Zhao LB, Liang GH, Zhang DN, Wu XR. Effect of a high fluoride water supply on children’s
intelligence. Fluoride 1996;29:190-2.

27 Tianjin, Fluoride Vol. 33 No. 2 49052 2000, Editorial 49 Fluoride 33 (2) 2000

28 Jay Seaveya Manchester, NH, USA Fluoride 2005;38(1):11–22 Research report 11
http://homepages.ihug.co.nz/~spittle/381%2011-22.pdf

29 "Existing data indicate that subsets of the population may be unusually susceptible to the toxic effects of fluoride and its compounds. These populations include the elderly, people with deficiencies of calcium, magnesium, and/or vitamin C, and people with cardiovascular and kidney problems... Because fluoride is ubiquitous in food and water, the potential for human exposure is substantial (ATSDR, p 112, 153)." The Agency for Toxic Substances and Disease Registry (ATSDR) stated in 1993:

30 Excerpts from: "Fluoride in Drinking Water: A Scientific Review of EPA's Standards" (National Research Council, 2006)

NRC's RESEARCH RECOMMENDATIONS:
"Fluoride should be included in nationwide biomonitoring surveys and nutritional studies; in particular, analysis of fluoride in blood and urine samples taken in these surveys would be valuable." p9

"To assist in estimating individual fluoride exposure from ingestion, manufacturers and producers should provide information on the fluoride content of commercial foods and beverages." p71

"The concentrations of fluoride in human bone as a function of exposure concentration, exposure duration, age, sex, and health status should be studied." p9

"Information is particularly needed on fluoride plasma and bone concentrations in people with small-tomoderate changes in renal function as well as in those with serious renal deficiency." p9

"More research is needed on the relation between fluoride exposure and dentin fluorosis and delayed tooth eruption patterns." p9

"A systematic study of clinical stage II and stage III skeletal fluorosis should be conducted to clarify the relationship between fluoride ingestion, fluoride concentration in bone, and clinical symptoms. " p10

"More studies of communities with drinking water containing fluoride at 2 mg/L or more are needed to assess potential bone fracture risk at these higher concentrations." p10

"Carefully conducted studies of exposure to fluoride and emerging health parameters of interest (e.g., endocrine effects and brain function) should be performed in populations in the United States exposed to various concentrations of fluoride." p10

"Better characterization of exposure to fluoride is needed in epidemiology studies investigating potential effects. Important exposure aspects of such studies would include the following: collecting data on general dietary status and dietary factors that could influence exposure or effects, such as calcium, iodine, and aluminum intakes." p72

"To permit better characterization of current exposures from airborne fluorides, ambient concentrations of airborne hydrogen fluoride and particulates should be reported on national aregional scales, especially for areas of known air pollution or known sources of airborne fluorides. Additional information on fluoride concentrations in soils in residential and recreational areas near industrial fluoride sources also should be obtained" p71-72

"The possibility of biological effects of SiF6 , as opposed to free fluoride ion, should be examined." p72

"The biological effects of aluminofluoride complexes should be researched further, including the conditions (exposure conditions and physiological conditions) under which the complexes can be expected to occur and to have biological effects." p72

"Thus, more studies are needed on fluoride concentrations in soft tissues (e.g., brain, thyroid, kidney) following chronic exposure." p83

"Research is needed on fluoride plasma and bone concentrations in people with small to moderate changes in renal function as well as patients with serious renal deficiency. Other potentially sensitive populations should be evaluated, including the elderly, postmenopausal women, and people with altered acid-base balance." p83

"More work is needed on the potential for release of fluoride by the metabolism of organofluorines." p83

"More research is needed on bone concentrations of fluoride in people with altered renal function, as well as other potentially sensitive populations (e.g., the elderly, post-menopausal women, people with altered acid-balance), to better understand the risks of musculoskeletal effects in these populations." p147

"the relationship between fertility and fluoride requires additional study." p161

"Two small studies have raised the possibility of an increased incidence of spina bifida occulta in fluorosisprone areas in India; larger, well-controlled studies are needed to evaluate that possibility further." p164

"More research is needed to clarify fluoride's biochemical effects on the brain." p186

"The possibility has been raised by the studies conducted in China that fluoride can affect intellectual abilities. Thus, studies of populations exposed to different concentrations of fluoride in drinking water should include measurements of reasoning ability, problem solving, IQ, and short- and long-term memory." p187

"Studies of populations exposed to different concentrations of fluoride should be undertaken to evaluate neurochemical changes that may be associated with dementia. Consideration should be given to assessing effects from chronic exposure, effects that might be delayed or occur late-in-life, and individual susceptibility." p187

"Further effort is necessary to characterize the direct and indirect mechanisms of fluoride's action on the endocrine system and the factors that determine the response, if any, in a given individual. Such studies would address the following...

  • identification of those factors, endogenous (e.g., age, sex, genetic factors, or preexisting disease) or exogenous (e.g., dietary calcium or iodine concentrations, malnutrition), associated with increased likelihood of effects of fluoride exposures in individuals.
  • consideration of the impact of multiple contaminants (e.g., fluoride and perchlorate) that affect
    the same endocrine system or mechanism." p223

"The effects of fluoride on various aspects of endocrine function should be examined particularly with respect to a possible role in the development of several diseases or mental states in the United States.
Major areas for investigation include the following:

  • thyroid disease (especially in light of decreasing iodine intake by the U.S. population);
  • nutritional (calcium-deficiency) rickets;
  • calcium metabolism (including measurements of both calcitonin and PTH);
  • pineal function (including, but not limited to, melatonin production); and
  • development of glucose intolerance and diabetes." p224

"Studies are needed to evaluate gastric responses to fluoride from natural sources at concentrations up to 4 mg/L and from artificial sources." p. 258

"Additional studies should be carried out to determine the incidence, prevalence, and severity of renal osteodystrophy in patients with renal impairments in areas where there is fluoride at up to 4 mg/L in the drinking water." p. 258

"The effect of low doses of fluoride on kidney and liver enzyme functions in humans needs to be carefully documented in communities exposed to different concentrations of fluoride in drinking water." p258

"In addition, studies could be conducted to determine what percentage of immunocompromised subjects have adverse reactions when exposed to fluoride in the range of 1-4 mg/L in drinking water." p259

"It is paramount that careful biochemical studies be conducted to determine what fluoride concentrations occur in the bone and surrounding interstitial fluids from exposure to fluoride in drinking water at up to 4 mg/L, because bone marrow is the source of the progenitors that produce the immune system cells." p 259

"Further research on a possible effect of fluoride on bladder cancer risk should be conducted." p288

"in vivo human genotoxicity studies in U.S. populations or other populations with nutritional and sociodemographic variables similar to those in the United States should be conducted." p288

31 The American Dental Association 1994, Institute of Medicine 1997, and recently the American Dietetic Association

32 Pediatrics May 1998 Vol. 95, Number 5 RE9511

33 http://www.epa.gov/fedrgstr/EPA-PEST/2005/July/Day-15/p13982.htm In response to industry requests, Dow AgroSciences has
developed ProFume gas fumigant (Sulfuryl fluoride) as an alternative to methyl bromide for the control of stored product insect pests
in mills, warehouses, storage structures, transportation vehicles, and many commodities and foods stored within them. Sulfuryl
fluoride, marketed as Vikane* Specialty Gas Fumigant, has provided over 40 years of effective control of structural insect pests such
as termites and wood boring beetles.
http://mbao.org/2004/Proceedings04/064%20WelkerJ%20UPDATE%20ON%20THEWelkerJ%20DEVELOPMENT%20AND%20C
OMMERCIALIZATION%20OF%20PROFUME.pdf

34


35 Fluoroquinolones (a recent antibiotic)
Flosequinan withdrawn 1993 (higher hospitalization rate than placebo)
Fenfluramine and Dexfenfluramine withdrawn 1997 (cardiac)
Temafloxacin (Omniflox) withdrawn 1992 (deaths, liver dysfunction)
Grepfloxacin withdrawn 1999 (serious cardiac events)
Fen-Phen withdrawn
Astemizole (allergy drug), Tolrestat (anti-diabetic)
Cisapride (Propulside) withdrawn 2000 (Cardiac)
Mibedrafil (Posicor) withdrawn 1998 (heart failure)

36 http://www.apfn.org/apfn/fluoride.htm

37 The Superior Court of the State of California Case No. 718228, Demurrer (October 22, 1992).

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