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The Fluoride Wars: How a Modest Public Health Measure Became America's Longest-Running Political Melodrama.

The Fluoride Wars: How a Modest Public Health Measure Became America's Longest-Running Political Melodrama, by R. Allan Freeze and Jay H. Lehr, hardcover, 383 pp, $39.95, ISBN 978-0470-44833-5, Hoboken, N.J., John Wiley & Sons, 2009.

This book is an invaluable addition to the already extensive literature about water fluoridation as a public health measure. The authors off era carefully crafted history of the fluoridation debate in the United States, which is a "tangled tale of intrigue that starts as a medical mystery story and ends in political farce."

They begin in prehistoric times, when dental caries as a disease was absent. The disease increased slowly after the Middle Ages, when refined sugar arrived on the market. It became epidemic in the late 19th century, and by the early part of the 20th century most Americans had tens of cavities, and more than 20% of the population eventually lost all their permanent teeth. The disease was so ubiquitous that the Public Health Service called it the "people's disease."

It was extremely painful, its cause was unknown, and there was no effective remedy (except for oil of cloves and cinnamon). The 1857 edition of Farmer's Almanac recommended: "Get a kettle of water. Let it come to a boil. Put your head into it and let simmer for precisely half an hour. Take out your head and shake all your teeth into a heap. Pick out the decayed ones and throw them away. The sound ones you can put back in again."

In 1901 an American surgeon at the United States Marine Hospital in Naples, Italy, noticed dark brown staining on the teeth of prospective U.S. immigrants and associated it with the spring-fed drinking water systems in the Neapolitan region (which later was found to be due to their increased fluoride content). These mottled teeth were found to be resistant to decay.

Researchers learned that a sucrose-rich diet; the presence of Streptococcus mutans, which metabolizes sucrose to form an acid; and susceptible teeth were all required for caries to occur. They developed three approaches for control. The first was dietary, through campaigns to reduce the sugar intake of children. The second was improved oral hygiene, through regular brushing and flossing, and the use of oral rinses. The third included strategies to increase the resistance of the teeth, such as use of oral fluoride supplements, use of fluoridated toothpaste, topical application of fluoride directly onto the teeth by dentists, and fluoridation of public water supplies. The last was thought to be the most economical and equitable approach to prevention.

Using fluoride in drinking water as a public health measure was proposed in 1942. Scientists at the Public Health Service established a threshold of 1.0 ppm as an ideal fluoride level that would prevent cavities while minimizing the side effect of tooth mottling, or dental fluorosis. In 1945, Grand Rapids, Michigan, became the first city to have artificially fluoridated water, a modest public health measure that, according to the authors, was to become one of the most controversial issues of our lifetime.

Soon thereafter, four large, long-term fluoridation trials found a 35% to 55% reduction in dental caries. Unfortunately, these studies were poorly designed. They were not blinded, and confounding factors were poorly controlled. But more recent, better-designed studies have confirmed that fluoridation does reduce cavities in children.

Nevertheless, the fluoride controversy continued. Many perceived a conflict between good science and public policy. Even though the U.S. Public Health Service, the American Dental Association, and the surgeon general all said that fluoride is good for you, public concern continued. Major players on both sides maintained polarized, entrenched positions and an adversarial mentality, making any type of civil discourse difficult.

For example, in 2000, after more than five decades, 26 cities held referenda on water fluoridation. Twelve of them approved, and 14 rejected the proposals.

Although there is no evidence that water fluoridation leads to any of these problems, most anti-fluoridationists believe that increased fluoride intake is responsible for an increased prevalence of hip fractures, heart disease, and cancer, and that fluoride, like lead, may be sapping the intelligence of our children. They believe that fluoridation's costs and health risks easily overwhelm the modest benefits of a reduction in dental caries.

By 2005,170 million Americans--two thirds of the population--used a fluoridated water supply. There has indeed been a sharp decline in tooth decay among children since World War II, but this has occurred equally in fluoridated and non-fluoridated communities. The authors suggest this may be due to the widespread use of fluoridated toothpaste, and to the "halo effect" caused by regional distribution of processed food and beverages prepared with fluoridated water. A decline of caries similar in timing and magnitude to that in the United States has occurred in many developed European countries, which have rejected water fluoridation, but instead have used topical fluoride treatments and public consumption of fluoride supplements.

One important unanswered problem has been that of the chronic health risks engendered by a lifetime of drinking fluoridated water. Mild dental fluorosis, or mottling of the teeth, has increased in fluoridated communities from 13.6% in 1940 to 51.3% in 1999. It is strongly associated with the use of fluoride toothpaste in early childhood. Some think that the "optimal" fluoride concentration in drinking water may need adjustment downward to 0.5 ppm.

Or, in the near future, with improved diet and hygiene and widespread use of fluoridated toothpaste, it may be reasonable to consider ending the fluoridation of public water supplies. Perhaps this finally will bring an end to America's longest-running political melodrama, the "Fluoride Wars."

Jerome Arnett, Jr., M.D.

Helvetia, W.V.
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Author:Arnett, Jerome, Jr.
Publication:Journal of American Physicians and Surgeons
Article Type:Book review
Date:Mar 22, 2010
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