Dr. Richard Musto says yes
Public health and preventive medicine physician and clinical professor at U of C
Community water fluoridation (CWF) is an essential and key element of efforts a community can make to improve the health of all its members. By adjusting the naturally occurring level of fluoride in its water supply to the recommended point, a community contributes an effective, safe and cost-saving method of reducing tooth decay in all ages, especially children.
Tooth decay is common in Canada, affecting nearly 60 per cent of children and virtually all adults. Fluoride works to prevent tooth decay by strengthening the enamel coating of teeth, both by making it more resistant to the effect of acids produced by bacteria and by assisting with repair. This effect is complemented by other topical fluoride sources such as toothpaste, varnishes or other professionally applied therapies. Because CWF is available regularly through the day (with every drink of water) it doesn’t require any special action. In communities with fluoridated water, people have fewer cavities in baby and adult teeth alike and better oral health.
CWF is one of several ways to prevent tooth decay and maintain good oral health and is the most cost-effective one. Others include eating healthy foods, avoiding lots of high-sugar beverages, regular brushing and flossing and going to the dentist for routine checkups and preventive care. CWF is particularly valuable for people who face challenges in accessing dental care and other preventive measures.
It’s safe. CWF has been practised in Canada for 76 years, over which time the best scientific evidence shows no increase in any systemic health condition caused by fluoride. Scientific research simply doesn’t support claims of adverse health effects. The only potential adverse effect that may occur is dental fluorosis, a discoloration of tooth enamel ranging from barely visible whitish flecking of the enamel in mild cases to pitting in a rare, severe form. People with mild fluorosis are generally unaware of the condition because it’s barely noticeable to the untrained eye and doesn’t affect tooth function.
CWF is highly cost-effective, saving people from missing work (to care for themselves or their children) and paying for dental treatment, as well as for insurance plans and provincial healthcare systems. For municipalities that bear the cost of implementation and maintenance, the practice must be recognized as a meaningful contribution to a healthier populace, alongside road safety, pathways for walking and cycling, and green spaces for everyone’s enjoyment.
Albertans are facing huge challenges as we emerge from the COVID-19 pandemic and seek how best to transition our economy. We have a tradition of pulling together and looking after one another in tough times. Community water fluoridation is an effective, safe and money-saving action we should support being implemented in our municipalities for the health of us all.
Dr. Bob Dickson Says No
Practising physician and founder of Safe Water Calgary
Is fluoride safe? No. The strongest scientific evidence is neurotoxicity—brain damage. Over 70 studies, several funded by the National Institutes of Health, found common fluoride levels can increase ADHD rates and lower IQ in children. The editor of JAMA Pediatrics, Dr. Dimitri Christakis, concluded “I would not want my wife to drink fluoridated water” if she were pregnant. The science is so robust that it’s the focus of an historic lawsuit in US federal court against the Environmental Protection Agency for allowing fluoridation. The judge stated “there is serious evidence” of fluoridation’s neurotoxicity.
But it’s not just brain damage. The National Research Council’s “Fluoride in Drinking Water” is considered the most comprehensive review on fluoride’s toxicity. NRC concluded that fluoride is an endocrine disruptor, increasing risk of dental fluorosis, hypothyroidism, diabetes, kidney disease and other diseases. NRC’s identification of the known risks and need for further research emphatically contradicts proponents’ insistence that fluoridation has been proven safe.
Is fluoride effective? Minimally, if at all. Globally, there’s little correlation between fluoridation and cavities. Income is the major factor linked to dental health. Proponents cite a 25 per cent cavity reduction, but peer-reviewed science shows this amounts to less than one cavity per child. And World Health Organization data shows fluoridated nations have similar cavity rates as non-fluoridated ones. Dr. Lindsay McLaren’s highly publicized 2016 study in Calgary found cavity rates rose after council voted to stop fluoridating in 2011. But a follow-up study showed cavity rates increased just as much before 2011 as after. Stopping fluoridation made no difference.
Is fluoridation cost-effective? In fact, it’s challenging to find a less efficient use of taxpayer money. Some 99 per cent of fluoride (toxic hydrofluosilicic acid waste from the fertilizer industry) added to water isn’t ingested, instead going down the drain with toilets, showers, lawns and industrial use. A report in Calgary estimated the cost of the infrastructure, chemicals and operations totalling over $30-million for 20 years.
Proponents tout studies showing that every $1 a municipality spends on fluoridation saves individuals $30 on dental bills. This figure is dubious, and none of these studies consider costs from fluoridation’s health risks, which can be huge. Every one-point decrease in IQ equates to over $20,000 less in lifetime earnings. Dozens of scientific studies show fluoridation corresponds to an average IQ loss of 3–9 points. Most tragic is the impairment of kids’ potential.
We can get fluoride in toothpaste, mouthwash, gels and rinses. Nobody should be forced to ingest a drug they don’t want, especially through their drinking water. Once water is fluoridated, the only alternatives are expensive filters or bottled water. This is especially unjust for low-income populations.
We must say no to this obsolete and harmful practice.
Dr. Richard Musto responds to Dr. Bob Dickson
It will be abundantly clear to the reader that Dr. Dickson and I are representing the scientific literature very differently, so I’ll begin my response with a short commentary on this.
Research on a community-level intervention such as water fluoridation (CWF) examines the impacts upon the whole population as well as subgroups, including, for example, children. To assist with the assessment of research studies and their potential relevance to public policy decisions, criteria and techniques have been developed and ideally are applied to all available reports. In this way guidance can be based on the collective evidence rather than isolated studies. Such criteria help dispense with the question Dr. Dickson once asked me—Why is “your” science always good and “ours” is bad? The answer is that neither “side” can claim to always have “good science.” Rather, the limitations in most studies need to be recognized, and proponents of a position must avoid seizing upon any single study that suits them. Decisions should be based on careful and comprehensive review of the research.
The Canadian Agency for Drugs and Technology in Health (CADTH) was created in 1989 to independently conduct such reviews, and it has done several on CWF. In the US the National Research Council, although not created for this specific purpose, does conduct detailed reviews, including the one in 2006 referred to by Dr. Dickson. This review, however, was focused on potential adverse effects of fluoride concentrations at 2 to 4 mg/L, which is three to six times higher than the 0.7 mg/L fluoride concentration standard for CWF in Canada. The NRC review pointed out that their conclusions (including that the maximum permissible level—4 mg/L—should be lowered to protect against severe dental fluorosis and some possible effects on bone) “do not address the lower exposures commonly experienced by most US citizens.” In other words, the review highlighted by Dr. Dickson is not about the fluoride concentration used in CWF. In any case, a subsequent review by the US Food and Drug Administration, which agency is responsible for setting the guidelines, determined that any change to the level was of low priority or represented negligible benefit, and so it remains the same today.
CADTH, the Canadian agency, assessed CWF in 2019 and published several reports (available at https://bit.ly/3E6cLBh). These found:
– consistent scientific evidence that CWF at current Canadian levels (0.7 mg/L) is associated with fewer dental caries (i.e., cavities) in children and adults alike;
– dental fluorosis increases with the level of fluoride exposure. In Canada, 12 per cent of children in areas with controlled water fluoridation experience fluorosis at a level termed “aesthetic concern”; it is generally not noticeable to the naked or untrained eye and does not affect tooth function;
– for 22 non-dental health conditions examined in this review, consistent evidence showed either no association with CWF or a mixture of limited evidence of no association and insufficient evidence to determine an association. In other words, dental fluorosis is the only side effect associated with fluoride at the concentration with CWF;
– insufficient evidence (only a few studies that showed mixed results) to determine the impact of CWF discontinuation on caries in children;
– CWF is ethically justified because of its health benefits, safety and equitable approach;
– from a societal perspective, and considering costs incurred by different levels of government, municipalities, private insurance and out-of-pocket costs for individuals, it costs a municipality less to introduce CWF than it does to not fluoridate (with the costs of implementation generally recovered within the first year). Similarly, it is more costly for a municipality to cease CWF than to maintain it, even if the current system requires upgrades.
Following publication of the JAMA Pediatrics article referred to by Dr. Dickson, CADTH did a rapid review of the evidence on any potential association between fluoride exposure and neurological development in children. Its assessment was that, because of the studies’ multiple limitations, there was insufficient evidence to conclude that exposure to fluoride at Canada’s CWF levels affects neurological development in children and adolescents.
The science around CWF will continue to evolve and it remains important for us to thoughtfully assess new reports and communicate the findings accurately and in a manner that is relevant to our local context.
In the meantime, we as a community are faced with a rising rate of dental caries and the pain, disruption and costs that come with them. Community water fluoridation makes a safe, effective and cost-saving contribution to our health and quality of life, which, along with the individual actions we can each take, can be uniquely available to every citizen simply by turning on the tap.
Dr. Bob Dickson responds to Dr. Richard Musto
I’ve known Dr. Musto for many years, and I respect his career and accomplishments. However, I’m afraid he hasn’t kept up on the most important recent studies, many conducted by Canadian scientists. As a Calgary physician who’s been studying the effects of fluoridation for decades, I have no doubt that the practice is obsolete and causes serious risks to human health.
Fluoridation violates one of the most sacred tenets of medicine—that no one should be forced to ingest a drug through drinking water, taking away their right of informed consent. No wonder it’s been rejected by 95 per cent of the world’s people. Some 97 per cent of Europeans drink unfluoridated water, and many countries, including Germany, France, Sweden and the Netherlands, have banned fluoridation. Many cite the fact that putting a drug in drinking water is unethical, taking away people’s right to choose whether they want to ingest fluoride or not.
Dr. Musto claims “Scientific research simply doesn’t support claims of adverse health effects.” The facts say just the opposite. The chemical used to fluoridate most water is fluorosilicic acid, a hazardous waste by-product from the phosphate fertilizer industry often tainted with lead and arsenic. Although the amounts included are legal, it’s widely acknowledged that there is no safe level of lead and arsenic.
The Fluoride Action Network (fluoridealert.org) thoroughly reviewed the 77 studies that have investigated the relationship between fluoride and human intelligence. Of these, 69 link elevated fluoride exposure with reduced IQs.
The US National Toxicology Program documented studies of fluoride’s neurotoxicity (brain damage), finding overwhelming evidence linking fluoride to IQ loss in children, including from pregnant women consuming fluoride or infants being fed formula mixed with fluoridated water. Their numbers tell the story:
– 25 of 27 of the highest-quality studies linked higher fluoride levels to lower IQs
– 11 of 11 studies detected this IQ loss at levels found in fluoridated water!
How can anyone look at this data and conclude that fluoridation is safe?
But it’s more than the sheer number of studies—it’s their quality. Fluoridation promoters rarely mention the historic lawsuit in US federal court against the EPA (Environmental Protection Agency) for allowing fluoridation. The EPA admitted in court that the four strongest neurotoxicity studies ever conducted all showed substantial IQ loss from fluoride or increase in ADHD rates—all at levels in fluoridated water.
Following the June 2020 trial, the case is moving forward. The judge should rule in the next 6–12 months whether fluoridation is an unreasonable risk to human health. Nobody can say which way he’ll rule, but he’s already said the EPA should “take a second look.” This case may very well mark the final chapter of fluoridation.
Three of the four studies cited in the trial were sponsored by the US National Institutes of Health, which only funds the most methodologically rigorous investigations. One was co-authored by scientists Dr. Christine Till from York University and Dr. Bruce Lanphear from Simon Fraser University, and published by the American Medical Association’s prestigious journal JAMA Pediatrics. Of the over 170 research studies accepted by JAMA Pediatrics in 2019, it ranked #1 on the Altmetric scale of quality and media interest.
Dr. Linda Birnbaum, former director of both the National Institute for Environmental Health Sciences and the National Toxicology Program, asserted in a 2020 article in Environmental Health News co-authored by Drs. Till and Lanphear that “New evidence questions existing policies about the safety of fluoride for babies’ developing brains. Given that safe alternatives are available and that there is no benefit of fluoride to babies’ teeth before they erupt or appear, it is time to protect those who are most vulnerable.”
Regarding effectiveness, Dr. Musto claimed that “In communities with fluoridated water, people have fewer cavities in baby and adult teeth alike and better oral health.” This simply isn’t supported by the data. The Cochrane network, a group of thousands of scientists worldwide, is considered the gold standard for evaluating effectiveness of medical interventions. It couldn’t find any evidence of fluoridation’s effectiveness in adults and said there was insufficient evidence that the practice helps narrow the cavity gap between lower- and higher-income families (see https://bit.ly/3xcoJ7V). As mentioned, World Health Organization statistics show that fluoridated nations have essentially the same cavity rates as unfluoridated ones. Even fluoridation promoters acknowledge that fluoride’s main preventive action is topical, not from swallowing.
Fluoridation isn’t fair to anyone, but it’s especially unjust for low-income families who can’t afford expensive filter systems or bottled water to avoid it. They must put themselves in harm’s way—they have no choice. This isn’t right.
As a doctor, I subscribe to our physician’s creed: First do no harm. I ask Dr. Musto to do the same.
