Daniel Stockin on Fluoridegate

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Scandal Widens, Calls for Hearings Grow as New Revelations Highlight Science in Conflict with Officials’ Statements on Water Fluoridation Safety

Part 1 of a Series, By Daniel G. Stockin, MPH
Thanks to www.Citizens.org

Following the Hurricane Katrina formaldehyde trailers fiasco and the Washington D.C. lead-in-drinking water disclosures, now yet another scandal provides evidence that what is said and done by public health experts may not be as important as the reasons behind what is left unsaid and undone.

Enter Fluoridegate, a multi-faceted scandal unfolding while simultaneously a growing number of cities and water utilities have halted water fluoridation or are considering legislation to end it.

City officials in Milwaukee, New York City and Phoenix have recently discussed ending water fluoridation. Quebec and Calgary in Canada, College Station in Texas, and Pinellas County in Florida have ended it, along with numerous smaller cities and agencies.

“I think there are safety concerns and fiscal concerns causing people to rethink fluoridation,” says Wally Babb, a former Georgia water plant operator reveling in the cities’ actions, since he was fired in 2008 for his stance against fluoridation.

“But I also think prosecutors and investigative bodies are going to be very interested to ask why certain groups and individuals did not share key information about fluoridation risks,” he says.

“If any scandal ever deserved a series of investigative hearings, this is it. This is going to call some very high level people on the carpet.”

Prominent Washington D.C. product safety attorney James S. Turner concurs.

“The evidence is shocking,” he says. “It’s time to put some of the key players under oath in Fluoridegate hearings.”

The developments point to a central question: Did a group of vested interest federal and private sector officials collude to use the public health infrastructure to control what the public hears about fluoridation and divert attention from increasingly bad news about harm from fluorides?

For those still unfamiliar with the developments, here are some of the deeply troubling questions of Fluoridegate.

Controlling the Discussion and Talking Points

Water fluoridation is the long-standing practice of adding fluoride chemicals to drinking water to help prevent cavities. For decades, Americans have been told that the practice is entirely safe, though controversy about fluoridation safety has never completely disappeared.

In 2011 a Freedom of Information Act request asked for the names, titles, and job descriptions of all persons past and present inside the U.S. Centers for Disease Control and Prevention (CDC) that had input into CDC’s decision to support fluoridation. The request turned up a disturbing fact: CDC’s Oral Health Directors, acting alone within CDC for more than 35 years, had sole input and control in deciding to support fluoridation.

The revelation raised obvious questions. How were CDC’s dental professionals, with expertise in oral health, competent to assess new research and make statements about possible harmful outside-the-mouth effects from fluorides? Why did CDC not seek assistance and input from its own cancer, diabetes, and minority health professionals, and from toxicologists in its sister organization, the Agency for Toxic Substances and Disease Registry?

Were improper influence and the Oral Health Division’s close ties to the American Dental Association with its long history of denying harm from fluoridation the reasons CDC continued to deny any outside-the-mouth harm?

Interestingly, a letter from ADA had protested that it was “very disturbed” about a proposed reorganization in CDC that would downgrade the status of the Oral Health Division, folding it inside another unit. In explaining that ADA had “come to value its relationship with the (Division of Oral Health)” and describing the two organizations’ “close collaborative relationship,” ADA listed water fluoridation as its number one example of collaborative efforts with the Division.

Was it collaboration…or collusion?

With the information disclosed by the Freedom of Information request, actions by CDC were now seen in a new light. CDC had continued to offer stout assurances that more than 60 years of “extensive research” had proven fluoridation to be safe. But in 2006 the prestigious National Research Council (NRC) of the National Academies of Science issued a 507 page report on fluorides that documented a long list of fundamental, basic-in-nature whole-body research that had never been performed.

Had CDC officials been lying in saying that extensive fluoridation safety research had been performed?

CDC had also issued a widely-circulated statement that fluoridation was one of the 10 great public health achievements in the 20th century. But in a 2008 article in Scientific American, John Doull, chairman of the NRC fluoride committee, stated, “…when the U.S. surgeon general comes out and says this is one of the 10 greatest achievements of the 20th century, that’s a hard hurdle to get over. But when we looked at the studies that have been done, we found that many of these questions are unsettled and we have much less information than we should, considering how long this [fluoridation] has been going on.” He also stated, “The thyroid changes do worry me.”

Cleverly calling fluoridation one of 10 great public health achievements had worked public relations wonders. It had preemptively diverted many from a deeper investigation of fluorides. But the NRC report and other developments would bring fluorides back under the microscope.

Unnerving Information for HIV, Organ Transplant, Diabetes and Kidney Patients

In addition to dismaying information about thyroid concerns, buried within the voluminous NRC report were other unnerving admissions such as this statement: “More research is needed to clarify fluoride’s biochemical effects on the brain.”

The technical jargon and size of the report are daunting, but readers willing to wade through it learn that consumers are ingesting uncontrolled amounts of fluorides through their water supply without our scientists knowing what this does to our brains.

Because fluorides deposit cumulatively in the bones over time, the report also says it is “paramount” that research be conducted because bone marrow is where immune cells have their genesis. It points out that research could be conducted to determine “what percentage of immunocompromised subjects have adverse reactions” at various levels of fluoride in water.

News of this is understandably alarming to organ transplant patients and persons with HIV/AIDS or congenital immune diseases, but there has been little or no communication of the concerns about fluoride immune system impacts to these groups.

The NRC report also listed diabetics, kidney patients, seniors, children, outdoor workers and other groups as “susceptible subpopulations” that are especially vulnerable to harm from ingested fluorides.

What was done with these startling statements in the report? Had they been quickly acted on and formally distributed by federal officials to affected stakeholder groups such as the National Kidney Foundation, the American Diabetes Association, thyroid health advocates, HIV support groups, child health groups, etc? If so, the groups were uniformly and strangely quiet about receiving it. And why did the Environmental Protection Agency (EPA) and CDC’s parent health agency take nearly five years, and until EPA was threatened by a fluoride fumigant lawsuit, to issue a tepid recommendation to slightly lower the level of fluorides in drinking water?

Was the fix in because the dental industry, water agencies, and other groups would face tremendous legal liability if fluorides were now admitted to be potentially harmful? And were CDC and other groups working to “spin” the NRC report, to do damage control?

Fluoridation advocates cited statements within the report that its purpose was not a specific assessment of water fluoridation, implying that the process of studying fluorides produced no information useful in assessing fluoridation safety. This tactic backfired because it is akin to saying that efforts to put a man on the moon did not produce information useful for other spaceflight programs. Plus, the report designated certain groups as “susceptible subpopulations” without respect to what concentration of fluoride was in their water.

Again, the question: Did a group of vested interest federal and private sector officials collude to use the public health infrastructure to control what the public hears about fluoridation and divert attention from increasingly bad news about harm from fluorides? This is where Fluoridegate hearings will come in. Both federal and state agencies and attorneys general will find numerous avenues of fertile investigation.

Harm to Minorities: the Issue that “Has the Potential to Gain Traction”

One of the key areas for investigation will focus on fluoridation promoters’ actions concerning disproportionate fluoridation risks and harm for minority groups.

For example, why did CDC fail to openly inform the black community of news that blacks are disproportionately harmed by “dental fluorosis,” a permanent and in many cases disfiguring staining of teeth that indicates childhood overexposure to fluorides? CDC continued to not openly share the information with minority advocacy groups even after The Lillie Center in Georgia presented a detailed fluoridation ethics complaint to CDC citing the omission in 2007.

And the issue of harm to black citizens continues to grow. In an April 2011 letter, leaders of the American Dental Association requested assistance from U.S. Assistant Secretary for Health Dr. Howard Koh to help deal with concerns raised by civil rights leaders Ambassador Andrew Young and Rev. Gerald Durley. The two courageous black community leaders had publicly issued letters calling for a halt to fluoridation. In the ADA leaders’ letter to Dr. Koh they explained why they were seeking his assistance to address the concerns Young and Durley had raised about fluoridation safety for minorities.

The letter from ADA leaders stated: “We believe that this issue has the potential to gain traction.”

Gain traction? Fluoridation advocates had long scoffed that fluoridation opponents’ arguments were unfounded. In fact, they said, fluoridation was especially helpful for minority and low income populations, helping eliminate oral health disparities. So what was there about the issue of minorities being harmed by fluoridation that could possibly gain traction?

Could it be that there is substance to the concerns? Does fluoridation in fact disproportionately harm minority populations?

Here we find more grist for Fluoridegate hearings. Studies and other information on fluoride exposure levels and harm had never effectively or formally been presented to minority leaders until recently, by fluoridation opponents.

For example, a fall 2009 study published in the Journal of Public Health Dentistry documented that black children are ingesting significantly more fluorides in water than white children. And CDC released information in 2005 documenting that blacks and hispanics have disproportionately more dental fluorosis than whites. CDC’s statistics were found deeply buried in the very last of 23 dizzying data tables in an article in CDC’s August 26, 2005 “MMWR” publication.

The news spread. Martin Luther King Jr.’s daughter Bernice King spoke out against fluoridation on a radio program. Her cousin, Alveda King, spoke out against fluoridation on her blog. And in the summer of 2011, the League of United Latin American Citizens passed a resolution opposing fluoridation.

Let the Litigation Begin

As part of its efforts to support community water fluoridation programs, the American Dental Association had published a long list, a compendium of organizations that had lent their names as endorsing fluoridation. Dozens of national and international health advocacy, government, and professional organizations were on the seemingly impressive list.

But now it appears that organizations on the list may be named in legal actions. Citizens and decision makers relied on the organizations’ listed names in deciding to buy-in to fluoridation. Very telling will be the groups’ responses to a simple question: Did your group do its own research into potential fluoridation risks prior to allowing your name to be used on ADA’s list, or did you provide a courtesy endorsement of fluoridation without doing your own research?

The list of persons, groups, companies, and agencies that may be sued extends beyond the organizations in ADA’s compendium list. It includes almost anyone that should have warned users of fluoride products of various concerns related to fluorides. Water utilities, bottled water providers, toothpaste sellers, government agencies, nonprofits and industry trade groups, and numerous other individuals and groups may find themselves in the lawsuit cross hairs.

Washington DC toxic tort attorney Chris Nidel said this: “I think when we look back we’ll ask why Fluoridegate didn’t surface earlier. There are serious concerns about possible conflict of interest and heavy editing of information being fed to the public about fluoride risks and impacts.”

Two fluoride-related legal cases were filed in 2011 in Maryland and California courts. Both cases encountered significant, but not unexpected challenges. It’s still early in the process of developing various types of fluoride litigation, but given the now-strongly growing interest in pursuing legal actions, the future looks to hold many fluoridation and fluoride-product-related cases. The sheer number of potentially harmed citizens — persons with dental fluorosis, kidney patients tipped into needing dialysis, diabetics, thyroid patients, etc — numbers in the millions.

Concerning upcoming legal cases and hearings, perhaps most delicious to long-time fluoridation opponents is the prospect that for the first time, key officials in government and private sector agencies can be put on the witness stand and directly questioned about harm from fluorides.

A few interesting questions may be: Why are we warned to spit out pea-sized amounts of fluoridated toothpaste, but we were told we can ingest the same amount of fluoride when it comes in a large glass of fluoridated drinking water? How can it be safe to drink as much fluoridated water as we’d like? And why haven’t Americans been told that fluorides accumulate in the pineal glands in our brains?

In 2008, the National Kidney Foundation’s board of directors quietly issued a new position statement on fluoridation, causing NKF’s name to be removed from the ADA’s compendium list of fluoridation endorsers. But why did NKF not openly announce its new statement? Was it because NKF had been a recipient of grant monies from the CDC and did not wish to risk the ire of CDC officials? Did NKF risk the health of its own constituents, most of who today do not know that the National Research Council has designated kidney patients and diabetics as especially susceptible to harm from ingested fluorides?

Affecting Our Babies and Even Our Pets

Many Americans do not know that for one-time, acute exposures, fluorides are known to be slightly less toxic than arsenic and slightly more toxic than lead. But even with longer-term, lower level chronic exposures, the risks are real, especially for babies and other groups that are particularly vulnerable to harm from fluorides. The NRC report stated that on a body weight basis, infants and young children are ingesting 3-4 times the amount of fluorides as are adults.

On another front, what is fluoridated water doing to our pets and horses? This issue has received little attention until recently, but given Americans’ deep protective instincts for their pets and horses, the issue threatens to become an enormous one in its own right. News of the deaths of the fluoridated water-poisoned horses of Colorado resident Cathy Justus is quickly spreading. A growing number of stunned pet and horse owners are educating themselves further about fluorides before they continue to provide fluoridated water for Fido, the family feline, or a beloved horse.

There are so many facets to the Fluoridegate scandal that it will not be surprising if a number of attorney generals, district attorneys, politicians, investigative journalists, philanthropists, and others make their mark uncovering the harm done and the names of those responsible. Fluorides are an equal opportunity offender, so it is also not surprising that both Democrats and Republicans are joining the calls for Fluoridegate hearings or for a halt to fluoridation.

What are the other key issues? Will there be sacrificial lambs among those subpoenaed for Fluoridegate hearings and court cases? Who will point fingers at each other to try to escape blame?

Part 2 of The Questions of Fluoridegate will delve further into the numerous swirling questions.

The Questions of Fluoridegate – Part 2

Scrutiny of Officials’ Actions Intensifies
By Daniel G. Stockin, MPH

As the Fluoridegate scandal continues to unravel, judges, juries, attorney generals and policy makers will readily recall an oft-proved truism: When the story offered by a stakeholder or person of interest changes, his actions and motives may bear further investigation. “I have trouble with the idea of requiring every person in a community to ingest fluoride in their water,” says Bill Dimas, a retired chief judge and now a city councilor in Santa Fe, New Mexico. “And the story about fluoride safety keeps changing, and this only adds to my doubts about imposing fluoridation.”

In 2011, U.S. officials recommended lowering the targeted amount of fluorides in drinking water for prevention of cavities. They also proposed phasing-out use of a fluoride pesticide. Federal Health & Human Services (HHS) managers had long resisted calls to end water fluoridation and
address growing amounts of “dental fluorosis,” a permanent staining and disfigurement of teeth caused by childhood fluoride exposure. Why did HHS change its firmly entrenched fluoridation guidance? Intensified scrutiny now focuses on what HHS, Environmental Protection Agency (EPA), and other officials and organizations said and did leading up to and around the time of the changed recommendation.

Caught Tiptoeing Out of the Room?

In a 2011 joint press release from EPA and HHS, Americans were told that the two agencies had “reached
an understanding” of the latest science on fluoride. Dr. Howard Koh, U.S. Assistant Secretary for Health,
stated that the HHS recommendation of a slightly lowered level of fluorides was “part of our ongoing
support of appropriate fluoridation for community water systems.”
It was odd, that the two agencies had to “reach an understanding.” EPA had done a new fluoride risk
assessment. Wouldn’t the science speak for itself? An objectively done risk analysis would allow the
chips to fall where they may. Was Dr. Koh’s statement about “ongoing support” for fluoridation evidence
of a non-negotiable, predetermined conclusion about fluoridation safety?
The revised HHS fluoridation recommendation was described as an action to help prevent dental
fluorosis. The news release said that fluorosis in the U.S. appears mostly in the very mild or mild form –
“as barely visible lacy white markings or spots on the enamel.”
ABC World News published this statement by Dr. Koh about the fluoride teeth stains: “In the vast
majority of those affected, it’s barely noticeable, even by dentists and oral health professionals.”
Dr. Koh’s comments compare strikingly with those of the American Dental Association, the dental
industry trade group with a self-ascribed “close collaborative relationship” with the HHS Oral Health
Division. ADA’s website states that, “In the vast majority of cases, enamel fluorosis appears as barely
noticeable faint white lines or streaks on tooth enamel… In fact, in many cases, the effect is so subtle that,
usually only a dental expert would notice it during an examination.”

 

The emphatic “barely visible, barely noticeable” statements raise an obvious question: Why lower the
recommended fluoridation level, regardless of the number of sources of a citizen’s fluoride exposure, if
the vast majority of resulting mild fluorosis cases are barely noticeable, even by dentists?
Are fluorosis impacts more of a concern than the statements would lead us to believe?
Fluoride chemical and water fluoridation opponents were beginning to enlist the assistance of attorneys.
Were federal officials’ actions a last-ditch attempt to try to avoid lawsuits, to tiptoe unnoticed out of the
room of fluoride harm responsibility?

Barely Noticeable No Longer

A wave of fluoride-related litigation now looms. In the federal district court in Maryland a
groundbreaking dental fluorosis legal action has been filed on behalf of a young girl who has fluorosis
that affects numerous teeth in her mouth. Her teeth stains are those of so-called “mild” dental fluorosis.
The blog of the Nidel Law toxic tort and environmental law firm in Washington D.C. shows a photo of
the girl’s teeth. (See http://www.nidellaw.com/blog/?p=106 ) Her mild fluorosis is anything but “barely
noticeable.” Based on estimates for teeth veneers and other associated expenses, it appears that her
lifetime costs for dental repair work alone may approach $100,000.

Both mild and very mild cases can be highly expensive and significantly impact the lives of those with the
disfigurement. Dental fluorosis expert and now-retired dentist Dr. David Kennedy puts it quite plainly:
“People need to know that ‘very mild’ can be very ugly.”

Dr. Koh’s and others’ soothing statements about dental fluorosis are now being viewed in light of
information about the classification system dentists use for fluorosis. The “Dean’s index” is set up so that
classification is based on an individual’s second-most-affected tooth. Unbelievably, for the purpose of
classifying fluorosis, the tooth with the greatest degree of fluoride staining is ignored, even if it is in a
highly visible position, such as a top front tooth. Perhaps even more shocking, “very mild” and “mild”
designations are made without respect to how many teeth are affected, whether two or up to ten, twelve or
more teeth have the disfigurement. Over time, white fluorosis stains can become a more easily visible
yellow or brown, but very mild and mild designations are made without respect to color and visibility.
Did Dr. Koh intentionally fail to share this key fluorosis information with the media and the public? Did
oral health officials at HHS and other dental agencies feed him misleading information to present about
fluorides? Who should bear responsibility for Dr. Koh’s statements?

Law firms are learning that dental and health officials did not openly tell consumers and water agencies
the whole story about fluorosis, including the fact that fluorides disproportionately impact certain groups
such as minorities. Dr. Koh is only one name on lists of persons who can potentially be called to testify in
legal actions and hearings.
The HHS National Center for Health Statistics has admitted that some form of dental fluorosis now
affects 41% of adolescents 12-15 years old. The sheer number of potential dental fluorosis legal cases is
anything but “barely noticeable.”

Double-Speak at EPA

In the early 1990s, Dr. William Marcus, senior toxicologist in the EPA’s Office of Drinking Water, was
fired for expressing his concerns about how data linking fluoride to cancers was being assessed in a way
that downgraded the evidence of risk. He pursued and won his case in front of an administrative law judge
who ordered him to be reinstated. U.S. Secretary of Labor Robert Reich also found in favor of Dr.
Marcus, noting in his written opinion, “I agree with the [administrative law judge] that Dr. Marcus should
prevail in his complaint of unlawful discrimination.”

EPA officials had retaliated against Dr. Marcus for his ethical stance in highlighting fluoride risks. The
details of his experience from two decades ago are considerably more shocking than their brief
description here. But today’s evolving Fluoridegate scandal highlights a continued culture of preferential,
special treatment of fluorides inside EPA, protecting the practice of water fluoridation.
Scientists use mathematical formulas to calculate risk, and one number used in the calculations is a
“database uncertainty factor” that is a compensating safety factor to address holes in our research
knowledge base.

In late 2010 the EPA issued documents describing fluoride health risks and exposures. In one of the
documents EPA stated that “the standard toxicity database for fluoride is complete,” and that this negates
the need for a database uncertainty factor in EPA’s fluoride risk calculations. Yet EPA acknowledged
neurological, hormone and other fluoride research needs.
EPA’s document was saying that we don’t know how toxic fluorides are for a number of body systems,
but we also have no uncertainty tied to our limited data on toxicity.

If you did a double-take when reading this statement, you did so for good reason. EPA’s document
contains double-speak. If an appropriate uncertainty factor was included in EPA’s calculations, the
mathematics of the risk assessment could have ended fluoridation.
The scientists in the EPA Office of Water that were involved in producing the document were Joyce
Morrissey Donohue and Tina Duke. Key questions that can be asked of them and others past and present
at EPA will include: Why did it take EPA so long to issue its 2010 assessment of fluoride risks after the
National Research Council recommended a new risk assessment? What was the nature of the relationship
between EPA managers and officials at the Oral Health Division at the Centers for Disease Control and
the American Dental Association? When did meetings and calls between them occur, and who was
present at the meetings? What punishments or reprimands were given to employees involved in Dr.
Marcus’ case, and what role did their work play in the latest assessment of fluoride risks?

Surgeon Generals in the Spotlight

In 2004 U.S. Surgeon General Richard Carmona released a statement calling water fluoridation “the
single most effective public health measure to prevent tooth decay and improve oral health over a
lifetime, for both children and adults.” His statement echoed, word for word, those of previous Surgeon
General David Satcher in 2001.

Their statements raise no eyebrows until they are contrasted with long-known information about “teeth
sealants.” Dentists have long known that teeth sealants are dramatically more effective than fluorides in
preventing cavities. The sealants are cavity-blocking resins placed in the grooves of children’s molars.
More than 80% of kids’ cavities occur in the pits and fissures of their back molars. Dentists, school
districts, and public health planners promote use of the sealants.

A 1984 editorial in the Journal of the American Dental Association stated this about pit and fissure
cavities in kids’ molars: “Although fluorides cannot be expected appreciably to reduce our incidence of

[cavities] on these surfaces, sealants can.” In 1987, an article in the Journal of the Canadian Dental
Association echoed this understanding in very plain language: “Pit and fissure cavities aren’t considered
to be preventable by fluorides, they are prevented by sealants.”
Given this knowledge about the relative ineffectiveness of fluorides, why did both Dr. Satcher and Dr.
Carmona call water fluoridation the “single most effective public health measure” to prevent tooth decay?
Did they deliberately fail to share the facts about teeth sealants? Were they misled by information from
dentists who did not want fluoridation to be questioned at any cost? Will Dr.’s Carmona and Satcher be
embarrassed in court hearings under oath? Will they retract their statements now?

There is even more unsettling information. The Centers for Disease Control and the American Dental
Association acknowledge that the primary effect of fluoride in preventing cavities is when fluorides touch
teeth topically, in the mouth – not by systemic absorption of fluorides throughout the body. Systemic
absorption had been the key reason to begin adding fluorides to water more than 60 years ago, so children
would drink the chemical and the fluorides would be incorporated into teeth forming under the gums,
helping the teeth to be strong and cavity-resistant. CDC also admitted in 2001 that the concentration of
fluorides in saliva from consuming fluoridated water is low, and that the fluorides in the saliva bathing the
teeth were “not likely to affect cariogenic [cavity producing] activity.”

The finding that topical effect was the primary and limited mechanism for fluoride cavity prevention
should have ended water fluoridation. Why had it not done so? This is another key question to ask of
persons placed under oath in Fluoridegate hearings and in court cases.

Questions about Fluoridated Toothpastes

As Fluoridegate unfolds, questions about toothpastes are also now being raised.

Fluoridated toothpaste tubes cautions parents that children should use a pea-sized amount of the product,
and not to swallow it. The warning label advises getting medical help or calling a poison control center if
more than used for brushing is accidentally swallowed.

The amount of fluoride in a pea-size amount of toothpaste is the same amount of fluoride that is
consumed when a child drinks a large glass of fluoridated city water. We spit out the fluoridated
toothpaste, but are encouraged to drink lots of fluoridated water without spitting it out. A logical, if
unnerving question thus presents itself: Should we be calling the poison control center if we drink
fluoridated city water?

There are other questions. Research shows that children do indeed often swallow toothpaste. Why are
fluoridated toothpastes flavored with enticing, sweet flavors and squeezed out on kids’ toothbrushes in
cheerful, bright colors, if children are expected not to swallow the taste bud-pleasing products?
For the very youngest children with teeth, a number of well-known toothpaste brands now offer a toddler
training toothpaste that is unfluoridated. Boxes for these products are emblazoned with “Fluoride-free.

Safe if swallowed,” or similar language.

Since being “Fluoride-free” is tied to being “Safe if swallowed,” and many parents do not know about or
cannot afford the unfluoridated products, what does this say about the safety of their children when
brushing their teeth? Do children in poor or limited-English families deserve to be safe any less than other
children?

What about dental fluorosis and toothpastes? It has long been known that fluoridated toothpastes, like
fluoridated water, can cause the disfiguring teeth staining of dental fluorosis. Why were unfluoridated
toddler toothpastes not offered sooner? What moved toothpaste companies to begin selling unfluoridated
products?

Were growing public awareness and potentially mammoth legal and financial risks a long-feared perfect
storm that finally arrived to confront toothpaste manufacturers?

Sacrificial Lambs, Scapegoats, and Sacred Cows

The Questions of Fluoridegate are numerous; they will provide much fodder for investigative hearings
and legal pursuits. And while dental fluorosis is clearly a subject to be investigated, even more
disconcerting will be what investigators learn when they delve even deeper: that fluorosis teeth
disfigurement is the visible tip of an underlying invisible iceberg of additional harm to the body.
A few key players in the scandal appear to have benefited from our deep-seated desire to trust the leaders
in our public health infrastructure. The list of key players involved will inevitably narrow to focus more
on those at higher levels of the chain of deferred authority that has enabled fluoridation to continue. But
as we watch the developing story unfold in an agricultural-sounding roundup of sacrificial lambs,
scapegoats, and sacred cows, we will be forced to reexamine where our trust is placed. We have all been
affected by the fluoridation-enabling actions of people and organizations that touch our daily lives.
Colson, Haldeman, and Ehrlichman became household names along with Richard Nixon as the Watergate
scandal unfolded. What names of individuals and corporations will be forever associated with
Fluoridegate?

As the Fluoridegate scandal continues to unravel, judges, juries, attorney generals and policy makers will
readily recall an oft-proved truism: When the story offered by a stakeholder or person of interest changes,
his actions and motives may bear further investigation.

“I have trouble with the idea of requiring every person in a community to ingest fluoride in their water,”
says Bill Dimas, a retired chief judge and now a city councilor in Santa Fe, New Mexico. “And the story
about fluoride safety keeps changing, and this only adds to my doubts about imposing fluoridation.”
In 2011, U.S. officials recommended lowering the targeted amount of fluorides in drinking water for
prevention of cavities. They also proposed phasing-out use of a fluoride pesticide.

Federal Health & Human Services (HHS) managers had long resisted calls to end water fluoridation and
address growing amounts of “dental fluorosis,” a permanent staining and disfigurement of teeth caused by
childhood fluoride exposure. Why did HHS change its firmly entrenched fluoridation guidance?
Intensified scrutiny now focuses on what HHS, Environmental Protection Agency (EPA), and other
officials and organizations said and did leading up to and around the time of the changed
recommendation.

Caught Tiptoeing Out of the Room?

In a 2011 joint press release from EPA and HHS, Americans were told that the two agencies had “reached
an understanding” of the latest science on fluoride. Dr. Howard Koh, U.S. Assistant Secretary for Health,
stated that the HHS recommendation of a slightly lowered level of fluorides was “part of our ongoing
support of appropriate fluoridation for community water systems.”

It was odd, that the two agencies had to “reach an understanding.” EPA had done a new fluoride risk
assessment. Wouldn’t the science speak for itself? An objectively done risk analysis would allow the
chips to fall where they may. Was Dr. Koh’s statement about “ongoing support” for fluoridation evidence
of a non-negotiable, predetermined conclusion about fluoridation safety?

The revised HHS fluoridation recommendation was described as an action to help prevent dental
fluorosis. The news release said that fluorosis in the U.S. appears mostly in the very mild or mild form –
“as barely visible lacy white markings or spots on the enamel.”

ABC World News published this statement by Dr. Koh about the fluoride teeth stains: “In the vast
majority of those affected, it’s barely noticeable, even by dentists and oral health professionals.”
Dr. Koh’s comments compare strikingly with those of the American Dental Association, the dental
industry trade group with a self-ascribed “close collaborative relationship” with the HHS Oral Health
Division. ADA’s website states that, “In the vast majority of cases, enamel fluorosis appears as barely
noticeable faint white lines or streaks on tooth enamel… In fact, in many cases, the effect is so subtle that,
usually only a dental expert would notice it during an examination.”

The emphatic “barely visible, barely noticeable” statements raise an obvious question: Why lower the
recommended fluoridation level, regardless of the number of sources of a citizen’s fluoride exposure, if
the vast majority of resulting mild fluorosis cases are barely noticeable, even by dentists?
Are fluorosis impacts more of a concern than the statements would lead us to believe?

Fluoride chemical and water fluoridation opponents were beginning to enlist the assistance of attorneys.
Were federal officials’ actions a last-ditch attempt to try to avoid lawsuits, to tiptoe unnoticed out of the
room of fluoride harm responsibility?

Barely Noticeable No Longer

A wave of fluoride-related litigation now looms. In the federal district court in Maryland a
groundbreaking dental fluorosis legal action has been filed on behalf of a young girl who has fluorosis
that affects numerous teeth in her mouth. Her teeth stains are those of so-called “mild” dental fluorosis.
The blog of the Nidel Law toxic tort and environmental law firm in Washington D.C. shows a photo of
the girl’s teeth. (See http://www.nidellaw.com/blog/?p=106 ) Her mild fluorosis is anything but “barely
noticeable.” Based on estimates for teeth veneers and other associated expenses, it appears that her
lifetime costs for dental repair work alone may approach $100,000.
Both mild and very mild cases can be highly expensive and significantly impact the lives of those with the
disfigurement. Dental fluorosis expert and now-retired dentist Dr. David Kennedy puts it quite plainly:
“People need to know that ‘very mild’ can be very ugly.”

Dr. Koh’s and others’ soothing statements about dental fluorosis are now being viewed in light of
information about the classification system dentists use for fluorosis. The “Dean’s index” is set up so that
classification is based on an individual’s second-most-affected tooth. Unbelievably, for the purpose of
classifying fluorosis, the tooth with the greatest degree of fluoride staining is ignored, even if it is in a
highly visible position, such as a top front tooth. Perhaps even more shocking, “very mild” and “mild”
designations are made without respect to how many teeth are affected, whether two or up to ten, twelve or
more teeth have the disfigurement. Over time, white fluorosis stains can become a more easily visible
yellow or brown, but very mild and mild designations are made without respect to color and visibility.
Did Dr. Koh intentionally fail to share this key fluorosis information with the media and the public? Did
oral health officials at HHS and other dental agencies feed him misleading information to present about
fluorides? Who should bear responsibility for Dr. Koh’s statements?

Law firms are learning that dental and health officials did not openly tell consumers and water agencies
the whole story about fluorosis, including the fact that fluorides disproportionately impact certain groups
such as minorities. Dr. Koh is only one name on lists of persons who can potentially be called to testify in
legal actions and hearings.

The HHS National Center for Health Statistics has admitted that some form of dental fluorosis now
affects 41% of adolescents 12-15 years old. The sheer number of potential dental fluorosis legal cases is
anything but “barely noticeable.”

Double-Speak at EPA

In the early 1990s, Dr. William Marcus, senior toxicologist in the EPA’s Office of Drinking Water, was
fired for expressing his concerns about how data linking fluoride to cancers was being assessed in a way
that downgraded the evidence of risk. He pursued and won his case in front of an administrative law judge
who ordered him to be reinstated. U.S. Secretary of Labor Robert Reich also found in favor of Dr.
Marcus, noting in his written opinion, “I agree with the [administrative law judge] that Dr. Marcus should
prevail in his complaint of unlawful discrimination.”

EPA officials had retaliated against Dr. Marcus for his ethical stance in highlighting fluoride risks. The
details of his experience from two decades ago are considerably more shocking than their brief
description here. But today’s evolving Fluoridegate scandal highlights a continued culture of preferential,
special treatment of fluorides inside EPA, protecting the practice of water fluoridation.
Scientists use mathematical formulas to calculate risk, and one number used in the calculations is a
“database uncertainty factor” that is a compensating safety factor to address holes in our research
knowledge base.

In late 2010 the EPA issued documents describing fluoride health risks and exposures. In one of the
documents EPA stated that “the standard toxicity database for fluoride is complete,” and that this negates
the need for a database uncertainty factor in EPA’s fluoride risk calculations. Yet EPA acknowledged
neurological, hormone and other fluoride research needs.

EPA’s document was saying that we don’t know how toxic fluorides are for a number of body systems,
but we also have no uncertainty tied to our limited data on toxicity.

If you did a double-take when reading this statement, you did so for good reason. EPA’s document
contains double-speak. If an appropriate uncertainty factor was included in EPA’s calculations, the
mathematics of the risk assessment could have ended fluoridation.

The scientists in the EPA Office of Water that were involved in producing the document were Joyce
Morrissey Donohue and Tina Duke. Key questions that can be asked of them and others past and present
at EPA will include: Why did it take EPA so long to issue its 2010 assessment of fluoride risks after the
National Research Council recommended a new risk assessment? What was the nature of the relationship
between EPA managers and officials at the Oral Health Division at the Centers for Disease Control and
the American Dental Association? When did meetings and calls between them occur, and who was
present at the meetings? What punishments or reprimands were given to employees involved in Dr.
Marcus’ case, and what role did their work play in the latest assessment of fluoride risks?
Surgeon Generals in the Spotlight

In 2004 U.S. Surgeon General Richard Carmona released a statement calling water fluoridation “the
single most effective public health measure to prevent tooth decay and improve oral health over a
lifetime, for both children and adults.” His statement echoed, word for word, those of previous Surgeon
General David Satcher in 2001.

Their statements raise no eyebrows until they are contrasted with long-known information about “teeth
sealants.” Dentists have long known that teeth sealants are dramatically more effective than fluorides in
preventing cavities. The sealants are cavity-blocking resins placed in the grooves of children’s molars.
More than 80% of kids’ cavities occur in the pits and fissures of their back molars. Dentists, school
districts, and public health planners promote use of the sealants.
A 1984 editorial in the Journal of the American Dental Association stated this about pit and fissure
cavities in kids’ molars: “Although fluorides cannot be expected appreciably to reduce our incidence of
[cavities] on these surfaces, sealants can.” In 1987, an article in the Journal of the Canadian Dental
Association echoed this understanding in very plain language: “Pit and fissure cavities aren’t considered
to be preventable by fluorides, they are prevented by sealants.”

Given this knowledge about the relative ineffectiveness of fluorides, why did both Dr. Satcher and Dr.
Carmona call water fluoridation the “single most effective public health measure” to prevent tooth decay?
Did they deliberately fail to share the facts about teeth sealants? Were they misled by information from
dentists who did not want fluoridation to be questioned at any cost? Will Dr.’s Carmona and Satcher be
embarrassed in court hearings under oath? Will they retract their statements now?

There is even more unsettling information. The Centers for Disease Control and the American Dental
Association acknowledge that the primary effect of fluoride in preventing cavities is when fluorides touch
teeth topically, in the mouth – not by systemic absorption of fluorides throughout the body. Systemic
absorption had been the key reason to begin adding fluorides to water more than 60 years ago, so children
would drink the chemical and the fluorides would be incorporated into teeth forming under the gums,
helping the teeth to be strong and cavity-resistant. CDC also admitted in 2001 that the concentration of
fluorides in saliva from consuming fluoridated water is low, and that the fluorides in the saliva bathing the
teeth were “not likely to affect cariogenic [cavity producing] activity.”

The finding that topical effect was the primary and limited mechanism for fluoride cavity prevention
should have ended water fluoridation. Why had it not done so? This is another key question to ask of
persons placed under oath in Fluoridegate hearings and in court cases.

Questions about Fluoridated Toothpastes

As Fluoridegate unfolds, questions about toothpastes are also now being raised.
Fluoridated toothpaste tubes cautions parents that children should use a pea-sized amount of the product,
and not to swallow it. The warning label advises getting medical help or calling a poison control center if
more than used for brushing is accidentally swallowed.

The amount of fluoride in a pea-size amount of toothpaste is the same amount of fluoride that is
consumed when a child drinks a large glass of fluoridated city water. We spit out the fluoridated
toothpaste, but are encouraged to drink lots of fluoridated water without spitting it out. A logical, if
unnerving question thus presents itself: Should we be calling the poison control center if we drink
fluoridated city water?

There are other questions. Research shows that children do indeed often swallow toothpaste. Why are
fluoridated toothpastes flavored with enticing, sweet flavors and squeezed out on kids’ toothbrushes in
cheerful, bright colors, if children are expected not to swallow the taste bud-pleasing products?
For the very youngest children with teeth, a number of well-known toothpaste brands now offer a toddler
training toothpaste that is unfluoridated. Boxes for these products are emblazoned with “Fluoride-free.
Safe if swallowed,” or similar language.

Since being “Fluoride-free” is tied to being “Safe if swallowed,” and many parents do not know about or
cannot afford the unfluoridated products, what does this say about the safety of their children when
brushing their teeth? Do children in poor or limited-English families deserve to be safe any less than other
children?

What about dental fluorosis and toothpastes? It has long been known that fluoridated toothpastes, like
fluoridated water, can cause the disfiguring teeth staining of dental fluorosis. Why were unfluoridated
toddler toothpastes not offered sooner? What moved toothpaste companies to begin selling unfluoridated
products?

Were growing public awareness and potentially mammoth legal and financial risks a long-feared perfect
storm that finally arrived to confront toothpaste manufacturers?

Sacrificial Lambs, Scapegoats, and Sacred Cows

The Questions of Fluoridegate are numerous; they will provide much fodder for investigative hearings
and legal pursuits. And while dental fluorosis is clearly a subject to be investigated, even more
disconcerting will be what investigators learn when they delve even deeper: that fluorosis teeth
disfigurement is the visible tip of an underlying invisible iceberg of additional harm to the body.
A few key players in the scandal appear to have benefited from our deep-seated desire to trust the leaders
in our public health infrastructure. The list of key players involved will inevitably narrow to focus more
on those at higher levels of the chain of deferred authority that has enabled fluoridation to continue. But
as we watch the developing story unfold in an agricultural-sounding roundup of sacrificial lambs,
scapegoats, and sacred cows, we will be forced to reexamine where our trust is placed. We have all been
affected by the fluoridation-enabling actions of people and organizations that touch our daily lives.
Colson, Haldeman, and Ehrlichman became household names along with Richard Nixon as the Watergate
scandal unfolded. What names of individuals and corporations will be forever associated with
Fluoridegate?

__________________________________________________________________________________

Daniel G. Stockin, MPH, is the former manager of the EPA Western Regional Lead Training Center. He is a career public health professional with a background in toxics assessment and hazardous materials management. He is known internationally for his work at The Lillie Center Inc., a Georgia-based firm working to end water fluoridation. He may be reached at: stockin2@yahoo.com

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