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June 1, 2012

Dear Mr. Deal:

Attached is a copy of your letter, with our responses inserted. You raise many challenges to fluoridation. We have made every effort to respond thoughtfully and respectfully to these. I remain absolutely convinced that fluoridation is safe and provides an important benefit to everyone who drinks it. It remains one of the great achievements of public health, responsible for dramatically reducing serious oral health problems among children and adults.


Gary Goldbaum, MD, MPH | Health Officer & Director | Administration

3020 Rucker Avenue, Ste 306 | Everett, WA 98201 | 425.339.5210 |


James Deal’s statements are formatted to the left margin, while Dr. Goldbaum’s responses are indented and italicized:

On February 9 of this year, Everett Utilities turned the fluoride off to repair pipes in the fluoridation building. The pipes were leaking hydrogen fluoride. Safe water groups urged the City Council not to restart fluoridation without first holding hearings. (The Herald, “Fluoridated Water Supply: Utility should have to prove its safety”, March 24.)

Snohomish Health District: The pipes were not leaking hydrogen fluoride. Mr. Deal misunderstood what he was told during his tour of the Everett Water Filtration Plant. The repairs to the plant’s chemical feed pipes were part of routine maintenance.

Writing with Dr. Stephen J. Lee, DDS, you responded that fluoridation is “safe and effective”. You announced that fluoridation would soon resume, and reassured the public that the two month interruption in fluoridation would not deprive them of the “benefits of fluoridation”. The tenor of your article would imply that you oppose holding hearings. (The Herald, “Fluoridated Water a safe, low-cost public health tool”, April 5).

Snohomish Health District: The Health District unequivocally supports community water fluoridation as a safe, effective, low cost, and equitable means to reduce tooth decay.  Nothing in the Herald commentary suggests that we oppose public discussion of important health issues.

 On April 10, Everett Utilities turned the fluoride back on. At the City Council meeting on April 11, Council President Gipson explained why the Council did not act to prevent fluoridation from restarting: There were referendums on fluoridation in 1990 and 1992, with fluoridation winning by 51% and 62%. “The voters have spoken. They elected us. They are the boss. We listen to them”.

Snohomish Health District: Yes, both the majority of the public and the majority of the health and scientific communities support water fluoridation.

Councilman Drew Nielsen takes the position that this is a complex scientific issue, that the Council is not a “science court”, and therefore that the Council must rely on recognized scientific authorities such as the CDC, EPA, and you.

Snohomish Health District: National organizations that review drinking water and fluoride quality include:

The U.S. Environmental Protection Agency (EPA), responsible for the safety and quality of drinking water in the United States.

The U.S. Food and Drug Administration (FDA), responsible for approving prescription and over-the-counter fluoride products marketed in the United States and for setting standards for labeling bottled water and over-the-counter fluoride products.

The U.S. Centers for Disease Control and Prevention (CDC), the nation’s health protection agency, tasked with saving lives, protecting people from health threats, and saving money through prevention.

NSF International, a not-for-profit, non-governmental organization, that is the world leader in standards development, product certification, education and risk management for public health and safety.

American Water Works Association, an international non-profit scientific and education society dedicated to the improvement of drinking water quality and supply.

With all due respect, we take issue with your position. Because the City Council is relying on you for scientific advice, I am addressing this letter to you and asking for a written response.

In your April 5 article you cite no scientific evidence to support your “safe and effective” assurances – except for your assertion that fluoride is naturally occurring. While it is true that fluoride is naturally occurring, so too are lead and arsenic. Being naturally occurring does not make something safe to add to our water and consume, especially when people drink different amounts of water and have different pre-existent conditions. In your response, please address this issue.

Snohomish Health District: Everything, including an excess of plain water, can be toxic. Toxicity is determined by the particular substance, the dose, and the dose over time.  Fluoride added to water at the level approved for oral health (.7 parts per million – 1.2ppm), is lower than fluoride levels found naturally in some drinking water, which can reach the EPA allowed 4ppm.

When you say that fluoride is naturally occurring, you imply that the fluoride added to Everett water is the naturally occurring type. It is not. Naturally occurring fluoride is generally calcium fluoride (CaF2), which is not even classified as a poison. It would take a half pound of calcium fluoride to kill an adult but just seven paperclips weight of fluorosilicic acid.

Snohomish Health District: It is the fluoride ion, not the solid forms of fluoride, that provides the benefits of fluoridation. Fluoride is an element that binds to many other elements. Calcium fluoride does not dissolve in water, is not naturally found in significant quantities in solution in water, and is therefore not useful in water fluoridation. However, calcium fluoride crystals, formed when tooth enamel is repaired during the remineralization process, form a tooth structure that is more resistant to tooth decay.  Fluorosilicic acid is a concentrated form of fluoride, is not to be consumed without first diluting with water, and is always diluted appropriately when used to provide its benefits to health. 

The fluoridation materials Everett uses is a brew of dozens of elements and compounds, including around 23% industrial grade fluorosilicic acid (H2SiF6) and 0.5% hydrogen fluoride (HF). It also contains dangerous levels of lead, arsenic, and other toxic substances.

Snohomish Health District:  Water contains dozens of elements and compounds. Many of the contaminants Mr. Deal names are found in the source water from the Sultan Basin, including arsenic.

Fluorosilicic acid is not an industrial grade compound. The processed compound shipped to Everett meets all federal and state requirements for safe treatment of drinking water. While the concentrated product (as do all concentrated additives) contain a variety of trace elements, these traces are either not detectable once diluted as recommended for the treatment of drinking water or occur in the finished drinking water at levels well below the safe limits set by the EPA.

Everett meets the water quality standards for arsenic and lead by very wide margins. Snohomish County residents are mailed a water quality report annually. 

Fluoridation started in 1945 with sodium fluoride, which is just as poisonous as fluorosilicic acid but contains less impurities. Around 92% of fluoridation is now done with the cheaper fluorosilicic acid. Phosphate fertilizer companies have a lot to sell – or pay to dispose of. By some estimates fluoridation has a $500 million impact on the fertilizer and chemical business.

Snohomish Health District:  The fluoride-rich by-products of the phosphate fertilizer industry are shipped to manufacturing plants for purification and recombination to create a variety of fluoride products for use in the treatment of drinking water.

Sodium fluoride is manufactured from fluorosilicic acid. Sodium fluoride is utterly impractical for fluoridation by a large water system like the City of Everett. It is predominantly used by small water systems and in very small treatment plants.

It is a consistent error on the part of pro-fluoridationists that they lump all forms of fluoride together. The different fluorides behave differently. For example, fluorosilicic acid both contains lead and has a special ability to leach lead out of pipes. This is important because Everett pipes like Seattle pipes – private and public – contain a LOT of lead.

It is impossible to remove all lead pipes in Everett at any reasonable cost or within any reasonable time frame. But it is easy to reduce lead levels, and that is to stop adding fluorosilicic acid to our water. Where fluoridation stops, blood lead levels drop. It is odd that we go to such great lengths to reduce exposure to lead from old paint, while we are blind to the lead that we ingest as a result of fluoridating our water.

In your April 5 article, you did not respond to the evidence we presented that the industrial grade of fluoride used contains lead and leaches lead from pipes. Please address this issue in your response.

Snohomish Health District:  There is no measurable lead in the treated drinking water leaving the plant. Mr. Deal was provided the results of the monitoring that shows this. Numerous samples have been collected from the treated water each year since fluoridation began in 1992.

Under the requirements of the EPA Lead and Copper rule which regulates corrosivity in drinking water to reduce the leaching of metals from consumer plumbing, Everett monitors for lead at consumer taps and using a “worst case” EPA sample collection protocol. The results from the past four rounds of samples collected over a dozen years show lead levels that are well below the standard set by the Lead and Copper regulation. Indeed, the levels are less than one-fifth the limits set by the standard.

The raw water from Spada Lake Reservoir has low pH and low alkalinity and is corrosive without treatment. pH and alkalinity are two of the main drivers of water corrosivity and the rate at which leaching of metals from plumbing into water occurs. Regardless of the addition of the fluoride chemical, this source water requires corrosion treatment to reduce corrosivity. Reduced corrosivity is accomplished by increasing the water pH to reduce the solubility of the water and increasing alkalinity to deposit a protective alkaline film inside of the plumbing. pH and alkalinity are adjusted to optimal levels as required by the regulation. The fluoride chemical has no net effect on water corrosivity because soda ash (sodium carbonate) is added in sufficient quantity to produce the target pH and alkalinity.

Keep in mind that this process reduces corrosivity and cannot eliminate it. There is no such thing as noncorrosive water. Water is the universal solvent.

Your response ignores another type of fluoride, hydrogen fluoride (HF), one of the most toxic and penetrating of all compounds. No drug which contains hydrogen fluoride may be “labeled, represented, or promoted” as an “anticares drug product” without prior FDA approval. See 21 CFR 310.545. Around 2.0% of Everett’s industrial fluorosilicic acid is hydrogen fluoride, a very high level of a highly toxic compound. The use of hydrogen fluoride to prevent tooth decay is illegal.

Snohomish Health District:  Fluoride is not a drug and is not regulated by the FDA. It is a natural element in all drinking water, and therefore regulated by the EPA.  Fluoridation is carefully regulated and is absolutely legal.

The prohibition on the use of hydrogen fluoride is for the direct application or handling of hydrogen fluoride on or by people and is the same as for any other strong acid. Concentrated hydrochloric or sulfuric acid cannot be handled without protection. Water system operators, who must handle the concentrated products, use accepted standards, personal protection equipment when necessary, and processes and equipment designed to limit their direct exposure and to allow them to safely handle the material.

In your article you rely on endorsements instead of scientific evidence, however, endorsements are not proof. You say that CDC and EPA endorse fluoridation, but this is only a half-truth. The EPA is divided into pro-industry and pro-consumer camps. It is the EPA administrators who support fluoridation. EPA scientists, represented by the EPA Union, strongly oppose fluoridation and do so based on science.

Snohomish Health District:  The “EPA Union” is the National Treasury Employees Union of the EPA, representing only 1,600 members out of the 18,000 EPA members nationwide. It does not represent the opinion or views of the EPA as an organization nor views of the majority of the professional employees of the agency.

Likewise the CDC (an agency under HHS) is divided. One small dental health office within CDC trumpets support for fluoridation, while CDC scientists post articles on the CDC web site which admit that 40.7% of children are getting dental fluorosis and that the effect of fluoride on teeth is “primarily topical” and “not systemic”.

The FDA too is divided. Although politics prevent the FDA from banning fluoridation (FDA too is under HHS), the FDA has never approved it. Although it has not done so yet, the FDA has warned that it could prosecute criminally those who violate FDA regulations.

Like legislatures, many of our agencies have been “captured” by the industries they regulate.

Further, endorsements cut both ways. Many respected scientists oppose fluoridation, including Arvid Carlsson, Nobel Laureate in medicine, along with thousands of doctors, dentists, nurses, PhDs, and other professionals. In your response, please explain why you rely so heavily on CDC and EPA endorsements.

Snohomish Health District:  The CDC and EPA are the leading national authorities for the scientific basis for the safety and health effects of fluoride.  Individuals may have different opinions, but they do not represent the views of the general scientific community.

The vast majority of health professionals support and endorse community water fluoridation as stated on the American Dental Association Web site.

You cite evidence that tooth decay has declined, and then you assert that fluoridation caused the decline. But you fail to prove any cause and effect connection. To the contrary, there is strong evidence that fluoridation does not reduce tooth decay. Tooth decay started declining before fluoridation was instituted and has continued declining both in fluoridated and non-fluoridated areas. The clearest proof that fluoridation is not the cause of the decline in tooth decay is the fact that decay rates have dropped just as much in non-fluoridated continental Europe as they have in the United States. When Cuba and East Germany stopped fluoridating, tooth decay declined.

Snohomish Health District:  No European country has banned water fluoridation.  Cuba and East Germany adopted salt fluoridation instead of water fluoridation.  When piped water supplies are not available, salt or milk fluoridation is often substituted.

Since the 1950’s fluoride has been made available in toothpastes, tablets, and in treatments at the dentist that also contribute to the declines in tooth decay for those that can afford them. They all have greater risks for fluorosis and toxicity than water fluoridation.

Fluoride in drinking water is safest because of its low concentration and effectiveness.

The CDC website lists many studies showing 10% to 30% reductions in decay. But these studies never claim that fluoridation eliminates all decay. Fluoridation is not a “magic bullet”. The real keys to ending decay are cutting out sugar, eating lots of mineral rich green foods, getting sunlight or vitamin D supplementation, brushing and flossing, and primary dental care. The new Affordable Care Act should cover primary dental care but does not.

For various reasons the poor have the most tooth decay and are most affected by dental fluorosis, particularly Blacks and Hispanics.

Snohomish Health District:  Studies of fluorosis among people of color have found no associations with fluoride in drinking water, but they did find significant associations with fluoride in toothpastes or supplements. Toothpastes and supplements result in significantly higher ingestion of fluoride than fluoride in water supplies that adjust the level of fluoride to .7-1.2ppm. Fluoride is most effective combined with good daily home care and positive eating behaviors.

Further, neither the EPA nor the CDC has any jurisdiction to encourage, finance, or require adding fluoride to water. The Safe Drinking Water forbids them from requiring fluoridation: “No national primary drinking water regulation may require the addition of any substance for preventive health care purposes unrelated to contamination of drinking water”.

Neither EPA nor CDC may require fluoridation, so they only encourage it and work to convince states, cities, and water districts to require it, passing the buck down the line to local governing bodies such as the Everett City Council, in an effort to avoid violating the Safe Drinking Water Act.

In our March 24 article, we pointed out that infants and fetuses are most vulnerable to fluoridation materials, that the toxins in fluoridation materials cross the placental barrier and the blood-brain barrier, that they damage brain tissue and reduce IQ while the fetus is still in the womb. Convincing studies show lower intelligence in fluoridated areas. Please address these issues in your response.

Snohomish Health District:  These studies were done in China and countries outside the United States. They had significant flaws in the research designs. For example, China, along with many countries, has fluoride levels in drinking water far in excess of the 4 ppm allowed in U.S. drinking water that were not accounted for in the analysis.

The CDC and the ADA admit that we are giving dental fluorosis to 40.7 percent of children age 12-15. You say that “the minor changes in the tooth surface caused by fluorosis are not detectable by the average consumer or considered unsightly”, but this is not correct. Of the 40.7% affected, 8.6% of those suffer from mild fluorosis (white spots and some yellow and brown spots with up to 50% of enamel impacted), and 3.6% suffer from moderate and severe fluorosis (white spots and brown spots and sometimes pitting and chalky teeth and 50-100% of enamel impacted). Thus, more than a quarter of fluorosis cases (8.6% + 3.6% = 12.2% / 40.7% = 30%) are ugly and difficult and costly to cover up. Cosmetic dentists say the cost for veneers can run $1,000 per tooth and replacement veneers are required The cost for veneers can run $1,000 per tooth, and over a lifetime can cost $100,000. These are not “minor changes in the tooth surface”.

Snohomish Health District:  Dental fluorosis occurs among some people in all communities, even in communities that do not fluoridate or have a low natural concentration of fluoride in their drinking water. Everyone is encouraged to know what steps can be taken to reduce the occurrence of dental fluorosis. Elimination of water fluoridation will not eliminate moderate or severe fluorosis. Severe fluorosis, which is cosmetically unsightly, is very rare in the U.S. provided fluoride levels are maintained less than 2ppm as recommended by the EPA.

You minimize the extent and significance of fluorosis. However, the number of children affected in absolute terms with mild, moderate, and severe fluorisis adds up to around 15,327 children age 12-15 living in the 700,000 person Everett service area, 3,238 with mild fluorosis, and 1,356 with moderate to severe fluorosis. See

Mild and moderate fluorosis are ugly and embarrassing. It is not acceptable to deface the teeth of this many children just to achieve an alleged 10% to 30% reduction in dental decay. This is especially true because fluoride can be administered topically.

Snohomish Health District:  Very mild and mild fluorosis is not ugly or embarrassing. Tooth decay is expensive to treat and leads to a lifetime of retreatment and escalating cost. Left untreated (or even during treatment itself), caries can lead to systemic infection and even death, all of which can be prevented.

Giving 40.7% of our children fluorosis in return for a 10% to 30% or even a non-existent reduction in decay is a bad bargain.

Most dentists believe fluoride is effective topically, via toothpaste and concentrated gels, but many dentists have concluded that it does not work systemically and therefore should not be forced on everyone through our drinking water. Please address the topical versus systemic issue in your response.

Snohomish Health District:  All fluorides work systemically and topically. When fluoride is available at low levels in drinking water, it is absorbed in the blood stream, circulates in the saliva, and becomes available at the enamel level of the crevicular fluid. As the teeth go through the daily demineralization/remineralization cycles, the fluoride is available at a constant level to remineralize tooth enamel that results in stronger fluoride structure. During tooth development years, fluoride is also incorporated into the developing enamel of the permanent teeth as fluorapetite, which is also resistant to tooth decay.

Topical fluorides, such as fluoride toothpastes and supplements are related to higher rates of fluorosis.  Moreover, fluoride treatments, limited to the application to teeth, are the most expensive of fluoride methods, wear off fairly quickly, and must be repeated regularly to maintain the benefits.

The question is not that fluoride is forced on everyone, but should the majority of Snohomish County residents be forced to pay the significant cost increase for alternatives. Other sources of drinking water are available for those that believe differently (e.g., home filtration or bottled water).

You make the standard pro-fluoridationist argument that fluoridation “saves $38 for every dollar invested”, a reference to Griffin’s Economic Evaluation of Fluoridation, which comes to such conclusions only by starting with the false assumptions that fluoridation (1) causes no collateral damage anyone drinking fluoridated water and (2) that there is a savings of $18 per hour in wages not lost by missing work to visit a dentist. However, Fluoride does cause harm, and the calculation presumes that even children and the unemployed save $18 per hour by not missing work. In her Tale of Two Studies, Carol Clinch shows this to be a contrived estimate based on incorrect assumptions. See also

Snohomish Health District:   Fluoride at the level of .7ppm to 1.2ppm does not cause harm. Fluoride at levels of 4 ppm or greater are not allowed in  drinking water in the United States.

Economists may disagree on the assumptions and ultimately on the economic benefits.  However, the health benefits are clear.  Given the low costs of fluoridation, the health benefits are cost-effective.

You assert that “more than 3,000 scientific studies have proven that appropriate fluoridation strengthens teeth …”, however, you do not say where these studies can be reviewed. In your response, please point out where I may access these 3,000 studies.

Snohomish Health District:  You can find listings of the studies included by the Reviews conducted by CDC, EPA and ADA (and others) and they are available (for free or by purchase) through the U.S. Library of Congress (PubMed-Medline) listings of scientific peer-reviewed literature.

Until I receive your response, I will rely on the studies which the CDC presents as most  important, the cases cited in CDC’s 2011 proposal to reduce fluoride added to water to .7 ppm. See:  If you read these studies, you will note that they discuss only tooth decay rates and dental fluorosis and that they consistently ignore the many harmful side effects of fluoridation – as do you.

Snohomish Health District:  The study you cite states that HHS recommends an optimal fluoride concentration of 0.7 mg/L for community water systems based on the following information:

• Community water fluoridation is the most cost-effective method of delivering fluoride for the prevention of tooth decay;

• In addition to drinking water, other sources of fluoride exposure have contributed to the prevention of dental caries and an increase in dental fluorosis prevalence;

• Significant caries preventive benefits can be achieved and risk of fluorosis reduced at 0.7 mg/L, the lowest concentration in the range of the U.S. Public Health Service recommendation.

• Recent data do not show a convincing relationship between fluid intake and ambient air temperature. Thus, there is no need for different recommendations for water fluoride concentrations in different temperature zones.

In our March 24 article we pointed out that the fluoridation materials themselves are illegal. That is because Washington law, WAC 246-290-220(3), says: “Any treatment chemicals … added to water intended for potable use must comply with ANSI/NSF Standard 60.” The NSF web site and the NSF Standard for Drinking Water Additives, say: “Standard 60 … requires a toxicology review to determine that the product is safe at its maximum use level and … to determine if any contaminant concentrations have the potential to cause adverse human health effects.” However, NSF officials have admitted under oath that toxicological studies are not being done. Thus, fluoridation materials do not “comply” with NSF 60, and fluoridating the water with them is illegal. Would you please address this issue in your response?

Snohomish Health District:  Everett Water District fluorosilicic acid compound meets the ANSI/NSF Standard required to create safe drinking water.

The consumption of undiluted, concentrated fluoride materials would be toxic.

The statement that fluoridation is illegal suggests a failure to understand the process by which NSF standards are set. The toxicology work needed to establish the standard was done by the EPA and others and was obtained by NSF as part of the standard development process. This information is available online. Toxicology studies are only required if no existing studies and data are available for the contaminant in question. This was not the case for fluoride, lead or arsenic, all of which were considered in the standard setting process and for which robust studies were available from the EPA.

In our March 24 article in the Herald, we suggested that hearings should be held regarding the health and effectiveness of fluoridation. Do you support or oppose hearings in which representatives from both camps may present their case on this important issue?

Snohomish Health District:  We support community water fluoridation as a safe, effective, low cost and equitable means to reduce tooth decay.  We defer to our elected officials to determine the need for hearings.  If hearings are held, we will certainly participate.

We pointed out that fluoridation materials are costing Everett around $300,000 per year. Everett buys a 5,200 gallon tanker load of fluorosilicic acid every three weeks and pours it into our water at the rate of 250 gallons per day. Each 5,200 gallon tanker load costs around $16,500. In your response would you please explain how you can justify such an expenditure, given the harsh cuts Everett is being forced to make in important services.

Snohomish Health District:  The $300,000 treatment cost of fluoridation equals approximately 54 cents per person per year for the 560,000 persons benefiting from fluoride in drinking water.  Elimination of fluoridation would save the average Snohomish County resident less than a penny a gallon.

In your April 5 article you directed readers to the I Like My Teeth web site, This web site features endorsements and smiling children but no scientific studies or other information which addresses the safety of effectiveness of fluoridation. In your response, please point out more substantial web sites.

Snohomish Health District:  The ADA, EPA and especially the CDC have valuable sources of information.

I would also ask whether you wrote your April 5 article with the approval of the Snohomish Health District and whether your article represents the official position of the District. Please address these questions in your response.

Snohomish Health District:  Recognizing that “fluoridation is the single most effective public health measure to prevent tooth decay,” the Snohomish Health District’s Board of Health formally endorsed fluoridation by unanimous vote of Resolution Number 89-27 at its May 9, 1989 meeting.