The Fluoride Debate







Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8

Question 9
Question 10
Question 11
Question 12

Question 13
Question 14

Question 15
Question 16
Question 17

Question 18
Question 19
Question 20
Question 21
Question 22
Question 23
Question 24
Question 25
Question 26
Question 27
Question 28
Question 29
Question 30
Question 31
Question 32
Question 33


Question 34
Question 35
Question 36
Question 37
Question 38
Question 39
Question 40

Question 41
Question 42
Question 43



Question 18.
Will the ingestion of optimally fluoridated water over a lifetime adversely affect bone health?

ADA's Fluoridation Facts Short Answer
According to generally accepted scientific knowledge, the ingestion of optimally fluoridated water does not have an adverse effect on bone health.116-120, 122

ADA's Fluoridation Facts Long Answer
The weight of scientific evidence does not supply an adequate basis for altering public health policy regarding fluoridation because of bone health concerns. A number of investigations have studied the effects on bone structure of individuals residing in communities with optimal and higher than optimal concentrations of fluoride in the drinking water. These studies have focused on whether there exists a possible link between fluoride and bone fractures. In addition, the role of fluoride in strengthening bone and preventing fractures has been investigated. Lastly, the possible association between fluoride and bone cancer has been studied.

Water Fluoridation Has No Significant Impact on Bone Mineral Density In 1991, a workshop, co-sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute of Dental Research, addressed the potential relationship of hip fracture and bone health in humans to fluoride exposure from drinking water. Meeting at the National Institutes of Health, researchers examined historic and contemporary research on fluoride exposure and bone health. At that time, participants concluded there was no basis for altering current public health policy regarding current guidelines for levels of fluoride in drinking water. Recommendations were made regarding additional research in several areas.116

In 1993, two studies were published demonstrating that exposure to fluoridated water does not contribute to an increased risk for hip fractures. One study looked at the risk of hip fractures in residents of two similar communities in Alberta, Canada.117 In this study, researchers compared a city with fluoridated drinking water optimally adjusted to 1 ppm to a city whose residents drank water containing naturally occurring fluoride at a concentration of only 0.3 ppm. No significant difference was observed in the overall hip fracture hospitalization rates for residents of both cities. "These findings suggest that fluoridation of drinking water has no impact, neither beneficial nor deleterious, on the risk of hip fracture."117

The second study examined the incidence of hip fracture rates before and after water fluoridation in Rochester, Minnesota.118 Researchers compared the hip fracture rates of men and women aged 50 and older from 1950 to 1959 (before the city's water supply was fluoridated in 1960) with the ten-year period after fluoridation. Their findings showed that hip fracture rates had decreased, and that the decrease began before fluoridation was introduced, and then continued. These data demonstrate no increase in the risk of hip fracture associated with fluoridation of the public water supply in Rochester, Minnesota.

Prior to 1993, the lead author of the 1993 Minnesota study had authored two earlier fluoridation-hip fracture studies showing a very slight increase in fracture risk in fluoridated communities.123, 124 The 1990 study examined the regional variation within the United States in the incidence of hip fracture in women aged 65 and over. The analysis of hip fracture incidence data at the county level demonstrated a strong pattern of regional variation among women, with a band of increased risk in the southern United States. The results of the analysis suggested that soft and fluoridated water, poverty, reduced sunlight exposure and rural location all increased the risk of hip fracture. In the summary, the author stated that no presently recognized factor or factors adequately explained the geographic variation.123 The second study, published in 1992, was a national ecologic study of the association between water fluoridation and hip fractures in women and men aged 65 and over. (In ecological studies, groups of people are studied instead of individuals.) The study reported a small positive ecologic association between fluoridation of public water supplies and the incidence of hip fracture among the aged. The authors stated that this observation did not yet provide a firm platform for health policy, but stated further research was warranted.124

In 1997, the lead author of the 1993 Minnesota study and the two studies noted in the preceding paragraph, issued a statement which concluded: "To my knowledge, no study has demonstrated that the introduction of fluoride to the public water supplies has increased the risk of (hip) fracture, let alone a doubling of the risk."125

An ecological study conducted in eastern Germany compared the incidence of hip fractures for adults living in Chemnitz (optimally fluoridated) and Halle (fluoride-deficient). The results suggested the consumption of optimally fluoridated water reduced the incidence of hip fractures in elderly individuals, especially women over 84 years of age.122

According to generally accepted scientific knowledge, the ingestion of optimally fluoridated water does not have an adverse effect on bone health.116-120, 122 Exposure to fluoride at levels considered optimal for the prevention of dental decay appears to have no significant impact on bone mineral density.126

Fluoride's Role in Strengthening Bone
The second major area of study regarding fluoride and bone health is the role of fluoride in strengthening bone and preventing fractures. For nearly 30 years, fluoride, primarily in the form of slow-release sodium fluoride, has been used as an experimental therapy to treat osteoporosis, a condition characterized by a reduction in the amount of bone mass. Individuals with osteoporosis may suffer bone fractures as a result of what would be considered minimal trauma. Sodium fluoride therapy has been used in individuals in an effort to reduce further bone loss, or add to existing bone mass and prevent further fractures.116 The results of the clinical trials have been mixed as noted in the two following studies. The need for further research is indicated.

In 1995, the final report of a four year study was published demonstrating the ability of fluoride to aid in an increase in bone mass.127 The study examined females with post-menopausal osteoporosis who took slow-release sodium fluoride (25 mg twice a day) and calcium citrate (400 mg twice a day) for four years in repeated 14 month cycles (12 months receiving treatment and 2 months not receiving treatment). The study concluded this treatment was safe and effective in reducing the number of new spinal fractures and adding new bone mass to the spine.127

In a six-year clinical trial in 50 postmenopausal women, treatment with sodium fluoride and supplemental calcium was not effective in the treatment of osteoporosis.128

No Association Between Fluoride and Bone Cancer
Lastly, the possible association between fluoride and bone cancer has been studied. In the early 1990s, two studies were conducted to evaluate the carcinogenicity of sodium fluoride in laboratory animals. The first study was conducted by the National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences.129 The second study was sponsored by the Proctor and Gamble Company.130 In both studies, higher than optimal concentrations of sodium fluoride were consumed by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight individual sex/species groups became available for analysis. Seven of these groups showed no significant evidence of malignant tumor formation. One group, male rats from the NTP study, showed "equivocal" evidence of carcinogenicity, which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas (malignant tumors of the bone) — that may be chemically related. The Ad Hoc Subcommittee on Fluoride of the U.S. Public Health Service combined the results of the two studies and stated: "Taken together, the two animal studies available at this time fail to establish an association between fluoride and cancer."54

Additional discussion on this topic may be found in Question 22.

Repeat of Question 18.
Will the ingestion of optimally fluoridated water over a lifetime adversely affect bone health?

Opposition's Response

Yes. The Journal of American Medical Association (JAMA) links hip fractures and fluoridation in four different issues since 1990. Studies published in the Journal in August 1992, specifically states that their objective was to "test the effect of water fluoridated to 1 ppm on the incidence of hip fractures." Their study demonstrated a link between hip fractures in the elderly and water fluoridated at 1 ppm, the so-called 'optimal dose.' "Hip fractures, (according to the report) are the second most common cause for admission (of elderly) to nursing homes accounting for approximately 60,000 admissions per year."

"Each year in the U.S. about 250,000 people over age 65 suffer hip fractures and 25% die within three months." (Chemical & Engineering News, July 30, 1990.)

" ... we recently reported the ecological association of discharge rates for hip fracture and water fluoride levels in 39 county districts in England. ... there appears to be a positive association between fluoride levels of county water supplies and fracture discharge rates. This ecologic association is consistent with a recently published study and others in progress." (Journal of the American Medical Association (JAMA) July 24, 1991.)

"We found a ... significant increase in the risk of hip fracture in both men and women exposed to artificial fluoridation at 1 ppm, suggesting that low levels of fluoride may increase the risk of hip fracture in the elderly." (Journal of the American Medical Association (JAMA) Aug. 12, 1992.)

"Thus, adjusting for major individual risk factors, this study suggests a deleterious effect of fluorine in drinking water on the risk of hip fractures, even for moderate concentrations of fluorine, and no effect on other kinds of fractures." (See 18-1: "Fluoride and Hip Fracture," JAMA, Vol. 273, No. 10, March 8, 1995, and "Hip Fracture Rates are Much Higher in People Residing in Fluoridated Communities" - chart).

"More recently, attention has shifted to lower dosages of fluoride, such as found in fluoridated water. There are now at least eight studies that showed an increase of hip fracture incidence in fluoridated compared to unfluoridated communities. They are summarized here." (See 18-2: "Brief Account of the Fluoridation/Hip Fracture Problem," by John R. Lee, M. D., June 30, 1995, for details on these eight studies).

" ... many studies (demonstrate) adverse effects to bone caused by fluoride at levels to which the majority of the U.S. population are exposed. ... the (Environmental Protection) Agency needs to take immediate action to prevent further injury from occurring to our aging population that result in fluoride induced hip fractures." (William Marcus, Ph.D., EPA scientist, statement to EPA Office of Drinking Water, July 29, 1991.)

"Based on data from the National Academy of Sciences, current levels of fluoride exposure in drinking water may cause arthritis in a substantial portion of the population long before they reach old age." (Robert J. Carton, Ph.D., former EPA scientist.)

"A review of recent scientific literature reveals a consistent pattern of evidence-hip fractures, skeletal fluorosis, the effect of fluoride on bone structure, fluoride levels in bones and osteosarcomas-pointing to the existence of causal mechanisms by which fluoride damages bones. ... and that there is negligible benefit from ingesting fluoride ..." (See 18-3: "New Evidence on Fluoridation," by Mark Diesendorf, Institute for Sustainable Futures, University of Technology, Sydney; John Colquhoun, Department of Education, University of Auckland, Auckland; Bruce J. Spittle, Department of Psychological Medicine, University of Otago Medical School, Dunedin; Douglas N. Everingham, Former Federal Minister for Health, Canberra; and Frederic w. Clutterbuck, Medical Practitioner, Queensland).

Women in high fluoride communities have much earlier and much worse osteoporosis than in low fluoride communities. There was "no protective effect (on bone mass or fracture) with higher fluoride" but more fractures were reported. (American Journal of Nutrition, 44:889-98, 1986.)

Dr. Saul Genuth, director of the radioimmunoassay laboratory at Cleveland's Mt. Sinai Hospital, said he "regretfully joined in the endocrinologic and metabolic drugs advisory committee's unanimous opinion that fluoride has yet to prove its worth in the treatment of postmenopausal osteoporosis." (See 18-4: "FDA Committee Spurns Fluoride," in Medical World News, Nov. 13, 1989).

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