EffectsofWaterFluoridationintheUnitedStates

PositiveandNegativeImpactofWaterFluoridationPolicy
March18th,2013
MichaelMannina,MargaretMorgan,NeilMurphy,BrianTrinh

Abstract
This report examines the positive and negative impacts of the United States policy to add fluoride
to public water supplies. We examined the history of fluoridation beginning with its initial use in
Colorado Springs, Colorado in 1944. We included a brief overview defining fluoride and the
specific water additives used in US public water systems. We researched public health sources
such as the Environmental Protection Agency (EPA) and the Center for Disease Control (CDC) to
understand regulations, safe levels and toxic levels of exposure. We examined Asia and Europes
policy towards fluoride additives. We consulted existing peer-reviewed studies from scholarly
databases on medicine and public health to investigate correlations between water fluoridation and
adverse health effects such as fluorosis, cancer, birth defects, and osteoporosis. We examined
correlations between water fluoridation and adverse environmental effects. We conclude that there
is a sufficient correlation of water fluoridation with adverse health and environmental effects to
warrant cessation of the policy and further research into the safety of water fluoridation policy in
the United States.

Introduction
Approximately 67% of the United States water supply is artificially fluoridated.1 Fluoride has been
added to the water supply since 1944 and has been hailed as a modern miracle reducing dental
cavities by an estimated 60%.2 With an annual cost of about $1 per person, fluoridation is
estimated to save $38 in dental work for every dollar spent on prevention.
There are the three types of fluoride additives used in US water fluoridation. Fluorosilicate Acid is
the most commonly used additive due to its low cost and ability to be easily stored and shipped.
The acid is a byproduct of the phosphate fertilizer industry and new studies are pointing evidence
at its toxicity at levels previously determined safe by the US EPA.
Current research is establishing links between fluoride and cancer, osteoporosis, and birth defects.
Freshwater levels previously deemed safe by the EPA are being studied as they appear to have a
toxic effect on organisms especially migrating salmon species.
As new findings on fluoride toxicity are released, national and international policies are beginning
to change. Sweden considers it a toxic additive to the body and declined policy to add it to their
public water systems.
We have reviewed existing literature and believe that there is enough evidence to warrant further
research on the issue and raise a red flag on permissible levels released into the environment. We
would like to examine why we add this chemical to public water supplies when we are unsure of
its safety as new evidence points to negative impacts on health and environment.

Research Methods
To evaluate the impact of water fluoridation policy on health, we researched existing literature on
the subject and analyzed existing data from sources such as the CDC website, the US National
Library of Medicine, and the National Institutes of Health. We reviewed the historical reasons
motivating the decision to fluoridate drinking water, the current status of the policy in the United
States, in addition to the claims made by opponents and proponents of the policy.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 1

 We also examined peer-reviewed scientific studies to determine whether they substantiated the
claims made by proponents and opponents of the policy regarding impact to public dental health
and public wellbeing. Specifically, we examined studies that investigated a correlation between
water fluoridation and reduced rates of dental cavities, increased rates of fluorosis, increased rates
of osteosarcoma and other cancers, increased rates of birth defects, and increased rates of
osteoporosis. We also examined studies that investigated the impact of water fluoridation on the
environment, specifically fresh water organisms.

Overview of Water Fluoridation

In this section we provide a brief overview of fluoride including its benefits to dental health, types
of fluoride, the history of fluoridation in the United States, and an overview of the policy debate.

What is Fluoride?
Fluoride is a chemical ion of the element fluorine. Fluorides are released naturally, into the
environment through the weathering of rocks and through atmospheric emissions from volcanoes
and seawater. Fluoride is found in several minerals, such as fluorapatite and fluorite. Fluoride is a
component of most types of soil, with total fluoride concentrations ranging from 20 to 1000 g/g
in areas without natural phosphate or fluoride deposits and up to several thousand micrograms per
gram in mineral soils with deposits of fluoride. Fluoride is also in many foods such as beer, soy
and green tea. 3

How Does Fluoride Help Teeth?

Fluoride protects teeth in three ways:
Reduces Demineralization - fluoride offers protection from demineralization from acids
when applied topically in toothpastes or mouthwash. When bacteria in the mouth combine
with sugars, they produce acid. This acid can erode tooth enamel and damage teeth.
Fluoride can protect teeth from demineralization caused by acids.
Remineralizes Damaged Bone - fluoride helps remineralize bone that has been damaged
by acids and helps harden bone and enamel. Dentists apply fluoride topically to teeth to
remineralize damage caused by acid.
Strengthens Developing Bone - with supplemental ingestion in adolescence, fluoride helps
teeth by altering the structure of the developing enamel so that it is more resistant to acid
attack. These structural changes occur as a child's enamel develops before he/she is seven
years old.4

Types of Fluoride Additives

Community water systems in the United States use one of three additives for water fluoridation:
Sodium fluoride (NaF) is a colorless crystalline salt used in fluoridation of water,
treatment of tooth decay. Sodium fluoride is also used industrially as an insecticide and a
disinfectant.
Sodium fluorosilicate (Na2SiF6 ) is used in water fluoridation. Na2SiF6 is the sodium salt
of fluorosilicic acid. It is a powder or very fine crystal that is easier to ship than fluorosilicic
acid making it less expensive and more commonly used than sodium fluoride.
Fluorosilicic acid is a colorless fuming liquid with a penetrating pungent odor, corrosive to
metals and tissue, both the fumes and very short contact with the liquid can cause severe
and painful burns. Used in water fluoridation, in hardening cement and ceramics, as a wood
preservative Haynes, William M., ed.5

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 History of Water Fluoridation in United States
The policy of water fluoridation in the United States is due, in part, to the research of a man by the
name of Dr. Frederik McKay. McKay moved to Colorado Springs from the East Coast in 1901.
McKay observed that many Colorado Springs natives had brown stains on their teeth. No literature
was written on the disorder, and local residents believed that the problem was caused by eating too
much pork. McKay initiated research into the disorder. In 1909, renowned dental researched Dr.
Green Vardiman Black joined Dr. McKay in his endeavor to find the cause of the mysterious
Colorado Brown Stain, as the disorder was named.
The water causation theory behind the dental disorder gained more ground in 1923, when McKay
went to Oakley, Idaho to meet with residents who too noticed stains on the teeth of their children.
McKay learned of a new water pipeline constructed for the town, and advised town leaders to
abandon the pipeline and use another spring for water. Within a few years the children of Oakley
began sprouting secondary teeth without any mottling. This gave credence to McKays initial
hypothesis that the stains were caused by the water supply but he still had no idea about what in
the water could be causing the problem.
The research led to a January 1931 letter written to Dr. McKay from the Aluminum Company of
America chemist H.V. Churchill. In the letter, Churchill asked McKay to collect water samples
from all the towns where the peculiar dental trouble has been experienced. Within months,
McKay had the answer he had been looking for high levels of water-borne fluoride caused the
discoloration of tooth enamel. 6

What Studies Were Done on Water Fluoridation?

A study in Bartlett, Texas, reported on potential health effects in people with long-term residence
of at least 15 years who consumed public water with a natural fluoride level of 8 ppm. These
findings were compared with long-term residents of nearby Cameron where fluoride level was 0.4
ppm. This study was performed in 1943 and 1953, and included a medical history, physical and
dental examinations, x-rays, and blood and urine analyses. The authors concluded: no clinically
significant physiological or functional effects resulted from prolonged ingestion of water
containing excessive fluoride except for dental fluorosis. 7
The main study came in 1945, in the town of Grand Rapids, Michigan. Grand Rapids became the
first city in the world to fluoridate its drinking water. The rate of tooth decay amongst the 30,000
schoolchildren was monitored over the studys 15 years. During this study, the city of Muskegon
acted as a control group. The study found that cavity rates dropped more than 60 percent among
Grand Rapids children born after fluoride was added to the water supply. After seeing the effects
in Grand Rapids, Muskegon began fluoridation in 1951. This meant that tooth decay was a
controllable disease for most people 6

Who is Fluoridation Policy Targeting?

As part of Healthy People 2010, a public health initiative by the U.S. Department of Health and
Human Services, the goal was set to increase the proportion of the American population served by
community water systems with optimally fluoridated water to 75% by the year 2010. 8
In California, in 1995, Assembly Bill 733 required water systems with 10,000 or more service
connections to fluoridate their water supply. According to the CDC, tooth decay affects 84% of
U.S. children, 96% of U.S. adults and 99.5% of adults 65 years and older. The CDC has set an
optimal range for fluoridation, between 0.7 and 1.2 ppm. The EPA has set an acceptable upper
limit of 4 ppm. Staying below a level of 2 ppm is the threshold where cosmetic staining in
developing teeth can be avoided. The state of California maintains a standard of 2 ppm, according
to the Contra Costa Water District website. 8

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 Government Policy
The CDC has recognized water fluoridation as one of ten great public health achievements of the
20th century. The CDC maintains that their job is to promote public health practices, and not their
responsibility to determine what levels of fluoride in water are safe, yet our understanding about
the safety of fluoridation is guided by federal regulations, comprehensive reviews by expert
panels, and individual studies (cdc.gov). Federal, state, and local municipalities define and
determine water safety standards. 10
Under the Safe Drinking Water Act, passed in 1974, the EPA set standards and procedures to
monitor state and local governments according to those regulations. In 1995, the CDC released a
recommendation and report on guidelines for the engineering aspects related to water fluoridation.
The recommendation includes administration, monitoring, surveillance, reporting, safety
procedures, and technical requirements. Each state has one state fluoridation administrator and one
state fluoridation specialist. Each month state administrator and specialists report the findings of
tests on each of the water systems in their respective states.
The American Dental Association (ADA) and the US Public Health Service (PHS) also supports
water fluoridation without reservations.13 The ADA policies endorse community water
fluoridation as a safe, beneficial and cost-effective public health measure for preventing dental
caries (ADA, 1997). They also encourage individual dentists and related professional
associations to take up leadership in support of community water fluoridation in addition to using
resources to collaborate with state and local agencies. The ADA public statements regarding safety
of water fluoridation are similar to those made by the CDC.

Implementation
Fluoridation of water supplies are accomplished by adding one of three compounds to drinking
water: Hydrofluosilicic acid (H2SiF6; also known as hexafluorosilicic, hexafluosilicic, silicofluoric,
or fluosilicic acid), Sodium silicofluoride (Na2SiF6), and Sodium fluoride (NaF). These compounds
were chosen for their solubility, safety, availability, and low cost. Currently, the optimal level for
water fluoridation is between 0.7 - 1.2 parts per million, depending on mean daily air temperature
for a geographic area.15 The PHS advises to stay within the recommended range to avoid
overexposure. They encourage educating the public about using small amounts of toothpaste or
mouthwash and teach children not to swallow. 16

Cost Savings
In 1999, the US annual cost of water fluoridation was on average of $0.72, ranging $0.17 - $7.62,
per person per year. 10 Factors that would influence the cost of fluoridating the water supply
include size of the community, amount and frequency of injections, type of equipment used, and
expertise of the personnel. According to the CDC, researchers from CDC and Terry College of
Business, University of Georgia, found that under typical conditions, the annual per-person cost
savings in fluoridated communities ranged from $16 in very small communities (<5,000) to nearly
$19 for larger communities (>20,000). 17
The analysis takes into account the costs of installing and maintaining necessary equipment and
operating water plants, the expected effectiveness of fluoridation, estimates of expected cavities in
non-fluoridated communities, treatment of cavities, and time lost visiting the dentist for
treatment. Even though the study used national survey statistics as part of the calculations, there
are generalizations about specific regions that may or may not be affected by water fluoridation.
Furthermore, the speculations about cavities in irregular communities do not give an entirely
accurate analysis of the costs. This is the only study that the CDC accredits to the cost savings of
water fluoridation. 18

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 Water Fluoridation Debate
In the controversy to administer water fluoridation to the general public water supply, countries
worldwide have differing stances and opinions regarding the matter. Opposing organizations
include the Sierra Club, International Chiropractic Association, and the League of United Latin
American Citizens. Opponents, who are against putting fluoride into their water, consider water
fluoridation an outdated form of mass medication. The water itself isnt treated such as other
chemicals like chlorine that purify any bacteria and toxins. The FDA labels fluoride as a drug, not
a nutrient. By adding fluoride to the water, public citizens would not be given a choice. The only
alternatives are to purchase purified bottled water and/or install private filtering system for
individual living areas. Most of Europe decline to add fluoride to their water for that reason.
Fluoridation is also considered outdated because fluoride alternatives are available, including
toothpaste or fluoridated salt, without entering the body. Opponents also consider fluoridation
unsafe because of adverse health effects, such fluorosis or cancer, which will be discussed later.
Supporters believe water fluoridation to breakthrough in public health. Supporting organizations
include World Health Organization and the American Dental Association. These supporters claim
water fluoridation improves dental health and reduces demineralization of teeth. They believe that
fluoridation helps improve the enamel of the teeth and reduce cavities.

International Positions on Water Fluoridation

The controversy over water fluoridation does not only exist within the US, and international
communities differ in their positions on water fluoridation. We contrast and compare United
States policy to what other nations across the globe have decided in fluoridating water. We
decided to look into parts of Asia, Europe, and Australia. Each continent reflected various
positions regarding water fluoridation. There are countries that blatantly opposed fluoridation
while others have conducted trials and attempted without success.
The Asiatic continent has many developed countries that present varying sides to the debate. Hong
Kong was one of the first countries to introduce water fluoridation, and continues to support it.
Currently, Hong Kong fluoridates 100% of their water; amounts ranging 0.2-0.7 mg/L.19 Along
with a long list of other chemicals added to their water supply, fluoride is carefully added to meet
World Health Organization (WHO) standards. Japan does not fluoridate their public water supply,
but Chinas situation provides an alternative insight. China showed increasing amounts of dental
cavities prior to fluoridation, which led to oral diseases according to national health surveys. In
2006, the World Health Organization discovered certain regions of China are unique with endemic
fluorosis, meaning populations in China get their fluoride from non-water sources, while other
populations receive very little fluoride.20 India has similar situations; for example, small village
populations in Assam experienced severe fluorosis from drinking naturally occurring fluoridated
water with levels as high as 5-23 mg/L.22 China and India are special exceptions where mass water
fluoridation does not benefit whole populations, especially areas that are not developed with
publicly treated water.
The majority of European countries declined to add fluoride to their public water systems.
Developed European countries that have rejected or banned fluoridated water include Austria,
Belgium, Finland, Germany, Sweden and Norway, due to health, legal, and ethical concerns.
Germany conducted a study in 1997 of nearly 300,000 subjects, ages 6-15, of two industrial
towns, one with fluoridated water and one without.22, 23 The data on the caries trend decreased for
both cities from 1987-1995. Germany stopped fluoridation prior to the study. The study reaffirms
Germanys stance on water fluoridation as unnecessary due to growing oral health care and
alternative access to fluoride products. Europe highlights an international trend of significant
reduced cavities and tooth decay within the past few decades.

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 This chart illustrates trends in tooth decay within developed countries:

While some countries such as Japan rejected water fluoridation outright, other countries
considered trials and undertook evaluations. In 1962, Sweden passed the Drinking Water
Fluoridation Act, only to have the act repealed in 1971. The Netherlands, East Germany, and
Finland also implemented water fluoridation and later removed it through legislature. Germany,
France, and Austria offer fluoridated salt alternatives for those who choose to buy them; this
avoids the need to add chemicals to the public water system. Spain and the United Kingdom
fluoridate only 10% of their water, while the Republic of Ireland is only country in Europe that
fluoridates over 70% of their water. Other than Singapore, Hong Kong and Ireland, only Canada,
Chile, and Australia fluoridate over 70% of their public water systems. 16,17,22,23

Health Effects of Water Fluoridation

The primary motivation for continuing water fluoridation policy in the United States is that it is
purported to significantly improve public dental health. We examined evidence to determine the
extent to which this is true, as well as whether reductions in cavity rates were directly attributable
to water fluoridation policy.
One of the criticisms of water fluoridation policy is that fluoride in drinking water has not been
demonstrated to be safe for human consumption. We examined whether existing scientific
evidence supports a correlation between adverse health effects and exposure to fluoride in
drinking water. Specifically, we looked at current research on correlations between water
fluoridation and fluorosis, cancer, birth defects, and osteoporosis. We chose to focus on these
conditions because research on their relationship to water fluoridation has been conducted in the
United States, and they represent the health conditions with the most robust research performed to
date.

Water Fluoridation and Improved Dental Health

We investigated the main byproducts, and possible correlations water fluoridation has to many
well-known causes. Fluorosis, although not a disease, is a byproduct of fluoridation affecting 1
out of 4 Americans, particularly affecting those in the first 8-9 years of life. The main argument

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 in favor of water fluoridation is the reduction of cavities and tooth decay. In the US, early studies
reported cavity reduction attributed to fluoridation ranged from 50% to 70%, but by the mid-1980s
the level of dental cavities of children who lived in communities with fluoridated water were only
18% lower than among those living in communities without fluoridated water (bt18). A review of
studies on the effectiveness of water fluoridation conducted in the United States in 1979-1989
found that caries reduction was 8%-37% among adolescents nationwide (bt19). No studies in the
US were found comparing fluoridated and non-fluoridated communities. These studies conducted
in the US focused on cavity reduction without reviewing trends in other countries.
European countries noticed an overall decline in cavities and tooth decay. These countries
conducted studies with a narrower focus by comparing cities of two locations, one with
fluoridation and one without. In a particular study by Kunzel, Eastern Germany revealed
significant declines in cavities and tooth decay after the cessation of fluoridation since the
reunification of Germany. Surveys of two German cities, Spremburg and Zittau, were conducted
prior to the study confirming this decline. The study focused on boy and girls of ages 8-16, who
were examined for the past 20 years using standardized methodological procedures.
Cavities were reduced by 48% on average due to water fluoridation. Following the years of 1993-
96, In Spremberg, cavities fell 38% and in Zittau cavities fell 20% (bt20). Though there are studies
that reveal positive effects of water fluoridation on the reduction of cavities, alternative studies
reveal reduction of cavities in non-fluoridated areas. The reduction of cavities can be attributed to
wider public knowledge of oral health care, such as proper brushing using fluoride toothpaste and
gels, rather than relying water fluoridation.

Photos of the varying degrees of fluorosis from mild to severe.

Dental fluorosis is a white, and in more severe cases brown, developmental defect of dental
enamel. Fluorosis is caused by overexposure to fluoride during first 8-9 years of life, and affects 1
out of 4 Americans ages 6 to 49.
Since mid-1980s, fluorosis has increased in children aged 12-15. 28

Water Fluoridation and Correlation With Cancer

To examine the potential correlation between fluoridated water and cancer, we examined existing
research performed in the United States. We looked at 3 studies on cancer in particular: Bassin et
al. (2005), Levy and Leclerc (2012), and Takahasi et al. (2001).

Bassin et al. (2005)

Osteosarcoma is a relatively rare type of cancer that affects bone tissue. In 2005, Elise Bassin
researched the exposure of osteosarcoma patients under the age of 14 to fluoridated water and
compared them to matched controls. Each patient was matched with a person who came from the

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 same demographic and geographic location but who was exposed to fluoride levels well below the
CDC recommendation for the area.
This recommendation depends on local climate factors that affect the rate of water evaporation
such as temperature and elevation, and ranges between 0.7ppm in warmer climates to 1.2ppm in
colder climates. The rate of water evaporation affects the concentration of non-water elements
such as fluoride. The levels of water fluoride exposure were compared between both osteosarcoma
cases and matched controls to determine if exposure was higher for the osteosarcoma group.
Justification
We examined the Bassin study because it was the first to demonstrate a correlation between cancer
and exposure to fluoridated drinking water. The study received a lot of interest and publicity due
to the implications of its findings. Because water fluoridation is so widespread throughout the
United States, the study raised a serious concern about the wellbeing of the public and it inspired a
debate on the possible connection between cancer and fluoridated water.
Methods
The study examined 103 cases of osteosarcoma at 11 hospitals located throughout the United
States, diagnosed between 1989 and 1992. Bassin et al. took a residential history for each case of
osteosarcoma that included the type of drinking water used at each address. Cases were
standardized into three groups by according to exposure as a percentage of local CDC water
fluoride recommendation: <30%, 30-99%, and >99%. Bassin et al. performed conditional logistic
regression to estimate the odds ratio for the association between fluoride exposure and
osteosarcoma, (Bassin, Wypij, Davis & Mittleman, 2006). Osteosarcoma rates in the 30-99% and
>99% groups were then compared to rates in the <30% group.
Findings
The study found that among males, exposure to fluoride at or above the target level was
associated with an increased risk of developing osteosarcoma, and the association was most
apparent between ages 4 and 12 with a peak at 6-8 years of age (Bassin, Wypij, Davis &
Mittleman, 2006). No association was found between fluoride exposure and osteosarcoma rates
among females under 20 years old.
These charts illustrate the data modeled in the study for males and females:

N
o
t
e
.

O
s
t
e
o
s
a
r
c
oma incidence rates by age. Adapted from Cancer Causes Control 17 (p. 424), by E. Bassin et al.,
2006. Adapted without permission.

These charts illustrate the odds ratios of developing osteosarcoma for the 30-99% and 100%+
exposure groups in comparison to the < 30% exposure group. Chart (a) on the left represents male
patients and chart (b) on the right represents female patients. For both charts, the dotted line
represents the 30-99% exposure group and the solid line represents the 100%+ exposure group.
In chart (a), we can see a spike in the odds ratio for developing osteosarcoma for males between
the ages of 4 and 12 who are exposed to 100+% of local limits. The association between

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 osteosarcoma and water fluoride is greatest for males between ages 6-8. Chart (b) illustrates that
the odds ratio for females remains relatively consistent throughout the age ranges studies.
Implications
The Bassin study discusses the implications of the association between fluoride exposure and an
increased risk of osteosarcoma in males, noting that all of their models were remarkably robust in
showing this effect, which coincides with the mid-childhood growth spurt, (Bassin, Wypij, Davis
& Mittleman, 2006). These findings, if accurate, suggest that young males who are growing
should be avoiding exposure to fluoride in drinking water in order to decrease the likelihood of
bone cancer.
Considerations
The study was structured in a way that would avoid confounders or hidden variables. Bassin et
al. accounted for climate differences that could lead to varying levels of water fluoride, and tried
restructuring the data to account for socioeconomic factors that might alter access to fluoridated
drinking water. The same association between osteosarcoma and water fluoride exposure in males
was demonstrated in each variation of the data model.

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 One factor that Bassin et al. do not explain in this study is why the association between
osteosarcoma and fluoridated drinking water is sex-specific. If the association is repeatable in
subsequent studies and proves to be accurate this correlation should be explained. One possible
explanation is that males under 15 may consume more community drinking water than females
under 15, consuming greater concentrations of fluoride. This hypothesis is discussed in more
depth below.
In 2006, Chester Douglass wrote a letter to the editor published in Cancer Causes Control that
urged readers not to over-interpret the results of the study. In it, he notes that two sets of data
have been collected each with their own control groups, that the Bassin study only looked at the
group of osteosarcoma cases diagnosed from 1989-1992, and that a similar study had not been
performed on the second group diagnosed from 1993-2000.

Levy et al. (2012)

In this study, Levy and Leclerc compared CDC statistics on cancer in the United States with the
percentage of each state that received fluoridated drinking water. They intended to investigate the
previous findings of Bassin et al.
Justification
We include this study because it was a direct response to the Bassin study. Levy and Leclerc
intended to explore the hypothesis that the percentage of the population on public water systems
receiving fluoridated water correlates with sex, age, and state-specific rates of osteosarcoma
incidence in continental U.S. children and adolescents; that young males are more at risk to
osteosarcoma than females, (Levy & Leclerc 2012). The purpose of the study was to use a
different research method to investigate the purported association between water fluoride and
increased osteosarcoma risk for children and adolescents, and to see if the association could be
substantiated.
Methods
Levy and Leclerc identified osteosarcoma incidence rates occurring in the continental U.S.
between 1999 and 2006, and categorized them according to age group and sex. They then
categorized each state by what percentage of the population was receiving community water
fluoridation (CWF). States in which 30% or less of the population received CWF were designated
low CWF states, and states in which 85% or more of the population received CWF were
designated high CWF states. Hawaii and Utah were excluded as outliers since less than 10% of the
populations in those states receive CWF.
Levy and Leclerc then performed a complementary analysis of data from the National Cancer
Institute to test the hypothesis that young males are more at risk to osteosarcoma than females,
(Levy & Leclerc 2012). They examined data from 1973 to 2007 and calculated osteosarcoma
incidence rates for males and females in each age group. They compared the incidence rates from
high CWF states to those from low CWF states.
Findings
This study found no statistical differences overall between males and females in the 5-9 and 10-14
age groups. Among cases in the 15-19 age group, males had a higher osteosarcoma incidence rate
overall than females. However, osteosarcoma rates among males and females were not
significantly different in high CWF states compared to low CWF states. In fact, osteosarcoma
rates were found to be nearly identical regardless of the percentage of the state receiving
fluoridated water.

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 This histogram chart shows the association between osteosarcoma incidence and age for both
males and females:

Note. Osteosarcoma incidence rates by age. Adapted from Cancer Epidemiology 36 (p. e86), by M.
Levy et al., 2012. Adapted without permission.

The data clearly show an increased rate of osteosarcoma nationwide for males in the 15-19 age
group. We found it puzzling that the authors conclude that there is no overall increased risk of
osteosarcoma overall for males in any age group studied, but they include nationwide data that
demonstrate an increased incidence rate in males ages 15-19. The chart above appears in their
paper and illustrates the overall osteosarcoma rates in the United States among males and females,
but this contradiction is not explained in the study.
Implications
Levy and Leclercs findings are significant because they do not confirm the association between
water fluoride and osteosarcoma in children and adolescents that was found by Bassin et al. in
cases under the age of 15, with the greatest association for males between the ages of 6 and 8.
We would expect to find osteosarcoma with greater frequency in states where a greater percentage
of the population receives fluoridated drinking water. The fact that osteosarcoma rates were not
any higher in high CWF states than low CWF also seems to count against the argument that water
fluoridation increases cancer risk.
Considerations
The differing findings of Levy and Leclerc could be due to the different methodology they used.
Instead of categorizing individual osteosarcoma cases by exposure to fluoride, Levy and Leclerc
categorize cases by whether the state was high CWF or low CWF. This methodology assumes that
an individuals fluoride exposure within each state is consistent throughout that state, and does not
take into consideration factors such as use of other sources of fluoride like supplements or dental
products.
The authors admit the problem of the ecological fallacy, which is the assumption that what is
true of a population is also true of the individual members of the population. They also consider
the possibility of unequal fluoride intake by males and females and cite two nationwide studies
that show that males generally had higher mean water intakes than females during childhood and
adolescence, (Levy & Leclerc 2012). The authors indicate that these findings skew their own
findings against the hypothesis that fluoride correlates with increased osteosarcoma risk, since
males under 15 consuming more fluoridated water than females of the same age group.

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 We believe that the studies demonstrating water consumption showing increased water fluoride
exposure, coupled with the problem of the ecological fallacy, may in fact lend credibility to the
association found in the Bassin study. If males under 15 are consuming more fluoridated water
than females, it could explain why the association between osteosarcoma and water fluoridation
was more pronounced among males in that age group.

Takahashi et al. (2001)

Takahashi et al. are Japanese research scientists who set out to investigate overall cancer rates in
the United States along the dimensions of location in the human body and exposure to water
fluoridation. They used linear regression analysis which is when you create a scatter plot of data
for one variable, plot a line that bisects the data points so that half are above and half are below,
repeat the procedure for a second variable, and then compare lines. If the lines are similar, a
correlation between the two variables is likely. In this case they compared cancer incidence and
exposure to fluoridated water.
Justification
We include this study because it found an association between water fluoridation in the United
States and cancer overall. While the study investigates data from the United States, it was
conducted by researchers from Japan. We believe this perspective is important to include because
it provides and additional degree of objectivity, as research done outside of the country is less
susceptible to potential political or economic pressure to skew findings.
Methods
Takahashi et al. examined cancer rates at 11 locations across the continental United States for 36
sites in the human body. They compared this against data from the 1985 Fluoridation Census
conducted by the U.S. Public Health Service. These fluoridation data were standardized to levels
defined by the CDC as optimally-fluoridated: between 0.7ppm and 1ppm. They calculated a
fluoridation index (FD) for each location which represented the percentage of the state population
receiving fluoridated water.
Takahashi et al. performed a linear regression analysis on these data to calculate the cancer
incidence ratio (CIR) for each body site at each geographical location. The CIR is a likelihood of
cancer expressed as a linear function of a locations fluoridation index.
Findings
The Takahashi study found a positive correlation between water fluoridation and cancer incidence
in 23 of the 36 sites within the human body. The study found that cancers of the oral cavity,
bones, and multiple myeloma associated with fluoride are in accordance with the higher
magnitude of accumulation of fluoride in these sites, (Takahashi et al. 2001). The greatest
correlation occurred for body sites responsible for elimination of waste and toxic elements. The
authors note that cancers of the colon and rectum, urinary bladder, and gall bladder associated
with the FD are in accordance with the extended presence of fluoride within the colorectal mass,
urine, and bile.
Implications
The findings of this study provide strong support to the position of anti-fluoridation groups. If
water fluoridation correlates positively with different types of cancer throughout the body, then
clearly it is against the interest of public health to continue exposing communities to water
fluoride. Since improving public health is the primary motivation for adding fluoride to
community drinking water and since this study demonstrates a harmful effect of fluoride on public
health, the policy to fluoridate drinking water in the United States should cease immediately until
further research can be performed. While the findings of this study require subsequent studies to
validate or invalidate its conclusions, we were unable to find any discussion or serious response to
the study.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 12

 Considerations
Takahashi et al. point out that while the study covers dates as early as 1973 the earliest cancer data
in their study were published in 1978. They urge that water fluoridation levels in the communities
they studied should be checked for stability during that time frame, as changes in the amount of
water fluoride could contribute a confounder effect and skew the results of the study. They also
indicate that while their research was performed in 2001 a large scale Fluoridation Census has not
been performed since 1985.

Correlation With Birth Defects

Takahashi et al. point out that it should be a great surprise that water fluoridation has been
practiced for about a half century without confirmation of the safety in terms of reproductive
health and genotoxicity. We investigate reproductive health and cumulative genotoxicity in this
section.

Fluoride Suppresses Thyroid Function

Fluoride was once prescribed as a treatment for hyperthyroidism. According to clinical research,
the fluoride dose capable of reducing thyroid function was low just 2 to 5 mg per day over
several months. This dose is well within the range people living in fluoridated communities
receive on a regular basis.
Because fluoride was given as a treatment for hyperthyroidism (overactive thyroid function), the
possibility of hypothyroidism (underactive thyroid function) becoming prevalent is plausible. In
hypothyroidism, the thyroid gland fails to produce sufficient quantities of the hormones
triiodothyronine (T3) and thyroxine (T4). Metabolically active cells need these hormones. Their
absence can have a wide range of effects, including fatigue, muscle/joint pain, depression, weight
gain, menstrual disturbances, impaired fertility, impaired memory and in ability to concentrate.

Fluoride May Lower I.Q.

In July 2012, Harvard researchers published a meta-analysis of 27 studies that have investigated
the relationship between fluoride and human intelligence. A majority of these studies found that
fluoride exposure was associated with reduced IQ in children. They concluded that their results
support the possibility of adverse effects of fluoride exposures on childrens neurodevelopment.
In 2007, scientists from the Neurotoxicology Division of the U.S. Environmental Protection
Agency identified fluoride as having substantial evidence of developmental neurotoxicity. After
reviewing fluoride toxicological data, the U.S. National Research Council, in 2006, said Its
apparent that fluorides have the ability to interfere with the functions of the brain.

Fluoride May Contribute to Mental Disorders

Robertas Bunevicius and Arthur J. Prange Jr. found that alterations in thyroid hormone activity
impair development of the fetal brain as well as function of the adult brain. During development,
thyroid hormore deficiency causes mental retardation and cretinism, which is a severe case of
physical and mental growth due to thyroid hormone deficiency. In their paper, Bunevicius and
Prange also found that different parameters for samples gave conflicting results on the connection
between thyroid disorders and mental symptoms. They point out when someone in the general
population develops these symptoms, thyroid dysfunction may be one of many possible
underlying causes.

Correlation With Osteoporosis

Osteoporosis is a condition where bones become weak and fragile, making them susceptible to
fractures. The National Osteoporosis Foundation estimates that half of all women older than 50
will break a bone because of osteoporosis. To investigate the possible correlation between long-
term exposure to water fluoridation and osteoporosis we examined a 1996 study by Karagas et al.
which was later repeated and confirmed by a second study performed in 2000 by Phipps et al.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 13

 Karagas et al. (1996)
The purpose of this study was to determine whether there was a correlation between exposure to
water fluoride and the occurrences of fractures in the elderly. Karagas et al. looked at bone
fracture rates among people between 65 and 85 years old from 1986 to 1990, and compared these
data to geographical region and fluoridation status.
Justification
Fluoride intake at high doses can cause severe fluorosis that causes bone deformities. We include
this study to investigate whether long-term exposure to fluoride at levels deemed acceptable in
drinking water could cause a cumulative deteriorative effect in women over the age of 65, since
that population is more susceptible to bone deterioration in the form of osteoporosis.
Methods
Karagas et al. used a 5% sample of the white U.S. Medicare population between the ages of 65 to
89 during the period of 1986-1990 to identify frequency of bone fractures for the hip, proximal
humerus, distal forearm, and ankle. These population data were collected by random selection of
the last three digits of the Health Insurance Claim Number of individuals eligible for Medicare
benefits. They excluded individuals over the age of 90 and individuals who were of nonwhite
races as there was insufficient data on those groups for a robust analysis.
They then used Poisson regression to look for an association by both geographical region and
water fluoridation status. Water fluoridation status was determined by data collected by the CDC
Fluoridation Census from 1969 to 1988. Subjects were classified as exposed or non-exposed to
fluoridated drinking water according to their county of residence listed in their Medicare record. A
county was considered fluoridated if at least 66% of its residents received fluoridated water, either
natural or supplemented, with a water fluoride level of 0.7ppm or higher. Karagas et al. then
calculated a fracture incidence rate for each type of bone fracture by dividing the number of
occurrences by the sum of the populations studied.
Findings
The study found no apparent impact of the fluoridation of drinking water on fractures of the hip or
ankle overall, but noted a possible slight association for fractures of the distal forearm and
proximal humerus among men. The table below illustrates this association. Relative risk (RR)
measures the risk of bone fracture for members of the fluoride-exposed group in terms of the risk
of those in the non-exposed group. A relative risk of 1.23 means that an individual who was
exposed to water fluoride is 23% more likely to experience a fracture than an individual who was
not.

Fracture Type RR Fracture Type RR

Men Hip 1.00 Women Hip 1.00
Proximal Humerus 1.23 Proximal Humerus 1.01
Distal Forearm 1.16 Distal Forearm 1.02
Ankle 1.01 Ankle 1.01

Note. Relative risk of bone fracture by exposure to water fluoride. Adapted from Annals of
Epidemiology 6 (p. 211), by M. Karagass et al., 1996. Adapted without permission.

As the table illustrates, men exposed to fluoride were 23% more likely to experience a fracture of
the proximal humerus and 16% more likely to experience a fracture of the distal forearm than men
who were not exposed to fluoride. Women were equally likely to experience bone fractures
independent of their fluoride exposure.
Implications
Overall, this study found no strong correlation between bone fractures and water fluoridation.
However, a 23% increased likelihood of bone fracture associated with exposure to fluoridated
water is statistically significant. We found it interesting to note that this study also found a sex-
specific association with water fluoridation and adverse health effects.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 14

 Considerations
One possible confounder in this study is the generalization of each individuals fluoride exposure
from regional fluoridation. Karagas et al. categorized counties as fluoridated if at least 66% of
residents received fluoridated public water. The findings of this study could be greatly
strengthened if it were repeated with an individual case history of exposure to water fluoride.

Environmental Effects of Water Fluoridation

In this section, we examine the environmental effects of water fluoridation, including whether
fluoride supplementation to public water increases fluoride content in natural freshwater, and
whether fluoride increases lead content to harmful levels.
Environmental concerns have been investigated in literature reviews for the TacomaPierce
County Health Department, Washington (August 2002),and the City of Port Angeles, Washington
(October 2003),and no negative impact of water fluoridation on the environment has been found.
Fluoride is naturally removed from ground water through soil filtration and dilution to statistically
insignificant levels. However, environmental fluoride contamination from aluminum smelting
plants and phosphate fertilizer factories has demonstrated fluorides toxic effect on organisms.

Increased Fluoride Content

The United States EPA and the Province of British Columbia adhere to a permissible level of
1.5 ppm (1.5 mg/L) for fluoride discharged into fresh water. Measurable levels in excess of this
allowance have demonstrated a negative impact on the environment. We examined the following
studies to establish a link between fluoride contamination and a negative impact on the
environment.

Dameker and Dey (1989)

High levels of fluoride were released into the water 1.6km above the John Day Dam on the
Columbia River. In a field study Damaker and Dey demonstrated that high salmon loss (Chinook
and Coho) 1982-1986, was caused by the inhibition of migration by fluoride contamination.
Justification
We examined the Dameker and Dey study because it suggested that concentrations of fluoride
exposure has lethal effects on and inhibit the migration of salmon species (Chinook and Coho)
whose stock are in serious decline. This study shows that fluoride contamination at levels lower
than current EPA standards of 0.2 mg/L deemed to be safe by have toxic effects on this organism.
Methods
The study examined the average daily discharge of fluoride. In 1982 the daily average was 384 kg.
This was associated, at the John Day Dam with a fluoride concentration of 0.5 mg/L and a
migration time of more than 150 hours and a 55% loss in population. In 1983, plant discharge was
reduced to 107kg/day ad migration time reduced to less than 28 hours with an 11% loss. In 1985,
fluoride discharge was reduced to 49 kg/day and was accompanied by a concentration of 0.2
mgF/L and a loss of 5%.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 15

 Findings
The study found that levels of fluoride as low as 0.17mg/L cause migratory inhibition and
reduction population. The table below demonstrates as the levels of fluoride contamination
decreased, migration time decreased and the population yield was greater.
Migration and Population Yield by Fluoride Contamination:

Year Daily Fluoride Contamination Dam Fluoride Levels Hours for Migration

1982 384 kg .5 mg/L 150

1983 107 kg .17 mg/L 28

1985 49 kg .2 mg/L 28

Implications
The study discusses a correlation between water fluoride contamination and a negative impact on
the migration and offspring yield for Chinook and CCCC salmon. Levels as low as 0.17 mg/L
appear to have migratory inhibition effects on the population, which means that the salmon dont
migrate as far when they are exposed to higher fluoride levels. These results demonstrate a need to
reexamine safe levels for fluoride levels in freshwater.
Considerations
Damkaer and Dey confirmed the cause-and-effect relationship by means of a two choice-flume for
fluoride gradient salmon behavior tests. They determined that the critical level of fluoride
contamination was 0.2 mg/L.

Camargo (2002)
The study examines fluorides toxicity on aquatic animals and invertebrates. Fluoride toxicity
appears to be more harmful to organisms living in soft water because the bioavailability of
fluoride ions is reduced with increasing water hardness.
Justification
We included this study because it demonstrated how fluorides toxicity to aquatic invertebrates and
fishes increases with increasing fluoride concentration, exposure time and water temperature.
Methods
The study compared several species of freshwater and marine invertebrates. They were exposed to
increasing levels of fluoride, temperature and water hardness levels. Fluoride levels from the
organisms were then measured for toxicity.
Findings
The toxic action of fluoride on the health of aquatic animals resides in the fact that fluoride ions
act as enzymatic poisons, inhibiting enzyme activity and ultimately interrupting metabolic
processes such as glycolysis and synthesis of proteins. Fluoride toxicity increases with
concentration, exposure time and water temperature. Two species appear to be especially sensitive
to the toxic effects of fluoride. Net spinning caddisfly larvae and upstream migrating salmon
appear to be the most sensitive species and are adversely affected by fluoride concentrations as
low as 0.5 mg/L.
Implications
The study demonstrates fluorides toxicity on organisms at levels previously deemed
safe/acceptable by the US EPA. Safe levels should be reexamined and changed in order to prevent
losses of endangered salmon species and other unknown damage to the ecosystem.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 16

 Considerations
The study examined many variables affecting the toxicity of fluoride contamination. Water
temperature, hardness and level of fluoride were closely monitored in lab experiments. Opponents
claim lab studies are not adequate as natural filtrations systems cannot be adequately simulated.

Increased Lead Concentrations

Higher blood lead levels (BPd) have been reported in children living in communities that receive
fluoridated water. We examined the following studies to demonstrate a link between fluoridated
water and increased lead levels stored in calcium deposits.

Sawan et al. (2010)

This study examined whether the administration of fluorosilic acid could increase BPd and
mineralized tissue lead concentrations in rats exposed to low levels of lead from the beginning of
gestation.
Justification
We included the Sawan study because it showed fluoride exposure combined with lead exposure
consistently increased blood-lead levels (BPb) and lead levels of calcified tissues in animals
exposed to low levels of lead. Low-level environmental exposure to lead has been associated with
sub-clinical deficit in neurocognitive function in young children.
Methods
Sawan conducted a rat study consisting of four groups of rats. The control group, the group
exposed to daily lead levels 30 mg/L, the group exposed daily to 100 mg/L fluorosilic acid and a
final group exposed to lead 30 mg/L and 100 mg/L fluoride. Animals were housed from
conception to 81 days of age. The collected samples of blood lead levels as well as bone samples
from the femurs and upper and lower incisors.
Findings
This study shows that co-exposure to fluoride and lead from the beginning of gestation
consistently increases the concentrations of lead in whole blood and in calcified tissues of 81 day
lab rats.
Implications
The implications of this study show a cause for concern. When fluoride exposure overlaps with
lead exposure there is an increased rate of lead absorption in bone and blood tissues. Children
living in old housing with lead pipes are extremely susceptible to the risk of lead exposure and
should limit fluoride consumption.
Considerations
This study only examined fluoride exposure to fluorosilic acid. Other fluoridation methods were
not examined and increases in lead concentrations may differ for different types of fluoride
additives.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 17

Conclusions
The policy to fluoridate public drinking water in the United States is a complicated issue that
affects nearly 67% of the population. In the areas we researched we have identified ways in which
the policy has been both harmful and helpful.

Background
Water fluoridation has been used to reduce US cavity rates since 1944. It protects teeth from
demineralization, strengthens developing bone and even helps to remineralize damaged to bone.
Fluorosilic Acid is the most commonly used additive used in fluoridation and most of the research
compiled is on this specific additive. Americans spend on average about $1 per person annually to
fund this public work. It is believed to save $38 for every $1 invested.

Health Effects
Water fluoridation is credited with reducing dental cavities by 60%. Fluorosis, the artificial
discoloring of teeth was believed to be the only negative effect water fluoridation. Bassin, et al.
linked a correlation to water fluoridation and cancer rates in young males. Levy, et al. expanded
this study but were unable to find any statistical increase in cancer rates among young boys or
girls. Takahashi, et al. study found a positive correlation between water fluoridation and cancer
incidences in 23 out of 36 sites in the body. Harvard researchers have established a link between
fluoride exposure and lower IQ rates.

Environmental Effects
The US EPA maintains fluoride is safe for natural water sources as it is believed to be filtered
through ground soil and diluted to undetectable levels. Dameker and Dey demonstrated in their
study that fluoride contamination from an aluminum smelting plant had a devastating impact of
migrating salmon species. Camargo studied the differing effects of fluoride levels in fresh vs. salt
water. They were able to establish that fluoride is more detrimental to fresh water species because
bioavailability of fluoride ions is reduced with increasing water hardness.

Suggestions
We conclude that there is a sufficient correlation of water fluoridation with adverse health and
environmental effects to warrant cessation of the policy and further research into the safety of
water fluoridation policy in the United States.

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 18

References
1. California Department of Public Health, Fluoridation by Public Water Systems, retrieved from
http://www.cdph.ca.gov/certlic/drinkingwater/pages/fluoridation.aspx
2. Center for Disease Control, Water Fluoridation Natures Way to Prevent Cavities, retrieved from
http://www.cdc.gov/fluoridation/pdf/natures_way.pdf
3. MedlinePlus Medical Encyclopedia , Fluoride in diet, retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/002420.htm
4. GreenFacts - Facts on Health and the Environment, Scientific Facts on Fluoride, retrieved from
http://www.greenfacts.org/en/fluoride/index.htm#2
5. Home | CAMEO Chemicals | NOAA, FLUOROSILICIC ACID retrieved from
http://cameochemicals.noaa.gov/chemical/9379
6. NIDCR. (2011, March 25). The story of fluoridation. Retrieved from
http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm
7. Lennon, M. A. (2006, September ). One in a million: the first community trial of water fluoridation. Retrieved from
http://www.who.int/bulletin/volumes/84/9/05-028209.pdf
8. Contra Costa Water District. (2013). Water quality: Frequently asked questions about fluoridation. Retrieved from
http://www.ccwater.com/waterquality/fluorideFAQs.asp
9. San Diego County Dental Society. (2013). Fluoridation: Brief history of fluoridation in california & san diego . Retrieved from
http://www.sdcds.org/Articles/21/brief-history-of-fluoridation-in-california-san-diego/34
10. CDC - Community Water Fluoridation - Oral Health. (n.d.). Centers for Disease Control and Prevention. Retrieved March 20,
2013, from http://www.cdc.gov/fluoridation
11. Summary of the Safe Drinking Water Act | Laws and Regulations | US EPA. (n.d.).US Environmental Protection Agency.
Retrieved March 20, 2013, from http://www.epa.gov/lawsregs/laws/sdwa.html
12. POLICY RECOMMENDATIONS. (n.d.).Health.gov | Your Portal to Health Information from the U.S. Government. Retrieved
March 20, 2013, from http://www.health.gov/environment/ReviewofFluoride/POL.htm
13. ADA Fluoridation Policy & Statements - American Dental Association - ADA.org. (n.d.). Home - American Dental Association
- ADA.org. Retrieved March 20, 2013, from http://www.ada.org/4045.aspx
14. Water fluoridation - New World Encyclopedia. (n.d.). Info:Main Page - New World Encyclopedia. Retrieved March 20, 2013,
from http://www.newworldencyclopedia.org/entry
15. Engineering and Administrative Recommendations forWater Fluoridation, 1995 . (n.d.). Centers for Disease Control and
Prevention. Retrieved March 20, 2013, from http://www.cdc.gov/mmwr/preview/mmwr
16. Reeves, T. G. (1986). Water fluoridation: a manual for engineers and technicians. Atlanta, Ga.: U.S. Dept. of Health and
Human Services, Public Health Service, Centers for Disease Control, Dental Disease Prevention Activity, Center for Prevention
Services.
17. Cost Savings - Fact Sheets - Community Water Fluoridation - Oral Health. (n.d.).Centers for Disease Control and Prevention.
Retrieved March 20, 2013, from http://www.cdc.gov/fluoridation/fact_sheets
18. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation (2001). J Publ Health Dent , 61(2),
7886.
19. WSD - Home. (n.d.). Water Supplies Department. Retrieved March 20, 2013, from http://www.wsd.gov.hk/en/home/index.htm
20. Petersen PE, Kwan S, Zhu L, Zhang BX, Bian JY (2008). "Effective use of fluorides in the People's Republic of China--a model
for WHO Mega Country initiatives". Community Dental Health 25 (4 Suppl 1): 25767.doi:10.1922/CDH_2475Petersen11
21. Fluoridation status of some countries. (n.d.). Fluoride: Protected Pollutant or Panacea?. Retrieved March 20, 2013, from
http://www.fluoridation.com/c-country.htm
22. Germany stopped fluoridation. (n.d.).Fluoride: Protected Pollutant or Panacea?. Retrieved March 20, 2013, from
http://www.fluoridation.com/c-germany.htm
23. Knzel W, Fischer T. (1997). Rise and fall of caries prevalence in German towns with different F concentrations in drinking
water. Caries Research, 31(3), 166-173.
24. Brunelle JA, Carlos JP (1990). Recent trends in dental caries in US children and the effect of water fluoridation. J Dent Res, 69,
723-7.
25. Newbrun E. (1989). Effectiveness of water fluoridation. J Public Health Dent, 49, 279-89.
26. Decline of caries prevalence after the cessation of water fluoridation in the former East Germany - Knzel - 2002 - Community
Dentistry and Oral Epidemiology - Wiley Online Library. (n.d.). Wiley Online Library. Retrieved March 20, 2013, from
http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0528.2000.028005382.x/abstract
27. Dentalwatch. (Photographer). (2013). Fluorosis chart. [Web Photo]. Retrieved from http://dentalwatch.org/fl/fluorosis.html
28. WebMD. (2011). Fluorosis overview. Retrieved from http://children.webmd.com/fluorosis-symptoms-causes-treatments
29. Bassin, E., Wypij, D., Davis, R., Mittleman, M. (2006). Age-specific fluoride exposure in drinking water and osteosarcoma
(united states). Cancer Causes Control, (17), 421-428. doi: 10.1007/s10552-005-0500-6. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/16596294
30. Levy, M., & Leclerc, B. (2012). Fluoride in drinking water and osteocarcoma incidence rates in the continental united states
among children and adolescents. Cancer Epidemiology, (36), e83-e88. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/22189446
31. Takahashi, K., Akiniwa, K., & Narita, K. (2001). Regression analysis of cancer incidence rates and water fluoride in the u.s.a.
based on iacr/iarc (who) data (1978-1992). J. Epidemiol, 11(4), 170-179. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/2003628
32. Fluoridealert.org. (2012). Thyroid. Retrieved from http://www.fluoridealert.org/issues/health/thyroid/
33. Choi, A. L. (2012, October). Developmental fluoride neurotoxicity: A systematic review and meta-analysis. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/pdf/ehp.1104912.pdf

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 19

 34. Bunevicius, R., & Prange Jr., A. J. (2010, July). Thyroid disease and mental disorders: cause and effect or only comorbidity?.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20404728
35. Karagass, M., Baron, J., Barret, J., & Jacobsen, S. (1996). Patterns of fracture among the united states elderly: Geographic and
fluoride effects. Annals of Epidemiology, 6(3), 209-216. doi: 10.1016/1047-2797(96)00006-3. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/8827156

M. Mannina, M. Morgan, N. Murphy, B. Trinh 3/18/13 20