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Fluoridation
U S A
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CDC statements don't match the references in their "Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States"

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Contents

  1. 2001 - CDC - adequate and tolerable intake
  2. 1999 - DRI - margin of safety - crippling skeletal fluorosis
  3. 1997 - DRI - margin of safety - crippling skeletal fluorosis
  4. 1993 - margin of safety - crippling skeletal fluorosis
  5. 1992 - margin of safety - EPA scientist letter to NAS/NRC
  6. 1991 - data source for margin of safety - crippling skeletal fluorosis
  7. 1990 - data source for margin of safety - crippling skeletal fluorosis
  8. 1980 - 1989 - tolerable dose - Recommended Dietary Allowances
  9. 1961 - Largent mentions one man, 20 ppm
  10. 1966 - Hodge mentions Largent's 20 ppm
  11. 1977 - contains Hodge's 1953 error re: Roholm - crippling skeletal fluorosis
  12. 1979 - margin of safety - Hodge corrects error, mentions 20 ppm area
  13. 1937 - original data source for - Hodge - NAS/NRC
  14. 1970 - Hodge - fluoride in water
  15. 1999 - calculating the adequate intake figures - DRI
  16. 1974 - daily fluoride intake in non-fluoridated areas
  17. 1943 - McClure - optimum dosage during the 1940s
  18. 1951 - fluoride in the diet prior to 1950
  19. 1953 - fluoride in the diet prior to 1950
  20. 1962 - absorption of fluoride from foods
  21. 1966 - daily fluoride intake
  22. 1991 - brittle bones, daily intake, thyroid effects
  23. 1945 - McClure - limited safety studies
  24. 1977 - margin of safety - dental
  25. 1971 - margin of safety - dental
  26. 1970 - margin of safety - dental
  27. 1944 - margin of safety - false teeth
  28. 1936 - margin of safety - gingivitis - H. Trendley Dean
  29. 1943 - margin of safety - H. Trendley Dean
  30. 1993 - margin of safety - increased cavities?
  31. 1991 - margin of safety - nutritional factors
  32. 1970 - margin of safety - World Health Organization
  33. 1970 - arthritis at 2 to 8 mg/day - World Health Organization
  34. 1971 - margin of safety - World Health Organization
  35. 1977 - margin of safety - NRC Canada
  36. 1968 - little reduction in dental decay - fluorosis in Puerto Rico
  37. 1941 - when fluoridation is halted
  38. 1978 - when fluoridation is halted
  39. 1991 - pesticide residues in fruit juices
  40. 1993 - retention of ingested fluoride
  41. 1956 - safety studies exclude subjects
  42. 1952 - safety studies - X-Rays
  43. 1954 - safety studies - X-Rays
  44. 1955 - safety study, Bartlett, Texas
  45. 1956 - safety studies exclude subjects
  46. 1957 - safety studies - X-Rays
  47. 1958 - safety studies exclude subjects
  48. 1963 - safety studies - arthritis
  49. 1971 - safety studies exclude subjects
  50. 1977 - safety studies questioned
  51. 1977 - safety studies - question about bone cancer
  52. 1978 - safety studies - higher crude death rate in fluoridated cities 1978
  53. 1987 - symptoms of poisoning - Krishnamachari - arthritis, fibromyalgia
  54. 1987 - symptoms of poisoning - Krishnamachari - bones and thyroid
  55. 1989 - symptoms of poisoning - Susheela
  56. 1993 - safety questions - USDHHS Tox Profile
  57. 1977 - worker health / public health
 

1. 2001 - CDC - adequate and tolerable intake

Recommended total dietary fluoride intake
Age         Reference   Adequate   Tolerable
             weight      intake   upper intake
           in pounds     mg/day     mg/day

0-6 months      16        0.01         0.7
6-12 months     20        0.5          0.9
1-3 years       29        0.7          1.3
4-8 years       48        1.1          2.2
>9 years      88-166   2.0 - 3.8      10.0
Source: Adapted from Institute of Medicine. Fluoride. In: Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press, 1997:288313. (based on 0.05 mg/kg/day for all age groups)

Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States", Centers for Disease Control, Morbidity and Mortality Weekly Report, August 17, 2001. 

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2. 1999 - DRI - margin of safety - crippling skeletal fluorosis

The development of skeletal fluorosis and its severity is directly related to the level and duration of exposure. Most epidemiological research has indicated that an intake of at least 10 mg/day for 10 or more years is needed to produce clinical signs of the milder forms of the condition. Hodge (1979) reported that evidence of crippling fluorosis was not seen in communities in the United States where water supplies contained up to 20 ppm. In such communities daily fluoride intakes of 20 mg would not be uncommon.

Nat'l Academy Press, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1999) 

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3. 1997 - DRI - margin of safety - crippling skeletal fluorosis

The development of skeletal fluorosis and its severity is directly related to the level and duration of exposure. Most research has indicated that an intake of at least 10 mg/day for 10 or more years is needed to produce clinical signs of the milder forms of the condition. Advanced stages of skeletal fluorosis are associated with intakes of fluoride ranging from 20 to 80 mg/day for 10 or more years (Hodge and Smith, 1977; WHO, 1984).

Nat'l Academy Press, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride - pre-publication internet copy (1997) 

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4. 1993 - margin of safety - crippling skeletal fluorosis

When bone-ash fluoride concentrations are 7,500 - 8,000 ppm or more, stages 2 and 3 of skeletal fluorosis are likely to occur. The clinical signs of these stages are chronic joint pain, dose-related calcification of ligaments, osteosclerosis, possible osteoporosis of long bones, and in severe cases, muscle wasting and neurological defects.

Crippling skeletal fluorosis might occur in people who have ingested 10-20 mg of fluoride per day for 10-20 years.

Health Effects of Ingested Fluoride, Subcommittee on Health Effects of Ingested Fluoride, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council, August 1993, p 59. 

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5. 1992 - margin of safety - EPA scientist letter to NAS/NRC

National Federation of Federal Employees

PROFESSIONALISM IN PUBLIC SERVICE

April 24, 1992

Dr. Kulbir Bakshi
National Academy of Sciences
HA 354
2101 Constitution Ave.
Washington, D.C. 20418

Dear Dr. Bakshi,

As I promised some time ago, enclosed are a series of letters having to do with skeletal fluorosis and the views of the National Academy of Sciences. They demonstrate that the Academy has not conducted a rigorous analysis of the oft stated conclusion that 20 to 80 mg/day for 20 years or more causes crippling skeletal fluorosis. The basis for this statement is apparently a pronouncement, not an analysis. The lowest ingested dose of fluoride in mg/kg/day for a lifetime that can cause the various stages of skeletal fluorosis is yet to be determined. This includes the earliest stages of the disease, not just the final stage of crippling skeletal fluorosis. The lowest effect level for individuals with impaired kidney function also needs to be determined. It is imperative that your committee address these issues.

Sincerely,

Robert J. Carton, Ph.D.
Vice-President, Local 2050
National Federation of Federal Employees
Box 76082
Washington, DC 20013 

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6. 1991 - data source for margin of safety - crippling skeletal fluorosis

Food and Nutrition Board

March 18, 1991

Dear Ms. Sherrell:

You continue to ask me the source of the statement in the 10th edition of the RDAs that "chronic toxicity fluorosis occurs after years of daily exposures of 20 to 80 mg of fluorine..."

In previous letters I have supplied you with supporting references: Hodge and Smith, 1965, World Health Organization, 1970; Krishnamachari, 1987; National Academy of Sciences, 1971; Roholm, 1937 The statement you quote from the American Dental Association pamphlet on water fluoridation "The Academy found that the daily intake required to produce symptoms of chronic toxicity . . . is 20 to 80 milligrams or more..." may be misleading. The RDA subcommittee did not conduct experiments and come up with this range; rather, we reported this figure based on the work of others and on review papers.

For your information, a report titled Review of Fluoride: Benefits and Risks was issued by the Public Health Service of the Department of Health and Human Services last month. Pp. 45-46 contains the following statement: "As most commonly reported for a person to develop crippling skeletal fluorosis, he or she must ingest 20 to 80 mg/day of fluoride (the equivalent to 10 ppm fluoridated water) for 10 to 20 years (Hodge and Smith, 1965: Hodge, 1979; WHO, 1984, National Academy of Sciences, 1980)."

The new references are as follows:

-Hodge, HC. 1979 The Safety of Fluoride Tablets or Drops. Continuing Evaluation of the Uses of Fluoride, Westview Press (1979)

Sincerely,

Paul R. Thomas, Ed.D., R.D.
Project Director 

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7. 1990 - data source for margin of safety - crippling skeletal fluorosis

Food and Nutrition Board

August 24, 1990

Dear Ms. Sherrell: 

I am in receipt of your letters dated August 14 and 16 in which you asked for further documentation and explanation of several statements about fluoride in our Food and Nutrition Board (FNB) publication, Recommended Dietary Allowances, 10th Edition. 

On August 10 I sent you a section from the book Fluorides, a 1971 National Academy of Sciences publication we used to support our statement that fluorosis "occurs after years of daily exposures of 20 to 80 mg of fluorine. . .". The reference given in that book for our statement is: 

Roholm, K. Fluorine Intoxication: A Clinical-Hygienic Study With a Review of the Literature and Some Experimental Investigations, pp. 213-253. Translated by W.E. Calvert, London: H.K. Lewis and Co., Ltd., 1937.

I sent you the Krishnamachari article of 1987 because it is a relatively recent review article on fluorine toxicity and we cited it in the RDA report. 

The recommendations for fluoride intake in the 10th edition of the RDAs (which range from 0.1 to 0.5 mg/day for young infants to 1.5 - 4.0 mg/day for adults from all sources--food and drink) are "estimated" by the FNB to be "safe and adequate" for healthy people in the United States. The purpose of our RDA report is to recommend intakes of nutrients that help to maintain the health of already healthy people and are not associated with signs of toxicity over the short- or long-term. The National Institute of Dental Research of the National Institutes of Health supports our recommendations. 

In response to your question, yes, the FNB considers its recommended intake levels of fluoride to be low enough "to avoid the earlier stages of fluoride toxicity, as well as the advanced crippling stages." Our fluoride recommendations haven't changed since they were first published in the 9th edition of the RDAs in 1980. In the current RDA report, we note that it is not clear whether fluoride is an essential nutrient, but that fluoride has "valuable effects on dental health" and thus should be considered a "beneficial element for humans." We cited recent studies estimating fluoride intake in the U.S. to range from approximately 0.9 to 1.7 mg/day. We also cited a 1983 study reporting fluoride intakes to be greater than 1.8 mg/day. 

The table in the RDA report in which our fluoride recommendation appears carries the following footnote: "Since the toxic levels for many trace elements may be only several times usual intakes, the upper levels for the trace elements given in this table should not be habitually exceeded." Therefore, we recommend that dietary fluoride intakes for adults, for example, not habitually exceed 4.0 mg/day; that would include the amount consumed in fluoridated water. 

I hope you find this information helpful. 

Sincerely, 

Paul R. Thomas, Ed.D., R.D.
Program Officer 

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8. 1980 - 1989 - tolerable dose - Recommended Dietary Allowances

Recommended Dietary Allowances 

Excessive Intakes and Toxicity 

Fluorine, like other trace elements, is toxic when consumed in excessive amounts. Chronic toxicity fluorosis affects bone health, kidney function, and possibly muscle and nerve function (Krishnamachari, 1987). The condition occurs after years of daily exposures of 20 to 80 mg of fluorine, far in excess of the average intake in the United States. 

Estimated Safe and Adequate Daily Dietary Intake

The estimated range of safe and adequate intakes of fluoride for adults is 1.5 to 4.0 mg/day. This takes into account the widely varying fluoride concentrations of diets consumed in the United States and includes both food sources and drinking water.

[NOTE: the 4 mg/day tolerable dosage is based on the erroneous belief in the 20-80 mg/day figures calculated by Hodge.] 

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9. 1961 - Largent mentions one man, 20 ppm

Concentrations of F found in the city water supply of O'Donnell, Texas were highest (20 to 25 ppm) yet reported in connection with a commercial water supply. High concentrations of other ions including magnesium and sulfate were also present in the water from this shallow well (less than 100 feet deep.) Needless to say, this supply was not used extensively for drinking purposes, and other sources of water were being explored.

Largent, E.J. Fluorosis. The health aspects of fluorine compounds (1961) Ohio State University Press, Columbus, Ohio.: 

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10. 1966 - Hodge mentions Largent's 20 ppm

Minerals: Fluorine and Dental Caries. 

[In this chapter there is a table IV titled "Relation of F ingested to that ingested in water and food consumed." Within this table 20 ppm F in water is listed, indicating an individual 30 years of age had consumed that amount for 8 years. This person was observed in a study for 45 days.]

[A footnote indicates the table was adapted from Largent (1961).]

Hodge, H.C. and Smith, F. A, Minerals: Fluorine. Advances in Chemistry: Symposium on Dietary Chemicals in Relation to Dental Caries, Dr. Robert S. Harris, editor. (papers compiled from a symposium held in 1966) 

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11. 1977 - contains Hodge's 1953 error re: Roholm - crippling skeletal fluorosis

[This article contains Hodge's original (1953) table of fluoride effects, with the infamous 20-80 mg/day figures which he corrected in 1979. ]

[There is no mention in this document of a 20 ppm naturally fluoridated area.]

Hodge, H. C. and Smith, F.A. (1977). Occupational fluoride exposure. J. Occup. Med., 19: 12-39 

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12. 1979 - margin of safety - Hodge corrects error, mentions 20 ppm area

Chronic effects follow protracted exposures. Crippling fluorosis as an occupational disease follows exposures estimated at 10 to over 25 mg of fluoride daily during periods of 10-20 years. The pattern of crippling fluorosis comprises hypermineralization (osteosclerosis), calcification of ligaments, and exostoses. In animals, osteoporosis and ostemalacia have also been observed in severely affected bone. In certain parts of the world, crippling fluorosis develops in individuals drinking water containing elevated amounts of fluoride, for example, 10 or more ppm; this was not seen in communities in the United States where the water supplies contained up to 20 ppm. About 10% of the lifetime residents of a U.S. community where the drinking water contained 8 ppm F exhibited detectable osteosclerosis. Osteosclerosis never occurs in exposed workmen in the U.S. whose urinary fluoride excretion is maintained below 5 mg F per liter (Irwin, quoted by Hodge and Smith, 1970). When urinary fluorides equal or exceed 9 mg F per liter, several years are required for the development of detectable osteosclerosis; the pelvic vertebrae show the earliest X-ray evidence of increased mineralization (Hodge and Smith, 1977)

The most important and widely disregarded fact about dental fluorosis is this: no safe established daily intake exists, i.e., the maximal amount in mg fluoride which consumed daily does NOT produce cosmetically damaging extensive white areas or brown stain in some individuals has not been fixed

Harold C. Hodge, The Safety of Fluoride Tablets or Drops in Johansen E, Taves DR, Olsen TO, eds. Continuing evaluation of the use of fluorides. Boulder, CO: Westview, 1979:255-256. (American Association for the Advancement of Science selected symposium no. 11). p. 255, 256 

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13. 1937 - original data source for - Hodge - NAS/NRC

Crippling Skeletal Fluorosis

In man the disease is probably caused by 0.20 -0.35 mg. fluorine daily per kg. body weight. The changes appear, however, only after several years of regular fluorine ingestion. ... Human osteosclerosis develops only after several years ... average period of employment of the cryolite workers who had just-recognizable sclerosis was 9.3 years ... Clinical experience indicates that the osteomalacic condition may be relatively quick in appearing, after the course of months or even weeks. 

The relation between the smallest dose of fluorine that affects the development of teeth, and the dose which causes osteosclerosis is almost the same, as in the case of the rat. 

Roholm, Kaj, Fluorine Intoxication: A Clinical-Hygienic Study With a Review of the Literature and Some Experimental Investigations, Translated. by W.E. Calvert., London: H.K. Lewis & Co., Ltd., 1937. (data base for Hodge, NAS/NRC) p282. 

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14. 1970 - Hodge - fluoride in water

Looking at all the potroom data available, a certain coherence appears. Air concentrations usually exceeded 2.5 mg F/m3. Urinary fluorides generally equaled or exceeded 9 ppm F. ... The incidence of osteosclerosis (1/10) in lifetime residents of a community with 8 ppm in the drinking water whose urines contained about 9 ppm F stresses the consonance of urinary values and osteoclerosis (Leone et al, 1955).

[NOTE: This paper focuses on airborne fluoride not F in water.]

[At the end of the introductory paragraph where Hodge is talking about how fluoride is ubiquitous ... quoting the last line "and drinking waters range from 0.01 ppm or less to 3 or 4 ppm and occasionally higher in United States communities (Hodge, H.C. and Smith, F. A, Minerals: Fluorine. Advances in Chemistry: Symposium on Dietary Chemicals in Relation to Dental Caries, Dr. Robert S. Harris,editor. In press.)]

Hodge, H.C. and Smith, F.A., Air Quality criteria for the effects of fluorides on man. J. Air Pollut. Control Assoc., 20; 226-232, 1970 

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15. 1999 - calculating the adequate intake figures - DRI

Community Water. 

During the 1940s, researchers determined that 1 ppm fluoride was the optimal concentration in community drinking water for climates similar to the Chicago area ( 88,89). This concentration would substantially reduce the prevalence of dental caries, while allowing an acceptably low prevalence (i.e., 10% - 12%) of very mild and mild enamel fluorosis and no moderate or severe enamel fluorosis. Water fluoridation for caries control began in 1945 and 1946, when the fluoride concentration was adjusted in the drinking water supplying four communities in the United States and Canada ( 2-5). This public health approach followed a long period of epidemiologic research into the effects of naturally occurring fluoride in drinking water ( 53,57,88,89).

AI Definition

Because data are not available to determine an Estimated Average Requirement (EAR), the reference value that will be used for fluoride is the AI. The AI is based on estimated intakes that have been shown to reduce the occurrence of dental caries maximally in a population without causing unwanted side effects including moderate dental fluorosis.

Nat'l Academy Press, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1999) 

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16. 1974 - daily fluoride intake in non-fluoridated areas

[table shows 3.4 mg day in non-fluoridated area]

Kramer L, Osis D, Wiatrowski E, Spencer H. Dietary fluoride in different areas of the United States. Am J Clin Nutr 1974;27:5904. 

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17. 1943 - McClure - optimum dosage during the 1940s

The production of endemic dental fluorosis (mottled enamel) in human beings by fluoride in drinking water is an outstanding example of the toxic effect of an excessive intake of the element.

[Note: McClure's dosage table shows average intake for older children is 0.03 mg/kg/day.]

McClure, Frank J., Ingestion of fluoride and dental caries -- quantitative relations based on food and water requirements of children 1 to 12 years old, American Journal Diseases of Children, 66:362, 1943. 

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18. 1951 - fluoride in the diet prior to 1950

Under normal conditions of living, fluorine is a trace element in human nutrition (McClure, 1951). Minute amounts are absorbed from certain foods and drinking water and, to a limited extent, are retained by dental and osseous tissues. The quantity of fluorine ingested in food is a relatively unimportant variable; the average diet contains 0.2 to 0.3 mg. daily. Of greater import is the variable quantity ingested in drinking water.

Report of the Ad Hoc Committee on the Fluoridation of Water Supplies, Division of Medical Sciences, National Research Council, Nov. 29, 1951. 

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19. 1953 - fluoride in the diet prior to 1950

A person drinking fluoridated water may be assumed to ingest only about 1 milligram per day from this source ... the development of mottled enamel is, however, a potential hazard of adding fluorides to food. The total daily intake of fluoride is the critical quantity.

Exclusive of drinking water, the average diet in the United States is calculated to provide 0.2 to 0.3 milligram of fluoride daily. ... drinking water ... can provide an optimal internal supplement of approximately one-half to 1 milligram of fluoride per day.

The problem of providing optimum fluoride intake for prevention of dental caries, Food and Nutrition Board, Division of Biology and Agriculture, National Academy of Sciences, National Research Council, Pub. #294, November 1953 - p. 477, 482 

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20. 1962 - absorption of fluoride from foods

Soluble fluoride is absorbed equally well from food or water. Ericsson has shown that absorption from milk may be somewhat slower than from food, but the total percentage eventually absorbed from the two vehicles do not differ.

Safety of Water Fluoridation, Journal American Dental Association, 65:598 (1962) Frank A. Smith, Ph.D. 

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21. 1966 - daily fluoride intake

Journal of Food Science 1966 (5 mg/day) Our data suggest that some healthy individuals will ingest up to 5 milligrams of fluoride per day, under normal indoor vocational conditions for North America... 

The Fluoride Content of Some Foods and Beverages,- Journal of Food Science 31:941, 1966 

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22. 1991 - brittle bones, daily intake, thyroid effects

Fluoride increases the stability of the crystal lattice in bone, but makes bone more brittle. ... The total quantity of fluoride ingested is the single most important factor in determining the clinical course of skeletal fluorosis; the severity of symptoms correlates directly with the level and duration of exposure. (p. 45)

Bone changes observed in human skeletal fluorosis are structural and functional, with a combination of osteosclerosis, osteomalacia, osteoporosis and exostosis formation, and secondary hyperparathyroidism in a proportion of patients.

The daily intake of most adults is about equally divided among food, drinking water, beverages, and mouthwash. (p. 15)

In India, Tanzania, and South Africa, crippling forms of skeletal fluorosis have been reported in pediatric age groups. Endemic bent knee is observed primarily in young and adolescent boys and is characterized by: simultaneous osteomalacia; osteosclerosis; and osteoporosis with secondary hyperparathyroidism. (p. 47)

Public Health Service Committee to Coordinate Environmental Health and Related Programs. Review of fluoride: benefits and risk. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991 

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23. 1945 - McClure - limited safety studies

Epidemiological studies of the non-dental effects of fluorine, as ingested in fluoride domestic waters, are extremely few in number and very limited in scope.

McClure, Frank J., Non Dental Physiological Effects of Trace Quantities of Fluorine, Journal American College of Dentists, vol 12, p. 50, 1945 

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24. 1977 - margin of safety - dental

The "moderate" dental fluorosis shown by Hodge and Smith (1965, p. 443) in a community with "about 2 ppm" would be objectionable to most, if not all, parents, although there seems to be little consumer research on the matter.

Drinking Water and Health, Safe Drinking Water Committee, National Academy of Sciences, NAS/NRC, 1977 p 396. 

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25. 1971 - margin of safety - dental

During tooth formation, the cells of the dental tissues, particularly the ameloblasts, are very sensitive to fluoride. At relatively low doses -- e.g., 2 ppm of fluoride in the water -- small spots, or mottling, vary in color from paper white to dark brown. The brown stain of the latter condition usually accumulates after eruption. These doses affect only the appearance, and not the structure, of the tooth. At higher doses, the cells may be affected and the tooth structure severely altered, so that the normally smooth surface shows hypoplastic corrugations. These effects -- mottled appearance and altered form --are produced only when the excessive amount of fluoride are ingested during the period of formation and calcification, i.e.,during the first 8 years of life in man. After the tooth erupts and calcification has been completed, ingested fluoride does not have adverse dental consequences.

Biologic Effects of Atmospheric Pollutants, FLUORIDES, Committee on Biologic Effects of Atmospheric Pollutants, Division of Medical Sciences, National Research Council, National Academy of Sciences, Washington, D.C., 1971 p 213. 

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26. 1970 - margin of safety - dental

Mottled enamel is a developmental injury ... one of the first visible signs of an excessive intake of fluoride during childhood.... Continuous use of water containing about 1.0 ppm of fluoride may result in the very mildest form of mottled enamel in 10% of children. The incidence rises to 40 to 50% at about 1.7 ppm; at 2.5 ppm it is as high as 80%, with 25% being classified as moderate or severe; between 4.0 and 6.0 ppm, the incidence approaches 100%, with marked increase in severity. 

The Pharmacological Basis of Therapeutics, Macmillan, Inc., (1970), 4th edition 

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27. 1944 - margin of safety - false teeth

With 1.6 to 4 ppm fluoride in water, 50% or more past age 24 have false teeth because of fluoride damage to their own. (St. David, Arizona)

The Effect of Fluorine On Dental Caries
Journal American Dental Association -31:1360, (1944) 

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28. 1936 - margin of safety - gingivitis - H. Trendley Dean

From observations made by one of us (HTD) in areas of relatively high fluoride concentration (more than 4.0 ppm) there is, likewise, sufficient evidence to suggest an apparent tendency to a higher incidence of gingivitis.

Dean, H. Trendley, Some Epidemiological Aspects of Chronic Endemic Dental Fluorosis, American Journal of Public Health, 26:567, 1936 

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29. 1943 - margin of safety - H. Trendley Dean

Differences in drinking and culinary habits of individuals may also cause quite a variation in their total fluorine intake, which in turn will influence the effect

In other words, we are dealing with a low-grade chronic poisoning of the formative dental organ, in which case some individuals may show a more severe reaction than others having a comparable fluorine intake.

There is some indication that there is an apparent tendency toward a higher incidence of gingival disturbances in areas of relatively high fluoride concentration (more than 4 ppm). ... Epidemiologic studies have shown that from the continuous use of water containing as much as 1 part per million of fluorine, the very mildest forms of dental fluorosis may develop in about 10 percent of the group.

Dean, H. Trendley, Endemic Dental Fluorosis or Mottled Enamel, Journal American Dental Association, 30:1278, 1943. 

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30. 1993 - margin of safety - increased cavities?

[There is evidence that with increasing fluoride concentrations, caries prevalence diminishes to a certain point and then increases again.]

Health Effects of Ingested Fluoride, Subcommittee on Health Effects of Ingested Fluoride, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council, August 1993 p 45 

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31. 1991 - margin of safety - nutritional factors

Severe crippling fluorosis is not seen in all residents of endemic areas; age of exposure as well as dose and duration of fluoride intake are critical in predicting the clinical signs and symptoms of skeletal fluorosis. Other factors reported to influence the incidence of skeletal fluorosis include: nutritional and calcium deficiencies; renal insufficiency; the level of bone turnover; and diets containing high levels of fluoride. Also, in certain occupational settings, the duration and exposure from the inhalation of products of manufacturing, e.g., aluminum, steel, iron, pesticides, fertilizers, and smelting of precious metals. Other factors influencing skeletal fluorosis include soil type or areas of volcanic rock, geophasia, syndromes of polydipsia excessive water consumption, and the type of physical activity.

Review of Fluoride Benefits and Risks, Department of Health & Human Services, February 1991 p 47. 

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32. 1970 - margin of safety - World Health Organization

Almost every known food and water supply contains traces of fluoride since fluorine is one of the more abundant elements in the earth's crust. The amount of fluoride in foods is of utmost significance, since the combined ingestion of fluorine-containing water, fluoridated dentifrices, and high-fluoride foods may be either a useful or a harmful nutritional practice. 

[this book also contains McClure's table indicating optimal total daily intake during childhood 50 years ago was 0.04mg/kg/day]

World Health Organization, Fluorides and Human Health, 1970, p 32. 

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33. 1970 - arthritis at 2 to 8 mg/day - World Health Organization

At higher levels of ingestion ... from 2 to 8 mg daily, skeletal fluorosis may arise ... Whereas dental fluorosis is easily recognized, the skeletal involvement is not clinically obvious until the advanced stage of crippling fluorosis ... early cases may be misdiagnosed as rheumatoid or osteo arthritis. 

World Health Organization, Fluorides and Human Health, 1970 p 239-240 

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34. 1971 - margin of safety - World Health Organization

In the assessment of the safety of a water supply with respect to the fluoride concentration, the total daily fluoride intake by the individual must be considered. Apart from variations in climatic conditions, it is well known that in certain areas, fluoride containing foods form an important part of the diet. The facts should be borne in mind in deciding the concentration of fluoride to be permitted in drinking water. 

World Health Organization, International Drinking Water Standards, 1971 

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35. 1977 - margin of safety - NRC Canada

Fluoride is a persistent bioaccumulator, and is entering into human food-and-beverage chains in increasing amounts. Careful consideration of all available data indicates that the amount of fluoride ingested daily in foods and beverages by adult humans living in fluoridated communities currently ranges between 3.5 and 5.5 mg. ... Long-term ingestion, with accumulation of fluoride in animals and man, induces metabolic and biochemical changes, the significance of which has not yet been fully assessed. It cannot be assumed that such changes are of no significance to human health ... There is no doubt that inadequate nutrition increases the severity of fluoride toxicosis ... fluoride has displayed mutagenic activity in studies of vegetation, insects, and mammalian oocytes. There is a high correlation between carcinogenicity and mutagenicity of pollutants, and fluoride has been one of the major pollutants in several situations where a high incidence of respiratory cancer has been observed

Environmental Fluoride (1977) National Research Council of Canada (NRCC No.16081) Associate Committee On Scientific Criteria For Environmental Quality 

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36. 1968 - little reduction in dental decay - fluorosis in Puerto Rico

In poverty areas of Puerto Rico there was relatively little reduction in cavities, but dental fluorosis was common. Puerto Rico discontinued its fluoridation projects. 

American Journal of Clinical Nutrition - 21:646, (1968) 

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37. 1941 - when fluoridation is halted

It would seem that the physiological effects, insofar as they relate to the inhibitory influence on dental caries, had carried over for several years after the change to the fluoride free water.

Dean HT, Jay P, Arnold FA Jr, Elvove E. Domestic water and dental caries. II. A study of 2,832 white children, aged 1214 years, of 8 suburban Chicago communities, including Lactobacillus acidophilus studies of 1,761 children. Public Health Rep 1941;56:76192 

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38. 1978 - when fluoridation is halted

To explore the usefulness of continued F exposures after eruption of all permanent teeth, the subjects with continuous use of F supplements or fluoridated water were compared with those who did not use either source after the age of about 12 years. The data indicate no significant differences in caries activity between groups.

Effects of Fluoride Supplementation From Birth on Dental Caries and Fluorosis in Teenaged Children, Archives of Oral Biology, 23:111-115 (1978) Aasenden & Peebles 

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39. 1991 - pesticide residues in fruit juices

Since it is common practice to use fluoride-containing insecticide in growing grapes, it is believed that contamination of these juices is occurring. [>6.8 ppm] ... fluoride supplementation should not be based solely upon the concentration of the drinking water, but should also consider the amount of different beverages consumed and their fluoride content.

Stannard, et al, Fluoride levels and fluoride contamination of fruit juices, Journal of Clinical Pediatric Dentistry, v16(1) 1991. 

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40. 1993 - retention of ingested fluoride

Approximately 50 percent of the daily intake of fluoride is cleared by the kidneys.

Review of Fluoride Benefits and Risks, Department of Health & Human Services, February 1991 p. 5

[see also: Health Effects of Ingested Fluoride, Subcommittee on Health Effects of Ingested Fluoride, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council, August 1993 p 85.] 

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41. 1956 - safety studies exclude subjects

[The only group examined were twelve-year-old boys, who had been drinking fluoridated water for ten years. Any boy who had shown any signs of illness during the two weeks previous to examination was excluded, on the grounds that only active (water-consuming), energetic boys should be checked. No attempts were made to examine adults, elderly people, the chronically ill, or even girls - and yet this study is often cited as proving fluoridation safe for everyone.] 

Newburgh-Kingston Caries-Fluorine Study, Pediatric Findings After Ten Years, Journal American Dental Association 52:296 (1956) 

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42. 1952 - safety studies - X-Rays

By the time these changes are demonstrable in man by x-ray studies, the functional disability may be considerable. 

Kidney Function & Structure In Chronic Fluorosis, British Journal Experimental Pathology 33:168, 1952 

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43. 1954 - safety studies - X-Rays

[In cases of advanced skeletal fluorosis, bone changes seen on X-Ray generally involve the spine, pelvis, and ribs. McClure ignored this fact, choosing to compare the development of the carpal bones of children's hands in Texas and Maryland.] 

McCauley and McClure, Effects of fluoride in drinking water on the osseous development of the hand and wrist in children, Pub Hlth Rep 69:671, 1954 

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44. 1955 - safety study, Bartlett, Texas

[Many researchers have commented on flaws in this study (Bartlett, Texas) in which X-Ray films made in 1943 were compared with films made in 1953. For example, in 1952 a defluoridation unit was installed in Bartlett, reducing the fluoride content to 1.2 ppm. Only 11 people were life-long residents of Bartlett. The Public Health Service says Cameron water contains 0.4 ppm fluoride -- the supply, however, is from the Little River, and such sources are notoriously variable in fluoride content. A single determination means absolutely nothing. As in the case of other Public Health Service studies, they are not comparing a fluoride city with a non fluoride city. Both are fluoride cities, and within a range where some Cameron people will ingest more water-borne fluoride than some in Bartlett.] 

Leone et al, Am J. Roentgen 74:874, 1955
A roentgenologic study of a human population exposed to high-fluoride domestic water. A ten-year study 

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45. 1956 - safety studies exclude subjects

No specimens were taken if there was any history of clinical illness, no matter how mild, during the previous two weeks. 

Study of Children Drinking Fluoridated and Nonfluoridated Water, Journal American Medical Association, 160:21-24 (1956) 

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46. 1957 - safety studies - X-Rays

[NOTE: This study reviewed X-Ray records on file at the Scott and White Clinic in Temple, Texas, for the 11-year period from 1943 to 1953. However, investigators didn't look at X-rays - they looked at the reports of people who looked at X-rays. No one was trained to recognize fluorosis, so no one saw it.] 

Stevenson and Watson, Fluoride osteosclerosis, Am J. Roentgen 78:13, 1957 

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47. 1958 - safety studies exclude subjects

Those with chronic illness and diseases known to affect bone structure were excluded. 

It is imperative to bear in mind the possibility that fluoride addition to other food items might become the source of excessive increments of the individual fluoride intake.

Pathologic Studies in Man After Prolonged Ingestion of Fluoride in Drinking Water, Public Health Reports 73:721-723,1958. 

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48. 1963 - safety studies - arthritis

Symptoms may be present prior to the development of definite radiological signs. A study of the incidence of rheumatic disorders in areas where fluoridation has been in progress for a number of years would be of interest. 

Endemic Fluorosis, Medicine 42:229, 1963 

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49. 1971 - safety studies exclude subjects

Furthermore, we excluded persons who had chronic diseases known to affect the bone such as cancer, leukemia, severe anemia, parathyroid disease, and renal disease that was severe enough to cause uremia ... Most of the deceased in the study had a short history of illness, such as myocardial infarction, pulmonary embolism, cerebral vascular disease, pneumonia, or trauma. 

Fluoridated Water, Skeletal Structure and Chemistry, HSMHA Health Reports, 86:820, (1971) 

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50. 1977 - safety studies questioned

Without statements about the power of the tests, the implication of finding no-effect is construed to be that no effect exists... further study is indicated. 

Drinking Water and Health (1977) page 398, National Academy of Sciences, National Research Council 

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51. 1977 - safety studies - question about bone cancer

There was an observation in the Kingston-Newburgh study that was considered spurious and has never been followed up. There was a 13.5% incidence of cortical defects in bone in the fluoridated community but only 7.5% in the nonfluoridated community. ... Caffey noted that the age, sex, and anatomical distribution of these bone defects are 'strikingly' similar to that of osteogenic sarcoma. 

The possibility of mutagenesis due to HF is potentially important in cancer of the stomach. Ingested fluoride ion can become HF in the stomach because the pH of HF is 3.18 and the pH of the stomach without food is generally about 1. Although stomach cancer rates show no consistent indication of a relationship to fluoridation in the United States, the much higher stomach cancer rates in Japan are related to intake patterns that are compatible with a hypothesis that fluoride is the crucial factor involved. 

Drinking Water and Health, National Research Council, 1977 

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52. 1978 - safety studies - higher crude death rate in fluoridated cities 1978

This pattern of a higher crude death rate in the cities with fluoridated water supplies was apparent for all categories of death except for those by accidental means and suicide.

Erickson, J. David, Mortality in Selected Cities With Fluoridated and Non-Fluoridated Water, New England Journal of Medicine, May 1978. 

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53. 1987 - Krishnamachari - symptoms of poisoning - arthritis, fibromyalgia

Pain is a cardinal feature due to arthritic lesions and to secondary peripheral nerve involvement. ... workers at risk: aluminum smelters, phosphate fertilizer, ceramics, steel, glass industries.

Trace Elements in Human and Animal Nutrition -- Fifth Edition, Edited by Walter Mertz, U. S. Dept. of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Beltsville, Maryland, 1987 p 369 

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54. 1987 - Krishnamachari - symptoms of poisoning - bones and thyroid

It is thus clear that the clinical picture of fluorosis includes softening of the bones and osteoporosis as well as secondary hyperparathyroidism on a global basis.

Trace Elements in Human and Animal Nutrition -- Fifth Edition, Edited by Walter Mertz, U. S. Dept. of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Beltsville, Maryland, 1987 p 380. 

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55. 1989 - symptoms of poisoning

The early warning signs of fluoride toxicity are the following: nausea, loss of appetite, gas formation and nagging pain in the stomach, chronic diarrhea, chronic constipation, persistent headache. The gastrointestinal system is one of the most sensitive systems in the body to react adversely to fluoride toxicity. It is possible that an individual may have either one or a few of the complaints listed ... other early complaints relate to the neuro-muscular systems. ... unusual fatigue, loss of muscle power and weakness and pain, excessive thirst and frequent urination, depression, tingling sensation in fingers and toes. ...allergic manifestations are also likely.

Susheela, A.K., Fluorosis -- Early Warning Signs and Diagnostic Test, Bulletin of the Nutrition Foundation of India,10:2, April 1989. 

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56. 1993 - safety questions - USDHHS Tox Profile

Existing data indicate that subsets of the population may be unusually susceptible to the toxic effects of fluoride and its compounds. These populations include the elderly, people with deficiencies of calcium, magnesium, and/or vitamin C, and people with cardiovascular and kidney problems. ... Because fluoride is excreted through the kidney, people with renal insufficiency would have impaired renal clearance of fluoride ... Impaired renal clearance of fluoride has also been found in people with diabetes mellitus and cardiac insufficiency. People over the age of 50 often have decreased renal fluoride clearance. ... This decreased clearance of fluoride may indicate that elderly people are more susceptible to fluoride toxicity. ... Because of the role of calcium in bone formation, calcium deficiency would be expected to increase susceptibility to effects of fluoride. 

Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (F), (April 1993), U.S. Dept. Health and Human Services, Agency for Toxic Substances and Disease Registry, p.112 

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57. 1977 - worker health / public health

Industrial physicians may be wise to recognize that primary allegiance must rest with the employer, but then we must expect that workers and the general public will be equally wise to recognize the same reality ... It is important to keep in mind that long-term health hazards are just as important to workers and to our society as acute health hazards and they are more difficult to detect. 

The Responsibility to Report Occupational Health Risks, Journal of Occupational Medicine - April (1977) 

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