FLUORIDATION OF WATER SUPPLIES ENDORSED BY COMMISSION AT ANNUAL MEETING The statement below on the effects of fluoridation of community water supplies upon the aged and chronically ill was adopted by the Commission on Chronic Illness at its fifth annual meeting in Chicago on March 18 Prevention of the occurrence of disease or prevention of its progress-is generally accepted as the most desirable solution to the growing problem of chronic illness in this country. The Commission on Chronic Illness is interested in furthering the adoption and use of any public health measures that will contribute to the prevention of chronic illness. Fluoridation of community water supplies has been undertaken by many communities as the public-health measure directed toward the prevention of dental caries. Fluoridation of public water supplies has been endorsed by leading professional organizations in the field. Dental caries is an important chronic disease-important in terms of widespread prevalence and destruction of useful tissue also important in the way that resulting loss of teeth may complicate the life of aged persons and persons suffering other disabling conditions. A The major portion of scientific opinion is that fluoridation of water supplies for the prevention of dental caries presents no hazard to public health. minority view is held by a number of qualified scientists who believe that the safety of this procedure has not been sufficiently demonstrated. Cognizant of the fact that fluoride compounds in large doses are poisonous, they advance the hypothesis that the small amounts contained in fluoridated water consumed over many years may by cumulation have subtle physiological effects especially detrimental to the aged and the chronically ill. The commission, concerned with the problems of chronic illness, did not feel that it could recommend fluoridation of public-water supplies without first taking cognizance of the possibility of detrimental effects. At the request of the board of directors of the commission, a committee of distinguished scientists reviewed and evaluated the available evidence to decide whether at this time a positive position could be taken with regard to this hypothetical danger. The committee was under the chairmanship of Dr. Kenneth F. Maxcy, professor of epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore. The other members were Dr. Edward J. Stieglitz, outstanding geriatrician of Washington, D. C., and Dr. Nathan Shock, Chief of the Section on Gerontology, National Institutes of Health, Public Health Service. This committee reports as follows: "The basic facts concerning fluoridation which have been established by the investigations of the past 20 years have been briefly set forth in the report of the Ad Hoc Committee on Fluoridation of the National Research Council.' Under normal conditions of living, fluorine is a trace element in human nutrition. Although minute amounts are present in certain foods and beverages, a variable and important source is drinking water. Public water supplies vary widely in the amount of fluoride naturally present. Children dependent upon supplies that are low in fluorides have a high dental caries attack rate as compared to children living in communities having water supplies containing about 1 part per million or more of fluoride. The advantage to the latter group is considerable: the incidence of carries is reduced by one-half to two-thirds. The caries preventive effect of adequate fluoride intake is principally conferred upon children up to the 12th year of life, during the period when dentine and enamel of permanent dentition are being formed. However, increased resistance to dental caries is carried over into later life to an appreciable degree. "When the trace quantities in drinking water required for optimal dental health are exceeded, undesirable physiological effects may be induced. The most sensitive indication of the latter is interference with normal calcification of the teeth, which is manifested in mottled enamel. This effect, although compatible with caries-resistant tooth structure, is esthetically undesirable. The level of fluoride concentration in drinking water which is associated with the appearance of mottled enamel varies with individual susceptibility and the amount of water consumed. Under the climatological conditions of the north 1 The Fluoridation of Domestic Water Supplies in North America as a Means of Controlling Dental Caries. A report of the United Kingdom Mission, Ministry of Health, Department of Health for Scotland, 1953. National Research Council Viewpoint on Fluoridation. Journal American Waterworks Association, vol. 44, No. 1, January 1952. ern part of the country it is reached when the fluoride content of domestic water supplies exceeds 1.5 p. p. m. 4 3 "In view of these facts, Trendley Dean and his associates developed the hypothesis that by adding fluorides in proper amounts to water supplies which were defiicient or low in this element it was possible to afford optimum caries preventive effect without causing mottled enamel. Controlled studies were begun in 1945 to test this hypothesis in Grand Rapids, Mich.; Muskegon, Mich.; Aurora, Ill.; and in Newburgh and Kingston, N. Y. Results now available from these studies are such as to definitely establish that the protection against caries given by naturally occurring fluorides is also conferred by water to which this element has been added. Careful annual medical examinations of children in the latter study including X-rays, urine analysis, and other laboratory tests over a 6-year period have failed to uncover any adverse effect from fluoridated drinking water. The children in Newburgh drinking fluoridated water showed no significant deviation in height or weight growth from those in Kingston where the water was essentially fluoride free. "The question posed by the minority of scientists is whether fluoride added to drinking water in quantities insufficient to cause mottled enamel (i. e., to a level of approximately 1 part per million) have, by cumulation in tissues, any physiological effects which may be detrimental to adults and to the chronically ill. Information bearing upon this question has been derived from two sources: (1) Studies on the metabolism of fluorides in man and in experimental animals; (2) observations on human populations exposed to water supplies having a fluoride content in excess of 1.5 parts per million. "The extensive literature dealing with metabolism and toxicology of fluoride compounds has been reviewed by the National Institute of Dental Research, United States Public Health Service and in an article by F. F. Heyroth in the Journal of the American Public Health Association.' In our judgment there has been a sufficient number of observations on human subjects, with support of animal experiments, to establish the pattern of metabolism. Up to a daily intake of 4 or 5 milligrams or more fluorides absorbed are almost completely eliminated in the urine and sweat. (To get 5 milligrams of fluoride daily one would have to drink about 5 quarts of water containing 1 part per million of fluoride every day.) Any residual is stored in the skeletal system, teeth and bones. Little, if any, remains in the soft tissues, liver, spleen, kidneys, etc. As the level of intake is lowered, stored fluorides tend to be partially eliminated. At high levels of fluoride intake (8 parts per million or more) changes occur in bones which may become evident by X-ray (bone fluorosis). However, storage of fluorides in the skeletal structure in the amounts considered here results in no functional disadvantage. In other words, the body possesses two potent protective mechanisms: (1) rapid excretion in the urine; (2) storage in the skeleton. "These studies of metabolism have been supplemented by a considerable number of observations on population groups naturally exposed for long periods of time to water supplies with varying fluoride content. In the United States, more than a million people, served by 453 different water supplies have, for generations used drinking water with a natural fluoride content from 1.5 to 8.0 parts per million. No definite evidence has been forthcoming that continued consumption of such water is in any way harmful to health. There have been no reports of evidence of changes in bone structure when the water supply contained less than 5 parts per million. "In a radiologic survey of 114 persons who had lived for at least 15 years at Bartlett, Tex., where the water supply contained 8 parts per million, 12 percent of those examined showed minimal X-ray evidence of increased density of the bones but in no case was there any deformity or interference with function. Medical examinations, which included urinalysis and blood counts, revealed no indication that the residents of Bartlett were less healthy than those of nearby Cameron, where the water contained only 0.3 part per million. Reports of bone Formerly Director, National Institute of Dental Research, National Institutes of Health. Effect of Fluoridated Public Water Supplies on Dental Caries Prevalence. Public Health Reports, by Francis A. Arnold, Jr., D. D. S., H. Trendley Dean, D. D. S., and John W. Knutson, D. D. S., Jr. P. H., vol. 68, p. 141, February 1953. Newburgh-Kingston Caries Fluorine Study V-Pediatric Aspects-Continuation Report, by Edward R. Schlesinger, M. D., David E. Overton, M. D., and Helen C. Chase, M. Sc., Journal American Public Health, vol. 43, p. 1011, August 1953. Unpublished memorandum. Copy in the files of Commission on Chronic Illness. Toxicological Evidence for the Safety of the Fluoridation of Public Water Supplies, by Francis F. Heyroth, M. D., Journal of American Public Health, vol. 42, p. 1568, December 1952. fluorosis in studies conducted in Italy, India, South Africa, and Argentina indicate similar relationships to the use of high fluoride bearing waters. "It is to be emphasized that the proponents of fluoridation of water recognize that excessive ingestion of fluorides is undesirable and that, where practical, they should either be removed by a treatment process or new sources of supply sought. They stress the necessity of keeping the fluoride content of drinking water below the level of that which causes mottled enamel, the most sensitive indication of an excess. 8 "On the hypothesis that a higher incidence of chronic disease would be reflected in higher mortality rates due to specific causes, the experience of cities with water supplies having a high fluoride content has been compared with that of cities having a low fluoride content. The most recent and comprehensive study of such data is one compiled by the United States Public Health Service and based on the 1949-50 census reports. In this analysis of mortality rates, all cities in the United States with 10,000 population or over in 1950, whose drinking water contained 0.7 part per million or more of fluoride naturally present were considered for inclusion. Each fluoride city was paired with the average of the three closest fluoride-free cities (with less than 0.2 part per million fluoride with populations of 10,000 and over. Deaths from cancer, heart disease, and nephritis per 100,000 population, adjusted for age, sex, and race in 28 fluoride and in 60 nonfluoride cities failed to show significant differences. "It is the contention of the minority that epidemiological studies or analysis of vital statistics cannot be relied upon to determine whether the condition of sick persons, such as those afflicted with chronic illness, particularly kidney ailments, would or would not be worsened by the ingestion of fluoridated water. Although the data are limited, experiments recently carried out at the National Institute of Dental Research on somewhat more than 50 cases who have evidence of damaged kidney function and who use drinking water containing 1 part per million of fluoride have come to our attention. The results indicate that the excretion pattern of fluorides in these patients with damaged kidneys is similar to that reported by McClure for healthy young men. The collection of negative evidence such as this for an absolute determination of no possible effect of fluorides in persons suffering from chronic illnesses is an endless and extremely complicated undertaking. Generally speaking, consideration of the primary factors in the causation of such illnesses far overshadows any minor or secondary effects which, in the light of present knowledge, could be assumed from ingestion of trace amounts of fluoride in drinking water." The commission has been advised by the foregoing expert opinion that extensive research into the toxicology of fluorine compounds has revealed no definite evidence that the continued consumption of drinking water containing fluorides at a level of about 1 part per million is in any way harmful to the health of adults or those suffering from chronic illness of any kind. While the evidence does not absolutely exclude this possibility, if a risk exists at all it is so minimal and inconspicuous that it has not been revealed in many years of investigation. The commission, therefore, urges American communities to adopt this publichealth measure as a positive step in the prevention of the chronic disease, dental caries. The fluoridation of water supplies involves no new experience in human welfare. Over 3 million people are living in ordinary good health on water naturally containing fluorides in the amounts recommended for caries control, or more. THE ROLE OF DENTISTRY IN CHRONIC ILLNESS [Reprinted by permission of Dental Health Highlights] The American people are showing increasing concern over the complex problems of chronic illness-its prevention and the need of adequate care for persons who are chronically disabled. The dental profession shares this concern and is working closely with representatives of other health professions who likewise have a stake in human rehabilitation. On March 18 to 20, a National Conference on Care of the Long-Term Patient was held in Chicago under the auspices of the commission on chronic illness. Some 400 representatives of 37 national health organizations and agencies learned that the overall-and almost overwhelming-problem of the care of the long-term patient is a problem of many segments, one of which is dental care. 8 Data in files of Commission on Chronic Illness. McClure, F. J., and Kinser, C. A., Fluoride Domestic Waters and Systemic Effects. Public Health Reports, vol. 59, p. 1575, 1944. Dr. David W. Brock,, chairman of the council on dental health, is the American Dental Association's official representative on the commission, and he and other dentists participated in the discussions. Dr. Brock presented to the conference the newly prepared statement adopted by the council on dental health entitled, "The Role of Dentistry in Chronic Illness." The statement, which is scheduled for publication in the May issue of the Journal of the American Dental Association, has five salient points which are listed in the following text: 1. A concept frequently overlooked is that many dental diseases are or may become chronic. Among these conditions are dental caries, gingivitis, advanced periodontal disease, and malocclusion. 2. Many of the major chronic illnesses have direct implications in the field of dentistry. Among these illnesses are diabetes mellitus, cancer, epilepsy, cerebral palsy, cardiovascular diseases, arthritis, cleft palate, tuberculosis, and nutritional disorders. 3. A serious problem exists in getting dental care to the bedfast patient, and dental societies and community groups can do much to develop programs to meet this need. 4. Community dental-health programs that lead to the prevention and control of dental diseases lead also to the prevention and alleviation of chronic illness and disability. 5. Good dental care is an important factor in contributing to the overall health and rehbilitation of persons who are chronically ill. The need for dental care of the long-term patient is not a subject for arbitrary consideration; it is a vital requirement in the rehabilitation of millions of persons. Therein lies the role of dentistry in chronic illness-as revealed by the facts that make up the council's statement. "MODEL WELFARE HOUSE" OPENED Morris County, N. J., has opened a new $1,151,750 "Model Welfare House" to house and provide care for its poor, chronically ill old men and women. Located near the top of Shonghum Mountain, the hospital is a 3-story, 138-bed structure, built in the shape of a Y. There are direct entrances on the ground level to the admitting room, kitchen, dining, smoking, recreational and occupational therapy rooms, chapel, morgue, and laundry. The dining room with a seating capacity of 112, is a half circle with the exterior wall of glass. The recreation room seats 160 persons and is adjacent to a large terrace facing the southwest. On the first floor are 48-bed wards for ambulatory men, two 8-bed and one 6-bed wards for ambulatory women, and three 2-bed rooms for men or women or couples. A nurse's station is located in the center of the rotunda to allow efficient control of administration of the wards. Bed patients are cared for on the second floor. There are 32 hospital beds for men and 22 for women, in addition to two 4-bed wards and three 2-bed rooms for either men or women. The top floor contains living quarters for the superintendent and 20 employees. Readers desiring further information on the "Model Welfare House" are referred to the January issue of The Welfare Reporter, official publication of the New Jersey Department of Institutions and Agencies, 135 West Hanover Street, Trenton. AMERICAN DENTAL ASSOCIATION, Hon. CHARLES A. WOLVERTON, Washington, D. C. DEAR CONGRESSMAN: For your information I am enclosing a copy of a special bulletin which is being distributed by the American Dental Association to its members. It relates to H. R. 2341. As you know, this bill proposes that Federal legislation be enacted which would prevent the fluoridation of community water supplies throughout the entire Nation. Fluoridation of water supplies is now in operation in nearly 1,000 United States cities and towns including Washington, D. C. The residents of these cities and towns number nearly 17 million. Fluoridation of water supplies has been demonstrated to be an effective, safe, and economical measure for the reduction of the incidence of tooth decay, particularly among children. In view of the importance of this matter the American Dental Association is asking its members to advise the Members of Congress on the subject of fluoridation in general and H. R. 2341 in particular. With all good wishes. Very truly yours, FRANCIS J. GARVEY, Secretary, Council on Legislation. INFORMATION BULLETIN To Members of the Dental Profession: The Wier bill, H. R. 2341, which is the subject of this issue of the ADA Information Bulletin, is a direct attack on the professional opinion of the overwhelming majority of dentists and physicians who have endorsed and recommended the fluoridation of community water supplies. Because of the importance of this health measure, it is requested that each member of the dental profession send immediately his views on the Wier bill, H. R. 2341, to the Member of Congress from his respective district and to the Honorable Charles A. Wolverton, chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D. C. DENTISTS URGED TO ADVISE CONGRESSMEN ON FLUORIDATION AS HEARINGS ARE CALLED ON BILL TO OUTLAW PROCEDURE The Committee on Interstate and Foreign Commerce of the United States House of Representatives has scheduled a public hearing at Washington, D. C., for May 25, 26 and 27 on a bill which proposes to prohibit the fluoridation of community water supplies throughout the Nation. The bill was introduced by Representative Wier (Democrat, Minnesota), of Minneapolis. The American Dental Association, which has repeatedly endorsed and recommended that fluoridation of community water supplies as a thoroughly safe, effective, and economical means of reducing significantly the incidence of tooth decay throughout the Nation, is strongly opposed to this bill, as are all other major national-health organizations in the United States. Members of the health professions are particularly concerned that a committee of the House of Representatives would at this late date attempt to bring back into the national political arena a completely nonpolitical issue which already has been decided by more than 40 years of extensive scientific research. The Wier bill itself is quite brief. The heading describes it as "a bill to protect the public health from the dangers of fluorination [sic] of water." The text of the bill follows: Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That no agency of the Government of the United States (including the government of the District of Columbia, and of each Territory and possession of the United States), and no agency of any State, or of any municipality or other political subdivision of a State, shall treat any public water supply with any fluoride compound, or make any water so treated available for general use in any hospital, post office, military installation, or other installation or institution owned or operated by or on behalf of any such agency. Obviously, there are grave doubts as to the constitutionality of this proposed bill which would have the Federal Government begin making decisions on health matters for local communities. There are also reasonable doubts that the measure, even if amended to meet tests of constitutionality, would ever come close to passage by either the House of Representatives or the Senate. Since May 1952, water supplies of the District of Columbia have been fluoridated with the consent of both Houses of Congress. The opponents of fluoridation will attempt to utilize the public hearings on the Wier bill as another sounding board for their oft repeated but totally unfounded charges that fluoridation of water is harmful. To the extent that these hearings can be used to delay the adoption of fluoridation projects in communities where they have been recommended by local health authorities-to that extent the whole affair will actually be harmful to the future dental health of all the children of those communities. |