So that you may know the extent to which commuities throughout the country have already accepted the fluoridation of public water supplies I am attaching to my statement as appendix D a list of the communities throughout the country which, according to information compiled by the association's council on dental health, are already adjusting their water supplies so that they contain the optimal amount of fluoride ion. You will notice that this list includes 944 communities in 43 States. The list is current as of May 14, 1954, just 2 weeks ago.

In conclusion, I thank you on behalf of the association for the opportunity to be present today to offer this testimony in support of a program of inestimable value to the people of the United States. The scientific aspects of the program will be discussed in detail by Drs. Dean and Doty, who will follow me. I hope that you will see fit to defeat this bill and by so doing to help in the improvement of the dental health of American citizens.

(The appendixes referred to follow :)

E. AUBREY Cox, M. D.,

APPENDIX A

Committee Chairman, City of Wichita Falls,

Wichita Falls, Tex.

MARCH 25, 1954.

DEAR DR. Cox: The American Cancer Society does not consider fluorine or the common fluorine salts to be carcinogenic. Its position, therefore, with respect to water fluoridation for the purpose of dental caries prophylaxis, is that such treatment of public water supplies is without danger so far as cancer causation is concerned.

The evidence is as follows:

(1) Laboratory:

(a) Sodium fluoride does not accelerate the growth of established Walker rat sarcoma in experimental animals.1 This is a standard test tumor widely used in biological testing of growth stimulating or inhibiting compounds.

(b) Sodium fluoride appears to actually inhibit the development of spontaneous mammary carcinoma in mice."

(c) Extensive toxicity studies of fluorine and its compounds, under numerous auspices, have failed to show that they have any cancer-causing or cancer-accelerating effects.

(d) The report of Alfred Taylor, Ph. D., of the biochemistry department of the University of Texas Medical Branch, that fluorine-containing water accelerated the appearance of breast tumors in CH mice (which are genetically highly sus ceptible to breast cancer) has been effectively countered by Dr. Edward Taylor,' who quoted the findings of two scientists of the National Cancer Institute after a review of Alfred Taylor's work: "Dr. Howard Andervont and I (Dr. H. T. Dean) have carefully evaluated the data with respect to the alleged relation of fluoride water to an accelerated rate in the development of mammary tumors and are of the opinion that the evidence adduced does not warrant any modification in the policy of recommending fluoridation of public water supplies for the partial control of dental caries."

(2) Epidemiologic:

(a) Swanberg has shown that the death rate from cancer in Grand Rapids, Mich., was 206/2/100,000 in the year 1944; that fluoridation was begun in that

1 Effect of Fluoride on Tumor Growth: Finerty, J. C., and Grace, J. D., Texas Reports on Biology and Medicine 10, 3 p. 501, 1952.

2 Tannenbaum, A., and Silverstone, H. Effect of Low Environmental Temperature Dinitrophenol, or Sodium Fluoride on the Formation of Tumors in Mice, Cancer Research, 9, 7, p. 385, 1949.

3 Taylor, E., Facts Relative to Tumors That Fluoridation is Harmful, Texas Dental Journal, p. 381, September 1951.

Swanberg, Harold, Fluoridation of Water and Its Relation to Cancer, Mississippi Valley Medical Journal, 75: 125-128, September 1953.

city in January 1945; and that the death rates per hundred thousand of population for succeeding years were as follows:

(b) A comprehensive study by the United States Public Health Service was based on all cities in the United States having population of 10,000 and over whose water contained 0.7 part per million or more fluoride naturally present, on one hand, and 0.2 part per million or less, on the other. No significant difference between the age adjusted death rates from cancer, heart disease, and nephritis in the 28 high-fluoride cities and the rates in 60 low-fluoride cities could be found.

(c) Studies of breast cancer incidence rates in 13 Texas cities divided into 3 groups according to fluoride content of drinking water showed that the rate was lower in cities with high fluoride content than in cities with low content. I trust the above provides you with helpful data. Needless to say, I shall be Eglad to be of any further help I can.

Sincerely yours,

CHARLES S. CAMERON, M. D.

APPENDIX B

POLICY OF THE AMERICAN DENTAL ASSOCIATION

Whereas numerous studies have demonstrated a decreased incidence of dental decay associated with the presence of fluoride occurring naturally in drinking water; and

Whereas there is a rapidly accumulating body of data derived from direct studies of the artificial addition of fluoride to drinking water; and

Whereas these data provide convincing evidence of the safety of this procedure and of its benefits in terms of reduced incidence of dental caries: Therefore be it

Resolved, That in the interest of public health, the American Dental Association recommends the fluoridation of municipal water supplies when the fluoridation procedure is approved by the local dental society and utilized in accordance with the standards established by the responsible health authority; and be it - further

Resolved, That the American Dental Association recommends the continuation of controlled studies of the benefits derived from the fluoridation of water = supplies.

APPENDIX C

INTERASSOCIATION COMMITTEE ON HEALTH

1790 Broadway, New York 19, N. Y.

MEMBER ASSOCIATIONS

American Dental Association

American Hospital Association

American Medical Association

American Nurses Association

American Public Health Association

American Public Welfare Association

STATEMENT OF INTERASSOCIATION COMMITTEE ON HEALTH

The following statement was unanimously approved by the member organiza=tions of the Interassociation Committee on Health-American Dental Association, American Hospital Association, American Medical Association, American Nurses Association, American Public Health Association, American Public Welfare Association:

Same as footnote 3.

Since scientific reports published 35 years ago on the prevalence of endemic dental fluorosis in the United States, evidence has accumulated demonstrating the influence of small amounts of fluoride on dental health. Too much fluoride in drinking water results in a condition known as dental fluorosis, or mottled enamel; too little is associated with a high dental caries-experience rate. Between these two extremes, however, there is an optimum concentration of fluoride of about 1 part per million which effectively prevents a substantial amount of dental caries without causing dental fluorosis.

The problem of uncontrolled dental caries.-In the average community not benefiting from fluorides in its water supply, up to 50 percent of the 2-year-old children have 1 or more carious teeth, and the caries attack continues at a high rate to the extent that 95 percent of the population is affected. Dental caries results also in considerable cost for corrective dental services throughout an individual's lifeime.

Unimpeded by preventive measures, dental caries creates a health problem of considerable magnitude because of its high rate of occurrence and its numerous sequelae that result from neglect. Dental defects thus created are accumulating at a rate 4 to 5 times faster than can be corrected by presently available dental personnel. Sound public health practice, therefore, requires a reduction in the size of the problem by the use of effective preventive measures; especially those measures which are applicable on a widespread basis and benefit all persons in the community.

Epedemiological studies. Epedemiological studies in many areas throughout the United States and abroad have shown that, within certain limits, a consistent inverse relationship exists between the fluoride content of drinking water and the amount of dental caries experience in children, particularly those using fluoride-bearing water continuously since birth. It has been found also that a concentration greater than about 1 part per million, provides little, if any, additional benefit. As the concentration increases beyond 2 parts per million, an increasing number of persons has fluorosed enamel that is easily detectable. Numerous investigations have shown that people reared in areas where drinking water contains approximately 1 part per million of fluorine have experienced only about one-third as much dental caries as those reared in areas where the water supplies are fluorine free. Evidence indicates also that the benefits are retained throughout life.

Studies on controlled fluoridation.-Studies begun in 1945 indicate that a similar degree of protection against dental caries is found in areas where the fluorine content has been adjusted to an optimum level as is found in areas where the same concentrations occur naturally. Statistical data show a significant reduction of dental caries in children and there is also evidence to suggest some protection to the teeth of persons who were young adults when fluoridation was undertaken. Continued observations will establish the ultimate degree of effectiveness in older age groups who used fluoridated water during childhood. Studies on safety of fluoridation.—There is extensive literature on the pharmacology and toxicology of fluorides. The reports include laboratory investigations as well as studies conducted among people who have lived continuously in areas where the drinking water contains high concentrations of fluorides. The most sensitive indication of an adverse physiological effect of fluoride ingestion is an enamel defect known as dental fluorosis. Accumulated experience provides no evidence that the prolonged ingestion of drinking water with a mean concentration of fluorides below the level causing dental fluorosis has any harmful effect.

A program involving the adjustment of the concentration of fluoride content in the municipal water supply is especially practical and safe because it is constantly subject to control by competent health authorities and does not require action on the part of individual citizens.

Cost and engineering aspects.-The cost of fluoridation is small considering its benefits. The cost of equipment has been found to range from several hundred dollars for a small town to about $15,000 for a city of 2,500,000 persons. Annual operating costs vary from 4 to 14 cents per person. These amounts are insignificant when compared with the costs of dental corrective services throughout a person's lifetime.

According to the American Waterworks Association, the addition of fluorides to a municipal water supply is feasible from an engineering standpoint. The mechanics of fluoridation are no more involved than those of water purification; moreover, the machinery and equipment commonly used in water plants is easily adapted. Through experience in towns and cities now fluoridating their

drinking water, standardized procedures have been developed which include appropriate supervision by official health authorities.

Need for wider adoption of fluoridation.-Although studies are still being conducted to determine the greatest amount of protection that may be realized from fluoridation, there is ample evidence to justify its use in any community where the water supply is deficient in fluorides and where the standards established by the State and local health authorities can be met.

There is evidence that the beneficial effects of fluoride-bearing water are obtained only after several years of continuous use. Every year that fluoridation is postponed, many thousands of children are deprived of the dental benefits which they might otherwise have obtained.

In order that this effective, inexpensive, and safe public-health measure may be adopted by additional communities as rapidly as possible, fluoridation must receive the continuing and active support of all professional, civic, and official organizations concerned with the health and welfare of the public.

National health organizations with policies favorable to fluoridation.—American Dental Association, American Medical Association, American Public Health Association, American Association of Public Health Dentists, United States Public Health Service, National Research Council, State and Territorial Health Officers Association, and State and Territorial Dental Health Directors. Resolved, That the Interassociation Committee on Health urges fluoridation of the fluoride-deficient public water supplies of this country as rapidly as plans can be approved by the local medical, dental, and health department officials and the State departments of health.

(Signed)

GEORGE BUGBEE,

Secretary.

APPENDIX D

AMERICAN DENTAL ASSOCIATION COUNCIL ON DENTAL HEALTH

STATUS OF FLUORIDATION IN THE UNITED STATES, ITS TERRITORIES AND POSSESSIONS,

MAY 14, 1954

1

In 944 communities in 43 States, the District of Columbia, the Panama Canal Zone, and Puerto Rico 16,847,209 persons are drinking water with controlled amounts of fluoride added, according to reports received in the ADA central office. In 1,152 communities in 44 States 3,570,021 persons are drinking water with a natural content of 0.7 to 2.0 parts per million of fluoride.2

In the United States, its Territories and possessions 20,417,330 persons are drinking water containing optimum amounts of fluoride.

Approximately 105 million persons in the United States (66 percent of the total United States population) are living in areas served by 16,750 public water supplies.'

In the United States 19.4 percent of the people served by public water supplies are drinking water containing optimum amounts of fluoride.

Controlled amounts of fluoride are being added to the water supplies of the following United States communities:

Inquiries for information on communities starting programs after May 14, 1954, should be addressed to the respective State health departments or the U. S. Public Health Service, Division of Dental Public Health, Washington 25, D. C.

2 USPHS report, March 31, 1953, PHS, IV and V.

NOTE. Communities indented are served by community above.