12. Bull, F. A., Dental Director, Wisconsin State Board of Health. Sheboygan survey-Deciduous teeth. October 8, 1951. 13. Bull, F. A., Dental Director, Wisconsin State Board of Health, Sheboygan survey-Permanent teeth. November 5, 1951. 14. Hill, I. N., Blayney, J. R., and Wolf, W.: The Evanston dental caries study. Vi. A comparison of the prefluoride with the postfluoride caries experience of 6-, 7-, and 7-year-old children in the study area (Evanston, Ill). Jnl. Dent. Res. 29:534 (Aug.) 1950. 15. Bellinger, W. R., Director, Division of Dental Hygiene, Kansas State Board of Health. Prelim. Report on Ottawa, Kansas, Caries-Fluoridation Project. Dec. 1951. 16. Frisch, J. G., Chairman, Wisconsin Dental Society Fluorine Study Committee. Report on Madison, Wisconsin, after 31⁄2 years of fluoridation with hydrofluoric acid. Dane County Dental Society and the Madison Department of Health. December 1951. 17. Dean, H. T., Arnold, F. S., Jr., Jay, P., and Knutson, J. W.: Studies on mass control of dental caries through fluoridation of the public water supply. Pub. Health Rep. 65: 1403 (October 27) 1950. 18. Ast, D. B., Finn, S. B., and Chase, H. C.: Newburgh-Kingston caries study III. Further analysis of dental findings including the permanent and deciduous dentitions after four years of water fluoridation. Jnl. Am. Dent. Assn. 42: 188 (Feb.) 1951. 19. Stadt, Z. M.: The Charlotte Fluoridation Demonstration. Jnl. North Carolina Dental Society. 35:53 (Jan.) 1952. 20. Erlenbach, F. M., and Tracy, E. T.: Control of Dental Caries by fluoridation of a water supply. Second year. Conn. Health Bull. (Sept. 1949 reprint). 21. Taylor, E., Dental Director, Texas State Bd. of Health. 1946-51 comparison of dental findings. 22. Hill, I. N., Blayney, J. R., and Wolf, W.: The Evanston dental caries study VII. The effect of artificially fluoridated water on dental caries experience of 12-, 13-, and 14-year-old school children. Jnl. Dent. Res. 30: 670 (Oct.) 1951. 23. Pelton, W. J.: Water fluoridation benefits at Lewiston, Idaho. American Dental Association Council on Dental Health Newsletter, Vol. 6, No. 7 (July 7) 1950. 24. Dean, H. T.: The advancement of fluoridation. Jnl. Am. Water Works Assn. 43: 17 (Jan.) 1951. 25. Dean, H. T.: Endemic dental fluorosis or mottled enamel. Jnl. Am. Dent. Assoc. 30: 1278 (Aug.) 1943. 26. Stadt, Z. M., and Phillips, R. S. Unpublished report. 27. DeCamp, F. H., Dental Director, Florida State Board of Health. Personal communication. [Reprinted from Journal of the National Medical Association, September 1953, vol. 45, No. 5, pp. 350-353] 1 FLUORIDATION IN THE PREVENTION OF DENTAL CARIES Clifton O. Dummett, D. D. S., Chief, Dental Service, Veterans' Administration Hospital, Tuskegee, Ala. It is significant and appropriate to begin this discussion on fluoridation with a statement by Col. John R. Wood, who is chairman of the Medical Research and Development Board of the Office of the Army Surgeon General. He told the American Pharmaceutical Manufacturers Association, "Badly needed is more research to find ways of preventing the enormous waste of human teeth. More than 40 percent of men entering the services in World War II needed immediate treatment to save their teeth about to be lost, and one-third of them needed treatment for toothaches. Five percent need new teeth to have enough to chew with. Even to date, our troops are losing collectively well over a million teeth per year. The cost of this care, at the most conservative civilian rate, exceeds $18 million a year. Yet, only about a million dollars a year are being spent on dental research, only part of that on methods of halting this waste." This statement by a physician discussing the topic of dental research to a group of pharmacists is illustrative of the relationships that exist between these professions. 1 Presented to a joint session of the Indiana State Medical, Dental, and Pharmaceutical Associations, May 20, 1953, Gary, Ind. Published with the permission of the Chief Medical Director, Veterans' Administration, who assumes no responsibility for the opinions expressed by the author. There is among the American people, a great need for more adequate dental services. This need has become recognized because much greater emphasis is being placed on the necessity and importance of visiting dentists regularly. The inability to fulfill a large portion of this need has occupied the attention of members of the dental profession. The dearth of personnel and facilities for training are conditions of which everyone is aware. It has become necessary, therefore, to attack the problem on limited fronts. Today when a dental program is established in a community, it is common for the dentist to limit his services almost entirely to emergency dental care. Such a program is certainly not satisfactory. Similar limitations occur in dental public health programs. There is a tremendous need for more adequate dental care for children. An apathetic attitude exists on the part of many people toward dental diseases insofar as they affect children. Such a commonplace acceptance of dental disease in children constitutes a real danger and an obstacle to progress in dental public health. Often heard are statements that the problem is too great to attack or that dental disease lacks in public appeal. Dental caries is the first disease that has come in for a concerted attack by dental researchers, who have been responsible for the accumulation of much important information on the topic of fluoridation. It is well established that certain preventive dental procedures are known to reduce the incidence of dental caries if they are applied at an early period. Some control of dental caries can be accomplished by the restricted use of refined carbohydrates, the use of topically applied fluorides to the teeth, the controlled fluoridation of municipal water supplies and the proper use of the toothbrush especially following the consumption of fermentable sugars. The use of fluorides, especially the fluoridation of public water supplies is rapidly developing into a comprehensive nationwide movement. The division of dental public health of the United States Public Health Service considers the promotion of controlled fluoridation, its priority one project. This is also true of the divisions of dental health of State health departments of this country as well as dental society groups. The committees of workshop, public relations, and dental health of the Tennessee State Dental Association recently conducted a workshop which had as its theme, "Help yourself to water fluoridation." The Institute of Public Health which was presented by the Dental Service of the Veterans' Administration Hospital in Tuskegee, Ala., in March 1952, had as one of its objectives. the presentation of modern scientific information about water fluoridation. Basically, this institute stressed the fact that all individuals interested in dental health should think, plan, and work together toward the goal of better dental and general health. The controlled fluoridation of water is a start in the right direction. If there is to be a solution to the dental caries problem, it will come through prevention. If prevention is to progress in eliminating the vast reservoir of untreated dental caries for future generations, preventive means must be applied to large segments of the population. Discouraging the sale and limiting the use of sugars, though effective in reducing caries, are not procedures that are readily followed. Human beings are not easily dissuaded from the use of refined carbohydrates. It would seem that the best means of reaching the entire population equitably is through a community water supply. Water is a commodity that is consumed consistently by all persons. It is highly advisable that any agent used for the purpose of reducing dental decay for the entire population should have five important requisites: (1) it must be of unquestionable value, (2) it must be relatively inexpensive, (3) it must be safe to use, (4) it must be easily utilized on a population basis, and (5) it must require little or no effort on the part of the individual benefited. It would appear that water fluoridation or the treatment of a communal water supply meets the requirements of a preventive agent most adequately. Nowhere in medicine, pharmacy, or dentistry has a preventive agent had such a vast amount of irrefutable evidence to recommend it and so little reliable confirmed evidence against it. The large amount of epidemiological and experimental evidence that has gone into the establishment of the fluorinecaries hypothesis is most impressive. As early as 1867, Magitot suggested that fluorine was associated in some way with the integrity of the tooth. In 1892, Sir Crichton Brown writing in the British medical journal, Lancet, indicated that teeth contained more fluorine than any other tissue in the body and that the fluorine was there to pre vent dental decay. In He suggested that foods rich in this element should be incorporated in the diet of children for that purpose. From 1908 to 1916, Drs. Black and McKay thoroughly studied the pathological condition of the teeth endemic among those reared in certain limited areas of southwestern United States. Among these individuals the teeth were poorly formed, stained, and pitted. To this disfiguring disease, they applied the term "mottled enamel." They observed that "mottled enamel" could be acquired only if persons resided in those areas during the period of tooth formation. Once acquired, it remained for life. They further observed that people moving into these areas after their teeth were formed did not acquire this disease. They established the fact that the cause of mottled enamel was in some way waterborne. 1931 through chemical analysis of water and through animal experiments, it was discovered that mottled enamel was caused by excessive amounts of fluorine in the drinking water supply. In 1938, Dean and his associates reexamined these endemic areas of southwestern United States and other areas in the Midwest where fluorosis was endemic. They found that the severity of the fluorosis was directly proportional to the fluorine content of the water consumed. Esthetically significant, mottling occurred only in individuals consuming over 1.5 parts per million of fluorine. The epidemiological studies of Dean and his associates further indicated that individuals consuming water containing one or more parts per million of fluorine had approximately 60 percent less dental caries than individuals in neighboring communities where fluorine-free water was consumed. They also made the important deduction that the reduction in dental caries was not inversely proportional to the fluorine content of the water supply. As a matter of fact there was just as great a reduction when the water contained 1 part per million of fluorine as when it contained 14 parts per million, and furthermore, one did not get disfiguring fluorosis. These observations by Dean and others from different areas of the world received additional confirmation from animal experiments and from chemical analyses of the fluorine content of sound and carious teeth. Recent studies indicate that this resistance to caries once acquired persists throughout life. There are actually 8 million persons in the United States consuming natural water containing 1 part per million of fluorine or over. The question soon presented itself as to why could not fluorine be added artificially to the water supplies in areas where fluorides were deficient. In 1938, Cox, speaking before the Pennsylvania Waterworks Association, suggested artificial fluoridation. By 1945 a number of communities in the United States were fluoridating their water on a demonstration basis. One of the community demonstration projects was the Newburgh-Kingston study which was initiated in 1944 by the New York State Health Department. A principal investigator in this project was Dr. Sidney Finn, now a faculty member of the University of Alabama's Dental School and consultant to the Dental Service of the Veterans' Administration Hospital Hospital in Tuskegee. For this demonstration project, Newburgh, N. Y., 60 miles above New York City, had its water fluoridated with 1.2 parts per million of sodium fluoride on May 2, 1945. Kingston, a similar sized city 30 miles above Newburgh, continued to drink fluorine-free water and served as a control. Annual dental examinations were made on the entire school populations of over 300 children in each city. At the end of 4 years, laboratory, clinical, and roentgenographic examinations all showed a markedly reduced caries activity in the schoolchildren of Newburgh. Medical studies were carried on at the same time to determine whether or not there were toxic systemic effects. Complete physical examinations consisting of height and weight measurements, examination of body organs, blood counts and hemoglobin, urinalysis, roentgenograms of long bones and ossification centers, visual acuity tests and audiometric examinations were made on the children in Newburgh and Kingston. After 7 years of fluoridation, no difference has been noted between the children of the 2 cities. There are several fluoride compounds available for water fluoridation. Among these are sodium fluoride, hydrofluoric acid and sodium silicofluoride. For small cities and towns sodium fluoride is recommended. Because of its solubility it is readily adaptable for use in inexpensive feeding equipment and the chemical is available in moderately abundant supply. It is a white crystalline salt which in commercial form is dyed nile green or light blue to distinguish it from other salts that are white. It is a very toxic substance, four or five grams, or a tablespoonful being a fatal dose. Yet in quantities of one part per million of fluoride it is perfectly safe to use in communal water supplies. One part per million is a very small amount. If one drinks on the average of 2 quarts of water a day containing 1 part per million of fluorine, he consumes roughly 4 milligrams of sodium fluoride. Since 4 grams or one tablespoonful is a lethal dose, to get this amount, one would have to consume one thousand times the amount of water he normally drinks in a day at one time, or 500 gallons of water at one sitting. One quarter of a gram of sodium fluoride when swallowed at one time may produce nausea and vomiting. In terms of fluoridated water, instead of the customary 2 quarts a day, one would have to drink 125 times that much or 63 gallons at one time. Those opposing fluoridation insist that fluoridated water might produce crippling fluorosis. This is observed only in areas where the residents consume at least 20 milligrams of fluoride a day over a period of 10 to 20 years. In the case of water fluoridation at 1 part per million of fluorine, instead of 2 quarts of water a day one would have to drink at least 2 gallons of water daily over a 10 to 20 year period, which is again over 10 times the average daily water consumption. Hodge, of the University of Rochester, has said that it is impossible to imagine any set of circumstances in which the fluoride content might become sufficient to bring about chronic high-grade fluorosis. There are many instances that can be cited where a chemical may be lethal in large amounts and beneficial in small amounts. Although iodine is a poison, small amounts of it are essential for the maintenance of life. Chlorine is used to kill bacteria in water supplies. It is common knowledge that it was used as a poison gas in the First World War. Even common table salt if consumed in large quantities may produce death. Sodium fluoride is another example of a chemical which might be toxic in large quantities, but is beneficial when used in small quantities. The evidence corroborating dental health benefits derived from waterborne fluorides is so overwhelmingly abundant that the measure is now endorsed by important international, national and local groups concerned with health. These organizations and agencies include the interassociation committee which is composed of the American Dental Association, the American Medical Association, the American Hospital Association, the American Nurses Association, the American Public Health Association and the American Welfare Association. There are several other endorsers of fluoridation: among them are the Federation Dentaire Internationale, the National Research Council, the United States Public Health Service, the State and Territorial Health Officers, the State and Territorial Dental Health Directors, the American Association of Public Health Dentists, a large majority of State dental societies, many State health departments, an increasing number of State medical societies and hundreds of county dental and medical groups, boards of health, local professional organizations and lay organizations such as the Jaycees, Rotarians, Lions, and Kiwanis. The impressive list of reponsible health groups which have endorsed fluoridation should be enough to challenge every dentist, physician, pharmacist, nurse, health officer, health worker, and every citizen to foster fluoridation in needed areas. In many instances the initiative of fluoridation comes through a dentist or local dental group, but there is no reason why health officers, health educators, physicians, or other members of the professions and communities cannot initiate the promotion. After the local dental group has endorsed the program, support should be sought from the medical group at a meeting of physicians alone or a combined meeting of physicians and dentists. In small communities it should be possible for the dentists to give leadership, and gain the broad support of many civic organizations without any loss of time. When all these groups have passed resolutions on behalf of fluoridation at meetings where the subject has been presented, then the matter should be brought to the board of health for its action. Finally, a delegation representing the various professional and lay organizations endorsing the measure should present the proposal to the governing body of the community for its approval. From the very beginning and all through the planning steps, the water plant operator should serve as a consultant to the principal organization or committee promoting fluoridation. Every meeting on fluoridation and every endorsement or resolution favoring the proposal should be widely publicized in the press and on the radio. A series of prepared articles should be published in the newspapers to enlighten the people of the community. Approximate initial costs and all subsequent annual costs should be established and there should be some estimation of the per capita cost initially and per annum thereafter. Because of the large number of approved programs in operation and because of the benefits reported from the study areas, promotion of fluoridation as a rule will not encounter objections from anyone. However, there are some tenacious opponents who may oppose it. They will accuse the proponents of every conceivable form of misrepresentation. Occasionally these persons may poison the minds of a sufficiently large number of people, so that the early development of a fluoridation program will be forestalled. In such cases it is absolutely essential to be patient but firm, for in many instances their arguments will be the source of their own defeat. It must be repeatedly emphasized that fluoridation may prevent only as much as 50 to 60 percent of dental caries. It is not 100 percent dental caries preventive. Unless there is a sustained program of dental health education, there is a great likelihood that over the years, people may develop a false sense of dental health security. For this reason, it is essential for dentists and physicians to continue to stress the need for a program of early, regular dental care to prevent tooth loss. The need for moderation in the consumption of carbohy drates, and the necessity for brushing or rinsing the teeth immediately after eating are very important additional essentials. THE NEW JERSEY STATE DENTAL SOCIETY, May 18, 1954. Hon. CHARLES A. WOLVERTON, Chairman, Interstate and Foreign Commerce Committee, DEAR SIR: I am writing at this time in connection with the scheduled hearings on the Wier bill (H. R. 2341) which I understand are to be held on May 25, 26, and 27. As chairman of the council on fluoridation of the New Jersey State Dental Society, I am, naturally, most interested in the disposition of this bill. I have been following the reports in dental and medical literature on the investigation of the possible harmful effects of fluoridation on health, and in the many years of review I find that there is no authenticated indication that any effects other than a sharp decrease in the amount of dental decay results from the introduction of the recommended amount of fluoride ion to drinking water. Anyone who takes the trouble to review the literature on the subject cannot help but be impressed by the pains to which these investigators have gone to exhaust all the possibilities of any ill effects, not only on the general health of the individual, but of any possible detrimental effect on any industrial process or product. The conclusions are uniformly the same, and have been reconfirmed over and over again. In addition to all this work done in areas where the fluoride ion has ben artificially added to the drinking water, we have the unique situation where statistics are available on the health, birth rate and death rate, incidence of various diseases, etc. in those areas of our country where the fluoride ion exists naturally in the drinking water, and where some 31⁄2 million persons have been ingesting this water all their lives. Medical societies have reported that in these areas where fluoride has been present for generations the rate of birth, death, sickness, bone fracture, etc., is approximately the same as in any other part of the country. There are those who maintain that such may be the case in naturally fluoridated areas but they imply that artificially added fluoride ion will have a totally different effect. It is a well-known truism of chemistry that an ion of fluoride (or of any element) is uniformly identical, regardless of source. In this connection I quote from A. P. Black, head of the department of chemistry, University of Florida, Gainesville: "There are no physical or chemical differences of any kind between fluorides naturally present in the water and fluorides being added in any forms presently being used in this country * these ions are identical, and it is not logical to suppose that the same ions in water would produce different effects, depending whether they were naturally present or have been added ***. The effects of natural fluorides and added fluorides in reducing dental caries are identical for the same concentration. This has been conclusively shown by comparison of the Grand Rapids and Newburgh data with data from the same age groups at Aurora, Ill., where fluorides are naturally present. The same conclusions have been reached in numerous other studies conducted throughout the country." The overwhelming weight of evidence leads us to but one conclusion: that there is not a shred of scientific evidence that sodium fluoride in drinking water |