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Home My WebLink AboutFluoridationresearch on fluorides and fluoridation', does not exist, certainly none investigating safety." -Dr. P. Mullenix, Ph.D., research scientist, 1997 letter to Calgary Councillors. "Many individuals with impeccable credentials in science, dentistry, and medicine have published incontrovertible evidence that fluoridation is harmful and does not reduce the incidence of dental caries". -Dr. A. Schatz, Ph.D., co -discoverer, at age 23, of the first effective treatment against tuberculosis — streptomycin —1997 letter to Calgary Councillors "Fluoride is an accumulative poison which accumulates in the skeletal structures, including the teeth, when the body is exposed to small daily intakes of this element. ...it is like lead accumulation in the bone until saturation occurs and then lead poisoning sets in." -Dr. P.H. Phillips, biochemist, University of Wisconsin "...the evidence is quite convincing that the addition of sodium fluoride to the public water supply at one part per million is extremely deleterious to the human body.... Prior to my hearing this case, I gave the matter of fluoridation little if any, thought but I received quite an education, and noted that the proponents of fluoridation do nothing more than try to impugn the objectivity of those who oppose fluoridation." -Supreme Court Justice J.P. Flaherty - former Chairman of the Pennsylvania Academy of Sciences - in a 1979 letter to the Mayor of Auckland, N.Z. "I am appalled at the prospect of using water as a vehicle for drugs...." -Dr. C.G. Heyd, former President of the American Medical Association "...When medical practitioners everywhere also recognize the severity of the problems of chronic fluoride toxicosis, and laws mandating truly safe drinking water are sincerely enforced, the health of millions will dramatically improve...." -The late Dr. George L. Waldbott, author of "Fluoridation, the Great Dilemma" "Fluorine is a general protoplasmic poison, but the most important symptoms of chronic fluorine poisoning known at present are mottling of the teeth and interference with bone formation." -DeEds F, Fluorine in Relation to Bone and Tooth Development, JADA, 23, 1936, p 574 "...no laboratory test has ever shown that 1 part per million fluoride in the drinking water reduces tooth decay." -Chief Dental officer, British Ministry of Health and Social Security, December 11, 1980. Fluoride & Your Body: FLUORIDE ACCIDENTS & POISONINGS Fluoride, the active ingredient in many pesticides and rodenticides, is a powerful poison - more acutely poisonous than lead. Because of this, accidental over -ingestion of fluoride can cause serious toxic symptoms. Each year there are thousands of reports to Poison Control centers in the United States related to excessive ingestion of fluoride toothpastes, mouthrinses, and supplements. Water fluoridation accidents, resulting in excess levels of fluoride in water, have been one of the sources of acute fluoride poisoning. FLUORIDE & DENTAL FLUOROSIS Excessive ingestion of fluoride during the early childhood years can damage the tooth - forming cells, leading to a defect in the enamel known as dental fluorosis. Teeth impacted by fluorosis have visible discoloration, ranging from white spots to brown and black stains. According to the Centers for Disease Control, 32% of American children now have some form of dental fluorosis, with 2 to 4% of children having the moderate to severe stages (CDC 2005). According to Dr. Hardy Limeback, Head of Preventive Dentistry at the University of Toronto, "it is illogical to assume that tooth enamel is the only tissue affected by low daily doses of fluoride ingestion. FLUORIDE & ALLERGY/HYPERSENSITIVITY As acknowledged by the Physicians' Desk Reference, some individuals are allergic/hypersensitive to fluoride. The largest, government -funded, clinical trial found that 1 % of individuals exposed to 1 mg/day of fluoride exhibited allergic/hypersensitive reactions, including skin reactions, gastric distress, and headache. FLUORIDE & the KIDNEYS The kidneys play a vital role in preventing the build-up of excessive fluoride in the body. Among healthy individuals, the kidneys excrete approximately 50% of the daily fluoride intake. However, among individuals with kidney disease, the kidneys' ability to excrete becomes markedly impaired, resulting in a build-up of fluoride within the body. It is well recognized that individuals with kidney disease have a heightened susceptibility to the cumulative toxic effects of fluoride. Of particular concern is the potential for fluoride, when accumulated in the skeletal system, to cause, or exacerbate, renal osteodystrophy - a bone disease commonly found among people with advanced kidney disease. In addition, fluoride has been definitively shown to poison kidney function at high doses over short-term exposures in both animals and humans. The impact of low doses of fluoride, given over long periods of time, has been inadequately studied. A recent animal study, conducted by scientists at the US Environmental Protection Agency (Varner 1998), reported that exposure to just 1 ppm fluoride caused kidney damage in rats if they drank the water for an extended period of time, while a new study from China found an increased rate of kidney disease among humans consuming more than 2 ppm (Liu 2005). Hence, the adverse effects to kidney function that fluoride causes at high doses over short periods of time, may also be replicated with small doses if consumed over long periods of time. FLUORIDE & the BRAIN Fluoride's ability to damage the brain represents one of the most active areas of research on fluoride toxicity today. Concern about fluoride's impact on the brain has been fueled by 18 human studies (from China, Mexico, India, and Iran) reporting IQ deficits among children exposed to excess fluoride, by 4 human studies indicating that fluoride can enter, and damage, the fetal brain; and by a growing number of animal studies finding damage to brain tissue (at levels as low as 1 ppm) and impairment of learning and memory among fluoride - treated groups. According to the US National Research Council, "it is apparent that fluorides have the ability to interfere with the functions of the brain." FLUORIDE & the PINEAL GLAND In the 1990s, it was discovered that the pineal gland is a major site of fluoride accumulation within the body - with higher concentrations of fluoride than either teeth or bone. Subsequent animal studies indicate that the accumulation of fluoride in the pineal gland can reduce the gland's synthesis of melatonin, a hormone that helps regulate the onset of puberty. Fluoride -treated animals were found to have reduced levels of circulating melatonin and an earlier onset of puberty than untreated animals. The scientist who conducted the research concluded: "The safety of the use of fluorides ultimately rests on the assumption that the developing enamel organ is most sensitive to the toxic effects of fluoride. The results from this study suggest that the pinealocytes may be as susceptible to fluoride as the developing enamel organ" (Luke 1997). The fact that fluoride's impact on the pineal gland was never studied, or even considered, before the 1990s, highlights a major gap in knowledge underpinning current policies on fluoride and health. According to the US National Research Council, "any agent that affects pineal function could affect human health in a variety of ways, including effects on sexual maturation, calcium metabolism, parathyroid function, postmenopausal osteoporosis, cancer, and psychiatric disease." FLUORIDE & the THYROID GLAND According to the US National Research Council, "several lines of information indicate an effect of fluoride exposure on thyroid function" - particularly among individuals with an iodine deficiency. Fluoride's potential to impair thyroid function is most clearly illustrated by the fact that -- up until the 1970s -- European doctors used fluoride as a thyroid -suppressing medication for patients with hyperthyroidism (over -active thyroid). Fluoride was utilized because it was found effective at reducing the activity of the thyroid gland - even at doses as low as 2 mg/day. Today, many people living in fluoridated communities are ingesting doses of fluoride (1.6-6.6 mg/day) that fall within the range of doses (2 to 10 mg/day) once used by doctors to reduce thyroid activity in hyperthyroid patients. This is of particular concern considering the widespread problem of hypothyroidism (under -active thyroid) in the United States. Symptoms of hypothyroidism include obesity, lethargy, depression, and heart disease. FLUORIDE & BONE DISEASE Excessive exposure to fluoride is well known to cause a bone disease called skeletal fluorosis. Skeletal fluorosis, especially in its early stages, is a difficult disease to diagnose, and can be readily confused with various forms of arthritis including osteoarthritis and rheumatoid arthritis. In its advanced stages, fluorosis can resemble a multitude of bone/joint diseases. In individuals with kidney disease, fluoride exposure can contribute to, and/or exacerbate, renal osteodystrophy. FLUORIDE & BONE FRACTURE The majority of animal studies investigating fluoride's effect on bone strength, have found fluoride to either have no effect or a negative effect on strength. According to the US National Research Council, "The weight of evidence indicates that, although fluoride might increase bone volume, there is less strength per unit volume." Studies on human populations consuming fluoride in drinking water have found an association between dental fluorosis and increased bone fracture in children; and between long-term consumption of fluoridated water and increased hip fracture in the elderly. Carefully conducted human clinical trials - including two "double-blind trials" - have found that fluoride (at doses of 18-34 mg/day for just 1-4 years) increases the rate of bone fracture, particularly hip fracture, among osteoporosis patients. FLUORIDE & CANCER According to the National Toxicology Program, "the preponderance of evidence" from laboratory'in vitro' studies indicates that fluoride is a mutagenic compound. Many substances which cause mutagenic damage also cause cancer. While the concentrations of fluoride causing mutagenic damage in laboratory studies are higher than the concentrations found in human blood, there are certain microenvironments in the body (e.g. the bones and the bladder) where the concentrations of fluoride can accumulate to levels comparable to, or in excess of, those causing mutagenic effects in the laboratory. Fluoride has been found to cause bone cancer (osteosarcoma) in government animal studies and rates of osteosarcoma among young males living in fluoridated areas have been found to be higher than young males living in unfluoridated areas. Osteosarcoma. while rare, is a very serious cancer. Children who develop osteosarcoma face a high probability of death (usually within 3 years) or amputation. Fluoride exposure has also been linked to bladder cancer - particularly among workers exposed to excess fluoride in the workplace. According to the US National Research Council, "further research on a possible effect of fluoride on bladder cancer risk should be conducted." FLUORIDE & the GASTROINTESTINAL TRACT Among people hypersensitive to fluoride, gastrointestinal ailments have been produced following ingestion of 1 mg tablets of fluoride or consumption of 1 ppm fluoridated water. A single ingestion of as little as 3 mg of fluoride, in carefully controlled clinical trials, has been found to produce damage to the gastric mucosa in healthy adult volunteers. No research on the gastric mucosa has ever been conducted to determine the effect of lower doses with repeated exposure. FLUORIDE & TOOTH DECAY (Caries) According to the current consensus view of the dental research community, fluoride's primary - if not sole - benefit to teeth comes from TOPICAL application to the exterior surface of teeth, not from ingestion. Perhaps not surprisingly, therefore, tooth decay rates have declined at similar rates in all western countries in the latter half of the 20th century irrespective of whether the country fluoridates its water or not. Today, tooth decay rates throughout continental western Europe are as low as the tooth decay rates in the United States - despite a profound disparity in water fluoridation prevalence in the two regions. Within countries that fluoridate their water, recent large-scale surveys of dental health - utilizing modern scientific methods not employed in the early surveys from the 1930s- 1950s - have found little difference in tooth decay, including "baby bottle tooth decay", between fluoridated and unfluoridated communities. Key Findings - Fluoride & the Brain: 1) Fluoride's ability to damage the brain represents one of the most active areas of research on fluoride toxicity today. 2) The research on fluoride and the brain has been fueled by 18 human studies from China, India, Iran, and Mexico finding elevated levels of fluoride exposure to be associated with IQ deficits in children. Fluoride's impact on IQ is exacerbated among children with low -iodine exposure. 3) The impact of fluoride on children's IQ has been documented even after controlling for children's lead exposure, iodine exposure, parental education and income status, and other known factors that might impact the results (Rocha-Amador 2007; Xiang 2003 a,b). 4) In addition to IQ studies, 3 studies (Yu 1996; Du 1992; Han 1989) have found that fluoride accumulates in the brain of the fetus, causing damage to cells and neurotransmitters and 1 study (Li 2004) has found a correlation between exposure to fluoride during fetal development and behavioral deficits among neonates. 5) Several recent studies have found that even adult exposures to fluoride may result in central nervous system disturbances, particularly among industrial workers. 5) The findings of neurological effects in fluoride -exposed humans is consistent with, and strengthened by, recent findings from over 40 animal studies published since 1992. As with the studies on humans, the studies on animals have reported an impairment in learning and memory prorcesses among the fluoride -treated groups. 6) The animal studies have also documented considerable evidence of direct toxic effects of fluoride on brain tissue, even at levels as low as 1 ppm fluoride in water (Varner 1998). These effects include: reduction in nicotinic acetylcholine receptors; reduction in lipid content; -- impaired anti -oxidant defense systems; -- damage to the hippocampus; -- damage to the purkinje cells; increased uptake of aluminum; -- formation of beta-amyloid plaques (the classic brain abnormality in Alzheimer's disease); -- exacerbation of lesions induced by iodine deficiency; and -- accumulation of fluoride in the pineal gland. 10 Facts about Fluoride 1) 97% of Western Europe has chosen fluoride -free water. This includes: Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, Netherlands, Northern Ireland, Norway, Scotland, Sweden, and Switzerland. (While some European countries add fluoride to salt, the majority do not.) Thus, rather than mandating fluoride treatment for the whole population, Western Europe allows individuals the right to choose, or refuse, fluoride. 2) Fluoride is the only chemical added to drinking water for the purpose of medication (to prevent tooth decay). All other treatment chemicals are added to treat the water (to improve the water's quality and safety - which fluoride does not do). This is one of the reasons why most of Europe has rejected fluoridation. For instance: In Germany, The argumentation of the Federal Ministry of Health against a general permission of fluoridation of drinking water is the problematic nature of compulsion medication." In Belgium, it is "the fundamental position of the drinking water sector that it is not its task to deliver medicinal treatment to people. This is the sole responsibility of health services." In Luxembourg, "In our views, drinking water isn't the suitable way for medicinal treatment and that people needing an addition of fluoride can decide by their own to use the most appropriate way." 3) Contrary to previous belief, fluoride has minimal benefit when swallowed. When water fluoridation began in the 1940s and '50s, dentists believed that fluoride needed to be swallowed in order to be most effective. This belief, however, has now been discredited by an extensive body of modern research (1). According to the Centers for Disease Control, fluoride's "predominant effect is post - eruptive and topical" (2). In other words, any benefits that accrue from the use of fluoride, come from the direct application of fluoride to the outside of teeth (after they have erupted into the mouth) and not from ingestion. There is no need, therefore, to expose all other tissues to fluoride by swallowing it. 10 4) Fluoridated water is no longer recommended for babies. In November of 2006, the American Dental Association (ADA) advised that parents should avoid giving babies fluoridated water (3). Other dental researchers have made similar recommendations over the past decade (4). Babies exposed to fluoride are at high risk of developing dental fluorosis - a permanent tooth defect caused by fluoride damaging the cells which form the teeth (5). Other tissues in the body may also be affected by early -life exposures to fluoride. According to a recent review published in the medical journal The Lancet, fluoride may damage the developing brain, causing learning deficits and other problems (6). 5) There are better ways of delivering fluoride than adding it to water. By adding fluoride to everyone's tap water, many infants and other at -risk populations will be put in harm's way. This is not only wrong, it is unnecessary. As Western Europe has demonstrated, there are many equally effective and less -intrusive ways of delivering fluoride to people who actually want it. For example: A) Topical fluoride products such as toothpaste and mouth rinses (which come with explicit instructions not to swallow) are readily available at all grocery stores and pharmacies. Thus, for those individuals who wish to use fluoride, it is very easy to find and very inexpensive to buy. B) If there is concern that some people in the community cannot afford to purchase fluoride toothpaste (a family -size tube of toothpaste costs as little as $2 to $3), the money saved by not fluoridating the water can be spent subsidizing topical fluoride products (or non -fluoride alternatives) for those families in need. C) The vast majority of fluoride added to water supplies is wasted, since over 99% of tap water is not actually consumed by a human being. It is used instead to wash cars, water the lawn, wash dishes, flush toilets, etc. 6) Ingestion of fluoride has little benefit, but many risks. Whereas fluoride's benefits come from topical contact with teeth, its risks to health (which involve many more tissues than the teeth) result from being swallowed. Adverse effects from fluoride ingestion have been associated with doses attainable by people living in fluoridated areas. For example: a) Risk to the brain. According to the National Research Council (NRC), fluoride can damage the brain. Animal studies conducted in the 1990s by EPA scientists found dementia -like effects at the same concentration (1 ppm) used to fluoridate water, while human studies have found adverse effects on IQ at levels as low as 0.9 ppm among children with nutrient deficiencies, and 1.8 ppm among children with adequate nutrient intake. (7-10) 11 b) Risk to the thyroid gland. According to the NRC, fluoride is an "endocrine disrupter." Most notably, the NRC has warned that doses of fluoride (0.01-0.03 mg/kg/day) achievable by drinking fluoridated water, may reduce the function of the thyroid among individuals with low -iodine intake. Reduction of thyroid activity can lead to loss of mental acuity, depression and weight gain (11) c) Risk to bones. According to the NRC, fluoride can diminish bone strength and increase the risk for bone fracture. While the NRC was unable to determine what level of fluoride is safe for bones, it noted that the best available information suggests that fracture risk may be increased at levels as low 1.5 ppm, which is only slightly higher than the concentration (0.7-1.2 ppm) added to water for fluoridation. (12) d) Risk for bone cancer. Animal and human studies — including a recent study from a team of Harvard scientists — have found a connection between fluoride and a serious form of bone cancer (osteosarcoma) in males under the age of 20. The connection between fluoride and osteosarcoma has been described by the National Toxicology Program as "biologically plausible." Up to half of adolescents who develop osteosarcoma die within a few years of diagnosis. (13-16) e) Risk to kidney patients. People with kidney disease have a heightened susceptibility to fluoride toxicity. The heightened risk stems from an impaired ability to excrete fluoride from the body. As a result, toxic levels of fluoride can accumulate in the bones, intensify the toxicity of aluminum build-up, and cause or exacerbate a painful bone disease known as renal osteodystrophy. (17-19) 7) The industrial chemicals used to fluoridate water may present unique health risks not found with naturally -occurring fluoride complexes . The chemicals - fluorosilicic acid, sodium silicofluoride, and sodium fluoride - used to fluoridate drinking water are industrial waste products from the phosphate fertilizer industry. Of these chemicals, fluorosilicic acid (FSA) is the most widely used. FSA is a corrosive acid which has been linked to higher blood lead levels in children. A recent study from the University of North Carolina found that FSA can - in combination with chlorinated compounds - leach lead from brass joints in water pipes, while a recent study from the University of Maryland suggests that the effect of fluoridation chemicals on blood lead levels may be greatest in houses built prior to 1946. Lead is a neurotoxin that can cause learning disabilities and behavioral problems in children. (20-23) 8) Water fluoridation's benefits to teeth have been exaggerated. Even proponents of water fluoridation admit that it is not as effective as it was once claimed to be. While proponents still believe in its effectiveness, a growing number of studies strongly question this assessment. (24-46) According to a systematic review published by the Ontario Ministry of Health and Long Term Care, "The magnitude of [fluoridation's] effect is not large in absolute terms, is often not statistically significant and may not be of clinical significance." (36) 12 a) No difference exists in tooth decay between fluoridated & unfluoridated countries. While water fluoridation is often credited with causing the reduction in tooth decay that has occurred in the US over the past 50 years, the same reductions in tooth decay have occurred in all western countries, most of which have never added fluoride to their water. The vast majority of Western Europe has rejected water fluoridation. Yet, according to comprehensive data from the World Health Organization, their tooth decay rates are just as low, and, in fact, often lower than the tooth decay rates in the US. (25, 35,44) b) Cavities do not increase when fluoridation stops. In contrast to earlier findings, five studies published since 2000 have reported no increase in tooth decay in communities which have ended fluoridation. (37-41) c) Fluoridation does not prevent oral health crises in low-income areas. While some allege that fluoridation is especially effective for low-income communities, there is very little evidence to support this claim. According to a recent systematic review from the British government, "The evidence about [fluoridation] reducing inequalities in dental health was of poor quality, contradictory and unreliable." (45) In the United States, severe dental crises are occurring in low-income areas irrespective of whether the community has fluoride added to its water supply. (46) In addition, several studies have confirmed that the incidence of severe tooth decay in children ("baby bottle tooth decay") is not significantly different in fluoridated vs. unfluoridated areas. (27,32,42) Thus, despite some emotionally -based claims to the contrary, water fluoridation does not prevent the oral health problems related to poverty and lack of dental -care access. 9) Fluoridation poses added burden and risk to low-income communities. Rather than being particularly beneficial to low-income communities, fluoridation is particularly burdensome and harmful. For example: a) Low-income families are least able to avoid fluoridated water. Due to the high costs of buying bottled water or expensive water filters, low-income households will be least able to avoid fluoride once it's added to the water. As a result, low-income families will be least capable of following ADA's recommendation that infants should not receive fluoridated water. This may explain why African American children have been found to suffer the highest rates of disfiguring dental fluorosis in the US. (47) b) Low-income families at greater risk of fluoride toxicity. In addition, it is now well established that individuals with inadequate nutrient intake have a significantly increased susceptibility to fluoride's toxic effects (48-51). Since nutrient deficiencies are most common in income communities, and since diseases known to increase susceptibility to fluoride are most prevalent in low-income areas (e.g. end -stage renal failure), it is likely that low-income communities will be at greatest risk from suffering adverse effects associated with fluoride exposure. According to Dr. Kathleen Thiessen, a member of the National Research Council's review of fluoride toxicity: "I would expect low-income communities to be more vulnerable to at least some of the effects of drinking fluoridated water." (51) 13 ' 10) Due to other sources, many people are being over -exposed to fluoride . Unlike when water fluoridation first began, Americans are now receiving fluoride from many other sources* besides the water supply. As a result many people are now exceeding the recommended daily intake, putting them at elevated risk of suffering toxic effects. For example, many children ingest more fluoride from toothpaste alone than is considered "optimal" for a full day's worth of ingestion. According to the Journal of Public Health Dentistry: "Virtually all authors have noted that some children could ingest more fluoride from [toothpaste] alone than is recommended as a total daily fluoride ingestion." (52) Because of the increase in fluoride exposure from all sources combined, the rate of dental fluorosis (a visible indicator of over -exposure to fluoride during childhood) has increased significantly over the past 50 years. Whereas dental fluorosis used to impact less than 10% of children in the 1940s, the latest national survey found that it now affects over 30% of children. (47, 53) * Sources of fluoride include: fluoride dental products, fluoride pesticides, fluorinated pharmaceuticals, processed foods made with fluoridated water, and tea. Key Findings - Water Fluoridation & Tooth Decay: 1) The addition of fluoride to water for the purpose of preventing tooth decay began in the 1940s with the belief that fluoride's primary benefit came from ingestion of fluoride during the tooth -forming years. It is now acknowledged by the dental research community, however, that fluoride's primary benefit comes from topical contact with teeth, and not from ingestion as previously assumed. It is also now acknowledged that fluoride is ineffective at preventing tooth decay in the pits & fissures of teeth - where the majority of decay occurs. 2) It is well recognized that tooth decay rates declined quite dramatically in all western countries in the latter half of the 20th century - irrespective of whether the country fluoridated its water or not. Today, tooth decay rates thoughout continental western Europe - where 98% of the population does not drink fluoridated water - are as low as the tooth decay rates in the United States, where a majority of the population drinks fluoridated water. 3) Within countries that fluoridate their water, recent large-scale surveys of dental health - utilizing modern scientific methods not employed in the early surveys from the 1930s- 1950s - have found little difference in tooth decay , including "baby bottle tooth decay", between fluoridated and unfluoridated communities. 4) The largest dental survey ever conducted in the United States, by the National Institute of Dental Research in 1986-87, found no difference in Decayed, Missing & 14 Filled Teeth, and a minimal difference in Decayed, Missing & Filled Surfaces among children who had lived their entire lives in a fluoridated or unfluoridated community. 5) Since 2000, four studies have reported that tooth decay does not increase, but continues to decrease, after water fluoridation is stopped. 6) Water fluoridation is often promoted as a means of preventing dental crises within low-income populations. It is becoming evident, however, that water fluoridation has been ineffective at preventing widespread tooth decay in poor urban areas of the United States - most of which have been fluoridated for 20 to 50 years. Excerpts from the Scientific Literature - Recent Surveys of Water Fluoridation/Tooth Decay: "This study assessed the relationship between dental caries and fluorosis at varying fluoride levels in drinking water. Methods: Subjects were followed from birth with questionnaires every 3-4 months to gather information on fluoride intake. 420 study subjects received dental examinations at age 5 on primary teeth and at age 9 on early - erupting permanent teeth... Conclusions: Fluorosis prevalence increased significantly with higher water fluoride levels; however, caries prevalence did not decline significantly." SOURCE: Hong L, Levy S, Warren J, Broffit B. (2006). Dental caries and fluorosis in relation to water fluoride levels. ADEA/AADR/CADR Conference, Orlando Florida, March 8-11, 2006. "This study reports changes in non-cavitated tooth surface diagnoses after a 4-year period... No fluoride, socioeconomic status or beverage variables were significantly associated with lesion progression." SOURCE: Warren JJ, Levy SM, Broffitt B, Kanellis MJ. (2006). Longitudinal study of non-cavitated carious lesion progression in the primary dentition. Journal of Public Health Dentistry 66(2):83-7. "in the present study, fluoridated water did not seem to have a positive effect on dental health, as it might have been expected in a community with the respective caries prevalence. SOURCE: Meyer-Lueckel H, et al. (2006). Caries and fluorosis in 6- and 9-year-old children residing in three communities in Iran. Community Dentistry and Oral Epidemiology 34:63-70. "Graphs of tooth decay trends for 12 year olds in 24 countries, prepared using the most recent World Health Organization data, show that the decline in dental decay in recent decades has been comparable in 16 nonfluoridated countries and 8 fluoridated countries which met the inclusion criteria of having (i) a mean annual per capita income in the year 2000 of US$10,000 or more, (ii) a population in the year 2000 of greater than 3 million, and (iii) suitable WHO caries data available. The WHO data do not support 15 fluoridation as being a reason for the decline in dental decay in 12 year olds that has been occurring in recent decades." SOURCE: Neurath C. (2005). Tooth decay trends for 12 year olds in nonfluoridated and fluoridated countries. Fluoride 38:324-325. "A Bayesian survival analysis is presented to examine the effect of fluoride -intake on the time to caries development of the permanent first molars in children between 7 and 12 years of age using a longitudinal study conducted in Flanders... Our analysis shows no convincing effect of fluoride -intake on caries development." SOURCE: Komarek A, et al. (2005). A Bayesian analysis of multivariate doubly -interval - censored dental data. Biostatistics 6:145-55. "In lifetime residents of fluoridated areas 47% had evidence of erosion; in 21 % erosion had progressed to the dentine or pulp. The corresponding figures in non -fluoridated areas were 43% and 21 % respectively... Levels in fluoridated and non -fluoridated areas were similar. SOURCE: Harding MA, et al. (2003). Dental erosion in 5-year-old Irish school children and associated factors: a pilot study. Community Dental Health 20(3):165-70. "There was no statistically significant difference between DMFT in municipalities of the same size, regardless of the presence or absence of fluoride in the water supply..." SOURCE: Sales -Peres SH, Bastos JR. (2002). [An epidemiological profile of dental caries in 12-year-old children residing in cities with and without fluoridated water supply in the central western area of the State of Sao Paulo, Brazil]. Cadernos de Saude Publica 18: 1281-8. "Water fluoridation status of the children's area of residence did not have a significant effect on Early Childhood Caries (ECC) at the 0.1 level of significance in the unadjusted logistic regression analysis, nor was it found to be a confounder of the effect of race/ethnicity on ECC prevalence in the multivariable model." SOURCE: Shiboski CH, et al. (2003). The association of early childhood caries and race/ethnicity among California preschool children. Journal of Public Health Dentistry 63(1):38-46. "[E]ven a longitudinal approach did not reveal a lower caries occurrence in the fluoridated than in the low -fluoride reference community." SOURCE: Seppa L. et al. (2002). Caries occurrence in a fluoridated and a nonfluoridated town in Finland: a retrospective study using longitudinal data from public dental records. Caries Research 36: 308-314. "The magnitude of [fluoridation's] effect is not large in absolute terms, is often not statistically significant and may not be of clinical significance." SOURCE: Locker, D. (1999). Benefits and Risks of Water Fluoridation. An Update of the 1996 Federal -Provincial Sub -committee Report. Prepared for Ontario Ministry of Health and Long Term Care. 16 "[R]esults of recent large-scale studies in at least three countries show that, when similar communities are compared and the traditional DMFT index of dental caries is used, there is no detectable difference in caries prevalence. This has been demonstrated for schoolchildren in the major cities of New Zealand, Australia, the US and elsewhere." SOURCE: Diesendorf, M. et al. (1997). New Evidence on Fluoridation. Australian and New Zealand Journal of Public Health. 21: 187-190. "Higher fluoride proportions appeared to be associated with lower dfs + DFS, with an estimated difference between fluoridated and non -fluoridated groups of 0.65 decayed or filled surfaces per child, but this association was not statistically significant. The effects of fluoridation on the other outcomes were small and not statistically significant." SOURCE: Domoto P, et al. (1996). The estimation of caries prevalence in small areas. Journal of Dental Research 75:1947-56. "lifetime exposure to fluoridation is associated with average reductions of 2.0 dmfs and between 0.12 and 0.30 DMFS per child compared with non -exposed children." (Note: DMFS = Decayed, Missing & Filled Surfaces. There are 128 tooth surfaces in a child's mouth. This study found a difference of 0.12 to 0.30 decayed surfaces, out of 128, between children in fluoridated & unfluoridated communities.) SOURCE: Spencer AJ, et al. (1996). Water fluoridation in Australia. Community Dental Health 13(Suppl 2):27-37. "Data from Head Start surveys show the prevalence of baby bottle tooth decay is about three times the national average among poor urban children, even in communities with a fluoridated water supply." SOURCE: Von Burg MM et al. (1995). Baby Bottle Tooth Decay: A Concern for All Mothers. Pediatric Nursing 21: 515-519. "Children attending centers showed no significant differences (in baby bottle tooth decay) based on fluoride status for the total sample or other variables." SOURCE: Barnes GP, et al. (1992). Ethnicity, location, age, and fluoridation factors in baby bottle tooth decay and caries prevalence of head start children. Public Health Reports 107: 167-73.span> "An analysis of national survey data collected by the National Institute of Dental Research (NIDR) concludes that children who live in areas of the U.S. where the water supplies are fluoridated have tooth decay rates nearly identical with those who live in nonfluoridated areas." SOURCE: Hileman, B. (1989). New Studies Cast Doubt on Fluoridation Benefits. Chemical & Engineering News. May 8. (See article) "We found that caries prevalences do vary between the geochemical regions of the state. In the total sample, however, there were no significant differences between those children drinking optimally fluoridated water and those drinking suboptimally fluoridated water." 17 SOURCE: Hildebolt CF, et al. (1989). Caries prevalences among geochemical regions of Missouri. American Journal of Physical Anthropology 78:79-92. "[Sjurvey results in British Columbia with only 11 per cent of the population using fluoridated water, show lower average DMFT rates than provinces with 40-70 percent of the population drinking fluoridated water. How does one explain this?... [S]chool districts recently reporting the highest caries free rates were totally unfluoridated." SOURCE: Gray, AS. (1987). Fluoridation: Time for a New Base Line? Journal of the Canadian Dental Association. 10: 763-765. "Recent studies and reports agree that the differences in dental decay prevalence between fluoridated and non -fluoridated areas in New Zealand are small. For 12- and 13-year old children nationally the percentages who were caries -free in each kind of area differed by only 1 or 2 per cent, and were often higher in the non -fluoridated part of a health district." SOURCE: Colquhoun, J. (1987). Child Dental Health Differences in New Zealand. Community Health Studies 6: 85-90. In this study in oral epidemiology, officially collected statistics are presented which show that, 15 yr after fluoridation commenced in Auckland, New Zealand, there was still a significant correlation between dental health of children and their social class. They also show that treatment levels have continued to decline in both fluoridated and unfluoridated areas, and are related to social class factors rather than to the presence or absence of water fluoridation... When the socioeconomic variable is allowed for, dental health appears to be better in the unfluoridated areas." SOURCE: Colquhoun J. (1985). Influence of social class and fluoridation on child dental health. Community Dentistry and Oral Epidemiology 13:37-41. SEE STUDY Excerpts from the Scientific Literature - Topical Vs. Systemic: "Fluoride is most effective when used topically, after the teeth have erupted." SOURCE: Cheng KK, et al. (2007). Adding fluoride to water supplies. British Medical Journal 335(7622):699-702. "it is now accepted that systemic fluoride plays a limited role in caries prevention." SOURCE: Pizzo G, Piscopo MR, Pizzo I, Giuliana G. (2007). Community water fluoridation and caries prevention: a critical review. Clinical Oral Investigations 11(3):189-93. "the major anticaries benefit of fluoride is topical and not systemic." SOURCE: National Research Council. (2006). Fluoride in Drinking Water: A Scientific Review of EPA's Standards. National Academies Press, Washington D.C. p 13. "Since the current scientific thought is that the cariostatic activity of fluoride is mainly due to its topical effects, the need to provide systemic fluoride supplementation for caries prevention is questionable." ffi SOURCE: European Commission. (2005). The Safety of Fluorine Compounds in Oral Hygiene Products for Children Under the Age of 6 Years. European Commission, Health & Consumer Protection Directorate -General, Scientific Committee on Consumer Products, September 20. "The results of more recent epidemiological and laboratory studies can be summarized by stating that posteruptive (topical) application of fluoride plays the dominant role in caries prevention." SOURCE: Hellwig E, Lennon AM. (2004). Systemic versus topical fluoride. Caries Research 38: 258-62. "When it was thought that fluoride had to be present during tooth mineralisation to 'improve' the biological apatite and the 'caries resistance' of the teeth, systemic fluoride administration was necessary for maximum benefit. Caries reduction therefore had to be balanced against increasing dental fluorosis. The 'caries resistance' concept was shown to be erroneous 25 years ago, but the new paradigm is not yet fully adopted in public health dentistry, so we still await real breakthroughs in more effective use of fluorides for caries prevention." SOURCE: Fejerskov O. (2004). Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Research 38: 182-91. "Current evidence strongly suggests that fluorides work primarily by topical means through direct action on the teeth and dental plaque. Thus ingestion of fluoride is not essential for caries prevention." SOURCE: Warren JJ, Levy SM. (2003). Current and future role of fluoride in nutrition. Dental Clinics of North America 47: 225-43. "[Tjhe majority of benefit from fluoride is now believed to be from its topical, rather than systemic, effects." SOURCE: Brothwell D, Limeback H. (2003). Breastfeeding is protective against dental fluorosis in a nonfluoridated rural area of Ontario, Canada. Journal of Human Lactation 19: 386-90. "For a long time, the systemic effect of fluoride was regarded to be most important, resulting in recommendations to use fluoride supplements such as tablets or drops. However, there is increasing evidence that the local effect of fluoride at the surface of the erupted teeth is by far more important." SOURCE: Zimmer S, et al. (2003). Recommendations for the Use of Fluoride in Caries Prevention. Oral Health & Preventive Dentistry 1: 45-51. "By 1981, it was therefore possible to propose a paradigm shift concerning the cariostatic mechanisms of fluorides in which it was argued that the predominant, if not the entire, explanation for how fluoride controls caries lesion development lies in its topical effect on de- and remineralization processes taking place at the interface between the tooth surface and the oral fluids. This concept has gained wide acceptance... With today's knowledge about the mechanisms of fluoride action, it is 19 important to appreciate that, as fluoride exerts its predominant effect... at the tooth/oral fluid interface, it is possible for maximum caries protection to be obtained without the ingestion of fluorides to any significant extent." SOURCE: Aoba T, Fejerskov O. (2002). Critical Review of Oral Biology and Medicine 13: 155-70. "[F]luoride's predominant effect is posteruptive and topical." SOURCE: Centers for Disease Control and Prevention. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Morbidity and Mortality Weekly Report 50(RR14): 1-42. The prevalence of dental caries in a population is not inversely related to the concentration of fluoride in enamel, and a higher concentration of enamel fluoride is not necessarily more efficacious in preventing dental caries." SOURCE: Centers for Disease Control and Prevention. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Morbidity and Mortality Weekly Report 50(RR14): 1-42. "Fluoride incorporated during tooth development is insufficient to play a significant role in caries protection." SOURCE: Featherstone, JDB. (2000). The Science and Practice of Caries Prevention. Journal of the American Dental Association 131: 887-899. "Current evidence suggests that the predominant beneficial effects of fluoride occur locally at the tooth surface, and that systemic (preeruptive) effects are of much less importance. SOURCE: Formon, SJ; Ekstrand, J; Ziegler, E. (2000). Fluoride Intake and Prevalence of Dental Fluorosis: Trends in Fluoride Intake with Special Attention to Infants. Journal of Public Health Dentistry 60: 131-9. "Fluoride supplementation regimens suffer from several shortcomings, the first of which may be their derivation from a time when the major effect of fluoride was thought to be systemic. Although evidence that fluoride exerts its effects mainly through topical contact is great, supplementation schemes still focus on the ingestion of fluoride." SOURCE: Adair SM. (1999). Overview of the history and current status of fluoride supplementation schedules. Journal of Public Health Dentistry 1999 59:252-8. "The case is essentially a risk -benefit issue - fluoride has little preeruptive impact on caries prevention, but presents a clear risk of fluorosis." SOURCE: Burt BA. (1999). The case for eliminating the use of dietary fluoride supplements for young children. Journal of Public Health Dentistry 59: 260-274. "Until recently the major caries -inhibitory effect of fluoride was thought to be due to its incorporation in tooth mineral during the development of the tooth prior to eruption... There is now overwhelming evidence that the primary caries -preventive 20 mechanisms of action of fluoride are post -eruptive through 'topical' effects for both children and adults." SOURCE: Featherstone JDB. (1999) Prevention and Reversal of Dental Caries: Role of Low Level Fluoride. Community Dentistry & Oral Epidemiology 27: 31-40. "[L]aboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children." SOURCE: Centers for Disease Control and Prevention. (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Morbidity and Mortality Weekly Report 48: 933-940. "[R]esearchers are discovering that the topical effects of fluoride are likely to mask any benefits that ingesting fluoride might have... This has obvious implications for the use of systemic fluorides to prevent dental caries." SOURCE: Limeback, H. (1999). A re-examination of the pre -eruptive and post -eruptive mechanism of the anti -caries effects of fluoride: is there any caries benefit from swallowing fluoride? Community Dentistry and Oral Epidemiology 27: 62-71. "Although it was initially thought that the main mode of action of fluoride was through its incorporation into enamel, thereby reducing the solubility of the enamel, this pre - eruptive effect is likely to be minor. The evidence for a post -eruptive effect, particularly its role in inhibiting demineralization and promoting remineralization, is much stronger." SOURCE: Locker D. (1999). Benefits and Risks of Water Fluoridation. An Update of the 1996 Federal -Provincial Sub -committee Report. Prepared for Ontario Ministry of Health and Long Term Care. "Recent research on the mechanism of action of fluoride in reducing the prevalence of dental caries (tooth decay) in humans shows that fluoride acts topically (at the surface of the teeth) and that there is neglible benefit in ingesting it." SOURCE: Diesendorf, M. et al. (1997). New Evidence on Fluoridation. Australian and New Zealand Journal of Public Health 21 : 187-190. "On the basis of the belief that an adequate intake of fluoride in early life is protective against caries in later life, fluoride supplements are recommended for infants and children living in areas in which the fluoride content of the drinking water is low. However, critical reviews of the evidence have led to the conclusion that the effect of fluoride in decreasing the prevalence and severity of dental caries is not primarily systemic but exerted locally within the oral cavity. Because fluoride supplements are quickly cleared from the mouth, the possibility must be considered that they may contribute to enamel fluorosis, which is unquestionably a systemic effect, while providing relatively little protection against dental caries." SOURCE: Ekstrand J, et al. (1994). Fluoride pharmacokinetics in infancy. Pediatric Research 35:157-163. `AI "It is now well -accepted that the primary anti -caries activity of fluoride is via topical action. SOURCE: Zero DT, et al. (1992). Fluoride concentrations in plaque, whole saliva, and ductal saliva after application of home -use topical fluorides. Journal of Dental Research 71:1768-1775. "I have argued in this paper that desirable effects of systemically administered fluoride are quire minimal or perhaps even absent altogether." SOURCE: Leverett DH. (1991). Appropriate uses of systemic fluoride: considerations for the '90s. Journal of Public Health Dentistry 51: 42-7. "It, therefore, becomes evident that a shift in thinking has taken place in terms of the mode of action of fluorides. Greater emphasis is now placed on topical rather than on systemic mechanisms... SOURCE: Wefel JS. (1990). Effects of fluoride on caries development and progression using intra-oral models. Journal of Dental Research 69(Spec No):626-33; "[E]vidence has continued to accumulate to support the hypothesis that the anti -caries mechanism of fluoride is mainly a topical one." SOURCE: Carlos JP. (1983) Comments on Fluoride. Journal of Pedodontics Winter. 135-136. "Until recently most caries preventive programs using fluoride have aimed at incorporating fluoride into the dental enamel. The relative role of enamel fluoride in caries prevention is now increasingly questioned, and based on rat experiments and reevaluation of human clinical data, it appears to be of minor importance... [A]ny method which places particular emphasis on incorporation of bound fluoride into dental enamel during formation may be of limited importance." SOURCE: Fejerskov O, Thylstrup A, Larsen MJ. (1981). Rational Use of Fluorides in Caries Prevention: A Concept based on Possible Cariostatic Mechanisms. Acta Odontologica Scandinavica 39: 241-249. Study: Fluoridated water causes brain damage in children Thursday, December 23, 2010 by: Ethan A. Huff, staff writer (NaturalNews) A new study pre -published in the journal Environmental Health Perspectives confirms that fluoridated water causes brain damage in children. The most recent among 23 others pertaining to fluoride and lowered IQ levels, the new study so strongly proves that fluoride is a dangerous, brain -destroying toxin that experts say it could be the one that finally ends water fluoridation. "This is the 24th study that has found this association, explained Paul Connett, Ph.D., director of the Fluoride Action Network (FAN). "[B]ut this study is stronger than the rest because the authors have controlled for key confounding variables and in addition to 22 correlating lowered IQ with levels of fluoride in the water, the authors found a correlation between lowered IQ and fluoride levels in children's blood." For the study, researchers evaluated 512 children ages 8-13 in two Chinese villages, one village with higher than average fluoride levels and the other with lower than average fluoride levels. After accounting for external variables like lead exposure, iodine deficiency and other conditions that might affect brain health, the team still found that the number of higher intelligence children in the low fluoride community was 350 percent higher than the number in the high fluoride community. "In this study we found a significant dose -response relation between fluoride level in serum and children's IQ," wrote the study authors. Though there have been numerous studies over the years the identify fluoride as a neurotoxin, most mainstream medical professionals in the U.S. have ignored them and continue to support water fluoridation. But the evidence continues to mount, and sooner or later the medical community will have to come to grips with the truth about fluoride. "This should be the study that finally ends water fluoridation," explained Tara Blank, Ph.D., Science and Health Officer at FAN. "Millions of American children are being exposed unnecessarily to this neurotoxin on a daily basis. Who in their right minds would risk lowering their child's intelligence in order to reduce a small amount of tooth decay, for which the evidence is very weak." Water Fluoridation: ` a Review of Recent Research and Actions Joel M. Kauffman, Ph. D. ABSTRACT Fluoridation of drinking water began 60 years ago in the United States, and it continues in 60% of public water supplies in the country today. Much of Australia, Canada, Ireland, and New Zealand have fluoridated water, but most developed non-English speaking countries have rejected this practice as nonbeneficial and possibly harmful. Current fluoridating agents, sodium hexafluorosilicate and hexafluorosilicic acid, which replaced sodium fluoride by 1980, differ from the calcium fluoride in naturally fluoridated water, which was the basis for claims of tooth decay prevention in early epidemiologic studies. Studies reported in the past 15 years support only possible slight benefits from water fluoridation for the deciduous teeth of 5-year-old children, although topical fluoride treatments may be effective. Harmful effects may include bone and tooth fractures and increased cancer rates. Complex legal maneuvers have been used in an effort to prevent or stop fluoridation. The case against it has been weakened by opponents' condemnation of all organofluorine compounds. Individuals can use several methods to remove fluoride from water. Essential Chemistry Fluorine (F, or F—F) is element #9 in the Periodic Table. The fluoride ion (F), which has one negative charge, must be accompanied by a cation such as sodium (Na), as in sodium fluoride (Na'F or NaF). Other inorganics, such as liquid hydrofluoric acid (HIT, often called hydrogen fluoride as a gas), hexafluorosilicic acid (H,SiF,), and compounds with a P—F bond, such as the sodium monofluorophosphate (Na,PO,F) used in toothpaste, as well as organics, such as methansulfonyl fluoride (CH,SO,F) and acetyl fluoride (CH,COF), also forth F" in water or alkali. The trifluoromethyl group (CF,—) or the fluorophenyl group (FQH ) are often incorporated into drug molecules to make them more resistant to being metabolized. Organic polymers (Teflon) and refrigerants with —CFz groups are usually extremely stable both chemically and thermally. Brief History of Fluoridation By the early 1900s it was noticed that inhabitants of some areas of the United States, especially parts of Colorado and Texas, had mottled teeth (dental fluorosis), and that children with fluorosis tended to have fewer cavities.' Usually the natural mineral fluorite, calcium fluoride (CaF,), is the source of fluoride ion. Industries that produced large quantities of fluoride byproducts were especially interested in this effect and have been accused by antifluoridation activists of promoting water fluoridation as a method of toxic waste disposal" Information concerning the quantities of the waste and the proportion used in fluoridation has been unobtainable. The purported value of fluoridation for dental health has, however, served to mitigate concerns about the toxicity of fluoride wastes. The Manhattan Project made use of uranium hexafluoride gas, fluoroorganic lubricants for metal bearings, and other fluorine - containing materials. Aluminum production, which increased greatly in World War II, utilized cryolite (Na,A1F,). Zinc and fluorocarbon production also soared with emissions of fluoride ion or its precursors. An Alcoa -sponsored biochemist, Gerald J. Cox, fluoridated some laboratory rats in a study and concluded that fluoride reduced cavities, writing that: "The case should be regarded as proved."' On Sept 29, 1939, at a meeting of the American Water Works Association in Johnstown, Pa., "...Cox proposed that America should now consider adding fluoride to the public water supply."' In the 1940s, certain major figures in the Manhattan Project and in fluoride -waste -producing industries succeeded in using some epidemiologic studies, now discredited,' to allow public water supplies to have sodium fluoride added in order to prove that 1 ppm of fluoride ion would "prevent tooth decay in children." None of these or later studies followed other dental or medical outcomes of fluoride consumption over long periods, a flaw that remains in many medical trials to this day,' Henry Trendley Dean, D.D.S., a U.S. Public Health Service researcher, at first opposed the addition of fluorides to city water supplies because of toxicity. He later changed his mind, perhaps believing that mottled teeth were a small price to pay for less decay, or perhaps for other reasons. He later became the first Director of the National Institute of Dental Research (NIDR), and then, in 1953, a top official of the American DentalAssociation (ADA), two organizations that remain unshakably committed to fluoridation' They claim the credit for the drop in tooth decay in the United States during the past 50 years. Once opposition by professionals was overcome, largely through the ADA and NIDR, the selling of fluoridation to the public was aided by hiring Edward L. Bernays, often called "the father of public relations," who had been hired earlier by the tobacco industry to persuade women to take up smoking.' Fluoridation with sodium fluoride (NaF) was begun in the United States in 1945. Today, fluoridation uses hexafluorosilicic acid (H,SiF,) and its sodium salt (Na,SiF,) almost exclusively. These are not pure, but recovered in crude form by scrubbing the gaseous emissions from the treatment of phosphate ores with sulfuric acid. They contain variable amounts of lead, arsenic, beryllium, vanadium, cadmium, and mercury.' Because of this change in fluoridation agents, old studies based on the use of natural calcium fluoride or on chemically pure sodium fluoride are irrelevant, even had they been done correctly. Calcium is a strong 38 Journal of American Physicians and Surgeons Volume 10 Number 2 Summer 2005 12 90 a 11 60 o 10 100 Decayed Teeth ro a �o ' o. 9 Fluoride 80 o n 60 .' = 8 Toothpaste 0 $ d 7 z 50 N 6 m c:40 3 ao 4 k 0w 20 Fluoridation 2 3 10 Z 1 0 0 0 .5 1.0 2.0 01930 1940 1950 1960 1970 1980 1990 ppm Fluoride Figure 1. Tooth decay rates in 5-year-old children (left scale) vs. water fluoridation percentage (right scale) and fluoride toothpaste percentage (right scale). From Colquhoun,' cited in Groves,' reprinted with permission. antagonist of fluoride, reduces its concentration in plasma, and inhibits its absorption from the intestine.' Fluoridation at 1 ppm fluoride reached its current extent by 1965. The proportion of fluoridated public water supplies is about 60% in the United States, 66% in Ireland, 55% in Canada, and 10% in England. Australia and New Zealand also use fluoridation extensively. At present almost none of the public water supplies in Austria, Germany, Luxemburg, Denmark, Finland, Norway, Sweden, the Netherlands, Switzerland, France, Italy, Belgium, Switzerland, Spain, Hungary, Portugal, Greece, Japan, and China are fluoridated. About half of these countries tried fluoridation, saw no benefit, and stopped it.' U.S. studies on the toxicity of fluorine compounds, not necessarily the ones used to fluoridate water, have reportedly been suppressed, classified, censored, and removed from the National Archives' Some of this activity has been traced to Harold Carpenter Hodge, Ph.D., a biochemist and toxicologist at the University of Rochester, where he supervised experiments for the Manhattan Project involving the injection of unsuspecting hospital patients with uranium and plutonium compounds. He later became chairman of the National Research Council's Committee on Toxicology and the leading promoter of fluoridation in the United States during the Cold War. In 1953, Hodge, using data from a European study,' estimated that the amount of daily fluoride intake for 10-20 years that would not cause crippling skeletal fluorosis was 20-80 mg/day. It was later found that he had confused mg/kg with mg/lb. An American antifluoride campaigner, Darlene Sherrell, used the same European study from 1937 to estimate that skeletal fluorosis might be avoided with intakes of no more than 10-25 mg/day.' In 1975, the U.S. Food and Drug Administration (FDA) explicitly designated fluoride as "not generally recognized as safe" and permitted no fluoride whatsoever to be added to food or to over- the-counter dietary supplements. Nevertheless, the Department of Health, Education and Welfare (now Health and Human Services) exempted fluoridated water from this ban, including fluoridated water used to process food.' In 1985, the U.S. Environmental Protection Agency (EPA) set 4 ppm (up from 2 ppm) as the safe level for fluoride in drinking water and prevailed in a lawsuit challenge.' Figure 2. Study of tooth decay in 29,000 elementary schoolchildren in Tucson, Ariz., vs. fluoride content of their drinking water. Reprinted from Judd', with permission. While the ADA, the Centers for Disease Control and Prevention (CDC), and the NIDR of the National Institutes for Health (NIH) still support fluoridation, some 17 U.S. organizations have withdrawn their support since 1990, including the American Academy of Allergy and Immunology, the American Academy of Diabetes, the American Cancer Society, the American Diabetes Association, the American Nurses Association, the American Psychiatric Association, the National Kidney Foundation, and the Society of Toxicology.' Discussion of the scientific studies on fluoridation, as presented in the following sections, has been neglected by most of the media in the United States. The unique journal Fluoride is not covered by PubMed. Michael Easley, M.P.H., national spokesman on fluoridation for the ADA, posted the following on the internet for dentists in 1996: "...anti -fluoride cultists will not be dissuaded by the truth.... Let them spew their garbage, ignore them, and go on with your discussions as if they weren't there.... [T]heir twisted minds have accepted the notion that it is OK to lie, slander, libel, exaggerate, misquote.... [S]ee what kooks they really are."' Some of the purported "lies" are presented in the next sections. Does Water Fluoridation Prevent Tooth Decay? Dean ran the first trial of fluoridation in Grand Rapids, Mich., in 1945, declaring it a success in comparison with nonfluoridated Muskegon, Mich. Since that time, he twice confessed in court that statistics from the early studies were invalid.' Newburgh, N.Y., next to be fluoridated in 1945, was compared with Kingston, N.Y., as a control. Early reports were favorable. But by 1989 workers at the New York State Department of Health found a difference of less than 1 fewer teeth decayed in 7-14—year-old children in Newburgh, favoring fluoridation. And by 1995 children's teeth in Kingston had slightly less tooth decay and half as much damage from fluoride.' This negative result was possibly caused by a change in the fluoridation agent, or possibly by more accurate reporting. North Shields, England, has no natural fluoride in its water, while South Shields has 1.4 ppm. While children of the same age had fewer decayed teeth in fluoridated South Shields, it was noticed that the onset of decay was merely delayed 3 years.' This finding Journal ofAmerican Physicians and Surgeons Volume 10 Number 2 Smnmer 2005 39 90 e0 70 m f 60 50 3 c a 40 o` L U 30 a 20 10 0 .5 1.0 2.0 3.0 ppm Fluoride Figure 3. Study of tooth decay in 22,000 Japanese schoolchildren vs. fluoride content of their drinking water. Reprinted from Judd,' with permission. may invalidate the early Michigan and New York trial results and confirm the findings by Yiamouyiannis" that fluoride lowers decay of deciduous teeth only. A favorable report on fluoridation from New Zealand was found to be biased by the deliberate choice of the nonfluoridated communities with the highest tooth decay rate in comparison with the two fluoridated communities with the lowest decay rates. When all decay rates for all children in that area of New Zealand were compared, there was no difference with respect to fluoridation.' Also, in New Zealand the number of decayed teeth per 5-year-old 'child has decreased steadily from 12 teeth in 1930 to 3 teeth in 1990. Neither the introduction of fluoridated water nor fluoridated toothpaste changed the downward slope of the graph of decay (see Figure 1). Because of this, John Colquhoun, appointed to promote fluoridation in New Zealand, now opposes it.' According to World Health Organization (WHO) figures, the most fluoridated country in the world, Ireland at 66%, does not have the least tooth decay. The five countries with less tooth decay (Finland, Denmark, UK, Sweden, and the Netherlands) had little or no water fluoridation (the rate was 10% in the UK).' Chile began fluoridating water in 1985, but stopped it when the average of 6.0 decayed teeth per 12-year-old child, which dropped to 5.3 by 1991, increased to 6.7 in 1995.' A study of 29,000 elementary school children in Tucson, Ariz., showed much more tooth decay when the fluoride level in the drinking water was higher (see Figure 2)' The extremes ranged from 6% of children with some decay in areas with water containing 0.0 ppm fluoride to 40% of children with some decay in areas with water containing 1.0 ppm fluoride. Fluoridation was forced on parts of Japan during its occupation by the United States. A study reported in 1972 on 22,000 schoolchildren (median age 13, range 5-17) showed 90% with some tooth decay at 0.0 ppm fluoride. This high number was attributed to the absence of calcium in the water. A minimum in decay (38% of children) occurred with 0.3 ppm fluoride and more calcium content. This increased to 44% at 1.0 ppm fluoride and further to 55% with decay at 3.0 ppm fluoride and still more calcium (see Figure 3). Japan subsequently reduced the maximum allowed fluoride level to 0.05 ppm.' The largest study on fluoridation and tooth decay involved 400,000 students (median age 13, range 5-17) in India (see Figure m a L .3 c w 9 L U 0 90 60 70 60 50 40 30 20 10 0 .5 1.0 2.0 3.0 ppm Fluoride Figure4. Study of tooth decay in 400,000 Indian schoolchildren vs. fluoride content of their drinking water. Reprinted from Judd,' with permission. 4). The percentage of children with decay was 23% at 0.0 pprn F 35% at 0.7 ppm; and 75% at 2.75 ppm''' Other studies over a 30- year period prompted Teotia and Teotia to write: "...dental caries were caused by high fluoride and low dietary calcium intakes, separately and through their interactions.... The only practical and effective public measure for the prevention and control of dental caries is the limitation of the fluoride content of drinking water to <0.5 ppm, and adequate calcium ... (> I g/day)."' Over a 20-year period from 1965-1985, the average number of decayed, missing, or filled teeth (DMFT) in 12-year-old children dropped by 50% in the United States. Proponents of fluoridation and vendors of fluoridated dental rinses and toothpastes took credit for this. However, the following nonfluoridated countries had even greater reductions in DMFT during similar 20-year periods: the Netherlands, 72%; Sweden, 82%; Finland, 98% "'" No adjustments were made for some of the obvious confounders, such as consumption of refined carbohydrates and the other mineral contents ofwater supply." NativeAmericans on reservations in this country have by far the most decay of any ethnic group in the United States, despite forcible fluoridation of their water and free dentistry for more than 50 years.' There was an overall increase in children 5-17 years old (median age 13) with tooth decay after initiation of water fluoridation. The tooth decay rate of children living in nonfluoridated American cities with average decay rates was 65% with natural fluoride levels of 0.4 ppm fluoride. This increased to 67%with fluoridation to I ppm. In high -decay cities, the decay rate of 71 % with 0.4 ppm fluoride increased to 75% with fluoridation to 1 ppm, according to a 1990 study of 39,207 children, aged 5-17, in 84 areas in the United States "' Reinterpretation of data from a 1986-1987 study by dentists gained by the NIDR showed that the decayrate of deciduous teeth in 5-year-olds was significantly lower in fluoridated areas (1.5 teeth per child) than in nonfluoridated areas (2.0 teeth per child), as shown in Figure 5' However, the decrease was no longer significant in 6-year-olds, and did not exist in children age 7 or older. Moreover, decay rates in permanent teeth in children aged 5-17 did not differ significantly at any age in areas with no, partial, or total fluoridation of water supplies (see Figure 6)' Earlier, widely accepted claims of caries reduction of 60% by fluoridation, published in the Journal of the American 40 Journal of American Physicians and Surgeons Volume 10 Numher 2 Summer 2005 2.50 2.00 Decayed 1.50 and filled deciduos teeth (DFr) 1.00 per child 0.50 M 5 6 7 8 9 10 11 12 13 14 15 16 17 Age � NF ff PF �F Figure 5. Decay of deciduous teeth in 39,207 white children in 84 areas in the United States. F, fluoridated; PF, partially fluoridated; NF, nonfluoridated areas. Reprinted from Yiamouyiannis° with permission. Decayed, missing, 4 and filled permanent 3 teeth (DMF) per child 2 Decayed, missing, 4 and filled permanent 3 teeth (DMF1) per 2 child Fj 5 6 7 8 9 1011 1213 1415 1617 Age 0 5 6 7 8 9 1011 12 13 14 15 16 17 Age ■F ❑ NF ® PF ■F ❑ NF ® PF Figure 6. Decay of permanent teeth in 39,207 white children in 84 areas in the United States. F, fluoridated; PF, partially fluoridated; NF, nonfluoridated areas. Reprinted from Yiamouyiannis,° with permission. MedicalAssociation and the Journal ofDeiiial Research using data from the same source, were not substantiated by Yiamouyiannis. On the basis of observational studies, Hardy Limeback, B.Sc., Ph.D., D.D.S., head of the Department of Preventive Dentistry for the University of Toronto and President of the Canadian Association for Dental Research, announced a reversal of his earlier profluoridation views. In an April 1999 interview, Limeback, once the primary promoter of fluoridation, stated: "Children under three should never use fluoridated toothpaste or drink fluoridated water. And baby formula must never be made up using Toronto tap water. Never." He remarked that "Vancouver, never fluoridated, has a lower cavity rate than Toronto, which has been fluoridated for 36 years [through 1999]."°'1 2 In a recent article in the Journal of the American Dental Association, Featherstone wrote that: "Fluoride incorporated during tooth development is insufficient to play a significant role in caries protection."" In fact, fluoridation of municipal water supplies increases tooth decay overall in some studies and has not been demonstrated to be effective in prevention of decay in the most convincing studies, such as those of Colquhoun, Kalsbeek, and Yiarnouyiannis,heconcluded. The effects of fluoridation were praised in a 2004 book, Fluorides in the Environment: Effects on Plants and Animals by L.H. Weinstein and A. Davison, but expert reviewers considered the book to be blatantly biased." Fluoride Supplements and Topical Application No adequate evidence for the effectiveness of fluoride supplements as pills or drops, or topical application of fluoride by means of toothpaste or dental rinses, had ever been presented.' Colquhoun's study concluded there was also no benefit from fluoridated toothpaste! "Until recently, the rationale for most caries preventive programs using fluoride was to incorporate fluoride into the dental enamel. The relative role of enamel fluoride in caries prevention is now increasingly questioned, and based on rat experiments and reevaluation of human clinical data, it appears to be of minor importance..."." In fact, "...the prevalence of dental caries in a population is not inversely related to the concentration of fluoride in enamel, and a higher concentration of enamel fluoride is not necessarily more efficacious in preventing dental caries."" Limeback found on reexamining the literature that topical effects of fluoride on newly erupted teeth were more likely to explain any benefit of fluoride than swallowing it in water or pill form." In vitro experiments showed that topical fluoride might protect tooth enamel by inhibition of bacterial metabolism, limiting acid generation." Is Fluoridation Safe for the General Population? In a report authored by Perry D. Cohn, Ph.D., M.P.H., for the New Jersey Department of Environmental Protection and the New Jersey Department of Health, the rates of bone cancer in fluoridated and nonfluoridated areas were compared. Both by counties or by municipalities, males under the age of 50 had 3 to 7 times as many bone cancers in the fluoridated areas. Males 10-19 years old fared the worst." An external review panel found no serious flaws with the study. Journal of American Physicians and Surgeons Volume 10 Number 2 Summer 2005 41 Cancer rates in the ten largest fluoridated cities in the United States and in the ten largest nonfluoridated cities were found to be the same before fluoridation began. After 20 years, the ten fluoridated cities had 10% more cancer deaths than the onfluoridated cities. The cancers were found in the tongue, mouth, pharynx, esophagus, stomach, colon, rectum, pancreas, larynx, bronchi, and lungs.' Hip fractures in two cities in Utah were compared: fluoridated Brigham City and nonfluoridated Cedar City. In the fluoridated (1 ppm) city, the hip fracture rate was twice as high as in the nonfluoridated city, in women around age 75. Men aged 80-85 also had twice the hip fracture rate in fluoridated Brigham City." The insidious nature of fluoride toxicity is that it does not cause bone density loss as found in osteoporosis by bone scans, but causes an increase in bone density with no clinical benefit. Fluoride makes both bones and teeth more brittle."" Early reports of supposed benefits of fluoridation to bone were quoted without citing later corrections or retractions," Dr. A. K. Susheela of the India Institute of Medical Sciences in New Delhi found that fluoride severely disrupts formation of bone matrix, inhibiting the hardening of bones. Site found that about 20 countries in the world have serious health problems due to excess fluoride. Her work showed that high levels of fluoride in drinking water were associated with birth defects, stillbirths, and early infant mortality.' Excess fluoride may also have detrimental neurologic effects. Rats given sodium fluoride in their drinking water at a concentration producing a plasma level of fluoride equivalent to that found in humans consuming water with 4 ppm of fluoride developed f symptoms resembling attention deficit -hyperactivity disorder. " Gerard F. Judd, Ph.D., lists 113 ailments reportedly caused by fluoride, all with literature citations to studies, of which 13 were double -blinded' So far, there are no known naturally occurring compounds of fluorine in the human body." Fluorine is not listed as even a trace element in whole body assays," showing that there is no requirement for it at all. Water fluoridated to 1 ppm fluoride is not safe in the general population. How much of the toxicity results from the arsenic and heavy metal contamination in the newer fluoridating agents is not yet known. Additionally, certain populations such as patients with diabetes or renal impairment are at increased risk, especially if they drink more than average amounts of water." A study comparing 25 young adults with fluorosis against 25 matched controls showed very significant impairment of glucose tolerance in those with fluorosis, which, however, was reversible when water with low fluoride levels was given" How Antifluoridationists Have Weakened Their Case Groups such as Parents for Fluoride Poisoned Children (PFPC), based in British Columbia, Canada, and the National Pure Water Association Ltd. in the UK justifiably attempt to prevent fluoridation of water. Unfortunately, they suffer from chemophobia, which is not only a fear of all "chemicals," but a fear of consulting with chemists. As a result, they list any material that contains fluorine in any form as a danger by claiming that it contains "fluoride," and certain book authors and many website authors opposing fluoridation repeat this unsound assertion. The list includes Teflon and Tefal non-stick pan coatings, fluorocarbon propellants, and many drugs. Drugs that contain fluorine include: fluoxetine (Prozac), ciprofloxacin (Cipro), flunitrazepam (Rohypnol), fluconazole (Diflucon), fluticasone (Flixonase or Flixotide), trifluoperazine (Stelazine), flucoxacillin (Floxapen), cerivastatin (Baycol), cisapride (Propulsid), astemizole (Hismanal), and fenfluramine (Pondimin). In fact, none of these materials either contain fluoride ion or are metabolized to generate any significant amount of fluoride ion. All contain the very stable carbon -fluorine bond in the form of trifluoromethyl (CF,—), difluoromethylene (—CFa), fluoroalkane (—CHF—), or fluorophenyl (FC,H ) groups. The fluoro groups are chosen for the drugs to retard their metabolism, increasing the duration of effective drug levels in the body. Judd, a chemist, did not make the mistake of confusing fluorine with fluoride in his book.' For Teflon, the maximum continuous service temperature is listed as 260°C or 500°F in the Chemical Rubber Co. Handbook of 1976-1977. Overheating Teflon may produce an irritant, perhaps perfluorooctanoic acid, but the irritant is unlikely to be fluoride ion. Asked for evidence on the toxicity of Teflon, the scientific advisor to one of the antifluoridation groups sent citations to four papers on the decomposition of Teflon by ionizing radiation. Clearly this is irrelevant to ordinary use in cooking. Fluorocarbon refrigerants and propellants such as R12, and flourine-containing general anesthetics such as halothane and methoxyflurane, are metabolized very slowly or not at all. However, some of the fluorine in the general anesthetics enflurane, desflurane, and isoflurane is metabolized to fluoride ion." Asked for evidence on the toxicity of fluorinated drugs, the scientific advisor to one of the antifluoridation groups provided citations to 13 papers. Ten of the 13 were published in 1952 or earlier. Some concerned analytical methods and methods of synthesis of fluorine -containing compounds. Citations from the 1930s showed the toxicity of sodium fluoride from its interference with thyroid hormone biosynthesis" Another from 1949 showed that that 3-fluoro-5-bromo(or iodo)tyrosine was toxic in mice, and five other fluorophenyl compounds less so." The toxicity of 3- fluorotyrosine and 3,5-difluorotyrosine was confirmed, including in humans,"" but this is a special case in which these amino acid derivatives interfere with thyroid hormone biosynthesis. Ciprofloxacin, like all drugs, is associated with some toxicity but not from fluoride. The scientific advisor to one of the antifluoridation groups cited a report showing elevated serum and urine levels of fluoride in children after administration of this drug." The actual elevation of fluoride in serum was from 0.08 to 0.21 ppm in 12 hours, and could not account for more than a fraction of the fluorine (23 mg) in the 400 mg doses used of ciprofloxacin; moreover, there was no follow-up measurement. The elevation of fluoride in urine from 0.97 to 1.12 ppm after a week was not statistically significant. The authors did not try to measure fluorinated metabolites or unchanged drug, and after MRI scans and about 2 years of follow-up by physical examinations, they pronounced short courses of ciprofloxacin safe in children. Although ciprofloxacin liberates fluoride under UVB illumination in vitro, it is metabolized in vivo mostly by hydroxylation and N- sulfation, not by loss of fluoride ion." The risk of rhabdomyolysis, the major toxicity of the statin drugs, is about the same with atorvastatin and pravastatin, which contain fluoro groups, and simvastatin, which does not." A group at Duke University Medical Center searched the literature from 42 Journal of American Physicians cord Surgeons Volume 10 Number 2 Summer 2005 November 1997 to February 2002 to find 60 cases of statin-induced memory loss, of which 36 were due to simvastatin, 23 to atorvastatin, and I to pravastatin." Clearly, there is no correlation with the presence of a fluoro group. Thus, the scientific evidence presented by members of certain antifluoridation groups and by others does not support their assertion that all fluorinated organic compounds are toxic because they contain fluorine. The case against fluoridation needs to be made solely on the basis of the effects of fluoride ions and their precursors in drinking water. Who Benefits from Fluoridation? Groves's book does not explain how water fluoridation can be continued despite all the evidence against it. Bryson's book, however, suggested that many corporations benefit. These included: US Steel, DuPont, Alcoa, Alcan, Reynolds Metals, I{aiser Aluminum, Pearsall Chemicals (now ELF Atochem), Allied Chemical, and the Florida phosphate fertilizer industry. Philadelphia, Pa., obtains its hexaflumosilicic acid from Solvay Fluoride. A dozen other manufacturers of hexafluorosilicic acid are listed on an antifluoridation website sponsored by the Fluoride Action Network Pesticide Project. It is stated that industry is able to profit by selling 155,000 tons of fluoride byproducts per year for water fluoridation instead of having to dispose of their as toxic waste at great expense.' Another consideration might be avoiding enormous tort liability that could be incurred if toxicity were officially recognized (especially in the absence of the EPA's "safe" level of 4 ppm). How Can Fluoridation of Water Be Stopped? Despite evidence for negligible benefit and considerable risk, the ADA, the American Medical Association (AMA), the CDC, the NIDR, the British Fluoridation Society, the WHO, and others have not retreated from their support for fluoridation. Because opposition has been marginalized, primarily by ignoring it, the only route to change appears to be through litigation. Had there been only one or two failed lawsuits over the years, one might conclude that the antifluoridation cause is hopeless. In fact, lawsuits have met with some success. Antifluoridation lawsuits were argued by attorney John Remington Graham in non - jury trials in Pittsburgh, Pa., in 1978; Alton, Ill., in 1980; and Houston, Tex., in 1982. In all cases, the judges found for the plaintiffs and issued injunctions against fluoridation on the grounds that it caused cancer and other ailments in humans. Based on the injunction in the Pittsburgh case, the Province of Quebec, Canada, stopped fluoridating. However, all three cases were overturned on appeal on trivial legalistic grounds. In spite of the appellate actions, however, thejudicial findings of fact, namely that fluoridation is an unreasonable risk to public health, remain on the record and unchallenged. After the Alton case, an attorney for the ADA, who was a member of the Rules Committee of the Illinois Supreme Court, told an audience that he was the one who had secured a stay of the execution of the nnnfluoridation injunction." There have been five lawsuits resulting in judgments against fluoridation: two in Pennsylvania and one each in Indiana, Ohio, and Missouri. None were decided on the merits of fluoridation, only on legal technicalities " Since fluorides have been shown in some studies to increase the risk of cancer, addition of any of them in any amount to water violated the Delaney Clause of the 1958 Amendment to the Food, Drug, and Cosmetic Act of 1938." The Delaney Clause was repealed in 1996 with passage ofthe Food Quality Protection Act. A stronger argmnent based on the cancer issue is that adding fluoride violates the EPA policy on setting drinking water standards under the Safe Drinking Water Act. Under this provision, the Maximum Contaminant Level Goal (a pure health -based standard) for carcinogens is zero, so adding any fluoride should be banned. This is apparently why the 1990 National Toxicology Program bioassay on sodium fluoride was "revised" so that the findings went from "clear evidence of carcinogenicity" to "equivocal" evidence. Without that change, the fluoridation program would have been unsustainable under law. Bottled water in a local supermarket sports an FDA -style food label, making it a food under the law. The FDA position that fluoride is neither an essential nor probably essential nutrient and is not safe at any level is inconsistent with its allowing fluoride to be added to a food.' Fluoride in water is also a medication that is forced upon people who do not want it. This is arguably a violation of law, because in the United States, people may not be medicated without their permission. Fluoridation is different from chlorination of water because the chlorine is used to kill microbes, not to medicate people. In India, the government constructed deJluoridation plants and attempted to end sales of fluoridated toothpaste, based on Susheela's work on the toxicity of fluoride.' Unfortunately, in the United States, class-action lawsuits may be the only way to influence municipal authorities, who are operating on the basis of old, erroneous information on which legal precedent rests. Removal of Fluoride Ion from Tap Water Since prevention mending fluoridation ofpublic water supplies is so difficult, your patients may wish to remove fluoride ion from their drinking water. Filters do not work because the diameter of a fluoride anion is 0.064 nm. Activated carbon "filters" are not effective, nor are water -softeners based on cation exchange resins designed to take out calcium, magnesium, and iron, not anions. It might be possible to make effective anion exchangers. There are three effective methods: use of a cartridge containing activated alumina adsorbent, the most expensive because the cartridge must be changed so often; reverse osmosis; and distillation, the least expensive method. Distillation costs about 7 cents per liter for electricity and about 2 cents per liter for depreciation of a distiller costing $135 at Sears, assuming a 5-year life. Distilled water is often passed through an activated carbon filter to remove volatile organics, and aerated for flavor." " Conclusions Artificial fluoridation of drinking water by municipalities at 1 ppm of fluoride ion probably does not reduce tooth decay, except for a minor effect on deciduous teeth. Hexafluorosilicic acid and its sodium salt, which contain other toxic substances because they are not purified, certainly have no significant benefit. Proponents of fluoridation have censored most media, ignored intelligent discussion of fluoridation, slandered most opponents of fluoridation, and overturned legaljudgments against fluoridation in Journal of American Physicians and Surgeons Volume 10 Number 2 Summer 2005 43 a manner that demonstrates their political power. Many published studies that had conclusions favoring fluoridation were later found unsupported by their raw data. There is evidence that fluoridation increases the incidence of 'jncer, hip fracturesJoint problems, and that by causing fluorosis it damages both teeth and bones. Other medical problems may also occur, including neurologic damage. Antifluoridationists compromise their credibility by unwarranted assertions that many stable fluorine -containing materials are harmful. The EPA should set the enforceable Maximum Contaminant Level at 0.4 ppm fluoride in drinking water. The FDA should reverse its position on permitting sale of products containing fluoride that claim dental benefit without proof of safety or effectiveness. Fluoridation of municipal water should cease. Defluoridation of naturally fluoridated water down to 0.4 ppm of fluoride should be mandated. Individuals should remove fluoride from their tap water if fluoridation cannot be stopped. Joel M. Kauffman, Ph.D., is Professor of Chemistry Emeritus at the University of the Sciences in Philadelphia, 600 S. 43rd St., Philadelphia, PA, 19104-4495. E-mail: kauffman@hsic.org. Acknowledgements: Frances Eleanor Heckert Pane, M.S.L.S., and Alayne Yates, M.D., edited the manuscript and provided key references, as did Michael A. Pane, Jr., J.D., LL.M, and Leslie Ann Bowman, A.M.L.S. Certain reviewers made important contributions. Potential conflicts of interest: The author has no financial interest in fluoridation or alternate treatments for public water supplies, or in any form of defluoridation. REFERENCES ' Groves B. Fluoride: Drinking Ourselves to Death. Dublin, Ireland: Newleaf; 2001. ' Bryson C. The Fluoride Deception. New York, N.Y.: Seven Stories Press; 2004. ° Foulkes RG. Editorial: Public deception on fluoride. Fluoride 2004;37(2):55-57. ° Cox GJ. New knowledge of fluoride in relation to dental caries. JAm Water Works Assoc 1939,,31:1926-1930. ° Judd GF. Good Teeth Birth to Death. Glendale, Ariz.: Research Publications Cc; 1996. ° Kauffman JM. Bias in recent papers on diets and drugs in peer -reviewed medical journals. JAm Phys Surg 2004;9:11-14. ' Teotia SPS, Teotia M. Dental caries: a disorder of high fluoride and low dietary calcium interactions. Fluoride 1994; 27(2):59-66. ° Yiamouyiannis JA. Water fluoridation and tooth decay: results from the 1986-1987 National Survey of U.S. Schoolchildren. Fluoride 1990;23(2):55-67. ' Colquhoun J. Why I changed my mind about water fluoridation. Perspect Biol Med 1997,,41(1):29-44. t0 Kalsbeek H, Verrips GHW. Dental caries and the use of fluorides in different European countries. J DentRes 1990;69(special issue):728-732. " Forbes B. Prominent researcher apologizes for pushing fluoride. The Tribune, Mesa, Ariz., Dec 5, 1999. Available at: http://www.apfn.net/ messageboard/10-17-04/discussion.cgi.5.html. Accessed Oct 17, 2004. " Limeback H. A re-examination of the pre -eruptive and post -eruptive mechanism of the anti -caries effects of fluoride: is there any anti -caries effect from swallowing fluoride? Community Dent Oral Epidemiol 1999;27(1):62-71. " Featherstone JDB. The science and practice of caries prevention. J Am DentAssoc 2000; 131:887-899. " Krook LP, Cornett P, Burgstrahler AW, Misplaced trust in official reports. Fluoride 2004;37(3):147-150. " Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2000;50(RR14):1-42.. 18 Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention: a concept based on possible cariostatic mechanisms. Acta OdontolScand 1981;39: 241-249, " Vanloveren C, Buijs JF Tencate JM. Protective effect of topically applied fluoride in relation to fluoride sensitivity of mutans streptococci. J Dental Res 1993;72:1184-1190. " Cohn PD. An Epidemiologic Report on Drinking Water and Fluoridation, NewJersey Department of Health, November 1992. " Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah's elderly population. JAMA 1992;268(6):746-748. 10 Lee JR. Editorial: fluoride and osteoporosis. Fluoride 1990;22(2):51-53. " Mullenix PJ, Denbesten PK, Schunior A, Kernan WJ. Neurotoxicity of sodium fluoride in rats. Neurotoxicol Terato/ 1994;17(2):169-177. " Lehninger AL, Nelson DL, Cox MM, Principles of Biochemistry. 2nd ad. New York, N.Y.: Worth Publishing Group; 1993. " Mincia C, Sabbioni E, Apostoli P, at al. Trace element reference values in tissues from inhabitants of the European Community I. A study of 46 elements in urine, blood and serum of Italian subjects. Sci Total Environ 1990;95:89-105. " Conneft M. Lelter to JNatl Cancerinst. Fluoride 2004;37(3):231-232. " Trivedi N, Mithal A, Gupta SK, Godbole MM. Reversible impairment of glucose tolerance in patients with endemic fluorosis. Diabetologia 1993;36:826-828. " Williams DA. Drug metabolism. In: Foye WO, Lemke TL, Williams DA, ads. Principles of Medicinal Chemistry. 4th ed. Media, Pa.: Williams & Wilkins; 1995:110-111. " Kraft K. Beitrage zur Biochemie des Fluors. I. Ober den Antagonismus zwischen Fluor and Thyroxin. HoppeSeyler's Zeitschrift der Physiol Chemie 1937;245:58-65. Euler H, Eichler O, Hindemith H. Ober die Wirkung einiger organischer Fluoride bet chronischer Darreichung. Naunyn-Schmiedeberg's Arch Pharma col 1949; 206:75-82. " Litzka G. Die antithyreotoxische Wirkung des Fiuotyrosins. Naunyn- Schmiedeberg's Arch Pha rmacol 1936;183:436-458. 3 0 Litzka G. Erfolgskontrolle bet Behandlung der Schilddruseniiberfunktion. ZeitschriRlDrKlinische Medizin 1937;131:791-9. " Litzka G. Die experimentellen Grundlagen der Behandlung des Morbus/Basedow and der Hyperthyreose mittels Fluortyrosin. Dtsch Med Wochenschr 1937;63:1037-1040. " Pradhan KM, Arora NK, Jena A, Susheela AK, Bhan MK. Safety of ciprofloxacin therapy in children: magnetic resonance images, body fluid levels of fluoride and linear growth.Acta Pediatrica 1995;84:555-560. "Graham DJ, Staffa JA, Shatin D, at al. Incidence of hospitalized rhabdomyolysis in patients treated with lipid -lowering drugs. JAMA 2004;292:2585-2590. " Wagstaff LR, Mitton MW, McLendon Arvik B, Doraiswamy PM. Stain - associated memory loss: analysis of 60 case reports and review of the literature. Pharmacotherapy 2003;23(7):871-880. " Graham JR, Morin P. Highlights in North American litigation during the twentieth century on artificial fluoridation of public water supplies. J Land Use Environ Law 1999;14(spring):195-248. Available at: http://www,law.fsu. edu/journals/landuse/voll42/Graham-final2.pdf. Accessed Sept. 26, 2004. " Pennsylvania Environmental Network, Aug 14, 2001. Available at: www. penweb.org/fluoride/lawandcourts/#courtcases. Accessed Sept 28, 2004. Legal Information Institute, Cornell University. Food and drug law: an overview. No date. Available at: http://www.law.cornell.edu/topics/ food _drugs.html. Accessed Apr 21, 2005. 'B Franks G. Fluoride in drinking water. Should you have it? How do you get rid of it if you don't want it? Denton, Tex.: Pure Water Products, LLC; 2005. Available at: http://www.purewatergazette.net/fluorideinwater.htm. Accessed Jan 3, 2005. " Letorney J Jr.. Blowing the lid off of distilled water myths. Rockland, Mass.: Durastill Export, Inc.; 2005. 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'A car, Ilk' o'*tl lit Tr, 2 4Nj tv Nnd M d H 0 N.D Ld (A It) ptj a- _70 W (1) L N Zj 00 'b Z 'b Lima .7 0 :b Q lb zb m I 10m r n 'A :b ct, ia 'p 7z of y L14 N fb I t rya rh rh U to! t r I -, 1 a F Fn Is' 10 N OD 70 Rt at ®r N mi LEV U L Q LLI -__I C Z J U k X k X mM tS � �__., a. v ,- :c Ac 3 a Q v tM1 I .09UNN�Sfd —416 TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 December 16, 1991 Gregory N. Connolly, D.M.D., M.P.H. Director, office of Dental Health The Commonwealth of Massachusetts Dept, of Public Health 150 Tremont St. Boston, MA 02111 Dear Dr. Connolly: The Board of Health in the town of Mansfield is hereby requesting the Department of Public Health's engineering staff their assistance in developing the plans for fluoridating Mansfield's public water supply. All of the legal steps have been completed. The Board of Health ordered fluoridation on June 20, 1991. The legal notice appeared in the Mansfield News on September 13, 1991. There was no appeal. We look forward to hearing from you. Thank you. Very truly yours, MANSFIELD BOARD OF HEALTH Michael VanSplinter Wr Chairman /dr cc: Town Manager Board of Selectmen Finance Committee Water Superintendent Town Engineer AMERICAN CANCER SOCIETY CANCER RESPONSE SYSTEM Printed On: 02/14/91 1-800-ACS-2345 Number 2214 FLUORIDE AND FLUORIDATION Date Reviewed 02/06/90 Preliminary results from a rodent toxicology study appear to have reopened questions regarding a possible link between fluoride and human cancer. The study was begun in 1985 by the National Toxicology Program of the U.S. Depart- ment of Health and Human Services and is now in its final phases of analysis and review. Formal presentation of results is scheduled for mid -March of 1990. Partial details of the study and its findings, however, began appearing in the press at the end of December 1989. The study has involved exposing rats and mice to different levels of fluoride in their drinking water over a two year period ( 0, 11, 45, and 79 parts per million (ppm) ), 50 to 80 animals per group. Preliminary information indicates that bone cancers (osteosarcoma) have occurred in animals exposed to 45 ppm or higher with a possible relationship to dose. . The implication of this study for human cancer risk is unclear. Dose levels were substantially higher in the study than levels encountered in human water supplies (water fluoridation levels are usually about 1 ppm, the upper limit set by the Evironmental Protection Agency being 4ppm; some natural water sources have had levels as high as 10 ppm), and extrapolation from animal observations to the human situation is difficult. No prior animal studies have indicated carcinogenicity, and extensive past epidemiologic work has shown no evidence that fluoride levels affect patterns of human 'cancer occurrence. These issues or course, nave been the subject of in meantime, fluoridation of public drink promoted as an effective and safe publ caries. Evidence that water fluoridat been repeatedly demonstrated, starting United States and Canada in the 1940's impact of water fluoridation appears t fluoride supplementation (toothpastes, If the NTP findings are confirmed in the EPA, under requirements of the Saf results in relation to its on -going re year ago. At. present, however, it see toxicologic and epidemiologic studies preliminary findings may have on prese fluoride use. sense public debate in past years. In the ing water supplies has been strongly Lc health means for preventing dental Lon is effective in preventing caries has with the initial community trials in the In recent years, however, the relative have diminished as other sources of foods, etc.) have increased. their final review, it seems likely that a Drinking Water Law, will consider those iiew of fluoride in water, begun over a ns premature to speculate whether further gill be required and what impact these it public health practices regarding Clark W. Heath, Jr., M.D. Vice President for Epidemiology and Statistics November 15, 1990 TO: Board of Health FROM: Edward Rosenberg RE: FLORIDATION I met with Selectmen Will Sarro in his capacity as Chairman of the Capital Impprovements Committee this afternoon to review the Board's examination of floridation of the Mansfield water supply, and how the Town could pay for this effort in the absence of State aid for floridation" Mr" Sarro indicated that funding could be provided either through the Capital Improvements budget or through the Municipal budget Capital Outlay Account. A concern he mentioned was to identify the ''true cost" per water cutomer for floridation, for both Year 1 (which would include capital plus operating expenses) and for Year 2 (operating expenses). The inference, probably justified, is that we should verify the Stae DPH Engineering Feasibility Study" Mr" Sarro also indicated he felt the Board should proceed without delay if we wanted to get the program implemented in FY92. Based on that comment, I recommend the Board do the following: 1. Set a date for a Public Hearing on the issue, preferably in early January 1991. 2" Request the assistance of DPH in preparing for and conducting the Public Hearing. Area dentists and dental care profrssionals can also be enlisted in this effort,, 8. Prepare a series of press releases for publication between now and a Public Hearing, so that the citizens can gain an understanding of the issue" Again, assistance can be requested from DPH" 4. Schedule a vote by the Board at the next meeting after the Public Hearing, 5" If the Board approves, schedule a meeting with the Selectmen to review the action, what we hope to accomplish, and how funding can be obtained" 6" Instruct the Health Agent to work with the Water Department to coordinate the program. Questions on Proposition 2 1/2 (Chapter 59) Local voters may modify the property tax levy limits imposed by Proposition 2 1/2 if a majority of the city council (with the mayor's ' approval if necessary) or a majority of the board of selectmen votes to place any of several questions on a regular or special local election ballot. The same body may place up to three such questions on the regular state election ballot in the city or town, if the Secretary of State receives a copy of their vote, attested by the city or town clerk, no later than the first Wednesday in August. The local initiative procedure, where available, may only be used to reduce the tax limits further. The text of each question appears in the statute. Ch. 59, §21C. fluoridation of V ic'water supply 'The question is placed on the ballot on petition of Vic the registered voters of the city or town. The petition must be filed with the city or town clerk at least 60 days before the next regular municipal or state election. This question may be placed on the ballot only after the local board of health has ordered fluoridation, and fluoridation may not be ordered again by the board of health for at least two years after a negative vote. The petition must be filed within 90 days of the order of the board of health. Ch. 111 §8C. Question on Horse & Dog Racing (Chapter 128A) Rescinding action of city council or selectmen approvinq race track location in municipality The question is placed on the ballot on petition of 12% of the voters of the city or town at a special municipal election within 45 days of the filing of the petition with the city council or selectmen. Ch. 128A §13A. Question on Boxing (Chapter 147) City or town licensed boxing matches The question is placed on the ballot at a city or town election if a petition signed by 10 percent of the registered voters is filed with the city or town clerk or election commission at least 30 days before the election. The question of revoking such a decision may be placed on the ballot in the same way. Ch. 147, §§49, 50. Question on Beano City or town license for operation of a game of b e 11 TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Board of Selectmen \�v FROM: Board of Health �5 DATE: June 26, 1991 RE . Flouridation Vote On June 20, 1991 the Board of Health made the following motion. The vote was 3-2, in favor of flouridating Mansfield's public water supply. MOTION: Move that the Board of Health order the flouridation of the public water supply of the Town of Mansfield. Further, recogniz Commonwealth, and towns waiting for Board requests th Finance Committee Committee include to implement this cc: Town Manager Town Clerk Finance Committee CIP Water Superintendent Town Engineer ing the financial condition of the that there are already nine other state aid for flouridation, the at the Board of Selectmen, the and the Capital Improvements the capital and operating costs order in the FY93 budget. 'TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TO . Board of Selectmen FROM: Board of Health DATE: June 26, 1991 RE . Flouridation Vote On June 20, 1991 the Board of Health made the following motion. The vote was 3-2, in favor of flouridating Mansfield's public water supply. MOTION: Move that the Board of Health order the flouridation of the public water supply of the Town of Mansfield. Further, recognizing the financial condition of the Commonwealth, and that there are already nine other towns waiting for state aid for flouridation, the Board requests that the Board of Selectmen, the Finance Committee and the Capital Improvements Committee include the capital and operating costs to implement this order in the FY93 budget. cc: Town Manager Town Clerk Finance Committee CIP Water Superintendent Town Engineer TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Board of Health Members 1v� FROM: Dianne Royle, Secretary��` DATE: October 19, 1989 RE Fluoridation I have reviewed the file on fluoridation and attached for your information pertinent articles and memos for your review. There is substantial research that stresses the importance of fluoride in the diet. As you are well aware, it is especially beneficial during the years of primary and secondary tooth growth. According to the American Journal of Public Health, claims that fluoride causes cancer, birth defects, kidney disease, Alzheimer's, etc., have been refuted repeatedly. I also telephoned Martha Wood, Dept. of Public Health, Div. of Dental Health, and she outlined for me the recommended procedure for the Board of Health to take. 1. Feasibility study: conducted by the DPH, no charge, about a two - month process, absolutely no committment on the Board of Health. 2. Ms. Wood will come to a Board of Health meeting and explain the feasibility study results. That study will answer many questions and be the deciding factor as to whether or not to proceed with fluoride. 3. DPH still does engineering work, purchases equipment and installs; HOWEVER, funds have not been appropriated this year. They hope funding would be reinstated next year. 4. One-year process from feasibility study review and to Board of Health ordering fluoridation in the water supply. Only Board of Health can order. 5. Legal notice must be published after order. 6. 90 days after notice, 10% of registered voters can petition to put a referendum question on either the Town ballot or State election ballot. Approximately 50% of the time fluoridation is ordered, a referendum is petitioned. Approximately 50% referendum questions pass. 7. No public hearing is required; however, an information night, series of information articles, cable program, etc. is recommended. onal -ider the 1 of the pensive ,nedical ,ds) AMERICAN JOURNAL OF Publlu iso Editorials mealth May 1989 Established 1911 Volume 79, Number 5 EDITOR Alfred Yankauer, MD, MPH ASSISTANT EDITOR Patricia Harige, ScD EDITORIAL BOARD Irene H. Butter, PhD (1990) Chair Dons Bloch, RN, DrPH (1989) Suzanne E. Dandoy, MD, MPH (1990) Joy G. Dryfoos, MA (1989) Frederick C. Green, MD (1991) Dieter Koch -Weser, PhD, MD (1991) Mary Grace Kovar, DrPH, MS (1991) Philip J. Landripn, MD (1990) Jean Pakter, MD, MPH (1909) Lee N. Robins, PhD (1991) Jeannette J. Simmons, DSc, MPH (1990) Zena Stein, MD, DrPH (1989) Fernando M. Trevino, PhD, MPH (1990) Julian A. Waller, MD (1989) (To be appointed) (1991) STAFF William H. MCBtath, MD, MPH Erecutfve DirectoriManaging Editor Jaclyn Alexander Publications Director Doyne Bailey. Assistant Managing Editor Brigitte Coulton Production Editor Mary Beth Kammann Advertising Manager Lucille Bow Marilyn Butler Annabelle Friedman Publication Assistants CONTRIBUTING EDITORS George J. Annas, JD, MPH Public Health and the Law _ Jean Conelley, MLS Book Corner Mary Grace Kovar, DrPH. MS New from NCHS Barbara G. Rosenkranlz, PhD Public Health Then and Now Hugh H. Tilson, MD, DrPH Notes from the Field Fluoridation Then and Now The fluoridation of community water supplies has come to be widely viewed — along with chlorination and immunization -as one of the most important of modern public health measures. Since it was first introduced into the drinking water in Grand Rapids, Michigan as part of a two -city community trial in 1945, fluoride has made a substantial contribution to the health of the American public of all ages.' The Grand Rapids undertaking was to prove so successful in reducing the prevalence of dental caries in children's teeth that the control city of Muskegon, Michigan soon insisted on also fluoridating its water.' Concurrently, the same effect was being noticed in a similar study in which children residing in the fluoridated city of Newburgh, New York were compared to children residing in the control city of Kingston, New York.' Today, 130 million Americans residing in 9,600 communities have access to fluori- dated drinking water.` However, in addition to producing more decay resistant teeth, fluoridation has often produced spirited and bellicose editorial responses in community newspapers, impassioned debates in local, state and federal courts, and continuing attempts to convince state and federal legislatures to rule it illegal.' The arguments against fluoridation have varied over the past four decades and have been asserted by a small. but vocal and often effective minority. History has shown that even where consid- erable scientific evidence is brought to bear against the anti -fluoridation perspective, it has little impact on those committed to "the fight.'"' At various points in time, fluoridation has been called illegal, a communist plot, immoral, and unconstitutional. It has been blamed forcancer, birth defects, osteoarthritis, kidney disease, premature aging, allergies and, most recently, Alzheimer's disease and AIDS.''" These claims have been refuted repeatedly. One of the most puzzling "anti -fluoridation" claims is that fluoride does not work. However, the overwhelming scientific evidence simply does not support this claim. A national study conducted in 1979-80 demonstrated that caries rates in school -aged children had declined by 37 per cent compared with a national study conducted eight years earlier." Children with exposure to water supplies with optimum amounts of fluoride during their lifetimes had 33 per cent less decay than those who had never been exposed." A follow-up study in 1986-87 indicated an additional 36 per cent decline in decay since 1979-80. with nearly one-half of the school children never having experienced decay in permanent teeth." Dozens of newspapers around the country highlighted the good news, with papers in many non -fluoridating communities decrying the continuing lack of fluoridation in theircommunity. Other recent studies are continuing to demonstrate the contribution that fluoridation makes to a community oral health in today's environment.' ''rt While the practice of fluoridating drinking water has steadily expanded over the past four decades, the use of fluorides in other ways has also grown dramatically. Today, topical fluorides arc applied in dental offices, fluoride mouthrinses and tablets are used in schools and homes, and virtually all dentifrice used in the US contains *Brunelle 3A. Miller AJ, Smith JI: DMFS in CS Children with and without Life-long Exposure to wait( Fluoridation (Abstract 030:). Paper presented at the meeting of the American Association for Denial Research, Cincinnati, Ohio, March P-20. 1983. ""National Institute of Dental Research NIDR releases results of new schoolchildren's survey. NIDR Research Digest, July 19M, AJPH May 1989, Vol. 79, No. 5 mg of dentifrice per brushing, an amount equivalent to 0.12- 0.3 mg of fluoride for most ADA-approved fluoridated denti- frices.1d For the preschool child, only the smallest amount of dentifrice (pea size) should be placed on the brush until the child can demonstrate the ability to rinse and expectorate thor- oughly. This will most likely take place after age 3 or 4. Denti- frices are not recommended in infancy. The use of an over-the-counter daily fluoride rinse can also provide excessive amounts of fluoride if swallowed by the pre- school child. Labels include warnings on the use of these prod- ucts by children under the age of 6 and the need for parental supervision. Dietary Habits Many dietary habits are established in infancy and further promoted as the child develops. These habits are influenced by parental preferences, family heritage, tradition, and the mass media. Health professionals often find parents and children reluctant to accept dietary recommendations. Nevertheless, there is considerable evidence in the professional and lay press that the public is becoming more conscious about dietary habits and selection of foods. Sugar and Caries The connection between sugars and dental caries has been reported for centuries. While the public's consumption of sug- ars has historically risen each year; usage has recently leveled off. The percentage of sucrose as a proportion of the total sugar consumption has declined in favor of corn products and artificial sweeteners." It was recently reported that the role of sugars in the etiology of caries may be weakening in children who are at low risk.. However, in children who are susceptible to smooth surface caries, total sugar consumption and frequency of sugar inges- tion between meals continue to be high risk factors16 (see sidebar). Acid Buffets Foods that raise interproximal pH by buffering microbially produced acids have been of great interest to manufacturers and dental researchers. It is well known that certain foods and snacks will cause a sharp decrease In plaque pH shortly after they are consumed. If used frequently, these foods are consid- ered to have high caries -producing potential. Recent studies show that some cheeses, as well as chewing gums, cause a rapid increase in plaque pH when consumed after a carbohy- drate challenge.17-21 Bottle and Breast Feeding Parents must be counseled on the indiscriminate and pro- longed use of the bottle or breast and inappropriate infant feed- ing practices. Baby bottle tooth decay (nursing caries) con- tinues to be a major health problem in infancy22 Ongoing counseling of parents by all health professionals and mass me- dia education will, hopefully, end this preventable feeding dis- order. Frosting of baby foods with sweetening products to improve palatability may cause a preference for sweets that continues throughout childhood and beyond. Parents should be taught to read ingredient labels on prepared foods and avoid those with Identifying the Child at High" Caries Risk Studies Suggest certain pediatric populations are at greater risk for caries than'others .$4 If these children could be identified early in life, comprehensive preven- `live programs could be designed especially for their ;' problems. Tests to measure levels of specific salivary microbes can assist dentists in identifying caries risks of individual children. The'Snyder test of lactobacilli in saliva, for example;'has been available to dentists since 1940.25 Re Gently, simpler and more accurate measures of salivary laciobacilli and measures of salivary streptococcus;mu tans have'': been hdroduced.46 27 -These tests of salivary microbes have been successfully used in studies of.12- yea r-olds fin Sweden and.9-',to 14-year-olds'in Milwau-' i....,.se,zs...r„A;.aA„al'tests of salivary lactobacilli were as ng program. I iship between a group of 31 aver, find are and the carlw related to sugar ;con- provided'an intensive toffersson et al. did not g Swedish13-year-olds.30 ationship between slrepo- incidence.'This may indi- the use of salivary tests of luate caries susceptibility. ;d to motivate and evaluate ranges in diet. odcrobiologic evaluations ;hild's risk for smooth sur- The demist can reduce.the :e and interproximal caries et, and improved oral by- 1 flossing. high percentages of refined carbohydrates; saturated fats, and salt, It is now possible to provide children with a variety of nourishing foods that will not only provide them appropriate daily caloric and nutritional requirements, but which can have a positive impact on oral health. Plaque Removal Parents should initiate removal of the infant's dental plaque shortly after the eruption of the first tootfi: This responsibility will, remain with the parent as further eruption progresses,' with a gradual shifting of responsibility to the child starting at age 7. The dentist can advise the parents of the child's pro- gress and make appropriate recommendations at each recall The positioning of the child and parent during plaque re- moval and the location of the procedure will be dependent on the child's age. The supine position on the changing table is recommended when working with an infant. The location can shift to"the knee -to -knee position between the parents and, finally, at the bathroom sink, as the child becomes more physi- develop a plan for the scheduled reexamination based on the initial findings. Parents must be informed that the responsibil- ity for their child's dental health rests with them. The infant can best be examined with the parent holding the child or in the knee -to -knee position with the dentist (Figure I). This position offers optimal stability and visibility as well as the warmth and feel of the parent. Most infants will fuss during the examination and parents should be alerted to this anticipated behavior prior to the exam. Figure 1. Knee -to -knee position fi)r infant denial examinaliao. ies and an increase in the moue cent anecdotal reports have discussed an increased incidence Of fluorosis although reviews have not suggesed a clear epide- miologic etiology.10 Fluoridated community water continues to be the most cost- effective means of delivering fluoride to the patient. However, reports now indicate that a growing number of households are turning to alternative sources because of the questionable qual- ity and potential health threat posed by contamination of ground waters, Bottled and processed water sales have in - in to last five years, totaling 2.2 bit - creased by almost 7070 lion dollars in 1988. The concentration of fluoride in these alternative waters varies widely and many tested suboptimally for a 3-year-old child. 11 12 Therefore, the dentist or physician can no longer assume the child is receiving optimal fluoride because they are living in a community with fluoridated water. There is a need to question the parent on water consumption and to water source used. If a bottled/processed water is the main source for cooking and drinking, it should be analyzed for fluoride concentration and appropriate recommendations should be made using a fluoride dosage schedule (Figure Concentration of Fluoride in water (ppm) Age 0.3 Greater }., in Less to 0.7 than 0.7 Years than 0.3 Counseling the Parent 0 0 Following tile Bilotti to 2 e examination, the dentist should initiate a dis- 0.25 0.25 0 cussion with tile oso e parents about maintaining optimal oral health 2 to 3 0.50 0 for their child. Topics to be discussed with the parents should 3 to 14 1.00 include: (1) the development and growth of the teeth; (2) prob- Figure 2, supplemental Fluoride [),sage Schedule (adjusted allowance in nog tents that might occur during teething and management of the problems; (3) when and how to clean the infant and preschool Fld a I Association,eared ,y the Cowuil on Dental 1Aerapeunics of the Atinerlcan Child's teeth; (4) the appropriate administration of fluoride; both systemically and topically, for optimal caries reduction; (5) the appropriate use of the bottle or breast for feeding and considerable evidence exists to support the importance of of a ily lase need for noa nutritfor ive sucking will a discussion oflthele tavaila- mineral zation andcto fluorideal remineralize the edecalthe cifieds eta el. of sources fluoride is ble devices; and (7) the appropriate "first aid" and ptofes- Daily cludingtcal fluor dated watertjand dentif ces, over the -counter sional follow-up for oral/dental trauma. The discussion of teething is an important aspect of the first fluoride rinses, and daily 'supplemental systemic- fluoride ets. Fluoride usage among schOOI-aged childen visit, Eruption of the primary teeth may cause sympt te i-fls Of ims ressiveI and t The 1986 Nafto al Health In erview Surveye- sore gums as well as restlessness, irritability, and a possible s P disruption of eating or sleeping habits. A topical anesthetic ported that 93% of school -aged children use a fluoridated den - of P gprogram." Ap- should be used only with caution as an aid to prevent discom- tifrice 13%a have used a fluoridated mouth rinse at home, an fort. Topical anesthetics may compromise the infant's normal it%a participated in a school -based benefited gag rellex; reduce his or her natural ability to protect the air- proximately 62%u of the population benefited from access to . Thet way and even cause toxicity leading to adverse systemic reac- ate for dentists topublic water lied with reevaluatetheir off office policies on the re, it is rrouttiine lions. Better recommendations might be cold teething rings or at use of semi-annual or annual topical applications of fluoride, massaging of the gains. Upset stomachs and "loose stools particularly in children who are at low risk to caries, or who may also appear with teething, are exposed daily to a topical fluoride either at home or at Fluoride Recommendations school. The use of fluoridated products for the preschool child for Optimal Results should Water fluoridation anti the use of a dentifrice with fluoride beenrepored that under children clayingest between tp0.12tand 0.3 have been credited with the significant reduction in (lentil car- �:. Action to Take - - - ---- -- 1EALTH NOTES,., continual So what are we to make of tT s ow , ;uI ---- e you turn it to your advantage? There are Cw things that you can do that will improve your i„ �^�'I 11('l: I h,,r �',, 11RR,^. I,)9➢C itIS�:1r,, nutrition and they are quite simple: another disease f-r Ih^ ,,,,nt of mmlikind; at least 11z (1) Eat your salad with your main, cooll—I �m„•� i•.rlu= have a]teady been st+.-icl:en course and not before it. .nrl I,•n, have died „f it. It's called ehrlichiosis, or (2) After cooking your carrots, beans, q,nrlulocytic I, is not a tlnusehold teu„ like and broccoli, add about 10 percent of finely I ,,•,,,� di::ense, but it probablywill be. chopped, warm but not cooked, vegetables to is not as easy to diagnose (or the dish before serving it. It will give it nr�) as Lyme disease as it does an excellent flavor as well as combat- the p„vluce the telltale rash around "digestive pathos is. " This can be done with s; re of the tick bite as does L}ant all fruits and vegetables, but not with „as one can get both IIGE and l,yine tick bite. But the pa- chicken, turkey, and all members of the bird rI„r„ rho same I i,•nt is more severe]y compromised as family. The best way to solve the problem of ill,, r,,•n conditions don't respond to cooking meat of any kind is to cook it below I I,- s,I„� antibiotics -- treatment for the critical temperature of 194 F (make sure I.y,,,- u,i I I not. cure uGE. rhis may he why You wash it thoroughly before cooking) . victims don't seem to re- :Ii•nd ,,,apple Lely when treated with Ref: Lee Foundation for Nutritional Research, iitiit, as it. is ineffective in HGE. Milwaukee, Wisconsin 53201, Reprint 4 101. I It,, i I ,•,t went of Resurrecting Pritikin Fluoridofion of Drinking Wate 9'be Pritikin diet, designed b Worse Than We Thought ncr,I who knew nothing of medicine ,nllriti.on beyond reading paperback For all these years of attacking fluori- Iles b,,n resurrected by the Preven- medicine Research Institute of dation of water, we have emphasized the can- e �:,usaiito, cal.ifornia. The diet cer potential and the likelihood that the �.•„nd� even worse than Pritikin's: no ingestion of this poison leads to hardening ,,"nl , nn chicken, no fish, no butter, of the arteries. There are other important ,I„ alcohol, no dairy products (except toxic effects, such as the increased brittle -- i �,�• Aefatted kind) , and no egg yolks. bones after long exposure to fluoride, ,m are expected to live on garbanzos, I,,,i ts, vegetables. But in a bow ness of but the effects of fluoride on the brain and in their master, they say you can eat were something we wondered about, but "P, i t i ki.n soups." Also, you can pig C011ldri , t prove. ,,,It,,,Itr,,, Draft "Free and Guiltless Gour- 114nt tortilla chips.° Now there is strong evidence of what we This frantic gobbling of grain, suspected: The fluoridators have been de- In-Inpinq of chestnuts, and eschewing stroying the brains of Americans for 50 years. ,fnl-nt, is an ancient, recurringdis- Sure the school system is lousy and getting r,ne of the most pathetic exam- worse, but when you add these new findings pi-•^ r,f this veggiemania was organ - to the maleducation our children are getting, ill the, abolitionist -north U.S. it's wonder we haven't forgotten how to in IR4I. A goofy preacher by the name „r prop.^,on Alcott established a com- a make'a, wheel or tie our shoelaces, ;.�. ,mmi.r.l. Cn111pR1/7P that was appropriately The recent study will be hard for the ,-,I led FI,Iitlands. 'rhecoumunerefused fluoridators to laugh off: Researchers from (continued on page 5) the Department of Toxicology, Forsyth Research Institute, the Department of Pedi- „y, a 7 " Second Opinion ` 10A y�al. iI1-it;Lry, PlasCmau Denlnl Center, and Vr,let inary Diaclnostic Laboratory, Iowa „Univ('I Lty have conrbiIled IIle ir talents �,ir,Ilurh a truly shocking and devastating "li,uurul 1.If fluoridaL.ion. have con- nll 1 I- pill IIic health malpi 3(1 ice and thaL we and others have been warn - ;((•riot for Lhe pasL 30 years. hr, I es;earchers reported on the work of I�iu�,r.F scientists who had studied Lite ef- of fluoride on the central nervous m in Humans. Their first: finding was 111 it a fluoride dose of only three to 11 1,,,t I s per million could affect the nervous ,f:t.eIll directly, long before the effects of'- 1—I r,t it f I.uorosi.s (a bone disease caused uotid(-) became apparent. (sage is well wi thin the range of received by millions of Americans, a 1 1 }- c-lur children. Toothpastes contain WOO OO 1 o I >00 parts per million of fluoride. i ':t a-1 i r,s have shown that young children I ,tv a (treat deal of the toothpaste they 1, ,r, I,r�%•arse it, s sweet.) The same is true of hr, mouClt rinses that contain 230 Lo 900 r, per million fluoride. These massive . u1l,nnilF,11L fluoride are in addition to that f„nod in most municipal water supplies, cola ,It inks, Ulo any other commercial beverage, -1,ir al Ippl,ication gels, dietary supple- ] -I- Ill s, and your everyday food. Compare those I it nkps wi Lh the Chinese finding that a mere I,, r= to 11. parts per million can directly n f I-r,c-t. your nervous system and you will I —o i n Lo see. the enormity. of-. the problem. - _.i.- Another study by the Chinese found that Irrdiuy 100 parts per million fluoride to nnnan:; affected the attention span of the „nl, jecLs. The American researchers decided I , ' (to further using rats, measuring their I"•1wvi.or and then determining the blood and I,l.iin tissue levels of fluoride. Their demonstrated "a link between ... III, it: i-cte exposures and behavioral disruption, in I Ito rat." illenatal. exposure resulted in "many Ill li.ivi.ors as seen in drug -induced hyperac i„ity." while weanling and adult exposures 1, 11 Lo changes similar to "cognitive (think - HEALTH NOTES•' continued I o nee beef, milk., eggs, hotter, nut fish (beginning to sound fmni1.ial rnLfee, tea, or salt: "Nothing could l,e eat. on that caused wrong or death I man r,r beast," Even the worms chat w"1 destroying the apple trees could n,lt be mol ested; "They had as much r.i ght. t 11 the apples as man." An Englishman noted at the t. im" that- the people in this human squirt �I cage had become enslaved to their farm animals due to their extreme animal - .rights attitude. But after winter sec in, all but Alcott and his long-suf- fering wife had fled this madness. So grain gobblers and wombat wom- shipers are not new to this weary old world and Fruitland is back for an- other run. All of this is simply veq"- tarianism gone mad and a stupid idea. The new Fruitlanders have studies to back up their claims for this zebra diet. I don't believe them. It sounds like a bad marketing ploy to sell their products. ReL Jm,nml of the Alllimn Medicsl As""tlo" Srptembsr 20, 1995; USA Todu', SeOtesu"' 21. 1995e The :iecret Sl:r, b] Otto Scott. 'u"olo1'tflio"ldr n. Pox 2011, M,lrpl,yo, ch 95241; t,lf 5C 011ts, by Louis. Mny Alcott, Boston; Ilouphton Mifflin co.. Oil. Silver Alert No, this is not an investment ad- visory. The alert is about eating silver. That is what is being recommended by >a.some hustlers and misguided health writers. "Ethical" rheumatologists have been having their patients eat - gold for their arthritis for the past: 30 years and that's, in my opinion, all establishment -protected scam. It's probably less toxic than silver, bill - equally ineffective as a therapeutic agent, and gold costs more than sil- Ver. Why don't they recommend tin or lead? At least the patients will die richer. The silver -for -everything -that - ails -you scam has been going on for a hundred years, even though there is no evidence that it's any better than (Continued on page G) l 7 .tr p'm n t, : 3y" z , �ntiryrY y I1EALTH NOTES ... continued Hssis,ippi mud for your ailments. ]n the 19th century, it was recommended fr,r I-.etanos and rheumatism. I11 the early 20t11 century up until World War 11, colds and gonorrhea were treated ai! h silver. The results were not inr ILL esSive. - ]n this last decade of the 20th cen- t uty, silver is back again as a treatment for (,50 different diseases! They even , efer to it as an "essential mineral" With no proof whatsoever. According to the latest hallucinations, taking silver pills will cure AIDS, 'rB, yeast infections, viral infections, bacte- rial. .infections, diabetes, chronic fatiguesyndrome, and, of course,can- r-r. They are available in every con- ceivable form (even injections) for every orifice. 'Phey claim it is without side ef- fects and safe for pregnant women and the little ones. This simply is not true. Silver causes argyria, a bluish ,lisr. l.nrntion of the ski:i, and n.urol.ogic deficits. It accumulates i n the hody, like lead, and causes re- nal damage. 'Ihe damage caused by ar- gyria is irreversible. Action to take: Pass on silver as a "nutrient" or internal treatment. There is a silver product that has been r,I) tl,e market for 30 years, called Sil- vadene. It is a fairly effective topi- ral cream for skin infections, but hy- drngen peroxide is better and a heck of a lot cheaper. r-L dem nnl of the Amen can Nedlcal Aascclatlon, Oct Ohrt In, MS. Natural Estrogens — neporting Back t4any of you have requested infor- nwti.nrl on natural. estrogens in order I o enable women to escape from taking horse -urine -derived estrogen for n1^nopausal and osteoporosis therapy. Unfortunately, the best natural es- trogens do not come packaged in a nice c•ontai.ner the doctor can prescibe for you. However, estrogen -like sub - (Continued on page 7) ing) defects" seen in humans. This landmark study is the first in th- West to demonstrate that (1) CNS function is vulnerable to fluoride, (2) the effects of exposure depend on the age of the animal, and (3) fluoride accumulates in brain tissue, which means, although the authors didn't say it, that fluoride poisoning CPuiri be the root cause, in conjunction with aluminum, of Alzheimer's disease. The authors concluded that fluoride poi on ing, at the "acceptable levels" of your be- nevolent health department and your dentist., "can be indicative" of motor dysfunction, IQ deficits, and learning disabilities in humans. Action to'Take (1) Avoid fluoride -containing toothpaste. You can find several different brands at your local health food store. They're even starting to sell it in some grocery stores. (2) Start a political action group in your city, if there isn't one, to get the fluoride out of your water. (3) Drink only bottled spring water that is certified to be fluoride -free. order bottled water in restaurants. (4) Make sure you have filters on your shower so that you will not be inhaling fluoride when you take a shower. You can order quality shower filters by calling 800-728-2288, You might even consider putting a filter on the intake water pipe of your home so all the water in your house is free from fluoride.. FeL Neuroto%lcolopy and Teratology, Vol 17, /H. 1995. Dying in Pain, Still CommO► I —And Unnecessaty why can't they get it right? Why do people have to suffer in pain at the end of their lives? Even in hospitals, patients are denied pain relief. because it's assumed they will become addicted if "too much" narcotic is given, A belief that is entirely without 6 l'l ' : Second Opinion Fluoride: The Benefits Can Last a Lifetime Tooth decay, also known as dental caries, is a health problem that has plagued humankind for cen- turies. Until as recently as 50 years ago, the dam- age caused by caries was an inevitable fact of life for most people. The disease often meant many visits to the dentist to have damaged and painful teeth repaired or removed. Today, primarily as a result of fluoride, damage caused by this problem can be reduced and, in many instances, prevented. Fluoride and its benefits for teeth were discovered in the 1930s. Dental scientists observed remark- ably low decay rates among people whose water supplies contained significant amounts of natural fluoride. Several studies conducted during the 1940s and 1950s confhnmed that when a small amount of fluoride is added to the community water supply, decay rates among residents of that community decrease. Although these studies fo- cused primarily on the benefits of water fluorida- tion for children, more recent studies demonstrate that decay rates in adults are also reduced as a re- sult of fluoride in the drinking water. Fluoride prevents tooth decay two ways: through direct contact with teeth and when people drink it in the water supply during the tooth forming years and later. The most inexpensive way to deliver the benefits of fluoride to all residents of a community is through water fluoridation. All water contains some fluoride naturally. When a community fluori- dates its water, it adjusts the level of fluoride in the water to prevent dental decay. Currently, over 144 million people in the United States are supplied with water containing enough fluoride to protect teeth. One of the health objectives contained in Healthy People 2000, the plan that sets health goals for the nation for the year 2000, calls for at least 75 per- cent of the nation's people to be served by commu- nity water systems providing optimal levels of fluoride. The current level is 62.1 percent. To reach this goal, approximately 30 million more peo- ple must gain access to fluoridated water through public water systems. Percentage of Public Water Supply Population Using Fluoridated Water 1992 3z 25.9 45M&4� 24A 410 3&7 21 �3.1 81.715.7 40A 1 sss 1 1 K0 64.0 13.0 o 48.4 66.7 55.6 NH 24.0 VT 57.4 MA 57.0 RI 100.0 GOA CT 85.9 NJ 16.2 DE 67.4 MD 85.8 n.1 DC 100.0 78.5 WV 82.1 0 Goal not attained Goal attained or exceeded USA Year 2000 Goal - 75% f DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control Atlanta GA 30333 Refer: FL-141 December 1993 FLUORIDATION FACT SHEET STATUS OF WATER FLUORIDATION IN THE UNITED STATES As of 12/31/92 ...... 1. Total U.S. Population (1992 Estimate) .................................. 259,544,000 - U.S. Population on Public Water Supply Systems ... 232,438,000 (per 1992 EPA data).....................................,10606,000 26 - U.S. Population Not Served by Public Water Supply Systems ................... . 2. Total No of Public Water Supply Systems (per 1992 EPA data) ..................... 59,158 18,273 - No. of Systems with population less than 100 ........................ • • • 18,238 - No. of Systems with population between 101-500 ....................... . ..... . - No. of Systems with population between 501-1000 ........................ • • ' ' 15,487 - No. of Systems with population over 1,000 ........ • • • • • • • • • • • • ' • ' ' ' ' ' • ' ' ' 3. Total No of Public Water Supply Systems that are Fluoridating 14,351 (1992 Fluoridation Census) ............................... 10,567 -Adiusted........................................................ 3,784 -Natural .................................................. 4. Total No. of Fluoridated Communities (1992 Fluoridation Census) .................... 10,496 - Adiusted 8,572 ...................................... 1,924 5. Total U.S. Population on Fluoridated Drinking Water Systems 144.6 million (1992 Fluoridation Census) 134.6 million - Adiusted.................................................... 10.0 million -Natural ................................................... 6. Percentage of U.S. Population Receiving Fluoridated Water: 134.6M+10.0M = 55.9% 258.5 7. Percentage of Total U.S.. Population on Public Water Supply Systems Receiving Fluoridated Water: 134.6M+10.0M = 62.2°% 232.4 8. Percentage - Small Systems Small water systems (<500 population) comprise 62.2% of U.S. community water systems, but serve 2.3 % of the population on public water supply systems. 9. Percentage - Large Systems Large water systems (> 100,000 population) comprise 0.6'% of community water systems, but serve 44.8% of the population on public water supply systems. Division of Oral Health National Center for Prevention Services COMMUNICATION POINTS REGARDING COMMUNITy WATER FLUORIDATION American Dental Association Council on Access, Prevention and Interprofessional Relations The benefits of public water fluoridation are well known. Since its introduction 50 years ago, fluoridation has been primarily responsible for improving the public's oral health status. The use of fluoridation to prevent tooth decay continues to be examined, even as the amazing results from its use continue. Today, many more sources of fluoride are available, making its use more convenient (accessible) to the general public. • Fluoridation of community water supplies is the single most effective public health measure to prevent tooth decay and to improve oral health for a lifetime. • Water fluoridation is the process of adjusting the natural level of fluoride to a sufficient concentration for protection against tooth decay. • Approximately 144 million U.S. residents in more than 10,000 communities are now served by water supplies in which the fluoride concentration has been adjusted to an optimal level (134.6 million residents) or the natural fluoride content is sufficient for improved dental health (10 million residents), according to a December 1993 report from the Centers for Disease Control. By the end of 1993, approximately 70% of all U.S. cities with populations of more than 100,000 - including 42 of the 50 largest cities - were fluoridating water, according to a December 1993 report from the Centers for Disease Control. • A national health objective for the year 2000 is to increase to at least 75% the proportion of persons served by community water systems providing optimal levels of fluoride. To achieve this objective, an additional 30 million persons must receive optimally fluoridated water from public water supplies. Fluoridation of community water supplies is supported by the ADA, the U.S. Public Health Service, the American Medical Association and the World Health Organization. Studies over the past 50 years have repeatedly confirmed the safety of water fluoridation at optimal levels (0.7-1.2 parts per million) and its effectiveness in preventing dental decay. 4/95 Routine consumption of fluoridated water and proper use of fluoride products is not harmful because most of the fluoride is excreted from the body. The only time there is a risk of getting too much fluoride is when fluoride products are misused, as in swallowing fluoride toothpaste or mouthrinses, inappropriate use of fluoride supplements, or drinking water with high natural amounts of fluoride. Dental fluorosis may occur when children drink water high in natural fluoride content when the enamel of their permanent teeth is forming. It can appear on the surface of teeth as faint lacy white lines or specks (mild to moderate), or stained and pitted enamel (severe). Dental fluorosis is a cosmetic effect and is not considered to be harmful to health. If children exhibit any fluorosis at all, it is usually a very mild form and often unnoticeable. Only a small percentage of children in the U.S. experience moderate to severe fluorosis. Fluorosis can be prevented through the appropriate use of fluoride -containing products. Children should take dietary fluoride supplements only when the home water supply is known to be deficient in fluoride. Children under the age of six should be supervised when using fluoride toothpastes (a pea -size amount) and mouthrinses to avoid excessive swallowing. -3- MRR 19 196 05: 54PM CRMP DRESSER & MCKEE T�L.�.�_ �®, � e. 4 .. rr- i9 Karen Kunz glues her son, Thomas, fluoride, Kunz drank fluoridated water all her life until moving to Worcester. Clenched. teeth over fluoride, R By Bruce Mohl .eLost swr . W ORCESTER -Karen Kunz says her last three dentists took one look in her mouth and knew immediately she hadn't grown up here. "As soon as f sit in the dentist's chair, they know," she Said. "They don't have to even put on the bright light." Kunz, 86, drank fluoridated water all her life until molting to Worcester nine years ago, and dentists say it shows. She has had only one cavity, and that came after she moved to Woreee• ter. Tonight, dentists and public health officials will try to per, suade the Worcester City Council that fluoridated water wrould do For the city's natives what it did for Kunz. But it won't be easy. Despite decades of research and stran'g support from the na- tion's scientific, medical and dental communities, fluoridation re- mains controversial in Massachusette and eel -ass the nation. Over the years, opponents have linked fluoride, once used in rat poisons, to cancer, hip fractures, premature aging, AIDS, birth defeats; allergic reactions, heart disease and even communist plots, None of the links has been proven, but Fwith scientific LUORIDE,' Page32 N 1N7 ^ A 00 ° O 0V C N r-C� i Q '�.Y ^y q q pp 0.1 yy .pD w O >>o 0 O �„ O :^. 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"N, „�a'.,W N 4 �: 14dtaa,m,n. i,. s •:WY+ Lund.. !n'd N'J31+1i']dp • t ®idado" n !s resistibid in lr'cestex OIR.UORmD �"Daaleaily all these peupe are doing — ,-—T�"�— j Continued from"age89 is MghteninI peaP'a" uhvy7'g}��] (r (�y't '/gr'f'7''try■ sure full of examples of ane•UmC Bonrde MCCattuak hall ustdtad Anal YY ers on flux �i�l ei W both aides In Nauek, and she war wonder drugs turning out ta'be pub. pWe that there ,could be problems' lie.health chances, the antllluordo. with loorido in the water. She'aaid'' :+i:' Here onto ntera to common 1990 found four raft out of 130 detente often And a rseepUve audl.''her elfeptldim of goveenmant,bnQ . nuemaona obout fluuridatjun: devoloped Done sanest after eni "" about it,me In! affwisle iu probably,? f tor.'.:, h Nweido d IisimnV drinking wpt0r containing no, Kra* I"ThinkWormitty nsaid ursn anao,Bs t.i in hat thiniing, "Today I dudst n g'I$ ;, ;,;•,Fluoride is indeed wide and Pride to Nniounfe, 86 m lOD Umut ''lot of things I de'vcr yueafio(ned l�:+� ,)war lined used as a vat poison, bat Arcata than the levefe In muniel- laiding opponent 'of nuoridstleh. �;foyb"she said; .',:r;f.: tP t %6{+irr:i, f" N duutUGte fa greater than the pally, Facilitated twtar, A Fabru-'•� "You're Putting chi&highly lokcaub , jIndaa Ldyl !Nd'(oltrntr ntaYv7; tI pati pgt'million wed in dank �' 1991 Nblic Health gorvice stance into the Weill,,. It's s small , `et 1Vprnestar vad now a talk :how' u Ing wetorn; study reviewed 60 ipidorhfology ' I amount,, I agree but WW 8D irid0 tath6aa On„Vfl'Ai3.A}f ;'A94+led' dwC t ' + A TeNort by Use denier our. 'euidids from the past 40 Vast 1 years whal't going to happen? a'r&,'rght9 agvnal nuotidadoni }le' d' lw'bilwse �L�ent"01 found monde and'eowtUded fluoridation poses , Fium'idauon se, the„Qpe'pu!$e aL he doesn't get NW the dtfor tsEtl il'dosea o(0 pops per mglion sw.• no cancer risk. A recent N9tlontl healthpolicy that isvotculon4y16e91;'bets averfluaGde'shealth eRecytie•y(•, ;, day for d0'yems would cause en- Censer Inatilute study recoiled nytionts, end It's ewyA,ga}.lost 'rlceuse auenfgto atudibs l2ni)'to hsrSel pm,blems. It would similar conolusion. ward the atudiee and Olb{Isdp'Olapo- fr 0ech other auh�.�,^,Jyp;3ii'i';IiUy, �A:, A,14wakeieal b mke'a Angie dose at a coneenGa-- Dnex nuorfde cause Ids (rp0. Gept4 And supporters hurl,.pt' Oath'"p.; : of ,tint Aevd a prab!4ija �fN'gbv-'I Uon of, $DW Pi million to lejee Iq the elderly? otM1Cr. "Witbn it'll a public, emotlana! ". ei+,inant modlaatingtsai0,ty. ar,'dny,'� knll'a:160•pouod man. The Env. Rldaat studies ape, inceino" issue like this, suentjlle frets acme• '1611, esrutlegy whemthem°om, deh•e ronanentel Protection Agency xl- alvd A report East your in Com. tlmer. aYe more suspect than they , er weya'of gOlVit umids, osedd.r lows ne' more than d parts Per mi Dentistry, and Oral Upide. . pre support",", chid: Dr: POtar P. t pits in Iwuo that can It's lop of , • millon of ilul id0 in drinking we- initially indicated fluoride levels Audetsa, a Worcester dondtt who . people in trial community.",,''' ;a°,; r. tea j: `'. i-*, four times the opumum level in ,.'. supports fluordpUon. ,: , ,,, The fluttddsdim, debate datbs W- Does' fluoridation increase lead' drinking wager were aseoeiu!ed . , Though Worteater is the largest We party poet of ihls century, when; poyamfl g? with reduced bone maw. Other city :n hlageauhuse9s not Auundat-, . lic10ntWta were, trying W discover Wilco fluoride is added Is wa- studies have indicated naarida Ing is Witter, it is not the oMy one,;;, what wan mottling Era,anstr i',Of ,., tar, In the form of hydrollugtfllck may be banilodal in cumbaung ' 8 pprielihold, 'New - Bedford, ; leash in ports of Colorado bad Texas, ` Plynnoush, Braintree nm{ 179 01 They balled the the mottling to Ihe" . acid, the acid drives down five pD at she water, making it more llkr ate0poro0U. aides And towns have chased not to waWr and aubsequently to Agenda' ly, t0 leach lead Dam piped. The Did ewftrtilatrd ban Duoride? $wise embassy arfleialx in fluoridate. Anot6er.6t eommunlUe& in the water, but they ales cook eeid's impost in dfhet by priding , Washington quid their Country have water sratie net conducive to', that mottled tooth were highly rmLw ', aadium hydroyjdo, which eP4 the data hot fluoridate its water, but fluoridation, and the remaining .111 test to dewy; , . • PH level and helps reduce the wa- DuoriOo is act banned, Settle still, municipalities, home: to about 2.4 , • Studies in communities where .'tech cOrrmive effect, tens can buy Dolt supplemented million people, do fluoridate. .. T,uolids occurred ssluraily'in the• .Dopy fluoride cause canter? with naarida. Warcwty rea(denta voted bto-1 agithAt Auridalloa In 1963, s ad )coal water'found for fewer eavitieswhere r the fluni& jp ns110rtn1 enidy completed In BBUOF MOi1L 0f$einL have .turned book $chiral, mnosntrallon wasgreao at, The mottling, later celled Atom I _ subsequent attempts. Most obearv.• ,eta, developers when Duodde aancaP-• •. of Ue nuaHde is earreted fool the also in touthpwtes and moat funds' an think the City Cowell EMIT vote, - friction i6 the inter exeeedcd g parts "per , -body, but some is ubaarlsed by boost prepared with fluoridated water. ' to suppart nuoddudon thus time, but million., r � I and jaeth. Jordan. Womeeter'nFemur may - oppunonH may mount a reftemmium Research indidated Oat fluoride Der hate iay' nuorilludG4 pee• or,. said the easy anew W fluoride gampakim to overturn il. at about I past par mUliUn _ the 'train tooth' decay to yaghge'' ohil• and even the possibility of health In NuUCR ieaidenV' valet! 61' aqutvdena of one amp in a bathtub . dren and, mot 40e4 in older $delta danger, makes fluoridation of water percent to 40 percent in 1988 to III- ]'oil OF water -to could reduce emntlea, as their game Mull. On average, it ' aupplice unnecessary. I ' adduce. but finding probiema Novo , by'0 much 410 percent. Pleuritic • mote about 60 Gallo a yedr cur per• Yet juut 'a pre U8 Food and delsyed'ImploMontabon. Lout week; ;a nelurally pi In all Inter %up•' ton, a lifetime coat of $87,50 fora Drug Adminlstrutimn recently er- a grroop of opponelttA eonvnced the plan - even bottled wrs atecontain it person who aver to ago 76; dend msnuNoturon of cereals, Board of 8elc0tmell thut queations . and officials began adding fluoride "You Can't get one small metal Bear and pence to add folio aid W :amain n1i nuoridelion. The as, to bring It to optimk" levels. restoration for that Wnount of man. PNCIU06 to help pregnant Women loconen ached the Baasd'pf Health The Mweuehucetts WApeN Be. ey," said Dr, Mlehneu pinaloy, a flu. avoid disabling birth Aefecte, health W investigate before proceeding, aauroes Authority, which provides'' pride oxpert,represanting the. officials io Maawehuralb say fluori• . 'M1Ve don't want it in Ur water. water to th million people In titan ' Amonean Dental Asawaiatbm lotion Ia a ewt-efiecdve and safe Ye. It's poison," Slid $•nirloy M. Drovol1, M1tmaechuaOtle, edge fluoride to the: •,,,; But the benelldpet W impof no. sponw W tooth decari- e leader Grins oppoaltien in Nadok. ", Water in the form of hydratluwili ;r1dA*d1 Wateria few dramatic today, "This is the third or fourth rime ant Roger Wade;, dh'eotor of tee ;; Aeldl The ltuadde is a bypr dueCof' � OU 0waa, ?ecentatudlasghow, pri, in the last 8D seers we've tiled this;' N&Uck Pabiir Healitt DO(ARmOn4 i"fftN{lieer produallni. :. ,1;:', nearly becabio febride is now found' mr A id Drnold, Owwik, Women• said there is no hew dredible Infer _', Coca added by apli414 Insehin= In a variety of other sources. Ill ill inL fal'e' eotnmiwioner of public heplib Fri raising goesdore $bout flu• , ery, the nublide Yamaha In solution laoR drinks produced by eompaniea and Bode enfuraemena "IV6 time to eddy ^C1us to the,aingle most stud• °-at a uoui level and do[i not of-,'. using fluoridaced, water, like the bring Wonlestor Into the gist can. led pectic: horith hone ever," he said, , foot the niateYs torte or, smell. Meat Coca -Cole plant in Needham. it 1s fury:' `\ hi, G('H Massachusetts Department of Environmental Protection For erP uw only I / 4 6 /'7 PmmN No. Transmittal r Transmittal Form for Permit Application a°°°°°°°I° — - i--- - ; i and Payment Perlowiff mellDenied 0ocislan Dale ate Y I Facility It) (if known) INSTRUCTIONS 1. Use a separate Transmittal Form for each permit application/category. 2. Use an original, 3-part Transmittal Form for each permit application/ category. Photocopies will not be accepted for permit application or payment. (You may use photocopies for reserve location, where applicable.) 3. Make check payable to Commonwealth of aassochusefls. Please mail check and yellow copy of transmittal form to: Dept. of Environ- mental Protection, P.O. Box 4062, Boston, MA, 02211. 4. Both fee exempt and non-exempt applicants meet moll yellow copy of transmittal form to: Dept. of Environ- mental Protection, P.O. Box 4062, Boston, MA, 02211. Permit Information Pame Cool, (seron Marotta - cab from Ite we of yVur *0#'(W Iwm) MIEN Fib L1) Wv)9'r Pe 14T-�_�;A/ PenVINM arlet Pro t nescrlpflon FUl3LiL Applicant/Legally Responsible Official ebl�✓i#RCf w- tu# /"F R 1) i V T 6 w 1v H R z L Were" ■� 6I ,�_7:�.� � cifr1roen Canbci Facility Information MRNAf _lIApiv.- J'$.TE rc %aiIry Nr�,1;NwAl: :ff# L L_ ,5 © W IFS i s r Ad PJV,s.F—i � � D I'f 1�._Oa o � 5 D �__., 6 /--■. � 313 �; _. Teleylarn Clry/ro°n Application Prepared By "_ E A_RL_LP_I_ cle/roxn male caext ® Other Related Permits. Are you oppiong for after perm/lb rebbd m t& pam"#Sv, pleas lbt flem babw. Amount Due Special Provisions: Fee Exempt (city, town, district, or municipal housing authority) (state agency it permit fee Is $100 or less) Hardship Request (payment extension according to 310 CMR 4.04(3)(c) 0 Alternative tiehedule Project Request (according to 310 CMR 4.05 and 4.10) Check No. WON: PMNI Appllaotion YELLOW: POMW KK' Appheent ylabl ? y check and YO&W copy of transmittal form to: ROV SN c/�-� 7� I / �,u-e tt),�o op -P P-, clLj O( e ✓ r �J� C 01 tis a ,i cj =C�C�D�IC MAR 13 1996 C SP v i ou-S (� Lu -p /lJ CC r C(4 �(GAJ �Cu �e0-neC( w- Ca�j�( PC� i Cie- Cam. l �e�1 _ \ Ql f: 2l� C w LQ O O a p 8D p p p y C F 0 O > Q « O 0 7 C 0 �% .� .� .o q m a; " •O ^' :O •«n '1y1 W I. in `d °> •� ,x N > v q x 0 �pA C G ro v g 0 c`i O a a. p .N 0 « p �d U « .p x ., 'y �y tt6yy y P. 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' ° a`tli m q d - an 0 i n '0 a a o 5 ox ° a.0 A N A oW �••�h«. $moo.• d a. 5 Vb a"a Q ea o� W o°gae��+�h S zA o°'Ca°„ o$C�SCgvoaaa� �kUo o 5 :? o$ p° o 4) Y wo 0.0 oaaid� r2 �,�o. oEcoa�� °�°� ee 3 m I y'�' 3s �.0„= a�i dv <°3i°i pp d > " o y o G 0 � „ O 'y •axe •>o' N � y id ° 0-0 y $w dA r,.5 a ° C y o 5 G NoW o0° 'o-� Po dp 3 C dd x ° a N o a 5 h° v s a o o s a ° o O � a� c h 8pA¢� 5 a 3 � 8 c aQ o ary �v o t) b � •� VI z 2! �D g O 7 y C o �.a.ouU `N" y°y o � 0.� Q o �a2.2 o off° 3 3 To ��ao�a+'o«ocd n °c��p0ya } N "I~ -0W ?� .�' ° `fir vcn a >, N� WxW � m aA"7rry CAt3uwc(7a°i! oo •O �•� '^ �p y h w y d >, d" a r L .75 a) r.N a C OC 3'a «d a., 3 P° o a 3S d m of ohs ° bo �( wz;zgi"d tea.w9FCO,c9Ctl Caw�aEc7 .v3N;°3.. wbo0N°a�'i raa5�'3eC 'C°��°atl e:Gy?�a.i• w Wa3 z E. .«o;v°aE] A °N $ jr' O N• o ° o °o > ° oo: ° ma o' o .0+°a°wepC080 P.a° F + +m }} C ooWWd O ° C CO dS rO + + +O p} + Co+ x++ +2o�.= oZcy 8 oo r a aapw = :3 Po m c o oa oa o a5&C�u0o 3F«2v. sa o« �U J THIN 11 15 44 WH 1� Date TOWN OF P'IAFI':_FIELD 517, P[11 TOWN OF MANSFIELD, MASSACHUSETTS 5o West Stmet, Mansfield, MA 02048 p FAX COVER SMEET From: Town of Mansfield 50 West Street Mansfield, MP_ 02048 Nine To: Time Phone: Fax: (508) 261-1083 Type of Form ��_ nutubl of pages ` {(including this sheet) if you i,c. not receive all ^`. }-, above paces, please contact sander. MeS Sao C: WL��- � �- M 17 =i 1:! 4,5 1 11 d '. k I : iJJ 1 Pi i ' , Hoard of Health Page 2 January 2, 1992 c. Letter from Rodney Dahlstrom, 992 West St, to BOH, Dec. 27, 1991, re: A lot on Riverwood Estates. Agent will respond to Mr. Dahlstrom and attempt to address his concerns. d. Project Bread, A Voice for the Hungry, Dec. 16, 1991, invitation to Legislative Breakfast on Feb. 14, 1992. a. VISITORS Town Manager, Bill Williams, was present to inform members of the shortage of funds for FY93, and the unlikelihood of an appropriation for fluoridating Mansfield's public water supply. It was the Town Manager's recommendation to defer all capital improvements (unless mandatory or emergency) until greater resources are available. At this time $77,000 has been recommended. Mr. Williams did speak with Ed Rosenberg earlier about this subject. Members Fontanini and Steele were under the impression that the BOH was planning to pursue funding through the State --not the Town. Agent reported that Member Rosenberg told him that he would be in favor of deferring fluoridation until FY94, but would expect a guarantee for funding from the Town. Mr. Williams stated that the Town cannot guarantee due to the unclear fiscal picture now and in the future. MOTION: To defer action for funding to fluoridate public water supply until it is economically feasible.. VanSplinter/Fontanini. All in favor. VOTED. 5. HEALTH AGENT'S REPORT a. Lawncare Update: Lawyer on vacation. Still have not heard any 110ws. b. East Mansfield Sewer: As Town Manager stated earlier tonight, the funding for this project is uncertain, since there are several variables to consider. Options are still being juggled. Agent wrote several questions for the attorney to answer, They are: (1) How is a moratorium by a BOH, for the purpose of sewer construction, put into place? (2) Can a moratorium be resd in phases? (3) How does a moratorium affect purchase and sales agrees 7 (4) What is the Town's or Board's liability for a moratorium? (5) ,' :t can ot� boards do? Chalrm-ni Austin asked if tP, i--,ard should still pursue legal counsel. Agent replied definitely. A memo l be sent to Town Manager with the questions. c. Air Quality Tests So. Main/Edgewc;d Sts. Area: All houses were tested fine except far two. The highest level was 5.0 (acceptable level is 1,0) of vinyl chloride. That house will 1 retested on Friday, Jan. 3rd, along with DEP and Rrzz:a Associates. d. perks and Plans: Final count for 1991: 167 peres and 203 plans. Concensus of Board is that growth is out of control. After much discussion, members agreed to invite planning board members for a round -table discussion to get their views on growth and what plans they may have for controlling it. Meeting is tentatively scheduled for February 6th. Maw The Commonwealth of Massachusetts Executive Office of Health and Human Services 1 Department of Public Health Office of Oral Health 250 Washington Street, 5th Floor WILLIAM F. WELD Boston, MA 02108-4619 Governor ARGEO PAUL CELLUCCI Lieutenant Governor - GERALD WHITSURN t Secretary DAVID H. MULLIGAN "�; j Commissioner June 10, 1996 Mr. Buckley, Superintendent DPW -Water Division Town Hall 50 West Street Mansfield, MA 02048 RE: FY"97 Water Fluoridation Grant of $31,000 Dear Mr. Buckley: Enclosed are our standard water fluoridation grant contract documents in the amount of $31,000 for FY'97 in response to the Town's letter of request dated May 7, 1996. While the amount will not cover the full anticipated capital cost estimate, it is a start. The amount may have to be lowered at a later date subject to amendment should the contract office order, as the fiscal year 1997 budget has not been set. Please secure the signature of Mr. William Williams, Mansfield Town Manager, at the red. x on top page and page. 2 in duplicate. Hewill have to sign a total of 4 times. Then submit both copies to this office for final approval. Upon approval one copy will be mailed to you. Upon approval Town purchase orders will be cut for purchases as drafted by our office, and the Town will be reimbursed dollar for dollar up to the contract amount. If you have any questions, please call meat (617) 624-5941. Very truly yours, Frederick P. Barker, P.E. Fluoridation Engineer FB:LB Enclosure: 2 contracts cc: Board of Health (No enclosures) ✓ __ - ��/9�O �� .� emu- �..-z�-�� .z��-�-�-��/� -�-. �. ✓, G� ��-��; � , ,1��?�-�-�c_� � �r� lip,. `' �� 1 � � `� ' — — I _ ��- (_��°-cam ,� o L.�i�yv�, !/i'C/ 1 �2 c��L� �G�z,�-�-C'i�.Lil�' l -�� iC�/fLLi�z��l � _ _ . r% �if%GL2�'� ��7ia2e�C� ✓t�j'G�L?!.L�.i _/�"/�"'� ��n I z � � �'� � November 15, 1990 TO, Board of Health FROM: Edward Rosenberg RE: FLORIDATION I met with Selectmen Will Sarro in his capacity as Chairman of the Capital impp'ovements Committee this afternoon to review the Board's examination of flori.dation of the Mansfield water supply, and how the Town could Pay for this effort in the absence of State aid for fl.ori.dation. Mr. Sarro indicated that funding could be provided -either through the Capital Improvements budget or through the Municipal budget Capital. Outlay Account. A concern he mentioned was to identify the "true cost" per water cutome'r for floridation, for both Year 1 (which would include capital plus operating expenses) and for Year 2 (operating expenses). The inference, probably justified, is that we should verify the Stae DPH Engineering Feasibility Study. Mr. Sarro also indicated he felt the Board :should proceed without delay :if we wanted to get the program implemented in FY92. Based on that comment, I recommend the Board do the following' i. Set a date for a Public Hearing on the issue, preferably in early January 1991. i:_r. Request the assistance of ilf•H .in preoaring Tor and conducting the Public Hearing. Area dentists and dental came profr-ss.ionals can also be enlisted in this effort. 3. Prepare a series of press releases !or publication between now an(J a Public Hearing, so that the citizens can gain an understanding of the issue. Again, assistance can be 'requested from DPH. P. u.. Schedule avote by the Board at the next meeting after i'. `r F ;_l!L.!_ Hearing. 5. If the Board approve_, schedule a meeting with the Selectmen to review the action, what we mope to accomplish, and how funding can be obtained. 6. Instruct the Health Agent to work with the Water Department to coordinate the program. Questions on Proposition 2 1/2 (Chapter 59) Local voters may modify the property tax levy limits imposed by Proposition 2 1/2 if a majority of the city council (with the mayor's approval if necessary) or a majority of the board of selectmen votes to place any of several questions on a regular or special local election ballot. The same body may place up to three such questions on the regular state election ballot in the city or town, if the Secretary of State receives a copy of their vote, attested by the city or town clerk, no later than the first Wednesday in August. The local initiative procedure, where available, appeabe rs ietoreduce tthe tax 121CS further. The text ofeach questionin the statute. Ch.59,§ Question on Fluoridation of public water supply (Chapter 111) Fluoridation of public water supply The question is placed on the ballot on petition of 10% of the registered voters of the city or town. The petition must be filed with the city or town clerk at least 60 days before the next regular municipal or state election. This question may be placed on the ballot only after the local board of health has ordered fluoridation, and fluoridation may not be ordered again by the board of healtfiledhfor withintleast two 90 days of thears orderter a of theeboardeofote. The health. Ch. 111n§8C. be Question on Horse & Dog Racing (Chapter 128A) Rescind in action of citt council or selectmen a roving rauc location in municipality The question is placed on the ballot on petition of 12% of the voters of the city or town at a special municipal election within 45 days of the filing of the petition with the city council or selectmen. Ch. 128A §13A. Question on Boxing (Chapter 147) City or town licensed boxing matches The question is placed on the ballot at a city or town election if a petition signed by 10 percent of the registered voters is filed with the city or town clerk or election commission at least 30 days before the election. The question of revoking such a decision may be placed on the ballot in the same way. Ch. 147, §§49, 50. Question on Beano City or town license for operation of a game of b COT the game of beano in any city or town shall regular city or town ballot by a petition signed by 5% voters. This question shall not be submitted to the than every four years. 1971 Mass. Acts ch. 486, §4, Mass. Acts ch. 244, §§2, 3, and 1975 Mass See G.L. ch. 10 §38 and following note in M.G.L.A. be The question be placed on the of the registered voters more often as amended by 1974 Acts ch. 779. 11 Page 6A THE MANSFIELD NEWS, Friday, September 13, 1991 Elm NOTICE OF MEETING BOARD OF HEALTH effective until n��W �y days after it has been ety pub, M nsfieldTown Manager The Commissioner of ofMansfiel �Mkxss r, fished. the County of Brlsto G ' tHehe DepComent of P blof ic BOARD OF HEALTH some other suitable pe, Massachusetts, Michael VanSplinter, be appointed trustee of " determined that the fluoride Chairman estate first giving a su CONSERVATION content of the public water Donald Steele, Clerk on his bond In pl COMMISSION supply for domestic use in Henry Austin Estelle Johnson b the town of Mansfield is not Peter Fontanini H you to ob On Monday, September the optimum wnof level for sound MN 9/13191 Edward Rosenberg thereto or your attar, 16 at 8:00 p.m. the Mans- dentl health and has so IN #N16006 sho I e a written apple field Conservation Commis- in said Court at Ta. ston will discuss proposed notified this Board of Health rules and regulations per- of his findings. on before ten o'clock in taining to the use(s) of con- The Board of Health of � forenoOf on o the tenthhe c servation properties in the town of Mansfield, after day of this citation. Mansfield. All interested making sufficient inquiry Of Witness, citizens are welcome. the matter, considers an ROTENBERG, 'ERNE, Copies of the proposed upward adjustment of the First Judge of said Cou uh rules and regulations are fluoride content of the water this fourth day of d Cou available for review at the suPPIY: available for COMMONWEALTH OF ber 1991. Town Clerk's office at Town dom is use, in the town of MASSACHUSETTS ROBERT E. PECI Hail. For additional informa- field to be in the best PROBATE AND FAMILY Regist, tion, please call Dick Lewis eresI of the inhabitants of COURT DEPARTMENT MN 9/13/91, 9/20/91 & Environmental & Conse the town. 9/27/91 lion Planner, at 261-7 Accordingly, it is hereby BRISTOL, SS. IN #N16242 ordMN 9/13/91 of Bred, under t 1 t Sehe authoction BC PROBATE COURT 67957 IN #N16220 of the general laws as of saidthe Commonwealth nand In TOWN OF NSFIELD adjustment that a thenoptimum the trust estate nt undeerdthe N,ARSFY level for sound dental will of George S. Wood late health be made in the fluo- of Mansfield in said County, ride content of the water deceased: for the benefit of supply available for Town of Mansfield. '!n o domestic use in the town of A petition has been re- COMMONWEALTH OF Mansfield. P MASSACHUSETTS wR M sented to said Court pray- SUPERIOR COURT This order shall not be ing that William F. Williams NORFOLK, SS. ORFOLK NEWSPAPER COMPANY, INC. IM 1-800.287-y 567 Cia s LOST &FOUND 5 MISCELLANEOUS 205 FOUND JUNE 14 young female FOR SALE YARD SALES 230 CLEANING— orange HerstriI tl cat, downtown Sharon. Her 1 kilts Is 7 weeks HANDMADE WOOL SWEATERS, SHARO . Septembe10 r 14 Saturday, WINDOW CLEANING C old & beautffun Mother & ki8en all need homes soon. Made in E uador. Ski outdoor 4 medium 6pm. Moving - offering lots of M. ANNIS AND SONS. 20 Years experience. Please call (617) 784-5718. excellent y, and prices. si617 (617; great slutll SHARON. ns r�_Sells- lellly Insured. faction 2416 fa ct GREY &WHITE MALE CAT found 78_T _ 16 Deedleld road, Sep• tember 14 -15. GREATEST MUL. CLEANGUARTER" K. Lake Massatoag Sharon, (617) 821-6044, NINTENDO TAPES. Good condl- lion. $17 each. (617) 784_9776 TI-FAMILY SALE. Furnllure, to s, ysi HOME Cleaning Professionals. Insured Pr games, books, tools, records & Bonded. Weekly 8 BI- cc LOST CAT. Orange and white, SHARON MEMORIAL PARK LOT much more. Weekly. Free estimates, (508) (5' Ilulfy tallatl male. Lost from comer Galilee 26 lot 450 spaces 1-q, ex- SHARON. 18 HAMPSHIRE AVE- 339-5858. RI I West and Dean St, Mansslleld, Saturday, 9/7/91. Reward. 5o8. celI nlpl0calloi, reduced price Call alIt r8 m 508 543-5533. NUE, Saturday and Sunday, September 14 HOUSE CLEANING. Reasonable rates, experienced, Ce ac 339-4073. SLEEP SOFA AND MATCHING and 15th, 10am- 4pm. Toys, Bikes, Clothes, and references. Call Debbie. 617-344-8128. Plr WANTED TO BUY 130 LOVE SEAT. Good condition. $165 For both. Much Morel ,,, CASTLE CLEANERS. Have our y do ANTIOI End tables and odds an ends. (617) 784-8838. SHARON. 24 Belcher Street off Bay Road, Saturday, September home expertly clean=. , same person to : nsu,o cra inc )FC cncn .— . __ ie o.,., — .,_._ . _ tro��,.,e :_ _ all TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 December 16, 1991 Gregory N. Connolly, D.M.D., M.P.H. Director, Office of Dental Health The Commonwealth of Massachusetts Dept. of Public Health 150 Tremont St. Boston, MA 02111 Dear Dr. Connolly: The Board of Health in the town of Mansfield is hereby requesting the Department of Public Health's engineering staff their assistance in developing the plans for fluoridating Mansfield's public water supply. All of the legal steps have been completed. The Board of Health ordered fluoridation on June 20, 1991. The legal notice appeared in the Mansfield News on September 13, 1991. There was no appeal. We look forward to hearing from you. Thank you. Very truly yours, MANSFIELD BOARD OF HEALTH Michael VanSplinter fir Chairman /dr cc: Town Manager Board of Selectmen Finance Committee Water Superintendent Town Engineer Aacl 160 9/mw/ff,J&v& William F. Weld � � 02>11 Governor David P. Forsberg Secretary David H. Mulligan commissioner January 17, 1992 Board of Health Town Hall 50 West Street RE: Proposed Water Fluoridation Mansfield, MA 02048 Engineering Agreement Dear Mr. Van Splinter: In response to the Town's request, enclosed is our standard fluoridation agreement in duplicate regarding engineering assistance to develop plans and specifications. Please review the proposed agreement, secure the necessary signatures, and return both copies to the Department. After the engineering has been completed by Mr. Barker, P.F.., Fluoridation Engineer, another agreement to cover installation of the necessary equipment by Town or their subcontractors will be drafted for your signatures. However, no capital grant funding is available at the present time. If you have any questions, please call Mr. Barker at (617) 727-0732. very truly yours, go y N. Connolly, D.h.D., M.P.H. Dir ctor Office of Dental Health C:B:f Enclosure (2) FLUORIDATION AGREEMENT BETWEEN THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH AND THE TOWN OF MANSFIELD Whereas, the Massachusetts Department of Public Health, hereinafter called "Department," advocates the promotion of sound dental health through the fluoridation of the public water supply for domestic use in any community where it is below optimal level; and Whereas the Department desires to render assistance to communities that have compiled with Chapter 111, Section 8C of the Massachusetts General Laws; and Whereas the Town of Mansfield acting through its Town Manager hereinafter called "Town", is an eligible community for said assistance, the following agreement is made between the respective parties: THE TOWN AGREES: 1. To make TOWN employees available to consult as necessary with the Department's registered professional engineer responsible for designing the fluoridation system and further to designate in writing a responsible and accessible person to act as the TOWN'S representative with respect to the work to be performed under this agreement. Such designated person shall have the complete authority to transmit instructions, receive information, interpret and define the TOWN'S policies and decisions with respect to materials, equipment, elements and systems pertinent to the Department's services. THE DEPARTMENT AGREES: 1. To provide a registered professional engineer to prepare the plans and specifications for the purchase and installation of the fluoridation equipment and accessories. The sodium fluoride system shall be designed substantially in accordance with the Department's feasibility study dated January 9, 1990. 1 of 2 2 of 2 Nothing herein shall be construed as creating any personal liability on the part of any officer or employee of the Department or the TOWN, nor shall it be construed as giving any rights or benefits here under to any one other than the TOWN and the Department. Town of Mansfield Town Manager Kichae/ Van Splinter * Chairman of Board of Health Gerald t. Hilaire Water Superintendent Date Massachsetts Department of Public Health Greg y onnolly, Dir cto Dental Heal h Date *Chairman of the Board of Health as of January 1, 1992 is Henry M. Austin. TOWN OF MANSFIELD) MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Town Manager and Water Superintendent FROM: Chairman, Board of Health��"� � RE Fluoridation Engineering Agreement DATE: February 10, 1992 Please find attached two copies of the fluoridation engineering agreement from the Dept. of Public Health. Your signatures are requested on both copies. You may return the copies to the Board of Health office and I will send them back to the DPH. Thank you. �� I C�:cea�lii�e- C�Ce f ✓ a"a� ,%(o�eaiL JervrcP.� William F. Weld 0 ' 02111 Governor David P. Forsberg Secretary David H. Mulligan Commissioner February 28, 1992 Board of Health Town Hall 50 West Street Mansfield, MA 02048 Att: Henry M. Austin, Chairman Gentlemen: RE: Water Fluoridation Engineering Agreement Enclosed is an executed copy of our water fluoridation engineering agreement. As article number one states, please mail the Department the name and phone number of your designated contact person so an appointment may be scheduled. If you have any questions, please call Mr. Fred Barker P.E., Fluoridation Engineer at 617-727-0732. Very truly yours, Gre y onnolly, D.M. ., M.P.H. Offi of Dental Health C:B:f Enclosure - agreement cc: Water Department Town Manager TOWN OF MANSFIELD, NIASSaCHT.'SETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO William F. Williams, Town Manager I� ,`_ FROM: Henry M. Austin, Chairman, Board of Health RE Water Fluoridation Engineering Agreement DATE: March 23, 1992 In reference to the attached memo from the Dept. of Public Health, would you please designate the contact person for the water fluoridation engineering? Also attached is a cony of the signed agreement. Thank you. TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 March 24, 1992 Mr. Gregory N. Connolly, D.M.D., M.P.H. Office of Dental Health The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 150 Tremont Street Boston, MA 02111 Re: Water Fluoridation Engineering Agreement Dear Mr. Connolly: Please be informed that I hereby designate Robert Swanson, P.E., DPW Director/Town Engineer, contact person for the water fluoridation engineering. Mr. Swanson can be reached at (508) 261-7330 to schedule an appointment. Thank you for your cooperation. Sincerely, William F. Williams Town Manager WFW/ego Cc: Henry Austin, Chairman, Board of Health L,Scott Leite, Health Agent Robert Swanson, DPW Director/Town Engineer Gerald St. Hilaire, Water & Wastewater Operations Manager a IS Z u U N •n 0 i a 1 II 1 II 1 II I II 1 11 1 II I II 1 II I it O 1 II 1 1 II 1 II 1 II 1 II 69 b9 64 69 � C• Ln m to m I- m CO m m m J 1-- 1 I I I I I I O M ca In iD I'l co m m m m m m ON m m m m m F 1-4 —1 ti A CAPITAL PROJECT DETAIL 1. Project Name: �t.uo21DFr;�o�/ of 4019r6�e— Suppe'L 2. Estimated Cost: a. Plans (Engineer/Architect/Survey/etc.) b. Land Acquisition c. Site Development d, Construction (and inspection)* e. Equipment/Furnishings f. Other g. 10% Contingency 1) 2) 3) 4) 5) 1 Z01 000 `)' 41 900 ---5-`-SaOZ TOTAL $=7odv== 1. cnri 36 bvrtt w1rN Towr4 u1J3oR P2� sM�/Ta +sr1 -- Z, (-omTw4"Nkj erg ku--� LANW * If project is to be substantially undertaken by Town forces (in whole or in part) provide a more detailed breakdown below or an attached sheet for the construction aspect. Item quantity Unit Cost Total Cost �C—Q SvcJ aa.. �j�v i c.E3 7z02Z ►�Z �c-�1`xc� �'l�k l wu�.i.ca�1 Cam.-- x. g't�, � �iwll�.�r�1 Cam.. ►�tz) I I139g.c C+Lc-v c✓kc_ Lp5t . TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO ' SCOTT LEITE , HEALTH AGENT FROM = DAVID ARCHARD ",TER OPERATIONS MANAGER D4 DATE : NOVEMBER 5 , 1992 RE = FLUORIDATION At thi.,> 7,oint , the design engineer for the Massachusetts Department of Healthy has completed the fluoridation system design for Cate Springs No.1 and the two Prescott wells No.H & 9 . Although the Water Department has had one of our operators on site during the survey , we have not reviewed the 100 o design . The Town has also supported the MDH in their Fluoridation funding efforts and asked to be included in any type of grant program that may be available in a August 31 , 1992 letter to the MDH . Year to date we have not heard from the MDH pertaining to possible grants . if You have any other questions , please give me a call TOWN OF MANSFIELD) MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Capital Impro��vem��ennts Committee Chairman FROM: Health Agent ``,,,v DATE: January 20, 1994 RE . Fluoridation Dave Archard will be presenting the request for fluoridation to Mansfield's public water supply on January 27th. This project is no longer under the jurisdiction of the Board of Health. Thank you. /dr cc: Dave Archard February 14, 1994 Fred Barker, P.E. Fluoridation Engineer Commonwealth of Massachusetts Dept. of Public Health 150 Tremont St. Boston, MA 0211 Dear Fred: Thank you for your efforts in engineering the fluoridation system for the town of Mansfield. As you did tell me, the plans are close to completion. The Board of Health is requesting that you expedite completion of these plans, if at all possible. Upon completion, please forward the plans to the Board of Health office so that a true cost determination can be made to assist the town in implementing fluoridation. Thank you for your assistance and cooperation. Sincerely, MANSFIELD BOARD OF HEALTH Scott Leite Health Agent /dr cc: Town Manager Town Engineer/Water Dept. TO: FROM: DATE: SUBJECT: TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM Robert Swanson, Town Engineer William F. Williams, Town Manager W t%✓ February 6, 1995 Water Fluoridation - Board of Health This is to confirm our verbal conversation where I requested you to expedite the project request of the Board of Health relative to Fluoridation. Please identify what if anything is wrong with the plans. Your timely attention is appreciated. WFW/ego / cc: V Carol Sosman, Chairman Board of Health ftirod.mom) TOWN OF MANSFIELD) MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM TO: Robert Swanson, Town Engineer FROM: William F. Williams, Town Manager DATE: March 30, 1995 SUBJECT: Health Department Request I received a reminder from the Chairman of the Board of Health that they have not yet received the requirements for the fluoridation project you were to provide them. If this is the responsibility of Dave Archard, Assistant Town Engineer, please advise him I need to respond to the Board of Health soon. WFW/ego cc: Daniel B. Clifford, DPW Director David Archard, Assistant Town Engineer v Scott Leite, Health Agent (lluorida.nmm) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM TO: Robert Swanson, Town Engineer FROM: William F. Williams, Town Manager V 9�O DATE: May 8, 1995 SUBJECT: Health Department Request Reference is made to my requests of February 6 and March 30, 1995 (copies attached) concerning information requested by the Board of Health relative to fluoridation. Please confirm in writing that you have responded and the date of your written reply. WFW/ego cc: V�cott Leite, Health Agent Enclosures (boh.mem) �G S TOWN OF MANSFIELD, MASSACHUSETT 50 West Street, Mansfield, MA 020 8 - MEMORANDUM TO: WILLIAM WILLIAMS, TOWN MANAGER FROM: BOB SWANSON, TOWN ENGINEER 56r-- DATE: 518/95 RE: REVIEW OF FLUORIDE INJECTION SYSTEM FOR ALL TOWN WELLS - YOUR MEMO OF 518/95 I have spent considerable time reviewing the design of the fluoride injection systems for all our wells. The design was completed by an engineer at the State Department of Public Health (DPH). There are two options available for fluoride injection: dry bagged powder or liquid. The design presented by the DPH is for the dry bagged powder. The bagged powder is mixed with water to form a slurry prior to injection into our water pipes. These systems would be placed in our existing well buildings. The powder systems will require more manpower and handling of the bags. At Cate Springs, the slung would have to be mixed approximately every other day. We have been attempting to eliminate the use of bagged chemicals, specifically lime, which is being replaced with the liquid KOH (potassium hydroxide) systems because of manpower and employee health concerns. With the liquid fluoride systems the liquid is directly pumped into the water pipes. The liquid is very heavy and weighs appinuximately 10.1 pounds per gallon. The liquid is available in 15, 30 or 55 gallon drums, all with significant weight. Even the weight of a 15 gallon drum is approximately 160 pounds, which cannot be handled by one laborer. Attleboro's Water Department is presently using drums and feels that the liquid fluoride uses less manpower and offers simpler injection systems. However, the liquid fluoride is required to be housed in a separate or attached shed that does not require heating. The smallest drum (15 gallons) would provide for a four (4) day supply at Cate Springs. We would be able to have multiple drums on hand at the various well sites to increase the time between drum deliveries. If we were to have the liquid systems installed, we may need to purchase a drum dolly (or hand truck) to have easier handling and reduced chance of injury with the drums. I have discussed the liquid systems With the State engineer who designed the systems and he would redesign our systems for the liquid fluoride if requested. I plan to continue my investigation of the two options and be completed within two weeks. As you can see from above, there is a significant amount of data to review. Both the powdered and liquid forms of fluoride have significant health risk considerations. I will discuss the matter with the Water Department personnel, especially the personnel who would be responsible for the day to day operations of the fluoride systems. I also wish to discuss the powder system with a present user of that type. File: E5: FLUORIDI m E . D TOWN OF MANSFUSETTS 50WDtstreSMaCHd MA02048 MEMORANDUM TO: WILLIAM WILLIAMS, TOWN MANAGER FROM: BOB SWANSON, TOWN ENGINEER It DATE: 5/22195 RIDE INJECTION SYSTEM FOR ALL TOWN RE: REVIEW OF FLUO WELLS As promised, I have completed the review of the fluoride design as provided by the State Department of Public Health. Based on discussions with David Ard desiardgn and Ben couture, they feel that theexisting wells ells should incorporate the proposed design with the supply of fluoride in 50 pound We will further evaluate the possibility of bulk liquid fluoride at the new Ash Well. of fluoride, Another itre o thaby he should use s who wish to have fluoride red is the use of tablets reatments The Town could are taken by supply the tablets to the residents requesting them. In this manner the residents who determinenot er would also wathoption of gfluoride. We can useootodtecomme having both methods, amount who use waerl ond fluoridation of the water supply and tablets, available for residents due to possible health effects. File: E35: FLUORID2 MEMORANDUM BOARD OF HEALTH TO : William F. Williams, Town Manager FROM: Carol C. Sosman, ChairmancIb DATE: July 12, 1995 RE : Fluoridation Please find attached a memo to Town Engineer, Bob Swanson. We would very much appreciate your forwarding it to him for his response. The Board's next meeting is August 3rd, and we would appreciate a response from Mr. Swanson by August 1 St. Thank you. cc: Bob Swanson Dave Archard Dan Clifford /dr MEMO R AN D UM BOARD OF HEALTH TO: Bob Swanson, Town Engineer FROM: Carol C. Sosman, Chairman DATE: July 12, 1995 RE : Fluoridation I have read your two memos dated May 8 and 22, 1995, with interest. Unfortunately, neither of them answers the questions you were asked to address by the Board of Health. In order not to lose the possibility of State funding for Mansfield's fluoridation project, we need to clear answers to some basic questions with no further loss of time. Please consult with staff from the Water Department, as needed, and provide a written response to the following questions by August 1st. 1. How many fluoridation units will be needed to fluoridate the Town water (number and location)? 2. Identify which locations can house the fluoridation equipment shown on the plans without modification, and estimate the installation cost per location. 3. Identify which facilities will need alterations and/or additions to accommodate the fluoridation equipment, describe the needed work, and estimate the cost per location (facility alteration and equipment installation). 4. Evaluate the operating impact of the addition of fluoridation equipment, estimating annual operating cost, including materials, labor, and maintenance expenses. 5. Combine the data from #2 through #4 to create a total fluoridation project profile, summarizing capital project tasks and costs, and annual operating costs, by location. 6. Optional: Identify alternate equipment/facility options, showing cost effects on the capital investment. 6a. Identify the operating effects of options identified in 95, and evaluate the cost advantages/disadvantages of each option. Page 2, MEMO, Town Engineer, July 12, 1995 Clearly, this analysis will require close cooperation between your office and the Water Department staff, especially in the analysis of the operating effects. The Board of Health looks forward to receiving your complete report. We welcome you to a meeting to discuss your findings. Thank you. cc: Dave Archard Dan Clifford Bill Williams /dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA02048 TO: CAROL SOSMAN, CHAIRMAN OF BOARD OF HEALTH FROM: BOB SWANSON, TOWN ENGINEER ��n DATE: 8/1/95 SUBJ: FLUORIDATION OF TOWN WELLS As per our telephone conversation of yesterday, I have discussed the two types of fluoride injection with Water Department personnel and they would prefer to install the sodium fluoride powder systems for the existing public drinking water wells. Also, as we discussed, I have the following comments on the questions in your July 12, 1995 memo. 1. A total of seven (7) fluoridation systems will be required to serve our existing wells. Systems will be required at the following wells: Cate Springs Well # 1, Albertini Well # 4, Witch Pond Well # 6, Dustin Well # 7, Prescott Well # 8, Prescott Well # 9, and one system serving the dual well arrangement of Albertini Wells # 2 and # 3. 2. The above mentioned wells presently have sufficient facilities to house the fluoridation systems. The designs for the systems have been previously completed by Mr. Fred Barker, PE, who is an engineer at the Massachusetts Department of Public Health (DPH). Mr. Barker visited the sites with Mr. Ben Couture, Mansfield's Water Operations Manager, in conjunction with the designs. The systems are designed for receiving the chemical in 50 lb bags of powder, dumping the powder into a liquid saturator and mixing it with water to form a fluoride slurry and injecting the slurry via manually controlled metering pumps into the water mains. Mr. Barker also estimated the capital costs of the systems to be $70,000 in 1990. 1 contacted Mr. Barker to discuss the costs and he feels that the costs have only escalated 5% since 1990. Thus, the capital cost in 1995 $ for all seven systems is $73,500 including private labor for installation. This total cost equates to a cost of $10,500 per system. Mr. Barker feels that we would be eligible for 100% reimbursement of these capital costs from the DPH. 3. Based on Mr. Barker's designs, there does not appear to be any alterations or additions required at any of the well sites. 4. Chemical costs are estimated to be $14 per million gallons of water treated. With an annual daily pumping rate of 2.2 million gallons per day the annual chemical costs are estimated to be $11,300 per year. We would also be eligible for state funding of the chemical costs for the first year of operation from the DPH. Labor costs are estimated to be $15/hr. and 0.25 hours per bag of chemical. Based on chemical usage of 20 lbs. per million gallons of water treated and 50 lb bags this cost is estimated to be $1,200 per year. The Water Department plans to provide this labor with existing personnel. Operating and Maintenance costs are estimated to be an additional 5 % of the capital cost per year, which equates to $3,675 per year. 5. A summary of the capital and operating costs are shown below: Capital Costs for Seven Systems $73,500 Operating Costs for Chemicals Labor Seven Systems Operation and Maintenance Total Annual Cost $11, 300/yr $1,200/yr 3 675/ r $16,175/yr 6. We have no optional equipment or fluoride injection systems under consideration. My previous memo also discussed the ability to have the Water Department fund the supply of fluoride pills at a local pharmacy. I contacted two pharmacists and they recommended treatment for children up to the age of 16 years, but noted that most children stop treatment at an age of 10 or 11 years. The pharmacists also provided the cost of the pills to be $8.18 per year per person for pills. Using 3000 residents and a cost of $8.18 per year would result in an annual cost of almost $24,500 per year, which is a significant increase over the direct fluoride injection into the water system. It is difficult to determine the number of residents who use bottled water and would need the pills to have proper fluoride treatments. cc: W. Williams D. Clifford S. Leite D. Archard TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA02048 Mansfield Health Department MEMORANDUM TO: William F. Williams, Town Manager FROM: Scott Leite, Health Agent n RE: Fluoridation./Capital Improvements Plan FY97 DATE: November 24, 1995 Attached are the documents necessary for the implementation of the fluoridation order. I have continued with Fred Barker, Massachusetts Department of Public Health, that the 5010 increase over his original estimate of S 70,000 for installation of the system remains an adequate amount. Therefore, as stated in the memorandum of August 1, 1995 from former Town Engineer Bob Swanson to Carol Sosman, Chair Board of Health, the amount of S 73,500 is the amount that needs to be submitted for the FY97 Capital Improvements Program. Additionally, as stated in the memorandum, an amount of money needs to be added to the Water Department's budget for the operation and maintenance of the ear; I fluoride injection system. The amount in the memorandum is for a full y believe that the full amount would not be necessary depending on how long construction of the system will take. If you have any questions, please do not hesitate to contact me. Attachments /dr - 7 - CAPITAL COST TO FLUORINATE MMNSFIELD PUBLIC WATER SUPPLY The following items apply to eight sodium fluoride metering systems necessary to fluoridate the water system: anti Item Estimated 1990 Costs 1 Fluoride specific -ion lab tester with $ 1,500 accessories 8 Furnish sodium fluoride metering systems $40,000 with all piping and electrical connections and spare parts (includes eighteen electronic or motor driven type metering pumps, eight saturators, two softeners, four interlocks, 5/8 inch water meters and two 3/4 inch reduced pressure backflow preventers) 1 Furnish representative or 100 feet out well $ 1,000 sample tap terminating in the wellhouse 1 Installation cost of above fluoride metering $20,000 systems and sample tap by Mansfield Water DeparbTent and/or their sub -contractors Miscellaneous equipment (safety equipment, $ 2,000 pallets, etc) 8 DPH state engineering services consisting $ 0 of plans, specifications, purchasing and installation advise at nine wells Allowance for contingencies and inflation $ 5,500 Total: $70,000 ELM F.V V of axe) ry a a . ... Sodium fluoride in 50 - 55 pound bags currently sells for $.68 - $.75 a pound delivered. The prices vary according to purity, supplier, and quantity of chemical bought per shipment. In 1988 the Mansfield Water Department produced approximately 741 million gallons from all sources. The delivered sodium fluoride cost for the Town is estimated to be $10,500 per year or $14 per million gallons. This figure allows for no increase over 1988 levels as 1989 water consumption actually declined. Manpower supplied by the Mansfield Water Department would be needed to monitor the fluoride levels, adjust the fluoride metering systems as needed, replenish the fluoride chemical in the saturators and keep the fluoride pumps in operating order. An estimate is an average daily labor cost of one half hour per system 3-4 hours per day to conduct daily tests, maintenance, and to meet all state requirements. Some days the manpower will be less, and some days more. No extra travel. time on weekends should be needed as the sources are checked. Electrical costs are estimated to cost less than $500 a year. TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 M--ns dd Board of HC2Ith TO: William F. Williams, Town Manager �y� FROM: Raymond K. Martin, D.D.S., Chairman /`L— RE: Fluoridation/Capital Improvements Plan FY97 DATE: December 18, 1995 As you are aware, the Town of Mansfield is currently under an order from the Board of Health to fluoridate the water supply. We have staved order, which became valid on December 16, 1991, until such time as the financial condition of the town improved and the position for a grant became favorable. It is our understanding that in the grant process the town must first have the money in place to complete the project, with reimbursement through the _*rant. Partly for these reasons and simply that the financial position of the town has improved, the Board wishes the Town to proceed with the fluoridation order. Since this is an improvement to the water system, we anticipate that the amount of S 73,500 recommended by then Town Engineer Robert swanson will be included in the Capital Improvement Plan or other appropriate budget location for fiscal year 1997. Additionally, the expenses of the water department should increase to facilitate implementation. The Board anticipates the fluoridation order will assume a high priority within the CIP. I look forward to meeting with you and the Capital Improvement Plan committee to resolve any question or problems connected with implementation of the order to fluoridate in fiscal year 1997. Attachment !dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 Mansfield Board of Health M I';� R, q DrVM TO: Capital Improvement Program Committee and Finance Com .ttee FROM: Raymond K. Martin, Chairman Board of Heal — RE: Fluoridation DATE: January 23, 1996 Thank you for the time you spent with Board of Health members discussing the issue of financing the fluoridation order. To recap our discussion, during 1990 and 1991, the Board of Health explored and held hearings regarding fluoridation of the public water supply. The order to fluoridate the public water supply was made on June 20, 1991. The order became final on December 16, 1991, without opposition. Attached is some information on fluoride which we hope will reinforce your support for the project. cc: Town Manager DPW /dr �) )} \ ! \ {=;3a \/\}/\ \) ZI Q) -- jgS Q) Z3 {/[)\\ | }82 \\ ) \}\ (® _ (\\)§ )\ \ ■/�G f \\ -N~- 2 t}\/() «eat ) ~° �)\\� )k - \) $\\\04 () g» k(ƒ/ j\ ) `e g°-a B E\a §\\\\ \ §\7)$ �o u\ \) \\) ■»�s, - a:§ �Kaimyu k°% LL:&es§ V%« develop a plan for the scheduled reexamination based on the initial findings. Parents must be informed that the responsibil- ity for their child's dental health rests with them. The infant can best be examined with the parent holding the child or in the knee -to -knee position with the dentist (Figure 1). This position offers optimal stability and visibility as well as the warmth and feel of the parent. Most infants will fuss during the examination and parents should be alerted to this anticipated behavior prior to the exam. Figure 1. Knee -to -knee position far infma dental examination. Counseling the Parent Following the examination, the dentist should initiate a dis- cussion with the parents about maintaining optimal oral health for their child, Topics to be discussed with the parents should include: (1) the development and growth of the teeth; (2) prob- lems that might occur during teething and management of the problems; (3) when and how to clean the infant and preschool child's teeth; (4) the appropriate administration of fluoride, both systemically and topically, for optimal caries reduction; (5) the appropriate use of the bottle or breast for feeding and consideration for weaning the child off both; (6) the infant's need for non -nutritive sucking with a discussion of the availa- ble devices; and (7) the appropriate "first aid" and profes- sional follow-up for oral/dental trauma. The discussion of teething is an important aspect of the first visit. Eruption of the primary teeth may cause symptoms of sore gains as well as restlessness, irritability, and a possible disruption of eating or sleeping habits. A topical anesthetic should be used only with caution as an aid to prevent discom- fort. 'Ibpical anesthetics may compromise the infant's normal gag reflex, reduce his or her natural ability to protect the air- way and even cause toxicity leading to adverse systemic reac- tions. Better recommendations might be cold teething rings of massaging of the gums. upset stomachs and "loose" stools may also appear with teething. Fluoride Recommendations for Optimal Results water fluoridation and the use of a dentifrice with fluoride have been credited with the significant reduction in dental car - ies and an increase in the number of caries -free children. Re- cent anecdotal reports have discussed an increased incidence of fluorosis although reviews have not suggesed a clear epide- miologic etiology.10 Fluoridated community water continues to be the most cost- effective means of delivering fluoride to the patient. However, reports now indicate that a growing number of households are turning to alternative sources because of the questionable qual- ity and potential health threat posed by contamination of ground waters. Bottled and processed water sales have in- creased by almost 70% in the last five years, totaling 2.2 bil- lion dollars in 1988. The concentration of fluoride in these alternative waters varies widely and many tested suboptimally for a 3-year-old child.11 13 Therefore, the dentist or physician can no longer assume the child is receiving optimal fluoride because they are living in a community with fluoridated water. There is a need to question the parent on water consumption and the water source used. If a bottled/processed water is the main source for cooking and drinking, it should be analyzed for fluoride concentration and appropriate recommendations should be made using a fluoride dosage schedule (Figure 2) 11.12 Concentration fir fluoride in water (pion) Age in Less 0.3 Greater Years than 0.3 to 0.7 than 0.7 Birth to 2 0.25 u 2 to 3 0.50 0.25 3 to 14 1.00 0.50 Figure 2. Supplemental Fluoride Dosage Schedule (adjusted allowance in mg F/day). Approved by the Council on Dental Therapeutics of the American Dental Association. Considerable evidence exists to support the importance of daily use of a topical fluoride to reverse the process of de- mineralization and to remineralize the decalcified enamel. Daily topical fluoride is available through a variety of sources including fluoridated water and dentifrices, over-the-counter fluoride rinses, and daily supplemental systemic fluoride drops and tablets. Fluoride usage among school -aged children is impressive. The 1986 National Health Interview Survey re- ported that 93% of school -aged children use a fluoridated den- tifrice, 13% have used a fluoridated mouth rinse at home, and I I % participated in a school -based rinsing program.17 Ap- proximately 62% of the population benefited from access to public water supplied with fluoride. Therefore, it is appropri- ate for dentists to reevaluate their office policies on the routine use of semi-annual or annual topical applications of fluoride, particularly in children who are at low risk to caries, or who are exposed daily to a topical fluoride either at home or at school. The use of fluoridated products for the preschool child should always be under the supervision of the parent. It has been reported that children may ingest between 0.12 and 0.3 TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE William F. Williams, Town Manager January 31, 1996 Dr. Raymond K. Martin, D.D.S. Chairman, Board of Health Town of Mansfield 50 West Street Mansfield, MA 02048 Dear Dr. 1 : This is to confirm and acknowledge your request for the fluoridation project funding for FY1997. The Board of Health has ordered the project for FY1997 and I shall pursue funding through the CIP budget as the top priority and work to secure their commitment. If and when the federal budget is completed, the reimbursement allocation can be officially secured. I will again ask the Finance Committee to match your request with revenue from our stabilization account, since you present a compelling case that it will be reimbursed. I apologize to you for any and all confusion our processing of your request has caused, and I am now ready, willing, and able to positively present your request for approval. Thank you for your cooperation. Sincerely, K William F. Williams Town Manager WFW/ego cc: Board of Selectmen Capital Improvements Committee John Buckley, Assistant DPW Director (hMR- M) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 January 23, 1996 Dianne Royle, Chairwoman Board of Selectmen 50 West St. Mansfield, MA 02048 Dear Mrs. Royle: The Mansfield Board of Health, under Mass. General Laws, Chapter 111, Section 8c, ordered the town of Mansfield on June 20, 1991 to fluoridate its public water supply. The order became final on December 16, 1991, without opposition. The Board of Health hereby requests that you, as Water Commissioners for the town of Mansfield, honor this order by funding the implementation of fluoridation of the public water supply in fiscal year 1997. We have had recent discussions with the Town Manager and the Capital Improvement Program Committee informing them of the likelihood of reimbursement from the Commonwealth. May we suggest that a variety of initial funding sources are possible such as the CIP, Water Department, Stabilization Fund or any reasonable combination. The estimated cost can be obtained through the Town Manager's office. Thank you. Very truly yours, MAN.S,�ELD BOARD OF HEALTH K. Martin, Chairman cc: Town Manager DPW Director Finance Committee CIP Committee /dr TOWN OF MANSFIELD) MASSACHUSETTS 50 West Street, Mansfield, MA 02048 Mansfield Board of Health *�,'1Q) R ,A,N, � U M TO: Capital Improvement Program Committee and Finance Committee FROM: Raymond K. Martin, Chairman Board of Health�40,, RE: Fluoridation DATE: January 23, 1996 Thank you for the time you spent with Board of Health members discussing the issue of financing the fluoridation order. To recap our discussion, during 1990 and 1991, the Board of Health explored and held hearings regarding fluoridation of the public water supply. The order to fluoridate the public water supply was made on June 20, 1991. The order became final on December 16, 1991, without opposition. Attached is some information on fluoride which we hope will reinforce your support for the project. cc: Town Manager DPW idr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 Man.' -field Board' of Health M M 04 R A N; D V M TO: William F. Williams, Town Manager FROM: Raymond K. Martin, D.D.S., Chairman��<��_ RE: Fluoridation/Capital Improvements Plan FY97 DATE: December 18, 1995 As you are aware, the Town of Mansfield is currently under an order from the Board of Health to fluoridate the water supply. We have staved order, which became valid on December 16, 1991, until such time as the financial condition of the town improved and the position for a grant became favorable. It is our understanding that in the grant process the town must first have the money in place to complete the project, with reimbursement through the grant. Partly for these reasons and simply that the financial position of the town has improved, the Board wishes the Town to proceed with the fluoridation order. Since this is an improvement to the water system, we anticipate that the amount of S 73,500 recommended by then Town Engineer Robert swanson will be included in the Capital Improvement Plan or other appropriate budget location for fiscal year 1997. Additionally, the expenses of the water department should increase to facilitate implementation. The Board anticipates the fluoridation order will assume a high priority within the CIP. I look forward to meeting with you and the Capital Improvement Plan committee to resolve any question or problems connected with implementation of the order to fluoridate in fiscal year 1997. Attachment /dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 BOARD OF HEALTH MEMORANDUM TO: William F. Williams, Town Manager FROM: Scott Leite, Health Age t DATE: November 2, 1995 SUBJECT: Fluoridation During 1991, the Board of Health began the process for ordering fluoridation to the public water supply. On January 3, 1992, as a result of the Board's vote, the order to fluoridate became valid. Because of fiscal problems and limitations, the order was stayed until a more favorable time. It is anticipated that in FY97 the Town will be funded for this work by a grant from the Massachusetts Department of Public Health/Office of Dental Health. The work is funded by a block grant from Congress and then further apportioned by the State. As you are aware, the Federal government is without a budget at this time, therefore the true status of Mansfield's grant is in question. It is the intent of the Board of Health that this project go forward, with or without the grant. It is my understanding from former Town Engineer, Robert Swanson that this will be a reimbursement from the state: therefore, the entire amount for this project needs to be budgeted in the FY 97 Capital Improvements plan. If you have any questions, please do not hesitate to contact me. /dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TO: CAROL SOSMAN, CHAIRMAN OF BOARD OF HEALTH FROM: BOB SWANSON, TOWN ENGINEER -6;z DATE: 811195 SUBJ: FLUORIDATION OF TOWN WELLS As per our telephone conversation of yesterday, I have discussed the two types of fluoride injection with Water Department personnel and they would prefer to install the sodium fluoride powder systems for the existing public drinking water wells. Also, as we discussed, I have the following comments on the questions in your July 12, 1995 memo. 1. A total of seven (7) fluoridation systems will be required to serve our existing wells. Systems will be required at the following wells: Cate Springs Well # 1, Albertini Well # 4, Witch Pond Well # 6, Dustin Well # 7, Prescott Well # 8, Prescott Well # 9, and one system serving the dual well arrangement of Albertini Wells # 2 and # 3. 2. The above mentioned wells presently have sufficient facilities to house the fluoridation systems. The designs for the systems have been previously completed by Mr. Fred Barker, PE, who is an engineer at the Massachusetts Department of Public Health (DPH). Mr. Barker visited the sites with Mr. Ben Couture, Mansfield's Water Operations Manager, in conjunction with the designs. The systems are designed for receiving the chemical in 50 lb bags of powder, dumping the powder into a liquid saturator and mixing it with water to form a fluoride slurry and injecting the slurry via manually controlled metering pumps into the water mains. Mr. Barker also estimated the capital costs of the systems to be $70,000 in 1990. 1 contacted Mr. Barker to discuss the costs and he feels that the costs have only escalated 5% since 1990. Thus, the capital cost in 1995 $ for all seven systems is $73,500 including private labor for installation. This total cost equates to a cost of $10,500 per system. Mr. Barker feels that we would be eligible for 100% reimbursement of these capital costs from the DPH. 3. Based on Mr. Barker's designs, there does not appear to be any alterations or additions required at any of the well sites. 4. Chemical costs are estimated to be $14 per million gallons of water treated. With an annual daily pumping rate of 2.2 million gallons per day the annual chemical costs are estimated to be $11,300 per year. We would also be eligible for state funding of the chemical costs for the first year of operation from the DPH. Labor costs are estimated to be $15/hr. and 0.25 hours per bag of chemical. Based on chemical usage of 20 lbs. per million gallons of water treated and 50 lb bags this cost is estimated to be $1,200 per year. The Water Department plans to provide this labor with existing personnel. Operating and Maintenance costs are estimated to be an additional 5 % of the capital cost per year, which equates to $3,675 per year. 5. A summary of the capital and operating costs are shown below: Capital Costs for Seven Systems $73,500 Operating Costs for Seven Systems Chemicals $11,300/yr Labor $1,200/yr Operation and Maintenance 3 675/ r Total Annual Cost $16,175/yr 6. We have no optional equipment or fluoride injection systems under consideration. My previous memo also discussed the ability to have the Water Department fund the supply of fluoride pills at a local pharmacy. I contacted two pharmacists and they recommended treatment for children up to the age of 16 years, but noted that most children stop treatment at an age of 10 or 11 years. The pharmacists also provided the cost of the pills to be $8.18 per year per person for pills. Using 3000 residents and a cost of $8.18 per year would result in an annual cost of almost $24,500 per year, which is a significant increase over the direct fluoride injection into the water system. It is difficult to determine the number of residents who use bottled water and would need the pills to have proper fluoride treatments. cc: W. Williams D. Clifford S. Leite D. Archard TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 August 23, 2013 Mr. Benjamin Yeransian 1 Winslow Way Mansfield, MA 02048 Dear Mr. Yeransian, Regarding your email of August 20, 2013 you wished to know "what governmental organization directly gives the order to the Town of Mansfield to fluoridate the water supplies". The Board of Health is the governmental body that ordered the fluoridation of the water supply. Below is the chronology of steps the Board of Health took in ordering fluoridation. As you can see, it was a ten year, very public process in which residents requested, affirmed and voted to fund fluoridation of the water supply. Enclosed are copies of the supporting documents. May 1,1986: Two residents met with. Board of Health to discuss initiating fluoridation of water. August 13,1986: Letter from Dr. Bailus Walker, Jr. commissioner of Public Health notifying Board of Health that fluoride content of Mansfield water supply is substantially below level recommended for dental health. January 30, 1991: Board of Health requested Selectmen to put non -binding referendum question on annual town election "Do you favor fluoridation of the municipal water?" February 29,1991: Fluoride Forum for public held by Board of Health before non -binding referendum vote. March 18, 1991: Annual Town Election Non -binding referendum question "Do you favor fluoridation of the municipal water?" was voted in affirmative. Yeransian August 23, 2013 Page 2 June 20,1991: Board of Health voted to order fluoridation of water. (No member questioned the value of fluoridation. Opposition votes questioned cost benefit of the size of the target group and the town's responsibility if an industrial accident regarding fluoride occurred.) September 13,1991: Order published in Mansfield News ninety -day appeal period followed. (No appeal filed.) April 1,1996: Annual Town meeting voted to fund fluoridation of water. Should you be questioning the gaps between 1986 and 1991 and 1991 and 1996, in the former, the Board of Health (a variety of members over the years) spent time learning and listening about fluoridation and in the latter the Town was waiting for state funding of the project and then decided to fund it with Mansfield resources as it had waited long enough. Thank you for your interest. Very truly yours, Scott Leite, Health Agent Enclosures THE FOLKMAN COMPANY, INC. Post Office Box 96 • Mansfield, MA • 02048 May 5, 1986 Martha C. Wood Assistant Director of Dental Department of Public Health Division of Dental Health 9th Floor 150 Tremont Street Boston, MA 02111 Health for Prevention Programs REa, Fluoridation of Mansfield's Dear Martha, Water supply On Wednesday May 1, 1986 I met with the Mansfield Board of Health to discuss initiating the fluoridation of Mansfield's water supply system. The Board has requested that I bring them the package of information which you sent to me, so that they can review the information prior to their next meeting. I have been invited to attend this meeting also. There are five members of the Board of Health, as well as a professional health department director. Any additional information which you can forward to me, so that I may present it to the Board of Health, would be appreciated. If this meeting goes well, then the of Selectmen (Water Commissioner). Director, if you should attend the waiting for his reply. next step is to meet with the Board I have asked Scott Leite, Health next Board of Health meeting. I am please call me at 339-6709 or 339-9435 should you have any questions. Thank you very much. Very truly yours, Paul J. Folkman, President PJF/eeh coo Scott Leite, Mansfield Board of Health 5 �? I ``A d , 1, MAY BAILUS WALKER, Jr, Ph.D. M.P.H. CammisaOW Edward Tartufo Chairperson Board of Health Town Hall 50 West Street Mansfield, MA 02048 Dear. Mr. Tartufo: 0 Bw&n ow-li August 13, 1986 The Department of Public Health has determined that the fluoride content of Mansfield's water supply is substantially below the level recommended for el of e for on ofnt othedecay ish1.0 parts ofvfluoride uper dmillion prevention partsof watere(ppm�- In accordance with the provisions of the Massachusetts General Laws, Chapter 111, Section 8C, the Department, in takingrecommendscognizanceof the dental Board heaof lth of order people of the Commonwealth, strongly the upward adjustment of the fluoride content of your water supply available for, domestic use to the optimal level for prevention and reduction of tooth decay. The'Department of Public Health provides free educational assistance to board d in int este members and local municipal officials theDepartmentwillordering npurchase and install In 'addition, through federal funding,e necessary equipment and buy the fluoride compound for two years. Communities ars costhohve fathebfluorideridated more than two compound through stateelocalraidreimbursed for part of the funds. if you have further questions, the Director of Dental Health, Gregory N. Connolly, D.M.D., M.P.H., and his staff are available as resources for you. Since ly,Oe Bailus Walker, Jr., Ph.D., M.P.H. Commissioner TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 M E M O R A N D U M TO: Board of Selectmen _ FROM: Scott Leite, Health A nt RE: Request for referendum ., ion on ballot DATE: January 30, 1991 The Board of Health ,would like to have the following non- binding referendum question placed on the March 1991 Election ballot. The opinion of the Tcwn .could of course be invaluable in deciding a course of action. "Do you favor fluoridation of the municipal water supply7 implementing fluoridation would cost approximately $70,000 to install and about $10,000 annually to provide. When state aid is again available, the ii 1p lEmEntattOn cost would be born by the Department of Public Health." FLOURIDATION FORUM QUALTERS MIDDLE SCHOOL FEBRUARY 28, 1991 MANSFIELD, MA -30 ��t t � 1. INTRODUCTION by Edward Rosenberg, Board of Health member. Ed will give a few -minute history of discussions of flouridation at Board of Health meetings. II. SPEAKER: MARTHA WOOD, Dept. of Public Health. Div. of Dental Health Ms. Wood will describe the process of public flouridation from the Commonwealth of Massachusetts perspective. She will update the public of the number of towns that are flouridated, refer to various studies conducted and reports issued on the merits of flouridation. She will be available to answer any questions that the public may have. III. SPEAKER: DR. ANTHONY VINCIGUERRA, Pediatric Dentist, North Attleboro Dr. Vinciguerra will give his point of view, through his experience of treating children, on the value of flouridation. He has patients who live in towns that are flouridated and towns that are not. He also will be available to answer questions. I am assuming that Ms. Wood and Dr. Vinciguerra will speak for about 15 min. each. The question and answer period could begin after speakers and the audience can direct a question to whomever they wish. Question/answer period can go on for maybe one hour?? I guess that depends on how many are in the audience and the number of questions they may have. Speakers: Please arrive at Qualters Middle School, East Street, Auditorium, around 7:00 PM for a briefing with Brad Sears, whose Cable program you will be on. His show begins at 7:30 PM. It will be cablecast throughout 17 communities. Please call me with any questions you may have. I can also give directions to QMS. Thank you again for volunteering your time. It is greatly appreciated. 508-261-7366. Dianne Royle Secretary to Board of Health February 14, 1991 Elections The following is a tabulation of votes for all four precincts for the January 10, 1991 Recall Election: PRECINCTS One Two Three Four TOW Thomas'M. Markt - Recall Blanks"` 13 22 19 23 77 For the Recall 463 380 419 404 1,666 Against'the Recall 508 467 521 467 1,963 Totals 964 869 -,958 894 3,706 Selectman Blanks;'. 25 30 28 45 128 Thomas M. Markt 487 452 508 445 1,892 Joseph C. Mcarthy 472 387 423 404 1,686 Totals 984 869 959 894 3,706 Amos M.Robinson - Recall Blanks.. 20 21 15 22 78 For the Recall 404 357 370 373 1,504 Against the Recall Sao 491 574 499 2,124 Totals 984 869 959 894 3,706 Board of Selectmen Blanks' 27 28 30 40 125 Amos M.Robinson 564 499 559 495 2,117 John w.Davern 393 342 370 359 1.464 Totals Totals 984 889 959 3,706 Wiilliam.R. Sarro - Recall Blanks 13 20 13 20 66 . For the Recall 491 412 442 438 1,783 Against the Recall 480 437 504 436 1,867 Totals 984 889 959 894 3,706 Board of Selectmen Blanks `• 33 36 39 34 142 William R. Sarro 465 428 480 433 1,806 John W.:Dunn 486 405 440 427 1,768 Totals - 984 869 959 894 3,706 Frank G: Colella - Recall Blanks 12 24 16 21 73 For the Recall 490 397 430 427 1,744 Against the Recall 482 448 513 446 1,889 Totals 984 869 958 894 3,706 Board of Selectmen Blanks 20 36 21 28 105 Frank G. Colella 464 443 494 447 1,848 Daniel R. Serpico 500 390 444 419 1,753 Totals 964 869 959 89 4 3,706 Edward J. Tartufo - Recall Blanks 17 24 15 26 82 For the Recall 423- 362 376 368 1,528 Against the Recall 544 483 569 500 2,096 Totals 8B4 869 959 894 3,706 Board of Selectmen Blanks Edward J. Tartufo 31 537 22 500 21 564 35 498 109 2,099 Gordon R. Penman 416 347 374 361 1,498 Totals 984 869 959 894 3,706 The following is a tabulation of votes for all four precincts for the March 18, 1991 Annual Town Election. Precincts One Two Three Four Total Selectman Blanks 6 14 13 11 44 *Joseph Pasquale 293 241 296 258 1,088 Daniel Serpico 212 280 229 230 951 Totals 511 535 538 499 2,083 School Committee Blanks 160 141 168 159`. 628 *Lawrence Roberts 351 394 370 340 1,455 Totals 511 535 538 499 2,083 Housing Authority ''32 Blanks 29 20 20 101 -Alice Armstrong 281 315 309 222 .1,127 Richard S. Blandon 201 20o 209 245 855 Totals 511 535 538 499 2,083 Moderator Blanks 145 129 154 141 569 'Robert H.H. Saquet 366 406 384 358 1,514 Totals 51 t 635 538 499 2,083 Question #1 - Fluoridation - Non -Binding Blanks 33 56 44 68 201 Yes 245 261 265 236 997 No 233 228 229 195 885 Totals 511 535 538 499 2,083 `Elected The following is a tabulation of votes for all four precincts for the June 18, 1991 Special Town Election. Precincts One Two Three Four Total Question #1 - East Mansfield Sewer - Debt Exclusion Blanks 1 - 2 2 5 Yes 82 82 98 141 403 No 118 92 163 72'�, 445 Totals 201 174 263 215 853 Question #2 - Municipal Outdoor Recreation Facility - Debt Exclusion Blanks - 1 2 1 4 Yes 89 79 97 128 393 No 112 94 164 86 466 Totals 201 174 263 215 853 The following is a tabulation of votes for all four precincts for the November 14, 1991 Special Election. Precincts One Two Three Four Total Question #1 - East Mansfield Sewer Debt Exclusion Blanks 0 0 1 0 1 Yes 162 233 235 411 1,041 No 135 85 165 111 496 Totals 297 318 401 522 1,538 The final tally of votes was completed at 8:15 p.m. Board of Health Page 2 June 20, 1991 4. VISITORS - No one tonight. 5. HEALTH AGENT'S REPORT - No report since Agent on vacation. 6. OLD BUSINESS a. Fluoridation: After many months of discussion, review of reports pro and con fluoridation, the Board members again discussed fluoridation and were prepared to make a motion. MOTION: Move that the Board of Health order the fluoridation of the public water supply of the town of Mansfield. Further, recognizing the financial condition of the Commonwealth, and that there already are nine other towns waiting for state aid for fluoridation, the Board requests that the Board of Selectmen, the Finance Committee and the Capital Improvements Committee include the capital and operating costs to implement this order in the FY93 budget. Ros_nberg/Austin. 3-.. VanSplinter and Fontanlni opposed. VOTED. Chairman VanSplinter feels that fluoridating a town's public water supply only affects a small group that will benefit from fluoridation, and member Rcsenberg feels the opposite, namely, that it affects every group in Town. 7. NEW BUSINESS a. Summer Schedule: Members agreed to meet on Thursday, July 18th and back on schedule for August, i.e., the 1st and 15th. An August meeting could be cancelled if business is slow. B. ADJOURNMENT MOTION: To adjourn at 8:30 PM. Steele/Austin. All in favor. VOTED Respectfully submitted, chairman Michael VanSplinter NEXT MEETING: JULY 13, 1991. See you then. )TICE OF MEETING THE MANSFIELD NEWS, Friday, September 13, 1991 BOARD OF HEALTH . effective until ninety (90) The Commissioner of the Department of Public Health, Commonwealth of Massachusetts, has determined that the fluoride CONSERVATION. content of the public water COMMISSION supply for domestic use in On Monday, September the town of Mansfield is not y P at optimum level for sound 16 at 8:00 p.m. the Mans- dental. health and has. so field Conservation Commis- notified this Board of Heahh sion will':I'discuss proposed .ofhis findings. rules and reguiations _ per- taining to the use(s) of con- servation properties in the town of Mansfield, after Mansffelil.; All interested making sufficient inquiry of citizens are welcome. the matter, (considers an Copies of the proposed upward adjustment of the rules and regulations are fluoride content of the water avaliabli'Ifor review at the supply, available for Town Clerics office at Town domestic use, In the town of Wall. For additional informa. Mansfield to be in the best tion, please call Dick Lewis, interest of the inhabitants of Environmental & Conserva. the town. Von Planner, sit 261-7378. Accordingly, it Is hereby ordered, under the authority MN 9(13/91 of Chapter 111, Section 8C IN #N16220 of the general laws as amended, that an upward TOWN'. OFMANSFIELD adjustment to the optimum level for .sound dental health be made in the fluo- ride content of .the water supply available for T . domestic use in the town of Mansfield. . This order Shall not be ORFOLK NEWSPAPER . COMPANY, INC. 400 1=800=287=1567 LOST & FOUND 5 FOUND JUNE 14 young female orange striped cat, downtown Sharon. Her 1 kitten is 7 weeks old & beausfull Mother & kitten all need homes soon. Please call (617) 784-5718. GREY & WHITE MALE CAT found Lake Massatoag Sharon, (617) 821-.6044. LOST,CAT. Orange and white, fluffy felled male. Lost from comer of West and Dean St, Mansfield, Saturday, 917181. Reward. 608- 339.4873. wampri TaRuV 18R days after it has been pub- lished. BOARD OF HEALTH Michael VanSplinter, Chairman Donald Steele, Clerk Henry Austin Peter Fontanini Edward Rosenberg MN 9/13/91 IN 4N16006 COMMONWEALTH OF MASSACHUSETTS PROBATE AND FAMILY COURTDEPARTMENT BRISTOL, SS. PROBATE COURT67957 To the Attorney General of said Commonwealth and to all persons Interested in the trust estate - under the will of George S. Wood late of Mansfield In said County, deceased: for the benefit of Town of Mansfield. A petition has been pre- sented to said Court pray- ing that William F. Williams n ROOM.'. I . MI Town Manager of Town of 'I Mansfield of Mansfield in the County of Bristol or h some other suitable person 6 be appointed trustee of said r estate first giving a surety F on his bond in place of Estelle Johnson, resigned: ` ff you desire to object thereto you or your attorney I should file a written appear- ance in said Court at Taun- ton before ten o'clock in the f forenoon on the tenth day of October 1991, the return i day, of this cha0on. Witness, ERNEST E ROTENBERG, Esquire,,,, First Judge of said Court, this fourth day of Septem- ber 1991. ROBERT E. PECK,. Register ,i MN 9113/91, 920/91 & t 9)27/91 r IN #N16242 t COMMONWEALTH OF k MASSACHUSETTS ) SUPERIOR COURT I NORFOLK, SS. 1 Class MISCELLANEOUS 205 YARD SALES 230 FOR SALE SHARON. 10 HAMPTON ROAD, MA HANDDE WOOL SWEATERS. Saturday, September 14. 9am- Made In Equador. Ski outdoor 6pm. Moving - offering lots of types, medium and large sizes, great stuffl excellent quality, low prices: (617) SHARON. 16 Deerfield road, Sep- 7a4-2465. tember 14 -15. GREATEST MUL- NINTENDO TAPES. Good condl- TI-FAMILY SALE. Furniture, toys, son. $17 each. (617) 784-9776. games, books, tools, records and SHARON MEMORIAL PARK LOT much more. Cade§ 26 lot 450 spaces 1-4, ex- SHARON. 18 HAMPSHIRE AVE- cellent location, reduced price Cali NUF, Saturday and Sunday, after Spin(506) 543-5533. September 14 and 15th,,10am- SLEEP SOFA AND MATCHING 4pm. Toys, Bikes, Clothes, and Much Morel LOVE SEAT. Good condition. $165 For both. End tables and SHARON. 24 Belcher Street off CLEANING 410 WINDOW CLEANING M. ANNIS AND SONS. 20 Years experience. Fully Insured. Satis- faction guaranteed. 617-444-2416 CLEANOUARTrAS HOME Cleaning Professionals. Insured & Bonded. Weekly & BI- Weekly. Free estimates, (508) 339-5858. HOUSE CLEANING. Reasonable rates, experienced, references. Can Debbie. 617344-8128. CASTLE CLEANERS. Have your home expertly cleaned by the same person to Insure careful ANNUAL TOWN MEETING APRIL 1,1996 The Annual Town Meeting was called to order at 7:30 P. M The meeting was held -at the Mansfield High School Auditorium, Best Street, Mansfield, Massachusetts. The total numbers of voters attending the session was 648. Those were 29 guests moluding eight from Troop 55. Moderator Saquet asked for a vote to allow the following to speak an necessary during the meeting. Lawrence Gallagher, Town Accountant; Robert. Manp otti; Town Counsel; Gale Famrgie, Council on Agmg Director, Scott Leite, Health Agent, Daniel Clifford; D.P.W. Direcbar, John Buckley ; D.P.W. Assistant Director, Rennedm Hackett,. W.U.C. Operators Manager, Richard Lewis, Eaviromental and Conservation Planner; Robert Ornek, Business Manager, Lee Azinheim; Town Engineer, John Larch, Electric Department Shaun Burke, Director of Planning and Development; Gerald Schermer, Veterans AgoM The motion passed on a majority show of hands vote. Ut0*A!*WA 44 Move the Town vote that the income from the sale of electricity to private consumers or for electricity supplies to municipal buildings or for municipal power and street lights, together with receipts fiom jobbing accounts, be appropriated for the Municipal Electric Department, the whole many part to be expended by the Manager of the Municipal Electric Department under the direction and control of the Board of Selectmen, for expenses of the Department for FY1997. Voted favorably -Majority vote - Show of hands At 8:00 P.M the Annual Town Meeting adjourned SPECIAL TOWN MEETING APRIL 1,1996 The Special TowaMeeting was called w order at 8:00 P.M ARTICLE t - Vote Move the Town vote to transfer $192,365 between various departmental budget accounts to defiay the expenses of the municipal Government during the remainder of Ore Fiscal year 1996 between the following accounts: FROM J! T° AMOl1NT Ambulance gxN= Ambulance Umcclmddaled $10,965 Ova$me Highway Pascual Service MolurPool Persced Savior 1,500 Police Personal Services wins Maintenance Hxpe" 801000 Employes Bacdts w awmsmem Sspeme 30,000 lanasee winter Maintenance Pamnal 20.000 Services wadawater Winter Maidwance Perewal 25,000 Pascual $"vices Smices wad-Iflr$xpmw Winter Nlawamoe Pasmal 25,000 Savica SIM65 Voted favorably -Majority vote - Show of hands ARTICLE 2 - Vote Move Ole Town vote to transfer from free cash $257.85 to pay the following .unpaid prioryear's bills: Sdmd MkhadLComollyRSom,Inc. $80.00 School Handiap Mobift bra. 58.00 BiShway HAD Sig %Tax 119.95 $257.95 Vote declared mumimously in favor by Moderator - Show ofhands ARTICLE 3 To see if the Town will vote to transfer from stabilization the Amount of $60.000 or Mill Pond Dam rehabilitation, or take any action in [elation thereto. SPONSOR: Board of Selectmen ARTICLE 3 - Vote Withdrawn by Selectmen Chairman William Madan ARTICLE 4 -Vote Move the Town vote to appropriate and transfer from stabilization account the sum of $73,300 for the purpose of implementing the Board of Health order of Jane 20, 1991, to fluoridate the water supply. Voted favorably on a standing vote count 388 in favor 168 opposed. The Special Town Meeting 4oumed at 8:40 P.M. At 9:40 P.M. the Annual Town Meeting was called to order. ARTICLE 3 - Vote Move the Town vote to appropriate $18,706,842a to defray the expanses of the Town departments, as further described in a document- eatitled `Town of Mansfield Municipal Budget 1996-97" for the easuing 12-month period beginning July 1, 1996, and to transfer funds from One following accounts: Raise from Taxation $17,337,690a Transfer from Available Funds: Wetlands Reserve Account 7.500 AmbulenoeFees 206,000 Abatementalf.nemptions 0 Pension Reserve 0 Free Cash 0 State Aid to Libraries 0 Water Operations 324,389 Wastewater Operations 367,144 Electric Department 464,119 . Capital Improvements Fund 0 1,369,152 TOTAL 18,706,842e . GRNERAL GOVERNMENT Selectmen Personal Services 0 Other Expenses 79,450 Total 79,450 51 Water Fluoridation A compilation of scientific summary regarding the dangers of adding Fluoride to our water supply Sourees listed in So—tiol) i Thanks to HuorideAlon.ort2 i6r organizin ., much of the information fl-om the large nrrtnbei c>f studies. {.'c:mipiled OF; f,aper,law rary 51 :'.UI , Beri Yeransian 'The level of fluoride the govwnimerit allows the public is based on sscienfificailV fratidulent inkit- 7<:afion and ii11ered re.outs. People cat) ba harmed sirmly by cirinkin� �va$e,r " -I?r. Robert Carton, Ph.D, former F..nvironmerd;:.i P:otecti:,n hge l-cy EScie115s' (20 years) "( am appalled at the iraspe-t of using water as a vehicle for drugs.... " -Ur. C.G3 i leyd, former Presldert of the .American Medical Association °F'I+,j�rrlAB is a carcmogen nhy :3r3V st=lri(Yi.rd we use. I believe ElaA shouid act itnmw3iately to protoct the PWblic, octjiust on tho, cancer daft, but on iile ;vidr;,101;e C6 !"one" factures, still i;;, 17714 ..)7fmicity, aril other effects. " Dr William Marcus, Ph.D, I " I ircr;inarV ProtecGr)ri AyencyS':;en'nst Water Fluoridation A compilation of scientific summary regarding the dangers of adding Fluoride to our water supply Sources listed in Section 1 Thanks to FluorideAlert.org for organizing much of the information from the large number of studies. )ate i Compiled on paper by Ben Yeransian January 5, 2012 co,f° `F ` byerans'lcnecon cuS�.112� 5Oc y63.63 53 "The level of fluoride the government allows the public is based on scientifically fraudulent information and altered reports. People can be harmed simply by drinking water " -Dr. Robert Carton, Ph.D, former Environmental Protection Agency Scientist (20 years) "/ am appalled at the prospect of using water as a vehicle for drugs.... " -Dr. C.G. Heyd, former President of the American Medical Association "Fluoride is a carcinogen by any standard we use. I believe EPA should act immediately to protect the public, not just on the cancer data, but on the evidence of bone fractures, arthritis, mutagenicity, and other effects. " -Dr. William Marcus, Ph.D, Environmental Protection Agency Scientist Note: There are too many scientific studies for me to print them all out. The Following is a list of 50 Reasons to Oppose Fluoridation, which summarizes all the studies completed. To view the individual studies in pdf format (entire scientific documents with overview) please visit FluorideAlert.org To show the magnitude of the scientific research completed in this area of study, 1 will start with the list of references followed by the 50 summarized conclusions from these studies. References: (Studies proving the 50 reasons following) Agency for Toxic Substances and Disease Registry (ATSDR) (1993). Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (F). U.S. Department of Health & Human Services, Public Health Service. ATSDR/TP-91/17. Alarcon -Herrera MT, at al. (2001). Well Water Fluoride, Dental fluorosis, Bone Fractures in the Guadiana Valley of Mexico. Fluoride. 34(2): 139-149. Allain P, et al. (1996). Enhancement of aluminum digestive absorption by fluoride in rats. Research Communications in Molecular Pathology and Pharmacology. 91: 225-31. Armfield JM and Spencer AJ (2004). Consumption of Nonpublic Water: Implications for Children's Caries Experience," Community Dentistry and Oral Epidemiology. 32(4): 283-96 Arnold HA. (1980). Letter to Dr. Ernest Newbrun. May 28, 1980. http://www.fluoridealert.org/uc-davis.htm Awadia AK, et al. (2002). Caries experience and caries predictors - a study of Tanzanian children consuming drinking water with different fluoride concentrations. Clinical Oral Investigations. (2002) 6:98- 103. Bachinskii PP, et al. (1985) Action of the body fluorine of healthy persons and thyroidopathy patients on the function of hypophyseal-thyroid the system. Probl Endokrinol (Mosk) 31: 25- 9. http://www.fluoridealert.org/epa-sf/appendix-e.pdf Barbier O. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological Interactions. 188: 319- 333. Barnes GP, et al. (1992). Ethnicity, location, age, and fluoridation factors in baby bottle tooth decay and caries prevalence of Head Start children. Public Health Reports. 107: 167-73. Barot VV. (1998). Occurrence of endemic fluorosis in human population of North Gujarat, India: human health risk. Bulletin of Environmental Contamination and Toxicology. 61: 303-10. Bassin EB. (2001). "Association Between Fluoride in Drinking Water During Growth and Development and the Incidence of Osteosarcoma for Children and Adolescents," DMSc thesis, Harvard School of Dental Medicine, Boston, Massachusetts. Bassin EB et al. (2006). Age -specific Fluoride Exposure in Drinking Water and Osteosarcoma (United States). Cancer Causes and Control. 17 (4): 421-28. Bayley TA, et al. (1990). Fluoride -induced fractures: relation to osteogenic effect. Journal of Bone and Mineral Research.5(Suppl 1):S217-22. Beltran -Aguilar ED et al. (2010). Prevalence and severity of dental fluorosis in the United States, 1999- 2004. NCHS DataBrief No. 53. U.S. DHHS, CDC, National Center for Health Statistics. Beltran -Aguilar ED et al. (2005). Surveillance for dental caries, dental sealants, tooth retention, endentulism, and enamel fluorosis-United States, 1988- 1994 and 1999-2002. CDC, MMWR, Surveillance Summaries, August 26, vol. 54, No SS-3, pp. 1-44. See Table 23. Bentley EM, et al. (1999). Fluoride ingestion from toothpaste by young children. British Dental Journal. 186: 460-2. Bhatnagar M, et al. (2002). Neurotoxicity of fluoride: neurodegeneration in hippocampus of female mice. Indian Journalof Experimental Biology. 40: 546-54. Bigay J, et al. (1987). Fluoride complexes of aluminium or beryllium act on G-proteins as reversibly bound analogues of the gamma phosphate of GTP. EMBO Journal. 6:2907-2913. Bigay J, et al. (1985). Fluoroaluminates activate transducin-GDP by mimicking the gamma -phosphate of GTP in its binding site. FEBS Letters. 191:181-185. Brothwell D, Limeback H. (2003). Breastfeeding is protective against dental fluorosis in a nonfluoridated rural area of Ontario, Canada.Journal of Human Lactation 19: 386-90. Brunelle JA, Carlos JP. (1990). Recent trends in dental caries in U.S. children and the effect of water fluoridation. Journalof Dental Research. 69(Special edition): 723-727. Bryson C. (2004). The Fluoride Deception. Seven Stories Press, New York. Burgstahler AW, et al. (1997). Fluoride in California wines and raisins. Fluoride. 30: "142-146. Caffey J. On Fibrous Defects in Cortical Walls: Their Radiological Appearance, Structure, Prevalence, Natural Course, and Diagnostic Significance in Advances in Pediatrics, ed. S. Z. Levin, (New York: Interscience, 1955). Calderon J et al. (2000). Influence of fluoride exposure on reaction time and visuospatial organization in children. Epidemiology1l(4):S153. Carlsson A. (1978). Current problems relating to the pharmacology and toxicology of fluorides. Journal of the Swedish Medical Association. 14: 1388-1392. Carnow BW, Conibear SA. (1981). Industrial fluorosis. Fluoride. 14: 172-181. Caspary WJ, et al (1987). Mutagenic activity of fluorides in mouse lymphoma cells. Mutation Research. 187:165-80. 1 Centers for Disease Control and Prevention (CDC). (2002). Prevalence of Self -Reported Arthritis or Chronic Joint Symptoms Among Adults --- United States, 2001. Mortality and Morbidity Weekly Report. 51: 948-950. Centers for Disease Control and Prevention (CDC). (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Morbidity and Mortality Weekly Report. 50(RR 14): 1-42. Centers for Disease Control and Prevention (CDC). (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Mortality and Morbidity Weekly Report. 48: 933- 940. Chachra et al. (2010) The long-term effects of water fluoridation on the human skeleton. Journal of Dental Research. 89(11): 1219-1223. Chen J, et al. (2003). Selective decreases of nicotinic acetylcholine receptors in PC12 cells exposed to fluoride. Toxicology. 183: 235-42. Chen J, et al. (2003). Selective decreases of nicotinic acetylcholine receptors in PC12 cells exposed to fluoride. Toxicology. 183: 235-42. Chen J, et al. (2002). [Studies on DNA damage and apoptosis in rat brain induced by fluoride] Zhonghua Yu Fang Yi Xue Za Zhi. 36 222-224. Chen YC, at al. (1997). Nutrition survey in dental fluorosis-afflicted areas. Fluoride. 30(2):77-80. Chinoy NJ, Narayana MV. (1994). In vitro fluoride toxicity in human spermatozoa. Reproductive Toxicology. 8:155-9. Chinoy NJ, at al. (1991). Microdose vasal injection of sodium fluoride in the rat. Reproductive Toxicology. 5: 505-12. Chinoy NJ, Sequeira E. (1989). Effects of fluoride on the histoarchitecture of reproductive organs of the male mouse.Reproductive Toxicology. 3: 261-7. P. D. Cohn (1992). An Epidemiologic Report on Drinking Water and Fluoridation, New Jersey Department of Health, Environmental Health Service, November 8, 1992. Note: The original title of this report was A Brief Report on the Association of Drinking Water Fluoridation and the Incidence of Osteosarcoma Among Young Males. The word "osteosarcoma" was deleted from the title soon after the report was released; http://fluoridealert.org/cohn-1992.pdf. Colquhoun J. (1997). Why I changed my mind about Fluoridation. Perspectives in Biology and Medicine 41: 29-44.http://www.fluoride-journal.com/98-31-2/312103.htm Connett PH, Beck J and Micklem S. The Case Against Fluoride: How Hazardous Waste Ended Up in Our Drinking Water and the Powerful Politics and Bad Science That Keep it There. Chelsea Green, White River Junction, VT, 2010. Connett,P (2004) 50 Reasons to Oppose Fluoridation (updated April 12, 2004). Reprinted in Medical Verites. 1:70-80, http://www.fluoridealert.org/50reasons.htm Connett M. (2004). Fluoride & Bone Damage: Published Data. Submission to National Research Council (NRC).http://www.fluoridealert.org/bone-data.pdf Connett, P. (2000). Fluoride: A Statement of Concern. Waste Not #459. January 2000. Waste Not, 82 Judson Street, Canton, NY 13617.http://www.fluoridealert.org/fluoride-statement.htm Connett P, Neurath C and Connett M. (2005). Revisiting the Fluoride-Osteosarcoma Connection in the Context of Elise Bassin's Findings: Part II." Submission to the National Research Council of the National Academies review panel on the Toxicologic Risk of Fluoride in Drinking Water, March 21, 2005 (revised April 8, 2005), http://www.fluoridealert.org/health/cancer/fan-nrc.part2.pdf Czerwinski E, et al. (1988). Bone and joint pathology in fluoride -exposed workers. Archives of Environmental Health. 43:340-343. Dambacher MA, at al. (1986). Long-term fluoride therapy of postmenopausal osteoporosis. Bone 7: 199- 205. De Liefde B. (1998). The decline of caries in New Zealand over the past 40 Years. New Zealand Dental Journal. 94: 109-113. Department of Health & Human Services. (U.S. DHHS) (1991). Review of Fluoride: Benefits and Risks. Report of the Ad Hoc Committee on Fluoride, Committee to Coordinate Environmental Health and Related Programs. Department of Health and Human Services, USA. DenBesten, P (1999). Biological mechanism of dental fluorosis relevant to the use of fluoride supplements. Community Dentistry and Oral Epidemiology. 27: 41-7. De Stefano TM. (1954). The fluoridation research studies and the general practitioner. Bulletin of Hudson County Dental Society. February. Diesendorf M.(1986). The mystery of declining tooth decay. Nature. 322: 125-129. http://www.fluoridealert.org/diesendorf.htm Ding Y at al. (2010. The relationships between low levels of urine fluoride on children's intelligence, dental fluorosis in endemic fluorosis areas in Hulunbuir, Inner Mongolia, China. Journal of Hazardous Materials. doi:10.1016/j.j hazmat.2010.12.097. Ditkoff BA, Lo Gerfo P. (2000). The Thyroid Guide. Harper -Collins. New York. Douglass CW and Joshipura K. (2006) "Caution Needed in Fluoride and Osteosarcoma Study" (letter), Cancer Causes & Control. 17 (4): 481-82. Du L. 1992. The effect of fluorine on the developing human brain. Chinese Journal of Pathology2l(4):218-20 (republished in Fluoride41:327-30). Online at http://fluoridealert.org/scher/du- 2008.pdf Duan X. et al. (2011). Excess Fluoride Interferes with Chloride -channel -dependent Endocytosis in Ameloblasts. J Dent Res. 90(2):175-180. Easley, M. (1999). Community fluoridation in America: the unprincipled opposition. Dental Watch,http://www.dentalwatch.org/fl/opposition.pdf (accessed March 21, 2010). Ekambaram P, Paul V. (2001). Calcium preventing locomotor behavioral and dental toxicities of fluoride by decreasing serum fluoride level in rats. Environmental Toxicology and Pharmacology. 9: 141-146. Ekstrand J, et al. (1981). No evidence of transfer of fluoride from plasma to breast milk. British Medical Journal (Clin Res Ed). 83: 761-2. Ekstrand J, et al. (1994). Fluoride pharmacokinetics in infancy. Pediatric Research. 35:157-163. Ekstrand J. (1996). Fluoride Intake. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Denmark. Pages 40-52. Elbetieha A, at al. (2000). Fertility effects of sodium fluoride in male mice. Fluoride. 33: 128-134. Emsley J, et al (1981). An unexpectedly strong hydrogen bond: ab initio calculations and spectroscopic studies of amidefluoride systems.Journal of the American Chemical Society. 103: 24-28. Fagin, D. (2008). Second Thoughts on Fluoride. Scientific American 298 (1)(January): 74-81; excerpts athttp://www.fluoridealert.org/sc.am.jan.2008.html Fein NJ, Cerklewski FL. (2001). Fluoride content of foods made with mechanically separated chicken. Journal of Agricultural Food Chemistry. 49: 4284-6. Feltman R, Kosel G. (1961). Prenatal and postnatal ingestion of fluorides - Fourteen years of investigation - Final report. Journal of Dental Medicine. 16: 190-99. Finney WF et al. (2006) Reexamination of Hexafluorosilicate Hydrolysis by Fluoride NMR and pH Measurement. Environmental Science & Technology 40 (8): 2572-77. Fluoridation Forum (2002). Forum on Fluoridation (Dublin, Ireland: Stationery Office, 2002),http://fluoridealert.org/re/fluoridation.forum.2002.pdf Fomon SJ, et al. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants.Journal of Public Health Dentistry. 60: 131-9. Franke J, at al. (1975). Industrial fluorosis. Fluoride. 8: 61-83. Freni SC. (1994). Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. Journal of Toxicology and Environmental Health. 42: 109-121. Freeze RA and Lehr JA. The Fluoride Wars: How a Modest Public Health Measure Became America's Longest -Running Political Melodrama. (Hoboken, NJ: John Wiley, 2009). Freni SC, Gaylor DW. (1992). International trends in the incidence of bone cancer are not related to drinking water fluoridation. Cancer.70: 611-8. Galletti P, Joyet G. (1958). Effect of fluorine on thyroidal iodine metabolism in hyperthyroidism. Journal of Clinical Endocrinology 18: 1102-1110. http://www.fluoridealert.org/galletti.htm Gerster JC, et al. (1983). Bilateral fractures of femoral neck in patients with moderate renal failure receiving fluoride for spinal osteoporosis. British Medical Journal (Clin Res Ed). 287(6394):723-5. Ghosh D, et al. (2002). Testicular toxicity in sodium fluoride treated rats: association with oxidative stress. Reproductive Toxicolology.16: 385. Gray, AS. (1987). Fluoridation: time for a new base line? Journal of the Canadian Dental Association. 53: 763-5. Grobleri SR, at al. (2001). Dental fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. International Journal of Paediatric Dentistry. 11(5):372-9. Guan ZZ, at al (1998). Influence of chronic fluorosis on membrane lipids in rat brain. Neurotoxicology and Teratol ogy.20: 537-542. Gutteridge DH, et al. (2002). A randomized trial of sodium fluoride (60 mg) +/- estrogen in postmenopausal osteoporotic vertebral fractures: increased vertebral fractures and peripheral bone loss with sodium fluoride; concurrent estrogen prevents peripheral loss, but not vertebral fractures. Osteoporosis International. 13(2):158-70. Gutteridge DH, et al. (1990). Spontaneous hip fractures in fluoride -treated patients: potential causative factors. Journal of Bone and Mineral Research. 5 Suppl 1:S205-15. Han H, Chang Z, Liu W. 1989. Effects of fluorine on the human fetus. Chinese Journal of Control of Endemic Diseases 4:136-138 (republished in Fluoride 41:321-6). Online at http://www.fluorid eresearch.org/414/files/FJ2008—v4l _n4—p321-326. pdf Hanmer R. (1983). Letter from Rebecca Hanmer, deputy assistant administrator for water, U.S. Environmental Protection Agency, to Leslie A. Russell, D.M.D, March 30, 1983. http://fluoridealert.org/re/hanmerl983.pdf Hazan S. (2004). Letter from Stan Hazan, General Manager, NSF Drinking Water Additives Certification Program, to Ken Calvert, Chairman, Subcommittee on Energy and the Environment, Committee on Science, US House of Representatives.July 7.http://www.keepersofthewell.org/product_pdfs/NSF_response.pdf Health Canada (2008). Findings and Recommendations of the Fluoride Expert Panel (January 2007). April 2008, http://fluoridealert.org/re/ca nad a.fluoride. expert. panel.2007.pdf Health Canada (2010). Guidelines for Canadian Drinking Water Quality: Guideline Technical Document — Fluoride. Health Canada Dated Dec 2010, published June 21, 2011. http://www.hc-sc.gc.ca/ewh- semt/pubs/water-eau/2011-fluoride-fluorure/index-eng. ph p Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research. 4: 223-5. Heilman JR et al. (1999). Assessing Fluoride Levels of Carbonated Soft Drinks. Journal of the American Dental Association. 130 (11): 1593-99. Heller KE, et al (1997). Dental caries and dental fluorosis at varying water fluoride concentrations. Journal of Public Health Dentistry. 57: 136-143. Hileman B. (1989). New studies cast doubt on fluoridation benefits. Chemical and Engineering News. May 8.http://www.fluoridealert.org/NIDR.htm Hileman B. (1988). Fluoridation of water: Questions about health risks and benefits remain after more than 40 years. Chemical and Engineering News. August 1: 26- 42. http://www.fluoridealert.org/hileman.htm Hirzy JW. (1999). Why the EPA's Headquarters Union of Scientists Opposes Fluoridation. Press release from National Treasury Employees Union. May 1. http://www.fluoridealert.org/hp-epa.htm Hong L, et al. (2006). Timing of fluoride intake in relation to development of fluorosis on maxillary central incisors. Community Dentistry and Oral Epidemiology 34:299-309. Hoover RN, et al. (1991 a). Time trends for bone and joint cancers and osteosarcomas in the Surveillance, Epidemiology and End Results (SEER) Program. National Cancer Institute In: Review of Fluoride: Benefits and Risks Report of the Ad Hoc Committee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs US Public Health Service. Appendix E. Hoover RN, et al. (1991 b). Time trends for bone and joint cancers and osteosarcomas in the Surveillance, Epidemiology and End Results (SEER) Program. National Cancer Institute In: Review of Fluoride: Benefits and Risks Report of the Ad Hoc Committee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs US Public Health Service. Appendix F. Inkovaara J, et al. (1975). Prophylactic fluoride treatment and aged bones. British Medical Journal. 3: 73- 4. Institute of Medicine. (1997). Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. National Academy Press. Johnson WJ, et al. (1979). Fluoridation and bone disease in renal patients. In: Johansen E, Taves DR, Olsen TO, Eds.Continuing Evaluation of the Use of Fluorides. AAAS Selected Symposium. Westview Press, Boulder, Colorado. pp. 275-293. Joseph S, Gadhia PK. (2000). Sister chromatid exchange frequency and chromosome aberrations in residents of fluoride endemic regions of South Gujarat. Fluoride. 33: 154-158. Juncos LI, Donadio JV. (1972). Renal failure and fluorosis. Journal of the American Medical Association 222: 783-5. Kelly JV. (2000). Letter to Senator Robert Smith, Chairman of Environment and Public Works Committee, U.S. Senate, August 14, 2000.http://www.fluoridealert.org/fda.htm Kilborn LG, et al. (1950). Fuuorosis with report of an advanced case. Canadian Medical Association Journal. 62: 135-141. Kim FM at al. (2011). An Assessment of Bone Fluoride and Osteosarcoma. J. Dent.Res. July 28, 2011 (published online).http://jdr.sagepub.com/content/early/2011/07/23/0022034511418828.full.pdf+html Kiritsy MC, et al. (1996). Assessing fluoride concentrations of juices and juice -flavored drinks. Journal of the American Dental Association. 127: 895-902. Kishi K, Ishida T. (1993). Clastogenic activity of sodium fluoride in great ape cells. Mutation Research. 301:183-8. Komarek AE (2005). A Bayesian Analysis of Multivariate Doubly -Interval -Censored Dental Data," Biostatistics. 6 (1):145-55. Kour K, Singh J. (1980). Histological finding of mice testes following fluoride ingestion. Fluoride. 13: 160- 162. Kumar A, Susheela AK. (1994). Ultrastructural studies of spermiogenesis in rabbit exposed to chronic fluoride toxicity. International Journal of Fertility and Menopausal Studies. 39:164-71. Kumar JV, Green EL. (1998). Recommendations for fluoride use in children. NY State Dental Journal. 64: 40-7. Kunzel W, Fischer T. (2000). Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Research.34: 20- 5. Kunzel W, et al. (2000). Decline in caries prevalence after the cessation of water fluoridation in former East Germany. Community Dentistry and Oral Epidemiology. 28: 382-389. Kunzel W, Fischer T. (1997). Rise and fall of caries prevalence in German towns with different F concentrations in drinking water. Caries Research. 31: 166-73. Kurttio PIN, et al. (1999). Exposure to natural fluoride in well water and hip fracture: A cohort analysis in Finland. American Journal of Epidemiology. 150(8): 817-824. Lalumandier JA, et al. (1995). The prevalence and risk factors of fluorosis among patients in a pediatric dental practice. Pediatric Dentistry. 17: 19-25. Levy SM, Guha-Chowdhury N. (1999). Total fluoride intake and implications for dietary fluoride supplementation. Journal of Public Health Dentistry. 59: 211-23. Levy SM et al. (2009). Associations of fluoride intake with children's bone measures at age 11. Community Dent OralEpidemiol.37(5):416-26. Levy SM, at al. (2010). Associations Between Fluorosis of Permanent Incisors and Fluoride Intake From Infant Formula, Other Dietary Sources and Dentifrice During Early Childhood. JADA 141:1190-1201. Li J, Yao L, Shao QL, Wu CY. 2004. Effects of high fluoride level on neonatal neurobehavioural development. Chinese Journal of Endemiology 23:464-465 (republished in Fluoride 41:165-70). Online at http://fluoridealert.org/scher/li.2008.pdf Li L. (2003). The biochemistry and physiology of metallic fluoride: action, mechanism, and implications. Critical Reviews of Oral Biology and Medicine. 14: 100-14. Li XS. (1995). Effect of fluoride exposure on intelligence in children. Fluoride 28: 189-192. Li Y, et al. (2001). Effect of long-term exposure to fluoride in drinking water on risks of bone fractures. Journal of Bone and Mineral Research 16: 932-9. Lin FF, et al. (1991). The relationship of a low -iodine and high -fluoride environment to subclinical cretinism in Xinjiang. Iodine Deficiency Disorder Newsletter. Vol. 7. No. 3. http://www.fluoridealert.org/]DD.htm Locker D. (1999). Benefits and Risks of Water Fluoridation. An Update of the 1996 Federal -Provincial Sub -committee Report. Prepared for Ontario Ministry of Health and Long Term Care. Long YG, et al. (2002). Chronic fluoride toxicity decreases the number of nicotinic acetylcholine receptors in rat brain. Neurotoxicology and Teratology. 24: 751-7. Lu XH, at al. (2000). Study of the mechanism of neurone apoptosis in rats from the chronic fluorosis. Chinese Journal of Epidemiology.19: 96-98. Luke J. (2001). Fluoride deposition in the aged human pineal gland. Caries Research 35: 125-128. Luke J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildord. Maas RP at al. (2007). Effects of Fluoridation and Disinfection Agent Combinations on Lead Leaching from Leaded -Brass Parts. Neurotoxicology. 28 (5): 1023-31. Mahaffey KR, Stone CL. (1976). Effect of High Fluorine (F) Intake on Tissue Lead (Pb) Concentrations. Federation Proceedings. 35: 256. Mahoney MC, et al. (1991). Bone cancer incidence rates in New York State: time trends and fluoridated drinking water. American Journal of Public Health. 81: 475-9. Mann J, et al. (1990). Fluorosis and dental caries in 6-8-year-old children in a 5 ppm fluoride area. Community Dentistry and Oral Epidemiology. 18: 77-9. Mann J, et al. (1987). Fluorosis and caries prevalence in a community drinking above -optimal fluoridated water. Community Dentistry and Oral Epidemiology. 15: 293-5. Marcus W. (1990). Memorandum from Dr. William Marcus, to Alan B. Hais, Acting Director Criteria & Standards Division ODW, US EPA. May 1, 1990. http://www.fluoridealert.org/marcus.htm Marcus W. (1990). Memorandum from Dr. William Marcus, to Alan B. Hais, Acting Director Criteria & Standards Division ODW, US EPA. May 1, 1990. http://www.fluoridealert.org/marcus.htm Marier J and Rose D. (1977). Environmental Fluoride. National Research Council of Canada. Associate Committee on Scientific Criteria for Environmental Quality. NRCC No. 16081, Ottawa, Canada. Marshall TA, et al. (2004). Associations between Intakes of Fluoride from Beverages during Infancy and Dental Fluorosis of Primary Teeth. Journal of the American College of Nutrition 23:108-16.Martin B. (1991). Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate. SUNY Press,Albany NY. Martin B. (1991). Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate. SUNY Press, Albany NY. Massler M, Schour I. (1952). Relation of endemic dental fluorosis to malnutrition. Journal of the American Dental Association. 44: 156-165. Masters R, at al. (2000). Association of silicofluoride treated water with elevated blood lead. Neurotoxicology. 21: 1091-1099. Masters RD, Coplan M. (1999). Water treatment with silicofluorides and lead toxicity. International Journal of Environmental Studies. 56: 435-449. Matsuo S, at al. (1998). Mechanism of toxic action of fluoride in dental fluorosis: whether trimeric G proteins participate in the disturbance of intracellular transport of secretory ameloblast exposed to fluoride. Archives of Toxicology. 72: 798- 806. Maupome G, et al. (2001). Patterns of dental caries following the cessation of water fluoridation. Community Dentistry and Oral Epidemiology. 29: 37-47. McClure F. (1970). Water fluoridation, the search and the victory. US Department of Health, Education, and Welfare, Washington DC. McDonagh M, et al. (2000). A Systematic Review of Public Water Fluoridation. NHS Center for Reviews and Dissemination, University of York, September 2000. http://www.fluoridealert.org/york.htm Meng Z, Zhang B. (1997). Chromosomal aberrations and micronuclei in lymphocytes of workers at a phosphate fertilizer factory. Mutation Research. 393: 283-288. Mihashi, M. and Tsutsui,T.(1996). Clastogenic activity of sodium fluoride to rat vertebral body -derived cells in culture. Mutation Research368: 7-13. Moolenburgh H. (1987). Fluoride: The Freedom Fight. Mainstream Publishing, Edinburgh. Morgan L, et al. (1998). Investigation of the possible associations between fluorosis, fluoride exposure, and childhood behavior problems. Pediatric Dentistry. 20: 244-252. Mullenix P, et al. (1995). Neurotoxicity of sodium fluoride in rats. Neurotoxicology and Teratology. 17: 169-177. Mullenix P, et al. (1995). Neurotoxicity of sodium fluoride in rats. Neurotoxicology and Teratology. 17: 169-177. Narayana MV, et al. (1994). Reversible effects of sodium fluoride ingestion on spermatozoa of the rat. International Journal of Fertility and Menopausal Studies. 39: 337-46. Narayana MV, Chinoy NJ. (1994). Effect of fluoride on rat testicular steroidogenesis. Fluoride. 27: 7-12. NHMRC (2007). National Health and Medical Research Council, A Systematic Review of the Efficacy and Safety of Fluoridation, reference no. EH41, Australian Government, December 27, 2007, http:Hwww.nhmrc.gov.au/publications/synopses/eh41syn.htm National Research Council (1977). Drinking Waterand Health, National Academy of Sciences, Washington DC: National Academy Press, 1977, 388-89. National Research Council. (1993). Health Effects of Ingested Fluoride. National Academy Press, Washington DC. National Sanitation Foundation International (NSF). (2000) National Research Council. (1993). Health Effects of Ingested Fluoride. National Academy Press, Washington DC. National Sanitation Foundation International (NSF). (2000) National Toxicology Program [NTP] (1990). Toxicology and Carcinogenesis Studies of Sodium Fluoride in F344IN Rats and 86C3f1 Mice. Technical report Series No. 393. NIH Publ. No 91-2848. National Institute of Environmental Health Sciences, Research Triangle Park, N.C. The results of this study are summarized in the Department of Health and Human Services report (DHHS,1991). NRC (2006). National Research Council of the National Academies, Fluoride in Drinking Water: A Scientific Review of EPA's Standards. Washington, DC: National Academies Press, http://books.nap.edu/openbook.php?record-id=11571 O'Duffy JD, et al. (1986). Mechanism of acute lower extremity pain syndrome in fluoride -treated osteoporotic patients.American Journal of Medicine. 80: 561-6. Olsson B. (1979). Dental findings in high -fluoride areas in Ethiopia. Community Dentistry and Oral Epidemiology. 7: 51-6. Orcel P, et al. (1990). Stress fractures of the lower limbs in osteoporotic patients treated with fluoride. Journal of Bone and Mineral Research. 5(Suppl 1): S191-4. Ortiz -Perez D, et al. (2003). Fluoride -induced disruption of reproductive hormones in men. Environmental Research 93:20-30. Paul V, at al. (1998). Effects of sodium fluoride on locomotor behavior and a few biochemical parameters in rats. Environmental Toxicology and Pharmacology. 6: 187-191. Pendrys DG, Katz RV. (1998). Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers' decision to reduce the fluoride concentration of infant formula. American Journal of Epidemiology 148:967-74. Pinkham, JR, ad. (1999). Pediatric Dentistry Infancy Through Adolescence. 3rd Edition. W B Saunders Co, Philadelphia. Public Health Service (PHS). (1993). Toward improving the oral health of Americans: an overview of oral health status, resources, and care delivery. Public Health Reports. 108: 657-72. Retief DH, at al. (1979). Relationships among fluoride concentration in enamel, degree of fluorosis and caries incidence in a community residing in a high fluoride area. Journal of Oral Pathology. 8: 224-36. Riggs BL, at al. (1990). Effect of Fluoride treatment on the Fracture Rates in Postmenopausal Women with Osteoporosis. New England Journal of Medicine 322: 802-809. Rocha-Amador D et al. (2009). Use of the Rey-Osterrieth Complex Figure Test for neurotoxicity evaluation of mixtures in children.Neurotoxicology 30(6):1149-54. Rozier RG. (1999). The prevalence and severity of enamel fluorosis in North American children. Journal of Public Health Dentistry. 59: 239-46. Sawan RMM at al. (2010) Fluoride Increases Lead Concentrations in Whole Blood and in Calcified Tissues from Lead -Exposed Rats. Toxicology. 271 1-2: 21-26. Schlesinger ER et al. (1956) Newburgh -Kingston Caries -Fluorine Study. XIII. Pediatric Findings After Ten Years," Journal of the American Dental Association. 52 (3):296-306. Schnitzler CM, et al. (1990). Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clinical Orthopaedics.(261): 268-75. Seholle RH. (1984). Preserving the perfect tooth (editorial). Journal of the American Dental Association. 108: 448. Seppa L, et al. (2000). Caries trends 1992-98 in two low -fluoride Finnish towns formerly with and without fluoride. Caries Research. 34: 462-8. Shannon, FT et al. (1986). Exposure to Fluoridated Water Supplies and Child Behaviour. New Zealand Medical Journal.99, (803): 416-18 Shao Q, et al. (2000). Influence of free radical inducer on the level of oxidative stress in brain of rats with fluorosis.Zhonghua Yu Fang Yi Xue Za Zhi. 34(6):330-2. Sharma R et al. (2008). Fluoride Induces Endoplasmic Reticulum Stress and Inhibits Protein Synthesis and Secretion. Environ Health Perspect. 116:1142-1146. Shashi A. (2003). Histopathological investigation of fluoride -induced neurotoxicity in rabbits. Fluoride. 36: 95-105. Shea JJ, et al. (1967). Allergy to fluoride. Annals of Allergy. 25:388-91 Sheth FJ, et al. (1994). Sister chromatid exchanges: A study in fluorotic individuals of North Gujurat. Fluoride. 27: 215-219. Shiboski CH, et al. (2003). The association of early childhood caries and race/ethnicity among California preschool children. Journal of Public Health Dentistry. 63:38-46. Shivarajashankara YM , et al. (2002). Brain lipid peroxidation and antioxidant systems of young rats in chronic fluoride intoxication.F/uoride. 35: 197-203. Shivarajashankara YM , et al. (2002). Histological changes in the brain of young fluoride -intoxicated rats. Fluoride. 35:12-21. Singh A, Jolly SS. (1970). Fluorides and Human Health. World Health Organization. pp 239-240 Singh A, et al. (1963). Endemic fluorosis: epidemiological, clinical and biochemical study of chronic fluoride intoxication in Punjab.Medicine. 42: 229-246. Spencer AJ et al. (1996).Water Fluoridation in Australia. Community Dental Health. 13 (suppl. 2):27-37. Spittle B. Fluoride Fatigue: Is Fluoride in Your Drinking Water -and from Other Sources- Making You Sick? (Dunedin, New Zealand: Paua Press, 2008), http://www.pauapress.com/fluoride/files/1418.pdf Sprando RL, et al. (1998). Testing the potential of sodium fluoride to affect spermatogenesis: a morphometric study. Food and Chemical Toxicology. 36: 1117-24. Sprando RL, et al. (1997). Testing the potential of sodium fluoride to affect spermatogenesis in the rat. Food and Chemical Toxicology.35: 881-90. Sprando RL, et al. (1996). Effect of intratesticular injection of sodium fluoride on spermatogenesis. Food and Chemical Toxicology. 34: 377-84. Stannard JG, et al. (1991). Fluoride Levels and Fluoride Contamination of Fruit Juices. Journal of Clinical Pediatric Dentistry. 16: 38-40. Stecher P, et al. (1960). The Merck Index of Chemicals and Drugs. Merck & Co., Inc, Rathway NJ. p. 952 Strunecka A, Patocka J. (1999). Pharmacological and toxicological effects of aluminofluoride complexes. Fluoride 32:230-242. Sun ZR, et al. (2000). Effects of high fluoride drinking water on the cerebral functions of mice. Chinese Journal of Epidemiology. 19: 262-263. Susheela AK. (1993). Prevalence of endemic fluorosis with gastrointestinal manifestations in people living in some North -Indian villages.Fluoride. 26: 97-104. Susheela AK and Jethanandani P (1996). Circulating testosterone levels in Skeletal Fluorosis patients. Clinical Toxicology.34 (2): 1-7. Susheela AK, Kumar A. (1991). A study of the effect of high concentrations of fluoride on the reproductive organs of malerabbits, using light and scanning electron microscopy. Journal of Reproductive Fertility. 92: 353-60, Sutton P. (1996). The Greatest Fraud: Fluoridation. Lorne, Australia: Kurunda Pty, Ltd. Sutton P. (1960). Fluoridation: Errors and Omissions in Experimental Trials. Melbourne University Press. Second Edition. Sutton, P. (1959). Fluoridation: Errors and Omissions in Experimental Trials. Melbourne University Press. First Edition. Teotia M, at al. (1998). Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India: year 2000. Indian Journal of Pediatrics. 65: 371-81. Teotia SPS, at al. (1976). Symposium on the non -skeletal phase of chronic fluorosis: The Joints. Fluoride. 9: 19-24. Tsutsui T, Suzuki N, Ohmori M, Maizumi H. (1984). Cytotoxicity, chromosome aberrations and unscheduled DNA synthesis in cultured human diploid fibroblasts induced by sodium fluoride. Mutation Research. 139:193-8. Tye CE et al. (2011). Fluoride Does not Inhibit Enamel Protease Activity. J Dent Res. 90(4): 489-494, U.S. EPA (2011). EPA and HHS Announce New Scientific Assessments and Actions on Fluoride / Agencies working together to maintain benefits of preventing tooth decay while preventing excessive exposure. Joint press release with DHHS, Jan 7, 2011 http://www2.fluoridealert.org/Alert/United- States/National/HHS-and-EPA-announce-new-scientificassessments- and -actions -on -fluoride Varner JA et al. (1998). Chronic Administration of Aluminum -Fluoride or Sodium -Fluoride to Rats in Drinking Water:Alterations in Neuronal and Cerebrovascular Integrity. Brain Research. 78 (1-2): 284-98. Waldbott GL, et al. (1978). Fluoridation: The Great Dilemma. Coronado Press, Inc., Lawrence, Kansas. Waldbott GL. (1965). A Struggle with Titans. Carlton Press, NY. Wang C, et al. (2000). Treatment Chemicals contribute to Arsenic Levels. Opflow. (Journal of the American Water Works Association. October 2000. Wang Y, at al. (1997). Changes of coenzyme Q content in brain tissues of rats with fluorosis. Zhonghua Yu Fang Yi Xue Za Zhi. 31: 330-3. Warren JJ at al. (2009). Considerations on Optimal Fluoride Intake Using Dental Fluorosis and Dental Caries Outcomes - A Longitudinal Study. Journal of Public Health Dentistry. 69 (2): 111-15. WHO (Online). WHO Oral Health Country/Area Profile Programme. Department of Noncommunicable Diseases Surveillance/Oral Health. WHO Collaborating Centre, Malmo University, Sweden. Williams JE, et al. (1990). Community water fluoride levels, preschool dietary patterns, and the occurrence of fluoride enamel opacities.Journal of Public Health Dentistry. 50: 276-81. Wu DQ, Wu Y. (1995). Micronucleus and sister chromatid exchange frequency in endemic fluorosis. Fluoride. 28: 125-127. Xiang Q, at al. (2003a). Effect of fluoride in drinking water on children's intelligence. Fluoride. 36: 84-94. Xiang Q. (2003b). Blood lead of children in Wamiao-Xinhuai intelligence study. Fluoride. 36: 138. Yu Y at al. (1996) Neurotransmitter and receptor changes in the brains of fetuses from areas of endemic fluorosis. Chinese) Endemiology 15: 257-259 (republished in Fluoride 41(2):134-8). Zakrzewska H, et al. (2002). In vitro influence of sodium fluoride on ram semen quality and enzyme activities. Fluoride.35: 153-160. Zhang, R., et al. (2009). A stable and sensitive testing system for potential carcinogens based on DNA damage -induced gene expression in human HepG2 cell. Toxicology in Vitro. 23:158-165. Zhang Z, et al. (2001). [Effects of selenium on the damage of learning -memory ability of mice induced by fluoride]. Wei Shang Yen Jiu.30: 144-6. Zhang Z, et al. (1999). [Effect of fluoride exposure on synaptic structure of brain areas related to learning - memory in mice] [Article in Chinese]. Wei Shang Yan Jiu. 28:210-2. Zhao ZL, et al. (1995). The influence of fluoride on the content of testosterone and cholesterol in rat. Fluoride. 28: 128-130. Ziegelbecker R. (1970). A critical review on the fluorine caries problem. Fluoride. 3: 71-79. Ziegelbecker R. (1981). Fluoridated Water and Teeth. Fluoride. 14 (3): 123-28, http://fluoridealert.org/re/zlegelbecker-1981.pdf. Zhai JX, et al. (2003). Studies on fluoride concentration and cholinesterase activity in rat hippocampus. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 21: 102-4. Zhao XL, Wu JH. (1998). Actions of sodium fluoride on acetylcholinesterase activities in rats. Biomedical and Environmental Sciences.11: 1-6 Zhao LB, at al (1996). Effect of high -fluoride water supply on children's intelligence. Fluoride. 29: 190-192. Section 2- More Information, Quotes, Concerns, Summaries 50 Reasons to Oppose Fluoridation: Updated August, 2011 By Paul Connett, PhD and other members of the Fluoride Action Network (including James Beck, MD, PhD, Michael Connett, JD, Hardy Limeback, DDS, PhD, David McRae and Spedding Micklem, D.Phil.) Introduction Fluoridation is the practice of adding a fluoride compound to the public drinking water supply ostensibly for the purpose of fighting tooth decay. The levels used range from 0.6 to 1.2 milligrams of fluoride ion per liter (or parts per million, ppm). The practice began in the U.S. in 1945 and was endorsed by the U.S. Public Health Service (PHS) in 1950. Very few countries have adopted this practice to any significant extent. Only eight countries in the world have more than 50% of their populations drinking artificially fluoridated water (Australia, Colombia, Ireland, Israel, Malaysia, New Zealand, Singapore, and the U.S.). In Europe, only Ireland (with 73% of the population fluoridated), the U.K. (10%) and Spain (10%) fluoridate some of their water supplies. In the U.S., about 70% of the population is drinking fluoridated water — that is approximately 200 million people and about half the number of people drinking artificially fluoridated water worldwide. Some countries have areas with high natural fluoride levels in the water. These include India, China and parts of Africa. In these countries measures are being taken to remove the fluoride because of the health problems that fluoride can cause. Fluoridation is a bad medical practice 1. Fluoride is the only chemical added to water for the purpose of medical treatment. The U.S. Food and Drug Administration (FDA) classifies fluoride as a drug when used to prevent or mitigate disease (FDA 2000). As a matter of basic logic, adding fluoride to water for the sole purpose of preventing tooth decay (a non -waterborne disease) is a form of medical treatment. All other water treatment chemicals are added to improve the water's quality or safety, which fluoride does not do. 2. Fluoridation is unethical. Informed consent is standard practice for all medication, and one of the key reasons why most of Western Europe has ruled against fluoridation. With water fluoridation we are allowing: governments to do to -low-Li vyliak mumuum uoctors cannot ao to individual patients. While referenda are preferential to imposed policies from government, it still leaves the problem of individual rights versus majority rule. Put another way: Does a voter have the right to require that their neighbor ingest a certain medication (even if it is against that neighbor's will)? 3. The dose cannot be controlled. Once fluoride is put in the water it is impossible to control the dose each individual receives because people drink different amounts of water. Being able to control the dose a patient receives is critical. Some people (e.g., manual laborers, athletes, diabetics, and people with kidney disease) drink substantially more water than others. 4. The fluoride goes to everyone regardless of age, health or vulnerability. According to Dr. Arvid Carlsson, the 2000 Nobel Laureate in Medicine and Physiology and one of the scientists who helped keep fluoridation out of Sweden: "Water fluoridation goes against leading principles of pharmacotherapy, which is progressing from a stereotyped medication -- of the type 1 tablet 3 times a day -- to a much more individualized therapy as regards both dosage and selection of drugs. The addition of drugs to the drinking water means exactly the opposite of an individualized therapy" (Carlsson 1978). 5. People now receive fluoride from many other sources besides water. Fluoridated water is not the only way people are exposed to fluoride. Other sources of fluoride include food and beverages processed with fluoridated water (Kiritsy 1996; Heilman 1999), fluoridated dental products (Bentley 1999; Levy 1999), mechanically deboned meat (Fein 2001), tea (Levy 1999), and pesticide residues (e.g., from cryolite) on food (Stannard 1991; Burgstahler 1997). It is now widely acknowledged that exposure to non -water sources of fluoride has significantly increased since the water fluoridation program first began (NRC 2006). 6. Fluoride is not an essential nutrient (National Research Council [NRC] 1993; Institute of Medicine [IOM] 1997, NRC 2006). No disease has ever been linked to a fluoride deficiency. It has never been shown that ingested fluoride is needed to produce decay -free teeth. Not a single biological process has been shown to require fluoride. On the contrary there is extensive evidence that fluoride can interfere with many important biological processes. Fluoride interferes with numerous enzymes (Waldbott 1978). In combination with aluminum, fluoride interferes with G-proteins (Bigay 1985, 1987). Such interactions give aluminum - fluoride complexes the potential to interfere with signals from growth factors, hormones and neurotransmitters (Strunecka & Patocka 1999; Li 2003). More and more studies are indicating that fluoride can interfere with biochemistry in fundamental ways (Barbier 2010). 7. The level in mothers' milk is very low. Considering reason #6 it is perhaps not surprising that the level of fluoride in mother's milk is remarkably low (0.004 ppm, NRC, 2006). This means that a bottle-fed baby consuming fluoridated water (0.6 — 1.2 ppm) can get up to 300 times more fluoride than a breast-fed baby. There are no benefits (see reasons #11-19), only risks (see reasons #21-36), for infants ingesting this heightened level of fluoride at such an early age (an age where susceptibility to environmental toxins is particularly high). 8. Fluoride accumulates in the body. Healthy adult kidneys excrete 50 to 60% of the fluoride they ingest each day (Marier & Rose 1971). The remainder accumulates in the body, largely in calcifying tissues such as the bones and pineal gland (Luke 1997, 2001). Infants and children excrete less fluoride from their kidneys and take up to 80% of ingested fluoride into their bones (Ekstrand 1994). The fluoride concentration in bone steadily increases over a lifetime (NRC 2006). 9. No health agency in fluoridated countries is monitoring fluoride exposure or side effects. No regular measurements are being made of the levels of fluoride in urine, blood, bones, hair, or nails of either the general population or sensitive subparts of the population (e.g., individuals with kidney disease). 10. There has never been a single randomized clinical trial to demonstrate fluoridation's effectiveness or safety. Despite the fact that fluoride has been added to community water supplies for over 60 years, "there have been no randomized trials of water fluoridation" (Chang 2007). Randomized studies are the standard method for determining the safety and effectiveness of any purportedly beneficial medical treatment. In 2000, the British Government's "York Review" could not give a single fluoridation trial a Grade A classification — despite 50 years of research (McDonagh 2000). The U.S. Food and Drug Administration (FDA) continues to classify fluoride as an "unapproved new drug." Swallowing fluoride provides no (or very little) benefit 11. Benefit is topical not systemic. The Centers for Disease Control and Prevention (CDC, 1999, 2001) has now acknowledged that the mechanism of fluoride's benefits are mainly topical, not systemic. There is no need whatsoever, therefore, to swallow fluoride to protect teeth. Since the purported benefit of fluoride is topical, and the risks are systemic, it makes more sense to deliver the fluoride directly to the tooth in the form of toothpaste. Since swallowing fluoride is unnecessary, and potentially dangerous, there is no justification for forcing people (against their will) to ingest fluoride through their water supply. 12. Fluoridation is not necessary. Most western, industrialized countries have rejected water fluoridation, but have nevertheless experienced the same decline in childhood dental decay as fluoridated countries. (See data from World Health Organization presented graphically in Figure 1). Figure 1. Tooth Decay Trends: Fluoridated vs. Unfluorldated Countries nt uo-I 1. ul>"aLAI111 (Alf dnra bmn Waid Hooflh Orponimtionl -0-Ao Jnj "NOwm -♦-Dannnuti .05 1 rnbn — 11.laua a—U A. 1111111, Year 13. Fluoridation's role in the decline of tooth decay is in serious doubt. The largest survey ever conducted in the US (over 39,000 children from 84 communities) by the National Institute of Dental Research showed little difference in tooth decay among children in fluoridated and non -fluoridated communities (Hileman 1989). According to NOR researchers, the study found an average difference of only 0.6 DMFS (Decayed, Missing, and Filled Surfaces) in the permanent teeth of children aged 5-17 residing their entire lives in either fluoridated or unfluoridated areas (Brunelle & Carlos, 1990). This difference is less than one tooth surface, and less than 1 % of the 100+ tooth surfaces available in a child's mouth. Large surveys from three Australian states have found even less of a benefit, with decay reductions ranging from 0 to 0.3 of one permanent tooth surface (Spencer 1996; Armfield & Spencer 2004). None of these studies have allowed for the possible delayed eruption of the teeth that may be caused by exposure to fluoride, for which there is some evidence (Komarek 2005). A one-year delay in eruption of the permanent teeth would eliminate the very small benefit recorded in these modern studies. 14. NIH-funded study on individual fluoride ingestion and tooth decay failed to find a significant correlation. A multi -million dollar, U.S. National Institutes of Health (NIH) -funded study (Warren 2009) found no relation between tooth decay and the amount of fluoride ingested by children. This is the first time that tooth decay has been investigated as a function of individual exposure as opposed to mere residence in a fluoridated community. 15. Tooth decay is high in low-income communities that have been fluoridated for years. Despite some claims to the contrary, water fluoridation cannot prevent the oral health crises that result from rampant poverty, inadequate nutrition, and lack of access to dental care. There have been numerous reports of severe dental crises in low-income neighborhoods of US cities that have been fluoridated for over 20 years (e.g., Boston, Cincinnati, New York City, and Pittsburgh). In addition, fluoridation has been repeatedly found to be ineffective at preventing the most serious oral health problem facing poor children, namely "baby bottle tooth decay," otherwise known as early childhood caries (Barnes 1992; Shiboski 2003). 16. Tooth decay does not go up when fluoridation`' is stopped. Where fluoridation has been discontinued in communities from Canada, the former East Germany, Cuba and Finland, dental decay has not increased but has generally continued to decrease (Maupome 2001; Kunzei & Fischer, 1997, 2000; Kunze) 2000; Seppa 2000). 17. Tooth decay was coming down before fluoridation started. Modern research (e.g., Diesendorf 1986; Colquhoun 1997) shows that decay rates were coming down before fluoridation was introduced in Australia and New Zealand and have O J_ S U ce w CL X W w w e W Q U W 0 LL 0 W w CO z 10 8 6 4 0 continued to decline even after its benefits would have been maximized (see Figure 2). Many other factors influence tooth decay. 1930 1940 1950 1960 1970 1980 1990 100 Z O OJ �Q Oy LLw wO z~� W 0 WO° LLJ aka a0 LL IL LL 0 0 Figure 2. The number of decayed teeth in 5-year olds in New Zealand, over the period 1930-1990. The percentage of the population drinking fluoridated water and the percentage of the total toothpaste sold containing fluoride are shown on the right hand axis (Colquhoun, 1993). 18. The studies ;that launched fluoridation were methodologically flawed. The early trials conducted between 1945 and 1955 in North America that helped to launch fluoridation, have been heavily criticized for their poor methodology and poor choice of control communities (De Stefano 1954; Sutton 1959, 1960, 1996; Ziegelbecker 1970). According to Dr. Hubert Arnold, a statistician from the University of California at Davis, the early fluoridation trials "are especially rich in fallacies, improper design, invalid use of statistical methods, omissions of contrary data, and just plain muddleheaded ness and hebetude." Serious questions have also been raised about Trendley Dean's (the father of fluoridation) famous 21-city study from 1942 (Ziegelbecker 1981). Children are being over -exposed to fluoride 19. Children are being over -exposed to fluoride. The fluoridation program has massively failed to achieve one of its key objectives, i.e., to lower dental decay rates while limiting the occurrence of dental fluorosis (a discoloring of tooth enamel caused by too much fluoride. The goal of the early promoters of fluoridation was to limit dental fluorosis (in its very mild form) to 10% of children (NRC 1993, pp. 6-7). In 2010, however, the Centers for Disease Control and Prevention (CDC) reported that 41 % of American adolescents had dental fluorosis, with 8.6% having mild fluorosis and 3.6% having either moderate or severe dental fluorosis (Beltran -Aguilar 2010). As the 41 % prevalence figure is a national average and includes children living in fluoridated and unfluoridated areas, the fluorosis rate in fluoridated communities will obviously be higher. The British Government's York Review estimated that up to 48% of children in fluoridated areas worldwide have dental fluorosis in all forms, with 12.5% having fluorosis of aesthetic concern (McDonagh, 2000). 20. The highest doses of fluoride are going to bottle-fed babies. Because of their sole reliance on liquids for their food intake, infants consuming formula made with fluoridated water have the highest exposure to fluoride, by bodyweight, in the population. Because infant exposure to fluoridated water has been repeatedly found to be a major risk factor for developing dental fluorosis later in life (Marshall 2004; Hong 2006; Levy 2010), a number of dental researchers have recommended that parents of newborns not use fluoridated water when reconstituting formula (Ekstrand 1996; Pendrys 1998; Fomon 2000; Brothwell 2003; Marshall 2004). Even the American Dental Association (ADA), the most ardent institutional proponent of fluoridation, distributed a November 6, 2006 email alert to its members recommending that parents be advised that formula should be made with "low or no -fluoride water." Unfortunately, the ADA has done little to get this information into the hands of parents. As a result, many parents remain unaware of the fluorosis risk from infant exposure to fluoridated water. Evidence of harm to other tissues 21. Dental fluorosis may be an indicator of wider systemic damage. There have been many suggestions as to the possible biochemical mechanisms underlying the development of dental fluorosis (Matsuo 1998; Den Besten 1999; Sharma 2008; Duan 2011; Tye 2011) and they are complicated for a lay reader. While promoters of fluoridation are content to dismiss dental fluorosis (in its milder forms) as merely a cosmetic effect, it is rash to assume that fluoride is not impacting other developing tissues when it is visibly damaging the teeth by some biochemical mechanism (Groth 1973; Colquhoun 1997). Moreover, ingested fluoride can only cause dental fluorosis during the period before the permanent teeth have erupted (6-8 years), other tissues are potentially susceptible to damage throughout life. For example, in areas of naturally high levels of fluoride the first indicator of harm is dental fluorosis in children. In the same communities many older people develop skeletal fluorosis. 22. Fluoride may damage the brain. According to the National Research Council (2006) "it i.q annarant }hat flunrirJee haGn iL.e :.M:G6, a..:..a�.r_-_ .. aa� .�_ e__` .• of the brain." In a review of the literature commissioned by the US Environmental Protection Agency (EPA), fluoride has been listed among about 100 chemicals for which there is "substantial' evidence of developmental neurotoxicity." Animal experiments show that fluoride accumulates in the brain and alters mental behavior in a manner consistent with a neurotoxic agent (Muilenix 1995). In total, there have now been over 100 animal 'experiments showing that fluoride can damage the brain and impact learning :and behavior. According to fluoridation proponents, these animal studies can be ignored because high doses were used. However, it is important to note that it takes 5-20 times more fluoride to reach the same plasma levels in rats as reached in humans (Sawan 2010). In fact, one animal experiment found effects at remarkably low doses (Varner 1998). In this study, rats fed for one year with 1 ppm fluoride in their water (the same level used in fluoridation programs), using either sodium fluoride or aluminum fluoride, had morphological changes to their kidneys and brains, an increased uptake of aluminum in the brain, and the formation of beta-amyloid deposits which are associated with Alzheimer's disease. Other animal studies have found effects on the brain at water fluoride levels as low as 5 ppm (Liu 2010).(For a complete listing of these studies. 23. Fluoride may lower IQ. There have now been 24 studies from China, Iran, India - - reduced IQ. One of these studies (Lin Fa-Fu 1991) indicates that even_ j_us.._t moderate levels of fluoride exposure (e.g., 0.9 ppm in the water) can exacerbate the neurological defects of iodine deficiency. In the absence of iodine deficiency, another research team (Xiang 2003a,b) estimated that fluoride may lower IQ at 1.9 ppm, while a recent preliminary study (Ding 2011) found a lowering of IQ in children drinking water at levels ranging from 0.3 to 3 ppm. The authors of this latter study reported that for each increase of 1 ppm fluoride measured in the urine there was a loss of 0.59 IQ points. None of these studies indicates an adequate margin of safety to protect all children drinking artificially fluoridated water from this affect. According to the National Research Council (2006), "the consistency of the results [in fluoride/IQ studies] appears significant enough to warrant additional research on the effects of fluoride on intelligence." Except for an early and small IQ study from New Zealand (Shannon et al., 1986) no fluoridating country has investigated the matter for themselves. 24. Fluoride may cause non -IQ neurotoxic effects. Reduced IQ is not the only neurotoxic effect that may result from fluoride exposure. At least three human studies have reported an association between fluoride exposure and impaired visual -spatial organization (Calderon 2000; Li 2004; Rocha-Amador 2009); while three other studies have found an association between prenatal fluoride exposure and fetal brain damage (Han 1989; Du 1992; Yu 1996). 25. Fluoride affects the pineal gland. Studies by Jennifer Luke (2001) show that fluoride accumulates in the human pineal gland to very high levels. In her Ph.D. thesis, Luke has also shown in animal studies that fluoride reduces melatonin production and leads to an earlier onset of puberty (Luke 1997). Consistent with Luke's findings, one of the earliest fluoridation trials in the U.S. (Schlesinger 1956) reported that on average young girls in the fluoridated community reached menstruation 5 months earlier than girls in the non -fluoridated community. Inexplicably, no fluoridating country has attempted to reproduce either Luke's or Schlesinger's findings or examine the issue any further. 26. Fluoride affects thyroid function. According to the U.S. National Research Council (2006), "several lines of information indicate an effect of fluoride exposure on thyroid function." In the Ukraine, Bachinskii (1985) found a lowering of thyroid function, among otherwise healthy people, at 2.3 ppm fluoride in water. In the middle of the 20th century, fluoride was prescribed by a number of European doctors to reduce the activity of the thyroid gland for those suffering from hyperthyroidism (overactive thyroid) (Stecher 1960; Waldbott 1978). According to a clinical study by Galletti and Joyet (1958), the thyroid function of hyperthyroid patients was effectively reduced at just 2.3 to 4.5 mg/day of fluoride ion. To put this finding in perspective, the Department of Health and Human Services (DHHS, 1991) has estimated that total fluoride exposure in fluoridated communities ranges from 1.6 to 6.6 mg/day. This is a remarkable fact, particularly considering the rampant and increasing problem of hypothyroidism (underactive thyroid) in the United States and other fluoridated countries. Symptoms of hypothyroidism include depression, fatigue, weight gain, muscle and joint pains, increased cholesterol levels, and heart disease. In 2010, the second most prescribed drug of the year was Synthroid (sodium levothyroxine) which is a hormone replacement drug used to treat an underactive thyroid. 27. Fluoride causes arthritic symptoms. Some of the early symptoms of skeletal fluorosis (a fluoride -induced bone and joint disease that impacts millions of people in India, China, and Africa), mimic the symptoms of arthritis (Singh 1963; Franke 1975; Teotia 1976; Carnow 1981; Czerwinski 1988; DHHS 1991). According to a review on fluoridation published in Chemical & Engineering News, "Because some of the clinical symptoms mimic arthritis, the first two clinical phases of skeletal fluorosis could be easily misdiagnosed" (Hileman 1988). Few, if any, studies have been done to determine the extent of this misdiagnosis, and whether the high prevalence of arthritis in America (1 in 3 Americans have some form of arthritis - CDC, 2002) and other fluoridated countries is related to growing fluoride exposure, which is highly plausible. Even when individuals in the U.S. suffer advanced forms of skeletal fluorosis (from drinking large amounts of tea), it has taken years of misdiagnoses before doctors finally correctly diagnosed the condition as fluorosis. 28. Fluoride damages bone. An early fluoridation trial (Newburgh -Kingston 1945- 55) found a significant two -fold increase in cortical bone defects among children in the fluoridated community (Schlesinger 1956). The cortical bone is the outside layer of the bone and is important to protect against fracture. While this result was not considered important at the time with respect to bone fractures, it did prompt questions about a possible link to osteosarcoma (Caffey, 1955; NAS, 1977). In 2001, Alarcon -Herrera and co-workers reported a linear correlation between the severity of dental fluorosis and the frequency of bone fractures in both children and adults in a high fluoride area in Mexico. 29. Fluoride may increase hip fractures in the elderly. When high doses of fluoride (average 26 mg per day) were used in trials to treat patients with osteoporosis in an effort to harden their bones and reduce fracture rates, it actually led to a higher number of fractures, particularly hip fractures (Inkovaara 1975; Gerster 1983; Dambacher 1986; O'Duffy 1986; Hedlund 1989; Bayley 1990; Gutteridge 1990. 2002; Orcel 1990; Riggs 1990 and Schnitzler 1990). Hip fracture is a very serious issue for the elderly, often leading to a loss of independence or a shortened life. There have been over a dozen studies published since 1990 that have investigated a possible relationship between hip fractures and long term consumption of artificially fluoridated water or water with high natural levels. The results have been mixed — some have found an association and others have not. Some have even claimed a protective effect. One very important study in China, which examined hip fractures in six Chinese villages, found what appears to be a dose -related increase in hip fracture as the concentration of fluoride rose from 1 ppm to 8 ppm (Li 2001) offering little comfort to those who drink a lot of fluoridated water. Moreover, in the only human epidemiological study to assess bone strength as a function of bone fluoride concentration, researchers from the University of Toronto found that (as with animal studies) the strength of bone declined with increasing fluoride content (Chachra 2010). Finally, a recent study from Iowa (Levy 2009), published data suggesting that low-level fluoride exposure may have a detrimental effect on cortical bone density in girls (an effect that has been repeatedly documented in clinical trials and which has been posited as an important mechanism by which fluoride may increase bone fracture rates). 30. People with impaired kidney function are particularly vulnerable to bone damage. Because of their inability to effectively excrete fluoride, people with kidney disease are prone to accumulating high levels of fluoride in their bone and blood. As a result of this high fluoride body burden, kidney patients have an elevated risk for developing skeletal fluorosis. In one of the few U.S. studies investigating the matter, crippling skeletal fluorosis was documented among patients with severe kidney disease drinking water with just 1.7 ppm fluoride (Johnson 1979). Since severe skeletal fluorosis in kidney patients has been detected in small case studies, it is likely that larger, systematic studies would detect skeletal fluorosis at even lower fluoride levels. 31. Fluoride may cause bone cancer (osteosarcoma). A U.S. government -funded animal study found a dose -dependent increase in bone cancer (osteosarcoma) in fluoride -treated, male rats (NTP 1990). Following the results of this study, the National Cancer Institute (NCI) reviewed national cancer data in the U.S. and found a significantly higher rate of osteosarcoma (a bone cancer) in young men in fluoridated versus unfluoridated areas (Hoover et al 1991a). While the NCI concluded (based on an analysis lacking statistical power) that fluoridation was not the cause (Hoover et al 1991 b), no explanation was provided to explain the higher rates in the fluoridated areas. A smaller study from New Jersey (Cohn 1992) found osteosarcoma rates to be up to 6 times higher in young men living in fluoridated versus unfluoridated areas. Other epidemiological studies of varying size and quality have failed to find this relationship (a summary of these can be found in Bassin, 2001 and Connett & Neurath, 2005). There are three reasons why a fluoride-osteosarcoma connection is plausible: First, fluoride accumulates to a high level in bone. Second, fluoride stimulates bone growth. And, third, fluoride can interfere with the genetic apparatus of bone cells in several ways; it has been shown to be mutagenic, cause chromosome damage, and interfere with the enzymes involved with DNA repair in both cell and tissue studies (Tsutsui 1984; Caspary 1987; Kishi 1993; Mihashi 1996; Zhang 2009). In addition to cell and tissue studies, a correlation between fluoride exposure and chromosome damage in humans has also been reported (Sheth 1994; Wu 1995; Meng 1997; Joseph 2000). 32.Proponents have failed to refute the Bass in-Osteosarcoma study. In 2001, Elise Bassin, a dentist, successfully defended her doctoral thesis at Harvard in which she found that young boys had a five -to -seven fold increased risk of getting osteosarcoma by the age of 20 if they drank fluoridated water during their mid -childhood growth spurt (age 6 to 8). The study was published in 2006 (Bassin 2006) but has been largely discounted by fluoridating countries because her thesis adviser Professor Chester Douglass (a promoter of fluoridation and a consultant for Colgate) promised a larger study that he claimed would discount her thesis (Douglass and Joshipura, 2006). Now, after 5 years of waiting the Douglass study has finally been published (Kim 2011) but in no way does this study discount Bassin's findings. The study, which used far fewer controls than Bassin's analysis, did not even attempt to assess the age -specific window of risk that Bassin identified. Indeed, by the authors' own admission, the study had no capacity to assess the risk of osteosarcoma among children and adolescents (the precise population of concern). For a critique of the Douglass study, click here. 33.Fluoride may cause reproductive problems. Fluoride administered to animals at high doses wreaks havoc on the male reproductive system - it damages sperm and increases the rate of infertility in a number of different species (Kour 1980; Chinoy 1989; Chinoy 1991; Susheela 1991; Chinoy 1994; Kumar 1994; Narayana 1994a,b; Zhao 1995; Elbetieha 2000; Ghosh 2002; Zakrzewska 2002). In addition, an epidemiological study from the US found increased rates of infertility among couples living in areas with 3 ppm or more fluoride in the water (Freni 1994), two studies have found reduced level of circulating testosterone in males living in high fluoride areas (Susheela 1996; Barot 1998), and a study of fluoride -exposed workers reported a "subclinical reproductive effect" (Ortiz -Perez 2003). While animal studies by FDA researchers have failed to find evidence of reproductive toxicity in fluoride -exposed rats (Sprando 1996, 1997, 1998), the National Research Council (2006) has recommended that, "the relationship between fluoride and fertility requires additional study." 34. Some individuals are highly sensitive to low levels of fluoride as shown by case studies and double blind studies (Shea 1967; Waldbott 1978; Moolenburgh 1987). In one study, which lasted 13 years, Feltman and Kosel (1961) showed that about 1 % of patients given 1 mg of fluoride each day developed negative reactions. Many individuals have reported suffering from symptoms such as fatigue, headaches, rashes and stomach and gastro intestinal tract problems, which disappear when they avoid fluoride in their water and diet. Frequently the symptoms reappear when they are unwittingly exposed to fluoride again (Spittle, 2008). No fluoridating government has conducted scientific studies to take this issue beyond these anecdotal reports. Without the willingness of governments to investigate these reports scientifically, should we as a society be forcing these people to ingest fluoride? 35. Other subsets of population are more vulnerable to fluoride's toxicity. In addition to people suffering from impaired kidney function discussed in reason #30 other subsets of the population are more vulnerable.to fluoride's toxic effects. According to the Agency for Toxic Substances and Disease Registry (ATSDR 1993) these include: infants, the elderly and diabetics. Also vulnerable are those who suffer from malnutrition (e.g., calcium, magnesium, vitamin C, vitamin D and iodine deficiencies and protein -poor diets. See: Massler & Schour 1952; Marier & Rose 1977; Lin Fa-Fu 1991; Chen 1997; Teotia 1998). No Margin of Safety 36. There is no margin of safety for several health effects. No one can deny that high natural levels of fluoride damage health. Millions of people in India and China have had their health compromised by fluoride. The real argument is about whether there is an adequate margin of safety between the doses that have been shown to cause harm in published studies and the total dose people receive consuming uncontrolled amounts of fluoridated water and non -water sources of fluoride. This margin of safety has to take into account the wide range of individual sensitivity expected in a large population (a safety factor of 10 is usually applied to the lowest level causing harm). Another safety factor is also needed to take into account the wide range of doses to which people are exposed. There is clearly no margin of safety for dental fluorosis (CDC, 2010) and based on the following studies nowhere near an adequate margin of safety for lowered IQ (Xiang 2003a,b; Ding 2011); lowered thyroid function (Galletti & Joyet 1958; Bachinskii 1985; Lin 1991); bone fractures in children (Alarcon - Herrera 2001) or hip fractures in the elderly (Kurttio 1999; Li 2001). All these harmful effects are discussed in the NRC (2006) review. Environmental Justice 37. Low-income families penalized by fluoridation. Those most likely to suffer from poor nutrition, and thus more likely to be more vulnerable to fluoride's toxic effects, are the poor, who unfortunately, are the very people being targeted by new fluoridation programs. While at heightened risk, poor families are least able to afford avoiding fluoride once it is added to the water supply. No financial support is being offered to these families to help them get alternative water supplies or to help pay the costs of treating unsightly cases of dental fluorosis. 38. Black and Hispanic children are more vulnerable to fluoride's toxicity. According to the CDC's national survey of dental fluorosis, black and Mexican -American children have significantly higher rates of dental fluorosis than white children (Beltran -Aguilar 2005, Table 23). The recognition that minority children appear to be more vulnerable to toxic effects of fluoride, combined with the fact that low-income families are less able to avoid drinking fluoridated water, has prompted prominent leaders in the environmental justice movement to oppose mandatory fluoridation in Georgia. In a statement issued in May 2011, the Rev. Andrew Young, a colleague of Martin Luther King, Jr., and former Mayor of Atlanta and former US Ambassador to the United Nations, stated: "I am most deeply concerned for poor families who have babies: if they cannot afford unfluoridated water for their babies' milk formula, do their babies not count? Of course they do. This is an issue of fairness, civil rights, and compassion. We must find better ways to prevent cavities, such as helping those most at risk for cavities obtain access to the services of a dentist... My father was a dentist. I formerly was a strong believer in the benefits of water fluoridation for preventing cavities. But many things that we began to do 50 or more years ago we now no longer do, because we have learned further information that changes our practices and policies. So it is with fluoridation." (see: http://www2.fluoridealert.org/Alert/United-States/Georgia/Atlanta- Civil-Rights-Leaders-Callfor- Halt -to -Water -Fluoridation) 39. Minorities are not being warned about their vulnerabilities to fluoride. The CDC is not warning black and Mexican -American children that they have higher rates of dental fluorosis than Caucasian children (see #38). This extra vulnerability may extend to other toxic effects of fluoride. Black Americans have higher rates of lactose intolerance, kidney problems and diabetes, all of which may exacerbate fluoride's toxicity. 40. Tooth'decay reflects low-income not low -fluoride intake. Since dental decay is most concentrated in poor communities, we should be spending our efforts trying to increase the access to dental care for low-income families. The highest rates of tooth decay today can be found in low-income areas that have been fluoridated for many years. The real "Oral Health Crisis" that exists today in the United States, is not a lack of fluoride but poverty and lack of dental insurance. The Surgeon General has estimated that 80% of dentists in the US do not treat children on Medicaid. The largely untested chemicals used in fluoridation programs 41. The chemicals used to fluoridate water are not pharmaceutical grade. Instead, they largely come from the wet scrubbing systems of the phosphate fertilizer industry. These chemicals (90% of which are sodium fluorosilicate and fluorosilicic acid), are classified hazardous wastes contaminated with various impurities. Recent testing by the National Sanitation Foundation suggest that the levels of arsenic in these silicon fluorides are relatively high (up to 1.6 ppb after dilution into public water) and of potential concern (NSF 2000 and Wang 2000). Arsenic is a known human carcinogen for which there is no safe level. This one contaminant alone could be increasing cancer rates — and unnecessarily so. 42.The silicon fluorides have not been tested comprehensively. The chemical usually tested in animal studies is pharmaceutical grade sodium fluoride, not industrial grade fluorosilicic acid. Proponents claim that once the silicon fluorides have been diluted at the public water works they are completely dissociated to free fluoride ions and hydrated silica and thus there is no need to examine the toxicology of these compounds. However, while a study from the University of Michigan (Finney et al., 2006) showed complete dissociation at neutral pH, in acidic conditions (pH 3) there was a stable complex containing five fluoride ions. Thus the possibility arises that such a complex may be regenerated in the stomach where the pH lies between 1 and 2. 43.The silicon fluorides may increase lead uptake into children's blood. Studies by Masters and Coplan 1999, 2000, 2007 show an association between the use of fluorosilicic acid (and its sodium salt) to fluoridate water and an increased uptake of lead into children's blood. Because of lead's acknowledged ability to damage the developing brain, this is a very serious finding. Nevertheless, it is being largely ignored by fluoridating countries. This association received some strong biochemical support from an animal study by Sawan et al. (2010) who found that exposure of rats to a combination of fluorosilicic acid and lead in their drinking water increased the uptake of lead into blood some threefold over exposure to lead alone. 44. Fluoride may leach lead from pipes, brass fittings and soldered joints. Maas et al (2007) have shown that fluoridating agents in combination with chlorinating agents such as chloroamine increase the leaching of lead from brass fittings used in plumbing. While proponents may argue about the neurotoxic effects of low levels of fluoride there is no argument that lead at very low levels lowers IQ in children. Continued promotion of fluoridation is unscientific 45. Key health studies have not been done. In the January 2008 issue of Scientific American, Professor John Doull, the chairman of the important 2006 National Research Council review, Fluoride in Drinking Water: A Review of EPA's Standards, is quoted as saying: What the committee found is that we've gone with the status quo regarding fluoride for many years —for too long really —and now we need to take a fresh look ... In the scientific community people tend to think this is settled. I mean, when the U.S. surgeon general comes out and says this is one of the top 10 greatest achievements of the 20th century, that's a hard hurdle to get over. But when we looked at the studies that have been done, we found that many of these questions are unsettled and we have much less information than we should, considering how long this [fluoridation] has been going on. The absence of studies is being used by promoters as meaning the absence of harm. This is an irresponsible position. 46. Endorsements do not represent scientific evidence. Many of those promoting fluoridation rely heavily on a list of endorsements. However, the U.S. PHS first endorsed fluoridation in 1950, before one single trial had been completed and before any significant health studies had been published (see chapters 9 and 10 in The Case Against Fluoride for the significance of this PHS endorsement for the future promotion of fluoridation). Many other endorsements swiftly followed with little evidence of any scientific rational for doing so. The continued use of these endorsements has more to do with political science than medical science. 47. Review panels hand-picked to deliver a pro -fluoridation result. Every so often, particularly when their fluoridation program is under threat, governments of fluoridating countries hand-pick panels to deliver reports that provide the necessary re -endorsement of the practice. In their recent book Fluoride Wars (2009), which is otherwise slanted toward fluoridation, Alan Freeze and Jay Lehr concede this point when they write: There is one anti-fluoridationist charge that does have some truth to it. Anti -fluoride forces have always claimed that the many government - sponsored review panels set up over the years to assess the costs and benefits of fluoridation were stacked in favor of fluoridation. A review of the membership of the various panels confirms this charge. The expert committees that put together reports by the American Association for the Advancement of Science in 1941, 1944 and 1954; the National Academy of Sciences in 1951, 1971, 1977 and 1993; the World Health Organization in 1958 and 1970; and the U.S. Public Health Service in 1991 are rife with the names of well-known medical and dental researchers who actively campaigned on behalf of fluoridation or whose research was held in high regard in the pro -fluoridation movement. Membership was interlocking and incestuous. The most recent examples of these self-fulfilling prophecies have come from the Irish Fluoridation Forum (2002); the National Health and Medical Research Council (NHMRC, 2007) and Health Canada (2008, 2010). The latter used a panel of six experts to review the health literature. Four of the six were pro - fluoridation dentists and the other two had no demonstrated expertise on fluoride. A notable exception to this trend was the appointment by the U.S. National Research Council of the first balanced panel of experts ever selected to look at fluoride's toxicity in the U.S. This panel of twelve reviewed the US EPA's safe drinking water standards for fluoride. After three and half years the panel concluded in a 507- page report that the safe drinking water standard was not protective of health and a new maximum contaminant level goal (MCLG) should be determined (NRC, 2006). If normal toxicological procedures and appropriate margins of safety were applied to their findings this report should spell an end to water fluoridation. Unfortunately in January of 2011 the US EPA Office of Water made it clear that they would not determine a value for the MCLG that would jeopardize the water fluoridation program (EPA press release, Jan 7, 2011. Once again politics was allowed to trump science. More and more independent scientists oppose fluoridation 48. Many; scientists oppose 'fluoridation. Proponents of fluoridation have maintained for many years— despite the fact that the earliest opponents of fluoridation were biochemists —that the only people opposed to fluoridation are not bona fide scientists. Today, as more and more scientists, doctors, dentists and other professionals, read the primary literature for themselves, rather than relying on self-serving statements from the ADA and the CDC, they are realizing that they and the general public have not been diligently informed by their professional bodies on this subject. As of July 2011, over 3700 professionals have signed a statement calling for an end to water fluoridation worldwide. This statement and a list of signatories can be found on the website of the Fluoride Action Network (see: www.FluorideAlert.org). A glimpse of the caliber of those opposing fluoridation can be gleaned by watching the 28-minute video "Professional Perspectives on Water fluoridation" which can be viewed online at the same FAN site. Proponents' dubious tactics 49. Proponents usually refuse to defend fluoridation in open debate. While pro - fluoridation officials continue to promote fluoridation with undiminished fervor, they usually refuse to defend the practice in open public debate — even when challenged to do so by organizations such as the Association for Science in the Public Interest, the American College of Toxicology, or the U.S. EPA (Bryson 2004). According to Dr. Michael Easley, a prominent lobbyist for fluoridation in the US, "Debates give the illusion that a scientific controversy exists when no credible people support the fluorophobics' view" (Easley, 1999). In light of proponents' refusal to debate this issue, Dr. Edward Groth, a Senior Scientist at Consumers Union, observed that, "the political profluoridation stance has evolved into a dogmatic, authoritarian, essentially antiscientific posture, one that discourages open debate of scientific issues" (Martin 1991). 50. Proponents use very dubious tactics to promotefluoridation. Many scientists, doctors and dentists who have spoken out publicly on this issue have been subjected to censorship and intimidation (Martin 1991). Dr. Phyllis Mullenix was fired from her position as Chair of Toxicology at Forsythe Dental Center for publishing her findings on fluoride and the brain (Mullenix 1995); and Dr. William Marcus was fired from the EPA for questioning the government's handling of the NTP's fluoride -cancer study (Bryson 2004). Many dentists and even doctors tell opponents in private that they are opposed to this practice but dare not speak out in public because of peer pressure and the fear of recriminations. Tactics like this would not be necessary if those promoting fluoridation were on secure scientific and ethical grounds. Conclusion: When it comes to controversies surrounding toxic chemicals, vested interests traditionally do their very best to discount animal studies and quibble with epidemiological findings. In the past, political pressures have led government agencies to drag their feet on regulating asbestos, benzene, DDT, PCBs, tetraethyl lead, tobacco and dioxins. With fluoridation we have had a sixty -year delay. Unfortunately, because government officials and dental leaders have put so much of their credibility on the line defending fluoridation, and because of the huge liabilities waiting in the wings if they admit that fluoridation has caused an increase in hip fracture, arthritis, bone cancer, brain disorders or thyroid problems, it will be very difficult for them to speak honestly and openly about the issue. But they must, not only to protect millions of people from unnecessary harm, but to protect the notion that, at its core, public health policy must be based on sound science not political expediency. They have a tool with which to do this: it's called the Precautionary Principle. Simply put, this says: if in doubt leave it out. This is what most European countries have done and their children's teeth have not suffered, while their public's trust has been strengthened. Just how much doubt is needed on just one of the health concerns identified above, to override a benefit, which when quantified in the largest survey ever conducted in the US, amounts to less than one tooth surface (out of 128) in a child's mouth? While fluoridation may not be the greatest environmental health threat, it is one of the easiest to end. It is as easy as turning off a spigot in the public water works. But to turn off that spigot takes political will and to get that we need masses more people informed and organized. Please get these 50 reasons to all your friends and encourage them to get fluoride out of their community and to help ban this practice worldwide. Postscript Further arguments against fluoridation, can be viewed at http://www.fluoridealert.org and in the book The Case Against Fluoridation (Chelsea Green, 2010). Arguments for fluoridation can be found at http://www.ada.org Publication history of the 50 Reasons These 50 Reasons were first compiled by Paul Connett and presented in person to the Fluoridation Forum in Ireland in October 2000. The document was refined in 2004 and published in Medical Veritas. See: http://www.fluoridealert.org/50reasons.htm In the introduction to this 2004 version it was explained that after over four years the Irish authorities had not been able to muster a response to the 50 Reasons, despite agreeing to do so in 2000. Eventually, an anonymous, incomplete and superficial response was posted on the Irish Department of Health and Children's website (see this response and addendum at:http://www.dohc.ie/other_health_issues/dental_ research/. Paul Connett's comprehensive response to this response can be accessed athttp://www.fluoridealert.org/50reasons.htm We learned on August 7, 2011 that this governmental response was prepared by an external contractor at a cost to the Irish taxpayers' of over 30,000 Euros. See: http://www.independent.ie/national- news/staggering-sums-spent-on-reportscommissioned- by-the-state- 2841922.html Since 2004, there have been many major scientific developments including the publication of the U.S. National Research Council report (NRC, 2006); the publication of Bassin's study on Osteosarcoma (Bassin 2006), and many more studies of fluoride's interaction with the brain, that have necessitated a major update of the 50 Reasons. This was compiled in August 2011. (See references at beginning of paper) -SECTION 2: More Information, Quotes, Concerns Summaries Included in this section: ■ Page 1: Quotes raising concern- (frightening, eye-opening) • Page 3-8: Fluoride & Your Body • Page 8: Key Findings - Fluoride & the Brain • Page 9: 10 Facts about Fluoride • Page 13: Key Findings- Water Fluoridation and Tooth Decay • Page 14: Recent Surveys of Water Fluoridation/Tooth Decay: ■ Page 17: Topical vs. Systemic • Page 21: One example of news article paraphrasing study • Page 23: Water Fluoridation: A Review of Recent Research and Actions, Joel M. Kauffman, Ph. D. QUOTES- FLUORIDE HEALTH EFFECTS DATABASE (Please notice source responsible for quote below each) "[T]he political profluoridation stance has evolved into a dogmatic, authoritarian, essentially antiscientific posture, one that discourages open debate of scientific issues." - Dr. Edward Groth, Senior Scientist, Consumers Union, 1991, "Journal editors often have refused for political reasons to publish information that raises questions about fluoridation." - Chemical & Engineering News, August 1, 1988. "We are left with compelling evidence that powerful interests with high financial stakes have colluded to prematurely close honest discussion and investigation into fluoride toxicity." - Dr. Sheldon Krimsky, Tufts University, August 16, 2004. "The Public Health Service, unfortunately, has locked itself into a position where it has made this statement on the record that there is absolutely no hazard to fluoridating public water supplies and the matter is closed. Now, that, of course, is immediately an unscientific approach." - Ralph Nader, Consumer Advocate, 1971. "Over the past ten years a large body of peer -reviewed science has raised concerns that fluoride may present unreasonable health risks, particularly among children, at levels routinely added to tap water in American cities." ENVIRONMENTAL WORKING GROUP, July 2005. "In summary, we hold that fluoridation is an unreasonable risk." US ENVIRONMENTAL PROTECTION AGENCY HEADQUARTERS' UNION, 2001. "Carefully conducted studies of exposure to fluoride and emerging health parameters of interest (e.g., endocrine effects and brain function) should be performed in populations in the United States exposed to various concentrations of fluoride." US NATIONAL RESEARCH COUNCIL, 2006 r "I am quite convinced that water fluoridation, in a not -too -distant future, will be consigned to medical history." Dr. ARVID CARLSSON, Pharmacologist, Nobel Laureate in Physiology and Medicine, 2000. "Children under three should never use fluoridated toothpaste. Or drink fluoridated water. And baby formula must never be made up using Toronto tap water. Never. In fluoridated areas, people should never use fluoride supplements. We tried to get them banned for children but (the dentists) wouldn't even look at the evidence we presented" - Dr. Hardy Limeback, biochemist and Professor of Dentistry, University of Toronto, former consultant to the Canadian Dental Association. "The level of fluoride the government allows the public is based on scientifically fraudulent information and altered reports. People can be harmed simply by drinking water." -Dr. Robert Carton, Ph.D, former Environmental Protection Agency Scientist (20 years), Food & Water Journal, Summer 1998 "Fluoride is a carcinogen by any standard we use. i believe EPA should act immediately to protect the public, not just on the cancer data, but on the evidence of bone fractures, arthritis, mutagenicity, and other effects." -Dr. William Marcus, Ph.D, Environmental Protection Agency Scientist, Food & Water Journal, Summer 1998 "Dental Fluorosis, no matter how slight is an irreversible pathological condition recognised by authorities around the world as the first readily detectable clinical symptom of previous chronic fluoride poisoning. To suggest we should ignore such a sign is as irrational as saying that the blue -black line which appears on the gums due to chronic lead poisoning is of no significance because it doesn't cause any pain or discomfort." -Dr. Geoffrey Smith, Dental Surgeon, New Scientist, May 5, 1983 We do know that the use of drinking water containing as little as 1.2 - 3.0 parts per million of fluorine will cause such developmental disturbances in bones as osteosclerosis, spondylosis and osteopetrosis, as well as goiter, and we cannot afford to run the risk of producing such serious systemic disturbances in applying what is at present a doubtful procedure intended to prevent development of dental disfigurements.... -Journal American Dental Association, October 1944, Editorial "As a toxicologist involved in fluoride research for over ten years, I was stunned by the Calgary Regional Health Authority's glib comments proclaiming water fluoridation safe. The 'fifty years' of studies about fluoride safety, do not exist. The "ongoing intensive m � W N N N NO W N 7 0 0 � y O O O✓Y O, 3^ G � R['' O x �y N^,1 E N W •S ly NI W N d�� dV 0 in � N w d d A � yl M N i`3 � dyy 'idl�3 as wG W 'dE A A o Gy o N w m N N O O H y H .t• � 1 O r M [L Np d y O U !dp�I p Z N 3 .yi O Sb n. ,fyry� O O N N Z d N W N N O O W N M P W GI N G ro 3 YA CC N � rYp 1 O d d1G � 0 O G H N 3 Y x w Y � � m � G H rd-I � µmj Y Z • yw1 � � Y N dpp .I d N P p � a a d S O U3E m � �y N N GATE VALVE WATER GLCr! '� WATER SOFTENER -r (OrnoNALI 6 rtaURt SOUIUM FLUO It IV INSTALLATION -SATURATOR I.,, FROM ELECTRICAL WIRING WELL PUMP SOLUTION FEEDER UNION v7ATER LIQUID METER LEVEL SATURATED SWITCH FLUORIDE SIPHON SOLUTION BREAKER TO POINT OF SHELF APPLICATION LT ✓� OVERFLOW ';t CONNECTION POWER'S SUPPLY i FLOATING STRAINER SATURATED FLUORIDE SOLUTION 13c:. .�:..•.• `.:,::..=�'rr:i: UPFLOW sC�s:;.,.i;•; . SATURATOR SODIUM FLUORIDE nhyr:<,. 1. SyG. DRAIN Y :: PLUG - 7 - CAPITAL COST TO FLUORIDATE MANSFIELD PUBLIC WATER SUPPLY The following items apply to eight sodium fluoride metering systems necessary to fluoridate the water system: Quantity Item Estimated 1990 Costs 1 Fluoride specific -ion lab tester with $ 1,500 accessories 8 Furnish sodium fluoride metering systems $40,000 with all piping and electrical connections and spare parts (includes eighteen electronic or motor driven type metering pumps, eight saturators, two softeners, four interlocks, 5/8 inch water meters and two 3/4 inch reduced pressure backflow preventers) 1 Furnish representative or 100 feet out well $ 1,000 sample tap terminating in the wellhouse 1 Installation cost of above fluoride metering $20,000 systems and sample tap by Mansfield Water Department and/or their sub -contractors Miscellaneous equipment (safety equipment, $ 2,000 pallets, etc) 8 DPH state engineering services consisting $ 0 of plans, specifications, purchasing and installation advise at nine wells Allowance for contingencies and inflation $ 5,500 Total: $70,000 1F ..•-r 0 Sodium fluoride in 50 - 55 pound bags currently sells for $.68 - $.75 a pound delivered. The prices vary according to purity, supplier, and quantity of chemical bought per shipment. In 1988 the Mansfield Water Department produced approximately 741 million gallons from all sources. The delivered sodium fluoride cost for the Town is estimated to be $10,500 per year or $14 per million gallons. This figure allows for no increase over 1988 levels as 1989 water consumption actually declined. Manpower supplied by the Mansfield Water Department would be needed to monitor the fluoride levels, adjust the fluoride metering systems as needed, replenish the fluoride chemical in the saturators and keep the fluoride pumps in operating order. An estimate is an average daily labor cost of one half hour per system 3-4 hours per day to conduct daily tests, maintenance, and to meet all state requirements. Some days the manpower will be less, and some days more. No extra travel time on weekends should be needed as the sources are checked. Electrical costs are estimated to cost less than $500 a year. YIZ4e' Daniel S. Greenbaum Commissioner �� Alow:'$ Gilbert T. Joly/jA�pG t , NR F Regions] Director ;.. eZQYf.PlPI�LP� ""'"_ ' �- �� ri�Oni March 30, 1990 Department of Public Health RE: MANSFIELD--Public Water Supply, Division of Dental Health Feasibility Study On Fluoridation 2nd Floor of Water Supply, PWS ID# 4167000 150 Tremont Street Boston, Massachusetts 02111 ATTENTION: Mr. Frederick Barker, P.E. Gentlemen: In response to your request, the Department of Environmental Protection has reviewed your feasibility study dated January 9, 1990 for fluoridation of the public water system operated by the Town of Mansfield. This Department is in agreement with your findings as presented in your report and as contained in the letter discussing the report to the Mansfield Board of Health from Gregory N. Connolly, DMP, MPH. The Department will be pleased to assist you further in this project in accordance with our interagency agreement. D/PCW/pcwkan cc: Board of Health 50 West Street Mansfield, MA 02048 Mansfield Water Department Town Hall 50 West Street Mansfield, MA 02048 Very truly yours, Lawrence S. S. Dayian, Chief Water Supply Section P.f»rod �n R""I'd Pnn" Wai, Y&� C odf42 02»> William F. Weld Governor David P. Forsberg Secretary David H. Mulligan Commissioner MEMORANDUM TO: Boards of Health FROM: Gregory N. Con YI D.M.D., M.P.H. Director, Off f Dental Health DATE: August 19_, _1991 For your information I am enclosing the U.S. Centers for Disease control's (CDC) recent summary on the benefits and risks of fluoride. As you will note, water fluoridation is still the most effective,- least costly means of preventing decay. 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O C WCU ma°Wj O m a o s ,o0E d c NN°mc W voa o N o aUO '47 N o c °O n O N UL(Jo O ON WD NNN N OpO� = Wo M d�W V'WwM dNLL CWN-�r ` y 0 0 Y m t f°� C m N f� O T'� N .WO L p T _O .1] L a to > n c C N C C7 N (O U m 00 '0m min dO� �❑aa m-c memm L NY wm cmi mm'L .L�.3 m'O m� w �o a min -Jo .'dC^a-m cN CN C V+ N NC ryN mOUO ,�= C "S cN C�p❑JWo�mN mW m o � nUo p_ -CEO _o W c u cUpo C J ooU Cc W> NOo No m=0moEW>y ° 7> wOO E p W«w . ❑EN wNJ C wo UUWYY U UTU ��=W wUb jp �w William F. Weld -qOt 6V11 02991 Governor David P. Forsberg Secretary David H. Mulligan Commissioner January 17, 1992 Board of Health Town Hall 50 West Street RE: Proposed Water Fluoridation Mansfield, MA 02048 Engineering Agreement Dear Mr. Van Splinter: In response to the Town's request, enclosed is our standard fluoridation agreement in duplicate regarding engineering assistance to develop plans and specifications. Please review the proposed agreement, secure the necessary signatures, and return both copies to the Department. After the engineering has been completed by Mr. Barker, P.E., Fluoridation Engineer, another agreement to cover installation of the necessary equipment by Town or their subcontractors will be drafted for your signatures. However, no capital grant funding is available at the present time. If you have any questions, please call Mr. Barker at (617) 727-0732. Very truly yours, go y N. Connolly, D. .D., M.P.H. Dir ctor Office of Dental Health C:B:I Enclosure (2) SPECIFICATIONS FOR CONSTRUCTION OF EIGHT FLUORIDATION SYSTEMS AT CATE SPRINGS WELL # 1 ALBERTINI WELLS # 2 AND # 3 ALBERTINI WELL # 4 (FRONT) WITCH WELL # 6 DUSTIN WELL # 7 PRESCOTT WELL # 8 PRESCOTT WELL # 9 MANSFIELD, MASSACHUSETTS Commonwealth of Massachusetts Massachusetts Department of Public Health Office of Dental Health 150 Tremont Street, 2nd Floor Boston, MA 02111 (ENGINEER) 6 March 29, 1994 TABLE OF CONTENTS Summary of Work and Operation 1 Plumbing Specifications 3 Plumbing Fixtures Specifications 5 Saturator Specifications 8 Electronic Type Metering Pump Specifications 9 Motor Driven Metering Pump Specifications 10 Metering Pump Accessories Specifications 11 General Items Specifications 13 Laboratory Testing Specifications 14 Operator Safety Equipment Specifications 16 Electrical Specifications 17 Outside Sample Tap Piping Specifications 19 Final Testing and Clean Up 21 (Refer to 10 pages of revised detailed plans dated 3/29/94) NO Work Included: Work under this Department of Public Health (DPH) - Mansfield Water Department (MWD) contract shall include MWD installing all DPH or MWD funded equipment and to test and place' in satisfactory working order all fluoride metering equipment at the eight wells. Engineering services and advise will be furnished by the DPH. B. Summary of Operation at Wells 1-4 and 6-9: Seven sodium fluoride upflow type sodium fluoride saturators will automatically provide a 4% saturated solution of sodium fluoride at eight locations. A make-up water line will automatically furnish a protected, and metered amount of water to the saturators, except at wells 4 and 6 the make-up water shall be also softened. A sodium fluoride solutions is applied to a 4-10 inch main at a rate of 13-130 gallons per day using one of the two chemical metering pumps provided. The second metering pump is a spare or standby. It is unplugged when not in use. (Wells 2 and 3 only have one spare as well 2 is infrequently used.) Normal operation at the wells shall be automatic which is provided through an interlock with the well pump motor. The metering pump rate and per cent full stroke rate shall be manually set. A calibration chamber is provided on the wall to correctly fix the proper feed rate resulting in optimally fluoridated water. An electrode type fluoride testing meter is,,provided as a check to insure all equipment is operating correctly. A 100 foot out sample tap will insure that a representative water sample is available at all times. E C. Ec(uipment Included: The following fluoride metering equipment and accessories shall be bought and paid by Mansfield Water Department and reimbursed by DPH on PV forms as specified in contract or as agreed: 1. Fifteen fluoride metering pumps with anti -siphon valves at wells # 1-4 and 6-9. 2. Seven upflow saturators with meters and DEP approved reduced pressure backflow preventers at wells # 1-4 and 6-9. 3. Eight corporation stops with injection nozzles at wells # 1-4 and 6-9. 4. One fluoride testing meter and lab accessories. 5. Miscellaneous operator safety equipment at wells # 1-4 and 6-9 (total 7 locations). 6. Piping, tubing, valves, supports, hangers, etc. at wells # 1-4 and 6-9 (total 7 locations). 7. Electrical metering pump interlocks at wells # 1-4 and 6- 9 (total 8). 3 Plumbing General: The plans do not show every detail and offset required to install the plastic drains, copper make-up water piping, and plastic discharge piping. All materials and installation procedure shall conform to the State Plumbing Code. I. Make-up Water Piping to Saturator A. Tyne All inside the building cold water piping used on the make-up water line shall be type L copper tubing. B. Installation Procedures 1. Piping installed in neat and workmanlike manner. 2. All lines run parallel to wall where possible, but not diagonal. 3. Lines pitched to low points with provision for draining these low points. 4. Before connecting, all piping cleaned including the ends. 5. Ends of copper piping after cutting shall be reamed to eliminate burrs. 6. Close nipples (less than 2 1/2 inches) should be avoided whenever possible. 7. All ends and interior surfaces of copper tubing to be soldered shall be prepared by cleaning them with steel wool until they are bright. After fluxing, the tube shall be inserted into the fitting as far as possible. Solder shall be of a type approved by the manufacturer, but not of a cored type. Use of solder containing lead is not allowed. A mixture of 95% tin, 5% antimony is acceptable. The joint shall be heated and finished to make a drip -tight connection. S. Unions shall be used to allow for dismantling of all water pipe and be of brass or bronze for joining copper pipe. 4 C. Pipe Hangers and Supports All copper piping shall be supported rigidly to maintain the required pitch and to prevent vibration. They shall be adjustable wrought -band, or wrought-clevis hangers with iron rods. Hangers touching the copper pipe shall be copper plated. Hangers or supports shall be less than 1 foot from each change in direction and not more than 6 feet apart. D. Valves Shut off valves rating up to at solder -joint ends section.) ZI. Plastic Chemical Piping shall be either angle or globe type with pressure least 150 psi. Valve shall be bronze and have (Ball type valves are discussed in the following A. Type Polyvinylchloride pipe (PVC) shall be schedule 80 normal impact pipe, type 1, grade 1, as manufactured by Chemtrol or approved equal, and bearing the National Sanitation Foundation (NSF) seal. B. Installation Procedures 1. Piping installed in neat and workmanlike manner. 2. All lines run parallel to wall where possible, but not diagonal. 3. Before connecting, all piping cleaned including the ends. 4. All ends of pipe and fitting to be joined by solvent welded joints shall be cleaned with special PVC cleaner. Then with a brush apply a heavy coat of PVC solvent cement to the pipe joining surface and a light coat to the socket joining surface. Immediately insert the pipe to the full socket depth while rotating the pipe or fitting one quarter turn. Wipe excess solvent away and do not touch for two minutes. C. pipe Hangers and Supports All PVC piping shall be supported without strain, but allow for free movement. Do not anchor pipe rigidly at walls. Hangers or supports shall be less than 1 foot from each change in direction and not more than 3 feet apart. Allow for thermal expansion and movement of PVC piping (20 foot long PVC pipe will increase 0.28 inches for a 40 degree F change in temperature, regardless of pipe diameter.) 5 D. Valves Shut off valves shall be ball valves made of PVC type 1. grade 1 with viton seals and teflon seats. Ball valves shall be "true union" type with socket joints. Valves shall be manufactured by Chemtrol or approved equal. In general, diameters shall range from 1/2 to 3/4 inch, as shown on the plans. E. Placement Polyethylene discharge tubing may be placed in straight runs in 3/4 inch PVC rigid chemical piping where indicated. 1. Water pressure reducing valve with integral strainer will remove any suspended impurities from the make-up water line while holding the water pressure to an adjustable range of (25 - 75) psi. The 1/2 inch bronze body valve shall have a removable stainless steel strainer. It shall be suitable for maximum pressure up to 150 psi and temperature up to 100°F. Inlet shall have union connection and outlet shall be threaded. Quantity required is seven. Suggested vendor is Watts Regulator Company of North Andover, MA, Watts # 35-BU. (Grainger # 2P080). 2. Water pressure gauge shall be used to monitor the water pressure supplied on the make-up water line. The gauge shall have a steel case, glass front, sized approximately 2" in diameter, range of 0 - 200 psi, 1/4 inch threaded bottom connection, graduations of at least 5 psi, figure interval of at least 40 psi, accuracy of at least + 3%. Quantity required is seven (Grainger # 2A145). 3. Domestic type water meter shall be used to keep daily records of volume of water pumped through the saturator tank. It shall be sized 1/2 X 5/8 inch and be of a non - remote type. The AWWA approved meter shall be installed where indicated on the plans with the dial face facing outward for easy reading. The units of measurement may be either U.S. gallons or cubic feet. It shall have a sweephand and totalizer. Quantity required is seven and shall be purchased from the Mansfield Water Department for sixty dollars, and Town shall submit an invoice to DPH, or as agreed. 4. Reduced pressure backflow preventer - The reduced pressure backflow preventer shall be an approved DEP model and size. It shall meet these specifications: 1. Bronze body 2. Stainless steel internal parts with tight seating rubber check valve assemblies M 3. Water temperature range - (33 - 100°)F 4. Water pressure up to 150 psi 5. Furnished with tightly closing upstream and downstream ball valves 6. Consists of two independently operating check valves with a pressure differential relief valve located between the two check valves 7. Designed for installation in a horizontal position 8. Consists of four test cooks for easy on -site testing purposes 9. Size - 1/2 inch The backflow preventer shall be supplied with all the manufacturer's rubber recommended spare parts (conbraco # 40-003- 04). The backflow preventer shall be installed on the make-up water line to each saturator as shown on the plans. The installation shall be subject to these DEP installation requirements. 1. (3-4) feet above the floor 2. 4 feet of clearance room in front for testing purposes 3. 1 foot clearance at each end 4. Minimum of 6 inches from the wall The backflow preventer shall be conbraco 40-203-04 or DEP approved equal. A total of seven reduced pressure backflow preventers shall be furnished. (The backflow preventer is required by DEP to prevent any siphoning of sodium fluoride back into the make-up water line in the remote event of an unexpected negative pressure in the main.) 5. Saturator Emergency Overflow Tank and Shut -Off Valve System A. The saturator shall have an emergency overflow tank and float actuated shut-off valve system as shown on the plans. B. The white cylindrical overflow tank shall be polyethylene with open top. Capacity is minimum of six gallons and sized a minimum of 11 inches inside diameter and 16 inches in height. One 3/4 inch diameter bulkhead connection with neoprene gasket shall be located two inches below the top. Overflow tank shall be sufficient to allow free vertical movement of float. 7 C. The overflow tank shall be installed on two standard concrete blocks at least 8 inches above the floor and secured to prevent lateral movement using the pipe as shown on the plans. The tank shall be equal to Terracon code 463-1 or approved equal. D. The emergency float -actuated shut off valve shall shut off the water in the make-up water line in the event the saturator liquid level switch fails and does not shut-off. It will shut-off in up position. Components: 1. Pressure rating 0-300 psi 2. Temperature rating - to 100OF 3. Operating fluid - 4% solution of sodium fluoride 4. Float - polypropylene 5. Minimum level change - 1 inch 6. Base plate - enameled steel 7. Float linkage and float rod - brass and PVC E. The float actuated shut-off valve shall have a fully hydraulic operation, no gears or mechanical linkage between valve and control, and use no lubrication. F. The float control shall be installed using factory supplied mounting handware (bracket). G. The float actuated shut-off valve shall have had a successful history of shutting off the water in the make-up water line in at least five different downflow type saturators in New England for over two years with no failures. The float actuated shut-off valve shall be equal to Cla-Val Company, float control model CF1-Cl. 6. Softener Portable Tyne 1. Polvpronvlene water softener chamber shall be used to remove any hardness ions in the make-up water line. The chamber shall be sized approximately 12 7/8" inches high by 5 inches outside diameter with 3/4 inches FPT inlet and outlet port,size and requires two 3/4 by 1/2 inch threaded adaptors. Chamber shall be suitable for maximum 125 psi pressure and temperature up to 100°F. Upper section shall contain O-ring seal and relief valve, and lower section shall be transparent. Suggested vendor is Utilities Supply Company of Medford, MA part number PP-1 or approved equal. Quantity required is two, one at well 4 and 6 as shown on the plans. 2. Minimum 1,000 grain (cation) zeolite replacement drop in type filter cartridges of proper size and approved by NSF or WQA or FDA. A total of 18 cartridges are required, I and 16 shall be spares. Suggested vendor is Mass. Environmental Quality Water, 837 Highland Ave., Needham, MA 02194 (617) 449-9283, Di -tech HR-1 series, 10 inch cation resin specialty cartridge or equal. 3. A small portable hardness tester of the "soap type" shall be furnished to determine when the softener requires regenerating, and to test its efficiency. Use the gage pet cock as sample site. Specifications for Saturator Sodium fluoride saturator - The sodium fluoride saturator shall be automatically capable of producing up to 840 gallons per day of a 4% saturated sodium fluoride solution. All parts and materials shall be selected for compatibility with sodium fluoride. The sodium fluoride saturator shall be the up - flow type and the downflow type are not acceptable. Components - The saturator shall consist of the parts listed below. 1. Tank The 50 gallon polyethylene tank shall have graduations every 5 gallons and be translucent to allow easy visual inspection of water level and sodium fluoride chemical depth. The free standing saturator tank shall have a 3/4 inch diameter overflow connection. 2. Tank cover The tank cover shall contain a fill hatch for easy loading of sodium fluoride without removing the cover. The sturdy cover shall support a liquid level switch. The removable cover shall contain an opening for the make-up water "line, suction line, and liquid level switch. 3. Pump suction A PVC strainer shall be provided for the pump suction to insure a clear solution intake. 4. Level control A 115 volt A.C. single phase, 60 cycle electrical liquid level switch shall control a 115 volt A.C. electrical solenoid valve to automatically maintain a proper solution level in the tank. The level control shall be the latest model using a float control type. A six foot power cord shall be provided. 9 5. Make-up water The make-up water line shall consist of a line 115 volt A.C. electrical solenoid valve, 2 gallon per minute flow control valve and non -pressure type vacuum breaker. The water shall enter the saturator at the bottom through a rigid slotted distributer tube assembly. The assembly shall be sufficient to distribute the water with enough turbulence so that the water will flow up through the bed of sodium fluoride and produce a 4% solution of sodium fluoride. The saturator model shall be LMI of Acton, MA # 28850, W & T # 47- 050 or approved equal. A total of seven saturators are required. A saturator shall be installed on the floor at each well as indicated on the plans. Electronic Type Metering Pump Specifications The chemical metering pumps shall be of the positive displacement type suitable for feeding a 4% saturated solution of sodium fluoride through a single transparent feeding head at a temperature range of (40 - 100)°F. Output volume shall be manually adjustable using readily accessible dial knobs for changing stroke length and stroke frequency. The maximum capacities and maximum discharge pressures are given below. Pump drive shall be totally enclosed with no moving parts using a solid state electronic pulser. Electrical power may not exceed average of 100 watts per hour under full speed. Power input shall be 115 VAC, 60 cycle. A grounded power cord shall be provided. All wetted parts shall be acceptable for use with a 4% saturated solution of sodium fluoride. Diaphragm shall have a teflon face or approved equal. An instruction book shall be provided. Pumps will be installed on a wall bracket or saturator cover where indicated on the plans. Suggested vendor is Liquid Metronics Incorporated (LMI), Acton, MA 01720 or approved equal. Location Quantity LMI# Maximum Capacity Maximum Discharge In Gallons per Pressure in Pound Hour Per Square Inch Wells # 2,3, 11 Clll-715 2.5 150 4,6,7,9 Well 8 2 Jaeco 3.12 150 (alternative EB-075-1H electronic pump) Each LMI pump shall have spare parts as shown: (LMI # SP-U2), total 11. 1. Teflon diaphragm - quantity 1 2. ceramic valve balls - quantity 4 3. teflon seal rings - quantity 4 4. spring - quantity 1 10 Motor Driven Metering Pump Specifications The chemical metering pumps shall be of the positive displacement type suitable for feeding a 4% solution of sodium fluoride through a single feeding head at a temperature range of (40-100)°F. The pump shall be of the mechanical activated diaphragm type. Output volume shall be manually adjustable by changing three or four step readily accessible pulled belts for changing stroking frequency. Stroke length shall be manually adjustable by turning a dial or crank over a 10:1 range. Pump drive shall be UL listed motor. Power input is 110 volts, AC, single phase 60 cycle current, and a 6' grounded power cord shall be supplied for each. All wetted parts shall be acceptable for use with a 4% saturated solution of sodium fluoride. Diaphragm shall have a hypalon face or approved equal. An instruction book shall be supplied. Each pump will be supplied with manufacturer's standard accessories. A footvalve and injection check valve or poppet shall be supplied for each pump. Each pump will be installed on bracket or shelf where indicated on plans and one will be a spare and unpowered when not in use. Suggested vendor is Wallace and Tiernan (W & T) PO. Box 6, Walpole, MA 02081, or approved equal. Location Quantity W&T # Maximum Capacity Maximum in Gallons per Discharge Hour Pressure in Pounds per Square Inch Cates 4 44-112 5.5 150 Spring Well 1 and Well 8 Each pump shall have spare parts as shown and be in addition to manufacturer's standard parts: 1, hypalon diaphragm - quantity four 2. rubber "V" belt -quantity four 3. valve poppets or balls -quantity eight 4. valve seats -quantity eight 5. "O" rings -quantity eight 6, lubricating oil -quantity eight quarts 11 Specifications for all Metering Pump Accessories The following accessories shall be supplied by the same pump manufacturer or his distributor as the metering pumps to assure compatibility of the parts: 1. The anti -siphon valve (also called back -pressure valve) shall prevent siphoning of the fluoride solution during negative water pressure and shall consist of a spring loaded (hypalon or teflon) diaphragm. Construction is of PVC or other suitable material compatible with a'solution of 4% sodium fluoride. It shall be mounted on the discharge line as indicated on the plans. The anti -siphon valve must be factory set to provide at least (15 - 20) psi back pressure at all times. Quantity required is fifteen, four for motor driven pumps and eleven for electronic pumps. 2. A pressure relief valve shall prevent damage to the metering pump caused by any accidental blockage or valve closure. It shall consist of a spring loaded (hypalon or teflon) diaphragm. Construction is of PVC or other suitable material compatible with a 4% solution of sodium fluoride. The pressure relief valve must be factory set to open in the range of (150 - 175) PSI. The pressure relief valve shall also function as a priming aid allowing the fluoride solution to drain back into the saturator through polyethylene tubing. Three feet of tubing shall be supplied for each valve. It shall be mounted on the discharge line as indicated on the plans. The pressure relief valve may also act as a combination anti -siphon valve -pressure relief valve. Quantity required is fifteen, four for motor driven pumps and eleven for electronic pumps. 3. A corporation stop with nozzle and check valve assembly shall inject the fluoride solution into the water main. A bronze corporation stop shall consist of a solid plug which operates freely and is rated at pressures up to at least 150 psi. The inlet shall be long enough to pass entirely through the wall of iron pipe at least 1/8 inch beyond the inside face of the pipe. The corporation stop shall be sized 3/4 inch NPT. A CPVC or other approved type nozzle assembly shall act as a diffuser tube inside the main being fluoridated. It shall extend inwards approximately 1/4 the diameter of the main for proper dispension. The pressure rating shall be up to at least 150 psi. It shall be sized as 3/8 inch. A check valve assembly shall permit removal of the discharge line without shutting off the water main being fluoridated. It shall be of the ball or poppet type and be rated for a solution of 4% sodium fluoride at pressure up to at least 150 psi. It shall be sized by the metering pump manufacturer. 12 The complete corporation stop/nozzle assembly with check valve shall be all supplied by the manufacturer or distributor and installed on the discharge line where shown on the plans. Quantity required is eight, two for motor driven pumps and six for electronic pumps. (LM1 # 10998). Saddles as specified by MWD shall be used. 4. Polyethylene discharge tubing rated at 150 psi shall be provided to transfer the fluoride solution. It will be cut and sized as needed. All left over tubing from coil shall be kept as spare. One 200 foot 1/2 inch OD coil shall be supplied. 5. Vinyl tubing shall be provided to transfer (suction) the fluoride solution to the metering pump. Diameter shall range from 3/8 - 3/4 inch OD. It will be cut and sized as needed from coils or standard tubing supplied by metering pump manufacturer. One 50 feet coil of 1/2 inch OD vinyl tubing shall be supplied. 6. A foot valve shall prevent the fluoride solution from draining out of the end of the suction line when the pump is "off". An integral one piece strainer shall also be supplied. Quantity required is fifteen one for each pump suction line as shown on the plans. At Alberteni well 3, the saturator cover shall be cut to allow two vinyl suction tubing with foot -valves in two extra slotted PVC suction pipes as directed. 7 A calibration chamber assembly shall assist the operator when setting the discharge or stroking rate of the metering pump. The chamber shall be of clear plastic or polypropylene and long enough to accommodate 500 ml with 10 ml subdivisions. The top shall be open to allow easy filling of water for test calibration purposes. The camber shall be secured to the wall and mounted higher than the metering pumps using pipe dip as shown on the plans. Each assembly, shall have a 6 foot long (or sufficient length to reach either metering pump) vinyl tubing attached to the bottom. It shall be physically disconnected when not in use. Quantity required is seven. Vinyl tubing OD shall match metering pump suction tubing OD. 8 Wall brackets shall support spare electronic type pumps where shown on plans. Polyurethane coated cast bracket with mounting screw, two lag bolts, one washer;, and two lead anchors shall be mounted facing either left or right as shown on plans. Quantity required is seven. LM1 number 28272. 9 Wall brackets shall be used to wall mount the motor driven fluoride metering pumps at well # 8 as shown on the plans. Each pump requires two brackets as recommended by the pump manufacturer. The dimensions are 19 inches deep, 12 inches tall, and 1 1/2 inches wide. Each bracket shall be predrilled with three 7/16 inch diameter wall holes and three 7/16 inch diameter pump mounting holes. Each bracket is attached to the pump station wall using three 3/8 inch - 7 X 3 inch long lag screws, lead anchors and washers on 1" plywood as directed. The pump is attached to each set of 13 wall brackets using six S.S. hex bolts 3/8 inch'- 16 X 1 3/4 inch long, six washers, six lockwashers, and six hex nuts. A total of two pairs of identical wall brackets are required with mounting hardware. Specification - General Items 1. Plastic container with lid shall be used to store excess opened bags of sodium fluoride chemical. The container will protect the opened bags of sodium fluoride from spillage and moisture. The container shall be sized 20-22 inches in diameter and 25-27 inches high (28-32) U.S. gallons), equipped with handles, and be colored black, gray, or blue. Containers may be purchased locally. Quantity required is seven (7). 2. Wooden skid shall be used to store several unopened bags of sodium fluoride to prevent sweating damage from floor moisture. They shall be stored as directed by the water department. Each wooden reusable hardwood skid will be sized 40 inches by 40 inches. It will consist of three (3) bottom full sized runners 40 inches by 2 inches by 4 inches; and 8 top boards 40 inches by 2 inches by 1 inch evenly spaced. Suggested vendor is Hanson Box and Lumber Company, Inc., 12 New Salem Street, Wakefield, MA 01880, or sodium fluoride vendor. Quantity required is four (4). 3. Polyethylene bucket shall be used to transfer the sodium fluoride from the 32 gallon container to the saturator. Each bucket shall have a pour spout, sturdy handle and have a 2 1/2 gallon capacity. Color is gray. (Lab Safety Supply, # JA- 8328, page 315, 1992 general catalog first edition.) Quantity is seven (7). 4. Polypropylene scoop shall be used to transfer the sodium fluoride from the 32 gallon container to the bucket. Each scoop shall be sized 9" X 6" X 3 1/2" and hold 2 1/1 quarts. (Lab Safety Supply # JA 11813, page 479, 1992 general catalog first edition.) Quantity is seven (7). 14 Lab Specifications A. The following portable fluoride lab tester shall be a specific -ion type using a US Public Health Service approved 1SE type meter and two electrodes with one year warranty: 1. Portable 6-9 volt battery operated meter with direct reading range of 0.1 - 10.0 mg/l or ppm (LCD display) fluoride, Hach no. 45400-00 or approved equal, quantity one. 2. Reference electrode with standard reference pin connector, Hach No. 44250-20 or approved equal, quantity one. 3. Fluoride electrode with BNC connector, user refillable, Hach No. 44500-71 or approved equal, quantity one. 4. Reference electrolyte (KCJZ) solution cartridge for storing in fluoride meter, Hach No. 21950-01 or approved equal, quantity three. 5. One 6 or 9 volt alkaline type battery for fluoride meter as recommended by manufacturer. 6. One 2-oz, fluoride electrode filling solution, Hach No. 44501-26. or approved equal. The above fluoride lab tester is available from Hach Company, PO Box 389, Loveland, CO 80539, tel. 1-800-227- HACH. B. Total ionic strength adjustment buffer (TISAB) for use in fluoride tests to reduce sample interferences and adjust sample pH, four liters of TISAB II solution. TISAB II is available from Red Bird Service, P.O. Box 155, Osgood, IN 47037, tel 1-800-428-3502, or approved equal, catalog No. T- 127, quantity two-4 1 container. C. Following fluoride accessories are available from Fisher Scientific Company 52 Fadem Road, Springfield, NJ 07081, tel. 1-800-343-5818, or approved equal: 1. One complete free standing electrode support assembly with plastic electrode holder and solid base. (Fisher # 13-637-675, page 1169, 1991 catalog). 2. One round magnetic type water stirrer using the magnetic induction method for use with the fluoride meter system. Stirrer shall be operated on 110 volt AC and have an adjustable speed switch. (Fisher # 14-493- 120MR, page 1473, 1991 catalog). 15 3. One 12 Inch magnetic stirring bar retriever for use as a pick up rod for magnetic stirrer. (Fisher # 14-511- 102, page 1477, 1991 catalog). 4. Four 12.7 mm long teflon coated micro bars for use as a stirrer with magnetic water stirrer (Fisher # 09-312- 102, page 1477, 1991 catalog). 5. Two bulk -type black safety rubber pipet filler precise to 0.01 ml for use with pipets. (Fisher # 13-681-50, page 1214, 1991 catalog). 6. Four volumetric pipets sized at 10 ml j; 0.02 ml, reusable type, made from borosilicate glass (Fisher # 13-650-2L, page 1207, 1991 catalog). 7. Ten polypropylene beakers sized at 50 ml, reusable type, for use with fluoride meter system (Fisher # 02- 593-50A, page 96, 1991 catalog). 8. One thermometer, range (-30 to 120)°F, filled with red fluid, 152 mm long. (Fisher # 15-021-5C, page 1540, 1991 catalog). 9. One polypropylene graduated cylinder, sized at 500 ml, 3.0 ml, with 5 ml subdivisions. (Fisher # 08-570- 21F, page 664, 1991 catalog). D. State Lawrence Experiment Station (LES) will supply 1.0 ppm and 2.0 ppm fresh fluoride standards (no buffer) in separate plastic 2L containers through MDPH, or purchased from Red Bird Service Inc. premixed with buffer. 16 Specifications - Operator Safety Equipment The following equipment (1-6) shall be supplied and kept next to the saturators and mounted on a wallhook as shown on the plans. 1. Neoprene gloves with nonslip finish, medium weight, one size fits all. (Fisher # 11-395-11, page 918, 1991 catalog.) Quantity is seven (7) 2. Rubber goggles molded to facial contours and fits over glasses. Meets ANSI requirements and has elastic headband. (Fisher # 17-277, page 1367, 1991 catalog.) Quantity is seven (7). 3. Rubberized cloth apron sized 46 X 33 inches. (Fisher # 01- 357, page 29, 1991 catalog.) Quantity is seven (7). 4. NIOSH/MSHA half mask respirator using replaceable fiber filter for toxic dusts. Respirator has contour molded face piece and adjustable headband. (Fisher # 17-644-1, page 14, 1990 safety manual catalog.) quantity is seven (7). 5. Replaceable dust/mist filters for above respirator. (Fisher # 17-646-7, page 15, 1990 safety manual catalog.) Quantity three packages of 12. 6. Replaceable retainer for above respirator. (Fisher # 17-649- 6, page 15, 1990 safety manual catalog.) Quantity seven (7) packages of six each. 17 Electrical Specifications General: The electrical work electrical power to systems. It is not specify a complete part. However, the given on the plans. Interpretation of plans: shall consist of providing run the ? _ fluoride metering the intention to show and electrical system with every general electrical system is 1. Exact locations of equipment shall be given by the Mansfield Water Department with recommendation by the MDPH. 2. All wiring shall comply with local, state, and national electrical codes. 3. All cutting and patching for openings shall be planned in advance, and any shutdown of existing electrical equipment shall be coordinated in advance with the approval of the Mansfield Water Department. 4. All connections to existing equipment shall be made as required. All original connections shall be left in operating order. Labor: All labor costs by the Town recommended electrical and instrumentation (pacing) contractors are the responsibility of the Mansfield Water Department as specified in the contract. Any electrical permits and local payments, if necessary, are the responsibility of the Mansfield Water Department. Materials: 1. All materials used shall be new and approved by local, state, and national electrical. codes and be U.L. listed. 2. The necessary materials shall be purchased and paid by the MDPH from the electrical contractor as needed and include, but are not limited to: 1. electrical conduit with couplings, ells, hangers, adaptors, etc. 2. 600 volt various size wires. 3. Receptacles, boxes, circuit breakers, switches, relays, etc. m Installation: 1. IMC conduit supports shall be spaced at 8 feet intervals or less. 2. PVC conduit supports shall be spaced at 5 feet intervals or less. 3. No PVC conduit shall be placed within 2 feet of the floor. 4. All circuits shall be labeled inside box next to circuit breaker. 19 Outside Sample Tap Piping Specifications 5' " All outside the building cold water sample line piping used shall be "soft" type K copper tubing - 3/4 inch. B. Installation Procedures: 1. Work shall begin on a dry day in the early morning hours so all backfilling may be done the same day. 2. Suitable care must be given when excavating close to existing water mains, and a hand shovel shall be used within six inches of any water main. 3. Excavated material must be placed at least three feet back from the edge to prevent rollback. 4. Minimum of 4 1/2-5 feet of cover required over the sample lines. 5. After tapping main, a 3/4 inch bronze corporation stop shall be inserted. Corporation stop must be tested in "off" and "on" position. A bronze saddle will be used when necessary as specified by the MWD. 6. Bronze 3/4 inch curb stop shall be accessible below ground through cast iron service box with 2 1/2 inch inside diameter extension type shaft. It shall be located as shown on the plans, and in general be within 10 feet of bronze,corporation stop. 7. Where new pipe passes through exterior walls, they shall be enclosed in a one and one-half inch pipe sleeve, such as schedule 80 PVC pipe, and caulked to provide a water tight connection. An alternative method is a compression type rubber link wall sleeve seal instead of'caulking. Or connect to existing sample tap where available. 8. All underground pipe shall be tested for leaks for 5 minutes under full pressure before being backfilled. No sharp stones or other objects shall be allowed to come in contact with the pipe. 9. Sample taps shall terminate inside the respective building over a drain or sump. Taps shall be complete with a stop valve and label, "Fluoride Sampling Tap". 10. Piping shall be installed as shown on the plans. 20 11. Any pavement replacement shall be according to Town specifications and similar to existing pavement. Material cost (receipt required) shall be reimbursable to the Town by the Department or as specified in Agreement. 12. Each one foot level of backfill under any road shall be thoroughly compacted to 950 of maximum by rolling, tamping, hand or vibrating with mechanical compacting equipment. 13. Fluoride sample tap summary: Well Source Wells 2, 3, and 4 C. LEAKAGE TEST Construction Status Present sample tap is too close, existing to be lengthened as shown on the plans. 1. All copper lines shall be tested for leaks for 1/2 hour under full pressure from the mains, and before backfilling has begun. 2. After flushing, a pressure gauge (200 psi) shall be temporarily installed inside the building downstream of the shut-off valve and used to record any loss of pressure (leakage). The curb stop and shut off valve shall be open while the corporation stop shall be closed. 3. The curb stop shall be tested after the above leakage test by shutting it off and noting if gauge drops to zero after building shut off valve and corporation stop is opened. 4. Any leaks shall be repaired, then tested again. 21 Final Testing and Clean -Up at Wells 1. All work shall be cleaned up at completion, and all surplus materials disposed of as directed by Mansfield Water Department (MWD) and Massachusetts Department of Public Health (MDPH). 2. Each saturator shall be filled with clean water and rinsed out to remove any dirt or dust. Then each saturator shall be filled through the make-up water piping to full status and disinfected with 3 oz of 5% chlorine bleach. After stirring, allow chlorine solution to sit for one hour. 3. Test each metering pump by pumping chlorine water to waste into a bucket for one-half (1/2) hour (disconnect injection nozzle tubing). Any leaks shall be repaired. 4. Reconnect the injection nozzle tubing and pump water into main via saturator system using each metering pump. Any leaks shall be repaired. 5. MDPH will test each pump at various combinations of percent of stroke length and strokes per minute using clean water and calibration chamber to insure metering pumps are operation. 6. MWD will test each pump for three days with wells on line using clean water supplied automatically through the saturator system. A total of two (2) - three (3) day tests are required. MDPH will set the pump percent stroke length and strokes per minute using 50 gallons of make-up water per million gallons rate. The pumps will be paced automatically from flow. 7. MWD will fill out the following table every four hours and give to MDPH for approval: Well name date, time, metering pump number, strokes per minute from dial or SCR panel, pump percent stroke length, gallons of well water pumped from totalizer, gpm rate of flow, gallons of water pumped from 1/2 inch make-up water totalizer. MDPH will prepare table for filling -in by MWD. 8. If the test results appear unsatisfactory, the test will be repeated after any repairs are made. MDPH will compute imaginary ppm for each four hour period using 50 gallons make-up water per 1.0 million gallons is equivalent to 1.0 ppm (fluoride). 9. MDPH will label each saturator "maximum," "add," and "minimum" on outside for easy reference. TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORAN➢UM TO Dave Archard, Ass't Town Engineer FROM: Scott Leite, Health Agent RE Plans for Fluoridation DATE: April 29, 1994 The Board of Health would appreciate a review of the attached plans received from Fred Barker for implementing fluoridation. Could you provide the feasibility of construction and estimated costs. Thank you. Board of Health Page 2 January 2, 1992 c. Letter from Rodney Dahlstrom, 992 West St, to BOH, Dec. 27, 1991, re: A lot on Riverwood Estates. Agent will respond to Mr. Dahlstrom and attempt to address his concerns. d. Project Bread, A Voice for the Hungry, Dec. 16, 1991, invitation to Legislative Breakfast on Feb. 14, 1992. 4. VISITORS Town Manager, Bill Williams, was present to inform members of the shortage of funds for FY93, and the unlikelihood of an appropriation for fluoridating Mansfield's public water supply. It was the Town Manager's recommendation to defer all capital improvements (unless mandatory or emergency) until greater resources are available. At this time $77,000 has been recommended. Mr. Williams did speak with Ed Rosenberg earlier about this subject. Members Fontanini and Steele were under the impression that the BOH was planning to pursue funding through the State --not the Town. Agent reported that Member Rosenberg told him that he would be in favor of deferring fluoridation until FY94, but would expect a guarantee for funding from the Town. Mr. Williams stated that the Town cannot guarantee due to the unclear fiscal picture now and in the future. MOTION: To defer action for funding to fluoridate public water supply until it is economically feasible. VanSplinter/Fontanini. All in favor. VOTED. 5. HEALTH AGENT'S REPORT a. Lawncare Update: Lawyer on vacation. Still have not heard any news. b. East Mansfield Sewer: As Town Manager stated earlier tonight, the funding for this project is uncertain, since there are several variables to consider. Options are still being juggled. Agent wrote several questions for the attorney to answer. They are: (1) How is a moratorium by a BOH, for the purpose of sewer construction, put into place? (2) Can a moratorium be released in phases? (3) How does a moratorium affect purchase and sales agreements? (4) What is the Town's or Board's liability for a moratorium? (5) What can other boards do? Chairman Austin asked if the Board should still pursue legal counsel. Agent replied definitely. A memo will be sent to Town Manager with the questions. c. Air Quality Tests So. Main/Edgewood Sts. Area: All houses were tested fine except for two. The highest level was 5.0 (acceptable level is 1.0) of vinyl chloride. That house will be retested on Friday, Jan. 3rd, along with DEP and Rizzo Associates. d. Perks and Plans: Final count for 1991: 167 peres and 203 plans. Concensus of Board is that growth is out of control. After much discussion, members agreed to invite planning board members for a round -table discussion to get their views on growth and what plans they may have for controlling it. Meeting is tentatively scheduled for February 6th. i f C i 112-1 D7:VRIt TO : William F. Williams, Town Manager FROM: Carol C. Sosman, ChairmanC� DATE: July 12, 1995 RE : Fluoridation Please find attached a memo to Town Engineer, Bob Swanson. We would very much appreciate your forwarding it to him for his response. The Board's next meeting is August 3rd, and we would appreciate a response from Mr. Swanson by August 1st. Thank you. cc: Bob Swanson Dave Archard Dan Clifford /dr TO: Bob Swanson, Town Engineer FROM: Carol C. Sosman, Chairm?s' DATE: July 12, 1995 RE Fluoridation I have read your two memos dated May 8 and 22, 1995, with interest. Unfortunately, neither of them answers the questions you were asked to address by the Board of Health. In order not to lose the possibility of State funding for Mansfield's fluoridation project, we need to clear answers to some basic questions with no further loss of time. Please consult with staff from the Water Department, as needed, and provide a written response to the following questions by August 1st. 1. How many fluoridation units will be needed to fluoridate the Town water (number and location)? 2. Identify which locations can house the fluoridation equipment shown on the plans without modification, and estimate the installation cost per location. 3. Identify which facilities will need alterations and/or additions to accommodate the fluoridation equipment, describe the needed work, and estimate the cost per location (facility alteration and equipment installation). 4. Evaluate the operating impact of the addition of fluoridation equipment, estimating annual operating cost, including materials, labor, and maintenance expenses. 5. Combine the data from #2 through #4 to create a total fluoridation project profile, summarizing capital project tasks and costs, and annual operating costs, by location. 6. Optional: Identify alternate equipment/facility options, showing cost effects on the capital investment. 6a. Identify the operating effects of options identified in #5, and evaluate the cost advantages/disadvantages of each option. a Page 2, MEMO, Town Engineer, July 12, 1995 Clearly, this analysis will require close cooperation between your office and the Water Department staff, especially in the analysis of the operating effects. The Board of Health looks forward to receiving your complete report. We welcome you to a meeting to discuss your findings. Thank you. cc: Dave Archard Dan Clifford Bill Williams /dr � � t kD \ \ \ kD $ / \ m = \ ( / � �kD n � } � � ƒ ; e _11 fDr / f ƒ \ \7. $ d 2 /,) irD { » 7 } $ } N \ ) i : e \ ! / } @ � ƒ f � \ { \ k \ 2 j cn § @ ✓yam (J cuc/o v� c.,rvcci�.u:,�Gcr,�c�r�cu BAILUS WALKER, Jr, PhD, M.P.H. Cammisscnar Division of Dental Health 9th Floor 617 727 -0732 Paul and Jane Folkman Box 96 Mansfield, MA 02048 (oxeauGiue � a� cfGuirnaira .>�xuiced �oa/an 021-11 lr April 3, 1986 Dear Paul and Jane: Thanks to you and the Mansfield Rotary for inviting me to speak Tuesday. I enjoyed meeting everyone and seeing Mansfield on a sunny spring day! Enclosed is 1) a copy of the state fluoridation law and 2) a form letter which can be used by the Board of Health requesting the free feasibility study. The study places the town under no obligation to further consider fluoridation. (It takes up to two months to schedule and complete the feasibility study.) 3) An example of a legal notice. If you still plan to. urge to Board of Health to order fluoridation before the end of May I will need to send the Board a ,"Commissioner's letter" notifying the Board that the water supply is felow 1 ppm of fluoride before fluoridation is ordered (a legal technicality required by the law). That can be done the week after you send your letter. I am also available to meet with the Board of Health to answer questions. Although a public hearing is not required by law, it is usually wise to hold one. (The hearing can be part of a regular Board of Health meeting.) I can also have a letter sent by John Nay, executive director of the Southeastern Massachusetts Health Planning Council, the HSA which covers Mansfield.I will also let the Massachusetts Dental Society know of your plans as this organization may provide a small contribution should the question go to referendum. I would encourage you to place fluoridation materials in the Town library and to contact appropriate community organizations. (PTAs, pre-school PTA, League of Women Voters. President Rosalie Barbate, 48Hampden Dr., Norwood, MA 02062 769-2886rSenior Citizens Center, etc.).The department can send materials directly to doctors and 'dentists for use in their waiting _._ _r terl to do so by the Board of Health or local citizens. As I mentioned, Heather Champigny, the Mansfield school nurse, 339-4595, has volunteered to send home information concerning fluoridation with students. (The Department of Public Health can provide the brochures.) Thank you again for your interest and enthusiasm. Yours truly, Martha C. Wood THE FOLKMAN COMPANY, INC. Post Office Box 96 • Mansfield, MA • 02048 May 5, 1986 Martha C. Wood Assistant Director of Dental Department of Public Health Division of Dental Health 9th Floor 150 Tremont Street Boston, MA 0E11.1 Health for prevention Programs RE: Fluoridation of Mansfield's Water Supply Dear Martha, On Wednesday May 1, 1986 I met with the Mansfield Board of Health to discuss initiating the fluoridation of Mansfield's water supply system. The Board has requested that I bring there the package of information which you sent to me, so that they can review the information prior to their next meeting. I have been invited to attend this meeting also. There are five members of the Board of Health, as well as a professional health department director. Any additional information which you can forward to me, so that I may present it to the Board of Health, would be appreciated. If this meeting goes well, then the next step is to meet with the Board of Selectmen (Water Commissioner). I have asked Scott Leite, Health Director, if you should attend the next Board of Health meeting. I am waiting for his reply. Please call me at 339-6709 or 339-8435 should you have any questions. Thank you very much. 0 �( Very truly yours, i; m,l,", l J, Y 8 06w.� Paul J. Folkman, President PJF/eeh cc: Scott Leite, Mansfield Board of Health &,, CAW 0/xzm'16,06t 1qo .0/ xeaa p BAILUS WALKER, Jr, Ph.D, M.P.H. �50 OT~XowC ,9bew Commissiarw August 13, 1986 Edward Tartufo Chairperson Board of Health Town Hall 50 West Street Mansfield, MA 02048 Dear Mr. Tartufo: The Department of. Public Health has determined that the fluoride content of Mansfield's water supply is substantially below the level recommended for dental health. The optimal level of fluoride for prevention and reduction of tooth decay is1.0parts of fluoride per million parts of water (ppm). In accordance with the provisions of the Massachusetts General Laws, Chapter 111, Section 8C, the Department, in taking cognizance of the dental health of the people of the Commonwealth, strongly recommends that the Board of Health order ` the upward adjustment of the fluoride content of your water supply available for domestic use to the optimal level for prevention and reduction of tooth decay. The Department of Public Health provides free educational assistance to board members and local municipal officials interested in ordering water fluoridation. In addition, through federal funding, the Department will purchase and install necessary equipment and buy the fluoride compound for two years. Communities which have been fluoridated more than two years are reimbursed for part of the cost of the fluoride compound through state local aid funds. If you have further questions, the Director of Dental Health, Gregory N. Connolly, D.M.D., M.P.H., and his staff are available as resources for you. Since ly,xy Bailus Walker, Jr., Ph.D., M.P.H. Commissioner y x1 BW:mfI AUG i 6 Division of Dental Health 2nd Floor 617 727-0732 07w fk� /' BAILUS WALKER, Jr, PhD, M.P.H. 150 �rencaoeL �GKPPC commissnw �� ✓cJoaCam, 02111 Don Steele 96 Rumford Avenue Mansfield, MA 02048 Dear Dr. Steele: April 24, 1987 Per our conversation this morning I am sending the enclosed material on smoking and fluoridation. In Northampton the non-smoking in public buildings includes private offices. It is up to the individual department head to enforce. The room where smoking is allowed is vented directly to the outside. The Board of Health reports "almost no problems." when developing a plan, please consider not allowing smoking in stairways, entranceways and restrooms. Smoking and non-smoking signage should be conspicuous. For restaurants, we recommend restaurants of 25 seats or more should be required to designate 50% as non-smoking. (Only 33% of Americans currently smoke.) Smoking sections should not be allowed between two non-smoking sections. Consider not allowing smoking at the cash register if it is next to the non-smoking section. In January, 1987, the Department surveyed via telephone 92 restaurants affected by local ordinances requiring non-smoking restaurant seating. Eighty- three percent said the ordinance had no effect on business, seven percent felt they had gained business, eight percent felth they had lost business and two percent preferred not to comment. None of the Boards of Health felt the ordinance required more staff time and had created no problems. Most informed restaurants of the requirement in person during normal inspections and on an ongoing basis on inspections look for proper signage. For more information concerning public buildings or restaurants, you could talk to Peter McErlain, director of the Northampton Board of Health, (413) 586-6950 or Maura Smith, Cambridge City Managers Office, 498-9011. For restaurants you could also call George Smith, director,Lexington Board of Health (862-0500) or Robert Carlson, director, Leominster Board of Health, 534-7533. As for fluoridation:.. Don Steele Page 2 April 24, 1987 We recommend as a first step Boards request a free feasibility study (form letter enclosed) which provides financial information and puts the town at no obligation. We also recommend a long term (one year) educational program consisting of making materials available at Town Hall, the library, schools and public meetings. (I have already spoken at the Mansfield Rotary Club.) A citizens committee can be developed to handle this. Once all legal steps have been completed for fluoridation, the state, with federal funds, will pay for or provide engineering design, equipment and installation of the system, any replacement equipment and the first two years of the compound. After the first two years the state with state funding reimburses the town for a portion of the cost of the compound. I would be glad to meet with the Board at any time to discuss either smoking policy or fluoridation. Yours truly, Martha C. Wood Assistant Director Division of Dental Health and Office of Non -Smoking and Health MCW:mf enclosure 92W �'Op� BAILLIS WALKER, Jr, PhD, M.P.H. �50 �xerno�eC JCXPPC Commissiorw (Today's Date) SAMPLE LETTER REQUESTING A FEASIBILITY STUDY FROM THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH Gregory N. Connolly, D.M.D., M.P.H. Director of Dental Health Department of Public Health 150 Tremont Street Boston, MA 02111 Dear Doctor Connolly: The Board of Health in the city/town of is hereby , requesting the Department of Public Health's engineering staff to conduct a free fluoride engineering feasibility study as their time permits. The Board of Health recognizes that the results of the feasibility study in no way obligate the community to fluoridate their public water supply. Signed by: Chairperson of Board of Health cc: Water Superintendent or Manager -90aWwtewt 61 �� BAILUS WALKER, Jr, Ph.D, M.P.H. �50 �xamonC �GrePt COMMIMEW Division of Dental Health Ad&N, ae 2nd Floor 617 727-0732 N TO: Boards of Health FROM: Gregory N. Connolly, D.M.D., M,,x] � Director of Dental Health ,(: DATE: June 1, 1987 E M 0 R A N D U M I want to bring to your attention two matters related to fluoridation. The first is the enclosed letter from the American Medical Association (AMA) that urges fluoridation of community water supplies. The Department of Public Health supports fluoridation and urges all communities to fluoridate. In Massachusetts the local Board of Health has the legal authority to order fluoridation. The Department assists all communities interested in fluoridation with a engineering feasibility study, consultation and educational materials and, once all legal steps have been completed, design work, funding for purchase and installation of equipment and two years of the fluoride compound. The second matter I wish to bring to your attention is a scientific advisory bulletin prepared by the Federal Centers for Disease Control (CDC) in response to recent misleading material distributed by a Massachusetts anti fluoridation group charging that fluoridated water causes Alzheimer's disease. As the advisory stresses, there is no scientific basis for these allegations. If you would like futher information, please call me at 617-727-0732. mf cc: Sue Bernstein District Health Officers "90 ANIEYUC,1�N MElliCAE ASSOCI IION a � 535 NORTH DEARBORN STREET CHICAGO. ILLINOIS 60610 PHONE (312)645-5000 TWX 910-221-0300 0 9N n HFOIC P� JAMES H SAMMONS, M0 Execirtme Vice P,eSidwt May 13, 1987 (645-4300) 1 Bailus Walker, Jr., PhD, MPH, Commissioner of Public Health Massachusetts Department of Public Health 150 Tremont St. Boston, MA 02111 Dear Doctor Walker: This letter is to apprise you of our concern for a large and neglected segment of Americans --some 39%--who live in areas where natural levels of fluoride in the drinking water are inadequate and no supplemental measures are available to provide protection against dental caries. You are no doubt well aware that the AP1A has been a long-time advocate of municipally fluoridated water supplies. Our support for fluoridation dates back to 1957; that support was reaffirmed in 1972 and again in 1974. What we stated in 1974 (HOD action I-74) is no less true today than it was then: "Few health measures have been accorded greater clinical and laboratory research, epidemiological study, massive clinical trial(s) of community populations and public attention —both favorable and adverse... . Research has established that people consuming water [throughout life] containing the [recommended] optimum level of fluoride [0.7-1.2 ppm] experience no adverse effects on their kidneys, thyroid glands, reproductive functions, growth, development, blood, urine or hearing. No cases of allergic reactions have been linked with consumption of water fluoridated at the recommended levels. "Research has also provided evidence that suitable amounts of fluoride may [help prevent or alleviate] bone diseases such as osteoporosis, especially in our aging population. DENTAL HEALTH T sources of FACT SHEET Fluoride Massachusetts Department of Public Health, Division of Dental Health, ISO Tremont Street, Boston, MA O2111 (617) 727-0732 Dr. Bailus Walker, Jr., Commissioner Dr. Gregory N. Connolly, Director of Dental Health What is Fluoride? All fluoride (F-)ions come from minerals occurring naturally in the ground. It is the thirteenth most common element found in the earths crust and twelfth most common found in the oceans. It is also the thirteenth most abundant element in the human body. What are the Common Sources of Fluoride? The mineral sources of the fluoride ion used in community water fluondation are fluorspar, which contains calcium fluoride (CaFZ ); cryolite, which contains fluoride combined with aluminum and sodium (Na3A1F6); and apatite, a calcium compound of fluoride, carbonates, and phosphates 1Ca1o(PO4,CO3 )6 (F,C1,011)2 1- Where is Fluoride Mined in the United States? Fluorspar (also called fluorite) is crystalline and comes in all colors. Found worldwide, the largest deposits in the United States are in southern Illinois and Indiana. Cryolite is rare in the United States and is more commonly found in Greenland and Europe. Apatite is the most common source of fluoride in this country and is found in phosphate rock (which looks like ordinary rock). Florida, Tennessee, and South Carolina are the major locations of apatite deposits in the United States. There are minor deposits of apatite in North Carolina, Montana, Idaho, Utah, and Wyoming. Regardless of the source or extraction process, all pure fluoride ions are chemically identical and occur naturally in a variety of ores. Why Add Fluoride to Water? All water contains some fluoride which leaches from fluoride -bearing rock formations. This leaching process is not limited to calcium fluoride formations but occurs with any fluoride -bearing rock. However, for good dental health children and adults need about one part of fluoride to every million parts of water (1 ppm). Most community water supplies in the United States contain less than 1 ppm of fluoride and, therefore, require "adjustment" in order to prevent cavities. This adjustment is made by adding fluorides which are refined from fluoride -bearing ores. The fluoride ion is unchanged by this refining process. The ion is the same whether it is leached from the rock by nature or extracted from fluoride -bearing ores and refined to fortify fluoride deficient water. The source of the fluoride ion has no effect on its absorption by the human body. Adding fluoride to public water supplies is comparable to adding other chemicals commonly used in drinking water supplies. These chemicals include chlorine, phosphate, and caustic soda (sodium hydroxide, NaOH). Fluoride is a natural component of water. It does not change its color or taste. Why axe There Different Fluoride Compounds? Fluoride is always found in a compound form and never in a free state in nature. When dissolved in water, these compounds dissociate into ions. Theoretically any compound containing fluoride could be used in "adjusting" water. However, practically speaking, the compound must have enough solubility to permit its use in routine water.plant practices. It must also be relatively inexpensive and readily available. In the United States, three compounds meet these criteria: sodium fluoride (Nan, until the early 1980's produced from fluorspar, now produced from apatite; hydrofluosilicic acid (112ST6 ), produced from apatite; and sodium silicofluoride (Na2STj ), also produced from apatite. What Determines Which fluoride Compound is Used? No single fluoride compound is ideal for all cities, towns, and districts. In some communities a different compound will be used at different well or reservoir locations. The Tina: selection depends on several engineering factors: ® Yield of each of the wells and reservoirs and rate of water production in gallons per minute. ® Number of fluoride injection points. ® Delivered cost per pound of fluoride compound(s) and cost per million gallons of water at optimum level (1 ppm). ® Capital cost of purchasing and installing fluoride feed equipment. ® Water department's personal preference which may take into account the amount of labor required for handling, maintenance, and testing of fluorides and fluoridation equipment. ® Chemical characteristics of water being fluoridated. ® Existing room to house the fluoride feed equipment. Fluoridation benefits adults as well as children. Drinking fluoridated water has been shown to result in up to 70 percent fewer cavities and fewer lost teeth. In addition, fluoridation is economical. In fact, every dollar spent adjusting fluoride deficient water saves the community up to $50 in future dental bills. ® Division of Dental Health Massachusetts Department of Public Health (617) 727-0732 a Your local Board of Health ® Your dentist or doctor Definitions atom - the smallest particle of an element element - any substance that cannot be separated ion - as electrically charged atom com. pound - a substance contmnin two or more alementa in fixed proportion 11/84 lom 120 MASSACHUSETTS COMMUNITIES RECEIVING WATER FLUORIDATION Fluoridated at 1 part fluoride per million parts water (pp,) City,/Town Year of Start-Uo City/Town Year of Start -UP Acton 1970 Medway 1953 Amesbury 1968 *Melrose 19 78 Amherst 1987 Middleton 195511 Andover " 1969 Millis 1983 Arlington 1978 *Milton Ashburnham 1957 "Nahant 1978 Athol 1952 1978 Natick (waiting completion) Attleboro 19 *Needham ( 1971 Ayer (Ft. Devens 1959 Newbury (part) t) 196699 (town waiting completion) Newburyport i969 Bedford 1978 "Newton (FL) 1963 *Belmont 1978 North Andover 1975 Belchertown School 1953 North Reading '971 Beverly 1952 *Norwood 1978 *Boston Bourne (Otis A.N,G.) 1978 Oak Bluffs (waiting completion) ion) "Brookline 1960 Oxford 987 Burlington (waiting completion) 1978 Peabody Pembroke 1983 *Cambridge (FL) 1974 *Quincy i969 Canton 1978 Reading 1978 1970 "Chelsea 1978 *Revere 1978 Cohasset 1956 Rockport (part natural) 1964 Concord 1970 *"Royalston Danvers 1951 Rutland 85 Dedham 1977 Salem 199 152 Dighton (part) 1971 Saugus i97878 Dracut 1982 Scituate 195 Duxbury 1987 Seekonk 19522 Essex 1970 Sharon 1983 *Everett 1978 Shrewsbury '953 Fall River 1973 Somerset 1969 Fitchburg 1975 *Somerville 1978 "Framingham (FL) 1970 Southbridge Franklin 1970 "Stoneham 1971 1978 Gardner 1987 Sturbridge 1968 Gloucester 1981 Sudbury 1960 Groveland (waiting completion) *Swampscott 1978 Hamilton 1956 Swansea 1969 -*Hardwick (part) Taunton 1981 Haverhill 1971 Templeton 1951 Hingham 1953 Tewksbury 1983 Holden (waiting completion) Topsfield 1953 Holliston 1970 Tyngsboro 1,987 Holyoke 1970 "Wakefield 1978 Hudson 1985 Walpole .978 Hull 1953 "Waltham ;g78 Ipswich 1971 **Ware (part) Lawrence 1983 *Watertown (FL) 1.9v1 *Lexington 1978 Wenham 1967 Lincoln 1971 Wellesley 1957 Longmeadow (waiting completion) Westborough 1974 Lowell 1982 Westford (waiting completion) "Lynnfield (FL) 1972 Westminster -968 (Lynnfield Center) 1959 West Newbury (part) 1969 Lynn 19 -Weston (FL) 1973 *Malden 197878 Westwood _977 M1tanchestrr 1983 Weymouth 1972 "Marblehead 1978 *Winchester (FL) 1956 Marlborough 1982 *Winthrop 1978 "Medford 1978 "Woburn (part) ;978 NOTES: " - Members of the Massachusetts Water Resources Authority, Cormerly Metropolitan Water District (MDC), fluoridated in 1978, • - Naturally Fluoridated at .7 or higher ppm (part) - Communities partially fluoridated. Check with local water department. (FL) - FLuoridating prior to HOC, PREPARED BY THE DEPARTMENT OF PUBLIC HEALTH - TEL: 617 727-1732 November 1988 (6) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 3 MEMORANDUM TO Board of Health Members FROM: Dianne Royle, Secretary( DATE: October 19, 1989 RE Fluoridation I have reviewed the file on fluoridation and attached for your information pertinent articles and memos for your review. There is substantial research that stresses the importance of fluoride in the diet. As you are well aware, it is especially beneficial during the years of primary and secondary tooth growth. According to the American Journal of Public Health, claims that fluoride causes cancer, birth defects, kidney disease, Alzheimer's, etc., have been refuted repeatedly. I also telephoned Martha Wood, Dept. of Public Health, Div. of Dental Health, and she outlined for me the recommended procedure for the Board of Health to take. 1. Feasibility study: conducted by the DPH, no charge, about a two - month process, absolutely no committment on the Board of Health. 2. Ms. Wood will come to a Board of Health meeting and explain the feasibility study results. That study will answer many questions and be the deciding factor as to whether or not to proceed with fluoride. 3. DPH still does engineering work, purchases equipment and installs; HOWEVER, funds have not been appropriated this year. They hope funding would be reinstated next year. 4. One-year process from feasibility study review and to Board of Health ordering fluoridation in the water supply. Only Board of Health can order. 5. Legal notice must be published after order. 6. 90 days after notice, 10% of registered voters can petition to put a referendum question on either the Town ballot or State election ballot. Approximately 50% of the time fluoridation is ordered, a referendum is petitioned. Approximately 50% referendum questions pass. 7. No public hearing is required; however, an information night, series of information articles, cable program, etc. is recommended. -)der the 1 of the hensive 'nedical ,ds) AMERICAN JOURNAL OF • 1 15 all Editorials May 1989 Established 1911 Volume 79, Number 5 EDITOR I Alfred Yankauer, MD, MPH Fluoridation Then and Now ASSISTANT EDITOR Patricia Hange, ScD EDITORIAL BOARD Irene H. Butter, PhD (1990) Chair Doris Bloch, RN, DrPH (1989) Suzanne E. Dandoy, MD, MPH (1990) Joy G. Dryfoos, MA (19g9) Frederick C. Green, MD (991) Dieter Koch -Weser, PhD, MD 191 Mary Grace Kovar, DrPH, MS (1991) Philip J. Landrigan, MD (1990) Jean Pakter, MD, MPH (1989) Lee N. Robins, PhD (1991) Jeannette J. Simmons, DSc, MPH (1990) Zena Stein, MD, DrPH (1989) Fernando M. Trevino, PhD, MPH (1990) Julian A. Wailer, MD (1989) (To be appointed) (1991) STAFF William H. McBeath, MD, MPH Ececutive DirectorlManaging Editor Jaclyn Alexander Publications Director Doyne Bailey. Assistant Managing £dfror Brigitte Coulson Production Editor Mary Beth Kammann Advertising Manager Lucille Bow Marilyn Butler Annabelle Friedman Publication Assistants CONTRIBI,TING EDITORS - George J. Annas. JD. MPH Public Health and the Law Jean Conelley, MLS Book Corner Mary Grace Kovar, DrPH. MS Nrw from NCHS Barbara G. Rosenkmniz, PhD Public Health There and Now Hugh H. Tilton, MD, DrPH Notes from the Field The fluoridation of community water supplies has come to be widely viewed -- along with chlorination and immunization -as one of the most important of modem public health measures. Since it was first introduced into the drinking water in Grand Rapids, Michigan as part of a two -city community trial in 1945, fluoride has made a substantial contribution to the health of the American public of all ages.' The Grand Rapids undertaking was to prove so successful in reducing the prevalence of dental caries in children's teeth that the control city of Muskegon, Michigan soon insisted on also fluoridating its water." Concurrently, the same effect was being noticed in a similar study in which children residing in the fluoridated city of Newburgh, New York were compared to children residing in the control city of Kingston, New York.' Today, 130 million Americans residing in 9,600 communities have access to fluori- dated drinking water.` However, in addition to producing more decay resistant teeth, fluoridation has often produced spirited and bellicose editorial responses in community newspapers, impassioned debates in local, state and federal courts, and continuing attempts to convince state and federal legislatures to rule it illegal.' The arguments against fluoridation have varied over the past four decades and have been asserted by a smal I, but vocal and often effective minority, History has shown that even where consid- erable scientific evidence is brought to bear against the anti -fluoridation perspective, it has little impact on those committed to "the fight."` At various; points in time, fluoridation has been called illegal, a communist plot, immoral, and unconstitutional. It has been blamed for cancer, birth defects, osteoarthritis, kidney disease, premature aging, allergies and, most recently, Alzheimer's disease and AIDS."' These claims have been refuted repeatedly. One of the most puzzling "anti -fluoridation" claims is that fluoride does not work. However, the overwhelming scientific evidence simply does not support this claim. A national study conducted in 1979—M demonstrated that caries rates in school -aged children had declined by 37 per cent compared with a national study conducted eight years earlier.' Children with exposure to water supplies with Optimum amounts of fluoride during their lifetimes had 33 per cent less decay than those who had never been exposed.* A follow-up study in I986-87 indicated an additional 36 per cent decline in decay since 1979-80, with nearly one-half of the school children never having experienced decay in permanent teeth." Dozens of newspapers around the country highlighted the good news, with papers, in many non -fluoridating communities decrying the continuing lack of fluoridation in their community. Other recent studies are continuing to demonstrate the contribution that fluoridation makes to a community oral health in today's environment.""t While the practice of fluoridating drinking water has steadily expanded over the past four decades, the use of fluorides in other ways has also grown dramatically. Today, topical fluorides are applied in dental offices, fluoride mouthrinses and tablets are used in schools and homes, and virtually all dentifrice used in the US contains •Brunelle )A. Miller At. Smith JP DMFS,n US Children with and without Lire -long Exposure to water Fluoridation (Abstract 0302). Paper presented at the meeting of the American Association for Dental Research, Cincinnati. Ohm, March I7-10. 19g3. "National Institute of Dental Research NIDR releases results of new schoolchildren's survey. NIDR Research Digest, July 1988, P.JPH May 1909, Vol. 79, No, 5 581 pacurc+sc��ca C�J� cuGive � e a� a &wnaor� Juiced �;�v BAILUS WALKER, Jr, PhD, M.P.H. i50 ✓xerrumC Axew Commissianer \ Division of Dental Health god&n 02111 L 9th Floor 617 727 -0732 April 3, 1986 Paul and Jane Folkman Box 96 Mansfield, MA 02048 Dear Paul and Jane: Thanks to you and the Mansfield Rotary for inviting me to speak Tuesday. I enjoyed meeting everyone and seeing Mansfield on a sunny spring dayl Enclosed is 1) a copy of the state fluoridation law and 2) a form letter which can be used by the Board of Health requesting the free feasibility study. The study places the town under no obligation to further consider fluoridation. (It takes up to two months to schedule and complete the feasibility study.) 3) An example of a legal notice. If you still plan to. urge to Board of Health to order fluoridation before the end of May I will need to send the Board a'"Commissioner's letter" notifying the Board that the water supply is felow 1 ppm of fluoride before fluoridation is ordered (a legal technicality required by the law). That can be done the week after you send your letter. I am also available to meet with the Board of Health to answer questions. Although a public hearing is not required by law, it is usually wise to hold one. (The hearing can be part of a regular Board of Health meeting.) - I can also have a letter sent by John Nay, executive director of the Southeastern Massachusetts Health Planning Council, the HSA which covers Mansfield. I will also let the Massachusetts Dental Society know of your plans as this organization may provide a small contribution should the question go to referendum. I would encourage you to place fluoridation materials in the Town library and to contact appropriate community organizations. (PTAs, pre-school PTA, League of Women Voters_ President Rosalie Barbate, 48Hampden Dr., Norwood, MA 02062 769-2886,Senior Citizens Center, etc.).The department can send materials directly to doctors and 'dentists for use in their waiting to do so by the Board of Health or local citizens. As I mentioned, Heather Champigny, the Mansfield school nurse, 339-4595, has volunteered to send home information concerning fluoridation with students. (The Department of Public Health can provide the brochures.) Thank you again for your interest and enthusiasm. Yours truly, Martha C. Wood MC;mi THE FOLKMAN COMPANY, INC. Post Office Box 96 • Mansfield, MA • 02048 May 5, 1966 Martha C. Wood Assistant Director of Dental Health for Prevention Programs Department of Public Health Division of Dental Health 9th Floor 150 Tremont Street Boston, MA 02111 RE: Fluoridation of Mansfield's Water Supply Dear Martha, On Wednesday May 1, 1986 I met with the Mansfield Beard of Health to discuss initiating the fluoridation of Mansfield's water supply system. The Board has requested that I bring them the package of information which you sent to me, so that they can review the information prior to their next meeting. I have been invited to attend this meeting also. There are five members of the Board of Health, as well as a professional health department director. Any additional information which you can forward to me, so that I may present it to the Board .of Health, would be appreciated. If this meeting goes well, then the next step is to meet with the Hoard of Selectmen (Water Commissioner). I have asked Scott Leite, Health Director, if you should attend the next Board of Health meeting. I am waiting for his reply. Please call me at 339-6709 or 339-8435 should you have any questions. Thank you very much. Very truly yours, MAY J8 1 Paul J. Folkmany President PJF/eeh ec: Scott Leite, Mansfield Board of Health rr r BAILUS WALKER, Jr, Ph.D, M.P.H. Comm/sslarer i Ar od&m 021),-1 August 13, 1986 Edward Tartufo Chairperson Board of Health Town Hall 50 West Street Mansfield, MA 02048 Dear Mr. Tartufo: The Department of Public Health has determined.. that the fluoride content of Mansfield's water supply is substantially below the level recommended for dental health. The optimal level of fluoride for prevention and reduction of tooth decay is 1.0 parts of fluoride per million parts of water (ppm). In accordance with the provisions of the Massachusetts General Laws, Chapter 111, Section 8C, the Department, in taking cognizance of the dental health of the people of the Commonwealth, strongly recommends that the Board of Health order the upward adjustment of the fluoride content of your water supply available for domestic use to the optimal level for prevention and reduction of tooth decay. The Department of Public Health provides free educational assistance to board members and local municipal officials interested in ordering water fluoridation In addition, through federal funding, the Department will purchase and install necessary equipment and buy the fluoride compound for two years. Communities which have been fluoridated more than two years are reimbursed for part of the cost of the fluoride compound through state local aid funds. If you have further questions, the Director of Dental Health, Gregory N. Connolly, D.M.D., M.P.H., and his staff are available as resources for you. Since 1y, 00 Bailus Walker, Jr., Ph.D., M.P.H. Commissioner BW:mfjfIt AUG l 6 ! BAILUS WALKER, Jr, Ph.0, M.P.H. 150 ✓xemx .�6ww commissaw Division of Dental Health �60,jt,an 02,1 2nd Floor 617 727-0732 April 24, 1987 Don Steele 96 Rumford Avenue Mansfield, MA 02048 Dear Dr. Steele: Per our conversation this morning I am sending the enclosed material on smoking and fluoridation. In Northampton the non-smoking in public buildings includes private offices. It is up to the individual department head to enforce. The room where smoking is allowed is vented directly to the outside. The Board of Health reports "almost no problems." When developing a plan, please consider not allowing smoking in stairways, entranceways and restrooms. Smoking and non-smoking signage should be conspicuous. _ For restaurants, we recommend restaurants of 25 seats or more should be required to designate 50% as non-smoking. (Only 33% of Americans currently smoke.) Smoking sections should not be allowed between two non-smoking sections. Consider not allowing smoking at the cash register if it is next to the non-smoking section. In January, 1987, the Department surveyed via telephone 92 restaurants affected by local ordinances requiring non-smoking restaurant seating. Eighty- three percent said the ordinance had no effect on business, seven percent felt they had gained business, eight percent felth they had lost business and two percent preferred not to comment. None of the Boards of Health felt the ordinance required more staff time and had created no problems. Most informed restaurants of the requirement in person during normal inspections and on an ongoing basis on inspections look for proper signage. For more information concerning public buildings or restaurants, you could talk to Peter McErlain, director of the Northampton Board of Health, (413) 586-6950 or Maura Smith, Cambridge City Managers Office, 498-9011. For restaurants you could also call George Smith, director,Lexington Board of Health (862-0500) or Robert Carlson, director, Leominster Board of Health, 534-7533. As for fluoridation:. Don Steele Page 2 April 24, 1987 We recommend as a first step Boards request a free feasibility study (form letter enclosed) which provides financial information and puts the town at no obligation. We also recommend a long term (one year) educational program consisting of making materials available at Town Hall, the library, schools and public meetings. (I have already spoken at the Mansfield Rotary Club.) A citizens committee can be developed to handle this. Once all legal steps have been completed for fluoridation, the state, with federal funds, will pay for or provide engineering design, equipment and installation of the system, any replacement equipment and the first two years of the compound. After the first two years the state with state funding reimburses the town for a portion of the cost of the compound. I would be glad to meet with the Board at any time to discuss either smoking policy or fluoridation. Yours truly, C. Martha C. Wood Assistant Director Division of Dental Health and office of Non -Smoking and Health MCW:mf enclosure �a�eacGive �� ce a�� c�`umea�rL .��Xv�icE'a BAILUS WALKER, Jr, Ph.D, M.P.H. gx-ev eC . 4ww Commlas"W Division of Dental Health 02 » 2nd Floor 617 727-0732 0 , r TO: Boards of Health FROM: Gregory N. Connolly, D.M.D., M.:f Director of Dental Health�'� DATE: June 1, 1987 M E M O R A N D U M I want to bring to your attention two matters related to fluoridation. The first is the enclosed letter from the American Medical Association (AMA) that urges fluoridation of community water supplies. The Department of Public Health supports fluoridation and urges all communities to fluoridate. In Massachusetts the local Board of Health has the legal authority to order fluoridation. The Department assists all communities interested in fluoridation with a engineering feasibility study, consultation and educational materials and, once all legal steps have been completed, design work, funding for purchase and installation of equipment and two years of the fluoride compound. The second matter I wish to bring to your attention is a scientific advisory bulletin prepared by the Federal Centers for Disease Control (CDC) in response to recent misleading material distributed by a Massachusetts anti fluoridation group charging that fluoridated water causes Alzheimer's disease. As the advisory stresses, there is no scientific basis for these allegations. If you would like futher information, please call me at 617-727-0732. mf cc: Sue Bernstein District Health Officers AN1E1UC,1N IMEDicAL AssocIA'110N 535 NORTH DEARBORN STREET • CHICAGO, ILLINOIS 60610 • PHONE (312) 645-6000 • TWX910-221-0300 JAMES H SAMMONS, MD E%eC'A, Ve Vice Pre Sld0t (645-4300) V Bailus Walker, Jr., PhD, MPH, Commissioner of Public Health Massachusetts Department of Public Health 150 Tremont St. Boston, MA 02111 Dear Doctor Walker: May 13, 1987 This letter is to apprise you of our concern for a large and neglected segment of Americans --some 39%--rho live in areas where natural levels of fluoride in the drinking water are inadequate and no supplemental measures are available to provide protection against dental caries. You are no doubt well aware that the AMA has been a long-time advocate of municipally fluoridated water supplies. Our support for fluoridation dates back to 1957; that support was reaffirmed in 1972 and again in 1974. What we stated in 1974 (HOD action I-74) is no less true today than it was then: "Few health measures have been accorded greater clinical and laboratory research, epidemiological study, massive clinical trial(s) of community populations and public attention —both favorable and adverse... . Research has established that people consuming water [throughout life] containing the [recommended] optimum level of fluoride [0.7-1.2 ppm] experience no adverse effects on their kidneys, thyroid glands, reproductive functions, growth, development, blood, urine or hearing. No cases of allergic reactions have been linked with consumption of water fluoridated at the recommended levels. "Research has also provided evidence that suitable amounts of fluoride may [help prevent or alleviate] bone diseases such as osteoporosis, especially in our aging population. DENTAL HEALTH Sources of FACT SHEET Fluoride Massachusetts Department of Public Health, Division of Dental Health, ISO Tremont Street, Boston, MA 02111 (617) 727.0732I Dr. Bailus Walker, Jr., Commissioner Dr. Gregory N. Connolly, Director of Dental Health What is Fluoride? All fluoride (F-)ions come from minerals occurring naturally in the ground It is the thirteenth most common element found in the earth's crust and twelfth most common found in the oceans. It is also the thirteenth most abundant element in the human body. What are the Common Sources of Fluoride? The mineral sources of the fluoride ion used in community water fluondation are fluorspar, which contains calcium fluoride (CaF2 ); cyolite, which contains fluoride combined with aluminum and sodium (Na3A1F6); and apatite, a calcium compound of fluoride, carbonates, and phosphates [Cato(PO4 , CO3 )6 (F, CI, 0")21 Where is Fluoride Mined in the United States? Fluorspar (also called fluorite) is crystalline and comes in all colors. Found worldwide, the largest deposits in the United States are in southern Illinois and Indiana. Cryolite is rare in the United States and is more commonly found in Greenland and Europe. Apatite is the most common source of fluoride in this country and is found in phosphate rock (which looks like ordinary rock). Florida, Tennessee, and South Carolina are the major locations of apatite deposits in the United States. There are minor deposits of apatite in North Carolina, Montana, Idaho, Utah, and Wyoming. Regardless of the source or extraction process, all pure fluoride ions are chemically identical and occur naturally in a variety of ores. Why Add Fluoride to Water? All water contains some fluoride which leaches from fluoride -bearing rock formations. This leaching process is not limited to calcium fluoride formations but occurs with any fluoride -bearing rock. However, for good dental health children and adults need about one part of fluoride to every million parts of water (1 ppm). Most community water supplies in the United States contain less than I ppm of fluoride and, therefore, require "adjustment" in order to prevent cavities. This adjustment is made by adding fluorides which are refined from fluoride -bearing ores. The fluoride ion is unchanged by this refining process. The ion is the same whether it is leached from the rock by nature or extracted from fluoride -bearing ores and refined to fortify fluoride deficient water. The source of the fluoride ion has no effect on its absorption by the human body. Adding fluoride to public water supplies is comparable to adding other chemicals commonly used in drinking water supplies. These chemicals include chlorine, phosphate, and caustic soda (sodium hydroxide, NaOH). Fluoride is a natural component of water. It does not change its color or taste. Why are There Different Fluoride Compounds? Fluoride is always found in a compound form and never in a free state in nature. When dissolved in water, these compounds dissociate into ions. Theoretically any compound containing fluoride could be used in "adjusting" water. However, practically speaking, the compound must have enough solubility to permit its use in routine water.plant practices. It must also be relatively inexpensive and readily available. In the United States, three compounds meet these criteria: sodium fluoride (NaF), until the early 1980's produced from fluorspar, now produced from apatite; hydrofluosilicic acid (HZ SiFs ), produced from apatite; and sodium silicofluoride (Naz SfF, ), also produced from apatite. What Determines Which Fluoride Compound is Used? No single fluoride compound is ideal for all cities, towns, and districts. In some communities a different compound will be used at different well or reservoir locations. The Tina: selection depends on several engineering factors: • Yield of each of the wells and reservoirs and rate of water production in gallons per minute. • Number of fluoride injection points. • Delivered cost per pound of fluoride compound(s) and cost per million gallons of water at optimum level (1 ppm). • Capital cost of purchasing and installing fluoride feed equipment. • Water department's personal preference which may take into account the amount of labor required for handling, maintenance, and testing of fluorides and fluoridation equipment. • Chemical characteristics of water being fluoridated. • Existing room to house the fluoride feed equipment. What are the Benefits of Water Fluoridation? Fluoridation benefits adults as well as children. Drinking fluoridated water has been shown to result in up to 70 percent fewer cavities and fewer lost teeth. In addition, fluoridation is economical. In fact, every dollar spent adjusting fluoride deficient water saves the community up to $50 in future dental bills. • Division of Dental Health Massachusetts Department of Public Health (617) 727-0732 • Your dentist or doctor Definitions atom - the smallest particle of an element element - any substance that cannot be separated ion - an electrically charged atom compound - a substance containing two or more elomant" i� _' ; cl proportions I1/s4 lOM 121 MASSACHUSETTS COMMUNITIES RECEIVING WATER FLUORIDATION Fluoridated at 1 part fluoride per million parts water (ppm) City/Town Year Of Start -Up City/Town Year of Start -UP Acton 1970 Medway 1953 Amesbury 1968 -Melrose 19 78 Amherst 1987 Middleton 1951 Andover 1978 Millis 1983 "Arlington 1978 *Milton 197878 Ashburnham 1957 •Nahant 1978 Athol 19 Natick (westing completion) Attleboro 197373 "Needham (FL) 1971 Ayer (Ft. Devens) 1959 Newbury (part) 1969 (town waiting completion) Newburyport 1969 Bedford 1978 -Newton (FL) 1963 *Belmont 1978 North Andover 1975 Belchertown School 1953 North Reading 1971 Beverly 1952 *Norwood 1978 Billerica (waiting completion) Oak Bluffs (waiting completion) "Boston 1978 Oxford 1987 Bourne (Otis A.N.C.) 1960 Peabody 1983 *Brookline 1978 Pembroke 1969 Burlington (waiting completion) *Quincy 1978 "Cambridge (FL) 1974 Reading 1970 Canton 1978 *Revere 19 78 *Chelsea 19 Rockport (part natural) 1984 84 Cohasset 195656 ••Royalstoh Concord 1970 Rutland 1985 Danvers 1951 Salem 1952 Dedham 1977 Saugus 1978 Dighton (part) 1971 Scituate 1954 Dracut 1982 Seekonk 1952 Duxbury 1987 Sharon 1953 Essex 1970 Shrewsbury 1953 - *Everett 1978 Somerset 1969 Fall River 1973 *Somerville 197 Fitchburg 1975 Southbridge 3971 *Framingham (FL) 1970 •Stoneham 1978 Franklin 1970 Sturbridge (waiting completion) Gardner 1987 Sudbury 1960 Gloucester 1981 *Swampscott 1978 Groveland (waiting completion) Swansea 1969 Hamilton 1956 Taunton 1981 ••Hardwick (part) Templeton 1951 Haverhill 1971 Tewksbury 198383 Hingham 1953 Topsfield 1953 Holden (waiting completion) Tyngsboro 1987 Holliston 1970 "Wakefield 197 Holyoke 1970 Walpole 19777 Hudson 1985 *Waltham 1978 Hull 1953 -*Ware (part) Ipswich 1971 -Watertown (FL) 1971 Lawrence 1983 Wenham 1967 *Lexington 1978 Wellesley 1907 Lincoln 1971 Westborough 1974 Longmeadow 1989 Westford (waiting completion) Lowell 1982 Westminster 1968 *Lynnfield (FL) 1972 West Newbury (part) 1969 (Lynnfield Center) 1959 -Weston (FL) 1973 Lynn 1983 Westwood 1977 *Malden 1978 Weymouth 1972 Manchester 1983 *Winchester (FL) 1956 *Marblehead 1978 *Winthrop 1978 Marlborough 1982 *Woburn (part) 1978 *Medford 1978 NOTES: * - Members of the Massachusetts Water Resources Authority fluoridated in 1978. Naturally Fluoridated at .7 or higher ppm (part) - Communities partially fluoridated. Check with local water department. , (FL) - Fluoridating prior to MDC. PREPARED BY THE DEPARTMENT OF PUBLIC HEALTH - TEL: 617 727-0732 January 1990 TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 November 8, 1989 Gregory N. Connolly, D.M.D., M.P.H. Director of Dental Health Department of Public Health 150 Tremont Street Boston, MA 02111 Dear Dr. Connolly: The Board of Health in the Town of Mansfield is hereby requesting the Department of Public Health's engineering staff to conduct a free fluoride engineering feasibility study as their time permits. The Board of Health recognizes that the results of the feasibility study in no way obligate the community to fluoridate their public water supply. Thank you. Very truly yours, �G�tJC2lcA— �� rV Edward J. Rose erg r Chairman, Board of Health cc: Water Superintendent Town Manager Board of Selectmen /dr w.e 0/ Michael S. Dukakis 1Jlli9dYAlre/LiYY�✓ZeCILtiL Governor Philipli'. Johnston �j'' !� Secretary 1,50 ✓1-wnLNL1/V&ee4 Da borah Prothrow-Stlth, M.D. O06'gJL 0,,07'11 GOrn�nifslener TEL: (617) 727.0732 FAX(617) 723.1659 January 9, 1990 Board of Health Town Hall 50 West Street Mansfield, MA 02048 RE: MANSFIELD-Public Water Supply Feasibility Study Regarding Fluoridation of Water Supply Gentlemen: At your request the Department of Public Health (DPH) conducted an investigation from an engineering perspective of the possible fluoridation of the Town's water supply. After reviewing all the facts, which included a site inspection of the eight sources, the Department is of the opinion that the water supply can be fluoridated safely and effectively at the optimum fluoride level of 1 ppm for sound dental health. The Department recommends that a small sodium fluoride metering system be installed at eight locations at a 1990 estimated cost of $70,000 plus $10,500 per year for the cost of the fluoride chemical. If you decide to proceed with water fluoridation the legal requirements under Massachusetts General Laws, Chapter ill Section Be must be completed first. When the Department first recommended fluoridation, grant funding was available to purchase and install fluoridation equipment. Due to recent reductions in the state budget funding is not available for next year. If the governor's revenue package is adopted funding may be available the following year. Board of Health Page 2 January 9, 1990 However, free engineering assistance in the form of detailed plans, specifications, and installation advice will be provided by the Department's engineer once legal requirements have been completed. Given the time that it takes to order fluoridation and develop engineering plans we still strongly recommended that you order fluoridation (18-24 months). If the board wishes to repeal its order in the future it may do so. If you have any questions after reading the enclosed report, please feel free to contact Mr. Frederick Barker, Fluoridation Engineer, at (617) 727-0732. If you wish to proceed with fluoridation of the public water supply, please contact Martha Wood, Assistant Director, at (617) 727-0732. Very truly yours, Grego onnolly, D.M.D., H. Dir ct Dental Health GNC:B:mf Enclosure cc: DEP-Lakeville DPW -Water Division E N G I N E E R I N G F E A S I B I L I T Y S T U D Y R E G A R D I N G F L U O R I D A T I O N O F M A N S F I E L D P U B L I C W A T E R S U P P L Y P r e p a r e d b y M a s s a c h u s e t t s D e p a r t m e n t o f P u b l i c H e a l t h F red Brick P. Barker Jr., P.E. F l u o r i d a t i o n E n g i n e e r J a n u a r y 1 9 9 0 FREDEFIC7( �'��, PIE 4CE �.41ii(ER, JR. 'C.i No. 29536 O � /e Michael S. Dukakis Governor Philip W. Johnston Secretary Commissioner TEL: (617) 727.0732 FAX: (617) 723.1659 �27�.�oOrr 1,50 ✓/ e%YLOII� Vf/ CPf 'qOd'I.O11' 02111 The Massachusetts Department of Public Health has conducted an engineering study of the Mansfield public water supply to ascertain whether or not the water could be fluoridated at optimum level for sound dental health. Water samples over the years from the wells have shown that a trace amount of fluoride occurs naturally. The amount of approximately 0.10 parts ryr million (ppm) or milligrams per liter (mg/1) of fluoride is well below Phe recommended optimum of 1.0 ppm. In order to complete the study, a visit to the Mansfield public water supply was made on December 15, 1989. The records were reviewed and studied. The Department wishes to thank Gerald St. Hilaire, Water Superintendent, and Ben Couture, Foreman,for their assistance in preparing this report. The conclusions drawn from this study are the Department's recommendations, which is not to say there are no other acceptable methods t,) fluoridate the public water system. WHY FLUORIDATE? Tooth decay is the most common disease found among both children and adults in this country. In Massachusetts, the prevalence of tooth decay is approximately 40 percent above the national average for individuals 12 years of age and older. Progress has been made in preventing tooth decay, mainly through fluoridation of community water supplies. Fluoridation has proven to be the most cost-effective method of producing significant reductions in tooth dewy. Children drinking fluoridated water from birth through adulthood can have up to 60 percent fewer cavities than youngsters living in non -fluoridated communities. In addition, the cost of regular dental care of children in fluoridated communities is about 50 percent less than that of children unable to drink fluoridated water from birth to adulthood. -2- The effectiveness of fluoridation was once more documented by a recent study in Holyoke, MA a full decade after fluoridation. The study compared the dental health of a group of children who grew up in Holyoke prior to fluoridation of the municipal water supply in 1970 with a similar group raised during the 1970's. The children ranged in age from seven to thirteen. The seven year olds who drank fluoridated water all their lives had 84 percent fewer cavities than their pre -fluoridation counterparts. The 13 year olds experienced a 50 percent drop in cavities. As of January 1990 approximately 56 percent of the Massachusetts population representing 113 cities, towns, and districts benefited from drinking fluoridated water. A substantial number of communities, however, have not yet fluoridated their water supply. DESCRIPTION OF EXISTING PUBLIC WATER SUPPLY Mansfield is served by nine wells and one proposed well. One well, is inactive due to high sodium. - Hydrated lime (Ca(OH)2 o H20) for corrosion control is presently added to all active wells except Albertini well # 4. Optimally fluoridated water from Attleboro is currently bought and supplied to 57 homes in certain sections of Bungay Road, West Street, and Balcom Street, Mansfield. SELECTING A FLUORIDE SYSTEM There are three fluoride chemicals that are currently being used to successfully fluoridate 113 cities and towns in the Commonwealth. These are sodium fluoride (NaF), sodium silicofluoride (Na2SiF6), and hydrofluosilicic acid (H2SiF6). No single fluoride compound is ideal for all cities and towns. The final selection of the fluoride compound(s) for Mansfield must take into account these factors: 1. Yield of each well and rate of water production in gallons per. minute. 2. Number of fluoride injection point(s). 3. Pressure at fluoride injection points(s). 4. Delivered cost per pound of fluoride compound(s) and fluoride compounds) cost per million gallons of water at optimum level (1.0 part per million). 5. Capital cost of purchasing and installing fluoride metering equipment. 6. Space to house fluoride metering equipment. 7. Water superintendent's personal preference which takes into account a minimum of labor for handling, maintenance, and testing. 8. Chemical characteristics of water being fluoridated. 9. Frequency that each well is used. 10. Items that are eligible for funding by the State Department of Public Health. Based on the survey, which considered all engineering aspects of the public water supply, the Department recommends that the Town consider a small sodium fluoride metering system at Cates Spring GP well, Albertini GP wells 2, 3 and 4, Witch Pond GP Well 6, Dustin GP Well 7, Prescott GP wells 8 and 9, and proposed Ash Tubular Well # 10 using eight application points. BRIEF DESCRIPTION OF SODIUM FLUORIDE METERING SYSTEMS AT EIGHT LOCATIONS TO SERVE NINE WELdS An economical and safe way of automatically preparing a stock solution of 4 percent sodium fluoride is provided by a sodium fluoride upflow saturator tank (see sketch on page 6). The constant solubility of sodium fluoride assures a uniform concentration over water temperatures normally encountered. Make-up water is automatically added (by means of a solenoid valve connected to a liquid level switch) to the 50 gallon plastic saturator tank. The four percent saturated solution of sodium fluoride is metered into the effluent main at each of the eight well stations by an electronic or motor driven metering pump. The water mixes with the sodium fluoride solution in the main to yield one part per million (ppm) of fluoride which is the optimum level for sound dental health. Every few days, depending on the volume of water being fluoridated, soditmi fluoride crystal (looks like white sugar) is added to the top of the saturator by the water department personnel. Sodium fluoride is bought in either 50, 55, or 100 pound bags. It may be stored at any of the water stations or garage on pallets. The eighteen fluoride metering pumps at eight locations would be constant rate subject to manual adjustment. Each metering pump would be electrically interconnected to the well pump motor to insure fluoride is only added to the water when the well is pumping water. To save capital costs and manpower, the fluoride facilities could be housed at well 3 to fluoridate wells 2 and 3 together. At all locations the fluoride metering pump would have a spare pump in parallel should the regular pump be out of operation for any reason. As an additional safeguard against over -feeding, all eighteen fluoride metering pumps will be equipped with an anti -siphon valve, and the water department would test each of the eight fluoride effluent mains daily for fluoride content using a specific -ion tester. If no water is pumped by any pump or consumed, then no fluoride test is required that particular day. 4 Monthly check samples from the wells and distribution system would be collected by the water department and sent to the state laboratory in Lawrence (LES) for fluoride analyses. 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Dukakis Governor Philip W. Johnston Secretary David H. Mulligan Commissioner TEL: (617) 727.0732 FAX: (617) 723.1659 TO: Local Boards of Health Local Water Departments FROM: Gregory N. Connoll , D. P. . RE: Fluoridation and Al ssociation with Cancer DATE: February 6, 1990 - M E M 0 - There have been recent news articles on preliminary data from an animal study done by the National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences that show a tendency for bone cancer in male rodents who were given high levels of fluoride. According to the Federal Centers of Disease Control it is premature and speculative to interpret the results at this time. For your information we are supplying a summary of preliminary results prepared by the Centers for Disease Control and press stories on the study. Studies done by the National Cancer Institute over a number of decades have found no relationship between water fluoridation and cancer in humans. From 1973-1987 bone cancer rates have remained steady while the number of persons using fluoridated water has increased. The type of bone cancer found among the rodents is rare in humans representing .01 percent of the 1.1 million cancers that occur annually. Based on the number of well done human studies that have found no association between fluoridation and cancer, the Department of Public Health continues to recommend fluoridation as a safe, effective way to prevent dental caries. We will monitor the progress on the National Toxicology Program Study and keep you informed of the results. lb Enclosure cc: Howard Spivak Van Dunn DATE:; February 5, 1990 FROM: Acting Director, Centers for Disease Control SUBJECT; Sodium Fluoride Bioassay Study TO: State Dental Directors Following is a cover letter from the National Toxicology Program report evaluating the long—term toxicity and carcinogenicity of sodium fluoride, The complete set of data tables and graphs will be sent to you within the next two days through your State Health Officer, If you have questions about this material, please contact the Dental Disease Prevention Activity, Center for Prevention Services, at (404) $39-1630. ! Walter R. Dowdle, Ph.D. I' Department of Health and Human Services Public Health Service i National Toxicology Program P. 0, Box 12233 Research Triangle Park, NC 27709 February 6 1990 Enclosed are the verified, but as yet uninterpreted, pathology data for the National Toxicology Program (NTP) study of the toxicity of sodium flouride. The National Toxicology Program conducted studies in two species of rodents to evaluate the long—term toxicity and carcinogenicity of sodium flouride, As indicated in the tables, sodium flouride was administered in the drinking water at concentrations of 0, 25, 100, or 175 ppm (equivalent to 0, 11, 45, and 79!ppm flouride) to Fisher 344 rats and BBC3F1 mice (six weeks old at the start bf,the study) of each sex for two years. Thore Were BO animals in each of the control and top dose groups and 50 in the low and mid dose groups, Ten additional animals per sex, species and dose were killed at 26 and 65 weeks; additional control animals were sacrificed in those Weeks in which an animal in a dosed group died, The animals received a gross Necropsy and histopathologic evaluation. These pathology data, along with other information regarding the design, conduct, and interpretation of the NTP study on the long—term toxicity of sodium; flouride, will be assembled into a draft NTP report by staff members, It must be emphasized that the scientific interpretation of these data is a complex process involving a number of scientific disciplines, Proper interpretation requires an understanding of the historical information concerning the variability of tumors and other lesions that occur normally in aged rodents of these strains and an appreciation of the most appropriate selection of study groups for statistical comparisons. Further, a very large number'of statistical tests have been performed because of the large number of different cancer types and sites examined by the pathologists. Therefore, it is expected that a number of statistically positive results will be found in the data by chance alone, These issues clearly indicate that until the scientific evaluation is completed in April, interpretation of these data is premature, URGENT -- PLEASE FORWARD TO STATE DENTAL DIRECTOR OR DESIGNATE DATE: January 23. 1990 FROM: Dental Disease Prevention Activity Center for Prevention Services Centers for Disease Control SUBJECT: FACT SHEET: National Toxicology Program (HTP) Study of Chronic Toxicity and Carcinogenicity of Sodium Fluoride. TO: All State and Territorial Dental Directors. Additional information about the NTP fluoride bioassay study was released today: it provides limited pathological findings.• This information was released prematurely an January 19. 1990. to a Scripps Howard reporter, prompting development of the accompanying "Fact Sheet." The preliminary findings of asteosareamas and squamous cell carcinomas in the study animals (F399 rats) were confirmed by a panel of pathology experts on January 12. For your conuenience. we have prepared a summary data table of the neoplastic lesions presented in the NTP "Fact Sheet." NTP representatives continue to stress that the study is ongoing and investigators have just begun the evaluation phase of the study. At the present time, It is inappropriate to cite the NTP study, either to support or to deny an association with human exposure to fluoride. Also enclosed in this information packet are copies of two news articles written by Robert Engelman and released by the Scripps Howard News Service. The articles were released on 01/20/90 and 01/23/90 and were available to approximately 350 subscribing newspapers around the country. We are aware of two cities in which the article appeared: Albuquerque, Hew Mexico, and Pittsburgh. Pennsylvania. We are in continuing contact with PHS agencies and the investigators at NTP, and will provide the final pathology data tables when they are released to the public and Federal agencies. We plan to continue to use the CDC Public Health Network, special mailings, and electronic bulletin -boards to inform State Health Agencies of developm_nts in and implications of the HTP study. ATTACHMENTS: (i) National Toxicology Program <HTP> Study of Chronic Toxicity and Carcinogenicity of Sodium Fluoride - FACT SHEET. Data Table: Confirmed Cases of Cancers Scripps Howard News Service: "Possible Link Between Cancer, Fluoride Found in Federal Study." Scripps Howard News Service: "EPA Promises Extensive Safety Review of Fluoridated Water." I � 8c ^ 11 U L N O I N bb L q E iq L a W� W 3 � Y 0 6 c ) o W4 p U •� 9 �-+ V J T A N L = L a 10 A \ C N � W �Oi ^ >• � N L Y V O 2 O v C O/J Zj •� O C C O ro g ai E S nY N R YI !! III J O V 4) Y C Y ^�' no•cE _" O al c u o a'o a w a°1+ L L 9 N' n E E! Y O J O\W c v NraUO Q Y a = A Ua C Ol ip C.�YY L Y N = C N69 L x O vac = W Y O O N i of L O y L Y � = L > N v anon y Y • =W � W 6 ? UN Q YY • U C L o mom•^� m La V Z � O N N U q ji 3 V�Y 69 U Y C O c a =1 n m L+m O^ O W O N I n W O q Nwo V N a L V O O C N a 4 £ Y C N O T O^ C Y 4'3L vt � o O aw ew aF-�O Yn 4-nE:NY N N V OY LW Y'OA y Y r0 ryL O m C I() lG qz Scn Acc. Z0t�,Z`f +14 j wu u , c�1 6P- -- x ?(l? 14 (VOIl LU4 CAA.4- jCjqZ) 1 I,39g.ss c4a Cc)si . TO: Bob Swanson, Town Engineer FROM: Carol C. Sosman, Chairman DATE: July 12, 1995 RE : Fluoridation I have read your two memos dated May 8 and 22, 1995, with interest. Unfortunately, neither of them answers the questions you were asked to address by the Board of Health. In order not to lose the possibility of State funding for Mansfield's fluoridation project, we need to clear answers to some basic questions with no further loss of time. Please consult with staff from the Water Department, as needed, and provide a written response to the following questions by August 1st. 1. How many fluoridation units will be needed to fluoridate the Town water (number and location)? 2. Identify which locations can house the fluoridation equipment shown on the plans without modification, and estimate the installation cost per location. 3. Identify which facilities will need alterations and/or additions to accommodate the fluoridation equipment, describe the needed work, and estimate the cost per location (facility alteration and equipment installation). 4. Evaluate the operating impact of the addition of fluoridation equipment, estimating annual operating cost, including materials, labor, and maintenance expenses. 5. Combine the data from #2 through #4 to create a total fluoridation project profile, summarizing capital project tasks and costs, and annual operating costs, by location. 6. Optional: Identify alternate equipment/facility options, showing cost effects on the capital investment. 6a. Identify the operating effects of options identified in #5, and evaluate the cost advantages/disadvantages of each option. Page 2, MEMO, Town Engineer, July 12, 1995 Clearly, this analysis will require close cooperation between your office and the Water Department staff, especially in the analysis of the operating effects. The Board of Health looks forward to receiving your complete report. We welcome you to a meeting to discuss your findings. Thank you. cc: Dave Archard Dan Clifford Bill Williams /dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 Mansfield Board of Health M Eram0 RANDUM TO: William F. Williams, Town Manager �jy� FROM: Raymond K. Martin, D.D.S., ChairmanlC►��<G-- RE: Fluoridation/Capital Improvements Plan FY97 DATE: December 18. 1995 As you are aware, the Town of Mansfield is currently under an order from the Board of Health to fluoridate the water supply. We have staved order, which became valid on December 16, 1991, until such time as the financial condition of the town improved and the position for a grant became favorable. It is our understanding that in the grant process the town must first have the money in place to complete the project, with reimbursement through the grant. Partly for these reasons and simply that the financial position of the town has improved, the Board wishes the Town to proceed with the fluoridation order. Since this is an improvement to the water system, we anticipate that the amount of $ 73,500 recommended by then Town Engineer Robert swanson will be included in the Capital Improvement Plan or other appropriate budget location for fiscal year 1997. Additionally, the expenses of the water department should increase to facilitate implementation. The Board anticipates the fluoridation order will assume a high priority within the CIP. I look forward to meeting with you and the Capital Improvement Plan committee to resolve any question or problems connected with implementation of the order to fluoridate in fiscal year 1997. Attachment /dr TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 December 16, 1991 Gregory N. Connolly, D.M.D., M.P.H. Director, Office of Dental Health The Commonwealth of Massachusetts Dept. of Public Health 150 Tremont St. Boston, MA 02111 Dear Dr. Connolly: The Board of Health in the town of Mansfield is hereby requesting the Department of Public Health's engineering staff their assistance in developing the plans for fluoridating Mansfield's public water supply. All of the legal steps have been completed. The Board of Health ordered fluoridation on June 20, 1991. The legal notice appeared in the Mansfield News on September 13, 1991. There was no appeal. We look forward to hearing from you. Thank you. Very truly yours, MANSFIELD BOARD OF HEALTH �6,ti �ac Michael VanSplinter Chairman /dr cc: Town Manager Board of Selectmen Finance Committee Water Superintendent Town Engineer 'TOWN OF MANSFIELD, MASSACHUSETTS 5o West Street, Mansfield, MA 02048 TO . Board of Selectmen FROM: Board of Health DATE: June 26, 1991 RE . Flouridation Vote On June 20, 1991 the Board of Health made the following motion. The vote was 3-2, in favor of flouridating Mansfield's public water supply. MOTION: Move that the Board of Health order the Flouridation of the public water supply of the Town of Mansfield. Further, recognizing the financial condition of the Commonwealth, and that there are already nine other towns waiting for state aid for flouridation, the Board requests that the Board of Selectmen, the Finance Committee and the Capital Improvements Committee include the capital and operating costs to implement this order in the FY93 budget. cc: Town Manager Town Clerk Finance Committee CIP Water Superintendent Town Engineer TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 Mansfield Health Department M EM O,RANDUM TO: William F. Williams, Town Manager FROM: Scott Leite, Health Agent r RE: Fluoridation/Capital Improvements Plan FY97 DATE: November 24, 1995 Attached are the documents necessary for the implementation of the fluoridation order. I have confirmed with Fred Barker, Massachusetts Department of Public Health, that the 5% increase over his original estimate of $ 70,000 for installation of the system remains an adequate amount. Therefore, as stated in the memorandum of August 1, 1995 from former Town Engineer Bob Swanson to Carol Sosman, Chair Board of Health, the amount of $ 73,500 is the amount that needs to be submitted for the FY97 Capital Improvements Program. Additionally, as stated in the memorandum, an amount of money needs to be added to the Water Department's budget for the operation and maintenance of the fluoride injection system. The amount in the memorandum is for a full year; I believe that the full amount would not be necessary depending on how long construction of the system will take. If you have any questions, please do not hesitate to contact me. Attachments /dr - 7 - CAPITAL ODST TO FLUORIDATE MANSFIELD PUBLIC WATER SUPPLY The following items apply to eight sodium fluoride metering systems necessary to fluoridate the water system: Quantity Item Estimated 1990 Costs . 1 Fluoride specific -ion lab tester with $ 1,500 accessories 8 Furnish sodium fluoride metering systems $40,000 with all piping and electrical connections and spare parts (includes eighteen electronic or motor driven type metering pumps, eight saturators, two softeners, four interlocks, 5/8 inch water meters and two 3/4 inch reduced pressure backflow preventers) 1 Furnish representative or 100 feet out well $ 1,000 sample tap terminating in the wellhouse 1 Installation cost of above fluoride metering $20,000 systems and sample tap by Mansfield water Department and/or their sub -contractors Miscellaneous equipment (safety equipment, $ 2,000 pallets, etc) 8 DPH state engineering services consisting $ 0 of plans, specifications, purchasing and installation advise at nine wells Allowance for contingencies and inflation $ 5,500 Total: $70,000 Eff.-In Sodium fluoride in 50 - 55 pound bags currently sells for $.68 - $.75 a pound delivered. The prices vary according to purity, supplier, and quantity of chemical bought per shipment. In 1988 the Mansfield Water Department produced approximately 741 million gallons from all sources. The delivered sodium fluoride cost for the Town is estimated to be $10,500 per year or $14 per million gallons. This figure allows for no increase cvpr 1988 levels as 1989 water consumption actually declined. Manpower supplied by the Mansfield Water Department would be needed to monitor the fluoride levels, adjust the fluoride metering systems as needed, replenish the fluoride chemical in the saturators and keep the fluoride pumps in operating order. An estimate is an average daily labor cost of one half hour per system 3-4 hours per day to conduct daily tests, maintenance, and to meet all state requirements. Some days the manpower will be less, and some days more. No extra travel time on weekends should be needed as the sources are checked. Electrical costs are estimated to cost less than $500 a year. TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TO: CAROL SOSMAN, CHAIRMAN OF BOARD OF HEALTH FROM: BOB SWANSON, TOWN ENGINEER -6;)rj DATE: 811195 SUBJ: FLUORIDATION OF TOWN WELLS As per our telephone conversation of yesterday, I have discussed the two types of fluoride injection with Water Department personnel and they would prefer to install the sodium fluoride powder systems for the existing public drinking water wells. Also, as we discussed, I have the following comments on the questions in your July 12, 1995 memo. 1. A total of seven (7) fluoridation systems will be required to serve our existing wells. Systems will be required at the following wells: Cate Springs Well # 1, Albertini Well # 4, Witch Pond Well # 6, Dustin Well # 7, Prescott Well # 8, Prescott Well # 9, and one system serving the dual well arrangement of Albertini Wells # 2 and # 3. 2. The above mentioned wells presently have sufficient facilities to house the fluoridation systems. The designs for the systems have been previously completed by Mr. Fred Barker, PE, who is an engineer at the Massachusetts Department of Public Health (DPH). Mr. Barker visited the sites with Mr. Ben Couture, Mansfield's Water Operations Manager, in conjunction with the designs. The systems are designed for receiving the chemical in 50 lb bags of powder, dumping the powder into a liquid saturator and mixing it with water to form a fluoride slurry and injecting the slurry via manually controlled metering pumps into the water mains. Mr. Barker also estimated the capital costs of the systems to be $70,000 in 1990. 1 contacted Mr. Barker to discuss the costs and he feels that the costs have only escalated 5% since 1990. Thus, the capital cost in 1995 $ for all seven systems is $73,500 including private labor for installation. This total cost equates to a cost of $10,500 per system. Mr. Barker feels that we would be eligible for 100% reimbursement of these capital costs from the DPH. 3. Based on Mr. Barker's designs, there does not appear to be any alterations or additions required at any of the well sites. 4. Chemical costs are estimated to be $14 per million gallons of water treated. With an annual daily pumping rate of 2.2 million gallons per day the annual chemical costs are estimated to be $11,300 per year. We would also be eligible for state funding of the chemical costs for the first year of operation from the DPH. Labor costs are estimated to be $15/hr. and 0.25 hours per bag of chemical. Based on chemical usage of 20 lbs. per million gallons of water treated and 50 lb bags this cost is estimated to be $1,200 per year. The Water Department plans to provide this labor with existing personnel. Operating and Maintenance costs are estimated to be an additional 5 % of the capital cost per year, which equates to $3,675 per year. 5. A summary of the capital and operating costs are shown below: Capital Costs for Seven Systems $73,500 Operating Costs for Seven Systems Chemicals $11, 300/yr Labor $1,200/yr Operation and Maintenance 3 675/ r Total Annual Cost $16,175/yr 6. We have no optional equipment or fluoride injection systems under consideration. My previous memo also discussed the ability to have the Water Department fund the supply of fluoride pills at a local pharmacy. I contacted two pharmacists and they recommended treatment for children up to the age of 16 years, but noted that most children stop treatment at an age of 10 or 11 years. The pharmacists also provided the cost of the pills to be $8.18 per year per person for pills. Using 3000 residents and a cost of $8.18 per year would result in an annual cost of almost $24,500 per year, which is a significant increase over the direct fluoride injection into the water system. It is difficult to determine the number of residents who use bottled water and would need the pills to have proper fluoride treatments. cc: W. Williams D. Clifford S. Leite D. Archard TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 March 24, 1992 Mr. Gregory N. Connolly, D.M.D., M.P.H. Office of Dental Health The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 150 Tremont Street Boston, MA 02111 Re: Water Fluoridation Engineering Agreement Dear Mr. Connolly: Please be informed that I hereby designate Robert Swanson, P.E., DPW Director/Town Engineer, contact person for the water fluoridation engineering. Mr. Swanson can be reached at (508) 261-7330 to schedule an appointment. Thank you for your cooperation. Sincerely, William F. Williams Town Manager WFW/ego cc: Henry Austin, Chairman, Board of Health L.Z�ott Leite, Health Agent Robert Swanson, DPW Director/Town Engineer Gerald St. Hilaire, Water & Wastewater Operations Manager TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Town Manager and Water Superintendent FROM: Chairman, Board of Health NmZ1. RE . Fluoridation Engineering Agreement DATE: February 10, 1992 Please find attached two copies of the fluoridation engineering agreement from the Dept. of Public Health. Your signatures are requested on both copies. You may return the copies to the Board of Health office and 1 will send them back to the DPH. Thank you. f xecutioe �ic� of ✓�a�t% grzcG ��inza� Jrrr�ice� /so li�ino/rb�I>i�Pb William F. Weld 00&0/?/ O21> Governor David P. Forsberg Secretary David H. Mulligan Commissioner February 28, 1992 Board of Health Town Hall 50 West Street Mansfield, MA 02048 Att: Henry M. Austin, Chairman Gentlemen: RE: Water Fluoridation Engineering Agreement Enclosed is an executed copy of our water fluoridation engineering agreement. As article number one states, please mail the Department the name and phone number of your designated contact person so an appointment may be scheduled. If you have any questions, please call Mr. Fred Barker P.E., Fluoridation Engineer at 617-727-0732. Very truly yours, Gre y onnolly, D.M.D., M.P.H. Offi of Dental Health C:B:f Enclosure - agreement cc: Water Department Town Manager FLUORIDATION AGREEMENT BETWEEN THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH AND THE TOWN OF MANSFIELD Whereas, the Massachusetts Department of Public Health, hereinafter called "Department," advocates the promotion of sound dental health through the fluoridation of the public water supply for domestic use in any community where it is below optimal level; and Whereas the Department desires to render assistance to communities that have compiled with Chapter 111, Section 8C of the Massachusetts General Laws; and Whereas the Town of Mansfield acting through its Town Manager hereinafter called "Town", is an eligible community for said assistance, the following agreement is made between the respective parties: THE TOWN AGREES: To make TOWN employees available to consult as necessary with the Department's registered professional engineer responsible for designing the fluoridation system and further to designate in writing a responsible and accessible person to act as the TOWN'S representative with respect to the work to be performed under this agreement. Such designated person shall have the complete authority to transmit instructions, receive information, interpret and define the TOWN'S policies and decisions with respect to materials, equipment, elements and systems pertinent to the Department's services. THE DEPARTMENT AGREES: To provide a registered professional engineer to prepare the plans and specifications for the purchase and installation of the fluoridation equipment and accessories. The sodium fluoride system shall be designed substantially in accordance with the Department's feasibility study dated January 9, 1990. 1 of 2 2 of 2 Nothing herein shall be construed as creating any personal liability on the part of any officer or employee of the Department or the TOWN, nor shall it be construed as giving any rights or benefits here under to any one other than the TOWN and the Department. Town of Mansfield Town Manager ichae Van splinter Chairman of Board of Health ,tea 1 j �� n Gerald -St. Hilaire Water Superintendent D-- 1t -` A Date Massachsetts Department of Public Health Greg y onnel.ly, DD4D., MPH. Dir�cto Dental Heal h Date *Chairman of the Board of Health as of January 1, 1992 is Henry M. Austin. ':'V 461, L� �7 TOWN OF MANSFIELD) MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO: WILLIAM WILLIAMS, TOWN MANAGER FROM: BOB SWANSON, TOWN ENGINEER DATE: 5/22/95 RE: REVIEW OF FLUORIDE INJECTION SYSTEM FOR ALL TOWN WELLS As promised, I have completed the review of the fluoride design as provided by the State Department of Public Health. Based on discussions with David Archard and Ben Couture, they feel that the existing wells should incorporate the proposed design with the supply of fluoride in 50 pound bags. We will further evaluate the possibility of bulk liquid fluoride at the new Ash Well. Another item that should be considered is the use of tablets or pills of fluoride, which are taken by mouth by the users who wish to have fluoride treatment. The Town could supply the tablets to the residents requesting them. In this manner the residents who use bottled water would also have the option of using fluoride. We cannot determine the amount of'residents who use bottled water. I do not recommend having both methods, fluoridation of the water supply and tablets, available for residents due to possible health effects. File: 05: FLUORID2 - -- S TOWN OF MANSFIELD, MASSACHUSETT ,C d 50 West Street, Mansfield, MA 020 8 MEMORANDUM TO: WILLIAM WILLIAMS, TOWN MANAGER FROM: BOB SWANSON, TOWN ENGINEER 5J6vrl_- DATE: 518/95 /G RE: REVIEW OF FLUORIDE INJECTION SYSTEM FOR ALL TOWN WELLS - YOUR MEMO OF 5/8/95 I have spent considerable time reviewing the design of the fluoride injection systems for all our wells. The design was completed by an engineer at the State Department of Public Health (DPH). There are two options available for fluoride injection: dry bagged powder or liquid. The design presented by the DPH is for the dry bagged powder. The bagged powder is mixed with water to form a slurry prior to injection into our water pipes. These systems would be placed in our existing well buildings. The powder systems will require more manpower and handling of the bags. At Cate Springs, the slurry would have to be mixed approximately every other day. We have been attempting to eliminate the use of bagged chemicals, specifically lime, which is being replaced with the liquid KOH (potassium hydroxide) systems because of manpower and employee health concerns. With the liquid fluoride systems the liquid is directly pumped into the water pipes. The liquid is very heavy and weighs approximately 10.1 pounds per gallon. The liquid is available in 15, 30 or 55 gallon drums, all with significant weight. Even the weight of a 15 gallon drum is approximately 160 pounds, which cannot be handled by one laborer. Attleboro's Water Department is presently using drums and feels that the liquid fluoride uses less manpower and offers simpler injection systems. However, the liquid fluoride is required to be housed in a separate or attached shed that does not require heating. The smallest drum (15 gallons) would provide for a four (4) day supply at Cate Springs. We would be able to have multiple drums on hand at the various well sites to increase the time between drum deliveries. If we were to have the liquid systems installed, we may need to purchase a drum dolly (or hand truck) to have easier handling and reduced chance of injury with the drums. I have discussed the liquid systems with the State engineer who designed the systems and he would redesign our systems for the liquid fluoride if requested. I plan to continue my investigation of the two options and be completed within two weeks. As you can see from above, there is a significant amount of data to review. Both the powdered and liquid forms of fluoride have significant health risk considerations. 1 will discuss the matter with the Water Department personnel, especially the personnel who would be responsible for the day to day operations of the fluoride systems. I also wish to discuss the powder -system with a present user of that type. File: B5: FLUORI07 y TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM TO: Robert Swanson, Town Engineer FROM: William F. Williams, Town Manager DATE: May 8, 1995 SUBJECT: Health Department Request Reference is made to my requests of February 6 and March 30, 1995 (copies attached) concerning information requested by the Board of Health relative to fluoridation. Please confirm in writing that you have responded and the date of your written reply. WFW/ego cc: V�cott Leite, Health Agent Enclosures (boh.mem) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM TO: Robert Swanson, Town Engineer FROM: William F. Williams, Town Manager w DATE: February 6, 1995 SUBJECT: Water Fluoridation - Board of Health This is to confirm our verbal conversation where I requested you to expedite the project request of the Board of Health relative to Fluoridation. Please identify what if anything is wrong with the plans. Your timely attention is appreciated. WFW/ego cc: 1/ Carol Sosman, Chairman Board of Health (Hurod.mem) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 TOWN MANAGER'S OFFICE MEMORANDUM TO: Robert Swanson, Town Engineer i FROM: William F. Williams, Town Manager DATE: March 30, 1995 SUBJECT: Health Department Request I received a reminder from the Chairman of the Board of Health that they have not yet received the requirements for the fluoridation project you were to provide them. If this is the responsibility of Dave Archard, Assistant Town Engineer, please advise him I need to respond to the Board of Health soon. WFW/ego cc: Daniel B. Clifford, DPW Director David Archard, Assistant Town Engineer V Scott Leite, Health Agent (nuodda.mem) TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Capital Improvemeennts Committee Chairman FROM: Health Agent 9 "d If DATE: January 20, 1994 RE . Fluoridation Dave Archard will be presenting the request for fluoridation to Mansfield's public water supply on January 27th. This project is no longer under the jurisdiction of the Board of Health. Thank you. /dr cc: Dave Archard TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO 1 SCOTT" LEITF , HEALTH A6aNT FROM = DAVID ARCHARD , HATER OPERATIONS MANAGER DA- DATE :: NOVEMBE,R S , 1992 Rf:''_ :: FLUORIDATION At this point , the design engineer for the Massachusetts Department of Health has completed the fluoridation system design for Cate Springs No.1 and the two Prescott wells No_H & 9 . Although the Water Department has had one of on) - operators on site during the survey , we have not reviewed the 100 % design u The Town has also supported the MDH in their Fluoridation funding efforts and asked to be included in any type of grant program that may be available in a August 31 1992 letter to the MDH . Year to date- we have not heard from the MDH pertaining to possible grants .. If you have any other questions , please give me a call February 14, 1994 Fred Barker, P.E. Fluoridation Engineer Commonwealth of Massachusetts Dept. of Public Health 150 Tremont St. Boston, MA 0211 Dear Fred: Thank you for your efforts in engineering the fluoridation system for the town of Mansfield. As you did tell me, the plans are close to completion. The Board of Health is requesting that you expedite completion of these plans, if at all possible. Upon completion, please forward the plans to the Board of Health office so that a true cost determination can be made to assist the town in implementing fluoridation. Thank you for your assistance and cooperation. Sincerely, MANSFIELD BOARD OF HEALTH Scott Leite Health Agent /dr cc: Town Manager Town Engineer/Water Dept. TOWN OF MANSFIELD, MASSACHUSETTS 50 West Street, Mansfield, MA 02048 MEMORANDUM TO . Board of Selectmen \Y �S FROM: Board of Health` DATE: June 26, 1991 RE . Flouridation Vote On June 20, 1991 the Board of Health made the following motion. The vote was 3-2, in favor of flouridating Mansfield's public water supply. MOTION: Move that the Board of Health order the flouridation of the public water supply of the Town of Mansfield. Further, recognizing the financial condition of the Commonwealth, and that there are already nine other towns waiting for state aid for flouridation, the Board requests that the Board of Selectmen, the Finance Committee and the Capital Improvements Committee include the capital and operating costs to implement this order in the FY93 budget. cc: Town Manager Town Clerk Finance Committee CIP Water Superintendent Town Engineer a4. FIOURE 2 0 W J J LL 0 Q 0 Z i 0 W Q 0 W 0 PPM FLUORIDE Simultaneous graph of decayed, missing and filled teeth (—) and average indices of fluorosis (-) vs FL content of water. Source: Hodge HC. JdD.41950:40:436-739. available. In addition, efforts should be redoubled to ensure the proper prescription and use of supplements. The possible relationship between fluoride dentifrices and enamel fluorosis, recently reviewed and discussed in depth," a is more equivocal. Studies indicate that variable and perhaps high quantities of fluoride can be ingested by children younger than 5 or 6 brushing with conventional fluoride toothpaste, and that this fluoride is readily absorbed through the child's gastro- intestinal tract." Thus, the role of fluoride dentifrice as a possible risk factor of fluorosis has been raised."" To date, one study has demonstrated a statistically significant, strong association between early fluoride dentifrice usage and very mild enamel fluorosis26 in a fluoridated population, and a second study reported a suggestive, though non- significant, association between early fluoride dentifrice usage and mild -to -moderate fluorosis in a a0 0 0 D J LL LL 0 non -fluoridated population.' j Although eight other studies have failed to show an association between fluoride dentifrice use and enamel fluorosis, serious j questions related to their sample size and ability to reveal any true association make it incorrect to interpret their findings as demonstrating that no association exists.'" In addition to dentifrices, the early home use of fluoride rinses and gels may also be associated with enamel fluorosis. By contrast, there is no indication that periodic professional topical fluoride applications are associated with fluorosis. The j repeatedly made recommendation that children be carefully supervised during brushing and allowed only to use pea -sized amounts of dentifrice. if followed, should help reduce any risk of fluorosis associated with early fluoride dentifrice use. However, since this approach requires populatiomvide education and adoption to be effective, careful consideration should be given to the introduction of a lower fluoride concentration toothpaste specifically for use by i children younger than 5 or 6. The finding during the 1970s that infant formula contained variable and often high concentra- tions of fluoride along with the report of an associated increase in the risk of fluorosis" led to formula manufacturers' voluntarily maintaining concentrations at a low level. Recent findings indicate that these beneficial changes continue, at least within the United States.' The relationship between fluoride in drinking water, caries and fluorosis was empirically established 50 years ago as a result of the classic work of Dean. No evidence suggests that this predictable, highly titratable and safe relationship has changed during this period. Thus, there is no rationale to alter this original and proven fluoride preventive regimen, which continues to serve as a model for other fluoride regimens. By contrast, additional fluoride sources introduced to duplicate or expand the benefits of j water fluoridation may not necessarily carry the same low risk for fluorosis. The presence of unpredictable quantities of fluoride in beverages, available in 1 non -fluoridated areas, further complicates the situation. It is prudent health practice to continue to monitor the benefit 1 risk relationship of all of these modalities and to make modifica- tions as necessary when indicated by the weight of evidence. CONCLUSIONS Continued research, therefore, should monitor the prevalence and severity of enamel fluorosis in both fluoridated and non -fluoridated populations, and investigate further the causes of fluorosis in today's children. Since there are many possible sources of ingested fluoride, studies that look simultaneously at the effects of these multiple sources are needed. Only recently have these types of studies been undertaken. ',_°.,a The choice of fluorosis index is also very important, with the choice being highly dependent on whether the study will investigate prevalence or seek to discover underlying risk factors.'" Histor- ically, the esthetic dimension of fluorosis has been assessed primarily as thejudgment of the clinical examiner. There is clearly a need for research to assess the esthetic. social and psychological ramifications of enamel fluorosis as expressed by the teenagers and young adults with fluorosis, as well as their parents and peers. The continuing goal of preventive fluoride regimens should be to reduce maximally the prevalence and severity of decay while minimizing the risk of objectionable enamel fluorosis. . I. Dean HT. The investigation of physiological effects by the epidemiological method. Ia: Moon.. FR. ed. Fluorine and dental heakic, Amer Assoc Adv Science 1942:19.=I 3. Dean HT. Fluorine in the control ofdenod caries Inc (xct,l 19514.811 J7. n. llotler IJ. Clinical standarmi used fordiageosmg fluorosis. in:McClure FJ.ed Water fluoddanon, Bemesda. ND'. L'S Dept of Heald,, Educator, and Welfare. 1970hnsen p. 72. J. Fit erskov O. Thylstrup A. Larsen W. Clinical and structural features and possible pathogenic mechanisms ofA Deato Arnold FA. d Elvov Res 197:;85,51 ate, :.Dean HT. Public Health Rep E.Dpme155-79 water and : tlenwlcanes .Thc Heald, Repnofflucandesi 6.Hodgee the pant ofhe minimum ofinea with in drinking water to DA the .404of minimum ernes with mawmum safety JAerUnks .Kunce ?,Backer larks O. Kudzu n.Caries Res Canes preventive w'aternum7.14, .Canes Res B. ,ystnizHS The furoreof water Ouoritlaideand Ixm syscemn flunntles. J Dent Res (Special asuel health or epanmen,of Health red. Human Sal son .Oral chums of Cmted States childchildren n 1 canonical survey of denialvanesml'S H pnlchationno 899Mi national and regionalfindingsDAM, , Bowen Brvrds,19H9 t in -in octd Bowen WH JInut Beof pedal ,, mound,• m aa!sn Arntal plague J (xm Hers (Special Iswo i IV!111 r _a 617 II Pendrs; M. Stamm JW RelatonsMpof total nuo me intake to beneficial 14f(cis and enamel fluoroste .1 !loin Hrsi Sp,•rwllssue H9Mt.fi9 i2Y:18 12.Clov,s J.Hargreaves JA. Fluonde intake from beverage consumption, Community Dent Oral Epe em:ol 1988:16.11.5 1:3. CS Dencou of Healm and Human Senores. Review of Fluoride: BenehU and Risks Report cf the ad hoc Dr. MrMry.a submt comnee on fluoride of theaommmee to a.aaaM psse..aor, nioducaceemhmmuchud D.paMm.nlon health and related B.MNer.l lelaron. pmgrams:1991.87 and Community IJ, WhilfoM CN The NMIDr, Unlwrally M mcc.1o9maland ......logical chat aersits Done.eUout, aerated of fluoride I Dom Res DW MW of .nlet., . S"nil lssue)1990.69-A09- F.rmirpzon DOppG. 49 Addir..a requaia for 15 Richard, A. Kragsnvip nr+rirsa to Us. :. Jowdhsen K. at al Dental Ouaross developed m posh awror• secrev., enamel J Dent Be, 1996,0,1406.9 16 Richards ]amen arI e•-::aphm-.•fdpma imuosr in i mmais J D,ro Be, 17 ?` ::nr„ D:I K.r:: Hv Ro9,d,numelassncwred a'ph 'd4ma:+•e;wmm mfam Imucula.and fluoride 11 . h'm:irn •.:,,,. Slu.l EL':denu•:I 1989.18ua19Y308 E%.r,H\1 Anpptoemmuuocrostudyofmv I. ...... flutuchexposure ur:s r r.....flood, de,eiopmen: Jlice, Res !4.::•.r W. Hs.:`, p."raPpnepna.. u.c,,,f ea:r...,nea;ee•n. [• a •h• III + J Nit, Hmlth Dent rid NkIo•rn •yndamin tocI 9nsem Lode. Nro,u i..... 14.9 . nrR:p.: I.N A.'n:vitn..`Wpatuitional, methods .'ifr:. - o, r,;enn.......swrawr and selfoppbed ee!s: ... ,r , .!,..�r•usml canes and increased fluorosis pr,wrr :... I Yuma Heath lien! 1991SI::1-! 1 "J P•-ncncI)C Bear min paper: some perspa'useson ' apprq.r:a•:• m:.. •.! Rw•nm• far top 199us and er,ond Deni! eil ii, 1,.i:l.5 s H••r..anz HS Ajgh,,nawuses,, RuonJe ::ns:d• ra:•ins :: n tln• vus Summary J Public Heuhh h•m IP9L51 iA:3 24 Szpunar SA. Burt BA Trends m the prevalence of denial Ruurr,s In In, I-mtM Statesa review J Public W.al::a K•nt 1917.47 Tl v _ : 1. cout El 1, Szpunar SM Fluoride in tau hunbcs, for Imdred nMesm,n for change. Pedtatr Dent l9M.. 111186 A 26 Osup (a), Leaky JL. Chipman VL. Risk factors for demai nuorous in a fluoridated mmmumn' J Dent Res ILAKGCIJBLLu'! S.J:Jmvm J. H..de"W no. fluoride concept of tnfant fornnd:.. nvatlahip to ISKS Pedmn Dem l9g'.9::3i 2M IsmaE Al. bodvur JM. Kavanaugh M. Bmsclan O. TesuerrPu.tu•L.etm. Phvaloncrofhoindcanesand RJr•nwi.vs,I , i m.indents.lbl: yeas.ofage. m eml nmm�un udated vices {ones -, B,90 Pcodr.' DO The Hunrosis struck a method for iweal... I rick fa•rom .I Public Health Pen, 6ti .IADA. VoL 122. September 1991 While enamel fluorosis does not directly affect oral health except in its severest forms, the recent U.S. Public Health Service Review of Fluoride Benefits and Risks" concluded that an increase in the prevalence of enamel fluorosis indicates that total fluoride exposure may be more than is necessary to prevent tooth decay. That report suggests that -prudent health practice generally dictates using no more of a substance than the amount necessary to achieve a desired effect." As suggested by Whitford," the present fluorosis trend is undesir- able. In addition to increasing the prevalence of potentially unesthetic enamel defects, it could FIGURE place health professionals at increased risk of litigation and damage the public's perception of safety leading to reduced acceptance of the use of all fluorides. Enamel is at risk of fluorosis onl,v while it is forming.Fluoride exposures. therefore. are potential fluorosis risk factors only during the first six to eight Fears of life. %%'hile the exact mechanism or mechanisms by which fluoride can cause enamel fluorosis are still under investigation, it appears that the so-called transition and earl maturation phase of enamel development (the third to sixth year of life for much of the perm- anent dentition) is the period during which the enamel is at greatest risk of fluorotic changes.' Recently, a number of studies have attempted to discover the underlying cause or causes of the observed increase in fluorosis, "'"" focusing mainly on fluoride supplements, fluoride toothpaste and diet. The studies have shown fluoride supplements during the first six years of life to be an important risk factor of ven mild to moderate enamel fluorosis depending on the specific study. Unfortunately, it is likely that the recommended ( lot just the inappropriate) use of supplement has contributed to this risk, since the design of these studies would not be likely to show a risk with supplements. if associated onl% with inappropriate usage.- his also likely. based on human and animal studies. that the supple ment modification in the tau• 1970s, which focused un changes in the first two years of life. was not adequate to Inwer this fluorosis risk. ' Evidence ishuilding. t1wrefon to support a redw lion and simplification in the Ihuaide supplement dosage sA Nodule. especially for tho third through sixth year of life when evidence suggests the dentition as a a hole most at risk of fluorosis. These modifications. which might include dosage by weight rather than age, and reformulation in a time -released preparation. shoul j be based on the best and most ' current fluoride -intake data Mild -to -moderate fluorosis" G4 JAUA.%0 13^_.Sopicmbrr1991 olC NOTICE THIS t:;ATERIAL MAY BE PROTECTED BY COPYRIGHT LAW -;TLE 17 U.S. C-,-E) DINTA[ f[UOHOSIS IN PERSPECTIVE DAVID G. PENDRYS, D.O.S., PH.D. Os the question of enamel fluorosis is once again before the profession, it is helpful to review its historical background. The work of Dean and others led to an understanding of the relationship between ingesting high concentrations of fluoride and enamel fluorosis, with clinical severity increasing with the amount of fluoride ingested.'' Dean was the first to present a method for evaluating this range of severity by establishing categories describing fluorosis. Categories vary clinically from a faint frosty white streaking or snow flaking in the mildest forms, to esthetically obvious opaque white mottling found in mild -to -moderate fluorosis. Associated brown staining and pitting occur in more severe forms. Figure 1 shows an example of fluorosis of mild -to -moderate severity as defined by Dean and Moller.' Histologically, enamel fluorosis is defined as the presence of a hypomineralized subsurface zone, lying beneath a well - mineralized enamel surface layer.' Dean's extensive observations not only quantified the dose relation- ship between ingested fluoride and enamel fluorosis prevalence and severity, but also defined its relationship with caries preva- lence," demonstrating that significant caries reduction could. be achieved at water fluoride concentrations below those causing noticeable enamel fluorosis. The relationship between fluoride in drinking water, caries and fluorosis was established 50 years ago. But additional sources that duplicate or expand fluoride benefits may not carry the same low risk for fluorosis and should be monitored. This relationship (Figure 2)., derived through direct empirical observation, led to the concept of an optimal fluoride concentration of about 1 part per million, and the advent of worldwide artificial ! water fluoridation."This caries- fluorosis relationship illustrates that: Virtual maximum caries I preventive efficacy can be achieved without noticeable fluorosis as a side effect: that is, a compromise between esthetics and dental health is not necessary: — Water fluoride concentration at about 1 ppm does not, by itself. lead to noticeable fluorosis. Rather, water fluoridation represents a remarkably titratable. safe method of efficacious caries prevention. These are important considerations since, despite consistent reports of declining caries prevalence in Western countries, the disease has not been eradicated. While the most recent National Institute of Dental Research survey of children aged 5 to 17 years reported that overall 00 percent were caries -free, only h; percent of 17-year-olds were in this categon•, having an average of eight decayed, missing or filled surfaces.- Evidence also suggests that the observed decrease in caries prevalence is the result of better control of the cariogeni, bacterial challenge, which of nscll'. has not diminished."' Clear evidence indicates that the prevalence of enamel fluorosis has increased in both fluoriclawd and non -fluoridated areas since Dean's time." The prevalence of very mild -to -mild enamel fluorosis has shown an increase of about 40 percent in fluoridated popula- tions. In notable contrast. the prevalence of very mild -to - moderate enamel fluorosis has shown a tenfold (that is, 900 percent) increase in non -fluori- dated populations. Today, some non -fluoridated populations may not be nearly as non -fluoridated as those of Dean's time." In the past 30 years, ingestible fluoride has become available from an array of intentional and unintentional sources, including fluoride supplements or vitamins, toothpastes and other fluoride - containing, topically applied preparations and beverages manufactured in fluoridated areas.�'These additional sources provide unpredictable and perhaps high sources of additional fluoride to the overall diet. .IADA.Cot t22.September l^^I ", Researchers should express reductions in caries scores as the number of tooth surfaces saved from caries, in addition to the percentage. RESEARCH ON THE RISKS OF FLUORIDE • Continue studies to elucidate the mechanisms of fluoride action on bone and teeth at the molecular and physical chemical levels. • Develop a method of quantitatively identifying dental fluorosis that is sensitive, specific, reliable and acceptable to the public. • Continue to study dental fluorosis to determine the etiology and trends in the prevalence of dental fluorosis. • Conduct analytical epidemiological studies of osteosarcoma to determine the risk factors associated with its development. Fluoride exposure and bone levels of fluoride should be included in the study design. • Evaluate the scientific merit of conducting further animal carcinogenicity studies which use a wide range of chronic fluoride doses. Industries sponsoring studies of fluoride should be encouraged to make their data publicly available to aid in this evaluation. • Conduct analytical epidemiological studies to•determine'the relationship, if any, among fluoride intake, fluoride bone levels, diet, body levels of nutrients such as calcium, and bone fractures. • Conduct studies on the reproductive toxicity of fluoride using various dose levels including the minimally toxic maternal dose. • Conduct further studies to investigate whether or not fluoride is genotoxic. ES-9 • In accordance with prudent health practice of using no more than the amount necessary to achieve a desired effect, health professionals and the public should avoid excessive and inappropriate fluoride exposure. For example• health professionals should prescribe fluoride dietary supplements only when the fluoride level of the home water supply is known to be deficient. Parents should educate young children to minimize swallowing of fluoridated toothpaste and to use only small amounts of toothpaste on the brush. • The U.S. Food and Drug Administration should review the labeling required for toothpaste and other fluoride containing products to ensure that the public has adequate knowledge to make informed decisions about their use, especially for young children (those under six years of age). • Manufacturers of toothpaste should be encouraged to make the fluoride levels in their products easily known. Manufacturers should determine whether toothpaste can be dispensed in a dose limited container for use by children. Manufacturers of dental products should explore whether the levels of fluoride can be reduced while preserving clinical effectiveness. • State health and drinking water programs should keep physicians, dentists, pharmacists. physician extenders, and communities informed about the fluoridation status of drinking water. This information will enable residents and health professionals to determine the need for water fluoridation or for supplemental forms of fluoride. • Communities with high natural fluoride levels in the public drinking water supply should comply with EPA regulations as mandated by the Safe Drinking Water Act. The Current primary and secondary maximum contaminant levels are 4 and 2 pans per million, respectively. • A,t action plan to implement research and policy recommendations should be developed. RESEARCH RECOMMENDATIONS RESEARCH ON THE BENEFITS OF FLUORIDE • Conduct surveys to evaluate the prevalence of dental caries over time and accurately assess exposure to fluoride. • Undertake studies to elucidate further the role of fluoride in preventing coronal and root decay in adults. Undertake studies to identify effective means of providing fluoride to individuals at high risk of dental caries. • Continue longitudinal studies of caries scores in cities after defluoridation or the discontinuation of fluoridation to supplement past information which coven; only 2-5 years of follow-up period. • Document the marginal risks, costs, and benefits of providing multiple fluoride regimens in the prevention of dental canes. • Determine the relationship among socioeconomic status, water fluoridation status, and the use of fluoride products. • In scoring dental caries, researchers should count individual surfaces rather than just the number of teeth because such scoring provides more information and greater sensitivity. ES-8 prudent public health practice dictates the reduction of unnecessary and inappropriate fluoride exposure. In the 1940s. drinking water and food were the major sources of fluoride exposure. Since then, additional sources of fluoride have become available through the introduction of fluoride containing dental products. Although the use of these products is likely responsible for some of the declines in caries scores, the inappropriate use of these products has also likely contributed to the observed increases in the prevalence of very mild and mild forms of dental fluorosis. • Further epidemiological studies are required to determine whether or not an association exists between various levels of fluoride in drinking water and bone fractures. • Crippling skeletal fluorosis is not a public health problem in the United States, as evidenced by the reports of only five cases in 30 years. Crippling skeletal fluorosis, a chronic bone and joint disease associated with extended exposure to high levels of fluoride, has been more prevalent in some regions outside the U.S. Well controlled studies have not demonstrated a beneficial effect of the use of high doses of fluoride in reducing osteoporosis and related bone fractures. • Genomxicity studies of fluoride, which are highly dependent on the methods used, often show contradictory findings. The most consistent finding is that fluoride has not been shown to be mutagenic in standard tests in bacteria (Ames Test). In some studies with different methodologies, fluoride has been reported to induce mutations and chromosome aberrations in cultured rodent and human cells. The 9=Wtoxicity of fluoride in humans and animals is unresolved despite numerous studies. Chronic low level fluoride exposure is not associated with birth defects. Studies also fail to establish an association between fluoride and Down Syndrome. There is no indication that chronic low level fluoride exposure of normal individuals presents a problem in other organ systems, such as the gastrointestinal, the genitourinary, and the respiratory systems. The effects of fluoride on the reproductive system merit further investigation in animal and human studies. POLICY RECOMMENDATIONS • The U.S. Public Health Service should continue to recommend the use of fluoride to prevent dental caries. • The U.S. Public Health Service should continue to support optimal fluoridation of drinking water. Cltmntly, the optimal level for water fluoridation is between 0.7 - 1.2 parts per million, depending on mean daily air temperature for a geographic area. • The U.S. Public Health Service should sponsor a scientific confemnec(s) to recommend both the optimal level of total fluoride exposure from all sources combined (including drinking water) and the appropriate usage of fluoride containing dental products in order to achieve the benefits of reduced dental caries and to mirdmi the occurrence of,dental fluorosis. • The U.S. Environmental Protection Agency should review its regulations concerning naturally occurring fluoride in drinking water based on the outcome of the scientific conference(s) recommended above and based on this report ES-7 Bone Fractures. Then; is some suggestion from epidemiological studies that the incidence of certain bone fracnims may be greater in some communities with either naturally high or .adjusted fluoride levels. However, there are a number of confounding factors that need resolution to determine whether or not an association exists. Additionally, other studies do not show an increase in the incidence of bone fractures: one study provided evidence of a lower incidence of'bone fractures in an optimally fluoridated community as compared to a similar community with trace levels of fluoride in the water. Therefore, further research is required. CONCLUSIONS Extensive studies over the past 50 years have established that individuals whose drinking water is fluoridated show a reduction in dental caries. Although the comparative degree of measurable benefit has been reduced recently as other fluoride sources have become available in non -fluoridated areas, the benefits of water fluoridation are still clearly evident Fewer caries are associated with fewer abscesses and extractions of teeth and with improved health. The health and economic benefits of water fluoridation accrue to individuals of all ages and socioeconomic groups, especially to poor children. Since the addition of fluoride to drinking water in the 1940s. other sources of fluoride have become available, including toothpastes, mouth rinses, and fluoride dietary supplements. These sources of fluoride also have proven to be effective in preventing dental caries. Estimates developed for this report show that fluoride exposure is generally greater in fluoridated areas; however, there is fluoride exposure in both fluoridated and non -fluoridated areas because of the variety of fluoride sources besides drinking water. Beverages and foods are sources of fluoride, especially if they have been prepared with fluoridated drinking wat: r. Optimal fluoridation of drinking water does not pose a detectable cancer risk to humans as evidenced by extensive human epidemiological data available to date, including the new studies prepared for this report. While the presence of fluoride in sources other than drinking water reduces the ability to discriminate between exposure. in fluoridated as compared to non -fluoridated communities, no trends in cancer risk, including the risk of osteosarcoma, were attributed to the introduction of fluoride into drinking water in these new studies. During two time periods, 1973-1980 and 1981-1987, there was an unexplained increase of osteosarcoma in males under age 20. The reason for this increase remains to be clarified, but an extensive analysis reveals that it is unrelated to the introduction and duration of fluoridation There are two methodologically acceptable studies of the carcinogenicity of fluoride in experimental animals. The Procter and Gamble study did not find any significant evidence of carcinogenicity in rats and mice of either sex. In the NTP study there was no evidence of carcinogenicity in mice and in female rats. Male rats showed "equivocal" evidence of carcinogenicity based on the finding of a small number of osteosarcomas. "Equivocal" evidence is defined by NTP as ".-interpreted as showing a marginal increase in neoplasms that may be chemically related" (DHHS, 1990). Taken together, the data available at this time from these two animal studies fail to establish an association , between fluoride and cancer. By comparison with the 1940s, the total prevalence of dental fluorosis has increased in non -fluoridated areas and may have hu=ased in optimally fluoridated areas. Such increases in dental fluorosis in a population signify that total fluoride exposures have increased and may be more than are necessary to prevent dental caries. For this reason, ES-6 relative mortality rates from cancer, including cancer of the bones and joints, were similar after 20-35 years of fluoridation as they were in the years preceding fluoridation. In addition, there was no relationship between the introduction and duration of fluoridation and the patterns of cancer incidence rates, including those of the bone and joint, and the subset of osteosart omas (Appendix ce For example, there were 91 observed cases of osteosartoma in the fluoridated areas, when 93 cases were expected based on rates in non -fluoridated areas. The NO also conducted a more detailed evaluation of osteosarcomas using nationwide age -adjusted incidence data from the entire SEER database for the years 1973.1987 (Appendix F). Osteosarcoma is a rare form of bone cancer, the cause of which is under study. Approximately 750 newly diagnosed cases occur each year in the United States, representing about 0.1 percent of all reported cancers. Between two time periods, 1973-1980 and 1981-1987, there was an unexplained increase in the annual incidence rates of osteosatcoma in young males under age 20 from 3.6 cases per 1.000.000 people (88 registry cases) to 5.5 cases per 1,000,000 people (100 registry cases). This compares to a decrease in young females of the same age group from 3.8 cases per 1,000.000 people (87 registry cases) to 3.7 cases per 1,000,000 people (63 registry cases). The amount of increase observed in young males was greater in fluoridated than in non -fluoridated areas. Although the mason for the increase in young males remains to be clarified, an extensive analysis reveals that it is unrelated to introduction and duration of fluoridation. In studying rare cancers, such as osteosarcoma, small increases in risk, on the order of five to 10 percent, would not likely be detected. While descriptive epidemiological studies ate useful in determining whether or not there is a credible association, the qualitative nature of any association, if one exists, can best be determined through more refined methods, such'as case-contml studies. Dental fluorosis. Dental fluorosis has been recognized since the turn of the century in people with high exposure to naturally occurring fluoride in drinking water. It has always been mote prevalent in fluoridated than non -fluoridated areas. Dental fluorosis only occurs during tooth formation and becomes apparent upon eruption of the teeth. It ranges from very mild symmetrical whitish areas on teeth (very mild dental fluorosis) to pitting of the enamel, frequently associated with brownish discoloration (severe dental fluorosis). The very mild form barely is detectable even by experienced dental personnel. Moderate and severe forms of dental fluorosis, considered by some investigators as presenting a cosmetic problem, do not appear to produce adverse dental health effects, such as the loss of tooth function, and represents less than six percent of the cases of fluorosis nationally. In the 1940s, about 10 percent of the population displayed very mild and mild dental fluorosis when the concentration of fluoride found naturally in the drinking water was about 1 pan per million (ppm). Over the last 40 years, in areas where fluoride is added to the drinking water to bring the total level of fluoride to about 1 ppm (optimally fluoridated areas), then; may have been an increase in the total prevalence of dental fluorosis. In non -fluoridated areas, then: is clear evidence that the total prevalence of dental fluorosis has increased over the Litt 40 years. The greater the fluoride exposure during tooth development. the greater the likelihood of dental fluorosis. In the 1940s and 1950s, the major sources of fluoride were from drinking water and food. Since then, numerous sources of, fluoride have become available, including dental products containing fluoride (e.g., toothpastes and mouth rinses) and fluoride dietary supplements. The inappropriate use of these products can contribute significantly to total fluoride intake. Increases in the prevalence of dental fluorosis in a population should be taken as evidence that fluoride exposure is increasing. Because dental fluorosis does not compromise oral health or tooth function, an increase in dental fluorosis, by itself, is not as much of a dental public health concern as it is an indication that total fluoride exposure may be mote than necessary to prevent tooth decay. Prudent public health practice generally dictates using no more of a substance than the amount necessary to achieve a desired effect. ES-5 the occurrence of tumor formation in many different organ systems. The peer review panel concluded that, "Under the conditions of these 2-yeardosed water studies, there was equivocal evidence of carcinogenic activity of sodium fluoride in male F344/N rats, based on the occurrence of a small number of osteosarcomas in dosed animals. There was no evidence of carcinogenic activity in female F344/N rats receiving sodium fluoride at concentrations of 25, 100, 4r 175 ppm (0, 11, 45, 79 ppm fluoride) in drinking water for 2 years. There was no evidence of carcinogenic activity of sodium 'fluoride in male or female mice receiving sodium fluoride at concentrations of 25, 100, or 175 ppm in drinking water for 2 years." The Ad Hoc Subcommirtee on Fluoride concurs with this conclusion. The other carcinogenicity study was sponsored by the Procter and Gamble Company using Cr.CD (Sprague-Dawley) rats and Cr1:CD-1 (ICR) mice both treated with 0, 4, 10, or 25 milligrams/kilogram/day sodium fluoride added to a low fluoride -basal diet. A second control group received powdered rodent chow. There was no evidence of malignant tumors associated with sodium fluoride in mice and rats of either sex in the Procter and Gamble study. While there were two osteosarcomas in the low dose female rats, one osteosarroma in &high dose male rat, and one fibroblastic sarcoma in a mid -dose male rat, these findings in treated animals were not statistically different from controls. Male and female mice in the study did have a statistically significant increase in benign bone tumors (dsteomas). The significance of a Type C retrovirus, detected in the osteomas, remains to be determined. Osteomas and osteosarcomas are different in anatomical site and clinical course. The FDA also noted difficulty in assessing the dose -related aspects of the osteomas in mice (see page 75-6). Furthermore, osteomas and osteosarcomas are so rare normally in rodents that the relationship between these tumors cannot be accurately stated. When the NTP and the Procter and.,Gambie studies are combined, a total of eight individual sex/species groups are available for analysis. Seven of these groups showed no significant evidence of malignant tumor formation. One of these groups, male rats from the NTP study, showed "equivocal" evidence of carcinogenicity, which is defined by NTP as a marginal increase in neoplasms—i.e., osteosarcomas—that may be chemically related. Taken together, the two animal studies available at this time fail to establish an association, between fluoride and cancer. There have been over 50 human epidemiology studies of the relationship between water fluoridation and cancer. Epidemiological studies of fluoride usually attempt to identify statistical associations between cancer rates and county or city-wide partems of water fluoridation. Expert panels which reviewed this international body of literature agree that there is no credible evidence of an association between either natural fluoride or adjusted fluoride in drinking water and human cancer (IARC, 1982; Knox, 1985). Interpretation of these studies is limited by the inability to measure individual fluoride exposures or to measure other individual predictors of cancer risk, such as smoking or occupational exposures. In March of 1990, the National Cancer Institute (NCI) updated and expanded an earlier analysis of cancer deaths, by county in the United States, to determine whether there is or is not an association between cancer and fluoride in drinking water. The new studies evaluated an additional 16 years of cancer mortality data, and also examined patterns of cancer incidence between 1973 and 1987 in the Surveillance, Epidemiology and End Results (SEER) Program cancer registries. SEER, an NCI sponsored network of population -based cancer incidence registries, started in 1973 and represents about 10 percent of the U.S. population. The SEER registries were used to obtain incidence data on all cancers, with special emphasis placed on trends in ommarcoma. Because mortality data do not contain information on rumor -specific pathology, analysis of osteosarcamas is limited to the incidence data. The NCI study identified no trends in cancer risk which could be attributed to the introduction of fluoride into drinking water. The study examined nationwide mortality data and incidence data from counties in Iowa and the Seattle. Washington metropolitan area. There were no consistent differences in the trends in cancer mortality iates among males and females living in counties having initiated ES-4 MAJOR FINDINGS' ASSESSMENT OF THE HEALTH BENEFITS OF FLUORIDE Fluoride has substantial benefits in the prevention of tooth decay. Numerous studies, taken together. clearly establish a causal relationship between water fluoridation' and the prevention of dental caries. While dental decay is reduced by fluoridated toothpaste and mouth rinses, professional fluoride imamr- ents and fluoride dietary supplements, fluoridation of water is the most cost-effective method. It provides the greatest benefit to those who can least afford preventive and restorative dentistry and reduces dental disease, loss of teeth, time away from work or school, and anesthesia -related risks associated with dental treatment. In the 1940s, children in communities with fluoridated drinking water had reductions in caries scores of about 60 percent as compared to those living in non -fluoridated communities. Recent studies still reveal that caries scores are lower in naturally or adjusted fluoridated arras; however, the differences in caries scores between fluoridated and non -fluoridated areas are not as great as those observed in the 1940s. This apparent change is likely explained by the presence, in non -fluoridated areas, of fluoride in beverages, food, dental products and dietary supplements. Fluoride has been used for nearly 30 years as an experimental therapy to treat osteoporosis, but has only recently been evaluated in controlled clinical trials. Two new U.S. clinical trials showed no significant reduction in the rates of bone fractures related to the administration of fluoride. An FDA advisory panel has concluded that fluoride therapy has not.been shown to be effective in [educing the frequency of vertebral fractures. ASSESSMENT OF THE HEALTH RISKS OF FLUORIDE Among the more significant health conditions evaluated in relation to fluoride intake are cancer, dental fluorosis, and bone fractures. Other conditions are evaluated in.the full report. Cancer. Two major scientific approaches have been used to determine whether an association exists between the use of fluoride and cancer. carcinogenicity studies in rodents. and human epidemiological analyses which compare cancer incidence and mortality between communities with fluoridated water and those with negligible amounts of fluoride in drinking water. Five carcinogenicity studies in animals have been reported in the biomedical literature. Three studies, conducted before 1970 and interpreted as negative, had significant methodological limitations, as judged by current standards of experimental design. Two subsequent studies were conducted using current standards to evaluate the carcinogenicity of sodium fluoride in experimental animals. One of the two carcinogenicity studies was conducted by the National Toxicology Program (NTP). This peer -reviewed study provided sodium fluoride in drinking water to rats and mice and determined 'For other findings. see Other Effects section page 87 of the report. 'Fluoridated area means that drinking water supplied to that area contains fluoride at least at the optimal level (0.7-1.2 ppm depending on temperature) either naturally or by the water's having been adjusted to that level. Non -fluoridated area means that the drinking water does not contain fluoride at the optimal level. The level of fluoride naturally present in the non -fluoridated areas varies from study to study, but generally ranges from negligible levels to less than 0.3 ppm. ES-3 EXECUTIVE SUMMARY This report is a comprehensive review and evaluation of the public health benefits and risks of fluoride from drinking water and other sources. Fluoride was first added tor public drinking water in the 1940s to prevent tooth decay. While controversy has sometimes surrounded community water fluoridation, over half of the U.S. population is served by drinking water that is fluoridated naturally or adjusted. Additionally, since the 1950s, fluorides have been incorporated into toothpaste, other dental products. and dietary supplements. The Assistant Secretary for Health. Dr. James O. Mason, requested an analysis of the benefits and risks of fluorides upon the receipt of the preliminary results of a study in which animals were given sodium fluoride in the drinking water. The study, conducted by the National Toxicology Program (NTP), a research and testing program within the U.S. Public Health Service (PHS), found a small number of malignant bone rumors (osteosarcomas) in male rats. The NTP study concluded that there was "equivocal" evidence of carcinogenic activity in male rats (DHHS, 1990). "Equivocal" evidence is one of five standard categories that are employed in NTP studies to describe the strength of the evidence of individual experiments. According to NTP's standard definition. "equivocal evidence of carcinogenicity is demonstrated by studies that are interpreted as showing a marginal increase of neoplasms that may be chemically related." The independent peer review panel which evaluated the NTP study requested the addition of a statement that further defined the term "equivocal evidence" of carcinogenicity as a category "for uncertain findings (emphasis added) demonstrated by studies that are -interpreted as showing a marginal Wcasase in neoplasms that may be chemically related" (DHHS, 1990). The NTP study found no evidence of carcinogenic activity of sodium fluoride in female rats, or in mice of either sex. Animal studies conducted at a range of dose levels, often at doses that are the maximum which can be tolerated without shortening the lifespan of the animal, are used to identify potential hazards to human health. The identification of a potential hazard from animal studies, which is one of the first steps in assessing a health risk to humans, does not necessarily mean that there is a risk to humans. Further steps are taken to determine potential human risks. Human epidemiological studies can help to determine if a hazard to humans exists. The results of epidemiological studies ate then analyzed in combination with information from animal studies, dose -response relationships, and patterns of human exposure in order to characterize the magnitude of the risk to humans. This process of characterizing human risk --the likely harm to human health —is called risk assessment. This report qualitatively assesses fluoride's health benefits as well as fluoride's health risks. It was prepared by the Ad Hoc Subcommittee on Fluoride of the PHS Committee to Coordinate Environmental Health and Related Programs (CCEHRP) and approved by CCEHRP. The data analyzed in the report include: the NTP study of sodium fluoride; human and animal studies published in the biomedical literature on both the benefits and the risks of fluoride; the U.S. Food and Drug Administration's (FDA) review of a chronic bioassay animal study sponsored by the Procter and Gamble Company; and new epidemiological studies performed by the National Cancer Institute (NCI). To ensure public input, an announcement was published in the Federal Register on March 1, 1990, soliciting peer -reviewed published articles on fluorides. A total of 24 individuals submitted over 100 articles which were considered by the Subcommittee. ES-2 EXECUTIVE SUMMARY REVIEW OF FLUORIDE BENEFTTS'AND RISKS REPORT OF THE AD HOC SUBCOMMITTEE ON FLUORIDE OF THE COMMITTEE TO COORDINATE ENVIRONMENTAL HEALTH AND RELATED PROGRAMS ' PUBLIC HEALTH SERVICE DEPARTMENT OF HEALTH AND HUMAN SERVICES FEBRUARY 1991 m EXECUTIVE SUMMARY REVIEW OF FLUORIDE BENEFITS RISKS REPORT OF THE AD HOC SUBCOMMITTEE ON FLUORIDE OF THE COMMITTEE TO COORDINATE ENVIRONMENTAL HEALTH AND RELATED PROGRAMS PUBLIC HEALTH SERVICE N SERVICES.G J�* S7 e H e WO %e, 3 jv'bivld3a FEBRUARY 1991 0 DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVKE Cs'RY z � laor UJ. OOARTMEMT OI HOACrm ANO HUMAN 16RVICCS ATTACHMENT 4 FOR IMMEDIATE RELEASE Contact: Sandra Lange Thursday, April 26, 1990 (919) 541-3201 STATEMENT BY DAVID P. RALL, M.D. PH.D. DIRECTOR NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES Today, April 26, 1990, the National Toxicology Program's (NTP) Board of Scientific Counselors' Technical Reports Review Panel met in Research Triangle Park, North Carolina. This group of non-HHS scientists reviewed and discussed in public forum the results of recent NTP studies in animals on the toxicity and carcinogenicity of sodium fluoride. In its evaluation of the NTP studies on sodium fluoride, the Panel agreed with the NTP that the evidence for bone tumor formation in male rats was too weak to be attributed to fluoride administration. To support their evaluation, the Panel noted that the bone tumor effect was not found in mice or in female rats receiving the same dose levels and that the increase in the numbers of affected male rats was small. Thus, the possibility that the marginal increase could have occurred by chance could not be ruled out, For these reasons, the Panel concurred with the NTP conclusions of "equivocal evidence of carcinogenic activity" in male rats and "no evidence of carcinogenic activity" in female rats or in male and female mice. Estimating potential risks to humans from fluori:4� exposure requires analyses of all the available information in addition to those reported today by the NTP, both experimental and epidemiological. Now that these NTP studies have been peer reviewed by the external peer review group, the results can be considered by the HHS as part of the Department's wider analysis of the appropriate use of fluorides in human health. The Department's analysis is being conducted under the leadership of Dr. Frank Young, the Deputy Assistant Secretary for Health, Science and Environment, Dr. Young's group, a subcommittee of a PHS Committee to Coordinate Environmental Health and Related Programs, has underway a thorough examination of scientific, peer -reviewed studies of the risks and benefits of fluorides. HHS RI 0 YJ. 0XPART%4XT Of N<ALTN ANO LAYMAN S9RVtC9S Attachment 3 FOR IMMEDIATE RELEASE CONTACT: Jim Brown Thursday, April 26, 1990 (202) 245-6867 STATEMENT BY JAMES 0. MASON, M.D. ASSISTANT SECRETARY FOR HEALTH Today's action by a panel of outside experts reviewed and confirmed the National Toxicology Program interpretation that its recent study of the toxicity and carcinogenicity of sodium fluoride administered to rats and mice produced "equivocal" results. The NTP's Board of Scientific Counselors' Technical Reports Review Panel concurred with the NIP conclusions that its two-year studies showed only "equivocal evidence of carcinogenic activity" in male rats and "no evidence of carcinogenic activity" in female rats or in male or female mice. The panel said "equivocal evidence" is a category for uncertain findings demonstrated by studies that are interpreted as showing a marginal increase of neoplasms that may be chemical related. The terms "equivocal evidence" and "no evidence" are drawn from five categories used in evaluating results of NTP studies. They are, in descending order: "clear evidence," some evidence," "equivocal evidence," "no evidence" and "inadequate study." Today's action was one step in a continuing evaluation of health risks and health benefits of fluoridation underway by the Public Health Service. The NTP panel's findings will be incorporated into a broader review of other animal and human studies involving fluoride now underway by a subcommittee of the PHS Committee to Coordinate Environmental Health and Related Programs chaired by Dr. Frank Young, Deputy Assistant Secretary for Health/Science and Environment. The subcommittee is gathering other scientifically peer -reviewed human and animal fluoride studies from throughout the world. These --along with today's NTP review findings --will be examined to ensure that every possible avenue of research has been re-examined in light of the NTP findings. The subcommittee is expected to report its conclusions in July. There is no information available at this time that would indicate need for any change in the Public Health Service policy of continued support for the use of fluorides for the prevention of tooth decay, Page 2 - Explanation of Levels of Evidence o Equivocal evidence of carcinogenic activity is demonstrated by studies that are interpreted as showing a marginal increase of neoplasms that may be chemically related. o No evidence of carcinogenic activity is demonstrated by studies that are interpreted as showing no chemically related increases in malignant or benign neoplasms. 0 Inadecuate study of carcinogenic activity is demonstrated by studies that because of major qualitative or quantitative limitation, cannot be interpreted as valid for showing either the presence or absence of carcinogenic activity. When a conclusion statement for a particular experiment is selected, consideration must be given to key factors that would extend the actual boundary of an individual category of evidence. Such consideration should allow for incorporationofscientific experience and current understanding of long-term carcinogenesis studies in laboratory animals, especially for those evaluations that may be on the borderline between two adjacent levels. These considerations should include: o adequacy of the experimental design and conduct; 0 occurrence of common versus uncommon neoplasia; o progression (or lack thereof) from benign to malignant neoplasia as well as from preneoplastic to neoplastic lesions; o some benign neoplasms have the capacity to regress but others (of the same morphologic type) progress. At present, it is impossible to identify the difference. Therefore, where progression is known to be a possibility, the most prudent course is to assume that benign neoplasms of those types have the potential to become malignant; o combining benign and malignant tumor incidence known or thought to represent stages of progression in the same organ or tissue; o latency in tumor induction; o multiplicity in site -specific neoplasia; o metastases; o supporting information from proliferative lesions (hyperplasia) in the same site of neoplasia or in other experiments (same lesion in another sex or species); o presence or absence of dose relationships; o statistical significance of the observed tumor increase; o concurrent control tumor incidence as well as the historical control rate and variability for a specific neoplasm; 0 survival -adjusted analyses and false positive or false negative concerns; o structure -activity correlations; and o in some cases, genetic toxicology. Source: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. NIP Technical Report on the Toxicology and Carcinogenesis Studies of Sodium Fluoride (CAS No, 7681-49.4) in F344/N Rats and B6C3F1 Mice (Drinking Water Studies). NIP TR 393, NIH Publication No. 90-2848, April 26, 1990. Attachment 2 EXPLANATION OF LEVELS OF EVIDENCE The National Toxicology Program describes the results of individual experiments on a chemical agent and notes the strength of the evidence for conclusions regarding each study. Negative results, in which the study animals do not have a greater incidence of neoplasia than control animals, do not necessarily mean that a chemical is not a carcinogen, inasmuch as the experiments are conducted under a limited set of conditions. Positive results demonstrate that a chemical is carcinogenic for laboratory animals under the conditions of the study and indicate that exposure to ,the chemical has the potential for hazard to humans. Other organizations, such as the International Agency for Research on Cancer, assign a strength of evidence for conclusions based on an examination of all available evidence, including animal studies such as those conducted by the NTP, epidemiologic studies, and estimates of exposure. Thus, the actual determination of risk to humans from chemicals found to be carcinogenic in laboratory animals requires a wider analysis that extends beyond the purview of these studies. Five categories of evidence of carcinogenic activity are used in the technical report review to summarize the strength of the evidence observed in each experiment: two categories for positive results (clear evidence and some evidence); one category for uncertain findings (equivocal evidence); one category for no observable effects (no evidence); and one category for experiments that cannot be evaluated because of major flaws (inadequate study), These categories of interpretative conclusions were first adopted in June 1983 and then revised in March 1986 for use in the technical report series to incorporate more specifically the concept of actual weight of evidence of carcinogenic activity. For each separate experiment (male rats, female rats, male mice, female mice), one of the following five categories is selected to describe the findings. These categories refer to the strength of the experimental evidence and not to potency or mechanism. o Clear evidence of carcinogenic activity is demonstrated by studies that are interpreted as showing a dose -related (i) increase of malignant neoplasms, (ii) increase of a combination of malignant and benign neoplasms, or (iii) marked increase of benign neoplasms if there is an indication from this or other studies of the ability of such tumors to progress to malignancy. o Some evidence of carcinogenic activity is demonstrated by studies that are interpreted as showing a chemically related increased incidence of neoplasms (malignant, benign, or combined) in which the strength of the response is less than that required for clear evidence. Page 2 - Summary of Peer Review Meeting studies that are interpreted as showing a marginal increase of neoplasms that may be chemically related. There was no evidence of carcinogenic activity in female F344/N,rats receiving sodium,.. fluoride at concentrations of 25, 100, or 175 ppm (11, 45, or 79 ppm fluoride) in drinking water for 2 years. There was no evidence of carcinogenic activity of sodium fluoride in male or female mice receiving sodium fluoride of 25, 100, or 175 ppm in drinking water for 2 years. Dosed rats had lesions typical of fluorosis of the teeth and high -dose female rats had increased osteosclerosis of long bone." DDPA will provide information about future developments in the NIP study, as well as findings and deliberations of the PHS Interagency Sodium, Fluoride Subcommittee, charged with conducting a risk -benefit analysis of fluoride, given the NIP findings. Attachment 1 SUMMARY OF PEER REVIEW MEETING: NTP STUDY ON SODIUM FLUORIDE APRIL 26, 1990 RESEARCH TRIANGLE PARK, NORTH CAROLINA On April 26, 1990, staff of the Dental Disease Prevention Activity (DDPA) attended the National Toxicology Program (NTP) peer review session on sodium fluoride at Research Triangle Park, North Carolina. For more than 5 hours a panel of non -government scientists reviewed and discussed findings of the NTP "Draft Technical Report on Sodium Fluoride." This panel voted unanimously in favor of the classification, "equivocalevidence of carcinogenicity." As indicated in the attached press release from Dr. David Rall, the panel agreed that "the evidence for bone tumor formation in male rats was too weak to be attributed to fluoride administration." The panel's recommendation was based on the small numbers of a particularly rare bone neoplasm found only in male test rats. None of these neoplasms were found in female rats or in mice of either sex tested under the uncommonly rigorous conditions of the study protocol. (The protocol included more intensive scrutiny; e.g., full body radiographs and histopathologic review of 8, rather than the usual 2, bone sites.) Following presentations by NTP staff., public testimony, and deliberation among panel members, the panel considered motions. The first motion supported the categorization, "no evidence," and was defeated because the rare bone neoplasms were present. The "equivocal evidence" motion was discussed and passed unanimously, indicating insufficient evidence to attribute these neoplasms, with certainty, to fluoride administration. The panel members recommended several modifications to the draft Technical Report to improve the quality of the final report. Recommendations included: (1) Addition of tables comparing pairwise-control animals with test.animals diagnosed with specific neoplasms of interest; (2) substitution of the term "control" for "0 ppm," because all animals received a diet containing up to 8 ppm fluoride per day; and (3) weakening the language about the genotoxic potential of fluoride (this was a recommendation of one principal reviewer). The final conclusions of the Toxicology and Carcinogenesis Studies of Sodium Fluoride in F344/N rats and B6C3F1 mice are stated as follows: "Under the conditions of these 2-year dosed water studies, there was equivocal evidence of carcinogenic activity of sodium fluoride in male F344/N rats, based on the occurrence of a small number of osteosarcomas in dosed animals. The uncertain category of findings, 'equivocal evidence of carcinogenic activity,' is demonstrated by Page 2 - FL-136 A draft Technical Report on toxicology and carcinogenesis studies of sodium fluoride was released by NTP on April 2, 1990, for public review and comment. 0n April 26, 1990, a peer review session was conducted at NTP headquarters in Research Triangle Park, North Carolina. For your information, we have attached the following documentation: a summary of the peer review meeting; an explanation of the levels of evidence; and statements by Dr. Mason and Dr. David P. Rall, Director, NIEHS. Dental Disease Prevention Activity Center for Prevention Services 4 Attachments 6 DEPARTMENT OF HEALTH & HUMAN SERVICES 4Mis� Public Health Service Centers for Disease Control Atlanta, Georgia 30333 Refer: FL-136 May 1990 PHS SUPPORT FOR THE USE OF FLUORIDES CONTINUES FOLLOWING PEER REVIEW OF NATIONAL TOXICOLOGY PROGRAM STUDY OF CHRONIC TOXICITY AND CARCINOGENICITY OF SODIUM FLUORIDE / "There is no information available at this time that would indicate need J for any change in the Public Health Service policy of continued support for,.the use of fluorides for the prevention of tooth decay." The above statement was made by Dr. James 0. Mason „Assistant Secretary for Health, following action taken by a panel of outside experts who reviewed and confirmed the National Toxicology Program interpretation that its recent study of the toxicity and carcinogenicity of sodium fluoride administered to rats and mice produced "equivocal" results. BACKGROUND INFORMATION - NATIONAL TOXICOLOGY PROGRAM The National Cancer Institute was directed by the Congressional Committee on Intergovernmental Relations and Human Resources "...to provide animal bioassay data concerning the potential carcinogenicity of sodium fluoride." The National Toxicology Program (NIP) was given the responsibility for carrying out and reporting the study. NTP is made up of four charter agencies of the U.S. Department of Health and Human Services: (1) the National Cancer Institute (NCI), National Institutes of Health; (2) the National _nstitute of Environmental Health Sciences (NIEHS), National Institutes of Health; (3) the National Center for Toxicological Research, Food and Drug Administration; and (4) the National Institute of Occupational Safety and Health, Centers for Disease Control. In July 1981, the Carcinogenesis Bioassay Testing Program, NCI, was transferred to NIEHS. NTP coordinates the relevant programs, staff, and resources from these Public Health Service agencies relating to basic and applied research and to biological assay development and validation. NIP develops, evaluates, and disseminates scientific information about potentially toxic and hazardous chemicals. This knowledge is used for protecting the health of the American people and for the primary prevention of disease. 4z� JO THE WASHINGTON POST FRIDAY, APRIL 27,1990 A7 No Significant Cancer Risk Seen in Fluoride National Toxicology Program Studied Rats and Mice for Two Years By Malcolm Gladwell Wuhingtm Pwt Staff Writer One of the largest studies ever conducted on the safety of fluoride has failed to produce any definitive evidence that the chemical, which is added to much of America's drink- ing water to prevent tooth decay, poses any significant cancer risk, a panel of government experts con- cluded yesterday. According. to the scientific review panel of the National Toxicology Program (NTP), a two-year study of fluoride in animals showed "no ev- idence of carcinbgeniciV in female rats, and male and female mice, and "equivocal evidence of carcinogenic activity' in male rats based on a slightly higher than normal incidence of tumors in male rats fed very high fluoride doses. It was claimed earlier this year that the study provided the first ev- idence that fluoride causes cancer. The panel's findings are expected to settle at least some of the con- troversy that has surrounded flu- oride since public health officials first began adding it to drinking wa- ter more than 40 years ago. Ac- cording to James 0. Mason, assist- ant •secretary of health, nothing in the study suggested the need "for any change in, the Public Health Service policy of continued support for the use of fluorides for the pre- vention of tooth decay." In the NTP study, 520 mice and 520 rats of both sexes were given either no fluoride or one of three different doses': of fluoride in their drinking water for two years. None of the 520 mice developed bone can- cer, the type of cancer that logically would be caused by fluoride, which accumulates in the bones, nor did any of the rats in a control group or any of the female rats. One male rat out of a group of 50 that drank water with 45 parts per million (ppm) of fluoride developed bone cancer, and three male rats out of 80 that drank water with 79 ppm developed bone cancer. According to the Academy of General Dentistry, a person would have to drink 360 glasses of heavily fluoridated water per day in order to be exposed to as much of the chemical as the rats drinking the 45 ppm dose and 700 glasses of water a day to have the same risk of can- cer as the rats at the 79 ppm dose. "The benefits of water fluorida- tion are undeniable," said Henry Finger, president of the ocademv. He said its effectiveness has been "documented in approximately 140 studies from 20 countries over sev. eral decades. Since 1945, commu- nity water fluoridation has helped create two generations of children who are 50 percent cavity -free." �\ ✓ 1Lli ��i� � ci�r/�QQ Cz�%/GL(.OG'(.f.0,� r �a7�f �'c // /�a/�i Michael S. Dukakis uU c gl L elffal A� Governor Philip W. Johnston >,jQ �eI72�2fiJC(i Secretary David H. Mulligan OO&V/L 02»> Commissioner TEL: (617) 727.0732 FAX: (617) 723.1659 TO: Boards of Health Water Department School Fluoride Mouthrinse Programs Fluoridation Network FROM: Gregory N. Connoll , D., M.P.H. DATE: May 21, 1990 M E M O R A N D U M As a follow-up to our January memo concerning fluoridation and alleged association with cancer, we wanted you to know the National Toxicology Program (NTP) study of the possible carcinogenicity of fluoride on rats and mice has been released. It showed "no evidence of carcinogenicity" in female rats or male or female mice and only "equivocal evidence" in male rats when these animals were given water with up to 79 ppm of fluoride (79 times amountof fluoride in fluoridated water.) A recently completed study by Hazelton Laboratories for Proctor and Gamble using a different strain of rat than the NTP study found no carcinogenicity from fluoride even when these rats were given twice the amount of fluoride used in the NTP study. These studies will be among those reviewed by a Public Health Service analysis of peer -reviewed human and animal fluoride studies from throughout the world. The PHS report should be available in July, or August. "There is, no information available at this time that would indicate need for any change in the Public Health Service policy of continued support for the use of fluorides for the prevention of tooth decay," according to James 0. Mason, M.D., Assistant Secretary for Health, U.S. Department of Health and Human Services. Based on this and other well done human studies that have found no association between fluoridation and cancer, the Department of Public Health continues to recommend fluoridation as a safe, effective way to prevent dental caries. We will continue to monitor studies of fluoride and will keep you informed. mf cc: Martha Wood Carole Roy Fred Barker /aG/f E7 FLUORID ------ 'luo E HELD CLUE , .! TO CANCER IN RATS Researchers Stress That Data Do Not Suggest Any Need for People to Worry By PHILIP J. HILTS WASHINGTON Jan, 25 — Research. ers have found preliminary evidence that fluoride causes cancer in male rats, Federal officials said today. But 'they cautioned that the study did not isuggest that the fluoride in waterand 1 toothpaste would cause cancer, ' Studies sponsored by the National Toxicological Program examined 1,360 mice and rats. The unexpected findings . showed that a handful of cases of bone i cancer might be attributed to fluoride - spiked water that the animals received j in their diet. . The cancers occurred mostly :at doses that are 50 to 100 times the amount humans ingest from water.or toothpaste, said James Brown, a' !spokesman for the Federal Depart- menr of Health and Human Services. he cancers occurred only in the male rats. For 40 years, health officials have advocated the use of fluoride in tooth. 'paste and in drinking water because it ' is so effective in reducing tooth decay, Extensive epidemiological research was done by the National Cancer Intl. tute and others in the 1970, said Dr. 'Samuel Broder, director of the Na- i tional Cancer Institute. "The issue has !been looked at carefully in the past," ,Dr. Broder said, "and there is just no ;evidence in humans for a connection ,between fluoride and cancer. But we will revisit the data again." The kind of cancer the mice and rats 'in the study got was bone cancer, which in humans accounts for only about 12,000 of the 1.1 million cancers ,re. corded each year in the United States, The mice and rats in the study were put in groups of 50. Among 50 male rats, one bone cancer was found at the medium dose of 45 parts per million. of iluonde and four more bone cancers were found in the male rats at the dose of 79 parts per million fluoride. Mice did not show any bone cancers, -tor did the female rats. The study is not strong evidence, but is "a weak signal" that fluoride can cause cancer, said a Federal official who is familiar with the study. ' Because the bone cancers occurred only in male rots and not at all In mice, in fight of the previous work, "the con. trolling data most be the human data," Di. Broder ,aid. mite -cancer link cited WASHINGTON (AP) — A gov. ernment-sponsored study indi. cates that high doses of fluoride maycause cancer in male rats, but public health officials cau. tioned Tuesday that the findings are preliminary. . Officials also said the findings .do not suggest that tooth -decay - fighting fluoride in drinking wa- ter and toothpaste could cause cancer in humans. "The,,firtdings must be eval- uatAd, scientific Sale cat C4,.-. C. ,e - _ _ •--'-� peer review before conclusions can be drawn," said Jim Brown, a spokesman for the'Public Health Service. Such a meeting is sched- uled for April26. ' "It should be noted that all pre- vijus studies including those by the National Cancer Institute, the Centers for Disease Control, the National Heart, Lung and Blood Institute as well as studies done in Canada, England, Australia, New Zealand and Norway show no linkage between ingested fluo- ride and mortality from cancer in twwo 4" 311 t45 humans," he said. In the study conducted Jd' National Toxicological Pr1,360 miceand rats wereter containing sodium IIFour male rats;given highgot bon.:cancer. None of male rats, nor any of the m female mire in the study, was found to have contracted cancer at any of the four doses given. The high'doses contained fluo- ride in far greater amounts than humans are exposed to in tooth- paste and water, Brown said. d Dental experts defend fluoridated water: NEW YORK (AP)— A study has found a possible link between fluoride and cancer in rats, but dental experts said previous re- search gives strong evidence that fluoridated water is safe. "You have to sort of consider that one study in relation to many others that have been carried out," said Colin Dawes, editor of the Journal of'Dental Research. . "There's no material that's been added to the diet or water that's been more thoroughly tested than fluoride, in terms of its potential toxicological ef- fects," he said. The evidence against its caus- ing cancer is overwhelming, said Dawes, professor of oral biology at the University of Manitoba. His journal is an official publication of the International Association for Dental Research. Dawes and other experts inter- viewed Wednesday were reacting to news that federal researchers had found cases of osteosarcoma, a form of bone cancer, in some rats fed high doses of fluoridated water. One rat in a group of 5o devel- oped the cancer after drinking water with 45 parts per million of fluoride over two years, while four rats in another group devel- oped it after drinking 79 parts per million during the period. Those concentrations are much higher than the ailerage 1 part Per -.million many communities put in their water to protect against cavities. High doses of po- tential cancer -causing substances are routinely used in rodent ex- periments to expose any effects. Osteosiecoma is uncommon in humans; with about 700 new cases ayear' ' An estimated 132 million Americans, about 53 percent of the population, drink water with enbugh fluuride to fight cavities, according to the National Insti- tute of Dental Research. Dental experts interviewed by The Associated Press said they could not comment on the new study itself because they had not seen the work, which is still pre- liminary and has not yet been re- leased by the government. But Gary Whitford of the -Medi- cal College of Georgia, who stud- ies side effects of fluoride, said previous research gives no evi- dence of a link to cancer. He participated in a study that found no harm when rats were fed high fluoride doses in the form of toothpaste daily for I6 months, he said. Asked if the federal study made him worry about the possibility of the substance causing cancer, he replied, "1 have no reason Ito think that that's a realistic post• bility." LN I, IM c �Q/ N N LJO 0 m Ln O � � O .m o 0 ° r ri o c� 3 3 °c a °c o 0 cA O N N 0 ,� � O -� co 0 0 0o v 3 o_ 0 3 0 N '-i V C7 O O o 3 3 z J o cn a Z i ' I W IW 0 O ro 64, i W n Wd F"7. Ak 0 n CD January 22, 1990 National Toxicology Program (NTP) Study of Chronic Toxicity and Carcinogenicity of Sodium Fluoride - FACT SHEET Sodium fluoride was administered in the drinking water at concentrations of 0, 23, 100, and 175 ppm (equals 0, 11, 45, and 79 ppm fluoride) to groups of male and female F344 rats and 86C3F1 mice, for two (2) years. There were 80 animals in the control and high doze groups, and 50 in the low and mid dose groups. The study is now in the evaluation phase. A panel of pathology experts evaluated the histopathology diagnoses on January 12. This review group has confirmed the preliminary findings Of osteosarccmas in male rats (incidences of 0/80 in control rats, 0/50 in the low dose group, 1/50 in the mid dose group, and 4/80 in the high dose group) and squamouz carcinomas in the tissues of the oral cavity in male and female rats (Male; 0/80 control, 0/50 low dose, 1/50 mid dose, and 1/80 high dose;'Female: 1/80 control, 0/50 low dose, 0/50 mid dose, and 3/80 high dose). Both rats and mice had dose -related fluorosis Of teeth and female rats had osteosclerosis of long bones. Validated (but as yet uninterpreted) pathology data tables will be available on approximately February 2. The entire data met along with statistical analyses, comparisons with historical control tumor incidence data and an interpretation of any potential biologically significant findings will be available in a draft Technical Report in mid -March. This report will undergo comprehensive peer review in an open -to -the -public meeting by the NTP Board of Scientific Counselors in mid -April. Fluoride January 29, 1990 Page A Fluoridation alao Can benefit adults in two ways. The Zir$t is through the remineraliZation process, in which beginning carious lesions in the enamel rail to enlarge or reverse because of frequent exposure to small amounts of tective benefit is in the. prevent fluoride. The other pr oion of root catiesi a progressive erosion of the root surface, adults w ith gingival recession_ Studies have affecting ncornorated into the structure demonstrated that fluoride is imoremore . to decal' shoulh of the root surface, making it resistant it become exposed as a result of gumiine recession. The annual cost of community water fluoridation averages on1Y 35-&0 cents per person in the united States. With the �care fluoride remains a preventive r escalating �h t at minimal cast of heal measure that benefits all members of the communi y cent In additionf the need for restorative dental care is 2t is estimated that. every Lower in fluoridated communities• o about $50 in dental dollar invested in fluoridation saves expenditures- #�i Fluoride January 29, 1990 Page- 3 Studies conducted by the National Cancer institute over a number of years have shown no correlation between water fluoridation and cancer. During the seer Study conducted by the NCI during each year from 1973-1987, the bone cancer rate among people remained steady, neither increasing .or decliring. The bone cancer the rodents got in the NTP Study is tare among humans and accounts for less than .01 percent of the 1.1 million cancers diagnosed each year. The ADA has firmly supported community water fluoridation since 1950, based on its continuing evaluation of the safety and efficacy of fluoridation. A total of 80 national and international organizations endorse or support water i. fluoridation, including the World Health Organization, the American Medical Association, and the O.S. Environmental Protection Agency. The effectiven6ss of water fluoridation has been documented in approximately 140 studies from 20 different countries over a period of saaerzl decades. The data from these studies continually have shown that children living in communities with fluoride adjusted water experienced an average reduction in tooth decry in the range of 17-40 percent_ Fluoride January 29, 1990 Page 2 In the NTP study, one rat among a group of 50 developed bore cancer after ingesting 45 parts per million of fluoride over two years, the average life expectancy of a rodent, :chile bony canoes appeared in four rats from another group after they drank 79 parts per million of fluoride over the game period of time. On average, a person ingests eight, eight -ounce glasses of water a day. A person would have to consume about 380 eight -ounce glasses of water a day to obtain 45 parts per million of fluoride, and nearly 700 glasses daily for 79 parts per million. 'it is totally inappropriate to draw any conclusions from this single study, or to suggest that it is applicable to human beings," said Dr. Enid Dieidle, director of Scientific Affairs of the ADP.. •The ADA wants to allay any concerns people might have about drinking fluoridated water as a result of these limited study findings. There is substantial scientific evidence supporting the benefits and safety of fluoridated water for humans." Indeed, numerous studies have shown that consumption of fluoride in community water supplies at the level recor4ns.ded for optimal dental health has no harmful effect ir, humans. - more - FOR IMMEDIATE RELEASE January 29, 1990 Dews Release CONTACT: C uck Green Philip Weintraub (312) 440-2806 FAR water fluoridation remains the safest, most effective and most economical public health measure to prevent tooth decay and to improve oral health for a lifetime, according to the American Dental Association (ADA). This reaffirmation of support for water fluoridation comes in the face of preliminary data from a study conducted by the National Toxicology Program (NTP). In this study, some rodents developed bone cancer after drinking water containing sodium fluoride. The ADA, however, emphasizes that no connection should be made between the preliminary results o;: that study and the likelingod of humans developing bone cancer by ingesting fluoride. The amount of sodium fluoride giver, thA rodents in the study far exceeded the optimal level of fluoride present in drinking water, one part per million. - more - aged children. Arch. Oral. 8401. 23:111-15, 1978. 17. Margolis, F.).; Ream and Mahaffey, H. Ten-year prospective study of deciduous and permanent dentition. Am. 1. Dis. Child. 129:794-8W, 1975. 18. FannfnB. E.A.; Cellier, K.M.; Leadbeate4 M.M.; and Somerville, C.M. South Aus- tralian kfnderganen children: Fluoride tablet supplements and dental Callas. Aust, lent. 1.20:7.9, 1975. 19. Infante, PF.. Dietary fluoride intake from supplements and communal water sup- plies. Am. I. Dis. Child: 129:835-3'7,,1975, 20. Hermon, D:K; Stookey, G.K.; and Beiswanger; B.B. Fluoridevftamin sup - elements: Ef[ects on dental caries and fluorosis when used in areas with sub optimum fluoride in the water supply. DADA. 95:965-71,1977. S.B:; and Korts, 21. Driscau, W.S.; Heiletz, D.C. Effect of chewable fluoride tablets on dental caries fn schoolchildren Results after six years of use, )ADA. 97:8204i24, 197& 22. D;�ou, w,5. What we know and dOnt know about dietary fluoride supplements -- the research basis. 1. Dent. Child. 52:259.64,1985. 23. Levy, S.M. Expansion of the proper Use of systemic fluoride supplements. JADA. 112:30 34,1986 24. j; fi: , W.S.; Heifetz, S.B.; Horowitz, H.S.; Kutgrnan, A.; Meyers, I•; and Zimmerman, E.R. Prevalence of dental caries and dental fluomsis in areas with negligible, optimal and abovemptimal fluoride concentrations in drinking wa• ter JADA. 113:29-33 1986 25. American Academy of Pediatrics, Com- mittee on Nutrition: Fluoride supple- mentation. Revised Dosage Schedule. pediatrics. 63:150-52,1979. 26. American Academy of Pediatrics, COm- mittee on Nutrition: Fluoride supple mentation. S dia d Homwf"H• 98(L 27. DrfscoB, for dietary cession of optimal dosage fluoride supplementation. JADA., 96:1050.53, 1978. humann in 28. salivand milk. Caries oResearch. 3:159 1969, yy, The 29. Johnson, J. J., Jr., and Bawden,1. fluoride content Of' t formulas avail- able in 1985. Ped. Dent. 9(1): * 37, 1997. 30. Newbrun, E.Water fluoridation and fluoridation supplements N caries PTe- vention.l. Calil. lent. Assoc.8:38A7, 1980. urzolit of l<�" ,earveo See us at the Hynes Convention Center — Booths No. 1300, 1301. ji Crimmings COMPANY SERVING DENTISTRY SINCE 1895 Equipment, Merchandise, Teeth, Facilities Planning, Leasing, Financial Planning 35 Soldiers Field Place Boston Massachusetts 02135 CALL US TOLL FREE 1-800-225-4528 in Massachusetts 1-800-362.4490 HEALTH PROFESSIONAL COLLABORATIVE CONSULTANTS TO THE MEDICAL AND DENTAL PROFESSIONAL Byron ALN-40 ides 45 Glen Circle, Waltham, MA 02154 (617) 894-2869 For 30 years a Full Service Practice Broker throughout New England. Both the prospective seller and prospective buyer can be assured full confidentiality. 1�5- 4Y— ,,,,,,,, Cal De artment of Public Health, provide a list of 117 comet � � �,�, - ,� in Massachusetts that are op- tintagy fluoridated. gCgp Dentists aressw. mu�aclalty The denied nlPbaPwf and mldVdent&9MPP�inM UrdlMkreBion. the largeMMtdmast exparNrroad. oriented pdan0rs for we are 11sho a�afuipoSirpquadtYractice in our health care both tuN Ind pan•tlme PositkNb P areas. centers located in goseen and SUROundinG subuWn PadodoM �dDic �te dafn baMdtapaoka9ewith WeoHer anetlYWMMrOaataNe W, no investment PlN" fend resume br Anthony T. lo"oo, D•M.D., MAn022,5 Director 2 Fenway PIW, Bostotb VHealth Planmmunity An Equal opporlunfry Employer merits to those chttdren in need. The dental p Profession and other Closely with P • y systemic.flu health professl( edals if greatest ben - rides are to be used to - ,fit by our population. summary 1 Alf children should receive one form of systemicoflf m ndal flluoride. propriate forms P 2. if a child is not receiving optimally fluoridated water, the dentist r� physician should prescribe fluoride supplements (tablets or drops). 3. The correct dosage must be deter- mined based on patient age and fluoride content of the patient's main water source(s)• 4. Special attention is �intakecessary for References I. Horowitz, H.S. Alternative methods of delivering fluorides: An update. Dent, Hyg.57-37-43,1983. noon of tooth 2. Dental sealants in thNanonal h sumtes of dewy. Proceedings' National Con - Health, Consensus Dev Suwenemenh fehmce. J. Dent. Ed. 49(2) PP 1.134,1984. 3• A guide to the use of fluoride for the prevention of dental caries. )ADA• 113: So3-65, 1986. 4. Fluoride rompounds. In AccepteAmerican Therapeutics, 40th ad. Qacago395�28• Dental Association,1984, pp. 5. Margolis, F• )•; Burt, B.A.; Schork, M.A., et al. Fluoride supplements for ti,n prac- - A survey of physicians presrnpbon1980. tires. Am. ), Da. a lg ; and 6. Gift, H.C.; Milton, tofessional in the The role reventi of caries pon. Chicago: delivery oaabon Health American Dental Ass Foundation�d983.. B.B.; and Walsh, V. 7. Gift, H.C.; enuon—results Physioans and caries prev of a physician survey of preventive dental services. )AMA 19K 252.e 4 D.I.Fluoride 8. Kuthy, R.A., and MgV , . practices 0 Ohio physicians - prescription ), pub. Health. Dent 47(l7Z76,1987. 4): 9. Levy, S•M•% Rptieuse tw North l W. Fluoride supplement1]4:347-50, 1987. Carolina dented �yr�rell A.F. Compliance 5. To arrive at the correct fluoride 10. Levy, S.M., viders with Recom- by Health Care Pro lemen- mended Systemic Fluoride Supp dose, these steps should be cation Protocol. Clin. pm-. Dent. followed: le of the 9(5):19-22,1981 A. Always have a ware S.M. Systemic fluoride supple- . practice man drinking water source u. Levy, or bottled orientation in an academic family (usually home tap setting. J. Fam. Praa. 24(5):1111534,536, water) analyzed for the fluo- 1997• 12. Arnold, F.A., Jr.; Dean, HT.; ]ate Pp%and ride content before Prescribing supplement, if you Knutson, l•W Effect of fluoridated va-public a fluoride water suppdes on dental caries pre58,19 do not have other specific lence. Pub. Health Rep. 7l:° 2-58' 1956. knowledge of water fluoride 13 Fluoridation Census 1980. Atlanta: U.S. content. The Massachusetts Department of Health and Human Sen- Department of Public Health, ices seaseCoHealthtnic_, Centers for Division of -Dental Health, t4. Horowitz, H.S.% Heifetz, S.B.: and law'. F.E. Effect cf school water Fluoridation co provides water fluoride assay services. dental caries: A final result in Elk Gd:c. B. When the fluoride content of Pennsylvania after 12 years. ]ADA. the water has been deter- 84,832-- 19 and Peebles. T.(fn C. Ets mined, the fluoride level and 15. oA n ode supplementation from both the child's age should be ve at on human deciduous and Permanent matched on table 1 to cirri teeth. Arch. Oml. Bfol.19:321-26. 1974. the correct supplement dose. 16. Aasenden, R., ana lvbble . T.c. Flfens .. ... _ r- w,.,.,i assistant direr- of fluoride supplementation s;°', ..'ooi;,1vt11 FLUORIDATION Sample ProKkiPtiontit' continued from page "I be reported o the provider so that RxSodiumFldwp eD1OF° pg5 mg Fldmp24 � the dosage of fluoride supplements �onedrapd�Y can be adjusted, if necessary. Sig waxc(�muhocfooda AlthIFOW ough children should seethe Cann ON: KM OUT OF RRACn dentist at a young age, most children OF 09 o (EN do not see a dentist before age three, 111ta is a peon for The complexities of controlling RuoridedmFetobeuaedwhmn75m& dosage for infants and youngertit is�d, Le., bowl bed+o two ride children � warerw ke6 children must, therefore,dentists and yem u1e1ip3ppm joint responsibility.tive R' physiciansconcemrnB Pam' RxsodwinHwAd• regimen and should provide gur- 1.1 Cg (O` CgF) dance m regulating supplement Dypeme:llll tabs bdore dosage. Also, remind the physician �` QW wish �bo eemrlds, •ol that dosage typically must be ad- bedGOW. ' justed at ages two and three* � N: KWOUP oFREA�E1 y Determination of water fluoride OF Fes°" levels and systemic fluoride needs ,�1Fa kM i0r maybebestaccomplishedasroutine bt""dWh &5%%6 paw of new and recall patient ex ceded 1e � w. aminationproceduresforerage16.nant laaaa. gtp'1�"°aFFm ama,t women and children under age 16. awnwabw+t�a °iide womgationtodentalhygtenistsOf �03Dele•darFcm some of these responsibilities has been suggested in order to facilitate the process Fluoride tablets are tow fluoride for. 0,25, 0.5, and 1.0 mg. mm- mulations. There are several rcial brands available.' (See also TZList of Accepted products.Fluoride Supplements" in the February 1988 issue of JADA.)Additionmany Pharmacies can provide a generic product. The taowed before ste sowing to prod be ovvide topical benefit. ' It is recommended that one avoid ingesting a fluoride tablet or drops with any source of soluble calcium A (e.g., milk) to allow greater absorp- tion of fluoride ions. Fluoride drops, often providing 0125 mg. or 0.25 mg. of fluoride per drop, should be used for those who t cannot chew a tablet. No o[ � than 264 mg. sodium fluoride, fluoride, should be Prescribed nat one time for safety I product should be kept in while - proof container in a secure p Sample prescriptions are shown for 0.5 mg. fluoride dosage tablets --A n 75 Mg. fluoride dosage drops* v v�h-�- IWIVN The biggest difficulty with fluoride supplements is patient co ape have ante. Numerous studios ess of documented the effectiven fluoride supplements in reducing dental caries. However, the sup- plementation schedule must be fol- lowed conscientiously. These studies have shown that the greatest caries reductions have occurred as a result of select PoPula- lions seeking pediatric dental or medical care on a regular basis and also as a result of follow-up from dedicated and enthusiastic dentists and physicians who were able to , comly motivate the patients to Therefore, ith wthe dosage regimen.encourage the dentist must od monitor the dvld's and attempt supplement use. Conclusion iclwillwen- It is hoped that this art courage and assist dentists in Ivlassa- chusehs in providing appropriate doses of systemic fluoride supple- MEDICAL- WASTE DISPOSAL- Co. INC. 28 SOUTH MAIN ST., SUITE 274 RANOOLw, FA�23 2360 (617) Dabnu Jjoms/a/n. `lm. ✓Ox .%n/ae/lol., lrlarre Cna,oGanr OUR SERVICES INCLUDE: • Infectious waste inservice • On -call & Scheduled pick-up • container choice • Manifest documentation CL15 WITH YOU FOR A EANER ENVIRONMENT COMPARE AND SAVE Dosage schedule The present guidelines for systemic fluoride supplements recommended by the American Dental Association, the American Academy of Pediatric Dentistry, and the American Acade- my of Pediatrics are shown in table 1 ,.rn-s7 Any water fluoride level greater than 0.3 ppm requires ad- justment from the full dosage sup- plement. Determination of appropriate dosage After determining the fluoride level of a patient's main source of drinking water obtaining umb lion from water ng samples or obtaining departments, schools, Massachusetts Department of Public Health, etc.), the practitioner must determine the appropriate supplement dosage, if any, to prescribe. For example, a four year old with a water fluoride level of 0.5 ppm would receive a 0.50 mg supplement instead of the "full' supplement dosage of 1.00 mg apPro- Table 1 Supplemental Fluoride Dosage Schedule (in mg. of Fluoride Per Day) lams per Mlpion Fluoride inwa� supplY Age of Child <03 0.3 to 07 >0.7 Oirthto2yrs.+ 0.25 0 0 2t0yrs. R50 0.25 0 3 to l3yrs.+ l.ao 0,5o 0 'Ikmmmended by the Caurrca on De++i rteo- apeutiraof the Ameim Dmut AW%Wkn. br the committee onNuw6wof theAmekm A,deay,jp"a,im,e,dbrthe Amerir n Aeademy0fhdkekned1t - rttk Amekan Aadmry Of FbAdrim ieC0tl1 merrde prn'dB appjwwt, from 2 week$ 0uovgh aiwt r�ge>b priate were the water fluoride level to be 0.2 ppm. It is essential to determine whether an infant is being exclusivelynbreeast- fed, bottle-fed, or obtaining lion from both sources. Totally breast- fed babies should be supplemented fully, since there are very low amounts of fluoride found in human milk, even when the mother resides in a fluoridated area. The major manufacturers of milk - based infant formulas have removed fluoride from their products which Previously contained variable levels. '9 An infant on milk -based formula now receives fluoride almost etclu' sively from the water which may be mixed with the formula,'"Therac. titioner must determineproper. tion of bottle-feeding and re those infants supplement accordingly for infants receiving nutrition from both sources. Since excessive fluoride can cause fluorosis, parents should contact the provider of the supplement (physi- cian or dentist) when changliquids occur in the infant's consumption so the fluoride supplementation can be adjusted. Significant changes in I eeding patterns, such as from tea -feeding slid bottle-feeding ds, must breast-feeding to continued on page 197 �►.s� p�cF�-rs t How do you decide which computer system is best for you? First learn more about computers. You can make intelligent decisions about dental computer systems if �u understand them. We offer classes on computers and their programs from information management to word processing. More importantly, we teach you the practice management skills behind computers. Call and we will send you a schedule of our classes. to office The PaRCcate marketing throughaA QualityaImage. Our Programmerycaneusstomefficiency internal is ae management firm ded customize The Dental Office Management system to fit your practice management needs. Proper practice management with the use of our system provides the following benefits: Complete billing and recall systems Reports of account receivables fhepa*X Reports on the status of patients Jrporation No monthly service fees excelknce in deatutry No insurance forms Fstimates for patients and insurance A,tvanced word processing •nl �'t ------ " fluoride in your community s water supply may be obtained from your I local water department, health department, or dental public health personnel. ha C. Wood, assis of dental health, ass"hustetts or Department of public Health, also can provide a list of 117 communities in Massachusetts that are optimally fluoridated. Fluoride supplements For children who do not receive andn�kwr� onfluOrrid water or regularly a lied ed water, the use of dietary fluoride supplements (tablets or drops) is a safe and effective means of reduclng the incidence of dental caries by up z and has to 60 percent or more been recommended for use in Private practices." In order to receive maxr- mum preventive benefits, the suP- plements must be taken daily from birth until at least age 1V Supplement protocol t is important that children receive the appropriate dose of systemic fluoride. This can be accomplished only if the practitioner knows the . fluoride concentration of thheer. (Oo-s main source oof drinkinge important casionally, patient water source must fluoride level sidered and the average determined.) Fluoride levels exceeding the op- timal are associated with an increased risk of dental fluorosis (motthnga'4 Although fluorosis is primarily cosmetic proble ,Se°tooth surEae cases oce n involve pitting Therefore, to avid o ceedin8ntioner reconunendedNhich comps . 'es in should know and the con - the area are fluoridated centrat.On of fluoride. le should A separate water same be submitted m order to determine the fluoride water, bottled water, or nfs community ti ndividual water supply ff the prac- tioner does not have prior specific knowledge of the level. Because there can be significant variations in water fluoride content from nearby wells, even geographic area, one shoulld not le fromrely on the results of a same different source, no matter hot nin in certain communities, pr dividually drilled rock wells greater than 300 feet deep have been found to contain up to 3 ppm of natural occurring fluoride. Water sampling procedures The Massachusetts Department of Public Health, Division of Dental Health, will analyze Patient's water samples for health professionals. Water sample bottles and further details about the program r be Massachusetts obtained by contacting: Department of Public Health, Divi- sion of Dental Health Z1150 Tremont Street, Boston, MA 777.0732, no charge. - INuvolfl Why would anyone spend money for a computer system to manage a dental office? To increase profits! It's that simple• for my practice. When the OFFICE MANAGEMENT• ble were 40%. I found I developed TKEmpl mente accounts receivable were reduced b ointments my system was implemented, my 2S0 parents not being ploPsuy recalled staffanMy computer Pad foritselfin first 2,5% without increasing my PP six months of use. Provides quality Image for a practice. It increases I invented and copyrighted ADVANCED woun pxocEssiNG which innovative internal marketing and a 9 tY patients. It smlplifie; the patient acceptance of treatment and the number of new p Production of letters and reports. he aRC Call us today! orporation C Corporation euelknce in dentutry The PaR P ,_n....ta., Avenue .. _. ..,_._. nil S Dietary Fluoride supplements for Massachusetts' Children` The Role of the Dentist by Martha C. Wood, MBA; Frederick P. Barker, Jr., PE; Steoen M. lzv! DDS, MPH; and Raymond A. Kuthy, DDS, MPH .- fluorides may be applied profes- The need for systemic supplements Community water fluoridation is Introduction sionally or self -applied• the most efficient and cost effective d fluoride solutions and -A-C roviding systemic fluoride e appropriate use of fluoride remains the best defense against br dental canes. This is true despite ex roved tensive efforts to develop re To methods of mechanical plaque moval, to develop chemical agents ch that safely and effectivelyreduce e cariogenic activity to d reduce the frequency of intake of a catiogenic foods by modification of 1 dietary practices.' pit -and -fissure sealants are an im- G port itweapon in caries control,' but their full impact depends heavily on the ability of fluorides to control smooth surface caries. Although the mechanisms by which fluorides exert 8 their caries -inhibiting effects are not full understood, they are thought f Y to include: ( ) reredmm on of enamel solubility emi�ytio of early callous lesions bacteria (3) action on plaque There has been greater interest in and understanding of the Len» tter- alL.tion process in 'ntcyeea� le - showing that many Y sions may be reversible if treated promptly andproperlY . fluoride. Fluoride products are intended for use either systemically or topically. S} sternic fluoride is ingested, ab sorbed, and incorporated into devel- oping bone and tooth structure. In locally on supeal fluorides work rficial rficial layers of enamel locally Pe and on plaque. systemic Methods of delivering y fluorides in the United States include community water fluoridation, school water fluoridation, and die- tary fluoride supplements. upp They in u a meth P is (applied in trays or with a tooth- for the preventiaohnno � onehalof the brush or applicator), fluoride den- Unfortimately, tifrices, and fluoride mouthrinses• population Of the United States Martha C. wood, MBA, is assistant director, dental health, MassachusettsaDepartmentrtment of Public Health. Unhersity of Frederick P. nod, Ir. PE, is a fluoridation en neet Massachusehs DP __. nns. MPH, is assistant professor, Dpartment of Preventive and Commvmty Dentistry,tCnouOhio State University'. n n of Vol. 49, No. 3, Summer 1989 TABLE 4 Risk of Developing Some New Caries Among Elderly Residents of Nonfluoridated and Fluoridated Communities, by Years of Residence w/ New % w/ Years of Type of Corona] Relative New Root Relative Residence it Community Caries Risk Caries Risk Life-long 174 Nonfluoridated 52.9 1.00 47.7 1.00 31+ 101 Fluoridated 43.6 .80 33.7 .71• 41 + 77 Fluoridated 41.6 .70 32.5 .68' 51+ 48 Fluoridated 33.3 .63' 31.3 .66• 61+ 26 Fluoridated 34.6 .65 34.6 .73 *Significantly less caries risk than for life-long residents of nonfluoridated communities (P<.05, Pearson x=, 1 df). cant and statistically significant reductions occurred only among people with long-term exposure to fluori- dated water. The effects of life-long residence could not be tested completely in this study because there were only eight participants who had life-long residence in naturally fluoridated communities. However, the significant benefits that resulted for those with 30 or 40 years of exposure suggest that fluoridation was beneficial for these elderly adults, even though the exposure started in adulthood. In this study, information on other sources of fluo- ride, such as Fluoride toothpastes and mouthrinses, was not collected. Thus, it is possible that the differ- ences in caries incidence were due to other sources of Fluorides. However, this possibility is not likely, since the survey area was a narrowly defined geographical area; the target population was fairly homogeneous; and the residents of the fluoridated communities were not significantly different from residents of the non - Fluoridated communities in age, sex, or previous dental caries (Table 1). Since the study population is from a narrowly de- fined geographical area, the results may not be general- izable to all other areas or populations. However, among populations that have similar characteristics and similar caries rates, comparable reductions in caries would likely result if the people were consuming fluori- dated water. In recent years, antifluoridationists have been in- creasingly successful in defeating fluoridation initia- tives and have been challenging existing fluoridation in some cities. One of the arguments often made in oppo- sition to the addition of fluoride to the community wa- tersupply is that fluoride does not benefit adults. Addi- tional studies like the one reported here are needed to provide further evidence that fluoridation is beneficial for older adults as well as for children. Such informa- tion would be very valuable in community efforts to implement or maintain fluoridation. 141 References 1. Changes in mortality among the elderly: United States, 1940-78. Hyattsville, MD: National Center for Health Statistics, 1984, Se- ries 3, pub no 84.106a. 2. Weintraub JA, Burt BA. Oral health status in the United States: tooth loss and edentulism. J Dent Educ 1985;49:368-76. 3. Beck JD, Hunt R). Oral health in the United States: problems of special patients. J Dent Educ 1985;49:407-25. 4. Eklund SA, Striffler DF. Anticarfes effect of various concentra- tions of Fluoride in drinking water: evaluation of empirical evi- dence. Public Health Rep 1980;95:486.90. S. Klein SP, Bokannan HM, Bell RM, et al. The cost and effective- ness of school -based preventive dental care. Am J Public Health 1985;75:382-91. 6. Nakata TM, Stepnick RJ, Zipkin 1. Chemistry and human dental cementum: the effect of age and Fluoride exposure on the concen- tration of ash, fluoride, calcium, phosphorus and magnesium. 1 Periodontol 1972;42:115-224. 7. Stepnick R), Nakata TM, ZipkinJL The effects of age'and fluoride, citrate and carbonate content of human cementum. 1 Periodontol 1975;46:45-60. 8. Yoon SH, Brudevold F, Gardner DE, Smith FA. Distribution of fluoride in teeth from areas with different levels of fluoride in the water supply. J Dent Res 1%0;39:845-56. 9. Banting DW, Stamm J W. Effects of age and length of exposure to fluoridated water on root surface fluoride concentration. Clin Prey Dent 1982;4:3.7. 10. Stamm JS, Banting DW. Comparison of root caries prevalence in adults with life-long residence in fluoridated and non -fluoridated communities lAbstractl. I Dent Res 1980;59A:405. 11. Burt BA, Ismail Al, Eklund SA. Root caries in an optimally fluori- dated and high -fluoride community. J Dent Res 198o;65:1154-8. 12. Bmstman BA. Impact of exposure io fluoride -adequate water on root surface caries in elderly. Gerodontics 1986;2:203.7. 13. Beck JS, Hunt R), Hand JS, Field HM. Prevalence of root caries and coronal caries in a non-Institutionalizvd elderly population. J Am Dent Assoc 1985;111:%4.7. 14. Hunt III, Beck JD. Methodological considerations in a dental vpi- demiulogical survey of an elderly population. J Public Health Dent 1985;45.?574. 15. Hand JS, Hunt RJ, Beck JD. Incidence of coronal and root caries in an older adult population. J Public Health Dent 1988;48:14-9. 16, low•a State Department of Health, Dental Health Program. Iowa Fluoridation Census, Des Moines, IA: 1982. 17. US Deptanment of Health, Education, and Welfare. Fluoridation census, 1975, Atlanta, GA: Public Health Service. Centers for DiseaseControl, Bureau of State Services, Dental Disease Prewn- tion Activity, 1977. 140 Journal of Public Health Dentistry TABLE 2 Coronal and Root Caries Incidence in 18 Months Among Elderly Residents of Nonfluoridated and Fluoridated Communities, by Years of Residence Years of Residence n Type of Community New Coronal Caries (Surfaces) Mean (SD) New Root Caries (Surfaces) Mean (SD) 61 + 26 Fluoridated 1.11 (2.18) 0.54 (0.86) 51-60 22 Fluoridated 1.21 (2.09) 0.55 (1.10) 41-50 29 Fluoridated 1.52 (1.81) 0.59 (1.10) 31-40 24 Fluoridated 1.67 (3.09) 1.04 (2.20) 21-30 35 Fluoridated 2.15 (4.98) 1.02 (1.41) 11-20 75 Fluoridated 1.93 (3.19) 1.21 (1.70) 5-10 39 Fluoridated 2.13 (2.68) 1.24 (2.14) Life-long 174 Nonfluoridated 1.95 (2.66) 1.11 (1.65) TABLE 3 Differences in Caries Incidence Between Elderly Life-long Residents of Nonfluoridated Communities and Selected Groups of Elderly Residents of Fluoridated Communities, by Years of Residence New Coronal New Root Years of Type of Caries (Surfaces) Caries (Surfaces) Residence n Community Mean (SD) Mean (SD) 61+ 26 Fluoridated 1.11 (2.18) 0.54 (0,86) 51 + 48 Fluoridated 1.12 (2.19)' 0.54 (0.97)' 41+ 77 Fluoridated 1.21 (2.01)' 0.56 (0.99)' 31+ 101 Fluoridated 1.33 (2.30)' 0,67 (1.38) Life-long 174 Nonfluoridated 1.95 (2.66) 1.11 (1.65) 'Statistically significant difference in caries increment between that group and the fife -long residents of nonfluortdated communities (Mann -Whitney test). communities were combined into a single group with a broader range of years of residency. The difference in mean corona) caries incidence noted between life-long residents of nonfluoridated communities and people who had resided in fluoridated communities for more than 30 years was statistically significant. Similarly, the difference in mean root caries incidence noted between life-long residents of nonfluoridated communities and people who had resided in fluoridated communities for more than 40 years was statistically significant. Multivariate analyses using regression techniques showed that the fluoridation effects on corona) caries ncidence remained practically the same when first con- trolling for the effects of age, sex, and number of teeth. The fluoridation effects on root caries incidence re- mained practically the same when first controlling for the effects of age, sex, and gingival recession. Table 4 shows the risk of developing some new caries among members of the elderly cohort surveyed. The risk of new coronal caries and the risk of new root caries both were lower among long-term residents of fluori- dated communities than among life-long residents of nonfluoridated communities. If the risk of developing some Coronal caries for life-long residents of nonfluori- dated communities is considered 1.00, the relative risk for people who lived in fluoridated communities for 30 years or more was 0.80 or less. Similarly, the risk of root caries was 0.73 or less. Discussion Dental caries is not usually considered an active dis- ease among health elderly adults, so fluoridation gen- erally has not been considered to be beneficial for older adults. However, new caries occurred in the elderly population surveyed, and long-term residents of fluori- dated communities had a lower risk and lower inci- dence of both coronal and root caries. Since fluoridation is a relatively low-cost caries -pre- ventive measure available to all -residents, the lower caries rates in the fluoridated communities probably could be considered clinically significant, as well. Resi- dence for the past five to 3(I years in fluoridated com- munities did not result in significant caries reductions, which indicates that the topical effect of currently con- sumed fluoridated water was not sufficient by itself to significantly reduce caries. Instead, clinically signifi- Vol. 49, No. 3, Summer 1989 sample of 520 dentate people randomly selected from the noninstitutionalized population aged 65 and older and residing in two rural Iowa counties. The sampling procedure and examination methods were reported previously (13-15). Residence histories also were col- lected at the time of the baseline examination. Informa- tion from these histories, the 1982 Iowa fluoridation census (16), and the 1975 national fluoridation census (17) were used to identify years of residence in fluori- dated or nonfluoridated communities. Of the original 520 dentate participants, 38 were not available for followup. Of the remaining 482 people available, 451 participated in the second examination, for a response rate of 94 percent. The participants were examined in -their homes by trained and standardized dentists. Caries incidence was determined from the surface -by -surface tooth changes between the two ex- aminations. Teeth that were lost between the baseline and 18-month followup examinations were not included. Most of the data used in this analysis were collected through dental examinations. Residence histories were collected through interviews, and drug regimens were recorded directly from the prescription containers. Subjects were classified as using xerostomic drugs if they took at least one drug daily that had a known xerostomic side effect. "Fluoridated drinking water has been shown to reduce the incidence of new caries in children; however, little is known about the effect of fluoridated water on new caries in adults." Of the 17 communities in the two rural counties sur- veyed, six had water supplies that were Fluoride -defi- cient (<0.5 ppm). Eight communities had water that was naturally fluoridated (>0.7 ppm), and three com- munities had been adjusting the fluoride level in the drinking water to 1.0 ppm for at least 15 years. For this analysis of fluoridation's effects, people were excluded who lived in rural areas, used private well water, or previously had lived in other communities for which fluoride levels could not be determined. All the resi- dents of the nonfluoridated communities who were included in this analysis were life-long residents. Only eight people had life-long residence in naturally fluori- dated communities; thus it was not possible to investi- gate the effects of life-long exposure to fluoridated water. Results As shown in Table 1, 174 people had lived in non - fluoridated communities all their lives, and 101 people 139 TABLE 1 Baseline Characteristics of Elderly Participants with More then 30 Years' Residence in Nonfluoridated and Fluoridated Communities Characteristic Life-long Residence in Nonfluoridated Community (n=174) > 30 Years' Residence in Fluoridated Community (n=101) Age 74.1 75.2 Number of teeth 18.1 18.4 % who are smokers 8.0 8.9 Sex (% female) 47.6 55.4 % on xerostomic drugs 37.9 48.5 Coronal caries (DFS) 15.6 12.4 Root caries (DFS) 2.3 1.9 Gingival recession (S) 30.6 28.4 Teeth w/ calculus 7.3 6.6 Teeth w/ 3+ min pockets 7.1 6.0 Severely mobile teeth 0.2 0.2 No significant differences between the two groups of communities (P<.0.5, x' and Mann -Whitney tests). had lived more than 30 years in fluoridated communi- ties. The data in Table 1 show that the residents of the two types of communities were similar in baseline char- acteristics. There were essentially no differences in av- erage age, average number pf teeth, or percent who were smokers. The fluoridated communities had slight- ly more females and slightly more people using xero- stomic drugs. In addition, the residents of the fluoridat- ed communities previously had less caries and periodontal disease. However, none of these differ- ences were statistically significant. Table 2 shows the corona) caries incidence and root caries incidence during the 18 months between exami- nations in the two types of communities, classified by years of residence. For coronal caries incidence, there were essentially no differences between residents of nonfluoridated communities and people who had re- sided in fluoridated communities for 30 years or less (1.93 to 2.15 surfaces). Beyond 30 years' residence, the increment was approximately one-third less and in- . creasingly less among successively longer term resi- dents (1.67 to 1.11 surfaces). For root caries incidence, there were minimal differences between residents of nonfluoridated communities and people who had re- sided in fluoridated communities 40 years or less (1.02 to 1.24 surfaces). Beyond 40 years' residence, root car- ies incidence was approximately 50 percent lower (0.54 to 0.59 surfaces). Despite the magnitude of the differences in caries incidence cited above, the relatively small sample sizes available in the older age groups in the fluoridated communities preclude a determination of statistically significant differences among the groups. Shown in Table 3 are the mean caries increments that resulted when some of the older age groups in the fluoridated 138 Journal of Pu lic Health Dentistry �% Effect of Residence in a Fluoridated Community on the Incidence of Coronal and Root Caries in an Older Adult Population Ronald J. Hunt, DOS, MS Preventive and Community Dentistry Janis B. Eldredge, ROH, MS Department of Dental Hygiene College of Dentistry University of Iowa Iowa City, IA 52242 James D. Beck, PhD Department of Dental Ecology School of Dentistry University of North Carolina Chapel Hill, NC Eighteen -month caries incidence among older adult residents of fluoridated and nonfluoridated communi- ties was compared. Rates for both coronal and root caries were consistently lower among long-term resi- dents of the fluoridated communities than among life- long residents of nonfluoridated communities. Cor- onal caries incidence was significantly lower for people who had resided in fluoridated communities for more than 30 years (1.95 vs 1.33 surfaces). Root caries incidence was significantly less among residents for more than 40 years (0.56 vs 1.11 surfaces). Fluoridation appeared to be beneficial for the older adults exam- ined, even though the exposure to fluoridated water began in adulthood. Key Words: fluoridation, coronal caries, root caries, elderly Introduction The proportion of the US population that is over age 65 is increasing (1) and older adults are keeping their teeth longer (2). National and regional studies in the US have shown that the prevalence of caries increases with age (3). However, little is known about the incidence of new caries in older age groups. Fluoridated drinking water has been shown to reduce the incidence of new caries in children (4,5); however, little is known about the effect of fluoridated water on new caries in adults. Fluoride levels in cementum and root dentin increase with longer exposure to fluoridated water (6-9); the effect of this increased fluoride content on subsequent caries development is unknown. The effect of fluoride on caries in adults is poorly defined. In the Stratford -Woodstock study in Canada, the adult residents (average age =40) of naturally fluo- ridated Stratford (1.6 ppm F) had 0.64 decayed or filled root lesions per person, while the adult residents of nonfluoridated Woodstock (average age=43) had 1.36 lesions per person (10). However, this study has not been described in a published paper, so any conclu- sions about the effect of fluoridation must be viewed with caution. In the Lordsburg-Deming study in New Mexico, Burt et al. (11) compared root caries prevalence among adults in Deming (optimally fluoridated, 0.7 ppm) with root caries prevalence among adults in Lordsburg (five times optimum F, 3.5 ppm). The root caries prevalence in Deming (average age=40) was 24 percent and in Lordsburg (average age=43) was 7 percent. The mean number of root lesions was 0.69 in Deming and 0.08 in Lordsburg. However, this study did not include a non - fluoridated community, so the effect of low levels of fluoride in the community water supply could not be evaluated. Brustman (12) has compared root caries scores in the elderly in two fluoridated and two nonfluoridated com- munities in New York. More root caries were found among residents of the nonfluoridated communities; but the examination for root caries in this study was limited to the mandibular anterior teeth and the sam- ples were not selected at random from the four commu- nities studied. Although the three epidemiologic studies cited above suggest that fluoridation has an effect on caries prevalence in adults, there have been no investigations reporting on the effects of fluoridation on the incidence of new coronal or root caries in adults. The study re- ported here investigated the effect of residence in a fluoridated community on the incidence of coronal and root caries in an elderly population. The data were taken from a longitudinal survey of a representative sample of elderly rural Iowans. Send correspondence and reprint requests to Dr. Hunt. Supported by NIDR Grant NRIII-DE06437. Manuscript received: 8/24/87; returned to author for revision: 11/I6/87; accepted for publication: 11/10/88. Methods The data used in this study were collected during baseline and 18-month followup examinations of a American Dietetic Association Reaffirms its Endorsement of Fluoridation The American Dietetic Association has reaffirmed its position on fluoridation, stating that .. appropriate fluoride supplementation, through its beneficial effects on dental health, has an important, positive impact on health and nutritional status." This position was approved by the House of Delegates on April 23, 1989. The association further stated: "The appropriate use of fluorides, through topical application, water fluoridation, or exoge- nous supplementation, has been shown to be a positive factor in the prevention of dental caries and remineralization of teeth. This is true for individuals of all ages. The use of fluorides and fluoridation is endorsed by almost all professional health organizations as the most effective dental pubic health measure in existence. "Fluoride is a natural element found at varying concentrations in all drinking water as well as in soil. Fluoride, characterized as an essential nutrient in the Recommended Dietary Allow- ances, is present in trace amounts in the body. In. optimal amounts in water food, fluoride reduces the prevalence of dental caries (decay)." Reference: "Position of the American Dietetic Association: The Impact of Fluoride on Dental Health." Public Health Reports, July 1989, Vol.89, No.7. 17 Tufts University Vol' 7' No. 8, October 1989 yD tritiOn Letter Is fluoridated water safe to drink9 Experts say it's the most effective dental public health measure available. Yet some 40 percent of Americans are still drinking water not yet treated with fluoride, a mmeral that helps strengthen tooth enamel and thereby fights cavities. One rea- son for the lapse ]s the publicity generated n antifluoridation groups who allege that theby mi e n- eral promotes chronic diseases such as AIDS cancer, and sickle cell anemia,But , that publicity is,,, .-f the the antifluorid' ounded. Concurrent with ationistsefforts to stir controversy, the American Dental Association reports that fluoridation has never been shown to increase the incidence on t or mortality of any chronic disease. SurTaking that reassurance one step further, the Heal h says the evidencetis eport on conclusive triton and levels oefluoride recommended for drinkin at the "are safe." g water Perhaps more to the point, the prevalence of cavi- ties has been shown to drop as anion Should take particular care to obtain tion for the optimal dosage, if necessary. Doses will vary according to the child's age and t of fluoride already, in the local wa ter she level upply Tat t �aegetables' as Your 3' as ever cauliflowerare right. Spinach, tomatoes, and and other veget good les fmayou p fact, eating those type of cancer that kills y help prptect against the year than any other —Jun ore Americans each t]sts at the Universit 9 cancer. when scien- Research Cen Y ofHawaiis Cancer more than ter compared the eating habits of dieter 3001ung cancer sufferers with the they Y practices of some 150 healthy individuals ate, he lessal likely thred that ey more vegetables eople disease. Y were to fall victim g People who drinkuca � -- birth to adolescence, savin uoridated water60 percent A specific protective effect was found for beta -car - dollars in dental bills, g families thousandss of °tene_a substance present in man the discomfort of not to mention orange and ye]]ov any such as carrots sitting under the on elll. minating sweet potatoes It's true that a condition known as brought about the d acorn squash. But what rosis, a harmless dental fluo- car risk was eatinggreatest reduction in lung afflict some mottling of the teeth, does vegetables. In othr wordsthe, thence of¢!l t g can. the naturally who live in communities YPes of tally occurrin where of Produce, the greater the "dose" ingly high —But the g fluoride levels which vegetables w a chosen efit, regardless of added to fluoride -le s or lowount �f t7uoride thatisceed- researchers sus Thbts the reason plies is relativel fluoride water sup- bles work ]n tandem t hell substances in ve discolor teeth, y low —definitely not enough P ward off the illness• gh to Compounds in cabbage called indoles, for If You are unsure about whether instance, are thought to have a contains adequateYour to Of their own, preventive effect check with fluoride to prevent P water It should be els are your dentist. In the event that the levnoted that smoking too low, he or she can decay,oth gla greatest cause of Jun g is by far the sin - supplements, Because it is beloved thYtlthelde cer Patients examined b 9 cancer. Most of the can- eral is most effective for children 13 were smokers or ex_ Y the sc]ent]sts, in fact, under, min- appears that eatin smokers. Thus, w parents ofyogngsters in that Years and faction, follow]n g vegetables bile it go group thou g a Produce -rich some pro- ght of as com P rich diet should not be DITORIAL ADvis pensation for a tobacco habit. hysicaland Nu,,i,;__ So Chai.,..-_.. _ Ag"1 . Evans, PhD A ray 1 Aging. Stanle Associ sor y N. CershoR, Nutrition and Dietetics. erobgy; Associate Din.,...,_ Tuna ologU. Stephen M. Bailey, PhD Associate Professor cHuntsv; Associate Director USDA Human Nutrition Research D. Human Physiology Laboratory, USDA Human r' Professor, Nutritional Biochemistry. Jeanne P C ate Professor Nutrition old Behovioc Robert 9I. h Center on Aging. Ernst J. Schaefer Rob Human Nutrition Researeh Confer r.on A in sso g g. it Frank L 7, No. 8, October 1989 l 1� j\S5 v V rV �a n.1 N c3