Unsolved:Water fluoridation controversy

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Short description: Overview of the debate over the anti-tooth decay measure
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The water fluoridation controversy arises from political, ethical, economic, and health considerations regarding the fluoridation of public water supplies.

For deprived groups in both maturing and matured countries, international and national agencies and dental associations across the world support the safety and effectiveness of water fluoridation.[1] Proponents of water fluoridation see it as a question of public health policy and equate the issue to vaccination and food fortification, citing significant benefits to dental health and minimal risks.[2][3]

In contrast, opponents of water fluoridation view it as an infringement of individual rights, if not an outright violation of medical ethics,[4] on the basis that individuals have no choice in the water that they drink, unless they drink more expensive bottled water.[5] A small minority of scientists have challenged the medical consensus, variously claiming that water fluoridation has no or little cariostatic benefits, may cause serious health problems, is not effective enough to justify the costs, and is pharmacologically obsolete.[6][7][8][9]

Opposition to fluoridation has existed since its initiation in the 1940s.[10] During the 1950s and 1960s, now-debunked conspiracy theorists claimed that fluoridation was a communist plot to undermine American public health.[11] In recent years, water fluoridation has become a prevalent health and political issue in many countries, resulting in some countries and communities discontinuing its use while others have expanded it.[12][13] The controversy is propelled by a significant public opposition supported by a minority of professionals,[14] which include researchers, dental and medical professionals, alternative medical practitioners, health food enthusiasts, a few religious groups (mostly Christian Scientists in the U.S.), and occasionally consumer groups and environmentalists.[15] Organized political opposition has come from libertarians,[16] the John Birch Society,[17] and from groups like the Green parties in the UK and New Zealand.[18]

Proponents and adversaries have been both criticized for overstating the benefits or overstating the risks, and understating the other, respectively.[19][20] Systematic reviews have cited the lack of high quality research for the benefits and risks of water fluoridation and questions that are still unsettled.[12][20][21] Researchers who oppose the practice state this as well.[22] According to a 2013 Congressional Research Service report on fluoride in drinking water, these gaps in the fluoridation scientific literature fuel the controversy.[13]

Public water fluoridation was first practiced in 1945, in the US. As of 2015, about 25 countries have supplemental water fluoridation to varying degrees, and 11 of them have more than 50% of their population drinking fluoridated water. A further 28 countries have water that is naturally fluoridated, though in many of them there are areas where fluoride is above the optimum level.[23] As of 2012, about 435 million people worldwide received water fluoridated at the recommended level, of whom 57 million (13%) received naturally fluoridated water and 377 million (87%) received artificially fluoridated water.[23] In 2014, three-quarters of the US population on the public water supply received fluoridated water, which represented two-thirds of the total US population.[24]

Medical consensus

National and international health agencies and dental associations throughout the world have endorsed water fluoridation as safe and effective.[1][25]

The views on the most effective method for community prevention of tooth decay are mixed. The Australian government states that water fluoridation is the most effective means of achieving fluoride exposure that is community-wide.[26] The World Health Organization states water fluoridation, when feasible and culturally acceptable, has substantial advantages, especially for subgroups at high risk,[27] while the European Commission finds no advantage to water fluoridation compared with topical use.[28]

FDI World Dental Federation supports water fluoridation as safe and effective.[23] the European Academy of Paediatric Dentistry,[29] and the national dental associations of Australia,[30] Canada,[31] and the U.S.[32] The American Dental Association calls water fluoridation "one of the safest and most beneficial, cost-effective public health measures for preventing, controlling, and in some cases reversing, tooth decay."[33]

In the English speaking nations—the United States, Canada, UK, Australia and New Zealand, all of which practice water fluoridation—many medical associations and authorities have published position statements and endorsed water fluoridation.

The U.S. Surgeon General,[34] the American Public Health Association,[35] the Royal Commission on the National Health Service,[36] Australian Medical Association,[37] New Zealand Medical Association,[38] and Health Canada support fluoridation, citing a number of international scientific reviews that indicate "there is no link between any adverse health effects and exposure to fluoride in drinking water at levels that are below the maximum acceptable concentration of 1.5 mg/L."[39] The Centers for Disease Control and Prevention listed water fluoridation as one of the ten great public health achievements of the 20th century in the U.S.,[40] along with vaccination, family planning, recognition of the dangers of smoking, and other achievements.[40]

In Israel, the Israeli Association of Public Health Physicians, the Israel Pediatric Association, and the Israel Dental Association, support fluoridation.[41]

The World Health Organization, looking at global public health, identifies fluoride as one of a few chemicals for which the contribution from drinking-water to overall intake is an important factor in preventing disease. This is because there is clear evidence that optimal concentrations of fluoride provide protection against cavities, both in children and in adults.[42][43][44]

Minority scientific view

The scientists or doctors who oppose water fluoridation argue that it has no or little cariostatic benefits, may cause serious health problems, is not effective enough to justify the costs, and is pharmacologically obsolete.[7][8][9] Arvid Carlsson has argued that fluoridation violates modern pharmacological principles and does not take into account individual variations in response, which can be considerable even when the dosage is fixed.[9][45] Paul Connett has stated "It's politics that is interfering with science in this issue ... It's a matter of political will, and you cannot change political will if you don't get the people. We must involve the people."[46]

Evidence

Proponents and opponents have been both criticized for overstating the benefits or risks, and understating the other, respectively.[19][20] Systematic reviews have cited the lack of high-quality research for the benefits and risks of water fluoridation and questions that are still unsettled.[12][20][21] A 2007 Nuffield Council on Bioethics report concluded that good evidence for or against water fluoridation is lacking.[47] Researchers who oppose the practice state this as well.[22] According to a 2013 Congressional Research Service report on fluoride in drinking water, these gaps in the fluoridation scientific literature fuel the controversy.[13] John Doull, chairman of the 2006 National Research Council committee report on fluoride in drinking water, has stated a similar conclusion regarding the source of the controversy: "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 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. I think that's why fluoridation is still being challenged so many years after it began. In the face of ignorance, controversy is rampant."[48][49]

Safety

Fluoride can be present naturally in water at concentrations well above recommended levels, which can have several long-term adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones.[50] In 1984 the World Health Organization recommended a guideline maximum fluoride value of 1.5 mg/L as a level at which fluorosis should be minimal, reaffirming it in 2006.[51]

Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation.[26] There is no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma.[26][52]

In rare cases improper implementation of water fluoridation can result in overfluoridation that causes outbreaks of acute fluoride poisoning, with symptoms that include nausea, vomiting, and diarrhea. Three such outbreaks were reported in the U.S. between 1991 and 1998, caused by fluoride concentrations as high as 220 mg/L; in the 1992 Alaska outbreak, 262 people became ill and one person died.[53] In 2010, approximately 60 gallons of fluoride were released into the water supply in Asheboro, North Carolina, in 90 minutes—an amount that was intended to be released in a 24-hour period.[54]

Like other common water additives such as chlorine, hydrofluosilicic acid and sodium silicofluoride decrease pH and cause a small increase of corrosivity, but this problem is easily addressed by increasing the pH.[55] Although it has been hypothesized that hydrofluosilicic acid and sodium silicofluoride might increase human lead uptake from water, a 2006 statistical analysis did not support concerns that these chemicals cause higher blood lead concentrations in children.[56] Trace levels of arsenic and lead may be present in fluoride compounds added to water; however, concentrations are below measurement limits.[55]

The effect of water fluoridation on the natural environment has been investigated, and no adverse effects have been established. Issues studied have included fluoride concentrations in groundwater and downstream rivers; lawns, gardens, and plants; consumption of plants grown in fluoridated water; air emissions; and equipment noise.[55]

Efficacy

Reviews have shown that water fluoridation reduces cavities in children.[21][28][57] A conclusion for the efficacy in adults is less clear with some reviews finding benefit and others not.[21][57] Studies in the U.S. in the 1950s and 1960s showed that water fluoridation reduced childhood cavities by fifty to sixty percent, while studies in 1989 and 1990 showed lower reductions (40% and 18% respectively), likely due to increasing use of fluoride from other sources, notably toothpaste, and also the "halo effect" of food and drink that is made in fluoridated areas and consumed in unfluoridated ones.[6]

A 2000 UK systematic review (York) found that water fluoridation was associated with a decreased proportion of children with cavities of 15% and with a decrease in decayed, missing, and filled primary teeth (average decreases was 2.25 teeth). The review found that the evidence was of moderate quality: few studies attempted to reduce observer bias, control for confounding factors, report variance measures, or use appropriate analysis. Although no major differences between natural and artificial fluoridation were apparent, the evidence was inadequate for a conclusion about any differences.[52] A 2002 systematic review found strong evidence that water fluoridation is effective at reducing overall tooth decay in communities.[58] A 2015 Cochrane review also found benefit in children.[21]

Fluoride may also prevent cavities in adults of all ages. A 2007 meta-analysis by CDC researchers found that water fluoridation prevented an estimated 27% of cavities in adults, about the same fraction as prevented by exposure to any delivery method of fluoride (29% average).[59] A 2011 European Commission review found that the benefits of water fluoridation for adult in terms of reductions in decay are limited.[28] 2015 Cochrane review found no conclusive research in adults.[21]

Most countries in Europe have experienced substantial declines in cavities without the use of water fluoridation.[1] For example, in Finland and Germany, tooth decay rates remained stable or continued to decline after water fluoridation stopped. Fluoridation may be useful in the U.S. because unlike most European countries, the U.S. does not have school-based dental care, many children do not visit a dentist regularly, and for many U.S. children water fluoridation is the prime source of exposure to fluoride.[60] The effectiveness of water fluoridation can vary according to circumstances such as whether preventive dental care is free to all children.[61]

Ethics

Water fluoridation pits the common good against individual rights.[citation needed] Some say the common good overrides individual rights, and equate it to vaccination and food fortification.[2][4] Others say that individual rights override the common good, and say that individuals have no choice in the water that they drink, unless they drink more expensive bottled water,[5] and some argue unequivocally that it does not stand up to scrutiny relative to the Nuremberg Code and other codes of medical ethics.[4]

Those who emphasize the public good emphasize the medical consensus that appropriate levels of water fluoridation are safe and effective to prevent cavities and see it as a public health intervention, replicating the benefits of naturally fluoridated water, which can free people from the misery and expense of tooth decay and toothache, with the greatest benefit accruing to those least able to help themselves. This perspective suggests it would be unethical to withhold such treatment.[62] In her book 50 Health Scares That Fizzled, Joan Callahan writes that, "For lower-income people with no insurance, fluoridated water (like enriched flour and fortified milk) looks more like a free preventative health measure that a few elitists are trying to take away."[63]

Those who emphasize individual or local choice, may view fluoridation as a violation of ethical or legal rules that prohibit medical treatment without medical supervision or informed consent or that prohibit administration of unlicensed medical substances,[1][64] view it as "mass medication",[65] or may even characterize it as a violation of the Nuremberg Code and the Council of Europe's Biomedical Convention of 1999.[4][13][19] Another journal article suggested applying the precautionary principle to this controversy, which calls for public policy to reflect a conservative approach to minimize risk in the setting where harm is possible (but not necessarily confirmed) and where the science is not settled.[66] Others have opposed it on the grounds of potential financial conflicts of interest driven by the chemical industry.[67]

A 2007 Nuffield Council on Bioethics report reached a conclusion mainly on three points, stating that :

  • The balance of benefit to risk ratio – is unclear due to the lack of good evidence for or against water fluoridation.
  • Alternatives to the practice exist – topical fluoride therapy (toothbrushing etc.)
  • The role of consent – It gets priority when there are potential harms.

The report therefore concluded that local and regional democratic procedures are the most appropriate way to decide whether to fluoridate.[47][68][69][70]

Opposition groups and campaigns

The controversy is propelled by a significant public opposition supported by a minority of professionals,[14] including researchers, dental and medical professionals, alternative medical practitioners such as chiropractors, health food enthusiasts, a few religious groups (mostly Christian Scientists in the U.S.), and occasionally consumer groups and environmentalists.[15] Organized political opposition has come from libertarians,[16] the John Birch Society,[17] and from groups like the Green parties in the UK and New Zealand.[18][67][17]:219–254

Opposition campaigns involve newspaper articles, talk radio, and public forums. Media reporters are often poorly equipped to explain the scientific issues, and are motivated to present controversy regardless of the underlying scientific merits. Websites, which are increasingly used by the public for health information, contain a wide range of material about fluoridation ranging from factual to fraudulent, with a disproportionate percentage opposed to fluoridation. Antifluoridationist literature links fluoride exposure to a wide variety of effects, including AIDS, allergy, Alzheimer's disease, arthritis, cancer, and low IQ, along with diseases of the gastrointestinal tract, kidney, pineal gland, and thyroid, though there is no scientific evidence linking fluoridation to these adverse health effects.[71][72]

Public opinion

Many people do not know that fluoridation is meant to prevent tooth decay, or that natural or bottled water can contain fluoride. As fluoridation does not appear to be an important issue for the general public in the U.S., the debate may reflect an argument between two relatively small lobbies for and against fluoridation.[73]

A survey of Australians in 2009 found that 70% supported and 15% opposed fluoridation. Those opposed were much more likely to score higher on outrage factors such as "unclear benefits".[74]

A study of focus groups from 16 European countries in 2003 found that fluoridation was opposed by a majority of focus group members in most of the countries, including France, Germany, and the UK.[73]

A survey in Sheffield, UK, performed in 1999 found that while a 62% majority favored water fluoridation in the city, the 31% who were opposed expressed their preference with greater intensity than supporters.[75]

Every year in the U.S., pro- and anti-fluoridationists face off in referendums or other public decision-making processes: in most of them, fluoridation is rejected.[15]

Use throughout the world

Despite support by public health organizations and dental authorities, the practice is controversial as a public health measure; some countries and communities have discontinued it, while others have expanded it.[12][13]

In the U.S., rejection in state and local communities is more likely when the decision is made by a public referendum; in Europe, most decisions against fluoridation have been made administratively.[10] Neither side of the dispute appears to be weakening or willing to concede.[15]

Water fluoridation is used in the United States, United Kingdom, Ireland, Canada, Australia, Israel, Hong Kong and a handful of other countries. Most countries failed to adopt fluoridation, yet experienced the same or greater decline in cavities as those countries that did fluoridate during the later half of the twentieth century.[76] The following nations previously fluoridated their water, but stopped the practice, with the years when water fluoridation started and stopped in parentheses:

  • Federal Republic of Germany (1952–1971)
  • Sweden (1952–1971)
  • Netherlands (1953–1976)
  • Czechoslovakia (1955–1990)
  • German Democratic Republic (1959–1990)
  • Soviet Union (1960–1990)
  • Finland (1959–1993)
  • Japan (1952–1972)[77]
  • Israel (1981–2014, 2016–) *Mandatory by law since 2002.[78][79][80]

In the United Kingdom a strategic health authority can direct a water company to fluoridate the water supply in an area if it is technically possible. The strategic health authority must consult with the local community and businesses in the affected area. The water company will act as a contractor in any new schemes and cannot refuse to fluoridate the supply.[81]

In areas with complex water sources, water fluoridation is more difficult and more costly. Alternative fluoridation methods have been proposed, and implemented in some parts of the world. The World Health Organization (WHO) is currently assessing the effects of fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe. The WHO supports fluoridation of water in some areas.[82] In some other countries, sodium fluoride is added to table salt.[83]

As of 2012, 25 countries have artificial water fluoridation to varying degrees, 11 of them have more than 50% of their population drinking fluoridated water. A further 28 countries have water that is naturally fluoridated, though in many of them the fluoride is above the optimum level.[23] As of 2012 about 435 million people worldwide received water fluoridated at the recommended level,[23] about 211 million of them living in the United States.[84]

History

Fluoridation began during a time of great optimism and faith in science and experts (the 1950s and 1960s), but even then, the public frequently objected. Opponents drew on distrust of experts and unease about medicine and science.[85] Controversies include disputes over fluoridation's benefits and the strength of the evidence basis for these benefits, the difficulty of identifying harms, legal issues over whether water fluoride is a medicine, and the ethics of mass intervention.[19]

The first large fluoridation controversy occurred in Wisconsin in 1950. Fluoridation opponents questioned the ethics, safety, and efficacy of fluoridation.[86] New Zealand was the second country to fluoridate, and similar controversies arose there.[87] Fears about fluoride were likely exacerbated by the reputation of fluoride compounds as insect poisons and by early literature which tended to use terms such as "toxic" and "low grade chronic fluoride poisoning" to describe mottling from consumption of 6 mg/L of fluoride prior to tooth eruption, a level of consumption not expected to occur under controlled fluoridation.[88] When voted upon, the outcomes tend to be negative, and thus fluoridation has had a history of gaining through administrative orders in North America.[86]

Conspiracy theories involving fluoridation are common, and include claims that fluoridation was motivated by protecting the U.S. atomic bomb program from litigation, that (as famously parodied in the film Dr. Strangelove, where a deranged U.S. Air Force general claimed that it would "sap and impurify all of our precious bodily fluids") it is part of a Communist or New World Order plot to take over the world, that it was pioneered by a German chemical company to make people submissive to those in power, that behind the scenes it is promoted by the sugary food or phosphate fertilizer or aluminium industries, or that it is a smokescreen to cover failure to provide dental care to the poor.[71] One such theory is that fluoridation was a public-relations ruse sponsored by fluoride polluters such as the aluminium maker Alcoa and the Manhattan Project, with conspirators that included industrialist Andrew Mellon and the Mellon Institute's researcher Gerald J. Cox, the Kettering Laboratory of the University of Cincinnati, the Federal Security Agency's administrator Oscar R. Ewing, and public-relations strategist Edward Bernays.[89] Specific antifluoridation arguments change to match the spirit of the time.[90]

Black-and-white political cartoon of a leering skull menacing a doll-holding little girl whose back is supported by an arm tagged "UNINFORMED PUBLIC". Nearby bones hold three large balls labeled "FLUORIDATED WATER", "POLIO MONKEY SERUMS", and "MENTAL HYGIENE etc." The cartoon is entitled "At the Sign of THE UNHOLY THREE", signed "B. SMART", and captioned "Are you willing to PUT IN PAWN to the UNHOLY THREE all of the material, mental, and spiritual resources of this GREAT REPUBLIC?"
Illustration in a 1955 flier by the Keep America Committee, alleging that fluoridation was a Communist plot

Outside North America, water fluoridation was adopted in some European countries, but in the late 1970s and early 1980s, Denmark and Sweden banned fluoridation when government panels found insufficient evidence of safety, and the Netherlands banned water fluoridation when "a group of medical practitioners presented evidence" that it caused negative effects in a percentage of the population.

Communist conspiracy theory (1940s–1960s)

Water fluoridation has frequently been the subject of conspiracy theories. During the "Second Red Scare" in the United States during the late 1940s and 1950s, and to a lesser extent in the 1960s, activists on the far right of American politics routinely asserted that fluoridation was part of a far-reaching plot to impose a socialist or communist regime. These opponents believed it was "another aspect of President Truman's drive to socialize medicine."[91] They also opposed other public health programs, notably mass vaccination and mental health services.[92] Their views were influenced by opposition to a number of major social and political changes that had happened in recent years: the growth of internationalism, particularly the UN and its programs; the introduction of social welfare provisions, particularly the various programs established by the New Deal; and government efforts to reduce perceived inequalities in the social structure of the United States.[93]

Others asserted the existence of "a Communist plot to deplete the brainpower and sap the strength of a generation of American children".[91] Dr. Charles Betts, a prominent anti-fluoridationist, charged that fluoridation was "better than using the atom bomb because the atom bomb has to be made, has to be transported to the place it is to be set off while poisonous fluorine has been placed right beside the water supplies by the Americans themselves ready to be dumped into the water mains whenever a Communist desires!" Similarly, a right-wing newsletter, the American Capsule News, claimed that "the Soviet General Staff is very happy about it. Anytime they get ready to strike, and their 5th column takes over, there are tons and tons of this poison 'standing by' municipal and military water systems ready to be poured in within 15 minutes."[11]

This controversy had a direct impact on local program during the 1950s and 1960s, where referendums on introducing fluoridation were defeated in over a thousand Florida communities. It was not until as late as the 1990s that fluoridated water was consumed by the majority of the population of the United States.[92]

The communist conspiracy argument declined in influence by the mid-1960s, becoming associated in the public mind with irrational fear and paranoia. It was portrayed in Stanley Kubrick's 1964 film Dr. Strangelove, in which the character General Jack D. Ripper initiates a nuclear war in the hope of thwarting a communist plot to "sap and impurify" the "precious bodily fluids" of the American people with fluoridated water. Another satire appeared in the 1967 movie In Like Flint, in which a character's fear of fluoridation is used to indicate that he is insane.

Some anti-fluoridationists claimed that the conspiracy theories were damaging their goals; Dr. Frederick Exner, an anti-fluoridation campaigner in the early 1960s, told a conference: "most people are not prepared to believe that fluoridation is a communist plot, and if you say it is, you are successfully ridiculed by the promoters. It is being done, effectively, every day ... some of the people on our side are the fluoridators' 'fifth column'."[11]

Later conspiracy theories

In 1987, Ian E. Stephens authored a self-published booklet, an extract of which was published in the Australian New Age publication Nexus magazine in 1995. In it he claimed he was told by "Charles Elliot Perkins" that: "Repeated doses of infinitesimal amounts of fluoride will in time reduce an individual's power to resist domination by slowly poisoning and narcotising a certain area of the brain and will thus make him submissive to the will of those who wish to govern him ... Both the Germans and the Russians added sodium fluoride to the drinking water of prisoners of war to make them stupid and docile." These statements have been dismissed by reputable Holocaust historians as untrue, but they are regularly repeated to the present day in conspiracy publications and websites.[94]

2006 US NRC report

U.S. opponents of fluoridation were heartened by a 2006 National Research Council report about hazards of water naturally fluoridated to high levels;[49] the report recommended lowering the U.S. maximum limit of 4 mg/L for fluoride in drinking water. The EPA did not act on that recommendation.[95]

Court cases

Ireland

In Ryan v. Attorney General (1965), the Supreme Court of Ireland held that water fluoridation did not infringe the plaintiff's right to bodily integrity.[96] The court found that such a right to bodily integrity did exist, even though it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.

Netherlands

Water was fluoridated in large parts of the Netherlands from 1960 to 1973, at which point the Supreme Court of the Netherlands declared fluoridation of drinking water unauthorized.[97] The Dutch Court decided that authorities had no legal basis for adding chemicals to drinking water if they did not also improve safety. It was also stated as support that consumers cannot choose a different tap water provider.[98] Drinking water has not been fluoridated in any part of the Netherlands since 1973.

United States

Fluoridation has been the subject of many court cases wherein activists have sued municipalities, asserting that their rights to consent to medical treatment and due process are infringed by mandatory water fluoridation.[4] Individuals have sued municipalities for a number of illnesses that they believe were caused by fluoridation of the city's water supply. In most of these cases, the courts have held in favor of cities, finding no or only a tenuous connection between health problems and widespread water fluoridation.[99] To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.[100]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 "Community water fluoridation and caries prevention: a critical review". Clinical Oral Investigations 11 (3): 189–193. September 2007. doi:10.1007/s00784-007-0111-6. PMID 17333303. 
  2. ↑ 2.0 2.1 * "The ethics of water fluoridation". Journal 66 (11): 592–593. December 2000. PMID 11253350. http://cda-adc.ca/jcda/vol-66/issue-11/592.html. 
  3. ↑ Perrella, Andrea ML, and Simon J. Kiss. "Risk perception, psychological heuristics and the water fluoridation controversy." Canadian journal of public health 106.4 (2015): e197-e203.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 "Fluoridation: a violation of medical ethics and human rights". International Journal of Occupational and Environmental Health 9 (1): 24–29. 1 March 2003. doi:10.1179/107735203800328830. PMID 12749628. 
  5. ↑ 5.0 5.1 "Fluoridation of water supplies. Debate on the ethics must be informed by sound science". BMJ 319 (7205): 269–270. July 1999. doi:10.1136/bmj.319.7205.269. PMID 10426716. 
  6. ↑ 6.0 6.1 Centers for Disease Control and Prevention (August 2001). "Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention". MMWR. Recommendations and Reports 50 (RR-14): 1–42. PMID 11521913. http://cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. 
  7. ↑ 7.0 7.1 "A critique of recent economic evaluations of community water fluoridation". International Journal of Occupational and Environmental Health 21 (2): 91–120. 3 December 2014. doi:10.1179/2049396714Y.0000000093. PMID 25471729. 
  8. ↑ 8.0 8.1 "Fluoride Risks Are Still A Challenge". Chemical & Engineering News 84 (36): 34–37. 4 November 2006. doi:10.1021/cen-v084n036.p034. http://pubs.acs.org/email/cen/html/090506090615.html. Retrieved 14 April 2016. 
  9. ↑ 9.0 9.1 9.2 "Book review: Is Fluoride Really All That Safe?". Chemical & Engineering News 82 (33): 35–36. 16 August 2004. doi:10.1021/cen-v082n033.p035. http://pubs.acs.org/cen/books/8233/8233books.html. Retrieved 19 April 2016. 
  10. ↑ 10.0 10.1 "The sociology of the fluoridation controversy: a reexamination". Sociol. Q. 30 (1): 59–76. 1989. doi:10.1111/j.1533-8525.1989.tb01511.x. http://www.uow.edu.au/~bmartin/pubs/89sq.html. 
  11. ↑ 11.0 11.1 11.2 The Politics of Healing. Routledge. 2004. p. 136. ISBN 978-0-415-93339-1. https://archive.org/details/politicshealingh00john. 
  12. ↑ 12.0 12.1 12.2 12.3 "Introduction to the SCHER opinion on Fluoridation". European Commission Scientific Committee on Health and Environmental Risks (SCHER). 2011. http://ec.europa.eu/health/scientific_committees/opinions_layman/fluoridation/en/l-3/1.htm#0. 
  13. ↑ 13.0 13.1 13.2 13.3 13.4 "Fluoride in Drinking Water: A Review of Fluoridation and Regulation Issues". 5 April 2013. pp. 1–4. https://www.fas.org/sgp/crs/misc/RL33280.pdf. 
  14. ↑ 14.0 14.1 "Analyzing the fluoridation controversy: resources and structures". Social Studies of Science 18 (2): 331–363. May 1988. doi:10.1177/030631288018002006. PMID 11621556. 
  15. ↑ 15.0 15.1 15.2 15.3 "The task is a political one: the promotion of fluoridation". Silent Victories: The History and Practice of Public Health in Twentieth-century America. Oxford University Press. 2007. pp. 323–342. ISBN 978-0-19-515069-8. 
  16. ↑ 16.0 16.1 "Consumer protection". Libertarian Party. http://www.dehnbase.org/lpus/library/platform/cp.html. 
  17. ↑ 17.0 17.1 17.2 The fluoride wars: how a modest public health measure became America's longest-running political melodrama. Hoboken: Wiley. 2009. ISBN 978-0-470-44833-5. 
  18. ↑ 18.0 18.1 "Water fights: believe it or not, the fluoridation war still rages – with a twist you may like". Natl Rev. 2003-06-30. http://www.thefreelibrary.com/Water+Fights%3a+Believe+it+or+not%2c+the+fluoridation+war+still+rages+--...-a0103135852. [yes|permanent dead link|dead link}}]
  19. ↑ 19.0 19.1 19.2 19.3 "Adding fluoride to water supplies". BMJ 335 (7622): 699–702. October 2007. doi:10.1136/bmj.39318.562951.BE. PMID 17916854. 
  20. ↑ 20.0 20.1 20.2 20.3 "What the 'York Review' on the fluoridation of drinking water really found". Centre for Reviews and Dissemination. York, United Kingdom: University of York. 28 October 2003. https://www.york.ac.uk/media/crd/Fluoridation%20Statement.pdf. 
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 "Water fluoridation for the prevention of dental caries". The Cochrane Database of Systematic Reviews 6 (6): CD010856. June 2015. doi:10.1002/14651858.CD010856.pub2. PMID 26092033. 
  22. ↑ 22.0 22.1 "Book Reviews: The case against fluoride: how hazardous waste ended up in our drinking water and the bad science and powerful politics that keep it there, by Paul Connett, James Beck, and H Spedding Micklem". Critical Public Health 22 (1): 113–114. 2012. doi:10.1080/09581596.2011.593350. ISSN 0958-1596. 
  23. ↑ 23.0 23.1 23.2 23.3 23.4 The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health (2012). "The extent of water fluoridation". One in a Million: The facts about water fluoridation (3rd ed.). Manchester: British Fluoridation Society. pp. 55–80. ISBN 978-0-9547684-0-9. https://docs.wixstatic.com/ugd/014a47_0776b576cf1c49308666cef7caae934e.pdf. 
  24. ↑ "Community Water Fluoridation --- 2014 Water Fluoridation Statistics". cdc.gov. https://www.cdc.gov/fluoridation/statistics/2014stats.htm. 
  25. ↑ "National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay". American Dental Association. http://www.ada.org/en/public-programs/advocating-for-the-public/fluoride-and-fluoridation/fluoridation-facts/fluoridation-facts-compendium. 
  26. ↑ 26.0 26.1 26.2 National Health and Medical Research Council (Australia) (2007). A systematic review of the efficacy and safety of fluoridation. ISBN 978-1864964158. http://nhmrc.gov.au/_files_nhmrc/file/publications/synopses/Eh41_Flouridation_PART_A.pdf. Retrieved 2009-10-13.  Summary: "A systematic review of the efficacy and safety of fluoridation". Evidence-Based Dentistry 9 (2): 39–43. 2008. doi:10.1038/sj.ebd.6400578. PMID 18584000. http://nhmrc.gov.au/_files_nhmrc/file/media/media/rel07/Fluoride_Flyer.pdf. 
  27. ↑ "Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach". Community Dentistry and Oral Epidemiology 32 (5): 319–321. October 2004. doi:10.1111/j.1600-0528.2004.00175.x. PMID 15341615. 
  28. ↑ 28.0 28.1 28.2 "What role does fluoride play in preventing tooth decay?". 2011. http://ec.europa.eu/health/scientific_committees/opinions_layman/fluoridation/en/l-3/5.htm#0. 
  29. ↑ European Academy of Paediatric Dentistry (September 2009). "Guidelines on the use of fluoride in children: an EAPD policy document". European Archives of Paediatric Dentistry 10 (3): 129–135. doi:10.1007/bf03262673. PMID 19772841. 
  30. ↑ Australian Dental Association. "Issues at a Glance Fluoride". http://www.ada.org.au/News-Media/Issues-at-a-Glance/Fluoride. 
  31. ↑ Canadian Dental Association (March 2003). "CDA position on use of fluorides in caries prevention". http://www.cda-adc.ca/_files/position_statements/fluoride.pdf. "update March 2012" 
  32. ↑ ADA Council on Access, Prevention and Interprofessional Relations (2005). "Fluoridation facts". American Dental Association. http://ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf. 
  33. ↑ "Water Fluoridation Press Kit". American Dental Association. 2005. https://www.ada.org/en/press-room/press-kits/water-fluoridation-press-kit. 
  34. ↑ "Surgeon General's Perspectives: Community Water Fluoridation – One of CDC's "10 Great Public Health Achievements of the 20th Century"". Public Health Reports 130 (4): 296–298. July–August 2015. doi:10.1177/003335491513000402. PMID 26346894. 
  35. ↑ American Public Health Association (2011). "APHA Reaffirms Its Support for Community Water Fluoridation". http://apha.org/news-and-media/news-releases/apha-news-releases/apha-reaffirms-its-support-for-community-water-fluoridation. 
  36. ↑ Royal Commission on the NHS Chapter 9. HMSO. 1979. ISBN 978-0101761505. http://www.sochealth.co.uk/national-health-service/royal-commission-on-the-national-health-service-contents/royal-commission-on-the-nhs-chapter-9/. Retrieved 19 May 2015. 
  37. ↑ Australian Government Department of Health and Ageing. "Fluoridation of drinking water" (in en). http://www.health.gov.au/internet/main/publishing.nsf/Content/dentalfluoridation. 
  38. ↑ "Questions and answers | Fluoride facts". http://www.fluoridefacts.govt.nz/questions-and-answers-0. 
  39. ↑ "Fluoride in Drinking Water". Health Canada. 2017-01-23. http://www.hc-sc.gc.ca/ewh-semt/water-eau/drink-potab/health-sante/faq_fluoride-fluorure-eng.php. 
  40. ↑ 40.0 40.1 Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC (1999). "Achievements in public health, 1900–1999: Fluoridation of drinking water to prevent dental caries". Morbidity and Mortality Weekly Report (MMWR) 48 (41): 933–940. http://cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm.  Contains H. Trendley Dean, D.D.S. Reprinted in: "From the Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: fluoridation of drinking water to prevent dental caries". JAMA 283 (10): 1283–1286. March 2000. doi:10.1001/jama.283.10.1283. PMID 10714718. 
  41. ↑ "Restoration of Fluoridation to Drinking Water, Ministry of Health". http://www.health.gov.il/English/Topics/Dental_Health/information/Pages/flouride-2015.aspx. 
  42. ↑ "Water fluoridation". World Water Day 2001: Oral health. World Health Organization. https://www.who.int/water_sanitation_health/oralhealth/en/index2.html. "There are few chemicals for which the contribution from drinking-water to overall intake is an important factor in preventing disease. One example is the effect of fluoride in drinking-water in protecting against dental caries." 
  43. ↑ Guidelines for Drinking-water Quality (4th ed.). World Health Organization. 2011. pp. 168, 175, 372, 370–373. ISBN 9789241548151. http://apps.who.int/iris/bitstream/10665/44584/1/9789241548151_eng.pdf. 
  44. ↑ Fawell et al. 2006, p. 32. "Concentrations in drinking-water of about 1 mg l–1 are associated with a lower incidence of dental caries, particularly in children, whereas excess intake of fluoride can result in dental fluorosis. In severe cases this can result in erosion of enamel. The margin between the beneficial effects of fluoride and the occurrence of dental fluorosis is small and public health programmes seek to retain a suitable balance between the two."
  45. ↑ The Fluoride Deception. New York: Seven Stories Press. 2004. pp. 240. ISBN 978-1609800086. https://archive.org/details/fluoridedeceptio00brys. 
  46. ↑ "The Health Hazards of Water Fluoridation (video)". HuffPost. 11 October 2010. http://www.huffingtonpost.com/dr-mercola/warning-this-daily-habit-_b_741635.html. 
  47. ↑ 47.0 47.1 "Beyond the 'nanny state': stewardship and public health". Public Health (Nuffield Council on Bioethics) 123 (1): e6–e10. January 2009. doi:10.1016/j.puhe.2008.10.025. PMID 19135693. PMC 7118790. http://www.nuffieldbioethics.org/fileLibrary/pdf/One_page_summary_public_health.pdf. 
  48. ↑ "Compulsory Water Fluoridation: Justifiable Public Health Benefit or Human Experimental Research Without Informed Consent?". William & Mary Environmental Law and Policy Review 39 (1): 225. December 2014. http://scholarship.law.wm.edu/wmelpr/vol39/iss1/7/. Retrieved 21 April 2016. 
  49. ↑ 49.0 49.1 "Second thoughts about fluoride". Scientific American 298 (1): 74–81. January 2008. doi:10.1038/scientificamerican0108-74. PMID 18225698. Bibcode: 2008SciAm.298a..74F. 
  50. ↑ Fawell et al. 2006, pp. 29–36.
  51. ↑ Fawell et al. 2006, pp. 37–39.
  52. ↑ 52.0 52.1 "A systematic review of public water fluoridation". 2000. http://www.york.ac.uk/inst/crd/CRD_Reports/crdreport18.pdf.  Report website: "Fluoridation of drinking water: a systematic review of its efficacy and safety". NHS Centre for Reviews and Dissemination. 2000. http://www.york.ac.uk/inst/crd/fluorid.htm.  Authors' summary: "Systematic review of water fluoridation". BMJ 321 (7265): 855–859. October 2000. doi:10.1136/bmj.321.7265.855. PMID 11021861.  Authors' commentary: "The York review – a systematic review of public water fluoridation: a commentary". British Dental Journal 192 (9): 495–497. May 2002. doi:10.1038/sj.bdj.4801410a. PMID 12047121. 
  53. ↑ "Is the water safe for my baby?". Pediatric Clinics of North America 48 (5): 1129–1152, viii. October 2001. doi:10.1016/S0031-3955(05)70365-5. PMID 11579665. 
  54. ↑ "Asheboro notifies residents of over-fluoridation of water". Fox 8. 2010-06-29. http://www.myfox8.com/news/wghp-asheboro-fluoride-release-100629,0,2164002.story. 
  55. ↑ 55.0 55.1 55.2 "Water fluoridation and the environment: current perspective in the United States". International Journal of Occupational and Environmental Health 10 (3): 343–350. 2004. doi:10.1179/oeh.2004.10.3.343. PMID 15473093. 
  56. ↑ "Blood lead concentrations in children and method of water fluoridation in the United States, 1988-1994". Environmental Health Perspectives 114 (1): 130–134. January 2006. doi:10.1289/ehp.8319. PMID 16393670. 
  57. ↑ 57.0 57.1 "Water fluoridation". European Archives of Paediatric Dentistry 10 (3): 141–148. September 2009. doi:10.1007/bf03262675. PMID 19772843. 
  58. ↑ "Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries". American Journal of Preventive Medicine 23 (1 Suppl): 21–54. July 2002. doi:10.1016/S0749-3797(02)00449-X. PMID 12091093. https://zenodo.org/record/1260085. 
  59. ↑ "Effectiveness of fluoride in preventing caries in adults". Journal of Dental Research 86 (5): 410–415. May 2007. doi:10.1177/154405910708600504. PMID 17452559.  Summary: "Fluoride prevents caries among adults of all ages". Evidence-Based Dentistry 8 (3): 72–73. 2007. doi:10.1038/sj.ebd.6400506. PMID 17891121. 
  60. ↑ "Changing the face of America: water fluoridation and oral health". Silent Victories: The History and Practice of Public Health in Twentieth-century America. Oxford University Press. 2007. pp. 307–322. ISBN 978-0195150698. 
  61. ↑ "Fluoridation, fractures, and teeth". BMJ 321 (7265): 844–845. October 2000. doi:10.1136/bmj.321.7265.844. PMID 11021844. 
  62. ↑ The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health (2012). "The ethics of water fluoridation". One in a Million: The facts about water fluoridation (3rd ed.). Manchester: British Fluoridation Society. pp. 88–92. ISBN 978-0954768409. https://bfsweb.org/download/1344/one-in-a-million/1Vng0bH7Tc1j0u_L_jJknMBC6OLwiY2TC/The%20ethics%20of%20water%20fluoridation%20(3rd%20edition,%202012). 
  63. ↑ 50 health scares that fizzled. Santa Barbara, Calif.: Greenwood. 2011. ISBN 978-0313385384. 
  64. ↑ "The science and ethics of water fluoridation". Journal 67 (10): 578–580. November 2001. PMID 11737979. http://www.cda-adc.ca/jcda/vol-67/issue-10/578.html. 
  65. ↑ "Water fluoridation contravenes UK law, EU directives and the European Convention on Human Rights and Biomedicine". Press office briefing.. UK Green Party. 2003. http://www.greenparty.org.uk/files/reports/2003/F%20illegality.htm. 
  66. ↑ "What does the precautionary principle mean for evidence-based dentistry?". The Journal of Evidence-Based Dental Practice 6 (1): 6–15. March 2006. doi:10.1016/j.jebdp.2005.12.006. PMID 17138389. 
  67. ↑ 67.0 67.1 "Health", Record of Policy Statements (Green Party), 2014, http://policy.greenparty.org.uk/he.html, retrieved 2014-11-22 
  68. ↑ Public health : ethical issues (Chapter 7 – Fluoridation of water). London: Nuffield Council on Bioethics. 2007. ISBN 978-1-904384-17-5. http://nuffieldbioethics.org/report/public-health-2/water-fluoridation/. Retrieved 25 April 2016. 
  69. ↑ "Community Water Fluoridation in the United States". American Public Health Association. https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/13/36/community-water-fluoridation-in-the-united-states. 
  70. ↑ "Is New Zealand water fluoridation justified?". The New Zealand Medical Journal 127 (1406): 80–86. November 2014. PMID 25447252. 
  71. ↑ 71.0 71.1 "When public action undermines public health: a critical examination of antifluoridationist literature". Australia and New Zealand Health Policy 4: 25. December 2007. doi:10.1186/1743-8462-4-25. PMID 18067684. 
  72. ↑ "Fact Sheet: Community Water Fluoridation". 2021. https://www.cdc.gov/fluoridation/resources/community-water-fluoridation-fact-sheet.html. 
  73. ↑ 73.0 73.1 "European citizens' opinions on water fluoridation". Community Dentistry and Oral Epidemiology 36 (2): 95–102. April 2008. doi:10.1111/j.1600-0528.2007.00373.x. PMID 18333872. 
  74. ↑ "Risk perception and water fluoridation support and opposition in Australia". Journal of Public Health Dentistry 70 (1): 58–66. 2009. doi:10.1111/j.1752-7325.2009.00144.x. PMID 19694932. 
  75. ↑ "Estimating the benefits of community water fluoridation using the willingness-to-pay technique: results of a pilot study". Community Dentistry and Oral Epidemiology 27 (2): 124–129. April 1999. doi:10.1111/j.1600-0528.1999.tb02001.x. PMID 10226722. 
  76. ↑ "The mystery of declining tooth decay". Nature 322 (6075): 125–129. 1986. doi:10.1038/322125a0. PMID 3523258. Bibcode: 1986Natur.322..125D. 
  77. ↑ "Associations between oral health behavior and anxiety about water fluoridation and motivation to establish water fluoridation in Japanese residents". Journal of Oral Science 53 (3): 313–319. September 2011. doi:10.2334/josnusd.53.313. PMID 21959658. 
  78. ↑ "הפלרת מי השתייה" (in Hebrew). Knesset Research and Information Center. 17 March 2014. pp. 2–3. https://www.knesset.gov.il/mmm/data/pdf/m00204.pdf. "Dates of beginning of Water fluoridation practice in Israel: 1981 Optional, 2002 Mandatory)" 
  79. ↑ "Israel Has Officially Banned Fluoridation of Its Drinking Water". Newsweek. 29 August 2014. http://www.newsweek.com/israel-has-officially-banned-fluoridation-its-drinking-water-267411. 
  80. ↑ "Water fluoridation set to return in Israel". ADA News. American Dental Association. 11 April 2016. http://www.ada.org/en/publications/ada-news/2016-archive/april/water-fluoridation-set-to-return-in-israel. 
  81. ↑ "About your water". United Utilities. http://www.unitedutilities.com/About-your-water.aspx. 
  82. ↑ "World Oral Health Report". World Health Organization. https://www.who.int/entity/oral_health/media/en/orh_report03_en.pdf. 
  83. ↑ "Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water". European Commission. 18 May 2010. http://ec.europa.eu/health/scientific_committees/environmental_risks/docs/scher_o_122.pdf. , citing "Production of fluoridated salt". Schweizer Monatsschrift für Zahnmedizin = Revue Mensuelle Suisse d'Odonto-Stomatologie = Rivista Mensile Svizzera di Odontologia e Stomatologia 116 (4): 367–370. 2006. PMID 16708522. 
  84. ↑ "Community Water Fluoridation … 2012 Water Fluoridation Statistics". cdc.gov. 2018-04-20. https://www.cdc.gov/fluoridation/statistics/2012stats.htm. 
  85. ↑ "Expertise, health, and popular opinion: debating water fluoridation, 1945–80". Can. Hist. Rev. 89 (3): 345–371. 2008. doi:10.3138/chr.89.3.345. 
  86. ↑ 86.0 86.1 "Fluoridation: why is it not more widely adopted?". CMAJ 137 (8): 705–708. October 1987. PMID 3651941. 
  87. ↑ "Fluoridation of Public Water Supplies in New Zealand:'Magic Bullet,'Rat Poison, or Communist Plot?". Health and History 7 (2): 17–29. 2005. doi:10.2307/40111610. http://www.historycooperative.org/journals/hah/7.2/wrapson.html. Retrieved 3 March 2009. 
  88. ↑ "Thirty years of fluoridation: a review". The American Journal of Clinical Nutrition 41 (1): 129–138. January 1985. doi:10.1093/ajcn/41.1.129. PMID 3917599. 
  89. ↑ Freeze & Lehr 2009, pp. 127–169.
  90. ↑ "The fluoridation war: a scientific dispute or a religious argument?". Journal of Public Health Dentistry 56 (5 Spec No): 246–252. 1996. doi:10.1111/j.1752-7325.1996.tb02447.x. PMID 9034969. 
  91. ↑ 91.0 91.1 The People's Health: A Memoir of Public Health and Its Evolution at Harvard. Joseph Henry Press. 2016. ISBN 978-0309054928. 
  92. ↑ 92.0 92.1 Henig 2016, p. 85.
  93. ↑ Senator Joe McCarthy. University of California Press. 1959. pp. 21–22. ISBN 978-0520204720. 
  94. ↑ "Truth about fluoride doesn't include Nazi myth". Politifact Florida. http://www.politifact.com/florida/statements/2011/oct/06/critics-water-fluoridation/truth-about-fluoride-doesnt-include-nazi-myth/. 
  95. ↑ National Research Council (2006). Fluoride in Drinking Water: A Scientific Review of EPA's Standards. Washington, DC: National Academies Press. ISBN 030910128X. http://books.nap.edu/catalog.php?record_id=11571. 
  96. ↑ "Ryan v. A.G. IESC 1; IR 294 (3 July, 1965)". Irish Supreme Court. http://www.bailii.org/ie/cases/IESC/1965/1.html. 
  97. ↑ "De strijd tegen fluoridering". De Gids 139 (2). 1976. https://books.google.com/books?id=3UoZAAAAIAAJ&q=fluoridering+nederland&pg=PA487. 
  98. ↑ "Deel 1: systeem, bevoegdheid, bevoegdheidsuitoefening, handhaving" (in nl). Bestuursrecht. Boom juridische studieboeken. Boom Juridische uitgevers. 2005. pp. 54–55. ISBN 978-9054545378. 
  99. ↑ "Beck v. City Council of Beverly Hills, 30 Cal. App. 3d 112, 115 (Cal. App. 2d Dist. 1973)". https://casetext.com/case/beck-v-city-council-of-beverly-hills. "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question." 
  100. ↑ "Fluoridation at fifty: what have we learned?". The Journal of Law, Medicine & Ethics 30 (3 Suppl): 117–121. 2002. PMID 12508513. https://heinonline.org/HOL/LandingPage?handle=hein.journals/medeth30&div=69&id=&page=. 

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