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Follow-up petition on health and environmental concerns regarding fluoridation of drinking water

Petition

Petition under Section 22 of the Auditor General Act for
the discontinuation of the addition of toxic substances to our drinking water (inorganic fluorides, inorganic arsenic, lead)
In violation of the Fishing Act,
section 34(1), which describe the provisions to conserve and protect fish habitat that sustain Canada’s fisheries resources, the harmful alteration,
section 35(1), which prohibits the harmful alteration, disruption or destruction (HADD) of fish habitat, and
sections 36-42 which control the deposition of any deleterious substance to water frequented by fish
Fluorosilicates in Drinking Water, at Recommended Doses Causes Social Harm, Financial Burdens and Dental Harm

Water fluoridation accounts for the Majority of Fluoride Exposure therefore
Water fluoridation is the single most important cause of Dental Fluorosis

[Original signed by Carole Clinch]

Carole Clinch
307 Normandy Ave, Waterloo, Ontario, Canada
caclinch@gmail.com
519-884-8184

April 14, 2008

Office of the Auditor General of Canada
Commissioner of the Environment and Sustainable Development
Attention: Petitions
240 Sparks Street
Ottawa, Ontario K1A 0G6

Toll free: 1-888-761-5953 (toll free)
Telephone: 613-995-3708
Fax: 613-941-8286
Email: petitions@oag-bvg.gc.ca

Introduction: Need for Sustainable Development

The addition of toxic substances to drinking water, hence source water is not an environmentally sustainable activity and is ineffective for the purpose in which it intended.

Evidence from the study by Daemker and Dey 1989 indicates that some species of fish (salmon) are harmed at levels of about 0.25mg/L. (Daemker, DM, Dey, DB. Evidence for fluoride effects on salmon passage at John Day Dam, Columbia River 1982-1986, North American Journal of fisheries management, 1989, 9, 154-162).

Evidence from Camargo 2003 demonstrates that net-spinning caddisfly larvae are harmed at fluoride levels as low as 0.2mg/L. Camargo states: “Discharges of fluoridated municipal waters also cause significant increases (about five times the natural background level) in the fluoride concentration of recipient rivers”. (Camargo JA. Fluoride toxicity to aquatic organisms: a review. Chemosphere. 2003 Jan;50(3):251-64)).

Water fluoridation accounts for the Majority of Fluoride Exposure therefore Water fluoridation is the single most important cause of Dental Fluorosis.

“The major dietary source of fluoride for most people in the United States is fluoridated municipal (community) drinking water, including water consumed directly, food and beverages prepared at home or in restaurants from municipal drinking water, and commercial beverages and processed foods originating from fluoridated municipalities.” US National Research Council Report on Fluorides in Drinking Water 2006 p24http://www.nap.edu/catalog/11571.html

25-70% of children now have dental fluorosis in Canada according to the Ontario Ministry of Health Report 1999.

In 2005 32 % of US children had dental fluorosis – an increase of 9 % compared to 1980. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism and Enamel Fluorosis - United States 1988-1994 and 1999-2002. Morbidity and Mortality Weekly Report, 26 Aug, 2005 54(SS-3).

Changes in Dental Fluorosis Following the Cessation of Water Fluoridation in Canada

Studies done in Canada demonstrate that:

• non-fluoridated BC had fewer cavities than fluoridated regions of Canada (Gray 1987)
• communities in BC which discontinued fluoridation saw a significant decrease in the incidence of dental fluorosis. ([Name withheld] 2006)

“When fluoride was removed from the water supply in 1992, the prevalence and severity of TFI [Thylstrup-Fejerskov index] scores decreased significantly…” [Information withheld]

“Survey results in British Columbia with only 11% of the population using fluoridated water show lower DMFT [decayed, missing, filled teeth] rates than provinces with 40-70% of the population drinking fluoridated water.”108 and “school districts recently reporting the highest caries-free rates in the province were totally unfluoridated.” Gray AS. 1987 Fluoridation. Time for a New Base Line? Journal of the Canadian Dental Association. 53(10): 763-765.

[Name withheld], a dentist in the faculty of Dentistry from the University of British Columbia found the incidence of dental fluorosis to be :

35 - 60 % in fluoridated communities
20 - 45 % in non-fluoridated communites,

[Name withheld] also found that there was an increase in the severity of dental fluorosis in fluoridated communities vs non-fluoridated communities. [Information withheld].

The following chart is from the Niagara Region. It shows a significant increase in dental fluorosis for 2005 and 2006.

Attempts to minimize the importance of dental fluorosis on the basis that some people want to call it “merely” cosmetic or of “questionable” health concern is not appreciated by those who have dental fluorosis. Those who must deal with the social embarrassment of these fluoride-damaged teeth; those who must pay the costs to repair this damage do not agree.

If someone goes out to your car and takes a key and scratches the hood of your car, right in front where you have to look at it each day when you drive it, but it doesn't stop your car from being able to be driven, and it is only a small segment of the whole car, do you believe you should have some recourse to collect damages from the person who scratched your car?

Is Health Canada unaware of the following dental treatments are used to repair damage from dental fluorosis?:

1. Very Mild to Mild Dental Fluorosis: polishing, bleaching ($500 minimum charge)
2. Moderate Dental Fluorisis: microabrasion and bleaching ($1,000 minimum charge)
3. Severe Dental Fluorosis: porcelain veneers or full crowns ($6-900/tooth - $10,000 minimum charge)

US PHS recommended guideline for water fluoridation: 0.7ppm – 1.2ppm
Health Canada recommended guideline for water fluoridation: 0.9 – 1.0ppm
The recommended guidelines between the US and Canada are virtually identical.

The following figure: Prevalence of enamel flurosis in persons aged 6-39 years, by age and severity of fluorosis – United States, National Health and Nutrition Examination Survey, 1999-2002.

25% of those surveyed had very mild to mild dental fluorosis
10% of those surveyed had moderate dental fluorosis
1% of those surveyed had severe fluorosis

Fluoride use Associated with Periodontal Disease, Gingivitis:

“We have found that fluoride, in the concentration range in which it is employed for the prevention of dental caries, stimulates the production of prostaglandins and thereby exacerbates the inflammatory response in gingivitis and periodontitis. The present invention is a method for preventing dental caries by administering a fluoride salt into the oral cavity while at the same time controlling periodontal bone loss by administering, in addition to the fluoride salt, an amount of an NSAID sufficient to inhibit the production of prostaglandins induced by the fluoride.” Aberg G, Jerussi TP, McCullough JR - "NSAID/fluoride periodontal compositions and methods" US Patent: 5,807,541, granted September 15, 1998.

“The results suggest that there is a strong association of occurrence of periodontal disease in high-fluoride areas. The role of plaque is well understood in contrast to the effect of fluorides on periodontal tissues. Fluoride must therefore be considered an important etiological agent in periodontal disease.” Vandana KL, Reddy MS. 2007 Assessment of Periodontal Status in Dental Fluorosis Subjects using Community Periodontal Index of Treatment Needs. Indian Journal of Dental Research 18(2):67-71.

“Among the very inadequately studied physical signs of fluoride toxicosis are inflammation and destruction of gingival and periodontal (gum) tissue. Published and unpublished observations by many men suggest rather strongly that periodontoclasia (gum disease) may be induced or aggravated by certain chemicals, including fluoride.” Hume VO 1952 Dental Items of Interest. Director of Forsyth Dental Infirmary for Children in Boston from Chris Bryson The Fluoride Deception Seven Stories Press; New Ed edition (March 1, 2006) P320.

Fluoride use Associated with Edentulism

According to a US Centers for Disease Control 2002 report http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5250a3.htm, Hawaii and California had the lowest rates of water fluoridation in the USA: 8.8% of the population in the state of Hawaii was fluoridated; 27.7% of the population in the state California was fluoridated. Kentucky had the highest rate of water fluoridation with virtually 100% (99.7%) of the population receiving fluoridated drinking water. In 2003, the American Dental Association awarded Kentucky with a “50 Year Award” for virtually 100% fluoridation for 50 years. (http://www.skagitcleanwater.com/Fluoridatio_concern_%20Brief_%200utline.pdf)

The CDC has claimed that community water fluoridation is the most effective method for preserving oral health. If tooth loss is a measurement of oral tooth health, then one would expect to see lower rates of edentulism in the fluoridated communities.

Generally speaking, when the percentage of fluoridated people in each state increases, so does the percentage of people with six or more missing teeth. There appears to be no life long reduction in dental decay with fluoridation and yet an increase in tooth loss associated with fluoridation.

More specifically, this 2002 CDC report states, “The prevalence of edentate persons (i.e., those who have lost all their natural teeth) ranged from 13% in Hawaii and California to 42% in Kentucky.” In other words, the highest rates of tooth loss in people over 60 years of age occur in the states with the highest rates of water fluoridation. The lowest rates of tooth loss in people over 60 years of age occur in the states with the lowest rates of water fluoridation.

Based on these numbers from the US CDC, fluoridation does not appear to have helped prevent tooth loss. Fluoridation does not benefit those without teeth.

Fluoride Dose Calculator

The following Chart provides a method for calculating the fluoride dose. According to the US National Research Council report on Fluorides 2006, high water consumers (athletes, lactating mothers, soldiers, outdoor workers, diabetic patients) consume up to 12 liters of water per day:

QUESTIONS

1. Dental fluorosis is caused by fluoride damage to the cells (ameloblasts) making tooth enamel during tooth formation. Does Health Canada believe that damaging the tooth enamel is beneficial?
2. Ingested fluoride and fluorosilicates go to every cell in the body – not just the teeth. A peer-reviewed study by Susheela et al 2005 demonstrates that even children with no dental fluorosis experience thyroid derangement with fluoride use. Can Health Canada prove that this ingested fluoride does not harm other parts of the body when it harms the teeth?
3. In a previous petition (#221) Health Canada claims that: “In Canada, it is the use of fluoridated toothpaste or fluoride supplements at the critical age which is of greater concern.” Dental fluorosis is due to total over-exposure of fluoride when teeth are developing. According to the NRC 2006 Report fluoridated water is the single largest source of fluoride exposure. How does Health Canada calculate that only 10% of dental fluorosis is attributable to water fluoridation which provides the majority (approximately 60%) of fluoride exposure? Why is fluoridated toothpaste or fluoride supplements a “greater concern” for fluoride over-exposure when the GREATER EXPOSURE of fluorides is from fluoridated water? Please provide calculations and references.
4. In a previous petition (#221) Health Canada claims that since 1996 there has been an overall decreasing trend of moderate dental fluorosis in Canada. The NHANES reports from the USA show a significant increase of dental fluorosis in the USA – (an increase of 9 %) compared to 1980. Recent data shows that dental fluorosis has increased dramatically in the Niagara Region. [Name withheld] et al 2006 demonstrates that when water fluoridation is DISCONTINUED there is a decrease in dental fluorosis. Is Health Canada referring to a decrease in dental fluorosis in communities which stop fluoridating? Would Health Canada please provide evidence of declining rates of dental fluorosis?
5. In a previous petition (#221) Health Canada claims that “There is no cost associated with questionable, very mild or mild fluorosis as these affect neither tooth function nor cosmetic aspects.”Does Health Canada deny the existence of the procedures and costs outlined above for polishing, bleaching, microabrasion, porcelain veneers and crowns used by many individuals to ameliorate the damage done to their teeth from over-exposure to fluorides?
6. Why does Health Canada deny that very mild or mild dental fluorosis is socially embarrassing and a “cosmetic concern”? Would anyone at Health Canada like to speak with some of the individuals who have spent thousands of dollars on these treatments and endured the social embarrassment and see if they agree that dental fluorosis does not affect “cosmetic aspects”?
7. Is Health Canada aware that dental fluorosis is associated with higher incidence of dental cavities? 1-17
8. In a previous petition (#221) Health Canada states: “Due to the low occurrence of fluorosis of cosmetic concern”. The 2002 US NHANES survey shows that dental fluorosis rates in the USA, (which uses artificial fluoridation concentrations which are virtually identical to Health Canada) for very mild to mild dental fluorosis rates are 25%, moderate dental fluorosis rates are 10% and severe dental fluorosis rates are about 1% which a total of 36%. Is it the opinion of Health Canada that a dental fluorosis rate of 25% (very mild and mild dental fluorosis) or 36% (all dental fluorosis) is a “low occurrence”?
9. Will Health Canada or the Public Health Service please provide incidence figures for mild, moderate and severe dental fluorosis in Canada as previously requested?
10. According to the Ontario Ministry of Health 1999 Review, dental fluorosis is twice as prevalent in fluoridated communities (20 to 75%) compared to non-fluoridated communities (12 to 45%). Does Health Canada believe that these prevalence rates are “very low”?
11. Will Health Canada or the Public Health Service please provide incidence figures of dental fluorosis comparing fluoridated to unfluoridated communities in Canada?
12. Is Health Canada aware of the study by [name withheld] 2006 which stated: “When fluoride was removed from the water supply in 1992, the prevalence and severity of TFI scores decreased significantly from the 1993-94 survey cycle when compared with the 1996-97 and 2002-03 survey cycles.”? Does Health Canada dispute the evidence by [name withheld] that dental fluorosis drops significantly when water fluoridation is discontinued?
13. Is Health Canada aware that Dean, considered to be the Father of Water Fluoridation, advised that when the average child in a community has mild fluorosis, ". . . it begins to constitute a public health problem warranting increasing consideration" (Dean 1942, p. 29).” NRC 2006 p 106? Does Health Canada disagree with Trendley Dean?
14. Should the parent pay the costs of dental fluorosis because they allowed their child drink oodles and oodles of water like they are told in health magazines or because they were not informed by anyone that there really is way too much fluoride in the food chain, as described in a recent Scientific American article, January 2008?
15. In a previous petition (#221) Health Canada states that: “water fluoridated at an optimal level would not lead to dental fluorosis” Does Health Canada understand the difference between concentration (mg/L) and dose (mg/day)? If so, explain how concentration levels provide you with accurate information about the dose of fluoride received in a day. Refer to above fluoride dose calculator for assistance.
16. In a previous petition (#221) Health Canada states that: “As with any medical condition, moderate to severe dental fluorosis should be identified by trained professionals and not by the general public.” Does Health Canada suggest that the public has no right to understand the phenomenon of dental and skeletal fluorosis? Does Health Canada believe that the very visible tooth mottling caused by fluoride exposure is too difficult for a lay person to see and assess? Or does Health Canada believe that it is too difficult for a lay individual to count the number of teeth damaged by dental fluorosis, once it is identified?
17. In a previous petition (#221) Health Canada states: “Health Canada has the position that fluoride supplements should not be used and that children under age 3 should not use fluoridated tooth paste unless deemed appropriate by a health professional assessed on an individual basis.” A glass of artificially fluoridated water contains the same amount of fluoride as a “pea-sized amount of toothpaste” which Health Canada recommends not be swallowed. A glass of artificially fluoridated water also contains unmeasured amounts of fluorosilicate compounds which are more toxic than “fluoride ions”. Please keep in mind that the amount of fluoridated water or fluoridated food consumed by any individual in a day cannot be controlled. Why does Health Canada deem a controlled dose of pharmaceutical grade fluoride supplements and fluoride toothpaste to be inappropriate for ingestion yet drinking the industrial grade fluorosilicate compounds and their released fluoride ions is appropriate?
18. According to a patent for fluoridated toothpaste which : “A method for preventing dental caries by administering fluoride and, at the same time controlling periodontal bone loss precipitated by the fluoride, by providing a combination of fluoride and NSAID is disclosed.” & “fluoride, in the concentration range in which it is employed for the prevention of dental caries, stimulates the production of prostaglandins and thereby exacerbates the inflammatory response in gingivitis and periodontitis”. (Aberg et al. 1998) Is Health Canada familiar with the research showing that fluoride causes gingivitis and periodontitis? If not, why not?
19. Is Health Canada familiar with the US Centers for Disease Control 2002 report http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5250a3.htm showing that “The prevalence of edentate persons (i.e., those who have lost all their natural teeth) ranged from 13% in Hawaii and California to 42% in Kentucky.” ? 100% of Kentucky receives artificial water fluoridation; 8.8% of the population in the state of Hawaii was fluoridated; 27.7% of the population in the state California was fluoridated. In other words, the highest rates of tooth loss occur in the states with the highest rates of water fluoridation. The lowest rates of tooth loss occur in the states with the lowest rates of water fluoridation. Does Health Canada dispute this CDC evidence that water fluoridation did not help to protect the population from tooth disease and tooth loss ?
20. “Electron microscopy revealed that fluoride ions could interrupt the crystal nucleation process, resulting in crystal perforation in the developing tooth enamel and the presence of amorphous minerals in bone crystals. Furthermore, the results of enzymatic analyses indicated that fluoride directly interfered with the synthesis of carbonic anhydrase by the enamel-forming cells [ameloblasts]” Does Health Canada have evidence which demonstrates that the conclusions by Kakei and cohorts are incorrect?: “regardless of its amount, fluoride intake has harmful effects on both tooth and bone formation.” Kakei M, Sakaeb T, Yoshikawac M, Tamurad N. 2007 Effect of fluoride ions on apatite crystal formation in rat hard tissues. Annals of Anatomy 189: 175—181.

Citations:

Bibliography of citations http://www.Slweb.org/bibliography.html

1. 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. (See abstract)
2. Budipramana ES, et al. (2002). Dental fluorosis and caries prevalence in the fluorosis endemic area of Asembagus, Indonesia. International Journal of Paediatric Dentistry 12(6):415-22. (See abstract)
3. Chibole O. (1988). Dental caries among children in high fluoride regions of Kenya. Journal of the Royal Society of Health 108: 32-33.
4. Cortes DF, et al. (1996). Drinking water fluoride levels, dental fluorosis, and caries experience in Brazil. Journal of Public Health Dentistry 56: 226-8. (See abstract)
5. Ekanayake L, Van Der Hoek W. (2002). Dental caries and developmental defects of enamel in relation to fluoride levels in drinking water in an arid area of sri lanka. Caries Research 36(6):398-404. (See abstract)
6. Grobleri SR, et 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. (See abstract)
7. Ibrahim YE, et al. (1997). Caries and dental fluorosis in a 0.25 and a 2.5 ppm fluoride area in the Sudan. International Journal of Paediatric Dentistry 7(3):161-6. (See abstract)
8. Manji F, Kapila S. (1986). Fluorides and fluorosis in Kenya. Part III: Fluorides, fluorosis and dental caries. Odonto-stomatologie tropicale 9:135-9.
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(2):77-9. (See abstract)
10. Mann J, et al. (1987). Fluorosis and caries prevalence in a community drinking above-optimal fluoridated water.Community Dentistry and Oral Epidemiology 15(5):293-5. (See abstract)
11. Nanayakkara D, et al. (1999). Dental fluorosis and caries incidence in rural children residing in a high fluoride area in the dry zone of Sri Lanka. Ceylon Journal of Medical Science 42:13-17.
12. Olsson B. (1979). Dental findings in high-fluoride areas in Ethiopia. Community Dentistry and Oral Epidemiology 7(1):51-6. (See abstract)
13. Roholm K. (1937). Fluoride intoxication: a clinical-hygienic study with a review of the literature and some experimental investigations. H.K. Lewis Ltd, London. (See excerpts)
14. Smith MC, Smith HV. (1940). Observations on the durability of mottled teeth. American Journal of Public Health 30: 1050-1052.
15. Teotia SPS, Teotia M. (1994). Dental caries: a disorder of high fluoride and low dietary calcium interactions (30 years of personal research). Fluoride 27(2): 59-66. (See abstract)
16. Vignarajah S. (1993). Dental caries and enamel opacities in children residing in urban and rural areas of Antigua with different levels of natural fluoride in drinking water. Community Dental Health 10: 159-166.
17. Wondwossen F, et al. (2004). The relationship between dental caries and dental fluorosis in areas with moderate- and high-fluoride drinking water in Ethiopia. Community Dentistry and Oral Epidemiology 32: 337-44. (See abstract)

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[Health Canada provided a supplementary response to this petition. The original response follows.]

25 March 2010

Ms. Carole Clinch
307 Normandy Avenue
Waterloo, Ontario N2K 1X6

Dear Ms. Clinch:

Thank you for bringing to my attention that a citation error appeared in Health Canada’s response to your environmental petition no. 221‑C.

With respect to your concerns as outlined in your environmental petition no. 221‑E of December 10, 2009, I am pleased to provide the following factual correction.

In response to question 4 of environmental petition no. 221‑C, Health Canada stated:

“The actual prevalence of moderate dental fluorosis in Canada is very low, and all evidence suggests that there has been an overall decreasing trend of moderate dental fluorosis in Canada since 1996. This is based on a review of Canadian data conducted by Clark et al. 2006.”

The citation for this statement will be corrected to read:

“The actual prevalence of moderate dental fluorosis in Canada is very low, and all evidence suggests that there has been an overall decreasing trend of moderate dental fluorosis in Canada since 1996. This is based on Health Canada (2008) Findings and Recommendations of the Fluoride Expert Panel Meeting ‑ Water, Air and Climate Change Bureau, Safe Environments Programme, Healthy Environments and Consumer Safety Branch, Health Canada, Ottawa. Further background information on this statement, including the original research taken into consideration, can be found in Clark, 2006. This document is available to the public upon request. To obtain a copy, please contact: water_eau@hc‑sc.gc.ca.”

I hope that you will find this information helpful.

Sincerely,

[Original signed by Leona Aglukkaq, Minister of Health]

Leona Aglukkaq

c.c. Mr. Scott Vaughan, Commissioner of the Environment and Sustainable Development

Joint Response: Health Canada, Public Health Agency of Canada

8 August 2008

Ms. Carole Clinch
307 Normandy Avenue
Waterloo, Ontario N2K 1X6

Dear Ms. Clinch:

This is in response to your environmental petition no. 221-C of April 14, 2008, addressed to Mr. Ronald C. Thompson, the former Interim Commissioner of the Environment and Sustainable Development (CESD).

In your petition you raised concerns about the addition of fluoridation chemicals to drinking water as it relates to its safety and toxicity. You also had additional questions about some of the answers Health Canada provided you in your environmental petition no. 221.

I am pleased to provide you with the enclosed joint Health Canada and Public Health Agency of Canada response to your petition.

I appreciate your interest in this important matter, and I hope that you will find this information useful.

Yours sincerely,

[Original signed by Tony Clement, Minister of Health and the Minister for the Federal Economic Development Initiative for Northern Ontario]

Tony Clement

Enclosure

c.c. Mr. Scott Vaughan, CESD

Health Canada Response to
Environmental Petition 221C filed by Ms. Carole Clinch
under Section 22 of the Auditor General Act
Received April 29, 2008

Petition for the discontinuation of the addition of toxic substances to our drinking water (inorganic fluorides, inorganic arsenic, lead)

August 27, 2008

Minister of Health and the Minister for the Federal Economic
Development Initiative for Northern Ontario

Background:

Health Canada works with the provinces and territories to develop the Guidelines for Canadian Drinking Water Quality. The Guidelines are then used by each province and territory as a basis to establish their own requirements for drinking water quality. Fluoride is one of the many substances for which a guideline has been established. The Maximum Acceptable Concentration (MAC) for fluoride has been established taking into consideration all sources of exposure to fluoride, including foods and dental products. In Canada, the fluoridation of drinking water supplies is a decision that is made by each municipality, in collaboration with the appropriate provincial or territorial authority. This decision may also include consultation with residents, often through a referendum.

Fluoride occurs naturally in many source waters in Canada. It can also be added to drinking water as a public health measure to protect dental health and prevent or reduce tooth decay. The fluoridation of drinking water supplies is a well-accepted measure to protect public health and is strongly supported by scientific evidence. Fluoride is used internationally to protect dental health. It has been added to public drinking water supplies around the world for more than half a century, as a public health/dental health measure. The use of fluoride in the prevention of dental caries continues to be endorsed by over 90 national and international professional health organizations including Health Canada, the Canadian Dental Association, the Canadian Medical Association, the World Health Organization and the Food and Drug Administration of the United States.

As part of its ongoing review of the health effects of exposure to fluoride in drinking water, Health Canada convened a panel of experts in January 2007 to provide advice and recommendations based on the current state of relevant science with respect to the fluoridation of water. Advice was sought from the Expert Panel on five specific issues of concern including Total Daily Intake of Fluoride; Dental Fluorosis; Other Health Effects; Risk Assessment; and Drinking Water Fluoridation: Risks and Benefits. Discussions were based on topic-specific literature reviews developed and presented by some of the invited experts.

The report produced by the Expert Panel will be used to help inform the development of an updated fluoride guideline for Canadian drinking water, by ensuring our analysis is based on the latest scientific evidence. The Expert Panel report was posted online and can be found at http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php.

Health Canada will continue to monitor the science and review new scientific reports and articles which explore possible links between fluoride and various health effects to ensure the health of Canadians is protected.

1. Dental fluorosis is caused by fluoride damage to the cells (ameloblasts) making tooth enamel during tooth formation. Does Health Canada believe that damaging the tooth enamel is beneficial?

Exposure to fluorides has benefits but in some cases may lead to fluorosis of varying degrees. Dental fluorosis can be classified in a number of ways. One of the most universally accepted classifications, and the one used in this document, was developed by H.T. Dean in 1942. The individual’s fluorosis score is based on the severest form of fluorosis recorded for two or more teeth. Dean’s Index is described in the table below:

Questionable, very mild and mild fluorosis have no effect on tooth form or function and may make the tooth enamel more resistant to decay. The end-point for cosmetic concern for fluoride is considered to be moderate dental fluorosis. The actual prevalence of moderate dental fluorosis in Canada is low, and all evidence suggests that since 1996 there has been an overall decreasing trend of moderate dental fluorosis in Canada. In the United States, where the optimal level of fluoride in drinking water is between 0.7 and 1.2 mg/L, (in Canada the current optimal levels are between 0.8 and 1.0 mg/L) approximately 10 percent of dental fluorosis is attributable to water fluoridation and is in the very mild or mild fluorosis categories, neither of which would be of cosmetic concern.

Health Canada endorses the fluoridation of drinking water at optimal levels, as defined in the Guidelines for Canadian Drinking Water Quality, in order to prevent tooth decay. The decision to fluoridate a water supply is made by provincial and territorial governments, in collaboration with their municipalities.

2. Ingested fluoride and fluorosilicates go to every cell in the body—not just the teeth. A peer-reviewed study by Susheela et al 2005 demonstrates that even children with no dental fluorosis experience thyroid derangement with fluoride use. Can Health Canada prove that this ingested fluoride does not harm other parts of the body when it harms the teeth?

Based on currently available published scientific literature, the weight of evidence does not support the claim that fluoride can cause adverse health effects, such as cancer, bone disease or hypothyroidism. Health Canada’s conclusions are based on internal scientific reviews of original relevant scientific studies that are published in internationally recognized peer-reviewed journals.

3. In a previous petition (#221) Health Canada claims that: “In Canada, it is the use of fluoridated toothpaste or fluoride supplements at the critical age which is of greater concern.” Dental fluorosis is due to total over-exposure of fluoride when teeth are developing. According to the NRC 2006 Report fluoridated water is the single largest source of fluoride exposure. How does Health Canada calculate that only 10 percent of dental fluorosis is attributable to water fluoridation which provides the majority (approximately 60 percent) of fluoride exposure? Why is fluoridated toothpaste or fluoride supplements a “greater concern” for fluoride over-exposure when the GREATER 7 EXPOSURE of fluorides is from fluoridated water? Please provide calculations and references.

Health Canada has taken into account exposure to fluoride from all sources to determine the maximum acceptable and optimal concentrations in drinking water. For further information, please consult the Guideline Technical Document on Fluoride available on the Health Canada website. http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/environ/fluor-eng.php

4. In a previous petition (#221) Health Canada claims that since 1996 there has been an overall decreasing trend of moderate dental fluorosis in Canada. The NHANES reports from the USA show a significant increase of dental fluorosis in the USA—(an increase of 9 percent) compared to 1980. Recent data shows that dental fluorosis has increased dramatically in the Niagara Region. [Name withheld] et al 2006 demonstrates that when water fluoridation is DISCONTINUED there is a decrease in dental fluorosis. Is Health Canada referring to a decrease in dental fluorosis in communities which stop fluoridating? Would Health Canada please provide evidence of declining rates of dental fluorosis?

The actual prevalence of moderate dental fluorosis in Canada is very low, and all evidence suggests that there has been an overall decreasing trend of moderate dental fluorosis in Canada since 1996. This is based on a review of Canadian data conducted by Clark et al 2006.

5. In a previous petition (#221) Health Canada claims that “There is no cost associated with questionable, very mild or mild fluorosis as these affect neither tooth function nor cosmetic aspects.” Does Health Canada deny the existence of the procedures and costs outlined above for polishing, bleaching, microabrasion, porcelain veneers and crowns used by many individuals to ameliorate the damage done to their teeth from overexposure to fluorides?

Health Canada does not deny the existence of cosmetic procedures and related costs. However, mild to moderate dental fluorosis does not affect tooth function nor does it lead to any functional or disease issues that would require dental treatment. In some cases of moderate dental fluorosis, an individual may choose to undergo cosmetic treatment.

6. Why does Health Canada deny that very mild or mild dental fluorosis is socially embarrassing and a “cosmetic concern”? Would anyone at Health Canada like to speak with some of the individuals who have spent thousands of dollars on these treatments and endured the social embarrassment and see if they agree that dental fluorosis does not affect “cosmetic aspects”?

The assessment of “cosmetic concerns” remain a personal choice and is therefore outside the mandate of Health Canada.

7. Is Health Canada aware that dental fluorosis is associated with higher incidence of
dental cavities?

Current science shows that fluoridation at optimal concentrations prevents dental caries. The references you have provided all look at situations in developing countries, where the state of dental health is not comparable to the Canadian situation, and levels of naturally-occurring fluoride are significantly higher than the Canadian Maximum Acceptable Concentration.

8. In a previous petition (#221) Health Canada states: “Due to the low occurrence of fluorosis of cosmetic concern.” The 2002 US NHANES survey shows that dental fluorosis rates in the USA, (which uses artificial fluoridation concentrations which are virtually identical to Health Canada) for very mild to mild dental fluorosis rates are 25 percent, moderate dental fluorosis rates are 10 percent and severe dental fluorosis rates are about 1 percent which a total of 36 percent. Is it the opinion of Health Canada that a dental fluorosis rate of 25 percent (very mild and mild dental fluorosis) or 36 percent (all dental fluorosis) is a “low occurrence”?

As mentioned earlier, the end-point for cosmetic concern is considered to be moderate dental fluorosis. Moderate dental fluorosis would not lead to any functional or disease issues that would require dental treatment. In some but not necessarily all cases of moderate dental fluorosis an individual may decide that cosmetic treatment is necessary. The actual prevalence of moderate dental fluorosis in Canada is low, and all evidence suggests that since 1996 there has been an overall decreasing trend of moderate dental fluorosis in Canada.

It is also important to note that comparisons between Canada and other countries regarding the levels of exposure should be done with caution, as dental fluorosis rates will depend on a number of factors, which include the geographical area, water fluoridation, diet, use of fluoridated dental products, use of nutritional supplements, general state of health, etc.

9. Will Health Canada or the Public Health Service please provide incidence figures for mild, moderate and severe dental fluorosis in Canada as previously requested?

11. Will Health Canada or the Public Health Service please provide incidence figures of dental fluorosis comparing fluoridated to unfluoridated communities in Canada?

Answer to Questions 9 & 11:

Health Canada and the Public Health Agency of Canada do not compile such information. As previously indicated, these figures are not available. You may be able to find some information in published scientific literature.

10. According to the Ontario Ministry of Health 1999 Review, dental fluorosis is twice as prevalent in fluoridated communities (20 to 75 percent) compared to non-fluoridated communities (12 to 45 percent). Does Health Canada believe that these prevalence rates are “very low”?

It is not appropriate for Health Canada to provide an opinion on a review from another agency.

12. Is Health Canada aware of the study by [name withheld] 2006 which stated: “When fluoride was removed from the water supply in 1992, the prevalence and severity of TFI scores decreased significantly from the 1993–94 survey cycle when compared with the 1996–97 and 2002–03 survey cycles.”? Does Health Canada dispute the evidence by [name withheld] that dental fluorosis drops significantly when water fluoridation is discontinued?

Health Canada is aware of this study, which includes additional information and conclusions regarding fluoridation. It is expected for dental fluorosis rates to drop if fluoridation is discontinued; so do the beneficial effects from fluoride.

13. Is Health Canada aware that Dean, considered to be the Father of Water Fluoridation, advised that when the average child in a community has mild fluorosis, ". . . it begins to constitute a public health problem warranting increasing consideration" (Dean 1942, p. 29).” NRC 2006 p 106? Does Health Canada disagree with Trendley Dean?

It is not appropriate for Health Canada to comment on an individual’s opinion. Our conclusions are based on internal scientific reviews of original relevant scientific studies that are published in internationally recognized peer-reviewed journals

14. Should the parent pay the costs of dental fluorosis because they allowed their child drink oodles and oodles of water like they are told in health magazines or because they were not informed by anyone that there really is way too much fluoride in the food chain, as described in a recent Scientific American article, January 2008?

There is no cost associated with questionable, very mild or mild fluorosis as these affect neither tooth function nor cosmetic aspects. As mentioned earlier, the end-point for cosmetic concern is considered to be moderate dental fluorosis. Moderate dental fluorosis would not lead to any functional or disease issues that would require dental treatment.

15. In a previous petition (#221) Health Canada states that: “water fluoridated at an optimal level would not lead to dental fluorosis” Does Health Canada understand the difference between concentration (mg/L) and dose (mg/day)? If so, explain how concentration levels provide you with accurate information about the dose of fluoride received in a day. Refer to above fluoride dose calculator for assistance.

Health Canada has taken into account exposure to fluoride from all sources to determine the maximum acceptable and optimal concentrations in drinking water. For further information, please consult the Guideline Technical Document on Fluoride available on the Health Canada website. http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/fluoride-fluorure/index-eng.php

16. In a previous petition (#221) Health Canada states that: “As with any medical condition, moderate to severe dental fluorosis should be identified by trained professionals and not by the general public.” Does Health Canada suggest that the public has no right to understand the phenomenon of dental and skeletal fluorosis? Does Health Canada believe that the very visible tooth mottling caused by fluoride exposure is too difficult for a lay person to see and assess? Or does Health Canada believe that it is too difficult for a lay individual to count the number of teeth damaged by dental fluorosis, once it is identified?

Self-diagnosis is never recommended. As indicated in an earlier response, dentists and other health professionals have access to scientific and medical documents to identify issues such as moderate to severe dental fluorosis. If an individual is concerned about their personal health, they should speak to their dentist or other health care provider.

17. In a previous petition (#221) Health Canada states: “Health Canada has the position that fluoride supplements should not be used and that children under age 3 should not use fluoridated tooth paste unless deemed appropriate by a health professional assessed on an individual basis.” A glass of artificially fluoridated water contains the same amount of fluoride as a “pea-sized amount of toothpaste” which Health Canada recommends not be swallowed. A glass of artificially fluoridated water also contains unmeasured amounts of fluorosilicate compounds which are more toxic than “fluoride ions”. Please keep in mind that the amount of fluoridated water or fluoridated food consumed by any individual in a day cannot be controlled. Why does Health Canada deem a controlled dose of pharmaceutical grade fluoride supplements and fluoride toothpaste to be inappropriate for ingestion yet drinking the industrial grade fluorosilicate compounds and their released fluoride ions is appropriate?

Health Canada has taken into account exposure to fluoride from all sources to determine the maximum acceptable and optimal concentrations in drinking water. For further information, please consult the Guideline Technical Document on Fluoride available on the Health Canada website. http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/fluoride-fluorure/index-eng.php

Water that is optimally fluoridated does not pose a problem with respect to moderate fluorosis for any age group and does not create a need to advise parents of a health concern. Rather, it is the use of fluoride supplements and the ingestion of fluoridated toothpaste during the critical ages that is of concern. As a result, Health Canada is recommending the following steps to minimize exposure in small children:

• Never give fluoridated mouthwash or mouth rinses to children under six years of age, as they may swallow it.
• Talk to your dentist before using fluoridated mouthwash.
• Health Canada does not recommend the use of fluoride supplements (drops or tablets).
• Make sure that your children use no more than a pea-sized amount of toothpaste on their toothbrush, and teach them not to swallow toothpaste. Children under six years of age should be supervised while brushing, and children under the age of three should have their teeth brushed by an adult without using any toothpaste.

18. According to a patent for fluoridated toothpaste which : “A method for preventing dental caries by administering fluoride and, at the same time controlling periodontal bone loss precipitated by the fluoride, by providing a combination of fluoride and NSAID is disclosed.” & “fluoride, in the concentration range in which it is employed for the prevention of dental caries, stimulates the production of prostaglandins and thereby exacerbates the inflammatory response in gingivitis and periodontitis”. (Aberg et al. 1998) Is Health Canada familiar with the research showing that fluoride causes gingivitis and periodontitis? If not, why not?

Based on currently available published scientific literature, the weight of evidence does not support the claim that fluoride can cause such adverse health effects.

Health Canada has taken into account exposure to fluoride from all sources to determine the maximum acceptable and optimal concentrations in drinking water. For further information, please consult the Guideline Technical Document on Fluoride available on the Health Canada website. http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/fluoride-fluorure/index-eng.php

19. Is Health Canada familiar with the US Centers for Disease Control 2002 report http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5250a3.htm showing that “The prevalence of edentate persons (i.e., those who have lost all their natural teeth) ranged from 13 percent in Hawaii and California to 42 percent in Kentucky.”? 100 percent of Kentucky receives artificial water fluoridation; 8.8 percent of the population in the state of Hawaii was 9 fluoridated; 27.7 percent of the population in the state California was fluoridated. In other words, the highest rates of tooth loss occur in the states with the highest rates of water fluoridation. The lowest rates of tooth loss occur in the states with the lowest rates of water fluoridation. Does Health Canada dispute this CDC evidence that water fluoridation did not help to protect the population from tooth disease and tooth loss?

As indicated previously, Health Canada cannot comment on reviews from other agencies. It is important to exercise caution in interpreting such data—tooth disease and tooth loss can be caused by a variety of factors and conditions, and coincidental data cannot be interpreted as either evidence or proof, which would require a direct cause-effect relationship to be established.

20. “Electron microscopy revealed that fluoride ions could interrupt the crystal nucleation process, resulting in crystal perforation in the developing tooth enamel and the presence of amorphous minerals in bone crystals. Furthermore, the results of enzymatic analyses indicated that fluoride directly interfered with the synthesis of carbonic anhydrase by the enamel-forming cells [ameloblasts]” Does Health Canada have evidence which demonstrates that the conclusions by Kakei and cohorts are incorrect?: “regardless of its amount, fluoride intake has harmful effects on both tooth and bone formation.” Kakei M, Sakaeb T, Yoshikawac M, Tamurad N. 2007 Effect of fluoride ions on apatite crystal formation in rat hard tissues. Annals of Anatomy 189: 175–181.

Health Canada recognizes that there is ongoing research in the scientific community with regards to the exact mechanism of action of fluoride on tooth structure. Health Canada’s fluoride expert panel determined that the end-point for cosmetic concern for fluoride is considered to be moderate dental fluorosis on the Dean’s Index. Further information can be found at http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php. The actual prevalence of moderate dental fluorosis in Canada is low, and all evidence suggests that since 1996 there has been an overall decreasing trend of moderate dental fluorosis in Canada.