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Untested Alternatives to Fluoridation of Domestic Water Supplies
Untested alternatives to fluoridation of domestic water supplies Sholom Pearlman, D .D .S ., M .S ., Chicago
Occasionally a well-intentioned scientist proposes an alternative to water fluorida tion with the purpose of providing a
ciated with substantially reduced caries rates.3 Such water is used in locally man ufactured beverages as well as in cooking and for drinking per se. Fluoride is thus
better method of using fluorine in the control o f dental caries. T h e author of a recent article,1’ 2 however, is apparently unfamiliar with much of the voluminous data that support the fluoridation pro gram. T h e author1 infers that water fluorida tion is wasteful, technically complex, un
consumed throughout each day by every child living in the community. I f fluoride were available only in dairy milk, many infants would receive little or none in the first weeks of life, growing children would obtain it to varying degrees de pending on their individual liking for milk, and older children, whose dietary
certain and irregular in its effect and in violation of the concepts o f religious freedom, and suggests that all these features might be avoided if fluoride were
habits are frequently improper, would receive an * indeterminate quantity of fluoride at a time when their teeth are still undergoing active formation. It
added to milk instead of to water.
should be added that many children con sume relatively large quantities of milk. There would be the additional prob lem o f deciding on the actual amount of
T h e first fallacy in this approach is in the unwarranted assumption that the use of fluoridated milk will necessarily result in a reduction in the incidence of dental caries. There is no direct factual evidence to support such an assumption. Any modification of the current method of
fluoride that would have to be added to milk to ensure an intake of fluoride that might produce effective results in con trolling caries. T h e intake o f water, though it may be somewhat irregular, is less variable than other items in human nutrition. Nuckolls has pointed out also
providing dietary fluoride must be studied thoroughly before it is effectuated. No such study has been made in the case of the present suggestion. In fact, the author
that the average individual does not con-
himself declares that “further thinking and research” are indicated.1 The principle o f water fluoridation does not necessarily hinge on the inges tion of a definite quantity, for example,
Assistant secretary, Council on Dental Therapeutics, American Dental Association. 1. McKee, Jack E. Fluorides. Engin. & Sc. 15:18 April 1952. 2. Editorial. Sclent. Am. 187:38 Oct. 1952. 3. Dean, H. T. Fluorine: water-borne fluorides and dental health. In Dentistry in public health, Pelton, W. J., and Wisan, J. M. Philadelphia, W. B. Saunders Co., 1949, p. 136-162.
1 mg., of fluoride per day but rather de rives from the observation that the pres ence of one or more parts per million of fluoride ion in domestic water is asso 287
288 • THE JO U R N A L O F THE A M E R IC A N DENTAL A SSO C IA T IO N
sume water beyond the normal metabolic
producing mottled enamel, to ensure that
requirement and that excessive amounts o f fluoride are not likely to be ingested when the mineral is provided through
the fluoridated milk would not find its way into those areas. T h e limited supply of suitable fluoride salts is cited in the article1 as an important
this medium.4 Evidence is still required to demon strate that fluoride may not be rendered partially unavailable for physiologic utili zation when it is added to milk. T o meas ure the dental benefit of milk-borne fluoride would require intensive investi gation for a number of years in large population groups at great expense. Such a project, though worth-while, appears unnecessary in view of the effectiveness and simplicity o f the water fluoridation programs now available. In communities where fluoride is added to the water supply, the material is in troduced into the mains by a constantfeed device whose output is regulated automatically by the actual flow of water into the distribution system. Devices of this type are reliable and require a mini m um of attention. T h e final solution is so dilute that even in the unlikely event that a large excess of fluoride may acci dentally be introduced during the feeding procedure, there is no danger of produc ing toxic concentrations. In a dairy, how ever, the chemicals would frequently have to be added to individual vats of milk; and rigorous vigilance would be neces sary to ensure that the concentrations would remain constant from batch to batch. This surveillance would entail careful testing by trained personnel, and even with such supervision the possibility of an accident would be comparatively great. T h e chemical determination of fluoride in milk is much more difficult and involved than the determination of
reason for using milk as a vehicle since lesser amounts of these compounds would be required. Reliable sources indicate, however, that the available supplies are more than adequate for present needs.8 As a result of the increasing demand for these substances, manufacturers are now actively producing more fluorides from hitherto neglected sources with little addi tional effort and at low cost. There is no reason to doubt that adequate supplies of fluorides will be available to all com munities requiring them in the foresee able future. Th e addition of fluoride to water is an inexpensive procedure in most commu nities. M c K e e in his article1 cites the extraordinary example of San Bernardino, whose water supply originates in 17 dif ferent sources. Estimates are presented which indicate that the annual cost of the necessary initial equipment, amor tized over 20 years,, would be about 20 cents per capita, in contrast to the aver age figure of 8.8 cents derived from actual cost data in 140 areas where the program has been instituted.® Even if the addi tional costs for servicing and for chem icals were to raise the estimate for San Bernardino to 30 cents per capita per year for the first 20 years, the savings that would eventually accrue from re duced dental needs far outweigh this unusually high estimate of cost for that city. In consideration of the low price of chemicals and the limited technical at tention required for continued operation,
fluoride in water. There are more than twelve million people in various areas of the United States who are already using water sup plies containing optimal or more than optimal amounts of fluoride.5 I f fluori dated milk were used, it would be neces sary, in order to avoid the possibility of
4. Item in News Letter, Council on Denfa) Health, American Dental Association June 9, 1952, p. 3. 5. Phair, W. P,, and Driscoll, M. F. The status of fluoridation programs in the United States, its terri tories and possessions. J.A.D.A. 45:555 Nov. 1952. ^ 6. A.W.W.A. task group E5-I0; committee on fluorida tion, materials and methods. Natural and applied fluoridation census: supplemental report. J.A.W.W.A. 44:943 Oct. 1952.
PEARLM AN . . . VO LUM E 46, M A R CH 1953 • 289
fluoridation of the water supply is ac tually the least expensive and most con venient method known for caries control. I f fluoridated milk were made available at even a fourth of a cent per quart above the regular price (a low estimate for the cost of chemicals, chemical control pro cedures, advertising, labeling and dis tribution ) , the annual cost per consumer, on the basis of one quart per day, would be about 90 cents, that is, 90 cents extra expense for ingesting fluorine in milk instead of in water notwithstanding the fact that the effectiveness of the milk in preventing caries and in reducing dental expense is still not established. T h e questions of religious freedom and freedom o f choice have been answered in detail elsewhere.7 It may be pointed out in addition that it would be a travesty of the democratic principle of free choice if a minority of misguided but militant partisans were to be permitted to prevent the majority of the population from choosing to obtain relief from dental dis
ease by the simplest, cheapest and most effective method available. Experiment and investigation may, after many years, reveal whether or not fluoridated milk may be useful in the control of dental caries. A t the present time it does not appear promising. Until an accumulation of scientific data indi cates the usefulness of other procedures, the current method utilizing fluoridation of domestic water supplies offers the only established means of reducing the in cidence of dental caries on a popular basis.8 Untested alternatives, such as the use of fluoridated tablets, table salt, chew ing gum, dentifrices, mouthwashes, bot tled water or milk, should not be advo cated, since the true issue tends to become clouded in the resulting confusion.
7. American Dental Association, Council on Denta! Health. Fluoridation facts: answers to criticisms of fluoridation. Chicago, American Dental Association, 1952, p . 8 . 8. American Dental Association, Council on Dental Therapeutics. Current status of dental uses of fluorides. J.A.D.A. 45:468 Oct. 1952.
Good Books * Good books are to the young mind what the warming sun and the refreshing rain of spring are to the seeds which have lain dormant in the frosts of winter. They are more, for they may save from that which is worse than death, as well as bless with that which is better than life. Horace M an n .
Occasionally a well-intentioned scientist proposes an alternative to water fluorida tion with the purpose of providing a
ciated with substantially reduced caries rates.3 Such water is used in locally man ufactured beverages as well as in cooking and for drinking per se. Fluoride is thus
better method of using fluorine in the control o f dental caries. T h e author of a recent article,1’ 2 however, is apparently unfamiliar with much of the voluminous data that support the fluoridation pro gram. T h e author1 infers that water fluorida tion is wasteful, technically complex, un
consumed throughout each day by every child living in the community. I f fluoride were available only in dairy milk, many infants would receive little or none in the first weeks of life, growing children would obtain it to varying degrees de pending on their individual liking for milk, and older children, whose dietary
certain and irregular in its effect and in violation of the concepts o f religious freedom, and suggests that all these features might be avoided if fluoride were
habits are frequently improper, would receive an * indeterminate quantity of fluoride at a time when their teeth are still undergoing active formation. It
added to milk instead of to water.
should be added that many children con sume relatively large quantities of milk. There would be the additional prob lem o f deciding on the actual amount of
T h e first fallacy in this approach is in the unwarranted assumption that the use of fluoridated milk will necessarily result in a reduction in the incidence of dental caries. There is no direct factual evidence to support such an assumption. Any modification of the current method of
fluoride that would have to be added to milk to ensure an intake of fluoride that might produce effective results in con trolling caries. T h e intake o f water, though it may be somewhat irregular, is less variable than other items in human nutrition. Nuckolls has pointed out also
providing dietary fluoride must be studied thoroughly before it is effectuated. No such study has been made in the case of the present suggestion. In fact, the author
that the average individual does not con-
himself declares that “further thinking and research” are indicated.1 The principle o f water fluoridation does not necessarily hinge on the inges tion of a definite quantity, for example,
Assistant secretary, Council on Dental Therapeutics, American Dental Association. 1. McKee, Jack E. Fluorides. Engin. & Sc. 15:18 April 1952. 2. Editorial. Sclent. Am. 187:38 Oct. 1952. 3. Dean, H. T. Fluorine: water-borne fluorides and dental health. In Dentistry in public health, Pelton, W. J., and Wisan, J. M. Philadelphia, W. B. Saunders Co., 1949, p. 136-162.
1 mg., of fluoride per day but rather de rives from the observation that the pres ence of one or more parts per million of fluoride ion in domestic water is asso 287
288 • THE JO U R N A L O F THE A M E R IC A N DENTAL A SSO C IA T IO N
sume water beyond the normal metabolic
producing mottled enamel, to ensure that
requirement and that excessive amounts o f fluoride are not likely to be ingested when the mineral is provided through
the fluoridated milk would not find its way into those areas. T h e limited supply of suitable fluoride salts is cited in the article1 as an important
this medium.4 Evidence is still required to demon strate that fluoride may not be rendered partially unavailable for physiologic utili zation when it is added to milk. T o meas ure the dental benefit of milk-borne fluoride would require intensive investi gation for a number of years in large population groups at great expense. Such a project, though worth-while, appears unnecessary in view of the effectiveness and simplicity o f the water fluoridation programs now available. In communities where fluoride is added to the water supply, the material is in troduced into the mains by a constantfeed device whose output is regulated automatically by the actual flow of water into the distribution system. Devices of this type are reliable and require a mini m um of attention. T h e final solution is so dilute that even in the unlikely event that a large excess of fluoride may acci dentally be introduced during the feeding procedure, there is no danger of produc ing toxic concentrations. In a dairy, how ever, the chemicals would frequently have to be added to individual vats of milk; and rigorous vigilance would be neces sary to ensure that the concentrations would remain constant from batch to batch. This surveillance would entail careful testing by trained personnel, and even with such supervision the possibility of an accident would be comparatively great. T h e chemical determination of fluoride in milk is much more difficult and involved than the determination of
reason for using milk as a vehicle since lesser amounts of these compounds would be required. Reliable sources indicate, however, that the available supplies are more than adequate for present needs.8 As a result of the increasing demand for these substances, manufacturers are now actively producing more fluorides from hitherto neglected sources with little addi tional effort and at low cost. There is no reason to doubt that adequate supplies of fluorides will be available to all com munities requiring them in the foresee able future. Th e addition of fluoride to water is an inexpensive procedure in most commu nities. M c K e e in his article1 cites the extraordinary example of San Bernardino, whose water supply originates in 17 dif ferent sources. Estimates are presented which indicate that the annual cost of the necessary initial equipment, amor tized over 20 years,, would be about 20 cents per capita, in contrast to the aver age figure of 8.8 cents derived from actual cost data in 140 areas where the program has been instituted.® Even if the addi tional costs for servicing and for chem icals were to raise the estimate for San Bernardino to 30 cents per capita per year for the first 20 years, the savings that would eventually accrue from re duced dental needs far outweigh this unusually high estimate of cost for that city. In consideration of the low price of chemicals and the limited technical at tention required for continued operation,
fluoride in water. There are more than twelve million people in various areas of the United States who are already using water sup plies containing optimal or more than optimal amounts of fluoride.5 I f fluori dated milk were used, it would be neces sary, in order to avoid the possibility of
4. Item in News Letter, Council on Denfa) Health, American Dental Association June 9, 1952, p. 3. 5. Phair, W. P,, and Driscoll, M. F. The status of fluoridation programs in the United States, its terri tories and possessions. J.A.D.A. 45:555 Nov. 1952. ^ 6. A.W.W.A. task group E5-I0; committee on fluorida tion, materials and methods. Natural and applied fluoridation census: supplemental report. J.A.W.W.A. 44:943 Oct. 1952.
PEARLM AN . . . VO LUM E 46, M A R CH 1953 • 289
fluoridation of the water supply is ac tually the least expensive and most con venient method known for caries control. I f fluoridated milk were made available at even a fourth of a cent per quart above the regular price (a low estimate for the cost of chemicals, chemical control pro cedures, advertising, labeling and dis tribution ) , the annual cost per consumer, on the basis of one quart per day, would be about 90 cents, that is, 90 cents extra expense for ingesting fluorine in milk instead of in water notwithstanding the fact that the effectiveness of the milk in preventing caries and in reducing dental expense is still not established. T h e questions of religious freedom and freedom o f choice have been answered in detail elsewhere.7 It may be pointed out in addition that it would be a travesty of the democratic principle of free choice if a minority of misguided but militant partisans were to be permitted to prevent the majority of the population from choosing to obtain relief from dental dis
ease by the simplest, cheapest and most effective method available. Experiment and investigation may, after many years, reveal whether or not fluoridated milk may be useful in the control of dental caries. A t the present time it does not appear promising. Until an accumulation of scientific data indi cates the usefulness of other procedures, the current method utilizing fluoridation of domestic water supplies offers the only established means of reducing the in cidence of dental caries on a popular basis.8 Untested alternatives, such as the use of fluoridated tablets, table salt, chew ing gum, dentifrices, mouthwashes, bot tled water or milk, should not be advo cated, since the true issue tends to become clouded in the resulting confusion.
7. American Dental Association, Council on Denta! Health. Fluoridation facts: answers to criticisms of fluoridation. Chicago, American Dental Association, 1952, p . 8 . 8. American Dental Association, Council on Dental Therapeutics. Current status of dental uses of fluorides. J.A.D.A. 45:468 Oct. 1952.
Good Books * Good books are to the young mind what the warming sun and the refreshing rain of spring are to the seeds which have lain dormant in the frosts of winter. They are more, for they may save from that which is worse than death, as well as bless with that which is better than life. Horace M an n .