Only four sentences in the whole review address safety. Three of these sentences comprise the entire section labeled, “Safety of water fluoridation”:

“Early investigations into the physiologic effects of fluoride in drinking water predated the first community field trials. Since 1950, opponents of water fluoridation have claimed it increased the risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, acquired immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions (24). The safety and effectiveness of water fluoridation have been re-evaluated frequently, and no credible evidence supports an association between fluoridation and any of these conditions (25).”

And one sentence in the last paragraph:

“3) opponents of water fluoridation often make unsubstantiated claims about adverse health effects of fluoridation in attempts to influence public opinion”

This is not a very strong case is it? It is even worse if one checks the supporting references.

Reference 24 is a chapter written by Harold Hodge in a book edited by Professor Newbrun. Newbrun is a well known promoter of fluoridation and thus hardly an impartial source on the matter. Harold Hodge, as has been well documented by Chris Bryson in his book “The Fluoride Deception,” was the chief toxicologist of the Manhattan project. In that capacity, he was not only part of the team which injected plutonium into patients without their knowledge, but he also oversaw the early fluoridation trial in Newburgh and Kingston, NY (1945-55). For 40 years Harold Hodge was the “much respected” toxicologist who repeatedly informed the American public that there were no health risks from fluoride at 1 ppm.

Reference 25 is the NRC review of the EPA’s drinking water standards for fluoride published in 1993. In other words, when the CDC issued their claims of safety in 1999 they were SIX YEARS out of date on the scientific literature.

As far as bone and fluoride is concerned, by 1999 there were a) numerous studies on fluoride causing bone damage in animals; b) clinical trials in which patients were given fluoride to fight osteporosis which led to an increase in fracture not a decrease as hoped, as well as links to increases in hip fracture in several human populations (see http://www.FluorideAction.net/health).

As far as Alzheimer’s disease is concerned, in 1998, Varner et al. had published their important work in Brain Research which showed that rats given water containing fluoride at 1 ppm led to kidney damage, brain damage , a greater uptake of aluminium into the brain and the formation of beta amyloid deposits which are characteristic of Alzheimer’s disease.

As far as intelligence is concerned, Mullenix et al. in 1995 had published their important work that showed that fluoride concentrated in rat brain, and could alter behavior and had predicted that this might mean that it could lower IQ in children. These predictions were fairly swiftly followed by papers from Chinese researchers which showed that fluoride was linked to lowering IQ in children. These were published in both Chinese publications and in English in the journal Fluoride. Several of these were available in 1999 (see http://www.FluorideAction.net/health).

You will notice how the authors of the CDC report attempt to cover their rear ends on their inaccurate claims by using the phrase “no credible evidence.” The CDC, like their cousins at the ADA, when challenged with ANY scientific evidence of harm  nearly always – regardless of the peer reviewed journal in which the article was published, or the quality of the work in question - dismiss the work as failing to meet their “lofty” scientific standards, or even more disdainfully, as “junk science.” Of course, this is the only thing that they can do if they wish to continue their fluoridation program at all costs. If there is nothing wrong with their program there must be something wrong with the evidence which indicates it may be harmful! It is called working backwards from the desired agenda.

A similar agenda is working in the only other words on safety in the CDC review, when they tell us that “opponents of water fluoridation often make unsubstantiated claims about adverse health effects of fluoridation in attempts to influence public opinion.”

Before we leave the key issue of safety, it is very interesting to note the huge double standard operating with the CDC’s use of the 1993 review by the NRC and its approach to the 2006 review by the same agency. In both instances the NRC was reviewing the same issue: the safety or otherwise of the EPA’s safe drinking water standard of 4 ppm. In 1999, the CDC was prepared to use the 1993 NRC review to claim a clean bill of health for water fluoridation. However in 2006, when the NRC, in the light of studies conducted since 1993 (and of course several conducted between 1993 and 1999), said that the 4 ppm was not protective of health and should be lowered, the CDC then turned around and said that this was not relevant to water fluoridation!

2. The complete omission of current dental fluorosis statistics.

Even though the CDC in its discussion of the history of water fluoridation referred to dental fluorosis, and stated that “At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild” the authors failed to mention that in a paper published in 1997 by Heller et al., the authors found that the incidence of dental fluorosis had increased nearly threefold, such that 29.9% of children in fluoridated communities had dental fluorosis on at least two teeth, and not all of it in the very mild category. Thus, since the stated objective of the water fluoridation program was to reduce tooth decay while minimizing dental fluorosis, these figures show that the program is clearly failing on at least one of these objectives. Now that is some omission!

3. The weak case made for effectiveness

In the section on the “History of water fluoridation” the authors claim that “The effectiveness of community water fluoridation in preventing dental caries prompted rapid adoption of this public health measure in cities throughout the United States. As a result, dental caries declined precipitously during the second half of the 20th century. For example, the mean DMFT among persons aged 12 years in the United States declined 68%, from 4.0 in 1966-1970 (14) to 1.3 in 1988-1994 (CDC, unpublished data, 1999) (Figure 1).”

Figure 1 shows a plot of tooth decay in 12 year olds in the U.S. coming down from the 1960’s to the 1990’s. On the same graph for the same period, the percentage of the population drinking fluoridated water is shown going up. The desired impression is that one line is coming down BECAUSE the other line is going up!

The weakness of this claim, and this impression, pivots around the words “as a result” in the paragraph above. It is true that there was a rapid adoption of fluoridation throughout the states, but the notion that this caused a “precipitious decline” in dental caries “during the second half of the 20th century” is wishful thinking. There is no question that the tooth decay indicator being considered (DMFTs in 12-year olds) has shown a dramatic decline over the period in question (from the 1960’s to the 1990’s) in the US, but the same declines – or greater – have been observed for the same period in many non-fluoridated countries. This becomes abundantly clear when Figure 1 is inspected and compared with data available online from the World Health Organization (see http://www.FluorideAction.net/who-dmft.htm).

A very important question to ask the authors of the CDC report is why they appear to be unaware of what has been happening to tooth decay in other countries, which contradicts their claim that tooth decay in the US has been coming down because more people are drinking fluoridated water. If they were really unaware of these WHO statistics, which are readily available on line, then it raises a huge question about their competence. If, on the other hand, they were aware of this WHO data then it poses an even greater question about their integrity.

In the section on the “Effectiveness of Water Fluoridation” the authors state that “Early studies reported that caries reduction attributable to fluoridation ranged from 50% to 70%, but by the mid-1980s the mean DMFS scores in the permanent dentition of children who lived in communities with fluoridated water were only 18% lower than among those living in communities without fluoridated water (15).”

It is true that the early trials of fluoridation in Grand Rapids, MI, Newburgh, NY, and Evanston, IL yielded claims of “caries reduction attributable to fluoridation (which) ranged from 50% to 70%” however these studies were full of methodological flaws. In fact, there were so many flaws that the late Dr. Philip Sutton wrote a whole book on the matter which was published in 1996. No one has ever successfully refuted this book or the monographs which preceded them. It is generally conceded that these studies would not pass muster today. Sadly, the promoters of fluoridation have yet to test the fluoridation hypothesis with double blind, randomly selected testing of populations, which is the gold standard as far as epidemiological studies are concerned.

It is also true that  “by the mid-1980s the mean DMFS scores in the permanent dentition of children who lived in communities with fluoridated water were only 18% lower than among those living in communities without fluoridated water (15).” Reference 15 refers to the largest survey of tooth decay ever conducted in the US, which was organized by the National Institute of Dental Research (NIDR). The study examined over 39,000 children in 84 communities. When Dr. Yiamouyiannis used the Freedom of Information Act to obtain the raw data from this survey, he found no significant difference in tooth decay between fluoridated communities and non-fluoridated communities, when he examined the Decayed Missing Filled Teeth (DMFT). When Brunelle and Carlos (reference 15) reported the result of this study in 1990, they used the more sensitive measure of tooth decay of DMFS (decayed, missing and filled SURFACES). For most teeth there are five surfaces. The figure of 18% comes from Table 6 which compared tooth decay in children aged 5 to 17 who had lived all their lives in fluoridated versus non-fluoridated communities. The average number of decayed missing and filled surfaces in the children from non-fluoridated communities was 3.39, and from the fluoridated communities was 2.69. This thus yielded an average difference of 0.6 of one tooth surface. When fully emerged there are 28 teeth in a child’s mouth, with a total of 128 surfaces. Thus, 0.6 of one tooth surface represents an absolute saving of less than 1% of the tooth surfaces available. 0.6 divided by 3.39 multiplied by a hundred does equal 18%. An 18% saving sounds a lot better than 0.6 of one tooth surface! We are actually talking about a saving which has little practical significance.

It is also true that “Since the early days of community water fluoridation, the prevalence of dental caries has declined in both communities with and communities without fluoridated water in the United States.” That is a very large concession which is largely ignored by zealous promoters of fluoridation today.  And while this trend “has been attributed largely to the diffusion of fluoridated water to areas without fluoridated water through bottling and processing of foods and beverages in areas with fluoridated water” by fluoridation promoters, this so-called “halo” effect cannot explain the fact that little difference in declines in tooth decay has been observed between fluoridated and non-fluoridated countries in Europe (as discussed above and illustrated by the figures in http://www.FluorideAction.net/who-dmft.htm ), since there is little fluoridation on mainland Europe. The “widespread use of fluoride toothpaste (17)” is a far more plausible suggestion. An even more likely explanation is that there is far greater correlation between standard of living and tooth decay than has ever been found with the ingestion of fluoride.

4. The concession that fluoride’s benefits are topical not systemic.

In the section entitled “Biologic Mechanism”, the authors provide the most damning evidence against the notion that drinking fluoridated water is a rational method of fighting tooth decay by admitting what many dental researchers had been reporting in the literature throughout the 1980’s, namely that fluoride works on the outside of the tooth not from inside of the body. This concession by the CDC indicated that for over 40 years promoters of fluoridation had been completely wrong on how fluoride worked to fight tooth decay. This is how the authors put it more delicately:

“Fluoride's caries-preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid-resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children (1).”

Oops! All those pediatricians and dentists who had been advising pregnant women to take fluoride tablets and parents to give fluoride drops to babies before their teeth had erupted (and some still do!) were wasting their time and worse possibly risking the development of the baby’s sensitive tissues.

However, this important concession goes along way to explain why it is so difficult to find a difference in tooth decay between children who have lived all their lives drinking fluoridated water and those drinking non-fluoridated water.

Conclusion. So this is the paper that underpins the CDC claim that “fluoridation is one of the top ten public health achievements of the 20th century.” It should be noted that MMWR reports only receive internal peer review, unlike other journals they are not subjected to external peer review. Based upon communications that Ralph Blois from Oregon had with the CDC, this infamous CDC report was actually written by one dentist: Scott Tomar. Dr. Tomar has since left the agency, but his misleading report continues to help dupe journalists, officials and citizens throughout the world, almost on a daily basis.

You have my permission to send this bulletin to any journalist, editor or official who cites this grossly inaccurate claim. You could call this analysis “parrot medicine.”

-----------------------------------------
Note the passages highlighted in bold in the MMWR report below are the ones cited in my analysis above.

MMWR (Mortality and Morbidity Weekly Report) Weekly
October 22, 1999 /48(41); 933-940
   
Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries

Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century. The history of water fluoridation is a classic example of clinical observation leading to epidemiologic investigation and community-based public health intervention. Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.

Dental Caries

Dental caries is an infectious, communicable, multifactorial disease in which bacteria dissolve the enamel surface of a tooth (1). Unchecked, the bacteria then may penetrate the underlying dentin and progress into the soft pulp tissue. Dental caries can result in loss of tooth structure and discomfort. Untreated caries can lead to incapacitating pain, a bacterial infection that leads to pulpal necrosis, tooth extraction and loss of dental function, and may progress to an acute systemic infection. The major etiologic factors for this disease are specific bacteria in dental plaque (particularly Streptococcus mutans and lactobacilli) on susceptible tooth surfaces and the availability of fermentable carbohydrates.

At the beginning of the 20th century, extensive dental caries was common in the United States and in most developed countries (2). No effective measures existed for preventing this disease, and the most frequent treatment was tooth extraction. Failure to meet the minimum standard of having six opposing teeth was a leading cause of rejection from military service in both world wars (3,4). Pioneering oral epidemiologists developed an index to measure the prevalence of dental caries using the number of decayed, missing, or filled teeth (DMFT) or decayed, missing, or filled tooth surfaces (DMFS) (5) rather than merely presence of dental caries, in part because nearly all persons in most age groups in the United States had evidence of the disease. Application of the DMFT index in epidemiologic surveys throughout the United States in the 1930s and 1940s allowed quantitative distinctions in dental caries experience among communities--an innovation that proved critical in identifying a preventive agent and evaluating its effects.

History of Water Fluoridation

Soon after establishing his dental practice in Colorado Springs, Colorado, in 1901, Dr. Frederick S. McKay noted an unusual permanent stain or "mottled enamel" (termed "Colorado brown stain" by area residents) on the teeth of many of his patients (6). After years of personal field investigations, McKay concluded that an agent in the public water supply probably was responsible for mottled enamel. McKay also observed that teeth affected by this condition seemed less susceptible to dental caries (7).

Dr. F. L. Robertson, a dentist in Bauxite, Arkansas, noted the presence of mottled enamel among children after a deep well was dug in 1909 to provide a local water supply. A hypothesis that something in the water was responsible for mottled enamel led local officials to abandon the well in 1927. In 1930, H. V. Churchill, a chemist with Aluminum Company of America, an aluminum manufacturing company that had bauxite mines in the town, used a newly available method of spectrographic analysis that identified high concentrations of fluoride (13.7 parts per million [ppm]) in the water of the abandoned well (8). Fluoride, the ion of the element fluorine, almost universally is found in soil and water but generally in very low concentrations (less than 1.0 ppm). On hearing of the new analytic method, McKay sent water samples to Churchill from areas where mottled enamel was endemic; these samples contained high levels of fluoride (2.0-12.0 ppm).

The identification of a possible etiologic agent for mottled enamel led to the establishment in 1931 of the Dental Hygiene Unit at the National Institute of Health headed by Dr. H. Trendley Dean. Dean's primary responsibility was to investigate the association between fluoride and mottled enamel (see box). Adopting the term "fluorosis" to replace "mottled enamel," Dean conducted extensive observational epidemiologic surveys and by 1942 had documented the prevalence of dental fluorosis for much of the United States (9). Dean developed the ordinally scaled Fluorosis Index to classify this condition. Very mild fluorosis was characterized by small, opaque "paper white" areas affecting less than or equal to 25% of the tooth surface; in mild fluorosis, 26%-50% of the tooth surface was affected. In moderate dental fluorosis, all enamel surfaces were involved and susceptible to frequent brown staining. Severe fluorosis was characterized by pitting of the enamel, widespread brown stains, and a "corroded" appearance (9).

Dean compared the prevalence of fluorosis with data collected by others on dental caries prevalence among children in 26 states (as measured by DMFT) and noted a strong inverse relation (10). This cross-sectional relation was confirmed in a study of 21 cities in Colorado, Illinois, Indiana, and Ohio (11). Caries among children was lower in cities with more fluoride in their community water supplies; at concentrations greater than 1.0 ppm, this association began to level off. At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild.

The hypothesis that dental caries could be prevented by adjusting the fluoride level of community water supplies from negligible levels to 1.0-1.2 ppm was tested in a prospective field study conducted in four pairs of cities (intervention and control) starting in 1945: Grand Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; Evanston and Oak Park, Illinois; and Brantford and Sarnia, Ontario, Canada. After conducting sequential cross-sectional surveys in these communities over 13-15 years, caries was reduced 50%-70% among children in the communities with fluoridated water (12). The prevalence of dental fluorosis in the intervention communities was comparable with what had been observed in cities where drinking water contained natural fluoride at 1.0 ppm. Epidemiologic investigations of patterns of water consumption and caries experience across different climates and geographic regions in the United States led in 1962 to the development of a recommended optimum range of fluoride concentration of 0.7-1.2 ppm, with the lower concentration recommended for warmer climates (where water consumption was higher) and the higher concentration for colder climates (13).

The effectiveness of community water fluoridation in preventing dental caries prompted rapid adoption of this public health measure in cities throughout the United States. As a result, dental caries declined precipitously during the second half of the 20th century. For example, the mean DMFT among persons aged 12 years in the United States declined 68%, from 4.0 in 1966-1970 (14) to 1.3 in 1988-1994 (CDC, unpublished data, 1999) (Figure 1). The American Dental Association, the American Medical Association, the World Health Organization, and other professional and scientific organizations quickly endorsed water fluoridation. Knowledge about the benefits of water fluoridation led to the development of other modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, and drops. Several countries in Europe and Latin America have added fluoride to table salt.

Effectiveness of Water Fluoridation

Early studies reported that caries reduction attributable to fluoridation ranged from 50% to 70%, but by the mid-1980s the mean DMFS scores in the permanent dentition of children who lived in communities with fluoridated water were only 18% lower than among those living in communities without fluoridated water (15). A review of studies on the effectiveness of water fluoridation conducted in the United States during 1979-1989 found that caries reduction was 8%-37% among adolescents (mean: 26.5%) (16).

Since the early days of community water fluoridation, the prevalence of dental caries has declined in both communities with and communities without fluoridated water in the United States. This trend has been attributed largely to the diffusion of fluoridated water to areas without fluoridated water through bottling and processing of foods and beverages in areas with fluoridated water and widespread use of fluoride toothpaste (17). Fluoride toothpaste is efficacious in preventing dental caries, but its effectiveness depends on frequency of use by persons or their caregivers. In contrast, water fluoridation reaches all residents of communities and generally is not dependent on individual behavior.

Although early studies focused mostly on children, water fluoridation also is effective in preventing dental caries among adults. Fluoridation reduces enamel caries in adults by 20%-40% (16) and prevents caries on the exposed root surfaces of teeth, a condition that particularly affects older adults.

Water fluoridation is especially beneficial for communities of low socioeconomic status (18). These communities have a disproportionate burden of dental caries and have less access than higher income communities to dental-care services and other sources of fluoride. Water fluoridation may help reduce such dental health disparities.

Biologic Mechanism

Fluoride's caries-preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid-resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children (1). These mechanisms include 1) inhibition of demineralization, 2) enhancement of remineralization, and 3) inhibition of bacterial activity in dental plaque (1).

Enamel and dentin are composed of mineral crystals (primarily calcium and phosphate) embedded in an organic protein/lipid matrix. Dental mineral is dissolved readily by acid produced by cariogenic bacteria when they metabolize fermentable carbohydrates. Fluoride present in solution at low levels, which becomes concentrated in dental plaque, can substantially inhibit dissolution of tooth mineral by acid.

Fluoride enhances remineralization by adsorbing to the tooth surface and attracting calcium ions present in saliva. Fluoride also acts to bring the calcium and phosphate ions together and is included in the chemical reaction that takes place, producing a crystal surface that is much less soluble in acid than the original tooth mineral (1).

Fluoride from topical sources such as fluoridated drinking water is taken up by cariogenic bacteria when they produce acid. Once inside the cells, fluoride interferes with enzyme activity of the bacteria and the control of intracellular pH. This reduces bacterial acid production, which directly reduces the dissolution rate of tooth mineral (19).

Population Served by Water Fluoridation

By the end of 1992, 10,567 public water systems serving 135 million persons in 8573 U.S. communities had instituted water fluoridation (20). Approximately 70% of all U.S. cities with populations of greater than 100,000 used fluoridated water. In addition, 3784 public water systems serving 10 million persons in 1924 communities had natural fluoride levels greater than or equal to 0.7 ppm. In total, 144 million persons in the United States (56% of the population) were receiving fluoridated water in 1992, including 62% of those served by public water systems. However, approximately 42,000 public water systems and 153 U.S. cities with populations greater than or equal to 50,000 have not instituted fluoridation.

Cost Effectiveness and Cost Savings of Fluoridation

Water fluoridation costs range from a mean of 31 cents per person per year in U.S. communities of greater than 50,000 persons to a mean of $2.12 per person in communities of less than 10,000 (1988 dollars) (21). Compared with other methods of community-based dental caries prevention, water fluoridation is the most cost effective for most areas of the United States in terms of cost per saved tooth surface (22).

Water fluoridation reduces direct health-care expenditures through primary prevention of dental caries and avoidance of restorative care. Per capita cost savings from 1 year of fluoridation may range from negligible amounts among very small communities with very low incidence of caries to $53 among large communities with a high incidence of disease (CDC, unpublished data, 1999). One economic analysis estimated that prevention of dental caries, largely attributed to fluoridation and fluoride-containing products, saved $39 billion (1990 dollars) in dental-care expenditures in the United States during 1979-1989 (23).

Safety of Water Fluoridation

Early investigations into the physiologic effects of fluoride in drinking water predated the first community field trials. Since 1950, opponents of water fluoridation have claimed it increased the risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, acquired immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions (24). The safety and effectiveness of water fluoridation have been re-evaluated frequently, and no credible evidence supports an association between fluoridation and any of these conditions (25) (my emphasis, PC)

21st Century Challenges

Despite the substantial decline in the prevalence and severity of dental caries in the United States during the 20th century, this largely preventable disease is still common. National data indicate that 67% of persons aged 12-17 years (26) and 94% of persons aged greater than or equal to 18 years (27) have experienced caries in their permanent teeth.

Among the most striking results of water fluoridation is the change in public attitudes and expectations regarding dental health. Tooth loss is no longer considered inevitable, and increasingly adults in the United States are retaining most of their teeth for a lifetime (12). For example, the percentage of persons aged 45-54 years who had lost all their permanent teeth decreased from 20.0% in 1960-1962 (28) to 9.1% in 1988-1994 (CDC, unpublished data, 1999). The oldest post-World War II "baby boomers" will reach age 60 years in the first decade of the 21st century, and more of that birth cohort will have a relatively intact dentition at that age than any generation in history. Thus, more teeth than ever will be at risk for caries among persons aged greater than or equal to 60 years. In the next century, water fluoridation will continue to help prevent caries among these older persons in the United States.

Most persons in the United States support community water fluoridation (29). Although the proportion of the U.S. population drinking fluoridated water increased fairly quickly from 1945 into the 1970s, the rate of increase has been much lower in recent years. This slowing in the expansion of fluoridation is attributable to several factors: 1) the public, some scientists, and policymakers may perceive that dental caries is no longer a public health problem or that fluoridation is no longer necessary or effective; 2) adoption of water fluoridation can require political processes that make institution of this public health measure difficult; 3) opponents of water fluoridation often make unsubstantiated claims about adverse health effects of fluoridation in attempts to influence public opinion (24); and 4) many of the U.S. public water systems that are not fluoridated tend to serve small populations, which increases the per capita cost of fluoridation. These barriers present serious challenges to expanding fluoridation in the United States in the 21st century. To overcome the challenges facing this preventive measure, public health professionals at the national, state, and local level will need to enhance their promotion of fluoridation and commit the necessary resources for equipment, personnel, and training.

Reported by Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

   1. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31-40.
   2. Burt BA. Influences for change in the dental health status of populations: an historical perspective. J Public Health Dent 1978;38:272-88.
   3. Britten RH, Perrott GSJ. Summary of physical findings on men drafted in world war. Pub Health Rep 1941;56:41-62.
   4. Klein H. Dental status and dental needs of young adult males, rejectable, or acceptable for military service, according to Selective Service dental requirements. Pub Health Rep 1941; 56:1369-87.
   5. Klein H, Palmer CE, Knutson JW. Studies on dental caries. I. Dental status and dental needs of elementary school children. Pub Health Rep 1938;53:751-65.
   6. McKay FS, Black GV. An investigation of mottled teeth: an endemic developmental imperfection of the enamel of the teeth, heretofore unknown in the literature of dentistry. Dental Cosmos 1916;58:477-84.
   7. McKay FS. Relation of mottled enamel to caries. J Am Dent A 1928;15:1429-37.
   8. Churchill HV. Occurrence of fluorides in some waters of the United States. J Ind Eng Chem 1931;23:996-8.
   9. Dean HT. The investigation of physiological effects by the epidemiological method. In: Moulton FR, ed. Fluorine and dental health. Washington, DC: American Association for the Advancement of Science 1942:23-31.
  10. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep 1938;53:1443-52.
  11. Dean HT. On the epidemiology of fluorine and dental caries. In: Gies WJ, ed. Fluorine in dental public health. New York, New York: New York Institute of Clinical Oral Pathology, 1945:19-30.
  12. Burt BA, Eklund SA. Dentistry, dental practice, and the community. 5th ed. Philadelphia, Pennsylvania: WB Saunders, 1999.
  13. Public Health Service. Public Health Service drinking water standards--revised 1962. Washington, DC: US Department of Health, Education, and Welfare, 1962. PHS publication no. 956.
  14. National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12-17 years--United States. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1974. Vital and health statistics, vol 11, no. 144. DHEW publication no. (HRA)75-1626.
  15. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water fluoridation. J Dent Res 1990;69:723-7.
 16. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279-89.
  17. Horowitz HS. The effectiveness of community water fluoridation in the United States. J Public Health Dent 1996;56:253-8.
  18. Riley JC, Lennon MA, Ellwood RP. The effect of water fluoridation and social inequalities on dental caries in 5-year-old children. Int J Epidemiol 1999;28:300-5.
  19. Shellis RP, Duckworth RM. Studies on the cariostatic mechanisms of fluoride. Int Dent J 1994;44(3 suppl 1):263-73.
  20. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993.
  21. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluoridation: 44 Florida communities. J Public Health Dent 1992;52:75-80.
  22. Burt BA, ed. Proceedings for the workshop: cost effectiveness of caries prevention in dental public health. J Public Health Dent 1989;49(5, special issue):251-344.
  23. Brown LJ, Beazoglou T, Heffley D. Estimated savings in U.S. dental expenditures, 1979-89. Public Health Rep 1994;109:195-203.
 24. Hodge HC. Evaluation of some objections to water fluoridation. In: Newbrun E, ed. Fluorides and dental caries. 3rd ed. Springfield, Illinois: Charles C. Thomas, 1986:221-55.
  25. National Research Council. Health effects of ingested fluoride. Washington, DC: National Academy Press, 1993.
 26. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res 1996;75:631-41.
  27. Winn DM, Brunelle JA, Selwitz RH, et al. Coronal and root caries in the dentition of adults in the United States, 1988-1991. J Dent Res 1996;75:642-51.
  28. National Center for Health Statistics. Decayed, missing, and filled teeth in adults--United States, 1960-1962. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1973. Vital and health statistics vol 11, no. 23. DHEW publication no. (HRA)74-1278.
  29. American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois: American Dental Association, 1998.
 

Figure 1

(PC: Please note we are not able to reproduce this figure here. It can be observed at
 http://www.FluorideAction.net/who-dmft.htm
where it is compared with the Figure that Chris Neurath derived from online WHO data, using the same indices for tooth decay (DMFT for 12-year olds), for several other industrialized countries, both non-fluoridated and fluoridated, over the same period used by the CDC.)

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