As more and more communities grapple with the issue of fluoridation - both those who are opposing efforts to put fluoride in their water and those trying to get it out (e.g. Burlington, Vermont) - there are five key and related issues which the public and decision makers need to consider.

1) Dentists have controlled this debate for far too long.

While I believe dentists have a valid role to play in discussing the benefits of fluoride for teeth (although few have studied the literature on this very closely), in my view, they should not be treated as 'experts' when it comes to the safety of fluoridation. Very few dentists get much of a training in biochemistry, toxicology, or general medicine. Teeth are important but they are not the only tissue in the body. It is absurd that concerns about the saving of a very little (if any) amount of tooth decay should overrule concerns about fluoride's potential impacts on the central nervous system, the pineal gland, the thyroid gland, the kidney, the reproductive system, and the bone.

2) Endorsements of this practice are meaningless unless they have come from agencies or individuals who have thoroughly studied the literature, are up-to-date and are free from a conflict of interest.

The most glaring failure in this respect is the CDC who in a 1999 review, while proclaiming that fluoridation was one of the top 10 public health achievements of the twentieth century, were 6 years out of date in the literature they cited to support their claim that there were no valid health concerns.

Communities must be especially careful not to be swayed by lists of dentists and doctors signing letters and advertisements proclaiming the "safety and effectiveness" of fluoridation. It is quite likely that not one single person on the list has read the latest literature and they are basing their endorsement on the position of their local or national professional bodies. Local dental associations are renowned for pressuring their members to toe the line on these matters.

3) Most health agencies have a conflict of interest on this issue.

If one examines the make up of the US Public Health Service, from the US Surgeon General down to the State Departments of Health and even local County Boards of Health, the policy is to promote fluoridation. That is the mandate which has been in place since the US Public Health Service endorsed fluoridation in 1950 (before one single trial or medical study had been completed). Not to do so is to risk individual employment and departmental funding.

The most obvious place where this mandate is in operation is with the State Health Departments' "Directors of Oral Health" and the Oral Health Division of the CDC. Their job is to promote fluoridation period.

So the key question is this. Does the CDC, or do the State Departments of Health, have any personnel in place to give a judgment on the health concerns being raised about exposure to fluoride, who are free of conflict of interest? It is naive to believe that a division director (e.g. Dr. William Maas, Director of the Oral Health Division at the CDC) following a mandate to promote fluoridation can be expected to give an impartial judgment on each health issue as it arises. But many decision makers treat their pronouncements ("fluoridation is safe and effective") as if they had emerged from some kind of unbiased enquiry independent of the promotion program.

I would be interested to know if anyone out there has any knowledge of any state or county health agency which has bifurcated this problem. In other words, have they assigned any personnel - other than the Oral Health division personnel - to independently review the health issues being raised? Or even initiated their own research and health monitoring programs on fluoride exposure?

4) Lack of follow-up on "red flag" studies.

Nowhere is the bias in this matter made more clear than the way studies which wave red flags on fluoride's dangers are treated. I am particularly thinking here about the 30 plus animal studies which indicate that fluoride damages the brain and the studies that fluoride lowers IQ in China. I am also thinking of Freni's 1994 study which indicated lowered fertility in US counties with 3 ppm fluoride in the water; Luke's study which showed that fluoride accumulates in the pineal gland (2001) and lowers melatonin levels in animals (1997) and the numerous studies which indicate that fluoride may interfere with thyroid function. Typically in my experience, agencies which are supposed to be protecting our health either ignore these studies or find someway to dismiss them on methodological grounds. What they seldom do is to try to repeat them. For example, I am aware of no country practicing fluoridation which has bothered to repeat Luke's studies on the pineal gland. This would not be difficult or expensive to do. In my view, this is a clear indication that these agencies are more interested in protecting a policy than protecting the people's health.

Let me give two more very clear and specific examples. When we cited the study by Bachinskii et al. (1985) that fluoride at relatively low levels (e.g. 2.3 ppm in water) lowers thyroid function to the US EPA Pesticide division as evidence that they were wrong to rely on the MCL of 4 ppm as the basis for their health risk assessment for the fluoride residues left on food treated with sulfuryl fluoride, their response was to say that the study was in Russian! This pathetic response clearly indicates an agency trying to wriggle around dangers rather than addressing them scientifically. More to the point: Can any one cite a study conducted in the US since 1985 which has investigated fluoride's impact on the thyroid gland? This same EPA pesticide division dismissed the studies of Xiang (2003a, b) on lowering of IQ in China, by pointing out that one of the confounding factors that Xiang had not considered was the possible impacts of incestuous relationships on IQ! Again how many studies have been conducted in the US to investigate the potential of fluoride to lower IQ. I know of only one small study by Morgan et al. Is one small study enough to resolve this very serious issue?

5) Are our health agencies -and policy makers - exercising due diligence in this matter?

Add all these questions together and we can roll it into one fundamental question: are our health agencies and professional organizations - from the federal to the local - exercising due diligence on this issue? The answer is a resounding NO. We desperately need our representatives in Washington to pursue these matters. They do not need to be either pro or anti-fluoridation to demand that we have at least the semblance of an independent watchdog in the agencies which promote this practice to carefully review health studies as they are published on its dangers and suggest follow-up studies of their own.