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Scientific knowledge in controversy:

the social dynamics of the fluoridation debate

Brian Martin

with a commentary by Edward Groth III

Published in 1991 by State University of New York Press, Albany

The version here differs from the published versionin a number of details of expression, a different format, different page numbering (151 instead of 274 pages) and omission of the index.

Contents

1. Introduction

2. Arguments

3. Coherent viewpoints

4. The struggle over credibility

5. Professional attack

6. A corporate connection?

7. Making a decision

8. Studying the controversy

106

The fluoridation controversy: which side is science on?

by Edward Groth III

122

Appendix: Fluoridation around the world

137

Acknowledgments

Albert Burgstahler, Edith Waldbott, and many others (too numerous to mention)plied me with valuable information through correspondence. Gay Antonopoulosobtained copies of many publications for me through interlibrary loans. I thank theindividuals listed in chapter 3 for their generosity in being interviewed. Discussions with Mark Diesendorf and Evelleen Richards provided me with insights. I received alarge number of valuable corrections and comments on the earlier drafts from AlbertBurgstahler, Brian Burt, John Colquhoun, Mark Diesendorf, Edward Groth III,Michael A. Lennon, Pam Scott, John Small, Donald Taves, and several anonymousreviewers. I especially thank Edward Groth III for his mammoth correspondence andfor writing the commentary.

1Introduction

The 1 August 1988 issue of

Chemical

Engineering News

contained an article thatcaused a sensation in the long-runningcontroversy over fluoridation. “Fluoridation of Water,” a special report written by associateeditor Bette Hileman,

surveyed the arguments both for and against the measure.Fluoridation is the addition of the elementfluorine — called “fluoride” when in anionized form — to public water supplies as ameasure to help prevent tooth decay inchildren. Hileman’s article outlined thestandard view that fluoridation greatly reducestooth decay, but also presented criticisms of this view. It described evidence both for andagainst claims that fluoridation may beinvolved in health problems, such as kidneydisease, hypersensitive reactions, and cancer.It also recounted some of the methods used inthe ardent promotion of fluoridation.Hileman had not been involved in thefluoridation debate that has raged for decades.In writing the article, she studied the issue andconsulted both supporters and opponents of fluoridation.The ideas in her article were not new, andmost of the evidence had been canvassedrepeatedly in other forums. Why, then, did itcause such an impact? The reason is that never before had such a major scientific publication presented both sides to the debate in such anextensive treatment. In particular, never beforein recent decades had a major professionalassociation, such as the American ChemicalSociety, publisher of

Chemical & Engineering News,

given the scientific criticisms of fluoridation such credibility.

In the English-speaking countries at least,fluoridation has long been virtually untouch-able for “serious scientists.” Opponents of fluoridation have been categorized as cranks,usually right-wing, and akin to those whothink the earth is flat.

In most dental, medical,and scientific journals, the arguments againstfluoridation are given little space and littlecredence.The

Chemical & Engineering News

articlerepresented a dramatic contrast to the usualdismissal of antifluoridation views. The articlegenerated news stories around the country andoverseas, and led to a large volume of correspondence in later issues. Not surpris-ingly, opponents of fluoridation weredelighted with the article; supporters weredismayed. More significantly, many corre-spondents congratulated Bette Hileman and

Chemical & Engineering News

for raising both sides of the issue for public discussion.

BRIEF HISTORY

The use of fluoride to prevent tooth decay was promoted by various individuals in Europe inthe 1800s.

But the key events on the road tofluoridation occurred later and in the UnitedStates.Frederick McKay, a dentist, first noticedstaining of teeth in his Colorado patients in1901. The colors ranged from white, yellow,and brown to black. In serious cases, there wasalso pitting of the enamel. Unlike most otherswho had noticed this mottling, McKay wasintrigued by it and, over the next threedecades, he pursued its origins. He noticedthat, whereas people who had lived in a particular community from birth had stainedteeth, newcomers to the district did not.Further investigation convinced McKay thatwater supplies were responsible.It was not until 1931 that chemical analysis provided an answer to what was causing thediscoloration: fluoride. H. V. Churchill, chief chemist at the Aluminum Company of America, supervised tests on water samplesand, with McKay’s help, established aconnection between fluoride in drinking water and mottled teeth. At about the same time,researchers M. C. Smith, E. M. Lantz, and H.

Scientific knowledge in controversy

V. Smith in Arizona were able to producemottling in the teeth of rats by feeding themfluoride. Also in the same year, H. Velureported the fluoride-mottling link based onwork in Morocco and Tunisia.McKay had long observed that mottledteeth, although unsightly, seemed to be moreresistant to decay. Discovery of the fluorideconnection finally stimulated the United StatesPublic Health Service (USPHS) to investigatethe issue. Led by H. Trendley Dean, USPHSscientists (mainly dentists) carried out surveysof decay in towns with different fluoride levelsand also carried out experiments with animals.A range of levels of fluoride led to thesevere mottling observed by McKay andothers. Severe mottling was widespread at five parts per million (ppm) and above, but lesscommon at lower concentration.

Investigatorslooked to see whether there was a concentra-tion that avoided most mottling while providing the benefits of reduced tooth decay.The level judged to be optimal in this regardwas 1.0 ppm.Only a small fraction of water supplies havehigh levels of fluoride naturally. Most haveless than 0.2 ppm, a concentration too small to provide much impact on decay. In 1939, it wasfirst proposed to add fluoride to waters thatnaturally have low fluoride levels. Fluoridewould be added to bring the concentration toabout 1.0 ppm.The proposal struck a chord with a smallnumber of dentists and public health officialsin the United States who began campaigningvigorously for fluoridation. Many others weremore cautious, including national healthadministrators and USPHS scientists who werestill studying the dental effects of fluoride. In1945, the first of a number of trials was begun.In these studies, two cities with similar characteristics were selected. Both had lownatural levels of fluoride in the water. One cityhad fluoride added to its water supply, whilethe other’s water remained unfluoridated.Rates of tooth decay in the cities weremonitored by periodic examination of children’s teeth.The first study involved Grand Rapids,Michigan, where water was fluoridated in1945. The water supply in control city,Muskegon, also in Michigan, remainedunfluoridated. In the same year and in NewYork State, Newburgh’s water was fluori-dated, while Kingston served as the control.Other important early studies involvedfluoridation of the water supplies in Evanston,Illinois, and Brantford, Ontario. Oak Park,Illinois, and Sarnia, Ontario, served as therespective controls.At the time, it was thought that fluorideacted by being incorporated into the growingenamel of children’s teeth. Hence, it wouldtake quite a few years to see the full effect of fluoridation. The trials were planned to last tenor fifteen years. But after only a few years, thereported reductions in tooth decay were quitestriking.The proponents of fluoridation — in particular, a few enthusiastic advocates such asWisconsin dentist John G. Frisch andWisconsin dental administrator Francis Bull — were impatient with delay. Their lobbyingwas aimed especially at administrators in theUSPHS, the most influential body in the public health field. H. Trendley Dean, whosework helped lay the ground for fluoridation,was not a supporter of rapid implementation, preferring to wait for the full results of thefluoridation trials. Along with others, his viewwas influential in maintaining the USPHS’scautious stand throughout the 1940s.The high-pressure tactics of Frisch, Bull,and others eventually won out. The topadministrators of the USPHS apparentlyoverruled Dean,

and, in 1950, the USPHSendorsed fluoridation. Shortly afterward, twokey professional bodies — the AmericanDental Association (ADA) and the AmericanMedical Association (AMA) — also expressedsupport.In the United States, however, decisionsconcerning public water supplies are made atthe level of states, cities, or towns. TheUSPHS endorsement did not force anycommunity to fluoridate, but it did providevital authoritative backing for local individualsand groups that pushed for it.The endorsements by the USPHS, ADA,and AMA were based on the claim that