If you're approaching this article on water fluoridation with trepidation, Paul Connett knows how you feel.

"I didn't want this issue," said Connett, the co-author of the recently published book The Case Against Fluoride, in a phone interview last week.

"When my wife dumped a whole bunch of papers on my desk one afternoon in July 1996 and said, 'Dear, would you read these papers?'" he recalled, "I said, 'What is it? What's it about?' She says, 'Fluoridation.' I said, 'Take it away. These people are crazy.'"

Connett already had a full-time job as a professor of chemistry at St. Lawrence University in Canton, New York. And for a decade he had been a vocal opponent of waste incineration, a cause that sent him around the world presenting lectures.

"I didn't want a third issue," Connett said. "I certainly didn't want this one, which was stigmatized ... as the province of a bunch of Flat Earth Society crazy people. And I'd succumbed to that same notion without doing any research."

That night the Village of Canton was considering whether to continue fluoridation of the city's drinking water. Connett said: "When I started to read the papers that she put there, my intention was as quickly as possible to find out where these crazy anti-fluoridationists had made some fundamental scientific mistakes and [determine] that there was nothing to worry about. ... It didn't take me long to realize that there were some very serious problems with that practice" of fluoridation.

He said he told his wife: "This is going to be easy. When they hear what I read this afternoon, there's no way they're going to continue fluoridation."

Connett was wrong. The crusade to stop fluoridation of Canton's drinking water took more than seven years after that first night. That initial meeting was what Connett called his "first shock. All the dentists and several doctors were lined up to give their complete, utter, confident assurance that this was the best thing since sliced bread. It was perfectly safe."

After the meeting, Connett said, he approached one doctor who had spoken in favor of fluoridation and asked him to read three papers; the doctor said he didn't have time. Connett replied, "You shouldn't let these people believe that you've read the literature - and it's your professional judgment that this is perfectly okay - when that's obviously not the case."

Yet that doctor was hardly alone in speaking without having reviewed the science behind fluoridation. "That discussion on that night was a microcosm of what I was to see for the next 14 years - that local, state, and federal officials will go onto public platforms and make these absolutely, 100-percent-, 150-percent-confident statements that fluoridation is perfectly safe and perfectly effective," Connett said. "And it's almost to the point that they get some kind of commission every time they use the words 'safe' and 'effective.' It's like a mantra - 'safe and effective,' 'safe and effective.' And they haven't read the literature; they haven't read it. And if they were to do so, they'd be utterly shocked at the way they've been corralled into supporting this nonsense."

mp3 Audio interview with Paul Connett (58 minutes).

So Connett became one of those Flat Earth Society crazies. And while it's unreasonable to expect many people to have a similarly lightning-quick epiphany, he hopes that his book will get people to consider the issue of fluoridation - probably for the first time - beyond the endorsements of professional societies and public-health officials.

Basic Arguments in The Case Against Fluoride

'The Case Against Fluoride'Connett's book, which was published in October, is meant as a corrective to six decades of fluoridation promotion. While the provocative subtitle is How Hazardous Waste Ended Up in Our Drinking Water & the Bad Science & Powerful Politics That Keep It There, the book's primary concern is science.

The Case Against Fluoride has three basic arguments:

· Fluoridation is bad medicine because it's a drug given to all without a doctor consultation, without informed consent, and without control over the amount of fluoride ingested. This is primarily an ethical argument based on the assertion that fluoride is a drug, in sense of the Merriam-Webster definition of "a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease."

· There is little or no sound scientific evidence of fluoridation's effectiveness in preventing tooth decay. Further, current evidence suggests that fluoride primarily works topically (in toothpaste, for example) rather than systemically (administered through drinking water). Connett and his co-authors review studies supporting the benefits of fluoridation and find them flawed.

· Fluoride administered through the public water supply might cause significant health problems. Connett and his co-authors argue that water fluoridation could have adverse health effects on the teeth (in the form of dental fluorosis), brain function (including lower IQ), the endocrine system (including the thyroid and pineal glands), bones, and kidneys. This section is premised on the medical-ethics principle of "First, do no harm." The authors emphasize "the important difference between the possible health effects caused by fluoride and those caused by fluoridation. There is no doubt at all about the former; the debate rages over the latter."

Underlying the last two core arguments is Connett's assertion that "the whole history of the exercise [of fluoridation] and the whole promotion of the exercise has lacked scientific rigor from the word 'go'" in 1950, when the U.S. Public Health Service first endorsed fluoridation.

The simplest way to state the book's premise is that until better scientific studies can be done on the effects of fluoridation, the risks of health problems far outweigh the proven benefits, which The Case Against Fluoride says are negligible.

As the book's conclusion states: "When exposing a whole population to a toxic substance - especially when the dose cannot be controlled - both decision makers and risk calculators have to be cautious, not cavalier. The decision to fluoridate does not provide an adequate margin of safety to protect everyone in the population, especially the most vulnerable."

In our interview, Connett summarized: "I don't think the notion that swallowing fluoride decreases tooth decay has been demonstrated rigorously from a scientific point of view. There have never been any double-blind, randomized clinical trials - the kind of thing the FDA [Food & Drug Administration] would insist upon if it actually did its job and investigated fluoride as a drug. At the moment, it's classified as an unapproved drug by the FDA. Why on Earth they should tolerate an unapproved drug going to over 180 million Americans every day is beyond me. ...

"If this practice was being entertained today, there's no way on God's Earth that they could get away with it."

Of course, fluoridation is already firmly established. According to the Centers for Disease Control & Prevention (CDC), 72.4 percent of Americans - more than 195 million - were receiving fluoridated drinking water in 2008. In Iowa, the percentage was 91.8, even though fluoridation is not required by the state. In Illinois, where mandatory public-water-supply fluoridation became state law in 1967, 95.4 percent of residents received fluoridated drinking water. (Illinois is one of 12 states to require fluoridation.)

The cities of Rock Island, Moline, and East Moline fluoridate their water supplies, and Iowa American Water provides fluoridated water to the Iowa Quad Cities.

Fluoride is found naturally in many water supplies. According to Iowa American Water, fluoride occurs naturally at a concentration of 0.1 to 0.3 milligrams per liter in the Mississippi River. Water utilities add fluoride to the water to reach an "optimal" level of 1.0 milligrams per liter, with the typical target range between 0.7 and 1.2 milligrams per liter. The federal Environmental Protection Agency (EPA) has set fluoride's "maximum contaminant level" at 4.0 milligrams per liter.

Oddly, there's no local control over fluoridation in the Quad Cities. In Illinois, that's a function of state law. But in Iowa, the situation is bizarre: Municipalities claim they have no jurisdiction over fluoridation and apparently haven't asked for fluoridated water in decades, yet Iowa American Water representatives said the company lets communities decide whether they want fluoridation. (See the sidebar "The Strange Case of Fluoridation in the Iowa Quad Cities.")

Ringing Endorsements

The first hurdle Connett needs to overcome is the widespread and intuitive belief that fluoridation is good. The general public understands that fluoride helps reduce tooth decay, so adding fluoride to the water supply seems like a no-brainer.

That thinking is shaped by the dental and public-health establishments.

The American Dental Association (ADA), on its "Fluoride & Fluoridation" Web page, makes the following claims about fluoridation: "Community water fluoridation is the single most effective public-health measure to prevent tooth decay. ... Studies conducted throughout the past 65 years have consistently shown that fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. ... Today, studies prove water fluoridation continues to be effective in reducing tooth decay by 20 to 40 percent, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste."

In 1999, the Centers for Disease Control & Prevention's Morbidity & Mortality Weekly Report named water fluoridation one of the "10 great public-health achievements" of the 20th Century. "The effectiveness of community water fluoridation in preventing dental caries [cavities] prompted rapid adoption of this public-health measure in cities throughout the United States," the CDC wrote. "As a result, dental caries declined precipitously during the second half of the 20th Century. For example, the mean DMFT [decayed, missing, or filled permanent teeth] among persons aged 12 years in the United States declined 68 percent, from 4.0 in 1966-1970 to 1.3 in 1988-1994."

Add to those unequivocal pronouncements the glib dismissal of people opposed to fluoridation. A June article in Salon.com on GOP U.S. Senate nominee Sharron Angle was typical in using opposition to fluoridation as political shorthand for "crazy": "There is growing proof that she is a genuine nut, and not just a run-of-the-mill hardcore ideologue. ... [I]t's been revealed ... that Angle is a staunch opponent of the fluoridation of our water supply."

That broad brush, Connett argued in our interview, keeps people away from the fluoridation issue. "This I think also applies to many people in the environmental movement," he said. "Many of them are perceived as being a little close to the edge, and they won't touch fluoridation because they feel that that in the public's eye will push them over the edge as being less than intelligent, less than balanced, less than whatever."

Does Fluoridation Prevent Tooth Decay?

Yet if you read Connett's book or peruse the Web site of the Fluoride Action Network - of which Connett is director - he seems eminently reasonable.

Take the CDC claim that DMFT declined 68 percent over two decades. That information is presented visually in the CDC article, and it's stunning: As fluoridation rises from roughly 40 percent of the population to more than 50, tooth decay plummets.

In lauding fluoridation as one of the great public-health achievements of the 20th Century, the CDC's Morbidity & Mortality Weekly Report presented the misleading graph above.

Yet The Case Against Fluoride in Chapter 6 pairs that graph with one showing tooth decay among 12-year-olds for roughly the same period in eight countries - four with fluoridated water and four without. Every country has a roughly similar decline in tooth decay. Non-fluoridated Denmark dropped from more more than 6 DMFT near 1980 to roughly 1 in 2000.

In other words, the CDC has taken a correlation and turned it (without evidence) into causation. Tooth decay has been dropping steadily and quickly in industrialized countries around the world, whether they fluoridate their water or not.

What Connett doesn't (and can't) do is fully explain why there's been such a dramatic decline in tooth decay. The widespread use of fluoride toothpaste is typically cited as one major factor, and Connett also suggested that increased income levels, better diets, decreased pollution, and antibiotics in processed food might play roles. "I don't think it's clear-cut," he said. "I think there are many possible factors."

But Connett and The Case Against Fluoride argue persuasively that studies showing the benefits of fluoridated water have grossly overstated its impact on tooth decay. The authors concede based on studies since 1980 that there might be an "extremely small" protective effect of fluoridation, "amounting on average to only a fraction of a tooth surface for the permanent teeth and not much more for the baby teeth."

Connett added in our interview: "Let's say for the sake of argument that there is a small benefit from ingesting fluoride. It doesn't rise above the background noise. Certain factors do rise about the background noise ... ." In particular, the authors claim, there is a stronger relationship between higher incomes and better oral health than between fluoridation and better oral health: "According to the results of a questionnaire administered to parents in all 50 states by the Department of Health & Human Services, there is absolutely no correlation between the percentage of parents who responded that their children had very good or excellent teeth and the percentage of the population in the state drinking fluoridated water. However, there is a very strong relation in all 50 states between the percentage of parents giving that answer and their income levels."

Connett noted that even in the literature endorsing fluoridation, there has been backtracking on the benefits of the practice. For example, the very same CDC article that lauds fluoridation as one of the 20th Century's great public-health achievements (and presents that grossly misleading chart) includes this statement: "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." That was a major argument for using water as a fluoride-delivery mechanism; it was thought there was a dental-health benefit to ingesting the fluoride. The article continues: "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."

Connett has seized on that statement and the research behind it to argue that if fluoride's benefits are "primarily" topical, there's no need to deliver it through the water.

This phenomenon - of praising fluoridation while also undermining claims about is effectiveness - is relatively common, Connett said. Studies often espouse the party pro-fluoridation line even when it's poorly supported by the presented evidence - likely a result of researchers being afraid of having their funding cut off, he said.

Does Fluoridation Cause Health Problems?

The claim that fluoridation isn't effective at its stated goal is just one component of The Case Against Fluoride.

The other scientific issue is whether fluoridation might cause health problems. This is a serious concern for two reasons. First, because in communities where the drinking water is fluoridated, it's nearly impossible to avoid at home, at work, and in restaurants. Second, while the concentration of fluoride is controlled in fluoridated water, the amount one ingests will vary widely depending on one's water intake. In other words, the dose is uncontrolled.

The Case Against Fluoride looks at many health studies related to fluoride, but a key piece of research is the 2006 National Research Council report Fluoride in Drinking Water: A Scientific Review of EPA's Standards. The report's summary states: "After reviewing research on various health effects from exposure to fluoride, including studies conducted in the last 10 years, this report concludes that EPA's drinking-water standard for fluoride does not protect against adverse health effects." The study concluded that the drinking-water standard of 4.0 milligrams per liter should be lowered but did not recommend to what level. The EPA has not changed its standard for fluoride.

The report had consensus that fluoridation at the maximum allowed concentration of 4.0 milligrams per liter can cause several health issues: dental fluorosis, skeletal fluorosis, and increased risk of bone fractures. Further, it said more research is needed in other areas, including neurobehavioral effects, reproductive and development effects, and endocrine effects.

It's critical to understand the difference between the charge of the National Research Council report - which only looked at the maximum contaminant level of 4.0 milligrams per liter - and typical fluoridation at 1.0 milligrams per liter. The negative health effects cited by the National Research Council might not emerge or be as serious in that normal water-fluoridation concentration. The Case Against Fluoride counters that fluoridation "is indiscriminate and offers no control over the dose received by an individual. It makes inadequate allowance for differing sensitivity to toxic effects, or for the size and body mass of recipients ... ."

Connett views the National Research Council report as a landmark review, the first thorough and balanced analysis in the United States of the literature on fluoridation health effects. "What the National Research Council report did was to say that the safe-drinking-water standard isn't safe, that the EPA should do a new health-risk assessment," he said.

Cracks in the Dam

The Case Against Fluoride was born of what Connett called "14 years of frustration" that began with that village meeting in Canton.

"It's very difficult to win this argument with sound bites, because the other side is covered with white coats and authority," he explained. "And so for years, they've kept dentists, doctors, scientists, and the media away from the details of the issue, away from the literature. And in place of science, they're able to substitute endorsements [and] 'authority,' and also able to denigrate opponents as junk scientists, etc. ...

"I wanted to write a book that put everything I knew between two covers ... . Anybody that is prepared to read it will see how foolish this practice is and why it needs to be stopped."

The book is undoubtedly a political document, in the sense that Connett and co-authors James Beck and H.S. Micklem take pains to be accessible to the general reader and aggressive in their argument while also being thorough. In Connett's view, the book needs to overcome six decades of endorsements - no small task.

His co-authors initially just reviewed his text, but Connett eventually asked them to sign on as co-authors and take a more active role. While he said the book is stronger as a result of their contributions, there was a second motive: "If it's just my name on it, they'll find a way of putting me into a box and then throwing the box away. ... I'm just the one crazy person out there who is opposed to fluoridation. 'Get rid of Connett and you get rid of the argument.' I said, 'They're going to ... find it very difficult if there's three of us. One from Canada, one from Scotland, and one from the United States; one a biologist, one a chemist, and one a physicist.'"

Yet Connett understands that his book isn't enough. The Case Against Fluoride encourages skepticism of the "official" perspectives on fluoridation, and it's only fair to apply the same level of scrutiny to his arguments and his interpretation of the science and the facts.

In that way, one measure of success for The Case Against Fluoride is whether it engages the public- and dental-health communities in a genuine debate about fluoridation. The book requires a response so readers can see for themselves whether Connett and his co-authors are guilty of the same sins they pin on fluoridation advocates.

"We make it clear that we've read the literature, we think it's a bad idea, and we're explaining why we think it's a bad idea," Connett said. "I think they've had almost a free ride up to now of getting their arguments across to the public and to the media. ... What I think should happen now is that in a year's time, we should see a book which is the case for fluoride, where they do their damnedest now to ... either agree with or disagree with every argument in our book, and to document it as thoroughly as we have. And in that wash, then, you will see if we've been highly selective in the literature that we've chosen.

"Remember: Our task is to show that there are flaws in this practice. ... I've sometimes used the analogy that fluoridation is like building a dam above a village. If a villager says, 'I think I see a crack in your dam,' it's not enough to say, 'Oh, you're just a peasant' or 'You're just a schoolteacher' or 'You're just a farmer; you're not an expert on dams, and therefore we can ignore what you say.' No. They have to respond to every flaw that we've seen in their dam structure. They are the ones that are supposed to be completely on top of this practice. This is something that they're forcing on us. ... It's they - the ADA and the CDC in particular - who are ... forcing this on people. ... They should be able to answer easily - easily - every argument that we've thrown at them. And we've thrown at them as many arguments as we could, and now we await their reply."

But Connett admitted that it's difficult to reach beyond those already against fluoridation: "When I give talks to communities, by and large the people who are pro-fluoridation don't show up."

And that, he said, is a function of the authoritative endorsements: "All these medical associations, all these dental associations, all these government agencies have said that fluoridation is good. Who are we to disagree? 'Do you really think all these organizations don't know what they're talking about, that they would deliberately harm us?'"

Connett doesn't subscribe to fluoridation conspiracy theories, that the practice was a nefarious effort to hurt the public.

But his book does sketch out a narrative (based heavily on Christopher Bryson's 2004 book The Fluoride Deception) that explains how fluoridation came about and why it continues: business interests (including the aluminum and phosphate-fertilizer industries that produce large volumes of fluoride waste that's used for fluoridation, and the sugar industry that wanted a way to reduce tooth decay without reducing sugar in the diet) combined with well-intentioned but poorly designed studies.

But if The Case Against Fluoride plays fair and is accurate, it remains baffling why the ADA and CDC continue to promote fluoridation. Skeptics of the book might find this issue hard to overcome.

The authors' best explanation concerns liability: "If it is admitted that fluoridation causes any harm, there are lawyers waiting in the wings to sue somebody. Many players might be subject to legal action, such as the fluoridated dental product manufacturers, dental organizations that have endorsed those products, the water utilities that add the fluoride to water, the local councils who are practicing medicine without a license, or the government health agencies that assure everyone that is safe to ingest fluoride."

Sidebar: The Strange Case of Fluoridation in the Iowa Quad Cities

(Return to the main story.)

If you oppose fluoridation or think that its safety and effectiveness need to be proved beyond a doubt, good luck in stopping the practice in the Quad Cities.

Illinois in 1967 mandated fluoridation of drinking water, meaning that any change would need to happen at the state rather than the local level.

The situation is more complicated in the Iowa Quad Cities. The state of Iowa does not mandate fluoridated drinking water, but local governments served by Iowa American Water would need to act unanimously to stop it.

Dennis J. Alt, a supervisor with the Water Supply Engineering Section of the Iowa Department of Natural Resources, wrote in response to an e-mail question: "In Iowa, a public water system, whether it is publicly or privately owned, can choose to add chemicals in order to treat the water. They do not need to receive approval from a unit of government or the people they serve. ... We do not require public water systems to add fluoride, nor do we prohibit it." (Utilities still need to comply with state and federal drinking-water standards.)

So with a water utility owned by a city government, there would be local control. But when the utility is privately owned - as it is in the Iowa Quad Cities - there isn't.

This situation was confirmed by the City of Davenport. In a 2007 memo responding to questions raised by Joel Webber, Acting Corporation Counsel Thomas D. Warner wrote: "The City does not have jurisdiction over drinking-water quality and cannot stop fluoridation of the water by the Iowa American Water Company. ... The [federal] Safe Drinking Water Act, the Iowa Code, and the Iowa Administrative Code occupy the field in this area and do not allow the City to assume any jurisdiction over the content of the public drinking water in Davenport."

Technically speaking, this is true.

However, Iowa American Water claims that it would comply with a request from local government to stop fluoridation. There's a big catch, though: Such a request would need to come from all the Iowa Quad Cities that Iowa American Water serves.

Lisa M. Reisen, Iowa American Water's manager of external affairs, provided this statement: "Ceasing fluoridation would require coordination of the cities, the Iowa Utilities Board, the Iowa Department of Natural Resources, and likely the health department. If we were directed by legislation (local or state), we would comply. Any agreement would have to be unanimous among all the communities served, because we can't tailor the treatment to individual communities."

That means there is effectively regional control over fluoridation in the Iowa Quad Cities, but not municipal control.

The issue of why Iowa American Water fluoridates the water in the Iowa Quad Cities lacks a complete answer. Iowa American Water officials cited a 1952 resolution involving the City of Davenport that started fluoridation here but could not say whether other municipalities signed on; Reisen said she could not locate a copy of the resolution. However, it is likely that Riverdale and Bettendorf were also parties; all three cities began having their water fluoridated on July 27, 1952, according to the Iowa Department of Public Health.

Reisen wrote that the company has no record of a community request for fluoridation beyond that resolution from 58 years ago.

And when asked whether the company regularly surveys the communities it serves about its fluoridation preferences, Reisen wrote: "Iowa American Water distributes an annual water-quality report to all customers and municipalities that clearly shows that we do fluoridate the water." She added that "fluoridation has not been an issue of concern with our customers or the cities we serve."

- Jeff Ignatius

(Return to the main story.)

Sidebar: Local Fluoridation

According to the Iowa Department of Public Health, the water supplied to Davenport, Bettendorf, and Riverdale by Iowa American Water and its forebear has been fluoridated since 1952.

Iowa American Water has provided fluoridated water to LeClaire since 2003. According to Iowa American Water External Affairs Manager Lisa M. Reisen, the company presently serves 142,000 people in the Iowa Quad Cities.

Moline began fluoridating its water supply in 1955, according to Gregory A. Swanson, the city's utilities general manager. Representatives of neither East Moline nor Rock Island could verify fluoridation prior to a 1967 state law requiring fluoridation.

Iowa American Water and the three major Illinois Quad Cities municipalities presently fluoridate their water with hexafluorosilicic acid purchased from Lucier Chemical Industries.

The product comes from the phosphate-fertilizer industry, and The Case Against Fluoride says the chemical is the "fluoridating agent in over 90 percent of the water supplies fluoridated in the United States." The book makes an issue of the fact that these chemicals are "not pharmaceutical grade, meaning that they are not of the same purity used in dental products." It claims that the chemical might cause health problems beyond those caused by fluoride itself.

- Jeff Ignatius

(Return to the main story.)

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