April 22, 2019

Dr. Hardy Limeback BSc PhD (Biochemistry) DDS — Dental Fluorosis: Permanent tooth scarring caused by fluoridation

Dental Fluorosis: Permanent tooth scarring caused by fluoridation

What is dental fluorosis?

Dental Fluorosis caused by water fluoridation is irreversible, disfiguring, psychologically damaging and costly to repair. In essence, it is medical assault on children.

When children are exposed to increased fluoride intake from birth to age 6 years, fluoride interferes with normal tooth development and their teeth develop dental defects on the enamel surfaces that vary from

  1. barely visible white lines or spots (very mild) to
  2. coalescing chalky white opaque areas (mild) to
  3. chalky enamel on all teeth that start to ‘pit’ and stain brown (moderate) to
  4. mottling of all teeth, with enamel pitting and staining (severe)

Researchers have often categorized the various severities of dental fluorosis with indices, two of which are shown in this composite diagram.

How big a problem is dental fluorosis?

I was astounded by the high prevalence of fluorosis in my local area, but there is nothing special about my area. It was fluoridated for years. Dental fluorosis is rampant in fluoridated communities like mine.

When epidemiologists in the UK did a systematic review of all the relevant studies on dental fluorosis (the well known York Review), many of them conducted in the US, it was concluded that every eighth child had objectionable dental fluorosis as a result of fluoridation. (McDonagh MS, Whiting PF, Wilson PM, et al. Systematic review of water fluoridation. BMJ. 2000 Oct 7;321(7265):855-9.)

In a recent US large scale study about 10% of children have fluorosis that needs to be treated (Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004.  NCHS Data Brief. 2010 Nov;(53):1-8.). The Center for Disease Control in the US reports that dental fluorosis has been increasing throughout the years. Fluorosis is always worse in fluoridated communities.

There have been several studies conducted in Canada to estimate fluorosis prevalence.

Twenty years ago dental fluorosis was found in nearly 70% of the children in fluoridated communities (Ismail AI, Shoveller J, Langille D, MacInnis WA, McNally M. Should the drinking water of Truro, Nova Scotia, be fluoridated? Water fluoridation in the 1990s. Community Dent Oral Epidemiol. 1993 Jun;21(3):118-25).

The prevalence of fluorosis was about 60% in Courtenay and Comox in BC but this declined significantly when fluoridation was halted (Clark DC, Shulman JD, Maupomé G, Levy SM. Changes in Dental Fluorosis Following the Cessation of Water Fluoridation. Community Dent Oral Epidemiol. 2006 Jun;34(3):197-204)

In 1999, Dr. David Locker, now deceased, conducted a review of fluoridation for the Ontario Ministry of Health and the First Nations and Inuit Health Branch. He reported, “current studies support the view that dental fluorosis has increased in both fluoridated and non-fluoridated communities. North American studies suggest rates of 20 to 75% in the former and 12 to 45% in the latter.”

It was after the Locker Report that Ontario decided to recommend a range of fluoride in drinking water from 0.5 ppm to 0.8 ppm.

The dental public health department in Toronto in a follow-up survey looked at whether fluorosis was still a problem in Toronto. It was. The authors reported

“Dental fluorosis of moderate severity (Tooth Surface Index of Fluorosis 2) was found among 14.0% of 7-year-olds, 12.3% of 13-year-olds and 13.2% of the 2 age groups combined.” (Leake J, Goettler F, Stahl-Quinlan B, Stewart H. Has the level of dental fluorosis among Toronto children changed? J Can Dent Assoc. 2002 Jan;68(1):21-5).

The authors even admitted “Nonetheless, the prevalence and severity of dental fluorosis among those we could identify as having been born in Toronto support the August 1999 decision to reduce Toronto’s water fluoride concentration to 0.8 ppm from the former 1.2 ppm.”

How did Toronto end up having 1.2 ppm fluoride in its drinking water in the first place?

It turns out that picking that level was based on a silly calculation that suggested children living in cities in hot climates (Texas, Nevada, Arizona) would consume a lot more water than those in moderate climates (the ‘optimum fluoride level was arbitrarily set at a nice round figure of 1.0 ppm) and those children living in colder cities (e.g. Toronto) would consume less water.

But wait a minute.

It is well known that fluoride, if it has any benefit, provides its benefit through topical means, by exposing the teeth AFTER they erupt into the mouth, not systemically, through ingestion. (CDC 1999. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Mortality and Morbidity Weekly Review (MMWR), 48(41);933-940 October 22, 1999.)

Someone messed up… and now they are reducing the fluoride in the drinking water without a peep to the public.

Dr. Dick Ito, in 2007, confirmed the observations I made in my own patients and found that in our region every tenth child had dental fluorosis that needed treatment (Ito D. A Cross-sectional Study to Compare Caries and Fluorosis in 7-year-old Schoolchildren from a Fluoridated Area with Those in a Neighbouring Non-fluoridated Area in Ontario. 2007, MSc Thesis, University of Toronto).

An attempt was made recently by the Chief Dental Officer of Canada to conduct a survey of fluorosis in Canada but this survey was not scientifically conducted. Non-fluoridated communities were selected at a ratio of two to one over fluoridated communities, it was not blinded or randomized, and there was no attempt to adjust for life-long fluoride exposure. The survey remains unpublished in an internationally-recognized journal and has not been peer-reviewed. Even so the Chief Dental Officer of Canada concluded that “the prevalence (of moderate to severe fluorosis) is too low to permit reporting”. http://cof-cof.ca/wp-content/uploads/2012/09/Oral-Health-Statistics-2007-2009-Canadian-Health-Measures-Survey-CHMS-Health-Canada.pdf

In my opinion, the Canadian Health Measures Survey did little to add to our knowledge of dental fluorosis and its national prevalence pattern.

The psychosocial effects of dental fluorosis.

Having treated dozens of children for dental fluorosis I can say from my own experience as a practicing dentist that these children are psychologically and socially affected by their dental ‘scarring’.  Similar to how children are psycologically and socially impacted by acne scarring from years of acne. Both such children are often ridiculed or ostricized simply because of the way they look.

How would society react to a medication added to the drinking water that was supposed to prevent skin infections but left 4% to 10% of the population with irreversible acne scars? Public health might say, we’re lowering more severe skin infections by 10%. Most teens get acne. Acne is just a cosmetic side effect of the medication that we are putting in your drinking water– the scars can be covered up by make-up.

Society looks down on children who have ‘scarred’ teeth. The study by Bennett concluded, “…participants were significantly more likely to make negative judgments involving health, aesthetic, and person attributions about faces with high levels of fluorosis, and to make negative judgments more quickly and positive judgments more slowly than those with lower levels of fluorosis.” (Bennett P, Williams D, Chestnutt I, Hood K, Lowe R. A reaction-time study of social, health, and personal attributions in relation to fluorosed teeth. Psychol Health Med. 2008 Jan;13(1):75-86.)

The cost of treating dental fluorosis.

It costs a LOT of money to treat dental fluorosis.

If you have to cap the teeth with porcelain crowns or cover the front of the teeth with porcelain veneers it can cost tens of thousands of dollars!
See http://cof-cof.ca/wp-content/uploads/2012/09/Osmunson-Water-Fluoridation-Intervention-Dentistry%E2%80%99s-Crown-Jewel-Or-Dark-Hour-Guest-Editorial-Fluoride-404214%E2%80%93221-Oct-Dec-2007.pdf for a discussion and some images.

I showed that some minor dental fluorosis can be treated with microabrasion and bleaching (Limeback H, Vieira AP, Lawrence H. Improving esthetically objectionable human  enamel fluorosis with a simple microabrasion technique. Eur J Oral Sci. 2006 May;114 Suppl 1:123-6; discussion 127-9, 380.)

However, because repairing dental fluorosis is considered ‘cosmetic’ dental insurance companies do not pay for these repairs.

In my estimate, repairing all those teeth with objectionable fluorosis costs families (on average) more money than it costs to treat the dental decay that fluoridation supposedly prevents.

Ingested fluoride makes teeth brittle and fracture more easily.

The next time you have to go to the dentist for a fractured tooth, ask yourself… Have I been drinking fluoridated water my whole life? Am I a post-fluoride baby?

If the answer is yes to either question, then your teeth are undoubtedly a little more brittle than your pre-fluoride parents. Fluoride accumulates in dentin, the mineralized tissue that supports the outer layer, the enamel. If dentin becomes brittle, entire portions of the tooth are at risk for breaking off, especially if you clench or grind your teeth.

Fluoride is toxic to the cells that make teeth. It alters the expression of genes. It interferes with cellular enzymes. Fluoride that is ingested changes teeth as they develop. If children from birth to age 6 years avoid ingestion of fluoride they do not get dental ‘scarring’.

Challenge to the reader: Look at kids’ teeth when they smile. See if you can identify dental fluorosis. Learn more about the condition. Tell the municipal councillor in your ward that you do not want your kids scarred for life by fluoride medication added to your drinking water by your municipality.

Take home message of blog: Dental fluorosis caused by water fluoridation is scarring our kids’ teeth for life. The practice is morally and ethically indefensible and it has to end.

Future blog topics:

1.Why infants are most at risk for dental fluorosis and developmental problems related to fluoridation.

2. Fluoridation increases lead uptake in children: the consequences.

3. Fluoridation has no effect on baby bottle tooth decay.