Exchange between Billy Budd and Louise Mantella
November 25 , 2013

From the debate blog by Ken Perrott
(Thanks to Louise Mantella for sending the PDFs)

COMMENT 47653 Billy Budd  November 25, 2013 at 8:41 am  |

Both of our debaters mistakenly take the CDC’s statement from 2001 as definitive.

Newer statements from the CDC, including a video of ADM Bailey, head of the CDC’s oral health division, clearly state that the systemic effect of fluoridation is important. The CDC’s 2001 report was written before Singh (2004) published results of the exquisite study in Australia that quantified the PRE-eruption or systemic effect. Another proof of the systemic effect is Kumar’s 2009 paper showing fluorosis in 1st molars protects them from caries Professor Connett certainly is on record that fluorosis is a systemic effect.

Also, the studies which show an adult effect in groups with childhood fluoride exposure are reasonable evidence - eg, Kobayashi (1992), and Neidell (2010). Other references could be listed.

From conversations with individuals in the Oral Health Division I’ve learned that the document has not been formally withdrawn because the issue of the systemic/topical debate is a very small part of the official consensus statement from the CDC’s Fluoride Recommendations Work Group. Significant trouble and expense went into producing this document and from the larger concern of proper public health one point is a tempest in a teapot.

It is important to read what CDC said in the 2-3 paragraphs that addressed this matter -

see: http://www.cdc.gov/fluoridation/guidelines/index.htm

The statement was intended to help readers understand topical benefits, not to prove there were no systemic benefits. Many studies show water fluoridation’s effectiveness. Those conclusions are not dependent on the details of the biologic mechanism causing the benefits.

There are always good explanations why arguments like this are not reasons for opposing fluoridation. If they were valid and sufficient, scientists would abandon the practice. The overwhelming professional support fluoridation enjoys is because of the huge literature supporting.

COMMENT 47704   Louise Mantella   November 25, 2013 at 10:47 pm |

Dear Billy Budd

There is nothing exquisite about the Singh paper.

“There are several limitations that should be considered. The major one is that the largest group in the study was children aged 6 to 7 years, who accounted for 28.8% of the study population. The permanent first molars in these children would not have been exposed to post-eruptive fluoride for sufficient time to prevent caries. Therefore, these subjects should not have been included in the study.”

Mascarenhas AK, Scott T. J Evid Based Dent Pract 8(1):17-8 (2008)

How did that one slip past peer-review?

The Neidell study is also very flawed.

By the author’s own admission:

“...we were assigning the probability of fluoridation exposure when in fact, an individual was either exposed to flouridation or not.” 

“The second concern is that we assigned historical fluoridation status to a respondent on the basis of the respondent’s current county of residence. Respondents, however, may not have lived in the same county for their entire lives.”

No conclusions concerning pre-eruptive effects can be drawn from this paper.

L

COMMENT 47733  Billy Budd    November 26, 2013 at 10:54 am  |

Louise - Re Singh, the problem of younger children is common to all school children survey based studies. The upshot of these inclusions however is that the effect of the topical effect of fluoridation is simply masked. Data restricted to older children may well show a relatively larger topical effect but would not expunge Singh’s findings.

Neidell’s study was based on historical residence which while clearly related to fluoride intake is not as precise as the sort of documentation being done currently in the Iowa Fluoride Study. Nonetheless, the effect of a less perfect fluoride intake estimate is to decrease the apparent cariostatic effect. It thus is really all the more remarkable that Neidell reported these findings.

Neidell’s opinion of the systemic benefits of swallowed fluoride in childhood is made very clear in the article’s Conclusions: “This study suggests that the benefits of CWF may be larger than previously believed and that CWF has a lasting improvement in racial/ethnic and economic disparities in oral health.”

Can I assume that you accept the Iida, Kumar paper showing that fluorosis protects teeth from cavities? Surely there is no argument that fluorosis is a systemic effect.

COMMENT 47741  Louise Mantella    November 26, 2013 at 12:04 pm

Dear Billy Bud

‘Can I assume that you accept the Iida, Kumar paper showing that fluorosis protects teeth from cavities? Surely there is no argument that fluorosis is a systemic effect.’

There is no argument that fluorosis is a systemic effect. However, fluorosis does NOT protect from cavities. It causes MORE cavities, and there many studies worldwide showing this. Below are a just a few:

- Azpeitia-Valadez Mde L, Rodríguez-Frausto M, Sánchez-Hernández MA. Prevalence of dental fluorosis in children between 6 to 15 years old. Rev Med Inst Mex Seguro Soc 46(1):67-72 (2008)

“Dental fluorosis is a defect in the formation of the enamel by high fluoride concentrations during tooth development. It produces hypomineralization of the enamel by increasing the porosity, thus exposing the tooth to decay….The severity was mild and very mild in 90 % of cases. Tooth decay appeared in 55 % of children with fluorosis and in 43 % of children without fluorosis….The prevalence of dental fluorosis is rapidly increasing. Tooth decay affected more often children with fluorosis.”

Pontigo-Loyola AP, Medina-Solis CE, Borges-Yañez SA, Patiño-Marín N, Islas-Márquez A, Maupome G. Prevalence and severity of dental caries in adolescents aged 12 and 15 living in communities with various fluoride concentrations. J Public Health Dent 67(1):8-13 (2007)

"Finally, an association of severity of dental fluorosis and caries severity was observed. While fluorosis was very common, it was often mild or very mild...The results showed that children with dental fluorosis have higher severity of caries (DMFT ≥ 4)."

"When we compared high-severity caries group (DMFT ≥ 4 as cutoff point), we observed higher caries severity in children with fluorosis (9.6 percent in very mild/mild, and 10.6 percent in moderate/severe) than children without fluorosis (7.8 percent). Additionally, compared only DMFT=0 versus DMFT ≥ 4 similar results were observed; prevalence of DMFT ≥ 4 in fluorosis-free children was 13.5, while 15.5 and 17.1 was observed in children with very mild/mild and moderate/severe fluorosis."

- Bajaj M, Blah BC, Goyal M, Jain M, Joshi A, Ko HH. Prevalence of dental problems in school children - a study in a rural community in Haryana. Indian Journal of Community Medicine 14 (3): 106-09 (1989)

“While only 54.4% of those without fluorosis had caries, 80% of those with fluorosis had caries.”

- Budipramana ES, Hapsoro A, Irmawati ES, Kuntari S. Dental fluorosis and caries prevalence in the fluorosis endemic area of Asembagus, Indonesia. Int J Paediatr Dent 12(6):415-22 (2002)

“In this study, DT (Decayed Permanent Teeth) increased with an increase in the fluoride content.”

- Hoffman N, Schlittler RH, Sousa M, Cypriano S. Prevalence of enamel defects and the relationship to dental caries in deciduous and permanent dentition in Indaiatuba, Sao Paulo, Brazil. Cad. Saode Publica 23(2):435-444 (2007)

“A positive association between dental caries and enamel defects (hypoplasia, demarcated opacity and dental fluorosis) was observed for schoolchildren aged 5. The results of this study indicated that children had increased odds of dental caries when enamel defect was present, both in deciduous and permanent dentition.”

So much for Kumar’s theory.

L

COMMENT 47747 Louise Mantella  November 26, 2013 at 2:00 pm  |

Dear Billy Bud

‘Louise - Re Singh, the problem of younger children is common to all school children survey based studies. The upshot of these inclusions however is that the effect of the topical effect of fluoridation is simply masked. Data restricted to older children may well show a relatively larger topical effect but would not expunge Singh’s findings.’

How does your response here address the problems with Singh’s study?

Once again, in Dr. Ana Mascarenhas’ words:

“There are several limitations that should be considered.
The major one is that the largest group in the study
was children aged 6 to 7 years, who accounted for 28.8%
of the study population. The permanent first molars in
these children would not have been exposed to posteruptive
fluoride for sufficient time to prevent caries.
Therefore, these subjects should not have been included
in the study. A further justification for not including these
children, is the data in Table 2, which show that in the
6- to 7-year age group, the DMFS6 was higher across all
categories (II, IV, VI, VIII) with post-exposure $50%,
when compared to the categories (I, III, V, VII) with
post-exposure #50%; whereas, in the other age groups,
the DMFS6 was consistently lower in categories with
post-exposure $50%, when compared to the categorie
with post-exposure #50%, except for groups III and IV.
Further, as reported by the authors, the distribution of
individuals by lifetime fluoride exposure levels was varied
with over 75% of the children experiencing either the
shortest level of exposure or the longest level of exposure
(41.4% and 36.1%, respectively), and there were fewer
than 250 subjects in 2 of the categories (III, VI), making
results from analyses in the smaller populations more
unstable, which is pertinent to the multivariate analyses
in Table 3. Category VI had the strongest caries-preventive
effect (RR = 0.52), but also had the lowest number of
individuals (182). Additionally, the authors report that
there were low caries levels in the proximal and smooth
surfaces; therefore, these results apply to pit and fissure
surfaces. The authors do not report excluding the
proximal and smooth surfaces from the study to keep
the analysis clean. Taken together, the above limitations
could have resulted in the effects seen.”

Mascarenhas AK, Scott T. Does exposure to fluoridated water during the crown completion and maturation phases of permanent first molars decrease pit and fissure caries? J Evid Based Dent Pract 8(1):17-8 (2008)

Secondly, regarding the Neidell paper:

‘Neidell’s opinion of the systemic benefits of swallowed fluoride in childhood is made very clear in the article’s Conclusions’

The conclusions are an opinion, as you state, they are not based on accurate science. You can’t just “assign the probability of fluoridation exposure when in fact, an individual was either exposed to fluoridation or not.”

There is still more wrong with this paper, including that no attempts whatsoever were made to adjust for the known 8 predictors for tooth loss. For a comparison as how to how this study should have been conducted, see Jiang’s paper from 2013.

Jiang Y, Okoro CA, Oh J, Fuller DL. Sociodemographic and health-related risk factors associated with tooth loss among adults in Rhode Island. Prev Chronic Dis. 2013 Mar;10:E45. doi: 10.5888/pcd10.110285.

I already addressed the Kumar/fluorosis matter in a separate post.

L

COMMENT 47748   Billy Budd  November 26, 2013 at 2:15 pm

Louise - I apologize for the length of this reply . . re the references you gave- they are all save Zimmer written prior to the CDC’s statement in 2001. I’ve previously noted how the CDC has changed their position based on new research.

Arends J, Christoffersen J. Nature and role of loosely bound fluoride in dental caries. J Dent Res 69:601-605 (1990)
This paper presents the author’s views of cariogenesis and contains no primary data. It is relatively old and like the CDC’s 2001 often quoted statement must be interpreted with more recent clinical human studies showing important cavity prevention from swallowed fluoride in childhood.

Bowen WH. Caries prevent ion - fluoride: reaction paper. Adv Dent Res 5:46-9 (1991)
Similar to Arends (1990) this is a review and reflects the greater understanding of the importance of the topical effect. Of importance to the larger debate is the abstract’s first sentence: “Although the prevalence of caries has declined in young persons in developed countries, there is still a need for water fluoridation.”

Duckworth RM, Gilbert RJ. Intra-oral models to assess cariogenicity: Evaluation of oral fluoride and pH. J Dent Res 71:934-944 (1992)

While this paper reviewed methodologies for enamel biopsy, as near as I can determine it did not report any data comparing caries with actual enamel fluoride concentration measurements.

Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention. A concept based on possible cariostatic mechanisms. Acta Odontol Scand 39(4):241-9 (1981)
ditto Arends.

Reich E, Schmalz G, Bergmann RL, Bergler H Bergmann E. Caries incidence in children after varying periods of fluoride tablet application. Dtsch Zahnartz Z 47:232-234 (1992)

This paper is not indexed in PubMed. I™m sorry but that is the cut criteria I use to identify sufficient scientific quality and peer review to make it worth my while to read.

Rosin-Grget K, Lincir I. Current concept on the anti caries fluoride mechanism of the action. Coll Antropol 25(2):703-12 (2001)
This paper, from Croatia, in the conclusion argues only that the topical effect is “more” important, not that the systemic effect is unimportant. It is very common for fluoridation opponents to jump from a reasonable statement that the topical effect is predominant to the political position that the systemic effect is unimportant.

Zimmer S, Jahn KR, Barthel CR. Recommendations for the use of fluoride in caries prevention. Oral Health Prev Dent 1(1):45-51 (2003)
Again, there are no primary data. Although this author believes the efficacy of fluoride is from ”local processes” he states: “Besides this, fluoridated water and fluoridated salt are still important. Although they have a systemic effect, the efficacy of these fluoride applications results from local processes.“ This underscores the most important point which is that the benefit of fluoridation has been demonstrated epidemiologically and that fact stands regardless of the underlying mechanism.

I don’t think the experience of a species (shark) not even in human’s taxonomic class has any relevance to setting public health policy. BTW, Whales have spectacular bone fluoride apparently without causing arthritis or osteogenic sarcoma.

Some of the known benefits of water fluoridation are possible only when fluoride is swallowed during tooth development. While the topical effect may be predominant, there is good evidence to support the importance of cariostatic systemic effects.

Epidemiological studies show fluoridation decreases grinding injury for both adults and children

Br Dent J. 2004 Oct 9;197(7):413-6; Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation. Bardsley PF, Taylor S, Milosevic A.

This confirms experimental literature showing that fluoride swallowed during tooth development has a number of effects on tooth structure including harder enamel and dentin. Clearly only a systemic effect can create harder, more wear resistant teeth.

Br Dent J. 1994 May 7;176(9):346-8. Comparison of the effect of fluoride and non-fluoride toothpaste on tooth wear in vitro and the influence of enamel fluoride concentration and hardness of enamel. Bartlett DW, Smith BG, Wilson RF.

J Dent Res. 2005 Oct;84(10):951-7. How does fluoride affect dentin microhardness and mineralization? Vieira A, Hancock R, Dumitriu M, Schwartz M, Limeback H, Grynpas M.

On the Nov 17 Open Parachute debate document I’ve previously referred to Groeneveld (1990), Singh (2004), Kobayashi (1992), Iida and Kumar (2009) and Neidell (2010). Janet had some minor criticisms of Singh and Neidell which to me and apparently the peer review editors were not sufficient to change the conclusions.

Kumar’s analysis of the largest data set ever collected of cavities in the adult teeth of school children found that fluorosis protects teeth from cavities. This is proof positive of a systemic effect benefit. He was able to quantify the protection and found:

“..the effect of the lower caries experience observed among teeth with mild fluorosis on overall health care cost savings could be substantial. According to these data, fluorosis in just four or five permanent first molars in a population may be associated with an average of approximately one fewer DMFS in that population. To produce the same effect, one would have to seal, and maintain sealants on, four to 15 permanent first molars, a process that would cost a great deal more. Therefore, anyone formulating guidance regarding the reduction of fluoride exposures must take into consideration the protection associated with the milder forms of enamel fluorosis.”

COMMENT 47751

Dear Billy Bud,

My references were specifically given in relation to Ken’s statements about fluoride in bioapatite.

For example, Ken wrote:

‘Accumulation of fluoride, together with calcium and phosphate, in our bioapatites is a normal part of development. This is beneficial because it helps strength our bones and teeth, and lowers their solubility.
Both insufficient fluoride, or excess fluoride in our bioapatites can cause problems.
Excessive dietary intake can result in excessive fluoride in our bones and teeth. Insufficient intake may also cause our bioapatites to be weaker and more prone to dissolve. When dietary intake of fluoride is reduced fluoride can be lost from bones and calcified tissues.
The scientific literature reports that fluoride has a systemic role benefitting bones and pre-erupted teeth.’

All my references were related to this issue - nothing else. Not fluoride effects on tooth structure and teeth grinding.

Now you are supplying me with first sentences of abstracts as “scientific” evidence?

Your ignorant statement about sharks’ teeth shows how little you know about fluorapatite and its solubility.

Regarding the Reich and Bergmann paper:

‘This paper is not indexed in PubMed. I’m sorry but that is the cut criteria I use to identify sufficient scientific quality and peer review to make it worth my while to read.’

You must live in the US?

I find it quite telling that once again, you give me the Kumar material, but neglect to address the studies I had just provided you with, showing that dental fluorosis - even very mild DF INCREASES caries. Now why is that? Certainly they must be on PubMed?

L

No further comment from Billy Budd was received by the time Mantella decided to no longer participate in the blog discussion due to fraudulent behaviour by the owner, Ken Perrott. SEE: Perrott - Mantella

Update

November 27, 2013

COMMENT 47831 Billy Budd November 28, 2013 at 7:26 am

Louise -re your post which ends with “So much for Kumars theory”.

That fluorosis prevents cavities is not a theory, but rather the result of clinical examinations in a data set which included over 39,000 US school children. Those data included tooth level observations by calibrated examiners. Nearly 17,000 subjects with complete residence histories formed the basis of Iida and Kumars statistical analysis. Focusing on the first molar, these data showed that fluorosis prevents cavities.

I note that none of the articles with appropriate publishing dates were of sufficient quality to be included in the exhaustive review published by the National Academy of Sciences in 2006. An entire chapter was devoted to enamel fluorosis. The bibliography upon which the report was based was a monumental accomplishment. One can be confident that your references would have been included if they deserved to be.

The paper by Pontigo-Loyola AP et al., (J Public Health Dent 67(1):8-13, 2007) well illustrates why these smaller and less well designed studies are not applicable in the US.

The subjects lived an altitude above >6,560 ft and drank water that exceeded 1.38 ppm. Their state is included in Mexico’s fluoridated domestic salt program. Over 80% had fluorosis which was moderate or severe in about a third. Because every child was exposed to fluoride and there was such a high level of advanced fluorosis and every child it is difficult to assess the relationship between fluorosis and caries. Dental work to improve appearance is likely common making it difficult to know if the “fillings” observation was due to cavities or cosmetic dentistry.

Factors such as age, gender, dental visit, socioeconomic status and locale had an effect on the study’s cavity measurements in the bivariate analysis. Therefore those factors must be controlled for to accurately measure an association between fluorosis and cavities

Compared to Iida and Kumar’s, this study is small, the population and fluoride exposure is not comparable to the US, observations of the filling component are not clear, and the analytical method lacks sophistication.

Adding more small poorly designed studies will not overturn the observations from a very large nation-wide US well designed study based on calibrated observations.

Lastly, I can only restate the fact that the observational science upon which community water fluoridation’s (CWF) benefits have been demonstrated is not dependent on the mechanistic explanation for effectiveness.

CWF simply prevents cavities. Preschoolers have fewer operations for mouth fulls of rotten teeth, adult teeth have fewer cavities, restorations last longer and there are fewer cavities on the exposed root surfaces of elderly people.

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It is highly doubtful that Louise Mantella will further participate on any discussion on the Perrott blog. If she does, we will post her reply on this page as well.

Paul Melters has posted a response to Billy Budd’s reply here.

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Update:
November 28, 2013

A new comment was posted by familar “dental expert” Johnny Johnson

COMMENT 47834 Dr. Johnny Johnson  November 28, 2013 at 8:49 am

Louise,

The references you make regarding fluorosis and caries are not from studies done in the United States, nor Canada. Perhaps your position would be better supported if you provided peer reviewed literature from the US or Canada that’s more applicable to the United States.

As Billy points out, studies must pass the critical review process that credible scientific journals require. That includes sample size, control of confounding factors (to the best that they can be), and a representative sampling of the population.

Taking literature that meets one’s own position is easy to do. I’m just as guilty of this bias as the next person. However, my bias is based on the literature that has appeared in refereed peer reviewed scientific journals worldwide. This literature is weighed by the experts in this particular field and debated in expert panels like the 2006 NRC Review of EPA standards, and the U.S. Community Preventive Services Task Force. These folks are tasked with reviewing volumes of literature and arriving at a consensus opinion. It is those experts that I rely on, not a handful of studies done somewhere, anywhere, that happens to support my position.

The science is crystal clear. Community water fluoridation is effective and safe. That’s the consensus opinion of our experts at this time. And it has been that same consensus for the past 68 years. When, and if that were to ever change, Ken would be one of the first to broadcast it, right after the CDC and other credible scientific groups have yelled it from the highest mountain.

Johnny Johnson, Jr., DMD, MS
Pediatric Dentist

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It is highly doubtful that Louise Mantella will further participate on any discussion on the Perrott blog. If she does, we will post her reply on this page as well.

Paul Melters has posted a response to Johnny Johnson’s reply here.