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Paul Melters’ response to Billy Budd - Comment 48178
December 9, 2013

COMMENT 48529 Paul Melters  December 10, 2013 at 10:18 am  

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In COMMENT 48178, Billy Budd writes:

BUDD: In response to the use of the use of Pontigo et al (2007) by “L” (#47741) and Paul Melters (#47925, 47953) one of the authors (Maupome) passes his views on to the Open Parachuge (sic) “debate.”

Rather than paraphrase and shorten what he said, with his permission his response is here unedited. As readers will note, he believes that the ”commonest finding in the literature“ is that fluorosis is associated with fewer cavities.

PM Response: You have been identified by Dr. Johnny Johnson as a “troll”, and accused of stealing segments from a post of his on another blog, without giving proper credit (Comment 47956).

Numerous parties have tried to contact Maupome to verify that he was indeed the author of the comments you posted. No response has been received.

So - for now, we will presume that Maupome did make these comments, and I will address your posts, and have them posted on my website. You have been distributing your nonsense on countless US blogs for the last year, and we shall make sure the public has a record of this discussion.

BUDD/Maupome: he believes that the ”commonest finding in the literature“ is that fluorosis is associated with fewer cavities.

PM Response: I don’t really care what Maupome believes in. I am interested in science.

    Maupome is certainly entitled to his own opinion, but he is not entitled to his own facts. There are hundreds of studies from the last 70 years showing that “moderate” and “severe” dental fluorosis is associated with INCREASED caries - including numerous recent ones from Mexico (Garcia-Perez et al, 2013; Molina-Frechero et al, 2012; Azpeita-Valadez et al, 2008).  Maupome is listed as co-author on two studies documenting the same (Pontigo-Loyola et al, 2007; Vallejos-Sánchez et al, 2007).

BUDD/Maupome: “I have contacted my co-authors and discussed the issues you posed. This issue of fluorosis conditions giving rise to carious lesions is really a matter of how severe the tissue changes need to be for -  all other things being equal in a cariogenic environment - clinically detectable decay to be there. The time and ages for decay and fluorosis development are so different that trying to tie the 2 things together is a daunting task.”

PM Response: Really? A “daunting task”? Wow. Others don't seem to be having such troubles?

BUDD/Maupome: “Like many of these issues in the F debate, the anti-F crowd is prone to selective quoting. My thinking is because they are looking for smaller concepts  and statements to support an idea they already have in their minds.

PM Response: Further below we shall see who is doing the selective quoting.

BUDD/Maupome: “It would be worthwhile noting that in the Pontigo et al., 2007 paper, in Table 3 it is reported that mild and very mild fluorosis were associated with lower caries experience.”

PM Response: To be frank - I am not too surprised that Maupome would try to pull something like this. Table 3 is only able to show this because the data has not been adjusted here for the two age groups (12 and 15 year olds), nor gender.

BUDD/Maupome: “With all of these analyses being bivariate in nature, it was not feasible to adjust the model to ascertain significance of that specific difference they mentioned. This is one way of saying that they are trying to read too much into the information reported. 

PM Response: Nobody is trying to read too much into the information reported. The authors - which include Maupome - state clearly what the findings were:

Pontigo-Loyola: “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).”


“...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."

How can one “read too much into the information” here?

BUDD/Maupome: More important to the overall issue is the fact that these communities have unusually high levels of F in the water (for the amounts found in the Americas), and are located at high altitudes above sea level  (which is a factor still incompletely understood in fluorosis development).”

PM Response: “Unusually high levels”? “More important to the overall issue”?

The fluoride in water was 1.38 ppm in San Marcos [128 children (8.3%)/first 6 years of life] and
1.42 ppm in Tula Centra [821 children (53.4%)/first 6 years of life)]. Those concentrations are only slightly higher than the upper limit of F- in US waters deemed “optimal” at the time (1.2 ppm).

Re: Altitude - again - this does not really matter here. It is well established that at high altitudes less fluoride is required to produce dental fluorosis of all grades.

Re: the comment: high altitudes above sea level (which is a factor still incompletely understood in fluorosis development”:

Interestingly - the authors state in another paper, dealing with the same data (Medina-Solis et al, 2008): 

“The hypothesized relationship between iodine deficiency and increased prevalence of fluorosis appears to be relevant to Hidalgo.” (Hidalgo has long been known to be an IDD area).

This makes complete sense - of course, as iodine deficiency increases sensitivity to TSH, and fluoride is a TSH analogue. TSH produces “dental fluorosis” - exactly like fluoride does, as has been known since the 1940s. 

BUDD/Maupome: “It is worthwhile pointing out that another paper from the same group in another location with fluoridated salt and negligible fluoride naturally available in water, Vallejos et al., we found few cases with severe  fluorosis (4 cases; 0.03%). In that study the presence of fluorosis was associated with lower caries experience -which is the commonest finding in the literature. See the tables below from Vallejos et al.”

(Note: Tables are omitted here, due to formatting problems, but can be seen in original comment 48178.)

PM Response: First of all - there is no citation or reference given. What study is being referred to?

Please note that these tables are entirely meaningless without knowing more details, such as the age of children. The Pontigo-Loyola et al. study was done on 12 and 15 year-olds. Please ask Maupome to provide exact citation and the data on age of children in the so-called “Vallejos et al.”

Moreover, regarding “Vallejos et al”, in the Pontigo-Loyola paper the following is found:

“The results show that children with dental fluorosis have higher severity of caries (DMFT =/>4. These finding are consistent with Vallejos et al.(19) in children with mixed dentition in Mexico, and with various international reports from less developed countries and moderate income countries.”

Must be another “Vallejos et al”  paper, uh? Who is doing the “selective quoting” here?

BUDD/Maupome: “I believe the largest problem we have is that the anti-F crowd assumes that all exposure to F leads to clinically detectable fluorosis, and that all fluorosis undermines the tissue structure enough to make the tooth surface more susceptible to caries. Those two are big leaps in thinking.”

PM Response: Not at all, really. A fluorosed tooth has been permanently damaged. (See also: Waidyasekera et al, 2007)

Once again - the evidence speaks for itself. Over 30 studies were presented to you already.

BUDD/Maupome: “The other aspect that you may want to consider is that a good chunk of the evidence for higher experience of caries being associated with dental caries seems to come from less developed countries, places in which multiple aspects of life may be associated with developmental enamel defects. One of them is malnutrition. None of these aspects have been studied appropriately, and thus we cannot grab a handful of papers with the association we are looking for, and attempt to generalize the results.”

PM Response: What? “higher experience of caries being associated with dental caries”? I presume you meant to write higher experience of caries being associated with _dental fluorosis_”?

At this point it must be noted again that the investigators here have published 3 papers on the study conducted in 1999.

The authors used the same data to address the validity of Dean’s index (Medina-Solis et al, 2008).

They used the same data to publish on the occurrence of dental fluorosis at high altitudes (Pontigo-Loyola et al, 2008).

(Interestingly, the authors neglected to inform the readers in both of those papers of their findings on the increase in caries severity in children with dental fluorosis!)

From what appears in the other two papers, the investigators were very well trained before the study started:

“Dental examinations were performed by two examiners previously trained and standardized (kappa interexaminer=0.85; intraexaminer=0.97). A pilot study was conducted beforehand to standardize fluorosis criteria...Fluorosis was differentiated from other opacities [24]. (Medina-Solis et al, 2008).

Feel free to forward these comments to Maupome.  His attempts here to whitewash his own findings have not been successful. (And do ask him whatever happened to the 514 missing children in the 2008 paper by himself and Pontigo-Loyola et al. According to “Materials and Methods” there should have been 1538 children, as in the other two papers; however - for some magic reason we only have the data on 1024, with no reason given at all for the exclusion of the 514.)

Further, I notice that you were unable to provide a reference as was requested.

I will ask once again - please provide ONE study capable of demonstrating the preventative effect of CWF that has accounted for established confounding factors such as race, gender, age, total intake, tooth eruption, brushing and other oral hygiene factors, SES.


Paul Melters

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)

DeEds F, Wilson RH, Cutting WC. Thyrotropic hormone and fluorine activity. Endocrinology
26(6):1053-1056 (1940)

Garcia-Perrez A, Irigoyen-Camacho ME, Borges-Yanez A. Fluorosis and Dental Caries in Mexican Schoolchildren Residing in Areas with Different Water Fluoride Concentrations and Receiving Fluoridated Salt. Caries Res 47(4):299-308 (2013)

Molina-Frechero N, Pierdant-Rodríguez AI, Oropeza-Oropeza A, Bologna-Molina R. Fluorosis and dental caries: an assessment of risk factors in Mexican children. Rev Invest Clin. 2012 64(1):67-73 (2012)

Medina-Solis CE, Pontigo-Loyola AP, Maupome G, Lamadrid-Figueroa H, Loyola-Rodríguez JP, Hernández-Romano J, Villalobos-Rodelo JJ, de Lourdes Marquez-Corona M. Dental fluorosis prevalence and severity using Dean's index based on six teeth and on 28 teeth. Clin Oral Investig. 2008 Sep;12(3):197-202. doi: 10.1007/s00784-007-0171-7. Epub 2008 Jan 8. PubMed PMID: 18183431.

Pontigo-Loyola AP, Islas-Márquez A, Loyola-Rodríguez JP, Maupome G, Marquez-Corona ML, Medina-Solis CE. Dental fluorosis in 12- and 15-year-olds at high altitudes in above-optimal fluoridated communities in Mexico. J Public Health Dent. 2008 Summer;68(3):163-6.

Vallejos-Sánchez AA, Medina-Solís CE, Casanova-Rosado JF, Maupomé G, Casanova-Rosado AJ, Minaya-Sánchez M. [Enamel defects, caries in primary dentition and fluoride sources: relationship with caries in permanent teeth]. Gac Sanit. 2007 May-Jun;21(3):227-34.

Waidyasekera PG, Nikaido T, Weerasinghe DD, Wettasinghe KA, Tagami J. Caries susceptibility of human fluorosed enamel and dentine. J Dent 35 (4):343-9 (2007)