Monday, January 19, 2009

Fluoride....again

Okay here is the deal.
I poured my heart and soul out on this blog on Friday.
I know that Friday is usually a weak day for dentist reading blogs.
I really wanted some dialogue on this one.
So I am printing it AGAIN.
If I don't get any responses, I will assume no dentists are reading my blog anymore.
I am not that sensitive but...
A couple of things before I get to the blog.
The Magic...has anyone been watching them. I really think they are the best team in the league, right now. One of my patients asked me if I wanted to go see the Magic play the Celtics on Thursday night....IN A SKYBOX. UH YEAH!!!!
The Gator Basketball team has won 10 in a row. Damn it has been a good year and it is only the 19th.
There is an outside chance I might (maybe a 10%) one of my patients has a SuperBowl ticket for me.....shh I don't want jinx myself by talking about it.
I saw a bunch of movies this weekend but I will tell you about them on Wednesday. You have some reading to do.
Oh before I forget...I missed How I Met Your Mother last week but my wife and I caught Worst Week. I was so funny. I think this one is a keeper.

I have been thinking of this topic for a month now.
I will get right to it.
I had this patient who had a 3 month old and wanted to know if I recommended fluoride supplements.
I said, "I don't know. I will make some calls and I have a JADA magazine in the back that is taking about this very subject. I will make the calls and I will read the article and get back to you."
I called my friend who is a pediatric dentist.
And this is where this story starts getting crazy.
I asked him what he does. He says, "I don't recommend fluoride supplements.
"WHAT?!!!
I said, "What do you mean?"
He repeated, "I don't recommend fluoride supplements."
I asked if this was an AAPD (American Academy of Pediatric Dentists) recommendation or was this your issue.
He said, "There is too much concern with Fluorosis to do any recommending."
His point was that if they get decay he is there to fix it.
If he recommends fluoride and they get Fluorosis he is to blame.
He is not saying that he wants them to get decay but his is saying that he doesn't want to be the scapegoat to problems that come with fluoride supplements.
I was shocked but I understood his philosophy.
As I was still spinning from this conversation I called another pediatric dentist and he didn't say the same thing but I could tell there was also some reservation to giving me a recommendation. He said something like, "I really try to get the parents to start drinking bottled water with fluoride in it."
Again, this is getting the kid fluoride but releasing any responsibility.
Hmmm?
So I went to the article and this is where it all blows up.
Okay the article is called Fluoride Supplements, Dental Caries and Fluorosis.
I got this out of the JADA magazine Volume 139, November 2008.
I am going to give you the cliff notes.
This article was basically an articles review. They did an article search from 1966-2006. They found 988 articles. Some of them were repeats. Some of them didn't fit the criteria so basically they widdled it down to 85 articles that were "right on" for what they were looking for.
They were looking for if fluoride worked. They were checking in three different age groups.
6 months to 3 years, 3 years to 6 years old, then children older than 6.
Okay the first sentence I highlighted was...In 2006 (yes, that is two years ago) the Australian Research Centre for Population Oral Health's workshop on the use of fluorides in caries prevention concluded that "fluoride supplements in the form of drops,or tablets to be chewed and/or swallowed should not be used.
"WHAT??!!!
I thought "let me just read some more". So a couple of paragraphs later..."This study (talking about another study) did NOT find statistically significant reduction in caries in permanent teeth."Then a couple of paragraphs later..."
The study (talking about yet another study) concluded that "the prenatal fluoride supplements had no benefits."
Then it goes on to say that in another study involving 12 year olds that in a five year period there was no significant differences in the kid that took fluoride supplements and the kid that received topical varnish and the kid that just got oral health education.
And last but not least, "...expectant mothers used fluoride supplements from the fourth month of pregnancy until the delivery and their children used the supplements until reaching the age of 3 years, showed no caries-preventive benefit."
The article was littered with more and more of this.
Am I shocking everyone?
At this time my head is about to explode.

Then the article goes on to say..."the odds of dental flourosis increased by 84% for each year of use of fluoride supplements between the ages of younger than 6 months and 7 years.

What the heck is going on here?
Am I the only one that thought fluoride was good for children.
I am the only one that when the kid comes in with alot of decay, I ask the parents where they live.
If they live in an area without fluoride in the water they get vitamins with fluoride. I thought everyone was doing this.
Don't tell me I am out of the loop again!

The article does go on to say "In permanent teeth, the daily use of supplements prevents dental decay. Okay so what did we learn?
Fluoride supplements are not any good from pre-birth to 6 years old. But have a place in preventing decay in permanent teeth. But don't use too much because you can get fluorosis.
Last thing....On the front of the article it lists the Clinical Implications to this article. "The current recommendations for use of fluoride supplements during the first six years of life should be re-examined.
"WELL YEAH!!!
Okay, who picks up the ball?
Who is responsible to let everyone know?
Is it the AGD?
Is is the ADA, I mean they published this thing? Is it the AAPD? Is it you?Who? Do we ignore this?
Do we brush it under the table? Do we just keep doing what we were doing? Don't rock the boat.
I would like to know what you think. Did you know about this?
Are you giving supplements?
Is this making your head spin?

Help a brother out.
john

9 comments:

Anonymous said...

you should post this on dental town.
i live in a city that does not have fluoridated water, and the older docs rx fluoride tabs. but i dunno... no where else i know does.

Anonymous said...

My fluoride guru is my in-house pedodontist. We practice in a town in southwest Mississippi that borders the Mississippi River. Our city and our sister across the river in Louisiana both provide fluoridated water supplies while the surrounding rural areas do not. And we can tell the difference.

My partner says that the fears over fluorosis are overstated. He says that the American Board of Pediatric Dentistry (of which he is a Diplomate) recommends no supplements in kids younger than six months. That's what he does and he never sees fluorosis in those kids. He stops supplements at age ten years, too.

He also says that most of his hospital patients are from the non-fluoridated areas.

Anonymous said...

In the my county here in Fl. The water utility company says not provide fluoride supplement since the water is now fluoridated. They actually mailed this out.

Anonymous said...

I just read the November 2008 JADA article closely. (You can get it here: http://jada.ada.org/cgi/reprint/139/11/1457 ) It re-opens a can of worms and dumps them out on the table. It finds that the reduction in decay was from a topical fluoride effect, but there was not a single study with any evidence of a systemic benefit. All of the studies finding a benefit had the kids chew the tablets rather than swallow them whole. This is similar to brushing with fluoridated toothpaste with a concentration of 1000 ppm F. It allows the high F concentration bathing the teeth to remineralize incipient lesions.

It is much different than directly swallowing F which gives no opportunity of achieving a high F concentration on the teeth. Systemic F exposure is what happens when you drink fluoridated water or fluoridated bottled water. It would be very interesting for the ADA to attempt a similar review of the literature based on studies of purely systemic F exposure. I think they would have an even harder time finding any high-quality Randomized Controlled Trials (RCTs) of systemic F.

Here is the key summary from the JADA article: "We believe that dentists should dismiss the misconception that there is a balance between caries and fluorosis, because patients can accrue the benefits of topical fluorides without developing fluorosis and without systemic intake."

Some of the top dental researchers agree that the benefits of fluoride are mostly, if not exclusively, topical. Even the US CDC has conceded this fact.

Bill Osmunson DDS, MPH said...

John, I hear your pain!!!

As a DDS, MPH I promoted water fluoridation and supplements (same concept)and then I read the literature on both sides. Oh my G. . .. It was like a knee in the gut.

Fluoridation/supplements no longer show a reduction in dental decay or dental expenses. Dentists are puzzled why there is no longer benefit with supplements or fluoridation.

With all the dental insurance computers crunching numbers, why have we not seen lower dental expenses in the fluoridated areas?

Perhaps because we are ingesting too much/adequate fluoride from many new sources. Without good research we can only speculate. Most industrialized countries do not fluoridate or recommend fluoride supplements. Even European Dental Associations no longer recommend fluoride supplements.

The medical risks from fluoridation/supplements are numerous and significant. As dentists we simply have not looked at the medical problems.

For example. Mother's milk has 0.004 ppm. Infant formula made with fluoridated water is 250 times more concentrated with fluoride than nature provides.

Do those promoting fluoridation/supplements consider mother's milk flawed and defective?
Not anymore. The CDC and ADA now recommend fluoride free water for infant formula. Hello???? How do we mass medicate everyone with water and not expect infants to get it. 3 out of 4 infants get formula.

Read your fluoridated toothpaste label (variable wording permitted by the FDA). "Drug facts." (Yes, fluoride when used to mitigate or prevent decay is defined by the FDA and state laws as a drug. More later) "Do not swallow" "Use a pea size amount." "If more than used for brushing is swallowed, contact the poison control center." Wow. The FDA is serious about not swallowing even a tiny amount. But how much fluoride is in that pea size of fluoride? 1/4 mg. Just 1/4 mg is serious bad according to the FDA. A quarter milligram is the same amount found in one glass (quarter liter) of fluoridated water.

We force people in a community to drink a drug which we should call the poison control center if one glass of that water is swallowed? Makes no sense. Why does our profession not permit discussion of that kind of scientific disconnect?

You can see a short video of my comments at http://www.youtube.com/watch?v=_Ys9q1cvKGk

It gets worse. Fluoride supplements/fluoridation chemicals are not FDA approved. Have never been approved.

Less than one drop of fluoride can kill a child. Very similar toxicity to strychnine and arsenic. Of course we use it in dilute form, but it is still a poison.

Think about it. We force people through water systems to be medicated with a poison which has not be approved by the FDA.

The court ruled in Doe v Rumsfield that the Government does not have the authority even in times of war to medicate a person with a drug which has not been approved for the purpose it is being given. In that court case it was for anthrax. In the case of fluoridation, the chemicals have not been approved nor have they been approved for the purpose in which they are given.

It gets much worse than that.

Simply the lack of benefit is no big deal by itself (IMO). But looking at the medical damage to brain, IQ, thyroid,bones, cancer, obesity and of course teeth makes fluoride supplements and fluoridation look very troubling.

Even worse, no one is considering total exposure. Huge increases in fluoride pesticides, fluoride post-harvest fumigants, medical and dental products. No "doctor" or agency is monitoring or evaluating how much fluoride we as a people are getting or if perhaps with the huge increases in exposure maybe fluoridation should be reduce to maybe 0.6 or 0.4 ppm instead of 1 ppm. No one is "responsible" or has jurisdiction.

See also www.fluoridealert.org and www.fluorideresearch.org and www.slweb.org. All very good sources for concerns and research on fluoride.

So much more, but that's enough for now.

Bill Osmunson DDS, MPH
bill@smilesofbellevue.com

gatordmd said...

I appreciate all your comments. They all appear to be well thought out BUT...Let me perfectly clear, this blog was not about whether I think Fluoride is bad or not.
We all can recongnize the benefit that fluoride. It is easy to see in the office when people that don't have fluoride in the water have a higher caries rate (at least this is what I see).
We all can recognize that fluorsis is bad.
But the blog is about the powers that be (who ever they are) having information that could effect a lot of people. It is about me having to read about some very important information buried around page 100 in the ADA magazine.
It is about how information get out in our field.
I mean remember when the American Heart Assoc. changed the premed laws. It was a big mess of whether to continue to do it or not. No one ever came out and screemed, "HEY DO NOT PREMED FOR A MURMUR ANYMORE!"
Do you know what I am saying?
Thanks again for your comments.
john

gatordmd said...

I appreciate all your comments. They all appear to be well thought out BUT...Let me perfectly clear, this blog was not about whether I think Fluoride is bad or not.
We all can recongnize the benefit that fluoride. It is easy to see in the office when people that don't have fluoride in the water have a higher caries rate (at least this is what I see).
We all can recognize that fluorsis is bad.
But the blog is about the powers that be (who ever they are) having information that could effect a lot of people. It is about me having to read about some very important information buried around page 100 in the ADA magazine.
It is about how information get out in our field.
I mean remember when the American Heart Assoc. changed the premed laws. It was a big mess of whether to continue to do it or not. No one ever came out and screemed, "HEY DO NOT PREMED FOR A MURMUR ANYMORE!"
Do you know what I am saying?
Thanks again for your comments.
john

Anonymous said...

Well when you put it that way. Here is the way I feel. Oral fluoride supplements tablets and drops are bad!!! Simply because you cannot tell when the patient has had enough or too much causing flurorsis. Human nature being the way it is, most parents think if a little is good a lot is better. Plus you never truly know what other sources of fluoride someone ingests.

However topical fluoride is good as long as it is not purposely swallowed in large quantities. That being said I don't think it does as much good as we think does.

And yes the powers that be will always have information that we do not.

gatordmd said...

I totally agree with you.

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