Debating Water Fluoridation Before Dr. Strangelove

In the 1930s, scientists learned that small amounts of fluoride naturally occurring in water could protect teeth from decay, and the idea of artificially adding fluoride to public water supplies to achieve the same effect arose. In the 1940s and early 1950s, a number of studies were completed to determine whether fluoride could have harmful effects. The research suggested that the possibility of harm was small. In the early 1950s, Canadian and US medical, dental, and public health bodies all endorsed water fluoridation. I argue in this article that some early concerns about the toxicity of fluoride were put aside as evidence regarding the effectiveness and safety of water fluoridation mounted and as the opposition was taken over by people with little standing in the scientific, medical, and dental communities. The sense of optimism that infused postwar science and the desire of dentists to have a magic bullet that could wipe out tooth decay also affected the scientific debate.

Baltimore and the Beginnings of the Fluoride Controversy

The fluoridation of municipal water as a preventive dental health measure has proven to be a contentious issue from its very outset. In 1952, Baltimore became the first major city in the United States to artificially add fluoride to its water supply. This study draws largely on print media sources as a means of discerning public sentiment, in order to evaluate the nature of Baltimore's fluoride controversy in its infancy. Initial response was influenced by prior exposure to the substance within the context of dentistry, as well as a continued trend of conservatism within the community. Logistical issues during implementation due to the necessary upscale of established practices to accommodate Baltimore's population served to further exacerbate concerns. Much of the opposition was predicated on the breadth of the measure, as evidenced by the myriad of personal concerns put forth in objection. Personal concerns developed into demands for personal autonomy, providing a philosophical foundation for the anti-fluoridation movement that persists today.

Twentieth century influences on Queensland dental practice: a tangential view

Political scientists, historians and journalists intermittently suggest that, within the Australian context, public policy and its administration in Queensland are different. Significant evidence suggests that, from colonial times, distance and decentralization have influenced Queenslanders' demographic profiles and collective identity. Using historical analysis to qualify and quantify both the alleged difference and its social significance warrants caution. Nonetheless, some developments in public dental policy and the practice of dentistry across Queensland provide intriguing contrasts. This study, a literature review, uses historical method. The authors focus on pivotal proceedings that affected both the dental profession and dental practice in the twentieth century. These events embraced the genesis and evolution of dental education and influenced fluoride politics and policies controlling the delivery of public dental services. These developments reflected not only the contemporaneous social and political fabric but also the broader influences on Queensland history, namely: area, distance, decentralization, groundwater, isolation and topography. The events and observations in this report lend some support to hypotheses concerning a Queensland difference within the Australian context of public policy and its administration.

Milestones in oral health services in the Republic of Ireland

With the many changes occurring in Ireland it would seem an opportune time to review the body of research conducted and policy enacted in the Republic of Ireland on oral health services and oral health. The dental health of the nation prior to water fluoridation, the legislation and policy decisions impacting on oral health up to budgetary changes, and the production of evidence-based guidelines will be discussed. The first national survey of dental health was conducted in Ireland in 1952 - 'Dental Caries in Ireland'. In the intervening 60 years, further surveys of the oral health of people in Ireland have been carried out. Legislation, surveys and policy documents that have shaped dentistry and the oral health of the population are set out in Tables 1 and 2. A more comprehensive description of the policies can be found in the thesis submitted in fulfilment of Masters in Dental Public Health (MDPH) by the lead author.

Cities without cavities: democracy, risk, and public health

This essay examines the history of fluoride debates in four Canadian cities. It argues that fluoride's opponents were primarily motivated by what they saw as the health and environmental risks of adding fluoride to the water supply. They also believed that fluoridating the public water supply was a fundamental violation of civil liberties. The fluoride debates have much to teach us about how people evaluate potential health risks and how they respond to state interventions in the field of public health.

'Into every home, into every body': organicism and anti-statism in the British anti-fluoridation movement, 1952-1960

This article argues that the anti-fluoridation campaigns in the 1950s stemmed from concerns about both the increasing 'chemicalization' of food and the growing authority of the state over the private home and individual body. The British Housewives League (BHL), an organization typically thought insignificant after the late 1940s, was in fact at the centre of these campaigns. Steeped in the beliefs of inter-war and wartime organicism, the housewives believed that government intervention in food production and distribution was producing a post-war diet laden with harmful chemicals. The Ministry of Health's proposals to test water fluoridation in select communities in the early 1950s only further convinced the housewives that the state was harming the nation both physically and politically. More and more citizens would have no choice but to drink impure, potentially harmful water, they argued, and the burgeoning state would continue encroaching on private homes and bodies. While scholars have already demonstrated that what we now think of as 'leftist' environmental ideas were popular among 'rightist' movements of the 1930s and 1940s, the anti-fluoridation campaigns show that the BHL continued in the post-war years to intertwine our present-day notions of 'left' and 'right' ideologies.

Collaboration, vision and reality: water fluoridation in New Zealand (1952-1968)

In comparison with that of other nations in the British Commonwealth, New Zealand's early and comparatively high adoption of water fluoridation was a distinctive health policy. National concerns about the caries epidemic and the legacies of TR Hunter, F Truby King, HP Pickerill and JP Walsh engendered a spirit of cooperation between the Department of Health, the New Zealand School Dental Service, the Medical Research Council (of New Zealand), the New Zealand Dental Association and the University of Otago's dental and medical schools. The consequence was a contagious culture of multidisciplinary research and institutional liaisons that produced exceptional dental epidemiology. The government's involvement in children's public dentistry harmonised with fluoride advocates' radical vision of community caries reduction. New Zealand assumed not only a leading international role in immediate post-World War cariology, but also the dominant position in the fluoride politics of the British Commonwealth. The incomplete fulfilment of Fuller's "Dreams Pursued" presents a case study that confirms the roles of both scientific evidence and centralised political authority in public health administration. Paradoxically, political scientists have largely ignored New Zealand's early adoption of water fluoridation. This paper addresses this deficiency.

Caries prevention through the fluoridation of milk. A review

The aim of this review is to give an overview of 50 years experience of milk fluoridation and draw conclusions about the applicability of the method. Fluoridated milk was first investigated in the early 1950s, almost simultaneously in Switzerland, the USA and Japan. Stimulated by the favourable results obtained from these early studies, the establishment of The Borrow Dental Milk Foundation (subsequently The Borrow Foundation) in England gave an excellent opportunity for further research, both clinical and non-clinical, and a productive collaboration with the World Health Organization from the early 1980s onwards. Numerous peer-reviewed publications in international journals showed clearly the bioavailability of fluoride in milk, and increased concentrations of fluoride in saliva, dental plaque, dental enamel and dentine, and urine, after consumption of fluoridated milk. Clinical trials were initiated in the 1980s--some of these can be classed as randomised controlled trials, while most of the clinical studies were community preventive programs. These evaluations showed clearly that the optimal daily intake of fluoride in milk is effective in preventing dental caries. At present, milk fluoridation programs are running continuously in about ten countries of the world. Fluoridation of milk can be recommended as a caries preventive measure where the fluoride concentration in drinking water is suboptimal, caries experience in children is significant, and there is an existing school milk program. The program should aim to provide fluoridated milk for at least 200 days per year and should commence before the children are 4 years of age.

Orthodontics in 3 millennia. Chapter 5: the American Board of Orthodontics, Albert Ketcham, and early 20th-century appliances

Early in the last century, 3 events put Colorado in the orthodontic spotlight: the discovery-by an orthodontist-of the caries-preventive powers of fluoridated water, the formation of dentistry's first specialty board, and the founding of a supply company by and for orthodontists. Meanwhile, inventive practitioners were giving the profession more choices of treatment modalities, and stainless steel was making its feeble debut.

The effective use of fluorides in public health

Dental caries remain a public health problem for many developing countries and for underprivileged populations in developed countries. This paper outlines the historical development of public health approaches to the use of fluoride and comments on their effectiveness. Early research and development was concerned with waterborne fluorides, both naturally occurring and added, and their effects on the prevalence and incidence of dental caries and dental fluorosis. In the latter half of the 20th century, the focus of research was on fluoride toothpastes and mouth rinses. More recently, systematic reviews summarizing these extensive databases have indicated that water fluoridation and fluoride toothpastes both substantially reduce the prevalence and incidence of dental caries. We present four case studies that illustrate the use of fluoride in modern public health practice, focusing on: recent water fluoridation schemes in California, USA; salt fluoridation in Jamaica; milk fluoridation in Chile; and the development of "affordable" fluoride toothpastes in Indonesia. Common themes are the concern to reduce demands for compliance with fluoride regimes that rely upon action by individuals and their families, and the issue of cost. We recommend that a community should use no more than one systemic fluoride (i.e. water or salt or milk fluoridation) combined with the use of fluoride toothpastes, and that the prevalence of dental fluorosis should be monitored in order to detect increases in or higher-than-acceptable levels.

An historical perspective on early progress of Queensland water fluoridation 1945-1954: sheep, climate and sugar

BACKGROUND

Queensland's virtual rejection of artificial water fluoridation sets it apart from other Australian states, yet the early fluoride environs has been scantily recorded.

METHODS

This paper used archives, literature review, personal interview and the traditional historic method.

RESULTS

The connection between Queensland artesian bore water and caries resistance was postulated as early as 1912. Four decades later, two Queensland-specific factors influenced the planning to fluoridate community water supplies. The first (1945-1950) was confusion between the high levels of fluoride in artesian water supplying the pastoral industry and the scientific concept of artificial water fluoridation of communal supplies. The second (1952-1954) involved further scientific investigation involving water consumption patterns, occupational dehydration and fluid homeostasis within a sub-tropical climate. The role of the Australian Dental Association Queensland Branch (ADAQ) in early fluoride politics was minimal. Four early protagonists are identified--two dentists, an engineer and the sugar industry.

CONCLUSIONS

Queensland had its advocates for artificial water fluoridation of communal supply as a means of caries prevention. Interest came from the dental, medical and engineering professions, and from the sugar industry. However, these efforts met with indifference based on confused extrapolation of the artesian experience (1945-1952) and hesitancy (1952-1954) due to contemporaneous concerns about human fluid homeostasis in Queensland's sub-tropical climate.

The artificial nature of fluoridated water: between nations, knowledge, and material flows

An exercise in "historical ontology," this paper charts the contrasting ways fluoridated water and its effects crystallized as objects of knowledge and concern in three quite different realms over the mid twentieth century. Among U.S. health officials and experts, fluoridated water emerged and stabilized as a public health goal, preventing tooth decay. Indian doctors and scientists defined it as a public health problem, causing "skeletal fluorosis." Fluoridated water also acquired an intense presence among laypeople in the United States, especially those voting in local referenda on fluoridation. More often than not rejecting it, suspecting bias and myopia in profluoridation expertise, they cobbled together a lay ontology that proved predictive of the varied and changing flows of fluoridated water itself. The paper concludes by suggesting a principle of environmental symmetry as an aid to this kind of comparative ontology.

History of water fluoridation

Fluoride, the milestone element of pediatric dentistry, as well as modern dentistry, has been utilized for the last six decades in practice. Researchers all over the world have used fluoride in several forms in the prevention of tooth decay. Today, we are aware that most of this work has involved clinical research with children. It is particularly pertinent that the subject be adequately presented in the field of pediatric dentistry. In 1940's and 1950's were the years of ten-year studies, where caries reductions were first described. The industry of systemic fluoridation, public campaigns and advertisements became popular mostly in western world in 1960's and 1970's. The fluoridated dentifrices and changes of dentifrice formulations were established in 1980's. Many stated that children should receive one form of systemic fluoride and appropriate forms of topical fluoride in 1990's. Analyses showed that maximum protection against caries is obtained when teeth erupt into an environment with low concentrations of ionic fluoride. The similarity in caries reductions obtained in water fluoridation studies and long-term studies with topically administered fluoride regimens, including fluoride-containing dentifrices, indicates that the pre-eruptive effect of fluoride is of borderline significance relative to the more significant post-eruptive effect. It has taken a long time to show that water fluoridation and topical fluoride programs were thus important measures for the control of caries at the community level. Today, we are aware of the fact that the trio of diet, dentifrice and supplementation should exceed the optimal levels.

Successes and drawbacks in the caries-preventive use of fluorides--lessons to be learnt from history

Water fluoridation was the first breakthrough in the practice of preventive cariology on a community level and has remained one of the cornerstones of prevention in dentistry. The concepts regarding the mechanisms of the caries-inhibitory effect, however, have changed in several respects. Today there is general agreement that topical effects on the erupted enamel are most important. The contention that there is no pre-eruptive effect whatsoever has created confusion; there is in fact evidence for a minor pre-eruptive protective effect. Around 1980 many experts believed that fluorides should not be used in high concentrations, for instance above those in dentifrices, because this could block remineralisation in the body of pre-cavity lesions. However, it is now known that such undesirable effects are negligible or non-existent. In the fifties and sixties, fluoride tablets were widely used in Europe and helped to make the concept of caries prevention popular. From 1980 onwards, fluoride dentifrices were found to have a much greater impact and were recognized as being able to lead to a decline of caries prevalence in entire countries, and fluoride tablets gradually lost their importance. Antifluoridationists were unable to delay or hinder the widespread use of fluoride toothpastes but in many cases have successfully opposed public health measures such as fluoridation of water or of salt. The spread of these methods, beneficial for all social strata, might have been more rapid if some of the experts had not propounded the erroneous supposition that fluoride dentifrice will be sufficient for caries prevention. Sale of fluoridated salt has been authorized in several countries on a nationwide scale. However, only Latin American countries have introduced salt fluoridation for entire populations. In Central and Eastern Europe where caries prevalence continues to be high and where the level of usage of topical fluorides including dentifrices will presumably remain at a low level for many years, salt fluoridation would be beneficial.

Dentistry between pathology and cosmetics

In ancient and medieval times, the prevalence of caries and periodontal disease varied. There were no treatments for dental hard tissue, but dental cosmetics played an important role. In the late 19th century, caries levels reached a maximum in Europe and North America after refined sugar became a cheap staple food. Toothlessness became frequent even in young adults. Caries prevention, effective on a public health scale, began with the introduction of water fluoridation in the 1940s. By 1985, dental academia had acknowledged that substantial declines could also be obtained in entire populations through topical fluorides, mainly in toothpastes. While decreasing caries prevalence is irrefutable in affluent countries, the specific reasons of the decline are still a matter of debate. In countries where caries has declined substantially, activities of dentists are shifting towards cosmetic dentistry. However, caries continues to be a problem for the lower socioeconomic strata, even in affluent countries, and is a serious problem in developing countries. Thus, water fluoridation is still important, and salt fluoridation should be considered where water fluoridation is not feasible. Both measures are extremely cheap to implement. Controlled fluoridation has a great potential for developing countries and low social strata of affluent countries. Its reduced effectiveness in high socioeconomic strata of affluent countries, due to the widespread usage of fluoride in toothpastes and other oral care products, should not detract from the public health value of fluoridation.

Fluoridation and the private practice of dentistry

Water fluoridation holds an important place in the history of Grand Rapids. This paper recounts the firsthand professional experiences of a dentist before and after he joined his father's established dental practice in Grand Rapids, only two years after fluoridation of the city's water supply began. The benefits of water fluoridation are documented through a review of office records. The prevalence of dental caries in patients who were born in Grand Rapids after water fluoridation began is low, and no case of a missing first permanent molar was found. Quadrant dentistry is no longer practiced. Children of parents born in Grand Rapids after the start of water fluoridation experience less decay than their parents, suggesting that factors in addition to water fluoridation have played a role in the downward trends in caries. The complete destruction of mouths of patients seen in this practice 50 years ago no longer happens, providing evidence of the benefits of water fluoridation, the most important advance ever in dentistry.

John E. Echternacht: practitioner and community leader

For Minnesota dentists with long memories, Dr Jack Echternacht is a legendary figure. He graduated from the University of Minnesota School of Dentistry in 1943. Except for a 3-year enlistment in the Navy during World War II, he has made his home and his professional life in Brainerd, on the edge of Minnesota's lake country. A few years after he started his general practice, reports began to appear about the striking reduction of dental caries in children's teeth when fluoride was placed in the drinking water. Excited by these prospects for better oral health, Dr Echternacht led a Chamber of Commerce initiative in 1954 to introduce fluoride into Brainerd's water supply. What seemed at first an easy victory turned into a 30-year struggle. Dr Echternacht's determination, persistence, and leadership during this fight for fluoridation led to his selection as a moral model in dentistry.

Commitment to community service: the story of Dr. Jack Echternacht

Using the criteria developed by Colby and Damon, the authors identified Dr. Jack Echternacht as a moral hero. This paper describes his thirty-year fight to fluoridate the drinking water of Brainerd, Minnesota. Family influences on his character are also presented.

Solving the mystery of the Colorado Brown Stain

The life and work of Dr. Frederick S. McKay in solving the mystery of the Colorado Brown Stain changed the objectives of restorative and preventive dentistry. McKay was an intellectually diversified man whose personal interests ranged from economics to opera. Professionally his strong commitment to research led to dedicate thirty years of his life to the search for the mysterious agent that caused the Colorado Brown Stain which mottled but also produced caries-free teeth. His discovery of fluoride in drinking water and its effect on enamel was a critical breakthrough in understanding the etiology and prevention of dental caries. This discovery is the foundation for water fluoridation which is the single most effective public health measure to inhibit tooth decay.

Water and turf: fluoridation and the 20th-century fate of waterworks engineers

Once central figures in American public health, waterworks engineers are no longer involved in many decisions made about the public water supplies. This paper argues that the profession's response to the early fluoridation movement of the 1940s and 1950s marked a change in the relationship between waterworks engineers and the other constitutive groups in public health and contributed to the disenfranchisement of the waterworks profession. Sensing a potentially divisive issue, two leaders of the profession, Abel Wolman and Linn Enslow, took steps they hoped would prevent a rift within the profession and allow waterworks engineering to continue its association with the wider public health community. Although the leaders saw the fluoridation issue differently, neither encouraged the profession to consider it openly or to take up the broader question of what limits, if any, should be placed on treating water supplies to meet human needs. Instead, they opted to locate authority for fluoridation outside the waterworks profession with dentists, doctors, and public health administrators. As a result, waterworks engineers conceded a great deal of the status and prestige associated with decision-making roles in community health issues and have largely faded from view.

The dawn of a new era

This paper reviews the scientific events culminating in the fluoridation of communal water supplies. Dental and medical studies completed by 1942 had established the safety and benefits of exposure to drinking water naturally containing fluoride. Researchers and public health workers concluded that it was possible to test the hypothesis that the dental benefits attained where fluoride levels around 1 ppm occurred naturally in drinking water could be safely replicated in low-fluoride areas by raising the level to this optimal concentration. Grand Rapids became the first test site and by the time the demonstration ended in 1959, around 40 million people in about 2,000 communities already were drinking water with fluoride levels that had been adjusted to optimal. The success of fluoridation brought the dawn of the era of caries control and created great opportunities for research and public health.