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Mild fluorosis pic available

Thanks to the prompt work of User:Dozenist, the picture to right is now available for us to use. What do you guys think? Xasodfuih (talk) 03:10, 25 February 2009 (UTC)

I think it's great! Thanks to you and to Dozenist. I added it. Eubulides (talk) 06:08, 25 February 2009 (UTC)
No problem. I try to help anytime I can with dental content. - Dozenist talk 13:47, 25 February 2009 (UTC)

Leads for country info

Google found this 2-page overview the reasons (allegdly) invoked by some countries in rejecting fluoridation (plus a graph, which I won't comment on). This is clearly an advocacy site, so we'd the need info from other sources, but it seems to exist.

Also quite interesting, according to this page, the Japanese Dental Association is the major stumbling block to water fluoridation in Japan; this is a personal web site, so we'd need something better for a FA article. But it raises the interesting question whether profits are one of the reasons some dentists oppose WF. The reviews I've read during the FAC made me conclude that a strong predictor for the recommendation made by a reviewer is whether (s)he was employed by a public health body or has a relationship with a dental education/practice. Without getting into speculation as to their motivations, the official position of dental associations in a few countries would be an interesting addition to the article. I'm having the impression that the "ethics" sections is missing an important factor (namely the money made by alternative treatments). Xasodfuih (talk) 01:12, 22 February 2009 (UTC)

After trawling through Science Direct, I was able to find this (no pubmed id?). It doesn't say why either country doesn't fluoridate water (anymore, as East Germany did it), but it has good coverage of preventive dental care in Germany and Japan. I'll add 1-2 sentences from it unless somebody objects, but I'm kinda tired now to write a good summary. Xasodfuih (talk) 03:39, 22 February 2009 (UTC)
A much better source, from a worldwide perspective, is already cited in the article (as "ref name=extent"):
  • The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health (2004). "The extent of water fluoridation". One in a Million: The facts about water fluoridation (2nd ed.). pp. 55–80. ISBN 095476840X. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)CS1 maint: multiple names: authors list (link)
This is an advocacy source so it has to be taken with a grain of salt, but it's a good source nonetheless. I will try to draft something if you don't beat me to it first. Eubulides (talk) 15:51, 22 February 2009 (UTC)
Go ahead, I'm supposed to be the reviewer. Xasodfuih (talk) 16:57, 22 February 2009 (UTC)
I did install something along these lines on 2009-02-24, but forgot to note it here until now. Eubulides (talk) 09:30, 26 February 2009 (UTC)
I had a look at the chapter you indicated (7), but I don't see any info on reasons for opposition in other countries (and it's mostly UK/US statistics). Perhaps you indicated the wrong chapter? Xasodfuih (talk) 11:59, 25 February 2009 (UTC)
I was referring to the commentary on p. 72 of chapter 7. Eubulides (talk) 09:30, 26 February 2009 (UTC)

Lead (Pb)

Is there a reason why PMID 16393670 isn't cited in relation to that? I see that their conclusion was contradicted by the later PMID 17420053. Can someone give me a 2-3 sentence summary on this issue. Not feeling like reading either paper, although I have full text access to both. Xasodfuih (talk) 05:19, 22 February 2009 (UTC)

We shouldn't be dipping into the primary sources at all in this area. This is an area where primary sources are being used to dispute a reliable review, and as per WP:MEDRS the article shouldn't be doing that. The theory that water fluoridation causes lead poisoning and increases crime rates is put out by just one group and is rejected by mainstream sources. As per WP:MEDRS, we should not be citing the primary sources Coplan et al. 2007 (PMID 17420053) and Maas et al. 2007 (PMID 17697714) when we have a reliable secondary source on the same subject, namely Pollick 2004 (PMID 15473093). Admittedly the group in question puts out lots of studies, but they have been rejected by the mainstream, and should not be emphasized merely because they happened to have put out some studies since the last time they were shot down (that would be WP:RECENTISM). I removed the lead-poisoning primary sources; the review is enough in this area. Eubulides (talk) 15:51, 22 February 2009 (UTC)
That group has indeed put out 3 studies (paste the url since it has brackets which screw the formatting: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Coplan%20MJ%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus) The last two are from 2007, so they're unlikely to be discussed in a review. What about the 2000 study (PMID 11233755)? Can you point out the issues with it? Xasodfuih (talk) 00:21, 23 February 2009 (UTC)
To answer my own question, the 2006 PMID 16393670 (Macek) spends a good chunk of the introduction bashing the previous studies by Masters and Copland; they conclude: "Controlling for covariates, water fluoridation method was significant only in the models that included dwellings built before 1946 and dwellings of unknown age. Across stratum-specific models for dwellings of known age, neither hydrofluosilicic acid nor sodium silicofluoride were associated with higher geometric mean PbB concentrations or prevalence values. Given these findings, our analyses, though not definitive, do not support concerns that silicofluorides in community water systems cause higher PbB concentrations in children." So, it looks like for very old dwellings it may be a factor, although the number of such dwellings in the US is probably vanishingly small. Macek specifically criticizes the 2000 Masters & Copland study for using untransformed Pb concentration in anaylsis of variance. By the way, these guys are all analysis/arguing about the same NHANES data from the 1990s. Xasodfuih (talk) 00:42, 23 February 2009 (UTC)
The rebuttal from Coplan is "However, using log transformed, less skewed data to find a central tendency does injustice to worst case children." Hardly a good statistical argument. Xasodfuih (talk) 02:52, 23 February 2009 (UTC)

This kerfuffle is poorly presented from thee PMID 15473093 article published in 2004 in a small-potatoes journal IJOEH (IF 1.48), which precedes the full publication of Macek PMID 16393670 in 2006, which was commissioned by the CDC specifically to investigate the claims by Masters and Coplan (2000), and really ought to be cited. Not having easy access to it, I guess that PMID 15473093 cited the preliminary (1-page?) publication of Macek in J Public Health Dent 2003;63(suppl 1):S36 [could not find it in pubmed], because Coplan 2007 cites it together with the final publication from Macek. Macek's 2006 paper is published in a much more reputable venue (EHP, the top environmental science journal, IF 5.something). Even Coplan's papers are published in a more reputable journal than the source currently used in this wiki article (Neurotoxicology has IF 3). I'm going to rewrite that paragraph; this has nothing to do with WP:RECENTISM, but has everything to with which article is the more credible source for statistics because both these groups used the same NHANES data. Xasodfuih (talk) 02:52, 23 February 2009 (UTC)

Update 1: Pollick is a very marginal source on this issue because he doesn't cite any of the primary sources being discussed above, as I incorrectly assumed above. Instead he cites .org/urbansky.pdf a paper by Urbanski (2000, ref 40 in Pollick). We should be citing this paper as well for the chemistry part, but given that the CDC bothered to commission Macek's study about the epidemiological association as a result of Master and Coplan's initial work, we need to cite that more specific (and recent) paper. Urbansky is most useful for the chemistry part: "Overall, we conclude that no credible evidence exists to show that water fluoridation has any quantifiable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead(0) or lead(II) compounds. The governing factors are the concentrations of a number of other species, such as (bi)carbonate, hydroxide, or chloride, whose effects far exceed those of fluoride or fluorosilicates under drinking water conditions." Xasodfuih (talk) 04:17, 23 February 2009 (UTC)

Regardless of PubMed's classification, Coplan et al. 2007 (PMID 17420053) is not a research article. It's a review. I gather that the original 2000 Masters studies did not use the NHANES data; it was an ecologic analysis and Macek said it had "uncertain sampling". Xasodfuih points out that Pollick does not provide very good coverage on this issue. It might be better for readers to cite Macek and Coplan 2007. That gives them a summary of the issue: Macek couldn't replicate the finding but did not definitively rule out the association, Coplan attempted a rebuttal. II | (t - c) 23:55, 24 February 2009 (UTC)

  • Coplan et al. 2007 (PMID 17420053) does not claim to be a review, and in reading it, it is not a review: it is a statement of a hypothesis, and it contains many claims that can only be characterized as speculations. For example, it says "chronic ingestion of SiFW is a major factor in the linkage of dental fluorosis with fluoridated water" based on extremely sketchy reports from India about "silicon" in water. My favorite was the claim "Contrary to common belief, fluorotic enamel per se does not prevent caries" in an attempt to undermine the well-established consensus that fluoride prevents cavities. This is not a reliable source at all.
  • Coplan is on record with letters containing section headers like "Why the CDC Cannot Be Trusted" and "EPA's continued effort at misdirection",[1] rhetoric that (to be frank) makes him look like a crank.
  • The balance of all this back-and-forth is that the mainstream opinion does not seem to take the Masters & Coplan hypotheses seriously any more. We should not be treating this as an issue where Masters & Coplan deserve equal time with the mainstream opinion that their theory is unfounded. Nor should we be giving the theory more WP:WEIGHT than other unsupported theories such as the arsenic-and-lead theory or the corrosivity theory.
  • One simple way to address the issue is to cite Macek et al. 2006 (PMID 16393670) on the topic, as this is the most authoritative recent source. I did that; hope it suffices.
Eubulides (talk) 09:30, 26 February 2009 (UTC)

Milk fluoridation fluorosis review in the safety section

I'm not sure this change added the detail in the right spot. The wording in that context is also problematic since might suggest that it's the fluoride in the milk that's "bad", whereas the one in the water is "good". Clearly any form of fluoridation can result in fluorosis; it's not the mode that matters, it's the overall dose. This is a point that the current wiki article fails to make clearly enough, and instead gets into an apparent contest between fluoridation modes at every opportunity. I suggest that that sentence be moved to the Alternative methods section. Xasodfuih (talk) 05:16, 23 February 2009 (UTC)

Sorry, I don't follow the previous comment. The change in question altered a sentence about fluoridated water added to infant formula; that sentence is about water (and/or formula) and is not about milk. Eubulides (talk) 09:30, 26 February 2009 (UTC)

Nuffield Council on Bioethics

This edit added a long quote from the 2007 Nuffield Council on Bioethics. Three thoughts: first, we should not have extensive quotes like that, but should be writing our own words. Second: in the context of this article, that coverage of the council is too long; it should be a brief sentence that summarizes what they said. Third, the coverage should be in the 1st paragraph of Water fluoridation #Ethics and politics (which talks about ethics), rather than at the end of the last paragraph (which talks about politics). Eubulides (talk) 17:57, 25 February 2009 (UTC)

I read the edit more carefully, and found that most of the points it makes are already addressed by Water fluoridation, with the exception that the Council decided that the most appropriate way to decide whether to fluoridate is to use democratic procedures that are at the local and regional, rather than national, level. This point is more useful in the last paragraph, so I struck that part of my comment above. I made this further edit to capture the new point, and to provide the following higher-quality citation to the Nuffield results:
Eubulides (talk) 09:30, 26 February 2009 (UTC)

European, not other industrialized

This edit changed "most European countries have experienced substantial declines" to "most other industrialized countries have experienced substantial declines". The cited source says "European" not "other industrialized"; (Pizzo et al. 2007, PMID 17333303) says "Moreover, in most European countries, where CWF has never been adopted, a substantial decline in caries prevalence has been reported in the last decades, with reductions in lifetime caries experience exceeding 75%." I changed the text to say "European". Eubulides (talk) 15:51, 22 February 2009 (UTC)

He also says right after that "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the 1970s." I was trying to cover more than Europe with that sentence. In Japan the fluoridated toothpaste utilization is about 88% in children and they don't have any water/salt/milk fluoridation. Xasodfuih (talk) 16:36, 22 February 2009 (UTC)
That's true, but it's still incorrect to cite Japan in replacing "most European countries have experienced substantial declines in tooth decay without its use" with "most industrialized countries have experienced substantial declines in tooth decay without its use", as parts of Japan formerly did use water fluoridation. The wording in the lead has to be very careful in following what the source says. By the way, although it's true that most European countries have seen declines without using fluoridation, that's only because the statement is counting countries, many of which have small populations. By the way, sorry I haven't caught up with the talk-page comments; I've been busy on the FAC page. I'll try to catch up with the comments here soon. Eubulides (talk) 17:50, 25 February 2009 (UTC)
Based on the sources I've seen, I think that Japan never fluoridated their water. Can you provide a reference for your claim that they did? Xasodfuih (talk) 10:11, 1 March 2009 (UTC)
Tsurumoto et al. 1998 (PMID 9669597) write "Japan had three brief experiences with water fluoridation." This is according to a Google Scholar snippet; I haven't tried to get full access to the paper, but I'd guess they're talking about Honshu. Okinawa (which is part of Japan) mostly used fluoridated water from 1945 to 1972, while it was under U.S. administration; see Tohyama 1996 (PMID 9002384). Eubulides (talk) 09:04, 2 March 2009 (UTC)

Fluorapatite

The article has a section on "mechanism" but the content is vague and talks about consequences, not mechanism - how fluoride works. My understanding is that fluoride effects one quite specific chemical reaction, converts some of apatite (component of enamel) to fluorapatite, and the latter is more resistant to bacterial attack. The change entails replacement of OH- with F-, and these are isostructural, virtually. --Smokefoot (talk) 15:24, 1 March 2009 (UTC)

Thanks, I rewrote the first part of "Mechanism" to try to cover that issue better. As part of the rewrite, I removed the claim "Fluoride has minimal effect on cavities after it is swallowed." (citing Featherstone 1999, PMID 10086924) since newer sources, such as Cury & Tenuta 2008 (PMID 18694871) don't seem as confident on this point, and Featherstone 2008 (PMID 18782377) doesn't seem to repeat it. Eubulides (talk) 09:04, 2 March 2009 (UTC)

A question about the byline of a source often used, One in a Million

Why is the One in a Million book being attributed to "The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health". I see nothing beyond "The British Fluoridation Society" in their copyright, although Worldcat lists some "et al." in the byline. Also, based on Worldcat, this appears to be a self-published book, although I don't think we should avoid it for that reason alone because they cite their sources. Xasodfuih (talk) 10:49, 1 March 2009 (UTC)

The cover of the document (PDF) lists all four organizations under the line "Published by", and page iv of the document lists all four organizations again along with their missions and contact details. It is a self-published book and it clearly is an advocacy document whose opinions we cannot state as fact; but the four organizations are high-quality ones and the facts that all four endorse it and that the book cites its sources are both good signs. Eubulides (talk) 09:04, 2 March 2009 (UTC)
Thanks for looking into that. I was getting a little worried because the printed book is held by only 4 libraries in the world (according to Worlcat, there might be more). Xasodfuih (talk) 10:26, 3 March 2009 (UTC)
You're welcome. Unfortunately Worldcat isn't that reliable about the availability of medical sources. These days, the vast majority of uses of medical sources are online uses. Eubulides (talk) 09:08, 4 March 2009 (UTC)

Psychological effects

The point about placebo psychological effects made by Lamberg et al. 1997 (PMID 9332806) was removed with the comment "remove 1997 research article which is not supported by the weight of the literature". I don't understand this remark; it is not controversial among reliable sources that placebo psychological effects exist. The placebo psychological-effect problem is obvious to experts, but not so obvious to the general public, so it's worth briefly mentioning here. I propose reinserting the point, focused a bit so that it takes up less text, as follows: "Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated.", citing Lamberg et al. Eubulides (talk) 15:51, 22 February 2009 (UTC)

I wasn't the editor to remove that, but I don't see how the placebo effect is related to bone fractures or cancer since neither of those are diagnosed based on subjective symptoms. If you want to say that idiosyncratic symptoms of XYZ are not influenced by WF, that's fine with me, but specify what XYZ is. Xasodfuih (talk) 05:03, 23 February 2009 (UTC)
It's not controversial that placebos can generate negative effects (the nocebo effect). But 1 study does not demonstrate that that the extent of the effect is uncontroversial in people complaining about symptoms due to water fluoridation. The research on actual hypersensitivity reactions is so closely-related that we can't cite one without the other. These reactions are backed up by more literature: case reports from various people, a double-blind study, and that 1961 study which found reactions in 1% of their sample group. This is all covered secondarily by the NRC 2006 report. Citing the 1997 research article (a "primary" study) without citing the other research articles (also "primary") is misleading, and will lead readers to think that all these symptoms are psychological. II | (t - c) 23:15, 24 February 2009 (UTC)
  • The proposed text doesn't say anything about the extent of the effect; it merely says that the effect exists, which is indisputable.
  • The placebo psychological effect operates across all the benefits and adverse effects of fluoridation; it is not at all limited to hypersensitivity.
  • There is nothing controversial about the placebo psychological effect per se. There is plenty controversial about the hypersensitivity studies; as the NRC 2006 report demonstrates, there is no mainstream consensus that hypersensitivity exists even at fluoride levels well above the recommended levels.
Eubulides (talk) 09:30, 26 February 2009 (UTC)
A negative placebo effect response to something is noncontroversial for everything. The extent and notability is what matters. I don't have access to your primary study, but we don't know how controversial it is because we don't have any decent secondary coverage of the paper. There's only been 1 study. People who see that study cited with your language will assume that all symptoms attributed to fluoride are from hypochondriacs. Further, that study is strange -- it said that around 30-40% attribute symptoms to fluoride. Normal communities do not attribute negative effects to water fluoridation at that level, especially since many people don't even know whether their community is fluoridated, or why it is. I can't support the addition and will vigorously contest its addition. Also, my reading of the NRC coverage of the hypersensitivity (page 269, page 208, and page 293) suggests that it's not that controversial. We can't be certain, but there's been zero negative studies and several positive studies. II | (t - c) 19:33, 26 February 2009 (UTC)
  • "notability is what matters" Every systematic review comments on the desirability of blinding; this is to avoid placebo psychological effects.
  • "There's only been 1 study." True, but there's no dispute among reliable sources that the placebo psychological effect exists. The point has been well understood for decades. For example:
"The power of suggestion has been vividly demonstrated on several occasions. For instance, in New York's Westchester County and two or three other localities the announcement that the water would be fluoridated was followed by a flood of complaints of bad-tasting water, sudden aches and pains, and dead goldfish and dogs—even before any fluoride was put into the water ! A witness before a Congressional committee declared that he had fainted from drinking two cups of coffee made from fluoridated water." Mausner B, Mausner J (1955). "Fluoridation: a study of the anti-scientific attitude". Sci Am. 192 (2): 35–39. Reprint: Health Educ J. 14 (3): 123–32. 1956. doi:10.1177/001789695601400304. {{cite journal}}: Missing or empty |title= (help)
The existence of the placebo psychological effect is not a controversial point, even on this talk page. We would of course prefer a reliable review on the placebo psychological effect in studies of fluoridation, but that is a rather specialized topic, for which reviews are not available, so we need to do the best we can.
  • "People who see that study cited with your language will assume that all symptoms attributed to fluoride are from hypochondriacs." I don't see why; the proposed language doesn't say anything about hypochondria, nor does it say anything about "all symptoms". If there is a concern about this, can you suggest specific wording that would help to allay that concern?
  • "Further, that study is strange -- it said that around 30-40% attribute symptoms to fluoride." Sorry, I don't know what this comment is referring to. The study never gives a range of 30–40%. And the study never asked respondents whether they attributed their symptoms to fluoride. Are you sure we're talking about the same study? I'm talking about Lamberg et al. 1997 (PMID 9332806).
  • "my reading of the NRC coverage of the hypersensitivity (page 269, page 208, and page 293) suggests that it's not that controversial. We can't be certain, but there's been zero negative studies and several positive studies." Sure there are negative studies. Page 269 says "Nevertheless, there are reports of areas in the United States where the drinking water contains fluoride at concentrations greater than 4 mg/L and as much as 8 mg/L (Leone et al. 1955b). Symptoms of GI distress or discomfort were not reported. In the United Kingdom, where tea drinking is more common, people can consume up to 9 mg of fluoride a day (Jenkins 1991). GI symptoms were not reported in the tea drinkers. The absence of symptoms might be related to the hardness of the water, which is high in some areas of the United Kingdom." Furthermore, only one of the pages you cite is relevant to hypersensitivity: page 208 is about Chinese studies involving natural fluoridation well above recommended levels, along with fluoridation from coal fires. Page 269 is about GI symptoms, not hypersensitivity, and says "Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated". Page 293 is the only citation about hypersensitivity, and it says that the anecdotal reports do not represent any type of hypersensitivity recognized by the American Academy of Allergy, and devotes most of its analysis (which is understandable, given the NRC's mandate) to fluoride concentrations well above recommended values. This is in contrast to the York review, which is devoted to water fluoridation, and which states there's no clear evidence of this adverse effect.
  • "I don't have access to your primary study, but we don't know how controversial it is" Again, no part of the study that is potentially controversial is being used to support the cited text. It is not controversial that the placebo psychological effect exists.
Eubulides (talk) 21:16, 26 February 2009 (UTC)

Lamberg study

(unindent) The Lamberg study says "The percentage of those with two or more symptoms was the same (45%) in November and in December but decreased to 32% in March. The mean number of symptoms per respondent decreased from 1.9 in November to 1.4 in March (P < 0.001) and in December-March from 1.8 to 1.2". That's the 30-40% that I'm talking about. It doesn't make sense that nearly half of the sample group would attribute their symptoms to fluoride, because in most communities there's almost zero complaints. Lamberg looked at an anomalous community. Also, the bottom of page 208 says "there are numerous reports of mental and physiological changes after exposure to fluoride from various routes (air, food, and water) and for various time periods (Waldbott et al. 1978). A number of the reports are, in fact, experimental studies of one or more individuals who underwent withdrawal from their source of fluoride exposure and subsequent re-exposures under “blind” conditions". My terms are clear and fair: if we cite the 1997 study, we have to mention the reported real reactions. If not, then we don't cite either. 22:29, 26 February 2009 (UTC) (signed:ImperfectlyInformed)

I actually don't see that the Lamberg study shows anything at all. If fluoridated water has maleficent effects, they could well persist for a month after cessation of exposure. This is the danger of relying on primary sources. I've only read the abstract, perhaps this is discussed in the paper itself. Franamax (talk) 23:21, 26 February 2009 (UTC)
  • This subthread (about the details of the study of Lamberg et al. 1997 (PMID 9332806)) has nothing to do with the original topic of this section (about whether Water fluoridation should mention placebo psychological effects). The proposed text doesn't talk about 32% or 45% or whatever; it says only that placebo psychological effects occur during fluoridation. So this subthread (and my following bullets) are irrelevant to the proposed text.
  • "I actually don't see that the Lamberg study shows anything at all. If fluoridated water has maleficent effects, they could well persist for a month after cessation of exposure." It would be remarkable if all the symptoms in question persisted practically unchanged for a month after fluoride was secretly removed, and then suddenly dropped, no? What mechanism would explain that? Also, some of the survey questions asked about the perceived quality of the water, e.g., a "fluoride taste". When the fluoride was secretly removed, the percentage of people who claimed they detected a "fluoride taste" remained the same for a month, until after the point in time that they thought the fluoride was removed; after that, they stopped reporting a "fluoride taste". The people who reported the "fluoride taste" seemed to be predisposed to reporting other perceived symptoms, further confirming the psychological aspect of these reports.
  • "It doesn't make sense that nearly half of the sample group would attribute their symptoms to fluoride" Again, the survey did not ask whether people attributed their symptoms to fluoride, and Lamberg et al. did not claim that nearly half the sample group attributed their symptoms to fluoride.
  • "in most communities there's almost zero complaints" Not true: many people complain of symptoms like insomnia or constipation, in communities all over the world.
  • "Lamberg looked at an anomalous community" No evidence has been presented to support that claim. The claim that the community was anomalous seems to be based on a misunderstanding of Lamberg et al.'s experiment.
  • "Also, the bottom of page 208 says" The bottom of the NRC report's page 208 is not clearly talking about exposures to fluoride at water-fluoridation levels; data about higher exposure levels may be relevant for the NRC study (which is about higher levels of fluoride exposure, and is not about water fluoridation) but it is not relevant here.
  • "My terms are clear and fair" This is not a bargaining situation. It is not reasonable to hold a well-supported and noncontroversial topic (namely, the placebo psychological effect) hostage to the insertion of a different, controversial and poorly-supported topic (namely, hypersensitivity to fluoride).
Eubulides (talk) 01:04, 27 February 2009 (UTC)
I'm a little confused here over the apparent conflation of "placebo"/"nocebo" with "psychological effects". The two are not necessarily synonymous. One is a (sub-)conscious process which attributes symptoms to causes, the other is a mysterious medical phenomenon which seemingly affects outcomes and may be associated with the unconscious mind. Having only read the Lambert abstract, I see nothing attributing a placebo/nocebo effect. Franamax (talk) 03:05, 27 February 2009 (UTC)
You are correct that Lamberg et al. do not use the word "placebo", and talk only about "psychological" effects. I'd rather not get hung up with terminology, so please pretend that I've uniformly written "psychological effect" rather than "placebo". I've changed the name of this section accordingly, and have struck out "placebo" and replaced it with "psychological" in my comments. Eubulides (talk) 09:15, 27 February 2009 (UTC)
I'm not really following? In the cases Eubulides is discussing, people attribute their symptoms to fluoridation even though it's not happening. It's not conscious. II | (t - c) 03:23, 27 February 2009 (UTC)
Well I did say I was confused. :) My point was that in the Lambert study, people were given the option to both define symptoms and ascribe them to a source. (Not sure on that, I've asked elsewhere for a copy of the paper) But mostly, the study assumes that there are no persistent medical effects and proceeds to the conclusion that the effects are ("may be") psychological. I just find that a little offputting when presented under the thread title "Placebo effects". Franamax (talk) 04:05, 27 February 2009 (UTC)
Lamberg et al. did not give people "the option to both define symptoms and ascribe them to a source". The paper says (p. 292) that the questionnaire asked "questions about the perceived presence or absence of 25 symptoms during the week of inquiry, water consumption patterns, perceived quality of water, opinions concerning water fluoridation and demographic data." Since the list of symptoms were fixed, respondents were not allowed to define them; and the questionnaire did not ask respondents to ascribe symptoms to any source. Eubulides (talk) 09:15, 27 February 2009 (UTC)
Since the study did not actually ask whether the people thought their symptoms were caused by fluoride, the study is even weaker than I thought in demonstrating that people psychologically perceive negative effects from fluoridation. II | (t - c) 03:26, 1 March 2009 (UTC)
I don't see why that would be. The study looked for a statistical association between reported symptoms and the presence of fluoridation. This is much more scientific than asking people whether they think fluoridation causes adverse effects. The latter would merely be an opinion survey. Eubulides (talk) 07:58, 1 March 2009 (UTC)
I've already showed you that the experimental studies mentioned on page 208 are discussed at greater length elsewhere and include the double-blind study at 1/mg L and the other 1961 study which thought that 1% of their sample size appeared hypersensitive. The latter study, published in the American Academy of Oral Medicine's Journal of dental medicine, is somewhat difficult to access. A report by the same authors (likely not the final version) was published in Science in 1955 [2]; it doesn't have the observation. Bruce Spittle's Fluoride Fatigue is a self-published book, but has a quote from the 1961 study (page 11 of the book, PDF page 19). It says "one percent of our cases reacted adversely to the fluoride (1 mg/day) tablets ... by the use of placebos, it was definitely established that the fluoride and not the binder was the causative agent". There have been no negative studies -- that is, nobody has taken these same people and retested them to replicate the results. A lack of GI reports is not the same; a fair percentage of the population suffers these conditions throughout their lives: it's called irritable bowel syndrome. A difference of 1% in fluoridated/unfluoridated communities would be difficult to estimate from epidemiology and random reports, but it would be easy to discover using the simple and superior double-blind RCT. Considering that two studies from two different research teams have reported these under double-blind conditions, and there have been numerous case reports, it's not fair to say that these are "controversial" -- and the NRC does not say that. It is fair to say that the results are not definitive, which the NRC does say. But keeping this issue out, which is covered well by a secondary source, while highlighting your own primary source, cannot be allowed. It's misleading and biased.
As far as wording to make it clear that all people reporting symptoms are not just idiots, I would simply add after your sentence "Other ther studies suggest, however, that perhaps 1% of the population could respond negatively to fluoride at 1 mg/L". Or something to that effect, citing NRC 2006 page 269. II | (t - c) 03:16, 27 February 2009 (UTC)
Please see #Feltman-Kosel 1961 etc. below. Eubulides (talk) 09:15, 27 February 2009 (UTC)

Back on track

Let's get back on track with PMID 9332806 since the other stuff is discussed in the next subsection. I support mentioning this as long as the symptoms attributed to WF are identfied (as well as the study allows). What I was objecting to was mainly objecting to was the vagueness of the statement, and placement after fractures and cancer, which can lead the reader to believe that an annoucement of WF discontinuation (that had already tanke place) reduced symptoms cancer or fractures. I don't have full text access to this; in the abstract I see only "symptoms related to the skin"; was GI among the other symptoms? Xasodfuih (talk) 23:52, 27 February 2009 (UTC) I would propose something like: "In 1992-3, three surveys were conducted in Kuopio, Finland—a city that discontinued fluoridation after public disputes; these surveys found that subjective symptoms, in particular those related to the skin, were unaffected by the actual discontinuation of fluoridation, but significantly dicreased after the offical announcement thereof, a month later, suggesting that fluoridation may have psychological effects which present as somatic symptoms." Xasodfuih (talk) 00:05, 28 February 2009 (UTC)

That's a big jargony and wordy. It also doesn't make clear that these are just symptoms randomly reported and not clearly associated by the respondents as related to fluoridation. The wording will need to be clear on that, since the abstract is not so clear. I'll break this into bullets:
  • Are skin symptoms subjective? I would say not, and the abstract does not say so. Subjective symptoms are "tiredness" sort of things. Skin symptoms are also not the typical thing you'd expect from someone suffering from psychological fluoride effects -- you would expect things like the fainting that Eubulides noted.
  • What's interesting about the Lamberg study is that the symptoms were mainly skin-related, and skin symptoms are what was mainly found by Feltman et al. in 1% of their 600 subjects .org/health/allergy/feltman-1956.html. Although Eubulides is correct that the acute dose of tablets isn't exactly comparable to water fluoridation's dose, the symptoms reported weren't acute. According to FAN, at least six editions of the Physicians Desk Reference (1994 most recent) report that skin symptoms are the most common reactions with fluoride hypersensitivity .org/health/allergy/pdr.html. There's no reason to suspect that FAN is falsely quoting the PDR, but if there's enough doubt, I can try to verify it.
  • FAN has a quote from Lamberg's study which suggests that Eubulides is not giving us the full story .org/health/allergy/:

    Following the termination of water fluoridation, "the significant decrease in the number of other skin rashes leaves room for speculation, seeming to favor the view that a small segment of the population may have some kind of intolerance to fluoride. This group of people should be studied further. The most frequently reported symptoms that disappeared from the time of actual to known discontinuation of fluoridation seemed to be itching and dryness of the skin."

    Thus, it seems that to cite Lamberg's article (and the rest of the literature) fairly, we would need to note that the hypersensitivity interpretation remains plausible. I'd like to look at the study, and technically my library says it has access back to 1997, but the Wiley-Blackwell merger seems to have caused some problems.
  • Franamax's point about these symptoms persisting for about a month is plausible, since fluoride does build up in the soft tissue and it would take a month or two for that to disappear. Presumably, this is what Lamberg et al. allude to in the quote above. II | (t - c) 03:26, 1 March 2009 (UTC)
  • I also disagree with Xasodfuih's proposal, as it would give a lot of weight to the details of a single primary study. Granted, no reliable sources disagree with the study, but still, we should not be spending nearly that many words on it.
  • "was GI among the other symptoms" Yes. The full set of symptoms in Table 3 is: joint pain; muscular pain; muscular tic (myokymia); muscular weakness; difficult breathing (dyspnea); pain in the chest; headache; dizziness (vertigo); numbness; visual disturbance; tinnitus; depression; insomnia; epigastric pain or heartburn; nausea or vomiting; diarrhea; constipation; dysuria; pain in the mouth or toung; nettle rash (urticaria); other skin rash (eczema); itching of the skin; dryness of the skin; smarting of the eyes; exceptional fatigue; other symptom(s); and none of the above symptoms.
  • Xasodfuih's point about confusion with cancer or fractures is well taken, though. How about if we append the proposed text to the 2nd paragraph of Evidence basis instead. Here's what the paragraph would look like afterwards:
"Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation.[1] There is no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma.[1] Other adverse effects lack sufficient evidence to reach a confident conclusion.[2] Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated.[3]"
  • "Are skin symptoms subjective? I would say not" The survey asked respondents for their opinion about whether they had skin symptoms; this was necessarily a subjective measurement.
  • "What's interesting about the Lamberg study is that the symptoms were mainly skin-related" No, symptoms were of a wide variety. For example, 13.6% of respondents complained of joint pain in November (when the water was fluoridated); 13.5% complained of joint pain in December (when they thought the water was fluoridated, but it wasn't); and 10.9% complained of joint pain in March (when the water was not fluoridated, and they knew it).
  • "Although Eubulides is correct that the acute dose of tablets isn't exactly comparable to water fluoridation's dose, the symptoms reported weren't acute." Again, this is citing an old primary source that is not about water fluoridation, and in an area where reliable reviews say there's no clear evidence of adverse effects. We should not be citing primary sources to dispute reliable reviews in this area.
  • "This group of people should be studied further." Agreed, they should be studied further. In a study that asks about lots of different symptoms, it shouldn't be surprising if we find changes that would be significant if we had studied just the one symptom. It's standard in studies that troll for significant results to find them (because they're looking at so many possible results, some are bound to be significant), and then to suggest further research. However, this single group of people that should be studied further is not of concern at the level of Water fluoridation #Safety, for the same reason that it's wasn't of concern to the York review.
  • "The most frequently reported symptoms that disappeared from the time of actual to known discontinuation of fluoridation seemed to be itching and dryness of the skin" (quote from Lamberg et al.) This quote omits the next couple of sentences from Lamberg et al., which read as follows: "The same was true, however, for the period from supposed to known discontinuation of fluoridation. The most frequently perceived symptoms were those that are often linked with the so-called psychosomatic diseases."
  • "fluoride does build up in the soft tissue and it would take a month or two for that to disappear." No, this study was about symptoms, not fluoride levels; and, as Lamberg et al. point out, even after massive intoxication with fluoride, symptoms usually last only 2 to 3 weeks. Their December survey was done after the fluoride concentration had been at its natural level for 3 weeks.
  • Anyway, this thread is spending waaaay too much time talking about the details that do not appear in Water fluoridation, and would not appear with the proposed wording. It's irrelevant to the article.
  • Again, as per WP:MEDRS, we should not be using a primary study to dispute reliable reviews. We should not be citing Lamberg et al. on skin rashes any more than we should be citing Feltman-Kosel 1961 on skin rashes. For skin rashes we should be citing the York review, and similar reliable reviews on adverse effects of water fluoridation.
Eubulides (talk) 07:58, 1 March 2009 (UTC)

Regarding the proposal to word this as "Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated.": I would prefer "In some individuals the belief that water is fluoridated may also have a psychological effect, manifesting as a large variety of symptoms, regardless of whether the water is actually fluoridated." It would be nice to be able to quantify how many is "some individuals"; it seems to be around 3% from the numbers quoted above. Xasodfuih (talk) 09:48, 1 March 2009 (UTC)

Thanks. Two further thoughts. "Manifesting" is medicalese and can easily be translated into ordinary English; "In some individuals" is redundant and can be removed. How about the following instead? "The belief that water is fluoridated may have a psychological effect with a large variety of symptoms, regardless of whether the water is actually fluoridated." (**) Eubulides (talk) 09:04, 2 March 2009 (UTC)
I don't think manifest is medicalese. Alternative wording: "A 1997 study found that people complained of certain symptoms regardless of whether fluoride was in the water or not, but these symptoms decreased after it was publicly-revealed that water fluoridation had been discontinued." Or briefer: "The findings of a 1997 study suggest that some symptoms reported by people in fluoridated communities are psychological". I still oppose dipping into a primary study to convey its limited findings. That people can have negative psychological reactions to substances is uncontroversial and obvious, but I'm not convinced it's necessary to emphasize this, especially given the possible and related allergy symptoms. You're best off doing a Request for Comment. II | (t - c) 22:40, 2 March 2009 (UTC)
  • I share the concern about dipping into a primary study to convey its findings. That's why the wording I proposed doesn't mention the study's detailed findings. Instead, it mentions the overall topic, which is uncontroversial and which the study supports, without giving the details of the study (which aren't all that important anyway).
  • The first alternative wording that II proposes dips into the study and reports its details; this isn't advisable and isn't needed, for reasons described in the previous bullet.
  • The second alternative wording implies that only the 1997 study suggests that psychological effects occur (which isn't the case; these effects have been demonstrated in several occasions starting in the 1950s, and the effects' existence is not controversial). The wording also says "some symptoms" whereas the source uses considerably stronger wording than "some"; e.g., (p. 295), "the prevalence of symptoms was significantly reduced only after the respondents had become aware of the discontinuation of fluoridation, which reveals that if fluoridation does affect the perception of symptoms, that effect must be mainly psychological."
  • Allergy symptoms (unlike the psychological effects) are controversial at recommended levels, and are an independent subject, which the proposed text doesn't (and is not intended to) address.
Eubulides (talk) 08:28, 3 March 2009 (UTC)
I'm still confused: did Lamberg trigger responses by noting in their questionnaire that Kupio's water is fluoridated? Were the questions leading in any way? And if Lamberg's survey did not remind their subjects that the water was fluoridated (even when it wasn't), then it's possible that the people weren't even aware of it at all. In that case, many of the symptoms could be purely random -- it's not uncommon for people to randomly feel better from one month to the next. It's not controversial that people will complain, and perhaps even faint, but there isn't a rigorous case that a significant portion of the population will have persistent psychosomatic symptoms, which is what this implies. II | (t - c) 17:45, 3 March 2009 (UTC)
Lamberg et al. 1997 (PMID 9332806) did not publish a copy of their questionnaire and their summary of the questionnaire does not directly answer your questions. Here's their summary: "The inquiries included questions about the perceived presence or absence of 25 symptoms during the week of inquiry, water consumption patterns, perceived quality of water, opinions concerning water fluoridation and detnographic data." Given that it was a fairly small town, that fluoridation was an active and controversial topic, and that the questionnaire specifically asked about fluoridation opinions, I think it unlikely that people were unaware of it. The proposed text (marked "(**)" above) does not state or imply that "a significant portion of the population will have persistent psychosomatic symptoms"; it doesn't use the words "significant", or "persistent", or "psychosomatic". Eubulides (talk) 09:08, 4 March 2009 (UTC)
Pretty surprising that they'd not mention such a thing, and it suggests that the questionnaire may have been leading. The abstract is vague enough that, combined with the wording, it does give the impression of persistent symptoms in a fair-sized group of the population, at least to me. Kuopio is not that small with a population of 91k. Further, it seems questionable that they're comparing different populations. They sampled 1000 people in November (%26 response, 260 people). Then they compared them to a different 1000 people in December (40% response, 400 people). They found the two groups reported similar frequency of symptoms? I'll admit that suggests, I suppose, that they had a large enough sample to approximate the mean of the population, and that's not a terribly small sample size. Then a few months later, the number of those 660 people with two symptoms or more dropped 13% - a significant amount of the population. Anyway, do Lamberg mention the reasoning behind this? If you're going to mention it, it should be mentioned in connection to its hypothesized causal mechanism: a fear of fluoridation's harmful effects. When communities have more fear (and possibly less education), you'd expect more symptoms. II | (t - c) 18:43, 4 March 2009 (UTC)

Like I wrote above, I prefer we give the percentage rather than dress it up in more or less vague words; 13% is significant, but less so than other psychological effects of placebo (e.g. in depression it's up to 30%). Xasodfuih (talk) 19:15, 4 March 2009 (UTC)

Their analysis also studied the intersections of the two groups (that is, the people who responded to both sets of surveys). The details of this single primary study should not be given so much prominence that we're talking about 13% or 30% or whatever; the exact percentages are not well-established by just one study. We should instead simply summarize the overall, uncontroversial fact that psychological effects do exist. Eubulides (talk) 00:42, 5 March 2009 (UTC)
At this point, I agree that it should be reinstated. I would prefer that it mention the hypothesized mechanism (fear), but it's up to you. I suppose I agree that percentages should not be used. II | (t - c) 18:47, 6 March 2009 (UTC)
Thanks. The source does say "fear" once, so it's sourced. I installed the most-recently-proposed wording above, except substituting "Fear" for "The belief". Eubulides (talk) 00:19, 7 March 2009 (UTC)

Feltman-Kosel 1961 etc.

  • As we've already discussed, that "double-blind" study (namely, the 1974 Grimbergen preliminary study) was heavily criticized by the NRC report, which wrote "the authors did not estimate what percentage of the population might have GI problems. The authors could have been examining a group of patients whose GI tracts were particularly hypersensitive."[3] Later, when the NRC summarizes its findings the issue of hypersensitivity, it doesn't even bother to mention the Grimbergen results; it talks only about case reports when it says "There are a few case reports of GI upset in subjects exposed to drinking water fluoridated at 1 mg/L. Those effects were observed in only a small number of cases, which suggest hypersensitivity. However, the available data are not robust enough to determine whether that is the case."[4] In short, the NRC appears to be fairly skeptical of Grimbergen 1974.
  • Also, as we've already discussed, the Grimbergen preliminary study was not in fact double-blind. Its subjects were asked to make their drinking water at home, using droppers full of either distilled water or of concentrated sodium fluoride or hexafluorosilicic acid. The reported concentration was over 5 g/L of fluoride, a value easily detectable by human senses. This was a "double-blind" study in which the "blindfolds" were easily removed without the experimenter noticing.
  • The 1961 study (namely, Feltman & Kosel 1961, J Dent Med 16(Oct.):190-8, another paper not indexed by PubMed) was not about water fluoridation. It administered fluoride using tablets containing about 1 mg of fluoride ion, a form of administration that is much different from water fluoridation (concentrated dosage all at once, rather than dilute dosage throughout the day). Furthermore, the test was not blinded; one can easily taste that much NaF in a tablet, and psychological effects could easily explain its results.
  • Of course, the above is just my own analysis, but come on: these are ancient and dubious studies whose results have never been replicated scientifically and which aren't treated seriously by reliable reviews of water fluoridation.
  • The NRC report summarized that area by saying, "The possibility that a small percentage of the population reacts systemically to fluoride, perhaps through changes in the immune system, cannot be ruled out".(page 269) This is a polite way of saying "one can't prove a negative", which is not at all the just-short-of-definitive evidence that is implied by the previous comments. On the contrary, the NRC summary is a fairly negative assessment on the existing evidence.
  • It is certainly fair, under these conditions, to say that claims of water fluoridation hypersensitivity are controversial.
  • The suggested wording, "perhaps 1% of the population could respond negatively to fluoride at 1 mg/L", is not at all what the NRC says. It says (page 269) "Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated"; that "complains of" suggests psychological effects may be involved, and that "less than 1%" is an upper bound, not an estimate of 1%.
  • Again, this secondary source, NRC 2006, is reliable but it is explicitly not about water fluoridation, and it cannot be used to support claims that water fluoridation causes GI or any other kinds of problems.
  • Furthermore, we have reliable secondary sources such as the York review which state that there is no clear evidence of these potential adverse effects. We should be deferring to expert opinion in this area, rather than scouting through obscure 1950s or 1960s primary studies of dubious quality in a controversial area.
  • Finally, again, the argument about hypersensitivity is irrelevant to the proposed text, which is about psychological effects, and is not about gastrointestinal or any other physical effects. There is no dispute among reliable sources that psychological effects exist and are significant. There is no reason to conflate this topic (which is not controversial among reliable sources) with the topic of hypersensitivity to water fluoridation (which is).

Eubulides (talk) 09:15, 27 February 2009 (UTC)

We've already said our cases, and I think you're plain wrong, and completely spinning the NRC. The NRC saying "they could have been analyzing a hypersensitive population" is not a "heavy criticism", and the studies might be ancient but they had a much better methodology. That the NRC's goal was to analyze levels above those used in water fluoridation is irrelevant if the studies discussed are clearly relevant to fluoridation. Your comments about Lamberg show that their assumption that these perceived symptoms are due to fluoridation is quite a big jump -- there's a very good chance that people were randomly feeling better the next month. II | (t - c) 17:41, 27 February 2009 (UTC)
I don't understand why you keep asserting that the NRC report cannot be cited. It clearly is about fluoride in drinking water. It must not be cited out of context (e.g. to attributed some side effect at higher concentrations to the <1mg/L used in optimal fluoridation). But I find this paragraph quite interesting (p. 269 - 275 you liked above):
I think this should be cited, but summarized along the lines: "GI effects of fluoride are well documented at concentrations higher than the recommended levels—the NRC estimates that at 4mg/L about 1% of the population may experience GI effects, possibly aggravated by dietary calcium deficiency." This is what I've got from NRC's writing, I wish their writing were a bit more clear; rephrase as necessary since I'm writing this in a hurry. It should go in the 3rd paragraph of safety, which discusses other effects (skeletal fluorosis) of fluoridation above the recommended level. (Also, you have the number wrong, 5mg/L not 5g/L, so not it would not have been detected by senses other than the gut.) [Sorry, I was confused about which study you were talking about due to the section heading.] Xasodfuih (talk) 20:02, 27 February 2009 (UTC)
I have not read much of the discussion taking place but I had mentioned this almost 3 years ago, that according to the National Academies, "The report does not examine the health risks or benefits of the artificially fluoridated water that millions of Americans drink, which contains 0.7 to 1.2 mg/L of fluoride. Although many municipalities add fluoride to drinking water for dental health purposes, certain communities' water supplies or individual wells contain higher amounts of naturally occurring fluoride; industrial pollution can also contribute to fluoride levels in water." It is also mentioned in the report itself on page 2, "Addressing questions of artificial fluoridation, economics, risk-benefit assessment, and water-treatment technology was not part of the committee’s charge." Thus, I am not sure why this reference has any relevance to the article, but if it is mentioned then there should be something that says the report was not examining water fluoridation as described in the article. - Dozenist talk 20:46, 27 February 2009 (UTC)
Whatever the PR person wrote in news release is obviously contradicted by the contents of the report, which examines side-effects at length. Also, are you claiming that at the same concentration natural and artificial fluoridation have different health effects, with latter somehow being safer? I really want to see a citation for this because we have a world map (from a "pro" group) that lumps together natural and artificial fluoridation as equally beneficial. Xasodfuih (talk) 20:58, 27 February 2009 (UTC)
Technically the committee was tasked to review only the EPA standards (2mg/4mg), not the recommended dosage (0.7 to 1.2 mg/L at the time) established by the U.S. Public Health Service:
If you really think that NRC's review of review toxicologic, epidemiologic, and clinical data isn't a review of toxicologic, epidemiologic, and clinical data, let me know. Based on their review findings, NRC makes comments, as they were asked to, mostly on the EPA (4mg/L) standard, and these comments should not be misquoted wrt. to concentration as to appear they apply to a lower concentration, but claiming that this report does not study the effects of water fluoridation is ridiculous. The wiki article already discusses effects (skeletal fluorosis) that occur at higher that the PHS recommended levels, making it clear when they occur; all I'm proposing is a similar statement on GI effects. Xasodfuih (talk) 21:15, 27 February 2009 (UTC)
Also, a number of primary studies mentioned in the report (table 9-1) are with water fluoridate at 1mg/L, although NRC could draw no definite conclusion from those—they've settled for the 5ppm study (Feltman-Kosel) as more credible, although, it's clear they consider that study of low quality as well; based on this study they've ventured the guess of 1% of population possibly experiencing GI symptoms at over 4mg/L, although they appear not so convinced due to the lack of case reports from US areas naturally fluoridated over that level (as well as tea drinkers from UK) even though there are studies that do find GI effects in India (<1-8mg/L range presumably average to 4), and then they posit that calcium may be the reason for the observed differences. They are clearly speculating from scant evidence, but WP:MEDRS says their allowed to since they're the experts doing the review, and User:Eubulides's reanalysis of the primary studies doesn't trump NRC's. (also the NRC reports seems to indicate that enterically coated tables may have been used to create the true blinding that Eubulides contests) I don't see a problem mentioning NRC's speculation wrt. to the GI effects at 4mg/L, as long as it's attributed. Xasodfuih (talk) 21:35, 27 February 2009 (UTC)
This finding is also within the scope of their mandate (if you're anal about that) since it's about the EPA max level, not the PHS recommended one. Xasodfuih (talk) 21:39, 27 February 2009 (UTC)
I am not getting into an edit war. I was just pointing out and referenced directly from the report, which said "Addressing questions of artificial fluoridation, economics, risk-benefit assessment, and water-treatment technology was not part of the committee’s charge." Other editors can comment based on that issue. - Dozenist talk 04:45, 28 February 2009 (UTC)
  • I agree with Dozenist that we should not be diving into the NRC review (which is not about water fluoridation) to pull out details of reports of GI symptoms. We can't cite those ancient sources directly to dispute our reliable reviews on water fluoridation; and we can't look at the NRC review for advice about WP:WEIGHT of adverse effects for water fluoridation at recommended levels, since the NRC review specifically says that it is not about that.
  • In Water fluoridation, the NRC review might plausibly be cited in the section of the article that talks about adverse effects at well above recommended levels. This section currently consists of the following 27 words: "Fluoride can occur naturally in water in concentrations well above recommended levels, which can have several adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones." In this sentence, adverse effects should be listed according to the weight that reliable sources give them. The NRC report summary devotes (by my count) 2616 words to adverse effects of fluoridation above recommended levels, starting on page 4. Of these words, it devotes about 39% to skeletal effects, 26% to dental effects, 16% to cancer and genotoxicity, and the remaining 19% to everything else. Gastrointestinal (GI) effects are discussed as 1/4 of a 119-word section, which means it gets about 1% of the NRC's weight. The NRC gives a low weight to GI effects because, as it says, "Such effects are unlikely to be a risk for the average individual exposed to fluoride at 4 mg/L in drinking water."
  • In contrast, in the WHO report on adverse effects of water that is naturally fluoridated above natural levels, gastrointestinal effects are not mentioned at all. That report emphasizes dental and skeletal fluorosis as well.
  • With all the in mind, it is a severe violation of WP:WEIGHT to even mention gastrointestinal symptoms in the sentence about fluoride well above recommended levels, much less emphasize GI symptoms by citing primary sources about them. Dozens if not hundreds of symptoms are attributed to high levels of fluoride; why focus on GI symptoms, when our reliable reviews do not?
Eubulides (talk) 07:58, 1 March 2009 (UTC)

See my proposal on Wikipedia:Featured article candidates/Water fluoridation for restructuring this article to avoid giving the impression that the NRC findings apply to normal fluoridation conditions. Basically, we should have separate sections for overdose and interactions per Wikipedia:WikiProject_Pharmacology/Style_guide. Xasodfuih (talk) 10:05, 1 March 2009 (UTC)

Article structure etc.

(Beginning of commentary copied here from Wikipedia:Featured article candidates/Water fluoridation.)

Here are my concerns regarding article structure. I'm going to assert that this article is about compound(s) with pharmaceutical benefit, or more precisely about a particular route of delivery thereof. This poses a few MOS-like problems. I think we don't have another FA like this to guide us. Ideally the fluoride therapy article should do the "heavy lifting" for things like mechanism/pharmacokinetics/side effects/overdose etc. But that article is in C-class shape with practically no useful sections to refer to for further info. So this FA is going to have to provide almost all the info of that kind—and it's almost there. WP:PHARM doesn't a have a "mandatory" (FA-wise) MOS, but it has some guidance for article structure and content here (I'll refer to this as PHARM:MOS). Furthermore, since this is a public health policy issue, cost should be discussed in more detail than in articles on other medications. My concrete suggestion based on stemming from the above are are:

  • The "safety" section should be called side effects. My impression is that some editors try to paint WF in the most favourable light possible, so they want to avoid "side effects" as a bad word. I think this is not quite right per WP:STRUCTURE. It's fine to add "safety" to the section heading, but since the most/only significant side effect at recommended concentration is aesthetical, not safety related, and considering that PHARM:MOS recommends using this terminology, I think that "side effects" is a better section for that title.
  • There should be a separate section about interactions. The recent addition of info about other sources of dietary fluoride is welcome (see archive for discussion), but I think the placement of that info in the "mechanism" section is suboptimal since that (2nd) paragraph says very little about the mechanism of anything, let alone the mechanism of the side effects due to overconsumption of fluoride. PHARM:MOS recommends having a section called "interactions" and I think that's where other sources of dietary fluoride should be discussed.
    • I would also move here the kerfuffle about the "proven", then disproved, epidemiological correlation between lead and silicofluorides, because this was hypothesized to be due to leaching of lead from bass pipes, which is an interaction in the pipe, not in the body, but it's close enough topic-wise.
  • A significant amount of discussion in the FAC archive and on the article's talk page circled around including or excluding information on side effects that occur fluoride concentrations above the PHS/WHO recommended levels, in particular info from the NRC report that evaluated the EPA's soft/hard maxiums of 2mg/L and 4mg/L respectively. The criteria for including such information in the safety section has been inconsistent. I propose we resolve this by having a separate section about overdose as recommended by PHARM:MOS (open to suggestions if overdose is not the best title in this case). This section should include the discussion about side effects that do not normally occur (meaning in the absence of other significant dietary sources) at the PHS recommended levels of WF, in particular skeletal fluorosis, and gastrointestinal effects. I would also move the info about WF accidents here.
    • A closely related issue was the discussion about the prevalence of the hypothesized fluoride Gastrointestinal (GI) hypersensitivity at recommended concentration. While the info on that is non-existant due to the lack of well controlled studies, the NRC did venture a guess about the occurrence of GI effects at concentrations above the EPA limit of 4mg/L. Based on a table of primary studies, only one of which was at 5ppm, the rest being well above that, the guestimated 1% prevalence at that level. Mentioning this appears to be a very sensitive issue with the long term editors of this article, for reasons I don't quite comprehend, but which I presume to be of the "not giving a finger for the fear they might lose the whole hand" variety.
    • The info about WF accidents could be more systematic, currently an example is given based on the well-known NEJM paper, but the much reviled NRC report lists some more. Please check to see if they are discussed in a systematic fashion somewhere.
  • Finally, since this is a public health issue, I would prefer a separate section about cost. This info is currently spread through several sections (implementation, effectiveness), and my guess is that most people would zone out the water pump picture in the implementation section and not read any further. There is enough info available to write a section on this, including the variance of unit cost with the size of the installation (see Truman for instance), and the absolute cost of installations (some Australian papers have this). The cost of the other systemic fluoridation methods (salt, tablets), as well as topicals could mentioned there as well—let the reader draw the conclusions; I think this would be uncontroversial WP:SYNT-wise.

These suggestions were brought to you by Xasodfuih (talk) 08:56, 1 March 2009 (UTC)

Since I was asked on my talk page, on a somewhat adversarial tone, to specify how the above relates to WP:WIAFA rules, and to move anything else to the article's talk page, here it goes by the book:
  • 1a- well-written: Article organization falls under that criterion in my opinion because well-written doesn't mean just "a sequence of grammatical sentences".
  • 1b- comprehensive: some of the issues above relate to lack of some information I consider important.
  • 1d- neutral: lack of information can lead to bias.
  • 2b- appropriate structure: while User:Colin disagrees that this article has anything to do with pharmaceuticals, I maintain that taking some guidance from Wikipedia:WikiProject_Pharmacology/Style_guide is appropriate.
  • Finally, making general observations without giving examples would be even more confusing. ...

Xasodfuih (talk) 09:43, 1 March 2009 (UTC)

(End of commentary copied here from Wikipedia:Featured article candidates/Water fluoridation.)

  • "The "safety" section should be called side effects." Safety should not be renamed to Side effects. Safety is a shorter and more-accurate title. Side effects can refer to either adverse effects or beneficial effects, whereas the current Safety section discusses only adverse effects. Adverse effects would be an acceptable title, but it's medical lingo that many typical readers won't know about, whereas Safety is simple, easily understood, and means the same thing.
  • "My impression is that some editors try to paint WF in the most favourable light possible, so they want to avoid "side effects" as a bad word." I don't have that impression. My reason for preferring "safety" is listed above. I don't know of any editors with the motivation or the behavior that you describe.
  • "considering that PHARM:MOS recommends using this terminology" I'm not sure what PHARM:MOS is; there is no PHARM:MOS. WP:MEDMOS does not address the issue of what sections should be in Water fluoridation. Water fluoridation is not a disease, or a drug, or a medical test, etc. The closest thing would be WP:MEDMOS #Drugs, but its sections are not particularly appropriate for water fluoridation (please see below).
  • "the WHO recommended max daily dosage of fluoride for adults/children still has not been added; see WHO, 2002, Environmetal Health Criteria 227. Fluorides." I'm not sure what the "still" is referring to; as far as I know that addendum has never been mentioned before here. Also, the abovementioned URL to section 11.0 does not contain any recommended max daily dosage. The WHO has recommended a maximum value of 1.5 mg/L for fluoride in drinking water; is that what you're referring to? If so, that figure was installed a couple of weeks ago.[5] If not, please specify clearly what the problem is here.
  • "There should be a separate section about interactions." It wouldn't hurt to improve the coverage of multiple sources of fluoride, but it would be a misnomer to use the term "interactions" to cover this. It is not a drug interaction (as fluoride is not normally considered a drug; and even if it were, drug interactions occur between different drugs) and the problem of fluoride from multiple sources is not called "interactions" in the literature on water fluoridation. Wikipedia is not the place to introduce nonstandard terminology like this.
  • "I would also move here the kerfuffle about the "proven", then disproved, epidemiological correlation between lead and silicofluorides" As explained earlier on the talk page, that raises serious WP:WEIGHT violations, as reliable sources do not consider the lead effects to be shown, any more than the dozens of other hypothesized adverse effects. We should be following what reliable reviews say on the subject of adverse effects; we should not be doing research of our own, by citing dueling primary sources.
  • "having a separate section about overdose" An Overdose section is reasonable for drugs, but not for water fluoridation. Overdose is a real problem with many drugs, but it is not a significant safety issue with water fluoridation per se. The main reason children get too much fluoride in industrialized countries is by swallowing toothpaste; in nonindustrialized countries, it's by ingesting water that's naturally fluoridated well above recommended levels. It's fine to have a brief discussion about overdose here, but giving it a separate section would raise serious WP:WEIGHT issues. Reliable reviews on water fluoridation do not contain Overdose sections, and Water fluoridation shouldn't either.
  • "Mentioning this [GI symptoms] appears to be a very sensitive issue with the long term editors of this article, for reasons I don't quite comprehend, but which I presume to be of the "not giving a finger for the fear they might lose the whole hand" variety." No, as described above, GI symptoms should not be emphasized because our reliable reviews on water fluoridation don't emphasize them. It's a WP:WEIGHT issue, pure and simple: we shouldn't emphasize relatively-unimportant safety issues, and should instead concentrate the safety-issue coverage in the same areas and weights that reliable sources do. Eubulides (talk) 23:24, 1 March 2009 (UTC)
  • "The info about WF accidents could be more systematic, currently an example is given based on the well-known NEJM paper, but the much reviled NRC report lists some more. Please check to see if they are discussed in a systematic fashion somewhere." I checked, and found nothing. All the collections I found were anecdotal. I used the NEJM paper because it killed somebody and was well-documented by a reliable source.
  • "I would prefer a separate section about cost." It's a reasonable suggestion to have cost discussed separately; I'll look into it. (Update: see #Cost below. Eubulides (talk) 09:13, 6 March 2009 (UTC))
  • "Article organization ... taking some guidance from Wikipedia:WikiProject_Pharmacology/Style_guide is appropriate." Like Colin, I disagree that the article should be structured like a drug article. The issues involved in water fluoridation are much, much differerent than the issues involved in (say) aspirin or cocaine. I have responded to the specific suggestions above, but the big picture is that this isn't a drug article.
  • "some of the issues above relate to lack of some information I consider important ... lack of information can lead to bias" This seems to be talking mostly about adverse effects. However, Water fluoridation should not focus on adverse effects far more heavily than reliable sources do. Any further emphasis on poorly-supported or highly-unlikely adverse effects, more so than reliable sources give, would raise serious WP:WEIGHT issues.
Eubulides (talk) 23:24, 1 March 2009 (UTC)
You're right that health effects of fluoride above the PHS-recommended levels should only be touched briefly in this article, and that already happens. Fluoride poisoning (title somewhat bad) already discusses the EPA standard, and a summary should be given in Fluoride (or fluorine see related discussion at WT:CHEM); I wrote "should" because the section of fluoride#Toxicology that's supposed to summarize that article is a WP:CFORK, although not because of POV issues. Chronic effects due to overexposure are not usually considered poisoning, but the article on Fluoride poisoning discusses mostly chornic rather than accute effects. Oh, well... Xasodfuih (talk) 17:53, 4 March 2009 (UTC)
Hopefully, this change defers the discussion to the proper places and distinguishes between chronic and acute effects of overexposure in the least amount of words; I've cited NRC for the survey of overfluoridation accidents, since the NEJM paper is a primary study that only discusses one (per WP:MEDRS), and you cannot justify the use of the adjective "rare" without citing a survey of such accidents. Xasodfuih (talk) 19:01, 4 March 2009 (UTC)
Thanks for that edit. The NRC doesn't actually say "rare", and neither the NRC nor the Medscape citations are about water fluoridation, so I attempted to further improve that change by replacing the NRC and Medscape citations with Penman et al. 1993 (PMID 9323392), a source that is directly on the topic of acute fluoride poisoning due to fluoride overfeed, and which does say "rare". I also changed the wording to use terms like "fluoride overfeed", "acute fluoride poisoning", rather than the term "overfluoridation" (which I vaguely recall having invented myself). Finally, for "gastrointestinal" I substituted "nausea and vomiting", which is easier for ordinary readers to understand and are the most-common symptoms. These wording changes all came from the Penman et al. source. Eubulides (talk) 00:42, 5 March 2009 (UTC)
I don't know how much of an improvement that is. PMID 9323392 is a primary study almost 15 years older, focused on one accident, and which cites a personal communication from a CDC employee to say that such accidents are "relatively infrequent", but doesn't say relative to what. While not using an adjective themselves, the NRC table lists practically all accidents that resulted in a publication. I cited medscape (in addition to the NEJM study) for the fact that gastrointestinal effects predominate; their page is a about overdosing with fluoride from ingesting a number of products; they don't mention water overfeed accidents explictitly, but it's not unreasonable to assume they don't mention those because they are rare; the NEJM paper list the same symptoms in its abstract, so the sources concur. Also, since you rightfully prefer less jargon, you could use the description from NEJM: "nausea, vomiting, diarrhea, abdominal pain"; it's a bit wordy though. Xasodfuih (talk) 02:02, 5 March 2009 (UTC)
I'm still leery of citing the NRC review, which specifically says that it's not about water fluoridation, and citing another source that doesn't mention water fluoridation either, and on top of that coming up with words like "rare" that are not in the sources; this is uncomfortably close to original research, and there are also WP:WEIGHT concerns. I searched harder for a better source, and found Balbus & Lang 2001 (PMID 11579665), a review on drinking water safety, which has a paragraph on water fluoridation and does say "rare" (and heh! it says "overfluoridation"). Balbus & Lang list 11 symptoms but the 1st three are enough here (same 1st three as the sources you mentioned). Now that we have a relatively reliable review on the subject there's no need to cite the primary sources. I gave it a whirl by installing this change:
"... fluoride overfeed overfluoridation that causes outbreaks of acute fluoride poisoning, with symptoms such as that include nausea, and vomiting, and diarrhea. For example, in Hooper Bay, Alaska, in 1992, a combination of equipment and human errors resulted in one of the two village wells being overfluoridated, causing one death and an estimated 295 nonfatal cases of fluoride poisoning "Three such outbreaks were reported in the U.S. between 1991 and 1998, caused by fluoride concentrations as high as 220 mg/L; in the 1992 Alaska outbreak, 262 people became ill and one person died."
Dunno why there's a discrepancy between the "295" and the "262" but at this level it doesn't really matter. Eubulides (talk) 03:58, 5 March 2009 (UTC)
That's fine with me. Xasodfuih (talk) 13:26, 5 March 2009 (UTC)

Cost

In response to the suggestion "I would prefer a separate section about cost" in the previous talk-page section, I created a new article section Cost, moved the cost-related discussion into this section, added a bit on the cost of salt fluoridation, and used {{inflation}} to adjust the cost estimates for inflation. Comments welcome. Eubulides (talk) 09:13, 6 March 2009 (UTC)

Purpose of fluoride

A recent edit added the claim "Fluoride has a topical benefit to tooth enamel, but has no other known purpose in humans." as a new 2nd second sentence of the lead. The first part of this claim ("topical benefit to tooth enamel") merely repeats the next sentence (which describes in detail how fluoridated water affects cavity formation); the second part of this claim ("has no other known purpose in humans") is not supported by the cited source (CDC 2001, PMID 11521913), does not summarize any part of Water fluoridation's body, and is vaguely unscientific to boot (as scientists aren't supposed to talk about inanimate substances having "purpose"). Fluoride certainly has other effects on humans; for example, in moderate quantities, it may help lower the risk of breaking bones—see NHMRC 2007 (PDF).

I made another change to try to fix the problems described above. Eubulides (talk) 07:28, 15 March 2009 (UTC)
Purpose in this case is obviously not referring to the cognitive sort of purpose. It would be perhaps clearer to say that fluoride has no known benefit in humans except its topical effect making tooth enamel more resistant to acid, as one of many ways of preventing cavities. Until and unless you find a WP:RS to show that fluoride provides any other benefit in humans, it's fair to say that.76.85.197.106 (talk) 16:25, 15 March 2009 (UTC)
Furthermore, the OP of this section is misreading his source. It states: "The authors of the three existing systematic review concur that water fluoridation at levels aimed at preventing dental caries has little effect on fracture risk - either protective or deleterious. The results of the subsequent original studies support this conclusion, although suggest that optimal fluoridation levels of 1 ppm may indeed result in a lower risk of fracture when compared to excessively high levels (well beyond those experienced in Australia). One study also indicated that optimal fluoridation levels may also lower overall fracture risk when compared to no fluoridation(the latter was not the case when hip fractures were considered in isolation)." I.E., excessive fluoride is bad for your bones and there is no evidence that fluoride benefits bones (excepting teeth) at any dose level.76.85.197.106 (talk) 16:30, 15 March 2009 (UTC)
The source says "optimal fluoridation levels may also lower overall fracture risk when compared to no fluoridation". But the main point is that none of this stuff is worth mentioning so early in the lead. The lead is about water fluoridation, and should not immediately, in its 2nd sentence, dive down into the minutiae about the effects of fluoride on bone fracture. The 1st paragraph of the lead should focus on the same subjects that reliable sources on water fluoridation focus on. None of these sources focus on the absence of (or possible presence of) alternative benefits of topical fluoride, so (as per WP:WEIGHT) Water fluoridation shouldn't either. Eubulides (talk) 18:39, 15 March 2009 (UTC)
That depends if they controlled the "no fluoridation" category to remove places that are natually fluoridated to excess, and controlled for all the other socioeconomic factors... Fair enough 76.85.197.106 (talk) 19:13, 17 March 2009 (UTC)

Xylitol etc.

This edit added 1226 bytes on xylitol, citing only favorable sources, which introduces both a WP:WEIGHT and a WP:NPOV problem.

  • First, weight. Many schemes are used for caries control. Anusavice 2005 (PMID 15897335) lists the following:
  • fluoride toothpaste (0.5 pages in Anusavice, by my count)
  • fluoridated water (0.5 pages)
  • fluoride mouthrinses, toothpaste, and gel (0.7 pages)
  • professionally applied fluoride supplemented with fluoride from toothpaste (0.5 pages)
  • fluoride varnish (0.7 pages)
  • antibacterial and antimicrobial and bactericidal agents (1.2 pages)
  • xylitol (0.3 pages)
  • ozone technology (0.4 pages)
Tellingly, Anusavice's Figure 5 (p. 545) does not bother to list xylitol or ozone technology; these appear to be the also-rans among the above-listed methods.
Anusavice also lists the following future approaches:
  • replacement therapy (1.9 pages)
  • genetically engineered, alkali-producing streptococci (0.2 pages)
  • caries vaccine (1.2 pages)
Given these weights, it's overkill for Water fluoridation to expend 1226 bytes on xylitol, when it spends many fewer bytes on other alternative methods (e.g., it spends zero bytes on antibacterial approaches, and 489 bytes on all future approaches combined).
  • Second, NPOV. As Anusavice makes clear, the evidence for the effectiveness of xylitol is controversial, and there are negative reviews. Other sources agree: for example, Bader 2007 (PMID 17967395) says:
"The evidence for efficacy of xylitol-based interventions is seen by some as controversial, even though xylitol has been shown to be effective in a large number of studies with varied populations, delivery methods, and experimental designs. There have been 3 recent reviews of portions of the evidence for the effectiveness of sugar alcohols in general, and xylitol in particular. The conclusions of the 3 reviews differ substantially, and in so doing, neatly reflect the current state of knowledge.... Thus, 3 reviews each examined portions of the available evidence. Each of these reviews found evidence for a xylitol preventive effect, but 2 reviews indicated that the available evidence was not strong enough to permit a firm conclusion of therapeutic effectiveness. Inconclusiveness was ascribed to generally weak designs without active controls and some contradictory, nonsignificant results. All of the studies indicated that the existing evidence needed to be supplemented by well-designed trials."
The best recent review I could find on xylitol gums was Desphande & Jadad 2008 (PMID 19047666), who concluded that evidence supports chewing polyol-containing gum as part of normal oral hygiene to prevent caries, but go on to write:
"The findings of our review do not agree with those reported by Lingstrom and colleagues that deemed the evidence for the use of sorbitol or xylitol in chewing gum inconclusive. Finding discordant reviews is not rare in the literature. The main differences between these reviews relate to inclusion criteria, quality scales, classification of study design and conclusions based on studies that were considered to be of high quality. We rated two original studies classified as low quality by Lingstrom and colleagues as high quality. We performed a sensitivity analysis by eliminating these two studies and still produced statistically significant results across all categories, further confirming the robustness of our findings."
  • While we're on the subject of alternative treatments, chlorhexidine's role in preventing tooth decay is also controversial. See, for example:
  • Autio-Gold J (2008). "The role of chlorhexidine in caries prevention". Oper Dent. 33 (6): 710–6. PMID 19051866.
  • Anyway, though it's clear that Water fluoridation should mention xylitol and chlorhexidine, it's not at all clear that it should be covering the discordant reviews and other controversies with respect these two approaches, unless we can find reliable sources that cover these treatments in relation to water fluoridation. Right now, only Anusavice has that role, as far as I know.
  • With all the above in mind, I made a further edit to simply list xylitol as one of the alternative therapies available, and also to briefly list chlorhexidine, fluoridated mouthwash, gel, and dental varnish. No doubt further improvements could be made, but we need to keep WP:WEIGHT and WP:NPOV in mind.

Eubulides (talk) 08:05, 11 March 2009 (UTC)

I don't really understand why chlorhexidine, which from my investigations has received relatively little coverage in the literature as a public-health measure, is equated with xylitol, which has several recent positive reviews which emphasize it as a public-health measure with proven effectiveness. There were the 2 JADA reviews I added, plus there's PMID 1736987 (2006), which argues for increasing its use in the U.S. Plus the AAPD's policy statement. As you said, xylitol's preventive effect is acknowledged. What does it mean for its therapeutic effectiveness to be controversial? Is fluoride's therapeutic effectiveness controversial? There's also the fact that reviews say that there's good evidence that xylitol helps block transmission of S. Mutans, which reduced cavities 70% in children whose mothers chewed the gum compared against the group that used chlorhexidine. In addition, the preceding sentence ("other public-health strategies have lacked impressive results") introduces a POV which clouds the next sentence and makes people think, wrongly, that xylitol is not effective for public-health control of cavities. Just because one review, Anusavice, does not emphasize xylitol does not mean that the several positive, and more recent, reviews should be discounted. Basically, the sentences need to be reworded to give appropriate weight to xylitol and not put the cloud over it. II | (t - c) 23:05, 12 March 2009 (UTC)
  • Chlorhexidine has actually received quite a bit of coverage in the literature as a method of controlling tooth decay. See, for example, Kocak et al. 2009 (PMID 19262732), Duarte et al. 2008 (PMID 19119578), Autio-Gold 2008 (PMID 19051866), Hoszek & Ericson 2008 (PMID 19051864), Hauser-Gerspach et al. 2008 (PMID 19034538), van Strijp et al. 2008 (PMID 18997466), and Lobo et al. 2008 (PMID 18954355), all published since November 1. This is as much or more interest in the recent literature than xylitol has seen.
  • Certainly xylitol is controversial. For example:
"Of the bulk sweeteners, xylitol has been the most studied and reviewed, and it is the most controversial. The controversy revolves around whether xylitol has an anticaries benefit and, therefore, is superior to the other polyols.... Although xylitol has anticariogenic properties, there is not sufficient evidence to recommend xylitol as a first-line anticaries strategy in light of the large body of evidence on the effectiveness of topical fluoride and dental sealants." Zero DT (2008). "Are sugar substitutes also anticariogenic?". J Am Dent Assoc. 139 (Suppl 2): 9S – 10S. PMID 18460675.
  • Fluoride's therapeutic effectivness is not controversial among reliable sources, as far as I know.
  • One can certainly find positive reviews for xylitol among reliable sources, but one can also find negative ones. It's not really the job of this article to be listing or citing all these reviews. This article's job is to present evidence about water fluoridation, and we should be relying on reliable secondary sources that compare water fluoridation to alternatives; we should not be going out and citing research on those alternatives ourselves. That is why it is better to rely on sources like Anusavice, which compare various forms of treatment for dental caries (including water fluoridation and its alternatives), to sources such as the ones that you and I have cited above, which are about xylitol and/or chlorhexidine, and which are not about water fluoridation.
  • Could you please suggest a better wording to avoid the wording cloud that you've discovered?
Eubulides (talk) 01:50, 13 March 2009 (UTC)
  • This reaction on the part of readers is reflective of the article's confused focus, in my opinion. If the article were clear on what the topic is, and stuck to the topic throughout the artcle, such confusing in readers would not arise. —Mattisse (Talk) 02:14, 13 March 2009 (UTC)
  • There's no evidence in this thread of confused focus on the part of either the Water fluoridation article or its readers. The article is about water fluoridation, whose goal is to reduce tooth decay; the topic in this thread is over how much weight to give to the article's treatment of alternative ways of achieving the same goal. Every Wikipedia article on public-health measures should consider such topics; for example, Chlorination should (and does) cover alternative disinfection methods such as chloramine and UV. While there may be legitimate disagreements over how much space Chlorination #Alternatives should devote to alternatives, there's nothing wrong with the idea per se of covering alternatives, nor does the existence of such coverage mean that Chlorination has a "confused focus". Eubulides (talk) 04:30, 13 March 2009 (UTC)

Chlorhexidine too

  • I apologize for the delay in responding. No offense, but your response did not have the quality that I've come to expect. Why did you throw up a bunch of random articles on chlorhexidine? The first shows reduced S. mutans, the second shows no reduction in caries, the third one (a review) actively says it shouldn't be used because of lack of information on side effects, the fourth is an in vitro study on chlorhexidine in restorative materials, the fifth also doesn't support chlorhexidine's use, the sixth does not support its use, and the seventh shows reduced S. mutans (big surprise).
  • We need to stick to reviews, particularly ones which focus on the public health use of the method we're discussing. There are plenty of reviews which encourage xylitol as a public-health approach because its safe and effective. You've plucked out a statement from an editorial that there's controversy over whether it's more effective than sorbitol, but sugar alcohols in general are not controversial. Chlorhexidine is controversial. It is primarily for gingivitis, stains the teeth, and irritates the "oral mucosa".
  • You've plucked out a controversy statement from a single editorial. Right after that statement it says this:

    The results of studies have shown that when sorbitol- and xylitol-containing chewing gum and candies were used three to five times per day, they had a caries-preventive effect in subjects compared with results in subjects who did not use chewing gum or candy, and xylitol generally had a larger caries-preventive benefit.4,5 Questions have been raised about whether the caries-preventive benefit of xylitol-containing chewing gum is due to salivary stimulation or to an antimicrobial effect. Unlike sorbitol, which can be metabolized slowly by some oral bacteria, xylitol has a bacteriostatic effect on mutans streptococci. It also has been reported to reduce mutans streptococci levels in plaque and saliva,6 block mother-to-child transmission of mutans streptococci7 and alter the acidogenic potential of plaque to subsequent sugar challenges.8 The results of direct head-to-head comparisons of sorbitol and xylitol have been mixed, and concerns have been raised about the independence and quality of the research.4

    A systematic review, PMID 19047666, of the xylitol vrs. other sugar alcohols issue shows that xylitol had the greatest reported effect. If we want to dabble into the recent research on xylitol, there's PMID 19085034 (showing longlasting morphological changes in S. mutans) or PMID 18657266 (showing reductions in S. mutans with both xylitol and a much higher dose of maltitol). PMID 17063022 actually concluded that xylitol had a remineralizing effect.
  • Anyway, the best way to resolve this is to just have a long sentence and a ref on both chlorhexidine and xylitol. Here's a rough proposed replacement for the current sentence: "Other agents to prevent tooth decay include noncariogenic sugar substitutes and chlorhexidine. Chlorhexidine is controversial and not recommended due to inconclusive efficacy and side-effect concerns (cite PMID 19051866), but the use of sugar substitutes, particularly sugar alchohols such as xylitol, have been recommended and implemented in some coutries." This could cite any number of reviews: PMID 18451371 says "particularly xylitol", PMID 18657266 discusses worldwide adoption in the intro, PMID 19216379 has the American Academy on Pediatric Dentistry's recommendation. There are 4-5 other reviews if we go back to 2002.
  • The review you mentioned which brought up the controversy focused on the therapeutic effectiveness. I asked whether there was controversy around fluoride's therapeutic effectiveness. That's because while it's clear that fluoride is effective for prevention, it's not clear that it effectively remineralizes early lesions, especially in the levels of fluoridated water. The sources don't seem to emphasize this effect. Our mechanism doesn't mention it; in fact it says the opposite ("controls the rate caries develop"). I recall reading somewhere that fluoride does bond with the less mineralized areas and remineralize teeth, but fluoride is mainly a preventative agent. There is real controversy over whether you can take xylitol and expect very small caries to disappear because some studies have found that. That isn't worth getting into here, and should not be conflated with whether xylitol is effective preventatively and could be recommended as a public-health measure.

As far as the controversy surrounding whether xylitol is more effective than sorbitol, most studies find that it is. While some think the case hasn't been finalized, that's not worth getting into here. Since all reviews emphasize xylitol, it has a plausible mechanism for reducing S. mutans further (sorbitol can be digested, xylitol cannot) and it is the one which has been adopted by several countries and the U.S. military, our article should be proportional to that and mention it "particularly". II | (t - c) 23:52, 17 March 2009 (UTC)

  • "your response did not have the quality that I've come to expect" Perhaps that's because you misread the response? The response was in no way an attempt to argue that clorhexidine should be used for tooth decay. It was merely a response to the claim that chlorhexidine "has received relatively little coverage in the literature as a public-health measure". Your comment did not revisit that claim, so I hope we can agree that chlorhexidine-for-tooth-decay has received quite a bit of coverage lately among reliable sources; if anything, it has gotten more coverage recently than xylitol has.
  • "We need to stick to reviews, particularly ones which focus on the public health use of the method we're discussing." I agree, but we have to remember that in the context of Water fluoridation, the "method we're discussing" is water fluoridation, not xylitol or chlorhexidine or anything else. We need to stick to reviews that put alternative methods like xylitol in the broader context that includes water fluoridation. We should not rely on reviews of xylitol per se. Such reviews would be necessary and appropriate for Xylitol but generally speaking they're neither necessary nor appropriate here.
  • "You've plucked out a controversy statement from a single editorial." That is because I was supporting a claim that xylitol is controversial, and there was no need to quote more once the claim was established, which it was. The extended quote that you gave, which ended with "concerns have been raised about the independence and quality of the research", does not disagree with the fact that xylitol is controversial; on the contrary, it continues to support the claim. We should not present xylitol as if it were a generally-agreed worthy substitute for water fluoridation; it is not.
  • "the best way to resolve this is to just have a long sentence and a ref on both chlorhexidine and xylitol." Something that's longer than the current treatment would be OK, but the proposed draft is quite unsatisfactory, as it constitutes unnecessary original research. Any coverage here of xylitol should be supported by a reliable review that covers the topic of xylitol in an overall context of caries control that includes water fluoridation. (Similarly for chlorhexidine, of course.) We should resist the temptation to incorporate results directly from reviews that cover only xylitol and/or chlorhexidine, as that's synthesis and should be avoided. Here we already have a reliable review on the overall area of caries reduction, namely Anusavice 2005 (PMID 15897335). This review places water fluoridation in context with alternatives and gives weights to these alternatives. We should not be disputing this review's weights by doing our own research into alternatives, in order to lengthen discussion of our preferred alternatives all out of proportion to the weight that our reliable source gives.
  • "it's not clear that it [fluoride] effectively remineralizes early lesions, especially in the levels of fluoridated water" Sorry, I don't follow this point. Reliable sources agree that frequent uses of small amounts of fluoride facilitate tooth remineralization. See, for example, CDC 2001 (PMID 11521913). The current article does not claim that this remineralization constitutes "therapy", nor is water fluoridation commonly treated as "therapy" by reliable sources, so I'm not sure why this particular topic is relevant to Water fluoridation (though it may well be relevant to Xylitol).
  • Or perhaps the point is that we should add to the article a statement that water fluoridation is intended to prevent tooth decay, not to repair cavities? That would be a good thing to add, if we can find a reliable source that states this clearly.
Eubulides (talk) 16:29, 19 March 2009 (UTC)
The original research policy should not be used to put misleading facts and omit important information from an article simply because nothing discusses the these misleading facts in direct relation to the article at hand -- rather the point is the topic at hand and the text itself. There's no original research: the proposed statement says nothing about these measures in relation to water fluoridation, only in relation to public health caries prevention. Just because Anusavice doesn't mention (and predates) concerns raised about chlorhexidine's side effects in a focused review and also doesn't mention xylitol's endorsement as a public health measure (also less common in 2005) should not be used to keep those facts out of the article and equivocate the two measures. My suggested text doesn't imply that xylitol is a replacement for fluoridation, but it does note that they reduce caries and have been recommended, and importantly notes that recent research does not recommend chlorhexidine. Since our positions seem incompatible, I'll be raising this at WP:OR/N at some point. II | (t - c) 17:16, 19 March 2009 (UTC)
  • "misleading facts" What is misleading about the current article? It says "Alternative individual treatments include the antibacterial agent chlorhexidine and the sugar substitute xylitol." If this is misleading, how could it be changed to be less misleading, without drawing the sort of problematic conclusions at issue here?
  • "omit important information" The issue here is a WP:WEIGHT one yes. As I understand it, the proposal is to mention xylitol as an important alternative to, or substitute for, water fluoridation. However, reliable sources do not state this, and Water fluoridation should not state or imply it.
  • "the proposed statement says nothing about these measures in relation to water fluoridation" Sure they do. They criticize chlorhexidine, and praise xylitol, in a section called Alternatives in an article called Water fluoridation. In context this is clearly a statement about the effectiveness of xylitol as an alternative to water fluoridation. As far as we know, reliable sources are not making statements like these, in contexts like these, so Water fluoridation should not be doing it either.
  • "Just because Anusavice doesn't mention (and predates) concerns" I share your concern that Anusavice 2005 (PMID 15897335) is a bit long in the tooth, so to speak; but we must be quite careful of substituting our own opinion for that of a reliable source, even if the source is four years old. One can easily find reliable sources, published in peer-reviewed medical journals that praise xylitol, and which criticize it; it is not our job to arbitrate and choose among those sources when we have a reliable review that does it for us.
  • "My suggested text doesn't imply that xylitol is a replacement" Sure it does, in context. And the text sharply criticizes chlorhexidine as a replacement, and contrasts it to xylitol, which it praises. This contrast, and this comparison to fluoridation, is not supported by any of the cited shources.
  • I'm not saying that the current text is perfect; far from it. But the proposed text is much worse, due to the WP:OR problem. Let's try to find a better approach. Wikipedia should not be advocating a particular alternative to water fluoridation over others, without any reliable source to base that relative advocacy on.
Eubulides (talk) 17:53, 19 March 2009 (UTC)
By the way, I should mention that I share the opinion that xylitol gum has better evidence for preventing cavities than chlorhexidine mouthwash does, and that the gum is a promising as a supplement to fluoridation for people who chew gum; but that's just my personal opinion. What matters for Wikipedia is what reliable sources say. Eubulides (talk) 17:58, 19 March 2009 (UTC)
I don't understand how you can say that "this contrast ... is not supported by any of the cited sources". The American Association of Pediatric Dentistry has endorsed xylitol; I showed a 2003 article which discussed increasing its use for public health; two recent JADA review articles come down favorably on it, and all the older articles that I can find aside from Lingstrom are favorable, particularly as a preventative rather than therapeutic measure. The gummy-bear article I mentioned discusses in its introduction the adoption of xylitol in Europe, by the U.S. military, and Japan. In comparison, chlorhexidine has only 1 recent review, which specifically says it should not be recommended. If you'd prefer, you can tweak my proposed statement to work in Anusavice's statement that alternative measures, including xylitol, are regarded as unproven, but to say that there's no real difference in opinion on chlorhexidine compared to xylitol is clearly false. II | (t - c) 18:06, 19 March 2009 (UTC)
Please see #Proposed xylitol-related addition below. Eubulides (talk) 19:45, 20 March 2009 (UTC)
  • "I don't understand how you can say that 'this contrast ... is not supported by any of the cited sources'." What I meant is that the cited sources do not support the proposed text's implied comparison of xylitol to chlorhexidine and to fluoride treatments such as water fluoridation.
  • "The American Association of Pediatric Dentistry has endorsed xylitol" I assume this refers to the 2006 endorsement (PDF) by the American Academy of Pediatric Dentistry of sugar substitutes, including xylitol. However, this endorsement did not place sugar substitutes in any context that included water fluoridation, so it provides no WP:WEIGHT guidance here.
  • "I showed a 2003 article" The string "2003" appears nowhere else in this thread, so I don't know what article is being referred to here. But if Anusavice 2005 (PMID 15897335) is a bit dated, surely a 2003 article would be even more worrisome from that point of view?
  • "two recent JADA review articles come down favorably on it" This apparently refers to the following two studies:
  • Ky et al. 2008 (PMID 18451371), which argues that school officials and the American Academy of Pediatrics should consider the benefits of chewing gum containing dental-protective substances, including xylitol (but also including fluoride (!)). This article indicates that xylitol-containing gum is a promising therapy but is not mainstream in the U.S.
  • Burt 2006 (PMID 16521385) is a better choice, since it places xylitol in the context of fluoride. It says "Dentists should stress that chewing xylitol-sweetened gum is a supplemental practice, not a substitution for a preventive dental program that includes the use of fluoride, consciously applied oral hygiene practices and regular professional visits."
  • I looked for other reliable sources that mentioned xylitol in the context of water fluoridation (or at least fluoride) and other caries prevention techniques, and found this recent one, which expresses mainstream opinion:
"Although xylitol has anticariogenic properties, there is not sufficient evidence to recommend xylitol as a first-line anticaries strategy in light of the large body of evidence on the effectiveness of topical fluoride and dental sealants. However, xylitol-containing chewing gum and mints can be recommended as an adjunct to other preventive intervention strategies if cost considerations do not outweigh effectiveness." (Zero 2008, PMID 18460675)
"Alternative individual treatments include the antibacterial agent chlorhexidine and the sugar substitute xylitol."
with this:
"Other agents to prevent tooth decay include antibacterials such as chlorhexidine and sugar substitutes such as xylitol.(citing Anusavice 2005) Xylitol-sweetened chewing gum has been recommended as a supplement to fluoride and other conventional treatments if the gum is not too costly.(citing Zero 2008)"

Eubulides (talk) 19:45, 20 March 2009 (UTC)

That's fine. My suggested wording was not intended to imply that xylitol is a substitute for everything, but only that it has been recommended in some countries. Similarly, our article should not imply that fluoridated water is a substitute for fluoridated toothpaste, even though fluoridated water is recommended. I still wonder about chlorhexidine; as that 2008 review stated, it is not recommended for public-health control of caries much and it's largely used for short-term control of gingitivis. But it's not that big of a deal. II | (t - c) 22:16, 20 March 2009 (UTC)
OK, thanks, installed. Eubulides (talk) 06:01, 21 March 2009 (UTC)

FDA admits Fluoride is dangerous

I'm new to wiki. Here is some information I found from the FDA's offical website. It says the water Fluoridation dangers far out way its benefits. Please look at this information and improve this article. Thank you - Jack

[http://www.fda.gov/ohrms/dockets/dockets/07p0070/07p-0070-cp00001-02-vol1.pdf[

[6]]]

[[7]]] —Preceding unsigned comment added by 74.132.196.42 (talk) 21:08, 18 March 2009 (UTC)

Hi Jack, welcome to Wikipedia. Can I recommend that you create an account? You do realise that these are a petition rather than being a document published by the FDA? FWIW these don't represent an official position by anybody other than the author of the actual petition. Shot info (talk) 01:25, 19 March 2009 (UTC)

"Adverse Effects" section

Since studies have shown that there are in fact adverse effects of fluoridated water, I think that there should be a section about this for readers to view. —Preceding unsigned comment added by Quarkde (talk • contribs) 18:55, 23 March 2009 (UTC)

There is such a section; it's called Safety, which is a shorter and more-easily-understood name. That section focuses on the safety effects of water fluoridated to recommended levels. It also briefly covers the somewhat-off-topic point of water that is fluoridated to well above recommended levels, discussing well-known adverse effects that include dental and skeletal fluorosis, weakened bones, nausea, vomiting, and diarrhea. However, this somewhat-off-topic discussion is (and must be) supported by reliable sources that are closely related to water fluoridation. There are dozens more adverse effects that have been reported for high fluoride concentrations, but this article is not about fluoride poisoning, and as per WP:WEIGHT it should not discuss them all, certainly not the poorly-attested ones such as the IQ claims that were recently added and immediately reverted. Instead, the IQ topic should be (and is) discussed in Fluoride poisoning. Eubulides (talk) 22:05, 23 March 2009 (UTC)

Types of fluoride: NaF, SF, CaF, and tin fluoride

I haven't seen much mention of the types of fluoride in the recent reviews, and since SiF and NaF are the standard, maybe it's not worth going into depth. However, there is some interesting research from older literature. The 1952 Choice of Fluoridating Agents in the Control of Dental Caries reviewed the literature, and found that tin fluoride seemed more effective than sodium fluoride, which seemed more effective than sodium silicofluoride, which was more effective than calcium fluoride. A study of the metabolism of types in rats [8] found that silicofluorides were excreted through the urine much more, sodium fluoride was somewhat mixed, and calcium fluoride was almost entirely excreted through the feces. Finding modern followups of this research seems worthwile. I'm also curious as to the natural fluoride generally is, and my impression is that it's usually calcium fluoride. II | (t - c) 20:06, 26 March 2009 (UTC)

I agree that it would be nice for the article to say what the main sources of natural fluoride in water, but a brief search didn't find anything along those lines; perhaps someone with a better search engine can look into that? As for tin (stannous) fluoride, etc., my impression from the recent literature is that the mainstream consensus is that, for water fluoridation, it doesn't matter which of the main fluoridation chemicals is used, as far as safety and effectiveness goes. I don't know of anybody seriously proposing using stannous fluoride or calcium fluoride for water fluoridation, and I expect that if recent reliable sources don't go into this topic with respect to water fluoridation, Water fluoridation shouldn't either. Eubulides (talk) 21:55, 26 March 2009 (UTC)
Following up my previous comment, I have still not found any reliable source talking about the main sources of natural fluoride in drinking water, and suspect that there aren't any. However, I did find a recent reliable review (Ozsvath 2009, doi:10.1007/s11157-008-9136-9) talking about natural sources in general and making the point that fluoride levels in water are usually controlled by the solubility of fluorite (which is not the same thing as saying that the fluoride came from fluorite deposits), so I added 3 sentences about that. This caused the resulting paragraph to be so long that I broke it into two. Eubulides (talk) 22:35, 9 April 2009 (UTC)

Water that naturally contains fluoride vs. Artificially fluoridated water

An extract from the Use around the world section:

In addition, at least 50 million people worldwide drink water that is naturally fluoridated to optimal levels; the actual number is unknown and is likely to be much higher. Naturally fluoridated water is used in many countries, including Argentina, France, Gabon, Libya, Mexico, Senegal, Sri Lanka, Tanzania, the U.S., and Zimbabwe. In some locations, notably parts of Africa, China, and India, natural fluoridation exceeds recommended levels

My question is when are their health concerns? Is it the fluoride alone that causes the health problems at high levels(in which case those drinking water naturally high in fluoride would suffer negative health effects), or are the health effects associated specifically with the method of artificially adding fluoride to the water? This paragraph seems to equate the too quite neatly giving the impression that there is no real difference. Also, the ref seems to be supplied from the British Fluoridation Society. An organisation highly biased in favour of adding fluoride to British water supplies. Shouldn't we be finding less biased references? I noticed it has been cited 5 times. Is citing the views of pro-fluoridation organisation any different from citing the views of the Fluoride action network? Tremello22 (talk) 19:35, 9 April 2009 (UTC)

  • As I understand it, reliable sources generally do not distinguish among the various sources of fluoride in water, and consider fluoride to be fluoride. For example, I don't know any reliable source that gives a good worldwide picture for what proportion of natural fluoride comes from (say) the mica in granite, versus other sources of natural fluoride. Among reliable sources, the health concerns related to excessive fluoride are almost entirely independent of the source of the fluoride. There is a minority view that the source chemical matters, which is covered in the penultimate paragraph of Water fluoridation #Safety, but this is limited (as far as we know) to one research group and the view has been sharply criticized by the mainstream (this criticism is also covered in that paragraph).
  • The source in question, "The extent of water fluoridation", is coauthored by the British Fluoridation Society, the UK Public Health Association, the British Dental Association, and the Faculty of Public Health. It is the most reliable source we know of on the worldwide extent of water fluoridation. Given that it's coauthored by several respected organizations, and that we cite it only on the extent of fluoridation (not its desirability), and that the claims it supports are not controversial, it's not at all the same as citing the Fluoride Action Network on how fluoride causes cancer (or whatever).
Eubulides (talk) 19:58, 9 April 2009 (UTC)
This study seems pretty relevant. It doesn't seem to be cited in the article. Bioavailability of Fluoride in Drinking Water:a Human Experimental Study, McGuire et al. 2005 Tremello22 (talk) 23:07, 9 April 2009 (UTC)
Thanks for mentioning that, I hadn't read that study. The critical comments about that study in Cheng et al. 2007 (PMID 17916854), in Sheldon & Holgate 2008 (PMID 18096887; also see authors' reply), and in Holgate & Sheldon 2007 (PMID 17962249) suggest that any summary of that study here should be worded quite carefully here. Perhaps a sentence on bioavailability could be added to the last paragraph in Water fluoridation #Mechanism, citing Cheng et al.? Cheng et al. would be preferable here, as WP:MEDRS says we should prefer reviews to primary sources. Eubulides (talk) 23:30, 9 April 2009 (UTC)
I hadn't looked into the reliability of the study and whether it was contentious. Now I have, I agree with what you say. It seems the study was set up due to the recommendations of the UK medical research council review: MDC: Water fluoridation and health, 2002. On a side note, should this MDC review be cited somewhere - it is a pretty comprehensive review, maybe better than the York review. Tremello22 (talk) 14:34, 13 April 2009 (UTC)
Thanks, I'll look into writing something cited by Cheng et al. then. I have not read the MRC report and agree that it could be cited. From reading the lay summary (I haven't had time to read the whole thing yet) it looks like it's particularly strong in describing areas that need further research, and could certainly be cited in that area. For safety and effectiveness I expect it's similar to the already-cited 2007 Australian systematic review in deferring to the York review. Anyway, I'll try to write back here after I've had the time to read it. Eubulides (talk) 16:39, 13 April 2009 (UTC)
Hold on. I am not sure it (Cheng and Sheldon) needs to be cited, I just agreed that the study was contentious. It depends how you are going to put it across. We'd have to think about weight and emphasis. More emphasis would need to be put on the fact that it is a bad study rather than the conclusions of the study. What Cheng and Sheldon objected to most was that "this report formed the basis of a series of claims by government for the safety of fluoridation" What they are saying is that the issue of bio-availability is highly relevant to water fluoridation and yet one flawed study is being used to veil real health concerns. Tremello22 (talk) 19:41, 13 April 2009 (UTC)
Yes, it needs to be put across accurately. As I understand it, (1) mainstream opinion from the underlying chemistry is that it should make no difference in terms of bioavailability as to which of these compounds is the source of the fluoride, (2) this opinion has not been verified by replicated high-quality scientific studies, (3) there has been one study, with poor statistical power, which found no significant difference among fluoride sources (agreeing with mainstream opinion), (4) this study was used in some way by the British government to conclude that fluoridation was safe, but (5) the claims made by the government were not well supported by the study's results due to its lack of statistical power. The previous sentence is way too long for Water fluoridation and I suspect that only points (1) and (2) are worth mentioning in the article. Eubulides (talk) 20:07, 13 April 2009 (UTC)
It depends what you mean by mainstream opinion. If there is only one flawed study, then what is the 'mainstream' basing their opinion on? Tremello22 (talk) 20:29, 13 April 2009 (UTC)
The underlying chemistry. See, for example, Urbansky ET (2002). "Fate of fluorosilicate drinking water additives". Chem Rev. 102 (8): 2837–54. doi:10.1021/cr020403c. PMID 12175269. This material is summarized in Ozsvath 2009 (doi:10.1007/s11157-008-9136-9) as follows: "Although there have been epidemiological studies suggesting that the ingestion of fluorosilicates might have different biological effects from those of sodium fluoride or fluoride from natural sources, this conclusion is not supported by theoretical considerations of fluorosilicate dissociation and hydrolysis equilibria." A different part of Ozsvath covers the same topic, and mentions that the highest-quality epidemiology study, namely Macek et al. 2006 (PMID 16393670), found no association, though it did not disprove an association. Eubulides (talk) 23:18, 13 April 2009 (UTC)
  • McGuire 2005 seems to say that calcium fluoride is the main type of natural fluoride ("occurring either naturally (predominantly from minerals such as fluorspar [calcium fluoride]"), and also says most safety studies have used it. It is a secondary source for these facts, although it doesn't cite sources so it's not a great source for them. I found it rather odd that McGuire didn't specify the chemical compounds used in the "natural" and "artificially" fluoridated water. Most likely they used calcium fluoride and sodium fluoride or silicofluorides respectively. Did I miss them specifying? It's also strange that everyone assumes there is no difference when McClure 1950, which was mentioned in Holwell et al. 1952 found such differences in the way rats metabolize these things. Weddle & Muhler 1957 found, similarly, that the presence of calcium increased the amount excreted through the feces by 3.5 times. Fluoride excreted through the feces presumably would not become as biologically active. Fleming 1959 found differences in rates administered calcium fluoride compared to the other types. The effect of calcium on the absorption of fluoride is mentioned in a 1990 book Trace metals and fluoride in bones and teeth, p. 143. Despite all this evidence, the 2002 WRC report referenced by McGuire 2005 ([www.bfsweb.org/documents/wrcreport.pdf Jackson et al. 2002]) concludes that natural and artificial fluorides are identically bioavailable, even though the only empirical study it seems to reference is a rat study on aluminium's effect (which it says could effect bioavailability). It doesn't discuss the early research at all. It doesn't clearly define naturally fluoridated water. It also doesn't seem to have been published, and is hosted on the British Fluoridation Society website. The 2002 MRC report seems to say, in section 3, that the inorganic ions (calcium, magnesium, aluminium) do decrease bioavailability, but when heavily diluted the effect is thought to be very small. Although it doesn't directly discuss the earlier rat studies and instead references Cremer and Buttner 1970, the rat studies had a relatively high fluoride intake. II | (t - c) 23:46, 13 April 2009 (UTC)
  • I agree that there seems to be a surprisingly lack of well controlled studies, considering the widespread assumptions of safety. The fact that a finding is not supported by "theoretical considerations" does not take the place of empirical evidence. —Mattisse (Talk) 00:05, 14 April 2009 (UTC)
  • "McGuire 2005 seems to say that calcium fluoride is the main type of natural fluoride" No, McGuire 2005 merely says that natural fluoride is "predominantly from minerals". It then goes on to say that fluorspar (a.k.a. fluorite) is one of those minerals, but that's not at all the same thing as saying that fluorite is the primary mineral. In practice, my impression is that fluorite is not the main mineral in areas where natural fluoride concentrations are high, but I know of no reliable sources in this area.
  • "I found it rather odd that McGuire didn't specify the chemical compounds used in the "natural" and "artificially" fluoridated water." For natural fluoridation, this is perfectly understandable, since it's hard to find out which minerals were the source of natural fluoride. Even for artificial fluoridation, I expect that it's difficult to figure out the source of the fluoride, without cooperation of the water utility (and even they may not know, if they switch among fluoride sources, which I expect that many do).
  • "It's also strange that everyone assumes there is no difference when McClure 1950" No recent reliable sources (and there are many) focus on McClure 1950 or on the 1990 book or whatever. It's not really our job to do detective work into obsolete sources. If recent reliable reviews give a relatively small weight to this old material, then Water fluoridation should too.
  • "The effect of calcium on the absorption of fluoride ..." That URL doesn't work for me, but it is speculated that calcium in the water may diffuse into plaque and provide more binding sites for fluoride; this is briefly discussed in Bruvo et al. 2008 (PMID 18362315), which Water fluoridation already cites. Water fluoridation already pushes speculation about calcium fairly far; I'm a bit leery about it pushing this too much farther, due to WP:WEIGHT issues, but perhaps something could be added.
  • Reliable sources agree that there is a lack of well-controlled studies in the area of safety and effectiveness, and this issue is currently mentioned in the lead and in the body. It might not hurt to add a bit more (if someone can come up with specific wording) but we have to be cautious about WP:WEIGHT issues here; there's only so many times we can say "more research needs to be done"....
Eubulides (talk) 01:11, 14 April 2009 (UTC)

Safety

The last time I visited the water fluoridation page there was a piece about the Hooper Bay incident which I thought was very misleading. I am pleased to find that entirely gone but wonder if the "SAFETY" section shouldn't include information with regards to the contemporary safety record fluoridation engineers have in the US and Canada and a description of the new automated monitoring systems. This is a significant area of citizen concern and interest.

I hope I posted this message correctly

Picker22 (talk) 06:21, 17 May 2009 (UTC)

Thanks for the comment. That information would be very useful in this article. Can you suggest reliable sources for this sort of thing? I did a brief search using Google Scholar and came up empty. Eubulides (talk) 16:08, 17 May 2009 (UTC)
I'll work on it. The information will most likely be found in water treatment trade journals. 209.216.191.208 (talk) 05:49, 18 May 2009 (UTC)

Dr. Strangelove

Should any mention of flouridation's role in Dr. Strangelove be mentioned. —Preceding unsigned comment added by 75.164.205.147 (talk) 03:28, 20 May 2009 (UTC)

Good suggestion; thanks. Done. Eubulides (talk) 03:47, 20 May 2009 (UTC)

Costs

I noticed that my information with respect to life-time total costs of a childhood cavity from the Delta Dental Insurance Data division was deleted and information referring to Griffin (2001) substituted.

I am assuming that "discounted lifetime cost" is a conversion from actual lifetime costs to an apportioned amount for a year's span. For purposes of comparing the economic costs and benefits of fluoridation programs that is appropriate. However, only comparing that number trivializes the lifetime economic burden of a cavity. From personal experience, I know that this very matter is often discussed in public debates over water fluoridation.

The general public poorly understands that once a cavity occurs, the tooth's fate is that of repeated restorations. All restorative options have a finite life expectancy. For example, a Norwegian study found the median median time to repeat restoration was 20 years for gold restorations, 12-14 years for amalgam restorations, and 7-8 years for composites.[4] As people age, crowns replace old fillings and some teeth require root canals or extractions. From the perspective of a lifetime, the importance of preventing childhood cavities in permanant teeth, is more clearly understood by knowing the actual cumulative costs.

I have requested a copy of the Griffin article from my regional medical school. I also hope to run down additional referenceable information with respect to other estimates of lifetime costs of a cavity. I'm hoping to discuss this further after these additional investigations.

Regards, Picker22 (talk) 05:16, 19 May 2009 (UTC)

I installed the change from the Delta Dental source (PDF) source to the Griffin et al. 2001 (PMID 11474918) source, so I'll take a crack at following up on your comment.
  • The discounted lifetime cost is the present value of the total lifetime cost. If the total lifetime cost is (say) $1000, the discounted cost will typically be far less (say, $200) because $200 in the bank now will pay out $1000 over the course of one's lifetime. When comparing the cost of fluoridation (which are paid earlier) to the benefits (which accrue later) it is appropriate to compare the present values of all the costs and benefits. I attempted to make this a bit clearer by wikilinking "discounted" to Present value in Water fluoridation #Cost.
  • The discounted lifetime cost is not apportioned for a year's span. The costs and benefits being compared in the "Assuming the worst case" sentence are lifetime figures for a single decayed surface; they are not annual figures.
  • The Delta Dental source is far less reliable than Griffin et al., as the Delta Dental source is unsigned, self-published, and not peer-reviewed. Griffin et al. is much better, but is not the best-quality source either, as it is a bit dated and is a primary source rather than a review.
  • Better sources in this area would be welcome. There is also O'Connell et al. 2005 (PMID 16263039), which is freely readable and is more recent, but it's just for Colorado and is also just a primary source so I have not read it carefully. Maupomé et al. 2007 (PMID 18087993) is another recent primary source, which is also limited (in this case, to Oregon and Washington), and is not freely readable, so I have not examined it carefully either. Please see WP:MEDRS for the sort of sources that Water fluoridation needs for medical facts and figures like this; what we really need here is a reliable review, not primary sources.
Hope this helps. Eubulides (talk) 06:34, 19 May 2009 (UTC)

Thank you for setting me straight with respect to the meaning of "discounted lifetime costs." I would think the use of the present value calculation to be a very complicated matter since the expenditures are spread non-linearly over a lifetime (or over about 66 years assuming the initial cavity occurred at age 10). Obviously I need to read the Griffin article to understand the methodology in this context.

I'm reasonably familiar with Maupomé (2007). It is of no help with this specific matter.

Of course the point is that the eventual economic and human cost of the initial cavity is much larger than the cost and experience of the first restoration. Although it is a very important perspective, I don't see this point as necessarily directly participating in the accounting of water fluoridation's economic net worth. Perhaps a qualitative statement could be made in a verifiable manner which meets Wikipedia standards. Picker22 (talk) 06:20, 20 May 2009 (UTC)

Yes, Griffin et al. 2001 do use complicated calculations (including an appendix of the equations used). They do handle the issue of expenditures spread out over the lifetime, each with a different discount rate. They stop at age 65, I assume because of the dentures factor. It is curious that Griffin et al.'s estimate of the average discounted lifetime cost ($100.62 in 1995 dollars) is soooo much lower than the Delta Dental estimate of about $2000 (2003 dollars) for the (presumably non-discounted) lifetime cost. Inflation would make that $100.62 grow to $130 or so by 2003, which is not nearly enough to explain the difference. Does discounting account for all the rest of the difference, or is there something else going on? I did track down the Delta Dental source to PMID 15559454, an index to an (unsigned?) October 2004 one-page article in Dentistry Today, but the table of contents at dentistrytoday.com for that issue does not list the article; curious. Eubulides (talk) 07:31, 20 May 2009 (UTC)
"Perhaps a qualitative statement could be made in a verifiable manner which meets Wikipedia standards." Sorry, I've lost context; what would the qualitative statement say? The article already says "... the estimated $142 average discounted lifetime cost of the decayed surface, which includes the cost to maintain the restored cavity."; isn't the 2nd half of this quote talking about the long-term cost? and if not, what more would need to be added? Eubulides (talk) 07:38, 20 May 2009 (UTC)

It is very annoying that Delta Dental did not publish their study. Insurance companies may be in the best position to answer some of the economic questions about dental care. The series of articles from the University of Washington based on their Blue Cross insured staff is an example of good data derived from insurance claims. eg: [5]

I agree that the reference to the "discounted long-term cost" technically and perhaps accurately refers to the matter. However, in my opinion, for many, if not most readers, it will not effectively convey the simple fact that a childhood cavity requires a lifetime of repeated restorations and interventions.

The Colorado study you mention is, in my opinion, flawed because it did not include the costs for deciduous teeth. The operative treatment under anesthesia of rampant childhood cavities is dramatically decreased by water fluoridation[6] and accounts for a significant portion of the total dental bill.[7]

I'll get back after I receive and digest the Griffin 2001 paper.

Thanks, Picker22 (talk) 04:23, 21 May 2009 (UTC)

Come to think of it, Griffin works for the CDC so her papers should be free. A bit of searching found an online copy (PDF) of Griffin et al. 2001 (PMID 11474918) at the CDC web site, so you don't need to wait for your library to give you a copy. I just now added this URL to the citation in Water fluoridation. Eubulides (talk) 05:09, 21 May 2009 (UTC)

Thanks Picker22 (talk) 05:26, 21 May 2009 (UTC)

You're welcome.
  • It certainly would be worth mentioning the repeated-restoration point more clearly. Do you think it'd be better to cover this in Cost, or in Goal?
  • I did a bit more searching and found a couple more sources:
  • Splieth CH, Fleßa S (2008). "Modelling lifelong costs of caries with and without fluoride use". Eur J Oral Sci. 116 (2): 164–9. doi:10.1111/j.1600-0722.2008.00524.x. PMID 18353011. This model estimates the total discounted lifetime cost for preventing and treating caries as €932/person without fluoridation, and €247/person with fluoridation. These costs are in Germany and use 2008 euros. Alas, this model evaluates salt fluoridation, not water fluoridation. However, if we assume about 10 decayed surfaces/person lifetime (would that be about right for Germany?) then this would work out to about €100 for the discounted lifetime cost of a decayed surface, which is reasonably close to the $142 estimate currently in Water fluoridation.
  • Wright JC, Bates MN, Cutress T, Lee M (2001). "The cost-effectiveness of fluoridating water supplies in New Zealand". Aust N Z J Public Health. 25 (2): 170–8. PMID 11357915.{{cite journal}}: CS1 maint: multiple names: authors list (link) The journal's web site is messed up and I couldn't get this article online.
Eubulides (talk) 07:14, 21 May 2009 (UTC)

I've read Griffin through. Griffin's costs are all calculated, not actual data points. She assumes that all restorations, both initial and subsequent, are amalgam. Even in 2001 most restorations were not amalgam. Late life treatments (crowns, root canals, extractions, prosthedontics, etc) are very expensive. They were not included yet surely must strongly contribute to the true total. Although the possibility the tooth was "lost" was considered, this appears to have decreased the lifetime cost; the missing tooth no longer requiring reconstruction. Perhaps these are at least some of the reasons her calculated estimates are lower than real world actual bills.

I am surprised the paper has not been criticized for excluding costs for deciduous teeth (citations above).

Whether Griffin's analysis of the net economic value of water fluoridation is valid is a different question than the smaller issue as to the accuracy of her calculated lifetime cost of a cavity. Summing actual dental bills surely better represents the actual lifetime cost of a cavity.

Frankly, truly understanding Griffin's methodologies is beyond my attention span. That they have been accepted as reasonable with respect to comparing the cost of water fluoridation and the avoided dental costs of cavities seems undeniable.

I will read the other references you listed. I have also requested [8] which was cited in a Australian Health Service report as containing the lifetime cost of a cavity.

Because the natural history of caries with respect to repeated maintenance is so poorly understood and generally comes up in discussions of water system expenses, I thought it best located in the Cost section. I can see how it would fit in the Goals and have no objection to it being there instead. Picker22 (talk) 08:00, 23 May 2009 (UTC)

OK, thanks, I took a shot at it by adding to Goal the text "Once a cavity occurs, the tooth's fate is that of repeated restorations, with estimates for the median life of an amalgam tooth filling ranging from 9 to 14 years.", citing Griffin et al. 2001 (PMID 11474918). I hope you don't mind my shamelessly stealing from the nice prose in your comment above. Suggestions for further improvements are welcome. Eubulides (talk) 08:57, 27 May 2009 (UTC)

That looks good to me. Thanks. I could not find a peer reviewed reference which actually tallied dental bills as did Delta Dental. It appears they have separate analyses from their various state and regional businesses.

I have realized reading these papers which use the discounted cost of a cavity that their estimate of the net economic value of water fluoridation depends as much on current interest rates as the physiology and chemistry of fluoride. Right now with insured returns of only 1-2%, water fluoridation looks even better. It may not have penciled in 1979 with interest rates in double digits. Picker22 (talk) 06:20, 28 May 2009 (UTC)

You're welcome. You're quite correct that the discount rate is an important assumption. However, fluoridation saves money under almost all reasonable scenarios. Griffin et al. did sensitivity and breakeven analyses that varied the discount rate assumption and found, for example, that for communities with over 20,000 people, water fluoridation saves money if the discount rate is less than 202% per annum. (Even 1979 wasn't that bad....) Eubulides (talk) 06:50, 28 May 2009 (UTC)

Professional Perspectives on Water Fluoridation

Youtube video - Professional Perspectives on Water Fluoridation Tremello22 (talk) 19:21, 21 May 2009 (UTC)

Eckardt vs. Erhardt, and 19th century fluoride research

As reference to early supplements containing potassium fluoride, a "Dr. Eckardt" is mentioned in the article. In fact, the paper cited gives that name as the author; but that certainly is a typo, for several related papers have been written by Dr. Erhardt, who was a public health officer of Emmendingen, near Freiburg, Germany. Dr. Carl Erhardt (1813-1875) had a famous brother, Dr. Wolfgang Erhardt, who worked as a physician for the German embassy at Rome, Italy, and who "endorsed" his brother' s pills, as cited by dentist Georg von Langsdorff in 1875.

There's even more in the early fluoride history than just a few recommendations. The issue was under heavy discussion since the beginning of the 19th century! For details see http://www.fluoride-history.de/fteeth1.htm . Of course, that part doesn'nt please the fluoridistas. They prefer to cite just one side, pro, of the issue. --Tren (talk) 10:55, 24 May 2009 (UTC)

Thanks for the correction. Do you have a full citation to the 1954 JADA paper, in the style already used in Water fluoridation? That is, can you fill in the blanks in the following use of the {{cite journal}} template?
  • {{cite journal |author= ???, ???, ??? |title= Potassium fluoride as a caries preventive: a report published 80 years ago |journal= J Am Dent Assoc |volume=49 |issue=? |pages=385–??? |year=1954}}
I confess that I don't see the relevance of the 19th-century history to the modern debate about the benefits and drawbacks of water fluoridation. Water fluoridation has space limitations and it cannot delve all that deeply into topics that aren't directly related to water fluoridation. However, the 19th-century fluoride research could be covered in somewhat greater detail in History of water fluoridation, and the pastilles etc. of the 19th century could be summarized in Fluoride therapy (which greatly needs a History section). Eubulides (talk) 18:57, 24 May 2009 (UTC)
No author of the short article, a translation of a paper by Erhardt, is given. It's just one page, p.385, in the September 1954 issue of the JADA. --Tren (talk) 19:21, 24 May 2009 (UTC)
Thanks; in that case we should probably cite the original too, so I've restored that. Is there a brief introduction to the translation that supports Water fluoridation's claim that Erhardt was a public health officer and that his name was misspelled in the original publication? Is the translator listed in that article? Was the September issue the 9th issue of volume 49 of that journal? Eubulides (talk) 19:42, 24 May 2009 (UTC)
The JADA article is a translation of another paper by Erhardt on the same topic. The original paper was published in "Memorabilien. Monatshefte für rationelle Ärzte" Vol. 19 (November, 1874) pp.359-360. Title: "Kali fluoratum zur Erhaltung der Zähne". The article was reported to the ADA by Eduard G. Friedrich of Chicago; there is no mention if the same person did the translation. Also a paper by Georg von Langsdorff (Dtsch. Vierteljahrsschrift für Zahnheilkunde 15 (1875) 430-9) refers to the public health officer ("Bezirksarzt") Dr. Erhardt. I did some research on Erhardt and was informed by the State Archive that he was a former spa doctor and was employed by the State since 1860, first at Gernsbach; worked since 1872 at Emmendingen, near Freiburg; died 1875 during a cure at Karlsruhe. As Erhardt himself wrote in a paper in 1851, a "Amtsarzt" or "Bezirksarzt" was employed and paid by the State to treat the poor. --Tren (talk) 17:07, 25 May 2009 (UTC)
Thanks again. I was unaware that there were two 1874 publications by Erhardt on the topic. Water fluoridation currently cites the March 1874 publication in Der praktische Arzt (which Google Books has digitized; I searched books.google.com for the string "Kali fluoratum zur Erhaltung der Zähne", in quotes, and it was the 1st of the 5 matches). Is this similar to (perhaps an earlier version of?) the identically titled November 1874 paper published in Memorabilien. Monatshefte für rationelle Ärzte, or are they quite different papers? Since the March 1874 paper identifies Erhardt as a "Bezirksarzt" that's a good enough source for us. Eubulides (talk) 18:26, 25 May 2009 (UTC)
Erhardt spread his stuff through several journals at the same time, in somewhat different wording. The November article cites more explicitly his alleged experiment on dogs. --Tren (talk) 18:45, 25 May 2009 (UTC)
You "don't see the relevance of the 19th-century history to the modern debate about the benefits and drawbacks of water fluoridation." The 19th century quotes cited in this article as well as in some pro-fluoridation papers, selectively quote the "pro" arguments, as if it was well known already then that fluoride was good for teeth. The opposing arguments are disregarded. Dentists and chemists(Wrampelmeyer, Michel, Gabriel) reported that theý found no difference in the fluoride content of sound vs. carious teeth. Berzelius, in his "Jahresberichte" of 1840, wrote that the low amounts of fluoride usually found in teeth are to be considered just accidental components. Gabriel, Harms and others made it perfectly clear that the amounts of fluoride found in teeth and bones with newer and more reliable methods are too low to form fluoroapatite at any significant rate. And they were actually supported by x-ray diffraction studies done in the 1930's. Yet, the fluoridistas still refer just to the purely speculative, unscientific, and unfounded claims of Crichton-Browne, Erhardt, Deninger, and (sometimes) a few others. This exactly is the relevance to the modern debate. "Opponents" are simply treated in an unfair way! Why not state that in the 19th century, the possible benefits of fluoride were subject of (sometimes heated) discussions. Many references for this are cited at the fluoride-history site given above. _That_ would be a fair statement. --Tren (talk) 18:32, 25 May 2009 (UTC)
Well, for starters, we don't have a reliable source saying there were heated discussions, so Water fluoridation can't say that. We also have to be cautious of sources devoted to fluoride in general, as opposed to water fluoridation in particular, as they may not have proper WP:WEIGHT from the water-fluoridation point of view. I do take your point that it's not right just to cite Erhardt 1874 and Crichton-Browne 1892; we need a broader overview of 19th-century fluoride research if we're going to mention it at all. I looked for a bit for one, found Cox 1952, installed a change that gives just a higher-level view of 19th-century fluoride research (citing Cox), and moved the excessive details to History of water fluoridation. I would like a more-recent reliable review of the 19th-century history, from a water-fluoridation viewpoint, but I don't have one. For example, I don't have ready access to Kargul et al. 2003 (PMID 12739679), or to Kumar & Moss 2008 (PMID 18329450). Anyway, hope this change helps. Eubulides (talk) 08:39, 26 May 2009 (UTC)

Cautious wording in Truman et al.

A recent edit made this change (italics are insertions):

"A 2002 systematic review found data seeming to support the conclusion that starting water fluoridation reduces tooth decay in the community by 30–50% overall, and that stopping it leads to an 18% increase when other fluoride sources are inadequate."

However, the cited source, Truman et al. 2002 (PMID 12091093), says this:

"Although we could not quantitatively combine effect measures from groups A and B, both seem to support the conclusion that community water fluoridation reduces dental caries by 30% to 50% of what could be expected for people not consuming fluoridated water. In addition, stopping CWF may lead to the median 17.9% increase in caries described above, in situations in which alternative sources of fluoride are inadequate."

The cited source uses phrases like "seem to support the conclusion" and "may lead", which is considerably more cautious than the new text in Water fluoridation which confidently asserts that starting CWF reduces caries such-and-such and stopping it increases it 18%. Perhaps the old wording was too wishy-washy, but the new wording is too confident. While we're in the neighborhood, the source talks about a "median" 18% increase and that info can easily be reflected in the text, and "in the community" is redundant with "overall". So I installed the following edit to try to further improve the text:

"A 2002 systematic review found that starting water fluoridation seems to reduces tooth decay in the community by 30–50% overall, and that stopping it may leads to an median 18% increase when other fluoride sources are inadequate."

Eubulides (talk) 21:25, 1 June 2009 (UTC)

I've read the paper closer than before. Perhaps there's a cultural difference in the use of "seem". To me it implies two things:
  1. The authors are guessing and we all know the gut has no place in scientific evaluation.
  2. The conclusion is an illusion that the authors are about to point out.
Neither meaning has a place in an encyclopaedia IMO. In addition "may" does not mean "is likely to" but rather "could possibly", which combined with the source figure of "17.9%" strikes me as a ridiculous combination of precision and indecision. Their conclusions is a solid "strong evidence shows that CWF is effective in reducing the cumulative experience of dental caries within communities." but their attempts to combine the study data to produce some figures fail IMO. Our readers could interpret those words as meaning "we are so unsure that it is also quite possible that starting water fluoridation would lead to an increase in caries or that stopping it would be beneficial".
I'm really not convinced it is worth repeating those numbers if there's no science or maths behind their creation. Looking at the charts in the paper, I'm left with the impression that there are so many variables at play, that the effect of introducing or ending a CWF scheme on a given community cannot be predicted accurately. This has implications for determining in advance if the side-effects or cost of introducing a scheme will make it worthwhile (though both could be measured afterwards and the scheme abandoned if necessary).
Lastly, I'm puzzled about the qualifying statement "when other fluoride sources are inadequate". Do they mean "inadequate" to a sizeable sub-population (fluoride toothpaste available, but high levels of non-usage) or absolutely (fluoride toothpaste generally unaffordable in the community, and water supply has inadequate fluoride). Surely the degree of "inadequacy" is proportional to the increase in caries experienced when one source of fluoride is removed. This further makes a nonsense of the "17.9%" figure IMO. Colin°Talk 22:46, 1 June 2009 (UTC)
This is being a bit hard on Truman et al., I think. They're just being very cautious in their wording. They are referring to a 17.9% figure that is precise for a reason (it's the median result of 5 studies) but I agree that pulling that figure out of context gives an impression of precision that is unwarranted. The "when other fluoride sources are inadequate" comment is talking, I think, about all other sources of fluoride; this includes not only toothpaste, but also rinses, varnishes, etc., plus halo-effect beverages; see p. 25 column 1 last paragraph. I do agree that the overall Truman numbers are presented confusingly in Water fluoridation. If you have access to Kumar 2008 (PMID 18694870), its table 1 (p. 9) has a much better summary of Truman et al. than we did, but it's fairly terse and including it here would require a lot of elaboration. I'm not sure it's worth it. So for now I removed the poorly-explained numbers and substituted Truman et al.'s conclusion, as follows:
"A 2002 systematic review found strong evidence that starting water fluoridation seems to reduce is effective at reducing overall tooth decay in communities the community by 30–50%, and that stopping it may lead to a median 18% increase when other fluoride sources are inadequate."
I hope this sentence is a useful summary of the the paragraph that it terminates, as it talks about communities as a whole, whereas the previously sentences in that paragraph are each individually limited either to children, or to adults. Eubulides (talk) 06:15, 2 June 2009 (UTC)
Yes, that's fine. I stick by my view that the 30-50% figure is just a hand-wavy opinion, which they are entitled to offer but needs context before it becomes repeatable here and sticks out compared to all the other stats that have confidence intervals, etc. The 17.9% figure is just silly and what they said is different to what was reproduced here. They said "stopping CWF may lead to the median 17.9% increase in caries described above" (i.e., you might get a result just like the median of the results in this analysis) whereas we said that "stopping CWF may lead to a median 18% increase", which (because "median" only makes sense within a sample) says "if several communities stopped CWF, the median of their increase may be 18%", which is too precise. But even thought they say "you may get this figure", it is worthless without some idea of how likely that "may" is. If you fill a 1 litre bucket with pebbles at a beach, you may get 243 pebbles. And you may not. Colin°Talk 08:22, 2 June 2009 (UTC)

Unreliable sources added to the lead

A recent edit added this text:

"though certain side effects have been suggested[1], such as calcification of the pineal gland[2], elevation of blood lead level[3], effects on thyroid activity[4], osteosarcoma [5], bone fractures[6], and decreased fertility[7]."

There are a couple of problem with this change.

  • The main problem is that it introduced several primary sources in order to dispute the conclusions of the reliable secondary sources cited in this article. This is contrary to WP:PSTS and of WP:MEDRS, which say that Wikipedia articles (particularly for medical facts and figures) should rely mainly on secondary sources such as reviews, and should not use primary sources to overturn the conclusions of secondary sources.
  • The sources cited by this new text are either irrelevant, or unreliable primary sources, or both:
  1. Paul Connetta Report of meeting and commentary: US National Research Council Subcommittee on Fluoride in Drinking Water Fluoride Vol. 36 No. 4 280-289 2003 [9]
    This is a personal report of one meeting of the U.S. NRC project that eventually produced a report that is explicitly not about water fluoridation. So not only is this source not reliable, it's about a different topic.
  2. Luke, Jennifer. "Fluoride Deposition in the Aged Human Pineal Gland". Caries Res. 2991 (35): 125–28. Retrieved 2009-05-20. {{cite journal}}: Cite has empty unknown parameters: |laysource=, |laydate=, |laysummary=, and |month= (help)
    This primary study presents zero evidence of adverse effects. The claim that it reports adverse effects is one of many unsupported claims that fluoridation is linked to "poisonings and various accidents, allergies, brain dysfunctions such as Alzheimer's disease, hyperactivity, low intelligence, arthritis, bone diseases including hip fractures and osteosarcomas, cancers, dental fluorosis, gastrointestinal problems, diseases of the kidney, pineal gland and thyroid gland, reproductive issues, AIDS, and even with increased tooth decay" (this list is from Armfield 2007, PMID 18067684, a reliable source on such claims). Water fluoridation already mentions some of these claims, which are not supported by the scientific evidence. I don't see any evidence that the pineal-gland claim is any more notable than the rest.
  3. Roger D. Masters; Myron J. Coplan. Water treatment with silicofluorides and lead toxicity International Journal of Environmental Studies, 1029-0400, Volume 56, Issue 4, 1999, Pages 435 – 449
    This primary study is reviewed by Pollick 2004 (PMID 15473093), already cited in the article. As per WP:MEDRS the article should not use primary studies to dispute reliable reviews.
  4. Galletti P, Joyet G. Effect of fluorine on thyroidal iodine metabolism in hyperthyroidism J Clin Endocrinol 1958;18:1102-10
    This is a 1958 (!) primary study. If it is not summarized in recent reliable reviews, it is not notable. As per WP:MEDRS it should not be cited directly.
  5. Cohn PD. A brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young males New Jersey Department of Health, November 8, 1992.
    This is a 1992 (also old!) primary study on osteosarcoma. Water fluoridation is citing a reliable review on osteosarcoma (NHMRC 2007) and should not be attempting to undermine the conclusions of this review with an old primary study.
  6. Li Y, Liang C, Slemenda CW, Ji R, Sun S, Cao J, et al. Effect of long-term exposure to fluoride in drinking water on risks of bone fractures. J Bone Miner Res 2001;16:932-9.
    This primary study reports that the risk of bone fracture is lower in water fluoridated to recommended levels. However, regardless of whether it is evidence for or against fluoridation, this shouldn't be cited directly; instead, the article should cite a reliable review of this study, which it already does (NHMRC 2007).
  7. Freni SC. Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. J Toxicol Environ Health 1994;42:109-21.
    This primary study is about fluoridation to well above recommended levels, and is thus not directly relevant to water fluoridation. Again, reliable reviews should be cited instead of this old primary study.
  • One other problem with the change: it altered the lead so that it no longer summarized the body, but instead contradicts the body. As per WP:LEAD, the lead is supposed to summarize the body.
  • With all these problems, the simplest thing was to revert the change, which I've done. I don't see any topic here that is worth mentioning in the article (certainly not in the lead), but perhaps something could be salvaged, and further comments are welcome.

Eubulides (talk) 05:57, 30 June 2009 (UTC)

I think it's ridiculous that you're removing my edit. Primary sources ARE acceptable, just not preferable. Look at any medical/scientific article on wikipedia. Even though secondary (review) sources are preferable in general, I'd say that wikipedia policy prefers many primary sources to few review sources. In the scientific community, no one would ever rely on a SINGLE review article, because even the authors of review articles can have a bias.
Regardless, I think it's absolutely foolish and POV to say "there is no clear evidence of any adverse effects" unless you're using some opinionated definition of "adverse." Look at some side-by-side X-rays of human brains, and you'll see that the pineal gland is invisible in people with a low fluoride intake and it is a bright (i.e., hardened with calcium) spot in people with fluoride in their drinking water. Fluoride in drinking water changes the pineal gland's composition and appearance, which probably changes its functioning, and though I'm sure no neurobiologist would say that's clearly adverse or beneficial, I think obvious side effects on the human brain shouldn't be marginalized.
I would just add an image of side-by-side brain x-rays and notate the calcified pineal gland, and since wikipedia's rules on images are more lenient, that probably would remain on the page. However, I don't have noncopyrighted images like that. I'd appreciate if somebody could post something like that, and I'd be happy to annotate it.
Either way, this article should NOT ignore the effects of fluoridated water on the pineal gland, so I'm going to add that one bit back in. I don't want to rewrite the entire article, so I'm just going to put it in the header. Inasilentway (talk) 14:46, 30 June 2009 (UTC)
I moved discussion of the pineal gland from the lead (where it definitely does not belong) into the body, and cited a reliable secondary source (a review) rather than a primary source directly. It's true that primary sources are acceptable on occasion, but they cannot be used to dispute reliable mainstream opinion, which is what was happening here. Please see WP:PSTS for details on this Wikipedia policy. Eubulides (talk) 20:56, 30 June 2009 (UTC)
I really think this article (or one or more of its authors) has hidden POV, and its featured article status should immediately be reviewed. I truly believe that it is unencyclopedic and biased--in the header it admits "Moderate-quality studies have investigated effectiveness; studies on adverse effects have been mostly of low quality" and yet it cites numerous review articles of the available research. I think that: 1)these secondary sources could not be reliable without adequate primary evidence, which is admittedly lacking 2)if it's true that the information is lacking, then it's probably more enlightening and manageable to refer to primary sources rather than equally uninformed secondary sources 3)specifics on primary evidence could easily and should be presented. Therefore, I think primary sources, such as the ones that were deleted from my first edit, should be allowed on this page.
I made my argument about x-ray evidence of human pineal gland calcification due to fluoride in drinking water earlier in this discussion. You can refer to pineal gland if you want confirmation. Granted, calcification of a gland of the brain is not a clear "adverse effect," but it is an obvious side effect. Yet even a mere reference to that fact was only grudgingly allowed to be included in the article after reverting my first TWO attempts at including it, and even then, it was inserted right next to the conspiracy theories section with a citation to a paper with only one reference to the pineal gland in the entire article in the section "Fear Mongering."
Maybe we need moderation/arbitration on this. The article probably should not be a featured article. My edits are being aggressively deleted and I think it's unfair and causes this article to push an unbalanced viewpoint. Maybe this is a reflection of a larger cultural bias in favor of water fluoridation, but I really do think this article, even subtleties of its wording, organization, and punctuation, is far too supportive of water fluoridation in light of the admittedly lacking research on its effects.Inasilentway (talk) 06:07, 1 July 2009 (UTC)
Please see #Numerous review articles below. Eubulides (talk) 07:51, 1 July 2009 (UTC)

Numerous review articles

  • "in the header it admits "Moderate-quality studies have investigated effectiveness; studies on adverse effects have been mostly of low quality" and yet it cites numerous review articles of the available research" And the very sentence quoted is supported by one of those review articles, namely the York review (2000). The York review, like the other reviews, summarizes primary studies of varying quality. There is nothing wrong with citing review articles; on the contrary, it's preferred (see WP:MEDRS). What's wrong, from a Wikipedia point of view, is to pick and choose some of the primary studies in order to dispute the reviews (see WP:PSTS for more on this).
  • "these secondary sources could not be reliable without adequate primary evidence" Secondary sources can certainly be reliable even in the presence of unreliable primary sources. They can say what is unreliable about the primary sources and why, and can give the consensus view on what the primary sources actually mean. For example, all currently-available reliable secondary sources agree that water fluoridation reduces cavities, even though the primary sources establishing this result are not high quality by today's standards.
  • "if it's true that the information is lacking, then it's probably more enlightening and manageable to refer to primary sources rather than equally uninformed secondary sources" No, the secondary sources are not "equally uninformed". They are written by published experts in the field. It would be against Wikipedia policy for us to second guess the experts. Again, please see WP:PSTS.
  • "specifics on primary evidence could easily and should be presented" No, because that's far too prone to abuse. Please see WP:MEDRS for why. For example, a Wikipedia editor could easily use primary sources to "prove" that water fluoridation causes AIDS. Another one could just as easily use them to "prove" that water fluoridation causes cavities. None of these "proofs" would pass muster in any serious scientific journal, and Wikipedia should not be passing along misinformation like this. The way to avoid this sort of problem is to rely on the best reviews available from mainstream scientific and medical sources.
  • "You can refer to pineal gland if you want confirmation." We cannot rely on other Wikipedia articles for confirmation of medical facts and figures. For obvious reasons we must rely on external reliable sources. There is no scientific evidence that water fluoridation adversely affects the pineal gland (or the thyroid, or the kidneys, etc.), and Water fluoridation should not say or imply otherwise. Dental fluorosis is the only adverse effect for which there is scientific evidence (admittedly low-quality evidence), and the topic of dental fluorosis is amply covered in Water fluoridation.
  • "Maybe this is a reflection of a larger cultural bias in favor of water fluoridation" Possibly so, but in that case Water fluoridation must faithfully reflect mainstream views. Wikipedia is not the place to conduct original research that proves the mainstream wrong.
  • To avoid reinventing the wheel on this subject, it might help to review the January good article review, the February peer review, the March featured-article candidacy, and the June featured-article candidacy.

Eubulides (talk) 07:51, 1 July 2009 (UTC)

Text deleted from the lead

A recent series of edits deleted significant text from the lead, causing the lead to be a less-than-faithful summary of the body as required by WP:SUMMARY. Here are the two chunks of text that were deleted (I'm rendering the citations inline in this copy):

  • "Fluoridated water has fluoride at a level that is effective for preventing cavities; this can occur naturally or by adding fluoride.(CDC 2001, PMID 11521913) Fluoridated water operates on tooth surfaces: in the mouth it creates low levels of fluoride in saliva, which reduces the rate at which tooth enamel demineralizes and increases the rate at which it remineralizes in the early stages of cavities.(Pizzo et al. 2007, PMID 17333303) Typically a fluoridated compound is added to drinking water, a process that costs an average of about $1.36 per person-year in the U.S.;(CDC 2001, PMID 11521913; Minn Fed 2009) defluoridation is needed when the naturally occurring fluoride level exceeds recommended limits.(Taricska et al. 2006, doi:10.1007/978-1-59745-029-4_9). A 1994 World Health Organization expert committee suggested a level of fluoride from 0.5 to 1.0 mg/L (milligrams per liter), depending on climate.(WHO 1994)"
  • This text summarizes the Implementation and Mechanism sections, and these sections need to be summarized in the lead.
  • This text summarizes the Goal section, another section that needs summarization in the lead.

The edits also made this change:

But the cited source (CDC 2001, PMID 11521913) does not say anything about a "premise"; it states, for example, "Community water fluoridation is a safe, effective, and inexpensive way to prevent dental caries." with no mention of a "premise". So this alteration is not supported by the cited source.

Some of the edit summaries that justified these changes seemed to be based on obsolete information (e.g., "misleading as implies topical effect, when the majority is systemic"); other edit summaries are debatable, but in any event I suggest any problems with the lead be discussed here before making such wholesale changes. I see that while writing up the above, another editor reverted these deletions, which was a good thing to do for now. Eubulides (talk) 21:53, 11 July 2009 (UTC)

"one of 10 greatest achievements... 20th century"

Mentioned twice....annoying, and repetitive...

Or is it just me? Is it possible to unify this? —Preceding unsigned comment added by 98.21.61.161 (talk) 04:10, 21 July 2009 (UTC)

One occurrence is in the lead and one in the body. The lead is supposed to summarize the body; see WP:LEAD. If there weren't repetition between the lead and the body, something would be wrong. Eubulides (talk) 04:13, 21 July 2009 (UTC)

consensus

14 Nobel Prize winners jointly stating fluoride is dangerous--is a conspiracy?? [www.nofluoride.com/presentations/Nobel%20Prize%20Winners.pdf]

210.50.176.57 (talk) 01:02, 1 August 2009 (UTC)

Who knows - could it be called an Appeal to Authority? Shot info (talk) 02:18, 1 August 2009 (UTC)
There is no such joint statement. There is an unsupported list floating around antifluoridation websites. For example, .org/50-reasons.htm#appendix4 this list mentions Hans von Euler-Chelpin (Chemistry, 1929) as being one of 14 Nobelists who "have opposed or expressed reservations about fluoridation"; however, the website cites no sources and is not itself a reliable source. Euler-Chelpin died in 1964 and his opinion about fluoridation (whatever it was) is no longer relevant to this article, except possibly to the History section. Eubulides (talk) 05:22, 1 August 2009 (UTC)
210.50.176.57, if you can provide a better source (after all, "Nofluoride" probably doesn't qualify as a reliable source for encyclopedic content) then it can be evaluated. But I agree with Eubulides, there is no way that this document can be independantly verified if it's actually correct, or misrepresenting the position of those 14 NP winners. This is a problem about sourcing material from poor sources, mainly as one cannot have a high confidence in the validity of their material. But if you have a good source, with the pertinent info, by all means submit it. Shot info (talk) 22:57, 5 August 2009 (UTC)
  1. ^ a b Cite error: The named reference NHMRC was invoked but never defined (see the help page).
  2. ^ Cite error: The named reference YorkReview2000 was invoked but never defined (see the help page).
  3. ^ Cite error: The named reference Lamberg was invoked but never defined (see the help page).
  4. ^ Acta Odontol Scand. 1994 Aug;52(4):234-42. The age of restorations in situ. Jokstad A, Mjör IA, Qvist V. Dental Faculty, University of Oslo, Norway.
  5. ^ J Periodontal Res. 1993 May;28(3):166-72. Fluoridation effects on periodontal disease among adults. Grembowski D, et al, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle
  6. ^ MMWR Morb Mortal Wkly Rep. 1999 Sep 3;48(34):753-7. Water fluoridation and costs of Medicaid treatment for dental decay--Louisiana, 1995-1996. Centers for Disease Control and Prevention (CDC).
  7. ^ J Public Health Dent. 2000 Winter;60(1):21-7. Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97. Griffin SO, et al
  8. ^ Operative Dentistry; Vol 26, Supplement 6, 2001; MH Anderson; "Current Concepts of Dental Caries and Its Prevention." p 11-18
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