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Section 6.

Appendix 1  Biographical notes about signatories.

Albert Burgstahler, Ph.D., has been researching the fluoridation issue for over 30 years. He is co-author of "Fluoridation: the Great Dilemma" (Coronado Press, Lawrence, Kansas, 1978), is currently the editor of the journal "Fluoride", and is on the executive board of the International Society for Fluoride Research.

Robert J. Carton, Ph.D., has been researching the fluoridation issue for over 20 years. He was former President of Local 2050 of the National Federation of Federal Employees, the union representing all the professionals at the headquarters of the U.S. Environmental Protection Agency in Washington, D.C.  Dr. Carton was involved in exposing the political pressures exerted to establish an unscientific drinking water standard (4 ppm) for fluoride.

Paul Connett, Ph.D., has been researching the fluoridation issue for over 6 years. He was an invited peer reviewer of the York Report (McDonagh et al, 2000) and testified before the Fluoridation Forum in October, 2000. Dr. Connett is a key organizer of the Fluoride Action Network which hosts the web page http://www.fluoridealert.org.

William Hirzy, Ph.D., is Vice-President of the National Treasury Employees Union, Chapter 280, which represents the professionals employed at the US EPA's headquarters in Washington, DC. This union has taken a position opposing water fluoridation. On June 29, 2000 Dr. Hirzy presented his Union's position in a statement he gave before the US Senate Subcommittee on Wildlife, Fisheries and Drinking Water (http://www.fluoridealert.org/testimony.htm).

Vyvyan Howard, MB, ChB, Ph.D., FRCPath., is a medically qualified toxico-pathologist. He is a past President of the Royal Microscopical Society. The primary research activity of his group concerns the action of toxic substances on the fetus and infant. He is currently investigating the differential neuro-developmental toxicity of various fluoride preparations. He wrote the foreword to the recent book on water fluoridation by Dr Barry Groves.

David C. Kennedy, DDS, is a Past-President and Fellow of the International Academy of Oral Medicine and Toxicology (IAOMT), the IAOMT's Fluoride Information Officer, and Special Project Consultant. In 1998 he and Dr. J. William Hirzy authored a risk assessment for ingested fluoride based upon the standard methodologies used by the US Environmental Protection Agency Global 86 program, full text available at http://www.saveteeth.org/, that demonstrated the current intake of fluoride already exceeds the minimum risk levels.

Hardy Limeback, Ph.D., DDS, is the former President of the Canadian Association for Dental Research, and one of Canada's leading fluoride researchers. He has acted as consultant to the Canadian Dental Association on fluoride and gave invited testimony to the Fluoridation Forum in October, 2000.

Roger Masters, Ph.D., has co-authored two papers with Myron Coplan (1999, 2000) which have shown an association of an increased uptake of lead into children's blood with the use of hexafluorosilicic acid (HFSA) and its sodium salt (NaSFA) as a fluoridating agent. Masters and Coplan have also shown a relationship with the use of the HFSA and NaSFA and violent behavior in communities in the US.

Tohru Murakami, Ph.D., DDS, is vice president of the Japanese Society for Fluoride Research. He has translated many articles on fluoridation into Japanese and circulated them via the Japanese Journal of Fluoride Research.

Bruce Spittle, Ph.D., has extensively reviewed the literature on fluoride's impact on the central nervous system (Spittle, B. (1994), Psychopharmacology of fluoride: a review. International Clinical Psychopharmacology, 9, 79-82; and Spittle, B. (2000), Fluoride and Intelligence (Editorial), Fluoride Vol. 33 No. 2: 49-52).

A.K. Susheela, Ph.D., is currently the Executive Director of India's Fluorosis Research and Rural Development Foundation located in Delhi. From 1969-1997 she served on the Faculty of the All India Institute of Medical Sciences (AIIMS) in New Delhi. During her tenure there, she set up the Fluorosis Research Laboratories. From 1987-97, Professor Susheela was in charge of the Fluorosis Control Cell of the Rajiv Gandhi National Drinking Water Mission (Govt. of India) and established the Fluorosis Diagnostic Facility at the AIIMS Hospital. She has assisted State Governments, throughout India, in implementing Fluorosis control programmes.  She was the President of the International Society for Fluoride Research (ISFR) for two consecutive terms during 1987 - 1991. She hosted the 13th International Conference of ISFR in New Delhi in November 1983. Professor Susheela is a Fellow of the National Academy of Medical Sciences and a Fellow of the Indian Academy of Sciences. During 1987, she won the prestigious Ranbaxy Research Foundation award in medical sciences. She has published many papers on the subject of fluorosis and recently summarized much of her work in a monograph.  

Appendix 2.  Dr Paul Connett's '50 Reasons to oppose fluoridation'.

See http://www.fluoridealert.org/50Reasons.htm

Appendix 3.  Responses to the York Review.

See http://www.fluoridealert.org/Sheldon.htm

Appendix 4.  A chronological listing of the animal, clinical and endemic studies of fluoride and bone, with quotations.

See http://www.slweb.org/f-bone.html

Appendix 5.  A chronological listing of the epidemiological hip fracture studies.

Studies Reporting an Association between fluoridated water (< 1.2 ppm fluoride) & hip fracture.

1) a) Cooper C, et al. (1991). Water fluoridation and hip fracture. JAMA 266: 513-514 (letter, a reanalysis of data presented in 1990 paper).

b) Cooper C, et al. (1990). Water fluoride concentration and fracture of the proximal femur. J Epidemiol Community Health 44: 17-19.

"We found a significant positive correlation between fluoride levels and discharge rates for hip fracture. This relationship persisted for both women and men... Using an appropriately weighted regression model, there appears to be a positive ecologic association between fluoride levels of county water supplies and fracture discharge rates. This ecologic association is consistent with a recently published study and others currently in progress."

2) Danielson C, et al. (1992). Hip fractures and fluoridation in Utah's elderly population. Journal of the American Medical Association 268(6): 746-748.

"We found a small but significant increase in the risk of hip fracture in both men and women exposed to artificial fluoridation at 1 ppm, suggesting that low levels of fluoride may increase the risk of hip fracture in the elderly."

3) Hegmann KT, et al. (2000). The Effects of Fluoridation on Degenerative Joint Disease (DJD) and Hip Fractures. Abstract #71, of the 33rd Annual Meeting of the Society For Epidemiological research, June 15-17, 2000. Published in a Supplement of Am. J. Epid. P. S18.

This study found an age-specific, statistically-significant relationship between fluoridation and hip fracture in women 75-84 years old - RR = 1.43 (95% CI, 1.02-1.84). An increase in hip fractures was also found in women aged 85 and older - RR = 1.42 (CI, 0.98 - 1.87).

4) Jacobsen SJ, et al. (1992). The association between water fluoridation and hip fracture among white women and men aged 65 years and older; a national ecologic study." Annals of Epidemiology 2: 617-626.

"In order to assess the association between water fluoridation and hip fracture, we identified 129 counties across the United States considered to be exposed to public water fluoridation and 194 counties without exposure...There was a small statistically significant positive association between fracture rates and fluoridation. The relative risk (95% confidence interval) of fracture in fluoridated counties compared to nonfluoridated counties was 1.08 (1.06 to 1.10) for women and 1.17 (1.13 to 1.22) for men."

5) Jacobsen SJ, et al. (1990). Regional variation in the incidence of hip fracture: US white women aged 65 years and olders. J Am Med Assoc 264(4): 500-2.

"This study examines the geographic distribution of hip fracture incidence in the United States at the county level. To this end, data are obtained from the Health Care Financing Administration (HCFA) and the Department of Veteran Affairs that identify all hospital discharges with a diagnosis of hip fracture for women aged 65 years and older for the period 1984 through 1987...After exclusions, 541,985 cases remained eligible for study... There is a weak positive association between the percent of county residents who receive fluoridated water and hip fracture incidence in the unadjusted analysis that is strengthened after adjustment."

6) a) Jacqmin-Gadda H, et al. (1995). Fluorine concentration in drinking water and fractures in the elderly. JAMA. 273: 775-776 (letter).

b) Jacqmin-Gadda H, et al. (1998). Risk factors for fractures in the elderly. Epidemiology 9(4): 417-423. (An elaboration of the 1995 study referred to in the JAMA letter).

"We found a higher risk of hip fractures for subjects exposed to fluorine concentrations over 0.11 mg per liter but without a dose-effect relation."

7) Keller C. (1991) Fluorides in drinking water. Unpublished results. Discussed in Gordon, S.L. and Corbin, S.B, (1992) Summary of Workshop on Drinking Water Fluoride Influence on Hip Fracture on Bone Health.  Osteoporosis Int. 2: 109-117.

" An ecologic study compared fracture rates in 216 counties with natural fluoride levels greater than 0.7 ppm with rates in 95 counties with naturally low fluoride (less than 0.4 PPM) in the drinking water. In general, with increasing dose of fluoride in the drinking water the hip fracture ratio also increased."

8) Kurttio PN, et al. (1999). Exposure to natural fluoride in well water and hip fracture: A cohort analysis in Finland. American Journal of Epidemiology 150(8): 817-824.

"[A]mong younger women, those aged 50-64 years, higher fluoride levels increased the risk of hip fractures."

9) May DS, Wilson MG. (1992). Hip fractures in relation to water fluoridation: an ecologic analysis. Unpublished data, discussed in Gordon SL, and Corbin SB. (1992). Summary of Workshop on Drinking Water Fluoride Inflruenbce on Hip Fracture on Bone Health. Osteoporosis Int. 2:109-117.

"The 1985 Fluoridation Census data were used for the 438 counties with populations over 100,000, which represents about 70% of the US population... The percentage of the population that received natural or adjusted fluoride (approximately 1 ppm) was estimated for each county. Medicare data for 1984-1987 were used to calculate the annual incidence of age adjusted hip fractures for white males and females age 65 and older. As the percentage of individuals exposed to fluoridated water increased within a county, the hip fracture rate generally rose for both sexes, but not in a smooth linear fashion... Adjustment for county latitude and longitude produced higher correlation values and significance for females and males."

Studies reporting an association between water-fluoride levels higher than fluoridated water (2 to 4 ppm) & hip fracture.

10) Li Y, et al. (2001). Effect of long-term exposure to fluoride in drinking water on risks of bone fractures. J Bone Miner Res.16(5):932-9.

"In general, the hip fracture prevalence was stable up to 1.06 ppm of fluoride and then appeared to rise, although it did not attain statistical significance until the water fluoride concentration reached 4.32 - 7.97 ppm... The prevalence of hip fractures was highest in the group with the highest water fluoride."

11) Sowers M, et al. (1991). A prospective study of bone mineral content and fracture in communities with differential fluoride exposure. American Journal of Epidemiology. 133: 649-660.

"Residence in the higher-fluoride community was associated with a significantly lower radial bone mass in premenopausal and postmenopausal women, an increased rate of radial bone mass loss in premenopausal women, and significantly more fractures among postmenopausal women."

Studies Reporting No Association between water fluoride & hip fracture.

(Note that in 4(!) of these 8 studies, an association was actually found between fluoride and some form of fracture. See notes and quotes below.)

12) Cauley J. et al. (1995). Effects of fluoridated drinking water on bone mass and fractures: the study of osteoporotic fractures. J Bone Min Res 10(7): 1076-86.

13) Feskanich D, et al. (1998). Use of toenail fluoride levels as an indicator for the risk of hip and forearm fractures in women. Epidemiology 9(4): 412-6.

While this study didn't find an association between water fluoride and hip fracture, it did find an association -- albeit non-significant 1.6 (0.8-3.1) -- between fluoride exposure and elevated rates of forearm fracture.

14) Hillier S, et al. (2000). Fluoride in drinking water and risk of hip fracture in the UK: a case control study. The Lancet 335: 265-2690.

15) Jacobsen SJ, et al. (1993). Hip Fracture Incidence Before and After the Fluoridation of the Public Water Supply, Rochester, Minnesota. American Journal of Public Health. 83: 743-745.

16) Karagas MR, et al. (1996). Patterns of Fracture among the United States Elderly: Geographic and Fluoride Effects. Ann. Epidemiol. 6 (3): 209-216.

As with Feskanich (1998) this study didn't find an association between fluoridation & hip fracture, but it did find an association between fluoridation and distal forearm fracture, as well as proximal humerus fracture. "Independent of geographic effects, men in fluoridated areas had modestly higher rates of fractures of the distal forearm and proximal humerus than did men in nonfluoridated areas."

17) Lehmann R, et al. (1998). Drinking Water Fluoridation: Bone Mineral Density and Hip Fracture Incidence. Bone. 22: 273-278.

18) Phipps KR, et al. (2000). Community water fluoridation, bone mineral density and fractures: prospective study of effects in older women. British Medical Journal. 321: 860-4.

As with Feskanich (1998) and Karagas (1996), this study didn't find an association between water fluoride & hip fracture, but it did find an association between water fluoride and other types of fracture - in this case, wrist fracture. "There was a non-significant trend toward an increased risk of wrist fracture." For a critique of this study, see http://www.fluoridealert.org/phipps.htm

19) Suarez-Almazor M, et al. (1993). The fluoridation of drinking water and hip fracture hospitalization rates in two Canadian communities. Am J Public Health. 83: 689-693.

Interestingly, while the authors of this study conclude that there is no association between fluoridation and hip fracture, their own data reveals a different picture. Namely, a statistically significant increase in hip fracture for men living in the fluoridated area. According to the authors, "although a statistically significant increase in the risk of hip fracture was observed among Edmonton men, this increase was relatively small (RR=1.12)."

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