Photo by Sandy Huffaker, Jr.

Dental fluorosis

Hillcrest dentist David Kennedy recently posed the following question to several friends with whom he was dining: What would you do if you knew that a toxic substance was going to be added to San Diego's water supply — a substance that would lower children's IQs, increase the cancer incidence, double the rate of hip fractures among the elderly? Kennedy has become convinced that fluoride causes all those ills and more. But the consensus of his affluent, well-educated dinner companions “was that they would buy bottled water," the dentist relates. "That hurts my heart.”

No one is yet adding fluoride to the city's drinking water. But two years ago, the state legislature passed a law ordering California communities with 10,000 or more households to start doing so on January 1,1997. The lawmakers didn't provide money to pay for this, so compliance has been slow. Its imminence, however, has driven the local dentist to charge into the latest battle of a war that's now more than 50 years old. Kennedy has filed a petition to place a measure on a statewide ballot that would prohibit fluoridation everywhere in California. October 15 is the deadline for collecting the roughly 750,000 signatures he needs. Should the measure qualify, a monstrous fight will unfold. Should the petition drive fail and fluoridated water begin to flow through the taps of San Diego households, what then?

Anti-fluoridation brochure

Ask Ellie Nadler and she’ll tell you that San Diego residents will begin to reap enormous benefits. “This is the most researched, the most studied public health program ever, and its effectiveness is equated with the pasteurization of milk, the purification of water, and immunization against communicable diseases!” says Nadler, coordinator of the San Diego Fluoridation Coalition. “Fluoridation is extremely effective at reducing tooth decay. That’s been proven over and over and over. Then you have to ask: Is that terribly important?” Nadler answers her own question by pointing out that 95 percent of Americans get one or more cavities at some point. “It’s a very costly disease in terms of time, discomfort, disfigurement, and money. And it’s highly preventable.”

Kennedy was raised with this philosophy. His father was a dentist who “painted my teeth with fluoride [gel] when I was eight or nine.” The senior Kennedy served on the Lawrence, Kansas, city council in the early 1950s, when the town faced the question of whether fluoride should be added to its drinking water. “Dad still remembers the public health officials who came and basically shouted down the opposition. They said, ‘It’s known to be safe. It’s been proven by hundreds and hundreds of studies.’ And blah, blah, blah. They had uniforms, and they were from the government. This was just after World War II. Dad had served in the military and fought to save this nation. And when somebody from the government came and made these kind of claims, you didn’t question them.”

How fluoridation by 1950 had come to be official U.S. government policy is a story that begins right after the turn of the century. According to Dentistry, Dental Practice and the Community (“the Bible for public health dentistry,” in the words of one local fluoridation advocate), a Colorado Springs dentist by the name of Frederick McKay noticed that many of his patients had “a curious blotching of the enamel,” and he decided to investigate the extent of Colorado Brown Stain, as the condition was known. Over the next 20 years, McKay found the spotted teeth to be endemic in many Midwestern states, and he began to suspect that the spotting was caused by something in the affected communities’ drinking water. In 1931, an Alcoa chemist named H.V. Churchill (to whom McKay had sent suspect water samples) determined that each of the samples contained the chemical fluoride.

“The immediate reaction of the scientific community to the identification of F [fluoride] in drinking waters was one of concern, because F in high concentrations was known to be a protoplasmic poison,” Dentistry, Dental Practice and the Community records. The Journal of Dental Research, for example, published an article that saw “no alternative except to discard fluorine-bearing water supplies and substitute others that are fluorine-free.” The federal government in 1931 appointed a U.S. Public Health Service dentist named H. Trendley Dean to further investigate the mottled tooth enamel.

By the mid-1950s, Dean was using the term “fluorosis” to refer to the condition, and he reported that in communities whose water contained as little as 1.0 parts per million (ppm) fluoride, 10 percent of the population had “mild or very mild” fluorosis. Any alarm that Dean felt about this, however, was mitigated by his growing conviction that drinking fluoridated water had another important consequence. Many of the people whose teeth were mottled also seemed to have a lower rate of tooth decay than people living in communities where drinking water contained less fluoride, Dean came to believe. By 1942, he had published what’s now known as the “21 Cities Study.” Based on analyses of the teeth of 7257 twelve- to fourteen-year-old children living in five Midwestern States, he concluded that the incidence of cavities dropped as the concentration of fluoride in the water approached 1.0 ppm; then it leveled off above that amount. Data from the study led “to the adoption of 1.0 to 1.2 ppm as the appropriate concentration of F in drinking water for temperate climates, a standard that remains in place today,” according to Dentistry, Dental Practice and the Community.

The first real-world tests of fluoridation began in early 1945, as the cities of Grand Rapids, Michigan, and Newburgh, New York, began adding fluoride at a rate of 1.0 parts per million to their water supplies. (Public officials assumed that no health risks were involved because people in other communities had been drinking water containing higher levels of fluoride without suffering any obvious harm other than the tooth-spotting.) Both studies were to last for ten years, after which tooth decay rates among children in Grand Rapids and Newburgh were to 0 be compared with those of kids in un-fluoridated Muskegon, Michigan, and Kingston, New York, respectively. But after only a year and a half, reports of the experiments’ success began to appear, and by 1949 Dr. Francis Bull, Wisconsin’s state dental health director, was telling the U.S. Congress that “municipalities should not wait for the completion of present large-scale control tests” before starting to fluoridate. By the following year, both the U.S. Public Health Service and the American Dental Association (ADA) had endorsed fluoridation, launching what would soon become a juggernaut.

From the very beginning, the drive to fluoridate America’s drinking water met with fierce opposition. Some naysayers voiced concerns about the safety of consuming even a highly dilute version of what had theretofore been used as a rat poison. In response, Bull in 1951 advised his fluoride-promoting peers to “lay off [the question of toxicity] altogether. Just pass it over. ‘We know there is absolutely no effect other than reducing tooth decay,’ you say and go on.’ ” Other fluoridation opponents bristled over the loss of their freedom to choose whether they wanted to consume the controversial compound. Film director Stanley Kubrick lampooned this camp in his 1964 film Dr. Strangelove, in which the deranged General Jack D. Ripper rants about precious bodily fluids and the Communist plot to contaminate them through fluoridation.

David Kennedy

It didn’t take long for San Diego to become embroiled in the fracas. Despite hearing some concerns about the long-term health effects of fluoride consumption, in 1951 the city council voted five to one to add the compound to the local water supply, and on the morning of November 11, 1952, fluoridated water began flowing to homes in East San Diego, University Heights, Mission Valley, and Pacific Beach; it reached other communities soon thereafter. Opponents sued the city but lost all the way up to the state supreme court. They then launched a successful petition drive to put the issue before the electorate, and on June 8, 1954, 53 percent of the voters agreed to forbid the addition of fluoride to San Diego’s drinking water.

Just two days later, the city council was instructing the city manager “to look into ways and means of getting [the proposition] on the ballot again,” the San Diego Union reported. Although the council backed down from this aggressive stance, public health officials continued to press for another vote throughout the 1960s. In 1968, proponents succeeded in getting a measure on the ballot to overturn the 1954 ban. But this proposition lost by a narrow margin.

Similar scenarios have played out in so many other California cities that today only about 17 percent of Californians consume fluoride in their drinking water. That compares to roughly 62 percent of the rest of the United States. Fluoridation nonetheless is much more prevalent in California than in Europe, where less than 1 percent of the continent’s population drinks fluoridated water.

Today the fluoride level in San Diego’s drinking water averages about .26 parts per million. That’s only a third of the amount (.7 to .8 ppm) that fluoridation proponents consider to be optimal for warm climates. (Elsewhere the optimal amount is thought to be 1.0 ppm [the equivalent of 1 milligram per liter], but proponents assume that people in warm climates drink more water.) These recommendations derive from the estimates of the 1940s but have “never been determined scientifically,” a 1995 article in the Journal of the American Dental Associationreminded readers. Nor has the Food and Drug Administration (FDA) ever evaluated the safety or the efficacy of adding fluoride to the water supply in order to reduce cavities; Nor has a formal dosage level ever been established, according to Herschel Horowitz, an independent dental consultant formerly on the staff of the National Institute for Dental Research. “That research has not been done,” Horowitz stated in a recent telephone interview. “Coming up with a number for how many milligrams per day individuals of various ages and sizes should ingest is just not known. We do know that where water is fluoridated at 1.0 parts per million, at least in the traditional studies, there’s maximum caries prevention with only minimal amounts of very mild or questionable fluorosis.”

The question of appropriate dosage tops the list of things that bother Kennedy about fluoridation. “The fact is that you cannot put a medication in the water supply and expect a reasonable consistency of dose at the human level,” he says. Some people drink only 4 cups of water per day (the quantity that early fluoridation proponents seemed to assume was the standard). But many drink 8 to 12 cups, and five out of every hundred drink more than 16, according to one study. About half of the fluoride taken into the healthy human body is excreted in urine, but people with kidney disease retain far more of the compound. In 1993, the U.S. Department of Health and Human Services stated in its Toxicological Profile on fluoride that “subsets of the population may be unusually susceptible to the toxic effects of fluoride and its compounds. These populations include the elderly, people with deficiencies of calcium, magnesium, and/or vitamin C, and people with cardiovascular and kidney problems....” Given fluoridation, that means “there are groups of people in our community who will have to abandon the public water supply or suffer the toxic effects of fluoride,” Kennedy says.

If you look beyond the drinking-water supply, the question of dosage becomes even more complex. In the 1940s, when the 1.0 ppm guideline was established, drinking water constituted the main source of fluoride; the food supply contained only negligible amounts. But this has changed, both opponents and supporters of fluoridation concur. Today beverages produced in places where the water is fluoridated (beer from Milwaukee, for example) wind up being fluoridated. Crops sprayed with fluoridated water also absorb some of the compound. A far more important influence on America’s food supply has been the proliferation of pesticides and fertilizers containing fluoride. Exposed in this way, different foods retain differing amounts of the chemical. One 1996 study of juices and juice-flavored drinks (published in the Journal of the American Dental Association) found that the mean concentration of fluoride in orange juices was only .13 parts per million — only half the concentration found in San Diego’s (low-fluoride) drinking water. On the other hand, the same study found that some of the white grape juices had fluoride concentrations of up to 2.8 parts per million. A child who drinks just one 250-milliliter box of such juice would get .7 milligrams of fluoride — the amount contained in four cups of water fluoridated to the level recommended for warm climates.

Modern dental products provide us with still more fluoride. Manufacturers impregnate dental floss with it. They lace mouthwashes with it. They cram it into toothpaste formulas. Kennedy points out that the average family-sized tube of most major toothpaste brands contains about 260 milligrams of fluoride. By some estimates, that’s enough to send a 110-pound adult to the hospital or to kill a child.

Few adults may swallow their toothpaste, but a lot of small children do. And so in 1991 toothpaste tubes began to carry warnings such as “Do not swallow—use only a pea-sized amount for children under six.” This year the Food and Drug Administration decided even those words weren’t strong enough. The agency ordered all manufacturers shipping fluoridated toothpastes as of April 7 to print a warning on their tubes advising parents whose children swallow more than a pea-sized amount to contact a poison control center at once.

Proponents of fluoridation have downplayed this embarrassing turn of events. “We think the FDA overreacted,” says Clifford Whall, director of product evaluations in the American Dental Association’s Council on Scientific Affairs. He says poison control centers do receive perhaps 4000 to 5000 calls a year from parents concerned about their toothpaste-eating offspring, but these calls “don’t have any serious outcomes.” That is, the children don’t get seriously ill or die, Whall says. Toothpaste contains other ingredients that induce vomiting, he adds, a fact that tends to limit further harm from the contents. Nadler of the San Diego Fluoridation Coalition concedes that when San Diego’s water does become fluoridated, there may be a danger that young children who use fluoridated toothpaste could consume too much fluoride. She suggests that parents might thus want to raise the age at which they allow their children to brush with the stuff. “It’s a matter of education,” Nadler says. “It’s a matter of parental supervision.”

Kennedy says he already encourages his patients to clean their teeth in alternative ways. When they tell him they can’t find an un-fluoridated dentifrice, he says he tells them, “ ‘Oh, you’ve been going to those drugstores. Don’t you know that you’re supposed to say no to drugs? Listen up! You’re supposed to go to a place where you can find health, a place that has health in the name.’ ” Besides health food stores, kitchen cabinets are another source of cheap, nontoxic alternatives, he advises. “You’ll find me using herbs or baking soda or salt.”

Kennedy says it wasn’t until the early 1980s that he turned his back on the conventional teeth-cleaning armamentarium. Under his dentist father’s supervision, he grew up brushing his own teeth with Crest and Colgate and the like, and he continued doing so when he went to college and got a degree in comparative biochemistry and physiology. He says he entered the University of Missouri’s dental school in 1967 with very traditional ideas. “I’m a kid from Kansas. We slice cows up and eat them.” Though he joined the U.S. Navy Reserve that year, his politics were liberal. “While other people were protesting the Vietnam War by throwing firebombs and burning flags, I was walking precincts for George McGovern. Because I believed in the political process, and the only way I could get a student deferment was to join the Navy.”

The first jolt to his orthodox assumptions about dentistry came his freshman year, Kennedy recalls. The occasion was a lecture on preventive dentistry by an Illinois dentist. “In an all-student assembly with over 400 professors and students, he asked this question: ‘How many dentists in the room this morning flossed?’ You know how many hands went up? None. Not a hand.” The lecturer went on to talk about the role of something called plaque. “You know the term?” Kennedy asks. “We didn’t. We’d never heard of flossing. We were never instructed in how to stop dental disease. We were instructed in how to cut holes in teeth surgically. Look at the degree: Doctor of Dental Surgery. You are cutting out disease. That’s what they do with lasers, drills, knives, spoons, excavators. You cut it out. It’s a surgical approach to bacterial infection, whereas [the lecturer] was talking about a biological approach.” Although the upperclassmen sitting on either side of Kennedy reacted with hostility and skepticism, these ideas rocked the first-year student from Kansas.

As he thought about the concept of preventive dentistry, Kennedy began to take stock of his own health practices, a subject that had never been at the forefront of his consciousness. “When I did the dietary analysis of myself as part of our nutrition class, I found that the majority of my vitamin C was coming from potato chips.” But he was beginning to think that “preventive dentistry is not about the teeth. It’s about health!” As he discovered such health gurus as Nathan Pritikin and Ken Cooper, he says, “I began to change every single aspect of my life.”

He says when he graduated from dental school in 1971, he was already thinking about writing a book about preventive dentistry. But other tasks also consumed his time. As part of his military service, he moved to San Diego and served on active duty at the Naval Training Center. After two years, he left the service to start his own private dental practice. From its inception, Kennedy says he placed heavy emphasis on teaching his patients how to limit the amount of bacteria in their mouths. In 1983 he began to use a microscope to help achieve that goal. “Before that, I was flying blind,” he says. “What you’re trying to do is remove gook from the teeth.” But with a microscope, you can identify the specific pathogens that constitute that gook and target them with the antibacterial agents that will best eradicate them. Moreover, “you can tell when you’re successful and when you’re not,” Kennedy asserts.

By the beginning of the 1980s, he was also making progress on his preventive dentistry book. He says he always intended to include within it a chapter on the role of fluoride, which he believed to be one of the keystones of modern preventive dentistry. “My sister-in-law likes to point out that in the ’70s I wrote a prescription for my nieces and nephews to have fluoride drops.” He did the same for patients. The chapter that he produced extolled the benefits of drinking fluoridated water and brushing with fluoridated toothpaste. It also urged patients to consider using fluoride supplements and rinses. To review its accuracy, Kennedy sent the manuscript to a physician friend in Florida. “And he sent it back with a big red scrawl and a note saying, ‘I think you need to check your references!’ ”

Startled, Kennedy dug out his fluoridation file, the one he’d set up when some of his patients had questioned the value of using fluoride and he in turn had sought supporting literature from the American Dental Association library. “They had sent me a stack an inch high of what they said were the pivotal papers....” Kennedy says he had skimmed the abstracts and thumbed through the data and accepted the conclusions without question. But the critique from his physician friend made him go back and scrutinize the contents of the file, and he concluded “that the pivotal papers are garbage!” He learned, for instance, that for his famous “21 Cities Study,” H. Trendley Dean had not selected the target populations in a blind or random manner, a significant failing considering that decay rates vary a great deal from city to city. Rather, Dean had chosen his cities after surveying a much larger number of communities. “He was allowed to pick the data that he tells you about,” Kennedy says. “It’s an un-blinded study that set out to prove a predetermined point.”

The San Diego dentist asserts that in other cases, study statistics were manipulated to paint a false picture. He cites the landmark Grand Rapids/Muskegon study as one example. Today fluoridation advocates state that “For each of the seven youngest age groups [studied in the two cities], advantages for Grand Rapids over Muskegon ranged between 214 and 450 percent.” That sounds overwhelming, as does the claim that the five-year-olds in Grand Rapids had 73 percent fewer cavities after drinking fluoric dated water for five years, compared to the five-year-olds in un-fluoridated Muskegon, whose cavity rate had increased by 133 percent. But look instead at the decay rates in both cities, and the picture changes. At the conclusion of the study, five-year-olds in Grand Rapids on average had .03 decayed, missing, and filled permanent teeth (DMFT) per child, versus an average of .14 decayed, missing, and filled permanent teeth in the Muskegon five-year-olds. That’s a difference of barely one-tenth of one cavity per five-year-old. In some age categories, the DMFT rate fell more among the un-fluoridated Muskegon kids. Overall, the Grand Rapids children — who had a slightly lower rate of tooth decay to begin with — had 5.14 decayed, missing, and filled permanent teeth per child at the conclusion of the study, whereas their un-fluoridated counterparts had 5.81. And Kennedy also points out that the study authors failed to take into account any of the variables such as diet, oral hygiene, dental care, and parental educational level, which are now recognized to “have a profound effect on tooth decay.”

Today the Hillcrest dentist has come to believe that none of the pro-fluoridation studies are sound. That assertion, echoed by a number of fluoridation opponents, outrages advocates. “There is absolutely no doubt [fluoridation] reduces cavities,” declares Nadler of the San Diego Fluoridation Coalition. “It’s been proven over and over and over again.” The ADA’s booklet Fluoridation Facts calls the effectiveness evidence “overwhelming” and refers to some 113 studies done in 23 countries that have shown favorable results. Kennedy concedes that he hasn’t read and critiqued every one of these, but he believes they all suffer from design flaws ranging from small study size to examiner bias, a charge reiterated in an article published earlier this year in the Australian and New Zealand Journal of Public Health. “Of the many studies used by proponents of fluoridation to claim that there are enormous benefits from fluoridation, not one is a randomized, controlled trial,” assert the authors, who include a former Australian federal health minister and a former convenor of the New Zealand Fluoridation Promotion Committee, both of whom became disillusioned with their pro-fluoridation counterparts. This article goes on to state that “hardly any of the many small-scale studies by enthusiasts of fluoridation are ‘blind’ and, in the rare cases when they are, the so-called control was selected from a known high-caries area.... Many other studies have had no controls.”

Kennedy adds that one of his fellow fluoridation opponents once offered $100,000 to anyone who could disprove the assertion that no large, broad-based blinded studies of permanent teeth have demonstrated a decline in tooth decay in response to fluoridation. “Nobody ever collected the money,” Kennedy says. In contrast, he says, “We [fluoridation opponents] have five major broad-based studies. One with 80,000 children. Another with 39,000 children. Another with 25,000. Huge studies that show there’s absolutely no [beneficial] relationship between fluoridation and tooth decay.” These have all been published in scientific and dental journals within the last 17 years, he adds.

In turn, fluoridation boosters have quibbled with aspects of the design of those studies. It’s enough to make the neutral observer despair of ever getting to the bottom of the effectiveness question. However, whether drinking fluoridated water cuts the tooth decay rate may not matter if Kennedy and other fluoridation opponents are right about the harmful effects of consuming the chemical.

Let’s start with dental fluorosis — those spots on the teeth that caught McKay’s attention nearly 100 years ago. Kennedy explains the condition in this way. “Say you’re a cell, and you’re going to make enamel. What you do is to lay out a perfectly beautiful crystal in long ribbons that you can almost see if you look at a tooth very carefully.” The material is crystalline hydroxyapatite, and “it’s a beautiful opalescent color,” Kennedy continues. “It reflects light. But when that cell is sucking too much fluoride into itself in making the crystal, it becomes poisoned. So instead of laying out good straight ribbons of enamel, it lays down a little tangle. In some cases it gets so sick it doesn’t make it at all, and you have a hole. That is dental fluorosis.”

In its mildest forms, the spots are small and white, rather than brown. Like many biological processes, the development of dental fluorosis can be affected by several factors. Children who drink lots of milk are less susceptible because the calcium in the milk binds with fluoride and inhibits its absorption. Magnesium, vitamin C, and selenium have a similar limiting influence, Kennedy says. Recent studies (published in such conservative organs as the Journal of the American Dental Association) estimate the incidence of dental fluorosis in fluoridated American communities today at 15 to 65 percent.

But this is no big deal, the fluoridation supporters insist. “At the optimum fluoride level, only the mildest forms of dental fluorosis occur, most of which is barely observable,” writes Stanley B. Heifetz, a professor at the University of Southern California’s School of Dentistry in Los Angeles. Even the larger, uglier brown spots seen in more severe cases represent a mere cosmetic problem, rather than a health concern, the proponents say.

“Only a dentist could believe that this amount of poisoning could go on and it would affect the teeth alone,” Kennedy says. “We know that if you skinned [people who have dental fluorosis] and looked at their bones, the same thing is happening to them.”

Even ardent advocates of fluoridation do concede that exposure to enough fluoride over time can wreak havoc with human bones. The damage takes the form of something known as skeletal fluorosis. Endemic in India and other parts of Asia and the Middle East where water fluoride levels are high, people drink a lot of water, and nutrition tends to be poor, this condition involves crippling of the spine and major joints, calcification of the ligaments, wasted muscles, and other deformities. Fluoridation defenders say that almost no one gets skeletal fluorosis in America: The critics retort that American doctors aren’t trained to diagnose the early phases of the disease, which have much subtler symptoms such as joint pain and stiffness. They add that it can take decades for symptoms of skeletal fluorosis to develop, as fluoride builds up in bone over time. Since fluoridation of America’s drinking water only began in the mid- 1940s, Americans may be harboring a time bomb, Kennedy asserts.

How much daily fluoride consumption can cause skeletal fluorosis? The ADA’s pro-fluoridation pamphlet Fluoridation Facts states that the National Academy of Sciences (NAS) “found that daily intake required to produce symptoms of chronic toxicity after years of consumption is 20 to 80 milligrams or more depending on body weight.” If that’s correct, then someone drinking tap water with 1 part per million of fluoride in it would seem to run little risk of contracting the disease, even if he or she were also swallowing some toothpaste and downing a few boxes of white grape juice every day. But how did the National Academy of Sciences derive those numbers? When a Michigan housewife named Darlene Sherrell began asking that question in 1989, the NAS program director overseeing recommended daily allowances referred her to the work of a European researcher named Roholm. Sherrell discovered that in 1937 Roholm wrote that consuming .20 to .35 milligrams of fluorine daily per kilogram of body weight for 11 years would probably cause skeletal fluorosis, and she also learned that a famous toxicologist named Harold Hodge in the early 1950s had used Roholm’s work to derive the figure of 20 to 80 milligrams for 10 to 20 years. But Sherrell says when she tried to duplicate Hodge’s arithmetic, it didn’t add up. “I finally figured out that Hodge must have made the mistake of multiplying by pounds instead of kilograms,” Sherrell recounts today. Correcting for that, the dangerous dose falls to 10 to 20 milligrams over 10 to 20 years. Sherrell also discovered that Hodge himself changed his figures in a 1979 book on fluoride, a fact that she made known to the NAS. In 1993, the NAS’s National Research Council stated that “Crippling skeletal fluorosis might occur in people who have ingested 10-20 mg of fluoride per day for 10-20 years.”

Though that still might sound like a lot of fluoride, Kennedy points out that if you think about ingesting fluoride over a longer period, say 40 to 80 years (as children living in fluoridated cities will do), then the dangerous dose falls to as low as 2.5 to 5 milligrams a day, an amount consumed by many Americans now.

Kennedy says a growing body of evidence has already linked fluoridated water consumption to higher rates of hip fractures among the elderly. At least eight reports of such a link have appeared in the last seven years in well-respected journals. On the other side of the fence, fluoridation boosters point to four studies that have shown no such link, leading them to conclude that “fluoridation neither increases nor decreases hip fracture risk,” in the words of Heifetz, the use dental school professor.

In a statement on the “Benefits Versus Concerns on Fluoridation” written earlier this year, Heifetz writes that “More than 50 credible epidemiologic studies of large communities with sizable populations. . .have found no evidence of a relation between fluoridation and an increased cancer risk as determined from standardized mortality rates.”

Fluoridation opponents, on the other hand, point to epidemiological studies that have found such a relationship. They also talk about the results of a clinical study conducted by the National Toxicology Program and made public in 1990. According to Kennedy, the independent testing agency hired to do the study concluded that laboratory rats given fluoridated water became “awash with disease. They had kidney failure. They had cancer of the lips, tongues, throat, bone, and liver. Gosh, that doesn’t sound too good,” the San Diego dentist comments. He says the U.S. Public Health Service thereupon “downgraded” the cancers found in the rats—reclassifying them as less serious conditions. Kennedy says the Public Health Service gave a summary of the study results (including the reclassified cancers) to an expert committee that declared that the cancer findings were “equivocal.” William Marcus, the senior science advisor for the Environmental Protection Agency’s (EPA) Office of Drinking Water, was so disturbed by this and other aspects of the study findings that he publicly protested the irregularities. The EPA fired him in response, but Marcus filed a lawsuit under the Whistleblowers Act. In 1993 Secretary of Labor Robert B. Reich found that the reason for the firing was “retaliation” and ordered that Marcus be given back pay, legal expenses, and $50,000 in damages.

Laboratory rats are at the heart of yet another area of concern to the fluoridation opponents: that of the impact of fluoride on the human brain. The key scientist who has worked in this area is Phyllis Mullenix, a neurotoxicologist with extensive academic credentials. Mullenix was working at Boston’s Children’s Hospital in 1982 when she was asked by the head of the Forsyth Dental Center (an affiliate of Harvard Medical School) to join the Forsyth Research Institute. The next year she was asked to establish a toxicology department there. “They wanted me to look at the environmental impact of various substances used in dentistry, things such as nitrous oxide, mercury, and fluoride,” Mullenix explained in a recent phone interview. Exposing rats to various substances and then seeing if the exposure has changed how the animals act lies at the heart of much toxicological research, but one drawback to this approach is that it requires subjective judgment. Mullenix says her first project at Forsyth was to develop a system of using computers to recognize and classify rat behavior patterns, something that had not been done before. It took her and her collaborators almost five years to get a reliable pattern-recognition system working, and then, at the urging of her boss, she began to use it on rats exposed to fluoridated drinking water.

Up to then, “fluoride hadn’t meant anything to me,” Mullenix insists. “Prior to 1987, I don’t think I’d ever uttered the word. Certainly I didn’t understand or appreciate the whole political background.” In the first three years that she exposed the rats to fluoride and analyzed their behavior, however, she began to view the substance with concern. “Some of the effects that we were seeing were quite disastrous.” She explains that rats exposed to the fluoride prenatally became markedly hyperactive (compared to control animals). Exposure after the rats were born appeared to have the opposite effect, creating what Mullenix calls the “couch-potato syndrome.” Mullenix also found that rats exposed to fluoride had significantly higher levels of fluoride deposits in their brains.

When she showed her preliminary data to her boss in 1990, she says he shared her concern and dispatched her to give a seminar on her results at the National Institute of Dental Research (NIDR) outside Washington, D.C. She says she was waiting to do so in the lobby of the institute’s main hospital, when she happened to notice a big display on the walls about “The Miracle of Fluoridation.” Only then did she begin to suspect what effect her presentation might have. Probably 25 people from a variety of federal agencies attended the seminar, and “they did look at me with absolute horror,” she recalls. “At one point I made some joke about The Miracle of Fluoridation, and I was struck by the fact that no one laughed.”

Mullenix wasn’t condemning fluoridation. “I said the data was disturbing, too big of a concern for me to just walk away from it. But all I was asking for was to do more studies.” She felt encouraged a few weeks later when the director of the NIDR wrote a letter to her boss at Forsyth, praising the computerized pattern-recognition technology and suggesting various ways for Mullenix to get funding for additional work. But though she followed the suggestions, no research money came from any of them, she says. “They were all dead ends.” By working on a shoestring, Mullenix nonetheless continued doing additional fluoride studies. (For example, she was able to work with animals being studied by a dentist who had a grant to study dental fluorosis.) She says by 1992 some of her colleagues at Forsyth had started to express their disapproval of her work. “I heard comments to the effect that I was jeopardizing funds that they receive from the NIDR.” Undeterred, Mullenix in 1993 decided it was time to write up her results from studying 532 rats. In March of 1994, she sent a manuscript describing her research to the peer-reviewed journal Neurotoxicology and Teratology. In May, the editor accepted it (with some revisions), and that same month, Mullenix was dismissed from the staff of the dental research institute.

Mullenix’s article reached print in February of 1995. By then she had sued the Forsyth Research Institute for wrongful termination, and in May of this year she accepted a settlement from her former employer. Since leaving Forsyth, she has regained her appointment at Children’s Hospital in Boston, but she says she hasn’t yet set up a lab there because no one will fund her to do additional fluoride studies.

If her own research has ground to a halt, Mullenix says other disturbing information about fluoride’s impact on the central nervous system has come to light in the last two years. Two Chinese epidemiological studies have suggested that children drinking fluoridated water may wind up with lower IQs than their counterparts in un-fluoridated areas. And Mullenix last year was jolted by the contents of some just-declassified U.S. government documents. They show that toxicologist Harold Hodge, who had served as the chief pharmacologist on the Manhattan Project, had expressed concerns about fluoride’s effect on the human central nervous system back in the mid- and late-1940s. But Hodge was ordered not to carry out experiments that would investigate those effects. When Mullenix joined the staff of the Forsyth Research Institute, Hodge was working in her department, and she says he took a keen interest in her fluoride/ rat work. “He came up to my lab on a daily basis!” But Hodge never mentioned his long-standing concerns about how fluoride might affect the human brain. “It's maddening,” Mullenix now says. “I don’t know who knew what and when.”

Back in 1984, David Kennedy knew nothing about fluoride’s effect on the central nervous system; Mullenix hadn’t yet begun her rat studies then, let alone published the results of them. Kennedy still believed (as he continues to believe today) that topical use of fluoride (as opposed to ingestion of it in drinking water) reduces tooth decay. But his research for his fluoridation chapter had convinced him to toss out his fluoridated rinses and fluoridated toothpaste. “You don’t prevent dental disease by nuking kids with poisonous sub-stances,” he says. “You do it by keeping the scum off the teeth, and if the scum does develop, you kill it with something like baking soda or salt. You can put those kinds of things in the cookies, and the kids won’t die. If you put fluoride in the cookies, the kids will.”

After he made that decision, Kennedy says he gave little thought to fluoride. “Fluoride wasn’t a problem.” With a few exceptions such as the San Francisco Bay Area and Beverly Hills, “California isn’t fluoridated,” Kennedy knew. “California cities had rejected it something like 78 times! So here I was, minding my own business, when somebody called me up and said, ‘Did you know that they’re going to mandate fluoridation for the whole state?’ ” He describes his reaction as “appalled.”

Kennedy learned that the proposal for mandatory fluoridation had come from Jackie Speier, the Democratic assemblywoman from Burlingame (which has fluoridated its water since 1955). Speier reportedly got the idea for her bill after her children began spending time in (un-fluoridated) Sacramento, and their pediatrician recommended giving them a fluoride supplement. She was “stunned” to learn how many of the state’s residents were missing out on fluoridation’s benefits, according to subsequent news reports. Jubilant at the prospect of a legislative champion, the California Dental Association (CDA) pledged $110,000 to help her get a bill passed. Speier rounded up four coauthors, and on February 22 of 1995, she introduced her bill.

“I initially thought that Jackie Speier was someone who was confused,” Kennedy says. He says his first response to the news of her bill was to do whatever he could to dispel that confusion. He flew up to attend the Assembly Environmental Health and Toxics Committee hearing, and he also paid the travel expenses of another anti-fluoridation activist from Ohio, John Yiamouyiannis. For that first committee meeting, Speier “brought in the big guns,” according to an analysis of the California fluoridation campaign published in the California Dental Association Journal this past January. “She presented videotaped testimony from former Surgeon General C. Everett Koop, who said fluoridation was an important benefit for poor families who lack proper dental care.” Koop pointed out that of the 150 large U.S. cities that do not fluoridate their water supply, 87 were in California, including Sacramento, Los Angeles, and San Diego, according to the journal. The article added that the chair of the California Fluoridation Task Force “urged the committee to look beyond the emotional hysteria presented by the anti-fluoridationists, who packed the hearing room.” (The CDA Journal article also compares opponents of the bill, to the mindless followers of the Grateful Dead and to the members of the Flat Earth Society.)

Speier’s bill passed that first committee by one vote, and it “squeaked its way through the Assembly Appropriations Committee by the same narrow margin,” according to the CDA Journal. Kennedy flew up for the Finance Committee meeting too, but he was beginning to grow discouraged. “They would decide on a Monday that a committee meeting was going to be on Wednesday. Well, how do you get to Sacramento if you’ve got an appointment book that’s full of patients? Three different times I canceled everybody, left my staff working (because otherwise it wouldn’t have been fair to them), and raced up to Sacramento — where they’d give me two minutes or something.”

The assembly passed the bill on June 2, and Kennedy says he pinned his hopes on the meeting of the Senate Health Committee, chaired by Diane Watson of Los Angeles. Kennedy says Watson’s chief aide assured him “that the committee would provide unlimited time and give a fair, balanced, and unbiased hearing of the scientific issues.” So Kennedy and a half dozen scientists opposed to fluoridation prepared to speak at the meeting. There Kennedy says Speier talked at length, along with representatives from the state dental hygienists’ society and the public health service, as well as various other proponents. In contrast, “What we got basically boiled down to about ten minutes,” Kennedy recalls. On top of that, only three (of the nine) committee members were present. “Finally they grabbed two other members who had been out in the hall and voted five to zero in favor of the bill,” Kennedy says.

“It was a done deal,” he declares today. “And when I realized that, my question was: What am I doing here? Why did I buy a late ticket on Southwest, which costs $230 instead of $90, cancel $3000 worth of treatment in my office — all to tell these fools what they don’t want to hear? It was an exercise in stupidity,” according to an analysis of the California fluoridation campaign published in the California Dental Association Journal this past January. “She presented videotaped testimony from former Surgeon General C. Everett Koop, who said fluoridation was an important benefit for poor families who lack proper dental care.” Koop pointed out that of the 150 large U.S. cities that do not fluoridate their water supply, 87 were in California, including Sacramento, Los Angeles, and San Diego, according to the journal. The article added that the chair of the California Fluoridation Task Force “urged the committee to look beyond the emotional hysteria presented by the anti-fluoridationists, who packed the hearing room.” (The CDA Journal article also compares opponents of the bill to the mindless followers of the Grateful Dead and to the members of the Flat Earth Society.)

Speier’s bill passed that first committee by one vote, and it “squeaked its way through the Assembly Appropriations Committee by the same narrow margin,” according to the CDA Journal. Kennedy flew up for the Finance Committee meeting too, but he was beginning to grow discouraged. “They would decide on a Monday that a committee meeting was going to be on Wednesday. Well, how do you get to Sacramento if you’ve got an appointment book that’s full of patients? Three different times I canceled everybody, left my staff working (because otherwise it wouldn’t have been fair to them), and raced up to Sacramento — where they’d give me two minutes or something.”

The assembly passed the bill on June 2, and Kennedy says he pinned his hopes on the meeting of the Senate Health Committee, chaired by Diane Watson of Los Angeles. Kennedy says Watson’s chief aide assured him “that the committee would provide unlimited time and give a fair, balanced, and unbiased hearing of the scientific issues.” So Kennedy and a half dozen scientists opposed to fluoridation prepared to speak at the meeting. There Kennedy says Speier talked at length, along with representatives from the state dental hygienists’ society and the public health service, as well as various other proponents. In contrast, “What we got basically boiled down to about ten minutes,” Kennedy recalls. On top of that, only three (of the nine) committee members were present. “Finally they grabbed two other members who had been out in the hall and voted five to zero in favor of the bill,” Kennedy says.

“It was a done deal,” he declares today. “And when I realized that, my question was: What am I doing here? Why did I buy a late ticket on Southwest, which costs $230 instead of $90, cancel $3000 worth of treatment in my office — all to tell these fools what they don’t want to hear? It was an exercise in stupidity.”

The full senate passed the bill 22 to 10, and Governor Pete Wilson signed it on October 9, 1995. Since then, un-fluoridated communities have been responding in a variety of ways. In Los Angeles, the city has decided to pay for the costs of fluoridating (even though L.A. residents passed a law banning fluoridation in 1975). Here in San Diego, where the 1954 ban is still on the books, the city attorney’s office has issued a report concluding that it would be illegal to spend local funds to carry out the mandate. But “they’re going to find a way around that,” Kennedy says. “It’s a temporary roadblock.”

He says he decided that an initiative was the only hope of averting a statewide catastrophe. He also concluded that his proposition should ask voters to ban fluoridation outright (since allowing communities to decide for themselves still might force fluoridation on individuals such as infants and the elderly who are particularly susceptible to fluoride’s toxic effects). In the hope of getting the measure on the November 1996 ballot, Kennedy filed the necessary paperwork in January of that year. He was preparing to organize a statewide grassroots signature-collection effort when he learned that the attorney general’s office was estimating that banning fluoridation would cost California taxpayers “about $15 million per year after five years.” A summary of this estimate would go on each petition form.

“That is absolute malarkey!” Kennedy exclaims. “In [the legislative analyst’s] fiscal estimate of Speier’s bill, they said that mandatory fluoridation would cost up to $60 million in year one alone — including up to $45 million to buy the equipment and up to $15 million to buy the chemicals. So my initiative should save $60 million, right? No, it’s going to cost $15 million because we’re going to have all this added tooth decay that’s going to immediately skyrocket up.”

Around this time, Kennedy gained an ally in the form of Jeff Green, a management consultant who had worked with the Hillcrest dentist for almost 20 years. Green grew up in San Diego County, and he says he’d never realized that any harmful effects were linked to fluoridation until he heard about Kennedy’s efforts to launch the initiative petition. Skeptical at first, Green says he started reading, and the weight of the evidence against fluoridation convinced him that the statewide mandate was a terrible thing. He committed himself to helping Kennedy, who was trying to get to the bottom of the loathsome fiscal estimate.

Kennedy learned that the summary had been written by a dentist named Robert Isman, a fluoridation advocate who had previously worked as a county health officer in Oregon. There Isman and a number of other county officials had been sued for using public funds to lobby against a Portland anti-fluoridation initiative. Isman had later moved to California and now works for the state’s Department of Health Services. To estimate the costs of banning fluoride in California, he had relied on a few small studies done in Europe, Kennedy and Green learned. In the European studies, “There were no controls of any of the other variables [affecting tooth decay rates],” Kennedy says. The researchers “didn’t determine whether the people brushed with a fluoridated toothpaste. They didn’t look at the total daily intake of fluoride. On and on and on.”

“I have never seen a study that controlled for all these other factors,” Isman says today. He says that researchers instead study subjects selected at random “to try to control for all those things that you, can’t control. The purpose of the random sample is to remove any kind of bias that might be introduced by those things that you don’t know about.” In the studies that he used, subjects were chosen at random, Isman says. From the study results, he concluded that banning fluoridation in California would cause a 40 to 67 percent rise in dental-treatment costs statewide. And as a result, taxpayers would pay millions of dollars more in Denti-Cal costs.

Looking at these calculations, Green says he and Kennedy wondered why state officials hadn’t compared the Denti-Cal costs for fluoridated versus un-fluoridated California communities. To make such a comparison themselves, they obtained the records showing what the state pays for indigent dental care in each county. They then related this data to each county’s fluoridation status and found “no rhyme or reason at all,” Green says. Non-fluoridated Napa County, for example, in 1995 paid $66.72 for dental costs per eligible Medi-Cal recipient, while Contra Costa County (99 percent fluoridated) paid $127.80 per person. Los Angeles County (5.2 percent fluoridated) paid $143.52 — almost the same as 100 percent fluoridated San Francisco, which paid $ 144.84. When Kennedy and Green had the figures weighted (to even out the size differences between the various counties) they found that in 1995 the average annual Medi-Cal cost per eligible recipient was $110.06 in non-fluoridated counties. The tab was slightly less ($107.26) in counties that were .5 to 10 percent fluoridated, but it climbed to $125.27 in the three counties that are between 90 and 100 percent fluoridated.

Isman argues that these figures are meaningless because they fail to take into account all the factors that influence tooth decay rates. But Kennedy nonetheless used them as evidence in a lawsuit that he filed against the state attorney general. Among other things, he asked that the fiscal estimate be deleted. The judge responded that even if he did this, Kennedy would have only 60 days left to collect all the required signatures (since the court proceedings had already consumed three of the five months allotted for signature gathering). The judge suggested that Kennedy refile the initiative and start the clock over again. Kennedy says the defendants’ lawyers pledged that any future fiscal estimates would not be biased, and the judge promised to schedule a hearing within 24 hours if a biased summary were prepared a second time.

“Suffering from a bloody nose and a damaged ego, I waited a while,” Kennedy says. “Then in January of 1997 I refiled it in the hopes that they would keep their word.” But when the attorney general’s office released the fiscal summary this past April, it was almost identical to the one the San Diego dentist had sued the government over the previous year. “There aren’t three words different,” he says.

He says the judge did keep his word and gave him an immediate hearing. But then he “basically ruled against us,” decreeing that if one authority agreed with the attorney general [that banning fluoridation in California would cost state taxpayers millions of dollars], the summary could not be considered “arbitrary and capricious.” Since Isman, the summary’s author, could be considered an authority, the summary passed that test.

Kennedy says at that point he and Green resigned themselves to proceeding in spite of the biased language. If their initiative qualifies for the ballot, “We’ll have another chance to get [the cost summary] removed,” Kennedy states. He explains that the standard for bias in a ballot argument is tougher than that for one on an initiative petition. “It’s the reasonable-man test,” Kennedy explains. “Would it be reasonable to include studies from a foreign country, rather than looking at the record of what has already happened in California?”

Since April, Green and Kennedy have been directing the petition drive. In order to do this, Green has put his management-consulting business on hold, and Kennedy says he tried to sell his dental practice. “But I found you can’t do that at a moment’s notice, so I decided to devote every spare moment I had. Everybody’s got spare time.” Kennedy says he sees patients three days per week. “That leaves me four days to do something else. Many people go surfing or sailing or golfing. What I do is to sit at the computer and work till 10:00 p.m.” The dentist also estimates that he’s funneled perhaps $100,000 of his personal savings into the fight.

That’s not enough of a war chest to hire professional signature-gatherers (the route taken by the vast majority of successful initiative sponsors and one that can cost up to $500,000). But Green and Kennedy claim that a small army of volunteers has materialized. “We have more than 5000 names of people who have called up and are circulating the petition,” Green says. Around 70 of those are dentists, according to Kennedy. A powerful ally also has been nutrition authority Julian Whittaker, who in August mailed the petition to each of his 75,000 California subscribers, pleading for their help. Other supporters have come from a broad-political spectrum. Kennedy says, “I was at one meeting the other day where a former president of the Environmental Health Coalition was sitting across from a lifelong member of the John Birch Society. There was also a past president of the Women Volunteers in Politics along with representatives from the Christian Coalition. They’re all in agreement that we do not need to poison the children.”

More moral support came this summer from a more distant source: the union representing all the scientists who work at the federal Environmental Protection Agency headquarters in Washington, D.C. A dozen years ago, this group protested when the EPA management decided to raise the maximum contaminant level for fluoride to 4.0 parts per million. The union even tried to join in a subsequent lawsuit filed by the National Resources Defense Council against the EPA management, citing “fraudulent alterations of data and negligent omission of fact to arrive at predetermined Agency political positions regarding fluoride.”

This past July 2, the union took the further step of voting — unanimously — to cosponsor Kennedy’s California Safe Drinking Water Initiative. Fluoride, the scientists’ union stated, is “a chemical substance for which there is substantial evidence of adverse health effects and, contrary to public perception, virtually no evidence of significant benefits.” The statement continued, “Our members’ review of the body of evidence over the last 11 years, including animals and human epidemiological studies, indicates a causal link between fluoride/fluoridation and cancer, genetic damage, neurological impairment, and bone pathology.”

Asked about the union’s stance, Nadler of the San Diego Fluoridation Coalition replied, “I don’t know very much about the union at all.” She also reiterated that “there are no valid studies in existence that corroborate” the EPA scientists’ assertion that fluoridation has adverse health effects. “I don’t know that I can make sense of [such opposition] because I don’t think it’s sensible. It’s not sensible and it’s not beneficial.”

Kennedy, in contrast, has a ready explanation for the force behind the fluoridation juggernaut. He says, “The short version is that there are 11 reasons why fluoride has been put into the water supply of this nation. And they are: money, money, money, money, money, money, money, money, money, money, money.” First and foremost, he contends, a national fluoridation policy solves a huge problem for many segments of American industry: disposing of what would otherwise be a toxic waste. If fluoridation is good for us, then companies “don’t have to clean up their smokestacks,” the dentist says. “Or they can pour their effluent right down the drain into the city sewer plant.” On the other hand, if everyone acknowledged fluoride to be a pesticide and a hazardous waste material, disposal could cost as much as $50 billion a year, by one estimate. “It’s used to crack gasoline,” Kennedy says. “It’s used to etch glass and circuit boards. It’s used in 100 different processes where you need a caustic chemical.”

Supporting fluoridation has also enriched the American Dental Association, Kennedy asserts, pointing out that the ADA has accepted a lot of money over the past 37 years in exchange for endorsing fluoride-fortified products such as Crest toothpaste. Among the rank-and-file dentists and public health workers, he sees ignorance and inertia. “Dentists follow dictates blindly,” he says. “They’re taught in school that it’s good, and they get sucked into it.”

As for the average citizen, Kennedy acknowledges that it’s easy to shrug, like his friends, and stock up on bottled water. “But if you allow the dumb dentists to put rat poison in the water supply because they claim it’s going to reduce tooth decay, if you just sit back and let that happen, are you willing to lose your country?” he asks. “Because that’s what will happen. If you dumb down the children, create learning disabilities and an inability to read and write, you’ll end up destroying the foundation of this country — an educated, intelligent populace. It’s a bigger threat to America than Russia ever was.”

Kennedy argues that the fall of the Iron Curtain revealed “a bunch of puky little Third World countries that are struggling to make a living. They never were a reason for Ronald Reagan to spend hundreds of billions of dollars on armaments. We were told they were. And yet the real threat is we have children dying of cancer.... What’s going on? It’s that we are living in a country with a government that is run by industry. It should be run without the government involved in your life. It shouldn’t be involved in medicating you. If you want to take fluoride, you can go to the store and buy it. But the government shouldn’t be deciding that you need X amount of fluoride in your water today.”