| "Some Important Developments..." cont. |
| 4- Topical Application Of Fluorides |
The idea that resistance to dental decay from ingestion of fluorides may result from incorporation of fluorine in the tooth substance led to topical application of fluorides for prevention of caries. Numerous experiences have been reported,65-77 the results varying from none65,77-80 up to as much as 50 per cent reduction33 in the caries increment. Most of the observations have been on children. Some reports indicate some slight caries preventive effects in adults72,73 others none.77,79 At least several separate treatments are considered to be necessary61,82 to secure any marked reduction, 7 to 15 applications69 yielding the best results. The preventive effect has been found to subside or to disappear 83-85 following interruption or discontinuance of the treatment.
More recently topical stannous fluoride has been reported86 to more effectively prevent caries than sodium fluoride; also to be effective in a toothpaste87 although sodium fluoride is not. It has been found experimentally to be markedly superior to sodium fluoride88 in protecting powdered enamel from the action of acids. The anti-enzyme effect of stannous fluoride has been shown to be a function of the tin content89-91 and not of the fluorine.
In carrying out the topical fluoride treatment a "thorough prophylaxis", which increases the uptake of fluoride,92 at one or more of the several treatments in the series is considered to be necessary. Elimination of this reduces the caries preventive effect by one half.82,93 This means that in the most over-optimistic claim of 40 per cent prevention 20 per cent results from the prophylaxis and not more than 20 per cent can be attributed to the fluoride.
In the Shaw publication in 1954, Bibby and Brudevold94 tabulated the caries control reported by 16 different authors in 31 separate studies of topical application of sodium fluoride and by 7 authors using other fluorides. In the light of the information in their two tables and of much other information in the literature, and considering that at least 20 per cent reduction results from the prophylaxis and perhaps other influences associated with the treatment, it is evident that topical application of fluorides has little or no specific caries preventive effect.
In 1948, Congress, influenced largely by the urgent request, advice and recommendation of representatives of the U. S. Public Health Service and of organized dentistry, appropriated $1,000,000 for a nation-wide demonstration and promotion of topical application of 2 per cent sodium fluoride.95,96 The stated purpose was to set up (roughly) one "field demonstration mobile unit for each state; to demonstrate to dentists, dental hygienists, state and local health department personnel, et cetera, the correct technic of making sodium fluoride application to the teeth; and generally to publicize and promote interest in the procedure".
The program was hastily inaugurated in 1948 and vigorously pursued. By October 1950, demonstrations had been conducted by the demonstration teams in 658 communities;97 and in many more since that time, all over the country.
This procedure, which has little or no specific caries preventive effect, has been promoted, more or less, also in many other countries. Dean98 quotes H. J. Schmidt, secretary general, European Organization for Research on Fluorine and Dental Caries Prophylaxis, as stating that it has been utilized extensively in recent years in Denmark, England, Finland, Germany, Holland, Hungary, Italy, Sweden, Switzerland and Yugoslavia.
Even now this procedure is being extensively publicized and promoted by the American Dental Association, especially through a leaflet99 printed and supplied for wide distribution, mainly through dentists in their offices. In this leaflet the Council on Dental Health of the American Dental Association recommends fluoridation of communal water supplies. They also recommend topical application of fluorides for children who do not have fluoridated water; and for those who do, unless they were born in a fluoridated area. They recommend a series of four separate applications at intervals of two to seven days, a course of such treatment to be given preferably at the ages of 3, 7, 10, and 13. They claim that this "will reduce the occurrence of dental decay by an average of 40 per cent".
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The first application of fluoride in the series is supposed to be preceded by a thorough cleaning of the teeth, the others not. Any reduction in the occurrence of dental decay from this treatment results largely, if not entirely from the prophylaxis and is small compared with practically 100 per cent prevention which results from the right method of personal oral hygiene. Even if it is believed that there is a specific effect, which there is not, amounting to as much as 20 per cent caries reduction from the fluoride, there is still no need for it.
Continued promotion of topical application of fluorides tends to perpetuate the existing confused information relative to caries and to further postpone the time when those who wish information can learn the fact that prevention of caries depends essentially upon effective personal oral hygiene plus occasional cleaning of the teeth by the dentist, and not upon any kind of medical treatment.
Topical fluoride could not have any preventive effect upon the much more important disease - periodontoclasia - which is always present, more or less, as gingivitis in childhood, and continues to advance from that time onward. On the other hand, the right method of personal oral hygiene, regularly followed, prevents or controls this disease and at the same time prevents caries and maintains a high state of oral cleanliness.
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Many variable factors and conditions contribute more or less to the origin and advancement of the lesions of both caries and periodontoclasia. It is not necessary to know, understand, or control each one of them in order to prevent these diseases. It is only necessary to know and to prevent or minimize the essential local etiological conditions - conditions without which the lesions do not occur. These consist of accumulation and retention of foreign material, composed primarily of bacteria, at the particular locations where the lesions originate. The necessary physical removal of this material at appropriate intervals (at night before retiring) can be accomplished only by the right method of personal oral hygiene. In the light of all presently known facts and experience any neglect of, or deviation from this method reduces the benefits in proportion to such neglect or deviation.
Personal oral hygiene is an individual and a personal matter. Each person must know and accurately follow an effective method. Such a method will be taught only by dentists (or others) who know and follow it themselves. Those who have the information and experience know that the highest degree of oral cleanliness and dental health results.
Any institution, agency, organization, or group concerned with promotion of dental health, not interested in looking into or confirming the fundamental facts upon which effective personal oral hygiene must be based, but wishing only to know the clinical observations of dentists who have had the necessary experience, now have the opportunity. Names can be furnished of dentists of the highest professional standing in their respective communities in 17 different states who have learned this effective method and have been enthusiastically teaching it to their suitable patients, some for several years. Their experiences and results surely would be interesting and enlightening to others who have not had such experiences. These dentists could be contacted in any practical way, or better still, they could be brought together in groups (a dozen or several times that many if wanted) for conferences and discussions.
Any one of these dentists could call in numerous patients for illustration of results, who have been following this effective method for several years. Individuals can be presented, of all ages up to past 80, who follow this method and are maintaining practically complete dental health thereby.
Improper and unnecessary brushing discussed under 1 and 2 above tend to correct themselves. The harmful influence of their promotion should gradually decline as more dentists learn and teach, as they surely will do sooner or later, effective personal oral hygiene.
Artificial fluoridation of communal water supplies is rapidly expanding. It has been advocated and promoted originally and continuously by the U. S. Public Health Service and by the American Dental Association. It has been officially endorsed and approved by several of the foremost national (and many regional) scientific organizations, including the American Medical Association100 and the American Association for the Advancement of Science,101 said to be the largest body of scientists in the world. Recently a group of more than a hundred prominent citizens and leading authorities in their respective fields, many of them physicians, organized a strong endorsement and recommendation102 of fluoridation, especially for the city of New York.
Under these circumstances of overwhelming authoritative and influential support, artificial fluoridation has been adopted in several hundred communities103 in this country. The trend is gaining momentum and promoters of it are meeting with greater success all the time.
A large number of reports of observations in naturally fluoridated districts and now in artificially fluoridated communities all show that the incidence of the advanced stage of caries-cavities and extracted teeth-in young people is reduced by fluoridation. This is accompanied by and results from the contemporary increase in periodontoclasia activity. It only increases the activity of this disease, which all people have from early childhood onward. It does not make sense to fluoridate the water, thereby increasing the activity of this more important disease, in order to lessen the caries activity.
Whenever the relationship between the early stages of the caries process and the early stages of periodontoclasia is better understood and the harmful effect of fluorides in this regard, is recognized and can become known, as surely will occur sooner or later, artificial fluoridation of public water supplies will have to be discontinued. Until that time its unfavorable influence upon dental health will continue wherever it has been adopted.
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Sufficient increase - in periodontoclasia (gingivitis) activity to retard caries results from 1 ppm fluoride in the water, which is therefore more harmful than beneficial, even to young children. The caries preventive effect is much less in older people but increased periodontoclasia activity results from chronic fluoride intoxication at any age before the teeth are finally lost in later life.
There is considerable difference of opinion as to the influence of association between caries and periodontoclasia.104-106 Many experienced dental practitioners are of the opinion that there is less caries activity in mouths with the most active periodontoclasia and that the two diseases tend to be mutually exclusive.
There are many reports in the literature relative to the influence of fluoridated water upon periodontoclasia (gingivitis) most of them indicating little or no effect, one way or another. These reports are mostly based upon the PMA index employed by Massler, Schour and associates.105-111 This method attempts to show the incidence of frank overt lesions (the advanced stage of the disease) but does not recognize or throw any light upon the early stage. The method is subject to unintentional and unavoidable bias112,113 and much variation between different examiners.
Most reports of surveys of the caries rate and evaluation of caries control measures are based upon the DMF method of Klein and Palmer.114 -116 Like the PMA this DMF method attempts to show the incidence of advanced stage lesions and does not recognize or throw any light upon early stage caries. It too is subject to as much as 100 per cent117 examiner bias and variation. It is evident that such methods could be of only limited significance as to the prevalence and the relationship of caries and periodontoclasia, and the effect of control measures.
An impressive report by Russell118 indicates that not only less periodontoclasia but less final loss of teeth was experienced by lifelong residents of Colorado Springs (2.5 ppm fluoride) than was found in a supposedly comparable group at Boulder, Colorado, with fluoride-free water. An example of contrasting report is that of Dale and McCauley126 of chronic fluoride intoxication from fumes of hydrofluoric acid. The unexposed control group had an average of 27.4 teeth remaining; whereas those in the exposed group had only 23.3 teeth left, those exposed more than ten years only 21.6.
Greenwood published119 an extensive review of fluoride intoxication up to 1940. There was then abundant evidence (proof) of the serious, irreversible, harmful, systemic effect of fluorine in excessive amounts, and in some not-so-excessive. A large volume of additional information relative to the subject has appeared since that time, mostly supporting the claim that 1 ppm is not harmful and assuming that any harmful effect could 'be recognized by the methods used.
Mottled enamel occurs in part of the population when there are only 2 or 3 ppm of fluoride in the water and in almost all when the content is still higher. Long continued intake of increased amounts of fluorine from fluoridated water120-138 or from contaminated air120,139,140 causes, not only mottled enamel and dental hypoplasia, but also profound changes in the other calcified tissues of the body. These changes include osteosclerosis, thinning of the lamina, increased density, opacity to x-rays, narrowing of the marrow spaces, lack of normal sharpness of the bone outlines, osteophytic formations on various bones, synostosis of various joints, especially of the vertebral column, excessive calcification of tendons, fasciae, ligaments and ligamentous attachments, "bridging" between the vertebral bodies giving rise to stiffness of the back (the so-called poker back), etc. These striking conditions are usually recognizable only after thirty or thirty-five years of exposure but they continue to exist as long as the sufferer lives, and to increase if the exposure continues. Reduction of the bone-marrow spaces, thus impairing and reducing the blood-making tissues of the body not only produces anemia but it also reduces the ability to make back blood in anemia from other causes.
The fact that these severe harmful effects have resulted from 3 times as much, or perhaps 5 to 10 times as much, fluoride in the water as is added in artificial fluoridation leaves room for doubt as to the complete safety and harmlessness of that procedure.
There is much individual variation in susceptibility to the known effects of fluorides, whether it be the beneficial caries retardation in children or the known harmful effects, such as increased periodontoclasia activity, mottled enamel and the cumulative damage to the bones, tendons and ligaments of the body. Citizens, officials, and health authorities of the community have to decide whether to expose the entire population of all ages, and in all conditions of health and vitality, to such possibly harmful effects in order to secure the limited caries preventive effect of fluoridation of the communal water supply.
The public looks to the U. S. Public Health Service and the dental profession, more than to any other health agency or authority for guidance relative to dental health. As long as they continue to actively advocate and to recommend topical fluoride treatment it will be wanted by many people. Although dentists, after practical experience, may be doubtful of the results they have seen they still will be confronted with the public demand for fluoride applications, as long as the promotional publicity continues.
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Attention has been directed to four separate but somewhat related developments unfavorably influencing dental health, which have taken place during the first half of the present century. Some of the reasons for such influence have been presented.
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