PREVENTIVE MEDICINE 1, 475-477 (1972)

The present acceptnnce of the health benefits of wuter fluoridation owes much to the patience and eloquence of George James u decnde ago.

Fluoridation Today: The James Legacy

STEPHEN J. Moss

Chnirmun, Department of Dentistry for Children, Brook&de Dental Center of New York University College of Dentistry,

New York, New York 10010

AND

LEONARDG.GALLO

Instructor, Department of Dentistry for Children, Brookdale Dentul Center of New York University College of Dentistry,

New York, New York 10010

“Ideas won’t keep. Something must be done about them.”

ALFREDNORTHWHITEHEAD Dialogues (1953)

On of the many causes for which Dr. George James fought during his redoubtable career was fluoridation. Many of you will remember him arguing patiently and eloquently during the 1960’s for fluoridation of the country’s community water supplies. For Dr. James this had become a classic example of what he termed “managerial medicine”: preventive medicine which pro- vides maximum benefits to the community at minimal cost.

However, the fact that today only 4,000 out of approximately 16,000 water supplies in the United States are fluoridated is alarming, especially when we consider the body of evidence that argues so conclusively for fluoridation.

The history of fluoride research began ironically with the attention given in the late nineteenth century to its toxicity. In 1901 a report from Naples, Italy linked the disfigurement of teeth to a substance in the drinking water which altered calcification. Similar reports from other parts of the world began to ap- pear, and in 1942 an article in the American Association for the Advancement of Science linked dental abnormality, or “mottled enamel” as it was termed, to the amount of fluoride in drinking water (1).

All the attention being paid to the toxicity of fluoride was paving the way for one of the outstanding achievements in dental research. By 1930 dentists in areas of the United States which had high amounts of endemic fluoride in the water began to notice a low caries rate in their patients. Soon additional epidemiological surveys repeatedly reinforced their impression that the con- centration of the fluoride was directly proportional to the prevention of dental decay.

Copyright @ 1972 by Academic Press, Inc. All rights of reproduction in any form reserved,

475

476 MOSS AND CALL0

Finnally, in 1942, the U. S. Public Health Service confirmed the hypothesis that fluoride inhibited dental caries. Their studies involved 21 cities selected on the basis of varying concentrations of fluoride in their public water supply. Children of 12-14 years of age with a history of continuous residency in a city having less than 0.5 ppm of fluoride in the domestic water had an average DMF (decayed, missing, and filled) rate of 7. In a similar group residing in a city where fluoride concentration was between 1.0 and 1.4 ppm the DMF was slightly less than 3 (1).

In 1945 a group of four important clinical studies were begun to show the effectiveness of artificial fluoride in the controlled public supply of drinking water. These studies were conducted in Grand Rapids, Michigan; Newburgh, New York; Brantford, Ontario; and Evanston, Illinois. The results showed a 55-60% reduction in the number of decayed, missing, or filled teeth of children continuously exposed to the fluoridated water from birth (2).

Another body of research during the 1940s focused on the topical applica- tion of fluoride. Beginning in 1942 with a report by Bibby (3), evidence has ac- cumulated on the effectiveness of controlling dental caries by topical applica- tion. The aim of topical treatment is the same as that of fluoridated water, i.e., to deposit fluoride in the form of a fluorapatite. In order to enrich the enamel with fluoride topically, the fluoride must penetrate the surface enamel and react with the apatite crystals. In the vast majority of tests and reports con- ducted on the effects of topical fluoride, the results are consistent: children aged 4-14 yr, when exposed to topical fluoride treatments will have a dental decay reduction of 40-60%.

Thus the scientific evidence gathered over many years teaches us that fluoridation provides upward of 50% reduction in overall dental caries. We have also learned that controlled fluoridation will not result in mottling of the enamel: A person drinking water of 1 ppm fluoride over an entire lifetime will not develop any fluorosis sufficient to mar the appearance of the teeth. Nor will he endanger his health. Examination of people who have lived all their lives in areas of high natural fluoride reveals no differences in disease morbid- ity or mortality.

In the future, new techniques developed for the use of fluoride will no doubt show similar results with clinical substantiation. But further investiga- tion must determine, for example, just how much of the fluoride in drinking water actually reaches children during the critical period of greatest need-from birth to 3 years of age-when many of those children predomi- nantly drink bottled milk and juices.

Whatever we learn in the next few years, we know now that fluoridation of public water supplies is incontrovertibly the most practical, economical, and conveninent means of providing significant dental protection for our commu- nities. And we have known this for many years.

Why, then, are three-quarters of the nation’s water supplies not providing the benefits of fluoridation?

Too few of us have followed the example of Dr. James. The vociferous minority against fluoridation which we face today is no different than the

GEORGE JAMES: FLUORIDATION 477

minority he faced in thousands of communities. He did so with a relentless campaign of public education that forced communities to perceive the value of fluoridation. And once that value was perceived communities willingly allocated funds, built facilities, and trained personnel.

We share another problem which faced Dr. James. The federal government today supports community dental projects with hundreds of thousands of dollars while neglecting fluoridation of community water supplies. This is painfully ironic when you consider the evidence for fluoridation and its yearly per capita cost: 10 cents.

There has never been a more propitious moment for following Dr. James’

example of vigorous public education. Preventive medicine is no longer an appealing concept. It has become a necessity. The concept of prevention is also growing in the thinking and practice of dentistry.

In the presence of all the scientific evidence needed to act, we recall Dr. James’ own words in the inaugural issue of this publication:

“The physician should act not only as practitioner but as leader and coun- selor on preventive medicine to his patient and to his community”

Now is the time to assert a managerial approach to preventive dentistry as well as medicine.

REFERENCES

1. MOULTON, F. R. Fluorine and dental health. Amer. Asso. Adwan. Sci., Publ. 19, Washington, D. C., 1942.

2. National Fluoride Content of Community Water Supplies- 1960. Bethesda, Maryland, U. S. Department of Health, Education, and Welfare, National Institutes of Health, Division of Dental Health.

3. BIBBY, B. G. Use of fluorine in the prevention of dental caries, II, Effects of sodium fluoride applications, I. Amer. Dent. Asso., 31,317 (1944).