F- is effective as a topical application to teeth for the prevention of dental decay. This will not be addressed in this presentation.

Operational (Observational) Science: a systematic approach to understanding that uses observable, testable, and repeatable experimentation to understand how nature commonly behaves.

Operational Science gives us data which the scientist then interprets and draws a conclusion.

“There are three kinds of lies: lies, damned lies, and statistics.” Benjamin Disraeli, 1st Earl of Beaconsfield and popularized by Mark Twain. The semi-ironic statement refers to the persuasive power of numbers, and succinctly describes how even accurate statistics can be used to bolster inaccurate arguments.

. . . fluoride prevents dental caries . . . fluoride prevents dental caries predominately after eruption of the predominately after eruption of the tooth into the mouth, and its tooth into the mouth, and its actions primarily are topicalactions primarily are topical for for both adults and children…”both adults and children…”

CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October

22.22.

CDC on Benefits: 1999 “Fluoridation is one of 10 great public health achievements of the 20th century. . . (http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp)

Fluoride’s anticaries effects are NOT systemic

•SJ Fomon, ed., Fluoride Nutrition of Normal Infants pp. 299-310. Philadelphia: Mosby 1993•Journal of the American Dental Association 7/2000•USDA www.nal.usda.gov/fnic/

“Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 1995 to the Secretary of Health and Human Services and Secretary of Agriculture.”

The laboratory and epidemiological research . . . Indicates that fluoride’s predominant effect is post-eruptive and topical . . . “The concentration of fluoride in ductal saliva as secreted is 0.016 ppm in fluoridated areas and 0.006 ppm in non-fluoridated areas. (27) Not likely to effect cariogenic activity.”

The CDC: MMWR Report August 17, 2001/Vol 50/No. RR-14

CDC 2001 Also Stated:

http://www.fluoridealert.org/health/teeth/caries/who-dmft.html

Tooth Decay Trends for 12 Year Olds: Fluoridated Vs. Unfluoridated Countries. Data from World Health Organization. (Graph by Chris Neurath).

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http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm National Survey of Children's Health. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Maryland: U.S. Department of Health and Human Services, 2005

http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htm

Although ecological studies are considered weak, certainly the number of cohorts and states is significant.

AK = 57.3%#16

“Studies prove water fluoridation continues to be effective in reducing tooth decay by 20-40%”http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp 7/13/06

Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49(5):279-89

Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water fluoridation. J Dent Res 1990;69(Spec Iss 723-7

ADA Positions & Statements

“The major anticaries benefit of fluoride is topical and not systemic” NRC 2006 p 13

1. A number of recent cessation studies show that stopping fluoridation does literally nothing to increase overall dental decay. Komarek et al, A Bayesian analysis of multivariate doubly-interval-censored dental data,

Biostatistics 2005 6 pp 145-155 Copy Available.

2. Modern studies find difficulty in measuring the benefits of fluoridation (no difference between fluoridated and non-fluoridated communities) Studies by: Brunelle, Angelilo, Clark, Ismail,

Slade, Kumar and in Australia by Armfield JM. Spencer AJ 2004, a very large study found No difference in dental decay in permanent teeth.

3. Not taking into account delayed tooth eruption makes early fluoridation studies “over-estimates of the

benefits”.... Fluoride added to drinking water may have simply

delayed caries in the past. Hardy Limeback DMD, PhDEven those flawed studies found 0.6 ppm F better than 1.0ppm. Edward &

Strickler

**http://www.doh.wa.gov/cfh/Oral_Health/Documents/SmileSurvey2005FullReport.pdf*http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdf#search='Oregon%20Decay%20experience‘http://quickfacts.census.gov/qfd/states/41000.html

http://www.cdc.gov/fluoridation/fact_sheets/states_stats2002.htm

http://www.fluoridationcenter.org/papers/2002/cdcmmwr022102.htm

“Effectiveness” Oregon WashingtonPopulation Fluoridated 19% 59%Decay % 6-8 yr. olds 57%* 59%**Any Permanent Teeth Extracted 60%**** 63% Very Good/Excellent Teeth 58%*** 51%

Low Income Children

Confounding FactorsMedian Income $42,593 $48,185Bachelor’s Degree 25.1% 27.7%English Spoken 88% 88%Race Similar +1% Hispanic +1% BlackPreventive Dental Visit 45% 60% (within 12 mo Low income)Delay in tooth eruption 10-20%

Fluoride Supplements ??? ???

***National Survey of Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm U.S. Department of Health and Human Services,

http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htmBRFSS 2002 http://www.dhs.state.or.us/dhs/ph/chs/brfs/02/orahea/dentvisi.shtml ****http://apps.nccd.cdc.gov/brfss/display.asp?state=WA&cat=OH&yr=2004&qkey=6610&grp=0&SUBMIT4=Go Sample size OR 3509 and WA 12,926 2004 data

Where is the

“20-40%”

Benefit?

ADA awarded Kentucky with “50 Year Award” for (100%) fluoridation 2003 42% were edentulous, #1 in USA (2002 Mortality Weekly

Report)

“With 1.6 to 4ppm fluoride in the water, 50% or more past age 24 have false teeth because of fluoride damage.” JADA 1944

Connecticut (87.5% water fluoridated)DetroitBoston

all report a crisis with decay and all have water fluoridation.http://www.fortwayne.com/mld/newssentinel/7521679.htm?template=contentModules/printstory.jsphttp://www.enquirer.com/editions/2002/10/06/loc_special_report.htmlhttp://www.fluoridealert.org/f-boston.htmhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=13678102&query_hl=1http://www.nhregister.com/site/news.cfm?newsid=14472801&BRD=1281&PAG=461&dept_id=517515&rfi=8&xb=kasan

Brunelle and Carlos Brunelle and Carlos (1990)(1990)

This was the largest dental survey in US. By the This was the largest dental survey in US. By the NIDR, 39,000 children.NIDR, 39,000 children.

The average difference in tooth decay, aged 5 –The average difference in tooth decay, aged 5 –17 years, was17 years, was

0.6 of one tooth surface out of 88 to 128 0.6 of one tooth surface out of 88 to 128 toothtooth surfaces.surfaces.

This difference was not shown to be statistically This difference was not shown to be statistically significant.significant.

Did not consider delay in tooth eruption caused Did not consider delay in tooth eruption caused by Fluoride.by Fluoride.

Spencer et al (1996 AUS) found benefits of Spencer et al (1996 AUS) found benefits of 0.12 - 0.12 -

0.30.3 tooth surfaces. tooth surfaces. de Liefde (1998 NZ) de Liefde (1998 NZ) “clinically meaningless.” “clinically meaningless.”

From Scientific American, Jan. 2008 pg. 78

Fluorosis of TeethFluorosis of TeethPermanent discoloration of the tooth, develops during tooth formation. Birth to 8th yr. NRC 2006 white spots or brown spots (endemic).

80% of US Children suffer from some degree of dental fluorosis. NRC 1993

ScienceDirect - Journal of Dentistry Caries susceptibility of human fluorosed enamel and dentine - "Fluoride bombs" explained? Peter Kearney

Normal Dentin Mild Fluorosis Moderate Fluorosis

"In summary, we hold that fluoridation is an unreasonable risk. That is, the toxicity of fluoride is so great and the purported benefits associated with it are so small - if there are any at all – that requiring every man, woman and child in America to ingest it borders on criminal behavior on the part of governments." -Dr. J. William Hirzy, Senior Vice-President, Headquarters Union, -US Environmental Protection Agency, March 26, 2001

EPA Scientists say “NO” to Fluoridation

May 1, 1999WHY EPA'S HEADQUARTERS UNION OFSCIENTISTS OPPOSES FLUORIDATION

3. Is it ethical to fluoridate public water?

Austria REJECTED: "toxic fluorides" NOT addedBelgium REJECTED: encourages self-determination – those who want fluoride should get it themselves.

Finland STOPPED: "...do not favor or recommend fluoridation of drinking water. There are better ways of providing the

fluoride our teeth need." A recent study found ..."no indication of an increasing trend of caries....“Germany STOPPED: A recent study found no evidence of an increasing trend of cariesDenmark REJECTED: "...toxic fluorides have never been added to the public water supplies in Denmark.“

Norway REJECTED: "...drinking water should not be fluoridated“Sweden BANNED: "not allowed". No safety data available!Netherlands REJECTED: Inevitably, whenever there is a court decision against fluoridation, the dental lobby

pushes to have the judgment overturned on a technicality or they try to get the laws changed to legalize it. Their tactics didn't work in the vast majority of Europe.

Hungary STOPPED: for technical reasons in the '60s. However, despite technological advances, Hungary remains unfluoridated.Japan REJECTED: "...may cause health problems...." The 0.8 -1.5 mg regulated level is for calcium-fluoride, not the hazardous waste by-product which is added with artificial fluoridation.Israel SUSPENDED mandatory fluoridation until the issue is reexamined from all aspects.: June 21, 2006 “The labor, welfare and health Knesset committee”China BANNED: "not allowed“France 40-50% fluoridated SaltIreland 74% FluoridatedUK 9% Fluoridated

Despite dental pressure, 90+% of European Governments and Dental Associations have rejected, banned, or stopped fluoridation

due to environmental, health, legal, or ethical concerns

Most European Dental Associations no longer recommend fluoride supplementsZimmer 2003

Shame: A Major Reason Why Most Medical Doctors Don't Shame: A Major Reason Why Most Medical Doctors Don't Change Their ViewsChange Their ViewsBy Frank Davidoff By Frank Davidoff In the 1960s the results of a large randomized controlled study by the University Group Diabetes In the 1960s the results of a large randomized controlled study by the University Group Diabetes Program showed that tolbutamide, virtually the only blood sugar lowering agent available at the time Program showed that tolbutamide, virtually the only blood sugar lowering agent available at the time in pill form, was associated with a significant increase in mortality in patients who developed in pill form, was associated with a significant increase in mortality in patients who developed myocardial infarction. myocardial infarction. The obvious response from the medical profession should have been gratitude: here was an The obvious response from the medical profession should have been gratitude: here was an important way to improve the safety of clinical practice. But in fact the response was doubt, outrage, important way to improve the safety of clinical practice. But in fact the response was doubt, outrage, even legal proceedings against the investigators; the controversy went on for years. even legal proceedings against the investigators; the controversy went on for years. Why? Why? An important clue surfaced at the annual meeting of the American Diabetes Association soon after An important clue surfaced at the annual meeting of the American Diabetes Association soon after the study was published. During the discussion a practitioner stood up and said he simply could not, the study was published. During the discussion a practitioner stood up and said he simply could not, and would not, accept the findings, because admitting to his patients that he had been using an and would not, accept the findings, because admitting to his patients that he had been using an unsafe treatment would shame him in their eyes. Other examples of such reactions to improvement unsafe treatment would shame him in their eyes. Other examples of such reactions to improvement efforts are not hard to find. efforts are not hard to find. Indeed, it is arguable that shame is the universal dark side of improvement.Indeed, it is arguable that shame is the universal dark side of improvement.After all, improvement means that, however good your performance has been, it is not as good as it After all, improvement means that, however good your performance has been, it is not as good as it could be. As such, the experience of shame helps to explain why improvement, which ought to be a could be. As such, the experience of shame helps to explain why improvement, which ought to be a "no brainer", is generally such a slow and difficult process."no brainer", is generally such a slow and difficult process.What is it about shame that makes it so hard to deal with? Along with embarrassment and guilt, What is it about shame that makes it so hard to deal with? Along with embarrassment and guilt, shame is one of the emotions that motivate moral behavior. Current thinking suggests that shame is shame is one of the emotions that motivate moral behavior. Current thinking suggests that shame is so devastating because it goes right to the core of a person's identity, making them feel exposed, so devastating because it goes right to the core of a person's identity, making them feel exposed, inferior, degraded; it leads to avoidance, to silence.inferior, degraded; it leads to avoidance, to silence.The enormous power of shame is apparent in the adoption of shaming by many human rights The enormous power of shame is apparent in the adoption of shaming by many human rights organizations as their principal lever for social change; on the flip side lies the obvious social organizations as their principal lever for social change; on the flip side lies the obvious social corrosiveness of "shameless" behavior. corrosiveness of "shameless" behavior. Despite its potential importance in medical life, Despite its potential importance in medical life, shame has received little attention in the shame has received little attention in the medical literaturemedical literature: a search on the term shame in Medline in November 2001 yielded only 947 : a search on the term shame in Medline in November 2001 yielded only 947 references out of the millions indexed. In a sense, shame is the "elephant in the room": something so references out of the millions indexed. In a sense, shame is the "elephant in the room": something so big and disturbing that we don't even see it, despite the fact that we keep bumping into it. big and disturbing that we don't even see it, despite the fact that we keep bumping into it. An important exception to this blindness to medical shame is a paper published in 1987 by the An important exception to this blindness to medical shame is a paper published in 1987 by the psychiatrist Aaron Lazare which reminded us that patients commonly see their diseases as defects, psychiatrist Aaron Lazare which reminded us that patients commonly see their diseases as defects, inadequacies, or shortcomings, and that visits to doctors' surgeries and hospitals involve potentially inadequacies, or shortcomings, and that visits to doctors' surgeries and hospitals involve potentially humiliating physical and psychological exposure.humiliating physical and psychological exposure.Patients respond by avoiding the healthcare system, withholding information, complaining, and suing. Patients respond by avoiding the healthcare system, withholding information, complaining, and suing. Doctors too can feel shamed in medical encounters, which Lazare suggests contributes to Doctors too can feel shamed in medical encounters, which Lazare suggests contributes to dissatisfaction with clinical practice. dissatisfaction with clinical practice.

Indeed, much of the extreme distress of doctors who are sued for malpractice appears to be attributable to the shame rather than to the financial losses. Also, who can doubt that a major concern underlying the controversy currently raging over mandatory reporting of medical errors is the fear of being shamed? Doctors may, in fact, be particularly vulnerable to shame, since they are self-selected for perfectionism when they choose to enter the profession. Moreover, the use of shaming as punishment for shortcomings and "moral errors" committed by medical students and trainees such as lack of sufficient dedication, hard work, and a proper reverence for role obligations probably contributes further to the extreme sensitivity of doctors to shaming. What are the lessons here for those working to improve the quality and safety of medical care? Firstly, we should recognize that shame is a powerful force in slowing or preventing improvement and that unless it is confronted and dealt with progress in improvement will be slow. Secondly, we should also recognize that shame is a fundamental human emotion and not about to go away. Once these ideas are understood, the work of mitigating and managing shame can flourish. This work has, of course, been under way for some time. The move away from "cutting off the tail of the performance curve" that is, getting rid of bad apples towards "shifting the whole curve" as the basic strategy in quality improvement and the recognition that medical error results as much from malfunctioning systems as from incompetent practitioners are important developments in this regard. They have helped to minimize challenges to the integrity of healthcare workers and support the transformation of medicine from a culture of blame to a culture of safety.But quality improvement has another powerful tool for managing shame. Bringing issues of quality and safety out of the shadows can, by itself, remove some of the sting associated with improvement. After all, how shameful can these issues be if they are being widely shared and openly discussed? Here is where reports by public bodies and journals like Quality and Safety in Health Care come in. More specifically, such a journal supports three major elements autonomy, mastery, and connectedness that motivate people to learn and improve, bolstering their competence and their sense of self worth, and thus serving as antidotes to shame.British Medical Journal 2002;324:623-624 March 16, 2002