Talk:Water fluoridation/Archive 2

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Archive 5

Why is America still fluoridating tap water supplies?

Most of Europe has stopped water fluoridation: http://www.fluoridation.com/c-country.htm - the reasoning of most European countries is that fluoride may be toxic, and that there are other ways of delivering fluoride to the teeth than forcing it into everyone's tap water.

How many Americans know that fluoride comes from the pesticide and aluminum industry as a by-product (that was originally discarded, causing pollution and toxicity in the surrounding areas)?

OBVIOUSLY, this is NOT the same as adding iodine to salt, Vitamin C to juice or Vitamin D to milk, since the tap water is not something a consumer goes to a store and purchases (and has many options to choose from) - because iodized salt, juice or milk with added vitamins can easily be avoided - but fluoridated water can not.

Even if a consumer chooses to filter their water, fluoride is still taken up by vegetables, fruits, grains, animals, and most restaurants that do not use advanced filtering for their water, use fluoridated water to cook with. --Aeditorr

Troll

This has nothing to do with editing the article or changing the content. Please address article content Cuvtixo (talk) 19:11, 26 September 2008 (UTC)

Duplication

Either the controversy should be fully discussed in this article or it should be fully discussed in water fluoridation controversy and merely summarized here. It should not be rehashed in both to the substantial degree that it is right now. For reasons I originally articulated months ago, I think it should merely be summarized here and fully explained in the controversy article. - Jersyko·talk 04:26, 24 May 2006 (UTC)

• Additionally, as I come back from my Wikibreak, I see that this article has been substantially expanded to highlight the controversy. This is violative of NPOV, imo. - Jersyko·talk 04:31, 24 May 2006 (UTC)

According to wiki policy (see WP:GFCA), both sides of a controversial issue should be described in the article. --AeronM (talk) 18:09, 28 February 2008 (UTC)

Only issues concerning "water fluoridation" should be discussed here and I think they basically are. See the prior discussion. The last arrangement was a pro fluoridation page in the water fluoridation page which was not NPOV. As discussed, the prior page failed to include health effects of fluoridation as well which deviates from other medications on Wikiepdia.

The only use for the water fluoridation controversy is if people want to make an article about the individuals advocating for or against water fluoridation.

--Editmore 08:58, 24 May 2006 (UTC)

By the way, I do not see how a long intro makes the article not NPOV. A number of people have worked hard to remove the POV language throughout the article and it is cited pretty well.

--Editmore 09:01, 24 May 2006 (UTC)

The long intro does not make the article POV, it makes the article unweildy and non-conforming with standard Wikipedia style. I disagree with you that the older version of the article was POV, however, even if it was, the current version is unacceptably POV as it is far too slanted toward emphasizing the controversy. I understand you had a recent discussion about this with another editor (who disagreed with you, might I add). Note, however, that an even older discussion took place months ago on this same subject, and an apprehensible consensus was reached. Finally, the main problem right now is content duplication between the two articles, which should probably be the first issue we address. - Jersyko·talk 12:56, 24 May 2006 (UTC)

The focus of the article is about water floridation and not the controversy. There is some controversy and that should be mentioned from a neutral point of view, however the focus of the article is on floridation not the controversy. On the other hand, the water fluoridation controversy article is a good spot to flesh out the aspects regarding the controversy.--Sk8ski 13:51, 24 May 2006 (UTC)

In that case you´d have just to write what is not a matter of controversy. But the controversy already starts with saying "Fluoride" is used for fluoridation. It´s not always "fluoride" (the simple fluoride ion, as in sodium fluoride) but fluorosilicates (or fluorosilicic acid) which dissociate in part (!another matter of controversy!) to release fluoride. Tren 13:45, 25 May 2006 (UTC)

And your comment demonstrates the problem - fluoride opponents see the entire issue as being controversial, i.e. it cannot be discussed as a scientific or historical phenomenon without also mentioning that it's possibly dangerous and controversial. Well, it can, and it was, actually, in the early May/late April versions of this article. If a subsection is added to that version of the article summarizing, briefly, the controversy with a prominent link to the controversy article, this article would be NPOV and would stay on topic. - Jersyko·talk 15:18, 25 May 2006 (UTC)

OK, the more I look at the changes to this article and the controversy article, the more I realize that the changes by various editors purportedly made to make the articles more NPOV are, in nearly every case, extremely one sided against fluoridation. My own view now is to rollback most if not all of the changes to these articles over the last month. I'll look through the history at some point soon and see exactly where the changes started to go wrong, but these articles, especially this one, are unacceptably POV at this point. - Jersyko·talk 14:59, 25 May 2006 (UTC)

By implying that edits referencinging the controversy are "wrong" indicates to me a stong POV on your part. Please see WP:NPOV. --AeronM (talk) 18:14, 28 February 2008 (UTC)

I count the space to be fairly equal not that there is anything requiring the area for both positions. Those wishing to edit should focus on citing articles better not removing either the studies or arguements for or against water fluoridation.

There are peer researched articles showing that water fluoridation reduces caries. There are others that show water fluoridation causes dental fluorosis. Both are appropriate to be in this section under "water fluoridation."

There are obviously people who wish that only article discussing the negative health effects of fluoridation were listed and others that believe only that studies showing the purported positive effects of fluoridation were listed. Both should refrain from trying to nuke the other side out of the discussion. Such an attempt to show only one or the other is not contructive and against Wiki rules and is basically vandalism.

--Editmore 01:07, 26 May 2006 (UTC)

Your comments assume that the controversy warrants more than a paragraph summary in this article because a lively debate is actually taking place among legitimate scientists and public health agencies about the controversy. - Jersyko·talk 01:22, 26 May 2006 (UTC)

Also, before accusing anyone of vandalism, I recommend you read (1) WP:NPOV (particularly the section on "undue weight") and (2) WP:NOT. Those two policies are vital to any information that is posted on Wikipedia. Thanks. - Jersyko·talk 01:24, 26 May 2006 (UTC)

My reversion

To explain my reversion, I'll merely point to the following: Wikipedia:Neutral point of view#Undue weight. Yes, this version is not perfect: there needs to be a subsection with a paragraph summarizing the controversy briefly. And I'm sure there are stylistic/grammar/spelling changes that need to be made. However, the reverted version adheres to NPOV, the other version does not. - Jersyko·talk 02:25, 26 May 2006 (UTC)

Please do not attempt to destory dozens of people's edits over the last month. You remxoved a whole lot of new content on the status of water fluoridation and replaced a whole slew of POV language which many of us worked to remove in many of the sections.

--Editmore 02:45, 26 May 2006 (UTC)

I suggest we work, again, to remove it, though I imagine that we disagree, exactly, about what is POV. Please read the section of the NPOV policy about undue weight I reference above (here it is again). Your characterization of my reversion as "destroying" your work is spurrious. Quite the contrary, the edits over the last month have created a POV article, thereby distorting (but by no means "destroying") the original article. I've demonstrated why the article is POV with a specific reference to the NPOV policy. I would suggest you proffer a counterargument to the point I've presented if you want to continue this discussion, but please stop mischaracterizing my actions with inflated rhetoric about "destroying" work and vanadlism. - Jersyko·talk 04:04, 26 May 2006 (UTC)

Contributing to this article is obviously a waste of time. Tren 10:19, 26 May 2006 (UTC) ---

Apparently bored with editing, Jersyko is trying to wipe out everyone's work over the last month. Please stop.

--AceLT 18:48, 26 May 2006 (UTC)

By the way, as has been explained to you, Wiki rules and common practices establish that criticisms go on the page of the topic. Also, the section areas in the US and world that have water fluoridation shouldn't have been wiped out either. I don't know why you believe that is "controversy."

--AceLT 19:18, 26 May 2006 (UTC)

You're giving undue weight to a minority view by including the controversy prominently in this article. I've cited a specific wikipedia policy that is applicable to this article. You invoke "wiki rules" and "common practices", but have not cited a specific rule that mandates that we discuss the controversy fully in this article, giving equal weight to both the majority and minority positions. Please point out the rules you are talking about that overrule NPOV/undue weight. Thanks. - Jersyko·talk 21:30, 26 May 2006 (UTC)

I've added a subsection on the controversy, FYI. - Jersyko·talk 21:37, 26 May 2006 (UTC)

I see it's been reverted again by a non-registered user. I would recommend that everyone involved here read Wikipedia:Sockpuppetry and the three revert rule. Thanks. - Jersyko·talk 22:08, 26 May 2006 (UTC)

Everyone take a breather.

Please see Wiki policy below. There are going to be multiple "conflicting views" on the subject like they are on others.

The neutral point of view

The neutral point of view is a means of dealing with conflicting views. The policy requires that, where there are or have been conflicting views, these should be presented fairly, but not asserted. All significant points of view are presented, not just the most popular one. It should not be asserted that the most popular view or some sort of intermediate view among the different views is the correct one. Readers are left to form their own opinions.

http://en.wikipedia.org/wiki/Wikipedia:Neutral_point_of_view

--216.174.242.58 22:17, 26 May 2006 (UTC)

Yes, that is the basic NPOV policy. But it is qualified by the undue weight portion of the same policy. - Jersyko·talk 22:27, 26 May 2006 (UTC)

Contributing to this article is obviously a waste of time. Tren 10:19, 26 May 2006 (UTC) ---

Yes. Unfortunately, it is far easier to revert a document than actually take the time to edit it. Hopefully, this article can continue on a normal editing track soon.

--AceLT 23:59, 26 May 2006 (UTC)

I merely want to point out that you continue to ignore my request and my point, instead continuing with overblown rhetoric and generalizations. I think you will find that when other editors take a look at this discussion, they are more influenced by policy arguments than rhetoric, so I would recommend either making reference to specific Wikipedia policy in response to my point about undue weight or conceding the point and working with me on the reverted version of the article if you believe it to be flawed stylistically, grammatically, or in content. If we cannot work out an agreement amongst ourselves, I will file a request for comment to get other users involved in this discussion. Jersyko·talk 00:13, 27 May 2006 (UTC)

If you would not have tried to erase everyone's work on the subject for the last month through multiple reversion attempts, your comments may have been taken more seriously.

I think if you look at the above comments you will see a number of references to Wiki policy, yet you have ignored them and sought to have the article contain a single POV and a silly reference to Dr. Strangelove which has nothing to do with water fluoridation.

Further, you have provided no justification for elimiating that section on the status of water fluoridation in the US and world which was one of the better sections and took alot of people alot of time.

Sure, go ahead and ask every contributor to this article in the last month whether you have their permission to eliminate their contributions.

--AceLT 00:39, 27 May 2006 (UTC)

Per WP:OWN, no one owns their contributions to this article or any other. I request no one's permission to edit, and require none. That's the beauty of Wikipedia. Regarding the minor, specific point about Dr. Strangelove -- what?? It's the most prominent pop culture reference to water fluoridation I'm aware of. If consensus is to remove it, fine, but I'd like to know exactly why it's against Wikipedia policy to include it when there's a perfectly reasonable reason to include it (I'm not against rewording or changing the placing of the reference, but it's difficult to justify failing to mention Strangelove at all). Next, I didn't eliminate the section of the status of water fluoridation in the US and the world, it's still there under "Implementation" in the version I reverted to. Finally, I'm still waiting to hear your response to my point about undue weight. - Jersyko·talk 01:13, 27 May 2006 (UTC)

Ok. I think this resolves the matter. Here is the most on point article in Wikipedia I have found after reviewing all of the above references and many, many more:

A POV fork is an attempt to evade NPOV guidelines by creating a new article about a certain subject that is already treated in an article often to avoid or highlight negative or positive viewpoints or facts. This is generally considered unacceptable. The generally accepted policy is that all facts and majority Points of View on a certain subject are treated in one article.

Thus, the attempt to "to avoid or highlight negative or positive viewpoints or facts" should not have been done in creating Water fluoridation controversy in the first place. The creation of the page was an impermissable POV fork.

By the way, this is a specific policy on the Undue Weight section.

http://en.wikipedia.org/wiki/Wikipedia:Neutral_point_of_view#Undue_weight

--Editmore 02:34, 27 May 2006 (UTC)

I'm afraid it doesn't resolve the matter. As a policy, WP:NPOV, and thus the section on Undue Weight, trumps the guideline contained at WP:POVFORK. In any event, I disagree that the controversy article is a POV fork. As a preliminary matter, note that the POV fork guideline talks about fairly representing the majority points of view on a certain subject. Anti-fluoridation is demonstrably not the majority point of view. Next, the controversy article is about a distinct subject--the water fluoridation controversy as opposed to water fluoridation generally. If the article talked only about how bad water fluoridation is, it would be a POV fork, but if the article objectively described the controversy, it would not be. Third, a POV fork is an article that is split into multiple articles solely so each can advocate a different stance on the subject. That's not what is happening here at all--this article is describing water fluordiation generally, the controversy article is describing the controversy. Neither should take a stance on the issue. However, since undue weight is given to the minority, anti-fluoride position in this article, it violates WP:NPOV. It would be impossible to cover the controversy thoroughly in this article and adhere to the undue weight policy. - Jersyko·talk 03:29, 27 May 2006 (UTC)

Its not that complex actually. The fact that there is such a thing as dental fluorosis is an accepted fact and accepted majority view. So is the fact that different areas have water fluoridation in them and some do not. Also, it is accepted that some people have been injured from malfunctions in water fluoridation overfeeds. Non of these are pro or anti fluoridation. They are simply facts that have cited references concerning water fluoridation. Thus, even using your reasoning, they belong on the water fluoridation page.

Trying to relagate them to another page because you do not want to see them is a POV fork as discussed above and is not permitted.

I certainly disagree with your suggestion that the POV fork policy is "trumpted" or invalid.

Instead of arguing (incorrectly I might add) that the Wiki fork policy is not valid, can't you just concede you made a mistake and help the rest of us edit the article instead of continuously trying to remove our work?

--Editmore 03:55, 27 May 2006 (UTC)

You say that I'm "relegating them to another page because [I] do not want to see them." No, in fact, I've suggested adding a summary of the controversy to the version I reverted to, then did so myself, in which I brought up fluorosis, among other things. I've never said that there cannot or should not be a discussion of water fluoridation system malfunctions in this article. Per my first comment in this section, note that I said that I know the reverted version is not perfect, but I know it adheres to WP:NPOV, while the current version does not. My goal is to remove the controversy discussion in this article and leave a summary in its place, I'm not against expanding the reverted version further, provided that the relevant Wikipedia policies are followed. - Jersyko·talk 04:09, 27 May 2006 (UTC)

Also, regarding the relative importance of WP:NPOV to WP:POVFORK, take a look at Wikipedia:Policies and guidelines. NPOV is a key policy, and is in fact one of the building blocks of Wikipedia and is non-negotiable. - Jersyko·talk 04:18, 27 May 2006 (UTC)

I reverted the article to return to the NPOV version. It is interesting that most of this information on the controversy was actually information that I wrote, and I firmly believe it belongs in the water fluoridation controversy article, NOT this one. - Dozenist talk 05:35, 27 May 2006 (UTC)

I've never said that there cannot or should not be a discussion of water fluoridation system malfunctions in this article.

I see. You also said earlier you were not against the article showing the areas which are fluoridated. Then I would suggest editing the page rather than trying to destroy it and expect others to work it back up again.

What parts do you specifically object to?

--Editmore 07:08, 27 May 2006 (UTC)

One can argue that the Wiki ban re: POV fork should it is "trumped" by another rule. Perhaps Wiki will change the rule in the future. However, for now it is valid.

http://en.wikipedia.org/wiki/Wikipedia:Neutral_point_of_view#Undue_weight

--Editmore 08:26, 27 May 2006 (UTC)--Editmore 08:26, 27 May 2006 (UTC)

Here's something to keep in mind to the content deletion attempts:

Try to avoid deleting things as a matter of principle. When you amend and edit, it is remarkable how you might see something useful in what was said. Most people have something useful to say. That includes you. Deletion upsets people and makes them feel they have wasted their time: consider moving their text to a sub-directory of their user pages instead (e.g. saying not quite the right place for it but so they can still use it): much less provocative.

http://en.wikipedia.org/wiki/Wikipedia:Wikiquette

--Editmore 09:00, 27 May 2006 (UTC)

This information is presented in the controversy article, and should be presented there. There is no rampant deletion of information occuring. - Dozenist talk 12:55, 27 May 2006 (UTC)

And I'll just keep referring back to Wikipedia:Neutral point of view#Undue weight, mmk? The parts I specifically object to in the version you prefer are: (1) the excessively long introduction which highlights the controversy for over half its length, thereby giving undue weight to the minority anti-fluoridation view, (2) nearly everything else in the article (other than the "history" section and the section on the status of fluoridation in different countries), as it is all related to the controversy, thereby giving undue weight to the minority anti-fluoridation view, and (3) numerous unsubstantiated, POV phrases that have been inserted into the article, such as (just as one example) "Water fluoridation remains controversial among the general public [in the United States]." - Jersyko·talk 14:41, 27 May 2006 (UTC)

Dental fluorosis is an example of a majority view on the effect of water fluoridation.

Continuing eliminating content related to it borders of vandalism.

There are a number of ways this page could work, but you appear only interested in reverting and not editing. I don't see how this is very productive.

--Editmore 17:42, 27 May 2006 (UTC)

Fluorosis is a majority accepted consequence of ingesting too much fluoride, not of water fluoridation itself. Also, you're simply lying by saying that the reverted version eliminates discussion of fluorosis, as it is discussed in the neutral version in more than one section, for crying out loud. Your continued inflated rhetoric about "vandalism" and "destroying" your work is not going to solve anything, but could cause me to report you to an administrator if it doesn't stop. - Jersyko·talk 19:48, 27 May 2006 (UTC)

Repeated content deletion on Water Fluoridation

Continuing eliminating content related to it borders of vandalism. --Editmore 17:42, 27 May 2006 (UTC)

Yes it does.

At this point, Jersyko doesn't seem to have any interest in editing or following Wikipedia rules that have been pointed out to him, only in wiping out 2/3rds of the article everyone worked on over the last month by numerous authors and trying to get his Strange Love material in.

I would suggest someone attempt mediation but I doubt it will do any good as the article can be modified anonymously. Now looking back over the last year of history, Jersyko has been doing this for quite some time on the page so its no surprise he's continuing.

If someone else has some suggestions, let me know.

--AceLT 21:06, 27 May 2006 (UTC)

Tell you what, I'll file a request for comment and we'll see what the community consensus is on this, ok? - Jersyko·talk 21:27, 27 May 2006 (UTC)

How about mediation?--AceLT 21:31, 27 May 2006 (UTC)

Mediation is later in the dispute resolution process than RFC. You're supposed to exhaust this type of rememdy first before something like Mediation or Arbitration. See Wikipedia:Dispute resolution. - Jersyko·talk 21:34, 27 May 2006 (UTC)

There is no "content deletion" going on here. This whole business about the controversy belongs in the article water fluoridation controversy, and actually most of the information here was taken from that article. This article's topic should remain only on water fluoridation itself, as was discussed much earlier before you began editing this article to emphasize the controversy. - Dozenist talk 22:16, 27 May 2006 (UTC)

RfC (1)

Please, cut the intro down - waaayyy down; as it stands, it is too long by a long stretch. Nobody wants to read an intro this long before they get to the meat. By the time they finish an intro like this they think they've finished the articela and then you see the ToC. See what I mean? Perhaps just one or two sentences that state the practicce is controversial, and then discuss the controversy in the main body further down.Bridesmill 22:23, 27 May 2006 (UTC)

I agree, perhaps something like this is what you're after? - Jersyko·talk 22:35, 27 May 2006 (UTC)

For what its worth, I think the article would look better if the different sections were combined. Thus, instead of arguments for an con, there were just sections such as status of water fluoridation across us and world, health effects, etc.

--Editmore 23:53, 27 May 2006 (UTC)

So you're suggesting to keep all the content but consolidate several of the sections, eliminating some section headings? How does that help the article adhere to Wikipedia:Neutral point of view#Undue weight, exactly? Also, I think Bridesmill has expressed concern about the readability of the article. Consolidating sections is going to hurt readability, not help it. - Jersyko·talk 23:58, 27 May 2006 (UTC)

I think about half of the space in the for and against area could be eliminated if the sections were combined. Having the pro and con has made some of the article duplicative. Other parts of the article seem like rhetoric pro and con instead of simply making a cited statement. Some of these can be taken out.

--Editmore 07:20, 28 May 2006 (UTC)

Also, the controversy is written in detail in the article, water fluoridation controversy. Only a summary is needed here. - Dozenist talk 00:46, 28 May 2006 (UTC)

Editmore Proposal

Here's how I would change the current page

Intro

I would eliminate the third and forth paragraphs. They deal with flouride alone and not water fluoridation. The paragraph about people worried about bottled water is really superfluous. However, if someone really felt strongly about it might be ok although lower down in the article.

History

This area is too long and I don't think people care about the history too much. Nevertheless something should still be there. Paragraphs 2, 3, and 4 look like they were cut and pasted from somewhere else and don't add much and some.

Arguments for and against

This section needs to be reorganized and renamed into sections similar to the following resulting in a significant space saving:

1) Claimed Benefits of water fluoridation

2) Health Concerns of water fluoridation

3) Ethical Concerns of water fluoridation

This will eliminate the back and forth part of the page completely and I would expect half of the space with be saved. This will also allow the page to look like a normal article again.

Status of Water Fluoridation Nationally and Internationally

This section should stay as is. I don't think there is much disagreement about it. However, the latest version has had alot of people wotk to improve the detail of it as well as making it more NPOV.

Acute Poisoning resulting from malfunctions in water fluoridation equipment -This section should remain the same.

Groups Opposing/Advocating Water Fluoridation - This section should remain the same

--Editmore 07:14, 28 May 2006 (UTC)

Intro - I'm glad you agree that it needs to be pared down. However, your proposed deletion would include only three sentences and in no way aid in fixing the undue weight problem, which is extremely disappointing. Upon second glance, I'm not sure I know which paragraphs you're talking about. Do you mean the fifth and sixth paragraphs, beginning with "Concerns among . . ."?
History - I'm in complete disagreement. Your statement that "people don't care about history too much" and proposal to cut out all of the information covering the period between ~1909 and the 1940s doesn't make any sense. Additionally, cutting out information from this section would merely serve to further highlight the controversy, adding to the undue weight problem.
Arguments for and against This section should be eliminated, renamed "controversy" or something similar, and summarized in a paragraph or two with a prominent link to the controversy article. This is the heart of the undue weight problem, and merely cutting its size by half isn't going to fix that.
Status of water fluoridation . . . - This section is also in the version I prefer, under Implementation. You're incorrect that this section is NPOV, as I've already given at least one example of a POV phrase that has been added to it in the last month (there are more). Also, much of the information that has been added is sourced to anti-fluoride websites, which I would prefer not be done per WP:RS.
Acute poisoning resulting from malfunctions .. . I'm ok with this section remaining, provided that it be renamed "Malfunctions in water fluoridation equipment" and that the argumentative language in the section is removed. This is not the place to rehash the anti-fluoridationist argument, but rather to merely state the fact that fluoridation equipment has occassionally malfunctioned, resulting in ill health effects.
Groups opposing/advocating . . . - Right now, it violates undue weight as it makes it appear that there are an equal number of opponents as there are advocates. Also, it merely serves to highlight the controversy, which is also violative of undue weight. It needs to go. A list of opponents could be added to the water fluoridation controversy article. - Jersyko·talk 14:26, 28 May 2006 (UTC)

There are currently 7 paragrphs in the introduction before the table of contents. I think paragrphs 5, 6 and 7 could be eliminated. One paragraph is about toothpaste. Another is about bottled water. Another talks about topical fluoride treatments. I think it is useful to see the groups supporting the groups supporting and opposing water fluoridation in paragraphs 3 and 4. However, since that it mentioned below, perhaps it is redundant.

--Editmore 00:45, 29 May 2006 (UTC)

I think it is useful to see the groups supporting the groups supporting and opposing water fluoridation And I'll go ahead and mention that your proposal, and your preferred version of the article, violates undue weight again. - Jersyko·talk 06:16, 29 May 2006 (UTC)

Yes, I know you believe that. And I have mentioned that your proposal to segregate the information represents a impermissible POV Content Forking WP:POVFORK.

Also,

Please look before you start eliminating links to sources. Some were from primary sources, others were not. Take a little time to differentiate between the two before just cutting out sections. Denzenist had the right idea and did some good work but took out some legitimate links too.

--Editmore 07:01, 29 May 2006 (UTC)

I've already explained, with agreement from Dozenist, that there is no POV fork if the second article presents the controversy objectively and without bias and the second article is necessary to prevent the original article from (1) being overlong and/or (2) violating other Wikipedia policy (like undue weight here). This type of splitting has numerous precedents on Wikipedia, one example can be found here and here. Your argument is a red herring that is merely distracting attention away from the undue weight problem that has still not been addressed here. - Jersyko·talk 15:12, 29 May 2006 (UTC)

To further eliminate POV fork from discussion, this sentence from the guideline is enlightening, and demonstrates that it is not relevant here: "A POV fork is a content fork deliberately created to avoid neutral point of view guidelines, often to avoid or highlight negative or positive viewpoints or facts." Since that is not what the controversy article is doing, but rather the article is objectively describing the controvery and merely presenting the arguments made by each side, the guideline is simply not relevant here, and I trust that it won't be brought up again. - Jersyko·talk 15:23, 29 May 2006 (UTC)

I can't believe all this has been written on the talk pages with almost no editing done at all. Further, it is useless to try to work the issue out if you keep trying to destroy other people's work in the meantime.

I am restoring the prior work done but keeping EamonnPKeane's new additions. Whether they need to be edited in the future is another issue but at least its an attempt to try to have the article have some positive direction in it.

You may not like the WP:POVFORK prohibition in Wikipedia that prevents you from trying to bifricate the article. However, the policy is still valid and we expect that you will abide by it.

--AceLT 20:56, 29 May 2006 (UTC)

Arbitration Proposal for Resolution

OK, this is a waste of time. All I am seeing is Jersyko hitting the reversion button with no attempt at editing. The only real editing attempts have been new people coming along.

Of course, he believes he is right. I think we can at least agree that this process isn't working and there is a difference of opinion on Wiki policy to say the least. It has certainly kept people away at editing the page which is a shame.

One way to resolve this quickly would be to agree on an arbitrator for issue and have everyone agree to the decision. Yes, yes, I know arbitration is a later process. However, it would certainly save time and effort and let the article be able to edited normally again.....for awhile at least.

Any suggestions for an arbitrator? Someone without ties to any of the parties who knows Wiki policy well?

Then anyone who wants to can make a short statement of how they believe they think the article should be structured and cite whatever Wiki policy they think is applicable and supports them.

--AceLT 21:14, 29 May 2006 (UTC)

I've been patient and willing to discuss this on this talk page. I've pointed to applicable Wikipedia policies, and made arguments in response to you guys' red herring attempts to change the issue from undue weight to POV forking. I've received no reply to my points about undue weight because, frankly, there is no reasonable response that can be formulated, as undue weight compels action to be taken to this article that you guys refuse to accept. Now you're talking about arbitration, which is ONLY a last resort option per Wikipedia:Dispute resolution. Arbitration often ends up with some users getting blocked or banned, either entirely or from editing one article or articles about one subject matter. That's why it's a last resort. The Rfc has barely been up for a day, why not give the community more time to comment and for consesus to develop? That's how things work here. I understand there are multiple fairly new users involved in this discussion, who perhaps are not experienced in dealing with Wikipedia policy, and especially how Wikipedia policy mandates discussion of contentious issues. Let me assure you that I've been in much more heated, long, and arduous discussions than this one, and that satisfactory results were reached by the end of each. I expect the same here. I also expect, however, that the unproductive rhetoric about me and others "destroying" work and "vandalizing" this article will stop, and that calls for skipping steps in the dispute resolution process cease. My ONLY concern is for this article to adhere to Wikipedia policy. I have no underhanded motive, bias, or prejudice. If you're so concerned about ending this discussion immediately instead of through discussion, perhaps consider whether you want to be involved in Wikipedia at all, as that is how things work here. I'll end this little speech with a plea for each person involved to, once again, read the neutral point of view policy, focusing on the undue weight section. Thanks. - Jersyko·talk 21:39, 29 May 2006 (UTC)

I am in complete agreement with Jersyko on this matter. As someone who has written almost all the content found in this article as it currently exists, I find your attempts to push for a version that violates neutral point of view, especially the issue of undue weight, and more recently the issue with reliable sources, completely disheartening. Instead of complaining about Jersyko, you should try to address the points he has made and spend time defending your arguments. - Dozenist talk 23:21, 29 May 2006 (UTC)

If I may, Dozenist, to clarify your point that you have "written almost all the content found in this article as it currently exists," this is true merely because a lot of it has been copied and pasted from the water fluoridation controversy article, where the undue weight policy functions differently given the distinct subject matter of the article. Additionally, while I think you're correct that a large majority of the text in this article is text you wrote originally, I'd also like to point out that multiple POV phrases (and rephrasing) have been inserted throughout, though not by you. I just didn't want any third parties that stumbled across this article to get the wrong idea ;). - Jersyko·talk 12:59, 30 May 2006 (UTC)

I agree that the article needs to be edited and I thought some progress was being made. But then I keep seeing someone keep reverting and erasing other people's material. With such actions, it makes it hard believe the discussion is going on in good faith.

No, I not a fan either of pro and con discussion.

As for NPOV, weighting and POV forking, I think everyone has read the articles pretty well and there is certainly a a disagreement over how it is interpreted for different sections.

Some sections have stronger reasons for being there than others. Some of it is redundent or not applicable.

--AceLT 00:35, 31 May 2006 (UTC)

As for NPOV, weighting and POV forking, I think everyone has read the articles pretty well and there is certainly a a disagreement over how it is interpreted for different sections - Actually, I'd love to hear your interpretation of WP:NPOV, reliable sources, undue weight, and WP:POVFORK. Do tell. - Jersyko·talk 01:13, 31 May 2006 (UTC)

Proposed edits

Since I'm a glutton for punishment, my proposed version of the article looks exactly like this, but I would add a small section (similar to but rewritten from the current version) on malfunction of water fluoridation equipment. My explanation for this preference is simple, neutral point of view, undue weight, reliable sources, and Wikipedia is not a soapbox. WP:POVFORK is not relevant to this article. As it stands, content is duplicated between this article and water fluoridation controversy. The controversy article was created, in part, so that excessive attention is not paid to the controversy in this article, thereby causing this article to violate undue weight by devoting a majority of its text to the controversy and the minority anti-fluoridation view. Presenting the anti-fluoridation and pro-fluoridation views equally in this article violates undue weight. Additionally, presenting and explaining the controversy fully, even if the arguments are appropriately weighted for scientific acceptance, in this article is violative of undue weight as it would require this article to spend a majority of its text on the controversy, which merely serves to highlight the controversy and give it undue weight. As the subject matter of the water fluoridation controversy article is distinct from the subject matter of this article, undue weight functions differently there. WP:POVFORK does not preempt the existence of the controversy article as it was not created or maintained (though it needs to be tweaked) for the purpose of avoiding or circumventing the neutral point of view policy, but rather is an article on a subject distinct from the subject matter of this article, the controversy surrounding fluoridation instead of fluoridation itself. I'm writing this so that my thoughts on this article will be absolutely clear. I've referenced relevant Wikipedia policy, as I've been doing all along on this talk page, which I again recommend that all participants in this discussion read thoroughly and absorb. Thanks. - Jersyko·talk 13:17, 30 May 2006 (UTC)

I have read your proposal. However, I don't see that it is much different froma old reverted version a month or so again you had. It does have an extra section.

However, it eliminated much of the material concerning the status of water fluoridation around the world that many people worked on and it has a number of POV statements that were changed to NPOV earlier. Then instead of the improved articles and information, you try to put in Dr. Strangeove to characterize the opponents to fluoridation. I don't see that is an accurate portrayal of them.

Finally it tries to use the title "implementation" instead of NPOV status.

I think we are aways away from resolution.

--AceLT 00:43, 31 May 2006 (UTC)

I respond merely to point out that my point in re undue weight is still unaddressed, in favor of minor quibbles over Dr. Strangelove and section title names. We can re-add the removed material that is NPOV in the implementation/countries section, though I'm afraid a lot of it is not. The main purpose of my proposal, however, and the one that is seemingly being ignored in favor of the minor quibbles I've noted, is that the controversy needs to be excised from this article for the most part. - Jersyko·talk 01:10, 31 May 2006 (UTC)

A side question: why is "Implementation" POV and "Status of Water Fluoridation Nationally and Internationally" NPOV? I know, I'm biting on the red herring, but it seems such a unique point that I had to . . . - Jersyko·talk 01:28, 31 May 2006 (UTC)

Observations

I don't want to dig into the content specifics but I would like to make some points based on my experience with the content policies and what that means for this article. This article is about water fluoridation, thus it should evenly survey all of the facets of that subject and not give undue weight to any one subtopic as Jersyko points out. The controversy is such a subtopic and should not be given undo prominence. Having a more detailed article on the controversy is not a POV fork as long as that article treats the controversy in an NPOV way. Instead, that is exactly the way it should be handled to cover more detail on a subtopic per WP summary style. More specifically, the lead is still too long. Per WP:LEAD it should be at most four paragraphs, but not huge ones either. Also, the structure separating pro and con arguments in different sections is a cop out, sorry. Instead, the article should address all of the facets of the topic in turn. I don't know the subject in detail to know what those are, but an article outline should be agreed upon for what are the most important facets of the topic and those should be how the article is sectioned. I won't judge the reversions and edits specifically (it may be that Jersyko or others are being unfair) but I will note AceLT and Editmore are not arguing on point at times. - Taxman ^Talk 11:34, 31 May 2006 (UTC)

Intro Discussion

Ok. Now I going to see if anyone agrees on anything other than they like to rever Someone tell me their response to this narrow issue on the intro which I posted earlier:

There are currently 7 paragrphs in the introduction before the table of contents. I think paragrphs 5, 6 and 7 could be eliminated. One paragraph is about toothpaste. Another is about bottled water. Another talks about topical fluoride treatments. I think it is useful to see the groups supporting the groups supporting and opposing water fluoridation in paragraphs 3 and 4. However, since that it mentioned below, perhaps it is redundant.

Agree? In part? in nothing?

--Editmore 07:52, 31 May 2006 (UTC)

Oh well. It could be worse. Someone could start using all CAPS.

--Editmore 07:52, 31 May 2006 (UTC)

I've edited down the intro per (1) undue weight, (2) the connected guidelines of reliable sources, no original research and WP:CITE, and (3) Taxman's, my, Bridesmill's, Dozenist's, and (at least in part) Editmore's agreement that it was too darn long.
Regarding the rest of the article, I'm flexible in that I'm not married to the exact text of my proposal above, but I would like the edited article to comply with relevant policies and guidelines and my response to Editmore's proposal. - Jersyko·talk 13:41, 31 May 2006 (UTC)

I like what you have done with the introduction. This is a much more acceptable version. Once everyone involved in this lively debate subscribes to the Assume Good Faith policy, some real progress can be made to get this article back on the right track. Thanks for your diligent commitment. --Sk8ski 14:09, 31 May 2006 (UTC)

I also appreciate the work you have been doing to improve the quality of the article and to change the content in order to make it adhere to wikipedia policy. Editing can get difficult at times, but your diligence is appreciated. - Dozenist talk 15:53, 31 May 2006 (UTC)

Editmore has reverted the changes I made to the intro, despite growing consensus that the edited version is superior to the version Editmore prefers (even Editmore admits that the intro is too bulky in that version). It seems that Bridesmill, Dozenist, Taxman, myself, and Sk8ski all agree that the intro needs to be drastically cut down, and some of those users have even expressed agreement with the edited version. Editmore, you say in your reversion edit summary "Can a version be worked out?", yes, it can, and it's the one I edited in yesterday. Consensus is important on Wikipedia. Let's let other editors comment on the edited version of the intro to see what they think, but that means it has to be in the article first. I have no doubt, based on initial comments and because it adheres to Wikipedia policy, that consensus will continue to develop in favor of the edited version. I see no basis behind the reversion. - Jersyko·talk 13:13, 1 June 2006 (UTC)

Some of Editmore were ok but Stange Love and bottled water should not have been in.

--AceLT 00:07, 2 June 2006 (UTC)

Take a look at other pages. The Dr. Strangelove reference could still be mentioned in the article as a reference at the bottom.

As for consensus, Jersyko wiped out a month worth of editing by around a dozen people who had a growing consensus of what the page looked like. If he had simply tried to improve the page, we wouldn't be where we are now.

--Editmore 00:45, 2 June 2006 (UTC)

Removed and took away different sections in into.

--Editmore 00:49, 2 June 2006 (UTC)

Editmore: you left 3 out of the 4 paragraphs in the intro to discuss controversy-related topics. As has been explained over and over and over, this is a blatant violation of undue weight, no way to slice it. Cutting out the information you choose to excise from the intro is making the undue weight problem worse, not better (though it does help the length problem, but "short length" isn't Wikipedia policy, undue weight is), as it leaves the intro with a higher percentage of controversy-related subject matter. It's becomming difficult to assume good faith here when you blatantly edit to violate policy that I've done my best to pound at you guys. Additionally, there is developing consensus in favor of the version of the intro I have posted. Stop saying I've "wiped out", "destroyed", or "vandalized" a "month's worth of editing." If this continues, I'll report it as a persistent pattern of assuming bad faith. Finally, your claim that the relevant edits were made in the last month by "about a dozen people" is a flat-out lie, as anyone that has the ability to read English and click on the article history button can see that you and AceLT made nearly every policy-violating edit to this article over the last month, not "a dozen people."

AceLT: your misleading edit summary, saying that you merely "removed Strange Love [sic]," when you in fact reverted every change I made to the intro, demonstrates bad faith on your part. I suggest not being misleading again. - Jersyko·talk 03:43, 2 June 2006 (UTC)

The edits are clear from the history. I do not believe Strange Love is appropriate as it tries to characterize the criticisms as communist conspiracies. Retained other changes by others I saw.

--AceLT 00:18, 3 June 2006 (UTC)

Yes, the edits are clear from the history. The history makes perfectly clear that, for the second time in a row, you have reverted all of my changes to the intro with a misleading edit summary.
Also, Strangelove is important because it's an instantly recognizable pop culture reference to water fluoridation (and the only one I'm aware of), thus it deserves to be mentioned in this article. As it's a film, a work of fiction, and because there's an article on it which is linked in this article, there's no danger of violating Wikipedia policy by doing something as innocuous as merely mentioning the context of Strangelove's depiction of fluoridation in this article. - Jersyko·talk 06:21, 3 June 2006 (UTC)

I do not believe Strange Love is appropriate as it tries to characterize the criticisms as communist conspiracies.

Yes, your right, it was written like that earlier. However, I think it has been edited some to make it more neutral. It probably needs more editing and needs to be in a pop note at the end of the article. Also, the fact is that it is part of a film. Take a look at other articles for example of such (pop) references.

--Editmore 07:21, 5 June 2006 (UTC)

Strangelove certainly belongs somewhere, likely not in the introduction though. I ratehr like sidebars or boxouts for that sort of thing, but that is uncommon in WP. This is topic which tends to attract enormous apathy, and a few a very few very strong views of religious intensity. The latter deserve coverage, otherwise readers might be left surprised, but proportionate coverage is not very much. Midgley 16:23, 7 June 2006 (UTC)

Another view (responding to the RfC)

The beginning of the article as it stands now is quite informative, at least up through the history section. The international status section looks like the scarred earth of a long edit war. Maybe replace it with someting simple and NPOV, like a paragraph or two or a chart explaining where it's used, rather than going into details with phrases like "Germany has consistently rejected...", etc.

Particularly since there is a separate article on the controversey (which I haven't read yet), perhaps that entire section (from the end of history to the beginning of see also) might be better left out of this article and discussed there? This would leave behind a good solid article and bring an end to what looks to me like an excersize in trench warfare. SB Johnny 01:07, 29 June 2006 (UTC)

Thanks for your response. Based on your response, I'm glad you didn't see this version of the article. I started working on the International status section just a bit this morning, and hope to pare it down considerably as I attempt to make it NPOV at the same time. In fact, there is a version of the same section, with a different title ("Implementation"), in an older version of the article that I think might be a good guide for what this section should look like. Anyway, let me know if you disagree, and thanks again for responding. · j·e·r·s·y·k·o talk · 01:24, 29 June 2006 (UTC)

My thoughts, looking at the current version, are in like with SB Johnny's, even though I'm looking at a version a month later than he was. Here's what I would suggest for the entire section:

Cut the U.S. section to one sentence: 67% of Americans are living in communities with fluoridated water according to a 2002 study.[15] Canada, one sentence: Approximately 40% of the Canadian population receives fluoridated water[20] Europe gets 4 sentences: Most of Europe does not fluoridate their water supply. The Republic of Ireland is the only EU nation to have mandatory fluoridation. In the United Kingdom, only two major cities, Birmingham and Newcastle, fluoridate their water supply.[24] Several nations, including France and Germany, have nation-wide bans on fluoridation. "Other" gets a few sentences too: In Brazil, about 45% of the cities have a fluoridated water supply. Australia has fluoridation in all but one state, Queensland, in which water fluoridation is under local government control. The government of South Africa supports the fluoridation of water supplies.[25] can stay IFF "supports" means "does it"; otherwise, like the rest of the section, it's irrelevant.

The rest of the International Status, with one exception, can be cut entirely from the article. If it's really that important, that's what the "controversy" article is for, otherwise, a city voting to suspend its fluoridation program and then reinstituting it is irrelevant trivia.

The one exception is "The cost of fluoridating water supplies in the United States has been researched.[19] In cities with a population of over 50,000 people, fluoridation costs 31 cents per person per year. The cost rises to $2.12 per person in cities with a population below 10,000." Move that to the intro, since it's technical information; or, better yet, put together a whole section regarding technical information on water fluoridation. The Literate Engineer 20:55, 26 July 2006 (UTC)

Children vs. adults

Does fluoridation help adult teeth, or only children? -- Beland 02:13, 9 August 2006 (UTC)

Horrible POV in this article

Wow, came to this page looking for chemical formulas relating to how flouride is effective in water, leaving scared to drink water and brush my teeth. I think there might be a little too much focus on what (I believe at least) to be a minority view among scientists and health professionals. Kinda reminds me of the Aluminium link to Alzheimer's link (which I thought had been debunked but still appears on Al(OH)3 page... hmmm...) (notregistered) —Preceding unsigned comment added by 131.170.90.2 (talk) 05:04, 29 May 2008 (UTC)

Very clearly, some biased editing has occured in this article to make it read like a ADA pro-fluoridation pamphlet. I have made some edits to remove this.--Fahrenheit451 10:56, 19 September 2006 (UTC)

How about some good faith, please? You removed very few words. Obviously, it wasn't THAT bad. · j e r s y k o talk · 13:40, 19 September 2006 (UTC)

I think if you check the definition of good faith, you will find it applies to the manner of dealing with other editors, although you may hold your own connotations of the term. I have every right to criticize POV editing and will boldly edit to contribute to a NPOV article. This one was flagrantly POV.--Fahrenheit451 21:12, 19 September 2006 (UTC)

Well, I agree with you that there were some POV phrases in the article. I suppose I merely disagree with your characterization of the article as "flagrantly POV" etc. I suppose I'll leave it at that. · j e r s y k o talk · 21:21, 19 September 2006 (UTC)

New Minor Edits

The american dental association is not a pro fluoridation group as such, as this is not their sole purpose (fluoridation) , they do however have a pro fluoridation stance, and have as such produced many pro fluoridation publications. The ADA has also been converted to a link so that information about the ADA stances can be entered there(Bouncingmolar 10:12, 9 February 2007 (UTC))

Australasia is overdue to be put on the map (Bouncingmolar 10:22, 9 February 2007 (UTC))

If I was naive, I would think that public health policies in the US and Ireland are either hopelessly behind times; or else this is one small but significant way that their respective conservative policy-makers have gone collectivist. I think it is simply amazing that "socialist" Europe has MOSTLY rejected water fluoridation, yet the overwhelming consensus of establishment experts in mega-capitalist, hyper-individualist "America" (the US) seem to hold on to this one piece of forced (collectivized) treatment (additive, benefit, medication, drugging, depending on your POV) of public water supplies as if it were sacrosanct. Yes, it is true that right-wing crazies in the 1950s and 60s thought fluoridation was a Commie plot, but now, even Ralph Nader opposes it. Everyone knows that big money is what determines government policy in the US; forcibly fluoridating everyone just to help those too poor, uneducated, undisciplined, or apathetic to get proper dental care may sound noble, but it's giving way too much credit to the powers-that-be and serves only to distract attention away from the real reason: convenient disposal of toxic waste, where citizens are forced to both pay for it and ingest it. Having only a majority, consensus, or authorized (official/ADA-approved) view is just as political as having one endorsed by Greenpeace or the John Birch Society. —The preceding unsigned comment was added by 12.40.34.150 (talk • contribs).

Exactly. And that's without even venturing in to the reports which indicate fluoride was originally added to the drinking water as a means of disposing of it! --AeronM (talk) 18:30, 28 February 2008 (UTC)

For the record, Europe, who has "rejected" water fluoridation, has embraced salt fluoridation and school-based fluoride rinses. - Dozenist talk 23:38, 23 February 2007 (UTC)

Bullcrap, where is the evidence for that statement?--Fahrenheit451 21:20, 4 June 2007 (UTC)

Try this. Please be civil. · jersyko talk 21:26, 4 June 2007 (UTC)

You be civil. You did not cite your friend Dozenist's statement. I see that you and he are buddies.--Fahrenheit451 21:59, 4 June 2007 (UTC)

I didn't directly cite it. But given that this is a talk page, I don't have to. Neither does he, actually. In that link I posted, however, are several studies (including undoubtedly reliable sources) of widespread salt fluoridation in Europe. But most importantly, it doesn't matter because this is a talk page and Dozenist doesn't have to cite his statements on a talk page. Yes, Dozenist and I are friends in real life. I helped him copyedit his featured articles. What's your point? · jersyko talk 22:08, 4 June 2007 (UTC)

Correct in that you don't have to cite anything on a discussion page. However, it can make discussions more productive and avoid disputes. I think you got my point. You and Dozenist are buddies. Thanks.--Fahrenheit451 23:41, 4 June 2007 (UTC)

Or you could assume good faith when someone knowledgeable makes such a statement on a talk page. Nevertheless, there is clearly an abundance of sources, so I'm not sure what you're getting at in continuing this conversation. · jersyko talk 23:47, 4 June 2007 (UTC)

Filters to remove fluoride

Some people have fluoridated tap water, but wish to avoid drinking systemic fluoride. Brita and other popular filters do NOT remove fluoride. The only options seem to be selected bottled water, or installing an expensive reverse osmosis system. "How to Remove Fluoride from Drinking Water" [1]

"Does BRITA reduce / remove fluoride ?
The BRITA Water Filter System does not remove fluoride from tap water. Fluoride is a negatively charged ion and does not react with the components of the BRITA Filter Cartridge." [2] -69.87.200.99 19:11, 3 May 2007 (UTC)

Concers with sources

I'm concerned with this series of edits, given that several of the sources cited are contained at anti-fluoridation websites. Their status as reliable sources is questionable. I am re-adding the cleanup tag that was removed adding an {{unreliable}} tag to the section. · jersyko talk 03:49, 26 August 2007 (UTC)

Jersyko, I'm concerned that you are pushing your pro-fluoridation POV here. Please explain why the web sites that I cited violate WP:RS. Specifically, the web site of the British Parliament, the Journal of American Physicians and Surgeons, Nature, and Fluoride Journal. If you cannot show that these sites are not reliable sources, then I remove the tag. You have 24 hours. --Fahrenheit451 04:07, 26 August 2007 (UTC)

You shouldn't be concerned that I'm pushing a pro-fluoridation POV, as I have not edited the article to remove the sources. Rather, I am merely attempting to begin a discussion regarding whether the sources that have been used are reliable.

On that point, here's an extremely relevant portion of the reliable sources policy, "Articles should rely on reliable, third-party published sources with a reputation for fact-checking and accuracy." I suppose we can discuss whether specific single-issue advocacy organizations that are opposed to fluoridation have or do not have such a reputation, but that's almost beside the point. Why? Because of the very fact that they are single-issue advocacy organizations.

Additionally, the reliable sources guideline states, "[i]n general, an article should use the most reliable and appropriate published sources to cover all majority and significant-minority published views . . . ." Thus, assuming, arguendo, that the anti-fluoridation websites can be found to be somehow reliable, surely they are not the most reliable and appropriate sources. Rather, news reports about the specific countries, reports in a peer-reviewed journal of general renown, or other such source that is not affiliated with an advocacy organization would be the most reliable and appropriate sources. Then again, this second hurdle is only reached if the first one is cleared, and I cannot see how it can be, though I'm certainly willing to hear the counterargument. · jersyko talk 04:24, 26 August 2007 (UTC)

One more point: I do not mean to question the reliability all of the sources you have used. Rather, only those sources that are related to or hosted by advocacy groups. I have amended my original statement as such. · jersyko talk 04:31, 26 August 2007 (UTC)

Jersyko, I will repeat myself once again: Please explain why the web sites that I cited violate WP:RS. Specifically, the web site of the British Parliament, the Journal of American Physicians and Surgeons, Nature, and Fluoride Journal. If you cannot show that these sites are not reliable sources, then I remove the tag. You have 24 hours.--Fahrenheit451 04:35, 26 August 2007 (UTC)

Your ultimatums are not going to foster debate, nor are they based on any Wikipedia policy. In fact, they likely violate WP:CONSENSUS. I have explained myself clearly; do you deny that some of the websites you have cited and claim to be reliable sources, for example, fluoridation.com, flouride-journal.com, and, yes, even the Journal of American Physicians and Surgeons, are either related to or are, explicitly, advocacy organizations? · jersyko talk 04:40, 26 August 2007 (UTC)

Your wikilawyering is not going to foster debate, nor is it based on any Wikipedia policy. In fact, it violates WP:RS and WP:V. If you refuse to answer my question, our discussion terminates right here and now.--Fahrenheit451 04:46, 26 August 2007 (UTC)

You don't have to continue discussing, but I'm not sure why you believe you can somehow terminate all discussion on point. In any event, you act as if I must prove that the sources are unreliable. No, actually, you must prove they are reliable. · jersyko talk 05:00, 26 August 2007 (UTC)

Jersyko, you take your own medicine and prove that every one of YOUR edits comes from a reliable source. It looks to me that we will need another RfC here for you. --Fahrenheit451 05:10, 26 August 2007 (UTC)

If you want to address other sections of the article or other issues, I suggest starting a new subsection on this talk page. This one is about whether specific sources added to the article are reliable. I take it that you are not interested in demonstrating that your sources are reliable. Thus, yes, I will start a new RfC to see if anyone else has an opinion. · jersyko talk 13:14, 26 August 2007 (UTC)

I am also concerned about using the fluordiation websites as a source. Some of the material seems to be clearly out of context. For example, it lists a letter stating that Austria does not allow toxic fluorides in its water, but no nation does. Austria DOES, however, add non-toxic fluorides within its water supply. In fact, it has even conducted studies to demonstrate which levels are adequate, as seen here. Djma12 ^(talk) 17:03, 26 August 2007 (UTC)

RfC

"The series of edits" refers to this. MessedRocker (talk) 02:10, 13 September 2007 (UTC)

1. Who must demonstrate the reliability or unreliability of sources, the editor adding the material with the sources or the editor challenging the material with the sources?
2. Are the sources included with this series of edits reliable sources? Material cited to the following sources has been specifically challenged: Journal of American Physicians and Surgeons [3], fluoridation.com, fluoride-journal.com. 08:27, August 26, 2007

ad 1) I am not really good about WP policies.

ad 2) A complicated series of questions. I would not regard a parliamentary site as an authority on scientific issues, but it would be a very authoritative source on legislative issues. (I am not in the mood to check what exactly the reference is supposed to show.) With Nature, it is the other way around. Again, it is important to see what the reference is supposed to show. And is this a research paper, a review paper, or an editorial opinion? It all depends. Websites with material that is not published in print are generally not authoritative. /Pieter Kuiper 13:47, 26 August 2007 (UTC)

I would accept anything in Nature. Publications of the the UK parliament should be good. The Journal of American Physicians and Surgeons sounds partisan, and if the same information could be found elsewhere, it would be good. However the facts cited to that journal don't appear very controversial. Are they likely to give the wrong answer to the question whether a country fluoridates their water or not? On a medical or scientific issue I'd be more careful. EdJohnston 16:05, 26 August 2007 (UTC)

• Concerning question 1, per WP:V, "The burden of evidence lies with the editor who adds or restores material".
• Concerning question 2, again per WP:V, "Articles should rely on reliable, third-party published sources with a reputation for fact-checking and accuracy." Neither the Journal of American Physicians and Surgeons or the fluoride websites would meet this criteria. HOWEVER, as EdJohnston pointed out, the statements about which nations use fluoridation should be widely available in neutral sources. If these sources can be found, there should be no reason to exclude these comments. Djma12 ^(talk) 16:53, 26 August 2007 (UTC)

• Note: I have removed statements based upon the Jour APS and the fluoride website b/c they do not meet WP:V standards for "reliable, third party" sources, and b/c some of the statements are blantaly out of context. (See above comment on Austria.) The parlimentary sources are only admissable if the relevant parlimentarians cited which sources they used during debate, as opposed to merely mentioning in passing. (See WP:V for primary vs secondary vs tertiary evidence.) However, if the relevant editors can find reputable sources for these statements (and they should be easily available from third party sources, fluoride websites do not count), then these can easily go back in. Djma12 ^(talk) 17:20, 26 August 2007 (UTC)
  • In the interest of consensus building, I will note that I agree with everything Djma12 said. Other, reliable, third-party sources regarding the status of water fluoridation in these countries would be great. · jersyko talk 18:21, 26 August 2007 (UTC)

• Consensus building is NOT the relevant point here, but rather WP:V and WP:RS, please do not attempt to misdirect this thread, Jersyko.--Fahrenheit451 02:45, 27 August 2007 (UTC)
  • Consensus building is always "the point". · jersyko talk 03:54, 27 August 2007 (UTC)

I'm going to throw my hat in with Djma12. As per concensus, the whole point is to have concensus *about* whether we're meeting the standards, such as WP:V and WP:RS -- Rei 17:08, 29 August 2007 (UTC)

External links

I noticed the recent edit war over the inclusion/exclusion of a series of 3 external links in this article. The rationale for excluding the links appears to be that they are "links to be avoided" under WP:EL in that they contain "factually inaccurate material or unverifiable research" and that the links violate WP:EL#Avoid_undue_weight_on_particular_points_of_view). On the other hand, the argument for keeping the links appears to be based on WP:NPOV.

In any event, I took a brief look at one of the websites linked. Two of the more prominent claims made there are that water fluoridation causes brain toxicity and cancer. I leave it up to the community and persons better versed in the science to determine whether claims like these disqualify these links from inclusion here. · jersyko talk 03:49, 29 August 2007 (UTC)

• There are legitimate concerns about fluoridation and I have no problem including them if they are cited from peer-reviewed medical journals. Notice that this website is merely citing editorials, lawsuits, and in one instance, itself. Djma12 ^(talk) 00:21, 30 August 2007 (UTC)

Those links look like they would provide good source material for what the anti-fluoridation camp says on the subject. In other words, they would be an excellent resource for Water fluoridation controversy. But that does not mean they are relevant to this article. Sheffield Steel^talkers_stalkers 15:40, 6 September 2007 (UTC)

Please see WP:GFCA, specifically the section "Decsribe The Controversy," which clearly applies here. --AeronM (talk) 18:34, 28 February 2008 (UTC)

Removed from first paragraph

The adoption of fluoridated water was spearheaded by Edward Bernays.

• This material is unsourced. Following the wikilink, we read that Edward Bernays was some sort of PR whizz (not doctor, dentist, nutritionist, etc.), and that one of his many campaigns was on behalf of some fluoridation group... a claim which is also unsourced. WP:V requires that material be verified.
• There is no documentation saying that Bernays' efforts actually had any effect on water fluoridation. Before credit can be given for this man's contribution, it must be shown to be a notable contribution per WP:N.
• This material is not documented in the body of the article. WP:LEAD says that the article lead should provide a concise summary of the contents of the article.

I hope this adequately explains why I've removed the material. Sheffield Steel^talk_stalk 21:10, 13 September 2007 (UTC)

More than adequately. I agree. · jersyko talk 21:20, 13 September 2007 (UTC)

Controversy and summary style

The #opposition subsection of this article is presented in summary style. The information recently added to the article, whether sourced or not, is appropriate in the controversy article but not this one. Why? Because this subsection is merely meant to be a very short summary of the controversy article and is not meant for details, which can be found in the main article. That's how summary style works. Actually, I'm not even sure that the information is even contained in the main article, making its inclusion in this short summary here all the more inappropriate.

Additionally, expanding the controversy/opposition section in this article, especially by including entirely anti-fluoridation information as the recently added paragraph contains, violates WP:UNDUE. This article must be more scientifically based than the controversy article, which is more about arguments and allegations than science (though it obviously does discuss the science). The new paragraph alleges that fluoride contains arsenic and causes cancer (with no citation). Actually, it doesn't "allege" any of that, it simply flatly states it as truth. Thus, even in the controversy article, this would be removable as presented as violating WP:NPOV. · jersyko talk 00:11, 28 September 2007 (UTC)

I see that the arsenic/cancer claim has now been sourced. I see no connection to fluoridation in the source, however. In any event, each of my concerns still stands, as the paragraph warrants removal from this article and possibly addition to the controversy article after a rewrite no matter how many sources are added. · jersyko talk 00:15, 28 September 2007 (UTC)

Jersyko, it seems that you keep hawking WP:UNDUE whenever an editor adds material or citations to an edit that go counter to your POV. Also, you comment while I was editing. Does it bother you that I add citations to an edit you don't like?--Fahrenheit451 00:19, 28 September 2007 (UTC)

Rather than commenting on the trends of my comments on talk pages or what or what does not bother me, do you care to respond, substantively, to my arguments? · jersyko talk 00:25, 28 September 2007 (UTC)

I see little substance to this particular argument of yours. The citations were very easy to find. I don't understand why you did not look for those yourself and simply add them.--Fahrenheit451 00:44, 28 September 2007 (UTC)

Agreed, citations are easy to find. However, you do not address my summary style, undue weight, or NPOV points. · jersyko talk 00:45, 28 September 2007 (UTC)

Because I see no NPOV violations in it. Undue weight, according to who? Summary style can be corrected with a little editing.--Fahrenheit451 00:52, 28 September 2007 (UTC)

Rfc

• My reasoning for removing the paragraph is contained in my comments in the subsection above. In sum, summary style, WP:NPOV, and WP:UNDUE support including only a very brief, one paragraph, neutral description of the controversy in this article, whereas the new addition is rather weighted against fluoridation and would be much more appropriate in the water fluoridation controversy article. · jersyko talk 00:36, 28 September 2007 (UTC)

• Substantial additions relating to the controversy should be made to the "controversy" article and discussed on its Talk page. Once an addition has gained consensus there, and is stable, it should be summarised in this article. Otherwise we run the risk of creating a POV fork of the "controversy" article. Sheffield Steel^talk_stalk 13:15, 28 September 2007 (UTC)

• Supporting Sheffield Steel's comment and adding the following observations and suggestions: This might be a symptom of 'blow-back' . Because...
  

There is a lot of this article's substance, 'forking' over into the other - hence the psycho-social phenomena of blow-back to readdress the balance. (Therefore, remove from the other article: those things that belong here – and what belongs there, may then - stop bleeding through into here) . Further Comment: Some months ago I came across these two articles and saw that some editors appear to be quite unaware that Policy formulation and implementations and scientific enquiry and advancement are different fields of human endeavour (one doesn't have to sit on many committees before feeling like you want to get them all in one big room and bang their heads together; but cross-organisational co-operations like that is so, very, very, rare). The lack of differentiation thus - it seems – to have lead to both articles appearing to be over dependant on Begging the Question . This leads to edit wars (as is quite plainly evident), as arguments from different premises can never be resolved.--Aspro 16:02, 2 October 2007 (UTC)

More problematic recent edits

Can anyone make a cogent case that this series of recent edits conforms to NPOV, RS, UNDUE etc.? I have absolutely no interest in continuing to edit war at this article, so I merely tagged it with {{POV}}. The additions not only are completely biased toward the anti-fluoridation position, but they also make the introduction entirely too long per the manual of style. It should all go, I see little salvageable information. Besides, nearly all of it is already contained, in substance, at water fluoridation controversy. · jersyko talk 19:53, 3 October 2007 (UTC)

BMJ

The British Medical Journal has published this article: doi:10.1136/bmj.39318.562951.BE JFW | T@lk 17:21, 8 October 2007 (UTC)

Unsubstantiated, unsourced statements without a NPOV

I removed the following:

"Water fluoridation has provoked controversy, although opponents of fluoridation have not assembled as a majority in the scientific community. Whether for health concerns, or for concerns of consent, or because their people are receiving fluoride through other means, some governments have ceased or decided not to start fluoridating their water. However, no country has discontinued or refused to adopt fluoridation simply because it was proven harmful in any way."

When all 11 unions representing over 7000 EPA employees have called for a moratorium on water fluoridation due to cancer concerns, I don't think it can be reasonably stated there's not a majority in the scientific community. I'm not saying there is, just that it can't be stated that there's not:

Associated Press Wednesday 31 August 2005

EPA unions call for moratorium on fluoride in drinking water

By Mathew Daly Associated Press Writer

WASHINGTON --Eleven unions representing more than 7,000 workers at the Environmental Protection Agency are calling for a national moratorium on programs to add fluoride to drinking water, citing what they call a possible cancer risk...

http://www.fluoridealert.org/news/2378.html

And it's also incorrect to say that "no country has discontinued or refused to adopt fluoridation simply because it was proven harmful in any way." Letters from the Japanese and Austrian governments dispute this, as does a Netherlands study:

"Japanese government and local water suppliers have considered there is no need to supply fluoridated water to ALL users because 1) impacts of fluoridated water on human health depends on each human being so that inappropriate application may cause health problems of vulnerable people..."

http://www.fluoridation.com/c-japan.htm

"...referring to your letter dated 5.2.2000 we allow us to inform you that toxic fluorides have never been added to the public water supplies in Austria."

http://www.fluoridation.com/c-austria.htm

The Netherlands banned fluoridation after a group of medical practitioners presented evidence that it caused reversible neuromuscular and gastrointestinal harm to some individuals in the population. (Grimbergen, GW. "A double blind test for determination of intolerance to fluoridated water". Fluoride 7 146-152 1974)

[edit] I moved "controversy" beneath "history" since the controversial aspect of water fluoridation is perhaps the paramount issue.

Also, I don't want to be accused of having a POV and I haven't edited anything under the "History" sub-heading, but I noticed the only studies cited which were all pro-fluoridation are the earliest ones from the 1930s and 40s. Is the contributor aware that other more recent studies conducted in NY state (a 50-year study) and Canada (between Toronto and Vancouver, B.C.) show either a slight or non-existent correlation between water fluoridation and dental caries? Is he also aware that the largest and most comprehensive study of over 39,000 school children conducted by the National Institute of Dental Research in 1986-87 concluded that there are no significant differences among caries incidences between the fluorodated and non-fluorodated communities? (except for a doubling of dental fluorosis in the fluoridated communities.) Without mentioning these much more comprehensive and recent studies, can this article truly be considered unbiased and NPOV?

Agree 100%. --AeronM (talk) 14:18, 6 March 2008 (UTC)

New source: Scientific America reports risks for flouoride (Reuters story)

• 'Second Thoughts about Fluoride,' Reports Scientific American Jan 2, 2008

"Some recent studies suggest that over-consumption of fluoride can raise the risks of disorders affecting teeth, bones, the brain and the thyroid gland," reports Scientific American editors (January 2008). "Scientific attitudes toward fluoridation may be starting to shift," writes author Dan Fagin.

I'll come back and take a look....not feeling well right now, but thought this would be an interesting reference for the article. TableManners^C·U·T 04:09, 17 January 2008 (UTC)

The item linked to above shows a pretty biased POV. The SciAm article itself could be interesting. I'll buy a copy tomorrow. Franamax (talk) 04:25, 17 January 2008 (UTC)

The bias of the source does not matter, only the reliablility, from what I understand. See WP:V. The threshold for inclusion in Wikipedia is verifiability, not truth. TableManners^C·U·T 15:50, 18 January 2008 (UTC)

Agreed and it the RS aspect I'm commenting on as regards the link above. It is released on PRNewswire and is a press release from an advocacy group. The Scientific American article itself, however, meets both RS and V. I have it now, it is quite interesting and well worth a read, Franamax (talk) 19:16, 18 January 2008 (UTC)

Specifically, how does fluoride help teeth?

I find it remarkable that in an encyclopaedia entry on water fluoridation it doesn't say how the fluoride actually helps teeth. Am i to presume that it is not known? If so, how anyone can justify adding it to water is beyond me. Tremello22 (talk) 20:48, 2 February 2008 (UTC)

The topic of whether or not fuoride is beneficial to humans is the subject of a great debate currently. In accordance with WP:NPOV and WP:GFCA, both sides of the controversy should be described in the article. --AeronM (talk) 18:40, 28 February 2008 (UTC)

This page seems to have the answers. I think it would enhance the article if we used some of it. Tremello22 (talk) 21:06, 2 February 2008 (UTC)

There is a link already in "See also" to Fluoride therapy which discusses the topic more thoroughly. This article is specifically about the issue of adding fluoride compunds to drinking water. Franamax (talk) 01:10, 3 February 2008 (UTC)

And for the record, the link you mention above comes from The Fluoride Debate website, an anti-fluoridation website. It would certainly not be considered a reliable source. From the homepage of The Fluoride Debate: "We believe that if people take the time to read and study both sides of the fluoridation debate — especially the science that has emerged over the last ten years — they will be appalled by the practice of putting this known toxic substance into the public drinking water." Better references than this website would be needed. - Dozenist talk 04:47, 3 February 2008 (UTC)

it is a reliable source, if you read it you would see it provides links to reliable sources within the article. This is the same for most anti-fluoride websites - there is a reason people are anti -it. It is not just for the sake of it. Tremello22 (talk) 15:09, 4 February 2008 (UTC)

It is not a reliable source. It is an advocacy website, an issue site. Generally (though there are exceptions), advocacy websites are not reliable sources for scientific facts. · jersyko talk 01:54, 5 February 2008 (UTC)

How can you say it isn't a reliable source when it quotes the research done by Canadian Medical Association Journal,University of Chicago,Journal of the American Medical Association, other numerous studies and testimonies from respected doctors? Answer:you can't. Tremello22 (talk) 13:00, 5 February 2008 (UTC)

The sources you are cite above may be reliable sources. I don't know. However, the question is whether the fluoride debate website is a reliable source. No matter what third party sources it may cite, it will never be a reliable source for scientific fact. Thanks. · jersyko talk 21:59, 5 February 2008 (UTC)

With regards to the initial question, here's an article from 2000 from the International Dental Journal.

• Role of Fluoride in Oral Health Promotion 2000

"It is now understood that the primary mode of action of fluoride in reducig dental caries is post-eruptive (topical), in that it promotes remineralisation, and inhibits demineralisation of dental enamel during the caries process."

It goes into a bit more detail which I won't list here. PatrickRBC (talk) 11:58, 6 March 2008 (UTC)

Controversy section

I've reworded the Controversy section and added some sources here. This is primarily based on the Scientific American article of Jan08 which I consider to be a RSS, I have included some primary sources to flesh things out and give some other places to look. Primary sources are of course not definitive, those of you with access to these sources, please feel free to review them to look for reviews within those sources. Also, please all feel free to correct the formatting of the sources!

There's some more work required to get the sources-tag off this section, let's all pitch in... Franamax (talk) 00:33, 17 February 2008 (UTC)

N.B. I have not put any of the reworded discussion or sources into Water fluoridation controversy where it also belongs. Franamax (talk) 01:45, 17 February 2008 (UTC)

Continuing here, I am going to revert this edit, it is somewhat incoherent, also my RSS, Scientific American Jan08 cites the same NAS study, nap.edu...record_id=11571 as the IP editor uses and reports the NAS as saying "current limit...4 mg/L... should be lowered". I see no discussion that "2ppm is harmful" as the IP editor states, and I invite the IP to produce a specific verifiable quote. Franamax (talk) 10:37, 28 February 2008 (UTC)

Further to Jwray's edits, I am going to roll them back without prejudice but with the following notes: the study was conducted with dosages of AlF and NaF compared to distilled water, the NaF dosage was 2.1ppm equivalent to the 0.5ppm AlF dosage, I'm not clear on how this compares to drinking water dosages of hexafluorosilicic acid as far as the equivalent number of fluoride atoms being consumed; the ref'd article abstract states "No differences...between the body weights", more rats died "in the AlF group", conspicuosly excluding the NaF group. Etc., etc. and only reading the article abstract, but are we comparing apples to oranges here? More importantly for our purposes, do we wish to include a single (apparently peer-reviewed) result, a study conducted with different chemicals, on different animals, in this primary article? Or is this finding more appropriate for the Water fluoridation controversy article?

I'm not trying to make a finding here, editors have done the B for bold, I've done the R for revert, now lets do the D bit of WP:BRD. Franamax (talk) 11:33, 28 February 2008 (UTC)

I think there is now adequate sourcing. I have removed the sources tag. --AeronM (talk) 18:45, 28 February 2008 (UTC)

POV tag

Jersyko, if you would like to add a POV tag to this article, you need to discuss your reasons on the talk page first. Thank you. --AeronM (talk) 22:25, 29 February 2008 (UTC)

Also, please address issues here on the talk page instead of in your edit summaries, so that a discussion can take place. Thank you. --AeronM (talk) 22:50, 29 February 2008 (UTC)

Relevant discussion is here. · jersyko talk 22:52, 29 February 2008 (UTC)

The first half of this article strikes me as quite biased against fluoridation. What strikes me is that most opposition seems to come from lay people, while as a generalisation medical, dental and health organisations seem strongly in favour of it.

• Queensland Health on Fluoridation Dec 7, 2007

"Water fluoridation is endorsed by professional bodies around the world including the World Health Organization, the American Medical Association, Centers for Disease Control and the British Medical Association.

It is also supported by a number of Australia's peak health bodies, including the Australian Medical Association, the Australian Dental Association, the National Health and Medical Research Council and the Public Health Association of Australia."

I don't see why a lay opinion, though valid, should carry as much weight as an educated one? You'd ask an engineer if he thought a bridge would stand up, not ban it because someone walking past heard a similar bridge fell over once. Anyway, just my two cents but I'm not going to change the article itself. PatrickRBC (talk) 11:28, 6 March 2008 (UTC)

The first paragraph blatantly omits any of the other side of the issue on this. We need to add something to balance for NPOV. --AeronM (talk) 00:49, 25 March 2008 (UTC)

NPOV does not = balance. See WP:NPOV. · jersyko talk 18:46, 27 March 2008 (UTC)

The Controversy section has been systematically stripped of any balance and should now be renamed "Opposition". Franamax (talk) 19:19, 27 March 2008 (UTC)

World status

Dozenist has removed 12 statements by 12 countries that inform readers about their fluoridation status. Dozenist does not consider the cited sources to be reliable.

I disagree with that assessment. The original sources cited include: the Ministry of Health of China, the Ministry for Environment in the Republic of Hungary, the Netherlands Directorate Drinking Water, the Ministry of Social Affairs and Health of Finland, and the Norway National Institute of Public Health.

Dozenist has dismissed these sources as unreliable. I respectfully disagree. In all candor, I would describe these sources as, "The Horse's Mouth."

I agree that the page needs to represent more of a worldwide view. Dozenist's actions make the page much less global.

Whereas these sources are actual world government officials charged with monitoring water quality, I hereby submit that Dozenist was hasty in removing the information. I will now restore what Dozenist took away. Petergkeyes (talk) 05:02, 19 May 2008 (UTC)

The section still needs proper references. When you first added the material, it was completely unreferenced; after a request, you've now provided some, but they are still problematic. Yes, the sources appear to be from who they say they are from, but it is all based on electronic copies of letters that are posted on websites of anti-fluoride groups. These groups have a vested interest in providing only material that would support their cause, so their suitability as a source is less than ideal. --Ckatz^chat_spy 06:07, 19 May 2008 (UTC)

Look up the source however you can, and then include the source as your main link. I believe you can link to full-text beside the primary source, especially since these are government publications (non-copyrighted). If you verify that the full-text on those pages are correct, then they don't have to easily verified by others. ImpIn | {talk - contribs} 18:26, 26 May 2008 (UTC)

Messiness of this and the controversy article

I'd like to improve both these articles and eventually would like them to be merged back together. I want to work entirely within NPOV policy and quite quickly get the non-worldwide tag off this article. If I take some quite bold steps in rearranging sections, then that's what I'm doing. Itsmejudith (talk) 16:20, 21 May 2008 (UTC)

There was a huge meta-study, covering something like 3000 primary studies, which I've been unable to locate. (Haven't had much time to look, unfortunately.) If you could dig that up, it would be much more valuable than having us pick and choose which studies to include. kwami (talk) 19:58, 21 May 2008 (UTC)

That could be the University of York survey, already covered. Itsmejudith (talk) 07:00, 22 May 2008 (UTC)

SELECTIVE QUOTE OF CDC PAPER

One quote from the CDC misrepresents their view. In the referenced section “COST-EFFECTIVENESS OF FLUORIDE MODALITIES” comparing various methods of fluoride delivery, (gels, varnish, mouthwash, water fluoridation, tablets, etc) and their cumulative and additive effects, the CDC says:

“Although solid data on the cost-effectiveness of fluoride modalities alone and in combination are needed, this information is scarce.”

In Wikipedia, the quote is used out of context,and says” “Effects

....However, the United States Centers for Disease Control states, “…solid data on the cost effectiveness of fluoride modalities…is scarce…” [7]”

This seems to be intended to disparage water fluoridation by selective quoting of the CDC, intimating that studies of water fluoridation itself are scarce. Readers should perhaps be referred to the CDC’s webpage on water fluoridation http://www.cdc.gov/fluoridation/ where they say: “Overview Community water fluoridation is safe and effective in preventing tooth decay, and has been identified by CDC as one of 10 great public health achievements of the 20th century. “ —Preceding unsigned comment added by 121.216.8.143 (talk) 01:40, 27 May 2008 (UTC)

The entire article is now tilted, once again, against the medical establishment. kwami (talk) 08:19, 27 May 2008 (UTC)

I rewrote the Effects section. I suggest we stick to metastudies and conclusions of major institutes such as the ADA, CDC, and WHO. There are literally thousands of studies out there, supporting any conclusion you like, so if we allow people to pick and choose their favorites, there will be no end to POV infighting. kwami (talk) 10:48, 27 May 2008 (UTC)

Sometimes it is claimed that water fluoridation is practiced at a very low cost. That claim is open to debate, and CDC's statement about scarce data regarding costs of fluoride modalities, including water fluoridation, is relevant, and should be restored. That is, if cost of fluoridation is relevant to this article. I would say that it is. Petergkeyes (talk) 07:05, 28 May 2008 (UTC)

The cost is certainly minimal compared to the cost of having uninsured families use the emergency room for all the extra toothaches and abcesses. kwami (talk) 11:53, 28 May 2008 (UTC)

Fluoride exposure, via overdose, can negatively affect life expectancy.

In 1990 the National Cancer Institute declared fluoride an equivocal carcinogen. People have died from fluoride overdose. A short browsing of the malfunctions section shows some of the mortalities. These are some of the reasons why I must remove the following claim, which was unsubstantiated by its citation. Also, the reference is from 1984. That is too old of a reference to be using to back up such a lofty claim.

"While extreme industrial exposure to fluoride will cause health problems, such as nephritis, there is considerable evidence to show that fluoride exposure does not cause cancer or birth defects. In addition it has not been shown to effect life expectancy."

The last claim is false, and, frankly, downright dangerous. Folks, please do not eat your toothpaste! Petergkeyes (talk) 07:41, 28 May 2008 (UTC)

Curiously there is a lot of people who do, who don't suffer ill health. But that is neither here nor there. Fluoride ions are a carcinogen? Really? Didn't know that, which compounds in particular? Shot info (talk) 07:57, 28 May 2008 (UTC)

Sodium fluoride. National Toxicology Program, 1990. Petergkeyes (talk) 23:09, 30 May 2008 (UTC)

Sorry 'bout that, had the wrong section # in the ref. And I assume they meant water-fluoridation-level exposure. (It's a summary.)

All that eating your toothpaste will do in the short term is maybe cause a stomach ache, though chronic ingestion is not a good idea. As for the date, there are later metastudies available, but I have yet to locate them. kwami (talk) 11:51, 28 May 2008 (UTC)

My understanding is that about 1/2 of a tube of toothpaste contains enough active ingredient to kill a small child. Petergkeyes (talk) 23:09, 30 May 2008 (UTC)

Is there a reliable source for this? Mainly as I regularly see such statements parrotted around on the University of Google, but no real substiciated sources. Shot info (talk) 01:49, 31 May 2008 (UTC)

Potentially fatal dose = 5 mg of fluoride per kg of bodyweight. This is "the minimum dose that could cause toxic signs and symptoms, including death, and that should trigger immediate therapeutic intervention and hospitalization... This does not mean that doses lower than 5.0 mg F/kg should be regarded as innocuous." (SOURCE: Journal of Dental Research 1987; 66:1056-1060.)

Akiniwa, K. (1997). Re-examination of acute toxicity of fluoride. Fluoride 30: 89-104.

Gessner BD, et al. (1994). Acute fluoride poisoning from a public water system. New England Journal of Medicine 330:95-9.

Levy SM, Guha-Chowdhury N. (1999). Total fluoride intake and implications for dietary fluoride supplementation. Journal of Public Health Dentistry 59: 211-23.

Spak CJ, et al. (1990). Studies of human gastric mucosa after application of 0.42% fluoride gel. Journal of Dental Research 69:426-9.

Shulman JD, Wells LM. (1997). Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. Journal of Public Health Dentistry 57: 150-8.

Whitford GM. (1987). Fluoride in dental products: safety considerations. Journal of Dental Research 66: 1056-60.

Faculty of Dentistry, Class of 2009, University of Toronto[4] Petergkeyes (talk) 08:36, 31 May 2008 (UTC)

Keepers of the Well

Is not a reliable source per WP:RS. It is a WP:FRINGE source. Shot info (talk) 07:57, 28 May 2008 (UTC)

While the front page of Keepers of the Well makes it look like the website will be full of activist poetry, if you venture into the site you will find it consists of reprints of: the Journal of the American Dental Association, the Centers for Disease Control and Prevention, the Environmental Protection Agency, the Board of Dental Examiners, Members of Congress, the American Water Works Association, the National Sanitation Foundation, Lucier Chemical Industry, LTD., the California Code of Regulations, the Food and Drug Administration, the National Academy of Sciences, Dental Cosmos, the Journal of Public Health Dentistry, and much more. There is a point of view, for sure. But the meticulous sourcing makes this a very reliable website. These are mainstream sources, not fringe. Petergkeyes (talk) 09:03, 31 May 2008 (UTC)

ADA Bottled Water advisory

This sentence fits better in the, "Bottled water" category than it does in the, "United States" category.

In October 2006, the United States Food and Drug Administration issued a health claim notification permitting water bottlers to claim that fluoridated bottled water can promote oral health. The claims are not allowed to be made on bottled water marketed to infants.[83]

Anybody mind if I move it? Petergkeyes (talk) 10:02, 29 May 2008 (UTC)

Yes, it only has something to do with bottled water in the US, give that it relates to the FDA only. Shot info (talk) 06:42, 30 May 2008 (UTC)

Valid point. The US section just got too crowded. Bottled water is a good category for the section. Petergkeyes (talk) 19:57, 13 June 2008 (UTC)

Is the title of this still appropriate?

Water fluoridation is simply the bulk of this article, salt and milk are also included, so maybe it may be worth dropping the water part and adding it as a subtitle or just mentioning how it is by far (i assume) the most popular method of fluoridation, or maybe other fluoridation articles to work on? —Preceding unsigned comment added by 81.141.2.124 (talk) 14:28, 29 May 2008 (UTC)

If the salt and milk fluoridation stuff stays, it may be sensible to drop the word, "water" from the title of this page. Petergkeyes (talk) 21:36, 1 June 2008 (UTC)

Does anybody else care to weigh in on this matter? I would perhaps lean toward dropping the, "water," part. That would necessitate some revisions. The milk and salt additions, while interesting, have clearly begun to steer this article away from the subject of water. They also mention a particular foundation repeatedly - it starts to look like advertising. Petergkeyes (talk) 19:49, 13 June 2008 (UTC)

As an alternative, perhaps salt fluoridation and milk fluoridation pages should be started. Petergkeyes (talk) 19:58, 13 June 2008 (UTC)

The references to the foundation wer quite heavy, but it is the only official body practicing milk fluoridation, and in fairness in the same article i mention the names of several uk water companies that practiced fluoridation, all of which were left in. At the same time the borrow foundation have stated that using the support of the dental community they wish to re-introduce fluoridated milk in china, which is relevant even if you don't want to even name the foundation. I was being impartial but when i wrote it i was thinking more of naming and shaming thhese people not advertising. By the same rationalle you could delete the whole article on adolf hitler because it is an advertisment for naziism, but this very act would prevent people from learning the important lessons from this part of history. If i were biased or inaccurate fair enough, but I put a lot of work in and to have it reduced to a couple of sentences for the sake of not mentioning a foundation whose name could have been subtly removed while leaving the information along side it in tact surely? —Preceding unsigned comment added by 77.101.84.115 (talk) 13:18, 13 July 2008 (UTC)

Is Peter Meiers a WP:RS

Time to have a look at WP:SELF. Shot info (talk) 06:42, 30 May 2008 (UTC)

Fluoride is ubiquitous in the environment

from natural and man-made sources. Thus, why the need to fluoridate water, salt, or milk, if it's everywhere? Aside from that, fluoridating salt is just foolish, as fluoride is antagonistic to proper iodine uptake, which salt is public health vehicle for. In reality, thyroid health is vastly more important than saving a few teeth, if any. —Preceding unsigned comment added by 76.67.97.228 (talk) 19:17, 31 May 2008 (UTC)

Does anyone put both fluoride and iodide in salt? Anyway, while fluoride is ubiquitous, it usually isn't found in high enough concentrations to have beneficial effects. Also, it's more than just a matter of saving a few teeth: after LA stopped fluoridating its water, half of all emergency-room visits were for dental problems, up sharply from the fluoridation years. kwami (talk) 04:04, 3 June 2008 (UTC)

Much of Europe and Latin America puts the two together. As for the levels of fluoride, fluoride does not just disappear after it's been used by the consumer in water. It becomes recycled, raising so-called "natural" existing levels. Remember, matter cannot be destroyed. Basic physics. Thus, it increases in the ecosystem.

Do you have information showing the numbers of dental related emergency visits? Even if what you say is factual, I doubt these figures were ever statistically analyzed for prevalence of "lack of fluoride" as the cause (you assume causal relationship), which is not an emergency by any reasonable standard. Surely you can't be debating the priority thyroid health should take over a possible breach in tooth enamel? It doesn't compare on any level.

Anyhow, considering that most internalized fluoride ends up in the thyroid and pineal glands, where it doesn't belong, and not in tooth enamel where it may have a beneficial effect, systemic fluoridation is a failure at what it's supposed to protect; tooth enamel.

Last, but not least, fluoride is not naturally part of the structure of teeth at all. (Taken from a paper on materials science, studying tooth enamel composition. "Microhardness and chemical composition of human tooth"):

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-14392003000300011

"Tooth enamel is the most mineralized tissue of human body. Its composition is 96 wt.% inorganic material and 4 wt.% organic material and water. In dentin, the inorganic material represents 70 wt.%. This inorganic material is mainly composed by a calcium phosphate related to the hexagonal hydroxyapatite, whose chemical formula is Ca10(PO4)6·2(OH) 1. X-ray energy dispersive spectroscopy (EDS) analysis of enamel and dentin also indicated the presence in small quantities of other elements such as Na, Cl and Mg 2."

As you can see, fluoride plays no part in this structure, and the replacement of the natural calcium-based hydroxyapatite with fluorapatite (fluoride), is the very definition of dental fluorosis, even if the fluorosis is not readily visible. Thus, it negates the argument that teeth need fluoride at all... Makes me think of the wisdom of opening a barbershop in a town full of bald men, or trying to sell them on a more expensive shampoo, if you'll pardon the humourous comparison . :)

It would be much more productive to ingrain in people personal responsibility of good oral hygiene when it comes to prevention. Eg. A majority still do not floss daily. Much more likely a contributing cause, along with direct trauma to the mouth, of these emergencies you mention. —Preceding unsigned comment added by 76.67.97.228 (talk) 16:53, 3 June 2008 (UTC)

Although much of what you say is correct, it sounds like selective reading. I wish I could dig up the LA emergency-room stats. Whether flossing would make fluoride redundant or not (and it appears not) is rather like the arguments for abstinence-only sex education—if everyone just waited until marriage and was faithful, there would be no need for STD health services, so let's eliminate them. Regardless of whether they should, a lot of people don't. How many people die every year from iodine deficiency in the US, compared to the number who die from tooth decay? Those emergency-room visits are serious. kwami (talk) 19:48, 3 June 2008 (UTC)

Much of what I say is correct? What isn't? Again, you show me nothing of the causality you say is present in these emergencies, between lack of fluoridation and the emergency itself. As well, you can't substantiate the number of emergencies in LA at all. You can't even prove the emergencies exist at all! Come on? Prove it! And the causality, as well.

So, what is it I've said you disagree with? You said I'm generally correct, yet you still argue (apparently about STDs and abstinence) which is wildly off topic. Stick to the topic, and debate me with proof, not just rhetorical tactics you learned (poorly) in school. You've not disproven anything I've stated. (And you do not know what I have read, so in what way is my reading selective? Don't accuse me of something you cannot back-up, or be accused of the same.)

FYI, thyroid problems are still a common complaint seen in medical practices and hospitals. Thyroid drugs are commonly prescribed across the world. I've been one of those patients. The rates are even going up in Newfoundland fishing villages, where there should be no problem, considering the heavy fish diet. Lot's of iodine in fish.

You said: "Whether flossing would make fluoride redundant or not (and it appears not)"

Answer: Good oral hygiene (regular brushing and flossing... I wasn't suggesting just one or the other, obviously) is critical to oral health. It is the single best thing to rid the mouth of the bacteria that creates the acids that erode enamel, and cause subsequent infections treated by periodontists. So who are you kidding? It "appears not" to whom? You? Fluoride doesn't protect teeth under the gum level, don't forget. Nor the gums themselves. But good oral hygiene does.

Added for emphasis: Only floss the teeth you want to keep.

Anyhow, I don't normally edit on this site as I just don't have the time, so don't expect a reply to your unproven emergencies, or STDs, or other. I was just here to comment on fluoridation in general, and I've done that.

—Preceding unsigned comment added by 76.67.97.228 (talk) 20:30, 3 June 2008 (UTC)

Says WHO and the United Nations, as cited in the article. Toothpaste does not replace the benefits of fluoridated water. And of course it helps the teeth under the gums. That's half the point. Or haven't you read the article? kwami (talk) 17:39, 4 June 2008 (UTC)

Wikipedia is not a reliable source, as any expert will tell you, but a starting point for basic information. So don't use it as a reference. And don't get angry because you're wrong, can't prove your point, and your ego got hurt. If you want to believe fluoride is a magical "pixie-dust" cure-all, fine. But don't expect me to believe your fairy-tales. You're just getting to be annoying now, with no debate, and lots of hot air. Just who are you trying to convince? Me? Your fellow editors? Yourself? You're very hostile for a guy who said he agrees with me in principle. And I will not answer you again because of this, your disingenuousness, and your rabid pro-fluoridation stance.

I did not write my comments to you, but to a wider audience (WP's readership). And I have not edited the main article, so what's your problem? You were bored? No wonder wikipedia is highly controversial as a source of information, and editors here get burnt out, feeling the need to debate endlessly.

P.S. Fluoride does nothing under the gumline, for either the gums, roots or ligaments. It's "beneficial effect" is only on tooth enamel, strengthening it. And all enamel is above the gumline. What you are stating is blatantly false, as can be seen even by reading the tooth enamel entry on this site. I will not put up with deceit... Why can't you just admit your ignorance on the subject. There's no shame to it. But there is when you try to pass yourself off as someone with more knowledge than you possess, which is clearly the case. Stick to astronomy or language, or whatever your "expertise" is. 76.67.97.228 (talk) 03:10, 5 June 2008 (UTC)

IP 76, do you care to get a account? Also, can I direct to you some of Wikipedia's policies including WP:NPA and WP:SPA. Shot info (talk) 03:52, 5 June 2008 (UTC)

So you can waste my time with your policies? You agree with Kwami. Fine. Erase my notes if they bother you so. And ban my IP. I have been more than fair with him, if you really look at it. And when I say he is ignorant, I mean on the subject matter. I will consider myself banned and unwelcome here. Happy now?

As a physician, I really have no time for wikipedia anyhow.76.67.97.228 (talk) 04:00, 5 June 2008 (UTC)

Feel free to comment on the contribution and not the contributor. It is up to you to follow the rules and to engage in the environment set down by them. Shot info (talk) 04:03, 5 June 2008 (UTC)

He made no real contribution to this. He merely tried to shout me down, and you know it.

Note: Some of my comments have been erased by Shot info. I will not re-add them to increase the conflict we seem to have, and I will cease to post. But I want this noted. And please do not erase this notice, Shot info, as you really had no business doing so in the first place. 76.67.97.228 (talk) 06:00, 5 June 2008 (UTC)

Click here to make it all clear. Shot info (talk) 06:04, 5 June 2008 (UTC)

You were rude, biased, and disingenuous by deleting comments that legitimately drew attention to you and said bias. Leave me alone, and I will do the same for you. 76.67.97.228 (talk) 06:14, 5 June 2008 (UTC)

Wow. I can't even tell what you're responding to half the time. Who's using Wikipedia as a reference? When I said fluoride works under the gum line, I meant systemic fluoride during tooth formation, which is half of its purpose. Rabidly pro-fluoride? I favor it because meta-studies have shown it to be safe and effective. If new data comes along that says differently (and I don't mean individual studies; with 3000+ studies you can find something to support any conclusion you like— thus the meta-studies), I would be happy to reevaluate. I don't have any invested interest in fluoride, but most of the anti-fluoride types I've met have been crackpots of the kind who call people "rabid" for disagreeing with them. kwami (talk) 07:35, 5 June 2008 (UTC)

Meta-studies, otherwise known as meta-analysis, can be a useful statistical tool, correlating groups of smaller studies. However, being statistical generalities, they provide no new research or insight, and are only as good as the studies included in the analysis (Read Meta-analysis#Trial_quality).

As to anti-fluoridationists being "crackpots", they are just people who value the notion of freedom of choice, and see mass fluoridation as an erosion of their right to choose. That is their message, as I understand it. But, I am not a member of any of these anti-fluoridation groups, and cannot speak for them. 76.70.116.54 (talk) 18:08, 5 June 2008 (UTC)

Fluoride Action Network

Some have suggested that Fluoride Action Network is not a reliable source. I strongly disagree with this sentiment. FAN has recently erroneously been removed as a citation for malfunctions in fluoridation equipment. FAN is one of the most visited, best referenced websites out there that does not favor fluoridation.

Some have suggested that only sources that endorse, support or favor water fluoridation can be considered reliable. Subscribing to that theory would leave Wikipedia readers blind to the constantly raging controversy over the practice.

FAN will be replaced as a good source for the at least 17 equipment malfunctions. Petergkeyes (talk) 01:17, 3 June 2008 (UTC)

I think you make a decent point. I count 9 people with scientific PhDs on FAN's advisory board. However, FAN mainly has news from other sources. That stuff should probably be cited directly after being verified, if possible. Also, they don't make note of whether they are reprinting with permission that I can see, which raises copyright concerns. ImpIn | (t - c) 01:26, 3 June 2008 (UTC)

FAN is not the source, it is merely "reprinting" information. In the context of supplying sources for all those particular facts, FAN is not a reliable source. When FAN decides to produce it's own information, then perhaps it can be considered a source. But for the "reproduction" of third party sources, it is not a RS. Reliable sources are credible published materials with a reliable publication process; their authors are generally regarded as trustworthy or authoritative in relation to the subject at hand. How reliable a source is depends on context. As a rule of thumb, the more people engaged in checking facts, analyzing legal issues, and scrutinizing the writing, the more reliable the publication. Sources should directly support the information as it is presented in an article and should be appropriate to the claims made; RS101 people. Shot info (talk) 01:45, 3 June 2008 (UTC)

Put another way, FAN is a locus for anti-fluoridation information. It's purpose is to oppose fluoridation and to collect anti-fluoridation references. This must suggest some degree of bias and the suspicion that FAN will adopt an uncritical approach as to what it will include on its site as "evidence". If the information FAN collates is reliable, then it can easily be traced to its original source, that source can be verified and referenced in the Wikipedia article, then there's no problem, right? Franamax (talk) 05:40, 3 June 2008 (UTC)

The last sentence has it spot on. Shot info (talk) 06:56, 3 June 2008 (UTC)

I agree with everything Franamax says above, except for this sentence: "This must suggest some degree of bias and the suspicion that FAN will adopt an uncritical approach as to what it will include on its site as 'evidence'". Taking a position on the issue does not equate to an uncritical approach to information gathering. FAN is highly critical, skeptical, and scientific. Editors should cease the inflammatory claims of, "unreliable," and "fringe," and read FAN for what it is: "a locus for (meticulously researched and referenced) anti-fluoridation information." Petergkeyes (talk) 09:50, 3 June 2008 (UTC)

FAN is a fringe organisation per WP:FRINGE. If it wishes to be taken seriously, it needs to be a little bit more serious that just a "locus". Shot info (talk) 23:34, 3 June 2008 (UTC)

From the online dictionary Merriam-Webster, Locus: 1 a: the place where something is situated or occurs. b: a center of activity, attention, or concentration. "in democracy the locus of power is in the people" — H. G. Rickover

There is no reason not to take a locus, or center, seriously. No matter how much detractors try to marginalize FAN, it will continue to be a reliable, mainstream source of information about fluoride. Petergkeyes (talk) 22:47, 4 June 2008 (UTC)

On the other hand, how is FAN different from Wikipedia as a locus? Yet we tell people all the time to not just take Wikipedia at its word, but instead to trace the information to its source. The best solution here is that you track down the referred material yourself, read it to be sure it says what is claimed, then source it directly. Franamax (talk) 23:07, 4 June 2008 (UTC)

Pete, go read WP:RS and WP:V. If you don't understand policy, or it's application, then you aren't going to understand why other people don't consider your "source" as a reliable one. Shot info (talk) 23:21, 4 June 2008 (UTC)

Cites

A name, A department, and a date. Dunno about you, but there seems to be a problem with the current cites and what Wikipedia would like. Will leave it sit for a week or so. Shot info

WP:Verifiability says: All material that is challenged or likely to be challenged needs a reliable, published source. Shot info (talk) 23:36, 3 June 2008 (UTC)

Per these discussions, I have removed several citations that have been challenged. If the material exists, it should be easy enough to source it from proper references, as was done with some of the other ones. --Ckatz^chat_spy 05:52, 12 June 2008 (UTC)

Ckatz removed valid double citations from most of Europe. There is no consensus that the sources are not reliable. Continuing along this path would remove large swaths of information about Europe from this page, and that would be unacceptable. This controversy deserves further discussion. Petergkeyes (talk) 06:36, 12 June 2008 (UTC)

The removed cites are links to copies of letters on an anti-fluoride site. There have been questions raised about the validity of such cites, and as such they are to be removed unless there is consensus to keep them. IIRC, you've managed to provide proper cites for other links that were challenged; I'd encourage you to do the same for this material. --Ckatz^chat_spy 07:05, 12 June 2008 (UTC)

Ckatz characterization of the cited sources is not accurate. Ckatz removed citations from: The Head of the Water Department of Austria, the Chief Engineer of the Ministry of Social Affairs and Health of Finland, the Director of the Protector of the Environment of France, the German Embassy, Hungary's Ministry for Environment, the Netherlands Drinking Water Director, the Norway National Institute of Public Health, the Danish Embassy, and the Water Department of Belgium. These are proper authorities telling us whether or not they fluoridate the water in their respective countries. Ckatz did not challenge the citations until I added convenience links to 2 websites where the letters have been published for about 8 years. While the websites in question [5][6] do not favor water fluoridation, it is silly and untrue to say that the websites are, "anti-fluoride."

Fluoride is a very powerful and useful material. It splits the uranium isotopes for the atomic bomb, it etches glass, most modern psychiatric drugs are made from it. And some people even like to brush their teeth with it.

But taking a position on whether or not to add hexafluorosilicic acid to public water supplies does not make one "pro-fluoride, or anti-fluoride." The fact that not one, but two websites reprint some of the letters from Eugene Albright begins to corroborate their reliability.

In short, many European countries do not fluoridate their water supplies. It would be a shame if Wikipedians burried this information beneath finger pointing, and cries of, "fringe." Petergkeyes (talk) 01:20, 13 June 2008 (UTC)

Please don't misrepresent myy edits. The links were removed because they all come from websites that oppose water fluoridation, not because one is quesioning the authority of government officials. No-one is trying to bury the information, just ensuring that the sources are ones that won't be questioned. You've already found some links for others that were questioned, so it shouldn't be too difficult to source the rest directly. --Ckatz^chat_spy 01:25, 13 June 2008 (UTC)

Perhaps it was an unfortunate coincidence, but when the citations were simply the government statements, they remained on the page. But minutes after I added convenience links to FAN and Fluoridation, the government statements were removed in their entirety. This suggests that you doubt what is being said by these government officials. Petergkeyes (talk) 01:53, 13 June 2008 (UTC)

Again, Peter, I would ask that you avoid misrepresenting my edits. If you look through the article history, you'll see that I also removed the uncited quotes when you added them in mid-May, saying "These are interesting quotes, but we have to have some way of verifying them. Please let me know if you need assistance in getting references." I hardly think that implies any doubt as to the officials. Please also keep in mind that you have demonstrated a very definite point of view on this issue through your edits; you must try to distance yourself from that if you wish to avoid repeated problems such as this. --Ckatz^chat_spy 02:17, 13 June 2008 (UTC)

(unindent) It is true that many European countries don't fluoridate water. But we have to make sure that we are not endorsing any point of view if we note that. It may simply be that the natural level of fluoride is fairly high anyway in these countries. In the UK the issue sometimes surfaces into public debate so maybe we could extend the section on the UK. Itsmejudith (talk) 09:52, 15 July 2008 (UTC)

Dead link, POV statement

Yesterday I removed this dead link Fluoretação da Água em Sistema Público de Abastecimento, from the Brazil section, but another editor mistakenly replaced it. At press time, the link was simply a cartoon of a man using a jackhammer. Please check to see that links are still good before replacing them. It would be much appreciated. I also removed this sentence from the Russian Federation section: “Further Expansion of this scheme is hoped for with the support of Chief Dental Officers of seven districts of Kazan.” The words, “hoped for,” indicate that it is clearly a POV statement, and must go. Petergkeyes (talk) 19:33, 13 June 2008 (UTC)

There are better ways to achieve this. The link can (and should) be tagged as "dead", rather than just removing the information. Furthermore, the note re: Russia can be addressed by rewriting the text in a more neutral fashion, not by just deleting it. If it is referenced to a valid source, it should stay. --Ckatz^chat_spy 20:06, 13 June 2008 (UTC)

The sentence regarding 40-80% was nonsense. The statement about some folks hoping for more fluoridated milk is facially rather believable, but those folks opinions about fluoridated milk are not facts, they are opinions. And they are not about water fluoridation, so I am suggesting perhaps there may be a better way to present the topics of fluoridated milk and salt. Perhaps a brief mention at the bottom, with links to full pages, if there is enough info to warrant new fluoridated milk and salt pages.

To rephrase the sentence in an attempt to be NPOV would likely be stilted, and self defeating. It would perhaps say something like, “Chief Dental Officers in seven Kazan districts endorse expansion of the measure, while (generic Russian holistic health, environmental and personal liberties groups) opposes it.” Petergkeyes (talk) 22:39, 13 June 2008 (UTC)

osteosarcoma reduced in fluoridated areas?

This claim will be removed if it can't be backed up with proper citations. Petergkeyes (talk) 22:06, 27 June 2008 (UTC)

Inflammatory image

Image:Unholy three.png is inappropriate in this article for several reasons. Despite the image's depiction of fluoridation as a subversive communist conspiracy, most opponents of water fluoridation are not conspiracy theory wackos. Indeed, conspiracy theories with regard to water fluoridation are so non-notable that the summary of Water fluoridation opposition provided in Water_fluoridation#Opposition only devotes a single sentence to them. To avoid unfairly tarnishing water fluoridation opponents with a paranoid conspiracy theory brush, this fifty-three year old image would be appropriate only in a section of an article specifically devoted to water fluoridation conspiracy theories, such as Opposition_to_water_fluoridation#Conspiracy_theories -- not in a general discussion of all opposition to fluoridation. 130.65.109.102 (talk) 17:51, 11 August 2008 (UTC)

Agreed with the above. Using a 50+ year-old picture to represent the current concerns is over the top. This picture is already in the opposition page under the conspiracy section. II | (t - c) 18:40, 11 August 2008 (UTC)

No worries. Amazing what happens when an IP comes to discuss their actions on a talk page :-) Shot info (talk) 23:11, 11 August 2008 (UTC)

Updated Cites

I have taken it upon myself to correct some invalid cites, #29, 30, and 50 to be precise. If these are incorrect (as I have taken them from the Opposition to water fluoridation page,) please feel free to correct these.
Mika'el (talk) 13:16, 11 September 2008 (UTC)

Out of place here

This section is about the cost benefit of water fluoridation. The effects of excessive fluoride in the water seems out of place here. The first sentence seems to be a fragment.

Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, Morbidity and Mortality Weekly Report, August 17, 2001, Centers for Disease Control and Prevention[26] Many communities need to reduce fluoride exposure. Consumption of water exceeding 10 ppm fluoride has been shown to lead to pathological changes in bone structure, and skeletal fluorosis.[27] [28] Debilitating environmental fluorosis of a portion of the population is a problem in several developing countries, where it is complicated by malnutrition. The effects of skeletal fluorosis can be slowly reversed through a reduction of fluoride intake and improved diet.[29]

--—CynRN ^(Talk) 18:04, 28 September 2008 (UTC)

I agree that it is out of place. II | (t - c) 18:11, 28 September 2008 (UTC)

I moved that paragraph to the Flourosis section. I have to say that this article has a huge anti-flouride bias. There is too much in history and it seems to come mostly from one anti-fluoride 'historian'. The benefits are downplayed and the risks are overblown. Fluorosis in most cases is a minor effect, but this idea is not conveyed. There is an inflammatory photo of 'severe fluorosis'. If anything two photos, of minor and severe could be included. Severe fluorosis is very rare. We need a neutral POV here! --—CynRN ^(Talk) 20:49, 28 September 2008 (UTC)

I took two POV statements from the dentists out of 'fluorosis' section. Too much POV for this section. Can be reinserted in Wikipedia Fluorosis, if needed. --—CynRN ^(Talk) 21:49, 28 September 2008 (UTC)

Effectiveness vs Cost-Effectiveness

This exchange was cut from ImperfectlyInformed's talk page. Please post article issues to the article talk page.

Hi II, I agree that an older study should not replace a newer one. However, I am concerned that the negative bits are picked out of the mostly positive information in these studies in order to cast doubt on the subject of water fluoridation. The phrase you replaced needs a little more explanation, in my opinion, about how it is refering to the fact that most people are exposed to more sources of fluoride than just water and that this hasn't been studied sufficiently. The article seems terribly biased against water fluoridation in general. --—CynRN ^(Talk) 14:59, 6 October 2008 (UTC)

The statement is regarding the cost-effectiveness of fluoridation rather than just the effectiveness. Anyway, the article, when done well, should be fairly critical of fluoridation because the most reliable estimates, such as the University of York review, are critical. I agree that the history section is dependent upon an unreliable website, incidentally. II | (t - c) 17:29, 6 October 2008 (UTC)

the article, like all Wikipedia articles, should not be "fairly critical" of fluoridation, highly critical, or uncritical -- or take any other position at all. It's not our place to render scientific or economic judgments. The article, i hope, will present the sources, and leave the reader to evaluate them. It is necessary to be careful to be fully representative, and not cherry-pick the studies which support ones point of view. You can give the dates, but not say that something supersedes unless there is a truly authoritative source to quote for that. DGG (talk) 03:58, 9 October 2008 (UTC)

If the best sources are fairly critical, then the article will be fairly critical. Who said it was my judgment? It was the judgment of the University of York's systematic review, published in the British Medical Journal. Per WP:MEDRS, that source is better than the CDC, which is tertiary, and truly is the authoritative source. Similarly, National Academy scientists were rather critical of the practice in the 2006 book on the subject. II | (t - c) 07:57, 9 October 2008 (UTC)

Tags at top of article

I saw the {{globalize}} and {{POV}} tags at the top of this article, came to the talk page to find discussion about them, and basically came up dry. I just now read the article for the first time and don't see significant problems in either area. For now I've removed the tags. Anyway, tags are not supposed to reflect a long-ago objection by an editor: they're supposed to reflect a continuing process to improve the article. Eubulides (talk) 20:09, 7 November 2008 (UTC)

Major restructuring

To be blunt, this article was written like a conspiracy-theorist's newsletter: disconnected paragraphs of irrelevant details full of weasel words and unnecessary opinions from individuals and advocacy groups. I've made an attempt to reduce that problem, but more work needs to be done (hence the cleanup tag). Opinions should be summarized on their own page.

I moved the summaries of mid-20th-century research to a special subsection of "History," put them in chronological order, and cleaned up some out-of-place advocacy. I was tempted to delete these paragraphs altogether, as they're probably irrelevant, but I didn't want to make that decision alone. If anyone else agrees, I'd encourage you to follow through. I also consolidated fluorosis into the section on health effects, since it has its own article.

There are a lot of ppm numbers thrown around, perhaps too many. The single most important one is absent: what concentration of fluoride is actually used in fluoridated water? If it's significantly and consistently far lower than that at which side effects occur, then much of this material doesn't belong here since it doesn't involve intentional fluoridation of water.

P.S. I didn't notice that I wasn't signed in when I edited the article itself, so the changes are attributed to an IP address. Sorry. Epistaxis (talk) 01:34, 10 November 2008 (UTC)

You may want to try that again, minus the vague allegations and rhetoric. Expert opinions from toxicology and dentistry researchers who have taken a long look at the scientific literature certainly belong on this page. And it is clear that you didn't read very carefully (or know much about the subject) if you didn't get the number which water is fluoridated at, which was stated clearly. II | (t - c) 09:59, 10 November 2008 (UTC)

The edits of these wise self-styled "experts" and guardians of Wikipedia´s "quality standards" make it obvious again that contributing to this article is a waste of time. Tren (talk) 20:56, 10 November 2008 (UTC)

I made these changes with the intention of improving the article and making it more encyclopedic. Please review my comments carefully. And in case that's still not clear: this article includes a lot of detail that, even if factual, is not informative about the issue. This includes a history of research studies performed in the mid-20th century. Few studies are noteworthy for being studies. What is noteworthy is the result of a study, as it pertains to the topic, and surely there are is a more recent study, or even a survey of studies, that could be cited instead.

Also, upon another close inspection of the article, the standard amount of fluoridation is still not there. Here is a list of the fluoride concentrations mentioned in the article:

• 2 to 13.7 ppm: contamination in Colorado, 1931
• 2.8 - 3.9 ppm: Amarillo 1936-7 (Wichita Falls is missing)
• 1 mg per day / 1 ppm: 1942 optimal fluoride
• 0.7 ppm to 1.2 ppm: present (?) CDC recommendation
• 1 ppm: 12.5% of people have aesthetic concerns about fluorosis (possibly the same number for decrease in cavities and decay, but this is not made clear and that number may be omitted)
• 0.7 – 1.2 mg/L: "above the commonly recommended dosage," causing side effects (or is this stated unclearly?)
• 1 – 3 mg/day: intake calculated by a Wikipedia author (?) based on recommended water consumption
• 4 mg/L: EPA maximum contaminant level, recommended by NRC to be lowered
• 1.4 – 2.4 mg/L: EPA MCL before 1985
• 1.5 mg/L: WHO caution
• 10 ppm: bone damage
• 0.07 – 1.2: optimal (WHO again?)
• 2 mg/L: NRC bone risk unknown
• 1 mg/L to 4 mg/L: differential known to increase risk
• 12 mg/day: expected to cause kidney side effects
• 4 mg/L: can possibly lead to the above intake
• 23 mg/day: some studies suggest negative liver effects
• 0.36 ± 0.15 mg/L (range 0.18-0.76 mg/L), 2.47 ± 0.79 mg/L (range 0.57-4.50 mg/L): areas compared for IQ in unpublished (?) studies

Not one of these is clearly stated as a typical fluoridation level introduced into a public water supply. And in an encyclopedia, as opposed to a medical reference book, I think most of these facts could be explained without having to specify the exact numbers; truly curious readers can follow the citations. Epistaxis (talk) 06:10, 11 November 2008 (UTC)

Epistaxis, I'm sorry if this sounds rude, but look at all those values you cited. Do you really think the fluoride level found naturally in 1931 Colorado water is the amount used? Now zero in on the present CDC recommendation, which differs "depending upon air temperature". Do you think that might mean something? It is stated in the second sentence on the cost-benefits section. In the possible health effects section, the section which you eliminated, it is stated again in the first sentence: "Negative health effects are generally associated with fluoride intake levels above the commonly recommended dosage, which is accomplished by fluoridating the water at 0.7 – 1.2 mg/L (0.7 for hot climates, 1.2 in cool climates)". So we have clear evidence that you didn't even read that section! I'm sorry if this sounds rude, but read before you make a big fuss! II | (t - c) 19:58, 11 November 2008 (UTC)

I'm pretty sure that the 0.7-1.2 ppm (mg/L) level is the general standard for municipal water supplies with added fluoride. The devil enters with the details: studies of natural water supply in excess of this level are included, in many cases with no 3rd-party comment on their methodological rigour; there is a valid argument that variation in daily water consumption (among water enthusiasts or low body-weight individuals, for example) could result in excessive fluoride intake, and this can be compounded by dietary intake. The current US regulation permits up to 4ppm I think, and this is a bone of controversy - even though no municipal facility is known to fluoridate to that level, it's within standard, so is (apparently) a legitimate target for commentary. Additionally, anytime there's a big tank of fluoride compounds hooked up to a water pipe, there's a risk that the entire tank can empty into the pipe, with toxic effect - again, a legitimate target of criticism.

Inclusion of the studies showing toxic effects at extremely high doses probably don't belong here, as we do have a separate article to describe the toxic effects. The studies which are not subject to 3rd-party commentary (review article or meta-study) are particularly on the edge. Here's a thought though - would it be possible to re-sort these data (maybe in a table) along a gradient of the fluoride level? Then the reported effects could be viewed by increasing dosage, and the "standard" and "maximum US allowable" dosage levels could be shown in-line. Franamax (talk) 06:50, 11 November 2008 (UTC)

Intake	Fluoride	Fluoride	Reported effects	Refs
mg/day	@1L/day	@3L/day
0.5	0.5mg/L	.167mg/L	none reported
2.0	2.0mg/L	.67mg/L	Elevated dental flourosis in children	[1]
4.0	4.0mg/L	1.33mg/L	kidneys are toast	[2]
20.0	20mg/L	6.7mg/L	so long baby!	[3]

Something like the above, only far, far less lame... Franamax (talk) 07:09, 11 November 2008 (UTC)

That would be an improvement over sprinkling these data throughout the text, but I still question whether the article should contain so many numbers at all. This isn't a medical reference; to treat it like one is at best irrelevant and at worst physically harmful. Maybe it should just state the recommended dosage and refer to "elevated" concentrations for the health effects etc. Curious medical scholars ought to follow the links to the primary sources anyway. --Epistaxis (talk) 08:24, 11 November 2008 (UTC)

First, there are 4 experts on fluoride and toxicology who say that some of the effects occurring at 2 – 4 ppm are relevant to municipal water fluoridation at 0.7 to 1.2. That's why some of this stuff is in here. The dosage is uncontrolled. Plus, it is nice to put a summary of the research up so that people know. In some cases it should qualm fears, since liver damage doesn't seem to happen until you get 23 mg/day (although the actual studies of that are slim). The osteosarcoma link occurs at the CDC's recommended levels, by the way. Also, the EPA standard on what can occur in drinking water (4 ppm) is also relevant, since natural fluoride is used as a substitute for added fluoride. II | (t - c) 19:58, 11 November 2008 (UTC)

What about this: "The CDC recommends fluoridation between 0.7 and 1.2 ppm, though the EPA allows higher levels for naturally occurring fluoride." "Typical fluoridation levels are between X and Y ppm" (still no source for this). "Higher levels of fluoridation can increase the incidence of fluorosis." "Extreme levels may lead to liver damage." "Osteosarcoma may result even at the recommended levels." This way, only the two most relevant figures are given, but all the important information is still there. If a physician really wants specific data or a survey of the latest literature, she probably isn't coming to Wikipedia for that information, and we have links to the sources for those kinds of details anyway. As I said before, for anyone other than an expert, such esoteric content is at best unencyclopedic, and at worst dangerously out of context. --Epistaxis (talk) 08:09, 12 November 2008 (UTC)

Let's hear what a few other people have to say on the issue. I don't think it is dangerous to summarize the conclusions of the National Research Council in this article. There's a lot of misinformation floating around, and this is not it. I also don't think it is amiss to cite conclusions of the NAS toxicology researchers arrived at after reviewing the evidence, although 2 of them aren't really that relevant. John Dull and Kathleen Thiessen's comments are the most relevant. Also, I certainly don't agree with you that fairly accurate summaries of the toxicological literature regarding fluoridation are "esoteric content" which are "at best unencyclopedic". Wikipedia is not dumbed down. We give people the dirty details and the numbers, especially when those numbers are simple and easy to understand. Take a look at the mathematics articles sometime. II | (t - c) 06:00, 20 November 2008 (UTC)

I agree with Epistaxis that there is waaaay too much detail about individual research studies, both in Water fluoridation #Early studies and in Water fluoridation #Possible adverse health effects. And as per WP:MEDRS and WP:RS we should be citing secondary reviews, not primary studies directly. This article certainly should not be citing ancient primary studies like Dean 1934 (!), nor should we be citing marginal speculative studies like Coplan et al. 2007. Stuff like that should be moved into a more detailed article on water fluoridation research, or perhaps into the opposition article. Eubulides (talk) 06:16, 20 November 2008 (UTC)

Change to lead overemphasized prevalence

This change to the lead has a couple of problems:

• It emphasizes the prevalence of water fluoridation all out of proportion to its weight in the body. The topic is only a small part of the body, and should not consume half the lead. A brief statistic of worldwide use should suffice.
• The cited source does not support the phrase "since the 1950s".
• I made this further change to try to improve the lead further.

Eubulides (talk) 09:15, 19 November 2008 (UTC)

The geographical prevalence is fundamental to providing a broad overview of the topic. Per WP:LEAD: "The lead should be able to stand alone as a concise overview of the article. It should establish context, explain why the subject is interesting or notable, and summarize the most important points—including any notable controversies that may exist." If you're going to mention that the United States routinely does, you're obligated to mention the fact that other developed nations do not in order to avoid misleading the reader. I hate to assume bad faith, but it seems as if you're trying to mislead the reader, especially since a common misconception in the United States is that water fluoridation is standard practice among developed nations. Let's hear what other people have to say. I may start a thread over at WP:NPOV/N and WP:MED to see if we can get an audience. II | (t - c) 09:23, 19 November 2008 (UTC)

Saying that 5.7% of the world's population drinks fluoridated water makes it pretty obvious that it's not that common worldwide, no? If you prefer a different concise wording to establish the contrast, please suggest it; but detailed statistics about this country and that region are out of place in the lead, due to the weight problem mentioned above. Eubulides (talk) 09:31, 19 November 2008 (UTC)

Well, no. Call me pessimistic, but I think a lot of American readers who consider themselves educated could take away from that statement that "oh, the US and the rest of the developed world fluoridates water, and the developing world doesn't". I don't think most people have a ballpark understanding of world population numbers. I still think the lead could be added to, especially in terms of evidence. And the CDC is a poor source, considering that its been promoting fluoridation for decades. The cost-benefits / efficacy section should give start with the York review. I may do that tomorrow. II | (t - c) 09:38, 19 November 2008 (UTC)

"Wikipedia is not dumbed down". And even if it were dumbed down, I doubt whether lots of American readers would be so dumb that they would think the developed world constitutes only 5.7% of world population. The revised wording still spent waaaaayy too much weight on prevalance compared to its weight in the body. I made this change to try to bring it back into balance. Eubulides (talk) 06:29, 20 November 2008 (UTC)

Having watched the edit wars for several years...
Would it not be more encyclopaedic to have the first paragraph explain that we are talking about a subject that should fall into the Category:Policy, for that it all it is (and all it can be) until the missing scientific research is conducted.
As it is now (starting with bold assertions) makes it sound like the benefits (or harms) are set in scientific concrete and is thus ensures the edit war continues. I blame med schools for instilling un-realistic view of how health polices come about and why and what is involved in their formulation – (but that's another matter). Having a separate article for the 'controversy' also guaranties polarisation, rather than the coming together and laying out of the known with the unknown.
Whilst some editors are left free to confuse the processes of agreeing policy and the process of scientific evaluation (or systematic review) in their minds, so the article will reflect that confusion don't you think? By always viewing it as just another policy however, it will then be a little easier to create text that explains simply why some countries change their water treatment policies from time to time -without another editor flagging it as POV in respect of one dogma or the other. The amount of 'weight' to give each aspect might also be a little easier to judge. I have seen a lot of editors generate acres of text over this article over the time I have been watching it and much time seems to be spent going back and forth and round and round. Maybe this different approach might help to anchor it.--Aspro (talk) 12:23, 20 November 2008 (UTC)

Major copyright infringement

This edit by 67.135.62.118 (talk · contribs · WHOIS) was a massive copyright infringement from here. I reverted it. Please don't do that. Eubulides (talk) 22:19, 30 November 2008 (UTC)

Evidence-basis changes

This set of edits has some problems:

1. It summarizes the York review as saying "there are no clear adverse effects aside from fluorosis". However, the earlier sentence that summarizes fluorosis talks about more-severe cases caused by too much fluoridation. A naive reader would easily conclude that typical fluoridation would cause these more-severe symptoms.
2. The York study doesn't merely say there are no clear adverse effects. For the most important and well-studied effects (cancers, bone fracture) it says that the best available evidence shows no association.
3. At this point, it would be better to cite Yeung 2008 (PMID 18584000) rather than the York review, done in 2000 (PMID 11021861). The reviews' conclusions are the same, from the point of view of the lead, but Yeung has more-recent data.
4. The set of edits alters the lead to say that WF has been "contentious" and that this is "generating an opposition to water fluoridation". But the contentiousness is not generating the opposition: it's the other way aroudn. The contentiousness is the result of proponents and and opponents arguing.
5. It alters the lead to cite an older source (McNeil 1985) that is not cited in the body. I don't see any reason to cite this older source in the lead; the claim was already well-sourced by a higher-quality and more up-to-date source (Cheng et al. 2007, PMID 17916854). Certainly the lead should not be citing sources that the body does not cite.
6. The set of edits alters Water fluoridation #Evidence basis so that it starts off with a criticism of the quality of the research. However, reliable sources don't start off that way. For example, Yeung's summary of findings (Table 3) starts off "Existing evidence strongly suggests water fluoridation is beneficial at reducing dental caries." We should lead with the primary results, and talk about quality of data later.
7. For sources that are relatively supportive of water fluoridation (the CDC), it gives in-text attribution ("the CDC has attributed"). For sources that are relatively critical of water fluoridation (the York review), it merely states their conclusions without attribution. This gives greater weight to critics of fluoridation, which is a POV presentation.
8. It give great weight and considerable to the York review's statement that it found no cost-effectiveness evidence that met its standards, and it removed the CDC's statement that fluoridation is cost-effective.
9. It removed the mention about the equitability of water fluoridation.
10. It presents the CDC's conclusions and then immediately argues with then ("but this has been disputed by others"). It does not do the same for the York conclusions.

I have attempted to work around some of these problems with this edit and with this edit. Eubulides (talk) 21:44, 21 December 2008 (UTC)

Numbered bullets for easier discussion.

1. I don't mind saying most of fluorosis is mild in order to avoid confusing the reader. It may be better to just use numbers in the body: 48% are expected to have fluorosis, with 12.5% having it at the aesthetic concern level. You may also want to mention the precautions that Australia has taken. I can't recall what Yeung said about how effective that was.
2. It is important to note that distinction. It is also important to note that the York review's conclusion on negative effects aside from bone fracture and osteosarcoma is that the studies "provide insufficient evidence on any particular outcome to permit confident conclusions" (14). The lead should specifically note where the high-quality evidence has been directed.
3. In general, we're trying to cover all the angles of information in the interests of being comprehensive. The Yeung review includes only study more than the York review, so while it is more up to date, its benefits over York should not be exaggerated. Yeung itself says that it largely depended upon the York review. If the Yeung review doesn't cover an angle covered by the York review, we cite the York review. If the two disagree, we note their disagreements. Let me know what your thoughts on this approach are. Since the Yeung review avoids discussing evidence quality and does not contradict the York's reviews conclusions, the York review should be cited.
4. Isn't this like what came first, the chicken or the egg? It seems obvious that the opposition movement would come after certain people contended that fluoridation has not been proven to be justified. Please restore.
5. OK.
6. If we're starting off a section on evidence basis, starting with a summary of the quality seems reasonable. Yeung avoids discussing quality, so the York review was used. I disagree with your conclusions here. We should lead with the quality and the results, since the results are informed by the quality. Anyway, I don't mind how it looks now.
7. The York review is obviously more reliable than the CDC, as it is independent. The CDC has been promoting fluoridation for 50 years and is defensive if someone says the evidence isn't as good as they've been saying. Thus, this is appropriate. However, if you want to attribute the York review's claims, feel free to do so.
8. Again, conflict of interest and reliability. The CDC not only has a conflict of interest, it is also unpublished and thus not subject to peer review. Stating that the reduction in caries in the US can be attributed to water fluoridation could probably not pass peer review. The CDC's cost-effectiveness is based on an unpublished workshop in 1989 which found little high-quality evidence, even before the York's critical review (which changed the dialogue from 50% reduction to 15%). The CDC source here is dated and unreliable.
9. I'm not seeing where I removed it. Anyway, the York review was only able to find C level evidence on the equitability. It's more up to date and more independent. Its conclusions (which are not that there's no evidence) are on page 14. Cite those before the CDC.
10. 5 European nations with neither water nor salt fluoridation have lower DMFTs in 12-year olds than the US. Overall, 10 European countries with no water fluoridation have lower DMFTs than the US. The WHO data is here. Fluoride Action Network has put in a graph her, along with snippets from various reviews. Cheng correctly points out that attributing the reduced cavities to water fluoridation cannot be justified, regardless of what the CDC says. Please put back the fact that this is disputed.

Looking through the changes, I don't have that big of a problem with them, but I don't like the way you've obfuscated how the research has gone. We should actually be getting a bit more specific by mentioning that most of the evidence is before and after studies, which is why the York review criticized it so much. There are no RCTs, even though RCTs are theoretically possible. Describing particular studies, when there have been a few key studies, is good, and you've eliminated that. The York review needs to be given more weight than the CDC in terms of equitability and cited when Yeung cannot be. The lead of effectiveness, that "water fluoridation most effective and socially equitable way to achieve wide exposure to fluoride's cavity-prevention effects" is untenable. It doesn't matter whether Yeung says it, it is just far too questionable and disputed to state so matter-of-factly. The York review had a different interpretation of the same evidence, so its interpretation needs to be included. The fact that the CDC's attribution of lower cavities to water fluoridation is highly questionable needs to be included. I don't understand why or how you can, in good faith, justify removing Cheng and Diesendorf's dispute of the claim. If we can't agree on these things, then we'll have to do some dispute resolution.

1. Yes, it might make sense to give the York numbers for fluorosis in the body of the article.
2. It's not clear that the lead needs to go into details about the difference between no-association and not-enough-evidence, simply because the York review makes that distinction. That sort of detail seems more appropriate for the body. At the level of abstraction appropriate for the lead, almost all major dental and health organizations either have found no association with adverse health effects or support water fluoridation. The lead shouldn't imply anything different, and shouldn't go into a lot of detail that makes it sound like there might be something different.
3. I don't know of any material area where the Yeung review disagrees with the York review. However, the Yeung review is more up to date, covers more material, and comes to more conclusions than the York review does. The Yeung review largely defers to the York review for the effectiveness of water fluoridation, but it also notes the issue of the halo effect, and for dental fluorosis it also relies on Griffen et al. 2001 as well as 11 other additional studies (not covered by the York review). I don't see any reason to omit results from the Yeung review in these areas.
4. If we can't show that contention led to opposition, we shouldn't assert that in the lead. (Just as we shouldn't assert the chicken came before the egg....)
5. OK.
6. If you don't mind how it looks now, let's move on to the more-important matters.
7. It is not at all clear that the difference (if any) in reliability between the York review and the CDC source requires in-text attribution for the CDC but not for York. The CDC has not existed for 50 years, so it can hardly be said to have been promoting anything for 50 years. The CDC is generally recognized as a reliable source on public-health issues, and we shouldn't be inserting text to undermine or dispute its results unless there is a conflict among reliable sources on what we are summarizing here, which there doesn't appear to be.
8. Claims that the CDC have a conflict of interest in this area are fringe claims, and the article should not be based on them. That sort of argument belongs in Opposition to water fluoridation, not here. There is no controversy among reliable sources for any claims in Water fluoridation that are currently sourced by the CDC, so there's no need to have in-text attribution for any of those claims.
9. The point about equitability is now sourced by Yeung 2008, not by the CDC.
10. The point about European results being different is addressed in the body, and is sourced by Burt & Tomar 2007, not by the CDC. I don't see anywhere that Cheng et al. 2007 (PMID 17916854) says anything like "attributing the reduced cavities to water fluoridation cannot be justified, regardless of what the CDC says"; perhaps you could supply an exact quote?

The followup remarks seem to be arguing against the CDC's conclusion that water fluoridation is associated with fewer cavities. But the York and Yeung reviews come to the same conclusions. I don't see why the article should be arguing against this point: it's the mainstream opinion. As per WP:NPOV we should base most of the coverage on the mainstream opinion, not on the fringe opinion that fluoridation does not help against tooth decay. Diesendorf 1986 (PMID 3523258) is way, way, dated; we should not be relying on 20-year-old sources for medical facts and figures, especially when up-to-date sources are available. Cheng et al. 2007 (PMID 17916854) is cited six times in the article; I'm not sure what removal is being talked about here. Eubulides (talk) 08:37, 22 December 2008 (UTC)

Please try not to mischaracterize my remarks. I've never edited to take out statements that water fluoridation reduces cavities, and I said just a second ago that I'm fine with the intro in the Evidence Basis section. What I do oppose is turning the effectiveness section into a fluffy, shallow promotional section. The York review stated that there is not limited evidence on the equitability or the cost-effectiveness. There is some evidence, yes, but it stated that it should be viewed with caution. Clearly, then, McDonagh seems to disagree with Yeung. Or maybe there is no disagreement, and the other public health measures have even less evidence, which allows Yeung to use that superlative. Either way, the evidence quality needs to be presented. Yeung includes only 1 relevant extra study (though categorized as Level IV), which actually found that caries did not increase after fluoridation was discontinued, so there's not a major reason to shut out York's differing interpretation of the evidence. Discussion of the quality of the efficacy should also not be ignored or relegated to a vague statement. In any other medical article, you would certainly be arguing that the quality of the evidence should be taken into consideration when discussing effects. Here's a pop question for you: how many of these before and after studies looked at confounding effects at all (toothpaste use, mouthwash, ect.)? I'll save you time: none. There's a reason the York review was critical and stated that it was "unable to discover any reliable good-quality evidence in the fluoridation literature world-wide".

Burt & Tomar 2007 speculate, without any sources, that better access to dentists for children in Europe explains the decline in cavities. That is just speculation and opinion if there are no sources using data to back it up. Cheng et al write that "[a decline in caries] has occurred regardless of the concentration of fluoride in water or the use of fluoridated salt, and it probably reflects use of fluoridated toothpastes and other factors, including perhaps aspects of nutrition". Similarly, Aoba et al 2002, states that "the dramatic decline in dental caries which we have witnessed in many different parts of the world has occurred without the dental profession being fully able to explain the relative role of fluoride in this intriguing process". II | (t - c) 01:29, 23 December 2008 (UTC)

• Sorry, I don't know what is meant by "mischaracterize my remarks". I don't recall claiming that you "edited to take out statements that water fluoridation reduces cavities", or anything like that.
• There was nothing fluffy or promotional about the effectiveness section. It accurately summarized recent, reliable reviews in the area.
• The York review does not disagree with Yeung on any substantial point. It certainly does not disagree on the issues of equitability and cost-effectiveness. The York review itself (McDonagh et al. 2000, PMID 11021861) never mentions equitability, cost-effectiveness, or caution. The full York report (which is not peer reviewed) says that they briefly researched studies of equitability only in England (not worldwide), and says that cost-effectiveness was outside the bounds of the review. No doubt this explains why issues of equitability and cost-effectiveness were not addressed in the York review itself.
• Water fluoridation gives detailed statistics from the York review, including ranges; surely this should suffice for "quality of the efficacy". It's certainly not vague.
• I don't see how York has a "differing interpretation of the evidence" from Yeung. On points where they both have interpretations, these interpretations substantially agree.
• Certainly the body should talk about the relatively low quality of the evidence. But it does that. What more is needed there?
• Burt & Tomar 2007 are a reliable source, and are giving the mainstream opinion about why the experience in Europe has been different. It substantially agrees with what Cheng is saying. Aoba & Fejerskov write that "Water fluoridation is by far the most cost-effective public health measure in caries prevention", and this does not disagree with their other statement (which you mention) that we can't fully explain how fluoride works.
• For more, please see #Effectiveness, motivation, biological mechanism, etc. below.

Eubulides (talk) 21:23, 27 December 2008 (UTC)

You said that "followup remarks seem to be arguing against the CDC's conclusion that water fluoridation is associated with fewer cavities". There was nothing in my remarks which argued that. What I do object to is the misleading implication that water fluoridation is necessary for low cavities rates, and that the evidence is incontrovertible. That's what you have been pushing, and that is not supported by any reviews. All the comments which are made to qualify the results, you pull out, even though they are highly pertinent. These include the York review's statements that it was unable to find high-quality evidence, the Yeung review's qualification that no studies controlled for topical fluorides, Pizzo's observation that caries have declined significantly in Europe, ect. Since none of this is mentioned, we can't say that these reviews are being accurately summarized. II | (t - c) 21:25, 30 December 2008 (UTC)

• I don't see anything in the article claiming, or implying, that "water fluoridation is necessary for low cavities rates", much less that the evidence is incontrovertible for that. Obviously the article should not say or imply that; if it does, we should fix it.
• Water fluoridation #Evidence basis says "the quality of the research on fluoridation has been generally low" and Water fluoridation #Effectiveness says "little high-quality research has been done on the cost-effectiveness and solid data are scarce". So the point is already being made, prominently, that high-quality evidence is lacking. We should emphasize this point roughly as much as high-quality reviews do, not more.
• Diving into each review, and pulling out just the negative parts of it, is not the right way to summarize what it says. We need to summarize the whole review, accurately, giving the big picture of what it says. For the big picture, it is quite reasonable to mention that evidence is lacking (which is what the article already says); it is not so reasonable to go into an enormous amount of detail as to which evidence is lacking and why, as that will bring on WP:WEIGHT problems, obscuring the big picture that there's widespread consensus among all reliable sources that fluoridation prevents cavities.

Eubulides (talk) 22:23, 30 December 2008 (UTC)

Politics

Following up on the discussion about the unsourced part of the lead in #Evidence-basis changes above, I found a recent reliable source on the politics of fluoridation, Armfield 2007 (PMID 18067684), and used it to source the following rewritten version that unsourced part: "and considerable opposition to water fluoridation exists despite its support by public health organizations". I also used the new source to improve Water fluoridation #Politics considerably, and moved the "top 10" point to Effectiveness, where it belongs better. The new version of Water fluoridation #Politics gives considerably more text to opponents of fluoridation than to proponents, but it does so from the mainstream point of view, so I hope that's OK. Eubulides (talk) 21:51, 22 December 2008 (UTC)

The section looks OK, but it could use a bit of balance. Armfield takes the relatively strong position that all scientific opponents are basically quacks, cites the York review selectively, and cites as one of his most authoritative sources that there is no scientific controversy the 1978 issue of Consumer Reports. It's not accurate to portray the opposition like that, when it includes notable and credentialed researchers such as Hardy Limeback and several other members of the recent NAS panel. Incidentally, even though the contentious -> opposition thing is over, I still don't understand how you can say that opposition can exist without contention. I'm guessing that you regard the contentions of mere citizens to be illegitimate? I'm surprised that you didn't notice the spot where Burt & Tomar mention that research scientists were among the early opponents. They note Sutton's methodological critique in 1959. II | (t - c) 01:29, 23 December 2008 (UTC)

I'm wondering if you'd mind answering my question here? II | (t - c) 21:25, 30 December 2008 (UTC)

By "my question" I assume you mean "I'm guessing that you regard the contentions of mere citizens to be illegitimate?". My answer is "no". I thought it was a rhetorical question and therefore did not require answer; my apologies if you intended it to be a serious question. Eubulides (talk) 22:23, 30 December 2008 (UTC)

Effectiveness, motivation, biological mechanism, etc.

This series of edits has several problems:

• It changed the section header Motivation to Motivation and biological mechanism and added a discussion of the history of fluoride's presumed biological mechanism. As the ungainly title suggests, this is mixing topics. Also, it is better to put historical stuff in the History section; this will allow us to keep the rest of the article up-to-date. I don't see the relevance of a detailed coverage of the dispute over fluoridation's mechanism into this article; this topic may be relevant to Fluoride therapy, but is only marginally relevant here, and it's certainly not relevant to Motivation, as the motivation for water fluoridation is almost entirely independent of how it works.
• It introduced distracting numeric details into the introductory paragraph of Evidence basis, using the following wording "At 1 mg/L 48% of the population is expected to have fluorosis, 12.5% of which is of aesthetic concern." These detailed numbers were introduced only into the part of that paragraph that is negative, which beefed it up and introduced WP:NPOV problems. There is no need for that level of detail in the brief summary; it should be put into the detailed section.
• Furthermore, the numbers are not correct: they understate the amount of fluorosis of aesthetic concern by more than a factor of two.
• Yeung 2008 (PMID 18584000) summarized those numbers in a different way, which is more useful: it gave the number needed to harm (NNH) for fluoridation versus no fluoridation. (This way was also used in the York review.)
• It removed the lead sentence of Effectiveness, thus making the section harder to follow.
• It adds prominence to the York review, mentioning it by name while not mentioning any other reviews by name. In its discussion of the York review it repeats the review's conclusions, which are already discussed; this overemphasis adds NPOV concerns. There is no need to emphasize the York review to this degree: it is not a revolutionary review nor (due to its age) is it the best and most reliable review right now. Any direct mention of it in the text should be in the History section.
• There is no need to give details like "26 studies met its inclusion criteria, all but 3 of which were 'before and after' studies" for the York review, when details like that are not given for other reviews.
• It relegates the more-recent Yeung review to a mere update of the York review. This is an inaccurate summary of the Yeung review. Yeung based its work on effectiveness on the York review's method, but it covered areas that the York review did not, and it refers to many more studies than jsut "one additional relevant study".
• It introduced discussion of that one study, without citing it. There is no good reason to single out that one study and discuss it in detail here; as per WP:MEDRS we should be summarizing reviews, not individual studies. If we do discuss it, we should cite it.
• It inaccurately summarizes the mainstream opinion about why the water fluoridation experience has been different in Europe. The mainstream opinion is that this is because of the other use of fluorides there, even if we don't fully understand how fluoridation works.
• It inserts text like "some believe" and "is believed to" in text supportive of fluoridation, while omitting qualifiers like that in front of text that is critical. This is clearly a POV problem.
• There's no reason, except perhaps in the History section, to talk about the obsolete theory that fluoride operates primarily preeruptively.
• The paragraph starting "Worldwide, a decline in tooth decay has been observed regardless of water or salt fluoridation" contains a string of claims that omit important caveats in the underlying sources and, together, presents a misleading summary of what is known about fluoridation. For example, the very first word in that paragraph, "Worldwide", is completely inaccurate: Box 1 (pp. 699 and 700) of the cited source (Cheng et al. 2007, PMID 17916854) is clearly talking only about EU countries, not about fluoridation worldwide.
• The statement "Water fluoridation has been regarded as extremely cost-effective for the past fifty years" understates the source, Pizzo et al. 2007 (PMID 17333303), which says that water fluoridation has been considered "the most cost-effective measure for the control of caries at the community level".
• The statement "Fluoridation is also believed to increase the equitability of caries prevention" is not supported by the cited source (Pizzo et al.) which says nothing about belief.
• The statement "The dental profession has not been able to fully explain this decline through the use of fluorides" is a inaccurate summary of the cited source, Aoba & Fejerskov 2002, which says that the dramatic decline in dental caries "has occurred without the dental profession being fully able to explain the relative role of fluoride in this intriguing process". That is, Aoba & Fejerskov imply that fluoride can entirely explain the dramatic decline in dental caries, even if we don't understand its mechanism fully; but the statement in Water fluoridation makes it sound like the decline in caries has occurred for reasons unknown, and we can't explain it with fluoridation (an implication that Aoba & Fejerskov do not make).

To help address these problems, along with some more-recently added changes alleging involvement by nefarious industries and Nazis, I have just now installed a series of edits, the most substantial was this one for Water fluoridation #Effectiveness. The result is by no means flawless, but I hope it is an improvement. Eubulides (talk) 21:23, 27 December 2008 (UTC)

Is there a reason that you don't like numbered bullets? It makes it less easy to reference your points. I changed it before, but since you're adopting that, I want to know why before I change it again.

• Motivation and mechanism are inextricably linked, and therefore there's a decent reason to discuss them together. Clearly fluoride's use is motivated by its mechanism? They can be separated if it's a big deal for you, but originally water fluoridation was believed to work almost entirely preeruptively and thus only in children, as the FWRG notes. This is a major fact related to mechanism, and deserves to be noted in that section. If we can't agree to include some historical context in the Mechanism section, we'll have to do mediation or I'll have to open a RfC.
• The Yeung review was a broad review of fluoridation. For efficacy, it relied basically entirely upon the York review, although it did find 1 additional study, which I described and which did not support water fluoridation. Since the Effectiveness section is focused on water fluoridation rather than other types, York is clearly superior to Yeung on water fluoridation's effectiveness. Yeung can be viewed as a collection of reviews, whereas York is a much more focused review of water fluoridation's effectiveness. This can be seen on page 33 of the report, where Yeung writes "[o]nly one additional relevant original study was identified in the current review and this did not change the conclusion of the existing systematic review [York]". For water fluoridation, it cites only two reviews that additional study -- and it says over and over that the York review was the superior one.
• Burt & Tomar do not cite data (or anything) for their assertion. Thus, it should not be stated as fact, as it is now. If something is supported by a careful, focused review of data, as the York review's conclusions are, and cited indisputably, then I'm fine with writing it as fact. It's not POV, and I don't see why we need to start throwing around accusations.
• One can interpret Aoba either way, but clearly if one can't explain fluoride's role in the decline, it's premature to assert conclusively that fluoride does explain the role. In any case, my version did cite Cheng in saying that the decline is largely attributed to fluorides, but mainly topical ones, and was more accurate in that it noted that the research isn't conclusive. If it isn't conclusive, or it's arguable, then we shouldn't put it in the article as if it is conclusive. That's the general problem with your approach to the Effectiveness section.

Should I just go ahead and try to do mediation or a RfC, or can we reach a happy medium on this Effectiveness section which notes the basic qualifications about the evidence raised by York's review, or even by Yeung's review (that the studies did not control for topical fluorides)? Relying largely on the Yeung review when the York review is indisputably the highest-quality review of water fluoridation's effectiveness seems like suffers from WP:RECENTISM bias. We know how up to date the York review is because Yeung did a literature search with its criteria, and found only 1 additional study, which was poor and did not support water fluoridation. Whether the York review is revolutionary or not, no substantive critique has appeared in 8 years; in fact there has been the exact opposite response. II | (t - c) 21:25, 30 December 2008 (UTC)

• In the past, I've found that numbered bullets don't work well on talk pages: people insert text between the numbers and then the numbers go haywire. Anyway, the numbers don't help all that much. It's no big deal either way; please feel free to use numbers in your comments.
• Motivation is "inextricably linked" only in the sense that it's related to fluoridation, and fluoridation is linked to its mechanism. Motivation is equally "inextricably linked" to history, and to the evidence basis, and to politics, and to all the other sections of Water fluoridation. Overall it's better to put historical matters in the History section, to avoid cluttering up the other sections with obsolete stuff. It is certainly better to avoid cluttering up the Motivation section with arguments about why part of long-ago arguments supporting fluoridation were incorrect.
• York is not at all "clearly superior" to Yeung on effectiveness. Yeung is more recent and has better data. Yeung covers every study that York does, and then some. It's rare for high-quality public-health reviews to be significantly worse than reviews done 8 years before, and Yeung is not an exception to this general rrule.
• Burt & Tomar are expert opinion on this subject, and no reliable source disagree with them. There is no reason to insist on Cochrane Collaboration quality reviews for every point in this article: we should be reporting the mainstream consensus, which we are doing in this case.
• There is a difference between not being able to explain every detail of how fluoride actually works (which we can't), and being able to show that fluoride prevents tooth decay (which we can). It's similar to autism: we don't know the exact mechanism for autism, but we do know (because we've done the science) that autism is highly heritable. This is not a question of interpreting Aoba either way: it is a question of whether mainstream scientific opinion is that fluoride prevents tooth decay, which is what the opinion clearly is.
• As mentioned above, the claim in the older version that "Worldwide, a decline in tooth decay has been observed regardless of water or salt fluoridation, and this decline usually attributed to the use of topical fluorides and perhaps nutrition." (citing Cheng et al. 2007, PMID 17916854) is incorrect. Cheng et al. say nothing about a "worldwide" decline: their claim is only about the EU. Cheng et al. do not attribute the decline to "topical fluorides" in general, but instead said that it was probably "fluoridated toothpastes and other factors".
• I'm not sure what "noted that the research isn't conclusive" refers to. The current version notes that fluoridation research is of low quality. That point needs to be made clearly, but it doesn't need to be repeated over and over.
• I agree that the Wikipedia article should not take sides when reliable sources disagree. But there isn't much disagreement here, among reliable sources.
• I don't know what is meant by "Yeung's review (that the studies did not control for topical fluorides)". I don't see anything to that effect in Yeung's review. Can you supply a page number and/or quote from the published review?
• Obviously further changes can be made in this area: Water fluoridation is by no means perfect. But we need to follow the main outline of what the reliable sources say: we should not be emphasizing just the negative parts (or just the positive parts, for that matter).
• I suggest that you propose further changes to address the concerns you raise, in the light of the above comments. I don't think an RfC or mediation is called for at this point, as I think we're still making progress in improving this article.

Eubulides (talk) 22:23, 30 December 2008 (UTC)

Moderate quality etc.

This edit added the sentence 'The evidence was of moderate quality, and none of the analyses controlled for other sources of fluoride.', with the edit summary 'Page 37 of Yeung's full report: "it should be noted that the analyses did not take into account the use of other sources of fluoride".' There are several problems with this edit:

• The cited source is the York review (PMID 11021861), not Yeung 2008 (PMID 18584000), so this text is incorrectly sourced.
• The comment on page 37 of the Yeung full report does not apply to the results of the York review. It applies only to Table 12 (page 38) of the Yeung full report. Pulling that comment out of the Yeung full report and placing it here, out of context, makes it appear that Yeung's comment applies to all of the York study, which it does not.
• The comment on page 37 of the Yeung full report says nothing about "moderate quality", so that part of the text does not seem to be sourced.
• Water fluoridation should not be reach down into the full Yeung report (which was not published in a refereed journal) to emphasize details that Yeung himself did not feel worth emphasizing in the published peer-reviewed article that Water fluoridation is citing. As per WP:MEDRS, the article should rely on peer-reviewed review articles in refereed journals for information about weight.

Eubulides (talk) 01:11, 31 December 2008 (UTC)

Neither the CDC nor Burt & Tomar are published in peer-reviewed articles, so it seems a bit like wikilawyering to say that a government agency report, similar to the CDC's reports, should not be cited. You really want to stick with that argument? I put the Yeung comment in there to answer your question, but I was also aware that the York review supported the statement I put in. The York review states the following:

The most serious defect of the studies of possible ben­eficial effects of water fluoridation was the lack of appropriate design and analysis. Many studies did not present an analysis at all, while others did not attempt to control for potentially confounding factors. Age, sex, social class, ethnicity, country, tooth type (primary or permanent), mean daily regional temperature, use of fluoride, total fluoride consumption, method of measurement (clinical exam or radiographs, or both), and training of examiners are all possible confound­ing factors in the assessment of development of dental caries.

Although I can't find it off the top of my head, I know that the only confounding factors controlled by any of the studies were age and possibly one other thing (not fluorides). I'll switch the statement to be closer to York's review, though. Yeung does relate York's statement that the evidence is of B quality (moderate quality, moderate bias). Use your PDF find function for any of the prior words. Also, Yeung does appear to be referring to all the York review's studies when he says none controlled for topical fluorides, contrary to your statement. II | (t - c) 01:36, 31 December 2008 (UTC)

• Yes, we should prefer high-quality review articles, as per WP:MEDRS. However, the CDC report in question (PMID 11521913) is a special case: it is published in Morbidity and Mortality Weekly Report, which, although not formally peer-reviewed, has a reputation higher than many peer-reviewed medical journals. For example, Olmsted et al. 2006 (PMID 17161735) lists MMWR as the equal of the best peer-reviewed journals as a source of information about infection control: it says, "Among nonpeer-reviewed periodicals, most infection control coordinators hold the CDC's MMWR in high regard. It is unique because the content contains science-based public health information and must meet rigorous criteria for publication (such as originality, quality, and timeliness)." WP:MEDRS already lists MMWR in an approving context, and it is the equal of peer-reviewed medical journals for most Wikipedia purposes.
• Burt & Tomar 2007 are published in a high-quality book Silent Victories: The History and Practice of Public Health in Twentieth-Century America (ISBN 0195150694), published by a respected university press (Oxford) and written and edited by prominent mainstream scientists and historians. While not strictly a peer-reviewed review, it's clearly a high-quality source as per WP:RS and WP:MEDRS. If we find a peer-reviewed review in a journal article, that would be better, but Burt & Tomar will do fine for now.
• Thanks for switching the statement to be closer to what the York review says, by replacing ", and none of the analyses controlled for other sources of fluoride" with ". Many studies did not appropriately control for observer bias and confounding factors, and many failed to use appropriate statistical techniques". I checked the York review (PMID 11021861), and found:

• It talked about "reducing potential observer bias" (p. 859) rather than controlling for observer bias.
• It did not mention "failed to use appropriate statistical techniques", or anything close to that that I could see.
• It said (p. 858) "The most serious defect of the studies of possible beneficial effects of water fluoridation was the lack of appropriate design and analysis. Many studies did not present an analysis at all, while others did not attempt to control for potentially confounding factors." When discussing flaws in the studies, we should be emphasizing this defect. The current wording mentions controlling for confounding factors, which is appropriate, but it does not mention design and analysis.

• I used my PDF find function on Yeung 2008 (PMID 18584000) and could not find anything about controlling for topical fluorides. Could you please give an exact quote and/or a page number? Thanks.

Eubulides (talk) 09:23, 31 December 2008 (UTC)

Asking for a third opinion. 01:47, 31 December 2008 (UTC)

Sorry, what exactly is that 3rd opinion being asked about? WP:3O#Active disagreements says "Disagreement as to whether to include critical statements made by a 2000 review, which were less stridently repeated by a 2008 review which largely depended upon the 2000 review." but I don't know which specific critical statements it is referring to. Eubulides (talk) 09:23, 31 December 2008 (UTC)

If we can agree on how it looks now, then I'll take down the 30 request. But generally I think an outside opinion on the entire situation wouldn't hurt. II | (t - c) 01:07, 1 January 2009 (UTC)

I agree that an outside opinion would help; still, it's not clear right now what the outside editor is being asked to look at. Eubulides (talk) 08:05, 1 January 2009 (UTC)

Caries decline etc.

This series of edits introduces some more problems:

• It introduces the claim "The tooth decay decline in industrialized nations is generally attributed to the use of topical fluorides", citing Pizzo et al. 2007 (PMID 17333303). But Pizzo et al. place an important qualifier on this claim: they are talking only about the decline in caries since the 1970s, not the decline before that.
• A nit: most non-expert readers won't know what a "topical fluoride" is; it needs to be explained.
• It uses the word "but" to oppose Pizzo et al.'s claim to the CDC's claim that the decline in tooth decay in the U.S. since water fluoridation began has been attributed largely to the fluoridation. These claims are not mutually exclusive, and the reliable sources are not opposing them, so we should not oppose them either.
• It inserts the claim "Diminishing returns to fluoride introductions have been observed as topical fluorides became more common, with early studies showing declines of around 50-60 percent and more recent studies in the range of 18-40 percent.", citing the FRWG, but the FRWG does not use the phrase "diminishing returns" and what they do say has nothing to do with with the common meaning of the term "diminishing return" as explained in Diminishing return.
• It inserts the claim "In Europe, many countries have experienced substantial declines in caries without the use of water fluoridation, leading some researchers to speculate that water fluoridation may be unnecessary in industrialized nations.", citing Pizzo et al. But Pizzo et al. do not say "some researchers" or anything like that. This needs to be reworded to avoid saying things that the source does not say. Also, the source says "most European countries", not "many European countries".
• It introduced duplicate citations to Pizzo et al.

I made this further change to attempt to address the above problems. Eubulides (talk) 08:05, 1 January 2009 (UTC)

Your edit looks pretty good. Some comments:

• Clearly there is tension between the CDC's statement that the decline in the US since the 1950s is largely attributed to water fluoridation and Pizzo's statement that the decline since the 1970s is attributed to topical fluorides. But I suppose it's fine the way it is.
• I beg to differ that average readers won't understand that term, but what you added certainly is more precise.
• I can't understand how that could be interpreted as anything but diminishing returns. Please explain how what Pizzo calls a "diminishing benefit" (citing that very same CDC source as well another) caused by the application of more and more of one product on a fixed surface (fluoride) is not a diminishing return. Using the exact same words that the source uses can introduce plagiarism problems. Summarizing with synonyms or well-known conceptual terms such as diminishing returns should not a problem.
• Pizzo et al are researchers, and they are speculating. I think you know that. Could you please explain how this was confusing to you? Certainly it's nothing like original research. Citing the more speculative conclusions of a few researchers with "some researchers" preface is pretty common, and there's nothing wrong with it except that it's awkward stylistically.
• Oh yeah, I meant to do that. Please reintroduce those duplicate citations.

II | (t - c) 09:22, 1 January 2009 (UTC)

• Diminishing returns are when each additional unit of variable input yields less and less output. When applied to water fluoridation, it would mean (I suppose) that each additional mg/mL of water fluoridation would yield less and less reduction in dental caries. But that's not what is being discussed here: the topic is that, in locales where toothpaste fluoridation works better, water fluoridation has less benefits than in locales where toothpaste fluoridation does not work as well. This is a different phenomenon; it is not diminishing returns.
• For Water fluoridation to say that Pizzo et al. are researchers, and that they are speculating, we would need a reliable source saying that they are researchers, and that they are speculating. We don't have such a source, and in the absence of such a source we shouldn't put material like that into the article.
• Even if we had a source for that claim, we shouldn't include it. People read Water fluoridation to find out about water fluoridation, not to find out about Giuseppe Pizzo. More generally, the main text of articles should not mention the identity of sources, as this clutters things up unnecessarily. There are exceptions for notable and/or controversial research, but nothing in Water fluoridation rises to that level.

Eubulides (talk) 19:39, 1 January 2009 (UTC)

• In the context of fluoride, it means that if you use brush your teeth with fluoridated toothpaste every day, drink fluoridated water, and use a fluoridated rinse or varnish, each one has a weaker and weaker effect because you're trying to add more fluoride when fluoride is already there and doing its thing. That's what Pizzo is referring to as a "diminishing benefit". And that is what's being discussed here: water fluoridation has less benefits in areas where toothpastes work better not for a mysterious reason, but simply because toothpastes are more commonly used and applied in areas where it "works better". The article doesn't need to be changed, but I'm surprised you're pushing back so hard against this basic, ubiquitous phenomenon. II | (t - c) 20:57, 1 January 2009 (UTC)

But that's now how fluoride works. It's not a question of adding more and more fluoride, and getting less and less benefit for each addition. On the contrary, it's a question of obtaining an optimal level; for some locations you need to remove fluoride, not add it. So it's not a case of diminishing returns in the classic sense (as described in Diminishing returns). Mentioning the phrase "diminishing returns" here might give the inexpert reader the misimpression that more fluoride is always better. Eubulides (talk) 00:09, 2 January 2009 (UTC)

"Oh yeah, I meant to do that. Please reintroduce those duplicate citations." By "duplicate citations" I meant that this version of the References section contains two copies of the citation to Pizzo et al. 2007 (PMID 17333303), once as reference [14] and once as reference [18] (the latter cited twice). In this edit I coalesced those two copies into a single copy; in the current version of References it is reference [14], cited three times. The total number of citations in the article did not change; it is only the number of copies in References has been reduced from 2 to 1. Eubulides (talk) 20:30, 1 January 2009 (UTC)

I know, I was joking. I forgot to add the / when referencing Pizzo and the bot added the full cite. Could we try to stick to things that matter rather than careless mistakes? Your focus on the above mistake makes you seem a bit robotic. I'm not sensitive about it, and I'll try to make less in the future, but it's not worth raising on the talk page. II | (t - c) 20:57, 1 January 2009 (UTC)

Borrow foundation sources

This edit was reverted by Trendley (talk · contribs) without comment on this talk page, the change log being "Milk fluoridation topic has been subject of discussion already!" I just now searched this talk page and its archives looking for discussion of "milk" and "Borrow" (for the Borrow foundation), and came up dry: I don't see anything relevant to the change.

The edit did four things:

• For less-reliable sources (self-published web pages by the Borrow Foundation) it substituted more-reliable ones (medical journal articles).
• It mentioned that fluoridated milk has been aimed at children, not adults.
• It mentioned that a Cochrane Collaboration review found insufficient evidence to support the practice.
• It removed detailed discussion of a dated example from Beijing.

All these changes seem to be improvements to me. None of these changes, as far as I can see, have been discussed on this talk page before now. On the theory that it's the dated example whose removal was being objected to, I reinstalled the change with one further improvement: an addition that mentions as an example the fluoridation of milk powder in rural Chile. I hope this suffices to remove the objection, whatever it is. Eubulides (talk) 18:45, 3 January 2009 (UTC)

Mechanism

I might have not spotted previous discussions on this, but I think this section is too short. This paper [7] gives a good synopsis of the biological mechanisms. Fluoride alters the tooth enamel and makes it less susceptible to attack by acid produced by bacterial metabolism, but equally importantly, it has a direct anti-bacterial action in that it inhibits bacterial enzymes inside their cells, (enolases I think). Graham Colm ^Talk 10:58, 11 January 2009 (UTC)

Unfortunately that paper (Featherstone 2000, PMID 10916327), although a reasonable one for its time, is somewhat obsolete.

• Soon after it was published, van Loveren 2001 (PMID 11359062) questioned whether fluoride's antimicrobial activity was of practical importance in preventing cavities.
• A couple of years later Marquis et al. 2003 (PMID 12586392) reviewed the area, and concluded "Any inhibitory effects fluoride may have on growth of plaque bacteria are not very pertinent to its anticaries action." The review also said that the antimicrobial-anticaries effects seemingly have to do with the acid tolerance of glycolysis by intact bacteria, not by any direct antibacterial effect.
• More-recent reliable sources state that the major action of fluoride is to inhibit demineralization and to encourage remineralization, and the bacteriostatic action of fluoride is no longer considered to be that well-supported. Here are three examples:

• Selwitz et al. 2007 (PMID 17208642), a recent and reliable review of dental caries, mentions only the demineralization/remineralization effects of fluoride.
• García-Godoy & Hicks 2008 (PMID 18460677), a recent, reliable (and freely-available) source, talks at length about the demineralization/remineralization effects of fluoride, but doesn't mention its antimicrobial effects. On the contrary, when it talks about eliminating bacteria, it limits itself to discussion of pro-biotic and molecular genetic techniques.
• Koo 2008 (PMID 18694872) is a bit more generous about the bacteriostatic theory, writing "Fluoride exerts its major effect by reducing demineralization and enhancing remineralization of early caries lesions (Dawes and ten Cate, 1990). However, there is a plethora of evidence which shows that fluoride, even at low concentrations, can affect the physiology of microbial cells, including cariogenic streptococci (as reviewed by Hamilton, 1990; van Loveren, 2001; Marquis et al., 2003)." That is, Koo isn't saying that fluoride has a significant and beneficial antibacterial action; all Koo says is that fluoride affects bacteria (which is indisputable, but of unknown significance).

Given what recent reliable sources say, Water fluoridation shouldn't be mentioning the obsolescent antibacterial theory, except perhaps in Fluoride #History. Eubulides (talk) 09:27, 12 January 2009 (UTC)

On second thought, perhaps it would be helpful to mention it briefly, if only to say that it's not like fluoride kills bacteria or anything. I added the text "Demineralization and remineralization is how fluoride exerts its major effect. Fluoride also affects the physiology of dental bacteria, although its effect on bacterial growth does not seem to be relevant to cavity prevention." to Water fluoridation #Mechanism. Thanks for the suggestion. Eubulides (talk) 09:54, 12 January 2009 (UTC)

This is the fullest, most lucid and interesting answer to a talk page question I have ever received. Thanks. Graham Colm ^Talk 18:58, 12 January 2009 (UTC)

Good overview

Here is a Canadian governmental paper form 1999 on the benefits and risks of fluoridation. http://www.health.gov.on.ca/english/public/pub/ministry_reports/fluoridation/fluor.pdf

--Doc James (talk · contribs · email) 18:19, 11 January 2009 (UTC)

And another from Quebec in 2007. http://www.inspq.qc.ca/pdf/publications/705-WaterFluoration.pdf

--Doc James (talk · contribs · email) 18:21, 11 January 2009 (UTC)

• The 1999 paper may well have been a good one, but it is outdated and is not published in a peer-reviewed journal. Is there any point that it makes that we can't support with an up-to-date source?
• The 2007 paper is much more up-to-date, but it is not peer-reviewed either. If we can cite a peer-reviewed source on a point, it'd be better to do that than to use this non-peer-reviewed source. That being said, the 2007 paper is of good quality, and is certainly a reliable source for the state of water fluoridation in Québec, as well as for advice about WP:WEIGHT issues. You mention below that it talks about health impacts and about fish. For health effects I think sources like Yeung 2008 (PMID 18584000) are better; for fish perhaps the 2007 paper could be referred to (see #Aquatic life below).

Eubulides (talk) 09:27, 12 January 2009 (UTC)

These are both government papers and well referenced. --Doc James (talk · contribs · email) 16:05, 12 January 2009 (UTC)

True on both counts. But this does not disagree with my comments. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Mechanism and worldwide view

The content of the English article is different from the content of articles about the same topic in other languages. For example, the article on the German Wikipedia mentions that fluoridation works through digestion of fluoride, which is then carried through blood to the teeth, while the English article says it works through fluoride reacting with saliva and plaque. Also, the German article is less favorable concerning water fluoridation than the English article, highlighting the effectiveness of other forms of fluoridation. It also quotes Canadian dentist Hardy Limeback who initially was a strong supporter of water fluoridation and now vehemently opposes it. It thus seems that this article does not represent a worldwide view. This is also supported by the misquote (now corrected) of a WHO paper as supporting water fluoridation, while the paper in effect does not take any position on the issue.

Another argument against water fluoridation is that usually less than 2% of public water supply is used as drinking water, and more and more households avoid tap water completely, relying on bottled water. Treating 100% of tap water with fluoride can thus be considered a waste of money, with decreasing effectiveness as bottled water use increases.--Mschiffler (talk) 03:04, 12 January 2009 (UTC)

• The German Wikipedia article is reporting an obsolete theory about fluoride's mechanism, involving the systemic action of fluoride ("blood to the teeth"). This theory is no longer supported by reliable sources, so the German article needs to be updated. It is now known that the effects of fluoride are primarily topical. This change to our understanding of fluoride's mechanism is briefly mentioned at the end of Water fluoridation #History.
• Hardy Limeback's work is cited several times in Pizzo et al. 2007 (PMID 17333303), a critical review of fluoridation that is cited multiple times in Water fluoridation. As per WP:MEDRS, we should prefer secondary reviews like Pizzo et al. to primary sources like the papers of Limeback.
• The main sources cited in Water fluoridation do reflect a worldwide view. Here is a list of every source that's cited 3 or more times:

• Australia:

• Yeung 2008 (PMID 18584000). This is the most-cited report in Water fluoridation: it is cited 7 times.
• Armfield 2007 (PMID 18067684), cited 4 times.

• Finland:

• Lamberg et al. 1997 (PMID 9332806), cited 3 times.

• Italy:

• Pizzo et al. 2007 (PMID 17333303), cited 3 times.

• UK:

• McDonagh et al. 2000 (PMID 11021861), cited 4 times.
• Cheng et al. 2007 (PMID 17916854), cited 5 times.
• British Fluoridation Society et al. 2004, cited 3 times.
• Jones et al. 2005 (PMID 16211158), cited 3 times. This has 2 UK, 1 Swiss, and 1 U.S. author.

• U.S.:

• CDC 2001 (PMID 11521913), cited 6 times.
• Reeves 1986, cited 4 times.
• Bailey et al. 2008 (PMID 18614991), cited 3 times.
• Burt & Tomar 2007 (in ISBN 0195150694), cited 3 times.

Roughly 1/3 of these citations are to U.S. sources. Given that the U.S. originated community water fluoridation, and that about half of the world's people who receive fluoridated water live in the U.S., this if anything is underweighted for the U.S.

• The WHO supports both fluoridation in general and water fluoridation in particular. The cited WHO source (Petersen 2008, PMID 18630105) said that the WHO recommends that "particular emphasis should be laid on" several elements, one of which is "Establishment of national plans for use of fluoride, based on appropriate programmes for automatic administration of fluoride through drinking-water, salt, or milk, or topical use of fluoride such as affordable fluoride toothpaste." It is true that the WHO does not support water fluoridation over and above other forms of fluoridation, but Water fluoridation never said otherwise. Water fluoridation did not quote the WHO at all, so I'm not sure what is being referred to by the "misquote (now corrected)". However, to help clarify the issue, I'll adjust the mention of the WHO to also cite the WHO report by Petersen & Lennon 2004 (PMID 15341615), which says "Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages" compared to other fluoridation techniques.
• The cost argument against fluoridation is not supported by reliable sources. One occasionally runs into the cost argument among the antifluoridation fringe, and so it'd be reasonable to discuss it in Opposition to water fluoridation, but not here. Newbrun 1996 (PMID 9034969) mentions the argument briefly, saying "Opponents have argued that since only a very small fraction (less than 0.1%) of public water supplies is actually drunk, most being used for other purposes such as washing, watering gardens, and flushing toilets, water fluoridation is inherently wasteful. Of course, the same logic also would stop water chlorination as wasteful." Newbrun then goes on to give the standard discussion of how fluoridation is cost-effective even though most public water is not ingested.
• Water fluoridation #Implementation already covers the use of bottled water (filtered water too).
• This edit inserted a couple of instances of "U.S." in the phrases "Almost all major U.S. health and dental organizations support water fluoridation" and "Despite support by public health organizations and authorities in the U.S.", but the cited source (which is Australian) is talking in general, and is not limiting its comments to the U.S. I therefore removed these instances of "U.S.".
• The same edit, with the comment "Corrected inaccurate quote of World Health Assembly 2007 document", inserted text saying that the WHO "does not have a position on water fluoridation". As mentioned above, this is not correct: the WHO favors several forms of fluoridation, one of them being water fluoridation. I made this edit to try to clarify the situation, by citing another source on the topic.

Eubulides (talk) 09:27, 12 January 2009 (UTC)

This paper at its end gives a list of all the organizations that support fluoridation. It list over a hundred. Well most are American many are international. http://www.inspq.qc.ca/pdf/publications/705-WaterFluoration.pdf --Doc James (talk · contribs · email) 16:18, 12 January 2009 (UTC)

There is a similar list (oriented for the UK instead of for Canada) in Support for water fluoridation (PDF). But do we really need detailed lists like that here? Surely this would be better to put into a subarticle about the controversy. At the high level, the important thing is that mainstream medical support is nearly universal, and we have a reliable source to that effect. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Faced with the evidence, I rest my case. Those who worked on the article have clearly done a lot of thorough research with impressive results. I was not familiar with Wikipedia:MEDRS and I am impressed by the high standards applied to sources, which even discard peer-reviewed primary research. The only thing I would suggest for the process of improving this article further is to keep in mind, as always, that many readers will not be nearly as familiar as you are with the topic. Therefore it may make sense to write a section to dispel some views that apparently are basic misconceptions, such as the transmission of fluoride to teeth through blood. As ridiculous as some of these views may sound to experts, this seemed plausible to me. The article itself did not convince me until I saw your reaction to my comment.--Mschiffler (talk) 01:29, 13 January 2009 (UTC)

Fluoride Action Network

Without wanting to take any position on this controversial issues, it seems that the article could benefit from adding the views of opponents to fluoridation beyond just the conspiracy theorists of the Cold War. For example, in the case of the U.S., some information from http://www.fluoridealert.org/ could be added. It seems that the activities of FAN are notable. It also seems that they raise issues not raised in the article, such as health impacts of fluoride compounds and the impact of fluoride on fish (not sure how valid they are, though).--Mschiffler (talk) 03:24, 12 January 2009 (UTC)

The above two Canadian paper touch on these points.--Doc James (talk · contribs · email) 04:43, 12 January 2009 (UTC)

The Fluoride Action Network is not a reliable source for information about water fluoridation. As per WP:MEDRS, Water fluoridation should not rely on web sites like that. Newspapers like the New York Times are more reliable than the Fluoride Action Network, but WP:MEDRS says the article should not rely on them for medical facts and figures either. As per WP:MEDRS, the article should not even be relying on primary studies published in peer-reviewed medical journals. Instead, Water fluoridation should use the highest quality secondary reviews published by reliable, peer-reviewed medical and scientific journals. Eubulides (talk) 09:27, 12 January 2009 (UTC)

Point well taken. I saw now that they are mentioned in Opposition to water fluoridation, where their positions belong.--Mschiffler (talk) 01:33, 13 January 2009 (UTC)

Population ≠ water systems

This edit replaced "two-thirds of the U.S. population on public water systems" with "two-thirds of U.S. public water systems". That is not at all the same thing, as most U.S. public water systems are small and have few users, and smaller water systems are less likely to be fluoridated. Also, that change removed the phrase "U.S. researchers discovered that"; but this phrase summarizes a big chunk of Water fluoridation #History, and without it that entire section would not be represented in the lead. I attempted this fix of the problem. Eubulides (talk) 09:27, 12 January 2009 (UTC)

Thanks for the headsup on my talkpage. The article now reads fluoridation prevents cavities, and it is now used by two-thirds of the U.S. population on public water systems. This could be ambiguous. Are two thirds of the US population on public systems or do two thirds of public systems use it. I guess the second is intended but this then begs the question as to how many have flouridated water. I'll leave it to others to fix. Happy to leave the plug for the US.Mccready (talk) 10:37, 12 January 2009 (UTC)

Thanks for the comment. I changed the wording to read "fluoridation prevents cavities, and it is now used by 61.5% of the U.S. population"; that's much simpler and corresponds better to the following "5.7% of people worldwide". Eubulides (talk) 10:52, 12 January 2009 (UTC)

Needs a section on ethics

Part of the controversy is about can we as a government / medical organization administer medication (fluoride) to people without their consent.

http://www.cda-adc.ca/jcda/vol-67/issue-10/578.pdf

This is dealt with on the page about opposition to water fluoridation, which should be changed to controversy around water fluoridation. The only people we are allowed to lock up for medication reason are those that are a risk to themselves or others. We are not allowed to force treatment on adults even if lack of such results in their death. But than we add iodine to salt and vitamins to flour so why not fluoride to water? The section on ethics is a little short.

--Doc James (talk · contribs · email) 16:27, 12 January 2009 (UTC)

It's true that the discussion of ethics is brief. But that is because it's written in summary style, with the main article about ethical concerns being elsewhere. It's not at all clear that ethics requires a whole section to itself in this article; that would raise WP:WEIGHT and WP:NPOV issues. It wouldn't hurt to add another sentence or two about ethics to Politics, though. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Does require a section under controversies I think... --Doc James (talk · contribs · email) 20:18, 12 January 2009 (UTC)

OK, I added an attempt at a section, citing the source mentioned above, along with 3 other relevant sources. Eubulides (talk) 23:13, 12 January 2009 (UTC)

Other review

I have looked at some of the literature. There are reviews that support fluoride in water and there are reviews that do not. The following does not. Oganessian E, Lencová E, Broukal Z (2007). "Is systemic fluoride supplementation for dental caries prevention in children still justifiable?". Prague Med Rep. 108 (4): 306–14. PMID 18780642.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Verses this review which says it is still a good idea. Kumar JV (2008). "Is water fluoridation still necessary?". Adv. Dent. Res. 20 (1): 8–12. PMID 18694870.

I have some concern with the POV of this article. Most supporting info is in the main article well non supporting info has been move to the article on opposition to fluoride. I know for a controversial article these two are hard to combine. But I think for this to reach good article status it should combine the two. What is becoming obvious is that the US supports fluoride. Canada is sort of in the middle and much of Europe does not. Why this is so is not really addressed.

--Doc James (talk · contribs · email) 16:41, 12 January 2009 (UTC)

I am aware of both reviews but do not currently have access to either. I am quite leery of citing works that no editors have read. If we can find reliable sources about why the U.S. supports fluoride and Europe does not, then we can cite them; but I am skeptical that reliable sources exist in this area, and it is not reasonable to require a Wikipedia article to answer questions that reliable sources do not answer. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Have access to both if you are interested. Limiting research to only that which is freely available is a bit restrictive. --Doc James (talk · contribs · email) 20:10, 12 January 2009 (UTC)

Yes, I am interested. I agree that we should use the best sources, even if they are not freely available. What's the next step? Can you summarize what they say? Most important, what would they add to the article that is not there already? Eubulides (talk) 23:13, 12 January 2009 (UTC)

The goal, by the way, is to describe fairly what reliable sources say about water fluoridation, according to the principles of WP:NPOV and WP:WEIGHT. Most of the negative material discussed in Opposition to water fluoridation is supported only by unreliable sources; it may be suitable for an article about politics but it is out of place here. Eubulides (talk) 23:13, 12 January 2009 (UTC)

Florosis

Saying that florosis in not a concern is a bit presumptuous and dated. --Doc James (talk · contribs · email) 16:43, 12 January 2009 (UTC)

Water fluoridation does not say that fluorosis is not a concern. It says only that the fluorosis caused by water fluoridation is mostly not considered to be of aesthetic concern. This is the mainstream consensus; the source for that claim is Yeung 2008 (PMID 18584000), which is certainly not dated. I know of no reliable source that disputes the claim, and can easily cite other reliable sources that agree. Eubulides (talk) 17:29, 12 January 2009 (UTC)

This lines looses me a bit: "At the commonly recommended dosage, the only clear adverse effect is dental fluorosis, most of which is mild and not considered to be of aesthetic concern. Compared to unfluoridated water, fluoridation to 1 mg/L is estimated to cause fluorosis in one of every 6 people, and to cause fluorosis of aesthetic concern in one of every 22 people"

Is it saying that mild dental flourosis is not a concern? Or that all flurosis is not a concern? It is than followed by a statement that 1 in 22 causes is an aesthetic concern? Sorry it makes my head spin.  :-) --Doc James (talk · contribs · email) 20:16, 12 January 2009 (UTC)

It is saying that most of the fluorosis is both (a) mild and (b) not of aesthetic concern. (It is not saying that all fluorosis is not a concern; severe fluorosis would be.) It is saying that fluoridation causes 1/6 (16.7%) of people to have fluorosis, and 1/22 (4.5%) of them to have fluorosis of aesthetic concern; by simple subtraction this would mean fluoridation causes 4/33 (12.1%) of people to have fluorosis that is not of aesthetic concern. With all this in mind, can you suggest a way to rephrase the sentence to make it clearer? Eubulides (talk) 23:13, 12 January 2009 (UTC)

Aquatic life

This edit added the following text to Water fluoridation #Safety:

Relatively little is known about fluoride's toxicity to aquatic life, and as of 2003 safe levels for aquatic life had not yet been determined. Discharges of municipal fluoridated water significantly increase the fluoride concentration in recipient rivers to about five times the natural background level, and fluoride can adversely affect invertebrates and fish at about 0.5 mg/L. The most sensitive animals are net-spinning caddisfly larvae and upstream-migrating adult salmon.[citing Camargo 2003, PMID 12656244] However, one 1990 study concluded that water fluoridation was likely to increase total river fluoride concentrations by only 0.001-0.002 mg/L.[citing Osterman 1990, PMID 2400035]

Camargo 2003 is not a reliable source on water fluoridation or on fluorides in the environment. In p. 85 of the chapter "Effects of inorganic fluorides on animals" of the book Fluorides in the Environment (ISBN 0851996833, dated 2004), Weinstein & Davidson write:

"Finally, in a review, Camargo (2003) suggested than in soft waters with low ionic concentrations the safe level should be below 0.5 mg F/l. Apart from the fact that effects at such levels have not been confirmed by sufficient authors and that a very limited range of species and genotypes has been investigated, there has been insufficient research into the effects of cations like aluminium. Nor have there been any long-term field studies at the community level. It is dangerous to extrapolate from simple, acute laboratory tests to recommending a limit that is unattainable."

Given the dubious quality of Camargo's review, and the fact that the review is not about water fluoridation but is about fluoride toxicity, we should not be citing it here, on both WP:RS and WP:OR grounds. Water fluoridation's existing text briefly talks about "no adverse effects" on "downstream rivers", and this is a high-quality summary of what reliable mainstream sources say; adding relatively-extensive discussion of a fringe theory fails on WP:WEIGHT and WP:FRINGE grounds. I therefore removed the text based on this source. Eubulides (talk) 09:27, 12 January 2009 (UTC)

One offhand critique does not suddenly make a PubMed-indexed, relatively recent review from an environmental researcher who has published over a couple dozen articles on the topic or closely related topics suddenly fringe and unreliable. A 2001 Canadian research report on the topic concluded that 0.12 mg/L was an appropriate interim standard, so clearly 0.5 mg/L is not that unreasonable. In fact, Pollick says that 0.5 mg/L is difficult to reach, and also says it 0.5 is dangerous to salmon. So Weinstein and Davison don't seem to be very up on their facts. By the way, I forgot to add that Camargo says the natural background level of a typical river is about 0.05 mg/L. 5 times that is 0.25 mg/L - he cites two studies for his statement that fluoridated water discharge increases levels by 5 times. Anyway, let's hear what other people have to say. You're certainly jumping to conclusions when you say Camargo is fringe and unreliable because Weinstein & Davison say his adverse effect level is overly cautious. I'm sure that many industry-supported scientists would say that, since he said that aluminum and phosphate industries increase the fluoride levels of water the most (10 and 100 times background levels, IIRC). If I felt like jumping to conclusions as quickly as you, I could flip it and say that since Camargo has more experience in environmental research, he should be given more weight than Pollick, who is not an environmental researcher but rather a fluoridation proponent. But I'm not going to do that. II | (t - c) 01:24, 13 January 2009 (UTC)

Weinstein & Davidson are not an "offhand critique"; they are reflecting mainstream opinion. Nor is Camargo's piece a secondary source (in the sense of WP:RS) of the topic of the effect of water fluoridation on the environment, as Camargo is reviewing his own work in that area. If Camargo had reported something of real interest with respect to water fluoridation, we would have expected to see other serious researchers build on his work. We have not; instead, what we've seen is unusually strong skepticism. Eubulides (talk) 18:55, 13 January 2009 (UTC)

WP:lead

This article is really very good. One thing that need to be address however is WP:lead before it can be promoted to GA. --Doc James (talk · contribs · email) 19:11, 13 January 2009 (UTC)

• Thanks for the comment. I modified the lead to try to address these concerns.
• One other thing: this recently-installed change to Water fluoridation #Ethics and politics has some WP:OR and WP:NPOV problems, but I haven't yet had time to review it carefully.

Eubulides (talk) 21:28, 13 January 2009 (UTC)

The only place I could see a possible WP:OR problem is mentioning the York review's critical statement, although that general statement is highlighted by Cheng and has served as a bit of a rallying point for opponents. Although the scientists are a minority, they should not be unduly marginalized as uninformed peasants. I'm not saying you've done this -- you've done a very good job -- but Armfield does marginalize them while other sources, including Burt and Tomar, describe them fairly neutrally. If you can find a reliable source which neutrally discusses the dissenting scientists in a more critical manner, feel free to add it. Also, although most sources on here won't mention it, the Dutch Supreme Court did rule fluoridation illegal in Denmark according to Denmark biologist Kim Bruning. He provided the source there. There's little reason to think that Arvid Carlsson is lying when he says that Sweden ruled similarly. II | (t - c) 20:51, 14 January 2009 (UTC)

I wonder whether it is worth mentioning that the York review was mentioned favourably by Ben Goldacre, a science journalist who is scathing about quackery and pseudoscience. He gave it as an example of the kind evidence-based medicine that journalists ignore or misinterpret because they are looking for an either/or story when the reality is more complex. On a related point, the abstract of the York review that we link to gives the confidence intervals for the proportions affected by fluorosis, and they are very wide. The full report presumably also has the confidence intervals. Although it will be more difficult to find a fluent wording accessible to lay readers, it would be better to give the confidence intervals instead of the means and/or medians. Itsmejudith (talk) 21:34, 14 January 2009 (UTC)

Thanks for the comment and suggestion. The Ben Goldacre remark might be suited for the controversy subarticle, but it'd be a bit out of place here, as this article focuses on fluoridation (not on the fluoridation controversy) and shouldn't be advocating its own sources. I added the 95% CI ranges to the text. Eubulides (talk) 21:48, 14 January 2009 (UTC)

Thank you for doing that, and good point. Itsmejudith (talk) 21:52, 14 January 2009 (UTC)

Given that the York reviewers were worried that the review was being misrepresented and said so in 2003, I don't think it is WP:OR to include their critical comments in the politics section. II | (t - c) 23:23, 14 January 2009 (UTC)

Neutrality of the evidence basis section.

I am concerned that the section "Evidence Basis" is at times presenting the evidence in favor of fluoridation as if the quality of the research on fluoridation very strong despite the first paragraph mentioning "the quality of the research on fluoridation has been generally low.". When statement "The introduction of fluoride toothpaste in the early 1970s has been the main reason for the decline in tooth decay since then in industrialized countries." seems to the imply that there is unanimous acceptance of fluoride toothpaste effect in reducing tooth decay when as I understand it there are competing theories for the reduction. One way to improve the section is the attribute the claims in favor of fluoride to the studies and meta-analysis that support them rather using language that implies the claims are undisputed by anyone. While it's true that the supporters outnumber the critics, the number of critics is still significant enough to warrant mention of their view on the flaws in the current research within the section.

--Cab88 (talk) 08:09, 14 January 2009 (UTC)

• If the article explicitly states "the quality of the research has been generally low", then what wording, specifically, is giving the impression that the quality is very strong?
• What "competing theories for the reduction" are there? If that claim about fluoride toothpaste is disputed by reliable sources, then presenting both sets of sources would be helpful; but I'm not aware of any such dispute.

Eubulides (talk) 08:19, 14 January 2009 (UTC)

IQ, hazmat fees, etc.

• This set of edits by 71.174.189.146 (talk · contribs · WHOIS) inserts several claims:

• There is a correlation between water fluoridation and mental retardation (or reduced IQ). The cited source is fluoridealert.org, an unreliable source for water fluoridation. And the source itself [8] does not claim that there is a correlation between water fluoridation and anything. Furthermore, the studies it mentions are not about water fluoridation: they are about naturally fluoridated water above the recommended levels. So this claim is not only not reliably sourced, it's original research to say that the (unreliable) source is about water fluoridation.
• Fluoridation is motivated by polluters wanting to get rid of toxic products they'd otherwise have to pay haszmat fees for. No reliable source is given.

• Also, insertion of phrases like "widely claimed" and "stated" (in front of "goal") and "Until recently" were made, without any support for these phrases among the cited sources.
• Because of these problems with the core Wikipedia policies of WP:V and WP:OR, I reverted the changes. If we can find reliable sources (not published in fringe web sites etc.) that support the claims, we can revisit the issue.

Eubulides (talk) 10:06, 14 January 2009 (UTC)

GA

Well done with all the changes. This page now fulfills wiki GA criteria and has been tagged as such. Congratulations.

--Doc James (talk · contribs · email) 16:02, 15 January 2009 (UTC)

Politics improvement

Water fluoridation #Ethics and politics had some problems. One paragraph talked about the arguments involved, which is fine, but the next rehearsed some old arguments against fluoridation and mentioned some individual fluoridation opponents. This section shouldn't be arguing against fluoridation, nor should it focus on individual opponents; that sort of detail is best left for Opposition to water fluoridation. However, it does make sense to discuss the nature of the opposition in general, using recent reliable sources and focusing on the overall movement rather than on individuals, so I rewrote the second paragraph to do that, in this change. I kept the reliable sources that talked about politics, while omitting articles that talked about efficacy, or were individual statements by opponents (this is too much detail). Eubulides (talk) 21:38, 15 January 2009 (UTC)

Should we semiprotect?

Water fluoridation was featured on Coast to Coast AM last night. Coast-to-Coast is a nightly conspiracy theory talk show. The show discusses several fringe theories that have been brought up in the discussion page (see the 1/14/09 edits above this post). I'd expect this particular page to be a vandal/fringe magnet for the next couple of days. Cheers. Murphy2010 (talk) 01:42, 15 January 2009 (UTC)

Darn. User Eublides beat me to it. Murphy2010 (talk) 01:43, 15 January 2009 (UTC)

It's getting pretty bad. I just now asked for page protection. Eubulides (talk) 19:58, 16 January 2009 (UTC)

I have semi-protected the article for three days and I will extend this if needed. Congratulations on the GA b.t.w. Graham. Graham Colm ^Talk 22:53, 16 January 2009 (UTC)

Fluoridation and adults

This edit changed "Fluoridation prevents cavities in both children and adults." to "Fluoride prevents cavities in both children and adults." with the comment "The article referenced in footnote 7 does not specifically address water fluoridation but rather fluoride when applied professionally, etc..". The comment is incorrect. It is true that the referenced article, Griffin et al. 2007 (PMID 17452559) also covers self- and professionally applied fluoride; but Griffin et al. separately and specifically covers water fluoridation, and says:

"How Effective is Community Water Fluoridation in Preventing Caries? The combined results of the 9 studies (7853 participants) examining the effectiveness of water fluoridation were significant at p < 0.001 (Table 2). Among the 7 studies including only lifelong residents of control or fluoridated-water communities (5409 participants; Appendix Table 8 and Appendix Fig. 2), the summary relative risk ratio was 0.654 (95% confidence interval [CI]: 0.490–0.874); this is equivalent to a prevented fraction of 34.6% (95%CI: 12.6%–51.0%). Heterogeneity was present. Heterogeneity was not an issue when we pooled the 5 fluoridation studies published after 1979 (2530 participants); the summary-prevented fraction was 27.2% (95%CI: 19.4%–34.3%)."

To help make this clearer I replaced "Fluoride" with "Water fluoridation", and in the next paragraph replaced "Fluoridation" with "Water fluoridation". Eubulides (talk) 07:48, 24 January 2009 (UTC)

Cumulative toxin, etc.

This edit has some good points, but also has several problems:

• It inserts the claim "fluoride is a cumulative toxin" into the lead, but this claim's source is an unreliable web site, and the claim does not summarize anything in the body. Please see WP:MEDRS for what constitutes a reliable source for medical facts and figures, and WP:LEAD for why the lead should summarize the body. The phrases "water fluoridation" and "cumulative toxin" appear often in WP:FRINGE sources, but hardly ever in reliable sources; Water fluoridation should not be emphasizing the fringe claim.
• It inserts the text "It is currently believed that" in front of a claim that the optimal level of fluoridation is 0.6 to 1.1 mg/L. Good point about the "optimal"; that word isn't in the cited source (Yeung 2008, PMID 18584000) and should be removed here. However, Yeung does not say "it is currently believed that"; it says "It is recommended ... that water be fluoridated in the target range of 0.6–1.1 mg/l...". Better to say "recommended" than "believed" here.
• It replaces "Fluoridation prevents cavities" with "Fluoridation is believed to increase resistance to cavities", but the cited sources (Yeung 2008; and Griffin et al. 2007, PMID 17452559), which are reliable, do not say "believed" or "increase resistance to", they simply say "prevents".
• It adds the word "Unfortunately,", which is WP:POV, and is not in the cited source (Yeung 2008).
• It removes the text "Fluoridation is not associated with other adverse effects." which is supported by a reliable source (McDonagh et al. 2000, PMID 11021861).
• When talking about fluorosis, it replaces the well-sourced text "most of this is mild and usually not considered to be of aesthetic concern" with the unsourced text "though this may be mild". The source for the original text is Yeung 2008. Let's stick with what the source says.
• It replaces "the quality of the research has been generally low" with "The quality of the research into the ill effects of fluoride has been generally low". The cited source uses phrases like "potential adverse effects" or "possible adverse effects"; it never says "ill effects". Good catch, though, as the source says that safety studies (not effectiveness studies) are almost all of low quality; the text needed to be revised to say this.
• It adds the text "there are many hypothesis of ill effects caused by fluoride, including cancer, hypothyroidism, and even increased risk of tooth decay" to the lead. These hypotheses are not supported by mainstream sources, are briefly and properly discussed in the Water fluoridation #Safety (with reliable sources cited there), and as per WP:WEIGHT should not be emphasized in in the lead; nor should an unreliable source be used in the lead.
• It inserts the text "Some argue that" in front of the claim "Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care" but the cited source (Burt & Tomar 2007, in ISBN 0-19-515069-4) doesn't say "some argue", and inserting the "some argue" here is clearly an editorial attempt to deprecate a reliable source. The "may" (which is in the source) is enough qualification here.
• It removes the point that tooth decay is a chronic disease. This point is well-sourced to Selwitz et al. 2007 (PMID 17208642).
• It removes the point that tooth decay's burdens fall particularly on children and the poor, also well-sourced to Selwitz et al.
• It replaces "Almost all" with "Most" in front of the phrase "major public health and dental organizations support water fluoridation", but the cited source (Armfield 2007, PMID 18067684) says "almost all", not "most".
• It moves the mention of salt, milk, and toothpaste fluoridation up a paragraph, next to the discussion of bottled water, but it's more logical to mention alternate fluoridation techniques next to the mention of Europe, which uses them.
• In the lead sentence. It replaces "to reduce" with "for the purpose of reducing". Lead sentences are supposed to be short and to the point; this extra verbiage gains readers nothing.
• It replaces "Fluoridation's goal" with "The goal of fluoridation"; again, isn't shorter wording better in the lead?

As per WP:RS, WP:MEDRS, and WP:WEIGHT, Water fluoridation should use reliable sources (preferably high-quality medical reviews) and should reflect mainstream opinion in proportion to its weight. It's not our job to argue with the experts, even if we disagree with them. I made this edit to try to fix the problems noted in the above remarks. Much of this is reversion to the previous version, when I couldn't glean any improvements out of the changes; but in some cases (noted above) there were good ideas in the changes and I tried to keep all these. Eubulides (talk) 06:04, 20 January 2009 (UTC)

The York review says in section 12.9, their overall conclusion, that the quality of the research is generally low. They do seem to be referring to research in general. I don't mind your changing it to refer to only adverse effects studies since moderate quality effectiveness studies do exist. I'm guessing that they passed up a lot of lower quality effectiveness studies. II | (t - c) 18:10, 20 January 2009 (UTC)

Thanks for mentioning this, since I didn't summarize York quite right in my previous change. Please see #York review's summary of research quality below. Eubulides (talk) 19:08, 20 January 2009 (UTC)

York review summary of research quality

Section 12.9 is of the York review is in their full report, which wasn't published in a peer-reviewed journal. The peer-reviewed paper (PMID 11021861) uses slightly-more-cautious wording and is more appropriate here. Its abstract says "The quality of studies was low to moderate." The discussion says that all effectiveness studies used "were of evidence level B (moderate)", that all fluorosis studies "were of evidence level C (lowest quality), except one level B study", of cancer studies "Eighteen of these studies were of evidence level C and eight of level B", of other possible adverse effects "quality of these studies was low; all studies were of evidence level C", and in conclusion "little high quality research has been undertaken". When I wrote the above-mentioned followup patch and talked about effectiveness studies, I mistakenly read only about the fluorosis studies, which were almost all of low quality; it would be more accurate to summarize all sets of studies (in the body) and to use the "little high quality research has been undertaken" idea in the lead. I made this change to try to reword the text to match the source better. Eubulides (talk) 19:08, 20 January 2009 (UTC)

Response to Above

Hi! It was my edit that you've paved over. I'm very concerned with the neutrality of this article, which was my motivation for my scope-widening edit. This article currently reads as though there are virtually no differing opinions which is, of course, quite incorrect. Rather the article should cleanly reflect that there exists differing opinions and leave the reader to decide for themselves. Also, I noted that you mentioned one of the websites I cited as "unreliable", however I must say that this article is full of website sources of questionable reliablity. While certainly the website citation in question was also of a low caliber, selectively filtering web sources is a dubious practice. In the end, I this article could be made significantly better by openly addressing concerns and letting the reader consider all things together.

Finally, I think there should be some care with the quotes. The article can not be a collection of quotes concatenated together. It has to be readible and as such should have good transitions. If you object to my changes then by all means find another way to make the article coherient in a way you feel is more representative of the sources. Selevercin (talk) 15:24, 31 January 2009 (UTC)

• Among reliable sources on water fluoridation, the opinions don't differ all that much, and the article currently reflects this. There are WP:FRINGE opinions that the article also mentions, but as per WP:WEIGHT the article should not emphasize them, or give them "equal time".
• The criteria used to determine which sources are reliable are given in WP:MEDRS. Generally speaking, the best sources are secondary sources published in reliable, peer-reviewed medical journals. Self-published web sites are very low on the reliability scale, and should be avoided when discussing medical facts and figures. I'm not aware of any such source in the current article, but if there is one, please mention it here.
• There aren't any quotes in Water fluoridation, so I'm not sure what the comment "care with the quotes" is referring to. Which transitions in particular are the problem? Certainly the article's prose could be improved, but I don't see much transition-improving in the edit in question.

Eubulides (talk) 15:49, 31 January 2009 (UTC)

Health Dangers

From the EPA...

http://www.epa.gov/safewater/contaminants/index.html#inorganic

"Potential Health Effects from Ingestion of Water / Sources of Contaminant in Drinking Water: Bone disease (pain and tenderness of the bones); Children may get mottled teeth; Water additive which promotes strong teeth / erosion of natural deposits; discharge from fertilizer and aluminum factories"

From the CDC...

http://www.cdc.gov/Fluoridation/safety.htm

http://www.cdc.gov/FLUORIDATION/safety/infant_formula.htm —Preceding unsigned comment added by 98.219.52.189 (talk) 21:38, 30 January 2009 (UTC)

Thanks for mentioning these sources. I made three changes to mention the points raised by the sources:

• This edit talks about the recent increases in prevalance of dental fluorosis in industrialized countries.
• This edit covers fluorosis and infant formulas.
• This edit cites the 2006 NRC report and mentions the consequences of higher levels of fluoridation.

Eubulides (talk) 06:36, 1 February 2009 (UTC)

Recent edits strayed from sources

The recently-installed set of changes has a series of problems. Generally speaking, the changes appear to have been made without references to what the cited sources say, and cause the text to diverge from the sources in material ways. For each change, I'll list the affected text, with inserted text in italics and removed text struck out.

• "Drinking fluoridated water creates low levels of fluoride in throughout the body including the saliva". The cited source, Pizzo et al. 2007 (PMID 17333303) do not support the revised claim: they don't talk about "throughout the body".
• "Water fluoridation prevents cavities in both children and some adults.". The cited source, Griffin et al. 2007 (PMID 17452559) doesn't say "some adults". Its results talk about all the adults studied. It says "The combined results of the 9 studies (7853 participants) examining the effectiveness of water fluoridation were significant at p < 0.001 (Table 2)." Table 2 says "Water fluoridation, all adults, coronal caries (9 studies; 7853 participants; Eklund < 0.001 et al., 1987; Englander and Wallace, 1962; Grembowski et al., 1992; Hunt et al., 1989; Morgan et al., 1992; Murray, 1971; Stamm et al., 1990; Thomas and Kassab, 1992; Wiktorsson et al., 1992)" with a combined p-value <0.001.
• "Fluoridation is not possibly associated with other adverse effects". The cited source, McDonagh et al. 2000 (PMID 11021861), doesn't say "possibly"; it says there was "no clear evidence of other potential adverse effects." We should probably use wording closer to the source here, but the "possibly" is further from the source, not closer.
• "Existing evidence strongly suggests that water fluoridation may prevents tooth decay." The cited source, Yeung 2008 (PMID 18584000) says "strongly" and does not say "may"; it says "Is intentional water fluoridation more effective than no water fluoridation in prevention of dental caries? Existing evidence strongly suggests water fluoridation is beneficial at reducing dental caries." We should say "reduce" rather than "prevent" though.
• "The best available evidence shows no is unconclusive association with other adverse effects." The cited source, McDonagh et al. 2000, doesn't say "inconclusive" or anything like that. However, in rereading the sources it appears that this "best available evidence" phraseology comes from the full report rather than from the peer-reviewed summary, and the text should be reworded to match that of the peer-reviewed summary.
• "research into other potential adverse effects has been almost all of low quality" This statement was well-sourced: the cited source, McDonagh 2000, under "Other possible adverse effects", says "The quality of these studies was low".
• "Water fluoridation is the most an effective and socially equitable way to achieve wide exposure to fluoride's cavity-prevention effects." This change strays from the cited source, Yeung 2008, which says "Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride." (my emphasis)
• "and has contributed to the dental health of children and adults worldwide" The cited source, CDC 2001 (PMID 11521913), says "adults also benefit from fluoride, rather than only children, as was previously assumed."
• "A 2000 systematic review found that fluoridation was possibly associated with a decreased proportion of children with cavities" The cited source, McDonagh 2000, does not say "possibly"; it says "Water fluoridation was associated with an increased proportion of children without caries and a reduction in the number of teeth affected by caries."
• "Fluoridation also prevents cavities in adults of all ages though at a much lesser rate as adult teeth are already hardened" The cited source, Yeung 2007 (PMID 17891121) does not support the new text; it doesn't talk at all about hardened text, and the percentage of averted caries for adults (estimated 27%) is less than the percentage for children (about 40%), but the cited source doesn't say "much lesser rate". The 27% figure is already mentioned in the text, and it would help to also mention the 40% figure, without saying "much lesser" (which would be WP:OR).
• "(9575% confidence interval [CI] 19–34%)" The cited source, Griffin et al. 2007 (PMID 17452559) talks about the standard 95% CI, not a 75% CI.
• "The decline in tooth decay in the U.S. since water fluoridation began in the 1950s has been attributed largely to the fluoridation" The cited source, Bailey et al. 2008 (PMID 18614991), says "largely"; it says "The decline in the prevalence and severity of dental caries (tooth decay) in the United States during the past 60 years has been attributed largely to the increased use of fluoride". However, now I see it's talking about fluoride, not fluoridation, so that should get fixed.
• "The introduction of fluoride toothpaste in the early 1970s has been may be the main reason for the decline in tooth decay since then in industrialized countries though no high-quality studies support such a claim." The cited source, Pizzo et al. 2007, say "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the early 1970s". It cites 5 studies. It does not say anything about "no high-quality studies".

To fix the above problems I reverted the edits in question, and then installed the following fixes:

• Reword the summary of the York Review to match more closely what the peer-reviewed version said, namely, that there is no clear evidence of other adverse effects.
• Remove claim that the decline in tooth decay in the U.S. since 1950 is attributed largely due to water fluoridation. It's attributed to fluoride in general, not to water fluoridation in particular.
• Say that fluoridation reduces rather than prevents tooth decay, when summarizing Yeung 2008.
• Mention the 40% reduction of cavities in children.
• Say "Fluoride" rather than "Fluoridation" when summarizing Yeung 2007.
• Say "Water fluoridation" rather than plain "fluoridation" when it's not clear that we're talking specifically about water fluoridation.

Eubulides (talk) 06:39, 8 February 2009 (UTC)

Problems with recent edits about Europe

This recently installed edit has some good points, but some problems (noted below) as well. In each quote below, italics marks inserted text and strikeouts deleted text.

• "It is controversial, and opposition to water fluoridation has been based on ethical, legal, safety, and efficacy grounds." The substance of this change is fine, but the wording is a bit odd, as the pronoun "it" comes before the nounphrase that it designates, and it's not clear (unless one already knows) whether the "it" refers to the fluoridation or to the opposition to fluoridation. To fix this, I replaced the above text with:

"It is controversial, and opposition to it has been based on ethical, legal, safety, and efficacy grounds."

• "... conversely, in Europe, most industrialized countries have experienced substantial declines in tooth decay by using fluoride toothpaste and other products instead without its use.<ref name=Pizzo/> Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care and less exposure to topical fluorides.<ref name=Burt/>"

• That "industrialized" isn't supported by the the cited source (Pizzo et al. 2007, PMID 17333303), which says that "most European countries" (not "most industrialized European countries") have experienced a substantial decline.
• The new phrase "less exposure to topical fluorides" is not supported by the cited source (Burt & Tomar 2007, in ISBN 0-19-515069-4). Their discussion (pp. 315 and 316) doesn't mention topical fluorides in particular; instead, it talks about two things, namely lack of access to dental treatment (in particular, "professional fluoride attention") and reducing "dental health disparities that exist between socioeconomic groups".
• Pizzo et al. talk about topical fluorides, but strongly emphasize toothpaste. They write "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the early 1970s [6, 9, 11, 26, 29]. The diminishing benefit from CWF has been also attributed to the large use of the other fluoride-containing products, including mouthrinse, dietary supplements, and professionally applied or prescribed gel, foam, or varnish [6, 26]." This emphasize the role of fluoridated toothpaste; other fluorides (which are not necessarily topical) are clearly secondary.

To try to fix the above problems, I replaced the above-quoted text with:

"conversely, in Europe, most countries have experienced substantial declines without its use, primarily due to fluoride toothpaste.<ref name=Pizzo/> Fluoridation may be more justified in the U.S. because of lack of access to dental care and of socioeconomic inequalities in dental health.<ref name=Burt/>"

Eubulides (talk) 07:03, 14 February 2009 (UTC)

Disputing the factual accuracy and neutrality of the Yeung study PMID 18584000

Here's the beef:

• The study is published in a journal not listed in JCR 2007: Evidence-Based Dentistry, despite being published by NPG, is rather obscure journal, not even in top 50 of dentistry journals! (Because of this I also don't have access to it)
• The sentence sourced from that journal is the 1st one used in the Effectiveness section giving it WP:UNDUE weight given the issue above
• The sentence, which is a copy&paste job from the abstract is a rather meaningless PC-drivel: "Water fluoridation is the most effective and socially equitable way to achieve community-wide exposure to fluoride's cavity-prevention effects".
  • Most effective it isn't; see the CDC 2007 study, PMID 17452559, where it's below average.
  • So, it's probably the only "socially equitable way" to give people fluoride. What did Yeung compare it with to come to this conclusion? Giving free toothbrushes and toothpaste? I'm asking this seriously. Someone with access to the paper please explain how he came to this conclusion. My honest conclusion from the face of it is this is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research.
  • Also, see this metaanalysis (same journal; but this one is old enough that access is free) that comes to somewhat different conclusion: "At the moment one should not rely on water fluoridation as the only means of bringing about equality in dental heath." (Yes, I realize that it's not the exact same question, but relevant nonetheless.)

Xasodfuih (talk) 02:31, 17 February 2009 (UTC)

The claim that Yeung 2008 (PMID 18584000) "is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research" is an unsupported opinion that does not withstand serious scrutiny. Addressing the comments one by one:

• "rather obscure journal"

• Evidence-based Dentistry began as a supplement of the British Dental Journal and became independent in 2000. Being newer, it understandably has a lower impact factor. However, it is quite a respectable dental journal in its area, namely, evidence-based medicine as applied to dentistry. As noted, one of the two sources cited in the above comment (namely Hausen 2002, doi:10.1038/sj.ebd.6400102) was published in Evidence-based Dentistry, which undermines the argument that EBD is an low-quality venue.

• No it doesn't; just because a somewhat contradictory result was published in the same venue, it doesn't make the venue anymore reputable. You have clearly committed a logical fallacy here. Xasodfuih (talk) 13:42, 17 February 2009 (UTC)

• My comment was not a purely logical argument: arguments about reputation are rarely pure matters of logic. This does not mean that my comment had no force. Evidence-based Dentistry is a respectable venue, perhaps the most respectable journal in the world on its titular topic. Eubulides (talk) 18:55, 17 February 2009 (UTC)

• The study in question, Yeung 2008 (PMID 18584000), is a reliable source by any reasonable standard. Its author has published several papers in the area of dentistry in general and fluoridation in particular. For example, Yeung is the lead author on the Cochrane Library review of fluoridated milk for preventing tooth decay (Yeung et al. 2005, PMID 16034911).

The Cochrane argument may not be strong. Unfortunately Cochrane teams, for example in acupuncture, have been unduly influenced by those with an agenda. Kevin McCready (talk) 14:00, 17 February 2009 (UTC)

• If even Cochrane is not good enough, then what is? Should we erase all of Water fluoridation{'}s sources and throw the article away? After all, none of its sources are published in venues better than Cochrane. I don't see evidence of an undue agenda in any of the Cochrane reviews that Yeung has helped coauthor; these are Yeung et al. 2005 (PMID 16034911) on fluoridated milk; Hayashi & Yeung 2003 (PMID 12535474) on ceramic inlays, and Nadin et al. 2003 (PMID 12535462) on pulp treatment. Again, no evidence has been presented to support the claim that Yeung 2008 (PMID 18584000) is an unreliable source, much less that Yeung "is not science". Eubulides (talk) 18:55, 17 February 2009 (UTC)

• Yeung 2008 is currently the highest-quality review available on water fluoridation. The other two of the top three are McDonagh et al. 2000 (PMID 11021861) and Truman et al. 2002 (PMID 12091093). All three reviews are cited in Water fluoridation, but Yeung 2008 naturally is cited the most often as it reviews more-recent studies than either McDonagh et al. and Truman et al., and covers more water-fluoridation-related issues than either of the earlier two reviews do.

• I strongly disagree that it's the "the highest-quality review"; this is your very subjective assessment. I agree however that McDonagh's (aka York report) is highly respected, and widely discussed, much more so than Yeung's. Xasodfuih (talk) 13:46, 17 February 2009 (UTC)

• It's correct that it's my own assessment, as is your assessment that McDonagh et al. is better. I agree the York review is respected, and has been discussed much more than Yeung has. Also, the York review is older, which on the plus side contributes to its citation count, and on the minus side means it's relatively dated. The Yeung review has the advantage of starting from the York review (which it largely defers to, on the issue of effectiveness) and then covering more material. For example, Yeung also covers the issue of the halo effect, and for dental fluorosis it also relies on Griffin et al. 2001 (PMID 11300171) as well as 11 other additional studies not covered by the York review. There is no good reason to omit these results here. Eubulides (talk) 18:55, 17 February 2009 (UTC)

• The cited conclusions of Yeung 2008 do not disagree with the conclusions of either of the other two major reviews on water fluoridation. There is obviously some controversy among reliable sources about water fluoridation, but it's in other areas, not here.

• "giving it WP:UNDUE weight" The topic in question comes up as the first sentence of the Recommendations section of the abstract of Yeung 2008, so it's clearly a weighty issue to Yeung. It is not for us to second-guess the weight given by reliable sources, unless of course we can find other equally-reliable sources disputing the weight in question. I doubt whether we'll be able to find that: the issue of equitable access comes up quite a bit in this area.
• "meaningless PC drivel" The phrase is summarizing what a reliable source says on an important topic. It neither meaningless, nor politically-correct, nor drivel.
• "Most effective it isn't; see the CDC 2007 study, PMID 17452559" The CDC study does not disagree with Yeung's claim. The CDC study says that community water fluoridation is about as effective for adults as fluoride from any source, e.g., fluoride toothpaste when the adults brush teeth properly. Yeung's claim is about community-wide exposure to fluoride, a different topic which also covers the case when adults (or children) don't properly brush their teeth.
• "What did Yeung compare it with" Yeung does not explicitly state what he compared community water fluoridation to. His paper and the corresponding full report (the latter is also cited in Water fluoridation, and is freely readable) cite many sources on various forms of fluoridation, which presumably formed the basis for his statement.
• "this is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research." I see no evidence to support this claim of bad faith, and I am extremely skeptical of the claim. Using this sort of unsupported argument, one could just as easily reject every source that Water fluoridation currently uses, which would not be reasonable.
• "At the moment one should not rely on water fluoridation as the only means of bringing about equality" That quote from Hausen 2002 (doi:10.1038/sj.ebd.6400102) does not contradict Yeung's statement. Furthermore, Hansen's commentary cites no studies dated after 2000, and significant work published since then exists in the area of water fluoridation and social equity. See, for example, Armfield 2005 (PMID 16255452), which Yeung's full paper cites.

Eubulides (talk) 08:52, 17 February 2009 (UTC)

• That's a cross-sectional study. It is not different in any significant way, except perhaps sample size, from other studies of this nature that have been done before. Xasodfuih (talk) 14:58, 17 February 2009 (UTC)

• Sorry, I've lost content; I don't know which study the previous "cross-sectional study" comment refers to. Eubulides (talk) 18:55, 17 February 2009 (UTC)

(undent) Other methods of applying fluoride are indeed far more effective for individuals. So perhaps any misunderstanding by a reader who may not focus on the qualification of "community-wide exposure" needs to be headed off. Kevin McCready (talk) 14:00, 17 February 2009 (UTC)

Indeed, this is what the "clarify me" tag was for. I think a FA-level article should explain this better. Unfortunately some long term editors here appear to be in constant "battle mode" and just reject any changes/objections; somewhat understandable given how Opposition to water fluoridation reads (i.e. POV fork). Xasodfuih (talk) 14:23, 17 February 2009 (UTC)

To summarize my concern: water fluoridation is "the most effective" in narrowly defined circumstances, probably so narrowly defined that nothing else qualifies as a competitive intervention ("community-wide exposure"). The BMJ editorial that introduced the York metaanalysis makes the following observations wrt. varying effectiveness [9]: Xasodfuih (talk) 14:59, 17 February 2009 (UTC)

“ In terms of benefits, the only aim of community water fluoridation is to prevent dental caries. A recent review of the effectiveness of water fluoridation in the United States shows that previous reductions in mean caries scores of one half to two thirds are no longer attainable because other methods of providing fluoride and the availability of products containing fluoride have reduced the prevalence of caries, thus diluting this measurement of effectiveness.(PMID 9034970) Similar findings have been reported from the United Kingdom.(PMID 8634899) The reduction in the relative effect of fluoridation, which is also seen in the systematic review by McDonagh et al has generally not been big enough to call into question the justification for fluoridating water.(cites York)

However, a much larger reduction occurred between 1973 and 1982 among 13-15 year olds in Finland: in 1973 the score of decayed and filled teeth was 43% lower in a fluoridated area than in a low fluoride area, whereas in 1982 there was no difference.(PMID 3861658) In Finland preventive dental care is provided free to all children, and this reduction shows that the relative effect of fluoridation can vary strongly depending on different circumstances.

”

I have looked at the lengthy original report and see no support for "the most effective and socially equitable way" statement. It did not appear amongst the numerous question subject of the systematic review. Just like the York review, the NHMRC review compared water fluoridation to no water fluoridation, and often relied on the York review for evidence e.g.:

“ Research question: Is intentional water fluoridation more efficacious than no water fluoridation in the prevention of dental caries?

The existing body of evidence strongly suggests that water fluoridation is beneficial at reducing dental caries. After adjustment for potential confounding variables, McDonagh et al (2000a) showed in their systematic review [...]

Research question: Is the use of topical fluoride supplementation more efficacious than no topical fluoride supplementation in the prevention of dental caries? There is consistent Level I evidence from existing systematic reviews and a review of additional original studies that topical fluoride agents reduce caries in children, when compared to no topical fluoride supplementation.

Research question: Is a combination of topical fluoride supplementation products more efficacious than a single topical fluoride supplementation product in the prevention of dental caries? There is Level I evidence that some combinations of topical agents may be more effective at preventing/reducing caries than single agents.

”

There is no comparison between various delivery methods. Finding the "the most effective" delivery method was not a a "research question". Ergo, the conclusion from the Yeung summary paper is his editorial opinion, and should be presented as such not as a bare fact. Xasodfuih (talk) 18:01, 17 February 2009 (UTC)

Thanks for all that work! To try to address the problem, I rewrote the claim to attribute it to the Yeung review in-text, and deemphasized it by putting it at the end of the paragraph rather than the start. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Changes early on 2009-02-17

The changes made early on 2009-02-17 UTC were mostly fine, but had three problems:

• Adding the {{dubious}} and {{Clarifyme}} templates isn't called for; this is discussed further in [[#Disputing the factual accuracy and neutrality of the Yeung study PMID 18584000|the previous talk-page section]]. Yeung 2008 (PMID 18584000), the cited source, is a reliable one. I'll leave the tags there for a bit to give the editor who installed the tags time to respond.
  • I have replaced them with more appropriate tags (see explanation in the section above). Xasodfuih (talk) 13:53, 17 February 2009 (UTC)
• A placeholder {{see also}} to Skeletal fluorosis and Fluoride poisoning was inserted at the start of the Safety section, with a comment "these would be better introduced in this section by saying that they don't happen at normal concentration". However, that section's 3rd paragraph already covers that issue, and wikilinks to both Skeletal fluorosis and Fluoride poisoning. Perhaps the 3rd paragraph was overlooked?
  • Indeed I had overlooked that; apologies. Xasodfuih (talk) 13:53, 17 February 2009 (UTC)
• Adding the illustration Image:FluorosisFromNIH.jpg is inappropriate for the Safety section. Using this image would convey to the casual reader the incorrect impression that water fluoridation causes severe enamel fluorosis. It would be greatly misleading to scare readers in this way.

Eubulides (talk) 08:52, 17 February 2009 (UTC)

• A similar picture (of better quality, equal severity, but copyrighted) appears in connection with water fluoridation in the source cited in the caption. If you find the factually correct caption misleading to a casual reader please adjust that instead. Or find a suitable picture of milder dental fluorosis— this was the only one available on commons. A FA should be well illustrated, and given that dental fluorosis is an aesthetic issue, a picture is very necessary. Xasodfuih (talk) 13:53, 17 February 2009 (UTC)

• I share your desire for better illustrations. I have looked hard for pictures, and have found none that are both free and appropriate here. As an aside, it is really amazing how poorly this stuff is documented on U.S. government [i.e., free] web sites.
• I would like pictures of teeth with no fluorosis at all, with fluorosis that is not of aesthetic concern, and fluorosis that is mild but is not of aesthetic concern, as these are the realistic images that one should have in an article about water fluoridation. Scary images of severe fluorosis are not appropriate here. It is better to have no picture than to have a highly misleading picture.

Eubulides (talk) 18:55, 17 February 2009 (UTC)

• I don't agree. The wiki has this in the 3rd paragraph of the Safety section (not added by me): "Fluoride can occur naturally in water in concentrations well above recommended levels, which can have several adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones. In 2006 the U.S. National Research Council recommended lowering the Maximum Contaminant Level Goal for fluoride, or known safe level independent of cost and feasibility, from its current value of 4 mg/L.[44]" This is exactly what was illustrated with that picture; a better quality picture, but showing a similarly severe dental fluorosis was given in the summary for the source [10]. Apparently the authors did not consider it misleading. Xasodfuih (talk) 19:36, 17 February 2009 (UTC)

• The coverage of fluoride well above recommended is somewhat tangential to Water fluoridation. It is present in the Safety section only to make it clear that we're not talking about increasing fluoride to levels so high as to cause fluorosis at the higher levels of severity.
• It would be heavily misleading if that section were illustrated by a picture of moderate or high levels of fluorosis, as the casual reader would see just the picture, and would think that it is a common or significant consequence of water fluoridation. It is not. The source cited in the previous comment is not about water fluoridation; it is about the consequences of fluoride well above recommended levels. It would be quite misleading to use its image here.
• It may well be that the current wording doesn't make the above points clearly enough, namely that the effects of fluoride well above recommended levels are not that relevant to the safety of water fluoridation. If so, we should improve the wording.

Eubulides (talk) 20:44, 17 February 2009 (UTC)

• Before I waste my time with Photoshop, do you find the left image from here acceptable? Xasodfuih (talk) 20:01, 17 February 2009 (UTC)

That's such a poor quality picture, it is hard to tell what is camera noise (which often shows as yellow splodges) and what is fluorosis. I'm not keen on trusting some dentist's home-made before/after pics either. This is an article on the artificial addition of fluoride to the water supply. So the effects of natural levels above those recommended aren't relevant. I wouldn't support the sort of pic from the paper Xasodfuih cites, which is clearly not the result of water fluoridation. This isn't an article on dental fluorosis in general. I'd be uncomfortable with any fluorosis pic in this article unless its source indicated this was typical of that produced by water fluoridation alone, and Eubulides' suggestion of a set of pics would be ideal (and avoid WEIGHT issues). But I don't think such a pic is required for FA and the article has ample appropriate pics for the topic. Colin°^Talk 20:37, 17 February 2009 (UTC)

I agree with Colin. The image on the left in Image:Fluorosisb&a.jpg has real problems. First, most of what the casual reader would see in that image is stain, not fluorosis. Second, we don't know how its fluorosis severity corresponds to the fluorisis of concern with water fluoridation. Much better would be the images in The Vermont Dept. of Health's page on fluoridated water, but alas, these are copyrighted. Eubulides (talk) 20:44, 17 February 2009 (UTC)

Section title for "Safety"

Shouldn't this be better called "side effects" since the main adverse effect is an aesthetic one, thus not a safety concern? Xasodfuih (talk) 15:19, 17 February 2009 (UTC)

I'd need further convincing. The section is broader than side-effects in that it covers bone-fracture risk and skeletal fluorosis. Kevin McCready (talk) 15:25, 17 February 2009 (UTC)

You have a point, but "safety" alone is too narrow of a title methinks. Call it "Adverse effects and safety" (or the other way around) then? Xasodfuih (talk) 15:42, 17 February 2009 (UTC)

I'm not fussed either way but I think safety alone covers it and has the advantage of simplicity. Kevin McCready (talk) 16:51, 17 February 2009 (UTC)

I don't have a strong opinion, but also mildly prefer the shorter title Safety. Eubulides (talk) 18:55, 17 February 2009 (UTC)

The research done on water fluoridation's safety is such that the high-quality assessments from the York review and the National Academy of Sciences don't conclude "water fluoridation is safe". That's stated in the section to some degree, although it could be made clearer, and it is in contrast to the opinions of public health agencies in fluoridating countries and the US, which have considered fluoridation safe since their inception. In science, you only find what you're looking for (what you've collected data on). Since we haven't really looked closely for many adverse affects, they won't show up on the radar. Even among the things that have been looked for, there's been a few positive, statistically significant osteosarcoma studies and other cancer relationships. II | (t - c) 18:41, 17 February 2009 (UTC)

Suggestions for specific wording changes to help clarify this would be helpful. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Nothing is absolutely safe. But the York and later NHMRC report do answer specific questions. Letters to the BMJ editor following the York report did point out that other questions have not been answered, e.g. the possibility of adverse effects of fluoride on the thyroid gland. McDonagh's reply ends with this: "Our review of water fluoridation is specific and appropriately narrow in focus. It is not the answer to the question of whether or not to fluoridate. Our review found a benefit in the form of reduction in caries, balanced against a dose related increase in fluorosis. We said that no clear evidence of other potential negative effects was found. We have been assiduous in our paper, our full report, and our contacts with the media, not to convey a message of no evidence of harm. We suggest caution against overinterpretation of our results and emphasise again that the quality of these data on benefit and harm is only low to moderate." I'm not sure that more cautionary statements are needed in this article though. YMMV. Xasodfuih (talk) 19:18, 17 February 2009 (UTC)

US maps somewhat misleading

The 2007 NHMRC report has a map (p. 19) showing that the Western US has a natural level of water fluoridation above 1.5mg/L. This should be at least said in the text, but preferably a map showing this natural level should also be presented. Xasodfuih (talk) 16:25, 17 February 2009 (UTC)

Might want to replace the southern Arizona map. Come to think of it it's pretty US focused. Kevin McCready (talk) 16:54, 17 February 2009 (UTC)

The NHMRC world map would be great, much better than the Arizona map as it has worldwide scope; but it's copyrighted, and in the meantime the Arizona map is the best free map I've found on the topic. The NHMRC map does not say that the entire Western U.S. has a fluoride above 1.5 mg/L; it merely says that higher-fluoride water is associated with the Western U.S. As can be seen from the Arizone map, a good-sized chunk of southern Arizona has water less than 2 mg/L (and I assume also less than 1.5 mg/L). I will look into adding text to the effect of what that world map says; that should be easy. Copying the map would raise copyright issues. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Requesting source verification for a Pizzo statement

"The introduction of fluoride toothpaste in the early 1970s has been the main reason for the decline in tooth decay in industrialized countries.[PMID 17333303]" It does not appear in the freely available 1st page on Springer, and I'm not having much luck with dentistry journals (this one is not so obscure, it's in top 20 or so for dentistry). Xasodfuih (talk) 23:22, 17 February 2009 (UTC)

It checks out (thanks to User:ImperfectlyInformed). Having read this paper I came to the (rather sad) conclusion that starting from the same studies (as other recent reviews) Pizzo et al. spin the spin ever so subtly towards the conclusion they prefer. The "which is the best delivery route for fluoride" question so far has been answered only by expert/narrative reviews rather than anything more systematic. And the conclusions differ in a rather predictable way. So this is how it should be presented. Xasodfuih (talk) 03:13, 18 February 2009 (UTC)

2009-02-17 changes

This recent set of edits had some problems:

• It added a {{pn}} tag after the claim "which is roughly equivalent to preventing 40% of cavities." A simple text search for "40%" in that source (Yeung 2007, PMID 17891121) will find the claim on the source's first page, which says: "The findings of the York review showed that there was a median change of 14.6% in the proportion of caries-free children, roughly equivalent to a prevented fraction of 40%." It is surely unnecessary to record a page number in a source that has only two pages.
• It changed the URL for the York final report from http://www.york.ac.uk/inst/crd/pdf/fluorid.pdf (which is the report itself) to http://www.york.ac.uk/inst/crd/fluorid.htm (which is a web page about the report) without changing the rest of the citation to match the new URL.
• It added the text "Adverse effects other than fluorosis, bone fracture, and cancer lack sufficient evidence to reach a confident conclusion.", citing the York Review. The York Review does not say this, or anything like this. It says that there is no clear evidence of any potential adverse effects other than dental fluorosis. I see nothing in the review about "confident conclusion", and nothing about "Adverse effects other than fluorosis, bone fracture, and cancer". Anyway, this sentence isn't needed here once we undo the change described in the next bullet.
• It removed the text "Some adverse effects lack sufficient evidence to reach a scientific conclusion.", citing Yeung 2008. This claim is hardly controversial, and serves as a useful introduction to the containing paragraph.
• It added the text "In contrast, reactions to fluoride have been reported in case studies and a 1974 double-blind study which found a gastrointestinal reaction to water fluoridated at 1 mg/L.", citing the NRC 2006 report. But the NRC 2006 report is specifically not about water fluoridation, and we should not be suggesting conclusions about water fluoridation based on that study. Furthermore the 1974 report is an old primary study on a subject that was reviewed by all the more-recent reviews on the subject that we already cite; as per WP:MEDRS, we should definitely not be using older primary studies to argue positions not taken by newer reliable reviews on this subject. Recent reviews are unanimous in saying there's no clear evidence of adverse effects other than dental fluorosis, and we should not be implying the contrary.
• More generally, this edit is building on the idea that the NRC 2006 report is important to the issue of water fluoridation. The study itself says that it is not. As the study is on a relatively marginal and local issue (should some advisory maximum level in the U.S. be changed? but water fluoridation goes nowhere near that level), it would be better to drop the study entirely, briefly mention the WHO suggestions in this not-that-relevant area, and move on. This will fit better into the Wikipedia aim of having a worldwide view.Eubulides (talk) 09:16, 18 February 2009 (UTC)

Responses:

• I got Yeung 2007 confused with Yeung 2008. Sorry.
• This is another thing which was pointless to point out, but thanks for changing the template.
• The York reviewers later commentary in the British Dental Journal clearly states that adverse effects other than those I noted don't have enough evidence to reach a conclusion. So does Yeung's full report. On the other hand, I'm looking at the published Yeung 2008 and he doesn't seem to say anything about these things. The sentence is too vague. Ironically, correcting the vagueness supports your POV, since it implies that confident conclusions can be made about cancer and bone fracture.
• The NRC 2006 report is the most focused review of the toxicology of chronic fluoride exposure. It has some conclusions which are clearly relevant to fluoridation, and these can be used -- especially if we have misleading text which directly contradicts what they've found, like the current citation to a single primary source which doesn't agree with the rest of the literature. Your argument sounds like wikilawyering, and this is an area where I won't budge. Should I raise it at WP:RS/N?
• It's not building on that idea at all. If the NRC comments on effects of fluoride exposure at the level used in fluoridation, these comments can be noted. I hadn't planned on citing it for other effects, but I won't let a biased and misleading summary of the literature remain in this article.
• The NRC report has gathered a lot of attention. It suggests that the margin of safety has been underestimated, it motivated concerns about excess exposure in children, and it's a source which opponents cite. Further, its chairman and 3 of its (12) members criticized fluoridation after it was published in a recent Scientific American article. Removing it makes the article seem biased. II | (t - c) 18:24, 18 February 2009 (UTC)

• "The York reviewers later commentary in the British Dental Journal clearly states that adverse effects other than those I noted don't have enough evidence to reach a conclusion." Thanks, I hadn't see that. I'll undo that change.
• "The NRC 2006 report ... has some conclusions which are clearly relevant to fluoridation". That report clearly states, multiple times, that it does not evaluate or make conclusions about the practice of water fluoridation. Its page 16, for example, says "As noted earlier, this report does not evaluate nor make judgments about the benefits, safety, or efficacy of artificial water fluoridation." We should not be second-guessing the authors of the report in order to say or imply that their conclusions are indeed about the safety of water fluoridation.
• "the current citation to a single primary source which doesn't agree with the rest of the literature" Which citation is that? Sorry, I've lost context.
• "The NRC report has gathered a lot of attention." That's quite true, but that does not mean it needs to be cited here, nor that its results are relevant. It focuses on whether the U.S. should remove more fluoride from water that is naturally fluoridated well above recommended levels. It can be cited on that question, but that is a different question, and is not a central issue to the safety of water fluoridation. We should not cite it in a misleading way, to imply that its results were intended to be about water fluoridation.
• The current text of Water fluoridation gives the lower WHO guideline of 1.5 mg/L, which makes the NRC report (which asks "should we lower some nonbinding U.S. advisory goal from 4 to 2 mg/L?") sort of a tempest in a teapot. It's about a question that is not that relevant to water fluoridation, and it's a local matter where we already have a global guideline, which is more conservative anyway.

Eubulides (talk) 00:01, 19 February 2009 (UTC)

Xaso's changes

This further set of recent edits made several improvements (thanks!) but had some problems:

• It inserts the text "In countries where caries prevalence has declined, the single common factor appears to be flouride toothpaste." which is a direct quote of the cited source without quote marks. The article generally does not use the word "caries", preferring the common terms "tooth decay" or "cavities"; we can rewrite it using these terms. Also, the "single common factor" text duplicates some of the next sentence; some rewriting can trim that. (Also, the "Thus" is not directly supported by the cited source, and should go.)
  • For minor adjustments like that you should just go ahead and do them; there's no need to post lengthy justifications here. Most likely nobody is going to object, and it will take less time for everyone involved (you writing, me reading). Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
• It inserted the text "Due to the paucity of studies in adults, this metaanalysis included studies without blind outcome assessment and cross-sectional studies of water fluoridation." which is, I'm afraid, going to be gobbledygook to our readers. And it's unnecessary gobbledygook for this article, really.
  • Feel free to say the sources were of lower quality than those in children studies if technical term (not gratuitous jargon in this case) are an issue. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • I see you already addressed this; thanks. Eubulides (talk) 00:01, 19 February 2009 (UTC)
• It introduced a 70-word rebuttal (sourced to Pizzo et al.) to a 23-word claim (sourced to Yeung), which hardly seems balanced. The rebuttal contains words like "however" that introduce POV and are not directly supported by the cited source. Also, the rebuttal had problems with coherency (at least, I couldn't follow it). In the water fluoridation review world, a better balance for Pizzo et al. 2007 is Kumar 2008, so we can use that.
  • Feel free to adjust, but Yeung's opinion needs balancing because there obviously are experts, publishing in mainstream journals, who don't agree with Yeung. In the mean time I have also read his paper, and there is nothing in it that's not in the full report. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • Thanks, I tried to do that with this edit. Eubulides (talk) 00:01, 19 February 2009 (UTC)
• It introduced a relatively long discussion about Finland, citing an old primary study, Parviainen et al. 1985 (PMID 3861658), and saying preventive care is free in Finland, citing Hausen 2000 (PMID 11021844). As per WP:MEDRS, we should not be directly citing primary sources like this, particularly older primary sources, when there are perfectly good recent reviews on the topic that make the connections for us. The newly introduced point, that the European system costs more, can be addressed by citing a review. Perhaps I'm missing the point here, but I didn't see much else that was added by the Finnish material that is not already addressed in the article.
  • The point here is: it needs some details on a non-US country (given the emphasis on US in the opening); it's also one of the few studies that compared costs of water flouridation to alternative deliveries. It's also one of the few studies that evaluated the subsitution of one prevention with another. Finally, it's one of the few (primary) studies cited in the BMJ editorial that accompanied the York report. Ergo, it stands out. It also ties in nicely with the following paragraphs about cost-effectiveness in general. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • You've replaced that with yet another study about the US :( Xasodfuih (talk) 15:10, 18 February 2009 (UTC)

• "it needs some details on a non-US country (given the emphasis on US in the opening)" As shown in Talk:Water fluoridation/Archive 2 #Mechanism and worldwide view, the article already relies heavily on non-U.S. sources, compared to the amount of research that has been published in the area. This is particularly true in the Effectiveness section. I don't think it's way out of balance, but if any balancing is to be done it should be to focus more on U.S. sources.
• "it's also one of the few studies that compared costs of water flouridation to alternative deliveries" That may well be, but this topic has been thoroughly reviewed by subsequent secondary sources, such as CDC 2001 (PMID 11521913); there really is no need for us to be bypassing their conclusions and directly citing primary sources in this area.
• "Finally, it's one of the few (primary) studies cited in the BMJ editorial that accompanied the York report." That BMJ editorial, Hausen 2000 (PMID 11021844), contains a paragraph citing several high-quality reviews giving the mainstream consensus that fluoride still reduces cavities, even in the modern world where people use use fluoride toothpaste; it then goes on give one sentence saying that there's an old study in Finland showing there's no difference. That context and weight was lost in the the change inserting the Finland study, which emphasized the Finnish results way out of proportion to what the Hausen said. Furthermore, our best sources are not Hausen, but the systematic reviews on the topic, namely the York review 2000 (PMID 11021861), Truman et al. 2002 (PMID 12091093), and Yeung 2008 (PMID 18584000); we should be following their lead on this topic, not Hausen's, and we should not be citing that old primary source ourselves.
• "You've replaced that with yet another study about the US" It was replaced with a citation to a review (Kumar 2008, PMID 18694870). It is better to cite recent high-quality reviews than old primary studies; whether the reviews are U.S. or non-U.S. is not that important. Also, is this really that controversial an issue? I don't know of any reliable source disagreeing with the claim that fluoridation is cheaper than toothpaste.

Eubulides (talk) 00:01, 19 February 2009 (UTC)

I made this series of further changes to try to address the above problems. Eubulides (talk) 09:16, 18 February 2009 (UTC)

Cleanup-combine tag

More disturbingly, the Alternative methods section preempts the discussion from the Effectivenss section proper. This should be a subsection of effectiveness that discusses the relative effectiveness and cost-effectiveness of fluoride delivery methods. Xasodfuih (talk) 15:59, 18 February 2009 (UTC)

Here's my proposal for dealing with this:

1. Move the Alternative methods section after Mechanism because at that point the reader should suspect that other delivery methods exist based on how fluoride works for preventing caries.
2. Keep Alternative methods descriptive; avoid comparisons of effectiveness (this may be easier said than done), relegating comparisons to the proper Effectiveness section, which in this proposed layout follows shortly, so the reader doesn't need to recall stuff said far back.

Thoughts? Xasodfuih (talk) 20:25, 18 February 2009 (UTC)

That proposal sounds fine. Another idea, which would be much simpler to implement, is to move Alternative methods to after Evidence basis; this should require only relatively-minor changes other than the move. The idea is that readers have just waded through Evidence basis and have the topic fresh on their minds, so when the topic is revisited in Alternative methods it's not jarring. Logically, the topic of the effectiveness of alternative methods can be covered either under Effectiveness or under Alternative methods; since Effectiveness is already rather long, it may make more sense to discuss the topic in Alternative methods (perhaps with a brief pointer from Effectiveness to Alternative methods). Eubulides (talk) 00:01, 19 February 2009 (UTC)

This works as well. I'm rather tired at this point (in the day) for FA-level prose. So, it's to you to do it today. I'll look over it tomorrow. Oh, and sorry I was bit irate on the FAC page. Xasodfuih (talk) 01:55, 19 February 2009 (UTC)

You call that irate? (But thanks.) Anyway, I gave it a shot. Eubulides (talk) 07:02, 19 February 2009 (UTC)

Placement of "Water fluoridation does not affect the appearance, taste, or smell of water."

I moved this from the mechanism section it was out of place there. But I'm not entirely happy where I put it in the lede, in part due to duplication with the caption of the "catchy" image. This sentence isn't much longer than "Human senses cannot detect whether the water is fluoridated", so perhaps it could replace it in the caption. Any other ideas how do deal with this? Xasodfuih (talk) 18:53, 18 February 2009 (UTC)

The lead should summarize the body, so if the lead says that fluoridation doesn't affect the appearance, the body should say that too. It would be fine to move the sentence from the lead to the caption, thus deleting the somewhat-awkwardly-worded "Human senses" sentence. By the way, that's the way the caption used to read; I changed it to the "Human senses" wording only because User:Chergles complained about captions sounding "like a public service message"[11]. Coming back to the issue now, I preferred the older, snappier wording of this particular caption, and don't think it sounds like a public-service message. Eubulides (talk) 00:01, 19 February 2009 (UTC)

I guess you can't please everyone. Ideally an issue like this should be mentioned in the body in a section dealing either with physicochemical properties of fluoridated water, or with the public acceptance of water fluoridation. But we don't quite have section like that (in Ethics and politics it would be rather odd). Perhaps move it to the implementation section, and prefix it with "At recommended dosage, fluoridation does not affect..."? I'll leave message to User:Chergles since he cares about this more than both of us it seems. Xasodfuih (talk) 01:37, 19 February 2009 (UTC)

Moving it to Implementation sounds fine. I'd rather avoid the "At recommended dosage," phrase, though. The phrase "water fluoridation" implies controlled addition of fluoride to recommended values, so there's no need to prepend "At recommended dosage" every time we write "water fluoridation". Also, prepending that phrase just here would imply that one can taste the fluoride at naturally occurring values above recommended dosage, which (as far as I know) isn't so. Eubulides (talk) 07:02, 19 February 2009 (UTC)

Fine your way. I was just trying to find some way to tie it in with the implementation stuff. Xasodfuih (talk) 13:13, 19 February 2009 (UTC)

Problem with general tone of article

Given that the York review says the quality of evidence is low, how come this article is so sure that water fluoridation reduces tooth decay? It seems like this article's purpose is just to promote water fluoridation. If Europe has reduced it's level of tooth decay without water fluoridation (so you could conclude that if it does have an effect, it is a little one); there are major ethical concerns about mass medication; there is massive cost involved - all these things - yet this article is massively imbalanced in favour of water fluoridation. Ridiculous. Tremello22 (talk) 22:30, 7 February 2009 (UTC)

• The York review does not say that the quality of evidence is low. It says that moderate-quality research exists as to water fluoridation's effectiveness. There is no doubt among reliable sources that fluoridation reduces tooth decay; the concerns expressed are that much of the evidence was gathered by studies that, by today's standards, are not of high quality. (I speculate that high quality studies are not being done partly because of their cost, partly due to ethical concerns in withholding fluoridation, and partly because nobody wants to spend the money to find out the same thing all over again; but this is just my speculation, and obviously as such does not belong in the article.)
• Most (but not all) of Europe has reduced its level of tooth decay by fluoridating salt and toothpaste and by having higher-quality dental care for everybody. This does not at all mean that water fluoridation has only a small effect; it means that water fluoridation is not the only way to reduce tooth decay. This latter is not a controversial point, and is discussed in Water fluoridation #Effectiveness.
• The ethical concerns about water fluoridation are discussed in Water fluoridation #Ethics and politics, at some length; they are also mentioned in the lead.
• The cost of water fluoridation is discussed in Water fluoridation #Implementation, and also mentioned in the lead. Water fluoridation is much cheaper than fluoridated toothpaste.
• Naturally, to someone who is strongly opposed to water fluoridation, the current article will seem imbalanced. The same is true for someone who is strongly supportive of water fluoridation. However, every statement in this recent version of the article (before some of today's edits, which I have not yet had time to review) is directly supported by a reliable source.

Eubulides (talk) 23:29, 7 February 2009 (UTC)

I do believe that a requirement of this Wikipedia post is to be impartial. This article on water fluoridation is not. There is a plenitude of scholarly research available that indicates that fluoride is a neurotoxin. When I wanted to include that edit into the article, supporting my work with scholarly research not of my own agenda, therefore not violating the rules, it was prohibited. Why? By not allowing me to post such information clearly shows a bias. If this is to be a reputable post, like any good informative and neutral presentation of fact (I teach English at a University), for there to be no agenda, both sides of an argument must be presented. For example, to make this post better, there should be a section showing the evidence that supports health risks of water fluoridation as well as the alleged benefits. This way, the reader has adequate representation of both sides. It is NOT the writers job to imply a position which this article, almost flamboyantly promulgates only pro-water fluoridation and is vehemently opposed to any conflicting statement that would oppose it's agenda. --which by the way, to iterate, reproaches the terms of posting. There clearly needs to be revisions made. Maybe someone more qualified than a Professor could help me with this? Here are some "reliable" sources to insert information into the post since I was not allowed to do so.

[12]

[13] Pan Gnosis (talk) 20:07, 19 February 2009 (UTC)

The edit you made was immediately reverted (not by me) because it made claims like "Fluoridated water has been scientifically noted to have zero health benefits" which are completely at variance with what reliable sources say. The sources given in that edit were WP:FRINGE sources, containing unscientific claims like the one that 10% of the cancer deaths in the U.S. are linked to fluoride.[14] As per WP:RS and WP:MEDRS, this article can't rely on sources like that; it needs high-quality secondary sources, such as what you'd find in a respectable peer-reviewed medical journal. Eubulides (talk) 15:51, 22 February 2009 (UTC)

Where are the 50-60% and 18–50% given in Truman? [15]

"Initial studies showed that water fluoridation led to reductions of 50–60% in childhood cavities; more recent estimates are lower (18–50%[37])" I don't see them giving either of these ranges, and I think the interpretation of their figures is quite wrong.

• First issue: they don't divide the studies by year. The have two groups of studies:
  • group A (before-and-after measurement with a control group)
  • group B (only-after measurement with a control group)
• Second issue: this is what the numbers actually are, and more importantly, what they mean (fig. 2-4 in paper, and table 3):
  • Starting fluoridation in group A: 29.1% median decrease in caries (range: 66.8% increase to 110.5% decrease)
    • [yes, some of these studies found an increase in cavities after starting fluoridation relative to the control group]
  • Stopping fluoridation in group A: 17.9% median increase in caries (range: 31.7% increase to 42.2% decrease)
    • [similarly, some of these studies found a decrease in cavities after stopping fluoridation relative to the control group]
  • Starting fluoridation in group B: 50.7% median decrease in caries (range: 22.3% decrease to 68.8% decrease)
  • Stopping fluoridation in group B: 59.9% median increase in caries (range: Not applicable)

Math:

• For group A, effects = ((Fpost - NoFpost) - (Fpre - NoFpre)) / NoFpre. [I've rearranged this a bit; see page 24 bottom]
• For group B, effects = (Fpost - NoFpost)/NoFpost.

• Fpre means dental caries prevalence in fluoridated community before fluoridation (or at first measurement during ongoing fluoridation)
• Fpost means dental caries prevalence in fluoridated community after fluoridation (or at second measurement during ongoing fluoridation)
• NoFpre means dental caries prevalence in nonfluoridated community before fluoridation (or at first measurement during ongoing fluoridation)
• NoFpost means dental caries prevalence in nonfluoridated community after fluoridation (or at second measurement during ongoing fluoridation).

I think what these numbers mean is too complicated to the average Wikipedia reader. If you have any idea on a simple, but non-misleading presentation, please let me know. I think the other studies (York, CDC) give enough numbers, even though they are split by children and adults.

On the other hand, Truman's numbers for dental sealant (fig. 5) are lot easier to explain: 60% median reduction in cavities. Xasodfuih (talk) 13:13, 19 February 2009 (UTC)

But their numbers are bit at odds with the other metaanalyses, which are easier to explain and have CIs, not just a median value (plus range) from a bunch of studies. Fairly big YMMV. Xasodfuih (talk) 13:17, 19 February 2009 (UTC)

Thanks for pointing out the problem. It exists because I tried to summarize two papers briefly in one sentence, and erred by smashing together incompatible numbers.

• First, the source cited for the entire sentence (CDC 2001, PMID 11521913) says, "Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%–60% (94--97). More recent estimates are lower — 18%–40% (98,99)." Their (98) is Brunelle & Carlos 1990 (PMID 2312893), which gives the 18% (increasing to 25% if some of the background effect due to topical fluoride was controlled); their (99) is Newbrun et al. 1989 (PMID 2681730), which gives a range 13–35% for ages 13 and up, 20–40% for ages 8 to 12, and 30–60% for ages under 8.
• Second, the CDC 2001 source has been updated by Truman et al. 2002 (PMID 12091093), a later CDC publication. It says (p. 27), "Although we could not quantitatively combine effect measures from groups A and B, both seem to support the conclusion that community water fluoridation reduces dental caries by 30% to 50% of what could be expected for people not consuming fluoridated water. In addition, stopping CWF may lead to the median 17.9% increase in caries described above, in situations in which alternative sources of fluoride are inadequate."
• As you pointed out, I combined these two results inappropriately. I think Truman et al. is the latest published CDC consensus, but it's not reporting the same statistics. I made this change to try to fix things, by summarizing the Truman et al. results separately.

Eubulides (talk) 18:12, 19 February 2009 (UTC)

• The "30% to 50%" bit is a fairly loose presentation of two median results, which do not form a statistically valid range. The average Wikipedia reader will conclude that the "average" must be 40%, which is an overstatement compared to the <30% (25% for post 1979-studies) from more careful metaanalyses (Griffin etc.) Xasodfuih (talk) 21:38, 19 February 2009 (UTC)
• Truman also finds 60% median reduction by using dental sealants by using the same (non-pooled) methond. If his estimates for size effect are to be considered good, this number needs to be presented as well in (in the alternative methods section); it was one of the main findings of their study (fig. 5) Xasodfuih (talk) 21:38, 19 February 2009 (UTC)

• In context I don't see a big problem. Water fluoridation #Effectiveness says "A 2002 systematic review found data seeming to support the conclusion that starting fluoridation reduces tooth decay by 30–50% overall, and that stopping it leads to an 18% increase when other fluoride sources are inadequate." The immediate "18%" tells the reader that the actual average is not going to be 40%. The Griffin results are for adults, so they're not directly comparable.
• Good point about the "60%"; I added that.

Eubulides (talk) 15:51, 22 February 2009 (UTC)

Yeah, I'm nitpicking too much. It's fine. Xasodfuih (talk) 16:58, 22 February 2009 (UTC)

Dixon and Shackley

This edit removed material supported by Dixon & Shackley 1999 (PMID 10226722), saying "this is a poor contrast since the study cited in the previous sentence included the UK". I'm not sure how to interpret that comment, but let me try to explain why it's helpful to mention both studies. The two studies are Dixon and Shakley, based on a UK survey, and Griffin et al. 2008 (PMID 18333872), based on focus groups in 2003. Griffin et al. remark (p. 101), "Dixon and Shackley's finding of a majority of their UK sample being in favour of fluoridation seems at odds with the response of our UK focus groups. But this may be due to the majority of people not holding strong views about dental public health, or an artefact of the way questions are asked, and the ability of people to develop and explain their opinions within qualitative research, compared with the 'Yes'/'No' option originally presented by Dixon and Shackley." Given that Griffin et al. found the contrast notable, it seems worth reporting the contrast here. Eubulides (talk) 15:51, 22 February 2009 (UTC)

Both these studies are low quality as far as surveys go, and they used different designs, not to mention they are 4 years apart, so I'm not at all convinced there's anything to contrast. The focus groups from Griffin were like 8 people / country if I recall correctly; the overall results were significant, but I doubt that per country results are (hence a contrast with Dixon seems rather meaningles). Also, you're not giving the per country results from Griffin, so the reader can't guess what you're trying to contrast. Since water fluoridation is practised in the UK, from the presentation of Griffin's study one can easily conclude that the UK guys were in favor; at least I did when reading that passage (and looked only at the abstracts of the sources). Also, it's quite possible that the opinion in the UK changed in the 4 or so years in between. The contrast you're trying to make just doesn't connect.

From Dixon the interesting result is that the strong conviction of the opposes; I'm fine with adding that back, and perhaps also say how many held the wrong info. Too bad there aren't any better studies. Xasodfuih (talk) 16:30, 22 February 2009 (UTC)

Also, very important caveat, all participants in Dixon's study were from Sheffield, weren't they? From the US studies on opposition to fluoridation it's well known that local opinion varies widely. So, I'm not convinced that Sheffield is representative for UK as a whole in this matter. Xasodfuih (talk) 16:56, 22 February 2009 (UTC)

I have reworded it accordingly. Xasodfuih (talk) 11:48, 25 February 2009 (UTC)

Mild fluorosis pic available

Thanks to the prompt work of User:Dozenist, the picture to right is now available for us to use. What do you guys think? Xasodfuih (talk) 03:10, 25 February 2009 (UTC)

I think it's great! Thanks to you and to Dozenist. I added it. Eubulides (talk) 06:08, 25 February 2009 (UTC)

No problem. I try to help anytime I can with dental content. - Dozenist talk 13:47, 25 February 2009 (UTC)

Leads for country info

Google found this 2-page overview the reasons (allegdly) invoked by some countries in rejecting fluoridation (plus a graph, which I won't comment on). This is clearly an advocacy site, so we'd the need info from other sources, but it seems to exist.

Also quite interesting, according to this page, the Japanese Dental Association is the major stumbling block to water fluoridation in Japan; this is a personal web site, so we'd need something better for a FA article. But it raises the interesting question whether profits are one of the reasons some dentists oppose WF. The reviews I've read during the FAC made me conclude that a strong predictor for the recommendation made by a reviewer is whether (s)he was employed by a public health body or has a relationship with a dental education/practice. Without getting into speculation as to their motivations, the official position of dental associations in a few countries would be an interesting addition to the article. I'm having the impression that the "ethics" sections is missing an important factor (namely the money made by alternative treatments). Xasodfuih (talk) 01:12, 22 February 2009 (UTC)

After trawling through Science Direct, I was able to find this (no pubmed id?). It doesn't say why either country doesn't fluoridate water (anymore, as East Germany did it), but it has good coverage of preventive dental care in Germany and Japan. I'll add 1-2 sentences from it unless somebody objects, but I'm kinda tired now to write a good summary. Xasodfuih (talk) 03:39, 22 February 2009 (UTC)

A much better source, from a worldwide perspective, is already cited in the article (as "ref name=extent"):

• The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health (2004). "The extent of water fluoridation". One in a Million: The facts about water fluoridation (2nd ed.). pp. 55–80. ISBN 095476840X. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)CS1 maint: multiple names: authors list (link)

This is an advocacy source so it has to be taken with a grain of salt, but it's a good source nonetheless. I will try to draft something if you don't beat me to it first. Eubulides (talk) 15:51, 22 February 2009 (UTC)

Go ahead, I'm supposed to be the reviewer. Xasodfuih (talk) 16:57, 22 February 2009 (UTC)

I did install something along these lines on 2009-02-24, but forgot to note it here until now. Eubulides (talk) 09:30, 26 February 2009 (UTC)

I had a look at the chapter you indicated (7), but I don't see any info on reasons for opposition in other countries (and it's mostly UK/US statistics). Perhaps you indicated the wrong chapter? Xasodfuih (talk) 11:59, 25 February 2009 (UTC)

I was referring to the commentary on p. 72 of chapter 7. Eubulides (talk) 09:30, 26 February 2009 (UTC)

Lead (Pb)

Is there a reason why PMID 16393670 isn't cited in relation to that? I see that their conclusion was contradicted by the later PMID 17420053. Can someone give me a 2-3 sentence summary on this issue. Not feeling like reading either paper, although I have full text access to both. Xasodfuih (talk) 05:19, 22 February 2009 (UTC)

We shouldn't be dipping into the primary sources at all in this area. This is an area where primary sources are being used to dispute a reliable review, and as per WP:MEDRS the article shouldn't be doing that. The theory that water fluoridation causes lead poisoning and increases crime rates is put out by just one group and is rejected by mainstream sources. As per WP:MEDRS, we should not be citing the primary sources Coplan et al. 2007 (PMID 17420053) and Maas et al. 2007 (PMID 17697714) when we have a reliable secondary source on the same subject, namely Pollick 2004 (PMID 15473093). Admittedly the group in question puts out lots of studies, but they have been rejected by the mainstream, and should not be emphasized merely because they happened to have put out some studies since the last time they were shot down (that would be WP:RECENTISM). I removed the lead-poisoning primary sources; the review is enough in this area. Eubulides (talk) 15:51, 22 February 2009 (UTC)

That group has indeed put out 3 studies (paste the url since it has brackets which screw the formatting: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Coplan%20MJ%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus) The last two are from 2007, so they're unlikely to be discussed in a review. What about the 2000 study (PMID 11233755)? Can you point out the issues with it? Xasodfuih (talk) 00:21, 23 February 2009 (UTC)

To answer my own question, the 2006 PMID 16393670 (Macek) spends a good chunk of the introduction bashing the previous studies by Masters and Copland; they conclude: "Controlling for covariates, water fluoridation method was significant only in the models that included dwellings built before 1946 and dwellings of unknown age. Across stratum-specific models for dwellings of known age, neither hydrofluosilicic acid nor sodium silicofluoride were associated with higher geometric mean PbB concentrations or prevalence values. Given these findings, our analyses, though not definitive, do not support concerns that silicofluorides in community water systems cause higher PbB concentrations in children." So, it looks like for very old dwellings it may be a factor, although the number of such dwellings in the US is probably vanishingly small. Macek specifically criticizes the 2000 Masters & Copland study for using untransformed Pb concentration in anaylsis of variance. By the way, these guys are all analysis/arguing about the same NHANES data from the 1990s. Xasodfuih (talk) 00:42, 23 February 2009 (UTC)

The rebuttal from Coplan is "However, using log transformed, less skewed data to find a central tendency does injustice to worst case children." Hardly a good statistical argument. Xasodfuih (talk) 02:52, 23 February 2009 (UTC)

This kerfuffle is poorly presented from thee PMID 15473093 article published in 2004 in a small-potatoes journal IJOEH (IF 1.48), which precedes the full publication of Macek PMID 16393670 in 2006, which was commissioned by the CDC specifically to investigate the claims by Masters and Coplan (2000), and really ought to be cited. Not having easy access to it, I guess that PMID 15473093 cited the preliminary (1-page?) publication of Macek in J Public Health Dent 2003;63(suppl 1):S36 [could not find it in pubmed], because Coplan 2007 cites it together with the final publication from Macek. Macek's 2006 paper is published in a much more reputable venue (EHP, the top environmental science journal, IF 5.something). Even Coplan's papers are published in a more reputable journal than the source currently used in this wiki article (Neurotoxicology has IF 3). I'm going to rewrite that paragraph; this has nothing to do with WP:RECENTISM, but has everything to with which article is the more credible source for statistics because both these groups used the same NHANES data. Xasodfuih (talk) 02:52, 23 February 2009 (UTC)

Update 1: Pollick is a very marginal source on this issue because he doesn't cite any of the primary sources being discussed above, as I incorrectly assumed above. Instead he cites a paper by Urbanski (2000, ref 40 in Pollick). We should be citing this paper as well for the chemistry part, but given that the CDC bothered to commission Macek's study about the epidemiological association as a result of Master and Coplan's initial work, we need to cite that more specific (and recent) paper. Urbansky is most useful for the chemistry part: "Overall, we conclude that no credible evidence exists to show that water fluoridation has any quantifiable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead(0) or lead(II) compounds. The governing factors are the concentrations of a number of other species, such as (bi)carbonate, hydroxide, or chloride, whose effects far exceed those of fluoride or fluorosilicates under drinking water conditions." Xasodfuih (talk) 04:17, 23 February 2009 (UTC)

Regardless of PubMed's classification, Coplan et al. 2007 (PMID 17420053) is not a research article. It's a review. I gather that the original 2000 Masters studies did not use the NHANES data; it was an ecologic analysis and Macek said it had "uncertain sampling". Xasodfuih points out that Pollick does not provide very good coverage on this issue. It might be better for readers to cite Macek and Coplan 2007. That gives them a summary of the issue: Macek couldn't replicate the finding but did not definitively rule out the association, Coplan attempted a rebuttal. II | (t - c) 23:55, 24 February 2009 (UTC)

• Coplan et al. 2007 (PMID 17420053) does not claim to be a review, and in reading it, it is not a review: it is a statement of a hypothesis, and it contains many claims that can only be characterized as speculations. For example, it says "chronic ingestion of SiFW is a major factor in the linkage of dental fluorosis with fluoridated water" based on extremely sketchy reports from India about "silicon" in water. My favorite was the claim "Contrary to common belief, fluorotic enamel per se does not prevent caries" in an attempt to undermine the well-established consensus that fluoride prevents cavities. This is not a reliable source at all.
• Coplan is on record with letters containing section headers like "Why the CDC Cannot Be Trusted" and "EPA's continued effort at misdirection",[16] rhetoric that (to be frank) makes him look like a crank.
• The balance of all this back-and-forth is that the mainstream opinion does not seem to take the Masters & Coplan hypotheses seriously any more. We should not be treating this as an issue where Masters & Coplan deserve equal time with the mainstream opinion that their theory is unfounded. Nor should we be giving the theory more WP:WEIGHT than other unsupported theories such as the arsenic-and-lead theory or the corrosivity theory.
• One simple way to address the issue is to cite Macek et al. 2006 (PMID 16393670) on the topic, as this is the most authoritative recent source. I did that; hope it suffices.

Eubulides (talk) 09:30, 26 February 2009 (UTC)

Milk fluoridation fluorosis review in the safety section

I'm not sure this change added the detail in the right spot. The wording in that context is also problematic since might suggest that it's the fluoride in the milk that's "bad", whereas the one in the water is "good". Clearly any form of fluoridation can result in fluorosis; it's not the mode that matters, it's the overall dose. This is a point that the current wiki article fails to make clearly enough, and instead gets into an apparent contest between fluoridation modes at every opportunity. I suggest that that sentence be moved to the Alternative methods section. Xasodfuih (talk) 05:16, 23 February 2009 (UTC)

Sorry, I don't follow the previous comment. The change in question altered a sentence about fluoridated water added to infant formula; that sentence is about water (and/or formula) and is not about milk. Eubulides (talk) 09:30, 26 February 2009 (UTC)

Nuffield Council on Bioethics

This edit added a long quote from the 2007 Nuffield Council on Bioethics. Three thoughts: first, we should not have extensive quotes like that, but should be writing our own words. Second: in the context of this article, that coverage of the council is too long; it should be a brief sentence that summarizes what they said. Third, the coverage should be in the 1st paragraph of Water fluoridation #Ethics and politics (which talks about ethics), rather than at the end of the last paragraph (which talks about politics). Eubulides (talk) 17:57, 25 February 2009 (UTC)

I read the edit more carefully, and found that most of the points it makes are already addressed by Water fluoridation, with the exception that the Council decided that the most appropriate way to decide whether to fluoridate is to use democratic procedures that are at the local and regional, rather than national, level. This point is more useful in the last paragraph, so I struck that part of my comment above. I made this further edit to capture the new point, and to provide the following higher-quality citation to the Nuffield results:

• Calman K (2009). "Beyond the 'nanny state': stewardship and public health". Public Health. 123 (1): e6–e10. doi:10.1016/j.puhe.2008.10.025. PMID 19135693. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)

Eubulides (talk) 09:30, 26 February 2009 (UTC)

European, not other industrialized

This edit changed "most European countries have experienced substantial declines" to "most other industrialized countries have experienced substantial declines". The cited source says "European" not "other industrialized"; (Pizzo et al. 2007, PMID 17333303) says "Moreover, in most European countries, where CWF has never been adopted, a substantial decline in caries prevalence has been reported in the last decades, with reductions in lifetime caries experience exceeding 75%." I changed the text to say "European". Eubulides (talk) 15:51, 22 February 2009 (UTC)

He also says right after that "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the 1970s." I was trying to cover more than Europe with that sentence. In Japan the fluoridated toothpaste utilization is about 88% in children and they don't have any water/salt/milk fluoridation. Xasodfuih (talk) 16:36, 22 February 2009 (UTC)

That's true, but it's still incorrect to cite Japan in replacing "most European countries have experienced substantial declines in tooth decay without its use" with "most industrialized countries have experienced substantial declines in tooth decay without its use", as parts of Japan formerly did use water fluoridation. The wording in the lead has to be very careful in following what the source says. By the way, although it's true that most European countries have seen declines without using fluoridation, that's only because the statement is counting countries, many of which have small populations. By the way, sorry I haven't caught up with the talk-page comments; I've been busy on the FAC page. I'll try to catch up with the comments here soon. Eubulides (talk) 17:50, 25 February 2009 (UTC)

Based on the sources I've seen, I think that Japan never fluoridated their water. Can you provide a reference for your claim that they did? Xasodfuih (talk) 10:11, 1 March 2009 (UTC)

Tsurumoto et al. 1998 (PMID 9669597) write "Japan had three brief experiences with water fluoridation." This is according to a Google Scholar snippet; I haven't tried to get full access to the paper, but I'd guess they're talking about Honshu. Okinawa (which is part of Japan) mostly used fluoridated water from 1945 to 1972, while it was under U.S. administration; see Tohyama 1996 (PMID 9002384). Eubulides (talk) 09:04, 2 March 2009 (UTC)

Fluorapatite

The article has a section on "mechanism" but the content is vague and talks about consequences, not mechanism - how fluoride works. My understanding is that fluoride effects one quite specific chemical reaction, converts some of apatite (component of enamel) to fluorapatite, and the latter is more resistant to bacterial attack. The change entails replacement of OH^- with F^-, and these are isostructural, virtually. --Smokefoot (talk) 15:24, 1 March 2009 (UTC)

Thanks, I rewrote the first part of "Mechanism" to try to cover that issue better. As part of the rewrite, I removed the claim "Fluoride has minimal effect on cavities after it is swallowed." (citing Featherstone 1999, PMID 10086924) since newer sources, such as Cury & Tenuta 2008 (PMID 18694871) don't seem as confident on this point, and Featherstone 2008 (PMID 18782377) doesn't seem to repeat it. Eubulides (talk) 09:04, 2 March 2009 (UTC)

A question about the byline of a source often used, One in a Million

Why is the One in a Million book being attributed to "The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health". I see nothing beyond "The British Fluoridation Society" in their copyright, although Worldcat lists some "et al." in the byline. Also, based on Worldcat, this appears to be a self-published book, although I don't think we should avoid it for that reason alone because they cite their sources. Xasodfuih (talk) 10:49, 1 March 2009 (UTC)

The cover of the document (PDF) lists all four organizations under the line "Published by", and page iv of the document lists all four organizations again along with their missions and contact details. It is a self-published book and it clearly is an advocacy document whose opinions we cannot state as fact; but the four organizations are high-quality ones and the facts that all four endorse it and that the book cites its sources are both good signs. Eubulides (talk) 09:04, 2 March 2009 (UTC)

Thanks for looking into that. I was getting a little worried because the printed book is held by only 4 libraries in the world (according to Worlcat, there might be more). Xasodfuih (talk) 10:26, 3 March 2009 (UTC)

You're welcome. Unfortunately Worldcat isn't that reliable about the availability of medical sources. These days, the vast majority of uses of medical sources are online uses. Eubulides (talk) 09:08, 4 March 2009 (UTC)

Psychological effects

The point about placebo psychological effects made by Lamberg et al. 1997 (PMID 9332806) was removed with the comment "remove 1997 research article which is not supported by the weight of the literature". I don't understand this remark; it is not controversial among reliable sources that placebo psychological effects exist. The placebo psychological-effect problem is obvious to experts, but not so obvious to the general public, so it's worth briefly mentioning here. I propose reinserting the point, focused a bit so that it takes up less text, as follows: "Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated.", citing Lamberg et al. Eubulides (talk) 15:51, 22 February 2009 (UTC)

I wasn't the editor to remove that, but I don't see how the placebo effect is related to bone fractures or cancer since neither of those are diagnosed based on subjective symptoms. If you want to say that idiosyncratic symptoms of XYZ are not influenced by WF, that's fine with me, but specify what XYZ is. Xasodfuih (talk) 05:03, 23 February 2009 (UTC)

It's not controversial that placebos can generate negative effects (the nocebo effect). But 1 study does not demonstrate that that the extent of the effect is uncontroversial in people complaining about symptoms due to water fluoridation. The research on actual hypersensitivity reactions is so closely-related that we can't cite one without the other. These reactions are backed up by more literature: case reports from various people, a double-blind study, and that 1961 study which found reactions in 1% of their sample group. This is all covered secondarily by the NRC 2006 report. Citing the 1997 research article (a "primary" study) without citing the other research articles (also "primary") is misleading, and will lead readers to think that all these symptoms are psychological. II | (t - c) 23:15, 24 February 2009 (UTC)

• The proposed text doesn't say anything about the extent of the effect; it merely says that the effect exists, which is indisputable.
• The placebo psychological effect operates across all the benefits and adverse effects of fluoridation; it is not at all limited to hypersensitivity.
• There is nothing controversial about the placebo psychological effect per se. There is plenty controversial about the hypersensitivity studies; as the NRC 2006 report demonstrates, there is no mainstream consensus that hypersensitivity exists even at fluoride levels well above the recommended levels.

Eubulides (talk) 09:30, 26 February 2009 (UTC)

A negative placebo effect response to something is noncontroversial for everything. The extent and notability is what matters. I don't have access to your primary study, but we don't know how controversial it is because we don't have any decent secondary coverage of the paper. There's only been 1 study. People who see that study cited with your language will assume that all symptoms attributed to fluoride are from hypochondriacs. Further, that study is strange -- it said that around 30-40% attribute symptoms to fluoride. Normal communities do not attribute negative effects to water fluoridation at that level, especially since many people don't even know whether their community is fluoridated, or why it is. I can't support the addition and will vigorously contest its addition. Also, my reading of the NRC coverage of the hypersensitivity (page 269, page 208, and page 293) suggests that it's not that controversial. We can't be certain, but there's been zero negative studies and several positive studies. II | (t - c) 19:33, 26 February 2009 (UTC)

• "notability is what matters" Every systematic review comments on the desirability of blinding; this is to avoid placebo psychological effects.
• "There's only been 1 study." True, but there's no dispute among reliable sources that the placebo psychological effect exists. The point has been well understood for decades. For example:

"The power of suggestion has been vividly demonstrated on several occasions. For instance, in New York's Westchester County and two or three other localities the announcement that the water would be fluoridated was followed by a flood of complaints of bad-tasting water, sudden aches and pains, and dead goldfish and dogs—even before any fluoride was put into the water ! A witness before a Congressional committee declared that he had fainted from drinking two cups of coffee made from fluoridated water." Mausner B, Mausner J (1955). "Fluoridation: a study of the anti-scientific attitude". Sci Am. 192 (2): 35–39. Reprint: Health Educ J. 14 (3): 123–32. 1956. doi:10.1177/001789695601400304. {{cite journal}}: Missing or empty |title= (help)

The existence of the placebo psychological effect is not a controversial point, even on this talk page. We would of course prefer a reliable review on the placebo psychological effect in studies of fluoridation, but that is a rather specialized topic, for which reviews are not available, so we need to do the best we can.

• "People who see that study cited with your language will assume that all symptoms attributed to fluoride are from hypochondriacs." I don't see why; the proposed language doesn't say anything about hypochondria, nor does it say anything about "all symptoms". If there is a concern about this, can you suggest specific wording that would help to allay that concern?
• "Further, that study is strange -- it said that around 30-40% attribute symptoms to fluoride." Sorry, I don't know what this comment is referring to. The study never gives a range of 30–40%. And the study never asked respondents whether they attributed their symptoms to fluoride. Are you sure we're talking about the same study? I'm talking about Lamberg et al. 1997 (PMID 9332806).
• "my reading of the NRC coverage of the hypersensitivity (page 269, page 208, and page 293) suggests that it's not that controversial. We can't be certain, but there's been zero negative studies and several positive studies." Sure there are negative studies. Page 269 says "Nevertheless, there are reports of areas in the United States where the drinking water contains fluoride at concentrations greater than 4 mg/L and as much as 8 mg/L (Leone et al. 1955b). Symptoms of GI distress or discomfort were not reported. In the United Kingdom, where tea drinking is more common, people can consume up to 9 mg of fluoride a day (Jenkins 1991). GI symptoms were not reported in the tea drinkers. The absence of symptoms might be related to the hardness of the water, which is high in some areas of the United Kingdom." Furthermore, only one of the pages you cite is relevant to hypersensitivity: page 208 is about Chinese studies involving natural fluoridation well above recommended levels, along with fluoridation from coal fires. Page 269 is about GI symptoms, not hypersensitivity, and says "Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated". Page 293 is the only citation about hypersensitivity, and it says that the anecdotal reports do not represent any type of hypersensitivity recognized by the American Academy of Allergy, and devotes most of its analysis (which is understandable, given the NRC's mandate) to fluoride concentrations well above recommended values. This is in contrast to the York review, which is devoted to water fluoridation, and which states there's no clear evidence of this adverse effect.
• "I don't have access to your primary study, but we don't know how controversial it is" Again, no part of the study that is potentially controversial is being used to support the cited text. It is not controversial that the placebo psychological effect exists.

Eubulides (talk) 21:16, 26 February 2009 (UTC)

Lamberg study

(unindent) The Lamberg study says "The percentage of those with two or more symptoms was the same (45%) in November and in December but decreased to 32% in March. The mean number of symptoms per respondent decreased from 1.9 in November to 1.4 in March (P < 0.001) and in December-March from 1.8 to 1.2". That's the 30-40% that I'm talking about. It doesn't make sense that nearly half of the sample group would attribute their symptoms to fluoride, because in most communities there's almost zero complaints. Lamberg looked at an anomalous community. Also, the bottom of page 208 says "there are numerous reports of mental and physiological changes after exposure to fluoride from various routes (air, food, and water) and for various time periods (Waldbott et al. 1978). A number of the reports are, in fact, experimental studies of one or more individuals who underwent withdrawal from their source of fluoride exposure and subsequent re-exposures under “blind” conditions". My terms are clear and fair: if we cite the 1997 study, we have to mention the reported real reactions. If not, then we don't cite either. 22:29, 26 February 2009 (UTC) (signed:ImperfectlyInformed)

I actually don't see that the Lamberg study shows anything at all. If fluoridated water has maleficent effects, they could well persist for a month after cessation of exposure. This is the danger of relying on primary sources. I've only read the abstract, perhaps this is discussed in the paper itself. Franamax (talk) 23:21, 26 February 2009 (UTC)

• This subthread (about the details of the study of Lamberg et al. 1997 (PMID 9332806)) has nothing to do with the original topic of this section (about whether Water fluoridation should mention placebo psychological effects). The proposed text doesn't talk about 32% or 45% or whatever; it says only that placebo psychological effects occur during fluoridation. So this subthread (and my following bullets) are irrelevant to the proposed text.
• "I actually don't see that the Lamberg study shows anything at all. If fluoridated water has maleficent effects, they could well persist for a month after cessation of exposure." It would be remarkable if all the symptoms in question persisted practically unchanged for a month after fluoride was secretly removed, and then suddenly dropped, no? What mechanism would explain that? Also, some of the survey questions asked about the perceived quality of the water, e.g., a "fluoride taste". When the fluoride was secretly removed, the percentage of people who claimed they detected a "fluoride taste" remained the same for a month, until after the point in time that they thought the fluoride was removed; after that, they stopped reporting a "fluoride taste". The people who reported the "fluoride taste" seemed to be predisposed to reporting other perceived symptoms, further confirming the psychological aspect of these reports.
• "It doesn't make sense that nearly half of the sample group would attribute their symptoms to fluoride" Again, the survey did not ask whether people attributed their symptoms to fluoride, and Lamberg et al. did not claim that nearly half the sample group attributed their symptoms to fluoride.
• "in most communities there's almost zero complaints" Not true: many people complain of symptoms like insomnia or constipation, in communities all over the world.
• "Lamberg looked at an anomalous community" No evidence has been presented to support that claim. The claim that the community was anomalous seems to be based on a misunderstanding of Lamberg et al.'s experiment.
• "Also, the bottom of page 208 says" The bottom of the NRC report's page 208 is not clearly talking about exposures to fluoride at water-fluoridation levels; data about higher exposure levels may be relevant for the NRC study (which is about higher levels of fluoride exposure, and is not about water fluoridation) but it is not relevant here.
• "My terms are clear and fair" This is not a bargaining situation. It is not reasonable to hold a well-supported and noncontroversial topic (namely, the placebo psychological effect) hostage to the insertion of a different, controversial and poorly-supported topic (namely, hypersensitivity to fluoride).

Eubulides (talk) 01:04, 27 February 2009 (UTC)

I'm a little confused here over the apparent conflation of "placebo"/"nocebo" with "psychological effects". The two are not necessarily synonymous. One is a (sub-)conscious process which attributes symptoms to causes, the other is a mysterious medical phenomenon which seemingly affects outcomes and may be associated with the unconscious mind. Having only read the Lambert abstract, I see nothing attributing a placebo/nocebo effect. Franamax (talk) 03:05, 27 February 2009 (UTC)

You are correct that Lamberg et al. do not use the word "placebo", and talk only about "psychological" effects. I'd rather not get hung up with terminology, so please pretend that I've uniformly written "psychological effect" rather than "placebo". I've changed the name of this section accordingly, and have struck out "placebo" and replaced it with "psychological" in my comments. Eubulides (talk) 09:15, 27 February 2009 (UTC)

I'm not really following? In the cases Eubulides is discussing, people attribute their symptoms to fluoridation even though it's not happening. It's not conscious. II | (t - c) 03:23, 27 February 2009 (UTC)

Well I did say I was confused. :) My point was that in the Lambert study, people were given the option to both define symptoms and ascribe them to a source. (Not sure on that, I've asked elsewhere for a copy of the paper) But mostly, the study assumes that there are no persistent medical effects and proceeds to the conclusion that the effects are ("may be") psychological. I just find that a little offputting when presented under the thread title "Placebo effects". Franamax (talk) 04:05, 27 February 2009 (UTC)

Lamberg et al. did not give people "the option to both define symptoms and ascribe them to a source". The paper says (p. 292) that the questionnaire asked "questions about the perceived presence or absence of 25 symptoms during the week of inquiry, water consumption patterns, perceived quality of water, opinions concerning water fluoridation and demographic data." Since the list of symptoms were fixed, respondents were not allowed to define them; and the questionnaire did not ask respondents to ascribe symptoms to any source. Eubulides (talk) 09:15, 27 February 2009 (UTC)

Since the study did not actually ask whether the people thought their symptoms were caused by fluoride, the study is even weaker than I thought in demonstrating that people psychologically perceive negative effects from fluoridation. II | (t - c) 03:26, 1 March 2009 (UTC)

I don't see why that would be. The study looked for a statistical association between reported symptoms and the presence of fluoridation. This is much more scientific than asking people whether they think fluoridation causes adverse effects. The latter would merely be an opinion survey. Eubulides (talk) 07:58, 1 March 2009 (UTC)

I've already showed you that the experimental studies mentioned on page 208 are discussed at greater length elsewhere and include the double-blind study at 1/mg L and the other 1961 study which thought that 1% of their sample size appeared hypersensitive. The latter study, published in the American Academy of Oral Medicine's Journal of dental medicine, is somewhat difficult to access. A report by the same authors (likely not the final version) was published in Science in 1955 [17]; it doesn't have the observation. Bruce Spittle's Fluoride Fatigue is a self-published book, but has a quote from the 1961 study (page 11 of the book, PDF page 19). It says "one percent of our cases reacted adversely to the fluoride (1 mg/day) tablets ... by the use of placebos, it was definitely established that the fluoride and not the binder was the causative agent". There have been no negative studies -- that is, nobody has taken these same people and retested them to replicate the results. A lack of GI reports is not the same; a fair percentage of the population suffers these conditions throughout their lives: it's called irritable bowel syndrome. A difference of 1% in fluoridated/unfluoridated communities would be difficult to estimate from epidemiology and random reports, but it would be easy to discover using the simple and superior double-blind RCT. Considering that two studies from two different research teams have reported these under double-blind conditions, and there have been numerous case reports, it's not fair to say that these are "controversial" -- and the NRC does not say that. It is fair to say that the results are not definitive, which the NRC does say. But keeping this issue out, which is covered well by a secondary source, while highlighting your own primary source, cannot be allowed. It's misleading and biased.

As far as wording to make it clear that all people reporting symptoms are not just idiots, I would simply add after your sentence "Other ther studies suggest, however, that perhaps 1% of the population could respond negatively to fluoride at 1 mg/L". Or something to that effect, citing NRC 2006 page 269. II | (t - c) 03:16, 27 February 2009 (UTC)

Please see #Feltman-Kosel 1961 etc. below. Eubulides (talk) 09:15, 27 February 2009 (UTC)

Back on track

Let's get back on track with PMID 9332806 since the other stuff is discussed in the next subsection. I support mentioning this as long as the symptoms attributed to WF are identfied (as well as the study allows). What I was objecting to was mainly objecting to was the vagueness of the statement, and placement after fractures and cancer, which can lead the reader to believe that an annoucement of WF discontinuation (that had already tanke place) reduced symptoms cancer or fractures. I don't have full text access to this; in the abstract I see only "symptoms related to the skin"; was GI among the other symptoms? Xasodfuih (talk) 23:52, 27 February 2009 (UTC) I would propose something like: "In 1992-3, three surveys were conducted in Kuopio, Finland—a city that discontinued fluoridation after public disputes; these surveys found that subjective symptoms, in particular those related to the skin, were unaffected by the actual discontinuation of fluoridation, but significantly dicreased after the offical announcement thereof, a month later, suggesting that fluoridation may have psychological effects which present as somatic symptoms." Xasodfuih (talk) 00:05, 28 February 2009 (UTC)

That's a big jargony and wordy. It also doesn't make clear that these are just symptoms randomly reported and not clearly associated by the respondents as related to fluoridation. The wording will need to be clear on that, since the abstract is not so clear. I'll break this into bullets:

• Are skin symptoms subjective? I would say not, and the abstract does not say so. Subjective symptoms are "tiredness" sort of things. Skin symptoms are also not the typical thing you'd expect from someone suffering from psychological fluoride effects -- you would expect things like the fainting that Eubulides noted.
• What's interesting about the Lamberg study is that the symptoms were mainly skin-related, and skin symptoms are what was mainly found by Feltman et al. in 1% of their 600 subjects [18]. Although Eubulides is correct that the acute dose of tablets isn't exactly comparable to water fluoridation's dose, the symptoms reported weren't acute. According to FAN, at least six editions of the Physicians Desk Reference (1994 most recent) report that skin symptoms are the most common reactions with fluoride hypersensitivity [19]. There's no reason to suspect that FAN is falsely quoting the PDR, but if there's enough doubt, I can try to verify it.
• FAN has a quote from Lamberg's study which suggests that Eubulides is not giving us the full story [20]:

  Following the termination of water fluoridation, "the significant decrease in the number of other skin rashes leaves room for speculation, seeming to favor the view that a small segment of the population may have some kind of intolerance to fluoride. This group of people should be studied further. The most frequently reported symptoms that disappeared from the time of actual to known discontinuation of fluoridation seemed to be itching and dryness of the skin."

  Thus, it seems that to cite Lamberg's article (and the rest of the literature) fairly, we would need to note that the hypersensitivity interpretation remains plausible. I'd like to look at the study, and technically my library says it has access back to 1997, but the Wiley-Blackwell merger seems to have caused some problems.
• Franamax's point about these symptoms persisting for about a month is plausible, since fluoride does build up in the soft tissue and it would take a month or two for that to disappear. Presumably, this is what Lamberg et al. allude to in the quote above. II | (t - c) 03:26, 1 March 2009 (UTC)

• I also disagree with Xasodfuih's proposal, as it would give a lot of weight to the details of a single primary study. Granted, no reliable sources disagree with the study, but still, we should not be spending nearly that many words on it.
• "was GI among the other symptoms" Yes. The full set of symptoms in Table 3 is: joint pain; muscular pain; muscular tic (myokymia); muscular weakness; difficult breathing (dyspnea); pain in the chest; headache; dizziness (vertigo); numbness; visual disturbance; tinnitus; depression; insomnia; epigastric pain or heartburn; nausea or vomiting; diarrhea; constipation; dysuria; pain in the mouth or toung; nettle rash (urticaria); other skin rash (eczema); itching of the skin; dryness of the skin; smarting of the eyes; exceptional fatigue; other symptom(s); and none of the above symptoms.
• Xasodfuih's point about confusion with cancer or fractures is well taken, though. How about if we append the proposed text to the 2nd paragraph of Evidence basis instead. Here's what the paragraph would look like afterwards:

"Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation. There is no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma. Other adverse effects lack sufficient evidence to reach a confident conclusion. Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated."

• "Are skin symptoms subjective? I would say not" The survey asked respondents for their opinion about whether they had skin symptoms; this was necessarily a subjective measurement.
• "What's interesting about the Lamberg study is that the symptoms were mainly skin-related" No, symptoms were of a wide variety. For example, 13.6% of respondents complained of joint pain in November (when the water was fluoridated); 13.5% complained of joint pain in December (when they thought the water was fluoridated, but it wasn't); and 10.9% complained of joint pain in March (when the water was not fluoridated, and they knew it).
• "Although Eubulides is correct that the acute dose of tablets isn't exactly comparable to water fluoridation's dose, the symptoms reported weren't acute." Again, this is citing an old primary source that is not about water fluoridation, and in an area where reliable reviews say there's no clear evidence of adverse effects. We should not be citing primary sources to dispute reliable reviews in this area.
• "This group of people should be studied further." Agreed, they should be studied further. In a study that asks about lots of different symptoms, it shouldn't be surprising if we find changes that would be significant if we had studied just the one symptom. It's standard in studies that troll for significant results to find them (because they're looking at so many possible results, some are bound to be significant), and then to suggest further research. However, this single group of people that should be studied further is not of concern at the level of Water fluoridation #Safety, for the same reason that it's wasn't of concern to the York review.
• "The most frequently reported symptoms that disappeared from the time of actual to known discontinuation of fluoridation seemed to be itching and dryness of the skin" (quote from Lamberg et al.) This quote omits the next couple of sentences from Lamberg et al., which read as follows: "The same was true, however, for the period from supposed to known discontinuation of fluoridation. The most frequently perceived symptoms were those that are often linked with the so-called psychosomatic diseases."
• "fluoride does build up in the soft tissue and it would take a month or two for that to disappear." No, this study was about symptoms, not fluoride levels; and, as Lamberg et al. point out, even after massive intoxication with fluoride, symptoms usually last only 2 to 3 weeks. Their December survey was done after the fluoride concentration had been at its natural level for 3 weeks.
• Anyway, this thread is spending waaaay too much time talking about the details that do not appear in Water fluoridation, and would not appear with the proposed wording. It's irrelevant to the article.
• Again, as per WP:MEDRS, we should not be using a primary study to dispute reliable reviews. We should not be citing Lamberg et al. on skin rashes any more than we should be citing Feltman-Kosel 1961 on skin rashes. For skin rashes we should be citing the York review, and similar reliable reviews on adverse effects of water fluoridation.

Eubulides (talk) 07:58, 1 March 2009 (UTC)

Regarding the proposal to word this as "Psychological effects may cause the perception of symptoms due to fluoridation, regardless of whether the water is actually fluoridated.": I would prefer "In some individuals the belief that water is fluoridated may also have a psychological effect, manifesting as a large variety of symptoms, regardless of whether the water is actually fluoridated." It would be nice to be able to quantify how many is "some individuals"; it seems to be around 3% from the numbers quoted above. Xasodfuih (talk) 09:48, 1 March 2009 (UTC)

Thanks. Two further thoughts. "Manifesting" is medicalese and can easily be translated into ordinary English; "In some individuals" is redundant and can be removed. How about the following instead? "The belief that water is fluoridated may have a psychological effect with a large variety of symptoms, regardless of whether the water is actually fluoridated." (**) Eubulides (talk) 09:04, 2 March 2009 (UTC)

I don't think manifest is medicalese. Alternative wording: "A 1997 study found that people complained of certain symptoms regardless of whether fluoride was in the water or not, but these symptoms decreased after it was publicly-revealed that water fluoridation had been discontinued." Or briefer: "The findings of a 1997 study suggest that some symptoms reported by people in fluoridated communities are psychological". I still oppose dipping into a primary study to convey its limited findings. That people can have negative psychological reactions to substances is uncontroversial and obvious, but I'm not convinced it's necessary to emphasize this, especially given the possible and related allergy symptoms. You're best off doing a Request for Comment. II | (t - c) 22:40, 2 March 2009 (UTC)

• I share the concern about dipping into a primary study to convey its findings. That's why the wording I proposed doesn't mention the study's detailed findings. Instead, it mentions the overall topic, which is uncontroversial and which the study supports, without giving the details of the study (which aren't all that important anyway).
• The first alternative wording that II proposes dips into the study and reports its details; this isn't advisable and isn't needed, for reasons described in the previous bullet.
• The second alternative wording implies that only the 1997 study suggests that psychological effects occur (which isn't the case; these effects have been demonstrated in several occasions starting in the 1950s, and the effects' existence is not controversial). The wording also says "some symptoms" whereas the source uses considerably stronger wording than "some"; e.g., (p. 295), "the prevalence of symptoms was significantly reduced only after the respondents had become aware of the discontinuation of fluoridation, which reveals that if fluoridation does affect the perception of symptoms, that effect must be mainly psychological."
• Allergy symptoms (unlike the psychological effects) are controversial at recommended levels, and are an independent subject, which the proposed text doesn't (and is not intended to) address.

Eubulides (talk) 08:28, 3 March 2009 (UTC)

I'm still confused: did Lamberg trigger responses by noting in their questionnaire that Kupio's water is fluoridated? Were the questions leading in any way? And if Lamberg's survey did not remind their subjects that the water was fluoridated (even when it wasn't), then it's possible that the people weren't even aware of it at all. In that case, many of the symptoms could be purely random -- it's not uncommon for people to randomly feel better from one month to the next. It's not controversial that people will complain, and perhaps even faint, but there isn't a rigorous case that a significant portion of the population will have persistent psychosomatic symptoms, which is what this implies. II | (t - c) 17:45, 3 March 2009 (UTC)

Lamberg et al. 1997 (PMID 9332806) did not publish a copy of their questionnaire and their summary of the questionnaire does not directly answer your questions. Here's their summary: "The inquiries included questions about the perceived presence or absence of 25 symptoms during the week of inquiry, water consumption patterns, perceived quality of water, opinions concerning water fluoridation and detnographic data." Given that it was a fairly small town, that fluoridation was an active and controversial topic, and that the questionnaire specifically asked about fluoridation opinions, I think it unlikely that people were unaware of it. The proposed text (marked "(**)" above) does not state or imply that "a significant portion of the population will have persistent psychosomatic symptoms"; it doesn't use the words "significant", or "persistent", or "psychosomatic". Eubulides (talk) 09:08, 4 March 2009 (UTC)

Pretty surprising that they'd not mention such a thing, and it suggests that the questionnaire may have been leading. The abstract is vague enough that, combined with the wording, it does give the impression of persistent symptoms in a fair-sized group of the population, at least to me. Kuopio is not that small with a population of 91k. Further, it seems questionable that they're comparing different populations. They sampled 1000 people in November (%26 response, 260 people). Then they compared them to a different 1000 people in December (40% response, 400 people). They found the two groups reported similar frequency of symptoms? I'll admit that suggests, I suppose, that they had a large enough sample to approximate the mean of the population, and that's not a terribly small sample size. Then a few months later, the number of those 660 people with two symptoms or more dropped 13% - a significant amount of the population. Anyway, do Lamberg mention the reasoning behind this? If you're going to mention it, it should be mentioned in connection to its hypothesized causal mechanism: a fear of fluoridation's harmful effects. When communities have more fear (and possibly less education), you'd expect more symptoms. II | (t - c) 18:43, 4 March 2009 (UTC)

Like I wrote above, I prefer we give the percentage rather than dress it up in more or less vague words; 13% is significant, but less so than other psychological effects of placebo (e.g. in depression it's up to 30%). Xasodfuih (talk) 19:15, 4 March 2009 (UTC)

Their analysis also studied the intersections of the two groups (that is, the people who responded to both sets of surveys). The details of this single primary study should not be given so much prominence that we're talking about 13% or 30% or whatever; the exact percentages are not well-established by just one study. We should instead simply summarize the overall, uncontroversial fact that psychological effects do exist. Eubulides (talk) 00:42, 5 March 2009 (UTC)

At this point, I agree that it should be reinstated. I would prefer that it mention the hypothesized mechanism (fear), but it's up to you. I suppose I agree that percentages should not be used. II | (t - c) 18:47, 6 March 2009 (UTC)

Thanks. The source does say "fear" once, so it's sourced. I installed the most-recently-proposed wording above, except substituting "Fear" for "The belief". Eubulides (talk) 00:19, 7 March 2009 (UTC)

Feltman-Kosel 1961 etc.

• As we've already discussed, that "double-blind" study (namely, the 1974 Grimbergen preliminary study) was heavily criticized by the NRC report, which wrote "the authors did not estimate what percentage of the population might have GI problems. The authors could have been examining a group of patients whose GI tracts were particularly hypersensitive."[21] Later, when the NRC summarizes its findings the issue of hypersensitivity, it doesn't even bother to mention the Grimbergen results; it talks only about case reports when it says "There are a few case reports of GI upset in subjects exposed to drinking water fluoridated at 1 mg/L. Those effects were observed in only a small number of cases, which suggest hypersensitivity. However, the available data are not robust enough to determine whether that is the case."[22] In short, the NRC appears to be fairly skeptical of Grimbergen 1974.
• Also, as we've already discussed, the Grimbergen preliminary study was not in fact double-blind. Its subjects were asked to make their drinking water at home, using droppers full of either distilled water or of concentrated sodium fluoride or hexafluorosilicic acid. The reported concentration was over 5 g/L of fluoride, a value easily detectable by human senses. This was a "double-blind" study in which the "blindfolds" were easily removed without the experimenter noticing.
• The 1961 study (namely, Feltman & Kosel 1961, J Dent Med 16(Oct.):190-8, another paper not indexed by PubMed) was not about water fluoridation. It administered fluoride using tablets containing about 1 mg of fluoride ion, a form of administration that is much different from water fluoridation (concentrated dosage all at once, rather than dilute dosage throughout the day). Furthermore, the test was not blinded; one can easily taste that much NaF in a tablet, and psychological effects could easily explain its results.
• Of course, the above is just my own analysis, but come on: these are ancient and dubious studies whose results have never been replicated scientifically and which aren't treated seriously by reliable reviews of water fluoridation.
• The NRC report summarized that area by saying, "The possibility that a small percentage of the population reacts systemically to fluoride, perhaps through changes in the immune system, cannot be ruled out".(page 269) This is a polite way of saying "one can't prove a negative", which is not at all the just-short-of-definitive evidence that is implied by the previous comments. On the contrary, the NRC summary is a fairly negative assessment on the existing evidence.
• It is certainly fair, under these conditions, to say that claims of water fluoridation hypersensitivity are controversial.
• The suggested wording, "perhaps 1% of the population could respond negatively to fluoride at 1 mg/L", is not at all what the NRC says. It says (page 269) "Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated"; that "complains of" suggests psychological effects may be involved, and that "less than 1%" is an upper bound, not an estimate of 1%.
• Again, this secondary source, NRC 2006, is reliable but it is explicitly not about water fluoridation, and it cannot be used to support claims that water fluoridation causes GI or any other kinds of problems.
• Furthermore, we have reliable secondary sources such as the York review which state that there is no clear evidence of these potential adverse effects. We should be deferring to expert opinion in this area, rather than scouting through obscure 1950s or 1960s primary studies of dubious quality in a controversial area.
• Finally, again, the argument about hypersensitivity is irrelevant to the proposed text, which is about psychological effects, and is not about gastrointestinal or any other physical effects. There is no dispute among reliable sources that psychological effects exist and are significant. There is no reason to conflate this topic (which is not controversial among reliable sources) with the topic of hypersensitivity to water fluoridation (which is).

Eubulides (talk) 09:15, 27 February 2009 (UTC)

We've already said our cases, and I think you're plain wrong, and completely spinning the NRC. The NRC saying "they could have been analyzing a hypersensitive population" is not a "heavy criticism", and the studies might be ancient but they had a much better methodology. That the NRC's goal was to analyze levels above those used in water fluoridation is irrelevant if the studies discussed are clearly relevant to fluoridation. Your comments about Lamberg show that their assumption that these perceived symptoms are due to fluoridation is quite a big jump -- there's a very good chance that people were randomly feeling better the next month. II | (t - c) 17:41, 27 February 2009 (UTC)

I don't understand why you keep asserting that the NRC report cannot be cited. It clearly is about fluoride in drinking water. It must not be cited out of context (e.g. to attributed some side effect at higher concentrations to the <1mg/L used in optimal fluoridation). But I find this paragraph quite interesting (p. 269 - 275 you liked above):

“ Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated (Feltman and Kosel 1961). The numerous fluoridation studies in the past failed to rigorously test for changes in GI symptoms and there are no studies on drinking water containing fluoride at 4 mg/L in which GI symptoms were carefully documented. Nevertheless, there are reports of areas in the United States where the drinking water contains fluoride at concentrations greater than 4 mg/L and as much as 8 mg/L (Leone et al. 1955b). Symptoms of GI distress or discomfort were not reported. In the United Kingdom, where tea drinking is more common, people can consume up to 9 mg of fluoride a day (Jenkins 1991). GI symptoms were not reported in the tea drinkers. The absence of symptoms might be related to the hardness of the water, which is high in some areas of the United Kingdom. Jenkins (1991) reported finding unexpectedly high concentrations of fluoride (as high as 14 mg/L) in soft water compared with hard water when boiled. In contrast, in India, where endemic fluorosis is well documented, severe GI symptoms are common (Gupta et al. 1992; Susheela et al. 1993; Dasarathy et al. 1996). One cannot rule out the influence of poor nutrition (the absence of dietary calcium in the stomach) contributing to the GI upset from fluoride ingestion. Chronic ingestion of drinking water rich in fluoride on an empty stomach is more likely to elicit symptoms. [...] In an early clinical trial using fluoride supplements, Feltman and Kosel (1961) administered fluoride tablets containing 1.2 mg of fluoride or placebo tablets to pregnant mothers and children up to 9 years of age. They determined that about 1% of the subjects complained of GI symptoms from the fluoride ingredient in the test tablets. If it is assumed that the stomach fluid volume after taking the fluoride supplement was approximately 250 mL, the concentration to which the stomach mucosal lining was exposed was in the neighborhood of 5 mg/L. GI effects appear to have been rarely evaluated in the fluoride supplement studies that followed the early ones in the 1950s and 1960s. Table 9-1 suggests that, as the fluoride concentration increases in drinking water, the percentage of the population with GI symptoms also increases. The table suggests that fluoride at 4 mg/L in the drinking water results in approximately 1% of the population experiencing GI symptoms (see Feltman and Kosel 1961). [...] In areas of endemic fluorosis, such as parts of India, most subjects suffer from GI damage and adverse GI symptoms (Gupta et al. 1992; Susheela et al. 1993; Dasarathy et al. 1996). In one study (Susheela et al. 1993), every fourth person exposed to fluoride in drinking water (<1 to 8 mg/L) reported adverse GI symptoms. The results from these studies cannot be compared with the water fluoridation studies summarized in Table 9-1, because in the osteoporosis trials fluoride was nearly always administered as enteric coated tablets along with calcium supplements and the nutrition status of populations in endemic fluorosis areas is different from that in the United States. ”

I think this should be cited, but summarized along the lines: "GI effects of fluoride are well documented at concentrations higher than the recommended levels—the NRC estimates that at 4mg/L about 1% of the population may experience GI effects, possibly aggravated by dietary calcium deficiency." This is what I've got from NRC's writing, I wish their writing were a bit more clear; rephrase as necessary since I'm writing this in a hurry. It should go in the 3rd paragraph of safety, which discusses other effects (skeletal fluorosis) of fluoridation above the recommended level. (Also, you have the number wrong, 5mg/L not 5g/L, so not it would not have been detected by senses other than the gut.) [Sorry, I was confused about which study you were talking about due to the section heading.] Xasodfuih (talk) 20:02, 27 February 2009 (UTC)

I have not read much of the discussion taking place but I had mentioned this almost 3 years ago, that according to the National Academies, "The report does not examine the health risks or benefits of the artificially fluoridated water that millions of Americans drink, which contains 0.7 to 1.2 mg/L of fluoride. Although many municipalities add fluoride to drinking water for dental health purposes, certain communities' water supplies or individual wells contain higher amounts of naturally occurring fluoride; industrial pollution can also contribute to fluoride levels in water." It is also mentioned in the report itself on page 2, "Addressing questions of artificial fluoridation, economics, risk-benefit assessment, and water-treatment technology was not part of the committee’s charge." Thus, I am not sure why this reference has any relevance to the article, but if it is mentioned then there should be something that says the report was not examining water fluoridation as described in the article. - Dozenist talk 20:46, 27 February 2009 (UTC)

Whatever the PR person wrote in news release is obviously contradicted by the contents of the report, which examines side-effects at length. Also, are you claiming that at the same concentration natural and artificial fluoridation have different health effects, with latter somehow being safer? I really want to see a citation for this because we have a world map (from a "pro" group) that lumps together natural and artificial fluoridation as equally beneficial. Xasodfuih (talk) 20:58, 27 February 2009 (UTC)

Technically the committee was tasked to review only the EPA standards (2mg/4mg), not the recommended dosage (0.7 to 1.2 mg/L at the time) established by the U.S. Public Health Service:

“ The committee was charged to review toxicologic, epidemiologic, and clinical data on fluoride— particularly data published since the NRC’s previous (1993) report—and exposure data on orally ingested fluoride from drinking water and other sources. On the basis of its review, the committee was asked to evaluate independently the scientific basis of EPA’s MCLG of 4 mg/L and SMCL of 2 mg/L in drinking water and the adequacy of those guidelines to protect children and others from adverse health effects. ”

If you really think that NRC's review of review toxicologic, epidemiologic, and clinical data isn't a review of toxicologic, epidemiologic, and clinical data, let me know. Based on their review findings, NRC makes comments, as they were asked to, mostly on the EPA (4mg/L) standard, and these comments should not be misquoted wrt. to concentration as to appear they apply to a lower concentration, but claiming that this report does not study the effects of water fluoridation is ridiculous. The wiki article already discusses effects (skeletal fluorosis) that occur at higher that the PHS recommended levels, making it clear when they occur; all I'm proposing is a similar statement on GI effects. Xasodfuih (talk) 21:15, 27 February 2009 (UTC)

Also, a number of primary studies mentioned in the report (table 9-1) are with water fluoridate at 1mg/L, although NRC could draw no definite conclusion from those—they've settled for the 5ppm study (Feltman-Kosel) as more credible, although, it's clear they consider that study of low quality as well; based on this study they've ventured the guess of 1% of population possibly experiencing GI symptoms at over 4mg/L, although they appear not so convinced due to the lack of case reports from US areas naturally fluoridated over that level (as well as tea drinkers from UK) even though there are studies that do find GI effects in India (<1-8mg/L range presumably average to 4), and then they posit that calcium may be the reason for the observed differences. They are clearly speculating from scant evidence, but WP:MEDRS says their allowed to since they're the experts doing the review, and User:Eubulides's reanalysis of the primary studies doesn't trump NRC's. (also the NRC reports seems to indicate that enterically coated tables may have been used to create the true blinding that Eubulides contests) I don't see a problem mentioning NRC's speculation wrt. to the GI effects at 4mg/L, as long as it's attributed. Xasodfuih (talk) 21:35, 27 February 2009 (UTC)

This finding is also within the scope of their mandate (if you're anal about that) since it's about the EPA max level, not the PHS recommended one. Xasodfuih (talk) 21:39, 27 February 2009 (UTC)

I am not getting into an edit war. I was just pointing out and referenced directly from the report, which said "Addressing questions of artificial fluoridation, economics, risk-benefit assessment, and water-treatment technology was not part of the committee’s charge." Other editors can comment based on that issue. - Dozenist talk 04:45, 28 February 2009 (UTC)

• I agree with Dozenist that we should not be diving into the NRC review (which is not about water fluoridation) to pull out details of reports of GI symptoms. We can't cite those ancient sources directly to dispute our reliable reviews on water fluoridation; and we can't look at the NRC review for advice about WP:WEIGHT of adverse effects for water fluoridation at recommended levels, since the NRC review specifically says that it is not about that.
• In Water fluoridation, the NRC review might plausibly be cited in the section of the article that talks about adverse effects at well above recommended levels. This section currently consists of the following 27 words: "Fluoride can occur naturally in water in concentrations well above recommended levels, which can have several adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones." In this sentence, adverse effects should be listed according to the weight that reliable sources give them. The NRC report summary devotes (by my count) 2616 words to adverse effects of fluoridation above recommended levels, starting on page 4. Of these words, it devotes about 39% to skeletal effects, 26% to dental effects, 16% to cancer and genotoxicity, and the remaining 19% to everything else. Gastrointestinal (GI) effects are discussed as 1/4 of a 119-word section, which means it gets about 1% of the NRC's weight. The NRC gives a low weight to GI effects because, as it says, "Such effects are unlikely to be a risk for the average individual exposed to fluoride at 4 mg/L in drinking water."
• In contrast, in the WHO report on adverse effects of water that is naturally fluoridated above natural levels, gastrointestinal effects are not mentioned at all. That report emphasizes dental and skeletal fluorosis as well.
• With all the in mind, it is a severe violation of WP:WEIGHT to even mention gastrointestinal symptoms in the sentence about fluoride well above recommended levels, much less emphasize GI symptoms by citing primary sources about them. Dozens if not hundreds of symptoms are attributed to high levels of fluoride; why focus on GI symptoms, when our reliable reviews do not?

Eubulides (talk) 07:58, 1 March 2009 (UTC)

See my proposal on Wikipedia:Featured article candidates/Water fluoridation for restructuring this article to avoid giving the impression that the NRC findings apply to normal fluoridation conditions. Basically, we should have separate sections for overdose and interactions per Wikipedia:WikiProject_Pharmacology/Style_guide. Xasodfuih (talk) 10:05, 1 March 2009 (UTC)

Article structure etc.

(Beginning of commentary copied here from Wikipedia:Featured article candidates/Water fluoridation.)

Here are my concerns regarding article structure. I'm going to assert that this article is about compound(s) with pharmaceutical benefit, or more precisely about a particular route of delivery thereof. This poses a few MOS-like problems. I think we don't have another FA like this to guide us. Ideally the fluoride therapy article should do the "heavy lifting" for things like mechanism/pharmacokinetics/side effects/overdose etc. But that article is in C-class shape with practically no useful sections to refer to for further info. So this FA is going to have to provide almost all the info of that kind—and it's almost there. WP:PHARM doesn't a have a "mandatory" (FA-wise) MOS, but it has some guidance for article structure and content here (I'll refer to this as PHARM:MOS). Furthermore, since this is a public health policy issue, cost should be discussed in more detail than in articles on other medications. My concrete suggestion based on stemming from the above are are:

• The "safety" section should be called side effects. My impression is that some editors try to paint WF in the most favourable light possible, so they want to avoid "side effects" as a bad word. I think this is not quite right per WP:STRUCTURE. It's fine to add "safety" to the section heading, but since the most/only significant side effect at recommended concentration is aesthetical, not safety related, and considering that PHARM:MOS recommends using this terminology, I think that "side effects" is a better section for that title.
  • As an addendum here, I have to remark the WHO recommended max daily dosage of fluoride for adults/children still has not been added; see WHO, 2002, Environmetal Health Criteria 227. Fluorides.
• There should be a separate section about interactions. The recent addition of info about other sources of dietary fluoride is welcome (see archive for discussion), but I think the placement of that info in the "mechanism" section is suboptimal since that (2nd) paragraph says very little about the mechanism of anything, let alone the mechanism of the side effects due to overconsumption of fluoride. PHARM:MOS recommends having a section called "interactions" and I think that's where other sources of dietary fluoride should be discussed.
  • I would also move here the kerfuffle about the "proven", then disproved, epidemiological correlation between lead and silicofluorides, because this was hypothesized to be due to leaching of lead from bass pipes, which is an interaction in the pipe, not in the body, but it's close enough topic-wise.
• A significant amount of discussion in the FAC archive and on the article's talk page circled around including or excluding information on side effects that occur fluoride concentrations above the PHS/WHO recommended levels, in particular info from the NRC report that evaluated the EPA's soft/hard maxiums of 2mg/L and 4mg/L respectively. The criteria for including such information in the safety section has been inconsistent. I propose we resolve this by having a separate section about overdose as recommended by PHARM:MOS (open to suggestions if overdose is not the best title in this case). This section should include the discussion about side effects that do not normally occur (meaning in the absence of other significant dietary sources) at the PHS recommended levels of WF, in particular skeletal fluorosis, and gastrointestinal effects. I would also move the info about WF accidents here.
  • A closely related issue was the discussion about the prevalence of the hypothesized fluoride Gastrointestinal (GI) hypersensitivity at recommended concentration. While the info on that is non-existant due to the lack of well controlled studies, the NRC did venture a guess about the occurrence of GI effects at concentrations above the EPA limit of 4mg/L. Based on a table of primary studies, only one of which was at 5ppm, the rest being well above that, the guestimated 1% prevalence at that level. Mentioning this appears to be a very sensitive issue with the long term editors of this article, for reasons I don't quite comprehend, but which I presume to be of the "not giving a finger for the fear they might lose the whole hand" variety.
  • The info about WF accidents could be more systematic, currently an example is given based on the well-known NEJM paper, but the much reviled NRC report lists some more. Please check to see if they are discussed in a systematic fashion somewhere.
• Finally, since this is a public health issue, I would prefer a separate section about cost. This info is currently spread through several sections (implementation, effectiveness), and my guess is that most people would zone out the water pump picture in the implementation section and not read any further. There is enough info available to write a section on this, including the variance of unit cost with the size of the installation (see Truman for instance), and the absolute cost of installations (some Australian papers have this). The cost of the other systemic fluoridation methods (salt, tablets), as well as topicals could mentioned there as well—let the reader draw the conclusions; I think this would be uncontroversial WP:SYNT-wise.

These suggestions were brought to you by Xasodfuih (talk) 08:56, 1 March 2009 (UTC)

Since I was asked on my talk page, on a somewhat adversarial tone, to specify how the above relates to WP:WIAFA rules, and to move anything else to the article's talk page, here it goes by the book:

• 1a- well-written: Article organization falls under that criterion in my opinion because well-written doesn't mean just "a sequence of grammatical sentences".
• 1b- comprehensive: some of the issues above relate to lack of some information I consider important.
• 1d- neutral: lack of information can lead to bias.
• 2b- appropriate structure: while User:Colin disagrees that this article has anything to do with pharmaceuticals, I maintain that taking some guidance from Wikipedia:WikiProject_Pharmacology/Style_guide is appropriate.
• Finally, making general observations without giving examples would be even more confusing. ...

Xasodfuih (talk) 09:43, 1 March 2009 (UTC)

(End of commentary copied here from Wikipedia:Featured article candidates/Water fluoridation.)

• "The "safety" section should be called side effects." Safety should not be renamed to Side effects. Safety is a shorter and more-accurate title. Side effects can refer to either adverse effects or beneficial effects, whereas the current Safety section discusses only adverse effects. Adverse effects would be an acceptable title, but it's medical lingo that many typical readers won't know about, whereas Safety is simple, easily understood, and means the same thing.
• "My impression is that some editors try to paint WF in the most favourable light possible, so they want to avoid "side effects" as a bad word." I don't have that impression. My reason for preferring "safety" is listed above. I don't know of any editors with the motivation or the behavior that you describe.
• "considering that PHARM:MOS recommends using this terminology" I'm not sure what PHARM:MOS is; there is no PHARM:MOS. WP:MEDMOS does not address the issue of what sections should be in Water fluoridation. Water fluoridation is not a disease, or a drug, or a medical test, etc. The closest thing would be WP:MEDMOS #Drugs, but its sections are not particularly appropriate for water fluoridation (please see below).
• "the WHO recommended max daily dosage of fluoride for adults/children still has not been added; see WHO, 2002, Environmetal Health Criteria 227. Fluorides." I'm not sure what the "still" is referring to; as far as I know that addendum has never been mentioned before here. Also, the abovementioned URL to section 11.0 does not contain any recommended max daily dosage. The WHO has recommended a maximum value of 1.5 mg/L for fluoride in drinking water; is that what you're referring to? If so, that figure was installed a couple of weeks ago.[23] If not, please specify clearly what the problem is here.
• "There should be a separate section about interactions." It wouldn't hurt to improve the coverage of multiple sources of fluoride, but it would be a misnomer to use the term "interactions" to cover this. It is not a drug interaction (as fluoride is not normally considered a drug; and even if it were, drug interactions occur between different drugs) and the problem of fluoride from multiple sources is not called "interactions" in the literature on water fluoridation. Wikipedia is not the place to introduce nonstandard terminology like this.
• "I would also move here the kerfuffle about the "proven", then disproved, epidemiological correlation between lead and silicofluorides" As explained earlier on the talk page, that raises serious WP:WEIGHT violations, as reliable sources do not consider the lead effects to be shown, any more than the dozens of other hypothesized adverse effects. We should be following what reliable reviews say on the subject of adverse effects; we should not be doing research of our own, by citing dueling primary sources.
• "having a separate section about overdose" An Overdose section is reasonable for drugs, but not for water fluoridation. Overdose is a real problem with many drugs, but it is not a significant safety issue with water fluoridation per se. The main reason children get too much fluoride in industrialized countries is by swallowing toothpaste; in nonindustrialized countries, it's by ingesting water that's naturally fluoridated well above recommended levels. It's fine to have a brief discussion about overdose here, but giving it a separate section would raise serious WP:WEIGHT issues. Reliable reviews on water fluoridation do not contain Overdose sections, and Water fluoridation shouldn't either.
• "Mentioning this [GI symptoms] appears to be a very sensitive issue with the long term editors of this article, for reasons I don't quite comprehend, but which I presume to be of the "not giving a finger for the fear they might lose the whole hand" variety." No, as described above, GI symptoms should not be emphasized because our reliable reviews on water fluoridation don't emphasize them. It's a WP:WEIGHT issue, pure and simple: we shouldn't emphasize relatively-unimportant safety issues, and should instead concentrate the safety-issue coverage in the same areas and weights that reliable sources do. Eubulides (talk) 23:24, 1 March 2009 (UTC)
• "The info about WF accidents could be more systematic, currently an example is given based on the well-known NEJM paper, but the much reviled NRC report lists some more. Please check to see if they are discussed in a systematic fashion somewhere." I checked, and found nothing. All the collections I found were anecdotal. I used the NEJM paper because it killed somebody and was well-documented by a reliable source.
• "I would prefer a separate section about cost." It's a reasonable suggestion to have cost discussed separately; I'll look into it. (Update: see #Cost below. Eubulides (talk) 09:13, 6 March 2009 (UTC))
• "Article organization ... taking some guidance from Wikipedia:WikiProject_Pharmacology/Style_guide is appropriate." Like Colin, I disagree that the article should be structured like a drug article. The issues involved in water fluoridation are much, much differerent than the issues involved in (say) aspirin or cocaine. I have responded to the specific suggestions above, but the big picture is that this isn't a drug article.
• "some of the issues above relate to lack of some information I consider important ... lack of information can lead to bias" This seems to be talking mostly about adverse effects. However, Water fluoridation should not focus on adverse effects far more heavily than reliable sources do. Any further emphasis on poorly-supported or highly-unlikely adverse effects, more so than reliable sources give, would raise serious WP:WEIGHT issues.

Eubulides (talk) 23:24, 1 March 2009 (UTC)

You're right that health effects of fluoride above the PHS-recommended levels should only be touched briefly in this article, and that already happens. Fluoride poisoning (title somewhat bad) already discusses the EPA standard, and a summary should be given in Fluoride (or fluorine see related discussion at WT:CHEM); I wrote "should" because the section of fluoride#Toxicology that's supposed to summarize that article is a WP:CFORK, although not because of POV issues. Chronic effects due to overexposure are not usually considered poisoning, but the article on Fluoride poisoning discusses mostly chornic rather than accute effects. Oh, well... Xasodfuih (talk) 17:53, 4 March 2009 (UTC)

Hopefully, this change defers the discussion to the proper places and distinguishes between chronic and acute effects of overexposure in the least amount of words; I've cited NRC for the survey of overfluoridation accidents, since the NEJM paper is a primary study that only discusses one (per WP:MEDRS), and you cannot justify the use of the adjective "rare" without citing a survey of such accidents. Xasodfuih (talk) 19:01, 4 March 2009 (UTC)

Thanks for that edit. The NRC doesn't actually say "rare", and neither the NRC nor the Medscape citations are about water fluoridation, so I attempted to further improve that change by replacing the NRC and Medscape citations with Penman et al. 1993 (PMID 9323392), a source that is directly on the topic of acute fluoride poisoning due to fluoride overfeed, and which does say "rare". I also changed the wording to use terms like "fluoride overfeed", "acute fluoride poisoning", rather than the term "overfluoridation" (which I vaguely recall having invented myself). Finally, for "gastrointestinal" I substituted "nausea and vomiting", which is easier for ordinary readers to understand and are the most-common symptoms. These wording changes all came from the Penman et al. source. Eubulides (talk) 00:42, 5 March 2009 (UTC)

I don't know how much of an improvement that is. PMID 9323392 is a primary study almost 15 years older, focused on one accident, and which cites a personal communication from a CDC employee to say that such accidents are "relatively infrequent", but doesn't say relative to what. While not using an adjective themselves, the NRC table lists practically all accidents that resulted in a publication. I cited medscape (in addition to the NEJM study) for the fact that gastrointestinal effects predominate; their page is a about overdosing with fluoride from ingesting a number of products; they don't mention water overfeed accidents explictitly, but it's not unreasonable to assume they don't mention those because they are rare; the NEJM paper list the same symptoms in its abstract, so the sources concur. Also, since you rightfully prefer less jargon, you could use the description from NEJM: "nausea, vomiting, diarrhea, abdominal pain"; it's a bit wordy though. Xasodfuih (talk) 02:02, 5 March 2009 (UTC)

I'm still leery of citing the NRC review, which specifically says that it's not about water fluoridation, and citing another source that doesn't mention water fluoridation either, and on top of that coming up with words like "rare" that are not in the sources; this is uncomfortably close to original research, and there are also WP:WEIGHT concerns. I searched harder for a better source, and found Balbus & Lang 2001 (PMID 11579665), a review on drinking water safety, which has a paragraph on water fluoridation and does say "rare" (and heh! it says "overfluoridation"). Balbus & Lang list 11 symptoms but the 1st three are enough here (same 1st three as the sources you mentioned). Now that we have a relatively reliable review on the subject there's no need to cite the primary sources. I gave it a whirl by installing this change:

"... fluoride overfeed overfluoridation that causes outbreaks of acute fluoride poisoning, with symptoms such as that include nausea, and vomiting, and diarrhea. For example, in Hooper Bay, Alaska, in 1992, a combination of equipment and human errors resulted in one of the two village wells being overfluoridated, causing one death and an estimated 295 nonfatal cases of fluoride poisoning "Three such outbreaks were reported in the U.S. between 1991 and 1998, caused by fluoride concentrations as high as 220 mg/L; in the 1992 Alaska outbreak, 262 people became ill and one person died."

Dunno why there's a discrepancy between the "295" and the "262" but at this level it doesn't really matter. Eubulides (talk) 03:58, 5 March 2009 (UTC)

That's fine with me. Xasodfuih (talk) 13:26, 5 March 2009 (UTC)

Cost

In response to the suggestion "I would prefer a separate section about cost" in the previous talk-page section, I created a new article section Cost, moved the cost-related discussion into this section, added a bit on the cost of salt fluoridation, and used {{inflation}} to adjust the cost estimates for inflation. Comments welcome. Eubulides (talk) 09:13, 6 March 2009 (UTC)

Purpose of fluoride

A recent edit added the claim "Fluoride has a topical benefit to tooth enamel, but has no other known purpose in humans." as a new 2nd second sentence of the lead. The first part of this claim ("topical benefit to tooth enamel") merely repeats the next sentence (which describes in detail how fluoridated water affects cavity formation); the second part of this claim ("has no other known purpose in humans") is not supported by the cited source (CDC 2001, PMID 11521913), does not summarize any part of Water fluoridation's body, and is vaguely unscientific to boot (as scientists aren't supposed to talk about inanimate substances having "purpose"). Fluoride certainly has other effects on humans; for example, in moderate quantities, it may help lower the risk of breaking bones—see NHMRC 2007 (PDF).

I made another change to try to fix the problems described above. Eubulides (talk) 07:28, 15 March 2009 (UTC)

Purpose in this case is obviously not referring to the cognitive sort of purpose. It would be perhaps clearer to say that fluoride has no known benefit in humans except its topical effect making tooth enamel more resistant to acid, as one of many ways of preventing cavities. Until and unless you find a WP:RS to show that fluoride provides any other benefit in humans, it's fair to say that.76.85.197.106 (talk) 16:25, 15 March 2009 (UTC)

Furthermore, the OP of this section is misreading his source. It states: "The authors of the three existing systematic review concur that water fluoridation at levels aimed at preventing dental caries has little effect on fracture risk - either protective or deleterious. The results of the subsequent original studies support this conclusion, although suggest that optimal fluoridation levels of 1 ppm may indeed result in a lower risk of fracture when compared to excessively high levels (well beyond those experienced in Australia). One study also indicated that optimal fluoridation levels may also lower overall fracture risk when compared to no fluoridation(the latter was not the case when hip fractures were considered in isolation)." I.E., excessive fluoride is bad for your bones and there is no evidence that fluoride benefits bones (excepting teeth) at any dose level.76.85.197.106 (talk) 16:30, 15 March 2009 (UTC)

The source says "optimal fluoridation levels may also lower overall fracture risk when compared to no fluoridation". But the main point is that none of this stuff is worth mentioning so early in the lead. The lead is about water fluoridation, and should not immediately, in its 2nd sentence, dive down into the minutiae about the effects of fluoride on bone fracture. The 1st paragraph of the lead should focus on the same subjects that reliable sources on water fluoridation focus on. None of these sources focus on the absence of (or possible presence of) alternative benefits of topical fluoride, so (as per WP:WEIGHT) Water fluoridation shouldn't either. Eubulides (talk) 18:39, 15 March 2009 (UTC)

That depends if they controlled the "no fluoridation" category to remove places that are natually fluoridated to excess, and controlled for all the other socioeconomic factors... Fair enough 76.85.197.106 (talk) 19:13, 17 March 2009 (UTC)

Xylitol etc.

This edit added 1226 bytes on xylitol, citing only favorable sources, which introduces both a WP:WEIGHT and a WP:NPOV problem.

• First, weight. Many schemes are used for caries control. Anusavice 2005 (PMID 15897335) lists the following:

• fluoride toothpaste (0.5 pages in Anusavice, by my count)
• fluoridated water (0.5 pages)
• fluoride mouthrinses, toothpaste, and gel (0.7 pages)
• professionally applied fluoride supplemented with fluoride from toothpaste (0.5 pages)
• fluoride varnish (0.7 pages)
• antibacterial and antimicrobial and bactericidal agents (1.2 pages)
• xylitol (0.3 pages)
• ozone technology (0.4 pages)

Tellingly, Anusavice's Figure 5 (p. 545) does not bother to list xylitol or ozone technology; these appear to be the also-rans among the above-listed methods.

Anusavice also lists the following future approaches:

• replacement therapy (1.9 pages)
• genetically engineered, alkali-producing streptococci (0.2 pages)
• caries vaccine (1.2 pages)

Given these weights, it's overkill for Water fluoridation to expend 1226 bytes on xylitol, when it spends many fewer bytes on other alternative methods (e.g., it spends zero bytes on antibacterial approaches, and 489 bytes on all future approaches combined).

• Second, NPOV. As Anusavice makes clear, the evidence for the effectiveness of xylitol is controversial, and there are negative reviews. Other sources agree: for example, Bader 2007 (PMID 17967395) says:

"The evidence for efficacy of xylitol-based interventions is seen by some as controversial, even though xylitol has been shown to be effective in a large number of studies with varied populations, delivery methods, and experimental designs. There have been 3 recent reviews of portions of the evidence for the effectiveness of sugar alcohols in general, and xylitol in particular. The conclusions of the 3 reviews differ substantially, and in so doing, neatly reflect the current state of knowledge.... Thus, 3 reviews each examined portions of the available evidence. Each of these reviews found evidence for a xylitol preventive effect, but 2 reviews indicated that the available evidence was not strong enough to permit a firm conclusion of therapeutic effectiveness. Inconclusiveness was ascribed to generally weak designs without active controls and some contradictory, nonsignificant results. All of the studies indicated that the existing evidence needed to be supplemented by well-designed trials."

The best recent review I could find on xylitol gums was Desphande & Jadad 2008 (PMID 19047666), who concluded that evidence supports chewing polyol-containing gum as part of normal oral hygiene to prevent caries, but go on to write:

"The findings of our review do not agree with those reported by Lingstrom and colleagues that deemed the evidence for the use of sorbitol or xylitol in chewing gum inconclusive. Finding discordant reviews is not rare in the literature. The main differences between these reviews relate to inclusion criteria, quality scales, classification of study design and conclusions based on studies that were considered to be of high quality. We rated two original studies classified as low quality by Lingstrom and colleagues as high quality. We performed a sensitivity analysis by eliminating these two studies and still produced statistically significant results across all categories, further confirming the robustness of our findings."

• While we're on the subject of alternative treatments, chlorhexidine's role in preventing tooth decay is also controversial. See, for example:

• Autio-Gold J (2008). "The role of chlorhexidine in caries prevention". Oper Dent. 33 (6): 710–6. PMID 19051866.

• Anyway, though it's clear that Water fluoridation should mention xylitol and chlorhexidine, it's not at all clear that it should be covering the discordant reviews and other controversies with respect these two approaches, unless we can find reliable sources that cover these treatments in relation to water fluoridation. Right now, only Anusavice has that role, as far as I know.
• With all the above in mind, I made a further edit to simply list xylitol as one of the alternative therapies available, and also to briefly list chlorhexidine, fluoridated mouthwash, gel, and dental varnish. No doubt further improvements could be made, but we need to keep WP:WEIGHT and WP:NPOV in mind.

Eubulides (talk) 08:05, 11 March 2009 (UTC)

I don't really understand why chlorhexidine, which from my investigations has received relatively little coverage in the literature as a public-health measure, is equated with xylitol, which has several recent positive reviews which emphasize it as a public-health measure with proven effectiveness. There were the 2 JADA reviews I added, plus there's PMID 1736987 (2006), which argues for increasing its use in the U.S. Plus the AAPD's policy statement. As you said, xylitol's preventive effect is acknowledged. What does it mean for its therapeutic effectiveness to be controversial? Is fluoride's therapeutic effectiveness controversial? There's also the fact that reviews say that there's good evidence that xylitol helps block transmission of S. Mutans, which reduced cavities 70% in children whose mothers chewed the gum compared against the group that used chlorhexidine. In addition, the preceding sentence ("other public-health strategies have lacked impressive results") introduces a POV which clouds the next sentence and makes people think, wrongly, that xylitol is not effective for public-health control of cavities. Just because one review, Anusavice, does not emphasize xylitol does not mean that the several positive, and more recent, reviews should be discounted. Basically, the sentences need to be reworded to give appropriate weight to xylitol and not put the cloud over it. II | (t - c) 23:05, 12 March 2009 (UTC)

• Chlorhexidine has actually received quite a bit of coverage in the literature as a method of controlling tooth decay. See, for example, Kocak et al. 2009 (PMID 19262732), Duarte et al. 2008 (PMID 19119578), Autio-Gold 2008 (PMID 19051866), Hoszek & Ericson 2008 (PMID 19051864), Hauser-Gerspach et al. 2008 (PMID 19034538), van Strijp et al. 2008 (PMID 18997466), and Lobo et al. 2008 (PMID 18954355), all published since November 1. This is as much or more interest in the recent literature than xylitol has seen.
• Certainly xylitol is controversial. For example:

"Of the bulk sweeteners, xylitol has been the most studied and reviewed, and it is the most controversial. The controversy revolves around whether xylitol has an anticaries benefit and, therefore, is superior to the other polyols.... Although xylitol has anticariogenic properties, there is not sufficient evidence to recommend xylitol as a first-line anticaries strategy in light of the large body of evidence on the effectiveness of topical fluoride and dental sealants." Zero DT (2008). "Are sugar substitutes also anticariogenic?". J Am Dent Assoc. 139 (Suppl 2): 9S–10S. PMID 18460675.

• Fluoride's therapeutic effectivness is not controversial among reliable sources, as far as I know.
• One can certainly find positive reviews for xylitol among reliable sources, but one can also find negative ones. It's not really the job of this article to be listing or citing all these reviews. This article's job is to present evidence about water fluoridation, and we should be relying on reliable secondary sources that compare water fluoridation to alternatives; we should not be going out and citing research on those alternatives ourselves. That is why it is better to rely on sources like Anusavice, which compare various forms of treatment for dental caries (including water fluoridation and its alternatives), to sources such as the ones that you and I have cited above, which are about xylitol and/or chlorhexidine, and which are not about water fluoridation.
• Could you please suggest a better wording to avoid the wording cloud that you've discovered?

Eubulides (talk) 01:50, 13 March 2009 (UTC)

• This reaction on the part of readers is reflective of the article's confused focus, in my opinion. If the article were clear on what the topic is, and stuck to the topic throughout the artcle, such confusing in readers would not arise. —Mattisse (Talk) 02:14, 13 March 2009 (UTC)

• There's no evidence in this thread of confused focus on the part of either the Water fluoridation article or its readers. The article is about water fluoridation, whose goal is to reduce tooth decay; the topic in this thread is over how much weight to give to the article's treatment of alternative ways of achieving the same goal. Every Wikipedia article on public-health measures should consider such topics; for example, Chlorination should (and does) cover alternative disinfection methods such as chloramine and UV. While there may be legitimate disagreements over how much space Chlorination #Alternatives should devote to alternatives, there's nothing wrong with the idea per se of covering alternatives, nor does the existence of such coverage mean that Chlorination has a "confused focus". Eubulides (talk) 04:30, 13 March 2009 (UTC)

Chlorhexidine too

• I apologize for the delay in responding. No offense, but your response did not have the quality that I've come to expect. Why did you throw up a bunch of random articles on chlorhexidine? The first shows reduced S. mutans, the second shows no reduction in caries, the third one (a review) actively says it shouldn't be used because of lack of information on side effects, the fourth is an in vitro study on chlorhexidine in restorative materials, the fifth also doesn't support chlorhexidine's use, the sixth does not support its use, and the seventh shows reduced S. mutans (big surprise).

• We need to stick to reviews, particularly ones which focus on the public health use of the method we're discussing. There are plenty of reviews which encourage xylitol as a public-health approach because its safe and effective. You've plucked out a statement from an editorial that there's controversy over whether it's more effective than sorbitol, but sugar alcohols in general are not controversial. Chlorhexidine is controversial. It is primarily for gingivitis, stains the teeth, and irritates the "oral mucosa".
• You've plucked out a controversy statement from a single editorial. Right after that statement it says this:

  The results of studies have shown that when sorbitol- and xylitol-containing chewing gum and candies were used three to five times per day, they had a caries-preventive effect in subjects compared with results in subjects who did not use chewing gum or candy, and xylitol generally had a larger caries-preventive benefit.4,5 Questions have been raised about whether the caries-preventive benefit of xylitol-containing chewing gum is due to salivary stimulation or to an antimicrobial effect. Unlike sorbitol, which can be metabolized slowly by some oral bacteria, xylitol has a bacteriostatic effect on mutans streptococci. It also has been reported to reduce mutans streptococci levels in plaque and saliva,6 block mother-to-child transmission of mutans streptococci7 and alter the acidogenic potential of plaque to subsequent sugar challenges.8 The results of direct head-to-head comparisons of sorbitol and xylitol have been mixed, and concerns have been raised about the independence and quality of the research.4

  A systematic review, PMID 19047666, of the xylitol vrs. other sugar alcohols issue shows that xylitol had the greatest reported effect. If we want to dabble into the recent research on xylitol, there's PMID 19085034 (showing longlasting morphological changes in S. mutans) or PMID 18657266 (showing reductions in S. mutans with both xylitol and a much higher dose of maltitol). PMID 17063022 actually concluded that xylitol had a remineralizing effect.
• Anyway, the best way to resolve this is to just have a long sentence and a ref on both chlorhexidine and xylitol. Here's a rough proposed replacement for the current sentence: "Other agents to prevent tooth decay include noncariogenic sugar substitutes and chlorhexidine. Chlorhexidine is controversial and not recommended due to inconclusive efficacy and side-effect concerns (cite PMID 19051866), but the use of sugar substitutes, particularly sugar alchohols such as xylitol, have been recommended and implemented in some coutries." This could cite any number of reviews: PMID 18451371 says "particularly xylitol", PMID 18657266 discusses worldwide adoption in the intro, PMID 19216379 has the American Academy on Pediatric Dentistry's recommendation. There are 4-5 other reviews if we go back to 2002.
• The review you mentioned which brought up the controversy focused on the therapeutic effectiveness. I asked whether there was controversy around fluoride's therapeutic effectiveness. That's because while it's clear that fluoride is effective for prevention, it's not clear that it effectively remineralizes early lesions, especially in the levels of fluoridated water. The sources don't seem to emphasize this effect. Our mechanism doesn't mention it; in fact it says the opposite ("controls the rate caries develop"). I recall reading somewhere that fluoride does bond with the less mineralized areas and remineralize teeth, but fluoride is mainly a preventative agent. There is real controversy over whether you can take xylitol and expect very small caries to disappear because some studies have found that. That isn't worth getting into here, and should not be conflated with whether xylitol is effective preventatively and could be recommended as a public-health measure.

As far as the controversy surrounding whether xylitol is more effective than sorbitol, most studies find that it is. While some think the case hasn't been finalized, that's not worth getting into here. Since all reviews emphasize xylitol, it has a plausible mechanism for reducing S. mutans further (sorbitol can be digested, xylitol cannot) and it is the one which has been adopted by several countries and the U.S. military, our article should be proportional to that and mention it "particularly". II | (t - c) 23:52, 17 March 2009 (UTC)

• "your response did not have the quality that I've come to expect" Perhaps that's because you misread the response? The response was in no way an attempt to argue that clorhexidine should be used for tooth decay. It was merely a response to the claim that chlorhexidine "has received relatively little coverage in the literature as a public-health measure". Your comment did not revisit that claim, so I hope we can agree that chlorhexidine-for-tooth-decay has received quite a bit of coverage lately among reliable sources; if anything, it has gotten more coverage recently than xylitol has.
• "We need to stick to reviews, particularly ones which focus on the public health use of the method we're discussing." I agree, but we have to remember that in the context of Water fluoridation, the "method we're discussing" is water fluoridation, not xylitol or chlorhexidine or anything else. We need to stick to reviews that put alternative methods like xylitol in the broader context that includes water fluoridation. We should not rely on reviews of xylitol per se. Such reviews would be necessary and appropriate for Xylitol but generally speaking they're neither necessary nor appropriate here.
• "You've plucked out a controversy statement from a single editorial." That is because I was supporting a claim that xylitol is controversial, and there was no need to quote more once the claim was established, which it was. The extended quote that you gave, which ended with "concerns have been raised about the independence and quality of the research", does not disagree with the fact that xylitol is controversial; on the contrary, it continues to support the claim. We should not present xylitol as if it were a generally-agreed worthy substitute for water fluoridation; it is not.
• "the best way to resolve this is to just have a long sentence and a ref on both chlorhexidine and xylitol." Something that's longer than the current treatment would be OK, but the proposed draft is quite unsatisfactory, as it constitutes unnecessary original research. Any coverage here of xylitol should be supported by a reliable review that covers the topic of xylitol in an overall context of caries control that includes water fluoridation. (Similarly for chlorhexidine, of course.) We should resist the temptation to incorporate results directly from reviews that cover only xylitol and/or chlorhexidine, as that's synthesis and should be avoided. Here we already have a reliable review on the overall area of caries reduction, namely Anusavice 2005 (PMID 15897335). This review places water fluoridation in context with alternatives and gives weights to these alternatives. We should not be disputing this review's weights by doing our own research into alternatives, in order to lengthen discussion of our preferred alternatives all out of proportion to the weight that our reliable source gives.
• "it's not clear that it [fluoride] effectively remineralizes early lesions, especially in the levels of fluoridated water" Sorry, I don't follow this point. Reliable sources agree that frequent uses of small amounts of fluoride facilitate tooth remineralization. See, for example, CDC 2001 (PMID 11521913). The current article does not claim that this remineralization constitutes "therapy", nor is water fluoridation commonly treated as "therapy" by reliable sources, so I'm not sure why this particular topic is relevant to Water fluoridation (though it may well be relevant to Xylitol).
• Or perhaps the point is that we should add to the article a statement that water fluoridation is intended to prevent tooth decay, not to repair cavities? That would be a good thing to add, if we can find a reliable source that states this clearly.

Eubulides (talk) 16:29, 19 March 2009 (UTC)

The original research policy should not be used to put misleading facts and omit important information from an article simply because nothing discusses the these misleading facts in direct relation to the article at hand -- rather the point is the topic at hand and the text itself. There's no original research: the proposed statement says nothing about these measures in relation to water fluoridation, only in relation to public health caries prevention. Just because Anusavice doesn't mention (and predates) concerns raised about chlorhexidine's side effects in a focused review and also doesn't mention xylitol's endorsement as a public health measure (also less common in 2005) should not be used to keep those facts out of the article and equivocate the two measures. My suggested text doesn't imply that xylitol is a replacement for fluoridation, but it does note that they reduce caries and have been recommended, and importantly notes that recent research does not recommend chlorhexidine. Since our positions seem incompatible, I'll be raising this at WP:OR/N at some point. II | (t - c) 17:16, 19 March 2009 (UTC)

• "misleading facts" What is misleading about the current article? It says "Alternative individual treatments include the antibacterial agent chlorhexidine and the sugar substitute xylitol." If this is misleading, how could it be changed to be less misleading, without drawing the sort of problematic conclusions at issue here?
• "omit important information" The issue here is a WP:WEIGHT one yes. As I understand it, the proposal is to mention xylitol as an important alternative to, or substitute for, water fluoridation. However, reliable sources do not state this, and Water fluoridation should not state or imply it.
• "the proposed statement says nothing about these measures in relation to water fluoridation" Sure they do. They criticize chlorhexidine, and praise xylitol, in a section called Alternatives in an article called Water fluoridation. In context this is clearly a statement about the effectiveness of xylitol as an alternative to water fluoridation. As far as we know, reliable sources are not making statements like these, in contexts like these, so Water fluoridation should not be doing it either.
• "Just because Anusavice doesn't mention (and predates) concerns" I share your concern that Anusavice 2005 (PMID 15897335) is a bit long in the tooth, so to speak; but we must be quite careful of substituting our own opinion for that of a reliable source, even if the source is four years old. One can easily find reliable sources, published in peer-reviewed medical journals that praise xylitol, and which criticize it; it is not our job to arbitrate and choose among those sources when we have a reliable review that does it for us.
• "My suggested text doesn't imply that xylitol is a replacement" Sure it does, in context. And the text sharply criticizes chlorhexidine as a replacement, and contrasts it to xylitol, which it praises. This contrast, and this comparison to fluoridation, is not supported by any of the cited shources.
• I'm not saying that the current text is perfect; far from it. But the proposed text is much worse, due to the WP:OR problem. Let's try to find a better approach. Wikipedia should not be advocating a particular alternative to water fluoridation over others, without any reliable source to base that relative advocacy on.

Eubulides (talk) 17:53, 19 March 2009 (UTC)

By the way, I should mention that I share the opinion that xylitol gum has better evidence for preventing cavities than chlorhexidine mouthwash does, and that the gum is a promising as a supplement to fluoridation for people who chew gum; but that's just my personal opinion. What matters for Wikipedia is what reliable sources say. Eubulides (talk) 17:58, 19 March 2009 (UTC)

I don't understand how you can say that "this contrast ... is not supported by any of the cited sources". The American Association of Pediatric Dentistry has endorsed xylitol; I showed a 2003 article which discussed increasing its use for public health; two recent JADA review articles come down favorably on it, and all the older articles that I can find aside from Lingstrom are favorable, particularly as a preventative rather than therapeutic measure. The gummy-bear article I mentioned discusses in its introduction the adoption of xylitol in Europe, by the U.S. military, and Japan. In comparison, chlorhexidine has only 1 recent review, which specifically says it should not be recommended. If you'd prefer, you can tweak my proposed statement to work in Anusavice's statement that alternative measures, including xylitol, are regarded as unproven, but to say that there's no real difference in opinion on chlorhexidine compared to xylitol is clearly false. II | (t - c) 18:06, 19 March 2009 (UTC)

Please see #Proposed xylitol-related addition below. Eubulides (talk) 19:45, 20 March 2009 (UTC)

Proposed xylitol-related addition

• "I don't understand how you can say that 'this contrast ... is not supported by any of the cited sources'." What I meant is that the cited sources do not support the proposed text's implied comparison of xylitol to chlorhexidine and to fluoride treatments such as water fluoridation.
• "The American Association of Pediatric Dentistry has endorsed xylitol" I assume this refers to the 2006 endorsement (PDF) by the American Academy of Pediatric Dentistry of sugar substitutes, including xylitol. However, this endorsement did not place sugar substitutes in any context that included water fluoridation, so it provides no WP:WEIGHT guidance here.
• "I showed a 2003 article" The string "2003" appears nowhere else in this thread, so I don't know what article is being referred to here. But if Anusavice 2005 (PMID 15897335) is a bit dated, surely a 2003 article would be even more worrisome from that point of view?
• "two recent JADA review articles come down favorably on it" This apparently refers to the following two studies:

• Ky et al. 2008 (PMID 18451371), which argues that school officials and the American Academy of Pediatrics should consider the benefits of chewing gum containing dental-protective substances, including xylitol (but also including fluoride (!)). This article indicates that xylitol-containing gum is a promising therapy but is not mainstream in the U.S.
• Burt 2006 (PMID 16521385) is a better choice, since it places xylitol in the context of fluoride. It says "Dentists should stress that chewing xylitol-sweetened gum is a supplemental practice, not a substitution for a preventive dental program that includes the use of fluoride, consciously applied oral hygiene practices and regular professional visits."

• I looked for other reliable sources that mentioned xylitol in the context of water fluoridation (or at least fluoride) and other caries prevention techniques, and found this recent one, which expresses mainstream opinion:

"Although xylitol has anticariogenic properties, there is not sufficient evidence to recommend xylitol as a first-line anticaries strategy in light of the large body of evidence on the effectiveness of topical fluoride and dental sealants. However, xylitol-containing chewing gum and mints can be recommended as an adjunct to other preventive intervention strategies if cost considerations do not outweigh effectiveness." (Zero 2008, PMID 18460675)

• With the above in mind, how about if we do the following instead? In Water fluoridation #Alternatives, replace this:

"Alternative individual treatments include the antibacterial agent chlorhexidine and the sugar substitute xylitol."

with this:

"Other agents to prevent tooth decay include antibacterials such as chlorhexidine and sugar substitutes such as xylitol.(citing Anusavice 2005) Xylitol-sweetened chewing gum has been recommended as a supplement to fluoride and other conventional treatments if the gum is not too costly.(citing Zero 2008)"

Eubulides (talk) 19:45, 20 March 2009 (UTC)

That's fine. My suggested wording was not intended to imply that xylitol is a substitute for everything, but only that it has been recommended in some countries. Similarly, our article should not imply that fluoridated water is a substitute for fluoridated toothpaste, even though fluoridated water is recommended. I still wonder about chlorhexidine; as that 2008 review stated, it is not recommended for public-health control of caries much and it's largely used for short-term control of gingitivis. But it's not that big of a deal. II | (t - c) 22:16, 20 March 2009 (UTC)

OK, thanks, installed. Eubulides (talk) 06:01, 21 March 2009 (UTC)

FDA admits Fluoride is dangerous

I'm new to wiki. Here is some information I found from the FDA's offical website. It says the water Fluoridation dangers far out way its benefits. Please look at this information and improve this article. Thank you - Jack

[http://www.fda.gov/ohrms/dockets/dockets/07p0070/07p-0070-cp00001-02-vol1.pdf[

[24]]]

[[25]]] —Preceding unsigned comment added by 74.132.196.42 (talk) 21:08, 18 March 2009 (UTC)

Hi Jack, welcome to Wikipedia. Can I recommend that you create an account? You do realise that these are a petition rather than being a document published by the FDA? FWIW these don't represent an official position by anybody other than the author of the actual petition. Shot info (talk) 01:25, 19 March 2009 (UTC)

"Adverse Effects" section

Since studies have shown that there are in fact adverse effects of fluoridated water, I think that there should be a section about this for readers to view. —Preceding unsigned comment added by Quarkde (talk • contribs) 18:55, 23 March 2009 (UTC)

There is such a section; it's called Safety, which is a shorter and more-easily-understood name. That section focuses on the safety effects of water fluoridated to recommended levels. It also briefly covers the somewhat-off-topic point of water that is fluoridated to well above recommended levels, discussing well-known adverse effects that include dental and skeletal fluorosis, weakened bones, nausea, vomiting, and diarrhea. However, this somewhat-off-topic discussion is (and must be) supported by reliable sources that are closely related to water fluoridation. There are dozens more adverse effects that have been reported for high fluoride concentrations, but this article is not about fluoride poisoning, and as per WP:WEIGHT it should not discuss them all, certainly not the poorly-attested ones such as the IQ claims that were recently added and immediately reverted. Instead, the IQ topic should be (and is) discussed in Fluoride poisoning. Eubulides (talk) 22:05, 23 March 2009 (UTC)

Types of fluoride: NaF, SF, CaF, and tin fluoride

I haven't seen much mention of the types of fluoride in the recent reviews, and since SiF and NaF are the standard, maybe it's not worth going into depth. However, there is some interesting research from older literature. The 1952 Choice of Fluoridating Agents in the Control of Dental Caries reviewed the literature, and found that tin fluoride seemed more effective than sodium fluoride, which seemed more effective than sodium silicofluoride, which was more effective than calcium fluoride. A study of the metabolism of types in rats [26] found that silicofluorides were excreted through the urine much more, sodium fluoride was somewhat mixed, and calcium fluoride was almost entirely excreted through the feces. Finding modern followups of this research seems worthwile. I'm also curious as to the natural fluoride generally is, and my impression is that it's usually calcium fluoride. II | (t - c) 20:06, 26 March 2009 (UTC)

I agree that it would be nice for the article to say what the main sources of natural fluoride in water, but a brief search didn't find anything along those lines; perhaps someone with a better search engine can look into that? As for tin (stannous) fluoride, etc., my impression from the recent literature is that the mainstream consensus is that, for water fluoridation, it doesn't matter which of the main fluoridation chemicals is used, as far as safety and effectiveness goes. I don't know of anybody seriously proposing using stannous fluoride or calcium fluoride for water fluoridation, and I expect that if recent reliable sources don't go into this topic with respect to water fluoridation, Water fluoridation shouldn't either. Eubulides (talk) 21:55, 26 March 2009 (UTC)

Following up my previous comment, I have still not found any reliable source talking about the main sources of natural fluoride in drinking water, and suspect that there aren't any. However, I did find a recent reliable review (Ozsvath 2009, doi:10.1007/s11157-008-9136-9) talking about natural sources in general and making the point that fluoride levels in water are usually controlled by the solubility of fluorite (which is not the same thing as saying that the fluoride came from fluorite deposits), so I added 3 sentences about that. This caused the resulting paragraph to be so long that I broke it into two. Eubulides (talk) 22:35, 9 April 2009 (UTC)

Water that naturally contains fluoride vs. Artificially fluoridated water

An extract from the Use around the world section:

In addition, at least 50 million people worldwide drink water that is naturally fluoridated to optimal levels; the actual number is unknown and is likely to be much higher. Naturally fluoridated water is used in many countries, including Argentina, France, Gabon, Libya, Mexico, Senegal, Sri Lanka, Tanzania, the U.S., and Zimbabwe. In some locations, notably parts of Africa, China, and India, natural fluoridation exceeds recommended levels

My question is when are their health concerns? Is it the fluoride alone that causes the health problems at high levels(in which case those drinking water naturally high in fluoride would suffer negative health effects), or are the health effects associated specifically with the method of artificially adding fluoride to the water? This paragraph seems to equate the too quite neatly giving the impression that there is no real difference. Also, the ref seems to be supplied from the British Fluoridation Society. An organisation highly biased in favour of adding fluoride to British water supplies. Shouldn't we be finding less biased references? I noticed it has been cited 5 times. Is citing the views of pro-fluoridation organisation any different from citing the views of the Fluoride action network? Tremello22 (talk) 19:35, 9 April 2009 (UTC)

• As I understand it, reliable sources generally do not distinguish among the various sources of fluoride in water, and consider fluoride to be fluoride. For example, I don't know any reliable source that gives a good worldwide picture for what proportion of natural fluoride comes from (say) the mica in granite, versus other sources of natural fluoride. Among reliable sources, the health concerns related to excessive fluoride are almost entirely independent of the source of the fluoride. There is a minority view that the source chemical matters, which is covered in the penultimate paragraph of Water fluoridation #Safety, but this is limited (as far as we know) to one research group and the view has been sharply criticized by the mainstream (this criticism is also covered in that paragraph).
• The source in question, "The extent of water fluoridation", is coauthored by the British Fluoridation Society, the UK Public Health Association, the British Dental Association, and the Faculty of Public Health. It is the most reliable source we know of on the worldwide extent of water fluoridation. Given that it's coauthored by several respected organizations, and that we cite it only on the extent of fluoridation (not its desirability), and that the claims it supports are not controversial, it's not at all the same as citing the Fluoride Action Network on how fluoride causes cancer (or whatever).

Eubulides (talk) 19:58, 9 April 2009 (UTC)

This study seems pretty relevant. It doesn't seem to be cited in the article. Bioavailability of Fluoride in Drinking Water:a Human Experimental Study, McGuire et al. 2005 Tremello22 (talk) 23:07, 9 April 2009 (UTC)

Thanks for mentioning that, I hadn't read that study. The critical comments about that study in Cheng et al. 2007 (PMID 17916854), in Sheldon & Holgate 2008 (PMID 18096887; also see authors' reply), and in Holgate & Sheldon 2007 (PMID 17962249) suggest that any summary of that study here should be worded quite carefully here. Perhaps a sentence on bioavailability could be added to the last paragraph in Water fluoridation #Mechanism, citing Cheng et al.? Cheng et al. would be preferable here, as WP:MEDRS says we should prefer reviews to primary sources. Eubulides (talk) 23:30, 9 April 2009 (UTC)

I hadn't looked into the reliability of the study and whether it was contentious. Now I have, I agree with what you say. It seems the study was set up due to the recommendations of the UK medical research council review: MDC: Water fluoridation and health, 2002. On a side note, should this MDC review be cited somewhere - it is a pretty comprehensive review, maybe better than the York review. Tremello22 (talk) 14:34, 13 April 2009 (UTC)

Thanks, I'll look into writing something cited by Cheng et al. then. I have not read the MRC report and agree that it could be cited. From reading the lay summary (I haven't had time to read the whole thing yet) it looks like it's particularly strong in describing areas that need further research, and could certainly be cited in that area. For safety and effectiveness I expect it's similar to the already-cited 2007 Australian systematic review in deferring to the York review. Anyway, I'll try to write back here after I've had the time to read it. Eubulides (talk) 16:39, 13 April 2009 (UTC)

Hold on. I am not sure it (Cheng and Sheldon) needs to be cited, I just agreed that the study was contentious. It depends how you are going to put it across. We'd have to think about weight and emphasis. More emphasis would need to be put on the fact that it is a bad study rather than the conclusions of the study. What Cheng and Sheldon objected to most was that "this report formed the basis of a series of claims by government for the safety of fluoridation" What they are saying is that the issue of bio-availability is highly relevant to water fluoridation and yet one flawed study is being used to veil real health concerns. Tremello22 (talk) 19:41, 13 April 2009 (UTC)

Yes, it needs to be put across accurately. As I understand it, (1) mainstream opinion from the underlying chemistry is that it should make no difference in terms of bioavailability as to which of these compounds is the source of the fluoride, (2) this opinion has not been verified by replicated high-quality scientific studies, (3) there has been one study, with poor statistical power, which found no significant difference among fluoride sources (agreeing with mainstream opinion), (4) this study was used in some way by the British government to conclude that fluoridation was safe, but (5) the claims made by the government were not well supported by the study's results due to its lack of statistical power. The previous sentence is way too long for Water fluoridation and I suspect that only points (1) and (2) are worth mentioning in the article. Eubulides (talk) 20:07, 13 April 2009 (UTC)

It depends what you mean by mainstream opinion. If there is only one flawed study, then what is the 'mainstream' basing their opinion on? Tremello22 (talk) 20:29, 13 April 2009 (UTC)

The underlying chemistry. See, for example, Urbansky ET (2002). "Fate of fluorosilicate drinking water additives". Chem Rev. 102 (8): 2837–54. doi:10.1021/cr020403c. PMID 12175269. This material is summarized in Ozsvath 2009 (doi:10.1007/s11157-008-9136-9) as follows: "Although there have been epidemiological studies suggesting that the ingestion of fluorosilicates might have different biological effects from those of sodium fluoride or fluoride from natural sources, this conclusion is not supported by theoretical considerations of fluorosilicate dissociation and hydrolysis equilibria." A different part of Ozsvath covers the same topic, and mentions that the highest-quality epidemiology study, namely Macek et al. 2006 (PMID 16393670), found no association, though it did not disprove an association. Eubulides (talk) 23:18, 13 April 2009 (UTC)

• McGuire 2005 seems to say that calcium fluoride is the main type of natural fluoride ("occurring either naturally (predominantly from minerals such as fluorspar [calcium fluoride]"), and also says most safety studies have used it. It is a secondary source for these facts, although it doesn't cite sources so it's not a great source for them. I found it rather odd that McGuire didn't specify the chemical compounds used in the "natural" and "artificially" fluoridated water. Most likely they used calcium fluoride and sodium fluoride or silicofluorides respectively. Did I miss them specifying? It's also strange that everyone assumes there is no difference when McClure 1950, which was mentioned in Holwell et al. 1952 found such differences in the way rats metabolize these things. Weddle & Muhler 1957 found, similarly, that the presence of calcium increased the amount excreted through the feces by 3.5 times. Fluoride excreted through the feces presumably would not become as biologically active. Fleming 1959 found differences in rates administered calcium fluoride compared to the other types. The effect of calcium on the absorption of fluoride is mentioned in a 1990 book Trace metals and fluoride in bones and teeth, p. 143. Despite all this evidence, the 2002 WRC report referenced by McGuire 2005 ([www.bfsweb.org/documents/wrcreport.pdf Jackson et al. 2002]) concludes that natural and artificial fluorides are identically bioavailable, even though the only empirical study it seems to reference is a rat study on aluminium's effect (which it says could effect bioavailability). It doesn't discuss the early research at all. It doesn't clearly define naturally fluoridated water. It also doesn't seem to have been published, and is hosted on the British Fluoridation Society website. The 2002 MRC report seems to say, in section 3, that the inorganic ions (calcium, magnesium, aluminium) do decrease bioavailability, but when heavily diluted the effect is thought to be very small. Although it doesn't directly discuss the earlier rat studies and instead references Cremer and Buttner 1970, the rat studies had a relatively high fluoride intake. II | (t - c) 23:46, 13 April 2009 (UTC)

• I agree that there seems to be a surprisingly lack of well controlled studies, considering the widespread assumptions of safety. The fact that a finding is not supported by "theoretical considerations" does not take the place of empirical evidence. —Mattisse (Talk) 00:05, 14 April 2009 (UTC)

• "McGuire 2005 seems to say that calcium fluoride is the main type of natural fluoride" No, McGuire 2005 merely says that natural fluoride is "predominantly from minerals". It then goes on to say that fluorspar (a.k.a. fluorite) is one of those minerals, but that's not at all the same thing as saying that fluorite is the primary mineral. In practice, my impression is that fluorite is not the main mineral in areas where natural fluoride concentrations are high, but I know of no reliable sources in this area.
• "I found it rather odd that McGuire didn't specify the chemical compounds used in the "natural" and "artificially" fluoridated water." For natural fluoridation, this is perfectly understandable, since it's hard to find out which minerals were the source of natural fluoride. Even for artificial fluoridation, I expect that it's difficult to figure out the source of the fluoride, without cooperation of the water utility (and even they may not know, if they switch among fluoride sources, which I expect that many do).
• "It's also strange that everyone assumes there is no difference when McClure 1950" No recent reliable sources (and there are many) focus on McClure 1950 or on the 1990 book or whatever. It's not really our job to do detective work into obsolete sources. If recent reliable reviews give a relatively small weight to this old material, then Water fluoridation should too.
• "The effect of calcium on the absorption of fluoride ..." That URL doesn't work for me, but it is speculated that calcium in the water may diffuse into plaque and provide more binding sites for fluoride; this is briefly discussed in Bruvo et al. 2008 (PMID 18362315), which Water fluoridation already cites. Water fluoridation already pushes speculation about calcium fairly far; I'm a bit leery about it pushing this too much farther, due to WP:WEIGHT issues, but perhaps something could be added.
• Reliable sources agree that there is a lack of well-controlled studies in the area of safety and effectiveness, and this issue is currently mentioned in the lead and in the body. It might not hurt to add a bit more (if someone can come up with specific wording) but we have to be cautious about WP:WEIGHT issues here; there's only so many times we can say "more research needs to be done"....

Eubulides (talk) 01:11, 14 April 2009 (UTC)

Safety

The last time I visited the water fluoridation page there was a piece about the Hooper Bay incident which I thought was very misleading. I am pleased to find that entirely gone but wonder if the "SAFETY" section shouldn't include information with regards to the contemporary safety record fluoridation engineers have in the US and Canada and a description of the new automated monitoring systems. This is a significant area of citizen concern and interest.

I hope I posted this message correctly

Picker22 (talk) 06:21, 17 May 2009 (UTC)

Thanks for the comment. That information would be very useful in this article. Can you suggest reliable sources for this sort of thing? I did a brief search using Google Scholar and came up empty. Eubulides (talk) 16:08, 17 May 2009 (UTC)

I'll work on it. The information will most likely be found in water treatment trade journals. 209.216.191.208 (talk) 05:49, 18 May 2009 (UTC)

Dr. Strangelove

Should any mention of flouridation's role in Dr. Strangelove be mentioned. —Preceding unsigned comment added by 75.164.205.147 (talk) 03:28, 20 May 2009 (UTC)

Good suggestion; thanks. Done. Eubulides (talk) 03:47, 20 May 2009 (UTC)

Costs

I noticed that my information with respect to life-time total costs of a childhood cavity from the Delta Dental Insurance Data division was deleted and information referring to Griffin (2001) substituted.

I am assuming that "discounted lifetime cost" is a conversion from actual lifetime costs to an apportioned amount for a year's span. For purposes of comparing the economic costs and benefits of fluoridation programs that is appropriate. However, only comparing that number trivializes the lifetime economic burden of a cavity. From personal experience, I know that this very matter is often discussed in public debates over water fluoridation.

The general public poorly understands that once a cavity occurs, the tooth's fate is that of repeated restorations. All restorative options have a finite life expectancy. For example, a Norwegian study found the median median time to repeat restoration was 20 years for gold restorations, 12-14 years for amalgam restorations, and 7-8 years for composites. As people age, crowns replace old fillings and some teeth require root canals or extractions. From the perspective of a lifetime, the importance of preventing childhood cavities in permanant teeth, is more clearly understood by knowing the actual cumulative costs.

I have requested a copy of the Griffin article from my regional medical school. I also hope to run down additional referenceable information with respect to other estimates of lifetime costs of a cavity. I'm hoping to discuss this further after these additional investigations.

Regards, Picker22 (talk) 05:16, 19 May 2009 (UTC)

I installed the change from the Delta Dental source (PDF) source to the Griffin et al. 2001 (PMID 11474918) source, so I'll take a crack at following up on your comment.

• The discounted lifetime cost is the present value of the total lifetime cost. If the total lifetime cost is (say) $1000, the discounted cost will typically be far less (say, $200) because $200 in the bank now will pay out $1000 over the course of one's lifetime. When comparing the cost of fluoridation (which are paid earlier) to the benefits (which accrue later) it is appropriate to compare the present values of all the costs and benefits. I attempted to make this a bit clearer by wikilinking "discounted" to Present value in Water fluoridation #Cost.
• The discounted lifetime cost is not apportioned for a year's span. The costs and benefits being compared in the "Assuming the worst case" sentence are lifetime figures for a single decayed surface; they are not annual figures.
• The Delta Dental source is far less reliable than Griffin et al., as the Delta Dental source is unsigned, self-published, and not peer-reviewed. Griffin et al. is much better, but is not the best-quality source either, as it is a bit dated and is a primary source rather than a review.
• Better sources in this area would be welcome. There is also O'Connell et al. 2005 (PMID 16263039), which is freely readable and is more recent, but it's just for Colorado and is also just a primary source so I have not read it carefully. Maupomé et al. 2007 (PMID 18087993) is another recent primary source, which is also limited (in this case, to Oregon and Washington), and is not freely readable, so I have not examined it carefully either. Please see WP:MEDRS for the sort of sources that Water fluoridation needs for medical facts and figures like this; what we really need here is a reliable review, not primary sources.

Hope this helps. Eubulides (talk) 06:34, 19 May 2009 (UTC)

Thank you for setting me straight with respect to the meaning of "discounted lifetime costs." I would think the use of the present value calculation to be a very complicated matter since the expenditures are spread non-linearly over a lifetime (or over about 66 years assuming the initial cavity occurred at age 10). Obviously I need to read the Griffin article to understand the methodology in this context.

I'm reasonably familiar with Maupomé (2007). It is of no help with this specific matter.

Of course the point is that the eventual economic and human cost of the initial cavity is much larger than the cost and experience of the first restoration. Although it is a very important perspective, I don't see this point as necessarily directly participating in the accounting of water fluoridation's economic net worth. Perhaps a qualitative statement could be made in a verifiable manner which meets Wikipedia standards. Picker22 (talk) 06:20, 20 May 2009 (UTC)

Yes, Griffin et al. 2001 do use complicated calculations (including an appendix of the equations used). They do handle the issue of expenditures spread out over the lifetime, each with a different discount rate. They stop at age 65, I assume because of the dentures factor. It is curious that Griffin et al.'s estimate of the average discounted lifetime cost ($100.62 in 1995 dollars) is soooo much lower than the Delta Dental estimate of about $2000 (2003 dollars) for the (presumably non-discounted) lifetime cost. Inflation would make that $100.62 grow to $130 or so by 2003, which is not nearly enough to explain the difference. Does discounting account for all the rest of the difference, or is there something else going on? I did track down the Delta Dental source to PMID 15559454, an index to an (unsigned?) October 2004 one-page article in Dentistry Today, but the table of contents at dentistrytoday.com for that issue does not list the article; curious. Eubulides (talk) 07:31, 20 May 2009 (UTC)

"Perhaps a qualitative statement could be made in a verifiable manner which meets Wikipedia standards." Sorry, I've lost context; what would the qualitative statement say? The article already says "... the estimated $142 average discounted lifetime cost of the decayed surface, which includes the cost to maintain the restored cavity."; isn't the 2nd half of this quote talking about the long-term cost? and if not, what more would need to be added? Eubulides (talk) 07:38, 20 May 2009 (UTC)

It is very annoying that Delta Dental did not publish their study. Insurance companies may be in the best position to answer some of the economic questions about dental care. The series of articles from the University of Washington based on their Blue Cross insured staff is an example of good data derived from insurance claims. eg:

I agree that the reference to the "discounted long-term cost" technically and perhaps accurately refers to the matter. However, in my opinion, for many, if not most readers, it will not effectively convey the simple fact that a childhood cavity requires a lifetime of repeated restorations and interventions.

The Colorado study you mention is, in my opinion, flawed because it did not include the costs for deciduous teeth. The operative treatment under anesthesia of rampant childhood cavities is dramatically decreased by water fluoridation and accounts for a significant portion of the total dental bill.

I'll get back after I receive and digest the Griffin 2001 paper.

Thanks, Picker22 (talk) 04:23, 21 May 2009 (UTC)

Come to think of it, Griffin works for the CDC so her papers should be free. A bit of searching found an online copy (PDF) of Griffin et al. 2001 (PMID 11474918) at the CDC web site, so you don't need to wait for your library to give you a copy. I just now added this URL to the citation in Water fluoridation. Eubulides (talk) 05:09, 21 May 2009 (UTC)

Thanks Picker22 (talk) 05:26, 21 May 2009 (UTC)

You're welcome.

• It certainly would be worth mentioning the repeated-restoration point more clearly. Do you think it'd be better to cover this in Cost, or in Goal?
• I did a bit more searching and found a couple more sources:

• Splieth CH, Fleßa S (2008). "Modelling lifelong costs of caries with and without fluoride use". Eur J Oral Sci. 116 (2): 164–9. doi:10.1111/j.1600-0722.2008.00524.x. PMID 18353011. This model estimates the total discounted lifetime cost for preventing and treating caries as €932/person without fluoridation, and €247/person with fluoridation. These costs are in Germany and use 2008 euros. Alas, this model evaluates salt fluoridation, not water fluoridation. However, if we assume about 10 decayed surfaces/person lifetime (would that be about right for Germany?) then this would work out to about €100 for the discounted lifetime cost of a decayed surface, which is reasonably close to the $142 estimate currently in Water fluoridation.
• Wright JC, Bates MN, Cutress T, Lee M (2001). "The cost-effectiveness of fluoridating water supplies in New Zealand". Aust N Z J Public Health. 25 (2): 170–8. PMID 11357915.{{cite journal}}: CS1 maint: multiple names: authors list (link) The journal's web site is messed up and I couldn't get this article online.

Eubulides (talk) 07:14, 21 May 2009 (UTC)

I've read Griffin through. Griffin's costs are all calculated, not actual data points. She assumes that all restorations, both initial and subsequent, are amalgam. Even in 2001 most restorations were not amalgam. Late life treatments (crowns, root canals, extractions, prosthedontics, etc) are very expensive. They were not included yet surely must strongly contribute to the true total. Although the possibility the tooth was "lost" was considered, this appears to have decreased the lifetime cost; the missing tooth no longer requiring reconstruction. Perhaps these are at least some of the reasons her calculated estimates are lower than real world actual bills.

I am surprised the paper has not been criticized for excluding costs for deciduous teeth (citations above).

Whether Griffin's analysis of the net economic value of water fluoridation is valid is a different question than the smaller issue as to the accuracy of her calculated lifetime cost of a cavity. Summing actual dental bills surely better represents the actual lifetime cost of a cavity.

Frankly, truly understanding Griffin's methodologies is beyond my attention span. That they have been accepted as reasonable with respect to comparing the cost of water fluoridation and the avoided dental costs of cavities seems undeniable.

I will read the other references you listed. I have also requested which was cited in a Australian Health Service report as containing the lifetime cost of a cavity.

Because the natural history of caries with respect to repeated maintenance is so poorly understood and generally comes up in discussions of water system expenses, I thought it best located in the Cost section. I can see how it would fit in the Goals and have no objection to it being there instead. Picker22 (talk) 08:00, 23 May 2009 (UTC)

OK, thanks, I took a shot at it by adding to Goal the text "Once a cavity occurs, the tooth's fate is that of repeated restorations, with estimates for the median life of an amalgam tooth filling ranging from 9 to 14 years.", citing Griffin et al. 2001 (PMID 11474918). I hope you don't mind my shamelessly stealing from the nice prose in your comment above. Suggestions for further improvements are welcome. Eubulides (talk) 08:57, 27 May 2009 (UTC)

That looks good to me. Thanks. I could not find a peer reviewed reference which actually tallied dental bills as did Delta Dental. It appears they have separate analyses from their various state and regional businesses.

I have realized reading these papers which use the discounted cost of a cavity that their estimate of the net economic value of water fluoridation depends as much on current interest rates as the physiology and chemistry of fluoride. Right now with insured returns of only 1-2%, water fluoridation looks even better. It may not have penciled in 1979 with interest rates in double digits. Picker22 (talk) 06:20, 28 May 2009 (UTC)

You're welcome. You're quite correct that the discount rate is an important assumption. However, fluoridation saves money under almost all reasonable scenarios. Griffin et al. did sensitivity and breakeven analyses that varied the discount rate assumption and found, for example, that for communities with over 20,000 people, water fluoridation saves money if the discount rate is less than 202% per annum. (Even 1979 wasn't that bad....) Eubulides (talk) 06:50, 28 May 2009 (UTC)