Fluoridation

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Fluoridation is the addition of fluorides to foods and cosmetics (toothpaste) and the application of highly concentrated preparations to the teeth for the purpose of caries prophylaxis . Fluoridated foods include table salt , drinking water and milk . Recently, so-called “ slow-release devices ” have also been used - small containers that are attached to the tooth or fillings enriched with fluoride that continuously release fluoride into the saliva over a longer period of time.

Dental caries

→ Main article : Dental caries

Caries etiology

Caries occurs in the hard tooth tissue ( tooth enamel , dentin ) through long-term effects of the metabolic products of bacteria that settle on the teeth and in the spaces between the teeth as plaque . Cariogenic bacteria ( lactobacilli and various types of streptococci, especially Streptococcus mutans ) form organic acids from carbohydrates such as sucrose , glucose and fructose , which lowers the pH value in both saliva and plaques. While the mentioned microorganisms can survive in this acidic environment, the main mineral component of the enamel, hydroxylapatite (also apatite (CaOH) ), is dissolved at pH values ​​below 5.5 . With the saliva, dissolved ions can be returned to the enamel ( remineralization ). However, if acids permanently dissolve more enamel than can be remineralized, erosions form . Under bacterial plaques, high acid concentrations can loosen the enamel in narrowly defined areas, creating cavities ("holes"). In addition to oral hygiene and thus the composition of the oral microflora, the number of microorganisms present and nutritional factors (e.g. frequency and intensity of the consumption of sugar or starch-containing products), other (partly genetically determined) factors determine the susceptibility to caries , among other things the composition and viscosity of the saliva, tooth shape and position (also size of the interdental spaces), the structure of the tooth substance, pits and fissures (the molars). In the case of dental caries, one speaks of a multifactorial event.

Caries Epidemiology

In the 1930s the DMF index became an important tool for comparing dental health between population groups. The index currently records decayed, missing and filled teeth (DMFT) or tooth surfaces (DMFS) per child, per 100 children or per 100 teeth examined. The parameters mentioned for the caries status were first used in 1931 by Selwyn D. Collins, chief statistician at the US Public Health Service, and Tagliafero Clark when examining school children and evaluated as the percentage with at least one rotten, filled or missing tooth. Shortly thereafter, Amanda L. Stoughton and Verna T. Meaker refined the measure by tabulating the percentage of children in different age groups with 1, 3, 5, 7, or 9 carious, filled, or missing teeth. For the analysis of data from the American Dental Association's first national caries survey (1934), physician Clarence A. Mills summed up the number of carious, filled or extracted teeth per 100 children for the first time and presented the numbers for each US state at the annual meeting of the IADR in March 1937 in Baltimore. In December 1937, Henry Klein and Carroll E. Palmer published their study, with which Klein claimed priority for the development of the DMF Index and on the basis of which also suggested for the first time a connection between the fluoride content of drinking water and the frequency of tooth decay. After quarreling with Trendley Dean, he left the Public Health Service in the early 1950s and moved to Paris. Klein undoubtedly deserves the credit of having discussed various disruptive factors in his work from 1937 and of having examined influences such as age, gender, diagnostic parameters, time of tooth eruption, etc. in a subsequent series of studies.

prophylaxis

In addition to restricting the intake of sugar and thoroughly removing plaque (oral hygiene), the use of fluorides can contribute to making tooth decay more difficult. Fluorides can replace OH groups in the hydroxyapatite in tooth enamel. In this case, forms fluorapatite (with a theoretical fluoride content of about 3.8%), which is less soluble in weak acids than the OH-form. Direct influences (e.g. enzyme inhibition) of fluoride on the oral flora are also possible. In laboratory tests it has been observed that Streptococcus mutans produces less acid at low fluoride concentrations. However, it is unclear what impact this reduced acid production has on the carious activity of bacteria in the human mouth. In addition to these explanatory models , the stimulation of saliva formation ( vagotonic , less viscous saliva) and a possibly resulting improved cleaning effect have also been discussed in the past .

According to a press release by the Bavarian State Dental Association, the view that prevailed until the late 1980s that the effect of fluoride was primarily based on its permanent incorporation into the crystal structures of enamel and dentin has fundamentally changed. Human tooth enamel contains a concentration of approx. 1,000 to 2,000 ppm (0.1%) fluoride in its outermost layer . At a depth of 25 µm, only approx. 100 ppm (0.01%) are found. Further studies have shown that the caries prophylactic effect of fluoride is mainly due to the labile fluoride reservoir that forms after the application of easily soluble fluoride in the form of a calcium fluoride (CaF ₂ ) layer that covers the tooth surface. Since the late 1990s, caries researchers have been convinced that the fluoride introduced into the crystal structures of the enamel during tooth development has a comparatively low effect on caries processes and that the caries-protective effect of the systemically absorbed fluorides, for example from drinking water, table salt, tablets, milk, etc. ., sets in after the tooth eruption. The decisive local protective effect of the fluorides absorbed systemically and brought to the tooth surfaces by the saliva begins in the aqueous phase at the interface between the tooth and its surroundings and in the water of crystallization of the outer layers of the enamel material. Demineralization during the acid attack, d. H. Mineral loss due to partial dissolution of enamel crystals is inhibited by the presence of fluoride. The fluoride diffuses with the acid into the enamel pores and acts on the crystal surfaces together with the fluorapatite that has already formed there against the subsequent acid attack. Initial research results on the prevention of caries in old age show in vitro that the local action of milk containing fluoride (10 ppm) on the root dentine of extracted human teeth has a clear effect on the remineralization of the previously artificially demineralized root dentine. The local action of artificial saliva enriched with NaF (10 ppm) shows an even stronger effect. Upon exposure to artificial saliva, an additional crystalline layer containing elevated levels of F and Ca was formed on the lesion.

The fluoride present in the aqueous solution on the crystal surface during the pH increase after a demineralization phase can combine with the dissolved calcium and phosphate ions and precipitate on the crystal surface or accumulate in the enamel as a fluorapatite- like crystalline material. Fluoride changes this mineral gain, known as remineralization , and thus makes the crystalline substance of the enamel more resistant to future acid attacks. At relatively high concentrations of fluoride ions, these can combine with calcium and precipitate as calcium fluoride (CaF ₂ ), from which the fluoride can slowly dissolve again as if from a depot and act as a "slow releasing device". The calcium fluoride thus becomes the source of fluoride ions, which in turn inhibit demineralization.

The released fluoride ion acts as a biocatalyst for the reintroduction of calcium and phosphate ions ; in the second place, it is built  into the uppermost enamel layers in exchange with the hydroxyl ion (OH-) of the apatite.

Fluoride

→ Main article : Fluorides

Olaflur

Dectaflur

For caries prophylaxis are sodium fluoride (included in fluoride tablets, toothpastes and mouthwashes), potassium fluoride (table salt), tin (II) fluoride (toothpastes) or amine fluorides (toothpastes and fluoride-containing gels, z. B. olaflur ) were used. Just like these, fluorido complexes are also classified under the terms “fluoride” or “fluorine” used as synonyms in common usage, such as B. Sodium monofluorophosphate (Na ₂ PO ₃ F, used in toothpastes) or the fluoridosilicates ( sodium hexafluoridosilicate , Na ₂ SiF ₆ ; hexafluoridosilicic acid , H ₂ SiF ₆ ), which have been used for the fluoridation of drinking water since the early 1950s. In the early days of drinking water fluoridation, people in Madison, a city in the American state of Wisconsin, even fluoridated with hydrofluoric acid , because this acid was produced in the region and was readily available there.

Recommended intake amounts

When drinking water fluoridation ("TWF", fluoride addition of approx. 1 mg per liter) was introduced in the USA around 1945, a daily fluoride intake of 1 to 1.5 mg per day was assumed (McClure), and this value was used later as the basis for fluoride administration in tablet form. It has been known for about 25 years that in places with drinking water fluoridation, the daily intake is around 3 mg (and more) per day. Accordingly, the Federal Institute for Consumer Health Protection and Veterinary Medicine (BGVV) adjusted the recommended intake for caries prophylaxis to 3.1 mg to 3.8 mg per day for people between 19 and 65 years of age in a statement (September 2001).

On the other hand, the WHO does not see itself in a position to set a value for a daily fluoride requirement, since fluoride is not an essential trace element and there are therefore no diagnostic parameters and no evidence of the existence of clinical symptoms of a "fluoride deficiency".

The average intake from food (without fluoride supplements and without drinks) in Germany is 0.4–0.5 mg per day. In various products one naturally finds an increased concentration of fluoride, e.g. B. in tea (black and green) or in mineral waters. In Germany, mineral waters with a fluoride content of more than 1.5 mg / l must be labeled as "containing fluoride", while those with less than 0.7 mg / l may be labeled as "suitable for baby food". At higher concentrations, the risk of dental fluorosis increases . In some areas in Germany (e.g. some places in the Eifel) the tap water naturally (depending on the geological formation) contains fluoride in concentrations of 1 mg / l and more.

Methods of fluoridation

Food fluoridation

Dissemination of fluoridated foods and drinking water

80-100%

60-80%

40-60%

20-40%

  1-20%

<1%

unknown

The fluoridation of drinking water was introduced on a trial basis in some cities in the USA in 1945 and has spread rapidly there since 1950. Later the American model was followed in some other countries such as Australia, Brazil, Chile, Ireland, Malaysia and Vietnam. 5.7% of the world population use fluoridated water. Until reunification, drinking water was fluoridated in some places in the former GDR. In West Germany, the Kassel district of Wahlershausen was supplied with fluoridated drinking water between 1952 and 1971 .

Today in most European countries, including Germany, Austria and Switzerland, drinking water is not fluoridated. The exceptions are Ireland, where around 71% of the population has fluoridated drinking water, and the UK with around 10% coverage. Public Health England , a scientific advisory board to the British government, came to the conclusion after an evaluation of this measure in March 2014 that the fluoridation of drinking water was a "safe and effective" measure. In the age group between one and four years, 45% fewer carious teeth were found. For five-year-olds it is 15% less and for twelve-year-olds 11%. As a consequence, the advisory board recommended the further expansion of drinking water fluoridation in England. In Sweden, however, the only experiment on drinking water fluoridation (since 1952 in Norrköping) was discontinued in 1962 due to the lack of a legal basis. In 1955, even fluoridation advocates signed a corresponding application there and recommended the introduction of fluoride-added table salt instead. One of the signatories, Gunnar Harder Santesson, held patents on salt fluoridation. When fluoridation was made possible in principle in 1962 following a bill by the Swedish Dental Society and the Swedish Society for Medical Sciences, some municipalities submitted corresponding applications, but did not complete the formalities, so that in 1971 the previous legal regulation was repealed. So Norrköping remained the only Swedish experience with drinking water fluoridation. In the Swiss city of Basel, drinking water fluoridation was discontinued in 2003, which has been carried out since 1962. Citizens had repeatedly submitted corresponding petitions there, which were rejected, until the addition to the water was stopped, allegedly due to concerns about fluoride oversupply due to fluoride salt also available. As in Switzerland, table salt with added fluoride is also available in Germany.

For 2004, the WHO lists 19 countries with drinking water fluoridation, including the USA, Australia, Malaysia, Colombia, Hong Kong and Singapore.

Alternatives to drinking water and salt fluoridation

Compared to the use of fluoridated water and food, especially the fluoridation of toothpaste has been accorded great importance since the 1970s, which has made water fluoridation less important. Regular brushing with toothpaste containing fluoride is generally sufficient. For patients with a high risk of tooth decay, the dentist can also apply a more highly concentrated fluoride preparation (varnish or gel) locally.

When applied locally , the fluoride-containing agent is applied in the oral cavity through toothpastes, mouthwashes, gels and varnishes and then remains detectable in the saliva for a while . The topical (local) application of higher concentrated fluoride products is more likely to lead to a loss of tooth minerals, as proven by a number of patents from the American Dental Association Health Foundation (ADAHF). According to the studies cited there, more highly concentrated fluoride products promote the removal of calcium from the apatite with the formation of calcium fluoride on the tooth surface, which is more easily washed away. For this reason, two-component toothpastes were developed in which fluoride on the one hand and calcium and phosphate on the other hand are kept separate, which are only mixed when squeezed out of the tube and are supposed to react on the tooth surface to form apatite.

When used systemically , fluoride is ingested with food or given as a tablet . The fluoride is absorbed in the digestive tract and transported through the blood . From there it can be incorporated into newly formed hard tooth tissue ( dentin ) and bone tissue or excreted in saliva. Examples include drinking water containing fluoride , mineral water , tablets, table salt , food containing fluoride ( fish , shellfish and tea ). The time it remains in the mouth is very short and the concentration of fluoride is usually very small, with the exception of using fluoride tablets. Therefore, fluorides ingested through food are unlikely to have a direct effect on tooth enamel.

The mixed application by sucking fluoride tablets or swallowing toothpaste containing fluoride has first local effects in the mouth and then systemic effects.

In a test by Stiftung Warentest (as of January 2019), toothpastes that do not contain fluoride were consistently rated "poor".

history

The explanations published so far on the history of caries prophylaxis with fluorides mainly relate from different perspectives to drinking water fluoridation (TWF), which is usually described as a success story of American dentistry.

After years of preparatory work, Frederick Sumner McKay achieved in 1925 that, for the first time in the history of dentistry, an entire city switched the water supply because of a dental phenomenon. In connection with the discovery of fluoride as the cause of the endemic dental fluorosis, William John Gies first expressed the vision of drinking water hygiene under the guidance of the dental profession . In 1938, Henry Trendley Dean spoke of the possibility of using the water network to control the frequency of tooth decay by adding fluoride. Frank Bull, one of the TWF's most dedicated early advocates, spoke nine years later of the “greatest thing in dentistry,” which is now sometimes referred to as its greatest contribution to public health.

Therefore, the fluoridation of drinking water has numerous advocates in dentistry, who perceive it as a gain in prestige - also on a political level.

Fluoride research in the 19th and early 20th centuries

The use of fluorides for the prophylaxis of dental caries was not originally a discovery of (American) dentistry. Trendley Dean cites the Emmendingen district doctor “Dr. Erhardt ”, who recommended fluoride pastilles as early as 1874. In addition, the Mainz chemist Albert Deninger mixed calcium fluoride into his family's food and the English doctor Sir James Crichton-Browne recommended that the fluoride-rich hulls of the grain should also be processed in the flour production.

But there was already controversy on the subject in the 19th century. As early as 1894, the chemist S. Gabriel described the discussion about the possible health significance of fluorides as "almost a struggle". Later historical reviews of the use of fluoride in caries prophylaxis give no indication of this.

The positive representations formed the basis for animal experiments by nutritionists around Elmer Verner McCollum . The researchers added sodium fluoride to the feed of rats. They wanted to test whether the fluoride really had the previously claimed beneficial effects. In 1925 they noticed tooth changes similar to those observed in people with mottled teeth . "To his chagrin," however, the group's dental advisor, Russell Welford Bunting, initially failed to see the link.

When Dean later pointed out the early recommendations, it was strategically advantageous. When he presented his thesis of the caries prophylactic effect of fluoride, fluorides had a very bad image and the majority of his colleagues were now looking for options to keep the fluoride content of drinking water as low as possible in order to curb the tooth discoloration that is endemic in some places.

The American chemist Gerald Judy Cox commented very selectively on the developments that preceded water fluoridation in Europe in the 19th and early 20th centuries and included them almost seamlessly in his presentation of history. In Europe, the early fluoride work only became interesting after the Second World War on an American initiative. Dean's quote was simply adopted in German-language reviews. Until then, dental circles, apart from locally limited individual activities (e.g. Hermann Schröder ), did not pay particular attention to this type of caries prophylaxis. The reasons given are contradicting analytical data and the toxic potential of fluorides.

Fluoride: cause of "mottled teeth"

In 1916, dentists Greene Vardiman Black & Frederick Sumner McKay reported in a series of articles about the endemic occurrence of mottled teeth in some regions of the United States. McKay suspected a special property of the local drinking water as the cause. This negative aspect was not very welcome in the cities with attractive tourist attractions. Then the phenomenon was also observed in the population of the city of Bauxite , Arkansas, where a subsidiary of the Aluminum Company of America ( Alcoa ) had the mineral bauxite mined. Bauxite is needed for the production of aluminum, the potential danger of which was already hotly debated at the time. ALCOA responded to the suspicion that the strange staining of teeth could also be traced back to aluminum by examining drinking water samples. To the surprise (and relief), however, they found fluoride in it, which was then also found to cause tooth damage in animal experiments. In the same year the United States Public Health Service (USPHS) occupied a dental research station with the dentist Henry Trendley Dean , the future "father of fluoridation." He was assigned a team of advisors, including Weston Price and Russel Bunting were members. Bunting, the former designated assistant to Willoughby D. Millers , had meanwhile continued his work at the University of Michigan after Miller's death, highlighting sugar and certain bacteria (lactobacilli) as the cause of tooth decay. Dean's task was initially to investigate the spread of mottled teeth and to find economically justifiable measures to contain them, but in January 1932, at the first meeting with the team of advisors, he was instructed to devote himself primarily to caries research after this task was completed.

Spotted teeth - less tooth decay?

In 1937, dental research at the USPHS was expanded and the influence of fluoride on the frequency of dental caries was placed in the foreground. A team visited the Texas cities of Amarillo and Wichita Falls for epidemiological research; Both cities had a comparable population, but different levels of fluoride in drinking water (Amarillo 4 ppm, Wichita Falls 0.4 ppm). In the same year, the first international government-level sugar agreement was signed in London , Bunting became the new dean of the Faculty of Dentistry at the University of Michigan and his assistant professor Philip Jay took over the research and acted as an advisor to the USPHS.

The view that causal caries prevention by reducing sugar consumption is ruled out for economic reasons (Jay, see above), was followed by the first fluoridation attempts: In Escanaba and Garrettsville , water sources with increased fluoride content (1.7 ppm) were developed and their water with water from existing ones Sources mixed to achieve 0.7 ppm fluoride levels. After two years there was still no evidence of any influence on the frequency of caries among the residents, but preparations for the first experiments with artificial fluoride addition began soon.

First attempts with drinking water fluoridation

In 1942 Trendley Dean and Philip Jay presented their statistical studies in 21 cities, according to which the incidence of tooth decay in children decreases with increasing fluoride concentration in the water. In 1945 the first attempts at fluoridation began in the US cities of Grand Rapids (Michigan) and Newburgh (New York) as well as in Brantford (Ontario, Canada).

Post-war fluoridation propaganda

After the war, Trendley Dean visited several German cities for dental examinations. Even David B. Ast , initiator of the Newburgh experiment, and Henry Klein (USPHS) traveled through European cities to the American Jewish Joint Distribution Committee to convey an image of the dental care of the Jewish displaced persons. Both provided their European colleagues with fluoride literature. In Europe people are hungry for literature, Ast wrote to Klein and told him to bring enough offprints to distribute.

From the perspective of the Americans, German dentistry was in a pitiful state at the end of the war: the presence of dentists in the military was far removed from the potential that had been mobilized in the USA; Dental training, whatever it was before the war, had been mercilessly sacrificed to the aims of the war; Dental techniques, sometimes born of improvisation and scarcity, do n't even begin to conform to American standards; knowledge of dental disease prevention and control has not even reached what the US had a decade or more ago. As a result, the dental profession in Germany is confronted with an enormous need for rehabilitation and reconstruction that will occupy at least a generation. That was the conclusion in an editorial from 1946, which is accompanied by a detailed report on dentistry in war-torn Germany. And this report also mentions that directors of dental university institutes in Germany had hardly noticed anything about the American fluorine research. Isolation was tightened when the Federation Dentaire Internationale (FDI) removed Germany (and Japan) from the list of members in 1947. On June 17, 1948, the “Dental Society at the University of Berlin” was founded. Georg Axhausen (1st chairman), Walter Drum (deputy chairman) and Hans Joachim Schmidt (Axhausen's senior physician at the dental clinic, clerk) belonged to its board of directors . The aim of the society was to create a forum for the dissemination and discussion of scientific findings, while eliminating economic and state-political goals. Then “Visit from America” brought a spirit of optimism to Berlin with information about American fluorine research. In view of their past (see the history of the dental profession) it is remarkable, but perhaps owed to their organizational talent that they developed, that the dentists Kessler, Schmidt , Euler and Wannenmacher soon appeared as leading members of the German Fluorine Commission , which in 1950 was part of the German Committee for Youth Dental Care (DAJ ) Founded. Corresponding members include the former NSDAP members Hans Heuser (also SA, NS Lecturers and Teachers Association) and Friedrich Proell . The fluoridation propaganda of the Americans offered the German dentists the opportunity to free themselves from isolation and to find international "scientific connection". In 1951 there was, among other things, a "large-scale fluorine campaign in the state of Hesse" by distributing fluoride pills to school children. "The total costs ... are partly borne by the American side". A lively exchange of dentists for study visits followed between Germany and the USA. As early as 1952, the FDI agreed to a resumption of Germany and Erich Müller promised unreserved cooperation for German dentistry. A year later, Walter Drum enthusiastically announced the victory over dental caries caused by fluorine .

On December 2, 1952, the first German drinking water fluoridation attempt began in Kassel-Wahlershausen, at the instigation of Heinrich Hornung . After a short time, the apparatus required repairs. The fluoridation plant in Kassel was finally shut down in 1971 by decision of the responsible ministry as a result of “legal and health considerations”. Nevertheless, a new attempt was made in 1984 to introduce fluoridation of drinking water in Berlin. The attempt failed because of the resistance of the population, supported by critical doctors and dentists.

Fluoridated table salt

But Senator Ulf Fink is now campaigning for a change in the law on the Federal Council to enable the fluoridation of table salt. After fluoridated table salt was introduced in France in 1987, economic relations in Germany required a corresponding adjustment. Since 1991, fluoridated table salt (with the addition of potassium fluoride or sodium fluoride) has been sold in Germany.

The development in Switzerland

A decision by the Zurich government council allowed fluoride to be added to table salt from July 1955, making Switzerland a pioneer in this field of disease prevention. In 1959, 40 percent of the table salt purchased from the United Swiss Rhine Saltworks was fluoridated. By the year 2000, the share of fluorinated table salt rose to over 80 percent of the market volume. Combined with precautionary measures in schools and fluoridated toothpaste, there was a decrease in caries incidence between 1964 and 2000 - taken from the population of the Canton of Zurich - by almost 90 percent. On the recommendation of the Swiss Federal Office of Public Health, in cooperation with the Fluorine and Iodine Commission of the Academy of Medical Sciences , 250 milligrams of fluoride are added to one kilogram of table salt in Switzerland (equivalent to 250 ppm). The addition by the salt manufacturer is voluntary.

In the canton of Basel-Stadt , fluoride was added to drinking water from 1962 to 2003, but fluoridated table salt was not available. This was then harmonized with the rest of Switzerland, not least to make logistics easier for large distributors.

“In the course of increased environmental awareness, the ecological argument was also more important, namely that 99% of the fluoridated water never reaches the target, but only becomes fluoride pollution of the Rhine. Finally, a financial argument also promoted the switch to fluoride salt: thanks to cost-cutting measures by industry and private households, Basel produces too much drinking water (up to 50%), which, due to its good quality, could easily be sold to neighboring Alsatian and German communities. However, only without the addition of fluoride, which French and German legislation strictly forbids. "

- Media release from the Canton of Basel-Stadt

controversy

Fluoridation, especially tap water, is the subject of controversial discussion from various angles. On the drinking water fluoridation is criticized by opponents that it requires no individual consent to medical intervention and you can withdraw it only with great effort. These opponents include the German Gas and Water Association (DVGW, formerly: German Association of Gas and Water Men), which would be responsible as the executive body in the case of the TWF. Since only salt fluoridation is practiced as mass prophylaxis in Germany, the controversy here is essentially limited to the health and effectiveness aspects of fluoridated table salt and the administration of fluoride tablets as well as fluoride application at the dentist, although some arguments about drinking water fluoridation are also relevant here.

effectiveness

The caries-inhibiting effectiveness of fluoride applications has been well documented.

Possible harmful effects

Tooth damage

→ Main article : Dental fluorosis

Mild form of dental fluorosis

While fluoride mg in a dosage of about 1 / day as an effective agent for the prophylaxis of caries is considered (fluoridation), it generates the dental fluorosis in higher doses, in which white to brown discolorations in the form of spots or stripes on the enamel surface form. Occasionally the entire tooth surface is discolored chalk white (matt) and interspersed with brown discoloration. The discoloration is the cause of impaired reabsorption of the organic enamel matrix. To a greater extent, this is not only cosmetically disruptive, but also harmful to the teeth, since the enamel surface becomes less resistant as a result. In some regions (Germany: Eifel), dental fluorosis is known, which occurs more frequently in the population due to increased fluoride intake with drinking water (≥ 1 mg / l). Overall, however, the incidence in Germany is low.

The concentration at which dental fluorosis occurs is controversial in the literature; values ​​of 0.03 to 1.0 mg fluoride / kg body weight and day are given.

Chronic damage

→ Main article : fluorosis

Some arguments against the use of fluoride relate to the acute and chronic toxic effects of fluorides and their complex salts, which from various sources can ultimately lead to an overall toxic effect. Fears arise in part from the use of fluorides as rat poisons and insecticides . As a result of mix-ups or as a means of suicides and murder attacks, they have often caused fatal acute poisoning in humans. Under certain conditions (e.g. consumption of many fluoride tablets by children, technical failure of systems for water fluoridation or ingestion of highly concentrated fluoride gels that are applied at the dentist), acute fluoride poisoning is also possible and has occurred with products for caries prophylaxis. In 1992, in a village in Alaska, a defect in the drinking water treatment system resulted in fluoride poisoning among the population and one death.

Chronic damage has become known from workers who are exposed to fluorides in the workplace. Bone fluorosis, which can also be induced by water with an excessive fluoride content, is caused by a fluoride-related stimulation of the bone-forming cells ( osteoblasts ). This effect has long been used in the now outdated osteoporosis therapy with high-dose fluoride administration ( iatrogenic fluorosis) . Bone fluorosis develops after long-term systemic intake of increased doses (> 10 mg fluoride daily), but without having any disease value. In the USA, for example, no health problems due to bone fluorosis were observed even in areas with high fluoride concentrations in drinking water. For severe bone fluorosis, around 20 to 80 mg fluoride would have to be consumed over 10 to 20 years. The fluorine osteopathy performs multiplication of the bone tissue to loss of elasticity and increased bone fragility ( osteosclerosis ) up to a complete stiffening of joints, or even the spine.

Immissions caused environmental damage to crops and livestock, which led to high claims for damages. A particularly well-documented example is the so-called Swiss fluorine war .

On the other hand, the toxic effects of fluorides in food must be taken into account with regard to the doses used. However, the question of the optimal fluoride dose has not been conclusively answered. Finally, a certain concentration z. B. in tap water (or table salt), the individual dose being determined by the amount of water or salt consumed and additional fluoride supply from other sources. According to the US National Research Council, the often excessive fluoride content of drinking water makes a stricter regulation of the fluoride supply necessary.

There have been assumptions that the use of low-concentration fluorine salts and compounds can also cause cancer and permanently damage the nervous system and other organs. In its 1982 assessment, the International Agency for Research on Cancer (IARC) came to the conclusion that there are no signs of increased cancer mortality in connection with the fluoride content of drinking water . However, the question was not whether fluorides in any concentration or dosage have harmful effects, but whether carcinogenic effects can be demonstrated in the context of the preparations and concentrations used in dentistry (TWF etc.). At the beginning of the 1990s, osteosarcomas were observed in feeding experiments in rats and mice with 45 and 79 times the recommended fluoride concentration in drinking water . In humans, a connection between osteosarcomas and drinking water fluoridation is now disputed. The National Cancer Institute has after evaluation of 2.3 million cancer deaths and 125,000 new cases of cancer detected in the United States no connection with fluoridated water.

There is also controversy between proponents and even within an agency, e.g. B. at the Federal Health Office: 1982 still against it, after the change of a department head for it. Salt fluoridation was rejected by the then Ministry of Health in October 1983; it was introduced in 1991. Conversely, the previously most prominent Canadian proponent of fluoridation, the dentist Hardy Limeback , University of Toronto, is now expressly against drinking water fluoridation.

Fluoride and IQ

The authors of a meta-analysis of studies, which were mainly carried out in China, conclude that areas with fluoride concentrations in drinking water between approx. 0.9 and 11 mg / l influence the cognitive development of children. The comparison was made between children who were born and grew up either in regions with low (0.18–2.35 ppm) or high (0.88–11.5 ppm) fluoride concentrations in drinking water. The average IQ of children should be around one to 0.45 points lower than that of children who live in areas with lower fluoride concentrations (<0.9 mg / l). However, the authors of the study also noted that every study used for the meta-analysis had serious, and in some cases very serious, deficiencies. In August 2016, the meta-analysis was taken up in a magazine of the Harvard TH Chan School of Public Health and a report by the Cochrane Collaboration on fluoridation was mentioned with the additional note that in a number of countries without TWF the frequency of caries had decreased as well as in countries with TWF. This article was followed by a storm of angry letters of protest from various dental organizations demanding the immediate withdrawal of the magazine article.

In a study carried out in New Zealand with around 1,000 test persons, no connection between fluoride intake from different sources and the intellect (or neurotoxicities) could be proven.

In the ELEMENT study ( Early Life Exposures in Mexico to Environmental Toxicants ) from 2016, which examined around 1,000 pregnant women and their children four and six to twelve years after birth, possible consequences of systemic fluoride intake (e.g. through fluoridated Drinking water) for cognition in a longitudinal study . A higher fluoride content in maternal urine was linearly associated with a lower General Cognitive Index (GCI) after four years in the MSCA ( McCarthy Scales of Children's Abilities ) test . Six to twelve year old schoolchildren showed in the WASI test ( Wechsler Abbreviated Scale of Intelligence) lower intelligence quotients at higher fluoride concentrations of at least 1 mg fluoride per liter. The study was criticized because of methodological weaknesses and inconsistencies in the study environment.

The claim, once again made in this context, that the toxicity of fluoride is ten times less than that of table salt, is just as inaccurate as it is dangerous: several grams of table salt are ingested every day, while this amount of fluoride is fatal and long-term damage from fluoride is just a few milligrams occur daily (see fluorosis ).

Academic dispute

Since 1996, the German Society for Pediatric and Adolescent Medicine (DGK) and the German Society for Nutrition (DGE ) have not yet joined the recommendations of the German Society for Dentistry, Oral and Maxillofacial Medicine (DGZMK) based on the mode of action of fluoride . In other countries, such as the USA, recommendations similar to those of the DGZMK have been in effect for a long time.

View of the DGZMK

Instead of the fluoride tablets or drops that most infants are currently given from the first month of life in the pediatrician practice, the DGZMK recommends using a fluoride-containing children's toothpaste from the first baby teeth at around six months. The main recommendations are in detail:

• From a dental point of view, no fluoridation measures are required in the first six months of life.
• When the first milk teeth appear, the parents should brush them once a day with a pea-sized amount of children's toothpaste containing fluoride (500 ppm fluoride). Toothpastes with a fruit or candy flavor are not recommended because they make it easy to swallow.
• From the second birthday, teeth should be brushed in the same way twice a day. This increases the caries protection and should help the child get used to daily dental care at an early stage. Teeth brushing of young children must be monitored, and parents should brush their child's teeth again well into school age.
• In addition to brushing your teeth with toothpaste containing fluoride, it is recommended to use table salt containing fluoride.
• From school entry, teeth should be brushed with a toothpaste with a fluoride content of 1000 to 1500 ppm and fluoridated table salt should be used regularly for cooking.
• Fluoride can be given in the form of tablets if fluoridated toothpaste and fluoridated table salt are not used. However, it should be ensured that the recommended daily amount is not exceeded. Food containing fluoride must also be taken into account here, as these also contribute to the daily intake of fluoride. It is therefore important that the individual fluoride status is ascertained in the pediatric or dental practice prior to the fluoride prescription.
• If fluoride tablets are already being administered, then they should not be swallowed, but rather sucked - because of the local effect that is in the foreground. This can only be done from a higher age of the child.

View of the DGK

Pediatricians advocate fluoride tablets for the first few years of life. From their point of view, this practice has proven itself: It takes into account the special conditions in infants and small children and ensures that as many children as possible are reliably supplied with fluoride.

The German Academy for Children and Adolescent Medicine e. V. therefore continues to recommend:

• In the first six months of life, i.e. H. Before the first baby tooth erupts, the infant should receive combined fluoride and vitamin D tablets or drops in the recommended fluoride amount of 0.25 mg / d.
• From the seventh to about 36th month of life, i.e. H. After the first milk teeth have erupted, fluoride administration should be continued in the form of tablets or drops at 0.25 mg / day (up to the age of 12 months in combination with vitamin D). At the same time, the child should be accustomed to daily dental care.
• Only when it is ensured from the age of around three that the teeth are regularly brushed at least twice a day without the toothpaste being essentially swallowed, and both table salt enriched with fluoride and toothpaste enriched with 500 ppm fluoride are used regularly a further external supply of fluoride with tablets or drops is no longer necessary.
• If these conditions are not complied with, the age-appropriate supply of fluoride should be continued with tablets (0.5–1.0 mg / day depending on age).
• If caries occurs, a pediatric dental treatment should be initiated.

In addition, very practical considerations are given that speak against the dental recommendations from a pediatrician point of view. These include:

• Young children often swallow toothpaste. However, since toothpastes are declared as cosmetics, they are not subject to food controls and are therefore not suitable for consumption (ingestion).
• It is recommended by pediatricians not to use any additional table salt at all in infant food. Therefore, a supplementary fluoride supply via fluoridated table salt, as recommended by dentists, is not given from the start.
• Small children cannot yet brush their teeth properly, and parents are often unsure how best to take care of children's teeth. However, there is insufficient infant and young child dental care to train parents on dental care.

Inconsistency

In an updated publication, which was published in the monthly Kinderheilkunde (special edition 9/2016), the authors write: “(...) the topical fluoride application with fluoridated children's toothpaste from the breakthrough of the first milk tooth, as described by the German Society for Tooth - Oral and maxillofacial medicine recommends, is not supported by paediatricians (...). ”The authors argue that children of this age cannot yet reliably spit out the“ preparations ”. This ability is only achieved at the age of four. The German Working Group for Youth Dental Care (DAJ) contradicts this.

The Saxon way

The different statements contributed to a great deal of uncertainty, especially among parents. In 2015, paediatricians and dentists founded a steering committee in Saxony in which they agreed on a compromise in a consensus paper in order to at least reduce the academic dispute. The main focus was on the use of fluorides from infancy and caries prophylaxis in toddlers. Because of the risk of dental fluorosis and possibly bone fluorosis , the simultaneous use of fluoride tablets and fluoridated toothpaste must be avoided. Kindergarten children and often elementary school children do not yet have sufficient toothbrushing technology. For this reason, it is advisable for the parents to clean up at least once a day, ideally until they have learned to use cursive.

Use of fluorides from infancy

Age	option A	Variant B
up to the completion of the 2nd year of life	Combined rickets and caries prophylaxis: Taking a vitamin D preparation (500 lU ) without added fluoride From the first tooth eruption, brush your teeth once a day with a "rice grain-sized" portion of fluoridated children's toothpaste (500 ppm fluoride) Use of fluoridated table salt when starting a solid diet *	Combined rickets and caries prophylaxis: Taking a combination preparation vitamin D (500 lU) with fluoride Once the first tooth has erupted, brush your teeth once a day with a “rice grain- sized” portion of fluoride-free children's toothpaste Use of fluoridated table salt when starting a solid diet *
from the 3rd year of life up to the completion of the 6th year of life	Brush your teeth twice a day with a "pea-sized" portion of fluoridated children's toothpaste (500 ppm fluoride) Use of fluoridated table salt * no use of fluoride tablets

• Table salt is generally extremely cautious to use in children, especially small children, from a nutritional point of view.

Ideological and economic aspects

Fluoride information event 1982

In the discussion about fluoridation, various variants of the prehistory are used as an aid to argumentation, which contain political or economic aspects. Fluorides are used in many industrial processes or occur as by-products, such as in the production of aluminum, steel, ceramics, phosphate fertilizers ( fluoridation ) and various fluorochemicals. Thoughts of possible conflicts of interest are likely, which concern either the trivialization of the products or the emissions associated with their manufacture or the lucrative disposal of by-products ("waste"). It is also claimed that it is particularly in the interest of the sugar industry to divert attention from the causes of dental caries and therefore to promote fluoridation. The disputes surrounding the dentist Johann Georg Schnitzer , who commented on this in his publications, should be considered in this context . In recent history, these conflicts have been mixed with the interests of the cosmetics and pharmaceutical industries (manufacturers of fluoridated toothpastes, mouthwashes, fluoride tablets, etc.).

Left or right plot?

In the USA, the fluoride problem had already caused political explosives on a number of occasions when it proved to be an effective means of generating political pressure during the “Cold War”. In his published work in 1952 The truth about water fluoridation claimed Charles Eliot Perkins , water fluoridation is by the English-born Russian Communists Kreminoff been brought to England in 1935. Shortly afterwards, English socialists introduced fluoridation in the United States, where they had many supporters in the highest positions.

Oliver Kenneth Goff declared in 1957 that he had been trained in a communist camp in the late 1930s where he was taught to use a sack of sodium fluoride in the waterworks to poison a city's entire water supply and create lethargy among the US population . During his training it was also discussed how water fluoridation was used in Russia to immobilize prisoners' camps.

So it was “clear” that a real communist would never drink fluoridated water. Conversely, according to this logic, someone who drank fluoridated water could not possibly be a communist. Whenever it was claimed again and again that a government was riddled with communists up to the highest positions, part of the “refutation” was the public declaration that you drink fluoridated water yourself. Occasionally even American presidents saw themselves compelled to do this : Dwight D. Eisenhower washed himself clean in this way, and his successor John F. Kennedy also saw himself compelled to make a corresponding declaration. In his defense speech, Kennedy didn't give a damn about the John Birch Society , which had forced him to act due to its growing political influence.

A film by Stanley Kubrick takes on this American anti-communist logic : Dr. Strange or: How I Learned to Love the Bomb . In one scene from this 1964 film, the insane General Jack D. Ripper explains to his assistant, Captain Mandrake: “There is no way a communist will ever drink a glass of water, because he knows exactly why ... fluoridation of the water - the most horrific communist attack to which we are at the mercy. ”Ripper himself only drinks“ distilled water ”(rainwater) and“ pure medical alcohol ”(Scotch). Alluding to a communist enforcement of the government, the American and Russian presidents are good friends trying to banish the threat of war created by Ripper. With the quotation on fluoridation taken out of context, the work is still often misused today for polemics against anti-fluoride opponents.

While the excesses of the McCarthy- era anti-fluoride were effectively in check, the American Dental Association struck the same line with its published dossiers on anti-fluoride: Doctors and scientists who spoke out against the measure were in the same breath Perkins, Goff, the Birch Society, and the Ku Klux Klan .

In a book and on various Internet sites, reference is made to an alleged statement by Perkins, who heard from an IG Farben employee that the Nazis wanted to enrich the drinking water with fluoride in conquered areas and in concentration camps in order to break the resistance to dumb the people. In the book by Joseph Borkin, which is occasionally cited as a reference, the term fluoride is nowhere mentioned. In addition, this presentation contradicts the statements published by Perkins in 1952. With reference to an alleged document from the US Public Health Service, it is reported on a website that in 1940 Adolf Hitler ordered the Frankfurt-based chemical factory IG Farben to produce large quantities of fluoride for use in the prisoners' drinking water. The calming effect of the fluorine is said to ensure discipline in the camps and dampen the inmates' drive to attempt escape. Sodium fluoride was also added to drinking water in the Soviet Union in order to calm down German prisoners of war in the camps. The Belgian Joris, who transported sodium fluoride to the Soviet Union during the war, reported this to the fluoride researcher Hans Moolenburgh.

The origin of such rumors of dumbing down can be found in anthroposophy . In April 1920, in a lecture in Dornach , Rudolf Steiner described the teeth as veritable fluorine suction devices and went on to say that humans need very small quantities of fluorine in their organism. “Because of these fluorine effects, he is tuned down to the right amount of stupidity that we already need in order to be human.” Otherwise he would achieve “a degree of cleverness” that almost annihilates him. A year later, the anthroposophist Oskar Römer took up Steiner's remarks in his work on dental caries. Around 30 years earlier, Hugo Schulz and Hermann von Tappeiner had already interpreted certain observations in their animal experiments with fluorides as paralysis of the central and peripheral nervous system.

Economic interests

Despite deep rifts, western nations were occasionally able to come to an agreement with the communists: on May 6, 1937, government representatives from various states (including the USA and the Soviet Union) concluded an international sugar agreement in London, in which, for the first time, at government level, export and import Quotas are set, a reduction in tax burdens and an increase in per capita sugar consumption are sought. An “International Sugar Council” based in London (“Sugar Bureau”) was set up as a central point of contact for all contractual matters.

Researchers at the University of Michigan, where research into the role of sugar and bacteria in the development of tooth decay had a long tradition, responded promptly: “Despite the enormous advertising expenditure in the sugar industry, attention is increasingly focused on the role of sugar in the development of dental caries. If this information were to become so widespread that the sugar trade was seriously affected, teeth could only be preserved at the expense of our economic prosperity. Too large a part of the world population depends directly on the sugar industry for the resulting emergency not to affect everyone. "But one had to offer an alternative:" ... It largely depends on the attitudes of the dentists whether the population meets the current situation Is negative or positive about considerations regarding fluorine in caries research. " [Orig. in Engl.]

The American Dental Association had no reservations about the sugar industry, and in a book review even expressed the hope that their efforts in the field of dentistry would be intensified. But that donations from the sugar industry for fluoride research were kept secret aroused suspicion elsewhere. In a preliminary remark to the book Survey of the Literature of Dental Caries , there was general reference to financial support from industrial circles. When asked, it was stated that the companies concerned did not want to be named. In an annual report for 1943-1959, however, at least the Sugar Research Foundation, which was founded by the sugar industry in 1943, lists its donation to the book project. The fact that the same foundation had sponsored an important fluoride symposium in October 1944 was only mentioned nine years later. More recently, interactions between the sugar industry and the National Institute of Dental Research have also become known.

The special view of the sugar problem was not limited to American researchers: in 1953, the Working Group for Fluorine Research and Caries Prevention (ORCA) was founded in Konstanz with the support of the sugar, beverage and fluorine industries. In 1967 there was an agreement between the Federal Association of German Dentists and the sugar industry, known as " Sweet Conversation ". The fact that the sugar industry is “not the enemy of research” was proven by z. For example, when she made two symposia of the Chair of Experimental Dentistry possible in 1976 in close connection with the Nutrition Working Group of the German Society for Dental, Oral and Maxillofacial Medicine through "generous financial support" and representatives of Südzucker AG and the Ochsenfurt sugar factory gave lectures on this occasion. The nutritionist Hans-Diedrich Cremer clarified amateur views and dealt with questions about the alleged lime and vitamin robber. In the same year, the German Federal Association of the Sugar Industry, the Central Marketing Company of the German Agricultural Industry ( CMA ) and the Sugar Working Group of the Sugar Processing Companies' associations founded the Information Group Oral Hygiene and Nutrition Behavior (IME) to promote sales . It should promote oral hygiene and fluoridation in the prevention of caries. Again, these agreements are cited as evidence that powerful economic interest groups are involved in the fluoridation controversy.

literature

• Elmar Hellwig, Joachim Klimek, Thomas Attin: Introduction to tooth preservation - examination knowledge of cariology, endodontology and periodontology . 6., revised. Edition. German Zahnärzte-Verl., Cologne 2013, ISBN 978-3-7691-3448-3 .
• Jan Ekstrand, Ole Fejerskov, Leon M Silverstone: Fluoride in dentistry . Munksgaard, Copenhagen 1988, ISBN 87-16-09962-1 .
• S2k guideline fluoridation measures for caries prophylaxis of the German Society for Dentistry, Oral and Maxillofacial Medicine (DGZMK). In: AWMF online (as of 2013)

Web links

• Patient information from the German Dental Association and the German Society for Dentistry, Oral and Maxillofacial Medicine (PDF; 125 kB)
• Fluoride in Drinking Water. A scientific review of EPA's standards - US National Research Council (Engl.)
• Fluoride in Drinking-water - WHO World Health Organization (PDF; 1.1 MB)

Individual evidence

This section needs to be revised: Much information on how to find the literature is missing, e.g. B. DOIs .
Please help to improve it , and then remove this flag.

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17. ↑ ^{a b} ZBay 3 - 00, Herbert Michel, How does fluoride really work? ( Memento of the original from July 19, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
18. ↑ Wolfgang H. Arnold, Bastian A. Heidt, Sebastian Kuntz, Ella A. Naumova, Alexei Gruverman: Effects of Fluoridated Milk on Root Dentin Remineralization. In: PLoS ONE. 9, 2014, p. E104327, doi: 10.1371 / journal.pone.0104327 .
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22. ↑ BGVV: Use of fluoridated foods and the effects of fluoride on health (PDF; 41 kB). July 2002, repetition of the statement from September 2001.
23. ↑ BfR January 2002, pp. 22-23 (PDF; 214 kB)
24. ↑ ^{a b c} Opinion of the BgVV from July 2002: Use of fluoridated foods and the effects of fluoride on health PDF file
25. ^ Meiers P .: "Fluoride and dental caries: second thoughts in view of recent evidence from Germany" , Fluoride 44: 1 (2011) 1-6. (PDF; 163 kB)
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38. ^ Fluoride & Tooth Decay: Topical Vs. Systemic Effects (English)
39. ↑ Toothpaste: The best toothpaste for your teeth , Stiftung Warentest, December 19, 2018. Accessed January 3, 2019.
40. ^ DR McNeil, The fight for fluoridation , Oxford University Press, New York 1957.
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43. ^ RR Harris, Dental Science in a new age. A history of the National Institute of Dental Research , Montrose Press, Rockville, MD, 1989.
44. ↑ AS Rymer, The political science of fluoridating public water supplies. A case study in deception. , Senior Honors Thesis, Department of Government, Dartmouth College, April 2000.
45. ↑ H. Ludigs, Fluoride and the History of American Dentistry, approx. 1900-1950 , Master's thesis, University of Konstanz 2013
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48. ^ William J. Gies: The status of dentistry. Notes on the question of whether dental practice should be included in medical practice, with comment on a substitute for state medicine. J dent Res 12 (1932) 945-990.
49. ↑ HT Dean: Endemic fluorosis and its relation to dental caries , Public Health Reports 53 (1938) 1443.
50. ^ FA Bull in Minutes of the AAPHD executive council meeting , Chicago, Ill., February 9, 1947, Bull. Am. Assn. Public Health Dent. 7: No.2 (May 1947) pp.31-32.
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52. ↑ see also H. Ludigs, loc. cit.
53. ^ T. Delessert, V. Barras: III. Dental art: craft or profession? A historical representation , Switzerland Mschr Zahnmed 121: 5 (2011) 468-472.
54. ↑ Brian Martin. Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate , Albany: State University of New York Press, 1991.
55. ↑ HT Dean, Domestic water and dental caries , J. Am. Water Works Ass. 35 (1943) pp. 1161-86.
56. ↑ P. Meiers: Dr. Erhardt's (Hunter's) fluoride lozenges ; Retrieved Feb. 29, 2016.
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59. ↑ S. Gabriel: Chemical investigations on the minerals of bones and teeth , Hoppe Seyler's Z. physiol. Chem. 18 (1894) 257-303.
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63. ↑ RW Bunting, The Story of Dental Caries , Overbeck, Ann Arbor, MI, 1953, p. 83.
64. ^ RA Lyttleton: The Gold Effect , Cambridge Printing Services, undated , ISBN 0-9517573-0-X .
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73. ↑ W. Jankowiak, The history of caries prophylaxis with fluorides , dissertation University of Berlin 1974.
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80. ↑ Peter Meiers: Questionable Fluoride Safety Studies: Bartlett - Cameron, Newburgh - Kingston. Accessed December 1, 2019 . 
81. ↑ Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1938, USPHS 1939, p. 56.
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83. ↑ Branch DB: Letter to Henry Klein, USPHS, Jan. 15, 1948; American Jewish Joint Distribution Committee Archives, Collection # 45/54, File 349.
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85. ↑ Daily news, Fédération Dentaire Internationale (FDI) , Zahnärztl. Rundschau 56:15 (1947) 239.
86. ^ Walter Drum, visit from America , Zahnärztliche Rundschau No. 16 (August 20, 1948) p. 245 and caries prophylaxis through fluorine compounds , p. 246.
87. ↑ Walter Drum, The scientific principles of tooth protection hardening , Berlinische Verlagsanstalt, Berlin 1949, p. 22.
88. ^ DAJ, From the work of youth dental care since 1949 , German Committee for Youth Dental Care, 1974, p. 21.
89. ^ Ernst Klee: The dictionary of persons on the Third Reich. Fischer Verlag, Frankfurt 2003, ISBN 978-3-9811483-4-3 .
90. ↑ Dentist World 6 (1951) 235.
91. ^ John Ennis, The Story of the Federation Dentaire Internationale , FDI, London 1967, p. 144 and P. 153, ISBN 0-9503687-0-9 .
92. ↑ Walter Drum: Victory over dental caries by fluorine. Verlag die Quintessenz, Berlin 1953.
93. ↑ Dentist Practice 4: No.5 (1953) p.6; Dental Praxis Nr. 24 (1954) p.6; Dental Practice No. 10 (1955) p. 5.
94. ↑ Dentist Message. No. 2 (1954) p. 60.
95. ↑ Is poison coming out of the pipe now? In: Die Zeit No. 32, from August 2, 1974.
96. ↑ DVGW: Documentation on the question of drinking water fluoridation, Eschborn 1975, p. 42.
97. ↑ Idris E .: "More harm than benefit from fluoride?", Selecta No. 2, v. January 9, 1984, p. 70.
98. ^ Symposium "Drinking Water Fluoridation" on January 27, 1984 in Berlin. Moderator: Karl E. Bergmann; Organizer: Senator for Health, Social Affairs and Family, Berlin, in cooperation with the Berlin Chamber of Dentists.
99. ↑ Müller, Klaus: Comment on More harm than benefit from fluoride? In: Selecta No. 8, v. February 20, 1984, pp. 564 + 565.
100. ↑ “Fink is distancing itself from fluorine plans for the water. Majority of those questioned against - Now reference to table salt ”, Der Tagesspiegel, August 25, 1984.
101. ↑ fluoride. Dental Health Working Group, accessed on December 1, 2019 . 
102. ↑ ^{a b} Pioneering in the fight against tooth decay: table salt fluoridated for 50 years . NZZ , October 17, 2005.
103. ↑ ^{a b} Table salt and prevention of tooth decay . In: teeth - patient newspaper of the Swiss Dental Society SSO . No. 31 . Central Information Comm., SSO Press and Information Service, Bern 2005, p. 1–4 ( sso.ch [PDF; 327 kB ]).
104. ↑ fluorine and Jodkommission. In: samw.ch. Swiss Academy of Medical Sciences, accessed on August 25, 2019 . 
105. ↑ ^{a b} Conversion from drinking water to salt fluoridation in Basel . Media release by the canton of Basel-Stadt, June 24, 2003.
106. ↑ Meiers P .: J. Orthomolecular Med. 16: 2 (2001) 73-82 (PDF; 392 kB)
107. ↑ DVGW: Documentation on the question of drinking water fluoridation , Eschborn 1975
108. ↑ Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VC, Shi X: Fluoride toothpastes of different concentrations for preventing dental caries in children an adolescents . In: Cochrane Database Syst Rev . No. 1, 2010, p. CD007868. PMID 20091655 .
109. ^ Bennett T. Amaechi, Cor van Loveren: Fluorides and Non-Fluoride Remineralization Systems . tape 23 . Karger Publishers, 2013, p. 15–26 , doi : 10.1159 / 000350458 ( karger.com [accessed February 18, 2018]).
110. ↑ dental fluorosis (English)
111. ↑ ^{a b c d e} Jean-Francois Roulet, Susanne Fath, Stefan Zimmer: Dental prophylaxis: textbook and practical guide . 5th edition. Elsevier Health Sciences, 2017, ISBN 978-3-437-18744-5 , pp. 139 ( limited preview in Google Book Search [accessed July 26, 2018]).
112. ↑ Hendrik Meyer-Lückel, Kim Ekstrand, Sebastian Paris: Caries: Science and Clinical Practice . Georg Thieme Verlag, September 5, 2012, ISBN 978-3-13-169321-1 , p. 200–.
113. ↑ DVGW: Documentation on the question of drinking water fluoridation. German Association of Gas and Water Specialists V., Eschborn, 1975
114. ↑ Meiers P., Fluoride-History Website (July 2006)
115. ↑ Meiers P .: fluoride poisoning - with special consideration of caries prophylaxis (118 Ref.); Experience healing 36 (1987) 162
116. ^ Bruker MO, Ziegelbecker R .: Caution fluorine; 7th edition, emu-Verlags GmbH, Lahnstein, 2005
117. ↑ Gessner BD, Beller M, Middaugh JP, Whitford GM: Acute fluoride poisoning from a public water system . In: N Engl J Med . 330, No. 2, 1994, pp. 95-9. PMID 8259189 .
118. ↑ Valentin H. et al .: Occupational Medicine. Vol. 2: Occupational diseases. Thieme, Stuttgart, 1971.
119. ↑ Fischer RE: Commercial poisoning by fluorine and its compounds. Writings of the Society of German Metalworkers and Miners , Issue 13, Clausthal-Zellerfeld 1963
120. ↑ German Research Foundation: Fluorine Effects. Research reports 14. Wiesbaden 1968.
121. ↑ Association of German Engineers: Fluorine-containing air pollutants. VDI reports No. 164, Düsseldorf, 1971.
122. ↑ Urs P. Gasche : farmers, monastery women, Alusuisse. How an industry plays out its power, civil servants disregard the will of the people and the environment is ruined. A true Swiss story. Zytglogge Verlag, Gümlingen (CH), 1981.
123. ↑ The fluorine war in the Fricktal
124. ↑ Fluoride in Drinking Water. A scientific review of EPA's standards - US National Research Council (Engl.)
125. ↑ P. Meiers: Does Water Fluoridation have Negative Side Effects? A Critique of the York Review, Objective 4, Sections 9.1-9.6 . In: Journal of Orthomolecular Medicine . tape 16 , no. 2 , 2001, p. 73-82 ( PDF ).
126. ↑ EB basin, D. Wypij, RB Davis, MA Mittleman, Ó. Springer: Age-specific fluoride exposure in drinking water and osteosarcoma (United States) . In: Cancer Causes & Control . tape 17 , 2006, p. 421-428 , doi : 10.1007 / s10552-005-0500-6 .
127. ↑ Some Aromatic Amines, Anthraquinones and Nitroso Compounds, and Inorganic Fluorides Used in Drinking-water and Dental Preparations. Summary of Data Reported and Evaluation . In: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans . tape 27 , 1982 ( PDF ).
128. ^ ^{A b} Jean-Francois Roulet, Susanne Fath, Stefan Zimmer: Dental prophylaxis: textbook and practical guide . 5th edition. Elsevier Health Sciences, 2017, ISBN 978-3-437-18744-5 , pp. 141 ( limited preview in Google Book Search [accessed July 26, 2018]).
129. ↑ Brock A. Lindsey et al .: Osteosarcoma Overview . In: Rheumatology and Therapy . tape 4 , no. 1 , December 8, 2016, p. 25-43 , doi : 10.1007 / s40744-016-0050-2 , PMID 27933467 , PMC 5443719 (free full text).
130. ↑ Schön D., Hoffmeister H., Darimont T., Mandelkow J., Sonneborn M .: "Health effects of drinking water constituents", SozEp reports 6/1982.
131. ↑ Bergmann KE (BGA): "Dental caries prophylaxis - use of fluorides" Opinion on the GGB of November 29, 1983; and: German Bundestag, 10th electoral term, printed matter 10/2403 v. November 20, 1984, answer of the Federal Government to the small question of the MPs Dr. Ehmke (Ettlingen), Ms. Schoppe and the DIE GRÜNEN parliamentary group, “Drinking water fluoridation”.
132. ↑ Letter from Dr. Drews, Federal Ministry for Youth, Family and Health, to Dr. H. Nieper, October 19, 1983 right. "Fluoridation of table salt".
133. ↑ Hardy Limeback: Why I am now officially opposed to adding fluoride to drinking water , April 2000
134. ↑ Choi, AL. et al . (2012): Developmental fluoride neurotoxicity: a systematic review and meta-analysis. In: Environ Health Perspect . 120 (10); 1362-1368; PMID 22820538 ; doi: 10.1289 / ehp.1104912 .
135. ^ ^{A b} Jean-Francois Roulet, Susanne Fath, Stefan Zimmer: Dental prophylaxis: textbook and practical guide . 5th edition. Elsevier Health Sciences, 2017, ISBN 978-3-437-18744-5 , pp. 140 ( limited preview in Google Book Search [accessed July 26, 2018]).
136. ↑ Is Fluoridated Water Safe?
137. ^ Letters in response
138. ↑ Jonathan M. Broadbent et al .: Community Water Fluoridation and Intelligence: Prospective Study in New Zealand . In: American Journal of Public Health . tape 105 , no. 1 , 2015, p. 72-76 , doi : 10.2105 / AJPH.2013.301857 , PMID 24832151 , PMC 4265943 (free full text).
139. ↑ Morteza Bashash, Deena Thomas et al. a .: Prenatal Fluoride Exposure and Cognitive Outcomes in Children at 4 and 6–12 Years of Age in Mexico. In: Environmental Health Perspectives. 125, 2017, doi: 10.1289 / EHP655 .
140. ↑ Dental fluoridation measures during pregnancy are safe! In: zm-online . ( zm-online.de [accessed on July 26, 2018]).
141. ↑ Conspiracy to keep going - DocCheck News . In: DocCheck News . ( doccheck.com [accessed July 30, 2018]).
142. ↑ Does fluoride harm the brain? ( Memento of the original from August 11, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
143. ↑ Recommendations for caries prophylaxis depending on the fluoride content in drinking water in the Free State of Saxony . In: Ärzteblatt Sachsen 4/2000 .
144. ↑ Fluoridation facts ( Memento of the original dated November 30, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , American Dental Association (ADA). Retrieved January 12, 2016. 
145. ↑ Fluoridation measures for caries prophylaxis , information from the German Dental Association and the German Society for Dentistry, Oral and Maxillofacial Medicine, as of 4/2013.
146. ↑ DGZMK: Recommendations for caries prophylaxis with fluorides, status 06/02, 2002 (PDF; 185 kB)
147. ↑ The use of toothpaste containing fluoride is safe and provides effective protection against tooth decay. Federal Dental Association, January 16, 2014. Caveat: The dangerous claim that table salt is 10 times more toxic than fluoride can be countered by the fact that table salt is consumed by the gram, while fluorides in the milligram range are already toxic Develop effects!
148. ↑ ^{a b} Brodehl, Johannes: Is caries prophylaxis with fluorides still relevant? Answer of the German Academy for Child and Adolescent Medicine e. V., Gynecological Practice 2003; 27: XX.
149. ↑ Monthly Paediatrics Special Edition September 2016 ( Memento of the original from October 4, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , P. 445. Retrieved October 4, 2016. 
150. ↑ B. Koletzko, K.-E. Bergmann, H. Przyrembel, Prophylactic fluoride administration in childhood , recommendations of the DGKJ (German Society for Child and Adolescent Medicine) and the DAKJ (German Academy for Children and Adolescent Medicine), Monthly Pediatric Medicine, June 2013, Volume 161, Issue 6, pp. 508-509 doi: 10.1007 / s00112-013-2934-3
151. ↑ Dissent about fluoride administration in children ( memento of the original from October 4, 2016 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , zm-online, September 29, 2016. Accessed October 4, 2016. 
152. ↑ Group prophylaxis for children under 3 , zm-online, August 16, 2016. Accessed October 4, 2016.
153. ↑ The Saxon Way - Caries prophylaxis in small children - A medical-dental consensus paper , Zahnärzteblatt Sachsen, 09/2015, pp. 28–31. Retrieved January 19, 2016.
154. ↑ The Saxon Way - Caries prophylaxis in toddlers , Zahnärztliche Mitteilungen 02/2016. Retrieved January 19, 2016.
155. ↑ G. Waldbott, AW Burgstahler, L. McKinney: fluoridation - the great dilemma , Coronado Press, Lawrence, Kansas, in 1978
156. ^ C. Bryson, The Fluoride Deception , Seven Stories Press, New York 2011.
157. ^ Johann Georg Schnitzer: Health Policy 2004 in Germany: The topic missed
158. ↑ The Honorable Family. Die Macht der Pharmaindustrie , Der Spiegel, No.43 of October 18, 1976, p. 188
159. ^ MO Bruker, R. Ziegelbecker: Caution Fluor , emu Verlag, Lahnstein, 7th edition, 2005, p. 428–.
160. ↑ J. Scott Walker: “Mottled Enamel,” J. Am. Dent. Assoc. 20 (1933) 1867.
161. ^ Leon R. Kramer: Proposed Nationwide Fluorine Survey, J. Am. Dent. Assoc. 33 (1946) 649.
162. ^ Tom Hudson: "Lake Elsinore Valley. Its story 1776-1977 ”, Laguna House, 1978.
163. ^ Charles Eliot Perkins: “The truth about water fluoridation”, The fluoridation educational Society, Washington 1952.
164. ^ KO Goff: “Lest we forget”, notarized transcript from March 19, 1957, reproduced in “American Sunbeam”, Jan. 3, 1983.
165. ^ "Kennedy lashes out at Birchites, other Rightist Fanatics," The Washington Post, Nov. 19, 1961.
166. ↑ Picard A.: "Making the American Mouth. Dentists and Public Health in the Twentieth Century", Rutgers University Press, New Brunswick, New Jersey, and London, 2009; P. 117.
167. ^ ADA Bureau of Public Information: "Comments on the Opponents of Fluoridation", J. Am. Dent. Assoc. 65 (1962) 694-710 and J. Am. Dent. Assoc. 71 (1965) 1155-1183.
168. ↑ Hans Moolenburgh: fluorides the freedom fight , Mainstream Publishing Company, Edinburgh, 1987; P. 51.
169. ^ J. Borkin: The unholy alliance of IG Farben (German edition of The Crime and Punishment of IG Farben ), The Free Press, New York, 1978
170. ^ Fluoride - The modern day DDT , US Public Health Service, 1997, p. 12
171. ↑ R. Steiner: Geisteswissenschaft und Medizin , 7th edition, Dornach 1999, p. 310.
172. ^ Oskar Römer: "About dental caries with reference to the results of Dr. Rudolf Steiner's spiritual research", Der kommende Tag AG Verlag, Stuttgart 1921
173. ↑ Hugo Schulz: Investigations on the effect of fluorosodium and hydrofluoric acid , Arch. Exp. Pathol. Pharmacol. 25 (1889) 326
174. ↑ H. Tappeiner: 1. On the knowledge of the effect of fluorosodium , Arch exp Pathol Pharmakol 25 (1889) 203
175. ↑ H. Tappeiner: 2nd communication on the effects of fluorosodium , Arch exp Pathol Pharmakol 27: 1 (1890) 108
176. ^ First international sugar agreement
177. ↑ New York Times, May 7, 1937, p. 9: “ World sugar pact signed at London ”.
178. ^ Bunting RW: "The story of dental caries," Ann Arbor, MI, 1953
179. ↑ Jay P .: “Research in dentistry: its importance to the public”, Proc. Ann. Meet. At the. Assn. Dent. Schools 17 (1940) 65 ff.
180. ^ Sugar Research Foundation to support caries research , J. Am. Dent. Assoc. 45 (1952) 247; and Book Review: Ten years of research, 1943-1953 , J. Am. Dent. Assoc. 48 (Feb. 1954) pp 231-232
181. ↑ LA Maynard in G. Toverud, GJ Cox, SB Finn, et al .: Survey of the Literature of Dental Caries , Food and Nutrition Board, National Research Council, Washington, 1952
182. ^ CA Barden: Why secret grants? , National Fluoridation News, Vol. 2, No. 1 (Jan. 1956) page 2
183. ↑ The Sugar Research Foundation , Science 98 (December 10, 1943) pp. 509-510; Science 101 (April 27, 1945) p.426
184. ^ Sugar Research Foundation Inc .: Sugar Research 1943-1959 , New York 1960; P. 28.
185. ↑ AH Merritt, WJ Gies: Fluorine in Dental Public Health. A Symposium at a monthly conference of the New York Institute of Clinical Oral Pathology, New York City, Oct. 20, 1944 , published 1945
186. ^ R. Schaffer, T. Blum: Festschrift in Commemoration of the Twentieth Anniversary of The New York Institute of Clinical Oral Pathology , Reprinted from Oral Surgery, Oral Medicine and Oral Pathology, Jan. 1953, p. 4.
187. ↑ Cristin E. Kearns, Stanton A. Glantz, Laura A. Schmidt, Simon Capewell: Sugar Industry Influence on the Scientific Agenda of the National Institute of Dental Research's 1971 National Caries Program: A Historical Analysis of Internal Documents. In: PLOS Medicine. 12, 2015, p. E1001798, doi: 10.1371 / journal.pmed.1001798 .
188. ↑ ^{a b} Helga Federspiel, Tooth for Tooth, 1986, p. 80.
189. ^ Zahnärztliche Mitteilungen, Vol. 57, No. 20, 1967, p. 974; quoted from: Max O. Bruker and Rudolf Ziegelbecker: Beware of fluorine. emu-Verlag, 2005, ISBN 3-89189-013-3 .
190. ↑ The "Deutsche" informs. Sugar and tooth - topic for eight nations in Würzburg . Dental Communications 66 (1976) 865-866