FLUORIDATION PROMOTION BY SCIENTISTS IN 2006: AN EXAMPLE OF TARDIVE PHOTOPSIA a

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1 157 FLUORIDATION PROMOTION BY SCIENTISTS IN 2006: AN EXAMPLE OF TARDIVE PHOTOPSIA a 157 SUMMARY: The continued endorsement of fluoridation by many authorities, despite the absence of an evidence-base, is consistent with the dynamics that often lead to established scientists being reluctant to embrace new findings, a phenomenon examined by Thomas Kuhn in his book The Structure of Scientific Revolutions. To aid the recognition and discussion of this process, by which those seeking knowledge are slow to see the light, bearing in mind the maxim that there are none so blind as those that will not see, a new descriptive term is proposed tardive photopsia. Thus the ongoing promotion of fluoridation by scientists in 2006, after the scientific foundation for it has collapsed, is an example of tardive photopsia. Keywords: Fluoridation promotion by scientists in 2006; Kuhn, Thomas; Paradigm change; Structure of scientific revolutions; Tardive photopsia; Water Fluoridation. It is unlikely that Edward de Vere, the 17th Earl of Oxford, writing with the pen name William Shakespeare, 1 had fluoridation in mind when Hamlet declared There is nothing either good or bad, but thinking makes it so but, after assisting for 12 years with the editing of Fluoride and attending five of the Society s international conferences, I have become aware how people of goodwill with strong humanitarian concerns can see fluoridation in these diverse ways and be strongly motivated either to increase the dietary intake of fluoride for the population or to work towards mitigating the effects of its ingestion. For many living in areas, such as parts of India and the People s Republic of China, where chronic fluoride poisoning or fluorosis is endemic, the toxicity caused by fluoride is only too evident. For others, living in areas such as Australia, Canada, Hong Kong, Ireland, New Zealand, Singapore, the United Kingdom, and the United States of America, where the toxic effects of fluoride are more subtle, there is a widespread contention that an important intervention is being denied those who would benefit from it, particularly socially disadvantaged children. Fluoridation, in which items in the diet, such as water, milk, and salt, are used as vehicles for delivering fluoride or a silicofluoride to a person, was founded on the belief that such systemic ingestion, in a person aged 12 or less, would strengthen the developing teeth and make them more resistant to dental decay. However, despite this belief still being held by many dental health officials, fluoride does not reduce dental decay in this manner. 2 The model should be abandoned forthwith. It is more appropriate to see the requirements for better teeth as a nutritionally balanced diet, rich in calcium and phosphorus without refined sugar, together with good dental care. In New Zealand the decline in tooth decay began before the use of fluorides was introduced. 3 The graphs of tooth decay trends, for 12-year-olds in 24 countries using World Health Organization data, do not show any difference in the rate of decline in dental decay that has occurred in recent decades between countries that have or have not added fluoride to their water. 4 Whilst some countries use fluoridated salt, the graphs show a decline in all the countries studied. a An illustrated version of this paper was presented at the XXVI Conference of the International Society for Fluoride Research, Wiesbaden, Germany, September 2005, with an abstract published in Fluoride 2005;38(3):250-1.

2 158 Rather than ingested fluoride improving dental health there is evidence that a higher fluoride intake causes both dental fluorosis and dental caries. 5,6 Studies of the effects of topical fluoride, on the demineralization/remineralization of enamel, antibacterial activity, and the inhibition of glycolysis, have not shown a clear benefit to exist. Fluoride exposure, administered topically, after tooth eruption may be beneficial to patients who are at high risk for caries, but nowadays the clinical evidence for even this benefit is statistically weak, and the gains may no longer be clinically significant. 2 At best only marginal amounts of caries reduction can be demonstrated for ingested fluoride. Recent large-scale studies show virtually no difference in tooth decay between fluoridated and nonfluoridated communities. 2 It is not good medical practice to treat a person without considering their needs, sensitivities, and individual circumstances. Yet this is what occurs when fluoride is added to dietary items. In contrast to water chlorination, where the object is to purify the water, in water fluoridation the water is used as a vehicle to administer fluoride to the person consuming the water. Systemically ingested fluoride disturbs thyroid hormone metabolism 7 leading to a delay in the eruption of the teeth 8 and their exposure to the decay producing environment. One of the earliest studies to describe the delay in caries due to fluoride was the Culemborg-Tiel study by Backer Dirks in ,10 A delay in the incidence of pit and fissure cavities was reported among the children in fluoridated Tiel. However, whereas in nonfluoridated Culemborg the incidence of pit and fissure caries tended to decrease at 9 13 years and level off thereafter, in fluoridated Tiel the incidence tended to increase steadily for as long as the children were followed, up to age 17. In addition, more recent studies of adolescents and young adults who have grown up in the fluoride toothpaste era indicate a prolonged risk of caries development on both pit and fissure and smooth surfaces. 10 Scientifically, no conclusions can be drawn about the effectiveness of fluoridation unless other variables such as socioeconomic status and disadvantage are controlled for. Modern studies, such as the study by Armfield and Spencer in Australia, 2004, show that there is no longer a difference in dental decay between fluoridated and nonfluoridated areas. 11 When the variables of socioeconomic status and disadvantage are ignored, and especially if different geographical areas or ethnic mixes are compared, a variety of statistics can be produced to bolster a particular argument, but they are unconvincing. An example of a statistic apparently favouring fluoridation is that 59.10% of children in the fluoridated part of Waitemata are caries free compared to 28.60% in the nonfluoridated part of Southland (using data for children in their 8th year at school, aged about 12 years, in New Zealand for 2004, and comparing groups with a cell size of at least 400). However the same data base can be used to produce a statistic that appears to support nonfluoridation since 61.69% of children in the nonfluoridated part of Waitemata are caries free compared to 31.00% in the fluoridated part of Southland. 12 Similar statistics can be produced using the mean DMFT score (mean number of decayed, missing or filled permanent teeth), where a lower score indicates better teeth. In favour of fluoridation, the mean DMFT score for children in the fluoridated part of the Northern region (Northland, Waitemata, Auckland, Counties Manukau) is 1.17 compared to 1.68 in the nonfluoridated part of the same area. In contrast, in support of nonfluoridation, the mean DMFT score for the children in the nonfluoridated part of the whole of the South Island (Nelson- 158

3 159 Malborough, West Coast, Canterbury, South Canterbury, Otago, Southland) is 1.62 compared to 1.79 in the fluoridated part. 12 Within a particular area, differences associated with ethnicity, which may reflect socioeconomic status and disadvantage, may be present, e.g., in the fluoridated part of Waikato 26.93% of Maori children are caries free compared to 34.60% of those classified as Other (non-maori, non-pacific Islander); in the nonfluoridated part of Waikato 24.90% of Maori children are caries free compared to 34.60% of those classified as Other. 12 The information now available on fluoride toxicity indicates that a focus on Stage III skeletal fluorosis in no longer appropriate, and that consideration needs to be given to a variety of areas including arthritis, bone cancer and fracture, brain function including pineal function (which is involved with the control of the onset of sexual maturity in females), fertility, glucose tolerance (impaired in Type II diabetes), and thyroid function. 13 When an adequate safety margin is allowed for in those who are most susceptible to toxicity, such as the newly born, and those with low iodine levels, impaired renal function, or higher levels of fluid intake, no room is left for adding additional fluoride to water. However, despite so much clear scientific evidence that water fluoridation is neither effective nor safe and therefore should be abandoned, some authorities, including the New Zealand Ministry of Health Manatü Hauora (in New Zealand government agencies have bilingual names in English and Maori), are encouraging an expansion of fluoridation. In seeking to understand the reasons for the divergence between current scientific theory and public health practice I have found the work of Thomas Kuhn in The Structure of Scientific Revolutions, 1962, to be relevant. 14 He explored what was necessary for scientists to make a paradigm shift and found that many could not make the change. He found that Nicolaus Copernicus and Isaac Newton were slow to make converts, Joseph Priestley never accepted the oxygen theory, and Lord Kelvin rejected the electromagnetic theory and at first pronounced X- rays to be an elaborate hoax. Similar comments have been made by others. Charles Darwin wrote in Origin of Species: Although I am fully convinced of the truth of the views given in this volume under the form of an abstract, I by no means expect to convince experienced naturalists whose minds are stocked with a multitude of facts all viewed, during a long course of years, from a point of view directly opposite to mine. It is so easy to hide our ignorance under such expressions as the plan of creation, unity of design, &c., and to think that we give an explanation when we only restate a fact. Any one whose disposition leads him to attach more weight to unexplained difficulties than to the explanation of a certain number of facts will certainly reject my theory. A few naturalists, endowed with much flexibility of mind, and who have already begun to doubt on the immutability of species, may be influenced by this volume; but I look with confidence to the future, to young and rising naturalists, who will be able to view both sides of the question with impartiality. Whoever is led to believe that species are mutable will do good service by conscientiously expressing his conviction; for only thus can the load of prejudice by which this subject is overwhelmed be removed. Leo Tolstoy maintained: I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they 159

4 160 have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives. Max Planck, sadly remarked: A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. It has been said that Science advances funeral by funeral. Kuhn considered that, rather than taking these observations to indicate that scientists were frail humans who could not admit their errors even when confronted with strict proof, in these matters, neither proof nor error was at issue. The transfer of allegiance from paradigm to paradigm was a conversion experience that could not be forced. Lifelong resistance, particularly from those with productive scientific careers, was not a violation of scientific standards but reflected the nature of scientific research itself. The source of the resistance was the assurance that the older paradigm would ultimately solve all its problems and, although this assurance at times appeared stubborn and pigheaded, it was what made normal puzzle-solving science possible. Normally scientific research occurs within a particular paradigm without the paradigm being questioned or an awareness that other paradigms may exist. To ask a scientist in such a setting if a new paradigm is needed is like asking a fish to describe water. The origin of the process whereby outmoded paradigms are clung to appears to lie in the receptiveness shown by many students to accept from their teachers what they regard as facts, rather than assistance in learning to think for themselves. Learning to think for oneself, rather than just accepting the opinions of authorities was a central feature of the renaissance and should be one of the goals of a university education. Galileo noted: In questions of science, the authority of a thousand is not worth the humble reasoning of a single individual. In a similar vein, Bertrand Russell observed: It is not the function of the university to cram the heads of students with as many facts as can be squeezed in. Its proper task is to lead them into habits of critical examination and an understanding of canons and criteria which bear on all subject matters. Cardinal Wolsey, , advanced: Be very careful what you put in that head, because you will never, ever get it out. Thus the origin of this reluctance to adopt new models may lie in the primacy given in the brain to early educational experiences, the acceptance of material on the basis that it was given by a trusted authority, and the rewards that have been experienced, even if only partially, when working with the old paradigm. The process whereby change eventually does occur was described by the German philosopher Arthur Schopenhaur who submitted: All truth passes through three stages: first it is ridiculed, second it is violently opposed, third it is accepted as being self-evident. Something of this is seen in the negative response to the discovery by Ignaz Semmelweis that puerperal fever was prevented by hand washing with chlorinated lime between autopsy work and the examination of women in childbirth labour. Similarly, George Bernard Shaw declared: All great truths begin as blasphemies. Albert Einstein asserted: Great thinkers have always encountered violent opposition from mediocre minds. Howard Aitken contended: Don t worry about people stealing your ideas. If your ideas are that good, you ll have to ram them down people s throats. 160

5 161 Thomas Kuhn concluded that techniques of persuasion were more important in changing paradigms than the documentation of proof and the demonstration of error. If a paradigm is ever to triumph it must gain some first supporters people who will develop it to the point where hardheaded arguments can be produced and multiplied. Then, as more scientists are converted, the exploration of the new paradigm may continue until, at last, only a few elderly hold-outs remain, and a new scientific community reforms as a single group. However, embracing a new paradigm at an early stage must often be done on faith that the new paradigm will succeed with the many large problems that confront it, knowing only that the older paradigm has failed with a few. Kuhn viewed the transfer of allegiance from a widely-held paradigm to one that contradicts it as a conversion experience that cannot be forced. An example of a conversion experience is given by Saul of Tarsus who spent years persecuting Christians but after belatedly seeing the light, while travelling on the road to Damascus, changed his name to Paul and began to promote Christianity. Thus a conversion experience, rather than a logical analysis of information, may be involved in accepting a new paradigm on fluoridation. To make a decision about whether a particular paradigm has outlived its usefulness requires a detailed examination of the evidence. As suggested by Arthur Schopenhaur, pointers for where to look for an outmoded paradigm are the presence of ridicule and violent opposition. These have characterized the fluoridation debate. I am suggesting that behind the reluctance, to move from a model for dental health involving the systemic administration of fluoride to one based on sound nutrition and dental care, may lie strong forces involving scientists doing their work within a restricted conceptual framework and being unable to take a wider view, to question authority, and to think for themselves whether their paradigm is still the most appropriate one. To aid the recognition and discussion of this process, by which those seeking knowledge are slow to see the light, bearing in mind the maxim that there are none so blind as those that will not see, a new descriptive term is proposed tardive photopsia. Tardive refers to being slow, opsia to seeing, and photo to light. It is not being suggested that tardive photopsia is a disease but rather that a situation is present in which unconscious processes or defence mechanisms are acting to preserve the status quo and impairing the capacity to evaluate new data. Just as children may be better able to deal with emotions and fears by playing with toys or hearing stories about witches or animals than by talking about what they are personally experiencing, so being able to give a name to a phenomenon may assist with seeing a particular situation in a more detached objective manner and make it easier to analyze what is happening. There are alternative ways to describe the unwillingness to face the facts of a situation. Andrijia Stamper, MD, a leader in Social Medicine and International Health, who played a critical role in the planning for the World Health Organization, pointed out a health deficit and stated in 1919, Of this deficit we are not aware because our eyes are blind and our ears deaf to it. 15 The term tardive photopsia is a label to describe this phenomenon of being blind to a particular problem because of cognitive obstacles, of being unaware because our eyes are blind and our ears deaf to it. The concept of tardive photopsia applies to scientists working in a particular paradigm. It would not be applicable to nonscientists whose job description includes promoting fluoridation or to those who have commercial interests in the sale or disposal of products or industrial waste containing fluoride. 161

6 162 Thus the continued promotion by scientists of fluoridation in 2006, when the practice no longer has scientific evidence to support it, may be seen as an example of tardive photopsia. Bruce MB, ChB, DPM, FRANZCP Managing Editor, Fluoride 727 Brighton Road, Ocean View Dunedin 9035, New Zealand REFERENCES 1 Anderson M. Shakespeare by another name: a biography of Edward de Vere, Earl of Oxford, the man who was Shakespeare. New York: Gotham Books; Burgstahler AW, Limeback H. Retreat of the fluoride-fluoridation paradigm [editorial]. Fluoride 2004;37: Colquhoun J. The decline in primary tooth decay in New Zealand before the use of fluorides. Fluoride 1988;21: Neurath C. Tooth decay trends for 12 year olds in nonfluoridated and fluoridated countries. Fluoride 2005;38: Teotia SPS, Teotia M. Dental caries: a disorder of high fluoride and low dietary calcium interactions (30 years of personal research). Fluoride 1994;27: Birkeland JM, Ibrahim YE, Ghandour IA, Haugejorden O. Severity of dental caries among 12-year-old Sudanese children with different fluoride exposure. Clin Oral Investig 2005;9: [abstract in Fluoride 2005;38:170.]. 7 Schuld A. Is dental fluorosis caused by thyroid hormone disturbances? [editorial]. Fluoride 2005;38: Komarek A, Lesaffre E, Harkanen T, Declerck D, Virtanen JI. A Bayesian analysis of multivariate doubly-interval-censored dental data. Biostatistics 2005;6: Backer Dirks O. The benefits of water fluoridation. Caries Res 1974;8 Suppl 1: Whelton H. Overview of the impact of changing global patterns of dental caries experience on caries clinical trials. J Dent Res 2004;83 Spec No C:C Armfield JM, Spencer AJ. Consumption of nonpublic water: implications for children s caries experiences. Community Dent Oral Epidemiol 2004;32: [abstract and comments by Dr Mark Diesendorf in Fluoride 2004;37:316-7]. 12 Ministry of Health Manatü Hauora, New Zealand Health Strategy DHB Toolkits [homepage on the Internet]. Wellington; Ministry of Health; c2006 [updated 2006 April; cited 2006 Aug 18]. Available from click on Oral Health, then Health Status, then Download data from Doull J, Boekelheide K, Farishian BG, Isaacson RL, Klotz JB, Kumar JV, Limeback H, Poole C, Puzas JE, Reed N-MR, Thiessen KM, Webster TF, Committee on Fluoride in Drinking Water, Board on Environmental Studies and Toxicology, Division on Earth and Life Studies, National Research Council of the National Academies. Fluoride in drinking water: a scientific review of EPA s standards [book on the Internet, the print version is forthcoming]. Washington, DC: The National Academies Press; [cited 2006 Aug 24, 467 p.]. Available for purchase online at: 14 Kuhn TS. The structure of scientific revolutions. 2nd ed. Neurath O, editor-in-chief; Carnap R, Morris C, associate editors. International encyclopedia of unified science. Vol 2, No. 2. Chicago: The University of Chicago Press; Stampar A. Voices from the past: on health politics. Am J Public Health 2006;96: [Originally published in Jugoslavenska njiva 1919;29-31:1-29 [in Hungarian]. Republished in English in: Grmek MD, editor; Halar M, translator. Revised by Waring LF. Serving the cause of public health: selected papers of Andrija Stampar [Izabrani clanci Andrije Stampara]. Monograph series, no. 3. Zagreb, Yugoslavia: Andrija Stampar School of Public Health, Medical Faculty of the University of Zagreb; p Copyright 2006 International Society for Fluoride Research Office: 727 Brighton Road, Ocean View, Dunedin 9035, New Zealand.