DEFLUORIDATIO N & AN UPDATE ON

Index
1 Introduction Methods available for defluoridation 2 - changing the water supply - ion exchange process - addition of chemicals 3 4 5 6 7 8 9 10 Practical experience of defluoridation Nalgonda technique Update on fluorosis Overall prevalence in India Overall prevalence in TamilNadu Antifluoridation Fluoride Bomb Conclusion 6 8 12 13 14 16 18 23 3 2

INTRODUCTION
Dental caries decreases but dental fluorosis increases as the concentration of fluoride in drinking water increases. Knowledge that excess level of fluoride in drinking water is related to the occurrence of dental fluorosis precedes the unravelling of the fluoride and caries relationship. High levels of dental fluorosis are disfiguring and constitute a public health problem such that drinking water facilities in some countries include upper limits for fluoride concentration. The US Public Health Services (1962) Drinking Water Standards list optimum fluoride concentration and upper control limits, which depend on the annual, mean maximum daily temperature. At that time, US Public Health Services estimated that about 4.2 million people lived in 1142 communities served by public health water supplies that exceeded the upper control limit for fluoride content. Many states in India have ground waters between 1 and 5 mg F/l and in some areas, fluoride concentration exceeds 21 mgF/l. High fluoride levels of more than 4 PPM are found in Punjab, Haryana, Rajasthan, Gujarat, Madhya Pradesh, Andhra Pradesh, TamilNadu. The Ministry of Health, Govt. of India have prescribed 1mg/l and 2mg/l as the permissive and excessive limits respectively. The Indian Standard Specification for drinking water gives a desirable limit of 0.6 1.2mg/l. (Indian Standard Institute, 1983). It was estimated in 1980 that 2240 villages or communities with a population of nearly 2 million appeared to be exposed to high fluoride levels that may require defluoridation.

Water defluoridation is defined as the downward adjustment of fluoride ion concentration in a public water supply so that the level of fluoride is maintained at the normal physiological level of 1 PPM to prevent dental caries with minimum possibility of causing dental fluorosis. The most obvious way of reducing exposure to water borne fluorides is to change the water supply to one containing an acceptable level of fluoride. Most other methods involve chemical or physiochemical removal of fluoride. These have been reviewed by Moller (1988) and with specific reference to India by Tewari and Goyal (1986). METHODS AVAILABLE FOR DEFLUORIDATION: Changing the water supply Based upon ion exchange process or adsorption Based on addition of chemicals to water during treatment Based upon ion exchange process or adsorption: Materials used in contact beds are: - processed bone - natural or synthetic tricalcium phosphate - hydroxy apatite - magnesia - activated alumina - activated carbon - ion exchangers Processed bone: Dried and crushed natural bone and bone char (dried and crushed bone heated to 6000C for 20 mins) are efficient removers of fluoride.

Later is preferred since bacterial contamination is reduced and taste is improved compared with natural bone. Bone char can be regenerated with caustic soda. It should be noted that the use of bone is unacceptable in some religious groups. A 3:1 mixture of bone char and charcoal has been used in Thailand and may be especially useful for household units. Hydroxyapatite: The affinity of fluoride for hydroxyapatite is an important reason for fluoride anticaries effect and is used as a method for defluoridation. Powdered hydroxyapatite is effective alone or in combination with tricalcium phosphate. Activated alumina: Mainly aluminium oxide investigated in the USA (Horowitz, Maier and Thompson, 1964) and India (Bulusu and Nawlakhe, 1988). Other methods such as reverse osmosis and electrolysis, although effective are too expensive to consider further. Activated carbon: This is produced from heated and ground wood, paddy husks, coconut fibre and other carboniferous waste. It is most effective when pH is low, but this is disadvantageous as the pH of the water then has been raised to make it acceptable for consumption. Lime and aluminium: Lime and aluminium sulphate both have a high affinity for fluoride and can be used for removal of excess fluoride from water either alone or in combination. Both lime and aluminium have disadvantages. First, control of pH and alkalinity is crucial when lime is used, and the method is only reasonable when removal of both hardness and fluoride is required. Secondly, dosage with aluminium has to
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be carefully controlled so as to allow excess levels of residual aluminium. The combined use of lime and aluminium is the central feature of the Nalgonda Technique which was developed at the Indian NEERI at Nagpur in 1974. It was developed for medium size communities but is adaptable down to village level. Magnesium oxide has been used as an alternative to calcium oxide, and aluminium chloride is sometimes used together with aluminium sulphate. Opinaya, Pameiyer and Gron(1987) investigated the possibilities of using magnesium oxide or bone meal to defluoridate Kenyan drinking water. MgO and bone meal are readily available and inexpensive in Kenya, where water fluoride levels exceed 9ppm. Both removed fluoride, but reaction time was faster with bone meal than with magnesium oxide, and the taste of the water treated with bone meal was also better. Ion exchange resins: These are commercially produced resins and are expensive and uneconomical in most circumstances. Taste of the treated water is sometimes poor. A number of these resins have been proposed. (Tewari and Goyal, 1986; Moller, 1988) Egs. of those investigated are: Polystrene resins Strongly basic quarternary ammonium type resins Sulphonated saw dust impregnated with aluminium Defluoron 1 Defluoron 2

Ion exchange resins:

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Anion exchange resins: Polysterene ion exchange resins in general and strongly basic quaternary ammonium type resin in particular Tulsion A-27, Deacodite FF(1 P) and Lawatit MIH 59.

Cation exchange resins: - Defluoron 1 sulphonated saw dust impregnated with 2% alum solution - Carbion good durability. Can be used on sodium and hydrogen cycles - Magnesia removes excess F (Ph of water is 10 or more acidification or recarbonation necessary) - Defluoron 2 - 1968. Sulphonated coal and works on Al cycles Based upon addition of chemicals to water during treatment: Chemical treatment methods include: - use of lime either alone or with magnesium salts - aluminium salts either alone or in combination with a coagulant air PRACTICAL EXPERIENCE IN DEFLUORIDATION: CHANGE IN WATER SUPPLY: When a new pipeline was established from Carpenter Springs to the village of Oakley, Idaho, USA in 1925, Mckay (1933) reported a dramatic reduction in the prevalence of brown stained teeth. 5 years later, Dean, Mckay and Elove (1938) reported a reduction in the mottled enamel in children, 10 years after the water supply of the town of Bauxite, Arkansas was changed and one year later, similar results were noted in South Dakota. However, replacement or dilution of a community water supply is not always practical or feasible. Partial replacement was described by Gerrie and Kehr (1957) where dental fluorosis was prevented by children using low fluoride bottled water.
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Britton, South Dakota, USA: In South Dakota, USA a defluoridation plant using synthetic hydroxyapatite became operational, which reduced the fluoride ion concentration to 3-6ppm only. Hence, it was closed 4 years later. When bone char was used, it reduced the fluoride level to 2.5ppm and later to 1.6ppm. Over a period of 16 years, the level of fluorosis fell from 100% to 29% of the children being affected. Barlett, Texas, USA: The fluoride level in water was 8ppm in USA. Defluoridation plant was installed by the USPHS. This used activated alumina in an insoluble granular form and reduced the fluoride level from 8ppm to 1 ppm. Prevalence of fluorosis in Barlett children fell from 96% in 1954 to 18% in 1964. India: India has extensive areas of endemic fluorosis. A pilot plant using anion exchange resins (carbion and defluoron::8:1) commenced at Gangapur, Rajasthan. Aluminium solution was used as the regenerant, but the solution was unsuccessful as most of the defluoron 1 was washed out. To overcome these problems, defluoron 2 was developed in 1968. Defluoron 2 sulphonated coal using aluminium solution as regenerant. Life of the medium 2 to 4 years

Tewari and Goyal (1986) reported that defluoron 2 was successful in removing fluorides, but regeneration and maintenance of the plant required skilled operator which was not readily available. In response to this drawback, NEERI developed the Nalgonda technique. Nalgonda District is a district in Andhra Pradesh. It has a population of 3,247,982 of which 13.32% is urban as of 2001. Its name is derived from two telugu words Nalla (Black) & Konda (Hills) i.e. Black Hills. NALGONDA TECHNIQUE: NEERI National Environmental Engineering Research Institute Process for removal of excess fluoride in ground water by using Nalgonda Technique By this method, safe drinking water with fluoride content within permissible limits of 1.5 mg/l for domestic and community use can be supplied. Salient features of process/technology: Excess fluoride in drinking water causes skeletal and dental fluorosis. This water can be purified at domestic and community levels. The process comprises addition of aluminum salts, lime and bleaching powder to the raw water followed by flocculation, sedimentation and filtration. The domestic level treatment is performed in a bucket or any plastic container. For community level, fill and draw type plants are used with capacity upto 400ml/day. Raw materials: High fluoridated raw water

Alum Lime Bleaching powder Domestic defluoridation filters: Stainless steel candle filters adopting Nalgonda technique. Equipment water filter of any size and make, fitted with candle filters and additional mixing device which can be used as domestic defluoridation filters. Community Level Defluoridation: Equipment and machinery required are setting tank, flash mix and pump, flocculator, rapid gravity sand filter and disinfection unit. Mechanism Of Defluoridation: Rapid mix Flocculation Sedimentation Filtration Operation and maintenance: Operated and maintained by individual household 22 l of fluoridated water = 20 l of defluoridated water 22l of test water upper chamber add reqd. dose of aluminium salt solution Mix rapidly 30 to 60 secs 10 to 20rpm coagulant rapidly and uniformly dispersed tiny flocs formed Slow mixing 10 to 15 mins. 2 to 4 rpm. Flocculated water settle and filter through fullers earth candles overnight. Treated water 6AM 1PPM F or less Filter washed daily before next filling.
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Package pump installed on hand pump schemes costing Rs. 1.6 lacs 250 population Requires skilled operator and chemicals 50 SS filters Rs. 35,000 Advantages: Low cost of investment Low cost of maintenance Salient features: No regeneration of media No handling of caustic acids and alkalies Only requires readily available chemicals used in conventional municipal water treatment Adaptable to domestic use Simplicity of design, construction, operation and maintenance Highly efficient removal of fluoride from 1.5 to 20 mgF/l to desirable levels. Little wastage of water and least disposal problem Needs minimum of mechanical and electrical equipment No energy except muscle energy for domestic equipment Indications for adopting nalgonda technique: Absence of acceptable, alternate low fluoride source within transportable distance Total dissolved solids are below 1500mg/l; desalination may be necessary when the total dissolved solids exceed 1500mg/l Raw water fluoride ranging from 1.5mgF to 20mgF/l. Cost effectiveness:
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Minimum economic unit size: 1. Domestic level: Capacity 25l/batch Cost Rs. 400 2. Community level: Capacity 400 l Cost Rs. 5 lakhs The cost of water defluoridated using the Nalgonda technique is about 1.5 to 3 times the cost of the untreated water, but it is likely to much cheaper than transporting water over long distances. (Bulusu, 1988) A defluoridation plant using Nalgonda technique was commissioned in the town of Kadiri, Andhra Pradesh in 1980 to treat water containing 4.1 to 4.8 mgF/l. During the first few years, the plant became a model of water treatment technology for defluoridation. The cost of treatment was calculated at 1rupee/m3. Subsequently, visitors reported that the operation and maintenance of the plant declined and this was confirmed by NEERI during two visits in 1984-86. These difficulties highlight the problem of maintenance and staffing.

UPDATE ON FLUOROSIS:

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The National Oral Health Survey and Fluoride Mapping of the Dental Council of India is the first ever national level epidemiological survey in the country, which was initiated in 2002. The scope of the survey was to collect information covering the following dimensions of oral health: Prevalence of oral health problems Fluoride levels in drinking water Eating habits affecting oral health Dental cleaning practices Awareness and knowledge of people on factors affecting oral health Treatment seeking behaviour of people for their oral health problems Dental fluorosis results from drinking water drawn from ground water sources containing a high fluoride content (more than 2ppm) over the period when teeth are in the process of development or mineralisation. The Deans index has been used in this study to record fluorosis status. Amount of water consumed and age when it is consumed are important factors which influence fluorosis. Fluorosis most frequently affects premolars and second molars. Since these teeth would have erupted at 12 and 15 years of age, these age groups assume the greatest importance for assessment of fluorosis status in the country. About 27% of the house holds in India use water with fluoride levels of 1.5ppm or more. Fluoride level in drinking water 1.5ppm or more - Few households in Delhi, Pondicherry and none in Chandigarh - 40-50% of households Gujarat, Karnataka, Maharashtra and UP

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- One quarter of households in Jammu & Kashmir, Kerala, TamilNadu & Haryana - About 10 or below % of households in remaining states and union territories OVERALL PREVALENCE IN INDIA: YOUNG CHILDREN (5 years): Overall 5% 2.2% (questionable cases were excluded) Severe form absent Moderate fluorosis 0.2% Very mild and mild 2% No marked gender related differentials Very mild and mild occurred both in urban and rural areas (rural>urban) Rural areas accounted for all of the moderate fluorosis 0.2% Fluorosis negligible or virtually absent Assam, Goa, Pondicherry, Jammu & Kashmir and TamilNadu. Many states 0.6 to 2.8% Moderate and severe form even rarer 12 years and 15 years: Overall: 10.2% and 9.9% 6% (questionable cases were excluded) Moderate form 0.8% Severe form 0.1%

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No gender differences Rural subjects marginally higher prevalence Haryana, UP, AP 12 year old children- severe fluorosis higher than the national average 35 44 & 65 74 years: 4.2% & 2.4% (exclusion of the questionable fluorosis) No gender differences Marginally more in rural areas Haryana and Gujarat above average prevalence of fluorosis. Overall, fluorosis very low prevalence in the country Moderate and severe fluorosis - <1% Very mild & mild not more than 5.1% in 12 & 15 year old children. Endemic fluorosis some pockets in some states localised and small PREVALENCE OF FLUOROSIS IN TAMILNADU: About 1/4ths of households in TamilNadu use drinking water with fluoride levels of 1.5ppm or more. This percentage is much higher in rural areas. The north region seems to have much higher levels of fluoride in water than other regions almost two thirds of the households had fluoride levels of more than 1.5ppm. 16% of the children are affected and mostly of the mild variety. This is cause of alarm. Rural areas are very highly affected compared to urban areas. Action needs to be taken to provide preventive measures and safe drinking water
EPIDEMIOLOGICAL STUDIES:

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Shivasankara AR, Shivaraja SYM, Hanumanth RS, et al (2000) studied the prevalence of skeletal and dental fluorosis among children of Kheru Thanda of Gulbarga, Karnataka, where the fluoride levels of water was 0.6 13.4ppm. 89% - dental fluorosis 39% - skeletal fluorosis Serum levels of the children showed elevated levels of alkaline phosphatase, alanine phosphatase, aspartate phosphatase and decreased levels of total protein, albumin and potassium. Bardsen A (1999) did a systematic review to find out the risk periods associated with the development of dental fluorosis in maxillary permanent central incisors. He said that no specific period of enamel formation is singled out as the being the most critical for the development of dental fluorosis. The duration of fluoride exposure during the amelogenesis, rather than specific risk periods, would seem to explain the development of dental fluorosis in the permanent maxillary central incisor. Kirzloghu Z, Saglam AMS, Simsek S, et al (2005) did a study to compare the occlusal disharmonies among 332 preschool children in a high fluoride area with those of 332 children in a low fluoride area of Turkey. Results showed that in a high fluoride area, anterior cross bite was significantly higher whereas anterior openbite and anterior crowding were significantly lower compared with those of the low fluoride area. No significant gender differences were found. ANTIFLUORIDATION:

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Despite the immutable evidence supporting water fluoridation, its universal implementation has been vehemently opposed by anti-fluoridationists. Water fluoridation is perhaps the only public health intervention where implementation is decided by the popular vote and the outcome is usually unfavorable. Since 1945, adding fluoride to public water supplies has been fiercely debated. To this day communities have fluoridation pushed onto them, without citizens being properly informed. Of all the chemicals mixed with water to make it safe, hydrofluorosalicic acid is the only one added for medical reasons. Sodium Fluoride was not added to toothpaste until around the time water fluoridation became commonplace. Many reasons can be found to do away with fluoridation. Fluoride is not added to the water to make it safe, it is added for medical purposes. Fluoride is a poison, and is rated between Lead and Arsenic on the international toxcicity chart. If you still like Fluoride, then rest assured you can get all that you need from Crest or Colgate. Expecting mothers, young children, and the elderly can be placed in the group most likely to have adverse health effects from fluoridation. Opposition to water fluoridation refers to activism against the fluoridation of public water supplies. The controversy occurs mainly in English-speaking countries, as Continental Europe does not practice water fluoridation, although some continental countries fluoridate salt. At the recommended concentration of 0.7 1.2 mg/L (0.7 for hot climate, 1.2 in cool climates) the only apparent side-effect appears to be dental fluorosis, but those organizations and individuals opposed raise concerns that the intake is not

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easily controlled, and that children, small individuals, and others may be more susceptible to health problems. Those opposed also argue that water fluoridation - imposes ethical issues, - may cause serious health problems, - is not effective enough to justify the costs. Opposition to fluoridation has existed since its initiation in the 1940s. During the 1950s and 1960s, some opponents of water fluoridation also put forward conspiracy theories describing fluoridation as a communist plot to undermine public health. Sociologists have typically viewed opposition to water fluoridation as irrational, while critics of this position have argued that this rests on an uncritical attitude toward scientific knowledge. Bristolians Against Fluoridation are trying to stop the fluoridation of the Bristol public water supply. Fluoride is an accumulative poison that, according to many scientific studies, can cause some serious debilitating adverse effects to human health. Fluoridation has got to stop. It is harmful to health and a violation of human rights says Daniela D-Ronberg, spokesperson for the newly-formed Kapiti Fluoridation-free Campaign I am particularly worried that we are still allowing this when the American Health Authorities are advising that babies are getting too much fluoride through the normal tap water when making up baby formula. Fluoride cannot be boiled out. Studies in New Zealand that looked at dental fluorosis (the first outward sign of fluoride poisoning) showed that 30% of children in fluoridated areas had some form of dental fluorosis as compared with only 15% in non-fluoridated areas.

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Dentists begin anti-fluoridation campaign??? Irish Dentists Opposing Fluoridation (IDOF) is a support group for dental professionals who wish to express their opposition to the addition of fluoride to drinking water. According to the group, fluoridation is 'undemocratic, unethical and unsafe'. "Most dentists would refuse to prescribe for a patient he/she has never met, whose medical history he/she does not know, a substance which is intended to create bodily change for the rest of their life. This is the water fluoridation ethos", IDOF said. In addition, the group intends to provide an education database of the current scientific literature showing, what it claims is, the health and dental damage caused by fluoride/fluoridation. FLUORIDE BOMB: Some fifty years after the United States began adding fluoride to public water supplies to reduce cavities in childrens teeth, declassified government documents are shedding new light on the roots of that still controversial public health measure, revealing a surprising connection between fluoride and the dawning of the nuclear age. Today, two thirds of U.S. public drinking water is fluoridated. Many municipalities still resist the practice, disbelieving the governments assurances of safety . Since the days of World War II, when this nation prevailed by building the worlds first atomic bomb, U.S. public health leaders have maintained that low doses of fluoride are safe for people, and good for childrens teeth. That safety verdict should now be re-examined in the light of hundreds of once-secret

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World War II documents obtained by Griffiths and Brysonincluding declassified papers of the Manhattan Project, the U.S. military group that built the atomic bomb. Fluoride was the key chemical in atomic bomb production, according to the documents. Massive quantities of fluoridemillions of tonswere essential for the manufacture of bomb-grade uranium and plutonium for nuclear weapons throughout the Cold War. One of the most toxic chemicals known, fluoride rapidly emerged as the leading chemical health hazard of the U.S. atomic bomb program both for workers and for nearby communities, the documents reveal. Other revelations include: Much of the original proof that fluoride is safe for humans in low doses was generated by A-bomb program scientists, who had been secretly ordered to provide "evidence useful in litigation" against defense contractors for fluoride injury to citizens. The first lawsuits against the U.S. A-bomb program were not over radiation, but over fluoride damage, the documents show. Human studies were required. Bomb program researchers played a leading role in the design and implementation of the most extensive U.S. study of the health effects of fluoridating public drinking waterconducted in Newburgh, New York from 1945 to 1956. Then, in a classified operation code-named "Program F," they secretly gathered and analysed blood and tissue samples from Newburgh citizens, with the cooperation of State Health Department personnel. The original secret versionobtained by these reportersof a 1948 study published by Program F scientists in the Journal of the American Dental Association shows that evidence of adverse health effects from fluoride was censored by the U.S. Atomic Energy Commission (AEC) -- considered the most powerful of Cold War agenciesfor reasons of national security.

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The bomb programs fluoride safety studies were conducted at the University of Rochester, site of one of the most notorious human radiation experiments of the Cold War, in which unsuspecting hospital patients were injected with toxic doses of radioactive plutonium. The fluoride studies were conducted with the same ethical mind-set, in which "national security" was paramount. The U.S. governments conflict of interestand its motive to prove fluoride "safe"has not until now been made clear to the general public in the furious debate over water fluoridation since the 1950s, nor to civilian researchers and health professionals, or journalists. The declassified documents resonate with a growing body of scientific evidence, and a chorus of questions, about the health effects of fluoride in the environment. Human exposure to fluoride has mushroomed since World War II, due not only to fluoridated water and toothpaste, but to environmental pollution by major industries from aluminum to pesticides: Fluoride is a critical industrial chemical. The impact can be seen, literally, in the smiles of our children. Large numbers of U.S. young peopleup to 80 percent in some citiesnow have dental fluorosis, the first visible sign of excessive fluoride exposure, according to the U.S. National Research Council. (The signs are whitish flecks or spots, particularly on the front teeth, or dark spots or stripes in more severe cases.) Less-known to the public is that fluoride also accumulates in bones "The teeth are windows to whats happening in the bones," explains Paul Connett, Professor of Chemistry at St. Lawrence (N.Y.) University. In recent years, pediatric bone specialists have expressed alarm about an increase in stress fractures among U.S. young people. Connett and other scientists are concerned that fluoride
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linked to bone damage by studies since the 1930s -- may be a contributing factor. The declassified documents add urgency: Much of the original proof that low-dose fluoride is safe for childrens bones came from U.S. bomb program scientists, according to this investigation. Now, researchers who have reviewed these declassified documents fear that Cold War national security considerations may have prevented objective scientific evaluation of vital public health questions concerning fluoride. Information was buried," concludes Dr. Phyllis Mullenix, former head of toxicology at Forsyth Dental Center in Boston, and now a critic of fluoridation. Animal studies Mullenix and co-workers conducted at Forsyth in the early 1990s indicated that fluoride was a powerful central nervous system (CNS) toxin, and might adversely affect human brain functioning, even at low doses. (New epidemiological evidence from China adds support, showing a correlation between low-dose fluoride exposure and diminished I.Q. in children.) Mullenixs results were published in 1995, in a reputable peer-reviewed scientific journal. During her investigation, Mullenix was astonished to discover there had been virtually no previous U.S. studies of fluorides effects on the human brain. Then, her application for a grant to continue her CNS research was turned down by the U.S. National Institutes of Health (NIH), where an NIH panel, she says, flatly told her that "fluoride does not have central nervous system effects." Declassified documents of the U.S. atomic-bomb program indicate otherwise. An April 29, 1944 Manhattan Project memo reports: "Clinical evidence suggests that uranium hexafluoride may have a rather marked central nervous system effect.... It seems most likely that the F [code for fluoride] component rather than the T [code for uranium] is the causative factor." The memostamped "secret"is addressed to the head of the Manhattan Projects Medical Section, Col. Stafford Warren. Colonel Warren is asked to
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approve a program of animal research on CNS effects: "Since work with these compounds is essential, it will be necessary to know in advance what mental effects may occur after exposure... This is important not only to protect a given individual, but also to prevent a confused workman from injuring others by improperly performing his duties." On the same day, Colonel Warren approved the CNS research program. This was in 1944, at the height of the Second World War and the nations race to build the worlds first atomic bomb. For research on fluorides CNS effects to be approved at such a momentous time, the supporting evidence set forth in the proposal forwarded along with the memo must have been persuasive. The proposal, however, is missing from the files of the U.S. National Archives. "If you find the memos, but the document they refer to is missing, its probably still classified," said Charles Reeves, chief librarian at the Atlanta branch of the U.S. National Archives and Records Administration, where the memos were found. Similarly, no results of the Manhattan Projects fluoride CNS research could be found in the files. After reviewing the memos, Mullenix declared herself "flabbergasted." She went on, "How could I be told by NIH that fluoride has no central nervous system effects when these documents were sitting there all the time?" She reasons that the Manhattan Project did do fluoride CNS studies"that kind of warning, that fluoride workers might be a danger to the bomb program by improperly performing their dutiesI cant imagine that would be ignoredbut that the results were buried because they might create a difficult legal and public relations problem for the government." The author of the 1944 CNS research proposal was Dr. Harold C. Hodge, at the time chief of fluoride toxicology studies for the University of Rochester division of the Manhattan Project. Nearly fifty years later at the Forsyth
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Dental Center in Boston, Dr. Mullenix was introduced to a gently ambling elderly man brought in to serve as a consultant on her CNS research Harold C. Hodge. By then Hodge had achieved status emeritus as a world authority on fluoride safety. "But even though he was supposed to be helping me," says Mullenix, "he never once mentioned the CNS work he had done for the Manhattan Project." The "black hole" in fluoride CNS research since the days of the Manhattan Project is unacceptable to Mullenix, who refuses to abandon the issue. "There is so much fluoride exposure now, and we simply do not know what it is doing," she says. "You cant just walk away from this." Dr. Antonio Noronha, an NIH scientific review advisor familiar with Dr. Mullenixs grant request, says her proposal was rejected by a scientific peerreview group. He terms her claim of institutional bias against fluoride CNS research "farfetched." He adds, "We strive very hard at NIH to make sure politics does not enter the picture." CONCLUSION: It has been suggested that countries with excessive levels of fluoride ingestion, particularly where there is a risk of severe dental fluorosis, should maintain maximum fluoride level of 1.5mg/l as recommended by WHO water quality guidelines, although this objective is admittedly not always technically easy to achieve. REFERENCES: Amrit Tewari. Fluorides and dental caries Murray J J.The Prevention of Dental Disease. Second Edition. Oxford University Press

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Fejerskov O, Ekstrand J, Brian B.Burt. Fluorides in Dentistry. Second Edition. Munksgaard Publishers. Soben Peter. Essentials of Preventive and Community Dentistry. Third Edition. Arya Publishing House. Hiremath S S. Textbook of Preventive and Community Dentistry. First Edition. Reed Elsevier India Private Limited. Kirzloghu Z, Saglam AMS, Simsek S, et al. Occusal disharmonies of primary dentition in a high and low fluoride area of Turkey. Fluoride 2005; 38(1): 57-64. Bardsen A. Risk periods associated with the development of dental fluorosis in maxillary permanent central incisors: a meta analysis. Acta Odonto Scand 1999; 57: 247-256 Shivasankara AR, Shivaraja SYM, Hanumanth RS, et al. A clinical and biochemical study of chronic fluoride toxicity in children of Kheru Thanda of Gulburga District, Karnataka, India. Fluoride 2000; 33(2): 66-73. Fluoride and the Atom Bomb related?????? By kaylaosteen3 - Posted on May 11th, 2006. Fluoride, Teeth, and the Atomic Bomb by Joel Griffiths and Chris Bryson July 1997 National oral health survey and fluoride mapping. 2002 2003. India. Dental Council of India. New Delhi. 2004. National oral health survey and fluoride mapping. 2002 2003. Tamil Nadu. Dental Council of India. New Delhi. 2004. http://www.myspace.com/cheathamaware http://www.irishhealth.com/article.html?id=3129
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http://en.wikipedia.org/wiki/Opposition_to_water_fluoridation

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