Is fluoride toothpaste a health hazard? The Delhi-based Fluorosis Research and Rural Development Foundation would like us to believe that it is. The Foundation is stepping up its long-running battle against toothpaste makers and is demanding statutory warnings on fluoride toothpaste tubes.
The Foundation says it has amassed data that shows that Indian drinking water already has abnormally high fluoride levels. As a result, any extra fluoride is a health threat. The foundation intends to launch a campaign to amend the Drugs and Cosmetics Act of 1945. Through this amendment they want fluoride toothpaste tubes to sport a statutory warning to alert customers. But, the Mumbai-based Toothpaste Manufacturers Association (TMA) sees this as a smear campaign guaranteed to hit fluoridated toothpaste sales.
True, fluorosis is a health hazard. But remember that only 5 per cent of our population lives in high fluoride areas or the known endemic fluoride belts. And, most of these are rural areas where the majority of the population doesnt even use toothpaste, says a spokesman for the TMA. Why raise a shindig about putting a warning on fluoridated toothpaste tubes and cartons? Cigarette packets have warnings emblazoned on them. Has it stopped people from smoking? asks an executive in a multinational toothpaste manufacturing company.
These arguments make the anti-fluoride lobby see red. The human body can only tolerate a maximum level of 1 milligram of fluoride per litre of drinking water or 1 part per million (ppm) of fluoride. Sixteen states in India, including Delhi, get drinking water with fluoride contamination ranging from 2 to 39 ppm, says Dr A K Susheela of the Fluorosis Research and Rural Development Foundation. She adds, Studies show we ingest high levels of fluoride in our drinking water. Under these circumstances it is criminal to add to the dangers by selling fluoridated toothpaste in India. It should be banned. We should only use non-fluoridated toothpaste.
It may be naive to suggest that only rural areas have water with high fluoride content, or that every villager in India still uses neem twigs. Recently, the Central Pollution Control Board (CPCB), collected water samples from 250 sites in and around the Capital. It discovered that 37 per cent of the samples it had collected had excess fluoride.
Similarly, tests (using the Ion Selective Electrode Method) conducted by the Fluorosis Control Cell in the All India Institute of Medical Sciences, also detected high levels of contamination. Areas like Green Park, Jangpura, Lodhi Road, Palam Village and Sabzi Mandi in Delhi have water with fluoride contamination ranging from 1.30 to 39 ppm.
According to anti-fluoride lobbyists, dental and skeletal fluorosis is caused by high intake of fluoride through water, food (black tea, rock salt), toothpaste and inhaling contaminated air. There is scientific evidence that shows that continued use of fluoride for the prevention of dental carries leads to dental fluorosis a painful condition which has no treatment or cure.
Keeping these harmful effects in mind, scientists have warned that children below the age of seven should not be permitted to use fluoride toothpaste, says Dr AK Susheela who has worked in this field for over two decades.
In Sweden all toothpaste tubes and cartons carry the statutory warning: Children under 4 years should use toothpaste without fluoride. Thats what toothpaste tubes should sport in India as well, feel anti-fluoride activists. They also point out that it should be mandatory for all manufacturers to clearly indicate how much fluoride their product contains. That would give the customer the opportunity to make an informed decision. Presently, Close-up Renew with macrogranules, marketed by Hindustan Lever Limited, does not bother to mention whether it is fluoridated or non-fluoridated. At least, Pepsodent G and Pepsodent 2 in 1 say Foaming Fluoridated Toothpaste.
And consumers might think twice if they knew about a recent study conducted in Sweden. Pediatricians, Carl-Johan Spak and Jan Ekstrand from the Karolinska Institute conducted a study on 38 children. Their findings indicate that children have lower renal fluoride clearance rates than adults. This means a moderate impairment of the renal function could lead to increased retention of fluoride and affect bone formation.
An estimated 30 million people in India, many of them children, suffer from fluoride poisoning. Skeletal fluorosis is not easily recognisable until the disease is at an advanced stage. Patients complain about severe pain and rigidity in the hip region, back and joints. Over long periods the spine may become calcified, crippling the victim, says private practitioner, Dr Ramesh Aggarwal. In dental fluorosis, the tell-tale, brown-stained teeth typical of this condition, can only be cured by acid etching or capping.
Besides bone and dental disease, fluoride entry into the body can destroy the lining of the stomach and intestine, destroy muscle structure, muscle function, deplete muscle energy, cause fatigue, and persistent headaches. It can also block blood vessels, warns Dr Aggarwal.
But the Indian Dental Association (IDA) supports the sale of fluoride toothpaste. It is well documented that 1 mg of fluoride in a litre of drinking water results in good protection against dental carries. In the West, in fluoride-deficient areas, fluoride supplementation is actually recommended. The aim of this is to incorporate as much fluoride as possible in the developing enamel during tooth formation in early childhood.
Fluoride actually combines with tooth enamel to make it stronger and protect it against cavities, says Dr L K Gandhi, member of the Dental Council of India and former president of the Indian Dental Association.
The therapeutic window for this therapy seems to be rather narrow because a slight increase of the daily dose may lead to fluorosis. As a consequence, recommendations of fluoride supplementation have recently been lowered in many countries, counters Dr A K Susheela. She adds, Fluoride is a potentially dangerous chemical which should be eliminated from drinking water in the West where it is fluoridated. In India, it should be banned altogether from toothpaste and mouth rinses. We already have too much fluoride in our water.
The Fluorosis Research and Rural Development Foundation has provided its findings to consumer activist H D Shourie, who is the director of Common Cause. But multinational toothpaste manufacturers are unfazed by the prospect of public interest litigations. In India, both sides of the debate agree that fluoride levels of 1 ppm in drinking water can help prevent tooth decay, says an executive in Colgate-Palmolive.
The multinationals have faced battles over fluoride in other emerging countries. During the mid-1980s, young Kenyan dental health lecturer Firoze Manji, created hell for fluoride toothpaste manufacturers. Finally, Colgate general manager Nuri Murad took Manji to lunch at an expensive restaurant and offered to finance his research, donate a library and buy him a clinic.
Of course, the whole thing backfired: Manji talked to the press and made his research findings public. Very soon after this, the Kenyan health authorities banned fluoride toothpaste advertisements under the Pharmacy and Poisons Act of Kenya. No sooner was the ban imposed in Kenya, that multinational firms Boots and Beechams brought out non-fluoridated toothpaste for sale in Kenya.
In India, both fluoride and non-fluoride toothpaste are available. Colgate for instance, manufacturers plain Colgate Dental Cream which accounts for 45.6 per cent of the market share. Its fluoridated variant, Colgate Calciguard, accounts for 3.5 per cent of the market share. Similarly, Forhans created by New York-based dentist R J Forhan, has a non-fluoridated paste which has 4.2 per cent of the market share, as also a fluoridated variant which has 3.8 per cent market share. The National Environment Research laboratory, Nagpur and the Madras Dental College, have found that toothpaste sold in India contains 800 to 3,000 ppm of fluoride. The toothpastes low in fluoride are the Ayurvedic ones, says Dr A K Susheela.
Officially, it is a straightforward scientific problem: How much fluoride is too much? But the fluoride toothpaste debate in India has also raised a more complex and sensitive issue. To what extent do multinational companies influence local experts?
The debate in India also questions the use of western standards in the third world. Research in the Philippines has suggested that in hot, tropical climates where people drink more water, a lower fluoride level around 0.5 ppm is more appropriate. Research conducted in the United States may have no bearing on third world conditions, says Dr A K Susheela. What works in the United States will not necessarily work in India.
