Dispelling Common Misstatements on Fluoridation

This author refutes what Rick North had to say about the effects of fluoridation

OPINION -- In a recent Lund Report opinion piece on fluoridation, Rick North has provided a litany of false claims, misinformation, and misrepresented science, all of which bears correction. The majority of his claims are those commonly made by the New York anti-fluoridation group, "Fluoride Action Network" (FAN) with which North seems to have developed a close affiliation. The following is my point-by-point explanation of the fallacies of North's statements and claims. The length of this piece is indicative of the amount of time and effort it takes to properly address the myriad erroneous, unsubstantiated claims anti-fluoridationists can put forth in a few short paragraphs.

1. North: "But last year, Griffin’s paper was thoroughly rebutted by the Lo/Thiessen study, which calculated no such savings. It determined that Griffin underestimated actual fluoridation equipment, repair and employee expenses ($7-$9 per hour labor costs?) and omitted any costs for related health problems caused by fluoridation chemicals, such as treatment for fluorosis".


Kathleen Thiessen is a long time, outspoken fluoridation opponent with ties to the New York antifluoridationst group, Fluoride Action Network. Her confirmation bias was clearly demonstrated in her endorsement of a 2013 study by William Hirzy, the current paid lobbyist for FAN. Hirzy used data from his study to petition the EPA to recommend cessation of use of HFA as a fluoridating substance. When EPA reviewers looked at Hirzy's data, however, they quickly determined that Hirzy had made a 70-fold error in his calculations. When correcting for these errors, the reviewers found Hirzy's data to demonstrate the exact opposite of what he had concluded. Upon learning of his error and rejection of his petition, Hirzy stated that he was "embarrassed", as well he should have been. The EPA record of Hirzy's petition and response by the EPA may be viewed:


Prior to the EPA review of Hirzy's data, Thiessen had been asked by a news writer to comment on his study. Her response?

"I think this is a reasonable study, and that they haven't inflated anything," said Kathleen Thiessen, a senior scientist at SENES Oak Ridge Inc., a health and environmental risk assessment company."


A complete list of the contents of fluoridated water at the tap, including precise amounts of any detected contaminants, and the EPA maximum allowable levels of safety, may be found:


B. Thiessen discredited her own study when she lumped all dental fluorosis into one category and included costs for expensive dental work to "repair" the effects of that dental fluorosis, as being a cost of fluoridation. The only dental fluorosis in any manner attributable to optimally fluoridated water is mild to very mild, a barely detectable effect which causes no adversity on cosmetics, form, function, or health of teeth. As peer-reviewed science has demonstrated mildly fluorosed teeth to be more decay resistant, many consider this effect to not even be undesirable, much less adverse. Mild dental fluorosis requires no dental treatment.

-----The Association Between Enamel Fluorosis and Dental Caries in U.S. Schoolchildren

Hiroko Iida, DDS, MPH and Jayanth V. Kumar, DDS, MPHhttp://jada.ada.org/content/140/7/855.long

C. There are no "fluoridation chemicals" ingested as a result of fluoridation, as North erroneously implied. The most commonly utilized substance to fluoridate water systems is hydrofluorosilic acid (HFA). Due to the pH of drinking water (~7), HFA is immediately and completely hydrolyzed (dissociated) upon addition to that water. After that point HFA no longer exists in that water. It does not reach the tap. It is not ingested. Therefore, it is not possible for "fluoridation chemicals" to cause any "related health problems". The only substances ingested as a result of fluoridation are fluoride ions, identical to those "naturally occurring" fluoride ions which have always existed in water, and trace contaminants in barely detectable amounts far below EPA mandated maximum allowable levels of safety. Finney, et al. conclusively demonstrated the complete hydrolysis of fluorosilicated in drinking water in his 2006 paper:

----Reexamination of Hexafluorosilicate Hydrolysis by F NMR and pH Measurement

William F. Finney, Erin Wilson, Andrew Callender, Michael D. Morris, and Larry W. Beck Environmental Science and Technology/ Vol 40, No. 8, 2006

D. In cherry-picking Thiessen's study, North ignores the volume of peer-reviewed science which clearly demonstrates the cost-effectiveness of fluoridation:

1) For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs.

------“Cost Savings of Community Water Fluoridation,”

U.S. Centers for Disease Control and Prevention, accessed on March 14, 2011 at  http://www.cdc.gov/fluoridation/fact_sheets/cost.htm.

2) A Texas study confirmed that the state saved $24 per child, per year in Medicaid expenditures for children because of the cavities that were prevented by drinking fluoridated water.

------ “Water Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid),

Department of Oral Health Website (2000), www.dshs.state.tx.us/dental/pdf/fluoridation.pdf,

3) A 2010 study in New York State found that Medicaid enrollees in less fluoridated counties needed 33 percent more fillings, root canals, and extractions than those in counties where fluoridated water was much more prevalent. As a result, the treatment costs per Medicaid recipient were $23.65 higher for those living in less fluoridated counties.

-------------Kumar J.V., Adekugbe O., Melnik T.A., “Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation Under Contemporary Conditions,”

Public Health Reports, (September-October 2010) Vol. 125, No. 5, 647-54.

------------The original figure ($23.63) was corrected in a subsequent edition of this journal and >clarified to be $23.65. See: “Letters to the Editor,”

Public Health Reports (November- December 2010), Vol. 125, 788.

4). Researchers estimated that in 2003 Colorado saved nearly $149 million in unnecessary treatment costs by fluoridating public water supplies—average savings of roughly $61 per person.

------O’Connell J.M. et al., “Costs and savings associated with community water fluoridation programs in Colorado,”

Preventing Chronic Disease (November 2005), accessed on March 12, 2011 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/.

5) A 1999 study compared Louisiana parishes (counties) that were fluoridated with those that were not. The study found that low-income children in communities without fluoridated water were three times more likely than those in communities with fluoridated water to need dental treatment in a hospital operating room.

-------“Water Fluoridation and Costs of Medicaid Treatment for Dental Decay – Louisiana,


Morbidity and Mortality Weekly Report, (U.S. Centers for Disease Control and Prevention), September 3, 1999, accessed on March 11, 2011 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4834a2.htm.

6) By reducing the incidence of decay, fluoridation makes it less likely that toothaches or other serious dental problems will drive people to hospital emergency rooms (ERs)—where treatment costs are high. A 2010 survey of hospitals in Washington State found that dental disorders were the leading reason why uninsured patients visited ERs.

-------Washington State Hospital Association, Emergency Room Use (October 2010) 8-12,

http://www.wsha.org/files/127/ERreport.pdf, accessed February 8, 2011.

7) "This study of Colorado’s young children provides evidence that may be immediately applicable to policy making within and beyond the state. Expansion of community water fluoridation (1.1) was found to be cost-saving even in an environment where most of the population receives fluoridated water, and additional savings are projected from reduced treatment and retreatment costs for children older than 6 years who are not considered in the model."

----A simulation model for designing effective interventions in early childhood caries Hirsch GB, Edelstein BL, Frosh M, Anselmo T.. Prev Chronic Dis 2012;9:110219.

DOI: http://dx.doi.org/10.5888/pcd9.110219External Web Site Icon.

8) Scientists who testified before Congress in 1995 estimated that national savings from water fluoridation totaled $3.84 billion each

------Michael W. Easley, DDS, MP, “Perspectives on the Science Supporting Florida’s Public

Health Policy for Community Water Fluoridation,”

Florida Journal of Environmental Health, Vol. 191, Dec. 2005, accessed on March 16, 2011 at http://www.doh.state.fl.us/family/dental/perspectives.pdf.

2. North: "Only 23% of the state is fluoridated, ranking us 48th in the country. Government and the American Dental Association consistently try to blame high cavity rates on lack of fluoridation."


Neither the ADA, the government, nor any other knowledgeable source has blamed high cavity rates solely on lack of fluoridation. Countless peer-reviewed studies have clearly demonstrated the effectiveness of fluoridation in preventing dental decay, however fluoridation is, obviously, but one of the myriad factors involved in cause and prevention of dental decay. The lack of fluoridation most certainly will keep cavity rates higher than they would be with fluoridation, but this initiative is not the only factor involved in dental decay, and has never been promoted or expected to completely eliminate the problem.

3. North: "To recap, virtually no such causation, or even correlation, exists:"

"Fluoridation: 48th"

"Childhood oral health: 29th"

"Adult oral health: 10th"


Such a superficial comparison ignores all other factors involved in dental decay, and assumes that the figures would not be worse in the absence of the 23% fluoridation.

5. North: 'In 1990, the largest U.S. study by the National Institute of Dental Research found that children drinking fluoridated water averaged only about half a cavity less than those drinking unfluoridated water."


A. The NIDR study did not make these findings. The findings quoted by North are the interpretation of that 1988 NIDR data by fringe activist/antifluoridationist, John Yiamouyiannis, also an antivaxxer who proclaimed that HIV does not cause AIDS. Yiamouyiannis died in 1995 while seeking Laetrile treatment in Mexico for his colorectal cancer.

Yiamouyiannis' study in which he reached these conclusions, was published only in "Fluoride", the publication of the antifluoridationist group "International Society For Fluoride Research". This publication is not even indexed in the extensive PubMed database of respected scientific publications.

----Water Fluoridation & Tooth Decay: Results from the 1986-1987 National Survey of US Schoolchildren


Volume 23, No. 2; April, 1990; pp 55-67

by John A. Yiamouyiannis, Ph.D.

B. In a peer-reviewed study utilizing the 1988 NIDR data, Brunelle and Carlos found:

"The decline in dental caries in U.S. schoolchildren, first observed nationwide in 1979-1980, was confirmed further by a second national epidemiological survey completed in 1987. Mean DMFS scores in persons aged 5-17 years had decreased about 36% during the interval, and, in 1987, approximately 50% of children were caries-free in the permanent dentition. Children who had always been exposed to community water fluoridation had mean DMFS scores about 18% lower than those who had never lived in fluoridated communities. When some of the "background" effect of topical fluoride was controlled, this difference increased to 25%. The results suggest that water fluoridation has played a dominant role in the decline in caries and must continue to be a major prevention methodology."

-----Recent trends in dental caries in U.S. children and the effect of water fluoridation.

Brunelle JA1, Carlos JP. J Dent Res. 1990 Feb;69 Spec No:723-7; discussion 820-3.

C. In a 2005 paper Pollick addressed the misuse of Brunelle and Carlos results by Yuamouyiannis and other antifluoridationists:

"This study [Brunelle and Carlos] is routinely read superficially by folks eager to discount fluoridation. The paper can be quoted as averages to minimize the effect because the 0.6 surface is the effect averaged over both age and geography. 5 year olds have only 1 or two permanent teeth and there is essentially no difference between cavity rates at that early age yet they are counted in calculating the 'average' "

"By age 17 the difference between fluoridated and non-fluoridated is about 1.6 surfaces and the benefit curve is sharply accelerating with a benefit just under 3 times higher than the 0.6 so commonly quoted."

-----Int J Occup Environ Health. 2005 Jul-Sep;11(3):322-6. Scientific evidence continues to support fluoridation of public water supplies. Pollick HF.

Additionally, in areas where fluoridation is common the Halo effect minimizes the differences between the two types of water systems. Thus the average results actually hide both the Halo Effect and the remarkable differences between communities where fluoridation is uncommon.

6. North: "In 1999, CDC acknowledged that fluoride’s “actions are primarily topical for both adults and children,” meaning surface applications like toothpaste"


A. The effects of fluoride are both topical and systemic. The systemic effects are clearly demonstrated in the mild to very mild dental fluorosis, the only dental fluorosis in any manner associated with optimally fluoridated water. Mild to very mild dental fluorosis is a barely detectable effect which causes no adverse effect on cosmetics, form, function, or health of teeth. As Iida, Kumar, et al. have demonstrated mildly fluorosed teeth to be more decay resistant, a decided benefit, many consider this effect to not even be undesirable, much less adverse. Dental fluorosis can only occur systemically.

—-The Association Between Enamel Fluorosis and Dental Caries in U.S. Schoolchildren Hiroko Iida, DDS, MPH and Jayanth V. Kumar, DDS, MPH http://jada.ada.org/content/140/7/855.long

B. Additionally, saliva with fluoride incorporated into it provides a constant bathing of the teeth in a low concentration of fluoride all throughout the day, a very effective means of dental decay prevention. Incorporation of fluoride into saliva occurs systemically.

From the CDC:

"Fluoride works to control early dental caries in several ways. Fluoride concentrated in plaque and saliva inhibits the demineralization of sound enamel and enhances the remineralization (i.e., recovery) of demineralized enamel. As cariogenic bacteria metabolize carbohydrates and produce acid, fluoride is released from dental plaque in response to lowered pH at the tooth-plaque interface. The released fluoride and the fluoride present in saliva are then taken up, along with calcium and phosphate, by de-mineralized enamel to establish an improved enamel crystal structure. This improved structure is more acid resistant and contains more fluoride and less carbonate.. Fluoride is more readily taken up by demineralized enamel than by sound enamel.. Cycles of demineralization and remineralization continue throughout the lifetime of the tooth."

--------Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States

United States Centers for Disease Control Recommendations and Reports  August 17, 2001/50(RR14);1-42

C. Additionally, in a 2014 study Cho, et al. found:

"Conclusions: While 6-year-old children who had not ingested fluoridated water showed higher dft in theWF-ceased area than in the non-WF area, 11-year-old children in theWF-ceased area who had ingested fluoridated water for approximately 4 years after birth showed significantly lower DMFT than those in the non-WF area. This suggests that the systemic effect of fluoride intake through water fluoridation could be important for the prevention of dental caries."

-----Systemic effect of water fluoridation on dental caries prevalence

Cho HJ, Jin BH, Park DY, Jung SH, Lee HS, Paik DI, Bae KH.

Community Dent Oral Epidemiol 2014; 42: 341–348. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

7. North: "Today, CDC, a major fluoridation promoter, says that fluoridation reduces cavities in children by 25%. Again, this is less than one cavity per child for an entire childhood."


Even if one accepts North's skewed interpretation here, one untreated cavity in one tooth can, and does, lead to a lifetime of extreme pain, debilitation, black discoloration and loss of teeth, development of serious medical conditions, and life-threatening infection. One untreated cavity in one tooth can, and does, lead to loss of the entire dentition. One untreated cavity in one tooth can, and does, lead to death.

8. North: The Iowa Study, funded by the National Institutes of Health, is the most comprehensive ongoing fluoride research project in the U.S. It found “The benefits of fluoride are mostly topical . . . findings suggest that achieving a caries-free status may have relatively little to do with fluoride intake (emphasis in the original) . . . recommending an ‘optimal’ fluoride intake is problematic.”


The out-of-context snippets of quotes provided by North, here, are plucked from studies by Levy, Wareen, et al.

A. The following is what Levy, et al. concluded from the Iowa data:

"Conclusions: D 2+ incidence on first molar occlusal surfaces in these young adolescents was associated with prior caries experience on other teeth as well as prior evidence of a D1 lesion on the occlusal surface. More frequent tooth brushing was protective of sound surfaces, and fluoride in home tap water was also protective, but significantly more so for adolescents in low-income families."

-----Factors associated with surface-level caries incidence in children aged 9 to 13: the Iowa Fluoride Study

Barbara Broffitt, MS; Steven M. Levy, DDS, MPH; JohnWarren, DDS, MS; Joseph E. Cavanaugh, PhD

B. The quote provided by North, "These findings suggest that achieving a caries-free status may have relatively little to do with fluoride intake…” is one frequently misused by FAN to imply support of its position. It is plucked from a 2009 study by Levy, Warren, et al:

Considerations on Optimal Fluoride Intake using Dental Fluorosis and Dental Caries Outcomes – A Longitudinal Study

John J. Warren, DDS, MS, Steven M. Levy, DDS, MPH, [...], and Karin Weber-Gasparoni, DDS, MS, PhD

J Public Health Dent. 2009 Spring; (69)2; 111-115

The entire sentence North plucked from this 2009 study reads: "Given the overlap among caries/fluorosis groups in mean fluoride intake and extreme variability in individual fluoride intakes firmly recommending an 'optimal fluoride intake is problematic.'

The following is a response from Dr. Steven Levy in regard to this misuse:

Dr. Levy:

1) We looked at total F intake from almost all sources (water, beverages, selected foods that absorb water, dietary F supplements, dentifrice)(they acknowledge this ok in their point #3)

2) But we did not say that we "found no relation between tooth decay and the amount of fluoride swallowed", but that it is very complicated--e.g., those with caries but not mild dental fluorosis tended to have lower F intake than the other 3 sub-groups

3) And in many other published articles and abstracts as well as unpublished data, we consistently see ~14-20% less decay among those in F areas, across exams at several ages

(for prevalence at 5, 9, 13 and 17 years and incidence across 4-year intervals) --even after adjusting for all that we can (brushing with F dentifrice, SES, dietary exposures, F supplements, etc.)

-Steven M. Levy, DDS, MPH

Wright-Bush-Shreves Endowed Professor of Research

Department of Preventive & Community Dentistry

University of Iowa

College of Dentistry

9. North: "Cochrane cited solid scientific data finding topical applications like sealants and varnish to be effective in two 2013 studies, but in 2015, it found virtually no such credible evidence for fluoridation:"

" 'The available data come predominantly from studies conducted prior to 1975 . . . over 97% of the 155 studies were at a high risk of bias, which reduces the overall quality of the results . . . We did not identify any evidence . . . to determine the effectiveness of water fluoridation for preventing caries in adults . . . There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across socio-economic status.' "


North once again provides out-of-context snippets, in this case, lumping them together to seem as if they are within the same paragraph. He notably omits the fact that the 155 studies were only those out of 4,600 considered by Cochrane which fit within the parameters set by this group. North's implication is that these 155 constitute the entire volume of fluoride literature. The best way to deal with this is to properly explain the Cochrane Review and provide exactly what this review stated in complete and proper context.....`

The 2015 Cochrane Review was an update of the 2000 York Review. As such Cochrane was constrained to set narrow parameters which were consistent with the narrow parameters originally set by York, for fluoridation studies it would review. It then culled over 4,600 fluoride studies and found 155 which fit within these parameters. This immediately excluded a large volume of of well over 4,000 quality, peer-reviewed fluoridation studies which Cochrane did not review. Within the 155 studies Cochrane chose to review, Cochrane deemed the majority to fall within the parameters it had established for them to be considered at high risk of bias. Cochrane did not state that the studies were biased, nor invalid.

The following is precisely what Cochrane reported:

"The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population’s oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review’s inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults."

Water fluoridation for the prevention of dental caries


Iheozor-Ejiofor Z, Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, Alam R,

Tugwell P, Welch V, Glenny AM

The Cochrane Collaboration

10. North: "Promoters invariably argue fluoridation helps low-income kids, but Cochrane found no credible studies indicating this.


This is patently false.

Cochrane did not state that it "found no credible studies indicating this". What it reported was that, within the 155 studies it chose to review, there was insufficient data for Cochrane to determine the impact of fluoridation across socio-economic status.

"There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES."

11. North: In fact, there has never been a randomized, controlled study of fluoridation to determine safety and effectiveness."


Cochrane fully understood that the randomly controlled trials against which it compared the quality of the observational studies it reviewed, are completely infeasible for large population-based public health initiatives such as water fluoridation, and would therefore never be done for this initiative. Cochrane understood the unfairness of comparing the observational studies of population-based initiatives on the basis of RCTs, and so stated in its report:

"However, there has been much debate around the appropriateness of GRADE when applied to public health interventions, particularly for research questions where evidence from randomised controlled trials is never going to be available due to the unfeasibility of conducting such trials. Community water fluoridation is one such area."


"we accept that the terminology of 'low quality' for evidence may appear too judgmental. We acknowledge that studies on water fluoridation, as for many public health interventions, are complex to undertake and that researchers are often constrained in their study design by practical considerations. For many public health interventions, the GRADE framework will always result in a rating of low or very low quality. Decision makers need to recognise that for some areas of research, the quality of the evidence will never be 'high' and that, as for any intervention, the recommendation for its use depends not just upon the quality of the evidence but also on factors such as acceptability and cost-effectiveness (Burford 2012)."

---Water fluoridation for the prevention of dental caries. (Review)

Iheozor-Ejiofor Z, Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, Alam R, Tugwell P, Welch V, Glenny AM

The Cochrane Collaboration

12. North: On-the- ground experiences in cities like Boston, New York, Cincinnati and Pittsburgh provide more evidence. For instance, San Antonio reported in 2011 that “After 9 years and $3 million of adding fluoride, research shows tooth decay hasn’t dropped among the poorest of Bexar County’s children. It has only increased – up 13 percent this year.”


North provides nothing but unsubstantiated personal opinion about what he claims to be "on-the-ground experiences" and what he deems was stated in an uncited report from San Antonio.

13. North: Finally, the ineffectiveness is apparent worldwide. A World Health Organization study found that nations that fluoridate have virtually the same cavity rates in children as nations that don’t (see graph compiled from WHO data below).


There is no "World Health Organization study" which reports what North claims here. To what he refers is a skewed interpretation of WHO data by FAN, not what was reported in any WHO study. The graph he presents is not one prepared by WHO. It is a graph prepared by Chris Neurath of FAN, which depicts the skewed misrepresentation of WHO data by FAN.

Ken Perrott, a Biochemical PhD in New Zealand has taken Connett to task repeatedly over the past couple of years, including in a direct online written debate with Connett on Perrott's website "Open Parachute". Perrott has provided an excellent, detailed exposure of how FAN has misrepresented WHO data with Neurath's graph. Perrott's piece may be found:

---Fluoridation: Connett’s naive use of WHO data debunked https://openparachute.wordpress.com/2015/08/12/fluoridation-connetts-nai...

Howard Pollick, has also very nicely exposed this FAN misrepresentation of WHO data:

---Scientific Evidence Continues to Support Fluoridation of Public Water Supplies

International Journal of Occupational and Environmental Health

Volume 11, Issue 3 (01 July 2005), pp. 322-326 http://www.maneyonline.com/doi/abs/10.1179/107735205800246055?url_ver=Z3...

14. North: Several factors have major effects on dental health, especially diet, personal dental habits, professional care and genetics. But based on a wealth of credible data, fluoridation isn’t one of them.


North has provided no "credible data". His anecdotal assertion that it exists, is meaningless.

Steven D. Slott, DDS is a general dentist in North Carolina. He is a founding member of the American Fluoridation Society, a non-profit, volunteer organization composed of healthcare professionals dedicated to education of the public, with evidence-based information on the public health initiative of water fluoridation. . Slott is the founder of the North Carolina Missions of Mercy, a large, portable free dental clinic which has provided, over the past decade, millions of dollars of free, comprehensive dental treatment to tens of thousands of the underserved population.

News source: 


Thank you for your article. Hopefully, it will give me a chance to clarify some major points.

You’ve made numerous statements of varying levels of accuracy and relevancy. But none refute my three main conclusions: Oregon doesn’t rank at the bottom of oral health, fluoridation doesn’t save money, and it’s minimally effective.

I won’t answer every criticism but will respond to representative statements you’ve made. In general, you seem to be saying that I’m taking quotes out of context. No quotes misrepresent their source and that’s why I provided links for each. Readers can decide for themselves.

Regarding oral health rankings, I chose one for kids and one for adults, two standard measurements used by the CDC, which favors fluoridation. The numbers showed clearly that Oregon didn’t rank at the bottom, or even close to it. If you (or anyone else) can document state-to-state data showing otherwise, I’ll revise my statement. If you can’t, it would seem to be further confirmation of what I said.

Regarding cost effectiveness, you said that I cherry-picked the Ko/Thiessen study. For the record, the “cherry” is the Griffin “$1 saves $38” study, which calculated the figures you, other pro-fluoridationists and state governments invariably use, and which were cited in the Lund Report article. All I did was select the study that debunked it.

Griffin’s study, which based fluoridation expenses on the CDC’s estimated labor costs of $7 - $9 an hour (in addition to other unrealistic numbers for equipment maintenance and repair), simply isn’t credible. Sacramento’s actual labor costs, for example, were about $100/hour, including benefits and overhead.

You also said that Ko/Thiessen “lumped all dental fluorosis into one category . . . as being a cost of fluoridation.”  Well, no. Ko/Thiessen only included treatment costs for moderate or severe, which can cost thousands of dollars to repair fluorosis damage. Griffin ignored these costs. (Thiessen, by the way, a nationally-recognized expert who you also criticized, was one of 12 scientists chosen by the National Academy of Sciences to compile the landmark 2006 report Fluoride in Drinking Water. It’s considered the most comprehensive, authoritative review ever done on fluoride’s toxicity.)

And fluoride, whatever its source, causes fluorosis.  The more fluoride, the more risk of fluorosis, at all levels. You said “The only dental fluorosis in any manner attributable to optimally fluoridated water is mild to very mild . . .” In other words, somehow the fluoride stops affecting teeth and doesn’t contribute to moderate or severe? This just doesn’t make any sense.

Finally, regarding fluoridation’s minimal effectiveness, I don’t have to respond to every study you’ve cited. The analysts in the Cochrane Collaboration have already covered this territory.

Cochrane eliminated over 4,000 studies at the start because they were either unrelated to the topic or couldn’t meet Cochrane’s minimum level criteria for having confidence in their results. These are the bulk of the “thousands” of studies pro-fluoridationists cite as evidence of its effectiveness.

For those studies making the first cut, they eliminated another 112 because of “inappropriate study design,” including “absence of data from two time points,” “unsuitable control group” or “absence of concurrent control group.” And of the 155 studies left, 97% were still at a high risk of bias. This doesn’t mean that virtually all 4,000+ studies are invalid, but it does mean that the conclusions of those dealing with effectiveness are questionable because their methodologies are weak. The fact that you’ve declared all the original 4,000+ studies “quality” says more about your judgment on fluoridation than anything I can say.

For an excellent article on how outdated and weak fluoridation studies are, see Newsweek at http://www.newsweek.com/fluoridation-may-not-prevent-cavities-huge-study-shows-348251.

Finally, I did want to acknowledge that you’re correct that I made a couple of mistakes, including the link to the statement about the ineffectiveness of fluoridation for many major cities. The right one is https://iaomt.org/wp-content/uploads/article_Connet-F-benefits-doubtful.pdf. However, contrary to what you also said, my quote on the ineffectiveness in San Antonio was linked correctly.

Second, you’re correct that the World Health Organization didn’t do a formal study on cavity rates in various countries, although WHO did gather and publish the data. The graph from that data clearly shows virtually no difference in cavity rates between fluoridated and unfluoridated nations. The authors of your citations supposedly in opposition don’t question that or the accuracy of the graph, but only different interpretations of it. 

Add up the evidence of fluoridation’s minimal effectiveness:  Oregon’s rankings, the Ko/Thiessen study, the NIDR and CDC’s figures, the Iowa Study (where the lead author himself – who you quoted - found effectiveness even less than the CDC), the Cochrane Report, the experience of numerous U.S. cities and the international WHO data shown in the graph. No one study or report may be definitive, but taken together, it’s a compelling picture.

I stand firmly by my conclusions and I’m glad that Oregon is pursuing far more effective alternative oral health measures such as getting more low-income kids professional dental care. That’s something we can all support.


Rick North


1.  There are no "varying levels of accuracy and relevance" in my comments.  They are all accurate and entirely relevant to your erroneous commentary. 

2. In regard to Oregon's oral health ranking....it makes no difference whether it is at the bottom or not. Fluoridation prevents dental decay in citizens of all ages, with prevention being the best "cure" for any disease.  You and the other antifluoridationists involved in the Portland debacle a couple of years ago did a reprehensible disservice to the citizens of Portland with your campaign of misinformation.

3.  In regard to your claim that fluoridation doesn't save money, yes, I clearly refuted it.  See #1 in my post.  Your denial of the science does not mean that it does not exist. 

4.  In regard to fluoridation being "minimally effective", your personal opinion differs from the peer-reviewed science, and the overwhelming consensus of the worldwide body of science and healthcare.  I will gladly cite as many peer-reviewed studies clearly demonstrating the effectiveness of fluoridation as you would reasonably care to read.  

5. Yes, you most certainly did use out-of-context quotes and your skewed interpretation of those quotes as "support" for your position. In my article I clearly and specifically explained several instances where you utilized this tactic.  Those comments speak for themselves.  I'm fine with the  ability of intelligent readers to discern the invalidity of your denial, of this fact.

6.  Obviously you commented on my article without having read it.  In item #1 I provided 8, peer-reviewed studies which clearly demonstrate the cost savings of fluoridation.  You cited one erroneous, cherry-picked study by Kathleen Thiessen, as your "evidence".

7.  Thiessen's inclusion of dental treatment for moderate/severe  dental fluorosis is completely deceptive.  The only dental fluorosis in any manner attributable to optimally fluoridated water is mild to very mild.  This level of dental fluorosis requires no treatment, thus no cost for such.  Severe dental fluorosis does not occur at a fluoride level of 2.0 ppm, as the 2006 NRC Committee on which Thiessen sat clearly evidenced.  

I clearly exposed Thiessen's confirmation bias against fluoridation in my article.  Yes, she was a member of the 2006 NRC Committee, one of three long time, outspoken fluoridation opponents who were invited to sit on that committee in order to give representation to fluoridation opponents.  Thiessen signed off on the final recommendation of that committee along with the other 11 members.  

8. Your attempt to associate the minuscule 0.7 ppm fluoride in fluoridated water with moderate/severe dental fluorosis is like associating a drop of water with a flood.  Yes, the drop contributes to the flood, but removal  of that drop will have absolutely no effect whatsoever on the flood.  The same is true with fluoridated water.  In the presence of chronic exposure to the high level of environmental, well-water, or improperly ingested toothpaste fluoride that it takes to cause moderate/severe dental fluorosis, the removal if 0.7 ppm from the water will have no effect whatsoever.  That a "drop" of fluoride is a part of the overwhelming flood, is not a reason to deprive entire populations the benefits of fluoridation.  The other sources are the problem in cases of moderate/severe, not the optimally fluoridated water. 

9. My comments on your misrepresentation of the Cochrane Review were crystal clear.  Read my item #9.

10.  The "Newsweek" article is little more than an erroneous opinion piece by freelancer Douglas Main who is well known for his antifluoridationist opinion pieces in the dubious online publication, "Natural News".  Why  the once proud "Newsweek" has slumped to the level of tabloid journalism is anyone's guess, but Main's article is so full of bias and errors that it is not worth the paper on which it is printed.  It is, however, typical of the "science" which antifluoridationists claim supports their position.  

For those intelligent readers who truly desire accurate information on the Cochrane Report.......rather than to be deceptively steered to a nonsensical article in "Newsweek", they should read the report, itself. It may be found:


11. Your attempt to defend the graph of WHO data fabricated by Chris Neurath of "FAN" demonstrates your clear lack of understanding of science.  Cherry-picking two or three points out of a multitude of points for each country is ridiculous and completely misrepresentative of that data.

12.  Your denial of facts, evidence, and peer-reviewed science does not equate to being a "compelling picture" of anything other than your complete lack of understanding of this issue.

Steven D. Slott, DDS

From reading Mr. Slott's article, one might almost be left with the impression that failure to add fluoridation chemicals to public water supplies is a leading cause of tooth decay.  Flurodation proponents have yet to show us any such causal data.  If the objective is to improve oral health, shouldn't our primary concern focus on what the actual causes of tooth decay really are in the first place?

Have Mr. Slott and his fellow fluoridation proponents ever looked at the possibility that diet and oral hygene just might possibly have a greater causal impact than the lack of fluoridation chemicals in our water?  Parents who give their kids candy, soft drinks and junk food may be causing more harm to their children than the parents who are trying to protect their children from the ravages of fluoridation.

Look at it this way, parents who do control their child's intake of junk food and soft drinks should not have to risk their own child's IQ and overall health to compensate for the parents who give their kids all the junk food/drinks they can consume.

We know that fluoride is a toxin which even small quantities can cause extreme harm and severe suffering to a very small but very real number of individuals.  (Same goes for Thalidomide, but we don't hear anyone advocating thalidomidation(sic) of public water systems!)  We also know that fluride causes less extreme harm but to a far greater number of individuals.  And we also know soft drinks and junk food have other adverse health effects besides just contributing to tooth decay.

Instead of contaminating everybody's drinking/bathing water, why not persuade soft drink companies and junk food producers to offer a version of their products containing fluoridation chemicals?  That way parents who are more concerned about their kid's teeth than their IQ can buy them candy and drinks laced with fluoride.  And everyone has a choice.



 Brianp...   Really.

It is an easily verified fact that there is enormous and overwhelming scientific consensus agreeing with Dr. Slott which finds fluoridation prevents cavities, is important, affordable (cost-effective) and safe.

Everyone should brush with fluoridated toothpaste twice a day, floss, see a dentist of dental hygienist regularly, drink fluoridated tap water instead of soda pop and sugar laden juices.   

No one in the Oral Public Health field thinks that fluoridation is the only important thing for healthier teeth.

Sadly, stinking red herring claims like your analogy to Thalidomide actually convince some citizens to oppose their own best interests and oppose what Surgeon General C. Everett Koop believe to be "the single most important commitment a community can make to its children and to future generations."

Billy Budd

Billy Budd (aka Chuck Haynie) is also a founding member of the American Fluoridation Society created with a 501c(4) status so we won't ever know who is funding them unless they tell us.  The American Fluoridation Society's political agenda is to promote and protect fluoridation - even though the science proves otherwise.

Fluoridationists have faith in fluoridation; but fluoridation research reviewers need science. And it's just not there.

The trusted UK-based Cochrane Group is yet another respected scientific research body to find that fluoridation’s benefits are built upon a house of cards (June 2015).  Cochrane reports that studies purporting to show fluoridation’s ability to reduce tooth decay are out-dated, have a high risk of bias and were conducted before the widespread use of fluoridated dental products, in other words - scientifically invalid. 

Fluoridation is newly framed as a boon to poor kids. But, Cochrane reports, “There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries [cavities] levels across SES [socio-economic-status or income]."

Other untrue arguments fluoridationists present to too-trusting governing bodies aren’t supported by valid science either e.g. fluoridation benefits adults and tooth decay rates go up when fluoridation is stopped. Cochrane could find no proof that this is true.

The CDC funded the Cochrane Review to upgrade the 2013 U.S. Community Preventive Services Task Force’s Fluoridation Recommendation (which itself is based on the same low-quality evidence.

When Cochrane's review didn't come out the way CDC would have liked, the CDC diverted attention away from Cochrane in favor of the out-dated Task Force Review. 

It should be noted that the Task Review says that the basis for its report is a previous 2000 fluoridation systematic review dubbed the "York Review" (McDonagh 2000). In 2003, the York (McDonagh 2000) reviewers were forced to explain: "We are concerned about the continuing misinterpretations of the evidence...We were unable to discover any reliable good-quality evidence in the fluoridation literature world-wide."

In the 1940s and 1950s, dentists in their eagerness to have a magic bullet that would enhance their professional prestige, promoted fluoridation heavily and dismissed legitimate debate over the merits of fluoridation within the scientific, medical and dental communities, according to an American Journal of Public Health article by Catherine Carstairs, PhD (June 2015).

Carstairs writes, “Moreover, some of the early fluoridation studies had methodological problems, which may have exaggerated their benefits.”

Carstairs concludes “After 70 years of investigation, there are still questions about how effective water fluoridation is at preventing dental decay and whether the possible risks are worth the benefits,” she writes.

Also surprised by the lack of valid fluoridation science, John Doull, PhD, Chairman, US National Research Council fluoride panel that produced the groundbreaking 2006 fluoride toxicology report was quoted by Scientific American as saying:

“What the com­mittee found is that we’ve gone with the status quo regarding fluoride for many years—for too long, really—and now we need to take a fresh look,” Doull says. “In the scientific community, people tend to think this is settled. I mean, when the U.S. surgeon general comes out and says this is one of the 10 greatest achievements of the 20th century, that’s a hard hurdle to get over. But when we looked at the studies that have been done, we found that many of these ques­tions are unsettled and we have much less infor­mation than we should, considering how long this [fluoridation] has been going on. I think that’s why fluoridation is still being challenged so many years after it began. In the face of igno­rance, controversy is rampant.”


Maybe Doull was surprised  because voices of opposition have been suppressed since the early days of fluoridation, according to Chemical and Engineering News (1988). Journals rarely published articles critical of fluoride or fluoridation.

Authors of a 1999 textbook (revised 2005), by Burt and Eklund,  admitted that the early fluoridation trials, which are the foundation for the entire fluoridation program, “were rather crude…statistical analysis by today’s standards, were primitive; data from the control communities were largely neglected after the initial reports, with conclusions based on the much weaker before-after analyses.”

Some examples of those mistakes were reported in  Fluoridation Errors and Omissions in Experimental Trials, by Sutton

In 2001, a National Institutes of Health (NIH)/CDC panel convened to evaluate tooth decay research, published between 1839 and 1965, and reported

 "... the panel was disappointed in the overall quality of the clinical data that it reviewed.  According to the panel, far too many studies were small, poorly described, or otherwise methodologically flawed" (over 560 studies evaluated fluoride use).

Even pro-fluoride dental researchers worried that the lack of evidence-based-dentistry practiced in the US will hurt their reputations. For example, Dentist Amid Ismail, when he was a Professor at the University of Michigan School of Dentistry, in a report to the NIH panel wrote,

"If the current weak trend of caries research in the United States continues, history will be harsh on all of us for our failure to use our knowledge and resources to reduce, if not eliminate, the burden of one of the world's most prevalent diseases."

In 2001, Cohen and Locker reported that fluoridation may be immoral with benefits exaggerated and risks minimized Journal of the Canadian Dental Association .   "Ethically, it cannot be argued that past benefits, by themselves, justify continuing the practice of fluoridation," they write.

A 1990 New York State  Department of Health report concluded

“The effectiveness of water fluoridation alone cannot now be determined…the effects of fluoride exposure cannot be accurately assessed based solely on the fluoride content of drinking water in an area”

In 1978, Pennsylvania Judge John P. Flaherty who had a science background, presided over a court case (Aikenhead v. Borough of West View), where fluoridation proponents were sworn under oath to tell the truth and were subjected to cross-examination. He concluded,

“In my view, the evidence is quite convincing that the addition of sodium fluoride to the public water supply at one part per million is extremely deleterious to the human body, and, a review of the evidence will disclose that there was no convincing evidence to the contrary...”

In the 1950’s, Francis Bull, the state dental director in Wisconsin, argued that cavities could be decreased by practicing good oral hygiene, restricting sugar consumption, and improving diet, but he didn’t trust the public to do that.  Fluoride, in his view, offered the first real preventive from dental caries, according to Carstairs AJPH article.

Bull infamously lead dental directors in 1951 to “sell” fluoridation with slick PR and political strategy but to never ever debate. For example:

“Now, why should we do a pre-fluoridation survey?  Is it to find out if fluoridation works? No. We have told the public it works, so we can’t go back on that.”

“You know these research people – they can’t get over their feeling that you have to have test tube and animal research before you start applying it to human beings.”

The “say this; not that” approach to political fluoridation activism is still encouraged by a pro-fluoridation activism websites including one by the American Academy of Pediatrics's  that was created by a PR agency.I

Taxpayers should be shocked to learn that the CDC doesn't study fluoridation safety but does spend time and money on political strategy to win fluoridation referenda, according to “The Public Votes on Fluoridation – Factors Linked to the Outcome ofFluoridation Campaigns,” (CDC April 2010)

Nys Cof


Nyscof.....sigh.....when you live in a glass house.......

So, okay......It interesting that "nyscof" alleges a lack of transparency for the AFS when:

1.  she is actually Carol Kopf, the "Media Relations Director" for the New york antifluoridationist faction "fluoride action network", who posts under the pseudonym "nyscof".

2. her own organization, "FAN" is buried within another non-profit such that there is little or no information avaiable about "FAN", it's funding sources, its salaries, expenses, or anything else.  I will state for the record that the only source of funding for the AFS, is the grant from Delta Dental, and that there are no salaries or compensation to anyone within the organization.  I challenge Kopf to disclose the same in regard to her "fluoride action network".  Her failure to do so will be taken as clear demonstration of the total lack of transparency of "FAN".

In regard to Kopf's claims, conspiracy nonsense, out-of-context information, and  personal opinions:

1.  There is no valid science which "proves otherwise", as Kopf erroneously claims.  There is no valid, peer-reviewed scientific evidence of any adverse effects of optimal level fluoride.  Countless, peer-reviewed scientific studies clearly demonstrate the effectiveness of fluoridation in the prevention of dental decay in entire populations.  I will gladly vite as many as Kopf would reasonably care to read.

2.  Fluoridation opponents constantly and inexplicably talk of "faith" and "religion" in regard to fluoridation, while being unable to produce any valid science, whatsoever, to support their flow of unsubstantiated nonsense.  In contrast, fluoridation proponents do not talk of "faith" and "religion" in regard to fluoridation, and provide volumes of properly cited, peer-reviewed scientific evidence to support the facts we present........as evidenced by my posts on this page.

Because antifluoridationists such as Kopf deny science and claim it not to exist, does not mean that it does not.

3. Kopf's personal opinion as to the findings of the Cochrane Review are unqualified snd meaningless.  I have fully addressed the misrepresentations of this review by "FAN" personnel such as North and Kopf in my previous posts on this page.

4.  Fluoridation has not been "reframed" as anything.  It has always been put forth as a public health initiative which benefits those of all ages and all levels of SES.

5.  Cochrane was not seeking "proof" of anything.  There are few, if any, scientific findings which can be proven.  Cochrane simply concluded that within the 155 studies it chose to review there was insufficient data for it to reach any conclusion about adults, cessation, and SES.  Nothing more, nothing less.

6.  The 2000 York Committee gauged the observational studies of fluoridation against randomly controlled trials which it considered to be the "gold standard".  It also eliminated from its review a large volume of quality cross-sectional studies due to the preference of the committee for longitudinal studies.  York graded the studies it reviewed on effectiveness at "B" level, those it reviewed on SES at  levels "B and "C", those it reviewed on negative effects at "C" level because they were not their preferred longitudinal design, and those it reviewed on "natural versus artificial" fluoridation at "B" level.  Given that the fluoride ions are identical in both "natural" and "artificial" fluoridation, any ratings on the differences between the two are moot. 

----A Systematic Review of Public Water Fluoridation Marian McDonagh, Penny Whiting,,Matthew Bradley, Janet Cooper, Alex Sutton, Ivor Chestnutt, Kate Misso, Paul Wilson, Elizabeth Treasure, Jos Kleijnen

NHS Centre for Reviews and Dissemination, University of York Dental Public Health Unit, The Dental School, University of Wales, Cardiff  University of Leicester, Department of Epidemiology and Public Health 

Cochrane was an update of York, thus it limited its review to only those studies which fit York's original parameters, once again,  eliminating a large volume of quality cross-sectional, observational studies.  However, Cochrane also recognized the infeasibility of performing the "gold standard" randomised controlled trials in large population-based public health initiatives such as water fluoridation, and the unfairness of grading the observational studies against RCTs.  

"However, there has been much debate around the appropriateness of GRADE when applied to public health interventions, particularly for research questions where evidence from randomised controlled trials is never going to be available due to the unfeasibility of conducting such trials. Community water fluoridation is one such area."


"However, we accept that the terminology of ’low quality’ for evidence may appear too judgmental. We acknowledge that studies on water fluoridation, as for many public health interventions, are complex to undertake and that researchers are often constrained in their study design by practical considerations. For many public health interventions, the GRADE framework will always result in a rating of low or very low quality. Decision makers need to recognise that for some areas of research, the quality of the evidence will never be ’high’ and that,as for any intervention, the recommendation for its use depends not just upon the quality of the evidence but also on factors such as acceptability and cost-effectiveness (Burford 2012)."

-----Water fluoridation for the prevention of dental caries (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

7.  The article by Carstairs was simply an opinion piece in which  she provided no substantiation for her commentary.  

8. John Doull, MD, PhD, Chair of the 2006 NRC Committee on Fluoride in Drinking Water made the following statement in 2013 in response to he constant out-of-context misuse of his 2007 statements by antifluoridationists such as that which Kopf attempts to do here:

"I do not believe there is any valid, scientific reason for fearing adverse health conditions from the consumption of water fluoridated at the optimal level"

---John Doull, MD, PhD, Chair of the National Academy of Sciences, National Research Council 2006 Committee Report on Fluoride in Drinking Water

He made the statement clear and concise in order to eliminate any misinterpretation and misuse.

9.  The out-of-context quote from Burt and Eklund is nothing more than a statement of the obvious.  Yes, scientific research 65 years ago was not on a par with what it is today.  So, what?  This does not negate the volumes of scientific literature on fluoridation since that time.  Again, I will be glad to cite as many peer-reviewed scientific studies on the effectiveness of fluoridation as Kopf would reasonably care to read, including many from within the past 5 years.

10.  Phillip Sutton was an outspoken Australian antifluoridationist from the middle of the last century.  His "paper" cited by Kopf, is from 1959, and posted on a little antifluoridationist website.  Yet another example of the "new, emerging science" antifluoridationists constantly claim exists somewhere or other, I suppose.

11. The out-of-context quote Kopf attributes to a 2001 NIH panel...... she "supports" with a cite to a meeting agenda.

12.  The out-of-context quote of Ismail provided by Kopf is in regard to caries research, not fluoridation.

13. The out-of-context quote from Cohen anf Locklear is simply the personal opinions of antifluoridationists who attempt to appeal to emotion, ethics, and "morality" rather than reliance on the peer-reviewed science.  There is, obviously, nothing immoral or unethical about approval by local officials  of the level of a naturally occurring mineral in public water supplies under their jurisdiction.  If anything, the "morality" question would be in regard to those who seek to remove the benefit and strict controls over the level of fluoride in these supplies, through the cessation of fluoridation.  With cessation, ingestion of fluoride in water would not cease.  Therefore, any perceived "risks" in regard to the litany of unsubstantiated claims constantly disseminated by antifluoridationists, would still remain.  Cessation only removes the benefit and the strict controls over concentration level.

14.  The out-of-context quote from the New York Department of Health simply reiterates the fact that due to other sources of fluoride now, its benefits cannot be accurately assessed based solely on that fluoride which is in the water.

15.  The 1978 personal opinion of some judge in Pennsylvania who has "a science background", whatever that means, is meaningless.  In the entire 70 year history of water fluoridation, there have been no proven adverse effects.  No court of last resort has ever ruled in favor of antifluoridationist claims of "adverse effects", "forced medication", or anything else.

16. The unsubstantiated claims in an opinion piece by Carstairs on what she deemed was stated by a Wisconsin dental director 65 years ago?  Seriously?  This must be more of that "new, emerging science" of Kopf's.

17. Kopf claims that a  website of the prestigious American Academy of Pediatrics is a "pro-fluoridation activism website"?  Oh, really?  The nations pediatricians are "pro-fluoridation activists"?  So, I suppose that instead of heeding the advice  and recommendations of the American Academy of Pediatrics we should heed....what.....the utter nonsense posted on Kopf's "FAN" website, "fluoridealert"?   Hmmmm.....


Steven D. Slott, DDS


“Stinking red herring claims”? You mean, like that bogus quote you repeatedly claim is from Surgeon General Koop?

John D Mac

I am sorry to be so slow to respond . . replying to this sort of thing is not my top priority

Here are some more C Everett Koop quotes re community water fluoridation:


"I encourage the dental profession in communities which do not enjoy the benefits of an optimally fluoridated drinking water supply to exercise effective leadership in bringing the concentration to within an optimum level."

C. Everett Koop, MD, Surgeon General, July 30, 1982


".., it is clear from the evidence that at the level of fluoride that is recommended for community water systems, dental decay is significantly reduced and no deleterious side effects are experienced.

. .with water fluoridation, the beneficial results have been markedly significant, consistent, and reproducible."

C. Everett Koop, MD, Surgeon General, November 28, 1988


One of the places the "most important" quote was reported is the Chicago Tribune