29th February 2008
The fluoridation debate has raged quietly for 50 years, occasionally hitting the headlines in a flurry of scare stories and conspiracy theories. Now, with news of government support for fluoridation schemes, it is surfacing again.
This month health secretary Alan Johnson recommended fluoride be added to water supplies to help prevent tooth decay and reduce health inequalities. Announcing new funding and guidance, he also urged a debate on the subject, stressing that Strategic Health Authorities – that were empowered to direct water companies to fluoridate in 2003 – should consult the public before making any decision.
A total of £14m a year will be available over the next three years to SHAs whose communities favour fluoridation. The Department of Health says: ‘This new government funding will allow SHAs in areas of poor dental health to meet the capital cost of fluoridation schemes without depleting funds designated for other health needs and facilities. To help SHAs assess the level of public support for local fluoridation schemes, the department is also issuing revised guidance to ensure local consultations are conducted in a fair and objective way.
‘Academic studies show that oral health is better in areas where tap water is already fluoridated and that the number of children with tooth decay decreases by 15 per cent. In practice the benefits are even greater. For example, children in fluoridated Birmingham have half the cases of tooth decay than children in non-fluoridated Manchester.’
In response to the DoH’s statement, a spokesman for campaign group the National Pure Water Association says: ‘The west Midlands spends far more on dental health per head of population when compared with Manchester. In Wolverhampton, after fluoridation rose from 32 per cent to 100 per cent in 1997, in the five years to 2002 expenditure on dental health more than doubled and the number of preventative procedures increased by 50 per cent.
‘Over the same period spending on dental health in Manchester and Lancashire was cut. Clearly, it is targeted expenditure that reduces dental health inequalities. Fluoridation is literally money down the drain.’
The NPWA is among a small, vocal minority that believes fluoridation is ineffective, unnecessary, unsafe, unethical and illegal. Its ethical and legal case rests on the definition of a medicinal product under EU law as ‘any substance or combination of substances presented as having properties for treating or preventing disease in human beings’.
Its spokesman said: ‘It’s a human rights issue by EU definition. By presenting fluoridation as a means of preventing tooth decay Alan Johnson confirms the practice is medication and this is carried out by water companies in violation of their customers’ human right to refuse consent to any medical intervention. Section 58 of the Water Act 2003 is therefore bad law as it conflicts with other UK, and EU law.’
Speaking in 1978 Nobel Laureate in Medicine and Physiology 2000 Dr Arvid Carlsson said: ‘Water fluoridation, in a not-too-distant future, will be consigned to medical history... it goes against leading principles of pharmacotherapy, which is progressing from a stereotyped medication, of the type one tablet three times a day, to a much more individualised therapy as regards both dosage and selection of drugs.’
Mr Carlsson, a leading opponent of fluoridation in Sweden and part of the panel that recommended the Swedish government reject it, which it did in 1971, was mistaken. Some 350 million people worldwide now drink artificially fluoridated water.
Campaigners claim that, as well as causing dental fluorosis in up to 48 per cent of children, fluoride can be responsible for serious health problems, and once it is in the water, it is impossible to control the dose.
Most vulnerable are the very young, the very old and those with poor diet, poor kidney function or iodine deficiency. Since dental decay is concentrated in poor communities, the anti-fluoride lobby says, we should spend our efforts trying to increase access to dental care for poor families.
But the pro-fluoride lobby insists less privileged children are less likely to brush their teeth, and therefore more likely to need fluoride from tap water for dental protection. Organisations like the British Fluoridation Society, which was supported by the government until 2006, say fluoridation is harmless, cheap, simple and effective, saving children and adults from the pain of toothache and individuals and the state from the cost of dental treatment.
The DoH says: ‘All water contains some fluoride. About half a million people in this country receive water which is naturally fluoridated at, or about, the optimum level for dental health of one part of fluoride per million of water. A further 5.5 million people receive water where the fluoride content has been increased at the request of the NHS. There has been 50 years experience of fluoridation in England, even longer in the US where some 170 million people receive fluoridated water. No evidence of risks to general health have been identified at the 1 part per million concentration used for artificially fluoridating public water supplies.’
In 1999 it commissioned the Centre for Reviews and Dissemination to review the efficacy and safety of fluoridation of drinking water.
The DoH says the report found fluoridation ‘increased the number of children without tooth decay by 15 per cent’. The NPWA says it, ‘was unable find any high quality research to support claims of efficacy or safety’.
In 2003 the CRD said: ‘We are concerned about the continuing misinterpretations of the evidence and think it is important that decision makers are aware of what the review really found. We were unable to discover any reliable good-quality evidence in the fluoridation literature worldwide. What evidence we found suggested that water fluoridation was likely to have a beneficial effect, but that the range could be anywhere from a substantial benefit to a slight disbenefit to children’s teeth.
‘This beneficial effect comes at the expense of an increase in the prevalence of fluorosis. The quality of this evidence was poor. An association with water fluoride and other adverse effects such as cancer, bone fracture and Down’s syndrome was not found. However, we felt that not enough was known because the quality of the evidence was poor.
‘The evidence about reducing inequalities in dental health was of poor quality, contradictory and unreliable.’
The statement adds that between the review’s publication in 2000 and release of the statement in 2003, no scientifically defensible review had altered its findings. ‘Only high-quality studies can fill in the gaps in knowledge about these and other aspects of fluoridation,’ it says. ‘Recourse to other evidence of a similar or lower level than that included in the York review, no matter how copious, cannot do this.’
Last month The Telegraph reported that Sir Iain Chalmers, editor of the James Lind Library in Oxford, and Prof Trevor Sheldon, deputy vice-chancellor at York University, who chaired the advisory board that oversaw the review, had said the review’s findings had been used selectively. In a joint statement they described the government’s assessment of the evidence in favour of fluoridation as ‘over-optimistic’ and the DoH’s objectivity as ‘questionable’.
They said tooth decay in 12-year-olds had reduced across Europe irrespective of whether there was fluoride in the water. In fact the countries with the biggest drop in childhood tooth decay – Sweden, Netherlands, Finland and Denmark – did not fluoridate.
The DoH said that in 2000 it responded to the York review with a commitment to commission further research to strengthen the evidence base on fluoridation. In 2001 it asked the Medical Research Council to identify research required to inform public policy on fluoridation. In 2003 the University of Newcastle investigated bioavailability (absorption) of fluoride from artificial and natural sources. In 2005 research on use of intra-oral cameras for obtaining more objective and quantative measures of enamel fluorosis was included in the NHS research programme.
While the NPWA and others pour scorn on the Newcastle report, a DoH spokesperson says: ‘The Newcastle study contributed to better understanding of the health effects of water fluoridation. [It] concluded that there were no statistically significant differences in bioavailability between artificially and naturally fluoridated water. In planning further research, we have agreed to take account of suggestions that the study be repeated with a larger sample size, within the inevitable constraints of the funding available.’
Alan Johnson says: ‘Fluoridation is scientifically supported, it’s legal, and it’s our policy, but only two or three areas currently have it and we need to go much further in areas where dental health needs to be improved.
‘There are people who hold strong views on this subject, so it’s important that any proposed schemes are fully and widely consulted on. The guidance will help local health bodies to ensure there’s an opportunity for everyone to put forward their views. The extra funding means that, should local people decide to support fluoridation, SHAs have the resources to implement it.’