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Appendix A
Water Fluoridation Review
Joint Report of the Adult Services and
Health Scrutiny Panel and the
Children and Young People’s
Services Scrutiny Panel
May 2007
Final – June 2007 PSOC
Page 1
CONTENTS
EXECUTIVE SUMMARY ……..…………...………………………………………3
1.
Original Concerns – why Members wanted to look at this Issue .............. 4
2.
Terms of Reference ....................................................................................... 5
3.
2.1
Methodology ......................................................................................... 6
3.1
3.2
National Level ....................................................................................... 8
Local Level.......................................................................................... 10
4.1
4.2
4.3
4.4
History of Fluoridation......................................................................... 12
How Fluoride Works............................................................................ 12
Optimal Fluoride Levels for Drinking Water ........................................ 13
Dental health improvement in recent years......................................... 13
5.1
5.2
5.3
5.4
5.5
Health Inequalities .............................................................................. 14
Pro-Fluoride Lobby ............................................................................. 17
Anti-Fluoride Lobby............................................................................. 18
The York Review: A Systematic Review of Public Water Fluoridation 18
Medical Research Council - Working Group Report: Water fluoridation
and health ........................................................................................... 19
Legislative and Policy Context..................................................................... 8
4.
Background.................................................................................................. 12
5.
Current debate ............................................................................................. 14
6.
Findings ....................................................................................................... 19
6.1
6.2
6.3
6.4
6.5
7.
Is there evidence that artificial fluoridation of the water supply prevents
tooth decay? ....................................................................................... 19
Is it safe to artificially fluoridate the water supply? .............................. 22
Alternatives to Fluoridated Water to improve Dental Health ............... 26
The Ethics of fluoridating Water Supplies ........................................... 28
Are there other Practical Considerations? .......................................... 30
Conclusions drawn from the Evidence ..................................................... 33
7.1
7.2
7.3
7.4
8.
Does adding fluoride to water reduce dental decay in children?......... 33
What are the risks?............................................................................. 34
What are the ethics of fluoridating water?........................................... 35
What is the current legal position and route for making changes to the
water supplies?................................................................................... 35
Recommendations ...................................................................................... 36
8.1
8.2
8.3
8.4
9.
Rotherham Metropolitan Borough Council .......................................... 36
Rotherham PCT.................................................................................. 36
NHS Yorkshire and the Humber (SHA)............................................... 37
Department of Health.......................................................................... 37
Thanks.......................................................................................................... 37
10.
Information Sources/References ............................................................... 38
11.
ANNEX 1 ....................................................................................................... 39
Final – June 2007 PSOC
Page 2
EXECUTIVE SUMMARY
The debate about water fluoridation is polarised, with strong views held on
both sides. The Department of Health and local health community strongly
support water fluoridation, yet there is a strong anti-fluoridation lobby that
opposes it for a range of compelling reasons.
The review group interviewed expert witnesses. It also looked at a great deal
of evidence, finding that the quality of research is variable1 and the
conclusions drawn from it are often contradictory. The review group
comprised eight lay people with a wide range of experience, but no medical
or dental background. However, it has established a view on the basis of
the evidence presented from all sides of this complex debate.
The review considered the issue of medical ethics and concluded that if
water fluoridation is considered to be medical intervention, then either the
permission of all those affected is required or there has to be compelling
evidence of benefits, with no other way of achieving the outcomes.
In Rotherham’s most deprived wards, the level of decay in five year-olds’
teeth has only improved marginally in the last 20 years, missing both local
and national targets. The review group was mindful of the urgent need to
improve the dental health of Rotherham’s most disadvantaged communities,
but in a way that considers the effects on the population as a whole.
There seems to be no doubt that fluoride – in very small amounts –
strengthens growing teeth and helps them resist decay. Fluoride toothpaste
has been widely used in the UK for the last 30 years and appears to have
been a major factor in dental health improvements, nationally. However,
what is less certain is the best way to get fluoride (and other preventative
interventions) to the individuals that would benefit most – i.e. those with the
worst dental health.
Too much fluoride certainly causes health problems – from minor cosmetic
markings on the teeth, to skeletal deformities and possibly other health
problems, where fluoride exposure is particularly high. What is more difficult
to identify is the optimum amount to produce the benefits without exposing
the community to the risks. By adding fluoride to tap water, it would be
impossible to control the amount of fluoride taken by each individual and
ensure that each individual (whose ability to absorb fluoride may differ widely
from the next person’s) receives the optimum level and not too much.
The review therefore concluded that that whilst there is evidence of the
benefits, the risks have not been sufficiently explored. Furthermore, it would
1
The York Review: A Systematic Review of Public Water Fluoridation (2000)
Final – June 2007 PSOC
Page 3
appear that significant improvements to dental health may be achieved
through other interventions.
Although water fluoridation appears to be a cost-effective way of reducing
dental caries because of its universal effect, the review group felt that the
cost of adding fluoride for the whole borough could be better spent improving
the dental health of those communities in greatest need.
Given the complexity of the arguments, the review wants to ensure that any
future consultation by the Strategic Health Authority provides sufficient
information about the benefits and risks of water fluoridation, so that the
public can make an informed choice.
The review makes a number of recommendations to the local, regional and
national health organisations, which, if implemented, should help reduce
Rotherham’s unacceptable inequalities in respect of dental health. These
are given in section 8 of this report.
However, the review’s key
recommendation is for Rotherham Council to reaffirm its policy against the
fluoridation of its water.
1.
ORIGINAL CONCERNS – WHY MEMBERS WANTED TO LOOK AT THIS
ISSUE
Whether adding fluoride to the water supply would improve Rotherham’s
dental health, especially that of children and young people living in areas of
social deprivation was raised during a previous Adult Services and Health
Scrutiny Panel review on dental care, held on 2 February 20062.
A new dental contract was introduced in April 2006, in the context of a
national shortage of NHS dentists. Recent reports3 suggest that a year on
from this, at least 30,000 people are waiting to find a dentist in Yorkshire.
There are now 10 per cent fewer dental practices in the region carrying out
NHS dentistry compared with two years ago.
The review heard that the dental health of 5 year olds in Rotherham has not
changed greatly since 1985 (see graph below4). The vast majority of decay
in 5 year olds is not treated (partly due to their reluctance to be treated) and
less than half of this group is registered with a dentist. The 2003 target5 for
Review of NHS Dental Provision in Rotherham – Adult Services and Health Scrutiny Panel
nd
2 February, 2006 (first part of a two stage review)
3
Yorkshire Post, 24 April 2007
4
Source: Dr Nigel Thomas, Director of Dental Public Health
5
Department of Health (1994) Oral Health Strategy for England set a target that five-yearold children should have an average of no more than one decayed, missing or filled tooth
and 70% of 5-year-olds should have no decay experience
2
Final – June 2007 PSOC
Page 4
this group is less than one dmft6 per patient. Locally, only Bassetlaw and
Chesterfield have managed to achieve this.
5 year olds in Rotherham 1985-2005
2
decayed
1
filled
extracted
0
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
20
03
20
05
te e th a ffe c te d
3
year
There is a considerable variation in disease levels between wards in
Rotherham with the 5 year olds in the more economically disadvantaged
wards having three times the level of dental decay than in other wards. This
is a reflection of the social economic status of communities, with poverty
being closely linked to poor dental health.
This is borne out by evidence from a local Rotherham dentist who asserted
that dental health among children has not really improved, with old and new
patients presenting with very high levels of disease. In his experience
sessions of intense oral health education has made little difference to
especially those who need it most.
Rotherham Primary Care Trust (PCT) proposed that improvements could be
made to dental health of children in particular, through water fluoridation.
However, recognising that this issue has generated considerable public
debate, the Adult Services and Health Scrutiny Panel agreed that a further
review would be held to consider the issue in more detail.
2.
TERMS OF REFERENCE
The following terms of reference were agreed:
Tooth decay is more usually reported in the literature as decayed, missing and filled teeth
(dmft in primary/baby teeth and DMFT in permanent teeth)
6
Final – June 2007 PSOC
Page 5
To consider the arguments for and against the artificial fluoridation of the
water supply provided to the people of Rotherham and to reach a view on
whether the Panel considers that fluoride should be added to the water
supply as a public health action.
a)
b)
c)
d)
e)
to determine whether adding fluoride to water is an effective means
of reducing dental decay in children
to identify the benefits and risks associated with adding fluoride to
water
to consider the ethics of fluoridating water supplies
to clarify the current legal position and route for making changes to
the water supply
to agree a view that can be discussed with full Council.
2.1
Methodology
2.1.1
The review was jointly undertaken by members of the Adult Services and
Health Scrutiny and Children and Young People’s Scrutiny Panels.
The members of the review group were as follows:
-
Cllr Beryl Billington
Cllr Rose McNeely
Cllr John Turner
George Hewitt (co-optee)
-
Cllr John Doyle (chair)
Cllr John Swift
Mick Hall (co-optee)
Ben Vergara-Carvallo (co-optee)
2.1.2
The review was supported by a consultant engaged through the Centre for
Public Scrutiny ‘expert advisor’ scheme7. The contribution and expertise of
Brenda Cook is gratefully acknowledged. In liaison with the Chair, Cllr John
Doyle, a panel of experts was selected to give evidence. Each witness was
contacted in advance and given a written brief detailing the scope of the
review and the process to be followed.
2.1.3
In order to meet the terms of reference, the review focused on the following
areas:
•
•
Is there evidence that artificial fluoridation of the water supply
prevents tooth decay? If so,
Is it safe to artificially fluoridate the water supply, i.e. are there risks
attached?
Health Scrutiny Committees can access up to 5 days free support from a Centre for Public
Scrutiny Advisory Team - a range of health scrutiny experts drawn from across the local
government and health sectors.
7
Final – June 2007 PSOC
Page 6
•
•
•
Are there alternatives to water fluoridation that can improve the dental
health of those individuals and groups that are most at risk from tooth
decay?
Is there an ethical issue about adding fluoride to the water supply,
which to a large extent removes the element of choice?
Are there other practical considerations, i.e. costs, consultation?
2.1.4
Acknowledging that the issue of water fluoridation is both a complex and
contentious issue, it was agreed that representatives of the pro- and antifluoride lobby should be contacted to give their views. It was also
recognised that in order for the panel to make an informed judgement, it was
important to understand dental health within Rotherham, particularly in the
context of the Borough’s socio-economic circumstances. To this end, both
the Director of Dental Public Health and a local dentist were invited to give
evidence. A number of other witnesses were called to focus on legal, ethical
and other practical considerations.
2.1.5
The review group set aside a morning and afternoon session over a single
day, Monday 19 February, to receive oral evidence and question the
witnesses. Each representative was asked to focus on their area of expertise
and their organisation’s position in relation to fluoridation. Many of the
witnesses gave detailed PowerPoint presentations to support their evidence.
We would like to thank all the witnesses for their time, co-operation and
willingness to engage in this process. Their contributions are gratefully
acknowledged.
•
•
•
•
•
•
•
•
Dr Nigel Thomas, Director of Dental Public Health, Rotherham PCT
Dr John Beal, Dental Advisor to NHS Yorkshire and the Humber
Professor Michael Lennon, British Fluoridation Society
Jason Field, Local dentist (Chair of the Local Dental Committee)
Dr Mark Taylor, Sheffield Institute of Biotechnological Law and Ethics
Elizabeth McDonagh, Chairman and Ian Packington, Vice-Chairman
of the National Pure Water Association
David Woolloff, Manager of Water Quality, Yorkshire Water
Louise Collins, Oral Health Promotion Co-ordinator, Rotherham PCT
2.1.6
Councillors Shaun Wright and Tony Mannion submitted papers outlining their
views on the issue, which were considered as part of the review. In addition,
Councillor Robin Stonebridge submitted a list of questions which were used
when drafting the supplementary questions.
2.1.7
Professor Sheldon was invited to attend the scrutiny review in person, but
unfortunately was unable to do so. He kindly agreed to provide a statement
and answer supplementary questions from the review group.
Final – June 2007 PSOC
Page 7
2.1.8
The majority of witnesses were allocated 30 minutes to give their evidence
although the pro- and anti-fluoridation organisations were both given 45
minutes each to explain their organisation’s position.
2.1.9
As with the majority of scrutiny meetings (unless confidential information is
being discussed), the review was held in public. There were approximately
25 people in the audience, the majority of whom stayed to hear the evidence
in its entirety. Given the number of witnesses giving evidence and thus the
tight timetable on the day, it was decided not to take questions from the floor.
Instead, members of the audience were invited to submit written questions.
These were considered by the review group and many were used to inform
further questions.
2.1.10 The review generated media interest, with both local press and radio
coverage. This reflected the substantial public interest in the subject.
2.1.11 In addition to the questions asked on the day, a series of supplementary
questions were identified. These questions focussed on gaps in evidence or
pursued lines of questioning arising from the witness’ presentations.
2.1.12 The review group reconvened on Tuesday 13 March to consider the
evidence and arrive at their recommendations. These are detailed in
Section 8 of the report.
2.1.13 The review was supported by Caroline Webb, Senior Scrutiny Adviser and
Delia Watts, Scrutiny Adviser.
3.
LEGISLATIVE AND POLICY CONTEXT
3.1
National Level
3.1.1
Since the early 1960s, successive UK Governments have supported water
fluoridation. Currently, approximately 10% of the UK population receives
fluoridated water from natural or artificial sources8. Arrangements for most
fluoridation schemes were made before 1985.
3.1.2
The Water (Fluoridation) Act 1985, consolidated in the Water Industry Act
1991, was intended to regularise the legislative framework, but it proved to
be ineffective. Section 87 of the Act stated that, when requested by health
authorities, water undertakers (water companies), "...may increase the
fluoride content of the water supplied by them within that area”. No new
schemes were introduced under this legislation. Water undertakers did not
feel equipped to make decisions on what they considered to be a public
British Fluoridation Society (2004) One in a Million – The Facts about Water Fluoridation
nd
2 ed. Manchester
8
Final – June 2007 PSOC
Page 8
health issue and their representatives pressed for the legislation to be
amended to make Strategic Health Authorities (SHAs) responsible for these
decisions.
3.1.3
As this legislation was largely seen as unworkable, new measures were
introduced in the Water Act 2003 (“the Water Act”). Section 58 of the Water
Act included wide-ranging amendments to the provisions on fluoridation in
section 87 of the Water Industry Act 1991. Most significantly, section 87(1)
was amended to impose an obligation on water undertakers and now reads:
“If requested in writing to do so by a relevant authority9, a water undertaker
shall enter into arrangements with the relevant authority to increase the
fluoride content of the water supplied by that undertaker to premises within
the area specified in the arrangements.”
3.1.4
In advice given to Strategic Health Authorities and Primary Care Trusts10,
Professor Raman Bedi, England’s Chief Dental Officer outlined the process
for consultation in line with the legislation. As it is generally Primary Care
Trusts who identify concerns about the oral health of their populations, it was
felt that they should identify the options for securing improvements. These
improvements should be informed by local dental health surveys. If it is felt
that fluoridation of water is the most effective solution, the Primary Care
Trusts should discuss this with their Strategic Health Authority.
3.1.5
Before going any further, the SHA should consult with the water company/ies
to ensure that any proposal is technically feasible. Next, the legislation
requires the appropriate Strategic Health Authority to consult locally and
ascertain the opinion of local people. This would include every local
authority affected, individuals and bodies with an interest (e.g. Public and
Patient Involvement forums, voluntary sector health and social care
organisations, consumer groups, businesses and environmental
organisations) and also the general public (via leaflets, posters, newspapers
and other media).
3.1.6
To date, NHS Yorkshire and Humber (the regional Strategic Health
Authority) has not undertaken such consultation within Rotherham and
therefore how such a consultation would be funded has not been
considered.
The SHA
Prof Bedi, R (2005) Fluoridation of Drinking Water, Guidance from the Chief Dental
Officer (Gateway Ref. 5136), Department of Health
9
10
Final – June 2007 PSOC
Page 9
3.2
Local Level
3.2.1
Current Council Policy
At present the water provided to people within Rotherham MBC area does
not have fluoride artificially added, although, along with all UK water, it is
naturally present at very low levels. The issue of water fluoridation was
initially discussed by the then Environmental Health Committee in July 1988.
Following these discussions, a recommendation was made that the Council
should oppose water fluoridation. In summary, the Committee reached a
view that:
•
•
•
•
Fluoridation of water is not a substitute for preventative dental care
and education from a properly staffed dental service;
The presence of other substances in water and food could affect the
level of bodily absorption of fluoride and thus its role in fighting tooth
decay;
Fluoridation of all water would deny consumer choice to those who
question the efficacy of mass fluoridation;
There was uncertainty that quality assurance could be guaranteed
from the newly privatised water industry.
The full minute of the meeting is provided at Annex 1. The Committee
subsequently noted a letter received by the Chief Executive in January 1997
from Yorkshire Water regarding its decision not to add fluoride to the water
supplies in Yorkshire.
3.2.2
It is worth noting that in 200111, the Cabinet supported a pilot project initiated
by the PCT to provide fluoridated milk12 to children at a primary school in the
Rawmarsh Sure Start area. The following year, they approved the extension
of the scheme to the other Sure Start areas in Rotherham. To date, no
formal evaluation of this scheme has taken place, and therefore it is difficult
to draw conclusion about its effectiveness. However, it is unlikely that the
scheme will be expanded due to problems with supply.
3.2.3
Although the Council supported the introduction of the pilot milk fluoridation
scheme, there has not been further discussion of water fluoridation within
any formal Council meeting since 1997.
11
12
Minute B211, Cabinet meeting held on 28 November, 2001
With a fluoride content of 2.6 ppm
Final – June 2007 PSOC
Page 10
3.2.4
Recent Policy Decisions in nearby Local Authorities
A number of other Councils within the Yorkshire and Humber region
including Calderdale and Bradford have formally resolved to oppose
fluoridation (both these decisions were taken in 2003). In early 2005, Leeds
City Council agreed a motion to oppose fluoride in water. Following a
presentation by Sheffield Director of Dental Health and a representative of
the National Pure Water Association, Sheffield City Council reaffirmed its
opposition to the fluoridation the public water supply at its meeting of 2
February, 2005. Of Rotherham’s other immediate neighbours, neither
Doncaster nor Barnsley Councils have discussed this issue in recent years.
3.2.5
Rotherham PCT
The PCT is strongly in favour of water fluoridation and recommends that
Rotherham’s water supply is fluoridated13. The Joint Annual Report of the
Directors of Public Health in South Yorkshire 2005/614, states that:
“Fluoridation is the strongest evidence based strategy for improved dental
health, with greatest potential to reduce inequalities in more deprived
communities”.
The views of individual dentists are not known, but Mr Field, Chair of the
Local Dental Committee is not aware of any dentist that opposes the PCT’s
line.
3.2.6
NHS Yorkshire and the Humber
The SHA has identified the dental health of children as one of the priority
areas which needs to be tackled as part of improving health and reducing
inequalities. Yorkshire is one of the areas furthest away from the target that
5-year-old children should have no more than an average of one decayed,
missing and filled teeth by the year 2003. In South Yorkshire the average
was over 2 teeth affected. Dr Beal believes that whilst the PCTs need to
implement a range of measures to improve dental health, water fluoridation
could be the major contributor to reducing the amount of tooth decay,
especially in children - although adults with their own teeth would also
benefit.
3.2.7
Rotherham’s Water Providers
The overwhelming majority of Rotherham’s domestic or commercial
premises and facilities are supplied with water from Yorkshire Water. A very
Rotherham PCT (December 2006) Rotherham Oral Health Strategy 2006/09 Section
4.8.1
14
Section 2, p 30
13
Final – June 2007 PSOC
Page 11
small number of businesses and households in the south of the Borough
receive services from Severn Trent Water.
4.
BACKGROUND
4.1
History of Fluoridation
4.1.1
All water supplies contain some fluoride. From observing different patterns
of dental decay in areas of differing levels of naturally fluoridated water that
the benefits of fluoride were first observed. The protective properties of
naturally fluoridated water were identified in America and England in the
1930s, leading to several large scale studies being undertaken. This
included the Grand Rapids trial in 1945, a community intervention which
tested the hypothesis that artificial fluoridation would reduce incidents of
dental decay. On the basis of the trial’s results, a number of American and
Canadian towns decided to increase the fluoride content of their water
supplies in the late 1940s.
In 1953, a group of British scientists examined these studies and
recommended to the Ministry of Health that similar research be undertaken
in Britain. These studies yielded similar results to those in North America,
influencing a number of areas around the country to artificially fluoridate their
water supplies.
4.1.2
Approximately 350 million people in over 30 countries currently drink
artificially fluoridated water, with a further 50 million drinking naturally
fluoridated water. The review group received evidence to suggest that
approximately 70% of water in the United States is or will shortly be,
fluoridated. Ireland currently fluoridates all mains water where possible.
4.1.3
Although water fluoridation is well established in the UK, it has not been
widely adopted. At present, about 10% of the UK population, which mostly
reside in either the West Midlands or around Newcastle-upon-Tyne, receives
fluoridated water.
4.2
How Fluoride Works
Bacteria constantly form on the inside of the mouth. Over time, these
bacteria can gradually erode away the enamel (the outer layer) of the tooth.
Once this layer is eroded, bacteria attack the soft core of the tooth, causing
cavities or other serious damage to teeth and gums.
Fluoride combats this process by strengthening the enamel and helping to
remineralise the tooth's surface. Once ingested into the body, fluoride travels
through the blood supply, where it makes its way into the bones and teeth.
Fluoride is easily absorbed into the teeth thanks to their porous outer
surface. Although it may be ingested through the public water supply,
fluoride also comes in the form of liquid gel or varnish that can be prescribed
by a dentist.
Final – June 2007 PSOC
Page 12
4.3
Optimal Fluoride Levels for Drinking Water
In some parts of the world, for example India, China, Thailand, and Kenya,
high levels of fluoride naturally present in ground waters causes dental and
skeletal fluorosis. Professor Sheldon pointed out that in some of these
countries other elements, for example arsenic, are also naturally present and
he asserts that an element’s natural occurrence is no guide to its desirability.
As a result the World Health Organisation has developed Guidelines15 for
drinking water quality and recommends a Guideline Value for fluoride at 1.5
ppm16. Professor Lennon cited that the WHO Guideline value is described as
“the concentration of a constituent that does not result in any significant risk
to health over a lifetime of consumption including different sensitivities that
may occur between life stages”17. In Professor Lennon’s view, governments
in countries where there are high levels of naturally occurring fluoride
generally recognise both the risks and potential benefits of fluoride and strive
to achieve a healthy balance.
4.3.1
Currently around six million people in England receive water, which either
has its level of fluoride adjusted to, or has a natural fluoride content of
around 1 milligram per litre (one part per million or 1ppm). Half a million
people in the UK currently receive water with a naturally occurring fluoride
content which is sufficient to benefit their dental health.
4.3.2
In May 2000, the Irish Forum on Fluoridation undertook the first major review
of water fluoridation since its introduction in Ireland in 1964. The resulting
Report recommended the optimal level of fluoride in drinking water should be
amended from the present level (0.8 to 1.0 ppm) to between 0.6 and 0.8
ppm, with a target value of 0.7 ppm.
4.4
Dental health improvement in recent years
Professor Sheldon suggested that improvements in dental health and
reduction in dental caries in countries that did not fluoridate water should
also be taken into consideration, as the increased use of toothpaste, better
dental/oral hygiene and nutrition over the years may have all played a role.
This point is illustrated by graph below that shows the trends in caries in EU
countries over the last few decades and illustrates the similar trends in both
water fluoridated and non fluoridated region.
World Health Organisation (2006) Briefing on Fluoride in Drinking Water
Parts per million
17
Source cited as World Health Organization 2006
15
16
Final – June 2007 PSOC
Page 13
Mean number of decayed, missing or filled teeth in 12 year olds in European Union
countries (1965 – 2003)
9
—
—
—
—
8
7
No water fluoridation
Water fluoridation (% population covered)
Salt fluoridation (% population covered)
Data not given
Mean DMFT
6
5
4
3
2
1
0
1965
Austria
Portugal (1%)
1970
1975
Denmark
Spain (3%)
1980
Finland
UK (9%)
1985
Year
Netherlands
France (40-50%)
1990
Sweden
Belgium
1995
Germany*
Greece
2000
2005
Ireland (74%**)
Italy
* Water fluoridation to 1.9% and salt fluoridation to 20 % of the population of former East
Germany. Discontinued after reunification.
2
** Coverage estimate from Whelon et al
†
Fluoridation details as stated by WHO Oral Health Country/Area Profile Programme
5.
CURRENT DEBATE
5.1
Health Inequalities
5.1.1
Dr Thomas’ argument centred on fluoridation’s role in tackling in oral health
inequalities. He quoted the Acheson Inquiry (1998) into Inequalities in
Health18, that identified whilst overall dental health in children is improving,
the differential in the number of decayed teeth between those in lower social
classes and those in classes I, II and III has increased. There is also a
geographical variation, with children living in the north having more dental
decay than those living in the midlands and the south.
Acheson Sir Donald, (1998) Independent Inquiry into Inequalities in Health Report,
Section 7, recommendation 22.2, The Stationery Office
18
Final – June 2007 PSOC
Page 14
5.1.2
In the most deprived areas, people are less likely to go to the dentist, or take
their children to the dentist, until they experience pain. This means that some
children do not see a dentist until they have tooth decay and need an
extraction or filling.
Dr Beal also stated that one of the reasons that children in social classes III,
IV and V benefit substantially from fluoridated water is that there is evidence
that children in social classes I and II quickly receive and implement health
promotion and ill health prevention messages. This contrasts with a delay of
20-40 years in the other social classes before they are seen to adopt health
behaviours. With fluoridation of water all people in classes receive the
benefit simultaneously. In his view, it is therefore the most cost effective
public health measure.
5.1.3
The Dental Health of Rotherham’s Children
Within the local region, the dental health of 5 year olds varies considerably,
as shown in the graph19 below:
Dental health of 5 year olds 2003-2004 South Yorks/South Humber
3
Teeth affected per average child
2.5
2
1.5
1
0.5
decayed teeth
missing teeth
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filled teeth
Dr Thomas commented that all the areas with better oral health than
Rotherham were either affluent or had artificially fluoridated water.
He also quoted a 2003/2004 survey carried out in association with the British
Association for the Study of Community Dentistry which showed that
Rotherham 5 year olds had an average dmft of 1.89, with some areas
around 4. This contrasts starkly with the national mean of only 1.49.
19
Rotherham PCT (December 2006) Rotherham Oral Health Strategy 2006/09
Final – June 2007 PSOC
Page 15
Furthermore, Dr Beal stressed the importance of considering how much
tooth decay individuals from some communities may have, rather than
focusing on the average dmft rates for the borough as a whole.
The distribution of poor oral health generally follows deprivation, with decay
rates being highest in Central, Herringthorpe, Park, Boston, Brampton,
Melton and Wentworth. (See Map below20 of dmft rates related to wards21.)
These communities are amongst those experiencing the highest level of
multiple deprivation in Rotherham and are targeted for special action under
the Neighbourhood Renewal Strategy22.
Rotherham PCT (December 2006) Rotherham Oral Health Strategy 2006/09
Rotherham Council ward boundaries changed in 2004. These figures relate to the old
ward boundaries – (note: there is an error in the original map. The left hand ‘Rawmarsh
East’ should read ‘Rawmarsh West’)
22
RMBC (2005) Neighbourhood Renewal Strategy 2005-2010, Section 5
20
21
Final – June 2007 PSOC
Page 16
The connection between deprivation and poor oral health is to do with the
increased likelihood of a poor diet, a less ordered lifestyle and lower
educational achievement. In his view, fluoride can therefore help to reduce
health inequalities.
5.2
Pro-Fluoride Lobby
Adding fluoride to water is credited by many for being responsible for a
decline in tooth decay and a reduction in incidents of dental caries. Its
supporters assert that it is convenient and as it is added to the water supply,
available to the general population, regardless of income. As demonstrated
above, children in deprived areas suffer from much higher levels of tooth
decay than their peers in more affluent areas.
Final – June 2007 PSOC
Page 17
Many health specialists, including the World Health Organisation, British
Fluoridation Society, British Medical Association, British Dental Association
and Royal College of Physicians claim that fluoridated water would address
this inequality.
5.3
Anti-Fluoride Lobby
Opponents to fluoridation suggest that decreases in dental decay could be
better explained by improvement in dental hygiene and diet rather than
water fluoridation. Furthermore, they claim that the long-term risks to health
or the environment attached to fluoridation have yet to be explored.
Consumption of fluoridated water at high concentrations has been proven to
cause severe skeletal deformities. Even at recommended levels, fluoridated
water can cause dental fluorosis (browning or mottling of the teeth) in young
people.
In the UK, supporters of the anti-fluoride lobby include the National Pure
Water Association, the Green Party and Friends of the Earth.
5.4
The York Review: A Systematic Review of Public Water Fluoridation
There has been little objective review of the pros and cons of fluoridating the
water supply and the polarised position of both sides has seriously clouded
the debate. In 1999, the Department of Health commissioned York
University’s NHS Centre for Reviews and Dissemination (CRD), to review
the evidence on fluoridation of water. The Review’s steering group was
chaired by Professor Trevor Sheldon, and during the course of the review it
considered 3000 research papers spanning over 50 years of evidence. The
review was published in 200023.
The review looked specifically at the effects on dental caries/decay, social
inequalities and any harmful effects. It commented on the poor quality of
evidence across all the areas it examined. It concluded that the evidence
suggested that water fluoridation was likely to have a beneficial effect. This
beneficial effect comes at the expense of an increase in the prevalence of
fluorosis (mottled teeth). No association between water fluoride and other
adverse effects such as cancer, bone fracture and Down's syndrome was
found. However, the Review team felt that not enough was known because
the quality of the evidence was again poor. The evidence about reducing
inequalities in dental health was contradictory and unreliable.
However, it should be noted that research has continued to be undertaken in the seven
years since the York Review and findings from some of these recent studies are referred to
elsewhere in this report.
23
Final – June 2007 PSOC
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5.5
Medical Research Council - Working Group Report: Water fluoridation
and health
In light of the York Review’s criticism of the quality of research, the
Department of Health commissioned the Medical Research Council to
consider some of the concerns that have been expressed about the safety of
fluoridation and make recommendations for further research.
The MRC’s key findings and recommendations include:
•
•
•
•
•
support for the findings of the York Review that fluoridating water may
have a beneficial effect on reducing tooth decay
the majority of research indicates that water fluoridation reduces
inequalities in dental decay between high and low social groups
additional information about fluoridation is needed by the public to
make informed decisions, particularly on the prevalence of forms of
dental fluorosis
the evidence does not support claims that fluoridated water affects the
immune system, the reproductive system, child development, the
kidneys or the gastro-intestinal tract. Consequently the MRC did not
recommend any further research in these areas.
comparison be made between the amount of fluoride the body
absorbs from water supplies in which it occurs naturally and those to
which it has been added artificially.
The York Review criticised that many studies did not take account of the
level of fluoride exposure from other sources, such as toothpastes and other
dental health care products containing fluoride, and the potential for fluoride
exposure from food sources, for example tea and fish. The MRC proposed
future studies on the impact of water fluoridation should take account of this.
6.
FINDINGS
6.1
Is there evidence that artificial fluoridation of the water supply prevents
tooth decay?
6.1.1
The York Review stated that the best available evidence suggests that
fluoridation of drinking water supplies does reduce dental caries. It
concluded that water fluoridation can reduce dental health inequalities
across social classes; particularly in children aged 5-12. The observational
research indicated that there is an increase in the percentage of caries free
children in areas with fluoridated water (about 15%). However, Professor
Final – June 2007 PSOC
Page 19
Sheldon urged caution as these estimates could be skewed and other
factors not taken into account.
6.1.2
In support of the benefits of fluoridation, Dr Beal gave examples of findings
in the Midlands and North of England in different age groups of children24 :
Fluoridated
Non-Fluoridated
Difference
3 year olds
Huddersfield25
dmft = 0.30
Dewsbury25??
dmft = 0.74
59%
5 year olds
Newcastle
dmft = 1.3
N Manchester
dmft = 3.3
61%
Bolton
DMFT = 3.8
40%
14-15 year olds Birmingham
DMFT = 2.3
6.1.3
Similarly, South Yorkshire’s dental health can be compared with that of the
Black Country, 97% of which receives fluoridated water26.
S Yorkshire
Average no. of dmft per 100 five year olds 178
(2003/04)
No. of children under ten given a general 2646
anaesthetic for dental treatment
(2002/03)
Black Country
100
683
Mr Lennon pointed out that children in some relatively deprived areas of the
West Midlands have fewer teeth affected by decay than children in parts of
the more affluent South East England.
6.1.4
Whilst this evidence supports the benefits of fluoridation, Professor Sheldon
pointed out that other data could be available which showed less stark
comparisons and may even show no difference between areas with or
without fluoride.
Source: Dr John Beal, SHA in answer to supplementary questions
Yorkshire Water terminated fluoridation at the time of privatisation in 1989 and the dmft rates for 5
year-olds has since increased to 4.6 (Source: Lord Chan in House of Lords debate on Water Act, 9
July 2003)
26
Source: Professor Michael Lennon, British Fluoridation Society in answer to supplementary
questions
24
25
Final – June 2007 PSOC
Page 20
6.1.5
Although all adults with their own teeth will benefit from fluoridation the
greatest benefit will be to those who live in the fluoridated area for much of
their life. Dr Beal quoted a series of studies supporting this. In Hartlepool
(fluoride at 1 ppm) and York (with negligible fluoride) which found that
fluoride reduced decay, tooth extractions and the need for partial dentures in
every 5-year age band from 15 to 65 years. In the fluoridated part of
Anglesey, lifelong adult residents aged 16-32 years had on average 30%
fewer decayed, missing or filled teeth compared to lifelong residents from the
non-fluoridated part. In Eire, 45-54 year olds still had 16.4 natural teeth in
fluoridated communities compared to only 10.7 in non-fluoridated
communities – a 34% difference. Dr Beal believes that there is a lifelong
benefit from fluoridation.
Professor Lennon explained that as adults reach their 50’s there is an
increased risk of tooth decay, therefore fluoride is of benefit to adults as well
as children. Treating dental disease in elderly patients can present
additional problems, ranging from their ability to attending a surgery to
complications with the treatment itself, particularly if they have other complex
medical requirements.
Root decay is also common in later adulthood. Mr Field suggested that
fluoride may help with this form of tooth decay.
6.1.6
A number of witnesses asserted that adding fluoride to water would reduce
dental problems and thus the need for intervention.
For example, extraction of decayed teeth in children is often done under
general anaesthetic due to the discomfort they may experience and their
reaction to this. Dr Beal told the review that general anaesthesia for
children’s dental treatment is used seven times more often in non-fluoridated
South Yorkshire than in fluoridated Birmingham and the Black Country. This
costs about £300 per child and has some health risks and can be distressing
for the child. Reducing child dental decay would reduce the need for general
anaesthesia.
Many people’s dental needs in later life are related to their disease pattern
when young. More adults are keeping their teeth into later life; fillings have a
finite lifespan and therefore having to fill teeth in younger adults/children
commits them to a lifetime of treatment needs.
6.1.7
Mr Field also referred to the new dental health contract, and stated that in his
view, this made it harder for dentists to undertake preventative work. If less
time was spent treating decay, more could be spent on health promotion,
preventive work, reducing waiting times, supporting smoking cessation etc.
There is a huge dental health need in Rotherham and whilst the NHS tried to
improve dental health education, fluoridation would help those who could not
access dentists for whatever reason. Mr Field stated that access to dentists
was still an issue for people in Rotherham (and elsewhere), and that if the
water supply were fluoridated, it was likely that there would be a reduction in
the experience of acute pain and long term dental needs.
Final – June 2007 PSOC
Page 21
6.2
Is it safe to artificially fluoridate the water supply?
6.2.1
Professor Sheldon was struck by how poor the quality of existing research
was, whether it focussed on beneficial or adverse effects. There is a
tendency for research to be less rigorous when the research body is trying to
prove a point – in this case, whether strongly pro or anti-fluoridation. Despite
the plethora of research undertaken, none has been conducted using the
rigorous ‘randomised control standards’. This standard enables the
researcher to evaluate whether the intervention itself, as opposed to other
factors, causes the observed outcomes. Until high quality studies are
undertaken providing more definite evidence, there will continue to be
legitimate scientific controversy over the likely effects and costs of water
fluoridation.
Professor Sheldon concluded that whilst there are likely to be some, but
maybe modest, benefits, there may be potential harm associated with water
fluoridation. Current research does not allow for confident judgement on
either the risks or benefits.
In Professor Sheldon’s view, people need to be able to make an informed
judgement of the risks and benefits of fluoridated water and the quality of
evidence available at the moment does not allow for this.
6.2.2
In Dr Thomas’ view fluoridation was safe, and this was supported through
research evidence, disputing some of Professor Sheldon’s statements
regarding the quality of evidence. A fluoride concentration of 1ppm equates
broadly to the fluoride naturally occurring in a cup of tea. He also quoted that
the safety of fluoridated water is supported by a number of key health
organisations27 and believes that members of the public support fluoridation,
citing positive responses in recent public surveys (although detailed findings
were not considered as part of this review).
6.2.3
Dental Fluorosis
6.2.3.1 Concerns were raised by the review group about the incidence of dental
fluorosis in children, which has been shown to be approximately twice as
prevalent in fluoridated Newcastle than in fluoride deficient
Northumberland28.
The York Review found evidence that adding fluoride to water does increase
the risk of fluorosis to the teeth. In areas of fluoridated water of 1.0ppm,
These include World Health Organisation, British Medical Association, British Dental
Association and Royal College of Physicians
28
Rock, P (2000) A prevalence study of dental fluorosis in infancy, British Dental Journal 26
August 2000, volume 189
27
Final – June 2007 PSOC
Page 22
there is likely to be an estimated 48% prevalence of dental fluorosis,
although the prevalence of fluorosis of significant aesthetic concern is likely
to be 12%. Mr Field’s explained that in his experience, visible fluorosis is
rare and in many cases is only detectable by dentists. Even where it is
visible, he believes it to be a cosmetic issue as opposed to tooth decay,
which is a health issue. In extreme cases, the marks on teeth can be hidden
either by tooth coloured filling or porcelain covers (veneers) on the most
visible teeth.
6.2.3.2 In the US, advice29 had recently given to parents not to mix fluoridated water
and baby milk together as this can lead to babies being exposed to fluoride
at 200 times the level naturally occurring in breast milk. It is suggested that
this could lead to dental fluorosis in permanent teeth. However, Dr Beal
asserts that there is no evidence of any adverse health effects from feeding
infants using fluoridated water. It has been known for a long time that there
is a small risk of dental fluorosis. The dental public health consultants would
endorse the advice given elsewhere, namely that parents who are
concerned can reduce even further the already small risk of dental fluorosis
by (preferably) breast feeding or using a ready-to-use infant formula or
making the powdered formula up with a suitable bottled water.
6.2.3.3 In the UK, all parents (regardless of whether their water is fluoridated) are
advised that children’s tooth brushing should be done using a smear or small
pea sized amount of fluoride toothpaste. Tooth brushing should be
supervised up to the age of 6 or 7 years. Parents of young children who are
at low risk of caries and living in a fluoridated area may consider using a
toothpaste with a lower level of fluoride (less than 600 ppm). Indicators of
low risk include little evidence of past tooth decay, no history of tooth decay
among siblings and good oral hygiene30.
6.2.3.4 Although some view dental fluorosis as a largely cosmetic issue, NPWA
believes that not only can it have a psychological effect on sufferers, but it is
also a key marker for developmental toxicity31, with an adverse effect on
dental, skeletal and brain tissues.
6.2.4
Whilst the risk of dental fluorosis is proven, other risks and their extent are
not clear. Because the quality of evidence was poor, it was difficult to make
informed conclusions about any other risks or potential harm. Professor
Sheldon suggested that even if there was a modest risk attached to water
fluoridation, as the population as a whole will be exposed to fluoride over a
prolonged period of time, a small risk could still equate to a large number of
people affected (if all water in England was fluoridated and there was 20%
risk, this would mean that 10,000 people could be affected across the
American Dental Association interim guidelines, 9 November 2006
Levine, RS and Stillman-Lowe, CR, (2004) The scientific basis of oral health education,
31
DenBesten, P. 1999 cited by NPWA
29
30
Final – June 2007 PSOC
Page 23
country).
Professor Sheldon summarised the problems as follows:
that it is difficult to measure the total exposure to fluoride because
water is not the only source;
there may be a long period of exposure required before an outcome is
seen, which makes it difficult to identify the risk;
there are a lot of ‘confounders’, i.e. other issues that may impact on the
findings such as environmental or health factors.
6.2.5
Mrs McDonagh states that although fluoride has low levels of acute toxicity,
it is not clear what the risks are when ingested over time. She also pointed
out that that if fluoride is not specifically looked for as a causal factor for
medical conditions, it will not be found. This is not routinely tested for in
England.
6.2.6
NPWA has concerns about the levels of fluoride ingested by people
receiving fluoridated water, particularly as the amount of water drunk can
vary hugely from one person to another. Also, as fluoride is found in other
sources, e.g. fish, tea and other foods as well as toothpaste, toiletries and
medicines, an individual is not able to control his/her individual intake of
fluoride.
6.2.7
Ian Packington asserted that one of the reasons that the Government was
promoting the fluoridation of water was to mask the levels of fluoride
pollution emitted by industry. He pointed out that the first UK cities to have
artificially fluoridated water were already the sites of heavy industry. No
specific evidence was provided to substantiate this claim at the review
meeting itself, but reference was made to a book which expounds this theory
and provides evidence to support it32.
6.2.8
Other potential Effects on Health
6.2.8.1 There is considerable evidence to link high fluoride levels in water in areas of
the developing world to bone spurs and skeletal deformities33. These
problems are exacerbated by poor diet. As the York Review found, it is
difficult to find evidence of skeletal fluorosis occurring in developed countries
that have fluoridated water supplies, whether artificial or naturally occurring.
Mrs McDonagh quoted the work of Dr Peter Mansfield that suggested that
there are higher concentrations of skeletal fluorosis in fluoridated areas
Bryson, C (2004) The Fluoride Deception, Seven Stories Press, U.S.
Skeletal fluorosis is found in people in India who have consumed naturally occurring
fluoride in doses ranging from 4 to 11 parts per million, although this is higher than the
amount permitted within the EU
32
33
Final – June 2007 PSOC
Page 24
(namely the West Midlands). He asserts that the skeletal fluorosis, often
attributed to arthritis, can have a detrimental effect of joints and tissue
function, including chronic back pain.
6.2.8.2 NPWA believes that ingestion of fluoride may lead to a wide range of health
problems including adverse thyroid function, irritable bowel syndrome,
neurological effects, renal problems, damaged sperm production, diabetes
and cancer. It also asserts that fluoridated water is linked to birth
deformities, cot death and still birth. The Association provided extensive
information to support these claims, however, the review group found it
difficult to develop an informed view due to conflicting evidence. The York
Review34 found that whilst many of these claims could not be substantiated,
this was mainly due to the poor quality of research rather than empirical
findings.
6.2.8.3 Mrs McDonagh quoted a study35 that found that hip fracture prevalence is
30% higher in fluoridated areas than those without fluoride added to the
water. However this is not supported by research by the Medical Research
Council36 and subsequent research showed that this level should be revised
downwards37. She quotes the view of Dr Hardy Limeback, Professor of
Preventative Dentistry at Toronto University is that “the evidence that
fluoridation is more harmful than beneficial is now overwhelming”. He makes
a link between fluoride and bone fractures and bone pain and asserts that
fluoride is not safe for individuals who cannot control their dose or in people
who retain too much fluoride38.
6.2.9
Plumbosolvency
A number of Rotherham households still have lead water pipes. The review
group was concerned that fluoridating Rotherham’s water may have an
effect on how much lead is absorbed these. Mr Woolloff stated that adding
fluoride is not expected to have any effect as all of Rotherham’s water is
conditioned with a small quantity of phosphate to minimise plumbosolvency.
It should be borne in mind that the York Review was limited to evaluating studies into the
effectiveness and possible harm of artificial fluoridation closest to the level of 1ppm
35
Water Fluoride Concentration on Fracture of the Proximal Femur (1990) Cooper, C et al
36
Professor David Coggon et al, (2000) Fluoride in drinking water and risk of hip fracture in
the UK: A case-control study, Medical Research Council (MRC) Southampton University,
37
Cooper C Wickham C Lacey R Barker D “ Water fluoride concentration and fracture of
the proximal femur” J. Epidemiol. Commun. Health (1990) 44: 17-19 c.f. subsequent letter
to JAMA: Cooper C Wickham C Barker D Jacobsen S “Water fluoridation and hip fracture”
JAMA (1991) 266: 513-514, where the original conclusion that “there is no significant
increase in hip fracture rates in the artificially fluoridated areas of the U.K.” had to be revised
to reflect a likely increase of incidence in the region of 15%
38
http://www.southcoasttoday.com/daily05-06/05-14-06/02opinion.htm, 14 May 2006 (link
no longer available)
34
Final – June 2007 PSOC
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6.3
Alternatives to Fluoridated Water to improve Dental Health
6.3.1
Screening and Prevention
Non-interventive treatments include tooth-scaling to remove plaque and
fissure sealants on the biting surfaces of molars.
However, these
approaches are preventative and cannot treat existing decay.
As part of its supplementary information NPWA submitted a paper which
suggested that screening and preventative work could best be provided in
schools39. Ms Collins stated that although there is evidence that input by
oral health promotion workers does increase knowledge around caring for
teeth and gums, it does not appear to affects dental disease levels.
6.3.2
Education
6.3.2.1 Although oral health can be achieved through education and improved
hygiene, Mr Field emphasised the difficulty in teaching children to brush their
teeth effectively. Ms Collins confirmed this by stating that one of the biggest
challenges for health promotion is the difficulty in encouraging people to
follow good practice when their lives may be chaotic and tooth brushing,
reducing sugar or buying toothpaste may not be their highest priority.
6.3.2.2 Ms Collins explained that the role of her team is to reduce inequalities in
dental disease experience, using a range of different interventions. These
include focusing on healthy diet and weaning, a dental milk scheme, the
‘brushing for life’ scheme and other group interventions, targeting groups
that were most at risk. The combined effect of this work has shown some
improvement in one area40, but that the reduction in tooth decay is less than
the fluoridation of water could achieve, and was not universal.
6.3.2.3 The most comprehensive evaluation carried out to date is that of the input
into the Rawmarsh Sure Start area (which included a fluoridated milk
scheme). It shows that an intensive approach to oral health promotion, the
inclusion of food work within the oral health promoter’s role and flooding the
area with training and resources can affect the disease levels in an area –
but only by 10%, i.e. average dmft dropped from 5 to 4.541. However, the
cost over the 7 years the project has run is £77,520 in wages (over 5 years)
and £28,146 in resource, staff development and travel money giving a total
of £105,666 for the life of the project to date. Therefore there must be
caution as this approach is time and cost intensive and not guaranteed to
work in the many other areas of Rotherham where there is the equivalent
Holdcroft C (2002) Preventative Dental Treatment and Dental Health Expenditure in
Wolverhampton 1997-2002, NPWA
40
Average dmft reduction of 0.5
41
Source: interim report - the official end of programme report is due out at the end of 2007
39
Final – June 2007 PSOC
Page 26
level of need.
6.3.2.4 The review group was told that interventions often rely upon short term
funding, yet it takes some time to be able to demonstrate improvement.
Funding for some of the current projects is about to change, and whilst the
team tries hard to work with other agencies, there is a packed health
promotion agenda and dental health is only a small part of it. It is therefore
difficult to sustain the work continuously at an adequate level.
6.3.3
Sharing Good Practice
6.3.3.1 Ms Collins explained that there is a local support group for oral health
promotion workers in Barnsley, Rotherham, Sheffield and Doncaster.
Members of the local group provide two study days for oral health promotion
workers from local area each year and are part of the National Oral Health
Promotion Group as well. These groups share practice that works and
issues within oral health and general health promotion. Rotherham’s Oral
Health Promotion Team also has links with the Department of Health to
share its experiences and absorb expertise into the work of the team. The
Team also works with many different teams and agencies and therefore
picks up good practice points from other areas as well as ensuring its
practice is incorporated into theirs.
6.3.4
Other Fluoride Treatments
6.3.4.1 ‘Fluoride paint’, i.e. fluoride painted onto the surface of the teeth does
provide some protection against dental caries, but it is not something that
can be done on a regular basis. Mr Field’s view is that it could not be as
effective as fluoridation of drinking water.
6.3.4.2 Alternative fluoride treatments (including toothpastes, gels, drops and
tablets) can also be prescribed, but Mr Field questioned whether they
reached the target groups. When asked about any risks attached to
children and adults ingesting fluoride from toothpaste, he explained that the
advice for children was to use very small amounts of toothpaste and that
there was special toothpaste for milk teeth that contained a lower level of
fluoride42. Children need to be taught how to brush their teeth properly and
to use the correct amount of toothpaste.
6.3.5
Delay or Prevention of Streptococcus mutans
Dental caries (tooth decay) is basically an infectious disease. When the first
teeth erupt, they can be colonized by Streptococcus mutans, the
predominant bacteria of dental plaque. This bacterium converts sugars and
42
Typically 500 ppm
Final – June 2007 PSOC
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carbohydrates in the mouth to acid, which dissolves and weakens the tooth
enamel - tooth decay.
Babies mainly pick up the Strep. mutans germ from their mothers during
delivery (it is also found in the genitourinary tract) or after birth by kissing or
other direct contact with saliva, coughing, sneezing or handling). The most
vulnerable time for infection is between 6 and 31 months. Mothers with high
levels of Strep. mutans infection due to poor oral hygiene are most likely to
infect their children. The later in childhood that a child becomes infected, the
lower his lifetime risk of infection43 .
Thus prevention of tooth decay in children requires delay or prevention of
Streptococcus mutans infection, or suppressing the germ's activity, together
with attention to mother's oral health before and after childbirth, since she is
the prime source of infection.
In Sweden since the 1970s there has been a programme targeted at
pregnant women and children from disadvantaged communities aiming to
remove Strep. mutans by using a range of preventative interventions44. This
has been shown to be effective in reducing dental decay in over a long
period.
6.3.5.1 Although there were animal studies in the early 1980s45, no vaccine is
currently available in UK against dental caries based on the mutans
streptococci antigen. In addition, such a vaccine is highly unlikely to be of
benefit as research has shown that if one variety of bacteria is removed from
the mouth, other bacteria tend to increase their colonisation to compensate.
Dr Thomas and Dr Beal both pointed out that bacteria other than
Streptococcus mutans (such as the lactobacilli) also cause dental caries.
However, if all bacteria are eliminated from the mouth, it may become
colonised by yeasts, leading to an unpleasant condition called ‘Black Hairy
Tongue’.
6.4
The Ethics of fluoridating Water Supplies
Whether or not water fluoridation reduces dental caries in children has been
subject to considerable debate. Much of the evidence is scientific rather than
moral and centres on the benefits and risks of adding fluoride to water
supplies. However, there is a clear moral dimension surrounding the
Source: http://www.drhull.com/EncyMaster/C/caries.html
Cited by NPWA: Varmland Experiment - Axelsson P, Paulander J, Svärdström G,
Tollskog G, Nordensten S: Integrated caries prevention: The effect of a needs-related
preventive program on dental caries in children – County of Värmland, Sweden – Results
after 12 years. Caries Res 1993, 27(suppl 1):83-84.
45
funded by the Department of Health
43
44
Final – June 2007 PSOC
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fluoridation issue arising from questions of informed consent and autonomy
to make decisions, particularly in the context of public health policies.
Dr Taylor explained that every decision that we make reflects a value
judgement. Mostly these are taken in one’s own self-interest. However, it is
important that consideration is also given to the interests of others, even
where conflict occurs. Ethics is the branch of philosophy that explores
value-laden decision making and conduct. Decisions made in public health
policy should be a reflection of the values and beliefs of individual decision
makers and of society as a whole, balancing the potential benefits and
harms of all alternatives. Bioethics is the study of the moral, social and
political problems that arise from medicine and the life sciences, that involve
human well-being.
6.4.1
Dr Taylor suggested that the UNESCO Universal Declaration on Bioethics
and Human Rights (2005) was an appropriate tool to assist in the
understanding of bioethical issues. Dr Taylor explained that Article 3 of the
UNESCO declaration, states that the freedom, dignity and autonomy of the
individual must be respected and they have the right to make their own
decisions. Article 6 considers the issue of ‘consent’ and states that:
“any preventive, diagnostic and therapeutic medical intervention is only to be
carried out with the prior, free and informed consent of the person
concerned, based on adequate information. The consent should, where
appropriate, be express and may be withdrawn by the person concerned at
any time and for any reason without disadvantage or prejudice”.
6.4.2
However, Dr Thomas explained that Article 27 of the Declaration qualifies
that the basic principles may be limited by law, in the interests of public
safety, for the protection of public health or for the protection of the rights
and freedoms of others.
6.4.3
In arriving at its conclusions, Dr Taylor urged the review group to be mindful
of the basic principle to protect autonomy and the individual’s right to give
consent. If supporting fluoridation, the review group must be confident that
the interests of those who would be positively affected are higher than those
who would be negatively affected, and that these interests must be shared.
The UNESCO Declaration makes it clear that choice should only be
restricted if there are clear benefits in doing so and if it can be demonstrated
that the benefits are greater than any harm caused. The primary question is
which is the more significant interest?
6.4.4
There is intense argument about whether fluoride constitutes a medicinal
product. Many say as it is a natural occurring substance, it should not be
Final – June 2007 PSOC
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classified as a medicine46. Professor Lennon was asked whether fluoridation
constituted mass medication. He answered that he did not believe that it
was as there were parts of Britain that received their fluoride naturally, such
as Hartlepool. Instead, he stated that fluoridation of the water supply
required people to take fluoride for the benefit of others. He explained that
he saw the decision to fluoridate as not being an individual’s decision but a
decision on behalf of the collective good.
6.4.5
A contrary position suggests that because fluoride has a biological effect and
is being used to prevent disease, it should be considered as a medicine. If
this is the case, Professor Sheldon argues that its safety and efficacy should
rely on the same standards of proof for other licensed medicines. On the
basis of the evidence presented to the York Review, he suggests that would
be unlikely that fluoride would receive a license if it was being considered as
a drug/medicinal product as its risks and benefits have not been
demonstrated with sufficient rigorous research.
In his view, if fluoride is a medicine in the form of fluoridated water, it is being
provided in an uncontrollable dose and without consent. It is also given to
people who cannot benefit (i.e. those without teeth) as well as those who
may benefit from it. He cited that the principle of informed consent i.e. every
individual has the right to refuse treatment, is enshrined in the Council of
Europe’s Convention on Human Rights and Biomedicine 199747. However,
the same convention allows exceptions to this in the interest of public safety
and the protection of public health.
Many members of the anti-fluoride lobby, including the NPWA, believe that
fluoride is a medicine and therefore as consent has not been sought, its
provision contravenes the European Convention on Human Rights and
Biomedicine.
6.5
Are there other Practical Considerations?
6.5.1
Cost-effectiveness
The UK Government does not classify fluoridated water as a medicinal product. Water
intended for human consumption falls within the definition of food and is thus regulated
partly under the Food Safety Act 1990 and partly under water legislation. Reference,
Hansard, 12 May 1999. Available from
http://www.publications.parliament.uk/pa/ld199899/ldhansrd/vo990512/text/90512w01.htm
47
Article 5 of the Convention stipulates that “an intervention in the health field may only be
carried out after the person concerned has given free and informed consent to it. This
person shall beforehand be given appropriate information as to the purpose and nature of
the intervention as well as on its consequences and risks. The person concerned may freely
withdraw consent at any time”. However, the UK Government is not a signatory to the
Convention and its principles have not been incorporated into domestic law.
46
Final – June 2007 PSOC
Page 30
A cost effectiveness evaluation would be an important part of the
background work that the SHA would undertake as part of the process of
identifying potential fluoridation schemes. That work would be done before
the SHA took a decision to proceed with a public consultation on fluoridation.
Whilst surprisingly little is known about the cost-effectiveness of many
common healthcare interventions, the cost-effectiveness of water fluoridation
has been studied extensively over many years. Both Dr Beal and Dr Thomas
referred to a study commissioned by the former Yorkshire and Trent
Regional Health Authorities48 that concluded: “in terms of cost, effect and the
certainty of that effect, the most cost-effective policy is fluoridation of water
supplies.”
In 1998 the University of York Health Economics Consortium undertook a
further, detailed, examination of the costs and benefits of water fluoridation
and concluded:
“In areas where the average number of decayed, missing or filled teeth per
child (dmft) is 2.0 or more (and especially if there are districts where it is
greater than 2.6), and where the local water treatment works serve
populations of at least 200,000 people, the benefits of water fluoridation are
likely to be significantly greater than the costs.”
To date, the PCT has not costed the benefits identified in dental health
improvement arising from water fluoridation. This work was undertaken in
the past by the Trent and Yorkshire Regional Health Authorities, and would
need to be updated prior to any consultation on water fluoridation taking
place.
The World Health Organisation’s view is that “Community water fluoridation
is safe and cost-effective and should be introduced and maintained
wherever it is socially acceptable and feasible”49.
6.5.2
Capital and Revenue Costs
Dr Beal stated that the capital costs for fluoridating Rotherham’s water is not
currently known and would have to be fully costed by Yorkshire Water prior
to any consultation being undertaken. Given that local water supply areas
are not co-terminus with PCT boundaries, this feasibility study would be
jointly commissioned by PCTs in the Yorkshire and Humber region.
Sanderson, D and Wilson, A, (1994) The cost effectiveness of fluoridation, York Health
Economics Consortium, University of York
49
World Health Organisation (1994) Fluorides and oral health: report of a WHO expert
committee on oral health status and fluoride use. World Health Organisation, Geneva
48
Final – June 2007 PSOC
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Both Dr Beal and Dr Thomas suggested that based on experience
elsewhere, the capital costs would be around £2 per head of the population
served and the revenue costs about 50p per head per year.
For
Rotherham’s population of 253,000, that would equate to £126,500 per year.
This is less than the gross cost of a single additional dentist in Rotherham
(annual contract value average £145,000) or the much greater cost of
treating any dental disease which would otherwise have occurred.
When Mr Woolloff was asked to comment on the possible costs of
fluoridating the water supply, he explained that he had not done any formal
costing recently, but his rough estimation was that it would cost between
£2.50 and £3.00 per million litres per day. This would equate to about £150
- £200 per day for Rotherham, plus significant capital costs which would be
likely to be between £2.5 and £5 million.
Subject to the availability of funding, the Department of Health will contribute
up to 60% of the capital costs50. The remainder of the capital would come
from the NHS locally, as would the revenue. Dr Beal stated that the
apportionment between SHA and PCTs has not been discussed but this
would be set out in any consultation which took place, but the savings in
treatment costs would benefit the NHS locally.
6.5.3
Public Consultation
Dr Thomas explained that the PCT cannot formally ask the SHA to consider
water fluoridation until a feasibility study has been undertaken and the
probable costs estimated by Yorkshire Water. Only once this has been done
would the SHA undertake a full public consultation on proposals to fluoridate
the water supply. It is likely that such a consultation would be across the
whole of the Yorkshire and Humber region.
6.5.4
Practicalities of fluoridating Rotherham’s Water Supply
6.5.4.1 Mr Woolloff explained that it would be hard to fluoridate Rotherham’s water
without including Sheffield’s due to close links between the supplies. He
stated that the actual process of adding fluoride was quite straightforward
and similar to other processes already undertaken by water providers. It
would involve bulk storage of the chemicals, dilution, metering, and control
systems. The health and safety risks would also be similar to risks already
dealt with by water providers as they already deal with difficult chemicals
such as chlorine.
6.5.4.2 When asked whether artificial fluoride was any different from natural fluoride,
Mr Woolloff explained that hexafluorosilicic acid would be used to fluoridate
drinking water and as a chemical it is corrosive. However, once it is diluted
50
Under section, 89(6) of the Water Act
Final – June 2007 PSOC
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the lime and calcium in water neutralise the acid and it is no different from
natural fluoride. He confirmed that it is virtually impossible for people to
remove fluoride from their domestic supply if the water was fluoridated and
they didn’t want it to be.
Insofar as public liability insurance is concerned, the Government has
accepted the principle that Water Undertakers should be indemnified against
any future claims that may arise from fluoridation (other than acts of
negligence).
7.
CONCLUSIONS DRAWN FROM THE EVIDENCE
The review group is aware that the debate about water fluoridation is
polarised, the quality of research is variable and the conclusions drawn, are
often contradictory. The review group comprised eight lay people with a
wide range of experience, but no medical or dental background. It
nonetheless endeavoured to establish a view on the basis of the evidence
presented from all sides of this complex debate.
7.1
Does adding fluoride to water reduce dental decay in children?
7.1.1
There is evidence that that fluoridated water reduces dental caries rates
across all communities – but will be of particular benefit to children from
living in areas of deprivation and disadvantage.
7.1.2
There has been no significant improvement in dental health of 4-5 year olds
in Rotherham over the last twenty years. Furthermore, many children will
have significant levels of dmft well above the borough average. However,
evidence suggests a slight improvement in the dental health of 12 year olds.
It is not clear what factors have influenced this improvement, which has
taken place without water fluoridation, but the use of fluoride toothpaste is
likely to be one.
7.1.3
Access to local dentists is an issue in Rotherham. Fluoridation of water has
the advantage of targeting the entire community, including those who may
not access dental care and may have a poorer diet.
7.1.4
Across the UK population as a whole, dental health has been steadily
improving. However, it is difficult to identify whether the improvements in
dental health in fluoridated areas can be attributed solely to water
fluoridation or if they are the result of general improvements to dental health.
These include increased use of fluoride products, higher levels of awareness
about dental hygiene, more preventative dental care etc.
7.1.5
In many respects water fluoridation is the easiest and most cost effective
way of preventing dental caries in children and young people, however there
are concerns, because fluoridation is the ‘cheapest’ option, that it could be
seen as an alternative to investing in possibly more costly, targeted
preventative interventions.
7.1.6
Preventative interventions take time to demonstrate improvements but often
Final – June 2007 PSOC
Page 33
rely upon short term funding, competing with other health promotion work for
resources. Given the uncertainty about funding, it is therefore difficult to
sustain the work continuously at an adequate level.
7.1.7
It appears that reducing the Strep. mutans bacterium in both mothers and
children reduces dental caries in those children. This can be done through a
combination of oral health education and the use of antibacterial
mouthwashes. This may be a viable alternative to water fluoridation that
carries fewer risks.
7.1.8
The review group had concerns about the diet of children and young people,
particularly the consumption of sugary foods and fizzy drinks, and the effect
on dental caries. They were not convinced that water fluoridation would
necessarily provide adequate protection if children continued to have a poor
diet and may not drink sufficient quantities of tap water.
7.1.9
Within the scope of this review, the review group did not consider in any
depth other models of dental health from comparative countries. However,
many European countries have made great improvements in the dental
health of young people without fluoridating the water supply. The review
group thought there may be some merit in further exploration of these
interventions.
7.2
What are the risks?
7.2.1
There is compelling evidence from elsewhere in the country to support water
fluoridation as a means of reducing dental caries particularly in younger
children. However, the review group was not satisfied that long term risks
had been explored sufficiently, particularly in respect of human and
environmental impact.
7.2.2
The risk of dental fluorosis is significant, ranging from minor occurrence to
incidents that are of significant concern to the individual affected and may
require cosmetic dental treatment. However, when fluorosis does occur, it is
often only visible to a dental professional. It is relatively rare for fluorosis to
be present at a level that affects an individual cosmetically.
7.2.3
The review group also had concerns about the effect of fluoridation on bottle
fed infants. It was not satisfied that the answers outlined in 6.2.3.2 offered
reassurance of safety.
7.2.4
The review group had serious concerns about the levels of fluoride ingested
by people receiving fluoridated water, particularly as the amount of water
drunk can vary hugely from one person to another. Also, as fluoride is found
in other products, an individual is not able to control his/her individual intake
of fluoride.
7.2.5
A review of fluoridation in Ireland recommended a reduction in the
concentration to an optimal level of 0.7ppm. In the UK, the recommended
optimal level has remained the same (at 1 ppm) for many years and the
review group is concerned that it might no longer be appropriate as fluoride
is now ingested through a variety of sources.
Final – June 2007 PSOC
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7.3
What are the ethics of fluoridating water?
7.3.1
As community leaders, it is important that Councillors make an informed
view of the ethical implications of water fluoridation, particular given the
controversy about whether this would constitute mass medication. Dr
Taylor’s evidence was key in informing the review group’s opinion. In line
with Article 6 of the UNESCO declaration, if water fluoridation does equate to
medical intervention, then the permission of all those affected is required or
have compelling evidence of benefits and there is no other way of achieving
outcomes.
7.3.2
The review group believes that whilst there is evidence of the benefits, the
risks have not been sufficiently explored. Furthermore, it would appear that
significant improvements to dental health may be achieved through other
interventions.
7.3.3
Although water fluoridation appears to be a cost-effective way of reducing
dental caries because of its universal effect, the review group questioned
whether the cost of adding fluoride for the whole borough could be better
spent improving the dental health of those communities in greatest need.
7.4
What is the current legal position and route for making changes to the
water supplies?
7.4.1
In recent years the Government has supported the principle of water
fluoridation to reduce dental caries and its Chief Dental Officer recommends
that PCTs and SHAs consider it as a realistic option to reduce health
inequalities51.
7.4.2
Rotherham PCT (together with other PCTs in the Yorkshire and Humber
Region) is in the preliminary stages of exploring the feasibility of water
fluoridation, but has yet to commission a full feasibility study.
7.4.3
It is not clear what the resource implications of water fluoridation would be
for the PCT, particularly as the Department of Health would only contribute
up to 60% of the capital costs and none of the revenue. However, any
substantial reduction in dental caries may result in reduced dental treatment
costs for the PCT.
7.4.4
For practical reasons it would be difficult to fluoridate Rotherham’s water
without that of Sheffield’s and other neighbouring areas. The current policy
of Sheffield City Council is to oppose water fluoridation.
Prof Bedi, R (2005) Fluoridation of Drinking Water. guidance from the Chief Dental Officer
(Gateway Ref. 5136), Department of Health
51
Final – June 2007 PSOC
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8.
RECOMMENDATIONS
8.1
Rotherham Metropolitan Borough Council
The review group considers that although water fluoridation could benefit
dental health (particularly for children in deprived communities), the longterm consequences are not sufficiently known. In addition, it is unhappy with
the ethical implications of universally adding fluoride to the water supply,
rather than offering fluoride supplements (and other preventative care) to
those in greatest need – particularly as such an intervention would not be of
universal benefit. This report therefore recommends that:
8.1.1
The Council’s current policy of opposing water fluoridation be reaffirmed.
8.1.2
The Council supports the principle of targeted intervention to reduced dental
health inequalities in those communities of greatest need.
8.1.3
That this report be included as part of the Council’s response in any future
formal consultation on proposals to fluoridate Rotherham’s water.
8.2
Rotherham PCT
8.2.1
Bring a report to Scrutiny on the current oral education work within the
borough, its cost and effectiveness and what factors have influenced the
improvements in the dental health of 12 year olds that have taken place
without water fluoridation. The report should include an indication of the
level of funding and staff resources that have been invested and how
sustainable these elements are in future service planning and also the
feasibility of improving dental health education in Rotherham, especially for
young children and for the most economically disadvantaged areas.
8.2.2
Given the link between diet and dental health, the review group suggests
that an assessment of the impact of recently-introduced healthy eating
initiatives52 on dental health be undertaken.
8.2.3
Report the evaluation of the targeted interventions in the Rawmarsh Sure
Start area (section 6.3.2.3)53 to Scrutiny, including an assessment of the
feasibility of extending this approach to other communities of need.
8.2.4
Evaluate the feasibility of targeting pregnant women in communities with
poor dental health, both before and after childbirth, to delay or prevent
Streptococcus mutans infection.
52
53
e.g. national 5-a-day campaign and healthy food in schools initiatives
At the end of 2007
Final – June 2007 PSOC
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8.3
NHS Yorkshire and the Humber (SHA)
8.3.1
Prior to undertaking any formal consultation on fluoridating Rotherham’s
water, seek additional evidence to address concerns about the possible
harmful effects.
8.3.2
Any consultation should reflect both the benefits, costs and risks associated
with water fluoridation so the general public can make an informed decision
about the issue.
8.3.3
Work with the relevant local authorities when identifying the list of
consultees.
8.3.4
That any consultation on proposals to fluoridate Rotherham’s water supply
takes place over at least a three month period.
8.3.5
Any decision to approve fluoridation should address the issues of informed
consent and autonomy and be considered in light of the UNESCO
Declaration54.
8.4
Department of Health
8.4.1
When reviewing the new dental contract, examine how preventative work in
children can be increased and targeted more effectively and ensure that the
resources invested are sustainable over time.
8.4.2
Continue to work with food manufacturers to further reduce sugar levels in
food and drink – and particularly those aimed at children.
8.4.3
Evaluate European alternatives to water fluoridation that could reduce health
inequalities in respect of children’s dental health.
8.4.4
In light of the increased use of fluoride products since the 1ppm optimal level
was set for the UK, reassess the appropriateness of this level.
8.4.5
Ensure that any further commissioned research into the effects of fluoride on
children’s dental health also considers the longer term impact on the health
of the adult population.
9.
THANKS
•
54
Dr John Beal, Dental Advisor to NHS Yorkshire and the Humber
UNESCO (2005) Universal Declaration on Bioethics and Human Rights
Final – June 2007 PSOC
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•
•
•
•
•
•
•
•
•
•
10.
Louise Collins, Oral Health Promotion Co-ordinator, Rotherham PCT
Brenda Cook, EAT Consultant, Centre for Public Scrutiny
Elizabeth McDonagh, Chairman and Ian Packington, Vice-Chairman
of the National Pure Water Association
Jason Field, Local dentist (Chair of the Local Dental Committee)
Professor Michael Lennon, British Fluoridation
Professor Trevor Sheldon, University of York
Dr Mark Taylor, Sheffield Institute of Biotechnological Law and Ethics
Dr Nigel Thomas, Director of Dental Public Health, Rotherham PCT
David Woolloff, Manager of Water Quality, Yorkshire Water
Cllrs Tony Mannion, Robin Stonebridge and Shaun Wright
INFORMATION SOURCES/REFERENCES
•
•
•
•
•
•
•
•
•
•
•
Acheson Sir Donald, (1998) Independent Inquiry into Inequalities in
Health Report, Section 7, The Stationery Office, London
American Dental Association, (2006) Interim Guidance on Fluoride
Intake for Infants and Young Children [online] Available from
<http://www.ada.org/public/topics/fluoride/infantsformula.asp>
Accessed on 24 April 2007
British Fluoridation Society (2004) One in a Million – The Facts about
Water Fluoridation 2nd ed. Manchester
Directors of Public Health in South Yorkshire (2006) Improving Health
- Narrowing the Divide: A Joint Annual Report of the Directors of
Public Health In South Yorkshire, 2005/2006 Rotherham Primary Care
Trust
Government of Ireland, (2002) Forum on Fluoridation, Stationery
Office, Dublin
Hull, J (2007) Caries, dental (tooth decay) [online] Available from
<http://www.drhull.com/EncyMaster/C/caries.html> Accessed on 24
April 2007
Medical Research Council, (2002): Working Group Report Water
Fluoridation and Health. MRC London.
Prof Bedi, R (2005) Fluoridation of Drinking Water, Guidance from the
Chief Dental Officer (Gateway Ref. 5136), Department of Health
Rotherham Partnership (2005) Neighbourhood Renewal Strategy
2005-2010
RMBC Adult Services and Health Scrutiny Panel (2006) Review of
NHS Dental Provision in Rotherham –2nd February, 2006 (first part of
a two stage review)
Rotherham PCT (2006) Rotherham Oral Health Strategy 2006/09
Final – June 2007 PSOC
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•
•
•
•
•
11.
Rock, P (2000) A prevalence study of dental fluorosis in infancy,
British Dental Journal 26 August 2000, volume 189
World Health Organisation (2006) Briefing on Fluoride in Drinking
Water [online]. Available from:
<http://www.who.int/oral_health/events/oral%20healtha.pdf>
Accessed 20 February 2007
UNESCO (2005) Universal Declaration on Bioethics and Human
Rights [online] Available from
<http://unesdoc.unesco.org/images/0014/001461/146180E.pdf>
Accessed 20 February 2007
University of York CRD, (2000): Fluoridation of the Water Supply: a
Systematic Review of its Efficacy and Safety. University of York. UK.
University of York, CRD (2003) What the 'York Review' on the
fluoridation of drinking water really found [online] Available from
http://www.york.ac.uk/inst/crd/fluoridnew.htm Accessed 13 March
2007
ANNEX 1
In 1988 the Environmental Health Committee recommended55 that
subject to the approval of the Policy and Resources Committee that:
1. This council requests that the Trent Regional Health Authority refrain from
any further action to add fluoride to the public water supply in the
Rotherham area, which the Borough Council opposes on the following
grounds:
a) Fluoridation of water is not a substitute for preventative dental care
and education - free and upon demand for all members of the
community from a properly staffed dental service;
b) The presence of dietary aluminium from water and other food
sources throws into question the level of bodily absorption of fluoride
and thus its role in fighting tooth decay
c) Unadulterated water should
community as a whole, and
with the means to purchase
consumer choice to those
fluoridation;
55
be available to meet the needs of the
not as a commodity available to those
it. Fluoridation of all water would deny
who question the efficacy of mass
Minute 563, July 1988
Final – June 2007 PSOC
Page 39
d) No quality assurance parameters exist that would safeguard the
supply from a privatised water industry placing profits before
standards. Until such time as the Water Authorities can control
undesirable elements in the supply to comply with EEC and World
Health Organisation standards it would be unrealistic to expect an
ability to comply in relation to fluoride monitoring.
2. This Council urges the Association of Metropolitan Authorities to press HM
Government to include water in proposals to further safeguard food quality
standards.
For further information about this report please contact:
Caroline Webb, Senior Scrutiny Adviser or Delia Watts, Scrutiny Adviser
Chief Executive’s Directorate, RMBC
The Eric Manns Building,
45 Moorgate Street, Rotherham, S60 2RB
tel: (01709) 822765
email: [email protected]
Final – June 2007 PSOC
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