BEIRUT: Fluoride won’t have a place in Lebanon’s salt shakers, at least for now. In December, activists and health professionals successfully stopped the implementation of a law that would have mandated fluoridation of all table salt in the country.
Through an online petition and meetings with Health Minister Wael Abou Faour, they warned that the law, originally passed by Parliament in 2011, would put the public at risk of illnesses associated with excessive fluoride exposure.
The health community in Lebanon and worldwide is divided on the issue of salt fluoridation. Opponents question its efficacy amid health risks of overexposure, while proponents say fluoridation is a highly effective measure in improving oral health.
“This is an issue of public health in Lebanon,” said Mounir Doumit, oral health spokesperson for the Public Health Ministry.
As the former dean of Lebanese University’s School of Dentistry, he supports salt fluoridation. He pointed to the findings of a 1994 oral health survey, which found alarmingly high rates of dental cavities and tooth decay among Lebanese public schoolchildren. Results showed that of children aged 12 and 15, 93 percent and 96 percent respectively, had cavities.
As a result of the 1994 survey, the Health and Education ministries began a multipronged campaign in 2007 targeting Lebanon’s public schools. The campaign raised awareness on proper oral hygiene, advised schools to provide less sugary food to students and started a weekly fluoride rinse for students.
Historically, dentists have recommended fluoride to protect against tooth decay and cavities. Water naturally contains fluoride, but not always at sufficient levels to protect teeth.
As a public health measure, countries worldwide have opted to add fluoride to water. In countries such as Lebanon, where water fluoridation would be impractical, salt fluoridation has been used instead.
Given the routine rinses in public schools, some have questioned the need for salt fluoridation.
Doumit said “local application cannot give a good result when the number of decayed, missing and filled teeth is already high.” He explained that fluoride and salt together could provide greater protection.
“We are not the first country to use these techniques,” he added.
He said the Health Ministry would not make an immediate decision on the fluoridation law, and acknowledged the need for including multiple viewpoints prior to moving forward.
He stressed, however, that both local and overseas dentists overwhelmingly support fluoridation as a protective measure.
Addressing concerns of properly mixing fluoride with salt, he said the ministry had consulted with an engineer to develop a proper technique so that 250 mg of fluoride are distributed through each kilogram of salt, as recommended by the WHO.
Omar Obeid, an AUB nutritionist, opposes salt fluoridation.
He cautioned against exposing the public to health risks of fluorosis, and questioned the effectiveness of salt fluoridation.
“Fluoride can protect 5-10 percent, but the major cause of dental decay is dental hygiene,” he said. He called for wider inclusion of key stakeholders in analyzing research and forming policy on oral health.
He cited dangers associated with excessive levels of fluoride and the need to tackle the root cause of tooth decay and cavities through better dental hygiene practices.
The activists had circulated an online petition citing dangers of overexposure to fluoride. Depending on the concentration of fluoride, risks can include tooth discoloration at the mild end of the spectrum. At extreme levels, fluorosis can cause bone density loss.
Findings from studies on fluoride draw a range of conclusions. One study that assessed the effects of salt fluoridation on middle-school-aged students in Mexico found significant decreases in the number of cavities, nine years after the addition of fluoride to salt.
However, a meta-analysis reviewing multiple studies on salt fluoridation called for further research to clarify whether fluoride was truly the causal factor for reduced number of cavities.
Obeid recently assessed fluoride excretion levels in schoolchildren the results of which will be published in a forthcoming study. He found that fluoride levels were not excessively low enough to warrant salt fluoridation.
He also noted that tea contains significant levels of fluoride, and as avid tea drinkers, the Lebanese receive sufficient exposure. He warned against exposure to a substance the body doesn’t need.
“Fluoride is a naturally occurring substance, but it is not a nutrient to the body,” he said, contrasting it with iodine, an essential nutrient long added to table salt for preventing goiter.
Obeid and other activists fear flouridation will not be administered properly by the salt industry. Getting the right concentration of fluoride in salt is essential as what is harmless in small amounts becomes toxic in large amounts.
“What if they don’t do a proper mixing of fluoride, this is what we are worried about. Who will control them and how?”
Professionals on both sides of the divide agree that oral health issues such as decay and cavities disproportionately affect Lebanon’s poor.
Children from low income homes are lacking in basic oral hygiene equipment.
“If you are in the public school system, you will notice that 80-90 percent of children don’t have a toothbrush at home, so even with fluoridation, decay won’t go down, in fact, you may be giving false hope with such a campaign,” Obeid said.
Dentist Jeff Khoury shared a similar view on the state of oral hygiene practices in Lebanon, saying the country is among the worse off worldwide when it comes to for oral health issues. Those with limited income have trouble affording preventative dental visits, and dental insurance is rare in Lebanon.
Considering the hard choices made in disadvantaged areas, Khoury asked, “Would you care about your teeth when you can’t afford food?”
He mentioned that many parents have a misconception in thinking their children don’t need to see a dentist until they grow permanent teeth.
“There is not enough awareness of how to clean the teeth and take the child every six months to the dentist.”
When it comes to salt fluoridation, Khoury said that the law should protect the public’s right to decide between fluoridated and unfluoridated table salt.
“I am a dentist, but at the end of the day, I think we should have the right to choose.”