Fluoridation, despite being hailed by the dental and medical professions as the “magic bullet”‚ in its arsenal in the fight against tooth decay, continues to be one of the most controversial medical issues of the past 50 years. Since the first UK fluoridation schemes were introduced in the 1960s, the documented dental benefits have been weighed up against dental fluorosis and associations, however weak, with increased risks of cancer, bone disease and birth defects.
Proponents of fluoridation, which include the World Health Organisation, say there is no evidence that fluoridation causes any harm. Opponents say there is no evidence to show that fluoridation is safe in the long term. Ironically, a systematic review of fluoridation, carried out in 2000 by a panel of experts at the University of York, supported both views. Rather than pass judgement on the safety of fluoridation, the panel recommended that more research be undertaken.
Fluoridation is the addition of silicofluorides at the level of one part per million to public water supplies. Large areas on the eastern side of the UK have naturally occurring fluoridated water, while Birmingham already has fluoride added to its water. About 11 per cent of the population receives fluoridated water, and many dentists will attest to the differences it has made in the oral health of those communities. So the government, backed by the medical and dental professions, is pursuing an agenda of targeted fluoridation. Water companies have had the power to add fluoride to drinking water since 1985 but may have opted not to, declaring it an issue for the health authorities and communities to decide. That is set to change. Health minister Lord Norman Warner was successful in having an amendment inserted into the Water Bill that will move the fluoridation debate out into the communities. The bill was passed by the Lords at 153 votes to 31 and, if passed by the Commons, will hand the decision to fluoridate drinking water to strategic health authorities and primary care trusts. Provided there is both a need for fluoridation and community support for the measure, SHAs and PCTs will be able to instruct local water companies to add fluoride to the drinking water.
The government hopes that, through targeted fluoridation, people – particularly children living in areas of social deprivation where tooth decay is often high – will benefit. Getting fluoride to these communities is essential if the government is serious about narrowing the health gap, according to Dr Nigel Carter, council member of the Royal Society for the Promotion of Health and chief executive of the British Dental Health Foundation.
“Having practised in both fluoridated Birmingham and Sandwell, which was previously non-fluoridated, I know it was possible to tell whether children were from a fluoridated or non-fluoridated area just by looking at their mouths,” Dr Carter said. “While children from Birmingham had virtually decay-free mouths, those from Sandwell often had multiple cavities and suffered through many extractions. Since fluoridation of Sandwell’s water in 1987, its children have moved from near the bottom of the dental health league to the top 10. I hope that this amendment will now be approved by the Commons and allow millions of children the opportunity to benefit from fluoride and grow up free from the pain and suffering that can be caused by dental decay.”
Sheila Jones, British Fluoridation Society research and information officer and National Alliance for Equality in Dental Health coordinator, is equally eager for the Commons to pass the bill. “If you look at social deprivation, you will see that it goes hand-in-hand with tooth decay,” she says. “If you were to have a map of Britain and map out the areas of social deprivation, and then map out the areas of tooth decay, you would find that those maps are almost identical. The same areas would be shaded, excluding those areas that are already receiving fluoridated water.
“A lot of people speak about the benefits of fluoridation but we must not lose sight of why this is needed,” she continues. “In areas of social deprivation, about one in three children will have received a general anaesthetic to have teeth extracted before the age of five. Some people have turned a blind eye to this need and have talked solely about the potential problems of putting fluoride in the water, but the problems of not putting fluoride in the water are greater. These children will continue to suffer high levels of tooth decay, and possible disfigurement, if we do not move on this and put fluoride in the water.”
However, National Pure Waters Association campaign director Jane Jones says that without more research into the long-term effects of fluoridation, the government and dental and medical professions may be doing children a disservice. She points to an open letter written by Prof Trevor Sheldon, chair of the advisory group which conducted the York review, where he writes, “the review team was surprised that, in spite of the large number of studies carried out over several decades, there is a dearth of reliable evidence with which to inform policy. 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.”
“There is a lot of scientific controversy over this issue and I think that, when scientists are diametrically opposed on the issue, we should automatically adopt the precautionary principle and not fluoridate the water,” Jane Jones says. “Silicofluorides are a Class 2 poison under the Poisons Act. It is illegal to dump fluoride in the sea, it is illegal to put it in landfill, so why is the government making it possible to put it in the drinking water? People say it is only a little bit, but it is a little bit for the rest of people’s lives.”
Jane Jones also disputes the claim that fluoride is not known to cause any harm, pointing to fluorosis (discoloured or mottled teeth) as a major cause for concern. “Fluorosis is a big issue,” she says. “It is visible in 48 per cent of the population living in fluoridated areas. Of this, 12.5 per cent is of major aesthetic concern. Parents in these communities are breaking their hearts over seeing their children’s teeth, and the cost of veneer to cover the fluorosis is an ongoing cost. It can really cost people quite a bit of money.”
But according to Sheila Jones, there can be no comparison between fluorosis and extraction. “We have to talk about dental fluorosis in perspective,” she says. “It affects the appearance of the teeth but it does not harm them in any way. You can’t necessarily put dental fluorosis against tooth decay and weigh them up. We do recognise that it is a problem and we want to minimise that. We have to strike a balance in the amount of fluoride we add to water, and scientists are agreed that it should be one part per million to benefit society but also minimise fluorosis. However, since the protective qualities of fluoride have been discovered, it has been used in many ways, particularly toothpaste and fluoride tablets. When you consider that many young children who use toothpaste do swallow a proportion of the toothpaste they use, you can understand why they ingest more fluoride and why they may suffer fluorosis.
“We are working on the problem,” she continues. “Dentists are advising parents on how to lower the risk of fluorosis and that can be done by using children’s toothpaste, which has a lower concentration of fluoride, and by supervising children when they brush their teeth to make sure they spit it out. In this way, parents can maximise the protection their child gets from fluoride, but minimise the risk of unsightly fluorosis. The vast majority of fluorosis which is out there in the community is not recognised by those that have it as it is very mild and would only be recognised by a dentist.
Of course it is incredibly distressing for parents, who have done all they can for their child’s dental health, to discover that their child has unsightly fluorosis. However, it can be treated with veneer, which is, contrary to what some believe, available on the NHS.”
There is also an ethical question around consent that must also be considered in the debate, according to Lord Edward Baldwin, secretary of the all party parliamentary group against fluoridation and also a member of the York review panel. “Fluoride deficiency is not recognised by the Department of Health as a condition. Fluoride could be given like calcium or iron, tailored to individual need, in a controlled dose, for a limited period, monitored and always respecting the patient’s right to refuse treatment. That is how medicines and supplements are given,” Lord Baldwin said during the Lords‚ debate.
“But consider fluoridation. It is given indiscriminately – forget the notion of targeting because it simply is not possible via the mains water supplies – to populations, many of whom do not want it and cannot benefit from it. It is given without the normal procedures of individual informed consent, which is a hallowed principle of medical ethics enshrined both in the patient’s charter and the European Biomedicine Convention. It is given without any medical licensing procedures, by an uncontrolled dose, and for a lifetime.”
Speaking to PHN, Lord Baldwin suggested a solution to the ethical crisis of administering fluoride to those who do not want it would be to put it in salt, a practice adopted by other European countries such as France and Switzerland. This way, he says, the consumption of fluoride becomes voluntary. He also believes that the dental profession needs to think more laterally to come up with other solutions that do not involve medicating those who do not need it.
“These professionals want to do something for children’s teeth and I can understand that,” he says. “After seeing the mouths of some of the children in this country, dental health becomes something of a crusade to some professionals and, when they see that there is something there, they grab at it and think that they have to use it. But in this case, a view such as this can do more harm than good because there are still many questions around fluoridation.
“One problem is that we are restricted in the way we think about the problem. We need to look at other measures that could have an effect on dental health. Why don’t we do a study on the effect that poor diet and sugary foods have on dental health to see if the problem can be addressed by encouraging children to eat less of those? Let’s get the fizzy drinks out of schools for a start. We have fluoride tablets and toothpaste and I think we should first be promoting that line a little stronger before going on to fluoridation.
If you look at the medical profession, it is doing a lot in the way of pushing non-smoking programmes and five-a-day – why can’t the dental profession look at more programmes on dental health?”
Supporters of fluoridation suggest that up to half of the British population do not own a toothbrush and do not regularly brush their teeth, making fluoridation all the more necessary. The government has also promised that no community will receive fluoridated water against its wishes and that extensive community consultation will be carried out beforehand. This will pave the way for hundreds of debates across the country, in which SHAs and PCTs will be expected to take the lead.