A THREE-YEAR-OLD girl toddles into a dental practice in the West of Scotland.
She has already lost 10 of her baby teeth to a diet of fizzy drinks and sweets.
Today, the dentist will decide the rest must come out, leaving her with empty gums until she is six or seven years old.
Even then, she may face problems. Without baby teeth to guide them into place, her second teeth may emerge in the wrong order or position – she may well need corrective treatment such as further extractions or bracework.
It is a scenario that Peter Feechan knows only too well. A dentist in Paisley, he is used to seeing tiny children who lose all their teeth as a result of poor diet and neglect.
“There are children who have all their teeth extracted by the age of three,” he says. “I am not talking about one isolated case. And it is not uncommon for children to have three general anaesthetics for extractions by the age of six or seven.
“There is a lot of apathy out there. We live in a world where people expect everything to be preventable or fixable. They don’t take care of themselves as they should and their children eat too many sugary substances.”
Feechan’s experiences are reflected across the country. According to Scottish Executive statistics, by the age of three more than 60% of
Scottish children from areas of severe deprivation have dental decay. By the age of five, 55% of all children are affected, compared with 30% in the Netherlands and 29% in Denmark.
In the face of such statistics, there is certain to be strong pressure on the Scottish Executive to follow the United States, New Zealand, Spain, Ireland and some parts of the UK by introducing fluoride to water or milk.
The pro-fluoridation lobby has strong support from the medical establishment, including the British Dental Association, the British Medical Association and the World Health Organisation.
They believe fluoridating the water is the most cost-effective way to improve the dental health of a nation apparently determined to persist with bad dental health practices.
But fluoridation is vehemently opposed by some consumer groups and researchers, who perceive it as mass medication through the water supplies.
They complain that too much fluoride causes dental fluorosis, which makes teeth brittle and leads to unsightly mottling.
More worryingly, they point to studies which suggest fluoride, a by-product of phosphate fertiliser or aluminium production, may be linked to conditions such as hip fractures and bone cancers and interfere with the functioning of the thyroid gland.
While, for years, such fears have been dismissed as “junk science” and opponents of fluoridation labelled cranks, there are indications that experts are growing more cautious about a chemical previously seen as a panacea.
Last month, the Medical Research Council released a report which said that, while there was no proof the fluoridation of water was dangerous, more research was needed into possible links with cancer.
“There is no reason to think that water fluoridation is responsible for any adverse health effects. But there is a lack of research on some important aspects,” says Dr Paul Harrison, director of the MRC Institute for Environment and Health, who chaired the group.
“Because of the wide use of toothpastes and other dental health care products, we need a better understanding of how much fluoride we’re all absorbing.”
However, for the British Dental Association, the case for the fluoridation of water is rock solid.
According to the government-commissioned York Report, carried out at York University, it reduces tooth decay by an average of 2.25 teeth per child and increases the number of children who are decay-free by 15%.
In Sandwell in the West Midlands, where the water has been fluoridated since 1986, five-year-olds have an average of 0.88 decayed, missing or filled teeth, compared with 2.35 in Bolton, where the water is not fluoridated.
“Putting fluoride in the water is the best way of delivering it to the population,” says British Dental Association spokesman Kieran Fallon. “It has been going on in parts of the West Midlands for 35 years, with no general detrimental effects.
“If you doubt that, you just have to think. The US is the most health-conscious nation in the world. More than 150 million of them drink fluoride in the water. Do you think they would put up with that if it was bad for them?”
Those who oppose fluoridation, however, feel too many doubts about its safety have been raised in a succession of studies linking it to one condition or another.
One of their principal concerns is that too much fluoride might increase the risk of osteoporosis.
Since scientists believe only half of ingested fluoride is excreted, the question raised is: if fluoride makes teeth hard and brittle, won’t it have the same effect on bones?
In the 1990s, the University of Bordeaux measured rates of hip fracture among old people in 75 parishes in south-western France and found those living in fluoridated areas suffered 86% more fractures than those living in non-fluoridated parts.
Tony Lees, from Hereford, is one of the few dentists to oppose fluoridation. He was an advocate until his own mother, who lived in Birmingham, where the water is fluoridated, died following a hip fracture.
“When I spoke to a consultant about her death, he told me it was partly her age, then he added: ‘But, of course, we get more hip fractures here because of the water.’
“At this point I decided to go and do some research of my own, and discovered that many studies already highlighted the dangers of fluoride.”
In the early 1990s, the Department of Health in New Jersey commissioned work to assess the incidence of osteosarcoma (a type of bone cancer) in the state in relation to water fluoridation.
The results indicated that in males under the age of 20, the risk of osteosarcoma was between two and seven times greater.
Other studies have suggested that fluoride interferes with the functioning of the thyroid gland, which produces hormones that regulate metabolism.
Dr Diane Phillips, a former GP and hospital doctor, was forced to give up work when she became ill after moving to Coventry, where the water is fluoridated. Things finally came to a head in 1997.
“It was quite a spectacular crash and burn. I just honestly didn’t know what was happening to me,” says Phillips, who also had an increased intake of fluoride because she was working with anaesthetics.
“That winter I had a couple of really bad colds that took ages to clear up, and one day I started to cry and couldn’t stop and couldn’t think straight.
“If I drove the car I would be so weak when I got back I wouldn’t be able to get out, I would have to lift my legs out. And I thought I had early Alzheimer’s disease at one stage.”
Later, Phillips was diagnosed as having thyroid problems.
When she started cutting fluoride out of her diet by filtering her water and using non-fluoride toothpastes, her health improved.
Dr Sheila Gibson, who used to work at Glasgow Homeopathy Hospital, carried out tests with fluoride on white blood cells. She found that, even when she used only 0.5 parts to a million, the fluoride had an effect on the immune system.
The validity of all these studies is questioned by the pro-fluoridation lobby.
But one by-product of fluoridation both sides acknowledge is the increase in dental fluorosis.
Indeed, the York Review found that in fluoridated areas, the incidence of dental fluorosis was 48%, with 12.5% of cases being described as “aesthetically disturbing”.
Peter Rice, who also lives in Coventry, knows the mess fluoride can make of enamel. His 17-year-old daughter Carla suffers from mottled front teeth, but has been told she will have to wait for treatment to replace the veneer on the enamel.
In June, she will turn 18 and will have to pay for it herself, at a cost of £300 to £400. The work has to be carried out every five to six years.
“We first began to notice the problem when Carla was nine or 10 years old,” says Rice.
“When you look at her from a distance, it seems as though her teeth are brilliant white, but when you get closer you can see the mottled effect.
“The terrible thing is we didn’t know what it was. At first, we used to say to her: ‘You can’t be cleaning your teeth properly. Go back up and do it again.’ So, of course, she was getting a double dose of fluoride toothpaste. The dentist didn’t explain to us that’s what was causing it.”
Aubrey Sheiham, professor of community dental health at University College London, still believes in fluoridation, but believes fluoride intake should be monitored.
“What we have been seeing, particularly in middle-class families, is children who swallow toothpaste, getting dental fluorosis,” he says.
“Parents should be aware only to use a pea-sized amount, and try to ensure that their children don’t swallow it.”
In Ireland, where 70% of people drink fluoridated water, the Forum on Fluoridation, set up by health minister Michael Martin, recently recommended the amount of fluoride be reduced from the “optimal” level of one part per million laid down in 1945, to 0.7 parts per million because of increased incidence of dental fluorosis.
Belgium has banned the sale of chewing gum, tablets and drops containing fluoride. And in the US, more than 50 cities and towns have stopped fluoridating their water since 1990.
In 1983, the last time the fluoridation of water was on the agenda in Scotland, Gorbals pensioner Catherine McColl held Strathclyde Regional Council to ransom.
In what was then the longest-running civil action in Scottish legal history, she prevented the local authority from fluoridating the water.
After 201 days, Lord Jauncey ruled that although there was no evidence that fluoridation was dangerous, the council was acting beyond its powers.
Should the Scottish Executive press ahead with plans for fluoridation now, there is little doubt there will be plenty of vocal consumers willing to take them on.