There is an amusing quote in director Stanley Kubrick’s film Dr Strangelove. In the 1964 movie starring Peter Sellers, General Jack D Ripper says: “Fluoridation is the most monstrously conceived and dangerous communist plot we have ever had to face.”

The quote is interesting for two reasons: firstly, it proves in an amusing way that the debate surrounding fluoridation is not a new one; and, secondly, it reveals that there are some extreme, and sometimes questionable, views attached to the subject.

In the Gulf region, and indeed in the wider Middle East, the issue has gained momentum again over the past few months and the issue is proving to be just as contentious.

Partly what makes it a subject of such heated debate is the region’s high prevalence of tooth decay, particularly among children. In the UAE, for example, a national survey for dental caries was carried out on five, 12 and 15-year-old children in 2002.

The study represented 5% of the total population and found that the prevalence of caries in the five, 12 and 15-year-old age brackets was 83%, 54% and 65% respectively.

The mean DMFT was 5.1 in five-year-olds, while the mean DMFT was 1.6 in 12-year-olds and 2.5 in 15-year-olds.

It’s a situation reflected across the Middle East. In Oman, dental caries remain a major public health problem, with an estimated 70-80% of schoolchildren and the majority of adults affected.

Oman’s Ministry of Health predicts in its five-year health plan (2006-2010) that changing living conditions and dietary habits will lead to cases of dental caries remaining high.

Inadequate exposure to fluoride is believed to be a major contributing factor to this prediction, alongside the growing consumption of sugars in sweets and soda drinks.

Further west in Jordan, an estimated 50% of children under the age of eight are believed to suffer from dental caries.

The situation is deemed of such importance that the Jordan Water Company (Miyahuna) is already planning to add fluoride to Amman’s water supply in a bid to improve the dental health of the capital city’s residents.

The view from the world

Most international dental agencies have faced down the fluoride question at some point, and believe squarely in its benefits.

The American Dental Association (ADA) has gone so far as to brand fluoridation the “single most effective public health measure to prevent decay”.

Both the World Health Organisation (WHO) and the British Medical Association support community water fluoridation as a means of cutting caries.

They base their recommendations on a host of reports, including that of former US Surgeon General David Satcher entitled Oral Health in America: A Report of the Surgeon General.

The report stated that fluoridation “continues to be the most cost-effective, practical and safe means of reducing and controlling he occurrence of dental decay in a community”.

The WHO, which initially stated its backing of fluoridation back in 1969, stated in 1994 that: “Providing that a community has a piped water supply, water fluoridation is the most effective method of reaching the whole population, so that all social classes benefit without the need for active participation on the part of individuals.”

In the US, where 66% of the population receives public supplies of fluoridated water, the US Public Health Service placed the optimum concentration for fluoride in water between 0.7 and 1.2 parts per million.

It is believed that a ceiling of four parts per million protects against the adverse health effects of too much fluoride.

Advocates of fluoridation point to research that states that fluoridated public water can help reduce dental decay by between 20 and 40%.

A good way to reveal the benefits of fluoridated water is also to examine the difference in tooth decay statistics between deprived and more affluent communities within a society.

Studies in the UK, for example, have shown that children in non-fluoridated under-privileged areas are more likely to have teeth extracted due to tooth decay than those in either affluent, or similar but fluoridated, areas.

For example, five-year-olds in non-fluoridated Manchester suffer almost two and a half times more tooth decay than those in fluoridated Birmingham, says the British Medical Association.

Dr Mark Partridge, associate at the British Dental Medical Clinic, Abu Dhabi, believes fluoridation could have a similar impact in the Middle East: “The percentage of decay in children is higher in the Gulf generally.”

“The water here is non-fluoridated, but when it’s been fluoridated, for example like it is in parts of the UK, it has cut down the incidences of decay quite significantly.”

The case against blanket fluoridation

But for every advocate there is a detractor. And, on the subject of blanket fluoridation, these detractors can be very passionate.

Attacked as a Communist plot in the US as far back as the 50s, ex-Nobel Prize-winner Dr Arvid Carlson has referred to fluoridation as “against all principles of modern pharmacology”.

In his book The Fluoride Deception, Christopher Bryson stated that the campaign to fluoridate drinking water in the US has been less about public health than a public relations ploy sponsored by industrial users of fluoride.

But serious health concerns are raised by those opposed to the introduction of fluoridated water. These concerns centre on the possible connections with health problems, including dental fluorosis, a possible weakening of the immune system and cancer.

Overdoses of fluoride are associated with liver damage and kidney function.

There are also doubts over its effectiveness. A study by the National Institute of Dental Research in the US revealed limited differences between levels of dental decay among children in fluoridated and non-fluoridated areas.

For Dr Nasser Malik, assistant director, Dental Center, at the Department of Health and Medical Services in Dubai, the evidence still backs the idea of treating water supplies.

“Although the controversy of public water fluoridation is still going on, the consensus among the leading health organisations is to support the process,” he explains.

“The main subjects of controversy are that fluoridating water supplies causes cancer, and tooth fluorosis, although there is no evidence of cancer connections.”