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TOWARDS BETTER ORAL HEALTH IN CHILDREN: ANALYSIS OF CONSULTATION RESPONSES

CHAPTER 10: FLUORIDATION OF WATER

The consultation stated:

The beneficial effects of fluoride in preventing dental decay have been apparent for many decades. It works by making the tooth more resistant to acid attack. Fluoride is present naturally in the environment and in some foods, as are, for instance, calcium, sodium and potassium. Different foods contain different quantities. Most natural drinking water supplies contain minute quantities of fluoride, but only one public drinking water supply in Scotland is at present at a level to have an effect on dental decay (optimum concentration 1 part per million). Fluoride is also present naturally in tea, fish and sea water.

The safety of fluoride has been the subject of much discussion - indeed it is one of the most extensively researched health measures. What can be said is that the balance of evidence suggests that fluoride, where properly used, offers a safe and effective route to better oral health.

No one, of course, can ever say that a substance is completely harmless in all instances as it depends on how it is used. If used to excess, any supplement that can be of benefit to health, whether vitamin or mineral, can produce undesirable effects. Recommended supplement dosages are calculated to maximise positive outcomes and to minimise adverse effects. So, as with all substances, care would be needed to ensure that the use of fluoride from different sources did not exceed recommended optimal doses.

It is the daily exposure of tooth surfaces to very low concentrations of fluoride that increases a tooth's ability to withstand the damage which results from the acid produced following sugar consumption. At present, in Scotland, many people's eating habits expose them to frequent consumption of sugar in foods and drinks with insufficient exposure to fluoride.

Consultees views were:

In Detail:

Of all topics for discussion set out in the consultation, the issue of potential fluoridation of water generated by far the greatest volume of response. The 5 petitions containing 6464 signatures focused on this issue as did the 151 anti-fluoride in water pre-printed responses (see Annex 4 for examples). Of the remaining responses, 2 out of every 3 focused entirely on this topic. In addition, other respondents commented on fluoride in water along with other issues.

Petitions and Pre-Printed Responses

The largest anti-fluoride in water petition contained some 6,253 signatures, was organised by the Highland Movement Against Water Fluoridation and was generated amongst the Highland region. Other petitions were smaller, originating from the Glasgow and Aberdeenshire areas. Finally, an anti-fluoride in water postcard petition, addressed to the consultation team, involved respondents from a variety of geographical areas across Scotland. These responses, whilst clearly significant to the consultation team in indicating views of many people on this single issue, did not contain any depth in terms of proffering solutions to the problem of children's oral health. The remainder of this chapter therefore relates to the remaining responses to the consultation.

Views on Potential Water Fluoridation

Where respondents indicated clearly their views for or against water fluoridation, it was possible to gauge relative levels of opinion. Of those 852 responses where individuals expressed a definite view, (excluding the 151 pre-printed responses and 5 petitions), only 3% were pro-fluoridation of water. Of the 217 responses where professionals proffered their clear opinion, 93% of dentists and NHS Boards/Trusts/Agencies were in favour of adding fluoride to water, with 25% of the remaining 122 responses from those expressing an opinion (other than those from individuals, dentists and NHS boards/trusts/agencies) being pro-fluoridation of water. The remainder of the chapter presents respondents' arguments against or for the fluoridation of the public water supply. It should be noted that views expressed are based on respondent perceptions that may or may not be factually accurate.No attempt is made in the analysis to make a judgement on the accuracy or otherwise of respondents' submissions.

NO TO FLUORIDE

Respondents presented a wide range of arguments against the fluoridation proposal. These could be grouped into the following broad categories:

• Perceived health risk

• Comments on breach of rights/patients charter

• Choice

• Ethical considerations

• Politically motivated/undemocractic

• Dosage

• Financial considerations

• Targeting of fluoride

• Research issues

• International experience

• Possible legal implications

• Sets an unwelcome precedent

• Public debate

• Equality issues

• Variety of miscellaneous reasons

Whilst there were far too many responses to be able to report every comment here, a representation of the key arguments made under each of these categories is outlined below.

Perceived Health Risks

People urged great caution in developing plans to fluoridate the water when they felt that there was not sufficient evidence to say for sure that this option would be totally safe for the entire population. It was an unacceptable risk with uncertain long-term effects and would constitute, " issuing a prescription medicine of unproven safety, efficacy and need" (indiv 28). Emotive terms such as "mass medication" of "innocent people" demonstrated the strength of feeling with many concerned that, " sufficient quantities of chemicals and pollutants lie within the water without more needing to be added" (indiv 904).

A great many respondents were of the view that a variety of medical and physical outcomes could result from fluoridating the water supply. These included:

On occasions, people supported their response with personal and family experience or by their interpretation of what they had read and heard. Many respondents cited particular categories of people whom they considered as being more susceptible to the negative effects of fluoride. These were: people with allergies, asthma, thyroid problems, the very young, the very old, those with vitamin and mineral deficiencies, cardio-vascular problems, cystitis, arthritis, Crohn's disease, MS, kidney disease or those with a poorly nourished diet. Operatives who had to handle fluoride were also perceived to be at particular risk.

A clear issue of contention was that respondents felt that health risks associated with fluoride were already established and known about. Previous warnings by BMA, WHO, UN and doctors were cited with various references to the US Food and Drug Agency ("… never approved fluoride as safe") and the Birmingham fluoridation experience (" don't swallow your toothpaste warnings"). People claimed that fluoride was known to be a rat poison, corrosive and toxic, containing mercury, lead and traces of arsenic, a waste product which once ingested tended to build up in a cumulative fashion.

Comments on Breach of Rights/Patients Charter

Relevant responses focused largely around 3 issues. Fluoridating the water supply was seen as:

• Breaching a basic right to unadulterated water in a democratic society

• Breaching the Charter of Human Rights (fluoridation seen as removing the right to be consulted on matters affecting individuals)

• Breaching the Patients Charter which enables patients to refuse treatment - no such option would exist with fluoridation

Choice

A key theme was resistance to the application of a "treatment" to an entire population without allowing for personal choice. For some, this "blanket coverage" (indiv 709) constituted the State taking away an individual's right to choose (East Aryshire Council). Any focus of particular pockets such as deprived areas was seen as distasteful and amounted to taking choice away from poor people.

Several respondents likened fluoride in water to being " forcefully drugged" (indiv 237), tantamount to " giving us all methadone because one section...(of the population )… is addicted to drugs" (indiv 461). Contrasts were made with other interventions of products where choice has been retained, e.g. organic foods (indiv 501), inoculations (Scottish Green Party), alcohol, tobacco (indiv 853).

Ethical Considerations

Linked with the arguments above, pressing ahead with fluoridating water was seen by many as ethically unacceptable and irresponsible. This action would not be fitting of a Scottish Government and an insult to the ethics of professions such as pharmacy (local Orthodox Presbyterian Church).

Politically Motivated/Undemocratic

Many respondents considered that adding fluoride to water would be undemocratic and would contribute to a lack of faith in the Government, " Scottish people lose heart when they see political parties joining forces to push through unpopular policies" (indiv 461). This action was seen to be contrary to the wishes of the people with one response representing the views of many, " water fluoridation should not be your decision - this should be left to the people of Scotland" (indiv 615). Indeed several people called for a referendum on the issue (e.g. Scottish Green Party, indiv 672).

Some saw the government as meddling with issues best left to individuals. The terms "nanny state" and "paternalism" were used frequently. Others perceived the Government as under a more sinister influence of commercialism, making fluoridation of water a "politico-economic" issue (indiv 208).

People questioned who stood to gain from this action with suggestions ranging from the manufacturers of bottled water (indiv 216), fluoride suppliers (indiv 1315), the Government in income from the sale of sweets (indiv 770), and industries needing to get rid of waste products economically (indivs 853, 870). Also questioned was the alleged disparity in Government funding to pro-fluoride organisations compared with the absence of central funding for anti-fluoride work (Highland Movement Against Water Fluoridation, Fortrose and Rosemarkie Community Council, indiv 1240).

Dosage

The perceived inability to control the level of fluoride on an individual basis was a major cause for concern. Many argued that no standard level of safe dosage existed (GP 51, indiv 41, Highland Movement Against Water Fluoridation). A central theme was that all individuals were different with varying levels of tolerance and absorption of food and drink substances, water drinking and toothbrushing habits. Within such a context, ensuring that nobody "overdosed" on fluoride would be impossible.

In addition, levels of fluoride in water would be very difficult to maintain at a constant (Fife Council). Re-cycling of water would affect dosage (indiv 182) and accidents involving adding too much fluoride were always possible (Royal Environmental Health Institute of Scotland, Crossford Community Council).

Ironically, those already maintaining healthy habits of water drinking regularly and brushing with fluoride toothpaste, stood to be most vulnerable to any such overdoses (Scottish Borders Environment Partnership).

Financial Considerations

Very many respondents commented on what they saw as the vast costs involved in implementing and running fluoridation schemes. Wider and longer-term costs were also envisaged in terms of dealing with adverse effects on people's health and subsequent litigation against the Government.

The sums involved would be far better directed at preventative schemes and campaigns rather than being "flushed away" (local Orthodox Presbyterian Church) or going "down the drain" (e.g. New York State Coalition Opposed to Fluoridation, indivs 240, 1008).

Many presented specific calculations of how much would be squandered, a typical example being that of indiv 265, " 96p in every £ would be wasted - only 4% is used for cooking and drinking".

Targeting of Fluoride

A large volume of responses delivered the message that fluoridation of water was indiscriminate in focus, affecting everyone, though addressed at the problems of just one sector of society. Typical comments were that this constituted:

• "taking a sledgehammer to crack a nut" (Voluntary Organisations NE Fife)

• "mass medication to protect a small percentage of the population" (indiv 280)

• "if I have a headache, I do not dose my whole family" (indiv 634)

Others remarked on water being an ill-suited vehicle for administering fluoride. One respondent summed this up succinctly, " those who need it most drink the least water and vice versa" (indiv 196). Others also commented on the in-direct "beneficiaries" of fluoride in water including family pets, gardens and various industries.

Research Issues

Many respondents disputed the basic premise that fluoride had a positive effect on children's teeth. Some claimed that no studies had been able to demonstrate this link. Others claimed research had not delivered absolute proof of the association.

Several commentators cited specific examples of lack of clear dental improvement despite a fluoridation programme in:

• Gateshead (indivs 33, 1032)

• Anglesey (indiv 78)

• Ireland (Scottish Green Party)

• USA (indiv 372, NY State Coalition Opposed to Fluoridation)

A few personal experiences were told: " I've lived in a high fluoride area and it did me no good - friends from low fluoride areas had better teeth" (indiv 241); " I come from a fluoridation area and have many fillings. My children have never had fluoride and have no cavities" (indiv 360). Finally, Scottish Borders Environmental Partnership made a comparison between the Borders (lower levels of dental caries, no fluoride) and Moray (higher levels of caries, natural fluoride).

International Experience

It total, 101 responses highlighted resistance to fluoridation of water in other countries. Most referred to European counterparts who have either never accepted such a scheme or had changed stance from being pro to anti fluoridation. The key argument remained, " why bring in fluoridation when other European countries are terminating such programmes?" (indiv 567).

Potential Legal Implications

Several respondents warned the Government of the likelihood of future legal action against them should fluoridation of water proceed. Cases were predicted in both Scottish and European courts, relating to violation of human rights or negative effects on health. A few responses went further to foresee cases of children suing parents for encouraging their consumption of fluoride.

Sets an Unwelcome Precedent

"What next?" was a question posed by 20 respondents to the consultation. Fluoridation of water was viewed as, " the tip of a very dangerous iceberg" (indiv 398) which set a " worrying precedent" (Scottish Civic Forum response 10). Some speculated on the next addition to water - Prozac or mass contraception (indiv 237), laxatives, aspirin, antacids (indiv 695), anti heart disease medicine (indiv 977), truth drugs (indiv 856) or " red wine … to prevent strokes" (indiv 1105).

Public Debate

Many responses portrayed a general mood of surprise at a lack of publicity, advertising and the low profile of the consultation given the perceived importance of the fluoridation of water issue. One suggestion was that the fluoride issue should have been separated from the other aspects and handled differently (Unison).

Some thought that the consultation should have been delivered to every residence in Scotland. Others (and as previously mentioned) stipulated that a Referendum was in order. A call was made for a more thorough public exercise focusing on fluoridation of water and involving a discussion of pros, cons and evidence (Paisley University).

Some suspicion was raised at this "so called" public consultation (indiv 255), with a cynical view being that the, " Executive have no intention of actually seeking the views of members of the public on the issue of water fluoridation" (Highland Movement Against Water Fluoridation).

Need to Keep Scottish Water Pure

Fourteen per cent of all routine responses to the consultation referred to the need or right to keep Scottish water pure or clean. Some people argued against further "chemicals" in drinking water. Others were concerned about detrimental impact of fluoride on taste of water.

Many respondents associated Scottish water with purity and considered this to be a major tourist attraction, e.g. " Scotland is well thought of for the purity of the water from its mountain springs. Tourists would not be impressed with poison being added to the water supply" (indiv 830).

Equality Issues

The 2 main arguments both focused around costs of anti-fluoride measures and the impact on those with low incomes. It was envisaged that if fluoridation of water proceeded, people would need to purchase large quantities of bottled water or water filtering equipment. Many sectors of society could ill-afford such items. Also, cosmetic veneering to conceal damage done by fluorosis was considered a luxury purchase, only affordable by some.

Variety of Miscellaneous Anti-Fluoridation Reasons

A small number of other arguments against fluoridation included:

• Unpleasant smell (indiv 170)

• Wider effect on environment (e.g. leaking into soil) (Scottish Green Party, indivs 46, 71, 182, 228, 243, 265)

• Gives out message that it is OK to eat sugar or not brush teeth as fluoride will negate the effect of these (indivs 196, 254, 1301)

• Doesn't tackle underlying causes of decay (indiv 249)

YES TO FLUORIDE

As previously stated, those in favour of adding fluoride to water were, in the main, health professionals. Most were very clear in articulating what they perceived as the outstanding benefits to oral health, a typical comment being, " water fluoridation in Scotland is the single most effective measure available to improve dental health and reduce dental health inequalities" (CDS Airedale NHS). Those favouring water fluoridation did not tend to provide lengthy justifications for their views - this being reflected in the relative length of this section of the report compared with the sections devoted to the anti-fluoride arguments. For the pro-fluoridation supporters, the oral health benefits of water fluoridation had already been proved, with fluoridation presenting the only clear-cut approach to ensuring that the government target on children's oral health could be achieved. A typical view was provided by the National Alliance for Equity in Dental Health, with their statement that no other measure could deliver the necessary improvements within 3-4 years of implementation.

Perceived improvements to teeth were not seen as immediate, but were expected to emerge within a few years of fluoridation, bringing " significant benefits" (e.g. Faculty of Public Health Medicine, Highland Area Dental Committee). Examples of representative comments were:

A few respondents cited specific estimates of fluoridation reducing decay, e.g. by 15% (National Alliance for Equity in Dental Health, Academic 1329), or "by half" (SE Sheffield PCT). Some individuals were in favour of fluoridation based on personal experience, - " my children's dental health has benefited from their fluoride intake" (indiv 199), " own children are from a fluoridated area and have not even had a tooth filled" (indiv 54). Others based their response on evidence from previous fluoridation schemes and naturally occurring fluoridated areas. Cited in favourable terms were:

For comparative purposes, further representative views of those in favour of fluoridating the water supply can be ordered under a number of the headings previously used for the anti-fluoridation arguments:

Perceived Health Risks

Many respondents placed weight on the reviews undertaken at York University (2001) and by the Medical Research Council (2002) which they considered had demonstrated clearly that water fluoridation was a safe procedure with no adverse health risks (e.g. Tayside NHS Board). Others referred to a wide body of scientific evidence (indiv 1132) " to support both its (water fluoridation ) efficacy and safety" (Scottish Association of Clinical Dental Directors). Despite what was perceived as a proven safety record (e.g. Royal College of Surgeons, Edinburgh) some respondents felt that this message had not been conveyed adequately to the public (One Plus) with opponents to water fluoridation basing their views on " spurious claims relating to unsubstantiated effects of fluoride on health" (Greater Glasgow NHS Board).

Choice

Interestingly, those pro fluoridation appeared to agree with those against on the lack of choice which would result from adding fluoride to the public water supply. However, whereas protesters perceived this as a negative aspect, those in favour of fluoridation tended to see this as a positive step in that it removed the need for active decisions to be taken by parents and children over opting in to other fluoride schemes. For example, the Faculty of Public Health Medicine of the Royal Colleges of Physicians viewed delivery of fluoride in other ways as a "soft" approach, unlikely to be effective because of the pro-activity required by the public in accessing fluoridated products. The resulting unequal distribution of fluoride amongst the public was seen as preventable by the blanket coverage offered by water fluoridation, " the only one measure that can reliably deliver to a whole population" (indiv 1132).

Some respondents, however, did acknowledge that lack of choice may be an issue but made a constructive suggestion on how to address this. Their argument was that fluoridation was welcome as long as the Government also provided access to free bottled water for those who wanted an alternative (e.g. Consumer Group 101, Amicus, Scottish Civic Forum, indiv 77).

Politically Motivated/Undemocratic

The notion that Scotland's people were generally against water fluoridation was disputed by a number of respondents. One view was that the voices being heard were those of a protesting minority of the public which drowned out the opinions of those in favour of adopting the measure. For example, the Greater Glasgow Area Dental Committee considered that the majority of the public was in favour of fluoridation, despite the negative position being presented by, " a vociferous minority". The Committee went on to report that, " Polls consistently show a majority of the public in favour of this as a caries prevention measure".

A number of respondents were in favour of water fluoridation but only if certain conditions were met. A referendum was most commonly called for, with a recommendation that the Government pursue schemes where the majority of the population has voted for this (e.g. British Fluoridation Society).

Dosage

Little mention was made of issues relating to ensuring appropriate dosage of fluoride in water. One individual (199), however, alluded to the risks of excess intake of fluoride being small and levels of fluoride in water being controllable.

Financial Considerations

Financial aspects of fluoridation of water were raised within the context of the perceived cost effectiveness of introducing this measure. Many respondents referred to the previous evidence of its cost effectiveness (e.g. Scottish Association of Clinical Dental Directors; NHS Lothian). Others considered it to be cost effective within urban areas where the water supplies rendered it technically feasible (National Alliance for Equity in Dental Health) but recognised the potential practical barriers in implementing in remote, rural communities with their numerous public water sources (Community Dental Department, Isle of Barra). A call was made for further cost benefit analysis to be undertaken for such smaller water supplies (British Association for the Study of Community Dentistry).

Research Issues

For those in favour of fluoridation, the research evidence clearly demonstrated the positive effect of this measure on oral health. Many respondents referred to an entire body of evidence that demonstrated this link, with the York Research and that conducted by the MRC frequently cited. The research evidence was perceived as robust and reliable with descriptors such as "scientific" (e.g. Salaried Primary Care Dental Service; Scottish Association of Clinical Dental Directors) and "authoritative" (National Alliance for Equity in Dental Health; Airedale PCT). Some respondents indicated their support for the MRC recommendation that new fluoridation schemes be introduced and evaluated.

Equality Issues

Two key themes emerged from responses. Firstly, respondents considered that fluoridation of the water supply would serve to reduce the inequalities currently witnessed in the oral health of children in Scotland (e.g. " it would … reduce the very pronounced disparity between different social groups" (Senior Dental Officer, 820)). Secondly, and linked to this, many respondents saw water fluoridation as benefiting disproportionately those children living in poverty. The following comments were typical:

" water fluoridation, particularly benefits the most vulnerable in our communities, namely young children who are living in impoverished conditions" (Birmingham City Council)

" fluoridation helps those who are least able to help themselves" (University of Dundee Dental School)

Need for Education

For many of the pro-fluoridation respondents, the evidence was clear that the Government needed to proceed with fluoridation of water. In pursuing this course of action, the key outstanding issues identified were how to ensure that the public understood the issues and were provided with clear information on evidence. Consistent with other findings emerging in this consultation, some consultees predicted the need for a major and sustained public education campaign to gain public confidence in and acceptance of, water fluoridation as a viable option (e.g. GP 18, indivs 98, 1132, 1344, City Dental Department Drumhar Health Centre, Scottish Civic Forum, Renfrewshire and Inverclyde PCT, Scottish Community Dental Service, Lothian Health Council, N. Lanarkshire Council). An interesting comparison was made with the campaign for compulsory seatbelts that overcame initial objections (Academic 1329). A degree of social marketing was recommended to promote the fluoridation message (NHS Forth Valley Board).

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