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Minutes of meeting of the Forum on Fluoridation on 5 April 2001
The Boardroom, Dublin Dental Hospital 

Present
Professor Pat Fottrell (Chairman)
Dr Wayne Anderson 
Professor John Clarkson
Dr Dominique Crowley
Dr Elizabeth Cullen
Dr Paddy Flanagan
Mr Oliver Fogarty
Ms Dorothy Gallagher
Dr Gerard Gavin
Dr Howard Johnson
Mr Kevin Moyles
Professor Moira O'Brien
Dr Mαire O'Connor
Professor Denis O'Mullane
Dr Carmel Parnell
Professor Miriam Wiley

Ms Nessa O'Doherty (Forum Secretariat)
Dr Miriam Owens (Rapporteur)

Apologies 
Professor William Binchy
Ms Dora Hennessy
Professor Cecily Kelleher
Dr Joe Mullen
Dr Margaret Shannon (Forum Secretariat)

Meeting

The Chairman welcomed Professor Hannu Hausen from the University of Oulu, Finland. Apologies were given for the members who could not attend this meeting.

Presentation by Professor Hannu Hausen

Professor Hausen gave a presentation entitled "Experience of Water Fluoridation in Finland". This was followed by a Q&A session.


Presentation by Professor John Clarkson

Professor Clarkson gave a presentation entitled "An Overview of Future Fluoride Delivery Systems". This was followed by a Q&A session.


The members of the Forum greatly appreciated both of the presentations and the Chairman thanked Professor Clarkson and Professor Hausen on their behalf.


Discussion following the presentations

Oral hygiene is very poor among children in Finland - only half of children wash their teeth even once a day and there is high sugar consumption.

Information is needed on the fluoride level in infant formula - one of the Forum's recommendations should be to have research carried out on this area. Ms Margaret O'Neill (Community Nutritionist) will be asked to address this area during her presentation.

Dr Cullen asked why advertisements show a large quantity of toothpaste on a toothbrush when the use of a pea-sized quantity is recommended on the packaging; the Forum agreed that this is an area which they will need to discuss further. Professor O'Mullane suggested that toothpaste could be put across the toothbrush instead of along it. Professor Clarkson suggested that toothpaste dispensers and tubes could be adapted to give a pea-sized amount each time. Due to the fact that many people do not read the instructions on toothpaste packaging regarding the quantity to be used, it was also suggested that the illustration on packages should be adjusted - the visual effect may be more effective than text. 

Dr O'Connor raised the subject of fluoridated salt - use of this alternative method of fluoride provision would give people choice as to whether to use it or not. However, if fluoridated salt is to be considered (i.e. if water fluoridation were to cease), it is important to remember that (a) people with certain medical conditions are limited in the amount of salt which they should use and (b) children should use less salt than adults. It would be difficult to guage intake and effectiveness of the fluoride when factoring in such issues.

In response to a question asking if there are any controls on levels of fluoride in toothpaste, it was clarified that the level of 1,500ppm is the specified EU level and must be complied with. The Forum agreed that further information on this should be sought and included in the Report - the advice of a pharmacist may be needed. It is important that a recommendation be made by the Forum regarding compliance with such control measures.

It was also agreed that it might be useful to have monitoring of other dental defects (enamel opacities) which mimic fluorosis as confusion exists in this area.

A question was raised as regards the existence, or otherwise, of persons who are at high risk of fluorosis - however, no data are available on this at this time.

It was agreed that the Forum's Report must contain recommendations regarding fluorosis - Professor Clarkson agreed to give assistance to the Rapporteur on headings for this area.


Minutes of Meeting of 8 February 2001

The minutes of the meeting of 8 February 2001 were discussed - the following change is to be made.

Paragraph (iv) on page 3 is to be amended to read:

(iv) Ms Gallagher asked if there are any studies on fluorosis in non-fluoridated areas; Professor O'Mullane explained that there are - levels of fluorosis have been monitored constantly since 1984 but (a) it is extremely difficult to measure and (b) not all enamel opacities can be attributed to fluoride. This area could form part of an important recommendation/observation of the Forum's Final Report. It was agreed to have a presentation on this and Professor Clarkson agreed to focus part of his forthcoming presentation on this area.

The Secretariat apologised to Professor O'Mullane for unintentionally misquoting him.


Update Details

(a) The Forum's website (www.fluoridationforum.ie) is up and running.

(b) Dr Caswell Evans has agreed to give a presentation to the Forum in July 2001.

(c) Ms Doreen Wilson, Chief Dental Officer, Northern Ireland, has agreed in principle to give a presentation to the Forum in June 2001 (to be confirmed in writing shortly).

(d) Dr Andrew Rynne has agreed to meet the Forum (at a date yet to be arranged) to discuss his concerns in relation to fluoridation - in particular the ethical issues which it poses. The Forum expressed gratitude to Dr Rynne for his willingness to meet them as it is crucial to elicit as many views on this issue as possible so that the Forum's discussions and subsequent Report will be comprehensive and balanced.

(e) Dr Philip Michael of the Irish Doctors' Environmental Association has agreed to give a presentation to the Forum to discuss the IDEA's concerns on the issue of fluoridation - the Secretariat will be in contact with him to agree a suitable date.

(f) Ms Darina Allen had agreed to give a presentation to the Forum in March 2001 - that meeting had to be cancelled due to the Foot and Mouth Disease control measures; however, Ms Allen has very kindly agreed to re-schedule her presentation and the Secretariat will be in contact with her shortly.

(g) As per (f) above, Professor Elizabeth Treasure has also agreed to re-schedule her presentation and it is hoped that this will be possible at the May 2001 meeting.

(h) Ms Claire Chambers, on behalf of the Irish Society of Toxicology, has been in contact to offer the Society's assistance to the Forum by way of a presentation or in an advisory capacity; the Forum expressed their gratitude and both offers are to be taken up.

(i) The meeting on 10 May 2001 is likely to run all day due to the amount of work and presentations which the Forum must get through.

(j) All members of the Forum are asked to prepare a four/five minute informal talk for 10 May 2001 which will express their views on the Forum's progress to date, proposed schedule/agenda, any deficits which are perceived to exist in the Forum's coverage of the relevant topic(s) and any other suggestions relevant to the Forum. 

(k) The Chairman thanked Dr Flanagan for the large volume of work which he has done for the Forum to date, particularly in relation to examining the views contained in the submissions received.

(l) It was agreed that radio and newspaper advertisements should be placed in order to thank everyone who forwarded a submission to the Forum. 

(m) Professor Clarkson advised the Forum that the Centre for Disease Control in Atlanta has not yet completed its report on fluoridation but he suggested that if any area of deficit / required expertise is identified by (Forum) members in the Forum's work to date, it might be useful to invite the relevant expert from the CDC to either meet the Forum or else advise in written format.

(n) Professor Binchy was unable to attend this meeting due a prior engagement but has undertaken to present his paper on relevant legislation and court cases at the meeting on 10 May 2001.

(o) Information regarding the source of the hydrofluosilicic acid is required for the Forum's Website as there have been many queries on this topic. Mr Moyles and Professor O'Mullane agreed to liaise on this and to forward their draft material to the Secretariat.

(p) The Secretariat has been in contact with the Minister's Office to discuss details regarding the presentation of the Forum's Report - this is to be clarified shortly.

(q) On behalf of the Forum, the Chairman thanked the Secretariat for all of the work carried out to date, and noted that the workload was particularly heavy recently due to the work related to the invitation for submissions. In particular, the Chairman requested that the excellent work by Ms Nessa O'Doherty be acknowledged.


Invitation for Submissions from the Public

The newspaper advertisements were in the national newspapers and ran on Sunday 26 and Monday 27 November 2000. The radio advertisements were given wide coverage on national and local radio stations and ran for the weeks commencing 5 February 2001, 12 February 2001 and a "reminder series" during the week commencing 5 March 2001. 

Dr Flanagan, as Chair of the sub-group to examine submissions, advised that in excess of 950 completed submissions have been received to date. The official closing date was 31 March 2001 but this is flexible as it important to receive the views of as many individuals/groups as possible. Dr Flanagan has examined and summarised the views contained in more than 650 submissions so far (the details of which will be circulated to the members of the relevant sub-group shortly) and is continuing to work on the remainder. Any member of the Forum who is interested in reading some/all of the submissions and/or the synopsis of same is invited to do so. Dr Flanagan will contact the members of this sub-group to arrange a meeting to discuss the submissions received. Any member of Forum who wishes to join this group is welcome to do so. 

It was noted that this area should form an important part of the Forum's report and recommendations. 

The Forum expressed gratitude that so many individuals and groups had taken the time to make submissions.

It was agreed that the results of this survey of views should be compared with those of the survey carried out by Drury Research.

A high number of the submissions received referred to the fertiliser industry - Ms Gallagher mentioned that a lot of the correspondence received by the Consumers' Association of Ireland also raised this issue. It was suggested by Dr Gavin that the Forum should seek the advice of an independent expert on hydrofluosilicic acid - perhaps the relevant expert from the Centre for Disease Control.

The submissions highlighted the desire for informed choice as a priority for many people. A large number of respondents mentioned their wish to have a choice in the matter of fluoridation of public water supplies. 

A large number of the submissions received indicated confusion regarding certain aspects of the issue i.e. many people confused chlorine (and its properties) with fluoride.

If Dr Flanagan and his sub-group need qualitative advice to assist in the synopsis of submissions received, Dr Crowley offered to suggest an expert in the area who would be willing to assist.

Dr Flanagan's sub-group will report at the meeting on 10 May 2001.


Related Issues

Mr Moyles mentioned that tests done so far by the Regional Analysts' Laboratory suggest that the hydrofluosilicic acid used is pure but further tests are being carried out; he will give the Forum additional details at a future meeting. It was agreed that this is important in view of the fact that a number of submissions received mentioned the alleged existence of substances such as cadmium and arsenic in the acid.

Dr Johnson mentioned that it would be useful to find a method to quantify total exposure to fluoride i.e., water, food, air pollution, etc. This may be an area on which the Society of Toxicology could advise. Dr Gavin suggested that Dr Joe Treacy also be asked for advice.

Ms Gallagher noted that when this information is made available to the Forum it will not be enough to just put it on the website - newspaper coverage would also be desirable in order to answer the public's queries. She also noted that the Food Safety Authority of Ireland has some very effective slogans and advertisements - a similar method could be utilised by the Forum.

It was agreed that the issue of behavioural change needs to be addressed again by the Forum in the context of oral hygiene, etc. 


Work of Sub-Groups

Dr Connett's "50 Reasons" 

Professor O'Mullane explained that a lot of work has been done so far by this sub-group and a lot of the references quoted have been sourced; however, it has not been possible to get all references required so it may be necessary to contact Dr Connett for assistance in this regard. This group will have their draft responses ready for the meeting in June 2001. It was pointed out by Professor O'Brien that the text of the references should be provided alongside the draft responses.

Sub-Group to meet County Councils

This Group was given the deadline of the meeting in June 2001 by which to have had their meeting with the Councils that have expressed concern regarding the fluoridation issue. Dr Mullen, as Chairman, will be advised of this deadline by the Secretariat.

Progress Report

Dr Owens is currently working on drafting the Forum's Progress Report and will circulate it to members of the relevant sub-group for amendment/comment; it will then be circulated to all of the Forum members.

The Chairman stated that it is important that further discussion regarding the Final Report be carried out at the meeting on 10 May 2001.

Sub-Group looking at Alternatives to Water Fluoridation 

Professor O'Mullane (Chairman) will be in contact with the members shortly; Professor Clarkson and Professor O'Mullane agreed to prepare a submission on this topic. Deadline given of the meeting in June 2001.

Sub-Group looking at the Ethics of Fluoridation

A discussion paper by Dr Parnell and Dr Cullen will be forwarded to Professor O'Mullane (Chairman) shortly - this will be circulated to the sub-group members and in-depth discussion will then commence on the issues raised. Deadline given of the meeting in June 2001.


Guest Speakers and Future Activities of the Forum

Discussion took place regarding the future activities of the Forum. Because the meeting of 8 March 2001 had to be cancelled due to the Foot and Mouth Disease control measures the Forum may have to extend their deadline by a month or alternatively hold additional meeting(s) in coming months. Ms Darina Allen and Professor Elizabeth Treasure have both very kindly agreed to re-schedule their presentations to the Forum and the Secretariat will liaise with them. It is hoped that Professor Treasure may be able to attend the meeting on 10 May 2001 - it is important that the two bio-statisticians attend this presentation.

The Secretariat will be in touch with Dr Andrew Rynne, Dr Philip Michael and other invited speakers and will advise the Forum as to the timetable for meetings as soon as possible.

The response to VOICE's letter has been drafted by the Chairman and it is hoped to issue this shortly. The members of Dr Flanagan's sub-group will be asked for their comments on the draft prior to issue.

Dr Cullen mentioned that she wrote to Dr Susheela and Dr Phyllis Mullinex asking them to make a submission to the Forum; Dr Susheela forwarded an order form for her book on the issue of fluoridation. The Rapporteur is following up on this. A response is awaited from Dr Mullinex.

Professor Clarkson and Dr Johnson mentioned that they both know of bio-statisticians who would be interested and willing to advise the Forum if required.

Dr Crowley stated that there is a need to address what is to happen after the Forum presents its Report to the Minister. The Chairman agreed strongly with this. Any member who has suggestions in this regard is asked to raise them at the meeting on 10 May 2001.


Next meeting

The Secretariat will advise the members as soon as possible regarding the scheduling of the next meeting.

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