Forum Minutes of Meetings
Minutes of meeting of the Forum on Fluoridation on 14 June
The Boardroom, Dublin Dental Hospital
Professor Pat Fottrell (Chairman)
Professor William Binchy
Professor John Clarkson
Dr Elizabeth Cullen
Dr Paddy Flanagan
Mr Oliver Fogarty
Dr Gerard Gavin
Dr Howard Johnson
Professor Cecily Kelleher
Mr Kevin Moyles
Dr Joe Mullen
Professor Moira O’Brien
Dr Máire O’Connor
Professor Denis O’Mullane
Dr Carmel Parnell
Ms Nessa O’Doherty (Forum Secretariat)
Dr Miriam Owens (Rapporteur)
Apologies were given for the members who could not
attend this meeting.
Minutes of Meeting of 10 May 2001
The minutes of the meeting of Thursday 10 May 2001 were
- Dr Crowley is resigning from the Forum after this meeting for personal
reasons. The other members of the Forum asked for it to be put on record
that Dr Crowley’s in-put into the Forum had been valuable and much
- The Secretariat contacted Ms Darina Allen to re-confirm the details
for her presentation which was scheduled for the Forum’s meeting in
July 2001; Ms Allen has decided not to proceed with her presentation and
will write to the Secretariat shortly outlining her reasons for this
- The Forum noted that Fluoride Free Water is marching to the Department
of Health and Children today.
- Ms Claire Chambers of The Society of Toxicology had requested some
details (eg levels of fluorosis, level of naturally occurring fluoride
in ground water, level of fluoride in mouthwashes, toothpastes, etc) in
order to assist the Society to prepare their submission to the Forum. At
the invitation of the Secretariat, Professor Clarkson spoke to Ms
Chambers on these matters. The Society will now proceed to prepare a
- Professor Clarkson has been in contact with Mr Tom Reeves of the
Centre for Disease Control in the USA, an internationally recognised
expert on hydrofluosilicic acid – the latter has forwarded some
information in relation to the acid and has also offered to speak to the
Forum if required. It was agreed that it is important to have an expert
on this area to speak to the Forum and the Secretariat will proceed to
invite Mr Reeves to the meeting in July 2001.
- Approximately fifteen submissions were received by the Forum from
expert/professional bodies – these will need to be examined by members
of the Forum with the relevant expertise. A list will be circulated to
the members of the Forum. Dr Flanagan will draft a summary of the
findings of the Sub-Group on Public Consultation which he will circulate
to the members of that Sub-Group shortly – this summary will highlight
the list of concerns most frequently raised by respondents. Ms Gallagher
and Dr Cullen are taking a detailed look at the submissions to check the
accuracy of the summary.
- The Chairman asked that all sub-groups try to finalise their work
before the end of June in order that their findings/results can be
presented the meeting in July 2001.
- A journalist from the Irish Times has asked to look at the submissions
received – it was agreed that the Forum has no objection to this in
principle; however, respondents may have forwarded their views on the
understanding that such submissions were private and would not be viewed
by any third party. It was agreed that the submissions should not be
released until after the Sub-Group on Public Consultation has completed
its examination. It was noted by members that it is not possible to
contact each respondent due to the fact that full addresses were not
necessary/provided. It is important, however, that the Forum be as open
- Some newspapers articles (circulated to the members before this
meeting) mentioned that a specific journalist had not been successful in
his attempts to contact members of the Forum. Three members of the Forum
stated that they had taken calls from the relevant journalist and had
explained that the Chairman had requested that, in the best interests of
the work of the Forum, members should refrain from making public
pronouncements on the subject of fluoridation until after the Forum’s
recommendations are presented to the Minister. The Chairman had pointed
out that any individual comments could compromise the work of the Forum
by appearing to pre-judge the Forum’s conclusions. The members of the
Forum are open-minded on the subject being examined and all conclusions
of the Forum will be reached following full and balanced consideration.
While the tone of some articles has been negative, it is more important
for the Forum to continue its work than to respond to individual
- The members were advised that the Department’s Freedom of
Information Officer has written to Dr Don MacAuley regarding his
requests and, in view of the large time commitment which would be
involved in collating the material for response, asked for a deposit to
be paid. A response is awaited from Dr MacAuley.
- Professor O’Mullane, as Chairman of the Sub-Group working on
responding to Dr Connett’s "50 Reasons", explained that this
is an enormous and very detailed task and is taking a lot of time to
compile; it is hoped that the response will be completed by the end of
- In relation to the Sub-Group on Alternatives, Professor Clarkson
explained that he and Professor O’Mullane are working on a paper which
their sub-group will discuss.
- The Sub-Group on Ethics met in Cork on 12 June 2001 – Professor O’Mullane
said that the meeting was useful but a lot of work is still required. It
was agreed that further expertise was required in order to advise this
Sub-Group – the Secretariat will liaise with Professor O’Mullane
with a view to contacting a specialist in that field.
- Dr Cullen is extremely concerned that the issues raised by the IDEA in
relation to nephrology and toxicology have not yet been adequately
addressed. Dr Owens explained that attempts have been made to elicit
advice from two paediatric/nephrology specialists and a toxicologist;
the latter is unable to meet the Forum due to a heavy workload but is
very willing to advise the Forum on relevant issues. The Secretariat
mentioned that the Society of Toxicology is willing to meet the Forum
but this may not be possible in time for the meeting in July 2001 due to
prior commitments; however, the Society is currently working on its
submission to the Forum. A commitment was given to Dr Cullen to follow
up on the need for advice on the issues raised by the IDEA. Suggestions
regarding the names of other experts in the field of nephrology were
requested from the members of the Forum.
- Dr Owens stated that the progress report is almost finished and will
be on the Forum’s web site shortly.
- A response has recently been received from VOICE following the
Chairman’s letter to the organisation.
- The meeting on 12 July 2001 will be lengthy as there will be several
presentations and the Forum has a lot to discuss on that date.
- The two Bio-Statisticians (Professor Don Barry and Dr Kevin Balanda)
have been in contact with each other following the presentation by
Professor Elizabeth Treasure on the "York Review" – the
Secretariat expects a written report on their conclusions shortly.
- Dr Mullen, on behalf of the Sub-Group to meet the County Councils, has
drafted a letter to be issued to the Councils.
- Professor Kelleher stated that her staff would be more than willing to
provide any additional information/data required on nutritional aspects,
particularly in relation to any questions raised following the
presentation by Ms Margaret O’Neill, Community Nutritionist. The
Chairman requested, in particular, an international league table of
- The guest presenters at the next meeting will include Dr Caswell Evans
(USA) and Dr Jacinta McLoughlin (DDH). The Secretariat will also try to
have a toxicologist present – any member with concerns regarding
toxicological issues should forward these in writing to the Secretariat
- Professor Paul Dowding will be asked by Dr Cullen, on behalf of the
Forum, to submit his views from an environmental perspective.
- Dr Owens, Rapporteur, is to prepare the outline of the first
draft of the Forum’s report and circulate it to the members of the
Forum before the meeting in July 2001 – the second draft will be done
in August 2001 and the third in September 2001. NB No recommendations
will be made or included in the draft until after the Forum has fully
completed its examination and discussion process. The deadline for
presentation of the report is now close and it is important that the
Forum make significant progress on the report over the summer period.
- Reference was made to the fact that Japan is considering introducing
- It was noted in relation to hydrofluosilicic acid that the levels
shown in the documentation from Dr Cullen (which was circulated to the
Forum) would indicate a very pure quality of acid used for fluoridation.
It is important to remember that although minerals such as arsenic or
chromium are present in very small quantities in the original acid there
is a very high dilution factor after addition to water which results in
extremely low final levels which are in no way harmful.
- The term "waste product" which is often used in the media in
relation to hydrofluosilicic acid is incorrect and will be explained in
detail in the final report of the Forum and by Mr Tom Reeves of the
Centre for Disease Control.
Presentation by Professor William Binchy –
"Fluoridation – The Legal Dimension"
The presentation was followed by a brief Q&A
- How would the European Court decide on the issue of water
- Extrapolating from relevant decisions made by the European Court so
far would appear to indicate that it would not be struck down.
The Chairman thanked Professor Binchy for his
well-researched and informative presentation.
Professor Binchy left at this stage due to a prior
engagement as did Dr O’Connor.
Presentation by Ms Doreen Wilson, Chief Dental Officer,
Northern Ireland – "Mid Term Evaluation of the 1995 Oral Health
The presentation was followed by a Q&A session.
Dr Mullen commented that he is involved in cross-border
work; the North Western Health Board often have dentists from Northern
Ireland who express surprise at the difference in the level of dental
caries between the two areas – and if one looks at the fluoridated areas
of the Republic of Ireland v non-fluoridated Northern Ireland the
difference is even more marked. Northern Ireland is considerably ahead of
the Republic of Ireland in terms of oral health promotion strategies but,
nevertheless, the Republic of Ireland has significantly fewer dental
cavities. Ms Wilson stated that huge resources have been put into oral
health promotion in Northern Ireland in the past five years but there has
been very little impact as a result, which is disheartening. In her
experience as Chief Dental Officer Ms Wilson said that if there is no
water fluoridation then massive resources are required for alternative
strategies which have had limited success. However, such a decision would
necessitate discussion on where resources are best targeted in the health
sector where there are so many competing demands.
Secretariat is to get a copy of the Oral Health
Strategy from Northern Ireland.
- What are the party political views on water fluoridation in Northern
- None given so far but Minister de Brún is very anxious to reduce
social inequalities. Any decision regarding the introduction of water
fluoridation in Northern Ireland would require in-depth consultation.
- In 1997 the relevant Minister decided not to have water fluoridation
in Northern Ireland – why?
- It was anticipated that there would be a lot of opposition at County
Council level. However, debate now could be very valuable as the
decision would be made locally (ie in the Assembly) rather than in
- How is the British situation so close to Ireland’s when they only
have a small amount of water fluoridation? Is diet a more important
factor than had been realised?
- Social deprivation is an important factor, most particularly in
- In the absence of water fluoridation, what other strategies could be
- An intense programme including fluoride mouthwashes/rinses, oral
health promotion, healthy eating projects, free toothbrushes, etc.
Society needs to change its eating habits – however, inducing this
change is very resource-intensive and has had limited success.
- Has either fluoridated salt or milk been considered?
- Both will be looked at in Northern Ireland, as will fluoridated
toothpastes and fluoridated water.
Comment: Evidence from pre-1960 period indicated a very
similar dental health situation in Northern Ireland to that of the
Republic of Ireland – ie starting from the same point – but there is a
large difference in dental cary levels now in spite of enormous efforts
made in Northern Ireland on alternatives to water fluoridation.
Comment: There is an important opportunity cost to be
considered here ie spending money on fluoridation or alternative methods
of oral health promotion – could that have a cost elsewhere in the
Ms Wilson stated that a large amount of money has been
invested in oral health services in Northern Ireland (UK£66m for one
million population approximately) but matters have basically stood still.
The projected revenue cost of fluoridating Northern Ireland’s water
supplies (UK£2m) would be a very small fraction of this cost.
Members were reminded that a paper by Mr Tim Holland of
UCC in relation to the cost-effectiveness of different methods of fluoride
delivery has recently been circulated by the Secretariat – this may be
of interest in relation to this discussion.
- Is Northern Ireland evaluating dental health promotion strategies to
see what is or is not working effectively?
- Not as such – but different strategies can reach different parts
of society. There is a need to place responsibility on the individual
for their own dental health.
- Does health promotion work?
- It is a matter of scale and how much is invested – it also depends
on the margin of gain desired.
Comment: If you persist at health promotion, it will
Comment: Yes, but the issue of equity is at play.
- To what extent has paediatric toothpaste usage been effective?
- This is very difficult to get information on but work on this area
Ms Wilson, as Chief Dental Officer, said she would like
to raise the profile of dentistry in society in Northern Ireland.
The Chairman thanked Ms Wilson for her interesting and
well-prepared presentation. Ms Wilson then left.
Presentation by Dr Patrick O’Sullivan, Irish Doctors’
Environmental Association (IDEA) – "Position Paper on
Dr O’Sullivan said he was grateful for the
opportunity to participate in this debate. The IDEA welcomes the Forum and
A Q&A session followed the presentation.
Q. If the questions raised by the IDEA were dealt
with satisfactorily by the Forum, would the IDEA still have a
fundamental problem in principle with water fluoridation?
A. The IDEA members on the whole dislike the addition
of unnecessary chemicals to anything - in the scenario detailed in the
Question above, Dr O’Sullivan would not personally have a problem with
fluoridation but other members of the IDEA might.
Comment: Very strongly concerned with the need to
address socio-economic differences – but examination of this issue leads
to examination of different aspects of risk eg relative, absolute or
attributable risk. It is crucial to examine alternatives and to bear
opportunity cost of any decision made in mind.
Dr O’Sullivan agreed that it is necessary to look at
the size of gain versus the potential for harm.
Comment: Dr O’Sullivan’s assertion that some
reports link fluoridation to increases in cancer is incorrect – one
needs to be very careful when quoting studies. However, in Dr O’Sullivan’s
defence, it is extremely difficult to know which studies one can rely on
– often they have to be examined in conjunction with other studies. The
Chairman invited the IDEA to submit papers/references in support of their
arguments and the Forum will examine them thoroughly. It was stressed that
such references should be from peer-reviewed internationally recognised
Comment: Agreement with Dr O’Sullivan that the issue
of fluoridation and premature babies needs to be examined.
Comment: In relation to the "York Review",
one of the difficulties in this regard is that no epidemiologist can prove
something is safe – but one can say (as the "York Review" team
did) that there is no evidence to prove it is not safe.
Dr O’Sullivan is very concerned regarding
contaminants in hydrofluosilicic acid.
Comment: The principle "First Do No Harm"
must always be borne in mind. In addition, there are issues of omission as
distinct from commission to consider – eg to remove something which is
of benefit to many may also be wrong.
Secretariat to get copy of the Combat Poverty Strategy
Report from Professor Kelleher.
The Chairman, on behalf of the Forum, expressed his
admiration for Dr O’Sullivan for his willingness to express his views to
the Forum and reiterated that the Forum regrets deeply the fact that
several individuals/bodies with anti-fluoridation views have declined
invitations to meet the Forum to convey their views. Dr O’Sullivan (on
behalf of the IDEA) was thanked sincerely for his contribution to this
important participative process.
Presentation by Dr Andrew Rynne on his concerns
regarding fluoridation and the Forum on Fluoridation
A Q&A session followed this presentation.
The Chairman, on behalf of the Forum, thanked Dr Rynne
sincerely for meeting the Forum and for conveying his views. It is
essential that views from all perspectives be heard by the Forum in order
for the debate to be fully rounded; the Forum has expressed, on several
occasions, its disappointment and regret that several individuals and
groups with anti-fluoridation views have declined invitations to meet the
Forum. It is particularly laudable in this case that Dr Rynne had the
courage of his convictions in putting his views across. However, both the
Chairman and members of the Forum were anxious to point out that, despite
Dr Rynne’s assertion to the contrary, each member of the Forum is
looking at the issue of fluoridation in an open-minded manner. Dr Rynne
pointed out that, in his opinion, it would be very difficult for a member
of the Forum who may have previously supported water fluoridation to
express any anxiety in this regard now as this may have an impact on
his/her professional reputation; again, the members pointed out that if
new scientific evidence were found by the Forum pointing to any harmful
effects they would have no problem in expressing this – it would not be
an admission of error but an acceptance of new evidence and learning. As
one member pointed out, the health and safety of his family and friends
are of more importance to him than his professional reputation – no
member of the Forum would seek to advance dental health at the expense of
general health if evidence of alleged harmful health effects were found.
The Chairman stated that the Forum would welcome any
peer-reviewed evidence which Dr Rynne would like to submit in support of
It was mentioned to Dr Rynne that over 1,000
submissions from the public and interested bodies have been received by
the Forum – the views contained therein are being examined and will be
The Chairman reiterated that the Forum has not yet
decided what recommendation(s) it will make – examination of the issue
is not yet complete; it is important to look at all of the concerns
It was mentioned to Dr Rynne that most of the points
raised by him have already been raised by other speakers/submissions and
the Forum will be addressing all of them. The members of the Forum come
from varied professional backgrounds – this multiplicity of expertise
will be of great benefit to the Forum in examining the different concerns.
There is need for more scientific research in this
The issue of freedom of choice is an important one for
consideration and discussion.
Dr Rynne said that the Forum would not be providing any
new studies or come up with any new information – he would like to see
funding for new studies being provided and fluoridation to cease. The
Forum agreed that, regardless of what other recommendation(s) it may make,
it will definitely recommend that further research be carried out.
Dr Rynne said that fluoridation may have had dental
benefit in the past but is not sure that this benefit continues now.
Reference was made by a member of the Forum to a new study of adult dental
health which will help to evaluate fluoridation – Dr Rynne is welcome to
look at this study and to comment on it.
The Chairman thanked Dr Rynne for his clear and concise
presentation. Dr Rynne then left.
Informal presentation by members of the Forum*
(*Most members had been given the opportunity to
give their informal presentation at the meeting in May 2001; those who
were unable to do so due to a prior/conflicting engagement were invited to
do so at the June 2001 meeting)
- is looking at this issue in a totally open-minded manner
- has learnt a lot from this process
- the issue of premature babies should be examined thoroughly
- the issue of dialysis patients should also be looked at but is not
aware that tap water is used during this process
- the Forum is an excellent opportunity to explore the issue of
fluoridation openly, accurately and scientifically.
- this debate has opened up fascinating avenues of thought
- the advantage of interdisciplinary exchange between Forum members is
- the Forum needs to decide on a level of benefit which is sought and
weigh that against other arguments
- the issue of errors of omission versus commission is fundamental to
this whole discussion
- while it is far too early to know if the Forum will recommend the
continuation or cessation of water fluoridation, in the event that it
continues a cohort surveillance system needs to be carried out rather
than sectional surveillance.
Professor Kelleher mentioned that she is going on
sabbatical for six months and will be, therefore, unable to attend any
further meetings – however, she is anxious to continue her participation
in the work of the Forum and will provide any advice and/or support
- came to the Forum with a neutral attitude
- the weight of evidence shown so far to the Forum would appear to
sway in terms of the benefits of fluoridation – however, much
research needs to be done
- has been concerned all along regarding the philosophical/ethical
view eg including the issue of breach of bodily integrity, but
Professor Binchy’s presentation has allayed some of her concerns in
- societal values change constantly – not sure how the Forum will
address this, but it is important that the views of the public be
taken into consideration.
- will provide his views in written form.
- has no agenda on this issue and is proceeding on an open-minded basis
- while scientific data is very important, the philosophical debate is
very challenging and important
- the very best scientific evidence available needs to be used in this
Next meeting on 12 July 2001.
NB Amendments to minutes above
At the Forum’s meeting of 12 July 2001, Dr Cullen
asked that it be noted in relation to paragraph 14 above that in addition
to the issues of toxicology and nephrology, she also expressed concern
that the ethical issues in relation to fluoridation have not yet been
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