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Minutes of meeting of the Forum on Fluoridation on 12 July 2001
The Boardroom, Dublin Dental Hospital

Present

  • Professor Pat Fottrell (Chairman)

  • Dr Wayne Anderson

  • Professor John Clarkson

  • Dr Elizabeth Cullen

  • Dr Paddy Flanagan

  • Ms Dorothy Gallagher

  • Dr Gerard Gavin

  • 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)

  • Dr Margaret Shannon (Forum Secretariat)

Apologies

  • Professor William Binchy

  • Mr Oliver Fogarty

  • Dr Howard Johnson

  • Professor Cecily Kelleher

  • Professor Miriam Wiley

Meeting

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 14 June 2001 were agreed with the following amendment to be made:

Dr Elizabeth Cullen asked that paragraph 14 be amended to reflect the fact that she expressed concern that the ethical issues in relation to fluoridation have not yet been adequately discussed by the Forum.

Matters arising

  1. Dr Cullen again expressed her concern that the Forum has not yet met with a toxicologist, a paediatric nephrologist and an ethicist. Ms Gallagher stated that the Consumers’ Association of Ireland is also concerned that the expertise of a renal expert be acquired. Dr Owens clarified that a paediatric nephrologist has recently agreed to look at relevant issues and will submit a paper to the Forum – she is also willing to meet the Forum in August 2001 if required. Dr Owens will arrange this meeting and will liaise with the members of the relevant sub-group – Ms Gallagher is to join this sub-group.
     
  2. Dr Richard Hull of the National University of Ireland, Galway, has agreed to meet the Sub-Group on Ethics – this meeting will take place in the next ten days. A copy of relevant documentation including Professor Binchy’s paper and Dr Cullen’s list of questions have been forwarded to Dr Hull in order to aid preparation for this meeting.
     
  3. Professor O’Mullane explained that the Sub-Group working on Dr Connett’s "50 Reasons" are working hard and hope to be able to circulate a draft response to the members of the Forum shortly.
     
  4. It was noted that a press release by a group entitled "Fluoride Free Water" quoted only part of a sentence from the Forum’s meeting of 5 April 2001. This press release may have given a misleading impression of what was actually minuted – see below.
  5. Extract from the minutes of the Forum’s meeting of 5 April 2001:

    "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."

    Extract from press release issued by the group entitle "Fluoride Free Water"

    "…..This pro-fluoride forum, like the others, seems more interested in hiding the truth and withholding information from the public than looking at fluoridation.

    An example of this occurred at a recent meeting of the Forum on Fluoridation on 5/4/2001. At this meeting, closed to the public, Mr. Kevin Moyles, Head Public Analyst, stated that "tests done so far by the Regional Analysts’ Laboratory suggest that the hydrofluosilicic acid (fluoridating agent) used is pure…." Fluoride Free Water recently obtained a full chemical analysis of this acid under FOI. This confidential document…, dated 14/2/2001, was forwarded to Mr. Kevin Moyles but did not indicate the acid as "pure". In fact, one quarter of the H2SiF6 (acid) is contaminated, including carcinogens such as arsenic, chromium, nickel and mercury. As Micheál Martin misled the Dail regarding the contents of this toxic cocktail last year, it is no great surprise that members of his "fluoride farce" continue to mislead the public and put all our health at risk."

    (NB The presentation made by Mr Tom Reeves of the CDC is also relevant to this – details below.)

  6. A list of the fifteen submissions received from professional groups/organisations was read to the Forum. It was decided to have a sub-group look at them:
  7. Dr Anderson
    Professor Clarkson
    Dr Cullen
    Dr Flanagan (convenor)
    Dr Gavin
    Mr Moyles
    Dr Mullen.

    A meeting of this sub-group will be organised by Dr Flanagan, ideally before the end of July 2001.

  8. The Progress Report, drafted by the Rapporteur, which details the Forum’s progress to February 2001 is now on the web site.
     
  9. Subsequent to the query from the Irish Times which was discussed at the June 2001 meeting of the Forum, Dr Flanagan spoke to the journalist in question, Ms Alison Healy, at the request of the Secretariat, and the relevant article concerning the views expressed by respondents was printed shortly thereafter.
     
  10. It was noted that Dr Gary Whitford, who earlier this year had to decline the Forum’s invitation to make a presentation due to a very heavy schedule, might now be able to meet the Forum, possibly in September 2001.
     
  11. Dr Cullen asked how rigid is the October 2001 deadline for the Forum’s Report; the Chairman strongly recommends that this deadline be complied with.
     
  12. Monaghan County Council contacted the Secretariat recently regarding a meeting on 3 September 2001 to which an anti-fluoridation speaker has been invited. They also plan to invite a dentist from the local health board. They requested that a member of the Forum attend. The Secretariat explained to the representative of the Council that a Forum representative would only be able to detail progress to date made by the Forum and that a neutral stance on the issue would be maintained until after the Final Report is presented to the Minister – the Council was satisfied with this. It was decided after much discussion by the Forum that it would not be appropriate for a Forum member to attend such a meeting until after the Final Report is presented to the Minister; however, a letter will be sent to the Council outlining progress to date.
     
  13. It was noted that the Secretariat has been receiving a number of irate and/or abusive telephone calls from members of the public and organisations who are opposed to water fluoridation. Two of the members of the Forum also mentioned that they had received calls of a similar nature. Members of the Forum expressed their concern and regret at this. While such persons/organisations are welcome to express their views this should be done in writing, if possible.
     
  14. Dr Cullen has written to Professor Mike Gibney of TCD (regarding total fluoride intake) and Dr Paul Dowding of TCD (regarding environmental issues) but has not as yet had a reply from either. It was agreed that the Forum should get advice on these issues so if a response is not forthcoming from the two aforementioned experts due to their very busy schedule, it will be necessary to contact other experts in their field.
     
  15. A letter has been drafted to inform County Councils of the Forum’s progress to date – this will be circulated and finalised shortly.
     
  16. Professor O’Brien has been unable to contact Dr Connett as yet (with regard to his email concerning a comment made by him in relation to osteoporosis) but will do so as soon as her extremely busy schedule permits.
     
  17. Dr Flanagan has circulated a draft summary of views contained in the submissions received by the Forum. Dr Cullen and Ms Gallagher have not yet completed their examination of the submissions and will convey their views to Dr Flanagan as soon as possible. Professor O’Brien thanked Dr Flanagan for the enormous amount of work that he put into drawing up this draft summary. Comments/requests for amendments in this draft should be forwarded to Dr Flanagan as soon as possible. It was noted that while all of the views submitted are important and will be considered by the Forum, it is important to explain (a) the differences between a qualitative and a quantitative study and (b) it was not a random sample – a select group volunteered their views and (c) this was not a scientific study.
     
  18. The Secretariat is to contact the Minister’s Office regarding the presentation of the Final Report.

Presentation by Dr Jacinta McLoughlin, Dublin Dental Hospital: "An Evaluation of Water Fluoridation Systems in Ireland"

The presentation was followed by a Q&A session.

Following a question, Dr McLoughlin explained what bunding means.

Q. Is the research contract looking at levels of fluoride in the body?

A. This is not in the remit of the study.

Comment: UCC is currently studying methods of examining total fluoride intake.

Professor O’Mullane mentioned that he got several interesting papers on the changing patterns of water consumption at recent conferences and will supply them to the Forum if required.

Q. Will the team be making recommendations regarding levels under 0.7ppm?

A. It is crucial to comply with the legislative limits so the team will be looking at both under-dosages and exceedances.

Comment: the data collection and results of this research contract will be useful to the Forum in identifying areas to be addressed.

  1. Are under-dosages linked to size of water plants?
  1. This looks quite likely but exact details have yet to be attained.

Comment: the larger the plant the better the results are likely to be; however, small plants can also be very accurate.

Comment: this has public health implications.

Dr McLoughlin undertook to forward a copy of the terms of reference of Fluoridation Monitoring Committees to the Secretariat.

  1. Have you considered if 0.8-1ppm is the appropriate level for today’s society?
  1. This is not in the remit of this study.
  1. When will the research project be finished?
  1. They are starting to draft their report now.

Comment: health boards tend to regard fluoridation as a more important issue than the Local Authorities do but changes in regionalisation of roles will be very beneficial.

The Chairman thanked Dr McLoughlin for a very interesting presentation.


Presentation by Mr Tom Reeves, Centre for Disease Control and Prevention, Atlanta, entitled "Engineering Aspects of Water Fluoridation"

A Q&A session followed the presentation.

  1. What is the current situation regarding fluoridation in other countries?
  1. Japan was very anti-fluoridation in its views but is now moving towards introducing water fluoridation. Korea is also considering introducing water fluoridation. Will send on relevant documentation to the Forum.
  1. Is there a relationship between size of water plants and accuracy of dosage in the USA?
  1. Will send on documentation with relevant details. There is a problem with lack of training in some of the smaller systems/plants in the USA.
  1. Most public water supplies in countries in Western Europe are not fluoridated but many of these countries still have good oral health levels, so why has the USA proceeded with fluoridation?
  1. The USA does not have universal health care. Many Western European countries invest heavily in alternative methods of fluoridation eg Switzerland uses four different types of salt, some of which are fluoridated. The CDC is of the view that if there is a good water system in place then water fluoridation is the best method but, if not, then alternatives can be effective.
  1. A lot of the claims made by anti-fluoridationists state that the EPA in the USA are anti-fluoridation – is this an accurate reflection and, if so, why do they feel this way?
  1. There are 3,000 scientists in the EPA – only 3 are anti-fluoridation but they are very vocal.
  1. Is there a danger of over-dosage from fluoridated toothpaste?
  1. There are 1,000ppm fluoride in fluoridated toothpaste (in comparison with 1ppm in fluoridated water) so there is a possible danger of over-dosage with toothpaste.
  1. What is the level of fluoride in fluoridated salt?
  1. 250-290ppm.
  1. Fluoridating salt is not an effective method due to health awareness for the need to cut down salt consumption – would you agree?
  1. Yes, that is one of the reasons why the USA does not use fluoridated salt.
  1. What are the views on fluorosis in the USA?
  1. There is no consensus in the USA as to whether fluorosis is a problem or not; however, it should be noted that most fluorosis there is at mild or very mild levels and is likely to be due to misuse of fluoridated alternatives.

Extensive discussion took place regarding the presence of contaminants in hydrofluosilicic acid, particularly the claims made in relation to arsenic and lead. It was clarified that the levels are so minute as to be virtually meaningless.

Mr Reeves offered to send copies of "Abuse of The Scientific Literature in an Antifluoridation Pamphlet" (2nd Edition, American Oral Health Institute) to the Forum for any member who might be interested in reading it.

Mr Reeves explained that many cities in the USA have fluoridated public water systems including New York, Los Angeles, Chicago, Detroit, Houston, Philadelphia, Phoenix, Dallas, San Francisco, Washington and Boston. He went on to say that, according to 1992 fluoridation census figures, 62% (*) of the people in areas where there are public water systems are drinking fluoridated water (artificial and natural) – this equates to a population of 144.6 million people. The CDC is preparing to announce the 2000 census figures which will see a slight increase in those statistics. (*These figures do not include California – however, when the relevant legislation in that state is implemented the overall level in the USA will increase to approximately 70%).

The Chairman thanked Mr Reeves for his very interesting presentation.


Presentation by Dr Caswell Evans, National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, USA, entitled "Fluoridation - Recent Developments in the USA"

A Q&A session followed the presentation.

Q. Why was water fluoridation introduced in California?

A. The level of oral health of children in California was found to be much lower than that of other states in the USA where water was fluoridated. There was a desire to bring California to the same dental health level as the high-achieving states.

Q. Was there an anti-fluoridation lobby in California?

A. There was certainly an anti-fluoridation group there but while it was vocal it was not particularly effective despite being given opportunities to present its case to the public.

Q. What is the impact of the halo effect? Is there a noticeable difference between one side of the USA and the other? (The "halo effect" refers to the diffusion of fluoride from fluoridated areas to surrounding nonfluoridated areas via bottled beverages and processed foods manufactured in the fluoridated areas.)

A. There is a high level of mobility in the USA (an average of one move per person/family every five years) which includes a large number of coast to coast movements so it is very difficult to gauge the halo effect.

Q. How many states have ceased public water fluoridation?

A. No states have ceased fluoridation of public water supplies but some small communities have done so.

Comment: the impression which was given to the Forum by Professor Limeback and Dr Connett during their presentations on 13 October 2000 on public attitudes to water fluoridation in the USA was completely different to that given during today’s presentations.

Comment: the Surgeon General’s Report (quoted by Dr Evans) links oral and general health with quality of life – this is a very important point to the general public in the USA and influences their attitudes to water fluoridation.

Comment by Dr Evans: he had not realised until recently that there are so many parallels between USA and Ireland eg levels of poverty, huge investment in orthodontic appliances and huge amount of sugar consumption. From a public health perspective, water fluoridation is the best method of improving dental health in the poorer sections of society and, in particular, in poor children who may have high sucrose consumption.

Comment: the observation made by Dr Evans as to the huge consumption of sugar in Ireland has been borne out by scientific evidence. There is a very high sugar consumption in Ireland compared to other countries.

  1. Kildare County Councillors recently had their urine tested to measure levels of fluoride – is this an important issue? Is there a danger of over-dosage?
  1. Found the issue a very curious one. The tests would not appear to have been carried out in a scientific manner. Urinary excretion is the body’s normal way of ridding itself of what it does not need so spikes in levels of particular substances are not unusual nor should it be the cause of anxiety.

Comment: As per Dr Gary Whitford, when one drinks something with a high fluoride level the body will excrete what it does not need very quickly which can cause a spike in the level if measured. If there is only a once-off over-dosage of fluoride it is not a problem but constant overdosing could possibly be.

  1. Qualitative research in Ireland shows that Irish people do not show a high level of awareness or concern with the issue of fluoridation but there is a degree of confusion. What is the feeling in the USA public? Is there an effort to raise awareness?
  1. The USA population appears more knowledgeable on the subject as it is constantly in the media; however, confusion is still possible due to conflicting and inaccurate claims in the literature and media.
  1. Are there any campaigns in the USA for fluoride free toothpaste?
  1. Over the counter dentifrices without fluoride are available in many outlets across the country and are easily accessible but the majority of toothpaste is fluoridated because this is what the market forces demand. However, work has been done to reduce the level of fluoride in paediatric toothpastes which is an appropriate move.
  1. One acknowledged side effect of fluoridation is fluorosis – are there any steps being taken in the USA to reduce fluorosis levels?
  1. The CDC Report due shortly will examine the issue of fluorosis. He would not personally categorise fluorosis as a public health issue per se but rather as a cosmetic issue. One should consider to what extent does dental disfigurement due to caries compare with possible dental disfigurement due to fluorosis. On a personal level, he would view the ability to reduce dental caries as preferable even at the possible cost of some cosmetic effects. It is also important to realise that most fluorosis is not detectable by the lay public/untrained eye.

The Chairman thanked Dr Evans for his very interesting presentation.


Sub-Groups and Related Issues

Sub-Group on Public Consultation

This group will try to finalise their summary shortly. Any comments on the draft should be sent to Dr Flanagan by the end of July 2001.

Sub-Group on Dr Connett’s "50 Reasons"

See (3) above. It has been noted that several of the original questions have been removed from Dr Connett’s web site.

Toxicological Issues

Dr Cullen stressed the importance of getting answers on toxicological issues. The Chairman noted that Dr Cullen was more than welcome to invite responses from toxicologists and also encouraged other members to nominate known experts in the toxicological field. If Dr Gary Whitford can meet the Forum in September 2001 this will also be arranged. The Rapporteur stated that Dr Joe Treacy would write to the Forum on toxicological issues as soon as possible. Professor Keith Tipton is looking at the issues regarding enzymes which were raised by Dr Connett. The Chairman stressed that it is important that the toxicological issues be followed up.

NB The Chairman emphasised the need for all relevant areas and issues of concern to be addressed before the Forum makes its recommendations to the Minister; as the time for presenting the Forum’s Final Report is rapidly approaching he urged all members of the Forum to do their utmost to address the outstanding issues.


Final Report

It may be useful to have a short "executive" summary in addition to the main report to aid access and understanding.


Other issues

Professor O’Mullane mentioned a paper entitled "Factors affecting caries levels amongst 5 year old children in County Kerry, Ireland" which may be of interest to members – he will forward a copy to the Secretariat for circulation.


There will be no meeting of the Forum during August 2001 as a number of members will be on holiday. The Forum will resume its discussions in September 2001.


Please Note:

The minutes of the meeting of Thursday 12 July 2001 (above) were agreed by the Forum on 3 September 2001 but with the following amendments to be made.

The two relevant paragraphs from the section on the presentation by Dr Caswell Evans and the subsequent Q&A session should read as follows:

Comment: the observation made by Dr Evans as to the high levels of consumption of sugar in Ireland has been borne out by scientific evidence. The frequency of consumption of foods and drinks sweetened with sugar is very high in Ireland compared to other countries.

Comment: Dr Gary Whitford’s research shows that when one drinks a liquid with a high fluoride level the body will excrete what it does not need very quickly which can cause spikes in the plasma and urine levels if measured. Such a once-off spike is not a problem but continuous excessive intake could be.


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