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Forum DocumentsSummary of Presentations Forum on FluoridationApril 2001
The Forum on Fluoridation was established Mr. Micheál Martin, TD, Minister for Health & Children on 29th May 2000 and held its first meeting on 6th September 2000. To review the fluoridation of public piped water supplies and the programme of research being undertaken on behalf of the health boards in the area. To report and to make recommendations to the Minister for Health and Children.
Professor Patrick Fottrell, Chairperson , Former President of National University of Ireland, Galway Dr. Gerard Gavin, Chief Dental Officer, Department of Health and Children Ms. Dora Hennessy, Principal Officer, Department of Health and Children Dr. Dominique Crowley, Deputy Chief Medical Officer, Department of Health & Children until 15/09/00, now Lecturer, Department of Community Medicine and Epidemiology, University College Dublin Mr. Oliver Fogarty, Engineering Inspector, Department of the Environment and Local Government Dr. Wayne Anderson, Chief Specialist, Food Safety Authority of Ireland Professor John Clarkson, Dean Dublin Dental School and Hospital Professor Denis O’Mullane, Head of Department of Oral Health and Development and Director of Oral Health Services Research Centre, University College Cork. Dr. Máire O’Connor, Specialist in Public Health Medicine, South Eastern Health Board and Faculty of Public Health Medicine Dr. Howard Johnson, Specialist in Public Health Medicine, Eastern Regional Health Authority Dr. Patrick Flanagan, Environmental Protection Agency Professor Moira O’Brien, Professor of Anatomy, Trinity College,Dublin Mr. Kevin Moyles, Regional Public Analyst, Dublin Professor William Binchy, Regius Professor of Law, Trinity College Dublin Professor Cecily Kelleher, Professor of Health Promotion, National University of Ireland, Galway Dr Joe Mullen, Principal Dental Surgeon, North Western Health Board Dr. Carmel Parnell, Irish Dental Association Professor Miriam Wiley, Head, Health Policy Research Centre, The Economic and Social Research Institute Ms. Dorothy Gallagher, Vice- Chair, Consumers’ Association of Ireland Ms Nessa O’Doherty, Forum Secretariat, Department of Health & Children Dr Margaret Shannon, Forum Secretariat, Department of Health & Children Dr Elizabeth Cullen, Co-Chair, Irish Doctor’s Environmental Association, since December 2000 The above members represent a broad spectrum of interests covering areas such as dental health, environmental health, food safety, public health, health promotion, ethics and consumerism. The following were invited by the Minister as members of the Forum, but declined the invitation: Ms Darina Allen, and Mr Dick Warner and a representative from Voice of Irish Concern for the Environment (VOICE). The Minister also informed the Forum that he would be pleased to invite additional members if requested by members of the Forum, through the Chairman. Dr Elizabeth Cullen was invited by the Minister on the request of the Chairman.
The following procedures were agreed by members of the Forum for delivery of presentations to the Forum. Members of the Forum were invited by the Chairman to make suggestions for presentations on all aspects of water fluoridation within the terms of reference of the Forum, while keeping in mind the importance of having a balance between those in favour and those opposed to water fluoridation. The Forum requested each presenter to submit a summary of their presentations beforehand if possible or as soon as possible afterwards. All claims and conclusions about water fluoridation and its alleged benefits or ill effects should be substantiated by evidence of publication in peer-reviewed journals or by the recommendations from recognized international health authorities such as the World Health Organisation. Members of the Forum were also requested by the Chairman to submit questions or issues beforehand which they wished to have addressed by presenters. It was also agreed that in keeping with the rationale of a Forum as much time as possible should be given for discussion of presentations. Members also agreed that every effort must be made to engage and encourage members of Irish organisations such as VOICE (Voice of Irish Concern for the Environment), The Consumers’ Association of Ireland and environmental organisations to make presentations on their views on water fluoridation. Members of the general public would be encouraged through advertisements in the media to make submissions. First Meeting 6th September 2000 Presentation by Professor Denis O’Mullane Dental School, University College Cork Professor O’Mullane presented a paper, which he had previously presented to a Joint Oireachtas Committee on Health and Children in July 2000. He covered the background to fluoridation and its current status worldwide, and provided data on the effectiveness in improving dental health of children in Ireland and the issue of fluorosis. He presented survey results, which demonstrated that the dental health of residents of fluoridated communities is considerably better than that of residents living in non-fluoridated communities. On the topic of fluorosis, he spoke of the difficulties encountered in measuring this phenomenon and the fact that not all dental opacities are related to fluoride. While acknowledging, in his opinion, that dental health has improved in non-fluoridated areas mainly due to the use of fluoridated toothpaste, and the ‘halo’ effect of water fluoridation (due to the consumption of drinks and foods manufactured in fluoridated areas), he pointed out that the main risk factors for dental caries persist, i.e. the frequent consumption of foods and drinks sweetened with sugar. He referred to research both ongoing and planned into dental health of both adults and children, being carried out by the Oral Health Services Research Centre in University Dental School, Cork in collaboration with Health Board Dentists. He referred also to collaborative work with international colleagues in the assessment of fluoride intake in young children. He concluded that in his opinion water fluoridation is effective and does not pose a hazard to general health. In view of the fact that while the level of sugar consumption is increasing and is the main cause of dental caries in Ireland today there should be no change in the current policy of water fluoridation. Presentation by Dr Gerard Gavin Department of Health and Children Dr Gavin presented a paper, which he had previously presented to a Joint Committee on Health and Children in July 2000. He discussed the marked decline in dental caries that has been achieved in recent decades and has been attributed to the fluoridation of public water supplies and to the increased use of other fluoride products. He concentrated on the questions of efficacy and safety of fluoridation. For the former he presented results of studies carried out in Ireland showing differences in dental caries levels of between 39% and 50% in children living in fluoridated areas over those residing in non-fluoridated areas. He also referred to a comparative study of dental caries in Dublin, where the water is fluoridated and Glasgow, where the water is not fluoridated. The similar demographic structure and similar levels of deprivation facilitated meaningful comparisons to be made. There was a difference of 45% in the level of dental caries between the two cities indicating that there was significantly more dental decay in the non-fluoridated city. On the question of safety, he made reference to the many authoritative organisations and international health agencies that have studied this aspect of water fluoridation, and that such work strongly supported both effectiveness and safety of the process. However, in light of the importance of ensuring the optimal fluoridation of populations, Dr Gavin supported the need for ongoing research so as to inform future policy decisions. He concluded by referring to the contract for oral health services research on all aspects of fluoride use, which was awarded by the Eastern Regional Health Authority on behalf of all the health boards.
Second Meeting 13th October 2000 Presentation by Professor Hardy Limeback Faculty of Dentistry, University of Toronto. Professor Limeback, focused on what he considered were the declining benefits of fluoridation. On the issue of dental fluorosis, he proffered the view that the benefits of fluoridation no longer outweigh the debits caused by unsightly fluorosis. To illustrate this view he presented case histories and photographs of Canadian children with fluorosis. He spoke of the cosmetic problems experienced by these children and the expense incurred in treatment. He detailed the Canadian approach to treatment, which includes the use of bleaching agents, and acknowledged that the diagnosis of the condition is very subjective. He was of the opinion that the severity of fluorosis as described by him is similar in the US and other countries and that legal cases will result from the condition. He was of the belief that fluorosis is due solely to water fluoridation and does not object to the use of fluoride toothpaste and other systemic population delivery systems. He also referred to studies, which looked at genotoxicity, cancer, reproductive problems, neurotoxicity, thyroid problems and skeletal effects. In the discussion which followed his presentation, Professor Limeback was of the opinion that fluorosis levels were high in Ireland. However, results of studies in Ireland were outlined and gave an opposite point of view.
Presentation by Professor Paul Connett St Lawrence University, New York Professor Connett stated he travelled to Ireland and delivered his presentation in the face of opposition from his supporters. He spoke with considerable conviction on a wide range of issues including genotoxicity, cancer, reproductive problems, neurotoxicity, thyroid and skeletal effects. He presented the key points in written format - "50 Reasons to Oppose Water Fluoridation". Unlike Professor Limeback, Professor Connett opposed all uses of fluoride. He cited studies, which he believed demonstrated the toxic nature of fluoride and held the view that the process of water fluoridation was a convenient method for disposing of hazardous waste. He discussed the Systematic Review of Public Water Fluoridation carried out by the NHS Centre for Reviews and Dissemination, University of York, a summary of which was published the previous week in the British Medical Journal and expressed the opinion that it was too focused on human epidemiology and that the chemical and biological issues warranted further attention. He felt that the York Review was limited in scope and that it would be unfortunate for the British government to treat it as the last word on the "science of efficacy and safety". He expressed concern for bottle fed babies where fluoridated water is used to reconstitute formula feeds, and for the British tea and beer drinking public in the event of fluoridation being extended to the entire country. He believed that the Precautionary Principle was not addressed by the authors of the York Review, due to the exclusion of animal and toxicological studies, and to the failure to acknowledge that a large number of leading dental researchers are now admitting that the beneficial effects of fluoride are topical and not systemic. He referred to animal and toxicological studies, which showed that fluoride inhibits enzymes called proteases, the visible consequences of which are visible i.e. dental fluorosis and may prove to be the tip of the biochemical iceberg. The use of animal studies, in which he believes one can control many factors more precisely than in human populations, is advantageous in that animal studies can be conducted prior to human exposure. He went on to look at the smaller picture of the fluoride ion and stated that what work had been done focused on the fluoride ion alone and that there has been insufficient work on hexafluosilicic acid and sodium hexafluorosilicate. He discussed the weaknesses of the York Review under the following headings: the benefits to teeth, dental fluorosis, hip fractures, cancer and other health effects. He referred to a number of papers which he believed should have been included in the Review. In looking at the strengths of the Review he acknowledged that the authors brought together a far greater selection of studies from independent researchers and anti-fluoride sources than hitherto has occurred in reports sponsored by English speaking governments. He felt that while some of this material was not used as decisively as it could have been, at least it had been referenced. He referred to the inclusion of articles published in Fluoride (the journal of the International Society for Fluoride Research, which publishes papers by anti-fluoridationists) as a welcome departure from the usual disdain with which this journal is normally viewed. In summarising his presentation, Professor Connett stated that it was essential that the Forum should respond to the 50 reasons he presented supporting opposition to water fluoridation. At the end of the presentations, both Professor Limeback and Professor Connett were asked to supply references for the various points they raised; both agreed to do so.
The Minister for Health and Children, Mr Michéal Martin T.D. The Minister addressed the Forum and welcomed Professors Connett and Limeback. He emphasised that the Forum was open to all opinions on water fluoridation and that he was particularly anxious that the concerns of organisations and members of the public should be considered by the Forum.
Third Meeting 9th November 2000 Presentation by Dr Paddy Flanagan The Environmental Protection Agency Dr Flanagan spoke in his capacity as compiler of the statutory Annual Report on Drinking Water Quality in Ireland, published by the Irish Environmental Protection Agency. This report is based on returns of the monitoring of drinking water carried out nationwide by the sanitary authorities. He circulated draft documentation from a forthcoming EPA Report. The Quality of Drinking Water in Ireland --- A Report for the Year 1999 with a Review of the Period 1997 – 1999. The data were presented under three supply category headings: (a) Public Water Supplies, (b) Group Water Schemes and (c) Small Private Supplies / Wells. However, while very few of categories (b) and (c) are fluoridated, fluoride measurements may be made routinely on some non-fluoridated supplies. The EPA places parametric exceedances into four arbitrary bands corresponding to roughly mild, moderate, serious and gross levels of excess. In the case of fluoride, the bands are: (1) 1001 – 1050 l g / l F; (11) 1051 – 1250 l g / l F; (111) 1251 – 1500 l g / l F; (1V) 1501 l g / l F upwards. In his commentary on this data Dr Flanagan pointed out that in earlier reports on drinking water quality, the EPA had commented on the fact that the greatest fraction of the fluoride exceedances fell into the second of the four exceedance "bands" and had castigated the sanitary authorities on their perceived lack of accuracy in dosage. It has now transpired that the fluoridation techniques may have been satisfactory but the exceedances arose from a combination of correct dosing procedures and an omission to take into account the natural background levels of fluoride in raw waters. Natural fluoride levels do not appear to be routinely monitored and it seems that sanitary authorities consequently consider the levels to be negligible. While legislation requires that background levels should be taken into account and has been complied with prior to commencing fluoridation, ongoing monitoring of these levels has not taken place. If such monitoring were to happen, Dr Flanagan is of the belief that deduction of this background value would eliminate many of the exceedances. The EPA urges the sanitary authorities to make parallel determinations of fluoride in raw and final fluoridated waters in order to establish background conditions, and in the meantime to ensure that their dosages are adjusted appropriately downwards. He recommended that the term "parts per million (ppm)" be replaced by the term "milligrams per litre (mg/l)", lest it lead to the use of the more ambiguous term "parts per billion (ppb)" in place of the correct term "micrograms per litre (l g/l)". Dr Flanagan circulated a written comment following the inaugural meeting of the forum. In this he welcomed the fact that the Forum will seek the views of experts opposed to fluoridation.
Presentation by Ms Dorothy Gallagher The Consumers’ Association of Ireland Ms Gallagher spoke at this meeting and subsequently provided written comments on the contents of the first meeting. She referred to a recent meeting of the Consumers’ Association of Ireland (CAI) where members expressed concern about what they perceived as the pro-fluoridation view of the Forum. She suggested that a representative of the anti-fluoridationist viewpoint be invited to join the Forum, and proposed Dr Elizabeth Cullen, from the Irish Doctors’ Environmental Association. Ms Gallagher made a subsequent written presentation at the Forum meeting in February. She stated that while the Consumers’ Association of Ireland (CAI) still maintains a position of neutrality on the issue of fluoridation, the Association will not publish on the subject until the results of Irish research are available; however, the CAI Council had voted for the liberty of choice for consumers regarding water fluoridation. At present, Ms Gallagher is researching both the benefits and adverse effects of fluoridation in order to improve the CAI archives on the subject. She commented on the response to two articles published in 2000 in the CAI’s magazine, "Consumers Choice" and supplied a number of examples of the e-mails received. The major issues in these e-mails appeared to be concern with overdosing with fluoride and concern with the use of silicofluorides in drinking water. She stressed that the CAI Executive wishes it to be known the presenting the e-mail response does not mean that the CAI supports or rejects the views expressed therein.
Presentation by Mr Oliver Fogarty Department of the Environment and Local Government Mr Fogarty provided information regarding training networks organised under the auspices of the Department of the Environment and Local Government, to provide in-house training for operators / professionals working in the water sector. North Western Health Board Dr Mullen presented his comments both written and verbal on the presentations of Professor Limeback and Professor Connett. He thought that Professor Limeback’s presentation was for the most part, clear and uncontroversial and that the main difference that he would have with the rest of the world’s dental academics is his belief that the benefits of fluoridation no longer outweigh the debits caused by unsightly fluorosis. Dr Mullen states that the overwhelming opinion in the dental profession is that the day has not yet arrived when debits outweigh the credits. While the clinical picture of fluorosis, described by Professor Limeback, has not been seen by Dr Mullen in his practice, he acknowledged that he would give Professor Limeback’s views greater consideration if he saw similar levels of fluorosis. A study in 1998 in the North Western Health Board showed that fluorosis rates were low and that there was a substantial difference in decay rates between fluoridated and non-fluoridated areas, and in neighbouring Northern Ireland health board areas, where water is not fluoridated. Dr Mullen felt it was significant that Professor Limeback had been unable to persuade the Canadian authorities to discontinue fluoridation, and that other Canadian academics had not shared his views. He felt that Professor Limeback’s closing comments about litigation, he felt were an unnecessary adjunct to the latter’s presentation and detracted from it. Dr Mullen was unimpressed with Professor Connett’s presentation, which he believed was designed for a lay public group rather then an Expert Forum and portrayed his opposition to all forms of fluoride. With regard to his scientific presentations, Dr Mullen believed Professor Connett posed a series of what he considered to be flimsy, far-fetched and highly elastic hypotheses. He gave toxicological and animal studies much more weight than other researchers have. Some papers quoted had not been subjected to peer review and had been published in the antifluoridationist Fluoride journal. In summary, Dr Mullen acknowledged the fact that Dr Connett made his presentation in the face of opposition from his supporters and that he provided the Forum with a useful template of 50 questions with which to answer the concerns of anti-fluoridationists. He provided feedback from his attendance at a public meeting in the British House of Commons hosted by a Junior Health Minister to which he was invited to attend as an observer by the British Fluoridation Society (BFS). This meeting was attended by mainly health professionals, health economists and politicians. He was interested to see the nature of the debate and the position held by the UK government. Dr Caswell Evans, Director of Public Health in Los Angeles, spoke on the US approach taken in California prior to the enactment of legislation to fluoridate public water supplies. Dr Evans, who was a member of the project team, which compiled the recent Surgeon General’s Report, which focused on oral health, spoke of the legislation in California where all cities with population over 20,000 were compulsorily fluoridated This legislation received public support and the debate on the issue of fluoridation has become of historical interest only.
Presentation by Dr Máire O’Connor South Eastern Health Board Dr O’Connor provided some background information on the document on water fluoridation recently published by the Research Committee on behalf of the Faculty of Public Health Medicine, of the Royal College of Physicians of Ireland. This document was produced as an educational document for members of the Faculty and later published in collaboration with the Dental Health Foundation. It dealt initially with the historical aspects of water fluoridation in Ireland:
The different sources of fluoride and the varied delivery methods were outlined and the views of the World Health Organisation’s (WHO) Expert Committee Report on Oral Health Status were quoted: i.e. strategies aimed at regular low level exposure to fluoride in the community are superior in terms of caries prevention to professional applications. While the dental benefits of fluoride were acknowledged, as were the concerns surrounding potential negative effects, the point was made that as part of any intervention programme, irrespective of its effectiveness and safety record, ongoing evaluation and surveillance is an essential factor.
Studies in England and Australia showed that water fluoridation was of greater benefit in children from disadvantaged backgrounds. A Welsh study demonstrated that the benefits from water fluoridation during childhood continued into adulthood. A survey of oral health of children in Glasgow and Dublin demonstrated that Dublin twelve year olds (fluoridated water) had on average 45% less DMFS (decayed, missing or filled surfaces) and DMFT (decayed, missing or filled teeth) scores than their Glaswegian counterparts (non-fluoridated). A comparative study of dental caries in children in Dublin, North London and Edinburgh revealed a paradoxical finding of a higher DMFT score in Dublin children where the water was fluoridated than in their counterparts where the water was not fluoridated. The lower caries level was considered to be due to several factors: (a) the use of fluoride toothpastes in these cities, (b) the marginal therapeutic effect of naturally occurring fluoride in some of the London areas and (c) a school rinsing programme with sodium fluoride solution. Various dental epidemiological studies performed since 1961 in Ireland were reviewed. A general decline in the incidence of dental caries was seen in many parts of the country. Epidemiological evidence from 5 year- old children living in non-fluoridated English communities indicated that a decline of caries experience began in the late 1950s or early 1960s. This steady decline accelerated in the mid 1970s. Fluoride toothpastes were first introduced in the 1970s and were therefore not associated with the initiation of the caries decline. The Faculty Research Committee expressed the view that the general decline in prevalence of dental caries in the past 20 years among children from all areas of Ireland could be a contributing factor to the apparent reduced effectiveness of water fluoridation when expressed in percentage terms. Any preventive agent will be apparently less effective when the condition becomes less prevalent. On the topic of cost effectiveness the authors concluded that the hypothesis that the daily use of fluoride toothpastes is now carrying out the entire function expected of fluoridation is not supported by evidence. With respect to concerns regarding general health effects of fluoride, relevant literature on fluorosis, bone health, cancer, renal disease and immune function was reviewed. While some degree of dental fluorosis will accompany the maintenance of a low level of fluoride in the mouth, the presence of mild fluorosis should be seen in the context of the significant dental cariostatic effect of fluoridated water and the associated health and social gain. . In the area of bone health, the authors referred to the concerns expressed about the alleged association between fluoridation of water and the incidence of hip fractures, but pointed out that most of the available evidence stems from ecological studies. Such studies have as their units of analysis populations or groups of people rather than individuals. Exposure to a factor is estimated by using a proxy variable. An ecological study design is useful in generating hypotheses, rather than proving hypotheses; lack of control for confounding variables is a problem in such studies. Ecological studies of the temporal relationship between fracture incidence and fluoridation were reviewed and revealed diverse findings: the former study showed a small positive association, while the latter revealed a higher incidence of hip fracture in the period prior to fluoridation. . With regard to the subject of cancer, the authors referred to a number of reports and reviews that failed to demonstrate a link between fluoride and cancer. They commented on the analytical errors that resulted in associations being made between water fluoridation and cancer risk. They pointed out that many studies looking at cancer and fluoridation were flawed: small sample size, changes in coding practices and confounding variables. In commenting on renal disease, the authors referred to a study which concluded that there was no evidence of increased incidence of renal disease or increased risk of renal dysfunction in humans exposed to up to 8mg fluoride per litre in drinking water. However, recommendations were made that studies of the effects of fluoride in individuals with renal insufficiency were required. Studies on the effects of fluoride on immune function had been reviewed in 1999. and the suggestion that fluoridation might affect immunity was not supported. Whilst fluoride at high concentrations can have inhibitory effects on lymphocytes and polymorphonuclear leucocyte function, these concentrations are many times higher than levels, which would be expected from fluoridation. The ethical issues surrounding water fluoridation were discussed. The debate concerns depriving those most at risk of caries of the proven benefits of water fluoridation versus the resistance to mass medication. With competing demands on limited resources for health care, there is an ethical responsibility to make available those measures which can achieve significant health gain. While there are other methods of fluoride delivery available, it is likely that children from relatively disadvantaged backgrounds, and who are at the greatest risk of dental caries, will be the least likely to take fluoride supplementation. In conclusion the authors hold the view that the available data strongly supports the continuation of the current water fluoridation policies. The epidemiological evidence that fluoride protects against dental caries is overwhelming. Concerns about adverse effects other than dental fluorosis have not been substantiated. However, as in all other areas of health care provision, due regard should be taken of the findings of the ongoing research in this area, so that the optimal format and degree of fluoridation can be harmonised with the changing needs of the population. The Faculty did not hold either pro or anti fluoridation views, but rather acknowledged the need for ongoing research into the subject.
Fourth Meeting 14th December 2000 Presentation by Drury Research and the Dental Health Foundation These two organisations presented the results of recent research, both qualitative and quantitative, into the public’s perception of fluoridation. A qualitative survey, using focus groups was carried out in July 2000 followed by a Landsdowne Omnibus survey of 1,180 adults between September 26th and October 6th 2000. Questions relating to oral health and fluoride issues were included in a questionnaire which covered a broad range of issues which were known to be topics of concern in the public’s mind; such issues included crime, drugs, pollution, health services, homelessness, litter, house prices, genetically modified foods and CJD. The qualitative element of the survey, performed in July 2000, set out to determine the following:
The researchers concluded that:
Some of the findings of the qualitative survey were employed in the development of a questionnaire for the quantitative section. With regard to fluoride in water it was found that when it comes to people’s general concerns, fluoride was not a high level concern. Less than 25% were very concerned, and 22% were fairly concerned. However, with regard to water pollution, over 50% were very concerned about water pollution. The researchers believed that if water fluoridation were to be presented in the light of a water pollutant, then it could potentially be a much higher-level concern. Information was gathered with regard to sources of information concerning fluoride. The mass media was the predominant source of information. The purpose of fluoride in water was confused between water purification and dental health. Participants were asked a number of questions to determine their attitudes to fluoride. Overall the findings were consistent with those of the qualitative survey findings.
The researchers recommended that a more balanced debate than is currently taking place is required in order to educate the public with regard to all aspects of water fluoridation. Particular mechanisms will be required to increase public awareness of the potential for ingestion of excessive amounts of fluoride and the subsequent adverse effects (via dental products in addition to drinking water), in light of the fact that both the environmental and dental health perspectives along with the issue of water purity are emotive issues and have been used by the anti-fluoridation campaign.
Report on the content analysis of media coverage of water fluoridation The Dental Health Foundation monitors the media coverage of water fluoridation in Ireland. Drury Research examined and evaluated this coverage in the period December 1999 to November 2000 and presented a written report of their findings to the Forum. The process involved the analysis of all monitored print, radio and television coverage of the water fluoridation issue. The total number of media articles / bulletins examined was 240 and included the following:
Each individual article / bulletin was examined and evaluated under three separate areas:
They were rated on a three point scale ranging from "Negative" (-1) to "Neutral " (0) to "Positive" (+1) The coding of all individual scores was carried out by executives from Drury Research and each rating was doubled checked by a second executive to ensure consistency in the evaluation process. Media coverage of the water fluoridation issue across print, T.V. and radio tended to be negative (over 50% scoring –1). The Researchers pointed out that the high percentage of negative coverage must be understood in light of its increased dramatic / sensational appeal and that the impact of this negative media coverage should not be underestimated as consumers may be more likely to recall negative versus positive information. Almost 50% of the total number of media headlines concernin g water fluoridation were negative with 43% being neutral and only 8% adopting a positive stance. The balance of the overall coverage also tended to be negatively predisposed towards water fluoridation (55%) with only 32% and 13% being neutral and positive respectively. Forty five percent of all printed articles headlines were negative (45%) with only 8% being positive. Only 15% of all printed articles were positively predisposed towards water fluoridation in their first three paragraphs. A little over half of all the national headlines printed were negative (51%). Only 4% of headlines were positive with the remainder being neutral. Only 6% of the first three paragraphs of the national articles were negative. In general the overall balance of the national articles tended to be negative (57%) with only 8% positive. Approximately one third of all national articles written adopted a neutral perspective. The Irish Independent appeared to be particularly negative in its overall coverage of the fluoridation issue (84%) negative. In contrast the Irish Times appeared to offer a more balanced perspective on the issue with 50% being negative, 33% neutral and 17% positive. With regard to the regional newspapers, coverage was even more negative, with 59% of Leinster, 63% of Munster and 51% of Connaught / Ulster regionals adopting a negative perspective overall. The overall positive scores for Leinster (11%), Munster (10%) and Connaught /Ulster (20%) were low. Printed articles outside the mainstream press seemed to adopt a more balanced outlook with approximately (49%) of the articles being neutral. The researchers suggested that this may be due to the more scientific nature of the medical publications such as the Irish Medical Times, Irish Medical News etc. While the monitoring of television coverage was limited to 6 bulletins, the researchers made the point that the impact of television coverage should not be underestimated. The majority of coverage tended to be negative. Of the six items monitored, 4 were negative and 2 were neutral. Total "overall" radio coverage was decidedly negative (63%) with approximately 1 in 5 programmes being neutral (21%) and only (16%) being positive. Regional radio was also decidedly negative with over two thirds (67%) of monitored programmes being negative and only 13% being positive. In summary, overall media coverage of the water fluoridation issue was predominately negative (52%) versus 14% positive. The printed media tended to be consistently negative in its communication of the water fluoridation issue at both nation and regional levels. Both radio and television (the two most impactful media) coverage tended to adopt a negative stance. Drury Research concluded that there is obviously a need to redress the balance, particularly in regional press, radio and general TV and radio coverage.
Presentation by Professor Moira O’Brien Trinity College, Dublin Professor O’Brien made a presentation on osteoporosis, in which she discussed cell activity in normal and diseased bone, the risk factors for the development of osteoporosis, the clinical significance of the disease, its diagnosis and prevention and the role of fluoride. She explained the normal bone remodelling cycle, where bone is resorbed, by osteoclasts, and new bone is formed, by osteoblasts, in a cycle lasting between 90 and 130 days. Where the two processes are in equilibrium, no change occurs in the bone structure; however, where resorption exceeds formation, bone loss occurs. Bone mass is related to age; peak bone mass is attained up until the late 20s; following this, a period of containment occurs where the bone mass remains fairly constant; after this, age related bone loss occurs. This loss occurs earlier in females following the menopause. She cited the WHO definition of osteoporosis: Osteoporosis is a disease characterised by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Osteoporosis may be primary, where it occurs post-menopause (Type 1) or in later years (Type 2) or secondary due to systemic disease or drug related. The risk factors for the development of primary osteoporosis were detailed: genetic, hypogonadism, low body weight, cigarette smoking, excess alcohol, low dietary calcium, vitamin D deficiency, late menarche, irregular menstruation, early menopause, physical inactivity and high caffeine intake. The diseases associated with secondary osteoporosis are: metabolic, endocrine, malignant, transplantation and connective tissue disorders. Drugs associated with this form of the condition are: excess thyroid hormone, anticonvulsant therapy, glucocorticoids, heparin and alcohol. The common sites for the development of osteoporotic fractures are the hip, spine and wrist. The most serious of these is the hip fracture. Approximately 60,000 hip fractures occur on an annual basis in Ireland. Aside from the fact that one in five patients die within 6 months of the fracture occurring, hip fractures lead to serious disability. Many basic functions such as dressing, climbing stairs, walking and transferring are markedly interfered with following a fracture. This can result in loss of both confidence and independence and increased risk of development of medical complications. Each year 40,000 spinal vertebral fractures are clinically diagnosed. A previous fracture more than doubles a patient’s risk of another spinal fracture. Professor O’Brien illustrated this point with a photograph, which showed a marked loss in stature as a result of spinal fractures. Fractures of the distal radius (Colles’ fracture) occur most commonly in women between 45 and 65 years of age. While all require immobilisation in plaster as outpatients, older patients, especially those living alone will require hospitalisation, with the consequent disruption to daily activities and loss of independence. A number of steps may be taken to prevent osteoporosis: adequate dietary calcium and vitamin D, reduced alcohol intake, smoking cessation, weight bearing exercise and appropriate medications. On the topic of fluoride and bone Professor O’Brien made the following points: Sodium fluoride as an anabolic substance, increases vertebral bone density, but does not reduce vertebral fracture rates. It was used in the past in the management of osteoporosis, but is no longer licensed in Ireland and Europe. It prolongs bone remodelling if given in twice the therapeutic dose. Experimental studies have shown that fluorotic bone is more resistant to compressive forces, but more easily fractured by torsional strains. The effect of fluoride on bone strength is bimodal. Moderate doses of fluoride have been shown to increase bone strength in experimental animals and high doses of continued exposure decrease strength. A physiological dose of fluoride, i.e. less than 2mg per day, promotes hydroxyapatite formation. It has no effect on bone but will prevent dental caries. Between 2 and 4 mg per day will cause mottling of teeth, but will not affect bone. Eight mg daily produces a 10% incidence of radiographically apparent ostesclerosis. Professor O’Brien referred to the benefits of exercise, especially weight bearing exercise in the maintenance of bone health, and the dangers of immobilisation.
Presentation by Ms Fiona Barbagallo School of Communications, Dublin City University Ms Barbagallo, unfortunately, was unable to attend the meeting in person, but a written presentation was made available to the Forum members. She reviewed how in the light of recent controversies, such as BSE, storage of nuclear wastes and genetically modified foods, that have shaken public confidence in the ability of decision makers, there has been a call for greater democratic, transparent and participatory policy processes. She cited a number of examples of how public participation has been recommended. The Irish Inter-Departmental Group on Modern Biotechnology recommended that two-way communication processes be adopted when communicating with the public [Inter-Departmental Group on Modern Biotechnology, 2000 #509]. This report stated, "Promoting public consultation and involvement such as discussion groups on the internet, debates involving different forms of lay and expert jury, and formal participative technology assessment exercises should be actively explored". She described public participation as two-way dialogue processes where policy makers and scientists listen and understand public concerns and values. The "public" can include groups that have a specific interest in the issue, such as environmental organisations and patient care groups; and lay people with no interest in the issue other than as citizens. She pointed out that on their own public participatory methods would not broaden policy decisions, as there must be a change in the cultures and constitutions of key decision-making institutions. She suggested that in the light of the Drury Research findings and the small number of submissions made in previous Irish consultation processes, an approach other than inviting written public submissions be adopted to ensure meaningful public consultation. In conclusion she recommended a two-dimension approach involving:
Ms Barbagallo looked at how public participation initiatives could be employed as an opportunity for lay people to provide advice to policy makers and provided examples of various methods.
Fifth Meeting 11th January 2001 Presentation by Dr Paul Beirne Oral Health Services Research Centre, University College, Cork. Dr Beirne presented a paper on the manner in which science is interpreted by the media and by the public. He made the point that while science is concerned with falsification of hypotheses, it is also about uncertainty. He defined good science as the acknowledgement and management of uncertainty. He dealt with the concepts of risk society and risk conflict. The former being "a society confronted by the challenge of the self-created possibility", while the latter refers to conflicting scientific definitions and interpretations of "risks". Society nowadays is more aware of risks associated with technology and self-created risks produced by scientific advances. Previous generations had no experience of such risks. He cited examples of GM foods, vaccination programmes, power lines, incinerators and fluoridation to illustrate the way in which "manufactured uncertainties" exist alongside conflicting expert definitions and interpretation of risks. He discussed the Precautionary Principle, which has been defined differently by various authors. In essence it involves weighing the evidence and balancing harm against benefit. He questions its use in informing policy decisions, where greater weight is given to scientific studies pointing in the direction of harm, even if the causal link between the activity and the possible harm has not been proven or is weak. In such a scenario, the precautionary principle can cost lives, as money spent in the prevention of risk cannot be spent on beneficial health care. He quoted "the three horsemen of the epidemiological apocalypse": chance, confounding and bias and illustrated how several studies addressing the same issue can produce widely varying estimates of risk. He made the point that while science is not about proof or certainty, but about disproof and uncertainty, nevertheless in common parlance, "scientific" is almost synonymous with "certain". He suggested that rather than giving greater weight to studies pointing in the direction of harm and adopting the precautionary principle, or maintaining the status quo, in order to inform policy we must examine alternative explanations and interpretations of data. He discussed the epistemic warrant, which is the degree to which there is reason to believe the evidence. In general there is little reason to believe a single study pointing in one direction, but there is good reason to believe a large number of studies all pointing in the same direction. On the manner in which the media deal with risk, he referred to the selectivity in the citation of data and the common repetition of discredited information. He cited examples of debate in the media where fluoridation was debated. He referred to what is described as "good" science: the acknowledgement of uncertainty, the management of uncertainty and the presentation of caveats. The public and private faces of science provide two quite diverse opinions on fluoride; however, it becomes difficult to practice "good" science and acknowledge uncertainty where the media "balancing" mechanism of pitting expert against expert / counter expert / activist has become the norm. While the role of the media is to inform, educate and entertain, education unfortunately takes a back seat to information and entertainment. Very few viewers / listeners would tune into a programme describing the methodological limitations of a particular study. Debates in the media have lead to confusion rather than clarity; contributions tend to be reduced to sound bites, which does not facilitate discussion of uncertainties or methodological limitations of the studies quoted. Dr Beirne feels we need to look elsewhere for alternative mechanisms of explaining, informing and involving the consumer more in issues such as fluoridation. For such public participation approaches to be of value they must be seen as legitimate and be recognised not as a substitute for scientific or technical information, but as components to be considered alongside scientific advice. When considering scientific and technical information he suggested that we should draw on expertise with various risk perspectives (environmental, consumer, economic, legal, ethical, public health) into a mature discussion of the issues. He adviseds that both public and political cultures need a greater appreciation of what science can and cannot be called upon to do, in order to tackle the crisis of trust that currently exists. Business must be conducted openly and transparently if scientists etc. wish their views to command public confidence and public respect. He referred to the UK government’s handling of the BSE situation, which had been characterised by public suspicion and dissatisfaction that important information was not being shared and discussed openly. A House of Lords inquiry into the situation had as one of its goals the intention to make the investigation as open as good practice and modern technology could ensure, with any significant material received made freely available to all. He posed the question as to whether the media would have benefited from seeing the Drury presentation on how the media was dealing with the fluoride issue. He feels that some members of the public would benefit form a better understanding of the scientific method, which would assist them in understanding risk conflicts and be healthily sceptical of claims and counterclaims. In conclusion he made the following points (1) in order to gain trust through openness, uncertainty should be recognised where it exists, (2) the public should be trusted to respond rationally to openness and (3) scientific investigation of risk should be open and transparent.
Presentation by Professor William Binchy Trinity College, Dublin Professor Binchy delivered a paper on the ethical issues surrounding fluoridation of water. He spoke of the changing values in society, changing perceptions in the role of the State and judicial changes. With regard to the changing values in society he spoke of the radical changes that have taken place with regard to personal autonomy and the reasons for these changes. With regard to the changing perceptions of the role of the State, the move to individualism has had the effect of weakening the role of the State in many areas. It is no longer considered appropriate for the State to have laws prohibiting suicide. On the other hand the state has assumed some wide-ranging new functions, such as the enhancement of social welfare, the encouragement of equality, improvements in citizens’ health and the protection of potentially vulnerable groups. In the area of the judiciary, he pointed out two changes which affect analysis of the ethical issues raised by fluoridation: the growth of judicial review of legislative and executive action and the judicial recognition of previously unarticulated personal rights reflecting autonomy-centred values, notably those of privacy, dignity and bodily integrity. He proceeded to set a framework for the analysis of the ethical aspects of fluoridation. This was done against the description of the fluoridation process as the introduction of a particular substance, under sanction of law, into the body of an autonomous adult, without necessarily that adult’s willing acceptance of that process. He laid out the ethical principles concerning the relationship between the State, the individual and legal sanctions, which may throw some light on the specific phenomenon of fluoridation of public water supplies. Discussion on these was laid out in detail in the text of the presentation, which Professor Binchy circulated. His analysis proceeded on the premise that fluoridation has some limited negative effects and that it succeeds in its goal of benefiting the community by contributing to a reduction in tooth decay. He acknowledged that the detail of the scientific debate is of importance to the moral assessment of the position. He spoke about the issues of proportionality and seriousness. The issue of proportionality, at the heart of the question, is dependent on the precise benefits that must be weighed against the precise debits, which the process involves. The values of privacy, autonomy, dignity and bodily integrity are compromised in the opinions of those opposed to water fluoridation. If these values are to be overridden, it may be argued that the reason for doing so should be a serious one, and the benefit should be incapable of being conferred in any other less intrusive way. He proceeded to look at how public health values could be balanced with autonomy-centred values. He described a number of models of public health and stated that in his view none of the models can resolve the question of the extent to which compulsion may be permitted to override principles of autonomy and bodily integrity. He concluded by stating that the ultimate resolution of the ethical debate will depend on the empirical facts. Professor Binchy has agreed to review the legal proceedings in relation to fluoridation, which took place in the 1960s and will present this review to the Forum in April 2001. He was also requested to look at what level of affirmative responsibility has the State to deliver alternative means of delivering fluoride if fluoridation of water supplies ceased, in light of the government’s reluctance to prescribe public health policy. He will address the two issues of adverse effects and invasion of autonomy.
Sixth Meeting 8th February 2001 South Eastern Health Board Mr Ray Parle, a Principal Environmental Officer in Waterford Community Care Area in the South Eastern Health Board, is currently doing a M.Sc. Course in Environmental Health Risk Management, in the Dublin Institute of Technology. As part of this course he is working on a thesis relating to risks of overdosing / under dosing of fluoride in public drinking water supplies in the South Eastern Health Board. He presented an outline of the work carried out to date, illustrated with preliminary data. He visited a sample of the local authority water treatment plants in the region and interviewed relevant staff. To assess operational reliability history and historical risk of over / under-dosing, sampling results of Environmental Health Departments were compiled for each plant in the region for a 10 year period. He used a process flow – diagram with the intention of using an approach akin to Hazard Analysis Critical Control Points (H.A.C.C.P.) risk evaluation to identify points in the process where control was critical. He identified points throughout the process where there were risks associated with either dosing or health and safety issues for staff. These points are summarised below. Raw Water Source Naturally occurring fluoride is a feature of water supplies in many parts of the country. At present there is no legal requirement to routinely test background levels of fluoride. Variations in levels from a given source may affect the final fluoride level if the source values are not constantly monitored. In this study it was found that with the exception of a few of the larger plants, regular monitoring of raw water fluoride levels does not generally take place. Where the water source is adjacent to the treatment plant, a significant risk of source contamination exists for a variety of reasons. The absence of contents level indicators or alarms on acid bulk storage tanks may predispose to accidental spillage or overfill during tank filling as will also the absence of secondary containment (i.e. bunding). Recommendations by Mr Parle
Delivery, Storage & Day Tank The factors associated with the risk of groundwater contamination mentioned above are also implicated in health and safety issues for plant personnel. Personal protective clothing, ventilation, safety data sheets and access to emergency wash / eye rinsing were the areas of immediate concern in many of the plants visited. The absence of low-level fill pipes resulted in plant personnel climbing onto tanks in order to gauge levels via the top of the open tank. The "day tank" is filled from the bulk storage tank on a regular basis. The capacity in many plants is more than one day: the mean value was noted to be 11 days. Filling tended in the main to take place by the manual opening of a valve. In the event of the operator being distracted, becoming ill or called away, the acid would continue to flow into the day tank and out of it into the water Recommendations by Mr Parle
Dosing Pumps & Pipework While there was a significant degree of standardisation in relation to types of pumps used a number of issues presented potential problems: an apparent lack of anti-siphonage valves in some plants and the danger that fluoride dosing could continue in the absence of water flowing due to the fact that in some plants the operation of the fluoride dosing pumps is triggered by the activation of the water pumps rather than by the flow of water. In some plants where separate supplies were treated on the same site, there was some difficulty in distinguishing the separate pipe networks. Accessibility to all pipes is essential in order to detect leaks. Recommendations by Mr Parle
Monitoring In assessing on-site monitoring it was found that all plants performed the legally required "volumetric" test, which entails the daily weighing of the acid used and comparing this against measured water flow. However, routine calibration of weighing scales had been performed in only 40% of plants, resulting in the questioning of the reliability of results obtained. The colorometric test, also required by law, was also problematic. This is a very subjective test and colour blindness may affect its accuracy. Recommendations by Mr Parle
Training & Security In many small water treatment plants the caretakers have no formal training with regard to the use and hazards of hydrofluosilicic acid. They tend to have duties other than with regard to fluoridation and may provide this service for a number of plants. Security issues arise in such a situation. There was a notable lack of security measures in many plants.
Recommendations by Mr Parle
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