** Updated 24/3/15 with additional post and links to new National Health and Medical Research Council (NHMRC) review.

For most Australians, the public controversy over fluoridating their water supply is a distant memory, if they remember it at all, but there are still parts of Australia where this demonstrably safe and effective health measure is strongly resisted. It’s a classic case of emotion and scaremongering winning out over evidence-based studies.  In the following piece, dentist and educator Michael Foley outlines the public health argument for fluoridation and calls on the scientific and health care communities to combat mis-information and anti-scientific arguments against this practice. 

The not-completely-in-jest term ‘crazification factor’ was coined when the wildly eccentric Alan Keyes was surprisingly well supported in a 2004 US Senate campaign against then Illinois State Senator Barack Obama.  It refers to the percentage of the population with a tenuous grasp on rational thought and an eagerness to embrace the conspiracy theory du jour.

Yes, we live in a wonderful world where the gullible can freely believe that vaccinations and ‘chemtrails’ are killing us.  Lots of people believe in fake moon landings, alien abductions, and homeopathy too.  But while many conspiracy theories are harmless nonsense, promotion of others can impact adversely on public health.  One of the longest running relates to the supposed dangers of water fluoridation, wonderfully satirised in the 1964 movie Dr Strangelove as an ‘…international Communist conspiracy to sap and impurify all of our precious bodily fluids.’  Amazingly, this belief lives on, despite fluoridation safely reducing dental caries (tooth decay) around the world for 70 years, and being labelled by the US-based Centers for Disease Control as one of the ten great public health achievements of the 20th century. 

A common accusation from the anti-fluoride lobby is that ‘study x’ found that fluoride in drinking water causes ‘disease y’, therefore fluoridation should be banned.  Apart from the fact that most of the studies quoted are methodologically weak or irrelevant to water fluoridation, correlation is not causation.

Even without the effects of bias, multiple studies investigating a hypothesized link between fluoride in drinking water and disease y will show a spread of results.  Different studies take different samples from different population groups, and random variations always exist.  If no causal effect exists between the two, experience shows us that a few studies will still show a positive relationship i.e. a greater exposure to fluoride in drinking water associated with a higher level of disease y.  A few studies will also show a negative relationship i.e. a greater exposure to fluoride in drinking water associated with a lower level of disease y.  And most studies will sit somewhere around the middle, showing no significant association either way.

This variability does not show that ‘science is divided’ or ‘the jury is out’, a common claim from opponents of fluoridation.  On the contrary.  A diversity of results largely centred around the no-effect value confirms only that random variation (and sometimes bias) exists in all public health research, and supports the null hypothesis that no causal association exists between the two variables.

Invariably, studies selectively ‘cherry-picked’ by anti-fluoridationists to link fluoridation with disease y are overwhelmed by larger studies and higher quality studies that find otherwise, or clear evidence on the ground that no such association exists.

Anti-fluoridationists also claim that no high quality evidence exists to show that fluoridation reduces dental caries in populations, and that’s true, if by high quality evidence we consider only randomised controlled trials.  But randomised controlled trials are often not practical, ethical or appropriate, and in the case of water fluoridation they’re not even possible.  Does that mean we can’t judge the effectiveness of water fluoridation?

Of course not.  Water fluoridation is one of the most heavily studied public health measures of all time, and the very consistent finding from the highest quality studies and reviews is that it safely and significantly reduces caries in both children and adults.  The differences in the levels of caries attributable to the effect of fluoridated water are far greater than could be accounted for by any other confounding variable.  The harms of smoking and public health benefits of seat belts and motorcycle helmets have never been demonstrated through randomised controlled trials either, but we’re very certain of their impacts on public health.

Unfortunately, many Australians are still denied the benefits of water fluoridation.  Most Australian cities fluoridated their water supplies in the 1960s and 70s, but successive Queensland governments left fluoridation decision making to local councils.  Understandably, when faced with all capital and ongoing costs, and a lack of support from state governments, most councils expressed no interest.  By 2007, only 5% of Queenslanders had access to fluoridated water, in contrast to around 90% of Australians in other states.  This changed only after legislation was finally passed in 2008 to mandate fluoridation in communities with populations over 1,000.  The fluoridation rollout program continued until 2012, when a new government inexplicably back-tracked, despite having supported the previous government’s legislation unanimously in 2008, and once again legislated to make water fluoridation a local government issue.

Many councils cited cost pressures for their subsequent decisions to opt out of fluoridation, despite the costs of fluoridation being outweighed many times over by saved dental treatment costs.  Others were swayed by a relentless misinformation campaign from science sceptics, conspiracy theorists and CAM practitioners.  A similar recent campaign in northern NSW saw their Chief Medical Officer being threatened with Sarin gas, and one fanatic urinating at the front door of a local dental surgery.  The net result is that around 500,000 regional Queenslanders and population pockets around the country still miss out on the decay-fighting benefits of water fluoridation.

The mishandling of water fluoridation policy is a health, social, and financial calamity.  Directly or indirectly, all Australians pay for the level of disease in our communities, whether it be diabetes or dementia or dental caries.  And it’s in all our interests to reduce the level of disease in our communities, particularly when we can do it simply, safely and cheaply.

It’s time for scientists and health professionals to be counted on water fluoridation.  Public health policy in Australia must be based on the weight of high quality scientific evidence and the best health interests of Australians, not conspiracy theory web sites and irrational scaremongering from eccentric fringe dwellers with the crazification factor coursing through their veins.

Michael Foley is a Queensland-based dentist.  He holds Masters degrees in public health and epidemiology, and lectures at the University of Queensland and Griffith University.

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The article below was submitted by Merilyn Haines on behalf of Queenslanders For Safe Water, Air and Food Inc in reply to the post above. Croakey notes:

In late February the National Health and Medical Research Council announced it was undertaking a review of the scientific evidence on water fluoridation and human health, following up on its 2007 public statement. An interim paper is due to be issued later this year, ahead of a final statement in 2016.

In a media release, CEO Warwick Anderson said: “Based on the work already conducted in the review, NHMRC is expected to maintain its support for fluoridation of water supplies as effective and safe.”  See further Croakey notes re studies mentioned in the post below.

Merilyn Haines writes:

Why there needs to be a widespread debate on fluoridation

Water fluoridation is a United States practice from the 1950s that most countries have never embraced. Although the World Health Organisation endorses fluoridation, the large majority of the WHO’s member states do not fluoridate their drinking water. Some 95 per cent of the world’s population do not use fluoridated water, including 97 per cent of western Europe’s population, however four European countries do allow the sale of fluoridated salt for voluntary purchase.

It is well acknowledged that fluoridation is a very contentious issue with a lot of the controversy stemming from fluoridation promoters claiming that fluoridation is not mass medication, while those who are opposed consider that, if a substance is added to drinking water for the specific intention of having of a therapeutic effect on the human body, then it is both a medicine and a medical treatment.

In 2003, the official Queensland Government Position Statement acknowledged that, without the express consent of the community, water fluoridation was unethical mass medication. This was echoed in the 2010 Policy Statement from the Local Government Association of Queensland (LGAQ) which was the basis, in January 2013, for the decision by the large majority of Cairns Regional Councillors to end fluoridation. Statements from a number of European health and environmental government representatives acknowledge that their countries do not fluoridate because of their consideration that fluoridation is mass medication.

Another controversial issue that needs to be debated in the 21st century is the issue of safety, particularly now there are 42 published human studies linking high fluoride exposure to lowering of children’s IQ. In 2012, Harvard University researchers published Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis that raised concerns about high fluoride exposure being a developmental neurotoxin as the average decrease in IQ across 27 studies was nearly 7 IQ points. In 2013, based on the body of work from the Harvard review, Lancet published a paper which officially classified fluoride as a developmental neurotoxin.

While fluoride concentration is controlled easily, there is no control over dose because how much water individuals drink cannot be controlled. Some athletes and outdoor workers, particularly miners, can consume 10 litres of water a day. When it is considered on a per-body- weight basis that infants and young children have approximately three to four times greater exposure than do adults and that bottle fed babies can ingest more than 200 times more fluoride than breast fed babies if infant formula is reconstituted with fluoridated water, then it is really time to re-think fluoridation.

Fluoridated toothpaste sold in Australia variously contains 500 milligrams fluoride per litre (children 2-6 years), 1,000mg per litre (adults) and 5,000mg per litre (often recommended for nursing home residents) – thus toothpaste supplies 500 to 5,000 times as much fluoride directly to teeth than does 1mg per litre fluoridated water.  When water fluoridation began in the 1950s, there were no fluoridated toothpastes – now 95 per cent or more of toothpaste sold in Australia is fluoridated.

The US Centre for Disease Control in 1999 and 2001 acknowledged the main action of fluoride was topical (when it touches teeth). The lead article in the 2000 American Dental Journal (Vol 131) (JDB Featherstone,  “The Science and Practice of Caries Prevention”) acknowledged that tooth enamel with higher fluoride levels does not withstand acidany better than enamel with lower levels of fluoride: “even when the outer enamel has higher fluoride levels, such as 1,000ppm, it does not measurably withstand acid-induced dissolution any better than enamel with lower levels of fluoride”. Additionally that “fluoride incorporated during tooth development [that is, from ingested fluoride] is insufficient to play a significant role in caries protection.”

Considering that there is not one single process in the human body that needs fluoride to function properly and no evidence that fluoride is an essential nutrient, that the main action of fluoride is topical and that drinking fluoridated water would only have a miniscule topical effect compared to application of toothpaste, then it should be debated why fluoride is still being forcibly added to Australians’ drinking water.

In 2009 Queensland Health acknowledged that no risk assessments had been done for fluoridation, and that the State Government  had just relied on a 2007 NHMRC recommendation when the Bligh Government mandated fluoridation. Mandated Queensland fluoridation was overturned at the end of 2012 and since then 24 Queensland councils have formally voted to reject fluoridation. Some  (Tablelands, Cassowary Coast, Hinchinbrook) have commissioned surveys and found that the majority of their residents did not support fluoridation. Mt Isa Council held a voluntary referendum in 2013 and found that 89 per cent of residents did not support fluoridation. Southern Downs Council recently ended fluoridation after their survey showed that 65 per cent of residents connected to the Warwick water supply wanted fluoridation discontinued, as did 70 per cent of residents connected to the Stanthorpe supply.

Last year the Israeli Health Minister ended all fluoridation in Israel citing health and other concerns. Recently, six major Irish Councils have passed motions opposing fluoridation.

When fluoridation first began, it was not recognised that fluoride was bio-accumulative, particularly accumulating in the bones and the brain’s Pineal gland and it was not recognised that fluoride was a neurotoxin. Yet nearly 70 years on, Australian fluoridation promoters claim fluoridation is perfectly safe despite a lack of any Australian health and safety studies.

Whether fluoridation is significantly effective is also in doubt considering that WHO data shows that childhood tooth decay has decreased similarly in the few heavily fluoridated countries compared to countries with no fluoridation.

What is not in doubt is that the time for a rational and honest debate on whether Australian fluoridation should continue is long overdue and, importantly, that this debate should not descend into personal vilifications from either side.

Merilyn Haines, a medical scientist for over 30 years, including with Queensland Health, (now retired) is the  president of Queenslanders For Safe Water, Air and Food Inc (QSWAF) ,a self- funded, not for profit incorporated association.

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Croakey further notes that the New South Wales Health Department has said each study considered in the Harvard review referred to above “had major deficiencies that limit the conclusions that can be drawn” and that “importantly, the low fluoride control groups often had exposures comparable to fluoride in drinking water in Australia and the high fluoride groups exposures up to 10 times higher than that allowed in drinking water in Australia.”

 

We note also that the Lancet article refers to “raised fluoride concentrations” and states that “further characterisation of the dose-response association would be desirable” (see pic).

 

 

 

 

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