Category Archives: Health and Medicine

Did the Royal Society get it wrong about fluoridation?

Did the Royal Society of NZ and the Office of the NZ Prime Minister’s Chief Science Advisor make a big mistake in their report Health Effects of Water Fluoridation: a Review of the Scientific Evidence)? Did they misrepresent a scientific paper which reported an effect of fluoride on the IQ of children?

This is what “Connett’s Crowd,” anti-fluoridation activists and propagandists, are saying in their attempts to discredit the review. So, did this review make the mistake its critics claim?

Well, no. It’s just a beat up. But there is a small mistake in the review’s executive summary which the anti-fluoridationists are pouncing on.

The issue

Most critics of community water fluoridation rely heavily on this paper:

Choi, A. L., Sun, G., Zhang, Y., & Grandjean, P. (2012). Developmental fluoride neurotoxicity: A systematic review and meta-analysis. Environmental Health Perspectives, 120(10), 1362–1368.

This was a metareview of mainly obscure and brief reports (see Quality and selection counts in fluoride research) indicating the possibility the fluoride intake by children living in high fluoride areas of China and Iran may suffer IQ deficits. Choi et al., (2012) used a statistical analysis to determine the possible size of the IQ drop averaged over all the studies. They found a small drop and said:

“The estimated decrease in average IQ associated with fluoride exposure based on our analysis may seem small and may be within the measurement error of IQ testing.”

Their abstract reported the:

“standardized weighted mean difference in IQ score between exposed and reference populations was –0.45 (95% confidence interval: –0.56, –0.35).”

(Their use of “standardised weighted mean difference” was poorly explained and has caused confusion with many readers. See below for a brief explanation of the term).

What did the Royal Society Review say about this?

The review discusses the question of possible neurotoxic effects on page 49-50. Their comment relevant to Choi et al., (2014) appears below (click to enlarge):

review1

And this is what is in the executive summary (click below to enlarge). It makes a very small mistake by referring to “less than one IQ point” when it should have said “less than one standard deviation.”

review2

So, the review reported the Choi et al., (2012) findings accurately but made a small mistake in the executive summary. This is really of no consequence because the overall message of the small size of the estimated IQ drop (described by the authors as “small and may be within the measurement error of IQ testing”) is not really altered.

What do the anti-fluoride critics say?

Such mistakes are inevitable and authors will universally say they usually find them only after publication when no correction is possible. I remember picking up 5 mistakes in one of my papers – mainly incorrect spelling of my own name several times and a mistake in the address of my institution – those were the early days of word processing! Of course no one used my mistakes to cast doubts on the scientific content of the paper.

Still, “Connett’s crowd” have been merciless in their criticism. Here is an example from the big man himself (see Water Fluoridation: The “Healthy” Practice That Has Deceived the World):

Gluckman and Skegg (sic)* mistakenly claim “a shift of less than one IQ point” in the 27 studies reviewed by Choi et al. (2012). What they have done here is to confuse the drop of half of one standard deviation reported by the authors with the actual drop in IQ, which was 6.9 points. Such an elementary mistake would not have been made by Gluckman and Skegg (sic)* if they had actually read the report, instead of relying on what fluoridation propagandists were saying about it.

* Of course Gluckman and Skegg – who Connett calls The ‘Hollow Men’ of New Zealand –  did not author this review.

H.S. Micklem, in the Fluoride Free NZ report on the Royal Society review, snipes:

“It is hard to imagine how this mistake could have been made by anyone who had actually read the papers that are disparaged so casually.”

I guess critics should read carefully before indulging in such snaky comments. All they have demonstrated is that they did not read past the executive summary of the review (and certainly did not read the relevant section in the review). Or, more seriously, that they wish to misrepresent the review by highlighting the mistake and ignoring what the review actually says.

(At Least Kathleen Thiessen was more honest in her comments in the FFNZ report because she did refer to page 49 as well as the mistake. However she still concluded “The RSNZ report is not accurate in its characterization of the Choi et al. (2012) article on effects of fluoride on children’s IQ.”)

Update: One of my commenters, picker22, has brought this to our attention – it puts the mistake mentioend above into context.

“The original press release from Harvard School of Public Health News service made the same error stating that the difference was .5 IQ points. This error on the part of Harvard led to more that a couple of mis-statements by fluoridation advocates in the US.

The current web page notes that the sentence reporting the magnitude of IQ change was “updated” Sept 5, 2012. Sadly, I didn’t copy the original.

http://www.hsph.harvard.edu/news/features/features/fluoride-childrens-health-grandjean-choi.html

Is Choi et al (2012) relevant to fluoridation?

Not really.

The only study specific to community water fluoridation (CWF) the Royal Society review mentions is Broadbent, et al., (2014). Community Water Fluoridation and Intelligence: Prospective Study in New Zealand.

The Choi et al., (2012) paper reviews reports mainly from areas of endemic fluorosis where fluoride intake is much higher than areas using CWF. Subsequently the same authors  made their own measurements in a similar area of China and did not find a significant relationship of drinking water fluoride to IQ (see Choi et al., 2014. Association of lifetime exposure to fluoride and cognitive functions in Chinese children: A pilot study).

The did, however, find a relationship of IQ to severe dental fluorosis. I discuss their findings in my article 

What is this “standardised weighted mean difference”

This term caused a lot of confusion with readers and critics. Choi et al., (2012) used this statistical device because they were attempting to estimate the average decrease in  IQ associated with fluoride exposure based on the difference in IQ between children from high fluoride villages and low fluoride villages in a large number of studies. Further, different IQ scales and measurement methods were used in the different studies which had different levels of variation in the data.

They therefore standardised the differences by expressing them as a fraction of the standard deviation for each study. A mean value over all studies was determined, weighting the contribution from each study according to the precision of the IQ measurements.

The standardised weighted mean difference value of 0.45 has meaning because we know it represents less than half of one standard deviation so it gives us an indication of how it compares with measurement error. But a value of 6.9 as used by Paul Connett is meaningless – until we are told the standard deviation. Choi et al. (2012)  did not report a difference of 6.9 implied by Paul Connett who appears to have obtained that value from a response to a letter to the editor where they use a hypothetical example to explain the meaning:

“For commonly used IQ scores with a mean of 100 and an SD of 15, 0.45 SDs is equivalent to 6.75 points (rounded to 7 points).”

Similar articles

“Do your own research!”

How many times have I had discussion partners on the internet say to me “Do your own research?”

Inevitably they are pushing some pseudoscientific or anti-scientific conspiracy theory – yet claiming science is their friend!

Here, one of the members of Paul Connett’s Fluoride Action Network team ( Carol Kopf, Media Director who uses the Twitter name @nyscof) tells critics to do their own research – internet research:

And if you type in fluoride adverse effects, you get 270 results

Well, I followed her advice and got this:

Fluoride adverse effects – PubMedScreenshot-fluoride

But unlike Carol Kopf I naturally didn’t stop there – I also typed in “water adverse effects” and got this:

Water adverse effects -PubMed
Screenshot-water

She has a really funny understanding of what the word research means.

Imagine if she followed her implied advice and refused to consume water because of all its adverse effects!

Similar articles

 


 

Cherry-picking and misinformation in Stan Litras’s anti-fluoride article

This is the second article in a series critiquing contributions to the Fluoride Free NZ report Scientific and Critical Analysis of the 2014 New Zealand Fluoridation Report.”

My first article Peer review of an anti-fluoride “peer review”  discussed Kathleen Theissen’s contribution. (It also discussed a draft contribution by Chris Neurath which does not appear in the final version).

I will shortly post a 3rd article discussing H. S. Micklem’s contribution.

See The farce of a “sciency” anti-fluoride report for an analysis of the close relationships between the authors and peer reviewers of the Fluoride Free report and anti-fluoride activist groups.


There is a lot in Stan Litras’s article to criticise – there is a lot which is misleading or outright wrong. I hope Stan will seriously consider my criticisms and respond to them, especially where he thinks I am wrong.

My criticisms should also be considered by Bruce Spittle and Hardy Limeback who Fluoride Free NZ listed as “peer reviewers” of Stan’s article. They must bear some responsibility for allowing the article to go ahead without the necessary corrections.

Litras makes many of his criticisms of community water fluoridation (CWF) in passing – without argument or evidence. But he declares:

“My comments will focus on the gross over statement of the purported benefits of fluoridation in our society, New Zealand, 2014.”

So, I will start with the claims he makes on this.

“Overseas studies” – The WHO data

Central to this are Stan’s assertions:

“The “elephant in the room” is that while decay rates fell in areas where fluoridation was implemented, it also fell in areas that weren’t, often at a faster rate. (8)”

And

“Globally, fluoridation is seen to make no difference to reduced decay rates, there being no difference between the few countries which use artificial fluoridation, and those that don’t. (8,7)”

His only evidence for this is a figure prepared by Chris Neurath from the Fluoride Action Network – using data from the World Health Organisation (WHO). Here it is in a slightly simpler version to the one used by Stan.

I am amazed that anti-fluoride propagandists keep using this graphic as “proof” that fluoride is ineffective. But they do – which can only mean they haven’t thought it through.

While the plots do show improvements in oral health for countries independent of fluoridation they say nothing about the effect of fluoride. Simple comparison of countries obscures all sorts of effects such as differences in culture, history, social and political policies, etc. Such plots are also influenced by changes and differences in dental treatment and measurement techniques.

Robyn Whyman in his report Does delayed tooth eruption negate the effect of water fluoridation? exposes the little trick Stan is trying to pull with the WHO data:

“Studies that appropriately compare the effectiveness of water fluoridation do not compare poorly controlled inter-country population samples. They generally compare age, sex, and where possible ethnicity matched groups from similar areas. Inter-country comparisons of health status, including oral health status, are notoriously difficult to interpret for cause and effect, because there are so many environmental, social and contextual differences that need to be considered.”

There are some within country data within the WHO data set Neurath used which can give a better idea of the beneficial effects of fluoridation. This plot shows the results for the WHO data for Ireland. A clear sign that fluoridation plays a beneficial role.

Neurath covered up evidence for the benefits of CWF by simply using the mean of fluoridated and unfluoridated areas for countries like Ireland and New Zealand. Also, the straight lines in Chris Neurath’s plots are a real give away to the poor quality of the data used. Two data points for each country!

New Zealand – Cherry-picking the MoH data

I have criticised Stan’s misrepresentation the Ministry of Health (MoH) data before. At the time he was using and misrepresenting some of my own graphics on his business website. He has since removed the offending article but now he returns with a vengeance – with tables and figures of his own.

This has given him free hand to cherry-pick and misrepresent to his heart’s content.

He claims:

“Ministry of Health figures recorded every year in 5 year olds and year 8s (12-13 year olds) consistently show minimal or no differences between fluoridated and nonfluoridated areas of NZ.”

stan_1

Cherry-picked data from Stan Litras

And he backs this up with a graph.

That looks about right. The data for 2011 shows 59.9% of 5 year olds in fluoridated areas were caries-free while 59.2% were carries free in non-fluoridated areas. No real difference.

But come on! A single data point, one year, one of the age groups for the fluoridated and unfluoridated areas! That is blatantly cherry-picking – as I mentioned in my article Cherry picking fluoridation data. In that I presented all the data for 5 year olds and year 8s, and for the total population and Maori, and for % caries free and decayed, missing and filled teeth (DMFT).

I have reproduced this data here in a simpler form using several figures.

caries-freeConsidering the % caries free data there are several points:

1: These do not “consistently show minimal or no differences between fluoridated and nonfluoridated areas” as Stan claims.

2. They do show a decline in differences between fluoridated and non-fluoridated areas in recent years.

3: This trend is less obvious for Maori but still present.

4: Stan has blatantly cherry-picked the  data points for 5 year-olds in 2011 to give him the least possible difference (see red circle in figure).

dmft

The data for decayed, missing and filled teeth (DMFT) shows similar trends.

Presumably both measures (% caries free and DMFT) are useful indicators of oral health but they probably convey complementary and not exactly the same information.

I discussed features of the graphs and their trends in in my articles Cherry picking fluoridation data and Fluoride debate: Response to Paul’s 5th article where I also discussed limitations in the data.

We need to appreciate this is just normal school clinic data, without technique standardisation for those making the measurements or proper recording of place of residence. The latter effect probably shows up more strongly after 2004 when a “hub and spoke” dental clinics system was introduced further confusing proper records of likely fluoride intake. One school dental clinic could serve a number of areas – both fluoridated and non-fluoridated. This mixing is a likely explanation for the apparent decline of the effectiveness of fluoridation after 2006.

So, yes, the MoH data is not straightforward. But this means it should be considered sensibly, taking into account its limitations and the social factors involved.  Instead, Stan has leapt in – found the data points which best fit his own biases and then tried to claim those data  are representative when they aren’t.

Stan presented another self-prepared graphic using data for the 4 different regions for 5 year olds (see his page 27). He appears not to have used the correct data – at least for the Northern and Southern regions.  My own graphic for this shows differences to his. (Of course, the mistake may be mine – if Stan can show I am wrong I will happily delete this part from my critique).

region-correct

Again, that data should also not just be considered at face value – or selected to confirm a bias. It has limitations. For example in this case there were only 55 children in the fluoridated Southern region compared with 7568 in the non-fluoridated area. A footnote on the data sheet says:

“2. Excludes Southern DHB because data were not reported for 1 Jan-20 Feb 2012, and fluoridation status was not captured for most children throughout 2012, due to transition to a new data system. “

Proper consideration of such data must take these sort of limitations into account. But of course all Stan Litras did was select data to support his assertions and ignore the rest. Any limitations in the data did not concern him.

Lifetime benefit

Stan has a thing about the “lifetime benefits,” or lack of benefits, of CWF. Most studies of CWF have used data for children – data for adults is less common but there is still research literature on this available.

But all Stan did on this was to cherry-pick a graphic (Figure 53) from the NZ Oral Health Survey showing no significant change in DMFT for 65-74 year olds between the years 1976, 1988 and 2009. He then claims:

“Data from the NZOHS 2010 do not support statements of a lifetime benefit, indicating that the action of fluoride is simply to delay the decay. (13)”

But he has had to work hard to avoid other data like that in Figure 49 below which do show a significant improvement in the number of retained teeth of that age group. The Oral Health Survey report itself says:

“In dentate adults aged 65–74 years, the mean number fell from 17.1 to 12.1 missing teeth per person on average from 1976 to 2009.”

mising-teeth

Again, instead of cherry-picking, searching for an image to fit his story, Stan should have considered the data and figures critically and intelligently. Perhaps the DMFT data does not show what he claims because more teeth have been retained in recent years. The decline in missing teeth could have been balanced by increases in fillings due to increase in remaining teeth. The lack of a significant difference in DMFT actually suggests the opposite to what he claims.

Litras also misrepresent the York review on the question of benefits from CWF for adults. He says:

“The York Review found there was no weight of evidence to support benefit in adults or in low SES groups, or increase of decay in cessation studies. (7)”

Just not true. The York report says:

“One study (Pot, 1974) found the proportion of adults with false teeth to be statistically significantly greater in the control (low-fluoride) area compared with the fluoridated area.”

Sheiham and James (2014) stressed that a proper assessment of oral health problems should include data for adults as well as children. Recent research is starting to take up this issue. For example O′Sullivan and O′Connell (2014) recently showed that water fluoridation provides a net health gain for older Irish adults.

Systemic vs topical

Stan promotes the common mythology of the anti-fluoridation propagandist that any mechanism for a beneficial effect of fluoride in restricting tooth decay is purely “topical.” He claims:

“It has been widely accepted since the 1990s that any effect on tooth decay from swallowing fluoride is insignificant or non-existent. To quote: CDC 1999: “the effect of Fluoride is topical “ (5); J Featherstone 1999: “the systemic effect is, unfortunately, insignificant” (6).”

Let’s consider what the sources Stan cites actually do say. I will quote from the 2001 edition of Stan’s citation 5 which he (partly) cites on page 36:

“Fluoride works to control early dental caries in several ways. Fluoride concentrated in plaque and saliva inhibits the demineralization of sound enamel and enhances the remineralization (i.e., recovery) of demineralized enamel (12,13 ). As cariogenic bacteria metabolize carbohydrates and produce acid, fluoride is released from dental plaque in response to lowered pH at the tooth-plaque interface (14 ). The released fluoride and the fluoride present in saliva are then taken up, along with calcium and phosphate, by demineralized enamel to establish an improved enamel crystal structure. This improved
structure is more acid resistant and contains more fluoride and less carbonate (12,15–19 ) (Figure 1). Fluoride is more readily taken up by demineralized enamel than by sound enamel (20 ). Cycles of demineralization and remineralization continue throughout the lifetime of the tooth.”

topical-mechanism

And

“Saliva is a major carrier of topical fluoride. The concentration of fluoride in ductal saliva, as it is secreted from salivary glands, is low — approximately 0.016 parts per million (ppm) in areas where drinking water is fluoridated and 0.006 ppm in nonfluoridated areas (27 ). This concentration of fluoride is not likely to affect cariogenic activity. However, drinking fluoridated water, brushing with fluoride toothpaste, or using other fluoride dental products can raise the concentration of fluoride in saliva present in the mouth 100-to 1,000-fold. The concentration returns to previous levels within 1–2 hours but, during this time, saliva serves as an important source of fluoride for concentration in plaque and for tooth remineralization (28 ).”

(Note: Stan simply quotes the first part of this statement (in red) in his article (page 36) and completely omits the second part (in black) – presumably because he wants to deny a role for fluoridated water in influencing the saliva fluoride concentrations. This cherry-picking of the CDC statement is typical for anti-fluoride propagandists – see Fluoridation – topical confusion).

There is an attempt to confuse a “topical” or “surface” mechanism with a “topical” application (eg toothpaste or dental treatments). However, fluoride is transferred to saliva from food and drink during ingestion so that ingested fluoride also contributes to the “topical” or “surface” mechanism.

However Stan wants to deny a “topical” role for ingested fluoride and claims (page 36):

“The required elevation of baseline levels only occurs after using fluoridated toothpaste or mouth rinse, a concentration of 1,000 ppm or more instead of 1 ppm from water.(24)”

His citation 24 is to Bruun (1984) and he misrepresents that paper which actually said:

“It was concluded that direct contact of the oral cavity with F in the drinking water is the most likely source of the elevated whole saliva fluoride and that the increased availability of fluoride in the oral fluids has an important relationship to the reduced caries progression observed in fluoridated areas.”

Systemic role.

Featherstone does say:

“Fluoride works primarily via topical mechanisms which include (1) inhibition of demineralization at the crystal surfaces inside the tooth, (2) enhancement of remineralization at the crystal surfaces (the resulting remineralized layer is very resistant to acid attack), and (3) inhibition of bacterial enzymes. Fluoride in drinking water and in fluoride-containing products reduces tooth decay via these mechanisms. Low but slightly elevated levels of fluoride in saliva and plaque provided from these sources help prevent and reverse caries by inhibiting demineralization and enhancing remineralization. The level of fluoride incorporated into dental mineral by systemic ingestion is insufficient to play a significant role in caries prevention. The effect of systemically ingested fluoride on caries is minimal.”

There is some debate over the role of systemic fluoride exuded by salivary glands. Many feel the concentration is too low – but because its effect is also determined by the presence of calcium, phosphate, organic species and pH it is best not to be dogmatic about this. It is, anyway, difficult to separate salivary fluoride derived from transfer from food and beverage in the oral cavity from that exuded by the salivary glands from systemic sources.

Stan is determined to deny a role for systemic fluoride during tooth development asserting:

“the erroneous theory that fluoride incorporated into children’s developing tooth enamel would make teeth more resistant to decay.”

While often neglected because of the concentration on surface mechanisms with existing teeth the theory that fluoride is incorporated into the developing teeth of children and confers a degree of protection is far from erroneous.

Newbrun (2004), for example, stressed in a review of the systemic role of fluoride and fluoridation on oral health:

“The role of systemic fluoride in caries prevention is neither “minimal” nor “of borderline significance.” On the contrary, it is a major factor in preventing pit and fissure caries, the most common site of tooth decay. Maximal caries-preventive effects of water fluoridation are achieved by exposure to optimal fluoride levels both pre- and posteruptively.”

Cho et al (2014) presented data showing that children exposed to CWF during teeth development retained an advantage over those never exposed to it even after fluoridation ceased.

Let’s stop confusing the issue. Systemic fluoride may not play a role with existing teeth but it does during tooth development – even if the relative contributions of systemic fluoride and “topical” or surface fluoride to lasting oral health are difficult to determine.

Tooth eruption delays

Stan resorts to special pleading when he claims with reference to NZ MoH data:

“Small apparent differences could be accounted for by other factors such as delayed eruption of teeth in fluoridated communities, therefore less time in the mouth exposed to plaque acids, ethnic distribution and urban/rural differences.”

He relies on the “York review” (McDonagh et al., 2000) to back up his “delayed tooth eruption” excuse:

“Importantly, the York Review noted that the variation of tooth eruption times between fluoridated and unfluoridated areas was not taken into account. (7)”

But that review actually said on this subject:

“It has been suggested that fluoridation may delay the eruption of teeth and thus caries incidence could be delayed as teeth would be exposed to decay for a shorter period of time. Only one study compared the number of erupted teeth per child. The difference was very small and in opposite directions in the two age groups examined, however no measure of the statistical significance of these differences was provided. Only one of the studies attempted to control for confounding factors using multivariate analysis (Maupomé 2000).”

Robyn Whyman has gone into this claim in more detail in his report Does delayed tooth eruption negate the effect of water fluoridation?Here he critiques Paul Connett’s reliance on this excuse and concludes from his review of the literature:

“The studies and reports cited by Professor Connett to try and validate an argument for delayed tooth eruption either do not make the claims he suggests, or do not have direct relevance to trying to assess the issue. The claimed association is at odds with the published literature which indicates minimal variation in eruption time of permanent teeth by exposure to fluoride. A rational explanation exists for the minimal variations that have been reported based on the relationship between fluoride exposure, caries experience in the primary teeth and emergence timing for the permanent teeth.”

The “delayed tooth eruption” excuse is nothing more than special pleading and straw clutching.

Socio-economic factors

Stan again misrepresented the York review regarding socio-economic effects on oral health and the effectiveness of CWF when he claimed “there was no weight of evidence to support benefit in adults or in low SES groups.” The York review actually said:

“Studies should also consider changes in social class structure over time. Only one included study addressed the positive effects of fluoridation in the adult population. Assessment of the long-term benefits of water fluoridation is needed.”

And

“Within the UK there is a strong social gradient associated with the prevalence of dental caries. This is found both in adults and in children. Those who are more deprived have significantly greater levels of disease. There is also geographical variation with the northwest of England, Scotland and Northern Ireland most severely affected. (Pitts, 1998; Kelly, 2000)”

There have been a range of studies internationally showing that fluoridation can aid in reducing differences in oral health due to socio-economic effects. See for example Cho, et al., (2014).

What happens when fluoridation is stopped

Stan briefly refers to this issue, citing (as anti-fluoridation activists always do) Künzel and·Fischer (2000). I will simply refer him, and interested readers to my article What happens when fluoridation is stopped? This boils down to the need to read the scientific literature properly as usually the anti-fluoridation activists ignore the details referring to fluoride treatments and procedures which replaced CWF.

There are a number of other points mentioned briefly by Stan Litras which could be discussed but this article is already too long so I will leave that to the comments section.

Conclusions

Stan Litras has simply indulged in blatant cherry-picking of data, and misrepresentation of the literature, in his critique of the recent review Health Effects of Water Fluoridation: a Review of the Scientific Evidence produced by the Royal Society of NZ together with the Office of the Prime Minister’s Chief Science Advisor. Perhaps we shouldn’t expect better from a political activist in the anti-fluoride movement but he, and Fluoride Free NZ, attempt to present this, and other articles in the collection, as objective and scientifically credible. It is neither – such cherry-picking and misrepresentation violates any scientific ethics and needs to be exposed for what it is. The Fluoride Free NZ claimed “peer reviewers,” Bruce Spittle and Hardy Limeback, must share responsibility because, by their endorsement, they signal their approval of such behaviour.

Note

I offered Stan Litras a right of reply to this post, or even an ongoing exchange with him along the lines of my debate with Paul Connett. He replied:

“I look forward to your comments on my review, as a lay person, but I cannot engage in a serious dialogue with someone who is not a peer with the same level of knowledge as myself in the dental field. “

Hopefully this means he will at least comment here, take issue with me where he thinks I am wrong and correct me where I am mistaken. I also hope than Bruce Spittle and Hardy Limeback will also take advantage of their right to comment here.

References

Bruun, C., & Thylstrup, A. (1984). Fluoride in Whole Saliva and Dental Caries Experience in Areas with High or Low Concentrations of Fluoride in the Drinking Water. Caries Research, 18(5), 450–456.

Centers for Disease Control and Prevention. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States (Vol. 50, p. 50).

Cho, H.-J., Jin, B.-H., Park, D.-Y., Jung, S.-H., Lee, H.-S., Paik, D.-I., & Bae, K.-H. (2014). Systemic effect of water fluoridation on dental caries prevalence. Community Dentistry and Oral Epidemiology.

Cho, H.-J., Lee, H.-S., Paik, D.-I., & Bae, K.-H. (2014). Association of dental caries with socioeconomic status in relation to different water fluoridation levels. Community Dentistry and Oral Epidemiology.

Fluoride Free New Zealand. (2014). Scientific and Critical Analysis of the 2014 New Zealand Fluoridation Report.

Künzel, W.;·Fischer, T. (2000). Caries Prevalence after Cessation of Water Fluoridation in La Salud, Cuba. Caries Res, 34, 20–25. Retrieved from http://www.karger.com/Article/Fulltext/16565

McDonagh, M., Whiting, P., Bradley, M., Cooper, J., Sutton, A., & Chestnutt, I. (2000). A Systematic Review of Public Water Fluoridation.

Ministry of Health. (2010). Our Oral Health Key findings of the 2009 New Zealand Oral Health Survey. Wellington, Ministry of Health.

Ministry of Health (2014) Age 5 and Year 8 oral health data from the Community Oral Health Service. http://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/oral-health-data-and-stats/age-5-and-year-8-oral-health-data-community-oral-health-service.

National Fluoridation Information Service (2011): Does Delayed Tooth
Eruption Negate The Effect of Water Fluoridation? National Fluoridation Information Service Advisory June 2011, Wellington, New Zealand.

O′Sullivan, V., & O′Connell, B. C. (2014). Water fluoridation, dentition status and bone health of older people in Ireland. Community Dentistry and Oral Epidemiology.

Sheiham, A., & James, W. P. T. (2014). A reappraisal of the quantitative relationship between sugar intake and dental caries: the need for new criteria for developing goals for sugar intake. BMC Public Health, 14(1), 863.

Similar articles

 

The farce of a “sciency” anti-fluoride report

F network

Click for a larger image

I came up with the image above after a quick glance at a “report” promoted by the local Fluoride Free groups and Paul Connett’s Fluoride Alert organisation. (Scientific and Critical Analysis of the 2014 New Zealand Fluoridation Report). It illustrates the incestuous network of authors and “peer reviewers” involved in producing the “report.” I have also illustrated connections of these people to a number of anti fluoride organisations and 2 publications.

The first column lists the authors in red, and their claimed peer reviewers in green. The third column lists the anti-fluoride organisations and several publications these people are connected to.

The middle column lists some other people who are also connected to these organisations and publications. I have already reviewed Kathleen Theissen’s article (see Peer review of an anti-fluoride “peer review”) and will get around to reviewing the other 2 articles (by H.S. Miclen and Stan Litras) later.

Meanwhile, lets just consider the connections between these authors, “peer reviewers” and anti-fluoride organisations.

Taking in each other’s laundry

Most of these names are familiar to anyone who has followed the anti-fluoride movement. That fact in itself shows how this report can in no way be seen as “expert,” “independent” or at all credible. Some details on the illustrated people, organisations and publications.

NRC Review minority: There were several disagreements on the 12 member panel which produce the 2006 NRC report “Fluoride in drinking water. A scientific review of EPA’s standards” because 3 members were anti-fluoride. They were Robert Issacson, Hardy Limeback and Kathleen Theissen. Hardy Limeback is involved in several anti-fluoride activist groups.

Kathleen Theissen appears not to be organisationally involved but regularly makes anti-fluoridation submissions when the issue is debated.

UPDATE: Steve Slott has reminded me of this example of Theissen’s lack of credibility as a peer reviewer of fluoridation-related papers:

“In July 2013, Douglas Main, that freelance reporter and bastion of “objectivity”, interviewed Thiessen to get her opinion on Hirzy’s study on which he based his petition to the EPA.

From the article:

“Experts not involved with Hirzy’s study agreed with its findings.”

“I think this is a reasonable study, and that they haven’t inflated anything,” said Kathleen Thiessen, a senior scientist at SENES Oak Ridge Inc., a health and environmental risk assessment company.”

When the EPA reviewers looked at Hirzy’s study they found that he had made a 70-fold miscalculation in his study. When corrected for that error, the EPA reviewers found that Hirzy’s data actually demonstrated the exact opposite of what he had concluded.

Seems Thiessen either didn’t bother to read Hirzy”s study prior to commenting on it, or she overlooked his glaring error, too.”

Fluoride/ISFR: The International Society for Fluoride Reasearch (ISFR) publishes the journal Fluoride and organises regular conferences. They provide an avenue for authors to publish anti-fluoride articles, and generally poor quality research from areas where endemic fluorosis is common which may not be acceptable in the normal scientific journal.

The Society is based in New Zealand and is registered here as a charity. Bruce Spittle is the treasurer and journal managing editor.

FTRC/Second look: The anti-fluoride organisation and web site Second Look as set up the Fluoride Toxicity Research Collaborative (FTRC). It appears to be a weak attempt to provide a front “scientific institute” for anti-fluoride activists who want to present themselves as scientific experts.

This reminds me of the creationist Biologic Institute set up by the intelligent design creationists at the Discovery Institute. Actually, the Intelligent Design “pretend” scientific journal Bio-complexity also reminds me of the anti-fluoride journal Fluoride.

The FTRC lists the following staff:

  • Russell Blaylock, M.D., FTRC Medical Director
  • Hardy Limeback, Ph.D., D.D.S, FTRC Principle Investigator
  • Phyllis J. Mullenix, PhD., FTRC Research Program Director
  • Aliss Terpstra, RNCP, FTRC Research Coordinator

So far they claim to have sponsored (financed?) 2 research papers only by Phyllis Mullinex. Have a read of them and make up your own mind about their quality.

Case Against Fluoride: This is Paul Connett’s book The Case against Fluoride: How Hazardous Waste Ended Up in Our Drinking Water and the Bad Science and Powerful Politics That Keep It There. It is usually treated as a holy scripture in the anti-fluoridation movement. His co-authors were H. S. Micklen and James Beck.

Connett is very proud of this book and relies on it to support his claim to be a “world expert” on fluoridation.

Fluorine in Medicine: This is the sole scientific paper that Paul Connett can claim authorship (actually co-authorship) to:

Strunecká, A. ., & Patočka, J.; Connett, P. (2004). Fluorine in medicine. Journal of Applied Biomedicine, 2, 141–150.

The senior author Anna Strunecká is also part of the anti-fluoride network illustrated above. I am personally very suspicious of the quality of the journal which published this paper – anti-fluoride people have a history of placing poor quality papers in suspect journals purely to attain some sort of scientific credibility. DonQuixoteJune2011

FIND: The Fluoride Information Network for Dentists is one of the local Fluoride Free’s astroturf organisations claiming about 8 members but only Stan Litras is active. Stan uses his FIND hat for his anti-fluoride press releases – such as the one promoting the “report” considered here.

NZ Tour of Don Quixote & Sancho Panza: Sorry, can’t help thinking of these two when the upcoming NZ tour of Paul Connett and Bill Hirzy is mentioned. They do seem to be charging local fluoridation windmills with meetings in Taupo and Auckland.

William Hirzy: He is Paul Connett’s wingman on the Don Quixote & Sancho Panza Tour. Unlike Paul’s sole co-authorship he actually has 2 published scientific papers related to fluoridation where he appears as senior author. (See Comparison of hydrofluorosilicic acid and pharmaceutical sodium fluoride as fluoridating agents—A cost–benefit analysis and Corrigendum to “Comparison of hydrofluorosilicic acid and pharmaceutical sodium fluoride as fluoridating agents—A cost–benefit analysis” [Environ. Sci. Policy 29 (2013) 81–86]“)

The “credibility” of his “expertise” on the subject is shown by the fact his second paper was necessary to correct the huge arithmetic mistake he made in the first paper!

Perhaps you can see why the Connett/Hirzy act brings Done Quixote and Sancho Panza to my mind.

Conclusion

The “report” is discredited even before addressing the arguments presented – simply because of the well-known anti-fluoride stance of all the authors and “peer-reviewers.” The diagrammatic network shows just how incestuous the “report” is. It is simply an attempt to put a “sciency” face on their political stand and their attack on the Royal Society Review.

As a scientific presentation it is a farce.

Similar articles

Water fluoridation and dental fluorosis – debunking some myths

Dental fluorosis is really the only “negative” side effect of community water fluoridation (CWF). It occurs in non-fluoridated as well as fluoridated areas but is often a little more common in the fluoridated areas.

However, there is a lot of rubbish about dental fluorosis spouted by anti-fluoride propagandists. It is worth putting dental fluorosis into its proper context and debunking some of the misinformation they promote.

Here are some facts.

1: Diagnosis of dental fluorosis involves grading teeth into 6 levels:

  1. No dental fluorosis
  2. Questionable
  3. Very mild
  4. Mild
  5. Moderate
  6. Severe.

Here are some photos of the different grades

2: The moderate/severe grades are rare in areas considered for CWF and fluoridation does not increase prevalence of those grades of dental fluorosis. However, those more severe forms are more common in areas where dental fluorosis is endemic like parts of China, India and north Africa.

Dental and skeletal fluorosis is a real problem in these endemic areas, but it is not a problem in the areas where CWF is used.

The figure below contrasts data for prevalence of dental fluorosis in NZ and the USA where CWF is common with data for an area of endemic fluorosis in China.

DF-grades-graph

3: The first 4 grades (none – mild) are judged purely “cosmetic. In fact children and parents often judge the grades questionable – mild more highly than none. Research finds these milder forms of dental fluorosis often improve dental health related quality of life (Do and Spencer, 2007; Chankanka et al., 2010; Peres et al., 2009; Biazevic et al., 2008; Büchel et al., 2011; Michel-Crosato et al., 2005).

In contrast research shows that the moderate/severe grades of dental fluorosis have a negative impact on health-related quality of life(Chankanka et al., 2010; Do and Spencer, 2007; Chikte et al., 2001).

4: Anti-fluoride propagandists often lump all grades together – presenting dental fluorosis as always bad. It also enables them to produce high figures to inflate the apparent problem. That is deceptive.

5: Anti-fluoride propagandists often use data from countries like India and China where fluorosis is endemic in their arguments against CWF. The figure above shows this is also deceptive.

Similar articles

Declan Waugh pushes another anti-fluoride myth

DeclanWaugh_photo

Declan Waugh – Champion cherry-picker

Declan Waugh seems a bit of a late developer. He has only just got around  to finding those papers that anti-fluoride propagandists like to cite as evidence that oral health does not decline when community water fluoridation is stopped. Of course, he cherry-picks the appropriate papers and is then careful not to give the full evidence.

But he has whipped up a Letter to the Editor promoting his new “discovery” – and encourages his fans to use the same information for their own letters to the editor.

Here’s Waugh’s claim in his letter to the editor (which he encourages his fan’s to duplicate).

Dear Sir.

In recent decades in four seperate countries notably Finland, the Netherlands, Germany and Cuba dental health professionals warned of the grave dangers to public health from discontinuation of water fluoridation. Yet ironically peer reviewed published scientific research demonstrated that dental health significantly improved among children when fluoridation of water ended. Scientific evidence proved in every case that the views and opinions of profluoridationalists among dental health professionals were misguided and errorneous. So why are we still listening to them?

Yours sincerely

  • Seppa L, Karkkainen S, Hausen H. Caries frequency in permanent teeth before and after discontinuation of water fluoridation in Kuopio, Finland. Commuity Dent Oral Epidemiol 1998;26:256 – 262.
  • Seppa L, Karkkainen S, Hausen H. Caries trends 1992 – 1998 in two low-fluoride Finnish towns formerly with and without fluoridation. Caries Res 2000;346:462 – 468.
  • Künzel W, Fischer T. Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Res. 2000 Jan-Feb;341:20-5.
  • Künzel W, Fischer T, Lorenz R, Brühmann S. Decline of caries prevalence after the cessation of water fluoridation in the former East Germany. Community Dent Oral Epidemiol. 2000 Oct;285:382-9.
  • Kalsbeek H, Kwant GW, Groeneveld A, Dirks OB, van Eck AA, Theuns HM. Caries experience of 15-year-old children in The Netherlands after discontinuation of water fluoridation. Caries Res. 1993;273:201-5

What these papers really say

I refered to this little myth in my article What happens when fluoridation is stopped? and will briefly repeat the information these propagandists always omit here.

L. Seppä, S. Kärkkäinen, and H. Hausen,Caries Trends 1992–1998 in Two Low-Fluoride Finnish Towns Formerly with and without Fluoridation.” Caries Research 34, no. 6 (2000): 462–68. The abstract for this paper concluded:

“The fact that no increase in caries was found in Kuopio despite discontinuation of water fluoridation and decrease in preventive procedures suggests that not all of these measures were necessary for each child.”

The authors commented further on this research in Seppa et al (2002). They found their “longitudinal approach did not reveal a lower caries occurrence in the fluoridated than in the low-fluoride reference community.” But commented:

“The main reason for the modest effect of water fluoridation in Finnish circumstances is probably the widespread use of other measures for caries prevention. The children have been exposed to such intense efforts to increase tooth resistance that the effect of water fluoridation does not show up any more. The results must not be extrapolated to countries with less intensive preventive dental care.”

W. Künzel and T. Fischer,Caries Prevalence after Cessation of Water Fluoridation in La Salud, Cuba.  Caries Research 34, no. 1 (2000): 20–25. Again this study found no increase in caries after stopping fluoridation but the authors suggested why:

“A possible explanation for this unexpected finding and for the good oral health status of the children in La Salud is the effect of the school mouthrinsing programme, which has involved fortnightly mouthrinses with 0.2% NaF solutions (i.e. 15 times/year) since 1990.”

W. Künzel, T. Fischer, R. Lorenz, and S. Brühmann,Decline of caries prevalence after the cessation of water fluoridation in the former East Germany Community Dentistry and Oral Epidemiology 28, no. 5 (2000): 382–89. These authors found no increase of caries in two German cities after fluoridation of water was stopped. But again the authors suggest why:

“The causes for the changed caries trend were seen on the one hand in improvements in attitudes towards oral health behaviour and, on the other hand, to the broader availability and application of preventive measures (F-salt, F-toothpastes, fissure sealants etc.).”

Kalsbeek, H., Kwant, G. W., Groeneveld, A., Dirks, B., van Eck, A. A. M. J., & Theuns, H. M. (1993). “Caries Experience of 15-Year-Old Children in The Netherlands after Discontinuation of Water Fluoridation. Caries Research, 27(3), 201–205. Tooth decay continued to decline after discontinutation of fluoridation in both the areas previously not fluoridated and fluoridated. But the authors say:

“The question as to whether water fluoridation would have had an additional effect if it had been continued (presuming the application of existing preventive measures) cannot be answered, as there are no remaining communities with fluoridated water in The Netherlands.”

Tooth decay is complex because it involves several factors. Improvements in public health, especially dental health availability, and alternative fluoridation options have produced a general improvement irrespective of the availability of community water fluoridation (CWF). However, where comparisons are made between fluoridated and unfluoridated areas in the absence of other differences the benefits are seen.

Studies do show increase in tooth decay when fluoridation stopped

Of course there are other studies which Declan Waugh and his anti-fluoride mates will refuse to cite because they do not support their claims. In Fluoride debate: Ken Perrott’s closing response to Paul Connett? I discussed a paper which did show an increase in tooth decay –  Attwood and Blinkhorn (1991), Dental health in schoolchildren 5 years after water fluoridation ceased in South-west Scotland.”  They measured dmft and DMFT – decayed, missing and filled teeth in primary and permanent teeth respectively.

The figures below illustrate the data from this paper which compared changes in oral health of two Scottish towns  in both 1980 and 1988. One town, Annan, had never had fluoridated water while the other, Stranraer, had it until 1983. This enabled the effects of both cessation of fluoridation and the generally observed improvement in oral health due to other factors to be compared and considered. The graphics show the results for 5 year old and 10 year old children.

Decayed missing and filled deciduous teeth for 5 year olds. Stranraer fluoridated until 1983. Annan not fluoridated.

Decayed missing and filled teeth for 10 year olds. Stranraer fluoridated until 1983. Annan not fluoridated.

The plots indicate aspects of the complexity of these sort of studies. Because 2 neighbouring towns were compared it was possible to measure the decline in oral health after discontinuation of fluoridation against a background of the general improvement in oral health, even in a non-fluoridated situation.

The moral here is don’t accept at face value the claims made by anti-fluoridation propagandists – even if they, like Declan Waugh, carry a self-endorsement of “scientist and fluoride researcher.”

Similar articles

Severe dental fluorosis the real cause of IQ deficits?

A new study finds cognitive function defects, like IQ, in children are not significantly related to fluoride in drinking water. But they are associated with medium and severe dental fluorosis.

This interests me for two reasons:

  1. The report is by Choi and Grandjean who had also authored the 2012 meta-review often used by anti-fluoride activists to claim that community water fluoridation causes a lowering of IQ (the authors subsequently pointed out the high fluoride concentrations in the papers they reviewed meant that conclusion is not valid)
  2. The data reported is consistent with my suggestion in Confirmation blindness on the fluoride-IQ issue that reported relationships between IQ and drinking water fluoride concentration could really indicate a relationship with severe dental fluorosis, and not drinking water fluoride itself.

The new report is:

Choi, A. L., Zhang, Y., Sun, G., Bellinger, D., Wang, K., Yang, X. J., … Grandjean, P. (2014). Association of lifetime exposure to fluoride and cognitive functions in Chinese children: A pilot study. Neurotoxicology and Teratology.

Firstly – this is only a pilot study and has several acknowledged weaknesses – the small number of children studied (51) being the most obvious. However, this is what was found:

“Sixty percent of the subjects examined had moderate or severe fluorosis. These children were exposed to elevated fluoride concentrations in drinking water. Children with normal or questionable Dean Index were all from households with a water fluoride concentration of 1 mg/L and had urinary fluoride excretion levels below 1 mg/L.”

The children were placed in 3 groups according to their degree of dental fluorosis:

  1. Normal/questionable (N=8)
  2. Very mild/mild (N=9)
  3. Moderate/severe (N=26)

The high proportion of children with moderate/sever dental fluorosis indicates the study involved an area of endemic fluorosis.

And the results of neuropsychological tests:

“Results of multiple regression models show that moderate and severe fluorosis was significantly associated with lower total and backward digit span scores when compared to the reference combined categories of normal and questionable fluorosis (Table 4). Although the associations between fluoride in urine and in drinking water with digit span were not significant, they were in the anticipated direction. Motor coordination and dexterity were not significantly associated with fluoride in drinking water and fluorosis although higher levels were associated with poorer scores as well. Other outcomes did not reveal any association with the fluoride exposure.”

The authors used a number of neuropsychological tests. The digit span test results suggest a “deficit in working memory” for the children with moderate and severe dental fluorosis. None of the other tests used show any signficant relationship with indices for fluoride exposure.

So, this pilot study did not show any association of neuropsychological tests with fluoride concentration in drinking water but it did find an association with medium and severe dental fluorosis. This is consistent with my speculation in Confirmation blindness on the fluoride-IQ issue that “a physical defect like dental and skeletal fluorosis could lead to decreasing IQ.”

I argued that:

“minor physical anomalies are known to be associated with learning difficulties and emotional illness in children (seeHilsheimer & Kurko 1979). It seems entirely reasonable that a physical anomaly like severe dental fluorosis could lead to learning difficulties in children which could be seen as lower IQ values.”

There are many problems with the studies anti-fluoride activists promote relating IQ to fluoride in drinking water. But it could be that any real effect seen with the higher fluoride concentrations could simply be explained by effects of the physical anomaly of medium and severe dental fluorosis common at these higher concentrations.

Unfortunately the authors of this study still do not consider this possibility. I guess it could be that someone with a hammer only sees nails, and chemical toxicologists are only capable of considering brain damage caused by toxic chemicals. The effects of physical anomalies on learning difficulties are probably quite outside their training and experience.

Their confirmation bias and mental blockage on this meant they were considering dental fluorosis as just another indicator of dietary fluoride intake. However, even that assumption has its problems because genetic differences are also known to be involved in dental fluorosis.

I think this must be why they ended with a conclusion that could well be quite unfounded:

“This pilot study in a community with stable lifetime fluoride exposures supports the notion that fluoride in drinking water may produce developmental neurotoxicity”

Dental fluorosis and community water fluoridation

Fluorosis is endemic in many parts of China and the high prevalence of medium/severe dental fluorosis (60%) among the children in the Choi et al (2014) pilot study shows their situation is not at all similar to that in areas of New Zealand and USA using community water fluoridation (CWF).

The figures below give some context.

Here are examples of the different degrees of dental fluorosis.

The graph below shows the situation reported for New Zealand in the 2009 New Zealand Oral health Survey (see Our Oral Health). No severe and only 2% moderate dental fluorosis reported.

This figure (taken from Fluorosis Facts: A Guide for Health Professionals) shows the amount  of moderate and severe dental fluorosis in the US is also very small.

Perhaps we can now contrast the situation here, in areas where CWF is common, with the situation in China in areas with endemic fluorosis where these studies were undertaken. The figure below is a slide from a presentation by Xiang (2014) to Paul Connett’s recent anti-fluoride “get-together” (Xiang 2014). This is not the very mild dental fluorosis attributed to CWF.

(Anti-fluoride people also often single out the study of Xiang, et al (2003). Effect of fluoride in drinking water on children’s intelligence. Fluoride, 36(2), 84–94, because unlike the others it is more detailed.  Xiang’s team has studied areas where fluorosis is endemic.)

Conclusion

Anti-fluoride activists often promote the meta-review of Choi et al (2012) in their arguments against CWF. However, there are many problems with these studies including the fact reported IQ effects were associated with much higher drinking water fluoride concentrations than occurs with CWF.

The new study of Choi et al (2014) did not confirm any association of neuropsychiatric measurements with drinking water fluoride concentration. However, it did show association of negative neuropsychological effects with medium/severe dental fluorosis.

This is consistent with the physical anomaly of severe dental fluorosis being the real cause of IQ effects and not any direct chemical toxic effect.

Similar articles

Declan Waugh claims it’s “clear as day”

Declan Waugh is an anti-fluoride propagandist who specialises in naively distorting scientific and medical information to “prove” community water fluoridation (CWF) is dangerous. A common tactic of his is to select, really cherry-pick, medical data to show the mortality or disease prevalence is greater in the Republic of Ireland – and other countries with CWF, than the rest of the world.

Similarly, he often cherry-picks data to “prove” a sudden increase in disease or deaths in Ireland after the introduction of CWF in the late 1960s. He has recently pulled this trick with Irish data for vascular diseases. It’s a simple (and naive) recipe. He has found data in a report and selected parts of it to fit his message – ignoring everything else and specifically discussion of the trends in the data by the specialists.

So he has produced this graph:

Declan-lie

You can see the point he is trying to drive home – but lets look at all the data in that table Waugh used from the cited “50 years of Heart Disease in Ireland“:

Looking at all the data

Irish-deaths

Perhaps we should consider the death rate – deaths/100,000 to correct for changes in total population

Ireland---heart

Another factor is changes of coding and diagnostic criteria used for reporting causes of death and details of vascular disease. The report lists a number of changes occurring in the periods 1958-1967, 1968 – 1978 and 1979 – 1999. It also refers to “the lack of specification of diagnoses during the early years covered by this review.” What this means is that some of the changes, especially the apparently sudden changes, may represent nothing more than changes in diagnostic criteria.

Waugh also simplifies the date that fluoridation commenced in Ireland – claiming 1965. The Irish Forum on fluoridation 2002 reported that CWF started in Dublin in 1974, in Cork in 1965 and over the next 5 years in other areas. This suggests another reason to be careful about interpreting sudden changes in data during 1964 – 1970 as due solely to introduction of CWF.

So things are nowhere as simple as Declan Waugh presents it. Of course they never are. The intelligent reader should read the report and not just rely on cherry-picked data and motivated rationalisation resulting from confirmation bias.

A more rational understanding

The report itself  states that Ireland does have a high mortality rate from cardiovascular disease, particularly compared with Europe. The report says:

“One way or another, the data from the 1950’s and 1960’s point to an ongoing epidemic of heart disease in Ireland for at least half a century. This is evidenced by the fact that in 1950, 31% of all deaths were due to vascular diseases.”

Although:

“The low rates of IHD mortality in the 1950’s and 1960’s is almost certainly a reflection of difficulties encountered in accurately diagnosing cardiac conditions at that time. Thus, many IHD deaths may have been coded to the ‘catch all’ category of ‘Other Myocardial Degeneration’ (ICD 422).”

And the decline in death rates since 1985:

“is the consequence of a multifaceted approach to the problem. Specifically it has been suggested that a proportion of the decline, ranging from 25% to 50%, may be due to primary prevention. A proportion of the decline (40% to 50%) may be related to early intervention and treatment of acute cardiovascular events and a proportion is due to secondary prevention among those with established disease (13-16). Data from the WHO MONICA project in 37 countries further suggested that a proportion of the decline in mortality may be related to economic
success (17).”

Another complicating factor has been “changes in the demographic structure of the population.”

So there you go. One can understand these fluctuations in death rate from cardiovascular disease using the normal factors related to changes in diagnosis, diet and health care, and treatment of cardiovascular events. No need to drag in the “universal demon” of fluoride.

Only one example

This is only one example of the sort of tricks Declan Waugh uses in his reports. He pretends to be a “scientist and fluoride researcher” and this, together with extensive scientific citation and dogmatic claims does fool some people. It fooled the Hamilton City Council in their consideration of CWF last year (see When politicians and bureaucrats decide the science).

He is dishonest – but his tactics are difficult to counter. It takes far less effort to present a naively “sciency” looking lie than to reasearch and communicate the facts. As they say, a lie can get half way around the world before truth can get its boots on.

IMG_0650

And that’s what Declan Waugh relies on. That is why he does not allow peer review of any of his reports. That is why he will not engage in an exchange with critics of his reports.

He knows he has critics. Just the other day on his Facebook page he moaned:

“There are some sick people out there in twitter land who joke about the graphics I produce. . . .they will present any possible excuse to try and discredit the association while point blankly refusing to even consider the biological mechanisms by which fluoride contributes to disease.”

Well, Declan, it is part of the scientific ethos to engage with your critics. Respond to their criticisms – show where and why you think they are wrong – or acknowledge your mistakes. You refuse to do that because you “point blankly” refuse to “even consider” the discussion and evidence of the experts who write the papers and reports you cherry pick from.

Similar articles

 

 

 

 

Fluoridation – a racist conspiracy?

Political activists campaigning on health issues often resort to scaremongering. This can be dangerous – especially when their stories have no real basis but rely on selective and distorted information.

Paul Connett’s Fluoride Action Network (FAN) often resorts to this sort of scaremongering. Now they are launching a series of stories dressed up as “exposès.”  The first is aimed at African-Americans and claims the US  “federal government has known for five decades that blacks were even more susceptible than whites to serious damage from fluoride added to water supplies, but it urged local governments to fluoridate the population anyway.”

Typically, Connett’s Crowd is promoting this campaign through FAN press releases which get picked up by “natural” health magazines and web pages. The articles are then heavily promoted throughout social media by activists – sometimes even making their way into the mass media (see Gov’t Failed to Warn about Fluoride’s Disproportionate Harm to Black Community and Feds: Blacks Suffer Most From Fluoride, Fluoridate Anyway).

The press release is summed up in the first paragraph:

“Government health authorities knew over 50 years ago that black Americans suffered greater harm from fluoridation, yet failed to warn the black community about their disproportionate risk, according to documents obtained by the Fluoride Action Network (FAN).”

So the evidence, the “document,” on which they hang this story, is a memo.

memo

Now, that is very pathetic to hang a campaign on, isn’t it. And the campaigners are also relying on the false idea that anything obtained via freedom of information inquiry must have been “secret” or “hidden” from the public eyes. (Incidentally they do the same with the Certificates of Analysis for fluoridation chemicals used by water treatment plants – even appearing to think that listing an analytical result for contaminants, however small, is somehow “proof” that the contamination is a problem – see Fluoridation: emotionally misrepresenting contamination and Natural News comes out with a load of heavy metal rubbish on fluoride).

Differences in dental fluorosis prevalence not hidden

But the scientific information comparing prevalence of dental fluorosis among US whites and African-Americans is neither new or hidden. In fact, FAN’s press release does refer to a little of this published data, but again typically they distort it.

In particular it uses data from studies where fluoride in drinking water were often higher than the optimum levels for community water fluoridation (CWF). Consequently the studies include some people exhibiting the medium and severe forms of dental fluorosis never observed with CWF.

One of the papers cited is Martinez-Mier, E. A., & Soto-Rojas, A. E. (2010). Differences in exposure and biological markers of fluoride among White and African American children. Journal of Public Health Dentistry, 70(3), 234–40. It did report higher amounts of dental fluorosis in the African-American children they studied. But it also found that the African-American children in the study reported using larger amounts of toothpaste and had higher urine fluoride concentrations than white children. It concluded:

“Differences in fluoride exposure between two racial groups were observed. These differences are complex and need to be better defined.”

This does not warrant claims of  African-Americans being more susceptible than whites. Nor is the information “explosive” as the FAN press release claims.

Another study cited was Williams, J. E., & Zwemer, J. D. (1990). Community Water Fluoride Levels, Preschool Dietary Patterns, and the Occurrence of Fluoride Enamel Opacities. Journal of Public Health Dentistry, 50(4), 276–281. But the study actually doesn’t back up the FAN claims as these authors found:

“higher TSIF scores [an index of dental fluorosis prevalence] were associated with city children significantly more than with county children. There was no association of TSIF scores either in the city children or the county children with respect to gender, race, preschool dietary patterns, or dentifrice ingestion.”

Another cited paper is Butler, W. J., Segreto, V., & Collins, E. (1985). Prevalence of dental mottling in school-aged lifetime residents of 16 Texas communities.  American Journal of Public Health, 75(12), 1408–1412. These authors found “children who were White or had a Spanish surname had about the same prevalence of mottling while Blacks had a higher prevalence.” This appears to support the FAN claim but air conditioning in the children’s home and total dissolved solids and zinc in the drinking water also influenced prevalence of mottling. Significant mottling only occurred where  drinking water fluoride concentrations were over 2 ppm making the conclusions irrelevant to CWF where concentrations are usually in the range 0.7 to 1 ppm

Finally, they cite Beltrán-Aguilar, E. D. ., & Gooch, B. F. ; (n.d.). Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis — United States, 1988–1994 and 1999–2002. Yes, this study did show African American had a slightly higher prevalence of very mild and mild dental fluorosis, as the figure below shows.

s403a1f19

They did not advance an explanation for this but note that “different hypotheses have been proposed, including biologic susceptibility or greater fluoride intake.” One could also suggest differences in residential location – especially as some of the people in the study had moderate or severe dental fluorosis indicating they were likely consuming drinking water with a fluoride content above the level recommended for CWF.

But we could make the same comparisons with tooth decay data from this study (see figure below):

s403a1f1

Perhaps we should be jumping up and down about the increased racial sensitivity of African-Americans and Mexican Americans to the disease of tooth decay and claim that this information has been suppressed or nothing done about the problem.

Or perhaps, as is most likely happening, authorities are just getting on with the job of working out how to deal with health inequalities in different ethnic groups.

 Conclusion

This campaign is just another of the scaremongering attempts of Connett’s crowd. Appealing to conspiracy theorists it uses a memo obtained as part of a freedom of information inquiry to imply a cover-up. The campaing cites studies which do show real differences but do not show they result from differences in sensitivity. And they are not large enough to justify the extreme language of the press release and reports.

Of course there may be similarities in the dental health conditions of disadvantaged ethnic groups in the US, and in New Zealand and Australia, but the way some anti-fluoride propagandists have used these press releases to “prove” that NZ Maori and Australian Aborigine are adversely effected by CWF borders on naive racism.

Similar articles

Fluoride debate: Second response to Rita Barnett-Rose – Daniel Ryan

Here is Daniel Ryan’s second response to Rita Barnett-Rose’s defence of here unpublished paper Compulsory water fluoridation: Justifiable public health benefit or human experimental research without informed consent“. That defence was posted yesterday at Fluoride debate: Response to Daniel Ryan’s critique – Rita Bartlett-Rose.

Daniel’s second response is available to download as a pdf.


Compulsory water fluoridation: second response to Rita Barnett-Rose

Dan Ryan 2

Daniel Ryan from the Making Sense of Fluoride group

Written by Daniel Ryan

5/10/2014

Introduction

This is my second response to Associate Professor Rita Barnett-Rose to her paper “Compulsory water fluoridation: justifiable public health benefit or human experimental research without informed consent”. It is a response to her document “RE: CWF Working Paper Article” (hereafter referred to as “Rita’s reply.”). I wish to thank Rita for acknowledging in that papers should be referenced accurately by using citations to the original sources rather than simply referencing activist sources. I am also pleased she is getting experts to review the science in her paper and am interested to know who the independent reviewers are.
In this this response I have collected a number of comments to consider under separate headings.

Objectively looking at the science.

Rita’s reply:

“…you object to my failure to include contrary studies that reaffirm the (English speaking countries’) public health agencies’/dental lobby positions on the safety and benefits of compulsory water fluoridation.”

“…with respect to your complaint or desire that I cite to contrary (i.e., pro-fluoridation) studies in addition to (or in lieu of) the published studies that I cite that tend to weigh against fluoridation”

“It is not meant to be an exhaustive examination of all studies on fluoridation and is specifically and accurately identified for what it is”

“…you are just as guilty of ‘cherry picking’ your sources and your studies as you suggest I am.”

“I am not interested in a battle of the studies debate”

“These reasons would remain even if compulsory water fluoridation were proven to be entirely safe, which it most definitely has not, despite the presumed “majority” view in the English speaking countries”

My reply:
Rita implies I only use ‘pro-fluoridation’ or ‘English speaking countries’ papers. This is incorrect – I cite papers which provide the best weight in regards to evidence. Science doesn’t take sides (good papers are neither “anti-fluoridation” nor “pro-fluoridation”, they present data and reasoning) and these are international. To clarify, my issue is not that Barnett-Rose (2014) was not using ‘pro-fluoridation’ papers, it was the quality of the studies themselves. Reviewers of the science should attempt to understand and evaluate the quality of the research.

I also look at the quality of journal. And I try to cite papers which are in high quality journals more as those journals attract the best scientific papers. Journals use a metric called “impact factor” that basically states how many times an average paper is cited by other papers. It is an independent, objective method to judge the quality of published research.
The hierarchy of scientific evidence in the literature is also important I illustrate this in the image below.

cm-evidence-listed-medicines-05-01
Secondary reviews published in peer-reviewed, high-impact journals and high quality randomised controlled trials with definitive results should be the preferred sources. For consideration of human health effects I consider that animal studies would be placed above “expert opinion” in this hierarchy.
Overall one needs to approach the literature intelligently and critically – considering the evidence provided in the individual papers and also considering other published material.

Instead I saw that Barnett-Rose (2014) did not evaluate the evidence well, only selecting evidence of harm in order to persuade the audience to accept her position. There is no reason to use low validity papers when there is plenty of high quality papers but unfortunately this happens when trying to “price” a preconceived idea.

An example of this is Barnett-Rose (2014) used an opinion article from the Scientific American many times as her source. This is not a scientific paper, it is not peer reviewed or in a research journal; furthermore the writer is not a scientist and definitely not an expert on the subject. This type of evidence would come below “expert opinion” on the image above. I hope such problems would be given as feedback from the independent reviewers.
Rita accuses me of cherry picking but fails to back this up. I do try to use only the best sources of evidence – usually systematic reviews. A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question.

The evidence shows

Rita’s reply:

“However, what I do believe is that the burden of proving safety and effectiveness lies with the pro-fluoridation side”

“It also appears to me that the pro-fluoridation side is playing “whack a mole” with the studies weighing against CWF – often trying to hammer down/marginalize the opposition each time a negative study pops up, rather than trying to consider the evidence objectively.”

“However, to me, if even one strong study exists, then the entire compulsory practice must be re-evaluated.”

My Reply:
The scientific consensus is that fluoridation works, it is safe and it is cost effective. We have evolved with fluoride and had it adjusted in our water for over 60 years in some countries. Developed countries where natural fluoride levels are low but choose not to use community water fluoridation (CWF) generally use other methods such as milk and salt fluoridation, which again are both safe and effective, or have very effective public health and dental systems. Over 5,500 papers have been systematically reviewed and no consistent association between fluoridation and illness has been found that has been confirmed through later research.

Using the latest evidence: Public Health England just released their water fluoridation review this month – Water fluoridation Health monitoring report for England 2014 and it concluded:

“This monitoring report provides evidence of lower dental caries rates in children living in fluoridated compared to non-fluoridated areas. Similarly, infant dental admission rates were substantially lower. There was no evidence of higher rates of the non-dental health indicators studied in fluoridated areas compared to non-fluoridated areas. Although the lower rates of kidney stones and bladder cancer found in fluoridated areas are of interest, the population-based, observational design of this report does not allow conclusions to be drawn regarding any causative or protective role of fluoride; similarly, the absence of any associations does not provide definitive evidence for a lack of a relationship.”

Last month a reviewHealth effects of water fluoridation: A review of the scientific evidence written on behalf of the Royal Society of New Zealand and the Office of the NZ Prime Minister’s Chief Science Advisor concluded:

“Councils with established CWF schemes in New Zealand can be confident that their continuation does not pose risks to public health, and promotes improved oral health in their communities, reducing health inequalities and saving on lifetime dental care costs for their citizens. Councils where CWF is not currently undertaken can confidently consider this as an appropriate public health measure, particularly those where the prevalence and severity of dental caries is high. A forthcoming study from the Ministry of Health is expected to provide further advice on how large a community needs to be before CWF is cost-effective (current indications point to all communities of 1000+ people). It is recommended that a review such as this one is repeated or updated every 10 years – or earlier if a large well-designed study is published that appears likely to have shifted the balance of health benefit vs health risk.”

Looking at the many other systematic reviews you will find a similar pattern. CWF is shown to be safe and effective. So the “burden of proof” really is on those claiming evidence of harm. They need to produce well supported and peer-reviewed studies which back up their claims.

If there is a strong evidence for health risks of fluoridation then I totally agree with Rita that it needs to be re-evaluated. Every year many studies are written on fluoridation and continued monitoring of the scientific findings occurs in many countries with the precautionary principle of being alert to any possible negative effects.

Health organisations

Rita’s reply:

“Please also note that any and all of your cites to the ADA lobby, or to the CDC (which, though its oral health division, works hand in hand with the ADA promoting fluoridation and thus has a serious conflict of interest/credibility problem) are unpersuasive to me – as they should be to anyone conducting even a minimum level of research into the history of and politics behind fluoridation (some of which is chronicled in my article, including the story of the EPA’s NTEU battle).”

“it does not take long to discover how politically motivated many “public health agencies” and “professional dental associations” are — or how willing they are to obscure, minimize, or bury contrary evidence or to marginalize the anti-fluoridation messengers, regardless of the evidence or the credentials of those messengers (e.g., Waldbott, Taylor, Marcus, Mullenix, Bassin, Hirzy).”

My reply:
I think Rita is placing her own bias on these judgments. One could equally say:

“It does not take long to discover how politically motivated Dr Paul Connett and FAN are — or how willing they are to obscure, misinform, or bury contrary evidence or to marginalise the pro-science messengers, regardless of the evidence or the credentials of those messengers.”

If Rita has a specific problem with the CDC or the ADA, I can use some of the many other hundreds of health organisations around the world. They all have similar conclusions about fluoridation. As I said in my first response, there is not one reputable health organisation that is against fluoridation. We already have Dr Paul Connett suggesting a massive conspiracy, I hope you do not agree with his accusations as this is generally the last resort for people who cannot find reasonable faults in the evidence but still refuse to believe it.

NRC Report

Rita’s reply:

“However, I believe that its review of fluoride toxicology is highly relevant to exposures from fluoridated water (and its exposure data itself suggests that some people drinking fluoridated water can, indeed, receive doses that can cause adverse health effects, including severe dental fluorosis and bone fractures).”

“In addition, in a number of health risk areas, the NRC panel concluded that there was not enough data, and/or that more research needed to be conducted, before definitive statements could be made with respect to other potential adverse health effects due to excess exposure to fluoride.”

My reply:
I will not repeat what I said in my earlier reply. The review itself said that it was not relevant to exposures to concentrations used for fluoridated water and to say it is “highly relevant” is spreading misinformation. The NRC report furthered shows the safety of fluoridation. As for the “more research needed”, that is always the case with science. That is why responsible public health agencies continue to monitor research findings.

Ethics

Rita’s reply:

“I would genuinely be interested in knowing why you feel so strongly that imposing this practice on everyone is ethically justifiable.”

“Thus, I am very curious as to why there appears to be such an aggressive campaign on the pro fluoridation side to impose this practice on the world – and why anyone believes that personal liberties and rights to bodily integrity should be sacrificed for a public health practice addressing a non-contagious disease.”

“I would also be interested in understanding where you personally believe compulsory public health practices should begin and end (e.g., do you believe governments should mandate compulsory flu shots? What about the HPV vaccine that the Governor of Texas tried to mandate for girls? Where should the personal right to bodily integrity begin and end, in your opinion? And how comfortable are you with public health officials mandating what is good for you?…)”

My reply:
I don’t see how you conclude that I “feel so strongly that imposing this practice on everyone”. I, myself, could say I am strongly against misinformation. The MSoF society is here to help explain what the actual scientific evidence shows to the public, not to advocate for CWF at any cost. It is up to the communities if they want to use CWF and we, the MSoF Society, support their democratic right to decide.

But regarding ethical aspects, you might be interested in what the Nuffield Council on Bioethics decided. It:

  • Rejected the prohibition of water fluoridation based on the argument of mass medication and restricting personal rights.
  • Affirmed that water fluoridation should be accepted based on the quantified risks and benefits, the potential alternatives, and, where there are harms, the role of consent.

They also used a ‘stewardship mode’ to analyse the acceptable degree of state intervention to improve population health, concluding that water fluoridation can be justified based on its contribution to the goals of stewardship: the reduction of health inequalities, the reduction of ill health, and the concern for children, who represent a vulnerable group.

The New Zealand High Court this year ruled that fluoridation of the water supply:

  • is not a medical treatment,
  • does not violate the right to refuse medicine,
  • is not in breach of the Bill of Rights, And that
  • the Council was thoughtful and responsible in making their decision to begin fluoridation, and had no obligation to consider “controversial factual issues” (anti-fluoride propaganda).

You could say there is an aggressive campaign on both sides, but people are pushing for fluoridation simply because it works – reducing up to 40% of caries over a whole population.

Dental caries is a serious chronic disease, it makes no difference if it is contagious or not. The Royal Society Review pointed out that:

“…tooth decay (dental caries) remains the single most common chronic disease among New Zealanders of all ages, with consequences including pain, infection, impaired chewing ability, tooth loss, compromised appearance, and absence from work or school. Tooth decay is an irreversible disease; if untreated it is cumulative through the lifespan, such that individuals who are adversely affected early in life tend to have pervasive decay by adulthood, and are likely to suffer extensive tooth loss later in life. Prevention of tooth decay is essential from very early childhood through to old age”.

The Royal Society Review also suggested that removing fluoridation would have direct and indirect costs to society.

“Tooth decay is responsible for significant health loss (lost years of healthy life) in New Zealand. The ‘burden’ of the disease – its ‘cost’ in terms of lost years of healthy life – is equivalent to 3/4 that of prostate cancer, and 2/5 that of breast cancer in New Zealand. Tooth decay thus has substantial direct and indirect costs to society.”

I am all for protecting the vulnerable. If individuals do not consent, they can simply choose not to partake of the community water supply (bottled water, filters, rain water, etc.). I feel this is starting to head slightly off-topic but to answer your question, if the vaccine given out is safe and effective for the general public then I have no problems with compulsory shots for children. While choice is nice thing to have, you cannot always get it, especially if it is going to lower the quality of life in children.

The New Zealand High Court summarised some ethical aspects in the decision I referred to above:

“Provided it does not have consequences for public health a person has the right to make even the poorest decisions in respect of their own health. But where the state, either directly or through local government, employs public health interventions, the right is not engaged. Were it otherwise, the individual’s right to refuse would become the individual’s right to decide outcomes for others. It would give any person a right of veto over public health measures which it is not only the right but often the responsibility of local authorities to deliver.”

The World Health Organization

Rita’s reply:

“Data published by the WHO suggests that the decline in dental caries is similar in both fluoridated and unfluoridated countries, and I have heard of no massive outbreak of a worldwide dental carie epidemic that has been attributed to a lack of fluoridated water (rather than to poverty, poor nutrition, or a lack of access to proper dental care).”

My reply:
Petersen & Lennon (2004), a WHO funded study showed dental caries remain a major public health concern, affecting 60–90% of schoolchildren and the vast majority of adults. While fluoride is not a silver bullet, it is just part of the problem, it should not be ignored when it can clearly help very effectively. Their study goes into a number of suggestions for alleviating tooth decay, one being fluoridation.

“Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages particularly for subgroups at high risk of caries. Alternatively, fluoridated salt, which retains consumer choice, can also be recommended. WHO is currently in the process of developing guidelines for milk fluoridation programs, based on experiences from community trials carried out in both developed and developing countries.”

As for the similar DMFT decline between fluoridated and unfluoridated countries Rita claims this needs to be considered critically. Fluoride occurs naturally everywhere and it is very hard to compare one country to others because of the many other contributing factors such as; history, culture, ethnic differences, as well as differences in health services, dental practice and assessments. The graphical evidence FAN promotes on their website and elsewhere they do not account for naturally occurring fluoride or other programs (fluoride vanish, mouth rinse programs, etc.) and different history and social practices. Their graphs also use only 2 data points for each country. There is no consideration of also changing fluoridation amounts over time and their graph is very confusing. It does not enable proper consideration of different DMFT declines in different countries. The stats show Denmark having the lowest DMFT and FAN marked them as not fluoridated, but they actually have high levels of naturally occurring fluoride.

Irish-2
If you look at the WHO data in more detail (graph left does this for the Irish Republic using the same WHO data) you will find that fluoridated areas show faster declines in DMFT than unfluoridated areas.

Making Sense of Fluoride

Rita’s reply:

“…you complain about FAN not being a legitimate source of credible scientific information, but your organization is also a political advocacy (pro-fluoridation) group”

“I urge you to conduct such a battle with a more appropriate sparring partner, such as FAN-NZ.”

My reply:
Like yourself, I am not a scientist – I am a software developer; my responses get checked by scientists but I would always look into the evidence in scientific studies. I avoid political or activist organisations (legitimate or not). The Making Sense of Fluoride society is not a pro-fluoridation group, we are a pro-science group. We will go with what the scientific consensus says and will spread warnings, if for example: some time in the future, CWF was really found to be harmful.

The objectives of the MSoF incorporated society are:

a) To foster awareness and dispel misinformation regarding fluoride with a focus on CWF.
b) Use the scientific method as the foundational platform upon which this awareness is promoted.

FANNZ, now known as Fluoride Free NZ (and a close partner of FAN), will always be anti-fluoride no matter what the evidence shows. For that reason it is usually not fruitful debating them. Their incorporated society main purposes make clear their opposition to CWF irrespective of the science:

a) To bring about the permanent end to public water fluoridation (“fluoridation”) in New Zealand.
b) To provide resources, both personal and material, to others opposing fluoridation in New Zealand.
c) To provide a central contact point for those opposing fluoridation in New Zealand.

Apology

Rita’s reply:

“This statement about “mounting scientific evidence” at the start of my paper (near fn. 2) actually references an entire section of my article – (“See discussion infra Sec. II-B”) — and not an opinion piece by Colquhoun, which is only referenced – appropriately – at footnote 65 (referring to “formerly avid fluoride proponents” who have changed their minds). I have no desire to engage with insincere zealots, so I hope that you simply made a mistake there.”

My reply:
I apologise for my mistaking you and any offense it may have caused you. It was clearly a simple mistake that anyone could have made and I had no intention to twist your words.

Wrapping up

Rita’s reply:

“After this exchange, however, I am only interested in a private discussion with you, which is something you may not be interested in as it may not advance your organization’s agenda”
“However, your Facebook posting has generated some contact to me by a few rude (and seemingly unbalanced) pro fluoridation folks”

My reply:
MSoF is always happy to have private discussions if you are willing to listen to our feedback. A lot of our work is outside of what the public sees but we always up for public exchanges to share to our followers.

You will find that your paper got sent all over Facebook and the media; because it was publicised in a press release from FAN. That is how I found out about it.
It is a pity you were subjected to insults because of that publicity. That said I was also hit with insults on Fluoride Free NZ Facebook pages because of my response to you. These insults are common and something I have gotten used too; in either case it is a shame that people feel it best to engage in debate in disrespectful ways. Fluoridation is an emotional topic for some – personally I do my best to stick with the science and keep my emotions out.

Thank you Rita for making time in reading our feedback and responding to us.

Similar articles