Tag Archives: community water fluoridation

Fluoridation not associated with ADHD – a myth put to rest

Fluoridated water is NOT associated with ADHD: Photo by mtl_moe

The myth of community water fluoridation causing attention deficit hyperactivity disorder (ADHD) is just not supported by the data. I show this in a new paper accepted for publication in the British Dental Journal. This should remove any validity for the claims about ADHD by anti-fluoride campaigners.

Mind you, I do not expect them to stop making those claims.

The citation for this new paper is (will be):

Perrott, K. W. (2017). Fluoridation and attention hyperactivity disorder – a critique of Malin and Till. British Dental Journal. In press.

The Background

The fluoridation causes ADHD myth was initially started by the publication of Malin & Till’s paper in 2015:

Malin, A. J., & Till, C. (2015). Exposure to fluoridated water and attention deficit hyperactivity disorder prevalence among children and adolescents in the United States: an ecological association. Environmental Health, 14.

It was quickly taken up and promoted by anti-fluoride campaigners – becoming one of their most cited papers when claiming harmful psychological effects from fluoridation. Part of the reason for its popularity is that it is the only published paper reporting an association between community water fluoridation (CWF) incidence and the prevalence of a psychological deficit. All other reports on this used by anti-fluoride campaigners are based on studies made in high fluoride regions like China where fluorosis is endemic. Those studies are just not relevant to CWF.

While many critics rejected Malin & Till’s conclusions on the simple basis that correlation does not mean causation I decided to look a bit deeper and test their statistical analyses. This was easy because they used published US data for each US state and such data is available for many factors.

I posted my original findings in the article ADHD linked to elevation not fluoridation. This showed that a number of factors were independently associated with ADHD prevalence (eg., home ownership, poverty, educational attainment, personal income, and % of the population older than 65) and these associations were just as significant statistically as the associaiton reported by Malin & Till.

However, multiple regression of possible modifying factors showed no statistically significant of ADHD prevalence with CWF incidence when mean state elevation was includedd.

The importance of elevation was confirmed by Huber et al. (2015):

Huber, R. S., Kim, T.-S., Kim, N., Kuykendall, M. D., Sherwood, S. N., Renshaw, P. F., & Kondo, D. G. (2015). Association Between Altitude and Regional Variation of ADHD in Youth. Journal of Attention Disorders.

Huber et al., (2015) did not include CWF incidence in their analyses. I have done this with the new paper in the British Dental Journal.

Publication problems

I firmly believe that scientific journals, like  Environmental Health which published the Malin & Till paper, have an ethical obligation to accept critiques of papers they publish (subject to peer review of course). Similarly, it is appropriate that any critique of a published paper is made in the journal where it was originally published. Implicit in this arrangement, of course, is that the authors of the original paper get the chance to respond to any critique and that the response be published by the original journal.

Unfortunately, this was not possible for this paper because the Chief Editor of  Environmental Health,  Prof Philippe Grandjeansimply refused to allow this critique to be considered for publication. No question of any peer reviuew. In his rejection he wrote:

“Although our journal does not currently have a time limit for submission of comments on articles published in EH, we are concerned that your response appears a very long time after the publication of the article that you criticize. During that period, new evidence has been published, and you cite some of it. There are additional studies that would also have to be taken into regard in a comprehensive comment, as would usually be the case after two years. In addition, the way the letter is written makes us believe that the letter is part of a controversy, and our journal is certainly not the appropriate forum for a dispute on fluoride policies.”

My response pointed out the reasons for the time gap (problems related to the journals large publication fee), that no other critique of the Malin & Till paper had yet been published and that any perceived polemics in the draft should normally be attended to by reviewers. This was ignored by Grandjean.

While Grandjean’s rejection astounded me – something I thought editors would consider unethical – it was perhaps understandable. Grandjean is directly involved as an author of several papers that activists use to criticise community water fluoridation. Examples are:

Grandjean is part of the research group that has published data on IQ deficits in areas of endemic fluorosis – studies central to the anti-fluoride activist claims that CWF damages IQ.  He has also often appears in news reports supporting research findings that are apparently critical of CWF so has an anti-fluoridation public standing.

In my posts Poor peer-review – a case study and Poor peer review – and its consequences I showed how the peer review of the original Malin & Till paper was one-sided and inadequate. I also provided a diagram (see below) showing the relationship of Grandjean as Chief Editor of the Journal, and the reviewers as proponents of chemical toxicity mechanisms of IQ deficits.

So, I guess a lesson learned. But the unethical nature of Grandjean’s response did surprise me.

I then submitted to paper to the British Dental Journal. It was peer-reviewed, revised and here we are.

The guts of the paper

This basically repeated the contents of my article ADHD linked to elevation not fluoridation. However, I tried to use Malin &Till’s paper as an example of problems in ecological or correlation studies. In particular the inadequate consideration of possible risk-modifying factors. Malin & Till clearly had a bias against CWF which they confirmed by limiting the choice of covariates that might show them wrong. I agree that a geographic factor like altitude may not have been obvious to them but their discussion showed a bias towards chemical toxicity mechanisms – even though other social factors are often considered to be implicated in ADHD prevalence.

Unfortunately, Malin & Till’s paper is not an isolated example. Another obvious example of confirmation bias is that of Peckham et al., (2015). They reported an association of hypothyroidism with fluoridation but did not include the most obvious example of iodine deficiency as a risk-modifying factor in their statistical analysis

Of course, anti-fluoride campaigners latched on to the papers of Peckham et al., (2015) and Malin & Till (2015) to “prove” fluoridation was harmful. I guess such biased use of the scientific literature simply to be expected from political activists.

However,  I also believe the scientific literature contains many other examples where inadequate statistical analyses in ecological studies have been used to argue for associations which may not be real. Such papers are easily adopted by activists who are arguing for or against specific social policies or social attitudes. For example, online articles about religion will sometimes refer to published correlations of religosity with IQ, educational level or scoio-economic status. Commenters simply select the studies which confirm the bias they are arguing for.

These sort of ecological or corellations studies can be useful for developing hypotheses for future study but it is wrong to use them to support an argument and worse as “proof” of an argument.

Take home message

  1. There is no statistically significant association of CWF with ADHD prevalence. Malin & Till’s study was flawed by lack of consideration of other possible risk-modifying factors;
  2. Be very wary of ecological or correlation studies.Correlation is not evidence for causation and many of these sudues iognore other possible important risk-modifying factors.

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Local anti-fluoride activists tell porkies yet again

FFNZ confuses lack of low fluoride studies on rats with human studies

Well, I suppose that’s not news. A bit surprising, though, because they are claiming the absence of research on fluoridation and IQ – which sort of conflicts with the previous attempts to actually condemn and misrepresent the actual research on fluoridation and IQ.

Fluoride Free NZ’s (FFNZ) face book page is claiming:

Would you be interested to know that no studies have been conducted on fluoridated water at 0.7ppm to determine whether there is IQ reduction? The National Toxicology Program are currently completing research to fill this gap. You would have thought that they would have done this in the 1950s before starting the fluoridation program wouldn’t you?

There have actually been three recent studies from three different countries which have specifically investigated the claim of an effect of fluoridation on IQ – and, unsurprisingly, all threes studies showed there was no effect.

Here are those studies:

New Zealand

Broadbent, J. M., Thomson, W. M., Ramrakha, S., Moffitt, T. E., Zeng, J., Foster Page, L. A., & Poulton, R. (2014). Community Water Fluoridation and Intelligence: Prospective Study in New Zealand. American Journal of Public Health, 105(1), 72–76.

In fact, anti-fluoride activists in the US, as well as New Zealand, have campaigned against this study. Their major criticism is that the study also included the effect of fluoride tablet use. They argue that this makes the unfluoridated control group useless because many participants will have consumed fluoride tablets. However, they ignore the fact that the statistical analysis corrected for this but still found no statistically significant difference in IQ of children and adults from fluoridated and unfluoridated areas.

Sweden

Other critics of the Broadbent et al. (2014) study have raised the issue of experimental power because of the numbers of people in the study. This could be a valid issue as it would determine the minimum effect size capable of being detected. Aggeborn & Öhman (2016) made that criticism of Broadbent et al., (2016) and all other fluoride-IQ studies. Their study is reported at:

Aggeborn L, Öhman M. (2016) The Effects of Fluoride in the Drinking Water. 2016.

Aggeborn & Öhman (2016) used much larger sample size than any of the other studies – over 81,000 observations compared with around 1000 or less for the commonly cited studies. It was also made on continually varying fluoride concentrations using the natural fluoride levels in Swedish drinking waters (the concentrations are similar to those in fluoridated communities), rather than the less effective approach of simply comparing two villages or fluoridated and unfluoridated regions. The confidence intervals were much smaller than those of other cited fluoride-IQ studies. This makes their conclusion that there was no effect of fluoride on cognitive measurements much more definitive. Incidentally, their study also indicated no effect of fluoride on the diagnosis of ADHD or muscular and skeleton diseases.

Canada

Another recent fluoridation-IQ study is that of Barbario (2016) made in Canada:

Barberio, AM. (2016). A Canadian Population-based Study of the Relationship between Fluoride Exposure and Indicators of Cognitive and Thyroid Functioning; Implications for Community Water Fluoridation. M. Sc. Thesis; Community Health Sciences, University of Calgary.

This study also had a large sample size – over 2,500 observations. This reported no statistically significant relationship of cognitive deficits to water fluoride.

Incidentally, Barberio (2016) also found there was no evidence of any relationship between fluoride exposure and thyroid functioning. That puts another pet claim of anti-fluoride campaigners to rest.

Animal studies

So much for NZFF’s claim that “no studies have been conducted on fluoridated water at 0.7ppm to determine whether there is IQ reduction.” But, just a minute, they are quoting the National Toxicology Program (NTP):

“No studies evaluated developmental exposure to fluoride at levels as low as 0.7 parts per million, the recommended level for community water fluoridation in the United States. Additional research is needed.”

But they omit the next sentence from the quote:

“NTP is conducting laboratory studies in rodents to fill data gaps identified in the systematic review of the animal studies.”

The NTP is discussing the research with animals, mainly rats, where effects of fluoride on the cognitive behaviour of the test animals have been reported but the fluoride concentrations are very high. And NTP’s assessment base on the review of the literature found only “a low to moderate level of evidence that the studies support adverse effects on learning and memory in animals exposed to fluoride in the diet or drinking water.” Hence the need for more research.

As part of the NTP’s research, which is currently underway, there are plans to extend studies to low fluoride concentrations more typical of that used in community water fluoridation.

The high concentrations used in animal studies is a major flaw in the anti-fluoride activist use of them to oppose community water fluoridation. For example, Mullinex et al (1995) (very commonly cited by anti-fluoride campaigners) fed test animals drinking water with up to 125 mg/L of fluoride (concentrations near 0.8 mg/L of fluoride are used in community water fluoridation).

While it is unlikely that the NTP research will find any significant effects of fluoride on the cognitive behaviour of rats at the low concentrations used in community water fluoridation the anti-fluoride campaigners have their fingers (and probably toes as well) crossed.

NTP will begin publishing the results of their new research next year (see Fluoride and IQ – another study coming up).

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Fluoridation: Open letter to Democrats for Social Credit

The only New Zealand political party opposing community water fluoridation relies on false information

The only political party in New Zealand campaigning against community water fluoridation is the Democrats for Social Credit. It is a minor party, nor represented in Parliament and of little influence. However, it does have connections with Fluoride Free NZ, the main anti-fluoride activist group, and its members have imposed anti-fluoridation policies on some groups they belong to. Two examples are Grey Power and the Hamilton Residents & Ratepayers Association – both of which presented anti-fluoride submissions to the recent parliamentary health committee hearings.

I wish to promote an open discussion with the Democrats for Social Credit about their anti-fluoridation policy so have sent them this Open Letter. If they are open to a good-faith discussion I am happy to provide space on this blog for an exchange of views on their policy.


David Trantor, Health Spokesperson for Democrats for Social Credit

Dear David Tranter,
Health Spokesman,
Democrats for Social Credit

You wrote an open letter to the Minister of Health critiquing the government’s policy on community water fluoridation (CWF) and posing some questions about dental health programmes, documented evidence relating to CWF and human rights aspects you consider relevant.

Here I take issue with some of your claims – particularly about dental health in Denmark and the scientific evidence supporting CWF. I believe the evidence does not support the anti-fluoridation policy of your party and your party should reconsider that policy.

If you believe my arguments here are mistaken or otherwise wish to defend the current anti-fluoride policy of your party I am open to a good-faith exchange of opinions and offer you the right of reply and the opportunity for a further discussion on this blog.

Natural fluoridation in Denmark

You point to the good dental health in Denmark and assert “they have never fluoridated their water.” This is true – but you ignore the fact that much of the Danish population benefits from natural levels of fluoride in their drinking water.

Unlike New Zealand parts of Denmark have drinking water fluoride concentrations similar to the optimum concentrations recommended for CWF. Map 1 from Kirkeskov et al., (2010) shows the distribution of different drinking water fluoride concentration ranges.  Map 2 shows the population distribution. We can see a significant fraction of the Danish population does have access to drinking water containing fluoride.

Map 1: Distribution of natural drinking water fluoride concentrations in Denmark. The town of Nexo is on the Baltic island of Bornholm – shown in the top left-hand rectangle.

Map 2: Population distribution in Denmark.

These natural levels of drinking water fluoride are beneficial to oral health in Denmark. Here is some data from Kirkeskov et al., (2010) illustrating this. The following graph compares the dental decay (numbers with more than 2 decayed, missing or filled teeth surfaces – dmfs) at various drinking water fluoride concentrations for 5 year-olds born in 1989 and 1999.

As we can see, the extent of decay declines with fluoride concentration.

There is a similar pattern for 15-year-olds born in 1979 and 1989. This figure shows the relative numbers with more than 2 decayed missing or filled teeth surfaces, DMFS, for 15-year-olds.

And the same pattern for 15-year-olds with more than 6 decayed, missing or filled tooth surfaces.

Danish dental health programmes

You refer to a “Nexux” programme and argue that this could be an alternative to CWF in New Zealand.

I think you are referring to the programme run in Nexo – a town on the east coast of the Baltic island of Bornholm, Denmark. It is a successful local dental health programme, but only one of several in Denmark. Nexo was in an area of very low socio-economic status and introduced a dental programme at the end of 1987 aimed at improving the dental health fo children.  Ekstrand & Christiansen, (2005) give this description of the programme:

“Since 1992, the program has been offered to children from the age of 8 months. It is based on three closely interrelated principles applied according to the individual child’s needs: (1) education of parents, children and adolescents in understanding dental caries as a localized disease, (2) intensive training in home-based plaque control and (3) early professional, non-operative intervention, including professional plaque removal, local application of 2% NaF and application of sealants. In the period when the children have erupting permanent first or second molars, the parents and children are instructed in using a tooth brushing technique specially designed for erupting molar teeth.”

As you can see it is a rather intensive programme and is not a Denmark-wide programme. It has been successful in Nexo, where 15-year-olds had DMFS (decayed, missing and filled tooth surfaces) values in 1986 (before introduction of the programme)  slightly higher than the Danish average. The equivalent values of DMFS for Nexo were the third lowest for all municipalities in 1993 and the lowest in 1999 (Ekstrand & Christiansen, 2005).

Elements of the Nexo programme will be used in other parts of Denmark, and in other countries. Especially where school-based programmes exist.

Incidentally, Map 1 indicates the concentration of natural fluoride in the drinking water on the island where Nexo is situated is similar to that recommended for community water fluoridation. Ekstrand et al., (2005) reports that the fluoride concentration in the Nexo drinking water is 0.8 mg/L.

Nexo is a complement to, not a substitute for, CWF

Each country and region adopt health programmes appropriate to their circumstance. In New Zealand, we have programmes which include some aspect of the Nexo programme or similar programmes like the ChildSmile programme in Scotland (see ChildSmile dental health – its pros and cons and ChildSmile – a complement, not an alternative, to fluoridation). For example the use of fluoride varnish treatments, especially in non-fluoridated areas.

New Zealand can learn from the experience of other countries and in practice, we may introduce some aspects of other programmes. But blanket transfer of full programmes is rare.

The important aspect, though, is none of these programmes is considered an alternative to fluoridation. They are considered as complementary to CWF, and not substitutes for CWF.  The Danish Dental Association has supported fluoridation for areas of low natural fluoride concentrations. Similarly, the British Dental Association in Scotland supports both ChildSmile and CWF and has publicly called for communities to move towards introducing water fluoridation.

In fact, we can consider that the programme used in Nexo (where the drinking water contains fluoride at 0.8 mg/L) actually complements the effect of natural community water fluoridation.

“Documented evidence”

You ask the Minister:

“Why do you ignore all the documented evidence against fluoridation instead of applying positive dental health policies such as the Denmark example?”

The “Denmark example” is dealt with above and it is not what you suggest. Similarly, I suggest the “documented evidence” you refer to really doesn’t give the viable argument “against fluoridation” you imply.

Unfortunately, you do not present any of this “documented evidence” for discussion. Perhaps, if you respond positively to my suggestion of a right of reply and an ongoing discussion, you can give this evidence.

“Informed consent”

You refer to the “H&D Commissioner’s Code of Rights” asserting that:

“no-one can be medicated without giving their informed consent” and “people have the right to give – or refuse – their INFORMED consent when fluoridation is applied to public water supplies?”

Well, I am all for people being properly informed and providing consent to the treatments used for their water supply. I see this as a democratic issue and I support democracy.

But you destroy your argument by suggesting fluoridation is a “medication” when it clearly is not – either legally or rationally. The legal argument was surely settled by the High Court decision in 2014 (see Corporate backers of anti-fluoride movement lose in NZ High Court) where Justice Rodney Hansen concluded:

“[80] In my view, fluoridation cannot be relevantly distinguished from the addition of chlorine or any other substance for the purpose of disinfecting drinking water, a process which itself may lead to the addition of contaminants as the water standards themselves assume. Both processes involve adding a chemical compound to the water. Both are undertaken for the prevention of disease. It is not material that one works by adding something to the water while the other achieves its purpose by taking unwanted organisms out.

[81] The addition of iodine to salt, folic acid to bread and the pasteurisation of milk are, in my view, equivalent interventions made to achieve public health benefits by means which could not be achieved nearly as effectively by medicating the populace individually. . . . All are intended to improve the health of the populace. But they do not, in my view, constitute medical treatment for the purpose of s 11″ [the relevant section of the NZBORA].”

Is scientific knowledge  really “one-sided” propaganda

You also weaken your argument by claiming:

“the one-sided propaganda used to support fluoridation is not informing people”

Describing objective scientific research and findings as “one-sided” simply displays your own bias – and willingness to discredit or ignore the science. Again, you do not give specific examples of the science you consider “one-sided propaganda” – hopefully, you will do so if you take up my offer of a right of reply and a continued discussion.

Democratic rights

You assert:

“when fluoridation is forced upon people it is nothing less than mass medication concerning which people have no opportunity to give – or refuse – their consent.”

The common anti-fluoride claim that people are having fluoridated water forced upon them always raises the picture in my mind of a person being held down and water being forced down their throat as in force-feeding.

Of course, that is ridiculous – for a number of reasons.

  • In New Zealand, there has usually been a democratic public consultation of some sort before the introduction of CWF – or even after its introduction. Local bodies have surveyed residents or used referenda. They have also used a consultation procedure relying on submissions from the public.The opportunity “to give – or refuse – their consent” has in most cases been far greater than for most decisions made by our representatives in this democracy of ours. Some voters find it annoying when asked for such consent (preferring their representatives decide) but I firmly believe it important to include the public in controversial decisions – even where the controversy results from scaremongering rather than facts (as it does with CWF).
  • There are alternatives for the minority. This means that democratic decisions made by a community can actually be a win-win situation. The majority get the social policy they want and have voted for. the minority have access to alternatives. In fact, most anti-fluoride activists already use alternatives – they filter their tap water or source a different supply. Some cities already provide “fluoride-free” water sources to help this. Sometimes I think the real motivation of these ideologically driven activists is to deny this social health policy to others rather than any real concern they have for their own access to water.
  • Some activists will acknowledge there is no evidence of any harmful side effects from CWF but invoke a “precautionary principle” to argue against it. They should be mollified by the fact that CWF is one of the most extensively researched topics. In a sense, we must thank the ideologically and commercially motivated anti-fluoride campaigners for this. Their activity is rarely successful in preventing CWF or fooling most of the public. But it does mean that researcher keep an eye on the arguments and are continually checking them out.

Conclusion

David, I believe you are mistaken, or misinformed, about the dental health programmes in Denmark. You ignore completely the availability of effective natural levels of fluoride in much of Denmark’s drinking water and seem unaware of the nature of the Nexo programme or its limited area of operation.

Expert opinion considers programmes like Nexo and the Scottish ChildSmile are effective complements to CWF – not substitutes for, or alternatives to, CWF. I support our health officials considering use of similar programmes in New Zealand but it is misleading for the Democrats for Social Credit to advocate for such programmes simply as a way of preventing or opposing CWF – which is  an effective, beneficial and safe social health measure.

I appreciate you may not accept my arguments or the facts I have presented here. If that is the case I urge you to accept my offer of a right of reply and ongoing good-faith discussion and am happy to help this by making space available on this blog.

I look forward to your response.

References

Ekstrand, K. R., & Christiansen, M. E. C. (2005). Outcomes of a non-operative caries treatment programme for children and adolescents. Caries Research, 39(6), 455–467.

Kirkeskov, L., Kristiansen, E., Bøggild, H., Von Platen-Hallermund, F., Sckerl, H., Carlsen, A., … Poulsen, S. (2010). The association between fluoride in drinking water and dental caries in Danish children. Linking data from health registers, environmental registers and administrative registers. Community Dentistry and Oral Epidemiology, 38(3), 206–212.

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Debunking anti-fluoridationist’s remaining 12 reasons for opposing fluoridation

New Zealand anti-fluoride campaigners have whittled their list of objections to community water fluoridation (CWF) down to 12 reasons. Maybe that’s progress – they used to tout a list of 50 reasons!

Let’s go through that list one by one and see if any stand up. I am responding here to each reason given in the Fluoride Free New Zealand’s (FFNZ) document Top 12 Reasons why Fluoridation Should End.

You can download a printable version of my responses.


1: Fluoride works by a surface reaction with existing teeth but research shows that it has a beneficial systemic effect with developing teeth.

The document asserts that “Fluoride promoters now claim that if there is any benefit from fluoride it is from contact with the surface of the tooth” and cite as their authority a High Court judge (incidentally, from a ruling that went against anti-fluoride campaigners). A High Court Judge is hardly an authority on scientific matters

Yes, the surface or “topical” action at the tooth surface is understood to be the predominant mechanism for existing teeth. The US Center for Disease Control illustrates this in its figure from the document Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States).

But, I pointed out in my article Cherry-picking and misinformation in Stan Litras’s anti-fluoride article, research also suggests fluoride is incorporated into the developing teeth of children and this helps provide protection.

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

2: Too much fluoride causes dental fluorosis but this is not relevant to CWF.

Some children from both fluoridated and non-fluoridated areas do exhibit dental fluorosis. This is thought to be due to excessive consumption of fluoridated toothpaste and one important factor used in determining the optimum concentration of fluoride used in CWF is to prevent the development of dental fluorosis.

Anti-fluoride propagandists usually cite horrific figures for dental fluorosis because they incorporate all forms of dental fluorosis, from the mildest to the most severe, into their figures. For example, they will cite Ministry of Health Oral Health Survey data to claim that New Zealanders have a prevalence of 45% dental fluorosis caused by fluoridation. In fact, the dental fluorosis of concern (the severe and moderate forms) is very rare and the NZ Oral Health survey (from which this data is taken) showed no difference between fluoridated and unfluoridated areas.

3: Fluoride is not a neurotoxin (or neurotoxicant) at concentrations used in CWF.

Sure, animals studies show effects at high concentrations and there are studies of possible negative cognitive effects from areas of endemic fluorosis where drinking water concentrations of fluoride are relatively high. However, studies from areas where CWF is used (Broadbent et al, 2014) or natural levels of fluoride in drinking water are similar (see More nails in the coffin of the anti-fluoridation myths around IQ and hypothyroidism) do not show any negative effect on cognitive ability. In fact, the research suggests that fluoride may actually improve cognitive ability and improve chances of employment and income in adults (see the last link).

The Lancet article cited by FFNZ did not classify fluoride as a “neurotoxin” and the only discussion of fluoride in that article related to the poor quality studies from areas of endemic fluorosis referred to above. Scientific journals publish research findings and reviews – they don’t pass regulations or get into classifications.

4: FFNZ’s reference to dose is simply an attempt to claim evidence from high concentrations studies is relevant to CWF. It isn’t.

All the research indicates that the optimum recommended concentrations used in CWF are high enough to help reduce tooth decay but low enough to have no negative health effects. Only very mild dental fluorosis. which is often judged positively by teenagers and parents, is a possible result of such low concentrations.

The US National Toxicology Review referred to will simply extend previous reviews of animal studies to include human studies. This research programme also plans to include some animal studies using low fluoride concentrations – precisely because most former studies have used high concentrations unrepresentative of CWF.

The fact that new research like this commonly occurs is a good thing as it helps guarantee that social health measures like CWF are safe and they provide confidence to the public that there is continuous monitoring that would pick up any formerly unseen problems.

5: Skeletal and dental fluorosis occurs in parts of the world with high drinking water fluoride concentration but this is not relevant to CWF

The World Health Organisation recommends that drinking water fluoride concentrations should be in the range  0.5 – 1.5 mg/l. High enough to support dental health but low enough to prevent skeletal fluorosis or dental fluorosis of any concern.

Anti-fluoride campaigners commonly refer to the negative health effects in areas of endemic fluorosis (eg., China, India, and Senegal) where drinking water fluoride concentrations are much higher than used for CWF. But those facts are completely irrelevant to the situation in countries like New Zealand. And they are irrelevant to CWF which uses much lower drinking water concentrations.

6: There is no credible evidence to suggest that fluoride is an endocrine disruptor at concentrations used for CWF

A number of animal and human studies have produced conflicting results for endocrine effects of fluoride. These studies suffer from the use of high or unspecified fluoride concentrations. Effects have sometimes been seen for human in areas of endemic fluorosis. Studies have often been confused because of confounding effects due to iodine deficiency (known to cause thyroid problems), calcium and water hardness.

This means that it is easy to cherry-pick individual studies to support claims of harm from fluoride but these are usually for areas of high fluoride concentration or the studies are flawed by the problem of confounding effects.

The authoritative 2014 New Zealand Fluoridation Review (Eason et al. Health effects of water fluoridation: A review of the scientific evidence) considered “alleged effects of CWF on health outcomes  . . . including effects on reproduction, endocrine function, cardiovascular and renal effects, and effects on the immune system. “ It concluded:

“The most reliable and valid evidence to date for all of these effects indicates that fluoride in levels used for CWF does not pose appreciable risks of harm to human health.”

7: Bottle-fed babies do not receive harmful amounts of fluoride.

The FFNZ claim they do is a common anti-fluoride misrepresentation of the health recommendations concerning CWF and bottle-fed babies. These recommendations advise that use of fluoridated water to reconstitute baby formula is not harmful. They simply suggest that parents who are concerned should occasionally use non-fluoridated water for that reconstitution – a peace of mind thing.

For example, the American Dental Association advises:

“Yes, it is safe to use fluoridated water to mix infant formula. If your baby is primarily fed infant formula, using fluoridated water might increase the chance for mild enamel fluorosis, but enamel fluorosis does not affect the health of your child or the health of your child’s teeth. ”

Where parents want to reduce the risk of dental fluorosis they:

“can use powdered or liquid concentrate formula mixed with water that either is fluoride-free or has low concentrations of fluoride.”

Arguments based on low concentrations in human breast milk simply rely on the naturalistic fallacy – the claim that something is good or right because it is natural (or bad or wrong because it is unnatural). There are common concerns about deficient levels of some beneficial elements in human breast milk and recommendations for using supplements. See, for example, Iron and fluoride in human milk.

8: Fluoridation chemicals are not contaminant-laden waste products.

For example, fluorosilicic acid, the most commonly used fluoridation chemical in New Zealand, is a by-product of the fertiliser industry. When used for water treatment it must pass rigorous restrictions on contaminant levels. Certificates of analysis are required.

contaminants-hfa

With these regulations and checks for water treatment chemicals, the concentration of any contaminant introduced into tap water by their use is much lower than the concentration of those contaminants already naturally present in the source water used. See Chemophobic scaremongering: Much ado about absolutely nothing for data based on a typical certificate of analysis for fluorosilicic acid and the natural concentrations of contaminants for the source water used by Hamilton City. The concentration of contaminants introduced into drinking water is well under 1% of the levels already naturally present in the water source (see graph).

9: Fluoridation is not a medicine and it does not violate human basic rights.

That was determined in High Court rulings – cases brought by anti-fluoride campaigners financed by the “natural”/alternative health industry. All appeals so far against those rulings have been rejected.

10:   Community water fluoridation is not suitable or necessary for many countries

A claim that only 5% of the world uses community water fluoridation is not relevant. Consider that just over 10% of the world do not have access to safe clean water so their people have more pressing concerns that water fluoridation. Many countries like China, India, and parts of North Africa use drinking water with fluoride concentrations that are excessive – fluoride removal or searches for alternative sources are their priority.

Even many developed countries or regions do not have reticulation systems which enable cost-effective fluoridation. This may be the case in Christchurch where the use of a number of bores may mean fluoridation of much of the city is not cost-effective.

Many countries already have natural concentrations of fluoride in their drinking water that are near optimum – making any supplementation unnecessary.

A recent review (O’Mullane et al., 2016) summarised the numbers of people around the world with access to beneficial levels of fluoride in their drinking water:

“General estimates for the number of people around the world whose water supplies contain naturally fluoridated water at the optimum level for oral health are around 50 million. This means that, when the numbers of people with artificially (369.2 million) and naturally fluoridated water supplies (50 million) at the optimum level are added together, the total is around 437.2 million.”

11: The effectiveness of community water fluoridation in reducing tooth decay is well established.

This fact is very often misrepresented by anti-fluoride campaigners. For example, in the FFNZ document, a recent New Zealand study is cited to argue that “there is no difference in decay rates between non-Māori children in fluoridated and non-fluoridated areas.” In fact, the authors of that study warned that the data for “non-Māori” children were misleading because it included data for Pacific Island children who have generally poorer dental health than other ethnic groups and are concentrated in fluoridated regions, thus distorting the data for non-Maori. When the data for all ethnic groups are considered separately it clearly shows the beneficial effects of community water fluoridation. This figure shows the non-Māori data corrected by removing the data for Pacific Island children. iut confirms that there is a difference in decay rates between fluoridated and non-fluoridated area.

Comparison of data for “other” (non-Māori/non-Pacifica) children in fluoridated (F) and unfluoridated (UF) areas. 5-year-old New Zealand children. dmft = decayed, missing and filled teeth.

FFNZ claims about the Cochrane Review and data from the District Health Boards and Ministry of Health are also incorrect. While the Cochrane Review did specifically exclude most recent studies because of its selection criteria it still concluded:

“Data suggest that the introduction of water fluoridation resulted in a 35% reduction in decayed, missing or filled baby teeth and a 26% reduction in decayed, missing or filled permanent teeth. It also increased the percentage of children with no decay by 15%. These results indicate that water fluoridation is effective at reducing levels of tooth decay in both children’s baby and permanent teeth.”

12: Community water fluoridation is only one part of successful dental health policies

These included regular fluoride varnishes, regular dental examinations, registering children into dental programmes, education measures such as guided toothbrushing, presenting children with toothpaste and toothbrushes, the involvement of parents in dental health and plaque checking and in dental health programmes generally. Health professionals see all these elements, including water fluoridation, as complementary. There is absolutely no suggestion that community water fluoridation means no other social dental health programme is used. However, in areas where community water fluoridation is not available health professionals will often introduce extra measures, such as wider use of fluoride dental varnishes, to help protect child dental health.

FFNZ misleads when it claims other aspects of a dental health programme can simply be substituted for water fluoridation. All parts of these programmes are complementary, one cannot normally be substituted for another.

Conclusions

So, none of the 12 reasons given by FFNZ for their opposition to CWF stand up to critical scrutiny.

Having whittled their original list down from 50 to only 12 reasons perhaps they should bite the bullet, face the facts, and continue whittling it down to zero.

That would then conform to the scientific information available.

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Premature births a factor in cognitive deficits observed in areas of endemic fluorosis?

premature

Could the increased incidence of premature births explain cognitive deficits observed in areas of endemic fluorosis? Image credit: New Kids-Center.

Anti-fluoridation activists are soon likely to be promoting a new paper reporting a study which found a relationship between maternal (in utero) exposure to fluoride and cognitive development delay in infants. Of course, they will be unlikely to mention the study occurred in an area of endemic fluorosis where drinking water fluoride concentrations are much higher than used in community water fluoridation (CWF). They are also unlikely to mention the possible role of premature births in cognitive development delay observed in the study.

The paper is:

Valdez Jiménez, L., López Guzmán, O. D., Cervantes Flores, M., Costilla-Salazar, R., Calderón Hernández, J., Alcaraz Contreras, Y., & Rocha-Amador, D. O. (2017). In utero exposure to fluoride and cognitive development delay in infants . Neurotoxicology

Valdez Jiménez et al., (2017) studied 65 mother-baby pairs in an area of endemic fluorosis in Mexico. The mothers had high levels of fluoride in their urine and this was negatively associated with cognitive functions (Mental Development Index – MDI) in the infants.

The concentration of fluoride in the tap water consumed by the mothers ranged from 0.5 to 12.5 mg/l, with about 90% of water samples containing fluoride above the World Health recommended maximum of 1.5 mg/l.

Fluoride in the mothers’ urine was also high – with the mean concentration for all the mothers of 1.9 mg/l  for the 1st trimester, 2.0 mg/l for the 2nd and 2.7 mg/l for the 3rd trimester. Urinary fluoride concentrations as high as 8.2 mg/l were found. This compares with a mean value of F in urine of 0.65 mg/L) for pregnant women residents in areas with low levels of F in drinking water (0.4 to 0.8 mg/l – similar to that recommended in community water fluoridation).

The MDI test used evaluates psychological processes such as attention, memory, sensory processing, exploration and manipulation, and concept formation. This was negatively associated with maternal urine fluoride concentrations – the association explaining about 24% of the variance.

Room of other influences

This data suggests that other confounding factors which weren’t measured could also contribute to the variation of the MDI results, and if such confounders were included in the statistical analysis the contribution from urinary fluoride may be much less than 24%.

However, I am interested in the data for premature births that were, unfortunately, not included in the statistical analysis. The paper reports “33.8% of children were born premature i.e. between weeks 28-36 and had a birth weight lower than 2.5 kg.” This is high for Mexico – as they say:

“The World Health Organization (WHO) in Mexico reported a rate of 7.3 cases per 100 births; compared with 33.8% of cases per 100 births that we observed in our study. We have 26.5% more cases than expected.”

According to their discussion, other researchers have also reported higher premature births in areas of endemic fluorosis, compared with non-endemic areas.

Is premature birth a mechanism explaining cognitive deficits?

This study differs from many others in that fluoride exposure to the pregnant mother, rather than the grown child, was investigated. While the authors tended to concentrate on possible chemical toxicity effects on the cognitive development of the child in utero it is also possible that indirect effects could operate. For example, premature birth and low birth weights could themselves be a factor in child cognitive development.

In fact, a quick glance a the literature indicates this may be the case. For example, Basten at al., (2015) reported that preterm birth was associated with “decreased intelligence, reading, and, in particular, mathematics attainment in middle childhood, as well as decreased educational qualifications in young adulthood.” It was also associated with decreased wealth at 42 years of age.

The influence of endemic fluorosis on premature births and birth weights may not involve fluoride directly. Health problems abound in endemic areas – as well as the obvious dental and skeletal fluorosis complaints also involve muscles, blood vessels, red blood cells, the gastrointestinal mucosa and other soft tissues. It is easy to see such health problems influencing the prevalence of premature births and birth weights.

Not relevant to CWF

Of course, none of this is relevant to community water fluoridation. Such fluoridated areas do not have the health problems of areas with endemic fluorosis where drinking water concentrations are much higher. But, of course, this does not stop opponents of CWF claiming that similar problems occur at the lower concentrations.

In case anyone attempts to use this suggestion as an argument against CWF I should mention the only study I could find that makes the link between CWF and fluoridation. Often cited by anti-fluoride campaigners it is a poster paper:

Hart et al., (2009). Relationship between municipal water fluoridation and preterm birth in Upstate New York.

Presented at an Annual Meeting of the American Public Health Association the study appears not to have been published in a peer-reviewed journal. While the authors claim to have found a small, but statistically significant, increase in premature births in fluoridated areas this could be due to a number of possible confounding factors.With only a brief abstract to go on it is impossible to critically assess the study  – in fact, I suspect the non-publication is probably an indication of poor quality.

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More nails in the coffin of the anti-fluoridation myths around IQ and hypothyroidism

thyroid_fluoride

Large Canadian study finds no effect of fluoridation on thyroid health

A new Canadian study shows no relationship of cognitive deficits or diagnosis of hypothyroidism with fluoride in drinking water. This work is important because it counters the claims made by anti-fluoride campaigners. While the campaigners cite scientific studies to support their claims, those studies are usually very weak, or irrelevant because they involve areas of endemic fluorosis where drinking water fluoride concentrations are much higher than in situations where community water fluoridation (CWF) is used.

The study is reported in:

Barberio, A. M. (2016). A Canadian Population-based Study of the Relationship between Fluoride Exposure and Indicators of Cognitive and Thyroid Functioning; Implications for Community Water Fluoridation. MSc Thesis, University of Calgary

This new study is important as it has the advantages of using a large representative sample of the Canadian population, with extensive data validation and quality control measures. It also uses individual-level estimates of fluoride exposure on the one hand, and thyroid health and cognitive problems on the other.

Fluoride exposure was measured both by concentration in tap water for selected households and concentration in urine samples from individuals.

Thyroid health

The Canadian study found:

“Fluoride exposure (from urine and tap water) was not associated with impaired thyroid functioning, as measured by self-reported diagnosis of a thyroid condition or abnormal TSH level.”

This contradicts the conclusions from the population-level study of Peckham et al., (2015) which reported that fluoridation was correlated with the prevalence of hypothyroidism. That study is quoted extensively by anti-fluoridation activists but has been roundly criticised because it did not include the influence of confounders – particularly iodine which is known to influence thyroid health.

Barberio (2016) also suggests that the different recommended fluoride concentrations used for CWF in Canada and the UK, and the fact that the Peckham et al (2015) study did not involve individual measures, could also be factors in the different findings.

Cognitive functioning

The Canadian study reported:

“Fluoride exposure (from urine and tap water) was not associated with self-reported diagnosis of a learning disability.”

Barberio (2016) did also investigate a more detailed diagnosis for cognitive problems and found:

“Higher urinary fluoride was associated with having ‘some’ compared to ‘no’ cognitive problems . . . . however, this association:

  • Was weak;

  • Was not dose-response in nature; and

  • Disappeared when the sample was constrained to those for whom we could discern fluoride exposure from drinking water.”

I guess anti-fluoride activists might latch on to this last point regarding urinary fluoride but, at least as far as tap water fluoride is concerned, there was no relationship with learning difficulties.

Conclusion

So – yet another large-scale study contradicts anti-fluoridationist claims. It shows that CWF has no influence on cognitive problems or thyroid health.

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Water fluoridation – what to expect in the near future

drinking-water-glass-wiki

Community water fluoridation (CWF) will persist in science news for the foreseeable future – not for any valid scientific reason but because of reaction to political pressures against it. This is particularly so in New Zealand where our parliament will be discussing legislative changes to fluoridation decision-making this year.

This is not to say that all the relevant news will be political. There is still ongoing research into the efficacy, cost-effectiveness and possible health effects of fluoridation. Although much of this is a response to pressure from opponents of this social health policy.

So what scientific and political news about CWF should we expect to see in the coming years?

The legislation

In the immediate future, this will be dominated by the new parliamentary legislation [Health (Fluoridation of Drinking Water) Amendment Bill– at least in New Zealand. However, US anti-fluoride campaigners are following this legislation very closely, and will probably become involved in submission on it, so I expect this will also get coverage internationally. At least in the alternative health media which has stong links to the US anti-fluoride activist organisation, Fluoride Action Network (FAN), and which routinely carry their press releases.

The NZ Parliamentary Health Committee is currently taking written submissions on the fluoridation bill. The deadline for these is February 2. Readers interested in making their own submission can find some information on the submission process in my article Fluoridation: members of parliament call for submissions from scientific and health experts.

The bill itself simply transfers the decision-making process for fluoridation from local councils to District Health Boards. But most submissions will inevitably be about the science and not the proposed changes to decision-making – and, considering the promise of the local anti-fluoride group to shower the committee with “thousands and thousands of submissions,” will misrepresent that science. I will be interested to see what allowance the committee chairman makes for such irrelevant submissions when it comes to the public hearings, which could begin as early as February.

The bill has support from all the parliamentary parties, except the small NZ First which apparently wants councils to keep responsibility for fluoridation decisions, but wants to make binding referendums obligatory. So, I predict the bill will be passed this year. However, there will probably be attempts at the committee stages to amend it to transfer decision-making to central government, probably the Ministry of Health. Such an amendment appears to be supported by the Labour Party, but not by the National Party.

The “IQ problem” – a current campaign

There will be some news about research on the question of possible cognitive effects of fluoride in drinking water in the next few years. Not because there is any concern about this among health professionals. But because the claim that fluoride causes a drop in IQ is pushed very strongly by anti-fluoride activists. While they have a long list of claimed negative health effects of fluoridation the IQ claim is currently central to their political campaigns.

The campaigners claim scientific support for this claim. But that support comes mainly from a number of poor quality papers outlining research results from areas of endemic fluorosis (where drinking water concentrations of fluoride are much higher than the optimum levels used for CWF), mainly in China. FAN has a lot invested in this claim because it financed the translation of many of these otherwise obscure papers into English.There is general agreement among health specialists that these studies are not relevant to CWF. Investigation of areas where CWF is used, and where natural fluoride levels are similar to those used in CWF have not shown any neurological effects due to fluoride.

There is general agreement among health specialists that these studies are not relevant to CWF. Investigation of areas where CWF is used, and where natural fluoride levels are similar to those used in CWF have not shown any neurological effects due to fluoride.

However, FAN is strongly pushing the idea that cognitive effects of fluoride (rather than very mild dental fluorosis) should be the main criteria used in determining the recommended maximum levels of fluoride in drinking water. They currently have a petition in front of the US Environmental Protection Agency (EPA) promoting this claim. This may make the news in the near future as the EPA must respond this month and the likely rejection of the petition will no doubt cause a flurry of press releases.

Paul Connett, who with other members of his family runs FAN, has also attempted to use the scientific publication path to promote this claim. His arguments and calculations defining an extremely low maximum concentration, are very naive and his draft paper has already been rejected by journals several times. However, he no doubt lives in hope for its eventual acceptance somewhere. If he is successful this will be trumpeted to the high heavens by his supporters because while they describe Paul Connett as the international authority of water fluoridation he actually has no proper scientific publications in that area.

Research on neurological effects

We expect some research publications in the next year or so from the current US National Toxicity Program research on claims that fluoride at the concentrations used in drinking water fluoridation could have neurological effects. This research is basically a systematic review – according to the proposal:

an “evaluation of the published literature to determine whether exposure to fluoride is associated with effects on neurodevelopment, specifically learning, memory, and cognition.”

The motivation for this work, apart from the political pressure arising from activist claims, is to attempt to evaluate possible effects at concentration relevant to CWF. (Most published animal and human studies have involved higher concentrations). As the proposal says:

“Previous evaluations have found support for an association between fluoride exposure and impaired cognition; however, many of the studies included exposure to high levels of fluoride. Most of the human evidence was from fluoride-endemic regions having high background levels of fluoride, and the animal studies typically included exposure during development to relatively high concentrations of fluoride (>10 mg/L) in drinking water. Thus, the existing literature is limited in its ability to evaluate potential neurocognitive effects of fluoride in people associated with the current U.S. Public Health Service drinking water guidance (0.7 mg/L).”

I discuss the background to the US National Toxicity Program fluoride research in my article Fluoride and IQ – another study coming up.

Canadian Professor Christine Till will soon start a study looking at cognitive and behavioral factors using a data set for pregnant women exposed to contaminants. She intends to investigate the possibility of relationships with markers for fluoride consumption (see ). Anti-fluoride campaigners hold out great hope for results from this study because Till’s previous research is widely used by them to claim that fluoridation causes increased prevalence of attention-deficit hyperactivity disorder (ADHD). However, that research was flawed because potential confounders were not considered properly. In fact, her reported statistically significant correlations disappears when the confounders are included (see  ADHD linked to elevation not fluoridation).

Problems in areas of endemic fluorosis

Health effects including cognitive deficits: The World Health Organisation recommends that drinking water fluoride concentrations should not be higher than 1.5 mg/L because of negative health effects of high concentrations. Many areas of the world do have high drinking water fluoride concentrations and those areas suffer from endemic fluorosis – dental and skeletal fluorosis. This is, of course, a serious problem and there is a continuous stream of research papers devoted to these areas.

This research is not relevant to CWF (where the optimum concentration of 0.7 mg/L or similar levels is used). But, of course, anti-fluoride campaigners will continue to cite these papers as “evidence” against CWF. We may even see an expert on endemic fluorosis being toured in New Zealand to provide scientific credibility to the anti-fluoride campaign. Dr. Ak.K. Susheela, who works on endemic fluorosis in India and has links with FAN, has been speaking at meetings organised by the anti-fluoride movement in North America and has been suggested as a speaker the local anti-fluoride campaigners should bring to New Zealand.

I expect there will be more papers reporting IQ deficits in areas of endemic fluorosis and these will most probably continue to use a chemical toxicity model to explain their results. I personally am interested in the possibility of researchers considering other models, such as the psychological effects of dental and physical deformities like dental and skeletal fluorosis (see Perrott et al. 2015. Severe dental fluorosis and cognitive deficits). Unlikely, considering how research can get locked into pet paradigms, but one can but hope.

Defluoridation: Another big issue in areas of endemic fluorosis is the need to lower drinking water fluoride concentrations. This if often done by finding alternative sources but there is continuing research on treatment methods to do this.

Again, not relevant to CWF – but I do follow this research and find some of it interesting chemically. Perhaps it reminds me of my own research many years ago.

Conclusions

The controversy around CWF is not going to go away. The opposition is strongly grounded in the “natural”/alternative health industry. It has plenty of financial and ideological resources and its message appeals to a significant minority of the population.

Most of the public interest this year will relate to the new legislation – expect plenty of press releases from the anti-fluoride groups as they organise to make and advertise their submissions, and express their anger at the probably inevitable decision that will go against them.

However, there will be a continuing dribble of research reports of relevance to CWF and to the claims advanced by anti-fluoride campaigners. While it is normal for a social health policy to be continually monitored and its literature reviewed, some of this research is a direct result of concerns raised by campaigners and activists.

Many in the scientific community find this sort of political activity annoying. But it does have its up side. CWF has been one of the most hotly contested social health programmes. Consequently is has received more than its fair share of literature reviews and new research.

And that is a good thing. Anti-fluoride activists often claim there is little research on the health effects of CWF. But that is just not true. Ironically it is the very political activity of such campaigners which has led to CWF being one of the most thoroughly researched social health policy.

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Fluoridation: New scientific review of fluoride and oral health

fluoride-oral-healthWant to get up to date on  research about community water fluoridation (CWF) and the effects of fluoride in dental health in general?

Have a read of this new review. It’s published in a special issue of  Community Dental Health devoted to the WHO approach to the prevention of dental caries through the use of fluoride. And is also deals with possible health effects of fluoridation and fluoride in general.

The Paper is:

O’Mullane et al (2016). Fluoride and Oral Health. Community Dental Health 33, 69–99.

Summary and recommendations

The paper summarises the general conclusions and recommendations about CWF as follows:

1. Community water fluoridation is safe and cost-effective and should be introduced and maintained wherever socially acceptable and feasible.
2. The optimum fluoride concentration will normally be within the range 0.5-1.0 mg/L.
3. The technical operation of water-fluoridation systems should be monitored and recorded regularly.
4. Surveys of dental caries and enamel fluorosis should be conducted periodically. For effective surveillance the World Health Organization suggests that clinical oral health surveys should be conducted regularly every five to six years in the same community or setting.

Requirements for a CWF programme

But it is interesting to read its conclusions about the requirements for implementation of water fluoridation. This gives us an idea of why some areas do not fluoridate and what the technical and social requirements are for a successful CWF programme. These are the sort of things that district health boards will need to consider under the current legislations being considered by the New Zealand parliament.

Here is their list:

1. A prevalence of dental caries in the community that is high or moderate, or firm indications that the caries level is increasing.
2. Attainment by the country (or area of a country) of a moderate level of economic and technological development.
3. Availability of a municipal water supply reaching a large proportion of homes.
4. Evidence that people drink water from the municipal supply rather than water from individual wells, rainwater tanks or other sources.
5. Availability of the equipment needed in a treatment plant or pumping station.
6. Availability of a reliable supply of a fluoride-containing chemical of acceptable quality.
7. Availability of trained workers in the water treatment plant who are able to maintain the system and keep adequate records.
8. Availability of sufficient funding for initial installation and running costs.

How many people have access to CWF internationally?

The review has an appendix providing data on worldwide totals for populations with artificially and naturally fluoridated water. This is very useful and anti-fluoride campaigners are well-known for misrepresenting this information in their attempts to claim that most countries reject CWF.

Here is the table for artificial CWF programs:

fluoirdation-world

It says in summary:

“The estimated worldwide total of people supplied with artificially fluoridated water as at April 2011 is 369,226,000 in 25 countries, including the United Kingdom, the United States, Canada, Brazil, Chile, Argentina, Peru, Panama, Guyana, Guatemala, Republic of Ireland, Spain, Serbia, Australia, New Zealand, Fiji, Malaysia, Singapore, Vietnam, Brunei, China (Special Administrative Region of Hong Kong), Papua New Guinea, Republic of Korea (South Korea), Israel and Libya.”

Natural fluoridation

The review also summarises data for people receiving fluoride through the natural levels of fluoride in their drinking water:

Natural fluoridation in the 25 countries operating artificial fluoridation schemes

“In the 25 countries with artificially fluoridated water there are an estimated 18,061,000 million people drinking naturally fluoridated water at or around the optimal level. That brings the total in these 25 countries consuming optimally fluoridated water to around 387,287,000 million.”

Other countries with natural fluoridation

“In addition, there are a further 27 countries with naturally fluoridated water supplied to an estimated 239,903,000 million people. However, it should be stressed that, in many instances, the naturally occurring fluoride level is in excess of the optimum – for example, in China, India, Argentina, Tanzania, Zambia and Zimbabwe. Total worldwide population drinking optimally fluoridated water.”

In summary – 437 million have access to fluoridated water

Combining data for artificial and natural fluoridation the review concludes:

“General estimates for the number of people around the world whose water supplies contain naturally fluoridated water at the optimum level for oral health are around 50 million. This means that, when the numbers of people with artificially (369.2 million) and naturally fluoridated water supplies (50 million) at the optimum level are added together, the total is around 437.2 million.”

Conclusion

This review is useful for anyone wanting an up-to-date picture of CWF, possible health effects and other issues.

I recommend that anyone active in the dental health area or who needs to respond to questions about fluoridation from the public have their own copy. they will refer to it again and again.

This link goes straight to the download of the pdf.

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Fluoridation cessation studies reviewed – overall increase in tooth decay noted

Anti-fluoride activists love to trot out studies where no increase in tooth decay was found after community water fluoridation  (CWF) ceased. They are cherry-picking, of course, because they ignore the studies which do show a decline in dental health. I have written about this before in What happens when fluoridation is stopped? and Anti-fluoridationist’s flawed attacks on Calgary study.

So I am pleased to see a new, just published, review of fluoridation cessation studies. Also pleased that it confirms my impression of the literature.

In short, this review concluded that:

“Overall, the published research points more to an increase in dental caries post-CWF cessation than otherwise.”

The study is published in this paper – it’s open access so you can download a pdf or see the full text:

Mclaren, L., & Singhal, S. (2016). Does cessation of community water fluoridation lead to an increase in tooth decay ? A systematic review of published studies. J Epidemiol Community Health 2, 1–7.

Unsurprisingly, these sort of studies have problems – humans cannot be treated as laboratory rats. Researchers must rely on ordinary data for dental health collected before and after cessation.

Nevertheless, these researchers managed to find 15 instances of cessation occurring in 13 countries and reported in 29 publications. Several of these were excluded because they did not consider specific cessation effects  but reported on the enduring benefits of CWF even after cessation when children were exposed to CWF in the first 4 years of life. Evidence supporting a beneficial systemic effect of CWF in developing teeth. Another instance was excluded because of the complexity of its reports results didn’t enable any conclusion about effects.

Of the remaining situations, eight showed an increase in tooth decay after CWF was stopped. These occurred in Europe, Asia and North America. This paper was obviously submitted before the publication of the Calgary cessation study (Measuring the short-term impact of fluoridation cessation on dental caries in Grade 2 children using tooth surface indices) which also showed an increase in tooth decay (see Anti-fluoridationist’s flawed attacks on Calgary study for a discussion of this paper). So there are really nine instances showing an increase in tooth decay.

The other three instances did not show an increase in tooth decay. These occurred in East Germany, Finland and Cuba. These last three are, of course, the only studies anti-fluoridationists ever mention.

It’s worth quoting an observation from the paper which could help explain these different results:

“Importantly, in all three interventions, there were other factors which could have contributed to findings observed. In Finland, the CWF-cessation community started to provide fluoride tablets to children postcessation. In East Germany, postcessation fissure sealants were paid for by statutory health funds. In Cuba, postcessation, all children received fluoride mouth rinses fortnightly, and children aged 2–5 years received 1–2 fluoride varnish applications annually. Those initiatives could have offset an impact of cessation on dental caries.”

This is a really useful review as the cessation literature has not been properly reviewed before. For example, the recent Cochrane Review only considered one cessation study and concluded: “there is insufficient information to determine the effect of stopping [CWF] on caries levels.” The authors stress the need for researchers to take advantage of research opportunities presented by CWF cessation.

The authors stress the need for researchers to take advantage of research opportunities presented by CWF cessation ( there is a lot of it about in some countries). The also say there is a need for information on how cessation impacts different socio-economic groups and how decisions about cessation are made.

CWF cessation studies are just one area where anti-fluoride campaigners cherry-pick the literature. This example underlines why readers must always treat claims made by these campaigners critically. Always look at the original studies, the data, other treatments, etc.  And check other research these campaigners are hiding.

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Anti-fluoridationists misrepresent new dental data for New Zealand children

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Another whopper from the anti-fluoridation movement in New Zealand.

They claimed yesterday that “data released by the Ministry of Health today confirm that water fluoridation is having no noticeable effect in reducing tooth decay” (see DHB Data Show No Benefit From Water Fluoridation).

Yet a simple scan of the data (which can be downloaded from the MoH website) shows this to be patently untrue.

Here is a graphical summary of the New Zealand-wide data for 5-year-olds and year 8 children. It is for 2014 and I have separated the data ethnically as well as presenting the summary for all children (“total”).

DMFT and dmft = decayed, missing and filled teeth.

2014_5_years

214---8-yrNow – don’t these figures show the press release headline and the first sentence  are completely dishonest?

The data for all children (“total”) Maori and “other” show children in fluoridated areas have a higher percentage of caries-free teeth and a lower mean value of decayed, missing and filled teeth. The data for Pacifica are less definite – because the vast majority of Pacific children live in fluoridated areas. I discussed this further in my last post A challenge to anti-fluoridationers to justify their misrepresentation of New Zealand research.

Cherry-picking

So the headline and main message of the anti-fluoridationists press release were outright lies. However, they will fall back on the claim that the press release does contain some facts.  But these are just cherry-picked snippets taken out of context to confirm the bias of the anti-fluoride mind.

For example, comparing data for Christchurch and Nelson-Marlborough with those for  Auckland and Counties-Manukau is just disingenuous if the ethnic differences (which we know clearly play a role in oral health) are not considered. Similarly, reference to the 2o14 “overturning” of the Hamilton Council decision to stop fluoridation is just silly considering that there are no separate data for the city and the Hamilton Council fiasco over water fluoridation overlapped the period the data covers.

Of course, this press release has been processed through the international anti-fluoridation – “natural”/alternative health media channels so expect to be bombarded with international reports based on these lies.

The lesson from this little story – don’t take claims made by anti-fluoridation campaigners, or similar activists with an anti-science agenda, at face value. Always check them out.

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