Anti-fluoridation group tells porkies about NZ fluoridation review

FFNZ spreads misinformation about the NZ fluoridation review – yet again

New Zealand opponents of community water fluoridation (CWF) are at it again. Their only response to the recently upgraded fluoridation review is to call it “propaganda” and to completely misrepresent it. But it’s interesting to look at their misrepresentation because it does highlight a basic flaw in the studies the anti-fluoride campaign has been promoting.

Fluoride Free NZ (FFNZ) claim in their recent press release (Chief Science Advisor Appears To Deliberately Mislead On Fluoride Science):

“among the many mistakes and reliance on out-of-date science, the most glaring issue is that she refers to two of the best studies ever carried out on fluoride and IQ (Mexico and Canada) as “having high prenatal exposure”. This is probably the most egregious misrepresentation in the review and hard to believe it was not done to purposely misrepresent.”

But this is completely false. In discussing the Canadian study the review actually says it:

“found that the mother’s exposure to fluoride during pregnancy was associated with lower IQ scores [54] in boys (but not girls), even at optimally fluoridated water levels (i.e. between 0.7-1.2 mg/L). If this finding were replicated in robust studies, it would potentially be concerning as Aotearoa New Zealand recommends fluoridation of water between 0.7 and 1.0 mg/L. There was significant and valid criticism of aspects of the study by many subject-matter experts when it was released (see for example, ‘expert reaction to study looking at maternal exposure to fluoride and IQ in children’). The study used sub-group analysis to find an association that is not explained in the paper (i.e. why were only boys affected [55] and why verbal IQ was not impacted), the effect appeared to be driven by the minority of participants that had much higher fluoride exposures (i.e. higher than those in Aotearoa New Zealand).” [My emphasis]

So the review does refer to the Canadian study being conducted at “optimally fluoridated water levels (i.e. between 0.7-1.2 mg/L)” – not at the elevated levels leading to “high prenatal exposure” that FFNZ falsely (and “egregiously”) asserts. But the key assertion by the NZ fluoridation review is that “the effect appeared to be driven by the minority of participants that had much higher fluoride exposures.”

Outliers lead to false conclusions

Canadian study promoted by opponents of community water fluoridation relies on just a few outliers  Image credit: The problem with outliers

It’s quite simple really. Even within a group exposed to levels of fluoride expected with CWF there can be some individuals who receive higher exposes (f0r instance through consumption of fluoridated toothpaste or industrial pollution).

Looking at the data in the Canadian study in the image below taken from Green et al (2019) we can see that while most data points are clustered together at urinary F concentrations less than 1 mg/L there are a few data points at high urinary F concentrations and these do appear to drive the relationship they report – particularly for boys.

For the more statistically inclined reader, the table below summarises the relationships obtained by linear regression analysis. While the authors reported a statistically significant relationship for all the urinary fluoride concentrations up to 2.5 mg/L when the four high-end outliers (> 2.0 mg/L) are removed there is no significant relationship.

So I think the suggestion of the updated NZ fluoridation review is quite correct. The effect reported by Green et al (2019) is driven by just a few outliers and there is no statistically significant relationship when those four outliers are removed. That gives a false impression of the effect of CWF and in fact, their data shows absolutely no difference between IQ in fluoridated areas and unfluoridated areas.

Note 1: There is a discrepancy in the first table between the relationship reported by Green et al (2019) and that based on digitally extracted data points. Unfortunately, only 82% of the claimed data points could be extracted which is strange as usually close to 100% of data points can be extracted. Other commenters have reported the same problem. So it appears the authors have not included all their data in the figures and they have so far refused to make their data available for independent statistical analysis.

Although the Green et al (2019) paper did not cite R-squared values in her Master thesis did cite an R-squared value of 0.049 for boys. The low R-squared values (meaning the inclusion of the coefficient explains at most only a few per cent of the variation) and relatively high regression standard errors suggest that the reported coefficients are meaningless (they can be ignored in any model) – even if statistically significant.

Note 2: In case anyone suggests I have neglected the FFNZ reference to the Mexican study. That study took place in an area of endemic fluorosis and the authors have no record of the water fluoride levels mothers were exposed to. Bashesh et al (2017) reported:

“By virtue of living in Mexico, individuals participating in the study have been exposed to fluoridated salt (at 250 ppm) and to varying degrees of naturally occurring fluoride in drinking water. Previous reports, based on samples taken from different urban and rural areas, indicate that natural water fluoride levels in Mexico City may range from 0.15 to 1:38 mg/L. Mean fluoride content for Mexico  City’s water supply is not available because fluoride is not reported as part of water quality control programs in Mexico.

Despite this, the Bashash study is often unjustly included with studies from areas of CWF by coauthors of Bashash and Green (see for example Farmus et al 2001). Anti-fluoride activists almost always make this mistake. Sure, they may attempt to justify their treatment of Bashash et al (2017) as relevant to CWF based on urinary fluoride values. But these a subject to so much variation and usually involve different collection and correction methods making comparison unjustified.

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Opponents of fluoridation all at sea with new legislation

Image credit: Why Ideology and Science Don’t Mix

Opponents of community water fluoridation (CWF) should be supporting the proposed fluoridation legislation instead of organising opposition to it.

Think about it.

If Fluoride Free NZ (FFNZ) was honest in its claim that they are “New Zealand’s leading advocate for science in the fluoridation debate” (see their press release  Open letter to Hon Andrew little, Minister of Health) then they should be supporting science rather than ideology and insist on the best scientific scrutiny of information relating to fluoridation.

If they honestly accept the claims of those cherry-picked anti-fluoride scientists they are quoting in their social media memes then they should welcome the opportunity to expose the research of those scientists to a proper critical review.

With scientific backers like this, opponents of community water fluoridation should be welcoming the new fluoridation legislation (example of social media memes promoted by the Fluoride Action Network)

And they should welcome the proposal that the proper place for such a scientific review is the office of the Director-general of health which can call on the best scientists for information and review of the evidence. That proposal is an integral part of the draft legislation which requires that the Director-General must consider the scientific evidence related to community water fluoridation before making a direction that CWF be introduced or stopped in a region (see clause 116E : Director-General may direct local authority to add or not to add fluoride to drinking water in the Supplementary Order Paper).

So, it appears strange that instead of welcoming the new legislation FFNZ is mobilising their supporters to oppose it. And their US colleagues at the Fluoridation Action Network are pouring their resources into the FFNZ campaign.

But why? It is ridiculous for pro-science people to campaign to retain the old system where the evaluation of evidence and decisions on CWF were made by scientific and political naive councillors in local bodies. Councillors who could be easily captured by activists and fooled by their misrepresentation of the science., Councillors who are more concerned with their next election or chances of claiming the Mayor’s job than any science. And councillors who are already predisposed to the claims of the activists, who may indeed be activists themselves, who were more concerned with ideological orientation than any science.

If the fluoridation opponents organised by FFNZ are really “leading advocates for science” and want recent research they are promoting to be considered in fluoridation decisions then they would be supporting the new legislation rather than opposing it.

Ideological distortion of science

I really wonder at a group of ideologically motivated people making submissions promoting their understanding (or misunderstanding) of the science to the Parliamentary Health Committee when that committee is simply not tasked with considering the science. Its job is to consider proposals for the reorganisation of the mechanism for making fluoridation decisions – nothing to do with science itself.

Instead of wasting their submissions on this bill, they should be saving them for promotion of their beliefs about what the science claims to the Director-General of Health and his/her staff. Once this bill is passed the Director-General of Health’s office should be a great place for these claims to be properly considered and reviewed.

That would be a vast improvement on the old situation when they took their arguments to scientifically and politically naive local body councils. Or brought in US anti-fluoridation spokesmen to speak to audiences of homoeopaths, head massagers and other alternative health advocates and their followers.

Or perhaps I am the naive one. Perhaps fluoridation opponents prefer to make their arguments to those local body councillors instead of scientifically capable people. Perhaps FFNZ is dishonest to claim they are ““New Zealand’s leading advocate for science in the fluoridation debate.” 

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An open letter to Paul Connet and the anti-fluoride movement

Image credit: How to Effectively Share Your Knowledge

Paul Connett and Vyvyan Howard have, through the local Fluoride Free New Zealand activist group, published an open letter addressed to NZ scientists and educators (see An Open Letter To NZ Scientists And Educators). It is strange to encourage scientific exchanges through press releases but if they are seriously interested in an exchange of informed scientific opinion on the research they mention I am all for it.

In fact, I renew my offer to Paul Connett for a new exchange on the new relevant research along the lines of the highly successful scientific exchange we had in 2013/2014 summarised in Conett & Perrott (2014) The Fluoride Debate.

Connett and Howard say they felt “let down” by the reception they received in their 2018 visit. But they should realise this sort of ridicule is inevitable when a supposedly scientific message is promoted by activist fringe groups with known funding by big business (in this case the “natural”/alternative health industry). The science should be treated more respectably and discussed in a proper scientific forum or via a proper scientific exchange rather than political style activist meetings.

It is this sort of respectable, informed and open scientific exchange I am offering to Paul Connett and Vyvyan Hoard.

Connett and Howard argue that there has recently been  “a dramatic change in the quality of these [fluoride] studies.” I agree that new research occurs all the time and there is plenty of scope upgrading of the scientific exchange we had in 2013/2014 to cover that new research. Consideration of the new research requires the objective, critical and intelligent consideration scientists are well used to and this is not helped by activist propaganda meetings. So I encourage Connett and Howard to accept my offer. after all, if they are confident in their own analysis of this research what do they have to lose?

Inaccuracies in “open letter”

One can see an “Open letter” as displaying a willingness to enter into a proper scientific exchange. However, Connett and Vivyan’s open letter includes inaccuracies and misinformation on the new research which simply demonstrates that a one-sided presentation cannot present the research findings properly.

For example, they misrepresent the 2014 New Zealand fluoridation review of Eason et al (2014). Health effects of water fluoridation: A review of the scientific evidence. Even to the extent of mistaking the authors (not Gluckman & Skegg as they claim) and misrepresenting the small mistake made in the summary which was later corrected. That attitude does not bode well for the proper consideration of the research.

Connett and Howard concentrate on new research relating child IQ to fluoride intake but they ignore completely the fact that all the research comparing IQ in fluoridated and unfluoridated areas show absolutely no effect. I have summarised the results for the three papers involve in this table.

Instead, they concentrated on a few extremely weak relationships reported in a few papers. But even here they get this wrong – for example, they say there is “a loss of about 4 IQ points in offspring for a range of 1 mg/liter of fluoride in mother’s urine.” The paper they refer to (Green et al 2019) actually found no statistically significant relationship between child IQ and maternal urinary fluoride for all children considered. The relationship Connett and Howard mention was actually for male children (no relationship for female children or for all children) and was very weak. These sort of weak relationships are commonly found in epidemiological research and are usually meaningless. In this case, Connett and Howard have simply cherry-picked one value and misrepresented it as applying to all children.

Both the Green et al (2019) and Till et al (2020) papers Connett and Howard refer to suffer from selecting a few weak statistically significant relationships and ignoring the larger number of non-significant relationships they found for the data they investigated. Connett and Howard also completely ignored the new studies that don’t fit their claims. For example that of Santa-Marina et al (2019). Fluorinated water consumption in pregnancy and neuropsychological development of children at 14 months and 4 years of age. which showed an opposite positive relationship of child IQ with maternal urinary fluoride. Similar they ignored the large Swedish study of Aggeborn & Öhman (2020). The Effects of Fluoride in the Drinking Water showing no effect of fluoride on IQ but positive effects on oral health and employment possibilities in later life.

In conclusion, I reiterate that genuine open scientific exchanges do not take place via press release and activist meetings. However, the fact that Connett and Howard have issued an “Open Letter” could be interpreted as inviting others to participate in a proper exchange. I endorse that concept and offer Connett and Howard space for a free and open exchange on the new research at this blog site.

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Anti-fluoride group coordinator responds to my article

Image credit: Debate. The science of communication.

My recent article Paul Connett’s misrepresentation of maternal F exposure study debunked got some online feedback and criticism from anti-fluoride activists. Mary Byrne, National coordinator Fluoride Free New Zealand, wrote a response and requested it is published on SciBlogs “in the interests of putting the record straight and providing balance.”

I welcome her response and have posted it here. Hopefully, this will satisfy her right of reply and help to develop some respectful, good faith, scientific exchange on the issue.

I will respond to Mary’s article within a few days.

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Perrott wrong. New US Government study does find large, statistically significant, lowering of IQ in children prenatally exposed to fluoride

By Mary Byrne, National coordinator Fluoride Free New Zealand.

While the New Zealand Ministry of Health remains silent on a landmark, multi-million-dollar, US Government funded study (Bashash et al), and the Minister of Health continues to claim safety based on out-dated advice, fluoride promoter Ken Perrott has sought to discredit the study via his blog posts and tweets.

Perrott claims that the results were not statistically significant but his analysis is incorrect.

The conclusion by the authors of this study, which was published in the top environmental health journal, Environmental Health Perspectives, was:

“In this study, higher prenatal fluoride exposure, in the general range of exposures reported for other general population samples of pregnant women and nonpregnant adults, was associated with lower scores on tests of cognitive function in the offspring at age 4 and 6–12 y.”

Perrott states the study has “a high degree of uncertainty”. But this contrasts with the

statistical analysis and conclusion of the team of distinguished neurotoxicity researchers from Harvard, the University of Toronto, Michigan and McGill. These researchers have written over 50 papers on similar studies of other environmental toxics like lead and mercury.

RESULTS: In multivariate models we found that an increase in maternal urine fluoride of 0.5 mg/L (approximately the IQR) predicted 3.15 (95% CI: −5.42, −0.87) and 2.50 (95% CI −4.12, −0.59) lower offspring GCI and IQ scores, respectively.

The 95% CI is the 95% Confidence Interval which is a way of judging how likely the results of the study sample reflect the true value for the population. In this study, the 95% CIs show the results are highly statistically significant. They give a p-value of 0.01 which means if the study were repeated 100 times with different samples of women only once could such a large effect be due to chance.

Perrott comes to his wrong conclusion because he has confused Confidence Intervals with Prediction Intervals and improperly used Prediction Intervals to judge the confidence in the results. A Prediction Interval is used to judge the confidence one has in predicting an effect on a single person, while a Confidence Interval is the proper measure to judge an effect on a population. In epidemiological studies, it is the average effect on the population that is of interest, not how accurately you can predict what will happen to a single person.

Despite the authors controlling for numerous confounders, Perrott claimed they did not do a very good job and had inadequately investigated gestational age and birth weight.

Once again Perrott makes a fundamental mistake when he says that the “gestational period < 39 weeks or > 39 weeks was inadequate” and “The cutoff point for birth weight (3.5 kg) was also too high.”

Perrott apparently did not understand the Bashash paper and mistook what was reported in Table 2 with how these covariates were actually treated in the regression models. The text of the paper plainly states:

“All models were adjusted for gestational age at birth (in weeks), birthweight (kilograms)”

Thus, each of these two variables were treated as continuous variables, not dichotomized into just two levels. Perrott’s criticism is baseless and reveals his misunderstanding of the Bashash paper.

Perrott states that the results are not relevant to countries with artificial fluoridation because it was done in Mexico where there is endemic fluorosis. But Perrott is wrong. The study was in Mexico City where there is no endemic fluorosis. Furthermore, the women’s fluoride exposures during pregnancy were in the same range as found in countries with artificial fluoridation such as New Zealand.

The study reports that for every 0.5 mg/L increase of fluoride in the urine of the mothers there was a statistically significant decrease in average IQ of the children of about 3 IQ points. It is therefore correct to say that a fluoride level in urine of 1 mg/L could result in a loss of 5 – 6 IQ points. This is particularly relevant to the New Zealand situation where fluoridation is carried out at 0.7 mg/L to 1 mg/L and fluoride urine levels have been found to be in this range².

There is no excuse for Health Minister, David Clark, to continue to bury his head in the sand. This level of science demands that the precautionary principle be invoked and fluoridation suspended immediately.

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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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Another anti-fluoridation whopper

We are all used to political activists fiddling statistics – but this has gone too far. Local anti-fluoride activists are so narcissistic they are now presenting their own clamouring as representing public opinion – even putting figures to it.

I find this really offensive. As a Hamiltonian, I objected to the undemocratic put our council took in stopping fluoridation in 2013. The attitude of voters was clear from a previous referendum which showed overwhelming support fo this safe and effective social health measure.Protests led to another referendum in October 21013 and again overwhelming support for community water fluoridation (CWF). A clear result and several months later the council reversed its stance –  we now have community water fluoridation again.

Yet anti-fluoride activists argued to reject the referendum result – so what is all the talk now about Patea and Waverly? Are they now objecting to a council which rejected the views of its electors?

Not at all. No referenda were held in Patea or Waverly. As far as I can tell there were no household surveys either. Simply the normal consultation process involving submissions. So where does Fluoride Free NZ (FFNZ) get its figures for the views of residents for the above poster? Are 85% of Patea and 75% of Waverly really opposed to CWF?

Again, no. Those figures represent the proportion of submissions presented to the council arguing against CWF. In fact, half of those submissions came from out of town – somewhere else in New Zealand or overseas. (Paul Connett, from the USA, and other members of his political activist group, the Fluoride Action Network, are regular submitters to New Zealand councils). This is typical of the way that these activists submerge councils with “submissions” when CWF is considered. Many submissions are simply copies or form letters.

By the same logic, FFNZ could argue that 75% of Hamiltonians were against fluoridation (because the overwhelming proportion of submissions to the council were). Despite the clear referenda results showing the opposite. In fact, FFNZ does list the submission number in the case of Hamilton as one of their referenda results!

Now we expect FFN to argue that over 90% of New Zealanders oppose fluoridation because that was the proprtion of anti-fluoride “submissions” to the recent selct committee hearings on the current fluoridation bill!

As they say – pull the other leg.

Wait – there is more!

But FFNZ goes even further over the top in their facebook presentation of this poster. They claim:

 

“In 2012 the South Taranaki District Council asked residents of Patea and Waverley if they would like fluoridation chemicals added to their water supply. The resounding answer was “NO”. However, Council went ahead and voted for it anyway. Because of the blatant disregard for the community’s wishes, New Health New Zealand took STDC to court. STDC have now spent $320,000 fighting this when they could have just backed off from fluoridation. This issue is going to go to Supreme Court some time in the future.
You have to wonder who these people are working for don’t you.”

So somehow the South Taranaki District High Council is to blame for the expenses involved in defending itself against court action – action taken by a lobby group of the New Zealand “natural”/alternative health industry. A big business worth billions that is pumping something like $100,000 a year into court actions agaisnt fluoridation. See Who is funding anti-fluoridation High Court action?, Big business funding of anti-science propaganda on health and Anti-fluoridationists go to Supreme Court – who is paying for this?

How ridiculous – even for these political activists.

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Non-fluoridated Christchurch does not have better teeth than fluoridated Auckland

It seems every time anti-fluoride propagandists present data it is either cherry-picked, distorted or misleading. Often all three. So it is hardly a surprise to find local anti-fluoride propagandists are telling porkies again.

They have been promoting the above graphic claiming it shows people in “non-fluoridated Christchurch have “better teeth.” But the graphic is based on naive cherry-picking of the data, it ignores the effect different ethnic groups have on the data and it uses a single cherry-picked year which fits their bias.

On top of that, axis values have been chosen to exaggerate differences and the labels are incorrect. The “non-fluoridated Christchurch” category uses data for Canterbury and the “fluoridated Hamilton” category uses data of the Waikato.

It seems that several of the commenters on the Fluoride Free NZ Facebook page where this graphic was first used saw the problems and raised them. All they got is insults for their time. These organisations do not seem capable of a rational discussion.

The Ministry of Health data they use is freely available on the MoH website. It provides oral health data for 5-year-old children and year 8 children. The data is presented annually and for different regions.

So let’s have a look at what the data really says – using more normal axis ranges and separating out ethnic groups.

The top graph here is still misleading because it does not take into account the effect of different ethnic groups. However, the correct categories are used and the more rational axis really cuts the exaggerated difference down to size.

In the second graphic the data for Māori and Pacifica have been removed – the MoH describes this group as “Other” – it is mainly Pakeha. We can see that the caries-free % is actually greater for fluoridated Auckland than it is for non-fluoridated Canterbury – exactly the opposite of what the anti-fluoride propagandists were claiming.

It is the same story for Māori – the caries-free % is actually higher in fluoridated Auckland than in non-fluoridated Canterbury.

The problem with the “Total” data is that Pacifica have a large effect – particularly in Auckland where Pacifica are concentrated. Pacifica generally have poorer oral health but are concentrated in fluoridated regions. This drives down the caries-free % figures for the fluoridated areas if the differences are not accommodated.

I referred to this effect of Pacifica on the data in my article A challenge to anti-fluoridationers to justify their misrepresentation of New Zealand research. There I was referring to a similar way anti-fluoride campaigners were misrepresenting data from recent New Zealand research. In this case, they were using data from a paper (Schluter & Lee 2016) and completely ignoring the distortions introduced by inclusion of Pacific – even though the authors had warned against the anomaly introduced by this.

There are other effects which should also be considered in a proper understanding of these data. It is easy to cherry-pick the data for a single year when differences are small – the anti-fluoride people do that a lot. OK if you want to confirm your biases but consideration of the data over multiple years helps indicate trends, identify anomalies and provide an idea of variations in the data. It is also important to consider the numbers in each region. For example, I have not included Pacific in the graphs above because they are concentrated in Auckland and the numbers in Canterbury and Waikato are very low (eg., 45 in Waikato in 2014).

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A challenge to anti-fluoridationers to justify their misrepresentation of New Zealand research

One of the frustrations I have with the fluoridation issue is the refusal of anti-fluoride activists to engage on the science. They will pontificate, but they won’t engage in discussion.

On the surface, one would think there is a difference of opinion or interpretation of scientific issues and that could be resolved by discussion. Yet local anti-fluoride campaigners refuse to enter into discussion. Again and again, I have offered space here to local anti-fluoride campaigners so that they could respond to my articles and they have inevitably rejected the offer. They have also blocked me, and other people discussing the science, from commenting on any of their social media pages or web sites. Even when they, themselves, call for a debate they reject specific responses I have made accepting that call.

So I am left with the only alternative of responding to their claim with an article here – or on a friendly web or blog site. At least that gives me space to present my argument – I just wish I could get some intelligent responses enabling engagement on the issues.

Misrepresentations repeated

The latest misrepresentation of the science is a claim by the Auckland Fluoride Free NZ Coordinator, Kane Titchener, that “recent research proves fluoridation [is] not needed.“

It repeats the same misrepresentation made by Wellington Anti-fluoride campaigner, Stan Litras, which I discussed in my article Anti-fluoridation cherry-pickers at it again. Kane has either ignored my article, chosen to ignore it or possibly not even understood it.

So here we go again.

Kane claims:

“A New Zealand study published in Bio Medical Central Oral Health last month shows dental health improved the greatest extent for children in non-fluoridated areas. There is now no difference in dental decay rates between non-Maori children who live in fluoridated areas and non-Maori children who live in non-fluoridated areas, proving that fluoridation is not needed for children to obtain good dental health.”

Although he doesn’t cite the study (wonder why), his use of two figures from the study show he is writing about the paper:

Schluter, P. J., & Lee, M. (2016). Water fluoridation and ethnic inequities in dental caries profiles of New Zealand children aged 5 and 12–13 years: analysis of national cross-sectional registry databases for the decade 2004–2013. BMC Oral Health, 16(1), 21.

His claim relies on the comparison of data for “non-Māori” children in fluoridated and fluoridated areas. No – he doesn’t misrepresent the data – he just ignores the discussion by these authors of problems with simple interpretation of the data for non-Māori because of the fact it is not ethnically uniform. In particular, he ignores the qualifications they place on the data because of the inclusion in non-Māori of data for Pacifica who have poorer dental health than the rest of this group and live predominantly in fluoridated areas. This, in effect, distorts the data by overestimating the poor oral health for “non-Māori” in the fluoridated areas.

The apparent convergence

The data used in this study were taken from the Ministry of Health’s website. This divides the total population of children surveyed into the ethnic groups Māori, Pacific and “Other.” While the “other’ group will not be completely uniform (for example including Pakeha, Asian, other groups) it becomes far less uniform when combined with the Pacific group to form the non-Māori group.

So, Kane salivates over this figure from the paper especially the plots for  non-Māori ethnicities in fluoridated (F) and non-fluoridated (NF) areas.

Fig. 1 No obvious decay experience (caries-free) percentages and mean dmft for 5-year old children over years 2004 to 2013, partitioned by Māori and non-Māori ethnicities and fluoridated (F) and non-fluoridated (NF) areas

Yes, that convergence is clear and I can see why Kane is clinging to it – who can blame him. But he completely ignores the warning from the paper:

“It is likely that a substantial driver of this convergence was due to significant changes within the dynamic and heterogeneous non-Māori groups both within and between DHB regions. In effect, the ecological fallacy – a logical flaw whereby analyses of group data are used to draw conclusions about an individual – may be operating within the non-Māori group.”

When the Pacific data is removed (as is the case for the “other” group effectively made up from non-Māori and non-Pacifica) we get the plots below.

Comparison of data for “other” (non-Māori/non-Pacifica) children in fluoridated (F) and unfluoridated (UF) areas.

Nowhere near as useful for Kane’s confirmation bias and the message he wants to promote. OK – there is still some evidence of convergence from about 2007 on between fluoridated and unfluoridated children. But the graphs do show that community water fluoridation is still having  a beneficial effect. And this apparent convergence could be explained by things like the introduction of “hub and spoke” dental clinics after 2004. One problem with this raw data is that children are allocated according to the fluoridation status of the school – rather than their residence. This will lead to incorrect allocation in some cases.

Some data for Pacifica

Just to underline the problems introduced by inclusion of Pacific in the non-Māori group of the study consider the data for Pacifica shown below.

Data for 5-year-old children. dmft = decayed, missing and filled teeth. The “other” group is non-Māori and non-Pacifica

The oral health of Pacifica is clearly poorer than that of the “other” group.

Also, Pacifica make up about 20% of the non-Māori fluoridated group. So they will influence the data for the non-Māori fluoridated group by reducing the % caries free and increasing the mean dmft.

So Kane, like Stan, is blatantly cherry-picking. He is misrepresenting the study – and its author – by ignoring (or covering up) the qualifications regarding the influence of inclusion of pacific in the non-Māori fluoridated group.

The challenge

Now, I repeat the offer I have made in the past to give a right of reply to both Kane Titchener and Stan Litras. They are welcome to comment here and if they want more space I am happy to give space for separate articles for them in the way I did for the debate with Paul Connett. Now I can’t be fairer than that, can I?

So what about it Stan and Kane? What are your responses to my criticisms of the way you have cherry-picked and misrepresented this New Zealand paper?

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NOTE: I have sent emails to both Kane and Stan asking them to respond and offering them right of reply.

UPDATE 1: Great minds and all that – Stan Litras sent out a press release today calling for a nation-wide debate on this issue (see FIND calls for a national debate on fluoridation). However, the seriousness of his request is rather compromised by his reply to my offer of a right of reply to the above article. He did respond to my email very quickly. This is what he wrote:

“Thanks for the offer, Ken, but I have not visited your blog site for a long time, as I object to the way you attempt to defame and discredit me.

You play the man and not the ball, which is not the mark of a reasonable person.

I hope to address that in due course as time permits, but for now I must leave you to indulge yourself without my company.”

So much for his wish for a “national debate” when he will not front up to a critique of his claims about the science.

UPDATE 2: Kane Titchener today also posted a press release today which was the text of the article I discuss in this post (see NZ research proves fluoridation not needed). He also responded quickly to my e-mail. The full text of his response was:

“Who is this?”

Rather strange – considering he often pesters me with emails.

So I guess both of them have turned down my offer.

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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.

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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.”

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.

Considering 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).

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).

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.”

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.”

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.

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