Water Fluoridation

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					Water Fluoridation

              Dr Stephen G Palmer
             Medical Officer of Health
                    May 2010
Medical Officer of Health

• Special relationship with the Council

• Doctor practicing in:
    – public health
    – Epidemiology
    – Health risk assessment &
      risk management

• Independent statutory officer

                                          Original map by Dr. John Snow showing the clusters
• Kapiti’s Medical Officer of Health        of cholera cases in the London epidemic of 1854
Provide advice – Not advocate

• Interpret the scientific literature:
    – Especially epidemiological studies
    – Studies that show benefits of fluoride
    – Studies that may show risks of fluoride

• What will happen if fluoridation is removed:
    – Drop in oral health status
    – Those that will be most affected
    – Benefits if any

• Tactics used by the opponents to fluoride to:
    – Deny the benefits of fluoride
    – Fear monger
Waipukurau health impact assessment (HIA) of
removing fluoridation - October 2009

• By Hawkes Bay Medical Officers of Health (x3)

• This HIA is:
   – Relevant to Kapiti (but 10x magnitude)
   – Mostly based on systematic reviews
   – Most up-to-date quality scientific information
   – Very conservative
   – Unbiased
Findings – Effect of removing fluoridation on health

• Health losses:                        • Health gains:
   – Caries up 15%                         – nil

   – Decayed, missing or filled teeth
     per person up to between
     0.6 –2.25

   – Greater impact on children from:
       • Lower income households
       • Maori and Pacific households

   – This is Least Case Scenario

                       We expect the same for Kapiti
Did consider possible health gains

•   Dental fluorosis (aesthetic)
•   Skeletal fluorosis
•   Osteosarcoma
•   Other health conditions

• Very rare:
   – boys aged:
       • 10-14 year olds = 1.14 cases per year for NZ
       • 15-19 year olds = 2.36 cases per year for NZ
   – Waipukurau:
       • 1 case in 893 years for 10-14 year old boys
       • 1 case in 411 years for 10-14 year old boys

• If there is a link?
   – Small clusters in fluoridated areas
   – Medical Officers of Health would be investigating these clusters
Based on this evidence my advice is that by removing water
fluoridation the community will receive no health gain at the
expense of harm being done to oral health.

• This is the best advice I can provide on the impact of
  removing water fluoridation.

• This advice is unlikely to change in the future.

• Further research will firm up the weight of evidence
  supporting this advice.
   – Eg Peter Dennison – Martin Lee study
The Process

• No invitations

• Annual Plan process – fast tracking

• Consultation?

• Impartiality?

• Ministry of Health viewed as heavy weights
Advice on – “Fluoridation – Fragmented Facts”

• My advice would have been not to use this report.

• Also my advice is that it would be very challenging to
  prepare a “pros” and “cons” report as the “cons” that are put
  forward do not stand up to close scrutiny.

• If asked I would have provided technical support to officers
  preparing an advisory report.
Advice on tactics used by opponents to Fluoride
              Denying the benefits of water fluoridation
   Selective reporting of studies   Downplaying or ignoring the evidence

   Selective reporting of results      Using ecological comparisons

                             Fear mongering
   Misrepresentation of the truth             Enforced medication

            The big lie                  Bamboozling with science

            Half-truths                       Moving the goalposts

             Innuendo                 Paranoia, conspiracy theories and
         Follow the leader
                                     Incomplete list
Selective reporting results and
Downplaying or ignoring evidence

                                                         From FANNZ submission to GWRC

 PR Newswire September 29 2009

 JADA Study Proves Fluoridation is Money down the Drain
    •   The Association Between Enamel Fluorosis and Dental Caries in
        U.S. Schoolchildren - Hiroko Iida and Jayanth V. Kumar
          – “Permanent maxillary right first molars with fluorosis consistently had
            lower levels of caries experience than did normal molars.”
          – “The results highlight the need for those considering policies regarding
            reduction in fluoride exposure to take into consideration the caries-
            preventive benefits associated with milder forms of enamel fluorosis.”
Misrepresentation of the truth and
The big lie
• Infant formula made up with fluoridated water:
   – ADA’s advice always about very mild fluorosis:
       • Which is not a health issue
   – Opponents to fluoride:
       •   Link it to moderate and severe fluorosis
       •   Link it to local children with teeth defects that are not linked to fluoride
       •   So seeds of doubt in parents of infants
       •   Infer “we are poisoning our babies”
• This is extreme misrepresentation and distortion of the truth:
   – This is telling a big lie
   – On a par with MMR vaccine causing autism
• FSANZ concludes the upper limit needs to revised upward
Mass Medication
• Fluoride is a medicine:
   –   Medical ethics – freedom of choice
   –   Linked to being poisoned
   –   Emotional argument
   –   Often picked up on and used by local government officials who are
       responsible for decision making

• Fluoride is already in the water:
   – It is a matter of augmenting it to an optimal level
   – Similar to iodine in table salt or chlorine in drinking water
• Population preventive strategy:
   – Those that are least able to make a choice gain the most benefit
   – Those that are best able to make a choice can opt out
Freedom of Choice – Medical Ethics
• Risk of harm:
   –   Diagnostic investigations, treatments or doing nothing
   –   All associated with risk of harm to the patient
   –   Higher risk – greater focus on informed choice
   –   Eg. Coronary artery angiography
        • Very invasive procedure
        • One in one thousand chance of death
        • Signed informed consent

• Fluoridation:
   – Risk of harm is negligible
   – Very effective
   – Population preventive strategy best method to reach all children and
     adults regardless of household income and ethnic group
   – There is still freedom choice
Tactics used by opponents to Fluoride

• My advice:
   – The tactics used by opponents to fluoride focus on:
       • Denying the benefits of water fluoridation
       • Fear mongering

   – The tactics can very effective and convincing:
       • Especially the recent videos

   – It is important that councillors guard against being influenced by
     these tactics

• Fluoridation is one of the 10 great public health
  achievements of the 20th century
   – “water fluoridation remains the most equitable and cost effective
     method of delivering fluoride to all members of most communities,
     regardless of age, educational attainment, or income level”.

• It is SAFE and Effective