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Water fluoridation 'a safe way of stopping tooth decay'

  • 4 Comments

“Adding fluoride to tap water could save the NHS millions and dramatically improve children’s dental health,” the Mail Online reports. A new UK study concluded that water fluoridation is a “safe and effective” way of preventing tooth decay in children.

The study used national data to compare the rates of tooth decay and other health outcomes in areas of England where fluoride either has or has not been added to the water.

Primarily, the study seems to confirm what is already well established – fluoride protects against tooth decay. Rates of tooth decay among five and 12-year-olds and hospital admissions for tooth decay in under-fives were significantly lower in water-fluoridated areas.

Whether fluoride could have detrimental effects on other areas of health has been a concern. This study didn’t find an adverse effect for any of the outcomes examined. In fact, water fluoridation was linked to small decreases in the rates of bladder cancer and kidney stones, and a tiny reduction in all-cause death. There was also no evidence water fluoridation increased the rates of children born with Down’s syndrome.

But we should not automatically assume water fluoridation is protective against bladder cancer, kidney stones and death, as the differences in rates are quite small and could be accounted for by many unmeasured factors.

Overall, the study lends support to the positive effects of water fluoridation on dental health among young children. However, firmer conclusions on possible wider health effects cannot be made. 

Where did the story come from?

The study was carried out by researchers from Public Health England (PHE) and was published in the peer-reviewed journal of Community Dentistry and Oral Epidemiology. No sources of financial support are reported.

In the interests of transparency, it should be made clear that Bazian Ltd carried out an independent analysis of key research submitted to South Central Strategic Health Authority as part of the public consultation on the proposal to fluoridate water in Southampton.

The Mail’s coverage is generally accurate, though their article focuses on the effects of child tooth decay. It doesn’t cover the aim of this research – to look into other health effects – or cover the limitations of the evidence. Saying that “putting fluoride in the water everywhere would save the NHS millions” is only an assumption. The article also doesn’t recognise that in some parts of the UK, fluoride naturally occurs at the recommended levels. 

What kind of research was this?

This was a cross-sectional study that aimed to look at the association between water fluoridation schemes in England and selected health outcomes.

Six million people in England are said to live in areas where the level of fluoride in water has been adjusted, the main reason being to reduce the public health burden of dental caries. Dental caries, or tooth decay, are reported to affect more than one-quarter of young children, with higher rates in areas of greater deprivation.

Fluoride has long been recognised to reduce the risk of dental caries. Water fluoridation schemes in England (mostly introduced from the late-60s to mid-80s) aim to achieve a level of one part fluoride per million (1ppm) in water, with a maximum permitted level of 1.5ppm.

However, while the dental effects of fluoride are well established, what is less known is whether fluoride could have other detrimental health effects or, conversely, possible health benefits. This study aimed to compare rates of dental and other health outcomes in areas of England with and without water fluoridation.  

What did the research involve?

This study used geographical information systems (computer systems used to track and assess data for defined geographical regions) and known patterns of water supply to estimate the level of exposure to fluoridated water in small areas and administrative districts in England.

Fluoride exposure was estimated for small areas (lower super output areas, LSOAs) with a population range of 1,000-3,000, and for administrative districts known as upper tier local authorities (UTLAs) and lower tier local authorities (LTLAs). Areas where the level of fluoride in water naturally reached around 1ppm without added fluoride were excluded.

Health outcomes examined for the regions (and their data source) were as follows:

  • dental caries at five and 12 years old – National Dental Epidemiology Programme for England
  • hospital admissions for dental caries in young children aged one to four years – 2012 Annual Report of the Chief Medical Officers
  • hip fractures – Hospital Episode Statistics (HES) data
  • kidney stones – HES data
  • Down’s syndrome – National Down syndrome Register
  • bladder cancer – English Cancer Registration
  • bone cancer – English Cancer Registration
  • overall cancer – English Cancer Registration
  • all-cause death – Office for National Statistics

The time period in which these outcomes were assessed varied for the individual outcome, but was mostly in the 2000s, up to 2010-13.

The associations between water fluoridation and these outcomes were adjusted for potential confounding factors of deprivation and ethnicity. With the exception of child dental caries, other outcomes were also adjusted for age and gender. Down’s syndrome was only adjusted for mother’s age.  

What were the basic results?

Around 1 in 10 of the LSOAs, LTLAs and UTLAs in England have water fluoridation schemes.

Looking at the dental outcomes, water fluoridation was associated with a significant reduction in the odds of child dental caries (28% reduction for five-year-olds and 21% for 12-year-olds). The rate of hospital admission for dental caries was 42 per 100,000 young children in fluoridated areas, compared with 370 in non-fluoridated areas. This was calculated as a 55% risk reduction.

Looking at other health outcomes, three statistically significant associations were found. Water fluoridation was associated with a reduction in the number of cases of bladder cancer and kidney stones (both 8% reduced incidence) and a small reduction in all-cause death (1.3% reduction).

There were no other associations found for any other health outcomes. 

How did the researchers interpret the results?

The researchers concluded that: “This study uses the comprehensive data sets available in England to provide reassurance that fluoridation is a safe and highly effective public health measure to reduce dental decay.

“Although lower rates of certain non-dental outcomes were found in fluoridated areas, the ecological, observational design prohibits any conclusions being drawn regarding a protective role of fluoridation.” 

Conclusion

This cross-sectional study used reliable national data on water fluoridation areas and linked this to registries and databases to see how this influenced the rate of different health outcomes.

Primarily, the study seems to confirm what is already quite well established – fluoride protects against tooth decay. The rate of tooth decay among young children is a particular concern and is a widespread problem across the UK. The study found rates of tooth decay among five and 12-year-olds and hospital admissions for tooth decay in under-fives were significantly lower in fluoridated areas.

The study also aimed to look at whether water fluoridation has any detrimental health effects. It didn’t find an adverse effect for any of the outcomes examined. In fact, water fluoridation was associated with decreased rates of bladder cancer and kidney stones. A reduction in all-cause mortality was also found, though this was tiny.

There are, however, important points to keep in mind:

  • This type of study cannot prove cause and effect. Given the known effect of fluoride on dental health, the reduction in rates of child tooth decay in fluoridated areas could be directly attributed to water fluoridation. But this link is not certain. For other health outcomes – as the researchers rightly acknowledge – you can be less sure. You cannot say from this study that fluoridating water definitely protects against bladder cancer or kidney stones, even less so from mortality risk. The risk decreases are relatively small, and there may be many other factors that account for the differences the study has not been able to examine.
  • For rates of child tooth decay, data is limited to the National Dental Epidemiology Programme for England, which gives information only for five and 12-year-olds. Though these may be representative, this still does not cover all children. For under-fives, dental health has been assessed through hospital admissions for tooth decay. This would not cover children who may have tooth decay, but are not admitted to hospital for extractions.
  • The study did not examine an exhaustive list of other health effects. Fluoride may have effects on other areas of health that this study has not examined.
  • The study examined by water fluoridation area. But there is no certainty that the people living in these areas have always lived here. You don’t know about their water exposure in other areas of the UK, or elsewhere.
  • Even if individuals had always resided in the area assessed, individual exposure could still vary widely. For example, some people could be drinking regular glasses of tap water throughout the day, while others may not.
  • Also, as the researchers say, they were not able to account for how long the water fluoridation scheme has been in place, which will vary between areas.

Overall, this study lends support to the positive effect of water fluoridation on dental health among young children. However, firmer conclusions on possible wider health effects cannot be made.

  • 4 Comments

Readers' comments (4)

  • Fluoridation is a dismal failure in the US. After 70 years of fluoridation, 60 years of fluoridated toothpaste, a glut of fluoridated dental products (and in higher concentrations), a fluoride-saturated food supply and US children are fluoride-overdosed and dentist deficient but it's been good for industry. The global market for Toothpaste is projected to reach US$14 billion by 2020.

    Instead of spreading less tooth decay across the land, fluoridation spread dental fluorosis (fluoride-discolored teeth) into every nook and cranny of America. Even though the CDC reports up to 60% of adolescents are afflicted with dental fluorosis, 51% of them have cavities.

    Opposite to predictions, since fluoridation began in 1945:

    1) Tooth decay crises occur in all fluoridated cities. http://www.FluorideNews.Blogspot.com

    2) New dental professionals were created, e.g. dental therapists.

    3) New dental schools opened.

    4) Dental expenditures went up substantially, higher than the inflation rate.

    5) Poor children’s cavities are more prevalent, severe, occur earlier and more likely to be untreated.

    6) Despite dental spending growth, 42% percent of adults and 4 million children with dental problems could not afford dental care.

    7) More states had the need to hire Dental Directors

    8) Since the Surgeon General announced a silent epidemic of tooth decay in 2000, scores of government, dental and oral health groups formed having countless meetings, symposiums, webinars and conventions including one focused on the growing tooth decay rates in toddlers because 1/3 of 3-year-olds now have cavities.

    9) Because the CDC's oral health group can't prove fluoridation is safe for everyone, the CDC hired public relations firms to spin data to make fluoridation more attractive than science and government reports show it is

    10) 52% of new recruits have oral health problems needing urgent attention that would delay overseas deployment

    11) dental socioeconomic disparities have increased.

    12) The National Center for Health
    Workforce Analysis projects The national demand for dentists is projected to grow by 20,400

    13) Between 2008 and 2010, more than 4,000,000 patients visited hospital emergency departments for assistance with dental conditions, accounting for 1 percent of all emergency room visits during such period and at a cost of $2,700,000,000.

    The United States spends more than $111,000,000,000 on dental care every year.

    US Senator and Presidential Candidate Bernie Sanders, in his 2012 report, “Dental Crisis in America,” says that 9,500 new dental providers are needed to meet the country’s current oral health needs and that tooth decay is the leading cause of school absenteeism

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  • Instead of addressing the points of this article which describe yet another study that finds fluoridation safe and effective, Nys Cof - who is a persistent anti-fluoridation activist - simply dumps a load of unsubstantiated claims that have nothing to do with the safety and effectiveness of fluoridation. Nys Cof seems to have no concept of the fact that correlations (even if accurate) do not automatically equal causation.

    I live in Littleton Colorado, I drink fluoridated Denver Water, I have been following the fluoridation controversy for years, and I support Community Water Fluoridation. I have never noticed any negative effects of the fluoride ion except that it seems to increase the hostility of certain members of society if they even hear the words, fluoride or fluoridation.

    When the Denver Water Board Commissioners announced they were reviewing the fluoridation policy I became interested in helping people in Denver and elsewhere understand the controversy and in providing resources to counter the distortions of available evidence by the fluoridation opponents (FOs).

    Consequently, I will post this message when I see that FOs have begun to spread their seeds of misinformation against the practice of fluoridation.

    Thankfully legitimate science prevailed over the fear-mongering and BiasScience of FOs in Denver on August 26th with the decision to continue fluoridation of the city’s drinking water.

    The resolution the Denver Water Board Commissioners adopted at its August 26, 2015 meeting stated: “Nothing has been presented to the Board or learned in our research that would justify ignoring the advice of these public health agencies and medical and community organizations, or deviating from the thoroughly researched and documented recommendation of the U.S. Public Health Service.”, http://www.denverwater.org/WaterQua.../WaterSafety/Fluoride/. That statement is important considering top FO spokesperson, Paul Connett, flew to Denver to give a presentation at the July 29th information session – – – and contributed nothing new or of value to the decision making process.

    For those who are concerned about fluoridation because of all the complete falsehoods and twisted truths spread by FOs, I put together a web page, http://www.cyber-nook.com/water/fluoridationreferences.htm, to provide evidence in support of the safety and effectiveness of drinking water fluoridation that is conveniently missing from the FOs’ propaganda. Don’t buy into the fear without doing your own research. If there are not enough references to convince you the FOs are distorting the evidence, simply go to the entire body of published evidence at www.pubmed.gov/ and do your own examination of the research.

    It is very easy to discover where the FOs have distorted the evidence to create fear using studies where the actual conclusions are completely contrary to how they have been presented. The 2012 ‘Harvard IQ’ study by Choi, et al. and the 2015 Cochrane review of water fluoridation are excellent examples.

    Remember, as you examine the evidence, science is a process by which the scientific community reaches a consensus (a communal agreement) about specific issues that is based on a complete evaluation of all the evidence that’s available. The scientific consensus on community water fluoridation for over 70 years has been that it is a safe and effective process for reducing dental caries in a community. All of the so-called evidence used by FOs has been exhaustively analyzed and found to be insufficient to change the consensus.

    The only way FOs can promote their agenda is to try and convince the public that fluoridation is ineffective and harmful to health. And the only way that can be accomplished is to:
    (1) Reference poor quality research that has been already been examined and dismissed by experts in the field,
    (2) Claim that known detrimental effects of exposure to high levels of fluoride automatically means low level exposure is also harmful,
    (3) Manipulate the conclusions of legitimate research to imply the practice of fluoridation is harmful.
    (4) Use fear instead of valid evidence to try and convince people the FOs’ position is valid.
    (5) Try and suggest that fluoridation is forced medication instead of a beneficial water treatment process – like chlorination and the addition of various other chemicals.
    (6) Try and discredit the respected science and healthcare professionals, and the highly respected science, healthcare, and regulatory organizations supporting fluoridation as being corrupt, inept, conspiracy laden, etc. It is ironic that FOs attempt to use the methods of science to justify their strongly held biases, but the only way that they can do that is to deny one of the key components of the scientific method - Consensus of the experts.

    As you read comments for and against fluoridation, note that comments from fluoridation supporters provide detailed responses that dissect each part of the FO’s claims. These answers can be verified by anyone who takes the time to read the relevant papers. In contrast, claims of the FOs either have no supporting evidence, or if there is evidence, you can check for yourself to see how it has been distorted.

    Randy Johnson

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  • Among her usual array of misinformation, "Nyscof", aka Carol Kopf, the "Media Relations Director" for the New York antifluoridationist faction, "Fluoride Action Network", actually presents some very convincing arguments which fully support fluoridation.


    1. Nyscof: "Fluoridation is a dismal failure in the US".

    Facts:
    Countless peer-reviewed scientific studies clearly demonstrate the effectiveness of fluoridation in the prevention of dental decay in entire populations. I will gladly cite as many as anyone would reasonably care to read.

    The overwhelming problem with untreated dental decay existing in the US and most other countries is a reason for fluoridation, not against it.

    2. Nyscof: "Instead of spreading less tooth decay across the land, fluoridation spread dental fluorosis (fluoride-discolored teeth) into every nook and cranny of America. Even though the CDC reports up to 60% of adolescents are afflicted with dental fluorosis, 51% of them have cavities.


    Facts:
    A. The only dental fluorosis in any manner attributable to optimally fluoridated water is mild to very mild, a barely detectable effect which causes no adverse effect on cosmetics, form, function, or health of teeth. As peer-reviewed science has demonstrated mildly fluorosed teeth to be more decay resistant, many consider this effect to not even be undesirable, much less adverse.

    The hypocrisy of nyscof and her "FAN" is clearly evident by their constant attempt to fear-monger about benign, barely detectable mild dental fluorosis, while discarding the lifetimes of extreme pain, debilitation, development of serious medical conditions, loss of teeth, and life-threatening infection directly resultant of untreated dental decay which could be, and is, prevented by water fluoridation.

    B. The 60% dental fluorosis to which nycof refers is actually 41%, as reported in a 2010 CDC study by Beltran-Aguilar. This 41% was composed of 37.1% with mild to very mild dental fluorosis, both of which are barely detectable, benign effects requiring no treatment, and which have no effect on cosmetics, form, function, or health of teeth....with the other 3.8% being those with moderate dental fluorosis, attributable to improper ingestion of toothpaste and/or exposure to abnormally high levels of environmental or well-water fluoride during the teeth forming years of 0-8.

    ----Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004
    Eugenio D. Beltrán-Aguilar, D.M.D., M.S., Dr.P.H.; Laurie Barker, M.S.P.H.; and Bruce A. Dye, D.D.S., M.P.H. 

    3. Nyscof: "Opposite to predictions, since fluoridation began in 1945:"

    Facts:
    A. There was no prediction made that there would be no crisis in untreated dental decay. Water fluoridation is simply a very effective means of preventing a significant amount of dental decay in entire populations. It was never expected to be a cure-all for all dental decay.

    B. "Fluoridenews" is nothing but nyscof/Kopf's own, personal blog, on which are posted her own skewed editorials. It is valid evidence of nothing.

    C. There was no prediction made that "new dental professionals" would not be created.

    D. There was no prediction made that new dental schools would not open. A number of dental schools closed in the early 1980's.

    E. There was no prediction made that dental expenditures would not increase. These increased expenditures are a reason for fluoridation, not against it.

    F. There was no prediction made that "Poor children’s cavities are more prevalent, severe, occur earlier and more likely to be untreated." Again, this is a reason for fluoridation, not against it.

    G. Poor access to affordable care is most certainly a problem. Again, this is a reason for fluoridation, not against it.

    H. There was no prediction that more states would not have a need to hire Dental Directors. Again, the need for more Dental Directors is a reason for fluoridation, not against it.

    I. There was no prediction made that meetings would not occur to discuss the problem of untreated dental decay.

    J. Because antifluoridationist groups cannot provide any valid, peer-reviewed scientific evidence that optimally fluoridated water is in any manner unsafe, they fall back on the tactic of attempting to discredit highly respect organizations such as the CDC, with unsubstantiated nonsense

    K. There was no prediction made that 52% of new recruits would not have oral health problems. Again, this is a reason for fluoridation, not against it.

    L. There was no prediction made that dental socioeconomic disparities would not increase. Again, this is a reason for fluoridation, not against it.

    M. There was no prediction made that as the population grows, there would not be an increased need for dentists.

    N. There was no prediction made that there would not be astronomical expenses incurred resultant of untreated dental decay.  MAt less than $1 per person, per year for fluoridation, the astronomical dental expenses are one of the most compelling reasons for water fluoridation. They certainly are not a reason to oppose it.

    O.  Congratulations to "US Senator and Presidential Candidate Bernie Sanders" for stating the obvious. The need for more dental providers and the overwhelming problem with untreated dental decay..........are reasons for fluoridation, not against it.

    Steven D. Slott, DDS

    Unsuitable or offensive? Report this comment

  • Among her usual array of misinformation, "Nyscof", aka Carol Kopf, the "Media Relations Director" for the New York antifluoridationist faction, "Fluoride Action Network", actually presents some very convincing arguments which fully support fluoridation.


    1. Nyscof: "Fluoridation is a dismal failure in the US".

    Facts:
    Countless peer-reviewed scientific studies clearly demonstrate the effectiveness of fluoridation in the prevention of dental decay in entire populations. I will gladly cite as many as anyone would reasonably care to read.

    The overwhelming problem with untreated dental decay existing in the US and most other countries is a reason for fluoridation, not against it.

    2. Nyscof: "Instead of spreading less tooth decay across the land, fluoridation spread dental fluorosis (fluoride-discolored teeth) into every nook and cranny of America. Even though the CDC reports up to 60% of adolescents are afflicted with dental fluorosis, 51% of them have cavities.


    Facts:
    A. The only dental fluorosis in any manner attributable to optimally fluoridated water is mild to very mild, a barely detectable effect which causes no adverse effect on cosmetics, form, function, or health of teeth. As peer-reviewed science has demonstrated mildly fluorosed teeth to be more decay resistant, many consider this effect to not even be undesirable, much less adverse.

    The hypocrisy of nyscof and her "FAN" is clearly evident by their constant attempt to fear-monger about benign, barely detectable mild dental fluorosis, while discarding the lifetimes of extreme pain, debilitation, development of serious medical conditions, loss of teeth, and life-threatening infection directly resultant of untreated dental decay which could be, and is, prevented by water fluoridation.

    B. The 60% dental fluorosis to which nycof refers is actually 41%, as reported in a 2010 CDC study by Beltran-Aguilar. This 41% was composed of 37.1% with mild to very mild dental fluorosis, both of which are barely detectable, benign effects requiring no treatment, and which have no effect on cosmetics, form, function, or health of teeth....with the other 3.8% being those with moderate dental fluorosis, attributable to improper ingestion of toothpaste and/or exposure to abnormally high levels of environmental or well-water fluoride during the teeth forming years of 0-8.

    ----Prevalence and Severity of Dental Fluorosis in the United States, 1999-2004
    Eugenio D. Beltrán-Aguilar, D.M.D., M.S., Dr.P.H.; Laurie Barker, M.S.P.H.; and Bruce A. Dye, D.D.S., M.P.H. 

    3. Nyscof: "Opposite to predictions, since fluoridation began in 1945:"

    Facts:
    A. There was no prediction made that there would be no crisis in untreated dental decay. Water fluoridation is simply a very effective means of preventing a significant amount of dental decay in entire populations. It was never expected to be a cure-all for all dental decay.

    B. "Fluoridenews" is nothing but nyscof/Kopf's own, personal blog, on which are posted her own skewed editorials. It is valid evidence of nothing.

    C. There was no prediction made that "new dental professionals" would not be created.

    D. There was no prediction made that new dental schools would not open. A number of dental schools closed in the early 1980's.

    E. There was no prediction made that dental expenditures would not increase. These increased expenditures are a reason for fluoridation, not against it.

    F. There was no prediction made that "Poor children’s cavities are more prevalent, severe, occur earlier and more likely to be untreated." Again, this is a reason for fluoridation, not against it.

    G. Poor access to affordable care is most certainly a problem. Again, this is a reason for fluoridation, not against it.

    H. There was no prediction that more states would not have a need to hire Dental Directors. Again, the need for more Dental Directors is a reason for fluoridation, not against it.

    I. There was no prediction made that meetings would not occur to discuss the problem of untreated dental decay.

    J. Because antifluoridationist groups cannot provide any valid, peer-reviewed scientific evidence that optimally fluoridated water is in any manner unsafe, they fall back on the tactic of attempting to discredit highly respect organizations such as the CDC, with unsubstantiated nonsense

    K. There was no prediction made that 52% of new recruits would not have oral health problems. Again, this is a reason for fluoridation, not against it.

    L. There was no prediction made that dental socioeconomic disparities would not increase. Again, this is a reason for fluoridation, not against it.

    M. There was no prediction made that as the population grows, there would not be an increased need for dentists.

    N. There was no prediction made that there would not be astronomical expenses incurred resultant of untreated dental decay.  MAt less than $1 per person, per year for fluoridation, the astronomical dental expenses are one of the most compelling reasons for water fluoridation. They certainly are not a reason to oppose it.

    O.  Congratulations to "US Senator and Presidential Candidate Bernie Sanders" for stating the obvious. The need for more dental providers and the overwhelming problem with untreated dental decay..........are reasons for fluoridation, not against it.

    Steven D. Slott, DDS

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