‘Educate not medicate’ were the last words heard from a panel of speakers on Tuesday night as the bell rang to close a three-and-a-half-hour workshop investigating the potential harms and benefits of fluoridating the Lismore water supply.
The audience heard claims and counterclaims, statistics, survey results and academic studies quoted regarding the efficacy or otherwise of the chemical. But perhaps the strongest argument raised by fluoride opponents was why governments feel it is appropriate to provide mass medication through the water supply.
The workshop preceded a Lismore City Council (LCC) meeting next week to decide finally whether the city’s water supply will be fluoridated or not.
The pro-fluoride team consisted of Dr Stephen Conaty (who replaced Professor Wayne Smith), the state’s chief medical officer, Dr Kerry Chant, and Dr Brendan White.
All agreed that there was no evidence that suggested any harm from fluoridating water other than dental fluorosis.
This was seriously discounted by the anti-fluoride team, which comprised Dr Andrew Taylor, Dr John Ryan and Merilyn Haines.
The latter group argued there was ‘ample evidence’ of harm associated with fluoridating water and questioned the ethical grounds for mass medication.
Both sides found common ground in the areas of preventive health measures, dental health education and accessibility to dental care playing integral roles to public dental health.
The night began with one hour of floor space for the anti-fluoride compound (AFC) team.
Dr Ryan, who sat on a committee of the Therapeutic Goods Administration (TGA) for six years, said the TGA has never evaluated fluoridation chemicals for their safety and effectiveness.
Dr Ryan said that water fluoridation is ‘mass medication’ and ‘there can be no comparisons with chlorination of water’.
‘Chlorination is to treat water to make it safe to drink; fluoridation is to treat people,’ Dr Ryan said.
‘Fluoride chemicals are added to public drinking water with the intention of having a therapeutic effect on part of the human body,’ Dr Ryan said.
‘Mass medication violates two serious principles of medical ethics; one is the principle of informed consent and the second is the principle of controlled dose.
‘Fluoridation does to a whole community what a doctor shouldn’t do to a single patient.’
Dosage is a critical argument according to Dr Ryan, who said that concentration in the water can be controlled but the dosage cannot.
‘The dose is dependent upon how much you drink,’ Dr Ryan said.
Dr Ryan listed the following high-intake fluoride groups: bottle-fed babies, labourers and athletes, people with diabetes, heavy tea drinkers and healthy people who drink a lot of water.
‘Bottle-fed babies will get 200 times the amount of fluoride than a breast-fed baby will get – much more than what mother nature intended,’ said Dr Ryan.
Although fluoride is naturally occurring in the environment, Dr Ryan said it is not a proven nutrient.
Dr Ryan said, ‘it is not an okay argument to say well we put folic acid and iodine, for example, as food additives to make amends for possible nutritional deficiency [as] there is no such thing as fluoride deficiency’.
The bioaccumulation of fluoride is also of concern to Dr Ryan.
‘Infants retain 80 per cent, healthy adults retain 50 per cent,’ said Dr Ryan. ‘Fluoride crosses the placenta, it is neurotoxic and deposits in the bone.’
Dr Ryan questioned councillors about their duty of care when he asked, ‘should councillors warn parents about constituting baby formula with fluoridated water?’
A group of studies put out by Harvard University were referenced by Dr Ryan to indicate that fluoride is a developmental neurotoxin.
‘Thirty-six human studies have found elevated fluoride exposure associated with reduced IQ and 16 animal studies showed fluoride exposure impairs the learning and memory capacity of animals,’ said Dr Ryan.
He said there were no Australian health and safety studies of fluoride exposure.
‘If you are looking at harm or risk a good place to start is the 2006 US National Research Council (NRC),’ he said.
The NRC research acknowledged that fluoridation can harm several body systems, he added.
‘The NRC was unanimous that under certain circumstances fluoride can weaken bones and can increase the risk of fractures.
‘The NRC acknowledged that fluoride can affect thyroid function. In the last decade fluoride was used to treat hyperthyroidism by European doctors around 2.3 to 4.5mg per day. These levels may be currently exceeded by those drinking tea or more than two to three litres of water per day!’
Results from a 2007 NSW dental health survey were shown by Dr Ryan.
‘Nearly 25 per cent of 11–12-year-olds in NSW fluoridated areas had some level of dental fluorosis,’ said Dr Ryan, ‘where 3.8 per cent of this age group showed moderate fluorosis. Only 0.2 per cent of 11–12 year olds in NSW non-fluoridated areas had moderate fluorosis.’
Dr Ryan said dental fluorosis was more than a decolouration of the teeth.
‘If fluoride harms the cells forming the developing teeth, what does it do to the rest of the body?’ he asked.
Dr Ryan said that the NRC recognised the increased risk of fluoride exposure to sufferers of kidney complaints and fluoride accumulation in the pineal gland was only discovered 15 years ago. He also said that around one per cent of the population are highly allergic to fluoride.
Good dental health does not rely on ingesting fluoride according to Dr Ryan: ‘it is continually proven to only work topically, we don’t need to swallow it’.
Dr Ryan said many countries have rejected fluoride, including: Germany, Italy, Sweden, Finland, France, Netherlands, Scotland, Belgium, Austria, Wales, Northern Ireland, India, Japan and China.
Earlier this year, 17 Queensland councils rejected fluoridation, he said.
Dr Ryan closed his presentation by quoting Professor Arvid Carlsson – Nobel prize in medicine 2000 – who said that fluoridation of water ‘is against all principles of modern pharmacology. It’s really obsolete. No doubt about that. I mean, I think those nations that are using it should feel ashamed of themselves. It’s against science.’
Merilyn Haines began her presentation talking about the chemical products used to fluoridate water, usually sodium fluoride, sodium silicofluoride or hydrofluorosilicic acid.
‘These are not pharmaceutical grade. Fluoridation codes of practice allow 500mg of heavy metals in every kilogram of sodium silicofluoride,’ said Ms Haines.
Ms Haines challenged the effectiveness of fluoridation and the media articles that bordered on ‘hysteria’ surrounding the dental health of children in northern NSW.
‘World trends show that child tooth decay has fallen equally in fluoridated and non-fluoridated countries; there is no difference,’ Ms Haines said.
‘The media suggested that every child in the north of NSW had a mouthful of rotting teeth. These were largely based on a North Coast Area Health Service (NCAHS) survey in 2007.
‘There would have been fewer than 50 children surveyed for each local government area (LGA) for the two age groups specified. Specific results for child tooth decay in Byron, Ballina and Lismore were not published.’
Ms Haines referred to data published in 2013 of an oral health report from NSW Health (from the 2007 survey), which showed that baby teeth in the northern NSW local health district area had the second-highest tooth decay in NSW.
‘You will also see that permanent teeth aged 11 to 12 are equivalent to four other districts and 0.2 of a tooth more decay than three other health districts. This is not third world country stuff.’
Lithgow was used as an example of fluoridation of an area that had below state average levels of tooth decay.
‘NSW Health has been trying to get Lithgow fluoridated for years. In 2010 they published a survey that compared non-fluoridated Lithgow with fluoridated Bathurst and fluoridated Orange as they were socially and economically comparable,’ said Ms Haines.
‘They found no statistical difference in baby tooth decay but they found that older children in Orange and Bathurst had less tooth decay than Lithgow. They did acknowledge that the average tooth decay in permanent teeth was low, less than the NSW and Australian average at that time.
‘Lithgow still got fluoride regardless.’
Ms Haines referred to an Australian Interstate Children’s Dental Survey that showed prior to fluoridation in Queensland, children at age 12 had very similar or even less decay than 12-year-olds from Tasmania (83 per cent fluoridated) and the ACT (100 per cent fluoridated).
According to Ms Haines, an adult oral health survey showed hardly any difference between the states.
Severe cases of tooth decay in small children are often used for the promotion of water fluoridation. Ms Haines sent a photograph of a child’s mouth with severe tooth decay used by the Queensland Health service to a professor at Toronto University.
‘He said this is baby-bottle tooth decay; it occurs in fluoridated cities and it is false and misleading to suggest that fluoridation would help these children,’ said Ms Haines.
Surveys (from 2005 to 2008) of popular support by NSW health for the support of fluoridation were reclassified as ‘push polls’ by Ms Haines.
‘These surveys only have small numbers in each area, eg in 2005 NSW Health surveyed 14 people in the Lismore LGA, 17 in 2006 and 19 in both 2007 and 2008. They also use leading questions,’ said Ms Haines.
Health risk assessments by NSW Health have not been carried out, according to Ms Haines, who referred to a right to information (RTI) request for any risk assessments or health impact statements that NSW Health had done for water fluoridation.
‘The outcome was the documents are not held by NSW Ministry of Health,’ said Ms Haines. ‘Instead they rely on the NHMRC 2007 review as proof of safety. The part that referred to water fluoridation was almost a copycat of the York University 2000 review.’
Professor Sheldon, who chaired the York review, later admitted the review ‘did not show water fluoridation to be safe; the quality of the research was too poor to establish with confidence whether or not there are potentially important adverse effects other than fluorosis; and that more research is needed’.
‘Prof Sheldon also said the size of the estimated benefit, only of the order of 15 per cent, is far from “massive”.’
The ethics of water fluoridation have not been formally considered, according to Ms Haines.
‘The Australian Ethics Committee has never considered fluoridation and yet Australia is a fluoridated country,’ said Ms Haines.
Dr Andrew Taylor is a local dentist who has worked in many districts and observed no difference between fluoridated and non-fluoridated areas, and believes images used of children with poor mouth decay are an exception.
‘This may be caused by one of many things: a child may be born with genetically affected teeth, low parental education, lack of parental care etc. This is not due to lack of fluoride,’ Dr Taylor said.
Dr Taylor challenged the core belief system used in dental education.
‘We are given information from our lecturers that we all believe to be true, and who are we to question? There is no time for independent research as a student, and there is an expectation that we will reproduce information at exam time.
‘In 1990, my eyes became open to misinformation about what we were taught. Look at mercury in dental amalgam – incredibly the use of dental amalgam is still taught in dental schools today,’ Dr Taylor said.
‘The history of fluoride has a past equally sordid as mercury amalgam. When it was first proposed to add fluoride waste from the aluminium industry to drinking water the American Medical Association, the American Dental Association and the US Public Health Service all expressed concerns saying fluorides are protoplasmic poisons inhibiting certain enzyme systems and they said they know the use of fluoridated drinking water containing 1, 2 and 3 ppm fluoride will cause developmental disturbances in bones.’
Dr Taylor has observed many NSW Department of Health presentations advocating water fluoridation
‘I am yet to see any real evidence to support the use of fluoridation. Their own document Oral Health 2020 indicates there is little to no difference in decay rates between NSW areas in permanent teeth of young people,’ Dr Taylor said.
Without risk assessment, Dr Taylor cannot see fluoridation as safe or effective and suggests preventive measures as being safer and more effective.
‘Adding fluoride to the water does not stop tooth decay. What we are lacking is effective education,’ said Dr Taylor.
‘Let’s look at what is available to us, a brand new five-chair dental clinic waiting to be used… we could run an education program with motivated local dentists, including myself, who could volunteer to provide practical pre- and ante-natal care… most local dentists have a fairly sharp social conscience.’
The pro-fluoridation team began with local dentist Dr Brendan White, who said that on moving here he was confronted straight away with poor dental health in children.
‘I moved from Adelaide, which is fluoridated, to here which isn’t, and noticed a difference straight away… I struggled to organise general anaesthetic for the worst cases,’ said Dr White.
Dr White said the ‘majority of the suffering is with five- to six-year-olds and is where fluoridation works and this area has amongst the worst in the state with this age bracket’.
He added that 11- to 12-year-olds ‘topped the state along with the zero- to four-year-olds’.
‘The reason the area doesn’t have the worst statistics among the older bracket,’ according to Dr White, is because ‘we treat them in the dentist chair under local anaesthetic; they don’t tend to go to hospital for treatment,’ he said.
Dr White began looking at dental fluorosis through fluoride occurring in the natural world and said that ‘individuals who are raised on a water supply containing a naturally high fluoride concentration develop teeth that have an unnaturally white appearance that may become stained and appear unsightly’.
But he said an American study of thousands of children living in environments where the drinking water was fluoridated at around one part per million ‘found the children had mainly normal teeth and that about 10 to 15 per cent had signs of very mild dental fluorosis’.
Naturally occurring fluoride was again referred to by Dr White, who said the above-mentioned research found abundant levels of tooth decay in communities where the fluoridate concentration was low.
The optimal concentration is 1ppm according to Dr White, who then quoted significant improvements from water fluoridation under the optimal concentration circumstances.
Dr White went on to discuss the basic pathology of tooth decay.
‘Under normal circumstances healthy saliva would remineralise the teeth,’ he said.
‘When fluoride is around it, the tooth will remineralise at a higher acid level than is achievable without fluoride, making those teeth more resistant to decay.’
Dr White then claimed that ‘water fluoridation accounts for 70 per cent of the reduction of dental decay, fluoride toothpaste accounted for 26 per cent and two per cent for fluoride tablets’.
These statistics were later questioned by Cr Isaac Smith, who said ‘that although our dental caries rates are still high they have dropped in the same fashion as elsewhere in the state with fluoridated water. So how can 70 per cent of that reduction be from fluoride?’
Dr White said that a lot of that reduction happened in the early 60s when water fluoridation and fluoride toothpaste were introduced, ‘it all happened at the same time’.
Cr Smith continued to press Dr White to agree that the ‘up to 80 per cent decrease in dental caries rates in this area can be directly related to toothpaste, oral hygiene and education’.
Dr White responded to Cr Gianpiero Battista’s question about preventive health saying that ‘it was difficult and expensive. I have tried it and tried it… preventive health doesn’t often reach the targeted part of the population you are trying to reach. Water fluoridation is equitable and reaches the part of the population we would have trouble reaching otherwise.’
The recent vote by Byron Shire councillors to not fluoridate their water supply was mentioned by Dr White, who said, ‘in Byron we lost but we didn’t even get to the vote five or six years ago, and really, one of our pro-fluoride councillors was away for this vote, so we lost by one vote’.
Cr Ekins referred Dr White to recent research that was presented at the American Dental Association annual session that she said, ‘shows that chocolate actually better repairs and remineralises teeth than fluoride’,
Dr Kerry Chant spoke on behalf of NSW Health and began her presentation by saying that ‘we are arguing at cross-purposes because clearly we are not saying you don’t have to do the other prevention stuff’.
‘We are picking up the lessons learnt and we are incorporating and sustainably embedding preventive dental health in our programs,’ said Dr Chant.
Receiving the optimum dosage of fluoride is a critical challenge of water fluoridation, as is administering public health messages to the target group.
Dr Chant said that ‘these programs, particularly with pregnant women, we know have challenges being receptive to health messages at a time when they are busy’.
The safety of fluoride was endorsed completely by Dr Chant who said that ‘proving a negative was very difficult’.
‘We monitor and evaluate and look at all literature available. We closely monitor our population and report on that… and have we observed epidemics of thyroid toxicosis when fluoride has been introduced? No. Can we pick up those? Yes.’
Dr Chant referred to NSW Health picking up the impacts of increased iodine in a small area that was connected to a soy product.
‘So in [terms of] a formal risk assessment of water fluoridation, no we haven’t [undertaken one]. But it is part of our standard operating environment to pick up clusters,’ said Dr Chant.
Dr Chant also argued that water fluoridation is cost effective, acceptable and ethical.
No other forms of fluoride supplementation – which include topical fluoride applications, fluoride toothpaste etc – have proven effectiveness or proven population reach as does fluoridation of the water supply, according to Dr Chant.
‘In some circumstances we do use strategies to access areas that cannot access fluoridated water. We are looking at fluoride varnishes to remote Aboriginal communities; it requires three applications a year so it is a very expensive way of engaging a high-risk population,’ she said.
Dr Chant acknowledged the small numbers in the NSW Health surveys regarding community acceptance of fluoride and stressed ‘there was no intent to mislead’.
‘Individual consent is not required because fluoride is a supplementation rather than medical intervention. Community consent is appropriate and adequate.’
‘Water fluoridation is ethical because the benefits outweigh the harms… we believe that dental fluorosis is the only side-effect of water fluoridation,’ said Dr Chant.
Cr Smith asked Dr Chant at her previous Lismore pro-fluoridation presentation for a breakdown by LGA for children ‘who have dental surgery at Lismore Base Hospital as it collects all the dental surgery for the region and given that some LGAs are fluoridated shouldn’t we see a decrease in those areas?’
Dr Chant said that she had to be careful providing that information ‘because of identification issues around small samples but I am happy to provide that (at some other time)’.
Cr Ritchie asked Dr Chant if ‘any of the strategies that Byron Shire wants to put in place will be effective?’
‘We have resources already in place particularly in the ante- and post-natal periods, and other preventive health messaging, and others coming on board next year, so we are keen to provide details on how those programs are travelling,’ said Dr Chant.
Cr Greg Bennett asked Dr Chant why so many European countries are rejecting fluoride.
‘… Some countries have taken other approaches, for which sustainability needs to be proven, but sadly a large part of the world does not have access to reticulated water which you need for fluoridation.’
Cr Bennett said ‘surely that is not an issue with Europe?’
‘No, but in Europe they come from different positions, what role governments take, so some of the policy positions dictate why they haven’t fluoridated… It is largely the political structural issues around the approach taken to public health,’ Dr Chant said.
Dr Stephen Conaty is also from NSW Health and was the last speaker for the pro-fluoridation team. He looked at issues evaluating harm from fluoride and described hierarchies of evidence.
‘When I was taught in epidemiology we were taught to not use hospital controls,’ said Dr Conaty. Hospital admissions for children with severe dental health decay are used regularly by NSW Health and some media to advocate for water fluoridation.
Cr Ekins asked Dr Chant to clear up the contradiction.
‘I use a range of indicators including population health surveys and hospital admissions,’ said Dr Chant.
Dr Conaty continued on to discount claims of effects from fluoride. Many of these harms only occurred as a result of high doses (around 4mg per litre) of fluoride, he said.
‘This does not apply to Australia as we do not have those concentrations,’ said Dr Conaty.
This was challenged by a couple of councillors and the public gallery as groups within the population drink more than others and could potentially be exposed to high doses, whereas the target group may not drink enough water to receive the optimum dosage advocated by NSW Health.
Dr Conaty said that ‘if you are consuming four times the amount of water as the average person you would be getting the equivalent dosage as someone who came from an area that was getting 4mg per litre of fluoride in their drinking water.’