Speech to Seanad Eireann: Fluoridation. January 2013

4th February 2013

I acknowledge and thank the Senators for holding this debate. I commend everyone who contributed, including Senators Norris and Quinn, who tabled this motion. The Government will not support it in its current form, but the Government has proposed an amendment that provides for the continuing review of this important issue of public interest and concern. As such, the amendment seems to cover the point about the need for these matters to be kept under review.

I wish to address a comment made by Senator Cullinane. He was not necessarily being critical, but it is important that I address his point. Senator Barrett and others on all sides of the argument also touched on it. It is not the Government’s intention, wish or belief that there would not be a debate on this issue or that raising and considering it in a motion of the House would not be appropriate. As a Minister of State in the Department, I would not be entitled to have an objection to the Seanad doing so. The Government has no objection to there being informed public debate, as has been the case with this discussion.

Most of those present in the Chamber are not scientists. Irrespective of what side of the House we are on, we must all rely on the expert opinion, scientific evidence and the reports that have been prepared.

On issues of public health or particularly issues which involve scientific or technical matters, we as politicians do not have that particular expertise to bring to the table in the way, for example, that Senator Barrett would have economic expertise or others would have different elements of expertise to bring to the table. This is a serious point; most of us do not have that kind of experience, therefore, we have to rely on the evidence. I think it was Senator Whelan who emphasised the importance of not being selective, not selecting this or that piece of evidence that might support an argument that we instinctively feel is right and then leap on one particular study and think it is the one I like most because it seems to accord with my thinking. We have to examine the evidence. What I would ask the House to do, and this is what the Government is doing with the Department of Health’s approach to this, is to look at the preponderance of evidence. No one is saying there are no studies that are critical of the policy or that there are no interventions that do not criticise or question the policy. There are such studies and certainly there are such claims, but I suggest in the strongest terms to colleagues that the preponderance of evidence supports a continuation of the policy of the Government while keeping it under continuing review. That is what I would ask colleagues to agree to in the course of this discussion and, I respectfully ask, in the decision they will make on foot of the motion before them.

I support the Government’s amendment to the motion which will come as no surprise. Many of the Senators have already outlined the original rationale for fluoridation, namely, fluoride at the optimal level in the water supply provides what has been described as a repair kit for teeth, making teeth more resistance to decay in people of all ages. I am very taken by the points that have been made in respect of the importance of dental health and it is not something that is a “by the way” comment or that can be treated lightly. It is a vitally important element of public health.

An all-Ireland study on children’s oral health in 2001-02 has shown that children and adolescents residing in fluoridated areas have fewer caries than those in non-fluoridated areas. The Oral Health of Irish Adults Study 2000-2002 also showed decay scores were lower among fluoridated groups for all age groups and particularly in the 35 to 44 age group. This is a study that puts clear evidence before us.

Water fluoridation is recognised by the Centers for Disease Control and Prevention of the United States public health service, as has been stated in the amendment to the motion, as one of the ten great public health achievements of the 20th century. Some 350 million people in 35 countries around the world have fluoridated water and 70% of the US population has water fluoridation.

The background to this, on which Senator Norris or others have touched, is that fluoridation began in Ireland in 1964 on foot of the Health (Fluoridation of Water Supplies) Act 1960. That Act provides that the health authorities shall arrange for the fluoridation of public piped-water supplies and that local authorities act as agents for the health authorities in providing, installing and maintaining equipment for fluoridation, in adding the fluoride to water and in testing the fluoride content of water to which fluoride has been added. These functions are provided for in the Fluoridation of Water Supplies Regulations 2007 which revokes previous fluoridation regulations. Currently approximately 68% of the population receives fluoridated public water supplies.

The policy of fluoridation, as was mentioned on a number of occasions in this debate, was the subject of a major review in 2000. A Forum on Fluoridation was established by the then Minister for Health and Children which comprised largely of persons with expert knowledge from the fields of public health, dental health, food safety, environmental protection, law and ethics, water quality and health promotion, together with a consumer representative. The report of the forum was published in 2002. Its main conclusion was that the fluoridation of public piped water supplies should continue as a public health measure. The forum also recommended that given the increased access to fluoridated toothpaste and in light of the best available scientific evidence, the optimal level of fluoride in water should be redefined from the then level of 0.8 to 1 parts per million to between 0.6 and 0.8 parts per million with a target value of 0.7 parts per million. The parts per million is equivalent to milligrams per litre. This change was implemented by the Fluoridation of Water Supplies Regulations 2007, to which I have referred. It is worth noting that EU law defines a maximum permitted concentration of 1.5 parts per million for public water supplies through its drinking water directives. The Irish levels are set at less than half that permitted by EU legislation.

Another important recommendation of the forum was that an expert body should be established to implement the recommendations of the forum and to advise the Minister and evaluate ongoing research on all aspects of fluoride. I emphasise the vital necessity of having a reliable source of scientific evidence that can be available for public consumption and for the information of public representatives such as ourselves in order that we can evaluate and assess the correctness or otherwise of the policy position being adopted. That export body is an important element and support for our work as public representatives and as a Government.

The expert body on fluorides and health was established in 2004. The expert body and its sub-committees have broad representation from areas such as dentistry, biochemistry, environmental health, public health medicine and food. The expert body also has a consumer input in terms of members of the public and representatives of consumer interests. The sub­committees of the expert body may also co-opt members as the need arises. Of the expert body’s 17 members, five are members of the dental profession. These include two former chief dental officers in the Department of Health, two senior academics, one of whom is also a former chief dental officer, and two from the public dental health service. They have extensive experience in areas of public health, dental epidemiology, statistics, fluorides and health promotion.

In evaluating ongoing research on all aspects of fluoridation, the expert body accepts the fundamental scientific tenet, and this is important, that any single piece of scientific evidence by itself remains essentially hypothetical unless it can be repeated or confirmed by other scientists or other studies. Therefore, it considers scientific evidence that has been submitted to examination by other scientists, usually by publication in recognised peer reviewed scientific journals, after such publication has been approved by independent referees, which is entirely in line with the practice that has been adopted for many years internationally in relation to the evaluation of scientific evidence. This ensures that the advice provided by the expert body is impartial and evidence-based.

The expert body is satisfied, having studied current peer reviewed scientific evidence worldwide, that water fluoridation at the optimal level does not cause any ill effects and continues to be safe and effective in improving the oral health of all age groups. These views are supported by reputable international agencies and valid scientific articles and reviews.

I am aware that consumers sometimes express concerns about potential negative effects on health of drinking fluoridated water, on the composition and source of fluoride or on the fact that some countries do not fluoridate their water supplies. I wish to assure the Senators that drinking fluoridated water with the optimal amount of fluoride is not harmful to human health. The opinion of the expert body on this matter is supported by the World Health Organization, the Centers for Disease Control and Prevention, the public health service and the surgeon general of the United States, the World Dental Federation, the International Association for Dental Research, the Royal College of Physicians of England and by major international scientifically validated reviews in many countries. A major review was conducted by the European Union in 2011. The main conclusions of the report of the EU’s Scientific Committee on Health and Environmental Risks are that there is no known health implications from fluoridating water at levels used in the EU.

The only known side effect of optimal water fluoridation is mild dental fluorosis. This has been known about since the 1930s. Dental fluorosis is a cosmetic or aesthetic condition which refers to the way teeth look. It is not considered to be an adverse health effect. At the levels of fluoride present in Ireland’s water supplies, any occurrence of dental fluorosis is very mild or mild and in most cases is only detectable by a dentist as faint white flecks on the surface of the teeth. In the majority of cases dental fluorosis generally does not require any treatment. Regularly conducted studies on dental health in Ireland, carried out when the upper limit for fluoridation was 1 parts per million - it is lower now - confirm the low level of dental fluorosis in Ireland.

The non-treatment of dental fluorosis has no health consequences. The non-treatment of tooth decay, on the other hand as was mentioned, can lead to pain, trauma, disfigurement, loss of teeth and function, problems with nutrition and growth, absenteeism from school or work and significant financial and social costs across the life cycle of an individual.

The fluoride added to our water supplies is in the form of hydrofluosilicic acid and is in compliance with the specifications for that substance, which are set out in the 2007 regulations. This issue was raised by Senator Keane. It is sourced as a primary product in Spain, mined directly from a raw material source, the mineral fluorospar. It then goes through a purification process to produce the acid. Representatives of the expert body on fluorides and health conducted a site visit to Spain and were satisfied that the production is in compliance with the quality, environmental and safety systems and procedures in place and that the company, Derivados del Fluor, strives to ensure these systems and procedures are maintained and continually reviewed.

It is sometimes claimed that the product used in Ireland is a waste product from the fertiliser industry; this is not the case. Others issues such as the toxicity or corrosiveness of the product are also raised from time to time. These issues only apply to the raw undiluted acid and necessitate great care and suitable safety precautions for those handling it. When added to water in the correct amount, the acid dissociates or separates completely releasing fluoride ions into the water and is not toxic or corrosive.

A code of practice has been produced by the expert body with the support and co-operation of organisations such as the local authorities, Environmental Health Officers Association, Health and Safety Authority, EPA, HSE and others. The purpose of the code is to ensure the proper implementation by all personnel involved of the procedures for the fluoridation of the public water supplies to the prescribed standards and to minimise the risk of injury or damage to plant, personnel and environment. The code does not modify or set aside in any way, the obligations or requirements of the operator of the water treatment plant under other legislation such as health and safety statues. The code applies to all water treatment plants where the fluoridation of water supplies is, or will be, carried out. The expert body will continually review this code of practice. The legislation on water fluoridation requires that a daily test be carried out at water treatment plants by the local authority water services staff. Monthly fluoride testing is carried out by the HSE and the EPA also carries out testing which requires monitoring of fluoride levels in water supplies. If the fluoride levels are found to be outside the range specified in the legislation, those responsible are notified, prompt adjustments are made to the dosing equipment and a new test carried out.

All EU states have fluoride, in one form or another, at the centre of their public policy approach. For some European countries, water fluoridation is impracticable due to the large number of separate water sources. Many of them choose salt fluoridation or milk fluoridation as an alternative to give the health benefits of fluoride exposure to their citizens. Several countries have opted to use other approaches to fluoridation such as in investing in large public dental services, as in Holland and the Nordic countries. In such cases, fluoride is administered to children in school clinics. This would require a significant investment in personnel and resources in Ireland. Water fluoridation is the most cost-effective method of preventing dental decay and thus overcoming the poor risk profile in Ireland. There is evidence also that other methods of fluoridation such as milk fluoridation or topical applications are not as clinically effective. There is also evidence that water fluoridation may have particular advantages for persons on lower income.

Major fluoridating countries include the USA, Australia, New Zealand, Canada, Malaysia, Israel, Singapore, Hong Kong, Colombia and Chile. Fluoridation coverage in the USA increased by approximately 24 million people between 2002 and 2012 and population coverage in Australia also increased in 2012. Almost 5.8 million people in the UK have fluoride added to their water and another 330,000 have naturally fluoridated water. Approximately 10% of the population in Spain have fluoridated water. Salt fluoridation is practised in many South and Central American countries and also in the EU, notably in France, Germany and other central European states.

Water fluoridation is one of the most widely studied public health policy initiatives in the world. The design and evidence is poor in some studies but the expert body only considers scientific evidence that has been peer reviewed and approved for publication in recognised scientific journals. Studies in Ireland and worldwide have found that water fluoridation has a significant benefit for dental health among both children and adults. Persons residing in fluoridated areas have better teeth with less disease than those residing in non-fluoridated areas. For example, in the last all-Ireland study conducted in 2001-02, there were approximately 40% fewer cavities in children living in fluoridated areas. Ireland is among the worst countries in Europe for high frequency consumption of sweets and confectionery by children and adolescents. Our children and adolescents have generally poor tooth brushing habits compared to their European counterparts. Accordingly, the use of fluoridated toothpastes alone is insufficient to prevent tooth decay.

The Health Research Board has recently approved funding for a study to be led by the Oral Health Services Research Centre of University College Cork and the Department of Health is a collaborator in the study. The study entitled, What Impact Have Major Policy Changes Had on Oral Health in Ireland? Establishing a Blueprint for Oral Health Surveillance, will consider the impact of changes on the oral health of children, following policy decisions relating to fluoride toothpaste use for infants and young children in 2002 and the reduced level of fluoridation in drinking water since 2007. Surveys on children’s and adults oral health have been conducted on a regular basis to measure the effectiveness of water fluoridation in the State. These include national studies in 1984, 1990, 2001 and 2002, regional studies between 1990 and 1999 and a cross-Border study in 2006. All these studies showed a substantial benefit in terms of the reduction in tooth decay experience. The expert body is unaware of convincing scientific evidence to the contrary in Ireland.

I wish to emphasise the main issues are that use of fluoridated water has a substantial benefit for oral health over and above the use of fluoridated toothpaste; water fluoridation is the most cost-effective method of preventing tooth decay and overcoming the high risk of dental caries in the Irish population given our dietary habits, which include consuming a large volume of confectionery and fizzy drinks, regrettably, and generally poor tooth brushing habits; there is evidence that water fluoridation has particular advantages for reducing dental health inequalities for persons on lower income; and our water fluoridation systems are subject to ongoing quality assurance to ensure compliance with legislation and standards.

I draw the attention of Senators to additional studies that are publicly available, including a position paper from the expert body published on its website in 2012. It is essentially a survey and it does not purport to pull together all the material and evidence. It offers an important and timely survey of the current position on water fluoridation and the views and the conclusion of the expert body. It is very much up to date and it has the benefit of analysing reviews conducted in a considerable number of countries in recent years such as the York review of 2000 to 2002 in England, Australia in 2008, Canada in 2010 and the US in 2006. None of these reviews has established a basis for considering that artificially fluoridated water poses systemic health risks. The position paper also deals with report of the EU scientific committee on health and environmental risks. The expert body report is up to date and concludes that:

There continues to be overwhelming evidence that water fluoridation significantly benefits dental health. The expert body is satisfied having studied current peer reviewed scientific evidence worldwide that water fluoridation does not cause any ill-effects and continues to be safe and effective.

The expert body is satisfied, having studied current peer reviewed scientific evidence worldwide, that water fluoridation does not cause any ill effects and continues to be safe and effective. Senator Cáit Keane raised a fair question on public information. There is also to be found on the website a document with which we are all familiar nowadays, FAQs, frequently asked questions, which appears to turn up everywhere. A list of 25 frequently asked questions is available which deal in some detail with some of the issues Senators have raised, including Senator Cáit Keane who asked what additives are used to fluoridate Irish drinking water the acid concerned, which I will not attempt to pronounce, and its source. The science surrounding the entire issue is broken down and explained in clear terms in the frequently asked questions document.

The report to which Senators have referred, which was prepared by Mr. Waugh, has been considered. I do not want Members to go away from the debate with the view that the Government, the Department or the expert group close their eye to documents, submissions or interventions that, for some reason, go against the grain. These documents are read. I have read Mr. Waugh’s report. The expert group has read his report and has published, again on the website, a detailed response dealing with each of the issues raised by Mr. Waugh. He raised some issues in respect of what he regards as legal objections. They are disposed of very clearly in the expert group’s response. The European Commission has addressed any concerns that may arise in respect of any suggestion that the policy runs counter to EU directives. It does not and the view of the European Commission in that regard is set out very carefully in the expert group report. There is no legal impediment either as a matter of Irish law - that has been the case for almost 50 years - or as a matter of European Union law to a water fluoridation policy.

In regard to the alleged adverse health affects, I have read Mr. Waugh’s report. I am a lay person in this regard; I am not a scientist. Even in those circumstances, one has to look for the evidence for some of the assertions made in that report. I can only rely on the expert group’s responses where it states in respect of Mr. Waugh’s report that the author does not include in the document the many reports and reviews from respected international agencies confirming that there are no known adverse affects on health from fluoridation. If a member of the public, including Mr. Waugh, or a Member of the House brings forward a report in good faith - I do not suggest anything other than good faith on his part - we would have an expectation that a scientific report would at least have regard to other evidence. The lifeblood of scientific research is that one puts forward one’s own hypothesis but one must have regard to the evidence against and one has to weigh up the issue. The author, Mr. Waugh, might well say it was not his job to look at all the other evidence but it is our job to weigh up the evidence and what is being said and to examine the science. The question we have to ask is not if there are objections or if some people are unhappy or if some people have campaigned against it in good faith but what is the preponderance of the evidence as we weigh it up. Let us look at the evidence we are given and the studies done and at the conclusions drawn from those studies. I accept what Senator Norris said about the importance of this kind of public health policy being kept under review. That is why the amendment to the motion notes that it should be and is kept under review. However, I do not accept that there is a sufficiency of evidence or objection that could conceivably persuade the House that it should seek to change it or draw it into question, which a call for a review on its own does. The point was made by Senator John Gilroy that language is very important.