Water Fluoridation

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Water Fluoridation

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

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Medical Officer of Health

• Special relationship with the Council
• Doctor practicing in
• public health
• Epidemiology
• Health risk assessment risk management
• Independent statutory officer
• Kapitis Medical Officer of Health

Original map by Dr. John Snow showing the
clusters of cholera cases in the London epidemic
of 1854
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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

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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
  available
• Very conservative
• Unbiased

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Findings Effect of removing fluoridation on
health

• Health losses
• Caries up 15
• 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

• Health gains
• nil

We expect the same for Kapiti
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Did consider possible health gains

• Dental fluorosis (aesthetic)
• Skeletal fluorosis
• Osteosarcoma
• Other health conditions
• But NO HEALTH LOSSES OR HEALTH GAINS

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Osteosarcoma

• 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

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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

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The Process

• No invitations
• Annual Plan process fast tracking
• Consultation?
• Impartiality?
• Ministry of Health viewed as heavy weights

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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.

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Advice on tactics used by opponents to Fluoride
Denying the benefits of water fluoridation Denying the benefits of water fluoridation
Selective reporting of studies Downplaying or ignoring the evidence
Selective reporting of results Using ecological comparisons
Fear mongering Fear mongering
Misrepresentation of the truth Enforced medication
The big lie Bamboozling with science
Half-truths Moving the goalposts
Innuendo Paranoia, conspiracy theories and extremism
Follow the leader
Incomplete list
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DENYING THE BENEFITS OF WATER FLUORIDATIONSelecti
ve 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.

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FEAR MONGERINGMisrepresentation of the truth
andThe big lie

• Infant formula made up with fluoridated water
• ADAs 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

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FEAR MONGERINGMass 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

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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

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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

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CDC

• 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