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Briefing on water fluoridation for london SHA and PCT CEs and DsPH

Water fluoridation is a safe and effective community measure to reduce inequalities in oral health. Amendments to the Water Act are currently going through Parliament, and if agreed should enable the provision of water fluoridation in communities who have approved this through appropriate local consultation. There are significant inequalities in oral health in London which could be addressed through water fluoridation. The presence of the London Ring Main would necessitate a coordinated pan London and wider approach, supported by a detailed feasibility study.

It is recommended that the London Health Agencies:-

  • review their individual position on water fluoridation, taking into account any recommendations from the forthcoming CMO/CDO report to ministers and the outcome of the current amendments to the Water Act
  • consider the establishment of a London Water fluoridation Working Group, of wide membership
  • consider commissioning the updating of the 1996/97 technical feasibility study, including costs

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Fluoride is naturally found in water, in the United Kingdom the levels are typically less than the optimum for dental health of 1 part per million. The benefits to teeth of fluoride in drinking water were discovered as the result of natural observational studies in the USA during the early 1900s.

The responsibility for water fluoridation currently lies with Strategic Health Authorities. The Water (fluoridation) Act 1985 requires District Health Authorities to consult widely in determining either initiation or cessation of water fluoridation. There have been many formal consultations carried out by Health Authorities since the 1985 legislation, but all formal requests for new schemes have been refused by the pre- and post-privatisation water industry as the Act gave the water companies the discretion to refuse. Amendments to the Water Act are currently going through due Parliamentary process.

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National and International fluoridation

3.1 Five million people in the UK now receive water in which the fluoride content has been artificially increased to a level of 1 part fluoride per million parts of water. In addition, about 500,000 people in this country receive water which naturally contains fluoride at a lower level, but which still confers some dental benefits. This translates to 10% of the total population of the UK.

Worldwide, around 360 million people drink water-containing fluoride, 317 million people in 39 countries benefit from artificially fluoridated and an additional 40 million benefit from water supplies which are naturally fluoridated. In the United States, since the mid 1990s, several large metropolitan areas have started fluoridation including Los Angeles, and Las Vegas. Many other US cities have been fluoridated for years New York, Chicago, Dallas etc. Forty-seven of the US's 50 largest cities are now fluoridated (66% of the population). 66% of the population of Australia drink fluoridated water, and 56% of New Zealand.

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The Evidence

The practice of fluoridation water has been endorsed by the World Health Organisation, the British Medical Association, the Faculty of Public Health Medicine, the British Dental Association, and in the USA, by the Surgeon General, the American Medical Association and the American Dental Association. These endorsements were made in the light of evidence from the many studies conducted worldwide over a period of at least 50 years that fluoridated drinking water reduces tooth decay and has no adverse effects.

World Health Organisation Expert Committee on Oral Health Status and Fluoride Use:

  • There is clear evidence that regular low-level exposure of a population to fluoride can reduce caries prevalence.
  • Community water fluoridation is safe and cost-effective and should be introduced and maintained wherever it is socially acceptable and feasible.

WHO Environmental Health Task Group - worldwide review of fluorides 2002: 1

  • No consistent evidence of association with morbidity or mortality due to cancer.
  • No evidence of association with spontaneous abortions/congenital malformations.
  • Conclusions similar to Medical Research Council Report.

The York Review. A comprehensive review evaluating the safety and efficacy of fluoridation was commissioned by the Government from the NHS Centre for Reviews and Dissemination and published in October 2000 2. The York Review - A systematic review of public water fluoridation found that fluoridation is effective in reducing tooth decay and that there is no evidence of harm - which is in line with the findings of all other authoritative reviews. In terms of reducing tooth decay the main finding was a mean reduction of 2.25 decayed, missing or filled teeth and an increase of 15% of children decay free. The review provided researchers and commissioners of research with an overview of the methodological limitations of previous research conducted in this area, i.e. because of the long history of fluoridation some of the evidence is old and was not conducted to current standards of research. The Government therefore commissioned the Medical Research Council to investigate the research required to strengthen the evidence base on fluoridation.

The Medical Research Council Report - Water fluoridation and Health was published on 5th September 02 3. This report provides further reassurance about the safety and effectiveness of fluoridating water supplies to improve dental health. Their main messages were as follows:

  • No evidence for significant health effects on immune system, reproductive system, child development, the kidneys, the gastro- intestinal tract
  • No evidence for significant health effects related to chemicals added in the fluoridation process, or for indirect effects such as increased leaching of lead from pipes and aluminium cooking utensils or altered uptake or toxicity of these substances
  • Available evidence shows no link between either cancer in general or any specific cancer type. MRC recommends an updated analysis of UK data in fluoridation and cancer rates
  • Hip fracture, current evidence suggests no effect, but cannot rule out small percentage change in either direction
  • Support for findings that it helps to reduce dental decay
  • Reduces inequalities in dental decay between high and low social groups
  • Support for findings that it helps to reduce dental decay

The association between dental fluorosis and drinking water has been recognised for over 100 years. Dental fluorosis is a cosmetic problem. There are also many other causes of dental mottling which may be difficult to differentiate form fluorosis clinically. The York Review estimated that 48% of the population in fluoridated areas will have some degree of dental fluorosis. Unsightly dental fluorosis will affect a much smaller percentage of people. Most people with mild dental fluorosis do not know that they have it, and because it gives the teeth a pearly white appearance at this level, such teeth are often considered more attractive. It has been suggested that the York estimate is far too high for the UK as it is based largely on united States data. The MRC suggested further work on this but said the UK prevalence of fluorosis likely to be of aesthetic concern is 3% in fluoridated areas and 1% in non-fluoridated areas. Whilst undesirable, dental fluorosis is not a health threat, nor is it as disfiguring as severe tooth decay.

The key research recommendations made were as follows:

  • Continued and improved monitoring of trends in fluoride intake - particularly in children
  • Whether the uptake of fluoride from artificially and naturally fluoridated water is the same.

A joint Chief Medical Officer/Chief Dental Officer Advisory Group is currently working through the recommendations of the MRC Report. It is anticipated that information from the review may be available by Autumn 2003. The biochemical research on bioavailability of fluoride form natural and artificial sources should also be published this autumn, plus information on fluoride intake in children from the fluoride in urine analysis within the National Diet and Nutrition Survey.

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Government Policy

The Independent Inquiry into Inequalities in Health stated that water fluoridation should decrease inequalities in dental caries between areas and between socio-economic groups (Acheson 1998). In "Saving lives-our healthier nation" (Department of Health 1999) 4, the government indicated that they agreed in principle to extend fluoridation, but announced it was commissioning a systematic review of evidence relating to the safety and effectiveness of water fluoridation (The York Review).

The All-Party Parliamentary Group on Primary Care and Public Health published their Inquiry into Water fluoridation in March 03 5. This report was supportive of water fluoridation and made the following recommendations:

  • That as a matter of public dental health policy, targeted water fluoridation be stated as a legitimate and effective means of tackling dental health inequalities.
  • That current legislation be amended to allow the responsible health body, who consider that the matters in recommendation 1 are relevant to their area, to require water companies to fluoridate as directed.
  • Health bodies in carrying out their function and in recommending fluoridation must fully consult the relevant population in an open, effective and transparent manner.
  • The Department of Health to agree a protocol/code of practice with the water utilities concerning matters such as costs and indemnities and if necessary legislate appropriately.

In Parliament the Water Act is currently going through due process and amendments are proposed to resolve the problem between the requests of Health Authorities to fluoridate and the actions of Water Companies in doing so. Amendments were considered in the House of Lords on 9th July when 153 peers voted for the amendments and 21 against. The Bill will return to the House of Commons in September. A recent Early Day Motion on fluoridation received 138 pro fluoridation signatories and 10 against. Decisions on water fluoridation would continue to be made at a local level subsequent to local consultation, led by Strategic Health Authorities

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Public Opinion

With reference to comments concerning the public and invasion of rights by mass medication on unknowing and unwilling citizens, four Gallup/NOP polls carried out over the past 18 years demonstrate overwhelming support for fluoridation. Four out of ten people think their water is already fluoridated, even though only 10% actually receive it. The following quotes may prove interesting:-

"The public health benefits of fluoridation are clear. The overwhelming evidence is that fluoridation is safe and effective. Recent opinion surveys have shown that more than two thirds of the public are in support, but as I willingly acknowledged, there are those who hold alternative views." - Tessa Jowell MP, Minister for Public Health. Hansard 6 May 1998.

Summary of a 1997 British Dental Association survey of MPs' opinions on water fluoridation. 70% of MPs support it, which reflects other public opinion polls.

"The right to fluoride free water is not a basic civil right... It is not a right which affects the ability of individuals to make autonomous choices... In considering the ethics of fluoridation... we should ask not are we entitled to impose fluoridation on unwilling people, but are the unwilling people entitled to impose the risks, damage and costs of failure to fluoridate on the community at large." - Professor John Harris, Centre for Social Ethics and Policy, University of Manchester. 1998.

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Inequalities in Oral Health in London

Dental decay is not equally distributed amongst the population. In children approximately 80% of the disease is found in 20% of the children, the children most affected coming from the lower socio-economic groups. Too many children in disadvantaged communities continue to carry the avoidable burden of pain, distress and disfigurement associated with severe tooth decay and its treatment - including the risk of general anaesthesia.

Fig:1 shows the average number of decayed missing and filled teeth per five year old child across London by old Health Authority. There will of course be wide variations within each of those old Authorities. Table 1 provides an analysis at PCT level. The inner London population in particular has some of the worst levels of dental decay in England and Wales. The York review confirms that water fluoridation significantly narrows the gap between young children living in poverty and their peers. It is also effective in improving the oral health of adults, since the 1950s studies have consistently shown that adults drinking optimally fluoridated water suffer less tooth decay. In Ireland 70% of the population drink fluoridated water and the national dental survey of adults shows that adults across all age groups living in fluoridated communities experience much less root surface decay than those living in non-fluoridated communities. 6

Table 1: Average decayed, missing and filled teeth in 5 year olds by PCT and Strategic Health Authority 2001/02

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Feasibility of Water fluoridation in London

An initial feasibility study of fluoridating the water supply of the Inner London Health Agencies was undertaken in 1996. The presence of the London Ring Main means that the London water supply is in practicea single supply. To achieve fluoridation of London it will be necessary to fluoridate the entire ring main system. This means that in addition to London fluoridation would extend as far afield as parts of Hertfordshire, Essex, Kent and Surrey. A further complication is that Thames Water, although the major supplier to London is not the only water supplier, but a number of other companies supply on both a regular and emergency basis. In 1996 Thames Water had six water treatment works and three surface water sources, all of these pumping into the ring main. This presents a further set of technical challenges in terms of whether the fluoride should be added at the treatment works or directly to the ring main. fluoridation at the treatment works would require all sources pumping into the ring main to fluoridate. Direct fluoridation of the ring main is not a technique that has been done before and would require a technical solution. The 1996 technical feasibility study involved ten water companies to determine the effect of fluoridating the London Ring Main. It was established that the most feasible scheme is the Thames Water London Zone plus the North Surrey Water Company plus the Sutton and East Surrey Water Company, which covered approximately nine million people. If fluoridation of London's water is to be undertaken an up to date and feasibility study will be required.

The capital cost of the London project described in 1996/97 was £11.2 million, with 60% being met by the Department of Health. The annual operational costs were £2.62 million. These costs would need to be split between the relevant health agencies on a pro rata basis.

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Alternative approaches to community based fluoride delivery

9.1 There are alternatives to water fluoridation. It can be added to milk, salt, flour or given directly via tablets or topical gels. We have also had the benefit of fluoride toothpastes since the 1970s. However the most effective way to reach those people in greatest need is through the water supply.

Fluoride toothpaste schemes - A government funded "Brushing for Life" scheme was commenced in 2001, targeted initially at the Health Authorities with the worst dental health in England and delivered via Sure Start Schemes. In London this involved:-

  • Kensington, Chelsea and Westminster
  • Camden & Islington
  • Ealing Hammersmith and Hounslow
  • Brent & Harrow

In 2002 the scheme was extended to all Sure Start areas. Although Brushing for Life is effective in delivering initial packs of fluoridated toothpaste and oral health material to families with young children its drawback as a preventive approach is that brushing with a fluoridated toothpaste requires continued positive action.

Milk fluoridation - The rationale for milk fluoridation is that it targets children directly and by having both fluoridated and non fluoridated milk available maintains consumer choice. It does however raise questions; firstly in efficacy as fluoride is incompletely ionized in milk so the post-eruptive effect is lessened, and secondly practical concerns because of the considerable number of children who do not drink milk. Some clinical trials have been conducted and caries levels were lower in groups consuming fluoridated milk 7, but further studies have been recommended. There are no milk fluoridation schemes in London. A large pilot scheme commenced in the North West in 1993, with a further scheme in Sheffield. A recent report of the evaluation of the Knowsley scheme 8 found that it had little impact on the primary dentition and, at best, a small impact on the permanent dentition in children who had entered the scheme at 3-5 years old and participated for 4 years.

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Information Sources
Reports & References