Water Fluoridation

1. Water Fluoridation Dr Stephen G Palmer Medical Officer of Health May 2010

2. Medical Officer of Health • Special relationship with the Council • Doctor practicing in: • public health • Epidemiology • Health risk assessment &risk management • Independent statutory officer • Kapiti’s Medical Officer of Health Original map by Dr. John Snow showing the clusters of cholera cases in the London epidemic of 1854

3. 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

4. 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

5. 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 Findings – Effect of removing fluoridation on health We expect the same for Kapiti

6. Did consider possible health gains • Dental fluorosis (aesthetic) • Skeletal fluorosis • Osteosarcoma • Other health conditions • But NO HEALTH LOSSES OR HEALTH GAINS

7. 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

8. 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

9. The Process • No invitations • Annual Plan process – fast tracking • Consultation? • Impartiality? • Ministry of Health viewed as heavy weights

10. 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.

11. Advice on tactics used by opponents to Fluoride Incomplete list

12. DENYING THE BENEFITS OF WATER FLUORIDATIONSelective reporting results and Downplaying or ignoring evidence • 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.” From FANNZ submission to GWRC PR Newswire September 29 2009 JADA Study Proves Fluoridation is Money down the Drain

13. FEAR MONGERINGMisrepresentation of the truth andThe big lie • Infant formula made up with fluoridated water: • ADA’s 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

14. 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

15. 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

16. 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

17. 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