Examples of authoritative reviews of the safety and/or effectiveness of fluoridation
BACK1.
Ministry of
Health, Department of Health for
Background
This is the report of a mission to
the
Conclusion
· That there is no
evidence of any danger to health from continued consumption of water containing
fluoride in low concentration.
· The evidence is
conclusive that water fluoridated at a level of 1 part per million reduces
tooth decay rates.
· There is nothing
to suggest that water containing fluoride, naturally derived, has properties
different from those of a water to which fluoride has
been added.
· That around 10%
of children drinking fluoridated water may develop very mild mottling of the
teeth; that this is not a hazard; and that it cannot be recognised without
expert examination.
· There was no
evidence that fluoridated water had an adverse effect on industrial processes.
Membership
The Mission membership was Jean Forrest, Dental Officer, Ministry
of Health, J Longwell, Principal
Scientific Officer in the Department of the Government Chemist, in charge of
the Division dealing with the Examination and Treatment of Water, Professor HH Stones, Professor of
Dental Surgery and Director of Dental Education, University of Liverpool,
Director and General Consultant Liverpool Dental Hospital, Member of the Dental
Research Committee, Medical Research Council, Member of the Liverpool Regional
Hospital Board and of the Board of Governors of the Liverpool United Hospitals,
AM Thomson Research Lecturer,
Department of Midwifery, University of Aberdeen.
References - 115 references listed.
2.
World Health Organisation (1958)
Report of Expert Committee on Water
Fluoridation. Technical Report Series No 146. World Health Organisation.
Background
This review was undertaken 13 years after the implementation of first artificial water fluoridation scheme in Grand Rapids USA.
Conclusion
The most convincing evidence of
the safety of water fluoridation comes from the numerous population groups (3
million in the
3.
Ministry of
Health, Scottish Office, Ministry of
housing and Local Government. (1962): The
conduct of the fluoridation studies in the
Background
It was a
recommendation of the earlier UK Mission to US that selected
· No evidence of
harm from fluoridation has been discerned despite continuous vigilance.
· Five years of
fluoridation in three study areas has brought about in each a substantial
improvement in the teeth of young children.
· The results
obtained so far are in line with American experience.
· The addition of
fluoride to water supplies at a specified level has presented no technical
difficulties.
Membership
The
Steering Committee included officials knowledgeable in the relevant dental,
medical, chemical, water supply and statistical matters drawn from the Ministry
of Health, Department of Health for
References - 41 listed.
4.
Department of
Health and Social Security, Scottish Office, Welsh Office. (1969): The fluoridation studies in the
Background
This was the second report of the
fluoridation studies of selected
Conclusion
· The fluoridation of water supplies at the level of 1
part per million is a highly effective way of reducing dental decay and is
completely safe.
· The Research
Committee has been unable to find any harmful effects resulting from the
fluoridation of water supplies.
Alternative measures are no effective substitute - none offers such
certainty of general improvement in the teeth of children.
· The strength of
the case for fluoridation of water supplies lies in the consistency of results
from different parts of the world.
The findings in this report add to the already substantial volume of
evidence of the effectiveness of this important public health measure.
· After 11 years
under review, medical practitioners reported only two patients with symptoms
which they felt might have been associated with fluoridation. Careful investigation in both instances
failed to attribute the symptoms to the drinking of fluoridated water.
Membership
The Committee on Research into Fluoridation was chaired by RM. Shaw, and members were: Dr W Alcock, Professor DAK Black, Dr ER Bransby, Dr G Crompton, JK Foreman, Surg.R/Admiral W Holgate, Professor GN Jenkins, Professor JN Mansbridge, Dr BR Nisbet, Miss JD Oswald, J Rodgers, Professor MA Rushton, Professor AI Darling, Professor GL Slack, Professor AM Thomson, Dr AE Martin
References - 40 listed.
5.
World Health
Organisation. (1970): Fluorides and human
health.
Background
This report followed a
request to the World Health Organisation from
the International Dental Federation for an authoritative up-to-date report on
the metabolism of fluorine (sic).
The objective was to provide an impartial review of the scientific literature
on the varied aspects of fluoridation, and the many complex questions relating
to the metabolism of fluorides and their utilisation in medicine and public
health.
Conclusion
The controlled enrichment of drinking water with fluoride has the support of overwhelming evidence.
Membership
29 international expert contributors and 93 international expert
reviewers.
References - over 800 listed.
6.
Background
The Royal College of
Physicians appointed a special committee in response to requests from the
dental profession for views on the medical aspects of fluoridation. The committee worked for 18 months, and
examined “a mass of data relating to the
effects of fluoride, and fluoridation of water supplies in particular.” Oral evidence was taken from the leading
members of organisations opposed to fluoridation and the literature published
by these bodies was examined in detail.
Conclusion
· The consumption
of water containing approximately 1mg/litre of fluoride in a temperate climate
is safe irrespective of the hardness of the water.
· Fluoride in water
added or naturally present at a level of approximately 1mg/litre over the years
of tooth formation substantially reduces dental caries throughout life.
· In comparison
with fluoridation, systemic fluoride supplements such as tablets, drops and
fluoridated salt have not been shown to be as effective on a community basis.
· Fluoridation does
not harm the environment.
· The College
recommends fluoridation of water supplies in the
Membership
Representatives of the dental profession and specialists in general medicine, paediatrics, community medicine, toxicology, epidemiology, and genetics.
References - 47 listed.
7.
Clemmesen, J.
(1983): The alleged association between artificial fluoridation of water
supplies and cancer: a review. Bull.
World. Health. Organ. 61, 871-883.
Background
This review followed allegations, from a single source, of increased risk of cancer associated with water fluoridation.
Conclusion
The
review showed the allegations to be erroneous.
“This misleading and refuted suggestion of an
association between artificial fluoridation and cancer, which, even if true,
would not have proved a causal relationship, has been responsible for a
considerable waste of effort and resources that are sorely needed for research
and prevention in other fields.”
Membership
Single author: J Clemmesen (Formerly Chief Pathologist
in Finsen Institute,
References - 32 listed
8.
Lord Jauncey.
(1983): Opinion of Lord Jauncey in causa
Mrs Catherine McColl (A.P.) against Strathclyde Regional Council.
Background
Scottish legal
challenge seeking to prevent fluoridation of Strathclyde water supplies. The Petitioner alleged (inter alia) that fluoridation would be
harmful, particularly in relation to the causation of cancer.
The court sat on 201 days
making this the longest and costliest case in Scottish legal history. The Judge, Lord Jauncey, took almost 12
months to consider the massive evidence.
Conclusion
Lord Jauncey completely vindicated the safety and efficacy of fluoridation. However, the Petitioner’s plea-in-law, that fluoridation was ultra vires, was sustained.
9.
Knox, E. G.
(1985): Fluoridation of water and cancer:
a review of the epidemiological evidence.
Background
Following allegations that fluoridation causes cancer the Department of Health set up a Working Party to undertake a fresh review of the epidemiological studies on cancer incidence and mortality amongst populations whose drinking water is either artificially fluoridated or contains high levels of fluoride from natural sources.
Conclusion
The enquiry “found nothing in any of the major classes of
epidemiological evidence which could lead to a conclusion that either fluoride
occurring naturally in water, or fluoride added to water supplies, is capable
of inducing cancer, or of increasing the mortality from cancer. This statement applies both to cancer as
a whole, and to cancer at a large number of specific sites. In this we concur with the great
majority of scientific investigators and commentators in this field.”
Membership
The Working Party was chaired by
Professor EG Knox, Professor of Social Medicine, University of Birmingham,
and membership included 10 eminent UK
scientists from the disciplines of Cancer Research, Cancer Epidemiology,
Medical Statistics, Biostatistics, Pathology and Water Research.
References - 110 references cited.
10.Ad
Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental
Health and Related Programs. (1991): Review
of Fluoride Benefits and Risks.
Background
This comprehensive review and evaluation of the public health benefits of fluoride in drinking water and other sources was prompted by a study of the national Toxicology Program which found “equivocal evidence” of carcinogenicity based on the occurrence of a small number of malignant bone tumours (osteosarcomas) in male rats.
Conclusion
In humans, optimal fluoridation of
drinking water does not pose a detectable cancer risk as evidenced by extensive
human epidemiological data reported to date, including new epidemiological
studies prepared for this report.
No trends in cancer risk, including the risk of osteosarcoma, were
attributed to the introduction and duration of water fluoridation. Chronic low
level fluoride exposure of normal individuals is not associated with birth
defects or Down Syndrome, nor is there any indication
that it presents a problem in any organ systems such as gastrointestinal,
genitourinary or respiratory.
Furthermore skeletal fluorosis is not a public health problem in the
Membership
The Ad-Hoc Subcommittee on Fluoride of the Committee to Coordinate
Environmental Health and Related Programs US Public Health Service was chaired by Frank Young MD PhD. Membership included over 30 eminent
References - 52 pages of references listed.
11.
Background
The first edition was published in 1975, the stated aim of the book was to present the evidence concerning the clinical effectiveness of fluoride , in its various forms, as a caries-inhibitory agent.
Conclusion
· The results of
the review of 113 community water fluoridation schemes show, beyond reasonable
doubt, that artificial fluoridation is effective in reducing caries experience
by approximately 50%, regardless of climate, race or social conditions.
· The effect of
water fluoridation on general health has been thoroughly investigated in a
series of population studies. There
is no evidence that the consumption of water containing approximately one part
per million of fluoride (in a temperate climate) is associated with any harmful
effect.
Authorship
3 authors: Professor JJ Murray, Professor and
Head, Department of Child Dental Health, University of Newcastle upon Tyne
Dental School, Professor AJ Rugg-Gunn,
Professor of Preventive Dentistry, departments of Child Dental Health and Oral
Biology, University of Newcastle upon Tyne Dental School, Professor GN Jenkins, Emeritus Professor of Oral Physiology, University
of Newcastle upon Tyne.
References - 36 pages of references listed.
12.National
Health and Medical Research Council. (1991): The effectiveness of water fluoridation.
Background
The Australian National Health and Medical Research Council (NHMRC) established a working group to assess claims that the benefits of water fluoridation have been greatly exaggerated. The working group assessed the three main issues: effectiveness, scientific fraud or misuse of data, and time-trends in caries rates. In addition, the working group reviewed available evidence of any adverse effects of fluoride exposure.
Conclusion
· Water
fluoridation continues to contribute to the prevention of dental caries and
therefore to provide an important community-wide and readily achievable
foundation to dental public health.
· A concentration
of 1 ppm secures most of the caries preventive effect available from
fluoridated water, while maintaining minimal contribution of water fluoride to
dental fluorosis in children.
· There is no
evidence of adverse health effects attributable to fluoride in communities
exposed to a combination of fluoridated water (1ppm) and contemporary
discretionary sources of fluoride.
· Avoidance of high
individual intake of fluoride in childhood can best be achieved by control of
discretionary sources of fluoride.
· Communities whose
water supply is not fluoridated should be encouraged to do so.
Membership
Professor AJ McMichael, Professor of Occupational
and Environmental Health, Department of Community Medicine, University of
Adelaide, Ms Hilda Bastian, Consumer’s Health Forum, Canberra, Professor RM Douglas, Director,
National Centre for Epidemiology and Population Health, Australian National
University, Canberra, Dr BT Homan,
Department of Dentistry, The University of Queensland, Dr BG Priestly, Department of Clinical and Experimental
Pharmacology, The University of Adelaide, Professor
AJ Spencer, Professor of Social and Preventive Dentistry, The University of
Adelaide, Dr SR Wilson, Statistics
Research Section, School of Mathematical Sciences, Australian National
University, Canberra, Mr GD Slade,
Public Health Research Fellow, Department of Dentistry, The University of
Adelaide.
References - 200 references listed.
13.Medical Research Council Physiological Medicine and
Infections Board (1993) Report of the
Working Group on fluoridation of drinking water - link with osteoporosis.
Background
In view of concerns that had been raised about the possible relationship between the fluoridation of public water supplies and incidence of osteoporosis, the Working Group had been convened. The Group’s remit was to review the evidence regarding the possible effects of fluoridation of public water supply on the incidence of osteoporosis, and to advise Council on whether further studies were necessary.
Conclusion
· The Working Group
remained unconvinced that the risk of hip fracture outweighed the benefits of
dental protection conferred by fluoridated drinking water.
· Additional
research to improve current knowledge and to underpin public health policy was
recommended.
Membership
The Group was chaired by Dr A Lucas, MRC Dunn Nutrition Unit,
References - 17 listed
14.Public
Health Commission. (1993): Fluoridation
of water supplies. Draft Policy Statement. May 1993.
Background
The
Conclusion
· Dental caries
remains a significant problem for New Zealanders. The adjustment of fluoride to 1 ppm
in the water is the most effective and efficient way of preventing dental
caries in the whole community receiving a reticulated water supply. The balance of evidence regarding health
effects is that there is no justification for changing current policy on
fluoridation.
· The Public Health
Commission recommends the continuation of water fluoridation programmes and
their extension where technically feasible.
Membership
Dr Elizabeth Treasure, Senior Lecturer,
Department of Community Dentistry, University of Otago, Dr Bernadette K Drummond, Senior Lecturer, Department of Community
Dental Health, University of Otago, Dr
Heather A Buchan, Senior Research Fellow, Department of Preventive and
Social Medicine, University of Otago, Dr
Michael G Beasley, Research Fellow, National Toxicology Unit, R Mark Henaghan, Senior Lecturer,
Faculty of Law, University of Otago, Dr
Barbara R Nicholas, Assistant to the Director, Bioethics Research Centre,
University of Otago.
References - 94 references listed
15.National
Research Council:
Background
The US Environmental Protection Agency (EPA) requested that the National Research Council’s Board on Environmental Studies and Toxicology (BEST) review the current toxicological and exposure data on fluoride and determine whether EPA’s maximum contaminant level of 4mg of fluoride per litre of drinking water is acceptable for protecting the public from potential adverse health effects of fluoride. In response to EPA’s request, BEST’s Committee on Toxicology (COT) established the Subcommittee on Health Effects of Ingested Fluoride. The subcommittee based its evaluation on a detailed examination of the data in the following areas:
·
Intake, metabolism, and disposition of fluoride.
·
Dental fluorosis.
·
Bone strength and the risk of bone fracture.
·
Effects on the renal, gastrointestinal, and immune
systems.
·
Reproductive effects in animals.
·
Gentotoxicity.
·
Carcinogenicty in animals and humans.
Conclusion
Currently allowed fluoride levels in drinking water do not pose a risk of health problems.
Membership
The subcommittee was chaired
by Bernard M Wagner, Wagner
Associates Inc, New Jersey, and members were: Brain Burt, University of Michigan, Kenneth P Cantor, National Cancer Institute, Steven M Levy, University of Iowa, Ernest Eugene McConnell, Raleigh, NC, Gary M Whitford, Medical College of Georgia, Augusta, GA
References - 400 references listed
16.Expert
Committee on Oral Health Status and Fluoride Use. (1994): Fluorides and oral health. WHO Technical Report Series No. 846.
Background
Reports of the World Health Organisation Expert Committee
on Oral Health Status and Fluoride Use provide the World Health Organisation with the latest scientific and technical
advice on the most appropriate public health use of fluoride for caries
control.
Conclusion
Community water fluoridation is safe and cost-effective and should be introduced and maintained wherever it is socially acceptable and feasible.
Membership
The Expert Committee was
chaired by Professor BA Burt, School
of Public Health, University of Michigan, and members were: Dr Y de Paiva Buischi, São Paulo,
Brazil, Dr I Ghandour, Faculty of
Dentistry, University of Khartoum, Sudan, Professor
JJ Murray, University of Newcastle upon Tyne, England, Dr DL Mwaniki, Medical Research Centre, Kenyan Medical Research
Institute, Nairobi, Kenya, Professor D
O’Mullane, Department of Preventive and Paediatric Dentistry, University
College, Cork, Ireland, Dr P
Phantumvanit, Faculty of Dentistry, Chulalongkorn University, Bankok,
Thailand, Professor SH Wei, Dean,
Faculty of Dentistry, University of Hong Kong, Hong Kong. Special contributions were made by a
further seven international experts in the fields of medicine and dentistry.
References - 15 references listed.
17.Health Promotion Wales (1996) Effective oral health promotion: literature review Technical Report
No 20.
Background
Literature review
by University College of Wales College of Medicine in partnership with Health
Promotion Wales. The
main aim of the review was to identify oral health promotion practices which
have been shown to be effective or ineffective.
Conclusions
· Water
fluoridation is effective at preventing dental caries. It is cheap, safe and reaches the whole
population.
· There is evidence
that it reduces inequalities in health.
· This literature
review has found no measures that will achieve the same levels of prevention as
fluoridation for the same resources.
References
109
references listed.
18.Proceedings
of the International Symposium on Water Fluoridation (1996) Community Dental Health 13 Suppl 2.
Background
These proceedings contain the
scientific papers presented at the International Symposium on Water
Fluoridation held in
Conclusions
· Fluoride in
drinking water has not been shown to cause an increase in the risk of
developing cancer. - Dr Paula
Cook-Mozaffari, MRC Cancer Epidemiology Research Group,
· The burden of
evidence suggesting that fluoridation might be a risk factor for hip fracture
is weak and not sufficient to retard the progress of the water fluoridation
programme. - Professor Cyrus Cooper,
MRC Environmental Epidemiology Unit,
· There is no
evidence of any deleterious effect on specific immunity following fluoridation
nor any confirmed reports of allergic reactions. - Professor SJ Challacombe, Department of Oral Medicine and
Pathology, UMDS, Guy’s Hospital,
References - Cancer:38
listed; Bone health: 38 listed; Immunology: 15 listed.
19.Kay L, Locker D (1997) Effectiveness of oral health promotion: a review.
Background
In 1996 the Health Education
Authority commissioned a review of the research evidence on the effectiveness
of oral health promotion interventions.
The research was carried out by Dr Liz Kay, of the Department of Oral
Health and Development,
Conclusions
· Evidence
concerning the effectiveness of fluoride is strong.
· There is no
evidence that oral health promotion per
se affects caries rates, even if changes in behaviour are achieved, unless
fluoride is being used.
References - 164 articles were reviewed.
20.Jones, G., Riley, M., Couper, D.,
and Dwyer, T. (1999): Water fluoridation, bone mass and fracture: a
quantitative overview of the literature.
Background
This study used the technique of meta-analysis to attempt to answer the questions:
1.
Is water fluoridation associated with altered
fracture risk (particularly of the hip) at a population level?
2.
Are the differences between studies consistent with
confounding or chance variation between studies?
Conclusions
Water
fluoridation both at levels aimed at preventing dental caries and, possibly, at
higher naturally occurring levels appear to have little effect on fracture
risk, either protective or deleterious, at a population level.
Authorship
References
- 40 listed.
21. Faculty of Public Health Medicine of the
Background
This review was conducted by the
Research Committee of the Royal College of Physicians of
Conclusion
The Committee
concluded that the epidemiological evidence that fluoride protects against
dental caries is overwhelming, and that concerns about adverse effects other
than dental fluorosis have not been substantiated. The Committee strongly supported the
continuation of the current water fluoridation policies in
Authorship
Research
Committee of the
References - 81 listed.
22. Burt,
B. A., and Eklund, S. A., eds. (1999): Fluoride Human Health and Caries
Prevention and Fluoridation of Drinking Water. In: Dentistry, Dental Practice, and the Community. 5th ed. pp 279-314 : WB Saunders.
The stated purpose of Burt
and Eklund’s book is to present dentistry and dental practice against the
backdrop of social events: economic, technological, and demographic trends, as
well as the distribution of the oral diseases. The chapters on fluoride and fluoridation
review and interpret the evidence on all aspects of water fluoridation.
Conclusion
The controlled
use of fluoride has improved the quality of life for all it reaches. Community water fluoridation is the most
cost-effective method of bringing fluoride to a community, and it benefits the
socially-deprived relatively more than the socially advantaged.
Authorship
Brian A Burt,
BDS, MPH, PhD, and Stephen A Eklund, DDS, MHSA, DrPH, Program in Dental Public
Health,
References – 314 listed.
23. Public Health Branch, Ontario Ministry of Health
(1999). Benefits and Risks of Water Fluoridation: An Update of the 1996
Federal-Provincial Sub-committee Report
The report was commissioned by the Ontario Ministry of
Health as part of
·
The
balance of evidence suggests that rates of dental decay are lower in fluoridated
than non-fluoridated communities
·
In
communities where the prevalence of dental caries is low, a careful assessment
of the balance between reductions in dental decay and increases in dental
fluorosis should be undertaken
·
Guidelines
on water fluoride levels should be flexible to accommodate communities with
different prevalence of dental decay
·
Studies
to date do not provide systematic and compelling evidence of adverse health
effects
Submitted by Dr David Locker of the
Community Dental Health Services Research Unit,
References
– 266
listed
24.
In its 1999 public health
White Paper Saving Lives: Our Healthier
Nation the UK Government committed itself to new legislation to ensure that
water suppliers fluoridate supplies when asked to do so by health
authorities. This commitment was
subject to confirmation of the benefits and safety of water fluoridation by
this independent systematic review of the evidence. The review was carried out by the
·
The report confirms that fluoridation reduces tooth
decay by, on average, 2 ¼ teeth per child and increases by 15% the proportion
of children completely free from tooth decay.
·
The review could find no evidence that water
fluoridation is linked to cancer, bone disease, or any other adverse health
effect.
·
On inequalities in dental health the report states
that “There appears to be some evidence that water fluoridation reduces the
inequalities in dental health across social classes in 5 and 12 year olds…”
·
The review found that the quality of studies was low
to moderate.
Team members: Dr Matthew Bradley, NHS
Centre for Reviews and Dissemination (CRD); Professor Jos Kleijnen, CRD; Dr
Marian McDonagh, CRD; Kate Misso, CRD; Penny Whiting, CRD; Dr. Ivor Chestnutt,
Dental Public Health Unit, Cardiff; Professor Elizabeth Treasure, Dental
School, University of Wales College of Medicine, Cardiff.
Advisory Panel: Professor Trevor Sheldon,
York Health Policy Group, University of York (Chair); The Earl Baldwin of
Bewdley, Vice President National Pure Water Association; Dr. Iain Chalmers, UK
Cochrane Centre; Dr. Sheila Gibson, Vice President National Pure Water
Association; Ms. Sarah Gorin, Help for Health Trust; Professor MA Lennon, Department of
Clinical Dental Sciences, University of Liverpool School of Dentistry, and
Chairman British Fluoridation Society; Dr. Peter Mansfield, President National
Pure Water Association; Professor JJ Murray, Dean of Dentistry, University of
Newcastle; Mr. Jerry Read, Department of Health; Dr. Derek Richards, Centre for
Evidence-Based Dentistry; Professor George Davey Smith, Department of Social
Medicine, University of Bristol; Ms. Pamela Taylor, Water UK.
References
The reviewers identified
3,236 references of which 251 met their inclusion criteria.
25. Continuous monitoring by Department of Health
In Health Circular HC(87)18,
to Regional Health Authorities and District Health Authorities giving guidance
on the introduction of schemes to fluoridate water supplies following the
passage of the 1985 Water (Fluoridation) Act, the Government undertook to:
“...continue to monitor any
further relevant evidence on the safety and effectiveness of fluoridation and
bring any significant new developments to the attention of health authorities.”
We understand that this
monitoring is ongoing and includes periodic reviews by the Committee on
Carcinogenicity in Food, Consumer Products and the Environment, the Committee
on Medical Aspects of Food Policy, the Committee on Toxicity of Chemicals in
Food, Consumer Products and the Environment, and the Physiological Medicine and
Infections Board of the Medical Research Council.