Examples of authoritative reviews of the safety and/or effectiveness of fluoridationBACK
Health, Department of Health for
This is the report of a mission to
· 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.
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.
World Health Organisation (1958)
Report of Expert Committee on Water
Fluoridation. Technical Report Series No 146. World Health Organisation.
This review was undertaken 13 years after the implementation of first artificial water fluoridation scheme in Grand Rapids USA.
The most convincing evidence of
the safety of water fluoridation comes from the numerous population groups (3
million in the
Health, Scottish Office, Ministry of
housing and Local Government. (1962): The
conduct of the fluoridation studies in the
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.
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.
Health and Social Security, Scottish Office, Welsh Office. (1969): The fluoridation studies in the
This was the second report of the
fluoridation studies of selected
· 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.
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.
Organisation. (1970): Fluorides and human
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.
The controlled enrichment of drinking water with fluoride has the support of overwhelming evidence.
29 international expert contributors and 93 international expert reviewers.
References - over 800 listed.
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.
· 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
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.
This review followed allegations, from a single source, of increased risk of cancer associated with water fluoridation.
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.”
Single author: J Clemmesen (Formerly Chief Pathologist
in Finsen Institute,
References - 32 listed
(1983): Opinion of Lord Jauncey in causa
Mrs Catherine McColl (A.P.) against Strathclyde Regional Council.
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.
Lord Jauncey completely vindicated the safety and efficacy of fluoridation. However, the Petitioner’s plea-in-law, that fluoridation was ultra vires, was sustained.
Knox, E. G.
(1985): Fluoridation of water and cancer:
a review of the epidemiological evidence.
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.
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.”
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.
Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental
Health and Related Programs. (1991): Review
of Fluoride Benefits and Risks.
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.
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
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.
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.
· 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.
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.
Health and Medical Research Council. (1991): The effectiveness of water fluoridation.
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.
· 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.
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.
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.
· 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.
The Group was chaired by Dr A Lucas, MRC Dunn Nutrition Unit,
References - 17 listed
Health Commission. (1993): Fluoridation
of water supplies. Draft Policy Statement. May 1993.
· 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.
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
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.
· Carcinogenicty in animals and humans.
Currently allowed fluoride levels in drinking water do not pose a risk of health problems.
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
Committee on Oral Health Status and Fluoride Use. (1994): Fluorides and oral health. WHO Technical Report Series No. 846.
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.
Community water fluoridation is safe and cost-effective and should be introduced and maintained wherever it is socially acceptable and feasible.
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
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.
· 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.
109 references listed.
18.Proceedings of the International Symposium on Water Fluoridation (1996) Community Dental Health 13 Suppl 2.
These proceedings contain the
scientific papers presented at the International Symposium on Water
Fluoridation held in
· 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.
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,
· 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.
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?
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.
References - 40 listed.
21. Faculty of Public Health Medicine of the
This review was conducted by the
Research Committee of the Royal College of Physicians of
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
Committee of the
References - 81 listed.
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.
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.
Brian A Burt,
BDS, MPH, PhD, and Stephen A Eklund, DDS, MHSA, DrPH, Program in Dental Public
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
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.
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.