forum on fluoridation 2002 Baile Átha Cliath Dublin Arna Fhoilsiú ag Oifig an tSoláthair Published by the Stationery Office. Le ceannach díreach ón To be purchased directly from the Oifig Dhíolta Foilseachán Rialtais, Government Publication Sales Office, Teach Sun Alliance, Sráid Theach Laighean, Baile Átha Cliath 2, Sun Alliance House, Molesworth Street, Dublin 2, nó tríd an bpost ó or by mail order from Foilseacháin Rialtais an Rannóg Post-Tráchta, Government Publications, Postal T`rade Section, 51 Faiche Stiabhna, Baile Átha Cliath 2, 51 St Stephens Green Teil: 01-647 6000; Fax: 01-647 6843 Tel: 01-647 6000; Fax: 01-647 6843 nó trí aon díoltóir leabhar. or through any bookseller. Available from: www.doh.ie © Government of Ireland 2002 www.flouridationforum.ie €20 Pn.10585 ISBN: 0755-711-572 Forum on Fluoridation 2002 Contents Chairman's Introduction 9 Membership of the Forum 11 Conclusions and Recommendations 13 Introduction 13 Overall Conclusions 13 Recommendations 14 Recommendation 1 Policy Aspects of Water Fluoridation 15 Recommendation 2 Technical Aspects of Water Fluoridation 16 Recommendation 3 Fluoride Toothpaste 17 Recommendation 4 Oral Health Care Industry 18 Recommendation 5 Infant Formula 18 Recommendation 6 Fluoride Research 18 Recommendation 7 Education, Information and Public Participation 19 Recommendation 7 Public Health and Professional Practice 20 Additional Views and Conclusions 21 Acknowledgements 21 Methodology of the Forum 22 Presentations and Submissions 23 A Note on Units and Terms 24 Chapter 1. The Public Consultation Process 25 Introduction 26 Risk and Hazard 26 Views of Members of the General Public 27 Some Criticism of the Forum 27 Clarification of Some Misconceptions 28 The Origin Of The Fluoride Additive 29 The Composition Of The Fluoride Additive 29 Objectionable Tastes In Water 31 Conclusion 31 Chapter 2. Analysis of the Submissions and Consultation Responses 33 Introduction 34 The Findings of the Consultation 35 Principal Issues / Themes arising from Consultation Submissions 36 Conclusions from Submissions 36 Survey of Public Opinion 37 Views of Individual Local Authorities, Health Boards and Professional Bodies 38 3 Contents Chapter 3. Dental Decay 39 Introduction 40 Burden of Illness from Dental Decay 41 Tooth Development 43 Measurement of Dental Decay 44 Risk Factors for Dental Decay 44 Sugar Consumption 45 Prevalence of Dental Decay 46 Dental Caries Surveys in Ireland 46 Chapter 4. Methods for Controlling Dental Decay 49 Introduction 50 Fluorides 50 Water Fluoridation 51 Salt Fluoridation 51 Fluoridated Milk 52 Fluoridated Sugar 52 Fluoride Supplements 53 Fluoride Toothpastes 53 Fluoride Mouth-rinsing 54 Professionally Applied Fluoride Products 54 Fissure Sealing 54 Plaque Control 56 Regular Professional Care 57 Other Strategies 57 Summary 57 Chapter 5. Provision of Oral Health Care Services 59 Background 60 The Position in Ireland 61 Public Funded Dentistry 61 Public Funded Dental scheme for Medical Card Adults 61 Social Insurance Funded dental Scheme 62 Private Health Insurance 62 Private Practice 62 Future Needs 62 International Comparisons 63 Chapter 6. The History of Water Fluoridation 65 The International Context 66 The Irish Context 68 Mandatory Legislation 72 A Constitutional Challenge to Water Fluoridation 74 Background 74 The Legal Challenge 74 The Implementation and Evaluation of Fluoridation in Ireland 76 4 Forum on Fluoridation 2002 Chapter 7. Fluoridation Status Worldwide 79 Chapter 8. Public Water Supplies 83 Background 84 Levels of Treatment 84 Structure and Operation 85 Geographic Influences 86 Conclusion 87 Chapter 9 Monitoring of Drinking Water 89 Background 90 Monitoring for Fluoride 91 Water Quality Standards for Fluoride 91 Chapter 10. The Application of Fluoride 93 Background Information 94 The Fluoridation Additive - HFSA 95 Quality Control 96 HFSA at the Treatment Plant 96 Dosage Rates 96 Chapter 11. Benefits and Risks of Water Fluoridation 99 Dental Decay 100 Mechanism of Action of Fluoride 104 Risks 105 Dental Fluorosis 105 Fluorosis in Ireland 106 General Health Effects 108 Background 108 Derivation of guideline values 108 Values for Fluoride 109 Fluoride Bio-availability 110 Acute Toxicity 111 Chronic Toxicity 113 Taves 113 Knox Report 113 Kaminsky et al 114 United States Public Health Service Report 115 National Research Council 116 Canadian Report 116 University of West Florida 118 York Review 119 Fluoride and Bone Health 120 Osteoporosis 120 Bone Mineral Density 121 Hillier et al 122 5 Contents Phipps et al 122 York Review 123 Demos et al 123 Chachra et al 123 Chapter 12 Controlling Dental Fluorosis 125 Introduction 126 Risk Factors for Dental Fluorosis 128 Fluoridated Drinking Water 128 Infant Formula 128 Fluoride Toothpaste 129 Fluoride Supplements 131 Fluoride Mouth Rinses 131 Strategies for Reducing Dental Fluorosis 131 Water Fluoridation Process 131 Infant Feeding 132 Fluoride Toothpaste 134 Chapter 13. The Ethical and Legal Dimension 135 Chapter 14. The Programme of Oral Health Research in Ireland 141 Background 142 Research on the role of fluorides in University College, Cork 142 Special Studies on Dental Caries and Fluorides 142 National Survey of Children's Dental Health, 1984 142 National Survey of Adult's Oral Health 1989-90 143 Regional Surveys of Oral Health 1990-99 143 Health Services Research Projects related to fluorides 143 National Survey of Adult Dental Health 144 National Survey of Children's Dental Health 144 Monitoring the use of fluoride modalities 145 Other Studies Related to Fluoride in the OHSRC 145 An Evaluation of Water Fluoridation Systems in Ireland, by Trinity College, Dublin 146 Other relevant research 147 Appendices 149 Appendix 1 Public Consultation Methodology 150 Appendix 2 The Public Consultation Comment Form 152 Appendix 3 Public Consultation: Geographical Scope 154 Appendix 4 Detailed Findings of the Consultation 157 Appendix 5 Dental Health Foundation Commissioned Research 163 Appendix 6 Views of Individual Local Authorities, Health Boards and Professional Bodies 164 Appendix 7 The Fluoridation Act, 1960, and Specimen Regulations, 1965 166 6 Forum on Fluoridation 2002 Appendix 8 Principal Fluoridated Water Supplies 173 Appendix 9 General Legislation Concerning Fluoride 182 Appendix 10 Fluoride and the Aquatic Environment 185 Appendix 11 HFSA Manufacture - A Summary 190 Appendix 12 Quality Control of HFSA 192 Appendix 13 Heavy Metals Concentrations in HFSA 193 Appendix 14 The Treatment of Drinking Water 196 Drinking Water 196 Water Treatment Processes 196 Coagulation and flocculation 196 Sedimentation or flotation 196 Rapid sand filtration 197 Slow sand filtration 197 Disinfection 197 Appendix 15 Technical Guidelines 198 Appendix 16 Presentations by Professor William Binchy 199 Fluoridation: The Legal Dimension 199 The right to bodily integrity 201 The right to health 212 The right to privacy 212 The right to autonomy 215 The Right to Dignity 215 The implications of judicial recognition of the rights on the fluoridation issue 219 Appendix 17 Presentation by Professor William Binchy: Fluoridation:Ethical Issues 227 Introduction 227 Changing values in society 227 Changing perceptions of the role of the State 228 Judicial changes 228 Fluoridation: A framework for ethical analysis 228 (i) Sanctions on conduct damaging to others 229 (ii) Sanctions on conduct damaging to oneself 229 (iii) Prevention of conduct damaging to others 230 (iv) Prevention of conduct damaging to oneself 232 (v) Affirmative obligations to act for the benefit of others 231 (vi) Affirmative obligations to act for the benefit of oneself 232 (vii) Controls on State action impacting on citizens 232 Fluoridation: balancing public health values with autonomy-centred values 233 Concluding observations 235 Appendix 18 Food Safety Authority Report on Infant Feeding and Fluoridated Tap Water 239 References 239 7 Contents 8 Chairman’s Introduction It is a pleasure to present this report of the Forum on Fluoridation to Mr Micheál Martin TD, Minister for Health and Children, who established the Forum. This is the first major review of water fluoridation since it was introduced in Ireland in 1964. The report is a comprehensive review, which aims to inform members of the public, legislators and health professionals about the benefits and risks of water fluoridation for human health. An overview is made of research undertaken in Ireland and elsewhere on water fluoridation together with recommendations on future research and more stringent monitoring procedures. The report was prepared after fourteen plenary meetings and several meetings of subgroups of the Forum during the past fourteen months. Individual members of the Forum made oral presentations to these meetings as well as seven persons from outside Ireland and seven persons from within this country. Every effort was made to strike a balance between presentations, which represented the views of individuals or groups in favour and against water fluoridation. The Forum is very grateful to all those who made oral presentations. In keeping with the ethos of a Forum, as much time as possible was allowed for discussions between presenters and Forum members. All presenters were informed that one of the main objectives of the Forum was to examine scientific evidence for and against water fluoridation. Therefore, any claims about the benefits or dangers of water fluoridation had to be substantiated by recognised scientific studies and not by anecdotal evidence or individual experiences. In this regard, presenters