nd September 2 , 2016 To: Mayor Naheed Nenshi Members of Council From: Councillor Diane Colley-Urquhart Councillor Richard Pootmans Councillor Peter Demong Re: Notice of Motion Water Fluoridation in The City of Calgary Over the past many months since the research study on “Measuring the Short-Term Impact of Fluoridation Cessation on Dental Caries in Grade 2 Children” was released by lead author and Albertan Dr. Lindsay McLaren, we have been meeting frequently to consider not only the findings, but to determine what an objective go-forward plan could be for Calgary City Council to consider. We have attached our Notice of Motion and this study, along with a related article that appeared in the International Journal for Equity in Health (on children’s dental caries before and after cessation of community water fluoridation) for your review and consideration. An important aspect of our meetings has included seeking professional expertise and advice from the University of Calgary’s O’Brien Institute for Public Health(OIPH) and from Dr. Richard Musto, MD, FRCPC – Medical Officer of Health – Calgary Zone – Alberta Health Services. While Dr. Musto is certainly an advocate for fluoridation, that is contrasted by Dr. William Ghali, the Scientific Director of the OIPH who approaches matters such as this from a purely scientific non-advocacy perspective. It is because of these conversations and advice, that we have developed the approach outlined in our Notice of Motion. The Institute has established deep engagement and longitudinal partnerships with governments, health systems, and public health agencies that shape policies that influence our health. This engagement occurs locally through municipalities (especially The City of Calgary), provincially (through the Ministry of Health, Alberta Health Services, and the Health Quality Council of Alberta), nationally (through the Public Health Agency of Canada, Health Canada, and the Canadian Institute for Health Information, among others), and internationally (through the World Health Organization, the Organization for Economic Cooperation and Development, and the World Bank). The OIPH is a credible agency to undertake this work. ...1 Dr. Ghali has secured millions of dollars of peer-reviewed research funding from various agencies, has published over 350 papers in peer-reviewed journals, and has been the recipient of numerous local, national, and international awards. Dr. Ghali is involved in a number of research initiatives, with specific focus on interdisciplinary approaches to evaluating and improving health system performance to produce better patient outcomes and improved system efficiency. The three of us believe that The Institute has the expertise and objectivity to undertake this work. Dr. Ghali and the OIPH have offered to conduct this scientific review at their own expense and to meet our timeline. Go Forward (OIPH) Proposal 1) Individual meetings will be offered to City Councillors to address individual questions. Members of City Council will be interviewed by OIPH researchers to develop a set of questions to review in the literature. These include, but are not limited to, specific questions around risks, costs, ethical considerations and efficacy. 2) The Institute would undertake a thorough process of carefully responding to each of the questions in as comprehensive a manner as possible, drawing on evidence from all sources. They would encourage compilation of any and all questions, and the domains of inquiry could touch on questions of 1) effectiveness, 2) safety, 3) costs, and 4) ethical considerations relating to fluoridation of water supplies. 3) The content generated would be summarized in a readable, digestible, cross referenced, synthesized policy brief with appended detail where appropriate. We look forward to any feedback you have for us as this proceeds to Council on September 12th, 2016. Community Dent Oral Epidemiol Ó 2016 The Authors. Community Dentistry and Oral Epidemiology Published by John Wiley & Sons Ltd All rights reserved Lindsay McLaren1, Steven Patterson2, Salima Thawer3, Peter Faris4, Measuring the short-term impact 5 6 Deborah McNeil , Melissa Potestio and Luke Shwart7 of fluoridation cessation on 1Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, dental caries in Grade 2 children Canada, 2School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada, 3Department of Community Health using tooth surface indices Sciences, University of Calgary, Calgary, Alberta, Canada, 4Research Facilitation, Research Priorities and Implementation, Alberta Health Services, Calgary, Alberta, Canada, 5Research and Innovation, Surveillance and Infrastructure, Population Public and Aboriginal Health, Alberta Health Services, Calgary, Alberta, Canada, McLaren L, Patterson S, Thawer S, Faris P, McNeil D, Potestio M, Shwart L. 6 Measuring the short-term impact of fluoridation cessation on dental caries in Alberta Cancer Prevention Legacy Fund, Population Public and Aboriginal Health, Grade 2 children using tooth surface indices. Community Dent Oral Epidemiol © Alberta Health Services and Department of 2016. 2016 The Authors. Community Dentistry and Oral Epidemiology Community Health Sciences, University of Published by John Wiley & Sons Ltd. Calgary, Calgary, Alberta, Canada, 7Formerly: Provincial Oral Health Office, This is an open access article under the terms of the Creative Commons Attribu- Alberta Health Services, Calgary, Alberta, tion-NonCommercial-NoDerivs License, which permits use and distribution in Canada any medium, provided the original work is properly cited, the use is non-com- mercial and no modifications or adaptations are made. Abstract – Objectives: To examine the short-term impact of fluoridation cessation on children’s caries experience measured by tooth surfaces. If there is an adverse short-term effect of cessation, it should be apparent when we focus on smooth tooth surfaces, where fluoride is most likely to have an impact for the age group and time frame considered in this study. Methods: We examined data from population-based samples of school children (Grade 2) in two similar cities in the province of Alberta, Canada: Calgary, where cessation occurred in May 2011 and Edmonton where fluoridation remains in place. We analysed change over time (2004/2005 to 2013/2014) in summary data for primary (defs) and permanent (DMFS) teeth for Calgary and Edmonton, for all tooth surfaces and smooth surfaces only. We also considered, for 2013/2014 only, the exposed subsample defined as lifelong residents who reported usually drinking tap water. Results: We observed, across the full sample, an increase in primary tooth decay (mean defs – all surfaces and smooth surfaces) in both cities, but the magnitude of the increase was greater in Calgary (F-cessation) than in Edmonton (F-continued). For permanent tooth decay, when focusing on Key words: fluoridation; Public health smooth surfaces among those affected (those with DMFS>0), we observed a Lindsay McLaren, Department of non-significant trend towards an increase in Calgary (F-cessation) that was not Community Health Sciences and O’Brien apparent in Edmonton (F-continued). Conclusions: Trends observed for primary Institute for Public Health, University of Calgary, Calgary, Alberta, Canada teeth were consistent with an adverse effect of fluoridation cessation on Tel.: 403-210-9424 children’s tooth decay, 2.5–3 years post-cessation. Trends for permanent teeth Fax: 403-270-7307 hinted at early indication of an adverse effect. It is important that future data e-mail: [email protected] collection efforts in the two cities be undertaken, to permit continued Submitted 6 July 2015; monitoring of these trends. accepted 9 January 2016 Since its initial implementation in 1945, much Mechanistically, fluoride benefits teeth by inhibiting research has been conducted on community water tooth demineralization, enhancing re-mineralization, fluoridation (CWF) and its impact on dental caries. and inhibiting enzyme activity of plaque bacteria1. doi: 10.1111/cdoe.12215 1 McLaren et al. While both a systemic (pre-eruptive) and a topical Tooth surface-level data would be preferable, if the (post-eruptive) mechanism of impact have been aim is to evaluate a prevention initiative20 such as studied intensively, experts now seem to agree that community water fluoridation or its cessation. fluoride’s major anti-cariogenic effect is post-erup- The purpose of this study was to examine the tive1,2; however, studies have continued to accrue impact of fluoridation cessation on children’s that are consistent with some pre-eruptive effect3. dental caries. Our analysis took advantage of the As a whole, the evidence base supports the bene- natural experiment opportunity provided by fluo- fits of fluoridation for preventing caries in popula- ridation cessation in the city of Calgary, Canada, tions4,5. However, systematic reviews have which occurred in May 2011 (after having been in highlighted methodological limitations of the evi- place since 1991). Published definitions of interven- dence base, such as weak study designs4,5. This tion in the research context highlight ‘intentional reflects that research on CWF and CWF cessation is change’21 and ‘to disturb the ‘natural’ order of observational (takes advantage of natural experi- things’22, and thus accommodate cessation (as well ment circumstances) and may rely on pre-existing as initiation) of CWF as a