Turn on the tap

The Scottish Government has been asked to consider fluoridation of the water supply – again. The evidence in its favour is overwhelming, say proponents, and COVID makes its consideration all the more urgent

09 April, 2021 / indepth
 Will Peakin  

In 1957, the ‘Fluorine Consultative Council’ convened in Dublin for the first of 15 meetings, culminating in its recommendation the following year that the public water supply in Ireland should be fluoridated.

Fluoridation was introduced to Dublin City in 1964, and Cork City the following year. By 1970 most of the major cities and towns in the Republic had fluoridated supplies and today 71 per cent of people in Ireland have access to fluoridated water. Between 1961 and 1963, a baseline national caries study was conducted; representative samples of five- to 16-year-olds were examined in each of the 26 counties in the Republic. High caries levels were recorded; for example, the mean decayed/missing/filled teeth (DMFT) for 15-year-old children was 8.2.

The Department of Health established a unit at University Dental School, Cork, in 1965 which conducted a number of studies on dental caries and fluoride in the late ‘60s and early ‘70s. A survey of a random sample of four- to 11-year-old school children in Cork City in 1969 showed that caries levels among children were substantially lower than those recorded in the 1961 baseline study.

A national survey of children’s dental health in 1984 showed a substantial decline in the prevalence of dental caries both in fluoridated and non-fluoridated communities, and the reduction was considerably greater in the fluoridated communities. In 2002, a ‘north-south’ survey showed a substantial decline from 1984 in dental caries in both fluoridated and non-fluoridated communities in the Republic, and in the non-fluoridated population of Northern Ireland. However, the decline was substantially greater in the fluoridated communities.

There was an increase in the prevalence of dental fluorosis in the Republic between 1984 and 2002, particularly in lifetime residents of fluoridated communities, prompting the Government to approve a reduction in the level of fluoride added to the water supplies and the introduction of guidance to reduce the ingestion of fluoride toothpaste in early childhood.

Today, Ireland’s Expert Body on Fluorides and Health is of the opinion that “there continues to be overwhelming evidence that water fluoridation significantly benefits dental health”. In January this year, researchers at Manchester University noted that “the most fundamental component of any population-wide caries-prevention strategy is sugar reduction through the use of upstream policy levers”.

However, they concluded, “with any highly prevalent chronic disease, the social and biological causal pathways involved are complex and action at multiple levels is required. Fluoride is highly effective at preventing caries and its use over the last 50 years has transformed dental health.”1

With the UK Government having announced its intention at the beginning of this year to take control over the decision of whether to fluoridate the water supply away from local authorities, the position of the Scottish Government will come into focus. “The public health crisis caused by the pandemic – and the resulting long-term pressure on health services – means that investment in prevention is now essential,” said Dr Robert Donald, chair of the British Dental Association’s Scottish Council.

He told Scottish Dental: “My view is that fluoridation of the water supply in Scotland is no longer a subject for debate. The evidence is clear that [it] is both safe and effective. With the disruption to Childsmile during the pandemic – fluoridation, which is complementary to Childsmile and not a replacement for it, would still have been benefitting our children.   It could also benefit the dental health of not only children, but the rest of the population, adolescents, working age people, and also the elderly by preventing root caries.”

In March, the BDA (Scotland) wrote to Mairi Gougeon, Scotland’s Minister for Public Health and Sport, reiterating its call to the Scottish Government “to support the introduction of local water fluoridation as a cost effective, evidence-based preventive measure where practical and clinically appropriate”.

David Conway, Professor of Dental Public Health at the University of Glasgow, said: “Despite major improvements in recent years, the dental health of the population of Scotland remains a challenge. For example, just over one in four children aged five have dental decay and 45- to 54-year-olds have, on average, 10 filled teeth. There are also wide inequalities in the burden of dental disease with those from poorer backgrounds having greater levels of dental decay.

“And as we recover from the COVID-19 pandemic, it is right that we look again at all options to improve the population’s health and oral health. So, yes, fluoridation of the water supply should be on the table. The evidence base is strong on the population benefits of water fluoridation. I would be supportive of reviewing the evidence, the cost-benefits, the practicalities, and feasibility – modelling impact on oral health and oral health inequalities. [It’s] very important that local communities are engaged with and their views and opinions sought.”

A consultation on Scotland’s Oral Health Improvement Plan was launched in the autumn of 2016. A summary of responses stated: “A large number of respondents commented that NHS dentistry needs to focus on prevention going forward, suggesting that this will help to address oral health inequalities” Respondents recommended consideration of public health measures, such as a sugar tax and water fluoridation. But when the Plan was published in 2018, it said: “Although we recognise that water fluoridation could make a positive contribution to improvements in oral health, the practicalities of implementing this means we have taken the view that alternative solutions are more achievable.”

Dr Donald said: “Scotland currently sits in a bizarre and strangely shameful position. I find it bizarre that the Scottish Government accepts that water fluoridation would benefit oral health in Scotland yet refuses to even try to introduce it. Health is a devolved issue and indeed the legislation enabling water fluoridation is entirely different between Scotland and England. However, the contrast between Holyrood and Westminster is stark on this issue. With dental decay rates in Scotland still higher than in England, Holyrood would be failing its population, especially its child population, by not supporting further measures to boost the progress made by Childsmile.”

Dr Donald believes the Scottish Government should ask each of the 14 health boards to undertake a feasibility study of water fluoridation for their populations. “It’s bizarre that health boards have not even been asked to find out if it is feasible to introduce water fluoridation for their populations. The Government should be funding feasibility studies. The water supply in Scotland should be fluoridated where practical and appropriate for local public health needs. It is a safe and effective public health intervention as part of a package of measures to improve dental health.

“The technical requirements for adjusting the level of fluoride are simple and the necessary legislation is already in place. I do accept that there may be a challenge to win over public opinion on this issue, but the Scottish Government has shown that it is willing to take on difficult challenges to help improve the health of the people in Scotland with the introduction of minimum pricing for alcohol. Banning smoking in public places was also an early public health measure introduced in Scotland before the remainder of the UK. I would urge the Scottish Government to show the same boldness on water fluoridation.”

1. Moore, D., Allen, T., Birch, S. et al. How effective and cost-effective is water fluoridation for adults? Protocol  for a 10-year retrospective cohort study. BDJ Open 7, 3 (2021). 

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