BDJ, VOLUME 190, NO. 7, APRIL 14 2001

Fluoridation jinks

Sir,

As a member of the advisory board to the recent systematic review of water fluoridation conducted by the NHS Centre for Reviews and Dissemination at York, I have looked in vain in the BDJ for a full analysis and discussion of the most significant piece of scientific work in the history of fluoridation. All I could find, apart from a letter about fluoridated toothpaste, were three short paragraphs in a leading article by M. Grace on 28th October (BDJ 2000; 189: 405), an abstract of a study on fluoride and bone problems which had appeared alongside the shortened version of the York report in the BMJ, on 11 November (BDJ 2000; 189: 488), and a long warning against anti-fluoridationist propaganda by R. J. Lowry on 25th November (BDJ 2000; 189: 528-530). Unless they have acquired copies of the report itself your readers will have no opportunity of learning what this landmark review concluded.

Grace’s article gives a comforting thumb-nail sketch for a profession, which has always promoted water fluoridation: effectiveness in reducing caries, reduction of inequalities in dental health, no dangers to worry about. These, he states, are ‘the facts’. (Perhaps significantly for this claim, the book by Richard Bach from which he quotes is entitled Illusions, not The Reluctant Messiah, and his ‘simple sentence’ about beliefs as traps is not to be found in it.) The report, however, gives a different picture. Lest I be thought a biased commentator on account of my opposition to fluoridation on other grounds, let me quote from Professor Sheldon, the founding director of the NHS Centre at York who chaired the advisory board which oversaw the review process, which he describes as having been conducted ‘to the highest inter-national scientific standards’.

He writes: ‘It is particularly worrying. . . that statements which mislead the public about the review’s findings have been made in press releases and briefings by the British Dental Association, British Medical Association, the National Alliance for Equity in Dental Health and the British Fluoridation Society. I should like to correct some of these errors.

1. While there is evidence that water fluoridation is effective at reducing caries, the quality of the studies was generally moderate and the size of the estimated benefit, only of the order of 15%, is far from ‘massive’.

2. The review found water fluoridation to be significantly associated with high levels of dental fluorosis, which was not characterised as just a ‘cosmetic issue’.

3. The review did not show water fluoridation to be safe. The quality of the research was too poor to establish with confidence whether or not there are potentially important adverse effects in addition to the high levels of fluorosis. The report recommended that more research was needed.

4. There was little evidence to show that water fluoridation has reduced social inequalities in dental health.

And finally:

7. ‘The review team was surprised that in spite of the large number of studies carried out over several decades there is a dearth of reliable evidence with which to inform policy. Until high quality studies are undertaken. . . there will continue to be legitimate scientific controversy over the likely effects and costs of water fluoridation.’

Why has the dental profession not been told this, but has been encouraged instead to  continue in its belief in fluoridation, and in the view that those who do not believe are propagandists who are biased, tell lies, use ‘terminological high jinks’ and cannot discriminate between argument and assertion? Professor Sheldon could have added that there is not a single high quality study in the fluoridation literature; that few of the questions addressed could be answered with any confidence; that the Government has accepted the need for more research; that the review only dealt with water fluoridation, not total exposure to fluoride; and that the BMJ article on fluoride and bones, purporting to give it a clean bill of health, had already been assessed by the York review team who assigned it to ‘level C’ evidence, i.e. ‘lowest quality, high risk of bias’.

None of the distinguished scientists I have been involved with, that I have discussed the implications for public health is now of the opinion that a policy of fluoridation is justified. All are astonished at the way that the dental profession is reacting to a changed situation.

Baldwin of Bewdley House of Lords

Editor replies: I would like to thank Earl Baldwin for his correction to my quote from Richard Bach. Unfortunately , neither he nor I can remember which book it came from.

Water fluoridation

Sir, — What is the Secretary of State for Health going to do about water fluoridation following the York Review? He is asking the Medical Research Council to come up with ‘any further research which could most productively be focused in order to strengthen the knowledge base concerning water fluoridation and its effect on health. Once this action is complete, we will review the need for legislation’ (letter to be undersigned, 5.1.01). Reading between the subordinate clauses, one gathers more obstacles and/or more research are promised. Meanwhile millions across the globe (including parts of England) are adding fluoride to the water and experiencing the benefits.

J. Hogan Wembley

Please send your letters to: The Editor British Dental Journal 64 Wimpole Street London W1M 8AL