Became Member: 15th November 1977
Left House: 9th May 2018 (Retired)
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These initiatives were driven by Earl Baldwin of Bewdley, and are more likely to reflect personal policy preferences.
Earl Baldwin of Bewdley has not introduced any legislation before Parliament
Earl Baldwin of Bewdley has not co-sponsored any Bills in the current parliamentary sitting
Most dental fluorosis in England is mild and unlikely to be of any concern from a cosmetic perspective. When discussing the public health impact of this condition, it is useful to distinguish between mild to moderate dental fluorosis and more severe fluorosis which is likely to be of concern from a cosmetic perspective, rather than overall levels.
The study described in the paper by McGrady et al in 2012 photographed teeth in order to reducing potential examiner bias, a key recommendation of the York Review. The results might therefore not be directly comparable to the results of studies using older methodology.
Public Health England’s 2014 water fluoridation health monitoring report was published subsequent to the responses given on 28 October 2013 and 5 December 2013 and included a section on dental fluorosis, drawing upon the 2012 report by McGrady et al. A copy of Water Fluoridation Health Monitoring Report for England 2014 is attached.
The report displayed the individual categories of dental fluorosis that were used in the 2012 report by McGrady et al, including the proportion who showed no signs of dental fluorosis in the two cities studied. This is shown in the following table.
Descriptive data for fluorosis total-fluorosis (TF) scores by city
| City | p-value (probability value) | |||
| Newcastle (fluoridated) | Manchester (non-fluoridated) | |||
| Number | % | Number | % | |
Fluorosis TF Score |
|
|
|
|
|
0 | 410 | 45% | 638 | 73% | P less than 0.0001 |
1 | 355 | 39% | 209 | 24% | |
2 | 79 | 9% | 16 | 2% | |
3 | 53 | 6% | 4 | 1% | |
4 | 8 | 1% | 0 | 0% | |
5 | 1 | 0.1% | 2 | 0.2% | |
Total | 906 |
| 869 |
| |
The probability values show that levels of dental fluorosis overall in fluoridated Newcastle were higher than in non-fluoridated Manchester. The proportion of children with dental fluorosis (TF score >0) was 55% in Newcastle compared to 27% in Manchester. Fluorosis recorded at a level of TF3, considered to be mild or mild to moderate, was 6% in Newcastle and 1% in Manchester. The prevalence of higher scores (TF4 or greater) was very low in both cities.
The methodology described in the 2012 paper by McGrady et al may give higher estimates of dental fluorosis compared to the direct examination by a dentist used in other surveys. The results give further assurance that there are low levels of dental fluorosis which might be of concern from a cosmetic perspective in both fluoridated and non-fluoridated areas.
The possible effects of fluoride in water have been extensively studied and reviewed over the last 50 years. In the United Kingdom the most recent review prior to the publication of Public Health England’s (PHE) Health Monitoring Report was undertaken by the National Health Service Centre for Reviews and Dissemination based at the University of York and published in 2000. The Medical Research Council subsequently, in 2002, reported to the Department of Health its advice on future research priorities. The US National Research Council reported in 2006 and the Australian National Health and Medical Research Council reported in 2007. PHE drew on these authoritative sources in selecting a number of indicators of health conditions for inclusion in the 2014 water fluoridation health monitoring report.
The chosen indicators of various health conditions were selected based on the evidence base, theoretical plausibility, potential impact on population health, the quality and availability of data, and the validity of the indicator. The selected indicators will be reviewed for future reports in the light of emerging evidence.
The article by KK Cheng et al did not provide any new evidence regarding hip fractures, but comments on the chance of detecting an increased risk of hip fracture for a speculated odds ratio of 1.2 in a previous study by Hiller et al. 2000. This only refers to a single study and it is important to consider the overall weight of evidence.
The overall weight of evidence and the consensus of opinion from authoritative reviews do not indicate that a drinking water concentration of 1 part fluoride per million parts of water presents an increased risk of hip fracture.
A more recent review of potential health effects from water fluoridation was published in 2015 by the Irish Research Board. The report concluded that a summary of the existing literature indicates that the relationship between fluoride in drinking water and bone health is inconsistent, with no definitive proof of protective or harmful effects.
The Public Health England report, Water Fluoridation: Health Monitoring Report for England 2014 was, of necessity, an ecological study. An ecological design is appropriate for monitoring health outcomes in fluoridated and non-fluoridated populations. All academic research has limitations. In designing and conducting research consideration must be taken regarding timescales for publication and cost to the public purse. Stating the limitations of the study within the body of a paper is considered good scientific practice.
The report discusses the limitations of this study design, including the potential for mis-classification of fluoride exposure status, using an ecological level of measurement with regard to water fluoridation rather than individual fluoride intake. The report’s findings, however, concur with those of numerous authoritative reviews of water fluoridation that finds levels of tooth decay are lower in fluoridated areas and that there is no convincing evidence that water fluoridation causes adverse health effects.
For these reasons the author’s conclusion "The report provides further reassurance that water fluoridation is a safe and effective public health measure" is appropriate.
With over 70 years’ experience of water fluoridation internationally and over 50 years’ experience in the United Kingdom, there has been no convincing scientific evidence to indicate that water fluoridation has caused harm to health.
The 2015 Cochrane review Water fluoridation for the prevention of dental caries was an update of a Cochrane review first completed in 2000. A panel of experts agreed the search criteria in the original review, and the update kept these largely unchanged.
The National Institute for Health Research is currently funding an evaluation of a water fluoridation scheme in Cumbria. This started in 2013 and the final report is expected to be published in 2021. Findings from the evaluation will be available for consideration in any subsequent systematic reviews relating to water fluoridation.
The 2015 Cochrane review Water fluoridation for the prevention of dental caries was an update of a Cochrane review first completed in 2000. A panel of experts agreed the search criteria in the original review, and the update kept these largely unchanged.
The National Institute for Health Research is currently funding an evaluation of a water fluoridation scheme in Cumbria. This started in 2013 and the final report is expected to be published in 2021. Findings from the evaluation will be available for consideration in any subsequent systematic reviews relating to water fluoridation.
The 2008 Water Strategy for England reported that households account for 52% of the use of public water supplies. Around 7% of the water used in homes is used for drinking and cooking; an additional percentage will be used for tooth brushing.
There are no separate figures for water supplied in fluoridation schemes. Such schemes tend to supply more urban areas and it is reasonable to expect a greater domestic use than would be the case for supplies serving areas with significant agricultural or industrial use.
There are a variety of community based oral health improvement programmes that have been shown to be effective in reducing dental decay. No single intervention is likely to provide a solution to oral health improvement priorities and many work together for maximum benefit, for example water fluoridation and fluoride toothpaste.
Public Health England recently reviewed such programmes and published an evidence informed toolkit entitled; Local authorities improving oral health: commissioning better oral health for children and young people, for local authorities to support their work on oral health improvement. Local authorities can therefore consider a range of oral health improvement programmes (including those which make up the Childsmile programme in Scotland and water fluoridation) and decide which or which combination is most appropriate to their local population’s needs. A copy of the toolkit is attached.
Scientific reviews over many years have shown that water fluoridation is an effective and safe public health measure. It is known that consuming fluoride in water at levels permitted by United Kingdom legislation, whether as a result of fluoridation or present naturally, can contribute to the risk of dental fluorosis, as can other sources of fluoride such as toothpaste if swallowed in excessive amounts.
In 2014 Public Health England published Water fluoridation Health monitoring report for
England, acting as guidance for dental teams on the prevention of dental disease in their patients. This included advice on reducing the risk of dental fluorosis from toothpaste ingestion among their patients, in particular young children. A copy of this guidance is attached.
Public Health England advise that there is no current evidence from monitoring data to support a variation of the target level for fluoride in drinking water.
Ecological studies are used for comparing public health outcomes in populations. This is particularly so where multiple populations can be included, there can be a proper account of other factors that might have affected the recorded levels of disease and where reasonable assurance that the ascertainment of disease or exposure to a factor under study has been the same for all observed populations.
As such, this study design is appropriate for monitoring health outcomes in fluoridated and non-fluoridated populations. As an example of the caution that should be adopted when observing differences between fluoridated and non-fluoridated populations, the authors of the 2014 Public Health England (PHE) health monitoring report, both in the report and in a recent summary in the scientific literature (Young et. al. 2015 which is attached) stressed that, whilst lower levels of renal stones and bladder cancer were observed in fluoridated populations, the ecological design prohibits any conclusions being drawn about a protective role of water fluoridation for these conditions.
The results of the 2015 ‘Cochrane Review’ Water fluoridation for the prevention of dental caries’, Iheozor-Ejiofor et al, Feb 2015 are broadly consistent with those from other systematic reviews conducted over the past 15 years in concluding that this public health measure is, as the Cochrane authors state, “effective at reducing levels of tooth decay in both children’s baby and permanent teeth.”
The Cochrane review used specific and relatively narrow criteria requiring that studies include baseline measures of dental caries in two communities, one of which then introduced fluoridation within three years. This approach had the consequence of excluding numerous studies conducted over the past 25 years which compared dental caries levels in fluoridated and non-fluoridated communities. The Cochrane reviewers acknowledge in their report that there may be concerns regarding the exclusion of these studies from their review.
The Cochrane review analysed studies conducted in different ways at different times in different places, finding consistent reductions in levels of dental caries following the introduction of fluoridation. The term ‘bias’ used in the Cochrane review has a specific scientific meaning relating to controlling for other factors such as dietary habits that might have affected the levels of dental caries in the populations studied. The reviewers recognise that this bias “may occur in either direction”.
Relatively recent studies which did not meet the reviewer’s specific inclusion criteria have continued to find substantial dental benefits of water fluoridation. Public Health England’s (PHE) recent Monitoring Report (2014) looked at fluoridated and non-fluoridated communities in England and found that communities served by water fluoridation schemes continue to show lower levels of tooth decay.
A copy of PHE’s report is attached.