Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the Written Answers by Earl Howe on 28 October 2013 (WA 213) and 5 December 2013 (WA 60–1), whether they will now answer the question why Public Health England, in comparing the percentages with dental fluorosis in fluoridated populations published by McGrady et al in 2012 with those from the York systematic review, cited small categories of fluorosis which were not found in the York review, but omitted the statistically comparable total-fluorosis figures of 55 per cent in fluoridated Newcastle against 48 per cent worldwide in the York review in 2000.
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, in the light of the statement in the Executive Summary of the <i>Water fluoridation: Health monitoring report for England 2014</i> that there is "no evidence of a difference in the rate of hip fractures between fluoridated and non-fluoridated areas", what account Public Health England took of the article "Adding fluoride to water supplies" by Cheng KK et al in the <i>British Medical Journal</i> of 7 October 2007, in which the authors state that if the population of England had an average lifetime exposure of ≥0.9 ppm fluoride in drinking water a modest association between fluoride and hip fracture, if such exists, would have a less than one in five chance of being detected despite potentially causing more than 10,000 excess fractures a year.
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the Written Answer by Lord Prior of Brampton on 17 November 2015 (HL3315), why the Executive Summary of the report by Public Health England <i>Water fluoridation: Health monitoring report for England 2014</i> concludes that "The report provides further reassurance that water fluoridation is a safe and effective public health measure", when the Limitations section of the report states that "there was potential for considerable misclassification of exposure status" and the Conclusion section states that "the population-based, observational design does not allow conclusions to be drawn regarding any causative or protective role of fluoride".
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the Written Answer by Lord Prior of Brampton on 12 October 2015 (HL1940), what plans they have to commission or financially to support further studies that might meet the "specific and relatively narrow criteria" of the 2015 Cochrane review <i>Water fluoridation for the prevention of dental caries</i>, in the light of the point made in that review’s abstract that "the applicability of the results to current lifestyles is unclear because the majority of the studies were conducted before fluoride toothpastes and the other preventative measures were widely used".
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the Written Answer by Lord Prior of Brampton on 12 October 2015 (HL1940), what assessment they have made of the reasons why systematic scientific reviews, such as Cochrane reviews, adopt "specific and relatively narrow criteria".
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the answer by Lord Prior of Brampton on 19 January (HL Deb, col 641) about the potential fortification of bread with folic acid to prevent neural tube defects in pregnancy, why they do not apply the argument "around choice and whether or not it is right to medicate the entire population for the benefit of a fairly small part of it" to the fluoridation of water supplies to prevent caries.
Answered by Lord Prior of Brampton
It has been the policy of successive governments that decisions on water fluoridation are best taken locally. There is a duty to consult the local population where local authorities propose the establishment of a new water fluoridation scheme. Some areas of the country have water supplies that naturally contain levels of fluoride similar to the target level for water fluoridation schemes where the levels are adjusted.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government what is their estimate of the percentage of water involved in fluoridation schemes that reaches the teeth of children it is designed to benefit, taking account of industrial, agricultural, municipal, domestic and other usage, and of the leakage from mains supplies.
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, in the light of the Written Answer by Earl Howe on 16 January 2013 (HL4464) describing the Childsmile programme as "very encouraging", whether they can give further information about the benefits of the programme as an alternative to water fluoridation in addressing dental decay and social inequalities in dental health.
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government, further to the Written Answer by Earl Howe on 16 January 2013 (HL4464), whether the potential disadvantages as well as advantages of water fluoridation for young children "are enjoyed regardless of personal behaviour".
Answered by Lord Prior of Brampton
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.
Asked by: Earl Baldwin of Bewdley (Crossbench - Excepted Hereditary)
Question to the Department of Health and Social Care:
To ask Her Majesty’s Government what is their view on the merits of reducing the concentration of fluoride in water supplies subject to fluoridation schemes from 1.0 to around 0.7 part per million, in the light of the experience of countries such as Canada, the Republic of Ireland, Hong Kong and Singapore.
Answered by Lord Prior of Brampton
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.