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Overview
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Scrutiny
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Water Fluoridation
Task Group
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Report of Findings
January 2004
For further information on this report contact
Sulafa Halstead or Debbie Franklyn
Principal Officers – Overview and Scrutiny
Lancashire County Council
01772 532203/532422
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Table of Contents
Background ........................................................................... 3
Scope of the Scrutiny Exercise .......................................... 3
Membership of the Task Group .......................................... 4
Thanks ................................................................................... 4
Aims and Objectives of the Task Group ........................... 4
Engaging Stakeholders ....................................................... 5
Information Gathered ........................................................... 7
Conclusions ........................................................................ 23
Recommendation ............................................................... 24
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Water Fluoridation
Task Group
Background
Reason for Suggestion:
The matter of water fluoridation was raised at the meeting of Full
Council on 17th July 2003. Council agreed that this matter be
referred to the Overview and Scrutiny Management Panel for
consideration and allocation to an Overview and Scrutiny
Committee for examination.
On 25th July 03 Management Panel referred the issue to the
External Overview and Scrutiny Committee. Members of the
committee agreed that a Task Group should be established,
including members with a range of views on the subject and that as
part of the exercise public opinion should be sought.
Current Position:
Water in Lancashire is not currently fluoridated.
Underlying Issue:
County Council’s Corporate Aim to make Lancashire a place where
people can live healthy lives.
Scope of the Scrutiny Exercise
To produce a report – for the External Overview and Scrutiny
Committee, initially, on the Task Group’s findings about water
fluoridation. To take advice from experts on all sides of the debate.
To consult with interested parties, including members of the public
in Lancashire and to include findings about public opinion in
Lancashire in the report.
3
Membership of the Task Group
The Water Fluoridation Group is made up of the following County
Councillors:
W Dwyer (Chair)
D Lloyd
V Murphy
G Roberts
G Roper
S Sutcliffe
M Wilson
Thanks
The Task Group would like to record their thanks to the many
organisations and members of the public who took part in the
consultation during Autumn 2003.
The Group would also like to thank the individuals who contributed
their time and expertise during the information-gathering stage of
the process:Linda Forrest, Fight Against Fluoridation
Jane Jones, NPWA (Representing North West Councils against
Fluoridation)
Dr Peter Lucas, Lecturer in Bioethics, UCL
Dr Stephen Morton, Director of Public Health, HRV PCT
Mrs Sarah Procter, Community Dental Service
Dr John Roberts, B.CH.D
Dr Gary Whittle, Consultant in Dental Public Health
Aims and Objectives of the Task Group
1. to determine if adding fluoride to water is an effective means of
reducing dental decay in children
2. to identify the benefits and risks associated with adding fluoride
to water
3. to clarify the current legal position and proposed changes
4. to consider the ethics of fluoridating water supplies
5. to seek public opinion
4
Engaging Stakeholders
Members of the Task Group discussed measures that could be
used to inform people across the county about the work being done
by the group, and ways in which the public could get involved.
A survey form was generated, in consultation with the council’s
research manager. This form was available electronically, via the
Lancashire County Council website. It could also be supplied in
hard copy by post, or people could complete it in person on the
days that the group visited Preston and Burnley. A copy can be
found at Appendix A.
Articles featured on the front page of ‘Vision’, the County
Council’s monthly household newspaper, in both
September and November giving details and inviting people
to contact Overview and Scrutiny officers if they would like
to receive a survey form.
The News Team also issued press releases about the activities of
the Group in order that local press could choose whether to inform
their readers.
As part of Local Democracy week (13-17 October 2003), the Chair
of the Fluoridation Task Group went out to meet people in Preston
and Burnley town centres to ask for their views on adding fluoride to
public water supplies. Using the County’s new trailer for the first
time - sited on Preston’s Flag market on Monday and outside the
Red Lion Pub on St James’ Street, Burnley on Thursday – County
Councillor Mrs Dwyer spent the day speaking to members of the
public. Many had very firm views about fluoridation. With assistance
from County Councillor Stephen Sutcliffe in Preston, and Officers
from Scrutiny Support and Corporate Communications on both
days, Mrs Dwyer encouraged passers-by to discuss the issues and
Both days generated considerable media interest.
The Chair of the Overview and Scrutiny Management Panel,
County Councillor Howard Gore, was interviewed in Burnley by
BBC Television. Councillor Gore explained that Overview and
Scrutiny Members are keen to hear the views of the people in
5
Lancashire about the issues that are important. The item was
featured on BBC1’s The Politics Show on Sunday 19 October.
On 24th November an
information-gathering
meeting of the Task
Group was webcast.
This was done so that
people could watch the
progress of the meeting
and hear responses to
questions put on their
behalf by the County
Councillors. The
meeting can still be
viewed on the County
Council website:http://www.lancashire.gov.uk/ (click on “watch council meetings”).
6
Information Gathered
The Task Group took advice from experts on all sides of the debate
and consulted with interested parties, including members of the
public in Lancashire. The information came in a variety of formats
and was presented to members of the Task Group. A summary of
the information gathered in relation to each aim is detailed below.
At the meeting on 24th November County Councillors voiced a
range of questions that had been put forward by members of the
public in Lancashire. These had been selected as representative of
recurrent concerns expressed by the population. In some cases
responses to specific questions are included below (indicated ‘Q’),
in other cases the subject of a question is encompassed within the
text. Responses given illustrate views from either or both sides of
the debate, dependant upon the particular subject being discussed.
Aim 1:
to determine if adding fluoride to water is an effective
means of reducing dental decay in children
In North-West England there is a high level of dental decay
amongst children, many of whom have to have extractions. The
average number of decayed, missing or filled teeth amongst five
year olds in the north-west is 2.58. The Government target at age
five is for an average of one.
The British Association for the Study of Community Dentistry
conducts annual surveys of dental caries prevalence in children
within a four-yearly cycle comprising those aged five, 12, and 14,
throughout Great Britain. The BADCD began these surveys in
1985-86 in England and Wales.
Tables of mean number of dmft for five-year old, in Lancashire since 1987/8
Surveys carried out for Lancs as part of the BASCD co-ordinated surveys
Deciduous teeth only.
Blackburn, Hyndburn and Ribble
Blackpool, Wyre and Fylde
Burnley, Pendle and Rossendale
Chorley and South Ribble
Lancaster
Preston
West Lancashire
1985 1987 1989 1991 1993 1995
-86 -88 -90 -92 -94 -96
2.62
2.46
2.58
2.03
2.52
3.83
2.37
2.22
2.00
3.37
1.61
2.41
2.05
1.67
2.50
2.16
3.10
1.90
2.75
2.43
1.89
2.51
1.97
3.31
1.68
2.71
1.92
1.34
3.06
2.62
3.23
1.90
2.79
2.68
2.46
More recent figures can be seen on the table that follows,
demonstrating a further reduction in the number of decayed,
missing and filled teeth amongst the County’s five year olds.
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2.57
1.97
3.12
2.06
2.53
2.83
2.18
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Q - How does fluoride affect the teeth, through direct contact or
through the blood? And how does the body deal with fluoride once
ingested, is it absorbed or expelled?
Through direct contact, it works topically, through gels, pastes etc. If
it is drunk the aim is that it is then re-excreted in salvia. However
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some experts are of the view that it doesn’t get to high enough
levels in saliva via ingestion to impact topically in the mouth. The
Centre for Disease Control records levels of fluoride in saliva at
0.016 ppm in fluoridated areas, this is not high enough to be
effective regarding protecting from carries. We keep ½ in the body
and excrete ½.
Q - At what age and for how long does a child need to take a
fluoride supplement to have maximum effect?
The earlier a child takes it the more beneficial effect it has, well into
the development of secondary teeth.
There are guidelines though, the current advice is that no fluoride
should be consumed before 6 months, and suggested intake levels
have been lowered over time.
Q - How will we make children drink this water? Why not provide
bottled fluoridated water for free in schools instead?
It’s too late when children get to school, it’s needed at an earlier
age. By fluoridating water they will get it in numerous ways, for
example squash is made with water and it will be in cooking.
Q - What percentage of proposed added fluoride would actually be
taken up by young children in the form of drinking water?
A very small amount, approximately 30% is used by industry, 30%
is lost through leaks in the delivery system, most of the rest is used
in gardens, car washing etc. United Utilities figures show that 3% of
water is used for human consumption.
Supporters say water fluoridation is the most cost-effective way to
get fluoride to the groups that need it, having an approximate cost
of £0.50 per person per year, compared with £10 for toothbrushes
and toothpaste.
The addition of fluoride to water supplies reduces the difference
between social classes. There is less difference between the dental
health of poor and wealthy areas in fluoridated areas than there is
in non-fluoridated areas.
Dr Gary Whittle, Consultant in Dental Public Health explained that
dental decay is much more unsightly than fluorosis and we shall
have failed our children if we fail to add fluoride to the water supply.
Dr Roberts promotes dental health and the connections with the
health of the mouth and the rest of the body. He agreed that it is
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great to use fluoride in dentistry and that it can help to make
improvements, but not through adding it to water. Dentists should
be allowed to use fluoride as appropriate in the treatment of
individuals.
Studies have shown that tooth decay in children is related to social
class; research indicates that water fluoridation reduces dental
caries (cavities) inequalities between high & low social groups.
The NHS Confederation believes that water fluoridation represents
an effective public health intervention for health authorities to
undertake to improve the oral health of their local populations and is
therefore an important component of Strategic Health Authority and
Primary Care Trust oral health strategies.
Q - Fluoridating the water will not improve the social conditions or
diet of those children who are "at risk", shouldn't measures to
improve children’s teeth be targeted at those who need it using
organisations such as Sure Start?
Sure Start are getting excellent results, once Sure Start and its
successors have improved dental health then long term we wouldn’t
need to replace fluoride equipment used to add fluoride by the
water providers, but currently the problem is bigger than Sure Start.
Schools can do all sorts of things, get rid of tuck shops, introduce
good nutrition and teach oral hygiene. Soft drinks machines are
profit making and so can be seen as attractive options, but don’t
have a place in school.
Tooth decay is part of a bigger problem encompassing other health
issues such as obesity. It is the effects of poor diet on whole child
that we should be looking at not covering up problems through
other methods. Health Authorities should increase efforts on cutting
sugar consumption and improving access to dental provision, only
45% of the population have access to an NHS dentist.
The University of York report concluded that water fluoridation
reduces the prevalence of tooth decay by an estimated 15%
Aim 2:
to identify the benefits and risks associated with adding
fluoride to water
Dental decay is a large problem, particularly amongst children in
East Lancashire. It is primarily a disease of poverty and
disadvantage and is more likely to occur in particular groups such
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as single parent families and ethnic groups. It is often easier to
reward children with sweets rather than trips out, computers and
designer clothes, and it is harder for those parents to remember to
give their children fluoride tablets.
Dr Morton suggested that there are numerous contributing factors
including the frequency of tooth cleaning, the amount and frequency
of sugar consumption and the lack of fluoride in water. It would
have been nice to have more robust studies available for the York
Review but there is no evidence of harm except for dental fluorosis.
However it is very important to have public support for this before
doing anything.
Dr Lucas pointed out that it is not correct to say that tooth decay is
caused by lack of fluoride in water. Something being absent not the
same as a deficiency.
Dental fluorosis is a physical manifestation of fluoride toxicity.
Veneering is the only remedial action available to correct the effects
of this fluorosis, and that this is not a cure only an expensive
cosmetic cover-up.
It is not logical to think that fluorisis only affects teeth, fluoride
accumulates throughout body. Dental research has shown the
pineal gland (relating to puberty) can be damaged by fluoride.
There is also an increase in lead uptake caused by the presence of
fluoride and some racial groups more affected by fluoride than
others. Lead uptake from the water supply is a particular problem in
Lancashire due to the nature and age of the housing stock here.
This would therefore be exacerbated by the addition of fluoride.
Q - What are the long-term effects of water fluoridation on the
population's health?
Establishing this is why the York Review was commissioned.
But there are over 40000 studies of fluoridation. The York Review
studied only 300 of these. The criteria of the review was narrowed
to exclude thyroid fluoride studies. The Chair of the review panel
said they did not find fluoridation to be safe, and that all studies
were poor and non-unbiased.
The University of York review found no clear association between
water fluoridation and adverse outcomes such as bone disorders,
hip fractures and cancer incidence. The more recent Medical
Research Council review made some recommendations for further
research; for example better information on the prevalence and
cosmetic importance of dental fluorosis.
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The Executive Summary of the York Review can be found at
Appendix B, or you can obtain the full report at
www.york.ac.uk/inst/crd/fluorid.htm
Canadian research shows doctors who have changed their minds
about the value of adding fluoride.
Q - What would be the impact on people who already use fluoride in
other products - will they have to change their usage?
Yes, Dr Proctor said that she would discontinue fluoride
supplements, but pointed out that none of her current patients take
regular fluoride supplements.
Q - How can we protect people taking medication who have, of
necessity been advised not to take fluoride supplements?
Dr Morton knew of no pharmacological product which recommends
not to prescribe it in fluoridated areas and said no medical condition
is adversely affected by fluoride. Renal dialysis needs all sorts of
things to be removed from the water used and to be de-ionised.
Q- What about people in vulnerable groups, such as AIDS
sufferers, unborn children & pregnant women or people with
allergies & in particular those with asthma?
Vulnerable groups would benefit from fluoride as much anyone else
- everyone gains some benefit, even in adults fluoride protects
against further tooth decay. Immuno-compromised patients can
have fatal impacts from dental decay.
Those with impaired immune systems could be at risk, there is no
science to prove otherwise. No one ever died from fluoride
deficiency but some people have an allergy to fluoride.
In higher levels fluoride can cause huge problems e.g. hip fractures
in the elderly. Damage through dental fluorosis could cause children
to be teased to extent where they suffer psychological damage.
Q - How can we control the level of fluoride we are consuming?
Especially if we drink the recommended 8 glasses a day - will there
be a recommended maximum daily intake of water, as with any
other medication? (& what about feeding babies formula made with
fluoridated water)
13
The government desired level of fluoride in water is 1 part per
million, this is equal to 1 mg of fluoride per litre of water. However
the current recommended intake level for children below six years is
zero fluoride. For adults it is 0.05mg. There is already naturally
occurring fluoride in foods - grape juice, cola, chicken bones.
The York Review is lacking but they used the best studies they
could find, but found no evidence to support any problems. The
review board did suggest that work should be done to look at the
difference in uptake by the body between natural and artificial
fluoride. Dr Morton would like to see these trials run in Lancashire
so the population could benefit from the addition of fluoride at the
same time.
Mothers naturally filter fluoride from breast milk but for babies on
formula it is best to use bottled non-fluoridated water to make up
the formula.
Q - What practical & affordable alternatives will there be for those
who cannot or do not wish to consume fluoridated water if
fluoridation occurs?
People can buy water or install a treatment plant in their house (at a
cost of £4-600). Even then there remains a problem for people
wishing to avoid fluoride as it would be contained in processed
food, prepared drinks, etc. However, as far as we are aware, there
is not a bigger market for mineral water in fluoridated water areas.
Jane Jones explained that there is a difference between natural
fluoride, Calcium Fluoride, and artificially added hexafluoric acid.
The drinking water inspectorate treats these as traditional
chemicals, which means that they don’t have toxicological data from
official sources in a way that would be required for other substances
such as arsenic or lead.
Dr Proctor detailed that she has particular responsibility for people
with special needs and children. She is a practising dentist who
sees the effects of dental decay everyday and thinks it would be
unethical not to put fluoride into water. This would benefit everyone
and is widely supported by those in the dental service. Dental
fluorosis is far better than dental decay. She said that we are not
talking about mass medication, but rather about targeted provision
to areas that need it such as the north-west.
The community dental service visit antenatal classes, nurseries,
schools, clubs and brownies - these children know what they should
be doing to look after their teeth but can’t or won’t. Currently all
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sorts of activities are undertaken to access people in high decay
rate areas, but not everyone is being reached
Aim 3:
to clarify the current legal position and recent changes
Until recently the 1985 Water (Fluoridation) Act (subsumed by the
1991 Water Industry Act) put no obligation on water companies to
add fluoride to water, even if requested to by the SHA. Between
1964 and 1975 a number of local authority water fluoridation
schemes were introduced in England and Wales. However
because the regulations did not place any obligation on water
companies to implement SHAs’ recommendations many SHAs
throughout the UK have been unable to implement fluoridation
proposals. According to the NHS Confederation over 60 health
authorities have had their requests for fluoridation refused by the
water supplier.
The Government took action to redress this situation and recently
included an amendment to the Water Bill, which has now passed
through parliament. This amendment detailed as follows1
“Fluoridation of water supplies at request of relevant authorities”
(1) If requested in writing to do so by a relevant authority, a water
undertaker shall enter into arrangements with the relevant authority
to increase the fluoride content of the water supplied by that
undertaker to premises within the area specified in the
arrangements.
(2) But a water undertaker shall not be required to enter into any
such arrangements until an indemnity with respect to the
arrangements has been given references to a relevant authority
- in relation to areas in England a relevant authority is a Strategic
Health Authority established under section 8 of the National Health
Service Act 1977. The area specified in arrangements under this
section may be the whole or any part of the area of the
Strategic Health Authority in question.
Strategic Health Authorities are responsible for all the costs
incurred in fluoridating the water supplies.
The arrangements shall be on such terms as may be agreed
between the relevant authority and the water undertaker or, in the
1
Water Act 2003 , 2003 Chapter 37
© Crown Copyright 2003 - Acts of Parliament printed from the website are printed under the superintendence
and authority of the Controller of HMSO being the Queen's Printer of Acts of Parliament.
15
absence of agreement, determined in accordance with section 87B
of the Bill.
Those terms shall include provision (a) requiring the relevant authority to meet the reasonable capital
and operating costs incurred by the water undertaker in giving effect
to the arrangements;
(b) specifying circumstances in which the requirement to increase
the fluoride content may be temporarily suspended; and
(c) for the variation of the arrangements at the request of the
relevant authority.
The Bill also states that before a request for a Water Authority to
add fluoride can be made that consultation must take place in
accordance with the regulations (not published at time of this
report). Parliamentary Under-Secretary of State for Health, Miss
Melanie Johnson, made it clear to the government Standing
Committee that with regard to consultation there is a difficulty in
weighing up the responses, but whatever the case, local opinion
must be in favour of any proposal to add fluoride to the water
supply. It will not proceed if all the indicators are overwhelmingly
against it, as the regulation to be introduced will make absolutely
clear. Whatever mechanism is used, a clear majority of people
should be in favour of fluoridation. She also discussed the cost of
consultation, which will come out of the NHS budgets, and
explained that the government will set out in regulations the
procedures that the strategic health authority must follow in
undertaking a consultation, and that they will be advised not to
embark on one if the funds for so doing have not been identified.
In addition, there is a requirement to monitor the effects on health in
any area where an arrangement is agreed to fluoridate the water,
and to report on the findings within four years of arrangements
coming into force.
Standing Committee D discussed the proposed changes to the bill
before the vote on 10th November. If you would like more
information about the debates of the Government’s Standing
Committee in relation to this subject please go to:
www.publications.parliament.uk/pa/cm200203/cmstand/d/cmwater.htm
Full details of the Water Bill 2003 section 58 Fluoridation of water
supplies can be found at
www.uk-legislation.hmso.gov.uk/acts/acts2003/30037--d.htm#58
Aim 4:
to consider the ethics of fluoridating water supplies
To clarify the distinction between ethical and safety or economic
issues: ethics is concerned with what is right and wrong, with what
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we should and should not be doing, over and above questions of
economic efficiency and safety.
Whether a given policy makes sense in terms of treatment and the
efficient use of resources is one thing, whether it makes ethical
sense is another, and in a society such as our own it is important to
appreciate that we can and should reject what is unethical,
regardless of (e.g.) how cost-effective it may be..
So for example article five of the European Convention on Human
Rights and Biomedicine states:
‘An intervention in the health field may only be carried out after the
person concerned has given free and informed consent to it’
This principle of respect for the informed choices of the subjects of
medical intervention is not the only important principle of medical
ethics. The principle of acting in the patient’s best interests is also
important. However, where the patient is able to give (or withhold)
informed consent, and where there is no serious risk of harm to
others if they do not do so, obtaining their consent is usually
considered to be a sine qua non of ethical medical intervention.
In light of the most important general principles governing medical
ethics world-wide, it is quite wrong to subject any individual to a
medical intervention he or she neither needs nor wants. Until such
time as the proponents of fluoridation are able to obtain the consent
of those affected – not of a majority of them, but of all of those who
are competent to give their consent – then fluoridation of public
water supplies looks highly unethical.
However others argue that if we can reduce inequalities between
people then we should do it. In that case the greater common good
must override personal choice. The Task Group heard this opposite
view from some - that fluoridation is perfectly ethical. As tooth
decay may be responsible for small number of deaths, through
anaesthetic, so you could say that it is unethical not to fluoridate.
The dental health of children is of concern to all of us, but water is
essential to life. Current chemicals that are added to water are to
treat it to make it safe to consume. Fluoride would be added to treat
humans. Fluoridation of the water supply takes away the right to
choose how much medication an individual takes. We are talking
about enforced treatment of those who don’t need treatment not just
those who do.
Q - Once a precedent has been set with fluoride what next? Will we
be force fed sedatives, laxatives, contraceptives, vitamins etc or
mass medicated in other ways?
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The consequences would become evident down the line. It is the
impact of taking that first step - mass medicating without consent –
that needs to be considered. To say that this would be targeted
action is misleading, targeting districts is still mass-medication of
people within that spatial area.
That is why it is important to have public debate. Children don’t
have right to give consent for medical treatment and can’t access
fluoride via shops. Children are the ones suffering and they are not
in a position to make the relevant choices. Dental decay is one of
the biggest inequalities we have in the UK.
Q - How can mass-medication be justified when other methods of
reducing decay are readily available & proven to be effective?
Health providers said they have thought about using other methods,
they said we could add it to confectionery, but we are trying to
discourage people from eating sugar and salt and we are not
discouraging them from drinking water. People need to be informed
and to discuss the ethics.150 years ago we didn’t have safe water
at all. It is an area with scope for discussion for give and take. The
community as a whole would benefit.
The Chief Medical Officer can’t force people to eat a better diet but
should be doing more to promote the nutritional side of things.
There would be huge support for this. 150 years ago only the very
rich suffered tooth decay as only the rich could afford sugar, water
fluoridation only masks the underlying problem.
We need an ethical solution to this dentistry problem. Ethical and
desirable options can pull us in different directions. It is important to
do what we can to reduce children’s dental decay. Ethics provide a
framework within which solutions should lie.
Aim 5:
to seek public opinion
There is public concern about long term health implications of some
medical treatments e.g. MMR vaccinations, and some people feel
the same way about the addition of fluoride to the water supply.
The survey form was available to people in the county
electronically, via the Lancashire County Council website, by post
and people could complete it in person on the days that the group
visited Preston and Burnley. 1095 responses have been received.
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Of all those who answered the question ‘Do you feel you are well
informed about the issue of water fluoridation?’ 41.6% felt they
knew a lot. A further 43.9% felt they know a little. 9.2% of those who
answered the question said they had heard of it but that's all and
2.6% had never heard of it til they were asked the question (2.6% of
those completing the questionnaire did not answer this question).
In response to the question ‘Do you think
Fluoride should be added to the water in
Lancashire?’ the following were received:
Total %
Yes
110 10.0
No
934 85.3
Don't know 51
4.7
County Councillors Howard Gore and Wendy
Dwyer in Burnley town centre to ask people for
their views
When further analysis of the responses is undertaken it becomes
apparent that the more our respondents felt they know about the
subject, the more likely they are to be against the idea of adding
fluoride to the water supply. The table below shows the proportion
of respondents who think yes/no/don’t know to the question ‘Do you
think Fluoride should be added to the water in Lancashire?’, split
according to how much they felt they know about the subject.
% total
Know a lot
41.6
Know a little
43.9
heard of it but that's all
9.2
never heard of it til now
2.6
not answered question
2.6
%y
5.48
11.0
17.8
32.1
17.2
%n
93.6
85.0
60.4
50.0
79.3
%d
0.88
3.95
21.8
17.9
3.45
This detail can be split further by responses received from different
District areas within the county. This can be found at Appendix C.
In relation to the question ‘Who do you think makes most valuable
contribution to a child having good dental health?’ the response
received was overwhelmingly that it is the child’s parents, with 85%
choosing this answer. The next most popular answer was Dentists,
which was chosen as making the most valuable contribution by only
7.1% of the respondents.
Of those who responded to the question ‘Which, if any, of the
following do you think would make the greatest improvement in
reducing the level of dental decay in children?’ 75.2% selected
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‘eating less sugar’, 67.5% ‘eating a healthier diet’ and 63.1% ‘Giving
parents more information about good dental health’.
Which of the following do you think would make greatest improvement in
reducing the level of dental decay in children?
Eating less sugar
Using fluoridated salt
Eating a healthier diet
Adding fluoride to the water
supply
More dentists who offer NHS
treatment
Providing fluoridated milk for
young children at school
Increasing the frequency of
cleaning teeth
Giving parents more information
about good dental health
Using toothpaste with added
fluoride
0
100
200
300
400
500
600
700
800
People also had plenty to contribute by way of comments on the
subject, issues they wished to raise and information to pass on.
They submitted questions for County Councillors to raise with the
witnesses that were invited to attend the November meeting. A list
of the questions that were asked at the meeting can be found at
Appendix D. These were chosen as representative of concerns
raised by many people, wherever possible answers given to these
questions can be found in the text of this document. Other
questions relating to the factual issues, such as who would make
any request for fluoride to be added and who would bear the cost,
have been answered in the section under Aim 3.
20
900
Results of responses received to the questions in the survey.
Who do you think makes most valuable contribution to a child having good dental health?
Total
The Government
The National Health Service
Lancashire County Council
Dentists
The child’s parents
The child
Schools
4
17
2
76
913
35
27
%
0.4
1.6
0.2
7.1
85.0
3.3
2.5
Which, if any, of the following do you think would make the greatest improvement in
reducing the level of dental decay in children?
Total
%
Using toothpaste with added fluoride
457
41.7
Giving parents more information about good dental health
691
63.1
Increasing the frequency of cleaning teeth
615
56.2
Providing fluoridated milk for young children at school
53
4.8
More dentists who offer NHS treatment
569
52.0
Adding fluoride to the water supply
73
6.7
Eating a healthier diet
739
67.5
Using fluoridated salt
7
0.6
Eating less sugar
823
75.2
None of these
1
0.1
Another method (give details)
42
3.8
Do you think Fluoride should be added to the water in Lancashire?
Total
Yes
110
No
934
Don't know
51
%
10.0
85.3
4.7
Do you feel you are well informed about the issue of water fluoridation?
Total
%
Know a lot
456
42.8
Know a little
481
45.1
Heard of it but that’s all
101
9.5
Never heard of it ‘til now
28
2.6
1066
Notes:
In Question 2, % is % of respondents who selected this answer not % of total responses
Total number of responses varies as some people chose not to respond to all questions
21
22
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Do you think fluoride should be added to the water in Lancashire?
200
180
160
140
120
100
y
n
d
80
60
40
20
0
Conclusions
In relation to each of the stated aims of the Task Group, members
have drawn the following conclusions:

to determine if adding fluoride to water is an effective means of
reducing dental decay in children
The University of York report concluded that water fluoridation is
likely to have a beneficial effect, but that the range could be
anywhere from a substantial benefit to a slight disbenefit to
children’s teeth. The addition of fluoride to the water supply could
help to reduce inequalities in dental health but the evidence for this
is was unreliable. It would not irradicate the problem of poor dental
health and does not overcome differences caused by social class.

to identify the benefits and risks associated with adding fluoride
to water
Dental decay is primarily a disease of poverty and disadvantage
and is more likely to occur in particular groups such as single parent
families and ethnic groups. Water fluoridation is seen by
government as a cost-effective way to get fluoride to the groups that
need it.
Any beneficial effect from adding fluoride comes at the expense of
an increase in the prevalence of dental fluorosis. Veneering is the
only remedial action available to correct the effects of this fluorosis,
and this is a cosmetic cover-up not a cure. The University of York
review found no clear association between water fluoridation and
adverse outcomes such as Down’s syndrome, bone fractures and
cancer incidence, however the report stated that evidence was
poor. Thyroid studies had not been included. Other use of fluoride
supplements would need to be ended if fluoride were added to the
water supply.

to clarify the current legal position and proposed changes
Changes to the Water Bill have now been passed by parliament,
but regulatory details including specifics relating to consultations to
be undertaken by Health Authorities are still awaited.

to consider the ethics of fluoridating water supplies
23
The distinction between ethical and safety or economic issues is
that ethics is concerned with what is right and wrong, with what we
should and should not be doing, over and above questions of
economic efficiency and safety. Whether a given policy makes
sense in terms of treatment and the efficient use of resources is one
thing, whether it makes ethical sense is another. In this case are we
talking about enforced treatment of those who don’t need treatment
not just those who do?
Alternatively there is the argument that if we can reduce inequalities
between people then we should do it. In that case the greater
common good would override personal choice.
Ethical and desirable options can pull us in different directions. It is
important to do what we can to reduce children’s dental decay.
Ethics provide a framework within which solutions should lie.

to seek public opinion
The responses received from the public clearly show that they
believe there are better ways to improve children’s dental health,
reducing sugar intake, change in diet and change of habits e.g.
brushing. It makes more sense to tackle causes of decay than
symptoms and there are many other ways to use fluoride without
adding it to the water supply. It is important for parents to look after
children’s teeth.
Recommendation
The recommendation made by members is as follows:
That, should County Council be consulted by the Health Authority
on any proposal to add fluoride to the water supply in any part of
Lancashire that this report be used to inform the response made.
24