Fear and fluoride, bedfellows amidst conflicting “evidence”

The Tantawangalo water supply source at Six Mile Creek. Image Kate Burke
The Tantawangalo water supply source at Six Mile Creek. Image Kate Burke/Raisin

The potential fluoridation of the Tantawanglo-Kiah Water System (Candelo, Wolumla, Merimbula, Tura, Pambula, Eden, Kiah) and the Brogo – Bermagui Water System (Quaama, Cobargo, Brogo, Wallaga Lake, Bermagui) has divided the Bega Valley community.

With Bega Valley Shire Council’s decision on whether to fluoridate or not still pending, the way forward seems far from clear.

By the way, the Bega – Tathra Water System has been fluoridated since 1963.

The international anti-fluoride Fluoride Action Network (FAN) challenges the safety of fluoridation despite reassurances from peak health bodies such as the Australian Medical Association and the Australian Dental Association.

FAN cites a series of scientific studies that point to negative health effects related to fluoride. Yet the World Health Organisation cites fluoridation of water as, “the most effective public health measure for the prevention of dental decay.”

The ingredients of this debate are a potent mix of conflicting evidence, with added fear, and a rather large ethical grey area.

It’s murky and hard to navigate.

Yet if you can familiarise yourself with this tricky landscape, you can start to make sense of the different perspectives people have on this issue, and perhaps take some of the fear out of the equation.

It turns out that scientific studies, the foundation stones of public health debate, are not always as rock solid as they seem.

While the fluoride debate touches on personal choice, welfare, and economics; scientific studies are a central part of pro and anti-fluoride argument.

A body of studies has been cited by the Fluoride Action Network pointing to potential effects of fluoride such as reduced IQ in children, obesity, and even cancer.

The Australian Medical Association claims that there is no appreciable link between fluoridation and these side effects.

But with so much at stake, how do you navigate the conflicting “evidence” that we’re finding?

Where better to begin than Google Scholar?! Google’s search engine for published academic studies. What happens when you search for “fluoride and IQ”?

Looking through the studies that have linked fluoride to lower IQ in children, one thing stands out – most studies that popped up didn’t test for other factors that could affect IQ.

Many studies were from China, India, or Mongolia, and compared towns that fluoridated water supplies with those that didn’t.

However, they didn’t check for other differences between the towns – levels of poverty, nutrition, potential lead and arsenic poisoning, all of which can affect the IQ of children.

This is like blaming weight gain on exercise, without considering diet.

These studies simply don’t meet the criteria needed to inform sound decision-making, yet they are published online alongside studies of higher quality.

Twenty low-quality studies that link lower IQ and fluoride, alongside only one quality study that finds no link, can look like strength in numbers and cast the wrong impression.

Assessing evidence doesn’t work like that. It’s not like voting. One study is not necessarily worth the same as another.

The problem is that scientific investigations can be carried out and published (particularly online) by any scientist, from any organisation. Most are carried out with noble intentions, but even noble intentions can be fed by bias – if you’re passionate about a cause, or feel that you’ve found an important link, established scientific practices might fall by the wayside.

Glass of water. Source pixabay.com 1160264
A glass of water. Source pixabay.com 1160264

Dr Andrew Wakefield’s study linking autism with vaccination is a famous example.

Dr Wakefield and his colleagues felt that they’d found an important link after reviewing the cases of eight people who’d been diagnosed with autism within a month of receiving the Measles Mumps Rubella (MMR) vaccine.

The investigation was found to be riddled with problems; their medical assessments and analysis of results were described as incomplete and biased.

Much of the criticism of Dr Wakefield’s study suggested it ignored statistical significance.

Given that 50,000 children per month were vaccinated with MMR in England at the time, eight presentations of autism were not enough to establish a link.

Statistical significance is needed for a scientific result to have meaning. Where health is concerned, this usually means two things –  that a lot of people were tested and the results were strong enough to discount coincidence and other confounding factors, such as nutrition and lead in the IQ example.

Dr Wakefield’s study was discredited, and wide scale, high-quality studies were carried out that found no link between autism and vaccination.  But his study was already fuelling the fears of parents across the globe.

When something appears to threaten the health of children, it can achieve notoriety.

It’s important to carefully examine the information you are given or find yourself, but how do you sift through the jargon, the publications, the conflicting evidence?

Putting your fear aside, how do you know what and who to trust?

Dr Will Grant of the Australian National University’s Centre for the Public Awareness of Science says that it’s almost impossible for one person to do this alone.

“While I’d love to say that I have the capacity to truthfully assess the veracity and rigour of all research that’s available online, I simply don’t have that capacity.  In fact, no one does,” he says.

“Instead we’re all forced to use the decision-making heuristics we’ve always used, typically though not exclusively, trusting a variety of voices in our networks that know better.”

Dr Grant says that we rely on institutions to process this information for us.

“But if I’m a person who doesn’t trust these institutions – and the number of people who don’t trust the central institutions of society is growing globally – then I’m going to trust other things,” he says.

Kate Burke
Kate Burke

Other things might include organisations like FAN, who question the reliability of institutionalised knowledge.

The FAN website claims it, “develops and maintains the world’s most comprehensive online database on fluoride compounds.”

Despite making this claim, they don’t give you a comprehensive review of the quality of materials in their database.

The Australian Government’s National Medical Health Research Council (NHMRC), is a not-for-profit research organisation that draws on the expertise of people tied to the University of Melbourne, Royal North Shore Hospital, The Cancer Council, Alfred Hospital, and Monash University, among other organisations.

The NHMRC has released a Health Effects of Fluoridation Evidence Evaluation Report through its Clinical Trials Centre at the University of Sydney which provides an analysis of fluoride research from the last decade.

It’s worth a read for two reasons.

Firstly, it assesses the quality of studies looking into the effects of fluoridation on dental caries (decay) and other symptoms from 2006-2015, and walks through them bit by bit, weighing up their value without apparent bias.

Secondly, its conclusions reflect the “greyness” of this debate. The NHMRC says the evidence appears to indicate that Australian water fluoridation standards are safe, while also suggesting there are gaps in the research.

The recommended level of fluoridation is shown to give a 35% reduction in dental caries. This is a significant number, as it means that more than a third of dental decay can be prevented by adding fluoride to a water supply.

This has knock-on effects for the rest of a person’s health and reduces financial pressure on individuals and the economy by cutting down on visits to the dentist.

The report also shows that recommended fluoride levels can increase the incidence of tooth discolouration due to fluorosis (a chronic condition caused by excessive intake of fluoride compounds, seen as mottling of the teeth) by around 12%.

Healthy teeth, Source Pixabay
Healthy teeth, Source Pixabay

The NHRMC document also gives many of the scientific reports presented in this debate a confidence grading.

The low overall confidence grading of the reports that raise concerns about cancer and IQ perhaps take some fear out of the equation, as the ratings are low enough to discount many of the studies altogether.

The presence of studies of higher quality (ie more thorough and more reliable) have tipped the balance of evidence away from such matters of concern.

However, if the NHRMC also suggests there are gaps in the research, why can’t we just test for the negative health effects that fuel much of the fear in a robust credible way?

In Australia, people are exposed to fluoride in a number of ways, including in toothpaste and tea, and it naturally occurs in the environment around us. This means that a person’s previous exposure to fluoride is very difficult to determine. To find a bunch of people who have never been exposed to fluoride as a control group, and then to test the effects of drinking fluoridated water on them, is extremely challenging.

And as the studies linking fluoride and IQ in China, India, and  Mongolia show us, these studies are problematic because there are so many other factors that can contribute to influence a person’s health.

Finding the fluoride link is not easy.

The NHMRC review gives us an indication of which way the evidence is swinging – and it’s telling us that fluoridation of our water supply will give us healthier teeth and that the only side effect of significant concern is discolouration caused by fluorosis.

It also tells us that other side effects are most likely not going to happen at Australian levels of fluoridation.

Our personal views on fluoridation are important and varied and can’t be discounted.

But it is important that we are able to critically assess the information that is given to us.  If we can’t do this on our own, we can at least have a look at how others have reviewed it and make sure that we’re satisfied with how they’ve done it, which perhaps takes some of the fear out of the equation.

 

*Kate Burke is completing her Masters in Science Communication through the Australian National University

*Above is an edited article that originally appeared on Raisin – stories of regional science and innovation

*Ian Campbell founder of About Regional is part-time media officer for Bega Valley Shire Council

16 thoughts on “Fear and fluoride, bedfellows amidst conflicting “evidence”

  1. Excellent, accessible coverage of a perennial divisive issue.
    Probably a little long for the average lay reader. Maybe some dot point summary for the quick grabbers?

  2. Good work Kate! (And thanks, Ian)

    Do the right thing, Bega Shire, and go Fluoride. Our kids don’t need to suffer like we did! Resistance to fluoridation is not science-based – it is ignorance based. Don’t let other people’s irrational fears stop you from making the right decision.

  3. Excellent article, Kate. The misinformation constantly disseminated by antifluoridationists, both intentionally, and unintentionally by virtue of ignorance of the facts, is staggering, and fueled by groups such as “FAN” which have a callous disregard for truth and accuracy.

    As far as the “FAN” boast that it “develops and maintains the world’s most comprehensive online database on fluoride compounds.” this is a typical red herring. The only fluoride substances relevant to the process of fluoridation are fluoride ions, identical to those which have always existed in water, and the small number of substances utilized to deliver additional fluoride ions into any given water supply. Of these substances, hydrofluorosilic acid is the one used in the overwhelming majority of fluoridated systems. Once HFA releases its fluoride ions into water, it no longer exists in that water. It does not reach the tap. It is not ingested. It is therefore of no concern, whatsoever. Whatever other fluoride compounds “FAN” has in its database, are of no relevance, and are used primarily by antifluoridationists to fear-monger about the properties of such substances

    In order to get a clear understanding of the studies claimed by “FAN” to support its position one need only read the recent EPA rejection of the latest meritless petition filed by “FAN” and a few other antifluoridationists in which they allege neurotoxicity of fluoride at the level at which water is fluoridated. In the 40 page rejection of this petition, the EPA systematically dismantled the arguments of the petitioners, providing a detailed explanation of the irrelevance, invalidity, and misrepresentation by the petititioners, of the studies claimed to support their claims.

    https://www.federalregister.gov/documents/2017/02/27/2017-03829/fluoride-chemicals-in-drinking-water-tsca-section-21-petition-reasons-for-agency-response

    Has this EPA exposé of “FAN”‘s misuse of the scientific literature cited in the “FAN” petition stopped “FAN” and its leader, Paul Connett, from continuing to cite these studies as “support”? No, of course not. As always when backed against the wall by facts and evidence, these antifluoridationists simply claim conspiracy and corruption, and continue on, undeterred.

    Steven D. Slott, DDS
    Communications Officer
    American Fluoridation Society

  4. Excellent article Ian, cutting through the hype, hyperbole, emotion & misinformation.
    It may just be a decision of form & function. The form being the potential for discolouration and the function being less dental caries.
    Given the extended health implications associated with dental health it would seem to me that the colour of teeth is just aesthetic whereas poor health is just a tad more serious.
    The teeth discolouration can also be remedied with whitening treatments.

    However, given all the above, and as a result of the some of the inconclusiveness of the more credible evidence, there may still be an argument for the precautionary approach.

    1. Good points, Kym. Let me address them:

      1. Dental fluorosis is the teeth discoloration about which antifluoridationists constantly seek to induce unwarranted fear. In actuality, the only level of this fluorosis which may be attributable to fluoridated water is mild to very mild, a barely detectable effect which causes no adverse effect on cosmetics, form, function, or health of teeth. As peer-reviewed science has demonstrated mildly fluorosed teeth to be more decay resistant, many consider this effect to not even be undesirable, much less adverse. Mild dental fluorosis requires no treatment. Most people who have this effect do not even realize it unless mentioned by their dentist during a dental examination.

      The only level of dental fluorosis considered to be anything other than a cosmetic effect is severe. This level is resultant of chronic exposure to an abnormally high level of well-water, or environmental fluoride, during the teeth developing years of 0-8. Severe dental fluorosis does not occur in communities with a water fluoride content of 2.0 ppm, or less. Water is fluoridated at 0.7 ppm, one third that level.

      2. The only argument for the precautionary approach is to take precaution against a significant amount of untreated dental infection, through the public health initiative of water fluoridation. Dental decay is a very serious bacterial infection occurring in close proximity to the brain, with a direct pathway to the rest of the body via the bloodstream. Left untreated, as it constantly is in hundreds of millions of people, this infection can, and does, cause lifetimes of extreme pain, debilitation, black discoloration and loss of teeth, development of serious medical conditions, and life-threatening infection. People have died as a direct result of untreated dental decay in but one tooth.

      These effects are well documented fact, not unsubstantiated claims, groundless speculation, and false information, as is put forth by antifluoridationists. Given that, in the 72 year history of fluoridation, there have been no proven adverse effects, coupled with the volumes of peer-reviewed scientific study clearly demonstrating the effectiveness of fluoridation in preventing significant amounts of dental infection in entire populations……there is no valid scientific reason not to fluoridate.

      The precautionary principle applies when there is not scientific consensus of the safety of an initiative. The public health benefits of fluoridation are publicly recognized by those such as the past 6 US Surgeons General, the Deans of the Harvard Schools of Medicine, Dentistry, and Public Health, the Australian Department of Health, the Australian NHMRC, the US CDC, the US National Academy of Medicine, the World Health Organization, the Australian Dental Association, the American Dental Association, the American Academy of Pediatrics, and over 100 more of the most highly respected healthcare, and healthcare-related organizations in the world.

      There is no credible organization in the world which opposes fluoridation.

      Clearly there is overwhelming scientific consensus of the safety of fluoridation. Therefore, the precautionary principle does not apply.

      Steven D. Slott, DDS
      Communications Officer
      American Fluoridation Society

      1. Mr Stott, Australia’s water is still fluoridated at 1ppm – and the SAFE Level for Banies has been increased, based on old science. Why did you not tell them that 40% of American children are Now suffering very visible Pitting and discolouration of the teeth. Note: this requires caps a $1,000. Per tooth to correct, which in turn need replacing approximately every 10 years minimum.. Whitening toothpaste will not help and keep consuming fluoride in the water will only make Fluorosis worse (Commonsense) Fluorosis is Fluoride Overdose.

  5. The same criteria must be applied to pro-fluoridation studies. The first human fluoridation experimentation started in 1945 in Grand Rapids, Michigan, for teeth effects and in Newburgh, New York, for health effects. Both studies were prematurely ended for political reasons before the permanent teeth had erupted in children born into the experiment. More about those experiments here http://fluoridedangers.blogspot.com/2008/01/1945-human-experiment-predicted-current.html Also, the most trusted group of researchers, the UK’s Cochrane Group, who reviewed all fluoridation studies in a meta analysis concluded that they could not find any quality evidence to prove fluoridation changes the “existing differences in tooth decay across socioeconomic groups.” Neither could they find valid evidence that fluoride reduces adults’ cavity rates nor that fluoridation cessation increases tooth decay Fluoridation may reduce cavities in children (2 primary teeth or 1 permanent tooth over their lifetime). But Cochrane cautions these studies have “high risk of bias” and were mostly done before preventive measures were widespread, e.g. fluoridated toothpaste and sealants. Diverting attention away from Cochrane, the Centers for Disease Control and the American Dental Association defended fluoridation recommending instead the 2013 U.S. Community Preventive Services Task Force’s Fluoridation Recommendation. But the Task Force also admitted it couldn’t evaluate how race, ethnicity and total fluoride intake influenced fluoridation effectiveness because of limited data. “Few studies provided data on socioeconomic status, and most studies had measurement issues; many didn’t blind examiners and there was a lack of consistency among indices used to measure caries.” Newsweek reports that scientists, who were assigned to review fluoridation research, are shocked at the lack of valid fluoridation-supporting evidence. Government agencies have a long history of minimizing reviews critical of fluoridation science. Fluoride supplements, first recommended based on the theory that fluoridation prevents tooth decay, unsurprisingly, also are mostly ineffective. In 2011, Cochrane “rated 10 trials as being at unclear risk of bias and one at high risk of bias, and therefore the trials provide weak evidence about the efficacy of fluoride supplements.” In fact, the US FDA says fluoride supplements are unapproved drugs because they have never been proven safe or effective.

    Submitted by: http://www.FluorideDangers.Blogspot.com

  6. It concerns me that Ian Campbell the Media officer for the BVSCouncil is behind this piece of pro fluoride propaganda being disseminated throughout the shire using his own Media platform (About Regional) to push a Council agenda, particularly when the council have resolved to support NSW Health department in their endeavours to convince the public of the supposed merits of Fluoridation. Ian knows full well how much of a contentious issue this issue is with the public, Is he doing this on behalf of the council? Would be a whole lot wiser to have given a balanced view or not engage in the issue at all. Perhaps Ian should explain himself and withdraw this one sided propaganda or stand down or face the consequences.

    1. Fraser, I respect your point of few and can understand some of what you point to.

      Briefly:

      *My part time work at Council is disclosed in any article where that is relevant as it was in this case.

      *Bega Valley Shire Council was not involved in any way with the publication of this article.

      *As you’d be aware, Council has contracted the communication and community engagement tied to this process out to a third party – Hunter H2O

      *The article is more commentary on the very debate you have been a part of and the forces and information at play. Author Kate Burke brings an expertise and clarity that has been missing.

      *Her work has since been published and discussed by local Fairfax Media and ABC Radio, a further indication of its merit and relevance.

      *Perhaps the article can be perceived as slightly pro-fluoride, which is the influence of the scientific advice quoted, drawn from Australia’s peak science and research organisations. Your own view no doubt influences your reading of this.

      *When the article was first published in mid-June, people from both sides of this discussion were able to present evidence and frame their personal view in a generally respectful way via About Regional, something I welcome.

      Regards
      Ian

  7. Ian,
    In addressing your comments

    * Just because you declare your relationship with Council on the issue it does not negate the fact you have published a piece expressing a view on a very contentious current Council issue. As an employee of Council you should realise you must be very careful not to become involved in Council issues using your supposed independent publication, particularly where it may have influence on the public or Councillors opinions, especially before decisions have been made. Like it or not people are looking at this publication as I have done and linking your relationship to Council and seeing a conflict of interest.

    *Very good to hear the Council have nothing to do with the publication of this article

    *I am aware, Council contracted the communication and community engagement tied to this process out to a third party – Hunter H2O, who are fluoride proponents which has been very concerning and brought a lot of distrust to a lot of people in the community about the potential of a corrupted process.

    *You statement that author Kate Burkes bringing an expertise and clarity that has been missing is only your opinion, there are a lot of people who have been and are still engaged in this issue who have done a whole lot more studying than Kate on this issue

    * It is very arguable of the credibility of both Fairfax Media (local papers) and the local ABC radio in determining what has merit or relevance.

    * Clearly it is a pro Fluoride publication, it discredits all anti fluoride studies

    1. Fraser,

      I am comfortable that a fair, open, and honest discussion has taken place…and that that it stands up to scrutiny.
      What hasn’t been declared is your membership of the largely anit-Council “Bega Valley Ratepayers Association”.

      Cheers
      Ian

  8. How dare you make that irrational statement about our association of which I am Vice president, we are not anti Council, we certainly have and do criticise Council, it is our job to scrutinise Councils decisions and efficiency and encourage high standards of performance, openness, transparency and accountability. We have close to 180 members and are growing strongly. Your statement is way out of line, again particularly given your position as an employee of Council

  9. An article that was clearly about the debate. I have corrected Fraser elsewhere for going off half-cocked at people when he regularly makes SM posts where it is unclear in what capacity he is acting. This was also demonstrated when the Secretary of his own organisation rebuked him for a post which hasn’t been approved by the BVSRRA management committee. Perhaps trying to shut down discussion of an important topic is on Fraser’s agenda?

    1. For the Reckord, My discussions on this post is purely on my own behalf, I am not an employee of council, I do not have a conflict of interest or cannot be perceived to have one. I am the Vice president of the Bega Valley Shire Ratepayers Association who do not have a declared position on fluoride.

  10. I think Kate’s article is a great example of good science communication, the subject of her Masters Degree. And the quote from Will Grant is very apt – if the scientific evidence could be easily weighed up by anyone interested in the topic, we would not have a difference of opinion. However there are two things I feel need to be mentioned. 1. I have done a lot of reading on google scholar and elsewhere on this issue and the two things about which there does seem to be universal agreement are that fluoride benefits tooth decay levels by action through DIRECT CONTACT with the teeth. In 1945 ( and thereabouts) when the first investigations on fluoride and teeth were done, there was no such thing as fluoridated toothpaste. Now there is, and it is in almost all brands of paste. If you don’t want to consume fluoride you have to really search out a brand that does not contain it. This means virtually all children are brushing with fluoridated paste and thus their teeth are contacted by fluoride and any benefit of it is being had by 99.9% of children. If a child is so neglected that they are not even being taught to brush their teeth, dental caries in later years will be the least of their problems. The second point of universal agreement is that more research needs to be conducted to clarify the dual questions of safety and effectiveness. 2. The NHMRC also has its own agenda at times and cannot be considered unbiased. To wit – their recent work on the efficacy of homoeopathy, in which there was no homoeopath on the committee doing the assessment of trials. No matter what you think about homoeopathy, that would not happen in any other area of study. Can you imagine a review of trials on the effects of many medical procedure without experts in that medical field being consulted and usually on the review panel? Possible bias at the NHMRC is clear from that example. (Internationally, their findings about homoeopathy have met with quite a degree of misgiving because of the poor way it was conducted). So – NHMRC opinion is not conclusive and almost all children are getting suffucient fluoride from toothpaste. This leaves, IMO, no argument for adding it to water. It’s superfluous. Given that more research needs to be conducted to really answer the safety question pretty conclusively, why would you do it? Considered in this way I find Kate’s article itself to suffer from bias, since it did not mention these two very salient points. Scientific research is supposed to try to disprove the hypothesis. If it cannot, the hypothesis is most likely, but not definitely, correct. This basic requirement for scientific research seems often to be set aside.

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