Archived decisions

Item 3

Hampshire County Council Health Overview and Scrutiny Committee

Proposals to fluoridate drinking water in Southampton and south west Hampshire. Themes for discussion at formal evidence days- 25 September 2008 and 6 October 2008.

Members of the Review Group have highlighted a number of key themes to stakeholders covering a range of different issues raised by the complex issue. The questions set out below are suggested as possible lines of inquiry but members may wish to explore other areas of interest. Stakeholders have been invited to focus the views they wish to present in relation to the following points:

1. Improving oral health:

_ What are the main causes of poor oral health and what can be done to address these?

_ What are the national trends in oral health- is there a difference between fluoridated and non-fluoridated countries?

_ How does fluoride improve oral health and is there any difference between the topical and systemic application.

_ What is the action of fluoride on teeth- is it equally effective on all surfaces.

_ How does fluoride reduce health inequalities? Is there evidence to show that fluoride- from water alone- has benefited disadvantaged communities?

_ What are the effects of fluoride in water on the health of infants, children, adolescents and adults.

_ There are conflicting views about the incidence and impact of fluorosis on oral health- is there any evidence to suggest that fluorosis can have a detrimental impact on the oral health of a population.

2. Ethics:

_ What are your views on the ethical considerations of adding fluoride to water?

_ Do the potential benefits support this level of intervention?

_ Have the potential dis-benefits been appropriately assessed?

_ Why do you think this issue arouses such strongly held articulate but diametrically opposed opinion?

_ How can lay people and the public come to an informed view about this proposal given the conflicting information and research presented?

3. Impact on health:

_ There is a substantial body of literature that indicates that there is at least a plausible impact of fluoride on bone and other systems but research in a number of areas is not of suitable quality to allow conclusions to be drawn about the effect of fluoride on the human body. Hip fractures and osteosarcoma are particular areas highlighted in some literature, but others relate to I.Q., the endocrine system and Downs syndrome. These concerns are disputed in other research. Given this conflicting information, what is your professional view on the impact of the addition of fluoride to drinking water on the general health and well being of the population affected?

_ Is there any evidence to suggest that some individuals may be allergic to, or could suffer an adverse reaction to fluoride?

_ Is there any evidence to suggest that some individuals may be more sensitive to fluoride because of a medical or other condition?

4. Alternatives to fluoride in water:

_ The literature indicates that there are a number of alternatives to adding fluoride to water which can have a beneficial impact on oral health- what is your understanding of the benefits and constraints of these alternatives.

_ Can the effectiveness of these alternative be demonstrated?

_ Are there any cost implications that need to be taken into account?

_ What are the available alternatives for SCPCT to consider.

5. Exposure to fluoride:

_ The current recommended levels of 1ppm of fluoride in water were set at a time when there was less availability of fluoride in diet and oral health products. What is the evidence to support this level being added to drinking water and how has the efficacy of this dose been evaluated.

_ Given the reduction in fluoride in drinking water in Ireland (down to 0.7 ppm) is there evidence that a similar level should now be considered in England.

_ There is conflicting information about the impact that changing life styles and exposure to fluoride has had on populations particularly in a tea drinking nation such as ours. What is the estimated exposure to fluoride in adults and children in the UK. How does this vary across fluoridated and non fluoridated areas.

_ What impact does the total exposure of an individual to fluoride have on the suggested efficacy of fluoride in drinking water

_ What is the threshold at which exposure to fluoride ceases to be therapeutic. How is individual exposure assesed

6. The nature of fluoride:

_ The SHA document says the fluoride added to drinking water is `specifically manufactured to meet very high quality standards' how is it manufactured and by whom.

_ Who regulates the production of fluoride and how is its safety quality assured

_ Do people absorb fluoride in a uniform/predictable way, what difference does hard water make to the way in which people absorb fluoride?

_ Do people retain different amounts of fluoride in their bodies, where is this deposited and does it have any health implications for individuals

7. Legal and technical considerations:

_ Are there any legal or technical issues that the bodies proposing to add fluoride to water need to take into account.

_ We would be particularly interested in your views on the expectation that the NHS will indemnify the water companies should this proceed and any implication this has for the NHS in the future.

_ Is there an impact on manufacturing industries that use high levels of water to produce their goods.

_ Is it feasible to add fluoride to water supplies in smaller areas than the distribution zones identified.

Additional Questions raised with Southampton City PCT:

NB it is unlikely that they will have the response to all of these queries at the meeting on 25 September- the deadline for producing this is 10 October.

1. Can you please set out clearly why this level of intervention is justified to improve the incidence of caries in children in Southampton.

2. Why has a level of 1ppm been requested and on what evidence base. What evidence is there to suggest that this more efficacious than the 0.7 ppm that is now used in Ireland.

3. All information seems to be based on dmft in 5 year olds. Can the PCT please provide details of the oral health of children and adults in the City, including DMFT for 12 year olds, over the last 5 years.

4. The technical studies supporting the feasibility assessment look at the dmft rate as an aggregate across a population. A postcode with a dmft rate of 48 could be made up of 16 children with a dmft of 3, or 8 children with a dmft rate of 6. The maps produced seem to indicate `hot spots' in the population but there are no figures relating to the number of children to be treated in the target populations. Are you able to demonstrate the level of tooth decay that individuals have as opposed to the average rates within communities and provide information about how many children are being targeted in each of the areas identified as having the highest levels of decay.

5. The same document concludes that `without any knowledge of the benefits that each scheme will deliver it is not possible to fully assess which schemes are cost effective and which are not'. It recommends that each of the schemes is reviewed once the dental benefits are known. Please confirm if this work has taken place and quantify the anticipated health benefits and disbenefits that it is estimated will accrue from this proposal being introduced.

6. The analysis of the economic implications notes that the efficacy of the fluoridation of water may be confounded by other external factors, such as the use of fluoridated toothpaste. What work has been done to assess total exposure to fluoride within a) the population of Southampton, b) the target population.

7. This report goes on to note that any reduced efficacy due to these factors would have a significant impact on the likely costs of the intervention. At what point would the PCT consider that the intervention was not cost effective.

8. The report also considers that dental fluorosis is cosmetic and will have no impact on NHS costs. Is the PCT of the view that fluorosis has no bearing on the health of children's teeth other than cosmetic. What options exist for treating fluorosis if it occurs and what is the estimated cost of this.

9. What is the current pattern of dental fluorosis across the Southampton population and how would this change if fluoride was added to drinking water. Would all children, even those who currently have good oral health be susceptible to developing fluorosis if fluoride was introduced to the drinking water.

10. The economic model works across averages in the population, not individual disease profiles, how will improvements of individual children in the target population be assessed.

11. The model also assumes all children are equally exposed to water fluoridation. How much water do a) children in Southampton currently drink on average per day, b) children in the target population currently drink on average per day. How much water needs to be ingested to obtain the intended oral health benefit.

12. Are there any individuals in the community affected that may be allergic to or otherwise adversely affected by ingesting fluoride in drinking water.

13. Why do you wish to proceed with this proposal even though only 7 of the 11 deprived areas will be covered.

14. What alternative strategies are you adopting for those areas not covered by fluoridated water.

15. What is the level of access to NHS dentistry within each of the deprived areas targeted for fluoridation. What percentage of children and adults in these areas are currently registered with an NHS dentist.

16. What research have you conducted with children and families living in the target areas regarding their understanding of the causes of poor oral health and preferences for tackling this issue.

17. What are the key factors contributing to the poor oral health in the population and what have you done to address these.

18. If the factors causing poor oral health persist into adulthood, what evidence is there that any benefits in the target population can be maintained.

19. Have you tried alternative strategies such as teethbrushing/mouthwashing schemes in pre schools, nurseries, schools, home visits to new mothers to advise about diet etc.

20. Given that health inequalities are caused by many different factors such as socio-economic considerations, lifestyle and diet, how will the introduction of fluoride to drinking water contribute to a reduction in inequalities.