Archived decisions

AT A MEETING of the WATER FLUORIDATION PANEL of the HEALTH OVERVIEW AND SCRUTINY COMMITTEE of the COUNTY COUNCIL held at The Castle, Winchester on Thursday, 25 September 2008.

PRESENT

Chairman:

pCouncillor Mrs. A.M. McNair Scott

Councillors:

p B. D. Dash p Mrs. M. Kerley

p G. W. Davies-Dear p Mrs. C.A. Leversha

p Mrs. P. Dickens p D.F. Wright

p K.D. Evans

Observers:

M. Cox Hampshire Local Information Network

Ms. P. Owen Hampshire Local Information Network

Councillor Mrs. E. Cooke Southampton City Council

Councillor Mrs. A. Rostand New Forest District Council

Officers:

Denise Holden Health Overview and Scrutiny Manager

Marie Mannveille Scrutiny Support Officer

David Pryke Principle Officer, Democratic Services

Glenn Taylor Assistant Head of Regulatory Services responsible for Scientific Services

Annie Righton New Forest District Council

Mary Amos Eastleigh Borough Council

Martin Day Southampton City Council

1. DECLARATIONS OF INTEREST

Members were mindful that, where they believed that they had a personal or personal prejudicial interest any matter to be considered at the meeting, they should normally, at the time of the debate, declare their interest, and having regard to the circumstances described in paragraphs 9, 10, 11 and 12 of the County Council's Code of Conduct, consider whether to leave the meeting whilst the matter was discussed save for exercising any right to speak in accordance with Paragraph 12 of the Code .

The following members declared a personal interest:

Councillor Mrs. P. Dickens - employed by NHS

Councillor D. Wright - wife a General Practice Manager.

2. CHAIRMAN'S COMMUNICATIONS

The Chairman welcomed everyone to the meeting and outlined the procedure for the day. She reminded everyone that this was a meeting in public and not a public meeting and that the public would not be able to speak at the meeting.

3. KEY THEMES

The Chairman reminded everyone of the key themes for consideration which were :

· Improving Oral Health

· Ethics

· Impact on Health

· Alternatives to Fluoride in Water

· Exposure to Fluoride

· The Nature of Fluoride

· Legal and Technical Considerations

4. PRESENTATIONS

a. Southampton City Primary Care Trust

Dr. Jeyanthi John, Consultant in Dental Public Health and

Dr. Andrew Mortimore, Southampton City Director of Public Health gave a presentation on behalf of Southampton City Primary Care Trust. They gave details of the population of Southampton and its health. Although health in Southampton was improving and life expectancy increasing there were still some health issues causing major concerns, one of which was that the dental health of children remained poor. Dental decay in five year olds was 52% more common and 2006 figures showed:

· 42% had at least one decayed, missing or filled teeth.

· The average five year old has 1.8 teeth decayed, missing or filled.

· The five year olds in 17 of the City's Primary Schools had an average of two or more decayed or filled teeth.

These were shown to be higher than the average rate for similar areas in England.

The Primary Care Trust had considered various options which included targeted approaches on diet education programmes, oral hygiene improvement programmes and improved access to dental care and advice; the population approach via water fluoridation and a combination of the various approaches. They gave details of each of the targeted approaches that they had tries and concluded that the combination approach would be the most effective.

They outlined the published research on the health effects of adding fluoride to water. They also gave details of the United Kingdom monitoring of existing fluoridation schemes which had shown no adverse effects from fluoridation. They had considered all issues very seriously, including ethics and were confident of the safety of adding fluoride to water.

When answering questions they agreed that poor diet for some children did cause dental problems and that they had been taking action to address this as well as oral hygiene. These had concluded that fluoride would improve the levels already achieved. They agreed that the Sure Start Programme in Southampton was proving successful especially in relation to children's diet but dental health had not yet been included in the programme. On the question of adding fluoridated water to baby formula they agreed that research in America had indicated a possible problem. They were encouraging mothers to breast feed and for those who did not suggested that bottled water that did not contain fluoride should be used. They were asked how much fluoride needed to be ingested to have any effect but did not give a definitive answer. Members also pointed out that tooth decay in Heart of Birmingham was still high ever though it had had fluoride in it `s water for many years. When questioned about the leaflets and other material produced in support of the proposal they confirmed that they had been actively commending their preferences to the public without overstating the evidence.

b. Nuffield Council on Bioethics

Hugh Whittall, Director of the Nuffield Council on Bioethics said that he was unable to say whether or not it was appropriate to add fluoride to water. He said that the addition of fluoride was an ethical issue, and that there were issues as to whether such actions were part of a "Nanny" state and whether such interventions were justifiable. He outlined a framework that policy makers should adopt before any public intervention and gave an example of wearing seat belts in cars. He said that water fluoridation was high on the intervention scale and a judgement needed to be taken as to its legitimacy, the level of intrusion involved, alternative strategies and the various policies being explained to those affected. There was a need to understand and evaluate the evidence. The York Review was the most recent and comprehensive review which, surprisingly, showed little evidence of good quality as it had been difficult to quantify. In looking at alternative strategies he said the following should be looked at/investigated:

· Other potential strategies which were less intrusive and involved choice and how effective they were.

· Proportionate intervention of the state to improve the oral health of the most vulnerable children.

· The reduction in health inequalities.

· How to target those most at risk.

He said that, in considering evidence, the balance of risk v benefits of adding fluoride to water must taken alongside that of possible alternatives, all debates should be impartial and that there should be a continual assessment of evidence. He noted that harm could come from both action and inaction. Although the report was clear on the action it was promoting in a number of other areas of public health policy, it had not been possible to come to a similar view on the issue of fluoridation of water supplies.

He was questioned about the Strategic Health Authority, being a non-elected body taking the final decision on fluoridation; he said that the state has different guises and it could be considered that the Strategic Health Authority was making the decision as a result of a law made by parliament, which was a democratic process although some people would argue for stronger democracy.

c. Hampshire Against Fluoridation

Stephen Peckham on behalf of Hampshire Against Fluoride outlined water fluoridation:

· Adding hexafluorosilicic acid (a by product of the phosphate industry and different to naturally occurring fluoride) to water.

· The current level of fluoride in water in the area was 0.08ppm and the proposal was to increase this to 1.0ppm, a 12 fold increase which would involve adding hundreds of tonnes of hexafluorosilicic acid to the water each year.

He said that the amount of dental caries in children varies substantially each year and that the proportion of people with dental caries had been improving each year. He gave details of dental health in the United Kingdom and the causes of dental caries. He said that the proposed scheme only covered 67% of the Southampton population with only 7 out of the 11 priority areas covered and no data had been provided on what proportion of affected children were covered by the scheme. The evidence of the efficacy of water fluoridation for the prevention of dental carious lesions was uncertain and data on the matter was not of a high standard. There was little difference in the rates of dental caries in fluoridated and non-fluoridated countries. He gave details of the United States experience on fluoridation. On dosage of fluoride he said that there was no universally accepted optimal level for the daily intake of fluoride, that most often cited by researchers was 0.05 to 0.07 milligrams of fluoride per kilogramme of body weight, and the optimal level of fluoride intake was not known with certainty. The World Health Organisation recommended that dental and public health administrators should be aware of the total fluoride exposure in the population before introducing any additional fluoride programme for caries prevention - this had not been done in Southampton. He outlined the effects of fluorosis and the studies that had been carried out on this in the United States.

He gave details of the actions taken by Southampton City Primary Care Trust and the problems with the consultation process. In summing up he said:

· Water fluoridation had not been proven to provide substantial benefits for caries prevention and the evidence on reducing inequalities was poor.

· Water fluoridation had not been proven to be safe.

· There was no demonstration of the need or potential benefit for Southampton residents.

· Fluoridated water had been shown to be dangerous for very young babies and children.

· Fluoride from whatever source was toxic and poisonous and accumulated in the body.

· Water fluoridation raised complex ethical, moral and legal issues that remained unsolved.

When asked what alternatives he would suggest to fluoride he suggested toothpaste, and more effective varnishes and gels to the teeth. The cost effectiveness of this varied according to the profession of the member of staff applying it eg. A dentist may not be cost effective whereas a nurse may be On the question of access to local NHS Dentists he said that the socially disadvantaged had less access.

d. British Fluoridation Society

Professor Mike Lennon said that there was a need to protect he dental health of adults as well as children. He gave details of severe tooth decay in children, dental abscesses for all age groups and tooth decay in the elderly. He said that fluoride occurred naturally in all water supplies and that at an optimum level it reduced tooth decay, the optimum level for dental health being one part of fluoride per million parts of water, in Britain around 300,000 people drank water with a natural content high enough to benefit their dental health, worldwide 50 million people drank naturally fluoridated water. He outlined the approach that had been taken to replicate the benefits of natural fluoridation since the 1940s, particularly in the United States and in some parts of the United Kingdom. He said that some parts of the United Kingdom still had unacceptable levels of tooth decay among children and that children in Southampton had 70% more decayed, missing and filled teeth than those in Birmingham and the West Midlands which had fluoridated water. Children from all social groups in fluoridated areas had less tooth decay than children in non-fluoridated areas. He outlined the reviews of the evidence on the safety of fluoride by medical and scientific bodies including The Royal College of Physicians 1976, NHS Centre for the Reviews and Dissemination at the University of York 2000 and Medical Research Council Working Group 2002. He stated that in 2007 the Nuffield Council on Bioethics said that priority should be given to measures that would address health inequalities and protect the health of children and vulnerable adults and stressed the value of belonging to a society in which each person's welfare, and that of the community, matters to everyone. He gave details of dental fluorosis and examples of different levels of it and the results of an NOP public opinion survey in 2003 on the percentage of people who thought that fluoride should be added to water to prevent tooth decay.

On being questioned about the effects of fluoridated water in infant formula he was of the opinion that it would not do any harm. When asked about the effects of fluoride on bone density and thyroid problems he said that it was a complex area but that in a study Professor Coughlan, a bone expert at Southampton University, had concluded that fluoridation had no effects on fracture rates. When asked if the Bristish Fluoridation Society document `One in a Million' had been amended following criticism from the Nuffield Council on Boethics he confirmed that it had not.

e. Adding Fluoride to Water Supplies (Cheng, Sheldon and Chalmers, British Medical Journal Article)

Professor Sir Iain Chalmers, editor of James Lind Library, outlined a report by Professors K.K. Cheng, Professor of Epidemiology, Birmingham University and Trevor Sheldon, Professor and Pro-Vice Chancellor Health Services Research, University of York identifying the issues adding fluoride to water supplies raised in the hope of furthering constructive public consultation and debate. He had served on the advisory council for the review. Their summary points were:

· Water fluoridation is highly controversial.

· Evidence is often misused or misinterpreted and uncertainties glossed over in polarised debates.

· Problems include identifying benefits and harms, whether fluoride is a medicine, and ethical implications .

He outlined the findings contained in various research which included the Global Consultation on Oral Health Through Fluoride, Cochrane systematic review on the effects of topically administered fluorides on dental health, Fluoride toothpastes: placebo controlled trials, the York Review, The Australian Government Systematic Review of the Efficacy and Safety of Fluoridation. The main findings of the York Review was "The defect of the studies of possible beneficial effects of water fluoridation was the lack of appropriate design and analysis. Many studies did not present an analysis at all while others did not attempt to control for potentially confounding factors." He quoted opposing views of the Anti Fluoridation Action Network - "There is absolutely NO evidence that it benefits childrens' teeth" and the British Dental Association press release, July 2000 - "Water fluoridation has been proven beyond doubt to be safe and to massively reduce tooth decay...There is no scientific controversy over the safety of water fluoridation" , both of which purported to be based on the findings of the York Review. Hhe said that:

· There was a demand for information and research on water fluoridation, improvements were required in the current evidence base for the fluoride in water debate.

· Research was required on the longer term effects of fluoride and its effects on the wider environment.

· Objective research was required on cost-benefit analysis of introducing fluoride to water.

· Comparative studies were required involving fluoridated and non-fluoridated areas and cross national experience.

In conclusion he said that local communities have a choice of at least three options:

· Add fluoride to water supplies.

· Don't add water to water supplies.

· Contribute to research, together with other communities, to reduce uncertainties about the effects of adding fluoride to water supplies.

When asked about the changes to regulations that would allow the Strategic Health Authority to decide whether or not fluoride should be added to drinking water he noted that the appropriateness of this was open to the Committee to raise with Parliament.

f. National Pure Water Association

Elizabeth McDonagh and John Graham, Chairman and Vice-Chairman of the National Pure Water Association gave details of dental fluorosis and the fact hat 48% of children in fluoridated areas had some degree of fluorosis and gave examples of skeletal fluorosis. They quoted a letter from Professor Sheldon in 2001 "The review team was surprised that in spite of the large number of studies carried out over several decades there is a dearth of reliable evidence with to inform policy. Until high quality studies are undertaken providing more definite evidence, there will continue to be legitimate scientific controversy over the likely effects and costs of water fluoridation." They outlined the findings of the York Review. They said that opinions varied on how much fluoride was safe and gave details of the findings of Professor Susheela who had written a treatise on fluorosis. They said that a third to a half of ingested fluoride was retained by the body, mainly in the bones. It accumulated over a lifetime and could cause:

· Dental Fluorosis

· Irritable bowel symptoms

· Infertility

· Red blood cell deterioration leading to iron deficiency and anaemia

· Aches in muscles and joints

· Changes to skeleton

· Neurological problems

Vulnerable groups who may exceed safe levels were:

· Babies

· Children who swallow their toothpaste

· Heavy tea-drinkers

· Diabetics, athletes, manual workers who drink more water than most people

· People with Hypersensitvity

· The Elderly

They said that whether someone is harmed by fluoride depended on the concentration of fluoride in their drinking water, on their total intake of fluoride from all sources and on the length of time of exposure. They gave details of the various sources of fluoride.

When questioned about possible effects of fluoride on health they said that blood and urine tests could look for levels of fluoride but that these were not routinely undertaken by health services.

AT A MEETING of the WATER FLUORIDATION PANEL of the HEALTH OVERVIEW AND SCRUTINY COMMITTEE of the COUNTY COUNCIL held at The Castle, Winchester on Monday, 6 October 2008.

PRESENT

Chairman:

p Councillor Mrs. A.M. McNair Scott

Councillors:

p B. D. Dash p Mrs. M. Kerley

a G. W. Davies-Dear p Mrs. C.A. Leversha

p Mrs. P. Dickens p D.F. Wright

a K.D. Evans

Observers:

Councillor Mrs. E. Cooke Southampton City Council

Councillor Mrs. T. Craig Eastleigh Borough Council

Councillor Mrs. A. Rostand New Forest District Council

Officers:

Denise Holden Health Overview and Scrutiny Manager

Marie Mannveille Scrutiny Support Officer

David Pryke Principle Officer, Democratic Services

Glenn Taylor Assistant Head of Regulatory Services responsible for Scientific Services

Annie Righton New Forest District Council

Martin Day Southampton City Council

Katie Benton Portsmouth City Council

Also in attendance:

Councillors Mrs C. Fraser and Mrs. A. Winstanley, Eastleigh Borough Council

1. DECLARATIONS OF INTEREST

The following members declared a personal interest:

Councillor Mrs. P. Dickens - employed by NHS

Councillor D. Wright - wife a General Practice Manager.

2. CHAIRMAN'S COMMUNICATIONS

3. KEY THEMES

The Chairman reminded everyone of the key themes for consideration which were :

· Improving Oral Health

· Ethics

· Impact on Health

· Alternatives to Fluoride in Water

· Exposure to Fluoride

· The Nature of Fluoride

· Legal and Technical Considerations

4. PRESENTATIONS

g. UK Councils Against Fluoridation

Liz Vaughan gave a short history of their organisation, which had been running since 1988, and the work that they had carried out with local authorities, their aim was to maintain basic rights. They had been alarmed with the content of the consultation documents provided by South Central Strategic Health Authority and as a result had complained to the NHS Counter Fraud and Security Management Service Division about them. Dr Tony Lees, a retired dentist, said that he was not originally opposed to fluoridation but became more and more aware of children with fluorosis in his practice which concerned him as dental fluorosis was noticeable and would cause aesthetic concern. This can be treated by veneers, however these can only be applied once the teeth are fully erupted (age 21) by which time dental care is no longer free. He offered veneers at £250 per tooth and understands that others charge £400 per tooth. As veneers are mainly porcelain they can break and may need replacing. When asked if the cost of this treatment could be claimed back from the authority that imposed fluoridation he said it was unlikely individuals could do so successfully. He said that tooth decay was caused by sugar and high sugar diets and the best way of prevention was mass education, not mass medication. He pointed out that high sugar diets may also lead to obesity and diabetes. He said that resources should be spent on those in need. Doug Cross, a forensic ecologist, said that, when considering fluoridation, the following questions should be asked:

· Is it feasible

· Is it cost effective

· Is it legal

He said that those promoting fluoridation had been selective in the evidence that they produced and that the law in Europe showed a very different picture, the European Courts of Justice had declared fluoride to be a medicine. As a result of this putting fluoride in water must be a medical decision and, as such, it is illegal because there is:

· Prohibition on supplying an unlicensed medicinal product (Fluoride has not been licensed as a medicine)

· Prohibition on advertising unlicensed medical products

· The Drinking Water Directive does not apply to waters which are medicinal within the meaning of the Council directive relating to medicinal products.

He said that the public consultation was a charade as the Strategic Health Authority had no authority to procure public endorsement for a prohibited act, councils had a responsibility and mandate to protect the public and that they must oppose consultation by Strategic Health Authorities by referring all efforts by Strategic Health Authorities to Parliament demanding compliance with medical law.

On being asked if there had been any successful legal actions taken Doug Cross said that private citizens were unlikely to be able to take legal action.

h. Portsmouth University Community Dentistry Project

Tony Horne, Project Director, Dental Outreach Project, Portsmouth University gave details of the University's proposals for a Dental Outreach Centre in conjunction with Kings College, London. The proposals included a £9m new build alongside the School of Professionals Complementary to Dentistry which would have a 20 chair dentistry clinic and enable 5^th Year Students 10 week placements. It was envisaged that those hard to reach patients in Portsmouth, East Hampshire and the Isle of Wight would benefit from the new services, which would be free. Portsmouth City, Hampshire and Isle of Wight Primary Care Trusts would be contributing towards the scheme which was hoped to be up and running by September 2010.

i. South Central Strategic Health Authority

John Newton, Regional Director of Public Health and Sandra White, Consultant in Dental Public Health gave details of the public consultation on the proposals for water fluoridation in Southampton and parts of southwest Hampshire. They outlined the process leading up to the public consultation and the consultation process including events planned, the legal framework under which the Strategic Health Authority was working, the proposals and the issues raised. They said that, currently almost six million people in the United Kingdom received fluoridated water at a level of one part per million and none of the schemes had been successfully challenged in the courts. They gave details of tooth decay trends in fluoridated and non-fluoridated countries across the world and the average decay, missing and filled teeth for children in England. They referred to the research that had been carried out in recent years including the York Review and reviews in Ireland and Australia. Throughout the process the Strategic Health Authority had received legal advice and was satisfied that all decisions to date conformed with legislation, human rights, ethics and mass medication had been taken into account. They gave details of the costs of the project:

· Capital Costs £471,000

· Revenue Costs £59,000

· Estimated net cost of water fluoridation over a 20 year period was £11,526 (32p per tooth)

· Based on:

- An expected lifetime of the fluoridation plant of 20 years during which differences in the incidence of new carious lesions will be observed

- Estimation of costs of treatment and restorative work over a 48 year period for patients who had incurred a carious lesion during the '20 year' period

- An estimated reduction in the incidence of caries in fluoridated areas of 25%

- An estimated number of births of 1434 per year

- An expected annual change in the birth rate of 0.3%.

On being questioned about the consultation they confirmed that 5,000 copies of the consultation document had been distributed to various sources including doctor and dentists surgeries but had not been sent to all individual households affected, the document was also available on the web. On the question of events to advise people about the proposals, which had all been organised in Southampton, they said that it had been difficult to find venues outside of Southampton of sufficient size to accommodate these outside of Southampton and within the area affected. They said that the amount of fluoride proposed to be added to the water, one part per million, was that advised by the World Health Organisation. They agreed that that water fluoridation was not the complete strategy and that promotion of oral hygiene and diet was necessary.

j. Southern Water Authority

Dr. Nigel Smetham, Head of Water Quality and Regulatory Assurance and Joanne Statton, Company Solicitor gave details of the water supply arrangements for the areas affected by the fluoridation proposals including the dosing at Otterbourne and Rownhams, the feasibility study carried out to effect the proposals and the installation of the fluoridation equipment. When looking at the purity of the dosed chemical they said that it must meet strict standards of quality set down in the European standard for hexafluorosilicic acid and gave details of the impurities. They gave information on the target dose, the dosing plant, monitoring of the dosing system and operator competence. On the question of costs they gave the following details:

· Feasibility study had been carried out included generic cost estimates but not site specifics

- cost estimates low compared to evidence from similar installations

· Each dosing location required three mains to be dosed

- three sets of dosing equipment

- cost estimates include only one set

· Potential need and additional cost for mains diversion if dosing in the distribution system

With regards the legal aspect they required:

· Agreement between Health Authority and Southern Water to be put in place

- model agreement from Dept of Health

- covers all aspects of dosing, performance, costs, suspension of dose, reporting

· Indemnity to be put in place

- in respect of liabilities which the water company may incur in complying with arrangements entered into by it pursuant to the Act.

In conclusion they said that the dosing plants must meet requirements of the Code of Practice on technical Aspects of Fluoridation of Water Supplies, dosing at Otterbourne was feasible and practical, dosing at Rownhams distribution centre was not considered reasonable or practical, cost estimates were believed to be low and were likely to rise once site specific issues were considered and dosing would be subject to satisfactory formal agreement and legal indemnity from the Department of Health.

On being questioned they said that one of the reasons for the required legal indemnity was to protect them against any possible liability the water company may incur in complying with arrangements entered into by it in pursuant to the Act.

k. British Dental Association

Ros Hamburger, a British Dental Association Member and Consultant in Dental Public Health, Heart of Birmingham Teaching Primary Care Trust gave details of experience of fluoridation in Birmingham and the West Midlands. She said that high tooth decay rates were linked to social deprivation and that fluoridation had reduced health inequalities. She gave comparisons for tooth decay in five year olds across England and how Birmingham compared with equivalent areas. On the impact on dental treatment she said that children in non-fluoridated areas were five times more likely to have a general anaesthetic then those in fluoridated areas. She said that there had been no evidence of harmful effects of fluoride and that the cost of fluoridation across the West Midlands was 40p per person per annum compared with the cost of £10+ for a single filling on the NHS.

On being questioned about fluorosis she said that it was difficult to get dentists to agree on what fluorosis was and that she had not come across dentists in Birmingham who were worried about fluorosis.

l. Hampshire Primary Care Trust

Richard Samuel, Director of Performance and Standards and Dr.Jeyanthi John, Consultant in Dental Public Health said that Hampshire childrens' oral health was better than the national average with only 32% of Hampshire children experiencing dental decay. An analysis of the data on oral health in Hampshire suggested that in the context of good oral health, oral health improvement measures should be targeted rather than population based and dental inequalities were located in pockets across Hampshire which may be better dealt with using local initiatives. The Hampshire Primary Care Trust was not considering fluoridation of water supplies across Hampshire unless it had established that targeted measures had not succeeded in improving the dental health of Hampshire's children and should this happen the views of Hampshire residents would be taken into account.

They outlined the priorities for therapeutic services which were:

· Increased access to routine dental care - procurement was now under way.

· Appropriate access to specialist care - service redesign was now underway.

· Continued care for vulnerable groups - working with the Primary Care Trust dental service.

· Prevention built into treatment plans

The Trust's priorities for prevention were:

· Continue with educational programmes regarding improving diet, reducing alcohol consumption and smoking cessation (common risk factor approach)

· Evaluate and extend supervised toothbrushing programmes with high fluoride toothpaste for targeted areas.

· Community fluoride varnish scheme pilot planned in high need areas - procurement process needed. (Fluoride varnish was already provided at dental clinics)

The Trust's role in relation to fluoride was to determine whether fluoridation was effective, it had a duty of collaboration with a legal duty of partnership and a responsibility to implement national initiatives. The Trust's Board had yet to make a decision on the Southampton proposals, this would happen at the Board meeting on 21 October 2008.

On being asked if Southampton City Primary Care Trust had consulted Hampshire Primary Care Trust on the proposals they confirmed that it had. On being asked about fluoride varnishing of children's teeth they said that two applications of the varnish would be required over a year and such applications would make a huge difference to children's teeth. One application of varnish was not sufficient.

m. British Association for the Study of Community Dentistry

Dr. Colwyn Jones, a past president of the British Association for Community Dentistry declared that he was also a member of the British Fluoridation Society. He supported the fluoridation of water supplies saying that would improve oral health with 14.8% more children being free of tooth decay and that the York Review had confirmed that fluoridation was effective and showed no evidence of a link with adverse health effects. On the question of ethics he compared the freedom from pain, misery, disfigurement, embarrassment and fiscal costs of tooth decay against freedom of choice, human/civil rights and compulsory medication. He said that currently about 6 million people in the United Kingdom and 160 million in the United States drank fluoridated water and that it was a well proven technology. On the question of fluorosis he said that the York Review suggested that it would affect 12% of children drinking fluoridated water however recent surveys suggested 4%. He said that it was a cosmetic problem and affected individuals rarely suffered from tooth decay.

n. Hampshire Local Dental Committee

Tony Lynn, Chairman of the Hampshire Local Dental Committee explained that the Local Dental committee was elected and funded by dentists and provided advice to dentists. The Committee was in favour of the fluoridation of water. He said that dental decay was totally preventable and showed examples of healthy and decayed teeth. He gave details of his experiences of children's teeth problems in the Andover area and said that in the 1950's Andover had added fluoride to its water supply and did show evidence in a decline in children's tooth decay at that time, however this was stopped after two years as a result of local pressure. He said that because of the costs of dentistry many people only go to a dentist when they are in pain and do not have regular check ups, fluoridation would prevent a great deal of tooth decay and as a result cut the number of people in pain. On being questioned about those countries that had ceased fluoridation and their cases of dental decay he said that he had no knowledge and the Local Dental Committee had not sought any evidence about this.

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