The Irish Expert Body on Fluorides and Health Briefing Note to the 
Joint Oireachtas Committee on Health & Children – 
Monday, 29th January 2007

Introduction
The Forum on Fluoridation undertook an independent, scientific evaluation of the role of water fluoridation in Ireland in 2002. The Forum examined evidence for and against water fluoridation reviewing best available, recognised scientific evidence. 

On the recommendation of the Forum on Fluoridation, the Irish Expert Body on Fluorides and Health was established in April 2004 by the Minister for Health and Children. This comprises of 26 independent specialists across a range of disciplines including dentistry, public health medicine, pediatrics, biochemistry, engineering, diet/nutrition, management, environment as well as consumer related representatives (membership attached). The Expert Body’s remit includes advising the Minister and evaluating ongoing research on all aspects of fluoride and its delivery methods as an established health technology.
The Expert Body is charged with overseeing the implementation of the Forum’s recommendations and ensuring that the systems employed to give effect to these recommendations are sound, transparent, and meet the highest standards of quality assurance and accountability.
Context/Water Fluoridation History
Water fluoridation is the adjustment of the natural low fluoride concentration of water to the level recommended for optimal dental health. It is considered that fluoridation of water supplies is the single most effective public health measure to prevent dental decay.  Throughout more than 60 years of research and practical experience of water fluoridation in the US (where some 170 million people are served by public water supplies that are fluoridated) the overwhelming weight of credible, peer reviewed scientific evidence has consistently indicated that water fluoridation is safe. 

The fluoridation of drinking water in Ireland dates back to the early 1960's. Global research, international studies and best practice on fluoridation have been evaluated in Ireland on a continuous basis before, during and since the introduction of fluoridation. Numerous studies have been published worldwide making fluoridation one of the most widely studied public health measures in history. Between 2004 and 2006 alone, the Expert Body reviewed and assessed 72 reference documents, research papers and health reports in relation to fluoride – both national and international. These deliberations, investigations and assessments are objective, independent and science-based. 

Benefit of Water Fluoridation  
Oral health surveys throughout the 1980s, 1990s and the current decade in Ireland have clearly demonstrated the benefits of Ireland’s water fluoridation policy for everybody in society, irrespective of their economic circumstances. Decay levels in Ireland prior to the introduction of water fluoridation were at epidemic levels: In the 1960’s the mean rates of decayed, missing or filled (dmft) teeth in 5-year-old children in Ireland was 5.6 in the Republic and 4.8 in Northern Ireland. Following the introduction of fluoridation in the Republic, subsequent surveys reported mean dmft rates of 1.8 in 5-year-olds living in fluoridated areas of the Republic in 1984. In contrast, the average dmft in 5-year-olds living in non-fluoridated Northern Ireland in 1984 was 4.5. The decay rates (DMFT) among 15-year-olds in the Republic prior to the introduction of fluoridation was 8.2 in the 1960’s. This had dropped to a mean DMFT of 4.1 in fluoridated areas of the Republic by 1984, yet remained at 9.2 in non-fluoridated Northern Ireland. A survey conducted in 2002 reported a mean DMFT rate of 3.6 among 15-year-olds in Northern Ireland, in comparison to a DMFT of 2.1 in 15-year-old resident of fluoridated communities in the Republic.

These decay rates in the Republic are likely to increase to at least in line with those of Northern Ireland without the benefit of water fluoridation. Water fluoridation is essential to counterbalance increasingly poor brushing habits and higher rates of snacking on sugary foods and drinks, where Irish teenagers rank poorly. The Health Behaviour of School-aged Children (HBSC) survey of 2002 discovered that 47.8% of 13-year-old boys in Ireland consumed sweets at least once a day. Out of 35 countries surveyed by the HBSC, Ireland ranked 3rd worst out of 35, with Finland having the lowest consumption, with 11.3% of 13-year-old boys consuming sweets at least once a day. These high levels of confectionary consumption amongst Irish teenagers is further compounded by the results from the HBSC survey that only 53.5% of 13-year-old boys in Ireland brush their teeth more than once a day. This is in comparison to 13-year-olds in Sweden, of which 77.1% brush their teeth more than once a day.  

International Practice
The effectiveness of water fluoridation in preventing dental decay continues to be endorsed by a comprehensive range of international bodies including the World Health Organization, the Centre for Disease Control and Prevention, the United States Public Health Service and the United States Surgeon General. In addition, in November 2006 last, the FDI World Dental Federation, International Association for Dental Research and World Health Organization confirmed “the efficiency, cost effectiveness and safety of the daily use of fluoride" in a statement issued at an international conference of 80 experts on fluoride and the prevention of dental decay.

Currently, some 40 countries fluoridate public water supplies including the US, Canada, Australia, New Zealand and the UK.  Most European countries employ some form of fluoridation programme usually through water or fluoridated salt. Some European countries have decided against water fluoridation for practical or other reasons, such as France for example, where fluoridated salt is used because of the technical difficulty in implementing water fluoridation policy across France’s 20,000 separate public water sources.    

Issues of Particular Consumer Interest
The Irish Expert Body on Fluorides and Health (Expert Body) is aware of an interim guidance statement from the American Dental Association in relation to the use of tap water to reconstitute powdered infant formula.

In the United States, drinking water may contain fluoride at levels up to 4mg/litre, and thus there is a possibility of infants receiving a larger than optimal amount of fluoride through infant formula that has been mixed with water containing such high levels of fluoride.

It has been established that the appropriate amount of fluoride in tap water is effective in controlling tooth decay. However, fluoride intake above optimal amounts can create a risk of enamel fluorosis in teeth. Enamel fluorosis is not a disease but rather refers to the way teeth look.  

Because water in the USA may contain fluoride in varying amounts, up to 4mg per litre, parents in the USA have been advised by the ADA to only use water that is fluoride-free or contains low levels of fluoride to reconstitute powdered or liquid concentrate infant formula. Parents and caregivers have also been advised to consult with their pediatrician, family physician or dentist on the most appropriate water to use in their area to reconstitute infant formula.

In Ireland, 1.0 mgs per litre is the current limit for artificially fluoridated tap water. Therefore, the Expert Body continues to advise that infant formula should be reconstituted with boiled tap water in accordance with manufacturers’ instructions, and they consider that fluoride in Irish tap water in the concentrations used poses no known medical problems for infants or the population in general.

The Forum on Fluoridation commissioned research found that there was no difference in the dental enamel of infants, between those who are breast-fed and those who receive infant formula reconstituted with tap water.  

Progress on Work Undertaken By Expert Body
The Expert Body is currently working across all eight recommendations as per the Forum on Fluoridation’s report. 

One of the key policy recommendations is to amend the 1966 regulations to reduce the level of fluoride in drinking water from 0.8-1.0ppm to between 0.6 and 0.8ppm, with a target value of 0.7ppm. This level of fluoride is deemed optimal for protecting the oral health of all age groups, whilst reducing the risk of fluorosis.  The legal instruments to effect this reduction have been prepared and their implementation is imminent.

Concurrently, the Expert Body has developed a detailed Code of Practice on the fluoridation of drinking water to ensure quality assurance across the delivery of water fluoridation. This Code sets standards and governs all quality systems and practices required for fluoride provision from storage, dosage, safety and technical aspects through to practical logistics.

A national audit of all fluoridation processes in water treatment plants in Ireland is about to be instigated.  Additionally, research will be undertaken to monitor the public health impact of the planned reduction in the water fluoridation level, from 0.8-1.0mg/l to 0.6-0.8mg/l.

Conclusion
Fundamentally the Expert Body maintains that there continues to be overwhelming evidence that water fluoridation significantly benefits dental health and through this, benefits overall health. The Expert Body’s view is that fluoridation is safe and effective, and that the recommendations that are being implemented to reduce the level in our water supplies and establish standards across all aspects of its delivery will ensure that water fluoridation continues to be a crucial, beneficial healthcare policy.