JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 10 Jul 2003

Vol. 1 No. 13

Forum on Fluoridation: Presentation.

Chairman

I welcome Dr. Don MacAuley, dental surgeon, and invite him to begin his presentation on the recommendations contained in the report of the forum on fluoridation. This will be followed by questions from members. I would draw attention to the fact that members of the committee have absolute privilege but this same privilege does not apply to witnesses appearing before the committee. I remind members of the long standing parliamentary practice to the effect that members should not comment on, criticise, or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I shall allow Dr. MacAuley ten minutes for the presentation. The others will then make their presentation which will be followed by a general question and answer session.

Deputy Gormley

On a point of order, will Dr. MacAuley be present when the others are here?

Chairman

No. Why?

Deputy Gormley

That makes sense because——

Chairman

They have requested that they make their presentation on their own and they are allowing Dr. MacAuley to make his presentation on his own.

Deputy Gormley

We want an exchange of ideas. I suggest Dr. MacAuley has more expertise than does the joint committee on these matters.

Chairman

We have a public gallery and Dr. MacAuley is welcome to sit there.

Deputy Gormley

Can he participate afterwards?

Chairman

Of course he will be asked to participate afterwards.

Deputy Gormley

He can remain here and afterwards he can engage in a proper debate and exchange of ideas.

Chairman

They do not want that. This committee can dictate the procedures. My understanding was that we would have a question and answer session between both at this committee. Can we agree the format that Dr. MacAuley gives his presentation, the others give a presentation to be followed by a question and answer session?

Deputy O. Mitchell

The other group should be present now. It would be utterly sterile if——

Chairman

All we can do is ask if they wish to attend and, if so, they are welcome.

Deputy O. Mitchell

It should be made clear that Dr. MacAuley will be here during their presentation.

Chairman

This committee would prefer if there was a question and answer session between both at the end of the day. It is a matter for them what they want to do in the interim period. Perhaps the clerk would tell them that if they wish to attend they are welcome to do so. I invite Dr. MacAuley to begin his presentation and he has ten minutes in which to do so.

Dr. Don MacAuley

Shall I wait for the other people to arrive?

Chairman

Does Dr. MacAuley think they will hang on his every word?

Dr. MacAuley

Absolutely.

Chairman

I invite Dr. MacAuley to commence his presentation.

Dr. MacAuley

I thank the joint committee for the opportunity to make this presentation on behalf of the Irish dentists opposing fluoridation. We are a group of 42 dentists who have reviewed the forum on fluoridation. This forum has failed to allay public concern about the safety of adding fluoride to our drinking water.

We object to the forum for four main reasons. The majority of the members had a pro - fluoridation bias. They ignored the European tooth decay experience and failed to address the evidence of harm, included in Professor Connell's 50 arguments against fluoridation. We also feel the forum buried a Food Safety Authority of Ireland's damning risk assessment. One of my reasons for refusing to attend the forum in January 2001 was that it was pro-fluoride and, therefore, it was not a serious, independent or fair assessment of fluoridation in Ireland. The Minister referred to the open nature of the forum but how open was it? If we look at the forum we can see it as present among the international fluoridation promoters. Professor O'Mullane is on a leaflet of the British Fluoridation Society where he is promoting fluoridation to the elderly. Other connections include the British Nutrition Foundation. Professor O'Mullane presented at a 1999 conference. Their advice on improving oral health placed fluoridation at No. 2 and sugar reduction moved to No. 5. Irish dentists opposing fluoridation believe that tooth decay is not due to lack of fluoride but a sugary diet is a major factor. This member appears to favour fluoridation before diet education.

Professor John Clarkson is president of the International Association of Dental Research which fully endorses and strongly recommends the practice of water fluoridation. Therefore, he would also not appear to be open on this subject. National fluoridation supporters include Dr. Gerard Gavin. These people have made their position on fluoride clear to the media, in publications and at conferences. Dr. Gerard Gavin has stated that "we consider fluoridation safe at the levels it is being used in Ireland".

Dr. Maire O'Connor and Dr. Howard Johnson co-authored a report which strongly supported the continuation of fluoridation. Dr. Joe O'Mullane was reported in the Irish Medical News as saying "fluoridation benefits dental health and adverse medical effects are unproven."

The forum set up a website in 2001 where it affirmed the independence of the chairman and stated he was not engaged in the practice of fluoridation. This may be so but Professor Fottrell and Thomas McDonogh are members of Galway University Foundation. Thomas McDonogh is the owner of Albatros Fertilizers Limited, the suppliers of the fluoridating agent which is distributed to the water treatment plants in Ireland.

Chairman

I must reiterate that we have absolute privilege here but those appearing before the committee do not have the same privilege. I remind you of that in respect of any statements you make here.

Dr. MacAuley

We believe that should have been declared before the forum sat.

In conclusion, the pro-fluoridation members should have been balanced in the forum. They should not have been allowed to act as judge or jury and we believe this has compromised the credibility of the forum. The forum was set up to protect a public health policy rather than to protect public health.

The forum also ignored the European tooth decay experience. The Minister reported on a "Prime Time Special" special programme that we have had fluoridation for 40 years and it has reduced dental decay by 70%, a staggering achievement. We believe tooth decay is related to many factors and has fallen in Ireland because of better diet, better brushing habits and the use of fluoride toothpaste. Compared to Europe, our 70% reduction is not that staggering. In the Netherlands, for example, there was an 89% reduction in the same period and an 88% reduction in Sweden. Those are World Health Organisation figures. People in Europe have better teeth than us but they do not have water fluoridation. In Ireland we hear the fluoridation mantra repeated again and again - for better teeth there must be fluoridation.

One of the cities in Europe which did fluoridate, Basel in Switzerland, stopped fluoridation in April after 41 years because it questioned the effectiveness of the process and stated that 99% of the fluoride went into the environment and was therefore wasted. New Zealand also questioned whether fluoridation has worked. If we look at this graph we can see the tooth decay figures from 1930 to 1990. Fluoridation was introduced in the 1960s but it has had no effect on that decay experience. The figures were dropping consistently from 1930 to 1990. This points to decay being affected by other factors.

According to the WHO statistics, Ireland's sugar consumption has reduced by 20%. We are also brushing our teeth more frequently. Health board studies have shown we are brushing our teeth now more than ever before. We are also using fluoride toothpaste much more often. It was introduced in the 1970s and 95% of all products contain fluoride.

Members will agree that the current scientific thought on fluoride has changed a great deal since the 1960s. It was believed then that it worked as a systemic, as in a swallowed basis, but now it is accepted that it works when it is in contact with the tooth, for example topically, in the use of fluoride toothpaste. Dr. Gerry Gavin stated that we would not deny that people in more affluent areas do not need fluoridation in their water because of the low levels of disease but dental decay, like many diseases, affects socially excluded people predominantly.

We believe the money from fluoridation would be better spent on a dental health education campaign focusing on those most in need. This would include a national confectionery and snacking campaign but Professor O'Mullane declared at the last meeting of the joint Oireachtas committee that dental health education does not work. We constantly hear the mantra that if we want better teeth, there must be fluoridation. We believe that is a conflict of interest. For this education strategy to work, the dental health fraternity would have to publicly oppose the confectionery and soft drinks industry in Ireland. Instead, our experts travel the world attending oral health conferences sponsored by thelikes of Cadbury, Tate and Lyle, Coca Cola and Nestlé.

As fluoridation continues we see in our dental surgeries more and more dental fluorosis fluoride tooth damage, and it is on the increase. I have included some pictures of patients of mine who have dental fluorosis. The first picture is a case of mild dental fluorosis and in the second the dental fluorosis is moderate. This photograph is of a 15 year old patient who is very traumatised by the appearance of her teeth. We can all see that is a fairly bad case of fluorosis We conclude, therefore, that fluoridation is not being used extensively in Europe but Europeans have better teeth.

The next reason for complaint against the forum is that it failed to answer Professor Connett's 50 arguments against fluoridation. I submitted an article to the NUIG which included 42 references. That document was dealt with by members of the forum but they failed to address any of the studies. That appears to be best practice within the forum. The same happened with Professor Connett who presented his paper in September 2000. The forum set up a committee to deal with that and promised a quick response. As the months passed, progress was promised but it never happened. It then became a difficult task and after two years there was no response to Professor Connett's 50 arguments.

The scientific critique of the forum, authored by Professor Connett and several other eminent scientists, concluded that the forum report was weak. Only 17 pages of the 295 pages of the forum publication dealt with health studies, and only two of those were an independent analysis. They also failed to study cases where fluoridation had been stopped in other countries around the world. In those countries, no tooth decay increase was shown.

The final and most important reason we have a problem with the forum is that we believe the forum buried the Food Safety Authority of Ireland's damning risk assessment. At the back of my presentation there are a number of freedom of information documents which may shine some light on this subject. A member of the forum requested the FSAI to carry out a fluoride assessment on bottle feeding infants. There was concern that bottle feeding infants, due to their large volume of water consumption and their small weights, were being overdosed with fluoride. That document was submitted by Dr. Wayne Anderson to the forum on 18 October 2001. It recommended "the precautionary principle should apply and recommends that infant formula should not be reconstituted with fluoridated tap water". We believe that represented the end of water fluoridation in Ireland. However, that document was withdrawn a week later. The reason for its withdrawal was that the forum did not have time to deal with it, but the forum report was not published for another 12 months. We want to know what went on in the year between the submission, the quick withdrawal of the document and the final report.

These actions are a damning indictment of the forum on fluoridation and we call on the Oireachtas committee to investigate them and examine the reason this document was, first, submitted and, second, withdrawn from the forum on fluoridation. Members will see from the FOI documents in the appendix that this document led the forum to consider the option of stopping water fluoridation. Thank you.

Chairman

Thank you, Dr. MacAuley. You are within budget and within time. What will bethe make-up of the response? You have tenminutes.

Professor Patrick Fottrell

I would like to give an introduction, if that is appropriate.

Chairman

That is not a problem. Who will speak on your behalf?

Professor Fottrell

Joe Mullen. I will take two minutes, if that is all right with you, Chairman, and he will take up the remainder of the time.

Chairman

That is fine. You might address the basic accusation that has been made, that you argued from a conclusion to a principle rather than from a principle to a conclusion.

Professor Fottrell

Before I do that I want to say to you, Chairman, Deputies and Senators that I welcome this opportunity. I am joined by Professor John Clarkson, who was mentioned by the previous speaker, and by Dr. Paddy Flanagan. Dr. Gerry Gavin, who is the chief dental officer, sends his apologies. He is in court today and he has other duties.

I thought we were here to have a good discussion, not character assassination. I would like to take up one issue since the previous speaker referred to me. As a president of a university, I was an ex officio member of a foundation which had many members, including business people. I left the university in July. The forum did not meet until September. I had no contact with the university from July 2000, and I joined the forum in September. There was no conflict of interest. I cut my links completely with the university.

Chairman

What was your membership?

Professor Fottrell

I was an ex officio member. As a president I am a member of the university foundation, as are all presidents. I did not know the details of members of the foundation. If I did I assure you, Chairman, I would have been put in an embarrassing position. This was to raise the profile of the university, nothing else. I resent that very much and I would like that recorded.

On the composition of the forum, all the people on the forum are internationally recognised. They have built up reputations over the years, both nationally and internationally, and those reputations are recognised throughout the world. They entered into the forum, as I did, with an open mind. We had no fixed views. I did not ask members of the forum for their final opinion until all the evidence was in from the last meeting on 25 October.

As regards the modus operandi, we actively sought views of pro and anti-fluoridation groups. We placed advertisements in all the media and it is highly regrettable that people who continued to go to the media would not do us the courtesy of coming before our forum on the pretext that we were biased. I reissue that invitation: the forum would be glad to meet any group or groups of individuals who have problems with water fluoridation.

We consulted widely with the public and we addressed the public issues in our final document. The report is a scientific review, not hearsay or individual experiences, which stands up to scientific scrutiny. That is an important point, Chairman. This is not a document that depends on anecdotal evidence or hearsay; it is a scientific review. The recommendations are in line with all international panels, including the WHO, all the bodies in the United States and the British Medical Council. We have given the report an Irish context but it is totally in line with all international recommendations. We will continue to welcome discussions and debate but not the type of character assassination we heard this morning.

Dr. Joe Mullen

I understood that today I was to talk about the conclusions and recommendations of the forum, so I prepared a document, which I will go through in a moment.

Chairman

Has it been circulated?

Dr. Mullen

I think it has, yes.

Chairman

Is someone else going to make a presentation?

Dr. Mullen

I will just deal with the conclusions and recommendations and then we can discuss some of the points.

Chairman

We will have questions and answers. You have ten minutes but I was just wondering if anyone else on the panel will be making a contribution.

Professor Fottrell

Professor Denis O'Mullane would also like to speak as the discussion develops.

Chairman

You have ten minutes to make your presentation and then we will have questions and answers.

Dr. Mullen

The task we were set was to determine whether fluoridation had benefited oral health, whether it posed any risk to general health, and to make a series of recommendations on our findings. The conclusions we drew were that fluoridation has certainly been effective in reducing dental decay in Ireland in children, adults and also the elderly as a specific group because of a specific condition that affects the elderly called root caries.

We found no evidence that health is adversely affected. The balance of evidence is certainly that there are no negative health affects in water fluoridated at one part per million or less. However, we found that while dental sclerosis rates are low in Ireland, they have been increasing since the 1980s. That indicates that people are getting more fluoride from sources other than fluoridated water than they were in the past.

Two members of the forum took separates views to the forum and their views are in the forum's report as well. The Consumers Association of Ireland had a member on the forum; it opposed fluoridation on the question of personal choice. The Irish Doctors' Environmental Association also took a neutral stance on the benefits and negative possibilities of fluoridation but also opposed the continuation of water fluoridation on the question of choice and the philosophy of that particular organisation.

Our recommendations are based on eight specific areas. There are four main recommendations on policy aspects, first, that water fluoridation should continue as a public health measure. However, a reappraisal of the data in the modern setting since the introduction of fluoridated toothpaste, indicates that we can now fluoridate water at a lower level than was previously necessary. We recommend this level to be between 0.6 and 0.8 as opposed to the previous level of 0.8 to 1.0.

We recommend amendments to the fluoridation of water supplies regulation to reflect these changes and to reflect changes in technologies, and also the setting up of an expert body to continue monitoring and surveillance of this area.

The second set of recommendations were on technical, engineering aspects which concern the fluoridation plant. There is quite a deal of detail in there concerning all plants, and about communication of results of fluoridation tests to the public, monitoring of the actual fluoridation agent and so on.

As regards recommendation three, on fluoride toothpaste, the evidence before us indicated that the main source of this extra fluoride that people are getting nowadays was from inappropriate swallowing of fluoridated toothpaste. Such toothpaste is fluoridated at over 1,000 times the concentration of fluoridated water, so a small amount of fluoridated toothpaste swallowed will raise a reasonably high level of fluoride in the body. The evidence is that we should continue to use fluoridated toothpaste because there is an additive benefit.

Fluoridated toothpaste and fluoridated water seem to work in different ways. When used together, one gets the best benefit. However, there are two conditions to that. Because decay levels are very low in Ireland decay risk for children under two years of age is very small. Therefore, we recommend that they do not need to use fluoridated toothpaste. Also, such children's swallowing reflex is not very good so they can swallow inappropriately. Because of the low risk and the risk of staining teeth, we recommend they do not use fluoridated toothpaste - they should simply brush their teeth with a toothbrush and water. However, if the decay risk is high then the advice changes. A professional can advise a person to use fluoridated toothpaste.

For children between the ages of two and seven, the risk of staining is still present but the decay risk is much higher. Therefore, we recommend the use of fluoridated toothpaste using a pea-sized amount of toothpaste on the brush. There are photographs of this in the forum report. As a rule of thumb, instead of putting toothpaste on the brush lengthways as one sees in the television advertisements, one should put it breadthways, which will provide approximately the correct amount. We do not recommend low fluoride toothpaste because there is not really any great evidence that it is effective in preventing tooth decay.

The fourth set of recommendations are on the oral health care industry and concern clear labelling of fluoride products, clear instructions on the use of the products and also child resistant closures on some fluoride products, such as mouth rinses. The concern there is primarily to do with other things that are in these rinses, including alcohol.

The fifth set of recommendations is on infant formula. There is an extensive appendix in the report dealing with this issue, which is a report by the Food Safety Authority. We recommend to continue constituting infant formula as before, with boiled tap water. We do not recommend the use of bottled water because there are other constituents in normal bottled water that are not good for children, particularly high sodium levels. Some bottled waters on the market are suitable and these tend to be French manufactured waters. For instance, where people are on group water schemes and there are high levels of nitrates in the water, certainly these bottled waters are suitable but this would be on professional advice. The general recommendation is simply to use tap water.

Recommendation six on fluoride research is to ensure that, as a matter of course, the fluoride research that is currently ongoing continues, that information on general health is also included, along with dental health, in future surveys, and that the expert body itself will prioritise research in this area.

Recommendation seven is on information and public perception. It is basically about getting the message to the public. One of the things that came across quite strongly in the public consultation was that there was a great deal of confusion as to what fluoridation was all about.

The eighth set of recommendations is on public health and professional practice which is concerned about getting the right information to professionals so that they will have the right information to give their clients.

In terms of disseminating the report and public participation, we have made presentations at a number of county councils, various professional bodies, health boards, the Irish Society for Toxicology, the Irish Society for Dentistry for Children, and local authority staff. We have been on local and national radio programmes to try to get the main information out. In addition, the Dental Health Foundation has also produced some very good information leaflets and posters for use in dental clinics on this topic.

Chairman

There are about 21 members in the group?

Professor Fottrell

Yes.

Chairman

We are talking about balance here. Two members demurred from the final decision. Was the opinion of the others regarding the findings unanimous?

Professor Fottrell

It was.

Chairman

That means that 19 of the 21 members were unanimous.

Professor Fottrell

Some members also spoke on behalf of the organisations rather than in an individual capacity, but all of the 19 members agreed.

Chairman

It was said that a majority of the members of your group was in favour of fluoridation before it was formally established and that the membership of the group was not balanced.

Professor Fottrell

Two members declined the initial invitation of the Minister. They were Darina Allen and Dick Warner. The Minister indicated that he would welcome it if the forum indicated it considered there was need for additional balance. We recommended the appointment of Dr. Liz Cullen, Irish Doctors for the Environment, to the forum and the Minister made the necessary appointment.

Chairman

Do you wish to respond to some of the issues raised by Mr. McAuley before we proceed to questions and answers?

Professor Fottrell

Do you wish me to deal with the personal issues or will we adhere to the general ones?

Chairman

Professor O'Mullane might like to refer the fact that his name was mentioned.

Professor Denis O’Mullane

Thank you, Chairman, for providing me with the opportunity to address the committee. I have addressed this matter before, where I have been told I promote water fluoridation. I have been measuring the effectiveness of water fluoridation for 32 years; I carry out studies to establish whether water fluoridation reduces dental decay. All the studies have shown that it does. When I am asked to present papers internationally on the effect of water fluoridation, if I say it works and if that is interpreted as the promotion of water fluoridation, I cannot do anything about it as an independent scientist.

I have reported figures which would show that the percentage reduction is not as high as it was 30 or 40 years ago on account of the introduction of water fluoridation. For example, recently the Minister announced the result of a North-South study in Ireland, which looked at dental decay levels north and south of the Border. It was, for the first time, done contemporaneously. In 1963, it was established that the level of dental decay was high in both jurisdictions. In 1970, fluoride toothpaste was introduced into Northern Ireland and the Republic of Ireland. The republic introduced water fluoridation in 1962 and 1963 in Dublin and Cork, and today, 73% of the population reside in fluoridated communities. Whereas dental decay levels both north and south of the Border were similar in the early 1960s, a study undertaken in the Republic in 1984 showed that water fluoridation was working. The most recent study - I understand members of the committee have a copy of it before them - shows that the level of dental decay is still considerably higher in Northern Ireland than in the Republic of Ireland. While Mr. McAuley may say water fluoridation does not work, our data show that it does. If that is promoting, or if it means I am an evangelist for water fluoridation - I have never been an evangelist - I tell you the facts. The facts are that it appears to work.

Mr. McAuley said that the pattern of consuming sugar fruits and drinks has fallen in this country. I do not know where the evidence for that originates because my understanding is that Ireland is high up the league table in terms of consuming foods and drinks sweetened with sugar. From my point of view, the evidence is there that water fluoridation is still working. If I was to find in my next study that it was not working I would also report that.

Chairman

Dr. Anderson, how do you respond to the suggestion that you issued a report from the Food Safety Authority of Ireland that was anti-fluoridation, but that within a week you withdrew it and it was never considered by the committee?

Dr. Anderson

Thank you, Chairman, for giving me the opportunity to address that issue. I was a member of the forum representing the Food Safety Authority of Ireland rather than being there in my own right. The report to which Mr. McAuley refers was a risk assessment done by the scientific committee of the Food Safety Authority of Ireland. That is our advisory committee comprising independent scientists from a number of different disciplines throughout the country, approximately 15 scientists in all.

When the issue of infant formula arose in the committee, I was asked by it to refer it to the Food Safety Authority of Ireland to consider if there was a problem, what was the risk with the infant formula and the use of fluoridated tapwater in its reconstitution. I put that to the committee and a working group made up of three people worked on a draft copy of the risk assessment. Risk assessment is an ongoing process and as new evidence comes to light different conclusions are reached. In October 2001, we produced a report which we, as the three members of the working group, considered to be adequate. That report was submitted to the scientific committee at its meeting in October.

The problem with the report and its withdrawal is one of process rather than scientific substance. I am as guilty as anyone for making that process work inefficiently. The report was finished and presented to the scientific committee by e-mail only two or three days prior to the meeting. It is a substantial report and we hoped that in those two or three days, the members would have had the chance to have it read and then attend the meeting. At the meeting, nine of the 15 members of the committee were present and six were absent. The nine members in attendance read through the report, listened to the discussions and accepted the report on behalf of the scientific committee, at which point I was correctly under the impression that the report was passed by it.

The meeting of the fluoridation forum was held a day or two after the scientific committee meeting and so I presented the report as the conclusions of the scientific of committee. In the preceding few days, some of the members who were not present at the scientific committee meeting contacted the Food Safety Authority of Ireland and the chairman of the scientific committee and basically said they felt that, having now read the report, it contained some errors and that it did not necessarily take account of all the available scientific evidence. At that point the chairman said that, effectively, the report was no longer supported by the majority of the scientific committee and I had to withdraw the report at the next meeting of the fluoridation forum, which I understand, and as Mr. McAuley suggests, was held only a week later because it no longer reflected the views of the scientific committee. From that day until through and into the third or fourth month in 2002, the committee reworked the report and added new scientific evidence.

A major problem with the original report is that exposure assessment - looking at how much fluoride children take in - was only done on an acute basis, that is, what was the maximum daily intake. It was not done on an average basis, such as how much do they take in over a full month period of life. That was a big problem because we were considering dental fluorosis which is a long-term effect. It was, therefore, correct to point that that was in error. I believe if we had published the report as originally submitted, it would basically not have stood up to scientific scrutiny, albeit saying exactly what Mr. McAuley says, that the report said it was not a good idea to be making up infant formula with fluoridated water, and that was based on the evidence in the report.

To cut a long story short, the final report was drafted. After several debates, it went through the scientific committee. All members of the scientific committee were asked specifically whether they supported the risk assessment. They did, and that became the adopted report of the scientific committee. Since that date, we have amended the process in the Food Safety Authority of Ireland by making sure that there is now a two week cooling down period for the scientific committee members whereby we will not be issuing reports they have signed off until they have had time to think about them and all the people who were not present have had time to read them. That was an error of process within the Food Safety Authority of Ireland.

Chairman

It sounds like a real process mess. How many scientists of the overall group were present when this was first adopted?

Dr. Anderson

Nine out of 15; there were six absent.

Chairman

Was it the six people who were not present who subsequently made the objections to the scientific analysis and basis of it, or did members who adopted the report make objections subsequently?

Dr. Anderson

It was some of the absent members.

Deputy Gormley

I thank all those who came and participated here. This has been a long-term interest of mine, Chairman, as you will be aware, and I am grateful for the opportunity to discuss it. That is why I asked specifically that the group could be together to debate this.

I am not interested in personalising the issue or in character assassination. I am here to determine the facts and that is my sole purpose. However it is important that we look at the make-up of the scientific committee to see are there people who are pro-fluoridation and anti-fluoridation in order to get a balance. Given their record, frankly for some of the people here to claim that they are not pro-fluoridation is a bit like the Pope saying he is not pro-Roman Catholicism. The fact is that Dr. MacAuley has stated clearly that he is anti-fluoridation. I like to see issues in these terms. One may well say that he is anti-fluoridation because, as an independent scientist, he has established the facts in such a way as Professor O'Mullane has stated. For the purposes of our debate, however, it is important that we establish that there are people here who are pro-fluoridation and there are people who are anti-fluoridation. It does not serve our purposes when people say they are objective commentators and honest brokers. That does not stand up to scrutiny.

It has also been stated here that they have dealt with the science of this matter. Would they agree that Professor Paul Connett, who was asked to come before the forum, delivered subsequently a thorough assessment of it in his own scientific critique of the fluoridation forum? His damning report shows that they have not dealt properly with the science.

There are a number of questions I want to go through systematically. When Professor O'Mullane came before the committee previously he stated that it was thought when fluoride was introduced that it acted systemically but now we know that it acts topically. I would ask all of them the following questions. Why then are we insisting that we ingest fluoride when we know that a large proportion stays in the bones - up to 50% as I understand it? Would they agree that dental fluorosis is a manifestation of fluoride overload or fluoride toxicity?

I regret that Dr. Gavin cannot be here and I am sure he has good reasons. I wanted to address this question to him but I will now address it to those who are present. Under section 6 of the Health Act, the Department is charged with carrying out health studies in order to determine the levels of fluoride and how it has affected people. Why have no such comprehensive health studies been carried out under this section? It seems terribly remiss of the Department that in 40 years it has not carried out such studies to determine how much fluoride is in Irish people's bones. I know that studies have been carried out. Dr. Mansfield carried out studies of fluoride in Kildare. He found that they were not fluoride deficient and, in fact, they were way above what is acceptable. I would like to know why the studies to which I referred earlier have not been done.

Why have they not dealt properly with the idea of the precautionary principle? Basically the precautionary principle states that when in doubt, you leave it out. Would they agree that there is enough doubt about fluoride to leave it out of our tap water? Would they also agree that there are people who have a certain genetic predisposed intolerance to fluoride? Why are we indulging in mass medication giving the same dosage to all when the genetic make-up of people is clearly different?

I ask the delegates to comment on the submission by Dr. Hardy Limeback. He came before the committee and spoke about delayed tooth eruption which is caused by fluoride. Therefore when they make comparisons they are not real because subsequently the problems appear in adulthood, not in childhood, and we are getting skewed results. In fact, Dr. Limeback stated that the report fails to demonstrate that over 30 years of fluoridation in Ireland has prevented tooth decay and that the number of fillings saved per child is impossible to estimate. He said that even if a net statistically significant difference could be found in adults, it would be so small as to be clinically irrelevant.

I am fascinated by the story relating to the FSAI, the fact that nine people agreed and subsequently those who were absent rang up the others and stated that they found further evidence, etc. Is it not the case that if the original report had been adopted, that would have been the end of water fluoridation? It was very convenient that people came back to say, "Sorry, we got it wrong. Let us look at this again." This was a damning report. Is that not the reality?

In those areas where fluoridation has been stopped, why has there been no significant increase in dental caries and why has that not been addressed properly in the full report? I will conclude with that question. I thank these people for coming before the committee and I hope we can continue to look at this issue in detail.

Professor Fottrell

There were seven questions asked.

Chairman

Deputy Mitchell, who must leave the meeting early due to another appointment, might have a corollary question.

Deputy O. Mitchell

There is some overlap and perhaps it would be best if Professor Fottrell holds off answering for a moment. Some of his answers will probably suffice for me.

I thank the members of the forum and Dr. MacAuley for the presentation. Unlike other members of the committee, I am totally new to this because I have been a member of the committee for one year only. I was not present for the debate which gave rise to the setting up of the forum.

I have absolutely no reason to suspect or to question the professionalism of the forum. It is unfair of Deputy Gormley to suggest that some members are not honest brokers. That is an unfair accusation just because they disagree with the outcome.

Deputy Gormley

I have a good basis for saying that. They have a record of being pro-fluoridation.

Deputy O. Mitchell

The notion of mass medication in regard to anything is totally repellent and I am frightened by it. I am not a scientist but the dosage my family, myself and others take in is immeasurable. The forum's brief contained three elements, the first of which was to determine whether fluoridation benefited dental health. Unlike others, I am inclined to believe it does. I base this on the history of my own teeth in comparison to those of my children who have benefited from fluoridation.

However, the second element related to the impact on an individual's health and I have worries in this regard. The forum stated there was no evidence of an impact on an individual's health. Why would anyone believe, because he or she does not see the physical manifestation of an illness, that something he or she ingests will have no impact on anything other than his or her teeth? That is not logical. Dental fluorosis is the result of too much fluoride and it damages teeth. Why then does the forum assume when there is an increasing incidence of dental fluorosis that there is not also an increasing incidence of damage to other body parts such as soft tissue and the skeleton?

The third element of the forum's brief was to make recommendations. I do not understand why, in terms of implementing the precautionary principle, the forum did not examine alternatives given they that are available and it is known the topical application is as effective as ingesting fluoride. Alternatives to fluoride are also available. Dosages cannot be controlled. For instance, if one walked along Grafton Street and looked at the thousands of young women, in particular, passing up and down, I can guarantee nine out of ten of them drink a gallon of water a day to control their weight. They say it is part of a detoxification process but most of them drink water as a weight control method. They take in significant amounts of tap water. Although they drink water out of a bottle, that does not mean they bought it. They usually buy the first bottle of the day but they continually refill it with tap water. They never move without the bottle. They have it at their desks when they are working and when they are out walking. Does that not generate a niggling worry that people are taking in so much fluoride, not only through water, but also through canned goods and so on?

Professor Fottrell

Most of the questions relate to dentistry and medicine. I will defer to my dental colleagues to reply, beginning with Professor Clarkson.

Deputy O. Mitchell

I have one final and importation question. One of the forum's recommendations was a reduction in the amount of fluoride. The report is a year old and the recommendation has still not been implemented. The Department of Health and Children allocates more than €500,000 to local authorities for fluoride. This money is needed by the health service. Why has the recommendation not been implemented?

Professor John Clarkson

My name was mentioned at the beginning of the report. I am president of the International Association for Dental Research, which represents 12,000 scientists throughout the world. These scientists are involved in molecular biology, genetics and materials of dentistry and I am the only Irish person to have held this post. It is not fair to say I am biased because I am president of an association that examines available scientific evidence.

Objectivity was the other issue mentioned by Deputy Gormley. As a scientist, one examines the science that is available over a period of time and one bases one's opinion on that. Based on the available scientific evidence, I am in favour of fluoridation and if the science changes tomorrow or the next day I will go with the science.

The question of whether fluorosis is toxic is a key issue in regard to fluoridation because that is a side effect. However, we knew that from the word go. Fluoride occurs naturally in water, fish and tea; it is everywhere. Adjusting the level upwards or downwards is not an issue. When it was discovered in the 1940s that fluoride had an effect on dental decay and one could contract fluorosis, the balance that needed to be struck was to get the right level in the water or through toothpaste so that there is a minimum amount of fluorosis and a maximum reduction in this disease, which has devastated young children and adults around the world. The change since the introduction of fluoride has been dramatic.

All scientists accept fluoride has been the main factor in reducing decay. There is no dispute among scientists on that. The issue is controlling the level so that there is a minimum occurrence of dental fluorosis and that relates to the Deputy's question about toxic or non-toxic effects. We always knew that would occur.

Deputy Gormley

Is it a manifestation of fluoride toxicity?

Professor Clarkson

It is a manifestation of fluoride. There are areas in the world in which there is 40 parts per million fluoride naturally in the water.

Deputy Gormley

Would that not suggest there is too much fluoride in us?

Professor Clarkson

If the amount of fluoride is increased, there will be more fluorosis.

Professor Fottrell

The Deputy used the word "toxicity". That is word for something that does damage. Fluorosis is a surface mottling of teeth. An implication has been made that Ireland is unique among European Union member states in fluoridating water mandatorily. Ireland is one of 40 countries that does so. A total of 320 million people worldwide consume fluoridated water every day and that number is increasing all the time. We hear about a little place like Basel but Japan, with a population of 180 million, recently began to fluoridate its water. That means a total of 500 million people will drink fluoridated water. We are not out of line; we are in step with the rest of the world.

The forum's recommendations are also in line with recommendations of bodies all over the world. One must always be conscious of some damage and monitoring of the situation. We made strong recommendations in the forum report regarding better quality assurance and improved quality control of all plants. We are conscious of that. Professor O'Mullane will address Deputy Connaughton's question.

Professor O’Mullane

I addressed the committee previously and I have that presentation with me, so my filing system is still good. One of the points I made in that presentation was that it was important in regard to fluorosis to understand where we were coming from, as Deputy Mitchell pointed out. I worked in the health board dental service in west Cork in the early 1960s and I spent my time extracting teeth in the City Hall in Cork. I showed photographs of how things were in the 1960s and I also demonstrated what we are talking about in regard to fluorosis. It is a mild alteration in the colour of the teeth. As Professor Clarkson pointed out, we did not know at the time there would be mild changes in the colour of teeth. A point was made about the topical effect as against the systemic effect. There is no doubt that our knowledge of how fluoride works has altered quite a lot in the last 30, 40 or 50 years. I did not say, Deputy Gormley, that there was no systemic effect. There is some systemic effect but the topical effect has been understated.

The second point is that when one is trying to apply fluoride topically compliance is an issue. For instance, let us look at toothpaste sales in this country. The number of people who brush their teeth is quite low. Even though toothbrushing habits are similar North and South of the Border, we still have less dental decay in the Republic of Ireland. Even though the topical effect exists - we know a bit more about it - there is also a systemic effect.

A point was made about Dr. Connett's 50 questions. When one looks at the body of the fluoridation report, almost all of these questions are addressed one way or the other. The reason for the change of tactic during the course of the forum on water fluoridation is that we were all participating in the forum on a voluntary basis. I was chairperson of the group looking at the 50 questions and we realised during the debate in the forum itself that the questions raised by Dr. Connett would be addressed in the body of the report, which is the case. We had a difficulty in relation to the 50 questions. We went to enormous trouble to try to get access to some of the references mentioned in the 50 questions; we still have difficulty getting access to them. There was a change of tactic, rightly, so that the questions would be addressed in the body of the report. A document is now being prepared addressing specifically the 50 questions which will be ready in due course.

Dr. Mullen

To reiterate what Dr. Clarkson said, as a principal dental surgeon with the health board, it is my job to monitor what the science is saying about all matters of dental health. When I report that science is saying fluoridation is safe and effective, that is what I am saying. If a better alternative came up in the morning, my interest is in better dental and general health, not in promoting fluoridation - they are two different things. I do not have shares in fluoridation companies and I do not have anyone twisting my arm to say anything positive about it. I would quite happily accept anything that was better than fluoridation.

I would like to address Deputy Mitchell's questions. On mass medication, this would get a lot of sympathy. It is a philosophical argument so to speak. It strikes me that when one puts a label on something it immediately conjures up a whole range of images. Some would say it is mass medication while others would say we are copying a natural phenomenon, which results in two different images. I respect people who take that point of view, which is a perfectly valid objection to fluoridation. I do not agree with it but I accept it.

On alternatives and working better, there are countries which have achieved excellent results without using water fluoridation but in each case they use some form of fluoridation. If it is not water fluoridation, it is fluoridated salt or it is fluoride directly applied in very comprehensive school dental services. On the question of why did we not examine areas where this stopped, we certainly did. We had a presentation from Professor Hanhausen reporting on the experience in Finland where they stopped fluoridation in one area. What they found was that dental decay did not rise after fluoride was stopped. In Finland there was a school dental service where children were brought in twice a year to have fluoride applied directly topically by dental hygienists and dentists. There are alternatives to water fluoridation but one must remember that this deals only with children. The report states that fluoridation has been shown to benefit children, adults and the elderly.

We looked at areas where this has been stopped and in each case some other form of fluoridation is used. Basle in Switzerland was referred to earlier and it should be remembered that all other areas in Switzerland use salt fluoridation. In some areas this is mandatory, therefore, salt in all processes such as baking and so on is fluoridated. A decision was made in Basel to replace water fluoridation with salt fluoridation. Fluoride is not the problem but they have decided salt fluoridation is more appropriate in Switzerland. It might be of interest to members to know that the first vote on the extension of fluoridation in Britain was taken last night in the House of Lords. Currently 10% of Britain is fluoridated and it is expected this will rise significantly when the Bill is passed.

On changes in behaviour, members have hit the nail on the head as to what possibly will mean the end of fluoridation in Ireland. If the report from the Food Safety Authority shows that infant bottle feeding would be a problem because of fluoridation - infant bottle feeding is a relatively new phenomenon which replaced cow's milk feeding over the years - it probably would have meant the end of water fluoridation or, at the very least, a serious reappraisal of it. If further evidence emerged that this was a problem, it would be a very serious blow to water fluoridation. If it turned out that non-fluoridated bottled water sales went through the roof, and people were using it exclusively, it might also be a good reason to stop water fluoridation. These are lifestyle changes which we cannot predict at the moment. It is one of the reasons an expert body needs to be set up to keep abreast of all these matters and, at the end of the day, to make a good judgment on what is the best way to achieve the best oral health, not to keepwater fluoridation but to achieve optimum oral health.

A question was raised about the implementation of the fluoridation levels. A number of teams have been travelling around the country addressing local authority staff and county councils. Currently the regulations state that the ratio should be 0.8 to one. We have been telling everyone to aim for 0.8 until the regulations are put in place. We will not report failures that come in between 0.6 and 0.8. The lower end of the current regulation is actually the top end of the new recommendations. I do not know why the current regulations have not been changed. That is a matter for the Department of Health and Children. I am just a member of the forum and I do not know if anyone else can advise on that issue.

Chairman

Is Dr. Mullen disappointed?

Dr. Mullen

I am. I hoped the forum's recommendations would have been acted on reasonably quickly.

Chairman

Would you regard it as a serious omission that the recommendation has been made and 12 months later it has not been implemented?

Dr. Mullen

I do not know enough about the processes in the Department of Health and Children to know what the current priorities are. I certainly would have preferred if the recommendations had been implemented. I do not know what the technical difficulties are.

Professor Fottrell

The type of town meetings, so to speak, which are taking place throughout the country to educate as many people as possible are important. I understand from the Department that the Minister has asked his officials to establish the expert group we recommended. No timetable has yet been set but I believe the formation of the group is near term - I am quoting. As I said in my introduction, this will allow the ongoing issues discussed by Deputies Mitchell, Gormley and Dr. MacAuley to be discussed with the expert group. We encourage everyone who has problems or anxieties to discuss them with the expert group. It is not helping anybody to have these discussions on the media. Discussion on different issues is confusing the public. These are sufficiently important to be discussed by groups in the forum and by the expert group.

Deputy Gormley

On a point of order, in the interest of balance it is important we hear from Dr. McAuley.

Chairman

I am conscious of that. The Deputy is arguing against himself. He asked several questions and there is an effort being made to answer them.

Deputy Gormley

I only got three.

Deputy O. Mitchell

I am wondering why the recommendations cannot be implemented ahead of the setting up of the expert group. Why is one dependent on the other?

Professor Fottrell

The recommendations can be implemented. The expert group was to continue to educate and explain.

Deputy O. Mitchell

So that is just a recommendation?

Professor Fottrell

Yes, it is. There is a great deal to be done in that area. During the public consultation undertaken by the forum - which was very comprehensive - many issues were raised leading us to form the opinion that there was a great deal of misinformation among members of the public. The public were confused about why we add chlorine to our water and with chlorine itself. We add chlorine to our water for health reasons. Many other issues were raised. We owe it to the public to inform and educate them about these issues. That would be an important role of the expert group.

Dr. Mullen

Deputy Gormley asked about the topical systemic effect.

Deputy Gormley

I accept that point. There is also FSAI and what happened there and delayed tooth eruption and the precautionary principle.

Dr. Mullen

On the issue of delayed tooth eruption, we have extensively reviewed the literature in that regard. A number of studies indicate that is the case.

Deputy Gormley

I am sorry, could you repeat that.

Dr. Mullen

We have reviewed the literature on the question of whether water fluoridation delays the eruption of teeth, eruption being the age at which teeth come into the mouth. There is a suggestion that fluoride for some reason delays the time at which that takes place. Therefore one gets a false effect. This is a complex issue because eruption of permanent teeth depends upon, in many instances, the shedding of the baby teeth. If the baby teeth are decayed they are extracted thereby speeding up the eruption of the permanent teeth in some cases. As a phenomenon, it is difficult to measure. We are examining the issue. One of the objectives of the study which I showed the Deputy - we are analysing the data at the moment - is to examine any differences in eruption patterns between people in the North of Ireland and in the Republic and between fluoridated and non-fluoridated areas. The Deputy has asked a very valid question but it is complicated by the fact that if one does not have water fluoridation the decay rate is higher in baby teeth, they are extracted and the eruption pattern changes.

Professor O’Mullane

The Deputy asked clinical relevant questions and quoted from Dr. Hardy Limeback about the relevance——

Deputy Gormley

Yes and why no proper studies have been carried out under section 6 of the Act.

Professor O’Mullane

I will speak to the issue of clinical relevance because I am a health board dentist. I work in the north-west of Ireland and we have very good contacts across the Border. The differences in decay rates manifest themselves in many ways, including more than four times a higher rate of referral for general anaesthetics north of the Border from Sligo-Leitrim and Fermanagh-South Tyrone. That is the difference in decay manifesting itself in a practical sense. The spread of decay in society is not even. It is very much a phenomenon of poverty as much as of anything else. One tends to find many people in fluoridated and non-fluoridated areas with very little decay and small groups of people with a great deal of decay. What one finds in the non-fluoridated areas is that that group is much bigger and has much more devastating decay leading to much more general anaesthetic cases. That, from my point of view, is a serious health benefit from fluoridation.

The Medical Research Council published in London the same week the forum on fluoridation published. They alluded to the fact in their study that fluoridation worldwide tended to benefit lower socio-economic groups preferentially because they carry a huge load in terms of dental decay.

Chairman

The final reply is to Dr. Anderson. Nine scientists adopt a report, recommend a report; the six who were not there come back and say the scientific analysis does not stand up. That does not say a great deal for the nine people who adopted that report in the first instance given that the circumstances and perspective of the report were dramatically changed.

Dr. Anderson

That depends on whether one believes a process should lead the Food Safety Authority or science. We believe it is science which leads the Food Safety Authority. If it was process we would have said "sorry, you've missed your chance, this is the report." If it is science then we did what we did which is effectively to re-enter that report to the next scientific committee when those members were present. There was a full debate where they were allowed to put their case. I cannot comment for the scientists but at that next meeting they decided the report needed further work.

Deputy Gormley

My question was do you accept that if the original report had been accepted that would have been the end of water fluoridation in Ireland?

Dr. Anderson

I do not know the full details of how that would have affected it, I would be speculating. I suggest that it would have had a serious effect on it. There is no doubt about that. That is why it was important that we got the report right scientifically. Scientists did not feel the report was correct and did further work on it and came up with the latest result. One will find the vast majority, if not everything of the scientific evidence contained in the original report, is still in it.

Deputy Gormley

The conclusions are different.

Dr. Anderson

Yes, they are and that makes a big difference.

Deputy Gormley

Of course it does.

Dr. Anderson

It is a very poor risk assessment association, that cannot be big enough to change its mind. If we obtain further evidence in the future that goes against this we will be quite happy to change our minds again.

Deputy Gormley

That is very convenient.

Professor Fottrell

When this was brought to my attention, I wanted to obtain the actual facts so it went back again to the scientific committee of the Food Safety Authority. They have their own modus operandi. I saw the initial report as a draft. The final report came following a second meeting of the scientific committee. Drafts are quite common. One can have a draft report up for consideration at another committee meeting.

Chairman

A draft which goes in the opposite direction is quite a turnaround.

Professor Fottrell

We, as the forum on fluoridation, are trying to determine the facts.

Chairman

Are you happy that the final report reflected accurate scientific measurement?

Professor O’Mullane

On the Food Safety Authority issue, it is important to note that the risk being assessed was fluorosis. There was no other risk. That has been made clear in both drafts. Eighteen months ago we conducted a study in Cork on the prevalence of dental fluorosis in baby teeth. Page 43 of the fluoridation report gives the actual dates of formation of teeth. It is a very complicated area. If, for instance, an infant consumes infant formula diluted with fluoridated water which results in fluorosis - that is the only risk being assessed by the Food Safety Authority - one would expect there would be a high prevalence of fluorosis in baby teeth. This study was conducted, it has been presented at international findings and we found certainly that there was fluorosis of a very mild nature in baby teeth but that it was confined, as one would expect, to those teeth which were forming during the first four or five months of life, that is, the back baby teeth, the molars. The level was no different in those who are using infant formula diluted with fluoridated water and those who were not. Those children will be followed up and if it is found that there is an issue, then I certainly would report that also. That is what I meant by being an objective scientist.

Deputy Fitzpatrick

To make my position clear, I am pro-fluoridation. I started practising dentistry before fluoridation was introduced. When I started, teeth extractions and fitting acrylic dentures were my daily work. When I finished practising, there were more dentists wishing to practice orthodontics. People were holding on to their teeth and overcrowding of teeth was the problem. It was apparent to me that fluoridation was doing the business for the young people of Ireland. Nothing I have heard today both from the Opposition and from Dr. MacAuley has convinced me that they have anything better in their bag. Fluoridation has been here for 40 years and the best we can get today is fluorosis. I do not think the argument stands up.

Dr. MacAuley

To answer the Deputy's question, I have worked in both fluoridated and unfluoridated areas and I still see the same levels of decay in both areas. He said that tooth decay has reduced because of fluoridation; that is the question. As I see it, fluoride toothpaste has not been considered. It was introduced in the 1970s in Europe. The forum members have consistently avoided talking about the European experience. The opinion that there are no adverse health effects is something I find hard to take. I will show the committee photographs of a 15 year old girl. If the members can tell her and her parents that what is in the photograph is not an adverse medical effect, then they are better than me.

Deputy Fitzpatrick

I practised in that era when we were doing clearances on teenagers.

Dr. MacAuley

As I said, these parents will be requested to cover this damage and the bill for that is between €6,000 and €8,000. That is not covered by the medical card scheme, the Department of Health and Children or by the PRSI schemes.

There seems to be a lot of contradiction at this meeting as regards fluoridation having an adverse health effect. The Food Safety Authority of Ireland in its conclusions in the executive summaries state that there is no evidence of any adverse effect other than dental fluorosis Does that mean the FSAI include this as an adverse health effect?

I have another question to ask of the FSAI. As far as the Irish Dentists Opposing Fluoridation is concerned a draft submitted is not a draft; a draft is something that is discussed among members and then it becomes a submission when submitted and not a draft. In its first recommendation in the initial assessment it concluded that the precautionary principles should apply and recommended that infant formula should not be reconstituted with fluoridated tap water. That changed significantly because the FSAI was recommending that tap water not be used but in the final summary tap water was not mentioned. The FSAI reiterated: "All babies should be breastfed except in very rare cases when breastfeeding is medically contraindicated. Exclusive breastfeeding should be practised during the first four to six months of life.". The FSAI must surely be aware that Ireland has the lowest rates of breastfeeding in Europe. Is it not deflecting its responsibility by first saying that tap water should not be used for infant formula and now saying that all mothers should be breastfeeding? That serious question needs to be answered.

One of the members mentioned the pea-sized amount of fluoride toothpaste and I ask if any of the members has contacted the Advertising Standards Authority of Ireland to inquire about these television advertisements which show huge swirls of toothpaste? I will not name the companies but we have all seen the advertisements. These advertisements are shown every day. Fluoride toothpaste is becoming more and more tasty for children with orange, banana and strawberry flavours. Has any member of the committee contacted the pharmaceutical sector which produces these toothpastes? These issues need to be addressed.

As regards diet and in response to Professor O'Mullane, the figure I was referring to was a WHO figure where our sugar consumption has reduced 20% since the 1960s. In response to Dr. Mullen, water fluoridation ceased in April 2003 after 41 years in Basle in Switzerland. Water fluoridation was not stopped in order to have salt fluoridation, according to their report. They said that there was no good reason to force a medication on the population and 99% of the fluoride added to the water is never consumed by humans, leading to an unnecessary load on the environment. Salt fluoridation is never mentioned in the report. Like fluoride toothpaste, it is a consumer issue and is not mass medicated, being something one can choose to buy or not.

As regards the invitation to the forum, I find that this type of invitation does not interest the Irish dentist. For instance, Professor Connett was invited to the forum and made his presentation in September 2000. In the following meeting, Dr. Mullen described Professor Connett's presentation as "emotive rather than scientific", even though he had submitted 121 scientific references in his 50 arguments against fluoridation and which, to date, have never been dealt with directly. It is also important to note that Dr. Seamus O'Hickey was employed by the forum to edit the responses to these arguments in October 2001, a month before the forum was due for publication. I wonder what happened to that response?

I am originally from the North and my teeth are fairly good. Comparing the two situations that Dr. Mullen compares, one must consider that there are compounding factors. The city of Derry is in the north-west area of Northern Ireland and that has not been taken into consideration. There is no population centre in the north-west of Ireland with a similar concentration of people. One must take diet and toothbrushing habits into consideration. In Europe the use of fluoride toothpaste has decreased the incidence of tooth decay. I contend that fluoridation is not causing this.

With reference to the New Zealand report, an historical perspective of New Zealand shows that in the period 1930 to 1999, the number of decayed teeth per person fell from ten per person to the current value of one or two. Fluoridation was introduced in the mid-1960s. If one examines that as a small area, one can say that fluoridation is causing tooth decay. From an overall historical perspective, however, tooth decay has been decreasing regardless of water fluoridation. Those are the conclusions I have reached.

Chairman

We have almost run out of time, but I will give Dr. Mullen an opportunity to respond.

Dr. Mullen

I am appalled that a dentist would charge €8,000 to treat fluorosis. I have encountered about four cases of people seeking treatment for dental fluorosis in the last two years. The problems of a girl from Manchester, where water is not fluoridated, can be attributed to fluoridated toothpaste. The treatment takes about 20 minutes and does not involve anaesthetic, drilling or anything else. It is a simple polishing technique that was demonstrated by an anti-fluoridation campaigner, Dr. Hardy Limeback, during a lecture at the forum on fluoridation. One of his principal objections to fluoridation in Canada is that private dentists can make a fortune by placing unnecessary crowns and bridges on teeth with fluorosis. Having said that, the treatment is very straightforward and simple. It certainly does not involve crown and bridge work.

I alluded to the European experience. Fluoridated salt is very common in Europe. I do not know of a European country where fluoride is not at the heart of preventative dental programmes in one form or another. As regards the decision taken in Basle, the communication I have had with a dental colleague in Switzerland indicated that the presence of fluoridated salt was a key factor. A decision was taken to have fluoridated salt where they did not previously have it. It was one of the key factors in the decision to cease water fluoridation.

I did not mention Derry during the discussion on the comparison with Northern Ireland. I drew a comparison between the Sligo-Leitrim region and the Fermanagh-south Tyrone region. I stand over my assertion that there was a major difference between general anaesthetic experience in the two regions, despite the fact that the use of fluoride toothpaste is higher in Northern Ireland. A recent survey in Northern Ireland demonstrates a very significant problem of fluorosis there. The Western Health and Social Services Board in Northern Ireland organises very good and imaginative oral health promotion programmes. Toothpaste is frequently supplied to schools in the region.

The last point I would like to make relates to the experience in New Zealand. The graph in question was drawn up by Dr. John Colquhoun, an anti-fluoridation campaigner in that country. It was not drawn up from standardised surveys but from incomplete school records. One cannot base any deductions from such records. The graph contradicts everything we know about the experience of dental caries in the western world.

Professor Fottrell

I thank the Chair and his colleagues on the joint committee for their time. I would like to summarise this matter by saying that while Dr. MacAuley's comments about a reduction in sugar consumption were correct, we have one of the highest levels of sugar consumption in the world. This nation is at risk in that regard. There is scientific evidence that water fluoridation has benefited the country - there is no doubt about it. There is no scientific evidence to suggest that water fluoridation is harmful in any way. Ireland is one of 40 countries that engages in water fluoridation at present. When Japan is fully engaged in fluoridation, 500 million people will be covered by water fluoridation programmes. The recommendations of the forum on fluoridation are in line with all international recommendations. Dr. Mullen has informed the committee that the House of Lords in the UK decided last night to approve steps to support water fluoridation, which works and is beneficial. There is no evidence that it causes any damage. We are a nation at risk because our levels of sugar consumption are high.

Deputy Gormley

May I remind the professor that no health studies have been carried out under section 6? I have asked why that is the case. How can Professor Fottrell say categorically that there are no health effects, given that no studies have been carried out?

Professor O’Mullane

May I answer that question? I would be appalled to think that Dr. MacAuley showed a picture of a case of dental fluorosis. I would like to establish, from a clinical point of view whether it is a case of dental fluorosis. The forum on fluoridation's recent study found there has been an increase in three grades of dental fluorosis - questionable, very mild and mild. The percentage increase in people affected by moderate or severe fluorosis reported in our study was zero. It is incorrect, according to our figures, to imply that a large proportion of the population is affected by the condition displayed by Dr. MacAuley.

A study of adult oral health conducted in 1990 included a questionnaire based on an index used by the American Society of Anaesthesiologists. The data have been published and are available. I ask the committee to examine them. Comparisons are regularly made between the health status of different nations. One does not have to conduct a study into everything.

May I make an observation in relation to the question of bone? It is ironic that a study was presented by Dr. Hardy Limeback at a meeting of the International Association for Dental Research. The study showed that there was no difference in the levels of fluoride in bone influoridated and non-fluoridated areas. It would be incorrect to suggest that the general health of the nation has not been monitored. It has been monitored, but there are different ways of doing it.

Deputy Gormley

Why has no study been carried out under the original Act in the last 40 years? That is the question.

Professor O’Mullane

The study that was carried out in 1990 was under the——

Deputy Gormley

Was it under section 6 of the Act?

Professor O’Mullane

It was funded by the Department of Health at that time. I presume——

Chairman

We need to conclude. May I thank both sides for presenting their cases today? The members of the committee benefited greatly from the presentations. We have a greater knowledge of the issue of fluoridation as a result. We are delighted to have had the opportunity to meet the members of the delegations so that some of the myths can be dispelled. It is obvious that reservations still abound. Dr. MacAuley is still not completely happy with what has happened. It has been a very rewarding morning. I thank the delegations for their presence.

The joint committee adjourned at 1.30 p.m. until 11.30 a.m. on Thursday, 18 September 2003.